Twice a year I attend a small meeting of Simpler executives and other advisors to talk about what is happening in healthcare. As I have reported in previous notes, Simpler now functions with a great deal of continuing flexibility within Watson IBM Health, just as Watson IBM Health functions with a great deal of administrative autonomy within the larger international IBM corporation. The new affiliation has not limited or modified Simpler’s relationships with any of it client organizations, and it theoretically offers expanded opportunities. The challenge remains how to optimize the new affiliation as part of the Watson Healthcare vision, mission and purpose. The IBM mission, vision, and purpose statement is inspiring. It is a statement with which I can feel aligned:

 

 Empowering Heroes, Transforming Health

Our purpose is to empower leaders, advocates and influencers in health through support that helps them achieve remarkable outcomes, accelerate discovery, make essential connections and gain confidence on their path to solving the world’s biggest health challenges.

Whether advancing toward a big-picture vision or delivering meaningful experiences to a single individual, our mission is to improve lives and enable hope. We arm health heroes with the technology and expertise they need to power thriving organizations, support vibrant communities and solve health challenges for people everywhere.

 

Three of us attending the meeting were asked to make presentations. Our assignment was to use three slides to discuss:

 

1) What have you been up to the last 6 months?  What has occupied your time?

2) What do you see as the Healthcare Industry trends the last 6 months?

3) What do you see happening in the industry over the next 12 months (through 2018)?

 

The first question was a bit of a challenge for a guy who is retired. I expanded on my theme that I was given by another retired friend recently. He said that retirement was a challenge, “You wake up in the morning with nothing to do, and by the end of the day you are half done.”

 

I modified the second question from speaking about healthcare trends over the last six months to talking about what had happened on the national scene over the last six months that would impact the future. Six months in healthcare is a short time to consider trends. My answer was incomplete but sufficient to generate a conversation:

 

• Passage of the tax reform bill after the failure of the Republicans to repeal and replace the ACA, this will guarantee continued pressure on Medicaid and Medicare.

 

• Repeal of the mandate as an add on to the tax reform bill

 

• Administrative attacks on the ACA

 

• Extension of CHIP and support for FQHCs [The funds that support the over 1250 Federally Qualified Health Centers that have over 8000 practice sites were finally renewed in the recent budget compromise.]

 

• Announcement of the collaboration between Amazon, Berkshire-Hathaway, and  JP Morgan. [It has to mean something big.]

 

I modified the last question to “Looking Forward Over the Next Year.” Continuing trends and likely challenges seemed to be important to consider. My list is by no means complete.

 

It will be a VUCA year: [VUCA is volatile, uncertain, complex and ambiguous]

 

• Continued downward pressure on finance from commercial payers, and Republican attempts to  reduce entitlements to reduce deficits

 

• Political confusion heightened by midterms causing everything to stand still and wait to see the outcome.

 

• Continued shifts away from FFS to value based reimbursement

 

• AI, Internet of Things, Growth of virtual visits, cyber security issues

 

• The opioid crisis will continue and may grow due to inadequate responses. [There is increasing meth use again in many parts of the country]

 

• Worsening personnel issues contributing to further burnout and further patient dissatisfaction

 

• Further consolidation driven by systems failures and attempts to capture populations and PCPs.

 

In answering this last question I was drawing on my recent board experiences, as well as my reading, and conversations with opinion leaders, and also with patients and providers. You may wonder, “ Where are the patients in the list?” I talk with neighbors, friends, family members, people in airports, and just about anyone I encounter who has had a healthcare experience or has healthcare worries. It is easy for me to bundle most of their comments under fears about cost and access which I would say fall under the first two points, and concerns about the attention to their concerns that seem to be a function of either healthcare finance or the lack of time, and consideration that they get form their providers. Most of the people I talk to don’t expect Ritz Carlton service. They just want an appointment and hope that once they get one the provider will have enough energy to give them some time and focus to help them. It is a low bar that is falling fast in many places.

 

Distilling the thoughts of three opinionated people into a useful discussion about complex problems is a difficult task. Adding to the difficulty of finding solutions is the fact that we have an uncertain political climate. Organizations under stress often do not have the means or the corporate energy to consider long range strategies or transformations. Their  leaders may be tired, distracted by many competing voices, or have competing personal concerns. The truth is that “burnout” is becoming a subject that annoys many people just like “global warming,” but it is a fact, and its presence and impact is universal in healthcare. Nurses and advanced level practitioners are burned out. Doctors, residents, and medical students report high levels of burnout.  It is also true that Senior management teams, middle managers, and front line supervisors are burned out. Professionals in healthcare related bureaucracies are burned out. No one seems happy, and many are so jaded that positive statements like “returning joy to practice” is met with ridicule and cynicism in the minds of many. Cynicism is a strong marker for burnout.

 

As I sat there dealing with the conflicted feelings of being happy that I no longer endured the stress of practice or management, and the concern I had for everyone trapped in the system, many of Don Berwick’s comments that I recently shared on this blog came rushing back to me.

 

Don anchored things in residual professionalism left over from Era 1 and the insights from some of the attention to data in Era 2, continuing with a renewal of what was important for leaders to know and foster, and culminating in the importance of the focus on the patient. For him goals are orienting. The most important goal is the Triple Aim. As he said, once the goal is clear, the method is the next consideration and the best methodology includes continuous improvement science guided by listening to what matters to patients, and efforts to focus on the necessity of interdependency.

 

I think the “way out of the woods” begins with leadership and is fueled by the fact that although we are all a bit jaded and depressed, some more than others, there is still great commitment to the noble goal of helping people. Don’s diagnosis of our leadership woes was coupled with a leadership prescription from Deming:

 

…Deming said that if leaders want to make things change there are four areas or disciplines they must master. First, you must master the nature and dynamics of systems. Second, you must understand variation through an understanding of statistics. Third, you must understand psychology as it explains individual motivation and group process, human perception, and adult learning. Fourth, you must master the plan, do, study, act cycle, PDSA that is built on how to continually learn in a complex system. When we use the PDSA cycle we learn like a child learns through efforts of continuous trials and failures leading to mastery, in essence it is an exercise in epistemology.

 

I believe those skills are a must. Perhaps the full set may not need to exist in every member of a leadership team, but all four must be appreciated by every member of the team, and the full set needs to be present in every team. Leadership teams must endeavor to function interdependently. Every leader should be clear about why they need to grow their skills and honestly assess where they need help. It takes a very special environment to allow people the luxury of not trying to hide their inadequacies. Somehow the trust needed to improve must exist. Professor Rebecca Henderson of Harvard Business School and others emphasize the importance of a trusting environment built on “relational contracts” in the creation of sustainable improvement. One needs to have the ability to fail to use the PDSA cycle of improvement.

 

It seems logical for Simpler to think about how to foster the leadership that would be necessary to create environments where continuous improvement has a chance. Simpler has a tradition of orthodoxy in Lean. If the world is changing, how should Lean change to be accessible to a distressed organization trying to survive the double challenge of financial pressure and workforce distress? Tools like Watson and other new AI enabled electronic “touches” offer potential solutions to current shortages, as do some mergers. If the task is integrating AI or some other new software product into the care model, work flows need to be reengineered. Mergers require reengineering or they lead to the opposite of the objective that created them. Lean philosophy, Lean leadership attitudes and practice, and Lean methodology still offer the best guidance along the path to improvement and innovation through a volatile, uncertain, complex and ambiguous future toward the vision of universal access, quality, and sustainability offered by the Triple Aim.

 

If I ask myself what is missing in the formula above, I keep coming back to the concerns about the patient and the realization that until healthcare leaders expand their universe to include being leaders in the effort to improve the social determinants of health and improving our political environment to one of bipartisan problem solving, the Triple Aim is an impossible reach. Don had something to say about that as well:

 

I can not imagine an American society that is healing without a commitment to care of the vulnerable, protection of the disadvantaged, the pursuit of social justice and equity, the repair of our criminal justice system, a whole bunch of what I regard as progressive policies which are currently under a very dark cloud given the national ethos and our national leadership today. It’s not OK. I just can’t help making a plea to the professionals who are listening to you in this podcast to be active in restoring a sense of social justice as a primary foundation for our nation. And if the politicians currently in charge won’t do it, and they won’t, then I think professionals have a duty, just as they do to the improvement of the system. They have a duty to the improvement of the moral foundations of the nation, and that for me is a part of Era 3, as well. So, excuse the political excursion here, but it is a time to speak up because what is going on is not OK.

 

When I left the meeting I was not sure what Simpler would be doing over the next year, but I did know that I had a renewed sense of purpose. There is too much for any one person to do, but there is much that we can accomplish together, if we acknowledge our interdependence, seek to become effective leaders, or follow effective leaders, and never forget why we do what we do, and what our goal is.