My arm's getting tired

What's the right metaphor?  Am I beating a dead horse or what?

As a person who has been engaged in public policy in a multitude of industries for well over three decades, I remain shocked at the lack of rigor involved in such matters in the health care field.  The issue is this:  There should be a number of preconditions before one seeks to use financial incentives or penalties to influence behavior.  If these conditions are not met, the financial tools will either not work or will have unintended consequences.

What might those conditions be?  Let's start with a few:
1)  Have a clear sense that the metric to be measured is determinative of the result sought.
2)  Ensure that the recipient of the financial payment or debit controls the work flow associated with the metric.
3)  Be confident that the recipient is likely to be influenced in the correct direction by the financial incentive.
4)  Ensure that the amount of the financial incentive is sufficiently meaningful to the recipient that it is likely to influence his or her behavior.
5)  Consider how to avoid the unintended consequences of the financial incentive, e.g., impacts on other metrics that are of concern.

We've talked about this problem with regard to penalizing hospitals for higher than average readmissions.  Now, Kaiser Health News summarizes a recent NEJM article, as follows:  "CMS penalties don't change hospital acquired infection rates."

A Medicare payment policy designed to push hospitals to cut their infection rates has had no effect in reducing two types of preventable infections among patients in intensive care units, researchers say in a study out Wednesday in the New England Journal of Medicine.

“The financial penalty did not further reduce infection rates, which were already going down because of multitude of (infection control) campaigns and interventions that were already ongoing,” said the study’s lead author Grace Lee, associate professor, Harvard Pilgrim Health Care Institute and Harvard Medical School.

Other studies have found the payment policy resulted in increased attention by hospital leaders – sometimes at the expense of other infections not targeted by the policy.

As policy efforts expand, the researchers say “careful evaluation is needed to determine when these programs work … and when they have unintended consequences.”

Piling on, Steffie Woolhandler, Dan Ariely, and David Himmelstein offer insights from behavioral economics in a post on Health Affairs Blog, entitled "Will pay for performance backfire?"  The introduction:

Paying for performance (P4P) has strong intuitive appeal.  Common sense and rigorous studies tell us that paying more for, say, angioplasties or immunizations yields more of them.  So paying doctors and hospitals for better care, not just more of it, seems like a no-brainer.  Yet while Medicare and many private insurers are charging ahead with pay-for-performance (P4P), researchers have been unable to show that it benefits patients.

Findings from the new field of behavioral economics may explain these negative results.  They challenge the traditional economic view that monetary reward is either the only motivator or is simply additive to intrinsic motivators such as purpose or altruism.  Studies have shown that monetary rewards can undermine motivation and worsen performance on cognitively complex and intrinsically rewarding work, suggesting that P4P may backfire.

Further on, they note:

The quality improvement literature has pinpointed many causes of quality breeches in medical care: fatigue; poorly designed workflow and care systems; undue commercial influence; knowledge gaps; memory lapses; reliance on inappropriate heuristics; poor interpersonal skills and insufficient teamwork, to name just a few.  But “not trying” is rarely cited.  Yet P4P implicitly blames lack of motivation for poor quality care.

But even when motivation is the problem, money isn’t always the solution.  Findings from the new field of behavioral economics indicate that performance bonuses often backfire, particularly for cognitively challenging work.

Are there financial incentives that could work in the complex environment of hospitals and physicians' offices?  Maybe so, but they will have to be much better designed that what we have seen so far.  We'll explore this in future posts.

Stunned into silence

I was talking with my soccer buddy Francesco about the common practice of Italians using their arms and hands when talking.  He related this story:

Visiting from Italy before attaining his current position at Harvard, he had gone to Arizona to do a guest lecture.  After a few minutes, a student in the front row interrupted the talk.  She said, "Professor, would you stop moving your arms so much?  Your hands are blocking your mouth.  I am hard of hearing, and I need to be able to see your lips to understand what you are saying."

Francesco reported, "I was stunned by the request.  I had no idea how I could talk!"

How'd you sleep?

How neat is this!  Science, Space & Robots reports:

The Ibis hotel group is installing robots in its Berlin, London and Paris hotels to paint your sleep patterns. Engadget reports that the robots will paint guests sleeping in its Sleep Art rooms. The robots monitor your sleep patterns using 80 sensors embedded in your mattress and then paint them on a black canvas. Take a look.  (Click here if you cannot see the video.)

A tale of two soccer games

If you had ever told me that I would issue a yellow card warning to an 11-year-old for dissent, I would have said you were crazy.  If you had told me that I would officiate a lopsided (6-1) boys high school game without having to yellow card one of those players, I would have been skeptical.  But both happened in the last two days.  The difference was totally based on the demeanor and attitude of the respective coaches.

During the little boys' game, the blue coach would gesture and expostulate whenever a call went the other way.  I'm not talking about major calls.  I'm talking about whether an out-of-bounds was a corner kick or a goal kick, or whether a throw-in went to the orange team or the blue team.  Pretty soon, as you would expect, his boys started to imitate his behavior, whether they were on the sidelines or in the game.  In fact, I told one or two of them to stop doing that and to focus on the playing.  I probably should have talked to the coach about it, but his words were not very loud, and the gestures didn't really interfere with the flow of the game.  There weren't many fouls in the game, and I prefer to let the kids play.

Well, this kind of behavior is contagious, and a coach from the orange team loudly questioned one of my calls--yelling across the entire length and width of the field--and pretty soon the other team's boys were also muttering about minor calls.  Finally, when I called a clear tripping foul on the orange team, one of the fellows yelled out "What!?" in a loud voice, clearly complaining about my call.  Needing an example for all, I called him over, and administered the yellow card for dissent.  He, abashed, said, "I'm sorry," just like an 11-year-old would say.

The referees out there will have advice and thoughts on what I might have done earlier in the game, and may even have thoughts about the efficacy of yellow cards with the age of players.  But the point is that the coaches set the example and tone of this game.  Two excellent groups of young players who would have had a marvelous time in a tight match found themselves judging a referee's calls instead of just playing the game.

A day later, I was officiating at a high school junior varsity game, where the blue team had clearly superior skills and ability compared to the white team.  As the score mounted, 3-1, 4-1, 5-1, the white players were getting more and more frustrated.  With boys this age, the result is often a kind of chippiness and undue aggressiveness.  The other team will then respond in kind.  Kids can get badly hurt at this stage in a high school game.  When I see it developing, I start to use calming words but also position myself ever closer to the play, so I can be on hand to calls fouls more quickly and with greater authority.  Such positioning also sends a message that someone is watching, so the fouls don't occur in the first place. In this case, I was helped by the white coach, who had seen the frustration mounting, too.  He would say, calmly, "Focus on the ball, boys," and other such things.  We got through the last fifteen minutes in the game in fine fashion, and the post-game handshakes were friendly and relaxed.  Again, a coach made a difference, but this time in a positive way.

After the little boys' game, I talked with my high school aged assistant referee and expressed some dismay that the coaches of the top team in each town would behave in such a fashion with 11-year-olds.  He said he had mentioned the problem to another experienced referee with whom he had worked, who commented that there has been a gradual degradation of coaching behavior among the coaches of the under-9 through under-12 teams.  I don't know how to validate whether there is such a trend.  I do know that it is an ineffective way to coach and teaches little boys bad habits that will get them into trouble in later years.

Election talk on WIHI

Friday, October 12, 2012: Navigating the Elections with a Clear-Eyed View
(1:00 – 2:00 PM Eastern Time)

Featuring:
Donald M. Berwick, MD, MPP, Former President and CEO, Institute for Healthcare Improvement; Former Administrator, Centers for Medicare & Medicaid Services
Chris Jennings, President, Jennings Policy Strategies (Washington, DC); Former Senior Health Care Advisor (Domestic Policy & National Economic Councils) to President Bill Clinton
 
We’re just weeks out from the November elections in the US and, depending on the outcome, health care reforms championed by the Obama administration will either continue unabated or possibly face some serious challenges — from a new President or a differently configured Congress. In the midst of this uncertainty, numerous individuals are keeping a close eye on the national policies and initiatives that have done the most of late to accelerate new payment schemes and the redesign of health care delivery, as well as expand insurance coverage.

IHI has two programs this fall to help you navigate this election cycle with a clarity of purpose that health care improvement requires more than ever in these tumultuous times: a WIHI with Dr. Don Berwick and Chris Jennings on October 12 and, on November 8, Out of the Blocks, an in-person, one-day conference in Washington, DC, featuring post-election analysis from Sen. Tom Daschle and Sen. Bill Frist, IHI President and CEO Maureen Bisognano, Virginia Mason CEO Gary Kaplan, and moderated by Don Berwick and NBC’s Nancy Snyderman, MD.

Because health care reform has become such a political flash point, it’s sometimes hard to find the “through line” for the improvement community in particular and the country as a whole. But Don Berwick says this is precisely what needs to happen. Starting with the October 12 WIHI, he’ll explain what “continuity of purpose” might entail in order to stay focused on a robust agenda that includes much greater attention to improving care across the continuum, reducing costs, and helping people and communities lead healthier lives. You can also count on Chris Jennings to summon his 25 years’ worth of experience as a health policy strategist to provide the freshest and most sanguine ways to think about reinventing health care in the US, even when political winds can, and often do, change directions.

Whether you’re steeped in forming an ACO or patient-centered medical home, innovating to improve the patient experience, hard at work on reducing avoidable readmissions, or engaged in any combination of these efforts and more, WIHI host Madge Kaplan invites you to mark your calendars and enroll for a special pre-election WIHI. And don’t forget Out of the Blocks on November 8th, a gathering in DC you won’t want to miss, immediately following the elections.

To enroll in the broadcast, please click here.

Inertia supports Baumol's disease

Steven Perlstein recently wrote a column for the Washington Post reminding us of a theory expounded by economists William Baumol and William Bowen, which has become known as "Baumol's Disease."  The idea, in short, is that there are some activities in society (like auto manufacturing and food production) that are subject to productivity improvements, and there are others (like education and doctoring) that are not as amenable to productivity improvements.  Everything else being equal, then, the percentage of a nation's spending that is devoted to the former will decline over time, while the percentage devoted to the latter will increase over time.

Baumol's theory was not the basis for my column a few days ago, in which I suggested that health care spending is likely to continue to rise in the developed nations.  I did suggest to a friend, though, that Baumol's idea might support the same type of conclusion.  He responded persuasively (to me at least):

Ahh, my theory is a little different, and I very much disagree that, "It’s hard, if not impossible, for them [education and health care] to be produced more efficiently". My theory is that costs escalate in higher ed and health care because the traffic will bear it--what would you not do for the health and education of your family? Providers have taken advantage of that to escalate costs and transfer wealth, and organized their value chains to maximize that transfer. It's very clear in higher ed: The colleges that you and I attended are far different, far costlier, and offer no better an education than 40 years ago. And while lifespan is longer, we are using greater and greater inputs of resources to eke out very small gains in outcomes, with huge variability and enormous non-value-added time, materials, personnel, etc. So no, I'm not buying the notion that "it will always take 23 minutes to play a sonata."

I agree with my friend because I have seen what happens when hospitals focus on providing a higher quality product.  If you do it well--improving quality and safety by reorganizing work in a thoughtful manner, relying on the thoughts and guidance of the front-line staff--there is a virtuous cycle with efficiency.  Waste is driven out of the system. Recall that my conclusion included this paragraph:

In all jurisdictions, the ability to deliver better value care will ultimately depend on the redesign of work in hospitals to improve quality and increase efficiency, whether by Lean principles or otherwise.  Unfortunately, this kind of approach will only be adopted by a small percentage of institutions.  It takes vision and leadership commitment, which are generally lacking in the industry.

So, Baumol is right, but he is wrong.  He is right that, as long as productivity gains do not occur in health care, its share of the national budget will grow.  He's wrong  if he thinks that the lack of productivity gains is immutable.  It is not immutable, but it is subject to a terrible degree of inertia.

Fenway and Longwood -- 1838 and 2012

Fenway area -- 1838

Almost six years ago, I wrote a blog post about changes in the Longwood area.  Then a few months ago, a 20-year EMT with Boston EMS got in touch with me about some work he has been doing to document changes in the area, and indeed throughout Boston.  Ed McCarthy notes: "I am an amateur Boston historian. I am using historical references to draw VERY accurate historical maps of Boston, neighborhood by neighborhood, in different time periods."

Ed has now produced beautiful images of the Fenway area, which includes the Longwood Avenue section, portions of which I have copied here.  (I tried to include the entire jpg, but it was too big for Blogspot--almost 20 megabytes!)  As that density of data suggests, his originals are strikingly beautiful, annotated with incredible detail, and can be purchased from him for $100 per print.

These are special images and great for your own walls or those of friends and colleagues. You can contact ed at emssbasn [at] comcast [dot] net.  If you would like his phone number, submit a comment to me with your email, and I will send it.  (I don't like to publish telephone numbers on the blog.)
 

Fenway area - 2012

The Times looks at hand-helds

An excellent video on the NY Times site today, called "Mobile Devices 'On Call' in Hospitals."  Worth watching.

How health care markets work

Thanks to @scanman and @gruntdoc for retweeting this story.

@OMGfacts reports that MRI machines in the US are being made larger to accommodate fatter Americans.  An excerpt:

The makers of MRI machines and other medical scanners are hurrying to make machines that are bigger and can withstand heavier people.  In the last 15 years, the diameters for CT scanners have grown 25% from 2 to 2 1/2 feet.

The source for this story is Newser, which reports: 

For equipment manufacturers, US obesity—which affects 28% of the population—offers a chance to rake in more cash. 

"The US is the biggest market for us, so every product we build has the obese American patient in mind," says a Siemens exec. "It more or less has turned into a design requirement." 

That story, in turn, refers to the original article in the Wall Street Journal:

Even as equipment grows, doctors say imaging obese patients remains challenging. Scanners now on the market fit all but the largest patients, but X-rays and other imaging signals still struggle to penetrate layers of fat and produce diagnostically useful images at normal doses. Radiologists say it takes much more radiation to effectively image obese patients, bringing new health risks.

$90 million. Golly.

In recent news reports, much was made of a gift by Partners Healthcare System, the (by far) dominant hospital and physician organization in Massachusetts.  PHS announced that it, along with its newly acquired insurance company, would be granting $90 million over the next fifteen years to 49 community health centers in the state.

To normal people, $90 million sounds like a lot.  To health care finance people, this sounds like about one percent of Partners’ billions in operating income during that period (assuming no increase in earnings from the generous reimbursement contracts it has secured, nor from its increase in market share over the coming years.)

To normal people, the idea of the gift seems generous.  To people concerned about market dominance, it feels like yet another way to cement or attract the loyalty of local health centers as referral sources for patients to be sent to PHS hospitals.

This is what happens when the state gives away the store to a dominant provider.  The provider uses the money and takes actions that burnish its image and help build market share.  Grant recipients, grateful for any crumbs, dare not complain.  The press dutifully reports the story without providing context.

When you think about it that way . . .

A friend of mine jokingly said, "What's all this talk about the US health care system being inefficient?  If we consider that the system was designed to transfer money from consumers to the various parts of the health care industry, we are twice as effective as the world average! Why would we expect that a free enterprise health care system designed by hospitals, doctors, pharmaceutical and device companies, IT firms, and industry consultants and suppliers would do anything other than maximize transfers of this sort?" 

Look below, and you can see that he is correct.  In this chart, the world average (including the US) of the percent of the economy devoted to health care is about 8%.  In the US, it is closer to 14%.  (Source is this web page.  Every chart I have seen shows slightly different numbers.)

But seriously, these kinds of charts don't really tell you much.  In most other countries, the health care budget is actually a budget, set by the parliament or other legislative body.  That acts as a brake on overall spending.  But when you have an administrative determination of a nation's health care budget, you don't know if that is the right amount to properly serve the public.

Recall my conversation a few years ago with a hospital CEO in Iceland, where

[t]he parliament uses, as a rough guide, a desire to maintain overall health care costs at a certain percentage -- 10 or 11% -- of GNP. The US, at 15% is viewed as too high. Other European countries, at under 10%, are viewed as too low.

Is this percentage based on a quantified assessment of the actual health care needs of the public, i.e., is it driven by public demand (e.g., a growing aging population)? No. Does it take into account the government's expectation for certain quantifiable levels of service quality, medical quality, or operational efficiency of hospitals and other parts of the system? No.

In essence, this appropriation by the parliament is a politically derived decision, just as it would be for any appropriation for a program of important national priority, and it therefore competes with other worthy national programs for resources.

Or let's recall what we learned in Denmark:

Denmark currently spends about 8% of its GDP on health care (not counting the educational subsidy to those studying to be doctors and nurses.) There is an expectation that this will be quickly rising, to over 10%, within just a few years. There is pressure on the government to spend more to enhance and expand services. For example, while treatment of heart disease is excellent, cancer care is considered less than adequate by US standards, with less use of imaging and chemotherapy; and there is a desire to upgrade it. There is also a huge building program going on -- eight new hospitals are under construction. Too many hospitals are engaged in high-level procedures, and there is a need to consolidate those, but there is reluctance from those currently engaged in those arenas. I had heard previously that the primary care system was very good, with quick care and integrated electronic medical records. The former is true. It is easy to get an appointment quickly, and the care is excellent. The latter is not. Integrated EMRs are not present at the primary care level, although they are at the hospitals. Finally, there is budget pressure: When the end of the fiscal year arrives and a hospital is behind on its budget, it "manages by congestion," delaying procedures until the next year. A colleague here jokingly said, "I don't know why people from abroad come to visit, thinking our system is wonderful. We think it is awful."

Putting aside my friend's sarcastic view, there are reasons for the variation in health care costs around the world.  The numbers in each country, over time, reflect the public's demand for services and the body politic's willingness or unwillingness to pay for those.  When it comes to reducing costs, it is important to remember that one person's costs are another person's income.  The politics of reallocating that money are very complex, in that legislators do not like to take things away from their constituents.  It is much more appealing to be additive rather than subtractive when you are in a legislature.

So don't expect big changes in the current situation.  Directionally, though, we can expect for the US a convergence with what we have seen elsewhere in the world.   We will likely see a move towards a more egalitarian (government provided or government-influenced) offering of insurance products for the majority of the workforce, combined with a less egalitarian offering of premium services for those with higher incomes.  For the rest of the world, likewise, we can expect a convergence with what we see in America, a less egalitarian offering of premium services for those with higher incomes overlaying a national system offering basic insurance coverage for the majority of the population.

In all jurisdictions, the ability to deliver better value care will ultimately depend on the redesign of work in hospitals to improve quality and increase efficiency, whether by Lean principles or otherwise.  Unfortunately, this kind of approach will only be adopted by a small percentage of institutions.  It takes vision and leadership commitment, which are generally lacking in the industry.

Meanwhile, though, attempts by the government or insurers to bolt on financial penalties and the like will have modest impacts.  In those attempts they are trying to get people who are not motivated by finances (doctors and nurses) to reduce costs or to get people who are highly motivated by finances (insurers, device and pharmaceutical companies, IT companies) to not invent ways to "transfer money from consumers to the various parts of the health care industry."

My prediction, therefore, is (with some minor ups and downs) a gradually increasing percentage of national budgets devoted to health care.  The demographics will drive this--older people living longer; Baby Boomers reaching the age of hospitalization, combined with a sense of entitlement about serving their aches and injuries; and a younger generation that is sedentary and overweight.  The body politic will allow this increase in national health care budgets to happen because it is just too hard to take things away from the voters.

Mass. Eye and Ear shares outcomes

The Massachusetts Eye and Ear Infirmary has published Quality and Outcomes 2012.  In his introduction, CEO John Fernandez notes:

Serving a largely outpatient population, Mass. Eye and Ear has just 41 inpatient beds, but upwards of 20,000 surgical patients each year. While challenging, creating measures and benchmarks specifically for these specialties brings great rewards. We realize that the first step in improving quality and outcomes comes from being able to measure them. You can’t get better (and demonstrate that you are better) unless you can measure and display where you are now. We are setting the standard in the United States, and indeed the world, with our commitment to publish outcomes.

The report is not only excellent in terms of clinical outcome transparency.  It is also highly informative with regard to types of procedures and surgeries.  All in all, well done!

Crowdsourcing advice

For those audiobook lovers out there:  At popular request, I am preparing an audio version of my book, Goal Play!  Leadership lessons from the soccer field.  My question is this:  On what platform(s) do you think it is best to offer the audiobook?  Is it Audible.com?  If you give them an exclusive, the audiobook is available on Amazon.com, Audible.com, and iTunes.com.  What other options are attractive to you?

Please offer your comments below.  Many thanks!

In Memoriam: Lia Lee

If there were only one book I could recommend to medical students and residents, it would be Anne Fadiman's The Spirit Catches You and You Fall Down.  It is a sensitively done narrative about a Hmong child in California with epilepsy who gets caught in a well-intentioned, but very difficult, divide between her parents' culture and that of the American doctors taking care of her.

The little girl, Lia Lee, recently died.  This obituary relates her story and that of Fadiman's documentation.  It starts:

In 1988, when Anne Fadiman met Lia Lee, then 5, for the first time, she wrote down her impressions in four spare lines that now read like found poetry: 

barefoot mother gently rocking silent child

diaper, sweater, strings around wrist

like a baby, but she’s so big

mother kisses and strokes her 

If you have not read the book, please consider doing so.

Oops, I forgot that detail

On the subject of the Obama-Romney debate, it was curious to hear Mr. Romney's version of the MA health care reform legislative process:  “I like the way we did it in Massachusetts.”  While later claiming credit for a bill that did not increase costs or cut benefits, he neglected to mention the intitial $300+ million federal Medicaid waiver that provided much of the financial support for the Massachusetts plan, and the continuing waiver of "$500 million annually in federal support for Commonwealth Care and the Health Safety Net, and more than $300 million annually in other federal support for services to low income and uninsured populations."

What about "All the News" don't you understand?

The tendency of The New York Times to publish opinion pieces masquerading as news stories continues.  Let's take today's piece about the Obama-Romney debate.

We learn:

That Mr. Romney used "the first presidential debate to invigorate his candidacy by presenting himself as an equal who can solve problems Mr. Obama has been unable to."

That "the president implored Americans to be patient."

That "the 90-minute debate unfolded much like a seminar by a business consultant and a college professor."

That "they talked over each other without connecting their ideas to voters."

That "if Mr. Romney’s goal was to show that he could project equal stature to the president, he succeeded."

That "Mr. Obama, who has appeared to take command of the race in most battleground states, seemed to adopt an air of caution."

That "style points went to Mr. Romney."

I am sure authors Jeff Zeleny and Jim Rutenberg are thoughtful and wise political analysts, but a front page, right column story is supposed to be news, not opinion.  Please don't tell us how we should evaluate the debate.  Report it.  If you want to publish an opinion piece, it should be labeled "news analysis," like the adjoining article.

Seeing through the veneer

I have mixed feelings about ambivalence.  On the one hand, as an economist, I believe in the power of pricing signals to influence behavior.  On the other hand, as an economist, I know that a misplaced pricing signal will either not influence behavior or will have unintended consequences.

But I am not ambivalent about one thing:  The CMS policy on readmission penalties falls clearly into the "other hand" category.  The program is wrong-headed in intent, flawed in design, and will have unintended consequences.

The Premier Safety Institute puts it nicely (sorry, an email newsletter with no link):

CMS has forged ahead despite concerns raised by the Premier healthcare alliance and other hospital groups about the potential for some safety net hospitals, those treating disproportionately large numbers of low income patients, to face penalties that they can least afford. There are also concerns about a lack of consideration in the penalties for planned or unrelated readmissions. Questions also continue about the methodology for measurement and lack of adjustment for socio-economic status.

But even the respected Kaiser Health News falls for the trap in its summary:

More than 2,000 hospitals — including some nationally recognized ones — will be penalized by the government starting in October because many of their patients are readmitted soon after discharge, new records show. Together, these hospitals will forfeit about $280 million in Medicare funds over the next year as the government begins a wide-ranging push to start paying health care providers based on the quality of care they provide.

It should read, "as the government begins a wide-ranging push to save money by penalizing health care providers based on a poorly conceived premise and poorly designed methodology."

Dear hospital folks, expect more of these kinds of metrics and penalties.  The folks in DC are primarily looking for money.  They are adopting administrative approaches to find it and have disguised their financial mechanisms with a veneer of concern for quality.

Sources

There is a symbiotic relationship between reporters and anonymous sources.  They knowingly use each other, the reporter to get a story that might not otherwise be possible, the source to get out a story that is advantageous to himself, to her organization, or to his or her cause.  This mutuality of purpose is well understood in the trade and by government officials, corporate PR flacks, and advocates.

There are times when anonymity is required, to protect a source’s life, liberty, or property.  Reporters and media outlets (in the United States) are generally legally protected from having to reveal the identity of sources.  This protection is part of our country’s freedom of press, a provision of the Constitution that is designed to prevent the government from unduly impairing the free exchange of ideas, including criticism of the government itself.

I have noticed a trend recently, though, that devalues this relationship, making a mockery of the valued and valuable symbiosis.  Let me give an example from a front page story in The New York Times, entitled “U.S. Abandoning Hopes for a Taliban Deal.”  Here’s the pertinent excerpt:

“I don’t see it happening in the next couple years,” said a senior coalition officer.  He and a number of other officials spoke on the condition of anonymity because of the delicacy of the effort to open talks.

Let’s parse this.  This is a “delicate” situation, but not so delicate that several government representatives have clearly been given authorization to set out the current point of view for publication in one of the most widely read newspapers in the world.  The purpose:  To float a trial public policy balloon--or to begin to ease the government out of a policy failure--either for internal audiences in the US or international audiences.  (Certainly, it is not to divulge state secrets to the Taliban, as they already know the state of play in Afghanistan!)  Note that the sources did not want anonymity to protect their government jobs.  Really, the only reason their names have not been made public is to give those senior officials plausible deniability in the event there is an adverse political reaction.

So the reporters have allowed themselves to become complicit in “selling” a policy point of view.  In so doing, they gets bylines on a front page story with “news” made more persuasive by quotes from unnamed sources.  This is not brave reporting of the sort we all appreciated when the late Arthur Ochs Sulzberger took on the U.S. government during the Vietnam War.  It is rather a stage in downgrading the valuable uses to which anonymous sources can be put.

I have also seen more insidious versions of using anonymous sources.  In one case, a newspaper splayed out a story about a well regarded person who had been forced out of his job as president of a non-profit human services organization.  The reporter in the case relied on two anonymous sources from the organization, who implied that the executive had been asked to leave because of issues related to harassment.  The story said that sources could not be identified because this was a “personnel matter” which they were not permitted to discuss publicly.

But the reporter allowed the sources' words to be used anyway, to discuss a personnel matter in an extremely public manner.  Three months later, in a story given less prominence, we learned that there was, in fact, no issue of harassment.  Indeed, the inside story, never published, was that long-serving trustees were upset about organizational changes made by this relatively new president, which included personnel actions against some staff in the institution.  Whether the “sources” were board members loyal to those staff members--or the staff members themselves, or others--they were basically spreading a story that was meant to reflect poorly on the ousted president.

So, the real story was one of poor governance, an aspect never covered by the reporter in the first instance or in the follow-up.  The reporter was used by trustees or staff members acting as improperly protected anonymous sources.

My hope is that anonymous sources will continue to make themselves available to reporters for important issues that deserve to see the light of day.  My wish, though, is that reporters will be judicious in their use of such sources.  I hope that the reporters will avoid those sources who are just hawking an administration’s trial balloon or are engaged in personal vendettas.

Lean is not negotiable

Please check out this article by @SusanCarr (Susan Carr) on Patient Safety and Quality Healthcare, summarizing a recent Lean session at Atrius Health.  I am pleased, but not at all surprised, that my friends and colleagues at Atrius continue to pursue a Lean philosophy and vision.  That approach has already paid huge dividends for the patients and staff at this multi-specialty practice, and the leadership of the organization understands that you don't do Lean, you embed it into the corporate culture for everyone, every day.  Excerpts from Susan's article:

Last week I attended a three-hour presentation given by Lean guru George Koenigsaecker to Atrius Health, an alliance of community-based medical groups in Massachusetts.

In his presentation, Koenigsaecker emphasized the role of leadership in implementing Lean, pointing out that Lean requires adults to learn new attitudes and behaviors—a far more sustained and challenging leadership effort than getting everyone on board with new technology and processes. Success with Lean takes time and involves culture change. That is always challenging, but traditional Lean teaching, beginning with Toyota, did not include leadership training of the sort that interests us today. TPS was taught and fostered through mentorship, without documented leadership principles.

I particularly like the last piece of advice raised by Koenigsaecker, as part of his suggestions to achieve this end:

Lean walk-the-talk.  Practicing Lean as a way of life. It starts to affect your thinking. You are teaching and contributing to the evolution of Lean. Lean is not negotiable; it’s who you are; it’s how you do what you do.

How a team degrades

I was recalling the other day one of the exercises we used to sensitize senior executives in my former hospital's Lean training program.   A group of colleagues sat around a table and were given a problem to solve.  Each person wore a hat with a label that could be seen by everyone at the table, except the person wearing the hat.  The label might say “whines,” “creative,” “combative,” “unintelligent,” or some other characteristic.

Strikingly, within just a few minutes, people at the table began to treat each person as though the assigned characteristic were true.  The whiner found himself ignored.  Likewise for the unintelligent person.  The creative person was seen to have all the best ideas.

This simulation exercise demonstrates the untoward power of stereotype.  There is a tendency of people, once given an expectation about another person, to find evidence in support of that expectation.  Everything the other person does or says seems to lend validity to the prior view, which, by the way, may have no basis in fact whatsoever.

I was recently the victim of such stereotyping, actually watching it occur and take hold over the course of just twenty minutes.  The setting was a pick-up soccer game.  While traveling far from home, I had been invited by a friend to join in his weekly game.  I know this is hard to believe, but I am actually a pretty good player.  I play several times per week with a group of excellent players from around the world in highly competitive games.  On this day, though, I had not played for several weeks, so I was a little rusty. I had just spent a long time on an airplane, and so I was also a bit stiff.  So, I decided I would be careful for the first part of the game, not wanting to pull a muscle or otherwise hurt myself.  In soccer, if you are careful, you are often not as effective on the field, and such was the case here.  The first couple of times a ball came to me, my passes were not as fast and crisply directed as usual.

What happened was that the other people on my team quickly decided, based on those first few touches, that I was not a good player.  They stopped passing the ball to me, notwithstanding that I was often open to receive a pass.  When I did happen to get the ball when it ricocheted my way, they did not expect me to do anything worthwhile with it, so they did not run to open space, where I could pass to them.  Thus, I did not have good options for releasing the ball to other players, so my passes tended to be intercepted more often by opposing players.  Later during a time out, I actually overheard some of my teammates muttering, “Well, he’s good at getting open, but he doesn’t run fast enough with the ball.”  Of course, they missed the point.  If you are good at getting open, you often don’t have to run fast with the ball.  Rather, you quickly send it to one of your other teammates who is open.  In that manner, the team as a whole moves the ball down the field.  In fact, if you try to be a hot shot and dribble down the field, you are much more likely to lose possession to the other team.

Meanwhile, the opposing team soon figured out that they did not have to cover me, as no one would pass to me.  This meant that the other team had an extra player to interfere with the rest of my team.  By turning the game from 11v11 to 11v10,  my teammates created a competitive advantage for the other team.  The score reflected this result.

It was a marvelous experience to both participate in and watch this unfortunate team dynamic develop.  As the recipient of my teammates’ denigration, I was surprised to see how quickly I turned to trying to prove myself.  Of course, at that point, you get more tense about every interaction with the ball and are more likely to make bad decisions or bad touches on the ball.  You could almost hear them raising eyebrows, as if to say, “See, he really is unreliable.”  It didn’t help that there was a loudmouth on my team who also felt the need to yell instructions at other players, often ill-timed and incorrect ones at that.  In my case, if he yelled an instruction, and I did something else, it was further proof of my incompetence.

I am not writing this so you will feel sorry for me.  (And I hope it won’t keep you from inviting me to play with one of your teams!)  I am writing it to demonstrate the process of team degradation for you.  We have all been in environments where one member of the team is stereotyped as less competent or less worthy, based on some early observations or preconceptions.  We then isolate that person and fail to give him or her a chance to participate and develop.  In so doing, we have effectively reduced the number of players on our team, and we have eliminated many opportunities for cooperation and creativity that might have helped our team succeed.  We might also inadvertently give our opponents a competitive advantage by weakening our own team.

A strong team is a learning organization that values all of its members.  It offers praise for jobs well done.  It offers support and encouragement when performance is less than what is hoped for.  It does not criticize or blame when mistakes occur; rather it seeks to learn lessons from those mistakes.

By the way, in my home soccer group, we have an unofficial rule that you pass more, not less, to players who are not as good.  By giving those players more touches, the stress associated with each pass is reduced.  The team as a whole thereby engages in behavior that helps those people develop and learn.  The overall level of play rises, and all enjoy the camaraderie that comes from a game well played.