Wednesday, December 12, 2012

Phase difference

@CherClarHealth, aka Cheryl Clark, reports some important comments by Don Berwick in an interview published this week in HealthLeaders Media.  An excerpt:

[T]here is a gap between the improvement movement on the one hand, which has a lot of knowledge about using improvement to achieve cost reduction, and the responsible public policymakers and public servants who formulate regulations and laws.

And I have to say the same gap often exists between the improvement movement and the C-suite in medical organizations, hospitals and large systems. There is too much distance between the front office and the front line, and so executives can fail to appreciate quality as a business strategy, just as policy makers can fail to appreciate quality as a public policy strategy. 

I feel like Don and I are like a sine function and a cosine function, moving along with the same periodicity, but slightly out of phase.  He notes:

I came out of the improvement movement. That's my original knowledge base; but I and many others are learning how to bring our knowledge into the political arena. That bridge needs to be built. 

In contrast, most of my previous experience comes out of the political arena, running state agencies in Massachusetts and Arkansas.  My stint in health care came along later.  With help from Don and his colleagues and other really great people around the world, I learned a bit about patient care.  But the way I applied it in the hospital setting was based on principles of negotiation and constituency building that have their roots in political theory and community organizing.

The main thing that I learned in the political environment is that top-down thinking does not work when you are trying to create a coalition or build a movement for change.  I also learned that financial incentives and penalties are not motivational, and that they are crude tools often accompanied by unintended consequences.  A good leader trusts in people's good intentions--their desire to do well and to do good--and understands that their underlying values can provide the foundation for transformational change.

The article concludes with this statement by Don:

You didn't ask me the optimist or pessimist question. The answer is, I'm an optimist. I like what I'm seeing at the local community level. And the next couple of years, the story of healthcare in America may be told community by community rather than from inside the Washington beltway.

Again, he and I are out of phase, but I am hoping he is right.  I am not yet an optimist.  I, too, see some wonderful things going on in some communities.  But I don't see leadership, and I don't yet see a movement.  The major question I get as I travel is, "How can I get my CEO (or my department head) to reduce 'the distance between the front office and the front line?'  I still see many, many CEOs, chiefs of service, and boards of trustees who have yet 'to appreciate quality as a business strategy.'  Their minds are elsewhere.  In my view, hope lies in three possible vectors for change:

1)  Small groups of like-minded people in organizations who get together and experiment with small, incremental improvements and prove the case to themselves and, gradually, to those in the upper echelons;

2)  The coming generation of medical students and residents, who are fascinated and passionate about employing the scientific method in clinical process improvement and who believe in using transparency to hold themselves accountable to the standard of care they have chosen;

3)  A budding patient advocacy movement, people like e-Patient Dave, Patty Skolnik, Helen Haskell, Linda Kenney and others who have experienced fear, pain, and/or tragedy and who persistently demand to be let in and be partners in the design and delivery of care.

Don is correct to point out that there are more examples than ever of movement, success, and excitement in community settings.  He's been at this a lot longer than I and so likely has a wiser perspective.  The "sine-cosine" phase difference between his optimism and my reluctance to be optimistic just yet is that I have seen the power and speed with which other political movements have emerged.  In my view, this one is still a bit pokey.  I'd like to see more acceleration.


e-Patient Dave said...

Funny you should mention this; in 2012 I've been wondering out loud about the sociology of movements - feminism, civil rights, gay rights - to better understand the status of our own movement. And so far I haven't found a model.

There MUST be something somewhere, something like: early "out-speakers" say the first odd things (may last many decades); some start to connect; they start to get noticed; etc. In some cases the establishment slaps 'em down. etc.

An essential parameter, I think, is who's got what to lose from the change. Another is what structures are in place to prevent change.

In healthcare an essential factor is that unlike most other industries, it's really hard to get good information on quality and costs, so it's hard for the market to reward good performers and deliver consequences to shoddy ones. That's starting to change, BUT it has to be accompanied with a consumer awakening so people USE that info.

Another is that it's real burden for most people to take their business elsewhere, especially in the middle of a crisis.

Anonymous said...

As a doctor increasingly disgusted with what i see in the field while trying to protect my elderly family members, I think the patients/public have not been politically radical enough, sadly. Where is the outrage?
All the movements you mention, Dave, had a radical wing which, while initially turning people off, had a pivotal role in eventually forcing change. This is especially important where strong economic and cultural factors keep the Establishment stakeholders wedded to the status quo. Exhortations to change because it is the right thing to do are falling on deaf ears.

nonlocal MD

Daniel Curto-Millet said...

From G+:

Good post. It shows well the multi-faceted problems of large systems, especially in HIT where institutional, political, etc...

Many criticise that small "movements" won't be able to create any solution. But I think that's besides the point because they end up creating networks of people sharing certain goals in all these different layers. That's what matters, not the products that come out of such small groups.

Tim Cook said...

From G+:

Great analysis of the referenced article by Mr. +Paul Levy regarding the separation between the improvement movement and the decision makers.

It seems that the upper echelons haven't learned from history. From the 1940's when Deming's principles and work with the Central Allied Command was later ignored by corporate America and politicians as well. That is until he turned around the Japanese auto industry.

Later variations on quality improvement and management have become in vogue as well. We have witnessed piles of cash put into training. But it seems that the results of evaluation are seldom implemented.

Maybe we should re-evaluate how we select politicians and CEOs?

Anonymous said...

Excellent post, that I happen to read today while preparing my presentation for the big congress of the National School of Public Health on "Economy and Healthcare in Crisis: Deadlocks and Overruns".
It's a good coincidence to read your post today as on the last day of the congress,on Saturday, the School will present new healthcare policy and financing proposals. The coincidence is good because quality is totally left out from policy considerations, as the main objective is to decide where to apply the new wave of spending cuts in healthcare. These cuts arise from the recent 3rd MOU signed last month with the Troica (IMF,ECB, EU).
The lack of concern for quality reflects not only on the condition of the hospitals, the services offered, the moral of the staff who are on strike every other day, but at all levels of healthcare. This is alarming as horizontal spending cuts and lack of a quality culture constitute a threat for public health and a poison for society.
What makes it worse is that the healthcare management, who are, in their great majority, political appointees (e.g. politicians who failed to be elected)do not have the slightest idea what it means to lead 2.000-3.000 people in a complex operation as a hospital and manage a very tight budget.
As you point out in your post there is no connection between the C-suite and front line depts.. Don Berwick is right to say that executives can fail to appreciate quality as a business strategy, just as policy makers can fail to appreciate quality as a public policy strategy. We see it happen every day. The lack of important consumers pressure for quality in healthcare is very important.
Regarding the patient movement in the USA, I don't really know how to characterize it. On one hand, there are top health activists like epatientDave, Regina Holliday, Helen Haskell, Karuna Jaggar, and a lot of others I have met in congresses or online and on the other hand, patient advocates who are happy just to help other patients like them and not interested at all in healthcare activism. This was a big surprise to me as judging from the former, I had come to the conclusion that there is a strong patient movement in the US.
I will agree with epatientDave that in healthcare it is twice as difficult to create a movement, not only because patients do lack accurate information on costs and quality but also because they don’t understand medical issues (lack of health literacy). Besides in many cultures, in the European too, citizens believe that it is not their duty to understand medical issues. The physician is the one who has the knowledge and will explain to them what to do to heal. Patients would hardly contest a doctor’s opinion. What they do if they do not agree with their physian?They just switch to another. In reality, people do not see a role for themselves in the practice of medicine other than that of recipient of prescriptions and instructions.
We have in several European countries extrovert patient advocates, definitely much lower key, than their American colleagues, but they are very few and scattered and do not constitute a movement that could trigger change. Several are considered lunatics or some kind of fanatics in their own countries, despite the fact that they are invited to speak at conferences, write in media, or have a great number of followers in social media.
Something you may not know is that your blog is followed by several Greek doctors healthcare CEOs (they told me so) and a post I had written in my blog referring to your own on Don Berwicks’s 10 recommendations for improvement of public healthcare systems is among my most read posts!

Anonymous said...

To illustrate why the patient groups, sans funding and organization, often come out on the short end of the discussion, there was a full page ad in today's Wall St. Journal from the American Hospital Association about arduous government regulations, with the following link leading to a propaganda sheet:

While much of this may not relate to quality improvement, it is a good indicator of the power and money, or lack thereof, possessed by all players.