HiPPOs, Rivals and Checklists

"Leadership is the ability to facilitate movement in the needed direction and have people feel good about it." - Tony Smith, consultant

I

I'll never forget one liver transplant selection meeting during my first year in fellowship as a gastroenterologist. I was still early in my training. I had just come off overnight call at another hospital and had dealt with the usual combination of ulcer bleed, variceal cirrhotics and diverticulitis.

A transplant selection meeting is an entirely fascinating if not somber meeting. A huge group of people - 40-50 at times - from chiefs of surgery all the way to social worker interns sit together and decide who to list and select for organs based on a dizzying array of factors.

Who lives who dies?

It's as high stakes as it gets.

As the hepatology fellow, I presented the cases to the entire group - a role that is anxiety and pressure filled as you can imagine. As I went through my list of cases, one patient's name caught my eye - one of the variceal bleeders I had just scope a few days ago. He had come in actively intoxicated and severe alcoholic cirrhosis

And he was approved for transplant listing and later received one.

I was flabbergasted. Apparently this patient was well connected to some big donors to the hospital. I talked privately to my attending, a mild manner person, afterwards - why didn't he say anything?

"We don't want to create any problems for the surgeons. Our job is to give them patients so they can get organs"

That experience never left me and more than anything was the residue of my own failure to speak truth to power.

II

We've talked extensively about how central culture is to an organization's effectiveness is. Healthcare struggles with innovation, reform, and quality improvement (among other things) because of a fundamental culture problem of HIPPOs - the highest paid person in the organization.

For all our emphasis on data and evidence based medicine, healthcare delivery is fundamentally heiarchical and personality driven. In medicine, it is often the problem of the highest ranking person in the room - in that regards, medicine and the military are quite similar.

This problem has worsened in the era of managed care and healthcare provider consolidation, in which employers have more financial leverage over their employees. People don't speak out because there is no psychological safety to do so. A top down organization is only so effective.

Of course there is value in the wisdom of experience, but over deference to its value is the reason healthcare has been stuck in every dimension - and why I didn't advocate during that organ transplant selection meeting.

It is also the reason that government tends to be slow to innovation and bureaucratic. As Jennifer Pahlka describes in her new book Recoding America, there is an over emphasis on compliance with protocol as opposed to asking hard questions regarding what an organization is doing and why. In her analysis of this problem, when asked why so many government workers don't speak out more, the usual answer is some form of "so I don't get blamed."

This is also the central problem with the use of checklists. While they have revolutionized healthcare safety, they are only useful for technical leadership problems. These are problems with clear solutions and defined metrics of success. Checklists, in this arena, are excellent tools for implementation.

However, adaptive leadership problems are ones in which no clear solution exists and multiple strategic options are available. They are characterized by limited information and uncertainty.

AI, social media, and remote work are two new professional technologies that will affect this bias dramatically. Millennials, in particular, who grew up as digital natives on social media networks like IG and TikTok as well as on Zoom. These are platforms in which there is no clear authority (clearly). Younger workers are more comfortable with decentralized or "flat" organizations in which decision making power is dispersed not unlike the blockchain. In fact, this is cloud life is the explicit dream of technologists in which all institutions and even nation states are irrelevant.

Social media spread healthcare (mis)information and reduce the relevance of traditional medical authority. AI seeks to promise a future in which our traditional expertise is less aggregated with doctors alone. These will shift the dynamics of the patient encounter in the clinic room, but it remains to be seen if this will translate to the boardroom.

III

Obama recognized this trend and specifically hired a team of rivals ala Lincoln to be in his cabinet. He wanted disagreement and foment. He recognized being the POTUS means avoiding yes men and women and out of the bubble that authority can create.

Remember, leadership creates authority but authority alone cannot be the basis of true leadership.

This is the central paradox of leadership - it takes incredible self control and strength to work through other people. To be able empower them but also direct them when needed. To invite disagreement but not become defensive.

What is the solution to the HIPOO? Provider and employee empowerment. People need to feel that their voices matter, their opinions actually count, and that there is encouragement not punishment for dissenting views.

Leaders should not only eat last but speak last. Let others speak their truth without fear of reprisal.

Don't "disagree but" but "disagree and" when it comes to decision making. "But" is a preposition that is a wall; "and" is a bridge. It allows for disagreement and yet opens a door for collective action.

Make everyone an expert. The pandemic demonstrated there is no such thing as unskilled labor, no matter how seemingly mundane a task appears.

And go to bat for people who speak truth to power.

It is what I needed back then during that liver transplant meeting.

And isn't that the hope of a leader? To be the source of support we wished we had?

Ignite your leadership,