Learning leadership from errors
James Stempien, MD
STORIES FROM OUR CCPES
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Most of my lessons on leadership have been learned from errors that I have made along the way. At times I’ve felt like a pinball bouncing from crisis to crisis, doing most of what I’m supposed to do — just a bit past time. Most of my errors have been correctable and excellent exercises in humility and enlightenment.
Back in 1992, I was medical director of Ialibu District Hospital in the Southern Highlands Province of Papua New Guinea. “Director,” of course, as I was the only physician, not only in the hospital but also in the entire district.
These were great times: the hospital had been without a physician for about 2 years. When I arrived, most of the wards were closed except for intensive care and obstetrics. No visits had been made to the surrounding clinics over the same period, and the dog associated with the doctor’s house had been left to fend for himself. Top
So much to do — surrounded by quality issues, it was heaven for a young wanna-be medical leader. We fed the dog, he vomited. I tried to use the phone; the lines had been cut some time before. I ordered meds, and realized our pharmacy was almost bare. Much to do, much to do.
The staff were eager to get the hospital up and running; the nurses, lab, and grounds staff were proud of their home hospital, but the lack of funding was very apparent. To see such a large hospital — with a potential of around 200 beds — virtually closed was perplexing. The medical, surgical, tuberculosis, and leprosy wards had been closed over the past 2 years and the patients sent home to wait for further instructions.
The problem was the toilet. When the hospital was built about 30 years before, it had multiple wards and a massive pit toilet with a rainwater shower and privy built above it. As in many health care regions, infrastructure is one budget, ongoing maintenance another; there had been none for the latter for quite some time. The massive pit toilet was full and unusable. To open the other wards of the hospital would require a new big pit, and this would require a major infrastructure project and a new structure standing over it.
To me, the first step seemed simple enough: we needed stuff, so I would get stuff. I wrote the provincial deputy health minister, outlining the problem, asking for support in terms of a crew, tools, and building materials. But I was told money was tight; the deputy health minister seemed uninterested. I was advised it was best to wait for him to decide when to repair the toilet and open the hospital wards, but no timeline existed, and, to be honest, he hadn’t even heard about the problem before I mentioned it.
Over the next few months, I worked with the local staff to develop a plan. We needed shovels and cement and would have to come up with the funds ourselves. In the local tradition, anyone requesting an x-ray without a clinical basis would have to pay for it. Our local radiology technicians kept the money in a locked box in a locked room. We kept close watch on the funds and, over the next few months, accumulated enough to buy the needed supplies from a cheap nongovernment source. Top
One of the nurses had done a course on the design and safe placement of pit toilets in the local environment. Our carpenter could design the building, and almost everyone had some carpentry or building skills, as they would have built their own homes.
The large hole was going to be the main part of the project. It was going to be about 3 m across and deep enough to function for many years. Any digging would have to be done by the hospital staff. Although we had a groundskeeper/security/maintenance person, we were planning a very big hole and it would take a long time with one shovel.
After much discussion, we planned a full day off for all hospital staff, a general digging day. It would have to be a day when all the staff were in town, neither a Monday nor a Friday as stragglers from home and early leavers would be affected. A Wednesday was chosen, clinics were canceled, food was planned, teams were organized so the digging would be continuous. Extra dirt would be carried to the edge of the hospital property by people not adept at digging. Lots of discussion of which clothes to wear and whether we could use the hospital laundry to wash personal clothes dirtied doing hospital work. “Of course” was the answer.
The morning was set, the crowd was arranged. I lived about a kilometre from the hospital and walked over a little after 8 am. It was raining, but I didn’t think much of it, as it often rained in Ialibu. When I arrived, all hospital staff members were assembled in our main meeting area. Lots of chatter was going on and lots of cups of hot beverages were being passed around. Tea, coffee, or Milo, a local favourite. The rain came down a bit harder, so I poured a cup for myself and chatted to the staff. Top
Not wanting to appear too obsessive, I figured I would let the local leaders be the first to start digging, but I astutely noted after a while that little was happening and second or third cups of hot beverages were being poured.
Rising up on my hind legs like a young Churchill, I mentioned that it was “time to start digging for the benefit of us all.” The faces of the staff were incredulous. “Impossible, it was raining,” “too hard to dig in the rain,” “Doctor, we can wait until the rain stops.”
I was irresolute. This was our one big day for the dig, it always rains in Ialibu, and I’ve seen people work out in the rain all the time. But the local staff didn’t seem excited to go out and work in what was now a small downpour, and I didn’t blame them. I’m a young doctor, not totally inexperienced, so I did the wise thing and had another cup of tea. Top
The rain continued, my mind fidgeted and so did my legs. It was decision time. I was the hospital CEO, chief of medical affairs, medical director, and the only physician, so I was allowed to make some decisions.
I grabbed a shovel and headed outside, a few of the local staff gently tried to stop me, “Doctor, maybe we can wait another day?” But after looking at the pluses and minuses of the local situation, dig now was the choice I made.
I headed out to the marked area and started to fill a wheelbarrow. I was wet; the rain was steady, but not hard, and a pleasant temperature. A few staff came out, initially with some minor protests but eventually grabbing tools and digging in. Soon all of us were digging, singing, working, and laughing; it was a hard day but at the end we created a big hole.
At the end of the day, we had a bit of a celebration with more cups of hot beverages out of the rain. We celebrated our hole and the teamwork that went into it.
A few months later the structure, showers, pipes, and toilets were all completed. At the official opening ceremony, speeches were made, a big meal was served, and some local dignitary who hadn’t helped in any way showed up to receive accolades.
When you approach the hospital, it seems pretty normal: five cinder-block buildings surrounded by a fence with some barbed wire loosely arranged at the top. A few gardens exist on the grounds; the verdant mass of flowers in front of the obstetrics ward is fertilized by nurses burying placentas post-delivery. The four largest buildings are wards, all of which are now open, a small administrative building, and a beautiful new toilet and bathing structure.
What lessons did I learn?
Successes and failures occur almost at the same time. The progression to completion was similar to starting one of our older hospital vehicles: lots of noise and smoke, half starts, and eventually the engine turns over to a cheer and a round of applause. Top
Use your local expertise. Somewhere in that crowd there is someone with extra knowledge or some level of inspiration that will help us all to success.
Front-line workers know what is going on; trust them, talk to them. The people on the front line doing the job every day have a unique perspective, and their knowledge is vital to any success. Get their input, feedback, pissed-off ramblings, and respond and learn from them.
Have a plan B or C or at least be prepared to come up with one in a hurry. No matter how well you plan, there is no way to anticipate every eventuality. That’s fine; a good leader takes that challenge and comes up with something.
Leaders lead from the front. World War I would have been a lot shorter if that was a military rule. It’s too easy to put out our dictates or decisions and lie back in the glory of our own intelligence. It’s much more satisfying to work with and learn from the people in your own organization.
Celebrate your success. Everyone needs a break and a pat on the back, especially me; take a few minutes and celebrate a small success. A meal, a few short speeches, and congratulations all around are a useful and meaningful thing.
It was a great toilet; I used it many times.
James Stempien, MD, and his wife Heather spent a year in Papua New Guinea where their first child was born. Since that time, he has been able to learn by error in other leadership roles. He is currently the unified department head of Emergency Medicine for the College of Medicine at the University of Saskatchewan.
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