24 November 2017

Dear Interested Readers


Pausing to Give Thanks

It is the season of thankfully recognizing all that we have been given. I am a lucky guy whose “cup runneth over.” Although I complain about many things, I am grateful to live in a country where I am free to complain. High on my list of blessings are that you read these letters, and the great support that is freely given by several people that has made them possible.

When I retired four years ago, I assumed that I was finished with my weekly letters. The first week not writing felt like a vacation. By the second week I was feeling like I had lost something that was a valuable part of my way of relating to the world. Fortunately for me, I had the good luck of having John Gallagher of Simpler as a good friend and adviser. He used good coaching technique and asked me the question, “Why do you feel like you can’t write?” I responded that I thought it was inappropriate and unfair to the leaders who were assuming my responsibilities for me to continue to write to my colleagues. He agreed, but he pointed out that over the years the letter had gained a wider circulation than the healthcare professionals at Atrius Health. The next week I trimmed my salutation from “Dear Atrius Colleagues and other Interested Readers” to “Dear Interested Readers” and I was off and running again. I soon realized that I could say more speaking as “just me” than as a CEO with a corporate responsibilities. I remain very thankful to John for his good advice.

I am thankful that my good fortune continued. Those first letters were circulated as an email with a long list of recipients. That doesn’t work well when the list grows long. About a year into the project, Steve Matteson, also a Simpler colleague, and an Interested Reader, opened the next door by introducing me to Peter Kriff, a childhood friend of his who is a public relations professional in Burlington, Vermont. Through Peter I was introduced to Robin Warhol, an Ohio State professor of literature who helped me edit the longer Friday letters into shorter “posts.” Peter also helped me create the Strategy Healthcare website.

Peter’s greatest gift to me was my introduction to Russ Morgan. I will never understand why I deserve the gracious gifts of time and support that I have received from Russ Morgan. Russ has been many things over an incredibly interesting life. Now he is the IT manager of the Currier Museum of Art in Manchester, New Hampshire. Russ is the the technical force behind all of the blog postings and the Friday “Healthcare Musings” letters. Russ is a very busy man with all of his responsibilities at the Currier, but every Tuesday he makes sure that Strategy Healthcare comes to you, and on every Friday he tolerates multiple requests from me for last minute corrections to these letters. It seems that I can’t see some typos until they are in the final format. Some errors I never see until after you get the letter. Trust me, without Russ’ help nothing would happen. I am most thankful for Russ. I do not have the courage to ask him why he freely offers so much time to this collaboration.

There are two other people who make this letter possible each week. I am very thankful and indebted to my son Jesse who donates his graphic arts skills to create the header each week. Finally, my last expression of gratitude for supporting this effort is for my wife. She reads it first and if it weren’t for her suggestions there would be more run on sentences than there are, and many letters would be 10,000 words long. I am so very thankful for all of these people and especially for you the “Interested Readers” of this letter. Without you I would be talking to myself.


Thankful For Something That Is Really Free

Seven years ago the same son that does the graphic work for this letter began an even more ambitious project than these letters. He made a commitment to himself to put a new song up on the Internet every week. He named the project “Mount Everest.” This Monday was the end of the seventh successful year. He has never missed a Monday, even while earning his Master’s degree in communications from NYU. There is no end in sight.

Over the seven years there is variation from complex arrangements with multiple instruments to simple offerings of pure poetry with a guitar. What is true of all of the pieces is that they speak of feelings and events that are real. They are a chronicle of the impressions of an observer and participant in our days that are sometimes good times and sometimes trying times. If you click on this link to Mount Everest, you can download a free album of what he feels are the best eighteen songs of this seventh year.


Forward to This Week’s Focus on Leadership in Healthcare

I have been wanting to write about leadership for sometime. Leadership has been a fascinating subject for me going back to childhood experiences in Scouts, on sports teams, and in various student organizations in high school and college. In retrospect it is a surprise to me that when I became a physician I did not immediately continue to seek out leadership roles for myself. I was so overwhelmed with the task of fulfilling my obligations to patients and my responsibilities as a young husband and father, that in the first five years of practice I had no energy for leadership. As time passed and I became more comfortable in my primary role as someone’s doctor, I began to notice things that I thought ought to change. I offered myself as a leader to the keepers of the status quo. At one point in the late seventies or early eighties I was invited to a two day off site seminar on “Situational Leadership.” Whether it was my belligerent attitude and some of the things I said in criticism of our management, or just the way the ball bounces, I did not make the grade. I was advised by the authorities to keep my focus on practice and leave the leading to them. Denied the opportunity to progress through the usual pathways of leadership development, I began to align with other voices of discontent and got involved in the governance of our practice. I was not an overnight success. It was a journey of more than twenty five years from losing my first run at a board seat to becoming CEO.

Leadership development is a personal growth process that never ends. The real learning curve did not begin until I became “a leader” and was finally at the table participating in decisions that would make a real difference in the evolution of our practice. I quickly learned that I did not know much. I did know that there were real deficiencies in the performances of our other leaders. We all had a lot to learn beyond knowing how to read a balance sheet or negotiate a contract. Over time I have learned that the learning never ends.

One of my habits that drives some people crazy is that I always want to start the story in the beginning and tell the long version. I want to pass on for you to examine the history of how we got to where we are, as well as some of the things that I think I have learned on my journey about leadership. I recognize that I am far from an authority on the subject of leadership, and admitting that to myself gives me a chance to continue to learn. Much of what I think I know may be wrong, but discovering what is wrong is the best way to learn. Examining our errors and failures is the most effective path to progress. My objective is to present some of the things I think I have learned against the background that may give them some validity. One thing that I know for sure is that self examining leadership in a time of change is important.

I do not think that I will exhaust the subject in one letter. This will be a continuing series that will appear from time to time. I started out writing about leadership in general. That’s like trying to boil the ocean, so I quickly reduced the scope of today’s letter to a memoir laced introduction, and then some specifics about the broader based skill set that leadership requires in times that call for transformation. The world does not need another book on leadership, but it does need us to continuously reflect on what has been written in the context of current challenging problems, events, and opportunities. In the future I hope to talk about several other connected leadership topics like leadership and integrity, leadership teams, distributed leadership, leadership with and without authority, VUCA leadership, Lean leadership skills, and how to develop leadership. It’s ambitious but I am looking forward to the journey.

Washington is on hold this week, and perhaps will be on hold after Thanksgiving as we continue to debate the finer points of the subject of inappropriate behavior in the workplace and in the political arena. What is happening/not happening in Washington is one of the reasons that now is a good time to discuss effective leadership. I see good leadership as critical to our ability as a nation to navigate the uncertainties that seem to cloud our future.


A Little History Plus Effective Leadership Skills For Times Like These

I love books and despite the convenience of Amazon there is nothing that I enjoy more than wandering around in a bookstore. When I get to the shelves in the business section I get the impression that there are more books on leadership and change management than any other subjects. My own library contains all the classics in leadership and some that were once the flavor of the month but now don’t get much attention. Talking about leadership and criticizing leaders for their failures has been a big part of the conversation since our ancestors began hunting in bands. We aren’t even the only species that depends on leaders or that has competition for leadership!

I can imagine that after a long day of hunting on the Serengeti with nothing to show for their effort and if there was nothing to roast, there would be much grunting and grousing around the campfire. Perhaps there were debates about whether or not it was time for a leadership change. Things have not changed much. The bands of hunters are now corporations, teams, departments in government, and the like, all organized around some idea, mission, product, administrative responsibility, or other such effort. Our teams and games are analogously organized as reflections of our more serious group endeavors and wars. We like to see organized groups move toward a goal, and every team has a coach or manager on the sidelines, and in many sports there is a leader on the field of play.

It was a little bit of a surprise when both the Yankees and the Red Sox fired their managers this year. Both teams exceeded preseason expectations, and had successful seasons; but in the end, they both were eliminated from the playoffs by the Astros. The owners of both teams must not have had confidence that they had the right leader to produce an even better result next year. I can imagine that even leaders like Belichick and Brady would not survive long if the Patriots suddenly started playing like the Cleveland Browns. The life expectancy of leaders is often all about what followers have recently experienced, and what they are expecting to experience in the very near future.

Yuval Noah Harari writes in Sapiens: A Short History of Humankind that our species rules the planet because 70,000 years ago we moved from just hunting in a pack to organizing ourselves around fictions that represented shared objectives that were abstract and often false. One example he offers of a false concept that was an effective organizing principle for a few millennia is the concept of the divine rights of monarchs. That fiction was rejected in France when they cut off the King’s head. Another fiction or myth that still lives is that paper money actually has value, and now by extension, that plastic credit cards have value. Money works because we all accept it as having value. The concept of credit is an even more abstract idea that is dependent on wide acceptance and trust.

When we lose confidence in these shared myths and accepted concepts things change, and we have events like revolutions, the collapse of markets, and the closure of banks. We all struggle until we restore trust in the myth or move on to a new one. We demand that our leaders be aligned with our myths. Our national myth has a set of Judeo-Christian and Western European values as its foundation. Atheists, Buddhists, and Muslims need not apply for high elected office.

Leadership is aligned with the myth and is the keeper/custodian of the current organizational fiction when things are going well. When things falter and there are questions about the underlying organizing principles and the power of the operative myths or constructs to harmonize our activities in a way that makes things better, we often think about changing leaders before we give up the myth and change the operating principles. Moving on to a new organizing principle or myth seems harder than just changing leaders. It’s easier to say, “What did he know anyway?” or “She lost her way; power went to her head.”

When there is an effective change of the organizing story or fiction, it is often true that the new principle is first seen as a message from a new and charismatic leader that is at variance with the old operating principles. Marx, Lenin and company, Jesus, or the Prophet Mohammed may be examples of this phenomena. Occasionally, someone notes that there is a new idea that is evolving that is in search of new leaders. I would offer Clay Christensen’s concept of “market disrupters” as an example. Christensen was not a leader per se, but his thesis sent current leaders or new wannabe leaders scrambling to see if his new ideas worked for them.

Looking back at how organizing stories have evolved over the last 500 years, it’s obvious that the growth of information produced by the scientific method of solving problems has destroyed many myths and the organizations that depended on them. Facts and the laws of science have transformed much of our society, but the process is not over and there is continuing resistance as we can see in the political debates about climate change. Culture and a desire to maintain the status quo coupled with self interest can still trump “enlightenment” and perpetuate operating systems long past the time when they are a positive organizing principle.

The most unstable part of our current mythology has to do with interpersonal relationships, and the relationships between races. For most of the last 70,000 years we have been quite comfortable with inequality, male dominance, and the abuse of minorities. We have manufactured supporting myths like “Manifest Destiny” and the “White Man’s Burden” to justify and support the global extraction of wealth for our own purposes through Imperialism and Colonialism. Many of our current leaders are caught in the transition between myths. This is true in politics and it is also true in healthcare.

In stable times good leadership in business often settles into “hard” management skills. One error is to equate management with leadership, but that is another discussion. In a stable environment it is often more than enough for leaders to be proficient in a basic a set of traditional business management skills like marketing, finance, supply chain management, and product research. In times of global transition like we are experiencing in healthcare and manufacturing, not to mention almost every other aspect of human endeavor, from driving taxis to education, those “hard” or left brain skills may be necessary, but they are no longer sufficient for successful leadership.

Now we hear about the “soft skills” and the related right brain attributes that are required for leadership in times of great transition. Those soft and right brained skills were part of what Daniel Pink was writing about when he published A Whole New Mind in 2005 and facetiously predicted a right brain take over of the world. I sometimes fear that many of our market controlling healthcare organizations are still being lead by leaders chosen for their “hard skills.” The pressure to get through this difficult moment and get back to the way things were, sort of the healthcare equivalent of “Make America Great Again,” makes us think that if we could just use our “hard skills” better, and do what we have always done with more intensity that might make us more effective, we will “right the ship” and all will be well again. Staying with what we know, even though it is not working, is more attractive than the pain and uncertainty of a transformation to a new mindset and a new “myth” that right brained/soft skilled leaders might facilitate.

About 25 years ago as I was evolving as a “leader” through my activities in governance, I become serially fascinated by a cascade of a whole new set of subjects. My specialty of cardiology seemed to be best understood from the position of systems theory which enabled my understanding of how things related to one another and facilitated clinical decision making. Blood flow as a function of force and resistance always made sense. I began to see analogous situations in our business. I began to notice that when things did not turn out as I had expected when I made a therapeutic decision, the reason could be better understood with insights from complexity theory. Armed with some knowledge of systems and complexity, there were many things that still could not be explained, especially when the process was managed by people. Problems made more sense when I learned a little bit about biases and other factors in the irrational choices of people. The observation of biases as explained by behavioral economics coupled with science, systems engineering, and complexity theory all seemed to be linked and hold promise, so I read more.

In a way, all of this theory was compatible with something I had known all along. I always believed that the servant leader model of leadership, or what Jim Collins called level 5 leadership was the best leadership framework for a healthcare organization. The icing on the cake for me was how all of these tools came together in the concepts of Lean philosophy and leadership. Foundational to the successful deployment of all of these skills is leadership empathy and the ability to sustain relational contracts.

It would be remarkable for one individual to suddenly appear on the scene with all of these tools polished and perfected, ready to rescue your practice or health system. I do believe that we have the ability to shape and mold the leaders we need. I believe it is possible to impart the components of the toolkit I describe to a new generation of leaders who could foster the transformation from what is failing to what might enable us to inhabit the new world of the Triple Aim. How to develop tomorrow’s leaders will be the subject of another letter sometime soon.


Gifts Abound, and There is a Little Yellow Squirrel Running Around

Earlier this year I was fascinated by the occasional sighting of a white squirrel in my neighborhood. Recently the Boston Globe has been writing about a similar white squirrel that has been living in the Public Gardens near the swan boats. Wednesday’s Globe had a picture of the Public Garden white squirrel in the company of one of its normally colored friends. Sometime in the late summer we noticed that our white squirrel was gone. My wife and I figured that it had moved on. We hoped that it had not become road kill.

Living on the edge of the wild we often have nature’s creatures “move in” with us. Our cat is a great “mouser.” Recently, late at night there have been “sounds” in the walls of our bedroom. My wife is concerned. I shrug my shoulders and say, “What do you expect? It’s cold out there.” Over the past few weeks, coincident with the sounds in the wall at night, we have had a yellow, blond, palomino, or Trumpish orange squirrel in the yard. My wife has succeeded where we failed last summer, and has captured photographic proof that you can study. It is in today’s header. I wish that she could have captured it in a photo with one of its gray-brown buddies.

During the day our new friend loves to hang out around the stacked wood on our deck. The stack is like its front porch. I believe the “front door” is the new hole in the soffit above our bedroom windows that my wife has discovered. The “door” is just above the stacked wood. So do white squirrels go yellow in cold weather, or is this some new strange visitor? I am thankful for the gift of such curiosities to ponder!

Because of the similarity of the yellow mane to the color of the coif of our president, I suggested that we call him Donald. My wife disagreed initially but then offered that more than a similar hair color, the similarity was that they were both obnoxious and unpredictable. She considers both to be a risk. I like watching Donald run around in the yard. She reasons that the squirrel might knaw a wire, and then the house burns down. The other Donald might blow us all to smithereens. I am thankful that we have an exterminator coming to screen out the squirrel, and wish there were as simple a solution to eliminate the risk of a nuclear disaster.

I hope that you will bundle up and walk off a few calories this weekend looking for what is strange and wonderful in your neighborhood. Holiday weekends with friends and family are a great time to create the memories for which we will be thankful some time in the future. If you are walking alone, you might listen to the free download from Mount Everest.