Leadership Lessons From the Military
Howard Schultz, CEO of Starbucks, has published a review of Gen. Stanley McChrystal’s book, Team of Teams: New Rules of Engagement for a Complex World. He highlights the following lessons from the book.
We must, for one, become more comfortable sharing information, and thus “sharing power,” with our own people, our own customers, and even with our critics.
Leaders must also get comfortable with the unknown. It is hubris to assume that we can know it all, yet instant accessibility to news and “unprecedented amounts of data” can seduce us into believing we’re prescient, even though “what we cannot know” grows even faster than what we know.” How we respond to the unexpected—how resilient we are—matters more than proper planning.
Concepts such as “empathy” and “values” still don’t make it into enough board rooms. But when a battle worn general suggests that “nurturing and organization” is more effective than trying to oversee every move and insists that his own leadership is more akin to gardening than chess, it is worth paying attention.
Mr. Schultz suggests these lessons are useful in healthcare and other organizations, and I agree. For physicians, knowledge has indeed been power. To some the ready availability of medical information on the Internet has been seen as a threat, but I sense that younger physicians see this as a way to bring the patient into the process of their care. On the other hand, meaningful use criteria mandate expensive secure data portals to allow patient access to their own information, which has proven costly and probably not as useful as the planners have assumed. Perhaps this should be seen as just as bump in the road of “progress,” but I have found that the patients who access their data are the ones who were already activated. I have not found the electronic health portals to be an activator. Nonetheless, the democratization of medical information has had a profound impact on the way medicine is practiced.
Quality performance data are also being made public in hopes of further improvement and activation, but I think this effort is not going to be as successful. First, for most diseases, we have very few performance measures that are solidly based on outcomes. Most of our current measures are rates of testing or prescribing with, at best, a loose correlation with outcomes of interest to the patient. Second, the unit of analysis is too small. Most data are being reported by physician. But for any number to be reasonably stable from a statistical perspective, there need to be 30 data points, or patients, involved. Even busy surgeons are not going to do more than 30 operations of one kind very often in a given year. It would make more sense if we could find ways to aggregate data into meaningful small groups, such as a practice, or perhaps a cluster of surgeons and a specific hospital, where hospital measures matter.
Neither patients nor doctors really like uncertainty, or the unknown. Whole industries are developing to mine big data with the expectation this will make care cheaper and more effective. The logic error is assuming that data is equal to information. On the other hand, big data may show that what we are currently doing has hazards. A recent report showed that for patients with hypertension, 63% were prescribed a statin, 43% were being treated for diabetes, 36% were prescribed an opiate, and 27% were on an antidepressant. 46% received an antibiotic prescription during the study period. What the study did not describe is how many patients were in more than two of these groups, but certainly many were. Predicting the value of tight blood pressure control in this real world dataset would be complex, given the confounders described. Yet we push on with tight control goals in elderly patients where the data don’t support the effort, because it is a publicly reported quality measure. This is the law of unintended consequences in action.
I have previously discussed the notion of resiliency in healthcare at length. In the context of this article, though, I want to share a recent report of how the people at Harvard Vanguard Medical Associates have used CQI methods to improve the resilience of their organization. The details of their methods are likely unique to their organization, but the principles seem to be generic. First, they spent time getting both senior management and middle management on board with the notion that improving measurable clinical outcomes was their primary goal. They then organized a process to get “breakthrough goals” accomplished that were important to their clinical teams, and used this as an opportunity to teach front line physicians, managers, and staff how to acquire data from their work so as to assess improvement. They then set about “managing for daily improvement.” To do this, they combined the usual policy and procedure approach with the guideline approach to develop a dynamic statement of “how we do things around here.” They developed visual data displays that were easy for everyone to see so they could see if improvements were being made, and they set about trying to solve problems on a daily basis, rather than waiting for the inevitable crisis to arise. In the terms of General McChrystal’s book, they were pushing information (not data) to the front line leaders and empowering them to make changes on the fly, just as he found it necessary to do conducting the war in Afghanistan.
I predict the winners in the current reshuffling of the healthcare deck will be those that build resilient organizations—particularly those that can prove they are taking care of patients and staff as well as their bank account. Curiously, there is no established business school model that accounts for the strategic value of building resilient, stable teams. My colleagues and I are in the process of trying to get empiric data that establish a relationship between staff stability and experience and both clinical and financial performance. Stay tuned.
14 May 2015
 The Wall Street Journal, 13 May 2015, p. A11.
 Polypharmacy and Hypertension. Group Practice Journal 2015(March);54:4.
 McGinnis G. A Transformative Journey at Harvard Vanguard Medical Associates. Group Practice Journal 2015(March):54:11-17.
Doctors and hospitals operate with different cultures and unexamined assumptions may cause conflict.
A short presentation about medical leadership grafted onto a presentation.
New Leadership Skills for Physicians
David Brooks has identified highly valued skills in the modern world. The good news is that physicians already use three of them.
Paradoxes for Physician Leadership
I started this website to share some notions about physician leadership. I have also reviewed many other people’s ideas about these subjects, some of which I have shared in other articles. What strikes me about much of the “literature” on physician leadership, though, is how they fail to grapple with the inherent paradoxes of the role of physician leader. Here are some that I think matter, with some links to other articles on this site, which develop the ideas in more detail.
The Case for Physician Leadership
Why the successful healthcare organization of the future must find a way to create physician leadership if it is to achieve the IHI Triple Aim.