16 February 2018

Dear Interested Readers,


Reflections on What I Read and Hear in the Media, and Background for This Week’s Theme

I’ve been in California this week. The trip began with a weekend visit to family in the Santa Cruz area followed by a trip down to San Diego for a meeting. My perspective is always a little different on the left coast where diversity is the norm, and there seems to be a more widespread awareness about the societal and ecological challenges of the future. Perhaps I am wrong, and it’s just an outsider’s perspective. The big local news before word came of the school shooting in Florida was that there have been over 250 deaths in the San Diego area from the flu this year. The deaths occurred among the youngest and oldest members of the community. National numbers are a little less explicit, but a recent CDC report confirms it is a bad year with most of the deaths coming from the H3N2 strain. Unfortunately, the vaccine created for use this year is suboptimal although not without some benefit.

News and numbers like this always raise questions. Are we adequately funding the development and production of the best possible vaccine? Did we adequately reach out to everyone with an opportunity to be vaccinated with what we had, even though it had its shortcomings? Were we prepared to receive and support the sick who came for care? Do we adequate sort those who need more intense care from those who can be safely sent home? I have read in the media of some children who were evaluated and sent home where they died within a few hours.

When problems arise like the flu outbreak, the opioid crisis, a slow response to some natural disaster, or yet another school shooting, there are several possible responses. Some politicians and professionals respond with an analysis that seems most focused on how the event or outcome is not their fault or was really the responsibility of some other agency or individual. Sometimes there is a virtual denial of responsibility and a sense of helplessness, as if there was nothing that could be done, or that available resources are inadequate. On occasion there is an effective response as there has been to the danger of flying in the post 9/11 era, or to the zika virus threat, or the ebola scare.

No matter how things play out we have developed a liturgy that we follow with each disaster. Almost always someone somewhere says, “The American people deserve better…” As I saw on television this time around, there are news conferences. The governor of whatever state the event occurred in makes positive statements about what will be done in the immediate aftermath of the situation, acknowledges the losses, and offers condolences. Sometimes the governor may personalize the event referring to concerns about his own children or grandchildren, as did Governor Scott of Florida. Soon there is an appearance by the president who repeats the same words, and promises actions. On Wednesday the president immediately identified mental health problems as the cause which they may be. He said nothing about guns, and how guns are one of the controllable vehicles that multiply one man’s mental health issues into potentially avoidable misery and suffering for so many.

The process usually includes promises of investigations, congressional and administrative considerations, and potential policy changes. Politicians talk about “holding people in their thoughts and prayers,” but are careful not to say anything that might challenge a key constituency in their political base, or recognize that any previous policy or decision like blocking the merging of Social Security Disability data for mental health reasons with the database on gun registration might have been a contributing factor to the problem at hand. It is hard to hold cynicism in abeyance when we have seen this movie before. We know that like many of the drugs we use in the practice of medicine, the public’s emotional response to bad news has a short half life. It is easy to talk about praying for victims. A cynic might say that many of the prayers are, “Thank God it was not me or one of my kids!” Even more cynical is the realization that the next news cycle may contain an event that will move the current problem off the airways and the front pages, and the agency or politician whose portfolio would suggest that he/she is accountable can count on the public's short attention span and emotional “disaster fatigue.”

The response that we rarely see is the actual in depth analysis that leads to substantial change and improvement. My face is red, and I hold myself accountable for not remembering the fact that there have been 18 school shootings since January 1. I guess that I must be numb or oblivious to a shooting unless there are more than ten deaths. Maybe I have just given up hope that there is any event that could lead to substantive change, and instead I am depending on an odds analysis that suggests that the chances are small that someone close to me might someday be harmed. Columbine should have been enough for all of us. If Columbine was not enough then surely Sandy Hook in Newtown should have sealed the deal even if shootings at concerts, theaters, and nightclubs don’t count. Maybe we will need to wait for a new generation. One of yesterday’s survivors said, “We’re children. You guys are adults.” It will be interesting to see if this time the adults do something that makes a difference. Don’t count on it.

As chance would have it there were two healthcare professionals from England at the meeting I attended in San Diego. Both of them have held high positions in the NHS. One had considerable personal contact with Tony Blair who worked hard to improve care in the NHS during the eleven years that he was the prime minister. I have known these folks for a few years, and we have had many conversations at other meetings where we have compared our experiences in both healthcare and societal and political issues as they vary across the Atlantic. Most things are very similar. We enjoy equally comfortable lifestyles. I get extra points for owning a vintage TR6. They respect us, but do not understand our reluctance to deal effectively with the issue of gun violence.

One of my British friends is a proud owner of several pistols, rifles, and shotguns. He enjoys hunting at his home in the country and likes target shooting. Some of his guns are collectibles. He has gone through a substantial process of licensing to prove his worthiness for gun ownership. He expects that the local police will visit his home several times a year to examine his guns, make sure that he is still responsible, and that his guns are in good working order, and are properly stored. That process feels good to him and reassures him that Britain’s death rate from gun violence will remain a small fraction of our rate. He points out that there is virtually no gun violence in Britain.

Since the police do not usually carry guns, he says that the criminals avoid them also. Britain still has crime and some gangs, but if criminals do use a weapon, it is usually a knife. It is hard to kill 17 people with a knife. This trip over my friends were impressed by how kindly and empathetically the San Diego police treated the homeless people on the street, many of whom have mental illnesses. Their society tries hard to treat everyone with equity and has a different approach to homelessness and the overall social safety net. Their approach has many limitations. They have cost concerns also. It just seems there is a mindset difference that leads to somewhat different outcomes.

In a column in the New York Times yesterday, Nicholas Kristof reiterated a suggestion that he made after one of the previous episodes of gun violence that occurred earlier this year. He suggested that we treat guns as a public health issue and he made his case with charts and facts. His column would be much too long for the attention span of some of our highest elected officials, and even though you probably do not have much political clout as an individual, I am sure if you read these notes, you can read and understand Kristoff’s presentation. Just to make the reading more interesting, focus on using the charts to compare the experience between America and Britain. Think about it with the same competitive focus we use when we think about winning gold medals in the Olympics.

It may surprise you to know that I do not think that we are going to hell in a handcart. I am persuaded by authors and thinkers like Robert Wright and Steven Pinker who point out the progress that we have made. Even authors like Ta’ Nehisi Coates who are very angry about the racism and inequality that persists do recognize our progress and the benefits we have achieved through science and technology as well as our expanded consciousness of human rights. This week I listened to an interesting podcast between Pinker and Ezra Klein about the ideas in Pinker’s new book, Enlightenment Now which I would recommend to you, if you would like company on a long drive or a four or five mile walk. It just feels to me that the progress we are making is the sort of progress that you can make trying to dig a trench with a spoon.

It is also true that although I do not think we are going to hell in a handcart, I do believe that we are walking through minefields where anyone of many active problems could suddenly escalate in surprising ways and negate all of our achievements. Human progress has always been a lurching path. We go forward and backward as the outcome of many complex functions over which most of us have little control. Our agency is limited, but not non existent. I implore you to think about what you can do as an individual, and what you might accomplish in concert with others to improve the problem of gun violence. Sometimes there is much to learn from focusing substantial attention on a difficult problem. Sometimes the changes required in improving one concern spill over to improve many other connected issues. That is one of the nice things about complexity.

The remainder of this letter is a continuation of reflections about the immediate future and the long range objective of the goals of the Triple Aim. My thoughts are a further distillation of what I took away from the conversation I reported last week between Zeev Neuwirth and Don Berwick, a discussion about Era 3 In Healthcare and the future of healthcare. You can review the condensed form of the first discussion on the Strategy Healthcare website. The meeting I attended this week in San Diego was a good place to bring others into the conversation about the future since it was a meeting of Simpler Advisors that focused on how to contribute more effectively to progress in healthcare over the next few years. Simpler has been a part of IBM Watson Health now for more than a year and the relationship, like all amalgamations, offers a combination of possibilities and frustrations. I hope that you enjoy the discussion.


Leadership and Lean: Challenges For The Future

Twice a year I attend a small meeting of Simpler executives and other advisors to talk about what is happening in healthcare. As I have reported in previous notes, Simpler now functions with a great deal of continuing flexibility within Watson IBM Health, just as Watson IBM Health functions with a great deal of administrative autonomy within the larger international IBM corporation. The new affiliation has not limited or modified Simpler’s relationships with any of it client organizations, and it theoretically offers expanded opportunities. The challenge remains how to optimize the new affiliation as part of the Watson Healthcare vision, mission and purpose. It is an inspiring statement with which I can feel aligned:

Empowering Heroes, Transforming Health

Our purpose is to empower leaders, advocates and influencers in health through support that helps them achieve remarkable outcomes, accelerate discovery, make essential connections and gain confidence on their path to solving the world’s biggest health challenges.

Whether advancing toward a big-picture vision or delivering meaningful experiences to a single individual, our mission is to improve lives and enable hope. We arm health heroes with the technology and expertise they need to power thriving organizations, support vibrant communities and solve health challenges for people everywhere.


Three of us were asked to make presentations. Our assignment was to use three slides to discuss:

1) What have you been up to the last 6 months? What has occupied your time?
2) What do you see as the Healthcare Industry trends the last 6 months?
3) What do you see happening in the industry over the next 12 months (through 2018)?

The first question was a bit of a challenge for a guy who is retired. I expanded on my theme that I was given by another retired friend recently. He said that retirement was a challenge, “You wake up in the morning with nothing to do, and by the end of the day you are half done.”

I modified the second question from speaking about healthcare trends over the last six months to talking about what had happened over the last six months that would impact the future. Six months in healthcare is a short time to consider trends. My answer was incomplete but sufficient to generate a conversation:

• Passage of the tax reform bill after the failure of the Republicans to repeal and replace the ACA, this will guarantee continued pressure on Medicaid and Medicare.
  

• Repeal of the mandate as an add on to the tax reform bill
  

• Administrative attacks on the ACA
  

• Extension of CHIP and support for FQHCs [The funds that support the over 1250 Federally Qualified Health Centers that have over 8000 practice sites were finally renewed in the recent budget compromise.]
  

• Announcement of the collaboration between Amazon, Berkshire-Hathaway, and JP Morgan. [It has to mean something big.]
  

I modified the last question less to “Looking Forward Over the Next Year.” Continuing trends and likely challenges seemed to be important to consider. My list is by no means complete. Perhaps you might add to the list or see things differently. If so please let me know! I said:

It will be a VUCA year: [VUCA is volatile, uncertain, complex and ambiguous]

• Continued downward pressure on finance from commercial payers, and Republican attempts to reduce entitlements to reduce deficits
  

• Political confusion heightened by midterms causing everything to stand still and wait to see the outcome.
  

• Continued shifts away from FFS to value based reimbursement
  

• AI, Internet of Things, Growth of virtual visits, cyber security issues
  

• The opioid crisis will continue and may grow due to inadequate responses. [There is increasing meth use again in many parts of the country]
  

• Worsening personnel issues contributing to further burnout and further patient dissatisfaction
  

• Further consolidation driven by systems failures and attempts to capture populations and PCPs.
  

In answering this last question I was drawing on my recent board experiences, as well as my reading, and conversations with opinion leaders, and also with patients and providers. You may wonder, “ Where are the patients in the list?” I talk with neighbors, friends, family members, people in airports, and just about anyone I encounter who has had a healthcare experience or has healthcare worries. It is easy for me to bundle most of their comments under fears about cost and access which I would say fall under the first two points, and concerns about the attention to their concerns that seem to be a function of either healthcare finance or the lack of time, and consideration that they get form their providers. Most of the people I talk to don’t expect Ritz Carlton service. They just want an appointment and hope that once they get one the provider will have enough energy to give them some time and focus to help them. It is a low bar that is falling fast in many places.

Distilling the thoughts and opinions of three opinionated people into a useful discussion about complex problems is a difficult task. Adding to the difficulty of finding solutions is the fact that we have an uncertain political climate. Organizations under stress often do not have the means or the corporate energy to consider long range strategies or transformations. Their leaders may be tired, distracted by many competing voices, or have competing personal concerns. The truth is that “burnout” is becoming a subject that annoys many people just like “global warming,” but it is a fact, and its presence and impact is universal in healthcare. CEOs are burned out. COOs are burned out. CMOs are burned out. Nurses and advanced level practitioners are burned out. Doctors, residents, and medical students report high levels of burnout. No one seems happy, and many are so jaded that positive statements like “returning joy to practice” is met with ridicule and cynicism in the minds of many. Cynicism is a strong marker for burnout.

As I sat there dealing with the conflicted feelings of being happy that I no longer endured the stress of practice or management, and the concern I had for everyone trapped in the system, many of Don Berwick’s comments that I passed on to you last week came rushing back to me. Don anchored things in residual professionalism left over from Era 1 and the insights from some of the attention to data in Era 2, continuing with a renewal of what was important for leaders to know and foster, and culminating in the importance of the focus on the patient. For him goals are orienting. The goal is the Triple Aim. As he said, once the goal is clear, the method is the next consideration and the best methodology includes continuous improvement science guided by listening to what matters to patients, and efforts to focus on the necessity of interdependency.

I think the “way out of the woods” begins with leadership and is fueled by the fact that although we are all a bit jaded and depressed, some more than others, there is still great commitment to the noble goal of helping people. Don’s diagnosis of our leadership woes was coupled with a leadership prescription from Deming:

...Deming said that if leaders want to make things change there are four areas or disciplines they must master. First, you must master the nature and dynamics of systems. Second, you must understand variation through an understanding of statistics. Third, you must understand psychology as it explains individual motivation and group process, human perception, and adult learning. Fourth, you must master the plan, do, study, act cycle, PDSA that is built on how to continually learn in a complex system. When we use the PDSA cycle we learn like a child learns through efforts of continuous trials and failures leading to mastery, in essence it is an exercise in epistemology.

I believe those skills are a must. Perhaps the full set may not need to exist in every member of a leadership team, but all four must be appreciated by every member of the team, and together they must endeavor to function interdependently. Every leader should be clear about why they need to grow their skills and honestly assess where they need help. It takes a very special environment to allow people the luxury of not trying to hide their inadequacies. Somehow the trust needed to improve must exist. Professor Rebecca Henderson of Harvard Business School and others emphasize the importance of a trusting environment built on “relational contracts” in the creation of sustainable improvement. One needs to have the ability to fail to use the PDSA cycle of improvement.

As the day wound down toward a pleasant dinner, it seemed logical for Simpler to think about how to foster the leadership that would be necessary to create environments where continuous improvement has a chance. Simpler has a tradition of orthodoxy in Lean. If the world is changing, how should Lean change to be accessible to a distressed organization trying to survive the double challenge of financial pressure and workforce distress. Tools like Watson and other new electronic “touches” offer potential solutions to current shortages as do some mergers. If the task is integrating AI or some other new software product into the care model, work flows need to be reengineered. Mergers require reengineering or they lead to the opposite of the objective that created them. Lean philosophy, Lean leadership attitudes and practice, and Lean methodology still offer the best guidance along the path through a volatile, uncertain, complex and ambiguous future toward the vision of universal access, quality, and sustainability offered by the Triple Aim.

If I ask myself what is missing in the formula above, I keep coming back to the concerns about the patient and the realization that until healthcare leaders expand their universe to include being leaders in the effort to improve the social determinants of health and improving our political environment to one of bipartisan problem solving, the Triple Aim is an impossible reach. Don had something to say about that as well:

I can not imagine an American society that is healing without a commitment to care of the vulnerable, protection of the disadvantaged, the pursuit of social justice and equity, the repair of our criminal justice system, a whole bunch of what I regard as progressive policies which are currently under a very dark cloud given the national ethos and our national leadership today. It’s not OK. I just can’t help making a plea to the professionals who are listening to you in this podcast to be active in restoring a sense of social justice as a primary foundation for our nation. And if the politicians currently in charge won’t do it, and they won’t, then I think professionals have a duty, just as they do to the improvement of the system. They have a duty to the improvement of the moral foundations of the nation, and that for me is a part of Era 3, as well. So, excuse the political excursion here, but it is a time to speak up because what is going on is not OK.

When I left the meeting I was not sure what Simpler would be doing over the next year, but I did know that I had a renewed sense of purpose. There is too much for any one person to do, but there is much that we can accomplish, if we acknowledge our interdependence, seek to become effective leaders, or follow effective leaders, and never forget why we do what we do, and what our goal is.


Delighted by the World Turning Yellow

I made my first trip to California in 1958. I was thirteen and my parents decided to turn a week of my father’s speaking at a church in Malibu into a family adventure. They organized many of our family trips around his speaking engagements or organizational meetings. The trip was a huge excursion across the Southwest facilitated by our first “air conditioned car.” On the way out we made camping stops in New Mexico and southern Arizona, and passed through Yuma, Arizona before spending a memorably miserable night near Thermal, California on the Salton Sea in the Imperial Valley where we were more than a hundred feet below sea level. The temperature was over one hundred degrees at midnight. I have never been back.

California was a blast for a thirteen year old whose dad had some local connections. We visited the sets of “Sky King” and “Lassie.” I rode all the rides at Disneyland and Knotts Berry Farm. On the trip back to Texas we visited the Grand Canyon, Las Vegas, and the Hoover Dam before spending a week at a cabin near Creede, Colorado where I caught my first rainbow trout. I guess that trip turned me into a lifelong enthusiast for California and over the last thirty years I may have visited as often as two or three times a year. Since we now have two grandsons living with their parents in the redwoods above Santa Cruz, the frequency of our California excursions can only increase.

Despite all my trips to the left coast, I never noticed acacia trees blooming before this week. I guess that I was never there during the short season when they bloom in the late winter and early spring. From what I learned reading the information in the link above, the trees are great for dry areas where the soil needs to be stabilized to prevent erosion. That must explain why the are so many of these trees in bloom along the highway from Santa Cruz over to Silicon Valley and along the coastal highway. But the highways are not the only place to find them as I discovered on my walks. Today’s header is a picture I took on a lovely side road near the San Lorenzo River. The neighborhood is a mix of redwoods, marones, huge oaks, black locust, and acacia. In a clearer area with plenty of sun, the acacia seems to rule. The discovery was a reminder to me that even as I move through my 73rd year there are things to learn and experience, thoughts yet to be thought, and beauty still waiting to be consciously enjoyed for the first time in my lifetime. It’s a rare day that a walk does not reveal something new and interesting or a totally new perspective on something that I had taken for granted.

Wherever you are this weekend I hope that you will be able to be out and about getting renewed by the surprises that you can discover. I have always believed that a positive catecholamine surge from exercise, or an unexpected dopamine dump from a chance encounter with beauty can repair the injury of several days of “soul sucking” existence in a dysfunctional work environment, or the troubling events that appear in the news.