12 October 2018
Dear Interested Readers,
Back to Box 4
In the post earlier this week entitled “You Can’t Get There From Here!” I wrote:
The obvious answer to the conundrum of “You can’t get there from here!” is to go to some place from which you can get there. If we can’t get to the Triple Aim anytime soon because of the political polarization that exists and is likely to persist where should we go to start our trip? I think that we must seek to repair what divides us.
There are many voices now that are saying the same thing, none more effectively than Thomas Friedman in an opinion piece in the New York Times this week entitled “The American Civil War, Part II.” Without being able to effectively discuss a shared vision for the future of our country it will be very hard to move healthcare from the individual concern with every person, family, and community working to achieve their own salvation to a collective effort built on the shared principle that the future of the nation will always be better if the health of every person living here, and that includes those with the curious distinction of “illegal alien,” is as healthy as possible. We are very good at organizing ourselves into various “tribes.” What prevents us from being one big tribe when it comes to healthcare?
It has always been hard for me to understand how our European cousins can see the wisdom of the collective benefit of social programs that work and all we see when we consider the potential benefit of doing things together is a slippery slope to higher taxes or communism. Europeans seem to be able to have more effective social programs exist side by side with prosperous economies built on a foundation of capitalism. It is true that history shows they have survived fascism and now are retreating from the challenges of migration with their own dysfunctional forms of nationalism, but their sense of “tribe” is more universal than we can muster on any subject other than defense.
Despite the national stains of slavery, the equally abusive Jim Crow era, and our centuries long abuse of indigenous peoples, no nation has ever talked as good a game of pluralism as we have. As an eager student of history during my years in school I was spoon fed tales of our glory filled with phrases like “manifest destiny,” “pioneer spirit”, and “life, liberty and the pursuit of happiness.” In grammar school we memorized the Gettysburg Address with its references to our history, bravery, and vision:
…our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal…It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced…that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion…that this nation, under God, shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth.
Perhaps you remember as a child memorizing the famous final words of Emma Lazarus’ sonnet, “The New Colossus” that can be read on the the base of Statue of Liberty:
“Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!”
Well into my late sixties I was naive enough to believe that all of the political turmoil that I had experienced since childhood, sometime in the late fifties when I began to notice the the world beyond what I could see with my own eyes, was part of a “normal” political process that was ultimately headed toward justice and equal opportunity. It was true that the Civil Rights struggle was painful for many, but then we passed the Civil Rights Act of 1964 and the Voting Rights Act of 1965. Despite the persistence of economic inequality I could see faint evidence of an improving meritocracy as well as efforts to make up for past inequities through efforts at affirmative action.
Nothing encouraged me more than seeing the wisdom of Crossing The Quality Chasm reflected in the ACA when it was passed in 2010. It seemed then that it was possible to imagine that through expansion of the concept of equity as one of the determinants of quality we were closer than we had ever been before to a future when America would join the mainstream of developed nations that recognized that a better future for everyone would be a function of pursuing universal quality healthcare as a generally accepted national core value.
The president is currently clarifying his point of view in a series of his rallies running up to the midterm elections. Just in case you aren’t attending one of those rallies he put his polarizing points of view into an opinion article in USA Today this week. As usual the core of his presentation was based on misinformation, the reframing of realities to confuse the hearer, and outright lies. After you read the president’s words, please read Glenn Kessler’s fact checking review in the Washington Post. For dessert then read Bernie Sanders’ presentation of the Medicare-For-All path to universal healthcare that the president lied about. Bernie touches on a lot of the big issues including the special risk borne by those (sooner or later most of us) who have a “pre existing” condition.
Just in case you don’t have a chance to read the president’s opinion piece here are just a few of the divisive, fear inducing things he said:
The Democrats want to outlaw private health care plans, taking away freedom to choose plans while letting anyone cross our border.
Democrats have already harmed seniors by slashing Medicare by more than $800 billion over 10 years to pay for Obamacare. Likewise, Democrats would gut Medicare with their planned government takeover of American health care.
The Democrats’ plan means that after a life of hard work and sacrifice, seniors would no longer be able to depend on the benefits they were promised. By eliminating Medicare as a program for seniors, and outlawing the ability of Americans to enroll in private and employer-based plans, the Democratic plan would inevitably lead to the massive rationing of health care.
The truth is that the centrist Democratic Party is dead. The new Democrats are radical socialists who want to model America’s economy after Venezuela.
Today’s Democratic Party is for open-borders socialism. This radical agenda would destroy American prosperity. Under its vision, costs will spiral out of control. Taxes will skyrocket. And Democrats will seek to slash budgets for seniors’ Medicare, Social Security and defense.
The articles referenced above by Bernie Sanders and Glenn Kessler are direct responses to the president’s distortions and fear mongering, Unfortunately, this polarizing process in American politics is now over a quarter of a century long. Tom Friedman traces the history in the article mentioned above, “American Civil War, Part II”:
In essence, we’ve moved from “partisanship,” which still allowed for political compromises in the end, “to tribalism,” which does not, explained political scientist Norman Ornstein, co-author, with Thomas Mann, of the book “It’s Even Worse Than It Looks: How the American Constitutional System Collided With the New Politics of Extremism.” In a tribal world it’s rule or die, compromise is a sin, enemies must be crushed and power must be held at all costs.
It would be easy to blame both sides equally for this shift, noted Ornstein, but it is just not true. After the end of the Cold War, he said, “tribal politics were introduced by Newt Gingrich when he came to Congress 40 years ago,” and then perfected by Mitch McConnell during the Barack Obama presidency, when McConnell declared his intention to use his G.O.P. Senate caucus to make Obama fail as a strategy for getting Republicans back in power.
Perhaps Lean theory and philosophy has something to offer us now. If nothing else it could form a framework of analysis of how we “get there from here.” I realize that many “Interested Readers” do not have a grounding in Lean practice. So here is a brief road map of the basic tool that has evolved in Lean practice. It is called an “A3” for the simple reason that it puts the entire strategic analysis of a problem and its solution on a 17 inch piece of paper called A3. The paper is divided into nine “boxes.” Each “box” is a step in analysis that essentially reproduces the logical steps of the scientific method that has propelled science over the last 500 years.
Box 1 is a statement of the problem or “reason for action.” Box 2 is a description of the “current state” or reality that is suboptimal. Box 3 is a vision of the ideal outcome or “desired state.” It may be a statement of a less than perfect intermediate achievable state of improvement if our goal is a large change. Box 4 is a critical step that most people have a tendency to ignore when they “jump” to the first solution that comes to mind. The process in Box 4 can be called a SWOT analysis. In a SWOT analysis one considers strengths, weaknesses, opportunities, and threats. In Box 4 you go as far “upstream” as possible to consider “root causes” of the problem. Sometimes during the work on Box 4 we discover threats that have been ignored or we discover that a potential solution will not work without the acquisition of a new asset. Box 4 demands patience, process, and critical thinking. It benefits from the point of view of many different observers. Respect for the opinion of others is a huge asset in a successful Box 4 process. Box 4 is where the opinion of those closest to the work can often reveal flaws in the formulations of management. Box 4 is where we wrestle with biases. After the work of Box 4 we a ready to chose a potential solution that considers all that was realized in the Box 4 analysis. Box 5 is the statement of the possible solution that fits what we learned in Box 4. Box 5 is a hypothesis. In box 5 we ask if we do x will y happen? X is the solution idea. Y is the desired state we described in Box 3. Boxes 6-8 describe the process of experimentation, documentation, and analysis. Box 9 is a reflection on what worked, what failed, what needs to be continued, what needs to change, and what we have learned all in service of the next cycle of continuous improvement.
So what happens when we discover from data that the “solution” proposed in Box 5 is not working? We return to Box 4 and look for what we overlooked or did not realize the first time we “passed through” Box 4. At this juncture we have invariably learned something from our effort. In metaphorical terms we discovered that “We can’t get there from here!” with the solution we had originally proposed. The reason is almost always something that we failed to consider in the original Box 4 analysis. Failure creates enlightenment and opportunity. The process is heuristic. It is learning by documented trial and error.
This cycle of recovery is called an A4. In an A4 we do not reproduce Boxes 1, 2 and 3. The problem is usually not the reason for action, the description of the current state, or the vision, although sometimes the scope of our vision is impractical and the ideal state will require multiple cycles of smaller steps. This would be particularly true in improving social problems. Since we are just going back to Box 4 the visual description of the new analysis can be documented on a smaller piece of paper, an 11 inch page called A4. I hope this brief guide to “A3” thinking will allow us all to stay together as we return to the issue of the future of healthcare in America.
Let’s imagine that the Triple Aim is the Box 3, the “ideal or desired state” in an “A3” Lean process. Continuing with that construct, the Box 1 “reason for action” is the fact that millions of people within our borders lack access to care and those that do have access often have care of low quality at a high cost. The Box 2 “current state” was painstakingly described in Crossing the Quality Chasm. The ACA was the Box 5 “experiment” that followed an “if this/then that” formulation. We have been testing the ACA as a “solution” for several years, and it is an improvement over what we had before but seems doomed to ultimately fail to achieve the “ideal or desired state” because of the resistance it has met.
Yes, I did not mention Box 4. Box 4 is the examination of the issues that should be considered in deriving the “solution,” the ACA. Looking back the execution of Box 4 was imperfect. At the root of its imperfection was the inability to fashion a bipartisan bill. Mitch McConnell and the Senate Republicans strategically did not meaningfully participate in its passage although its very core concepts were ideas that originated with Republican strategists. After the heroic and amazingly strategic narrow passage of the ACA it has been delayed and damaged by continuing attacks which continue. Now with a conservative Supreme Court and with this president as the “healthcare administrator in chief” it is easy to see that it is time for what we call an “A4” in Lean terminology.
It is hard to admit that “You can not get there from here!” and then metaphorically go back up the road to Box 4 and find another route to the “ideal or desired state”, the Triple Aim. An A4 is the correct response to an honest recognition that the experimental solution has not yielded the desired result, the Triple Aim. Going back to Box 4 we should recognize that “You can’t get there from here!” to the the Triple Aim, to the healthcare most Americans say they want without a bipartisan consensus that if America is to fulfill all of those ideals that we have woven into our collective image of what America ought to be, then we must give everyone an opportunity to enjoy a full measure of health. Good health is not enough. We need a population that is educated and able to fill good jobs. We need housing. We need to rebuild a sense of community on the common understanding that life does not need to be a zero sum negotiation that requires losers to have a few winners.
As much as I like the philosophy and vision of Bernie Sanders, “Medicare For All” represents a jump to solution. If it does pass before we attempt to establish a common objective, it will be a “socialist” victory that will always be resisted, as was the ACA, and perhaps last only as long as the Democratic Party can hold power. Good Lean process calls for a return to the SWOT analysis of Box 4 and a search for greater understanding of why our experiment did not work. We will need to develop a revised solution that includes countermeasures to the problems that we have discovered as we tried the ACA. It is clear that we went “upstream” a long way with Crossing the Quality Chasm, but we did not go far enough. We did not go far enough to truly understand what has gone wrong with the “American Dream” and why we have devolved to multiple tribes that will not extend to everyone what we want for ourselves. Somewhere in the muck is the deep political divide that seems to be growing every day. With that kind of root cause issue we are just spinning our wheels as we try to move toward the Triple Aim.
It occurs to me that the article by Don Berwick and others from JAMA that I quoted recently contains valuable Box 4 wisdom. These points are not political statements and could perhaps be used to forward healthcare policies that both Democrats and Republicans could work from if we were to elect a Congress that reflected a national consensus that we all eventually suffer great loss if we perpetuate the current highly partisan, indeed tribal, dysfunctional climate.
- Systems thinking drives the transformation and continual improvement of care delivery
- Care delivery prioritizes the needs of patients, health care staff, and the larger community.
- Decision making is evidence-based and context-specific.
- Trade-offs in health care reflect societal values and priorities.
- Care is integrated and coordinated across the patient journey.
- Care makes optimal use of technologies to be anticipatory and predictive at all system levels.
- Leadership, policy, culture, and incentives are aligned at all system levels to achieve quality aims and promote integrity, stewardship, and accountability.
- Navigating the care delivery system is transparent and easy.
- Problems are addressed at the source, and patients and health care staff are empowered to solve them.
- Patients and health care staff co-design the transformation of care delivery and engage together in continual improvement.
- The transformation of care delivery is driven by continuous feedback, learning, and improvement
- The transformation of care delivery is a multidisciplinary process with adequate resources and support.
- The transformation of care delivery is supported by invested leaders.
I did not make a mistake when I bolded the 4th and 7th bullets. Accepting those two foundational realities are core to getting on a road that can deliver us to the Triple Aim. With leadership, and an ability to articulate widely accepted societal values that can be used to set priorities we will be on a road with the expectation that: “We can get there from here!”
The Colors Come Round Again
If you read these notes with any regularity, you know that I really love summer. I should emphasize that I am really like a good parent with many children. I love all the seasons and cherish each one for its uniquely charming characteristics.
Fall snuck up on me this year. It burst into full glory while I was in North Carolina sharing the celebration of my father’s life with my family. I returned home early Monday morning and the first thing I noticed was the change in the temperature. It had been over ninety with a high humidity in Lincolnton during the funeral. When I stepped off the plane in Manchester about midnight on Sunday night, I was shivering and a got a little wet recovering my car from the long term parking lot. The temperature was in the high forties with a drizzling rain. In the darkness I could not see what I could feel. Summer was gone. I had forgotten that the green of spring moves from south to north. The colors of fall move from north to south. I made a note to self to be sure to stay home in the fall.
My first activity on most mornings is to look out at the lake. What I saw on Monday was a ring of color around the lake muted by the low hanging gray clouds and fog. Things cleared a little by late afternoon and I tired to capture what I saw on my walk. I love the lower angle of the fall sun and the highlights that are created in the late afternoon. By Tuesday the sun was out and the colors were dazzling from early morning until after sunset. That is when my wife captured the scene that had eluded me and is the header for this letter. Who needs summer?
The fall colors are like picked flowers. They don’t last long. They were in ascendancy last weekend. They will be close to peak this weekend. They will be past peak by next weekend. We are lucky this weekend. The Red Sox games against the Astros are in the evening and the Patriots are playing Kansas City on Sunday night. You will have all day Saturday and Sunday to enjoy one of nature’s greatest moments.
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
