Potatoes, Pirates, and Leap Years

Today is February 29th, which only occurs once every four years!  Of course, when I think of February 29th, I think of the Gilbert and Sullivan opera "The Pirates of Penzance" (not really, but maybe I should!).  At the beginning of the opera, the character Frederic believes that he is going to be released from his pirate apprenticeship, since he has reached his 21st birthday.  Unfortunately for Frederic, he learns that he was born on February 29th ("Leap Day"), and so he technically has had only five birthdays and is therefore still bound to the Pirate King as his apprentice.  Frederic's dilemma (which is described in the song, "Paradox") is an example of what is called a veridical paradox, i.e. one where the result is absurd but nevertheless true.  There's another well-known example of a veridical paradox called the "Potato Paradox".  If you look this paradox up on the Internet, you will find a reference to the 2015 movie "The Martian", starring Matt Damon.

I don't think that the "Potato Paradox" actually came up in "The Martian" (or the book by Andy Weir on which the movie was based), but it certainly seems like it could have been mentioned.  If you've read the book, watched the movie, or both, you will remember that Mark Watney grows potatoes to try to survive until his rescue from Mars (he actually uses his own feces as fertilizer).  In one memorable line, Watney says, "They say once you grow crops somewhere you officially colonized it.  So technically, I colonized Mars.  In your face Neil Armstrong!"

So, what exactly is the "Potato Paradox"?  It goes something like this:

Mark grows 100 kg of potatoes, which consist of 99% water. He then leaves them outside overnight so that they consist of 98% water. What is their new weight?

The answer may surprise you - it's 50 kg!  Allow me to explain.  If the potatoes are 99% water, that means that their dry mass is 1%.  In other words, 100 kg of potatoes contains 1 kg dry mass, which does not change.  In order for the potatoes to change to 98% water, the dry mass has to equal 2% of the overall weight of the potatoes.  If the dry mass cannot change, it has to follow that the total mass of the potatoes has to decrease.  Since the proportion of dry mass has doubled, the total mass must be halved to 50 kg!

The American philosopher and logician W.V.O. Quine distinguished between three different classes of paradoxes - the aforementioned veridical paradox, the falsidical paradox, and the antimony.  As I mentioned above, the "The Pirates of Penzance" paradox and the "Potato Paradox"  are two examples of a veridical paradox, i.e. one where the result is absurd but nevertheless true.  The Monty Hall problem, Arrow's impossibility theorem, and the birthday problem are other examples of a veridical paradox, all of which I've posted about in the past.

A falsidical paradox is one that not only appears to be false but actually is false.  Zeno's paradoxes are classic examples here.  Recall the race between Achilles and a tortoise - "In a race, the quickest runner can never overtake the slowest, since the pursuer must first reach the point whence the pursued started, so that the slower must always hold a lead."  As the story goes, Zeno imagined that the Greek hero, Achilles was challenged to a footrace by a tortoise.  Achilles was a gracious and fair fellow, so he gave the tortoise a head start of 100 paces.  If both Achilles and the tortoise start at exactly the same time ("On your mark, get set, go!"), and if both Achilles and the tortoise run at constant speeds (Achilles being very fast and the tortoise being very slow), then after a finite period of time, Achilles will reach the point where the tortoise started (100 paces away).  Importantly, the tortoise will no longer be there!  He has moved, albeit slowly, to a new place, just a little farther away.  Now, it will take Achilles a finite period of time to cover the new distance that separates him from the tortoise, and he will eventually reach where the tortoise was after the race started.  Again, the tortoise will not be there, as he has moved to a new position, just a little farther away.  In this manner, whenever Achilles arrives at the point where the tortoise has been, he will still have some distance to go before he can reach the tortoise.

An antimony cannot be classified as either veridical or falsidical and reaches a self-contradictory result by applying properly accepted methods of logic and reasoning.  I'll talk about the classic Liar's paradox, one famous antimony, next time.  But for now, Happy Leap Day! 

Math-loving People Person

As I've stated many times, I am married to a genuine math whiz!  Everyone in our family knows it - whenever our kids had trouble with math homework growing up, they always went to their mother!  She also happens to be a middle school math teacher, and occasionally she will have me take her tests or answer some of her homework questions, in order to "test them out" so to speak.  Based on my success on these questions, I suppose that I could still pass middle school math, but only just so! 

Just the other night, she asked me a question that involved aysymptotes and growth curves (specifically, could a growth curve actually "grow" more negative).  I questioned her answer, but of course, she was right and I was wrong.  I had suggested that what is true from a purely mathematical standpoint may not be as relevant in the real-world.  She countered with the example of an organization that starts out in debt, which continues to worsen over time (i.e. "growing debt").  I guess that I still have some things to learn (or relearn)!  And I admit that I've gone back to re-learn some of the things I learned in high school algebra and geometry!

Many experts are pointing out that mathematical literacy is becoming increasingly more important in the Information Age.  The U.S. Department of Labor stated that math-related careers will grow at four times the rate of other jobs over the course of the next decade.   A recent study by David Deming at Harvard University concluded that mathematics will be one of the most in demand skills for the future workforce, with jobs that require math skills growing the fastest.  Just as important, however, as both the graphic below demonstrates and an article ("It's never been more lucrative to be a math-loving people person") in Harvard Business Review suggests, math skills are insufficient on their own.  Social skills (often called "soft skills" in leadership) are equally as important.

Catherine Weinberger, a professor at University of California Santa Barbara published the results of a study in the journal The Review of Economics and Statistics ("The Increasing Complementarity between Cognitive and Social Skills") a few years ago.  Professor Weinberger investigated what skills and experiences learned in high school most predicted income-earning potential in adulthood.  She found that the return on being good at math has significantly increased over the last few decades (hooray for math!).  She also found that the return on having leadership and interpersonal skills (learned and developed through participation in extramural activities such as sports, clubs, service organizations, and the arts, for example) has also increased.  Most importantly, however, is the fact that having both math skills and social skills resulted in the highest adult incomes.  Professor Weinberger suggests that, "Just making students sit down and learn math and try to get their test scores up isn’t enough. Giving up recess to focus on math skills might not be the best investment in our future workforce."

In other words, "EQ" (emotional intelligence) may be just as important as "IQ" (here, referring specifically to math intelligence).  I am pretty sure that my wife would agree that "It's never been more important to be a math-loving people person."  I will continue to post about the "soft skills" of leadership, but I hope that you will indulge me as I write about some of the more interesting things I've learned about math in future posts!

"You must unlearn what you have learned..."

There's a famous scene in the 1980 film "The Empire Strikes Back" (perhaps the greatest movie sequel in the history of cinema), where the great Jedi Master Yoda is trying to convince Luke Skywalker that he can use the Force to lift his X-wing fighter out of the swamp on the planet Dagobah.  Luke counters that using the Force to lift small stones, as he has been doing (here's the entire scene), is different from trying to lift something as heavy as a spaceship.  Yoga then says the classic line, "No. No different.  Only in your mind.  You must unlearn what you have learned."

Yoda was right (that's why he was a Jedi Master).  I've commented a number of times in previous posts that change is not easy.  Change is difficult for everyone.  Leading through change is even more difficult.  As I mentioned in a recent post, change is the law of leadership.  Just take a look at how different experts have labeled the pervasive resistance to change in most organizations - "fossilized as the status quo", "cognitive rigidity", and "organizational constipator" are two of my favorites.  There are just as many metaphors used to describe the process of leading and navigating an organization through change - consider Kurt Lewin's three-step change model of unfreeze-change-refreeze (note that the unfreezing stage mostly deals with "overcoming organizational inertia and dismantling the existing mindset") or even John Kotter's 8-step change model that leverages the "burning platform". 

As organizations focus on High Reliability Organization (HRO) principles, fostering a culture of continuous improvement, and becoming a so-called "learning organization", they would do well to remember that "learning" doesn't occur unless there is "unlearning".  Some would even argue that learning is "only half the process...the other half is unlearning".  Gary Klein (see his book, Streetlights and Shadows: Searching for the Keys to Adaptive Decisionmaking) uses a metaphor of "shedding a snakeskin" - as we outgrow our existing mental models, we need to shed them to develop new ways of thinking.  The ancient Chinese philosopher Lao Tzu said, "To attain knowledge, add things every day. To attain wisdom, subtract things every day."

It would be extremely naive to assume that "unlearning" is a simple and straightforward process (see all of my comments above about resistance to change).  There are (at least) three types of "unlearning" - "routine unlearning" (also known as "fading"), "accelerated and direct unlearning" (also known as "wiping"), and "deep unlearning" (also known as "shock and rupture").  Occasionally, simple habits fade away over time as we learn and develop new habits.  With repetition and reinforcement, these new habits become sustained over time, and we forget (see the famous Ebbinghaus forgetting curve) the old habits, which fade with lack of use.  This "routine unlearning" or "fading" typically occurs slowly over time with habits that are often subconscious and with very little emotional impact on individuals ("old ways of doing things recede, prior expectations fade, discomfort is reduced, and forgetting takes place").  

"Directed unlearning" or "wiping" requires a conscious, deliberate action by individuals to change how they think and act.  "Directed unlearning" is usually triggered by an imposed change event and typically occurs more slowly over time.  Moreover, the emotional impact is more variable than in "routine unlearning" but is still typically not significant.  Here, in order to change, individuals have to "wipe out" past learning.

"Deep learning" often entails a radical break with the past.  It is usually triggered by a sudden, unexpected, and often unpleasant event that forces a change in habit or behavior.  Rather than slowly moving down the Ebbinghaus forgetting curve, "deep learning" results in "dropping off a cliff".  In order to change, individuals usually have to confront deeply held convictions, assumptions, and beliefs, and as a result, the emotional impact of this kind of unlearning is significant - "the process shocks, hurts, and threatens; it challenges ingrained cognitions and behaviors, and it triggers grieving."

The process of unlearning has three parts.  First, we have to recognize that the old mental models are no longer relevant or useful (here is where Kotter's "burning platform" can help).  Here, we have to be open to being vulnerable, willing to listen, and capable of considering new ideas.  Second, we need to find or create a new mental model that can better serve the goals of the organization.  Here, leaders can use data to help inform and drive the learning and change.  In addition, leaders absolutely have to create psychological safety and be willing to tolerate failure as the new mental models take effect.  Third, we need to ingrain these new mental models through repetition, reinforcement, and practice.  

For a really interesting take on the concept of "unlearning" and "learning", check out the following video on TEDEd ("The Backwards Brain Bicycle").  After a group of welders altered a bicycle (they changed the steering mechanism so that when you turned the handlebars to the left, the wheel would turn to the right, and vice versa), engineer Destin Sandlin found out that he could no longer ride a bicycle.  However, with time, he "unlearned" the old way of riding a normal bicycle and learned to ride the backwards one!

Just to finish out the story from "The Empire Strikes Back" - Yoda proves his point to Luke Skywalker and uses the Force to lift the X-wing fighter out of the swamp.  Luke exclaims in surprise, "I don't believe it", to which Yoda responds, "That is why you fail."

May you lead in interesting times...

Today marks the four year anniversary at my current organization.  As I reflect on my time here, I can't help but think about everything that our organization has been through and what we continue to go through.  Starting at a new organization and moving to a new city right at the start of the COVID-19 pandemic wasn't easy, but I can't think of a better or faster way of learning about an organization than during a time of crisis.  John F. Kennedy gave a speech at the Convocation of the United Negro College Fund in Indianapolis, Indiana on April 12, 1959.  Just a few minutes into his speech, he famously said, "When written in Chinese, the word "crisis" is composed of two characters – one represents danger and one represents opportunity."  Even if what JFK said wasn't technically true, I do see his point.  Crises often present organizations with opportunities to change - hopefully for the better.  As Winston Churchill said (many times apparently), "Never let a good crisis go to waste."

If I were to be completely honest though, COVID-19 was a different kind of crisis.  Most crises are time-limited.  It is true that they come on suddenly and unexpectedly.  I have previously talked about the different stages of a disaster, as proposed by Barry Turner in his book Man-made Disasters (see "The Failure of Foresight").  The last stage, after "Rescue and Salvage" is "Full Cultural Readjustment," which marks the time in which organizations conduct a thorough analysis of the what's, why's, and how's of the crisis and implement changes to prevent or better respond to the next one.  Unfortunately, there really hasn't been a "Full Cultural Readjustment" period, at least for health care organizations, following COVID-19.  Our recovery has been slow, and many would argue that we are not even close to fully recovering.  With this in mind, I've found two articles to be extremely interesting and timely.  Amy Edmondson, who is perhaps best known for her groundbreaking work on psychological safety, and Michaela Kerrissey wrote an excellent article in Harvard Business Review called "Leading Through A Sustained Crisis Requires a Different Approach".  Ronald Heifetz, Alexander Grashow, and Marty Linsky (also in Harvard Business Review) wrote the second article (which is an older, pre-COVID era but equally inciteful article), "Leadership in a (Permanent) Crisis".  Both articles emphasize that leading during a sustained crisis (as opposed to the typical crisis that is relatively short-lived that Turner describes in his book).

Edmondson and Kerrissey emphasize that "In a sustained crisis, problems are more ambiguous and tradeoffs less clear.  The galvanizing moment is gone.  Reserves have been depleted."  They go on to say, "What works for a sudden crisis won't work for a sustained crisis.  In the latter, instead of fast reactivity, leaders must practice intentional proactivity...In a sustained crisis, what's needed is wide-scale experimentation and local decision-making to engage people in a broad range of priorities, to find new solutions in a decentralized way that energizes.  There is a greater emphasis on pausing to learn, explore, and experiment rather than simply act and act fast."

Heifetz and colleagues also talk about what they call "adaptive leadership" and write, "The organizational adaptability required to meet a relentless succession of challenges is beyond anyone's current expertise.  No one in a position of authority - none of us, in fact - has been here before.  An organization that depends solely on its senior managers to deal with the challenges risks failure."  They suggest that adaptive leadership really requires a change in mindset and new leadership practices:

1. Foster adaptation

Leaders must "develop next practices while excelling at today's best practices."  Unfortunately, adaptation requires members within the organization to "confront loyalty to legacy practices" and move past the mindset that what got us to here, won't get us to there (my words, not theirs).  Similar to Edmondson and Kerrissey, they emphasize the need for experimentation anf agility.  

2. Embrace disequilibrium

Heifetz and colleagues write that "the art of leadership in today's world involves orchestrating the inevitable conflict, chaos, and confusion of change so taht the disturbance is productive rather than destructive."  I've mentioned in previous posts (see, for example, "Connecting the dots...") that complex adaptive systems thrive at the edge of chaos!  Innovation and change involve discomfort and courage.

3. Generate leadership

Leadership at the edge of chaos requires what Heifetz and colleagues call "distributed leadership responsibility" (and what I have referred to in previous posts as networked leadership - see, for example "Today's color is Teal" and "Tame the Chaos").  Edmondson and Kerrissey call this "widening the aperture" and recommend flattening the organization and rejected the top-down command that is better suited to a short-term crisis.  

Someone once said, "May you live in interesting times."  Legend has it that this was actually an ancient Chinese curse, which is probably not entirely true.  However, Robert F. Kennedy used the phrase in his "Day of Affirmation Address" in Cape Town, South Africa on June 6, 1966 (an incredible read by the way!):

There is a Chinese curse which says, “May he live in interesting times.” Like it or not, we live in interesting times. They are times of danger and uncertainty; but they are also the most creative of any time in the history of mankind.

I think that when Kennedy used the word interesting, he really meant challenging.  If that is indeed the case, we certainly do live in interesting times.  I've been saying for a while that these are the times when we need leadership the most.  When I think about the difficult times that we've all been through these past couple of years, I can't help but think of Vice Admiral James Stockdale who wrote about his time for almost 8 years as a prisoner-of-war (POW) during the Vietnam War.  Stockdale was tortured over 20 times during his imprisonment and was later awarded the Congressional Medal of Honor.  When asked to reflect on that time and how he was able to keep going,  Stockdale responded, "I never lost faith in the end of the story, I never doubted not only that I would get out, but also that I would prevail in the end and turn the experience into the defining event of my life, which, in retrospect, I would not trade."  He would call his time as a POW the defining event in his life - a moment that he would not trade!  Those eight years were when Stockdale's leadership was challenged the most, but if you read his Congressional Medal of Honor citation you will see that time was when his leadership was at its best. 

Finally, I can't talk about crisis leadership without mentioning the concentration camp survivor, psychologist, and author Viktor Frankl, who reflected on his years at a concentration camp in his superb book Man's Search for Meaning.  Frankl said, "Life is never made unbearable by circumstances, but only by lack of meaning and purpose."  With meaning and purpose, we can do great things.  And leaders were born for times such as this one.  Rather than a curse, I see a blessing: May we all live and lead in interesting times. 

A Window to Man's Soul

I have never really fully understood art (see my post "There's no place like home..." for one anecdote about a family trip to a museum of modern art).  It was usually my worst and least favorite subject in grade school (Art always competed closely with Penmanship for that distinction).  However, I am starting to learn to appreciate it more as I grow older.  I think I've finally figured out that it's not necessarily about how other people see, appreciate, and interpret the artist's meanings - it's about how I personally see, appreciate, and interpret it.  I think most artists would agree.  The French Impressionist artist Edgar Degas said, "Art is not what you see, but what you make others see."

Art also provides a view of society itself.  I think he was talking about all different forms of art, but the British comedian, actor, and playwright Ben Elton said, "Artists don't create society, they reflect it."  I had this exact point in mind when I first read about something called "performance art" and one if its artists, Marina Abramović.  Abramović famously did a six-hour work / performance which she called "Rhythm 0" in Naples in 1974.  The work involved Abramović standing motionless and without speaking while the audience was instructed to do whatever they wished, using one of 72 objects (which included a rose, feather, perfume, honey, bread, grapes, wine, scissors, a scalpel, nails, a metal bar, a gun, and a bullet) that she had placed on a table.  Her instructions (posted on the table) were simple:

Instructions:

There are 72 objects on the table that one can use on me as desired.

Performance.

I am the object...

During this period I take full responsibility.

Duration: 6 hours (8 pm – 2 am).

Abramović said that her purpose for the work was to determine how far the public would go: "What is the public about and what are they going to do in this kind of situation?"

At first, the audience members were gentle.  For example, someone gave her a kiss.  Another gave her the rose.  However, things deteriorated fairly quickly, and the performance became quite dangerous for Abramović.  Art critic Thomas McEvilley witnessed the performance and said:

It began tamely. Someone turned her around. Someone thrust her arms into the air. Someone touched her somewhat intimately. The Neapolitan night began to heat up. In the third hour all her clothes were cut from her with razor sharp blades. In the fourth hour the same blades began to explore her skin. Her throat was slashed so someone could suck her blood. Various minor sexual assaults were carried out on her body. She was so committed to the piece that she would not have resisted rape or murder. Faced with her abdication of will, with its implied collapse of human psychology, a protective group began to define itself in the audience. When a loaded gun was thrust to Marina's head and her own finger was being worked around the trigger, a fight broke out between the audience factions.

Abramović described the event afterwards, stating, "What I learned was that ... if you leave it up to the audience, they can kill you ... I felt really violated: they cut up my clothes, stuck rose thorns in my stomach, one person aimed the gun at my head, and another took it away. It created an aggressive atmosphere. After exactly 6 hours, as planned, I stood up and started walking toward the audience. Everyone ran away, to escape an actual confrontation."

When I first read about this "work of art", I immediately thought of Stanley Milgram's experiment from the early 1960's (not his famous "small world experiment" which I described in "Six degrees of Kevin Bacon" and "It's a small world after all...").  You've probably heard of this experiment too.  Study participants ("teachers") were told that they were helping to conduct an experiment, in which they had to administer electric shocks to the "learners" (who were actually investigators in the study) based on their ability to learn a task.  Each participant was given a set of instructions by another investigator, who was dressed in a white lab coat ("authority figure").  The teachers were instructed to administer varying levels of electric shock every time that the "learners" answered incorrectly (note that no shocks were actually delivered).  If the "teachers" asked to halt the experiment (the "learners" acted like they were in pain each time a shock was delivered, and at times they would plead with the "teacher" to stop hurting them), the investigator would instruct them to continue.  Surprisingly, more than half of the "teachers" continued to administer electric shocks, even up to what would normally be a lethal dose!

Milgram published his results in a paper entitled "The Perils of Obedience" in Harper's Magazine.  He wrote:

The legal and philosophic aspects of obedience are of enormous importance, but they say very little about how most people behave in concrete situations. I set up a simple experiment at Yale University to test how much pain an ordinary citizen would inflict on another person simply because he was ordered to by an experimental scientist. Stark authority was pitted against the subjects' [participants'] strongest moral imperatives against hurting others, and, with the subjects' [participants'] ears ringing with the screams of the victims, authority won more often than not. The extreme willingness of adults to go to almost any lengths on the command of an authority constitutes the chief finding of the study and the fact most urgently demanding explanation. Ordinary people, simply doing their jobs, and without any particular hostility on their part, can become agents in a terrible destructive process. Moreover, even when the destructive effects of their work become patently clear, and they are asked to carry out actions incompatible with fundamental standards of morality, relatively few people have the resources needed to resist authority.

The following statement is poignant, particularly in view of "Rhythm 0": "Ordinary people, simply doing their jobs, and without any particular hostility on their part, can become agents in a terrible destructive process."  I am also reminded of the famous "Stanford prison experiment" conducted by Philip Zimbardo in 1971, as well as the "Blue Eyes/Brown Eyes" experiment conducted by Jane Elliott, which was the subject of a 1970 PBS documentary "The Eye of the Storm".  All of these experiments have a lot to say (none of it positive) about group behavior and provide some insight into what has come to be known as "mob mentality".

I have a couple of important observations.  First, without question, there's no way that any research body would approve conducting the Milgram experiment, the Stanford prison experiment, or the "Blue Eyes/Brown Eyes" experiment today.  Second, given that all of these experiments, as well as the "Rhythm 0" art performance, occurred in the 1970's, it's tempting to speculate that society was different during the 1970's.  While that is absolutely true, I would argue that, if anything, societal norms have changed for the worse.  I actually shudder to think what would have happened if Marina Abramović had delivered her performance today.  Her performance is still written about today (see "Rhythm 0: A Scandalous Performance" and "Marina Abramović’s shocking Rhythm 0 performance shows why we still cannot trust people in power" both written in the past couple of years").

Lady Bird Johnson said, "Art is the window to man's soul.  Without it, he would never be able to see beyond his immediate world; nor could the world see the man within."  I would also suggest that art is a window to society's soul.  

The “Nelson Touch”

The management guru Peter Drucker reportedly once said, "Culture eats strategy for lunch."  I won't disagree with one of the leading authorities on management science, and in my experience, I've usually found this statement to be true.  However, I would also say that it's hard to completely separate strategy from culture, as organizations with the "right culture" usually have the "right strategy" and vice versa.  As Boris Groysberg, Jeremiah Lee, Jesse Price, and J. Yo-Jud Cheng write in a Harvard Business Review article (see "The Leader's Guide to Corporate Culture"), "strategy and culture are among the primary levers" for leaders.  Strategy helps provide a roadmap about how an organization will achieve its overarching goals.  It's hard to accomplish anything in the absence of a guiding vision and set of priorities to help guide where an organization allocates its resources.  Culture, however, is perhaps less tangible and encompasses the organization's values, beliefs, assumptions, and norms.  As Groysberg and his colleagues suggest (and I couldn't agree more), culture is "a more elusive lever, because much of it is anchored in unspoken behaviors, mindsets, and social patterns."  

With this framework in mind, I want to talk about the Battle of Trafalgar, a naval engagement that occurred on October 21, 1805 and which resulted in an overwhelming victory for the British Royal Navy over the combined fleets of France and Spain (see the excellent article, "Why Trafalgar was won before it was fought: Lessons from resource-based theory" by Charles Pringle and Mark Kroll published in the Academy of Management Executive journal in 1997).  Pringle and Kroll suggest that Vice-Admiral Horatio Nelson, 1st Viscount Nelson, generally regarded as the greatest officer in the history of the British Royal Navy possessed the superior advantages of leadership, strategy, and culture that more or less made the victory at Trafalgar a foregone conclusion.

By the time of the Battle of Trafalgar, Napoleon Bonaparte dominated Europe, but he needed to conquer England in order to become the true master of Europe and the Mediterranean.  Napoleon knew that he would have to invade England, but in order to do that, he would first have to defeat the Royal Navy.  The British Royal Navy had achieved what many before had not thought possible, a string of major victories over Napoleon's navy (Napoleon himself would say in 1815, "In all my plans I have always been thwarted by the British Fleet").  He had assembled a combined French-Spanish fleet, which was unfortunately bottled up in the Spanish port of Cadiz, near Cape Trafalgar (which is near the entrance to the Mediterranean Sea).  Thirty-three ships (and 30,000 men) under the command of French Vice Admiral Pierre Charles de Villeneuve sailed from Cadiz on October 18, 1805.  Two days later, they were intercepted by the British fleet of 27 ships (and 17,000 men) under the command of Nelson.  

Villeneuve formed his ships into a single line of battle, which was the tactic at that time.  Nelson, however, did something completely different.  He ordered his ships into two groups, which cut through the French-Spanish line at a right angle.  This unconventional tactic surprised the French-Spanish fleet, creating confusion and giving the advantage to the British.  Within a few hours, the Royal Navy had destroyed or captured eighteen of Villeneuve's ships without losing a single ship.  They seized thousands of prisoners, including Villeneuve himself.  It was an overwhelming victory for the British, who only suffered 1,500 casualties (unfortunately, one of those casualties was Lord Nelson, who was shot and killed by a French sniper).

Let's look at what Pringle and Kroll have to say about the battle.  As a reminder, they believe that the British victory was all but a foregone conclusion, primarily due superior leadership (Nelson), strategy, and culture.  The first key factor was, of course, Nelson.  He was an inspirational leader, a brilliant strategist, and and unconventional tactician.  Pringle and Kroll write, "Two hundred years after the Battle of Trafalgar, Nelson is still regarded as one of the most ingenious battle strategists and effective field commanders in naval history."  Villeneuve was outmatched in every way, and he knew it.  Nelson also believed in decentralized authority and responsibility (an early proponent of the High Reliability Organization principle of "Deference to Expertise"?).  Particularly in the heat of battle, Nelson would say that "England expects that every man will do his duty" and "...in case signals can neither be seen or perfectly understood, no captain can do very wrong if he places his ship alongside that of the enemy."

The second key factor that separated the British from the French was England's seafaring heritage.  Napoleon himself recognized that "one could not be a good seaman unless one was brought up to it from the cradle."  England was and always has been an island nation with a proud seafaring heritage.  Sea trade was vital to the economy, and the best way to protect that trade was to control the sea lanes.  The British Royal Navy was the most powerful navy in the world at that time.  Just as important, though England had a smaller population compared to France, it had three times as many merchant ships as the French.  All of this created a steady supply of trained, experienced sailors.  In addition, going to sea was one of the few opportunities to advance in society, which helped create a continuous supply of experienced officers as well.  Promotions were based largely upon merit, so leaders like Nelson rose through the ranks because of their knowledge, abilities, and skills.

The third key factor was the winning tradition of the British Royal Navy.  The Royal Navy had already won 8 major sea battles over the French, three of which were led by Nelson.  They had never lost a battle, and they expected to win (whereas the French and Spanish did not).  They shared a common goal (defending England, their home) and a common culture.  In contrast, the Spanish were reluctant allies at best and expected to be sold out by the French.  The Spanish Admiral had already asked to be relieved of command prior to the battle, and Villeneuve himself had been previously defeated by Nelson at the Battle of the Nile in 1798.

Pringle and Kroll believe that if the Battle of Trafalgar had been fought five times, the British would have won five times.  It was that one-sided of a victory!  They state, "The Royal Navy's success was based on its ability to convey understanding of its mission and goals to its members, to socialize them into the navy's culture, to train them how to perform their jobs, and then to empower them to make their own decisions within broad policy guidlines."  Here, once again, Pringle and Kroll emphasize the importance of culture.  But they also emphasize the importance of "Deference to Expertise" and write, "When an organization - or ship - is in a rapidly changing environment, it is essential that members who are on the scene be able to make their own decisions."  I could not have said it better myself.

There are a number of important takeaways here for organizations today.  Here is a blueprint for how to build a culture that eats strategy for lunch (some of which come directly from Pringle and Kroll's article and some of which I added, based on my interpretation of their article):

1. Understand and accentuate the organization's heritage.

Heritage is an important part of organizational culture.  As Pringle and Kroll write, "Heroes, stories, legends, rituals, and symbols are important elements of any organization's tradition.  They inspire not only the organization's members, but also those who seek to join."  However, there is one important consideration that absolutely should be kept in mind as well (see next point below).

2.  Cultivate a strong culture - but one that embraces change.

Organizations should build upon their heritage and cultural traditions, yet at the same time, they should be willing to embrace change, when necessary (see my posts "The need for change is not an indictment of the past", "Culture eats strategy", "Reverence versus Respect", and  "Holiday Traditions").  Building on the comments above, Pringle and Kroll write, "Accentuating heritage does not mean saying, 'this is the way we have always done it, and we have been successful, so why should we change?'  Pride in an organization's past accomplishments can be instilled while simultaneously embracing change through a deliberate, ongoing, and widespread socialization process."  The onboarding process is a great time to socialize cultural heritage!

3.  "Defer to Expertise."

There is simply no way that a leader can be involved in every single decision throughout an organization.  Leaders should establish guardrails, based upon the overall mission, vision, and key priorities (i.e. the strategy) of the organization.  Within these guardrails, frontline leaders should have full authority, responsibility, and accountability for making decisions on their own (see also the related concepts of "commander's intent and "Auftragstaktik").

4. "Leaders must lead." 

Leaders should follow Nelson's example and lead by example.  Nelson's ship, the HMS Victory, was the first ship in the fight.  One of my mentors used to say that, "As a leader, I won't ask anyone to do something that I am not willing to do myself."  Albert Schweitzer said, "The three most important ways to lead people are...by example, by example, by example."  Eleanor Roosevelt said, "Example is the best lesson there is..."  You get the idea.  Leaders lead.

5. "The more we sweat in training, the less they bleed in war!" 

I first heard this when I was on active duty in the U.S. Navy.  Basically, this means that organizations should invest in training.  The return on investment is immeasurable.  

"The Day the Ravens Left the Tower"

Several years ago, I had the opportunity to speak at a one of the Risky Business conferences, which were a series of conferences whose sole purpose was to share experiences and ideas from different high-risk industries, all with the goal of improving safety and outcomes in the health care industry.  The conferences were started by two pediatric critical care specialists named Allan Goldman and Peter Laussen and a British Airways pilot named Guy Hirst.  Many of these conferences were held in London, England.  Unfortunately, I don't think that they've had a conference since the COVID-19 pandemic.  Regardless, I would have to say that attending this conference was truly one of the highlights of my career, at least up to that point.  I've posted a couple of times about the conference (see "Risky Business" and "Fallor, ergo sum"), which obviously made a big impression on me.  

As one of the invited speakers (actually I was an invited speaker at a joint pediatric patient safety conference held at the same time), I was invited to attend the Ceremony of the Keys at the Tower of London.  Every night for the past several centuries, the Chief Yeoman Warder of the Queen's Royal Guard by soldiers as he locks up the fortress.  It was simply amazing!  The members of the Queen's Royal Guard (the legendary Beefeaters) also gave us a tour, and we were introduced to the famous Tower ravens.  Legend has it that "if the Tower of London ravens are lost or fly away, the Crown will fall and Britain with it" (the legend is the subject of an awesome song from the 1980's "The Day The Ravens Left The Tower" by The Alarm).  As you can imagine, the ravens are very well-cared for!

I don't know about the legend, but there is also a famous paradox that involves ravens, called simply the "raven paradox".  The German philosopher Carl Hempel first discussed this paradox in a 1965 essay entitled "Studies in the Logic of Confirmation".  The paradox has to do with inductive reasoning (see my post on induction versus deduction, "Elementary, my dear Watson" for more).  Remember, induction moves from the specific to the general, while deduction moves from the general to the specific (syllogisms, introduced in my last post, are examples of deduction).  

Suppose you see a raven (maybe at the Tower of London) and note that it is black.  You then see another raven, maybe in a different location or perhaps in the same location on a different day.  Again, you note that these ravens are black too.  After seeing several ravens and noting that all of them are black, you make the inductive argument, "All ravens are black."  Essentially, you have followed the scientific method by (1) make an observation, (2) form a hypothesis, (3) test the hypothesis, and (4) generate a conclusion.  

Here is where things get interesting (at least to me).  There is another side to this argument.  If you accept the statement that "all ravens are black", then you can logically accept the statement (by induction) that "if an object is a raven, then it is black."  Similarly, you can also logically accept the statement (this is called a contrapositive statement), "If an object isn't black, it's not a raven."  You are essentially following the logic, "If A, then B" is an equivalent statement to "If not B, then not A."

Here's the problem (and the reason why this is called the "raven paradox").  Suppose you now go outside and pick a green apple off the tree in your backyard.  The object in your hand is not black, so it's not a raven.  Well, of course that makes sense, right?  But hold on, I said above that the two statements "If A, then B" and "If not B, then not A" are equivalent.  So, by saying that "the green apple is not black, so it's not a raven" is functionally equivalent to saying that "all ravens are black".  Moreover, it doesn't have to be a green apple (apparently experts in logic like green apples) - it could be a red sports car, the blue sky, the green grass.  Whatever object you see that is not black and therefore not a raven is strengthening your original statement that "all ravens are black."  And therein lies the paradox.  We have actually strengthened our original hypothesis by finding a green apple!

The myriad ways that individuals over the years have attempted to resolve this paradox is even more complicated and confusing, so I think I will just stop here.  My point in all of this is to foster some interest in exploring further the very fascinating (at least in my opinion) discipline of formal logic, which is a topic that I hope to return to in future posts.

Happy Birthday Boss!

No, not that Boss!  Today, February 15th, is Ernest Shackleton's birthday!  Shackleton (whose men called him "Boss") was born on this day in 1874.  He is arguably one of history's most legendary leaders and explorers.  If you are a leader, you should definitely learn more about him!  Fellow Antarctic explorer Raymond Priestley once said, "For scientific discovery give me Scott; for speed and efficiency of travel give me Amundsen; but when disaster strikes and all hope is gone, get down on your knees and pray for Shackleton."

I've mentioned Shackleton several times in the past (see "Now is the time to lead" and "Better a live donkey than a dead lion..." for two of my favorites).  However, in honor of Shackleton's birthday, I will repost one of my first posts on Shackleton and his leadership ("The Last Voyage of the Endurance" from February 26, 2017):

I just finished another really good book about the ill-fated 1914 Antarctic expedition led by Sir Ernest Shackleton (Endurance: Shackleton's Incredible Voyage).  Shackleton led a British crew of 27 other men aboard the ship, "Endurance" (named after the Shackleton family motto, By endurance we conquer) on an expedition whose objective was to be the first land crossing of the continent of Antarctica.  Allegedly, Shackleton selected his crew from more than 5,000 applications in response to an advertisement in the London Times that stated, "Men wanted for hazardous journey.  Low wages, bitter cold, long hours of complete darkness.  Safe return doubtful.  Honour and recognition in event of success."  The plan was to sail across from South Georgia Island across the Weddell Sea to Vahsel Bay, where a smaller group would travel by dogsled across the continent to the Ross Sea, where another ship would be waiting to take them home.  The first part of the expedition went according to plan, but the Endurance was eventually caught in the pack ice.  The ship was crushed and eventually sank, and the rest of the book details how Shackleton led his men to safety nearly 2 years after leaving South Georgia Island (if you want the details - read the book!).

There have been a number of leadership books based upon the Endurance expedition - there is no question that Shackleton's leadership as well as his men's perseverance made the difference between life and death.  It is a wondrous example of the human spirit that all 28 men survived to tell the tale.  One of his men called Shackleton "the greatest leader that ever came on God's earth, bar none."  Someone else said, "For scientific leadership, give me Scott; for swift and efficient travel, Amundsen; but when you are in a hopeless situation, when there seems no way out, get down on your knees and pray for Shackleton."

What was it about Sir Ernest Shackleton that made him such a great leader?  In one word - steadfastness.  Shackleton was focused on one simple goal - getting his men safely home.  He remained optimistic, even when there was no reason to be so.  He said, "If you're a leader, a fellow that other fellows look to, you've got to keep going."  "Difficulties are just things to overcome, after all."  And finally, "Optimism is true moral courage." 

Randy Pausch, the MIT professor who gave "The Last Lecture" while suffering from terminal pancreatic cancer (he later wrote an inspirational book of the same name) said, "Complaining does not work as a strategy.  We all have finite time and energy.  Any time we spend whining is unlikely to help us achieve our goals.  And it won't make us happier."

Shackleton understood this too.  When you are spending day after day floating on an ice floe in the middle of the Weddell Sea, trying to survive on nothing but seal meat cooked using blubber on a stove during the long, dark night of the Antarctic winter, time may be unlimited, but energy is not.  The less time spent on complaining, the more energy was left to do things that truly mattered - like surviving.  Tenacity.  Perseverance.  Indefatigable will.  These are the characteristics that led Shackleton's crew all the way to home.

While we as leaders may never spend time eating seal meat on an ice floe in the Weddell Sea, the story of the last voyage of the Endurance provides us with an important lesson.  Difficulties and setbacks are truly "just things to overcome, after all."  Keep your eyes pointing forward to the goal and never waver.  Trust in yourself and your team - and lead the way home.

"The Road Less Traveled"

I've always liked the poem "The Road Less Traveled" by Robert Frost.  It's an easy poem to like, as Frost's message is simple and profound at the same time.  You've probably heard it before - it's the one that ends with:

Two roads diverged in a yellow wood, and I - 

I took the one less traveled by,

And that has made all the difference.

I was thinking of this poem when I reviewed a study published in the journal Management Science by Diswas S. KC, Maryam Kouchaki, Bradley Staats, and Francesca Gino.  I think you will understand why in a moment, but for now, I want to focus on the specifics of the study.

The authors mentioned a quote by the founder of scientific management, Frederick Winslow Taylor, who I've mentioned a couple of times in past quotes (see in particular, "A Response to Medical Taylorism").  It's a curious quote for the topic that they researched (in my opinion, a quote from "The Road Less Traveled" would have been better), though I think I understand their intent:

"In the past the man has been first; in the future the system must be first.  This in no sense, however, implies that great men are not needed.  On the contrary, the first object of any good system must be that of developing first-class men."

They briefly talk about the role of Taylor's scientific management in improving operations, particularly in manufacturing.  However, they also emphasize that the field of operations management, with its traditional focus on inanimate objects (e.g., machines, inventory) has too long neglected the importance of people and process.  I wholeheartedly agree - people and process are incredibly important to the success of an organization, and the health care industry, which is the subject of this particular study, is proof of that concept.  

The authors first discuss what is currently known on this topic.  For example, a previous study found that radiologists typically read and interpret films that they expect to finish quickly first, before moving on to the films that may take longer to read and interpret.  Unfortunately, by doing so they actually spend more time in the long run, taking longer to finish reading through a batch of films than it otherwise should have taken.  

There are three proposed reasons for why individuals choose to do easier tasks first when they encounter high levels of workload.  First, according to something called the "goal gradient hypothesis", our motivation increases as we near the achievement of our goal.  For example, customers at a coffee shop who are given a free coffee card with 2 out of 12 stamps already punched in will fill the rest of their card quicker than those customers who are given a card with no stamps already punched.  Two studies (see "Slow first, fast later" and "The efficiency of slacking off") found that health care providers work faster near the end of their shift.  Second, completing work makes people feel good.  There is something quite satisfying about finishing our "To Do List".  Third, individuals may prioritize the things that they can finish quickly because they believe that it may shorten the overall time it takes to finish all of their work.  

The authors first studied patient flow through a busy metropolitan emergency department over a 2 year period, involving just over 90,000 total patient encounters.  Consistent with prior research, they found that physicians are more likely to pick up easier patients (as opposed to a difficult one) when their workload is higher.  In other words, when the emergency department is busy, providers will choose to see the easiest patients first (assuming patients have been triaged appropriately - emergency departments always prioritize care of the sickest patients before anyone else).  True to form, these patients had a shorter length of stay in the emergency department, so the individual physicians' short-term productivity actually improved.  However, the long-term productivity (in terms of the total number of patients any one provider can see during her or his shift) actually got worse!  

The authors next conducted a number of laboratory studies (using undergraduate students as study subjects) to help identify the reasons why individuals prioritize easier tasks when they get busier.  They again demonstrated the short-term productivity gain and long-term productivity loss found in the real-world setting of the busy emergency department.  They also found that, in general, as individuals experience higher workloads, they prioritize simple and easy tasks because it gives them a sense of goal achievement (call it the "completion high").  

It's great to see a study that uses health care as a model - usually it's the other way around, in that those of us working in health care have to adapt practices studied and proven in other industries.  In addition, the implications of a task prioritization that results in a short-term gain at the expense of a long-term loss is of significant interest, both within and outside the health care industry.  It will be interesting to see additional studies on this topic.  For now then, it seems that taking "the road less traveled" (in this context, choosing to prioritize the more difficult tasks over the simpler ones first) is better in the long-run (remember my post "Eat that frog!").

“See one, Do one, Teach one”

There's a quote that popped up recently in my social media feed that was attributed to the Dutch Post-Impressionist painter Vincent van Gogh: "I am always doing what I can't do yet in order to learn how to do it."  Apparently there is some fairly concrete evidence that he actually said it, though not exactly how it's often quoted.  I love the quote, because it nicely encapsulates the sentiment that you have to step outside of your comfort zone and be comfortable with failure, if you want to learn and grow.

As I mentioned in my "2024 Leadership Reverie Reading List", one of the books that I read over the winter break this year was the new book by Adam Grant, Hidden Potential: The Science of Achieving Greater Things.  Grant makes the point that all of us, not just geniuses and superstars, can achieve great things in life.  What's the secret sauce for maximizing your potential and achieving greatness?  It's being comfortable with discomfort.  As Grant suggests, "The best way to accelerate growth is to embrace, seek, and amplify discomfort."

Grant also suggested that, "People who make major strides are rarely freaks of nature.  They're usually freaks of nurture."  In other words, we all need great teachers, mentors, coaches, and peers to help us grow and reach our fullest potential.  Whenever we try something new, or even after we perform a task that we've done before, we often ask for feedback.  "How did I do?" is a natural response.  Unfortunately, feedback focuses on what we've done in the past.  A study from Harvard Business School (see also the article "Why asking for advice is more effective than asking for feedback" in Harvard Business Review) suggests that it's better to ask for advice, such as "What can I do better next time?"  Most of us also provide fairly vague feedback that is generally positive in nature, while advice is typically more specific and concrete.  What's even more interesting is that we tend to perform better after we give others advice!  Grant calls this the "coach effect" and writes, "Teaching others can build our competence. But it’s coaching others that elevates our confidence."  He cites another study (the senior author was Angela Duckworth, of Grit fame) that found that high school students who were randomly assigned to give motivational advice to their peers went on to earn higher grades themselves.

As it turns out, studies have shown that we learn more from our peers than we do from the so-called experts!  A lot of this probably has to do with something I've posted about before called the curse of expertise.  Experts actually have more difficulty describing and explaining how they do things compared to the non-experts.  For example, college students learn more from their non-tenured professors than they do from the tenured ones.  The best athletes rarely, if ever, make the best coaches.   

I am reminded of the famous "See one, Do one, Teach one" saying that I first learned as a medical student.  The theory is that the best way to learn a new skill is to observe someone else doing it, then actually do it yourself, and then teach it to someone else.  It doesn't actually happen like that, but the concepts are what's important.  Observe.  Do.  Then teach to someone else.  It takes all three, and the peer teaching is possibly the most important!  As Benjamin Franklin reportedly said, "Tell me and I forget.  Teach me and I remember.  Involve me and I learn."  

How to argue like a Greek philosopher

I recently read a book by the Presidential speechwriter Jeff Nussbaum called Undelivered: The Never-Heard Speeches That Would Have Rewritten History (a gift from one of our daughters that has been sitting on my nightstand for a few months - remember tsundoku!).  I really enjoyed it!  Nussbaum collected several speeches through the course of American history that, for one reason or another, were never delivered (for example, Richard Nixon's speech announcing that he was not going to resign as U.S. President or Hillary Clinton's victory speech following the 2016 Presidential election).  These speeches, written but never made, not only tell us a little bit about our past, but they also inform our present.  Nussbaum also provides some insight into the craft of speechwriting.  It's well worth a read!

One of the speechwriting techniques that Nussbaum reveals has its origins in ancient Greek philosophy.  The philosopher Aristotle wrote a text around the 4th century BCE called Rhetoric, which has become the definitive text on the art of rhetoric.  The word "rhetoric" is defined as the art of effective or persuasive speaking or writing, and Aristotle is often credited with developing the art of persuasion or argument.  He writes:

"There are, then, these three means of effecting persuasion.  The man who is to be in command of them must, it is clear, be able (1) to reason logically, (2) to understand human character and goodness in their various forms, and (3) to understand the emotions - that is, to name them and describe them, to know their causes and the way in which they are excited."

These three means of persuasion are commonly referred to as logos, ethos, and pathos.

Logos (logic) is about making a logical or reasoned argument to make a point.  Aristotle suggested that the most effective use of logic is to encourage the audience to reach the conclusion to your argument on their own!  He also recommended using what is called a syllogism, a way of combining two premises and drawing a new conclusion that logically follows from them:

(1) All men are mortal.  (2) Socrates is a man.  Therefore, (3) Socrates is mortal.

An example of an appeal to logos is to use facts, data, or statistics to make an argument (used in a campaign to stop texting and driving): "According to the Federal Highway Commission, 40% of all traffic accidents occur while people are texting while driving."

Ethos (ethics) is about establishing your credibility or authority to speak on the subject at hand.  The speaker or writer should cite authorities or experts on the subject (or provide the credentials that establish that he or she is an expert, so-called first-person authority).  It is the verbal or written equivalent of all the diplomas that physicians hang on their walls in their offices or clinic. 

An example of an appeal to ethos would be (when used to encourage people to spay or neuter their dogs and cats): "My name is Dr. Joe Brown, and I am an veterinarian with over 20 years of experience.  Please spay or neuter your pets."

Pathos (emotion) is about using emotion to sway the audience.  The most important point here is that you have to know your audience beforehand to be able to predict their emotional response.  Speakers and writers use pathos when they try to "tug on the heartstrings" of their audience.

An example of an appeal to pathos would be (when used to encourage people not to litter) would be the famous commercial from 1970 in which a Native American cries when he sees all the trash on the side of a road (see the link here).

Aristotle recommends appealing to all three together.  For example, if your daughter is trying to sell Girl Scout cookies, the best chance of success would be to have her wear her uniform (ethos) and tell prospective buyers:

"You should buy some Girl Scout cookies, because they are really delicious!  I love the Thin Mints!" (logos).  "And besides, you will be supporting us Girl Scouts so that we can go to camp this year and have a really great time!" (pathos).

I've heard about Aristotle's framework before, but I really enjoyed reading about how Jeff Nussbaum used (and still uses) it in his speechwriting.  The framework has certainly stood the test of time!

"Measure What Matters"

I've been thinking a lot about measurement lately.  I recently attended the 2024 Critical Care Congress of the Society of Critical Care Medicine, where I gave a presentation entitled "How to Use ICU Metrics and Financial Data" at the Leadership, Empowerment, and Development (LEAD) Program.  Later during Congress, I participated in a Pro/Con style debate, where I gave a presentation entitled "ICU Metrics Don't Improve Outcomes" (I was the "Con").  Thankfully, both presentations seem well-received.  Here are the main points from both talks:

Most commonly used health care quality metrics actually don't measure the quality of care.  

I've made this point a number of times before in previous posts (see "The cost(s) of quality", "You give to get to give", and "Invest your money wisely..."), and I again referenced an important study published by Dr. Elizabeth Bradley, a health policy researcher and President of Vassar College, who also wrote an excellent book on this subject called The American Health Care Paradox: Why Spending More is Getting Us Less.  Dr. Bradley makes the compelling case that if we truly want to improve health (as measured by the commonly cited quality metrics of life expectancy, infant mortality, maternal mortality, etc), we should be investing our money on improving the social determinants of health.  We often hear that despite spending more than any other country on health care ("care" being defined as what clinicians do for their patients in the clinic or hospital setting), health outcomes in the United States are are among the lowest for developed countries.  Unfortunately, the quality of the American health care delivery system is measured by outcome metrics that are mostly determined by what happens outside the care delivery system (some say as high as 80% of outcome metrics are determined by the social influencers of health).  We are measuring health delivery and not health care delivery.  My point here is that we should use the correct set of metrics that are measuring what we are trying to improve.

Process measures don't always accurately reflect outcomes.

Avedis Donabedian, a physician and one of the founders of the health care quality movement, described what is now called the Donabedian model (see the Figure below).  Donabedian believed that the quality of care can and should be measured using structure, process, and outcome metrics.  Structure refers to all of the factors that describe the context in which care is provided (i.e., physical facilities, staffing models, use of an electronic health record, availability of equipment, etc).  Process refers to how care is provided (i.e., compliance with bundles).  Outcome refers to the end-result of the care that is provided (i.e., length of stay, mortality, etc).

Several years ago, I provided a list of examples of commonly used ICU metrics, breaking them down using both the Donabedian model and the Institute of Medicine's six domains of quality:

The important thing to remember is that there is not always a cause-and-effect relationship between, in particular, process measures and outcome measures.  Health care organizations typically measure process measures, as they are usually more easily measured.  Unfortunately, process measures cannot always be used as a proxy for outcomes.  Ideally, organizations should utilize a portfolio of measures that use all three - structure, process, and outcome.

Goldilocks was right.  

I was visiting a health care organization a few years ago, and my tour guide was very excited to show me their "Improvement Wall".  I walked into a small room and virtually every inch of the four walls were covered with charts and graphs of all the measures that they were tracking.  Rather than being impressed though, I respectfully asked how long it took someone to print these charts and graphs out every week on a regular basis.  The lesson here is that it is easy to get carried away, and by doing so, organizations will get lost in their measures.  The "Goldilocks Principle" applies here - remember, the K in KPI stands for "key" performance measures.  It's easier to "game the system" with too few measures, and too narrow of a focus will create blind spots.  Conversely, too many measures leads to a loss of focus! We should be using a relatively limited set of measures that can be used to drive improvement. Consider what the Institute for Healthcare Improvement's President Emeritus and Senior Fellow and former CMS Administrator (and pediatrician), Don Berwick says about metrics.  Berwick is a HUGE proponent of using data to drive improvement, but he lists "Metrics Glut" as one of his "Seven roadblocks to improving patient safety".  He says, "We need to stop excessive measurement.  I vote for a 50 percent reduction in all metrics currently being used."  

Beware Goodhart's Law.

I've also posted a lot on "Goodhart's Law" (see "Your quality measure is no longer useful...", "Forced ranking - Goodhart's Law redux?", "Tyranny of metrics", and "You manage what you measure") that states, "When a measure becomes a target, it ceases to be a good measure."  The economist, Charles Goodhart, first described the concept in 1975, stating more technically that "Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes."  For example, if you measure productivity (and more importantly, incentivize) in a nail factory based upon the number of nails made, you may find that your factory produces thousands and thousands of very tiny nails that aren't actually useful.  On the other hand, if you base productivity on the total weight of all nails made, you may find that your factory produces a fewer number of large, thick, heavy nails that also can't be used.  There are a number of examples of Goodhart's Law in health care today - my favorite (discussed in my post, "Tyranny of metrics" which are also discussed in the great book by Jerry Muller) is the National Health Service's efforts to reduce boarding in the emergency department (ED) by instituting a 4 hour benchmark to evaluate, treat, and make a decision to admit or discharge a patient.  When the data was graphed out (see the excellent review published by Julie Eatock, Matthew Cooke, and Terry P. Young), there was a peak of hospital admissions from the ED right at four hours!  I suspect that some (not all) patients were admitted to the hospital rather than waiting a little longer to determine if they truly needed to be admitted, which is a waste of limited resources.

Beware the Cobra effect.

The "Cobra effect" (which I first discussed in "Is this another April Fool's joke?") is basically another name for something that is called the "Law of Unintended Consequences" (it's also another version of "Goodhart's Law").  As the story goes, during the British colonial rule of India, there was a big problem with cobras - they were killing a lot of people.  The British government decided to control the cobra population (smart administrators that they were) by offering a bounty for each dead cobra that was brought to the local authorities.  What a great way to encourage the local population to take matters into their own hands, right?  Well, unfortunately, the plan backfired.  The local entrepreneurs started breeding cobras so that they could turn more cobras in to the government authorities and make a nice profit!  The government caught on fairly quickly and abandoned the program.  The entrepreneurs released the cobras that were bred in captivity into the wild - and the cobra population increased to even higher numbers than before the program started!  Similar to the point I made above, be careful of what metrics and what benchmarks that you incentivize, as there are always unintended consequences.

Measure what matters.

Building upon the "Goldilocks Principle" above, W. Edwards Deming, widely considered one of the founders of the quality improvement movement, listed 14 points for quality management.  Point #11 (there were actually two, which he labeled 11a and 11b) is:

11a.  Eliminate work standards (quotas) on the factory floor. Substitute leadership.

11b.  Eliminate management by objective. Eliminate management by numbers, numerical goals. Substitute leadership.

He also listed the 7 deadly diseases of management, of which #5 is Management by use only of visible figures, with little or no consideration of figures that are unknown or unknowable.  What does it say when two of the leading authorities on quality improvement in history (Deming and Berwick) caution against excessive measurement and key performance metrics?  While it is certainly true that you can only manage what gets measured (to paraphrase Peter Drucker), you should only measure what truly matters (see the superb book by John Doerr, Measure What Matters) and needs to be managed!

Accountability and authority must align.

I've also made this point before (see my Accountability-Authority Matrix), but don't just listen to me.  Joseph Juran, one of the other founders of quality improvement, states that when it comes to managing quality: (1) Goals must be clearly defined; (2) Actual performance must be measured; and (3) Authority to act must be present.  Individuals need the authority to be able to act on data to drive improvement.  In addition, they should not be held accountable for metrics that they have no authority to influence or change.

Please don't misunderstand me.  I am a firm believer in measurement.  It's one of the foundational principles of quality improvement.  However, as in all things, there are a few important caveats that should be kept top of mind, some of which I have listed here.