How Much Do Leaders Care?

It is true that no one cares how much you know until they know how much you care

 

1.    A husband and father earns the right to lead his family by caring for his wife and children.

2.    A minister earns the right to preach by caring for his congregation.

3.    A physician earns the right to teach medical students and residents by caring for them, and the right to influence and even direct his patients by caring for them.

4.    A commander earns the right to command by caring for his soldiers.

5.    A manager earns the right to lead by caring for his employees.

6.    A teacher earns the right to teach by caring for his students.

7.    A king earns the right to rule and a prime minister or president earns the right to preside (exercise authority or control) by caring for his citizens.

 

Caring is not merely feeling benevolent emotions.  Actually, since emotions are merely a side effect of thoughts and actions, benevolent emotions are an outgrowth, not a cause or a definition, or caring.  Leaders who care do the following for those who follow them:

 

1.    Learn about them

2.    Pray for them

3.    Encourage them

4.    Talk to them

5.    Listen to them

6.    Rebuke them

7.    Mentor them

8.    Teach them

9.    Be accountable to them

Discovery and Innovation in the Business of Health Care

Discovering things previously unknown is one of the most important, and most enjoyable, things that anyone can do. Most people do it every day, whether as simple as finding a new restaurant they love or discovering a new comet in the heavens. Fundamentally, new discoveries come from observation, analysis, and experimentation. A husband looking for a new restaurant to try with his wife might observe something that in his experience resembles a restaurant on a street corner. He then analyzes the available information to decide if he wants to try it; what kind of food they, the opening hours, and whether it is clean and inviting. Finally he and his wife try it out, completing the process of discovery.

New discoveries are often far more difficult than finding a great new place to eat. Identifying a new comet can require expensive equipment and uncommon expertise, while sequencing the human genome, learning about subatomic particles or curing cancer are some of the slowest and most resource intensive discoveries of all. The discovery that smoking causes lung cancer followed the same observation-analysis-experimentation sequence. In the 1930s a few surgeons noticed that they seemed to be performing lung cancer surgeries on a lot of smokers. Some published their observations and that induced others to analyze the existing information and hypothesize that smoking is associated with lung cancer. Researchers then developed experiments to test the hypothesis and in 1956 the British Doctors Study provided the first convincing evidence that smoking increased the risk of lung cancer.

Service industries such as health care use quantitative and qualitative methods to make new discoveries to improve the services that they provide to their customers. As a natural science, medicine makes new discoveries using a vast array of natural science methods such as laboratory and imaging techniques. As a social science, medicine also uses surveys, focus groups, and other techniques to gain information on people and their behavior.  As a business, medicine uses social science and other techniques to continuously improve its services to its stakeholders; including patients, family, staff, and others.

This article hopes to cover some of the methods that organizations, especially medical, can use to make new discoveries. In so doing, health care professionals can find the right questions and the right techniques to answer these questions for the benefit of their patients and others. 

Benchmarking

Regardless of the type of organization, benchmarking processes and outcomes against peers is useful. Manufacturers might reverse engineer a competitor’s product to improve their own and service companies might review the literature or even use secret shoppers to find best practices in their field that they can modify and imitate. 

Quantitative Methods

Since Frederick Taylor’s Principles of Scientific Management (1911), quantitative assessment of problems in business has been the standard. This should not be surprising, since Taylor’s key ideological tenets held sway over business thinking for much of the 20th century.

1.    The primary, if not the only, goal of human behavior and thought is efficiency.

2.    Technical calculation is in all respects superior to human judgment.

3.    Human judgment cannot be trusted because it is plagued by laxity, ambiguity and unnecessary complexity.

4.    Subjectivity is an obstacle to clear thinking.

5.    What cannot be measured either does not exist or is of no value.

6.    The affairs of citizens are best guided and conducted by experts.

Quantitative methods of making new discoveries have led to great advances in business and health care. Excluding bench and other basic research, these methods generally involve large numbers, both large numbers of subjects and large numbers of data points. They tend to involve standardized instruments to evaluate characteristics of their subjects, whether monitors to measure blood pressure or surveys to measure opinions.

Timing Categories of Quantitative Studies

Examples of Quantitative Studies

Prospective

Cohort – select a risk or protective factor and compare exposed with unexposed to see what outcomes they will develop.

 

 

Clinical Trial – select an intervention and compare exposed with unexposed to see what outcome they will develop.

Retrospective

Retrospective Cohort – select a risk or protective factor and compare exposed with unexposed to see what outcomes they have developed.

 

 

Case Control – select an outcome and look back in time (survey or other measurement device) to see what they were exposed to

Current

Cross-Sectional (prevalence) – examine risk or protective factors and outcomes that subjects have now.

Such quantitative methods are widely used in medicine and even in business. Data can be collected by instruments such as blood pressure monitors or laboratory equipment depending upon the object of the study. Data can also be collected by standardized surveys when investigators want to discover personal opinions or experiences. When done properly they provide valuable information which can be generalized beyond the study group to the larger population.

Qualitative Methods

These methods often involve much smaller numbers of subjects but provide much deeper insight into the needs and opinions of a small group or each subject. Focus groups, clusters of subjects specially selected by the researchers and working together, can provide qualitative data. Commonly used in business and politics, focus groups get individual responses which are conditioned by the group. 

Individual interviews are not guided by standardized surveys with preselected responses, such as “strongly agree – agree – neutral – disagree – strongly disagree” as is found in the Likert scale. Rather, while covering standard topics, they encourage group or individual stories from the subjects which pertain to the question at hand.

Design Thinking Process

A currently popular way of getting information, especially the qualitative component, is the Design Thinking Process (DTP). While qualitative methods often try to eliminate or minimize the subjective element in problem solving, design thinking attempts to “combine empathy for the context of a problem, creativity in the generation of insights and solutions, and rationality to analyze and fit solutions to the context (http://en.wikipedia.org/wiki/Design_thinking).”

Rather than dozens or even thousands of subjects, DTP typically recruits 10-12 subjects specially selected for some characteristics of interest to the researchers. They find the subjects through social media mapping, identifying frequent users of services, or asking key staff to recommend specific users. Simultaneously investigators try to ensure a representative demographic mix. In a hospital emergency department (ED), for example, study personnel might identify key opinion leaders who write about that ED and its services in Facebook, Twitter, or a blog. They might also examine hospital records to see which people used it the most and ask ED staff to recommend patients for the study.

After potential subjects are identified they have to be screened to decide who to include. A key determiner is who has the biggest potential influence to improve patient and system outcomes. Subjects must commit not only to providing data but also to help develop solutions.

Once researchers have a suitable number of the right volunteers, data gathering – individual interviews of each subject – begins. The first step is to develop a “journey map” for each subject. For a study to improve ED services in a community hospital, the map may begin when the patient first developed the symptoms that led them to the ED. They may be asked questions like this:

1.    Where and when did you first think that you might need to seek care? Why did you decide to go, and how did you get there? Please describe in detail what happened and how you felt.

2.    Who did you interact with at each location in the process? At home with family? With the EMS personnel? In the ED?

3.    What touch points did you have with the medical system? How was your interaction with each?

4.    What is your impression of the areas that you encountered? It is useful at this point to show patients pictures of pertinent locations, such as ED exam rooms, waiting rooms or front desks. These key areas color peoples’ opinions of everything and everyone else in the process.

5.    What could you see, hear, smell, feel, or even taste at each area? Was the environment hot, cold, too dark, too bright, too noisy, or something else?

6.    Were you given educational information? If so, was it useful? Why?

7.    What did you experience that was unexpected?

8.    Did you experience negative emotions? Which ones? Why?

9.    Did you experience positive emotions? Which ones? Why?

10.Was your experience seamless or fragmented?

Journey maps may begin even earlier. The first interaction that one person has with another or that a person has with an organization may be the expectation that one has of the other. Stakeholders may know, or think they know, well known people and organizations simply from their reputations. Therefore it is incumbent on everyone to consider how to improve others’ expectations of them, not just the physical interactions.

Journey maps also end later than the final physical interaction between people and organizations because of memory. A patient may have a wonderful experience in a hospital overall but have one truly bad interaction at discharge. That person’s memory of terrific care will be tainted and maybe even superseded by that last memory. Since memories of prior experiences color future expectations, people and organizations must manage them if they hope to please their stakeholders. The time-based process of interactions can be described like this:

Expectation

Does the customer or other stakeholder have expectations of the person or organization? If so, what are they, and how can they be improved?

First Impression

What does the customer or other stakeholder encounter the first time they make physical contact with services?

Discovery

Assuming the customer or other stakeholder stays with the person or organization, both parties begin to discover what the other is really like. Expectations and first impressions give way to lasting experience.

Usage

Assuming that discovery is satisfactory to all involved, they begin working together to accomplish mutual goals.

Memory

Eventually the interaction, whether an episode of care or something else, is finished. All parties remember their interactions, for good or for ill, and these memories shape future expectations.

Interactions between stakeholders and organizations do not occur only in time but also in space, and journey mapping also discovers these interactions. Some interactions happen directly to a stakeholder, such as a patient having surgery. Other interactions happen to their family or friends, such as a desk clerk being kind, or rude, to visitors trying to see the patient after surgery. Still other interactions happen in the public sphere, such as when a stakeholder sees a news story or an advertisement about a hospital. Innovators can find valuable clues on how to improve a customer’s (or a patient’s) experience by considering both time and space in their interactions with the organization.

For ongoing interactions between an individual and an organization, having the customer (patient) keep a week long journal of her interactions with the organization is useful. It is important to interview the subject in her context, such as home or work, to get the most insightful answers. Once each person has described their journey, researchers will begin to identify commonalities between them on the journey maps. They should use those commonalities to make a journey map of the subjects, which is called the Experience Map.

Simultaneous with gathering information from customers, known as patients in the health care setting, investigators begin selecting key organizational actors to participate. These may be doctors, nurses, and health care administrators, and their task is to join with the patients and solve the problems identified. First they write a blueprint of how the current service is designed. The blueprint helps match the front end experiences that the patient sees with the back end processes that the providers do. In the ED example, these staff members would carefully outline the current processes for screening and treating patients, as well as other pertinent processes. They would also identify principles that need to guide their thinking. For example, interactions with patients and other staff must be pleasant while at the same time being meaningful. “Pleasant and Meaningful Interactions in the ED” then becomes a key principle, known as an “Experience Pillar”, in the process.

Solving the Problem

The data gathering process is iterative; new data will constantly appear and be integrated into thinking on the research question and hypothesis. The solution process is also iterative; new data will modify the proposed solution and suggest improvements. Just as customers and staff are integrated into the data collection efforts, so customers and staff should be integrated into the problem solving efforts. The team that does this is the Co-Creation Team.

Looking at the service blueprint and the experience map, the Co-Creation Team uses Ideation sessions to look at the problems and at ways to fix them. They identify many possible solutions, but especially those that are small scale, low cost, and can be implemented quickly. The team presents its recommendation to decision makers and if all goes well their ideas are piloted. The easiest and quickest approach to the pilot project is to begin with the minimum viable solution tested in the minimum viable service. For example, rather than piloting a new mobile phone application to help patients coordinate their care with hundreds of patients in many different clinics and diagnostic categories, organizations can pilot a small version with a few dozen patients in one clinic in one diagnostic category.  In the National Capital Region, our pilot will involve a few dozen amputees in the Wounded Warrior clinic.

How to Optimize Discovery

Benchmarking, quantitative and qualitative methods are not contradictory but complementary in discovering how to best make a widget, provide a service, or care for a patient. In general terms, quantitative research and benchmarking can identify what is happening and where, while qualitative research can show how it is happening and why.

Conclusion

In a world of constant change, individuals and organizations must continually improve. To do this we must think differently, constantly making new discoveries. Using benchmarking, quantitative and qualitative methods provides a good means to do that.

Healing the Health Care Cost Conundrum

The military health care system is different in many ways from the civilian system, but a primary difference is the income incentive. Simply put, health care providers and other medical professionals are not paid based on the number of patients that they see or the number of procedures that they do. Instead they receive a fixed salary with few if any bonuses for productivity or quality. The budgets for military health care institutions, and many others in the Federal government, are based on Congressional appropriations, not on productivity. This has been changing in the past decade but remains largely true today.

Civilian medicine is not so. They are paid for what they did, patients seen and procedures done, and everyone on staff is usually highly motivated to do more. Some have described such fee-for-service reimbursement arrangements as “you eat what you kill.” In some practices, that can equate to more visits and more procedures, even if some are not medically required.

Each system has advantages and disadvantages. If medical personnel have no financial incentive to see more patients, they will generally see fewer. Since the fixed costs of health care are high the cost per patient will increase. Further, access to care may decrease if doctors see few patients per day. If medical personnel are paid by the patient seen and procedure done, they will generally see more, potentially improving access to care and decreasing the cost per patient. Unfortunately, they will also do more, including procedures with marginal benefit to the patient.

Some say that health care in the United States is poor, and they are wrong. While some population health metrics show that we have a long way to go, others show how far we have come. Most metrics of medical care demonstrate that we have the most advanced system in the world. Health care in the United States is good, but is very expensive. As these facts illustrate, finding the right balance in payment for health care in America is difficult. Nonetheless, there are some simple ways to reduce prices and control costs in US health care.

Require transparent pricing – Bitter Pill: Why Medical Bills are Killing Us was the cover story on the 20 February 2013 issue of Time magazine. It described frightening patient experiences with huge bills, inconsistency in pricing, and even duplicity. Though biased, the article raises some valid concerns. Just as pricing in other fields should be transparent to the consumer, so should pricing in health care.

Require transparent quality measures – It is difficult, but not impossible, to measure the quality of a health care institution or system. HEDIS and Oryx measures are commonly used and effective, as are readmission rates. Health care facilities could advertise and compete on their accreditation scores, such as Joint Commission. Consumers need quality measures in addition to transparent pricing to know where and when to spend their health care dollar.

Reform the Relative Value Scale Update Committee – Medicare and insurance payments are determined by a 31-member group that is dominated by specialists, with only one seat reserved for a primary-care doctor. Hence specialist payments are high and primary care payments are low. Primary care accounts for 51.3% of all visits to office based physicians in the US, while it has only 3% representation on this committee (http://www.ahrq.gov/research/pcwork1.htm).

Prescribe generic medications – Health care providers should use generic drugs whenever possible. They are regulated just as much as name brand drugs and are far cheaper. Generics tend to older drugs because of patent law and therefore have much more safety and efficacy data than newer drugs.

Make more medications and devices available over the counter (OTC) – self health care, often involving OTC medications and devices, can save a lot of money for American health care payers, including consumers. Widespread availability will drive costs down and quality up due to the forces of competition. Information on the proper use of these things is more available than ever before due to the Internet and computer applications. Pharmacists are usually available at point of purchase to answer questions and the health care providers are becoming more readily available via secure messaging over mobile devices for consultation. Devices themselves, such as Automatic External Defibrillators, have become smarter. Quality concerns are still valid but must be balanced against access to care concerns.

Engineer health, don’t just advocate it – Occupational health experts have long known that it is better to engineer out workplace hazards than it is to use administrative controls to prevent injury and illness. Sidewalks, bike lanes, traffic circles, parks, and other community improvements encourage active lifestyles and improve health. Seat belts, bike helmets, fluoridated water and immunizations are other examples. They are far more effective than administrative and advertising programs designed to encourage or force healthy behavior.

Reward good behavior – Payers such as employers and the government, should provide meaningful rewards for people who improve their health by stopping smoking, losing weight, and making other positive behavior changes. Reduced insurance premiums and health savings account benefits are two possible motivators. These rewards should not be given to those who do not improve their health in a measurable way. Ultimately the responsibility for the health of each person lies with that person, and those who are successful should be rewarded.

Encourage insurance competition – Nationwide competition between insurers, when paired with the other reforms mentioned here, would go far to control costs and still maintain reasonable levels of quality.

Enact tort reform – Like it or not, defensive medicine wastes money and can create a hostile environment between physicians and patients. Further, it limits providers’ ability and willingness to provide pro-bono or low cost care. Some patients are thereby denied care entirely, a bad outcome for everyone involved (except perhaps tort attorneys). While patients should be compensated for mistakes, limiting punitive damages introduces safeguards into the system which benefit everyone.

Take hospice seriously – Many patients with terminal diseases could benefit from home hospice care earlier after diagnosis. During the 1990s, 25% of health care costs were incurred in the last year of life (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1464043/). Most people would prefer to die at home, but 56% die in hospitals and 19% in nursing homes (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282180/).

A health savings account (HSA) for everyone – Anytime that patients take a bigger role in their health care, everyone wins. Tax exempt and employer contribution HSAs help consumers get better health care, and better health, for their dollar.

Institute patient and family centered medical homes (PFCMH) – The concept behind PFCMH is that the patients and their families are the most important parts of the health care system. The medical team is responsible for the total health of patients enrolled to them and is rewarded for healthy patients rather than the number of visits or procedures. The data suggest that patients who receive care in the PFCMH context are healthier and happier, and costs are lower, than patients receiving care in other systems.

Practice evidenced based medicine – Medical research provides medical answers in terms of averages, such as how long a typical woman with breast cancer might survive. It cannot answer how long a particular individual with breast cancer will survive. Clinical practice guidelines (CPG) provide the best way to manage the “average” patient. Since most patients are, by definition, around average, CPGs are useful. It takes the individual acumen of the physician to determine how best to use the CPG for each individual patient. The Veteran’s Administration and the Department of Defense have made some excellent CPGs which can be found at http://www.healthquality.va.gov/.

Promote physical fitness

Physical exercise helps everyone at every stage of life. Whether a child on the ward or an elderly person in the intensive care unit, activity helps physical and mental health. Passively putting unconscious patients through the full range of motion in all of their joints improves strength, range of motion, and overall functionality. Having the patient actively do the same thing, unless contraindicated, is even better. Rehabilitation after surgery or injury and prehabiltation before make outcomes much better. There are few people on earth who wouldn’t benefit from more physical activity.

Avoid emergency departments except for genuine emergencies – Non-urgent or emergent care done in emergency rooms is more expensive and lower quality than that same care provided in a doctor’s office.

Encourage support of family and friends – many patients who have difficulty with activities of daily living need care in expensive skilled nursing facilities. Doing the same care at home with visiting home health nursing personnel is better for the patients and saves money.

Compete for patient dollars – Informed and engaged patients and families are the best defense against bad health outcomes and unclear or even exorbitant costs.

Conclusion

While some improvements in health care are complicated, others are simple. Making the improvements mentioned here would go far toward lowering costs and improving quality in American health care. Insofar as is germane to the military system, we are doing all of these. We cannot afford not to do them.

 

Using the Military Decision Making Process in Civilian Organizations

The vocabulary of the Military Decision Making Process (MDMP) is not typical for civilian organizations, but the concepts are germane.  Translating MDMP into health care can be very useful for process improvement.

Mission receipt – The commander provides the mission to his or her command. In a civilian setting, this would be the leader at any level.

Mission analysis – Identify explicit and implicit tasks

METT-TC – Mission, “Enemy” (forces opposing mission accomplishment), Troops (resources available to accomplish mission), Terrain (environmental factors affecting mission), Time, and Civil considerations (maximizing benefit and minimizing damage to peripherally involved parties)

Course of Action (COA) Development

Multiple courses of action required (at least three). Each COA must specify how that course of action will accomplish the mission (who, what, where, when).  The mission is the “why”. Always consider the following concepts in COA development:

1. Battlespace

To an Army planner, “close” operations means close to the forward line of troops, “deep” means behind enemy troops, and “rear” means behind his own troops. He must prepare to fight in all zones of battlespace.

In a marketing campaign, “close” operations might be marketing to your immediate customers and community.  “Deep” operations might be marketing your product to potential customers and communities nearby.  “Rear” operations might be marketing yourself to your employees and other internal stakeholders.

2. Center of Gravity

The center of gravity is the key difficulty underlying every problem.  In Operation Desert Storm, the centers of gravity of the Iraqi forces were the command and control network, the air defense network and the Republican Guard.  Allied forces destroyed these centers of gravity first, and Iraq was defeated.

In health care, one of the biggest problems is access to care, getting enough of the right kind of medical interventions to meet the demand.  Centers of gravity include leadership, and may include personnel, space, or some other factor, depending upon the situation.

3. Combined Operations

To an Army planner, combined operations means that forces in every element, land, sea, air, space and cyberspace, must engage to achieve the objective.  In a marketing campaign, “land” may be person to person, “air” may be radio and television, “sea” may be direct mail, and “cyberspace” is cyberspace.  Thinking about initiatives in terms of combined operations helps ensure that leaders don’t miss valuable opportunities to act.

COA Analysis – Analyze each COA for risks and benefits including cost, safety, etc.

COA Comparison – Use a decision matrix, comparing the advantages and disadvantages of each course of action. This includes a comparison of hazard probability (frequent, probable, occasional, remote, or improbable) with hazard severity (catastrophic, critical, marginal, negligible).

COA Approval – after a decision brief, the commander or other decision maker decides which course of action the organization will follow.

Orders Production – the headquarters staff produces the guidance document for the organization

Warning Order (WARNO)– indicates that an order is about to be issued

Operations Order (OPORD) – the main order

Fragmentary Order (FRAGO) – a partial order that provides additional information to the OPORD.  It may precede or follow it.

Civilian organizations, and especially health care, do not use “orders” in the military sense but nonetheless use documents for policy, instruction and direction. The military Orders paradigm provides a useful guide.