Why is transformation so difficult?

Transformation in healthcare needs to occur within a complex dynamic system (i.e. a chaotic mess). Clear communication, shared goals and problem solving are especially challenging in healthcare environments. There are multiple and sometimes conflicting missions. The socialization of healthcare professionals is fragmented and often exists outside the organization and pre-employment. Our organizational structures further strengthen these silos. There are incredibly strong external pressures, constraints and influences from multiple stakeholders (payers, consumers, government agencies, etc.). The core tasks in healthcare often occur locally in complex, dynamic, and ambiguous situations and settings. Patient-driven variability is often a necessity and yet there is a good amount of unnecessary variability. Healthcare is pluralistic. It’s a conglomerate of missions, values, stakeholders, professionals, regulations, processes and practices.

Here are some transformational changes we’ve all been considering with my assessments of where we are:

Team-based care –We’ve been talking about it so much it’s become a cliché, yet we’re not so good at it.  If we actually did it, it would be transformational.

Deeper and expanded competencies – Lot’s of problems get in the way of this, and we’re dreadful at solving problems in healthcare.  This tactic is necessary for reducing costs.  All stakeholders (internal and external) need to get on board.

Explicit goal setting incentivized using internal and external motivators – we think we’re good at this, and we’ve gotten better, but we’ve not transformed how we do this. Why? Because we think we can set goals at the highest level and have them make sense at the local level. Hello? McFly? It doesn’t work.

Local change with targeted centralized support – uh… what we ask for too often is local support for centralized change. Is that you again McFly?

Feedback and redesign with front-line workers and patients at the center of the work. – Who has time for that?  We can do this, but only if we integrate it into our daily workflows and practice.

Use systems, process and team-based thinking. – ugh.  Clinical pathways help change the paradigm and demonstrate the benefit of doing this, but one problem is that professionals don’t know how to do this kind of work without a lot of coaching.

Agile engaging high-performance management systems – Does anyone in healthcare even know what this means?

One last thought…Many of us have been on a journey to point out what we consider to be a cancer in healthcare - variability.  Could variability be the malady of all maladies for healthcare?  Yet variability is often necessary as is cell growth and tissue regeneration; variability at the right time applied to the right patient is the right thing to do.  Also, attacking variability with blunt tools has negative consequences, much like using radiation and cytotoxic chemotherapy to fight cancer.   A better way to frame variability: there is good variability, acceptable variability and bad variability (normal, benign and malignant). We need to address the malignant variabilities with targeted and intelligent tools.

Transformation: asking the right questions

Transformation starts with asking the right questions. My favorite first question is, “what problem are we trying to solve?” Followed by “why?” If you’re in the service industry and the problem you’re trying to solve is a financial one, that’s not transformational, it’s operational. If the problem isn’t about those you’re serving, then it’s the wrong problem. Loss of focus on true north goals often sends problem solvers down the wrong path; be sure staff define the right problem and stick to it.  And don’t let operational problems get in the way of solving the real big ones.

Common customer oriented problems are cost, convenience and experience. When considering these, it’s important to not forget the most important problem, “Why they’re coming to you or want to come to you in the first place.” – forget that fundamental, and you’ll go out of business.  Perhaps one question for transformation could be, “How can we solve patients’ problems quicker, cheaper and where they are?”

Transformation also starts with realizing what we shouldn’t tolerate, and generating paradigm shifts.  The  patient safety movement is an example of transformation. It started 20 years ago with Dr. Leape using data, and asking the right question, “why are we tolerating this?” We look back now and we can’t believe the things we tolerated. Another example is the patient- and family-centered care approach to delivering care, and designing that delivery. This movement brought about a paradigm shift in how people think about healthcare.

Perhaps another question to ask, “Is what we’re doing and how we’re doing it the best way when you consider the value it brings to the consumer assuming they have to pay every cent of the cost plus a margin?” People are willing to pay a lot to get their cancer cured. They aren’t willing to pay a lot to get a sore throat looked at and cared for.  To think about this try the “miss work” or “miss school” test (e.g. if a family that values their child’s education is willing to take their child out of class to go to the doctor, that service is of value. If it’s not then they will either not go, or they’ll go somewhere after school that is quick and convenient– i.e. CVS minute clinic).

We think patients and families value all healthcare equally, but their behavior suggests they don’t.  We need to provide value starting with thinking a little differently about what value means to those we serve: “if the patient had to pay every cent of the cost of their healthcare, how would we do it differently?”

In some cases we may need to be explicit about the value.  For example if a family takes their child to the doctor primarily to get vaccines, what would happen if they were to become solely responsible for the cost?   They would start going to CVS to get them.  Just walk in, get the shot and leave whenever at a cheap cost, no doctor involved (and by the way stop at the do-it-yourself height and weight station on your way out). Yet, there is value in going to and paying for the doctor visit that may not be entirely understood.

What kind of hours should we ask our professionals to work?

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 2nd 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 5th 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.

The art of dialogue: an indispensable leadership skill

I became a physician “leader” frankly because staff asked me to change things or they would quit.   It started 17 years ago.  I was an informal “leader”, becoming increasingly formal over the next 5 years.  It was a rough road for many reasons, but my lack of skills, knowledge, awareness, maturity, preparedness, good mentoring, and sleep were at the top of the list.

Because I was so bad, I was given the gift of a professional coach, which was helpful with guiding my self-learning and reflecting. Thankfully, I was able to improve on some of my deficiencies; the one that I had to work on the most, both because of my ineptitude and the importance of it, was having discussions and dialogues with people.

I’m still learning and practicing dialogue. I wish it were easier, but its not. The biggest problem is that it takes time, which we don’t have a lot of. The second biggest problem is that we’re human, and have learned some unfortunate human habits. The biggest of these habits is a tendency to be defensive, to take things personally and to hold onto ideas and memories with too much dogma, blinding ideology, and just plain old-fashioned emotion. This internal milieu interferes with listening, learning, and most importantly thinking. We’ve all seen how egos and lack of humility (hubris) can derail good conversations, but that’s only part of the story. The other big problem we humans have is judging (criticus).   We judge, judge, judge.  Dialogue can be derailed by hubris and criticus. Being aware of these barriers is the first step, doing our best to abate them, without beating each other up about them, is the second.

Suppressing our hubris and criticus is important when having a dialogue, but without respect, appreciation, a desire to learn, and time, it still won’t happen. Stepping outside ourselves, our attachments and our preoccupations isn’t easy, but necessary.  Try asking yourself: do I really know everything that needs to be known? Is my view truly the only possible viewpoint that has merit? Have I thought of all the possibilities? Am I showing how much I care about the people in the room? What else might we face in the future that makes how we accomplish this conversation as important as what the conversation is about?

William Isaacs in his famous 1999 book Dialogue and the Art of Thinking Together describes 4 steps we can take when participating in dialogue: Listening, Respecting, Suspending and Voicing. Out of these 4, suspending is often the hardest (aside from leaving voicing until the end). Edgar Schein has talked about “accessing your ignorance” as a means to start the suspending process. To access one’s ignorance, one must pause, embrace humility and suspend judgment. This practice naturally leads to the advice that one ought to ask questions first, then voice their opinion second; seek to understand before being understood.  Questions are most effective when coming from a place of ignorance.

Dialogue is about reducing our collective ignorance.  It doesn’t make it completely go away, but we’re better prepared to face our challenges nonetheless, and face them together.

A Loop for Getting Somewhere

We’re faced with what seems to be impossible challenges: doing more, doing better, and doing it all with less, while at the same time promoting professional joy, facilitating engagement, and ensuring legal and regulatory compliance. On top of that, the expectations of the families and communities we serve too often goes beyond what we can meet.   And dare I say, the expectations of our front-line colleagues has followed suit in some cases.

There’s a team leadership loop I’ve observed when teams are at their best.  I call it the MLSA loop: mindfulness, learning, sensemaking, and action.   The learning and action steps are the easiest for people to understand (but often the hardest for teams to do). Whereas mindfulness and sensemaking are hardest to understand, but the best teams seem to do it naturally.

Sensemaking is facilitated when there is sufficient wisdom present, which comes from practical knowledge of theory and best practice, and accumulation of thoughtfully and honestly reflected experiences.   Sensemaking can be recognized when its there, but its hard to insert when its missing. It can be nurtured when leaders support training, professional development, provide time for open reflection, and have a plan for recognizing, and retaining senior people.

Mindfulness is facilitated when high-reliability attributes are present along with humility and acceptance. Humility is necessary to create the right environment of openness and collective presence. Acceptance is necessary in order to eliminate the negative emotions that can derail a team.  Acceptance also helps drive the needed amount of focus a team needs to stay on the correct rail.

Collective presence refers to the combinations of team alertness and calmness, and  team diversity and respect, which allow for optimal flow of information and ideas.

Applying this loop to the broader context of today’s healthcare environment could aid leaders as they struggle with the seemingly impossible challenges they face. There is hope and solace for the beleaguered leader in this model of how effective teams face complex, high-risk, and high-emotion situations.

Achieving mindfulness before we begin to learn ensures we are open, thoughtful, and broad minded. Learning before we make sense of things, ensures that we frame things in a helpful, focused and positive way, which will drive optimal and flexible action. More importantly perhaps, is that mindfulness enhances our ability to assert a positive and confident outlook, and meet the challenges with confidence, calm, and the positive outlook and impenetrable will others need from us to stay on track.

Be mindful my friend.

THE SUCCESSFUL LEADER’S GENOME EXPLORED

Over 10 years ago (and probably long before that) a paradigm of leadership different from the top-down approach started to surface: as highly educated and skilled people increasingly constitute the workforce , leaders must learn to lead leaders, not just followers.  As much as I’ve been a slow learner, it appears I’m not alone.  It wasn’t until this month’s Harvard Business Review that I discovered one root cause: most senior leaders, including board members, actually don’t appear to encourage, incentivize or even model the right kind of leadership needed today, and they don’t hire it.

Described in What Great CEOs Do Differently by the CEO Genome Project (HBR May/June 2017) are 4 behaviors of the most successful CEOs: 1) deciding with speed and conviction, 2) engaging for impact, 3) adapting proactively, and 4) delivering reliably.   In other words: set a course and believe in it, inspire and engage others, continuously learn, improve and renew, and deliver results consistently.

The article doesn’t really describe the genome, but rather gene expression.  They do mention in passing a few “genes” such as, “…while boards often gravitate to charismatic extroverts, introverts are more likely to exceed expectations…”

Mistakes boards make are because they focus on the downstream impact of gene expression.  Nearly all successful CEOs in this study had made rather significant mistakes in the past. Yet, boards and others who choose leaders shy away from anyone who’s made a large mistake.   High confidence improves the likelihood of a person being hired, but makes no difference in whether they’re successful or not (an example of focusing on the wrong gene expression).

There are a few more genes that others have pointed out that are supported by the CEO Genome project: 1) focusing on something bigger than themselves, and sacrificing themselves to that vision, 2) humility, and 3) …you guessed it… the ability to lead leaders, although this may not be the gene, just the expression.

The ability to inspire people who are leaders, especially those with a suboptimal leadership gene expression profile, eludes many of us.  Is it emotional intelligence?  No, a lot of good leaders have that.  I think it’s more fundamental than that.   I think its mindfulness or openness.  Mindfulness allows one to achieve a certain level of awareness, acceptance, humble inquiry, honest reflection, and caring with a sense of service.  It used to be called taking the higher road, calling it mindfulness begins to describe how to get there.

Total Leadership Revisited

Almost 10 years ago I heard an interview on NPR with Stewart Friedman regarding what was then a new book called Total Leadership. At the time I was nearing the end of a long recovery from burnout.  Total Leadership was one of the better books for helping me achieve better balance in my life, and for helping me envision a healthier professional life as a physician leader.

There are two major premises in his book: 1) by integrating your professional, personal, family and community realms, finding common ground and synergy, you can be a total “leader” and achieve better work-life balance, and 2) by being your self, your whole self, and respecting the whole of others, and embracing your creativity, you will find joy and fulfillment in what you do.

Perhaps the best active advice this book provided for me were those that involved reflection.   For example, acting with integrity (being whole) sounds easy, but when you reflect on key crucial moments you may discover that the values you hold dear when calm and collected, can sometimes take a back seat when the heat is on or when things don’t go well.  If you truly value respecting the diverse views of others then you’ll listen even when emotions are high. You don’t have to agree but you’re able to acknowledge and kindly consider their perspective, which by the way takes longer than a few seconds.   Another example is honesty and trustworthiness. Most of us value these, yet, we are often dogmatic about things, which when truly dissected, the facts of which aren’t quite as black and white. In other words we aren’t as dedicated to the truth as we are our attachments to our own biases, our own perspectives.

This last point, reflecting to get closer to the truth of things, is actually a key daily activity for beating burnout. Burnout spirals because our reality is adversely shifted by negative bias.  Be Real, Be Whole, Be Innovative and Be Reflective and you can reduce/prevent burnout.

Being innovative is more about experimenting with new ideas and new ways of doing things than it is about dreaming up the next big idea and thinking it will fix everything (remember be dedicated to the truth). True innovators are doers. Its action on an idea and learning from that action, which takes honest reflection that makes innovation truly energizing (and successful).  And energy is an antidote for burnout (and we all like succeeding).

One of the exercises described in this book is to write a vision of you as a Total Leader in 10 years.  It’s been almost 10 years and as I read what I wrote back then, I realize that I achieved the vision (mostly).  Thank you Stewart Friedman.

Stop, Drop and Roll if you’re burning

All this talk about burnout has me… well… burned out. Theories abound and prevalence data is flying about.  Are 54% of physicians burned out, or is it 25%? Is it because we’re worked too hard, or because the “new-trophy-for-everyone” generation is finally being hit with reality?

I can tell you from experience, burnout occurs when there are big things about your work you resent, and the rewards become overshadowed by these key persistent resentments. Working 24/7/365 isn’t the problem, its what you’re not doing because you’re working all the time that is. Its not what we’re doing, it’s what we aren’t that leads to burnout.

Duh? Well… it’s not that simple, and once again it comes back to resentment. Most of us resent what we can’t do because we work so hard, but not all resentments are the same; expectations are the second key contributing factor. If you expected to have a lot of purchasing power because of excellent compensation as a physician only to found out that you really don’t because you chose a lower paying specialty, then you may resent what you do. If you expected to be home by 6 pm most nights only to find out that to finish your charting and phone calls you have to stay until 8pm, you may resent what you do. Know your expectations and be aware of your resentments.

Burnout is best prevented, because fixing it can be hard. Both prevention and cure takes efforts on the part of the individual as well as the “system”. The microsystem (your team/clinic or pod), the mesosystem (the group practice, department or service line), and the macrosystem (hospital or network) all need to participate in the process. But without the individual taking ownership, efforts often fail.

The 4 horsemen of burnout from the HappyMD (https://www.thehappymd.com/blog/bid/290379/Physician-Burnout-The-Four-Horsemen-of-the-Physician-Burnout-Apocalypse) are around every corner and their momentum can be difficult to slow. The Workaholic, the Superhero, the Perfectionist, and the Lone Ranger are wicked creatures. All four have haunted me, possessed me and driven me into the ground (nearly literally). The system can’t exorcise them unless the individual desires it so.

But often the individual who carries the burden won’t let go of it unless others are there to take some of it away.  I survived by lowering my expectations (forget about getting home to see the kids before bed, forget about exercising or having friends, forget about doing those things that bring you joy to your work).  What I didn’t know was that constant stress kills.  My advice to anyone who is approaching burnout or is cooking at a broil: be true to yourself, your family and your patients and stop the 4 horsemen in their tracks, because once you’re toast, scraping off the burnt parts is painful, and what’s left isn’t all that appetizing.  If you’re on one of those horses or all of them, stop, drop and rock and roll on your own terms (and take your family and friends with you).

Driving organizational success in children’s healthcare

In 1998 Jeffrey Pfeffer published an article in California Management Review describing what he sees as the seven practices of a successful organization. Comparing these practices to your typical health care organization today portends a crisis (some say the crisis has arrived).   Here is the list (with sarcastic commentary included for comedic effect – because if we didn’t laugh…) :

Employment security – apparently the data suggests that when employees fear for their jobs, they under perform – who knew?

Selective Hiring – the larger the applicant pool the better your workforce…mmmm – pediatric professionals weren’t in abundance as of … yesterday. Choosing employees to your organizational culture and the unique needs of your teams… is currently a luxury.

Self-managed teams and decentralization as basic elements of organizational design – uh – I’m not sure Dr Pfeffer realizes this… but it’s hard to empower practices and units in health care to actually manage their own performance – it takes time, training, dedicated people and robust real time data management – not to mention team meetings and engagement of front-line staff in analysis, action plan formulation, testing ideas, and managing sustained change. It’s easier to just tell them what to do, even if it’s wrong.

High compensation contingent on organizational performance – define performance, define high.   Is it ok to do high compensation no matter what? That would be great, because then we wouldn’t have to change anything.

Extensive training – Doesn’t everyone come into the health care workforce already trained?  Can’t they train themselves?

Reduction of status differences – we might actually be improving on this one in health care, but I’m not sure it’s having the impact we had hoped for.  Instead of collaborating we created more silos. Professionals who do shift work can’t make it to meeting where having reduced status differences allow for free exchange of perspectives and ideas.  Physician burnout has increased, because more and more tends to be dumped on them in this new order of everyone is equal and no one should do menial work, except the person who is ultimately responsible (oh, right, that difference still exists).

Sharing of financial and performance information throughout the organization- we have been tying to get better at this, but it’s …well… complicated.

So, what is the secret sauce for changing our organizational practices?  Sarcasm aside, let me put on my sunshine hat (yes, I actually have one). Accountable care will create the forces needed to shift health care into the realm of organizational success.  Fee for brief units or services of care has created a system of volume rather than value with regulatory and tort systems that drive fear rather than rationale thinking.

Working in teams, driving local continuous improvement, and driving true waste out of our processes, using the data management and sharing necessary to do so, with the staff training and professional development required, which will attract people to health care where professional joy is a given, will get us to the seven practices, and will create a care system that patients and families find value in and the workforce is proud of.

Versatility and Balance

It helps to be focused on a few priority goals and values. It’s nice to be able to describe your mission, vision and strategy in a quick elevator speech.   For a leader to have a few outstanding character traits and to be clear for what they stand are good as well. Yet, to be successful these must be balanced with the study and grasp of diverse and complex hard and soft data and the possession of environmental, organizational, and emotional intelligence.

Balance is key.   Flexibility and versatility are essential in today’s leadership environment.   The capacity for renewal and reinvention are increasingly important as well. I’ve become convinced that one reason humility and will are level 5 leadership traits is because they are necessary for achieving balance and versatility. And they are needed if one is going to leverage renewal and reinvention to stay relevant.

Kaplan and Kaiser articulated this concept of versatile leadership in a 2003 MIT Sloan Management Review article. They framed it as forceful leadership balanced with enabling leadership, and strategic leadership balanced with operational leadership. Awareness of these types and their vices and virtues can help a leader in today’s world of rapid change, generational differences, and unprecedented ambiguity.

 

kaplan-and-kaiser

Confidence is important, yet better if it comes from knowing which style to lean on, rather than always leaning on the style the leader knows best. Courage is required to take the risks of switching back and forth. And, of course, leaders must work on developing their competence in all 4 styles. Humility assists the leader in recognizing the need to shift to a different style, and the need to work on developing skills in those less used styles. Will assists the leader in overcoming the inevitable bumps that come from shifting.

For executive leaders, it is often helpful to verbalize to direct reports and others from which leadership perspective you are operating in a given situation and why. Versatility is essential, yet it can have its downsides. One of those pifalls is creating confusion regarding the roles and expectations of others on the team. Are we being strategic or operational? Forceful or enabling? Am I to be using the same style?

Knowing where to start and where to shift can be challenging. Wisdom derived from experience and thoughtful reflection aids this. Wisdom complements humility and will, and may in fact be the difference between the nimble versatile leader and the awkward novice.

So, be focused and use sound bites, stand up for your values and principles, be visionary and relational, yet not too much. Be careful not to slight the detail work of change management, performance improvement, and plan execution, yet not at the expense of ignoring the changing environmental forces and keeping an eye on the big picture. Don’t forget the importance of opening up dialogue and listening to others, and when needed be a forceful leader, communicating with clarity, and reframing and renewing in inspiring ways.