Think big, act small

I recently came across a great quote by the Stoic writer Ryan Holiday a few days ago.  As I have mentioned several times in the past, I subscribe to a daily email from Holiday called "The Daily Stoic".  Holiday has also written several short books on Stoic philosophy, which I also highly recommend.  The quote came from one of these books, called Ego is the Enemy.  I thought it was profoundly appropriate.  Holiday said, "We will learn that though we think big, we must act and live small in order to accomplish what we seek.  Because we will be action and education focused, and forgo validation and status, our ambition will not be grandiose but iterative - one foot in front of the other, learning and growing and putting in the time."  Wow.

Think big.  Dream big.  Do not be afraid to stretch yourself beyond your limits.  But on the other hand, act and live small.  A wise man once said that the journey of 1,000 miles begins with a single step.  In order to reach our goals and fulfill our ambition, we have to start somewhere.  Anywhere.  With one foot placed right in front of the other.

When I read this quote, I thought a lot about so-called stretch goals, which the management expert Jim Collins sometimes calls BHAGs, or "Big, hairy, audacious goals".  But I also thought about SMART goals and something called the "perfection premium".  Remember, SMART goals are ones that are specific, measurable, achievable, relevant, and time-bound.  In other words, think big but act small.  Even the most audacious BHAGs start with smaller scale SMART goals.

Honor Code

The United States Military Academy (more commonly known as West Point) was founded in 1802.  Since its inception, the officer corps operated upon a code of honor - an officer's word was his bond.  Cheating was informally added to this code by superintendent Sylvanus Thayer a few years later in order to increase the academic standards at the academy.  Allegations of theft (stealing) were addressed via the normal Army regulations.  Superintendent Douglas MacArthur (yes, that one) formalized the honor code in 1922 when he commissioned the first Cadet Honor Committee to review all allegations of honor infractions.  However, Superintendent Maxwell Taylor (another famous Army general) drafted the first Honor Code in 1947, which has more or less existed in its current form until the present day (the words expressly forbidding toleration of honor code violations were added in 1970).

The Honor Code is simple, but powerful, "A cadet will not lie, cheat, or steal, or tolerate those who do."

The punishment for violating the Honor Code, either the first part that forbids a cadet from lying, cheating, or stealing or the second part, which forbids a cadet from tolerating another cadet from doing so, can be significant, up to and including expulsion from West Point.  There is a standardized process to investigate any allegations of violation of the Honor Code, as well as a formal hearing process.  Cadets are first tried by a jury of their peers, and if found guilty, the case goes up to the commandant to either impose sanctions or recommend expulsion (the final decision on whether to expel a cadet is made by the Secretary of the Army).

As hard as it is for a Navy guy to say anything positive about the Army (though the United States Naval Academy has its own version of the honor code), the West Point Army Code is incredibly powerful and very well stated.  I really like the last phrase, "or tolerate those who do."  West Point is using what is commonly called "200% accountability" here - I am not only accountable for my own personal behavior, but I am also accountable for making sure that those around me are held accountable as well.  I've talked about this in a couple of posts in the past (see for example "Stop. Point and Cross" and "The Patriot Way").

I was just having this conversation with someone at the hospital.  Take the notoriously poor compliance with hand hygiene in most hospitals, despite the evidence showing that handwashing is one of the most effective ways to prevent transmission of infections between patients and between patients and providers.  While there are technological fixes to help improve compliance, one of the best ways is for those providers on the front lines to hold each other accountable for it.  It's like the famous adage, "If you see something, say something."  If you see someone who is not following handwashing rules, call that individual out!

200% accountability.  The Honor Code.  These are both ways to improve how we work together for a greater common goal.  

Your focus determines your reality

Several of members of the Wheeler family are training for the 25th Flying Pig Marathon in Cincinnati, Ohio later this Spring.  Rather than running outside in the dark and cold weather, I've been spending a lot of time on the treadmill this winter.  I usually pass the time by watching one of the Great Courses or most recently one of the the MasterClass videos.  I am currently watching the MasterClass by Bob Iger, the former and once again current CEO at The Walt Disney Company.  It's been pretty good so far, which doesn't surprise me because I really enjoyed his book on leadership, The Ride of a Lifetime. 

One of Iger's MasterClass videos starts with a scene from the 1999 movie, "The Phantom Menace", Episode 1 in the Star Wars canon.  In this particular scene, the Jedi Master Qui Gon Jinn tells a young Anakin Skywalker, "Always remember, your focus determines your reality."  Iger follows the video clip with a discussion on his lengthy interview process for the CEO position at Disney.  His first admonition was to always be true to yourself, stating "If you can't be true to yourself, how can you be true to others?"  His second admonition, paraphrasing the Master Jedi, "Stay focused."

Iger had a friend who happened to be a political consultant help him prepare for the series of interviews with Disney's board members.  When Iger started to list his key strategic priorities for Disney, his friend told him to stop at three (Iger could have listed five or six).  It's all about focus.  As Iger suggested, if you have more than three strategic priorities, you tend to get lost.  More importantly, your customers and employees get lost too.

Iger proposed three strategic imperatives for Disney that he would prioritize and focus upon as the new CEO:

1. Invest most of Disney's capital in high-quality branded content (i.e, creativity)

2. Use technology to make more compelling content and to reach people in more innovative ways.

3. Grow globally, deepening connection to markets around the world.

That's it.  Everything Iger did as the CEO boiled down to these three priorities.  Was he successful?  I will let you be the judge of that, but consider that during his tenure as CEO from 2005-2020, Disney acquired Pixar, Marvel Entertainment, Lucasfilm, and 21st Century Fox.  During his 15 years as CEO, Disney increased its market capitalization fivefold.  Following his retirement in 2020, he was replaced by Bob Chapek, though Disney brought him back as CEO just recently.

"Always remember, your focus determines your reality."

Don't hold a grudge

As I mentioned last time, I just recently finished reading A. Scott Berg's biography of Woodrow Wilson and learned a lot about a President and a time that I didn't know previously.  Like all leaders, President Wilson certainly had his faults (the book only loosely referred to some of the accusations of racism that have appeared more recently - see the article in The Atlantic by the writer Dick Lehr as well as a more recent press statement from his alma mater, Princeton University).  I will leave that discussion for others who are more qualified.  I did notice another fault of Wilson's which, while far less important than his beliefs on diversity, equity, and inclusion, are still relevant for leaders today - he often held a grudge.

President Wilson was a college professor and later the President of his alma mater, Princeton University.  Just as you would expect to find in any position of leadership, there were a lot of politics that he had to address during his tenure as Princeton's college president.  Apparently, there was a fight between some prominent alumni as well as a faction within the administration over where to build a graduate school (see the great review of the fight here).  Wilson would eventually lose the fight (both politics and money were involved).  More importantly, one of his greatest and oldest friends, John Grier Hibben, who actually became Princeton's 14th President when Wilson left to become the Governor of New Jersey, sided with the alumni.  Wilson would never forgive Hibben.  Hibben (and other mutual friends) tried to reconcile and restore the friendship, but Wilson resisted for the rest of his life.  At one point, while President of the United States, Wilson returned to Princeton and even refused to shake hands or meet with Hibben, who was then president of the university.

There is at least one more example of a time when one of Wilson's friends disagreed with him, which led to the break-up of the friendship.  Again, Wilson would never forgive the friend.  I can certainly empathize with how Wilson felt - particularly with Hibben, Wilson felt betrayed during one of the most difficult times in his life.  

The evidence shows that holding a grudge negatively impacts our mental wellbeing.  At the end of the day, it's not worth it.  The ancient Chinese philosopher Confucius said, "To be wronged is nothing, unless you continue to remember it."  The writer Charlotte Bronte once wrote, "Life appears to me too short to be spent nursing animosity or registering wrongs."

As I have said many, many times, leadership is not easy, particularly in difficult times.  The natural tendency is to look towards an organization's leaders and point the finger of blame at them for everything that is going wrong (whether or not these things are under the leaders' control).  I've found in my own experience (trust me), whether as a leader or a follower, it's better to forgive and move on.  Don't hold a grudge.  It's just not worth it in the end.

"Win by the Audacity of Method"

For the past few years, I've been in a book club that is reading biographies of the U.S. Presidents in order, starting with George Washington.  The book club met virtually during the pandemic, but lately they've been meeting in person again (which has created some difficulties for me, as the book club meets at the Mercantile Library in Cincinnati, Ohio).  I've tried to keep up with them from afar.  

I just finished reading A. Scott Berg's biography of Woodrow Wilson and learned a lot about a President and a time that I didn't know previously.  I remember learning about Wilson's 14 Points and his proposal for the League of Nations at the Treaty of Versailles following World War I.  However, I never knew that President Wilson suffered a stroke in the middle of his second term, which basically resulted in an abrupt cessation (more or less) of all activities by the Executive Branch of our government (remember that this occurred long before the 25th Amendment to the U.S. Constitution)!

I remember learning about the highly controversial Alien and Sedition Acts of 1798, but I don't remember learning that Congress passed very similar (and equally controversial) legislation called the Espionage Act of 1917 and the Sedition Act of 1918 during Wilson's term in office.  As controversial as these were, I have to confess that President Wilson was exactly the kind of leader that the our country needed to help prepare for the United States' entry into World War I.  

President Wilson delivered a famous speech to the naval officers of the Atlantic Fleet on August 11, 1917 onboard the USS Pennsylvania, the flagship of the U.S. Atlantic Fleet (the ship was at the U.S. Naval Base in Norfolk, Virginia at the time).  The speech was not prepared in advance, and the members of the press weren't aware of it beforehand.  Wilson addressed the men "in confidence" and delivered a message of inspiration, asking them to look beyond the lessons in their manuals and be prepared to fight a war like no other war before in history.  He warned that the upcoming war was without precedent and "therefore it is a war in one sense for amateurs. Nobody ever before conducted a war like this and therefore nobody can pretend to be a professional in a war like this." 

Wilson admonished these officers to "please leave out of your vocabulary altogether the word 'prudent.'  Do the thing that is audacious to the utmost point of risk and daring, because that is exactly the thing that the other side does not understand.  And you will win by the audacity of method when you cannot win by circumspection and prudence."

He went on to say that "so far a experience in this kind of war is concerned we are all of the same rank. I am not saying that I do not expect the Admirals to tell us what to do, but I am saying that I want the youngest and most modest youngster in the service to tell us what we ought to do if he knows what it is."  That sounds a lot like the High Reliability Organization (HRO) principle of "deference to expertise" to me!

Just to make sure that the officers knew that he would lead by example, Wilson continued, "Now, I am willing to make any sacrifice for that. I mean any sacrifice of time or anything else. I am ready to put myself at the disposal of any officer in the Navy who thinks he knows how to run this war. I will not undertake to tell you whether he does or not, because I know that I do not, but I will undertake to put him in communication with those who can find out whether his idea will work or not. I have the authority to do that and I will do it with the greatest pleasure."

It's a message of inspiration, but even more so it is an example of great leadership.  

Disappointed but not defeated

It's the Monday after Super Bowl Sunday!  It ended up being a really exciting game at the end, and congratulations to the Kansas City Chiefs on winning their third Super Bowl (and second in the last four years).  The Philadelphia Eagles played a great game, so I am sure that Eagles fans are disappointed this morning.  I don't know how this actually breaks down, but I would bet that about one-third of the people who watched the game last night were happy with the outcome, one-third of the people watching were disappointed, and the rest could care less (give or take).  While at the end of the day, the Super Bowl is just a game, dealing with disappointment can be difficult.  

The writer and blogger Ryan Holiday posted about dealing with disappointment a week or so ago in his blog, The Daily Stoic (see "You can be this, but don't be that").  Look at how NFL coach Steve Wilks dealt with what I am sure was a big disappointment for him.  Wilks was named the Interim Head Coach of the Carolina Panthers, after the team fired Head Coach Matt Rhule on October 10, 2022.  During Wilks' stint as the head coach, Carolina had a record of 6-6, which is not bad when you consider how they started, winning only one game out of the first five games of the season.  The Panthers finished 7-10, but apparently that still wasn't good enough for the Panthers owner and general manager.  They ended up hiring Frank Reich instead.  

I have nothing personally against Coach Reich, but let's take a look at why he was available in the first place.  He was fired as the Head Coach of the Indianapolis Colts earlier in the season after a 3-5-1 record up to that point in the season.  Even if you do like Frank Reich, the hire was a real head-scratcher to me.

Steve Wilks had every right to be disappointed and even angry.  But how did he respond?  He said, "The sun rose this morning and by the grace of God so did I...I’m disappointed but not defeated. Many people aren’t built for this but I know what it means to persevere and see it through.”

The writer Ernest Hemingway wrote in his classic novel, The Old Man and The Sea, "Man is not made for defeat.  A man can be destroyed but not defeated."  There's an old Japanese proverb about resilience (I mentioned it previously in my post, "The Oak and the Reeds"), which says "Fall seven times, rise up eight."  It's been said so many times by so many different people, that it really is a cliché - what matters is not how or when you fail, but how you persevere.  Wilks responded in the best way possible.

Holiday concludes his post by saying, "You don’t control what the fates decide for you. You don’t choose to be passed over for a job. Nobody wants to come face to face with an error or an unpleasant reality. But you do control whether you give up, whether you let it break your heart, whether you are defeated."

Great moments in Super Bowl history

I know there are a few members of our family that are really excited about the game tomorrow at Super Bowl LVII between the Kansas City Chiefs and the Philadelphia Eagles.  It should be an exciting game. I'm sure there will be some new additions to the "Greatest Moments in Super Bowl History" list.  

Who remembers when James Harrison of the Pittsburgh Steelers intercepted a pass at the goal line and returned it for a touchdown in Super Bowl XLIII?  Or how about when the lights went out at the Superdome in Super Bowl XLVVII?  I still remember the San Francisco 49ers defense stopping the Cincinnati Bengals for four plays in a row at the 3 yard line, late in the third quarter in Super Bowl XVI.  How about David Tyree's "helmet catch" in Super Bowl XLII?

While all of these are "great" moments, there are some bad moments too.  Remember when Dallas Cowboys defensive lineman Leon Lett recovered a fumble and ran it back for a touchdown in Super Bowl XXVII?  Well, almost.  While turning around and trying to "showboat" near the goal line, Buffalo Bills wide received Don Beebe caught up to him and knocked the ball out of Lett's hands, resulting in a touchback.  But maybe one of the all-time gaffs was when the Seattle Seahawks were trying to punch it for the go-ahead score late in the game in Super Bowl XLIX against the New England Patriots.  Instead of letting the league's best running back, Marshawn Lynch run it in, Seahawks Head Coach Peter Carroll instead called for a pass play, resulting in an interception that ultimately lost the game.  Carroll's choice of plays has been called "the dumbest call in Super Bowl history" and "a terrible Super Bowl mistake."

Ryan Holiday, who writes a blog called the Daily Stoic wrote a great post yesterday on Pete Carroll's bad play call ("How to Handle a Bad Call").  Rather than trying to shy away or pass off the blame to someone else, Carroll totally owned it.  He said, "I told those guys, ‘That’s my fault, totally.'"  Holiday writes, "That's what a leader does."

Leaders make the best decision with the information that they have currently in front of them.  If the decision goes well, the best leaders will share the credit.  However, if the decision goes poorly, the best leaders take the blame.  Leadership isn't supposed to be easy.

Holiday continues, "Big or small, a crime or a bad play call, every decision lives in the past. In the here and now, they no longer exist, can no longer be touched. All that remains is what you do next. You can take responsibility. You can build on the lessons of your mistake. You can move forward. You can make sure you don’t compound the mistake. You can decide how the next part of the story gets written."  That's leadership at its best.

Pizza Party!

Wow, did I miss a big opportunity!  Apparently, yesterday (February 9th) was National Pizza Day.  Well, it's always better to be late than never, I suppose.  I have always been a HUGE fan of pizza.  As a matter of fact, I am hoping to build an outdoor wood-fired pizza oven in our backyard this summer!  Here are a couple of "pizza fun facts":

1. According to the Yale Food Addiction Scale (who knew there was such a thing?!?!?), pizza is ranked as the food most associated with addictive-like eating behaviors.  As it turns out, everyone loves pizza!

2. Apparently, in the late 1960's, the U.S. Army's 113 Military Intelligence Unit delivered pizzas in order to spy on reports and politicians (see the article "Pizza" in The New Yorker for more).

3. This past January, a group in Los Angeles, California worked with Pizza Hut and YouTube star Airrack to set a new record for the world's largest pizza.  The pizza was 13,990 square feet!  Here's a great picture (from the CNN website):

4. Paul Fenech traveled 12,346.6 miles from Madrid to Wellington, New Zealand in order to hand-deliver a pizza to Niko Apostolakis in 2006.  While I don't know if there is a world record for the longest pizza delivery, I bet this one would take the cake (or should I say, "take the pie"?).

5. Apparently, Pizza Hut once delivered a pizza to the top of Mount Kilimanjaro in Tanzania!  It's in the Guinness Book of World Records.

6. And finally, while I beg to differ, apparently the city of Portland, Oregon was recently rated by "Modernist Pizza" as the best pizza city in the United States (come on, where's Chicago?).

Enough about pizza you say, right?  What does pizza have to do with leadership?  Well, as it turns out, there is some method to my madness.  I actually came across another very interesting field experiment conducted by Dan Ariely (I've posted about a number of Ariely's studies in the past - see "Are trick-or-treaters honest?", "The IKEA effect", and "Prisoner 24601" for a few of my favorites) that involved, of all things, pizza!  In full disclosure, I came across a rather cynical post on my Twitter feed about hospital administrators and pizza parties.  However, after actually reading the study, I think there are some rather important findings that actually have more to do with intrinsic motivation than extrinsic motivation (another favorite topic of mine - see "Lessons from Gross Anatomy" and "Holes").

Ariely and his team worked with a large global high-tech semiconductor manufacturing plant in Israel and measured changes in productivity after implementing four different incentive bonus plans (see the full publication, "It's (not) all about the Jacksons: Testing different types of short-term bonuses in the field").  The experiment involved 156 employees, whose productivity (in terms of the quantity and quality of chips manufactured) was measured for 3 weeks before the intervention to determine a baseline.  Employees were told about the incentive program, which they earned by increasing their productivity on Day 1 of the study - the bonus was delivered on Day 2, and then all incentives stopped until the following week, when the bonus changed per the experiment's protocol.  Realistically, very few, if any, incentive programs are set up in this fashion.  However, I still think the results are quite interesting. 

As I mentioned, four different incentive bonuses were used (and all employees participated in each of the incentive bonus programs).  First, employees received cash compensation in the amount of US $25.  Second, employees received a voucher to purchase a pizza dinner for their family (cash equivalent US $25).  Third, employees received verbal recognition from their direct supervisor.  In the final plan, employees could choose between either the cash or the pizza voucher. 

Ariely and his team found that using incentive bonuses did, in fact, increase productivity.  The increase in productivity was higher for employees receiving the pizza voucher and verbal reward, though the differences were not statistically significant.  They also found that the increase in productivity returned back to baseline once the incentives were removed, consistent with prior research in this area (once the extrinsic motivation to perform is removed, employees no longer feel the need to exert the extra effort required to increase productivity).  The drop in productivity was greatest for the cash reward, but again the differences were not statistically significant.  Overall, the verbal reward appeared to be the most effective at increasing productivity!

Apparently, Ariely published slightly different results in his new book Payoff: The Hidden Logic That Shapes Our Motivations (for a summary of these findings, see an online article here).  Here, Ariely found that the pizza voucher performed better than the cash rewards.  What's important to recognize is that cash incentives aren't always the best incentives to work harder.  Recognition from the boss or organization may be an even more effective way to motivate employees to work hard - whatever the organization can do to make their employees feel valued (and that can even include a voucher for a family pizza meal apparently).

Collectively, most of the work in this area has been fairly consistent.  Dbo Au writes in "How Pizza Magically Enhances Productivity" that "the best way to motivate employees and increase their productivity is to pay them a fair wage and make them feel valued by the company."  Sometimes, simply recognizing an employee for a job well done can go a long way.

Huddles aren't just for football

This coming Sunday afternoon, an estimated 100 million people will watch Super Bowl LVI between the AFC champion Kansas City Chiefs and the NFC champion Philadelphia Eagles.  If you happen to be one of those 100 million individuals, you will undoubtedly notice that almost before every play, the teams (usually the offense) will huddle before coming to the line of scrimmage.  Teams will use the huddle to celebrate what happened on the last play and strategize about the next one.  

As I have discussed in the past, huddles are not just used by football teams (see in particular "The morning huddle" and "Before I make a mistake...").  Restaurants use them at the beginning of a shift - usually the chef meets with the wait staff to go over the nightly specials, any VIP guests coming in, etc.  As I mentioned in one post, supermarkets and retail stores also "huddle up" at the beginning of the day.  Several hospitals now utilize a daily operations brief or daily safety brief at least once per day (the Cleveland Clinic pioneered the use of a tiered huddle system - basically several huddles scaling up throughout the organization).  All of these are great examples of the use of huddles to improve communication, improve situation awareness, develop a shared mental model, and align on a specific operational plan.  

High reliability organizations (HROs) frequently use tiered huddles and daily safety briefs, but they also leverage huddles similar to how football teams use them.  Trauma resuscitation teams often huddle together before an expected patient arrives in the emergency department.  Similarly, neonatal delivery room resuscitation teams and/or "Code Blue" teams do as well.  These kinds of huddles are a great opportunity for teams (especially so-called the swift action teams that I mentioned in my post "Who is Will someone?") to take a pause, align on a shared mental model, and formulate a plan of action.  Huddles aren't just for football teams!

Blindfolded Resuscitation

Last time I briefly mentioned a concept known as "closed loop communication", which many High Reliability Organizations (HROs) utilize to prevent errors or minimize their impact.  Briefly defined, "closed loop communication" is when the individual receiving a command or instruction immediately repeats it back to make sure that the message is understood correctly.  The sender then acknowledges that the message repeated back is the correct one.  The American Heart Association's Center for Health Innovation uses the following diagram to depict the principle of "closed loop communication":

Consider the following example, taken from the script used during the United States Navy's Change of Command Ceremony.  In this particular example (completely fictitious), Captain Jones is assuming command of the USS America from Captain Smith:

Captain Jones: "I am ready to relieve you, sir."

Captain Smith: "I am ready to be relieved, Captain."

Captain Jones: "I relieve you, Captain."

Captain Smith: "I stand relieved, sir."

There is absolutely no question that the sender's (Captain Jones) communication was both heard and understood by the receiver (Captain Smith).  We also know the exact point in time that command authority has exchanged hands.

Let's look at another example, again from the U.S. Navy, as depicted in the 1990 movie, "The Hunt for Red October".  Watch the following film clip, "Conn Sonar, Crazy Ivan".  Here, the Captain's command "All Stop, Quick Quiet" is repeated by the crew member who is responsible for shutting off the submarine's engines.  Again, the sender's message is understood and acknowledged in such a way that the sender knows with absolute certainty that the message was delivered and understood.

I recently came across a couple of articles on "blindfolded resuscitation", a concept used to train health care workers in the importance of "closed loop communication" (see "The blindfolded code training exercise" and "Advanced closed-loop communication training: The blindfolded resuscitation").  Here, the "Code Blue" team leader wears a blindfold and is positioned facing away from the rest of the members of the team (forcing him/her to speak loudly and clearly).  The only way that the team can successfully resuscitate the "patient" during the simulation is to communicate clearly using "closed loop communication".  Studies using this training technique in a variety of different scenarios have demonstrated that it can significantly improve both the quantity and quality of "closed loop communication" used during resuscitations.

Next time we will continue along this theme of high reliability leadership and communication techniques.

Happy National Women Physicians Day!

Today, February 3rd, is the 202nd birthday of Dr. Elizabeth Blackwell, the very first woman in the United States to earn a medical degree.  Dr. Blackwell was famously allowed to attend medical school as a prank by her fellow students.  She had applied to a number of medical schools, only to be told that medicine was a profession not meant for women.  She applied to Geneva Medical College (now known as Norton College of Medicine at SUNY Upstate Medical University).  Apparently the faculty asked the other (both current and incoming) medical students to vote on whether to accept her or not (the stipulation was that the vote had to be unanimous).  The students voted unanimously for her acceptance as a funny way to get back at the faculty.  Dr. Blackwell entered medical school with the 1847 class and graduated in 1849.  During those days, medical school consisted of a one year course of study that was repeated in the second year.  The faculty and students eventually came around, and when the dean of the medical school awarded Dr. Blackwell her diploma, he stood up and bowed to her.

Dr. Blackwell continued to encounter prejudice throughout her career, and later left the United States to continue her training in Europe.  There, while caring for an infant with ophthalmia neonatorum, she accidentally contaminated her own eye and contracted the infection.  Unfortunately, she became blind in that eye, which forced her to abandon her dream of becoming a surgeon.  She would later return to the United States, where she founded the New York Infirmary for Women and Children with her younger sister, Emily Blackwell (who incidentally was the third woman to graduate from a U.S. medical school).  Both Drs. Blackwell focused on women’s health, pediatrics, and social justice.  

The Doctors Blackwell were pioneers in medicine and early advocates for a woman’s right to practice our profession.  Their story was superbly told in an excellent book by the author Janice Nimura (The Doctors Blackwell: How Two Pioneering Sisters Brought Medicine to Women and Women to Medicine) National Women Physicians Day was established to honor Dr. Elizabeth Blackwell and recognizes the contributions of all women in medicine.  While we have come a long way since Dr. Elizabeth Blackwell graduated from Geneva Medical College, the struggles for women’s equity in our profession remains a real one today (see just one example from my own specialty, pediatric critical care medicine, in an article my colleagues and I published a few years ago).  There is work ahead, and we all must play a role.  However, for now, congratulations to all of my women colleagues and friends in medicine, and Happy National Women Physicians Day!

Who is Will Someone?

I briefly mentioned something that I called the Accountability-Authority Matrix last month.  Today I wanted to raise an issue that frequently comes up, particularly during events that involve some degree of urgency and stress and that involves making sure that authority and accountability are assigned clearly and appropriately.  I will start with a clinical example, which I have found to be particularly useful when engaging on this topic.

The literature on teams frequently talks about crisis response teams that are characterized by (1) rapid deployment (often with little warning or pre-planning), (2) limited team familiarity (in other words, the members of the team have very little history of working together and, in some cases, may not even know each other), (3) rapid progression through Tuckman's stages of group development (forming-storming-norming-performing), and (4) relatively short lifespan (i.e. the team or group dissolves once the crisis is over).  These kinds of teams have been called swift action teams in the literature, and if you've ever spent time in a hospital (not as a patient, but as a health care worker), you're probably thinking about the Code Blue team as the perfect example of this kind of team.

For those of you who don't work in health care, a "Code Blue" is called when a patient has an emergency event, such as a cardiac arrest or breathing difficulty.  Most, if not all, hospitals have a team of health care professionals that respond to these events, called either "Code Blue Teams" or "Code Teams".  The roles and responsibilities are frequently decided in advance, though unfortunately this is not always the case.  Thankfully, "Code Blue" events are relatively rare in the hospital setting, so the members of these teams have other patient care responsibilities.  When a "Code Blue" is called, the members of the code team stop their normal duties and responsibilities and proceed quickly to the location in the hospital that is experiencing the event.  If roles and responsibilities have not been decided in advance, the code team quickly forms and the code team leader immediately assigns the different responsibilities (performing chest compressions, drawing up and administering medications, documenting the actions performed, etc).  Once the emergency is over, the members of the code team return to their normal duties.

As you can imagine, one of the most important responsibilities for the leader of the code team is communication and coordination with the other members of the group (see one of my favorite articles on this topic, "Leadership of resuscitation: Lighthouse Leadership" published in 1999 in the journal Resuscitation).  The same is true really for any swift action team.  Experts in this area speak to the importance of closed loop communication, using a shared mental model, briefs, huddles, and debriefs.  One aspect of closed loop communication that I've personally found to be important involves assigning accountability and authority.  It involves the "who" and "what" of closed loop communication and avoiding confusion as much as possible.  

Imagine the following scenario.  A code team has responded to an event.  Upon arrival, the senior physician immediately takes charge and assumes responsibility for leading the rest of the team.  The leader is working through the problem and suddenly looks up, "Will someone please draw a blood gas?"  Who is the team leader referring to?  Is there someone on the team named "Will Someone" perhaps?

Of course, I am being a bit cheeky.  There is likely nobody on the code team who has the name, "Will Someone."  But in the absence of clear, targeted, and direct communication towards a specific individual, who is going to assume responsibility for drawing the blood gas?  The likely result is that no one will do so, and in about five minutes the team leader is going to start asking for the results of a blood test that no one drew.

What should the team leader have done instead?  A more effective approach would have been to point directly at one specific individual, hopefully use that individual's real name, and say, "John Doe, will you please draw a blood gas?" (of course, John Doe is a fictitious person here).  

Specific, direct, and targeted communication avoids the confusion associated with trying to figure out which person on the team is named "Will Someone"!  Assigning clear authority and accountability during a code event (or in any situation involving a swift action team) is always a good leadership practice!  We'll talk more about some of these leadership practices in the next few posts, as collectively they comprise some of the best leadership practices of high reliability organizations.