Tuesday, August 03, 2010

On purpose

An email I sent to our staff last night:


Stick with me through some background that might seem irrelevant. Then, I hope you like where it leads!

A few weeks ago, I heard a talk by Roy Spence, the author of It's Not What You Sell, It's What You Stand For: Why Every Extraordinary Business Is Driven by Purpose. As suggested by the book's title, his proposition is that truly excellent organizations are those characterized by a common sense of purpose. This is different from having a mission statement or corporate objective, which state a business direction. It is more about having a desire to change the world for the better.

An example Roy gave was Southwest Airlines, who purpose is to give people the freedom to fly. You could probably quote the tag line: “You are now free to move about the country.” I listened as he talked about the airline’s actualization of this sense of purpose. One example occurred when the entire airline industry decided to start charging for baggage. Southwest was advised by its financial people that doing the same would save millions of dollars and make millions of dollars. The company decided, though, that charging people for luggage would conflict with its purpose and so -- contrary to all advice -- not only decided not to charge for luggage but to begin a now famous Bags Fly Free advertising campaign. “We love bags!” proclaimed actual baggage handlers on the tarmac.

Sure enough, the company did not save or make millions of dollars from this decision. It made billions of dollars, as the public responded by shifting gobs of business from other carriers.

I hadn’t thought about this much until today, when I got on an American Airlines flight and noticed virtually every passenger board a full flight with a “rollerboard” style suitcase to put in the overhead bins. They were all trying to avoid the $25 fee for checking their bags.

The tension was palpable among the passengers and the flight attendants. Passenger who boarded later peered ahead in the aisle wondering when the next open spot would be for their bags. Flight attendants were alternating between repacking each overhead bin to maximize its carrying capacity and hurrying passengers along so we could have an “on-time departure.”

The result: Airline employees were devoting all of their emotional energy to the baggage. If you had questions about anything else, they could not make eye contact because they were scanning the bins for empty spaces.

Another result: Passengers’ relative comfort with the flight had already been diminished, and we hadn’t even taken off yet. Categories were created between the “have’s” and “have not’s”. Those of us who arrived earlier (because of “priority access”) felt the calm superiority of secure overhead bag placement, while those who arrived after felt like they had missed something. One person actually asked me how I had managed to get on board before her.

To think, this all started with a different sense of purpose. For Southwest’s staff, everything is about wanting to give us the freedom to fly, and because of that, the airline’s customers never have a doubt.

I realized that I’d be hard-pressed to know American Airlines’ purpose. I opened up the magazine in the seat pocket to see if I could find it. There is a letter from the CEO which says something about “all my AA colleagues all over the world who put their hearts and souls into taking you wheresoever you want to go in the world.” At first blush, you might say that is the same thing Southwest says, but it is not quite the same. The AA line is about their doing something for you, not your doing something for yourself. It is not liberating: It is creating a dependence.

Let’s switch to medicine and hospitals now. As you all know, at BIDMC, we have a long-standing purpose. It is not a business objective in our strategic plan or mission statement, but it is deeply held: “To treat patients and their families as we would want members of our own family treated.” Achieving this purpose is a full time endeavor for all of us who work here -- including those involved in research and teaching as well as clinical care.

In the last eight years, we have accomplished a financial turn-around, successfully implemented a strategic plan and gained market share, dramatically enhanced patient quality and safety, come together as a community during economic hard times to save jobs and to protect our most vulnerable staff members, and begun an approach to process improvement (Lean) that is highly respectful of one another.

And, through it all, we took great care of patients and their families.

Notwithstanding these great successes, we have begun to learn that we cannot satisfy our purpose if we make all the decisions for patients and their families. In the ICUs and elsewhere we have established patient and family advisory councils that bring in the wisdom of our clients in logistics, space planning, and even clinical protocols. Several months ago, I wrote about one such effort in our ICUs that actually received international recognition.

Of all the lessons we have learned here at BIDMC, this may be the hardest. It is very different from the training received by doctors, and even that received by many nurses. Beyond being respectful, empathetic, and compassionate, it requires us to be ever modest about our knowledge and in our demeanor.

This kind of approach is most successful when it is a partnership, where dependence in one direction is transformed into bidirectional interdependence. I'm not writing today to provide lots of details, but to give you a heads up: Over the coming months, look for an expansion in our engagement with these advisory councils and other outreach to our patients and their families. We also plan to work with the Institute for Healthcare Improvement to encourage and enhance the activities of patient-run organizations in Boston and beyond.

If we can learn to be full partners with our patients in carrying out our purpose, the sky’s the limit.

Thanks, as always, for your involvement, support, ideas, passion, and encouragement.




Bob McGuire said...

Great illustration of the outcomes that can be realized when effort is united by a shared sense of purpose. I doubt you have trouble with people "sticking with you" Paul.

jessica lipnack said...

A self-referential response to your thoughtful post about the purpose of purpose. From Jeff Stamps's and my book, Virtual Teams, p. 279, "If purpose is the glue, trust is the grease." One can write 8 terabytes of words and only a few catch on--this phrase has, including my once sitting in a workshop where the leader said, "As I like to say, if purpose is the glue..."

Anonymous said...

This would seem to be the logical next frontier into which BIDMC will lead the way; an inspired insight, Paul.
I will be interested to follow your experiences, because I think "patient-centered", or whatever term one uses for partnership with patients, means different things to different people. I have read anecdotal accounts of such absurdities as a doctor saying to a patient who has seen him for a lump in the neck - 'what do you think we should do about it?'
It will be illuminating to utilize resources such as IHI attendees and your resident patient-experts to further define this term and explore what a partnership really means, for both partners.

nonlocal MD

stop smoking help said...

I enjoy reading your approach versus the traditional hospital leader. At my former hospital, we had a leader who liked to lead only so he could hear the forced applause and get his name on the "radio health hour" as an influential person in health care.

But he failed to cast a vision or perhaps, he simply failed to have a vision. What I like about your analogy is that you show how SW Airlines has a culture that incorporates the vision. Many facilities do not have a culture to match the vision.

Again, the system I used to work for wanted to serve the community and then one year later, substantially pulled the community service programs because they were not profitable. Even inpatient smoking cessation counseling and education was downsized because of staffing utilization patterns (according to the "consultants"). Then the facility became about the patient journey. The next year, outpatient and homehealth services were cut over financial viability concerns.

It's hard to get around a vision that changes based on the biweekly financial reports and scorecards.

Maybe they'd like a new CEO? :)

Leon in CA said...

Paul, when you wrote “not your doing something for yourself. It is not liberating: It is creating a dependence”, I shouted YES! Someone out there in healthcare is catching on.

I’m an advocate for a new business model started by a Seattle area company called LyfeBank which the consumer is in control of their health insurance decisions. Hopefully this model grows rapidly before we have the total dependant, top-down single payor system.

Pam Ressler said...

As always, beautifully articulated, Paul. Embracing relationship-centered care as an evolution of patient-centered care honors and respects the knowledge and expertise of all participants and leads to a more satisfying and trusting partnership for all involved.

I fully appreciated your airline analogy -- especially since I viewed a similar scenario up close and personal last week flying home with my husband and daughter. Since we were on a full flight, the gate agent made the offer to check passengers' roller bags (for free!) in exchange for priority boarding. At the time, I was quite impressed with this creative solution for avoiding angry passengers who would not have space for their roller bags. So much so, that my family gatechecked our roller bags and felt very smug and satisfied as we boarded in Zone 2...our smugness evaporated when we landed at Logan and then proceeded to wait for 40 minutes for our bags. Creative idea, lousy execution. What I took away from the expereince relates to health care -- creative ideas need to be followed by solutions that everyone feels a part of and takes responsiblity for, otherwise there is breakdown of trust and the "relationship" suffers. I have flown Southwest in the past and find, even when things are not going smoothly (air traffic delays, weather etc) Southwest employees seem to see the overall experience for everyone (passengers and employees) as important -- there is a sense of shared responsibility for the expereince and a sense of relationship. We in healthcare can learn a lot from observing! P.S. I don't think I will be checking my rollerbag in the near future -- I will be jockeying with the others for overhead bin space!

Flyer said...

Just remember that Logan does the bags, not Southwest, and Logan has the worst baggage department in the US. I don't know if it's management (refusing to add workers in busy times) or the workers themselves. But it's bad.

Brad F. said...

Um...Paul. Did you read minds here:


wow. i loved your post on this subject and wont forget it. reading this doubles down on that commitment