Who is the greatest?

As a sports fanatic, I always watch the Super Bowl, even if my favorite team isn't playing.  I also enjoy watching the television commercials, and there was a time when our family used to rate the quality of each commercial!  If you watched Super Bowl LIX a few weeks ago, you may have noticed a commercial by NYU Langone Hospital, which showed several hospital leaders playing football.  At the very end, former New York Giants wide receiver Victor Cruz says, "Seriously, you guys are the best...", to which one of the hospital leaders replies, "We sure are."  Cruz then says, "At the health system stuff."  The advertisement then makes the statement that NYU Langone was ranked #1 for quality care in the United States.

We know that NYU Langone paid at least $8 million on the 30-second advertisement, which is the going rate for television commercials airing during the Super Bowl.  One of the physicians who appeared in the ad said that the commercial took almost nine hours to record.  The question that is being asked is whether it was appropriate for a not-for-profit hospital to spend over $8 million on a commercial advertisement.  Just as important (at least in my opinion), Michael Millenson, a journalist for Forbes magazine, asked whether the claim of being #1 was accurate (see his article, "NYU Langone Super Bowl Ad Claimed 'We're #1,' But Where's Scorecard?").

If you really paid close attention during the commercial, you may have caught the reference shown at the bottom of the video during the final 2 seconds of the commercial, stating "2024 Vizient Quality and Accountability Ranking.  Ranked #1 out of 115 participating comprehensive academic medical centers."  Vizient, Inc. started out as a group purchasing organization, which allows member hospitals to secure volume discounts on supplies and other purchases, though more recently the organization has started a consulting practice to help hospitals improve the quality of care that they deliver at lower costs.  I went to their website (see "Vizient announces 2024 top performers in clinical quality"), which lists NYU Langone Hospital as one of 14 top performers in clinical quality in the comprehensive academic medical center category.  While they are listed first, it's not clear that they were ranked first, as no numerical ranking is provided.  Vizient states that they based their ratings on their own clinical database, as well as publicly available data from the HCAHPS survey (patient and family experience survey data) and the CDC's National Healthcare Safety Network (patient safety and outcome data).  

Notably, NYU Langone Hospital is also listed as a Honor Roll hospital by U.S. News and World Report.  Importantly, USNWR stopped providing overall numerical rankings for hospitals last year.  I am sure that the recognition that NYU Langone Hospital is well deserved, and they should certainly be proud of both these achievements.  Unfortunately, neither the Vizient study nor the USNWR survey tell me with any degree of confidence whether NYU Langone Hospital is the greatest hospital, in terms of providing the best in clinical care.  As I've mentioned at least a couple of times in the past (see "Do hospital rankings matter?" and most recently, "The first step is to clearly define the problem..."), It's impossible to clearly define "greatness" by any one or even a set of measures.  I wonder if we should even try.

A few years ago, a group of physician scientists and experts in outcomes measurement assigned a grade (think A, B, C, D, or F) to the various hospital rankings and ratings systems that are commonly used (these findings were published in the online journal, NEJM Catalyst in an article titled, "Rating the Raters: An Evaluation of Publicly Reported Hospital Quality Rating Systems").  Importantly, no rating system received an A (the top grade) or F (a failing grade).  The highest grade received was a B, by USNWR.  The authors of the study concluded, "Each rating system had unique weaknesses that led to potential misclassification of hospital performance, ranging from inclusion of flawed measures, use of proprietary data that are not validated, and methodological decisions.  More broadly, there were several issues that limited all rating systems we examined: limited data and measures, lack of robust data audits, composite measure development, measuring diverse hospital types together, and lack of formal peer review of their methods."  Notably, the Vizient ranking was not included in this study.

It's clear that these rating systems do actually matter, particularly when patients have a choice of where they can go to seek care.  Unfortunately, hospitals spend a lot of money on responding to these surveys, and I do wonder how much "gaming the system" goes on when they do provide their internal quality data.  Most of the ratings systems aren't very transparent with their methods, which has also led to further questions on their overall accuracy.

Regardless, I do think that NYU Langone Hospital deserves our congratulations, particularly when it's widely acknowledged that the system was in near collapse in the mid-2000's.  I've talked about the hospital's remarkable turnaround in my post "Elevators, M&M's, dust balls, and toilet paper", which is further detailed in a book by William Haseltine, World Class: A Story of Adversity, Transformation, and Success at NYU Langone Health.  However, I do agree with some of the critics who've called into question whether it's appropriate for a not-for-profit hospital to spend $8 million on a one-time television advertisement.  

Suffice it to say, I don't have a lot of confidence in any rating system, as I don't think it's possible to rank a hospital accurately, even when using a whole set of validated measures.  For that matter, I don't think it's possible to define "greatness", at least when it comes to clinical quality.  But that's a topic for another post...

Safety First!

I went to the construction site for one of our new ambulatory centers a few days ago to celebrate an important milestone with the team.  There are a few well-known milestones in construction - groundbreaking (putting the shovel to the ground), topping off (sometimes called topping out, which is when the last beam is put into place at the top of the building), watertight (sometimes called wind and watertight, which is when the building has effectively been sealed off from the weather and interior work begins), owner handoff (when construction is completed and the builder hands the building off to the owners), and of course, the grand opening.  There are probably a few that I'm missing, but nevertheless, in this case, we were celebrating reaching the watertight milestone.

We toured the facility and thanked the construction team.  I was impressed to learn that the construction team was getting ready to celebrate 365 days without a safety event (they were actually just one day short when I toured the site).  Of course, that particular milestone caught my attention.  I asked for further information on their milestone.  The threshold for that particular metric was any safety incident that caused an injury severe enough to result in lost or restricted worktime.  We then talked about our staff injury metrics, which are very similar.  We track Occupational Safety and Health Administration (OSHA)-recordable injuries (any staff injury that requires medical treatment above first aid) and DART (any staff injury resulting in days away, restricted, or transferred from the usual work assignment).  

Unfortunately, workplace injuries in the health care industry are all too common, and surprisingly our OSHA-recordable injury rate and DART rate far surpass most other industries.  We believe that it's hard to keep patients safe when our staff don't feel safe.  Therefore, we have designed our Staff Safety program to closely mirror our Patient Safety program.  While the injuries and specific interventions are different, the safety culture that we are trying to build and develop is exactly the same for patients and staff.  For too long, hospitals have considered patient safety issues, such as central line infections or pressure ulcers as unavoidable, particularly in hospitals that care for the most complicated patients.  The same belief was true for staff safety.  Most hospitals now have thankfully adopted a different stance.

It may be a long time before we reach the milestone of 365 days without a staff safety event.  However, that doesn't mean we shouldn't try.  The health care industry has a lot to learn from other industries, such as commercial aviation, nuclear power, and construction.  This week happens to be National Patient Safety Awareness Week - what is your organization doing to keep your patients and staff safe?

What's holding you back?

There are at least a couple of books that I've known about for a long time through recommendations from friends, colleagues, and family members that I am hoping to finally read this year.  I recently crossed off The Hitchhiker's Guide to the Galaxy by Douglas Adams right before the winter holidays.  I know that Adams wrote a few more, but I don't know if I will pick any of them up this year.

I've always wanted to read Zen and the Art of Motorcycle Maintenance by Robert Pirsig.  It's supposed to be a fictionalized autobiography that apparently has more to do with philosophy than it does motorcycle repair.  Apparently Pirsig created the title as a play on words of another book by Eugen Herrigel published in 1948, Zen in the Art of Archery by Eugen Herrigel, which is an attempt by Herrigel to understand Zen Buddhism through the sport of archery. Pirsig himself explained that, despite its title, his book "should in no way be associated with that great body of factual information relating to orthodox Zen Buddhist practice. It's not very factual on motorcycles, either."  The book has sold over 5 million copies since its original publication in 1978, which is impressive considering the fact that Pirsig received over 120 rejections by book editors before someone finally accepted it for publication.

In the book, Pirsig talks about what is known as the South Indian Monkey Trap.  At least that's what I've been told - I hope to find out soon enough!  I am not sure there was ever really such a thing, but then again, I have no way to either prove or disprove it.  The "monkey trap" is simply a hollowed out coconut with a small hole, just large enough to accommodate a monkey's open hand.  However, if the monkey makes a fist inside the coconut, the hole won't let the monkey pull its hand out of the coconut.  Hunters would "bait" the coconut with a piece of fruit (e.g., a banana), tie the coconut to a tree, and then wait.  We are told that the monkey would try to grab the piece of fruit and would never let go of it, such that the monkey would be "trapped".  The hunter would then be able to capture the monkey.  

The moral of the story is that the monkey's greed for the fruit led to its easy capture.  The next logical question then, what is the version of the "South Indian Monkey Trap" in your life?  What are you refusing to give up that's holding you back from making progress?  What idea, practice, or habit that you just can't seem to give up is preventing you from being the best version of you?

Two words - Wait and Hope

When I was growing up, I remember watching an animated version of Alexandre Dumas' The Count of Monte Cristo.  To be honest, the only part that I really remember was when the main protagonist, Edmond Dantès, is locked up in prison and meets his mentor, the Abbé Faria, an Italian priest and polymath who teaches him mathematics, science, theology, arts, literature, philosophy, and languages during the decade or so that they try to dig a tunnel below the prison walls to make their escape.  

Several years ago, I picked up a copy of the book and read it for the first time.  It's a great story with so much more to it than what I had remembered from my childhood.  Over the years, I've watched the different film versions of the book, including the 2002 version starring Jim Caviezel as Dantès, legendary actor Richard Harris as Faria, and Guy Pearce as Fernand Mondego, one of the story's main antagonists.  

During a recent flight home from a trip to London, I watched the 2024 French language version of The Count of Monte Cristo (Le Comte de Monte-Cristo).  I thought the movie was excellent.  While the novel is far too complex to be fully adapted to film, I thought this version came the closest to the story as originally told by Dumas.  

Both the novel and the 2024 film end with a quote that I thought was really important.  I don't want to spoil the story, but at the very end, Dantès looks upon his closest friends and departs with the message that "All human wisdom is contained in these two words - wait and hope."  It's a powerful reminder to all of us that patience, perseverance, and faith are the keys to leading through adversity.

Tony Blair’s On Leadership

My wife and I recently spent a week in London, and we had a fabulous time!  We both attended our first Premier League football match (Arsenal vs. Manchester City), and we toured almost all of the major venues.  My favorites were St. Paul's Cathedral (amazing!), Windsor Castle, and the Roman baths in the city of Bath.  Being a history buff, I also enjoyed our "behind the glass" tour of the Winston Churchill War Rooms (it was actually the second time I've been to the War Rooms).  We also toured Parliament, which was very interesting.  As we walked out through the Gift Shop, I noticed a book by former British Prime Minister Tony Blair called On Leadership: Lessons for the 21st Century.  As soon as we got back to our hotel, I ordered the book through our local public library back at home.

If I were being honest, I thought that Blair provided some important insights on what it means to be a leader.  However, I was slightly disappointed that he focused, at times, on how to be a leader in government (which is a main focus for his institute, the Tony Blair Institute for Global Change).  In an interview with Raju Narisetti (McKinsey & Company) for the book, Blair said, "There are lots of books about how to be a better CEO or a better football coach.  But no one, as far as I know, who's been in a senior position in government has written a book that's literally just simply about the challenges of governing."

Blair draws extensively from his own political career to illustrate many of the concepts that he feels are important to being a good Leader (he emphasizes that being in the position of leader is not the same thing as being a Leader, and he always capitalizes the word Leader throughout the book to emphasize that concept).  While there are certainly some key insights that can be applied to leadership in general, he always talks about how to apply these principles to being a Leader in politics.

The book's description on Amazon.com is very specific:

Sir Tony Blair learnt the precepts of governing the hard way: by leading a country for over ten years.  In that time he came to understand that there were certain key characteristics of successful government that he wished he had known when he started.  Now Sir Tony Blair has written the manual on political leadership that he would have wanted back in 1997...

I would be remiss if I didn't at least credit Blair for providing some general leadership principles that can be applied to being a good Leader more generally (and outside of the world of politics).  First, Blair emphasizes the importance of vision, communication, and decisiveness. These three characteristics are definitely important foundational principles for leadership.  He also spends a lot of time talking about the need for adaptability (and a little patience), especially in times of change.  Given the turbulent world we live in today, Blair also talks about the need for Leaders to find the appropriate balance between holding firm beliefs (and staying true to their own values), while being open to new ideas.  Throughout the book, he highlights the importance of building teams, connecting with and inspiring others, and making tough choices, while managing both risks and responsibilities.  .

There are some additional key insights that I would also like to highlight.  Perhaps most importantly, Blair provides a very good discussion on what is meant by leadership.  He describes leadership as follow:

Standing in front of a crowd that is expecting to be pleased but instead being prepared to displease it.  Spelling out the truth rather than the shibboleth.  Persuading, not placating, the audience that is not naturally on your side.  Addressing the head and not the heart of those who are.  The willingness to take not just the mantle but what goes with it should that mantle be worn seriously: the criticism as well as the adulation, the necessity of a decision and not simply debate; of substance as well as shine; of advancing and not just being; of action and not mere analysis; to resolve the problem and not simply articulate it.  And to keep going even when it looks like defeat is as plausible an outcome as victory; to retreat tactically, but never strategically.  This is leadership.  And to realise that giving people what they want is not the goal of leadership.

Blair also talks about how difficult it is to be a Leader in today's world.  He writes, "Leaders have the courage not to go with the flow.  They speak up when others stay silent.  They act when others hesitate.  They take the risk, not because they fail to identify it as risk but because they believe a higher purpose means the risk should be taken."  He mentions a quote by Chinggis (or Genghis) Khan, who said about leadership that, "Conquering the world on horseback was easy; the hard part was when you had to dismount and govern."

As I mentioned above, Blair talks about three key principles that are the bedrock to leadership - having a vision, communicating well, and being decisive.  Remember that a vision is the ultimate goal or idea that leaders have for the direction of their organization. The ultimate goal or idea becomes the basis of a strategy, which plans how the organization can reach its vision.   Blair writes, "The word strategy derives from the Greek strategia - meaning generalship.  Without it, there is no leadership...Its presence does not guarantee success; but its absence pretty much guarantees failure."

Blair dedicated an entire chapter to the importance of technology.  For example, he talks about leaders who are hesitant about the application of technology (I'm thinking in particular of artificial intelligence) versus those who see technology as an important part of the future of an organization that should be embraced.  I mentioned the Luddites in my post "The Glass Cage".  Blair mentions the Luddites in his chapter on technology, writing:

If there's another lesson to be learnt from the Industrial Revolution in particular, and history in general, it's that such things [referring to technological advances, like artificial intelligence], once invented by human ingenuity, are never disinvented by  human anxiety.  The machine-breaking Luddites of the early nineteenth century tried to hold back the tide of change.  They failed.

Blair then suggests what leaders can and should do, writing:

The answer, therefore, is not to resist or deny the revolution, but to understand it fully, to access its opportunities and mitigate its risks.  Don't let fear or the inevitable campaigns against this revolution create hesitation.  Let the sense of the opportunities energise the spirit of change.

Blair believes that rather than creating more problems and hassles for Leaders, technology is going to vastly improve leadership.  He goes on to suggest that, because of the technological advances that are occurring, it is indeed a great time to be in leadership.  These words are reassuring to me, especially given all of the challenges that we, as leaders, have faced in the last couple of years.

There are some other points that Blair mentioned in his book that I will likely re-visit in future posts.  For now, I will end this post, as I frequently do, with a quote.  In this case, the quote (by Tony Blair) perfectly encapsulates what it means to be a Leader in today's world.  Blair said, "The art of leadership is saying no, not yes."

Familiarity breeds contempt...

There is an old saying that has been around for hundreds, if not thousands, of years: "Familiarity breeds contempt."  The earliest known source that I can find is from the sixth century BCE in one of Aesop's Fables, "The Lion and the Fox".  A fox happens to meet a lion in the forest one day and is shy and afraid, because the fox had never encountered a lion before.  The fox runs away and hides.  The next day, the fox runs into the same lion a second time, but instead of running away, the fox stands behind a tree and watches the lion carefully and closely.  The fox encounters the lion for a third time later, but this time stands proudly in front of the lion and asks, "What's going on?"  We are led to believe that the fox becomes too comfortable with the lion and ends up getting eaten as a result.  Familiarity, in this case, caused the fox to let his guard down, when he definitely should have been more careful around the "King of the Jungle".

The question I would ask is whether this ancient proverb is, in fact, true.  As we get to know a complete stranger, are we more apt to like the individual more or less?  Conventional wisdom would suggest the former.  Nicholas Carr, who is becoming one of my favorite authors as of late, writes about this very subject in his most recent book, Superbloom: How Technologies of Connection Tear Us Apart (based partly on an article he wrote for The Boston Globe in 2017, "How tech created a global village - and put us at each other's throats").  Carr starts with the premise that since the invention of the telegraph in the 19th century, there's been an attitude that advances in communication technology would promote social harmony.  In other words, the more we know each other, the better connected we become as a society.  

For example, a New York Times columnist celebrated the laying of transatlantic Western Union cables in 1899 by writing, "Nothing so fosters and promotes a mutual understanding and a community sentiment and interests as cheap, speedy, and convenient communication."  Guglielmo Marconi wrote in 1912 that his invention of the radio would "make war impossible, because it will make war ridiculous."  Later, John J. Carty, an engineer at AT&T said in a 1923 interview that the telephone would "join all the peoples of the earth in one brotherhood."  The Canadian writer and philosopher Marshall McLuhan, perhaps most famous for coining the phrase "the medium is the message" as well as predicting the World Wide Web nearly 30 years before it was invented, suggested in his book The Gutenberg Galaxy that the new era of communication would create a "global village", bringing us all closer together as one society.  Finally, Meta's Mark Zuckerberg suggested in 2012 that Facebook was more than a business, it was on a social mission to make the world a better place, writing, "People sharing more creates a more open culture and leads to a better understanding of the lives and perspectives of others."

As Carr points out in the Boston Globe article, if greater communication brings people together more, then we should be seeing greater harmony (in Carr's words, "a planetary outbreak of peace, love, and understanding"), not less.  It's fairly obvious who Carr blames for the current state of affairs.  Social media, rather than bringing us closer together as Zuckerberg hoped for in 2012, has only pushed us further apart.  

Carr refers to social media in Superbloom by stating, "As a machine for harvesting attention, its productivity is unmatched.  As a machine for bending the will, it is a triumph of efficiency.  In engineering what we pay attention to, it also engineers much else about us - how we talk, how we see other people, how we experience the world."  And more often than what was previously the case, our society spends more time communicating in the virtual world via social media than they do in the real world.  He suggests that "a full fifteen years before the arrival of COVID-19, people were already choosing lockdown."  

The abundance of research also tells us that greater communication doesn't lead to greater social harmony.  The evidence tells us that (1) people are more willing to share information on social media that they wouldn't share in person or in other modes of communication (called the online disinhibition effect); (2) the more we know about someone, the less we like them (see Michael Norton's article, "Less is more: The lure of ambiguity, or why familiarity breeds contempt" as one example of many similar studies).  A group of British researchers labeled this "digital crowding", stating "With the advent of social media, it is inevitable that we will end up knowing more about people, and also more likely that we end up disliking them because of it."  We have become like the fox in Aesop's Fable.  We would do well to remember that things didn't go to well with the fox in the end. 

The Death of Command and Control

If you've ever read up on the research on human motivation, you've probably encountered Maslow's Hierarchy of Human Needs or Herzberg's Two Factor Model.  There's also a good chance that you've heard about the work by Douglas McGregor in the 1950's and 1960's on Theory X and Theory Y.  As it turns out, McGregor was actually a student of Abraham Maslow, who was actually a contemporary of Frederick Herzberg.  McGregor developed and introduced his model in his book, The Human Side of Enterprise, first published in 1960.  Notably, leadership expert Warren Bennis once said of McGregor, "Just as every economist, knowingly or not, pays his dues to Keynes, we are all, one way or another, disciples of McGregor."

What's important to know about McGregor's theory is this - while Theory X generally has a negative view of workers, Theory Y generally has a positive one.  Theory X believes that the typical worker or employee has little ambition, avoids responsibility, and is focused primarily on achieving their own personal goals and interests.  Theory Y, in contrast, believes that the typical worker or employees is internally motivated, enjoys their job, and works hard to better themselves without a direct reward in return.  

Leaders and managers who subscribe to the Theory X viewpoint, then, will rely upon a more authoritative, top-down/hierarchical approach.  They will use punishment and rewards to motivate their workers or employees.  They will develop and enforce (again through punishment and/or rewards) strict policies and procedures that are to be followed as routine.  Conversely, leaders and managers who subscribe to the Theory Y viewpoint are more democratic in their approach.  They believe that in a positive workplace culture that emphasizes autonomy (with accountability), responsibility, and "deference to expertise".

It's important to realize that McGregor saw both Theory X and Theory Y as two ends along a continuum.  Consistent with situational leadership theory developed by Paul Hersey and Ken Blanchard or contingent leadership theory developed by Fred Fiedler, the most effective leaders would at times use both methods, depending on the specific needs or context of the situation.  It's also not too hard to figure out which theory the most prevalent leadership approach used today is based upon - there was actually an article ("Beyond Theory Y") published in 1970 in the Harvard Business Review that again emphasizes that both approaches can and likely should be used, depending on the specific needs of the situation at hand or the problem to be solved.

So why then are their articles touting the "death" of Command and Control (see for example, "Command and Control is Dead" or "Command and Control Leadership is Dead" or "The Death of Command and Control: Why Old-School Leadership is Killing Your Team's Potential")?  Command and Control (C2) refers to a leadership and management approach traditionally used in the military, but it has also been used in non-military organizations as well.  The "Command" part of C2 refers to the process of directing, issuing orders, and providing leadership for a particular group, project, or operation.  The "Control" part of C2 refers to the process of monitoring compliance with policies and procedures (and enforcing them) and ensuring the proper execution of orders and tasks.  As you can probably guess, C2 is more top-down, hierarchical, and authoritarian/autocratic and definitely leans more toward the Theory X approach.

Kathy Miller Perkins wrote an excellent article for Forbes magazine ("Shift Your Leadership Style: Guidelines for Agile Leadership"), in which she outlines the exact approach that McGregor recommended all those years ago.  She writes, "Steering through the complex waters of modern leadership requires more than a single, go-to approach.  It demands the skill to adapt swiftly, changing your leadership style on the fly to tackle constantly shifting conditions and challenges."  In short, the leader's in today's VUCA (or BANI) world need to be agile, and agile leadership, consistent with both situational leadership theory and contingent leadership theory, includes "Command and Control".  

Perkins lists a number of situations where a more autocratic or C2 approach may be preferred:

1. Agile leadership during a crisis: "When navigating through treacherous waters with reefs and storms, you may need a crew that follows your orders as an experienced leader."

2. Agile leadership in highly predictable environments: A C2 approach can be most effective with work that is highly predictable, well-defined, and repetitive in nature.  Perkins gives the example of a manager at a fast-food restaurant, where setting clear expectations and ensuring compliance with standard operating procedures, rules, and regulations can drive efficiency and high performance.

3. Agile leadership in regulated environments: Again, with tight regulatory environments, a C2 approach may be preferred over other approaches, particularly when variation from standards can result in significant problems for the organization.

Perkins concludes her article by stating, "Leadership in this century is not about clinging to a single, comfortable style but about developing the situation awareness and flexibility to switch between approaches as the context demands."  Rather than being dead, "Command and Control" leadership is here to stay, even if used relatively sparingly and for specific situations or contexts.