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American Learning and Development Consultant, Kate Zabriskie, said ‘The Customer’s perception is your reality.’ This truth is applicable to all industries, but it is especially true of healthcare. In most industries the customer is the end-user of the product. As a customer, you are interested in how the product functions, how it looks and whether it meets your personal needs. Normally, the customer is blissfully unaware of any of the steps in the manufacturing process or the attitude of the staff that work for the organisation because usually all you experience is the end product. In healthcare, the patient is both the customer and the product. They are the ultimate end-user, but they are also the product, the entity that is ‘manufactured’ or ‘processed.’ So not only are patients interested in the end result of the care they receive, but they experience every step of the ‘manufacturing’ process first hand. As a consequence, the relationship between healthcare provider and the patient is incredibly special and its importance should not be underestimated.

Recently, there has been a large focus on measuring and quantifying patient experience over the last few years, but are we measuring the right things?

Apart from some cosmetic surgery procedures, Healthcare is not a luxury purchase. It’s not like buying an expensive handbag or the latest model of your favourite mobile phone. Neither, is it an impulse purchase, like buying an expensive coffee or an unplanned snack between meals as a treat. In general, people only seek healthcare when something has gone wrong. It’s a distress purchase. This changes the dynamic between the customer and the service provider. It is based on need rather than want. In addition, being ill or injured is not particularly enjoyable. Consequently, measuring how good an experience it has been may not be the right metric. Could having a tooth extracted ever be a good experience?

Measuring patient satisfaction is difficult, but measuring patient experience is equally as hard. This is fundamentally because as an industry we have forgotten to truly listen to our patients, but focus on our own organisational agendas.

Patient satisfaction is not binary, it is seldom wonderful or awful – it’s usually somewhere in between. Thinking of patient satisfaction in a binary manner categorises it like every other outcome measure and devalues its importance. Thinking of patient satisfaction in this way shifts the healthcare providers focus back onto the organisation and treats the patient as if they were a number and not a person and reinforces all that is wrong in modern healthcare.

The high-achieving healthcare organisations realise that their focus should not be on their organisation, but instead they should be focussing on providing patient-centred care. They understanding that what matters to their patients is what is important, because they are only there because of their patients, rather than the perverse, but all too common view, that patients are there for the benefit if the healthcare provider.

We should measure what matters to our patients and not ask them to fit in with a long list of metrics that we think are important, but in reality are meaningless to them. When measuring patient satisfaction we should attempt to capture the softer, but equally important, metrics such as empathy and the attentiveness shown by staff in addition to clinical outcomes as these measure the art, rather than the science, of healthcare delivery. For example, for the relative of a patient that is dying in a hospice from cancer measuring the clinical outcome is meaningless. Nor is it likely to have been an enjoyable experience. However, contact with warm and empathetic staff can leave relatives satisfied that their loved one received excellent care at the time of their greatest need.

So if the patient’s perception is our reality, perhaps we should start listening more thoughtfully.

By Dr Paul Jarvis
Improvement projects in hospitals frequently fail to deliver the expected levels of improvement. From our work around the world we have identified 8 key characteristics that the more successful organisations demonstrate. These steps are associated with a greater internal organisational improvement capability.

1. Focus on the innovators and the early adopters first
There are always going to be people who are resistant to change in any workforce. Unfortunately, too much time is spent placating these. Meanwhile, those who are willing to try new ways of working are overlooked. Nurture the forward thinkers – they are likely to be an untapped resource. Do not ignore the laggards, just do not make them the focus of the team.

2. The power of words
Celebrate success. When something has made a positive impact celebrate it. Sharing the positive stories will motivate the entire workforce. Success belongs to the workforce, not the leaders. Give them the credit.

3. Identify key issues that motivate your workforce
All too often improvement projects are pursued that are not the most pressing problems for the frontline staff. This reinforces the feeling that change is done to, rather than with, people. These kinds of projects are unlikely to inspire the workforce and are likely to fail. If you focus on those issues that matter to people they will want to work on them and improve the care they deliver.

4. Do not try and boil the sea
Do not attempt something that is too big or unrealistic through one initiative. If there was one solution, you would probably already be doing it. Large scale change is brought about through numerous small incremental steps. The secret to resolving large issues is a piecemeal approach. By focussing on small, but significant projects, success is achieved through small steps.

5. You need senior support
Effective change agents influence others through their relationships, ability and expertise, but occasionally they will come up against resistance that seems impossible to overcome. Despite our best efforts improvement stalls. This is usually due to human factors rather than a problem with strategy. Quite often this is due to a lack of one’s positional power. Continually pushing against this kind of resistance often leads to frustration, anger and disengagement. To counter situations like this it is important to find and develop relationships at senior levels of the organisation. Used sparingly, senior colleagues helping to unblock a problem works well. However, overuse of senior power runs the risk of the work force feeling they are having change done to them. Knowing when and how to use senior support is a delicate art.

6. The only person you can change is yourself
As change agents we often have to influence others. The only real way of changing the behaviour of others is for us to change the way we as individuals behaviour. Our conversations have to support the change we wish to bring about. If our behave does not support what we want to do, or we create adversaries who feel threatened then it is unlikely that any improvement will be realised. Hospitals are very tribal. There are many departments, professions and disciplines, each having their own rules and culture. Navigating this political landscape requires a great deal of sensitivity.

7. Keep momentum
We mention previously that large strategic goals are achieved by incremental small steps. We have also said celebrate your successes, however, there comes a point when the next step has to be taken. This is often a tricky judgement call as change fatigue and disengagement can set in if the pace is too unrelenting. Equally, resting on one’s laurels means that projects stall.

8. No secrets, instead bring fun into the workplace
Delivering frontline patient care is emotionally draining and exhausting. Some patient stories can be harrowing and as a clinician you can not fail to be affected by these. So motivating the clinical workforce can seem difficult. The role of fun in the workplace may seem incongruous in such a setting, but it is absolutely necessary. If improvement projects are seen as extra work I do not have time to do and there is no thanks at the end of it then it is the perfect recipe for disengagement. The other things that rob people of their joy are secrets. Vague answers and avoidant behaviour can significantly knock the confidence of the team and as a result any ambiguity or perceived threat can derail the improvement process. Transparency and laughter are more likely to motivate a team to succeed.

Building an internal improvement capacity within a healthcare organisation is primarily about supporting the workforce rather than endless levels of training. Of course, there will be a need for some skills development, but most teams know what the problems are and what needs to be done. However, to do this they need time, space and support. If organisations are able to apply these three things our reliance upon external management consultancies will diminish.
By Dr Paul Jarvis
"Gemba," is a Japanese word which means the "the real place" and in industry it has come to represent the ‘place where value is created.’ So in healthcare, going to the Gemba means spending time where the patients are, on wards, in clinics or even at the patient’s bedside where the real work of healthcare takes place.

Going to the Gemba is a key part of being a leader and healthcare manager. It is based on the principal that problems are not solved by faceless managers in remote offices; instead one should get as close to the place where value is created, primarily to gain understanding. The fundamental purpose of going to the Gemba is to learn and understand. Only then can we start to create solutions.

From our experiences of working with healthcare providers across the world we see problems being ‘solved’ high up in the organisation’s hierarchy, in boardrooms and offices. Ultimately, ill-conceived solutions and strategies are forced down onto the workforce leading to alienation and further contributing to the overburden of staff with minimal improvement.

The commonest behaviour we see is the creation of unnecessary, mandatory paperwork that is forced onto the staff that has been implemented because of a lack of understanding or appreciation of what the staff actually do. All this does is it creates a complex audit trail that does not benefit patients, but exists purely to satisfy the anxieties of the organisation’s senior management. Healthcare is an extremely complex system and because of this making changes leads to unintentional consequences. Attempting to solve a problem based on ill-informed assumptions is likely to lead to change, but not necessarily improvement. If you do not understand what actually happens at a patient level how can you propose a meaningful solution?

Healthcare professionals are trained in solving problems. Our instincts are to make things better and rescue people. However, we have to resist jumping to solutions and spend time learning and understanding. So rather than spending most of our times in meetings we should spend our time at the Gemba.

Being a successful organisation relies on having an understanding of what happens at the Gemba. This is the core business of healthcare – healthcare is about patients, not meetings. Neglecting the core business is the easiest way to make an organisation fail. Consequently, healthcare managers should aim to be operational (at the Gemba) instead of administrative (in offices and meetings) as much as possible.

Visiting the Gemba should not be akin to a ‘Royal Visit,’ where senior staff walk around departments waving at people and blessing the workers by spending time with them. Neither should it be a spying trip to see what the troops are up to. Instead, visiting the Gemba should be steeped in humility, where the executives acknowledge they are not the experts and they are there to learn. Toyota Chairman Fujio Cho summed up going to the Gemba as "Go see, learn what happens, ask why and show respect."

Respect is a crucial behaviour when visiting the Gemba. Fundamentally, showing respect for the workforce is the best way of motivating them. In addition, visiting the Gemba allows one to see firsthand the three key areas of inefficiency:
  • Wastefulness
  • Overburdened staff
  • Variation

Understanding how these three things directly impact on patient care is the key to solving almost every problem we encounter in healthcare. However, it takes more than understanding as respect also means once we have identified a problem we do whatever we can to resolve it.

So, next time you are sitting in a meeting and find the people around the table trying to solve a problem encourage everyone to get up and go to the Gemba. Before jumping to conclusions, get to know your workforce and go and see what is happening with your own eyes. Seek understanding and observe any of the 3 inefficiencies. This valuable information will enable you to work with your team to create a much more appropriate and credible solution. Visiting the Gemba is so empowering and is one of the most important principles and practices of good leadership.

By Dr Paul Jarvis
Working as both an Emergency Medicine Consultant and a Management Consultant means I visit many Emergency Departments around the world. One thing has become clear to me, irrespective of whether the Emergency Department is in the United Kingdom, Scandinavia, North America or the Middle East; we are all trying to solve the same problem. Overcrowding.
Overcrowding is caused by many factors intrinsic and extrinsic to the Emergency Department. Patients suffer in crowded Emergency Departments as it is associated with poor patient experience, low staff morale and increased mortality and morbidity.

It is easy to for us embedded on the frontline to look at problems external to our service as the sole cause of our woes, and it is true that external factors do influence patient flow, but there are many things that we can do in the Emergency Department to reduce overcrowding whilst problems are being resolved elsewhere in the system.
The key to reducing overcrowding is shortening patient journey times. The shorter the patient journey times, the fewer the number of patients in the department at any one point in time. Time saved at the beginning of the patient journey has a greater impact on the overall total journey time than time saved at the end. This works in a similar way to compound interest on a bank account. Compound interest is interest added to the initial sum of money so that the added interest also earns interest from then on. Similarly, time saved early in a process leads to an amplification of this time-saving throughout the process.
Using this principle, we undertook an experiment using a consultant-led rapid assessment model and performed investigations as soon as the patient arrived. In addition, we introduced Point of Care Testing into the initial assessment process as a means of introducing considerable time-saving early in the process.
We showed that utilising rapid diagnostics at the front door of the Emergency Department reduces patient journey times by approximately 40%. This reduces the number of patients undergoing care in the Emergency Department at any one time by approximately 45%.
Consultant-led rapid assessment utilising Point of Care Testing significantly reduces the number of patients waiting and helps to reduce overcrowding. However, running a Consultant-led rapid assessment model is labour intensive and for it to be successful the balance between capacity and demand has to be struck. Prior to embarking on this working pattern it is imperative that nursing numbers and the work content are calculated, otherwise it leads to burn out and queuing. 
By Dr Paul Jarvis
Pain assessment and management at triage is obviously important, but in one department I visited, there was no drug cupboard at triage. So the staff had worked around the system.  Rather than walking from triage, locating drug cupboard keys, obtaining one gram of paracetamol, giving the keys back to a member of staff in majors and going back to the patient in triage (several minutes later), a stash of paracetamol, NSAIDs and codeine were hidden in the triage desk draw.  Unlocked.  We all accepted this, not as ideal, but as the best solution until ‘someone’ sorted a drug cupboard.

Not everyone accepts analgesia at triage.  Some patients after waiting to be seen in minors are still in pain and require further analgesia.  In minors there was a locked drugs cupboard.  But as there are a number of staff who regularly require access to the drug cupboard, do you constantly interrupt your colleagues whist with other patients, trying to locate those keys, or do you leave the keys on a shelf above the computer, so it is easily accessible and thus prevent interruptions and delays?  Clearly neither of these solutions was ideal, but the latter, more risky strategy was often adopted.  

So a new small drugs cupboard was installed in the room behind triage, and an electronic drug cupboard into the main department.  Job done!  Or is it?
When you listen to Matt Parker, former head of Marginal Gains for the British cycling team, the reason that the team has been so successful is that they constantly look for small incremental changes that will shave a 100th of a second off here and a 10th of a second off there.  When translated to caring for patients at triage or in minors, shaving 2 minutes off the time to see 30 minors patients seen in a shift, releases an hour of time, enabling another 4 patients to be seen. 
It is more time consuming to get up and get the analgesia from the next room at triage, and to walk to the drugs cupboard, key in patient details and drug requirement than having a stash of pills in the triage draw, or in your pocket.  We did not address the culture.

Amalberti’s model of system migration and transgression in practice suddenly made sense.  We had been operating in the ‘illegal normal’ zone in my department regarding the medicines code.   Many people routinely drive 80 miles per hour on the motorway despite being aware that this is above the legal limit.  And which of us would question this or suggest to a colleague that this isn’t advisable?  This is ‘the normalisation of deviance’.  This is pills in the pocket in my department.  However the department should be more akin to a 50 zone, and then 80mph is clearly not acceptable.
The initial safe space of action, as defined at the design stage, is usually much narrower than the range of operation in actual practice. External pressures on performance, from the organization or from individuals, make migration of the system almost unavoidable. Normally, migration is limited to borderline tolerated conditions of use (BTCUs) in which staff tacitly accept routine minor violations. However, some individuals commit more extreme violations, either because of personal characteristics or because of exceptional circumstances, whether real or imagined. The behaviour of these people may encourage further extreme violations in other staff.   Qual Saf Health Care. Dec 2006; 15(Suppl 1): i66–i71.

Culture is created by people and, in turn, their behaviour is moulded by the culture they work in. Solutions that work around a problem, such as keeping prescription medications in an unlocked drawer because it is too time consuming to adopt the ‘correct’ behaviours, are likely to be commonplace in all our workplaces. Once these ‘work-arounds’ are discovered it is important we pay attention to why this is happening as well as prevent unsafe practices from becoming embedded. In my example the staff did not deliberately break the rules due to due to any malicious intent, it was so they could see patients in a more timely manner. Wanting to do what is best for the patients is clearly a good thing and something we should encourage. Consequently, as leaders we need to ask what can we do to ensure that ‘work-arounds’ are not necessary.

Pills in pockets and keys on shelves are not something usually measured or reported.  What else is going on unrecognised or unchallenged that is unsafe? Can safety be measured in a metric like time-based quality indicators?  When safety fails, the results of non-safety can be measured (e.g. clinical incidents), but the root cause is a narrative personal to that department and hospital’s systems and culture.
By Dr Sally-Anne Wilson
From my personal experiences of working in and with the National Health Service the majority of Acute Trusts in England have an organisational management structure that is based on clinical units which are combined to make bigger clinical divisions.
Consider a 50-year old lady that presents to the Emergency Department (ED) with abdominal pain. After assessment by the Emergency Physician she was referred appropriately to the General Surgeons. The patient was transferred to the surgical ward. After assessment by a member of the surgical team a CT scan of the abdomen and pelvis is requested. The next day the CT is performed which identifies an ovarian swelling. The surgeon then refers to the Gynaecologist for further investigation which leads ultimately to an operation. In this not uncommon clinical scenario the patient moves between different departments and clinical divisions. The ED is part of the Division of Medicine, the General Surgery Department is part of the Division of Surgery, Radiology sits within the Diagnostics Division and Gynaecology part of the Women’s and Children’s Health Division.  The patient is blissfully unaware of these transitions across divisions, but they dictate the timeliness of her care.


Each department functions as an independent unit or silo. The staff working in each silo do a great job, but they only focus on their piece of the patient-based jigsaw. Their managers also work within the same silos. Everyone is working to the beat of their own series of targets and clinical indicators. No-one has ownership of the overall patient journey and nobody is driving the process forward thereby ensuring the patient’s transition between departments is smooth and timely. In reality the interfaces between silos are as real as brick walls. To inadvertently cross them can often be slow and sometimes even dangerous. Rarely are patients able to flow through the system, because the system is not designed to flow. Instead patients are moved along their journey by one department having to use a lot of effort as they metaphorically and physically push the patient into the next silo. In this ‘vertical’ divisional structure, power comes from the top, work becomes fragmented and it is easy for communication to be lost.
Due to the fact that the system relies on ‘Push’ rather than ‘Pull’ it causes friction between the various silos. This friction causes bad feeling, resentment and suspicion. Similarly budgets are also bound to these silos and this results in arguments about who is paying for a particular component of care. Sadly we often forget that there is a patient trapped in the middle of it.

This fragmented silo system causes us to try and manage an interdependent system as if it were compiled of independent entities. The irony of the word ‘Divisions’ should not be overlooked.
So I ask myself does it have to be like this? Is there an alternative
This may be an Utopian dream, but could we move away from rigid ‘vertical’ divisions towards a more ‘horizontal’ organisational structure which mimics the patient journey? Instead on having to force patients through metaphorical brick walls, we could have a system that has people and processes aligned to deliver the right care, on time, every time.
Vertical organisations are built upon the concept of hierarchical authority, where power and authority belongs to few and the majority of employees are subservient. Vertical organisations have steep authority gradients, and reducing levels of autonomy the further from the top you go. The vertical system encourages fragmentation, creating multiple silos that only have a narrow focus on their particular section of the care pathway, often at the expense of other silos.
In a horizontal system all hospital departments are integrated into the process so that they are aligned to deliver a common goal: safe, efficient and effective patient care from start to finish of the patient journey. The whole system is designed to be able to meet the patient’s needs and has the capacity to meet demand. Instead of a divisional management structure that runs a silo, the management structure in a horizontal organisation has managers that own the process from start to finish. So a manager has the responsibility, and is accountable, for ensuring all of the patients care is delivered to the right specification and in the correct timeframe.
Horizontal organisations have a much shallower authority gradient. This eliminates the hierarchical nature of vertical organisation promoting collaboration between departments (rather than fragmentation) with the common goal of more effective and more efficient patient care. So if the hospital management system adopted a more ‘horizontal’ approach so that managers were not responsible for a silo, but instead responsible for the entire patient journey it might knock down some of the invisible walls thereby reducing the inertia that exists within our hospitals. Management would move away from being primarily administrative and become more focussed on operational matters.
Horizontal systems are based upon a different hierarchy to vertical systems. Instead of the silo-based hierarchy of a vertical system, the horizontal system’s hierarchy is solely focussed on meeting the needs of our patients. This is dependent upon efficient connections between the patients (our customers) and those supplying the service (our departments, organisations, etc), with the needs of the patient being paramount. The patient is the ‘external’ customer, and the hospital service the patient requires is the supplier.
In addition, a hospital department such as the ED is an ‘internal’ customer of the organisation as it requires the other departments (suppliers) to deliver care to its patients. For example, the ED is dependent upon radiology and laboratory services to meet the needs of the patient. Likewise if the patient requires admission to the Surgical Admissions they also become a supplier to the ED.
The priority for the clinical staff in each clinical area is to focus on the patients trying to access their service and the patients currently under their care. As there is currently a struggle for patients to move on to the next department the clinical staff have to continue to look after patients long after their component of the patient’s care is complete. Consequently there has to be a clear and unambiguous signal that when one department’s work is complete and the patient requires the next part of their service. It is then the responsibility of that next department to ensure there is adequate capacity to take over responsibility for that patient seamlessly and commence their component of care immediately.
This paradigm shift in the way we consider delivering healthcare is vital if we are going to see a change in hospital performance. Patients do want to wait for services, consequently the whole organisation needs to be aligned so that there is no delay in moving between departments. Services need to be designed so that they can meet capacity and are able to meet variations in demand.
Due to their different skills there will always be some degree of ‘silo-ism’ amongst clinicians. Indeed this is a good way of concentrating expertise, but currently hospital managers tend to work in the same clinical silos as clinicians which further enhances this ‘tribalism.’ Consequently improvement initiatives are based to improve the performance of one department which tends to have limited impact on the overall patient journey.
What is necessary to make this happen?
Hierarchies, budgets, metrics and job plans must all be rotated through ninety degrees as part of a scientific organisational re-design. Horizontal reorganisation is not just necessary for the clinical areas, to achieve this there has to be change across an organisation as a whole. The factors within an organisation that confer power and legitimacy must be aligned to deliver on the whole patient journey, rather than each department focusing on delivering its own requirements. To ensure that the system is able to meet the needs our patients all executive board and managerial activity needs to be aligned to help the clinical teams deliver the care the patients need. Due to the fundamental nature of change, it is somewhat ironic that converting a vertical organisation into a horizontal one can only be undertaken through a top down approach initiated from within an organisation; but it needs to be done.
By Dr Paul Jarvis
Leading a multidisciplinary healthcare team is both a privilege and a challenge. The first thing I noticed on taking up my position was the greater degree of responsibility that was placed upon me, but more importantly I realised how little I had been prepared for the task. Healthcare leadership is still dominated by doctors and I can not help feeling this is an historic remnant of ‘Doctor knows best.’ There seems to be a false belief in healthcare that because you are able to treat patients you are automatically capable of leading a team. However, it is obvious they are two entirely different roles requiring two very different skill sets.

There is no magic formula for leadership; trying to copy someone else is likely to result in a lack of authenticity and leadership gestures that may seem a little clumsy. Leading a team is a dynamic and highly personal process and there are a wide variety of possible styles that you could employ. The best leaders, those who achieve the best results, will often be learning equal amounts about their own skills and behaviours as they do about those of their team. As with any skill, everyone has their own innate level of ability to lead people successfully and I believe the skill of leadership is having the self-awareness to know the limit of your abilities and the strengths of others. Below are some tips I have learnt through my experience of leading a healthcare team.
Accept that everybody is different
This is possibly the most important tip. Whilst all healthcare professionals generally share some common motivations, desires and attributes, you will get the best out of people if you treat them as individuals. Techniques that work with one individual may not work with another, or another group, so take time to get to know your team well. You may identify an individual’s personality type which may improve your working relationship with them.
Walk the walk
Good leadership techniques are borne out of mutual respect and appreciation between all parties, so all leaders should begin by setting a standard that he or she would expect from others. Colleagues will quickly lose respect for someone who does not demonstrate a commitment to undertake tasks they expect others to do. If you want people to work long hours and take pride in their work, then you should demonstrate that you have these capabilities too. Being a leader does not mean sending edicts down from on high, but rolling your sleeves up and sharing the work.
Invest in relationships
It sounds obvious, but good leadership is not merely about making successful demands on your team. There are a few tried and tested ways of ensuring that your team performs well. Arguably, the best way of achieving this is to invest in each personal relationship; going out of your way to do things purely for the benefit of the team and its individuals. If you do not manage to do this, there is a danger that your team will associate you solely with requests for work, and this may create a negative psychology in the very people that you are trying to lead.
Choose your words carefully – They matter!
Your evaluation and feedback of the work produced by one of your team is one of the key areas by which you can either greatly increase loyalty, performance and respect, or greatly diminish it. Human beings hate to be criticised, and will generally go on the defensive when placed in this position, so choose your words carefully if you want to enthuse rather than deflate.
Be a helping hand
Successful leaders have the ability to be able to display empathy for a colleague’s challenges, and in many cases are in a position to offer help and support. This is an essential part of leadership as people generally respond well to professional relationships where the other party seems to be doing things with them. Most employees will gladly undertake tasks if they feel they are being helped and supported.
Have clear channels of communication
Good communication is vital to good leadership and it is essential that you establish a line of regular communication that suits both you and your team. Communication is bi-directional, your team need to hear from you, but you have to listen to them. If your team only ever hear your voice but you never get them to tell you their feelings and observations you will struggle. Ideally, once a week you should aim to set aside some dedicated time for communicating news to your team, and allow them to update you on their projects. Sessions like this really encourage team spirit, a feeling of togetherness and can be a highly effective way of identifying challenges and celebrating successes as a team.
It is the result that matters
Avoid being domineering. Insisting that things have to be done exclusively your way often leads to your team withdrawing from you. Just because you think it is a good idea does not necessarily mean that it is the best idea; listen to your team. The people who are closest to the patients often have the best ideas on how to improve the care they deliver. Being a steward who creates the environment within which your team can grow and improve is likely to deliver greater results than a dictatorship. Encouraging your team, rather than giving orders, is more likely to foster engagement.
In summary, leadership is about people not power. The best leaders spend time talking and listening, rather than simply telling others how to act. It is often said that leadership is a lonely path to tread; this is not true, you are surrounded by your team - spend time with them, chances are they are brilliant.

by Dr Paul Jarvis