1. Executive Mistakes in Healthcare Paul B. Hofmann, DrPH, FACHE Hofmann Healthcare Group Moraga, California, USA

2. Leading in Challenging Times Merely adequate leadership sufficient in absence of competing priorities and values Exceptional leadership essential  Limited financial/non-financial resources  Politically powerful opposing opinions  Serious conflicts of interest/incompatible incentives  Severe time constraints and pressures  Major unmet expectations  Significant uncertainty re future events and outcomes

3. Three Most Under-Recognized Ethical Issues Facing Most Healthcare Organizations Promoting unrealistic expectations: over- promising and under-delivering to staff, patients, community Rationalizing inappropriate or incompetent behavior Failing to acknowledge and address executive mistakes

4. Ethics and Ethics Standards Ethics  make right choice in face of competing values and focusing on what ought to be decision, action or behavior, especially when there is conflict or uncertainty Organizational Ethics Standards  “improve care, treatment, services and outcomes by recognizing and respecting the rights of each patient and by conducting business in an ethical manner” (Joint Commission 2008)

5. Lack of Attention on Executive versus Clinical Mistakes Rationalization of management as art versus science – in denial Ambiguous decision-making processes and performance criteria – inadequate metrics Difficulty in obtaining consensus about what constitutes “right” decision – not immediately apparent Management ego, fear of reprimand or job loss – arrogance, defensiveness, insecurity

6. Definition and Examples of Management Mistakes Definition – making or not making decision without assessing evidence and stakeholder perspectives, placing patients, staff, organization and/or community at risk Examples  Failure to act promptly when conditions change, to delegate and hold subordinates accountable, to fulfill commitments, to allocate resources fairly, to serve as an effective role model and to empower others  Pattern of making decisions prematurely, belatedly or secretively (alienating and demoralizing subordinates and staff), exhibiting or tolerating abuse of power

7. Factors Contributing to Executive Mistakes Relentless pressures to accommodate special interest groups and multiple constituencies Competent leaders compromised by flawed systems and bureaucracies Lack of time and encouragement to acknowledge, evaluate and learn from mistakes Tendency to make unwise appointments of competent clinicians to management positions Deficiencies in preparing, developing and mentoring future executives

8. Mitigating Impact of Executive Mistakes Admit, disclose and analyze mistakes, recognizing difficult choices sometimes will be wrong choices Accept professional/personal fallibility and imperfections Promote organizational culture where freedom to take reasonable risks, to fail and to learn is reality, not simply rhetoric

9. Representative Steps to Reduce Executive Mistakes in Healthcare Make use of case studies to encourage discussion of mistakes and learning opportunities created by mistakes Conduct staff survey to determine if disclosure of mistakes is considered likely or if fear of retribution discourages admission Develop policy on management mistakes, including definition, criteria for reporting, assurance of non-recrimination, to whom mistakes will be disclosed, description of available resources and specific steps to be taken when reportable mistake has occurred

10. Representative Steps to Reduce Executive Mistakes (cont.) Prepare, implement and monitor organizational and professional codes of ethics Incorporate questions about mistakes in annual senior management and supervisory performance reviews Conduct formal audits of major financial and strategic decisions to assess whether results met forecasted outcomes and, if not, to identify how decision-making process could have been improved

11. Benefits of Addressing Executive Mistakes Inevitability of mistakes is acknowledged Admission of fallibility by executives will earn respect of clinical colleagues Individual and organizational credibility will be enhanced Promoting examination of mistakes will improve management and organizational performance Ultimate beneficiaries are patients, staff members and communities