Marina Gorbis's Blog, page 1539

Military Leadership Lessons for Training Doctors

Elite medical training programs proudly proclaim that they are preparing future healthcare leaders. But with their focus on clinical disease management and research, training programs actually offer little in the way of true leadership training – authentic experience that helps young doctors develop the leadership skills they will need.

To address this gap, the Vanderbilt Department of Otolaryngology developed a 4-year program that consists of selected Naval ROTC leadership topics, public speaking training, a micro-MBA course, and a capstone leadership project on community disease prevention that puts students into leadership roles.

When I describe this program I get a lot of questions about the military portion. Why reach out to the ROTC? Medicine and the military seem to reside in opposite worlds, the former devoted to saving lives and the latter, when called upon, to ending them. Yet, both are made up of large, complex organizations with clear leadership needs at many levels. The military is highly disciplined in its leadership training, understanding that leadership skills aren’t automatically endowed upon joining the organization. Medicine, contrastingly, assumes that its intelligent, industrious providers will somehow evolve into leaders as circumstances require, but without formal leadership training. So, we contacted the ROTC to see what we could learn from them.

Over the course of a year, we learned a lot about how the Navy trains leaders, and have incorporated many military training strategies into the leadership education for our young otolaryngology trainees. Several lessons have emerged from this experiment that are applicable in medical training and, indeed, throughout health care.

Lesson 1: Medicine must increase its focus on fundamental communication skills.

Young recruits entering the Navy are often unskilled in (or unaware of) the basic interpersonal social graces that enhance relationships. Sailors are taught to stand when someone enters the room, to shake hands and make eye contact, to use polite greetings like “sir” and “ma’am,” and to listen attentively. Young doctors typically receive little such training. Any patient can tell you that health care providers are uneven at best in their greeting and communication skills. Health care leaders, and indeed any provider, must communicate well both verbally and non-verbally. But these days harried providers often make more eye contact with a computer screen than with the patient and family. Providers also increasingly must communicate with groups ranging from internal stakeholders to large audiences at external meetings. Yet doctors rarely receive training in public speaking – and it shows.

What we do now:  To build skills in one-on-one communication, we train our residents using paid actors as simulated patients. To enhance presentation ability, we have added an eight-hour course in public speaking to our curriculum.

Lesson 2: Medicine needs to expand selection criteria for promotion and train individuals to take on the next responsibility.

When Navy personnel — having been evaluated frequently according to a standardized method — receive a promotion, they are considered unprepared to assume the new command. As one ROTC trainer explained,  “When you are promoted on a Friday afternoon, nothing magical happens over the weekend to make you smarter, richer, better looking – or a better leader — by Monday morning”.  For each promotion, the Navy sends the individual for additional training, customized for the new position, before he or she assumes the new role. Medicine’s promotion tracks are currently structured for success in research, educational and/or clinical skills; promotion is not based on pre-eminence in managerial or leadership skills.  Even a full professor typically remains ignorant of vital skills related to organizational behavior, operations management, finance and strategy. And no tailored management or leadership training is regularly offered for physicians who become departmental service chiefs, chairs or deans, or who assume hospital executive roles.

What we do now: We have added an 18-hour micro-MBA course for our resident trainees that exposes them to senior administrators from national healthcare organizations such as Kaiser Permanente, Partners HealthCare, and Vanderbilt University Medical Center. The coursecovers topics including healthcare policy, finance, and organizational culture as well as decision making (led by an Air Force colonel) and conflict resolution (led by a minister). Importantly, in each of the past 4 years one faculty or staff member has matriculated for a master’s degree in healthcare management.

Lesson 3: Medicine must embrace checklists and debriefings to improve safety.

In an earlier time, a persistent level of naval aviation accidental injury and death seemed inevitable.  Unwilling to accept its accident rate, the Navy introduced pre-flight checklists and post-flight debriefings for every flight – and accident rates have fallen. Although conscious efforts to improve quality and safety in medicine are under way, checklists in medicine are still novel; debriefings, regrettably, mainly occur only in response to poor outcomes.

What we do now:  To teach us about their method, our ROTC team entered the room in flight suits and reenacted the lengthy processes of checklist and debriefing as it would happen on an aircraft carrier. Knowing that surgeons only erratically conduct organized postoperative debriefings, we are creating a formal debriefing program and our faculty and trainees have already have begun impromptu post-operative performance conversations after most surgical procedures.

Lesson 4: Medicine needs to reflect on perpetuation.

Our ROTC collaborators advanced the surprising opinion that the sole role of the Navy was not the defense of the nation. Instead, they posited that the Navy’s equally important role is perpetuation of the organization so that the future national defense never will be in peril. Perpetuation requires training to be continually upgraded to anticipate future needs. Medicine largely trains using classroom educational models developed a century ago – a tired didactic methodology based mainly on the lecture format (plus our still-successful experiential methodology based on active participation in the clinics and operating rooms).

What we do now: Our Otolaryngology training program has revitalized the traditional didactic training program and uses educational methods pioneered in business schools to de-emphasize lectures and promote active team learning, using Bloom’s Taxonomy of learning objectives as an intellectual platform.

Our program is a work in progress, but we have early indications of success.  For example, this year our residents have undertaken a capstone project that tests their leadership skills. Residents divide into teams and work with Vanderbilt undergraduates, primary care physicians, and others on population-health projects focused on preventing head and neck cancers.  They must define their goal, determine performance measures, find and engage allies, create budgets, and publicly report their results, using the tools they’ve acquired through the program. Our annual resident rankings on a standardized national survey reveal a 100% satisfaction with our training approach, compared to the national average of 74%. In an anonymous vote last year, the residents unanimously supported an acceleration and expansion of the changes we’ve begun – despite the increased workload they represent.

We are fortunate that our resident-level training efforts are aligned within our larger medical school culture since the wrong culture can eat the best strategy. Any group working to implement leadership training within a healthcare organization must be mindful of the broader organizational culture and be prepared to overcome inertia (and sometimes active resistance) in order to effect behavior change. That, after all, is what the best leaders do.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us at healtheditors@hbr.org, and sign up to receive updates here.

Leading Health Care Innovation

From the Editors of Harvard Business Review and the New England Journal of Medicine




Leading Health Care Innovation: Editor’s Welcome
Why Health Care Is Stuck — And How to Fix It
Getting Real About Health Care Value
Understanding the Drivers of Patient Experience

Is It Ever OK to Break Into Your Colleague’s Computer?

Rick was looking for Kelly, one of the analysts who supported his consulting team. Kelly’s hours were a mystery, and Rick was confused and annoyed. He tried to check her calendar online, but, after struggling to locate it, he solicited help from an IT specialist. They found all sorts of surprising weekday appointments at the gym, lunch with friends, and even horseback riding — all fifteen miles outside the city. They went to the department head who authorized a review of Kelly’s entry and exit records from the lower level parking garage.  Kelly was a nuisance employee and maybe Rick had the goods on her now.

Steve, a portfolio manager for a major mutual fund company, understood that his company monitored internet use of all employees. The surveillance was even tighter for the traders, and an alert flashed on Steve’s PC when his trader, Eric, started surfing questionable sites. He warned Eric to cut it out, but the alert kept flashing. Eric was a great trader, but this posed a real difficulty for Steve — what should he do with the information he possessed?

I had been preparing a client presentation with several of my colleagues at our asset management firm. The night before the meeting, I reviewed the document on my laptop at home, noticing that several key pieces of information were missing. Early the next morning, I emailed the group to explain what we still needed, but one person was out and not easily accessible. We realized that the required data was only on his password protected computer. I didn’t know whether to unlock his computer or try to work around the problem.

The digital age offers us immense opportunities to hone our detective skills, to observe our colleagues in an entirely new, not necessarily flattering light, and also presents tremendous challenges in terms of how we use that information. Fingering the transgressor may be the most satisfying aspect to digital sleuthing, but managers must understand the negative impact of monitoring our co-workers. The more aggressive the data mining, the higher the risk of abuse, and the more supervisors must tread sensitively to re-establish any lost trust.

At large companies, employee handbooks warn us not to expect privacy protection for whatever content we write, read, watch, or send on corporate owned computing equipment, including our smartphones.

Electronic Performance Monitoring or EPM has become widespread at many corporations to track, count, and analyze employee keystrokes. An important paper by Laurel McNall and Sylvia Roch makes very clear that workers, justifiably, worry about being watched, particularly when they don’t know how their bosses are using information.

Heisenberg’s uncertainty principle states that the act of observation alters that which is being observed. Observing your employees via careful digital sleuthing will similarly alter their behavior. On the negative side, it may create worker dissatisfaction, hurt morale, and erode trust. But it can also have a positive impact, if it promotes awareness of the public nature of our electronic presence and results in more thoughtful and responsible behavior. We need to learn how to harness the power of digital surveillance as a benign force.

George, the CEO of a technology company with over 150 employees, believes that you need to be careful when confronting someone with intelligence gained from data mining. Other than the case of an egregious act, the cultural destruction might well outweigh the benefit. Not only the accused but everyone else who hears about it will wonder, “What kind of company do I work for?”

Martha, who manages a staff of hundreds at a health care facility, says she uses a “root cause” analysis to decifer  digital errors and distinguish between a mistake caused by a systemic failure or individual oversight. In addition, she conducts substitute testing, which recreates the exact problem, to determine whether another person would have made the same error. She believes that her staff understands and accepts that management uses monitoring and digitally-sourced information to improve institution-wide performance rather than to assign blame. As Devasheesh Bhave described in his study of EPM, the feedback offered is essential.

In the case of Kelly, who was taking horseback riding lessons on company time, Rick made sure her boss saw her garage timestamps. She lost her job immediately. The record of her comings and goings in the parking garage painted a clear picture of abuse. The consequence of surveillance fit the crime and it still sends the right message to everyone who hears about it.

Steve couldn’t sit on Eric’s website transgressions; the trader was also fired. Eric sued the company, maintained that he did not receive sufficient warning, that he received email links to pornography from other traders inside and outside the firm which he did not open, and that the monitoring system unfairly targeted his computer. Steve is torn. Eric was a great trader, but he has not worked in two years and, with a lawsuit pending, he cannot get a job. Steve worries that he might have jumped to conclusions and wonders if he should have given Eric a harsher warning.

I couldn’t bear the idea of hacking into someone’s computer, having never done something like that before. We managed to pull together most of the missing data, and the client didn’t notice the difference. We then implemented some new processes for timelines and safeguards which probably should have existed in the first place. The incident forced us to consider important questions about intra-office transparency and the extent of privacy at our firm. I wonder, however, under what circumstances I might make the opposite decision — to unlock the computer.

The more we can sift through and massage the troves of data accumulating on our servers, the greater the need to understand how to use that output, the positive and negative implications, and how to craft and deliver the appropriate message to our colleagues.

A Heart-Shaped Bowl Makes You More Altruistic

46.3% of restaurant customers left tips when they were given heart-shaped dishes for their money, compared with just 31.2% and 26.2% when the tip dishes were round or square, respectively, says Nicolas Guéguen of the Université de Bretagne Sud in France (the experiment was conducted in France, where tipping is not expected because a service charge is included in the bill). The findings suggest that a simple physical cue such as a heart-shaped bowl can induce thoughts of love, which activate altruism and helping behavior.

The Rise of Compassionate Management (Finally)

Don’t look now, but all of a sudden the topic of compassionate management is becoming trendy.

A growing number of business conferences are focusing in on the topic of compassion at work. There’s the International Working Group on Compassionate Organizations. There’s the Changing Culture in the Workplace Conference. Then there’s Wisdom 2.0, dedicated to “exploring living with greater awareness, wisdom and compassion in the modern age.” The speakers are no slouches: eBay founder Pierre Omidyar, Bill Ford (yes, that Bill Ford), Karen May (VP of Talent at Google), and Linked In CEO Jeff Weiner top the bill. At TED, Karen Armstrong’s talk about reviving the Golden Rule won the TED prize in 2009 and has given rise to a Charter for Compassion signed by nearly 100,000 people.

More evidence of this trend comes from the Conscious Capitalism movement, whose membership includes companies like Southwest Airlines, Google, the Container Store, Whole Foods Market, and Nordstrom. One of the cornerstones of the movement is to try to take care not just of your shareholders, but all stakeholders (investors, workers, customers, and so on). One member is Tata, the Indian conglomerate, who makes no bones about it: “Our purpose is to improve the quality of life of the communities we serve.”

While the importance of compassion at work has long been touted by scholars like Peter Senge, Fred Kofman, Jane Dutton and others as a foundational precept of good management, managers of the traditional, critical, efficiency-at-all-costs stripe have scoffed. This isn’t surprising: given the number of nasty managers still sitting at the top of organizations, it’s easy to assume that the compassionate ones don’t often get hired, let alone encouraged and promoted. In fact, a Notre Dame study found that nice guys really do finish last, with more agreeable people earning less than those who are willing to be disagreeable. And all too often, compassionate people lack boundaries, thus allowing themselves to be used and abused; they become “toxic handlers” who absorb the organizational pain without much personal gain.

But something in the zeitgeist is changing. At Wisdom 2.0, LinkedIn CEO Jeff Weiner told the audience that he is on a personal mission to “expand the world’s collective wisdom and compassion,” and that he had made the practice of compassionate management a core value at the company. For example, he described a former colleague who was publicly disparaging someone on the team. Realizing that he’d made that mistake himself, Weiner took the fellow aside and said, “If you are going to do this, find a mirror and do it to yourself first. You’re projecting your perspective and assumptions onto that person.”

To manage compassionately, Weiner noted, doesn’t come naturally to most managers. It requires spending the time to walk in someone else’s shoes — to understand what kind of baggage that person is bringing to work; what kinds of stresses she’s under; what her strengths and weaknesses are. In high-pressure environments, such a time investment is anathema to most of us. But such an investment is analogous to the work of a carpenter who carefully measures a piece of wood three times before cutting once: spending such “compassion time” with an employee, Weiner insists, pays off in that person’s much greater efficiency, productivity and effectiveness (and obviates later regrets). It’s not just altruism: as it turns out, companies that practice conscious capitalism perform ten times better than companies that don’t.

Findings like this may be one reason for compassion’s rise in the workplace: perhaps years of research are finally making a dent. Over and over, it’s been shown that compassion concretely benefits the corporate bottom line. Marcus Buckingham’s work on employee engagement has shown that engagement is critical to organizational success. Plenty of others have shown that practicing compassion is good  for your business. Consider what happened when a call-center company called Appletree consciously set about increasing compassion among employees. The company set up the equivalent of a “Make A Wish” foundation to serve its adult employees, which it called “Dream On.” The CEO, John Ratliff, claimed that the gambit changed the culture of his company. (Call centers have a notoriously high turnover rate, largely because the employees listen to unhappy callers all day.) The Dream On program allowed employees to express compassion to each other on an everyday basis. As a result, the company’s turnover rate dropped from 97% to 33% within six months. (You can learn more about this story and much more about the effect of compassion in organizations here.)

The evidence also shows that compassion boosts employee well-being and health — another important contributor to the bottom line. And as my good friend Dr. Edward Hallowell shows in his book Connect: 12 Vital Ties that Open Your Heart, Lengthen Your Life and Deepen Your Soul, the more we compassionately connect, the better we feel, and the more others are there to support us when we need it, as even the most seemingly invulnerable of us someday, inevitably, will.

I also have a suspicion. It’s just a hunch, but I suspect most of us are experiencing cynicism fatigue. The overwhelmingly bad news springing from the news media leaves most people with two options: either they become cynics who drown themselves in their own pleasures, or they try to make a difference. Most of the smart people I know are little a bit of both, but they fight their cynical side. They try to work on something of worth at work and in the world. There is no better way to start doing this than to practice the golden rule on an hourly basis.

Of course, some of us are inherently more compassionate and empathetic than others. But the good news is that it’s possible to strengthen one’s compassion muscle — and so become a better manager. Researchers from the Center for Investigating Healthy Minds at the University of Wisconson-Madison’s Waisman Center found that engaging in compassion meditation — where you practice feeling compassion for different groups of people, including yourself — seemed to increase a sense of altruism.

To me, this is all great news.  The more compassion we can practice (starting right now), the better. And given that we spend so much of our lives at work, there is no better place to start than with the person in the next cubicle.

Great Teams Are a Mix of Old and New

The best teams, we tend to think, are like a band of brothers. They’ve been together for a long time. They know each other extremely well. And they are more successful as a result. It’s common sense, right? Well, it turns out that great teams — the most creative, the most innovative — are more temporary in nature that you’d think. Take Broadway. The best productions, researchers have found, are made up of rag-tag groups — a mix of old and new faces. The old faces bring knowledge of the best processes and the best working methods, and the new folks bring a fresh creative spirit to the table. The most innovative companies work in similar ways, too. Ad-hoc teams form around a given project, then disband. But it’s not so easy pull off — in order for this to work, the entire organization has to be diverse enough in order to make temporary teams a reality.

Personal Branding for Introverts

I had just finished a talk at a leading technology company when an engineer approached me. “I liked your ideas about personal branding, and I can see how they’d work,” he told me. “But most of them aren’t for me — I’m an introvert. Is there anything I can do?” What he didn’t realize is that (like an estimated one-third to one-half of the population) I’m one, too.

Despite the common misperception that all introverts are shy, and vice versa, they’re two very different phenomena. (Author and introversion expert Susan Cain defines shyness as “the fear of negative judgment,” while introversion is “a preference for quiet, minimally stimulating environments.”) I actually like giving talks to large groups (that day, there were 180 people in the room and another 325 watching online). I’m happy to mingle and answer questions afterward. But at a certain point, I’ve learned through experience, I have to get away and go somewhere by myself.

Conference organizers and attendees will often ask you to join them for dinner the evening before, or cocktails afterward. Rationally, it’s a win-win: they perceive more value because they get to interact with you personally, and you can make interesting business connections and learn tidbits about attendees that allow you to personalize your talk. For those good reasons, I’ll often say yes, but I’ve had to learn my limits: if I’ve been traveling too much, or had a frenzied schedule that day, or my social chops are hampered by lack of sleep, it’s far better to refuse. Like a car that requires periodic oil changes, I have to recharge with quiet, alone time.

It’s true that many of the best ways to establish your brand in the professional world are still weighted toward extroverts: taking leadership positions in professional associations, starting your own conference or networking group, or — indeed — embracing public speaking (all of which frequently entail extended social contact).

Over time, I’ve learned “when to say when” and graciously call it an evening. But for many introverts, it’s a tough balance. One executive at a large consulting firm once asked me how she could be truly authentic in her dealings with others, given how uncomfortable she was when it came to networking; she worried she’d have to put on a smiley, hypersocial façade. Yet I’m convinced it’s possible to be real about building connections and developing our personal brands, while still respecting our natural tendencies.

First, social media may actually be an area where introverts, who thrive on quiet contemplation, have an advantage. With a blog — one of the best techniques for demonstrating thought leadership — you can take your time, formulate your thoughts, and engage in real dialogue with others. Indeed, while extroverts desperate for their next fix are trading business cards at cocktail parties, you can build a global brand on the strength of your ideas.

Next, with a little strategy and effort, you can become a connector one person at a time. A friend of mine used to work at a large research hospital; it was a sprawling institution with countless divisions and initiatives. She made a simple commitment: each week, she’d ask a person from a different office or department to lunch. Often, she’d meet them initially at company meetings or through project work; if the suggestion to have lunch together didn’t arise naturally, she’d tell them about her project, and they were almost always intrigued enough to join her.

Within a few months, she had begun to build a robust network inside her organization — on her own, quiet terms (Susan Cain herself told HBR that we ought to “be figuring out ways where people can kind of pick and choose their environments, and then be at their best.”) My friend’s “lunch initiative” exemplifies the research of Ronald Burt at the University of Chicago, who urges workers to “bridge structural gaps” in their organizations. In other words, you can make yourself professionally indispensable if you develop connections that enable you to break through silos, and identify and surmount knowledge gaps.

Introverts can also use subtle cues to establish their personal brand. As well-known psychologist Robert Cialdini told me during an interview for my book Reinventing You, simply placing diplomas or awards on your office walls can help reinforce your expertise to others. (Cialdini saw this powerful effect in action at an Arizona hospital he advised; exercise compliance increased 32% almost immediately after the physical therapy unit started displaying their staff’s credentials.)

Finally, use your downtime strategically. You’re likely to need more “thinking time,” as introvert and former Campbell Soup Company CEO Doug Conant advised in an HBR post. So while the extroverts may be schmoozing with colleagues after work, you can ensure you’re being productive while you recharge by reading industry journals or thinking creatively about your company and your career. (Introverts often do their best thinking on their own, as Harvard Business School Professor Francesca Gino suggests, rather than amidst the scrum of an office brainstorming session.)

In popular imagination, personal branding is often equated with high-octane, flesh-pressing showmanship. But there are other, sometimes better, ways you can define yourself and your reputation. Taking the time to reflect and be thoughtful about how you’d like to be seen and then living that out through your writing and your interpersonal relationships (and even your décor) is a powerful way to ensure you’re seen as the leader you are.

Why Health Care Is Stuck — And How to Fix It

The pressures for fundamental change in health care have been building for decades, but meaningful change has been limited while the urgency of change only grows. The moment of discontinuity has arrived. Already unsustainable costs, an aging population, advances in medicine, and a growing proportion of patients in low reimbursement government programs have made the status quo unsustainable. Change is inevitable.

There is only one real solution, which is to dramatically increase the value of health care. Value is the outcomes achieved for patients relative to the money spent. Without major improvements in value, services will need to be restricted, the incomes of health care professionals will fall, and patients will be asked to pay even more.

In our October Harvard Business Review article “The Strategy That Will Fix Health Care” we describe the strategic agenda that is necessary to create a high value health care delivery system. We believe that there is no longer any doubt about how to increase the value of care. The question is whether providers can make the necessary changes.

Why has it been so hard for health care organizations to improve outcomes and efficiency, despite their best intentions? With so many good, smart people working so hard? With patients’ needs so obvious and so compelling? And with such deep societal concerns about health care spending? The answer is complex, but the result is clear: progress in health care has been all but paralyzed by self-reinforcing barriers to change.

We are confident that providers can overcome these barriers by starting with a shared understanding of why they are stuck.  We think the most important barriers include the following:

Providers are organized and reimbursed around what they do, rather than what patients need.

Most health care delivery organizations are organized around physicians and specialties. Within a hospital, physicians are members of the departments and divisions and specialize in what they were trained to do. They treat a broad range of conditions relevant to their field—for example, a neurologist will see patients with headaches, provide stroke care, and treat multiple sclerosis and other conditions with a neurological component. Physicians are physically located in their specialty units, and patients are expected to find their way to them. In this structure, physicians generally work hard to help patients during each encounter – and their assumption is that if they do so, they are doing their job.  In this context, their efforts to improve care have focused largely on raising the volume of the discrete services they provide, with “efficiency” gauged in terms of “throughput.”

This approach may have made more sense in the past, when there was so much less that medicine could do, and it was possible for specialists to know all there was to know in their field. Today, however, medical progress has made many previously untreatable diseases treatable, and some even curable. Many more types of clinicians must work together to deliver state-of-the-art care. A patient with diabetes, for example, might need care from physicians trained in endocrinology, nephrology, cardiology, vascular surgery, ophthalmology, podiatry, and primary care.

Yet the current siloed organization of care makes multidisciplinary, integrated care extremely difficult, even if clinicians are part of the same institution and utilize the same electronic medical records. At one well-known teaching hospital, a survey showed that 15% of staff physicians did not realize that they were all members of the same physician organization. This is an indication of how strong their main identification is with their specialty divisions.

In this legacy structure, effective teamwork is possible but it doesn’t happen naturally. Duplication and delay are built into the system. Patients are forced to coordinate their own care and make sure their various physicians are communicating.

Care fragmentation is reinforced by the fee-for-service model in which each doctor, specialist or otherwise, is paid separately, while the hospital receives its own payment.  Physicians believe that they are compensated for what they do as individuals; basic teamwork functions that are critical to meeting the needs of patients, like meetings to review performance or even using the electronic medical record, are sometimes labeled “unfunded mandates.” Some high-value services are not reimbursed at all, such as follow-up telephone contact after hospitalizations or “virtual” or informal consultations that avert the need for an office visit. The result is that crucial work required for high value care does not get done.

Some new payment models provide reimbursement for care coordinators, but those coordinators are typically superimposed over the current fragmented care process, leaving the basic organizational structure intact. Although an overlay is less disruptive than restructuring the organization of care, it adds cost and essentially treats the symptom of faulty organization rather than the cause. And those added costs have led many to mistakenly conclude that excellent care is inherently more costly, which has hindered efforts to guide patients to the highest-value providers.

Free-agent physicians operate independently, rather than as part of an integrated team.

Not only is care siloed by specialty, but much specialty care in the U.S. is delivered by independent physicians in private practice. A study of Medicare patients, for example, showed that patients saw a median of seven different physicians in four different practices each year, with little or no integration among them.

In many ways, independent doctors have dominated medicine’s culture. “Free agent” physicians view themselves as equity-owners of autonomous businesses, and few have placed a high priority on integrating care with other clinicians as a means to improve value for patients. Instead, there are tensions among different specialists over what they are paid. And, there are inevitable conflicts with hospitals over compensation, staffing, desired facilities, and who should bear risk, not to mention threats to move business to other hospitals. All of this makes multidisciplinary, integrated care challenging – or impossible.

To address these issues, there are a growing number of joint venture models in which hospitals and independent physicians become partners, but the jury is still out on their impact and durability. Joint ventures can help boost integration and shift care to higher value models, but complexity remains about decision rights, responsibilities, and dividing revenues. Such joint ventures often fall short of true partnership, and prove fruitless.

The proportion of physicians that are employed is rising, an important enabler of high value care. When all the physicians involved in care are employed by a larger organization, teamwork can become part of the job description. However, the trust that is crucial to well-functioning teams takes time and work to develop especially when physicians have only recently become employed.

Patient volume is fragmented, making every patient a special case.

Health care systems in virtually every country, including the U.S., disperse rather than aggregate patients with similar needs. A century ago, hospitals sprang up in almost every small town or city, and served any patient walking in the door. This made sense when there was not much that medicine could do for many patients beyond relieving their symptoms. Because hospitalizations could easily last a month or more, close proximity was essential to allow visits by family members. The result was that most providers treated a relatively small number of most types of cases.

Today, however, medicine is far more advanced and specialized and lengths of stay are much shorter. Treating a high volume of patients with a particular medical condition is critical to value, to build experience in highly sophisticated and technical diagnostics and procedures, work more effectively in multidisciplinary teams, and better measure how patients are doing. In the existing fragmented system, providers have limited experience in each type of case, leading to less efficiency, more dropped balls, and worse patient outcomes. Fragmentation also means that most providers are unable to integrate support personnel with specialized skills in a disease area directly into the team —such as nutritionists or behavioral health specialists. There is overwhelming evidence that having a high volume of patients with a particular condition is important to value, and, conversely, that care by local providers with small populations can lead to poor outcomes.

Despite the clear benefit of focusing on the areas with adequate patient volume, providers tend to cling to every service line and duplicate services across health systems. Boards of directors are loath to close services in any facility, in part because politicians mistakenly equate local service with better care. Antitrust regulators are also remain wary of consolidation, mistakenly seeing the relevant market as highly localized and believing that the more providers of a given service in the region the better.

Massive cross-subsidies in reimbursement for individual services have distorted care and stalled care integration.

Under the prevailing fee-for-service payment system, there is a loose relationship at best between the fees paid and the actual costs of performing that service. Flawed reimbursement methodologies have made some services lucrative (for example, radiology and chemotherapy), while others are reimbursed below actual costs (mental health and palliative care, for instance). Organizations use high-margin services to cross-subsidize the money-losing areas, with severe, perverse consequences. Virtually every provider organization is motivated to invest in profitable services like bariatric and vascular surgery in a desperate grab for enough lucrative business to stay alive. The result is excess capacity and overprovision of these services, yet insufficient volume for most providers to deliver excellent or efficient care.

Cross-subsidization across services, even those needed in caring for the same condition such as less reimbursed cardiology drug therapy and highly reimbursed interventional procedures, works against making the highest value care choices while creating tensions among providers, undermining team-based, integrated care. Providers involved in patients’ care fight over responsibility and compensation rather work together. High value but poorly reimbursed services, such as palliative care, are underprovided.

No participant in the system has good information about patient outcomes and the cost of care.

Flying blind is dangerous. When there are no data on how you are doing, and whether new interventions or practices actually improve outcomes or lower costs, initiatives to improve performance can end up doing more harm than good.

The shocking truth in health care is that there are few data on the actual outcomes that matter to patients with specific conditions. Instead of recognizing that quality is determined by outcomes, providers tend to define quality on the basis of compliance with guidelines (for example, reliability in ordering certain tests or “door-to-balloon” time for patients with myocardial infarction) and patient status as measured by a limited number of clinical indicators (such as LDL cholesterol levels and hemoglobin A1c) which are incomplete predictors of outcomes but not actual outcomes themselves.

There is also a near complete absence of data on the true costs of care for a patient with a particular condition over the full care cycle, crippling efforts to improve value. The lack of cost information starts with widespread confusion about the difference between costs and charges. Most clinicians also have no way of knowing what things actually cost or how much time care processes take. Without the ability to understand the costs of the care for specific conditions, or how costs compare to outcomes, efforts at cost reduction revert to power struggles and arbitrary cuts. Efforts to improve performance become mired in turf wars, personal opinions, and clashes of ego. Resources tend to flow to services that seem to be the most profitable or whose advocates are most skilled in internal politics.

Information technology has often made care integration and value improvement harder, rather than enabling it.

Most clinical information systems have been designed around specialties, procedures, or care sites, and focused on scheduling and fee-for-service billing. Few systems were designed to keep track of individual patients over a full care cycle, and provide all the caregivers involved with comprehensive patient information. Few if any clinicians involved in the care of a patient have complete information. Information systems can also make it almost impossible to collect information on outcomes that matter. Highly relevant data (for example, incontinence or falls) are not captured in EMRs at all, and much outcome information is buried in “free text” fields within clinician notes, which makes it hard to extract or act upon.

The information systems used by health insurance plans have been no better, and maybe worse. They are designed to adjudicate and pay bills for individual services not measure the overall care and value for patients. Most insurers cannot even capture whether a patient is dead or alive. Good luck trying to piece together the overall charges for one episode of care if it spans the end of the calendar year.  Faulty information systems make it all too easy to give up and continue with business as usual. For example, insurers throw up their hands about bundled payments because legacy systems are coded for fee-for-service payments.

BREAKING DOWN THE BARRIERS

As the figure below shows, the barriers to change in the legacy system are interdependent and mutually reinforcing.

Fee-for-service payments for specialties as well as private practice physicians reinforce the siloed organization of care. Fragmented IT solutions work against multidisciplinary care models, rather than enabling them. Misunderstandings about profitability because of inaccurate costing leads to overly broad service lines, a problem exacerbated by the fact that providers attempt to serve all the needs in their service area. Low patient volumes in many conditions, due to serving only the immediate geographic area and duplicating  services across locations, reinforce the siloed structure of care delivery because providers cannot afford to have dedicated teams. And so on.

Because these barriers to change reinforce each other, incremental fixes do not work.  As a result, progress in truly restructuring health care delivery has been stymied. The legacy structure almost guarantees low or uneven value for patients, yet it is extremely resistant to change.

These barriers to change make it clear that to move from the legacy system to a value-based system needs to be a true strategic transformation, not just a series of isolated steps. In our article, we describe the six components of this transformation, from organizing into integrated practice units, and measuring outcomes and costs, to expanding excellent service geographically and building a new kind of IT platform, as shown in the figure below.

This transformation will not happen overnight and each component will take time to roll out. But a true solution to our health care problem is within our grasp.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us at healtheditors@hbr.org, and sign up to receive updates here.

Leading Health Care Innovation

From the Editors of Harvard Business Review and The New England Journal of Medicine




Leading Health Care Innovation: Editor’s Welcome
Getting Real About Health Care Value
Understanding the Drivers of Patient Experience

Getting Real About Health Care Value

Words can spearhead social transformation.  Let’s hope that’s true for “value” in health care. Where other mantras – such as quality or managed care – have failed to galvanize the system’s diverse stakeholders, value may have a chance.

What seems special about the term is that, seemingly simple, it is actually complex and subtle. Under its umbrella, a wide range of interested parties can find the things they hold most dear, from improved patient outcomes to coordination of care to efficiency to patient-centeredness. And it is intuitively appealing. As Thomas Lee noted in the New England Journal of Medicine, “no one can oppose this goal and expect long-term success.”

The question, of course, is whether the term will help spur the fundamental changes that our health care sector so desperately needs. In this regard, a closer examination of the value concept confirms its appeal but also exposes the daunting challenges facing health system reformers.

Michael Porter has defined value as “health outcomes achieved per dollar spent.” Any survivor of introductory microeconomics will hear echoes in this phrase of one basic measure of economic efficiency: output per unit of input. An efficient business gets the most output possible, given current technology, from every dollar spent.

Porter and colleagues adapt microeconomics to health care through their definition of output: patient-centered health outcomes. These are results that individual patients desire: survival, speedy and uncomplicated recovery, and maintenance of well-being over the long term. These are also things that clinicians, payers, and purchasers should seek for their patients, employees, and customers. The value movement’s definition of outcomes treats the patient as a whole person, insists that measures of outcome transcend disease-specific indicators to account for all of the patient’s conditions, and include data collected over time and space to produce comprehensive measures of patient well-being. Value proponents further insist that inputs be measured comprehensively to include all the costs of producing desired outcomes.

Widely adopted, the concept of value would provide a north star toward which health care providers could navigate.  Its emphasis on the whole patient and comprehensively measured costs would encourage teamwork among clinicians and coordination of care across specialties, clinical units, and health care organizations. The focus on patient-centered outcomes would support increased effort to measure patient-reported outcomes of care, such as their level of function and perceived health status over time.

Promising as it is, the emphasis on value also raises illuminating and challenging questions. The first is: why all the fuss with defining it? In most markets consumers define value by purchasing and using things. In the 1990s, personal computers had considerable value. We know that because consumers bought lots of them. Now, with the arrival of tablets, personal computers seem to be losing value.  And so it goes for untold numbers of goods and services in our market-oriented economy. Eminent professors don’t wrack their brains defining the intrinsic value of electric shavers, overcoats, or roast beef.

We need to define the value of health care, however, for a simple but profound reason explained in 1963 by Nobel-prize-winning economist Kenneth Arrow. Arrow showed that health care markets don’t work as others do, because consumers lack the information to make good purchasing decisions. Health care is simply too complex for most people to understand. And health care decisions can be enormously consequential, with irreversible effects that make them qualitatively different from bad purchases in other markets. Americans are therefore reluctant to let the principle of caveat emptor prevail. One reason to define value carefully and systematically is to enable consumers to understand what they are getting, an essential condition for functioning health care markets.

The compelling need for a good definition of health care value highlights another fundamental challenge. We have not yet developed scientifically sound or accepted approaches to defining or measuring either patient-centered outcomes of care, or – surprisingly – the costs of producing those outcomes. The scientific hurdles to defining patient-centered outcomes are numerous. Outcomes can be subtle and multidimensional, involving not only physiological and functional results, but also patients’ perceptions and valuations of their care and health status.  The ability of health care organizations to measure costs is primitive at best and doesn’t meet the standards used in many other advanced industries. Equally challenging is the lack of data systems to support outcome measurement.  Producing the holistic assessments needed requires the aggregation over time and space of data from multiple clinicians and health care organizations, as well as patients themselves. The health care system’s electronic data systems are just now entering the modern age.

Given the value of measuring value, and the current obstacles to doing so, still another urgent question arises: what should we do now? Despite recent moderation in health care costs, our health care system is burning through the nation’s cash at an extraordinary rate and producing results that, by almost every currently available measure, are disappointing.

To turn the promise of value measurement into the reality of better care at lower cost, a few short-term actions seem prudent. First, the nation needs a plan to turn the concept of value into practical indicators. Since government, the private sector, consumers and voters all have a vital stake in health system improvement, they should all participate in a process of perfecting and implementing value measures, preferably under the leadership of a respected, disinterested institution. The Institute of Medicine comes to mind, but others could be imagined.  This process should produce an evolving set of measures that will be imperfect initially but improve over time.

Second, both government and the private sector need to invest in the science and electronic data systems that support value measurement. Investments in systems should focus on speeding the refinement of standards for defining and transporting critical data elements that must be shared by patients, providers, and insurers to create patient-centered outcome measures.

Third, in consultation with consumers and providers, governments need to develop privacy and security policies that will assure consumers that their health care data will be protected when shared for the purpose of value measurement.

Last, and perhaps most important, the trend toward paying providers on the basis of the best available value measurements needs to continue. These payment policies motivate providers to use value measures to their fullest extent for the purpose of improving processes of care and meeting patients’ needs and expectation.

To some observers putting value at the forefront of health care reform may seem obvious and non-controversial.  As Lee notes, who can be against it?  To use an American cliché, it seems a little like motherhood and apple pie: comfortable and widely endorsed. But the value movement could be much more than that.  When value does become a well-accepted principle, we’ll be much closer to making health care better for everyone.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us at healtheditors@hbr.org, and sign up to receive updates here.

Leading Health Care Innovation

From the Editors of Harvard Business Review and The New England Journal of Medicine




Leading Health Care Innovation: Editor’s Welcome
Why Health Care Is Stuck — And How to Fix It
Understanding the Drivers of Patient Experience

Understanding the Drivers of the Patient Experience

Many hospitals, including the Cleveland Clinic, are implementing a variety of strategies to improve the patient experience —an issue that’s rapidly becoming a top priority in health care. The Accountable Care Act now links performance related to patient-experience metrics to reimbursement. For the first time, the pay of hospitals and eventually individual providers will be partly based on how they are rated by patients. Few disagree on the importance and the need to be more patient centric, but what exactly is the “patient experience”?

A 2012 industry survey asked top hospital leaders (CEOs, COOs, and others) what was necessary to improve the patient experience. The top six recommendations included: new facilities, private rooms, food on demand, bedside-interactive computers, unrestricted visiting hours, and more quiet time so patients could rest. There was one problem with them: They were not based on a systematic examination of what most patients really wanted. In other words, hospital executives wanted to focus on what they felt were important drivers of the patient experience but didn’t know for sure.

To truly improve the patient experience, it is important to get the patient’s perspective. National trends in data on the U.S. patient experience suggest that some groups of patients regularly score their experiences higher than others.

For example, surgical patients tend to give hospitals higher ratings than patients admitted with chronic medical conditions. Surgical patients may view or interpret their experience differently. Consider a patient who underwent surgery for a broken leg. If the patient receives high-quality health care (her leg was fixed, her questions were answered, she feels better, and she understood what was being done to her), she may not care whether she believed her providers were treating her with courtesy or respect or showed her compassion.

Now consider a patient who consistently uses the health care system — someone with multiple, chronic medical conditions that remain incurable and are only treatable from a maintenance standpoint. If he doesn’t feel that his caregivers are compassionate, that may heavily influence his overall perception of the experience. Since his relationship with health care givers is more prolonged (or permanent), he may need more of the “human side” of caring.

Why is it important for caregivers to know the drivers of patient experience? First, not being clear about the drivers can often be a significant barrier to launching a patient-experience initiative. Second, knowing the drivers helps leaders identify the most effective ways to achieve quick victories. Third, the economics of the levers is quite different. Improving some of these dimensions (such as providing private rooms) would be cost prohibitive for most hospitals. Others (such as improving communication between patients and caregivers) could reduce the overall cost of providing health care and also improve medical outcomes.

Faced with the task of understanding the drivers of patient experience, health care organizations have taken — and can take — multiple approaches to discerning the drivers of patient experience. Below, we review briefly some of the innovative approaches to better understand patient needs that have been tried in various organizations, including the UCLA Medical Center in Los Angeles, Methodist Hospital in Houston, St. Joseph’s Hospital in Phoenix, and the Cleveland Clinic.

Create patient advisory councils. A very simple but effective approach in many contexts is to identify a group of patients that can act as the customers’ “voice” within the organizations. It is easy for an organization to lose touch with its customers’ evolving needs.

Today, Voice of the Patient Advisory Councils are used at the Cleveland Clinic to ensure that the organization does not lose track of patients’ needs. Councils have assisted with redesigning waiting rooms, providing advice on improving the admission guide, and helping managers better understand communication needs in the hospital.

Dig deeper into patients’ experiences. Hospitals can use data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) — the patient-satisfaction surveys conducted for the Centers for Medicare and Medicaid Services — to compare how their performance compares with that of other U.S. hospitals. Hospitals can leverage the HCAHPS data better by both digging deeper into the data and paying attention to anecdotal comments and complaints. This allows hospitals to understand not only how their patients feel about their experience but also why they felt the way they did.

Using such a process, the Cleveland Clinic found that patients were more satisfied when they had caregivers who smiled more. But when the Clinic dug deeper, it discovered that patients were not concerned about whether about their caregivers had happy expressions per se; rather, they were concerned when doctors’ and nurses’ had stern expressions because they interpreted them to mean that caregivers were concealing problems from them. This caused anxiety and, as a result, adversely affected patient satisfaction.

Have leaders make regular rounds. At UCLA Medical Center, as well as other hospitals across the country, senior leaders (both clinical and non-clinical) make a habit of wandering throughout the hospital and talking to patients, their families, and caregivers (including physicians, nurses, food-service workers who deliver the meals, and environmental-service workers who clean the rooms. These rounds need to be done on a regular basis and at least once a month. Such direct contact provides leaders with a firsthand understanding of patient needs.

This is important for two reasons. One, it is easy for leaders — even clinical leaders in hospitals who have direct patient contact in the normal course of performing their jobs — to lose touch with patient needs. Two, leadership rounds are an important means of exposing non-medical leaders in finance, operations, and other areas of the hospitals to the front lines of patient care. Finally, by regularly seeing and hearing with their own eyes and ears what’s happening on the front lines of patient care, leaders can help identify problems and opportunities for improvement.

Tell stories. There is nothing more moving than the incredible stories that patients relay about their experiences in the hospital. Sharing these stories — both good and bad — is important to employees. The good stories highlight the importance of their roles and demonstrate the incredible gratitude that patients have for their work. The bad stories often help explain the negative feelings about the hospital that some patients have. (At the Methodist Hospital in Houston, CEO Marc Bloom opens every meeting of the board of trustees by relaying a patient’s account of his or her stay. Sometimes it was good and sometimes bad.  At the end, he reminds everyone that “this is what we do.”)

We are big fans of analyzing data to understand and improve patient experience. However, presentations that rely on excessive amounts of data can be dry and uninspiring. Conveying the same message through a well-told story can be powerful and inspirational. Also, storytelling can help strengthen caregivers’ emotional bonds with the organization and their jobs, which, in turn, can make it easier to engage employees in the organization’s mission to deliver world-class care to patients.

Leaders of health care organizations in recent years have focused primarily on delivering superior medical outcomes at lower costs. In addition, they also need to focus on improving the patient experience. A poor experience compromises a hospital’s reputation among patients and other physicians and adversely affects employees’ engagement levels. Moreover, with the changes in the reimbursement policies in many countries, it can have a negative impact on a hospital’s economics. But improving the patient experience will be hard to do without a better understanding of what patients really want. We hope others will offer comments and share what they’ve learned from their own efforts to understand what drives patient satisfaction.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us at healtheditors@hbr.org, and sign up to receive updates here.

Leading Health Care Innovation

From the Editors of Harvard Business Review and The New England Journal of Medicine




Leading Health Care Innovation: Editor’s Welcome
Why Health Care Is Stuck — And How to Fix It
Getting Real About Health Care Value

Leading Health Care Innovation: Editors’ Welcome

In the United States and throughout the world, health care is undergoing a transformation. It is a reaction to the broad recognition that the current system — such as it is — is unsustainable. The clear solution is to increase the value of care: improving patient outcomes while containing, if not reducing, costs. Breakthroughs, especially in genomics, promise to deepen understanding of diseases and ways to combat them. But all stakeholders — governments, consumers, insurers, employers and providers themselves — realize that scientific advances alone will not suffice. To produce the best health outcomes at the lowest cost, virtually every aspect of the delivery system must be revamped — from leadership, organizational structures and culture, and processes, to teamwork, and incentives.

While the debate rages about the best ways to reform the overall system and produce higher value in health care in the future, institutions are conducting thousands of initiatives to find better ways of doing things in the here and now.  In this fertile environment, Harvard Business Review and the New England Journal of Medicine are hosting this insight center. It is a forum for the debate and a place where members of the health care sector can share the results of their efforts to innovate. The insight center is pilot endeavor designed to test the waters for a permanent publication, and we welcome your feedback.

The insight center will run from Sept. 17 until Nov. 15. Its contents will span three broad areas:

The “Big Ideas” section will feature articles about the foundational principles in the formulation of a high-value health care system.
The “Managing Innovations” section will focus on the organization and delivery of health care and how to orchestrate change.
The “From the Front Lines” section will offer accounts of solutions to specific problems that practitioners have implemented in their organizations.

As the pilot project progresses, we encourage you participate by adding your comments to the discussion thread and to propose articles by e-mailing us at healtheditors@hbr.org.

For more about the Insight Center and the collaboration between HBR and the NEJM, see this editorial by the Journal’s editors.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth and sign up to receive updates here.

Leading Health Care Innovation

From the Editors of Harvard Business Review and The New England Journal of Medicine




Why Health Care Is Stuck — And How to Fix It
Getting Real About Health Care Value
Understanding the Drivers of Patient Experience