In his book, The Power of Habits, author Charles Duhigg tells the story of the Rhode Island Hospital. Even though it was a leading educational hospital and Level 1 Trauma Center it was also a place of feudal fights where nurses were pitted against surgeons. Nurses even had their own color coded method of identifying surgeons they worked with. Quoting Duhigg: “Blue meant ‘nice,’ red meant ‘jerk,’ and black meant, ‘whatever you do, don’t contradict them or they’ll take your head off.’ ”

Duhigg recounts the true story of an elderly man who was brought in with a Subdural Hematoma. Immediate surgery was required. Ignoring repeated caution from the nurses, the surgeon stated: (Quoting Duhigg): “If that’s what you want, then call the fucking ER and find the family! In the meantime, I’m going to save his life.” Within two weeks the man was dead. The surgeon operated on the wrong side of the man’s head. It would be easy to say that the fault was the surgeon’s and he should be dismissed, (he was). However, over the next four years similar accidents occurred for which the hospital paid $500,000 in fines.

The good news is that changes were made. It might be obvious to say, they implemented check lists and other procedural changes to improve patient safety. However, the stronger reality is that they challenged, broke and then transformed the entire leadership system. Leaders become subservient to the requirements of a system rather than every leader establishing their own operating procedures. The result was a dramatic drop in errors and a prestigious award for Critical Nursing. Where the old leadership system put the surgeon at the top of the pyramid with virtual unquestionable authority, the new system empowered everyone around the care of the patient – delivering maximum value. Duhigg concludes with an example of a routine surgery performed by an experienced and well trained surgeon. Before he started he went through a check list but missed a minor point. In response, the youngest and least experienced nurse pointed out the error which was welcomed by the surgeon.

A leadership system, therefore, is the system that connects leaders, and organizes the elements they control with the critical relationships to produce the desired outcome – maximum value. With the example of Rhode Island Hospital and the old system, surgeons had enormous and virtual dictatorial power, which often came at the expense of their patients. Under the new system, the surgeons recognized the nurses as part of a total system of patient care. The result was more medical value provided to the patient. It was not a matter power and control. It was about delivering to the patient maximum medical value for their health.