13 November 2015
Dear Interested Readers,
Inside This Week’s Letter
There is nothing ordinary or typical about Vermont. Vermont feels like it is populated by people who seem to have a greater than average concern for the environment and for one another. Perhaps the crafts, art, music and interest in extracting as much from life as possible, plus its interesting and empathetic social philosophy that seems so proximate everywhere you turn is because many of the lasting elements of the "peace, love and back to basics" movement of the sixties and seventies came to rest in the beautiful valleys between those Green Mountains and along the eastern shore of Lake Champlain. This week’s letter is largely devoted to what is happening in healthcare in this state with a most remarkable sense of social responsibility. Perhaps theirs is not a beacon for all of us to follow, perhaps Vermont is just an anachronism, a simpler world where naivete and an undeniable desire for a better world will eventually collide with insurmountable realities. You decide.
The second section was a gift to me that I am passing on to you. Consider it a brief didactic guide and another future oriented competency discussion. It is about an article from the past, a description of “institutional intelligence” which may be like “military intelligence” an oxymoron in the minds of some.
I am hopeful that you will return this next week or in the very near future to strategyhealthcare.com where on the right side of the home page under the Elizabeth McCarthy story you will see a new place to click that is labeled “reference materials”. If you click “reference materials” you will find the speech by Dr. Ebert that I posted last July and also a new entry, the complete text intermingled with the slides that I presented to the Massachusetts Medical Society as “The Annual Oration” on November 28, 2012. “The Oration” is an event that has occurred yearly since 1803. I felt that the invitation from the MMS to give the Oration was a recognition of the great work and strategic conceptual accomplishments of my colleagues at Atrius Health and its legacy organizations. The Oration was an opportunity for me to pass along to others what I had learned from my experience in this great organization. It has been three years since the speech was given. I am sure that it already seems a bit out of date but I hope that you might find some benefit in reviewing the concepts that were discussed.
There has been a longer than usual hiatus between postings on strategyhealthcare.com due to the heavy schedules of some of the producers and the fact that the people who do the real work have other real jobs that compete for their time, but the regular postings will return soon. I do hope that you will direct friends to the site and let them know that is where they can sign up for these letters. It remains my hope that in some small way you might find these musings and strategyhealthcare.com helpful to you on your own journey to be a part of better care as described in the Triple Aim Plus One.
Looking For the Future in Vermont
This time last week I was attending a unique healthcare meeting in Stowe, Vermont. The Vermont Medical Society was meeting in a joint session with the Vermont Chapters of the American Academy of Pediatrics, the American College of Physicians, the American College of Surgeons and the Vermont Academy of Family Physicians as well as the Vermont Psychiatric Association. The agenda was as unique as the audience.
The Keynote address was delivered by Dr. Helen Riess from the MGH whose presentation was entitled “Professional Empathy Research: How Empathy Improves the Patient Experience, Improves Health Outcomes, and Reduces Costs”. She was terrific. Who knew empathy could be taught? Empathy can be measured and the impact of the absence of empathy can be measured down to the level of clinical outcomes and cost. The talk was complete with the neuroanatomy of empathy and a description of the external expressions of concern that patients can sense and that physicians who care about the outcomes of their patients can modify. Her research uses changes in electrical conductance in the skin to show either synchrony or discordance between patients and their physicians. Her final fact of importance, backed by data, was her demonstration that improved empathy reduces clinician burnout and “infuses meaning and joy back into work”.
The clinical subjects discussed in the open forum included opioid overuse and abuse and “The Health Effects and Social Policy of Marijuana”, as well as a multidisciplinary session called “Clinical Pearls: The Top Things Your colleagues Want You to Know”. I picked up a few surgical, psychiatric and pediatric pearls in that session that may be of future benefit for family, friends and my grandchildren, since my days of directly providing care are over.
Over the two days of meetings I suffered a few pangs of a desire to pick up my stethoscope and head to the hospital or office. Those feelings were most intense when I attended the breakout sessions that were more practice specific. In one of those sessions I heard one of the best clinical presentations I have ever heard, entitled “Management of Common Cardiovascular Issues”. I was intrigued by the discussion of the assisted suicide experience in Vermont which was part of a panel discussion, “Supporting Our Patients In Aging”. The panel included Dr. Riess but also a medical ethicist who is both an Episcopal priest and physician who provides hospital consultative services about ethical issues and another physician who is a geriatrician involved in hospice care. The panel discussed specific cases that demonstrated practical and ethical concerns in the care of those at the end of life. During that discussion I relived many of the meetings I had experienced over the years with patients and their families as we struggled together to find the wisdom to make the decision that best fit their values and hopes.
As great as the clinical discussions were, I had to remind myself that I was there to get a better feel for the mind of clinical leadership at a moment of great transition in Vermont. The subject that was at the core of the conference was the future of care in Vermont. I think that someone had a stroke of genius when they decided to weave a program from threads of traditional clinical discussions with a chance to talk about concerns and provide new information about the evolving policy issues that will determine the future of practice in Vermont. It was as if they had read some of Dr. Heifetz's thoughts about adaptive change. You might remember the quote from last week’s letter:
Adaptive challenges are difficult because their solutions require people to change their ways. Unlike known or routine problem solving for which past ways of thinking and operating are sufficient, adaptive work demands three challenging human tasks: figuring out what to conserve from past practices, figuring out what to discard from past practices, and inventing new ways that build from the best of the past. Your analysis of an adaptive challenge must take into account the human dimensions of the changes required--the human costs, pace of adjustment, tolerance for conflict, uncertainty, and risks, and the resilience of the culture and network of authority and lateral relationships necessary for carrying the organization through the pain of change…
It seemed that the activities were one big exercise designed to help Vermont’s physician leaders to come together to discern “what to conserve from past practices, ...what to discard from past practices, and [consider] inventing new ways that build from the best of the past". To actively assist the objective, the important discussion on the first day was entitled “Taking the Lead: Physician Roles in Health Reform”. It was a review of innovative efforts in several statewide value streams that had created opportunities for a wide variety of physicians to get involved in projects that would begin to transform practice while bringing them together across geography and between institutions.
The work was sponsored by a SIM grant to the state from CMS. The SIM grant also enabled my attendance at the meeting. The innovations presented ranged from collaborative efforts to use lab resources more efficiently to the practical approach to the reality that Vermont has a critical shortage of general surgeons. On Saturday the discussion of the future continued with a panel of clinical leaders and healthcare executives discussing the “Future of Payment Reform”.
Perhaps you heard about the proposal that Vermont’s Governor Shumlin had supported that would have created a single payer system. “Single payer” had been under strategic development for most of the past four years until the Governor withdrew the recommendation earlier this year. The Governor’s decision to abandon a single payer model did not change the perceived need for statewide clinical integration, quality improvement and cost reduction. It did not change the concern of many that the future health of Vermonters is at risk from the rising costs of the current system of fee for service care. Abandonment of a single payer model did not change the fact that there is a majority opinion within the state that the future health of Vermont’s citizens is absolutely dependent on clinical collaboration and cost control and that the pursuit of those objectives is still under the control of one single authority, The Green Mountain Care Board.
The panel included some members of the Green Mountain Care Board which has had the regulatory authority over hospitals in Vermont for most of the last five years and does have the statutory authority to set rates of payment for payers, hospitals and providers which it has not yet exercised. The Board has been meeting in working sessions for several hours every week as it has been trying to create a finance model that blends payment from public and private sources into one revenue stream.
The plan is dependent on negotiating waivers from CMS as well as having all three ACOs in the state merge into one care delivery mechanism that would negotiate with the Green Mountain Care Board for the resources to manage one clinical enterprise which provides the care for all Vermonters. An MOU has been signed by the three ACOs. The waivers from Medicare are still being negotiated and hospitals, primary care and specialty care are trying to figure out how to move from competing with one another to collaborating for the benefit of all Vermonters. Perhaps as a show of support Todd Moore, CEO of OneCare, the largest of the ACOs was on the panel and Dr. John Brumsted, the President and CEO of the University of Vermont Medical Center was present during the panel discussion and said a few words of support.
The Chair of the Green Mountain Care Board who was appointed by the Governor, is Al Gobeille. He is a young businessman who owns several restaurants in the Burlington area. He was the lunchtime Keynote speaker on Saturday. I do not think I have ever heard a better discussion of healthcare reform, its challenges and its opportunities than he delivered. He related healthcare to his experience in the food service business in a very effective way that was not offensive. He expressed amazement at the entitlement that was exercised by hospitals and physicians when they make revenue rather than costs, quality and service their highest objective.
He spent some time focusing on the proper dependent relationship of revenue, profitability and institutional success to outcomes, costs and service. He emphasized the uncertainty about revenue that most businesses experience. He subtly and facetiously questioned how healthcare got it the other way around thinking that revenue needs to be guaranteed regardless of quality and cost. He noted that it seemed that in healthcare concerns about revenue drives everything. He seemed to see a relationship between fragmented care and high cost as an expression of this inversion that saw revenue and not the cost, quality and service of the product as the focus of the effort.
In a humorous way he was able to express that his success as a businessman was a function of his ability to manage costs, develop a staff that delivered service and offer high quality meals to customers who would chose to return. Those are the factors that are real in his world and determine the revenue and profitability of his restaurants. Most important though was his sense of urgency. He can count. He knows that Vermont is the “second oldest” state (Maine has the oldest average age) and the healthcare needs of its senior population are increasing daily. He knows that the stress of a difficult economy is contributing to the burden of disease in the whole population and that the cost of care is out of sync with economic growth. He knows that “out of pocket costs” of care for a family of four with an income of $60,000 per year are crippling their ability to participate in the economy. The rate of the increase in their costs will soon make their theoretical charges more than half of their income which will be unsustainable. He also knows that all of the baby boomer doctors that populate the delivery system are retiring. He knows that as lovely as Vermont is for a vacation, recruiting PCPs, pediatricians, family physicians and internists alike is increasingly difficult. He knows that the number of general surgeons in the community setting is already approaching an emergency concern. He is keenly aware of the fact that there are already 5000 children in St. Albans and surrounding Franklin County who have no doctor. This man, who is the lay chair of the Green Mountain Care Board, can eloquent express that he knows where he is and what time it is.
Vermont has been actively trying to find its way to a better system of care since the 90s. Since 2006 “The Blueprint for Health” has been Vermont’s state-led initiative to implement PCMH related initiatives in every practice in the state. Since 2010 Vermont law has defined the Blueprint as a “program for integrating a system of health care for patients, improving the health of the overall population, and improving control over health care costs by promoting health maintenance, prevention, and care coordination and management.”
“The Blueprint” has had some successes and some failures. As is true with all attempts to create meaningful change, the journey to the vision of all Vermonters getting care in a medical home environment has been slow. Meaningful change in social and professional systems is always slow and there are always barriers. The critics accentuate the barriers and the proponents inflate the successes. The “Blueprint” vision was laudable but incomplete because it did not adequately address issues of finance and the integration of the primary care medical home with the rest of the care delivery system. Now the Green Mountain Care Board has broad authority that may accelerate the journey toward the vision that the Blueprint is seeking to describe.
Creating a confluence of resources that are an alternative to single payer and supporting the evolution of a single ACO that will be the delivery mechanism that combines the improved primary care practices with the hospitals and specialists as one integrated system are the dual challenges that the Green Mountain Care Board has the authority to assign to itself. Vermont through its legislature and its own experience has created a moment of opportunity that is truly remarkable.
The plans and efforts in Vermont should be of interest to us all. There are many things that make the situation in Vermont more interesting as a learning lab for much of the country than is Massachusetts. First, Vermont has given real authority and some resources to one expert board that is actively seeking what is best for Vermonters. I never heard it said directly but I got the distinct feeling that like it or not, the board puts the future health of its citizens a step ahead as a priority than it does the moment to moment financial worries of hospitals and physicians. Mr. Gobeille even said at one point that he sees the billions of dollars on the balance sheets of the hospitals of the Medical Center as a resource. [I think that Dr. Brumsted had left the room before he talked about appropriating the balance sheet of the Medical Center.] Can you imagine the Health Policy Commission of Massachusetts which hardly has a “bully pulpit,” much less any real regulatory authority, announcing that it sees the tens of billions of dollars on the balance sheets of the academic medical centers of Massachusetts as resources to be used to transform the delivery of care in Massachusetts with the objective of lowering the cost and improving the quality of care? The seismic response to that assertion would be greater than 8.0 on the Richter scale.
What also makes Vermont interesting is that it is an almost perfect pilot for much of America where life is centered in small towns with incomplete medical resources. In those environments we must look at the transformation of care differently. In much of the broad stretch of the country we may end up looking at the future through the lens of regional planning and not the evolution of competitive markets. Vermont’s small cities and towns dotted across a landscape of farms and mountains defines the problems of a new healthcare in terms of geography and a small defined population. Many states or parts of states have a similar distribution of population and geography.
The solutions derived from the evolution of a system of care and optimally designed for the megalopolises on the two coasts or the large cities of the heartland may not work in places like rural Pennsylvania, Kentucky, much of Iowa, New Mexico, and the list goes on and on. As a conceptual consideration, it is a huge advantage that the large majority of the residents of the state get tertiary care in only two academic medical centers, the University of Vermont and Dartmouth Hitchcock which are both a part of OneCare, the largest ACO and would be the major hospital resources in the new single ACO. [Despite the fact that Dartmouth Hitchcock is over the Connecticut River in New Hampshire, forty percent of its patients are from neighboring Vermont and it is a founding member of OneCare, the largest ACO into which the two smaller ACOs will possibly move.] No location in the state has a multiplicity of providers which makes market competition between providers on quality, price and service impossible. The total population of the state is 630,000 which is smaller than the primary care population of Atrius Health, a fact that adds to the plausibility of treating the delivery of care in the state as one enterprise.
The doctors who had gathered at Stowe were well aware of the history of healthcare reform in their state. They did not seem to be resistant to the funding proposals of the Green Mountain Care Board. They seemed intrigued or at least interested in exploring what it might mean to have all of their services be delivered through an ACO and receive their compensation through the ACO. I dislike the old cliche, “The devil is in the details”, but that is where the discussion now seems to be. It is rapidly becoming an exercise of detail consideration. What I heard from many voices that included the citizen chair of the board and many of the physicians that spoke was a fear about the future of primary care, mental health services, and chronic and preventative care. Several physicians seemed worried about how to blend the culture of those services with the distinctly different worldview and culture of specialists and hospitals in a system where most of the assets were preordained to end up supporting hospitals and specialists. As one PCP said, “We are 5% of the total expense of care. How does the tail wag the dog?” To that question I said to myself, “By realizing that in a global payment environment you lead the transformation that leads to a more judicious use of the other 95%".
One proposal that already seems baked into the plan is that as a first step the change in payment affect only primary care and that specialists continue to be paid FFS. It was never explicitly expressed but it was my assumption that Primary Care practices will have a global budget and that their judicious management of those budgets will essentially make the specialists subcontractors to them. Controlling and integrating the care of their patients for better outcomes on a budget is the mechanism that grants PCPs the operational ability to impact specialty and hospital use. How they work with specialists will determine the way that 5% tail with an eye on what is efficient and effective will be able to wag the 95% body of expense.
There is an interesting resource of information about Vermont’s journey which I heard people discussing. It is a blog written by a local journalist, Hamilton Davis. I quickly checked it out and discovered Ham Davis’ blog, avermontjournal.com, to be a terrific resource that oriented me to much of what I saw and heard. In his blog you will find a set of graphics that you may find useful as you try to follow the narrative of what has happened and what the Green Mountain Care Board hopes will happen.
As excellent as the graphics are they do not quite outline the story in terms of the confluence of efforts and assets going from the recent past to the current interim state. I paint my picture with words so here is an outline with references to time that I hope will augment your understanding of what has happened and hopefully will happen in the very near future. The picture that I hope evolves in your mind’s eye will show how the continuing “Blueprint” efforts to improve primary care along the lines of medical homes fits nicely into the new finance through the ACO and the necessity of primary care to manage the resources that flow from payers through the Green Mountain Care Board as a single source of income to the merged ACO. I hope the list below will also help you appreciate the vision that is powering the Green Mountain Care Board strategy and was in essence the subject of the conversation over the two days.
WHAT DID EXIST: Independent primary care physicians, primary care physicians in federally qualified health centers, and primary care associated with academic medical centers all working in a traditional way with specialist in private practice, community hospitals and academic medical centers. Care is provided in community hospital environments and in academic medical centers. Where care occurs is more a function of circumstance and finance than as a function of the coordination of care to insure that it is delivered in the most appropriate site that is closest to the patient’s home.
THE INTERIM REALITY: Primary care practices in the private environment, the federally qualified health centers, and in affiliation with hospitals are attempting to follow the path outlined in the Blueprint toward more robust medical homes that focus on a better use of resources through care coordination, population management tools and team based care. Some patients from publicly funded sources, plus a minority of commercially funded patients, get their care from three ACOs. OneCare includes Dartmouth and The University of Vermont Medical Center plus most of the community hospitals. There is an IPA based ACO with about 70 independent practitioners. Another ACO serves federally qualified health centers. Specialty care and Primary care is FFS and the ACOs are upside sharing of savings with no risk. OneCare has already been qualified as a Next Generation ACO.
THE FUTURE VISION:
- Medicare, Medicaid, commercial insurance and out of pocket co pays are blended into one revenue stream by the Green Mountain Care Board (GMCB). This requires a waiver from CMS and continued adequate funding from the state for Medicaid.
- The IPA affiliated ACO and the FQHC ACO blend into the larger OneCare ACO. An MOU has been signed and discussions continue. There is optimism about a positive outcome.
- The GMCB negotiates risk contracts, budgets and payment details with the ACO that cover all the willing physicians and hospitals in the state.
- Most Vermonters get their care through the ACO. All patients are attributed to a PCP.
- Hospitals and primary care are paid through the risk contracts.
- Specialties are paid FFS. (Presumably units of care delivered by specialists are ordered by primary care through the referral process since all patients are attributed.)
As you might imagine, the discussions were full of questions and concerns from the floor that you might have asked if you, like them, were trying to understand a sweeping proposal and decide whether or not to accept an invitation to be a pioneer in an effort that will define a future that is quite different from anything anyone ever expected. There were concerns expressed about inadequate mechanisms of attribution and an inability to control leakage especially as older patients migrate to warmer climates to avoid the winter weather. Many were at a loss to understand how the program could tend to both the investment and financial needs of primary care and behavioral health when specialists and hospitals required so much of the healthcare dollar. Specifically many just spoke to the spiraling negative effect on retention and recruitment of PCPs at the current balance of workload, regulatory burden and compensation. The loss of physicians in Franklin County was exhibit one in that argument.
Many spoke to their apprehension about the tensions in the working relationships between primary care and hospital based physicians and specialists. There is a tradition of independent practice in Vermont and those physicians are not sure how they will fare in a more integrated environment. One compelling argument that was mentioned several times for Vermont’s continuing to search for solution was the new law that I have mentioned before, MACRA, the Medicare Access and CHIP Reauthorization Act of 2015. The link points to an article written by Patrick Conway, MD, the CMO of CMS, and others. The article notes that “the comment period” before final regulations on this legislation has been extended until November 17. It is important to remember that MACRA was passed with bipartisan support and replaces the SGR. It is noteworthy that MACRA is connected in theme to the ACA but is not part of it and is likely to survive as a value based replacement for the SGR no matter which party wins the presidency in 2016.
As I listened to the presentations and heard the questions that they were asking of one another there would have been nothing that I would have enjoyed more than to join their conversation. I held my comments to myself, but had I spoken there would have been many things that I would have said.
- First and foremost I would have saluted them for the progress that they have made. I was impressed with the clarity of their overall vision and the understanding and cooperation within state government and between state government and high levels of healthcare leadership that have allowed them to get this far.
- Second, it is remarkable that they have fostered a conversation over several years that has lead to a critical mass of leaders who have an understanding of the challenges ahead. Lean teaches that the square root of “n” is the number of leaders compared to the number of people in the whole organization needed to foster change. If “n” is 100 then 10 leaders are needed. I do not know the total number of physicians in Vermont and I feel that “n” in a healthcare system includes all of its employees and participants so that there is a continuing need to communicate and educate all those who participate in the delivery of care in Vermont. Some critical number must “care why”. [See discussion in the next section for a definition of “care why”.]
- Thirdly, the system must work with Vermonters for their benefit. Finding others from the community who can articulate an understanding of the objectives of healthcare reform like the Green Mountain Care Board chair, Mr. Al Gobeille is a challenge that must be meet. The audacious goal would be for all Vermonters to understand the objectives of good care and its importance to their community, and then trust but hold accountable those whose task it is to give them good care. Perhaps someday pigs will fly or it will snow on the fourth of July. At a minimum there must be a continuing conversation about community benefit. It would be nice if it could also extend to education.
- Finally, do not be discouraged by the natural pace of progress. Good ideas emerge. Some work out, some do not, but any effort reduces the level of ambiguity about the possible. The Governor’s retraction of “single payer” after four years of discussion is a great example of this reality. “Strategic deployment” is part of a process of continuous improvement. The dream of better care and the tools to effect that dream will require Vermont to think of itself as one enterprise and adopt an organizational operating system for that enterprise. There are good examples to learn from. I am thinking of Denver Health and the recently renamed New York Health and Hospitals Corporation, NYC Health + Hospitals. Both organizations have transformed the care of large populations using Lean culture and tools.
My list could go on with more detail for quite a while. Future success is dependent upon the continuing great leadership that they have and the cultivation of more leaders who are aligned with the vision and goals of the original Blueprint and the subsequent evolution of thought from the experience gained on the journey. Last week I referred to an essay published recently by my son on his music blog. It represented a new direction for him and the content of the post speaks to how we view the future. He was writing about his thoughts regarding the future to his audience of Millennials who were celebrating the 30th anniversary of the Back to the Future trilogy or franchise.
The Back to the Future trilogy suggests that the ripple effects of our decisions can be felt on a macro scale as well; that what we do can change the whole world, not merely our own lives. The bleak alternate 1985 of Back to the Future Part II is a parable about abuses of power and the pitfalls of greed. This is a basic lesson that we can all take to heart. What we do today will impact the world we live in tomorrow. Like Back to the Future, this lesson seems like it’s all about what lies ahead of us, but it is fundamentally a statement about the present, and what we decide to do with it.
We’re not Marty McFly and we don’t have time machines. Are you disappointed that 2015 doesn’t look like a fantasy dreamed up by Hollywood decades ago? It’s okay if you are. I am too, but only a little bit. It’s fun to tally up what the films got right or wrong, but here’s the real point: if you don’t like the way 2015 looks, do something about it. I’m not necessarily saying you should go out and build a hover-board (actually, who am I kidding? If you can, please go build a hover-board), but there’s a lot we can do right now to live in a better world. You don’t have to work in Hollywood to see what could use some improvement. Since you can’t hop in the DeLorean and patch up your mistakes after you’ve made them, it seems like you’ve got to do the best you can right now. If you don’t like the trajectory you’re on, change it. There’s no time like the present.
A few words changed here and there and that is a great battle cry for a better future for healthcare. I also stumbled on another comment about the future this week in one of the daily emails that come from The New Yorker.
To live in the modern world is to live partially in the future—at least, in one’s mind. Perhaps, in some ancient period, time felt more self-contained. Back then, when you imagined the next year or decade, you merely refashioned, gently, the time in which you were living. That’s not the way it works now. In today’s careening, technomaniacal world, dramatic change feels just around the corner. We see the present as an urgent moment, a final chance to prepare for what’s to come.
—Erin Overbey and Joshua Rothman, Archivists, The New Yorker, November 8, 2015
It is sort of interesting to conceptualize that the last spurt of growth in Vermont seemed to come from baby boomer “hippies” who took to the mountains to find a simpler, slower lifestyle infused with music, art, perhaps using some chemicals to expand their minds, but generally rejecting the pace of a world from which they felt a little alienated. Some of them now discover that good care that can be afforded and sustained for themselves and their community is within their grasp if only they can act like a community. Their story, as it unfolds further, will be worth watching for the rest of us who would like to see their principles scaled up to larger populations, if they can get it right.
An Unexpected Gift
Last Sunday evening the neighbors that we know best invited us to share dinner with them and another couple whom we had briefly met once or twice before. They are an interesting couple. He is a self employed consultant with decades of experience in planning urban and community projects. She has a leadership role in IT project management at Dartmouth. We all have grown children who are figuring out how to be successful in a world that is much more competitive for opportunity than the world we entered in the sixties and early seventies. I looked forward to the evening based on the previous brief opportunities to chat.
At the table I was seated next to the woman who is the IT manager. We had a rich conversation about all that is happening at Dartmouth, including the status of it graduate schools. I commented to her that one of the most useful and informative papers I had ever read came from the Tuck School which is Dartmouth’s School of Business. She asked me who wrote it and what was it about and I confessed that I did not have the author, the reference or anything other than what I remembered, and was certain that what persisted in my mind after 20 years was perhaps not even what the authors wanted to impart. I had searched for the article and never found it and I had asked my daughter-in-law who is a librarian at UC Santa Cruz to help me and both of us had come up dry. I was not even sure who had given me the Xeroxed copy that I had read and I had lost all those years ago. I have occasionally, over the last eight years, obliquely referenced in these letters what I remember from the article but I am sure that there was more that I have lost or never appreciated since, in the interim, my own experience has grown.
She quickly responded that she loved a research challenge and that she would try to find a copy. The best I could tell her was that the article described a ladder of learning that climbed from no knowledge of a subject to what, to how, to why, to “care why”. Less than twenty four hours later she sent me the reference and then dropped off a copy at my home on her way home from work. Here is the URL. Unlike many of the HBS articles, you can read this one for free.
https://hbr.org/1996/03/making-the-most-of-the-best
The authors are James Brian Quinn, Philip Anderson, and Sydney Finkelstein. In the interim Professor Quinn has passed on, Professor Anderson now holds the faculty chair named in honor of Professor Quinn and Professor Finkelstein is internationally known as an author on leadership and strategy. Reading the paper now there is much more in it than I ever appreciated, or if I did appreciate it in 1996, did not retain. The core of their concepts, I did remember and rather accurately, although superficially. It is my hope that you read the whole paper. Like many HBR classics it has continuing value to those who want to understand organizations. Another frequent HBR contributor of the 80s and 90s, Charles Handy, wrote a chapter “The Citizen Organization” in his recent book of essays entitled The Second Curve, Thoughts on Reinventing Society. In the chapter Handy presents a view that builds on employee creativity and intelligence and envisions the corporations of the future to be more effective because they are more democratic. Not quite like the faculties of universities but composed of people who do “care why” although he describes their characteristics and does not use that term. He is primarily talking about today’s younger people who will lead in the future when he says:
“...having been brought to regard their parents as service providers rather than authority figures, they have learnt negotiating skills early on. As a result they have no problems questioning or contradicting authority. Having acquired interactive skills in their early schooling, they like working in groups, solving problems and developing these skills...they respect leaders...who respect them...knowing more about their jobs than their bosses and adept at using social and information technologies, they can be demanding but interesting colleagues.”
One message in Handy’s book is that the past is the most significant barrier to the future but a barrier that time and the inevitable departure of today’s leaders will overcome.
I think that an accumulation of “care why” knowledge in the emerging generation of leadership is a reason to have hope for the realization of the Triple Aim Plus One through more “democratic organizations. I also think that Lean is the best currently available operating system that can hold a more democratic organization together as it decreases the chasm between management and the intellectual capabilities of the modern workforce. Once gain, as Handy says:
The change will come, if it does, from new organizations led by individuals of the sort...who will want to create the kind of company [healthcare enterprise?] that they themselves would be comfortable working for, because a Second Curve in organizations and society is seldom led by those who were in charge of the first curve. Sad but true.
With that introduction here is the core of that paper that I read 20 years ago. I hope that you at least read the fourth point, that was the point that really caught my imagination, the “care why piece” which I have bolded.
Cognitive knowledge (or know-what) is the basic mastery of a discipline that professionals achieve through extensive training and certification. This knowledge is essential, but usually far from sufficient, for commercial success.
Advanced skills (know-how) translate “book learning” into effective execution. The ability to apply the rules of a discipline to complex real-world problems is the most widespread value-creating professional skill level.
Systems understanding (know-why) is deep knowledge of the web of cause-and-effect relationships underlying a discipline. It permits professionals to move beyond the execution of tasks to solve larger and more complex problems—and to create extraordinary value. Professionals with know-why can anticipate subtle interactions and unintended consequences. The ultimate expression of systems understanding is highly trained intuition—for example, the insight of a seasoned research director who knows instinctively which projects to fund and exactly when to do so.
Self-motivated creativity (care-why) consists of will, motivation, and adaptability for success. Highly motivated and creative groups often outperform groups with greater physical or financial resources. Without self-motivated creativity, intellectual leaders can lose their knowledge advantage through complacency. They may fail to adapt aggressively to changing external conditions and particularly to innovations that obsolesce their earlier skills—just as the techniques of molecular design are superseding chemical screening in pharmaceuticals today. That is why the highest level of intellect is now so vital. Organizations that nurture care-why in their people can simultaneously thrive in the face of today’s rapid changes and renew their cognitive knowledge, advanced skills, and systems understanding in order to compete in the next wave of advances.
Intellect clearly resides in the brains of professionals. The first three levels can also exist in the organization’s systems, databases, or operating technologies, whereas the fourth is often found in its culture. The value of intellect increases markedly as one moves up the intellectual scale from cognitive knowledge to self-motivated creativity. Yet most enterprises focus virtually all their training attention on developing basic (rather than advanced) skills and little or none on systems or creative skills.
Baseball Withdrawal
The season has been over almost two weeks since the dramatic conclusion in the fifth game of the World Series. You would think that managers would have learned by now that any pitcher worth his salt is going to want to stay in the game even when statistics and an objective eye can say that they are toast. I am coming to realize more and more that team sports are as much about management’s performance as they are about the performance of individual athletes. Great athletes can cover up many defects in management and coaching but great coaching and management can get better results from more ordinary athletes and bad management wastes the best efforts of everyone. Those principles apply to healthcare as well as well as all sports.
I enjoy the daily demonstration of these realities that baseball offers from early April through late October and a day or so of November some years. The weekly dosing interval of football is not therapeutic for me and basketball and hockey do not allow the same sort of moment to moment opportunity to see the the subtleties of the player/management interaction. My mirror neurons just do not work as well in those sports.
One disappointment from my trip to Vermont was that the combination of weather, shortened daylight hours, and full meeting schedules conspired to deny me the joy of walk there but as I was coming and going I did enjoy the scenery as you can see by the dark beauty of a late afternoon shot of Mount Mansfield in the header this week. Next trip I am going earlier or staying later. I am learning from a mistake.
No matter what the weather will be this weekend, it is a good bet that it will not be long until it is worse so take every opportunity to be out and about on your two legs when the sun does shine, as I hope it will on you and me this weekend. |
