Leading Beyond Mediocrity

Mediocre leadership that fails to invest in extraordinary, excellent and superior outcomes is a major reason why healthcare reform is moving forward at a lighting fast pace. And it often results from difficult conversations that never took place.

As leaders in a time of great transition, having the courage to start difficult conversions has become the expectation, not the exception. We must approach these conversations from a pure heart that only accepts extraordinary, excellent or superior outcomes.

Two critical components of difficult conversions are stewardship and accountability.  Why are stewardship and accountability essential? Consider each of these facts about our profession (or better yet, our call in life):

· A 2001 study in five states found that medical debt contributed to 46.2% of all personal bankruptcies and in 2007, 62.1% of filers for bankruptcies claimed high medical expenses.1

· The United States pays twice as much for healthcare as other wealthy nations but lags behind in measures such as infant mortality and life expectancy. According to the World Health Organization, the United States spent more on healthcare per capita ($7,146) and more on healthcare as a percentage of its gross domestic product (15.2%) than any other nation.

·The  U.S. Census Bureau estimates that 16.3% of the population (49.9 million people)were uninsured in 2010.

· In 2000, the Institutes of Medicine published a landmark report, "To Err is Human," documenting annual deaths in hospitals due to errors, which  totaled 48,000 to 98,000. A 2003 follow-up study by HealthGrades showed there were 296,000 deaths in three years, the equivalent of three fully loaded 747 jets crashing each week. The airline industry has addressed its high risk environment by becoming obsessed with preventing failure. As healthcare adapts this mindset, we will mature into a high reliability industry.

How can leaders hardwire stewardship and accountability into difficult conversions? Here are some best practices with recent examples from my role as director of pulmonary services and co-interim director of the ER.

Leaders ask difficult questions. People possess the ability to deceive themselves, and in doing so deceive others.   In my hospital, there were two people who were charge specialists. Nobody knew what they did or when they worked. With  a very significant expansion of their role on the immediate horizon, we quickly realized they had been protected to the point that they were clueless about the rapidly changing reimbursement environment. They never acquired formal coding education. Leaders have a duty to constantly validate and grow their staff's skills.

Leaders expect and only accept excellence.  Failure to realize that leaders are held to a higher standard opens the door to doubt. Research shows the majority of employee turnover happens because people leave the leader, not the job.

Leaders must address any negative comments, especially those made in public. What is started in public sometimes must be finished in public. This NEVER means an unprofessional, ugly response. Asking the person to publicly repeat their comment so we can ensure accuracy and then asking them to explain what they mean is a powerful tool. This gives the leader the opportunity to clarify misunderstandings and set the record straight. Simply put, it is an extension of our patient safety tool: validate and verify. 

Leaders are guardians of trust. Trust is the foundation of great teams. Leaders' daily actions are either making deposits or withdrawals. Being aware of this and surrounding yourself with truth-tellers is essential.

Teammates who start to trust their leaders will eventually to ask bigger questions about "Sacred Cows" or exceptions to the rules. For example, when we started daily safety huddles, teammates often asked operations-related questions. These were wonderful because they enabled me to fix things that led staff to create "workaround processes." As their trust level grew, they raised questions about unsafe physician's practices. Be thankful for opportunities like these. Keep in mind that teammates are making a case for change, not revenge. Their comments are expressing concern for a senior leader.

Leaders expect constructive debate. Leaders rarely need to act alone; we are called to be part of a team.  Leaders and followers are expected to constructively debate any and all topics. This is essential to build trust and clarify expectations before commitment. It is very important in operational processes so that many possibilities are considered and a hybrid policy is the outcome. Like a hybrid car engine, it takes the best of different models and uses them to create the best function.

Leaders never compromise doing the right thing. Character is who you are when nobody else is around. The decision to do the right thing is made before the situation arises.

For example, involuntary and voluntary turnover were being counted together in my hospital's personnel decisions, and the ER department manager was being penalized for high turnover. He decided to hold staff accountable to the higher standard and appeal to his manager and human resources to change the way turnover was counted. Later, it was amended so only voluntary turnover counts.

Leaders have blind spots. We all have areas where we need growth and we tend to have a short fuse on our temper in certain situations. We need to encourage folks to hold us accountable.
When the emergency room was working with the family birth place on the flow of their patients, I was out of line and unprofessional with a fellow leader. Afterwards, I returned to that fellow leader and asked for forgiveness. I shared with those present that I was wrong and removed myself from the situation. A much better outcome took place.

Leaders consistently demonstrate a return on the investment of resources. Every resource must be carefully considered for its return on investment. What is the expected outcome? How will we measure that outcome in terms of safety, quality and financially?

When we were benchmarking our department, we dissected what peer departments were doing. Some of the "best performers" were doing budget-boosting procedures that accounted for 30% of their budget. But these procedures' return of investment did not improve patient clinical outcome and in fact added approximately $200,000 of additional expense out of DRG payment.

The time for change is now. It is possible to strengthen mediocre leadership skills; in fact, it will resonate well with teammates. They have desired this change for many years.

Stan Holland, MS, RRT, is director of pulmonary services at Rockingham Memorial Hospital in Harrisonburg, Va.


1. Himmelstein DU, Thorne D, Warren E.  Medical Bankruptcy in the United States, 2007:

Results of a National Study. The American Journal of Medicine. 2009:1-6. Available from:

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