4 December 2015

Dear Interested Readers,

Inside This Week’s Letter

There are two sections to this week’s letter. The first section begins as a celebration of the opportunities that exist in healthcare. It continues as an attempt to explain how Lean can mitigate the issues that we could lump together as professional stress and dissatisfaction. I realized that what I was writing could be a book so I pulled up short with an abbreviated discussion of leadership. I will return to the subject in the near future.

The second section is my attempt to rationalize the horrible events in California this Wednesday. It is not an answer and there is nothing definitive in the outcome of my consideration. It is also an attempt to make some sense of not being able to completely accept age old biblical wisdom. It is just one man’s point of view. My confused ideas are no more valid than yours. Perhaps you could consider this an invitation to tell me how you are feeling.

Some of you must be directing friends to strategyhealthcare.com because there are several new “Interested Readers” this week that I would like to welcome to these musings. I hope to see many of you at the IHI meeting in Orlando this week. If you do not go, you can be sure that I will try to give you my impression of this annual event next week.

The Real Service and Leadership Opportunities in Healthcare

It has always been my bias that anyone who wants to have a career in healthcare was seeking something more than a job. There are many paths into a satisfying career in healthcare. Medical school, a nursing degree, or advanced programs to become a PA or NP are obvious choices; but there are also a plethora of other pathways for great professional satisfaction through clinical specialties like pharmacy, optometry, audiometry and podiatry. When discussing the benefits of a career in healthcare it would be either pejorative or naively narrow minded not to include the technical specialists in the lab, and imaging. Worse yet would be to fail to recognize that the term “healthcare professional” should apply equally to those who saw an opportunity with their MPH or MBA to perform critical business or management functions. The list of critical contributors in any healthcare organization would be in adequate if we failed to recognize that we could not get through the night and into tomorrow without the assistance of those in health IT.

As we think inclusively about all the opportunities to find more than a job in healthcare we should not forget the consultants who support our clinicians and managers in their strategic planning efforts. I can not imagine healthcare today without the skills of people with unique competencies to offer us in Lean, Six Sigma and other forms of continuous improvement. Device manufacturers and pharmaceutical companies get a lot of grief when we want to blame someone other than ourselves for tolerating the persistence of inadequate systems for the rising cost of care. But would we want to go forward without the hope of better drugs and amazing new devices? I recently saw a medical engineering marvel. It was a computerized exoskeleton that may allow many paraplegics to walk again!

Perhaps greatest among those who serve, and deserve the title healthcare professional, are the OR techs, medical assistants and clerical staff that lead patients through the overwhelming complexities of care delivery and enable the clinicians to focus on the patient. Whenever I address workforce issues in healthcare, I always hesitate for fear of an omission of some group whose work is essential and whose efforts I applaud and admire. It seems that within the variety of traditional opportunities and the rapidly growing list of new ways to aid in the pursuit of the Triple Aim there is an opportunity for anyone who wants to serve humankind to find a meaningful career in healthcare.

As healthcare transforms itself and evolves, I fear that despite my good intentions, I have already failed to catalog all the choices that exit now or will exist in the near future. As extensive as the catalogue above is, I did not list population managers, data analysts, translators and those who spend their day just trying to help people enroll in the programs that best meet their needs when there are a staggering number of potential options. It should be exciting for anyone who is drawn to human service to know that they can employ their existing talents and grow their competencies in new areas that will continue to expand into the future.The whole point to this introduction is that today there are more opportunities than ever before to find much more than “just a job” in healthcare. I believe that most people who are employed in healthcare today are there not by accident, but because they want to help people in whatever way their talents and skills might be used.

The readership of this letter is an example of what I am trying to say. There is at least one “Interested Reader” for every group that I have mentioned above! The scope of “Interested Readers” is broader even than the list I have made of healthcare professionals. Some “Interested Readers” are not even employed in healthcare but care deeply about it and are contributing to the Triple Aim by their interest in a better world.They are politicians, economists, or concerned citizens that care enough about the future of healthcare to want to read something that might help them take a different look at, or stay abreast of, issues that matter.

It is paradoxical that despite all of the opportunity and professional satisfaction in healthcare one of the issues of greatest concern that challenges future success is the emotional health and happiness of healthcare professionals. My friend and colleague, Dr. Paul DeChant, is worried about burnout among healthcare professionals, especially doctors. He knows that despite the fact that healthcare is populated by very competent and caring people who chose their profession because of their desire to serve and contribute to better care, those same people are becoming disillusioned, angry and often profoundly depressed. I share his concern.

No one really knows the numerator or the denominator that fully describe the extent of the problem. All of us have felt the breeze, sensed the change in the weather, occasionally felt the earth tremble or smelled an odor in that air that warns us that something may be on the edge of burning or exploding. Indeed, it is almost amazing that healthcare functions at all given the extent to which its professionals seem to be losing their enthusiasm and compassion as many succumb to the “dark side” of anger and self interest, or worse, become depressed and even are at risk of substance abuse or suicide.

You might ask, “So what’s new? There has been stress in healthcare for a long time”. You could also ask, “What makes you think healthcare is more of a concern to society as a whole than inadequate education or the persistent racial conflicts and inequalities that every new police shooting underlines?” As we look around our troubled society maybe healthcare is better off than many other areas. A majority of the population must get pretty good care and healthcare employs so many people that perhaps our requests for transformation are unrealistic and impractical. There are people who are not so sure that things should change. There are well meaning people who believe that our plate of social concerns is too full and might ask, “Why should we be concerned with healthcare when we have domestic vigilantes with assault rifles who regularly attack social agencies, churches and schools for reasons that make sense only to them?”.

Some people may believe that the appeal of fundamentalism, dualism, xenophobia, nationalism, tribalism, egoism are all greater threats to us than our healthcare system which can still deliver your babies and put your broken limbs in a cast. The current bizarre presidential campaign season still has eleven months to run and that very dysfunctional political discussion and the response that it seems to be getting from the public may be evidence that there are many worries that trump the concerns of healthcare professionals and their diminished sense of professional satisfaction or personal actualization.

There is another way to look at our current VUCA (volatile, uncertain, complex and ambiguous) world. Don Berwick brought an important point home to me several years ago when he asserted that healthcare was mostly local. He suggested that as we think globally, we should act locally. You can be concerned about global warming and can reduce your own carbon footprint. You can be sure to vote and support candidates who do not try to appeal to the self-centered interests of a disillusioned electorate. You can be willing to pay more local taxes to provide better infrastructure and social safety net programs where you live. In all those areas your individual efforts are going to be a very small, albeit necessary and important, part of a distant solution, but in each area you can make a difference where you are. The logic for focusing first on what you can do locally makes even greater sense if you have made the choice to work in healthcare. In healthcare you can choose to make a measurable impact today.

“How so, really?”, you ask.

Let me speak from experience. My first employment in healthcare was as an orderly (medical assistant) at the South Carolina Baptist Hospital in May 1964. I took the minimum wage job on the advice of my father. I am fortunate that he is still alive and providing me with guidance at age 95!. Dad suggested that if I was really interested in being a doctor, I should check out what it was like to be around sick people in a hospital.

I immediately felt like I was doing something that made a difference. I was certain that every act of care, every time I helped a nurse do her job changing bandages on a severely burned patient, every time I struggled with a big oxygen tank or every time I turned a patient or straightened their bed I was doing something that made a difference. The feeling was very similar to the experience of satisfaction that arose later from the direct act providing care as a physician, or even later leading a healthcare organization where the act of care was indirect and expressed through the thousands of professionals who were the real contacts with the patients. I hope that other professionals like school teachers, social workers, ministers, priests, and who knows, even lawyers and investment advisors enjoy the same sense of professional satisfaction from their work.

The current realities of anger, depression and burnout that affect so many healthcare professionals have negated or blunted for many this natural sense of great satisfaction from helping patients that I was fortunate to enjoy for almost fifty years from my first day as an orderly to my last day as a CEO. It is the opportunity for service that satisfies the need for professional purpose that was the hook for me and for almost everyone I have ever met in healthcare.

Paul DeChant’s mission is to help “ return joy to practice”. His hypothesis is that the solution is to spread Lean culture and methodology. The thought that Lean could hold the answer for the problems that plague healthcare is not new. The title of John Toussaint’s first book suggests the idea of the ability of Lean to mend healthcare. On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry (2010) has been with us for a while and was written with the belief that Lean was the answer to healthcare’s woes. The title of Patty Gabow’s great book, The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System (2015) which describes the evolution of the Lean experience at Denver Health also suggests that Lean is a “powerful medicine”, a cure for our “ailing healthcare system.”

To read about what Lean has done in someone else’s organization is inspiring but personal experience is better. When Harvard Vanguard and Atrius began to implement Lean in 2009 the senior management team had been to ThedaCare, Virginia Mason and Group Health to see what Lean had accomplished in those organizations. What we saw made us envious but also filled us with hope and inspired us to see if Lean could bring the same benefits to our patients and healthcare professionals that we had witnessed in the organizations we visited.

Seeing Lean in action in someone else’s practice is not the same as experiencing Lean in your own practice. Reading about Lean tools and process is not the same as actively using the tools in concert with colleagues to solve a problem or improve a process of care that affects your patients. Reading about, hearing, or observing on a site visit how empowered the healthcare professionals are in Appleton, Wisconsin, Denver, Colorado or in Seattle, Washington is not the same as listening to colleagues in Chelmsford, Watertown, Kenmore Square or Wellesley that you have known for up to 35 years as they tell you how empowered to improve care they feel.

It is also easy to observe that the people who are solving problems, eliminating waste and better serving patients with their new Lean skills are not suffering from anger, depression, and burnout. They do experience much joy in their work. They tell you that they are excited about the possibility in each new day. They are engaged. It makes sense since their frustration, anger, sense of futility and subsequent fatigue and depression was primarily the product of being trapped in a dysfunctional system that they could not fix alone and that negated much of their ability to do the acts of service for people that they came to healthcare to do.

How does Lean turn the anger and darkness to light and hope? My partial answer is that Lean can free healthcare professionals from working in a system that continuously throws them one problem after another to solve again and again without any permanent sense of solution. What a joy it is! I have seen faces change the minute a person realizes that they might be freed of work that reproduces the fatigue and frustration of Sisyphus who angered the Gods and was condemned to the futile and hopeless task of eternally pushing a stone to the top of a hill only to have it roll back down again.

Another part of my answer requires a reference to Daniel Pink’s fabulous book, Drive:The Surprising Truth About What Motivates Us (2009). In that important book Pink examines the fallacy that most of us can be managed by the carrot and stick approach. Clearly one of the reasons we must work is to survive, and until those basic needs are met carrots and sticks can be compelling, but for most of us after our basic needs are met, money is not the motivator it may be for CEOs earning hundreds of times the income of the average worker. For our work to be meaningful nothing is more important than solving problems and a job that provides the joy of solving problems and helping people is much more of a draw than carrots and sticks.

As Pink says:

Behavioral scientists often divide what we do on the job or learn in school into two categories: “algorithmic” and “heuristic”. An algorithmic task is one in which you follow a set of established instructions down a single pathway to one conclusion. That is, there’s an algorithm for solving it. A heuristic task is the opposite. Precisely because no algorithm exists for it, you have to experiment with possibilities and devise a novel solution.

Healthcare is very algorithmic, and for good reasons, but it is also fraught with an amazing amount of variation which we elevate to a value by calling it “clinical autonomy”. Its algorithms often have enormous amounts of waste and many defects permanently embedded in the system which are daily sources of frustration for the people who are trapped in silos.

We should recognize that there is a balance between “standard work”, the algorithm that defines the safest, least wasteful way of completing a task that we know, and the search to replace old and wasteful algorithms with new standard work. With Lean the people that live with the algorithms and suffer from their mindless tierany are empowered to replace those dysfunctional algorithms. They have the joy of replacing those broken processes with new and efficient standard work that they develop by a heuristic process that we call a “kaizen” or “rapid improvement event” (RIE). They also do it through Management for Daily Improvement. It is within these kinds of processes that we get the sharpest photo of joy being returned to practice.

There is great joy in being a witness to timeless art like a beautiful performance of a great opera or enjoying the awe and natural beauty of a huge whale arching high into the air. For me there has never been anything more inspiring than to see a young medical assistant suddenly produce an idea that is worth testing as an improvement in a process that has been a daily frustration for her and the physicians and nurses that she supports. You can see great joy on the faces of the whole team at a Friday morning “report out” of the new standard work that they have created together over the course of the previous four days.

Heuristic joy is possible only if people are given the opportunity to solve problems. To capture and multiply the positive effect of solved problems requires structure that provides tools and the ability to transfer and accept what has been learned. When we think about tools we are generally thinking about machines or the tools that make machines. What is remarkable about our age is that tools are more often composed of ideas and information than steel and rubber. Lean is not delivered on a truck and you can not buy it from GE or Siemens. The most significant component of the transformation is a new type of leadership that exists as “standard work” throughout the organization.

Every healthcare professional title that I listed at the beginning of this piece needs to be modified. For example nurse becomes nurse/problem solving teammate/leader. Pharmacist becomes pharmacist/problem solver teammate/ leader. Medical assistant becomes medical assistant/ problem solver teammate/leader. Everyone’s standard work is enlarged by the empowerment of Lean to grant them the ability to recognize problems and participate in the improvement in processes that they know best. Everyone is simultaneously valued for their leadership contributions.

Jim Collins gave us an advanced understanding of leadership in Good to Great with his picture of the “servant leader” or “level five” leadership. Bob Johansen in Leaders Make the Future: Ten New Leadership Skills for an Uncertain Future described a new set of competencies that many senior leaders will need but do not possess. Lean leadership principles permeate every level of the organization in a fashion somewhat similar to Collins’ description of five levels. Lean leadership also requires new competencies and it goes even further in its requirement of personal transformation of leadership as the essential ingredient in the creation of a Lean organization that has the power to restore the joy of being a healthcare professional. John Toussaint’s latest book, Management on the Mend: The Healthcare Executive Guide to System Transformation clearly states the challenge that faces any organization that sees Lean as the answer to the their attempts to survive in the current complexity of healthcare. He writes based on an analysis of 145 organizations that he has visited in 15 countries.

I understand why I am seeing hope and failure in nearly equal measure. Teams of clinicians and administrators using lean thinking are making breakthroughs every week as they increase quality and reduce costs. But the essential transformation of the organization is not happening due to some basic misunderstanding about lean in healthcare.

The most common problem I see is that leaders fail to recognize the magnitude of change that will be required and that change extends to leaders on the personal level.

Lean Leadership A to Z and top to bottom is a fascinating subject to ponder. You can not buy it but you can have it, learn to do it and enjoy being a part of it. In the near future I will continue the practical discussion of the necessary leadership transformation and the diffusion of leadership changes that must flow through the whole enterprise if Paul DeChant’s dream of using Lean to return joy to practice is going to occur.

Rights, Religion, and Guns

The thing that hath been, it is that which shall be; and that which is done is that which shall be done: and there is no new thing under the sun. Ecclesiastes 1:9 King James Version (KJV)

That thought from the Hebrew scriptures pops into my head more and more often the longer I live. Perhaps it is because of the “sameness” of the reports of events in the news. There is an almost daily report of some mass shooting; the New York Times reports that so far this year in 209 out of 336 days, at least one shooting left four or more people injured or dead. Some of the recent ones like the dramatic shooting in San Bernardino this week or in Colorado at Planned Parenthood last week, seem to stand out as uniquely horrible, but I think that the President was right when he suggested that the stories are more similar than different. What did Mary Travers sing with Peter and Paul about where the flowers had gone and when will they ever learn?

That little bit of scripture from Ecclesiastes must have been first planted in my mind as a “bookmark” for days like Wednesday. Some Sunday School teacher must have buried the seed more than sixty years ago as the “memory verse” part of some lesson. Tradition says that King Solomon wrote Ecclesiastes in his old age. The title “Ecclesiastes” translates essentially as “gatherer”, “connector” or “preacher”. Given the influence of preachers and the facts that he was also the king and a pretty good writer Ecclesiastes has been accepted wisdom for a long time. In another way, even though he did develop a reputation for his wisdom, I do not think that it would be a stretch to consider the book to be an old man’s musings or that it describes a world weary point of view. However you chose to view it, the advice does seem solid. Its message is worth considering when everything seems out of control.

The first few chapters are pretty depressing as Solomon seems stuck on the idea that despite all he has learned and done, he has not accomplished much and everything will soon be negated by death. He sees death as the reward of both the good and the evil. By the third chapter he is feeling a little better and we have the wisdom that was lifted as a song title “To every thing there is a season…” As Solomon struggles to prove that wisdom and experience are worth something and have some ability to counterbalance the downer statement with which he began, he spews off a lot of practical wisdom that is still applicable for us today. For example:

Two are better than one;because they have a good reward for their labor. For if they fall, the one will lift up his fellow…

Whatever thy hand findeth to do, do it with thy might…

Wisdom is better than weapons of war: but one sinner destroyeth much good…

The words of a wise man’s mouth are gracious; but the lips of a fool will swallow up himself

If you read all of the 12 chapters (not much longer than some of my letters) you can recognize some progression of his thought but in the end you are left with the concept that despite all of your wisdom and effort you will die and be forgotten. That leaves us with two paths. The first clearly endorses wisdom as a means for a well-lived earthly life and also suggests that we should live our lives vigorously:

Go thy way, eat thy bread with joy, and drink thy wine with a merry heart…Live joyfully with the wife whom thou lovest all the days of the life of thy vanity… Whatsoever thy hand findeth to do, do it with thy might… Ecclesiastes 9:7-10.

The second possible path is not exclusive of the first:

Fear God, and keep his commandments; for this is the whole duty of man” (12:13).

This is ancient wisdom that we should take under consideration but not necessarily accept. Despite Solomon’s opening suggestion that nothing changes, there has been some improvement in the intervening 2500 to 3000 years since Ecclesiastes was written. What has not changed are the basics of human nature that he described. People are still prone to make the same errors and stumble because of the same vanities. We still ultimately die and most of us will be forgotten. What has changed is that although there is little under the sun different about our basic tendencies, we have developed the capacity to bring improvement to our world when we try together to make things better. I see that some people are trying hard to live in harmony with one another and our planet, and their number is growing.

I believe that we are learners. We are very slow learners, but there are many new things under the sun even if we exclude Apple products from our analysis. We have made some progress with civil rights. The plight of children has improved. The plight and opportunities for some women have improved a little bit. We have survived the bloodiest century of human existence and at least some people have learned that genocide is wrong and that diversity is the greatest expression of humankind.

Ironically, our mechanism of government is both the origin of some of our frustration and also fortifies and insures our progress when a progressive law is finally passed. That is what happens when you value the protection of minority rights. I believe that someday we will have equality. Someday we will have sensible gun control. Someday we will have a transformed and better system of healthcare. Someday we will no longer need to be reminded that black lives matter because it will be a settled matter accepted without question or controversy. Someday we will not have to be reminded that people on the radical fringes of religion are just that, more than two standard deviations from the mean, and not a description of an entire religion or ethnic group. Someday we will all know that mental illness is not the same as evil. Someday most of us will know that it is true that:

For to him that is joined to all the living there is hope…Ecclesiastes 9:4

A better world is possible but not easy to obtain, but I believe that sooner or later we will learn to ask earnestly of ourselves, “What part of the problem am I? What can I do to help build a better world?

Walking In The Sun

I hope that someone has a freezer full of venison as the benefit of the deer that sacrificed itself on the right front fender of our car early on Thanksgiving morning. As I reported last week we did make it to Miami in time to have a great visit. I am usually not a great fan of Florida. It is often too hot or too humid and it is definitely too crowded. There are things beside spending time with my granddaughter that I do enjoy in Coconut Grove where my son and his family live. There is a huge park down the street that borders Biscayne Bay. It is lush with cinder walking trails, a fitness course and great views across the water toward Key Biscayne. The grass is always green and there is always a very diverse population of people just enjoying being outside. The picture in today’s header does not do the park justice but I will not see such a warm sunny day in New Hampshire until next May. I did not waste my chance to enjoy walking and jogging in the sun!

My reading of Ecclesiastes suggests that taking advantage of the good moments in life is the best strategy. It also suggests doing things together is better because For if they fall, the one will lift up his fellow…I hear that we are expecting warmer weather in New England this weekend. The Patriots game starts at sundown so I hope that you will find someone for a walk in the midday sun. I will be walking with my Dad in North Carolina, as my sibs and I gather to celebrate his 95th birthday!


GeneL160 Be well, be thoughtful, do good work, and drop me a line now and then,


Dr. Gene Lindsey