Don't fear criticism

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

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

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

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

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

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

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

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

Rally Point

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

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

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

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

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

Sell Ice Cream!

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

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

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

So how can leaders feel less lonely?  Executive leadership coach Melanie Parish recommends these five ways to overcome the "loneliness of leadership":

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

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

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

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

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

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

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

Wash Your Hands!

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

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

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

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

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

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

"100 apples divided by 15 red herrings"

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

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

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

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

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

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

Place Kickers

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

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

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

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

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

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

Annual Gallup survey on honesty and ethics among professionals

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

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

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

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

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