Clean 'em up: An approach to hand hygiene

Noticing the ineffectiveness of certain approaches to garnering hospital and doctor compliance with important safety standards (like hand hygiene), Brad Flansbaum offers an intriguing way to improve:

Assemble a moderately sized pod of hospitals, matched on demographics, payer, SES, bed size, etc., and keep them as geographically proximate as possible.  If they compete, even better.  Have them decide on a monitoring system they will purchase together at a discount (I hear vendors like big orders).  If CMS has a little seed money sitting in a slush fund, still better.  Alternatively, maybe even condition participation on a half-percent penalty give back from another program like the HRRP or VBP.

All the institutions must agree on the rules of the multi-year monitoring project, and each must publish their sum scores in a publicly accessible database (individuals would be held harmless for this endeavor).  The catch? The bottom performers pay a penalty into a patient safety fund–one significant enough to make the bean counters take notice, but not enough to discourage continued participation.

However, there is another catch: CMS cannot touch the lucre.  It funds worthwhile QI efforts of the mini-consortium, overseen by a self-appointed, representative board and approved by the Feds.
(Restrictions apply, of course, and the headline purchased by the victors in their local papers cannot read, “Hey losers, you owe us 5%.  Also, before you give us the check, wash your hands.  Oh yeah, prospective patients are forewarned.”)

Oversimplified?  Yes.  Crazy? No.  But you get the picture.

All kidding aside, regardless of how you monitor handwashing compliance, if penalties translate to individual and hospital hurt, financial or otherwise, folks must buy in.  The guts of any modern day solution will require technology and upfront costs.  Anything less will lead front-line providers to push back and harbor more ill will against a regulatory system they increasingly see as suffocating and harsh (read: n=10 on a core measure).  Occasional and mediocre monitoring just won’t do.

Advice to students and young professionals when you don't like a critique of your work

I've been thinking hard about whether to share what follows.  I've finally decided to do so now, at the start of the fall semester, as a form of advice to students and young professionals.  The advice is actually quite simple:  Learning to write well requires you to be open to honest criticism.  It is all right if you don't like how a professor or someone else responds to your writing, but try to put aside your personal feelings and draw whatever value you can from someone who has taken the time and made an effort to be helpful to you. Also, be gracious.

The background is as follows.  A junior faculty member at a medical school recently asked me to read and critique a book s/he had published.  I am often asked by students and other young professionals to do this, and I am always happy to pitch in, in the hope of being helpful during the formative stages of their careers.

In this case, I felt that the book was not very good. It's not that the ideas it contained were off base. Rather, the writing wasn't persuasive and clear.  I wanted to be honest in my critique, but I also wanted to do my best to make the review a good learning experience.  So, I actually consulted with a number of senior academic faculty members to get their advice on how I should approach the task.  What I wrote is what follows--but then stay tuned for the author's response, and my rejoinder.

Here's my email to the author, with items changed to protect his/her identity:

Thanks so much for sending me your book.  I think it is a great concept and, of course, timely. You asked for feedback, so here goes:

I've seen many instances, like this, where the author has a lot of good things to say, supported by powerful stories.  The problem that occurs is that your own depth of knowledge and understanding of the issues gets in the way of presenting them to readers who are not as attuned as you to the issues.  Why?  In short, because you put in too much, and it is overwhelming.

I always used to tell my students that everything you write should be considered an advocacy document.  You are trying to persuade the reader that your stories are apt and compelling, and the generalizable lessons you draw from those stories are equally apt and compelling. It is very, very difficult to do this when you are so close to the subject.

So my short answer to your feedback request is that the book could have used a major dose of editing, preferably by someone who was not familiar with the topic.  Only that kind of detached observer can tell you where you have done well and where things need to be reworked.  For example, a story might be compelling to you because you experienced it; but in the telling the power does not come through.  It might be the story itself, and it might be how it is told.  

There is also a serious need to separate your personal journey and feelings from a more detached presentation of the evidence you bring to bear in making your points. The reader will know that it is personal--after all, you wrote the book.  But if each story is made too personal, it loses its power as a potentially generalizable example.

Beyond the substance, the design and presentation of the paragraphs and other graphical issues needs major work.  The text comes across as overly dense.  Something about the font size and margins and line spacing and indentation is just wrong--making the book much harder to read.  The publisher should have provided you with better graphic arts support.  

These are general observations.  I could best illustrate them to you if we went through several pages and chapters of the book.  I'd welcome the chance to do that next time I am in your vicinity.  

I want to close with both encouragement and a warning. [Name,] you have the potential to make a big difference in this field because of your commitment to the issues and sound judgment and passion.  But, if you hope to advance in the academic world, your finished writing products need to reach a higher level.  That's certainly achievable, but it will take some work and help.

With fond regards,

Paul

--

And now the author's reponse: 

Dear Paul,

Thank you for taking time to send your feedback. I will let my current work (as well as future career work) answer your email but to be very honest, I am disappointed by your email. Of course not because you didn’t like the book, the writing style or the way I choose to generate knowledge — it’s normal that a personal book will evoke different personal responses. What you find problematic has been a guide for others.

What disappoints me is the rather linear logic you used to develop and organize your arguments.  I shared your email with my mentors, both whom are incredibly well respected and successful palliative medicine physicians in two different settings, and they were underwhelmed (and actually confused) by the email's lack of understanding of and sensitivity towards the complexity of clinical life, aging and policy issues, and health care settings in general, particularly in the context of advanced illness. They were also taken back and concerned by the email’s lack of understanding around systems (ED and hospice), system theory, qualitative methods, and communication theory. 

My own voice will continue to develop, and my mentors and I are on a mission to make a difference through understanding, learning and change, rather than endless critique and dismissal of differing points of view and voices that are always in motion.

Best of luck,

--

To which I felt compelled to reply: 

To be absolutely clear, [name], my comments were not in the least "an endless critique and dismissal of differing points of view and voices that are always in motion."  You asked for an honest critique of your writing, which is simply what I offered.  If you had just wanted encomiums, you needn't have asked.  This was not a critique of your ideas.  I'm sorry either I did not make that clear, or you did not understand.  I offered to illustrate the points to you in detail and in person, but you have chosen to cast aside that offer.  

Your comment about my lack of "understanding of and sensitivity towards the complexity of clinical life, aging and policy issues, and health care settings in general, particularly in the context of advanced illness" is off base.  You know nothing about my experience or knowledge of those issues.  Ditto for my knowledge of system theory and the like. My last bit of advice to you, for future correspondence with others, is that you do little in offering a persuasive retort by attacking the supposed knowledge and experience of the reviewer.  

I'm so pleased you will continue in your efforts to bring greater light to this important field, and I wish you the best.

Sincerely,

Time for HOPE Award nominations

Nominations are now being accepted for the Annual MITSS HOPE Award that recognizes people – patients, families, healthcare providers, hospitals (or teams or departments therein), academic institutions, community health centers, grass roots organizations, etc. – who exemplify the mission of Medically Induced Trauma Support Services: Supporting Healing and Restoring Hope to patients, families, and clinicians affected by adverse medical events. The award is sponsored by the healthcare software firm RL Solutions and the winner will receive a $5,000 cash prize. Nominations are due by September 25, 2015, and the award will be presented at the MITSS 14^th Annual Dinner at the Sheraton Boston Hotel on Thursday, November 12, 2015, from 5:30 to 9 p.m. For more information or to nominate someone (self-nominations will be accepted), visit the link above or call MITSS at 617-232-0090 or e-mail wtobin [at] mitss [dot] org.

Mutual self-interest leads to antitrust concerns

We have a bright new Attorney General here in Massachusetts who has already earned her bona fides with regard to putting the brakes on economically unsupported market power expansion by the local dominant provider network.  That corporation, Partners Healthcare System (PHS), has now indicated that its primary expansion activities will be outside of the United States, but that statement hides a bit of misdirection.  Indeed, PHS remains focused on maintaining its hold on physician organizations and its overall market share here in the state.

It is on this front that the provider group is engaged in a relationship with one of the country's largest electronic health record companies, Epic.  And it is here that the Attorney General should rejoin the antitrust battle--not only in Massachusetts on her own--but in cooperation with Attorneys General in other states.  The target, though, should not be the provider groups per se, but rather the EHR corporation.

What we are seeing here is a remarkable reinforcement of mutual self-interest in the behavioral patterns of the two entities. Here's how it works.  Partners enters into a contract with Epic for the construction of an EHR for its facilities.  The two organizations go to the Partners-affiliated, but independent, medical practice groups and tell them that they have to install the Epic EHR--even if the EHR they have had for years is perfectly adequate for their purposes.  If a doctors' practice asks why they can't keep their old system, Epic makes clear that interoperability between its system and the practice's legacy system is not feasible.  Meanwhile, to clinch the conversion, Partners also informs the local practices that failure to install the Epic system will foreclose those practices from participating in the favorable insurance contracting relationships it enjoys.

It is in this manner that the Epic-Partners actions box out the competition in this market, acting on the pair's mutual self-interest.  They are complicit with each other in helping to ensure that PHS keeps its network strong by holding on to physician groups and that Epic expands its market power by expelling established competitors.  This may not be your usual type of anti-trust activity, but it is anti-trust activity nonetheless.  And you can bet it is happening in other states as well.

In the past, Attorneys General have joined forces on matters of interest to many states--public health, environmental protection, and the like.  Here, we have a pattern of behavior that seeks to limit competition in an arena of great importance to the public well-being. I hope that our new AG puts this case on her list of priorities for her term of office and seeks allies from other states to join her.

Enjoy life. Stay Safe. Love every mile.

Back in September, I wrote about a defect in the design of the passenger side airbag mechanism in my 2012 Subaru Impreza.

We’d be driving along, and all of a sudden the passenger airbag would shut off, leaving the passenger unprotected.

A service attendant mentioned that the on-off switch had nothing to do with weight. It was based on the amount of water in a person’s body. 

There is no warning about this shut-off system on the passenger side visor. And, if you check the owner’s manual, there is nothing about this issue in the opening section’s safety precautions, although there is material about the speed and force of airbag deployment. Later, embedded on page 42, there is this advisory if you happen to turn to that page: “If the front passenger’s seat cushion is wet, this may adversely affect the ability to determine deployment.  If the seat cushion is wet, the front passenger should stop sitting on the front passenger’s seat. Wipe off water from the seat immediately, let the seat dry naturally and then check the SRS airbag system warning light.…”

Let’s say you’ve never noticed this “feature.” You’re driving home from the beach on a crowded highway at 60 mph with your family in a full car, and the passenger airbag shuts off. Perhaps you see the shut-off light suddenly illuminating. How exactly do you stop the front passenger from sitting in the front passenger’s seat? Perhaps you don’t even see the shut-off advisory light, in that you are focused on the holiday traffic. In either case, your passenger faces an unexpected hazard.

When I brought this to the attention of Subaru, there was no recognition of the danger associated with the design.  So imagine my interest when I received the following recall notice from Subaru this week:

SUBARU OF AMERICA, INC. has decided that a defect, which relates to motor vehicle safety, exists in certain 2012 model year Impreza vehicles equipped with a capacitance-type occupant detection system (ODS) in the front passenger seat.

You received this notice because our records indicate that you currently own one of these vehicles. 

DESCRIPTION OF THE SAFETY DEFECT AND SAFETY HAZARD
When a right front seat passenger plugs a cell phone or other device into the accessory power outlet or touches a metal part of the vehicle that is grounded (such as the seat adjustment lever), the ODS may erroneously determine that the front passenger seat is unoccupied and deactivate the front passenger air bag.

Should this happen, the Air Bag Warning Light will illuminate and the Passenger Air Bag Indicator will illuminate “OFF”, providing a visual warning that the air bag system is not operating properly.
The passenger air bag will not deploy under these circumstances, increasing the risk of injury to a front seat passenger in the event of a crash. 

REPAIR
Subaru will replace the ODS Occupant Control Unit in your vehicle with a modified one at no cost to you. 

Hmm, I wonder why one defect warrants a recall when the other does not. As I noted back in September:

Many Subaru owners are outdoor types who will drive home after a jaunt to the beach or a hike in the wet woods. How many of them know they are in danger when they do so?

I like my car.  I just want to "enjoy life, stay safe, and love every mile." What does it take to get this company's attention?

Searching for a Google search answer

The search box on this blog (yes, the one up there at the top of the page to the left)  is really inadequate, so I decided to send a note to a Google friend, asking him/her to forward it to the right people: 

Dear Google, 

Your search engine inside of Blogger is awful.  It actually better to search for something on my blog by using Google search outside of the blog platform than within it.

The problem with the current situation is that people doing a search within the platform often can't find things from previous blog posts.  They assume that the search box is just as good as a regular Google search, but attuned to the specific blog. 

Can you please fix this?  Or just get rid of the search box on Blogger so people aren't misled.

The reply from my friend:

Dear Paul,

We secretly love getting letters like this, because it reinforces the truth that Google search is so good, it's even better than searching within any specific Google product. We hear the same things about non-Google services like Netflix, that Netflix users have given up on searching within Netflix and search the Netflix catalog on Google instead.

Now, we can't officially say this, and internal politics won't allow us to do something as drastic (and obvious) as turning off the search within Blogger. But we know you're right. And we're sort of sorry.

Sincerely,

A Googler who sees enough awareness of this get ignored from the inside and doesn't know where to send it.

Do We Really Learn From Our Mistakes?

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for the last several days, I have reprinted the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint, with added photos, is the last of this series and is from a post dated July 20 2015, "Do We Really Learn From Our Mistakes?"

It’s often said that we learn from our mistakes. Indeed, many a business course in leadership offers that premise as a given. I’ve glibly repeated this often in my classes, speeches, and advisory work.
“You don’t learn from your successes,” I point out, “but rather from your errors.”

But do we really learn from our mistakes as a matter of course?

My friend and colleague Michael Wheeler, in his wonderful book The Art of Negotiation, warns us that it is:

all to easy to be overconfident about our ability to observe and learn. A leader who ruled his country for more than forty years put it well: “The truly strange thing in your lives is that you not only fail, but you fail to learn your lesson . . . No matter how much your beliefs betray you, this is never accepted by you. You are distinguished by your inability to recognize the truth, no matter how irrefutable.”

Wheeler continues:

It one thing to recognize this truth in the abstract, but it’s another to live by it. The writer was the Libyan leader Mu’ammar Gaddafi, who several years later refused political asylum even as his regime was collapsing around him. Gaddafi was captured, beaten, and killed by rebel forces.

Sometimes our inability to be reflective practitioners derives from cognitive errors and biases. Because these failures are cognitive, it is almost impossible to see them happening or, afterwards, to realize that they have occurred.

Cognitive errors show up in many forms. Of the most common are:

• Anchoring: the tendency for your first observation to carry disproportionate weight in your decision-making.
• Confirmation bias: often accompanied with anchoring, our confirmation bias values evidence that seems to support our view while discounting evidence that is contrary to your view.
• Recent experience: Even statistically irrelevant recent events carry more power merely because of their placement in time.
• Patterning: We are prone, too, to see patterns that don’t exist. Our minds like order, and we will assert the existence of dispositive parameters—even when the actual pattern of events is totally random.

We teach doctors about these cognitive weaknesses — anchoring, confirmation bias, and patterning — but we tell them that they are unlikely to recognize that they are happening. Instead, we need them to buy into systems of group behavior that protect them from themselves.

An illustrative example comes from Joris Lemson, MD PH.D., medical director of the pediatric intensive care unit at Radboud University Nijmegen Medical Centre in the Netherlands. One day, he ordered a dose of strong medicine for a small boy. The nurse obeyed the order, and the boy almost died from the choice of medication.

Later, when the doctor confessed his distress to the nurse, she said, “I wondered about the choice of drugs. If you had been an inexperienced doctor, I would have questioned the order. But I figured, with your experience, you would know what you were doing, and so I didn’t say anything.”

In relating the story to me, he said, “It was at that moment that I realized that I needed to be protected from my own mistakes.” He then instituted a strong training program in Crew Resource Management (CRM). This set of techniques, derived from military aircraft cockpits, offers particular help in hierarchical situations. It empowers subordinate members of the team to interrupt a pilot, doctor, or other chief and help that person from making a serious error.

Joris is honest about the progress of this effort in his PICU. He notes improvement and general compliance with the approach and procedures, but he also notes lapses. For instance, sometimes he as leader will forget to conduct the debriefing. That’s all right, but not if the other crew members forget to remind him when it happens. A tenet of CRM is mutual responsibility and authority: If the chief forgets to carry out part of the protocol, the others are required to point this out.

Oddly, those of us in more office-based leadership positions do not protect ourselves from this kind of error. We might tell people that we want to hear when we are going wrong, but do we behave in such a way that those call-outs are encouraged? Do we greet an interruption or criticism with a gracious smile and a thank-you? Or is our (perhaps unconscious) scowl of displeasure enough to teach subordinates that they are proceeding at their own risk by doing what we think we told them to do?

We need to understand that there is an uneven pattern of power in the boss-subordinate relationship. Our reports, for good reason, have learned over the years that the person who points out that the king has no clothing often ends up on the street or left behind when it comes to promotions or other career advancement. With the scowl, we cement that fear into people’s everyday lives.

Michael Wheeler summarizes the issue by saying, “You have to monitor your own behavior to make sure it aligns with your intentions.”

Following Through: Create The Right Environment For Learning

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint, with an additional photo, is from a post dated June 3, 2015, "Following Through: Create The Right Environment For Learning."

One of my twelve year old soccer players, Adair, was having trouble consistently kicking long and accurate through balls. As I watched her, I noticed that most everything about her body position going into the kick was fine, but she ended up punching the ball with her foot rather than following through, or she would cross one leg over the other as she delivered the kick.

“You need to follow through better, and don’t cross your leg,” I instructed, to no avail. The pattern of inconsistent, low power kicks continued, often not leaving the ground, and often not directed at the target.

In a moment of insight, I remembered that she plays golf. I asked her, “What does your golf instructor tell you about driving a ball? Doesn’t he say to think about where your club will end up at the end of the stroke?”

“Yes,” she said, “the club head should end up high above my head at the end of the swing.”

“Oh my gosh! So I should do the same here?”

“Right,” I said. “Don’t worry about your foot kicking the ball hard. Just like in golf: If you try to hit the ball hard, what happens? Your body loses the natural leverage and balance that makes a swing work well. Think about where you want your foot to end up after the kick: Up high and pointing towards your target.”

“I want to try it!” she exclaimed.

We stood about 30 yards apart, and she nailed five, then ten, then twenty perfect through balls, arching gracefully through the air and landing directly at my feet.

At our game the next day, Adair used her newly developed skill to place a 25-yard free kick at an angle from the goal in the upper left hand corner of the net. She glanced over, flashed a thumb’s up, and offered a smile that seemed to say, “Look what I can do!” I smiled and returned the thumbs up. It was her moment of satisfaction and joy.

Privately I thought: It isn’t often that a coach gets such immediate validation of a pedagogical technique.

Adair reminded me of an important lesson from the world’s greatest basketball coach, John Wooden. He used to say, “You haven’t taught till they’ve learned.” He meant that if your student wasn’t learning something, chances are it was due to your failure as a teacher. The trick is to employ a pedagogical approach that meets the needs of the student, not the staid patterns of the coach.

Here, I had started with didactic instruction, the least likely way to help a young player employ and perfect a new physical skill. Is there little wonder why it failed? It did not fail because of any lack of intent on Adair’s part. Indeed, she is very well intentioned and extremely focused on improving—with a desire quite typical of 12-year-old girls who do not want to let their team down.

No, it failed because her coach was not sufficiently empathetic about her learning process.

Like the stereotypical American tourist trying to get a native-speaking person in another country to understand his English, I was just saying the same thing over and over. In a figurative sense, I was not paying attention to what she was “telling” me, not in words, but in the behavioral pattern of her body. Once I woke up and was able to see how my own stubbornness was interfering with her need to establish a new conceptual framework for her kick, I could be free to try a new approach.

As coach, all I needed to do was to help Adair to draw the analogy to some other part of her experience. Then, the physical concept became intuitively clear. She could make the connection and apply the analogous skill effectively and consistently.

I am telling this story in this Forum to help leaders remember that it is usually not your job to engage in didactic instruction of your staff. That leaves them as uncreative drones trying to do what you say rather than employing their broad perceptive powers and inquisitive inclinations to develop the impetus for change.

Your job is to create the conditions for a learning environment, having sufficient empathy with your people to understand where they are in their learning process and to learn what interventions you can offer that will help them grow and excel.

Don’t lecture. Ask. Listen. Explore. Experiment.

As a leader, you are ultimately a coach. The best coaches let their players take credit for success. Just stand on the sidelines and smile when it happens.

Ice cream helps, too!

Valuing Introverts

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint, with some small additions, is from a post dated March 24, 2015, "Valuing Introverts."

The Wharton School’s Adam Grant has noted: “If you look at existing leadership research, extroversion stands out as the most consistent and robust predictor of who becomes a leader and who is rated an effective leader.” Writer and introvert-activist Susan Cain has also pointed out that introverts are often passed over for leadership positions.

While there are notable exceptions, I think that these observers tend to be correct. I’m not saying things should be this way, but they often are.

If you are one of those extroverted leaders, you have probably created a corporate environment that is comfortable to you and other extroverts. Cain notes the pervasiveness of this phenomenon, saying, “We have this belief system right now that holds that all creativity and all productivity comes from an oddly gregarious place. Our most important institutions are designed for extroverts and their need for lots of stimulation.”

Given that one-half to one-third of people tend toward introversion, the lack of work environment that introverts would find comfortable is deeply troubling. As a leader, though, you have a more serious problem: Those introverts often have the most helpful insights about thorny problems or often could say something that could keep you from making a really bad decision.

Indeed, your team is much more likely to suffer from groupthink if introverts don’t feel empowered.  They will remain silent while the rest of the group adopts the opinion of the most dominant people in the group.  Your team will likely suffer from confirmation bias, the tendency to be anchored by the dominant view and find evidence that supports this preconceived notion, ignoring that which doesn’t.  In short, if you have created a work environment that denies introverts the opportunity to participate on their terms, you lose a potential treasure trove of useful input.

I came to notice this—often too late–during my leadership experience in several settings of government, the private sector, and health care.  Like many of you, I had been trained to believe that group work would be the most productive and creative way to scope out problems and identify solutions.  Task forces, white boards, and group facilitators were the standard package for solving problems at the organizations that I led.

But privacy and autonomy can be very useful catalysts for innovation too.  “Solitude is a crucial ingredient to creativity,” Cain argues. “For some people, it is the air that they breathe.”  Einstein, (above), is quoted as having said, "The monotony and solitude of a quiet life stimulates the creative mind."

If you wish to avoid groupthink, it may be better to allow your staff to go out and work alone for some portion of a problem-solving exercise.  There, they can be free from the distortion of group dynamics.

I understand that this cannot be the sole method of problem-solving.  After all, you need to build a coalition of the entire team to have a successful implementation—and you certainly want to hear critiques of a plan from all affected divisions in the organization. But you need a strategy to engage introverts beyond task forces, group discussions and other highly social settings.

Another way to engage introverts is to channel introvert characteristics in your own behavior.  Grant writes, “We tend to assume that we need to be extremely enthusiastic, outgoing and assertive, and we try to bring employees on board with a lot of excitement, a clear vision and direction, but there is real value in a leader being more reserved, quieter, in some cases silent, in order to create space for employees to enter the dialogue.”

Grant relates the story of the CEO of one Fortune 500 company who has a policy of silence for the first 15 minutes of meetings. He did not utter a single word, although he is an extrovert. Grant explains, “He feels that he has a tendency, once he gets excited about ideas, to run with them to the point where, at times, it leaves employees feeling like they weren’t included. So he tries to combat that: ‘I want you guys to tell me whatever you’re thinking about — suggestions, feedback, questions — and the floor is yours.’ He listens quietly and takes notes.”

But one executive’s mindful silence is not enough. You’ll need to make sure that other extroverts in the room do not dominate. I recall meetings in which our chief of surgery (no surprise!) would sometimes try to assert control over a discussion of our hospital’s Chiefs Council.  We needed to make explicit time for, and request comments from, the less outspoken chiefs of other departments. Luckily, the chair of the Council, our chief of psychiatry, was a master of calm and could help assure participation by all.

Cain offers a bit of sage advice to us extroverts, one that is especially important for leaders: “Have the courage to speak softly.  While Western culture favors the man of action over the man of contemplation, give introverts the freedom to come up with their ideas.”

False Memories Generate Persuasive Truths

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint, with an added footnote and embedded links, is from a post dated February 5, 2015, "False Memories Generate Persuasive Truths."

There has been much written lately about the tendency of people to develop false memories about events they have witnessed or experienced. I’m not talking about folks who intentionally mislead themselves or others about a given series of actions or events—perhaps, say, to alleviate guilt or horror. I’m talking about people who truly, deeply believe that they saw something occur as they now remember it. Their brains are incapable of understanding that their views of the events are flawed.

This phenomenon might be one of the highest forms of cognitive errors, and it raises serious questions for those of us in leadership roles who like to be, in Donald Schön’s words, reflective practitioners. Don’s concept was elegant. Over the years, we develop a framework based on our experiences and observations that guides our actions and choices today.

A reflective practitioner is one who works within that framework but who is constantly testing it based on new information. As we learn from recent events, we reconfigure our world view and adapt our leadership methods to our newly revised conception. We then attempt to persuade people in our organizations and those outside that the path we’ve chosen is one they should join.

But if our memories might be flawed, how do we know that the lessons we draw from them are likely to be accurate, much less helpful? Should we try to build in a method of self-correction to help us compensate for our cognitive weaknesses? After all, our organizations and our people are counting on us to be analytical, thoughtful, and precise. If the memories are flawed, won’t our conclusions also be?

We could answer this by saying to ourselves, “Hey, I do the best I can. If I miss something important because I didn’t realize that I was mis-remembering, I’ll make mid-course corrections later. Meanwhile, I’ll present the facts and figures and my impeccable logic, and the power of that logic will cause people to follow my lead.”

That’s not a bad answer, but there is a better one. I recently had a chance to attend a marvelous literature festival in Jaipur, India.

Many of the best authors in the world presented there, and one session was called “The Art of the Memoir.” Among the panelists were Anchee Min (born in China and now in the U.S.); South Africa’s Mark Gevisser; the U.K.’s Brigid Keenan; and Joanna Rakoff from the U.S.

All of these authors had written memoirs, i.e., books about a portion of their own lives. The conversation turned to the question of how to assure that a memoir was accurate. It quickly became clear that narrative was more important than accuracy. Rakoff put it this way: “A memoir is not what happened. It’s what I wrote about what happened.” She did not mean that she was intentionally clouding the factual history surrounding events. She meant that she had to make sense of what had happened and be able to transcribe it in a way that was useful, compelling, and entertaining for herself and her readers. In short, she had to be persuasive.

Gevisser went further along these lines: “The memory only happened once I found the language for it.” Keenan suggested that finding the language is an iterative process. Even for someone who has trained herself to keep daily notes, “The transformation of a journal to memoir takes about eight drafts.”

What possible lesson can we draw from these authors? To me, they displayed an acceptance of the likelihood of cognitive errors in their remembrance of events. Indeed, they considered the existence of a gap between memory and fact to be an asset. Instead of saying, “Hey, I do the best I can,” they endorse and cherish the existence of the gap. Their focus is on creating a narrative that can teach a lesson or motivate readers.

There is a leadership parallel here. The great leaders are those who offer a persuasive narrative to their potential followers. The likelihood of building a coalition in support of a given direction is directly proportional to the power of that narrative. How is that narrative most likely to be persuasive?

My friend and colleague James Sebenius, at Harvard Business School, recently reminded me of important lessons related to persuasion. Centuries ago, Aristotle suggested that there are three aspects of persuasion—logos, ethos, and pathos. The tendency of many leaders today is to rely on logos (logic, reason, and evidence) to motivate their followers.

Facts certainly have their place, but the other parts of Aristotle’s equation are equally powerful. Both pathos (connecting emotionally) and ethos (establishing your good character) are best transmitted by stories. Vivid and specific language complement logic and evidence. Stories that reflect the story-teller’s principles and vulnerability likewise add persuasive appeal.

The authors in Jaipur were, in essence, telling us to channel Aristotle. Understand that your memories are likely to be flawed, but confidently use the memories you have. Take the time to draw from them elements of a persuasive appeal. As the political organizer Marshall Ganz (and the ancient Jewish philosopher Hillel) would have put it: First share the story of your self. Next, draw connections with your listeners and help them understand that your story is about “us,” the organization and its purpose. Finally, create a sense of urgency and communicate that this a story about “now,” with an imperative for action today.*

In this manner, false memories will generate persuasive truths.
--
* “If I am not for myself, who will be for me? If I am only for myself, what am I? And if not now, when?” (Pirkei Avot Chapter 1:14)

Coaching through failure

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint (retitled and with the real names included) is from a post dated July 11, 2014, "How I Coach."

In this season of world class soccer, I hope you’ll forgive a short autobiographical moment from my most important pastime: coaching girls soccer. I’ve learned so much from these children over more than two decades and have put many of those lessons in my book Goal Play!

In fact, my current slogan is, “If you can effectively coach 12-year-olds in soccer, you can run an academic medical center!” This is not a statement about the comparative emotional ages of doctors and 12-year-old girls: It is a realization about how people of all ages deal with what is often the distress of learning and how you, as a leader, can help encourage them to grow as part of a learning organization.

Today’s story is about disappointment, when a member of your team has failed and feels inadequate to the task at hand. How do you present a compelling and honest narrative to a discouraged person so that he or she can move on, gain confidence, and remain a productive and happy member of the team?

The setting is a rainy, cold, and muddy soccer game, in which Liisa was playing goalkeeper in the second half of the game and let the two winning shots get past her. She was greatly discouraged and was convinced she was accountable for losing the game. She compared herself to her teammate Abby, who had successfully defended the goal in the first half, and she went home and told her parents that this would be her last soccer season. Instead, she would play basketball, a sport in which she felt more accomplished.

Although I talked to her and reassured her right after the game, I know that a more persuasive approach might be possible once a few hours had passed.

Here’s the email I sent:

Dear Liisa,
I know you were so sad after yesterday’s game, and I felt very badly for you. I tried to cheer you up a bit, but I know it was not the right time, and I didn’t succeed. Would you mind if I offered some more thoughts now?

Let me start with the basics: You are a terrific person, a great team player, and a natural leader among your teammates. Plus, you are an excellent soccer player and, yes, an excellent goalie. We all, your teammates and coaches, admire and respect you.

The playing conditions yesterday were awful for you as goalie. In fact, they were worse for you than for Abby because the field got wetter and wetter as the game went along. The ball got muddier and muddier, and it also became more saturated with water. As a result, it was increasingly hard to hold on to. Also, because of the extra weight, it had more momentum when it was kicked, making it extremely difficult to catch or stop.

When you are a goalie, it is easy to remember the balls that get by, but you forget about all the other times you saved the play and rescued the team from defensive lapses. You did that plenty of times, plus you also “directed traffic” from your position as goalie, helping your teammates respond to and anticipate what the other team was doing. I will tell you that most goalies your age are not as good as you are on all of those counts. That is a very special set of skills, requiring presence and maturity.

The setting is a rainy, cold, and muddy soccer game, in which Laura (name changed) was playing goalkeeper in the second half of the game and let the two winning shots get past her. She was greatly discouraged and was convinced she was accountable for losing the game. She compared herself to her teammate Alice, who had successfully defended the goal in the first half, and she went home and told her parents that this would be her last soccer season. Instead, she would play basketball, a sport in which she felt more accomplished.
Although I talked to her and reassured her right after the game, I know that a more persuasive approach might be possible once a few hours had passed.
Here’s the email I sent:

Dear Laura,
I know you were so sad after yesterday’s game, and I felt very badly for you. I tried to cheer you up a bit, but I know it was not the right time, and I didn’t succeed. Would you mind if I offered some more thoughts now?
Let me start with the basics: You are a terrific person, a great team player, and a natural leader among your teammates. Plus, you are an excellent soccer player and, yes, an excellent goalie. We all, your teammates and coaches, admire and respect you.
The playing conditions yesterday were awful for you as goalie. In fact, they were worse for you than for Alice because the field got wetter and wetter as the game went along. The ball got muddier and muddier, and it also became more saturated with water. As a result, it was increasingly hard to hold on to. Also, because of the extra weight, it had more momentum when it was kicked, making it extremely difficult to catch or stop.
When you are a goalie, it is easy to remember the balls that get by, but you forget about all the other times you saved the play and rescued the team from defensive lapses. You did that plenty of times, plus you also “directed traffic” from your position as goalie, helping your teammates respond to and anticipate what the other team was doing. I will tell you that most goalies your age are not as good as you are on all of those counts. That is a very special set of skills, requiring presence and maturity.
Briana Scurry, the goalie for the US national women’s team, was once asked if she thought about the balls that got by her–and plenty did. Her answer, “Never! I only think about the ones I stopped. When I plan for the next game, I visualize success. If another ball gets past me in a game, I immediately put it behind me and get back to visualizing success.”
I don’t know if you feel you can do what Briana did, but it is worth thinking about.
It’s ok to feel sad about yesterday’s experience, but you must believe me that you in no way let anyone down. Your teammates and coaches understood totally what you were up against, and they admired you for trying your best. And, after all, isn’t that the most we can hope for?
So, take yesterday as one of those important learning experiences. When adversity strikes, cry if you need to, but then walk off with your head up high, smiling, and say, “I’m a great goalie!” Because, my dear, Laura, you are. Indeed, you are more than that. You are a great person, and no one can take that away from you.
Fondly, Paul

And here’s how this bright young lady responded:

Thank you very much Coach Paul for this thoughtful email. I will try to continue visualizing success and put yesterday behind me. This was a very kind and well thought out email and I appreciate it very much. See you on Wednesday!!
Thanks again!
Laura

Success! We are reminded by this story that the leader’s most important attribute is empathy. Let’s employ it to help our team members visualize success by learning from the failures they encounter.
- See more at: http://www.athenahealth.com/leadership-forum/coaching-through-failure#sthash.9nboA8QN.dpuf

Briana Scurry, the goalie for the US national women’s team, was once asked if she thought about the balls that got by her–and plenty did. Her answer, “Never! I only think about the ones I stopped. When I plan for the next game, I visualize success. If another ball gets past me in a game, I immediately put it behind me and get back to visualizing success.”

I don’t know if you feel you can do what Briana did, but it is worth thinking about.

It’s ok to feel sad about yesterday’s experience, but you must believe me that you in no way let anyone down. Your teammates and coaches understood totally what you were up against, and they admired you for trying your best. And, after all, isn’t that the most we can hope for?

So, take yesterday as one of those important learning experiences. When adversity strikes, cry if you need to, but then walk off with your head up high, smiling, and say, “I’m a great goalie!” Because, my dear, Liisa, you are. Indeed, you are more than that. You are a great person, and no one can take that away from you.

Fondly, Paul

And here’s how this bright young lady responded:

Thank you very much Coach Paul for this thoughtful email. I will try to continue visualizing success and put yesterday behind me. This was a very kind and well thought out email and I appreciate it very much. See you on Wednesday!!
Thanks again!
Liisa

Success! We are reminded by this story that the leader’s most important attribute is empathy. Let’s employ it to help our team members visualize success by learning from the failures they encounter.

Knowing When It's Time To Leave

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint, with some additional embedded links, is from a post dated March 27, 2014, "Knowing When It's Time To Leave."

In a recent article on the HBR Blog Network, Manfed F. R. Kets de Vries asks the question, “How long should a CEO stay in his job?” He answers by saying, “seven years in probably the period of maximum effectiveness for most people in what can be a very stressful job.” He goes further to describe three phases that characterize the tenure of many CEOs — entry, consolidation, and decline.

He asks, “So what can be done when a CEO starts to decline? The best scenario, of course, is if that the CEO himself realizes what is happening, acknowledges his increasing ineffectiveness, and looks for new horizons when the going is still good. Ideally, that is at the point when they are in the sweet spot of being at the peak of their performance, just before decline.”

In my case, I arrived at Beth Israel Deaconess Medical Center in January of 2002, with the assignment to lead a financial turn-around of an extremely troubled organization. By September of 2003, we officially declared the end of the turn-around, as the hospital had returned to sustained profitability.

Having survived, it was then time to engage in a full-fledged series of strategic plans—focusing on the three parts of this academic medical center’s mission–clinical care, education, and research. By engaging the faculty and staff, we were able to reach a consensus on the overall direction of the place.

Meanwhile, due in great measure to the recruitment of Dr. Mark Zeidel as chief of medicine, we began an intense program in safety and quality improvement. Mark’s commitment to this journey was soon matched by the other incumbent chiefs and supplemented by the recruitment of new chiefs of pathology, radiology, and anaesthesia. My role in this effort was to initiate unprecedented levels of transparency with regard to clinical outcomes. Our Board was on board, too, adopting a four-year goal of eliminating preventable harm in our hospital, and posting on our corporate website—for the world to see—progress towards that goal. Every quarter, the actual numbers and types of cases of harm in our hospital would be made transparent.

In March of 2009, we faced a new crisis as the financial meltdown occurred in the US economy. Having started the fiscal year with projections of a $20 million surplus, by mid-year we were instead looking at a likely $20 million deficit. My COO and CFO recommended laying off 400 people to balance the budget.

I refused and instead asked people in the hospital to suggest ways in which they were willing to absorb personal financial sacrifices to help avoid layoffs. The response—which received national attention—was overwhelming. We not only avoided the layoffs, but we were able to exempt the lowest paid workers from having to participate in any of the sacrifices chosen by the others.

In August of 2009—right in line with de Vries’s timetable—I woke up one morning and realized I was tired. I was tired from a job that had extremely demanding physical and psychological components. I was also tired of the job, having felt that I had done my most creative work. I was ready for new challenges. In terms of my personal health and well-being, it was time to leave. Also, it was time to let a new person with more energy and enthusiasm handle the next stage of challenges facing the hospital.

But I decided to stay on. Why? Here’s where I let myself be trapped by the close personal relationships that had grown between the staff and me. Hospitals are compelling and emotionally complex places, and an empathic CEO feels the joy and pains of the staff and builds a deep personal bond with these well intentioned people who devote their lives to eliminating human suffering caused by disease.

In this case, there was an additional anchor. I felt an obligation to our generous staff to stay long enough to see the hospital through its financial crises and to restore the pay cuts and reductions in benefits that they had voluntary taken. I knew that this new turn-around effort might last at least another year, and I decided to commit myself to staying the course.

Sure enough, by the fall of 2010, our fiscal health had been restored. I was able to restore the cuts in pay and benefits. I was even able to award everyone with a $500 bonus out of gratitude for all they had done to help to the hospital and one another.

This was a source of great personal satisfaction for me, but as I look back on the experience, I realize that it was a mistake to stay beyond the seven years. While my motivation in staying was not selfish—it fact, it was just the opposite—it was self-centered. Was I the only person who could have led the organization through that recovery? No, there were many able leaders in the hospital who would have done just fine without me. But my dedication to the staff made me want to stay long enough to feel that I had delivered the goods to them.

As de Vries suggests, it is at such a moment when a Board needs to step in. They need to closely monitor not only the performance of the CEO but his emotional mindset. They must overcome inertia in governance, the natural reluctance to change horses when the race is going well. The loyalty and friendship that a Board feels towards a successful CEO is, ironically, a danger. It leads to complacency on the Board’s part, particularly during moments of corporate triumph. It is precisely then that a Board needs to carry out its most important function—telling themselves and the CEO that it is time for him to move on.

The Wrong Map

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated February 7, 2014, "The Wrong Map."

My good friend and negotiation guru Michael Wheeler includes an anecdote in his new book, The Art of Negotiation: “Many years ago, a military patrol was caught in a fierce blizzard in the Swiss Alps. The soldiers were lost and frightened, but one of them found a map tucked in his pocket. After consulting it, the men built a shelter, planned their route, and then waited out the storm. When the weather cleared three days later, they made their way back to the base camp.”

Wheeler continues, “Their commanding officer, relieved that his men had survived the ordeal, asked how they made their way out. A young soldier produced the life-saving map, and the officer studied it carefully. He was shocked to see that it was a map of the Pyrenees Mountains that border Spain and France, not the Alps.”

He suggests three reasons how the wrong map could help save climbers lost in the Alps: it rekindled the soldiers’ confidence, provided an impetus to get moving, and sharpened the soldiers’ awareness.

While Mike uses the anecdote to draw lessons for negotiators, perhaps it also offers suggestions to leaders in health care. Their institutions face formidable challenges, and the way forward is not always clear. They know that standing still — failing to act — is more dangerous than going in slightly the wrong direction. But how do you motivate your staff to take action and deal with the ambiguity of the situation?

The traditional wisdom is that you have to “create a burning platform.” Such an approach uses the threat of imminent financial disaster or major loss of market share as an incentive to those in the organization. Well, maybe. But the problem with a burning platform is that your people fear that the only way to go as they step off the platform is down.

Few people want to take accountability for initiative in that situation. Frankly, most people are risk-averse, and telling them that the world depends on them for decisive action is not highly motivational.

So, how do we get people past their natural risk-averse tendency? How do we suggest to them that any (thoughtful) action is better than sitting back and waiting? How do we get them moving in a direction that has some probability of being correct? How do we help them sharpen their awareness so they are alert to the need for mid-course corrections if the original path proves to be off target?

What map of the Alps can we offer our staff?
 
The traditional one is a strategic plan: We engage in a long process to survey our strengths, weakness, opportunities, and threats. We fan out through the organization and create working groups to enhance buy-in of our analysis and the alternatives we choose. We overlay the process with nifty charts and graphs, careful to include the “levers” that will make a difference in our financial situation or competitive posture. Then we assign the strategic initiatives to various inter-disciplinary groups and create key performance indicators for each division of the company to measure our progress in carrying out the plan.

It is hard to imagine a less inspirational start to a journey of change than this kind of centralized, highly numerical, and bureaucratic approach. Here’s a secret. Every strategic plan I have seen in the health care world says the same thing: “Let’s focus on what we are good at that pays us well, where we can gain market share, and do more of that. For the things we don’t do as well, or where payment is not good, it’s okay not to grow or even to shrink.”

I’m not suggesting that an organization should avoid a strategic vision. Indeed, having such a vision is a key role of senior management. I am suggesting that the way to give your “soldiers” the confidence to leave the campsite, engage in experiments, take risks, and be creative does not come from an externally generated strategic process. Instead, we need to allow confidence-building measures to grow organically from within the organization.

In previous columns, I’ve talked about the value of the Lean process improvement philosophy in reducing waste, i.e., improving the operating efficiency in an organization. With the Lean approach, the front-line staff is empowered, expected and encouraged to call out problems in the work place. Management is expected to swarm around those identified problems—in real time—and invent experiments to test out countermeasures to improve the delivery of goods or services to the customer.

Well, it turns out that Lean also provides that “map of the Alps” in an uncertain environment. The “map” here is a general philosophy, approach, and set of tools that is independent of the actual physical and competitive work environment. It maintains and enhances our confidence as a team. The “every person every day” theme of Lean provides ongoing impetus to keep moving. Finally, knowing that the organization expects and encourages the staff to call out workplace waste sharpens their awareness.

The “map” for dealing with the challenges of a health care institution is being held by every staff person in our organizations. Our job is to create an environment in which they can feel the map in their pockets and set off each day in the right direction — to reduce waste, improve efficiency, and deliver better service to patients and families.

Bridging the Gap Between Planning and Reality

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated December 17, 2013, "Bridging the Gap Between Planning and Reality."

A colleague once said, “Every plan is excellent, until it’s tested. It’s execution that’s the problem.” And so it is.

Clay Shirky wrote an excellent article about the gulf between planning and reality. Although the focus was on the misadventures of Healthcare.gov, the US government’s insurance exchange website, the broader lessons that he presents are worthy of consideration in many other settings.

Shirky notes: The management question, when trying anything new, is “When does reality trump planning?”

In the case of Healthcare.gov:

For the officials overseeing Healthcare.gov, the preferred answer was “Never.” Every time there was a chance to create some sort of public experimentation, or even just some clarity about its methods and goals, the imperative was to deny the opposition anything to criticize.

Failure is always an option. Engineers work as hard as they do because they understand the risk of failure. And for anything it might have meant in its screenplay version, here that sentiment means the opposite; the unnamed executives were saying “Addressing the possibility of failure is not an option.”

Project advocates enter every endeavor with a theory of the case, a vision of how things should be. But, as my late colleague Donald Schön noted, reflective practitioners are constantly reviewing the evidence to modify their framework in response to reality.

A comment on Shirky’s article summarizes this nicely:

“Any personal opinion you had given really doesn’t mean anything.” This is the key principle behind making anything work well — from writing an essay to building a bridge to creating a website. If it doesn’t work, throw out your preconceptions and re-conceive.

There is a cognitive basis for our failure to be reflective practitioners. We are all people of habit. The attributes that permitted us as cavemen to recognize the saber-toothed tiger the second time we saw it and to respond in the appropriate way (“Run!”) work well in the highly simplistic natural world. In a Darwinian sense, we evolved perfectly for that world. We developed a learning style that gave us a competitive evolutionary advantage, a learning style based on memory, stubbornness, and brute force.

But the more difficult world of complex organizations — overladen with political, organizational, and cultural forces and with technological challenges — presents an environment in which those cognitive attributes now present as cognitive errors. We struggle with this. Indeed, as MIT professor Rosalind Picard has outlined, successful learning has three phases: interest, distress, and pleasure.

We feel distress in the second phase because it is during that portion of the cycle that we must overcome our prejudices and develop a new framework within which to proceed. We resist. Sometimes we recognize that we have hit a plateau and need to adopt a new approach to proceed. Sometimes we don’t recognize that our framework is flawed and we uselessly proceed apace, until disaster occurs or a competitor outruns us.

Learning Organizations & Lean Philosophy

Places that are true learning organizations have built in a structure that calls the question early and often. One such structure (but not the only) is offered by the Lean philosophy. By encouraging front-line staff to call out problems they encounter in their daily life, managers are given real-time signals as to flaws in their organization’s processes. The leadership team then visits the sites of the flaws and invents experiments to achieve incremental improvements in work flow. Using the scientific method, those experiments are tested and evaluated, with redesign being a constant part of the process. Lean organizations understand that there is no group of central planners clever enough to design an optimum complex process. Lean leaders do not lack for a strong purpose—indeed audacious goals are favored—but neither do they lack humility.

Lean and other similarly designed organizations can only exist where the senior leadership is a strong advocate for the proposition that reflective practice is the best way to achieve outstanding performance for their customers. The leaders of such organizations embed that modesty and reflection in every aspect of their lives.

I’ve had the pleasure of visiting a number of hospitals that work along these lines. The results are palpable — better service to patients, higher quality, less waste, and more staff satisfaction. Such results are irrespective of the type of payment regime employed to compensate the doctors and the hospital. They are irrespective of the societal form of health care, be it a national public system or a dispersed private pay system.

Such hospitals remain anomalies in their industry, although the number is growing. Adoption tends to center in systems with a strong communitarian spirit, where the trustees and clinical and administrative leaders view their job mainly as providing a public service as opposed to supporting the personal and institutional prerogatives of physicians. Thus, while a few academic medical centers have gotten on board, many have not, trapped by age-old patterns of deference to the doctors. Ironically, in those academic medical centers that have adopted Lean or a similar approach, physicians report tremendous satisfaction from their engagement with process improvement and from the enhanced sense of teamwork with members of the staff throughout the hospital.

The young cadre of rising health care leaders I see when I address clinical and administrative training programs, and when I speak at conferences and in hospital settings, understand that the future is brightest for learning organizations. They thirst for experience in trying out these approaches, and they intend to lead in the manner of reflective practitioners. I say to current health care leaders, when you find one of these rising stars, grab him or her for your place. They are going to teach you something special.

Advocating Through Inquiry

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated October 31, 2013, "Advocating Through Inquiry."

Here’s a familiar story in America’s hospitals. An “old fashioned” surgeon decides that the protocols and procedures put in place by the medical executive committee or other governing body don’t apply to him. “I’ve done it this way for 30 years, and it works fine. I’m the busiest surgeon here, and no one is going to tell me how to do my job.”

People in the risk management field will advise you that such a person is a high risk. His attitude often carries over to treatment of people in the OR. At best, he is uncompromising and lacking empathy. At worse, he is psychologically or perhaps even physically abusive to lower level staff. He also tends to treat patients with a lack of respect. He has more patient complaints on file compared to his peers. When he finally makes a mistake that causes a patient harm, he is a likely candidate for a large malpractice lawsuit.

And yet, notwithstanding this behavior, the hospital leadership is unlikely to do much to correct the problem. The surgeon has a great reputation in the community and is the source for many referrals. So, at most, when an egregious incident is reported to his chief, the reaction might be, “Yeah, I guess I won’t give him his full bonus this year.”

Clearly, such an approach is inadequate and will not resolve the underlying problems. It fails because the message is not delivered at or near the time of the incident. Also, there is not always a nexus drawn between the financial penalty and the behavioral issue. Finally, financial penalties do not have a lasting impact on behavior, if they work at all.

Institutionally, we are advocates for greater adherence to clinical approaches that are safer and deliver higher quality care. We also seek behavior between doctors and colleagues—and doctors and families—that is mutually respectful and reflects a partnership in delivering care. When a doctor has been habitually misbehaving on any of these fronts, we need a way to persuade him to change his ways.

Authority vs. Awareness Intervention

An alternative and more effective approach is outlined in several articles by Gerald Hickson and others from the Vanderbilt University School of Medicine. One article presents a hypothetical example about an emergency room doctor who has misbehaved:

Dr. Trauma has high productivity. Nonetheless, you cannot offer excuses for his performance. Others in the department conduct themselves professionally. In addition, this is not the first time that Dr. Trauma has behaved this way. During the past two years, other team members submitted event reports that describe similar behaviors. Some of the coworker and patient complaints suggest that Dr. Trauma gets angry in pressured circumstances.

You previously spoke with Dr. Trauma about several complaints from coworkers and patients. You find it concerning that Dr. Trauma failed to self-correct after this feedback. Given the accumulation of patient and staff complaints and the current event analysis, you decide that what is right for Dr. Trauma and the organization is for you, as his chief, to . . . require Dr. Trauma to undergo a comprehensive mental health evaluation and, if indicated, a defined treatment plan. Failure to comply would subject the physician to a loss of privileges.

Certainly this kind of “authority intervention” would get someone’s attention, but hospitals are wary of this approach, in that it has the potential of knocking a high performer off the clinical rolls. Also, chiefs often have a personal relationship with the doctor in question, one that makes it difficult to suggest that his colleague is medically impaired.

But Hickson, et al., also point out that a preliminary step can be effective and help avoid the authority intervention. They term this an “awareness intervention” by a peer. Awareness intervention is based on the premise that “each professional has a responsibility that colleagues and systems do no harm” and that “concerted effort to remove systemic or behavioral threats to quality must include willingness to provide feedback to others observed to behave unprofessionally.” It relies on “sharing aggregated data that present the appearance of a pattern that sets the professional apart from his/her peers.”

The key element of awareness intervention is to have a trained peer “messenger” present the data (e.g., the high relative number of patient complaints) and encourage the physician to reflect on what might be behind that pattern, but not to provide directive or corrective advice. The reason? “If a messenger offers a plan that does not ‘work,’ the high-risk doctor can blame the plan and the messenger. We therefore want messengers who promote ‘awareness’ and encourage self regulation.”

The Vanderbilt experience suggests that this form of intervention is often successful. When it is not, the organization moves up the ladder to the type of authority intervention mentioned above.

Some readers might be surprised that awareness intervention would achieve any result. But let’s look at the underlying psychology. First, doctors view themselves as scientists and can be persuaded by data. Second, the troubled physician is treated respectfully. Third, the remediation plan is not prescribed by another and therefore cannot be viewed as externally imposed. It is his own creation based on his understanding of his problems.

If we think about it more generally, though, the Vanderbilt approach is based on an old theory of persuasion, one put forth by St. Francis: “Grant that I may not so much … be understood as to understand.” Or as Steven Covey restated it, “Seek first to understand and then to be understood.”

Hickson and colleagues have designed a program that achieves advocacy through inquiry. We stimulate the troubled doctor to consider the reasons for his behavior and the results that stem from it. We ask him to reveal his understanding of those reasons by designing and acting on a plan to remediate them. We learn things about that doctor that can be very helpful in our dealings with him but may also be useful more broadly in our institution. Ultimately, through this process, he understands, too, where we are coming from and adopts behaviors consistent with the greater good. Our advocacy has succeeded.

Negotiating on Purpose

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated September 25, 2013, "Negotiating on Purpose."

After her fifteen year-old son Lewis Blackman died from a series of preventable medical errors, Helen Haskell diagnosed the problems in the hospital by saying, “This was a system that was operating for its own benefit.”

What she meant was that each person in the hospital was unthinkingly engaged in a series of tasks that had become disconnected from the underlying purpose of the hospital. They were driven by their inclinations and imperatives rather than by the patient’s needs. Indeed, they were so trapped in that form of work that they could not notice the entreaties of a seriously concerned mother as her son deteriorated.

I once heard a Harvard business professor describe the financial imperatives of many hospitals in a less personalized, but analogous fashion. He called hospitals “business cost structures in search of revenue streams.”

What he meant was that the business strategies of the hospital had become detached from the humanistic purposes that had led to the creation of the hospital. There was thus a parallel to the individuals’ behavior noticed by Helen.

What a perversion of human endeavor when things reach this point! Activity for the sake of activity in the context of an organization that has lost its soul.

Lest we get distracted by the current debate about the incentives that might correspond to different payment models—fee for service, bundled, or capitated rates–is important to note that this kind of perverted personal and corporate behavior is not driven by rate design. The failure of Lewis Blackman’s doctors and nurses had nothing to do with financial incentives. No, the systemic forces at work that killed this young man were based on ego, fear, poorly functioning hierarchy, lack of communication, and cognitive errors.

Likewise, the corporate search for revenue for the entities that constitute our hospitals and health systems has not been driven by rate design. Under any payment regime, the underlying issue is that hospitals are huge fixed-cost enterprises, and the incentive to “feed the beast” often drives corporate strategy, driving out humanistic concerns. Indeed, it may be that a movement to provider risk-sharing will simply compound the problem in that it will require hospital systems to accumulate greater financial reserves to hedge the actuarial risks that are being transferred in their direction.

Let’s not lose the irony of this kind of situation. The people who have chosen to be in the health care field are, for the most part, the most well intentioned people in the world. They have devoted their lives to alleviating human suffering caused by disease. They are intelligent and thoughtful and highly trained.

Indeed, if each of us in health care were asked to state the purpose of our institution in our own words, I bet we would say something similar. In my former hospital it was codified as follows: “We hope to take care of patients in the manner we would want members of our own family cared for.”

People’s behavior in the moment, though, often is at variance with such purposes. Corporate imperatives likewise go awry.

It is at time like this that we search for leadership that will help steer the ship and those in it in a more humanistic direction. Surely the leader cannot be agnostic with regard to financial concerns, but he or she needs to act to help the organization put purpose above all. What can we expect and hope for from great leaders at this juncture in medicine’s crisis of purpose? The usual answer—inspiration—is not correct.

Professors often draw a distinction between management and leadership, noting that leaders have the ability to inspire people in an organization to a higher purpose. Yes, there is the kind of inspiration that occurs during a crisis, like that offered by Winston Churchill during World War II or Franklin Roosevelt during the Depression. But for most organizations involved in the day-to-day work of providing a service to the public, the professors’ description is off point, for the leader’s ability to inspire is not germane. The ability to inspire can provide a shot in the arm, but it seldom leads to sustained and mindful action on the part of people in an organization in support of its purpose.

My view is that inspiration comes from within and is tied to those ethical standards and good intentions that caused people to enter the health care professions in the first place. The leader’s job, then, is not to inspire. It is to use his or her influence to help create a supportive environment that permits the waiting reservoir of such intentions to be tapped.

Paul O’Neill, former Secretary of the Treasury and CEO of Alcoa Aluminum, has set forth a three-part test for an organization seeking to empower its staff to fulfill its mission:

1. Are my staff treated with dignity and respect by everyone, regardless of role or rank in the organization?

2. Are they given the knowledge, tools and support they need in order to make a contribution to our organization and that adds meaning to their life?

3. Are they recognized for their contribution?

The leader’s job is to carry out an ongoing negotiation with the various constituencies in a hospital to persuade them that it is in their interest to organize their work and behavior in such a manner as to permit these conditions to take hold. You might find it strange that I frame this responsibility as a negotiation, but that turns out to be a more apt description than others that might be used.

Hospitals are filled with highly trained professionals who want to spend their time doing the things they are trained to do. Those people are not generally trained in the kind of interpersonal skills and team behavior that is required to support Mr. O’Neill’s desired conditions. The leader has to persuade those individuals that their own role will be enhanced if they learn to behave in such a manner as will help develop O’Neill’s conditions. In negotiation parlance, they have to be made to feel that agreeing to such an approach is a better path than their alternative, i.e., not agreeing to it.

People who are likely to be the future leaders of health care institutions in America and abroad often come to me for career and training advice. My constant refrain is to learn the principles and framework of negotiation strategy. Negotiation can be defined as means of satisfying parties’ underlying interests by jointly decided action. You cannot be a leader if you do not know how to help a hospital’s constituencies understand that their interests are coincident with the purpose of your organization and if you cannot help them jointly decide on the actions needed to carry out that purpose.