Narcissism: what keeps a high-achiever from being a great leader

With the awareness of saying something stupid comes learning and even at times insight. This awareness doesn’t erase one’s stupidity, but it may make one smarter for the future. I was recently talking with a friend about physician leaders and out leaked an incorrect generalizing comment. I suggested that physicians who tend to be self-centric in their view if not narcissistic aren’t good leaders. What I meant to say was that a lack of broad perspective is a barrier to being an effective leader, however, it may not be a barrier to positive contributions to organizational learning and problem-solving, not to mention being a good physician.  Dogmatic views and attachment to narrow perspectives can interfere with good leadership in complex, diverse and uncertain environments. However, in certain situations those qualities can be helpful. Not being a good listener is a problem if your leading a diverse group through complex issues, but good listeners (aka good leaders) like people who will speak up, and that’s were physicians, even those who are somewhat self-serving can contribute facts, ideas and insights.

As I tried to recover from my stupidity, a thought popped into my head. Could narcissistic physician leaders start to lose their effectiveness the more broadly their leadership asks them to think and function? What if they contribute quite well until they get to the executive leadership level? In 2012 Justin Menkes wrote a short article for the Harvard Business Review entitled: “Narcissism: the difference between high achievers and leaders.” He suggested that high achievers who are also narcissists can do very well to a point, however, at the executive level they can sink your company. The narcissism just gets in the way.

In 2000 and 2004 in the Harvard Business Review, Michael MacCoby published “Narcissistic leaders: the incredible pros, the inevitable cons” where he suggested that narcissistic leaders do have the advantage in certain situations, specifically where there is chaos or opportunity for innovation. Implied but not specifically stated in his article is that you have to be really good at what you’re doing (e.g Bill Gates, Jack Welch, etc.). Healthcare may be going through a lot of change, and some would claim chaos, but at the heart of providing health care is the patient, a person who doesn’t need chaos or change, they need high-reliability. Narcissism won’t get you that at the micro- or macro-system levels. Even beyond health care delivery, narcissism is potentially dangerous in healthcare. Just consider the case of Theranos and Elizabeth Holmes. Narcissism, even if you think you’re doing a good and just thing, gets in the way.


Is Health Care a Business?

I haven’t entered a blog in over 4 months, primarily because I’ve been held hostage by a financial crisis.  We were successful in reversing the crisis, but not without some “damage”.  The biggest damage I’m learning has been staff morale.

In the last several months I’ve heard several front-line staff tell me that health care has become too much like a business with too much focus on RVUs and money.  Some have “attacked” me personally for being too focused on the business aspects.  Financial strength is critical for long-term success (i.e. staying in business), and action is necessary when it’s eroding.  And it’s not about the money, its about preserving the organization, the service it provides to the communities, and the people who provide the service.

This message was lost somewhere along the way.  I do admit that communication is hard and as hard as I tried to frame things in a balanced manner, the complete message didn’t always get across. The root of this seems to be the cascading of the message – the ability of middle and front-line managers to communicate the message as intended: “We need everyone to think about where and how we can be more productive and where and how we can be more efficient recognizing that not all areas will have the same focus or countermeasures,” becomes “We need to see more patients or we’re all going to lose our jobs!”  Hope is an important part of any message in a crisis and hope doesn’t appear to cascade.

Let’s make no mistake about it…health care is a business and it is the responsibility of management to keep it in business. Front-line people need to recognize that reality. However, management needs to face the reality that staff are emotionally attached to what they do, how they do it, and attached to their own personal finances whether they want to admit or not.   They are running a business at home, but don’t want to see their organization run like a business.

Celebrating early successes, thanking people, pointing out where we are excelling, and providing reminders that what we do is important to our patients and families…isn’t enough. Paying people the same amount and giving them a raise at the end of the year despite the huge challenges in making that happen isn’t appreciated nor is it enough. So, what is a leader to do?

Deming in his writings and speeches gave us a clue – the key processes and results of a business need to be constantly scrutinized for improvement and the improvement efforts need to include everyone.  So, when the crisis hits, everyone is already on the same page. These key processes and results rarely change – they are constant – regardless of any crisis.  Metrics of efficiency, which often include financial markers, are now included in the critical processes and results of healthcare.  If you’re in healthcare, expect to hear more and more about the importance of finances along side patient safety and the care experience.

Key financial metrics and other metrics of efficiency are results, outcomes, that if not constantly improved will put you out of “business”, out of “mission”.




What Managers Do

Outcomes aren’t “managed”, processes and behaviors are.  Outcomes are consequences, which we analyze for the purpose of informing system design and driving behavior.  Thus, if management is to drive processes and behaviors, its stand to reason that knowledge about how they’re performing would be critical. Yet, we often don’t collect these data, and if we do, we struggle to understand what they’re telling us.

Furthermore, managers would be masters at systems design and improvement, and skilled at influencing behavior. Yet, managers are best at creating schedules, tracking budgets, coordinating resources, and analyzing outcomes.  And we’re great at getting performance evaluations done by the deadline (notice I didn’t say how great we are at performance evaluations).

So, do we have this all wrong? What are the barriers to getting it right?  Lack of time? If so, why do we lack time?  –  We all know the answer to that one: we spend so much time on the other stuff.

Senior managers often ask: “What are your results?” and “What are you doing to improve them?”  Therefore, that’s where we focus.  Instead they might want to ask: “What are your critical processes and vital behaviors?” and “What are you doing to improve them, and how are you doing with that?”

I’ve talked about care experience survey results before, which are sampled outcomes, lag by about a month, and are reported monthly, which further adds to the lagging.  In other words, they’re outcomes – and it’s behaviors and processes on which we ought to focus day-to-day.

To manage these two things, we first identify, define, measure and analyze them.  Then can we manage and improve them. And in doing this we perform cause analysis, solve problems (breakdown barriers) and execute change.   – And the big one: influence behavior.

I’ve found that getting people to see things differently, and think about things differently as well as creatively, is often an important step. Human biases are multiple and strong. In my opinion changing paradigms is critical for changing behavior.  When one is creative they are essentially building new paradigms.

Deming was correct when he made the psychology of people a pillar of quality improvement, along with systems thinking, knowledge processing (learning), and variation analysis.  Good managers know the psychology of people and use it to influence behaviors.



Does a healthcare macrosystem need mesosytems?

What it needs is great microsystems (units and practices).  What I’ve observed is that mesosystems are often workarounds. They are created when the macrosystem fails to or can’t support the development of microsystems (units and practices) in such a way that they are high functioning, effective learning, and capably connecting units.  Mesosytems take many shapes [separate business entities or divisions, service lines, discipline silos (e.g. nursing services and medical staff), middle managers, committees, work groups, etc.].  Special effort needs to be taken to not create too much waste when putting a mesosystem in place.

How the mesosystem is set up and structured is important. Many children’s hospitals within a hospital are set up as a mesosystem. It make sense, because the business of children’s hospitals is different from the business of adult health care units. However, the children’s hospital needs to be big enough to warrant the investment of its mesosytem.  Supporting functions that become mesosytems are also typically not lean and create significant waste.  The best example of this in health care organizations is the separation of nursing services and medical staff into large mesosystems.  It often creates waste.  This isn’t to say that creating connections among disciplines isn’t helpful, but it needs to be done in a way that limits waste and maximizes the functioning of the microsystem.

The question for every health care organization ought to be: what does it take to have high-functioning, effective learning, capably connecting units or microsystems?  At the microsystem level is where the output and performance of the organization matters the most.  The manager(s) and leader(s) of those units need to be effective at managing processes and leading people.   They need to be good at connecting with the leaders and managers of other units, and they need to be good at managing up to their bosses. They need ready access to and processes that effectively connect them to support systems (e.g. HR, Finance, IT, facilities, etc.). They also need to connect well with other units or microsystems where they share patients and critical interdependencies. And finally they need to be well connected to the macrosystem leadership. Achieving this isn’t easy, but creating a complex set of mesosystem workarounds isn’t the leanest approach.  So, it needs to be deployed carefully, and in some cases not deployed.

Good managers and leaders of microsystems are capable of driving continuous improvement and adaptation through team learning and robust quality improvement. Learning takes transparency, a just culture, and coordinated teamwork. Processes have to be mapped out, visible and constantly scrutinized through daily management.   Robust quality improvement processes and tools need to be in place with skills and knowledge of quality improvement integrated throughout the team. The ideal would be to embed these attributes into the microsystem, not leave them up to a mesosystem to do them.  Support services are just that.  They are there to help the microsystem and are embedded in the microsystem as much as possible.

Great teams start with members who are there to serve

I recently attended a conference of health care administrators and executives and one of the topics was developing high-performance teams. I was asked to sit on a panel and give a brief presentation on the subject. I’m not entirely sure why I was standing up there, but I assumed it was to give a physician’s perspective. I struggled with where to start and where to end; the capacity and capability for physicians to be part of effective teams is variable.  Some physicians are great at it most of the time and some aren’t some times and other not most of the time, and the reasons range from lack of skill to lack of sleep.

The other 2 panel members had great insights and advice: 1) Teams are critical to success now and in the future given the rapid changing landscape of healthcare, 2) Teams need to be interdisciplinary, 3) Clinical teams benefit when there is a physician co-leader, and 4) Common ground is reached when making the patient the focus of the goals of the team. They gave examples of successful teams in their organizations: the key elements were clear purpose and goals, senior leadership support and involvement, openness, and transparency. I decided to focus on the key attributes of successful teams, which boiled down to 1) collective leadership, 2) strong culture, 3)  inspiring purpose and 4) focused discipline.

I also discussed the importance of the attributes of each member of the team.  A great team member has 1) commitment to the task, 2) openness to discuss crucial and sensitive topics, 3) humility for listening and learning, 4) ability to maintain group optimism and enthusiasm, and 5) skills for acknowledging the dogmatic, then help them be better team members. These attributes were taken from the literature on teamwork and #5 seemed especially pertinent to physicians. Physicians tend to be dogmatic. And dogmatism can squash a team, especially in today’s rapidly changing environment and evolving workforce of generation Xers and Yers.  The message is that good teams have individuals who can acknowledge dogmatism  in a constructive way and help that person contribute.

There is a passage in Managing the Unexpected by Karl Weick and Kathleen Sutcliffe that speaks to how individuals on teams create a culture that drives team effectiveness: “Expertise resides in the heed with which people view their inputs as contributions rather than as solitary acts, represent the system within which their contributions and those of others interlock to produce outcomes, and subordinate their contributions to the well-being of the system, constantly mindful of what that system needs to remain productive and resilient.” [Managing the Unexpected p. 78]  When physicians are on teams, it’s usually because they bring critical expertise. Physicians are great team members when their actions and words serve the best interest of the organization, its people and the patients and communities they serve.

Communicating: some wise advice from Lao Tzu

For a leader one of the toughest challenges is communicating. Getting right the what and the how, the who and the when and even the where isn’t easy.  In certain situations, there is no perfect way.  Sometimes it’s not just what is said or how it’s said, but who is saying it that matters the most.   Effective communication starts with the speaker, the leader: their credibility and the level of trust the team or organization has in the leader.

Over the years I’ve worked hard at improving the effectiveness of my communication. With patients and families I’m effective most of the time, but there is always room to improve – the approach to communicating needs to be tailored to the individual, as well as the situation and circumstances – and that’s hard to get right every time.   Even within one episode of communication, the approach needs to be fluid.  This takes emotional intelligence and practice.

Lao Tau has some advice for communicators.  Lao Tau said, “He who knows does not speak.” He also said, “Practice doing ‘not doing’.” These two tenets of Daoism need to be front of mind when a leader is communicating.  He is telling us to listen – do more listening than speaking.

One can gain many lessons about communicating from Daoism. Daoism encourages one to consider that the whole is real and the divisive is perceptual.  A single idea or opinion cannot be good or bad, because that would place judgment, which is a comparative and perceptual approach not a synergistic or uniting one. To throw out an idea would threaten the balance of the whole.  Lao Tzu said, “Long and short complement each other.” Meaning you can’t have long unless you have short.  In communicating, one would do well to remember that nothing is really new, or better, or old or bad, it simply is, and whatever it is complements and colors the conversation, making it more whole, more real.  To do this takes listening.

Nevertheless speaking must be done. It’s what people expect from leaders. My first goal when I speak is to drive common values and principles, to align thinking and actions, and to motivate effort towards a shared vision.  In other words: be inspiring.  My second goal is to be a sensemaker.

It is the job of the leader to bring order to the whole in order to influence the group to reach their shared vision. This is called sensemaking. A leader must do it well and communicate it well to be a good leader. Lao Tzu said, “What is a wise man’s job, but to make another wise.” A leader’s job is to create wisdom for all. Great communicating requires a humanistic approach, which results in an increase in collective wisdom.

Tackling Task Saturation

Task saturation is the phenomenon whereby one’s brain becomes overloaded with significant information or stimuli and begins to fail itself. Task saturation often happens to a person when there is a crisis or when they are multitasking or when there is more to do in a given amount of time than is possible. Sounds like healthcare to me.

Pilots and nuclear reactor operators have developed methods and tools for overcoming task saturation. The most prominent are: 1) checklists, 2) mutual support, 3) crosschecks, and 4) huddles. Over the years, I’ve seen these things work in healthcare, but I’ve not seen them used as often as they could.  Crosschecks include double checks with colleagues, and making sure that all key indicators that will allow for effective sensemaking and situational awareness are being monitored.

Checklists exist in healthcare, but not often for crises or when the system is overwhelmed. Mutual support exists, but it’s often not there at times when it’s needed the most. Crosschecks are also used, such as in structured code situations, but they aren’t used enough. Huddles are increasingly being used, but often the time when they aren’t is when task saturation or a crisis is occurring. No one wants to take the time out to do it.

EMRs can be used to provide checklists, reminders and crosschecks. Working in teams and having huddles can provide mutual support. Having the collective discipline to stick to these principles when they are most needed is critical. Having “practiced” as a team with “learning” (debriefing) as part of the process is helpful.

The best medicine for task saturation, of course, is to avoid it from happening in the first place. Nevertheless, it happens enough in healthcare that it would be best to be prepared. How does one avoid task saturation? There have been examples where variability has been reduced despite the notion that variability in demand and volumes can’t be controlled in health care. Surge plans, flexible staffing, flexible roles, and early warning systems are all examples of preventing task saturation.


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.