2 March 2018

Dear Interested Readers,


Comments On Last Week’s Letter and a Commitment

I have a sense that the readership of this weekly letter dropped about 20% as I began to write about politics, and my concerns about Donald Trump as he was running for president. Before I began “getting political” about the time of the party conventions back in 2016 I had been reluctant to write about political events and issues. As the campaigns evolved in 2016 it became clear to me that the way forward in healthcare would be more challenged by political events than any other determinant. Perhaps I was encouraged by Don Berwick’s venture in 2014 into politics as a candidate for the Democratic Party’s nomination for Governor of Massachusetts. He connected a lot of dots for me between public policy and the future of healthcare. As I thought about the proper stance for me to assume, I realized that I was finally freed from the constraints of my very public role as the leader of a healthcare organization. I was also free of the constraints of direct patient care. I have always believed that introducing my politics, or thoughts on religion, in the exam room or at the bedside was inappropriate.

As I thought about how this weekly conversation I have with you might change if I began to introduce a political perspective, I reasoned that the dialogue that might arise if I expressed my opinions and then invited you to respond could be a conversation that would be beneficial to all of us and perhaps make a small contribution in the overall progress toward the Triple Aim. I was not so naive as to imagine that we would all have the same point of view. I also realized that some readers would reject the opportunity and just stop opening the letters. Most of us avoid the media and articles that we know will challenge us. I have a hard time listening to an alternative point of view. Perhaps it is wrong that I never watch Fox News or listen to any of the right wing talk shows. I could pick Sean Hannity out of a line up, but it is only because I have seen him make rare appearances on some of the media that I do watch.

I do not look at Breitbart and I prefer the New York Times and the Washington Post. I recently terminated my subscription to the Wall Street Journal which is now owned by Rupert Murdoch and was always a little too conservative for my tastes. In an attempt to be a little bit more balanced I have subscribed to the The Everyday American: Your Weekly Guide to The Goings on in Congress published by the House Republicans. I have made an effort to read it, but rarely get further the the first few lines before I give up.

A local friend who does read Breitbart has suggested that I examine poverty from a point of view that is more consistent with his worldview by reading Poor No More by Peter Cove. Cove was the founder in 1984 of America’s first for-profit welfare-to-work company, America Works. I’ll admit that before investing the time to read the book I needed to learn a lot about Peter Cove and and his wife Lee Bowles who is CEO of their company. I’ve done my research, but I have still not been able to get very far past the introduction of his book where he proposes that all welfare programs, except those that take care of the “truly disabled,” be eliminated except for the Earned Income Tax Credit (EITC), the Child Tax Credit (CTC), and other refundable tax credits. These programs reward work with tax reductions.

My own emotional experience with the conservative media makes me empathetic to my friends who want nothing to do with the liberal media. My viceral difficulties with Poor No More and The Everyday American are, I am sure, very similar to the aversion experienced by some Interested Readers who no longer see a benefit in opening these notes since I began to “get political.” Despite the desire to listen only to those whose views reflect my own, I am committed to three resolutions. First, I will continue my nascent efforts to listen with an open mind to those whose views differ from mine. Second, I will continue to search for areas of common ground or shared concern where the first steps toward progress might be made. Third, I will promise to always, literally in every letter, connect any political points back to the conversation about healthcare. I wish that I could add to the list that I will promise not to use sarcasm. I know that we owe each other respect, and that snide remarks are divisive and rarely change anyone’s mind, but there is also something cathartic in pointing out the irrational and inconsistent behavior of those who threaten what you care about.

I felt chided at church last Sunday. A few times a year I serve as the “liturgist,” the person who reads the scripture that the minister will address in his sermon. The reading was an excerpt from “The Sermon on the Mount.” If there were only a brief scrap of scripture that we could save perhaps it would be Matthew Chapters 5-8. The advice that is provided is a great example rejecting “conventional wisdom.” I would imagine that as Martin Luther King, Jr. struggled to lead the nonviolent movement for Civil Rights he would have turned to this scripture many times. I was asked to read Matthew 5:43-48. In very few words we are challenged to accept a radical change of behavior which I continuously fail to achieve. I remain quite “imperfect.”

43 Ye have heard that it hath been said, Thou shalt love thy neighbour, and hate thine enemy.

48 Be ye therefore perfect, even as your Father which is in heaven is perfect.

The minister gave it his best shot. Let’s just say that he did admit that loving those who despise you and cause you grief will be a big challenge for most of us. I have to admit that the sun does shine for those who want to slash programs for the poor, love their assault rifles, and cherish the idea of deporting millions. It also occurred to me that we have a choice. We can try to find new solutions or we can watch things get worse. If things do get worse, there will be a brief sense of satisfaction from saying, “I told you so!” But what kind of victory would that be?

The minister did not mention John Lennon but I did think of his pleading, almost hymn like song, “Imagine”, as my mind wandered, as it often does when something he is saying gets me thinking. Years ago I heard the song as a condemnation of religion. I don’t hear it quite that way now. I hear Lennon suggesting that we should focus on what we can do here and now to improve the human condition. I prefer to believe that when our religions become divisive they have been co opted for extractive purposes and have lost their way from God’s will. The last four lines are an invitation to join the effort to imagine a better world.

You may say I'm a dreamer
But I'm not the only one
I hope some day you'll join us
And the world will be as one

In response to last week’s letter I was pleased to hear from an “Interested Reader” that there is a bipartisan group of citizens that call themselves “Better Angels.” On their website they say:

Better Angels is a national citizens' movement to reduce political polarization in the United States by bringing liberals and conservatives together to understand each other beyond stereotypes, forming red/blue community alliances, teaching practical skills for communicating across political differences, and making a strong public argument for depolarization.

That sounds wonderful. I plan to spend even more time checking them out. I have read several thought provoking articles on their website. It is not all “kumbaya,” but decorum and civility are not as common as they once were. There is knowledge that needs to be reclaimed and virtues that we might want to consider resuscitating. If you do go to the website let me suggest that you read the article on “Piggybacking” written by the founder, David Blankenhorn. Blankenhorn has been on the scene as a leader in the discussion of complex social issues for many years. He is well known as a man who is capable of changing his mind on deeper reflection. He famously wrote a thoughtful op ed piece in the New York Times in 2012 rejecting his previous resistance to same sex marriage.

I received several comments on the main section of last week’s letter which can be reviewed in a much shorter edited form on the Strategy Healthcare website. The same Interested Reader who introduced me to “Better Angels” began his note with kudos for well thrown snarky barbs at the president. Another responder thought that I let the president off to easily. He commented: “I wish you had added that his racism, sexism, putting down those that are handicapped, and homophobia have turned back the clock for this country.” Another reader focused on the importance of the “rule of law” and pointed out the importance of our institutions in the defense of democracy. He noted that he fears a “manufactured” crisis as justification for an attempt to seize greater control. He said, “I believe that our institutions are strong enough to resist Trump’s confused yearning for autocratic control but as he has suggested a great crisis could give him the opportunity to “bring us together.” All of these responses are encouraging.

My point last week was not to be encyclopedic in the listing of Trump’s inadequacies as president. He has proven that the more complaints are registered, the more loyal his base becomes. I do not think there is much future in laughing him out of office, nor do I believe any case can be made that will diminish the loyalty of his most loyal supporters. I think that most of us have become relatively numb to his lack of judgement when talking. His daily demonstrations of behaviors that redefine the presidency as a position with the gravity and dignity of a reality show host no longer leave us agast. I do believe that long ago he has proven his point that he could go out onto Fifth Avenue and shot someone and never be charged. I also believe that he and he alone can do something that will shake the trust of his base. It will be hard for them when that happens because it will require admitting that they have been conned. Donald Trump has had business partners lose faith in him before and it will happen again.

I can’t touch the comedic skills of Stephen Colbert, John Oliver, Jimmy Kimmel, Samantha Bee, or Marc Maron who now have found new fame and fortune making fun of the president to the 60% of the nation that give him low marks. What it all means is beyond my analytic skills and I will direct you to pundits of the “fake media” like Tom Friedman, who have passed judgement on what his contradictions and obfuscations must mean. My point last week was to make it clear that “the gift” was the creation within you and me of the resolve to decide now that enough is enough and recognize that as we seek dialog with those on the other side of the aisle, the ballot box is our best option for cutting the losses that seem to increase on a daily basis. The president will most likely be president until 2021, but many of those who are protecting him, aiding and abetting him now, can be voted out in 2018.


Cultivating a New Generation of Leaders in Healthcare

Over four years into retirement I frequently wonder what opportunity, if any, do I still have to make a contribution. I reexamined that question last week as I was patting myself on the back for writing these letters for ten years. What often lifts me from my funk is a comment from a reader like the ones I referenced in the first section. One thing that really lifts my spirits and makes me feel that I have an opportunity to contribute is for some young or mid career leader to ask me to write a letter of recommendation to help them move forward toward a goal. Another thrill is for someone who I know has huge potential to ask me for advice about what would be a logical next career step. It is a thrill to find a voice mail from a call I missed and hear the voice of someone who has always impressed me asking if I would read the manuscript of the book they have just finished writing and consider writing a forward for them. I have been blessed recently to have all three of those requests.

Several weeks ago when I was reviewing the conversation between Don Berwick and Zeev Neuwirth, I reported Don’s description of W. Edmunds Deming’s comments about leadership. In case you don’t remember, here is what I wrote on the Strategy Healthcare site about Don’s comments.

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

Leaders who don’t have these skills will “get themselves confused” because they will not understand systems, will misinterpret variation and motivation, and they will not support testing. After observing leaders for forty years, Don believes Deming is right. At corporate retreats, and visits with leaders in their institutions, he doubts that many of them use these skills. They are looking for silver bullets, quick solutions. They misuse Lean and Six Sigma by failing to recognize the need for their own mastery and transformation. In Era 3 leaders “get back to school” in complexity, variation, psychology, and the science of continuous improvement to enable them to lead toward improved care in a systematic and sustainable way.

As I thought about each one of the people who had asked for my advice or assistance, I realized that all three of them scored 100% on Deming’s criteria. What was also interesting was that one was a physician with public health training, another was a healthcare administrator with impressive systems skills, and the third was a systems engineer who was focused on innovation and redesign of the delivery system. All three had impressive technical skills as a given, and were masters of systems theory. All three could have taught courses on statistics. All three have remarkable interpersonal skills and are great communicators. They were all “old souls” who have wisdom and a depth of understanding of the human condition that is remarkable to have been acquired in the short time of the first half of their career. All three were masters of the PDCA cycle, and all of their collective accomplishments fit into the domain of continuous improvement.

As I was reflecting on my windfall of opportunity to contribute to their goals, I thought about an event that occurred back in April of 2008. I have mentioned it before. At the time I was part of a study group of CEOs sponsored by funds from Blue Cross of Massachusetts. Our group had traveled to Dartmouth to spend the day with some of the big thinkers at the Dartmouth Institute. To my delight I found myself sitting next to the great Paul Batalden. To put that into perspective, it would be like shooting baskets on the same court with Michael Jordan. I was well aware of his work on “micro systems” in healthcare, his participation in the founding of the IHI, and his famous observation that “Every system is perfectly designed to produce the results it gets.”

Toward the end of the day after several hours of group discussion we were in a relaxed conversation when he revealed to me that he was very concerned about the future of the movement of which he was a founder. He made it very clear that everything that had been learned or gained over several decades of work to improve the quality and safety of healthcare was vulnerable to a failure of the transfer of leadership to the next generation. I may have misunderstood him, but my impression was that he was not sure whether the passion that had driven him and the other pioneers in the movement would be sustained over the time it would take to really make a difference.

Batalden’s concern was hard for me accept. I was full of enthusiasm. I had been to the annual IHI meetings in Orlando and had sat with 6,000 other committed healthcare professionals as we heard the inspiring speeches of Don Berwick. Those meetings are the closest thing in healthcare to a Billy Graham crusade of the fifties. Then I did the math. There are almost a million physicians who are practicing and another one hundred thousand who are inactive or retired. There are over three million nurses of various types with about 10% not working by choice or circumstance. We have more than 5,500 hospitals. A mix of 6,000 doctors, nurses, and other healthcare professionals was a drop in the bucket. We were not even the tail attempting to wag the dog. At best we were the flea causing the dog to want to scratch every now and then. We were the tiny spark trying to start a fire with wet tinder and green wood. Batalden was right. There is plenty of reason to be concerned. And that was before we began to talk about burnout.

The three young leaders that contacted me recently all carry the spark of Batalden and Berwick. It is my belief that all three of these young leaders match the Deming formula and can maintain and exceed the accomplishments of my generation. I also know that they are not alone. There are many others in the next generation who can step up and carry on the work. What I do not know is whether they will be distracted or discouraged by the internal and external challenges of healthcare over the next decade. I am concerned that healthcare is retreating into a defensive posture with the reduced objective of surviving, and willing to shift its focus away from the challenges of the quality chasm and the Triple Aim in favor of OK care for some people, some of the time.

The skills that the young leaders I know have developed were gained in part because “the system” provided opportunities and support. One real risk ahead for all of us as we “fiddle and diddle” with the politics of what healthcare should be like for all of us is that the opportunities that made them what they are will be dwindling and unavailable to others. It is not hard to imagine fewer young systems engineers, not as many young physicians with population management skills, and a dearth of talented administrators equipped and ready to advance the work that needs to be done. If the kind of expertise my three friends offer seems common in the large medical centers on the coasts and in the upper midwest, or in cities with a university system, that’s great, but we have hardly established a beachhead on a better future. Remember there are more than 5,500 hospitals that need to be transformed to a “new way of walking.” We need to remember that as we are fighting for the survival of Medicaid as we know it, and resisting an effort to reduce the Medicare spend by decree rather than by systems improvement, we may be entering a vicious downward cycle. One part of a strategy for the future must be to find or develop more young leaders who fit Deming's description. How do we do it? How do we pick up the pace? Batalden’s concern was real ten years ago and our challenges remain.


The Sap is Rising. Let’s Boil It!

It feels like we are going to have an early Spring. February was very warm with several days that felt like April interspersed with mid March. If you read this note within a few hours of when it hits your inbox, the forecasters are telling me that I will be in the midst of a storm that is likely to be snow where I live but could be heavy rain fifty miles away in Manchester where I am scheduled for a flight on Saturday. There is no doubt that in North Carolina, my weekend destination, will be enjoying sunshine and comfortable temps in the sixties. March may be my favorite month in my ancestral stomping grounds. I can expect to hear birds chirp, see lots of budding shrubs and trees, and enjoy sticking my nose into the the early buds of camellias and azaleas.

My neighbors in my adopted home of New London, New Hampshire have introduced me to their late winter/ early spring interface activities. The sap in maple trees rises when the temp is in the twenties at night and the forties during the day. The average tree produces about 10 gallons per tap and larger trees can have two taps. If you look closely at the picture in today’s header you can see a bucket hanging from a maple tree behind my friends who are boiling sap to make syrup. The “sugarmaster” here is Steve, the fellow on the right. When he is not boiling sap he is an attorney who consults in the energy sector, but he is also the heart and soul of multiple non profit efforts to improve the community. He is a “better angel.” He serves on the land trust board, runs a program that delivers free firewood to the needy, started a local movement called “Love is a Verb” that seeks to give people a helping hand when they need it, and serves as a counselor for many of the youth in our area. Those are only a few of the things he does. It seems ironic to me that criminals are often sentenced to community service. I doubt that there are many people who provide more hours of community service in any year than Steve. He is also the guy that pushes me on winter hikes.

Next to Steve is Moly who came to America in the 90s as an immigrant from Liberia. Moly is a local teacher and educational administrator who is also involved in many service activities in our community, and like me, likes to follow Steve’s lead in community service adventures. Most recently Steve has led a group of about 15 of us in a systematic look at poverty. It is a sad reality that well meaning folks doing great things for people in need can never really change the arc of inequality and poverty. Our well meaning charitable activities are valuable but insufficient to make a real difference in the long term issues that create and perpetuate poverty. These are the things we discuss as we watch the sap boil.

There is a math to sugaring. Steve taps 34 trees on his land. Each tree gives 10 to twenty gallons of sap. If a tree averages 15 gallons and if it takes 50 gallons of sap to boil down to one gallon of syrup then Steve’s maximum production for the season will be about 10 gallons. He will burn more than a cord of wood which is worth about $300 dollars and spend many hours tending the trees and the fire that boils down the sap. I don’t think anybody will get rich making maple syrup. Not pictured because she was off on an errand is Nancy, who is married to Steve and really manages the “work flow” and focuses on the finesse in the final boiling process that makes a big difference in the product quality. Like healthcare, sugaring is a complex process that offers opportunities to many and depends on workflows and teamwork. By next year Steve and Nancy hope to have a built a “sugar shack” that will allow them to get out of the mud and boil sugar on the days when it rains or snows. Steve and Nancy, as you probably have guessed, give away most of what they produce. It is good to be a friend of Steve and Nancy.

If you would like to see sugaring in action, on the weekend of March 24 many sugar shacks in our area will be welcoming visitors. I can hardly wait!