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i

Operating Room Leadership

and Perioperative Practice
Management
ii
iii

Operating Room Leadership

and Perioperative Practice
Management
Second Edition
Edited by
Alan David Kaye MD, PhD
Louisiana State University Health Science Center, New Orleans, LA

Richard D. Urman MD, MBA

Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

Charles J. Fox, III MD

Louisiana State University Health Sciences Center, Shreveport, LA

Managing Editor:
Elyse M. Cornett, PhD
LSU Health Shreveport, Shreveport, LA, USA
iv

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education, learning, and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/​9781107197367
DOI: 10.1017/​9781108178402
© Cambridge University Press 2012, 2019
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2012 by Cambridge University Press
This edition published 2019
Printed in the United Kingdom by TJ International Ltd. Padstow Cornwall
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ISBN 978-​1-​107-​19736-​7 Hardback
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can make no warranties that the information contained herein is totally free from error, not
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v

I dedicate this book to my wife, Dr. Kim Kaye, my son, Aaron Joshua Kaye,
my daughter, Rachel Jane Kaye, and my many colleagues at LSU School of
Medicine and Tulane School of Medicine in New Orleans. I am honored
to be a part of your lives.
A. D. K.

I dedicate this book to my wife, Dr. Zina Matlyuk-​Urman, my parents,

and our daughters, Abigail Rose and Isabelle Grace; to my colleagues
among physicians, nurses, and administrators at Harvard who supported
my efforts in writing this book; and to my patients who I hope will be the
ultimate beneficiaries of this work.
R. D. U.

I dedicate this book to my wife, Mary Beth, for her selfless devotion to
our family, and to our kids, Chris, Mary Elise, Patrick, Julia, Claire, and
Margaret, who enrich our lives more than we ever imagined.
C. J. F.
vi
vii
Contents
List of Contributors page ix
Foreword 1 xiii
Foreword 2 xv
Preface to the Second Edition xvii
Section 1 — Leadership and Strategy
1 Leadership Principles 1
Christoph Egger and Alex Macario
2 The Path to a Successful Operating Room
Environment 17
Ross Musumeci, Alan David Kaye, Omar A.
Gafur, Charles J. Fox, and Richard D. Urman
3 Strategic Planning 26
Michael R. Williams
4 Decision Making: The Art and the Science
Michael R. Williams
5 Implications of Emotional Intelligence and
Collaboration for Operating Room Leadership
and Management 40
Markus M. Luedi, Jonas Schnider,
and Frank Stueber
6 Operating Room Culture Change 44
Shilpadevi Patil, Debbie Chandler,
Elyse M. Cornett, and Charles J. Fox
Section 2 — Economic Considerations,
Efficiency, and Design
7 Flow Disruptions in Surgery 51
David S. Silver and Douglas P. Slakey
8 Influence of Operating Room Staffing
and Scheduling on Operating Room
Productivity 56
Franklin Dexter and Richard H. Epstein
9 Operations Management and Financial
Performance 78
Seth Christian
10 Reengineering Operating Room
Function 88
Nigel N. Robertson
11 Operating Room Design and
Construction: Technical Considerations 107
Judith S. Dahle and Pat Patterson
12 Operating an Ambulatory Surgery Center
as a Successful Business 122
John J. Wellik
13 Influence of Patient-​and Procedure-​Specific
33 Factors on Operating Room Efficiency and
Decision Making 135
Markus M. Luedi, Thomas J. Sieber, and
Dietrich Doll
14 Operating Room Management in the
Perioperative Surgical Home and Other
Future Care Models 140
Juhan Paiste, John Schlitt,
and Thomas R. Vetter
15 Non-Operating Room Locations 147
John M. Trummel, Brenda A. Gentz, and
William R. Furman
16 Efficiency and Scheduling 156
Brian C. Spence and William R. Furman
17 Operating Room Budgets: An Overview 160
Steven Boggs and Sanjana Vig
Section 3 — Surgical and Anesthesia
Practice Management
18 Preoperative Evaluation and
Management 173
Alicia G. Kalamas
vii
viii

Contents

19 Identifying Bottleneck Constraints to Improve 31 Procedural Sedation: Clinical and Safety

the Preoperative Evaluation Process 185 Considerations 298
Mitchell H. Tsai, Elie Sarraf, Kyle R. Kirkham, Ann Bui and Richard D. Urman
and Terrence L. Trentman
32 Medical Informatics in the Perioperative
20 Anesthesia Practice Management 198 Period 309
Sonya Pease Ori Gottlieb and Keith J. Ruskin
21 Defining the Anesthesia Value 33 Simulation as a Tool to Improve Patient
Proposition 213 Safety 316
Jody Locke Valeriy Kozmenko, Lyubov Kozmenko,
Melvin Wyche III, and Alan David Kaye
22 Anesthesia Billing, Coding, and
Compliance 225 34 Education in Operating Room
Devona Slater Management 322
Sanjana Vig, Steven D. Boggs, Richard D. Urman,
23 Postanesthesia Care Unit Management:
and Mitchell H. Tsai
Building a Safe and Efficient Service 239
Henry Liu, Longqiu Yang, Michael Green, 35 Organizations Dedicated to and Current
and Alan David Kaye Overview of Enhanced Recovery After
Surgery 333
24 Pain Practice Management 248
Bret D. Alvis, Adam B. King, Matthew
Steven Waldman
D. McEvoy, and Jesse M. Ehrenfeld
25 Office-​Based Surgery Practice 255
36 Checklist Utility in the Perioperative
Jonathan P. Eskander, Cory Roberts,
Care Environment 341
and Charles J. Fox
Blas Catalani and Ezekiel B. Tayler
26 The Future of Perioperative Medicine 267
37 Anesthesiology Disaster Management and
Michael R. Hicks and Laurie Saletnik
Emergency Preparedness 348
Ezekiel B. Tayler, Blas Catalani, Jill Cooley,
and Chris Sharp
Section 4 — Nursing
38 Novel Technology for Patient
27 Operating Room Metrics 275
Engagement 356
Todd Brown
Matthew B. Novitch, Peter A. Gold, Aiden Feng,
28 Operating Room Staffing Guidelines 278 and Mark R. Jones
Todd Brown
29 Resource Management 284
Todd Brown
Index 365
Section 5 — Safety, Standards, and
Information Technology
30 The Joint Commission, CMS, and Other
Standards 289
Shermeen B. Vakharia and Zeev Kain

viii
ix
Contributors
Bret D. Alvis, MD
Nashville Veterans Affairs Medical Center, Nashville,
TN, USA
Steven D. Boggs, MD, MBA
The University of Tennessee College of Medicine,
Memphis, TN, USA
Todd Brown, RN, MBA
Director Alvarez & Marsal/Adjunct Professor
at IUPUI, Indianapolis, IN
Ann Bui, MD
Oakland Medical Center, Department of
Anesthesiology, 2nd Floor, 3600 Broadway
Oakland, CA, USA
Blas Catalani, MD, MPH
University of Tennessee Health Science Center,
Memphis, TN, USA
Debbie Chandler, MD
LSU Health Shreveport, Shreveport, LA, USA
Seth Christian, MD, MBA
Perioperative Management Fellow, Department
of Anesthesiology, Tulane University School of
Medicine, New Orleans, LA, USA
Jill Cooley, MD
University of Tennessee Health Sciences Center,
Department of Anesthesiology, Memphis, TN, USA
Elyse M. Cornett, PhD
LSU Health Shreveport, Shreveport, LA, USA
Judith S. Dahle, MS, MSG, RN
Senior Clinical Director – Perioperative Services,
OR Efficiencies Perioperative Consulting Team,
OR Efficiencies LLC, Naples, FL
Franklin Dexter, MD, PhD
University of Iowa, Iowa City, IA, USA
Dietrich Doll, MD, PhD
St. Marienhospital Vechta, Vechta, Germany
Christoph Egger, MD, MBA, FACHE
Klinik Beau-​Site, Bern, Switzerland
Jesse M. Ehrenfeld, MD, MPH
Vanderbilt University Medical Center, Nashville,
TN, USA
Richard H. Epstein, MD, CPHIMS
University of Miami, Coral Gables, FL, USA
Jonathan P. Eskander, MD, MBA
Department of Anesthesiology, LSU Health
Shreveport, Shreveport, LA, USA
Charles J. Fox, MD
Louisiana State University Health Sciences Center,
Shreveport, LA, USA
William R. Furman, MD, MMHC
Surveyer, The Joint Commission,
Oakbrook Terrace, IL, USA
Aiden Feng, MD, MBA
Brigham and Women’s Hospital, Boston, MA, USA
Omar A. Gafur, MD
Instructor of Anesthesiology, Boston University
School of Medicine
Brenda A. Gentz, MD
University of Arizona, Tucson, AZ, USA
Peter A. Gold, MD
Northwell Health Orthopedic Institute, Great Neck,
NY, USA
Ori Gottlieb, MD, FASA
Associate Professor of Anesthesia & Critical Care,
Department of Anestheisa & Critical Care,
University of Chicago, Chicago, IL
ix
x

Contributors

Michael Green, DO Alex Macario, MD, MBA

Drexel University College of Medicine, Stanford University School of Medicine,
Philadelphia, PA, USA Stanford, CA, USA
Michael R. Hicks, MD, MBA, MHCM, FACHE Matthew D. McEvoy, MD
University of North Texas Health Science Center, Nashville Veterans Affairs Medical Center,
Fort Worth, TX, USA Nashville, TN, USA
Mark R. Jones, MD Ross Musumeci, MD, MBA
Beth Israel Deaconess Medical Center, Boston, Anaesthesia Associates of MA, Assistant Professor
MA, USA of Anesthesia, Boston University School of Medicine,
Boston, MA, USA
Zeev Kain, MD, MBA
University of California School of Medicine, Matthew B. Novitch, BS
Irvine, CA, USA Medical College of Wisconsin, Wausau, WI, USA
Alicia G. Kalamas, MD Juhan Paiste, MD, MBA
Medical Director, Preoperative Clinic and Associate University of Alabama at Birmingham School of
Clinical Professor, Department of Anesthesia and Medicine, Birmingham, AL, USA
Perioperative Care, University of California, San
Francisco, CA, USA Shilpadevi Patil, MD
LSU Health Shreveport, Shreveport, LA, USA
Alan David Kaye, MD, PhD
Louisiana State University Health Science Center, Pat Patterson, BA
New Orleans, LA, USA Editor, OR Manager Newsletter, Rockville, MD, USA

Adam B. King, MD Sonya Pease, MD, MBA

Nashville Veterans Affairs Medical Center, Nashville, Chief Medical Officer, TeamHealth Anesthesia,
TN, USA Knoxville, TN, USA

Kyle R. Kirkham, MD, FRCPC Cory Roberts, BS

University of Toronto, ON, Canada
Lyubov Kozmenko, BSN
LSU School of Nursing Faculty, Acting Director
of the Simulation Center, LSU School of Medicine,
New Orleans, LA, USA
Medical Student, Tulane Schoool of Medicine,
New Orleans, LA
Nigel N. Robertson, MB, ChB, FANZCA
Staff Specialist Anesthesiologist, Auckland
City Hospital, Auckland, New Zealand

Valeriy Kozmenko, MD Keith J. Ruskin, MD

Department of Anesthesiology, LSU School
of Medicine, New Orleans, LA, USA
Henry Liu, MD
Drexel University College of Medicine,
Philadelphia, PA, USA
Professor of Anesthesiology and Neurosurgery,
Yale University School of Medicine,
New Haven, CT, USA
Laurie Saletnik, RN, DNP
Johns Hopkins Hospital, Baltimore, MD, USA

Jody Locke, MA Elie Sarraf, MD

Anesthesia Business Consultants, University of Vermont College of Medicine,
Jackson, MI, USA Burlington, VT, USA

Markus M. Luedi, MD, MBA John Schlitt, MD

Bern University Hospital Inselspital, Bern, Capitol Anesthesiology Association,
Switzerland Austin, TX, USA

x
xi

Contributors

Jonas Schnider, MD, MBA Mitchell H. Tsai, MD, MMM

Bern University Hospital Inselspital, Bern, University of Vermont College of Medicine,
Switzerland Burlington, VT, USA
Chris Sharp, MD Richard D. Urman, MD, MBA
University of Tennessee Health Sciences Center, Brigham and Women’s Hospital, Harvard Medical
Department of Anesthesiology, Tennessee TN School, Boston, MA, USA

Thomas J. Sieber, MD, MBA Shermeen B. Vakharia, MD, MBA

Kantonsspital Graubuenden, Chur, Switzerland University of California School of Medicine,
Irvine, CA, USA
David S. Silver, BS
Medical Student, Tulane School of Medicine, Thomas R. Vetter, MD, MPH
New Orleans, LA Dell Medical School at the University of Texas at
Austin, Austin, TX, USA
Douglas P. Slakey, MD, MPH
Regents Professor and Chairman of Surgery, Sanjana Vig, MD, MBA
Department of Surgery, Section of General Surgery, University of California, San Diego, CA, USA
Tulane Medical Center Surgery & GI Clinic, Steven Waldman, MD, JD
New Orleans, LA
Clinical Professor of Anesthesiology, University
Devona Slater, CHC, CMCP, CHA of Missouri at Kansas City School of Medicine,
ACE President & Sr. Compliance Auditor, Kansas City, MO, USA
Anesthesia & Pain Management Compliance John J. Wellik, CPA, MBA
Auditors, KS, USA Senior Vice President, Chief Administrative Officer,
Brian C. Spence, MD, MHCDS United Surgical Partners International, Inc.,
Addison, TX, USA
Dartmouth Geisel School of Medicine,
Lebanon, NH, USA Michael R. Williams, DO, MD, MBA
Chief Executive Officer, Hill Country Memorial,
Frank Stueber, MD
Fredericksburg, TX, USA; Executive Vice
Bern University Hospital Inselspital,
President, AnesthesiaCare, an EmCare Affiliate,
Bern, Switzerland
Dallas, TX, USA
Ezekiel B. Tayler, DO Melvin Wyche III, MD
Main Line HealthCare ICU Intensive Medicine,
Director of Simulation and Assistant Professor,
Philadelphia, PA, USA
Department of Anesthesia, LSU School of Medicine,
Terrence L. Trentman, MD New Orleans, LA, USA
Mayo Clinic, Phoenix, AZ, USA Longqiu Yang, MD
John M. Trummel, MD Huangshi Central Hospital, Huangshi Shi, Hubei
Province, China
Dartmouth Geisel School of Medicine,
Lebanon, NH, USA

xi
xii
xiii
Foreword 1
Evolution describes our past. Revolution defines
our future. Surgical services are in a period of revo-
lutionary change, and financial and operational effi-
ciency will remain important. However, it is no longer
sufficient to simply refine our current processes. We
must reengineer our models, designing toward our
future of bundled care, shared risk, and value-​based
payments to determine our success.
We must also look outside of our traditional tem-
poral and geographic boundaries. The days when a sur-
gical encounter is viewed as an event in isolation must
be put behind us. To maximize the value provided to
our patients, we will include preconditioning efforts
prior to surgery, and examine the longer-​term outcomes
and effects of our actions during the perioperative and
recovery periods. Through integrating multidiscip-
linary teams into the entire care process, we will draw
on the unique talents and knowledge of each group,
maximizing safety, efficacy, and patient satisfaction.
Expanding our geography will ensure that our
patients receive care in the most convenient and
cost-​effective location. Ambulatory, office-​based, and
nontraditional procedural locations such as radi-
ology and gastroenterology suites are experiencing
increasing demands for service. Applying the know-
ledge held by experts in OR suite management will be
critical for the success of these areas.
This textbook highlights processes, techniques, and
expert knowledge to prepare today’s and tomorrow’s
leaders for these challenges. Only through exemplary
leadership will we be able to realize the success which
is critical for our sustained vision of providing excel-
lence to the patients we serve.
Paul St. Jacques, MD
President, Association of Anesthesia Clinical
Directors (AACD)
Quality and Patient Safety Director,
Department of Anesthesiology,
Vanderbilt University Medical Center,
The Vanderbilt Clinic,
Nashville, TN
xiii
xiv
xv
Foreword 2
Healthcare delivery, surgery, anesthesia, and oper-
ating rooms (ORs) have all undergone astonishing
changes in the past decades. Coupled with scientific
advancement, all areas of medicine now recognize the
importance of providing cost-​effective care. For this
reason, it is somewhat surprising that a standardized
curriculum has not been developed for anesthesia
residents and anesthesiologists who are interested in
leading and managing operating suites. Individuals
wanting to assume leadership in these areas must have
specialized knowledge over unique areas of finance,
operations, management, legal issues, and electronic
records. This second edition of Operating Room
Leadership and Perioperative Practice Management by
Drs. Kaye, Fox, and Urman goes a long way in bridging
this gap. The standardization of an essential corpus of
knowledge that should be mastered for OR leadership
will be another step in this process. The International
Consortium on OR Management, Education and
Training (iCORMET) fully supports such steps and
commends the authors of this volume.
Steven D. Boggs, MD, MBA
President, iCORMET,
Steven Dale Boggs, MD, FASA, MBA
Professor and Chair
Department of Anesthesiology
The University of Tennessee College of Medicine
Memphis, TN
xv
xvi
xvi
Preface to the Second Edition
With the operating room (OR) and practice man-
agement science constantly evolving, we undertook
a laborious task of writing a second edition to this
already popular textbook. We changed the title of the
book to reflect the inclusion of topics related to peri-
operative practice management, adding topics that are
important for anesthesiologists, surgeons, nurses, and
administrators. Thus this new edition is now entitled
Operating Room Leadership and Perioperative Practice
Management. We hope that you find the additional
topics useful in your daily clinical practice or admin-
istrative activities, especially given the constantly
evolving regulatory and payer environments and
published research. We have significantly updated and
expanded each section of the book, with an emphasis
on areas such as leadership training, teamwork, and
OR culture change; perioperative surgical home; non-​
OR locations; efficiency, scheduling, and budgeting;
anesthesia practice management and post-​anesthesia
care unit. Three chapters speak exclusively about
nursing, education, and checklists.
We believe that our book currently represents the
only up-​to-​date, evidence-​based text that encompasses
the “A to Z” of OR management: metrics, scheduling,
human resource management, leadership principles,
economics, quality assurance, recovery, information
technology, ambulatory practice, and topics spe-
cific to surgeons, anesthesiologists, and pain service
providers.
Years ago, the OR stood alone, and little attention
was given to the perioperative period. This is because
until the 1980s the OR generated large profits, des-
pite its inefficiencies. Thus, hospital administrators
allowed it a great deal of autonomy. However, today’s
administrators realize that, although the OR is typic-
ally one of the biggest sources of revenue for a hos-
pital, it is also one of the largest areas of expense.
This, coupled with increasing requirements for cost
containment in healthcare and a demand for account-
ability to the federal and state governments, insurance
companies, hospital administrators, surgeons, and
patients, has magnified the need for an effective and
efficient perioperative process. While there was little
centralized leadership in the perioperative period of
the past, perioperative management is now a critical
feature of successful hospitals.
As mentioned above, today’s perioperative prac-
tice of medicine has evolved significantly and is now
influenced by a vast array of factors, both medical and
administrative. Because of this, knowledge of hospital
economics and administration, OR mechanics and
metrics, preoperative patient optimization strategies,
human resources, financial planning, governmental
policy and procedures, and clinical perioperative
management is necessary in order to succeed. A good
management team must bring together these diverse
components to maximize productivity. Today there
are more regulations, quality measures, and outcome
expectations, which push innovation and result in
additional burdens and challenges for hospitals. The
need for this expensive technology, to compete with
other hospitals, forces reform and new thoughts
for traditional ways of the past. Staffing ratios, pre-
operative visits, and postoperative care will be highly
scrutinized financially, while clinical and adminis-
trative “multitasking” is now expected. Putting an
emphasis on quality data definition and collection,
leadership style, simulation, and OR design will lead
to the creation of a more productive and efficient peri-
operative process.
We should not lose sight of the fact that the OR
is where miracles happen every single day through
teamwork, natural talent, hard work, and empathy.
From all of this, we create game-​changing and life-​
altering experiences for patients. Without effective
and efficient leadership from all areas –​nursing,
administration, surgery, and anesthesia services –​we
are doomed to fail. Let us also remember that all of us
will be patients one day, and so let us strive to make a
first-​class OR in the best interests of everyone.
xvii
xvi

Preface to the Second Edition

As we have observed from our real-​life experiences administration, surgery, anesthesia, or nursing services,
collectively accumulated over the past three decades, as we all do our best to move forward into the future.
the science of perioperative patient care is constantly
evolving. This speaks to the enormous complexities in all Alan D. Kaye, MD, PhD
aspects of management and development of a winning New Orleans, LA
OR. We applaud all the authors for their hard work and
dedication. Their chapters give a practical insight into Richard D. Urman, MD, MBA
creating a successful perioperative program. Boston, MA
We all face challenges in the OR environment. We
hope the ideas and practical solutions discussed in this Charles J. Fox III, MD
expanded second edition will benefit any stakeholder in Shreveport, LA

xviii
1
Section 1 Leadership and Strategy
Leadership Principles
Chapter
1 Christoph Egger and Alex Macario
Contents
Evolution of Leadership 1
Significance of Leadership for Healthcare
Organizations 4
Evolution of Leadership
What Is Leadership?
As individuals move up within an organization and
accept more responsibility, their interest in leader-
ship rises as they have more people reporting to them.
Leadership is about leading people, or the capacity
to lead, and specifically the behavior of an individual
when directing the activities of a group towards a
shared goal [1]. Akin to a conductor of an orchestra,
a leader has a capacity to direct and motivate multiple
professionals to perform to their peak ability while
minimizing uncoordinated activity.
In our own experience, leadership is about making
sure everyone in the organization (1) shares vision
and purpose, (2) is engaged in the future outcome of
the organization, and therefore (3) favors collabor-
ation over pursuing their own agenda. Among many
other responsibilities, leaders are role models for the
values of the organization, set the optimal course, and
establish priorities. Making people connect and col-
laborate, as well as finding the appropriate style and
amount of communication, are formidable challenges,
but central tasks for healthcare leaders.
Just because a person is in a leadership position
doesn’t make him or her a leader [2].
The goals of this chapter are to review what is known
from the published literature about leadership in gen-
eral and in the context of healthcare organizations to
illustrate the operating room (OR) suite as a challen-
ging workplace, where different parties must cooperate
or thwart each other, and to identify the challenges
inherent to an OR leadership position.
Downloaded from https://www.cambridge.org/core. La Trobe University, on 03 Dec 2018 at 05:06:52, subject to the Cambridge Core terms of use, available at
Challenges in OR Leadership 7
Game Theory in the OR Context 11
Conclusion 14
References 14
Predispositions for Leaders
Trait theory, which suggests that leadership abil-
ities depend on the personal qualities of the leader,
is controversial. However, some traits are related to
leadership emergence and effectiveness. Leadership
emergence refers to whether and to what degree an
individual is viewed as a leader by others within a
work group. On the other hand, leadership effective-
ness is a phenomenon affecting interactions between
groups, and refers to a leader’s performance in influ-
encing and guiding the activities of his or her unit
toward achievement of its goals.
Five dimensions can be used to describe the most
prominent aspects of personality: neuroticism, extra-
version, openness to experience, agreeableness, and
conscientiousness. This five-​ factor model of per-
sonality was also shown to be a reasonable basis for
examining dispositional predictors of leadership [3].
Extraversion and conscientiousness are the most
important traits of leaders, and these dimensions are
more strongly related to leadership emergence than to
leadership effectiveness.
The following traits are associated with successful
leaders [4]: humility, courage, integrity, vigilance
and passion, inspiration, sense of duty and dedica-
tion, compassion, discipline, generosity, dedication
to continuous learning, collaborative approach, and
competitiveness.
Appendix A has a checklist that may be a way for
leaders to self-​assess some of their own strengths and
weaknesses as leader. In addition, it could be used by
people working in a surgical suite to evaluate the OR
director.
1
2
Section 1: Leadership and Strategy
Leadership Styles
Multiple differing leadership styles have been described.
Some aspects of each leadership style definition overlap
with one another [5–​8] (Box 1.1).
The mix of the healthcare workforce and the com-
plexity of the medical workplace demand a team
approach to problem solving. This requires a leader
who is comfortable “sharing power” by empowering
Box 1.1. Leadership Styles
Authoritarian (coercive, commanding) leaders employ
coercive tactics to enforce rules and to manipulate
people and decision making.
• Derived from the Prussian military, the command-​
and-​control model is the primary management
strategy.
• Believe in a top-​down, line-​and-​staff
organizational chart with clear levels of authority
and reporting processes.
• Demand immediate compliance to orders and
accomplish tasks by bullying and sometimes
demeaning the followers.
• Used in situations where the company or group
requires a complete turnaround.
• May be effective during catastrophes or dealing
with underperforming employees, as a last resort.
Pacesetting leaders set high performance standards
for themselves and their followers and exemplify
the behaviors they are seeking from other group
members.
• Give little or no feedback on how the followers
are doing except to jump in to take over when the
followers lag.
• Work best when followers are self-​motivated and
highly skilled.
• May be effective to get quick results from a highly
motivated and competent team.
Transactional leaders balance and integrate the
organizational goals and expectations with the needs
of the people doing the work.
• Work through creating well-​defined structures,
clear goals, and distinct rewards for following
orders.
• Motivate workers by offering rewards for what the
leaders need to be done.
• Offer the appeal of employment and security in
return for collaboration and assistance.
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Authoritative (visionary) leaders mobilize people
toward a compelling vision.
• Most effective when a new vision is needed,
or when the path to that vision is not always
clear.
• Though the leader is considered an authority, this
type of leader allows followers to figure out the
best way to accomplish their goals.
• May be effective when changes require a new
vision, or when a clear direction is needed.
Coaching leaders are genuinely interested in helping
others succeed and hence develop people for the
future.
• Help employees identify both their strengths
and weaknesses, and provide feedback to their
subordinates on their performance.
• By delegating tasks they give employees
challenging assignments.
• May be effective to help employees improve their
performance or develop long-​term strengths.
Democratic (participative) leaders build consensus
through participation.
• Give members of the work group a vote or a say
in nearly every decision the team makes.
• A collaborative process brings a family
atmosphere to the workplace and creates respect
for the contributions made by each member.
• When used effectively, the democratic leader
builds flexibility and responsibility. This helps
identify new ways to do things with fresh ideas.
• The level of involvement required by this
approach (e.g., decision making) can be time
consuming.
• Appropriate for building buy-​in or consensus, or
for receiving input from valuable employees.
Affiliative leaders often are more sensitive to the value
of people than reaching goals.
• Pride themselves on their ability to keep
employees happy, and create a harmonious work
environment.
• Attempt to build strong emotional bonds
with those being led, with the hope that these
relationships will bring about a strong sense of
loyalty in their followers.
• May be appropriate to resolve tensions in a team
or to motivate people in difficult situations.
Authentic leaders use a deep self-​awareness to engage
followers, to shape organizational environments, and
3
eventually allow the organization to achieve persist-
ently high performance.
• Authenticity involves both owning one’s personal
experiences (values, preferences, thoughts,
emotions, and beliefs) and acting in accordance
with one’s true self.
• The ability of a leader to behave authentically as
a person (authenticity of the person) positively
affects his or her leadership efficacy (leadership
multiplier).
Transformational leaders care about human
understanding –​they transform and motivate
followers through their idealized influence (or
charisma) and role model, intellectual stimulation,
and individual consideration.
• Aim at creating an environment where every
person is empowered and motivated to fulfill his
or her highest needs.
• Each member becomes a part of a collective
identity and productive learning community of
the organization.
• See themselves as servants to others and guide
them in creating and embracing a vision for
the organization. This inspires and brings forth
top performance and creates a belief system
of integrity. Servant leadership demands that a
leader places company goals and values first, the
management team and employees second, and
the leader’s own welfare third. In this paradigm,
leaders exist to permit production and to
obliterate obstacles, not acquire power, glory,
wealth, or fame.
people and is able to make decisions with a balance
of idealism and pragmatism –​a leadership concept
described as “leading from behind” [9]. This type of
leader understands how to create an environment or
culture in which other people are willing and able to
lead. For example, the image of the shepherd behind
his herd is based on Nelson Mandela’s autobiography
Long Walk to Freedom and acknowledgment that lead-
ership is a collective activity in which different people
act at a different time.
This image of leadership is backed by the idea
of Theory Y people, as described in McGregor’s The
Human Side of Enterprise [10, 11]. According to
McGregor, people can be divided into the two groups,
Theory X and Theory Y. Theory X assumptions are:
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Chapter 1: Leadership Principles
• People are inherently lazy and will avoid work if
they can.
• Most people have little desire for responsibility
and prefer to be directed.
• People must be coerced, controlled, or threatened
with punishment to get them to perform.
On the other hand, Theory Y postulates that:
• Work is as natural as play and rest.
• People are ambitious, self-​motivated, and will
readily accept greater responsibility.
• People will use their creativity, ingenuity, and
imagination to solve problems.
In reality, a person’s beliefs will fall somewhere
between Theory X and Theory Y. Whereas Theory X
leaders enforce the rules of behavior and punish those
who violate the standards, Theory Y leaders function
as “coaches,” encouraging their team. They focus on
developing and facilitating the team through nurturing,
encouragement, support, and positive reinforcement.
Situational Leadership
Goleman suggests that successful leaders employ
multiple leadership styles and should be able to
move between leadership styles according to a spe-
cific situation (situational leadership) [6]. OR lead-
ership requires this adaptive style because of the
personalities encountered in a highly trained and
demanding workplace. For example, during a cardiac
resuscitation, an authoritarian or coercive leadership
style may be appropriate to make sure all Code team
members receive clear instructions. In contrast, an
affiliate style may be appropriate to resolve a conflict
between two surgeons disputing over a certain OR
time slot.
Goleman’s situational leadership model suggests
that although leaders may have a preferred style, they
must identify and select the appropriate mix of various
leadership behaviors in a given situation.
“Emotional intelligence” (EI) may be a better pre-
dictor and attribute of leadership effectiveness than
intellectual intelligence (IQ) or technical skills [12].
EI is a person’s ability to be aware of and being able
to manage and use emotions appropriately in dealing
with people under various situations (Box 1.2).
Experienced leaders with well-​developed EI compe-
tencies may be more effective and have more satisfied
and committed staff members, who better attend to
patient care needs.
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Section 1: Leadership and Strategy

with bundled prospective payment systems (PPS)

Box 1.2. Five Main Components of EI using case-​ based lump sums based on diagnoses-​
Self-​awareness Understand one’s own emotions, related groups (DRG), and capitation and other com-
strengths, weaknesses, needs, pensation systems that shift financial risk from the
drives, and their effect on others. payer to the service providers. For example, one of the
Self-​regulation The ability to control and manage major goals of the Patient Protection and Affordable
feelings and moods so they are Care Act (PPACA), a US federal statute signed into
appropriate. law in 2010, is to reduce healthcare costs. Specifically,
Motivation A passion to work for reasons that
structural changes in the healthcare system made by
goes beyond money and status;
the PPACA aim to shift the healthcare system from
persistence and confidence.
Empathy The ability to understand the emo- paying-​for-​quantity to paying-​for-​quality (value-​
tional makeup of other people; based care [VBC]).
sensitivity to others’ needs and Such profound transformation with reimburse­
emotions. ment, technological, policy, and procedural and struc-
Social skill Proficiency in managing rela­ tural changes intensifies the need for and challenges of
tionship and building strong col- healthcare leadership [14].
laborative networks; ability to There are unique leadership challenges inherent to
influence and lead people. healthcare [15]:
• Healthcare leaders face inconsistent or conflicting
dynamic demands from external stakeholders
(e.g., patients, regulatory, institutional and market
Difference between Management forces, and others).
and Leadership • As a “human” service rendered directly by
An often heard concept is that managers are people providers, healthcare is prone to natural
busy with operational tasks (command and control), variability.
whereas leaders engage in strategic endeavors (vision • Healthcare is a technology-​intensive sector with
and mission, change management). To quote Naylor, a high frequency of innovation. Such advances
most persons have worked “with leaders who were exacerbate tensions in balancing cost, quality, and
not particularly skilled at management, but who had access to healthcare services.
an ability to win loyalty and carry others with them • Healthcare leaders must interact with powerful
through their clarity of vision, generosity of spirit, and and dominating professionals (e.g., physicians)
‘people skills’. Ironically, then, leadership may be most who may not be employees of the organization.
obviously exerted when others follow a person who
has no direct authority over them, and may be less
important in strictly hierarchical organizations where
Leadership in the Healthcare Literature
managerial discipline prevails” [13]. In 2002, a review of 6,628 articles revealed that most
The differences between managers and leaders of the healthcare and business literature on leadership
then may simply be attributed to different leadership consisted of anecdotal or theoretical discussion [16].
styles (e.g., transactional and transformational) or Only a few articles include correlations of qualities or
different leader positions (top executive versus middle styles of leadership with measurable outcomes such
management). as positive changes in organizations. It is still unclear
what leadership attributes are important in improving
either patient care outcomes or team and organiza-
Significance of Leadership for tional outcomes.
Healthcare Organizations There are, however, some specific studies of
Governments around the globe are increasingly leadership in healthcare that are noteworthy [15].
searching for cost containment practices to counter Transformational leadership style is more likely to be
mounting healthcare expenditures. This has led to used by leaders in not-​for-​profit organizations than
declining reimbursement for physician and hospital by leaders in for-​profit organizations. In the hospital
services, the replacement of fee-​for-​service payments setting, transformational leadership style has been

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Chapter 1: Leadership Principles

shown to be positively and significantly associated Table 1.1 HLA Competency Directory
with staff satisfaction, extra effort from staff, perceived
Competency Competency cluster
unit performance, and staff retention. Some weak domain
evidence indicates that leadership matters more for
nonprofessionals (e.g., nursing assistants, clerks, sec- Communication • Relationship management
and relationship • Communication skills
retaries) than professionals. management • Facilitation and negotiation
Managers with higher ranks demonstrate more
transformational behavior than those lower in the Leadership • Leadership skills and behavior
• Organizational climate and
hierarchy. Of note, healthcare leaders may perceive the
culture
use of rewards as transformational leader behavior. • Communicating vision
In contrast, surveys of leaders in industries outside • Managing change
healthcare indicate the use of such reward systems as
Professionalism • Personal and professional
linked to a transactional leadership style. Physician accountability
executives with management degrees were more likely • Professional development and
to provide transformational leadership than those lifelong learning
without training [17]. Despite evidence that supports • Contributions to the community
transformational leadership theory for the healthcare and profession
setting, leadership style is but one important factor Knowledge of the • Healthcare systems and
in successful organizational change. Organizational healthcare organizations
environment • Healthcare personnel
structure and culture matter just as much. Participative
• The patient’s perspective
and person-​focused leadership styles are positively
• The community and the
associated with nursing staff ’s job satisfaction, reten- environment
tion, and organizational commitment.
Business skills and • General management
In the healthcare and hospital setting, leaders must knowledge • Financial management
take into account their followers’ expectations and • Human resource management
understand how and why professionals respond (or • Organizational dynamics and
not) to different leadership styles. governance
The Healthcare Leadership Alliance (HLA) • Strategic planning and
has developed the HLA Competency Directory as marketing
an instrument for healthcare executives to use in • Information management
assessing their expertise in critical areas of healthcare • Risk management
• Quality improvement
management [18]. Within the HLA Competency
Directory, the competencies are categorized into five
critical domains and, within each domain, 3–​4 clusters
healthcare and the critical need for further rigorous
of competencies (Table 1.1).
study of the issue [19].
Managers with advanced education may be more
effective in leadership roles. Junior nurse managers
value clinical and communications skills compared Physician Leadership
to senior managers who value negotiation skills and Hospitals with the greatest clinician participation
business knowledge more [15]. in management scored about 50 percent higher on
A systematic review of articles related to physician important drivers of performance than compared to
leadership and EI showed that many authors from a hospitals with low levels of clinical leadership [20].
broad range of medical specialties recommend culti- Doctors in physician-​led organizations seem to be
vating physician leadership, including EI training, at leading in the areas of quality, service, and cost [21].
an executive level in all medical institutions. Although Physicians have to have enough power and authority
evidence supports the association of EI with business to affect change –​to determine how quality is defined,
outcomes outside of healthcare, there is a paucity of what protocols will be developed, and how to hold
scientific research examining the benefits of EI in each other accountable for meeting objectives [22]. In
healthcare. A gap has been described between advo- the perioperative setting, strong physician leadership
cacy for EI as an essential training competency in is required for compliance with surgical checklists

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Section 1: Leadership and Strategy

and site marking to prevent wrong-​site surgery. On Table 1.2 Differences between Clinicians and Manager/​Leader
matters of clinical medicine and practice, physicians
Clinician Manager/​leader
listen to respected peers. A well-​trained and accepted
physician leader may better inspire, convince, and Clinical competence Interpersonal competence
influence their colleagues. It is critical for this person 1:1 interaction 1:N interaction
to serve as a change agent to manage and influence Doers Planners
clinical practice patterns and adherence to guidelines. Value autonomy Value collaboration
However, a common myth is that a physician
Reactive Proactive
successful in clinical practice can easily transfer to
Identification with profession Identification with company
leading an organization [23]. In fact, being a medical
expert does not guarantee being a good leader. It is chal- Patient advocate Organization advocate
lenging to hire physician leaders who will end up being Lay IT/​IS skills IT/​IS power user
successful as it is difficult to assess candidates for lead- Informal communication Formal communication
ership positions. Deegan et al. point out that “as a con- Leadership skills optional Leadership skills essential
sequence of the way … physicians have been selected,
Member of “brotherhood/​ Member of the “dark side”
educated, and socialized during their training many are sisterhood”
highly competitive, relatively independent practitioners.
Micromanaging a must Overmanaging a sure way to fail
They often eschew teamwork and collaboration and
Independent Adaptation to a boss
other affiliative behaviors” [24]. When assessing phys-
ician leader candidates, the use of a structured decision-​ Pursuit of self-​interest Trustworthiness
making process for assessment and selection should be
considered. Physicians aspiring to be leaders actively
reflect and internalize the results of feedback and link • A need to overcome an us-​versus-​them mentality
this information directly to a formal plan of study to between physicians and health administrators.
gain the competencies needed for their future leadership For newly appointed physician leaders, a robust
roles. Physicians in the midst of the transition between onboarding and specific leadership program is crit-
clinical and managerial/​ leadership positions start to ical. Onboarding may include coaching, which can be
realize the substantial differences between clinical and driven by another leader from within the organization
managerial/​leadership positions, and that the behaviors who has more leadership experience, or by an external
that serve them well in their clinical workspace (such as coach. In the past, healthcare has been slow to adopt
the OR) may be the exact opposite of what they need as systematic organizationally based leadership develop-
executive leaders in hospitals (Table 1.2). ment programs. Instead, responsibility for leadership
Various barriers exist for physicians to take leader­ development has often been left to individuals and the
ship roles [25]: profession.
• Identity linked to leadership roles may threaten
the physicians’ view of themselves as clinical Leadership Is Critical in the Management
professionals. of Perioperative Services
• Deep-​rooted skepticism about the value of The OR suite is a complex working environment, with
spending time on leadership. different groups of individuals involved in a coordinated
• Lack of career development or financial incentives. effort to perform highly skilled interventions. This is
• Lack of leadership and management training. analogous to high-​reliability organizations, such as avi-
• Risk of losing credibility with clinical colleagues ation, the military, and nuclear industries, where the
and others. importance of a wide variety of factors for development
• The greater risk of unemployment as a leader/​ of a favorable outcome has been long stressed [26].
manager than as a clinician. These include ergonomic factors such as the quality
• A loss of popularity due to making tough of interface design, team coordination and leadership,
decisions. organizational culture, and quality of decision making.
• The need to learn to being accountable to their The role of a leader and manager is central to
organization as opposed to their colleagues. forming high-​ performance interprofessional teams.

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7
Underlying key principles for successful team building
are a shared vision and mission. To align the goals of
employees and physicians, the leader must convey the
vision and strategies [27].
The following factors contribute to the growing
need for a dedicated professional as a perioperative
leader:
• Growing surgical caseload, exceeding regular
workday shift-​hours.
• Medical consumables included in case-​based
lump-​sum payment, which cannot be charged
separately to the payer.
• Multiple lines of authority causing a lack of
continuity and ownership for decisions.
• Large variety of professionals working in the
OR suite.
• Difficulties in recruiting and retaining healthcare
professionals.
• Increasing number of ORs and creation of
different OR suites within the same facility.
• Increasing number of nonsurgical interventions
outside the surgical suite with growing need for
hospital-​wide provider scheduling.
• Lack of physician involvement in OR leadership.
Challenges in OR Leadership
Organizational Structures of OR Leadership
Hospitals have always been in search of the optimal
OR leadership structure. The need for leadership
training was recognized more than 60 years ago.
For example, in the English literature of the 1950s,
a textbook contained descriptions of the ideal OR
governance structure and recommended that “the
administration of the surgical department shall be
under the direction of a competent registered nurse
who has executive ability and who is specially trained
in operating-​ room management” [28]. In 1983,
an article about OR management delineated eight
managerial measures to improve OR management
efficiency and effectiveness. One of these measures
was the identification of a clear line of authority
and appointment of an individual with far-​reaching
responsibilities, including policy making, running
the daily schedule, and managing staff stepping out
of line [29]. The article pointed out that this person
would not only have to be a senior physician with
institutional authority but also be formally recognized
as being in charge.
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Chapter 1: Leadership Principles
There is no perfect organizational structure. The
organizational structure of an OR suite must be indi-
vidually tailored to its internal and external needs.
Small organizations often feature a flat hierarchy and
do not require many formal organizational structures.
These organizations benefit from close relationships
between people. This allows for quick and informal
problem solving. An OR charge nurse or nursing dir-
ector as the sole formal leader may be sufficient in small
OR suites since ad hoc problem-​solving groups form
spontaneously and dissolve naturally.
Large organizations, on the other hand, with several
surgical subspecialties require a more complex organiza-
tional and leadership structure because coopera­tion and
coordination of tasks among depart­ments is challenging.
OR suites of large medical centers often feature several
complementary leadership structures (Box 1.3).
Outside of the United States, OR management is a
relatively young science, and knowing the leader­ship
literature is also a recent phenomenon. In Germany,
OR management first appeared in the scientific litera-
ture in 1999. The reason this topic produced interest
much later than it did in the United States may be
the introduction of the German DRG reimburse-
ment, a PPS for inpatient hospital services in 2003. In
the United States, PPS was introduced in the 1980s.
With the introduction of government-​ mandated
healthcare cost containment measures such as PPS,
hospital revenues declined and hospital and physician
executives aimed to find innovative ways to increase
OR efficiency (see Franklin Dexter’s chapter).
Lonely at the Top
Leaders are often alone with their thoughts because
they need to keep an emotional distance and avoid con-
flict of interests in their professional environment [33].
Leaders are able to develop relationships with people
based on respect, not on friendship [34]. In addition,
leaders are often surrounded by people with opposite
opinions on certain topics for valid reasons. Making
decisions that are unpopular with some stakeholders
and being attacked for those decisions may increase
isolation for the leader. Decision making in uncertainty
is a task that exacerbates the leader’s loneliness.
One of the interesting observations by leaders
is how streams of information suddenly dry up
when that person becomes the head of an organ-
ization or a group. People hesitate to speak freely
with a leader and so adopt a more formal tone while
7
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Section 1: Leadership and Strategy
Box 1.3. Leadership Positions and Structures for
the Surgical Suite
Physician OR leadership position (e.g., OR
medical director): May be a facilitator, mediator,
and negotiator position to balance the priorities of
each group in the OR (surgeons, anesthesiologists,
nurses, hospital administrators, etc.).
Alternatively, the OR medical director may be
positioned to be a distinct authority: A position
frequently recommended by the German OR
management literature (“OR manager”) [30, 31].
This may be explained by the fact that in Germany,
as in many other European countries, most
physicians are employed by the hospital. Where
there are many independent, powerful physicians
(especially surgeons), a tall or centralized organ-
ization with a top decision-​making leader may be
an ineffective leadership structure.
A standing OR committee with strategic and
oversight responsibilities (e.g., “OR oversight
committee,” “OR board”): This committee may
consist of the chairs of surgical services and/​or
departments, the chief of the anesthesia
department and nurse managers of the
perioperative area, and representatives of
the hospital administration. The role of this
committee is to provide fair and balanced OR
governance [32].
Additional smaller OR management teams may
be formed with operational responsibilities (e.g.,
OR executive committee): A typical formation
includes a senior surgeon and anesthesiologist
(who may be medical co-​directors of the OR
suite), the director of surgical services, and a
senior hospital executive.
Administrative executive physician: This
position may be labeled Chief Medical Officer
or Vice President of Medical Affairs, and refers
to a position often used as a third-​party
mediator to facilitate finding solutions between
two conflicting parties (e.g., between different
surgical departments or between the hospital
administration and anesthesia department).
communicating. The challenge for a leader then is
to find and develop other methods for figuring out
what is really going on. A leader in the surgical suite
needs to work hard to get people to share their views,
and must proactively develop positive relationships
so that colleagues feel comfortable and provide their
honest opinions.
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Culture and Informal Organization
Understanding the organizational culture of the OR
suite is key to successful and effective leadership. For
example, change management and implementing
patient safety initiatives are hard to accomplish
without understanding the values, assumptions,
preferences, unwritten rules, and behaviors of a cer-
tain workplace. If leaders are not conscious of the cul-
ture in which they are embedded, those cultures will
manage them [35]. The leader needs to perceive the
functional and dysfunctional elements of the existing
culture and to manage cultural evolution and change
in such a way that the group can thrive.
Organizational culture is the essence of the
informal organization [36].
In 1976, Hall developed the iceberg analogy of
culture [37]. If the culture of a society was an ice-
berg, some aspects of culture would be easy to see
and understand, above the surface. On the other
hand, below the water, there is a larger portion of cul-
ture hidden beneath the surface that is related to the
beliefs, existing relationships, and values of a society.
This underwater part of the iceberg culture is diffi-
cult for the new leader to understand and includes
elements such as the definition of sin, concept of
justice, work ethic, definition of insanity, approaches
to problem solving, fiscal expression, and approaches
to interpersonal relationships. Hall suggests that the
only way to learn the invisible bulk of the culture
below the surface is by actively participating in the
culture. Similarly, organizational culture comprises
the visible values and behaviors within an organiza-
tion, shaped by employee perks and benefits, policies
and procedures, and the company brand [38]. It often
turns out that the majority of what drives the behaviors
within the organization is unseen and inaccessible to
leaders unless they actively seek that information, far
below the surface. This culture includes the history
of the institution, the existing relationships among
people and departments, the incentive system and
the unintended consequences of the incentive system,
and relationships with various stakeholders. “The way
things get done around here” is a one working defin-
ition within the hidden part of organizational culture.
If leaders are unaware of these aspects of corporate
culture, they may feel frustrated at not being able to
get things accomplished.
In addition to the formal relationships depicted on
organizational charts, in every OR suite, there are also
9
information relationships. There may be an informal
network, coalitions of people, and even hierarchy. For
example, a powerful surgeon may be able to exert his
or her influence on the scheduling process and circum-
vent official scheduling rules. These informal affiliations
shape the organization’s culture, and they can either
facilitate or impede change. An important aspect of
perioperative leadership is understanding and accepting
these relationships, managing the informal chain of
command, and even leveraging these affiliations.
People Alignment and Change
Tensions between the different professional groups
working in the OR probably existed ever since the
first surgeries were performed. A nursing report from
Australia from the early twentieth century noted that
the “disaccord between nurses and physicians often
led to troubles in the OR because the physicians would
never announce the beginning of surgeries in a timely
fashion, but would then suddenly appear in the OR
where they would have to wait for the nurses to be
finished with their preparatory work” [39].
A core issue for leaders of the OR suite is that the
goals of the various professions are not well aligned
with those of the hospital and the OR suite. This
dilemma is known in economics as “principal–​agent
problem,” where difficulties arise under conditions
of incomplete and asymmetric information when a
principal hires and motivates an agent to act on behalf
of the principal [40]. Getting people to move in the
same direction is a crucial leadership activity. People
alignment involves communicating the organization’s
direction to those whose cooperation may be needed
to create coalitions that help people understand the
overall vision and stay committed to its achievement
[41]. One of various managerial mechanisms that
may be used to align the interests of the agent in
solidarity with those of the principal is performance
measurement. In the OR environment, well-​designed
reporting systems must define relevant performance
measures (key performance indicators). This feedback
is provided to those owning the critical processes and
should be gauged in relation to the OR suite’s goals
and its most important stakeholders. The OR environ-
ment with conflicting goals requires a strong leader-
ship to enforce hospital and OR suite strategies. In US
hospitals, the shift toward employment of physicians
continues to grow, becoming an important focus of
alignment.
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Chapter 1: Leadership Principles
Another core leadership activity involves
establishing the organization’s direction, i.e., pro-
ducing change and transformation. Reasons for
organizations to initiate change include barriers to
collaboration due to silos, insufficient innovation, and
unpreparedness to excel in the future. Change rarely
happens in a linear fashion. Instead, it more often is
a cyclical process. Kotter’s cyclical accelerator model
involves eight key components [42]:
1. Create and sustain a sense of urgency: Top leaders
describe an opportunity that will appeal to
individuals.
2. Build and maintain a guiding coalition of
effective, volunteer employees who role-​models
the change.
3. Formulate a strategic vision and develop
initiatives designed and executed fast and well
enough to make the vision reality.
4. Enlist a volunteer group of employees who buy in
to the envisioned goals and share a commitment
toward making the change.
5. Enable action and empowerment across
employees by removing barriers such as
inefficient processes or hierarchies.
6. Generate and communicate short-​term wins
to provide proof that the change created actual
results.
7. Sustain acceleration: Adapt quickly to shifting
business environments in order to maintain speed
and enhance competitiveness.
8. Institute change: Individuals must understand
the importance of agility and speed for the
organization’s success.
Various change initiatives in the perioperative
setting have been described following Kotter’s model
[43–​45].
How can a leader assess his or her individual
impact? Covey encouraged leaders to work within
their smaller circle of influence, wherein they will be
able to make a difference, as opposed to spending
time in their circle of concern, whereby they have
very little to contribute [46]. For example, our circle
of concern may include the broader issues of politics
and the reforming and uncertain future of healthcare,
such as PPACA. Covey recommended that the energy
of leaders be focused on their circle of influence, i.e.,
on the issues they have influence over, such as the
adoption of lean management system into day-​to-​day
hospital operations.
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Section 1: Leadership and Strategy
Effective leaders recognize two primary types of
change: from the outside-​in (structural) and from the
inside-​out (cultural/​behavioral). A focus on cultural
change is a core to sustaining structural change. It is
cultural change –​the change of the collective behavior
of individuals within the organization –​that will make
possible a structural change at the organization and
administrative levels. And it is changing people from
within which makes organizational change so diffi-
cult. For example, in a complex clinical environment
like a quaternary care hospital’s OR, the culture may
need to be fundamentally addressed before structural
changes, such as checklists and other patient safety
measures, can be successfully implemented [47].
However, it is hard for leaders to simultaneously
tackle all “soft” issues (such as culture and motivation)
that are necessary for transforming organizations.
Sirkin et al. have found that focusing on these
issues alone may not bring about change because
organizations also need to consider the hard factors
such as the time they take to complete a change ini-
tiative, the number of people required to execute it,
etc. [48]. There is a consistent correlation between the
outcomes of change programs (success versus failure)
and the following four variables:
D The duration of time until the change program
is completed; for change program, this refers
to the amount of time between reviews of
milestones.
I The project team’s performance integrity; that is,
the capabilities of project teams.
C The commitment of senior executives and staff
to change.
E The effort over and above the usual work that
the change initiative demands of employees.
The DICE framework comprises a set of simple
questions that help executives score their projects on
each of the four factors. Organizations can use DICE
assessments to force conversations about projects, to
gauge whether projects are on track or in trouble, and
to manage project portfolios.
Social Capital
Waisel described social capital as an overall indicator
of the quality of the relationships within a community
and applied it to the OR suite [49]. Increasing social
capital improves communication and trust that, in
turn, improves most cooperative undertakings. In the
OR suite, the social capital benefits of expectations of
10
Downloaded from https://www.cambridge.org/core. La Trobe University, on 03 Dec 2018 at 05:06:52, subject to the Cambridge Core terms of use, available at
trust, robust norms, and better communication help
to achieve community goals.
The norm should be that medical professionals
seek flawless behavior, particularly in regard to
interacting with others and respecting operational
guidelines. Other than in the case of small teams,
large groups of people are less likely to have developed
personal histories of successful interactions. In the
absence of a personal history of trust, the expect-
ation of trust from social capital permits individuals
who enter into negotiations to assume that they will
be treated in a fair, appropriate, and civil manner.
Functional operational guidelines help to develop
trust in the organization. Improved behavior and
successful interactions increase trust and commu-
nication, which, in turn, improves the OR working
environment and increases the success of cooperative
ventures, such as having more efficient ORs.
Importance of Building Trust on Survival
of Coalitions
Dialogue promotes understanding between parties in
conflict, and the resulting relationship promotes trust
between diverse entities [50]. This trust is based on
the fact that there is respect for one another’s opinion
and that team members are willing to listen and share
viewpoints openly. If and when leaders promote an
environment in which they are comfortable taking on
the challenging dialogues (i.e., productive conflict),
they can effectively lead change and build respect
in the perioperative setting. This leads to a stronger
team and better adherence to patient safety measures.
A common example is OR nurses speaking up prior to
a wrong-​site surgery.
The Impact of Leadership on Patient
Safety and Quality Initiatives
Many have stated that the magic ingredient to success
in patient safety is leadership [2]. Communication
and leadership failure are two of the most frequent
causes of adverse events [51]. Previous studies have
identified that teamwork, communication, and situ-
ation awareness are most important to work safely and
effectively in a surgical environment and for minim-
izing technical errors [52, 53].
How is a leader able to move the team to the next
level of safety culture? Before a change can be suc-
cessfully implemented, the leader must first assess
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 CAPITOLO XVI.
LA FINE.

Quando giunse il momento, per Ernesto e per me, di recarci a

Washington, il papà non volle accompagnarci: si era appassionato
alla vita proletaria. Egli considerava il nostro misero rione come un
vasto laboratorio sociologico, e sembrava travolto in una
interminabile orgia di ricerche. Fraternizzava con gli operai, ed era
ammesso con intimità in numerose famiglie; inoltre faceva dei lavori
in pelle, essendo il lavoro manuale, per lui, una distrazione e, nello
stesso tempo, oggetto di osservazioni scientifiche. Vi prendeva
gusto e rincasava con le tasche piene di appunti, sempre pronto a
raccontare qualche nuova avventura. Era il tipo perfetto dello
scienziato.
Non era obbligato a lavorare, perchè Ernesto guadagnava, con le
sue traduzioni, tanto da mantenere tutti e tre; ma papà si ostinava a
voler conquistare il suo tipo d’ideale preferito che, a giudicare dalla
varietà delle metamorfosi professionali, doveva essere Proteo.
Non dimenticherò mai la sera in cui ci portò il suo inventario di
merciaio ambulante, venditore di lacci e bretelle, nè il giorno in cui
entrai per comperare della roba nella drogheria d’angolo e fui servita
da lui. Dopo ciò, seppi, senza troppa sorpresa, che era stato per
tutta una settimana, garzone nel bar di fronte a noi. Fu,
successivamente, guardia notturna, rivenditore ambulante di patate,
incollatore di cartellini in un negozio d’imballaggio, facchino in una
fabbrica di scatole di cartone, portatore d’acqua in una squadra
impiegata nella costruzione di una linea tranviaria; e seppi pure che
si era fatto accogliere nel Sindacato dei lavoratori di vasellame, poco
tempo prima che questo fosse sciolto.
Credo che fosse affascinato dall’esempio del vescovo, o, perlomeno,
dall’abito di lavoro di quello, perchè usava anch’egli un camiciotto di
cotone di poco prezzo, e un vestito di tela con una stretta cintura sui
fianchi. Della sua vita antica, conservò solo l’abitudine di cambiarsi
l’abito pel pranzo, o, meglio, per la cena.
Io ero felice, in qualunque luogo, con Ernesto; e la felicità di mio
padre, in quelle condizioni, aumentava la mia.
— Da piccolo, — diceva, — ero molto curioso. Volevo sapere tutti i
perchè e i come. In questo modo, del resto, divenni uno scienziato.
Oggi, la vita mi sembra degna di osservazione, come nella mia
infanzia; e in fondo, è la nostra curiosità che la rende degna d’essere
vissuta.
Talvolta, si spingeva a nord di Market Street, nel quartiere dei negozi
e dei teatri, e là vendeva giornali, faceva commissioni, il portiere. Un
giorno, chiudendo lo sportello di una vettura, si trovò a faccia a
faccia con il signor Wickson. E con gran giubilo ci raccontò di
quell’incidente, la sera stessa.
— Wickson mi ha guardato attentamente, mentre chiudevo lo
sportello, e ha mormorato: — Oh! che il diavolo mi porti! — Proprio
così si è espresso: — Oh! il diavolo mi porti! Era arrossito, così
confuso, che ha dimenticato di darmi la mancia. Ma riacquistò il suo
spirito ben presto, giacchè, dopo pochi giri di ruota, la vettura ritornò
al punto di partenza, e Wickson si sporse dal finestrino e si rivolse a
me:
— Voi, professore, come mai? Oh! è troppo! Che cosa posso fare
per voi?
— Ho chiuso il vostro sportello, — risposi. — Secondo l’uso, potreste
darmi una piccola mancia.
— Non si tratta di questo, — borbottò. — Voglio dire fare qualche
cosa che vi possa giovare.
— Parlava seriamente; provava senza dubbio, un dolore lancinante,
nella sua coscienza indurita. Indugiai un po’ prima di rispondere:
quando apersi la bocca, egli mi ascoltò attentamente: ma avreste
dovuto vederlo quando ebbi finito.
— Ebbene, — dissi, — potreste forse rendermi la casa e le mie
azioni delle Filande della Sierra.
Papà s’interruppe.
— Che cosa rispose? — chiesi con impazienza.
— Nulla: che cosa poteva rispondere? Ma io ripresi la parola: —
Spero che siate felice. — Egli mi guardava con curiosità e sorpresa.
Insistetti: — Ditemi, siete felice? — Immediatamente, diede ordine al
cocchiere di partire, e lo udii che bestemmiava furiosamente. Quel
malnato non mi aveva dato la mancia e tanto meno restituito la mia
casa e i miei poderi. Vedi, dunque, cara, che la carriera di tuo padre,
come factotum di strada, è cosparsa di delusioni.
Per questo amore all’osservazione, papà rimase nel nostro
appartamento di Pell Street, mentre Ernesto ed io andavamo a
Washington. L’antico ordine delle cose era virtualmente morto, e il
colpo di grazia stava per giungere prima di quanto immaginassi.
Contrariamente alla nostra aspettativa, non fu fatto nessun
ostruzionismo per impedire ai socialisti eletti di prendere possesso
dei loro seggi al Congresso. Sembrava che tutto camminasse su
delle ruote, e io ridevo di Ernesto che vedeva perfino in questa
facilità come un sinistro presagio. Trovammo i nostri compagni
socialisti pieni di fiducia nelle loro forze, e pieni di disegni ottimisti.
Alcuni fittavoli eletti al Congresso avevano accresciuto la nostra
potenza; così che elaborammo con loro un programma
particolareggiato di ciò che v’era da fare. Ernesto partecipava
lealmente ed energicamente a questi lavori, quantunque non
potesse fare a meno di ripetere, ogni tanto, e apparentemente fuori
di proposito: «Quanto alla polvere, le combinazioni chimiche valgono
meglio dei miscugli meccanici, credetemi!».
Le cose cominciarono a guastarsi, per i fittavoli, negli Stati di cui si
erano impadroniti con le elezioni: non fu permesso ai nuovi eletti di
prendere possesso della loro carica. I predecessori si rifiutavano di
cedere loro il posto, e, col semplice pretesto di irregolarità elettorali
imbrogliarono le cose in un dedalo di procedura burocratica.
I fittavoli furono ridotti all’impotenza: i tribunali, loro ultima speme,
erano nelle mani dei nemici. Il momento era difficilissimo: tutto
sarebbe stato perduto se i contadini, così ingannati, avessero fatto
appello alla violenza. Noi socialisti impiegavamo tutte le nostre forze
per trattenerli.
Ernesto passò giorni e notti senza chiudere occhio. I grandi capi dei
fittavoli vedevano il pericolo e operavano in perfetto accordo con noi.
Ma tutto questo non servì a nulla: l’oligarchia voleva la violenza, e
mise in azione i suoi agenti provocatori, i quali, indiscutibilmente,
provocarono la rivolta dei contadini.
Questa scoppiò nei dodici Stati. I fittavoli espropriati si
impadronirono, a forza, dei loro Governi. Essendo questo modo di
procedere incostituzionale, gli Stati Uniti misero in moto l’esercito; gli
agenti del Tallone di Ferro eccitavano ovunque la popolazione,
travestiti da artigiani, fittavoli o contadini. A Sacramento, capitale
della California, i padroni erano riusciti a mantenere l’ordine, quando
un nuvolo di poliziotti segreti si rovesciò sulla città condannata. Dei
gruppi composti esclusivamente di spie incendiarono e
saccheggiarono diversi fabbricati e officine, e infiammarono le menti
del popolo a tal punto, che esso si unì con loro nel saccheggio. Per
alimentare questo incendio, fu distribuito l’alcool a flutti nei quartieri
poveri. Poi, quando tutto fu pronto, entrarono in iscena le truppe
degli Stati Uniti, che erano in realtà i soldati del Tallone di Ferro.
Undicimila uomini, donne e bambini, furono fucilati per le strade di
Sacramento, o assassinati nelle case. Il Governo nazionale prese il
posto del Governo di Stato, e tutto fu perduto per la California.
Anche altrove le cose andarono in modo analogo. Tutti gli Stati
dell’Unione delle Fattorie, furono domati con la violenza e affogati
nel sangue. Come sempre, dapprima il disordine era scatenato dagli
agenti segreti e dalle Centurie Nere, poi, immediatamente le truppe
regolari erano chiamate in soccorso. La sommossa e il terrore
regnavano in tutti i distretti.
Giorno e notte fumigavano gl’incendî delle fattorie e dei negozi, delle
città e dei villaggi. Si ricorse all’uso della dinamite: si fecero saltare
ponti, gallerie, deragliare i treni. I poveri fittavoli furono fucilati e
impiccati in massa. Le rappresaglie furono terribili: numerosi
plutocrati e ufficiali furono massacrati. I cuori erano assetati di
sangue e di vendetta. L’esercito regolare combatteva i possidenti
con l’accanimento che avrebbero usato contro i pellirosse, nè
mancavano le scuse per questo. Duemilaottocento soldati etano stati
annientati nell’Oregon da una spaventosa serie di esplosioni di
dinamite, e numerosi treni militari erano stati distrutti nello stesso
modo, così che i soldati difendevano la loro pelle, proprio come i
fittavoli.
Circa la milizia, la legge del 1903 venne applicata, e i lavoratori di
ogni Stato furono obbligati, pena la morte, a fucilare i loro compagni
degli altri Stati. Naturalmente le cose non andarono lisce in principio:
molti ufficiali furono uccisi, e molti cittadini condannati dal Consiglio
di guerra. La profezia di Ernesto si avverò con spaventosa
precisione, circa il signor M. Kowalt e il signor Asmunsen. Tutti e
due, dichiarati idonei per la milizia, furono arruolati in California per
la spedizione di repressione contro i fittavoli del Missuri. Tutti e due
rifiutarono di prestar servizio; ma non fu loro concesso neppure il
tempo di confessarsi: sottoposti a un Consiglio di guerra
improvvisato, furono subito bell’e spacciati. Morirono tutti e due con
la schiena rivolta al plotone di esecuzione.
Molti giovanotti, per non servire nella milizia, si rifugiarono sulle
montagne e diventarono disertori, ma vennero in seguito puniti, in
tempi migliori. Non avevano guadagnato nulla aspettando, perchè il
Governo fece un proclama invitante i cittadini abili ad abbandonare
le montagne entro il termine massimo di tre mesi. Alla scadenza del
termine, mezzo milione di soldati furono mandati ovunque nelle
regioni montuose; e non ci fu nè processo, nè giudizio: ogni uomo
che incontravano era ucciso sul posto. La truppa agiva secondo il
criterio che solo i proscritti erano restati in montagna. Qualche
gruppo, trincerato in forti posizioni, resistette valorosamente, ma alla
fine tutti i disertori dalla milizia furono sterminati.
Nello stesso tempo, nella mente del popolo era impressa una
lezione più immediata, col castigo inflitto alla milizia ribelle del
Kansas. Questa rivolta importantissima avvenne proprio al principio
delle operazioni militari contro i fittavoli. Seimila uomini della milizia
si sollevarono: da parecchie settimane erano turbolenti e
malcontenti, ed erano tenuti prigionieri per questo motivo. È fuori
dubbio, però, che la prima rivolta fu precipitata da agenti provocatori.
Nella notte del 22 aprile, gli uomini di truppa si ammutinarono ed
uccisero gli ufficiali, di cui solo pochi poterono sfuggire al massacro.
Questo oltrepassava il programma del Tallone di Ferro, i cui agenti
avevano lavorato sin troppo bene. Ma tutto era grano buono da
macinare per la plutocrazia, ormai preparata all’esplosione:
l’uccisione di tanti ufficiali avrebbe fornito una giustificazione per
quanto sarebbe accaduto dopo.
Come in sogno, quarantamila uomini dell’esercito regolare
circondarono l’accampamento, o, meglio, la trappola. Gl’infelici militi
si accorsero che le cartucce prese al deposito non erano del calibro
dei loro fucili, ed innalzarono la bandiera bianca per arrendersi, ma
fu vano: nessuno di essi sopravvisse. I seimila furono sterminati.
Dapprima bombardati da lungi con scariche di obici e di shrapnels,
furono poi falciati, a colpi di mitragliatrice, mentre si lanciavano
disperatamente contro le linee che li attorniavano. Ho parlato con un
testimonio oculare: egli mi ha detto che neppure un milite potè
avvicinarsi a meno di cinquanta metri da quella macchina micidiale.
Il suolo era cosparso di cadaveri. In una carica finale di cavalleria, i
feriti furono massacrati a colpi di sciabola e di rivoltella e schiacciati
sotto gli zoccoli dei cavalli.
Mentre avveniva la distruzione dei contadini, accadeva la rivolta dei
minatori, ultimo rantolo d’agonia del lavoro organizzato. Dichiararono
sciopero in centocinquantamila. Ma erano troppo sparsi in tanti
paesi, per poter avere vantaggio della loro forza numerica. Furono
isolati nei loro rispettivi distretti, battuti e obbligati a sottomettersi. Fu
la prima operazione di reclutamento di schiavi, in massa. Pocock vi
guadagnò i galloni di capociurma supremo, e nello stesso tempo un
odio inestinguibile da parte del proletariato [89]. La sua vita fu
soggetta a numerosi attentati; ma sembrava che possedesse un
talismano contro la morte. I minatori devono a lui l’introduzione di un
sistema di passaporto alla russa, che tolse loro la libertà di andare
da una parte all’altra del Paese.
Pure, i socialisti resistevano. Mentre i contadini spiravano fra le
fiamme e il sangue, mentre il sindacalismo era smantellato, noi
rimanevamo compatti e perfezionavamo le nostre organizzazioni
segrete. Inutilmente i fittavoli ci facevano rimostranze: noi
rispondevamo, e con ragione, che qualunque rivolta da parte nostra
sarebbe stata la fine di ogni rivoluzione, per sempre. Il Tallone di
Ferro, dapprima titubante circa il modo di agire con l’insieme del
proletariato, avrebbe trovato le cose più semplici e lisce che non si
aspettasse, e non avrebbe desiderato altro, per finirla una buona
volta, che una sollevazione da parte nostra. Ma noi sventammo
questo, a dispetto degli agenti provocatori che brulicavano nelle
nostre file, e usavano sistemi molto grossolani, in quei tempi, e
avevano molto da imparare. Costoro furono dai nostri gruppi di
combattimento soppiantati a poco a poco.
Fu un compito arduo e sanguinoso, ma lottavamo per la nostra vita e
per la Rivoluzione, ed eravamo obbligati a combattere il nemico colle
sue stesse armi. Però noi combattevamo con lealtà. Nessun agente
del Tallone di Ferro fu giustiziato senza processo. Può darsi che si
siano commessi errori, ma se vi furono, furono molto rari. I nostri
Gruppi di Combattimento erano formati dai migliori nostri compagni,
dai più arditi, dai più disposti al sacrificio di se stessi.
Un giorno, dopo dieci anni, Ernesto fece un calcolo: servendosi dei
dati forniti dai capi di questi Gruppi, calcolò che la durata media della
vita degli iscritti, uomini e donne, non oltrepassasse i cinque anni.
Tutti i Compagni dei Gruppi di Combattimento erano degli eroi; e il
più strano è che a tutti essi ripugnava attentare alla vita umana.
Quegli amanti della libertà, facevano violenza alla loro natura,
pensando che nessun sacrificio era troppo grande per una causa
così nobile. [90]
Lo scopo che ci eravamo imposti era triplo. Volevamo, per primo,
purgare le nostre file dagli agenti provocatori; in seguito, organizzare
i Gruppi di Combattimento all’infuori dell’organizzazione segreta e
generale della Rivoluzione; in ultimo, introdurre i nostri agenti scelti,
in tutti i rami dell’Oligarchia, nelle caste operaie, specialmente fra i
telegrafisti, segretari e commessi, nell’Esercito, fra le spie e i
guardiaciurme. Era un’opera lenta e pericolosa, e spesso i nostri
sforzi fallivamo.
Il Tallone di Ferro aveva trionfato nella guerra aperta: ma noi
stavamo all’erta, nell’altra guerra, sotterranea, sconcertante e
terribile che avevamo intrapresa. In questa lotta tutto era invisibile,
quasi tutto imprevisto: come una lotta fra ciechi, ma fatta con molto
ordine, secondo uno scopo e una direttiva. I nostri agenti
s’insinuavano fra gli ingranaggi di tutta l’organizzazione del Tallone
di Ferro mentre la nostra era permeata dagli agenti avversarî;
secondo una tattica tortuosa ed oscura, piena di intrighi e
cospirazioni, di mine e contromine. E dietro tutto questo, sempre
minacciosa, stava la morte, la morte violenta e terribile. Uomini e
donne sparivano, i nostri migliori, i nostri più cari compagni. Si
vedevano oggi, domani erano svaniti, e non si rivedevano mai più, e
sapevamo che erano morti.
Non c’erano più, in nessun luogo, nè sicurezza nè fiducia. L’uomo
che complottava con noi poteva essere un agente del Tallone di
Ferro. Ma era lo stesso dalle due parti; eppure eravamo costretti a
lavorare con fiducia e certezza. Fummo spesso traditi; la natura
umana è debole. Il Tallone di Ferro poteva dare denaro e
divertimenti nelle sue meravigliose città di piacere e di riposo; noi
non avevamo altre attrattive che la soddisfazione di essere fedeli a
un nobile ideale; e questa lealtà non aspettava altra ricompensa che
il continuo pericolo, la tortura e la morte.
La morte costituiva l’unico mezzo di cui disponevamo per punire
quella debolezza umana; ed era una necessità per noi castigare i
traditori. Quando accadeva che uno dei nostri ci tradisse, uno o più
vendicatori fedeli erano lanciati alle sue calcagna. Poteva accadere
di fallire nell’esecuzione dei nostri decreti contro i nostri nemici,
come nel caso di Pocock, ma la punizione era infallibile quando si
trattava di castigare i falsi fratelli. Alcuni compagni si lasciarono
corrompere col nostro permesso, per avere accesso nelle città
meravigliose, ed eseguirvi le nostre sentenze contro i veri venduti.
Ma, in fondo, esercitavamo un tale timore, che era più pericoloso
tradirci, che restarci fedeli.
La Rivoluzione assumeva un carattere profondamente religioso. Noi
adoravamo il suo altare che era quello della Libertà. Il suo spirito
divino ci rischiarava. Uomini e donne si consacravano alla Causa e
ad essa votavano i loro nati, come un tempo al servizio di Dio.
Eravamo gli adoratori dell’Umanità.
 CAPITOLO XVII.
LA LIVREA ROSSA.

Durante la devastazione degli Stati appartenenti ai Fittavoli, i

rappresentanti di questo partito sparirono dal Congresso. Furono
istruiti processi per alto tradimento e il posto di essi fu occupato da
creature del Tallone di Ferro. I socialisti formavano la minoranza e
sentivano avvicinarsi la fine.
Il Congresso e il Senato erano ormai soltanto vani fantocci. Le
questioni pubbliche vi erano gravemente dibattute e votate secondo
le forme tradizionali, ma servivano solo a convalidare con una
procedura costituzionale, gli atti della Oligarchia.
Ernesto era nel fitto della mischia quando sopraggiunse la fine;
avvenne durante la discussione di un disegno di legge per
l’assistenza agli scioperanti. La crisi dell’anno precedente aveva
abbassato numerose masse del proletariato a un livello inferiore a
quello della carestia, e il propagarsi e il prolungarsi dei disordini ve le
tenevano sempre più. Milioni di persone morivano di fame, mentre
gli oligarchi e loro sostenitori si rimpinzavano a dismisura [91].
Chiamavamo quegli infelici, il popolo dell’abisso [92]: e per alleviare le
loro sofferenze, i socialisti avevano presentato quel disegno di legge,
che al Tallone di Ferro non piacque. Esso aveva il suo modo di
vedere, per la sistemazione del lavoro di milioni di esseri, e siccome
questo modo di vedere non era il nostro, così aveva dato ordini
affinchè il nostro disegno fosse respinto.
Ernesto ed i suoi compagni sapevano che il loro sforzo sarebbe
stato vano, ma, stanchi di essere tenuti nell’incertezza, desideravano
una decisione qualunque. Non potendo ottener nulla, speravano
almeno di porre termine a quella farsa legislativa in cui erano
costretti a rappresentare una parte passiva. Ignoravamo quale
aspetto avrebbe assunto la scena finale; ma non l’avremmo mai
immaginata più drammatica di quale avvenne in realtà.
Quel giorno, mi trovavo nella tribuna riservata al pubblico.
Sapevamo tutti che sarebbe accaduto qualche cosa di terribile. Un
pericolo incombeva, e la sua presenza era là, visibile
nell’atteggiamento delle truppe allineate nei corridoi e degli ufficiali
raggruppati alle porte della sala. L’oligarchia stava evidentemente
per isferrare un gran colpo.
Ernesto aveva preso la parola, e descriveva le sofferenze dei
disoccupati, come se accarezzasse la folle speranza di intenerire
quei cuori e quelle coscienze; ma i membri repubblicani e
democratici sogghignavano e si burlavano di lui, interrompendolo
con esclamazioni e rumori.
Ernesto mutò tattica improvvisamente.
— So benissimo che nulla di quanto dico potrà influire su voi, —
esclamò —: non avete anima. Siete degl’invertebrati, dei rammolliti.
Vi chiamate pomposamente repubblicani e democratici, ma non
esiste un partito di questo nome: in questa Camera non ci sono nè
repubblicani, nè democratici. Non siete altro che adulatori e mezzani
delle creature della plutocrazia. Parlate all’antica del vostro amore
per la libertà, voi che portate sulle spalle il marchio rosso del Tallone
di Ferro.
La sua voce fu coperta dalle grida: «Abbasso! abbasso!», ed egli
aspettò, sdegnosamente, che il chiasso si fosse calmato. Allora,
aprendo le braccia, come per abbracciarli tutti, volgendosi verso i
suoi compagni, gridò:
— Ascoltate il muggito delle bestie ben pasciute!
Il rumore riprese più forte: il presidente batteva sul tavolo per
ottenere il silenzio, e guardava di sottecchi verso gli ufficiali
ammucchiati alle porte. Ci furono delle grida di: «Sedizione!», e un
membro di New York, noto per la sua rotondità, lanciò l’epiteto di:
«Anarchico!».
L’aspetto di Ernesto non era dei più rassicuranti: tutto il suo spirito
combattivo vibrava; la sua espressione era quella di un animale
aggressivo. Pure, rimaneva calmo e padrone di sè.
— Ricordate, — gridò con una voce che dominò il tumulto, — voi
che non mostrate alcuna pietà per il Proletariato, ricordate che verrà
giorno in cui il Proletariato non avrà pietà di voi.
Le grida di: «Sedizioso! Anarchico!» raddoppiarono.
— So che non voterete questo disegno di legge, — continuò
Ernesto. — Avete avuto dai vostri padroni l’ordine di votare contro. E
osate trattarmi da anarchico, voi che avete distrutto il governo del
popolo, voi che apparite in pubblico con la vostra vergognosa livrea
rossa! Non credo nel fuoco dell’inferno, ma a volte mi spiace, e sono
tentato di crederci, in questo momento, perchè lo zolfo e la pece non
sarebbero di troppo per punire i vostri delitti, come meriterebbero.
Finchè esisteranno i vostri simili, l’inferno sarà una necessità
cosmica.
Ci fu un movimento alle porte. Ernesto, il presidente e tutti i deputati
guardarono in quella direzione.
— Perchè non ordinate ai vostri soldati di entrare, di adempiere al
loro compito, signor presidente? — chiese Ernesto. — Essi vi
servirebbero e accontenterebbero subito.
— Ci sono altri piani in vista, — fu la risposta —: per questo sono qui
i soldati.
— Piani contro di noi, suppongo, — schernì Ernesto. — Assassinio o
roba del genere.
Alla parola «assassinio» il tumulto ricominciò. Ernesto non poteva
più farsi sentire, ma rimaneva in piedi, aspettando la calma. In
questo momento avvenne ciò che avvenne. Dal mio posto, sulla
tribuna, non vidi altro che il lampo di un’esplosione, e il suo rumore
mi stordì: vidi Ernesto vacillare e cadere fra una nuvola di fumo,
mentre i soldati si precipitavano in tutti gli spazi liberi. I suoi
compagni in piedi, inferociti, erano pronti a qualsiasi violenza, ma
Ernesto li calmò in un attimo, ed agitò le braccia per imporre loro
silenzio.
— È un complotto, state attenti! — gridò loro con ansia. — Non vi
movete, o sarete tutti uccisi.
Detto questo, si abbandonò lentamente, proprio quando i soldati
giungevano sino a lui. Un istante dopo, fecero sgombrare le tribune
e non vidi più nulla. Non mi permisero di avvicinarlo, sebbene fosse
mio marito; anzi, appena ebbi detto il mio nome, fui arrestata.
Contemporaneamente furono arrestati tutti i membri socialisti del
Congresso, presenti a Washington, compreso l’infelice Simpton,
obbligato a letto da una febbre tifoidea.
Il processo fu rapido: tutti erano già condannati. Quanto a Ernesto,
come per miracolo, non fu giustiziato. Fu uno sbaglio dell’oligarchia,
che le costò caro. In quel tempo, essa era troppo sicura di sè:
inebriata del successo, non credeva che un manipolo di eroi potesse
avere la forza di minare la sua solida base. Domani, quando
scoppierà la grande rivolta, e tutto il mondo acclamerà al passo delle
folle in marcia, l’oligarchia capirà, ma troppo tardi, fino a qual punto
si sia ingigantita l’eroica banda. [93]
Essendo io stessa rivoluzionaria e fiduciaria delle speranze, dei
timori e dei disegni segreti, posso meglio d’ogni altro rispondere
all’accusa lanciata contro di loro, di aver fatto esplodere quella
bomba al Congresso. E posso affermare sicuramente, senza riserva
nè dubbio, che i socialisti, sia quelli del Congresso, sia quelli di fuori,
erano estranei all’esplosione. Non sappiamo chi abbia lanciato
l’ordigno, ma siamo sicuri che non fu lanciato da nessuno dei nostri.
D’altra parte, diversi indizî tendono a dimostrare che il Tallone di
Ferro sia il responsabile di quell’atto. Naturalmente, non possiamo
provarlo, e la nostra conclusione è solo fondata su presupposti.
Ecco i fatti, quali li conosciamo. Era stato indirizzato al Presidente
della camera, dagli agenti segreti del Governo, un messaggio per
prevenirlo che i membri socialisti del Congresso avrebbero usato
una tattica terroristica, e che avevano già fissato il giorno per
eseguirlo. Quel giorno, era precisamente quello dell’esplosione. Per
precauzione, il Campidoglio era stato circondato dalla truppa. Ma
siccome noi non sapevamo nulla della faccenda della bomba, e che
una bomba era scoppiata realmente, e che le autorità avevano
provveduto alla difesa in previsione dell’esplosione, è naturale
concludere che il Tallone di Ferro ne sapesse qualche cosa.
Affermiamo inoltre che il Tallone di Ferro fu colpevole di
quell’attentato, che preparò ed eseguì con lo scopo di accollarcene
la responsabilità, e di causare con ciò la nostra rovina.
Dal Presidente, l’avvertimento passò a tutti i membri della Camera
che indossavano la livrea rossa. Durante il discorso di Ernesto, essi
sapevano che un atto di violenza sarebbe stato commesso; e
bisogna render loro questa giustizia: essi credevano sinceramente
che sarebbe stato commesso dai socialisti. Al processo, sempre in
buona fede, molti testimoniarono che avevano veduto Ernesto
prepararsi per lanciare la bomba, scoppiata prima del tempo.
Naturalmente non avevano veduto nulla di ciò, ma, nella loro
fantasia eccitata dalla paura, credevano di aver veduto.
In tribunale. Ernesto fece la seguente dichiarazione:
«È ragionevole ammettere che se avessi avuto l’intenzione di
lanciare una bomba avrei scelto una così piccola bomba,
inoffensiva? Non c’era neppure dentro polvere bastante. Ha fatto
molto fumo, ma non ha ferito alcuno tranne me. È scoppiata proprio
ai miei piedi e non mi ha ucciso. Credetemi, quando mi immischierò
in simili faccende e vorrò adoperare macchine infernali, farò danni
maggiori. Non ci sarà solo fumo ne’ miei petardi».
Il pubblico ministero replicò che la debolezza dell’ordigno era dovuta
a errore dei socialisti, e così l’esplosione intempestiva, avendo
Ernesto lasciato cadere l’ordigno, per nervosismo. E
quest’argomentazione era rafforzata dalla testimonianza di coloro
che pretendevano di aver visto Ernesto maneggiare la bomba e
lasciarla cadere.
Dal canto nostro, nessuno sapeva come fosse stata lanciata.
Ernesto mi disse che un attimo prima dell’esplosione aveva sentito e
veduto battere il pavimento vicino a lui. Lo affermò pure al processo,
ma nessuno credette. D’altronde, la cosa era «cucinata», secondo
l’espressione popolare. Il Tallone di Ferro aveva deciso di
distruggerci e non c’era da lottare contro di lui.
Secondo un proverbio, la verità finisce sempre col trionfare: [94]
comincio a dubitarne. Diciannove anni sono trascorsi, e con tutti i
nostri sforzi incessanti, non siamo riusciti a scoprire l’autore del
lancio della bomba. Evidentemente dev’essere stato un agente del
Tallone di Ferro, ma non siamo mai riusciti a raccogliere il benchè
minimo indizio sulla sua identità, ed oggi non rimane che classificare
la cosa fra gli enigmi storici.
 CAPITOLO XVIII.
ALL’OMBRA DEL MONTE SONOMA.

Non ho molto da dire di ciò che mi accadde personalmente in questo

periodo di tempo, se non che fui tenuta sei mesi in carcere, senza
alcuna imputazione di reato. Ero semplicemente classificata fra i
sospetti, parola terribile che doveva essere ben presto conosciuta da
tutti i rivoluzionarî. Pertanto, il nostro servizio segreto, ancora in
formazione, cominciava a funzionare. Verso la fine del secondo
mese di prigionia, uno dei miei carcerieri mi si rivelò come un
rivoluzionario, in rapporto con la nostra organizzazione. Alcune
settimane dopo, Giuseppe Parkhurst, che era appena stato
nominato medico delle carceri, si fece conoscere come membro di
uno dei nostri Gruppi di Combattimento.
Così, attraverso tutta la trama dell’oligarchia, la nostra
organizzazione tesseva insidiosamente la sua tela. Ero informata di
quanto avveniva all’estero, e ognuno dei nostri capi reclusi era in
relazione con i nostri bravi compagni, che si celavano sotto la livrea
del Tallone di Ferro. Quantunque Ernesto fosse rinchiuso a tre miglia
di là, sulla costa del Pacifico, io ero continuamente in comunicazione
con lui, così che potemmo corrispondere per mezzo di lettere, con
perfetta regolarità. I nostri capi, prigionieri o liberi, potevano dunque
discutere e dirigere il movimento. Sarebbe stato facile, dopo alcuni
mesi, fare evadere parecchi di essi, ma poichè il carcere non
limitava la nostra attività, risolvemmo di evitare ogni tentativo
prematuro. C’erano in carcere cinquantadue rappresentanti e più di
trecento altri capi rivoluzionarii, che decidemmo di liberare tutti
insieme. L’evasione di pochi avrebbe allarmato gli oligarchi, e, forse,
impedita la liberazione degli altri. D’altra parte, pensavamo che
quella fuga collettiva, organizzata in tutto il paese, avrebbe avuto sul
proletariato un’enorme ripercussione psichica, e che quella
dimostrazione della nostra forza avrebbe ispirato fiducia a tutti.
Fu convenuto, dunque, quando fui rilasciata dopo sei mesi, che avrei
dovuto sparire e preparare un rifugio sicuro per Ernesto. Ma non era
facile; appena in libertà, le spie del Tallone di Ferro mi si misero alle
calcagna. Bisognava far loro perdere le tracce e andare in California.
Riuscimmo nell’intento in un modo abbastanza comico. Aveva già
preso grande sviluppo il sistema dei passaporti alla russa. Se volevo
rivedere Ernesto dovevo far perdere completamente le mie tracce,
perchè, se fossi stata seguita, lo avrebbero ripreso. Non potevo
neppure, però, viaggiare travestita da proletaria: non mi rimaneva
altro espediente se non quello di fingermi un membro dell’oligarchia.
Gli Oligarchi supremi erano pochi, ma migliaia di persone di minor
valore, come i signori Wickson, per esempio, che possedevano
milioni, erano i satelliti degli astri maggiori. Poichè le mogli e le figlie
di questi oligarchi minori erano numerosissime, fu deciso che sarei
passata come una di loro. Anni dopo, la cosa sarebbe stata
impossibile, perchè il sistema dei passaporti fu così perfezionato,
che tutti, uomini, donne e bambini, vennero descritti, e seguiti a
passo a passo.
Al momento opportuno le mie spie furono avviate su una falsa
traccia. Un’ora dopo, Avis Everhard non esisteva più, mentre una
certa signora Felida Van Verdighan, accompagnata da due
cameriere e da un cane dal lungo pelo ricciuto, che aveva pure la
sua cameriera, [95] entrava nel salone di un vagone Pullman, [96] che,
qualche istante dopo, filava verso occidente.
Le tre cameriere che mi accompagnavano erano tre rivoluzionarie, di
cui due facevano parte dei Gruppi di Combattimento, e la terza,
Grazia Holbrook, ammessa l’anno seguente a far parte di un gruppo,
fu giustiziata, sei mesi dopo, dal Tallone di Ferro. Questa serviva il
cane! Delle due altre, una, Berta Stok, sparì dodici anni dopo; l’altra,
Anna Roylston, vive ancora e ha parte sempre più importante nella
Rivoluzione [97].
Giungemmo, attraverso gli Stati Uniti, senza il più piccolo incidente,
fino alla California. Quando il treno si fermò a Oakland, alla Stazione
della XVIª Via, scendemmo, e Felicia Van Verdighan scomparve per
sempre, con le due cameriere, il cane e la cameriera del cane. Le tre
giovani andarono con dei compagni fidati, altri si incaricarono di me.
Mezz’ora dopo aver lasciato il treno, ero a bordo di un piccolo
battello da pesca nelle acque della baia di San Francisco. Sbalzati
da terribile raffiche di vento, andammo alla deriva per quasi tutta la
notte. Ma vedevo le luci di Alcatraz dove Ernesto era rinchiuso, e
quella vicinanza mi riconfortava. All’alba, a forza di remi,
raggiungemmo le isole Marin. Là, rimanemmo nascosti tutto il
giorno; la notte seguente, portati dalla marea e spinti dal vento,
attraversammo in due ore la baia di San Pablo e risalimmo il
Petaluma Creek.
Un altro compagno mi aspettava con i cavalli, e senza ritardo ci
mettemmo in cammino, al lume delle stelle. A settentrione potevo
vedere la massa indistinta del monte Sonoma, verso il quale
eravamo diretti. Lasciammo alla nostra destra la vecchia città di
Sonoma e risalimmo un canalone che sprofondava nei primi
contrafforti della montagna. La strada, da carreggiabile, divenne
sentiero, e poi un semplice passaggio per le bestie, che finì col
perdersi nei pascoli dell’alta montagna. Raggiungemmo a cavallo la
cima del monte Sonoma. Era questo il cammino più sicuro, perchè
nessuno, là, poteva osservare il nostro passaggio.
L’aurora ci sorprese sulla cresta del versante settentrionale, e l’aria
grigia ci vide andare a precipizio, attraverso boschi di querce
intristite nelle gole profonde ancora tiepide in quella fine d’estate;
dove s’inalzavano i maestosi sequoia. Poichè quello era per me un
luogo familiare e caro, io, ora, facevo da guida. Era il mio
nascondiglio, l’avevo scelto io. Entrammo in una prateria
abbassando le sbarre ad un passaggio e l’attraversammo; poi,
oltrepassato un piccolo rialzo ricoperto di querce, discendemmo in
una prateria più piccola, e risalimmo un’altra cresta, questa volta
all’ombra dei «mandroños» e dei «manzanìtas» dorati. I primi raggi
del sole ci colpirono la schiena, mentre salivamo. Un volo di quaglie
si levò con rumore dal bosco; un grosso coniglio attraversò la nostra
strada, a salti rapidi e silenziosi; un daino, al quale il sole indorava il
collo e le spalle, valicò la cresta davanti a noi, e scomparve.
Seguimmo per un tratto la pista dell’animale, discendemmo poi, a
picco, seguendo un sentiero a zig-zag che l’animale aveva
disegnato, nel folto di un magnifico gruppo di sequoia che
contornava uno stagno dalle acque fatte oscure dai minerali disciolti
che contenevano. Conoscevo quel cammino sin nei minimi
particolari, perchè un tempo, uno scrittore, mio amico, aveva
posseduto la fattoria. Anch’egli era diventato rivoluzionario, ma con
minor fortuna di me, perchè era già sparito, e nessuno aveva saputo
mai dove nè come fosse morto. Lui solo conosceva il segreto del
nascondiglio verso il quale mi dirigevo. Aveva comperato la fattoria
per la bellezza pittoresca di questa, e l’aveva pagata cara, con
grande scandalo dei fattori del luogo. Si divertiva a raccontarmi
come quand’egli ne diceva il prezzo, costoro alzassero la testa con
aria costernata, e dopo una seria operazione di calcolo mentale,
finissero coll’esclamare: «Non potrete ricavarne il sei per cento».
Ma era morto, e i suoi figli non avevano ereditato la fattoria. Caso
strano, essa apparteneva al signor Wickson, che possedeva
attualmente tutto il pendio orientale e settentrionale del monte
Sonoma, dalla proprietà degli Spreckels fino alla linea di cinta della
vallata Bennett. Ne aveva fatto un magnifico parco di daini, che si
stendeva per migliaia di acri di prateria in pendio dolce, di boschi e di
canaloni, dove gli animali si movevano in libertà, come se fossero
nello stato selvaggio. Gli antichi proprietarî del terreno erano stati
scacciati, e un asilo per deficienti era stato demolito per far posto ai
daini.
Come se non bastasse tutto ciò, il padiglione della bandita del signor
Wickson era situato a un quarto di miglio dal mio rifugio. Ma questo,
anzichè un pericolo, costituiva una garanzia di sicurezza. Saremmo
stati sotto l’egida d’uno degli oligarchi secondarî. Ogni sospetto
sarebbe stato stornato da questo fatto. L’ultimo angolo del mondo,
dove le spie del Tallone di Ferro potessero pensare di cercare
Ernesto e me, sarebbe stato certo il parco dei daini del signor
Wickson.
Legammo i nostri cavalli sotto i sequoia, vicino allo stagno. Da un
nascondiglio fatto in un tronco marcio, il mio compagno levò un
rifornimento di oggetti varî: un sacco di farina di cinquanta libbre,
scatole di conserva di ogni specie, utensili da cucina, coperte di
lana, tele cerate, libri e l’occorrente per scrivere, un grosso pacco di
lettere, un bidone di cinque galloni di petrolio, e un gran rotolo di
grossa corda. Quell’approvvigionamento era tanto considerevole,
che ci sarebbero voluti numerosi viaggi per trasportarlo al nostro
asilo. Per fortuna, il rifugio non era lontano. Mi caricai del pacco di
corda e, per prima, mi inoltrai in un fitto di arbusti e di viti vergini
intrecciate, che formavano, fra due monticelli boscosi, come un viale
verde, che finiva bruscamente sul letto scosceso d’un corso d’acqua.
Era questo un piccolo ruscelletto alimentato anche da sorgenti, che i
più forti calori dell’estate non inaridivano mai. Da ogni parte
sorgevano monticelli boscosi: ce n’erano molti, e sembravano gettati
là, dal gesto negligente di un Titano. S’inalzavano a qualche
centinaio di piedi sulla base, ma erano senza nucleo roccioso,
composto solo di terra vulcanica rossa, la famosa terra color vino
della Sonoma. Fra quei rialzi, il piccolo ruscello si era scavato un
letto molto scosceso e profondamente incassato.
Bisognò lavorar di piedi e di mani, per scendere fino al letto del
ruscello, e, una volta là, per seguirne il corso lungo un centinaio di
piedi. Allora arrivammo al grande abisso. Nulla rivelava l’esistenza di
quel baratro, che non era un buco nel vero senso della parola. Ci si
trascinava carponi fra un inestricabile confusione dì arbusti e di
tronchi, e ci si trovava sul margine dell’abisso, e, attraverso una
cortina verde, si poteva approssimativamente giudicare che il baratro
avesse duecento piedi di lunghezza, altrettanti di larghezza, e circa
la metà di profondità. Forse per qualche causa geologica remota,
all’epoca della formazione dei monticelli, e certo per effetto di
un’erosione capricciosa, l’escavazione era avvenuta nel corso dei