| 9 February 2018 Dear Interested Readers, An Introduction to a Great Freebie and What’s InsideSeveral weeks ago I was surprised to get an email from an old friend and colleague, Zeev Neuwirth. It was not a personal email. I am sure that I was just a name on a distribution list, but it was a welcome announcement of a new weekly podcast that my old friend had launched last August under the title, Creating a New Healthcare. Just in case you didn't get the notice and are not very facile with managing podcasts, here are the crucial instructions so that you will not miss out on this great new, totally free, opportunity. Instructions to Manually Download: (1) Go to iTunes (if you have an Apple device) or Google Play (if you have an android device). (2) Type in Creating a New Healthcare, in the 'Search' Box. If you have trouble finding it on Google Play, you can go directly to http://shoutengine.com/CreatingaNewHealthcare/(3) Click 'Subscribe' and download one (or more) of the recorded episodes. If you go back all the way to the initial podcast on August 17, 2017, Zeev will give you his credentials, and you will learn that he is currently Senior Medical Director of Population Health at Carolinas Healthcare System Medical Group. I would introduce him by saying that he was one of the principal authors of the Harvard Vanguard/ Atrius Health strategic plan of 2008 that I have referred to in the last two of these letters. I have spoken of Zeev many times in these letters, but just for review, I first met Zeev in about 2006 when he was hired as the Chief of IM for our Kenmore Square office, the largest Atrius site and the first practice of the old Harvard Community Health Plan. My primary care practice and most of my cardiology practice was at the Kenmore site. Said differently, Zeev was once one of my clinical bosses. He came to us as his first job after completing an MPH at the Harvard School of Public Health. Prior to his MPH, he had practiced primarily at New York area teaching hospitals. Wherever he went he had tried to make things better through the early adoption of innovations and efforts at continuous improvement. It was Zeev who initially introduced Lean to our organization. I well remember his attempts to get my attention by dropping a large box of reprints about Lean and clinical improvement on my desk. What really got my attention was how he began to work with an enthusiasm that soon made a measurable difference in the experience of our patients, and improved the efficiency of the practice in ways that before long the life of everyone in our practice much easier. Soon Zeev was the Vice President for Clinical Improvement and Innovation for all of our sites. After becoming the CEO, my office was just a few steps from his. His office walls were covered with white boards full of plans and projects in process. It did not take us long to realize that if we were going to reduce waste and improve quality in pursuit of the Triple Aim, we needed to make continuous improvement our objective and Lean our operating system. As will be reviewed in the main section of this letter, leadership is a critical ingredient in continuous improvement. I consider Zeev’s creation of a robust leadership academy as a critical and unparalleled accomplishment that was foundational to our success. Each podcast after the introduction is a conversation between Zeev and someone of interest working on a leading edge in healthcare. When I was working with Zeev I was amazed by his ability to find and connect with really interesting people. He has a nose for innovators. Our program in “Shared Medical Appointments” was an example. He had connected with one of the inventors/advocates of the idea, Ed Noffsinger, and brought him in to get us going. I love the recurrent introduction, with slight variations, that I have heard Zeev give at the start of each of the podcasts that I have heard: Hello, I’m Zeev Neuwirth, and welcome to “Creating a New Healthcare,” a podcast series for healthcare leaders who are interested in fresh perspectives, new ideas, bold solutions, and a renewed sense of meaning and purpose in their journey to advance patient centered, customer oriented value based healthcare.That’s an offer that leads me to say, “Thank you! I think I will have some of what you are offering!” I’ve listened to several of the back programs now as well as the two most current editions. They are all terrific, and the subjects vary across a wide spectrum of interests from recent applications of artificial intelligence to a moving discussion of “Compassionate Connected Care” with Christine Dempsey, Chief Nursing Officer at Press-Ganey. I think Zeev is the Terry Gross or Ezra Klein of healthcare. He leads the interviews well because he knows his subject, and his natural inquiring nature creates an excellent interview that has a takeaway for anyone in healthcare no matter what their background or personal expertise might be. As I scanned down the list of programs my eye fell on November 4, “The Third Era of Medicine with Don Berwick.” My heart stopped. What a treat for me! It would be an opportunity to be a fly on the wall, and listen to a conversation between two of my heroes! The 67 minute conversation did not disappoint me. It is a totally spontaneous back and forth conversation that was a review of Don’s concept of the three eras of healthcare. I had been among the 6000 or so attendees at the annual IHI meeting in Orlando in December 2015 when he delivered the keynote address that announced the concept. I have read what he has presented on the IHI website explaining the concept, and I have watched the videos that are available. I thought that I knew what he really meant, but was delighted to discover from the conversation with Zeev that there was much more in Don’s evolving thought than I had appreciated. I encourage you to listen to the conversation. Here is a link to make it easy. The link connects you to all of the podcasts. The conversation with Don Berwick is number 14. If you do not have time to listen to the podcast, I hope that you persevere and read to the end of my description of the conversation. At the end of the conversation with Zeev, Don spontaneously gives us his view of the responsibility that healthcare professionals have to protect care and be active advocates in the midst of these difficult political times. I have been feeling apprehensive as I have expressed my own political sensibilities. Don covers the same territory, and is much more succinct. I have transcribed for you exactly what he said. Beyond Silver Bullets: Understanding Era Three of HealthcareWhen Zeev Neuwirth and Don Berwick sat down together last November to record their remarkable conversation about Era 3 in Medicine, he introduced Don with a review of his remarkable career as a pediatrician, and as a pioneer in the quality, safety, and reliability movement in healthcare since the late eighties. He led the work that introduced the world to the importance of new ways of looking at what we do as a co author of the important IOM publications To Err Is Human and Crossing the Quality Chasm. As a co founder and the President of the Institute for Healthcare Improvement. Don was one of the authors of the Triple Aim in 2007, and has had an international impact with the conversations about better care that have led to worldwide conceptual changes. Zeev reminded listeners that Don’s work in the UK with their National Health Service led Queen Elizabeth II in 2005 to award him Honorary Knight Commander of the British Empire, the highest honor that the British bestow upon a foreigner. What Zeev did not say was that the irony of it all was that it was his work with the NHS that motivated Republican members of the Senate, who considered the British system to be socialized medicine, to deny him confirmation when President Obama nominated him as the administrator of CMS in 2010. He was installed as a “recess” appointee which limited his tenure to 18 months. When Don tried to win the Democratic nomination for Governor in Massachusetts in 2014, I heard career employees of CMS say that Don’s tenure was the height of their careers at CMS. I have my own personal experience with Don. We were colleagues at Harvard Community Health Plan and we have interacted many times over the years since he left HCHP to start IHI. I visited him twice on business while he was leading CMS and we were moving to become a Pioneer ACO. One of my fondest memories of that experience was when he pointed to the quotation by Hubert Humphrey that is carved into the wall of the building that houses the Department of Health and Human Services where CMS is housed. The words are compatible with the personal mission that Don has pursued during his entire career. It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.
I think that you will see that what Don calls “era three” is an attempt to move closer to the spirit of Humphrey’s statement which I am sure he thought about everyday as he passed it on the wall near the elevator to his office while he was serving in Washington. After his introduction, Zeev led off the conversation by going directly to a discussion of the nine items Don had identified as needing change as we moved into the future of healthcare, what he has called, the “moral era.” Below is the slide from Don’s original presentation that presents those nine issues. I have published it before and many of you may have seen it in publications of the IHI, or have heard Don talk about it, so it may be familiar. What was a surprise for me was to hear Don’s answer when Zeev asked him about the thought process that produced the list. |
| | He said he was thinking about how conversations about what to do next, or debates about the future of healthcare always seemed to have the tone of a fight. He wondered, “What are we fighting about?” The answer is complex, but what he settled on emerged from his framing of two previous eras that were in conflict with each other, and now are in conflict with a better future. He implied that in any conversation there were still those of us who were most comfortable with the attitudes and social relationships of either era one or two. It seems to me that one’s point of has a lot has to do with when and where one was trained.
Era 1 was about professionalism. Medicine was embraced as a noble endeavor. Doctors have knowledge that others cannot access. There is the idea that if patients do find information, they misinterpret or misapply it. In Era 1 doctors self regulate. They use science. There is an aura of professionalism and culture around medicine that goes back more than a thousand years. Don’s father was a doctor in a small town, and as a respected doctor, he was treated as if he were “quite royal and had special privileges.” I entered medicine in the twilight of this era, and I was trained by doctors who were wonderful examples of all of its virtues. In many ways the best of the attitudes of Era 1 are still valuable, and are still palpable in our times. It was also an era when the patient sat at the feet of a standing doctor in a white coat, and listened to the diagnosis and accepted the prescribed treatment without questions that challenged the doctor’s authority. There was little transparency. The profession governed and judged itself.
Era 2 evolved in beginning in the late seventies and early eighties along with the emergence of data about our performance. We became aware of variation in practice along with the troublesome data about the cost and safety of healthcare. As Don talked I remembered a moment in the mid to late eighties when he rushed up to me as I was going to a governance meeting in at our main offices in Brookline Village, where Don had his office as HCHP’s Vice President for quality. He said something like “Gene, I have this exciting data that you need to see. It’s not safe to get healthcare at Kenmore!”
Kenmore was the site where we both practiced. Don’s work and the work of others like Jack Wennberg at Dartmouth startled all of us with evidence of the unwanted variation and other defects in our care as Era 1 collided with Era 2. Many of us remember the hard feelings and conflicts that emerged as we began to compare our methods and outcomes. We went from being unquestioned on our pedestals to feeling like defendants in a criminal investigation. What occurred was “control.” The era was notable for its conversations and arguments about accountability and pay for performance. The product is still with us with intensive measurement, attempts at gaming, and the associated increases in waste and cost increases. Don implies that we go where we have data which is not necessarily where we have need.
Don imagined Era 3 by asking what lay beyond the conflict between Era1 and Era 2. He wondered what would be “the foundational charter” for working better together? He imagined that it would include a “respectful account of the important parts of professionalism, for sure.” He went on to say that Era 3 takes “a respectful account of the important parts of transparency, proper payment, and econometrics, but it does not stop there.” It moves forward to a vision of a much better system that he implies arises out of the combination of the two previous eras tempered by what we have learned is important, but has been largely ignored, which is the importance of how we view our relationship with the patient.
He called the list of nine principles a “first draft’ that was an attempt to describe a change in “mindset” and priorities that would lead to a much better system that would converge on the interests of patients, families, and communities. Era 1 thinking would support measurement that promoted learning. The measurements of Era 2 were about “accountability, incentive, reward and punishment and its just ballooned” with an “insane amount of metrics that impedes work.” His conclusion: let’s put measurement on a diet and use it for learning and improvement and not as a tool in combat or compensation. He went on to say that the other eight principles also reflected his thinking about how to move away from conflict. Era 3 is a course correction.
Zeev then asked about “the reason, the problem we are trying to solve.” Don responded that we were here to relieve suffering and to try to prevent it. He went on to say that our purpose was all about patients, families and communities. He then said that the best “framing” of what we are trying to get done came from John Whittington and Tom Nolan. He credited the Triple Aim to them even though his name is on the paper and most people I know associate it with him, and probably do not even know the other two to whom Don gives the credit.
Don calls Tom Nolan “my main mentor” and identifies him as a protege of Joe Juran. Juran, along with W. Edwards Deming, are considered the pioneers of improvement science. The Triple Aim is the best answer to “what are we about”: better care for individuals, better health which you can’t get through healthcare alone but requires addressing population issues and the social and behavioral determinants of health, and lower costs. Costs need to be controlled because cost “confiscates resources.” “It [healthcare] is such an important and charismatic endeavour that when it wants money, it gets money.” That money “comes from somewhere... other government investments like housing or transport, or education and criminal justice…” He then reminds us that a third of what we are spending on healthcare is waste.
Better care, better health, lower cost is the set of goals that improves the system. The method that he recommends to pursue these goals is change through improvement science. Era 2 choses accountability and incentives. Era 1 choses “professional heroism.” Don’s view is that neither heroism or accountability hold the “keys to the Triple Aim.” The Triple Aim is a “shared enterprise of redesign.” The way to stay on track is to be constantly aware of what the goals are: better care, better health, lower costs.
Zeev then asks, “How do we put metrics on a diet, and what should we be talking about more..how do we course correct?” Don responds that the answers to his questions are “leadership dependent.” If we are going to get better, “You kinda have to know how you are doing.” Reflection, if not quantitative measurement, is part of any sensible approach to improvement. Don implies with a “cart before the horse” analogy that we have focused on measurement and have forgotten improvement. The key is to establish a leadership commitment to approach the improvement of complex systems scientifically. The solution requires “clarity of aim,” a “whole new way to engage the workforce in spirit and intent, through joy and growth, and development and respect for their motivations.” After you understand how things get better you then “hire measurement, it’s your servant.” He points out that in Era 2 we put the measures in the forefront and then “everybody sits around talking about how do we measure, and do we have the reports?… it’s very wasteful.”
In a long back and forth with Zeev about the history of systems science, purpose, and the importance of their alignment with the task of improvement, Don reminds us that Deming said that if leaders want to make things change there are four areas or disciplines they must master. First, you must master the nature and dynamics of systems. Second, you must understand variation through an understanding of statistics. Third, you must understand psychology as it explains individual motivation and group process, human perception, and adult learning. Fourth, you must master the plan, do, study, act cycle, PDSA that is built on how to continually learn in a complex system. When we use the PDSA cycle we learn like a child learns through efforts of continuous trials and failures leading to mastery, in essence it is an exercise in epistemology.
Don endorses Deming’s assertion that these are the areas leaders must master. Leaders who don’t have these skills will get themselves into trouble. They will not understand systems and “get themselves confused.” They will misinterpret variation and motivation, and they will not support testing. Don says that after observing leaders for forty years that he believes Deming is right. He continued by saying that as he goes to corporate retreats and visits with leaders in their institutions, he doubts that many of them have this set of prerequisite skills. They are looking for silver bullets, quick solutions. He implies that they misuse Lean and Six Sigma by failing to recognize the need for their own mastery and transformation. As he said this the image of Yoda counseling Luke Skywalker flashed through my minds eye, and I had the thought that we needed more Jedi knights leading rebel forces with a commitment to the Triple Aim. Depending on a superficial understanding of healthcare’s complexities, and being satisfied with the status quo is like the Death Star of the Dark Side. In Era 3 leaders “get back to school” in complexity, variation, psychology, and the science of continuous improvement to enable them to lead toward improved care in a systematic and sustainable way.
Zeev then asked Don what he would tell Leaders and boards as a “call to action.” Don was consistent and said that they must employ the basics principles of scientific improvement. They must have a “clarity of aim,” a “constancy of purpose for improvement.” He asks, “What are they there for?” He suggests that they “pick the stuff that they really want to make better.” He implies that asking those critical questions is their job, and asking will point them in the right direction.
Zeev asked about a “call to action”. Don framed his answer for a call to action as a question to ask leaders. It was something like, “What are you going to do for the people you serve to pursue the Triple Aim?” He says when you answer that question there are only two parts to the quality journey, “aim and method.” Once the Triple Aim is your goal, then method matters. He said that he had two pieces of advice on method. First, is really, really listen to the patients. Get the voice of the people you serve into the room all the time, at every level. Secondly, embrace interdependency. Heroes never were the solution. The solutions are found in dialog. Get everybody into the room. You can’t get a great system by focusing in an isolated way on its parts. The parts must fit together efficiently. I had the sense that he was saying that silos do not work. The metrics can’t be “just about parts.”
Zeev then asked about patient reported outcome metrics. That question from Zeev initiated a conversation about asking patients, “What matters to you?” rather than “What is the matter with you?” The PREMS and PROMS metrics are important to Don. PREMS are patient reported experience metrics, and PROMS are patient reported outcomes measures. Don said that if he were leading an organization now, he would get everyone into the “What matters to you?” mode. He would “make that a never ending inquiry.” This is what he cares about. “What matters to you?” is “the superordinate metric.” The other metrics should be chosen to measure progress toward what matters to patients.
Late in the interview Zeev asked for specific examples that illustrated Era 3 thinking. Don responded with several stories that moved the conversation from the theoretical to proven practicality. At one point he commented, “The new era is not an imaginary place. It does exist. It just doesn’t exist everywhere.”
The last part of the conversation was about how to tackle the huge problem of the second leg of the Triple Aim, better health for the community. Hospitals and medical practices rarely define it as their concern, although Don was able to give examples of institutions that did recognize that it was. I believe that our failure to take on the job of making a difference in the realm of the social determinants of health and disease may be the primary reason that we are so far from the Triple Aim. Throughout the conversation Don and Zeev acknowledge that the care offered in hospitals is a minor contributor in the overall endeavor to improve health. Despite the fact that traditional care does not do much to improve the health of the community, it does consume the bulk of our resources. The health of the community seems to be like a child without a parent. No one owns the problem, and the resources to make a difference are slim. Era 3 acknowledges these realities. The question is whether describing the problem will lead to a more effective methodology. Don recognizes that doctors and hospitals can’t do it alone, but he challenges us to take a leadership role in organizing the efforts. The IHI has organized a “Leadership Alliance” to begin to make a difference. Don gives kudos to Cincinnati Children’s Hospital, Bellin Health in Wisconsin, and Kaiser.
Zeev closed the interview by asking if, from Don’s perspective, there was anything left unsaid. Don said he was optimistic about the future. His takeaway is that there really are ways we can get better, but we must do it together using scientific methods that help us deal with complexity and systems. He said, “If you are feeling lost, maybe you are trying the wrong way.” He then said that he “personally had to take cognizance of the political environment.” My ears perked up. I will give you exactly what Don said:
I can not imagine an American society that is healing without a commitment to care of the vulnerable, protection of the disadvantaged, the pursuit of social justice and equity, the repair of our criminal justice system, a whole bunch of what I regard as progressive policies which are currently under a very dark cloud given the national ethos and our national leadership today. It’s not OK. I just can’t help making a plea to the professionals who are listening to you in this podcast to be active in restoring a sense of social justice as a primary foundation for our nation. And if the politicians currently in charge won’t do it, and they won’t, then I think professionals have a duty, just as they do to the improvement of the system. They have a duty to the improvement of the moral foundations of the nation, and that for me is a part of Era 3, as well. So, excuse the political excursion here, but it is a time to speak up because what is going on is not OK.
Up Close With Thunder or Lightning?
As I have mentioned several times before, one of my favorite routes for my daily walk is up and over Burpee Hill Road. Many of the pictures that I have used as headers for these letters are scenes from along the five mile route that I follow. It’s a simple out and back walk with the turnaround at Herrick Cove on Lake Sunapee.
There is a large permanent pier on Herrick Cove that is just a few feet off New Hampshire 103A, the road that runs south along the eastern shore of the lake toward Newbury at the other end. At the dock there is a roadside historical marker that tells a story. In the late nineteenth and early twentieth centuries vacationers coming from New York and other cities would ride the train to Newbury. In Newbury the tourists would transfer to big lake boats that would deliver them to hotels and large estates at various locations around the lake. Two of the old boats still operate out of Sunapee Harbor in the summer to give vacationers a trip around the lake, and an opportunity for romantic moonlight dining. In the old days visitors coming to the New London Inn and Twin Lake Villas on Little Lake Sunapee would take a three mile buggy ride from the pier to their final destination.
I think that the reason the mostly unpaved road that I walk as the last mile toward Herrick Cove and the first mile back from Herrick Cove has such a pompous name, Columbus Avenue, may be a carry over from those days because it is the most direct route into town from the pier. It took me a while to figure out why an unpaved road though the woods had such an auspicious name. Boston has its Columbus Avenue, and New York has its Columbus Avenue. In my old hometown, Waco, Texas, some of the finest old homes were on Columbus Avenue, as was my high school. In New London there is not much to see on Columbus Avenue but Thunder and Lightning.
Columbus Avenue either begins or ends, depending on which direction you are headed, at an old farmhouse and barn complex at the corner of Burpee Road and Columbus Avenue. I walk up and over Burpee and then take a sharp right on Columbus at exactly one and a half miles and then proceed down Columbus to Herrick Cove where I turn around and go back the way I came. Behind and around the old farmhouse, its barn, and other outbuildings, is a rolling, rocky pasture of several acres bordered on the far side by thick woods with a little brook running down the middle of the pasture and into the woods. That pasture is the home of Thunder and Lightning.
I have been told that Thunder and Lightning are brothers. I have only seen them together a few times. Perhaps when I go by, one of them is in the barn or on the other side of the farmhouse out of my view. Perhaps one of them is visiting elsewhere. I worry a bit, but I rarely see anyone out to question, although what I know I did glean from one chance conversation with a woman of years similar to mine who was out in the pasture near the fence one day last summer. Near the road, that woman or some other caretaker, has dumped several bales of hay. The folks who plow the road have carefully cut out the snow bank in front of the pile of hay so that I, and I presume others, can easily stop and confer with whomever has the pasture duty, be it Thunder or Lightning.
You will have to take my word for it because today’s header shows only Thunder or Lightning when he was standing away from the hay. I was able to get closer because of the hay and the “carve out” on the road for a chat, pat and “selfie” with my friend, be he Thunder or Lightning. He is friendly and loves for someone to rub his nose or scratch behind his ears. Let me warn you though, in case you stop by to visit him, he is quick. His main interest is in getting his nose into you coat pocket. Mine was empty. I assume other visitors bring apples and sugar cubes.
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| | A good long walk with friends, or to meet friends, is a really good way to get over any residual catecholamine surges that maybe disturbing your sleep if your team won the Super Bowl. It might also be a good chance to listen to Zeev and Don. If like me, you have been in a state of disbelief or grief since last Sunday night, taking a walk while you share your grief with an understanding friend like Thunder or Lightning can bring great comfort. Thunder or Lightning always knew that it was just a game.
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| Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
Dr. Gene Lindsey
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| | The Healthcare Musings Archive
Previous editions of the "Healthcare Musings" newsletter, by Dr. Gene Lindsey are now archived and available to you at:
www.getresponse.com/archive/strategy_healthcare
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