If you change how they think then you will change how they act.
In this case, “they” refers to physicians. Many of the posts here at HCR have been critical of the cost, inefficiency and ineffectiveness of corporate health care and the non-providers who are in charge. However, the most important posts at HCR are those that ask physicians to look in the mirror, reassess the state of the profession and take charge of reforming the system.
What is the best pathway to change and reform the activities and behaviors of a profession? One can apply external positive and negative reinforcement to good and bad behaviors. Alternatively, one can change the thinking that leads to behavior. In other words, one can change the culture!!! As mentioned in previous posts the concept of culture is at times difficult for the bottom line grinders to appreciate. Difficult to define, measure and manage. However, it is the unwavering belief of HCR that establishing a new culture for physicians and other providers is easier than it may seem and is the only pathway to meaningful change in the health care system that results in an improvement in quality and a reduction in cost.
Organizational culture has been defined in various ways by many management experts and anthropologists. One of the common themes in the definitions of culture links thoughts to actions. The thought components have been described as values, norms, and beliefs. HCR is constructing a framework for health care culture that will define the important values and priorities for physicians and other providers. At the same time HCR will develop the strategies necessary to allow the values and priorities to evolve into a culture with measurable improvements in quality and cost.
One of the most important values to establish in the health care system is that of service. Health care is above all else a service industry. Perhaps the most important service industry. Health care needs to prioritize and value service above all else. For physicians there is a service obligation to many but most importantly there is a service obligation to patients to provide evidence-based, humanistic and cost-effective health care. Physicians also have a service obligation to their colleagues and other providers to be an effective part of a multidisciplinary team. There is a service obligation for physicians to educate and mentor those in training and there is a service obligation to the general public to be productive citizens.
Service is one of the principle values/priorities on which HCR will create the successful cultural change in health care. While others look to change behavior through process HCR will change behavior by changing the way physicians think.
Hyperbole from irritated health care providers distraught with years of dealing with a growing health care bureaucracy that adds cost with no clear value in return? Nope. These are the words of Gary Hamel. Mr Hamel is a management expert who founded Strategos, an international management consulting firm. He has been credited as one of the originators of the concept of core competencies. In 2008 The Wall Street Journal listed him as one of the world’s most influential business thinkers. In 2009 Fortune magazine called him “the world’s leading expert on business strategy”.
“First, Let’s Fire All the Managers‘ was the title of an article written by Mr. Hamel that was published in the Harvard Business Review in December 2011. The first sentence in the paper states that “management is the least efficient activity in your organization”. Mr. Hamel then goes on to explain how an ever-expanding hierarchy of managers comes with an excessive financial and productivity cost to an organization. Too many people telling other people what to do and not enough people doing things. The message seems to be that leaders should spend resources on delivering the product or service not in creating a hierarchy.
There is evidence that an excessive managerial hierarchy is pervasive in the health care system. In 2013, The Institute of Medicine published “Best Care at Lower Cost. The Path to Continuously Learning Health Care in America.” A very striking table in this publication lists the estimated sources of $765 billion of waste. Excess administrative cost is responsible for $190 billion. That amounts to @ 25% of all of the waste. It is likely that a large proportion of this excess administrative cost is directly related to an excessive managerial hierarchy. And every provider will tell you that it is rare that a manager or administrator ever asks if there is a way that they can help you provide better care. Rather, they focus on how you can generate more revenue. A product of the current, and hopefully at some point historic, model of volume driven corporate health care.
What is the ideal ratio of managers and VPs to health care providers? One is often referred to data from the Medical Group Management Association (MGMA). These data are backward and sideways looking. Is anyone looking toward the horizon? Does anyone look at that 25% of excess cost as a target for cost savings? In a previous post here at HCR titled “Tell Me What You Do Again And Why It’s Important?” a scenario was depicted where every manager and VP was asked to justify their value to the organization by answering one simple question: How do you help providers deliver value (evidence based and cost-effective) driven care? Not being willing or able to pursue this issue translates into leaving $190 billion dollars on the table.
One of the main themes of HCR is to redefine the practice of Medicine and establish a new culture. The anti-corporate health care culture. The first step in eliminating the cost of unnecessary managers and administrators is to empower providers. The providers then must accept the new responsibility and be held accountable. Providers have been kept in the dark regarding the operations of health care. If providers were empowered with financial data and became active participants in the health care delivery process layers of unnecessary managers could be eliminated. Or better yet they can refocus their efforts toward helping providers deliver better care.
There are $190 billion sitting there.
Time is one of the few non-renewable resources and the most important one. For health care providers the delivery of care has gotten incredibly complicated and frustrating and no provider feels as if they have enough time to dedicate to caring for patients. The focus has been on generating volume not quality. And while providers have been asked to deliver more there have been layers of MBA and administrative “processes” most of which have never been demonstrated to make health care better and all of which take time away from patient care. A physician recently shared his irritation with having to complete multiple forms, all documenting the same information, after a simple surgical procedure. So the administrative leadership of health care has pushed providers to deliver more volume faster and has made it more difficult to do so. Sounds like a situation in need of a healthy dose of Toyota Lean.
While many physicians and providers assume a defensive position when non-health care management strategies are implemented it may be beneficial for physicians and other providers to embrace the Toyota Lean strategies. The goal of Toyota Lean is to eliminate waste and enhance value. If successful one can assume that a great deal of wasted time could be recovered. And just think of the possibilities.
More time to read. A theme here at HCR has been that the erosion of the practice of medicine as a profession has been the single greatest detriment to quality health care. And it is the opinion of HCR that the sine qua non of a profession is the mastery of the body of science, data and literature which forms the foundation of the profession. What if an hour per day of useless administrative process was eliminated and instead that time was used to review all of the relevant journal articles that had been published that day? It is likely that there would be more evidence based care. And it is likely that there would be less anecdotal care which has been show to be inefficient, ineffective and costly. If one were interviewing applicants to be their personal physician I would hire the one that reads the most. Physicians need more time to read.
More time to listen. The value of listening to what a patient has to say has been completely trivialized in the current model of health care. When a physician is an hour behind in the office because he/she has triple booked appointments to meet volume targets listening to a patient is not a priority. However, listening is always important. Always. Listening establishes the fact that the physician-patient relationship is based on communication that is bidirectional. If a physician listens he/she can almost always ascertain something about a patient or a patient’s disease that is unique and thus the care can be customized. Physicians need more time to listen.
More time to explain. The physician-patient relationship works best when it is based on communication and education. Patients need to be engaged and active participants in their care. Patients are appreciative if they are educated with respect to their disease and therapy. They are also much likely to be compliant. Physicians need more time to educate their patients.
As health care reform moves forward there is a great deal of effort focused on eliminating waste. The efforts need to include not just wasted money but also wasted time. And there is an enormous amount of wasted time. A system must then be developed where physicians and other providers are enabled to genuinely improve health care in the ways described.
We start with a hypothetical situation. You have just been diagnosed with a serious but not urgent medical condition and have been given two options for care.
Option A involves a health care system in which the administration just launched a patient experience campaign of which they are very proud. You call for an appointment and the phone picks up on the second ring. A very bubbly receptionist schedules you for an appointment tomorrow. You arrive in the office which has been meticulously designed and apportioned with the finest furniture. Calm music plays in the background. The atmosphere is relaxing. You are promptly escorted back to an examination room and placed in a very comfortable gown. You can’t help notice the great art on the walls and wonder how much this must have cost. In walks your new doctor and right from the start your relaxed state begins to change. He seems nervous, rushed and unprepared. Really doesn’t listen much. You never become engaged in a dialogue. There is no education. What you don’t know is that he has thrown up the white flag and surrendered to the corporate model of medicine years ago. He just wants to see as many patients as he can today. The other thing you don’t know is that he hasn’t picked up a book or read a journal article in years. Maybe goes to a continuing education meeting a year in a nice resort town.
Option B is next. You call for an appointment and the very polite office person tells you that the next opening is a day next week. When you show up the office is clean but a little dated. No music or art. As you are led into the examination room you begin to get a little anxious about the entire “feel” here so far. In walks your new doctor. The visit begins with an introduction and a few minutes of small talk. The doctor does a lot of listening and you feel engaged in your care. You get the feeling that this person is genuinely interested in helping you. What you don’t know here is that this doctor has refused to give in to corporate medicine model. Even more importantly, this doctor realizes that knowledge is the foundation of quality health care. He spends at least 2-4 hours per week keeping up with the ever-changing medical literature within his specialty. You will receive the latest evidence based care.
So is your choice option A or option B? Of course the goal is to have the best of both and the two are not mutually exclusive. However, the focus of current health care leadership seems to be on everything but helping doctors practice better medicine. Do they not understand where the most important improvements in health care quality are to be made? Do they really think that pretty offices and timely appointments define quality health care? Is this what the general public believes or are they smarter?
Hopefully this extreme dichotomous example will help those in leadership focus on what it really important.
Honestly. Did no one really see this coming? Did those in leadership positions just chose to ignore the signs? Maybe they saw the warning signs and just didn’t know what to do. The story might be comparable to the auto industry here in the US. Ignored external pressures. No willingness to change or adapt. Anyway here we are. Our health care system is now in full crisis mode. The system doesn’t deliver care as well as it should. The two most important stakeholders, patients and physicians, are very unhappy and fed up. And now the external environment has changed dramatically with the Affordable Care Act. In all likelihood the current health care crisis was preventable if there were thoughtful leaders in place.
Adaptive leadership is a strategy that dates back to a 1994 book titled “Leadership Without Easy Answers” written by a Harvard professor by the name of Ronald Heifetz. Professor Heifetz has studied and written about leadership, adaptation, systems and change. The publications describing his work are available at his website (http://www.cambridge-leadership.com). The foundation of adaptive leadership is change that enables the capacity to thrive. The concept is analogous to the process of evolution. A quote from Charles Darwin at the website states: “it is not the strongest who survive but those who are most adaptable”. Professor Heifetz notes that we are in an ever-changing environment that requires leaders to appropriately respond. He states that one of the key issues that enables the capacity to thrive is the ability to distinguish technical problems from adaptive challenges. Technical problems are those that can be solved with an organization’s current structure and processes. Two + two equals four. Technical problems can be fixed by an organizations existing authoritative expertise. An adaptive challenge is significantly different. As the title of his book suggests there are no easy answers. The solutions to adaptive challenges involve “changing people’s priorities, beliefs, habits and loyalties”. To HCR this sounds like a culture change.
Some of the key points of adaptive leadership outlined by Professor Heifetz may be uncomfortable for traditional leaders. The first is that organizational adaptation occurs through experimentation. Not too many leaders responsible for a bottom line are comfortable with experimentation but when you think about it every new initiative is an experiment. Second, adaptive change takes time. This is another way of saying that we need to plan for the long-term not just short-term profit and loss statements. Other key points of adaptive leadership would seem to be less stressful for traditional leaders. Adaptive leadership does not require a complete overhaul of an organization. Leaders must identify and preserve what is working and identify and change what is not working.
Health care take notice. The leadership of the health care system in the US has spent decades applying technical fixes to adaptive challenges. Leadership did not see, or chose to ignore, the adaptive challenges that were in front of them. It is now time for thoughtful leaders to make adaptive change that will allow the health care system to thrive.
The patient care case for culture is easy. The providers on the front line of health care get it. For decades the focus of health care leadership has been on efficiency as opposed to quality and patient care. Health care organizations, top-heavy with MBAs, have applied all of their efforts toward cutting excess. Definitely a necessary mission. But with the health care system in crisis it is time for a change. The drive for efficiency has crossed the equilibrium line and care and quality have started to be compromised (references available). And where have the savings gone? Certainly not passed along to patients or providers. Providers and patients want the future to be about quality, outcomes and value. And the foundation for quality and value is culture. But not everyone is on board with culture. That top-heavy leadership still would rather grind the bottom line.
So what about a business case for culture? What can a focus on organizational culture do for you? According to a post by George Bradt at Forbes.com in 2012 corporate culture is the only way that an organization can develop a sustainable competitive advantage: “Corporate Culture: The Only Truly Sustainable Competitive Advantage”. Not buying it? Well the argument that Mr. Bradt makes is as follows. Competitors can hire away top employees. Competitors can reverse engineer your product and duplicate your services. Culture on the other hand is more complex. Mr. Bradt makes a very unique analogy between music and culture. He notes that all music is composed from the same 12 notes but there is good music and bad. All culture is based on the same 5 components and of course then there are good cultures and bad. Mr. Bradt states that all culture is comprised of: (1) behavior (2) relationships (3) attitude (4) value and (5) environment. It is the association of these components that defines a winning culture that provides a sustainable competitive advantage. It’s the people and their interactions. It is very reminiscent of a previous post where winning culture was likened to making 2+2=5.
The leadership of health care organizations should pay careful attention. It’s time to get rid of the top-heavy health care system where minions spend every waking moment on efficiency while completely ignoring quality. The game is no longer about initiatives that result in small incremental improvements. Any room full of monkeys can do that these days so there is no great advantage. Efficiency can now be looked at as a commodity. Mr. Bradt’s post provides an eye-opening argument on how culture provides the only sustainable competitive advantage for an organization.
HCR is still trying to determine the author of the following: “you can tell a lot about an organization’s culture by what people are talking about”. So true.
In health care there is still no one talking quality!!!
Recently, a physician executive approached a physician about making improvements within a certain specialty service line of health care. The physician executive presented a very well thought-out and researched process map and timeline of particular care path. Then came the disappointment. Rather than focus on how the outcomes at the end of the process map could be improved the physician executive asked how people can move through the process faster. Honestly? Is this the priority of every health care executive? Why wasn’t the talk about outcomes and quality? Is the health car system really committed to action on quality or is the quality talk just talk? Maybe quality is just too difficult and no one wants to really do the heavy lifting.
It is understandable that patients would like their health care to proceed as expeditiously as possible. In some scenarios in health care rapidity is a medical necessity. In other scenarios however rapidity is honestly just a luxury. Is it a luxury for which we are willing to pay? Like any other metric in health care the time it takes a patient to complete a particular pathway of care can be optimized. Also, like any other metric the optimization will require resources. Resources such as time, people and money. As we stand at a crossroads between the old way and a potential new and better way the smart allocation of resources is imperative. So who will make the call? In this particular scenario one option would be to invest extra resources into the pathway so that patients move through faster. If patients are getting slowed down in the testing process then just add extra hours of testing with the additional people and equipment. Those who now are focused on quality would say that those resources could be better spent. The alternative is to expect more from the current resources. So just have the current providers and equipment work faster. There is an obligatory loss of personalized care in this instance. Also, shouldn’t health care be one of the industries where people are encouraged to work smarter not harder?
The entire issue of getting people through the system as quickly as possible is a great example of how patient’s expectations should be managed. The timeliness of care should, like everything else, be evidence based and patients and physicians need to commit to this principle. Do we want to invest precious resources on getting people through the system faster as a remedy for anxiety or do we want to invest those resources into quality and outcomes. Education is a much better and inexpensive fix for anxiety.
As the meeting with the physician executive came to a close it was also noted that in addition to the initiative of getting people through the system faster the institution would be allocating resources to a spa.
Quality endures. Investing the resources necessary to establish a solid foundation always pays off in the end. Always. The foundation of health care is the delivery of health care services from a physician to a patient. Over time layers of excess have been added to the foundation. The layers did not strengthen the foundation but rather weakened it. The additional layers not only weakened the foundation of health care, the doctor-patient relationship, but added cost with little in return. As layers of excess were being added to the foundation the external environment was changing as well. The system was appropriately deemed no longer financially sustainable and cut backs in funding were implemented. A disastrous situation.
Enter the corporate model of health care management. While there are some institutions in the U.S. that are managed by physicians (actually the more successful ones) in most health care systems the top 5 layers of leadership have never practiced medicine because they were trained to be business people. They don’t know what its like to be face to face with another human being who has just been diagnosed with a terminal illness. That is not and should never be looked at as 15 minute new patient visit. They have never experienced the frustration and self-doubt that follows when a physician has apparently done everything right and a patient still has a bad outcome. They have done nothing to fix the broken foundation of health care because they were never trained to do that and don’t know how. Rather, the corporate model of health care knows one thing: fix the bottom line. So for years health care administrators have had a singular focus. They have spent decades, as the saying goes, putting lipstick and perfume on the pig. The focus has been on how to make this month’s balance sheet look better than last month’s balance sheet.
Now it would be naive to think that there was no fat to be cut out of the system. And one can never discount the importance of operational efficiencies. But for years the crumbling foundation has been ignored, layers of waste have been added to the foundation and the focus had been simply on making the bottom line look better. No one saw this coming?
Every decision in health care now has to be made with one question in mind: How is this going to help physicians provide quality health care to their patients? And the layers of weight on the foundation need to be reassessed. Is there value there? Re-establishing the doctor-patient relationship requires re-establishing the culture of health care. The profession of medicine must be redone. Physicians should first and foremost realize that they in the business to provide a very important service to society not purely for self enhancement. Physicians should be encouraged to read, read and read some more rather than work, work and work even harder. Isn’t that one of the key differentiators between a profession and a trade? The patients need to become more engaged and set the bar higher for their physicians. They should expect an encounter with a highly educated professional who does as much listening as they do talking. The encounter should be educational. It should be personal.
Health care doesn’t need more myopic fixes on the bottom line. Someone needs to have a plan with the long view.
If culture is such an important component to a successful organization why then isn’t it a major focus of every C-suite? The answer to this question is related to several fundamental aspects of human nature itself. First, we prefer the concrete over the abstract. Second, we prefer instant gratification over delayed gratification. And lastly, uncertainty makes us very nervous. We would much rather live the in the world of formulas, business plans, and reports. Also, some believe that the bottom line drives the business. In reality it is the business, and more specifically the people and the culture, that drives the bottom line.
Most businesses are driven by a monthly profit and loss statement and knowing that 2+2=4 provides them with something to follow and manage.
The concept of culture is a completely different universe. Many have written about the importance of culture in successful organizations. The number of “cultural illuminati” continues to grow. While many understand the importance of organizational culture as the “secret sauce” of success no one seems to have the recipe for the sauce. One of the cultural illuminati is Bernard Rosauer. Mr. Rosauer is currently the president of the Wisconsin Compensation Ratings Bureau. He has had a successful 30 year career in the data-intense insurance industry. At one point in his career he was assigned the responsibility of organic corporate growth and customer retention. He developed an incredibly insightful approach which is detailed at his website ThreeBellCurves. A free white paper is available for download at the website and Mr. Rosauer lectures and provides executive training based on the Three Bell Curves concepts. It is a great read that helps leaders maintain focus on the three most important aspects of business culture: the customers (patients for the health care industry), the work, and the employees.
The Three Bell Curves white paper also has a great introductory paragraph regarding culture. In one paragraph Mr. Rosauer elegantly describes culture as an emergence. He uses a definition that describes the essence of culture and at the same time demonstrates why the term culture induces anxiety in most managers:
“An emergence is a novel, complex and often immeasurable state resulting from the combination of two or more simple ingredients.”
He then goes on to describe an emergence as:
“In simple terms, an emergence can be explained as those times when 2+2=5.”
An emergence. That is a difficult sell to those who believe that the bottom line drives the business. Even for those who understand that the business drives the bottom line the cultural emergence is a challenge. There is no step wise process to manage. Rather, establishing the foundation for cultural emergence begins with a simple combination of good people who have a laser focus on the appropriate priorities. With the appropriate support and patience a very successful culture then emerges over time. This organically grown culture differentiates the organization from all competitors, provides stability in the face of challenges and fads and then ultimately drives the bottom line.
If you are a physician who has been in a leadership position any time over the last 20 years then chances are you have contributed significantly, with acts of commission or acts of omission, to the current problems in health care and the profession of medicine. Not all of you but most of you. Maybe not all of the time but most of the time.
There is no plausible denial. No pointing fingers in another direction. Look in the mirror. It’s about personal responsibility. You helped to get health care where it is today. And that’s not a good place. Physicians in leadership positions should have been leading the charge of advocacy. Advocating for patients. Advocating for physicians and the practice of medicine. It hasn’t happened. In fact, rather than resisting the pressures that have created the current corporate model of medicine an argument could be made that physicians in leadership positions have in fact allowed themselves to be used as tools to take health care where it is today.
Some, if not most, of the guilty physician leaders have had a pedestrian existence with just local toxic influence. However, others have had positions of national prestige. Icons within their respective fields. Department Chairman and leaders of national organizations and societies. In both scenarios the position of leadership was more often used for self-serving purposes rather than strengthening the profession. While young physicians were looking for mentors, advisers and advocates they instead were left with physician leaders beating them on the nose with rolled-up newspapers like bad puppies. While patients were looking for a strong presence to defend their interests they instead were left to deal with the forces of corporate medicine alone.
Is there an explanation for why physician leaders have historically forsaken patients and the profession? Was a leadership position simply an easier path? Did leadership provide better compensation? Ego? Maybe they entered the position with good intentions and then realized they lacked the courage, fortitude and know-how to fight the good fight. The reason is irrelevant. The bottom line is that they were in a position to make a difference and they did nothing to help the cause of patients and their doctors. Hopefully future physician leaders will realize the importance of their position. Their obligations lie first and foremost in preserving health care as defined as the exchange of services from a professional to a person in need. Although a corporate entity may sign the paycheck they
Physician leaders of the past 20 years get to claim today’s health care system as their legacy. They haven’t provided a solution so that means they have been part of the problem. It’s what they helped create.