29 May 2015
Dear Interested Reader,
Inside This Week's Letter
My wife notes that Mercury is in a retrograde position for another two weeks which may explain why I had some difficulty delivering my thoughts this week. If you ever plan to watch the TV program Mad Men scroll down through the first third of the letter so that your viewing experience will not be spoiled. My thesis is a recurrent message. Transformational change is hard at any level whether you are a Madison Avenue Executive in the sixties or the “you” is a collective enterprise in healthcare.
The second section is shorter and written to ask for your help. Is Lean harder in the ambulatory environment than in the hospital? How do we more effectively tap into the leadership of physicians to catalyze Lean transformation and the pursuit of the Triple Aim while improving “burnout”.
At the end of the letter I reflect on the joy of being with more than 200 Lean professionals from across the country and around the world this week at the annual meeting of Simpler which was joined by Truven and Joan Wellman Associates since they are all now part of the same enterprise and dedicated to the pursuit of the Triple Aim by combining their competencies in data and leading Lean transformation.
Just a reminder to check for new postings on the Strategy Healthcare blog.
The End of Mad Men and the Pursuit of the Triple Aim
SPOILER ALERT! If you plan to watch the last episode of Mad Men and just have not gotten around to it you may want to pass on reading further. Just skip down until you see “The Triple Aimers Have Missed the Mark...”.
Nancy (my wife) and I had watched all 91 of the previous episodes of Mad Men during the “seven seasons”, going back to its beginning in 2007. Our excitement was building as the final episodes were ticking off and the show approached its 92nd and final episode. We did not begin watching it when the show first aired, but we joined the second wave of viewers early on after the show had won so many awards (so far, 15 Emmys). We just utilized the technology of Netflix and “On Demand” viewing, and quickly caught up as we finally joined the millions who had been enthralled by this odyssey through the sixties.
It was not until this year that we discovered there was a parallel literature of critical analysis and interpretation that greatly expanded our “customer satisfaction”. It seems that the entertainment and healthcare industries can both benefit from the old business reality that “the informed consumer is a better customer”. As the final date approached it became obvious that we would be visiting my son and his fiancee in Brooklyn when the show aired its final segment in the 10PM Sunday night slot on May 17th. That was a problem because they do not own a television and do not have a cable connection. What they do watch is on their computers through Hulu, Netflix and the like. What were we to do?
We decided that we would just have to close our ears to any information and avoid reading anything that might spoil our viewing experience now delayed until later in the week after we returned home to Comcast. For my wife it became almost like waiting for the appointed day to unwrap an interesting looking package, think birthday or Christmas. She tolerated the suspense, secure in her knowledge that the program was waiting for her on both “On Demand” and on a recording that she had programmed.
With a remarkable demonstration of self discipline she also downloaded all of her usual commentaries about the show as they appeared on the Internet, but never even peeked at them. My comments are linked to one of those commentaries. If you are not familiar with the show, Wikipedia has a lengthy overview that contains many interesting facts and serves as a good examination of how art interacts with current and past history and culture.
As the show wound down over the last few episodes and it became clear how the storylines involving most of the characters would be resolved, there was still a lot of ambiguity around the main character, Don Draper. I became worried that Don, the adman with the complicated past history who is the “hero” of the show, was losing it again just as he had so many times as the program followed him through success and failure from 1960 and into the seventies. We had become accustomed to Don undermining his own happiness and success, only to reinvent himself with greater success but no increased yield in happiness, although at times he did give us some inclination that he was reflecting on what went wrong and might grow from his most recent failures. Despite the history of Don’s approach and repeated flirtations with redemption and actualization, the last year seemed to be one continuous spiral downward with no chance for him to pull out of the nosedive. He seemed on a track to self destruction.
A couple of episodes prior to the end, Don walked out of an important meeting. It was almost like he was singing “Take This Job and Shove It” even though the song was not written until 1977. He was clearly burned out. Over the next couple of episodes we watched him sink even lower as he drove across the country in a huge Cadillac from the age of fins before giving away most of what he had, including the Cadillac, to people that he encountered along his journey.
After he had nothing left he connected with an "almost family member" from his past and with this symbolic figure, who may be more desperate than he was, he ends up on the California Coast at a place that looks to me a lot like the Esalen Retreat in the Big Sur. The climax approaches as she leaves him in the night and he awakens to the realization that he is stranded. What follows is a desperate call to the East Coast during which he articulates all the failures of his life. Suddenly he is confronted with the metaphorical fork in the road where he might finally be forced to make a life altering decision or, in my imagination, end it all with a swan dive onto the rocks and surf hundreds of feet below the beautiful grounds of the retreat.
The dénouement of the entire ninety-two segments began a few minutes later when after the desperate phone call to the East Coast and his moment of almost fatal self awareness, he goes into a group therapy session and experiences relief by being able to empathize with another man who like himself has come close to rock bottom. The series ends with him in a group experience looking out over the Pacific with a big smile on his face as he imagines a new sales gimmick. As the show ends we are presented with the famous Coca-Cola ad of 1971 with a host of singers standing in a similar spot on the Big Sur doing one of the most famous ads of all time, Coke’s 1971 musical advertisement, “I’d Like to Teach the World to Sing.” (Coke had been one of Don's clients before his hasty departure from New York)
As the Internet commentary says:
“That grin plus the Coke commercial added up to the perfect ending for a drama that was consistently hard-edged yet essentially compassionate, and more perceptive about the realities of human behavior than almost any show in TV history. It hinted at renewal and deep change even as the rest of the episode carefully assured us that Don was still Don: that he wasn’t about to execute an about-face and become a selfless and tender mate, a sensitive and responsible co-worker, a doting dad to his soon-to-be-motherless kids, or anything else that smacked of audience pandering.”
Don was consistent. He had ambitions and dreams and then failed. He made mistakes and then tried again. Perhaps with each effort he was a little better but never becoming quite yet what he wanted to be. We are left with the idea that Don does not quit. He gets up after he falls and makes yet another run at achieving the personal goals that are so elusive. As the commentary said:
There was, however, no question that Don had learned something. Maybe it was only one thing, but it was important, and you saw him learn it in the group-therapy scene, hearing a man tell a story about being unable to recognize love when it’s given, and unable to love himself because of his feelings of worthlessness. Don’s reaction — crossing the room to embrace the man — felt like a break from the show’s bone-deep skepticism about whether people can change, to what degree, and under what conditions, and whether the change can be permanent and genuinely transformative...This is, then, a hopeful ending, not just for Don, and for the other characters — all of whom reinvented themselves professionally and personally, and showed signs of having learned from past mistakes — but for America itself...The sense of genuine renewal in Mad Men’s finale threw a lot of viewers for a loop... It suggested that while the leopard cannot change all of its spots, changing one or two might not be out of the question.”
It sounds like continuous improvement to me.
You can imagine my surprise when with these thoughts of individual transformation and renewal that are really universal all freshly reinvigorated in my imagination, I open my email early on Tuesday morning and I was confronted by Paul Levy’s blog posting entitled, “The Triple Aimers have missed the mark..”
Paul proceeds by saying,
“This is one of those columns that will risk the respect and friendship of some of my closest colleagues in the health care world. In addition to disagreeing with me, they may argue that I am giving aid and ammunition to "the enemy," where the enemy might be viewed as those forces in the healthcare world who really don't want things to change. But as you shall see, I will assert that it is those very colleagues who--by focusing on an overly simplistic ideological approach to health care policy--are inadvertently giving succor to that same group by providing political cover for nefarious behavior. I refer to many of the most prominent advocates of the Triple Aim.
His statement had frozen me. I would not imagine myself as a “prominent advocate” for the Triple Aim” but I certainly am an advocate and I know from my travels that the Triple Aim is a banner around which many people across the country have rallied. Even though Paul’s comments contain little painful elements of truth they do not add up to the conclusion that he extract from them. Paul has occasionally pushed back on some of my weekly dissertations when I have sounded like an apologist as I have described my acceptance of ACOs and the ACA despite their imperfections or have sought to elevate the Triple Aim to the equivalent of scripture. We are friends and colleagues but we occasionally find ourselves on opposite ends of the spectrum from ever hopeful Pollyanna to hard nosed realist.
I respect Paul’s enormous strategic capabilities and systems knowledge so when he makes a point I must listen. He has been a leader and a visionary with an edge. He understands systems. He is a healthcare engineer who misses few details. I read his words with fear and trepidation. You can click on the link above and read his thesis for yourself.
Looking for the elements of guidance and truth in his note I do believe that he is bone chilling but correct when he says:
But policy-making is not so simple as setting forth seemingly self-evident or self-fulfilling goals. Policy-making must take place in the cauldron of competing private and public interests. The transmogrification of goals into policies, statutes, regulation, and corporate and individual action can be ugly and can result in unintended consequences. It is on this point that I argue that the Triple Aim has been hijacked.
It has been hijacked by powerful political and economic forces--often represented by the nation's hospitals in general and by academic medical centers in particular--but also aided and abetted by federal action.
The Triple Aim never seemed like a downhill slide to success for me. It has always felt like the organizational equivalent of rock climbing without a safety harness. His analysis of the naivete of the do-gooders of the Triple Aim extends to include the ACA, the folly of ACOs and the focus on “wellness” as the tools of transformation because the large "powers that be" will co opt these innovations for their own self-serving purposes. I disagree. Did you really imagine that the kings of the status quo were just going to say, “Come to think of it, your right. Let’s fix healthcare now.” Have you not noticed the blood on the floor from the fights in the state capitals around the country, in Washington and in the controversies aired at the Health Policy Commission in Massachusetts. I know people who believe in the Triple Aim and have worked hard to make it the organizing focus of reform who have the scars to prove that bravery and commitment in the face of long odds is a better description of their efforts than suggesting that they are naive in their approach to strategy and have been duped by the powerful self interests of healthcare.
Again, Paul comes back toward where I live and demonstrates his powerful communication skills to call out the disingenuous among us when he eloquently writes:
It's not that the doctors and nurses are any less caring or dedicated, but rather that the leaders of these centers have become calcified with regard to their social mission. They focus instead on expanding market share, growing margins, and attracting philanthropists to contribute to unnecessary and flamboyant edifices. They have no real interest in reducing costs, but rather in obtaining and securing revenue streams to cover ever-increasing costs. Most importantly, they neglect the harm they cause to patients in their facilities, preferring to assert that they deliver high quality care without being willing to be transparent with regard to actual clinical outcomes.
In his further dissertation on the improbability of the success of the ACA and federal intervention to create change that leads to the realization of the Triple Aim, he reports that advocates often accept minimal accomplishments as evidence of incremental change that will lead to future success by quoting someone:
"Well, it's [the ACA] not a perfect measure, in the grand scheme of things, but it has moved hospitals to focus on the discharge process in a far more meaningful way, and that's making a difference."
At this point he forces us again to wince with a statement that contains truth but is less than a full description of what has been accomplished:
Is that really the best the Triple Aim advocates can do? While billions are being extracted from insurers by growing monopolies, while billions more are being extracted from all of us by complicity between hospitals and equipment manufacturers, while low income families are forgoing care because they can't afford the deductible, we relish a single digit percent improvement in readmissions that has the consequence of hurting facilities caring for the poor?
My retort here is that he must not be reading what I read or see what I see. There are many more accomplishments and changes than lower readmission rates. By now my confidence is returning and I am beginning to think that his arguments are based on viewing the issues from a different perspective than I do; the very narrow perspective of a hospital CEO who was forced to spend his leadership time making the tough decisions that allowed a venerable but stressed institution to survive in a very harsh environment and an unfair market. Just as I am developing empathy for him and am trying to understand from whence he comes he frightens me again with a prediction that may be true but not coupled to any real suggestion that leads to a positive counter action to a dystopian view of the future of healthcare.
Look, there's nothing wrong with the Triple Aim objectives. What's wrong is that its most prominent advocates--some of the most influential health care experts in the country--have focused so heavily on that ideological approach to health care policy that they have absented themselves from the real battles over power, money, customer choice, and cost. They are losing ground every day. While they glance elsewhere, the Triple Aim is being turned on its head: The individual experience of care will degrade; the health of populations will decline; and the per capita costs of care for populations will rise.
My response to this was, “Maybe we should just shoot ourselves or turn our energy elsewhere to a less important but perhaps noble and achievable goal. I decided to write Paul and did. I told him that it was one of his best, if not the best thing he had written. Why? Because it is ironically motivational for fighters to have someone predict their failure. Also, his points bear consideration and in the end we can develop counter measures against the possibility that he might be a least partly right. For sure he is correct to suggest that we must have the strength of conviction and the strategies to stand up and make progress against greed. Paul responded to my note by expanding his concerns about the ineffective interoperability of our EMRs and the need for more transparency. Important issues but neither a complete answer or defense to the the vulnerable state that he had written about so passionately.
In the hours that followed I found myself thinking about how slow progress can be in our personal lives and in our society. We are all a little like Don Draper. We make progress one slow step at a time. We change our spots, not all at once, but one or two at a time. Paul is anxious for the whole loaf. He wants greed outed and wrongs rectified now. He wants St. George to ride in and slay the dragon now. He is right, that is not going to happen.
In his book about character David Brooks described Frances Perkins, the long serving Secretary of Labor in Roosevelt's multiple administrations who would take a “half a loaf” of progress and be happy. She seemed to favor a Don Draper like slow progress. Call it incremental, call it slow, but I call it continuous improvement toward a lasting transformation. I believe in the Don Draper method of halting and staggering progress.
My life’s experience informs me even more than the extractions that I can make from TV shows and books. I attended segregated schools and watched noble and proud people move to the back of the bus back in the fifties and sixties. Incremental social change has occurred as the result of a long struggle, even as we all admit that we have many more "spots to change". What is most remarkable is how fast attitudes have changed about same sex marriage but even there “fast” is really measured in decades. The journey for equality in every part of our collective American experience is maddeningly slow but I believe that in healthcare, as in all aspects of our collective experience, “we shall [eventually, some day] overcome”. I am sustained by the reality that if something is unsustainable, it will not go on forever.
Even the simple minded odyssey of Don Draper gives hope to the fact that there is a possibility of individual and collective redemption and transformation if we just stay engaged. I believe that even the large academic medical centers will ultimately realize that there economics of "extraction" is not sustainable. Sweeping change does occur in the affairs of humankind. Apartheid ended in South Africa and the wall fell in Berlin after very long struggles. The struggle for the Triple Aim was always destined to be a long struggle toward a noble objective, but like Don Draper, every now and then we can smile as we take yet another small step in the right direction.
Commentators like Paul serve us all by pointing out how far we must still travel. At the end of my reflections on his complaint I realized that the power of his words had stunned me for a moment but I can't accept a dystopian view of our future. History advises that the status quo is a challenge that more often than not falls to the the empathy and energy of people dedicated to a vision of a better state. There is hope for Don Draper and there is hope for all of us, both individuals and institutions, who struggle against our own self interests in a time of certain change.
Do We Need Another Lean “How To” Book?
I do not know if you have ever read a book about Lean, or more specifically, about Lean in Healthcare. I have about a “yard” of Lean books on my bookshelf. My four favorites include two specific books on healthcare, Patty Gabow’s recent book, The Lean Prescription:Powerful Medicine for our Ailing Healthcare and John Toussaint’s first book, On the Mend. George Koenigsaecker's book, Leading the Lean Enterprise Transformation, 2nd Ed. is a great discussion of Lean tools and philosophy from A to Z. Then there is the classic, The High Velocity Edge,by Steven Spear that really introduced most of American manufacturing to just how the Japanese were producing great products that were also taking away American market share at home and abroad.
There are many very good books that cover almost every aspect of Lean, and I am sure that more are on the way. Maybe you have a different set of favorites, or perhaps you have never read a book about Lean and all you know is by word of mouth or from occasional comments two or three degrees of separation from someone who actually has had a Lean experience or has read a book about Lean. Despite all the good information to be found in these classics and more that occupy my bookshelf, none of them directly address the issues that Paul DeChant, John Gallagher and I have observed and experienced trying to introduce Lean into the ambulatory environment. We believe that a Lean transformation of the ambulatory environment is the biggest step that a practice can take toward the Triple Aim “plus one”; we are also convinced that it is a difficult step. Most importantly, we believe that there are experiences that we have had or observed that could be useful and could be encouraging information for any individual or organization that is contemplating using Lean in the ambulatory practice.A Lean book specific to the issues of the ambulatory practice needs to address the realities of how to shorten the time to Lean success and how to efficiently and effectively engage physicians in the transformation of practice. We believe that the greatest issue facing healthcare is the discovery of an operating system that reduces waste, improves quality and safety, improves outcomes and improves patient satisfaction while improving the professional experience of practice. The majority of Lean success in healthcare has been focused in the hospital where initial opportunities are more obvious and results are frequently dramatic with relatively small investments of time and money. In the hospital measurable change can occur simply by applying tools that really are not heavily dependent on physician participation. Practice transformation in healthcare is much more than just employing tools, but tools alone can do more in the intense environment of the hospital than in the more diffuse world of the ambulatory practice. We believe that focusing only on finance and clinical efficiency and effectiveness will not lead to the new operating system that will be critical to future improvement of care in both the hospital and in the office, but especially in office practice. We believe that practice transformation facilitated by Lean philosophy and tools represents the optimal approach to the challenges of the Triple Aim and simultaneously has the power to effectively engage physicians in collaboration with other healthcare professionals. We believe that unless there is a much greater and more universal physician engagement in the process of transformation there is little likelihood for the changes that everyone says are so important because of the strategic control and position of physicians in almost every process of care in the office practice. Engaging physicians to save themselves and simultaneous lead others to a better system of care is a crucial component of the objective of improving care in the image of the Triple Aim. Let there be no ambiguity on the issues. Increasing costs, declining quality, poor access and a poor patient experience are real threats to the future of healthcare; but we believe that addressing these issues alone without specific attention to the issues relating to the declining satisfaction of practice would be a serious strategic error that will not lead to a system of care that anyone wants. It is also true that professional dissatisfaction as an expression of anger over externally imposed changes and new requirements of regulations are not limited to physicians. Nurses, physician assistants and the whole hierarchy of administrators share many of these emotions and frustrations, with many professionals in healthcare as potential or actual victims of “burnout”. The stress of practice related demands and issues has never been higher. The issues are getting worse and no real solutions for all healthcare professionals exist now to protect the quality of care. Without addressing the specific issues of the ambulatory environment in conversations with engaged physicians there is a real risk that neglect can further degrade the experience and cost of care. Lean can help, but often the gains are limited because changes must occur around barriers with physicians. Over the last decade the declining environment of practice without effective ways for physicians to respond has been a progressive source of frustration that has driven many physicians from practice. The issues of practice are as big a threat to the future of our nation’s healthcare as deteriorating finance, declining quality and poor patient experience. It may be controversial to say, but the practice environment within a hospital system where Kaplan, Toussaint and Gabow have documented the incredible benefits of Lean as an operating system is an environment that is largely maintained for physicians by others. Nursing, administration, and hospital boards maintain an environment where the goal is to support the productivity of the physician and improve the experience of the patient. Often the physician is treated like a guest from whom little is expected and much is feared. Even in the hospital it is likely that the results are better and the process works faster with less resistance when lead by physicians, as was true at Virginia Mason, ThedaCare and Denver Health; but even the hospital based physician leaders must spend substantial time and energy selling their physician colleagues on the benefits of Lean. Ironic as it may seem, in the hospital great amounts of waste can be removed and value created for the customer without ever involving physicians. There are many examples of improvement in the way emergency rooms function, the ways patients are moved and transferred, in the performance of purchasing and supply, in the efficiency of finance operations, in all aspects of human resources management, from the standard work of nursing processes and even the creation of operating room efficiency and safety, without ever involving physicians. Lean culture can even begin to take root in the hospital without widespread Lean understanding or involvement from the medical staff. Not so in the ambulatory world of healthcare. Without the support and leadership of physicians the seeds of Lean yield a limited harvest in the ambulatory world. In ambulatory practices large and small of all types from small private to large employed environments, physicians, especially primary care physicians, are much more critical to the possibility of successfully employing Lean tools.
We believe that Lean should be attractive to physicians who are natural problem solvers, love data and understand the experimental methodology of the scientific method. There are major issues to be addressed if we are to help physicians overcome the barriers that make it hard for them to give adequate attention to transformation. Most of them are working so hard in the current dysfunctional system of care that they have little energy for learning, even if the potential payout is huge. Paul, John and I care about the future of practice and hope that a book that addresses the unique challenges of the ambulatory environment would be worth a couple of inches on your Lean bookshelf. It would be a book that specifically addresses how to effectively introduce Lean to busy physicians. We believe that infusing Lean efforts with engaged frontline physicians will accelerate everyone's progress toward the Triple Aim plus one.
One of the tools for problem solving in a world characterized by volatility, uncertainty, complexity, and ambiguity is “crowd sourcing”. I know that many of you share our concerns about engaging physicians in transformational work. Your ideas and experiences would be valuable to us as we seek to collate our collective experience. A3 thinking is important. Your confirmation or concerns about the reasons for action that I have stated above would be appreciated as well as you sense of current state, complete with examples, and an ideal state would be helpful. Any offering in the context of barriers or concerns as well as potential solution comments would be great. If that is too complicated just a brief note about any connected thought to physician engagement would be appreciated.
I Had Never been to “old” Alexandria Before I have been to Washington dozens of times and I guess that I have been all around Old Alexandria but never was “in it” as I went through Reagan Airport or crossed the Potomac on bridges to see the Pentagon and the Arlington National Cemetery. I even thought I had been in Alexandria on my way to Mount Vernon but I had never really been there. If you are like me and have not been to “old” Alexandria, I highly recommend it as a very walkable and delightful community. It reminds me of Beacon Hill, Strawberry Banks in Portsmouth, New Hampshire, Savannah, Georgia and Charleston, South Carolina. Its an old port with well preserved homes and businesses from the seventeen hundreds.
I was in Alexandria for the annual meeting of Simpler for whom I have the honor of being a senior advisor along with one of the people I most admire in healthcare, Dr. Patty Gabow. The meeting this year was huge because not only is Simpler growing but it has combined forces with another well known Lean consultancy, Joan Wellman Associates ( or JWA) and both are now owned by Truven Analytics the best source of data on more than 3000 hospitals in this country and even more from around the world. As usual I learned a lot and enjoyed both formal and informal conversations about how Simpler and JWA can evolve with the new resources from Truven to be more effective than ever before.
What draws me to these affairs and what I enjoy most is just being around people who have a great sense of purpose and are working hard to improve all aspects of care. I hear of their own transformations and continuous improvement as they seek to improve their ability to mentor the many hospitals and practices from around the country that look to them for help with their own Lean transformational aspirations. Smart people, people who understand and practice respect, people who feel that helping healthcare improve any way they can is a high ambition, are great people with whom to spend a little time. I have never been in an organization with such a strong sense of family and such an obvious desire to support one another. At times I have to pinch myself to determine if I am in a business meeting or in a gathering of good souls committed to doing good work.
I was having such a good time that I barely noticed the lumps the Sox took in Minnesota. At least they won in Texas last night. I am beginning to realize that the Sox could make it a very long summer but that is not so bad since there are only 14 weekends this year between Memorial Day and Labor Day and anything that makes summer feel longer cannot be all bad!
Enjoy the weekend and remember when/if you go to Washington that “Old”Alexandria is a great place for a long walk.
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