Over four years into retirement I frequently wonder what opportunities, if any, do I still have to make a contribution. I reexamined that question recently as I was patting myself on the back for writing my weekly letter, now called “Healthcare Musings,” for ten years. [If you are not on the distribution list, a sign up box is conveniently located on this site.] What often lifts me from my funk is a comment from one of the regular readers of the weekly letter. One thing that really lifts my spirits and makes me feel that I have an opportunity to contribute is for some young or mid career leader to ask me to write a letter of recommendation to help them move forward toward a goal. Another thrill is for someone who I know has huge potential to ask me for advice about what would be a logical next career step. It is a thrill to find a voice mail from a call I missed and hear the voice of someone who has always impressed me asking if I would read the manuscript of the book they have just finished writing, and consider writing a forward for them. I have been blessed recently to have all three of those requests.
Several weeks ago when I was reviewing the conversation between Don Berwick and Zeev Neuwirth, I reported Don’s description of W. Edmunds Deming’s comments about leadership. In case you don’t remember, check out “Beyond Silver Bullets: Embracing Era 3 of Healthcare” where I wrote on this site about Don’s comments. For convenience, the part I am referring to was:
Deming said that if leaders want to make things change there are four areas or disciplines they must master. First, master the nature and dynamics of systems. Second, understand variation through an understanding of statistics. Third, understand psychology as it explains individual motivation and group process, human perception, and adult learning. Fourth, master the plan, do, study, act cycle, PDSA that is built on how to continually learn in a complex system. It is an exercise in epistemology.
Leaders who don’t have these skills will “get themselves confused” because they will not understand systems, will misinterpret variation and motivation, and they will not support testing. After observing leaders for forty years, Don believes Deming is right. At corporate retreats, and visits with leaders in their institutions, he doubts that many of them use these skills. They are looking for silver bullets, quick solutions. They misuse Lean and Six Sigma by failing to recognize the need for their own mastery and transformation. In Era 3 leaders “get back to school” in complexity, variation, psychology, and the science of continuous improvement to enable them to lead toward improved care in a systematic and sustainable way.
As I thought about each one of the people who had asked for my advice or assistance, I realized that all three of them scored 100% on Deming’s criteria. What was also interesting was that one was a physician with public health training, another was a healthcare administrator with impressive systems skills, and the third was a systems engineer who was focused on innovation and redesign of the delivery system. All three had impressive technical skills as a given, and were masters of systems theory. All three could have taught courses on statistics. All three have remarkable interpersonal skills and are great communicators. They were all “old souls” who have wisdom and a depth of understanding of the human condition that is remarkable to have been acquired in the short time of the first half of their career. All three were masters of the PDCA cycle, and all of their collective accomplishments fit into the domain of continuous improvement.
As I was reflecting on my windfall of opportunity to contribute to their goals, I thought about an event that occurred back in April of 2008. I have mentioned it before. At the time I was part of a study group of CEOs sponsored by funds from Blue Cross of Massachusetts. Our group had traveled to Dartmouth to spend the day with some of the big thinkers at the Dartmouth Institute. To my delight I found myself sitting next to the great Paul Batalden. To put that into perspective, it would be like shooting baskets on the same court with Michael Jordan. I was well aware of his work on “micro systems” in healthcare, his participation in the founding of the IHI, and his famous observation that “Every system is perfectly designed to produce the results it gets.”
Toward the end of the day, after several hours of group discussion, we were in a relaxed conversation when he revealed to me that he was very concerned about the future of the movement of which he was a founder. He made it very clear that everything that had been learned or gained over several decades of work to improve the quality and safety of healthcare was vulnerable to a failure of the transfer of leadership to the next generation. I may have misunderstood him, but my impression was that he was not sure whether the passion that had driven him and the other pioneers in the movement would be sustained over the time it would take to really make a difference.
Batalden’s concern was hard for me accept. I was full of enthusiasm. I had been to the annual IHI meetings in Orlando and had sat with 6,000 other committed healthcare professionals as we heard the inspiring speeches of Don Berwick. Those meetings are the closest thing in healthcare to a Billy Graham crusade of the fifties. Then I did the math. There are almost a million physicians who are practicing and another one hundred thousand who are inactive or retired. There are over three million nurses of various types with about 10% not working by choice or circumstance. We have more than 5,500 hospitals. A mix of 6,000 doctors, nurses, and other healthcare professionals was a drop in the bucket. We were not even the tail attempting to wag the dog. At best we were the flea causing the dog to want to scratch every now and then. We were the tiny spark trying to start a fire with wet tinder and green wood. Batalden was right. There is plenty of reason to be concerned. And that was before we began to talk about burnout.
The three young leaders that contacted me recently all carry the spark of Batalden and Berwick. It is my belief that all three of these young leaders match the Deming formula and can maintain and exceed the accomplishments of my generation. I also know that they are not alone. There are many others in the next generation who can step up and carry on the work. What I do not know is whether they will be distracted or discouraged by the internal and external challenges of healthcare over the next decade. I am concerned that healthcare is retreating into a defensive posture with the reduced objective of surviving, and willing to shift its focus away from the challenges of the quality chasm and the Triple Aim in favor of OK care for some people, some of the time.
The skills that the young leaders I know have developed were gained in part because “the system” provided opportunities and support. One real risk ahead for all of us as we “fiddle and diddle” with the politics of what healthcare should be like for all of us is that the opportunities that made them what they are will be dwindling and unavailable to others. It is not hard to imagine fewer young systems engineers, not as many young physicians with population management skills, and a dearth of talented administrators equipped and ready to advance the work that needs to be done. If the kind of expertise my three friends offer seems common in the large medical centers on the coasts and in the upper midwest, or in cities with a university system, that’s great, but we have hardly established a beachhead on a better future. Remember there are more than 5,500 hospitals that need to be transformed to a “new way of walking.”
The picture at the head of this post is of the Watsonville Community Hospital, Watsonville, California. I wondered recently as I passed by on a trip with my grandsons to visit the aquarium in nearby Monterrey what this hospital’s approach to the future might be? Does it have a knowledgeable leadership that might guide it through the challenges of the next 10 or 20 years?
I was impressed by the outward appearance of its physical plant. Next to the hospital was a clinic that had signage that suggested that it provided community oriented outpatient services to diabetics. The hospital sits in the middle of miles and miles of some of the most beautiful and productive farmland in this country. I know that the community has a large Hispanic population and that there may be many “illegals” in the community. How will this hospital fare with the almost certain reductions in revenue that lie ahead as Congress in its post “tax reform” environment seeks to economize by attacking Medicare and Medicaid funding? Are they prepared for the challenge? Do they have leaders who fulfill Deming’s criteria? Are they ready? Their website is encouraging. They talk about quality and safety.
We need to remember that as we are fighting for the survival of Medicaid as we know it, and resisting an effort to reduce the Medicare spend by decree rather than by systems improvement, we may be entering a vicious downward cycle. One part of a strategy for the future must be to find or develop more young leaders who fit Deming’s description. Even if Watsonville has the leaders it needs for a challenging future, I am certain that there are other hospitals who are not ready for the challenges that are coming at us and may not have Deming formula leaders. How do we do meet the challenge? How do we pick up the pace? How do we quickly develop the leaders that every community needs? Batalden’s concern was real ten years ago and our challenges are even greater now.
