| 12 June 2015
Dear Interested Readers,
Inside the Letter This Week
I hope that you will enhance your reading pleasure this week by clicking on all the links in this letter. Beyond that I hope that you watch the videos and read the documents that the links will reveal. I have read them all and think that I have learned a lot. This letter is about innovation. In the first section we examine possible lessons to be learned about innovation from the Shakers and Steve Jobs who is someone I thought I understood but didn’t.
The second section is about how we learn from dialog with one another as I am informed of a remarkable breakthrough document from an “interested reader” and how that document may signal that real change is in progress as hospitals and physicians begin to use the language of the Triple Aim.
I hope that you will continue to make a weekly visit to strategyhealthcare.com and suggest both this letter and that website to your friends and colleagues.
This next week I will be at the Dartmouth-Brookings annual ACO summit in Washington. I will try to function as a reporter. The meeting will not be over until Friday so look for the report on the meeting in the letter of June 26. If you are also headed to Washington, please catch me and say hello.
Steve Jobs and The Shakers: What they can teach us about innovation
One of my greatest sources of joy is to experience again and again how ideas, insights and opportunities emerge out of unforeseen circumstances when one is engaged with the world with a philosophy and purpose in mind. They say that necessity is the mother of Invention. Perhaps frustration and failure is Invention’s father. To those thoughts I would add that commitment to a concept, a cause or an ideal is Invention’s muse.
The serendipity that I experience most often these days is the process by which an idea comes to me each week as I begin to try to think about what I might say that will inform and entertain us both. As often as not, which is true for the second section of this letter, the subject comes from one of you, my much beloved Interested Readers. This week’s theme of innovation is a pretty standard concept. In a way any conversation about innovation in healthcare at this moment in time would be like a minister, priest or rabbi delivering a homily on the concept of loving and living in harmony with your neighbors. Another simile might be that to write or talk about innovation in healthcare would be like a politician of any stripe talking about taxes or their sense of the validity of global warming. The politicians and the clerics share with me the problem of trying to make fresh and interesting an idea that you may already think you understand. In these days of information overload a big part of successful communication is figuring out how to speak or write in a way that will surprise you the reader, and capture your attention, since you probably think that you already know what we are going to say even before we say it.
Two recent events stand behind the “hook” that I am using this week to talk about innovation in healthcare. The first event goes back to the end of May. I have always had a problem physically being in more than one place at one time. The last week of May I was scheduled to be at the Simpler/Truven meeting in Alexandria, VA from Tuesday through Friday and had an overlapping commitment at a board dinner and strategy session on Thursday night in Corning, New York, followed by the regular meeting of the Guthrie Health board at Guthrie’s Corning Hospital on Friday morning.
My five year commitment to the Guthrie board is a fiduciary responsibility and I felt that I needed to leave the Alexandria meeting early on Thursday to get to the evening dinner and strategy session in Corning on time. Having resolved the moral ambiguity that was the uncomfortable part of my problem, the mundane issue was how to get from Alexandria to Corning. Corning is serviced by the airport in Elmira, NY. Elmira is the lovely little town where Mark Twain enjoyed spending his summers and is now spending eternity. I also have some distant ancestors who lived in the area before heading south to North Carolina. You can also get to Corning by flying to Rochester, NY and then driving over a hundred miles. There is no easy way to get to the area in modern times.
The usual process of flying to Elmira requires changing planes in Philadelphia because the only flights into Elmira come from Detroit or Philadelphia. It is easier and faster to get to San Francisco from Washington than it is to get to Elmira. My batting average making the connection in Philly to get to or from Elmira is lower than the team batting average of the Phillies and like the Red Sox, the Phillies are in last place because they do not hit well. [According to MLB.com current team batting average of the Phillies is 0.239. The Red Sox are a little better at 0.246.]
After my analysis I decided that the most efficient and reliable way to be sure that I arrived on time would be to rent a car and drive the six hours it would take. I figured that I would save time and be in control of my own destiny. My decision did mean that I would have a second six hour drive on Friday from Corning to the Manchester, New Hampshire airport where I had left my car when I flew to Washington.
I love NPR and probably listen to it as much as most people do; but 12 hours of NPR did not seem like a marathon I wanted to run. I decided that I would treat myself to the audiobook recording of a book that I have been eager to read, the new biography of Steve Jobs, Becoming Steve Jobs: The Evolution of a Reckless Upstart into a Visionary Leader by Brent Schlender and Rick Tetzeli. I loved Walter Isaacson's authorized biography of Jobs that was published in 2011 shortly after his death. The reviews of this new book suggested that it was less focused on the negative aspects of Job’s eccentric personality than Isaacson's homage that was a twisted celebration and bizarrely romantic picture of the genius.
The new book had been hailed by many who knew Jobs as a realistic picture of his evolution as a leader, and as a human being. Schlender and Tetzeli tell the story of a man who learns from his failure and rejection and becomes capable of empathy. The authors frame his remarkable accomplishments that followed his complete failure and rejection by the company he co-founded as a journey toward personal excellence and maturity that was built on his evolving patience and emotional growth and the understanding of how to be a leader that could inspire others to do their best. I had been intrigued by the review in the New York Times back in March and was eager to read the book. I like to “read” with my ears, so this was my big chance.
The second event occurred last week when my friend Doug Beers and his wife Leslie Taylor were visiting us from Portland, Oregon. On one day we decided to visit the Shaker Village in Enfield, New Hampshire. It had been ten years since I had last been there when my mother and father visited for my 60th birthday. My major motivation for wanting to share Enfield with Leslie and Doug was that the previous weekend the CBS Sunday Morning program with Charles Osgood had a feature about the Shakers. We record Osgood and “Face the Nation” every Sunday for delayed viewing because both are usually so informative.
If you clicked on the link and listened to the five minute story about the Shakers you would have noted that they filmed the segment at the Shaker Museum in Hancock, MA. At the peak of the Shaker movement in the nineteenth century there were more than a dozen of these communities from Maine to Kentucky. The Enfield Museum is near my home in New London and among the many buildings on the site is a massive granite building that was once the largest structure North of Boston. [You can see the building. It is the large building to the right in the header picture this week.] From their three thousand acre estate on the shores of Lake Mascoma in Enfield, the Enfield Shakers were the most powerful economic force in the community. They owned and controlled mills and shops that employed hundreds of people from the area and were very involved in the community even as they lived apart.
What was consistent across all of the Shaker communities was a reverence for work, an abhorrence for waste and excess, a genius for functional design and innovation, and an abiding love that extended to everything and everyone in the world around them. Perhaps their strict code of celibacy is better known than their sense of order and design. It is our loss that they have not survived but in many ways their influence lives on through their impact on design. [The last four Shakers live together in Maine.] There are many books about the Shaker movement and their eccentricities and at least one focuses on Shaker Innovation, Inspired Innovations: A Celebration of Shaker Ingenuity by M. Stephen Miller. If you click on the link be sure to scroll up for the pictures and be sure to read the introduction.
As we toured the Enfield site I was overwhelmed by the obvious commitment to quality and customer satisfaction that defined the Shaker approach to work. Their religious beliefs forbade them from delivering to customers any product that was not perfect. Blemished or irregular products were deconstructed and the pieces were recycled into products that met their specifications and expectations. As I stood there in the museum enjoying once again the simplicity and good sense of their beautiful and functional products, I reflected on the low bar of expectation expressed by the joke, “Good enough for government work…!” You definitely get a better product when you buy from a supplier who believes that where they spend eternity will be a function of the quality of the product that they deliver to you, the customer. It is hard to beat a product or a service that is delivered with a “heavenly” motivation.
An interesting component of Job’s story that may have more significance than his much publicized ego was that like the Shakers he had a genuine fascination with spirituality. From his late teens until his death he had an attraction to and practiced Buddhism in a lifelong search for enlightenment of the spiritual part of his being. Like the Shakers, he loved design and the efficiency of good design. Like the Shakers he was interested in the interface between the user and the machine. Going back to the Apple II, his products were appealing to both eye and hand. He cared about hardware and software but most importantly he cared about the harmony between the hardware, software and the user.
For Jobs money earned was not as much an objective as it was a means to further success and a scoring system. He had a defined purpose which was consistent from the first Apple to his last day at work. As time went along he became more and more effective in his growing skill and knowledge in pursuit of the same objective. The purpose is described by Brent Schlender and Rick Tetzeli as, “The grand scheme—bringing computing tools to people who could employ them creatively to enhance their lives and work—remained the same.”
Excerpt From: Brent Schlender & Rick Tetzeli. “Becoming Steve Jobs.” iBooks. https://itun.es/us/CwE03.l
As memorable as many of his early products were, we forgive many of them in retrospect for their failure to live up to the expectations he created by the well orchestrated media campaigns that preceded the products. The 1984 Superbowl ad that announced the Macintosh is considered by many to be the greatest ad ever made and it aired only one time. Jobs was much less interested in producing products for corporate users than for individuals. The Super Bowl ad shows an individual, specifically an athletic woman, in conflict with the system, think IBM and later Microsoft.
The famous ad program , “Think Different” that he introduced on his return to Apple was thought by many to be a homage to himself, but in fact it was derivative of one of his core objectives which was to make products that would enable creative people. He chose Richard Dreyfus over himself as narrator because he anticipated that the ad would be criticized as an indirect ad about him and his creativity. If you click on the “Think Different” link and have the patience to listen to the 16 minute YouTube replay of Jobs introducing the ad campaign to his senior leaders, you will get the added bonus of hearing in his own words his philosophy about great products and the philosophy that produces and markets great products. As an exercise try to imagine how you would market health using similar customer focused principles.
The new Jobs book sends a disproportionate amount of time on the dark period of his career between 1985 when he was voted off the island of Apple and 1997 when he returned to save Apple. The authors describe his very slowly developing success at Pixar and the yet more educational failure he experienced at NeXT. His major accomplishment at NeXT was not the creation of the incredibile computer that he wanted to build but the smaller accomplishment of generating software that enabled web design in the early days of that technology. NeXT was not a success unless you count getting back the money for your investors that they gave you after you sold them a dream that you did not realize. The main thrust of the Schlender and Tetzeli book is to describe how through failure he found knowledge of himself and became a leader as well as a real visionary who realized that the way to see the future was to follow the world and your progress from one product to the next by instinct and the observation of what the work and ideas of others could make possible that they did not recognize.
We remember Jobs for the Apple II, the MacIntosh, Toy Story, the iMac, iTunes, the iPod, Apple Stores, the iTunes Store, the iPhone, and the iPad. What he should primarily be remembered for is the creation of the world’s most unique enterprise.The products followed the personal transformation of Jobs that then allowed the transformation of the Apple Corporation that evolved after his 1997 return. The Steve Jobs that created that corporation was a transformed and mature leader who was demanding and involved without being a micromanager. This later version of Jobs was a team builder who followed the instincts of his collaborators more than the egoist and angry driver who imagined that he was the origin of all creative ideas that he then badgered others to build.The products upon which his fame rests could only have come from empowered teams in a great enterprise. They are too complex to be the inventions or innovations of a single individual. They are the output of teams working together at an innovative enterprise that could combine a knowledge of what was wanted by customers with what would be wanted if it existed and delivered with a relentless pursuit of benefit for the customer, and only secondarily for the provider or investor.
By definition, innovation is much more than an “improvement” or “invention”. A “successful” innovation is something that is a combination of improvements, inventions and creative ideas assembled as a product or process that surprises and delights customers. A successful innovation is such a profoundly positive experience for customers that their desire to have what they could not previously imagine creates a “pull” that guarantees the success of the product in the market. A real innovation changes things forever and is the cure for the stasis and false comfort of the status quo.
Not all of Jobs’s innovations were “successful” but what is often learned from the attempt to innovate is the foundation for a later success. My favorite Apple product is probably iTunes, although I love all my Apples. I love as well the beauty and service of the Apple Store and the convenience of buying my music and audiobooks in the iTunes stores. The story of the evolution the original iTunes software to the iPod, the iPhone and a new method for distributing and enjoying music is my favorite sequential story from the book and perhaps is the best lesson for healthcare beyond the necessity of transformation. The story begins with Jobs’s search for software tools that could be integrated with Apple’s operating system to enable customers to be creative. He needed something to boost lagging iMac sales. His first idea was based on his recognition of the new era of personal video recording and he ended up with the iPhone we use today.
He had the idea that software that helped amatuer movie makers produce “finished looking” home productions would be beneficial to their desire to be creative. The response to the opportunity to innovate was iMovie. iMovie was a bust. Steven Spielberg could probably make the original iMovie work but few others could. He even challenged each member of his senior management team to try to make a four minute home movie over one weekend. The results were not impressive. I know that I failed digital editing with much later iterations of iMovie. The product was wrong but the idea of giving customers control of media was right and it was the continuing search for a product that ordinary users could apply to manage what they cared about that led to iTunes shortly after the iMovie failure. In a very quick succession of releases we had the evolution of the iPod, the digital sale and distribution of music, iTunes software for PCs, and then the iPhone. Engaging and enabling clients in healthcare is currently more like iMovie than iTunes. We have very few enterprises where there is the combination of leadership, empowerment and creative talent where a similar sequence could occur. We are definitely “pre-Shaker” in our understanding of how to innovate in healthcare.
The real question is whether or not we will keep trying like Steve did during his dark period to get ourselves a level of transformation that will enable success that is recognized by our customers. We are still in the earliest phases of what is possible in healthcare through innovation. What might we accomplish if we treated our customers with the Shaker philosophy of striving for perfection as we delivered the products of our innovation? What if our desire for innovation was driven by the respect for customer, the abhorrence of imperfection and waste and the understanding of the advantages of simplicity that were characteristic of the Shakers and is so characteristic of Apple products? Can we learn from Steve Jobs that personal and organizational transformation can create a culture that fosters an environment of innovation?
Almost everywhere I go I see and hear medical people talking about the need for innovation and their motives most often seem to be about loss avoidance in an era of declining revenue. Perhaps I do not understand what they are saying and it is possible that by inference I am suspecting that their motivations are self serving. We talk about innovating with the hope that it is a road to survival and security. Innovation is where we should look for the answers for the future but we must recognize what the Shakers and Jobs learned. It is not about us. It is about the patients. Can we enable them with better and better products and processes of care that delight them and give them an increasing ability to promote their own health and self care? I believe that we can produce innovations that enable and inform patients and that we will eventually use innovation to bring everyone closer to the Triple Aim.
Sophisticated Lean thinkers recognize that organizational transformation is dependent on leadership that is enlightened and transformed. Our current systems can be improved with Lean but we should also be using Lean culture and philosophy to transform the heart and minds of leadership and every participant in the work of the enterprise. Any organization that is trying to do Lean without the hands-on observable participation and leadership of the CEO, CMO, COO and the other senior leaders is wasting resources. I believe that where we have leadership that promotes and lives by a culture and a philosophy of care that respects people, abhors waste and poor quality and safety and seeks to understand what matters to patients, we will be more likely to see effective innovation. As the number of healthcare organizations accept the challenge to foster these ideals, the more effective we will be in our search for the innovations that will collectively add up to deliver on Dr. Ebert’s predictiction:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
I Would Not have Believed It If I Had Not Read It Myself
One of the people who has taught me so much is my friend Chris Jedrey. Chris is also, in the opinion of many, including me, the best healthcare lawyer in the country. Chris is a voracious reader and indeed was a Harvard faculty member who taught the major works of yesteryear before going to law school as a second career. He remains a wonderful teacher as he has become a wise counsellor. I regularly get instructive notes from Chris. Not long ago I received a cryptic note from Chris after we had been exchanging a few ideas about the slowly evolving success of the Triple Aim.
Attached is a document that was just published and is the work product of an integrated team formed by AHA and AMA. I thought you would find it of interest.
That was all he wrote. He was absolutely correct and I recommend this eight page PDF to you with the same endorsement.
The first few paragraphs are the answer to the question, “ What is really happening in healthcare today?”. As we all sit and wait for the Supreme Court’s decision in King v. Burwell and fear that a decision for King will put everything that has been accomplished since passage of the Affordable Care Act back in the box, this document appears as a joint communication from the American Hospital Association and the AMA and expresses a reality that suggests to me that the world has already changed in a way that precludes a return to the “way things were”. I have “bolded” a few phrases in the first paragraph for emphasis.
Integrated Leadership for Hospitals and Health Systems: Principles for Success
In the current healthcare environment, there are many forces, both internal and external, that require some physicians and hospitals to rethink their traditional relationships. These physicians and hospitals are being both pulled and pushed together in new ways by these changes, including increased direct employment of physicians by hospitals, the development of Accountable Care Organizations (intended to manage the quality and cost of care of defined populations of patients), new payment methodologies and financial incentives from public and private payers, and the need to deliver greater value in an increasingly competitive marketplace. Among the suggested solutions is a call for integrated physician-hospital leadership. The ultimate marker of success of all new models of care will be if patients have a better experience, improved health and a lower per capita cost compared to current models. It is possible that integrated leadership would benefit patients by focusing on developing new channels for patient engagement, and delivering care in a manner that eliminates overuse, underuse and misuse of resources while increasing physician professional satisfaction, building trust relationships and financial stability for both physicians and hospitals.
Granted they said “It is possible…” but their toe in in the doorway of change. The specifics get better and better as the document flows nicely, logically and positively through eight pages of analysis and recommendations about managing the transition and transformation to more effective patient centered collaboration between the Hatfields and McCoys of physicians and hospitals as hospitals and doctors develop new competencies of collaboration and shared responsibility.
The document is a little bittersweet for me, given the reality that over the last two years of my experience as a CEO my major objective was to engage our hospital partners in exactly the kind of relationships that are now being discussed as emerging necessities.That little bit of self pity is completely negated by seeing this document that seems to me to validate much of the message that so many healthcare progressives have advocated for so long. I hope that you will spend some time reading this thoughtful document. I applaud the leadership of both the AHA and the AMA for recognizing the importance of making such a statement. If you read as far as page seven you will be amazed to read the statement:
A robust aligned primary care network is critical for chronic disease management and population health strategies to be successful. Providing primary care the appropriate representation and voice needed to lead population health improvement initiatives may be a challenge in the existing leadership structure of the current hospital/health system environment, but it is clearly a need to be addressed in the near term.
Much of the analysis is about developing physician leadership competencies and reviewing the changes in culture that will be necessary to experience. The document is really calling for a revolutionary transformation from the seats of power of the status quo. A new healthcare paradigm of doctor and hospital collaboration that elevates primary care to a new level of responsibility would have to be described as a “transformation”. Would it be the critical step to creating the platform for meaningful innovation? It makes me wish I was forty or fifty or even sixty with the opportunity to be involved in the evolution of an exciting future.
Baseball and Walking with Friends
Going to Fenway Park these days is like visiting a friend with a terminal illness. I was really excited after the come from behind win last Sunday over a real bad team, the Oakland A’s. It was the thinking of a Pollyanna that this lonely win might signal a real turn around. I was hoping that it would be the beginning of a streak, and it was. They lost the next three games in Baltimore and tonight I will be at Fenway with a friend as they stagger home with new wounds and unravelling emotions. Losing is a bummer. I know. I once played on a football team that was 1-9. It was the end of a deteriorating dream and the next year I was a medical student.
I will recover from the expected trauma of the trip to Fenway by taking a long walk with Chris Jedrey on Saturday and then celebrating a graduation with friends before returning to New Hampshire. I hate to remind you that there are only 12 more weekends until Labor Day weekend when the summer ends abruptly at 6PM on the holiday. Make the most of each one of them! |
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