7 August 2015
Dear Interested Readers,
Inside this Week's Letter
What is not inside this week’s letter but deserves comment and perhaps a moment of silence is the fact that yesterday was the 70th anniversary of the dropping of the atom bomb on Hiroshima. More than 70,000 people died in a flash and tens of thousands in a delayed fashion. The justification was that a “traditional” invasion of Japan would have cost the lives of many times more American soldiers in a D-Day like invasion and a protracted fight to the end on the islands of Japan. We have all lived in the continuing state of fear of a nuclear conclusion to the history of our species that this event initiated. The debate over the potential treaty with Iran is just the latest movement in this long dance with fear.
The bulk of this week’s letter is my review of John Toussaint’s recently published book. Discussing a new and exciting book by John Toussaint opens up many possible pathways for my “musings” to follow. I hope that at the end of the journey you will be eager to read this new contribution for yourself.
The second section of the letter is a quick review of The Older Americans Act that like so much important “Great Society Legislation” was also passed and signed fifty years ago. It was signed by Lyndon Johnson on July 14, 1965 just a few weeks before he signed the act that created the much better known Medicare and Medicaid programs.
Finally there are thoughts generated by rainbows and knuckleballs and my weekly reminder to you to visit the child of these musings, stratrgyhealthcare.com, where these thoughts live in perpetuity on the Internet and where your friends and colleagues can sign up for their own weekly copy.
The Gift of a Jewel From John
Several months ago I learned from John Toussaint that he had a third book in the works. I am sure that many of you have favorite authors or musicians and can understand my excitement in the context of the way you feel when you hear that one of your favorites has a new book or album coming out. The excitement is even greater when the previous work was a very enjoyable read or a fantastic collection of tunes that you played over and over. Expectations and sometimes apprehensions can be high in that time between learning that a new work is on the way and its arrival. Will the artist be a “one hit wonder”? Will the author be someone who struggles on subsequent attempts to get back to the “mountaintop” of success and the promise of earlier work?
This last week, in an interview on “Fresh Air”, I heard “Buzz” Bissinger, the author of Friday Night Lights, the fabulously successful book published in 1990 about the high school football team in Odessa, Texas. Bissinger talked about his twenty-five year struggle to return to the success that he enjoyed with that first book. Friday Night Lights sold more than two millions copies and became a successful movie and TV show. Not bad for a work of narrative non fiction. Bissinger compared himself to the high school football star who did not know what to do with life after graduation as he tried to explain just how miserable his initial, and not to be repeated success, had made him. I can’t remember whether Bissinger quoted F. Scott Fitzgerald’s famous line “There are no second acts in American lives” or whether that quote just popped into my mind as I was listening to the interview. Sustaining success is always a challenge.
Neither “one hit wonder” concerns nor troubles with a second act seem to have bothered John Toussaint. My explanation is that one of the reasons that John has escaped these maladies is that he is dedicated to a cause. His cause is the improvement of healthcare. On the last page of the new book, John sums up the reason for organizational transformation in a way that it appears to me, from my personal contact with him, that he has also applied to his own life. He is a man who lives his message.
“The purpose of this transformation is to create a culture of care centered on the patient’s well-being. This involves the relentless pursuit of operational excellence, breaking down silos that keep us focused within our departments, and continuous improvement.”
I think there is great evidence that John has walked the talk. Indeed the necessity that leaders be personally transformed if organizational transformation is to occur is a recurrent theme in the book which is really an open letter to healthcare leadership and their boards with the express purpose of convincing them that leadership is critical to Lean success. He introduces this idea on page three!
The most common problem that I see [discussing the more than 145 organizations that he has personally visited that are in various stages of understanding Lean] is that leaders fail to recognize the magnitude of change that will be required and that change extends to leaders on a personal level.
Before hitting the high points of John’s book, which was written with Emily Adams, as were his two previous books, I want to describe some of my own experiences with John over the past seven years because it is from the consistency of those experiences and my own observation of his personal transformation that I gain confidence in the importance of making a forceful recommendation to you to read this latest book. In his writing John readily uses his own experience and the experiences that he has observed while visiting the “gemba” of those 145 hospitals, practices, and health systems across this country and in distant places around the planet.
Between 2006 and 2008 the Atrius Health board and leadership team became increasingly convinced that it needed to lead significant changes if Atrius was ever going to meet its quality and safety goals and prepare for what would surely be an eventual downward pressure on revenue in the aftermath of costs concerns that would flow from the passage of the Massachusetts mandate (Chapter 58, “Romneycare”) that provided access to care for most of the citizens of Massachusetts. Zeev Neuwirth had introduced us to Lean when he became the Chief of Internal Medicine at our Kenmore practice a year or so earlier. Kenmore was the location of my own primary care practice and I was impressed as Zeev presented to me (I was board chair at the time) what he thought Lean could do for us. His efforts generated amazing enthusiasm within the nursing and support staff of the Internal Medicine practice and the doctors began to get interested as the beneficiaries of improved staff performance. After the success at Kenmore, Zeev became our first VP for Clinical Improvement and Practice Transformation. He lead the Lead project that was funded for us by Blue Cross of Massachusetts and during that pilot at our Chelmsford site we continued to try to find our way with Lean using the services of a consultant.
After becoming CEO early in 2008, I spent a lot of time with Zeev and some other key members of the Senior Management team articulating a strategic plan. The more we thought about the challenges ahead, the more we were reminded of the old adage from Maine, “You can’t get there from here!” It was clearer than ever before that real changes would be necessary if we had any chance of achieving the multi year goals that we were establishing. We could not achieve our objectives working the way we had been working. A transformation was necessary.
Zeev continued to argue that we needed to pursue Lean as the vector of our transformation. I think that Zeev realized that he had to sell me on the fact that Lean was the route we wanted to follow to achieve our goals. I realized that I needed to sell the idea of a Lean transformation to the the other senior leaders, the board, and all of our physicians. The physicians elected their colleagues who were on the board and ultimately their approval as well as their participation was critical to the success of any initiative.
Zeev pushed me to look at other organizations that had begun a Lean journey. We visited Group Health and Virginia Mason in Seattle and began to understand “what good looked like” but the clinching activity was a long phone call to John Toussaint at ThedaCare. I was pretty sure before the call that Zeev was right about Lean. I can remember my apprehension about a conference call with someone I had never met. I had a very clear idea of what ThedaCare had accomplished. Zeev had prepared me well but I was asking myself, “Why would John Toussaint be interested in talking to us?”
Now after almost seven years of knowing John and enjoying three books and many visits with him at ThedaCare, at various meetings around the country and through his several visits to Atrius, I know know the answer to my question. John is passionate about Lean as the answer for the problems of our broken system of care and is committed to the transformation of all of healthcare, not just the success of ThedaCare. His actions as much as his writing suggest that he believes that the transformation of all of healthcare will occur one leader, one practice, one hospital and one health system at a time. He is so committed to the idea that they need Lean that he is willing to be an emissary to everyone. A few years ago I jokingly compared
John to St. Paul who spent his time traveling all over the known world of his day starting churches and writing his letters back to the churches he started to help them understand how to continue their transformation.
Looking back on that call from a perspective of seven years, I do not know how far at that time John had traveled toward his own understanding and planning of the role that he would eventually assume “spreading the gospel” of Lean. I do know that he spent more than an hour talking about the Thedacare experience with us. I do know now that with his colleagues at the Thedacare Center for Healthcare Value he has done the same thing for many organizations and many other hesitant CEOs.
What made our conversation work was his patience, openness and his obvious passion for care improvement. He revealed what he believed worked and what he was sure from his own experience that we should not do. He talked about what he had learned and did not try to hide the mistakes that had taught him those lessons. At the end of the conversation I asked him how he would advise that we get started and he suggested that we hire Simpler to help us since they had been useful in helping ThedaCare get started; so we did. I also sent my management team to visit ThedaCare. They came back brimming with the enthusiasm which would sustain them through the tough work of changing minds and changing how we worked.
Most of what John told Zeev and me you can now read in the first book, On the Mend: Revolutionizing Healthcare to Save Lives and Transform Industry. When It was published we were well into our Lean journey and gaining some momentum. In my weekly letter I suggested that we would provide a copy for any employee who would promise to read it. In the end we distributed 1500 copies. After that every new hire got a copy when I met with them.
After John left the position as CEO of ThedaCare with all of its local leadership responsibilities and moved on to lead the ThedaCare Center for Healthcare Value, we saw him with some regularity at Atrius. A typical visit involved a morning with the senior management team and rounds in the gemba during the afternoon. Watching John in action is an amazing experience. He follows the formula of coaching, teaching and mentoring and is an intense listener who clearly enjoys seeing the evidence from front line staff that they are thinking and engaged and that what they are learning and the success that they are experiencing is giving them the courage to begin to solve even larger problems. Against this background let’s look at the new book.
The first clue that the book is an important departure from the usual “how to” Lean book and contains a wisdom earned through experience is in the title, Management on the Mend:The Healthcare Executive Guide to System Transformation. “On the Mend” is an echo from that first hit book but the focus on the healthcare executive is a new and unique perspective. The word guide is also a clue that the book will lay out a methodology derived from experience. I like books that begin by telling you what they are going to tell you. In the introduction John lays out the bones of the whole book and then with the subsequent chapters puts a lot of muscle on that skeleton with examples from real organizations that he has visited.
He begins by quickly reviewing what would be called the “reason for action”; the continuing dysfunctional nature of American healthcare. He moves quickly to confirm his methodology that I implied earlier. The bolded print is from me for emphasis.
In the six years since I left my position as CEO of a major cradle-to-grave health system in Wisconsin in order to help others achieve the kind of breakthrough transformation we built at Thedacare,Inc., I have spent most of my time in other people’s hospitals and clinics. Every time I am invited to lecture or present findings to executive boards, I have one stipulation. Part of the visit must include a substantive visit to the units or offices where care is taking place.
He goes on to objectively establish his expertise and make a critical observation by saying:
After more than 145 such visits in 15 countries--and continuing at a rate of two or three new sites every month--I understand why I am seeing hope and failure in nearly equal measure. Teams of clinicians and administrators using lean thinking are making breakthroughs every week as they increase quality and reduce costs. But the essential transformation of the organizations is not happening due to some basic misunderstandings about lean in healthcare.
He sees organizations “doing Lean” which is not the same as “becoming Lean”. The next sentence which I have already given you earlier bears repeating and is his diagnostic statement/hypothesis from his observations:
The most common problem that I see is that leaders fail to recognize the magnitude of change that will be required and that change extends to leaders on a personal level.
He describes that he sees CEOs who think their role is to hire someone to teach Lean tools to their staff and then begin to enjoy the benefit while never leaving the comfort of their office. as he says:
When I see this kind of attempt taking place, it always looks to me like the leaders have simply handed over the keys to consultants or the improvement staff and expect them to return with something new, high performing, in place of the old organization. This does not work… So, for the record, lean healthcare is not an improvement program. It is an operating system within a management system that requires a complete cultural transformation.
Much of the book is about how to move from old school thinking that he calls “Sloan Management” or “management by objective” the dominant methodology of management today named for Alfred Sloan the GM CEO and archetypical twentieth century CEO to ideals of “management by process” described Deming, one of the original quality thinkers whose work was foundational to the evolution of Lean.
He goes on to say that he sees managers everywhere who are frustrated “trying to manage two ways at once”. He observes that the failures he sees are the symptoms of management by objectives in a Lean environment, “which does not work”.
….Lean demands real, system-wide change by every manager, starting at the top. Senior leaders cannot delegate a profound cultural shift; they cannot expect others to change while they continue working in the same old command-and-control style, checking the numbers without really understanding how the numbers were or were not achieved.
These are the biggest problems I see…:failure of leadership to engage in the substance of change and mistaking the lean operating and management system for a quick improvement program…
He says that he has been reluctant to prescribe a “single best way” to launch Lean but one senses that he has seen enough confusing, wasted effort and misconception in his Pauline travels that he has gained the courage to set those concerns aside because of the strength of his conviction that Lean is the way to “mend” American healthcare and we must move faster.
Below are his steps for the clinical transformation which are fully explained in the first section of the book with a chapter on each step. The second section focuses more on the transformation of the support functions like HR, finance and IT and the the book concludes with two fabulous final chapters “Barriers to the Work” and “Taking the First Step”. The “Barriers” chapter discusses concerns from “within the practice” and also barriers “lurking outside the practice”. The three concerns from outside the practice are 1) the trouble practices are having accommodating to the shift in finance from fee for service to payment that is population or value based, 2) the lack of data transparency and 3) the failure of medical schools to shift their focus and begin to prepare young physicians with the tools they will need to practice and manage in quality systems.
Here are the steps John prescribes that will lead to transformation.
“A Revolution In Six Steps”
- Lay the foundation. I would actually label this as step zero. It is that process of preparing the senior leadership and the board as well as the planning for the details of what will follow. “Prework” includes “recognizing that change is necessary... admitting that you need to change. Not just your organization. You.” This section is similar to the story I told about the process that Atrius went through. John is consistent. He advises hiring a facilitator with deep Lean knowledge to come in and work with the senior team. The outcome should be a five year plan that describes “... goals [and metrics], in five areas, safety, quality, people, delivery and cost”. These are the five “True North” pilars. Vigorous communication with the organization begins at this time and never ends.
- Create the Model Cell. The Model Cell will be like a learning lab. It will be where others come to see what good looks like. It will be an important component of communication. By observing it people will begin to understand the what, why and how of transformation.
- Establish Values and Principles. In my mind, this process is concurrent with both steps one and two. As John says: “Values are the highest beliefs and aspirations of the leaders; these are what steer the company...putting the customers first, finding joy in work, and continuous learning...The scientific method should be a principle common to all lean transformations…” He adds, “Clearly stating the organization’s values and principles should reassure employees who fear change. Adhering to those values is part of the pact that needs to be formed between senior leaders and staff…” I would add that this process is about trust. It never ends. The chapter “Values and Principles” may be the chapter that everyone should read first and then reread on a regular basis for inspiration or when the journey gets difficult.
- Build the Central Improvement Team. John suggests that the team be 1% of FTE. We were close to that number. The use of the team as a training ground for future leaders is outlined. This is the “infrastructure” of Lean in the organization. My experience would suggest that every step in the process benefits from guidance from an experienced external source but this step and the creation of the Model Cell are both steps where guidance from experienced sensei is critical to completion.
- Redesign Management Systems. This is about introducing daily management systems that focus on process. This is a big part of the shift away from “Sloan Management” or management by objective toward management by process where the front line workers are empowered to solve the problems and the “leaders”, the executives, become coaches, mentors and teachers as they move through the gemba. This is where we all define our “standard work” and create the environment for collaboration. When this process gets going in the Model Cell and good managers from other parts of the organization see it they will create a “pull”. I observed in our organization that as we spread Lean we often discovered that by the time the Lean team came with corporate resources and focus, elements of Lean were already in place. I spoke facetiously of “metastatic Lean”. John describes promoting this phenomena by saying: “Let the demand for this exciting new system build. Encourage advocates to tell their colleagues and direct reports about the model cell; feed stories about progress of this work into any available communication channels.
- Spread the Work. With the development of the Model Cell you have your own local example of “what good looks like”. One key observation is that as new cells are created or encouraged to develop, the process and “standard work” of the model cell is just a starting point. The new models will be encouraged to learn by starting further cycles of improvement.
As stated earlier, the second section of the book is about aligning the rest of the organization with the transformation in the practice. This may result in a movement away from the useless exercise of developing an annual budget toward a more insightful process of “forecasting” over six or so quarters. The transformation will cross over the threshold “into the boardrooms and executive suites where system-wide changes need to be addressed…”
Whether you are contemplating Lean as a way of addressing your challenges, as we were at Atrius in 2006-2008, or whether you have been using Lean tools but have hit the wall and are not getting what you once got from Lean, there is a message in this book for you. I support John’s assertion although there are potentially other ways to achieve the changes that are necessary to mend our broken healthcare system but there is none better than Lean.
Reading the book is an excellent use of your time for the inspiration it provides through the recounting of experiences from practices and organizations around the country and the world. ThedaCare has been a “Model Cell” for many of us as has Denver Health and Virginia Mason. John now adds others like Palo Alto Medical Foundation, Stanford Hospitals and Clinics, Lehigh Valley Health, and Winona Health to the growing list where leadership and Lean have come together to make a remarkable difference solving big problems in tough times.
Like St. Paul, John is both burdened and ecstatic with the possibility that he has had a continuing experience that has provided him with knowledge that he must spread. As he says at the end of the book:
We share these stories because we know that the principles of lean thinking work in healthcare. We know that our industry needs to change radically to meet the coming challenges, and we have discovered the way to do it, while making people more engaged and focused on patient care.
The journey, like all of them, starts with the first step forward. Join us.
The Older Americans Act
Last week’s New England Journal of Medicine had a great article in the “Perspective” section, “The Older Americans Act at 50”. Unfortunately at this time the article is available online only to those who are subscribers so I will try to give a very brief overview of its thoughtful content. I find that many physicians are totally unaware of this program or if they are they are aware of it they do not know how to maximize its benefit for their patients or see it as a potential asset in our quest for better care and healthier communities in pursuit of the Triple Aim.
The OAA was a part of the larger set of programs we knew as Johnson’s “Great Society”. It was framed with aspirational rhetoric that may have described a set of attitudes that
existed then that we may be forgetting now. Johnson said,
The Older Americans Act clearly affirms our Nation’s sense of responsibility toward the well-being of all of our older citizens...Every State and every community can now move toward a coordinated program of services and opportunities for our older citizens. We revere them: we extend them our affection; we respect them.
The authors give a bit of the current state of the law. It survives in the aftermath of the neglect and underfunding of our post “sequestration” world to serve about 13 million of our most isolated elderly citizens. Programs include meals (40% of budget), caregiver support, personal care, and transportation assistance (60% of budget). The budget has been flat for ten years even as the demand has increased, generated by the exploding population of older Americans.
The article points out that a program like OAA that allows us to age at home makes great sense when you realize that one year of home delivered meals costs nearly the same as one emergency department visit and less than a week in a nursing home costs. Even in its underfunded state, the program seeks to address the socioeconomic determinants of health.
Considering the threats to this valuable program that are the function of underfunding, the authors make a few suggestions.
- Value-based systems can partner with existing community-based initiatives for older adults. Chronic Disease Self-Management Programs in a community setting are one example.
- Hold value-driven health systems accountable for ensuring that seniors can successfully navigate a network of medical, long-term, and social supports. It has been shown that savings can be generated if ACOs hire community based health navigators.
- Health systems can directly provide and advocate for better social supports for elderly American. Creative distribution of benefits like housing and food could yield their cost plus savings when applied to vulnerable populations. This recommendation is built on the clearly demonstrated fact OAA programs have documented that “social supports engender value, in part by improving clinical outcomes and reducing utilization for vulnerable patients”.
The OAA has provided real value for fifty years. Its future is vulnerable. I know from the Atrius Pioneer ACO experience which did seek to develop relationships with local aging programs that the value that the authors are seeking to defend with their proposals is real. We owe it to seniors and to everyone to continue this work. We should build on it in the framework of our evolving systems of care. Are we up to the challenge? Are we even aware of the threat?
Double Rainbows, Knuckleballs, a Host of Republican Wannabes and So Long Jon
My family is recovering this week after the excitement of my son’s wedding. It was a beautiful event held outdoors late on Saturday afternoon after a brief heavy shower that cleared the air of humidity and left us with a few bright clouds to decorate the sky. Back in New Hampshire we have had afternoon showers on many days. On Monday afternoon the reward after the brief late afternoon shower was a double rainbow over the lake which you can see if you look at the header for this week’s letter.
Usually a week that contains a series with the Yankees is an exciting week for me. I held out hope for a recovery by the Sox for as long as possible. Miracles can happen but the math is beginning to make it even unlikely that a miracle could produce a wild card birth for the playoffs. Now is the test of a true fan. If you love the game, a performance like Steven Wright’s knuckleball taming of the Yankees on Wednesday night was a delight no matter where you are in the standings.
Last night I was at Fenway for Bonnie Raitt and James Taylor. It is fun to be part of a crowd that looks older than you do; well about as old. James is a little on the youthful side of seventy and Bonnie is also eligible for Medicare. They still rock!
The Fox News Republican fandango and Jon Stewart's final show await me on the DVR to fill up any indoor time that the weather might offer this coming weekend. I plan to be out walking or fishing, weather permitting, because the summer is fading fast. Make every minute of what is left of this sweet season count. |
