Managers Are Necessary; Leaders Are Essential

Abstract

In 1943, the Allied Forces teetered on the verge of a historic military collapse in the Burmese Theater of World War II. The weapon that was devastating the British Fourteenth Army was not battleships or bombers but the tiny Anopheles mosquitoes that carried malarial parasites. For every man wounded in action, another 124 were evacuated for disease; at the peak, 84% of His Majesty’s fighting force was infected. New pesticides, new malarial medications, and the best efforts of highly trained sanitation officers and front-line physicians failed to solve this seemingly intractable problem—intractable until Commander Field Marshall William Slim realized that it was not a medical problem, but a leadership problem. Slim set out to rigidly enforce malaria prophylaxis, with robust accountability. “I, therefore had surprise checks of whole units, every man being examined. If the overall result was less than 95% positive, I sacked the commanding officer. I only had to sack three; by then the rest had got my meaning.”1Slim W.J.S. Defeat Into Victory: Battling Japan in Burma and India, 1942-1945. Cooper Square Press, New York, NY2000Google Scholar A single resolute leader understood the absolutely vital role of his personal executive leadership to resolving that crisis because he recounted, “Good doctors are no use without good discipline. More than half the battle against disease is fought, not by the doctors, but by the regimental officers.”1Slim W.J.S. Defeat Into Victory: Battling Japan in Burma and India, 1942-1945. Cooper Square Press, New York, NY2000Google Scholar Congratulations to Dr. Chang et al for bravely and brilliantly demonstrating again with scientific methodology what we learned from General Slim 74 years ago: that committed senior executive leadership using a data-driven hospitalwide approach and applying accountability to performance is absolutely essential for solving medical systems issues.2Chang A.M. Cohen D.J. Lin A. et al.Hospital strategies for reducing emergency department crowding: a mixed-methods study.Ann Emerg Med. 2017; (https://doi.org/10.1016/j.annemergmed.2017.07.022)Abstract Full Text Full Text PDF Scopus (64) Google Scholar Hundreds of articles have looked at a variety of solution sets ranging from primary care diversion and physicians in triage to surgical schedule smoothing and pushing inpatient wards to adopt boarders.3Rabin E. Kocher K. McClelland M. et al.Solutions to emergency department “boarding” and crowding are underused and may need to be legislated.Health Aff (Millwood). 2012; 31: 1757-1766Crossref PubMed Scopus (107) Google Scholar But those strategies focus on the “what” and the “how.” The truth may be that what matters most is the “who” in solving this seemingly intractable problem. As Sir Slim later summarized, “Managers are necessary; leaders are essential.” We were surprised that the investigators found that leaders from both high- and low-performing hospitals shared the same “theoretical model of [emergency department] ED crowding,” namely, that the primary cause of ED crowding was hospital crowding. Anecdotally, it seems that not all C suites have arrived at that conclusion and continue to see ED crowding as a cause, not an effect. Approaching the real-time influence of leadership on clinical outcomes is challenging, and no doubt that is why the authors collected data from only 12 hospitals. Our hope is that they now further develop explicit methods and data sets to expand this effort to a much broader sample size and continue to determine what organizational and individual leadership components are most important to resolving this principal crisis of our specialty.4Warden G. Griffin R.B. Erickson S.M. et al.Hospital-Based Emergency Care: At the Breaking Point. The National Academies Press, Washington, DC2007: 424Google Scholar Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods StudyAnnals of Emergency MedicineVol. 71Issue 4PreviewEmergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high-performing, low-performing, and high-performance improving hospitals to reduce ED crowding. Full-Text PDF In reply:Annals of Emergency MedicineVol. 71Issue 3PreviewWe thank Drs. Adams and Moore for their commentary on our article. In accordance with our qualitative findings, we agree that leadership is the key to success in addressing emergency department (ED) crowding, rather than the “what” or “how.” These exemplar leaders in our cohort were able to design and execute solutions that were specific to their hospital.1 We saw this in multiple hospitals, which reported that strategies were implemented, but not well executed. Thus, survey studies that focus on solutions such as inpatient boarding or providers in triage do not describe the entire picture. Full-Text PDF