14 August 2015
Dear Interested Readers,
Inside this Week's Letter
Even though August 14 is the 70th anniversary of VJ day and the 80th anniversary of FDR’s signing of the act that created Social Security, I have not written about them but I do want you to note the events. The victory over Japan signaled the end of hostilities of WWII on August 14,1945, exactly ten years after FDR signed Social Security in 1935. This was a joyous day 70 years ago and I feel that I should give it some notice. Our victory over Japan resulted in a tumultuous celebration, the spirit of which is captured in the iconic photograph in today’s header. August 14 is a big day in our history.
This week’s letter does begin with a big “hello and welcome aboard" to many new readers who were an unexpected benefit of Paul Levy's comments about last week's review of John Toussaint's new book, Management on the Mend. The readership of this letter increased over 10% following that review and Paul's subsequent comments on his blog! I then share excerpts from Paul's blog, posted this past week, which in my opinion include some of his best work. For me this connection of our readers who are interested in many of the same subjects, is a startling demonstration of the power of electronic communications.
The letter then continues with a discussion of the history of our healthcare system based on a lecture I gave this past Monday at the Tufts Health Care Institute. This section connects the events from over a hundred years ago, from the Bull Moose Party of Teddy Roosevelt to events that can be traced through the creation of Social Security in 1935, Medicare and Medicaid in 1965 and on to our current healthcare discussions. This section relies in part on my own remembrances of growing up in the post war explosion of babies, business, and the tension of the struggle for the full and just implementation of what the Declaration of Independence suggests are the “inalienable right” of everyone, not just white male landowners.
The final more whimsical (as always) section begins with a recurrent musical trigger in my mind that causes me to ponder the realities of the fading summer season and the seasons of my own years. I go on with some continuing narrative about Roger Goodell and TB12, as well as the struggles of my beloved Sox. I attempt to share the pain of having tickets to a few more opportunities to pay $45 for parking and even more good money for bad food and beverages while continuing to watch the slow motion completion of an organizational disaster that seems to have lost its way for a lack of focused leadership, a recurrent theme in sports, politics and healthcare.
As always I want to remind readers old and new that your comments about any thing that I write or whatever is on you mind may be sent directly to me just hitting “reply” to this email. I hope that you also visit the blog, strategyhealthcare.com, where you can ponder these same ideas in a shortened, better edited form, and find the PDF of the “story” that I published last spring in these Musings as well as the full text of a famous speech made by Robert Ebert in 1967. The blog is also where your friends and colleagues might sign up to receive their own copy each week of these “Musings”.
The Power of A Positive Comment
Just a few minutes after the publication of last week’s letter which focused primarily on John Toussaint’s new book, Management on the Mend, I received an email from Paul Levy, my friend and former CEO of the Beth Israel Deaconess Medical Center. For many years Paul has written a far ranging blog on healthcare that once was entitled entitled Running a Hospital. After he left the BIDMC, he quickly changed the title to Not Running a Hospital and did not break stride. I am a regular reader of his blog and I am envious of his ability to put up several postings a week.
Paul and I have the sort of relationship that survives occasional differences of opinion. He will frequently write me after one of my letters to inform me of the narrowness of my view or at a minimum, a difference in perspective. We have always been able to find common ground on the key issues of the importance of safety, quality, patient centeredness, collaboration and attention to the training of the next generation of medical professionals. From my perspective we differ primarily from the perspective of time. Paul is impatient and a little bit angry with what he sees as the motives and direction of many of the powers that be in healthcare. I tend to have a more hopeful, long term view and enjoy celebrating small gains in what I believe is a slow, slow process that is moving in the right direction. I wish it would move faster but, as my wife frequently says, “I have been to the theater” and from my experiences in life, I accept the way our American world works.
Our President seems to share my perspective on time and America's slow but steady progress as revealed in an interesting letter he wrote this week to the editors of the New York Times Magazine in response to an article they published about attempts to undermine the Voters Rights Act signed, along with much of the Civil Rights and social legislation of President Johnson’s “Great Society”, during the amazing summer of 1965.
The President begins the letter with a thought that I have bolded for your attention. It resonates with my experience:
‘‘We the People of the United States, in Order to form a more perfect Union. ...’’ It’s a cruel irony that the words that set our democracy in motion were used as part of the so-called literacy test designed to deny Rosanell and so many other African-Americans the right to vote. Yet more than 70 years ago, as she defiantly delivered the Preamble to our Constitution, Rosanell also reaffirmed its fundamental truth. What makes our country great is not that we are perfect, but that with time, courage and effort, we can become more perfect. What makes America special is our capacity to change.
I believe that there is a harmony between my willingness to work toward a better outcome in times to come and Paul’s sense that yesterday was too late already. We see eye to eye on the broader scope of the issues that must be resolved for the Triple Aim, an “ideal or better state” of healthcare, to emerge for all. We share a commitment to expressing our belief, derivative of our personal experiences, of the importance of Lean and continuous improvement. We both understand that an organization is rudderless and nothing works without leadership.
My exchange with Paul continued through a few cycles of emails and included some jokes about his eligibility for Medicare since I noted from my Google calendar that it was also his birthday. I mistakenly thought, perhaps because of the fact that we also share gray hair, that this was his birthday that made him eligible for Medicare. Not so! After that error, he moved the conversation to the more serious discussion of leadership referencing John’s book. I was surprised that suddenly our conversation had become a blog posting complete with links to my letter as you can read below:
For some of us, one thing that makes Friday a great day is receiving Gene Lindsey's weekly email. It's full of observations about the health care world, living in the woods of New Hampshire, and baseball--not to mention nostalgic visits to his childhood. (You can read previous editions here.)
Gene is a die-hard adherent of Lean, a process improvement and managerial philosophy that has both been used to great effect in the hospital world and has been an utter failure in the hospital world. I am pleased that my hospital's experience fell into the former camp. In this week's edition, Gene reviews John Toussaint's latest book Management on the Mend, where he excerpts useful thoughts offered by one of the most successful employers of Lean.
Why has Lean succeeded in some places and failed in others? Gene summarizes the key lesson from the book:
"I think there is great evidence that John has walked the talk. Indeed the necessity that leaders be personally transformed if organizational transformation is to occur is a recurrent theme in the book which is really an open letter to healthcare leadership and their boards with the express purpose of convincing them that leadership is critical to Lean success. He introduces this idea on page three!
"The most common problem that I see [discussing the more than 145 organizations that he has personally visited that are in various stages of understanding Lean] is that leaders fail to recognize the magnitude of change that will be required and that change extends to leaders on a personal level."
I wrote back to Gene:
I went through it by osmosis, I guess, but as I look back on it later, I see a major maturation that took place in my leadership approach…
The most important outcome of the exchange is that the review triggered Paul to republish in this week’s blog postings excerpts from a series of articles on leadership that he wrote for Athenahealth. I have enjoyed everyone of them and you can too if you click here. Be sure to scroll back to Monday to enjoy the whole series. Each posting begins with the same intro:
Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since then. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here.
The second outcome of our exchange was probably derivative of that very complimentary first sentence of his Friday posting: For some of us, one thing that makes Friday a great day is receiving Gene Lindsey's weekly email.
Beginning a few minutes after the publication of that sentence my email began to ping regularly with notifications of people signing up to receive the Friday letter. The pinging continued through the weekend and did not stop until Tuesday. When the dust settled, the readership of this letter had increased by more than 10%. There are new readers from every section of the country, Canada, Scotland, and England!
To the new readers, I say welcome! I hope that we will form a long term relationship and that you will follow Paul’s example of frequently giving me feedback. Some of the letters that I have most enjoyed writing were letters that evolved from reader input. To Paul, I am grateful for your interest and support and will continue to look every day for your blog. Apparently I am only one of a host of your many “Interested Readers”.
Yesterday’s posting from Not Running a Hospital seems important to pass on to you in case your good intention to check it out gets deferred. It is a perfect example of the clarity of his writing and of his justifiable impatience with change and his anger directed at the slow to change “status quo”. What follows is abridged from the original. The bold areas represent thoughts that I do not want you to miss:
After her fifteen year-old son Lewis Blackman died from a series of preventable medical errors, Helen Haskell diagnosed the problems in the hospital by saying, “This was a system that was operating for its own benefit.”...
I once heard a Harvard business professor describe the financial imperatives of many hospitals in a less personalized, but analogous fashion. He called hospitals “business cost structures in search of revenue streams.”
What he meant was that the business strategies of the hospital had become detached from the humanistic purposes that had led to the creation of the hospital. There was thus a parallel to the individual's behavior noticed by Helen.
What a perversion of human endeavor when things reach this point! Activity for the sake of activity in the context of an organization that has lost its soul.
Lest we get distracted by the current debate about the incentives that might correspond to different payment models—fee for service, bundled, or capitated rates–is important to note that this kind of perverted personal and corporate behavior is not driven by rate design. The failure of Lewis Blackman’s doctors and nurses had nothing to do with financial incentives. No, the systemic forces at work that killed this young man were based on ego, fear, poorly functioning hierarchy, lack of communication, and cognitive errors.
Likewise, the corporate search for revenue for the entities that constitute our hospitals and health systems has not been driven by rate design. Under any payment regime, the underlying issue is that hospitals are huge fixed-cost enterprises, and the incentive to “feed the beast” often drives corporate strategy, driving out humanistic concerns. Indeed, it may be that a movement to provider risk-sharing will simply compound the problem in that it will require hospital systems to accumulate greater financial reserves to hedge the actuarial risks that are being transferred in their direction.
Let’s not lose the irony of this kind of situation. The people who have chosen to be in the health care field are, for the most part, the most well intentioned people in the world. They have devoted their lives to alleviating human suffering caused by disease. They are intelligent and thoughtful and highly trained.
Indeed, if each of us in health care were asked to state the purpose of our institution in our own words, I bet we would say something similar. In my former hospital it was codified as follows: “We hope to take care of patients in the manner we would want members of our own family cared for.”
People’s behavior in the moment, though, often is at variance with such purposes. Corporate imperatives likewise go awry.
It is at time like this that we search for leadership that will help steer the ship and those in it in a more humanistic direction. Surely the leader cannot be agnostic with regard to financial concerns, but he or she needs to act to help the organization put purpose above all. What can we expect and hope for from great leaders at this juncture in medicine’s crisis of purpose? The usual answer—inspiration—is not correct...
My view is that inspiration comes from within and is tied to those ethical standards and good intentions that caused people to enter the health care professions in the first place. The leader’s job, then, is not to inspire. It is to use his or her influence to help create a supportive environment that permits the waiting reservoir of such intentions to be tapped.
Paul O’Neill, former Secretary of the Treasury and CEO of Alcoa Aluminum, has set forth a three-part test for an organization seeking to empower its staff to fulfill its mission:
- Are my staff treated with dignity and respect by everyone, regardless of role or rank in the organization?
- Are they given the knowledge, tools and support they need in order to make a contribution to our organization and that adds meaning to their life?
- Are they recognized for their contribution?
The leader’s job is to carry out an ongoing negotiation with the various constituencies in a hospital to persuade them that it is in their interest to organize their work and behavior in such a manner as to permit these conditions to take hold... You cannot be a leader if you do not know how to help a hospital’s constituencies understand that their interests are coincident with the purpose of your organization and if you cannot help them jointly decide on the actions needed to carry out that purpose.
“Lately it occurs to me what a long, strange trip it's been.”
Many of you, dear Interested Readers, will know that I have lifted the title of this section from “Truckin'” by the Grateful Dead. It certainly expresses the way I feel about the process that occupies so much of healthcare’s collective attention these days. The thought is also at the root of some of the apparent but not real differences in the way Paul and I see this moment in time. It is certainly connected to President Obama’s feelings expressed in his letter to the editor that you may have read from the link earlier in this letter and it was the driving concept behind the presentation that I gave at Tufts last Monday.
I was delighted several months ago when Rosalie Phillips, an old acquaintance and colleague from the glory days of a young and radical Harvard Community Health Plan, called me with her colleague, Ralph Halpern, to ask if I would participate in their annual one week course for young healthcare leaders who were still in their residencies. The course has been an annual event for many years. I had spoken for them in 2013 about ACOs but last year our trip to see our newborn grandson precluded my participation. My surprise was that Rosalie and Ralph wanted to know if I would accept the task of speaking to the title “The Evolution of the U.S. Health Care and Insurance System”.
I was delighted with their request because although I had never given such a talk and would have to create the talk from scratch, I believe that the history of where we come from informs our solution approach to many of our current concerns. I have always had an interest in the “origin of the moment”. My interest in the connections that history reveals goes way back. I was the DAR Award recipient for the best eighth grade student in American history! I think I won the award not on the basis of what I was taught but based on the fact that in the seventh grade I got “hooked” on the historical novels of Kenneth Roberts who treated history accurately in his tales of adventure like Northwest Passage, Rabble in Arms, and Lydia Bailey.
As I accepted the offer, I informed them that I would be drawing heavily on two books that I have mentioned in these notes before, The Heart of Power (2009) by David Rosenthal and James Morone and Power, Politics and Universal Health Care (2011) by Stuart Altman and David Shactman. They suggested that I also use Jonathan Oberlander’s 2012 article in the NEJM. What you will read, if you chose to go further, is a combination of those works plus some of my own ideas and connections as a witness to the last 50 years of the journey. I knew that my entire audience would have been born at least a decade if not two after I started to practice. I was not sure what they knew or whether they would have any interest in or could come to appreciate the story that I wanted to tell or agree with the conclusions that I would extract.
As I thought about the residents, I realized that these concerns may apply to many of you as well. I vaguely remembered a story from Plato or perhaps Socrates or Aristotle or one of their contemporaries about the acquisition of awareness and the importance of our culture of origin in determining what we see, think and do while we are here. I am not referring to Plato’s famous metaphor of the “cave”. That is another story, although related in many ways.
In the story that vaguely resides in the shadows of my memory, we are born into the world knowing nothing. It is like entering a room where there has been an ongoing conversation for years. We do not know the language and we have no personal experience with the subject discussed, or the people who are talking. We are just there. Things gradually change and we acquire the language of the room and come to accept and feel affiliated with the others in the room. We join the conversation. Others enter the room and in time add their voices and ideas to the conversation. We begin to notice that some are leaving the room and their voices are no longer heard.
At some point we may realize that from our perspective there are flaws in the rationale of the conversation. We gain the courage to participate. Our participation in the conversation may change our point of view. Perhaps as time passes we begin to see ways in which we want to redirect the conversation. Finally we realize that there are very few people in the room who have been in the conversation as long as we have. Other voices begin to become louder and gain the attention of more and more of the new arrivals. Their ideas are in part built old ideas as well as on our ideas, either as an acceptance or a rejection of our thoughts. Then we realize that for us the time is late. We are weary. It is time to leave the conversation to the more recently arrived voices that are gaining their confidence. The conversation has moved on and there is little for us to contribute that seems fresh or interesting to the others in the conversation.
Some may remember for a while what we said; but in the end most of what we contributed persists only in the context of little bits and pieces that are not individually distinguishable and the specifics of our contribution has been appropriately lost as the faces and voices in the room continue to change. Others are coming to take our place. We depart the room with others who together with us wish the best for those who are now leading the conversation.
My poor rendition does not highlight well how important it is to recognize that the culture in the room and the conversation is affected by events unknown to or forgotten by many of those in the room. It is my assumption that Santayana was referring to this concept when he famously said that those who do not remember the past are doomed to repeat it.
All these thoughts were in my head as I prepared my slides in early July and the same thoughts flashed again across my mind the moment as I rose to speak to all of the earnest and attentive young clinicians who were gathered in front of me. I had been given the benefit of the slides and notes of two speakers who had been assigned this subject in previous years but I had been in the conversation long enough to want to put it together my way.
Below with some explanation are some of the points I tried to make about the journey to universal coverage and the Triple Aim beginning over 100 years ago. That concept establishes the longevity of this journey. Teddy Roosevelt had a “plank” in his 1912 “Bull Moose” party platform that would have given everyone healthcare.
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