When It Doesn’t Work: Failure Leadership in Healthcare

F rank Eckhart was very frustrated. It was

now very clear that their major quality

initiative had not worked. It wasn’t so much that

they had spent much money and energy on imple-

menting what the board and senior team had made

a key strategic objective, but rather they had

placed so much hope in the difference the initia-

tive would make for both patients and providers.

As the systems senior vice president and chief

nurse executive, he had been charged with leading

the project and guiding the initiative toward suc-

cess for the whole system.

April 201342 Nurse Leader

Tim Porter-O’Grady, DM, EdD, NEA-BC, FAAN

There was no pressure coming from above to abandon theprogram, and there was not yet a general feeling from

other members of the senior staff that the initiative was fail-ing, but to Frank, all the signs were there: little staff engage-ment, poor quality outcome measures, inconsistency inapplication, unit manger complaints about the additionalworkload, and a general lack of agreement on deliverables.Frank felt a sense of panic when he realized that the programneeded a complete recalibration and an entirely differentapproach if it was ever to make the difference for whicheveryone had hoped.

How would he explain to his colleagues on the seniorteam that the approach had failed and the program as cur-rently constructed simply was not working? Worse, howwould they generate additional resources and time toreconfigure their approach, extending the timelines,processes, and results beyond the parameters outlined in thestrategic plan? And, personally, how would this reflect onhim and his leadership, and what effect would it have onhis career and his leadership in the eyes of his peers and theorganization he lead?

Frank’s scenario plays out multiple times and in manyorganizations across the world. In fact, the incidence of failurein processes and projects is higher than the indicators of suc-cess.1 Yet there is little scholarship or dialogue on the man-agement of failure and the appropriate processes necessary toaccommodate its impact and the realities of confronting it asa normative condition. From a systems perspective, the falloutfrom unaddressed and uncompensated failure is inestimable inrelationship to human dynamics, resource use, and its strategicimpact on organizations. Chris Argyris, the noted organiza-tional scientist, often pointed out the considerable costs ofstrategic activities where the linkage between decision-mak-ers and implementers was so misaligned that less than 20% ofstrategic objectives were successful in many Fortune 500organizations.2 This certainly represents a record of the evi-dence of waste of human and material resources and thepower of misalignment of strategic and tactical systems insupport of work at the organizational point of service. Suchfailure is notable, especially since it is understudied, and thereremains a paucity of resources available to help systems lead-ership address it.

THE PERSONAL RISKS OF FAILUREThere are perhaps few circumstances that can generate morecareer angst in the leader than the possibility of role or careerfailure. The personal impact on both the psychodynamics ofthe individual and the financial implications are sufficient todrive the consideration and management of failure to thefurthest reaches of the psyche. Yet it is that very fear thatvirtually guarantees that failures are not frankly acknowl-edged and appropriately dealt with in a way that demon-strates both engagement and learning. Classically, the reactionto the potential for failure is to retreat from it in a way thatdistances the individual from the possibility of personal iden-tification with the elements of risk related to a failure. In thepresence of failure, individuals attempt to inure themselves

from the blame or personal connection to the processes asso-ciated with the failure. The goal in this circumstance is per-sonal protection and the reduction of risk such that thereflected “pain” associated with the failure does not land onthe individual in a way that endangers other’s perception oftheir competence or their capacity to lead.3

The effort to maintain personal integrity acts to reduce theangst or fear related to impending failure. The vulnerabilityinherent in the potential for failure accelerates the perception ofpersonal risk and the dangers it might create in terms of one'srelationship to the organization or to the threat created withregard to the individual's role or position. There is also a certainlevel of incredulity related to the impending failure; a sense ofawe that the best laid plans and the commitment of the highestlevels of the organization were not accurate, effective, nor ulti-mately successful. In addition, there is a loss of confidence in theself and in others who conceived and led the failing initiative.All in all, the individual does not really want to deep dive intoaddressing the failure and would rather identify it as somethingexternal to the individual enough that it can be either modifiedor moderated in a way that will reduce the presentation of it asa personal failure.4

ORGANIZATIONAL FAILUREThere is a broader engagement in the mythological journeyof the cover-up of failure. The larger organization also playsits part in the conspiracy of denial by creating responses thatjustify the failure or place it in a broader, safer context.5

Comments such as “The timing wasn’t right” or “The work-load was just too great” or “We just didn’t have enough time”provide a chance to modify the potential for success andtherefore ameliorate the intensity of any sense of humanfailing. Furthermore, the failure to establish a strong mutualunderstanding and set of metrics against which organizationalsuccess will be measured accelerates the opportunity forsystem-wide failure.

No one wants to fail. Indeed, an organization-wide mutu-al conspiracy favoring success and minimizing failure operatesdeep within the collective consciousness of systems creating afundamental bias toward success.6 Certainly, the enthusiasmfor success serves as an inherent source of motivation, direct-ing the enterprise toward accomplishment. It also, however,creates an opaque barrier that walls off failure as superfluous.This opacity diminishes leadership awareness of and availabil-ity to the emergence of failure soon enough to address itwithin the context of the broader journey to success.

MACRO VERSUS MICRO FAILURESystems generally do not fail all at once.7 This notion that allthe forces of the environment converged to conspire againstwhole-systems success creates a generalized amorphousaccountability that fails to isolate and clarify the key indicesof failure. The failure of most organizational initiatives relatesprimarily to the more localized emerging inadequacies foundin smaller units of measure.8 It is the simple, more localvacancies of action and inaction that more often than notaggregate to create broad-based failure. Simple issues drive

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failure, such as lack of mutual understanding of purpose andgoals, unclear individual responsibility, poor translation intospecific action, lack of personal ownership and engagement,poor alignment of strategy, tactics, and action, and poor good-ness of fit between the insight of executives and the realitiesof those at the point of service.9 Each of these more microissues aggregates, creating a macro impact, “chunking” slowlyand inexorably toward a whole-systems failure.

PREDICTIVE AND ADAPTIVE CAPACITYPerhaps the most common and significant failures in organ-izations are embedded in the leadership's inability to adjustand adapt the organization to changes in its prevailingenvironment. The most notable skill in times of broad andintensive change is evidenced by the aptitude of leadershipto assess the trajectory of environmental change, the locusof the organization within its trajectory, and the ability torealign organization and people in a way that sustains thesystem. This tremendously important predictive and adap-tive capacity of the leader often provides the key differencebetween sustainable success and a series of incrementalfailures.10 The fluidity and mobility that best representadaptation to a rapidly changing environment require lead-ership to help the organization surrender attachment tostructures, rituals, and routines that impede its availabilityto the necessary adaptations to important environmentaland contextual shifts.11 Indeed, much of the work of lead-ership is represented in the effort to create an organization-al culture of mobility and portability, creating anorganizational frame that requires nimble and just-in-timemechanisms that reflect an organizational availability andreadiness to adjust to the critical constituencies of a con-stantly changing environment.12

HARNESSING FAILUREFailure is a powerful organizational and leadership toolthat, when harnessed, facilitates the propulsion of the sys-tem toward sustainable success. However, failure must beseen as a fundamental element of strategy and one of anumber of metrics that enable a system to assess the rele-vance of its decisions and actions. In short, failure is anelemental tool of success.13

There are a number of purposeful mechanisms for har-nessing the inevitability of failure and making anticipation ofit and response to it an intentional part of leadership work.Rather than using failure as a mechanism for blame andrecidivistic action, understanding its dynamics and harnessingthem as a structural part of constructing strategy and under-taking tactics for success puts failure in the proper contextand makes positive use of its potential contribution.

Incorporate Failure as an Element of StrategyAlthough some failure is certainly the result of poor plan-ning and execution, failure also contains elements of therandom and serendipitous forces at work in the environ-ment. In short, the potential for failure is present in allhuman undertaking.14 This reality should alert the leader tothe ever-present potential for failure in the best-laid plans,providing an opportunity for anticipating its impact, evalu-ating its effect, and compensating for its presence. Errorwill always occur, from misreading the environment, mis-perceiving the elements and impact of change, not antici-pating the vagaries of a destructive innovation, beingunprepared for an unanticipated critical environmentalshift, and so on.15 In any of these scenarios, the ability oforganizational leadership to create a culture of awareness,anticipation, and responsiveness that can nimbly act withagility and availability to the critical moment is essential tosustainable adaptation. This means that organizations andsystems see fluidity, mobility, and portability as a fundamen-tal way of doing business and as an organizational perform-ance requisite embedded in all structures and roles.16

Agree on Purpose, Trajectory, and ActionSo often at the initiation of plans and strategies, leadersassume that once agreement has been achieved, action andimplementation of the agreement is all that is required. Mostoften, however, in retrospect, the challenge has been thatwhat leaders thought they had agreed to does not alwaysresonate with the perception of other members of the leader-ship team regarding what they presumed has been agreed.17

Agreement and alignment are critical first-stage elements ofsuccessful failure management strategies.

It is important for team leaders to recognize the potentialfor failure embedded in agreement. Consistent understandingof purpose and goals is critical to alignment and concertedaction undertaken in all the places where correct process isrequired . Important to the accuracy and veracity of decisionsand design is clarity around what exactly was decided andwhat form action should take.18 Validating the initial align-ment of understanding between and among leadership deci-sion-makers is a critical first step. The team leader should notallow members to leave the room following a critical deci-sion without first validating with each, his or her verbalizedunderstanding and languaging of what they think was decid-ed at the table. Each member stating back to the table as awhole their verbalized understanding of what was agreed toadvances clarity, reduces ambiguity, and establishes the floorfor concerted action.19

April 201344 Nurse Leader

Failure should be seen as a

component of the processes of

evaluation, recalibration, and

corrective engagement.

Make Failure Expectation a Metric of ProgressFailure should never be seen in exceptional terms. It shouldnot be looked at as egregious, significant, or emotionally orintellectually aberrant. Instead, failure should be seen as anelement, a component of the processes of evaluation, recali-bration, and corrective engagement. Failure should be antici-pated at the same level of diligence as success is sought.Wresting from failure the powerful negative connotations andemotional content we attach to it places it in an appropriatecontext, making it simply another tool in the armamentari-um of analysis and evaluation of progress.20

Being as consistently alert for the signposts and the trajec-tory leading away from preferred values or outcomes is acritical part of good leadership decision-making. In this case,rather than acting as an impediment to success, the evaluationof a failure circumstance or condition at any given point inthe process can indicate several things important to achievingsuccess: a significant environmental shift, misalignment ofstrategy and process, an inadequate or inaccurate goal, orincongruence between decision, processes, and outcome. Allof these are elements of the normative dynamic associatedwith the winds of uncertainty and unpredictability deeplyensconced in the complex interface between persons, organi-zations, and the environment.21 Leaders, therefore, must moveout of simplistic management notions of linear cause andeffect toward more effectively dealing with the multimodalinteraction of forces operating at the many organizationalintersections impacting the synergy between decision, action,and outcome.22

Disarming Failure as a Personal ImpedimentPerhaps the most ability-daunting characteristic of organiza-tional or systems failure is the personal attributions of specificleaders with regard to their perceptions of individual inade-quacy. This is heightened by a unique American characteristicfor assigning individual blame for systems failures.23 Althoughthe importance of individual accountability in leadershipdecision-making cannot be underestimated, risking the lead-ership challenges and vagaries of systems change isconstrained inside a culture of blame.24 No strategic impera-tive, innovation, or systems change can be undertaken in arisk-free environment. Although it is important that leadersmaintain a high level of strategic diligence and competencein undertaking major change, and apply the appropriate disci-plines associated with the careful deliberation, planning, andexecution of major change, leaders must do so with therecognition that there is no straight line to success.

As well, there is no guarantee that the goodness of fitbetween environmental demand and organizational responseseen at one point in a strategic trajectory will not be radicallyaltered by emerging conditions and circumstances at someother point. These threats to process effectiveness are contin-uous, often iterative, and certainly endless. The issue in thiscircumstance is not to be afraid of the potential for failurebut, instead, to recognize its potential is present in everyeffort, initiative, or process. It is the awareness and availabilityto the emergence of failure at any point along the change

continuum for which the leader must be ever vigilant. Itmust be remembered that the aggregation of failure hauntsthe hallows of leadership’s lack of awareness, inattention,dearth of metrics, absence of process discipline, inadequateevaluation, micromanagement, and the lack of stakeholderengagement and ownership.25

Furthermore, individual leadership’s enriched enthusiasmand angst for accomplishment, achievement, personal recog-nition, and acclaim creates a sort of conscious translucency toanything that might suggest that great outcomes could in anyway be challenged or limited by an accumulated aggregationof unseen errors. In this case, the desire for outcome andimpact blinds leadership to all evidence to the contrary.26

Out of the enthusiasm for an exciting outcome emerges anexecutive “groupthink,” where the allied enthusiasm of theleadership team for accomplishing meaningful goals limitstheir availability to recognizing and confronting the evidencethat precludes the system from achieving them. Divesting thejourney toward successful outcome from the ego demands ofpersonal validation goes far in ameliorating the aggregationof unaddressed errors and helps focus the leader on the man-agement disciplines that ensure the use of effective mecha-nisms for addressing meaningful change.27

CONCLUSIONThere is much about failure management we are just begin-ning to comprehend. The fundamentals of understanding thatare beginning to emerge affirm that systems failures generallyresult from an array of management actions that simply didnot address the inherent inevitable failure elements residentin every change strategy. The capacity for leadership to recog-nize the characteristics and actions of failure evident in allstructure change is critical to its success.

The primary role of leadership is to create a culture thatembraces failure as much a part of success as is progress.Identifying personal and organizational attributes resulting inthe avoidance or diminishment of the action of error andfailure creates a framework and milieu that places failure in itsproper context in the change journey. Embracing and appro-priately addressing inherent failure permits leadership toenable the value of failure in informing and refining thejourney to personal and organizational success. NL

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Tim Porter-O’Grady, DM, EdD, NEA-BC, FAAN, is the SeniorPartner of Tim Porter-O’Grady Associates and an associate professorat Emory University in Atlanta, Georgia. He can be reached attim@tpogassociates.com.

1541-4612/2013/ $ See front matterCopyright 2013 by Mosby Inc.All rights reserved.http://dx.doi.org/10.1016/j.mnl.2012.12.004