Monday, January 30, 2023

Don't fear criticism

Every once in a while, I come across an online post that I feel has an important enough of a message to be shared.  Over the weekend, I came across a video of a teacher writing math problems on the dry erase board (see the video here).  Call me a little crazy, but it seemed a little weird that he was writing the multiplication table for the number 9 to a group of students who looked to be at least high school age.  Oh well, that detail is not too important.  He wrote down the wrong answer for 9 x 10 (he wrote "91"), and one of his students called him out on it.  The teacher then admits that he wrote down the wrong answer on purpose, because he wanted to teach his students an important lesson.

The teacher asked why no one in the class had recognized or said anything after he wrote down the first 9 math facts correctly, asking "No one congratulated me, why?"  He goes on to say, "I made a mistake and you laughed and criticized."  The students responded with something along the lines of "You're the teacher, you're supposed to be smart."

The teacher goes on to say that just because he is an authority figure, it doesn't mean that he is smarter or better than his students, nor does it mean that he is perfect.  Authority figures - whether they are teachers or leaders, will absolutely make mistakes!  Nobody is perfect.  He goes on to say that the world is quick to criticize and find fault and much slower to praise or acknowledge the positives.  He goes on to say, "Those of you who are lucky enough to succeed or become 'successful' will likely experience more criticism than the rest.  Because you'll find that the one thing people love more than pointing out another's mistakes is when they can do it to someone who's achieved more than them."

The teacher concludes with three points that he wants his students to remember:

1. Try to notice the good in others.  If someone makes a mistake, try to let them know in a kind way, and praise more than you blame.

2. When, not if but when, you are criticized, remember the good in you.

3. Remember criticism is something that you can avoid easily by saying nothing, doing nothing, and being nothing.

He concludes by admonishing his students, "Don't fear criticism, but know when it comes that it's the result of your success, not your failures."

Friday, January 27, 2023

Rally Point

Several years ago, as part of my military training, I took a course called C4 (Combat Casualty Care Course).  The course started at Brooke Army Medical Center (BAMC) with the American College of Surgeons' two-day Advanced Trauma Life Support course, followed by a three-day training exercise in the field at Camp Bullis in San Antonio, Texas.  We learned how to perform battlefield triage, as well as the initial evaluation, resuscitation, and stabilization of trauma patients in austere environments.  We also learned how to set up and lead a battalion aid station and coordinate evacuation of trauma patients in combat conditions.  

Our C4 course instructor and unit's (our class was split into smaller units of about 10-12 students each) Officer in Charge (OIC) was an Army Ranger and Blackhawk helicopter pilot, who was very enthusiastic about showing us what it was like to be in the infantry!  We moved through the countryside in full camouflage (including face paint!) in tactical formation (i.e. silent and steathy).  It was during these "troop movements" in tactical columns that I learned about something called a "rally point" from our OIC.  As defined by the U.S. Army, a "rally point" is a place designated by the unit leader (usually at the squad, platoon, or company level) where the unit moves to reassemble and reorganize.  As I reflect on the state of the health care industry today, my mind immediately went back to the concept of a "rally point".

All of us need a place to relax, recharge, and get away from the everyday concerns of the world.  I used to have a place across the street from the hospital that I called my "happy place" (really, it was just a quiet bench in a park) where I would occasionally go have a cup of coffee and escape the stresses and challenges of the work day.  But that's not what I am talking about here.  Let's go back to my analogy.  If the military unit gets separated or has to withdraw from a difficult situation, the soldiers know that they should find their way back to the "rally point" - once there, the unit can re-group and plan a counteroffensive.  The same is true for all of us in health care.  We need to go back to what we are doing well, re-group, and plan our counteroffensive to return back to where we were pre-pandemic - and in all truth, to a place better than where were were pre-pandemic!

For me, my "rally point" may have occurred yesterday.  I was sitting to the final presentations from our most recent class of "Improvement Scholar" graduates.  It was so great to see the engagement and enthusiasm from the graduates, but it was even better to see how their colleagues came to support them!  There was one area of our hospital that had really been struggling for a long time until relatively recently.  One of the graduates from that area presented her project, which was incredibly successful.  I counted at least 25-30 other members from her team who were there to support her and cheer her on! It was great to see, and it took me back to those days at Camp Bullis when I first learned about "rally points."

I think leaders need to find their own "rally point" - look for the small wins, really anything that you can build momentum from and help your team turn things around for a better future.  We've all been through a lot these past three years.  It's time to go to our "rally point", regroup, refocus, recharge, and move forward!

Wednesday, January 25, 2023

Sell Ice Cream!

There is a famous quote attributed to the late Steve Jobs, co-founder and former CEO of Apple, Inc.  Jobs said, "If you want to make everyone happy, don't be a leader.  Sell ice cream."  I can certainly appreciate that advice!  Leadership is not always about popularity, and popularity shouldn't be the goal. Nevertheless, the higher you rise in the organizational hierarchy, oftentimes the less popular you become.  

There will be times as a leader that you have to make unpopular decisions that are in the best interests of the organization, even if they are not in the best interests of some of the major stakeholders within the organization.  And as the saying goes, "Muck flows uphill."  The organization's problems are the leader's problems.  Finally, leaders are frequently held accountable for decisions or issues for which they have limited or no authority (see "The Accountability-Authority Matrix").  It's not always fair, but it's part of the job that you sign up for when you become a leader.  And it can often make it seem like leaders are all alone.

I have posted in the past on the so-called "loneliness of leadership" (see my posts, "It's lonely at the top" and "Now is the time to lead").  A survey in 2012 by the Harvard Business Review found that more than half of CEO's report being lonely in their roles as leaders.  As the English playwright, William Shakespeare famously wrote in his play, Henry IV, "Uneasy lies the head that wears the crown."  All leaders have bosses too (even CEO's), and leaders rarely have the luxury of expressing their doubts, misgivings, or anxieties to their bosses.  It's even less likely that they can do so with the members on their team.  Leaders are expected to remain positive and optimistic about the future, even if the data suggests otherwise.  And leaders can never have a "bad day" (even though we are just like everyone else and have them).


1. Establish lifelines: Find peers outside of your organization or even outside of your industry that you can spend time with and learn from - there is a good bet that these leaders will have some of the similar experiences, anxieties, and misgivings as you do.

2. Exchange answers for questions: Leaders don't need to always know all of the answers.  Don't even try!  Be comfortable saying, "I don't know" (which can oftentimes be paired with the response, "But I will find out").  Don't be afraid to ask questions or even have the members of your team suggest potential solutions to their problems.  

3. Manage up: Find an ally above you in the organizational hierarchy.  Share positive triumphs, and don't be afraid to ask for advice.  

4. Be interesting: Find personal interests and/or hobbies outside of work.  You will be more successful professionally if you are more fulfilled personally.

5. Practice extreme self-care: Leadership isn't easy.  Don't forget the importance of self-care! Whatever you do to relax and decompress, do it.  

Lastly, be sure to read.  I have often found comfort and reassurance learning about how other leaders have faced similar (or even worse) challenges during their own leadership journey.  Reading is an activity that I enjoy (it's part of my "extreme self-care"), but I have used reading to "establish lifelines" with other great leaders in history.

Leadership is not supposed to be easy.  But it doesn't always have to be lonely.  

Monday, January 23, 2023

Wash Your Hands!

Personal hygiene is incredibly important!  Just consider some of the following statistics, as reported by the Centers for Disease Control and Prevention (CDC).  Handwashing can reduce the spread of infections, such as the common cold (by up to one-third) and deaths from diarrhea (by up to one-half).  If everyone washed their hands with soap and water, 1 million deaths per year would be prevented!  And how about this for a fun fact, the average swimmer contributes at least 0.14 grams of fecal material to the water, usually within the first 15 minutes of getting in the pool.  Taking a shower before swimming removes this fecal material from the body and can significantly reduce the spread of infections.  

Despite all of the evidence showing that basic handwashing significantly reduces the spread of infections in the hospital, most studies report that hospital workers follow this basic infection control measure on average only about 75% of the time.  Of course, rates vary significantly from hospital to hospital, with most studies reporting compliance rates from a low of 30% to a high of 91%.  As such, there is a lot of interest in trying to improve compliance with handwashing in the health care setting!

Some hospitals have tried using monetary incentives as a way to improve handwashing compliance.  I've posted about some of the advantages and disadvantages of monetary incentives in the past.  On the positive side, providing monetary incentives can reinforce desired behaviors (e.g. handowashing) or increase an individual's motivation to work hard to achieve an organizational goal.  Monetary incentives rely upon Homo economicus, the theory that we are rational beings that would choose to maximize our own self-interest and thus address the principal-agent problem.  However, on the negative side, providing monetary incentives effectively changes the relationship between the organization and the employee from a cooperative one to a transactional, contractual one.  Once that transactional relationship has been established, if the monetary incentive is withdrawn, the employee no longer feels the need to exhibit the desired behavior.  I have also talked about the so-called "crowding out effect" and intrinsic versus extrinsic motivation (see my post, "Holes" for more).  Alternatively, neoclassical economic theory suggests that agents (in this case, the employees) can derive utility from contributing to organizational goals, even in the absence of monetary incentives.

With all of this in mind, Harvard Business School professor Dr. Susanna Gallani analyzed the results of a natural experiment conducted at one large hospital, in which monetary incentives were used in an attempt to improve handwashing compliance.  All hospital employees contributed to the goal of improving handwashing compliance from a baseline (during Q1, or the pre-intervention period) of 91% (which is actually pretty good) to the stretch goal of 95% by the end of Q2.  If the stretch goal was met, every employee would receive $1,200 at the end of Q2.  Notably, physicians also contributed to the overall goal but were not eligible for the monetary bonus (physicians were not allowed to be employed by the hospital due to the corporate practice of medicine laws in California, where the study was performed).  Instead, hospital employees motivated the physicians to wash their hands through peer pressure, reinforcement, and social rewards such as recognition.  These practices ended at the completio of the intervention in Q2.

Importantly, handwashing compliance did improve by the end of Q2, and the employees received their bonus.  However, over the course of the next two quarters (Q3 and Q4, respectively), handwashing compliance decreased to the pre-intervention levels or in some cases, even worse than before the incentive plan!  Physicians, on the other hand, demonstrated a slower improvement in handwashing compliance relative to the hospital employees.  However, the improvement in handwashing compliance persisted through the end of Q4!  As Gallani concluded, "While monetary incentives generated a more pronounced improvement, it was short-lived.  On the other hand, peer pressure techniques generated a change in behavior that persisted beyond the removal of the incentive."

Dr. Gallani published a summary of her findings in the Harvard Business Review (see the article, "Incentives Don't Help People Change, but Peer Pressure Does").  Dr. Gallani suggested that even if the monetary incentives didn't produce sustained improvements in handwashing compliance with the hospital employees, "the existence of the monetary incentive helped generate the peer pressure applied to the physicians, leading to longer-lasting success."  It's a very interesting take on the whole intrinsice versus extrinsic motivation argument, and it strongly suggests that perhaps leaders and managers should pay greater attention to how they motivate their employees.






Thursday, January 19, 2023

"100 apples divided by 15 red herrings"

I have posted about the need for public reporting of quality metrics in the past (see my post, "In God we trust - All others bring data").  In order to fully understand any quality metric, however, we have to be fully transparent and consistent on how we define these metrics.  With that in mind, I was particularly interested in an article published several years ago by Dr. Lisa Iezzoni ("100 Apples Divided by 15 Red Herrings: A Cautionary Tale from the Mid-19th Century on Comparing Hospital Mortality Rates").  Dr Iezzoni stated very eloquently, "Even hospital mortality rates, a seemingly straightforward staple of many provider 'report cards', can be modulated by the manner in which they are calculated."  

Dr. Iezzoni told the story of Florence Nightingale, a 19th century British social reformer and statistician who is perhaps best known as the founder of the nursing profession.  Following her experiences as a nurse during the Crimean War, Nightingale published her Notes on Hospitals, in which she recommended a number of changes in how hospitals could be set up and operated to minimize the number of deaths caused by unsanitary conditions.  She turned to another prominent social reformer and physician, William Farr to collaborate (a very early example of the importance of dyad leadership in health care).  Both Nightingale and Farr had significant concerns about the number of deaths occuring in English hospitals, particularly urban hospitals (at the time, mortality rates were believed to be higher in urban hospitals compared to rural hospitals, though this may have been related more to case-mix - see below).  

Nightingale and Farr conducted an analysis of the number of deaths occuring in the "106 principal hospitals of England" in 1861 and reported a mortality rate of 90.84% in the 24 hospitals in the city of London!  They also found a mortality rate of 39.41% in 25 county and provincial hospitals, so on the face of it, their analysis appeared to support the hypothesis that patients were more likely to die in urban versus rural hospitals.  Even more impressive in my mind was the mortality rate reported by the 13 military hospitals (15.67%)!












Let's take a closer look though.  Mortality rates were calculated by dividing the total number of deaths at the hospitals in 1861 by the number of patients at the hospitals on April 8, 1861.  What?!?!?  In other words, the numerator was based upon the total number of deaths that occurred over the period of one year, while the denominator was based upon the number of patients in the hospital on a single, specific day.  That just does not make sense.  Using the total number of patients in the hospital over the entire year as a denominator, the mortality rate in the London hospitals dropped to 9.7%.

I don't think that any hospital today reports mortality rates like Nightingale and Farr did in their analysis.  However, the point here is that you need to be extremely careful when comparing mortality rates between hospitals.  Some experts even feel that comparing hospital mortality as a quality metric is inappropriate!  Back to the 1860's, many rural hospitals explicitly refused patients with tuberculosis or who were close to death, whereas urban hospitals admitted everyone.  In other words, case-mix by severity of illness also matters.  As another 19th century critic wrote, "Any comparison which ignores the difference between the apple-cheeked farm-laborers who seek relief at Stoke Pogis (probably for rheumatism and sore legs) and the wizzened, red-herring-like mechanics of Soho or Southwark, who comes from a London hospital, is fallacious."  Even today, hospitals can differ significantly when it comes to the kinds of patients that they take care of, and adjusting mortality for these differences is fraught with problems.

It's amazing to me that we are having the same discussions today that were going on in the 1860's!  The take-home point is that transparency about how metrics are defined is just as important as transparency about those metrics themselves.  We don't want to be in a situation where we are dividing 100 apples by 15 red herrings!

Tuesday, January 17, 2023

Place Kickers

We used to dream about leading our team on a game-winning touchdown drive, making a last second basket to win the game, or hitting a walk-off home run.  Honestly though, I never dreamed about kicking a last second field goal as a child!  I can't imagine being a place kicker in football.  If you kick the field goal, you are the hero, but if you miss?  Well, we've all seen how that one ends too.

Last night, the Dallas Cowboys beat the Tampa Bay Buccaneers in the NFC Wild Card Play-offs for the National Football League.   It wasn't a very close game.  The Cowboys' place kicker, Brett Maher missed four extra point attempts in a row.  Apparently, no one has ever missed four extra point attempts in a single game in the history of the league, and the last time anyone missed three attempts was in 1993.  Even worse, Maher had missed the last extra point attempt in his last game, so he really had missed five extra point attempts in a row!  Thankfully, he was successful on his fifth attempt last night.

Maher is otherwise a good place kicker.  During this past season, he made 50 out of 53 extra point attempts, and he holds the NFL record for most field goals over 60 yards (four).  Clearly he has the skill to be a successful place kicker in the NFL, so who knows what's going on with him.  

While I was watching the game last night, I came across a video of Baltimore Ravens kicker Justin Tucker kicking a 87 yard field goal during warm-ups.  Tucker currently holds the NFL record for the longest field goal (66 yards), but I am still quite impressed!  So, the question to ask is whether we will ever see an attempt of a field goal that long in an actual game?

I think in order to answer that question, we have to look at Brett Maher's struggles again.  Why is Maher missing his extra points?  Why will we likely not see a 87 yard field goal attempt in an actual game?  The answer is that there is a big difference between doing something in practice versus doing something in a game.  Everything is different - stress levels, crowd noise, opposing players are on the field, etc.  Some factors can be simulated in practice, but at the end of the day, the stress level in real life versus simulation/practice is just not something that can be replicated.

There is an old adage, "Practice makes perfect."  Well, maybe not perfect.  But practice is clearly important.  And no matter what you are doing, whether it is kicking a field goal, shooting a free throw in basketball, resuscitating a patient in the emergency room, or giving a speech in front of an audience, the closer that you can replicate true "game time" conditions during practice, the more prepared you will be for real life situations.

Sunday, January 15, 2023

Annual Gallup survey on honesty and ethics among professionals

The Gallup organization recently released the results of their annual public survey measuring the ethics and honesty of professions (as they have been doing annually since 1990).  The latest findings again show that the nursing profession has the highest ethics rating among all professions, with 79% of U.S. adults stating that nurses have either "High" or "Very High" honest and ethical standards.  Of note, the rating this year fell (for the first time, I believe) by 10 percentage points compared to the highest ever rating recorded in 2020.  Remember though, that the 2020 survey was conducted at the height of the COVID-19 pandemic, and nurses were clearly and publicly on the front lines.  

Importantly, nurses have held the top ranking for every year of the survey, except one, since 1999 (which was the first year that they were added to the survey).  That year, firefighters earned a record-high 90% rating in their only appearance on the list following the 9/11 terrorist attacks.  I am honored to continue to work beside my nursing colleagues, taking care of the patients and families that we are humbled to serve.  Congratulations to nurses everywhere and thank you for what you do every single day!

Two other health-related professions also scored high - medical doctors and pharmacists ranked second and third behind nurses with 62% and 58% of Americans, respectively, rating them "High" or "Very High".  Similar to nurses, both professions dropped compared to their 2020 ratings.  Here is a graphic of the ethics rating for nurses, medical doctors, and pharmacists over time:





















Pharmacists have historically ranked higher than medical doctors, though this changed during the COVID-19 pandemic.  

High school teachers (53%) and police officers (50%) also ranked high on the list of professions in this year's survey.  The results of the survey with all of the professions that were rated is shown below:



Friday, January 13, 2023

Six blind men from Indostan

The American poet, John Godfrey Saxe wrote a poem called "The Blind Men and the Elephant", based upon a much older story about six blind men (from India, at least in one story) who come across an elephant for the very first time and describe the animal based upon their individual perspectives.  The first man touched the elephant's trunk and compared the animal to a snake.  The second man touched the elephant's ear and compared the animal to a large fan.  The third man placed his hand on the elephant's side and described the animal like a stone wall.  I think you get the picture, but the remaining three compared the elephant to a rope (tail), tree (leg), or spear (tusk).  If not, just take a look at the cartoon below (which I believe is by Gary Larson, from The Far Side, but I'm not 100% sure):














As a funny aside, there is also a joke about six blind elephants who come across a man for the very first time.  The first blind elephant accidentally steps on the man and concludes that "Man is flat."  The rest of the elephants all agreed.

The point is that each of us have our own individual perspectives, yet rarely do we get to see everyone's perspective at once.  I am certainly reminded of the High Reliability Organization (HRO) principle of "Reluctance to Simplify" here , as well as the so-called "Rashomon Effect" (and the 2008 movie, "Vantage Point"), which I have discussed before in the past.  As the physicist Werner Heisenberg (most famous for the "Heisenberg uncertainty principle") eloquently stated, "We have to remember that what we observe is not nature in itself, but nature exposed to our method of questioning."

Health care organizations that aspire to be High Reliability Organizations (HROs) analyze adverse events and so-called near misses in order to maximize the information that can be learned in order to prevent these events from happening again in the future (see "Preoccupation with Failure").  Many, if not most, hospitals have invested in web-based incident reporting systems that allow staff members to report their concerns about patient and staff safety.  For example, providers will report if a patient receives the wrong dose of medication or even the wrong medication.  These events will be reviewed by both local and hospital safety leaders to determine what factors were responsible for the error.  Safety leaders can also monitor the incident reporting system for certain trends or patterns, which then often prompt more formal, systemic corrective measures.

With this in mind, I was interested to read a study published in 2010 by a team at Brigham and Women's Hospital in Boston ("Integrating incident data from five reporting systems to assess patient safety: Making sense of the elephant") and the accompanying editorial, "The elephant of patient safety: what you see depends on how you look"in the same issue of the Joint Commission Journal on Quality and Patient Safety.  These investigators compared the nature of safety reports obtained through five different commonly utilized systems - voluntary incident reporting systems (as described in the paragraph above), patient and family complaints, reports to risk management, medical malpractice claims, and executive walk rounds.  They collected data for a 22 month period (2004-2006), though they included 10 years worth of malpractice claims data.

Here is the breakdown of events that they reviewed and classified (using a system that they developed and validated):

1. Incident Reporting - 8,616 reports
2. Reports to Risk Management - 1,003 reports
3. Patient/Family Complaints - 4,722 reports
4. Executive Walk Rounds - 61 walk rounds
5. Malpractice Claims - 322 claims (over 10 years, rather than 22 months)

Importantly, the individuals who completed each report was very different.  By far, bedside nurses completed most of the reports submitted to the incident reporting system (only 2.5% of these reports were submitted by physicians - this is very similar to my anecdotal experience), while over 50% of the risk management reports were reported by physicians.  As a result, the categories of incidents reported were very different between the five systems.  

1. Incident Reporting: Patient identification issues (e.g. wrong patient or wrong medication), Falls, and Medication errors

2. Reports to Risk Management: Issues around technical skills, patient and family behavior, administrative issues, or concerns about clinical judgement/decisionmaking

3. Patient/Family Complaints: Communication, Ancillary services (patient transport, kitchen, environmental serivces), administrative issues (e.g. scheduling or care coordination issues)

4. Executive Walk Rounds: Equipment problems, Electronic Medical Record, Infrastructure or resources (staffing, available supplies)

5. Malpractice Claims: Clinical judgement and/or decisionmaking, Communication, Technical skills, problems with medical records

In other words, any hospital that relies upon only one or even a couple of these incident reporting methods will, just like the six men of Indostan, not have the complete picture!  Each of the five systems capture different issues, and in many cases, these issues would not be identified in any of the other systems.  Similarly, any study reporting patient safety incidents using only one of these different systems should be viewed with some level of skepticism. 

Wednesday, January 11, 2023

"In the tent..."

As many of you know, I like to watch sports movies and war movies.  One of my all-time favorites is the 1972 film The Godfather starring Marlon Brando, Al Pacino, James Caan, Robert Duvall, and Diane Keaton (among many, many other famous actors).  The film was directed by Francis Ford Coppola and tells the story of the Corleone crime family.  The sequel, The Godfather II, at least in my opinion, was an even better movie (we won't talk about the final installment of the trilogy).  There is a scene in the second movie in which the crime boss Michael Corleone, played by the actor Al Pacino, tells one of his henchmen, "Keep your friends close and your enemies even closer."  It's a great scene and an even greater quote. 

I recently started watching the MasterClass on Leadership by the author Doris Kearns Goodwin.  Goodwin was a White House Fellow during Lyndon Johnson's Presidential Administration and tells a story in the first episode of how she was selected to work as Johnson's personal assistant, even after it came out that she had written an article in The New Republic describing the process to remove Johnson from his presidency for his management of the war in Vietnam (it was entitled, "How to Dump Lyndon Johnson").  Johnson reportedly said, "Oh, bring her down for a year and if I can't win her over, no one can."  Talk about keeping your enemies closer!  It was Johnson who also said, in a way that only he could say it, "Better to have your enemies inside the tent pissing out, than outside the tent pissing in."  Okay!

Goodwin talks about this "keeping your enemies close" and "inside the tent" extensively in her excellent book (one of my all-time favorites) Team of Rivals: The Political Genius of Abraham LincolnAfter he was elected President, Lincoln named several of his political rivals to his Cabinet, a number of whom he had defeated for the nomination earlier that year.  Rather than worrying about being overshadowed by his more experienced (and more educated) rivals, Lincoln rationalized that the country was in crisis, so he needed the best leaders on his team.  These men were some of the best and the brightest leaders in America at the time, so Lincoln would say, "I had no right to deprive the country of their services."

Goodwin goes on to tell how Presidents Franklin Roosevelt and Lyndon Johnson, two other Presidents that she has written biographies about, followed a similar strategy when selecting their Cabinets.  She also tells about how President Barack Obama selected his chief rival for the nomination, Hillary Clinton, as his Secretary of State.

It's hard to imagine a leader building a "team of rivals" today, but then again, it's hard to imagine that a team of individuals who all act and think the same could ever be successful in our complex world either.  Part of leadership is learning to manage conflict in a productive way.  With that in mind, as you start to build a team, consider both Michael Corleone's and Lyndon Johnson's admonitions to keep your enemies inside the tent and remember how Abraham Lincoln built his team of rivals.

Monday, January 9, 2023

Two words - persist and resist

I'm going to keep today's post very simple (sometimes short and sweet is the best strategy).  I have found a lot of comfort by reading and learning about Stoic philosophy during the last couple of years, so I hope that you will continue to indulge me when I post about a story or lesson that I've found particularly helpful to me.  The ancient Greek Stoic philosopher Epictetus wrote, "Two words should be committed to memory and obeyed by alternatively exhorting and restraining ourselves, words that will ensure we lead a mainly blameless and untroubled life."  Those two words were persist and resist.  

Epictetus is telling us that we need to have the courage to continue to do what is right ("persist"), while at the same time restraining ourselves from doing what is wrong ("resist").  We live in a difficult world right now - perhaps that is true for every generation, but it certainly seems like our generation has had our fair share!  Epictetus reminds us once again that we should persist in our efforts to do what is good, regardless of the obstacles that we face.  He also tells us that we should resist the temptation to take the easy road or to cease in our efforts because of the naysayers that we encounter along our journey through this life.  We should resist all the discouragement and distraction and keep moving forward.  They are simple words, but the message is a powerful one.  Persist and Resist.

Saturday, January 7, 2023

The Peter Principle

Scott Adams, who writes the syndicated cartoon strip "Dilbert" wrote an article ("Manager's Journal: The Dilbert Principle") for the Wall Street Journal in 1995 in which he discussed a concept that he called the "Dilbert Principle", which states that organizations tend to systematically promote incompetent employees to management in order to get them out of the day-to-day operations of the organization.  Adams further explained, "I wrote The Dilbert Principle around the concept that in many cases the least competent, least smart people are promoted, simply because they're the ones you don't want doing actual work.  You want them ordering the doughnuts and yelling at people for not doing their assignments - you know, the easy work.  Your heart surgeons and your computer programmers - your smart people - aren't in management.  That principle was literally happening everywhere."

A similar principle was articulated by Laurence J. Peter and Raymond Hull in their book, The Peter Principle.  The so-called "Peter Principle" is slightly different.  Whereas the "Dilbert Principle" assumes that incompetent individuals are promoted into management positions, the "Peter Principle" assumes that people are promoted because they are competent.  The important difference is that according to the "Peter Principle", individuals are promoted until they eventually reach a position in the organizational hierarchy that requires knowledge, skills, and talents that they do not possess.  At that point, they become stuck in their current position, having reached a plateau.  Peter and Hull explained their principle by classically stating, "In a hierarchy, every employee tends to rise to his or her level of incompetence."  Peter also offered a corollary, "In time, every post tends to be occupied by an employee who is incompetent to carry out its duties."

While both the "Dilbert Principle" and the "Peter Principle" are meant to be satirical, there is evidence to support, at least in part, the "Peter Principle".  Importantly, the concept now known as the "Peter Principle" has been known for over 200 years.  Apparently, the Enlightenment playwright and philosopher Gotthold Ephraim Lessing wrote about a sergeant who avoids an opportunity to be promoted in his 1763 play Minna von Barnhelm, stating "I am a good sergeant; I might easily make a bad captain, and certainly an even worse general.  One knows from experience."  Similarly, the Prussian general and military theorist Carl von Clausewitz wrote that "there is nothing more common than to hear of men losing their energy on being raised to a higher position, to which they do not feel themselves equal" (this sounds a lot like the so-called imposter syndrome to me).  Finally, the Spanish philosopher JosĂ© Ortega y Gasset articulated an early version of the  "Peter Principle" in 1910 when he stated, "All public employees should be demoted to their immediately lower level, as they have been promoted until turning incompetent."

It is with this background in mind that I read with great interest the 2010 winner of the Ig Nobel Prize in Management by Alessandro Pluchino, Andrea Rapisarda, and Cesare Garofalo, "The Peter Principle Revisited: A Computational Study" (this group also won the 2018 Ig Nobel Prize, which I wrote about in a recent post, "Lucky Breaks").  These investigators used an agent-based simulation model to show that in a hierarchical organizational structure in which the mechanism of promotion rewards the best members, then not only is the "Peter Principle" realistically possible, it is unavoidable and results in a significant reduction of organizational efficiency.

The investigators modeled a pyramidal organization made up of a total of 160 positions distributed over six hierarchical levels (there were 81 agents in the bottom layer, denoted level 6, 41 agents in level 5, 21 in level 4, 11 in level 3, 5 in level 2, and 1 in level 1).  Each individual agent was characterized only by age (ranging from 18-60 years, which increased by 1 for each cycle of the simulation) and degree of competence (ranging from 1-10) - these were randomly determined based on two normal distributions at the start of the simulation.  At each cycle of the simulation, all the agents with a competence under a fixed competence threshold (to model termination of employment) or over a fixed age threshold (to model retirement) left the organization, leaving their positions empty.  These empty positions were then replaced by promoting an agent from one level down and so on.  Empty positions at the bottom level were filled randomly with new agents (to model hiring at the base level).

Two possible mechanisms of transmission of competence were modeled (in other words, when one agent from the level immediately below was promoted to fill an empty position in the level immediately above) - the common sense hypothesis and the Peter hypothesis.  With the common sense hypothesis, the promoted agent inherited his/her previous level of competence with a small random variation (+/- 10%), while in the Peter hypothesis competence was randomly determined independently of the old degree of competence.  

Finally, three different strategies were used to promote agents from one level to the next - Best, Random, or Worst.  With the Best strategy, the highest rated agent (in terms of competence) was promoted, while in the Worst strategy, the lowest rated agent was promoted.  With the Random strategy, the agent who was promoted was randomly determined.  Overall efficiency of the organization was calculated based upon the summing the total competences of each level, which was then weighted by multiplying the sum of competences by the hierarchical level (1, 2, 3, 4, 5, or 6).

The simulation was run for 1,000 cycles and was further averaged over 50 different iterations of the initial baseline conditions.  The results show that if the best person is always promoted (as would be typical for most organizations I think), then the best organizational efficiency depends upon the common sense hypothesis being valid and true.  Moreover, the worst results occur if the Peter hypothesis is valid and true.  All of that makes sense, but surprisingly the best results were obtained when the worst performer was promoted (Worst strategy) and the Peter hypothesis was valid and true!  Promoting an agent at random was intermediately effective.  Just look at the following Figure and Table from the manuscript, which compares the gains and losses (from initial baseline conditions) for all of the combinations of promotional strategies and transmission of competence:




















The most consistent (and probably safest) strategy, regardless of whether the common sense hypothesis or Peter hypothesis was true was to either promote by random completely (essentially drawing a name from a hat) or selecting the best and worst performers and then choosing at random.  In other words, the best way to improve organizational efficiency (as a proxy for organizational success) is to promote people randomly or to shortlist the best and the worst performer in a given group and randomly select between the two.  Finally, when they analyzed the progression of agents as they ascended the organizational hierarchy, they found that if the best performers are always promoted and the Peter hypothesis is valid and true, then all the agents will eventually end their career at the level where their competence is minimal (or conversely, where their incompetence is greatest), thus confirming the "Peter Principle".

So, what does all of this mean?  Let's take a look at a couple of the assumptions made by these investigators.  Is it reasonable to assume that individuals will maintain their previous degree of competence whenever they are promoted to a new and higher position in the organizational hierarchy?  Probably not (in other words, the common sense hypothesis Pluchino and colleagues describe doesn't always hold true).  However, I do think it is reasonable to assume that individuals will maintain at least some degree of their previous level of competence, so just assigning the level of competence at random (which is what Pluchino and colleagues did with their Peter hypothesis) doesn't seem correct either.  Regardless, the results of this study are certainly compelling and suggest that promoting the "best qualified" candidate may not always be the best strategy for the organization!   

Thursday, January 5, 2023

The Accountability-Authority Matrix

Several years ago, I sat and listened to an executive leader admonish a mid-level manager for failing to satisfactorily meet a set of Key Performance Indicators that he had absolutely zero control over.  To his credit, the mid-level manager tried to point out that he didn't have any operational responsibility or authority over these KPI's, which unfortunately only made the executive more angry.  It wasn't a good day, and it was an even worse demonstration of leadership.

I've thought a lot about that day, which prompted me to review the management literature on authority, responsibility, and accountability.  After consulting a number of sources, I came up with the following 2x2 table to explain some of the challenges that leaders and managers face when it comes to authority and accountability gradients.   


















Using this 2x2 matrix, individuals who neither possess a lot of authority nor accountability are classified as followers.  I would argue that in order to be a good leader, you have to start by learning to be a good follower (see "Learn to follow, and then learn to lead...").  However, even followers need some degree of accountability.  Those individuals with a lot of accountability but no authority (such as the case in my story above) are not really leaders - nor are they managers.  These poor souls have been placed in an unenviable position of being "pseudo-managers."  Those individuals who possess a lot of authority with no accountability are, in my opinion, more like dictators.  These individuals essentially do as they please with very little oversight or accountability.  Finally, it is the individuals with a balance of both authority and accountability who are the leaders in this framework.

During my research, I also came across the well-known RACI model, a responsibility assignment matrix that is frequently used in project management.  It's essentially a simple spreadsheet or table that lists all of the key stakeholders on a particular project, with their role denoted by a single letter.  "R" stands for "Responsible" (the individual or group who is ultimately responsible for the completion of the project), "A" stands for "Accountable" (the individual - and it is typically a single individual - who makes sure that the "Responsible" individual or group actually completes the project, "C" stands for "Consulted" (the individual or group who provides input and/or feedback on the work being done for the project), and "I" stands for "Informed" (those individuals who need to be aware that the project is being conducted but who do not necessarily need to be consulted to complete the project).  I have found the RACI model to be a useful framework to tease out the finer points of accountability and authority in real-world leadership situations as well.

The important point here is to always make sure that the level of accountability and the level of authority are both appropriate to the situation and consistent with each other.  Unfortunately, as my anecdote at the beginning of the post shows, that is not always the case.

Tuesday, January 3, 2023

2023 Leadership Reverie Reading List

As I have done in years past, I put together a leadership reading list for 2023.  Again, similar to last year's post, the list is in no particular order and includes both books that I have read (mostly in this past year) or ones that I haven't but are on my list to read.

The Emperor of All Maladies:  A Biography of Cancer by Siddhartha Mukherjee: Mukherjee is a physician and researcher at Columbia University who won the 2011 Pulitzer Prize in General Non-fiction for his first book, a comprehensive history of cancer.  Mukherjee summarizes the book and explains the title in his author's note, "In a sense, this is a military history—one in which the adversary is formless, timeless, and pervasive. Here, too, there are victories and losses, campaigns upon campaigns, heroes and hubris, survival and resilience—and inevitably, the wounded, the condemned, the forgotten, the dead. In the end, cancer truly emerges, as a nineteenth-century surgeon once wrote in a book’s frontispiece, as “the emperor of all maladies, the king of terrors.”  While a bit long, it’s a great book that captured my interest and was hard to put down.

One Mission: How Leaders Build a Team of Teams by Chris Fussell, C.W. Goodyear, and General Stanley McChrystal: I read General McChrystal's earlier book, Team of Teams: New Rules of Engagement for a Complex World a few years ago and absolutely loved it.  I picked this book up at an airport bookstore on a business trip several months ago, but I just haven't had the time to read it yet.  I plan to read it soon!

The Gene: An Intimate History by Siddhartha Mukherjee: I literally just finished this book, and all I can say is that if I had read this book during college, my courses in molecular biology and genetics would have made a ton more sense!  Just as he did for cancer, Mukherjee provides an in-depth history of genetics, explaining in easy to understand terms all of the early groundbreaking experimental studies in genetics, including Mendel's pea plant experiments, Darwin's travels to the Galapagos Islands, which resulted in his book The Origin of Species, and the discovery of the structure of DNA by Watson and Crick.  The book proceeds all the way through the Human Genome Project to gene therapy and finally to the most recent discovery of CRISPR/Cas9 and its myriad applications.

Leaders: Myth and Reality by General Stanley McChrystal, Jeff Eggers, and Jay Mangone: I've had this book on my list since I first heard about it.  General McChrystal profiles thirteen leaders throughout history.  As many of you know, I really enjoy reading about history, and I love reading about historical leaders even more!

Churchill: Walking with Destiny by Andrew Roberts: As I mentioned in a couple of posts last year ("Broken Like an Egg Shell..." and "Keep Buggering On"), I read this massive biography on Winston Churchill by Andrew Roberts and absolutely loved it!  It's become one of my favorite biographies on one of my favorite leaders.  I highly, highly recommend this one, even though it will take you some time to get through the more than 1,100 pages of text!

The Evolution of Cooperation by Robert Axelrod: I wrote about Axelrod's research in a post earlier this past year ("Tit for Tat"), so this one has been on my list of books to read too.  Axelrod conducted his famous computerized Prisoner's Dilemma tournament and found that the best strategy for playing repetitive (often called "sequential games" in game theory) games of the Prisoner's Dilemma was a strategy based upon cooperation called the "Tit for Tat" strategy.  I imagine that this book delves into that subject in greater detail.

The Innovator's Prescription: A Disruptive Solution for Health Care by Clayton Christensen: I've read (and enjoyed) a number of books by the late Harvard Business School professor Clayton Christensen, who unfortunately died from complications of leukemia in 2020.  Christensen first described his concept of "disruptive innovation" in his book, The Innovator's Dilemma.  In this book, Christensen applies his theory to health care and suggests possible ways that our health care delivery system can be improved.

The Art of Strategy: A Game Theorist's Guide to Success in Business and Life by Avinash Dixit and Barry Nalebuff: I've been posting a lot about game theory this past year, and this book is largely to blame!  These two economics professors revised their classic text, Thinking Strategically (which I've also read) with this book on how to use game theory to make better business decisions.  It's an absolute gem!

The Last King: The Misunderstood Reign of George III by Andrew Roberts: I've heard a lot about George III in my life, going all the way back to elementary school when I first learned about the Revolutionary War (and most recently in the musical Hamilton!), but I can honestly say that I don't really know much about him.  I put this book on my list because I enjoyed Roberts' biography of Winston Churchill so much (see above).

And There Was Light: Abraham Lincoln and the American Struggle by Jon Meacham: My wife and I recently had some bookshelves installed in our living room, and while I was putting all our books away, she asked me, "You really like Abraham Lincoln, don't you?"  It was a rhetorical question.  Here's one of the latest biographies on arguably our greatest Presidents, so naturally this one makes it to the list this year.

Sunday, January 1, 2023

Top Ten Posts of 2022

Since we just closed out another year, I wanted to share the top ten Leadership Reverie blog posts for 2022:

1.   "No words" (January 24, 2022)



4.  "Be the best at getting better..." (October 2, 2022)

5.  "I'm sorry, we are out of that" (October 16, 2022)

6.  "Imagine the worst" (October 10, 2022)

7.  "Wicked" (September 18, 2022)

8.  "It's complicated..." (September 13, 2022)



I continue to learn a lot from researching and writing these posts.  I recently went back and read my very first blog post ("First blog post!") written on January 2, 2016.  I created this blog for two reasons. First, I've always enjoyed writing and this blog created a venue for me to follow at least one of my favorite activities.  Second, I have always enjoyed reading and learning about leadership, and this blog provided me with a place to record some of my favorite lessons and/or stories from the leadership literature.  For both of these reasons, I would go on writing this blog even if no one other than a few close friends and family members read it (actually, I would still write this blog even if absolutely no one else but me read it).  Regardless, the fact that at least a few of you have spent the time reading (and some of you have even commented) my work provides even more motivation and inspiration to continue.

A lot has happened since January 2, 2016.  Leadership Reverie has surpassed just over 770 blog posts with over 175.000 views.  I am thankful for those of you who have continued to stick with me since the beginning, and I welcome those of you who have only recently started to read.  I hope all of you have a blessed and prosperous 2023.  Happy New Year!