Achieving leadership presence in a post-enron world. (Leading Questions).

With turmoil rocking the corporate world the traditional pillars of our well-being in business and finance are wobbly and no one can give assurance about when--or if--things will right themselves. Security is in extremely short supply.

Good people everywhere are worried about how their lives will be changed by this loss of trust and confidence in once-solid institutions. How will they cope? What can you count on anymore?

The answer is, you can count on real leaders--people who are doing the right things, for the right reasons--to help restore the faith and credibility that are now so sadly lacking. It won't be quick or easy but it will occur, because leaders always step up when they're needed.

Although casual cynicism engendered by recent events has made it more difficult to identify leaders in our midst, we know they're out there. But don't be fooled by flashy style or hype; real leaders have little need for either of those.

Whether you're looking for leaders or looking to become one yourself, here are six low-key hallmarks of leadership:

* Be honest and maintain integrity

* Admit mistakes

* Be good to your people

* Be inquisitive

* Be nice

* Maintain time for teaching and reflection

* Be honest and maintain integrity

Honesty is a key leadership attribute that's a personal character trait.

Honest dealings in one-on-one experiences with individuals are exemplified best by transparency. A physician executive leader models honest behavior by doing the right thing and by rooting out dishonesty of others. An obvious issue--such as Medicaid fraud, for example--is wrong and must not be tolerated.

More difficult areas of honesty arise when the executive is placed between two difficult choices that may result in political fallout. It may be easier, in the short term, to make both groups lobbying for their direction believe they will get their way. However, in the long run, this impairs and often destroys the leader's credibility.

Executives who want everyone to feel good about their decisions are not leaders. Leaders must decide on action, move forward and discuss the decision openly and honestly to maintain and expand leadership presence.

Integrity impacts communities. It's time to acknowledge that most physicians respond to how they are paid by seeking ways to maximize income. Variations in practice patterns--such as decisions to complete a hysterectomy--have been shown to be driven by economics as much as medicine.

Several studies show a direct correlation of hysterectomy rates with the methodology of reimbursement--more hysterectomies are completed if you are paid to do them, while medical management is more common if surgery does not result in higher compensation. (1) This is an issue of integrity. When it is indicated, shouldn't a hysterectomy be recommended, regardless of the compensation method?

Similarly, the entire issue of expert opinion for medical-legal claims taints our profession. When a physician accepts payment to serve as an expert witness in medical-legal claim, the result is often a payment to provide the payer's opinion, not an expert opinion. Shouldn't the physician's opinion be the same regardless of who pays-defense or plaintiff? Physicians who sell their opinions to the highest bidder at the cost of individual and professional integrity damage our profession.

Physicians as a community are looking for leaders with integrity to make decisions and solve problems; however, one can't have real integrity and also be universally liked. True leaders choose integrity over popularity and compensation.

Admit mistakes

Nobody's perfect; mistakes are made. The trouble is, few are willing to acknowledge errors, and fewer still take responsibility and face the consequences.

Since Watergate, it's been clear that the cover-up can be more offensive than the original error. The medical profession is currently re-examining hormone replacement therapy and arthroscopy as just two examples of treatment situations that could cause patients and their families to lose confidence in their providers.

It's not right for patients to learn of massive medical errors from the newspapers or television rather than their own physicians.

Leaders respond with focused action to situations caused by mistakes.

For example, one large Midwestern health system became concerned about the efficacy of certain sterilization procedures it had used for a particular surgery. Rather than hunker down and wait for trouble, this system got ahead of the problem by sending letters offering free testing to all who had had the procedure to ensure they had not been adversely affected.

Newspapers and television in their market were enthusiastic in praising the system for its courageous concern for patients and a negative was turned into a positive.

Be good to your people

Your people should feel valued and respected. Genuine empathy for their issues and concerns gives them a powerful reason to stay with you.

A leader always sets clear objectives so that, when things get tough (as they usually do), there will be no scapegoating. When your people know you're with them for the long haul, that loyalty is repaid with their own.

Just consider the current and growing nursing shortage. A recent study reports that:

* Nursing school graduation rates have fallen 23 percent.

* The average nurse's age is 45.

* The average retirement age is 46

* All this will result in hospitals being short more than 500,000 nurses by the year 2020. (2)

As this "perfect storm" brews, we all need to look for solutions. In the meantime, leaders do everything possible to ensure that those now on the front lines are not strained to exhaustion through double shifts and mandatory overtime. Leaders look for solutions to reduce the burden and abuse of their people.

And on the administrative side, leaders encourage--insist, if need be--that key managers and executives take real vacations. No one can constantly work 100-hour weeks without serious consequences. Batteries need recharging.

Be inquisitive

A leader doesn't take things at face value but listens and looks hard at the quality of all claims. Just because a sales rep says a product is superior doesn't make it so.

Pharmaceutical companies use every strategy, even routinely employing attractive young women as reps because they are more likely to garner a bit of the (mostly male) physicians' time in a busy day. Now, as the number of women physicians increases in certain specialties, some companies are deploying attractive young men in sales roles.

Occasionally, you hear of a heroic physician who's responsible for the hospital's or clinical practice's formulary taking second and third looks at requests for new products, and asking: Why change? Is it really better? Is it worth the additional expense?

Going head-to-head with companies and colleagues isn't easy, but it's the right thing to do if it avoids unnecessary costs or improves patient care quality.

And every once in a while, being inquisitive can save lives, too. Remember the national tragedy that Dr. Frances Kelsey at the FDA averted because she refused to certify thalidomide for sale in the U.S. in the early 1960s?

Be nice

To a physician leader, being nice can mean hanging out with employees to discover what's up, and what's getting them down. It can be as informal as a cup of coffee or as formal as an appreciation luncheon. But this is the stuff that counts.

The terminology MBWA (managing by walking around) may be dated, but the idea is still important. If the only time you see your people is when there's a problem, you're missing out on the chance to experience the culture and quality of their work.

Quantitative data on length of stay, morbidity or other statistics is vital, of course, but it's got to be complemented with qualitative information that comes from knowing what your people are experiencing daily.

Being nice can help to defuse situations that should never become situations in the first place. Saturday Night Live comic Dana Carvey said he sued the surgeon after a flubbed cardiac surgery that could have cost him his life because his physician refused to apologize for the mistake.

Maintain time for teaching and reflection

As the demands on our health care organizations become more intense, the brain power of an organization becomes even more critical for success and eventually survival.

The opportunity to build a better health care product, care for patients more efficiently, increase the speed to market of key services, improve process efficiencies and break down unnecessary organizational bureaucracy requires time to think, create new ideas and teach those ideas throughout the organization.

Deliberate, substantial thought is required to improve the typical highly complex, structured health care organization. As the government works to balance the budget while paying for the "war on terrorism," health care will be continually pressured to provide more for less.

Companies that continue to experience double-digit health care inflation rates will expect less-costly services to maintain competitiveness of their products and will shift an even greater financial burden on their employees.

As the nursing shortage becomes even more critical, health care leaders must learn how to care for patients in a different way. All of these very real issues that challenge leaders to improve quality and reduce costs will require the development of true learning organizations.

Noel Tichy's recent book, The Cycle of Leadership -- How Great Leaders Teach Their Companies To Win, suggests that winning organizations are teaching organizations built around virtuous teaching cycles. (3)

The best organizations create aligned brains and leadership at all organizational levels. Unfortunately, most health care organizations have a silo mentality with an authority-driven structure that severely restricts improvement--such as nurses only learn from nurses, neurosurgeons only learn from neurosurgeons and finance people learn from other finance gurus.

We need leaders to break artificial boundaries to make revolutionary improvements in health care. While it is easier to lead small organizations to a teaching model, other organizations such as General Electric and Yum! Brands developed organizational infrastructures to engage hundreds of thousands of employees in the teaching and learning cycle. Creating this teaching and learning model in health care will take real leadership.

Only one leadership 'secret'

While it might be more comforting to think that leadership has "secrets" for success, these attributes are obviously plain skills and behaviors available to anyone who wants to try them on. The only real secret is persistence...but you knew that already, didn't you?

References:

(1.) Ransom, SB, McNeeley, SG, Kruger, ML, Doot, G, Cotton, DB. "The Effect of capitated and Fee-for-service Remuneration on Physician Decision Making in Gynecology." Obstet Gynecol. 1996, 87:707-10.

(2.) Watson, DS. "The Perfect Storm," AORN Journal, June 2002, No. 6, Vol. 75, p. 1068.

(3.) Tichy, NM. The Cycle of Leadership-How Great Leaders Teach Their Companies to Win. New York, HarperBusiness, 2002.

Scott Ransom, DO, MBA, MPH is vice president at Witt/Kieffer in Oak Brook, III. In addition, he serves as an associate professor in health management and policy at the University of Michigan and associate professor in obstetrics and gynecology at Wayne State University School of Medicine. He can be reached by phone at 6301575-6130 or by e-mail at [e-mail]