4 October 2019
Dear Interested Readers,
A Closer Look At Strategy and Culture
I really appreciate getting comments from my readers. Most of the comments do not come through the comment function of the letter. Most “interested readers” who have something to say just hit “reply” on the email that was the connection to the letter. Their note then comes directly to my personal email, drgenelindsey@gmail.com. I like that. It is easy for me to respond and feels like a personal connection even when I may never have met them. When I think that one of those comments has a significant point that I feel would be of benefit to others, I will ask if it is OK to either post the comment or include their note in an upcoming letter, if I remove information that might identify them. Such was the case this Wednesday when I was delighted to get a note from a consultant that once was of great help to me at Atrius Health, and since that time has become a friend whom I will drive down to see for dinner or a walk when he has business that brings him to Boston.
His note got me thinking when I realized that he was bringing a new perspective to the conversation about the impact of culture on strategies to lower healthcare costs, achieve universal access to care, and realize he Triple Aim. His comment also underlined the wisdom of Dr. Ebert’s analysis from more than fifty years ago that:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
Here is what he had to say:
Hi Gene,
Long time to talk to. I must admit, this week’s letter is the first I have dove into the past few months. Things are busy… for me, but I do feel a bit of treading water and not going forward. I had the opportunity to spend nearly 3 weeks in September at the King Faisal Specialist Hospital in Riyadh, Saudi Arabia. Imagine how surprised I was that their challenges are nearly the same there as they are here in the states even though nobody pays for their Healthcare. It is provided ‘free’. But, that doesn’t fix the problem. We know that AND Saudi government is considering a move to more of a Medicare model than a free model. Regardless, it was culture that was eating strategy. Although patients were ready to be discharged, they could refuse and say they weren’t ready, resulting in an average LOS at this hospital of 1200 beds and 15,000 employees to be greater than 10 days!!!!
I hope we get the work. It wouldn’t be transformation, but more advisory, as well as implementing a Command Center with alerts and tiered responses. The stories are many. It was a great learning experience on many fronts. I miss our conversations.
I responded to my friend immediately. To my delight, I discovered that he will be in Boston later this month, and I will drive down to see him so that we can do some catching up. His work brings him into contact with a variety of American healthcare systems, including some of our largest academic medical centers. I enjoy getting his perspectives, like the observations he has made on the hospital Riyadh, Saudi Arabia. You can rest assured that I will pass on what he observes because I know that he is a good “diagnostician” of the ills of the organizations that he helps. Just like a clinician managing many patients with a chronic disease, what he sees in one system is often present in others.
As I thought about his note, and the phrase, “…it was culture eating strategy…,” I realized that he was confirming the concepts about culture and strategy from David Shore that I had tried to communicate to you in the note to which his comment was attached. Below I have bolded the key sentence to which I think he was connecting. The remainder of the paragraph is also worth further discussion.
He then addressed the old wisdom that “culture eats strategy for lunch.” Transformation and cultural change are more difficult than they appear. There are cultures, subcultures, and countercultures in every organization. Strategy formation is a starting place. Implementation is what lies beyond strategy. Transformational change is resisted because of fear, because of the unknown. It is easy to derail a strategy by asking, “What are the unintended consequences?” People fear change even when it is for the good. An innovation must produce a positive change.
When we think about our efforts to improve the cost and experience of care, it is wise to remember the first part of Dr. Ebert’s admonition. Apparently the Saudi’s had not been exposed to Dr. Ebert’s thoughts because they have had to discover on their own that:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money.
Dr. Ebert points out that improvements will occur when we evolve better care delivery and financing mechanisms.
These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
Dr. Ebert’s thought suggests, and the later wisdom found in Crossing the Quality Chasm expands on the reality that inefficiency and waste, a lack of effectiveness, delays in the delivery of care, inequalities between populations, defects in safety, and even a lack of patient centeredness are primarily connected to systems issues, and not to available resources. The reality that good care is a function of good systems keeps my friend employed and moving from organization to organization like a traveling evangelist spreading the gospel as he teaches administrators and clinicians the principles of continuous improvement.
The implication of Dr. Ebert’s statement and the observations of my friend in his American engagements, and even with his Saudi experience, is that change is hard and that understanding how culture interacts with change is key to improvement. If you have already read Tuesday’s note, as my friend did, or if you want to click on the link above that connects to my description of David Shore’s presentation that was entitled “Leading Change Initiatives with Actionable Strategies,” you will appreciate the connections that Shore made between strategy, culture, implementation, and transformation. My friend’s experience in Saudi Arabia seems to have confirmed this observation and added another dimension, the culture of patients.
My friend’s comment startled me because I realized that even if we succeed in convincing the medical community that it is time for “transformational change,” we will still need to “sell” the necessity of change to patients and their families.
If one steps back from the current debate about how to achieve universal coverage, it is easy to see that we must simultaneously sell the change to healthcare professionals and the “healthcare industrial complex” and to the public. Both contingencies are frightened of the changes they envision in their future. They are not so sure that any change will be a positive event for them and their family. Many healthcare professionals and many patients have “CAVE” syndrome. Significant numbers of people in both camps are “consistently against virtually anything.” We hope that education, primarily in the form of political, economic, and ethical arguments, will overcome the resistance that they generate together. Over the years it has been the fears of individuals, in both populations, professionals and patients, about the personal impact of change, that has been a major part of the explanation for why the transformational process for healthcare has been such a slow drawn out process.
I know from my own practice in an era of even less change that patients ask their doctors and nurses about what they think. I heard those questions during the Clinton attempts at reform. I heard it during the 2008 election cycle. I heard those questions and concerns as the ACA was being drafted. Now I hear a request for an opinion at parties and social events as soon as someone learns that I was a doctor.
Professor Shore emphasized that a good strategy is useless unless it is implemented. Change is impossible to implement unless it is seen as positive. The hard work is in the implementation. When we make our implementation plans we often forget that we must have an educational process that considers culture change as we attempt to make the “sale” that the proposed changes will be positive and are necessary for sustainable success. We must understand and attempt to change the culture of those who work in the system that we are changing, and then with their help speak to the fears and uncertainty generated by what our patients read and see in the media. If our professionals are not aligned with change and what politicians are saying, we will be disappointed with the success of our efforts to educate the recipients of care to the importance of a transformation that will lower the total cost of care while assuring quality, safety, and acceptable access to everyone.
We forget that there are two processes of transformation occurring simultaneously. There are the external transformational attempts that are legislated, and are a response to state and national concerns about cost, access and quality. There is a simultaneous process of internal change and proposed transformation that is driven by the current and potential operational concerns in the organizations where we work that are strategic responses to the unstable external environment.
I can relate from personal experience that the cascade of strategy, culture change, education, and implementation that professor Shore pointed out is true. I became the CEO of Harvard Vanguard and Atrius Health in early February of 2008. I followed the advice that is easy to find in management literature, and is certainly the first step in a Lean approach to transformation; I went to the “gemba.” The link is to the Wikipedia description of the “gemba,” or as I was taught to think, “The place where things are happening.”
Genba (現場, also romanized as gemba) is a Japanese term meaning “the actual place”. Japanese detectives call the crime scene genba, and Japanese TV reporters may refer to themselves as reporting from genba. In business, genba refers to the place where value is created; in manufacturing the genba is the factory floor. It can be any “site” such as a construction site, sales floor or where the service provider interacts directly with the customer.
In lean manufacturing, the idea of genba is that the problems are visible, and the best improvement ideas will come from going to the genba. The gemba walk, much like Management By Walking Around (MBWA), is an activity that takes management to the front lines to look for waste and opportunities to practice genba kaizen, or practical shop floor improvement.
In quality management, genba means the manufacturing floor and the idea is that if a problem occurs, the engineers must go there to understand the full impact of the problem, gathering data from all sources. Unlike focus groups and surveys, genba visits are not scripted or bound by what one wants to ask.
Glenn Mazur introduced this term into Quality Function Deployment (QFD, a quality system for new products where manufacturing has not begun) to mean the customer’s place of business or lifestyle. The idea is that to be customer-driven, one must go to the customer’s genba to understand his problems and opportunities, using all one’s senses to gather and process data.
Just as the Wikipedia note describes, I was following the primary tenet of “management by walking around.” At the time it was an intuitive act because I had not yet learned any of the theory of practice in Lean. I did have a beginner’s understanding and experience with TQM from activities in our organization in the mid nineties. I had discovered and accepted the urgency and the logic for improving quality and safety that To Err Is Human offered in 1999. I had studied the theory for the necessity of improving quality through a systems approach fostered by Crossing the Quality Chasm (2001). I had known Don Berwick as a friend and colleague going back to the late seventies. I was quite aware of Don’s articulation, in collaboration with Tom Nolan and John Whittington, of the Triple Aim in 2007-2008 as a product of their work at the Institute for Healthcare Improvement. I lived in the gemba as a clinician, but I also knew that my view of our geographically dispersed system was limited. I needed to meet everyone across the many locations where we had practices, procedural unit, labs, and business offices and hear their ideas, and understand their concerns. In three months, the senior management team had evolved its ideas and we were able to write a strategic vision and plan that would inform all that we did for the next five years.
I was proud of what my team had created, but in a very short time we realized that conceptualizing and writing a plan had little or no value if there was a limited understanding of the plan and an inherent mistrust of any deviation from what we had been doing forever among our staff. Our culture needed to change or it would eat our great strategy. Our professionals lived in a protected environment that shielded them from the external pressures that were more obvious to physicians in independent practices who were forced to deal more directly with the payers, and who were more acutely focused on the economic importance of acquiring and satisfying patients. The good news about our culture was that despite our inefficiencies and a generalized lack of understanding of the wider world of practice, we did think that we had a culture of quality and safety. Indeed the priority of quality and safety was frequently presented as an ethical reason for resisting the reengineering of the care model that might lower the cost of care while improving all the domains of quality. “Clinical autonomy,” the professional birthright of every clinician, and the “mother of clinical variation,” was defended with the same vigor sustained by the culture that gun owners demonstrate as they defend the Second Amendment.
Our culture of clinical autonomy had subcultures. Nurses did not share the culture of doctors or advanced practice clinicians. Doctors were apprehensive about collaborative practice with either nurses or advanced practice clinicians. Primary care physicians, procedurally oriented medical specialists, and surgeons saw the world through very different cultural lenses. No one thought about the necessity of presenting the benefits of change in the system of care to patients because we were all focused on how we would personally be affected by the proposed changes. A no brainer improvement like online scheduling through a reliable patient portal was a threat to many clinicians and even a source of apprehension for patients. Culture, subculture, and countercultures in the world of professionals coexisted with multiple cultures, subcultures, and countercultures within the world of patients. It is often easier to see other people’s problems than your own. In Saudi Arabia it was easy for my consultant friend to see that it is one thing to provide “free care” and another thing to alter the culture of patients in a way that supports the efficient use of expensive resources.
Serendipity frequently amazes me. On the same day that I opened the email with my friend’s comments, I also thought to check out one of my favorite sources of insight, the biweekly letter from the Commonwealth Fund, “The Commonwealth Connection.” The October 1, 2019 edition contained an interesting title that connected to the issue of change from the perspective of patients:
The introduction included information that we have all heard before:
While the Affordable Care Act (ACA) has dramatically cut the number of Americans without health insurance, reduced consumers’ overall out-of-pocket spending, and ensured that people with preexisting health conditions can get the coverage they need, significant problems remain: about 30 million people remain uninsured, an estimated 44 million are underinsured, and health care costs are growing faster than median income in most states.
The Commonwealth Fund’s new Health Insurance in America Survey provides the latest information on the state of health insurance coverage for working-age adults, their coverage experiences and views, and their views of current health policy proposals.
When I got into the article and all of its charts and conclusions, I realized that we don’t have much consensus among the electorate about “next steps” in the effort to achieve universal coverage. Since about 90% of patients are covered and a majority of them are apprehensive about change, even if change would be of great benefit to them, we have a lot of work to do if we ever hope to legislate a better path to the Triple Aim.
I recommend that you spend a few minutes examining the findings, but I know many of you are busy so here are some of the highlights:
Survey Highlights:
- 13.8 percent of U.S. working-age adults are uninsured, down from 19.9 percent just prior to the ACA’s coverage expansions — statistically the same as in 2018.
- Just over a quarter (27%) of adults favor eliminating all private health insurance and making public insurance like Medicare the only coverage option. But 40 percent said they do not know enough to form an opinion.
- While a larger percentage of Democrats (43%) favored replacing all private insurance with a public plan compared to Republicans (12%) and independents (27%), 41 percent said they did not know enough to say.
- More than two-thirds (68%) of adults in states that have not yet expanded Medicaid favor expanding eligibility for the program. Majorities of Democrats (91%) and independents (74%) favor doing so, while Republicans are split, with 42 percent in favor and 48 percent opposed.
- Large majorities of insured adults are satisfied with their current coverage, with those enrolled in Medicaid and employer plans the most satisfied.
There were other significant comments:
Among uninsured adults who knew the mandate penalty was repealed, one-quarter chose not to get coverage because of the repeal.
Affordability is the top reason (51%) why Americans who shopped for marketplace coverage didn’t enroll in a plan.
Replacing private insurance with public insurance like Medicare does not have strong support, but many need more information.
There is strong public support for expanding Medicaid in the states that haven’t yet…
Most adults were satisfied with their current health coverage, with those enrolled in Medicaid and employer plans the most satisfied.
Nearly two in five adults lacked confidence in affording health care if they became very sick.
Premiums can be unaffordable for people with incomes just over the marketplace subsidy threshold ($48,560 for an individual or $100,400 for a family of four).
Congress and the Trump administration have passed laws and taken executive actions on the ACA, such as repealing the individual mandate penalty and encouraging states to enact work requirements for Medicaid beneficiaries.
Lack of access to subsidized coverage among undocumented immigrants.
Those are informative but also somewhat disappointing facts and realities that suggest that even though as many as 70 million American either have no health coverage or are inadequately covered, there is significant resistance to change. It also means that we should be debating more than how we will be striving for universal access. We should be discussing the fact that if the Triple aim is our goal, we may need to expand our strategic discussion and also develop an educational emphasis that brings clinicians along in a way that will engage them in a more effective “secondary sale” to the patients who look to them for advice.
One significant conclusion of the authors points back to the role of clinicians in determining the cost of care:
Ongoing affordability concerns appear to play a more important role than the mandate penalty in people’s decisions to get coverage. In our survey, about half of adults who visited the marketplaces but did not enroll in a plan said they couldn’t find affordable coverage.
It is rare that I hear of a practice, or individual clinicians examining how they contribute to the cost of care. Costs are usually considered to be external realities that are largely beyond the influence of the individual clinician. That is wrong. The clinical choices we make drive the cost of care. The effort to work with the patient to insure that we do everything that is necessary and avoid those things that don’t add value is particularly hard to do in an environment where finance for the individual and for the enterprise is a function of volume. The large scale shift from volume to value is a strategy begging for implementation and resisted by cultures, subcultures, and countercultures.
The paper ends with sober observations:
Since the ACA’s passage in 2010, Congress has not passed legislation to get more people covered or to improve the affordability or cost-protection of private plans. Though many states have stepped up in multiple ways, it’s clear that improving coverage for all U.S. residents will require federal legislation. Several Democratic members of Congress and presidential candidates have introduced bills or put forth proposals to that end. These approaches are an amalgam of provisions that individually or collectively have the potential to make significant improvements in coverage.
Our survey indicates that much of the public currently needs more information before supporting a Medicare-for-all approach. Given the complexity of our health care system, this may also be the case regarding other approaches to improving coverage, including those advanced by Republicans. It may be up to the candidates to educate voters about what their proposals would mean for them and for the health care system, and what financing trade-offs might be required to achieve them.
I should add that we are fortunate to live in America. My guess is that in Saudi Arabia some member of the royal family will ultimately decide what to do about the cost of their free care. In America we have the opportunity to debate and determine the outcome through a process that rests on a Constitution that never lead to a perfect solution, but up till now has always provided a path for all of us to participate in the search for solutions. Things could be worse. To protect the future of healthcare and preserve the opportunity to pursue the Triple Aim we now realize that we must also protect and preserve the Constitution and the orderly process of engagement that it offers.
Fall in All Its Transient Glory
I believe in the truth of many clichés. “A picture is worth a thousand words” is a cliché that makes my point. I would point to today’s header as evidence of the truth of that worn out phrase.
On Wednesday afternoon, after reading my friend’s email about his trip to Saudi Arabia, I set out on my daily walk. The sky was a mass of low hanging clouds, and although there was some color to the leaves, the colors were pretty dull. I decided to take a route that would take me on a dirt road through some woods that were crossed by a few old logging roads. There are very few houses in the second and third miles of the walk, and I enjoy the solitude of the walk through the woods. As I made the turn onto the road, the light improved and suddenly the colors began to dance along both sides of the road, as you can see for yourself.
Summer is short, but shorter still is the beauty of the fall. The colors seem to change by the hour. I know that any moment we could have a heavy rain with wind, and the result would be the decimation of the color as the leaves are prematurely stripped from their limbs. It’s hard to see, but if you look closely along the edge of the road, you can see that even our ubiquitous ferns are participating in the celebration of color.
The forecast for the “Upper Valley” is for clear skies and fall temperatures on Saturday and for rain on Sunday. I hope that you will have clear skies and a good chance to check out bright colors wherever you might be this weekend. I’ll be walking in the rain on Sunday as I participate in our local “Crop Walk” to combat hunger. I don’t mind walking in the rain, but I hope that it will be a gentle rain that won’t curtail the color display. I am hoping that the show will last at least until the Columbus Day weekend.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
