All posts by Nate Hagstrom

Chair of Pediatrics at Lehigh Valley Health Network and, Physician Executive for the Children's Hospital at Lehigh Valley Hospital
Quality & Safety

Tackling Task Saturation

Task saturation is the phenomenon whereby one’s brain becomes overloaded with significant information or stimuli and begins to fail itself. Task saturation often happens to a person when there is a crisis or when they are multitasking or when there is more to do in a given amount of time than is possible. Sounds like healthcare to me.

Pilots and nuclear reactor operators have developed methods and tools for overcoming task saturation. The most prominent are: 1) checklists, 2) mutual support, 3) crosschecks, and 4) huddles. Over the years, I’ve seen these things work in healthcare, but I’ve not seen them used as often as they could.  Crosschecks include double checks with colleagues, and making sure that all key indicators that will allow for effective sensemaking and situational awareness are being monitored.

Checklists exist in healthcare, but not often for crises or when the system is overwhelmed. Mutual support exists, but it’s often not there at times when it’s needed the most. Crosschecks are also used, such as in structured code situations, but they aren’t used enough. Huddles are increasingly being used, but often the time when they aren’t is when task saturation or a crisis is occurring. No one wants to take the time out to do it.

EMRs can be used to provide checklists, reminders and crosschecks. Working in teams and having huddles can provide mutual support. Having the collective discipline to stick to these principles when they are most needed is critical. Having “practiced” as a team with “learning” (debriefing) as part of the process is helpful.

The best medicine for task saturation, of course, is to avoid it from happening in the first place. Nevertheless, it happens enough in healthcare that it would be best to be prepared. How does one avoid task saturation? There have been examples where variability has been reduced despite the notion that variability in demand and volumes can’t be controlled in health care. Surge plans, flexible staffing, flexible roles, and early warning systems are all examples of preventing task saturation.

 

Leadership, Management

Managing Professional Performance Requires Leadership

Leading and managing are two different disciplines, which share some theories and practices with some important differences.

When it comes to processes, managers monitor for variance, look for reasons for variances and then attempt to correct those variances within the boundaries of the system within which they work. Leaders challenge current processes, redesign processes, and create new ones. Managers keep the status quo functioning as best it can. Leaders change the status quo. When it comes to people, managers perform essentially the same functions as above with some important modifications, which require leadership skills.

First, people require clear expectations followed by coaching and if need be training. They need to be told when they are doing something right so they keep doing it and when they are doing something not quite right so they can correct.  The first time they are told to adjust its done in a supportive manner where the manager assumes positive intent, meaning they assume there may be gaps in knowledge and/or inadequate skills that need to be filled, and most importantly they assume the person wants to excel in their performance.

The second time under performance is discussed the approach is still supportive but includes a more inquisitive or Socratic approach, meaning the manager probes with non-judgmental questions what barriers might exist to better performance. Two-way communication is established. The coaching becomes more specific to the individual getting at those root causes for the under performance that are unique to that individual and situation.

The third time is when formal action plans are required.  Good managers are good at anything that’s formal, so they excel at the beginning (although handing someone a job description doesn’t count) and at the end of the process. Good managers, who are also good leaders, are also good at the coaching part. Coaching implies that the manager’s number one goal is to help the person perform better and have more pride in their work. Good coaches are servant-leaders.

Second, people respond best when there is respect, trust and collegiality in the workplace, in other words the stronger the culture the more likely people are to perform well. Managers need to nurture strong cultures. This takes leadership.  Culture aren’t necessarily managed, they are nurtured, renewed, developed, given identity, and modeled.  In other words, cultures are led, not managed.

There are some coaching leadership principles that are worth mentioning. First, feedback whether it be positive or negative, needs to be as immediate as possible. This isn’t because it sticks better, although it might, and it isn’t because details are needed to provide good feedback, although that might help, it’s because the sooner the person knows the quicker they can start to correct before it becomes habit or before so much damage is done that they can’t recover.  Second, coaching needs to include explanations, encouragement and empowerment. Third, among professionals (e.g. physicians) coaching is more an act of persuasion and influence. Its about being non-judgmental, and establishing mutual respect and purpose before having the conversation.  It’s about humility and dedication to the truth, and its about playing the role of servant leader.

 

 

Leadership

The One Thing

I was recently asked what was the most important thing I’ve done to bring positive change to the Children’s Hospital where I’m a leader. I was surprised by the question because we’re early in the journey, what we’ve accomplished so far certainly isn’t just my doing, and it isn’t just from one thing.   I replied, “Relentless alignment, disciplined improvement, and empowering accountability.”  But I quickly realized it didn’t answer the question: “What’s the One Thing?”

Is it Relentless Alignment?  This does take the most effort and time. Alignment is important and one must be relentless in pursuing it. I started with the creation of a vision and plan, followed by formulating specific metrics and milestones.  And then came the constant consistent communication, which included clarity around priorities and transparency regarding results.  Alignment is about inspiring a shared vision and creating a renewed culture of excellence.

Is it Disciplined Improvement?  Constancy of purpose around continuously improving quality is important, but without discipline, it doesn’t happen. Consistent use of standard methods at all levels, and especially by the senior leaders, coupled with a culture of open communication, experimentation, and learning are required. It’s about the 20-mile march. We are using Lean and the science of quality improvement to provide the needed discipline.  We manage our projects using a disciplined approach.  And we prioritize our projects using decision support tools when possible.  Lean and CQI work well when used consistently with an unwavering discipline.  Standard work is a powerful tool.  Quality improvement is about optimizing outcomes while minimizing waste engaging everyone in the process using standard work to do so.

Is it Empowering Accountability?  I call this Management by Leadership.  When things don’t happen as expected or performance is less than desired, its often a systems issue, a communication problem, a structural misalignment, a talent and/or resource issue. And often one of the root causes is a lack of staff engagement. Front-line management often isn’t equipped or empowered to address these higher level issues. We’ve been emphasizing leadership more than management and systems more then individuals when it comes to what needs to work better.  I will admit, however, that I’m a management fanatic underneath.  I have checklists for everything.  However, I consider myself a management disciple of W. Edwards Deming.  I follow his theory of profound knowledge:  appreciation of systems, theory of knowledge, the psychology of change, and understanding of variation.

In health care, superb leadership is a must-have.  Yes, management excellence is also needed, but its best when born from excellent leadership.  The Leadership Challenge articulated by Kouzes and Posner has been a useful frame for me.  Leaders 1) inspire a shared vision, 2) model the way, 3) challenge the process, 4) enable others to act, and 5) encourage the heart. I see these 5 things as enabling a leader to achieve relentless alignment, disciplined improvement, and empowering accountability.

So, to answer the question “what is the most important thing?” I would have to say leadership is the most important thing that has made a difference at our children’s hospital.

 

 

 

 

Leadership

Why servant and transformational leadership are rare

As a novice leader I learned through reading  followed by experimenting with what I was learning.  I’m forever in debt to my team at the time for indulging me.  Without the opportunity to experiment and practice, I wouldn’t have developed into a leader.  My organization also provided me with a professional coach, which was essential for learning from the results of my experiments and reflecting on my practice.

With knowledge and experience I entered larger circles where it appeared that most weren’t reading the same books.  There were a few who were, and thank goodness for them.  As a physician leader I was following a different set of principles and driven by a different set of values than most.  It wasn’t an easy path.  My resolve, however, grew stronger, because every time I doubted myself, that original team cheered me on.  They knew long before I did, that I was a servant leader.

My continued hunger for knowledge eventually brought me to learn about servant leadership. When I first read about it, it seemed so obvious.   And it helped me realize who I was as a leader and why I found it so hard to be a good one. It would have been easier to only worry about my own success and always be looking to boost my own ego. I was doing servant leadership and it was hard.

Years later in the optional reading list of one of my classes at Harvard was an article entitled: “The Power of Servant Leadership to Transform Health Care Organizations for the 21st Century Economy.” It was written by Richard Schwartz and Thomas Tumblin and published in 2002 (10 years earlier!).  I fell of my chair when I realized Dr. Schwartz was a surgeon, and the article was published in the Archives of Surgery (no disrespect to my surgical colleagues, but renewed respect).

As I read it I couldn’t help as a student of leadership to think that the concepts being professed in this article were revolutionary and exactly what we needed in healthcare (they were hypothesizing the same). I thought to myself, “So, why hasn’t the concept caught on?” Well… because it’s hard.  duh.

Applying the concepts of servant, situational and transformational leadership to drive a learning organization is brilliant, but it’s hard. One would think it might be easier in health care than other industries. Not so.   Why?

First, how we choose our leaders, especially our physician leaders, is not aligned with these styles of leadership.   Why is that?  Two reasons: 1) these attributes and skills are rare, and 2) the things we look for in our physician leaders are counter to them.

Second, how we train our leaders does very little to foster the attributes of these three styles. Why? Two reasons: 1) those doing the training, the mentoring and setting the example don’t often have them, and 2) it takes a tremendous amount of self-reflection and self-awareness to be a servant leader.  It happens through self-driven training and transformation, and too many of us aren’t reflecting and aren’t aware enough.  One’s emotional intelligence must be high.

And finally, those who become physicians, those who are most driven to succeed and therefore be put in the leader spotlight got there because of a relentless focus on their own achievement, not on the achievement of teams and others.

Time to change the paradigm.

 

Patient & Family Satisfaction

How to improve your patient satisfaction scores

Want to improve your scores?  First, be reluctant to over simplify.   A patient encounter with a health care system is complex. One day I followed a family from start to finish in a pediatric hematology-oncology clinic. I was looking for ways to improve the care experience. During my care experience tracer we encountered over 12 different people. And that doesn’t include any pre-visit interactions.

From start to finish took over 90 minutes starting with the parking attendant, then the greeter at the front entrance, and then the staff member in the elevator who smiled and said “Hi”.   The clinic visit included the usual suspects: receptionist, medical assistant, nurse practitioner and physician. The clinic visit ended with an MA and a nurse drawing blood followed by a stop at the receptionist desk to make a follow-up appointment. The total experience ended with the valet parking attendant (different than the first guy).

For an encounter to be considered exceptional by a family every person needs to smile, be kind, attend to their needs in a timely and effective manner, and look like they love what they are doing and are especially pleased to be helping that particular family. Those last two points are often overlooked. They are perhaps the secret ingredients.

Burned out, overwhelmed, unhappy, unsupported, and under appreciated staff don’t take pride in their work or the work of the organization.  These staff are a barrier to good satisfaction scores. They fall into three buckets: 1) those who won’t change, 2) those who aren’t engaged and have lost interest, but can be salvaged, and 3) those who don’t understand what is expected of them or how to deliver what’s expected.

The people in the first bucket need to be let go. They are usually a small number. Some will leave without being fired, because they just don’t fit into the culture.  Others just need to be told to look for another job.

The people in the second bucket can be salvaged, but it’s not easy. Prevention is always the best medicine when it comes to eliminating burnout and poor engagement. Nevertheless, engagement rescue is often necessary, and it can be done.  It starts with respecting where they are coming from, involving them in two-way dialogue, and giving them a shared vision (aka hope).

The people in the third bucket need supportive, positive and empowering training and managing. It doesn’t take a lot to increase their engagement, increase their understanding, and help them use those vital behaviors.  There are multiple good tools and best practices out there.  Its a matter of choosing those that are a good fit for the current situation and culture.

There is a fourth category of staff who affect negative scores that are worth mentioning as well. Those who do well most days, but when the going gets tough, they falter. Those in this fourth category like all of us need gentle reminders, but it’s often the system that needs help.  Inadequate facilities, incorrect staffing models, mixed priorities, and lack of process management often create environments that make it very difficult for staff to deliver a great experience reliably every patient every time.  Its the responsibility of management to enable and empower.  Its the job of the staff to execute reliably and effectively.

 

 

Population & Public Health

Getting to the Moon was Easy

In Health Affairs (December 2014) were multiple articles on children’s health, including The Changing Nature of Children’s Health Development: New Challenges Require New Policy Solutions.  The authors, Neal Halfon et al., suggest that the current health care system is poorly designed to ensure optimal lasting health of children into their adult years.   Using the science of life-course health development to support their view, they assert that factors present in early during childhood impact health throughout life more so than we appreciate, and that our current approach to health in the U.S. doesn’t address these early influences.

This new science provides an explanatory framework for understanding how poor health and social adversity during childhood can affect lifelong health. Early interventions, especially in early childhood, have been shown to lessen the impact of these social and environmental influences. The authors contend: “Studying life-course health development has left little doubt that a nurturing and materially sufficient early life is an essential component of a healthy society.”

The authors call for a national action plan, with involvement of public, private, philanthropic, and faith-based sectors, where local and regional partnerships would link child health care providers, city and county governments, payers, employers, and schools. They suggest that most health creating interventions need to have its roots at the local and regional level. They propose the child health care community drive the creation of community accountable health development systems designed as integrated networks of medical homes, early childhood programs, school health centers, children’s hospitals, and other community health services.

What the article doesn’t do is reveal the secret to achieving this vision. Those communities that have made some progress all have one thing in common: funding.   And the funding typically comes from a mix of local, regional and national sources, many of whom consider themselves partners in fulfilling the vision, which generally leads to the funding being somewhat sustainable over a long period of time, enough to discover how to make a difference, and demonstrating some results.   In addition to funding, perseverance may be a critical ingredient to the formula.

If We Can Put a Man on the Moon is a book by William Eggers.  Mr. Eggers provides some thoughts on why we are failing to solve our biggest social problems.   Lots of great insights except for perhaps one when it comes to children: the social transformation that needs to take place to improve the health and wellbeing of our children will take a lot more people believing in it and participating in it than what it took to put someone on the moon.  It will require the public thinking more long-term than ever before and more about the children than themselves.   The Moon was easy.

 

 

Care Transformation

Is health care corrupted?

Recently in the New York Times I saw an invited editorial by Pamela Hartzband (a Boston Physician) and her husband Jerome Groopman (a Boston physician who wrote How Doctors Think). The editorial was entitled How Medical Care is Being Corrupted (http://www.nytimes.com/2014/11/19/opinion/how-medical-care-is-being-corrupted.html?_r=1).

Drs. Hartzband and Groopman assert that pay for performance is not good for health care because it will incentivize physicians not to do what’s in the best interest of their patients.  Of course, incentivizing can lead to unintended consequences, but I would assert that our current fee-for-service system has more damaging consequences.

A few days later my former health care policy teacher wrote about this op-ed in his blog (http://www.managinghealthcarecosts.blogspot.com). He wasn’t impressed either.  He felt that the perfect way to compensate physicians doesn’t exist, and not holding physicians accountable for providing evidence-based care isn’t a good idea.  In addition we need to hold systems accountable for not causing unnecessary harm.

Are they suggesting that fee for service is better? And hasn’t created corruption?   Mmmm…

Current pay for performance formulas and strategies are far from perfect. The triple aim in its simplified version contains a paradox for sure – better population health and better care for the individual patient? What? And add better cost to that and you get a triple paradox, especially when you consider that no one in health care wants to be paid less.

Could pay for performance lead to gaming of the system and undesirable behaviors? Probably. Would it be worse than what we have now? Probably not.

Hasn’t the current reimbursement system led to poor quality, unreliable safety, overuse, misuse and underuse? Haven’t physicians made decisions about what kind of medicine to practice, where to practice, what kind of patients to care for and what to do for those patients based on our current fee for service reimbursement? Don’t we essentially have a corrupt health care system now?  Perhaps I’m being too negative, but the Hartzband-Groopman op-ed by not addressing these questions at least a little lacks some credibility.

Physicians have often elevated themselves to a mystical high road, creating a façade of selflessness and high morality. Drs Groopman and Hartzband have only repeated this cliché in their op-ed. The reality is that physicians have repeatedly demonstrated that they are merely human and their motivations are prone to selfishness.  In fact, their op-ed suggests this.  Physicians’ decisions ought to be centered on the needs and goals of the patient and evidence-based.  We could add the needs of the community and population as well.  They need to be fairly rewarded for doing their job well and for the quantity at which they do it.  Balance is the key.

Care Transformation, Leadership

Who’s on first, What’s on second and I don’t know who’s on third

Who’s on first? – Is it the patient?  The doctor?  The hospital?  The payer? In our everyday clinical (and non-clinical) practice we need to remind ourselves it’s the patient. When the patient is first, safety is first, quality is first, the care experience is first, and access is first.  Soon cost will be more of a consideration as individuals become increasingly responsible for the cost.

What’s on second? – If the patient’s on first, then what’s on second? Is it the doctor? The hospital? The payer?   It must be one of those, right? Wrong. Knowledge, information, and data are on second. It’s a huge “What” in health care and we’re not so good at managing, using and communicating it.  We simply have to get better at it. It will take technology and its proper application to disrupt our current system. There is good news.  We’re on the early part of the slope.

I don’t know who’s on third – Yes, we often don’t know and it’s a problem.  Once again, it’s not the doctors, the payers or the hospitals.  Culture is on third.  Culture defines and drives performance. And most of us don’t know much about it or how to influence it, let alone manage it. Culture is the end result of the behaviors, processes, strategies, values and visions put forth by leadership.  Its the driver of organizational behavior.  And culture is really what you are trying to influence when you make decisions and act as a leader. Putting in place a new process isn’t in of itself going to do much. Its what it does to the culture that really matters in the long run.

Baseball as a metaphor: Health care delivery is a team sport, and each position must be played well for the team to win. The physician, although not “on first” is certainly in the position of being captain, or at least the pitcher. The catcher is the advanced practitioner or nurse who helps manage the patients. And there are others on the team that the patient relies on.  Increasingly we are using medical assistants to assist us in collecting data, navigating patients and monitoring adherence.  The culture of the team is as important as the competence of each individual. We’ve seen that play out in major league sports time and time again.

So, what’s the secret sauce for creating a strong culture of excellence and reliability in health care? The evidence would suggest that its leadership.  I recently suggested in our organization that we have a leadership credo for our clinical transformation initiative. Someone on the work group asked why.  A fair question.  The reason is because leadership sets the tone, it’s the key to culture. If the leaders aren’t consistent, reliable, mindful, committed to transformation, committed to our chosen improvement tools, and committed to culture shift, then the effort fails. If we aren’t all rowing in the same direction as leaders, then the effort fails.

What’s your leadership credo?  And does each person on your leadership team share and live the same credo?

Management

What not to do to cut health care costs

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…

Care Transformation

Redesigning to be Patient & Family-Centered

I recently wrote down some guiding principles for redesigning patient-centered care delivery.  These patient-centered directives are taken from years of reading, hearing and seeing best practices and principles.  I’ve especially been influenced by the speeches and writings of Don Berwick and Bev Johnson.

Here they are:

  • “Don’t harm me”
  • “Don’t unnecessarily disrupt my time, my place, my money, my dignity, my privacy”
  • “Do comfort me and care about me while you care for me”
  • “Do keep me informed in real-time”
  • “Do include me in decision-making”
  • “Do help me manage my illness so I can be and feel healthier”
  • “Nothing for me without me”

Here are some systems-thinking principles to keep in mind:

  • Value streams are mapped through the eyes of the patient and family.
  • Processes are designed to maximize value for the patient and family (and community).
  • What we do is for the patient and family, and how we do it is also for the patient and family.
  • The system is designed with the patient and family as well as for the patient and family
  • The system anticipates the needs of the patient and family
  • The system is flexible and predictable in the eyes of the patient and family
  • The Voice of the Customer is used in every process improvement and redesign

You might recognize that there are 14 points here.  You also might recognize that half of them are directly from the voice of the patient (a lucky seven).  These are powerful and transformative principles when followed relentlessly and deliberately.  I’ve followed these principles to the best of my ability as a physician and a leader and they work.