5 January 2018

Dear Interested Readers,


What’s Inside and Comments About Treating Each Other With Respect Expecting Accountability

Last week’s letter was an attempt to take a year end look at how our healthcare system compares to systems of care in other nations that live in our “economic neighborhood.” This week’s letter is a tongue in cheek attempt to use my own experience from faulty efforts to successfully use the custom of New Year’s resolutions for self improvement to offer some insights from Lean philosophy and tools that might buttress our hopes for the Triple Aim. Whether or not the attempt to amuse you succeeds, there is an underlying urgency to this conversation that only you can mitigate.

As important as I feel the message of this letter is, and despite the reality that we are beginning a year in which we are vulnerable on many fronts because we lack the leadership in Congress or from the presidency to assure our progress toward an equitable future and the preservation of what we have accomplished, I feel it is time to comment on the amazing “# MeToo” movement. I feel no need to discuss the pros or cons of any specific case or try to offer commentary on the possibility of false accusations. I do feel the need to express admiration for the courage shown by so many of the women and men who have come forward to describe their own experience with the pain, suffering, loss of opportunity, and the personal confusion that the abusive behavior of coworkers, bosses, trusted authority figures, and even family members have created in their lives.

Terms like abuser, predator, and monster seem appropriate for some of perpetrators of the actions that have been described by the women and men who have come forward. We all have suffered as we have seen people that we once admired and respected be revealed as having a side we never imagined. It is possible that there have been some who are falsely accused. If so, I hope that in time they will be exonerated.

I have been persuaded by those who say that when we bemoan the loss of the entertainment of a gifted actor or comedian, the beauty created by a conductor or choreographer, or the insight of a perceptive journalist or TV personality, we are blind to what we lost from the potential performances, creativity, and insight of the women and men who were stifled by the abuses that are just now coming to light.

It is much too soon to know what all of this revelation and condemnation will eventually accomplish. I have heard thoughtful people express the concern that there could be a “backlash” against the movement. I fear that like the “Black Lives Matter” movement much will be lost through misunderstanding and attempts to mitigate the complaints with comments that begin with, “That may be true, but what about…?”

Lives were changed by abuse before the outings. Lives will surely be changed with the outings and the revelation of abuses. A few things stand out in the moment for me. Many of the “dismissals” have occurred after years of cover ups by colleagues, employers, and even boards of directors that failed some kind of test. Trust in people who should have known better and should have protected integrity has been damaged. That statement makes me sound naive. I am not really naive, and accept the human frailty that we all share. I do come from a background that spouts that “we are all sinners.” Nevertheless I am saddened by one more loss of our collective integrity..

Power and position seems to be associated with an entitlement that allows us to discount values. We love to say that power corrupts, but there are people in positions of power whose commitment we admire and whose behavior serves as an example to us all. David Brooks wrote a book, The Road to Character that gave us examples of famous lives that can provide hope as we despair over those who have recently disappointed us.

Some years ago I felt that I was frequently misunderstood. After asking myself what part of the problem I owned, it occurred to me that in our culture we function predominantly from the position that it is the speaker’s responsibility to be understood. True, the hearer has responsibility to listen, but when the interaction fails it is often the “speaker” who fails to “make the sale” or to gain the acceptance of his idea. Speakers are dependent on their hearers to trust them, or even to be willing to listen to them. Nothing dims the likelihood of success in communication like a loss of trust associated with a damaged reputation. Damaged trust discounts individuals, and it can discount institutions, including those that provide healthcare.

When the perpetrator of the abuse is a celebrity, the reinforcing cycle of a damaged reputation and the accountability of loss of an effective voice is the outcome that we can expect when we fail to treat people with the respect they deserve. I hope that the courage that has fueled the “#MeToo” movement will initiate a wave of understanding that will inform us all that even in a complex world where people of power and authority feel they can act with disrespect for others without being discovered, we will begin to realize that we are always accountable for the damage that we do.

So far the “outings” have not resulted fines or prison sentences, but positions of power and respect have been lost and lives changed in ways that should instruct us all. There has been a measure of justice and accountability demanded in the court of public opinion which has always been a higher court where reputation and trust matter. We should all take note and learn from the experience of those who have been called out for their lack of respect for those vulnerable to their position and power. As difficult as it has been to live through the recurrent disappoint of observing the clay feet of the once famous, I hope that time will prove the outcome worth the pain. I think we have made some progress, and we owe the #MeToo movement our thanks and support.


Diving Into 2018 With Hope and a Plan

January is named for the two faced Roman god, Janus. One face looks forward in time, as one looks back assessing what has happened. Most of us adopt a “Janus” posture this time of year. At our holiday gatherings what has happened over the last year is a favorite conversational topic. With much less certainty we talk about what we expect will happen in the coming year. Journalists cash in telling us about all the great things we missed, the movies we did not see, the books we did not read, and the ideas that we did not ponder or appreciate in the flurry of the year we just survived. They make lists of the famous people who died and review the disasters that most of us survived. A few brave pundits give us prophecies of what to expect in the coming year. Most of us take in all this information and in quiet moments of contemplation, perhaps while sitting in traffic or waiting in a check out line, we begin to imagine and resolve what we will try to do to improve ourselves over the next year.

For as long as I can remember I have been an enthusiastic creator of New Year’s resolutions. Like most folks, I fail to achieve most of the objectives outlined by my resolutions, but Lean has taught me that the value of the exercise lies not in considering what you achieve, but in understanding how you failed. Among my friends who practice Lean I frequently hear the admonition that we manage what we measure. As I do a mental accounting of last year’s resolutions, I find that I failed on most of them but came closer to success or gave up less soon on the exercise whenever I used a method that usually included some form of keeping score. I am hoping that even for the projects that failed miserably using the Lean concept of hansei, or “deep reflection,” will enable more success this year. Hansei involves the Janus-like activity of looking back and looking forward. It is self reflection. Lean lives on collecting the objective measurements that confirm whether or not the solution to a problem or the work to improve a process was effective.

I failed to learn Spanish this year despite investing in an app called Babel. The lesson learned was that after you purchase the app you must invest a few minutes each day listening to it, and you are more likely to listen if you keep a diary of how often you listen and commit to some regularity. My guitar and piano skills did not increase as much this last year as I had hoped back on January 1, 2017. The truth is that I sat down at the keyboard much less than once a week, and rarely for more than 20 minutes. It was August before I even got the piano tuned. At the rate I am going I will be several hundred years old before I get in my 10,000 hours. Carnegie Hall is not in my future. I think the same solution might work for music that will work for Spanish, but Lean also teaches us not to start too many projects at once.

I did better with my exercise goals. With the help of a wetsuit to extend my effort into the fall, I swam almost every day between June and mid October. I did better with swimming than Spanish because I made a stronger commitment and prospectively scheduled when I would do it. I could have started sooner if I had found my wetsuit in May, but I did not locate where I had “stored” it before July, long after I needed it. Lean teaches us that everything should have a place and be returned to that place after use. It’s the sort of wisdom my mother tried to give me, but I ignored. If I had learned from my mom, or had more effectively applied Lean thinking in October of 2016 when I stored the wetsuit, I would have known where the suit was, and I would have been back to swimming in May when the water temp got into the mid fifties.

My best effort was my walking/jogging “mileage.” I wanted to do 1500 miles in 2017. I did 1,444. Just setting a goal makes it a game. I like games. My games have rules. Never miss more than two days without a walk or jog. Never go out for less than a four mile walk. Less than four miles isn’t worth the effort to put on your shoes. I usually log the effort in a dairy, and visually manage my progress toward the yearly goal with “countermeasures” when I get behind. That is Lean thinking also. In Lean we use “bowling charts” and “visual management” to stay on track toward objectives that cover long periods of time and use countermeasures to get back on track when the charts suggest that we are losing ground to the objective. When I apply hansei to my barely missed walking/ jogging goal several things come to mind as explanations for failing to reach my goal. First and probably most significant is that I did not write down what I had done each day, as I have in past years. I got sloppy and depended on Nike’s running app to “keep score.” As great as the app is, it does not have the same visual impact that my weekly log has. Now as I look at the whole year, asking myself why I failed, I can see that the major reason why I missed my goal was that I missed an inordinate number of walks while traveling, but did not do “makeups” as a countermeasures because I did not have the feedback from the app that I did from my diary based “bowling chart.” The data suggests that I need to be careful to get in a walk or jog everyday when I am traveling.

My experience this year reminds me that we manage what we measure and consider. I did a lot of measuring and not enough considering. My overarching goal for 2018 is to be more “aware” in all things. In my little self improvement games it translates into being more oriented toward focusing on the supports like metrics and visual management that are foundational for “considering” and the development of countermeasures, rather than abandoning my resolutions. I know from personal experience that applying hansei to my failed efforts at self improvement will improve my chances of having the success I desire in 2018, but that is of importance only to me.

The real issue at hand is how we will do as a nation in our recurrent resolution to improve healthcare in 2018. Did we learn enough in 2017 to make progress toward the Triple Aim in 2018? Since we are all limited by our personal “reach,” the important question is what you will be doing where you live and work. Will your efforts make a difference in your community and in your workplace? Will your community and your workplace be affected enough by what you do to become part of a larger effort that will make a difference at a regional level? Will the song you sing be loud enough and in the right key to join in a national choir demanding and contributing to an effective effort to move us down the road toward universal access, improved outcomes, and the effective use of resources that will carry us closer to the Triple Aim and sustainably improve the health of our nation? I hope so.

It has become somewhat of a cliche to say, “Hope is not a plan.” I could summarize all of the verbiage above by saying that failure coupled with reflection can foster resilience and improvement if there is a methodology that supports continuous improvement and a commitment to a purpose. There are a lot of indicators to suggest that when we sit by the fire on some snowy day next January and reflect on what happened and what we learned in 2018, we will feel like progress was made because individually we followed plans that made us part of a large national and even international movement that desired a safer, healthier, more equitable world for everyone. I think that it is prudent to point out that no one is safe, and no one’s health is assured, no matter what their wealth, as long as inequality exists in any on its many forms and as long as we allow our planet to be abused for short term benefits to a few. So what is your plan?

I will answer the question for myself since I can’t answer it for you. I plan to be active where I have the opportunity to make a difference. My wife and I can make a difference in our community by being active in the community programs of social action that exist. Some are sponsored by the ecumenical movement among the churches. Some are sponsored through civic organizations like nonprofits that provide recreational opportunities for youth or protect land and water resources through trusts and associations. Some, like the local VNA, the hospital, and local nonprofits to support women, children and families in crisis are involved with healthcare and education. We also plan to be active in the local and state election process supporting progressive candidates.

Lean thinking frequently gets to a statement of “if _ is done then_ will happen.” It is the hypothesis upon which improvements are tested and then revised in a continuous process of improvement. My “if” statement is quite long and I have put it in the form of a positive statement of “ my personal plan to support hope.” It is as follows:

I will continue in board and foundation work in healthcare. I will continue to try to offer advice that supports the objectives of the Triple Aim to the for-profit companies that seek my advice. I will continue to focus on acquiring new knowledge that will aid myself and others in our collective journey toward a healthier world and the Triple Aim. I will share what I learn from reading, conversations and conferences through writing and opportunities to speak to individuals and groups. I will offer mentoring to anyone who requests it. I will endeavor to be open to the views and concerns of others, and by trying to understand the concerns of others, treat every statement of differing opinion with respect.

That’s my plan for hope. I am open to advise and ready for countermeasures if what follows my “if” is not a “then” of progress toward better health. I urge you to do the same.

We like to think we are good getting better. Last week’s letter and the companion SHC posting documented how poorly our country’s healthcare compares to other developed nations. The reality is that we are getting worse in the moment as judged by life expectancy at both birth and age sixty five. As always, men fare worse than women. This week David Blumenthal, President of the Commonwealth Fund, published a piece in Stat discussing the reality of our decline in an article entitled “Drop in U.S. life expectancy is an ‘indictment of the American health care system’. ” In the article he emphasizes, yet again, how our lack of universal coverage, our fragmented delivery system, our lack of progressive social programs, the behavior of our pharmaceutical industry, and who knows what other factors beyond the opioid crisis, are the cause of our deteriorating status in longevity. Do we need more notice as “A Reason For Action?”


A Blue Moon in January

It was cold, really cold, like below zero, where I live on New Year’s Day. We had guests spending a few days with us, and I also needed to drive my son and his wife to Lebanon to catch the bus to New York, so it was nearly dark before my friend Jim and I headed out for a frosty walk just before sunset. I was not going to start the year by putting zero miles in my log, even though the temperature was below zero. It was a very satisfying walk and just as we topped the hill above the public boat landing I saw the huge yellow orange moon just above the dark horizon in our eastern sky. The view took my breath away, and was a bonus near the end of a great walk. Was the surprise a positive omen for 2018? I would like to think so.

My good friend and community activist in New London, Nancy Allenby, was kind enough to allow me to use her fantastic shot of the moon as today’s header. The picture was taken from her car around midnight the night before, on New Year’s Eve.

This January is a “Blue Moon” month. There are two definitions for a blue moon. One definition makes literal sense. Sometimes the moon looks blue when there is smoke or other particles in the atmosphere. The more interesting definition that comes to my mind is that a Blue Moon occurs when there are two full moons in one month. That definition is the basis for the phrase “once in a Blue Moon” which means “rarely,” since on average there are two full moons in the same month about once every 32 months. The other “Blue Moon” that comes to my mind is the Bluegrass classic of Earl Monroe, covered by Elvis, “Blue Moon of Kentucky.”

Many “moons” have names that date back to primitive times. The name of the first moon of January, the one I saw on my walk, is a “Wolf Moon.” This moon also happened to be a “Supermoon” which is why it caught Nancy’s eye even on the night before it was really full. “Supermoon” is a new descriptive term defined in 1979 as a full moon that looks larger when the moon is very close to the earth, within 90% of its closest orbit. The moon on January 1-2 will be the only Supermoon of 2018. The next full moon on January 31 will be a “Blue Moon.” But there is more! In some places the Blue Moon on January 31 will also be a “Blood Moon” because it will look red in places where it causes a total lunar eclipse. Perhaps January’s moons are another indication that 2018 will be a unique year.

Well, if that isn’t enough, let me suggest that you listen to “Rise of the Supermoon” which is one of my favorite songs written by my son back in March 2011 to celebrate the largest super Supermoon that had been seen since 1993. I think the March 2011 Supermoon will not be surpassed for many years to come. The song frequently pops into my head when I look at a beautiful full moon, even if it is not really a Supermoon. The notes my son wrote to go along with that song still deliver a message worth hearing as we start a new year:

The world stood perfectly still as I stood there lost in the wonder of the colossus above. Somewhere a child cried out “It’s the moon!” What a perfect moment. Although I stood by myself, I was not alone. People all over the East coast were looking at the same thing, and soon the moon would rise over the rest of America, and the world as a whole would be treated to a singularly unique sight. I’m not sure how long I stayed there looking at the massive unblinking eye, but as I drove home I saw evidence of humanity’s collective reaction. As I drove down a four lane highway I saw a car come to a complete stop in the middle of its lane so that the driver could crane his head out of the window for a better view. Humanity stopped in its tracks to take in the sight of the moon.

It is so comforting to know that in an age of cynicism we are not totally beyond wonder. Just as our primitive ancestors would have marveled at the familiar satellite suddenly transformed, so do we marvel. We have seen the moon before, but we have not seen the moon like this. I feel as though I have seen humanity before, but I have not seen humanity like this. All too often it is tragedy or disaster that captures our collective attention (and often enough it should). On Saturday night is was wonder. May we hold on to that wonder as tightly as we can.

Isn’t it wonderful to lose yourself in the of the natural world? Natural beauty is a reliable antidote to the misery that we can manufacture as we all pursue our self interests in a world where we have manufactured good reasons, both political and environmental, for apprehension about our collective future. Let me invite you to resolve spending as much time in the natural world as possible this year. I know that it is a good strategy that will protect both your health and happiness. Don’t miss the Blue-Blood Moon later this month!