| 27 May 2016
Dear Interested Readers,
What’s Inside the Letter This Week
This week’s letter is a return to the discussion of the future of practice. I am beginning a series that will be an update of many of the things that I have discussed over the years. The series will take several weeks. I begin by going over some foundational principles, or to use another construction metaphor, create the framework upon which to build a better experience of care and of practice. I hope that in this and in the subsequent letters we can enjoy trying to envision how care delivery might change over the next decade.
I hope to be able to focus on the “feel” of care as we examine the “how” of care. It is important that care delivery be efficient and effective but it is also important that it feels comfortable and satisfying for patients and professionally rewarding for the providing professionals. I will also examine some of the continuing barriers that will eventually fall or will continue to distort how the future evolves.
The second section is a continuing look at the controversy over Lean and whether it is “medical Taylorism” as described by Jerome Groopman and Pamela Hartzband. I call on Daniel Kahneman for his insights in this ongoing debate.
The letter closes with thoughts about the Sox and the Cubs in contrast to Donald, Bernie and Hillary. I am thankful that there is at least one race worthy of my daily attention this summer. I am sure that you will see that in my mind there is a high coefficient of correlation between these topics.
Perhaps sometime over this long Memorial Day weekend while you are relaxing on your deck with a cool beverage, or are passing time by browsing Facebook on your iPad or smartphone while waiting in line at an airport, you might click out of social media and click onto strategyhealthcare.com to check out the latest post. It is the one with Monty Hall offering you the choice of three curtains. With Monty you could have what was behind only one of them. I hope that you will exercise your option to look behind all of the pictures on strategyhealthcare.com and invitie your friends to also check it out and sign up for these letters.
A Review of the Foundations of the Future of Care Delivery
Do you have enough time in your busy day to think about the future of medical practice? Do you feel like you are plodding through the last lap of something that must give way to something different; or do you look forward to the acceleration of the transitions that are already taking shape? How will the ways that we delivery care in ten years be similar to the past and how will the future be different than what you experience today? How is your little piece of the healthcare world going to evolve?
One thing that already seems to be in transition is the expectation of patients. What many patients want from the relationship with the doctors they see and the other providers that make up their care team is a more “horizontal” and collaborative connection. Just the fact that many patients receive care from a team of providers is itself a future oriented change. Are we ready for the the real digitalization of care? How will IBM’s Watson and our increasing facility with big data support or undermine our clinical opinions and use of “expert intuition”?
Over the next few weeks I would like to explore the future of practice, or if you prefer, care delivery, from every point of view. I want to look at the future from the perspective of patients and families. What will be their experience of care on the other side of the great transition from volume to value? Certainly I will look at the issues from the vantage point of those who directly touch patients: the doctors, nurses, NPs, PAs, various therapists, social workers, medical assistants, pharmacists and others. The inclusive list is endless. I always fear offending someone or some group because in the future everyone’s contribution will be required to maximize our efforts to achieve the Triple Aim.
The challenge that we face is that even with every provider working efficiently and “at the top of their license” there is reason to question whether or not we will be able to offer every patient the timely access to care that meets their needs. We have always loathed the rationing of care, even as we used how we financed care as a mechanism to do it. In the future will further “rationing” be forced by shortages of the professionals needed to staff our current method of care?
One reason my letters get wordy is that I fear offending some portion of my readership. I have done that before. As an aside, before we begin our contemplation of the future of care, let me tell you a story about why I feel the need to be “wordy” when addressing my readers. The past has a lot to teach us as we seek to be more effective in the future.
Shortly after I first began to write these letters, more than eight years ago, I was surprised one day to see the name of one of our most respected senior physician leaders on my schedule. When she entered the room it was immediately obvious to me that she was on a mission to correct some error that I had made. My visitor was never an individual to waste time with pleasantries, mince words, or leave one wondering for long just where she stood on any subject. She was held in high regard for the best of reasons. She was devoted to her practice and to the “art” of medicine. She put her patients first. She delivered superb care. But, she never met an administrator whose performance she could not criticize. Many of her colleagues would walk the other way if they saw her coming for fear that she would begin to address one of their shortcomings. She did not “suffer fools”. I had always been intimidated by her and did not know how to climb the wall to where she stood defending herself with aloof disdain for everything and everyone who did not measure up to some standard that she alone defined and understood. I always had assumed that she counted me among those whom she considered to be a “problem for themselves and others”.
The first words out of her mouth as she cleared the doorway to my office were something like, “I am here to talk about these stupid letters that you are writing every week. They are really simple minded. It is as if you are writing to my medical assistant!” She looked surprised when I said, “Well, yes! I am writing to your medical assistant as well as the secretary in your unit, the maintenance crew at your site, the people in the pharmacy, the lady at the front desk, the woman working at a computer in finance, and the people drawing blood in the lab. I am writing to everybody including you, your colleague in the adjoining office, the nurse practitioners in your unit and the PA across the hall in Urology. The letter is meant for everyone who is a contributor to our mission.”
She looked surprised by my response and I could see her trying to quickly process the idea that my letter was meant for a much wider audience than just her and other physicians in our practice. It seemed implausible to her that the letter was not an exclusive communication to her and her physician colleagues. I think that she had the idea that there were two layers in our organization. There was an upper layer composed of the doctors, and then there was a lower level where everyone else who supported the doctors resided.
She was right that the practice had been organized with the physicians as “Physician Members of the Corporation”. Despite the fact that we were a 501c3 non profit organization, physicians held prominent roles in governance as well as management and all of the doctors uniquely bore risk for the clinical and financial performance of the enterprise. What she failed to realize was that the patients she cared so much for needed her to recognize that she could not do, and really did not want to do, everything for them that they needed to be done. Her patients needed her to feel and function like she was a part of a team.
Since that experience I have gone out of my way to specifically name as many of the types of professionals I can in my writing hoping to avoid further confusion. Nothing would make me happier than to drop into the slow drawl of my home region and just say, “Hey, y’all, listen up! I wanna tell ya what’s on my mind.” I do believe that we are in the midst of a growing realization that we are moving from a sense of “I”, where the doctor is at the center of the enterprise, to an inclusive and effective “we” that recognizes our professional interdependence. But, we are not quite there yet.
Perhaps sometime before I go on to my reward I will get over the emotional trauma that was the outcome of that doctor’s visit to me. Perhaps the day will come when I no longer feel that I need to explicitly name as many professional types as I can to avoid the misconception that I am only writing to doctors. Perhaps someday in the future of healthcare we will fully respect and embrace everyone’s contribution to the job none of us can perform alone.
Beyond just looking at how care will be experienced by patients and all of the professionals that form the “we” of the delivery team, I also want to look at how the delivery of care will change for professional groups and organizations. To completely view the future we will also need to imagine the concerns and needs of employers, commercial payers, regulatory agencies and especially those who take a special interest in improving the lot of the populations who are currently underserved and disenfranchised. The objective I am describing will be covered over several letters.
Where do we start? I will not start with Hippocrates but will make references back over the broad expanse of practice between him and the publication of Crossing the Quality Chasm in 2001. I will also embrace Don Berwick’s three eras of practice and some of my comments will reference his Era 3 which we are entering now and even speculate about the eras to follow. It makes sense that if there have been Eras 1 and 2 before Era 3, that there will eventually be Eras 4 and 5 with even more to follow.
So what was so great about Crossing the Quality Chasm and why do I continue to celebrate it and refer to it as something that is as important and as fresh today as when it was published fifteen years ago? There are at least three great ideas in Crossing the Quality Chasm.
- Our system of care is best seen as a complex adaptive system. Improving it and managing it requires understanding complexity.
- Crossing the Quality Chasm gave us a functional definition of what to look for when we were examining a system of care for its quality. What amazes me is that even after fifteen years there are many who still do not know that quality care is patient centered, safe, efficient, effective, timely and equitable.
- Finally Crossing the Quality Chasm gave us a description of the practice or care delivery system for which we were searching. It gave us the :
The Ten Descriptors of Better Systems of Care
- Care based on continuous healing relationships:
- Customization based on patient’s needs and values.
- The patient as the source of control. Encourage shared decision-making.
- Shared knowledge and the free flow of information:
- Evidence based decision making.
- Safety as a system property.
- The need for transparency.
- Anticipation of need.
- Continuous decrease in waste.
- Cooperation among clinicians. [“I to we” within practices, across practices, across systems and throughout the community.]
There are a myriad of ways to design a better system of care for the future that would have all of these properties and produce care that fits the six domains in the definition of quality. Location, existing assets, and characteristics of the populations that need to be served are all determinants that must be considered as we move from what is to what will be. Different populations will require different systems, but all of the systems that are the answer to the needs of a specific population will contain these ten components or properties.
At about this time in a discussion with many loose ends someone is bound to raise their hand and say. “Excuse me. What problem are we trying to solve?” The answer to that question has been better articulated since 2007 when the IHI published the Triple Aim. Our problem can now be explicitly stated as:
How do we achieve better care for everyone, healthier communities, and sustainable medical costs? When we do achieve the Triple Aim we will finally have:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
I first heard that more fluid and inspiring revision of the “wonky” Triple Aim last year at the IHI meetings. At the same time I was introduced to the IHI’s “100 Million Healthier Lives Campaign" and its “new rules for radical redesign" in healthcare.
New Rules for Radical Redesign in Health Care
Change the balance of power: Co-produce health and wellbeing in partnership with patients, families, and communities.
Standardize what makes sense: Standardize what is possible to reduce unnecessary variation and increase the time available for individualized care.
Customize to the individual: Contextualize care to an individual’s needs, values, and preferences, guided by an understanding of what matters to the person in addition to “What’s the matter?”
Promote wellbeing: Focus on outcomes that matter the most to people, appreciating that their health and happiness may not require health care.
Create joy in work: Cultivate and mobilize the pride and joy of the health care workforce.
Make it easy: Continually reduce waste and all non-value-added requirements and activities for patients, families, and clinicians.
Move knowledge, not people: Exploit all helpful capacities of modern digital care and continually substitute better alternatives for visits and institutional stays. Meet people where they are, literally.
Collaborate and cooperate: Recognize that the health care system is embedded in a network that extends beyond traditional walls. Eliminate silos and teardown self-protective institutional or professional boundaries that impede flow and responsiveness.
Assume abundance: Use all the assets that can help to optimize the social, economic, and physical environment, especially those brought by patients, families, and communities.
Return the money: Return the money from health care savings to other public and private purposes.
Does “I to We”, the concepts of quality, and the descriptors of the ten properties of a better system of care plus the Triple Aim and the New Rules for Radical Redesign in Health Care give us enough clarity to imagine the delivery of care in the future? I think not.
Remember Dr. Ebert’s admonition:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
We need a methodology to organize the framework and operating system of care delivery. My vote has been to use Lean as the tool and the instrument of culture evolution necessary to support the innovation that will design the future of care. I know of no better way than Lean to effectively tap into the wisdom of healthcare’s many professionals, customers and suppliers and organize that wisdom into something that meets the needs of all of its stakeholders.
Lean and the foundational principles above are all necessary for the future but are still insufficient. Dr. Ebert considered several components of the operating system and so far I have not mentioned financing. Will we move toward more risk and more effective use of prospective budgets built on the needs of populations? I think that is what MACRA and the collaboration between payers and CMS is suggesting will happen. I also think that suggestion will move from a nudge to a demand. I certainly would not build an image of the future on a fee for service chassis.
Next week I will look at the future from the perspective of the patient building from the foundation or framework laid down here. Let me know if there are other foundational issues that you would include.
The Continuing Conversation in the NEJM About the Relationship Between Taylorism and Lean
I have no idea just how the New England Journal of Medicine decides which “letters to the editor” it publishes in response to controversial articles. I do know that many friends and colleagues like Patty Gabow, the former CEO of Denver Health and John Toussaint of ThedaCare were very upset by the article, “Medical Taylorism” by Groopman and Hartzband in the January 14 NEJM. Toussaint, Patrick Conway at CMS and Stephen Shortell at the University of California eventually were able to publish a rebuttal on the Health Affairs Blog in early April, but the letters and articles they and many others submitted to the NEJM were rejected or discouraged. You can imagine my surprise when last week I saw in the “Correspondence” section two letters and a response from Groopman and Hartzband under the banner, “Medical Taylorism, Lean and Toyota”.
The letters were respectful, brief, and concise. They reported that Lean, as currently practiced at Toyota or in hundreds of medical institutions around the world, is not Taylorism. Taylorism and Lean differ primarily in that Taylorism has been management driving workers with a clock in processes usually developed, designed and implemented from above. Lean is a process built on respect for people, the principles of the scientific method, and the realization that those doing the work best know how to improve the work. Groopman and Hartzband were predictably dismissive of the objections to their article. They criticized the letters to the editor as “subjective” in their highly subjective response.
In the above letters, despite claims of science, we are struck by highly subjective terms used by Lean consultants including “unnecessary variation”, “best possible care”, and eliminating “complexity”. In much of patient care, there is no standard regarding what “is best”. As opposed to a factory assembly line, medicine necessarily involves considerable complexity and uncertainty. The patient’s “condition” will never be the only variable in the system, nor should it be, because patients and medical professionals are people---individuals with diverse goals, preferences, and personal styles that matter.
I am always amazed by the serendipity in my life. Earlier this week I decided to take a walk while listening to a YouTube presentation of a talk by Daniel Kahneman that was sponsored a few years ago by Google. I found the talk on the Internet while I was doing research for last week’s Musings about behavioral economics. A little over three minutes into the presentation Kahneman began talking about Atul Gawande and Jerome Groopman. With the help of the closed caption function on YouTube I have transcribed the salient part of his comments for you.
Kahneman is speaking and I have made some minor edits indicated by dots and brackets.
...intuition has been discussed a lot in recent years and...there are two camps in this discussion naturally there is the pro and the con. And of course many people will have read Malcolm Gladwell’s Blink which although it is not [an] unconditional defense of intuition, it certainly gave people the impression that sometimes we magically know things without knowing why we know them. Within the discipline of psychology and the decision making there is a group and it is headed by a very interesting figure called Gary Kline who wrote a book that I recommend. It is Sources of Power, is one of his books that I would recommend most warmly. And they are great believers in expert intuition. The other side there are skeptics about intuition in general and including expert intuition. And I have long been counted as one of the skeptics because my early work with Amos Tversky was about intuitive errors and flaws and biases of intuitive thinking.
Today you find that discussion in many places and for example in medicine among popular writers; two writers both of whom write for the New Yorker, Jerome Groopman and Atul Gawande. They clearly differ. Atul Gawande is in favor of formal systems, very skeptical about human judgment and wanting to prove all the time and Jerome Groopman being in fact, although he doesn’t quite admit he really likes good old fashion medical intuition of course he likes physicians well-education. But he doesn’t like formal systems and the issue in medicine is “What are the role of evidence based medicine and how do you allocate that with the function of “intuition?”
I guess that says it pretty well and Daniel Kahneman’s opinion and mine are highly aligned. Gawande manages complexity for the benefit of individual patients with checklists and systematic thinking which are both highly aligned with Lean, the scientific method and the struggle to be objective. Dr. Groopman is an accomplished scientist, and I am sure that his scientific articles are not built on conjecture alone. He is also a practicing physician who writes about the “art of medicine” and I dare say, a believer in the intuitive judgement of experts. As stated above he is a proponent for variation in the pursuit of what is best for the patient. As Groopman and Hartzband say,
The patient’s “condition” will never be the only variable in the system, nor should it be, because patients and medical professionals are people---individuals with diverse goals, preferences, and personal styles that matter.
“Subjectivity” and “ambiguity” are frequently found with complexity. Kahneman spends quite a bit of time in book Thinking, Fast and Slow arguing for the use of algorithms as an antidote to the errors that complicate working in complex systems. He cites evidence that systems and algorithms produce measurably better results. If Groopman and Hartzband really understood Lean they would know that “intuition” expressed as a hypothesis following the gathering of data and the analysis in boxes 1 through 4 of an A3 is always confirmed by experimentation. The “subjectivity” that Groopman and Hartzband both practice and deplore, is the hallmark of the clinical autonomy that he romanticizes in his prose. I find it unacceptable to accept, “In much of patient care, there is no standard regarding what “is best”. We must be constantly using Lean tools and the process of quality improvement to define what s the best known practice at the time. Clinical intuition is used to the benefit of many patients when it is turned into objective outcomes as Lean is applied to healthcare.
I think that it is important to recognize that the article by Groopman and Hartzband is a representation of the thoughtful resistance of the status quo. Attempts to create change using improvement science seems to be perceived as a threat to our most sacred cow, clinical autonomy. Lean challenges much of what they value. Many doctors do believe in intuitive expertise and in many circumstances where a best practice is not clear, so do I, but we only remember the successes of “clinical judgement”. We easily forget to look for the denominator of all of our experiences and so we are able to forget or ignore just how often we harm people trusting the human frailty of experts without a system like the ones being built today using Lean principles to support them.
Two Races: One More Interesting Than the Other
I am writing to you from among the redwoods in the hills above Santa Cruz, California. My wife and I are here to enjoy the long weekend with our grandson and his parents. In New Hampshire we have enjoyed the fact that we saw the last of the political ads back in February but now in California we find that we are back in the thick of it as Bernie and his followers continue their campaign, more on principle than possibility or well articulated policy. Hillary is running up and down the state promising to love, honor and accept anyone who would rather have Bernie but doesn’t want Donald and therefore may settle for her.
Donald Trump is still busy with his campaign of self promotion as he tries to convince everyone that he is really not a loose cannon and that a closer look will reveal that anyone should be able to find something that they like in who he is. Republicans, who just a few weeks ago wanted anyone but him, but who now must decide to either hold their nose and stand with him or search for some other alternative born of desperation, are in an even more uncomfortable position than the Democrats who respect Hillary’s expertise and are inspired by Bernie’s long term passionate commitment to equality by pursuing fundamental changes to our social fabric.
A few weeks ago in the discussion of “relational contracts” I offered you concepts from a Harvard Business School Professor, Rebecca Henderson. Professor Henderson stressed that relational contracts rest on two principles: clarity and credibility. As the campaign for the presidential nominations winds down, I see that each of the candidates who is still active has a relative problem with either clarity or credibility. Likability and the likelihood of being elected seems loosely and variably correlated to clarity and credibility in strange ways.
Trump is the most interesting candidate because he succeeds by capitalizing on the fact that he is not likable and makes long lists of those whom he dislikes and disdains. His lack of clarity and total lack of credibility are translated into huge assets for his core supporters who suffer from many of the same identifiable traits that he demonstrates like Dunning-Kruger Syndrome, paranoia, misogyny, xenophobia and narcissism. His ultimate triumph is predicted more by the majority of voters considering him not to be so bad compared to his artful misrepresentation of his opponents. Perhaps those are the competencies that are the foundation for success in our world of continuous conflict.
In contrast to Trump, Clinton seems to be unable to shed any of the disdain that her enemies push her way. They have successfully negated any consideration of her competence by undermining her character and credibility. Ironically, it seems that the closer she gets to the nomination the further she moves from the possibility of winning the election.
Over the last few weeks the question most often asked is an invitation to speculate on why Bernie is still in the race. My best guess is that it is not about this election but about the future of the Democratic party. Bernie, like me, is also old enough to remember that Hubert Humphrey won the nomination in 1968 after Bobby Kennedy was shot and Gene McCarthy was outmaneuvered. California is a constant reminder that strange things can happen.
Where would I be without the relief of baseball, fishing and walking? It has been another exciting week for Sox fans. Despite last night’s loss there has been a lot of amazing baseball at Fenway. Will this be another World Series season? Will Jackie Bradley, Jr. start another extended hitting streak like the one that ended after 29 games last night? We will see. In a year of unlikely events anything can happen. Might it be that in October we will witness a Cubs v. Sox Series?
The picture in the header this week shows a blue heron enjoying the solitude of my swim float in the early morning mist. I love surprises like unexpectedly seeing a heron in some place where you would not expect it to be. The Memorial Day weekend is the emotional beginning of summer for me. In the summer I am out and about in nature on walks and on the lake looking for surprises like a blue heron on a misty float. I hope that you will be out this weekend also looking to be delighted by an unexpected surprise.
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| Please share your thoughts, concerns, celebrations and stories with me. I love it when I hear from you, especially if we have never met!
Be well, Gene
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