Author: Dr. Derek Wheeler

Attending Physician

Associate Chief of Staff

Associate Professor, UC Department of Pediatrics

“Leadership is the art of accomplishing more than the science of management says is possible.”
General Colin Powell, Chairman (Ret), Joint Chiefs of Staff

“Our lives begin to end the day we become silent about things that matter.”
Martin Luther King, Jr.

Leadership is a word you hear about a lot these days.  There are over 94,000 books on leadership available for purchase on Amazon.com.  As of June 27, 2013, a PubMed search using the key word leadership generated over 36,000 articles relevant to healthcare.  Given all of this attention, I think it is safe to assume that leadership is an important topic!  However, is it safe to assume that leadership is important to building a high reliability organization?  What exactly is leadership?  Finally, and perhaps most importantly, can leadership be taught?

We know that high reliability organizations are based upon strong and effective leadership (1).  Mark Chassin, the President and CEO of the Joint Commission, said that there are three elements that are critical for achieving high reliability in health care today – leadership, safety culture, and a robust system of process improvement (2).  Leadership in high reliability organizations is all about setting the overall tone and mission priorities that build a culture of reliability and safety (3, 4).  John Kotter, one of the world’s foremost authorities on leadership, draws an important distinction between leadership and management.  Leadership consists of establishing the direction, aligning the people, and motivating and inspiring people, all of which “promotes movement” to change for the better.  Management, on the other hand, consists of planning and budgeting, organizing and staffing, and controlling and problem solving to make sure that an organization runs efficiently and smoothly (5, 6).  Both leadership and management are incredibly important – but true transformation into a high reliability organization requires strong leadership.

We also know that achieving quality and safety can be expensive (7).  Building a high reliability organization takes a significant investment of resources, which may be a difficult proposition, especially at a time when these resources are so limited in healthcare.  Strong leadership is therefore required to provide the necessary resources and eliminate the barriers that are required to achieve high reliability.

Unfortunately, there have been a number of high profile cases suggesting that misaligned or misdirected leadership priorities were directly responsible for poor outcomes, e.g. the children’s heart surgery program at the Bristol Royal Infirmary (8) and the more recently published Francis report (9) to name a few.  Now, more than ever, we need strong leadership to establish and build a reporting culture, so that healthcare providers are encouraged – even rewarded – to report safety incidents and near-misses.  We need leadership to build a learning culture, so that healthcare providers at the bedside can learn from their mistakes, slips, and lapses.  We need leadership to build a flexible culture, based upon mutual respect and trust, in which the traditional managerial hierarchy is flattened so that we truly push crisis decision-making to the bedside.  Finally, we need leadership to build a just culture, where the distinction between what is acceptable and unacceptable behavior is clear (10, 11).

So, leadership is important and foundational, but what exactly is leadership?  I define leadership as the ability to develop, plan, communicate, and execute a vision in order to accomplish an objective.  Successful leaders know how to define the task at hand and frame it in such a way that their teams share a collective mental model of the situation.  Successful leaders know what it will take for their teams to achieve these objectives and will ensure that their teams have the right set of tools, training, and experience to fulfill these objectives.  Successful leaders know how to provide their teams with the proper reinforcement and feedback to further influence successful completion of the team’s objectives and prepare for the next task.

Given my military background, I have always been interested in learning about the different leadership styles and influences of great military leaders.  I particularly admire the leadership of the famous Civil War general, Joshua Lawrence Chamberlain (12).  Chamberlain was awarded the Congressional Medal of Honor at the Battle of Gettysburg for feats immortalized in the novel, The Killer Angels (13) and the film Gettysburg that was based on that same novel.  During the Battle of Gettysburg, Chamberlain was a Colonel in charge of the 20th Maine Regiment of the Union Army.  On the second day of the battle, Union forces had been pushed back to a defensive position on a line of hills south of the town of Gettysburg, Pennsylvania.  The 20th Maine Regiment was positioned at the extreme left flank of the Union line, where they had received orders to defend a hill known as Little Round Top.  This particular defensive position was extremely important to maintain.  The Confederate army led several charges up the hill in an attempt to flank the Union defensive line, which would have led to the destruction of the entire Union Army.  However, each attempt was successfully repelled by the 20th Maine Regiment.  Towards the end of the day, the 20th Maine Regiment had suffered many casualties and was almost out of ammunition.  Chamberlain immediately recognized the predicament in which they were in and ordered his men to fix bayonets and charge downhill, executing an extremely complex marching maneuver known as a “right-wheel forward.”  The Union line was saved and the Union Army went on to win the battle.  Chamberlain continued to serve for the remainder of the Civil War with great distinction and had the honor of receiving General Robert E. Lee’s surrender at Appomattox Court House, ending the war.

I admire Joshua Chamberlain’s courage under fire, as well as his tenacity and leadership at the Battle of Gettysburg.  He clearly understood the objective (“hold Little Round Top at all costs”) and was able to communicate that objective, however difficult, to his troops.  He developed a plan to defend the hill and was able to execute that plan flawlessly.  However, I most admire Chamberlain for the fact that he did not come from a military background.  Many of the great leaders during the Civil War (Grant, Sherman, Lee, Jackson, and Longstreet, to name just a few) received their military education and training at the U.S. Military Academy at West Point.  Many of these leaders served with distinction in the Army during the Mexican-American War.  Chamberlain, on the other hand, graduated from Bowdoin College and the Bangor Theological Seminary in his home state, Maine.  Following graduation, he became a college professor, teaching rhetoric at his alma mater.  He entered the war without any formal training in military science.  Rather, he enlisted in the Army with a strong desire to serve his country.

Chamberlain’s story is an inspiration and lesson for us all.  His story tells us that leadership, one of the most important and foundational elements in any high reliability organization can be learned.  While there is no doubt that he had the necessary passion, courage, and resolve, Chamberlain clearly lacked military training and experience.  Chamberlain’s leadership, developed over many years serving as a college professor and honed to perfection during the initial stages of the Civil War, saved the day.  General Colin Powell, another military leader from more recent times said, “Good leaders are made, not born” (14).

Leadership is key to achieving high reliability in health care.  We can learn a lot about leadership from other industries, just like we can apply many of the lessons learned from other high reliability organizations in health care.  The transformation that is required, however, will require strong leadership.  Fortunately, we know that leadership is a learned trait!  Now the onus is on us to not only provide that strong leadership, but also to train and mentor our young providers in health care to be the kinds of leaders that we will need tomorrow.

1. Roberts KH, Yu K, van Stralen D.  Patient safety as an organizational systems issue: Lessons from a variety of industries.  In: Youngberg BJ, Hatlie MJ (eds): The Patient Safety Handbook, Sudbury, MA: Jones and Bartlett, 2004.

2. Chassin MR, Loeb JM.  The ongoing quality improvement journey: Next stop, high reliability.  Health Aff 2011; 30:559-568

3. Ruchlin HS, Dubbs NL, Callahan MA.  The role of leadership in instilling a culture of safety: Lessons from the literature.  J Healthc Manag 2004; 49:47-59

4. Clarke JR, Lerner JC, Marella W.  The role for leaders of health care organizations in patient safety.  Am J Med Quality 2007; 22:311-318

5. Kotter JP.  A Force for Change: How Leadership Differs from Management,  New York: The Free Press, 1990

6. Kotter JP.  Leading change: Why transformation efforts fail.  Harv Bus Rev 1995; 73:660-668

7. Repenning NP, Sterman JD.  Nobody ever gets credit for fixing problems that never happened: Creating and sustaining process improvement.  Calif Manage Rev 2001; 43:64-88

8. Learning from Bristol: The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995http://webarchive.nationalarchives.gov.uk/20090811143745/http://www.bristol-inquiry.org.uk, Accessed June 27, 2013

9. Mid Staffordshire NHS Foundation Trust.  Public Inquiry – Chaired by Robert Francis QC.  Final Report.  Three volumes.  2013. www.midstaffspublicinquiry.com/report, Accessed June 27, 2013

10. Halligan A.  The Francis report: What you permit, you promote.  J R Soc Med 2013; 106:116-117

11. Reason J.  Human error: Models and management.  British Med J 2000; 320:768-770

12. Joshua Lawrence Chamberlain. http://www.civilwar.org/education/history/biographies/joshua-lawrence-chamberlain.html?gclid=CMP5_L-4hLgCFegWMgodGHoAvw, Accessed June 27, 2013.

13. Shaara M.  The Killer Angels: A Novel of the Civil War, New York: Ballantine Books, 1974

14. Stanford Graduate School of Business.  Good Leaders Are Made, Not Born, Says Colin Powell.  November 1, 2005. http://www.gsb.stanford.edu/news/headlines/vftt_powell.shtml, Accessed June 27, 2013.