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
Care Transformation

The Smart Cogs of Health Care

Health care is at a cross roads.  Are physicians the problem or the solution?  I’m not sure how much of the problem they are, but I’m certain they are part of the solution.  Physician behavior is the result of the system within which they work.

Truthfully physicians are the “smart cogs” of health care.  And we need to design a system that optimally leverages this strength.  Deming referred to those front line workers who most understand the processes as the smart cogs.   In health care smart cogs serve two purposes: 1) applying, adjusting and adapting standard processes to individual patients, and 2) leading the creation and continuous improvement of those standard processes.

However, our system of health care hasn’t empowered or enabled physicians to be effective smart cogs.   First, the fee for service model has driven the idea that every thing must be related to the generation of RVUs.  Thus, physicians don’t have the time to do job #2 of the smart cog, and they spend less time doing job #1 simply because it takes time.  Second, the capacity for physician to understand the processes of care is decreasing.  With increasing complexity, even the smartest physicians are finding it hard to be experts in care delivery.  Third, applying the science of quality improvement generates data, and that data needs to be analyzed, which takes time as well as expert knowledge of the science of improvement.  Physicians lack the time and often the skills.   Fourth, medical science knowledge and evidence is expanding at a pace the individual isn’t capable of processing, especially the busy clinician.

So, what to do?  Consolidate, collaborate and commit.  Consolidate into integrated networks where scale can allow for physicians to organize in such a way to allow for proactive process and pathway development and maintaining.  Collaborate across disciplines, departments and care settings to create more patient-centered, effective, efficient and coordinated care processes and clinical pathways that breakdown traditional provider and setting-centric boundaries.  Commit to a new way of managing care and changing the current system with its poorly aligned incentives and poorly coordinated components.

John Haughom, MD, wrote a blog that discusses this issue as well (http://thehealthcareblog.com/blog/2014/05/07/a-declaration-of-independence-is-only-the-beginning/).  He mentions two organizations who have figured out how to empower and enable the smart cogs (Intermountain Health and Virginia Mason).   Dr. Haughom also mentions the importance of having the will to change despite the barriers we face.  Many physicians want to see change, yet they aren’t driving change.  Many managers of health care systems want to see change, yet they can’t make it happen fast enough.  We seem to be caught in the hamster wheel of the current system.  We need to figure out how to allow enough breaks from the current wheel to improve the efficiency of the system, so that more resource and time can be freed up to allow for more proactive process improvement.

Care Transformation

Ode to Deming, Part I

W. Edwards Deming is a bit of a hero to me.  His theory of profound knowledge is a thing of grace.  He understood the interdependency of people and systems and the importance of purpose and knowledge.  His 14 points are full of wisdom (to get the full breadth of his wisdom, one needs to read his books).

 Systems thinking and engineering is not new, even in healthcare.  Yet, it remains on the fringe.  Why is this?  One reason may be the failure of enough physicians to realize the utility of seeing care delivery in the context of systems.  They are leaders of care teams, and most are either not fond of systems thinking or know little about it.  Another reason may be administrators lack of first hand knowledge of care delivery, despite grasping the importance of systems thinking .  Administrators are good business people who have devoted their careers to health care (God Bless them), however they don’t often have broad bedside, and across the care continuum experience in delivering care.   Another reason: health care has been a successful industry and good to most working in it, thus there is little sense of urgency for change.

Perhaps another reason why systems thinking isn’t top of mind in health care is organizational culture.  Organizational cultures in health care tend to encourage autonomy and independence, and trust tends to be low.  This results in those directly involved in health care delivery (physicians, advanced practitioners, nurses, technicians, medical assistants and receptionists) lacking empowerment and capacity for change and spending time on systems redesign.

 When I was taking care of patients full-time, I loved it.  Yet, there was a voice inside my head that kept nudging me: “The system is broken and can’t continue on its current path. You can help fix it.”  My concern for health care had nothing to do with its economics.  As a pediatric hematologist-oncologist the only opinion I had on economics was how little I was paid relative to many other medical and surgical specialists. 

So, what were the reasons I had this voice in my head?  What we were doing in health care back then wasn’t consistently patient or family-centered, it wasn’t really efficient or timely, the quality, experience and components of care were variable and often unpredictable.  Substandard care was delivered too often, staff were unhappy and many felt powerless and/or burnt-out, and trust and respect among different disciplines and departments was too low.  And I saw all of these short-comings as problems related to systems design, not people.  There was a lack of awareness for the interdependencies of the processes of care leading to a lack of true teamwork and collaboration, which is needed in such interdependent systems.  Finally, the knowledge, will and resources for driving systems redesign were and still are hard to come by.

So, Deming became my hero.  His writings spoke to me.  My impressions and instincts were validated and expanded by his writings.  His profound theory of knowledge states that performance can be improved if leadership 1) adopts a systems way of thinking, 2) respects the importance of understanding variation, 3) uses the power of knowledge correctly, and 4) applies the psychology of change to their actions.  

Effective leaders change systems with the purpose of continuously improving performance towards a shared purpose.  In health care we need more systems thinking.  We need to keep going back to the basics that Deming eloquently laid out and improve the performance of our systems. 

At the same time, system changes can’t be so disruptive that the care we are delivering today declines in quality or access, and the financial viability of our health care institutions is threatened.

Management

An Interesting Frame for Improving Meetings

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 5th 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.

Leadership

Adaptive Leadership

It’s been said managers maintain order and leaders change it; the best measure of a leader is the breadth and depth of effective change.  In The Practice of Adaptive Leadership: Tools and Tactics for Changing Your Organization and Your World (HBP 2009) Ronald Heifetz, Alexander Grashow, and Mary Linsky suggest that most leaders aren’t adaptive leaders. They exercise authority, power and/or influence, but not adaptive leadership.

When it comes to technical issues, most leaders demonstrate advanced technical skill.  However, when it comes to adaptive challenges, most leaders fall short, either because they fail to recognize adaptive challenges, they fear the costs of exercising adaptive leadership (e.g. losing their job), or they lack the right tools and tactics (so they fail and lose their job).

A table from The Practice of Adaptive Leadership compares technical leadership to adaptive (Figure 2.3:  Leadership from a position of authority  Figure_2_3 ).

Technical problems often involve managerial intervention and systems engineering. Adaptive challenges often involve people and culture. Technical problems are solved fast by a small group.  Adaptive challenges are dealt with over time and involve many people. Technical problems are well defined and contained.  Adaptive challenges are messy and require framing and reframing.  Technical problems are relatively easy.  Adaptive challenges are hard.

For leaders in healthcare this is a time for adaptive leadership and  technical leadership; too much disruption might threaten access to services and erode quality, but not enough disruption and an organization may fail.  Health care reform is necessary given high costs and less than desirable outcomes. Thus adaptive challenges will continue to surface.

Because adaptive change involves people and culture, and requires courage balanced with consideration, a certain collective leadership capacity across the system is needed to meet adaptive challenges.  The physician workforce as a whole is perceived to be resistant to change, overly protective of our self-interests, and lacking a full perspective on the issues.  If physician leaders communicate unilaterally, listen poorly, and learn slowly, they won’t be effective adaptive leaders.  Adaptive leaders can’t be overly dogmatic know-it-alls.  Rather they must possess the skills to effectively participate in constructive conversations about the need to change, how to change and how to help people cope with the losses that come with change.

 

Strategy

Strategic Planning and Hoshin Kanri

In health care we are facing a change in our collective theory of business. Peter Drucker wrote about the need for organizations to test and adjust their theory of business from time to time (HBR 1994). Checking three main assumptions needs to be a regular if not ongoing part of doing business: assumptions about the environment, about the mission of the organization, and about the core competencies needed to achieve success. Drucker suggests that the assumptions in all three areas must fit reality, fit each other, and be constantly tested.   An organization’s theory of business must receive preventive care using two interventions: abandoning parts of the business that are no longer needed for success and studying non-customers. There must also be early diagnosis of holes in the system. One of the early warning signs is unexpected failure. The other warning signs include unexpected success, rapid growth and attaining the current vision. In health care there is no shortage of unexpected failure. Time to check our assumptions.

The concept of strategic planning is well known to most leaders and managers. It’s a process whereby the organization aligns and coordinates its efforts towards the achievement of shared and cascading goals and objectives. This planning is formulated after careful consideration of shifts in the environment, namely competitive and consumer related, but also political and economical. Another important consideration is the gap between current performance and desired performance. And finally, given limited resources and seemingly unlimited possibilities, decisions based on business priorities and values are made, which typically requires guiding principles and a process for decision-making.

Across organizations approaches to planning differ and within organizations the approach may differ from one period to the next. Differences arise from a variety of factors including leader preference, recent events, culture, and whether the last strategic plan was considered a success or a failure. An organization could decide not to have a strategic plan, others might keep it very simple providing just a framework or keep it very focused on one decision, such as a merger or acquisition. Others may choose to get detailed and include tactics and describe specific projects. Regardless, all need to follow the hoshin kanri principles of direction management: 1) focus on shared goals, 2) communicate goals to all leaders, 3) involve all leaders in planning to achieve the goals and 4) hold participants accountable for achieving their part of the plan.  There are two fundamental tools used in the hoshin kanri approach: 1) hoshin tables, and 2) periodic reviews of progress.

The Baldrige Award is typically given to those organizations who are adept at horizontal and vertical deployment of their strategy (DA Garvin HBR 1991).  They have an element of hoshin kanri in their strategic planning and execution .

 

Leadership, Strategy

The enemies of transformation, the secret weapon and how to use it

Having been out of training and working in the real world of academic health care for only 16 years, I hesitate to make judgments or conclusions. Instead I make hypotheses or formulate theories. Having only 24 hours in a day, I can’t test every hypothesis. Thus, I have presuppositions.  My three presuppositions below describe the enemies of transformation, the secret weapon of trust and the means to acquire it

The first presupposition is that we have four enemies in health care: Hubris, Cacoethes Carpendi, Seorsum and Avaritia. Hubris speaks to the collective and individual excessive confidence and arrogance that is prevalent among health care professionals and organizations. Cacoethes Caprendi means compulsive habit for finding fault, which refers to the blaming culture that can be found in health care organizations with regularity. Seorsum means apart or not together, referring to the lack of alignment and the inability to integrate varied self-interests into shared goals and values, and (most importantly) shared expectations of behaviors and results. Avaritia is latin for greed. Greed is the elephant in the room no one seems to want to address (not addressing it may lead to it devouring us). Some don’t see these four as enemies, and some don’t see they exist in the first place.   There is variable penetration to be sure, but they are there.

The second presupposition is that trust is lacking in health care organizations today, which makes everything from timely decision-making to efficient and effective teamwork elusive. Have a vision? Great! Have a strategy? Good for you! Have an execution plan?   Wow, impressive! Have trust in your organization? No? Then forget it.  The lack of trust hypothesis is harder to test, because trust lies under the surface. I’m convinced it’s a real problem. Those organizations that work on building a trust culture will adapt to external forces of change faster and more successfully. Trust is the secret sauce or weapon (I prefer the weapon metaphor when it comes to fighting enemies).

The third presupposition is that leadership in health care is lacking capacity.  I attribute this to my Intelligence-Ego Ratio theory.  An individual’s leadership is more effective if their intelligence is greater than their ego.  The optimal ratio is 2-3 (2-3 times more intelligence than ego). It’s counter-productive in the long-run to be <2.   One with a ratio of <2 may get placed into a leadership position.  However,  the organization’s success will have a ceiling.   One with a ratio of >3 will find it hard to get recognized as a leader, but long-term success is more likely.   This theory essentially states that intelligence is incredibly important, but if you let your ego trump your intelligence, you’ll eventually look like an idiot.  Humility is key to being the best leader one can be.  It drives a desire to continuously improve every day.  It allows you to be more open to learning from mistakes or miscues.  It allows you to build trust.

Intelligence doesn’t just mean mental capacity or complex problem-solving abilities. It also means the insatiable desire to learn and continuously fill the head with data, information and experiences (not just your own).  It also refers to emotional intelligence, the capacity to understand where you are and where others are with regards to relationships; relationships with self, others, the organization and society.  Intelligence essentially refers to the capacity to expand your awareness and perspective larger than anyone else around you.

So, what do we do about these presuppositions?  Take the following steps: 1) Increase awareness regarding the enemies, the secret weapon of trust, and the importance of the right leadership, 2) Embrace humility as organizations and as leaders, 3) Be resolved to succeed, persevere and do the right things, 4) Accept the need to change, 5) Drive change through continuous improvement, 6) Have relentless focus on mission, vision, values and principles, and  7) Get results on the most important shared goals.  If you aren’t getting the right results, then go back to 1 and start over.

Leadership

Physicians as Leaders

The ACPE has just published a white paper on the value of physician leadership by Peter Angood and Susan Birk (may-june-white-paper-(small)) . I would encourage leaders from all disciplines in health care to read it. In addition to nicely illustrating the value of physicians participating as leaders, it provides insights as to how physicians  can be better leaders, and suggests the journey that they must go through to get there. For non-physicians to understand the journey could be valuable as well.

Physicians are typically intelligent quick learners who are outcomes-driven and often innovative problem-solvers. However, their training and the skills that often make them great physicians can get in the way of their ability to lead. The white paper shows a table from an October 2012 issue of Trustee magazine. The table compares the nature of medicine to the nature of leadership. For non-physicians to understand where physicians are coming from during those crucial dialogues could help turn those discussions into collaborative learning. Physicians who want to be better leaders ought to study this table as well. It points out that to go from practicing physician to physician executive, one must give up autonomy and isolated problem-solving for collaboration and narrow scope and predictability for broad perspective and ambiguity.

medicine-vs-leadership-table

Children’s hospitals are blessed with committed and compassionate physicians (many of whom were also likely to be in the top 10 of their graduating medical school classes). These physicians often have great ideas and are often very engaged. They have a strong desire to help their institution solve problems. These same physicians are also used to dealing with relatively well-defined problems (and if they’re not, making them so before tackling them). They are also used to receiving lots of thanks and praise from others (or at least a sustaining dose of it). As a physician makes the transition to leadership, they will find themselves dealing with messy problems that are ill defined and have no simple easy clear answer. They will meet resistance to change, complaints about all sorts of things and very little thanks.

We need physicians to be leaders at all levels. For some they will struggle to make these shifts, but they’re input and participation is still valuable. For others it will take them time, but their other strengths make the waiting worthwhile. And then for some, the transition will be successful enough to allow them to be great leaders at a time when we need great leaders. The challenge for those physicians will be to stay connected with their clinical past in order to maintain their credibility with those physicians who continue doing the great work of delivering and continuously improving health care.

A few physician leaders will need to be more transformational leaders than transactional leaders.  The best leaders will recognize the value of both approaches and be adept at both.  Yet, they will tend to the transformational.  These leaders will meet more resistance, perhaps to the brink of rejection, and less thanks, even in the face of success.

A leader who has a transformational North Star with a principle-centered approach grounded in the power of relationships and collaboration is what is needed in today’s dynamic and uncertain health care environment.  To persevere s/he will need to embrace humility and servant leadership.

-Thanks for reading, Nate

 

 

Strategy

A Note on Health Care Reform and Children’s Health Care

1 Comment

The affordable care act was designed in part to reduce health care costs.   A principal strategy is to bring the issue of cost per “unit” of care to the table of decision-making in a much more transparent way, while shifting the burden of costs more directly to those receiving the care (the patients) and to those delivering the care (the providers). The presupposition is that if the patients share more of the cost they will utilize fewer health care resources and if the providers share risk they will make health care delivery more efficient and safe, with less overuse and waste.  With price as a more prominent driver of consumer choice, prices will drop in a competitive market place.  Disruptive innovations will be encouraged.

So, what does this mean for us involved in delivering children’s health care?  It means that in addition to improving health increasingly more effectively and on a larger scale, we must also lower the cost per unit of care.   Preventive care, subspecialty care, treatment of acute and chronic illness, procedures, and many of the things we do to help our patients, we must do at a lower cost. Preventable harm and complications, reworks and duplications of care, and inefficient use of people and resources must be minimized.

We have been rewarded on volume (fee-for-service) for a very long time. Our systems, processes, and the way we think are all geared towards producing high volumes.  Many physicians’ compensation is largely dependent on this one measure of work. This has created a way of doing things that will make it difficult for many health care organizations to do well in the new order of health care, whenever that might arrive.

And therein lies the conundrum, when will value based purchasing truly arrive?  Some are thinking it will be years and its best to not change things until it arrives.  What do you think Children’s Hospitals ought to do to position themselves for the future?

I for one think children’s hospitals need to lead the way.