Tuesday, September 01, 2015

MA Health Quality Partners display variation

Here's some nice work from the Massachusetts Health Quality Partners, a part of their Practice Pattern Variation Analysis (PPVA) program. There are 40 conditions identified by MHQP where they have identified significant differences in the use of medical services for similar conditions. The idea is that:

Clinical leadership can address the causes of the variation and determine whether the variation is clinically warranted, how to initiate change if it is not, and consider how the variation impacts quality, safety and cost. Through PPVA, the medical community can work  toward adoption of community developed standards and actions that will improve quality care for patients.

I think this is a thoughtful approach to variation, one that is engaging and respectful of clinicians.  I was interested to see this recent example:

One of the conditions MHQP's PPVA program identified as a strong opportunity to better understand variation was the frequency of ultrasounds during pregnancy.  

Major epidemiological studies on this matter have not been undertaken since the 1990s, when the equipment emitted only one eighth of the acoustic energy being emitted with today's modern equipment (2012 British Institute of Radiology). Moreover, an analysis of published literature released by the Cochran Collaboration on fetal ultrasound concluded that "routine scans do not seem to be associated with reductions in adverse outcomes for babies" (Cochrane Collaboration 2010).

In 2014 MHQP's statewide PPVA program  identified the number of ultrasounds after the first trimester in uncomplicated pregnancies as one of over 40 conditions that demonstrated significant practice variation among clinical providers.  MHQP engaged with Massachusetts Chapter of the American College of Obstetricians and Gynecologists and concluded that  for the Massachusetts commercial patient population, the average number of ultrasounds per uncomplicated pregnancy after the first trimester was greater than 4, with patients receiving between as few as 1 and as many as  9 ultrasounds per pregnancy. 

Monday, August 31, 2015

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.

Sunday, August 30, 2015

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,

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.


Saturday, August 29, 2015

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 14th 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.

Thursday, August 27, 2015

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.

Wednesday, August 26, 2015

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. 

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. 

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.

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.”

Tuesday, August 25, 2015

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!

Monday, August 24, 2015

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.”