Lessons from Global Health Development: Sustainable Change Contrarian

Part 1 of a three-part series

“We cannot solve our problems with the same level of thinking that created them.” ― Albert Einstein

In the U.S., some refer to healthcare system change as an oxymoron. It is complicated. It is hard. And while progress has been made, we have a long way to go.

But if such change in healthcare is challenging in the richest nation, then imagine it in low resource countries. In many sub-Saharan African countries, healthcare must compete with investment in other more impactful determinants of health such as education, food security, and sanitation that, if present, are weakly established. Layer in different governments, languages/dialects, and cultures; include frontier rural locations, tribal influences and religious differences and the challenge to improve health and healthcare in countries such as Tanzania, Madagascar, and Nigeria can feel truly overwhelming.

Historically, the traditional approach to both change in U.S. healthcare and global development has been to identify needs and direct resources, typically money, at the perceived needs. This pattern has resulted in little success and in many cases, regression, harm and/or increased costs. In global development, despite over a trillion dollars channeled to low resource countries in the past two decades, little progress – and often regress – has resulted (Taylor, Empowerment On An Unstable Planet). In U.S. healthcare, it has created and perpetuated a medical industrial system that is three times as expensive as other countries for almost median outcomes. The lesson? Funds are zero sum limited; human energy is not. And the only real empowerment is self-empowerment.

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Off Track – Now What?

It happens. The organization is off plan…by a lot; and it is not the first time. More than a modest correction or a “wait until next month.” Many factors were likely involved, but the relentless dynamics of the market have overwhelmed a longstanding management team. It is akin to a cyclist who has slipped back from the peloton due to chronic cadence deficit – and now the gap is widening.

When a leadership change is made while the organization is on plan, it is often political. When an organization is off plan, and a leadership change is NOT made, it is often political (or paralysis). But when performance is off plan and the board and/or corporate office makes a CEO change, what are the key considerations?

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Sustainable Population Health:

Part B – Catcher or Pitcher?

Part B of this article addresses how growth plans of healthcare systems distinguish population health management from community and public health.

Part A of this article clarified the terminology and implications of Community, Public and Population Health. So what does all this this mean for healthcare system leaders’ growth plans?

Healthcare providers have historically played catcher, “receiving” patients who sought care. Access meant being available when and where patients sought them. The transition from volume-based care to population health management requires a role change of providers from catcher/receiver to pitcher/initiator. The transfer of utilization and intensity (and possibly actuarial) risk to providers requires providers to be economically accountable for care and the health of a population. The good news is that this is a better alignment with the societal view of healthcare as a service (in economics, a ‘good’ with a cost) that is necessary but not a value-add. The bad news for providers is that this is contrary to traditional culture and payment incentives. This change is not a transition, but a transformation that involves many transitions.

Is Less Healthcare Better?

From a community and public health perspective, success involves preventing disease and reducing the demand for healthcare services. Success for providers often means growth in healthcare services. Traditional revenue growth for providers involved price and quantity (P & Q). Providers feel conflicted: more P and Q meant economic success, but now, with increasing “value-based” care (more-risk, if not full risk), less P and Q means success.

Studies have called out pricing as the primary reason why costs in the U.S. are significantly higher than in other developed countries (Uwe Reinhart, ‘It’s the Prices Stupid’). Increasingly transparent societal forces are serving to limit growth in P. And the ascendance of population health management is serving to put downward pressure on Q – the quantity of health services provided. Read Full Article.

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Sustainable Population Health -- Who's on First?

Part A of this article clarifies the blurring terminology that can inadvertently stunt health improvement understanding and action.

Post-truth, Fake news, Misinformation (Dictionary.com words of the year for 2016, 2017 and 2018, respectively). Let’s be clear: How is population health different from community and public health? How does it relate to health disparities? A senior leader discussion on these topics can begin to sound like a rendition of Abbott and Costello’s “Who’s On First?”

The terms Community Health, Public Health and Population Health are often used with the same broad brush. But advancement in our thinking and action start with clarity of our language and terminology. Clearly there is much common ground with these terms. To start 2019 off with clarity, below is a summary delineation of these terms. Read Full Article

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Mitigating Decision-making Errors Along a Transformation Journey

In Part A of this two-part article on decision-making errors, the main categories and types of decision and judgement errors were reviewed along with some associated logic fallacies.

So What?

Two practical questions emerge. First, what can we do to improve our judgement? A combination of antidotes is often recommended to mitigate the untoward effects of these decision traps: being humble and aware, knowing yourself and knowing others, and following a process are the top three. The first, being aware, is like telling a pitcher to “throw strikes” (well-intended, but not of great practical help – this is what the pitcher is trying to do but it does not help him/her do it!). The second, to know oneself, is harder than diamonds and steel, according to Benjamin Franklin. The third, following a process, offers the most tangible promise for something we can actually do that can consistently make a difference.

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Decision Making Traps: Decider Beware

Leadership Transformation Series

This is Part 4A in this Four-part Leadership Transformation Series (LTS); 4B will follow.

Transformation in healthcare is personal: it requires the transformation of health system leaders. The LTS begins to speak to key differences in some of the fundamentals of transformational vs traditional leadership in healthcare.

This article focuses on how we make decisions: 4A Reviews decision-making errors.

4B Addresses how to mitigate decision-making errors

Leaders – and their organizations - succeed or fail based on their decisions. Yet the evidence is clear that our decision making is perilously fraught with biases and irrational behaviors of which we are not even aware. These biases are so ingrained in our psyche that, like water to fish, we cannot imagine that they are even there, much less clouding our view – regardless of how “well-intended and objective” we believe we are. In short, bad decision-making is largely hard-wired.’ Just as many medical errors are associated with unexplained variation in medical decision-making (How Doctors Think), so too are many leadership errors are associated with unexplained variation in management decision making.

Traditional change is oriented in the past; it involves more, faster, better, but not different (Daniel Prosser). Transformation is future-oriented; it requires the creation of something from nothing, i.e., letting go and giving up something in the past to create something new. This means that, to do transformation well, it is even more important that our hidden decision biases be flushed out and made explicit. Leaders on a transformation journey are at higher risk for decision making traps and consequences than in traditional change. Said differently, leadership decision making in transformation is less forgiving.

A brief review of categories and types of decision and judgement errors include the following: (Read Full Article)

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The Operating Model: Closing the Strategy-Execution Gap

Leadership Transformation Series

The Operating Model: Closing the Strategy-Execution Gap

This is Part 3 of a Four-Part Leadership Transformation Series (LTS).

Read Part 1 and Part 2.

Transformation in healthcare is personal: it requires the transformation of health system leaders. This LTS begins to speak to key differences in some of the fundamentals of transformational vs traditional leadership in healthcare.

This article focuses on how leaders operate.

You have a strategy. How do you rate your organization’s execution of that strategy on a 1-10 scale? For most, it is not high – or as high as they would like. Closing the strategy-implementation (aka, the knowing-doing or what-how) gap is the leadership Achilles heel of any business, but especially for hospitals, a business recognized by Drucker as the most complex organization to lead. Given that his observation pre-dated some of today’s larger and more evolved and blended academic-community healthcare systems, the complexity he referred to then has only increased. Across industries, the results of studies consistently identify unsuccessful execution for the vast majority of strategies; and the results of CEO surveys cite execution as the biggest current challenge, but reasons for such failure and concern vary widely. A sampling of HBR articles on the topic cite too much of an internal focus, poor CEO preparation in both strategy AND execution, “a people problem.” (Read Full Article)

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Systemizing Healthcare: The Integrator Role

This is Part 2 of a Four-part Leadership Transformation Series (LTS). (Read Part 1 Here)

Transformation in healthcare is personal: it requires the transformation of health system leaders. This LTS begins to speak to key differences in some of the fundamentals of transformational vs traditional leadership in healthcare.

This article focuses on the changing role delineation of leaders.

The leadership need for ‘the Integrator’ is re-shaping traditional CEO and COO roles.

A few decades ago, the role of ‘the Integrator’ in healthcare leadership did not exist – at least not in the form needed today. Unlike roles with new names – CTO, CMIO, CPHMO, etc. - the same titles of CEO or COO may be used for a healthcare system, yet the shapes of these roles bear little resemblance to those with the same titles used in a hospital or other ‘vertical.’

While a hospital administrator/CEO is expected to stay close to the pulse of acute care operations, the system CEO is expected to transcend operations to assure an aerial view/perspective, i.e., to become more visionary and system-focused. The transition from hospital to system requires a view that is less entrenched with how we have run hospitals and more focused on the population served. Despite use of the same title for both roles, it is the difference between being ‘tied down’ and ‘freed up.’ (REAd Full Article)

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The Fourth Discipline: Transition Management

Leadership Transformation Series

This is Part 1 of a Four-Part Leadership Transformation Series (LTS).

2012 Womens Olympic Triathlon finish in London - After two hours of racing with the best in the world, what would one or two seconds in transition time have meant for the top three athletes?

Transformation in healthcare is personal: it requires the transformation of health system leaders. This LTS begins to speak to key differences in some of the fundamentals of transformational vs traditional leadership in healthcare.

This article focuses on how the nature of our work is changing.

Many compare the healthcare transformation journey to one of our oldest Olympic sports: “It’s a marathon!” Although this might reflect the persistence, resilience and endurance sentiment, I offer an analogy upgrade from one of our newest Olympic sports: “It’s a triathlon!”

Why?

First, transformation requires mastery of multiple disciplines. We – and our organizations - may have competency in one or two disciplines, but adaptive learning is required to develop and integrate the different and stronger skills needed for next level or breakthrough performance. We cannot count on simply doing more of the same ‘one foot in front of the other’ plodding and grinding to advance our mission – our people are burning out. Unlike in the run or bike, the first triathlon discipline – the swim - does not ask as much of the legs. While the upper body provides most of the forward propulsion, for swim speed it is more important to reduce drag. Drag is not a material factor in running, but it is in running our organizations – and barnacles, barriers and anchors come in many, mostly self-inflicted, forms.( Read Full Article)

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Healthcare Integration: Ship-to-Shore Work and the Ultimate Weapon

Veterans Day reminds me of my father. In WWII, he landed on Omaha Beach on D-Day.

As Steven Ambrose details in his book “D-Day,” the Allies planned the Normandy invasion for three years, but as soon as our troops hit the beaches, the plans went out the window. To the ‘man on the ground,’ NOTHING was as planned. And on the beaches, formal leaders were dead or not available. Survival and progress to save the free world depended on rapid learning and action, i.e., adaptive leadership. Our troops felt empowered to act, German forces felt compelled to wait for Hitler’s direction. The rest of this leadership story, as they say, is history.

Despite asserting to my Dad, in my youth, the growing impact of technology, e.g., pilotless planes, long-range capabilities, etc., he remained convicted of the mantra “the ultimate weapon is the man on the ground.”* My Dad and his colleagues, some of whom made it past D-Day, are heroes. I have since learned that there were others “on the ground” back in the U.S. who heroically enabled these heroes. During the planning for the largest invasion in modern history, a significant challenge was figuring out how to get our troops from ‘ship-to-shore.’ The U.S. federal government knew how make large ships to get our troops across the English Channel, but they could not get our troops to the shore. Enter Andrew Jackson Higgins, who was described by Dwight D. Eisenhower in 1964 as “the man who won the war for us.” (Read Full Article)

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