Thursday, October 01, 2015

Two books

I'm often asked to read books and post reviews here, and I thus find my bookshelf overly full.  I just can't get to them all.  (Indeed, I just donated a few dozen books--some read and some never opened--to one of our local hospital management degree programs!)

I recently received two requests, and frankly, I was hesitant.  For one thing, I am friendly (in the internet virtual kind of way) with the authors, and when friendship is involved little good can come of an honest review. For another, the topics were troublesome and likely to be a bit timeworn--yet another book styled as a guide to personal health and yet another autobiography about the trials and tribulations of being a doctor.

Well, what a relief!  They are both very good, and I am pleased to recommend them to you.

An Illustrated Guide to Personal Health

Tom Emerick and Robert Woods, with some important help from illustrator Madi Schmidt, offer 40 common sense steps to improving your health.  Don't worry.  You don't have to adopt all 40, but you might like to.  As the authors note:

Alas, medical care can really only deal with about 20 to 25 percent of the things that cause you to die before your time.  The remaining 75 to 80 percent [other than genetics] of health risks come from . . . factors . . . you alone can control.

With good humor the authors warn:

As you read this book, you will see a lot of repetitive redundancy, over and over.  Why? We are trying to inculcate you with certain principles.

Much of what we have written here is documented science.

Some of what we wrote here is less science than a merger of philosophy and personal observations.

And then the final disclosure:

Some people do almost everything wrong their entire lives, and we mean everything, and live to be age ninety. 

I'll let some of the chapter headings titillate your interest. To find out more, buy the book. Don't worry.  It's short.

Avoid Hand Dryers in Public Restrooms

Avoid Antibacterial Soaps and Gels

Let Kids Play in Dirt

Don't Take Multivitamins

Envy is a Killer

Brush and Floss Your Teeth Regularly

Retirement Can be Bad for Your Health

Medicine Man, Memoir of a Cancer Physician

As first glance, Peter Kennedy is the stereotypical overly intelligent young man who dives into his medical school textbooks to learn everything so he will never face the possibility of not knowing something important that he might face in the classroom or the clinic.  There not much hint of emotional intelligence as we read that chapter.  Later, too, we see his impatience with colleagues, administrators, and regulations, and we are set on believing that he is overly hard-driving and arrogant.

Why on earth would we consider his life to be interesting? Simply, because we watch him grow as a human being and as a doctor.

It turns out that this fellow is deeply dedicated to his patients. We like to talk about patient-centeredness today, as though it is a new concept.  Decades ago, Peter walked the walk, sometimes literally.  Here are some excerpts from his fellowship period:

The work [of taking care of indigent patient's in the Ben Taub cancer service] was long and rarely exciting.  On those occasions where I couldn't quite understand a patient's difficulty with immediate family or home issues, I ventured into the Fifth Ward (Houston's ghetto district) to visit patients at night in their homes. It was plain stupid to go alone. I had seen hundreds of the wounded from that region, more than enough to make me wary, but I was never approached or threatened on those visits.  It was at those times that the total impact of a patient's journey to improvement or death upon his family became reality to me.

As I talked with patient and family . . . I felt something in the room change. And as I explained a mother's medical status, her husband, her children, and any extended family present would calm down and give me all their attention.  Some of the free-floating anxiety, and the suspicion and wariness about a physician in their home at nine p.m. began to dissipate.

I pushed past my own hesitation a little further.  Patient and family were presented with a gentle reboot of sorts, a statement of data rather than information mixed with hysteria or bias. . . . They became active participants in their own disease and its treatment.

[He'd say:]

"When I am sure you understand all of this, and you must try very hard to do so, we'll talk about what can be done to reverse, stop, or cure this cancer.  I'll tell you about treatment, warts and all.  Nothing will be held back"

"Then we'll use this information to decide what we as a team think is best."

And then Peter offers this confession to the reader:

As I became more deeply involved in it, I began to impart a quality I did not know I had--true empathy.

I had been trained originally to use evasion and misdirection as tools to maintain hope. 

It is unusual for an author to display the vulnerability that Peter offers, not just on these clinical matters, but with regard to his personal life.  (I'll leave those sections to you.)  His story is a compelling one. It is a privilege to be asked to read it. I am pleased to recommend the book to medical students, clinicians, administrators, and patients.

Wednesday, September 30, 2015

Building resiliency

What's the secret of building resiliency, the ability to withstand unexpected challenges, into your organization?  Lots of leaders I know take this attitude: "When the crunch comes, we'll deal with it. I'll explain that we have a burning platform, and the team will respond."

Well, yes, they will, but to the extent that you succeed in handling the crisis?  If so, will the team respond in a way that creates the potential for future success, or will the effort just get you through the crisis?

A recent story [subscription required] in the UK Health Service Journal shows what happens when an administrative fiat is issued to deal with a budget shortfall.  Excerpts:

The financial ‘stretch targets’ and emergency measures imposed by NHS regulators will fail to make significant inroads into the total provider sector deficit, analysis by HSJ reveals.

Providers had forecast a combined year-end deficit of £2.1bn at the start of 2015-16, which prompted Monitor and the NHS Trust Development Authority to order them to revisit their financial plans for the year in August.

Emergency measures were announced, such as a recruitment freeze for non-clinical roles, while many trusts were asked to work to new stretch targets or control totals.

[HSJ[ findings revealed that at least 13 of these organisations were not given stretch targets, while at least seven have declined to alter their plans. For three organisations, their positions deteriorated.

Contrast that experience with the one at my former hospital when we faced a budget crunch in 2008-9 because of the financial crisis.  For several years, we had built a culture to support a learning organization, one in which the staff felt empowered and engaged and encouraged to redesign work flows.  When the bad numbers hit, we asked people to consider whether they would be willing to make sacrifices to save the jobs of others.  They did, willingly and enthusiastically.

Brian, from finance, said:

Obviously, I want to keep this job. I’m sure I echo most people’s thoughts when I say that no one wants anyone else to be laid off, and we are all willing to do whatever is necessary to make sure that as few as possible actually lose their jobs.

Catherine, a nurse, offered:

I would be more than happy to forgo a pay raise and reduce my earned time if that would mean another person in the hospital could keep their job. I think this is a great idea and I hope my colleagues feel the same.

And Bernice, an MRI technician, agreed:

I would rather take the loss of my yearly raise than see a fellow employee laid off.

And another:

I know the next few months will be extremely difficult for all of us. But it is so comforting to know that the people I work with are not just sitting back and letting things happen.

After this afternoon’s meeting, we had our own “post-town meeting meeting” to review what you had said, and to toss around suggestions. I know those little meetings are happening all over the medical center. I have never been prouder of the people I work with and the hospital I work for.

The challenge also enhanced our internal sense of community.

Lois, a manager in our Department of Medicine, said, “I think we will learn much from the process. I even dare to believe that we will become a community of healing for one another, just as we are for our patients.”

The end result of this entire process was that we were able to balance the budget with hardly any layoffs. And much to our amazement, we achieved national renown for our hospital. Readers emailed a Boston Globe story by Kevin Cullen detailing the events to over 14,000 other people around the world. The story was also posted on the Yahoo home page for an entire day, viewed there by hundreds of thousands of people. ABC news, NBC news, and PBS all came to do feature stories, seen by millions of viewers.

The pride among our staff was palpable. Patients, too, felt a part of the story and helped spread the word. Here’s a note from Bob, who had had cardiac surgery at our hospital:

I just watched the NBC clip about the employees of BI. I must tell you how much I appreciated the care that I received from all of the folks who attended to me while I was recovering from my surgery. This is most true of the ‘low-level’ employees. The folks who helped me wash, brought me my meals and took me for my x-rays were all professional and courteous. For this reason alone, I am so glad to hear of the efforts all of the BIDMC employees to ensure that everyone can keep their jobs.

About a year and a half later, we were able to restore the salary and benefits to our staff, and even pay a small bonus when our business improved. Jerry wrote a typical response: 

I’m sure you were inundated with thank you emails for this bonus, but I felt the need to add mine to the list. I also wanted to mention that when I told my wife about this she said, “What a wonderful place to work. That would have never happened at my company.”

I’m sure the five hundred dollars will come in handy, but the fact that our leadership even thought of this is what makes BIDMC such a great place to work. We came together when times were tough, and now we are sharing the wealth as finances improve. To me this sounds more like a family than a workplace.

Tuesday, September 29, 2015

In appreciation: Vivian Li

The worth of a city can be measured in part by the caliber of the people who devote themselves to its improvement.  By that measure, Boston has much to credit from the engagement of Vivian Li as long-time head of the Boston Harbor Association, created to promote a clean, alive and accessible Boston Harbor.  Many have considered her the unofficial mayor of Boston's waterfront for the last quarter century, and that would not be a bad summary.

She's now off to new adventures in Pittsburgh, and there is a farewell celebration for her tonight.  For today, I'll skip her many accomplishments but rather focus on her approach and demeanor.  

I don't know of anyone in this city who has worked with Vivian who doesn't admire her and consider her a friend and colleague.  Those of us who worked at the Massachusetts Water Resources Authority certainly viewed her in that light. Invariably pleasant and respectful in her dealings--even in the most contentious disputes--she has approached her job with intelligence, judgment, and good humor. Her objective has always been to achieve the public good.  But her other objective has been to achieve a coalition for the public good, to build the institutional and community infrastructure to support the wise use of the waterfont resource. In that regard, her legacy will outlast her tenure at TBHA.

I join thousands who know her in wishing her well and happiness.  Pittsburgh, you've landed a gem!

Sunday, September 27, 2015

Will no one rid me of this priest?

As we consider the leadership failures that led to the current debacle at Volkswagen, we can take a lesson from English history.

Henry II, facing a disagreement with Archbishop of Canterbury Thomas Beckett in 1164, is reported to have shouted out in frustration, “Will no one rid me of this troublesome priest?” Four knights heard what Henry had shouted and interpreted it to mean that the king wanted Beckett dead. They rode to Canterbury and did the deed.

This story exemplifies the term myrmidon. From this source, we get the following definition: "A loyal follower; especially: a subordinate who executes orders unquestioningly or unscrupulously."

One of the dangers for a CEO is the tendency for your subordinates to take what you say and execute it to a degree you never intended.

Now, let's take a quick look at the VW story, courtesy of the New York Times:

Martin Winterkorn, Volkswagen’s chief executive, took the stage four years ago at the automaker’s new plant in Chattanooga, Tenn., and outlined a bold strategy. The company, he said, was in the midst of a plan to more than triple its sales in the United States in just a decade — setting it on a course to sweep by Toyota to become the world’s largest automaker.

“By 2018, we want to take our group to the very top of the global car industry,” he told the two United States senators, the governor of Tennessee and the other dignitaries gathered for the opening of Volkswagen’s first American factory in decades.

One way Volkswagen aimed to achieve its lofty goal was by betting on diesel-powered cars — instead of hybrid-electric vehicles like the Toyota Prius — promising high mileage and low emissions without sacrificing performance. 

The determination by Mr. Winterkorn, the company’s hard-charging chief executive, to surpass Toyota put enormous strain on his managers to deliver growth in America.

Volkswagen officials now state that Mr. Wintrerkorn knew nothing of the regulatory cheating that his engineers had designed into the company's engines.  Some are skeptical:

“For something of this magnitude, one would expect that the CEO would know, and if he doesn’t know, then he’s willfully ignorant,” said Jeffrey A. Thinnes, a former Daimler executive who works as a consultant for European companies on compliance and ethics issues.

We may never know.  But what we can be sure of is that the myrmidons at VW thought they were carrying out the intent of the CEO.

Friday, September 25, 2015

Part of the school day

For several years, I've had the pleasure of expanding my role as referee of youth league soccer games to officiate in high school games.  Although covering some of the same age groups, there is a different feel to these school games.  School loyalties are different from town team loyalties.  Coaches are more often professional and paid rather than being volunteer parents.

One of the things drilled into the referees is that the matches are "part of the school day." We're told that the main value of the athletic endeavors is that they are part of the curriculum. The coaches, we are advised, have a teaching role, just like in the classroom. Indeed, many of the coaches are classroom teachers, too, during the previous hours in the day.  Our job is to defer to these teachers in matters of deportment and discipline (while of course officiating the game in a fair manner and one which helps ensure the safety of the teenagers.)

So, what happens to all that when the coach loses it?  When, in the excitement and stress of the match, he or she feels that calls are not going their way and when he or she loudly and persistently dissents from the calls made by the referees.

In youth soccer matches, the established ethic is that the coach shall not dissent, in word or deed, from the calls made by the referee.  Indeed, a coach can be disciplined--and even ejected--for doing so to excess.  Not so in the high school matches (except in very extreme cases.)  When the yelling begins, you maintain your composure as a referee and just continue to do your best.

I don't have a problem with that.  I personally have taken a lot more heat as a public official and CEO than I get from the sidelines of a soccer match.  I've had hundreds of people screaming at me in public meetings, death threats from aggrieved parties, not to mention really nasty commentators in the media.  I've learned to breathe deeply and go on.

No, the problem I have relates to the setting: The game is supposed to be part of the school day. The coach's role is that of a teacher.  What possible lesson is being taught to the students when the coach engages in obnoxious and disrespectful behavior to uniformed officials who main job is to use their judgment to maintain a fair and safe environment?  Who is there to remind the coaches that the circumstances of the game should not overtake their roles as mentors and role models for the children?

Wednesday, September 23, 2015

Blindfolds on? Good, let's lead.

My Australian friend Marie Bismark and colleagues published an article a couple of years ago about the role of boards in clinical governance in over 80 health service boards in the state of Victoria.  There was one remarkably revealing quote about the 233 board members who answered the survey:

Almost every respondent believed the overall quality of care their service delivered was as good as, or better than, the typical Victorian health service.

In an earlier article, Ashish Jha and Arnold Epstein found similar results:

When asked about their current level of performance, respondents from 66 percent of U.S. hospitals rated their institution’s performance on the Joint Commission core measures or HQA measures as better or much better than that of the typical U.S. hospital.  Only 1 percent reported that their institution’s performance was worse or much worse than the typical hospital. Among the low-performing hospitals, no respondent reported that their performance was worse or much worse than that of the typical U.S. hospital, while 58 percent reported their performance to be better or much better. 
Hospital Board Chairs’ Perceptions Of Hospital Performance, Compared With A Typical U.S. Hospital, On The Joint Commission Core Measures, 2007–08

Marie and her co-authors suggest:

A recognised cause of these so-called "Lake Wobegon effects" named after Garrison Keillor's fictional community in which all the women are strong, all the men are good looking, all the children are above average, is unavailability or underuse of reliable information on peer performance.

I'd go a step further. A couple of months ago, I recalled

a wonderful story from Amitai Ziv, the director of MSR, the Israel Center for Medical Simulation at Sheba Medical Center on the outskirts of Tel Aviv.  He relates how Israeli fighter pilots would return from their missions and debrief how things went.  The self-reported reviews of performance were very good.  Then, the air force installed recording devices on the planes, and it turns out that the actual performance was not nearly as good as had previously been reported.  The conclusion: It's not that people are poorly intentioned or attempt to mislead about their performance. It's just that we tend to think we are doing better than we actually are.  

I think the issue is not the unavailability of reliable information on peer performance.  I think the issue is a failure, in the first instance, to even measure one's own performance and to share that with one's own team. After all, the issue is not so much benchmarking.  That only goes so far.  As I've often said, there is no virture in benchmarking to a substandard norm.

So, the first step is to accurately collect one's own data and make it transparent to your own team. It is that transparency--more than benchmarking--that will establish the creative tension in an organization that will drive people to meet their own stated standard of clinical excellence.  A smart board does not have to apply pressure on its staff by drawing comparisons with others. Rather, they take governance steps to demand transparency, so that the deep sense of purpose that is inherent in the clinical staff is employed to stimulate the team to do better on their own.

Sunday, September 20, 2015

"Visiting relatives can be annoying."

Noam Chomsky is one of the world's treasures, the greatest living expert in the field of linguistics.  When you get a hear him talk, it is like absorbing great music.  If you are like me, you don't grasp a lot of what he says.  After all, how do you even begin to assimilate his 60 years of research in the field into your own head as he presents his points of view and his evidence? Nonetheless, it is a wonderful experience, and I was so pleased to have a chance to watch and listen at an MIT seminar last week. What follows is a short exposition of what I thought I heard and learned! I follow with an extrapolation to issues of negotiation and leadership.

Turning briefly to the popular literature, Deborah Tannen wrote a great book a few years ago, called You Just Don't Understand, about how "women and men live in different worlds...made of different words." She demonstrated how miscommunication is rampant between the sexes.

Noam goes well beyond this characterization of communication problems. His view is that "language is not designed for communication." That's language, not talking.  Stick with me.  He points out that the development of the generative process for language formation that's in our brains was a relatively recent evolutionary event, occurring in the last 60,000 years or so.  It's evolutionary value seems to be mainly an internal one, providing us with a personal ability to conceptualize, plan, and conceive.  He posits that the mechanism of language is based on the simplest possible construction, "a minimalist computational system."

In contrast, the externalization of language through our sensory and motor systems--whether through talking or sign language or touch--has nothing to do with language formation.  Those sensory and motor systems existed for eons before language evolved.  Indeed, humans and apes have virtually identical sensory and motor systems.

The relatively primitive mechanism that maps language onto and through the sensory and motor systems is quite imperfect in presenting the concepts and ideas that our internal language creates. Accordingly, the recipient of the language does not get a totally clear picture of what the speaker means.  In the words of someone at the seminar, "So you're saying that language is there to let me think. Never mind about the listener." "Exactly," said Noam.

The title of this post is a highly simplified example.  "Visiting relatives can be annoying."  Is it the relatives who are annoying or is it a visit to relatives that is annoying?  The sentence is ambiguous even though the speaker likely has a clear concept in his or her mind.

I know it's risky to extrapolate from the deep philosophy and science of linguistics theory to everyday matters of human behavior, but permit me to take some leaps to fields in which you and I are involved every day.

So, let's leave Noam behind for a minute and acknowledge that most of the failures that occur in negotiating satisfactory and lasting agreements are often tied to miscommunication.  The ability of one party to fully understand the interests of the other and the resultant ability to engage in value creating deals often fall flat on their face because of a failure to communicate.  (Yes, I know that sometimes such a failure is intentional on the part of one party or the other. I'm talking about cases in which both parties have an interest in achieving a successful negotiated agreement.)

Likewise, leaders who attempt to carry out strategic initiatives for their organizations often find themselves frustrated by the staff's lack of commitment to those new directions.  Later they find out that their seemingly clear messaging to their staff was not fully understood.  (Yes, I know that sometimes people are recalcitrant. I'm talking about folks who want to be on board with the corporate direction.)

Those of us who teach negotiation and leadership often offer suggestions to people to help enhance communication and understanding. (Active listening is one such technique.) What I didn't understand before hearing Noam was how deeply embedded is not only the possibility of miscommunication, but the likelihood of it.  You don't have to understand all of his science to accept the conclusion that all of us have a special duty to expect--and try to overcome--the cognitive glitches that exist when we talk and listen.

Wednesday, September 16, 2015

"Our patients are sicker."

There are several archetypal lies in America (and other countries!):

"The check is in the mail."

"I'll still respect you in the morning."

"I'm from the government, and I'm here to help you."

"I'm from academia, and I'm here to clarify things."

And many in the medical world have now added:

"Our patients are sicker."

The last Lake-Wobegon-inspired one occurs when you present a hospital leader or a doctor with risk-adjusted data showing that their record on quality and safety is below that of other places.  (An accompanying phrase is often, "I don't believe the data.")

A study from the Annals of Surgery a few years ago (Volume 250, Number 6, December 2009)  refutes this view of the world.  A friend summarizes:

Some people thought that hospitals with higher mortality rates had higher complication rates, but that seems not to be the driving factor behind increased mortality, at least according to this study. Using the Medicare database, this group found that the risk of complications such as pneumonia, MI, hemorrhage, etc. after high risk surgery was only slightly different (36.4% vs. 32.7%) between high and low mortality hospitals; however, the risk of dying from a complication once it occurred (i.e. failure to rescue) was much worse in the worst performing hospitals compared to the best (16.7% vs. 6.8%). This failure to rescue was in fact the major contributor to the 2.5 fold increase in risk-adjusted mortality at the worst performing hospitals compared to the best (8% vs. 3%).  

The authors concluded that high mortality hospitals are "not as good at recognition and management of complications once they occur." Although data on what makes a hospital good at patient rescue is limited, much of it may be related to trigger systems, teamwork, nursing culture and availability of certain services as they outlined in their interesting discussion.

In summary, the way work is organized in a hospital and a culture of communication and respect matter, even if "your patients are sicker."

Sunday, September 13, 2015

"I don't trust nurses."

At a recent training program in quality and safety improvement, one focusing on the topic of communication in clinical settings, a second year resident said firmly, "I don't trust nurses. I don't pay attention to what they say."

Now, this might be a case of extrapolation from something that residents are often told, "Don't trust anybody." In that context, "trust" is not used the way commonly understood. No, in that case, it means, "Do your own analysis of the patient's condition and don't assume that what you heard from someone else is still correct." That's fine.

But that wasn't the context of this young doctor's remark. Here, rather, was an affirmative statement about the value of nurses and about their judgment.

We could consider this an isolated case of an arrogant person and let it go at that, but I fear what we saw here is a more commonly occurring disrespect for those "underneath us" in many clinical settings, manufacturing industries, and service organizations.

Here's a story about a young, wise doctor named Michael Howell, excerpted from my book Goal Play!

Michael had some intuition about how to solve the problem of decompensating patients based on his literature review of articles from Australia. Early in 2005, he led a six-week pilot program on two medical wards and one surgical ward to test out his version of rapid response teams. Under this program, if a nurse notices that a patient has developed a certain condition, based on a standardized set of criteria (“triggers”), the nurse is required to call the doctor, the senior nurse in charge, and the respiratory therapist—and they all come to see the patient. They collaborate on a plan of care for the patient going forward. Regardless of the time of day or night, the intern/resident then calls the attending doctor in charge of the patient to let him/her know that the patient has “triggered."

Under Michael’s plan, the standard set of triggers is based on changes in heart rate, blood pressure, oxygen saturation, urine output, an acute change in the patient’s conscious state, or a marked nursing concern. The last one, “marked nursing concern,” means that if the nurse has any concern whatsoever about the patient, based on observation or instinct, s/he is authorized to call a trigger.

Well, it turned out that Howell’s program was incredibly effective. 

Over the course of the first year, the hospital observed significant reductions in “code blue” cardiac arrest events and a significant reduction (a 47% decrease) in relative risk of non-ICU death for our patients. Residents now needed to practice emergency resuscitation mainly in the simulation center because so few actual patients needed it. What a lovely problem to have. We also learned a lot about teamwork, communication, and systems of care as a result of closely reviewing our responses to called triggers.

Here's something else we learned over time. There were many objections at the start of this program from attending physicians and residents that certain "lazy" or "inexperienced" or "uninformed" nurses would use the RRT "marked nursing concern" trigger as an excuse to pass the buck on certain patients.

Well, we learned instead that triggers based on "marked nursing concern" (amounting over several years to 38% in total and 18% in the absence of other vital sign criteria) were as or more likely than the other categories to accurately reflect the fact that a patient was in trouble. Putting it another way, if we had not recognized the unique ability of nurses to be especially attentive to patients' conditions, a number of people at our hospital would have decompensated, perhaps leading to their death. (The 18% figure amounts to over a thousand patients during the five-year study period.)

When you think about it, then, the attitude reflected in the resident's statement--"I don't trust nurses. I don't pay attention to what they say."--is not just arrogant. It is negligent. Research of malpractice claims shows that a failure in communication is often a contributing cause to the error leading to a lawsuit.

As Kathleen Bartholomew notes: "When nurses and physician don't communicate, it's the patient who loses every time." A person who has decided that he or she will habitually ignore the information provided by another member of the team invites error and harm.

I surely never want to be cared for by this young doctor!  Who is more likely to have an accurate sense of the patient's condition than the nurse? After all, nurses are at the patient's bedside for much of the day, while doctors drop by from time to time. Attentiveness to a patient's needs cannot be measured by whether an "MD" follows a clinician's name instead of an "RN."

Wednesday, September 09, 2015

The magic ratio of 5:1

Those of us involved in sports coaching are often told that the most effective mix of positive reinforcement to negative comments is 5:1.  I think this ratio might derive from research in the 1970's by Robert and Evelyn Kirkhart.*  They found that children in classrooms thrived when the ratio of feedback was 5 parts positive feedback to 1 part constructive feedback. In contrast, children sunk into despair if the ratio fell down to 2:1 or 1:1.

Not just any praise worked.  It was more effective if praise was truthful and related in real time to a specific event. It also had to be sincere and credible to have an impact.

I'm told, too, that a video analysis of the practice sessions run by John Wooden, arguably the greatest coach of all time, showed that 87% of his comments were positive reinforcement. Hmm, about a 5:1 ratio.

By the way--and maybe (or maybe not) a bit off our topic today--it was John Guttman in the 1990s who extended the research to married couples, showing that marriages were considerably more stable if there were five times as many positive feelings and interactions between husband and wife as there were negative. Guttman termed this the "magic ratio."

By contrast, I know of many leaders who intentionally run their companies as "low praise zones."  When I was in the state government, one of my colleagues did so for his agency.  He berated people when they made errors (sometimes calling them late at night) and would seldom, if ever, give them praise for a job well done. Nonetheless, many of his managers adored him, were loyal to him, and did every thing possible to make him satisfied. The agency, by the way, was successful in its mission in many respects.

It appeared to me that these managers were engaged in a relationship pattern equivalent to that of a codependent abused spouse.  I've since seen it in other settings.

In the hospital world, for example, I've seen a chief of surgery who behaved in a similar fashion to my government colleague.  Nary a kind word would come out of his mouth.  He ruled with fear, anger, and disdain. And yet his underlings--whether attending physicians or residents--would suck it up and take it, almost as a badge of honor.  They remained intensely loyal to him.  The surgery department, by the way, was quite good.

In the music world, I've seen a conductor of the same ilk.  Sarcasm and mean-spirited gossip were his weapons of choice.  People who were the conductor's favorites on one day would discover that, on another, they were in the dog house. And yet, as above, the members of the ensemble were remarkably loyal.  The music production of this group, by the way, was excellent.

I'd like to say that the 5:1 ratio is the way to go to produce a team of engaged and creative individuals best suited to carry out the mission of an organization.  It troubles me to think that the Commander Queeg approach I've just summarized might work as well.  All I know is that it would make me extremely uncomfortable to behave in such a way, and so I've tended to attract managers who prefer my approach and who have accomplished great things in places I've led.

If you are a leader in an organization, where do you stand on the spectrum of 5:1 versus 1:5?
* Kirkhart, Robert; Kirkhart, Evelyn (1972). "The Bruised Self: Mending in the Early Years". In Yamamoto, Kaoru. The Child and His Image: Self Concept in the Early Years. New York: Houghton Mifflin. ISBN 0-395-12571-5.