Protected, Immune, Vulnerable?
The plaintiffs, two individuals with substantial losses in the Madoff Ponzi scheme, are attempting to recover losses from the SEC but, as Henruiques describes they:
"[face]a significant uphill fight because the legal doctrine of sovereign immunity makes it extremely difficult to sue a government agency for the consequences of its official activity."
However the legal case being developed claims that this immunity applies only to the SEC's official functions such as rule making, decisions, and formal policies but:
" [the plaintiffs] assert that the doctrine does not shield the S.E.C. from the consequences of "serial, gross negligence" in carrying out its day-to-day duties."
In short, the content of policy and decisions is protected but not the "negligence" involved in carrying out its oversight responsibilities or in implementing those policies and decisions. Suggesting that those who allegedly failed repeatedly to follow up on credible allegations of malfeasance by Madoff - or the SEC itself - maybe vulnerable to suit for damages.
?SEC = ?QIC
It could be argued that SEC's role in investigation, oversight, and correction of investment behavior somewhat resembles that of a hospital Quality or Peer Review Committee. And the SEC employees charged with implementation resemble hospital and physician leaders charged with implementation of professional correction, error reduction, and quality improvement activities. Historically, Quality Improvement Committees (QIC) and Peer Review Committees (PRC) and their participants have similarly enjoyed confidentiality from discovery and legal immunity for their activities.
But is the argument being advanced by the Madoff plaintiffs transferable? PRC and QIC protections were designed to encourage the free flow of quality and safety data, to encourage self reporting, and to limit the vulnerability of participants from intimidation by [mainly] physicians who are investigated or sanctioned. All critically important protections. But in today's patient safety conscious environment, will members of QIC or PRC who fail to collect the right data, draw the right conclusions, or appreciate the significance of trends that are before them be protected? Should they be? If physician leaders and executives receiving reports of systematic errors or safety lapses from the QIC or PRC fail to act effectively to make improvements will they be protected?
Is Quality Accountability a Risk to be Managed?
The SEC's immunity appears to be under re-examination. Perhaps the vulnerability of hospitals and health care leaders will be as well. A 2009 Tennessee Court of Appeals case tested the ability to extend peer review protections to hospital management in cases of credentialing. While the ruling in this case was in favor of upholding hospital protection for the Credentials Committee endorsement of a physician for whom there was strong evidence of poor care, the April 27, 2099 Nashville Post's news report of the case makes it clear that the broader question of how far to extend peer review immunity to decisions made by hospital leadership is likely to be scrutinized by legislators in the future:
"The attorney noted that this was probably the closest analysis the [peer review] statute has ever received and may have pointed out some of the unintended consequences of its language, which may be flawed. But that is a problem for legislators, who the attorney opined did not likely see a scenario rising from that particular bit of legislation."
Personal and corporate accountability for participating in and acting upon "protected" quality improvement activities may be yet another risk to be managed by health care leaders.
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Who Would Pull a Stunt Like This?
This piece is about the resurgence of interest in crop dusting as a professional niche among pilots - now that the major airline industry is teetering and the commuter lines offer sub sub entry level pay as reward for trying to consistently fly people safely while being neither well fed or well rested. Apparently crop dusting pays better and offers pilots the opportunity to "really fly" and be "at one" with an aircraft:
"Pilots are drawn to crop-dusting not only for the money, but also for the chance to be their own bosses and to do the kind of low-altitude flying and stuntlike maneuvers one wouldn't dream of performing in a big jet."
Wasn't this part of the reason many people went into medicine, nursing, and health care entrepreneurship years ago? To be close to the action, to have a role in wiping out disease and misery, to make way for the healthy growth, and to determine one's own destiny just a bit? (I'm convinced that Jonathan Welsh, the author and a staff writer for the automotive section of the WSJ, must have been subliminally thinking about health care when he wrote this piece. After all, he married a pediatrician and is the son of a dental office manager. He must get it.)
Raising a Health Care Crop Duster
Does Welsh's article suggest that there's still a way to get back to basics and to break out after years of being constrained by the ever tightening world of health care regulation, diminishing reimbursement, increasing litigiousness, and widespread cynicism about the commitment of health care leaders to health care? If there is such a path, does it involve coming down from the stratosphere of the executive management level reports and reacquainting health care leaders with what is happening on the ground?
"...[One crop duster trainee] considers himself a good pilot but is quick to admit that he lacked a feel for what the plane is doing because so much of his flight training had focused on instrumentation....To be a good crop-duster, he says, a pilot has to be intimate enough with the airplane that flying it becomes second nature. Knowing which controls to move and how to coordinate them precisely helps him feel at home in almost any type of plane. But flight schools no longer teach those basic "stick and rudder" skills, he says."
Is health care improvement, at least in part, about mentoring emerging leaders closer to the ground? Do we rely too heavily on high tech instruments and not enough on the "visual flight rules" that govern low altitude piloting? That's not to say that we'd want to be in a full size jet (complex health center or health related company) without them. But what got USAir Flight 1549 safely to the ground (well, to the water anyway) earlier this year was the fact that the pilot, "Sully" Sullenberger, regularly flew gliders and other small aircraft and had some instincts about how an airplane behaves. Even without much of that other stuff.
Learning by Doing
Our instruments are, of course, different from those in the cockpit. As clinicians they are lab tests, xrays, electronic monitors, the EHR, clinical simulations, etc. As health care executives they are dashboards, quarterly financials, consumer satisfaction surveys, and dynamic models. And we are increasingly comfortable using them as proxies for teaching about how to handle what happens on the ground or at the bedside.
Is this enough? Is it how we should train and mentor our emerging health care leaders? I'm not just talking about having general intelligence about operations, or managing by walking around (MBWA), but about having the instinct, skill, and experience to know exactly what it takes to solve complex health care problems in the trenches, occasionally even solving them, and enjoying the process:
The problem with most pilots, [the instructor] believes, is that they work to reach a certain skill level, become content and stop seeking improvement. He worries that [trainee] enthusiasm will eventually wane. "In the end he'll have to decide whether to settle for being a hack airplane driver or become a real pilot who never stops learning."
You never know when that might come in handy.
]]>Well maybe there's another side to this story - at least if you believe the lessons of The Upside Of Bad Online Customer Reviews which appeared on Forbes.com August 4, 2009. This short piece by Mirela Iverac, a frequent Forbes contributor, is a provocative read for those health care leaders who might be willing to consider the other side of conventional wisdom on this point.
Lemons into Lemonade
Iverac recounts the counterintuitive experience of online retailer eBags which publishes uncensored online reviews of the products it carries:
"eBags is among the only 50% of online retailers that offer online ratings and reviews, according to the latest figures from Forrester research. Meanwhile, 80% of Web buyers troll reviews when shopping online."
I'm one of the 80%. Are you? Do you think it's any different for health care consumers? Given the proliferation of online health information sites and the enhanced attention health care organizations are giving their own sites, I doubt it.
In 2004, eBags first leveraged negative online consumer feedback about one of its products into a major retail success. Since then, it has apparently repeated the trick many times; using consumer structured feedback to learn about product deficiencies and then correcting them.
Improvement v. Ratings
Carefully structured surveys used by health care provider organizations may get to some of that information - but let's be honest. Both survey organizations and the health care provider organizations that engage them benefit from positive results. Have we ever surveyed health care consumers to determine how much stock they put in Press-Ganey, for instance?
So what this is really about is obtaining the critical customer feedback necessary to make changes that will actually make things better (and safer) in the eye of the customer. The willingness of consumers to state their opinions (and disagree with each other) online can be invaluable and it's underused - actually avoided - by hospitals and providers. When is the last time you browse a hospital web site that had online consumer comments on the patient experience in the ED? A terrifying thought for hospital CEOs. But as Iverac sees it:
"The lingering fear: Negative reviews will send customers running the other way...It's misplaced. Barely 25% of online shoppers report that they are unlikely to purchase a product after reading negative reviews, and most take those reviews with a bowling ball of salt. Truth is, negative reviews probably won't hurt your business--and they ultimately may help boost customer conversion rates."
She goes on to provide additional examples of other retail and service companies that have turned receptiveness to public feedback into an asset. The eBag experience seems to prove this out:
"Nearly 1.8 million reviews are now on eBags' Web site. According to BizRate, online reviews are one of the top reasons customers choose eBags over "50 sites they could find on Google selling the exact same product, often at the exact same price," says [eBag Founder]Cobb."
Managing Expectations
Of course health care is different. Or so we say. But consumer choice behavior is probably not as different as we'd like to believe and the world is changing more in the direction of showing reality everywhere. There's probably a "first mover" advantage to be had here - not to mention incalculable operational and safety improvement opportunities to harvest.
As Iverac points out through additional examples, there's another side to all of this too. "Making it right" for complaining consumers can yield very positive - and equally public - image enhancing "word of mouth" support.
Finally, comes advantage in the ever important management of customer expectations as they read a mix of positive and realistic experiences:
"A final, powerful psychological aspect to bad reviews: According to studies by Bazaarvoice, provider of customer-review software, exposing a product's weaknesses sets realistic expectations, thus reducing the number of product returns."
I'm not advocating jumping into this with both feet but after reading this piece it seems to me that as health care leaders we've been a bit too squeamish about publishing some of our blemishes. After all, if it's good enough for eBags...
]]>Cars, Apples, Berries, and ?? Health Care Organizations
Jana and Rowley consider Ito's appointment to dual leadership roles at a time when technical innovation will be a key to market success. While this is not common in the business world, they easily point to Steve Jobs (of Apple) and Mark Lazaridis (of Research in Motion - the BlackBerry company) who are successful inventors continuing to lead innovation in their companies while filling corporate executive roles requiring competency and focus well beyond their areas of technical brilliance. The authors' interpretation is that:
"...having knowledge of materials, engineering, and hands-on experience designing inventive products can help Ito make smarter business decisions about investments in new technologies and products."
Ito himself is quoted in the article as describing the choice as a strategic one:
"The direction of the business and the direction of the technology need to be aligned as early as possible [in my tenure as CEO] so that we can maximize efficiency and effectiveness."
Aligning business and technology sounds an awful lot like health care organizations today. Don't we face a similar need to innovate for survival as regulations change, reimbursement tightens, technology expands, and the business of making health care work is like at no previous time interwoven with the business of business success?
The Limits of Clinical Executive Leadership?
There is little published data documenting how many senior hospital executive leaders (COO, CEO, CFO) are clinicians while also holding significant clinical leadership portfolios (CMO, CNO, Department Chair, etc) in large health care organizations. My sense is, not many as a percent of all organizations. And I suspect that fewer yet hold those senior executive positions and still practice or hold significant clinical leadership positions (Department Chairs, Practice Leads, etc.).
Yet this is a time that calls for substantial clinical delivery system innovation. Health care reform is nigh. The first wave of "Accountable Care Organizations" and "Medical Home" demonstrations already call for new and close partnerships between the delivery of professional and support services, the acquisition and use of technology, and the critical participation of health care finance and operations experts. Aren't physicians and nurses best positioned (as are Ito, Jobs, and Lazaridis) to align the delivery of care and the business of care?
So should we expect to see - or should we intentionally place - more clinicians in executive leadership positions in order to have knowledgeable innovators at the highest organizational levels? Instead of the prevailing model where CEO, COO, and CFO executives "partner with" CMOs and CNOs as necessary to balance business with clinical care, does the future require it be the other way around? If so, what are the ramifications for better preparing clinician leaders in terms if formal education (business and management curricula) and "on the job" training (mentoring, coaching, and experiential training)? And for preparing erstwhile senior executives to take different roles vis a vis clinical leaders?
Sustainable Innovation?
And if clinicians do assume more executive roles, can they maintain their clinical currency sufficiently to be guardians of the business and of the quality and appropriateness of care? Will the need to combine skill sets at the top be temporary - until a new order is established - or permanent because new equilibrium is not likely to be achieved?
Ito apparently recognizes that for him, at least, the dual role can't last very long:
"Although he's certainly had experience on both the business and design fronts, Ito makes clear that he's aware that wearing two hats will be challenging. He told BusinessWeek that the strategy behind the dual appointment might be temporary. That is, once he gets Honda back on track financially, he might pass the R&D post onto someone else."
If clinicians follow the same route will they, in the end, give up medicine or management? Which role will clinicians in leadership ultimately decide provides them with the best opportunities to improve care? Is it possible to go back?
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Tools for Permanent Crisis Management
The article by Heifetz et al is rooted in the perspective that "nothing will ever be the same" in the years to follow the 2008-2009 economic meltdown. To them, this implies that current and future leadership styles must accommodate anticipated long term environmental instability rather than a return to "business as usual" as the recession appears to ease. In order to be successful, they recommend leadership styles that foster adaptation, embrace disequilibrium, and generate deep leadership pipelines within organizations.
Fostering Adaptation
To the authors, this means actively transcending conventional industry wisdom and some of the successful business techniques (not principles) that worked in the last decade rather than returning to them with the expectation of success going forward. They even go as far as to encourage wide scale experimentation, anticipating pockets of failure, to identify adaptations for wider use. They cite, as one example, the electronics retailer Best Buy which recently made fundamental changes in both consumer marketing and leadership strategies to adapt to an increasingly female consumer market - thereby repositioning itself for success going forward. The authors counsel that the courage and foresight to do things differently, rather than retreat into comfort zones that worked in previous years, will differentiate organizations that emerge from 08-09 in a health fashion.
Embracing Disequilibrium
Heifetz cited Paul Levy's success as the "turnaround leader" at Beth Israel Deaconess (BID) Hospital in Boston as an example of leadership that carefully leveraged uncertainty and instability as a potent lever for engaging an organization to change its culture and sustainably pull itself out of crisis:"...a successful turnaround was no guarantee of long term success in an environment clouded by uncertainty....Keeping an organization in a productive zone of disequilibrium is a delicate task...if [the heat] is consistently too low, people won't feel the need to ask uncomfortable questions or make difficult decisions. If it's consistently too high, the organization risks a meltdown..."The authors go on to cite Levy's successful use of potentially unstable devices (publication of error rates) and public cultural confrontation (of unproductive cross professional squabbles) to expose the implications of an unacceptable status quo and drive the changes essential to BID's survival.
Generating LeadershipWhile the need to generate deep organizational leadership pipelines may seem like a "no brainer" in theory, in my experience it's not often practice intentionally. Heifetz wrote about an organizational culture at the executive recruiting firm Egon Zehnder International which harnessed its core values of independence, shared ownership, and shared decision making as an intentional strategy to leverage internal leaders at all levels to resist and, ultimately, transcend recession in its industry. The firm's absolute reliance on the sense of shared destiny among its empowered owner-consultants:
"Zehnder's collaborative and distributed leadership model informed a strategic review ... The firm took a bottom-up approach to sketching out its future, involving every partner, from junior to senior, in the process...led to a successful recession business strategy that did not involve downsizing staff or services or compromising its model of growing the firm while continuously distributing leadership.
Heal Thy Self?
The authors close this piece with a valuable section on leadership self care. No, not early to bed, exercise regularly, eat well, and take a deep cleansing breath 5 times a day. Rather, being attentive to the techniques business leaders should consider using to ensure clarity, objectivity, and perspective. These include balancing optimism with reality, using reflection, reaching out to trusted advisors and confidants, being attentive and responsive to the emotions of self and others, and maintaining boundaries between self and work. It's less than a page but very high value reading.
There's a tendency in crisis to simply do the familiar as well as possible or to take calculated risks and, if successful, retreat to the familiar as soon as possible. Health care leaders are loathe to rock the cultural or operational boat - much less embrace instability. Physician leaders and other executive health care leaders push themselves to extraordinary levels of personal performance and responsibility often to the exclusion of valuable self preservation techniques and support systems.
This article examines several industries (including our own) to suggest that going forward health care leaders may need to intentionally and permanently do it differently. While attending to some critical self care issues. Talk about cultural change!
Crossing T's, Dotting I's, or Splitting Hairs?
This blog considered the benefits and pitfalls of collaboration and the seemingly ideal collaborative prototype of "T-Shaped" leaders in April (In Pursuit of T-Shaped Health Care Leaders). Buxton suggests that to optimize innovation, T Shaped leaders - in the words of Insead's Morten T. Hansen "executives who are equally adept at working across an organisation and up and down a vertical niche" - should now give way to "I Shaped" ones:
"These [people] have their feet firmly planted in the mud of the practical world, and yet stretch far enough to stick their head in the clouds when they need to. Furthermore, they simultaneously span all of the space in between."
He goes on to describe I-ers as the kids who were always deeply involved in some messy project that proved they were grounded in reality while also showing the ability to transcend the mundane to achieve abstract brilliance.
But are I's who can dig in the dirt and stretch to the sky really more innovative and collaborative than T's who work up, down, and across organizations? Aren't both potentially viable platforms for organizational leadership? Can't I's and T's exist simultaneously in the same person? Maybe the ideals are actually I-Ts?
Three Pillars in Design
Buxton's rationale for I's instead of T's comes from what he sees as a more complex view of team composition:
"At Microsoft (MSFT), we try to make sure that in looking at new product or services ideas, we have at least three Ts, which we call BXT, reflecting equal levels of competence and creativity in three domains: business, experience (in design), and technology. These are three interdependent and interwoven pillars we see as the foundation for what we do."
But Buxton asserts that the qualities needed are actually different and that the most successful innovators must:
"...have their feet firmly planted in the mud of the practical world, and yet stretch far enough to stick their head in the clouds when they need to. Furthermore, they simultaneously span all of the space in between."
So instead of finding maximal innovation potential in the horizontal continuum across disciplines, Buxton seems to value more greatly the continuum spanning in the trenches practical experience to higher level design, strategy, or dissemination.
His article goes on to describe six qualities of the best cross disciplinary teams - well worth reading.
Four in Health Care?
The I-shaped prototype is actually recognizable in the many successful health care leaders who had early and deep clinical careers before becoming successful executives. But don't I-shaped leaders need to rapidly and effectively learn T-ness in our complex health care environment? It seems that spanning Buxton's three pillars (business, design experience, and technology) pales in comparison to what it takes, , for instance, to successfully manage and/or innovate in an academic medical center (AMC).
In his forthcoming, provocative book on the history and survival of AMCs, Dr. Arthur Feldman, Chair of the Department of Medicine at Jefferson Medical College, soberly notes that the classic tripartite AMC delivering clinical care, professional education, and research can only thrive in the current environment if it transforms itself. He sees today's viable AMC as clinical-care centric organization supported by four pillars - or in his words, "spheres of influence" - which are disease focused research, professional education, enabling structures, and business success. Now that's a handful, isn't it?
Are there enough letters in the alphabet to describe the leaders we need to manage that beast?
This Guest Post was kindly authored by Allan Kornberg, MD MBA, Senior Vice President of National Initiative for Children's Healthcare Quality. His biographical sketch can be found at the end of his post.
The July 8, 2009 Wall Street Journal noted the passing of Robert S. McNamara (former Ford CEO, Secretary of Defense, and President of the World Bank) with From McNamara to Obama an opinion piece by Bret Stephens who comments on the dangers of too much rationalism - or more aptly - on the dangers of hubris. Not an insignificant pitfall for health care leaders to consider.
McNamara was celebrated as a well read, cerebral man, who was one of JFK's 'best and brightest.' That phrase, coined as the title of David Halberstam's 1972 book about the Kennedy era brain trust, today carries more than a small amount of irony. Earlier this year, this blog commented on the nature of health care leadership teams in Is the Brightest Leadership Team Necessarily the Best Team?. Mr. Stephens however drilled down on Mr. McNamara alone who, in his words:
"...symbolized the idea that one could manage and control events, in an intelligent, rational way. Taking on a guerrilla war was like buying a sick foreign company; you brought your systems to it."
McNamara's downfall, and that of President Kennedy's successor (Lyndon Johnson) as well, was the Vietnam War. "Blind rationalism" or "knowing" the right answer or the right way to do things without necessarily testing incrementally and learning from testing, led to a war that did not end well for America. McNamara subsequently took the World Bank helm, arguably as penance for the death and destruction and failure in Vietnam in part at his hand, and brought the same decision making approach that relied on massive data, detailed five year plans, and a problem solving approach that didn't regularly seek alternative options. The result was more nuanced than that of the Vietnam War. But in the end, McNamara's 13 years of World Bank leadership and the associated massive lending spree which triggered a Third World debt crisis, may have catalyzed Africa's decent into chaos by provided funds for corruption on a large scale in many developing countries.
Stephens makes the point that rationalism isn't the same as reason (and certainly not the same as common sense). Or as, in my words, good judgment. He goes on to quote William Easterly in The White Man's Burden:
"A Planner thinks he already knows the answers; he thinks of poverty as a technical engineering problem that his answers will solve. A Searcher admits he doesn't know the answers in advance; he believes that poverty is a complicated tangle of political, social, historical, institutional, and technological factors. A Searcher hopes to find answers to individual problems only by trial and error experimentation. A Planner believes outsiders know enough to impose solutions."
Stephens then compares McNamara to President Obama and raises concern that the current administration's approach to banking, autos, climate change, and health care may run the same risks that McNamara and the rest of Kennedy's 'best and the brightest' by - as our British friends would say - 'being too smart by half.'
Regardless of where health care leaders fall on the political spectrum, thinking as a Searcher can be of great value. Absent a genuine time sensitive emergency (which for the combat officer may be incoming missiles and for the physician a critical major trauma patient) in which case decisive action is necessary, an incremental, empirical, learning approach has value. In quality improvement we learn and teach that, whether it's Deming on the manufacturing floor or Berwick in the hospital, rapid cycle, 'plan-do-study-act,' there is great value to iterative approaches to improvement. Incremental learning at each step yields the best solutions, foundations for sustainability, and potential for dissemination.
Whether one is running a country, a health system, or a clinic, an approach that involves accepting that we may not know the answers in advance, and that incorporates a willingness to err and learn as we go, deserves to be respected.
Health care leaders....go forth and be Searchers.
Allan Kornberg, MD MBA is a pediatrician with 25 years of clinical and executive experience. Dr. Kornberg practiced in both a primary care office that he co-founded and as chief of emergency medicine at a children's hospital. He has held executive positions with hospitals and health plans in New York, Georgia, and Massachusetts including as CEO of Network Health, a Medicaid managed care plan serving Massachusetts. He is currently senior vice-president of the National Initiative for Children's Healthcare Quality.
Power of the Connection
This blog has previously commented on the potential power of non-insider innovation that might be obtained by leveraging social networks (Crowdsourcing as a Health Care Redesign Tool), through the placement of leaders from the outside (Could Outsiders Represent and Inside Track for Health Care Leaders), and by relying heavily on consumer specifications and requirements (What Can Tata Motors Teach Health Care Leaders). But the concept of expert innovation networks goes beyond these occasional and informal approaches to get "newthink" into organizations. The authors suggest that:
"...given today's fast-paced global marketplace and limited resources for research and development, companies often struggle simply to survive, let alone innovate... rather than going back to the drawing board, companies should go outside their walls and tap into "innovation networks."
One of the sources for this piece, a senior fellow at the Mack Center for Technological Innovation, described it thusly:
If you look at most organizations, they're focused on what is their intellectual IQ," Huston said. "What we're talking about is moving from inventing to connecting."
Six Degrees of Separation?
So what do innovation networks look like and do they actually work? They span a variety of arrangements among multiple partners outside the firm's own industry or market that reciprocally provide innovative inputs as part of their core collaborative arrangement. According to this article, Proctor & Gamble, the successful consumer products company, increased its innovation output by nearly 2/3 by involving:
"...hundreds of outside partners in research and development. The strategy presumed that for every scientist at P&G, there were at least 200 outside the company who could do similar work. With that mindset, the company's intellectual assets became not just "our know-how" but also "who we knew."
Another example cited in the article involves how Exxon found a solution to the problem of cleaning up spilled oil trapped below the surface of Prince William Sound after the Valdez disaster by offering a "challenge award" to a large network of non-oil industry resources. The answer that had stumped oil engineers for 20 years came from a construction engineer who applied his experience working with cement to the problem of creating a pumpable liquid out of frozen oil.
InnoCentive, a Waltham MA solutions company has made a business of consolidating mostly individuals and some companies into a virtual solutions network of 175,000 resources for its clients. In successfully solving client problems, it has learned that:
"... the background of the solver who solved the problem" was "no less than six disciplines away" from the subject area in which the problem emerged. "What that means is, if all the Stanford Ph.D.s in your chemistry lab could have solved the problem, they would have solved it already."
Meaning that many solutions didn't even remotely come from the experts we usually expect to generate them. So try this as a rough translation into our lingo: "...if all the smart doctors and health care leaders in our organizations could solve all of our problems, they would have done so already."
I don't know how applicable this is to health care. But something tells me that we are accustomed to looking inside for what frequently turn out to be inadequate (or certainly less than innovative) fixes to health care operations inefficiencies, technologic limitations, and patient service failures. Perhaps a few degrees of separation and a formal network of contributors would be a good thing.
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Doing our Homework
The pretty clear business point made by Ms. Scanlon in this article is that "doing the homework" on a new product, service, or image may be up for re-examination. In the case of a corporate initiative the holy grail is obtaining preference, trend, and purchasing pattern information through market research based on a combination of surveys and purchase pattern data. HD needed to get an edge on Staples, it's key competitor, so:
"...the first step was to understand the problem and the opportunities. A standard customer survey commissioned by the company in 2006 provided a starting point, revealing a split in how men and women thought about office supplies....
But while that observation opened the door to a new strategy, it wasn't enough to tell Office Max what to do:
"In order to get beyond the survey data, Office Max asked GravityTank, a Chicago innovation consultancy, to study women who buy office supplies. 'If you wanted to understand the behaviors of a long lost tribe in the Amazon, you wouldn't send them a census survey. You'd observe them,' says Ryan Vero, OfficeMax executive vice-president and chief merchandising officer, who initiated the research. Ditto, he says, with consumers. 'Ethnographies are a critical component of our innovation process.'"
Try Looking at the Patient
In this day of extensive remote data availability, clinical and business managers can easily solve the problem, invent the product, or evaluate the process "on paper" or "on screen." Thanks to robust modern informational technologies, thorough laboratory and radiographic testing (for clinical problems) and detailed performance metrics (for business processes) are available online. So it's tempting (and sometimes necessary) for clinicians to conduct "armchair rounds" as the basis for treatment recommendations and for business leaders to conduct "remote troubleshooting" as a means to leverage management and make critical decisions. But as anyone who has been a clinician for a while knows, doing so is at your (or the patient's) hazard.
So for Office Max, the homework only began with the data - the real innovations came as a result of direct customer observation. Which led to a significant refocus of its competitive product and marketing strategy towards the purchasing habits and preferences of female office products purchasers. And it learned how to do it through careful observation on the ground:
"Over the course of two weeks, the Gravity Tank field teams, including a researcher and videographer/photographer, spent one or two days with each subject, arriving at the woman's home in the morning and shadowing her as she traveled to work and back. 'We try to watch for workarounds. Things people don't necessarily perceive as a problem, because they've developed a way around it...'"
But not every situation requires expert ethnographers and videographers. Sometimes it;s just careful and direct managerial observation and attentiveness. An approach that may be underutilized by health care leaders in solving, for instance, persistent operational problems (in a way that works for staff and patients), designing facilities and clinical programs (to real use requirements), clinical information systems (to actually decrease physician work), and managed care operations (to conform with the reality of network physicians with multiple payor relationships).
How To
Scanlon offers some pretty simple steps that can be used by any health care leader. These stay far short of hiring a busload of consultants - which might be warranted for major strategic changes such as Office Max's. But the approaches apply well to new products, programs, or initiatives as well as to day to day operational challenges. What they have in common is "looking beyond the numbers," stepping out, and observing users and the user environment:
Focus on Unspoken Needs]]>By watching the patient or user behavior, find out what they can't (or won't) easily tell you in response to surveys and questionnaires. What slows them down, frustrates them, causes them to work around the system, or - worst case - not return!
Study customers in their environment
The Office Max approach began before the store encounter and extended beyond it to provide a full environmental picture of the consumer experience. There's value in observing patient or user behavior at the clinic, in the hospital, or in the user setting (in the case of a product). But only by understanding the continuum of experience that included the "before and after" can insights be gained into barriers to getting there and complying with advice and recommendations. Which is the data you need to achieve high user penetration to services or high compliance (and results) clinically.
Watch for Contradictions
Ever hear a patient, physician, or product user promise to do something that never ended up happening? Or describe a requirement that really didn't result in pleasing them in the end? Observation gets you out of the "what I say v. what I do" dilemma.
Identify Your Target Customer
According to Scalon it doesn't take high numbers of observations, just the right ones: "In-depth ethnographic studies usually involve no more than a dozen subjects, so make sure they are the right ones." This increases the up front challenge but results in high value, limited resource, study.
Use Multiple Tools to Record Material
Just like any test or metric, measure from different angles using different tools. Listen to the heart AND get an ECG if you want to be sure of what's going on. In the case of ethnographic observation, take notes, use video and audio recordings, and perhaps use multiple observers over time. The goal is to get it right, not quick.
Surprise: New Leadership Measures
O'Toole (a Professor at the Daniels College of Business in Denver) and Bennis (also a Professor, at USC) begin by suggesting that in the future, corporate leaders will be evaluated not solely on their ability to produce business results but by:
"...[a]new metric of corporate leadership...the extent to which executives create organizations that are economically, ethically, and socially sustainable...whatever their strategies and tactics, we believe prudent leaders will see that increased transparency is a fundamental first step."
The case is made on the basis of a new definition of "increasing shareholder value" which encompasses newly important shareholder non-financial values including organizational behavior in the ecologic, employee relations, and social consciousness domains. So while it will be necessary to deliver "business results," strategies that achieve a great bottom line will not be sufficient to earn corporate leaders the recognition they seek from (Boards or shareholders) if this is accomplished through tactics that don't also demonstrate taking the high road in corporate culture and behavior.
Candor, Performance, and Public Expectations
So Medical Directors and CEOs of hospital, managed care organization, medical group, and health related businesses should pay close attention! Those corporate leaders are probably ourselves as well.
O'Toole and Bennis make the case for the inextricable relationship between internal candor and public positioning:
"...no organization can be honest with the public if it's not honest with itself, we define transparency broadly, as the degree to which information flows freely within an organization, among managers and employees, and outward to stakeholders."
This is particularly important for us to appreciate in this time of increasing public scrutiny of everything from finances to clinical outcomes to the safety or care, devices, and pharmaceuticals. O'Toole and Bennis further make the case that without internal candor and transparency, effective and durable innovation is impossible due to internal communication feedback barriers that make it impossible to frankly share information about new product, technique, and process performance.
In the past, perhaps, it was routine to launch new products, services, or care programs letting let the marketplace later reveal safety and efficacy flaws - but no more. And we've observed more than once that organizational leaders are increasingly held accountable for those failures - first by the public and the courts and next by Boards and shareholders.
And Wilkin, in his short piece on the repairing international financial crisis, makes the strong case that the need for candor is global and that it won't go away:
"Rather than hoping that public pressure will go away, banks and asset management firms should embrace transparency. Doing so will help them rebuild their reputations more quickly."
Pilots, Cockpit Crews, and Health Care Teams
So how are organizational leaders to behave? Well for starters, here's how NOT to behave - learned from studies of errors made in cockpits:
"The stereotypical take-charge "flyboy" pilots, who acted immediately on their gut instincts, made the wrong decisions far more often than the more open, inclusive pilots who said to their crews, in effect, "We've got a problem. How do you read it?" before choosing a course of action.
This has everything to do with the culture of transparency (or not) in the work setting:
Leaders are far likelier to make mistakes when they act on too little information than when they wait to learn more...pilots who'd made the right choices routinely had open exchanges with their crew members....crew members who had regularly worked with the "decisive" pilots were unwilling to intervene--even when they had information that might save the plane.... "
Health care leaders, and "persons in charge" in general, are frequently welcomed as problem solvers. However, resisting the temptation to default to being an action oriented, "decisive" leader long enough to get the right information from a range of informants can actually be a significant part of many solutions.
8 Steps to a Culture of Transparency
O'Toole and Bennis provide the leadership recipe for candor and transparency in sufficient detail to help you think about your personal leadership style as well as how to retool a health care organization to make your leadership role consistent with how you are likely to be measured in the future. The headlines from their HBR article are below. I thought about commenting on each one based on what I see in health care organizations but the commentary would stretch another page or more.
I'll just say that steps 2,3,4,5, and 7 are the ones most needed in the health care organizations I consult to.
While most of the steps below are intuitive from their titles it's well worth reading the full article for details and nuance:
1. Tell the truth 2. Encourage people to speak truth to power 3. Reward contrarians 4. Practice having unpleasant conversations 5. Diversify your sources of information 6. Admit your mistakes 7. Build an organizational architecture that supports candor 8. Set information free]]>
The shortest this month, and the most concentrated value per word for health care leaders, is provided in Ten Fatal Flaws That Derail Leaders by Jack Zenger and Joseph Folkman. It's a great list of "don'ts" that serves up way more impact than the few minutes of your reading time it takes.
Surveya Results for Failed Leaders
The authors, both leadership development consultants, looked back at the results of several hundred 360-degree feedback instruments completed by Fortune 500 leaders who were dismissed from their positions in subsequent years. They compared these to a much larger database of feedback results on leaders who were deemed ineffective and identified the convergences. Essentially, they identified the feedback from co-workers, subordinates, and supervisors that predicts eventual leadership failure. Each failed leader received feedback in one or more of these areas:
- Lack energy end enthusiasm
- Accept their own mediocre performance
- Lack clear vision and direction
- Have poor judgment
- Don't collaborate
- Don't walk the talk
- Resist new ideas
- Don't learn from mistakes
- Lack interpersonal skills
- Fail to develop others
Wherefore Health Care Leaders?
So these are sort of obvious, right? Well, according to the authors:
"These sound like obvious flaws that any leader would try to fix. But the ineffective leaders we studied were often unaware that they exhibited these behaviors. In fact, those who were rated most negatively rated themselves substantially more positively."
In my consulting work I find 360-degree evaluations in use in many organizations 0- but rarely are they used for health care leaders. This is at their (your) own peril. So if you are thinking you're a star in the eyes of your peers, maybe you should ask some of them how you rate in each of these areas. And maybe even consider instituting a 360-degree program in your shop.
Which Sins do Health Care Leaders Favor?
Since this article is short, it would be a sin of its own to make the commentary more than twice the length of the original. So here are some quick notes on the top sins I see most out there - and the order and places in which I tend to see them. But as I'm sure you know, we are immune to none of those identified by Zenger and Folkman:
1. Fail to develop others: In medical training we have historically gone with a "survival of the fittest" approach to talent development. And a "superman" approach to personal responsibility for achieving the impossible. Neither leverage through the development of others not intentional leadership training and mentoring come naturally.While this is slowly changing on the clinical side, it appears to be alive and well on the senior leadership end at many institutions. At most organizations where I consult, in addition to frustration about how much leaders must manage in their (unleveraged) portfolios, lack of physician leadership pipeline is on the short list of worries. I am currently doing unrelated strategic leadership work simultaneously at an academic medical center, a risk bearing IPA, a large community hospital, and a semi rural health system - all of which are concerned about their lack of intentionality around physician leadership development.
The more forward health care institutions are launching leadership development and mentoring programs but there are few models and no data out there on the effectiveness of mentoring models for academic centers or community hospitals. It's bad enough that the state of the art is underdeveloped - but for a leader to stand in the way of what can be done is a cardinal sin.
2. Accept their own mediocre performance: This is tied to the additional sin of disbelieving any data or measurement system that could be applied to objectively characterizing your effectiveness. I find these most common in provider delivery organizations in the context of productivity, quality, and utilization metrics. Physicians generally bristle at having patient care measured in part by productivity, or by what they see as imperfect measures of clinical quality. However, the best actually rise to the occasion and innovate efficiencies while participating in the development and proper measurement of meaningful metrics of quality. In my experience, the strata that expends effort on justifying their outlier status, or debating about measurement systems that most others accept, tend to be increasingly marginalized and poor leadership material going forward.
3. Lack clear vision and direction: There's a popular video on You Tube these days that illustrates the hazards of highly efficient movement without attention to the goal. It's hard to succeed in health care these days without being in constant intentional motion. But the failure to pause over strategic direction, to do effective longer range planning, and to consider nontraditional solutions is an affliction I see frequently in both provider and payor organizations.
I worry less about these leaders being dismissed than I do about their missing the boat or, worse, going down with ship that, like the antelope in the video link above, is headed for disaster.
Watch it, and think about your organization (and your leadership style).
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The Leadership Squeeze
AARP and others have documented a trend of rising self employment among older Americans. According to Perman:
"...experts believe the stock market's recent brutalization of retirement accounts will prod additional older Americans to start their own businesses. A combination of economic volatility as well as the growing number of baby boomers with time, energy, and money on their hands has redefined the starting age for new startups and has led to a surge in senior citizen entrepreneurs."
Is there any reason to believe that physicians and health care executives are any exception to this trend? While a minority of "high rollers" might do just fine with 40% less retirement principal, many retired or nearly retired - but highly experienced - docs and execs are probably not all that comfortable with the prospect of the future income stream available from the "201k."
At the same time the following conditions converge: (1) natural pressures on near retirees to step down in favor of the next generation; (2) increasing opportunities for entrepreneurship and creativity within new and existing health care organizations; and (3) insufficient seasoned health care leaders to go around. In addition, if younger professionals are not encouraged to advance in their careers and rise into mid and high level leadership positions, the resulting squeeze could lead to short term friction and long term distortion of health care staffing and leadership dynamics.
Post Career Docs and Hospital Execs as a Leadership Pool?
We used to tout the importance of capturing the value of retirees and made much of encouraging them to volunteer their time for good causes. In health care this often meant Board membership, teaching, or fundraising. I wonder if there's a more intentional and strategic use for this generation. Perman notes the potential:
"A combination of economic volatility as well as the growing number of baby boomers with time, energy, and money on their hands has redefined the starting age for new startups and has led to a surge in senior citizen entrepreneurs. This is a category that is only recently being studied."
She refers to classical entrepreneurs - self-starters who choose to begin new ventures with money to invest. This minority of individuals puts capital at risk seeking either independence in business development or high financial returns on funds they can afford to put at risk. But that's not for everyone, and especially not for "201k-ers."
But couldn't we intentionally encourage the larger pool of more risk averse but highly energetic and experienced spirits to step out of hierarchical line leadership positions with waiting lines below them and into leadership for newer initiatives and structures (related to medical homes, or accountable care organizations) collaborative ventures between physicians and hospitals (joint operating councils, cross functional service lines), or leadership mentoring roles?
More Experience, Less Filling?
These new and complex activities require creativity, experience, a degree of gravitas (which usually means grey hair), and the ability to focus on doing things differently. They would benefit from leadership with a low level of political self interest and a high community benefit perspective. They may ultimately be essential to health system success and yet may or may not show the big financial returns (in the short run) that justify or attract high priced leadership.
Enter recent or impending retirees who have skill set, demand stimulation, may be interested and motivated to attack interesting challenges they couldn't focus on while having stressful "day leadership" jobs, and who - as retired from active practice or hospital leadership - could be one step removed from direct self interest, and whose financial requirements may consist of "filling gaps" rather than creating de novo wealth.
Sounds to me like a promising low calorie high energy tonic.
Purity or Split Personality?
More and more physicians these days either get MBAs or learn business and management on their own sufficiently to effectively manage multimillion dollar practices, hospitals, or health related businesses - often while practicing as well. I regularly write about some of the leadership challenges faced by physicians turned organizational moguls, however I never express much doubt about the financial acumen of these colleagues. My concern is usually about other skills or values that are required for success as business leaders.
The Economist editor makes the point that:
"A set of shared values is one of the defining features of a profession. Lawyers and doctors have their own codes, but business-school professors tend to embrace Milton Friedman's claim that the only responsibility of business is to maximise profits."
Reflecting on this I do find that something curious sometimes takes place when physician leaders become organizational or practice leaders. They become pretty tough business people - more than a match for hospital executives, contractors, vendors, etc. Profit mazimization is something I hear a lot about when conversations turn to free standing imaging centers, labs, surgi-centers, who will care for indigent patients, etc. And even younger physicians who are not in leadership positions (other than for their own families) are looking very carefully at the bottom line (in dollars and work load) before entering into any healing deals.
Profit is not inherently a bad thing. But sometimes it seems as though profit maximization runs as deep (or deeper) than the Hippocratic commitment to: "...preserve the purity of [our] life and [our] art."
Good for the Patient or Good for the Wallet?
The Oath obligates us to: "... prescribe regimens for the good of [our] patients according to [our] ability and [our] judgment and never do harm to anyone."
As physician leaders seek economic profit maximization, is the patient always first? Is quality and safety always first? Or does some impurity sneak in there when business pragmatism supervenes and we are in financial negotiations? When it does, it always seems a little unbecoming to me. Especially when the tough negotiators are highly respected physicians who provide impeccable - sometimes legendary - patient care and attentiveness. Or promising young physicians who seem less attentive to the opportunity to serve than finding balance in their lives.
So when physician leaders are in roles of hard nosed profit maximizers, are they behaving contrary to the Oath or merely outside of its purview? Does the Oath's obligation cross over to our business roles, or do we, as do the nascent and pure MBAs, also need a supplemental Oath to: "serve the greater good", "act with the utmost integrity" and guard against "decisions and behaviour that advance [our] own narrow ambitions, but harm the enterprise and the societies it serves?"
Both, And
Ideally we should be able to both make a buck (or three), provide outstanding patient care, safety, and experience, seek the greater good when there is a choice between sufficient profit and more profit, all while preserving amicable - or even productive - relationships with other elements of the health care continuum. According to The Economist, supporters of the new MBA oath argue that:
"the goal of maximising shareholder value has become a justification for short-termism and, in particular, rapid personal enrichment. They are concerned about managers doing things that drive up the share price quickly at the expense of a firm's lasting health. Management gurus such as Jim "Good to Great" Collins argue that shareholders are likely to earn better returns in the long run if firms are led by managers with integrity and a desire to play a constructive role in society."
Pie in the sky or the right talk before we groom a new generation of profit maximizers who, incidentally, do some healing when the risk-reward ratio favors it?
]]>None of us knows what it really felt like to be a leader coping with the radical new inventions of the printing press, automobile, or telephone. But we assume those were times of relatively incremental and sequential environmental change than leaders were able to manage more expectantly than we can today. Even the introduction of the mainframe computer seemed to come at us relatively slowly. But the capacity for even small changes to cycle rapidly through introduction, dissemination, mutation, replication, and obsolescence is a contemporary phenomenon . And it seems, if anything, to be accelerating. Ms. Love reminds us that this demands a radically different approach to leadership:
In this high-stakes game of survival, the most successful leaders will demonstrate the ability to simultaneously monitor these forces, measure their impact, and create new opportunities rather than wait for them to appear. The rules of business have indeed changed--in a way that demands leadership at the speed of thought and the capacity to build measured, decisive, and inventive teams.
The article offers some insights and principles for survival that frame how leaders can retain sanity and perhaps improve effectiveness in this warp speed environment. Most applied pretty well to health care leaders. I divide them into three dimensions in which executive leadership competency is crucial: perception, decision making, and communication/engagement. Notably, "action" is a dimension left to managers.
Perception
The need to expand the number of radar screens: Love refers to the multiple signals coming to leadership's attention simultaneously, like: tonight's Board meeting requiring a crucial financial presentation; a bed/census crisis requiring 15 discharges immediately; a surgeon calling from the OR because a piece of equipment needed intraoperatively is malfunctioning and there is no backup for it; negotiations with several electronic health record vendors at a delicate stage; a belligerent family in the ED complaining about a prolonged wait; a fresh and time limited opportunity to develop a piece of real estate in partnership with other parties; etc.
Ms. Love's elixir is building leadership capacity: ".. for discerning what to ignore and what is critical to address because it affects success." Health care leaders today must have the personal skills and hard wired processes to help them prioritize, delegate, and - at times - defer issues that when standing alone would demand attention but in the context of competing signals must take a back seat.100% Certainty is a luxury purchase: While careful decision making remains a leadership priority: "successful organizations in this new economy will be comprised of leaders who are decisive, measured risk-takers." With fewer incoming signals leadership can afford to seek more certainty. With multiple, competing demands for leadership attention, requiring the highest degree of confidence for most decisions will be paralytic.
Physicians who practice in acute or critical care settings are accustomed to making decisions with less than perfect information, knowing the patient will deteriorate if the wait for confirmation is too long. In this case, executive leaders have something to learn from the trauma surgeon's playbook. There's a critical amount of information necessary for decision making - sometimes that also needs to be sufficient.
There is no time to solve the wrong problems really well: Health care leaders are creative, thoughtful, and improvement oriented. Even mission focused dreamers sometimes. According to Love, those are assets to be deployed in a measured fashion only for the highest priority issues: "Opportunities have long since evaporated for developing elaborate plans and strategies that aren't applicable to the organization's most pressing issues."
Decision Making
Redistribute the authority to say 'Yes': In the article this was all about enabling customer service representatives to please the customer. Good enough, but I'd like you to consider this to apply more broadly to delegation. If there's any failing I've seen frequently among senior health care leaders struggling to get on top of the multiple radar signals, it lies in the tendency to centralize rather than distribute authority and accountability.
The pace and complexity of problems and opportunities facing health care leaders absolutely requires a layered accountable infrastructure comprised of competent and trusted decision making. If there's any way to avert some of the leadership "no win" choice scenarios brought on by too many decisions on the plate, it's to have some of the fly balls fielded well by subordinate and emerging leaders.
Communication/Engagement
Trust and transparency are your allies - verify that you've communicated effectively: Ms. Love wisely counsels: "If leadership messages and crucial information about the state of the business are not penetrating all levels of the organization, the business will function with a handicap that may derail its success." Right next to limited delegation on my list of health care leadership foibles is the tendency to communicate insufficiently, inadequately, unilaterally, or without sufficient intentionality to get people on board and committed to the direction required by the organization. And being unaware that they have failed.
As leaders, we are asking a lot of our followers. Not only to do more with less, and do it more quickly and more accurately, but bring others along and do so in a way that satisfies customers, colleagues, and partners. You simply can't obtain that sort of allegiance without telling the story of organizational strategy well, completely, frequently, and with enough detail to make it an imperative. And oh yeah, by the way, listening to questions and concerns not only with an ear to giving good one line answers but as a barometer of understanding, support, and of constructive - and potentially initiative saving - advice and criticism.You can't win without smart, passionate people: I certainly can't say it better than Alaina Love did:
"Everyone in this business environment needs to bring an A game, making it essential for leaders to identify the very best talent and then support their ongoing development. This is not the time to dial back on employee-development programs; it is the time to insure that your development dollars are being spent where the return will be greatest."
Your people are the only asset that can get leadership from today's challenges to tomorrow's success. Lightning or no lightning, ignore any other pithy advice given above and always take time for them.
The American Management Association, publishes a number of informative and topical monthly newsletters on management issues of which Leader's Edge, in which this short piece by Bruce L. Katcher appeared in May, is one. Dr. Katcher, an organizational psychologist, is an expert in employee opinion polling which makes his comments about the institutional impact of waffling particularly credible. While neither his focus, nor that of the American Management Association is on health care, waffling is a generic leadership condition to which health care leaders are far from immune. Katcher usefully informs us of the internal cost of waffling and counsels some prevention techniques.
Syrup or No Syrup...
Since the 2004 Presidential elections we've heard a lot about waffling and "flip-flopping." So we know it's supposed to be a bad thing. Indeed for John Kerry, no amount of syrup on the purported waffle was sufficient to make it edible. As politics is a rich medium for discussions of waffling, Katcher kicks off his commentary using the more recent example of how Timothy Geithner's "flip flopping" on how the federal economic bailout would be operationalized impacted economic markets. Despite attempts to characterize his conflicting statements as "flexibility," it engendered a lack of confidence in his leadership and in Katcher's words: "This was a good example of how poor decision making made a bad situation worse by bringing about a loss of confidence that then dramatically impacted the market."
Cooking in the Dark
The health care environment is nothing if not uncertain - perhaps more so than the economy. Given potential policy change potentially impacting reimbursement and organization of health care; the inevitable epidemiologic surprises; unpredictable professional work force dynamics; and rapidly emerging technologies in general - and the impact of the electronic health record specifically to name just a few, it is clear that the world of health care leaders is filled with multiple likely and widely divergent possibilities in the near and long run. While it's not always possible for health care leaders to unfailingly know where to go next, in order to keep colleagues, staff, and employees on board, it's important to move there with clarity and confidence. According to Katcher:
If employees trust their leaders and believe they make sound decisions, they will follow them even when they don't agree with their decisions. The key is that they believe their leaders can provide them with a clear, consistent direction...Our research shows that only one out of two employees believes the leader of his organization makes sound decisions.
Although health care leaders may be temporarily protected from employee defection by an unfavorable economy, when recovery inevitably occurs employees and staff won't be glued to their current organizations. As the "smart money" is now on investing in preparation or recovery, if they are already confident that their leaders charted a straight course through the bad times, they may be more likely to stick around, assuming the same leaders will do even better in good times.
Recipe for a Dark Kitchen
So while it's not likely health care leaders will know or do what's right in every circumstance, it is certainly possible to stack the odds and to be sufficiently thoughtful about the direction taken to avoid rapid and repeated waffling. Katcher offers some sound advice on how to do this. For health care leaders, particularly for physician leaders who are accustomed to making decisions relatively independently and sticking to them, these may seem like uncomfortable recipes, but Katcher's 3 step cookbook may fit these murky times:
1. Think before you act: Katcher means really thinking through the ramifications of decisions, communications, and operational approaches to responding to current conditions. As problems present themselves - be they impending reimbursement changes, real revenue shortfalls, market erosion, or quality lapses - it makes all the sense in the world to think through the available options and how to best implement and communicate them. Even if the best option ends up being a layoff, program elimination, or delay of a strategic initiative the way to get from here to there can either contribute to the problem or to the solution. I'm currently consulting to two organizations who are facing hardship in fundamentally different ways:So as health care leaders we bear yet another burden. Not only do we need to present an appealing menu for customers and staff and execute it flawlessly, we have to anticipate what ingredients will become unavailable, when that might happen, how we will substitute new offerings with less fat and same taste, and how we will rewrite the menu in a way that continues to sound appealing and consistent with how we advertise our kitchen.Leadership in an academic health center client is responding to budgetary shortfalls by forcing a reallocation of revenues from healthy Departments to unhealthy ones with little regard to promises and strategies previously in place. Different stories are told every day about how it is being done and This approach risks eroding the confidence of the best performers and threatening the organization's long term strategic interests.
Executive leadership in a large community hospital on the rebound from losses attributable to prior failed leadership engaged its physicians and executives in making the tough choices about where resources would be allocated and recovered handsomely from substantial operating losses despite the recent economic collapse. The executive management team persisted in funding a major future oriented electronic health record implementation despite the challenging economy. As a result, Staff and physician morale are high and the hospital system has positioned itself extremely well in a highly competitive market.
2. Check decisions with others before going public: Katcher wisely counsels that before making and announcing key decisions, leaders should first challenge representatives of key constituencies (in his opinion these would be optimists, pessimists, pragmatists and the cautious) to respectively indicate what they find most advantageous (optimists), risky (pessimists), challenging (pragmatists) or frightening (the cautious) and why they thusly believe. This means speaking seriously, and potentially in confidence, with those who may hold opposing beliefs. Only by taking a "360 degree" sounding can leaders reasonably anticipate the pitfalls and resistance ahead and frame decisions in a fashion that reflects due consideration to multiple points of view.
3. Fully communicate decisions
Even if steps 1 and 2 (above) are accomplished well, and tough decisions are arrived at with outstanding process, health care leaders typically fall down in communicating that process to stakeholder constituencies. If only the result is understood, leaders will be judged on the palatability of the decision. In challenging times, decisions are likely to be unpalatable. Acceptance, allegiance, and respect will only result from a well understood and communicated process that makes the alternatives considered - and rejected - clear and logical. Katcher informs us that:
"Our research also shows that only 38% of employees believe management does a good job explaining the reasons behind its decisions. Employees want to be treated like adults. They want to know why a decision was made, what the risks are, and what potential rewards they can expect. Most importantly, they want honesty from their leaders."
And all without the option of waffles.