This week’s letter comes to you from South Africa. Being half a world away gives me the opportunity to write to you from the perspective that is available when you step back a little way and your nose is not right up against what you are trying to describe. This letter is a “musing” for sure as I dissect a metaphor and try to attach its meaning for me to the pace of the quest for the Triple Aim Plus One. I hope that what follows will not hurt anyone’s feelings.
The second section is an exercise in self-indulgence as I describe my great joy of seeing the evolving Atrius Health Innovation Center that triggered a trip down memory lane for me. The letter concludes with a little taste of Africa.
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Like Digging a Ditch With a Spoon
I can’t remember when I began to refer to any difficult task as like “trying to dig a ditch with a spoon”. I do remember being amazed by the story in the movie Shawshank Redemption where the character played by Tim Robbins demonstrated great industry and perseverance as over a period of many years he dug a tunnel from his cell to freedom using what I thought was a spoon. If you clicked on the link above you discovered that what I remembered as a spoon was actually a rock hammer, but the metaphor is still valuable.
Many times over the last decade or so I have muttered to myself, “This is like digging ditches with a spoon!”. It is easy to feel overwhelmed with responsibility if you are in a leadership position in a large multispecialty group practice that is trying to survive in a very difficult market where there is vigorous competition, new demands on clinicians, patients who are apprehensive about what change will mean for their care, increasing regulation from new state and federal legislation with new laws to understand, and complicated new mechanisms for payment both from the insurers and the government payers, all against a background of falling relative reimbursement.
When you add an attempt to foster a Lean transformation to all the external pressures that your organization is trying to understand and overcome, that spoon that you have been digging away with seems to get smaller and the tunnel that you must dig to the new and brighter future feels like it is longer. Many have resisted the idea of introducing Lean as part of their strategy, even though Lean might give them a much-needed way to meet the challenges that exist now plus the new ones that will evolve in the future. Those that feel overwhelmed now believe Lean will be adding another degree of difficulty to the maneuvers that their organization must go though. They fail to recognize that without a new way of approaching their challenges their spoon will just get smaller and smaller. The options to consider feel like a dilemma (my definition for dilemma is a choice between unacceptable alternatives). You know in your gut that without a Lean transformation, a goal as audacious as the “Triple Aim Plus One” is an unlikely possibility. Even the more common goal of maintaining the status quo is impossible for most.
Times like these in healthcare evoke many metaphors to describe the path forward, but the old reassuring or enticing metaphors for transition like “glide path to success” or “as easy as falling off a log” do not apply in this era. We are past the time when we can advocate for change with the metaphor of a “burning platform”. In today’s world of volatility, uncertainty, complexity and ambiguity, our “platforms” do not burn, they explode!
A few weeks ago I reported on the mixed results in the recent healthcare finance news. Based on data released by CMS, ACOs seem to be making some small improvements both in quality and cost, but compared to the distance that we still need to go, it does feel like we are just beginning to dig our ditch with a spoon. I forwarded less hopeful news from Massachusetts. The 2014 financial results were recently released by CHIA (the Center for Healthcare Information and Analysis). The 2012 passage of Chapter 224 requires that CHIA publish the financial results yearly. The latest results suggest that Massachusetts is losing ground to their self-imposed goal of limiting the increase in the cost of care to the equivalent of the increase in the state GDP. It is as if someone is putting back with a shovel what we are removing with a spoon. Sadly, many of those who tried to give an explanation for the dismal results pointed their fingers at Medicaid. It would take me a whole letter just to begin to express my feelings about the ways in which we fail patients whose care is financed through Medicaid. I will write that letter soon.
I realize that there are many of my colleagues in healthcare who still say, “What is the problem?” They point to the fact that their margins have been maintained. They have a deep distrust of any suggestions about changing either the way they work or how they are paid. They deny a need for change and they have actively resisted new regulations, preparation for new payment models, suggestions that they consider new structures, and suggestions that they should consider Lean as an aid to preparing for an uncertain future.
They are not open to ideas about reengineering their workflows or changing their working relationships within their practices to improve the efficiency or effectiveness of their use of resources. Could it be that they are hoping the discussions of the last ten years and most of the evolving changes created by the ACA will go away like waking from a bad dream? They do not want to hear that the pressure to reduce costs, increase transparency, and satisfy patients with higher quality and safer care that is easier to access is just beginning.
There are many customers of healthcare who like the care that they get now despite its expense to their employer or to taxpayers. Many probably also think that the folks like me who warn them of the negative potential of current and future developments are just using rhetoric to manufacture a crisis that they aren’t buying. They have the same response to those in the environmental community who advocate that we each seek to reduce our “carbon footprint”.
They feel beleaguered and are sick and tired of Washington’s attempts to solve problems with new laws and regulations. Most of them are distrustful of any analysis of the policy wonks and do not want to hear the reassurances of people like me that there is a real possibility that the Triple Aim Plus One might deliver us all into a better world, if only we would try harder. They can only imagine higher costs and lower value for themselves as the derivative of attempts to use government regulations, programs and funds (money that surely will result in increased taxes for them to pay) for something that will not benefit them in any way that they anticipate or want to try to understand.
Neither this disgruntled public nor many of their congressmen and senators want to consider the benefits to all that are derivative to expanding coverage to include everyone. The popular view among these threatened satisfied patients, worried practitioners, and distrustful elected officials continues to be that change threatens something that is just fine, as far as they are concerned.
Their bias is supported by plenty of political pundits, well placed and well known physicians and some well regarded institutions, as well as many candidates for high office who are working hard every day to reassure those who are distrustful of change that they are right about the issues. They are also reassured by these voices that they are justified in their dislike of the several simultaneous attempts at improving their lives, and the lives of those less fortunate. They see no potential benefit to improving education, housing, employment, the environment or creating opportunity for everyone through social engineering. There seems to exist a reinforcing process of “catchball” that advocates a “do nothing” or “watch and wait” attitude. The conversation between them and their sources of information reinforces their resistance as the issues go round and round within the world that is not so sure that we need change. Some unexpectedly successful candidates for higher office are tapping into an anger and resistance that stems from those fears.
My desire to be positive about the future and my continuing search for evidence of progress that can be cited as proof that we are all moving toward the Triple Aim, albeit very slowly though great resistance and with great effort, was why I began to conceptualize the journey to the Triple Aim Plus One as like “digging a ditch with a spoon”. I have a smile on my face while employing this metaphor! I remember that at the end of the story and after a lot of hard work, risk taking and being smarter than the warden, Tim Robbins and Morgan Freeman are free and enjoying their Triple Aim. In the last scene from the movie they are walking on a lovely beach in Mexico with money in their pockets and their only worry seems to be avoiding sunburn. Hard work, courage, intelligence and a dream, all maintained over a long time, had set them free. The character played by Robbins had gotten to his goal one “spoonful” at a time assisted by collaboration and support from Freeman’s character.
As I thought more and more about my metaphor about ditches and spoons, I decided to do a little Google research to find out the story behind the metaphor. Here is what I learned. The metaphor goes back to at least the thirties and is a derivative of discussions about work creation by government programs. In essence, advocates for government sponsored work programs suggested that we could put a lot of unemployed and able-bodied men to work by giving them a shovel to start digging ditches to lay pipe and build roads.
More recently the conservative economist Milton Freedman has facetiously responded to such suggestions for economic expansion by saying that if you can improve the economy by giving 100 men a shovel why not give a thousand men a spoon to dig the same ditch?
Ironically, I have seen a hundred men with shovels being pretty efficient digging a ditch. In 2005 I accompanied my son on a trip to Beijing. He was enrolling for a year of language study in a program at Tsinghua University, China’s answer to MIT. The Tsinghua campus is enormous and is populated with acres and acres of huge monolithic cold grey stone buildings that have a somewhat “Soviet” like feel to their architecture. Beijing’s usual low hanging smog gives a post apocalyptic grey coloring to the vast university and enhances the sense of oppression and impending doom that I felt as we walked across campus.
As we passed through the fortress like gates to the campus we could see a huge multicolored banner hung above the entrance to their business school. The words and Chinese characters on the banner implored the students who passed under it to “study for the glory of China”. I muttered to myself as I read it, “and for the economic defeat of America.” I had the feeling that I was standing in the middle of an education factory where work was taken very seriously in preparation and anticipation of some form of world dominance.
Seeing people hard at work everywhere I went in China reinforced my feeling of concern about our declining success in the face of their emerging economy. Much of the time the work they were doing was being done the hard way, using hand tools from an earlier age. Despite working conditions that would be unacceptable in our society, evidence that change was happening at a breathtaking pace was easy to see and believe. Across the horizon there were enormous cranes that were the indicators that yet another huge building was under construction.
Despite the ominous and repressive feel of the buildings, the low hanging sky and the cranes on the horizon, I thought that the campus had a certain beauty. There were wide walkways, a large arboretum, and frequent gardens between the buildings that were surrounded by green lawns. Dotted across the campus were groves of magnificent trees, flowers, statuary, and decorative ponds with romantic arching footbridges.
We had to walk more than a mile across the campus to a distant office where my son would complete paperwork to obtain an apartment. During the walk I noticed that one enormous and less repressive newer building was labeled “Center for Nanotechnology”. As we walked along further and turned at the corner, I could see that behind the building there was a line of at least a hundred men with shovels. They were digging a deep trench from the street to the back of the building that was dozens of yards back from the roadway. Concrete pipe was laid out along one side of a chalk line that marked the proposed path of their trench. I was surprised that there was no backhoe. All that I saw was men furiously digging. No one was idly leaning on his shovel. Their shovels were a blur of movement as a neat pile of dirt appeared on the opposite side of the line from where the pipe was waiting to be laid in the deep trench that was rapidly replacing the chalk line.
We walked on to finish our mission of jumping through all the bureaucratic hoops in the process so that my son would have a place to live before classes began sometime in the next few days. A few hours later in the day with our task accomplished and after a brief trip to the building where most of my son’s classes would be held, we walked back by the site of all the furious digging. To my surprise the men, the pipe and the dirt were gone. The sod that they removed before beginning the trench was back in its place and I assumed that the dirt and the pipe were in the hole and that the Center for Nanotechnology had either a new water supply or a more effective sewer system. Who needs a backhoe when you have a hundred strong backs with quick shovels? In a land of 1.4 billion people, a hundred men with shovels is a much more efficient solution than a backhoe.
I am hoping that in healthcare we will be accelerating our responses to our challenges. We are moving slowly forward in many ways at the moment. The experience in Massachusetts should be analyzed and lessons learned. The future we desire may feel like it is a thousand years away if we continue to move at our current pace. I prefer to dream that the slow progress we are making now will accelerate as we trade in spoons for shovels and enlist more and more in the process of moving to the use of more efficient tools like backhoes. Should I have said Lean?
Meeting Satisfied Harvard Vanguard Patients in Distant Places
I hope that all of my “Interested Readers” will someday experience the joy that I have found in retirement. I consider everyday of the nearly four decades that I worked at Harvard Community Health Plan and its legacy organizations well spent. It was a gift to spend my career in an organization that was conceived as the response to a noble idea and populated by people who have always been dedicated to fulfilling that ambition. As humans we desire affiliation with others. We tenaciously hold on to family and community. Most of us find more joy in being affiliated with a successful team than succeeding as a lone player or operator. Nothing brings us more happiness than to root for our team. We love to hear of our team’s victories or to learn that our team is held in high esteem. Even after our active days are over, our sense of affiliation still brings us pleasure when our team is doing well.
This last week I had the pleasure of joining other members of the Simpler Advisory Group for a visit with the team at the new Innovation Center at Atrius Health. The Innovation Center was one of the most significant outcomes of the process that has forged the new Atrius. As the work they are planning and doing was presented and explained, I could sense that spoons were being rapidly replaced by backhoes. They are hard at work using the continuously evolving tools for Lean innovation in a Lean culture motivated by the dream of accelerating the journey to the Triple Aim Plus One.
As the members of the current team who lead innovation described how they saw their work advancing into the future, it was a great experience and joy for me to think back over my forty years about the previous players on the team and see in my mind's eye all of my colleagues who had made their contributions over the years. I thought about Bob Buxbaum’s commitment to the “model clinic unit” back in the mid eighties. I thought about the foundational training programs for nurse practitioners developed in the seventies in collaboration with Simmons College and lead by people like Stella Goldberg, Sharon Steinberg and Elizabeth Caulfield. I thought about Don Berwick’s original work in quality and safety from the eighties. I remembered all of the work of the seventies, eighties and nineties to bring computers into the office flow. I remembered the groups that developed algorithms for care delivered on the phone and in the office. There was a lot of work done with spoons but each spoonful of creativity added to a mountain of clinical experience.
As I was thinking about the past, my eye fell on a little piece of paper pasted on the wall in the midst of all of the flow charts and other pieces of their complex system of visual management that is so much a part of Lean. On the little piece of paper were a few paragraphs from my last letter to the practice before retirement. The letter was entitled “The View From Mount Pisgah”. It was a reference to Mount Pisgah from where the beauty of the Promised Land could be seen in the distance. It felt very good and rewarding to see those few words from the past buried on that wall that was covered with the directions to that better place in the future to which they are headed as fast as their experiments will take them.
Last Saturday, a few days after my visit to the Innovation Center, my wife and I traveled to Africa. After a fifteen-hour flight and a few hours of sleep, we took a walk around the lovely grounds of a “country manor” near Johannesburg where we were to spend our first night in Africa. During the walk we began a conversation with people that had been on our flight and invited them to have dinner with us. They were from Indiana but we quickly learn that the wife had lived in Boston. She had been a nursing student at BU and had then married and had two children in her first marriage before life took her to Indiana. While in Boston she and her family received all of their healthcare at the Kenmore office of Harvard Vanguard. She had nothing but praise for the care that she and her children received.
Later we flew to Durban before heading into the bush. On the three-hour ride from Durban to the lodge where we have spent most of the week we met a couple from Florida but they had lived in Boston for many years. You guessed it. They had nothing but praise for the care they received over many years at Kenmore and said that there was nothing where they now live that comes close to that care they had enjoyed with us. It is a small world, but then again over the last forty six years millions of people have gotten great care at Kenmore and at all of the various practices that now make up Atrius Health. I see the Innovation Center as a logical next step in the mission of an organization that at its heart has always realized that what Dr. Ebert said in 1965 was true.
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
The practice was started to find that solution that would constitute a conceptual framework and operating system that can provide optimally for the health needs of the population. The Innovation Center is the next step in that search and the continuing search will guarantee that fifty years and more from now this team will still be playing and its retirees will still be hearing echoes of the satisfaction and service that it has given to millions of people in need of good care.
I Have Found Rupert
As the picture in today’s header proves, this week I was successful in reestablishing a relationship with my boyhood friend Rupert, the nearsighted rhinoceros. I enjoyed meeting several members of his family and some of his neighbors as they all gathered at the local “watering hole” after a long day. While we were observing the social activities at the water hole some rude hippos and some pushy elephants arrived and made things a little tense for a while until it was clear that there was enough room on the beach in front of the old watering hole to accommodate all who wanted a drink.
The only problem I have discovered this week is that it is not the animals but me that is in the cage. The people must stay confined to the grounds of the lodge behind a wall where it is hard to take a walk or in the trucks that take us out to see the animals. The animals may go anywhere they please. Here it is they who are protected from us, or more specifically, the poachers who are from our species.
I will catch up with my walking next week and hope that you are keeping up with your efforts this week.
