16 June 2017
Dear Interested Readers,
What’s Inside and the Usual Comments About What’s Happening in Washington Garrison Keillor’s nostalgia provoking weekly radio program was one of the highlights of my week for most of the last thirty years until he “retired” last year. One thing that I liked about the show was that the format never changed. I always knew what to expect and yet within those expectations I was frequently surprised and delighted in ways that I had not expected! I loved the eclectic offering of music. I loved his “radio dramas” like “Dusty and Lefty:
Lives of the Cowboys” and “
Guy Noir” the man who is always trying to “find the answers to life’s persistent questions.” [If you have few minutes and have nostalgia for nostalgia, click on the links.] But, the best of all Garrison’s inventions was the “
News From Lake Wobegon” which always began with the predictable line, “It’s been a quiet week in Lake Wobegon, Minnesota, my hometown.” I thought that, “Well it’s been a quiet week in Washington, D.C., our capital…” would have been a good way to start this letter to you, but things changed with Mr. Session’s appearance before the Senate intelligence committee, the president’s comments about healthcare, and the tragic events on a neighborhood baseball diamond while Republicans were preparing for their annual faceoff against the Democrats. It was yet another undoing of a brief fantasy. Unless we choose to live off the grid and only read the classics, it may be true that it will be only in our nostalgic dreams that we can ever again enjoy a quiet week.
I was not disturbed by the attorney general’s performance before the congressional committee. I think his inflated sense of violation, limp excuses, and the use of vague and unsubstantiated departmental prohibitions against answering questions spoke volumes, or at the least leave us with a sense that Mr. Mueller will have much to report to Congress at some later time. The tragic event at the early morning practice of the Republican Congressional baseball team was an initial surprise, but then not after a few seconds consideration. We seem to be in an era when the popular response to any disagreement is anger and action rather than patience and reason. Some feel so marginalized or so offended that it does not take much provocation to lead them to throw everything away for a few seconds of outrageous expression of opinion. I am hopeful that the upside of this latest tragedy will be more than the fact that the number wounded was small and that only the shooter died. I hope that the event will trigger a miracle, and that prudence and civility will be restored to our national discourse before something far worse happens.
What is really interesting about President Trump at any moment since his election is the question of what set of principles or strategies guide his comments and actions. Both his comments and actions can appear to be disconnected from his most recently stated objectives or opinion. This week’s comment that the
AHCA as passed by the House in early May was “mean” certainly left me scratching my head. The link provided is a CNN report from Wednesday of the president’s assessment plus a flashback clip of Jake Tapper’s CNN report in early May that includes Mr. Trump’s enthusiastic celebration of the AHCA. What is going on leaves plenty of room for speculation, especially since all of the deliberation in the
Senate’s special committee where a few older white guys are writing the Senate version of the AHCA has been done behind closed doors.
Perhaps the most definitive report on what the president said and what it may all mean comes from an
article in the Washington Post that contains the core report of the president’s comment as reported by the Associated Press:
President Donald Trump told Republican senators Tuesday that the House-passed health care bill he helped revive is “mean” and urged them to craft a version that is “more generous,” congressional sources said.
The House GOP threw the American Health Care Act together with little regard to its impact on ordinary Americans and was willing to slash health care for the poor and middle class while shoveling tax cuts into the coffers of the richest Americans. Trump insisted they pass something and then threw a celebration in the Rose Garden. So much for that. To all this I scratch my head in wonder and say, “Everyday brings a new surprise and with each surprise a little bit of hope!” I wonder if you have written a letter to a senator. It’s not too late! Check out
last week’s Strategy Healthcare posting if you need more guidance.
The bulk of my letter this week arose from three different sources that I will try to bring together for you. The first source is a set of recent conversations and email exchanges with “Interested Reader,” Dr. Fred Bloom, whom I first met when he was in a leadership position at Geisinger nearly a decade ago. Now Fred is President of the Guthrie Medical Group and serves with me on the board of The Guthrie Health System, the largest provider of care for the twin tiers of south central New York and north central Pennsylvania. Guthrie has four hospitals and more than twenty ambulatory sites in this region of small cities in New York like Corning, Ithaca, and Elmira, and somewhat smaller towns in Pennsylvania like Sayre, Towanda and Troy. The majority, if not all, of the physicians, nurses and other healthcare professionals that see patients within the clinics and hospitals of Guthrie Health are employed by the system.
Guthrie draws its patients from a wide geographical area of lovely farms, lakes and mountains in the spectacular region that lies west of Binghamton, New York and just south of the Finger Lakes extending west past Corning, New York and south far into neighboring Pennsylvania. The small communities, towns and cities of this huge area are embedded in a rural environment that has very little diversity. Over the past several years the economy has been stimulated by natural gas produced from fracking the huge deposits of
Marcelluss shale. That boom has stressed the area’s infrastructure, especially housing and healthcare. Beyond the healthcare related issues that are derivative of the gas industry, Guthrie faces challenges that are similar to most other rural and small town areas of the nation. Those challenges may appear to be similar but in many ways are even more difficult to resolve than those that are experienced in a large urban environment like Boston that has several academic medical institutions and many large community hospitals competing in an environment of generous third party reimbursement. The challenges may be different, but the goals of care and the competencies required of leadership are similar even if the resources may not be the same. Fred and I, along with other Guthrie execs and board members, have talked about these differences and the strategies to consider as Guthrie evolves to continue its mission.
The second source for the section is my own experience as a medical practitioner and as a medical leader with corporate responsibilities for the mission and viability of an organization that is dedicated to improving both the experience of care and the experience of providing care. More than three years into retirement, not a day goes by that I do not spend some time reflecting on the experiences I had in practice and as a practice leader. “Do overs” are rare in this life. There is not much future in continuously pondering what “shoulda, woulda, coulda” have been best things to do, but there may be some benefit from trying to pass on to those who face similar challenges now what I learned in real time and in reflection. I still get a few opportunities to do that. I think that was what Fred was asking me to do when we were talking, and as recently as this week what another interested reader and current leader had on his mind when he called to discuss a problem that faced him in his role. Those calls make all my mistakes a little easier to justify. If true learning comes more from error than success, then I have had the opportunity to learn a lot.
The third source that I would like to connect to the discussion of the challenges that face Fred Bloom and all other medical leaders who are trying hard to direct the necessary transformation of their organization and make the right decisions in a time of uncertainty is taken from chapter 12, “The Planner and the Doer”, of Richard Thaler’s Misbehaving: The Making of Behavioral Economics. I hope that the curious combination of these three stimuli might be enlightening for those who are trying to lead toward tomorrow’s realization of
...Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.. and for those who are totally immersed in trying to provide care today in the midst of demands that seem overwhelming, and at least for the short term are likely to get worse before they get better.
The letter ends with a brief report on early summer activities and some reflections about Father’s Day. By the time you read this letter I will be headed to North Carolina for a much anticipated Father’s Day experience with my siblings and our father who gets to the gym several times a week and has a pretty full life at age 96 despite a growing list of medical concerns.
Thoughts on What To Do When You’re Not Sure And Other Adventures In Healthcare as “Agents”and “Principals” As I look back over my experience both as a practitioner and as a medical leader, I am reminded of the joke about the bimodal life of an anesthesiologist. The joke describes the life of those who pass gas for a living as composed of interminably long periods of boredom punctuated by moments of terror. Nothing describes a moment of terror for me more than knowing that the situation demands a decision, and at the moment I do not know what to do! The need to make a decision in the context of uncertainty is an apt description of a frequent situation for almost anyone in healthcare, whether they are directly involved in the care of the patient or whether they are working as a manager to support those who provide the care.
Professional life is always about applying experience and special knowledge to problems. The message of behavioral economics is that we are often encumbered by our biases when we are problem solving. We irrationally apply biases derived from experience with problems that are not comparable to the issues at hand when we have to make decisions in circumstances of uncertainty.
Not long after I became a CEO I was attending a conference in Orlando offered by the Lean Enterprise Institute. The event had a strange beginning. After recovering my baggage at the airport, I climbed into a taxi and gave the driver the name of my hotel. He smiled and advised me to get out of the cab and to go back into the airport where I should ascend the escalator to the second floor where I would find my hotel. I spent three days in Orlando and never left the airport. At sometime during my stay I was wandering through a bookstore in the airport and discovered Dan Ariely’s wonderful book
Predictably Irrational. The book was my introduction to behavioral economics, a subject of which I had only a limited understanding. Many books later I have come to realize that there is no better aid to the art of decision making in the face of uncertainty than at least some introductory understanding of behavioral economics. My most recent adventure in reading in the field has been Richard Thaler’s,
Misbehaving: The Making of Behavioral Economics. Thaler’s book and every book that I have ever read in the field of behavioral economics has taught me something about myself and the way I approached the activities that consumed so much of my time and attention during my professional life. The problem for me was that the learning came after most of my professional decisions had been made.
The first lesson to be learned from behavioral economics is built on the knowledge of how our biases cloud our objectivity and lead to avoidable mistakes and suboptimal outcomes. In medical practice these biases that are imbedded in our attempts to solve diagnostic problems and plot successful steps in the management of complex clinical processes can lead to harm. I am sure that these biases are the origin of many medical errors. In his book Thaler reaches beyond how things work at the individual level and begins to look at collective issues. I think that it would be possible to use his insights to better understand the current national lack of social solidarity that leads to failed legislation and persistent social distress, but that is too big a leap from the individual to the whole nation. Let’s just look at the tensions that might be better understood between doctors and patients and doctors and their leadership. I am usually very careful to use language that includes all clinicians and all non practicing healthcare professionals in any discussion. For this piece I am going to limit the discussion to what I know from being a doctor and a medical manager, the CEO of an organization that employs many doctors and other healthcare professionals.
Thaler begins his discussion by talking about self control and the ability to stick with a strategy. A good example of our frequent failures is the common New Year’s resolution to get in shape by sticking with a diet and going to the gym on a regular schedule. If personal “continuous improvement” requires a strategy about what you want to do and another strategy to enable you to stick with the strategy through efficient self control, how much harder is it to get a whole group of doctors to stick to a plan of practice transformation, or at another level consider the difficulty we experience when we try to engage patients in self management?
At the level of the self motivated individual, Thaler adopts the metaphor that
Daniel Kahneman offered us in his great book, Thinking Fast and Slow of there being two agents in our minds, one that is an automatic and quick doer, and the other agent that is a reflective planner and very deliberate thinker. When we are working with patients who are often driven by wants and needs in the moment that undermine their desire to be healthy, we use a combination of information and advocacy to try to get them to delay gratification in the moment for the long term benefits of following a path that offers very little immediate gratification but over the long haul will make them healthier.
Thaler is not writing about doctors and patients or doctors and managers, but I feel quite comfortable with the idea of extrapolating his theories to both experiences because his ideas provide understanding to the various issues that I remember from my own experience and that trouble those like Dr. Bloom who are still “in the game.” Thaler does some extrapolating of his own. He begins with a paper from 1976 by Jensen and Meckling from the University of Rochester. They proposed a “principal-agent” model to understand the tensions that exist between management and the professionals in an organization around executing strategy. The bosses or owners are the “principals” or managers with the responsibility for the business (or mission) strategy and the overall success of the enterprise. The “agents” are those to whom authority is delegated to execute the strategy. The agents are “doers” who interact with customers and external business partners through the “rules” ( policies and procedures) or mechanisms that have been established by the principals, who are the planners.
Thaler focuses on the interdependence between the principals (thinking slow) and the agents (thinking fast). The principals, or managers, if you wish, establish expectations. The rules and policies that they create push the agents toward the “right” actions. Agents who follow the rules and deliver the expected outcomes earn rewards. To further their strategic objectives the principals often try exhortation and the introduction of guilt meant to further motivate the agents. The agents are the experts in the work of the business and it is hard to prevent them from pursuing their own agendas or to get them to learn or follow a new agenda. If you are thinking about the internal conflicts between compensation programs that reward physicians for volume work while managers are seeking to establish new programs that will promote value based organizational performance, then you are getting the picture. I was once amused by how
Craig Samitt, who is now CMO of Anthem, described the compensation programs of most medical groups as “funky” because the physicians were still compensated for volume performance while the organization was signing more and more contracts that were moving them toward value based reimbursement.
The management process that Thaler describes is one that doctors love to call “top down” management. John Toussaint has described it as both
management by objectives and “Sloan Management” in a dual honor for Alfred Sloan the long time CEO of General Motors and perhaps the Sloan School of Management at MIT. Toussaint points out that practitioners of Lean management are “managing by process” and that rather than setting objectives and cascading responsibility for achieving those objectives from the lofty position at the top of the organization they gain insight from the practitioners at the point of service. They support them as they seek to solve the problems that are creating waste and adding no value for those who come to the practice for service. Strategy development and deployment occurs as the outcome of an active process that goes up and down the organizational structure in a process we call “catch ball” between the “principals” and the “agents”. The new role of the principals is to coach, teach and mentor and not to command or drive compliance with blame, guilt or exhortation.
I became fascinated with the possibilities that Lean offered as a “better way.” It became obvious to me that the transition was not easy and does not succeed if there is any lack of engagement by the “principals” or the agents. The “agents” do not trust “principals” that espouse Lean and then continue to practice as directors in a system of management by objective. It is interesting that most successful introductions of Lean also include a process of “renegotiating” the relationship or contract between the doctors and other agents of the practice and the principals or managers. Such processes create trust and are foundational to the stable
“relational contracts” that enable Lean transformation.
I like the phrase “distributed leadership.” To me it implies a blurring of the line between agents and principals that is consistent with Lean. It is also consistent with the concept of
subsidiarity. Local decision making and problem solving are foundational Lean principles. When practicing physicians accept the responsibility of becoming a participant in management by process then the Lean leader’s new role becomes being a coach, teacher, and mentor and is critical to the success of the new order.
So why do so many practices try Lean but fail in their transformational efforts? In my opinion Lean failures occur when the managers fail to recognize that the transformation begins with them. They must “think slow” and realize that much of what they have been doing has been driven by biases that do not deliver the answers they need. I know that Dr. Bloom believes in the Triple Aim and in the benefits of Lean management. My advice to him was stay the course. Focus on developing the same awareness and understanding that he has throughout the entire Guthrie management team and encourage the use of Lean philosophy and practice throughout all the hospitals and practice sites of Guthrie. Transformation is largely a process of unlearning the old relationship between principals and agents and learning how to distribute leadership and the focus of real change to the agents at the point of care. It is a process with a learning curve. To come full circle it becomes a process that requires a strategy to stay with the strategy. It is not easy to give up what you know but is no longer working, and embrace what you do not know and stay with it until it works. The successful organizations have all engaged mentors or guides for their leadership teams. Patty Gabow gives a great description of the folly of a “do-it-yourself Lean transformation” in her wonderful book
The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System.
So, my advice to anyone who does not know what to do in this moment of confusion created by the repeal and replace process in Congress is to focus on your organization’s transformation. Whatever bill is passed by Congress, the ability of your organization to survive and the well being of the patients who depend on your services will be best served by your intensified
focus on pursuing the Triple Aim through a process of transformation and continuous improvement. That strategy will serve you well no matter what happens next in Congress.
The Thermometer and the Callendar Agree, It’s Summer The second three day run of temps over 90 before Father’s Day is some sort of record that has not added up to the greatest spring that I can remember over more than seven decades. What is novel is not that it has been very hot or very cold but that it has alternatively been very hot and very cold and not much that was nice in between. This last Tuesday my wife and I decided to drive to the New Hampshire and Maine Coast as a diversion from thinking about the heat. Tuesday was a scorcher and a little walk around Strawberry Banke in Portsmouth took the starch out of us. Fortunately a cold front came through without the rain that soaked the Red Sox fans who were sitting through extra innings in a Boston victory over Philly.
Wednesday was predicted to be glorius with temps in the low seventies with dry air and clear skies and it was, as you can see from today’s header which was snapped as we walked along the “cliff walk” above York Beach. Yesterday was another beauty and I snagged a nice big bass as I paddled around the lake in the twilight listening to the Red Sox lose 1-0 to the worst team in baseball and blow a great pitching performance from their ace. These are the things that tell me summer is here.
Keeping up my strategy to exercise enough to live to be a hundred will be a challenge this weekend as I head to North Carolina for a Father’s Day gathering with my sibs, our Dad who is 96, and his wife who is supporting his own strategy to become a centurion. Father’s Day is a great day for families to reconnect. I hope I will be able to convince my brother and perhaps my sisters to walk with me in the North Carolina heat.Whatever your strategy is for the weekend just remember the point of today’s letter is that you need a strategy to enforce your strategy and a good strategy is to reach out to others.
