The Costs of Leadership—Part 2
My recent article on the costs of leadership prompted some input that calls for elaboration. At one point I wrote:
“Consider a buzz phrase we use all the time in medical organizations—we want to provide excellent clinical care. What does that look like? How do the leaders make the definition real once it is agreed upon? We have considered this issue in detail in other articles on this website, so let me just say that each organization must define high quality care for itself, being careful to be as granular and specific as possible. Too often, I fear, we opt for platitudes that sound good, but have no working definition, and certainly no way to insure they are incorporated as a matter of routine.”
Paolo Quattrone wrote that corporations should take lessons from the Roman Catholic Society of Jesus, more familiarly known as the Jesuits, if they wanted to endure. He states:
“When facing the unknown…or the unknowable…and still having to function, it is best to conduct oneself according to the Jesuit adage perinde ac cadaver, or “in the manner of a corpse,” and making a difference by remaining indifferent…When governing means dealing with difference, nothing is more powerful than nothing. To exploit the power of the negative, rather than seeking comfort in positive, but useless and transitory definitions of purpose, it is better to turn to rhetoric, religion, and accounting for their exploratory and community-building power.”
Obviously, I don’t agree with his position, but it does remind me that I failed to emphasize the limits of leadership when I wrote: “Another cost of leadership, then, means defining and making operational a working definition of the organization’s goals.” One thing to remember is that medical care takes place in the context of one caregiver and one patient at a time (even if others are in the room,) and both persons bring individual knowledge, skills, attitudes, and assumptions into the encounter. And none of these elements is known in detail, not even to the individuals. What leadership has to do is define the boundaries of what is acceptable, not try to regulate the encounter, which is essentially unknowable and unmeasurable. Another way to express the issue is to recognize that “high quality care” is also inherently unmeasurable and is, at best, an aspirational goal. However, organizations can and do have an obligation to minimize the risks of giving bad care.
Measurement, or the accounting culture as I have labeled it previously, is here to stay, because it reflects a desire for “objectivity,” as opposed to subjectivity. This desire has costs to both leaders and followers, as noted by my son, who works on the business side of a university.
“Amongst a number of other things that occurred to me, there can be an acute sense of being over scrutinized and under-appreciated in any metrics driven organization. Coupled with the distance between accountability as a leader and direct agency to influence the outcome and that sounds like a recipe for frustration to me.
A variation on a Hermann grid optical illusion, got me thinking of an analogy to watching, metrics and the motivation on the part of those being measured. From a figurative “top-down”, it is frustrating to know there are 12 dots and be unaware of why you are unable to see all the dots at once. From a bottom-up perspective, it would create the frustration of being graded on all of the dots, but only “noticed” for the negatives, the bias in any sort of process improvement.
It struck me as a parallel to the situation with your nursing leaders. In the abstract calculation of the “cost” of metrics, what estimate is made for the impact on morale of those being measured? Metrics are also somewhat, interpretive – sometimes cited as reading the writing on the wall. When Daniel interpreted the writing on the wall, he told Belshazzar he had been weighed and found wanting – personal failure and doom was the message.”
Finally, Gitte Frederiksen has presented the view that the traditional hierarchical organization chart obscures the point that great leadership is always relational. And hierarchies, and “impersonal” metrics interfere with this.I am reminded, as one example, of the famous photograph of General Eisenhower meeting with soldiers from the 101st Airborne Division the day before D-Day. The general and soldiers all knew some of them would be killed the next day, and he thought it important to meet with some of them and make sure they understood the why, using his personal charisma to make the point. He also had two messages in his pocket, the one for success that was actually issued the next day, and the other taking personal responsibility and blame for failure.
Leadership is invariably personal, both to the leader and to those being lead. The leader often gets undue credit when things go well, but also gets undue blame when things go badly. Certainly, in our contentious times, no decision, however carefully stated and explained, can escape criticism, and the person making the decision will also be criticized. I wonder if our current misapplication of metrics, which do have a role, reflect a desire to hide from this reality? After all, the “numbers made me do it.” Is this just a modern, secular version of “the devil made me do it?”
30 November 2022
 Quattrone P. Jesuits in the Boardroom. 4 November 2022. Accessed 18 November 2022 at https://aeon.co/essays/lessons-in-corporate-governance-from-the-jesuits.htm
 https://www.ted.com/talks/gitte_frederiksen_great_leadership_is_a_network_not_a_hierarchy, viewed 17 November 2022.
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