Lifespace and Lifetime Leadership · authors intend readers to pray for. Every day and in every country pastors, teachers and other Christian leaders rank high on the tally of needs.

Copyright - Mark D. Harris 2014 Page 1

Lifespace and Lifetime

Leadership

Mark D. Harris

MD, MPH, MBA, MDiv

Colonel, SFS, US Army


Table of Contents

Introduction: The Need for Leadership 3

Leadership in Space and Time 4

Part 1 - Lifespace and Lifetime Leadership – Foundational Matters 6

Chapter 1 - Six Leader Tasks 7

Chapter 2 - Leadership in Followership 9

Chapter 3-Leadership in Excellence 11

Chapter 4-Leadership in Vision 14

Chapter 5-Leadership in Communication 17

Chapter 6- Leadership in Systems and Structures 20

Chapter 7-Leadership in Selfless Service 22

Part 2 - Lifespace and Lifetime Leadership – Practical Matters 24

Chapter 8 - Awards and Recognition Ceremonies – Are They Really All About You? 25

Chapter 9 - Bridging Strategic Thinking with Tactical Operations 29

Chapter 10 - Briefing Senior Leaders 34

Chapter 11 - Business Models for the 1st and 21st Centuries 40

Chapter 12 - Discovery and Innovation in the Business of Health Care 43

Chapter 13 - Formal Business Visits and Town Halls 50

Chapter 14- Getting People to Answer 57

Chapter 15- Getting Things Done in Military Medicine 62

Chapter 16- Integrity and Leadership 71

Chapter 17- Making Meetings Matter 75

Chapter 18 - The Dance of the Headquarters 82

Chapter 19 - The Informative Brief 87

Chapter 20 - The Long Shadow - How to follow a Superstar 91

Chapter 21- Understanding Problems 94

Chapter 22- What to do with Tradition 97

Appendix – Leadership Models 101


Introduction - The Need for Leadership

Why do we need to talk about leadership?

Many are calling out for better military leadership:

1. Forbes magazine 27 July 2012 - The Key Missing Ingredient in Leadership Today

2. Forbes magazine 31 July 2012 - The Key Missing Leadership Ingredient: Part 2 -- The

Military

3. Time magazine 21 Jan 2013 – Why Can’t the US Military Grow Better Leaders?

4. Washington Post 28 Jan 2014 - Pentagon investigations point to military system that

promotes abusive leaders.

The need for leadership in health care

1. The US spends more on health care than any other developed country

2. Quality is the best in the world in many areas (cancer survival)

3. Life expectancy and infant mortality are not as good as some other countries spending

else.

4. Benefits of US health care are unevenly spread throughout the population

5. Costs are growing fast

6. Estimated 30% waste in the system

The need for leadership in Christian ministry

Operation World is a prayer guide for missions throughout the world which highlights countries

and ministries each day for 365 days. It lists answers to prayer and then prayer needs that the

authors’ intend readers to pray for. Every day and in every country pastors, teachers and other

Christian leaders rank high on the tally of needs.

My professional background is in military medicine and my non-profit background is in Christian

ministry, so the examples that I will use come largely from those fields. However the underlying

principles are useful in every field. The chapter “Getting things done in Military Medicine” could

have a few words and examples changed and be renamed “Getting things done in the financial

industry” or “Getting things done in politics” or any other field. Readers are encouraged to

grasp the principles and apply them to their own situation.


Leadership in Space and Time

The universe was created to function in space and time, or spacetime as our physics teachers

would say, because really space and time are two aspects of the same thing. Man thinks in

space and time, acts in space and time, and lives in space and time. He also leads in space and

time.

Leadership theories and models provide useful insights for students of leadership, and each

addresses a different life space and life time. For example, the Temperaments Model of

Personality and the Jungian theories about personality, as expressed in the Myers-Briggs

inventory, look at individual characteristics, borne of nature and of nurture, and their effects on

leadership. The lifespace they focus on is the person, and though they describe attributes that

last for a lifetime, they focus on early life, the time when personality is primarily developed.

Leadership studies focusing on leader attributes have been among the earliest approaches to

building better leaders.

The following timeline illustrates leadership models and their spacetime emphasis.

Theory Temperaments (Four Humors) Jung (Myers-Briggs personality)

Three levels of leadership

Five Levels of Personal Influence

Types of Leadership

Situational Leadership

Space Individual leaders

1. Public – with distant others

2. Private – with close others

3. Personal – within yourself

1. Vision casting

2. Living out convictions and values

3. Sharing teachable points of view

4. Hands on skill development

5. Personal impact

1. Administrative 2. Entrepreneurial 3. Mentoring 4. Crisis

1. Directing 2. Coaching 3. Supporting 4. Delegating

Time Most influenced by early life

Emphasize actions at discrete times in life

Emphasize relationships throughout life

Emphasize adapting to the situation at hand

Emphasize adapting to characteristics of followers


Other types of leadership, such as servant leadership, focus on the character of the leader and

how he perceives his responsibilities as leader. In years as a leader in health care, the military,

and the Church, I find that focusing on “what a leader does” instead of “who a leader is” is

more productive producing long term change.


Part 1


Leadership – Foundational

Matters


Six Leader Tasks

Six Leader Tasks is an approach to leadership that I have developed over more than two

decades in military, medicine, ministry, and business. It is intended to provide another

framework, a largely temporal one, into which leaders can use other models. For example,

servant leadership and behavioral styles speak on how leaders lead in the present and how they

can do it better in the future. Six Leader Tasks discusses how leaders develop and improve

chronologically over a lifetime. Six Leader Tasks also has iterative and continuous application.

Six Leader Tasks is roughly chronological. A well raised child begins by learning to follow

(Followership). With time he gains expertise through formal and informal education. Eventually

the individual’s aptitudes and inclinations lead to a choice of career, or at least a general field of

endeavor. As the person learns more about his field (Excellence), he gains a sense of where his

field is and where it should be going (Vision). With the experience of years in the field his vision

becomes clearer and he learns to communicate it with others (Communication). If the man has

followed well, has become excellent in his field, has a clear picture of where his organization

should be going and has communicated it effectively to others, he is likely to be given positions

of responsibility through which he can shape the organization (Systems and Structures). Such

heights can be dizzying, and the successful man must remain grounded in the reality that it is

not about him lest he self-destruct through arrogance (Selfless Service). This process occurs

over years.

Six Leader Tasks is also iterative. As early as high school high achieving young men and women

who have learned to follow, join groups such as clubs and honor societies. They become

excellent compared to their peers in their group subjects, develop a vision for where the group

should grow, communicate the vision to others, and develop policies to shape the group. When

they enter college and the workforce the process repeats itself with other groups and other

people. A young officer will go through the process as he leads a platoon, a company, a

battalion, a brigade, and perhaps even a division. A young businesswoman will go through the

process as she leads a small department, a larger department, a store, a local group of stores,

and perhaps even all her company’s stores in a region.

Six Leader Tasks is also continuous. Chief executives must also be followers, Nobel-winning

scientists must continuously gain excellence, presidents must refine their vision, movie stars

must improve their communication, master architects and policy leaders must build better

systems and structures, and monarchs must serve selflessly. The man or woman who fails to

grow is the one who ultimately fails completely.


I have taught the concepts of Six Leader Tasks to military members, civilians, businesspeople,

health care workers, and ministers. It has been effective in their leadership ambitions, and I

hope that this construct will serve my new readers and students also.

Leadership in Followership Six Leader Tasks

Leadership in Excellence

Leadership in Vision Leadership in Communication Leadership in Systems and Structures

Leadership in Selfless Service


Leadership in Followership

Key Concepts

Learn to

follow before

you lead

Learn to obey

before you are

obeyed

Learn to

understand

before you are

understood

Learn to experience

the bottom before

you are on top

Learn to serve

before you are

served

Mentoring in Military Leadership – Military education includes the standard didactic (lecture)

and experiential (lab) structure. However, personnel are typically assigned to the same job for

2-3 years, and so the potential for mentoring is great. Mentoring is a continuum; from highly

formal and structured programs to completely informal and unstructured programs that have

more of the feel of a friendship than a business relationship. Mentoring can occur over long

periods of time, or can be as brief as one event. Sometimes mentors do not recognize the role

they played in others’ lives. COL (R) Charles Callahan, COL (R) John McGrath and GEN Martin

Dempsey have been mentors in my military career

Mentoring in Health Care Leadership – Traditional medical education begins in college, and

traditional college courses include didactic (lecture) as well as experiential (lab) instruction. The

first two years of medical school often follow the same structure. The second half, and all of

postgraduate residency training, include a smaller percentage of formal lectures and a greater

percentage of on-the-job (OJT) training. Mentoring is difficult because this OJT occurs in

rotations of 2-4 weeks, with trainers and trainees swapping out regularly. Dr. Kevin deWeber

and Dr. James Cook have been mentors for me in medicine.

Mentoring in Christian Leadership – It is possible to have a productive life in health care as a

“lone wolf”, a superspecialist in a narrow field who interacts little with others. This approach is

difficult in the military and impossible in the Church. Even as Elijah mentored Elisha, young

ministers cannot succeed without the guiding hand of a godly mentor. Reverend Richard

Harding, Reverend Reid Jepson, and Reverend Mike Woods have been mentors for me in

ministry.

Uniquenesses of Followership in the Military – The worst outcome in business is often to ruin

the business and lose a job, the worst outcome in health care might be to kill a patient and lose

a career, but the worst outcome in the military is to lose one’s own life, and the lives of one’s

friends. Therefore the need to follow well, including instant obedience if necessary, is

paramount. Leaders and followers must have implicit confidence in one another and at times

must obey without question. This is the case often in combat, when there is never enough time.


In the movie The Karate Kid, the high school aged hero Daniel was learning from karate from

the much older and wiser Mr. Myagi. Mr. Myagi had instructed Daniel to wash his cars, clean

his deck, paint his fence, and even paint his house and done so doing specific movements that

would train his student in blocking, martial arts defensive maneuvers. Daniel did the work but

grew increasingly exasperated as his lessons seemed less like karate and more like slavery.

Most high school kids, and even adults, wouldn’t have done it for long. Feeling like he was

being used instead of being trained, he lost his temper and nearly quit. Mr. Myagi revealed the

value in his lessons, and Daniel continued. He had to learn followership; to obey, to serve, to

understand, to follow, and to trust, before he could learn excellence in karate, and later in life.

In another example, I served as an orderly in a hospital in La Mirada, CA, while in college. Later I

worked as an emergency medical technician (ambulance driver) in Riverside, CA while on

summer break from medical school. As a medical student I followed the orders of my attending

and my residents, and got varying degrees of respect from my patients.

When I followed well, with a humble spirit, an open mind and a willingness to work hard, I

learned a lot. I also gained credibility with all of those involved, the nurses, the doctors, and the

patients. When I followed poorly, proudly unwilling to listen or to work, I learned little and I lost

standing with the others.

Discussion/Application

Have you been mentored? What experiences have you had? Who were some of your mentors?

How did things turn out for you? Have you experienced the kind of implicit leadership and

followership so required in combat? Have you had an experience in which you felt mistreated,

only to find that your leader was doing the very best thing for you?

Every leader must learn to follow; no one enters any field or organization at the top. What

experiences have you had in being willing, or unwilling, to follow? How did things turn out for

you?

http://www.youtube.com/watch?v=1K24jL-06H0



Types of power - The most effective leaders are excellent in all of these:

Position and rank

power

Expert

power

Connection

power

Reward and

punishment

Referent power

Where you sit on

the

organizational

chart

What you

know about

the topic at

hand

Who you know

who can assist

with the issue at

hand

What can you

do for and to

others

Being liked and

respected, which

gives the ability to

convey approval to

others

Expert power is harder to gain in the military since the services require an additional set of skills

in its leaders. An infantry officer must learn infantry skills and also military skills. An Air Force

pilot must learn to fly an aircraft and also to be an Air Force Officer. A Navy physician must be

an excellent health care professional as well as an excellent naval officer. Naturally, all of these

people must also learn business skills such as budgeting, logistics and human relations.

Position power is also different in the military. Many organizations have one primary hierarchy,

that of position. A businessman in a small retail company may progress from store manager to

district manager to vice president to president of his company. A physician may move from

service chief to department chief to chief medical officer to chief executive of his hospital. The

military has two primary hierarchies, one of position and another of rank. These usually track

together but sometimes do not. A sharp lieutenant colonel (LTC) commanding an infantry

battalion may have a colonel (COL) as his battalion physician. The LTC has greater position

power but the COL has greater rank power.

Leaders must build power in all of these areas to effectively lead their team. In medicine,

doctors spend their early days becoming excellent doctors. Referent and expert power usually

come first, followed by connection power. Position and reward/punishment follows

last. Leadership is possible without position power or reward and punishment power. These are

among the weakest kinds of power.

In medicine, physicians have always held the dominant position in the power structure. This is

because physicians possess the expert power, including knowledge and technical expertise, that

people want and need. Nurses, technicians, and others play vital roles and are just as important

to the overall health care team (and the patient’s overall health) as the physician is. Expert

power is extremely important in health care, probably more so than in other fields such as

business. Medicine is also different from other fields in that it deals in intensely important and


personal issues, sometimes life and death. As such some people consider health care to be a

right in a way that owning a car or other commercial activities is not.

Young aspirants to the health care industry sometimes come to me asking what field they

should pursue. Most want to become doctors, largely because of the perceived money,

prestige, and importance to the patient. However a health care worker’s importance has to do

with the patient’s need at the moment. For someone presenting to the emergency room with a

ruptured appendix, the most important people are the front desk clerk and the triage nurse. If

they fail in their work, the patient is in danger. Next the emergency physician steps on to the

center stage, needing to quickly make the right diagnosis and refer to the right surgeon. After

this the nursing staff becomes the most vital in this person’s care. During the operation the

highest paid members of the team, anesthesia and surgery, take leading roles. Once the

operation is over, nurses again become the most important members of the health care team

for that patient at that time.

There can be a discrepancy between position and rank power in health care, especially in

academics. Person A may be an associate professor and run a department, but person B may be

a full professor and run nothing at all.

Billy Mitchell (1879-1936) is known as the Father of the US Air Force. A self-trained pilot in

1916, he became one of the most successful American pilots in WWI and eventually

commanded all US Army combat air units in France. In 1918 at the age of 39 he was promoted

to Brigadier General, but was so abrasive and insubordinate that he was reduced to Colonel and

ultimately court martialed in 1925.

William Worrall Mayo (1819–1911) and his sons William James Mayo (1861–1939) and Charles

Horace Mayo (1865–1939) founded the world renowned Mayo Clinic. Their good surgical

outcomes as a result of early adoption of surgical sterilization, their pioneering medical records

and their innovative group practice model made them leaders in American medicine. Both of

the brothers served as president of the American Medical Association.


In what areas of power are you strong? In what areas are you weak? What are you doing to

strengthen both? In areas of weakness, what are you doing to build the right team around you

to compensate? Do you listen to your team?

What struggles have you faced with discrepancies in power in your organization? What about

circumstances in which position and rank power did not coincide?


Excellence in a technical field is vital to have expert authority in the field, but technical

expertise is not enough. The finest leaders are expert in their field, are likeable, and have good

connections. They are able to develop a solid vision, communicate well and serve others even

before they hold powerful positions.

In what areas of power are you strong? In what areas are you weak? What are you doing to

strengthen both? In areas of weakness, what are you doing to build the right team around you

to compensate? Do you listen to your team?


Leadership in Vision

The fundamental task of leadership is to know where the organization needs to go. In the

military, the enemy forces are the most common target. In health care, the patient is the North

Star, the guiding light, and meeting his or her needs, and those of the other stakeholders, is the

objective. Only then can the leader begin figuring out how to get there and motivating his

followers to do so.

‘I see only one thing,’ Napoleon declared in 1797, ‘namely the enemy’s main body. I try to crush

it, confident that secondary matters will then settle themselves.’ Likewise Lincoln told his Army

commander, George McClellan “I think Lee's army and not Richmond, is your true objective

point.”

Once he or she knows where to go, the leader must figure out how to get there. Then he or she

must motivate his or her followers to get there.

1. Vision is impossible without imagination, because such a person will not be able to

envision how the future should look.

2. Vision is impossible without expertise (expert power), because a leader must know

where an organization (and an industry) is before he can lead it to where it should be.

3. Vision is impossible without connection power because other experts help shape the

vision into a realistic and workable future.

4. Progress on the vision is impossible without connection power because no one can do

anything worthwhile alone. Others are always required, even for seemingly individual

activities (sports, academics). Others with expert and referent power must buy into the

vision, make it their own, and shape and promote it.

5. Progress on the vision is impossible without referential power because people will not

follow those they dislike, or at least do not believe in.

6. The leader himself must be passionate about the vision. No one can long inspire others

who himself is not inspired. Leaders must exemplify the vision.

7. Must be clear, accepted by the majority of stakeholders, and translatable into

measurable outcomes that matter to the stakeholders.

8. Must be overarching, integrating other initiatives into itself

One of the biggest problems in military leadership is the moral ambiguity which so often occurs

in war. One friend of mine, an intelligence officer, said “Sometimes I feel like telling people ‘I

don’t want to be thanked for my service; I want to be forgiven for my service.’” He had been in

hard combat, and been forced to kill people who threatened his life outside of combat.


Other stressors and moral quandaries afflict the military leader. During Vietnam warriors were

reviled, but today warriors are honored. One Chinese saying goes “Good iron doesn’t make

nails, and good men don’t make soldiers.” A Victorian attitude suggested that the British Army

was comprised of the “froth and the dregs” of society. Democracy is by its nature

uncomfortable with the military because military power is typically the tool of tyranny.

In peacetime the role of the soldier is to train. In wartime the role of the soldier is less well

defined. It may be to search, to destroy, to teach, to negotiate, to mediate, or even to heal. In

war, friends and enemies can sometimes be confused. Even the women and children that in our

culture are noncombatants, ones to be protected, sometimes rise up and try to kill you. At the

same time, war is news, and the eyes of the world are on every warrior, waiting for him or her

to do something brave, or stupid.

On Easter Sunday in 2004 I was at the Baghdad International Airport (BIAP) with 1AD. Shia

insurgents attacked BIAP’s western defenses and I went with my medic to figure out what was

going on and help with casualties. On arrival we discovered that the enemy had stopped firing

and presumably melted back into the woodline. The unit commander in that sector asked if we

had come to evacuate the Iraqi wounded from the battlefield. We responded under heavy

guard. My medic and I found an Iraqi man with an abdominal wound, his wounded preteen son,

a slightly wounded friend, and his dead wife. All had assaulted US forces on the wall. We took

the wounded to a nearby Air Force surgical unit. Having a whole family attack us as an enemy

was one of the strangest things I have experienced.

From a health care perspective, Inova Fairfax Hospital in Falls Church, VA is ranked nationally in

1 adult and 1 pediatric specialties. It was also high-performing in 11 adult specialties, as shown

below. Inova Fairfax Hospital is a 927-bed general medical and surgical facility with 48,092

admissions in the most recent year reported. It performed 17,401 annual inpatient and 17,295

outpatient surgeries. Its emergency room had 138,679 visits. Inova Fairfax Hospital is a teaching

hospital. The INOVA vision is:

1. Hospital based care - we are OneINOVA. At every INOVA facility for each and every

patient, we provide high quality, highly personalized care

2. Community based coordinated care - We will look outside our hospitals to build an

integrated network of facilities, providers and programs to support our community.

3. Destination Clinical Services - we are recognized locally and globally for our health

expertise. People turn to us for specialized clinical care as well as general health and

wellness services.



Have you had experience formulating a vision in a military context? What difficulties did you

encounter? What did you do with the moral and other difficulties noted above?

Sounds good, but what are some of the hidden complexities? Distinctions in Vision in Health

Care

1. What patients and families want versus what patients need 2. What patients and families want versus what is possible 3. What patients and families are paying for versus what someone else is paying for 4. Health care as a social good (or ministry) versus health care business 5. Individual versus community responsibility 6. Personalized versus standardized care


Leadership in Communication

Leaders must communicate the vision to their followers, but they must also communicate the

desire and ability to fulfill the vision. Leaders only accomplish the change they need through

others; they cannot do it by themselves. Therefore training is one of the leaders’ greatest

responsibilities. Key communication principles:

Right message Right messenger Right method Right audience Right time

Stakeholders - Patients, families, payers (employers, government), organizational staff,

affiliated providers, other medical organizations, general community

Formal and informal communication to and from leaders and stakeholders

1. Background communication - the continual flow of good news stories intended to make

each stakeholder pleased with the organization

2. Crisis communication - episodic communication when something bad happens. This

must control damage and can even build stakeholder confidence if done well.

Differences in military communication

1. Hierarchy inhibits communication and hierarchy facilitates communication

2. Structure and Rules inhibit communication and structure and rules facilitate

communication

3. Command (TASKORD) vs staff (informal)

4. Knowing and teaching the system will allow leaders to make it work

For further discussion, please visit Communication in and between Military Organizations at

http://mdharrismd.com/2013/03/31/communication-in-and-between-military-organizations/.

Leaders must communicate the vision to their followers, but they must also communicate the

desire and ability to fulfill the vision. Leaders only accomplish the change they need through

others; they cannot do it by themselves. Therefore training is one of the leaders’ greatest

responsibilities.

Examples

1. Medical training to junior doctors, nurses and ancillary personnel. - Epidemiology and

Biostatistics For curious clinicians, preventive sports medicine

http://mdharrismd.com/2013/03/31/communication-in-and-between-military-organizations/


2. Business training to administrative personnel - Making meetings matter, GS civilian

personnel discipline, Admin Support - How to Manage a Meeting, Formal Business Visits and

Town Halls, Discovery and Innovation in the Business of Health Care, Briefing Senior Leaders

3. Communication and Customer service training to all personnel - help improve connection

and referent power.

4. Training stakeholders outside the organization and communication to them to shape the

environment to accomplish the vision.

5. Educational communication

a. Patients and families - Fit to Win

b. Staff - TeamSTEPPS

Stakeholders - Patients, families, payers (employers, government), organizational staff,

affiliated providers, other medical organizations, general community

Formal and informal communication to and from leaders and stakeholders

1. Background communication - the continual flow of good news stories intended to make

each stakeholder pleased with the organization

2. Crisis communication - episodic communication when something bad happens. This

must control damage and can even build stakeholder confidence if done well.

Illustration

Let subordinates know what you are thinking. MG Joe Hooker at Antietam vs MG George

Meade at Gettysburg.

After the debacle with Howard’s 11th Corps at Chancellorsville, MG Hooker, who had received a

concussion from a Confederate shell that exploded near him in his headquarters, fell back

rather than pressing his attack. He partially blamed his some of his subordinates for the disaster

and they rebelled against him. In Lincoln’s deliberations on whether to keep him as commander

of the Army of the Potomac, Hooker’s refusal to share his intentions with his subordinates, his

boss GEN Henry Halleck, and even the President, was a major factor. Four days before the

Battle of Gettysburg Lincoln replaced Hooker with Meade, a general far more open in his

communication.

Sir William Osler (July 12, 1849 – December 29, 1919) is known as the Father of Modern

Medicine and helped found the Johns Hopkins Hospital and the Johns Hopkins School of

Medicine. Some of his favorite quotes to teach his students were:


"He who studies medicine without books sails an uncharted sea, but he who studies medicine

without patients does not go to sea at all."

"Listen to your patient, he is telling you the diagnosis."

It was said about him “He brought medical students into the wards for bedside teaching."


What do we do to ensure that we communicate effectively to all of our stakeholders? How can

we improve what we do?


Leadership in Systems and Structures

Leaders build the environment for their followers to succeed. This is another reason why

technical expertise in a given field is not enough. Leaders must have organizational knowledge

to know where they are and where they need to go.

Structure prevents a leader from being considered capricious.

Structure in the military – the US military is famous for work-arounds rather than knowing the

systems. Knowing the system is vital. Having a system and using it, especially if it is mutually

accepted, is better than not having one. It has more credibility even for those it works against.

Leaders build the environment for their followers to succeed. This is another reason why

technical expertise in a given field is not enough. Leaders must have organizational knowledge

to know where they are and where they need to go.

Structure in health care

1. Physical

2. Administrative - PCMH and medical neighborhood, secure messaging

3. Educational – trained and competent professionals

Illustration

Structure is one of the most important predictors of success. Frederick the Great was renowned

for his superb training and Napoleon for his inspired logistics.

An example of the place that Frederick holds in history as a ruler is seen in Napoleon

Bonaparte, who saw the Prussian king as the greatest tactical genius of all time;[41] after

Napoleon's victory of the Fourth Coalition in 1807, he visited Frederick's tomb in Potsdam and

remarked to his officers, "Gentlemen, if this man was still alive I would not be here".[42]

Frederick and Napoleon are perhaps the most admiringly quoted military leaders in Clausewitz'

On War. More than Frederick's use of the oblique order, Clausewitz praised particularly the

quick and skillful movement of his troops.[43]

Coaches, umpires and referees provide the rules, environment and plans and then let players

play the game. Generals train and equip their soldiers and then these soldiers fight the war. In

the same way, health care leaders provide the structures and then let technical professionals

take care of the patients.



How do you institute the structures that your subordinates will use to accomplish the

organizational goals? Have you considered your human capital structure? Your logistics

structure? Your policies and standard operating procedures?


Leading in Selfless Service

Success without successors is failure. Bill Clinton scandal - does character matter? In the final

analysis, character is all that matters

Selflessness in military operations involves several things

1. Living through the same conditions and dangers as your followers.

2. Coping well with the responsibility as well as the mental complexity.

3. Transitioning between roles, whether leader, soldier, logistician, medic, signal man, or

whatever else you have, effectively.

4. Taking responsibility for your mistakes and for those of your men.

Illustration

Personal sacrifice and courage

Frederick the Great of Prussia frequently led his military forces personally and had six horses

shot from under him during battle. Chesty Puller (USMC) fought alongside his men at

Guadalcanal, earning accolades for his personal bravery.

King Lune of Archenland said in C.S. Lewis Horse and his Boy...

“For this is what it means to be a king: to be first in every desperate attack and last in every

desperate retreat, and when there’s hunger in the land (as must be now and then in bad years)

to wear finer clothes and laugh louder over a scantier meal than any man in your land.”

Mental aspects of leadership

One frequent disconnect for me was the mindset required for the missions I did. On Sunday

mornings, for example, I would begin the day preparing to lead music (and sometimes teach) at

the First Armored Division Headquarters. Ministry requires a certain mindset, mentally mixing

the nature and needs of man, the character of God, and the practical issues of church work.

After the services I would go to the battalion aid station to see patients, adopting a “medical

mindset” of medical practicalities, science and compassion. After lunch I would go on a mission,

often a preventive medicine base inspection, in a convoy through the heart of Baghdad. Sitting

in the right front seat of the Humvee I would smile and wave at the Iraqis that thronged the

streets around us while holding a loaded pistol just out of sight. My mindset shifted from

medicine and ministry to military, accomplishing the mission while being constant on guard and

ready to kill if necessary. The mental shifts could be exhausting.



What does selfless leadership mean? Have we embraced it? If so, how? Give examples

Leadership in Followership Six Leader Tasks


Leadership in Vision Leadership in Communication Leadership in Systems and Structures

Leadership in Selfless Service


Part 2


Leadership – Practical Matters


Awards and Recognition Ceremonies – Are They Really

All About You?

“A soldier will fight long and hard for a bit of colored ribbon.” Napoleon Bonaparte An Air Force physician had not had a ceremony for his promotion to major and asked me if he should have one for his coming promotion to lieutenant colonel. His former supervisor was not pleased, and though this bright and self-effacing young officer didn’t want to be honored in front of others, he also didn’t want to get in trouble. During two years as Chief Medical Officer at an Army hospital in Virginia, I routinely interviewed people leaving the Army. Several retiring officers said that they did not want retirement ceremonies. They felt that such events put too much focus on them and they wanted to pass quietly into civilian life. I had recently transferred to a new unit and was meeting the rest of the command staff. While admiring the photos, awards, unit colors and certificates of the Command Sergeant Major (CSM), he said to me “Sir, don’t bother about all that. It’s just my ‘I love me’ wall.” What is the right answer? Are awards and recognition exclusively, or even mostly, for the individual? We have all been put off by self-absorbed people crowing about their honors, but are honors really about crowing? What impact do honors given to an individual have on others in the same organization? This paper is intended to address some of these questions. The Importance of Awards Since before the Greeks gave laurel wreaths for winners at the ancient Olympics, mankind has understood the need for awards. There is neither a school nor an organization in the world that, in some fashion, does not award its top performers. The Arts have the Grammy Awards, the Oscars, and the Pulitzer Prize. The Sciences have the Noble Prize and awards from various professional groups. Sports have the most valuable player awards, the Olympics, and various championships. The military has dozens of awards, from the Good Conduct Medal to the Medal of Honor. Though easy to disparage, as when John Kerry threw away his medals from Vietnam, awards are powerful motivators. U.S. Olympic sprinter Wilma Rudolph wrote “The feeling of accomplishment welled up inside of me, three Olympic gold medals. I knew that was something nobody could ever take away from me, ever.” The Importance of Recognition Ceremonies


Every person on earth engages in ceremony, including birthday parties, religious services, graduations, marriages and funerals. It is the ceremonial occasions, not the day to day grind of meetings, emails, and other work, that people remember decades later. In Thornton Wilder’s Pulitzer and Tony Award winning play Our Town, when the recently deceased Emily Webb is given the chance to observe just one day of her earthly life, she chooses a ceremonial occasion, her 12th birthday. There is no culture or individual in which ceremony does not play a major role. It provides the milestones for our lives and in many ways defines who we are.

James Humes was a speechwriter for Eisenhower, Nixon, Ford and Reagan, specializing in ceremonial rather than policy speeches. In his book The Sir Winston Method; the Five Secrets of Speaking the Language of Leadership, Humes wrote that “I was called ‘the Schmalze king’, but I took pride in the title.“ He is right. Some of the greatest speeches in history, such as Pericles’ Funeral Oration and Lincoln’s Gettysburg Address, have been ceremonial. Martin Luther King Jr’s “I Have a Dream” was ceremonial, given during a civil rights march and staged at the Lincoln Memorial. What should leaders do? Given these facts, military officers and enlisted personnel at all levels must grant awards whenever earned. They must also encourage and require that their soldiers, sailors, marines and airmen participate in ceremonies for others and host ceremonies themselves. There are several specific reasons:

1. They encourage attendees in their pursuit of higher rank, a 20+ year career, etc. 2. They foster respect and appreciation for military traditions. 3. They confer appropriate weight on the accomplishment itself (rank, award or

retirement). 4. They engender camaraderie and esprit de corps in units. 5. They help with recruitment and retention. 6. They provide a venue for unit command to show their appreciation for their soldiers and

civilians. 7. They are a source of pride and encouragement in families. 8. They forge a link between the individual and others, past and present, in the new group

(rank, award, etc.). For example, when a soldier joins the NCO corps, he/she joins the ranks of a long and distinguished line of American NCOs throughout our history. When a soldier is awarded a Purple Heart, he/she joins others who have also been honorably wounded for their country.

9. They mark important transition points in the life of an individual and an organization. 10. They recognize individual achievement.

Notice that on this list of 10 reasons why awards and recognition ceremonies are important, only the last has to do with the awardee. All of the others have to do with others. Awards and


recognition ceremonies ultimately benefit the unit and other soldiers more than they do the one receiving the award. In our cynical age many disparage the ideas of honor and tradition, but in our human hearts we know that our earthly sojourn will end and we desperately want our lives to mean something; to be involved in a good cause far greater than ourselves. Because of this, recognition is one of the most powerful of human motivators. Leaders must never let an opportunity to award and recognize someone for good performance go by. Sometimes, as noted above, medical soldiers and officers take awards and recognition ceremonies too lightly. Often they don’t even know how they are supposed to occur. As a result, I have included a few notes on a sample ceremony. A Sample Army Promotion ceremony Preparation

1. Planning and coordination must be started at least six weeks before the event. 2. The soldier being promoted must contact the personnel officer to confirm the date of

the promotion and the receipt of the orders. The personnel officer is critical in the process and must be consulted at all stages.

3. The soldier must also contact their chain of command including the Unit Commander (CDR) to inform them of the promotion and work out the details such as a the date, time, etc. The Chain of Command will make sure that the unit colors and soldier support are available.

4. The one being promoted needs to invite whoever he chooses to be in the ceremony. 5. All soldiers involved in the ceremony should be in dress uniform (usually Army service

uniform) unless the ceremony is occurring in a combat zone. 6. Civilians should be in business attire.

Sample program

1. Moderator welcomes attendees to the promotion. Unit colors provide the backdrop to the promotion

2. Entry of the official party (CDR, CSM, soldier being promoted) 3. National Anthem 4. Invocation 5. Promoting officer/NCO provides remarks - a brief history of the promoted soldier,

including family and career. 6. Reading of the promotion orders 7. Pinning of the rank (pictures) 8. Reaffirmation of the Oath of Office – optional (pictures) 9. Promoted officer comments (may include the presentation of a gift to the spouse,

children, family, etc.)


10. Conclusion (Army Song, benediction, or simply “This concludes our ceremony”) 11. Reception

Traditions in other services are also rich. The naval tradition of the bell and the side boys is especially enjoyable. What about the “I love me wall?” We have seen that awards and recognition ceremonies are more about others than about the person recognized at the time they are given. They are also more about others than about the person recognized when they are later displayed on a wall, a table, or a business card. As a physician I have had patients come into the office and look at my medical school and residency diplomas. As a patient I have done the same at other physician’s offices. Physicians know what academic credentials they have and don’t need to be reminded. Patients do not know what credentials their doctors have but they need to know. After all, they will be sharing responsibility for their health with that person. As a soldier, I enjoy looking at the awards and other memorabilia in others’ offices. They may have served in a unit or location where I served. Perhaps we will have memories or acquaintances in common. Others’ careers have encouraged and motivated me over the years and perhaps mine can do so for someone else. Even on the rare times that I pause and look at the unit colors or Iraqi flag on my wall, it is to remember times, places and comrades in arms. How many soldiers, or others, really stare at a wall of certificates and glory in themselves? Conclusion I told the Air Force major to get help from his chain of command and the personnel officer and plan his promotion ceremony. I told the retiring officers that they needed to have a retirement ceremony even if they didn’t feel that they wanted it. I told the CSM that his wall was a benefit to all of the rest of us more than it was to him. We wanted to get to know the senior leaders that we work with. Afterwards, most of them understood and appreciated the guidance. After all, awards and recognition ceremonies are really not about you, or me, but about us.


Bridging Strategic Thinking with Tactical Operations

The Need for and Difficulties Getting the Strategic View

The Service Secretaries, Chiefs of Staff, Surgeons General, and other senior military leaders

regularly send out updates on what is happening in their world to their subordinates. The Army

Chief of Staff, for example, sends out a regular update on priorities to all Army colonels. These

are rarely more than one to two pages, but in the hustle and bustle of daily activities, often do

not get read. Leaders rely on the news, local word of mouth, or perhaps nothing at all, to build

their mental picture of what is going on outside their organization; the environment in which

they work. Without a desire to see and a clear view of the greater strategic situation, military

units and other organizations fail.

The military considers its colonels and generals to be strategic leaders, but as in every

organization, many of these leaders spend most of their time on day to day activities. An

example of the “tyranny of the urgent”, important but non-urgent strategic matters are often

brushed aside so that these leaders can handle urgent matters, whether important or not. The

military is not unique; leaders at all levels of government and in the private sector struggle with

the same thing. Stephen Covey identified this problem in his famous book The Seven Habits of

Highly Effective People.

Why is this? First, it is difficult to measure (and thus justify paying for) strategic awareness and

thinking. Second, the immediacy of phone calls and emails distracts leaders and eliminates the

large blocks of uninterrupted time required for deeper thought. Third, changes in technology

have shortened our attention spans and changed the way that we think, as Nicholas Carr in his

book The Shallows ably contends. Fourth, the problem solving skills that make leaders

successful in tactical and operational roles do not lend themselves to strategic thinking, in

which imagination is at least as important. Fifth, modern communication makes us aware of

more problems than we can impact, and people, even leaders, often feel helpless to change

anything outside their immediate control (Neil Postman, Amusing Ourselves to Death). Sixth,

expectations of leaders have changed; personal issues such as money or family problems in

their troops that in years past would have never come to the attention of a senior commander

(because the squad or platoon leader would have handled it) now consume significant amounts

of time. Some argue that the Peter Principle, the idea that people are promoted to a level at

which they are no longer effective, may play a role. Time and space constrain my ability to list

more.

The biggest reason for the lack of strategic awareness and strategic thinking in the military, and

any organization, is that once leaders have a clear picture of the environment, or at least as


clear as this inherently murky picture can be, they have to do something about it. The broad

outlines of what to do may be clear; as was the case in the aftermath of the Haiti earthquake in

2010. They may be fuzzy; as was the case with the starvation in Somali in 1993. The broad

outlines may be nearly indistinguishable; as is the case when considering how to defeat

international terrorism. Often the proper course of action is known only after the event, when

it is too late to change course. Sometimes the best answer is never entirely clear. Once leaders

understand the broad outlines of what needs to be done, they have to determine specific tasks

for their subordinates to accomplish. Such is no small feat, and in combat operations, the US

military does it well.

At the same time for these decision makers, the relentless drumbeat of media head hunters

(not all of the media, but some) means that no incorrect decision, no matter how reasonable it

seemed at the time, goes unpunished. Even good decisions, which inevitably have some

downside, are attacked. The attacks are not new, but their pervasiveness is. Such is, and always

has been, the nature of leadership. One wonders how this impacts the desires of people today

to take responsibility for others, to be leaders, or even to grow up.

The Strategic View in the Military and Military Medicine in 2012

Turning from the general to the specific, consider the current principles and priorities of the US

military:

Army (Sec Army Nov 2012) Navy (CNO Sailing Directions Sep 2011)

Air Force (Chief of Staff, Jul 2011)

Ensure a highly capable Army within budgetary constraints

Remain ready to meet current challenges today

Partner with Joint and Coalition teams to win today’s fights, holding any target at risk

Champion soldiers, civilians and families

Enable and support sailors, Navy civilians, and their families

Develop and care for our airmen and their families

Enhance Army activities in the Asia-Pacific region

Maintain the “watch” as ground forces draw down in the Middle East

Establish control in air, space and cyberspace

Ensure accountability Our Navy ethos defines us and describes the standard for character and behavior

Recapture acquisitions excellence

Transform the institutional Army

Build a relevant and capable future force

Continue to strengthen the Air Force nuclear enterprise

Codify Army total force policy

Adequately fund reset and modernization

Sustain fleet capability through effective maintenance, timely

Modernize our air, space, and cyber inventories,


modernization, and sustained production of proven ships and aircraft

organizations and training.

Strengthen information assurance and cybersecurity

Cyberspace operationalized…providing superior awareness and control

Develop effective energy solutions

Finalize Arlington National Cemetery reforms

We can see common themes in these principles and priorities, themes which have not changed

since Caesar crossed the Rubicon. The first priority for all of the services is to maintain a military

force that is capable of accomplishing its current mission within resource constraints. Wars

traditionally leave both victor and vanquished bankrupt, but the victor can loot the vanquished

and pay for some of his expenses. The current US actions in Iraq and Afghanistan have been

financed largely by debt; a time honored way of paying for war since the Pharaohs, Louis XIV,

and the Confederate States.

How must military medicine behave as a result? Sometimes medical personnel act as though

what we do is so important that price should be no object. As noble as that may sound, cost is

always a factor. A decision to do an intervention in one patient is a decision not to do one in

another, or to forgo some other worthwhile activity. Resources are always limited, and the

reaction “make the other guy pay” can’t be sustained forever. Many things that we do in

medicine are not effective, much less cost effective, but we do them anyway. Other things

(such as vaccinations and public health) are effective and cost effective but we don’t do them.

Clinical practice guidelines, evidence based design, evidence based medicine, and coordinated

care are some of the key ways for military medicine to meet these priorities.

The second priority is that leaders must take care of those who fight the battles. Good leaders

recognize the need to care for fighting men (and women) and their families. If soldiers cannot

fight, their army cannot win. Napoleon noted that “an army marches on its stomach.” Sun Tzu

wrote:

“Regard your soldiers as your children, and they will follow you into the deepest valleys;

look upon them as your own beloved sons, and they will stand by you even unto death.

If, however, you are indulgent, but unable to make your authority felt; kind hearted, but

unable to enforce your commands; and incapable, moreover, of quelling disorder; then

your soldiers must be likened to spoilt children; they are useless for any practical

purpose.”


Even tyrants from Julius Caesar to Adolf Hitler took care of their most loyal soldiers, giving

special favors to the Praetorian Guard and Schutzstaffel (SS), respectively, to get them into

power and keep them there. Medical forces must provide the best medical care for the entire

force, and must train and equip medical forces. Every day we must make progress towards

these goals. Medical leaders must see themselves not only as clinicians, but also as soldiers,

sailors, airmen, and officers. They must then behave as such.

The third priority is to go where the action is. The Middle East has been a global hot spot since

Cain killed Abel and shows no sign of cooling down. However, while Europe was a consistent

center of power and frequent theater of combat in the past five centuries, it has cooled. Asia,

with six of the ten most powerful nations in the world, is heating up. US forces need to increase

their presence there, and so does military medicine. Humanitarian efforts such as the annual

USNS Mercy cruise, and public health efforts need to augment current military medical forces in

the region, whether ashore (Hawaii, Korea, Japan) or afloat.

The fourth priority has to do with legitimacy. The Services have endured many scandals in

recent years, from sexual scandals to acquisitions scandals. In order to retain the trust of the

American people, those who pay the bills and provide the warriors, the Armed Forces must be

perceived by Americans as legitimate. During Vietnam the services faced a crisis of legitimacy,

and the broken and demoralized force of the 1970s was the national result. Broken and

demoralized veterans were the personal result. The problem at Arlington Cemetery is also a

problem with legitimacy.

Military medicine must also continually strive for legitimacy with the American people. We

must be the world leaders in what we do, combat casualty care and rehabilitation, and in public

health. We must be excellent in primary care and all other areas. Our warriors and families

need, and the taxpayers demand, nothing less. Honest mistakes can and must be tolerated, but

incompetence at any level cannot be.

The fifth priority has to do with reset, transformation and modernization. After long fights, such

as the past decade in Afghanistan and Iraq, people and equipment need to be retrained, rested,

and repaired. In the long run, militaries cannot use the technologies of yesteryear and expect to

win, or even survive. The Mamelukes of Egypt tried and were crushed by the Ottomans in the

Battle of Merj Dabik (1515). They also cannot use the tactics of yesteryear with the weapons of

today – both sides discovered this early in the American Civil War, losing huge numbers of

soldiers in Napoleonic charges against Minie Balls, rifled cannon, and other modern weapons.

The signature platforms of the Army (tanks, trucks, artillery), the Navy (ships), and the Air Force

(aircraft), and every other technology, need regular updating to keep the advantage over

potential foes.


What should military medicine do? We seem to have a never ending array of new equipment,

but often don’t work out the specifics on how to best use it to care for our patients. Imaging

such as magnetic resonance imaging is no substitute for a good history and physical exam, and

remote monitoring is no substitute for attentive nursing care. Defensive medicine wastes time

and money. Research must be applied to the bedside, and process improvement must become

a way of life.

Conclusion

America gained worldwide supremacy in all of the elements of national power; diplomatic,

informational, military and economic, because of its people. Industrious and visionary leaders

and followers teamed up to make our nation a force for good in the world. Military followers

and leaders must do no less. Despite the difficulties and the opposition, we must take the time

to gain the strategic view and give it to our teams. Leaders must then translate that view into

day to day operations. Only then we will fulfill our mandate as leaders and lead our units, our

organizations and our nation to be what it was meant to be; as John Winthrop (1630) and

Ronald Reagan (1989) put it, “a shining city on a hill.”


Briefing Senior Leaders One of the most daunting tasks faced by junior officers in the military, and subordinates in any organization, is how to formally communicate with their boss and other senior leaders. Some senior leaders are easy to communicate with; they welcome open discussion and make those briefing them comfortable. Others are hard to communicate with, and as people progress up the ranks they find that senior leaders become harder and harder to brief. This is not because senior leaders are bad people morally, they are certainly not worse than others on average. It is not because they are stupid or lazy; senior leaders have to be relatively intelligent and ambitious or they wouldn’t make it to senior levels. Rather it is because they are very busy people who don't have time for the unprepared, the uninterested, the verbose, and the comic. They expect their subordinates to bring them trustworthy information, problems and solutions. Such leaders don’t have the time or the ability to double the information they are given, and they can’t fix everything, regardless of their position. The Boss Is Neither Friend nor Foe Senior leaders are not your friend. One of the biggest mistakes a junior briefer can make is to treat their boss like a buddy; someone that they might hang out at a bar with. One Navy captain in charge of construction on an installation, was asked by an admiral when the barbeque pit for wounded warriors would be done. He replied “In time for barbeque season.” Such a response takes your breath away, and is not likely to engender favor with senior leaders. Some senior leaders are friendly and others frosty, some are unflappable and others are unpleaseable, but no briefer should treat them, at least not during a formal briefing, as a friend. Neither is the senior leader your foe. He has a mission to accomplish and has limited time and resources in which to do it. Brusque tones, interruptions or curt replies shouldn’t be taken as a personal attack; they rarely are. Use the Leader’s Language Preparing a good brief begins before the first word is spoken. Senior leaders do a lot of communicating, both verbal and written, and junior leaders must listen carefully to what they say. In the military, senior leaders frequently put out a “command philosophy” as well as guidance on the mission and vision of the organization. Briefs from subordinates should demonstrate how they have nested their issues into the mission, vision and philosophy of their leader. Make sure to know the senior leader's priorities at all times. If you are unsure, check with his staff or even him. Brief topics that are priorities and those that are important. Each person has their own priorities but can’t be allowed to shift focus and resources away from those of the boss.


There are two purposes for a formal brief. The first is to inform the listeners (especially the senior leader) about an issue. The second is to get a decision, usually one desired by the briefer, from the senior leader. Whether providing an information brief or a decision brief, junior leaders should use language that the senior leader they are briefing has used before. They should also use it in the way that he used it whenever possible. First, it proves to the leader that the briefer has been listening. Second, people understand better when they hear terms that they already know. Third, everyone likes to be validated by hearing their words from someone else' mouth.

One subordinate of mine was especially good. I frequently tell my staff that even if they don’t have command or other formal authority over others in a situation, they can still “exercise influence” and “shape the battlefield”. In one brief several months ago this officer was explaining a complicated issue over which we had limited control. He said “Sir, I know that we cannot force this decision but if we execute course of action 2, it will dramatically increase our influence and ability to shape the battlefield.” I smiled inside. This officer was right; we did what he recommended and the issue was eventually resolved in our favor. Use The Format That The Senior Leader Wants To Use. Ask Questions Senior leaders in any organization address hundreds of challenging issues, and see hundreds if not thousands of slides and other briefing materials, per week. Most have a preferred format for these slides; one that communicates best to them, and briefers must learn to use their boss’ preferred format. As a young officer this made no sense to me, but with time I have learned that there are many reasons leaders do it.

1. Personal issues – if your boss wants big letters, she may be nearsighted. If he wants different colors, he may be red-green color blind. If she wants a certain font, she may have trouble deciphering some. Senior leaders tend to be older than their subordinates and often have excellent personal reasons for wanting something a certain way.

2. Clarity – some slides are simply too busy and confusing, while others say little and are a waste of time. Using your boss’ suggested format can help avoid these problems. Furthermore, inconsistent slide format itself can distract viewers so that they focus on the format and not on the content.

3. Image – each organization wants to portray a certain image to itself and to the outside world. Each stakeholder has an idea of what the organization should be and wants it to fit their mental image. Health care facilities should have slides that portray competence and compassion while armored divisions should have slides that portray power. Leaders know this and choose a format for slides, and all of their other communications, that reflects the image they want.

4. Aligning with another organization – Lower headquarters will often use communication tools such as slides to visually align themselves with higher headquarters. Slides in Army medicine, for example, typically have a medical emblem and an Army emblem.


5. Preference - There are as many other reasons as there are bosses. Junior leaders should simply use the slide format that the boss wants.

Never Embarrass the Boss Another big mistake in briefing a senior leader is to embarrass him or her in public. This includes asking questions that he or she is not prepared to answer, and bringing up controversial items in an open forum. One way to avoid both of these problems is to send the slides that you will be using to the leader 72 working hours ahead of time. This will give him an opportunity to review the brief and make changes. He may tell you to take something out, put something in, or change something else, but either way he will not be blindsided. A copy should go to the staff of the senior leader because they will be able to troubleshoot the brief as well. When you get updates, change the brief accordingly. Along the same lines, anticipate how the senior leader and everyone else in the room, will react to each item. Communicators are briefing not only the boss, but also everyone in the room, on the phone, and in the videoteleconference. You’ve Got Two Minutes with the Elephant…Use It Well

Be concise and quick. A senior leader has very little time to spend on each brief, so communicators must capture his attention quickly. Brief the most important issues, especially the ones that he needs to do something about, first. Also, don't repeat on the same slide or even different slides. A slide that I saw recently had the same information three different times on the same slide. It is OK to repeat a verbal point because repetition is necessary for the ear, but don’t repeat a written point on a slide. When You Swim With Sharks, Don’t Bleed

Early in my medical internship in El Paso Texas I was on call for the orthopedics service and was scheduled to present a patient to the orthopedic senior physicians the following morning. It was a busy night and I wasn’t as prepared as I wanted to be for the morning report. I began by reporting the patient’s injury, the ambulance call, and the patient’s time in the emergency department in detail. I tried to answer a few questions but could not. Before I had even finished a senior orthopedist stopped my presentation in mid-sentence and said in a voice that filled the room: “congratulations, that was the worst patient presentation I have ever heard.” The other orthopedic surgeons were amused, the residents laughed aloud, and I left the room feeling a lot like Charlie Brown. Afterwards a sympathetic resident came up to me and said “Know everything about your patient. Anticipate every question that they will ask and be ready. These guys are sharks and if you show the slightest uncertainty or weakness, they will eat you alive. When you swim with sharks, don’t bleed.” Not every brief of senior leaders will be this painful, but some will. However embarrassing, they provide a not-to-be-missed opportunity to improve.


Every briefer must do the same. Know your slides or brief inside and out. Review them carefully and anticipate questions before the brief. Have colleagues "Murder board" the brief, asking tough questions in adversarial tones. It cannot be emphasized enough “when you swim with sharks, don’t bleed.” Identify and Brief Outcome, Not Just Process, Metrics, and Focus on the Right Outcomes

In the 1980s emergency departments routinely started a lidocaine drip to prevent abnormal

heart rhythms in heart attack patients. In the 1990s primary care providers routinely prescribed

estrogen to control menopausal and post-menopausal symptoms in older women. A common

quality of care metric was whether or not the medication was prescribed, and doctors could be

punished for not doing these widely accepted interventions.

As more studies on lidocaine in heart attack patients and estrogen in post-menopausal women

were completed, however, researchers discovered that patients who received lidocaine died

more often than those who did not. Worse patient outcomes also occurred in women who

received estrogen. The medical conventional wisdom turned out to hurt people, not help them.

Why, because it measured a process (whether medications were given) and focused on the

wrong outcomes (heart rhythm and menopausal symptoms) rather than the important

outcomes (death and serious disease).

Mistakes like this happen in every area. Emergency managers sometimes measure

preparedness by the number and type of ambulances available to respond to an event (a

process measure) rather than by the ability to evacuate patients from that event, forgetting

that ambulances are not the only way, and sometimes not even the best way, to move injured

people. Businesses measure how many customers say they are pleased with the company (the

wrong outcome measure) rather the measuring how many become loyal customers and

encourage their friends to become loyal customers as well (the right outcome measure).

If You Need the Senior Leader To Do Something, Let Him Know Exactly What You Want Him To Do Every leader, no matter how senior, has limited power and influence. The best are acutely aware of their limits and are careful in how they exercise their authority. As influence and power increase they become more associated with perception; a person’s power and influence are what others perceive it to be. Consider the US President, the “most powerful man in the world.” His power over the mightiest military and largest economy in the world is impressive, but it is completely limited by the will of the people. If others don’t do what he wants, the President has little power. Even if they comply his power is limited by physical realities, the other branches of government, businesses and other organizations, and the rest of the world. Tyrants such as Nero since the dawn of time have forgotten this, and paid a heavy price.


Junior leaders should try to identify the scope of their boss’ authority and consider their issue from his perspective. Avoid comments and requests that don't directly impact the leader's area of responsibility. If the boss runs a tank company in Iraq or an auto distributor in Texas, don’t brief him on the price of corn in Kansas. Also consider, “If my leader grants my request, how will other stakeholders perceive the decision?” If there will be opposition, the leader must decide how much it will be and how to handle it. The astute junior leader will have considered all of this before making a request. A new hospital commander asked my preventive medicine team to provide an introductory brief and asked for three things that he could do to help us. As we planned for the meeting, one junior leader suggested that we ask to hire several new people and one wanted to increase our budget by more than 30%. I refused, telling them that our requests had to be targeted to an important mission, carefully thought through, and limited to what our new boss could actually do. Rather than requesting new hires we asked for authority over another section that was key to our mission but administratively owned by a different department. Rather than trying to increase our budget we suggested that some funds allocated to a little used line item shared between departments be redirected to our department. He agreed to both. Don't Tell Him Something That He Already Knows, Don't Assume That He Knows More Than He Does, and Don’t Be Hard to Follow The most senior leaders have a broad scope of duties and will probably not know nearly as much as any individual subject matter expert does. He will know the mission, vision, and idea behind whatever is being briefed so speakers must not speak in generalities. Too many briefers waste slides with statements like “this will save money” or “this will improve quality of care” without providing any details on how it will do either. The message of each slide or other document should be clear at a glance. Briefers should cover the slide top to bottom and left to right, just like reading. If the boss needs more details, take them from the slide notes, illustrate them with back up slides, or explain them in supporting documents. If a process is involved then ensure a read ahead was provided which explains the process. The

slides should walk the leader step by step through the process. Have the same slides during the

brief and answer any questions on the process at the brief.

Have an assistant capture all comments and due outs from the meeting It is not possible to carefully observe a meeting or briefing, capture all of the due outs and give the brief at the same time. Be sure that at least one another person attends to support the briefer.


Execute the due outs as quickly as possible and report to the appropriate person (staff or senior leader) ASAP. Use the approved reporting format. It is OK to mess up occasionally when doing a briefing to a senior leader; it is not OK to make the same mistake again. Junior leaders, colleagues and administrative support personnel (when available) should look at what went wrong and what went right after each brief to a senior leader. Then they should consider how to fix their errors and how to build on their successes. Conclusion Briefing senior leaders can be frightening to subordinates and many try to avoid it altogether. Some senior leaders make themselves easy to communicate with and some make it hard. Some junior officers are naturally better at communicating and some are worse. Nonetheless, every officer and leader, junior or senior, owes it to his or her organization to be the best communicator that he or she can be. Having written this essay, the reader may presume that the author considers himself an expert in the topic. Nothing could be further from the truth. The tips contained herein are the honest fruits of years of work, both successes and failures. Pain has proven to be a greater teacher. Even though I know many good things to do, I sometimes don’t find the time to do them. The journey to excellence in communication seems short, but actually lasts a lifetime.


Business Models for the 1st and 21st Centuries

Several women at a baby shower share stories about giving birth, providing tips with an

expectant mother on how to make it easier and more pleasant. One older woman gives a

beautiful baby dress, while another shares the address of a bargain baby store. A farmer plants

acres of wheat. He labors over his fields for several months, watering and weeding while his

crop comes in, and then harvests an abundance of the golden grain. Two generals pore over a

map on a battlefield, discussing how to defeat the enemy dug in on a ridgeline nearby. They are

not sure of their opponent’s strength and disposition, but they are losing the initiative and need

to act soon.

These three scenarios have been repeated thousands of times since the dawn of history, but

they capture three basic business models. The first is called Facilitated Networking, in which

people and organizations, often non-business entities, share advice, products and services.

Everyone has a network, but businesses build and facilitate the right platform so the right

people, those interested in the issue, come together. For example, eBay and Craig’s List bring

together buyers and sellers for products and services, Prosper.com brings together loaners and

lendees, and Kickstarter brings together philanthropists. Wikipedia assembles people who want

to write articles. The business does not make money through its products, because in these

cases there is none, but through the platform. Networked organizations typically make money,

from advertising for example, based on how many people use their network or platform.

The second example speaks to the Value Added Process (VAP) business model. Farmers have

been plying their trade since the dawn of civilization, but their essential task is to take soil,

seed, sky, and sweat and produce delicious and healthy crops for people and animals. The task

is difficult but the processes are fairly well defined. Further, certain inputs can reliably predict

certain outputs. For example, a given amount of plowing, weeding, and watering will, aside

from large, unforeseen events, produce a given amount of grain. This business model is among

the most common in history. Auto manufacturers take parts, adding value in the form of skill

and machinery, and make cars. Merchants take products from sellers, adding value in the form

of trucks, ships and aircraft, and deliver them to their buyers. Doctors encounter people who

are sick or injured, add value in the form of skills, knowledge, and equipment, and make them

healthy again. VAP organizations typically make money by calculating their costs to add the

value, adding a competitive profit margin, and selling the good or service.

The third scenario illustrates the Solution Shop business model. The problem seems well

defined, but it is not. The issue is complex, and it is not clear which combination of processes

will accomplish the goal. Experts in the field are needed to solve these kinds of problems, and

the outcomes are not guaranteed. Solution Shops require multidisciplinary teams to accomplish


their goals, because no single individual can acquire enough information and experience to

handle such complex and poorly defined problems. The US space program (NASA), from the

moon landings to the Space Shuttle, is a good example. In modern business, the innovators at

Microsoft, Apple, Disney, and a host of others fit well into this category. Law firms and business

consultants are usually solution shops. Because outcomes are uncertain, solution shops

generally charge fee for service, such as a certain amount per hour.

It is easy to see that all businesses incorporate some aspects of each business model into their

operations. For example, NASA incorporates standard value added processes and Disney

facilitates networks of customers and fans for their mutual benefit. However, successful

organizations have one primary business model. Facebook is primarily a facilitated network, a

company that makes peanuts into peanut butter is primarily value added, and research

institutions are essentially solution centered. Organizations other than businesses, religious or

charitable organizations, for example, also fall into these categories.

When one organization tries to operate under two primary business models, confusion and

complexity result. Health care includes components from all three primary business models, but

the VAP and Solution Shop models predominate. Patients and providers network together in

person and virtually via support groups for many disease processes. Hospitals and health care

systems often facilitate these networks in their areas. Many processes in health care, from the

doctor’s office to the intensive care unit, are value added. For example, when a child with an

ear infection seeks care at an outpatient clinic, the provider can be pretty confident of how to

make the right diagnosis and equally confident that the right antibiotics will fix the problem. In

an otherwise healthy child, the issue is not highly complex, the course of action is largely

standardized, and a good outcome is generally the result. Other processes in health care,

however, follow the Solution Shop business model. A patient with poorly understood

complications of diabetes might need the services of an endocrinologist, a vascular surgeon, an

ophthalmologist, a nephrologist, and others, all of whom are supported by a cadre of

specialized nurses and other support staff in a Diabetes Institute. This confusion of business

models is one reason that health care is so expensive and so hard to measure.

In order to discover which type of business model is most appropriate for a company, or any

organization, the leadership must decide exactly what they want their company to do; they

must clearly understand the problem and decide exactly how they want to address it. Since all

organizations want to make money, or at least stay solvent over time, they must decide how

they are going to do so. Once leaders understand the problem and know how they want to

address it, the type of business model that they should use will become clear.

Conclusion


Solomon said “There is nothing new under the sun.” This axiom is certainly true for business

models. The three types, facilitated networks, value added processes and solution shops, have

been around since the dawn of time and will endure until the end of it. While all organizations

are a mix of these models, most have one predominant model by which to organize themselves

and meet the needs and wants of their customers and other stakeholders. Leaders of

organizations should exhaustively analyze the problem they wish to address, their mission and

vision, and organize themselves into the right business model. Then they will be postured for

success.


Discovery and Innovation in the Business of Health Care

Discovering things previously unknown is one of the most important, and most enjoyable,

things that anyone can do. Most people do it every day, whether as simple as finding a new

restaurant they love or discovering a new comet in the heavens. Fundamentally, new

discoveries come from observation, analysis, and experimentation. A husband looking for a new

restaurant to try with his wife might observe something that in his experience resembles a

restaurant on a street corner. He then analyzes the available information to decide if he wants

to try it; what kind of food they, the opening hours, and whether it is clean and inviting. Finally

he and his wife try it out, completing the process of discovery.

New discoveries are often far more difficult than finding a great new place to eat. Identifying a

new comet can require expensive equipment and uncommon expertise, while sequencing the

human genome, learning about subatomic particles or curing cancer are some of the slowest

and most resource intensive discoveries of all. The discovery that smoking causes lung cancer

followed the same observation-analysis-experimentation sequence. In the 1930s a few

surgeons noticed that they seemed to be performing lung cancer surgeries on a lot of smokers.

Some published their observations and that induced others to analyze the existing information

and hypothesize that smoking is associated with lung cancer. Researchers then developed

experiments to test the hypothesis and in 1956 the British Doctors Study provided the first

convincing evidence that smoking increased the risk of lung cancer.

Service industries such as health care use quantitative and qualitative methods to make new

discoveries to improve the services that they provide to their customers. As a natural science,

medicine makes new discoveries using a vast array of natural science methods such as

laboratory and imaging techniques. As a social science, medicine also uses surveys, focus

groups, and other techniques to gain information on people and their behavior. As a business,

medicine uses social science and other techniques to continuously improve its services to its

stakeholders; including patients, family, staff, and others.

This article hopes to cover some of the methods that organizations, especially medical, can use

to make new discoveries. In so doing, health care professionals can find the right questions and

the right techniques to answer these questions for the benefit of their patients and others.

Benchmarking

Regardless of the type of organization, benchmarking processes and outcomes against peers is

useful. Manufacturers might reverse engineer a competitor’s product to improve their own and

service companies might review the literature or even use secret shoppers to find best

practices in their field that they can modify and imitate.


Quantitative Methods

Since Frederick Taylor’s Principles of Scientific Management (1911), quantitative assessment of

problems in business has been the standard. This should not be surprising, since Taylor’s key

ideological tenets held sway over business thinking for much of the 20th century.

1. The primary, if not the only, goal of human behavior and thought is efficiency.

2. Technical calculation is in all respects superior to human judgment.

3. Human judgment cannot be trusted because it is plagued by laxity, ambiguity and

unnecessary complexity.

4. Subjectivity is an obstacle to clear thinking.

5. What cannot be measured either does not exist or is of no value.

6. The affairs of citizens are best guided and conducted by experts.

Quantitative methods of making new discoveries have led to great advances in business and

health care. Excluding bench and other basic research, these methods generally involve large

numbers, both large numbers of subjects and large numbers of data points. They tend to

involve standardized instruments to evaluate characteristics of their subjects, whether

monitors to measure blood pressure or surveys to measure opinions.

Timing Categories of

Quantitative Studies

Examples of Quantitative Studies

Prospective Cohort – select a risk or protective factor and compare exposed with

unexposed to see what outcomes they will develop.

Clinical Trial – select an intervention and compare exposed with

unexposed to see what outcome they will develop.

Retrospective Retrospective Cohort - select a risk or protective factor and compare

exposed with unexposed to see what outcomes they have developed.

Case Control – select an outcome and look back in time (survey or


other measurement device) to see what they were exposed to

Current Cross-Sectional (prevalence) – examine risk or protective factors and

outcomes that subjects have now.

Such quantitative methods are widely used in medicine and even in business. Data can be

collected by instruments such as blood pressure monitors or laboratory equipment depending

upon the object of the study. Data can also be collected by standardized surveys when

investigators want to discover personal opinions or experiences. When done properly they

provide valuable information which can be generalized beyond the study group to the larger

population.

Qualitative Methods

These methods often involve much smaller numbers of subjects but provide much deeper

insight into the needs and opinions of a small group or each subject. Focus groups, clusters of

subjects specially selected by the researchers and working together, can provide qualitative

data. Commonly used in business and politics, focus groups get individual responses which are

conditioned by the group.

Individual interviews are not guided by standardized surveys with preselected responses, such

as “strongly agree – agree – neutral – disagree – strongly disagree” as is found in the Likert

scale. Rather, while covering standard topics, they encourage group or individual stories from

the subjects which pertain to the question at hand.

Design Thinking Process

A currently popular way of getting information, especially the qualitative component, is the

Design Thinking Process (DTP). While qualitative methods often try to eliminate or minimize the

subjective element in problem solving, design thinking attempts to “combine empathy for the

context of a problem, creativity in the generation of insights and solutions, and rationality to

analyze and fit solutions to the context (http://en.wikipedia.org/wiki/Design_thinking).”

Rather than dozens or even thousands of subjects, DTP typically recruits 10-12 subjects

specially selected for some characteristics of interest to the researchers. They find the subjects

through social media mapping, identifying frequent users of services, or asking key staff to

recommend specific users. Simultaneously investigators try to ensure a representative

demographic mix. In a hospital emergency department (ED), for example, study personnel

might identify key opinion leaders who write about that ED and its services in Facebook,

http://en.wikipedia.org/wiki/Design_thinking)


Twitter, or a blog. They might also examine hospital records to see which people used it the

most and ask ED staff to recommend patients for the study.

After potential subjects are identified they have to be screened to decide who to include. A key

determiner is who has the biggest potential influence to improve patient and system outcomes.

Subjects must commit not only to providing data but also to help develop solutions.

Once researchers have a suitable number of the right volunteers, data gathering - individual

interviews of each subject – begins. The first step is to develop a “journey map” for each

subject. For a study to improve ED services in a community hospital, the map may begin when

the patient first developed the symptoms that led them to the ED. They may be asked

questions like this:

1. Where and when did you first think that you might need to seek care? Why did you

decide to go, and how did you get there? Please describe in detail what happened and

how you felt.

2. Who did you interact with at each location in the process? At home with family? With

the EMS personnel? In the ED?

3. What touch points did you have with the medical system? How was your interaction

with each?

4. What is your impression of the areas that you encountered? It is useful at this point to

show patients pictures of pertinent locations, such as ED exam rooms, waiting rooms or

front desks. These key areas color peoples’ opinions of everything and everyone else in

the process.

5. What could you see, hear, smell, feel, or even taste at each area? Was the environment

hot, cold, too dark, too bright, too noisy, or something else?

6. Were you given educational information? If so, was it useful? Why?

7. What did you experience that was unexpected?

8. Did you experience negative emotions? Which ones? Why?

9. Did you experience positive emotions? Which ones? Why?

10. Was your experience seamless or fragmented?

Journey maps may begin even earlier. The first interaction that one person has with another or

that a person has with an organization may be the expectation that one has of the other.


Stakeholders may know, or think they know, well known people and organizations simply from

their reputations. Therefore it is incumbent on everyone to consider how to improve others’

expectations of them, not just the physical interactions.

Journey maps also end later than the final physical interaction between people and

organizations because of memory. A patient may have a wonderful experience in a hospital

overall but have one truly bad interaction at discharge. That person’s memory of terrific care

will be tainted and maybe even superseded by that last memory. Since memories of prior

experiences color future expectations, people and organizations must manage them if they

hope to please their stakeholders. The time-based process of interactions can be described like

this:

Expectation Does the customer or other stakeholder have expectations of the person or

organization? If so, what are they, and how can they be improved?

First

Impression

What does the customer or other stakeholder encounter the first time they

make physical contact with services?

Discovery Assuming the customer or other stakeholder stays with the person or

organization, both parties begin to discover what the other is really like.

Expectations and first impressions give way to lasting experience.

Usage Assuming that discovery is satisfactory to all involved, they begin working

together to accomplish mutual goals.

Memory Eventually the interaction, whether an episode of care or something else, is

finished. All parties remember their interactions, for good or for ill, and these

memories shape future expectations.

Interactions between stakeholders and organizations do not occur only in time but also in

space, and journey mapping also discovers these interactions. Some interactions happen

directly to a stakeholder, such as a patient having surgery. Other interactions happen to their

family or friends, such as a desk clerk being kind, or rude, to visitors trying to see the patient

after surgery. Still other interactions happen in the public sphere, such as when a stakeholder

sees a news story or an advertisement about a hospital. Innovators can find valuable clues on

how to improve a customer’s (or a patient’s) experience by considering both time and space in

their interactions with the organization.

For ongoing interactions between an individual and an organization, having the customer

(patient) keep a week long journal of her interactions with the organization is useful. It is


important to interview the subject in her context, such as home or work, to get the most

insightful answers. Once each person has described their journey, researchers will begin to

identify commonalities between them on the journey maps. They should use those

commonalities to make a journey map of the subjects, which is called the Experience Map.

Simultaneous with gathering information from customers, known as patients in the health care

setting, investigators begin selecting key organizational actors to participate. These may be

doctors, nurses, and health care administrators, and their task is to join with the patients and

solve the problems identified. First they write a blueprint of how the current service is

designed. The blueprint helps match the front end experiences that the patient sees with the

back end processes that the providers do. In the ED example, these staff members would

carefully outline the current processes for screening and treating patients, as well as other

pertinent processes. They would also identify principles that need to guide their thinking. For

example, interactions with patients and other staff must be pleasant while at the same time

being meaningful. “Pleasant and Meaningful Interactions in the ED” then becomes a key

principle, known as an “Experience Pillar”, in the process.

Solving the Problem

The data gathering process is iterative; new data will constantly appear and be integrated into

thinking on the research question and hypothesis. The solution process is also iterative; new

data will modify the proposed solution and suggest improvements. Just as customers and staff

are integrated into the data collection efforts, so customers and staff should be integrated into

the problem solving efforts. The team that does this is the Co-Creation Team.

Looking at the service blueprint and the experience map, the Co-Creation Team uses Ideation

sessions to look at the problems and at ways to fix them. They identify many possible solutions,

but especially those that are small scale, low cost, and can be implemented quickly. The team

presents its recommendation to decision makers and if all goes well their ideas are piloted. The

easiest and quickest approach to the pilot project is to begin with the minimum viable solution

tested in the minimum viable service. For example, rather than piloting a new mobile phone

application to help patients coordinate their care with hundreds of patients in many different

clinics and diagnostic categories, organizations can pilot a small version with a few dozen

patients in one clinic in one diagnostic category. In the National Capital Region, our pilot will

involve a few dozen amputees in the Wounded Warrior clinic.

How to Optimize Discovery

Benchmarking, quantitative and qualitative methods are not contradictory but complementary

in discovering how to best make a widget, provide a service, or care for a patient. In general


terms, quantitative research and benchmarking can identify what is happening and where,

while qualitative research can show how it is happening and why.

Conclusion

In a world of constant change, individuals and organizations must continually improve. To do

this we must think differently, constantly making new discoveries. Using benchmarking,

quantitative and qualitative methods provides a good means to do that.


Formal Business Visits and Town Halls

Management gurus since the 1970s have taught leaders to “manage by walking around

(MBWA)”; getting out of the office and into the workplace to see for themselves what was

going on in their organization. It is a very old idea. Though generals such as Napoleon and

business tycoons such as Henry Ford were legendary for getting first-hand information about

their organization and its environment, MBWA has been around since before Moses walked

among the people of Israel during the Exodus (c. 1400 BC).

Most MBWA is informal, with the boss walking from department to department or store to

store, meeting people, talking and most importantly listening to them. There are times,

however, when leaders need to interact with their organizations and with other organizations

more formally. My leadership team in the National Capital Region Medical Directorate

(NCRMD), part of the Defense Health Agency, meets with leaders and workers at military

hospitals and clinics throughout our market. We also visit Federal Facilities such as the

Veteran’s Administration, and major regional partners including the hospitals and clinics of the

Johns Hopkins, Medstar and INOVA systems. Sometimes formal trips to universities and other

non-medical facilities are required, and often my team and I stand before a group of

stakeholders in a town hall or public forum.

Visits are important. They provide a chance to get acquainted and discuss matters important to

both parties. Typically my team receives a brief from the clinic including their leadership, their

services, their successes and their struggles. I always like to hear good news stories from our

subordinate facilities and learn about their best staff so we can reward them publically.

Sometimes my team provides a brief to them on key things that they need to know from higher

headquarters. Finally we have a tour. Over the years, I can think of dozens of successful

initiatives that have begun while collaborating during a visit.

Town halls are also important. Whether a group of hospital employees needing motivation or a

crowd of military retirees seeking medical care, leaders must listen to their concerns and must

be perceived as listening. It does little good to listen but appear as though you are not, and it

does no good at all to only pretend to listen. Town halls have provided a useful venue to get our

messages out and to get their messages in.

Visits and town halls, however, require a lot of work. Because both are ceremonial events, and

because of the traditional mistrust between levels of an organization, visits and town halls need

to be carefully planned and executed. Leaders and administrative support staff can get nervous.

When my Executive Assistant calls a hospital or clinic to arrange a visit, the first question that


she always hears is “why?” Sometimes the “why” is interrogative and other times it is

accusatory.

Formal Visits to Other Organizations

1. What do you want to accomplish during the visit?

Most people don’t want to waste time, and some consider visits from higher headquarters to

be a waste of time; an interruption from their real work. Others see visits from their senior

leaders as validation that what they do matters, and these visits help them feel more a part of

the community. Most understand that the people from higher headquarters can provide

resources and guidance for their mission, and professional mentoring. Our general goals are

mentioned above, but we form specific goals as well. During a visit to the Veteran’s

Administration Hospital in the District of Columbia (DC VA), one of our specific goals was to

propose a sharing agreement for inpatient behavioral health services. Today that agreement is

nearly complete.

2. How do you want to accomplish it?

It is hard for formal visits to be productive with an agenda, including approximate durations for

each item. Taking minutes is also mandatory, since items discussed, conclusions reached, due

outs (work to be done) and action officers (those responsible to get it done) must be tracked.

Both parties to the visit must shape the agenda, since doing so makes the visit collaborative

instead of coercive. Appendix A contains a sample agenda and list of slides for a visit to a

subordinate facility. The list will need to be adjusted depending upon circumstances. For

example, if the leaders know each other well, there is no need for slides identifying the leaders.

3. Who do you want to meet?

My team tries to anticipate the needs of the facility we will be visiting and comes up with a

draft list of attendees. Then we discuss the list with them to determine the final list. For

example, for a visit to an outpatient clinic we would bring along our experts in primary care,

appointing, referrals, and whatever specialties that clinic offered. For our visit to the nursing

research unit at the National Institutes of Health (NIH), we included senior nursing researchers

and physician researchers from Walter Reed and educators and clinicians from the Uniformed

Services University for the Health Sciences. Sharing bios is a good idea. During a visit to the DC

VA I discovered that our host and I went to the same graduate school, and during a visit to the

NIH sharing bios enabled us to introduce people with common research interests.

To prevent overwhelming our hosts we try to keep our team to no more than 4-5 people.

4. How do you want to communicate the essentials for the meeting?

The Clinical, Business and Warrior Operations Division (CBWO) of the NCRMD has crafted a

paragraph that we send to places we wish to visit to describe why we wish to come, who will


come, and what we would like to do. Our team of executive assistants plans the when and

where. Additionally, we have a list of Frequently Asked Questions (FAQs) (Appendix B) that we

can send out for specifics. In the days before the visit we decide on themes to cover.

5. A preparation list for visits – introductory paragraph, agenda, host slides, visitor slides,

FAQs, date/time/location,

Town Hall and Panel-type Events

Business meetings feature representatives discussing issues, and town halls are another

variation on that theme. Town halls often involve senior leaders standing before groups of

people and answering questions, sometimes aggressive and accusatory ones.

1. What do you want to accomplish with the town hall meeting? Groups sponsoring town

hall meetings often say that they want to listen to their constituents. This is true, but

they also want to speak to their constituents, explaining complicated issues and getting

messages out. Town hall meetings demonstrate to the stakeholders that their leaders

value them and actively seek feedback. The theme of the meeting needs to match the

needs of the stakeholders.

2. How do you want to accomplish it? Community events such as town hall meetings need

an agenda to guide discussion and minutes to record discussion. Leaders should work

with their public affairs teams to craft short, pithy talking points so their message will be

heard and remembered. Communication isn’t only verbal. Wearing the right uniform or

civilian business attire, having good posture and listening intently are important.

Displays or posters can send worthwhile messages, and the venue itself speaks volumes.

3. Recommendations during town hall meetings

a. Arrive early and talk personally to attendees – Gain as much good will as you

can; most people find it harder to publically skewer someone they know

personally than someone they do not.

b. Have your support team arrive early to ensure that the venue, the audiovisual

support, and other key parts of the meeting are working. This is true even if you

are not the host – poor performance hurts all participants.

c. Be aware of recent news and other key events that affect your listeners. Use this

knowledge to personalize your discussion.

d. Don’t argue – even if the questioner is rude and wrong. As the authority in the

room, arguing only makes you look bad.

e. Listen completely to the concern or question, and then repeat it aloud.

Sometimes others don’t hear it, and you want to be sure that you know what the

problem is.


f. After reflecting the question back, reply briefly and honestly. Then add the

talking point that is most relevant.

g. Have a compatriot mingle in the crowd and get the name, question, phone

number and email address of those who asked a question. Once you have the

answer, close the loop with the person who asked it.

Permissions

Many facilities have more than one higher headquarters. Military medicine is divided into

geographic markets, including the National Capital Region, the Tidewater Region, the Puget

Sound Region, the San Antonio Region, the Colorado Springs Region, and the Hawaii Region.

The Walter Reed National Military Medical Center, the Fort Belvoir Community Hospital, the

Joint Pathology Center, and some other facilities in the National Capital Region military medical

market fall directly under the National Capital Region Medical Directorate (NCRMD). Other

clinics, however, have split responsibilities. For example, the Navy clinics at Quantico and

Annapolis answer to the NCRMD for market issues and Navy Medicine-East for administrative

issues. The same is true for the Army clinics at Fort Meade and Fort Myer and the Air Force

clinic at Joint Base Andrews. Sometimes local clinics want teams visiting from one headquarters

to first get permission from the other. Though it may not be technically necessary, if it keeps

peace in the market and protects the local command, do it.

Commanders visit their subordinate facilities, but so do staff teams. A key part of staff work is

to visit the leaders and staffs of other facilities. As the Chief Medical Officer I do not visit as a

commander but as a senior staff director of the NCRMD. My team has blanket permission from

the NCRMD Director (and previously the JTF Cap Med Commander) to visit whatever facilities

we deem necessary to accomplish organizational goals. To avoid encroaching on the

prerogatives of our Director, we coordinate our visits with hers and ensure that we do not

repeat messages. For example, she discusses strategic issues on her visits, while we focus on

operational and tactical issues.

If communication and trust between people and commands is poor it may be hard to get

permission. Rather than appealing to higher authorities leaders should try to convince the

recalcitrant that the visit is in everyone’s best interest. When my JTF Cap Med team wanted to

visit the Quantico clinic, the clinic leadership was excited to host us but their higher

headquarters at Navy Medicine – National Capital Area (NCA), said “no”. I met with the

NavMed NCA team, told them why this was important and how they would benefit, and offered

to let one of their leaders join our visiting team. They agreed and the Quantico visit was a great

success. Keeping minutes of visits allows us to document successes and justify further visits.


Permissions and coordination are also indispensable at Town Hall meeting and other

community events. Everyone involved must know and agree on the goals of the meeting and

must have an idea who will talk and what they will say.

Conclusion

Visits and town hall meetings are vital functions for any senior leader, but seldom are we taught

how to do them. This article is intended to help senior leaders and their staff members better

use formal visits and town halls to meet organizational goals. By taking important processes

and standardizing them, we can decrease confusion and get more done.

Formal Visit to a Subordinate Command - Sample Agenda and Briefing Slides

Time Item Notes

1300-1305

Welcome

1305-1345

Local facility Brief and Discussion

Title slide – facility, briefer and date

Slide 1 – Overview of brief

Slide 2 – Leadership team Facility director, chief officers (medical, nursing, operations, financial), other key players whether they are present or not

Slide 3 – Floor plan or map of facilities

Provides a snapshot of the size of the building and scope of services

Slide 4 – Population overview Who do we want to serve? In military medical facilities, this is the beneficiary population.

Slide 5 – Population served Who do we serve? In military medical facilities, this is the enrolled population for primary care.

Slide 6 – Services offered to primary customers/patients

Primary care, behavioral health, specialty care, ancillary services, public health, surgical, etc.

Slide 7 – Services offered to others

Education, research, etc.

Slide 8 – Quality metrics – primary care

Access to care, continuity of care, emergency department utilization, secure messaging, HEDIS

Slide 9 – Quality metrics – specialty care

Access to care, ORYX, Partnership for Patients, operating room utilization

Slide 10 – Facility SWOT Analysis Strengths, weaknesses, opportunities, threats

Slide 11 - Competitive environment

Primary competitors and market share for each


Slide 12 – Competitive advantages and disadvantages

Ours and theirs

Slide 13 – Marketing and communication

Ours and theirs

Slide 14 – Financial Inflows Defense health program, other health insurance, other Federal reimbursement (Medicare, VA)

Slide 15 – Financial Outflows Civilian personnel, pharmacy, contracts, other major cost centers

Slide 16 - Future plans and timelines

Services, costs

Slide 17 – Recent victories Three things to be proud of, including the people who made them happen

Slide 18 – Recent struggles Three things to overcome, including the people who are key to overcoming

Slide 19 - Needs from higher HQ Three things that they need from us

Slides 20 – Summary

1345-1350

Break

1350-1410

Higher Headquarters Brief and Discussion

Slide 1 – Overview of brief

Slide 2 – Leadership team

Slide 3 – Military medical regional overview

What is happening at the other hospitals and clinics in the region?

Slide 4 – Business plan metrics How well is the region accomplishing its goals

Slide 5 – Business plan metrics

Slide 6 – Public sector developments

How are the political and governmental environments changing?

Slide 7 – Private sector developments

How are the competitive and economic environments changing?

Slide 8 - Other developments Other changes that the subordinate facility should know about

Slide 9 - Our response What higher headquarters is doing about these changes

Slide 10 - Summary

1410-1420

Roundtable

1420-1500

Facility Tour When possible, meet and recognize the people who made the “Recent Victories” happen. Award commander’s coins if available.

1500 HQ team departs


Frequently Asked Questions

1. What is the purpose for this visit?

2. What do you want included in the introductory brief?

3. How long do you think that this visit will last?

4. Who needs to be present?

5. Have you cleared this with (another headquarters)?

6. Do you have bios for your team members?

7. Do you want bios for our team members?


Getting People to Answer

A Navy Lieutenant Commander (LCDR) came into my office recently. “Sir, I have emailed Lt. Col

X several times and she hasn’t answered yet. All I get is radio silence. Could you help?” This

young officer was voicing a concern that I hear frequently; someone that they are trying to

work with, or get something from, wasn’t answering. Or at least they weren’t answering fast

enough to suit us at higher headquarters. When faced with such a problem, many junior

staffers go to the Boss, hoping that he or she will contact the person and get immediate results.

Sometimes if the issue is urgent that is the right approach. Sometimes even going directly to

the boss of Lt. Col X is the best approach. Often, however, it is better for the junior staffer to

get the information themselves, and there are many ways to do that. I have been faced with

similar problems in the past and have learned the hard way that, unless the issue is urgent, I

need to exhaust my options for resolving problems, such as radio silence from someone I am

supposed to work with, before going further up the chain.

Make sure that you are asking for the right thing

Ultimately any request, whether for information or for a task to be done, must be right. The

energy that it takes to do it must be worth the value that comes out of it. We have to ask the

right person; it is no good asking the chief of patient administration to do something that the

chief of neurosurgery should be doing. We have to be clear in our request and respectful in the

delivery. We must only make ethical demands. In medicine our requests must be the right thing

to do for our patients and other stakeholders.

Give a little time

Sometimes it is a little embarrassing to remember past mistakes. Several years ago our

commander at William Beaumont Army Medical Center received a suggestion to cut imaging

costs by preventing physicians’ assistants, nurse practitioners and primary care physicians from

ordering expensive magnetic resonance imaging (MRI) scans. He asked me to get information

from my department, primary care, and from other departments to address the question. In

the flood of other tasks I quickly forgot until a few days before the information was due. A cold

knot welled up in my stomach and a sent out a flood of emails to everyone involved so that I

could at least shift the blame to them if I didn’t get the data in time. Or so I thought…

There are lots of good reasons why people don’t respond as quickly as we would like.

Sometimes they just don’t get the message, whether because it is lost in cyberspace or because

they are out of the office. Other times they get it but are so far behind on email that they don’t

see it. The more emails I receive, the more I sympathize with this problem. Everyone is busy,


and an issue that I consider urgent may not be urgent to someone else. Sometimes requests

are confusing and the recipient truly doesn’t know what they are being asked to do.

Assume the best

Most people do not want to do the wrong thing. If your request is reasonable and you ask in a

timely and friendly manner, most will want to honor it and will feel guilty if they don’t. We

sometimes assume that we will act with wisdom and compassion while others act with

foolishness and spite, assuming the best about ourselves but the worst about others. This

arrogant attitude only makes it harder to get good things done.

Even in the worst of circumstances it is usually unhelpful to assume malice. Shortly after my

father died my mother received an email from her health insurance provider stating that he had

technically been off of her insurance during his last six months of life. Therefore they were

going to bill her for his chemotherapy, radiation therapy and hospitalizations. Mom was panicky

and my brother was furious, so she asked me what to do. I replied that in situations like this you

will more often be correct if you assume laziness and incompetence rather than malice and

villainy. Calmed slightly, my mother called the insurance company. After getting referred a

couple of levels up the management chain, she learned that a computer error, a policy change,

and an unwillingness on the part of some of their staff to look deeper had combined to

generate this misunderstanding. Everything was covered.

Flip the roles

In another instance we had asked our subordinate command to provide a report about a recent

mock Joint Commission inspection. Rumor suggested that the results were not pretty, and they

were dragging their feet. After many weeks and many entreaties our Quality Management shop

turned to me for help. I contacted their chief of staff, listened while she explained their

perspective and then clearly explained ours. Then I asked “if our roles were reversed, wouldn’t

you and your commander want the same thing?” The report appeared in my inbox the same

day.

Name drop

Every organization is conscious of rank and position, no matter how flat they are

organizationally. The larger the organization, however, the more conscious of such things it

tends to be. Nowhere is this more true than in the military. Sometimes stating that a request is

from a colonel or Navy captain rather than from a lieutenant commander or major is enough to

get results. Even better, sending an email that has the higher ranking officer on the courtesy

copy list lets the recipient know that a boss is looking at the request. More than once this has

made the difference between action and inaction.


Fingers, voice and feet

It is easy to send an email, and equally easy to miss or ignore an email. It is much harder to

ignore a ringing phone, especially one that rings again and again. It is hardest of all to ignore a

person sitting across from your desk or in the waiting room outside your office. If the target of

your inquiry is not intentionally avoiding the issue, a phone call may be all that is needed to get

results. Phone tag is not a bad thing if you are able to make headway. Further, emails can be

confusing, clouding the picture more than clarifying it in many cases. This is especially true for

complicated or contentious issues. Even if the target of your inquiry is intentionally avoiding

you, a phone call or even a visit is vital. The communication motto for my staff is “friendly, but

relentless.”

In the modern day of emails, texts and web posts it can be difficult and even threatening to

have tense conversations over the phone or in person, but some things will never get done

otherwise. People who can handle these situations well are like diamonds, scarce and precious.

Give something they want

Everyone wants something, and the person that you need information from is no exception.

Sometimes they feel overwhelmed and want less to do so if you have asked them for three

things and reduce that to only two, they may be happy enough to comply. Sometimes they

want an encouraging word or even a complement about them to their boss. Sometimes they

just want to be listened to, and if you spend five minutes listening to their challenges they will

reward you with what you need. Sometimes they need help with what you are asking them to

do; the Navy LCDR offered to help Lt Col X compile the data he requested.

People at lower headquarters need to know that their higher headquarters is doing something

to benefit them. Staffers at higher levels can make their work easier by being value added for

those at lower levels. Sometimes giving them “something they want” means protecting them

from something that they don’t want.

Think outside the organization itself. Higher levels of command have more than just money and

people to give to their subordinates. They have expertise and experience to share, and

sometimes people at lower commands need and even want that expertise. They also have

access to media outlets, whether a base newspaper or a local radio station, where they can

spread the word about the good things that their subordinate command is doing.

Double team, diversely if possible

In the introductory story the Navy LCDR was trying to get information from Lt. Col X, and was

getting the stiff arm. He had given it time, assumed the best, and dropped names. He had called


and gotten nothing, so the next approach was to double team her. A young active duty Navy

male had tried, so he enlisted an older civilian female.

Why try this, because two can apply more pressure than one, and can apply it in slightly

different ways. Who knows why Lt. Col X was resisting his entreaties? Perhaps this officer had a

mannerism that she didn’t like, perhaps she interpreted his actions negatively, or his age, race,

sex, service, or something else put her off. Discrimination based on these factors exists, and we

must overcome it. As rational as we like to think we are, man is an inherently irrational

creature. Man is also a tribal creature, with whom identity and identification matter. Perhaps

involving someone who was more like Lt. Col X would influence her to provide the assistance

needed.

The 360

Those we try to influence do not work alone; they have bosses, subordinates and peers. Since

Lt. Col X outranked the Navy LCDR, another possibility was for him to approach her deputy, an

Army major, and ask if Lt. Col X had been out of the office or had some other reason why she

hadn’t replied. He then asked if he could do anything to help the major help his boss, Lt Col X.

This technique is useful because everyone is influenced by those around them. Perhaps

convincing a certain peer of Lt Col X that this task was important would be enough to get her to

do it. Even a trusted subordinate could do the trick.

The Boss

If the request for information or the task that needs to be done is urgent, sometimes lower

level staffers have to go straight to their Boss, and he or she has to go straight to the other

person’s Boss. Most requests, however, are routine. If a staff member has done everything that

he or she can and still gets nowhere, the Boss must act. Senior leaders have various options,

including all of the ones noted above. For example, I could go directly to Lt Col X’s boss or to her

boss two levels up.

There is danger in doing this in the wrong way. Years ago when I was a young Army captain I

was working in a clinic in Germany and my boss had made an unpopular decision and gone to

lunch. A few minutes later a brigadier general came into the clinic. Since I was the ranking

officer there at the time our near-panicky executive officer came to me and said “Dr. Harris, a

general is at the front desk and wants to speak to you!” When I asked the general what I could

do for him, he said “Dr. Harris, someone at this clinic made a decision a few minutes ago and I

came in hoping that I could influence that decision.” He never said “I order you”, he never

demanded, and he was never cross or even stern. Knowing that he had tremendous power, the

general was very gentle in how he used it. I never forgot the lesson.


There is also danger in doing this too much. Leaders and subordinates grow weary of leaders

who seem to be throwing their weight around. Senior leaders are generally very busy and have

little time to devote to non-senior-leader level things. Getting involved in staff level work too

often impairs a leader’s own ability to get other work done.

Conclusion

Poor communication and cooperation at every level is, and always has been, a problem in and

between organizations. Staffers must do everything they can to fix this problem, including

asking for the right thing, allowing time and assuming the best. They can flip the roles, drop

names, and use fingers, voice and feet to accomplish their mission, always being ready to give a

little in order to get a little. They enlist other people to help them. If all else fails or if time is

short, they ask their boss for assistance. Ultimately the mission is what matters, and everyone

at every level must accomplish it.


Getting Things Done in Military Medicine

Like everything in government, military medicine is a vast bureaucracy. As such, military

medicine is inherently resistant to change; sometimes it seems that people work four times as

hard to get one-fourth of the work done. Nonetheless good people do good things every day,

and slowly the prow of this lumbering battleship gets pointed in the right direction. I have

spent over 23 years in military medicine, including 18 months as a liaison in Washington at the

Department of Health and Human Services, and have learned a few things along the way. This

paper is intended to help my staff, others currently in military medicine, and perhaps even

those after us, get good things done in the US military health system.

Step One – The Idea

Nothing gets better unless someone thinks of it first. This requires the desire to think about

how to improve a situation, an extensive though not exhaustive understanding of the current

situation, and time to think. Every part is vital; we have all suffered through legions of ideas

presented by well intentioned people who did not understand the situation they were trying to

fix, or hadn’t thought clearly about their proposed solution. Occasionally someone with little or

no knowledge of a situation has a great idea about how to improve it, but this is rare. Once we

have an idea we need to think it through on our own, identify risks and benefits in the short

term, and try to anticipate longer term effects.

For example, a patient may want longer appointments with her physician to get more

complaints addressed for the same investment in time and money. A health care administrator

may want shorter appointments to maximize profits. It would be easy to assume that the

patient is right and the administrator is wrong, since in medicine we try to put patient needs

first. However, if a doctor sees patients in the clinic eight hours per day and each appointment

is 15 minutes long, he can see 32 patients. If the appointments are 30 minutes long he can see

16 patients. Unless there is excess capacity in the system as a whole so that the other 16

patients can get care from someone else, they will go without. The question then becomes, if

our medical ethic is to do the most good for the most people, does the benefit of longer

appointments for this patient outweigh the other patients’ need to get care at all?

Another key question is “does this idea align with the overall strategy of the service, the

department, and the organization as a whole? If so, proceed. If not, it should be taken up in

another venue. Writers write good novels that are rejected because they are submitted to non-

fiction publishers. Don’t make this mistake. Every initiative has a concept of operations

(CONOPs) which outlines what the initiative is intended to do and this is the right time to

formulate an informal CONOPs.


Most ideas will not survive this step, and that is not a bad thing. Rejection of an idea does not

mean rejection of the idea maker, and no one has consistently good ideas. The lesson is not

that people should stop having ideas, but to have them and think them through.

Step Two – Analysis

After the idea generator has carefully considered his or her idea and still deems it worthy to

pursue, formal analysis begins. In research, investigators do a literature review to see if others

in their field and with similar obstacles have had the idea before. If they did, what was the

result? In business, process improvers seek other companies that struggle with the same

problem to discover what they are doing about it. This is called benchmarking. Governments,

non-profits and others worth their salt do the same thing. In a world of seven billion people and

thousands of organizations facing similar obstacles, it is unusual for an idea to be completely

new.

Once these innovators have completed the literature review and the benchmarking, it is time to

see if the idea might work in their specific situation. Kaiser Wilhelm II of Germany, having

devoured Alfred Thayer Mahon’s Influence of Sea Power on History, loved the idea of building a

blue water navy to challenge Great Britain in the years prior to World War 1. He imitated the

British and even surpassed them in some areas; investing billions of German goldmarks, only to

discover during the war that his Kaiserlichemarine still could not defeat the Royal Navy. The

Kaiser had reviewed the most current literature and benchmarked against the best in the

world, but did not make sure that what he discovered would not carry over to his specific

situation.

First, the project team further refines the CONOPs. Also, most organizations use business case

analyses (BCA) to determine how an idea might fare in their specific situation. There are many

formats for these depending on the needs of the organization, and so individual formats will

not be discussed here. However, most BCAs consider only or primarily the financial aspects of

an idea. I would argue that the analysis must consider the desires of all, or at least most, of the

stakeholders in an organization. In military medicine BCAs might address the following:

1. Financial - Will this idea make money, lose money, or break even? Consider the short,

medium and long term.

2. Educational - Will this idea help our employees, our patients, and/or our other

stakeholders perform better in their responsibilities or expectations?

3. Research - Will this idea contribute significantly to the body of knowledge in this field? Is

research one of the key missions of this organization?

4. Quality - Will our patients and families receive better care? Will our staff have better

working conditions? Will our other stakeholders benefit in some tangible way?


5. Mandate - Is our higher headquarters or some other entity with authority over us

mandating that we do this?

If we don’t include all of these factors, and more depending upon the situation, in our BCA, we

will overlook some worthwhile initiatives and harm our organization. The environment is

constantly changing and every institution must adapt to these changes. This is the time to

further develop the CONOPs.

Part of any analysis is deciding how processes will flow. For example, to decide whether or not

to fund a residential treatment center (RTC) for substance abuse, innovators had to figure out

who would be admitted to the RTC and how. They had to envision how the patient’s care

would occur, how long it would be, and the characteristics (how many, what type) of staff

would be required. Innovators had to conceive the process for discharge and follow up long

before the first patient ever darkened the door. Research and educational opportunities

needed to be considered, as well as quality of care issues. Metrics and methods to implement

the RTC had to be devised, as did metrics and methods to maintain the RTC once it was fully

operational. In short, the idea makers have to construct their ideas completely in their minds

and on paper (or computer screen) long before it becomes reality. In the Seven Habits of Highly

Effective People, Steven Covey argues that every project must begin with the end in mind. First

comes the mental creation, and only later comes the physical creation. As the team figures out

how they think the processes will look, they need to prepare flowcharts for each process and

explanations of each step. These will be useful to comprehensively think through the processes

and explain them to others.

It is unusual for one person to have the skills, time and other resources to do all of this by

themselves, so the idea-creator has to enlist the help of others. Even if the idea-generator can

do the entire analysis, he shouldn’t – he needs a team to get political momentum if nothing

else. Until the others have caught the vision, the innovator must use personal connections or

whatever other resources he has to sell the idea. If the idea is truly good and the analysis shows

that it might work, the project will gain a life of its own. Eventually a team will coalesce which

will work on the project and advocate for it.

Analyses take time, energy, focus and skills and so the supervisors of those analyzing the

project will need to allow their people to do it. Information briefs are used to inform leaders

about a project and, implicitly but not explicitly, their approval to continue working on it. Plan

these briefs carefully and show progress – no one wants a good project killed because it was

communicated poorly to a leader who then withdrew the resources to keep evaluating it.

Step 3 – Decision


Once the analysis is completely done, the innovator has to sell the idea, which has now become

a project, to the decision maker. This person or group will vary depending upon the scope of

the project and the resources required. The clinic chief will decide on a project to change work

processes in a single clinic, and the chief executive officer or the board of directors will decide

on a project to build a new hospital for the health care system. In the later case, however,

several lower level leaders will usually have to support the project before it even makes it to

the boss. Every organization is unique, but the key point is that every project champion and her

team have to shepherd their project through every step of the appropriate chain to get it

approved and implemented.

The process is similar at every decision making level:

1. Decide who needs to be influenced and how to influence them.

2. Identify who is likely to support the project, who is likely to oppose the project, and

why.

3. Begin to informally socialize the project with likely supporters, see if they actually

support it, and gauge their enthusiasm. Lukewarm support will kill a project at least as

effectively as outright opposition.

4. Encourage enthusiastic supporters to become more enthusiastic and to influence their

less enthusiastic peers. Ask them who else at their level will support the project, how

strongly, and who will oppose it. One person will need to become a champion.

5. Float the idea carefully with those will are likely to oppose it. If they are against it, ask

why and take their feedback seriously. They may be right, and ideas that looked good on

the surface, even after analysis, have been appropriately killed by intelligent opposition.

Improving the project on the basis of criticism from opponents is also a good way to

turn opponents into supporters.

6. Provide information briefs about the project to interested and important players,

including the ultimate decision maker.

7. Make the reasonable and intelligent changes suggested by supporters and opponents as

long as those changes do not ruin the project altogether. Fight for the important stuff

and be flexible on the unimportant stuff.

Once the project team believes that they have a critical mass of supporters and have effectively

addressed the concerns of the opposition at each level, they should prepare a decision brief for

the decision maker. Send the brief to the decision maker ahead of time so he or she can review

it at leisure. Never ask a leader for a decision on something that he or she has never seen

before; the answer is likely to be no. The leader will probably send the decision brief to trusted

associates and subordinates so it can be useful to get their buy in ahead of time. The project

team should do everything they can to make approval a foregone conclusion.


The decision brief is a key document. Subject to individual variations in a command or

organization, it should include the following information:

1. Slide 1 - Title of the Presentation (name of the issue), briefer and date

2. Slide 2 - Mission as received

3. Slide 3 - Mission analysis - Current Situation (METT-TC) narrative and metrics

4. Slide 4 - Mission analysis - Desired End State (METT-TC) narrative and metrics

5. Slide 5 - Mission implicit and explicit tasks

6. Slide 6 - Summary of Courses of Action (COAs)

7. Slide 7 - COA 1 including supporting metrics

8. Slide 8 - COA 1 advantages and disadvantages (in all of the areas noted below)


10. Slide 10 - COA 2 advantages and disadvantages (as COA 1)


12. Slide 12 - COA 3 advantages and disadvantages (as COA 1)

13. Slide 13 - Additional COA supporting metrics

14. Slide 14 - Additional COA advantages and disadvantages (as COA 1)

15. Slide 15 - Decision matrix

16. Slide 16 - Recommended COA

17. Slide 17 - Questions

18. Backup slides – hidden and not included in presentation unless requested

19. Decision Matrix - Side by side comparisons of the courses of action, ranked from 1 to 3

as the most to least desirable.

a. Personnel b. Information/Intelligence c. Operations/Training d. Logistics and Facilities e. Finance and Money f. Public affairs/customer relations

This list is longer than many commanders want their decision briefs to be, but it is comprehensive. Slides 2 and 5 will often be back-ups, the COA slides will often be combined into one slide per COA, and slides 13 and 14 may not be needed at all. As with all communication, presenters will tailor the brief to the needs of the audience. The Mission Analysis slides deserve comment. The military uses the acronym METT-TC to assist staffers in comprehensively analyzing missions given to them by their commander (or higher commands).

1. Mission – as provided


2. Enemy (forces opposing mission accomplishment) – in health care, this may refer to competitors, pathogens, or failure of the staff to follow certain practices such as hand washing.

3. Troops (resources available to accomplish mission) – in health care, this usually refers to the people available to address the problem. If the mission is to decrease hospital acquired infections, “troops” will include staff members, patients, family members, and others working together to prevent infection transmission.

4. Terrain (environmental factors affecting mission) – in health care, the physical environment, the fiscal environment, the regulatory environment, the political environment, and others are included. In the example of hospital acquired infections, multi-patient rooms are a risk factor for infection that would be included under “terrain”.

5. Time 6. Civil considerations (maximizing benefit and minimizing damage to peripherally involved

parties) – health care systems have many stakeholders besides the staff, the patients and their families. Payers such as employers, governments, and the local communities also play important roles in the life of their local hospitals and clinics.

A common mistake with decision briefs is to make them too general. Decision makers cannot

make decisions based on vague generalities such as “decrease hospital acquired infections”.

They want specifics such as “this initiative will decrease the incidence of staph aureus and other

common percutaneously acquired infections by 20% in the adult medical-surgical ward in six

months after implementation at a cost of $41 per inpatient bed day.” Everyone knows that

hospital acquired infections are a bad thing; leaders need to know exactly what to expect, how

to measure it, how much will it cost, and similar specifics. The project team should rehearse

among themselves and prebrief supportive members of their chain of command (or authority)

to get constructive feedback. Canvas your team to ensure that the final decision brief will be

the right message presented by the right messenger using the right method at the right

moment to the right audience. Make sure that the team carefully considers everyone who will

be in the room, who are they and what do they need?

After the project is approved at each level, go on to the next level until the last decision maker

has given the thumbs up. Don’t ask for any decisions prematurely or without the appropriate

preparation because once a leader has said no it is very hard to reverse it. To reverse one’s own

decision is seen as inconsistency at best and weakness at worst. It forces the decider to admit

to having possibly made a mistake, and human psychology makes that hard to do. Far better to

get the initial yes.

Step 4 – Implementation

Far too often when we get the decision that we want we pop the champagne corks and think

our work is done. Popping the corks is fine for an evening or perhaps a weekend, but then the


real work begins. The implementation plan should have been completed during the Analysis

phase and edited during the Decision, so the initial way forward should be mapped out.

However, as the Prussian Field Marshall Helmuth von Moltke (1800-1891) observed “no battle

plan ever survives contact with the enemy.” Change is a fearsome opponent, and will not

surrender easily. People that the project team thought were allies will disappoint them, either

with opposition or with indifference, and some ideas which smelled like a rose on the drawing

board begin to smell like something else in practice.

Five types of documents are important to starting a new program.

1. CONOPs (final)

2. Action plan – this specifies who will do what, when and where they will do it, and with

whom. How to do it may be specified or unspecified depending upon the situation.

3. Timeline – the written action plan needs to be visually laid out on a timeline with

milestones so that those involved can grasp at a glance what needs to be done, when,

and how it fits into the overall project. The military uses stoplight colors (red, yellow,

green) to identify the status of milestones.

a. Red – Major obstacles or delays; task will not be achieved by the time indicated.

b. Yellow – Moderate obstacles or delays; task may not be achieved by the time

indicated.

c. Green – Minor or no obstacles or delays; task should be completed by the time

indicated.

4. Process flowcharts – As the initiative is implemented, the expected process flowcharts

which were drawn in the Analysis phase will be modified to conform to reality on the

ground. Each point on the chart should be explained. In accompanying text.

5. Issuances, including policies, charters, orders and other documents – For large projects,

or those generated by a higher command to a lower one, these documents guide the

subordinates in how to implement the new system.

One common pitfall in implementing a new project is failing to consider important aspects of

the project. In offering a new service such as joint replacement services in a community

hospital, for example, project leaders usually remember to make sure that there are patients

who need the surgery and surgical staff who can do the surgery. They may not remember,

however, that people need to be trained to buy the implants, suppliers need to be found, and a

host of seemingly little things need to be done to get this off the ground. As the proverb says:

“For want of a nail the shoe was lost; for want of a shoe the horse was lost; for want of a horse

the knight was lost; for want of a knight the battle was lost; for want of the battle the kingdom

was lost – all for the want of a nail.”


The smallest oversight can derail a project, and nothing can be left to chance. Therefore the US

Department of Defense uses the acronym DOTMLPF to guide comprehensive thinking on any

issue.

1. D – Doctrine (how we do what we do – big picture)

2. O – Organization (how we are organized to accomplish our mission)

3. T - Training (how we teach others to accomplish the mission at the tactical level – Army

foxhole, Navy deck plate, Air Force flight line, medical bedside or clinic)

4. M – Material (what things we need to accomplish our mission)

5. L – Leadership (who are our leaders and how do we prepare them)

6. P – Personnel (who do we need to complete the mission, and where/how do we get

them)

7. F – Facilities (real property, buildings, etc. that contribute to our mission

accomplishment)

Looking at initiatives in this light is essential to remembering the major details necessary to

implement any program.

The last thing to consider when implementing a project is how to measure the implementation.

The timeline is necessary but not sufficient. People need to be hired, equipment needs to be

purchased, space needs to be finalized, training needs to be done and documents need to be

written. All of those must be done on time and within budget, and each must be monitored

with appropriate metrics to judge progress. When hiring people for the Patient Centered

Medical Home, we tracked money budgeted and people hired, ensuring that when the

personnel budget for implementation was zero, we had 100% of our staff on board. When

implementing secure messaging between patients and providers, we tracked what percentage

of our enrolled patients was signed up to use the system.

Step 5 – Monitoring

Once a project is implemented, the project team can relax; but only for an evening or a

weekend. The final stage, monitoring, goes on for the life of the project. Decision makers need

to know the outcomes of their decisions, and all stakeholders want to know how their

organization is doing. Metrics should be reported regularly, often monthly, and should be

manageable. Management often wants more metrics than they actually use, and each request

for information requires someone’s time. Effort that they spend preparing metrics in reports

could be spent in other activities, such as taking care of patients. Also, metrics must measure

outcomes that people care about, not merely on how well an organization does a process.

Metrics must also focus on outcomes that are important.


Patients who come to emergency departments for heart attacks often develop abnormal

electrical activity in their hearts. This abnormal activity often preceded sudden cardiac arrest.

When I first started medical school we were taught to give lidocaine, an anti-arrhythmic

medication, to all heart attack patients, hoping to prevent abnormal electrical activity and

thereby prevent sudden death. It made sense, at least until science caught up with practice.

Good research showed that patients without abnormal heart electrical activity who received

anti-arrhythmics in such circumstances were more likely to die, not less, than patients who did

not. We found that we were measuring the wrong thing; the outcome that we wanted was

healthier patients, but the outcome that we had been measuring was a healthier looking

electrocardiogram tracing.

Metrics must be tied to the topics mentioned in the Analysis section:

1. Financial – Is the project making money, losing money, or breaking even? Consider the

short, medium and long term.

2. Educational – Is the project helping our employees, our patients, and/or our other

stakeholders perform better in their responsibilities or expectations?

3. Research – Is the project contributing significantly to the body of knowledge in this

field? Is this research contributing to accomplishing the key missions of this

organization?

4. Quality - Are our patients and families receiving better care? Does our staff have better

working conditions? Do our other stakeholders benefit in some tangible way? If so,

how?

5. Mandate - Is our higher headquarters or some other entity with authority over us

pleased with this project? Are we accomplishing what they intended?

There are many other possible metrics, but the number can be quickly overwhelming. No more

than 30 metrics can be routinely followed and adequately addressed for most organizations.

Conclusion

It has taken over 4,000 words to tell a simple story. Getting positive change in military medicine

is hard, but it can be done. Though all large bureaucracies seem impenetrable, and the US

military bureaucracy is one of the largest, hard-working people with good ideas, courage and

perseverance can and will do great things for our country. More importantly, we will do these

things for our patients. No one who has ever held the hand of a grandmother as she passes into

eternity, or comforted the father of a fallen warrior, or cared for a mother and her terminally ill

child, can stop trying to do better. Hopefully, this paper will help future American warriors and

healers get things done in military medicine.


Integrity and Leadership

In the fall of 1996, several allegations of sexual misconduct between Army leaders and their subordinates became public. The ensuing investigations found many cases in which the allegations were true, and trust began to erode within and towards the US Army. As a result, the Army sought to clarify and promote the values which have been at the heart of American military service for over 200 years. Leaders felt that by emphasizing the values that we held, fought for and died for, they could produce a better fighting force. The mnemonic “LDRSHIP”, pronounced as “leadership”, communicated what the Army was all about. Loyalty - Bear true faith and allegiance to the U.S. Constitution, the Army, your unit, and other Soldiers. General Washington was not the greatest battlefield tactician, but his overall strategy proved to be sound: keep the army intact, wear down British resolve, and avoid decisive battles except to exploit enemy mistakes. And if his soldiers would have not followed his orders the British would have won the Revolutionary War. Duty - Fulfill your obligations, even if it calls for sacrifice. Respect - Treat people as they should be treated. Selfless Service - Sacrifice your welfare, and your life if need be, for that of the Republic, the Army, and your subordinates. Honor - Live up to the code of a U.S. Army Soldier. Integrity - Do what's right, legally and morally. Personal Courage - Face danger, adversity or death with steadfast bravery. Shortly after these were codified, a blitz of information, including dog tag cards, posters, and media spots communicated these values to the soldiers and to the nation. “LDRSHIP” has become an integral concept in the life of American soldiers. Many soldiers understand that Integrity is the fundamental value of all. John Maxwell in “Developing the Leader Within You” says without hesitation that Integrity, the state of being complete or unified, is the most important ingredient of leadership. The word “integrity” is related to the word “integer”, which is defined as “any number that is not a fraction”. A man with integrity is therefore a man who is not divided in his motivations, his actions, or his beliefs. Not only does the man with integrity know the right ways to think and the right things to do, he thinks them and does them without division within himself. He does not pretend but is in reality what he appears to be. The united man walks his talk and has tremendous credibility as a result. A man without integrity is divided, distracted, and ultimately disabled by the competing priorities and passions within himself, as James describes in James 1:6-8. He is a hypocrite and will soon betray those who trust him. Maxwell identified seven reasons why integrity is so important. Integrity builds trust.


A 21 September 2007 Business Week article entitled “Where have all the leaders gone?” stated “Trust is the coin of the realm in both democracy and capitalism. Without trust, the system cannot function effectively. People become cynical, disengaged, and even prone to anarchy and rebellion.” A poll cited in the same article said that a dismal 18% of Americans trust the values and ethics of business leaders and only 15% trust their political leaders. Why? Because they have been betrayed so often in the past by leaders who talked a good talk but whose walk proved that their leader could not be trusted either to know what to do or to do it consistently. Formal authority derived from rank and position is a poor and unreliable way to get things done, but authority borne from the trust of subordinates, earned by years of faithful leadership, can move the world. Integrity has high influence value. William Wilberforce and his band of political misfits outlawed the slave trade in the British Empire largely through their persistent, faithful witness, both in their words and in their lives. Paul and Martin Luther, in their integrity, promoted the Church. Gandhi and King, in their integrity, advanced civil rights. Conversely, Karl Marx rejected religion and founded the Communist Movement, the cause of untold suffering and godlessness in the 20th Century, was influenced by the lack of integrity of his father. Heinrich Marx jettisoned supposedly strongly held religious views, alternately Jewish and Christian, to benefit his legal practice. No man has perfect integrity, but the list of men who wielded great influence as a direct result of their great integrity goes on nearly forever. Integrity facilitates high standards. A man with integrity will be morally excellent and will also be outstanding in his chosen field of endeavor. Excellence in any field of endeavor is beautiful and invites imitation. Christian integrity, a single minded devotedness to serve the Lord in His calling, will compel the Christian to be excellent in that call. A morally and professionally outstanding leader will breed morally and professionally excellent followers and the organization will flourish. A leader who understands that his rights decrease and his responsibilities increase as he advances will breed followers who fight less for their own needs and rights and more for those of others. Integrity results in a solid reputation, not just an image. In the mid-1990s, Canon ran an ad campaign for its photography line of products featuring the tennis star Andre Agassi. The theme of the campaign was “Image is Everything”. The campaign taught a concept prevalent in our society: that how you look and act, not who you are, is what matters. Canon itself didn’t really believe the ads because the company continued to make cameras and lenses that were good, they didn’t just look good. The damage to impressionable minds, unfortunately, was already done. People who are more interested in their image than in their integrity will talk and act differently depending upon who they are with. When given a choice between making a decision that is best for others and one that is best for themselves, they will routinely choose the latter. When


their team succeeds, they will hoard the credit and ignore the contributions of others. Their reputation, not their character, is first in their mind. A man of integrity will adjust his talk and actions to benefit those he is with but not to the point of moral compromise. He will routinely make the choice that benefits others and only when truly needed, such as when his physiological needs must be met, make the choice primarily for himself. He will be truthful in his assessment of credit and blame, but seek to encourage others before advancing himself. Integrity means living it myself before leading others. Parents complain that their children watch too much television, but they sit for hours every day in front of the tube. Employers whine that their employees seem lazy, but they show up late and leave early every day. Pastors groan that their congregants don’t take the Christian disciplines seriously, but they seem to miss their prayer and Bible study times more days than not. Leaders who do these things fail to understand a fundamental truth about leadership…you can’t expect others to do what you cannot or will not do yourself. Integrity helps a leader to be credible, not just clever. Legitimacy in leadership suggests that the person in charge has the right to be there, both legally, in accordance with law, and morally, in accordance with what is right ethically and what is best for the organization. It is easy for a clever man to be appointed or elected to a leadership position and therefore have a legal right to be there. Such men, if they lack integrity, have no moral right, either because they will not do what is right ethically or because they lack the skills or character to be in that position. People of integrity expect to have credibility, to be believed, because they know and hold to what is morally right and best for their organization. They have courage and patience, knowing that eventually time will prove them correct. Integrity is a hard won achievement. Grass grows quickly, is never very strong, and withers soon after it sprouts. Redwood trees grow very slowly, are mighty, and live for centuries. Anything and everything good takes time and effort to develop. People looking for a quick success will not develop integrity, but those with a horizon that stretches to a lifetime, or an eternity, will invest what it takes. The battle for integrity is fought and won or lost in every thought, every action, and every moment of a man’s life. Only those who want it like a drowning man wants air will fully succeed. Conclusion In 1996, the US Army realized that something was needed to combat serious abuses against soldiers and serious attacks on the credibility of those who defend our nation. They took ancient values, clarified and taught them to every soldier. One of those values, integrity,


underlies all of the others. Integrity is the foundation to leadership, and is well worth the lifetime it takes to develop.


Making Meetings Matter

Despite the triumph of American arms in the Revolutionary War, by 1787 the former colonies, loosely affiliated under the Articles of Confederation, were suffering severe setbacks at home and abroad. The Articles allowed only for a very weak central government which was incapable of regulating activities between the states at home and equally impotent at defending American interests abroad (such as with the Barbary pirates). Citizens knew that a stronger central government was needed and convened the US Constitutional Convention in Philadelphia from 25 May to 17 September 1787. The group included delegations of leading men of each state. Each delegate had been appointed by the state legislature and commanded the respect of its citizens. Each state (except Rhode Island) sent a delegation, reflecting the beliefs of their legislatures in the objectives and the importance of the Convention. The Convention had a formal process which was overseen and chaired by the most respected man in the colonies at that time, George Washington. Members included politicians, lawyers, scientists, soldiers, physicians, and businessmen. The Convention almost broke up several times because of the differences of opinion and the personalities of influential members. The Committee of Style and Arrangement, headed by Gouverneur Morris and including several intelligent and ambitious men who wanted to make a mark on history, created the final draft of the Constitution and made important adjustments. Alexander Hamilton’s reputation suffered as a result of his participation, but James Madison’s was enhanced. After the convention the delegates went back to their home states and lobbied their state legislatures to ratify the document. Nine states, the number required by the predecessor of the Constitution, the Articles of Confederation, ratified it by 26 July 1788. All thirteen finally did by May 1790, and the United States was born. Though no state got everything that they wanted, by having participated in the Convention, the States had enough confidence in the process and in the final product to accept it. The Constitutional Convention of 1787 was an excellent example of a meeting that mattered. Leaders holding meetings today would do well to follow its example. The Example of the Constitutional Convention Meetings are among the most loved and hated activities of any organization. Some believe that they are a waste of time, with the “real work” occurring before or after. This is a misperception. Meetings serve many important purposes: 1. They bring together the stakeholders of an issue and allow each representative to advocate

for his or her constituency and participate in the outcome. If this is not done, the stakeholder will not feel a part of the product of the meeting and will either not support it or actively resist it.


2. They provide a forum for a variety of ideas and concerns surrounding the issue at hand. Such diversity of thought may provide better outcomes.

3. They identify those individuals most concerned with the issue and most likely to succeed as action officers on the issue.

4. They communicate that organizations, not just individuals, support the project. 5. They demonstrate that decisions are being made according to a formal process and

therefore provide credibility in the minds of people inside and outside the system. 6. They are ceremonial occasions for people to enhance (or diminish) their stature among

others. The Constitutional Convention brought the right stakeholders in the thirteen states together to discuss issues of vital interest to all. Organizers ensured that each state sent its chosen representatives. These men would not only represent the state at the Convention but represent the Convention to their state; lobbying the legislature to ratify whatever the Convention finally produced. Though the participants were all wealthy white men, they had a diversity of thought which produced a lasting result. Speaking with the voice of their state, each delegate represented not only himself but also his legislature and his citizens. The process was very formal and opposing ideas were heard and respected. The Convention was alive with ceremony, with the greatest man in the former colonies, George Washington, guiding the process. The Chairman The mission of the chairman of the meeting is to make sure that the meeting accomplishes its goals within the allotted time and with the proper procedures. He or she is the guardian of the process. Since any committee must have credibility with those on the committee and all of the other stakeholders, an important goal of any committee and major goal of the chairman is to protect the integrity of the process. The chairman of the meeting and those sponsoring it must be prepared. They must have a specific outcome in mind. What exactly should this meeting accomplish? Will a document be produced? Will attendees agree to participate in something? Are the right people present to make decisions? Are the right people invited to bring the information back to their leaders? Powers of the Chairman 1. Control the date, time and place. 2. Control the duration and agenda. Even after a topic is on the formal agenda, the chairman

can choose not to discuss it. This is typically done with topics that are less important and when the time is running short.

3. Determine which participants in the meeting speak, and for how long. Sometimes a chairman will need to cut off someone who is being disruptive or long winded. It should be done as respectfully as possible.


4. Adjourn the meeting at any time. It is a good idea to let people know when the meeting will adjourn at various points in the last half of the meeting. They will self-select their comments to meet this goal.

These powers are considerable. A chairman can kill a proposal by scheduling a meeting at a time when the proposal’s main advocate cannot attend, or by refusing to bring an issue to a vote. He can damage his opposition by limiting their time to speak or changing the venue to a more hostile location. For example, lawyers commonly ask judges to change the location of trials and composition of juries in their favor. When the group votes on an issue, the chairman should generally vote last, and may only need to vote to break a tie. Since the power of a committee chairman is great, he must not use it to further his personal agenda. The chairman must instead use these powers to accomplish the goals of the meeting and guard the integrity of the process. Abusing them will decrease the credibility of the chairman, the meeting, the participants, and the process as a whole. The chairman should also be on time, but may (rarely) choose to come in a little late to communicate a point to the attendees. He should also end on time unless there is a compelling reason not to. Compelling reasons are rare. George Washington was masterful. He spoke very little during the Constitutional Convention, preferring to guide the proceedings administratively. When he spoke, Washington was incisive. One delegate suggested that the US army should be limited to 3,000 troops. Washington replied “if we do that we must certainly include a provision that no enemy be allowed to attack us with more than 3,000 troops.” The matter was settled. Preparation for the Meeting

1. Secure the right venue such as a conference room. If it will be a teleconference or a video teleconference, ensure that the appropriate communications (dial in numbers, etc.) are set up.

2. Organizers review the participant list and the agenda with the chair of the meeting. 3. Action officers and subject matter experts who will be briefing prepare their slides and

documents ahead of time. These are forwarded to the meeting organizers for review. If they are appropriate, they should be distributed to the participants as read aheads at least five working days prior to the meeting.

4. Organizers ensure that adequate parking and seating is available. 5. Longer meetings should include scheduled breaks every two hours and include food and

drink if the meeting will last more than one-half day. 6. Multiday meetings should include provisions for overnight accommodations for

participants. 7. Roles for each meeting – organizers, chairman, recorder/minutes taker, timekeeper,

briefers, other participants


Agenda

1. Welcome – The chair of the meeting welcomes the participants, makes or allows introductions as necessary, and describes the purpose of the meeting.

2. Old Business – Successful meetings should generate tasks that various participants have to accomplish after the meeting. The status and suspense date of each task should be briefed by the action officer, the person charged with accomplishing the task. Eventually the tasks should be completed and the issues closed in the minutes.

3. New Business – New items that need to be discussed by the group are included. Subject matter experts will brief each item, and they will work each issue with the appropriate action officer on the committee.

4. Roundtable – Each participant is given the opportunity to discuss any other issue that is appropriate for this venue.

5. Minutes first draft – The recorder clarifies any questions he or she may have about the meeting and provides an initial summary for the participants.

6. Adjourn. Attendees The discussion above describes the characteristics of attendees. Organizers must invite people who understand and support the mission of the organization and have the credibility and authority to meet the mission. Attendees must come prepared. They should receive the agenda and pertinent preparatory material (read aheads) before the meeting and review them before the meeting. For ad hoc meetings, at least 90% of those who should be at the meeting must be there. For meetings of standing committees, a quorum (however defined in the founding documents) must be present. Organizers must keep attendance and let each member’s supervisor know when someone fails to show without prior coordination. Everyone in a meeting should participate, either by contributing to the discussion or at least taking notes for dissemination in proper venues. Those who do not participate should not be invited back. In the Articles of Confederation, each state, no matter the geographic size or population, received one vote in Congress. In the 1787 Constitutional Convention the allocation of votes was the same. This meant that the smaller states, including Vermont, Connecticut, New Hampshire, New York, New Jersey, Delaware, Georgia and the Carolinas had nine votes and the larger states, including Virginia, Pennsylvania and Massachusetts, had only three (Rhode Island did not send a delegation). The small states were determined to maintain the One State One Vote system rather than move to a system that allocated votes based on population because they would lose power and the bigger states would gain. The Pennsylvania delegate James Wilson, a chief proponent of allocating votes in the new Congress based on population, had to find a way to divide the small state voting bloc. He did so by striking a bargain with the Deep South slave-holding states. If they would back allocating votes in Congress by population, he would insert language into the new Constitution protecting slavery. After a summer of haggling the deal was made: the House would seat members based on population, the Senate would


seat members two per state, and slavery would linger on in America until washed away in a torrent of blood and fire only 78 years hence. As this example should make clear, the composition of the attendees, especially deciding who can vote, is critical. Meeting organizers, especially when chartering new groups, should identify the group’s goals and then decide how to craft the group to best achieve those goals. Groups in which everyone agrees and which are meant to be temporary may not need a formal charter, but most groups should be chartered. Participants should be diverse, reflecting the many points of view of all of the key stakeholders to the issue. Each member should be a respected member of whatever community they are representing. This will allow them to sell the work of the group to their constituents. All stakeholders should have, and should believe that they have, a meaningful part in the process. No matter how good the product, if the representatives can’t convince their constituents of its quality, the meeting will fail. Presenters There are two basic types of briefs or presentations, the information brief and the decision brief. The information brief transmits information to the audience (and often a decision maker) about some event, concern, topic of interest, etc. The leader will typically request more information or more collaboration prior to the decision brief. There can be many information briefs. The decision brief presents courses of action to a decision maker with the expectation that he or she will be able to make a decision on the issue at hand. Typically once a leader makes a decision it is final unless other information is produced. Therefore the decision brief must present the reasonable courses of action comprehensively and then make a sound recommendation regarding which the decision maker should choose. For more information on these briefs, see Getting Things Done in Military Medicine. Minutes If there is one part of meetings which is misunderstood and neglected, it is minutes. Minutes are the formal record of the meeting, including who said what and which decisions were made. The recorder must be clearly identified in the minutes and the notes must be comprehensive. Minutes form an important part of the historical record for the organization and are legal documents. Meeting minutes are often subpoenaed in court cases and must be able to withstand legal scrutiny. Meeting organizers must ask themselves, “if a meeting is not important enough to be recorded and verified, is it important enough to have?” If the purpose of meetings is to get the right things done, the purpose of minutes is to record what was done and document it so that past meetings can direct future action. The obligatory review of the minutes of previous meetings, too often perfunctory, should be done with care. Having a consistent format for minutes allows the recorder to have a first draft done by the end of the meeting. James Madison (Virginia) kept a journal of the Constitutional Convention which provides the most detailed account available. Robert Yates (New York), Rufus King (Massachusetts), and


William Pierce (Georgia) kept some extant records. Charles Pinckney (South Carolina) also kept notes but these have not survived. General Notes Meetings sometimes seem to be a waste of time, and sometimes they are. No meeting should be held without a purpose, and that purpose must be important. There are other ways to help make sure that meetings are worthwhile: 1. Remember that communication must be regular, and regular communication must be

planned. Meetings must occur at predictable dates and times, and must have specific agendas and participants. Section, service and department meetings should happen at least once per month, on average.

2. Formal meetings worth having are worth preparing for, and this must include formulating a purpose, an agenda and minutes. A specific product should come out of every meeting, even if the product is simply information dissemination. Workers in complex organizations frequently complain that they do not know what is going on in other areas of their organization, and well executed meetings can address that problem.

3. How to accomplish the purpose of the meeting a. Right message – The message must support the strategy. The Constitutional

Convention was called to fashion a central government for a loose coalition of states. The delegates had to agree to specific provisions and prepare a specific document. Their mission and their message mattered.

b. Right venue – Philadelphia was centrally located in the colonies and was the de facto home of the new government. Independence Hall in Philadelphia, the site of the signing of the Declaration of Independence and the Second Continental Congress, fit the occasion.

c. Right presenters – The chair of a meeting sets the tone of the meeting, serious or flippant, formal or informal, and friendly or adversarial. Presenters must be knowledgeable and concise.

d. Right audience – Each state sent not one but several leading men to serve as delegates. These men also had the most to lose if they did not represent their state. Stated again, the interests of the delegates aligned closely with the interests of the people they represented.

e. Right medium – As the famous philosopher of communication Marshall McLuhan wrote, “the medium is the message.” Words and pictures on a slide or handout are not the only ways to get a message across. Football teams meet to discuss game films and manufacturers communicate using models of their wares. Once meeting organizers have decided what they hope to accomplish, they need to use the right medium to do it.

4. Information discussed at staff meetings must be communicated throughout the organization in department/service meetings, emails, “cascading from level to level” with no one left out.

5. Meetings should be at least cordial in tone.


6. Rules of order, such as Robert’s Rules of Order, are useful for keeping meetings fair and orderly. They must not be allowed to dominate discussion, but they must be used to direct discussion.

7. Participants should show up on time, because failure to do so communicates that those on time are not as important as the one who is late. A time keeper should remind the chair of the time and the chair must keep things moving.

Other meeting types The structured meeting that is presented here is not the only possible or the only productive type. Every industry needs some meetings which are less structured, especially if the goal is the free flow of ideas and innovation. Organizers planning such meetings still need to carefully consider their goals and the best format to achieve those goals. Planning matters. Conclusion Gathering to solve problems is important in the modern business, government, and other organizations. Such gatherings, called “meetings”, are common, and they are as important as the purpose for which they were called. They are as productive as the productivity of the attendees. Meetings are as focused as the clarity of their structure. The US Constitutional Convention of 1787 is a terrific example of what a meeting should be. By any account, it was a meeting that mattered. It is the author’s hope that gleaning lessons from the Founding Fathers will help meetings today accomplish more and make our organizations and our nation better than ever before.


The Dance of the Headquarters

In Iraq in late 2003 a draft recommendation came to the Task Force 1st Armored Division

Headquarters from our higher headquarters, the Combined Joint Task Force Headquarters. It

referenced tuberculosis in Iraq and proposed aggressive use of preventive measures against the

disease, citing huge numbers of new cases per year. As the Task Force Preventive Medicine

Officer and Deputy Division Surgeon, I was responsible to review all public health and other

medical recommendations coming from outside. The math didn’t seem right and I went to the

World Health Organization website to check the incidence and prevalence of tuberculosis in

Iraq. Suddenly I realized that whoever had made the recommendation had badly overestimated

the incidence of new tuberculosis cases. To our medical team it was just another example of

trouble from our higher headquarters.

A few months later and still in Baghdad, our team visited the medical staff of one of our

subordinate brigades. We asked questions of patients seen, quality of care, training plans, and

changes in the rate of diseases we were seeing. Some of the leadership asked why we needed

all of that information, and lamented that they were spending time generating reports that

they could have spent taking care of patients. My team did our best to explain that these data

were worthwhile and useful, but they seemed unconvinced. After all, we were from higher

headquarters.

The relationship between superior and subordinate headquarters has been troubled since war

began. Lower commands believe that higher ones have no idea what they can do and what they

are facing, and higher commands complain that lower ones neither know nor care about the

strategic situation and how their unit contributes to the mission as a whole. Sometimes lower

commands are right, as when Rommel and his Afrika Korps disobeyed orders from the

Oberkommando der Wehrmacht (OKW), the German high command. The OKW ordered

Rommel to hold Libya, but he attacked and nearly swept the British out of Africa in 1942.

Sometimes higher commands are right, as when Jeb Stuart led his cavalry on a pointless ride to

the east of Meade’s army, leaving Robert E. Lee and the Army of Northern Virginia without

reconnaissance during the Gettysburg campaign in 1863.

Navy relations between lower and higher commands can be even frostier. Being alone on a ship

hundreds of miles from the nearest friend, a captain and his crew have near complete

autonomy, and near complete responsibility, for themselves and their mission. Even the

admiral commanding the fleet has to ask permission to board a subordinate’s ship. A friend of

mine once described the relationship by service, saying that Army units view higher

headquarters with indifference, and Navy units view higher headquarters with indignation.


Against this backdrop, some on my staff have asked me to discuss the relationship between

higher and lower headquarters. This paper intends to address this question.

Higher headquarters provide mission guidance, while lower headquarters direct units for

mission accomplishment

Probably the single most important thing that higher headquarters do for their subordinates is

to provide and clarify their mission – what they are supposed to do. The highest headquarters

in the United States, the National Command Authority, sets the mission in its broadest terms in

the National Security Strategy (NSS). The next level, the Department of Defense, interprets the

NSS in military terms and so forms the National Military Strategy (NMS). Each service then

produces subsidiary documents to interpret the NMS for their service. Subordinate commands,

from geographic commands (i.e. European Command) to functional commands (i.e. Medical

Command) do the same at their level and in their context. Eventually every rifle company, every

frigate, every air squadron, and every hospital has a mission statement and strategy which

describes how they will do their part to accomplish the NSS.

Each headquarters must not only identify its mission and strategy but must communicate it to

headquarters above and below them. This task is vital and endless as the continual press of

events makes it difficult for even the most dedicated unit to maintain its focus on the mission.

Higher headquarters provide resources, while lower headquarters direct the use of those

resources to accomplish the mission.

It is impossible to accomplish tasks without resources, and higher headquarters are responsible

to give lower ones whatever they need to fulfill their mission. This requires that they identify

clearly what they want their subordinates to do and listen carefully when their subordinates

describe what they need to do it. They must then provide their own analysis, discuss the results

with the ones who will be executing the mission, and meet the need. Once the initial need is

met, commands at all levels must keep watch over operations to ensure that resupply and

refitting are done regularly and as needed. The mission is paramount.

No command ever felt like it had enough resources, and higher and lower commands have both

made mistakes in this area as well. McClellan always overestimated the strength of Lee’s forces

and chronically asked for reinforcements for the Army of the Potomac. As a result, he lost to a

numerically inferior army in the Peninsular Campaign and failed to end the Civil War in 1862.

On the other hand, the German Army Group South was tasked to provide food, fuel and

ammunition to Von Paulus’ beleaguered and starving 6th Army at Stalingrad. What few aircraft

got through the gauntlet of Soviet air and antiaircraft never had enough to sustain the troops.

One shipment contained condoms instead of food or ammunition.


Higher headquarters provide information from equivalent and higher levels, and lower

headquarters provide information from the front line.

Subordinate headquarters need to know more than just the mission. Most do not have

intelligence shops and so rely on their higher headquarters to keep them abreast of what is

going on around them. We may never know if Admiral Husband E Kimmel and General Walter

C. Short could have anticipated the attack on Pearl Harbor had they been given all of the

information that the US Government knew regarding an imminent Japanese attack. In 1999,

Senator William V. Roth (R-DE) wrote that “they were denied vital intelligence that was

available in Washington.” Whether this would have made a difference of not, the fact remains

that one of the most important tasks of higher headquarters is to keep lower headquarters

informed of all information they need to do their duty.

The converse is also true. During the German assault on Crete (20-31 May 1941), the British

high command provided accurate and timely information to MG Bernard Freyberg’s Greek and

British troops due to the decoded Enigma intercepts. However, commanders on the ground

misunderstood and misused some of the information, allowing the Germans to capture the

Maleme airfield, reinforce their position, and capture the island. In this case, poor

communication between command elements played a decisive role.

Higher headquarters provide top cover, representing subordinate units at higher levels and

shielding them from inappropriate tasks from outsiders.

Sir Douglas Haig (1861-1928) was the supreme commander of British forces in France during

most of World War I. Millions of men had become casualties and the war had deadlocked in

trench warfare since October of 1914. Despite the experience of the German and French at

Verdun, who had suffered 700,000 dead, wounded and missing while gaining nothing in the

battle of Verdun (February to December 1916), Haig planned and launched a major British

offensive at the Somme in July. The British suffered 60,000 casualties on the first day, and over

600,000 by the time the battle ended in November 1916. Lieutenant Bernard Montgomery,

who later became the senior British commander in World War II, wrote:

"The higher staffs were out of touch with the regimental officers and with the troops.

The former lived in comfort, which became greater as the distance of their headquarters

behind the lines increased. There was no harm in this provided there was touch and

sympathy between the staff and the troops. This was often lacking. The frightful

casualties appalled me. There is a story of Sir Douglas Haig's Chief of Staff who was to

return to England after the heavy fighting during the winter of 1917-18 on the

Passchendaele front. Before leaving he said he would like to visit the Passchendaele

Ridge and see the country. When he saw the mud and the ghastly conditions under


which the soldiers had fought and died." Apparently he was upset by what he saw and

said: "Do you mean to tell me that the soldiers had to fight under such conditions? Why

was I never told about this before?"

Haig was no different than most other European commanders at the time, and he ignored some

of his subordinates when they told him before the bloodletting that the offensive was a bad

idea. These commanders, who knew the obstacles far better than Haig did, tried to save their

units from disaster, performing this function of higher headquarters, but were unable.

As a senior officer in the Joint Task Force National Capital Medicine (JTF Cap Med), I am

routinely required to prioritize tasks that outside commands and other groups try to assign to

our subordinate hospitals, the Walter Reed National Military Medical Center and the Fort

Belvoir Community Hospital. Sometimes I am successful in diverting unnecessary tasks, or

necessary tasks that should actually be done by others, away from these already overworked

units. Other times I am not. Either way, it is our duty in the higher headquarters to enable our

subordinates to do their mission, and that sometimes means deflecting distracters to that

mission.

Higher headquarters provide expertise

The way to become a commander or a staff officer at a higher headquarters is to succeed at a

lower one, since those who are unsuccessful are not given greater responsibility. Therefore

people serving in higher headquarters units should, and usually do, have training, skills and

experience to assist people in subordinate units to accomplish key tasks. Higher headquarters

does not do the work of lower headquarters, but helps them do it themselves.

Higher headquarters coordinate efforts between lower level units

It was 16 June 1815, and Napoleon had just returned to France from exile in Elba and formed a

new army to fight the invading Allies. He marched into Belgium and was faced with the English

Army to the north and the Prussians marching to attack from the east. Napoleon had no chance

of beating the combined Allied Armies, but he could win if he could destroy them one at a time.

An allied Dutch-Belgian infantry division had occupied the strategic crossroads at the Belgian

hamlet of Quatre-Bras, and Napoleon ordered Marshal Ney, a French wing commander, to take

it. Another wing commander, Marshall Grouchy, was told to fight the Prussians in the east.

Over the course of the day, Marshall Ney wasted six precious hours and failed to take Quatre-

Bras, and his I Corps commander D’Erlon marched his troops repeatedly between Quatre-Bras

and the Prussians at Ligny in the east, failing to influence either engagement. Napoleon and

Grouchy were more successful against Blucher at Ligny, but failed to win a decisive victory. The

failure of French arms on 16 June, largely due to a failure of communication and coordination,


ended in the French disaster and the destruction of their empire at Waterloo, only two days

hence.

Whether fighting historic battles, coordinating training exercises or taking care of patients,

higher headquarters coordinate the activities of their subordinate commands. Last summer

Walter Reed National Military Medical Center needed surgeons, operative nurses and other

surgical staff to help them care for the crush of combat casualties arriving from Afghanistan.

Other military hospitals in the national capital region (NCR), coordinated by the JTF Cap Med

contributed those professionals, and the wounded received the care that they needed.

Conclusion

It is often difficult for young officers and soldiers to know how to relate to headquarters, higher

and lower. Misunderstandings abound, and it is easy for misunderstandings to develop into

hostility. Mission failure is an all-too-common result.


The Informative Brief

A senior civilian official in the military health system was at a surgical conference with a young

Navy colleague. They chatted, and in the course of their conversation the Navy surgeon

mentioned some exciting things that he was doing in his clinic to improve access, operating

room utilization and quality of care. The civilian official asked the younger man to prepare a

talk to present to a group of senior leaders. Eventually word of this arrangement spread

throughout the levels of command and my team was tasked with making sure that the brief

accomplished its purpose.

The Navy surgeon was smart, industrious, and enthusiastic about his team’s accomplishments.

Their record was impressive, providing more patient care with better outcomes, higher

satisfaction and fewer resources than before. Operating room utilization improved, and the

surgical fellowship, threatened by poor case mix and volume, was on firmer ground.

Their brief was less impressive, containing slides without themes, results without numbers, and

a slide sequence that meandered without destination. It said some things which would better

have been omitted and omitted things that needed to be shouted from the mountain tops. This

article will address the need to communicate more effectively through slide presentations.

The two primary kinds of briefs in the military are the information brief and the decision brief.

The former seeks to convey important information to the audience, while the latter seeks a

favorable decision from a decision maker. Although not every information brief needs to use

slides, the practice is common.

The Slide Show

At a formal dinner Winston Churchill was served dessert, studied it carefully, and then

exclaimed to the waiter “Take it away, it has no theme!” Too many presentations suffer from

the same malady; the communicator is not entirely clear what he is trying to communicate.

After the title slide, the first slide in any presentation must describe the purpose. The purpose

must answer two questions:

1. Why I am giving the presentation.

2. Why you will want to listen. This is the “hook” of the presentation; the speaker wants

his audience hungry for the meal he is about to serve.

One purpose statement I saw recently, “To provide background information on the surgical

services at XXX medical center in the YYY health care network and how our initiative may be

expected to improve them” may elicit a puzzled yawn. The audience was from other medical

facilities in the region and they were more interested in their own hospitals than in XXX. These


health care executives only cared about how the experience at XXX could help them improve

their facility. A better purpose statement might have been “To describe surgical services at XXX

medical center and discuss how our experience could benefit others.” This purpose statement

is less wordy and emphasizes not what the speaker did but what the listeners can do. It

suggests interaction and discussion rather than a one-way lecture. This is the time to tell a

short and powerful story to illustrate the purpose and why the audience should care about it.

Members of the audience decide whether or not they will listen in the first 30 seconds, so the

beginning must be good.

The purpose must be limited in scope to what can reasonably be accomplished in the time

allotted. No 10 minute brief can convey a detailed analysis of the Rise and Fall of the Roman

Empire. Even if the speaker could do it, the audience couldn’t absorb it. The purpose must be

laser focused and limited to the time available.

After the “purpose” slides, the next slides should tell a story; what was the problem, what was

the solution, and what were the results? Leaders rarely want to study hundreds or even dozens

of slides and usually want to see fewer than 10. Since a standard brief is 10 minutes with 5

additional for questions and since each slide takes about one minute to cover, each question

should be answered in one or two slides.

1. What was the problem? In the example above, what was operating room utilization?

What were the graduate medical education implications? The slide should feature two

or three key metrics and a clear graphic to communicate the problem.

2. What was the solution? What did the team actually do to fix the problem? This needs to

be specific as well. Was the solution a process reengineering, a sharing agreement, a

new training program, an equipment purchase, a personnel hire, or something else?

Perhaps it was a combination of these things. The solution needs to be clear at a glance

to someone who has never seen the slide before. For example, one of the problems in

the example noted above was unnecessary referrals from primary care. By training the

primary care partners, the surgical team was able to see more patients requiring surgical

intervention.

3. What were the results? How much did operating room utilization increase? How did the

case number and mix improve? How did that impact the accreditation of the fellowship?

Use the same metrics that were used in describing the problem.

The last section of the information brief, called perhaps the Application, should focus on how

this impacts the audience. It bears repeating that the audience will listen if they expect to

eventually get something back. The speaker needs to know the audience, what they expect to

get back, and how to give it to them. The most effective speakers spend time before, during


and after their briefs getting to know their listeners. Why did these people come? What do they

want? How do they want it?

The last slide of the information brief is the conclusion slide. It includes only those bullets that

the speaker wants the audience to remember. This is the place to summarize the talk and ask

questions. Back up slides are placed after the conclusion and not meant to be shown unless

someone in the audience asks a specific question that pertains to the slide. They should be held

to the same standard as any other slide.

Another way to structure a brief is the Hook-Book-Look-Took mnemonic:

Hook – Something to get and hold the attention of the audience Book – The content of what you want to say. Look – What does the content mean? Took – How does the content and its meaning apply to the audience? It’s no stretch to figure out that the Hook is in the purpose, the Book and Look are in the

content slides (problem, solution and results) and the Took is the application slide.

The Slide

Just as the entire slide show has a theme and a direction, each slide must have the same. Real

estate in the mind of a decision maker is precious, and real estate on the slide is vital to gain

real estate in the mind. The briefer must make sure that each slide, and each element on the

slide, contributes to achieving the goal.

1. The theme of the slide should be understandable at a glance.

2. Nothing should be distracting.

3. Use bullets rather than sentences because extraneous words make the whole thing less

likely to be read.

4. Make the bullets as short and information-packed as possible.

5. Use high contrast colors or black and white and keep the font large enough to be read

easily in the venue. Walk to the back of the room yourself and look.

6. In general, a slide should contain no more than five to seven bullets, with each bullet

containing eight to ten words. The final bullet should be a transition to the next slide.

7. Each slide must contain new information or a fresh approach to understanding old

information. Many presentations die because slide after slide includes things that the

audience already knows. A recent slide deck that I reviewed had nine slides, one of

which cited a national-level survey which confirmed that patients have a choice when

selecting health care. The data was too general to be useful, and the slide is gone…the

speaker can “voice track” it; say it instead of having it on a slide.


8. Ensure that each participant has a paper copy of the brief to read before the meeting (a

“read ahead”). Also ensure that each one has one during the meeting.

Churchill opened one of his speeches to Parliament by saying “I am going to give a long speech

today as I have not had time to prepare a short one.” He was right. It is harder to condense

thoughts into a short delivery, but that is what speakers need to do. Briefers need to use no

more words than are absolutely necessary to communicate their message.

Conclusion

Many people complain that nothing ever seems to get done in government, in the corporate

world, and elsewhere. One reason is that staff members do a poor analysis and give poor

counsel to their leaders. Other times staff members do a good analysis but fail to communicate

it effectively. After discussing the brief with the Navy surgeon, we came up with a much better

product. He gave the brief to the senior leaders and the feedback we received was that he “hit

it out of the park.” However, his success was not primarily because of better slides; he made

most but not all of the changes that we recommended. Rather his success was because of him.

This young surgeon was skilled, dedicated, and excited about his story. He believed in his work

and that enthusiasm made everyone else believe in it too. More than anything, humans are

relational creatures. The right message is important, and hopefully this essay will help us all

improve it, but so is having the right messenger. It is best to have both.


The Long Shadow - How to follow a Superstar

A Tennessee democrat who was firmly committed to the Union, Andrew Johnson had a

distinguished career as congressman, senator and governor of his state. Hoping to send a

message of reconciliation to the rebellious South, Lincoln chose Johnson as his vice president in

1864. Johnson’s debut on the national stage went poorly, with a rambling and perhaps drunken

speech when he assumed office in March 1865. Lincoln followed with a masterpiece, his Second

Inaugural Address. Little did anyone know that in only six weeks, at one of the most crucial

times in American history, the rambler would be President.

A Missouri democrat who came to national prominence investigating fraud, waste and abuse

on the Committee of Military Affairs during the Second World War, Harry Truman had earlier

served as farmer, haberdasher, judge and US senator. With President Franklin Roosevelt in

declining health and many expecting that he would not survive his fourth term, the party

looked for a vice president who could succeed in the top job. Eighty-two days after the

Inauguration, Roosevelt lay dead, and Truman took the top job.

Johnson struggled during his presidency, continually battling Congress on civil rights and other

issues, being impeached by the House, and retaining his job by only one vote in the Senate.

Historians have judged him to be among the worst presidents. Truman could never compete

with the wildly popular Roosevelt, and did not try. He stuck to his agenda and his style through

the atomic bomb, economic upheaval, strikes, the war in Korea, and the start of the Cold War.

Though his approval rating was 22%, the worst ever, in the final year of his presidency, Harry

Truman is now ranked among the best US presidents.

Many have considered why Johnson failed and Truman succeeded in their quest to follow a

superstar. Johnson had the disadvantage of following a relatively young and still healthy

president who no one expected to die. He also had to rebuild the nation. Truman’s ascension to

the presidency was expected, but he had to stabilize the world. This article attempts to help

leaders know how to follow predecessors whom others consider to be superstars.

Publicly Acknowledge Reality

1. Your predecessor is loved; do not be perceived as diminishing that in any way. If you do,

you, not he, will be diminished.

2. Charles de Gaulle is the most famous man credited with saying “The graveyards of the

world are full of indispensable men.” While it is true that the world will not collapse

with the loss of any individual, it is equally true that no one is replaceable. Each person's


combination of knowledge, skills, personality, and industry is unique. Don't even try to

replace a predecessor.

3. However, many people could do any given job competently. Your job is not to replace a

superstar, but to use your unique attributes to move the team and the organization to

the next level and face a new set of challenges.

4. No one, no matter how good, can or should stay in a job forever. New times call for new

people. Lincoln had an excellent plan for bringing the United States back together after

the Civil War, but Lincoln was one of the greatest leaders in human history. Judging

from his performance at Yalta, it is not clear that Roosevelt grasped how the world

would be after World War 2, and not clear that he had a sound plan.

5. There are some people in the organization who do not consider your predecessor a

superstar. No one is loved by everyone. No matter how good you are, you are not loved

by everyone either.

Transition

1. If your predecessor is a real superstar, he will be sad to leave the people he has worked

with so well. However, he will not impair your transition.

2. Once she is gone, she will not interfere in the organization. She will stay gone unless

asked to assist.

Your task

1. Maintain the advances of your predecessor. Andrew Johnson kept Lincoln’s rough

outline for gently bringing the South back into the Union, although he struggled against

a vindictive Republican congress. William Taft advanced, albeit imperfectly, Theodore

Roosevelt’s progressive agenda. Neither tried to turn back the clock.

2. Move the organization ahead to meet new challenges. Moses led the Hebrews out of

Egypt, but Joshua led them into the Promised Land. Moses’ task was great and his

results were legendary. Joshua’s task was also great, and his results also stood the test

of time.

3. Know and use your own style. You will fail if you try to mimic someone else. You have

strengths and weaknesses just like she does.

4. Improve your strengths, improve your weaknesses, and use your staff to help

compensate. Andrew Carnegie, the American steel magnate, famously opined that the

key to success was to surround yourself with good people.

5. Leaders are beloved by their troops because they love their troops. You must care for

your people more than you care for yourself. The Chinese military writer Sun Tzu wrote


“Regard your soldiers as your children, and they will follow you into the deepest

valleys; look upon them as your own beloved sons, and they will stand by you

even unto death. If, however, you are indulgent, but unable to make your

authority felt; kind-hearted, but unable to enforce your commands; and

incapable, moreover, of quelling disorder: then your soldiers must be likened to

spoilt children; they are useless for any practical purpose.”

6. Leaders are respected because they know their job better than anyone else, and work

hard.

7. Leaders are followed because they know where the organization should go and how to

get there.

8. As you are accomplishing your mission, enjoy your job and your team. They will not

enjoy you if you do not enjoy them.

Anticipate a Positive Future

1. Make sure that your team knows that while their beloved leader has moved on, the

team's future is bright. It is your job and theirs to make the future better.

2. If your predecessor is a real superstar, rather than someone who is interested primarily

in himself and his legacy, he will want your tenure to be even better than his, because

he wants the best for the organization. The group's well-being is more important to him

than his own.

Conclusion

Some may argue that Andrew Johnson had no chance to succeed following Lincoln, and that the

best he could have done was to be a placeholder until the next president came in and the magic

of Lincoln had faded from public memory. However, as the examples of Truman and Joshua

prove, capable men can succeed in the long shadow of superstars.

You may be following a superstar, but no matter how good, his or her time is over, and yours

has begun. You have been placed in this new role by your superiors, and by powers even

higher. You must respect and appreciate the past, but you must shape the future. Now all that

remains is to do it.


Understanding Problems

A fellow student from the public health program at Johns Hopkins came to me with a research

idea many years ago. Performing publishable research is a requirement of the program, and we

were struggling with the most fundamental issue; thoroughly understanding the problem that

you wish to address. Our team wrestled with the possibilities, explored lots of dead ends, and

sought guidance from more experienced researchers. Eventually a reasonable, although not

groundbreaking, plan took shape.

Defining the problem can be hard in clinical medicine. For example, suppose a 45 year old

plumber presents to a physician for low back pain which began after lifting a heavy pipe three

days before. The subjective severity was 6/10. He has had intermittent back pain for several

years and sometimes has lancinating pain down the back of his left leg to his calf. He is

overweight, does not exercise outside of work, suffers from depression, and has poor core

strength and lower extremity flexibility. The patient is able to work but only with difficulty. The

doctor in this case could define the problem as acute low back pain, prescribing pain

medications and relative rest. He could define it as an acute exacerbation of chronic low back

pain with intermittent sciatica, doing the above and also giving him medications for the nerve

pain. The doctor could define the problem as above, but add that it is complicated by

biomechanical issues (overweight, weak core musculature, tight hamstrings) and psychosocial

problems (depression). In that case he could add physical therapy, a weight loss program, an

exercise program, and an antidepressant to the plan. Lastly the doctor could do some

combination of the above or send him to a subspecialist to figure it out.

Let us consider variations on this clinical vignette to learn how to define a problem. Problems

have several characteristics, among which are size, shape, complexity and color. The size of a

problem is how big it seems to those affected by it. Patients do not often assign a size to their

problem except for small, medium or large. It is usually up to the clinician to ask the patient to

assign a specific value to it. Also, the size of a clinical problem includes how the problem

impacts function. The plumber in this case may be unable to work or even sleep with this level

of pain, or he may have few limitations.

The shape of a problem refers to how the problem will change over time. Some problems will

resolve on their own and so their shape may be visualized as an inverted pyramid. If this patient

was 25, fit, flexible, trim, and without mental health concerns, this problem would probably

resolve itself over a few days, and the physician would need to do little. In this patient’s current

situation the acute problem should get a little better but the overall issue may be steady over

time, at least for a while. If this patient were unable to function, the problem would worsen.


His lack of activity would weaken him further, adding to his weight and poor flexibility. His

inability to work would introduce money problems and probably add to his depression.

The Shape of Problems *

Resolve over time Steady over time Worsen over time

Present size of problem






Future size of problem






* Note that these shapes describe the general progress of the problem. In reality, issues tend to wax and wane over the short

term, and so the shapes would have wavy edges but the trend would remain. Problems can be complex or simple. A diaper rash in a healthy infant is usually simple, while metastatic

cancer in an elder is usually complex. Problems can be deceiving. The plumber in this clinical vignette

seems at first glance to have a simple problem; back pain when he lifted a heavy pipe. As noted above,

however, with further digging the doctor realized that this patient had an underlying problem of

significant complexity. Also, the complexity of a problem is usually related to size, but not always. An

otherwise healthy family whose house was just hit by a tree has a big problem, but not necessarily a

complex one.

The color of a problem refers to how those people involved see it. Our patient above may see his

problem as a temporary setback, an aberration in his overall good health. If we use the colors of a

stoplight as our paradigm, where green is “good” and red is “bad”, the resilient plumber may see his

current medical state as light yellow. Conversely he may perceive this problem as deep, lasting, and

unremitting. In that case the color might be dark red. Others can influence how the stakeholders of a

problem see its color, but ultimately each person decides for himself what color, and how light or dark, a

situation is. Sometimes a “green” problem, such as a financial windfall, can turn red, as many lottery

winners have discovered. Sometimes a “red” problem, such as a cancer diagnosis, can turn green, with

the cancer cured and the family closer together as a result. Sometimes good circumstances turn out to

be very bad, as on 6 August 1945 when Hiroshima boasted beautiful sunny skies while Kokura, Nagata

and Nagasaki faced clouds.

Other Examples

Problems in other areas also have a size, shape, complexity and color. A man whose car has a flat tire

generally faces a small and simple but steady problem (since the flat tire will not fix itself). Depending

upon the man, he may color it as “no big deal”, perhaps light yellow, or a great tragedy, dark red,

because he fears that it will make him late to work again and he will lose his job.


In the late 1990s Microsoft was probably the dominant computer company in the world, but it was in

danger. The Internet was expanding and more and more work was done in interconnected

environments rather than on individual computers. Mobile computing was growing as well. The

companies problems probably looked small and self-limited, albeit complex. Many in the business may

have ignored the warning signals altogether. How could they have known that Apple, a company that

they thought they had beaten in the late 1980s, would come back? Today the market capitalization of

mighty Microsoft is $327B, and that of little Apple is $467B.

The Ottoman invasions into southeastern Europe were a huge and worsening problem to the eastern

Europeans. After the Battle of Nicopolis (1396) and the fall of Constantinople (1453), the Turks

controlled the Balkans. After the Battle of Mohacs (1526) they controlled Hungary and they were even

able to besiege Vienna (1529, 1683). However, because of their slow movement, rough terrain, poor

roads, weak logistics base and limited annual campaign seasons, they never had the power to move

further into Europe. Contemporary Western European chronicles spoke of the Turks occupying Germany

or marching through Paris, but this was not a realistic possibility at the time.

Application

Why is it important to thoroughly understand each problem that we face? Because mankind is notorious

for judging problems wrongly. Either we catastrophize, fearing and even expecting the worst possible

outcome, however unlikely it may be, or we minimize, underestimating things that can cause real and

lasting harm. People tend to overestimate the likelihood and severity of the unknown, as when a

woman with mild fatigue and nonspecific pain for a week assumes she has cancer, and to underestimate

the likelihood and severity of the familiar, as when a man with a beach house in South Carolina doesn’t

board up his windows in the face of an approaching level 4 hurricane.

Late in life, Mark Twain wrote “I am an old man and have known a great many troubles, but most of

them never happened.” Thomas Jefferson voiced a similar sentiment when he wrote “How much pain

have cost us the evils which never happened.” These poignantly speak to man’s tendency to

misunderstand the size and shape of problems, to color them darker than they actually are, and to

imagine some when they don’t even exist.

By carefully and objectively evaluating problems and understanding them better, we are more likely to

deal with them rationally and effectively. The woman with mild fatigue and nonspecific pain might wait

another week to see if her symptoms resolve, which they probably will. The man facing a natural

disaster might board up his windows and even evacuate his family.

Conclusion

We have seen that all problems have size, shape, complexity and color. Each characteristic is related to

the others, and the skilled problem solver will address all of them. The skilled doctor, pastor, counselor,

or leader will keep their problems in perspective, noting their real characteristics, not exaggerating or

minimizing them, and deal with these problems appropriately. Such people will help other people, and

their whole organizations, to do the same.


What to do with Tradition

Last week I was on a mission trip to Chicago with the youth choir from our church, and one of

my favorite parts was the chance to talk with the kids. I have been going for several years and

have seen youth born since 1993 on these journeys. Also for the past three weeks, my family

and I have hosted three women in their early to mid-20s working in Washington DC as part of a

journalism internship for World Magazine. These groups represent the last half of the

generation that demographers call the Millennials, roughly defined as people born between

1980 and 2000.

As we talked, one theme that arose was a tendency among some to dislike tradition. This

theme is at odds with some data indicating that Millennials seek tradition, but the difference

may be in semantics. Since in the course of normal conversation few people clearly define their

terms, and we didn’t either, it is not certain what each person in my non-scientific sample

meant. However it was apparent that each speaker had a slightly different definition, many

relating the word “tradition” to the phrase “we’ve always done it this way.” Since authors from

Tom Peters (born 1942) to Colin Powell (born 1937) have warned readers not to blindly adopt

traditional ways of doing things, it is worth asking ourselves “What should we do with

tradition?”

As with any discussion, the first priority is to define tradition. Merriam Webster online defines it

as “a way of thinking, behaving, or doing something that has been used by the people in a

particular group, family, society, etc., for a long time (http://www.merriam-

webster.com/dictionary/tradition).” Using this definition, disliking tradition is similar to disliking

air, because tradition permeates everything we are and do. The languages we speak, the places

we live and the food we eat are heavily influenced by tradition. Not all traditions are so

fundamental, however.

Advantages of Traditions

Traditions arise and endure because they meet a need of the people who developed them.

Women have traditionally worn dresses or skirts because anatomical requirements for

urination, menstruation, pregnancy and childbirth make such clothing more practical. Men have

traditionally worn trousers because they do not have the same physical needs and because

running, jumping and riding horses, activities common in hunting and in battle, are easier in

pants.

An estimated 70-90% of people worldwide are right hand dominant. When marching or riding

on roads in antiquity, soldiers and travelers preferred to stay on the left so that they had more

space to defend themselves with their sword, held in the right hand, if attacked from the road.

http://www.merriam-webster.com/dictionary/tradition

http://www.merriam-webster.com/dictionary/tradition


Since most traffic was on the left hand side, cities and empires codified reality with law. To this

day members of the former British Commonwealth nations drive on the left hand side of the

road. However in America people drive their cars on the right hand side of the road, probably

because early wagons had no driver’s seat, so wagon drivers sat on the left rear horse of the

team and wielded the whip in their right hand. This tradition also met a need.

Traditions serve to communicate. The marathon has been a popular long distance race for at

least 100 years. Its name refers to the Greek victory at the Battle of Marathon (490 BC) and its

distance is roughly the distance run by the Greek messenger Pheidippides to announce the

victory to the city of Athens. When someone today mentions a marathon, listeners immediately

know that he or she is referring to a running race of 26.2 miles with its origins in ancient Greek

tradition. In another example, the Battle of the Alamo was a siege and massacre of Texan

defenders by Mexican troops under General Santa Anna in 1836. The phrase “Remember the

Alamo” became shorthand for strength, honor and sacrifice in American military parlance.

People and groups with shared traditions find it easier to communicate than those without,

even if they speak the same language.

Traditions also serve to unite. Family traditions at Christmas, Easter, birthdays, and other

holidays help form the glue that holds families together through good and bad times. The

traditional wedding ceremony is an often expensive and public commitment made by bride and

groom, and by their families and friends, to make this marriage work. Naval traditions, such as

the ringing of a bell at retirement ceremonies, reminiscent of ringing when a senior officer

arrived at and departed his ship, help change individual recruits from varied backgrounds into

united sailors.

Despite our human tendency to think that our ancestors were inferior to us, in reality they lived

their lives and adapted to their environment at least as well as we do. Traditions have

advantages.

Disadvantages of Traditions

Traditions may cease to work. For centuries the United States had rules and laws relating to

horse drawn carriages. Drivers, builders, passengers, law makers and law enforcers had roles to

play in the enterprise. Then within a few short years in the early 20th century, the industry

vanished, superseded by “horse-less carriages”. Swiss watchmakers were the world leaders in

watch technology in the 1960s, but with the advent of the quartz watch in the 1970s, Japanese

watchmakers such as Casio and Seiko dominated the market. The mechanical watch on which

the Swiss had built their industry for centuries was overshadowed in the blink of an eye. In both

cases, the environment changed radically and the old traditions, their “way of doing business”,

could no longer compete.


While traditions admit some, they exclude others. While “Remember the Alamo” was a rallying

cry for Americans, helping them to be united and to communicate better, it ostracized

Mexicans. This Us-Them mentality ultimately harms both us and them, as it is generally better

to get along with everyone if possible.

Some traditional beliefs are simply wrong. Before 1903 many were convinced that man could

never fly, and before 1969 the idea of a man walking on the moon was ludicrous. Women were

believed to be irrational due to their hormones; two women were found innocent of murder

charges in England in 1851 due to temporary insanity from menstruation. People from races

other than the majority have frequently been seen as inferior, such as blacks in the American

South. These traditions have been disregarded, and rightfully so.

What do we do with traditions?

Some traditions are a matter of personal preference and will endure as long as people enjoy

them. Whether a church sings hymns or choruses is largely dependent on its congregation. In

general, however, there are three things that any individual or group can do with each of their

identified traditions.

1. Eliminate it without replacement.

2. Replace it.

3. Keep it – either unchanged or modified.

Some traditions are no longer functional and hold no value for communication or unity.

Procedures for using carbon paper to make duplicate copies of typewritten documents fall into

this category. Some traditions are outdated and need to be replaced to address new realities.

Lamps powered by gas or kerosene have been largely replaced by electric lights, but many still

exist. Still other traditions need to stay the way they are; British will drive on the left and

Americans on the right for the foreseeable future.

Practically speaking, what do we do when our company has a problem and an old timer says

“we have always done it this way.”

1. Ignore the guy, because times are different now and we need to change our previous

traditions.

2. Laud the guy, because we need to stick with what worked in the past and brought us the

success we’ve seen so far.

3. Take the guy’s recommendations, add it to the list of possible courses of action,

evaluate it just as rigorously as we do with all other potential courses of action in light of

the changing conditions, and select whatever fits best.

Perhaps the third option is, almost always, the right way to go.


Conclusion

Wrong traditions should be discarded, just like all errors, but most traditions endure because

they work, or worked. Many new ideas, no matter how good they sound, have not and will not

work. Each individual and each organization must decide what they will do with each tradition

they encounter, but they should not take that decision lightly. In the past 6,000 years of human

history, only technology has really changed. Relative to technology, the natural world, human

physiology, and human nature have not. Therefore to reject tradition simply because it is old is

foolish. New ideas are indispensable, but time-proven remedies still hold great promise for the

future.


Appendix – Leadership Models

http://en.wikipedia.org/wiki/Three_levels_of_le

adership_model

http://en.wikipedia.org/wiki/Managerial_grid_

model

Public leadership

1. Setting the vision, staying focused: 4

behaviors.

2. Organizing, planning, giving power to

others: 2 behaviors.

3. Ideation, problem-solving, decision-

making: 10 behaviors.

4. Executing: 6 behaviors.

5. Group building and maintenance: 12

behaviors.

Private leadership

1. Individual purpose and task (e.g.

appraising, selecting, disciplining): 5

behaviors.

2. Individual building and maintenance

(e.g. recognizing rising talent): 9

behaviors.

Personal leadership

1. Technical know-how and skill

2. The right attitude towards other people

3. Psychological self-mastery.

http://en.wikipedia.org/wiki/Three_levels_of_leadership_model

http://en.wikipedia.org/wiki/Three_levels_of_leadership_model

http://en.wikipedia.org/wiki/Managerial_grid_model

http://en.wikipedia.org/wiki/Managerial_grid_model


Behavioral styles theory

Leadership Presence – (1) personal power – command

over one’s thoughts, feelings and actions; (2) high, real

self-esteem; (3) the drive to be more, to learn, to

grow; (4) a balance of an energetic sense of purpose

with a concern for the service of others and respect

for their free will; (5) intuition; (6) being in the now;

(7) inner peace of mind and a sense of fulfillment

The Leadership Challenge - Model the Way, Inspire a

Shared Vision, Challenge the Process, Enable Others to

Act, Encourage the Heart.

Traits theory – certain qualities are found in leaders

Servant Leadership (http://en.wikipedia.org/wiki/Servant_leadership)

Greenleaf Center

A servant-leader focuses primarily on the growth and well-being of people and the

communities to which they belong. While traditional leadership generally involves the

accumulation and exercise of power by one at the “top of the pyramid,” servant leadership is

http://en.wikipedia.org/wiki/Servant_leadership


different. The servant-leader shares power, puts the needs of others first and helps people

develop and perform as highly as possible.

History of Servant Leadership

Servant leadership is an ancient philosophy. There are passages that relate to servant

leadership in the Tao Te Ching, attributed to Lao-Tzu, who is believed to have lived in China

between 570 BC and 490 BC:

The highest type of ruler is one of whose existence the people are barely aware. Next comes

one whom they love and praise. Next comes one whom they fear. Next comes one whom they

despise and defy.

When you are lacking in faith, others will be unfaithful to you.

The Sage is self-effacing and scanty of words. When his task is accomplished and things have

been completed, All the people say, ‘We ourselves have achieved it!’[6]

Chanakya wrote, in the 4th century BC, in his book Arthashastra:

"the king [leader] shall consider as good, not what pleases himself but what pleases his subjects

[followers]" "the king [leader] is a paid servant and enjoys the resources of the state together

with the people."

In the Christian tradition, Mark 10:42-45 is often quoted in discussions of servant leadership:

Islam - "the leader of a people is their servant"

Does the servant leader end up doing all of the work? No, each person, including the leader,

does his or her job in what they have the greatest competitive advantage to do, for the benefit

of the stake holds of the organization. Example - Jesus and Lazarus

Situational Leadership Theory


http://en.wikipedia.org/wiki/Situation

al_leadership_theory

Development Levels

D1 - Low competence and low

commitment[8]

D2 - Low competence and high

commitment

D3 - High competence and

low/variable commitment

D4 - High competence and high

commitment

Behavior

types

S1: Telling - is characterized by one-way communication in which the leader

defines the roles of the individual or group and provides the what, how, why,

when and where to do the task;

S2: Selling - while the leader is still providing the direction, he or she is now

using two-way communication and providing the socio-emotional support that

will allow the individual or group being influenced to buy into the process;

S3: Participating - this is how shared decision-making about aspects of how the

task is accomplished and the leader is providing less task behaviours while

maintaining high relationship behavior;

S4: Delegating - the leader is still involved in decisions; however, the process

and responsibility has been passed to the individual or group. The leader stays

involved to monitor progress.

Maturity

levels

M1 - They still lack the specific skills required for the job in hand and are unable

and unwilling to do or to take responsibility for this job or task. (According to

Ken Blanchard "The honeymoon is over")

M2 - They are unable to take on responsibility for the task being done; however,

they are willing to work at the task. They are novice but enthusiastic.

http://en.wikipedia.org/wiki/Situational_leadership_theory

http://en.wikipedia.org/wiki/Situational_leadership_theory

http://en.wikipedia.org/wiki/Situational_leadership_theory#cite_note-8


M3 - They are experienced and able to do the task but lack the confidence or the

willingness to take on responsibility.

M4 - They are experienced at the task, and comfortable with their own ability to

do it well. They are able and willing to not only do the task, but to take

responsibility for the task.

Lifespace and Lifetime Leadership · authors intend readers to pray for. Every day and in every country pastors, teachers and other Christian leaders rank high on the tally of needs.

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