Continuing on the three-legged stool riff: more on "Just Culture," workforce engagement, and leadership in healthcare.

First, some selections from Maccoby's more general book on "Leadership" as I continue to try to connect some significant dots.

As is my customary M.O., I let the authors speak for themselves in extended excerpts. No need for my interpretation here. These are all smart, accomplished people with cogent points of view (buy and study their respective books; I get nothing for making these recommendations).

Just keep in mind my assertions from my prior post, i.e., that significant improvement in healthcare requires just as much focus and effort on the psychosocial "health" of the healthcare workforce itself as it does on technological/clinical advances and "process re-engineering." Inordinate attention to those two "legs of the stool" to the exclusion of improving the engagement/morale "health" of the healthcare workforce culture itself will seriously hamper the reform/improvement effort. We run the risk of falling prey yet again to the pernicious "Rescuer-Victim-Persecutor Triangle" amid our recurrent searches for scapegoats when initiatives bear insufficient fruit.

Leaders for Health Care

THE HEALTHCARE INDUSTRY is huge, making up from 13 to 16 percent of the U.S. economy. It’s a knowledge industry that should provide solutions rather than just products and services, but its mode of production and the social character of many of its key professionals lag behind the times. Health care is an industry desperately in need of visionary leaders who partner with operational and network leaders to transform organizations and even influence the social character of physicians…

LEADERS FOR HEALTHCARE ORGANIZATIONS

Policy makers function in a rarified atmosphere, far from the organizations that have to implement their policies. Listening to the reports about the poor quality of health care, I asked myself whether some healthcare organizations were doing things right, especially improving quality and controlling costs. In the healthcare business, where there’s a huge variation in management approaches, someone somewhere is usually ahead of the curve, and you can always learn from the best cases…

We found that leadership is essential to improve the quality of patient care and cut unnecessary costs. In some of the most prestigious healthcare organizations, we found an angry clash between doctors practicing an obsolete craft-based mode of production, and hospitals, organized like industrial bureaucracies, whose administrators were attempting to force the physicians into the iron cage.

The result was a cold war in which all the parties—doctors, hospitals, patients—were losers. In contrast, we met visionary leaders who were transforming both the medical mode of production and hospital bureaucracies into learning organizations, self-organizing and adaptive to the changing technology and markets.

To fully grasp the leadership challenge, we need to understand the social character of doctors. Traditionally, medicine has been much like a craft, organized like a cottage industry with sole proprietors and small partnerships, based on the physician’s reputation and personal relationships with colleagues and patients. Doctors reinforce their professional identity within a guildlike structure that determines membership and monopolizes functions. There are, to be sure, some important differences: unlike artisan crafts, medicine depends on a widely shared, relatively open scientific knowledge base. Yet the parallels are striking. Although the doctor’s education begins with formal training, specialization is gained through apprenticeship.12 The ideal leadership model, as with other crafts, is the most accomplished practitioner, the master craftsman who represents the interests of his peers. If he does that effectively, he creates a strong transferential followership. The physician-patient relationship has depended on the patient’s trust of the doctor’s expertise and caring attitude. For centuries, the technology has been hand tools—stethoscope, scalpel, needles, etc.—and a limited number of useful medicines. The model of care has been biomedical, with a strong dose of positive transference to the doctor as a parental figure to cement trust and strengthen a placebo effect that aids natural self-healing.

Historical studies have shown that the model of the autonomous professional physician in America has been institutionalized through a long process starting in the nineteenth century, driven in part by the need for doctors to establish a solid basis of prestige to replace the image of unregulated quackery of the time. The establishment of medical education and licensing was crucial to creating a sense both among the public and among physicians themselves that their use of up-to-date scientific knowledge and their professional ethics warranted respect and financial reward. During the twentieth century the AMA (American Medical Association) worked for this professional autonomy, repeatedly fighting off regulators…

The explosion of medical knowledge, new drugs, and new technologies calls for standardization and collaboration among experts. But the craft mode of production resists standardization. Each craftsman does things his own way, which is why there is so much variability in medical care, and so much misdiagnosis and needless cost.

Inevitably, this craft mode has been attacked by bureaucracies. As the doctors have held on to their traditional model, cost-control efforts such as health maintenance organizations (HMOs) and medical protocols imposed by insurance companies have weakened their autonomy and pushed many into joining group practices or becoming employees of healthcare organizations. Furthermore, both the changing social character of patients and the information revolution have also undermined the doctor’s unchallenged authority…

THE IDENTITY OF DOCTORS

Resistance to change is rooted in the typical physician personality type and the professional socialization that molds this personality to fit the traditional medical mode of production. Based on interviews and questionnaires we gave to senior physicians and medical school graduates, we found that most had a particular professional variation of the bureaucratic social character. The most common personality type was a productive obsessive-erotic personality—systematic, careful, and caring. Doctors saw themselves as expert-helpers who are supposed to have all the answers to a patient’s complaint. A few doctors, particularly orthopedic and cardiac surgeons, were narcissistic-obsessives.

As defined by the Oxford English Dictionary, an expert is “a person with the status of an authority by reason of special skill, training or knowledge.” The root of expert is the Latin expertus, meaning tried or experienced. For experts in any profession, both self-esteem and employment security are gained by status and respect, recognition by peers and superiors. The physicians we interviewed typically display their awards and diplomas on their office walls to testify to their achievements and impress their patients. Experts have a strong need for autonomy. At their best, they stand for high standards of service and knowledge. The physician’s view of professionalism fits the Calvinistic concept of professing a calling to serve others—the meaning of their work is not just exercising expertise, but also helping suffering people.

However, at their worst, their obsessive qualities make these experts inflexible know-it-alls. Rooted in a craft system of master and apprentice, where knowledge is based on experience, at a time when medical knowledge quickly becomes out-of-date and competence calls for continual learning, the physician’s personality can be a major roadblock to change. Physician experts prize control and resist empowering others, which they see as loss of control. This is a complaint we heard repeatedly from nurses and administrators. Physicians, like many other experts—for example, university faculty—don’t appreciate the added value of the organization over what they do as individuals…

The clash of cultures between physicians and hospital administrators is a conflict between the craft mode of individual authority, self-generated revenue, personal style of care, and patient advocacy as opposed to the industrial bureaucratic mode of centralized management, financial controls, standardized procedures, and rules based on fairness.

TOWARD A KNOWLEDGE MODE OF PRODUCTION

Can health care be reorganized as a knowledge mode of production that tackles variability of practice, improves outcomes, and controls cost, yet allows physicians to be creative and maintain a healing relationship with patients while retaining the best values of the craft tradition? Unless this question can be answered in the affirmative, many of the policy proposals offered by the National Coalition on Health Care won’t connect with the real world of health care…

The ideal health system will challenge physicians and all healthcare professionals—nurses, administrators, technicians—to work together to improve productivity and also the patient’s experience. In most systems today, patients with complex problems have to trudge from one specialist to another, making their own appointments, carrying their records from office to office, repeating their medical histories, filling out similar medical history and insurance forms over and over again. It’s a hassle that can only be solved by transforming the medical mode of production.

The ideal moves from what is essentially a sick care system to a true health maintenance system. It expands the care model from a purely biomedical and craft mode to a biopsychosocial and epidemiological knowledge mode of production. This move requires collaboration between healthcare professionals and everyone in a community...

MacCoby, Michael (2007-10-04). The Leaders We Need: And What Makes Us Follow (pp. 103-116). Harvard Business Review Press. Kindle Edition.

The Culture of Do and Tell

When we compare some of the artifacts and behaviors that we observe with some of the values that we are told about, we find inconsistencies, which tell us that there is a deeper level to culture, one that includes what we can think of as tacit assumptions. Such assumptions may have been values at one time, but, by consensus, they have come to be taken for granted and dropped out of conscious debate. It is these assumptions that really drive the manifest behavioral elements and are, therefore, the essence of a culture.

The most common example of this in the United States is that we claim to value teamwork and talk about it all the time, but the artifacts— our promotional systems and rewards systems— are entirely individualistic. We espouse equality of opportunity and freedom, but the artifacts— poorer education, little opportunity, and various forms of discrimination for ghetto minorities— suggest that there are other assumptions having to do with pragmatism and “rugged individualism” that operate all the time and really determine our behavior…

All cultures have rules about status and respect based on deep assumptions about what merits status. In many societies basic humility toward persons whose positions are based on birthright is taken for granted and automatically felt. In societies that are Western, more egalitarian, and individualistic, we tend to respect only high achievers, based on the Horatio Alger myth of working one’s way up from the bottom. We tend to experience optional humility in the presence of those who have achieved more, but the Here-and-now Humility, based on awareness of dependency, is often missing.

The degree to which superiors and subordinates can be humble differs by the basic assumptions of the culture they grew up in. The more authoritarian the culture, the greater the sociological distance between the upper and lower levels of status or achievement, and, therefore, the harder it is for the superior to be humble and learn the art of Humble Inquiry…

THE MAIN PROBLEM– A CULTURE THAT VALUES TASK ACCOMPLISHMENT MORE THAN RELATIONSHIP BUILDING

The U.S. culture is individualistic, competitive, optimistic, and pragmatic. We believe that the basic unit of society is the individual, whose rights have to be protected at all costs. We are entrepreneurial and admire individual accomplishment. We thrive on competition. Optimism and pragmatism show up in the way we are oriented toward the short term and in our dislike of long-range planning. We do not like to fix things and improve them while they are still working. We prefer to run things until they break because we believe we can then fix them or replace them. We are arrogant and deep down believe we can fix anything—“ The impossible just takes a little longer.” We are impatient and, with information technology’s ability to do things faster, we are even more impatient. Most important of all, we value task accomplishment over relationship building and either are not aware of this cultural bias or, worse, don’t care and don’t want to be bothered with it.

We do not like or trust groups. We believe that committees and meetings are a waste of time and that group decisions diffuse accountability. We only spend money and time on team building when it appears to be pragmatically necessary to get the job done. We tout and admire teamwork and the winning team (espoused values), but we don’t for a minute believe that the team could have done it without the individual star, who usually receives much greater pay (tacit assumption).

We would never consider for a moment paying the team members equally. In the Olympics we usually have some of the world’s fastest runners yet have lost some of the relay races because we could not pass the baton without dropping it! We take it for granted that accountability must be individual; there must be someone to praise for victory and someone to blame for defeat, the individual where “the buck stops.”

In fact, instead of admiring relationships, we value and admire individual competitiveness, winning out over each other, outdoing each other conversationally, pulling the clever con game, and selling stuff that the customer does not need. We believe in caveat emptor (let the buyer beware), and we justify exploitation with “There’s a sucker born every minute.” We breed mistrust of strangers, but we don’t have any formulas for how to test or build trust. We value our freedom without realizing that this breeds caution and mistrust of each other…

In politics we build relationships with some people to further our goals and in order to gain advantage over other people. We build coalitions in order to gain power and, in that process, make it more necessary to be careful in deciding whom we can trust. We assume that we can automatically trust family only to discover betrayal among family members. Basically, in our money-conscious society of today, we don’t really know whom to trust and, worse, we don’t know how to create a trusting relationship. We value loyalty in the abstract, but in our pluralistic society, it is not at all clear to whom one should be loyal beyond oneself.

When we are sent off to outward-bound retreats to build teamwork, we view that as a necessary price of doing business and sometimes even enjoy and benefit but still think of it as just a means to the end of task accomplishment.

When the airlines first investigated some of their serious accidents, they found that some resulted from communication failures in the cockpit. In several dramatic cases the senior person just plain did not pay attention to the junior person who was giving out key information as the plane crashed. For a time, the airlines launched team-training programs and even assigned crews that had trained together to work with each other in the cockpit. But when this became too expensive and too unwieldy to manage, they went back to a rotational system where checklists and professionalism were expected to facilitate the necessary communication. It was even reported that some teams became overconfident and developed bad habits leading to safety shortcuts that justified dropping the team training…

Social distance across rank levels is considered OK. In fact, personal relationships across ranks are considered dangerous because they could lead to bias in assigning work and rewards…

In medicine today, we vocally deplore the fact that the system limits the amount of time that doctors can spend with patients because of our espoused value that building a relationship with patients is good medicine, but we accept short visits as an inevitable pragmatic necessity because of the tacit assumption that economic criteria rather than social ones should drive the system. We accept what we regard as economic necessities even though there is growing evidence that communication problems between doctors and patients cause treatment failures and are sometimes responsible for patients taking the wrong doses of a medicine. Valuing task accomplishment over relationship building shows up in how often doctors are disrespectful of nurses and technicians and even of patients. They often depersonalize and ignore the patient in their discussion with the interns who have been brought along to view the “case.” All of this is driven by the need to accomplish tasks in a cost-effective manner, which translates into cramming as many tasks as possible into each unit of time and not bothering with relationship building because that might take too long…

A SECOND PROBLEM– THE CULTURE OF TELL 

We take it for granted that telling is more valued than asking. Asking the right questions is valued, but asking in general is not. To ask is to reveal ignorance and weakness. Knowing things is highly valued, and telling people what we know is almost automatic because we have made it habitual in most situations…

Knowing things is highly valued in most cultures. With age we supposedly get wiser, which usually means knowing more. So we go to older people to get answers and expect to get them. When the supplicant climbs the mountain to reach the wise guru, and his question is answered with another question, we put this into a cartoon and laugh about it…

...deep down many of us believe that if you are not winning, you are losing…

Consider again the operating room of today in which the surgeon, the anesthesiologist, key nursing staff, and surgical technicians have to work in perfect harmony with each other in undertaking a complex operation. Consider that they not only have different professions and ranks, but they are likely to be of different generations and possibly different national cultures, which may have their own values and norms around relationships, authority, and trust. So let me restate the problem:

The world is becoming more technologically complex, interdependent, and culturally diverse, which makes the building of relationships more and more necessary to get things accomplished and, at the same time, more difficult. Relationships are the key to good communication; good communication is the key to successful task accomplishment; and Humble Inquiry, based on Here-and-now Humility, is the key to good relationships…

The Special Challenge to Leaders

Culturally it is more appropriate for the person of higher status to do more telling and for the subordinate to do more inquiring and listening. This works when 1) both parties have the same superordinate goal, 2) the superior knows the answers, and 3) the subordinate understands what is being told…

If surgeons have not built relationships with their teams, team members may withhold information and jeopardize patient safety because they do not feel psychologically safe to speak up to the higher-status person…

Only by making the subordinate feel psychologically safe can the superior hope to get the information and help needed…

Subordinates are always in a vulnerable position and must, therefore, first be reassured before they will fully commit to open communication and collaboration. Consider again the situation of the hospital patient. One thing that the doctor can offer in this situation by humbly inquiring is to make the patient feel like a whole person rather than a scientific subject...

Schein, Edgar H. (2013-09-02). Humble Inquiry: The Gentle Art of Asking Instead of Telling (BK Business) (pp. 53-65). Berrett-Koehler Publishers. Kindle Edition.

Remember again Dr. Leape’s testimony before Congress that the single greatest impediment to reducing medical errors is that we punish people for making mistakes. Can you see what he’s referring to in the Washington State statute? Can you see the expectation that we have set for healthcare professionals? Perfection is the standard. Don’t meet that standard in aviation, and you are called “careless.” Don’t meet it in healthcare, and you’re called “unprofessional.” The doctor who makes a simple prescription ordering error is lumped in with the doctor who anesthetizes his patient for the sole purpose of molesting her. Both are unprofessional, both are condemned and face state sanction for their unprofessional conduct. Whack! This is America—and we’re proud to be perfect…

All regulators should reconsider how they regulate. They should first abandon the no harm, no foul system of accountability. Choices, after all, do matter. We need not wait for harm to use our regulatory power. Second, regulators should look at where they have created expectations of perfection. Perfection cannot be the standard. Third, they should look to where their enforcement practices create unnecessary impediments to learning. Regulators must find an appropriate balance between system and individual accountability. The pendulum, in many cases, has swung too far toward perfection on the part of the individual as the means for obtaining good system performance. That’s playing Whack-a-Mole…

Do we expect our physician to always get it right? Do we expect our dry cleaners to perform flawlessly? Do we expect our favorite restaurant to always deliver our meal exactly to our specifications?…

Consider what makes a sport, a sport. You might say that it is not the “real thing” when compared to our jobs, or raising a child. It is meant to be play instead. You might also look at how we design a particular sport. We don’t design sports so that participants get it right all of the time. To the contrary, we design games with the intent of causing human error. We design the game to produce a wide variation of human performance—so that the good players can excel against their peers. Natural talent, training, and attitude attempt to overcome the system designed with the express purpose of eliciting poor human performance…

It may seem strange to compare sports to being a commercial pilot or a doctor. They are more similar than we’d like to admit. In both, we ask individuals to perform as best they can. We design a system around them, and then we ask them to make the best possible behavioral choices they can within that system. In both the work world and in sports, we should expect human fallibility, human mistakes. In sports, we actually design the game to enhance that fallibility. The built-in, or enhanced, fallibility is what makes the game interesting. In medicine, we design the system to minimize that fallibility, but our fallibility remains.

We cannot and should not expect perfection from each other—no matter how critical the task may be. Our power is in the systems we build around imperfect human beings and in our expectations of them within those systems. A bad outcome should never automatically qualify a human being for blame and punishment. In the case of simple human error, there is no wrongdoer, there is no unjustly injured victim. There is only the predictable path that through our shared human fallibility we’re someday going to hurt each other—whether at work, at home, or at play on the soccer field.

Perhaps sports can teach us all a thing or two about human fallibility and demonstrate to us all that there are alternatives to the game of Whack-a-Mole…

You can make a difference not only in your own life, but in the lives of your children, friends, and co-workers. You can make a difference in the event an airline, restaurant, hobby shop, or hospital inadvertently harms you, whether physically or financially. The power is in your hands. Legislators are steeped in the game of Whack-a-Mole. They will be unwilling to change the game until we the people demand the change. How?

Saving Yourself

First, own your personal fallibility. Don’t believe that you are above being an inherently fallible human being. You can’t will yourself to perfection. Know that when an error hits you, it’s not necessarily an indication of bad behavior. You are not a wrongdoer worthy of public condemnation and sanction simply because you made a mistake. Second, know that you have choices to make. Choices about the system you design around yourself. Choices to make within that system—from drinking and driving, to relying heavily on your faulty memory. Our choices will determine the risks we impose on others, and it is for our choices that society can rightly stand in judgment. Third, don’t let the severity bias lull you. Just because you had a good outcome doesn’t mean your risky choice ought to be validated. Step back, search your mind and your soul: am I doing the right thing? No harm, no foul cannot be a guiding principal of life. Remember, each day is a spin of the roulette wheel—saving ourselves and saving others means we try every day to maximize the number of spaces through good system design and good behavioral choices. Just because we didn’t land on double zero today does not mean that the double zero isn’t there.

Marx, David (2012-06-06). Whack-a-Mole: The Price We Pay For Expecting Perfection (Kindle Locations 1441-2189). By Your Side Studios. Kindle Edition.

I was glad to see someone else make the "sports" analogy, one I make frequently. High-morale, high-engagement "High Performance Teams" will indeed be ever more important in the healthcare space. They just don't happen by accident. All the "systems re-engineering" in the world (not to mention inane "Workplace Wellness" dicta) will come to naught, relegated to yet another recursion of Dilbert Zone MEGO cynicism absent psychosocially healthy healthcare workforce teams lead by real leaders focused on real results.

The fact that this is not more widely acknowledged is disconcerting to me. We are, I guess, burdened by an evolved corporate paradigm borne of our "Superior/Subordinate" command-and-control military model, one certainly having its place within the military, but utterly inappropriate and long past its Sell-By date in the civilian world. It is fundamentally inimical to patient safety, and detrimental to the Triple Aim.

I repeat,

A psychosocially healthy workplace is a significant profitability and sustainability differentiator.

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A CAUTIONARY CONNECTION?

apropos of the Health IT leg of the reform stool, recall my prior post of April 17th, wherein I cited Simon Head's admonitory book "Mindless: Why Smarter Machines are Making Dumber Humans."

...When applied to core services Scientific Management deals instead in “unsituated actions,” meaning that the chief task of the employee, whether as a physician or a call center agent, is not to apply her own judgment and skill to the complex situations she encounters. Instead, her task is to work out which predetermined category a patient, client, householder, or customer belongs to, so that the appropriate treatment, reward, or advice already worked out by scientific managers can be applied. But these rudimentary classifications drag us as customers into the maw of Scientific Management, no less than they do the employees we are dealing with. Just as the core workplace relationship between the managers and the managed denies employees the scope to develop their talents, so the further relationship of the employees with us as their counterparties too often deals in an attenuated version of ourselves that, hedged about by the ever-present constraints of time, can too easily end up as abstract representations on a digital screen. For those with the financial wherewithal, the concierge economy with all its enticements is an escape from this rushed, dehumanized world.

OF ALL THE case histories we have examined here, perhaps the most chilling are those situated well beyond the strictly business world and even beyond the gaze of tightly networked computers. These are the theories and practices of the emotional labor experts of HRM [Human Resources Management], which intrude upon our innermost beings, and the efforts to impose an industrial production regime at a great university such as Oxford. These ventures show that the vandalism of the CBS world knows no limits, and there is no corner of our lives that is beyond the reach of process...

In this CBS [Computerized Business Systems] world concepts such as empowerment and skill no longer mean what they once did. To be skilled and empowered is to be in a state of perfect, frictionless harmony with the system, in perfect conformity with its rules and commands. Because experience and wisdom reside in the system and not in those who use it, the experience that users accumulate over time does not make them any more valuable to the system. Indeed, the contrary is true, because older workers may become wedded to past practices of the system that are now obsolete. These veterans can and should be fired and replaced by younger workers who can be paid less and have no crusty attachments to past practices...

What is to be done? Before looking for answers, it is worth taking stock of the headwinds most Americans face, judged by the statistics for the long-term stagnation or decline of their real earnings: first, their employment in workplaces that do not make full use of their skills and subject them to intrusive systems of monitoring and control; second, the stagnation or shrinkage of their real earnings, related directly to this deskilling; third, their need to shoulder increasing health care and pension costs, dumped on them by employers; and fourth, the growing insecurity of the workplace, linked to outsourcing, globalization, and a corporate readiness to have early recourse to layoffs. These are not the acts of a corporate leadership that values the skills and loyalty of its workforce and wants to strengthen these ties over time. These are indeed the claims of countless corporate mission statements, but the record reveals a preference for harsh cost-cutting strategies in which high employee turnover and high employee cynicism can be offset by system expertise and with the system’s control mechanisms ensuring that employees act as the systems prescribe...

If a clear majority of Americans are losing out in today’s economy, as they are, the political task is to create a dominant coalition from among them that would include low-income minorities and whites of the Walmart and Amazon world, middle managers and middle administrators whose real incomes have been steadily eroding, and even nonelite professionals of the nonconcierge economy suffering the same fate. The political debate is central, and it should be very much part of this debate that the progressive critique of the economy include the issues of white-collar industrialism discussed here.

The progressive response to the harshness of nineteenth-century capitalism was fueled by a growing awareness of what was going on behind factory walls. CBSs are by comparison invisible, and they benefit from this obscurity. This needs to end, and this books is a modest step in that direction. Yet there are grounds for optimism. The future contours of the economic debate are fluid because the future course of the economy itself is fluid. With its failure to reward the majority of Americans, the economy’s present course is unsustainable, and as this becomes more and more apparent, volatility will spill over to the public debate and open it up. 

In macroeconomics this unsustainability goes beyond the preoccupation with public spending and the public debt, currently the number-one concern in Washington. It is bound up with the difficulty of achieving strong, sustained growth as long as consumer-producers are in eclipse, blunting what was once the economy’s most reliable source of demand and making the tasks of deficit reduction immeasurably harder...

Head, Simon (2014-02-11). Mindless: Why Smarter Machines are Making Dumber Humans (pp. 188-193). Basic Books. Kindle Edition.

 Panopticon Health IT? Dubious "Quality Measures"-driven "Cookbook Medicine"? EHR-assisted "productivity treadmill" concerns? Taylorism 2.0? Replacing team-based front-line clinical and operations judgment with the managerial imperatives of the clean-hands MBA Suits and HR departments? Go to any mainstream healthcare / health IT blog, and you'll see ample display of these kinds of concerns, both in the posts and in the comments sections.

Recall from Dr. Toussaint's writings? "Manage processes, lead people"? The concerns aired by Simon Head pertaining to HRM, BPR, and CBS reveal evidence that some organizations are moving in the other direction -- using IT to manage people. In healthcare this is precisely the wrong thrust, and will only serve to deepen the cynicism of many critics of HIT and cannot but throw sand in the improvement gears.
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More to come. I'm on VAC in Hawaii this week. Below, a couple of my hundreds of shots thus far. The Pearl Harbor tour was sobering.