In the 1990s, Jeff Pfeffer (Stanford Business School) suggested these 7 “practices” as common themes seen in successful organizations:

• Employment security
• Selective hiring of new personnel
• Self-managed teams and decentralization of decision making as the basic principle of organizational design
• Comparatively high compensation contingent on organizational performance
• Extensive training
• Reduced status distinctions and barriers, including dress, language, office arrangements, and wage differences across levels
• Extensive sharing of financial and performance information throughout the organization

The first sentence of the conclusion in his 1998 California Business Review article read, “Firms often attempt to implement organizational innovations, such as those described here, piecemeal.”  He went on to say, “Implementing practices in isolation may not have as much effect, however, and, under some circumstances, it could actually be counterproductive.”  He’s suggesting bundled approaches are better.  Sounds complex, and like a lot of work.  Yet, it makes sense: you can hire the right people, provide them with secure employment, pay them well with bonuses tied to organizational performance, be transparent with financial and performance information, and even provide extensive training, but it won’t work unless the work environment and culture fosters self-managed teams and reduces status distinctions.

Within each of these there is a mini-bundle as well.  The implication being, if you don’t execute on the details of these practices, you won’t get the desired effect.  For example here is the bundle for selective hiring of new personnel:

• Screen for attitude and fit, not for skills that can be readily trained
• Be clear about the most critical skills, behaviors, attitudes – be as specific as possible
• Use several rounds of interviews
• When possible involve senior people
• Continuously evaluate and improve the recruiting process

So, what is the bundle for self-managed teams and decentralization of decision making as the basic principle of organizational design?  First the structure must lend itself to teams.  In health care, this is often the case given the complex differences across populations of patients, diseases and care settings.  The challenge for larger organizations becomes maintaining that local control while ensuring sharing and implementation of best practices in order to reduce counterproductive variation.  Second, problem solving is encouraged at the local level from idea generating to ideas testing to hardwiring of the best solution(s).  Given the drive for standardization, this local team problem solving can be impeded if standardization is done just for the sake of standardizing.  Larger organizations achieve balance by driving accountability at the level of results, and less at the level of process.  Third, hierarchical control must be minimized and middle management, especially when not part of a team, reduced.  This is hard for many organizations, especially large ones.

Healthcare is at risk because of the significant control IT and finance now have over how teams function.  IT through its tight control of information systems, which are now integral to daily work, and finance by controlling costs and FTEs without local knowledge of the daily work, are forcing teams into boxes that don’t deliver the performance ultimately needed.  Giving too much control to parts of the organization that don’t have expertise in the core product or service of the organization drives short term and self-serving thinking and action.

Comments on  “Spreading at Scale: A Practical Leadership Model for Change” by Amy Compton-Phillips, M https://catalyst.nejm.org/doi/full/10.1056/CAT.19.1083

In a recent NEJM Catalyst blog Dr. Compton-Phillips described a mental model applied to addressing variation across a large network (PSJ).  The mental model was presented as being new, however, it can be found in many leadership and management publications over the last 50 years.  In fact many don’t need to go further than their own organization to find this model in action.   Vision, Trust, Data, Capacity and Alignment are not only intuitive, but proven and tested elements.  The blog does serve to remind us of these elements telling a story that eloquently illustrates them in action, yet two essential elements are implied but not spoken: resources and effective management.  Both are inferred in figure 4.

Hidden lesson #1 in this post is the requisite need for resources to drive change effectively.  Although resources aren’t directly addressed in the blog, the dependence on them is obvious in the change narrative.  The need for resources makes choosing the right thing on which to focus an important first step; resources are limited and must be used prudently.   Vision can drive prioritization, and it can also inspire people to action.  Inspiration is good fuel for change, especially when resource are limited, yet no amount of inspiration will overcome the error of not providing resources.  The process of prioritization also helps shape the “why” which is key to each of the 5 elements.  The more stakeholders involved in the prioritization the better, but the law of diminishing returns does exist here.

A lack of resources was a root cause of nearly every failed attempt at change I’ve witnessed.  There are multiple examples of why resources are important in the blog.  One example is how PSJ utilized the time of leaders and colleagues from high performing hospitals to assist low performing ones through the formation of work groups; work groups are a significant expense.  Another example is the use of cascading scorecards or dashboards; you can’t collect, use, manage, present, discuss, or analyze data without resources.  In 2007 I was the first to use a scorecard in my organization.  It took me hours to build it and maintain it.  Some of the fields were populated with estimations, or distant surrogate markers, or nothing at all.  It was all done by hand.  Although it served a purpose and did help to drive change, its effectiveness and efficiency was impacted by a lack of resources.

Hidden lesson #2 is that change management is, well, management.  Leadership is a necessary element at every step especially in the beginning.  Yet without local management of people and processes, change initiatives fail.  Existing managers, who already possess effective change management skills and tools, are essential.  One of those tools is an existing strong daily management system. The blog does mention the need for skills, tools and tactics specific to the change effort, and I agree.  Yet, these enablers need to align with the existing daily management system.   For example, if a team doesn’t take the time to frequently huddle around metrics, run by an effective leader and manger, using an already existing cadence embedded in an established management system, a change effort has a high likelihood of failing.  Furthermore, not deliberately leveraging that existing management system to drive engagement around the specific change effort would be unwise.   A daily management system enables alignment.

Alignment requires leadership and management and starts through establishing a shared vision, both of which are mentioned in the blog.   Established values and principles embedded in an existing common management system with built in quality improvement skills and tools assist alignment.  Constantly communicating the “why” and the “what’s in it for me” as mentioned in the blog builds alignment.  The disciplined cadence of a daily management system is a channel for this constant communication.

Because all change is local, and alignment is possible only when local groups stay connected to the larger whole in ways that are mutually beneficial, any change management approach needs to consider how to trust local teams with ample autonomy to solve local barriers to change.  Change is both individual and team based, and both are dependent on local elements of leadership, management, vision, trust, data, and capacity.  Empowering these local environments while driving a common vision through standard work is perhaps the most important deliverable of senior management in any change management initiative.  A strong daily management system allows this to happen with greater ease.

When I hired the first advanced practitioner in my management career, she worked 5 days a week in our sickle cell center. Most days she worked 9-10 hours; occasionally more than that and sometimes less than that. After about a year, things got busier and her hours per day increased to 10-11. She began to get burned out. It wasn’t just the additional hour, it was what she was giving up (time with family, time to get personal things done, sleep). In addition despite putting in the extra time, she didn’t feel as if she was getting everything done. She left after being with us only 2 years. She was good at what she did and losing her hurt us terribly.

When I hired our 2^nd advanced practitioner around the same time for our cancer center, she asked to work four 10-hour days. The operations director of the practices (a nurse by training – who had been in management for over 20 years) was against it. She told me that professionals ought to work 9-10 hours a day, 5 days a week, which is 45-50 hours, and to do that working 4 days a week, she’ll need to work 12-hour days, and she won’t do it, and the clinic is only open for 10 hours. The director said. “this is just a way to make the same amount of money working less, and she won’t be here everyday and someone else will need to do her duties that 5^th day, which usually doesn’t work.”  The advanced practitioner worked with me for over 10 years, only leaving when I left.  She averaged 11-12 hours a day, and there were days she didn’t leave until I did, which was after 9pm most nights. The operations director was wrong. There were adjustments we needed to make to the practitioners workflows (she spent the last few hours of the day documenting, calling families with labs, handling refills and writing orders for the next day).

There are several morals to this story:

• Yes, professionals need to work 45-50 hours a week, if they aren’t they are costing the system too much. Why should one professional be allowed a 40-hour week when the majority who are doing a good job work 10-20% more than that.
• If professionals work 50-60 hours a week, burnout is a risk. That extra 5-10 hours is golden, and its not the work that’s burning them out, its what they’re giving up that’s killing them. And if they feel like they aren’t keeping up despite working extra, then they will surely burnout.
• Working 4 days a week reduces burnout, but it doesn’t have to reduce productivity.
• 20 years in management doesn’t mean you always know what you’re doing. To be wise requires managing your biases, thinking outside the box, and being open to the ideas of others just as much as having knowledge and experience.

I haven’t entered a blog in over 4 months, primarily because I’ve been held hostage by a financial crisis.  We were successful in reversing the crisis, but not without some “damage”.  The biggest damage I’m learning has been staff morale.

In the last several months I’ve heard several front-line staff tell me that health care has become too much like a business with too much focus on RVUs and money.  Some have “attacked” me personally for being too focused on the business aspects.  Financial strength is critical for long-term success (i.e. staying in business), and action is necessary when it’s eroding.  And it’s not about the money, its about preserving the organization, the service it provides to the communities, and the people who provide the service.

This message was lost somewhere along the way.  I do admit that communication is hard and as hard as I tried to frame things in a balanced manner, the complete message didn’t always get across. The root of this seems to be the cascading of the message – the ability of middle and front-line managers to communicate the message as intended: “We need everyone to think about where and how we can be more productive and where and how we can be more efficient recognizing that not all areas will have the same focus or countermeasures,” becomes “We need to see more patients or we’re all going to lose our jobs!”  Hope is an important part of any message in a crisis and hope doesn’t appear to cascade.

Let’s make no mistake about it…health care is a business and it is the responsibility of management to keep it in business. Front-line people need to recognize that reality. However, management needs to face the reality that staff are emotionally attached to what they do, how they do it, and attached to their own personal finances whether they want to admit or not.   They are running a business at home, but don’t want to see their organization run like a business.

Celebrating early successes, thanking people, pointing out where we are excelling, and providing reminders that what we do is important to our patients and families…isn’t enough. Paying people the same amount and giving them a raise at the end of the year despite the huge challenges in making that happen isn’t appreciated nor is it enough. So, what is a leader to do?

Deming in his writings and speeches gave us a clue – the key processes and results of a business need to be constantly scrutinized for improvement and the improvement efforts need to include everyone.  So, when the crisis hits, everyone is already on the same page. These key processes and results rarely change – they are constant – regardless of any crisis.  Metrics of efficiency, which often include financial markers, are now included in the critical processes and results of healthcare.  If you’re in healthcare, expect to hear more and more about the importance of finances along side patient safety and the care experience.

Key financial metrics and other metrics of efficiency are results, outcomes, that if not constantly improved will put you out of “business”, out of “mission”.

Outcomes aren’t “managed”, processes and behaviors are.  Outcomes are consequences, which we analyze for the purpose of informing system design and driving behavior.  Thus, if management is to drive processes and behaviors, its stand to reason that knowledge about how they’re performing would be critical. Yet, we often don’t collect these data, and if we do, we struggle to understand what they’re telling us.

Furthermore, managers would be masters at systems design and improvement, and skilled at influencing behavior. Yet, managers are best at creating schedules, tracking budgets, coordinating resources, and analyzing outcomes.  And we’re great at getting performance evaluations done by the deadline (notice I didn’t say how great we are at performance evaluations).

So, do we have this all wrong? What are the barriers to getting it right?  Lack of time? If so, why do we lack time?  –  We all know the answer to that one: we spend so much time on the other stuff.

Senior managers often ask: “What are your results?” and “What are you doing to improve them?”  Therefore, that’s where we focus.  Instead they might want to ask: “What are your critical processes and vital behaviors?” and “What are you doing to improve them, and how are you doing with that?”

I’ve talked about care experience survey results before, which are sampled outcomes, lag by about a month, and are reported monthly, which further adds to the lagging.  In other words, they’re outcomes – and it’s behaviors and processes on which we ought to focus day-to-day.

To manage these two things, we first identify, define, measure and analyze them.  Then can we manage and improve them. And in doing this we perform cause analysis, solve problems (breakdown barriers) and execute change.   – And the big one: influence behavior.

I’ve found that getting people to see things differently, and think about things differently as well as creatively, is often an important step. Human biases are multiple and strong. In my opinion changing paradigms is critical for changing behavior.  When one is creative they are essentially building new paradigms.

Deming was correct when he made the psychology of people a pillar of quality improvement, along with systems thinking, knowledge processing (learning), and variation analysis.  Good managers know the psychology of people and use it to influence behaviors.

What it needs is great microsystems (units and practices).  What I’ve observed is that mesosystems are often workarounds. They are created when the macrosystem fails to or can’t support the development of microsystems (units and practices) in such a way that they are high functioning, effective learning, and capably connecting units.  Mesosytems take many shapes [separate business entities or divisions, service lines, discipline silos (e.g. nursing services and medical staff), middle managers, committees, work groups, etc.].  Special effort needs to be taken to not create too much waste when putting a mesosystem in place.

How the mesosystem is set up and structured is important. Many children’s hospitals within a hospital are set up as a mesosystem. It make sense, because the business of children’s hospitals is different from the business of adult health care units. However, the children’s hospital needs to be big enough to warrant the investment of its mesosytem.  Supporting functions that become mesosytems are also typically not lean and create significant waste.  The best example of this in health care organizations is the separation of nursing services and medical staff into large mesosystems.  It often creates waste.  This isn’t to say that creating connections among disciplines isn’t helpful, but it needs to be done in a way that limits waste and maximizes the functioning of the microsystem.

The question for every health care organization ought to be: what does it take to have high-functioning, effective learning, capably connecting units or microsystems?  At the microsystem level is where the output and performance of the organization matters the most.  The manager(s) and leader(s) of those units need to be effective at managing processes and leading people.   They need to be good at connecting with the leaders and managers of other units, and they need to be good at managing up to their bosses. They need ready access to and processes that effectively connect them to support systems (e.g. HR, Finance, IT, facilities, etc.). They also need to connect well with other units or microsystems where they share patients and critical interdependencies. And finally they need to be well connected to the macrosystem leadership. Achieving this isn’t easy, but creating a complex set of mesosystem workarounds isn’t the leanest approach.  So, it needs to be deployed carefully, and in some cases not deployed.

Good managers and leaders of microsystems are capable of driving continuous improvement and adaptation through team learning and robust quality improvement. Learning takes transparency, a just culture, and coordinated teamwork. Processes have to be mapped out, visible and constantly scrutinized through daily management.   Robust quality improvement processes and tools need to be in place with skills and knowledge of quality improvement integrated throughout the team. The ideal would be to embed these attributes into the microsystem, not leave them up to a mesosystem to do them.  Support services are just that.  They are there to help the microsystem and are embedded in the microsystem as much as possible.

In this month’s Harvard Business Review (November 2014) there’s an article by Robert Kaplan and Derek Haas entitled How Not to Cut Health Care Costs. The authors list 5 common mistakes that health care systems and teams make when trying to lower costs:

• Cutting back on support staff,
• Underinvesting in space and equipment,
• Focusing narrowly on procurement prices,
• Maximizing patient throughput,
• Failing to benchmark and standardize.

I can only imagine that some must have been scratching their head while reading this article.

Here is my summary:

#1 Cutting back on staff:   It turns out that support staff aren’t the expense problem and cutting them creates bottlenecks and more work for clinical staff who could instead be directly helping patients instead of doing clerical work, managing schedules, and solving operational problems.

#2 Underinvesting in space and equipment:   Space and equipment can drive up costs if not managed prudently, however, too often these items are cut to the point of creating bottlenecks and wasting more expensive resources (like doctors).

#3 Too much focus on small procurement prices:  It turns out that saving $0.10 on every 100 gauze may be a victory for the supply chain manager, but it does very little for the bottom line. It would be better to reduce the waste of relatively expensive supplies that are common in health care. This is especially true in procedure oriented areas.  And it turns out that the variability in use of these expensive supplies is considerable, suggesting room for improvement.

#4 Maximizing patient throughput:  This is my favorite.  The article asserts that pushing doctors to see more patients, or incentivizing them to see more patients (same thing), leads to increased health care costs , and not just because they will tend to do more than they really need to, but because they aren’t making long-term investments in their patients. An example is talking about advanced directives for people with terminal illnesses, or counseling patients with end stage renal disease who are likely to need dialysis.

#5 Failing to standardize:  Need I say anything further – not taking the time to standardize the processes of care and of doing business (operations) sets a system up for unnecessary variability, confusion, reworks, poor communication, etc.

There is an interesting paragraph towards the end of the article that states: “High health care costs are the result of mismatched capacity, fragmented delivery, suboptimal outcomes and inefficient use of highly skilled clinical and technical staff. The current practice of managing and cutting costs does nothing to address those problems.”

Articles that make you go ummmm…

People often come to meetings with emotions, be they good or bad.  Emotions are often created during meetings (be they good or bad).  Regardless of where the emotions come from, they can derail a meeting.  Or they can make it interesting – in a good way if controlled and managed or a bad way if unbridled).  Therefore part of running a good meeting is recognizing and managing emotions.

Abraham Maslow’s hierarchy of needs offers a frame  for categorizing the emotions that might show up in the meeting room.  The most labile of emotions will come from those who don’t feel safe or secure.  A leader can create safety by using simple “icebreakers”, being genuinely thankful people are there, and/or being clear about the agenda and the process.  Safety is helpful but not sufficient.

A meeting can still get rocky if there is feeling of failure or lack of empowerment (low esteem).  The leader at this point must emphasize recent successes no matter how small.  Remind the group of their purpose and vision.  Be positive and encouraging.  Individuals need to feel confident in their ability to contribute and succeed for a meeting to have optimal participation free of distracting emotions.  Once this need is met, then the leader is ready to address the next hierarchy of need, which is cooperation or sense of belonging.

It’s easy to assume that cooperation exists among a group.  The person facilitating the meeting  may not be aware that there are people in the room who are resentful of one another and/or have lost trust in one another.  If there is lack of cooperation, then time must be devoted to a conversation where differences are discussed, shared values and purpose are mined for and brought to the surface.

The leader may want to remind the group of the diverse strengths people bring to the room, emphasize how working together will bring the best results, and perhaps discuss shared interests.

Those who aren’t feeling part of the group will become disengaged and their negative emotions may impact the effectiveness of the meeting .  Sometimes the work done on gaining cooperation helps, but when it doesn’t, the leader might call on those who might feel on the fringe to provide their thoughts about something, tell a positive story about a recent accomplishment of that individual, or openly praise them for something well done.

Only once the group’s hierarchy of needs have been addressed is the meeting ready to accomplish its goal –  to create new ideas, a new approach, a new way of seeing something, or a new plan.

Once the creating and growing begins its natural for divergence.  The leader’s role is to drive convergence, which can be accomplished by addressing the 5^th emotional need in Maslow’s model: the need to be driven by core values and a purpose larger than oneself.  The perfect time to bring back the mission, vision, guiding principles, and shared values of the group.  This will drive them to come to a “final” solution or plan, to reach the goal of the meeting.

Having the results of a meeting wrapped around purpose and meaning gives it energy, which will carry it out of the meeting room and into action.