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             \author[1]{Mark J.  Bonica}

             \author[2]{Christopher  Mayhugh}

             \author[3]{Mark D.  Mellott}

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\date{\small \em Received: 15 December 2019 Accepted: 4 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


This article examines the career narratives of healthcare executives to develop a model of executive leadership competencies. Interviews with thirty executives drawn from a health leadership podcast are examined for themes of leadership failures and surprises. Grounded theory is used to identify a pattern of weaknesses from the lived experiences the executives, then a positive model of leadership is developed from these lessons learned the hard way. The final model consists of three nested categories: organizational awareness, constructing the team, and self-regulation.

\end{abstract}


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\let\tabcellsep& 	 	 		 \par
Abstract-This article examines the career narratives of healthcare executives to develop a model of executive leadership competencies. Interviews with thirty executives drawn from a health leadership podcast are examined for themes of leadership failures and surprises. Grounded theory is used to identify a pattern of weaknesses from the lived experiences the executives, then a positive model of leadership is developed from these lessons learned the hard way. The final model consists of three nested categories: organizational awareness, constructing the team, and selfregulation.\par
I.\par
Purpose n this paper, we examine the stories of successful healthcare executives and the role that surprise and failure have played in shaping their leadership values and behaviors. Failure is an excellent teacher, because as Nietzche famously stated, "what does not kill me makes me stronger." \hyperref[b0]{1} Being a healthcare executive is not easy. We focus on failure because it reveals our weaknesses, and it is in these moments that lessons for later success are often learned. Moments of surprise, while not necessarily failures, also reveal to us when our mental model 2 of the world is not correct, and we need to reformulate how we understand and respond to stimulus. In this paper, we examine the self-reported failures and moments of surprise of healthcare executives, cluster them into three broad categories, and then take these moments of epiphany and invert them to suggest a positive model of executive leadership competencies.\par
The purpose of this study is to understand how senior healthcare executives learn from the unique and unexpected challenges associated with their roles as organizational leaders.\par
Using experiential learning theory \hyperref[b2]{3,}\hyperref[b3]{4} the study examines the lived experiences of senior healthcare executives as told through their own career narratives in a series of podcast interviews, and focuses on leadership lessons learned "the hard way"by making mistakes and dealing with the unexpected. 
\section[{II.}]{II.} 
\section[{Methods}]{Methods}\par
The data for our study is drawn from the podcast, the Health Leader Forge \hyperref[b4]{5} , a long form podcast that features in-depth interviews with individual healthcare leaders, exploring their careers and leadership philosophies. No institutional review board review was required for this study because the interviews are secondary data, and the participants understood their interviews would be made public.\par
At the time of writing, the Health Leader Forge had 63 published interviews. The participants in the interview series represent a purposive, heterogeneous sample.\par
Interview participants were selected to represent a wide range of executive roles in a wide range of healthcare delivery organizations.\par
The authors employed a grounded theory \hyperref[b5]{6,}\hyperref[b6]{7} approach to the data, to explore patterns in executive leadership in healthcare from the collected interviews. Grounded theory is inherently inductive -the researcher begins with an agnostic approach to the question and allows the data to speak. In this case, the question about a model of leadership was open-ended enough that it allowed a broad range of responses from the participants. A first pass using open coding focused on looking for leadership styles and approaches that might inform such a model, labeling themes as they manifested. In the second round of coding the researchers compared the open coding results, looking for interrater agreement. One question asked in many of the interviews, "Can you tell me about a leadership lesson you learned the hard way?" yielded interesting answers that stood out. The answers to the "hard way" question were isolated and a subsequent round of coding was then conducted jointly, refining the codes into common themes. As we worked, we realized there were also instances where the executives interviewed were caught by surprise by reactions to their behavior or were caught by surprise by the behavior of others. We went back through the interviews looking for lessons that came to the participants by surprise. We decided to incorporate these surprises into our sample, as the responses to these occasions were substantially similar to the answers to the "hard way" question. Ultimately, a total of 30 interviews included answers to the "hard way" question or included references to moments of surprise that were also opportunities for learning and reorientation for the executives. These answers were coded and collected into three categories discussed below. 
\section[{III.}]{III.} 
\section[{Results}]{Results}\par
After reviewing the 30 transcripts, three overarching themes emerged where leaders identified failures or surprises that caused them to have an epiphany related to their leadership. The three broad themes were: self-regulation, constructing the team, and organizational awareness. Individual respondents are identified by first name throughout the paper (see Appendix 1 for data about the participants and their organizations). 
\section[{a) Self-Regulation}]{a) Self-Regulation}\par
The first theme we identified was around selfregulation. The category emerged from comments that executives related about their one-on-one relations between themselves and individuals where they regretted not having maintained some element of selfcontrol. Within this category, three sub-categories emerged. We identified these three sub-categories as reversion, listening, and misuse of the power gradient. 
\section[{Self-Regulation -Reversion}]{Self-Regulation -Reversion}\par
The first relates to their desire to revert to an individual contributor and fix things themselves rather than working through their subordinates. As Mike, a critical access hospital CEO says (see Table  {\ref 1} below), executives are driven individuals and often get their first opportunities as managers are due to their high performance as an individual contributor. Nirav, speaking about his time as a state commissioner of health, found himself being chastised by his employees not to solve their problems for them. Rich, who came up through the ranks to be CFO of a large academic medical center, has had to resist the temptation to get over-focused on the job rather than enabling his team. The transition to supervisor from individual performer, and then from first level supervisor to manager and eventually to executive requires the abandonment of one identity and the taking on of another \hyperref[b10]{11} . Executives work through their subordinate leaders to solve problems. As Mike notes, this introduces opportunities for diverse approaches that the executive her/himself might not come up with, and that might be better than the executive could devise her/himself. However, when Ken, a physician by training, made the transition to leadership, he found himself sometimes having to dive down into areas that he did not necessarily know from when he was an individual contributor. In his quote, he talks about drilling down into financial information. Thus, there are times when it is appropriate for an executive to get involved the details of the organization, to take on the role of "mechanic" (as Rich says), even if the problem is not in their original individual contributor role. Nevertheless, the temptation to revert to individual performer and solve problems is ever-present, even when one reaches the executive level. Executives need to be on guard against reversion, while at the same time knowing when to dig into a problem. 
\section[{Table 1: Self-Regulation -Reversion}]{Table 1: Self-Regulation -Reversion}\par
Participant Quote 
\section[{Mike}]{Mike}\par
One of the challenges of being a leader at this level, because usually people who aspire and achieve this level are pretty confident people, and they're problem solvers to begin with and somewhat impatient. There's a degree of impatience there, and that's not a bad thing for an administrator, and a desire to do well and move forward quickly and just keep moving on. Solve the next problem, bring it on, bring it on.\par
Letting people make their own mistakes and learn from them is difficult, and that was one of the lessons I have to learn here? The advantage there is maybe they're gonna do it a little differently than I may of assumed, and it was the right way, and there is an opportunity in there. 
\section[{Nirav}]{Nirav}\par
Early on, I had an urgency to say, "Let's fix this," and I wanted to roll up my sleeves and fix it and learned right away that it wasn't my job to fix it. It was my job to support and to help, but it was someone else's job to fix it. That's fair and I learned about that very quickly. 
\section[{Rich}]{Rich}\par
I guess in some cases I am such a mechanic sometimes, and you mentioned I'm in the weeds. I know what you have to do. I've done it before. If I'm in a computer system, or whatever I'm doing, and I get locked and loaded on the job, and trying to get it done and maybe not the context of the job. You might underweight the politics or the collateral damage of the relationships if you're saying look, I can't let this fail. 
\section[{Ken}]{Ken}\par
There was one in particular where I trusted the areas where ... the financial numbers were coming together. In fact, what I really realized was that perhaps the numbers were a little soft. As I got into that particular, I did find that they were soft and not as reproducible as I would like to have them.\par
Listening came up with several executives as a lesson learned the hard way, and also comes up repeatedly as a critical behavior in interviews with other executives who did not mention it as a failing. As Mike noted (above), executives tend to be "somewhat impatient." Within the category of listening includes recognition of this impatience, or as Karen says, to "knee-jerk" (see Table \hyperref[tab_1]{2}). Instead, executives should take the time to gather perspectives, "rather than trying to direct their perspectives" (Greg T), and take the time to "get their ducks in a row" (Samantha). Knee-jerk responses are often wrong because they are made with incomplete information.\par
Several executives, when asked what advice they would give their younger selves if they were given the opportunity, said they would tell their younger selves to be better listeners. Dan focuses specifically on being more present, and not allowing his thoughts to wander. In a similar vein, it took Rich time and experience to realize that he had already moved on in a conversation and was not listening to what the person was saying. He had already solved the problem in his head, and so there was no more need to continue to listen to the subordinate. Instead, for Rich, it was time to give orders to execute. Yet the subordinate, who may not have the same abilities as Rich, or the same level of experience which would enable making the intuitive leaps Rich was making, was not there. this failure to listen ties back to the urge to revert to a problem solver rather than an enabler. To manage and motivate subordinates, these executives realized it was important to stay engaged even if the executives themselves could see the answer. As Jay, the CEO of a Community Mental Health Clinic, says, "My role is to, really again, help to create and foster an environment where they can be successful in their roles." To lead through your subordinates, you need to listen to them. If you are an executive, you have to have the patience to let them work through the problem without reverting to problem-solver mode yourself.  
\section[{Samantha}]{Samantha}\par
You have to sit back and take in information and learn and understand why things are being done. And not come in and say, "well you guys are doing this, that, and the other thing wrong" and make changes and fix it. Get the lay of the land first. Ask questions. Get people's input. Get people's assistance with the solution because you get better buy-in in the roll out. I've learned the hard way to take a step back, get more information, get all my ducks in a row, involve the right people and then move forward.\par
Greg T I should listen twice as much as I speak and she was right. I think I learned a lot by trying to listen to the folks that I worked with and understand their perspective, rather than trying to direct their perspective. 
\section[{Dan}]{Dan}\par
Failing to listen to people has been one of my 3. Self-Regulation -Misuse of the Power Gradient Hierarchical organizations create a power gradient based on positional authority. People higher in the power gradient have greater discretion in how they treat people below them. The third common mistake is failing to exert proper restraint in the use of their positional power or to abuse the power gradient. An executive is vested with positional power and the autonomy and discretion to use that power to advance the interests of her/his organization. Dave and Rob related stories where they recognized after the fact that they had misused their positional power. In Dave's case, the misuse was the result of a misguided but conscious decision. He recognized that he had power, and a choice set of ways that he could exercise that power. He chose to use a communication style that he was entitled to use, but he realized after the fact that his choice of style was an inappropriate match to the situation. Rob also exercised his power. Caught by surprise by a mock code blue drill, Rob publically upbraided a subordinate. Rob's misuse of his power was a failure of self-control. The situation was embarrassing, but he only compounded the situation through his reaction. Had he maintained his bearing, he could have turned an awkward situation into a teaching opportunity. Instead, he damaged his relationship with his subordinate and damaged his reputation.  
\section[{Global Journal of Management and Business Research}]{Global Journal of Management and Business Research} 
\section[{Self-Regulation -Listening}]{Self-Regulation -Listening}\par
While Dave and Rob's misuses of the power gradient were confined to specific situations, Pat admits to creating a persona of intimidation without being aware of it. He thought he was listening and engaging appropriately, but instead, his people feared him. He would have remained unaware of it except for his volunteering to participate in a 360 performance review. After he became aware of how his behavior was affecting his subordinates, he engaged an executive coach and worked with this team to improve his selfregulation in this area.\par
None of these executives were misusing their power and the power gradient for personal gain, or for the explicit purpose of intimidation, and when presented with the evidence, sought to improve themselves. As the recent \#MeToo 9 movement has shown, individuals with positional power in organizations can abuse their power by engaging in sexual harassment and predation, and other unethical or criminal acts. These findings suggest leaders should not only be aware of their own selfregulation but monitor and help other people in power positions to ensure organizations are managed in an ethical manner.  
\section[{Pat}]{Pat}\par
[results of a 360] I dug into the results, read the comments, and frankly I was devastated? I was aware that I was intimidating people, but not really understanding how that impacted them, the devastation that that could have, even by just a stare, even by just a stare. 
\section[{b) Constructing the Team}]{b) Constructing the Team}\par
The second general theme that emerged from the data was the importance of constructing the team. For this paper, we are focused on what the executive her/him self does. So for our purposes here, we limit the scope of constructing the team to the individuals with whom the executive is directly responsible for and surrounds her/himself. Constructing the team is a continuous process but involves two critical decisions on the part of the executive: who to hire and who to remove from the team or more succinctly, who to fire.\par
Senior executives, especially at the CEO level, are responsible for organizational hiring processes. In a large, mature organization, the CEO would delegate the authority to develop those processes to the human resources division. Thus, the CEO oversees the construction of the organization, and most other organization-wide priorities through her/his team. 
\section[{Constructing the Team -Hiring}]{Constructing the Team -Hiring}\par
As John F, CEO of a world-renowned specialty hospital, said, "The most important thing is hiring good folks" (see Table \hyperref[tab_4]{4}). The associated mistake several executives made was hiring the wrong people. Michael, Sheila, and other executives talk about going against their gut when hiring and coming to regret it. An executive might hire against their better judgment because the short-term cost of not having the position filled is high in terms of lost productivity, or because of the threat of losing funding for the position. While most of the executives interviewed expressed concern about organizational fit when hiring, Jill articulated it as a lesson learned the hard way. It is possible to have a fully competent and talented person who would be a mistake to bring on the team because her/his values do not match the organization's. Greg T stated, "you have to have the skill set to get in the room", and John F stated that, at his level, any serious candidate is going to be competent. As Jill notes, even if the individual is talented, the match of values is critical for team success.\par
Hiring the right people allows the executive to give her/his team autonomy. Kevin C talks about the autonomy he gives his senior management team because he knows they are the right fit. Jill's team is often distributed and out of sight, but she knows "even if they're out weird hours ... and you're not seeing them" you can "trust that they're absolutely doing the right thing". John P says because his organization has hired the right people, they can take an attitude of "Figure it out, get it done."  
\section[{Jill}]{Jill}\par
You can find really talented people that sometimes just don't fit. And as hard as you try to make them fit into the culture of your organization and buy into the vision, and you thought all of the pieces were there and they're not. Even though they're a talented contributor, because they're not buying into that vision or that philosophy or that culture, they're actually pulling the team down. 
\section[{Constructing the Team -Firing}]{Constructing the Team -Firing}\par
Once someone is on the team, it is up to the executive to coach and mentor the individual so that s/he can become a high performing member. Comments from Joni, John P, and Patsy show the obligation executives feel toward members of their team, even as the individual's performance is failing to meet expectations. Waiting too long to fire was one of the most common mistakes executives discussed. Most healthcare executives are successful because they want to help people -they want to help patients and they want to help the people who make up their organization. They want to give, as Patsy says, they want to "mentor and educate."\par
As Skip points out, there are limits to what you can do to change someone. Interviews indicate that executives believe fit is more difficult to change than particular skill sets. Most executives interviewed talked about hiring for fit first and then training specific skills. Joni said she looked for "shining eyes" -meaning you could see the individual's passion for caring in her/his eyes. "I can't teach passion", she added. However, as Joni herself found out, passion might not be the problem. The problem might simply be fit, either fit with the organizational values, or fit with a new CEO. After 25 years at a community hospital and working her way up to CNO, Joni related that she was fired by an incoming CEO. She was hired not long after to be an associate CNO of a large academic medical center. John F ultimately made the decision to let go some of his senior staff in order to get the team he needed, as mentioned above. He fired them because they were not a good fit with him, not because they were not competent: "[W]hen you get to the senior levels, there is a lot of how you fit with the rest of the team, or your skills fit into the organization at this point in time? There are plenty of people that have left here that are very skilled, good people, that they just weren't the type of person we needed for the next 5 years." Having the wrong people on the team can be poison for the organization, as Skip notes. 
\section[{Table 5: Constructing the Team -Firing}]{Table 5: Constructing the Team -Firing}\par
Participant Quote Joni but the failure of a leader to address someone's performance will never end well. Never end well. We have an obligation as leaders to either ? when I hire someone, I feel a commitment to their success, but in one case, I wanted this person to be successful, I believe, more than they did.\par
John P I thought I could get the person there through working and counseling and everything. One of the things that, certainly in our environment I learned from this, is if there's a gut feel about something, you're better off making that move sooner rather than later. Patsy I, as an individual, always want to give, I want to mentor and educate and help that whatever person it is that isn't working out, I want to help them along to get there. My lesson learned has been that there have been times and it's been more than once when I've left somebody in the position too long. 
\section[{Skip}]{Skip}\par
You can change people, but not much. You learn that over time too. You learn to make some pretty quick judgments and evaluations. You try not to judge people but you can certainly evaluate them. And when you see things that really aren't going right, the difficult pieces are always in staff management. You can't have one person out of synch or they can poison the whole system. 
\section[{c) Organizational Awareness}]{c) Organizational Awareness}\par
The third category that emerged from the data was organizational awareness. Whereas constructing the team had to do with the executive and her/his relationship with her/his immediate team, organizational awareness has to do with how the executive interacts with the larger organization beyond her/his team. Two principle subcategories emerged from the data: the executive's awareness and understanding of the organization's capacity to absorb change, and the executive's understanding of how her/his power interacts and distorts her/his communications. A third category also emerged that applies only to CEOs because it deals with the unique challenges of being in that role, specifically the dual challenge of not having peers to confide in within the organization, and having the burden of being the ultimate responsible individual. 
\section[{Organizational Awareness -Change Capacity}]{Organizational Awareness -Change Capacity}\par
Warren tells a story of his first CEO role when he was younger and had a high level of energy and wanted to push his organization to improve in every way. The problems of self-regulation that come from the personality types of highly successful executives appear here again. The executive wants to push the organization faster than it can move. If s/he exercises patience and listens, s/he might be able to discover where the slowdowns are and perhaps why they exist. The lesson Warren learned was there are many opportunities ("lemons"-see Table \hyperref[tab_5]{6}), but any organization has a limited capacity for change at any given time. A good leader needs to prioritize where s/he is going to put the organization's focus.\par
Steve tried to protect his employees from a change that was being imposed as the result of a corporate reorganization of two subsidiaries. While his motive was to protect his people, his perspective was ultimately myopic. The long-run result was the creation of multiple classes of employees and organizational conflict. The lesson learned is that sometimes change is inevitable and has to be absorbed and adjusted to, rather than resisted.\par
Jay and Greg W, both CEOs, wrestled with how to implement electronic health records in their clinics. Jay tried to overcome resistance by putting the most outspoken physician critic in the position of physician champion. Greg recognized that he had not put enough emphasis on engaging stakeholders. The lesson learned in both cases is an organization's capacity for change can be expanded if managed properly.\par
The common theme of this category is how executives handle change management matters. Some change is inevitable, some change is necessary, but effective executives are sensitive to where their organization stands with respect to a particular change, and use that awareness to work through their teams to lead change effectively.  
\section[{Jay}]{Jay}\par
We picked a physician champion who we thought would be the most difficult to accept the change, to be the representative, and I probably shouldn't have done just that... Because he's the one who left, I probably should have partnered that person with someone who I thought would truly embrace it, and done more directly, rather than counting on this person to be communicating back to the psychiatry team... 
\section[{Greg W}]{Greg W}\par
I don't think we adequately engaged the users of this system, and it has made for some ill feelings and some strife so I have to get out there. I own it. I have to acknowledge that this is not going well and ultimately it will be my decision as to whether we continue with this, but in terms of my own education, I need to do a better job of making sure I engage the stakeholders and engage them adequately. 
\section[{Global Journal of Management and Business Research}]{Global Journal of Management and Business Research}\par
Volume XX Issue XII Version I Year 2020 ( ) A 
\section[{Organizational Awareness -Communication}]{Organizational Awareness -Communication}\par
Senior leaders have to exercise caution when interacting with organizational members, especially those with whom the executive only has occasional contact. Organizational members know that the executive holds knowledge about the organization that they are not privy to, and they also know that the executive holds power to influence the structure and incentives within the organization. As a result, individuals look to executives for cues about the future of the organization, while simultaneously currying favor for their respective areas.\par
Gary and Joe were surprised by the impact of their words and even their body language after becoming CEOs. Gary found he had to modulate his sense of humor, otherwise his sarcasm would be treated as a literal command. Joe found that even a frown in public could create a rumor that the hospital was poised at the edge of ruin. As a senior leader, Jean found that her habit of working late led her employees to believe that was what she expected of them. Wanting to please her, they began working longer hours than necessary. It was only after a spouse explained the impact she was having on her soldiers that she realized how her actions were being perceived. Thus, an executive, and especially a senior leader like a CEO, has to be aware that s/he is "on all the time, 24/7", as Joe says.\par
Sam discovered that his choice to open a position to external candidates communicated a lack of confidence and trust in the employees working his organization who might have filled the role. He had not thought through what the implied message was and how it would be perceived. His lack of awareness about what he was communicating caused a rift of trust that took time and effort to repair.\par
Kevin D jokes that he suddenly became an excellent writer when he became CEO; no one would find fault with his memos. While humorous, the story reveals the danger of the power gradient and communication: no one wants to tell the emperor he is naked. A few badly worded memos will most likely not get anyone killed; bad policy in a hospital can lead to critical safety failures. Executives need to be aware that the power gradient can impede communication. [I] realized that I'm always on all the time, 24/7. I can't be walking down the skybridge and looking down, or be with my thoughts. I have to be smiling. People would say, "What's wrong? Something's going wrong in the hospital." Even when I'm out in the community, I'm always the CEO and that is just more than I expected. I knew I expected it, but I think the degree was much higher than I've anticipated. 
\section[{Sam}]{Sam}\par
I know it was the wrong thing to do at the time because it basically sent the message of there's nobody here good enough to take this job on and we've got a bunch of people covering the role right now as well, and none of them are good enough...And so I think that was damaging to my credibility at the time, but of course I was able to work through it and gain the trust back... it's like I said, everybody's watching. So that does send a message. 
\section[{Kevin D}]{Kevin D}\par
The other thing I joke about this sometimes too, is it used to be I would write a memo and send it out to my colleagues and say, "Hey, give me some edits on this." And I'd get all kinds of edits and now sometimes I send it out and say, "Hey give me some edits on this," and you get back, "Looks good.  
\section[{Organizational}]{Organizational}\par
Awareness-The Burden of Accountability One of the common questions asked in the podcast of CEOs is, "What surprised you about becoming a CEO?" Six of the eleven CEOs in the sample responded with some variation on the burden of accountability. All of them mentioned the weight of ultimate responsibility for the organization; most of them used some variation on "the buck stops here". kevin C and Gerry, two of the longest sitting CEOs, explicitly mentioned loneliness, as did Peter, a relatively new CEO. As Gerry notes, the CEO often must hold back information from people s/he would otherwise confide.\par
Kevin C and Kevin D talked about getting more comfortable with the burden with time, but that you never really get comfortable with it. Mike notes it is a burden that is "all mine." The burden arises from having no one to turn to; everyone turns to you to have the answers, especially when "when something goes wrong" as Kevin C said. Peter notes that he did not recognize the psychological safety having a good CEO as a boss provided until the backstop the CEO creates was removed. Jay and Kevin D report the odd sensation of realizing that everyone was looking to them suddenly, and that being able to simply disagree was a privilege no longer available to them.\par
The CEO has a unique role in the organization. We put the burden of accountability under organizational awareness because the CEO has to understand that the burden cannot be shared. Referring back to the communication element of this theme, it often cannot even be mentioned. The CEO must continue to show confidence even when, or especially when, something goes wrong. Otherwise, the other organizational members might come to believe the backstop is weakening or being removed. The CEO must be aware that the organization is looking to her/him to be the backstop, and the CEO has to accept and maintain that role.  
\section[{Peter}]{Peter}\par
The one thing that I'm always surprised about in this position is how lonely it is. It is a very lonely position. Unless you've done it, you can't really truly understand it. I thought, as a COO, that I knew exactly what it was going to be about and that I could do it. What I didn't realize is all of the confidence I had in the way I executed my job as COO was backed up by the safety of a good CEO, that he provided a safe environment for me, and so I felt confident. When the buck stops at your desk and you have 21 bosses who their objective is to do right by the community, and so the moment they cease to find value in you as their chief executive, you're gone. 
\section[{Kevin D}]{Kevin D}\par
I can remember being here very early, maybe my first week or so, sitting right in this office where you and I are sitting, and having to make a decision at this table with three other people. And often times decision aren't black and white and it was like okay, then they're all looking at you like well, what's the decision? And there's that comfort of being a Director or Vice President, or whatever where you feel like I can feel free to say, "Well I don't think that's going to work." But when the rubber meets the road, as CEO you've got to make those decisions. And that's really freeing, and it's really gratifying, and it's also really scary at times. I think you get more comfortable with that as you are used to being in the roles. I've been a CEO for about five and a half years now. And I'm more comfortable with it. That being said, I don't think you don't completely ever get comfortable with it. 
\section[{Jay}]{Jay}\par
The first thing is that sense that when you're not the CEO, you always have someone that you can kick it up to. Suddenly everybody's looking at you, like you're supposed to come with ready-made answers and know this. 
\section[{Mike}]{Mike}\par
What has surprised me most I guess is the sheer immensity of that responsibility when that buck stops here? I'm comfortable there, but what's surprising is the responsibility, the accountability is still mine. 
\section[{V. A Positive Model of Healthcare Executive Leadership Competencies}]{V. A Positive Model of Healthcare Executive Leadership Competencies}\par
From the three themes and various sub-themes that emerged from the data, we have developed a positive model of critical healthcare executive leadership competencies. Executives are expected to have a wide variety of competencies; these are leadership competencies only. The executives in our sample come from a wide array of organizations, backgrounds, and positions. We use their failures and surprises to identify the sources of challenge to senior leaders. By focusing on what is most challenging, we suggest the positive competencies executives should develop in order to be prepared for the threats to their success and the success of the organizations they lead \hyperref[b11]{12} .\par
Our model presumes a hierarchical organization, like a hospital. The individual who fills the role we have referred to as "the executive" is assumed to sit at the top of a unit hierarchy. This person could be the president or CEO of a hospital, for example, but does not have to be the CEO. The "executive" could refer to any leader in the organization above the level of front-line supervisor -that is, anyone who leads through at least one layer of management. Thus, the executive could also be a vice president, and the hierarchy s/he sits at the top of is part of a larger hierarchy with levels above her/him. The executive's team refers to her/his immediate and closest subordinates. For example, the CEO's team would consist of a CFO, COO, CNO, etc. These are individuals who report directly to the CEO and whom s/he has the most daily contact, and through whom s/he attempts to manage the organization. As with any large organization, such as a hospital, there is a large population of individuals who report in some fashion through a hierarchy to the executive through the executive's team. These individuals have varying degrees of social distance from the executive and align somewhere below the executive on the organizational power gradient. Self-regulation would still apply to a first-line supervisor, but the other elements would be diminished, as the "team" and the "organization" become one.  We have drawn this model as a series of nested, tangent circles. The circles are tangent rather than concentric because the tangency point represents where the executive touches the organization directly through her/his actions, without the intermediation of her/his team. The tangent point also symbolizes the fact that the executive, as well as his team, have direct contact with the external environment, in their roles, on behalf of the organization. The outer ring represents boundaries of the organization, and the core leadership competency for the executive is organizational awareness. The middle ring represents the boundaries of the executive's team. The core leadership competence here is the continual construction of the team. The innermost circle represents the executive her/himself, and the core competence is self-regulation.\par
1. Bear the Burden of Accountability: Executives must develop an ability to cope with a unique level of accountability and understand that this is not something that can be shared, particularly at the CEO level.\par
For the model, we start with the outer circle, and we start specifically with the role of the CEO. The role of the CEO, with respect to the organization, occurs at the tangent point because this is the point where the CEO's actions impact the organization directly. For this model, the tangent point can be thought of as the keystone in an arch. Arch technology was a powerful innovation employed by the Romans, for example, to great effect in their architecture, such as the aqueducts that still exist and function today. An arch can bear more weight than a lintel, and can be made with many small stones, rather than one massive stone. Thus, an arch is an excellent metaphor for a human organization. Many small stones, which separately are relatively useless, when brought together can bear a greater load than a single stone of the same weight. Nevertheless, an arch cannot bear weight until it has its keystone. The strength of the arch comes from the relationship between the individual parts, and the keystone's role is to complete the structure, locking the other stones into place so they can perform their roles. Like the keystone, the CEO performs a singular role. That role is to bear ultimate responsibility for the organization. The keystone doesn't share its role with the other stones. As Kevin C says, "When there's a singular level of accountability, there's a singular level of accountability and with that a unique loneliness to yourself."\par
The metaphoric role of the organizational keystone is true to a lesser degree for leaders subordinate to the CEO as well. Whereas the CEO's role is unique because s/he sits at the singular accountable spot for the entire organization, individual executives within the organization also hold accountable roles, and their respective teams and subordinates look to them to perform the keystone role. What is the keystone role? It is not to do all the work of the organization, or even to do the hardest work of the organization. Indeed, keystones do not bear the greatest load in an arch. The keystone role of the executive is to provide the confidence and final accountability that is necessary for all the other parts to continue to perform their respective roles. The first element of Organizational Awareness is for the executive to bear the burden of accountability. 
\section[{Communicational Awareness: Executives must}]{Communicational Awareness: Executives must}\par
understand the fact that they are constantly being observed and must take time to ensure their intent in their casual and formal communications is clear, while maintaining an environment of psychological safety for subordinates to question and provide feedback.\par
Organizational awareness focuses on the executive interacting with the organization as a whole. Communication with subordinates outside of the executive's team will be less intimate. The executive must be cognizant of how s/he is being observed by the organization, as well as being in tune with how her/his actions are being processed by the organization. With regard to being observed by the organization, executives need to develop an awareness that their every action is being observed and evaluated not only by their primary team, but by every subordinate in the executive's organization. When an executive interacts, either casually or formally, with subordinates who are not part of her/his immediate team, these subordinates will not have as nuanced knowledge of the executive's communication style, nor will they have the full context of executive decision making. A casual comment made by the executive can easily be misinterpreted as either a sign of impending doom, or a directive to make some radical change. As Joe, a CEO, noted, "Everything I said was amplified". Because of the power gradient, subordinates may take casual comments as directives, or sarcasm or jokes literally.\par
Subordinates outside of the executive's team will also seek to please the executive using the limited information provided by each encounter.\par
The executive also must bear in mind that subordinates will seek to please her/him, and as a result, subordinates will seek to avoid being the source of criticism directed at the executive. It is therefore critical that the executive create an environment of psychological safety where questioning is allowed, and feedback encouraged. Organizations are complex, and change will often have unpredictable second and third-order effects that may not be immediately evident to the executive or perhaps her/his team. Organizational change requires the creation of uncertainty and a requirement for the members of the affected segments of the organization to adjust to the change. Taking Lewin's model of organizational change \hyperref[b9]{10} , one must unfreeze the portion of the organization that is to be changed, invest in developing the new arrangements, and then invest in freezing, or making permanent, the new arrangements. The process of change is costly, requiring the sacrifice of previous investments by the members effected, and the making of new investments by the affected members as well as the leadership team. As we have learned, executives are impatient by nature and will perceive many things about her/his organization that could be improved. The executive must develop skill at gauging the cost of change and how much change at any given time the organization can absorb and process. Organizations have varying levels of resilience and may face both internally and externally driven change. The executive must recognize that the change process is costly, and the process of running simultaneous change may exceed the organization's capacity. One cannot squeeze all the lemons at once, as Warren told us, so the executive must be selective and prioritize.\par
e) The Middle Circle-The Team and its ongoing Construction When an executive has assembled a competent team that is aligned with the executive's vision for the organization, the executive amplifies her/his leadership through her/his subordinate leaders. The construction of the team is a somewhat fluid and continuous process. No member stays forever, members will come and go, and the needs of the organization will change. While there was some discussion of skill competence in the data, most responses focused on team fit. Over a career, executives come to recognize, viscerally, the importance of getting the right people on the team, and getting the wrong people off the team as a core competency. Some executives have pointed out that hiring the right subordinate leaders is, in fact, the most important thing they do. Furthermore, some executives are willing to hire a new member knowing that the new member would require training to come up to the technical performance levels required by the job, but the individual was hired because s/he demonstrated excellent potential and good fit with the team. The executive's overconfidence in her/his ability to mentor and coach proved in some cases to be detrimental in that it delayed the executive from removing the poorly performing individual from the team. An executive should be wary of overconfidence in this area; as Skip told us, you can change people, but not much.\par
In our model, the team performs an intermediating role between the executive and the organization. The executive, the innermost circle, sits within the team, like a yoke inside an egg. The executive is both part of the team and a separate entity. This is especially true with the special function of the CEO -the larger and more hierarchical the organization, the more important the intermediating function of the team. The executive's intent is carried out through her/his team. The better degree of fit between the team and the executive, the more they share a common understanding of the needs of the organization, the more accurately and effectively the team can act on behalf of the executive. Fit, as we learned, is critical. Poor fit results in poor intermediation of intent, and disco ordination within the larger organization as the intermediating subordinate moves her/his portion of the organization in a manner that is out of sync with the rest of the organization. Fixing the problems of coordination is costly for all members of the organization in terms of time and resources.\par
We treat hiring and firing as two sides of the same competency. Therefore there is a single competency:\par
Constructing the Team: Executives must hire for both competence and fit. They must learn to remove ineffective members of the team quickly and humanely.\par
f) The Innermost Circle-The Executive and Self-Regulation 1. Manage through Others: Executives must manage through others, and focus on creating the environment where subordinates can solve problems.\par
As we heard, executives are driven individuals and often get their first opportunities as managers due to their high performance as individual contributors. The transition to supervisor from individual performer, and then from first-level supervisor to manager and eventually to executive requires the abandonment of one identity and the taking on of another. As rewarding as it is to be a problem solver, Nirav and others warned us that this is not the role of the executive. Executives progressively need to be people who set up and support other people to solve problems. 
\section[{2.}]{2.}\par
Listening: Executives must be expert listeners, making the time to gather perspectives and integrate the input into their decision making.\par
Listening is both a behavior and a skill. Executives in the sample consistently speak of the importance of listening, of slowing down and taking stock, of ensuring they have the full picture. Given their predilection for action, this is a behavioral challenge most of them recognized. An effective executive leads by listening to her/his people. Listening involves not just slowing down, but processing and integrating the deeper knowledge subordinates (and peers, if not the CEO) are trying to share. Listening also provides an acknowledgment of the value of the listened to person or group.\par
3. Appropriately use the power gradient: Executives must master the appropriate use of their positional power to empower their subordinates and achieve the mission. The executives interviewed told stories of how they had inadvertently misused their positional power. Each of them remembered his mistake and made efforts to improve it. Positional power is a tool available to the executive. The executive uses it continuously, and it passively shapes all of her/his interactions within the organization even when s/he is not intentionally calling upon it. Active use of positional power should be drawn upon sparingly and only after careful listening.\par
IV. 
\section[{Weaknesses and Future Research}]{Weaknesses and Future Research}\par
This study has several weaknesses. First, the data was gathered in a public forum. The executives who were interviewed may have shared different stories of failure and surprise had they been given confidentiality. Furthermore, there are executives not included in the sample because they would not agree to participate in a podcast. The fact that most of these findings were repeated by multiple executives supports the likelihood of generalizability. Second, the relatively small number of participants yields an exploratory model that needs to be further verified. Third, the sample was diverse in terms of role and organization type but limited geographically. It may be that a more geographically diverse set of participants would have different insights. Finally, there is selection bias in the fact that these executives survived their failures and surprises. There may be good lessons to be learned from executives whose careers did not survive.\par
Future research should seek to validate the model using a larger sample from a more geographically diverse population. 
\section[{V. onclusion}]{V. onclusion}\par
Each of the executives who were interviewed for the podcast and were ultimately cited here are highly successful individuals. The fact that they were willing to share mistakes in a public forum should be regarded with admiration. Failure is a crucible we all inevitably pass through to some degree. The stories these executives shared served as crucible experiences for them, converting failures in the moment into competencies for future success. The Model of Executive Leadership Learned the Hard Way is a useful model for thinking about the leadership tasks of a senior leader, and for rising leaders seeking to enter the executive ranks.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}VolumeA}\end{figure}
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\noindent\textbf{} \par 
\begin{longtable}{P{0.85\textwidth}}
Learned the Hard Way: A Model of Executive Leadership\\
Competencies\\
I tell people, "If you're doing everything right, then you're not\\
learning." You learn by making mistakes... You have to learn\\
how to fall, and you have to learn how to get up. -Peter, CEO\end{longtable} \par
 
\caption{\label{tab_0}}\end{figure}
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\noindent\textbf{2} \par 
\begin{longtable}{P{0.09927007299270073\textwidth}P{0.7507299270072992\textwidth}}
Participant\tabcellsep Quote\\
Karen\tabcellsep Always get the full story before making a decision. Don't knee-jerk. That's something I've had to discipline myself.\end{longtable} \par
 
\caption{\label{tab_1}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{}
\end{longtable} \par
  {\small\itshape [Note: Boy, talk about a important life lesson. You know? Rob I lost it. I totally flipped out. I used a lot of profanity words because here again my adrenaline was pumping and I had no idea they were going to do a mock code blue drill within my department. What did I learn from that? One, keep your cool. Have some tact?]} 
\caption{\label{tab_3}Table 3 :}\end{figure}
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\noindent\textbf{4} \par 
\begin{longtable}{P{0.6568181818181817\textwidth}P{0.19318181818181818\textwidth}}
Participant\tabcellsep Quote\\
John F\tabcellsep \end{longtable} \par
 
\caption{\label{tab_4}Table 4 :}\end{figure}
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\noindent\textbf{6} \par 
\begin{longtable}{P{0.584375\textwidth}P{0.265625\textwidth}}
Participant\tabcellsep Quote\end{longtable} \par
  {\small\itshape [Note: Warren Don't squeeze every lemon at once, wait for them to get ripe. Not everything's a crisis and the real trick is what needs to be squeezed and what doesn't... You have to prioritize and you have to know when it's politically right to squeeze that lemon.SteveWhen you try to do what you think is the right thing in the form of protecting somebody from a change, the odds are pretty good it's going to bite you in the long run because you can't stop a change.]} 
\caption{\label{tab_5}Table 6 :}\end{figure}
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\noindent\textbf{7} \par 
\begin{longtable}{P{0.584375\textwidth}P{0.265625\textwidth}}
Participant\tabcellsep Quote\end{longtable} \par
  {\small\itshape [Note: GaryI had to be very, very careful, because I have a sarcastic sense of humor, and I may say something that I mean in a humorous way, I had to be very, very careful what I said out there because people were literally taking that to heart. You underestimate what the power of your words are, I think, in a leadership position like this. Joe I didn't realize how much things would change on what I said, what I did, my body language. Everything I said was amplified. Everything I did was projected, and I just didn't realize how much of that was taking place.]} 
\caption{\label{tab_6}Table 7 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{8} \par 
\begin{longtable}{P{0.584375\textwidth}P{0.265625\textwidth}}
Participant\tabcellsep Quote\end{longtable} \par
  {\small\itshape [Note: Kevin CYou bear the responsibility for those elements and when something goes wrong it's a very lonely time to recognize that truly the buck does stop with you. The thing that I learned a lot out of that is to be comfortable in that loneliness. To embrace it for what it is.GerryIt's lonely at the top. I never really understood what that meant, until I was a CEO... You don't have ... There's a lot of things I can't share with my management team. There are a lot of things I can't share with my board. It's difficult sometimes.]} 
\caption{\label{tab_8}Table 8 :}\end{figure}
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