Category Archives: Leadership

Managing Professional Performance Requires Leadership

Leading and managing are two different disciplines, which share some theories and practices with some important differences.

When it comes to processes, managers monitor for variance, look for reasons for variances and then attempt to correct those variances within the boundaries of the system within which they work. Leaders challenge current processes, redesign processes, and create new ones. Managers keep the status quo functioning as best it can. Leaders change the status quo. When it comes to people, managers perform essentially the same functions as above with some important modifications, which require leadership skills.

First, people require clear expectations followed by coaching and if need be training. They need to be told when they are doing something right so they keep doing it and when they are doing something not quite right so they can correct.  The first time they are told to adjust its done in a supportive manner where the manager assumes positive intent, meaning they assume there may be gaps in knowledge and/or inadequate skills that need to be filled, and most importantly they assume the person wants to excel in their performance.

The second time under performance is discussed the approach is still supportive but includes a more inquisitive or Socratic approach, meaning the manager probes with non-judgmental questions what barriers might exist to better performance. Two-way communication is established. The coaching becomes more specific to the individual getting at those root causes for the under performance that are unique to that individual and situation.

The third time is when formal action plans are required.  Good managers are good at anything that’s formal, so they excel at the beginning (although handing someone a job description doesn’t count) and at the end of the process. Good managers, who are also good leaders, are also good at the coaching part. Coaching implies that the manager’s number one goal is to help the person perform better and have more pride in their work. Good coaches are servant-leaders.

Second, people respond best when there is respect, trust and collegiality in the workplace, in other words the stronger the culture the more likely people are to perform well. Managers need to nurture strong cultures. This takes leadership.  Culture aren’t necessarily managed, they are nurtured, renewed, developed, given identity, and modeled.  In other words, cultures are led, not managed.

There are some coaching leadership principles that are worth mentioning. First, feedback whether it be positive or negative, needs to be as immediate as possible. This isn’t because it sticks better, although it might, and it isn’t because details are needed to provide good feedback, although that might help, it’s because the sooner the person knows the quicker they can start to correct before it becomes habit or before so much damage is done that they can’t recover.  Second, coaching needs to include explanations, encouragement and empowerment. Third, among professionals (e.g. physicians) coaching is more an act of persuasion and influence. Its about being non-judgmental, and establishing mutual respect and purpose before having the conversation.  It’s about humility and dedication to the truth, and its about playing the role of servant leader.



The One Thing

I was recently asked what was the most important thing I’ve done to bring positive change to the Children’s Hospital where I’m a leader. I was surprised by the question because we’re early in the journey, what we’ve accomplished so far certainly isn’t just my doing, and it isn’t just from one thing.   I replied, “Relentless alignment, disciplined improvement, and empowering accountability.”  But I quickly realized it didn’t answer the question: “What’s the One Thing?”

Is it Relentless Alignment?  This does take the most effort and time. Alignment is important and one must be relentless in pursuing it. I started with the creation of a vision and plan, followed by formulating specific metrics and milestones.  And then came the constant consistent communication, which included clarity around priorities and transparency regarding results.  Alignment is about inspiring a shared vision and creating a renewed culture of excellence.

Is it Disciplined Improvement?  Constancy of purpose around continuously improving quality is important, but without discipline, it doesn’t happen. Consistent use of standard methods at all levels, and especially by the senior leaders, coupled with a culture of open communication, experimentation, and learning are required. It’s about the 20-mile march. We are using Lean and the science of quality improvement to provide the needed discipline.  We manage our projects using a disciplined approach.  And we prioritize our projects using decision support tools when possible.  Lean and CQI work well when used consistently with an unwavering discipline.  Standard work is a powerful tool.  Quality improvement is about optimizing outcomes while minimizing waste engaging everyone in the process using standard work to do so.

Is it Empowering Accountability?  I call this Management by Leadership.  When things don’t happen as expected or performance is less than desired, its often a systems issue, a communication problem, a structural misalignment, a talent and/or resource issue. And often one of the root causes is a lack of staff engagement. Front-line management often isn’t equipped or empowered to address these higher level issues. We’ve been emphasizing leadership more than management and systems more then individuals when it comes to what needs to work better.  I will admit, however, that I’m a management fanatic underneath.  I have checklists for everything.  However, I consider myself a management disciple of W. Edwards Deming.  I follow his theory of profound knowledge:  appreciation of systems, theory of knowledge, the psychology of change, and understanding of variation.

In health care, superb leadership is a must-have.  Yes, management excellence is also needed, but its best when born from excellent leadership.  The Leadership Challenge articulated by Kouzes and Posner has been a useful frame for me.  Leaders 1) inspire a shared vision, 2) model the way, 3) challenge the process, 4) enable others to act, and 5) encourage the heart. I see these 5 things as enabling a leader to achieve relentless alignment, disciplined improvement, and empowering accountability.

So, to answer the question “what is the most important thing?” I would have to say leadership is the most important thing that has made a difference at our children’s hospital.





Why servant and transformational leadership are rare

As a novice leader I learned through reading  followed by experimenting with what I was learning.  I’m forever in debt to my team at the time for indulging me.  Without the opportunity to experiment and practice, I wouldn’t have developed into a leader.  My organization also provided me with a professional coach, which was essential for learning from the results of my experiments and reflecting on my practice.

With knowledge and experience I entered larger circles where it appeared that most weren’t reading the same books.  There were a few who were, and thank goodness for them.  As a physician leader I was following a different set of principles and driven by a different set of values than most.  It wasn’t an easy path.  My resolve, however, grew stronger, because every time I doubted myself, that original team cheered me on.  They knew long before I did, that I was a servant leader.

My continued hunger for knowledge eventually brought me to learn about servant leadership. When I first read about it, it seemed so obvious.   And it helped me realize who I was as a leader and why I found it so hard to be a good one. It would have been easier to only worry about my own success and always be looking to boost my own ego. I was doing servant leadership and it was hard.

Years later in the optional reading list of one of my classes at Harvard was an article entitled: “The Power of Servant Leadership to Transform Health Care Organizations for the 21st Century Economy.” It was written by Richard Schwartz and Thomas Tumblin and published in 2002 (10 years earlier!).  I fell of my chair when I realized Dr. Schwartz was a surgeon, and the article was published in the Archives of Surgery (no disrespect to my surgical colleagues, but renewed respect).

As I read it I couldn’t help as a student of leadership to think that the concepts being professed in this article were revolutionary and exactly what we needed in healthcare (they were hypothesizing the same). I thought to myself, “So, why hasn’t the concept caught on?” Well… because it’s hard.  duh.

Applying the concepts of servant, situational and transformational leadership to drive a learning organization is brilliant, but it’s hard. One would think it might be easier in health care than other industries. Not so.   Why?

First, how we choose our leaders, especially our physician leaders, is not aligned with these styles of leadership.   Why is that?  Two reasons: 1) these attributes and skills are rare, and 2) the things we look for in our physician leaders are counter to them.

Second, how we train our leaders does very little to foster the attributes of these three styles. Why? Two reasons: 1) those doing the training, the mentoring and setting the example don’t often have them, and 2) it takes a tremendous amount of self-reflection and self-awareness to be a servant leader.  It happens through self-driven training and transformation, and too many of us aren’t reflecting and aren’t aware enough.  One’s emotional intelligence must be high.

And finally, those who become physicians, those who are most driven to succeed and therefore be put in the leader spotlight got there because of a relentless focus on their own achievement, not on the achievement of teams and others.

Time to change the paradigm.


Who’s on first, What’s on second and I don’t know who’s on third

Who’s on first? – Is it the patient?  The doctor?  The hospital?  The payer? In our everyday clinical (and non-clinical) practice we need to remind ourselves it’s the patient. When the patient is first, safety is first, quality is first, the care experience is first, and access is first.  Soon cost will be more of a consideration as individuals become increasingly responsible for the cost.

What’s on second? – If the patient’s on first, then what’s on second? Is it the doctor? The hospital? The payer?   It must be one of those, right? Wrong. Knowledge, information, and data are on second. It’s a huge “What” in health care and we’re not so good at managing, using and communicating it.  We simply have to get better at it. It will take technology and its proper application to disrupt our current system. There is good news.  We’re on the early part of the slope.

I don’t know who’s on third – Yes, we often don’t know and it’s a problem.  Once again, it’s not the doctors, the payers or the hospitals.  Culture is on third.  Culture defines and drives performance. And most of us don’t know much about it or how to influence it, let alone manage it. Culture is the end result of the behaviors, processes, strategies, values and visions put forth by leadership.  Its the driver of organizational behavior.  And culture is really what you are trying to influence when you make decisions and act as a leader. Putting in place a new process isn’t in of itself going to do much. Its what it does to the culture that really matters in the long run.

Baseball as a metaphor: Health care delivery is a team sport, and each position must be played well for the team to win. The physician, although not “on first” is certainly in the position of being captain, or at least the pitcher. The catcher is the advanced practitioner or nurse who helps manage the patients. And there are others on the team that the patient relies on.  Increasingly we are using medical assistants to assist us in collecting data, navigating patients and monitoring adherence.  The culture of the team is as important as the competence of each individual. We’ve seen that play out in major league sports time and time again.

So, what’s the secret sauce for creating a strong culture of excellence and reliability in health care? The evidence would suggest that its leadership.  I recently suggested in our organization that we have a leadership credo for our clinical transformation initiative. Someone on the work group asked why.  A fair question.  The reason is because leadership sets the tone, it’s the key to culture. If the leaders aren’t consistent, reliable, mindful, committed to transformation, committed to our chosen improvement tools, and committed to culture shift, then the effort fails. If we aren’t all rowing in the same direction as leaders, then the effort fails.

What’s your leadership credo?  And does each person on your leadership team share and live the same credo?

Adaptive Leadership

It’s been said managers maintain order and leaders change it; the best measure of a leader is the breadth and depth of effective change.  In The Practice of Adaptive Leadership: Tools and Tactics for Changing Your Organization and Your World (HBP 2009) Ronald Heifetz, Alexander Grashow, and Mary Linsky suggest that most leaders aren’t adaptive leaders. They exercise authority, power and/or influence, but not adaptive leadership.

When it comes to technical issues, most leaders demonstrate advanced technical skill.  However, when it comes to adaptive challenges, most leaders fall short, either because they fail to recognize adaptive challenges, they fear the costs of exercising adaptive leadership (e.g. losing their job), or they lack the right tools and tactics (so they fail and lose their job).

A table from The Practice of Adaptive Leadership compares technical leadership to adaptive (Figure 2.3:  Leadership from a position of authority  Figure_2_3 ).

Technical problems often involve managerial intervention and systems engineering. Adaptive challenges often involve people and culture. Technical problems are solved fast by a small group.  Adaptive challenges are dealt with over time and involve many people. Technical problems are well defined and contained.  Adaptive challenges are messy and require framing and reframing.  Technical problems are relatively easy.  Adaptive challenges are hard.

For leaders in healthcare this is a time for adaptive leadership and  technical leadership; too much disruption might threaten access to services and erode quality, but not enough disruption and an organization may fail.  Health care reform is necessary given high costs and less than desirable outcomes. Thus adaptive challenges will continue to surface.

Because adaptive change involves people and culture, and requires courage balanced with consideration, a certain collective leadership capacity across the system is needed to meet adaptive challenges.  The physician workforce as a whole is perceived to be resistant to change, overly protective of our self-interests, and lacking a full perspective on the issues.  If physician leaders communicate unilaterally, listen poorly, and learn slowly, they won’t be effective adaptive leaders.  Adaptive leaders can’t be overly dogmatic know-it-alls.  Rather they must possess the skills to effectively participate in constructive conversations about the need to change, how to change and how to help people cope with the losses that come with change.


The enemies of transformation, the secret weapon and how to use it

Having been out of training and working in the real world of academic health care for only 16 years, I hesitate to make judgments or conclusions. Instead I make hypotheses or formulate theories. Having only 24 hours in a day, I can’t test every hypothesis. Thus, I have presuppositions.  My three presuppositions below describe the enemies of transformation, the secret weapon of trust and the means to acquire it

The first presupposition is that we have four enemies in health care: Hubris, Cacoethes Carpendi, Seorsum and Avaritia. Hubris speaks to the collective and individual excessive confidence and arrogance that is prevalent among health care professionals and organizations. Cacoethes Caprendi means compulsive habit for finding fault, which refers to the blaming culture that can be found in health care organizations with regularity. Seorsum means apart or not together, referring to the lack of alignment and the inability to integrate varied self-interests into shared goals and values, and (most importantly) shared expectations of behaviors and results. Avaritia is latin for greed. Greed is the elephant in the room no one seems to want to address (not addressing it may lead to it devouring us). Some don’t see these four as enemies, and some don’t see they exist in the first place.   There is variable penetration to be sure, but they are there.

The second presupposition is that trust is lacking in health care organizations today, which makes everything from timely decision-making to efficient and effective teamwork elusive. Have a vision? Great! Have a strategy? Good for you! Have an execution plan?   Wow, impressive! Have trust in your organization? No? Then forget it.  The lack of trust hypothesis is harder to test, because trust lies under the surface. I’m convinced it’s a real problem. Those organizations that work on building a trust culture will adapt to external forces of change faster and more successfully. Trust is the secret sauce or weapon (I prefer the weapon metaphor when it comes to fighting enemies).

The third presupposition is that leadership in health care is lacking capacity.  I attribute this to my Intelligence-Ego Ratio theory.  An individual’s leadership is more effective if their intelligence is greater than their ego.  The optimal ratio is 2-3 (2-3 times more intelligence than ego). It’s counter-productive in the long-run to be <2.   One with a ratio of <2 may get placed into a leadership position.  However,  the organization’s success will have a ceiling.   One with a ratio of >3 will find it hard to get recognized as a leader, but long-term success is more likely.   This theory essentially states that intelligence is incredibly important, but if you let your ego trump your intelligence, you’ll eventually look like an idiot.  Humility is key to being the best leader one can be.  It drives a desire to continuously improve every day.  It allows you to be more open to learning from mistakes or miscues.  It allows you to build trust.

Intelligence doesn’t just mean mental capacity or complex problem-solving abilities. It also means the insatiable desire to learn and continuously fill the head with data, information and experiences (not just your own).  It also refers to emotional intelligence, the capacity to understand where you are and where others are with regards to relationships; relationships with self, others, the organization and society.  Intelligence essentially refers to the capacity to expand your awareness and perspective larger than anyone else around you.

So, what do we do about these presuppositions?  Take the following steps: 1) Increase awareness regarding the enemies, the secret weapon of trust, and the importance of the right leadership, 2) Embrace humility as organizations and as leaders, 3) Be resolved to succeed, persevere and do the right things, 4) Accept the need to change, 5) Drive change through continuous improvement, 6) Have relentless focus on mission, vision, values and principles, and  7) Get results on the most important shared goals.  If you aren’t getting the right results, then go back to 1 and start over.

Physicians as Leaders

The ACPE has just published a white paper on the value of physician leadership by Peter Angood and Susan Birk (may-june-white-paper-(small)) . I would encourage leaders from all disciplines in health care to read it. In addition to nicely illustrating the value of physicians participating as leaders, it provides insights as to how physicians  can be better leaders, and suggests the journey that they must go through to get there. For non-physicians to understand the journey could be valuable as well.

Physicians are typically intelligent quick learners who are outcomes-driven and often innovative problem-solvers. However, their training and the skills that often make them great physicians can get in the way of their ability to lead. The white paper shows a table from an October 2012 issue of Trustee magazine. The table compares the nature of medicine to the nature of leadership. For non-physicians to understand where physicians are coming from during those crucial dialogues could help turn those discussions into collaborative learning. Physicians who want to be better leaders ought to study this table as well. It points out that to go from practicing physician to physician executive, one must give up autonomy and isolated problem-solving for collaboration and narrow scope and predictability for broad perspective and ambiguity.


Children’s hospitals are blessed with committed and compassionate physicians (many of whom were also likely to be in the top 10 of their graduating medical school classes). These physicians often have great ideas and are often very engaged. They have a strong desire to help their institution solve problems. These same physicians are also used to dealing with relatively well-defined problems (and if they’re not, making them so before tackling them). They are also used to receiving lots of thanks and praise from others (or at least a sustaining dose of it). As a physician makes the transition to leadership, they will find themselves dealing with messy problems that are ill defined and have no simple easy clear answer. They will meet resistance to change, complaints about all sorts of things and very little thanks.

We need physicians to be leaders at all levels. For some they will struggle to make these shifts, but they’re input and participation is still valuable. For others it will take them time, but their other strengths make the waiting worthwhile. And then for some, the transition will be successful enough to allow them to be great leaders at a time when we need great leaders. The challenge for those physicians will be to stay connected with their clinical past in order to maintain their credibility with those physicians who continue doing the great work of delivering and continuously improving health care.

A few physician leaders will need to be more transformational leaders than transactional leaders.  The best leaders will recognize the value of both approaches and be adept at both.  Yet, they will tend to the transformational.  These leaders will meet more resistance, perhaps to the brink of rejection, and less thanks, even in the face of success.

A leader who has a transformational North Star with a principle-centered approach grounded in the power of relationships and collaboration is what is needed in today’s dynamic and uncertain health care environment.  To persevere s/he will need to embrace humility and servant leadership.

-Thanks for reading, Nate