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You will no doubt remember the song the Lost Boys were singing as they followed Peter Pan around Neverland. Peter was a charismatic leader, although I am not sure whether he was a good or bad leader; he was certainly entertaining and the Lost Boys had great fun.

In my career I have had the privilege of working with and for many excellent leaders and also, unfortunately, have had the calamity of working with and for several very poor leaders. I have learned a lot from these experiences and in some instances, have learned even more from observing the characteristics and behaviours of deficient leaders. Observing poor outcomes and harm done to patients, often the consequence in part of poor leadership, has enhanced my own skills considerably.

I was at a quality and safety conference awhile back and after giving a presentation on the importance of developing and sustaining a strong safety culture, I was approached by a doctor who wanted to know just what I meant. I found his comment perplexing and, frankly, a little insulting. Hadn’t he paid attention to what I had been discussing for the past 45 minutes?

The doctor commented that he knew all about this “safety stuff” and that if the nurses would just pay attention to details, then “all the errors would go away”. I asked him about his role in his hospital and he told me that he had retired from active practice a couple of years ago and that his friend, the hospital CEO, had asked him to take over the hospital’s quality and safety program on a part time basis. As we discussed this position and his interest in taking on these responsibilities, it became apparent to me that he had received no formal training or meaningful experience in quality improvement science or personnel management. Nor did he have an understanding of human factors affecting individual performance, teaming and teamwork, or any of the other mosaic tiles that should reveal an image of higher quality and safety. Not only that, the tone of his queries was arrogant, suggesting an unwillingness to recognize the need to learn about these important matters despite his responsibility for safety and quality in his institution.

When I discussed this with some colleagues later that evening, one of them mentioned that she was familiar with the hospital where this doctor was working. The hospital had recently received dismal marks on both accreditation and regulatory compliance inspections, the chief nurse had resigned three months before the inspection after voicing concerns about human resource management, and poor patient care, and many of the experienced clinical staff in various disciplines also were resigning in droves. Hiring the retired doctor for the position of “part time” quality and safety leader was an attempt by the CEO to demonstrate his commitment to improvement and “satisfy the inspectors”, a poor attempt by any standard.

It struck me that the CEO didn’t really understand, first and foremost, what the mission of his hospital must be. He seemed to have lost focus, assuming he ever had one, on providing highest quality, safest healthcare services in deference to other aspects of hospital performance, presumably financial. As a result, patients were likely to suffer and be harmed. Providing highest quality, medically necessary and appropriate healthcare services improves safety and protects an institution’s financial bottom line, but he didn’t seem to “get it”. His strategy for rectifying crucial findings of the inspection teams was simply to apply a bandage, a soiled bandage in my view, instead of delving deeply for the correct diagnosis of his institution’s problems. He was content to hire someone with no real qualifications for a position of great importance, a quintessential pillar supporting the ethical foundation of his hospital.

His institution was failing because he was failing to acknowledge his key responsibilities and to respond appropriately to develop and sustain a culture of quality and safety and to provide resources for improving quality and safety, including appointing a full time, qualified leader with appropriate skills for the job. By default, the hospital’s board of directors was deficient in not holding the CEO accountable and conceivably not even understanding what really matters. Short-sighted, misdirected leadership was pervasive and, sadly, was likely to continue. Patients could continue to be harmed. The hospital needed its leaders to change their outlook and perspectives, to focus on what matters most to patients.

There was a solution at hand. “Sometimes, if you can’t get the people to change, then you may have to change the people.”²