15 April 2016
Dear Interested Readers,
Preview and Background for this Week’s Letter
I love the music, history and food of New Orleans but after our recent visit my wife and I have decided that it is an old town meant for the younger set. My trip there was to attend the GPIN meeting. This week’s letter is an overview of that meeting. In it I have tried to hit the high points in a way that provides you some insights. It would be impossible for me to recreate the whole meeting.
This was my third trip to this very interesting city that is literally dripping with culture and history, although many of its visitors come for a good time that they would never want to discuss with their neighbors. My first time to Bourbon Street was on a family trip when I was about twelve. It was also the first time for my parents and they quickly discovered that there were things on Bourbon Street for me to see that they would prefer for me to save for later in life. Our self guided tour quickly detoured to another attraction in a less racy part of town. At that time I was a big fan of visiting historical monuments and battlefields.
My second trip was as an adult and I brought along my youngest son. We were more interested in visiting and viewing the Ninth Ward in the aftermath of Katrina and to hear the music at Preservation Hall than we were interested in the agenda of the meeting, although I do remember hearing a great talk by Atul Gawande about the difference between ignorance and ineptitude. What I remember most about that trip was standing in the Ninth Ward and looking up at the Mississippi River above me behind the levee as a big ship passed overhead. That was weird.
This time around the city was mostly background noise as I was focused on extracting a great experience from the GPIN meeting. GPIN meets twice a year in nice places but for me the meeting and the people attending the meeting are the main attraction and not the city where it just happens to occur. The usual attendance is 250 to 300. The agenda is constructed by a subset of the attendees from its member groups. Many attendees return again and again so that over the years one develops relationships that are meaningful and that can be quickly renewed with a phone call or email between meetings. Everyone has the same agenda, which is to improve group practice although no two groups are exactly alike. There is much to discuss and share. You can be sure that if a subject is not discussed at GPIN it is probably not that important and any topic on the agenda is on the “cutting edge” of practice. There are usually several participants from each group since it is the group that is the member of the association. Attendees may be practitioners of all types, middle managers, board members or denizens of the C suite. There is no such thing as rank in determining influence or speaking time from the floor either by professional type, position or by region or group. The whole affair is quite egalitarian. There are small groups from rural areas as well as huge groups associated with large academic medical centers.
It is “I to We” at the industry level. Everyone understands the Triple Aim and the six domains of quality as presented in Crossing the Quality Chasm. Almost everyone is on a journey of continuous improvement so that there is a common language and cultures seem more similar than different. Most every group shares the same common tools and has the same common concerns about current problems and future challenges. The whole meeting is about sharing best practices and working together to understand how to improve.
One recurrent high point from meeting to meeting is hearing from carefully chosen outside speakers who are often from other industries. GPIN always reminds me that the greatest challenges we face call for the “softer” skills of management and those skills are best learned and shared in an environment of good fellowship. The New Orleans meeting lived up to the precedents set by more than twenty years of previous meetings. This letter contains a few of the high points.
At the end of the letter I bemoan the fact that so far this spring the fishing has not been so great and the Sox are up and down and have not yet found their groove. Spring is still struggling for its place in the sun and I hope that you might get a chuckle from my discussion of these most important issues as you lay your own plans for the weekend.
I hope that I do not annoy you with my weekly request that you look at strategyhealthcare.com. My wife thinks that I do. I am sensitive these days to the annoyance of constant requests because almost every day my medical school sends me a request for a donation by mail or online. They are using the excuse of the upcoming 45th reunion to ask me for more money. Perhaps you get similar requests from your medical school or university that already has more money than many Sub Saharan nations. I am more inclined to send the money to an organization working with refugees.
Just like my med schools request for more money, I am begging once again for more attention. As I do every week, I am asking that you check out strategyhealthcare.com. Half of last week’s letter made a nice post about the article “Finding Value in Unexpected Places — Fixing the Medicare Physician Fee Schedule”. I am sure that you will remember that this is where you can direct your colleagues or even your friends who are not in healthcare, if they desire to sign up to get their own copy of this letter sent to them each week.
Learning In the Big Easy
One of the greatest perks of being a Senior Adviser for Simpler is that I get to go to GPIN with a couple of colleagues, Paul DeChant and John Gallagher, to represent Simpler, which is one of the corporate sponsors of the meeting. I am always excited about the meeting and I am eager to find out who the visiting speakers will be. This year I was delighted to open the agenda and discover that Jeff Goldsmith, the only man I personally know who is a professional healthcare futurist, was speaking on the second day. Just the opportunity to hear Jeff speak would have made my trip worthwhile. I have been heeding his advice about the future since the early ‘90s and he has always been both controversial and right. What I also enjoy are the surprises that I get from speakers who are not even indirectly involved in healthcare. You do not learn much if you only hear what you know or are looking to hear.
The first speaker, as the conference kicked off, was Chris Fussell a former Navy Seal officer, who was General Stanley McChrystal’s Chief of Staff when he was the commander of Special Operations in Iraq and Afghanistan. The description of his talk was immediately intriguing:
Drawing from his experiences fighting dispersed terrorists networks overseas, Chris discusses lessons learned from transforming Special Operations into an agile and adaptive team of teams, and how he has transferred those learnings to solve complex problems, overcome adversity, and drive high performance in business environments.
Mr. Fussell is a co author with the General of a book they have published recently that has been well received, Team of Teams: New Rules of Engagement for a Complex World. The link is to a great review of the book from the Washington Post. The book was the talk.
Here is some food for thought:
“We abandoned many of the precepts that had helped establish our efficacy in the twentieth century, because the twenty-first century is a different game with different rules.”
That sounds like adaptive change to me. His talk suggested that adaptive change in the military meets the same sort of resistance that it encounters in healthcare and yet change is critical to success in both. Both also share the necessity for a new leadership style:
“In the old model, subordinates provided information and leaders disseminated commands. We reversed it: we had our leaders provide information so that subordinates could take the initiative and make decisions.”
That sounds a lot like Lean leadership to me. Mr. Fussell pointed out time and again that the old style of military management just would not work when you faced an enemy as evasive, fluid and unstructured, but precise as Al Qaeda is. With them there is no stand and fight. They are here and then gone to reappear where you least expect them and sometimes right behind you. Responsiveness requires intense communication up and down from field to headquarters and back. The tools were visual management and the equivalent of a big world wide huddle and MDI board that stretched from the Middle East to Washington and met everyday. There was standard work for everybody. Cycle times decreased a hundredfold and productivity as measured by raids against the enemy went up more than a hundred fold from a few a month to dozens every night.
The obvious linkage between this exercise in adaptive change in our special forces, which had been very siloed before General McChrystal took charge, to the changes that are now needed in healthcare is compelling. We, like General McChrystal, live in a VUCA world (volatile, uncertain, complex and ambiguous) and adaptive change coupled with a new leadership paradigm is needed in healthcare with almost the same urgency as it was needed in Iraq and Afghanistan. Now that they are retired from the military, the wisdom of General McChrystal and Mr. Fussell can be accessed through The McChrystal Group.
I have always been impressed that in our search for best practices we find some of our greatest treasures outside of medicine. Teaching ourselves what we already know is important, but it is clear that many of our breakthrough moments have come from the transfer of ideas and best practices from other industries and sciences, including the military. Lean, fiber optics, echo technology, MRIs and the effective use of big data are just a few of the examples of ideas and technologies that come to mind that medicine has gleaned from engineering, other sciences, the military and industry.
What is harder to do on the spur of the moment is to think of what the practice of medicine has transferred to other professions and industries. We do not even have a lock on professionalism and critical thinking. The body is composed of interdependent systems that in good health are united in an environmental harmony, which we frequently disregard in the individual as well as in the larger world. Perhaps I am too influenced by the recent Pixar movie, Inside Out that described the emotional turmoil of a young girl as she sought to adapt to her family’s move. Her emotions were a team of teams that had to become more efficient and effective.
The remainder of the first day was very much like one large Friday “report out” after a week when there have been several productive RIEs (rapid improvement events or Kaizan). Multiple groups presented recent breakthrough projects. This exercise is a window that allows one to see what people are working on. Access was a big subject! Everyone is feeling the pinch in primary care but it is also an issue in specialties. How to make the most of a scarce resource, access to Primary Care, is suddenly getting a lot of attention. As we look to be safer and more efficient and patient centric, how the referral process works becomes a concern. Just how to create workflows that will both meet the needs of more patients with more problems as the older population lives longer but can also deal with the different demands of a growing younger population, will be our greatest challenge over the next decade. The current models of care delivery will become impossible to staff with doctors and nurses doing old standard work. We need new and more efficient workflows to better leverage our professional expertise and we need innovations that will allow us to do more for more people as we embrace population management and finance.
During the first hour and a half of day two and day three of the meetings, GPIN conducts a discussion of “Hot Topics”. The topics are proposed and prioritized by voting before the meeting. There is a combination of open mike debate and sharing open to anyone who wants to speak coupled with audience wide electronic voting to bring everyone into the process. The list of Hot Topics is always instructive. It is a rank ordering of the problems that face the groups. Reviewing the list of Hot Topics from several years would provide an interesting set of “snap shots” that would display the evolution of both thought and issues in time. The topics for this year in descending order, with the subject getting the most votes first and the least votes last are:
- Virtual care--telehealth/ phone visits/ online diagnosis and treatment
- Population Health/ Behavioral Health/ Clinical Analytics/ Patient engagement
- Physician well being and retention
- Value based provider compensation/ Engagement/ Culture Change
- Medicare ACOs/ Bundled Payment/ Chronic Care Management
- Patient Experience/ CGCAHPS/ Online reputation management/ Did you use an outside consultant?
This year was remarkable because compensation fell to fourth as a topic of interest! Concerns about physician burnout hit the list for the first time in my memory at third place and only a few votes below the two leading subjects. I was pleased and proud that my colleague from Simpler, Dr. Paul Dechant, the former CEO of Sutter Gould Medical Group, made what I considered to be the most enlightened and effective comments on the challenges of physician burnout. Heads were nodding in affirmation all around the room as he spoke. He is quickly becoming an expert on the subject and is writing a book on burnout which I am eager to read. He believes that Lean is an effective therapy for burnout and I agree that, when done right, it can be.
There were four Plenary Session presentations. The “team of team” presentation was the first. The session presented by Jeff Goldsmith that I was eagerly anticipating was second and I will spend some time discussing his presentation. There were two other excellent presentation as well. Like Chris Fussell, they both drew their comments from books that they had written. I will just give you the name of their book and the published description of their talks.
Jonathan Fader, Ph.D. is sports psychologist for the New York Mets and is Co-Founder, Union Square Practice, Albert Einstein School of Medicine. His talk was as informative as it was entertaining:
Research has demonstrated the effectiveness of Motivational Interviewing (MI) in increasing motivation for change and encouraging the achievement of individual goals. This session will highlight motivational interviewing techniques that are successfully being used to engage patients across a spectrum of target populations to improve health outcomes. The second portion of the session will address how these same techniques may be used by leaders to help their colleagues achieve optimal performance.
His book Life as Sport: What Top Athletes Can Teach You about How to Win in Life is scheduled for publication in early May.
Dr. Gilbert Welch is the author of Less Medicine, More Health--7 Assumptions that Drive too Much Medical Care. He has practiced medicine and taught at Dartmouth for more than 25 years.
A recent survey of physicians suggested that nearly one-half said their patients received too much medical care. But it is hard to communicate the nuances--that medical care can do a lot of good, but can also do harm--during a fifteen minute clinic visit clinic visit. This session will consider the seven assumptions that drive the excessively optimistic demand for medical care that encourages overuse, and how physicians can begin to impact these assumptions.
Those seven assumptions that are the source of confusion, waste and pain that drive too much medical care are:
- All risks can be lowered
- It’s always better to fix the problem
- Sooner is always better
- It never hurts to get more information
- Action is always better than inaction
- Newer is always better
- It’s all about avoiding death
Give those seven fallacies some consideration and you may buy the book. I was pleased that everyone in attendance got one for free! It’s next up after Team of Teams on my reading list.
I have saved my discussion of Jeff Goldsmith’s presentation for last, even though in real life I often eat dessert first. Even the description in the program was provocative.
How would your strategy change if the future actually turns out to be different from what everyone expects? Jeff Goldsmith talks about the future of healthcare payment and delivery reform, how it is affecting local markets around the US, and shares the “no regrets” strategies that position healthcare’s major actors for an uncertain, post-health reform future.
Jeff begins with the challenging question, “What if the crowd is wrong?”. By that he means what if guys like me who have been saying that- Costs are rising uncontrollably and to control them, we need to change how health providers are paid.
- Population-based payment is the end state [future] of US healthcare payment.
- Providers will have to shift from treatment to prevention to manage population health risk.
- “Disruptive Technologies” will undermine the traditional business of healthcare, forcing transformative change.
- Consumer empowerment will strengthen the role of consumer choice in the health system.
What if we, the doom and gloom wet blanket crowd using these arguments to push for change and the Triple Aim, are WRONG! That is a pretty challenging “what if”!
If the questions he asks were not challenging enough, he then spent the next forty five minutes going through about fifty challenging slides to show how each of these givens may not be true. My favorite slide in this deck, meant to shock us into critical thinking, was one where he said:
If We Really Want Healthy Populations?
- We Need a Healthier, More Just Society
- And a More Vibrant Economy
- And More Intact Families
- And a Much More Robust Investment in Public Health
That slide made me feel much better, but then he began jousting with Clay Christensen, the father of “disruptive innovation”, and once again he was flashing up a slide to take on the currently popular conventional thinking of the gurus that we all listen to and replacing their “wisdom” with his own insights.
Peter Drucker Was Closer to the Mark Than Christensen
- Disruption is Really Hard
- Finding Ways of Short Circuiting the Process of Fulfilling Customer Needs is a Surer Route to Entrepreneurial Success than Disruption
There was one bomb yet to drop. He flashed up a slide that showed a complex of modern bed towers at some generic academic medical center that one imagines is building tentacles into the community as it gobbles up practices and community hospitals to build its integrated delivery system (IDN). He then reviewed the last forty years of system consolidation in healthcare identifying a few successes, but then asked about the likelihood of a better outcome this time around. His answer to his own question:
Will it Happen This Time?
- Not Unless Total Cost of Care/Quality in the IDN is Provably Better Than Market
- If Not, Health Plans Other Than Your Own Will Not Delegate Risk to You!
- Unless You Are in Massachusetts or Maryland!
I was not sure if that last statement was a compliment or a condemnation for Massachusetts and Maryland. His point though was that consolidation has not proven to be a reliable path to cost reduction or improved quality or service; in fact, it is more likely to be a path to more cost if the driver is loss avoidance.
At this juncture Jeff moved into a discussion of positive possibilities. Here I am going to write what I think that he was saying. He announced that group practice organized around the desire to deliver value for patients was the core mechanism and motivation for better integrated care. The path to a better system of care did not run through hospitals organizing care to maintain their margin, but rather through practices that cared. Remember, he is talking to an organization, GPIN, that exists for this explicit purpose. Then he told us what we already knew and have been discussing together for over twenty years at GPIN meetings. Indeed, we had been talking about in our ‘Hot Topics” conversation just before he rose to speak.
It (transformation to better group practice) Does Not Happen Overnight. Culture Change is Hard!
The most important point came next on slide #55 and it could easily have been the last slide, but it was reinforced by six more slides for emphasis.
What Am I Telling Clinical and Health System Leaders to Do? - Learn to Run on Regular Gas
- Develop a Fault-Intolerant Clinical Culture Built on Continuous Care Improvement
- Teach Your Young Clinicians Elegant Diagnosis and Resource Sensitive Clinical Care
- Smooth and Light the Patient’s Pathway through the Care Episode
- Become the Health System of Choice in Your Communities and Regions
There was no standing ovation, but as I looked around the room I saw heads nodding in agreement. His bottom line was a message of good stewardship, professional values, and patient centricity. We must focus on the reality that as professionals our first concern is to be worthy of the trust that our patients put in us. I said to myself, “I know that; we all know that.”
In late 2008, not long after I became a CEO, the bottom fell out of the economy. Everyone’s future was uncertain. We knew we needed to do something but we were afraid of doing something wrong. We were frozen by the ambiguity of the moment. As an organization were just like the two deer my wife and I hit at sixty miles per hour on a cold night this winter as the deer froze in our headlights crossing the Interstate near our home.
To resolve our ambiguity we decided to create as many scenarios as we could imagine and then play them out to see if we could come up with a core strategy of what we should be doing no matter what the future held for us and our patients. The outcome that fit every scenario was essentially the list that Jeff presented in his 55th slide. Not long after that analysis we began our Lean journey in earnest. We focused on customer service and began to try to arm our clinicians and supporting professionals with the tools that they would need to make good decisions. We realized that we needed a journey of transformation that would better enable us to to draw success from collaboration with one another and the business partners who shared our values as together we faced an uncertain future. If you think otherwise, you might consider investing in lottery tickets.
I do not know whether Jeff’s predictions will come true, but I know that his suggestions offer a prudent path to a better future and that down that long path we may discover something that looks like a world where the Triple Aim has a chance.
It was a good trip. I wish you had been there to hear and see it all yourself.
Already Worried, but What Am I To Do?
We are still within the first three weeks of this young baseball season but I have already added the Red Sox to my list of active worries to be reviewed each day on my walk. There is a song that says that you can’t buy love. Over the years the Yankees seem to be the only team that can consistently buy success and even their success at buying success seems to be waning. The Red Sox spend Mr. Henry’s money like it was from a Monopoly Game and yet it seems that the harder they try to buy instant success the “behinder” they get.
Last year’s cash dump on the “Panda”, AKA Pablo Sandoval, has been a head-shaker from the get go. He started the season on the bench and now he has mysteriously disappeared to the disabled list. How did he get disabled sitting on the bench? Ah yes, splinters. The new ace pitchers can sure “bring the heat” but opposing hitters seem not to be that intimidated and have already socked more “dingers” off of the pair than I would have foolishly wished that they would have coughed up all year. I keep telling myself that the year is young and there have already been some exciting wins and great individual performances, but I do not see championship consistency yet and although it is a long season and much can happen, I am already worried.
My concerns extend to other areas as well. I was recently asked a security question for use if I had forgotten a password, “What is your favorite outdoor warm weather activity?” Without a moment's hesitation I answered “fishing”. “Whoa!”, you may say, “What about walking/jogging?”. Those are my favorite all round outdoor activities but I do them in all weather and seasons: rain, shine, snow, cold or in gentle breezes of spring and horrendous heat of summer. Fishing is my warm weather passion.
I have this app to guide my fishing called “Fish Time Pro”. Everyday for the last week it has predicted that the fishing in my lake and all the streams and lakes in my area will be “poor”. Through personal experience I have confirmed that this is accurate. I have tried all the tricks I know for several hours on several days and have only enjoyed two brief hits and imagine that down under the water some trout just had second thoughts and spit out my fly. It is at times like this that I am so happy that I can still walk and jog a little. Listening to the Sox blow a lead is much easier if it occurs on a good walk.
I remain hopeful that the Sox will improve and the fish will bite but it is nice to have some certainty in life. I know that there is no such thing as a bad walk. I hope that you will be out on you favorite trail or road this weekend. I have my plans made.
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