| 25 March 2016
Dear Interested Readers,
Overview of This Week’s Letter
The discussion of Lean leadership continues this week but the focus shifts from the CEO and senior management to middle management. Specifically the question under consideration is what a person who has a leadership position does in an organization to promote the evolution of a Lean culture when senior leadership seems distracted, disinterested or just not effective. Perhaps it is overly dramatic to use the phrase “speaking truth to power” but grant me the use of some hyperbole.
My attention this week is split between the plans I had made to explore Lean leadership and the fact that this week is the sixth anniversary of the Affordable Care Act. We all know what has happened since the law was passed. There are differences of opinion about what has been accomplished. The opinions range from a disaster to the greatest domestic accomplishment of the last fifty years. Opinions aside, what is most important is what will happen in the future. The answer to that question is “it depends”.
Spring is coming to New England in fits and starts. While out for a walk/jog this week I was listening to some of my son’s early music. One tune spoke to me. This week’s letter concludes with a few thoughts engendered by the combination of his song, some exercise and a Spring day .
Last week’s letter was long, but I really believe in the importance of relational contracts to the success of Lean! Trust must be a foundational principle in any successful Lean organization. Autocrates can achieve limited success utilizing techniques for control and motivation built on abuse and exploitation in an environment of fear and disrespect in the workplace, but I do not believe they can create sustainable breakthrough improvements in performance and quality. There is a revised and shortened version of last week’s discussion of relational contracts on strategyhealthcare.com which I hope that you will check out soon. If you ever think about forwarding one of these letters to a friend or colleague, please suggest to them that they sign up to get the letter sent to them each week.
How to “Speak Truth To Power”
Lean gets started in different ways, but for it to survive and thrive and move from being used as a set of tools to being the core of a culture and operating system that is the source of sustained excellence, eventually the CEO and senior management must lead. One Lean consultant, Jamie Flinchbaugh, has said,
...recognize that few companies start a lean program with upper management support. Sometimes, but very rarely, lean originates and is lead by senior management. Slightly more often, someone in senior management gets the journey started, but does not maintain it. However, most common is the scenario where someone else in the organization needs to get them on board.
That was certainly the experience at Harvard Vanguard and Atrius Health. The Vanguard story is worth mentioning because many Interested Readers may find themselves in an organization that is “doing Lean” or “Lean like” activities and are wondering what they could try to do to move senior leadership and their board to becoming more effective Lean leaders.
In 2005 Harvard Vanguard hired Dr. Zeev Neuwirth to be the Chief of Internal Medicine at its largest and oldest site, the Kenmore Center. Kenmore is located at the edge of the Longwood Medical Area and is little more than the distance of a major league homerun down the street from the Red Sox at Fenway Park.
Zeev had interrupted an interesting medical career in academic practice and consulting to go back to the Harvard School of Public Health. After completing his MPH he was full of exciting ideas about reinventing the practice when he took the job as Chief of Kenmore IM. When he arrived at Kenmore Zeev was confronted with an environment that was still recovering from the stresses that had been associated with the practice’s near death experience following the financial collapse of Harvard Pilgrim Health Care. In 2005 the spirits of the practice fell even further with the departure of our very popular CEO, Ken Paulus who most of us credited with having saved the practice.
My primary care practice and the central cardiology practice were located at Kenmore and I can attest to the dysfunctional environment that greeted Zeev. I can also easily remember the enthusiasm that he brought to his new assignment. One day he presented me with about ten inches of reprints outlining the wonders of Lean. I can remember thinking that he must be crazy if he thought that I would ever have time to read even one of the papers, but I did invite him to sit down and tell me about his ideas and Lean. I was already vaguely aware that he was doing something with the support staff that was making a difference. He talked continuously about respect and the wisdom of the people doing the work. His enthusiasm was attracting a diverse group of professionals, as well as support staff. People were getting excited about clinical improvement.
About this time our search for a new CEO was completed and when she arrived I told her about my impression of the benefits that I had experienced as the workflows in my unit were improving with Zeev’s work building teams and creating better “standard work” with his “spaghetti” diagrams and constant cheerleading. He had “started a fire”. Being the board chair as well as one of the frontline clinicians gave me an interesting perspective. As board chair, I was present when strategic decisions were made and I had a fiduciary responsibility. We talked about being better at the board but Zeev was making things better. For years I had been frustrated by the bureaucracy of management. I had no operational responsibility, so when I left the boardroom I was just one of the doctors and experienced how the message and strategy developed in the boardroom were often modified as decisions were passed through several layers of management in a large complex and dispersed enterprise.
I compared the experience to the old “gossip game” of “telephone” that we had played at parties in junior high school. In the game it is amazing and fun to see how the message gets distorted as it is whispered from one person to the next. When the last person reports what they heard it is often the “opposite” or at least greatly distorted from the original message as information and data “dropout” occurs with each new transmission of the message. Zeev was turning everything upside down at one of our many sites by taking the initiative to do what management had just been talking about doing.
As an employee board chair I was also frequently surprised by what the management team would decide and implement. The CEO was impressed with what Zeev was doing and created for him the position of VP of Clinical Improvement and Innovation. Unfortunately it was almost a silent launch without much attempt to communicate to the board or the practice. One day I was surprised to learn that Zeev had been promoted when I got the news just like everyone did, through a perfunctory memo.
Outside the organization there was some serendipity. About the time of Zeev’s promotion Massachusetts Blue Cross decided to invest many millions of dollars in grants to five organizations, four hospitals and Atrius. The program was called LEAD and the vision of Blue Cross was that the five organizations would each create a pilot program of transformation to improve quality, safety, cost, and patient satisfaction. The money was given to Zeev as “seed” money for his new role. Zeev hired a “sensei” and targeted two of our sites as pilots.
Zeev met with some resistance, or at least skepticism, from other members of the senior management team who were not sure just what his role and responsibility was. His success was at the periphery of their interests in just a few of our many sites, but when I suddenly became CEO I was impressed with what he had accomplished even without widespread buy-in from other members of the management team. Zeev’s story is documented in the second chapter of a little book by James Champy and Harry Greenspun, Reengineering Health Care: A Manifesto for Radically Rethinking Health Care. Click on the link to read an excerpt of the chapter. Google books leaves out a page here and there and some of Zeev’s colleagues would have told some part of the story differently than I have. It took over three years of “doing Lean” or activities that looked like Lean before there was a consensus among senior management that we should begin the journey to “become Lean” almost a year after I became CEO.
My reason for telling the origin story of Lean at Harvard Vanguard/Atrius Health is that it is not a unique experience. Many organizations are introduced to Lean by the passionate initiative of a middle manager. Sometimes senior management thinks that naming a leader and providing a little budget before going on with business as usually is evidence of supporting Lean. That certainly was what Zeev experienced. Even when a senior leader or even the CEO or board chair declares that they are supportive of Lean, it is not enough. Nothing sustainable happens until senior management, the board, and the CEO see the need for their own transformation and adoption of a new culture and operating system. Everyone must understand that their “standard work” must change.
An effective Lean organization will have a vigorous conversation between the levels of management and with the frontline. “Catchball” is a bidirectional discussion up and down the organization that involves everyone in the evolution of “breakthrough” strategies and strategic deployment. That vital conversation requires involved leadership at every level and can never happen without the senior leadership team and the board being more than supportive. They must be involved, and their actions, understanding and commitment must be obvious to everyone in the organization. As discussed last week, the relational contracts that are the foundation of a learning and improving organization will be heavily discounted and misunderstood without the obvious and authentic embrace of Lean by senior leaders and the board.
When Lean does enter an organization at a level below the senior management team its sponsors often find themselves forced to “speak truth to power.” That phrase reminds one of martyrs and patriots. Robert Kennedy gave a famous speech in Cape Town, South Africa in 1966 at an event called the Annual Day of Affirmation. The speech was meant to encourage those fighting apartheid. Mandela and many leaders were in jail having spoken truth to power. Kennedy used the moment to speak not only to those in the struggle against apartheid but also to speak to the folks back home. I may be misusing RFK’s advice to say that it applies to those seeking to grow and spread Lean in their workplace from a position deep in the organization, but I think not. Robert Kennedy told his South African audience:
It is from numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.
I put “how to influence senior management into Google and hit enter. What I got was simple and straightforward advice.
If you want upper management support, then part of your job is to do whatever it takes to gain that support. One way you can do that is by applying lean to your own job and your own sphere of influence – whether that is just you, a team, a department or a process. You have to deliver results anyway, so why not use lean to do it? This will make things around you more effective, which then may influence upper management to support lean because of the results you achieve. Additionally, you will learn as part of the process, which is all the reason any of us should need.
In essence that is what Zeev did in a neat package. The same article had another question and answer that was surprisingly empathetic for senior management and is worth consideration:
Q: How do you assure lean thinking is being applied by leadership?
...First, manage expectations. This, in part, may involve a lowering of the bar. But, too often, we place an expectation on leadership that they live up to lean principles every minute of every day with no lapses….Executives are human beings and mistakes will happen – and they will happen often. Expect that they will learn, try, engage and learn some more. But, although you should pursue perfection, do not make the mistake of expecting it.
Second, if leadership is to apply lean thinking, then they must learn true lean principles and not just lean tools... Next, they need to reinforce the right behaviors by making it visible. Too often, I see leaders change their ways, but no one really gets to see the change because the leader does not talk about it. Change needs to be communicated to the rest of the corporation. Make sure people not only see it, but also understand it. It is not enough to just change – if people don’t understand it, they will not know how to emulate it.
Finally, start to measure it. I don’t mean with a metric, but either through shadowing, coaches or even more formal reviews. Begin to articulate the behavior changes and evaluate their success. In the end, the war for people’s minds and hearts will probably have a few casualties along the way as there will be some people who cannot act on what is being asked of them. But, you have to at least give them a chance. Some might surprise you.
There is another great thought later in the article:
Many managers believe they are very supportive. They view themselves as 100 percent behind the lean efforts. The problem is that behind is still behind, but engaged typically means out in front. They might be very interested in what lean can do for them, but not really know what they should do about it.
I think there is wisdom in this statement. None of us can be objective in our self assessment. If you are in an organization where senior leadership, the CEO and the board may think they are supporting Lean but there is less certainty in their sincerity or commitment at your level in the organization, then there may be benefit in initiating a conversation that lets them know that you and your colleagues really need their leadership. That is speaking truth to power.
We tend to think only of Lean’s spread from manufacturing to healthcare, but it is moving through many industries. My search led to an interesting PDF of over 100 pages from McKinsey, the consulting firm, written for the financial services industry. The paper discusses managerial behavior in a way that you may find useful if you do chose to “speak truth to power” asking your management to get out ahead and lead. To be useful I lifted and compressed some of it for your consideration:
The perception that behavior is a “soft” topic leads managers to assume they can rely on their own instincts, an approach that seldom leads to sustainable long-term change. Instead, managers need to take the time to understand some of the factors that influence human behavior. In our experience, organizations that have achieved true behavioral change in the context of a lean transformation have incorporated six often-overlooked insights.
- People need to feel that change matters
- Change must be seen as fair
- Positive feedback and active learning help make change last
- Changing behavior means changing mindsets
- People won’t change unless their leaders do
- Personal involvement creates ownership and impact
It is a good list and I think that it offers actionable information and help to leaders at all levels of leadership in healthcare. Put it together with your own commitment and numberless diverse acts of courage and belief; and who knows we may move closer to the day when we produce for our patients and communities
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
Happy Birthday ACA! As President Obama was visiting Cuba this week the ACA turned six years old! It is hard to be exact because there were a series of bill signings that occurred between March 23, 2010 and March 30, 2010. Given the alignment of the anniversary with the President’s historic trip it seemed reasonable to me to ask the question, “How good is the healthcare in Cuba?” I have heard that it is pretty good, which is hard to believe. With over fifty years of significant economic sanctions one might expect that the health of the average Cuban may have suffered. It turns out that no matter what your hunch, the answer is that Cubans are a pretty healthy lot with a life expectancy that equals many of the world’s advanced economies and just noses out our number. In 2012 life expectancy in Cuba was 79.07 years according to Google and was 78.74 years in America.
What is really interesting is that there is no East, West, urban, or suburban variation in life expectancy or class variation in health in Cuba and they do it for next to nothing compared to US expenses. One would hope that since we are the discoverers of much of the science that should improve health, the inventors of impressive new meds and devices, and have technical and educational institutions that are the envy of the world, we would blow away the Cubans like we did in the baseball game on Tuesday. What distresses me most is that after providing access to almost 20 million new healthcare recipients through the ACA we should begin to see more progress. Looking at life expectancy state by state shows that we have a lot of variation. It seems that there is some correlation between those states with the lowest life expectancy and the list of states that have resisted the Medicaid expansion offered through the ACA as the overlap in the next two images seems to suggest.
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| | Fortunately the list is getting shorter. We can be encouraged by history. Sometimes it just takes us a while to get everybody on board with progress. Medicaid was passed in 1965. It was not until 1982 that Arizona became the last state to make it available to its citizens.
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| | There is also the appearance of some correlation between states with large African American populations and lower life expectancy. Before the states at the top of the list get too self congratulatory it is good to note that if we looked at the data even more closely we would see that in states that look good in the aggregate, there is huge variation.
Massachusetts ranks a close fifth in life expectancy behind Hawaii, Minnesota, California and Connecticut at 80.52 years. In the Back Bay of Boston the life expectancy is over 90 years. In Roxbury, a predominantly African American neighborhood just three miles away and in the shadow of the Longwood Medical Area and Harvard Medical School, the life expectancy is under 59 years. That underlines the accomplishment of Cuba where there is no variation across all populations. The bimodal nature of life expectancy between affluent and economically challenged communities brings real a sense of pomposity to our human rights posture. Dr. Martin Luther King, Jr. spoke to the issue when he said:
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” — Dr. Martin Luther King, Jr.
It is probably appropriate to bring up that quote on the sixth anniversary of the ACA since it surfaced from time to time during the legislative run up to the passage of the ACA.
Several months back I reviewed an article from the New England Journal by Benjamin Sommers that looked at the ACA after five years. It was entitled “Health Care Reform's Unfinished Work — Remaining Barriers to Coverage and Access”. As we celebrate the sixth anniversary of the passage of the ACA it is worth reading the last two paragraphs of that paper.
These considerations notwithstanding, the ACA is succeeding in expanding coverage and access, with promising indications for population health. But challenges remain; the fundamental political question is how — and whether — they'll be addressed. Though some members of both political parties favor replacing the ACA entirely, that seems unlikely to happen. Liberals who believe a single-payer system is the easiest method of eliminating cracks in our patchwork coverage approach must face the political realities that derailed a single-payer effort in liberal Vermont and have made it so challenging to implement even a centrist national health care reform law. Many conservatives still advocate “repeal and replace,” but the almost-certain backlash against taking coverage away from more than 15 million Americans makes it hard to imagine this rhetoric becoming reality, even if Republicans control Congress and the White House after 2016.
What's likely, then, is health care reform version 1.1, rather than version 2.0. We'll probably see substantial debate over refining the ACA rather than replacing it, much as occurred after the enactment of Medicaid and Medicare in 1965. Perspectives on how to do so will vary; some policymakers will argue that the law isn't generous enough, while others will insist that it's already too costly and intrusive. Ultimately, there are likely to be only incremental changes — which will be warranted, since there's still much to be done to improve coverage and access to care for all Americans.
I hope some day we can expand and improve the ACA. Whether we go for ACA 1.1 or ACA 2.0 is a question, like who will be the next justice on the Supreme Court, that may be determined by the election this fall and by subsequent elections over the next several years. I do harbor the fear that if we are not careful, we could let the benefits that we have already obtained through the ACA slip away. We might fall even further behind Cuba where they seem to have come closer to the Triple Aim than we have come with care that is:
...better than we have ever seen (in many parts of America), health for everybody (in every community in Cuba) that is better than we (all of us not just most of us) have ever known, and cost we can’t seem to afford but Cuba can: for every person, every time.
As the communications between our countries improves maybe we will be able to understand how they have done it. There is a pretty impressive collection of articles on the Internet, some from the WHO, that give a balanced view of Cuban healthcare.The link that I chose may be to a source that exaggerates the accomplishments of Cuba, but the last few paragraphs do suggest how they have achieved such a healthy population despite their poverty.
I know that I must not know the whole story and that there are surely many ways in which their egregious violations of human rights discount what they have done, but within the bounds of their means they have done something quite remarkable for all of their people. For starters, healthcare is an entitlement shared by everyone. Cuba seems to be a positive deviant that deserves study.
Despite its status as a low-income country, Cuba's medical system is recognized as one of the best in the world. Cuba's world renown healthcare system places emphasis on prevention, with thousands of doctors providing front-line care to Cubans throughout the country.
Cuba's doctors also serve throughout the world, providing primary care to impoverished communities and assisting in natural disasters and health crises, such as the Ebola outbreak in West Africa.
Cuban medical researchers have also made important discoveries, including the development of a lung cancer vaccine, which will soon be available in the United States thanks to a deal signed between the government of Cuba and the state of New York.
I hope that by the tenth anniversary of the ACA, coinciding with the next presidential election, things will be improved for all Americans. I will not argue that we should have less income inequality in America or that we should avoid trade agreements with the far East, or that we carpet bomb ISIS and discourage immigration with walls, but I will argue that there is no justifiable reason for us to not to consider it our collective obligation to be sure that everyone who lives in this country has the care that will optimize their health. We owe it to one another. It should be a goal we all share, like freedom.
Spring in New England
There are no flowering trees yet, but here and there I have heard that you can find a “crocus”. I would not be truthful if I said I had seen one, but I do see evidence of the sap rising. There are buckets hanging from maple trees up and down the roads I walk, as you can see in the header this week. What I also know for sure, as a sign of Spring, is that if I get my exercise in before seven in the evening, I do not need to wear my neon vest and flashing light.
Lately the iTunes app on my phone seems on the fritz and will not shuffle tunes. It will just play the same song over and over; so last Sunday I decided to listen to my son’s music starting from the beginning. The playlist is 279 songs long and contains over thirteen hours of his original music.I was pushing myself a little harder than usual and was up to his twentieth tune which I am sure that I have heard at least seventy-seven times (iTunes keeps a count). Perhaps it was the fatigue or perhaps it was the phrase:
And I gotta say that the spring in New England’s
Got a powerful feeling
And I’m thinking I’ll be covering some ground
Whatever the trigger was, I discovered something new in something old and familiar.
You can hear the song Counting Colors and Covering Ground by clicking on the link. If you do go to his website, you can also read the lyrics and the associated essay.
My epiphany continued with the passage:
And I got this feeling
If you pulled back the curtain
That everyone is nervous
And nobody is certain
If I had one wish it’d be to live one step further along
But that’s the easy way and God knows it’s wrong
And if it’s all been a lesson
I’m not sure I learned it
If it’s enough of a blessing
To know your own purpose
I’d live like I meant it
Yeah I’d live like I buried my worries
In a sturdy old box years ago
Knowing your purpose and living life like you buried your worries in a sturdy old box years ago has taken me a lifetime to just approach, much less achieve. Perhaps it is hard to bury worries and focus on knowing one’s purpose because of the cacophony in the background of our lives in a world of volatility, uncertainty, complexity, and ambiguity. These are good things to contemplate under crystal clear skies in lengthening days while shuffling along lakeside.
I hope that this weekend will be one of meaning for you whether you are celebrating Easter or are just out enjoying the fresh air of an early Spring weekend.
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| Be well, keep growing and looking for purpose as an antidote for worries,
Gene
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