11 March 2016
Dear Interested Readers,
What’s Inside This Week’s Letter Plus Shameless Self Promotion of Strategyhealthcare.com
This week’s letter begins a series that will run over the next several weeks, perhaps interrupted by a few breaks. The series will be an ambitious attempt to look at what creates success in an organization committed to continuous improvement. Lean is my personal favorite flavor of continuous improvement. I see Lean to be a term like “jazz” that defines an evolving philosophy that thrives on innovation. To revert to the sort of analogies that were once a significant part of educational testing, I would say that Lean is to continuous improvement as jazz is to music. Jazz is a continuously evolving art form that allows individual expression within a context of an understood structure.
On first introduction to Lean there are basic principles and tools that one is well advised to master, just as a fledgling musician should master an instrument and become familiar with the classical scales. The basics of Lean are built on realities that that can be traced back to the emergence of the scientific method if not further, but its future utility lies in its ability to be a creative approach that brings order and productivity out of the chaos of complexity. [Please feel free to disagree or offer an alternative opinion!]
I once read that a person can learn the rules of backgammon and be playing the game in less than thirty minutes but that it takes more than a lifetime to master the game. I have seen the same be true with Lean. Thirty minutes into their first RIE being managed by a skilled sensei, a person who has never had any personal experience with Lean before, can be “doing” Lean, but years later that same individual will still be adding to their knowledge base and will have a still growing insight and awareness of the power of the philosophy and culture that Lean spawns. Lean stimulates a process of growth that never ends.
As is true with any journey, planning an itinerary is a good way to start, but the fun of the trip is in the learning that is the product of a willingness to deviate from that itinerary that you spent so much time developing. The joy of travel is in the discovery and the learning that can occur unexpectedly when you become adventurous and deviate from the tyranny of your itinerary. Some of my greatest adventures on the road occurred when I submitted to the whim of my curiosity or paused long enough to explore what was behind a door or down an unexpected alternative route that I serendipitously discovered on the way to the place that I had planned to visit. I am hoping that this journey of a few week’s letters into the heart of Lean might launch you on some side trips of personal discovery. Forewarned, I hope that you will not think I am too scattered when I go down a few rabbit holes. There is nothing that is more exciting than finding treasure in a place where you never expected it to be!
As is true with much of what is new and interesting that I have discovered over the last five years, the idea for this exploration began in a conversation with John Gallaher, my personal guru and friend at Simpler. John and I have been collaborating recently to develop our thoughts about how to advance understanding about the role of leadership in a Lean organization. Our conversation has been driven by the reality that together we are responsible for a presentation about leadership which will be given at a conference for participants from Lean organizations in to be held in Chicago in mid April. It is my hope that you will enjoy the next few weeks and that you will be eager to try to improve what evolves by sending me your ideas. I would love for you to share anecdotes with me from your own Lean adventures. Perhaps you will direct the conversation down a road where there is real treasure.
Last week’s outburst about the Presidential Primary process has been shortened and revised a little bit and is up on strategyhealthcare.com. I would also like to inform you, if you have not seen it, that there is also a recent posting entitled “Concierge Medicine: Still Not a Good Idea”. In that piece I refer to “Harley Street” medicine. If you you listened closely to the dialog and followed the plot in the last episode of Downton Abbey that was aired on Sunday night on PBS, you heard the phrase “Harley Street” at least twice.
In my mind Downton Abbey was an an elaborate artistic exploration of “adaptive change”. The resolution of one of the plot lines in the final episode included a misdiagnosis by a Harley Street specialist that almost resulted in the loss of true love for Isobel Crawley (herself a personification of the tension between the evolving English middle class and the old upper class). Isobel’s suitor, Lord Merton, Richard (Dickie) Grey was told by his overpriced Harley Street doc (think concierge medicine) that he had pernicious anemia. Minot, Murphy and Whipple won the Nobel Prize in 1934 for discovering that “intrinsic factor” was the cure for pernicious anemia which was still a grim diagnosis in 1925 when poor Lord Merton was given his death sentence.
Fortunately for Isobel and the shy Lord Merton, the solid local PCP, Dr. Clarkson, was skeptical about the Harley Street diagnosis and discovered that the real cause of Dickie’s anemia was iron deficiency. Although Julian Fellowes, the creator of Downton seems impeccable in his ability to avoid anachronisms, and I am sure that he would have never subjected Lord Merton to a colonoscopy, we will just have to be happy that there was a wedding and that the couple will live happily ever after and hope that the iron deficiency was not secondary to colon cancer since there will be no more episodes of Downton Abbey.
Please remember to tell friends that they can sign up for the Friday Healthcare Musings by visiting strategyhealthcare.com.
“...leaders fail to recognize the magnitude of change that will be required and that change extends to the leaders on a personal level.”
Please hold that thought from John Toussaint’s great book, Management on the Mend: The Healthcare Executive Guide to System Transformation while I digress.
One of my favorite concepts from medical school was the debatable observation by Ernst Haeckel that “ontogeny recapitulates philology”. There is a certain poetry and symmetry in that thought even if it a little bit of an exaggeration. For those of you who did not go to medical school and did not click on the link, it roughly translates as: the development of the individual (ontogeny) follows the path that its ancestors traveled (phylogeny) throughout evolution.
I would like to take some license and add a corollary to this “faux” scientific statement about the physical development of the individual and extend it to the social development of the individual and then to individuals in groups as they form organizations. In other words, when it comes to personal development and organizational development we all start at the beginning and follow a path that is not much different than the path our ancestors followed as they emerged in Africa 200,000 years ago and began to work in groups to their advantage. Having gotten the basics of group and leader down pat over the first 100,000 years, we began to wander out of Africa into Europe and Asia and beyond until we had reached every corner of the planet.
I can imagine that your experience is similar to mine when I think back over what I can remember about my experience with my four sons and my current observations of my two grandchildren. Those observations confirm for me that the social concept of ontogeny recapitulating philology holds. We all played alone at first and then began to play together in games that were more and more imaginative and complex. As the games developed some became inventors of narrative and others accepted direction of the basic context but would want to embellish the idea with their own contributions. Roles and responsibilities evolved and with them there were conflicts to be resolved.
One of my fascinations with the creation narrative of Apple is its evolution from a “garage adventure” of two adolescents that was hardly more than a science club project to being one of the most complex organizations in the history of the world. All along the way ontogeny was recapitulating philology. The origin story and history of my own home organization, the Harvard Community Health Plan, is yet another confirmation of the fact that all organisms and social structures seem to follow relatively similar pathways.
In medicine there is great benefit in understanding what is similar and how the problem in the moment fits or uniquely differs from previous experience. The same is true with social structures. As is true in medicine, the ability to understand the moment as a function of recognized patterns and apply reliable tools is a great advantage as we seek to create understanding in what seems to be chaos. I will insert here the first principle of Lean problem solving. Lean teaches that when there is a problem or a reason for action do not just grasp the first idea that comes to mind but rather pause, and if possible, go to where the problem is and observe what is happening and think through the options and potential outcomes before working with those doing the work to test a plan of action.
The concept that Lean offers is not really new because wise people have been doing it for millennia. It is good practice to ask those who are involved what is happening, and what they see as the issues and possible best solution. The contribution of Lean is to remind us that people who feel respected and who are invited to be involved will contribute more than those who are commanded, disrespected or threatened.
For reasons that are beyond my understanding it seems that the higher people rise in any structure the more they feel vulnerable if they ask for or accept the input of others. If you enjoyed the allegorical and abstract presentation of Apple and the relationship between Steve Jobs and his cofounder Steve Wozniak in the recent movie where Michael Fassbender played Jobs, you saw this dynamic again and again. What was beyond the ability of a two hour movie to present was how Jobs ultimately overcame his inability to collaborate consistently and equitably. It was a shame that the movie did not show the transformation that occurred as he became successful with a different and more respectful relationship with the people at Pixar and later back again at Apple with Jony Ive and others.
Before I became a board chair or a CEO and even long before my experience as a formal organizational leader, I was trapped in a dysfunctional set of concepts about leadership. If you look at my life’s history there were many clues that I wanted to be a leader. As an adolescent on teams and in organizations, I was always a “captain” or a “president”. In junior high school I was student council president. In high school I was class president after being in the school for one year. In college I was active in many activities and president of at least one before I went into a period where I assumed the persona of someone on the periphery who was distrustful of leadership. My period of distrustful aloofness lasted until I had been in practice for a decade and until I began to realize that I could organize the dissatisfaction of others to match my own. In every situation my concept of leadership was what people describe with the cliche as “top down”. It was the leader’s responsibility to create the agenda and make things happen.
My distorted concepts were right out of what social historians would call the “big man” concept of leadership. Somehow I did not recognize through a close observation of history that there were some other examples of leadership like the one offered by Ghandi. Unfortunately, it seems that the “big man” leadership concept remains a primal urge that is hard for all of us to move past. We are discovering this reality again as we suffer through this year’s process of choosing a new president. The desire to find the right “big man” is different this year only in that one of the candidates for “big man” is a woman and that many are willing to disregard civility and appeal to the darkest components of fear and self interest as they make the case for why they should be the next “big man”.
My first exposure to the idea that there were actually different leadership concepts and roles came in the early eighties when the management of HCHP hired a consultant to hold a couple of days of off-site seminars for potential leaders. There I was exposed to a presentation of a philosophy that was gaining acceptance in the late seventies and early eighties, situational leadership. What I took away from that conference and what you will learn if you click on the link is that there are different leadership styles and you can change them like changing your clothes. The key to which suit to put on is circumstantial and depends on the situation as described by who the followers are and what the situation is. Sometimes one should be directive, at other times collaborative. To be facetious, you do not wear a tux to a cookout or Bermuda shorts to a formal event. The concept was interesting but felt manipulative and perhaps more like acting than leading. In the end I just continued to be myself with mixed results.
The next big experience for me was the exposure to the work of Jim Collins as presented in Good to Great: Why Some Companies Make the Leap...and Others Don’t. The concept of the structured levels of leadership culminating in “Level Five Leadership” took my breath away. It was the intellectual equivalent of the first view of Yosemite Valley from Inspiration Point. Then there is the almost spiritual question: Is a level 5 leader an example of a “servant leader"?. Reading Collins was the first step in a process of personal transformation. His work presented many “threads” that I began to follow simultaneously with the literature and ideas of the quality and safety movement.
My new responsibilities as CEO coincided with a remarkable event, the resurgence of the Boston Celtics! Under the leadership of “Doc” Rivers and with a core of veterans who were all looking for a championship that had eluded them through otherwise illustrious individual careers, the Celtics coopted some African “theology” and built a championship team around the concept of “ubuntu”. If you followed the last link you read the players talking about ubuntu. Perhaps Desmond Tutu can give us a broader appreciation for this philosophy which is counter to self interest.
Bishop Tutu: Ubuntu is a concept that we have in our Bantu languages at home. Ubuntu is the essence of being a person. It means that we are people through other people. We can’t be fully human alone. We are made for interdependence, we are made for family. Indeed, my humanity is caught up in your humanity, and when your humanity is enhanced mine is enhanced as well. Likewise, when you are dehumanized, inexorably, I am dehumanized as well. As an individual, when you have Ubuntu, you embrace others. You are generous, compassionate. If the world had more Ubuntu, we would not have war. We would not have this huge gap between the rich and the poor. You are rich so that you can make up what is lacking for others. You are powerful so that you can help the weak, just as a mother or father helps their children. This is God’s dream.
Not long after I began to contemplate ubuntu, and was asking myself how its philosophy fit with the lessons that I had failed to incorporate into my concepts of leadership, I was exposed to Lean for the first time. In subsequent letters I will tell that story in full, but as an introductory chronology let me jump forward a year or so to an opportunity that I had to attend some seminars at MIT’s Sloan School. Once again I was surprised by an introduction that I was not expecting. The speaker was Professor John van Maanen whose work in organizational behavior focuses on organizational ethnography. In the course of his discussion of informal organizational leadership he threw out the term, VUCA. VUCA was not the main concept that he offered but his description of this acronym and its utility in conceptualizing solutions arising out of complexity so fascinated me that I began to do some reading on my own which took me to Bob Johansen’s book, Leaders Make the Future: Ten New Leadership Skills for an Uncertain World.
Those new skills which Johansen described included activities such as rapid prototyping and crowdsourcing and seemed totally aligned with the thinking of Collins, his teacher, Peter Drucker, Charles Handy, Desmond Tutu and Doc Rivers and all that I was learning about leading in a Lean environment. The pieces of the picture of the leader that I wanted to try to be were coming together. As a picture of the deep personal transformation that would be required of me was coming into focus, I did not know that there was more to come.
When I first read Accountable Care Organizations: Your Guide to Strategy, Design and Implementation published in 2011 by my friend and former colleague, Marc Bard and his colleague Mike Nugent, I was captivated by Chapter Five, “Accountable Care Sociology”. That sounds pretty dry but the core lesson for me was the amalgamation of ubuntu, the motivation for continuous improvement, and managing the complexity and uncertainty of a volatile and ambiguous medical environment. The authors pointed out that it was necessary to our mission for clinicians to move from their historical mindset of “I am accountable” to a new position, “we are accountable”.
At that moment I realized that servant leadership, level five leadership, ubuntu, management skills for an uncertain future, and “I to We” all came together in the standard work of a Lean leader. It was also clear that if I was to be true to my responsibility, I had to continue on a course of self discovery and personal learning and transformation even as I was expecting, even demanding, that others individually and collectively change, which takes me back to where this long and winding road began:
“...leaders fail to recognize the magnitude of change that will be required and that change extends to the leaders on a personal level.”
John Toussaint wrote those words after he wrote:
After more than 145 such visits in 15 countries [visits to organizations that are practicing Lean]...I understand why I am seeing hope and failure in nearly equal measure. Teams of clinicians and administrators using lean thinking are making breakthroughs every week as they increase quality and reduce costs. But the essential transformation of the organization is not happening due to some basic misunderstandings about lean in healthcare.
Then he wrote:
The most common problem I see is that leaders fail to recognize the magnitude of change that will be required and that change extends to the leaders on a personal level....lean healthcare is not an improvement program. It is an operating system that requires a complete cultural transformation....the two jobs available in a lean organization are problem solver and problem solver support staff. The CEO is support staff; his or her job is to identify and remove barriers so that problem solvers...can see and solve problems.
Dr. Toussaint's description of the role of the CEO is about as far as you can get from “big man” management. John Gallagher and I, as well as others within the conversation at Simpler, agree that for an organization to get beyond Lean as a tool bag and experience all the benefit to long term success that Lean can foster, will require much more from the CEO and Senior management team than many CEOs who think that their organizations are “doing Lean” realize.
Failure can arise from many sources. Lean failures often come from what you do not know that you do not know. Many CEOs who think their organizations are doing Lean do not realize that their organization is actually on a road to failure because they are not performing their role. It is painful to know that many people within organizations that are “doing Lean” realize that they could do more if their CEO and other senior managers would realize that success requires that they be transformed also and that they must move from “managing by objective” to “managing by process”.
Lean can enter an organization at any level of the structure, but it will not succeed without the transformation of senior leadership that Dr. Toussaint has deemed to be necessary. Leadership transformation is fundamental as the precursor of the creation of a culture where Lean can thrive. Senior leadership may introduce Lean and then abandon it to other managers or consultants and moves on to other interests. Sometimes Lean enters an organization through middle management and a transformation occurs in one process but is limited from further spread until senior management becomes convinced that Lean is the operating system that is most compatible with solving the problems of the future that challenge the mission and sustainability of the enterprise.
The presentation in April in Chicago will explore how a person in an organization that is just “doing Lean” with a CEO who is distant and uninvolved can “speak truth to power”. I hope to continue the conversation about what Lean leadership is and what “standard work” for CEOs and senior leadership looks like as the discussion continues next week.
Melting Ice and Changing Time
My wife took the picture in this week’s header last weekend. The ice on the lake was still thick enough for what looked like a pretty enthusiastic game of hockey, but the warm weather and rain this week have created dense fog over the lake as the ice begins to melt leaving clear water near the shore that I can see in several places where the road where I am walking comes close to the shore. This has been the winter that never really arrived. We had more snow last year before Christmas than we had all winter this year. We had a “snow drought”. I am sure happy that I never got around to laying down several hundred dollars for that unlimited pass for skiing that they offer as a challenge to those of us who are over 70.
Early Sunday morning the clock goes forward an hour, and who knows, by this time next week I may have tossed a fly into the widening water between the shore and the residual ice just to see if there is a nice rainbow that is starving after being under the ice for the last three months. It is that time of year when things change rapidly. The Red Sox open their season in a little more than three weeks on April 4 in Cleveland and then come back to Fenway full of hope and expectation on April 11 to play the Orioles. I can hardly wait!
I hope that you will drop me an email with your ideas about leadership. |
