25 December 2015
Dear Interested Readers,
Inside This Week’s Letter
It’s a holiday letter that I hope will have meaning for everyone in the diverse world of the Interested Readers of these musings. Whether you are celebrating Christmas or just enjoying a few days of year end respite with family and friends, I hope that you are happy and well at this very special time of the year.
It is a time of parties, homecomings, giving gifts and making resolutions. It is a time when we review where we have been, sum up what we have learned and look forward with the hope that we will do better with a new start. Those will be my themes for this week and next week. I have come to realize that the speech that Don Berwick gave in Orlando on December 9 was a gift to us all. For the third week running his speech inspires my “musings”. I begin with someone else’s review of the speech and then put my own emphasis on his surprising reference to “civility” which seems to be in short supply. The second thought section springs from comments about last week’s discussion of hope and optimism.
I will repeat my weekly request that you visit strategyhealthcare.com where you will find a new posting from earlier this week. Consider it a gift to me because the Internet rewards those sites that people visit. You might also give information about the site to a friend. Remember that information is the most unusual of gifts because you can both give it away and keep it for yourself!
Civility, What a Retro Idea!
I can’t get Don Berwick’s closing keynote address at the 27th IHI Forum out of my head. I have been waiting to see if the IHI posts a video version but so far I have not found anything. I did find an excellent report of the speech. You may remember that I have commented at length about this remarkable speech in the last two of these “weekly musings”.
The article that I found was published in Health and Hospital Network Magazine and was written by Marty Stempniak. He has also published a short video of Don discussing the meat of what he hopes will be Era 3 of healthcare, a return to purpose. If you spend the four minutes necessary to view and listen to this clip you will be richly rewarded for a very small investment.
Mr. Stempniak was as enthralled by Don's speech as I was and at one point near the end of his review he says, “There’s a lot more I, as the reporter, could say about what was a wonderful, wonderful speech, probably the best I’ve seen in my four short years covering health care conferences, but I’ll leave it at that.”. Here is his insightful review of Don’s nine steps to Era 3 which are the core actions necessary to adopt the mindset of Don’s Era 3.
Berwick offered health care leaders nine steps they can take to begin moving into this new age, which he tentatively dubbed as “the moral era”. Here they are, in Don’s own words as reported by Mr. Stempniak:
- Stop excessive measurement: I don’t mean that we should stop measuring. Indeed, I celebrate transparency in every form. How else can you learn? But we need to tame measurement. It has gone crazy. Far from showing us our way, these searchlights training on us, they blind us. We can’t find Sean in that glare. I vote for a 50 percent reduction in all metrics currently being used.
- Abandon complex incentives: We need a moratorium, I think, on complex incentive programs for individual health care workers, especially for doctors, nurses and therapists. If a program is too complicated to understand, too complicated to act upon by getting better, then it isn’t an incentive program. It’s a confusion program. It’s a full-employment program for consultants.
- Decrease focus on finance: This could be impossible. I feel naïve, almost, suggesting it, but for just a while, wouldn’t it be great if we could step off the treadmill of revenue maximizing? … If leaders really did care about profit, they would concentrate unremittingly on meeting the needs of people who came to them for help, but they aren’t. We aren’t.
- Avoid professional prerogative at the expense of the whole: From Era 1, we clinicians, doctors, nurses, we inherited the privilege. It’s still there. We can still use it. It’s the trump card of prerogative over needs, over the interests of others. ‘It’s my operating room time.’ ‘I give the orders.’ ‘Only a doctor can.’ ‘Only a nurse can.’ These are habits and beliefs that die very hard, but they’re not needed. They’re in our way.
- Recommit to improvement science: For improvement methods to work, you have to use them, and most of us are not. I’m trying to be polite, but I am stunned by the number of organizations I visit today in which no one has studied [W. Edwards] Deming’s work, no one recognizes a process control chart, no one has mastered the power of testing PDSA (plan-do-study-act), Nathaniel’s Method or the route to the top. You can see the proof of concept. This is beyond theory now.
- Embrace transparency: The right rule is really clear to me. Anything we know about our work, anything, anything we know about our work, the people and communities we serve can know too, without delay, without cost or smoke screens. What we know, they know, period.
- Protect civility: With the self-satisfaction courted by Era 1, with the accusatory posture that’s at the heart of Era 2, civility and, therefore, possibility have been in much too short of supply. I don’t lack a sense of humor, although I may sound like it right now, but in my opinion, jokes about herding cats or green eyeshades or soulless bureaucrats or the surgical personality, or the demanding patient — these are not funny.
- Listen. Really listen: These terms — coproduction, patient-centered care, what matters to you — they’re encoding a new balance of power: the authentic transfer of control over people’s lives to the people themselves. That includes, and I have to say this, above all, it has to include the voices of the poor, the disadvantaged, the excluded. They need our mission most.
- Reject greed: For whatever reason, we have slipped into a tolerance of greed in our own backyard and it has got to stop … We cannot ask for trust if we tolerate greed. The public is too smart.
Perhaps because of the general lack of civility that we sense in human discourse today Don’s reference to civility should not have been a surprise for me. Harsh and hurtful expressions of opinion and deep disdain for others seems to hit to us in the face everytime we open a newspaper, turn on our computers, tune in to the radio or sit down to watch the evening news. Don called out this lack of civility as a huge barrier to progress in healthcare. From the moment he said it, I have been captivated by Don’s emphasis on this point. A great leader points out not only what we should begin to do but also what we must cease doing or give up. I really did not get it until Don made his point number 7. Since the moment he called for a return “civility” I have not been able to get that idea out of my head. I hear his suggestion as being more than giving up bad behavior toward one another. I hear him expanding and adding depth to our growing realization that respect is a cornerstone of collective problem solving and progress. Perhaps if there is any shortcoming in Mr. Stempniak’s reporting it is that he has failed to generate the same sense of surprise for me about “civility” that I experienced when I heard Don say it.
My challenge to you is for you to think about what civility means to you. For me it means much more than avoiding poor humor that degrades others as some of our current politicians use for short term gain. I think that calling out a lack of civility is to open a window that reveals the contempt that we sometimes hold for some of our colleagues and neighbors who honestly have a different point of view that arises from an experience in life that we have not tried to understand. Practicing civility would require us to earnestly ask one another, “What matters to you?”. Practicing civility would also include diminishing discord by each of us asking ourselves, “What part of the problem am I?”. A journey toward civility would be a journey toward understanding why progress toward the Triple Aim seems to be so difficult. Don has launched a conversation that should attract us all.
Comments About Last Week’s Letter, More On Hope
Several Interested Readers sent me their comments about last week’s discussion of hope and optimism. One comment was associated with a bit of education for me.
I loved your distinction between optimism and hope. I wanted you to see how another writer/poet handled that idea.
The “Interested Reader” offered me a piece from Vaclav Havel, noted playwright, philosopher, essayist and the first president of the Czech Republic. I thought that I should pass it on to you. In less than two hundred words it said what it took me more than three thousand words to say. Havel was a real writer. I hope that his words say something to you.
Hope is a state of mind, not of the world. Either we have hope or we don't; it is a dimension of the soul, and it's not essentially dependent on some particular observation of the world or estimate of the situation. Hope is not prognostication. It is an orientation of the spirit, and orientation of the heart; it transcends the world that is immediately experienced, and is anchored somewhere beyond its horizons ...Hope, in this deep and powerful sense, is not the same as joy that things are going well, or willingness to invest in enterprises that are obviously heading for success, but rather an ability to work for something because it is good, not just because it stands a chance to succeed. The more propitious the situation in which we demonstrate hope, the deeper the hope is. Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out.
Vaclav Havel
Ideas seem to come in groups almost like they were friends. On one of my walks this week I was listening to Robert Caro’s third volume of the life of Lyndon Johnson, Master of the Senate. So far in four volumes Caro has written over three thousand pages about the life of Johnson. There is a fifth and final volume that Caro has promised to be ready in the next few years. What I have enjoyed most about Caro’s style is how he spends so much time describing the world as Johnson knew it. Johnson was the Senate Majority leader through most of the fifties. There were many big issues of the fifties that were part of my first observations of the wider world. I clearly remember our fears of the Soviet Union, how awful Joe McCarthy was, the early adventures of our attempts to go into space, the horror of the execution of the Rosenbergs, the seeming futility of the War in Korea, and the Montgomery bus boycott.
I was eleven years old in 1956 when Martin Luther King, Jr managed the first real victory in the struggle for civil rights in Montgomery using the philosophy of nonviolence which he adopted from Ghandi. Caro writes as much about the other players and issues of the fifties as he does about Johnson. Caro weaves Johnson’s pursuit of his ambition to be president with the lives of the other significant social and political figures and the issues that they pursued in ways that required Johnson either to change or camouflage his own feelings and ideas. Johnson was ultimately transformed and in part redeemed by realizing that to achieve his own personal goals he had to be mindful of how others perceived him.
While I was walking, Caro was discussing Martin Luther King, Jr.’s emergence as the leader of the movement during the Montgomery Bus Boycott of 1955-56. I was stopped in my track’s when King was quoted as saying:
You know there comes a time when time itself is ready for change.
Wow! What a statement of hope! It was made at a mass meeting of the Montgomery Improvement Association at the First Baptist Church where Ralph Abernathy was pastor. King’s home was bombed with dynamite the same night, yet he had hope. It would take almost a year before the Supreme Court would rule that the segregation on the buses in Alabama was unconstitutional, but the Supreme Court did and the next day King enjoyed the fruit of his hope and persistence when he boarded a bus for a ride in the front seat.
Optimism would not have lasted through a year of harassment, arrests, and personal threats. Only hope and something worth living to achieve could sustain King through such a long ordeal and give him the strength to lead a community through the hate and aggression that denied them what was their right.
Perhaps it is a stretch to try to attach the effort to obtain civil rights for over 16 million people (the Black population of the USA in 1956) with the on going effort to provide care for everyone in America consistent with the new expression of the Triple Aim:
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
The hardest part is the …for every person, every time.
My hope going into this year is that the time has come again when time itself is ready for change, ready for the movement toward purpose that Don Berwick called for in his IHI speech that closed the 27th Forum. That is why the quote, “You know there comes a time when time itself is ready for change” resonated with me. As I was walking along and thinking about what I had just heard coming out of my earbuds, I had a thought. Has anyone ever publicly committed themselves to do whatever they could to contribute to the achievement of the Trip Aim?
The IHI website will lead you to an excellent review of the first seven years of the Triple Aim published in the Milbank Foundation Quarterly. It is loaded with great information and chronicles the story but it occurs to me that it lacks passion. The Triple Aim was foundational for the ACA and its concepts have been adopted widely at an intellectual level, but do they move you emotionally? During the later part of my tenure at Atrius Health I heard people in management and on the board suggest that the Triple Aim or the Triple Aim Plus One should become our mission and strategic objective. I have been to the websites of Gundersen Health, Bellin Healthcare and ThedaCare, all in Wisconsin (perhaps three of the most successful organizations in the country in terms of the Triple Aim); all of them practice continuous improvement science as if the Triple Aim were their mission and strategic vision, but even within these organizations there is no statement of the importance of the points of the Triple Aim in the way they are working for a better future.
I think that we are missing an opportunity. Last week I made a list of ten points that I hold to be true and one of the points I made was that I have never met anyone in healthcare who disagreed with the concepts of the Triple Aim. Even though they do not disagree with the goals of the Triple Aim, that is not the same as saying that there is a passion for the Triple Aim or the sense of purpose that would be necessary to achieve it. My statement that no one disagreed with the Triple Aim was a statement of hope. What would give me even more hope would be to hear people, practices, institutions and even politicians explicitly say that the Triple Aim was their most important aim, the core of their collective purpose.
Years ago Roger Fisher and others at the Harvard Negotiation Project suggested that looking for common interest was the key to progress. I bolded the last part of the last sentence of this piece that I have lifted from their website for emphasis.
HNP is perhaps best known for the development of the theory of “principled negotiation,” as presented in Getting to YES: Negotiating Agreement Without Giving In, by Roger Fisher, Bill Ury, and Bruce Patton. First published in 1981, and revised and expanded in a tenth anniversary edition (Penguin 1991), Getting to YES outlines a commonsense approach to negotiation that has been read by millions of people in 25 different languages. In clear, straightforward writing, Getting to YES shows negotiators how to separate relationship issues from substance and deal with the latter by focusing on interests, not positions; inventing options for mutual gain; and using independent standards of fairness to avoid a bitter contest of will.
I see the current state of healthcare as one huge negotiation, or if you prefer, hundreds of interconnected and interdependent negotiations that are largely functions of self interest. What if everyone became explicitly focused on the Triple Aim as the objective of their negotiation. To do so would require people, practices, hospitals and health systems to recognize that their own self interest was best protected and advanced by putting the interests of patients, families and communities ahead of their own. That’s always seemed like good strategy or good game theory in most other businesses. When I worked at Sears back in the early sixties the first thing they told me was, “The customer is always right!”
So if our discussions began with the mutual recognition by people on both sides of the table that we shared a belief in the Triple Aim and that the outcome of our negotiation should advance our shared aim, how would things change? It would be a recognition that they were at the table to share opinions about how together they could contribute to the Triple Aim. Would such an affirmation of shared purpose change the conversation? Would our discussions have different outcomes?
This is the time of year when we reflect and rededicate ourselves to doing a better job. Everyone I know quotes Einstein and says that insanity is doing the same thing over and over again expecting a different outcome. What if the thing we changed to avoid being accused of insanity was to seek to have everyone, every practice, every hospital, every health system, and every regulator or politician explicitly pledge to make the Triple Aim their goal? I would love to see it tried! Would you do it? Let me know.
Peace On Earth, Good Will to All
Since before the beginning of our collective memory at this time of the year when the sun seems to have little interest in us, and with its neglect each passing day seems colder than the one before, people have been coming together to find courage and joy in the company of others. Last weekend my wife and I were invited by new friends who are the personification of outreach and community service to join them in sharing a local tradition of coming together at the Meeting House in South Sutton, New Hampshire.
If you clicked on the link you can read a little of its history and see a picture of it as it appears on a warm summer day. The header picture for today is the way it appeared as we left after enjoying the 45th Annual Christmas Pageant. The Meetinghouse is almost exactly as it was when it was built in 1839. It has no lights, no heating system, and as far as I could see, no plumbing. Those who gather there wear caps, gloves, and parkas, and cover themselves with blankets as they huddle for more warmth in candle light as close as possible to their neighbors. It feels colder in the building than outside in the night air. Sitting in the darkness and waiting for the program to begin gives you a real appreciation for what life in nineteenth century New England must have been like.
Part of me wishes that I could say that this event has been an annual affair for more than a hundred years but the pageant in its current form was created in 1971 by a group that called themselves the “Sutton Homesteaders”. Their desire was to spread the true meaning of Christmas with a “magical happening”. The original script was written by a man named Tom Lowe and is still followed today. It includes the singing of songs, children reenacting the Christmas story, and traditional readings including Clement Moore’s a “A Visit from St. Nicholas”, better known by its first line, “Twas the night before Christmas”. Tom Lowe’s brother Don was the first reader and members of the Lowe family are still continuing the tradition.
In my imagination and from my understanding of a pamphlet available at the pageant, the “Sutton Homesteaders” were good souls who embodied the best traits of what we called “hippies”. They gathered in Sutton in the mid sixties at a village party and “were inspired to create a monthly gathering to encourage community spirit and to provide for neighbors in need for celebration”. They also produced summer musicals until the mid eighties, “thanks to the talent from vaudeville” of the Lowes and the musical abilities of many of the other “Homesteaders”.
Following the pageant everyone gathered in the Historical Society on the other side of the village green where it was warm and there was plenty to eat and warm beverages to drink. The only thing missing from a perfect Yuletide experience was some snow. I was reminded that we are at our best when we are engaged with others in pursuit of a common goal. Sharing the same experience is a great equalizer. It is hard to lose your way to self interest when everyone comes together with a collective interest. Every year we revisit these experiences. Next week we will begin to make resolutions that we hope will sustain us as we try to improve ourselves and our community in a New Year. We live from year to year with the renewed hope for better communities and a world at peace that comes to us each year in response to our darkest and coldest nights.
I hope that your Holidays are joyous and that our collective hopes and insights about community will enhance our civility and love and respect for one another in the year ahead as we pursue the Triple Aim and better health for everyone, no matter how diverse our backgrounds and political mindsets might be. |
