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Monday, June 30, 2014

Back to the health IT tech stuff: NISTIR 7988

Executive Summary
Adoption of Electronic Health Record (EHR) systems in hospitals and outpatient clinics is accelerating. EHRs can support and revolutionize the way information is used to provide high-quality and safe patient care. At the same time, however, issues with workflow integration have contributed to slow rates of EHR adoption in some settings, including ambulatory outpatient care. Workflow is a set of tasks, grouped chronologically into processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal. Workflow analysis is an integral part of the early stages of the User-Centered Design (UCD) process. UCD is an approach to designing systems and employs both formative and summative methods in order to achieve systematic discovery of useful functions grounded in an understanding of the work domain.

In response to workflow integration challenges with EHRs, clinicians often develop workarounds to complete clinical tasks in ways other than were intended by system designers. A frequent workaround, for example, is copying and pasting text from a previous progress note for a patient to serve as a draft for the current progress note. In this report, two human factors workflow modeling tools, process mapping and goal-means decomposition, were used to collect, visualize, and document insights and the end-user needs to improve EHR workflow for clinicians in outpatient care settings. The findings identified clinical activities that require more relevant and flexible workflows in EHR designs to support end users’ needs. Based on the insights generated during collegial discussions with physician Subject Matter Experts (SMEs) and three interdisciplinary team meetings with clinical and human factors experts, we created process map visualizations and a goal-means decomposition diagram...
39 pages. Well worth your time. Link to the full document here (pdf).

Figure 1. The SEIPS framework for work system elements

From our literature review, workflow, workaround, and work system are defined as follows:

  • Workflow: A set of tasks, grouped chronologically into processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal.
  • Workaround: Actions that do not follow explicit rules, assumptions, workflow regulations, or intentions of system designers.
  • Work system: The five main elements from the Systems Engineering Initiative for Patient Safety (SEIPS) model are used to define the work system (Figure 1): 1) people (individuals and teams), 2) physical environment, 3) tools and technologies, 4) tasks, and 5) organizational characteristics.
 Below, one of my graphical takes on workflow.

Click to enlarge it it's difficult to read. Interesting, "the Systems Engineering Initiative for Patient Safety." Recall one on my earlier posts regarding "Systems Engineering." The "SEIPS model" publication is firewalled, so I've not yet been able to find it and read it without paying (cheapskate), but I bet it's safe to say it contains zilch about the cultural "workforce engagement" impediment that I've been discussing of late. You instead get stuff like this:
There is immense literature on workflow modeling in general, including agent-based modeling and other “humans-not-in-the-loop” modeling. In our review, we focused on approaches to analyzing and depicting workflow from a human factors perspective. Human factors is defined as “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance.” Human factors modeling methods are based primarily upon extraction of process flow and insights about challenges and variation from Subject Matter Experts (SMEs) during collegial discussions...
"...the understanding of interactions among humans..."

To include psychosocial workplace toxicity? 'eh? Do we not need to understand that factor?

Another of my workflow graphics.

Again, click to enlarge it it's difficult to read.

My graphics are better. :)

OK, I've just read all of it. Very good elucidation of the problems bedeviling EHR use in clinical workflow. Again, worth your (and my) time.
In response to workflow integration challenges with ambulatory physicians using EHRs, we have employed standard human factors methods in order to identify insights for EHR developers and ambulatory care centers. The methods illustrated in this document are process maps and goal-means decomposition diagrams informed by goal-oriented individual collegial discussions with physician Subject Matter Experts to walk through the typical workflow of a returning patient in an ambulatory care setting. We have identified a wide variety of potential opportunities to improve workflow with EHRs from a physician perspective. We anticipate that improving workflow might require an expansion in focus from the historical goal of supporting reimbursement to also improving quality of patient care as well as the quality of work-life for physicians. In order to increase the ease of implementing our insights, we provide a set of targeted recommendations.
Yeah. Blah, blah, blah. All necessary and good, but, nothing really new here. And, nothing whatsoever on the implicit, fundamental (albeit overlooked) "cultural/interpersonal" aspects of "Human Factors."

Another of my Photoshops.

Clinical practice is an irreducibly "high cognitive burden" enterprise requiring accurate and effective ongoing n-way communication between all participants. High performance teams have to be healthy -- in every sense of the word.

Re-read my little recent trilogy:


In which my friend Dr. Leslie calls me out. And, my response:


More to come...

The final day of the current SCOTUS term

Today comes the final day SCOTUS term decision in the controversial "Hobby Lobby" case, one deciding whether the "religious views of a corporation" (a proxy for those of its owners) trump the contraceptive mandate provisions of the PPACA (pejoratively, "ObamaCare").

Two years ago, they narrowly upheld the PPACA. This goofy song just fell right out of my head in about 15 seconds in reaction. I tried to give it my best Springsteen, with mixed results.

 UPDATE: Hobby Lobby prevails, 5-4. Narrow decision, not The End of Western Civilization As We Know It. Nonetheless, the ruling is yet another blow against the Equal Protection Clause of the Constitution, insofar as it "carves out" a religion-based exception for complying with equal protection via provision of the otherwise legal medical services that only women have need of.

The SCOTUS majority ruled that the government had options available to achieve the desired end (coverage of the morally controversial yet lawful womens' health tx's) that should have been used under RFRA (the Religious Freedom Restoration Act).

I agree. It's called Single Payer. Take employers out of the health care intermediation business. Do away with "employer mandate" and "individual mandate" entirely.

I know...

More to come.

Wednesday, June 25, 2014

The "Talking Stick" and the three-legged stool of sustained, transformative healthcare QI

My recent posts have ruminated on what I see as the underappreciated necessity for focusing on the "psychosocial health" of the healthcare workforce as much as focusing on policy reform (e.g., P4P, ACOs, PCMH), and process QI tactics (e.g., Lean/PDSA, 6 Sigma, Agile), including the clinical QI Health IT-borne "predictive analytics" fruits of ""Evidence Based Medicine" (EBM) and "Comparative Effectiveness Research" (CER). Evidence of psychosocially dysfunctional healthcare organizational cultures is not difficult to find (a bit of a sad irony, actually). From the patient safety-inimical "Bully Culture" down to the "merely" enervating emotionally toxic, I place it squarely within Dr. Toussaint's "8th Waste" (misused talent). See my prior posts,
Add one more book to my accruing stash, Nicholas Epley's interesting "Mindwise: How We Understand What Others Think, Believe, Feel, and Want."

I finished "Mindwise" on my flight back to Oakland from Honolulu Monday afternoon. Thoroughly enjoyed it.

What is the "Talking Stick"?
A final challenge to getting perspective is that others’ words are unclear, leaving room for misinterpretation. The egocentric biases we discussed in chapter 5 make you believe you are communicating your thoughts, beliefs, attitudes, and instructions more clearly than you actually are. To really enable someone to understand what’s on your mind, you not only need to be clear, you need to be painfully clear. If you’re getting someone’s perspective, you not only need to listen, you need to verify that your understanding is correct. Native Americans reportedly had a method for doing this very thing, called the “talking stick.” When different tribes had a dispute, they would gather to discuss their differences. During these conversations, only the person holding the talking stick was allowed to speak. When that person finished, they would hand the stick to another elder, who would first have to reiterate the last speaker’s position to that person’s satisfaction. Only when the first person felt understood could the next person make a new point. The brilliance of this method comes not from its ability to enable speaking but, rather, from how it fosters listening. If you have to reiterate someone else’s point to their satisfaction, then you’ll find out if you’ve understood correctly or incorrectly.

Although the talking stick is commonly recommended on the public-speaking circuit, I have yet to see it used regularly in any modern household or organization...

Epley, Nicholas (2014-02-11). Mindwise: How We Understand What Others Think, Believe, Feel, and Want (Vintage) (pp. 180-181). Knopf Doubleday Publishing Group. Kindle Edition.
This goes to Covey's "seek first to understand, and then to be understood."

My first grad school course was that of "Argument Analysis." The methodology being taught was actually comprised of two equally important sequential components: [1] forthright, comprehensive "argument analysis," followed by [2] "equally forthright argument evaluation." You cannot effectively evaluate a proffer until you fully understand it.

Talking Stick methodology.

You had to choose a refereed mainstream journal article to deconstruct and evaluate. I chose the 1994 JAMA paper "A Better Quality Alternative: Single Payer National Health System Reform" (pdf). The analytical method entailed numbering every sub-argument premise-to-conclusion element (I went with paragraph/sentence-clause enumeration), and then "flow-charting" each to depict the logic flow.

Tedious, in a word, after 49 paragraphs of painstaking analytical attention to logic flow and meaning. But, only after having honestly and accurately done so ("seek first to understand") could you move on to effectively "evaluate" the relative merits of each claim and how much weight of evidence they provided to the main "argument"/assertion.
Read the dotted lines as "despite" or "notwithstanding," and the solid lines as "because"/"therefore" in the direction indicated by the arrows (the arrowheads indicate the "therefore" or "consequently" conclusion).
There has been a good bit of recent clamor for teaching "critical thinking" skills in the healthcare space. You can readily find numerous books on the subject. to wit:

CHAPTER 1. What Is Critical Thinking, Clinical Reasoning, and Clinical Judgment?

This chapter at a glance
Critical Thinking: Behind Every Healed Patient
Critical Thinking: Not Simply Being Critical
Rewards of Learning to Think Critically
How This Book Helps You Improve Thinking
    Brain-Based Learning
    Organized for Novices and Experts
What ’ s the Difference between Thinking and Critical Thinking?
Critical Thinking: Some Different Descriptions
    A Synonym: Reasoning
    Common Critical Thinking Descriptions
Critical Thinking, Clinical Reasoning, and Clinical Judgment
    Applied Definition
Problem-Focused Versus Outcome-Focused Thinking
What about Common Sense?
What Do Critical Thinkers Look Like?
Critical Thinking Indicators (CTIs)
What’s Familiar and What’s New?
    What’s Familiar
    What’s New
4-Circle CT Model: Get the Picture?
Thinking Ahead, Thinking-in-Action, Thinking Back (Reflecting)
Putting It All Together
Critical Thinking Exercises
Key Points/Summary
Having taught Critical Thinking and Argument Analysis at the collegiate level for a number of years (great fun), I've often thought that this might be an area wherein I could serve as a short course training consultant to healthcare organizations. I could teach undergrad Critical Thinking without ever once having to refer to a text or notes.

Below, my summary "logic molecule" illustration.

But, as my recent studies have pointed out to me anew, it's not just about the mechanics of applied rational reasoning -- deduction, induction, astute recognition of structural / syllogistic, rhetorical, and statistical fallacies, the lexical and semantic nuances of "definition," the "scientific method" and so forth. It's not just about me, or you. It's about us. i.e., it's equally about interpersonal relations and mutual perceptions -- organizational dynamics. It's about "culture."

It's about "Humble Inquiry," about being "Mindwise," about the nurturing of the mutual-accountability "Just Culture" necessary for a collegial, high-engagement, high-performance interdisciplinary team-based workforce.

All of which goes necessarily to "Leadership," as leaders are the only ones with the requisite authority -- the ones who ultimately set and enforce the tone of organizational culture for better or worse. "Critical thinkers" in a psychosocially toxic organization may well simply be seen as insubordinate troublemakers.

It's about authenticity at every level within an organization, and the nurturing of a healthy culture that supports it.
...nurturing of the mutual-accountability "Just Culture" necessary for a collegial, high-engagement, high-performance interdisciplinary team-based workforce.
High morale and engagement and openness to the ongoing rigors of process improvement and effective high-cognitive burden teamwork simply requires it.

Some random clips from the breadth of "Mindwise"

Arguably, your brain’s greatest skill is its ability to think about the minds of others in order to understand them better… the kind of mind reading you do intuitively every day of your life, dozens of times a day, when you infer what others are thinking, feeling, wanting, or intending. The kind that enables you to build and maintain the intimate relationships that make life worth living, to maintain a desired reputation in the eyes of others, to work effectively in teams, and to outwit and outlast your competitors…

During the day in between, you easily recognize that your employees are clueless, but are sure your boss thinks you’re brilliant. You sense that your coworker is lying when he calls in sick but are confident that your clients are honest when they claim to love your work...

Fortunately for improvement’s sake, the mistakes we make trying to understand the minds of others are predictable and therefore correctable. Our mistakes come from the two most basic questions that underlie any social interaction. First, does “it” have a mind? And second, what state is that other mind in?

We can make mistakes with the first question by failing to engage our mind-reading ability when we should, thereby failing to consider the mind of another and running the risk of treating him or her like a relatively mindless animal or object. These mistakes are at the heart of dehumanization. But we can also make mistakes by engaging our ability when we shouldn’t, thereby attributing a mind to something that is actually mindless. These mistakes are at the heart of anthropomorphism…

Once we’re trying to read the minds of others, we can make mistakes with the second question by misunderstanding others’ thoughts, beliefs, attitudes, or emotions, thereby misunderstanding what state another mind is in. Our most common mistakes come from excessive egocentrism, overreliance on stereotypes, and an all-to-easy assumption that others’ minds match their actions…

Our species has conquered the Earth because of our ability to understand the minds of others, not because of our opposable thumbs or handiness with tools.

In fact, this ability forms the backbone of all cooperative social life. This is why those with greater social sensitivity have stronger friendships, better marriages, and are happier with their lives in general. At work, leaders do better when they have some sense of whether or not their instructions are being understood...

[T]here can be a significant disconnect between what people think about themselves and how they actually behave...

Understanding the associative nature of your brain is absolutely essential for understanding why it’s hard to know some aspects of your own mind. Over the course of evolution, your genetic code has inherited certain associative networks that help keep you alive long enough for you to pass along your genetic material through children…These positive associations, however, can make it hard to know yourself accurately...

Decades before psychologists made any of these discoveries about the full reach of unconscious processes, Carl Jung said, “In each of us there is another whom we do not know.”… We don’t understand ourselves perfectly well because we have access to only part of what’s going on inside our heads...

The reason is that we introspect about our own minds in the same way we do about the minds of others: by using a theory that makes sense of our own behavior even when we lack direct access to the actual causes of it. It works quickly and automatically, and it simply doesn’t account for what you don’t know…

What’s surprising is how easily introspection makes us feel like we know what’s going on in our own heads, even when we don’t. We simply have little awareness that we’re spinning a story rather than reporting the facts...

The important point here is that the stories we tell about the workings of our minds rely on the same mind-reading abilities we use to make sense of the minds of other people… The only difference in the way we make sense of our own minds versus other people’s minds is that we know we’re guessing about the minds of others. The sense of privileged access you have to the actual workings of your own mind— to the causes and processes that guide your thoughts and behavior— appears to be an illusion...

Illusions matter not simply because they are interesting but because they are consequential. The ability to introspect—“ to feel ourselves thinking,” as William James put it— creates an illusion that we know our own minds more deeply than we actually do. This illusion has one disturbing consequence: it can make your mind appear superior to the minds of others...

[W]ithout awareness of all of the constructive processes going on in your brain that allow you to see color, it seems to you that color exists out there in the world, rather than inside your own head— that the color red is actually on the apple in front of you, rather than simply appearing red to you because of the magic done by your neural connections. This creates what psychologists refer to as naïve realism: the intuitive sense that we see the world out there as it actually is, rather than as it appears from our own perspective.

If a person thinks he or she sees the world as it actually is, then what happens when he or she meets someone who sees the world differently? When your friend tells you that the red apple is brown, who do you think needs to visit the eye doctor? Naïve realism suggests an answer: they do. It calls to mind a famous line of George Carlin’s: “Have you ever noticed that everyone driving slower than you is an idiot, and anyone going faster than you is a maniac?”

Arguing about the color of an apple or speed on the highway is relatively trivial, but arguing about abortion rights, religion, same-sex marriage, gun control, or any other important issue on which opinions diverge is a serious matter, with conflict inflamed by the fuel of naïve realism. If the illusions you hold about your own brain lead you to believe that you see the world as it actually is and you find that others see the world differently, then they must be the ones who are biased, distorted, uninformed, ignorant, unreasonable, or evil. Having these kinds of thoughts about the minds of others is what escalates differences of opinion into differences worth fighting (and sometimes dying) for…

A more accurate understanding first requires the recognition that your judgment could be wrong, or could at least be wrong more often than you might think...

Even doctors— those whose business is to treat others humanely— can remain disengaged from the minds of their patients, particularly when those patients are easily seen as different from the doctors themselves. Until the early 1990s, for instance, it was routine practice for infants to undergo surgery without anesthesia. Why? Because at the time, doctors did not believe that infants were able to experience pain, a fundamental capacity of the human mind. “How often we used to be reassured by more senior physicians that newborn infants cannot feel pain,” Dr. Mary Ellen Avery writes in the opening of Pain in Neonates. “Oh yes, they cry when restrained and during procedures, but ‘that is different.’” Doctors have long understood infants as human beings in the biological sense, but only in the last twenty years have they understood them as human beings in the psychological sense… Engaging with the mind of another person depends not only on the type of person you are but also on the context you are in...


Many African traditions speak of a concept known as ubuntu: “a person is a person through other persons.” Your humanity comes from the way you treat others, the idea goes, not the way you behave in isolation. Humanity comes from treating others as human beings, not in the biological sense of having a fully human body but in the psychological sense of having a fully human mind. I have spent the last fistful of pages explaining how good people like you and I can, under the right circumstances, remain disengaged from the minds of others and thereby treat them as relatively mindless. By failing to engage our capacity to understand the minds of other people, we not only become indifferent to them, we risk losing some of our own humanity.

But this is not a book about social justice; it is a book about social understanding. Engaging more directly with the minds of others can not only make you behave more humanely toward others, it can make you behave more intelligently in the presence of others as well...

Every business leader is charged with getting things done through people. This requires understanding what actually motivates people in their jobs. This is an obvious mind-reading problem: What do my employees really want?

Leaders have two kinds of incentives at their disposal: intrinsic and extrinsic. Intrinsic incentives are any inherent to the job itself, such as the pleasure of accomplishing something worthwhile, learning new things, developing skills, or feeling proud about your work. Extrinsic incentives are outcomes that are separable from the job itself, such as getting paid, earning fringe benefits, getting a bonus, or having job security. Notice that the effect of extrinsic incentives on other people can be observed directly because it involves an obvious exchange of goods for services, whereas the impact of intrinsic incentives can really only be felt and experienced on the inside. You can see that both you and others work harder when money is at stake, but the metrics of pride and meaning and a sense of self-worth are emotional states that you feel rather than see. As a result, you can recognize intrinsic motivations more easily in yourself than in others...

Galileo may have removed the Earth from the center of the universe, but every person on this planet is still at the center of his or her own universe. As Galileo knew, to see the world accurately, you need to look in the right place and then view it through the right lens. These are two pieces of wisdom that you and I can easily forget…

One consequence of being at the center of your own universe is that it’s easy to overestimate your importance in it, both for better and for worse.

Your own beliefs serve as a lens for understanding what others are likely to believe, as well as how strongly they are likely to believe it. But your mind contains multitudes, and beliefs are not the only lens that can alter your perceptions. Knowledge can also do it. For example, read the following sentence:


Now please go back and count how many f’s appear in that sentence. This is important. I’ll wait for you.

How many did you find? More than you can count on one hand? If not, then we have just confirmed that you are a terrific reader but a terrible counter. Try it again. Look harder. I’ll be patient. Found all six yet? Don’t forget that “of” has an f in it. See them all now? Most people who read this sentence fail to spot all six of the f’s on their first pass. Instead, most see only three.

Why so few? This example has nothing to do with your beliefs and everything to do with your knowledge. Your expertise with English blinds you from seeing some of the letters. You know how to read so well that you can hear the sounds of the letters as you read over them. From your expert perspective, every time you see the word “of” you hear a v rather than an f and, therefore, miss it. This is why first graders are more likely to find all six in this task than fifth graders, and why young children are likely to do better on this than you did as well. 30 Your expert ears are clouding your vision.

This example illustrates what psychologists refer to as the curse of knowledge, another textbook example of the lens problem. Knowledge is a curse because once you have it, you can’t imagine what it’s like not to possess it. You’ve seen other people cursed many times. For instance, while on vacation, have you ever tried to get driving directions from a local? Or talked to an IT person who can’t explain how to operate your computer without using impenetrable computer science jargon? In one experiment, expert cell phone users predicted it would take a novice, on average, only thirteen minutes to learn how to use a new cell phone. It actually took novices, on average, thirty-two minutes.

The expert’s problem is assuming that what’s so clear in his or her own mind is more obvious to others than it actually is. Each of us has unique areas of expertise, but we are all experts on one issue very near and dear to us: ourselves. We live, work, and sleep with ourselves every day. We know what we looked like in the morning, how we felt yesterday, what we were doing five years ago.

The problem of expertise is one of many examples of mistakes that come from projecting our own minds onto others: assuming that others know, think, believe, or feel as we do ourselves. Of course, we do not project ourselves onto others completely. We do so in some situations more than in others, and we project more onto some minds than others. The less we know about the mind of another, the more we use our own to fill in the blanks.

Every student in a negotiation class learns that the secret to solving disputes is recognizing that the other side may not have completely opposing interests, and may have more overlap in interests than you would guess. Solving disputes therefore requires openly discussing each others’ actual interests, identifying similarities, and then identifying integrative solutions that maximize the benefits for both sides…

Sadly, negotiations over our differences rarely end so sensibly. When groups are defined by their differences, conflict is fought over the differences we imagine, suppose, or expect from others rather than over the genuine, multifaceted, and often more moderate differences that actually exist. When groups are defined by their differences, people think they have less in common with people of other races or faiths or genders than they actually do and, as a result, avoid even talking with them. When groups are defined by their differences, the minds we imagine in others may be more extreme than the minds that actually encounter.

If there’s anything surprising left to learn about stereotypes, however, it’s how quickly we drop them as soon as we go from reasoning about the mind of a group to the mind of an individual whose behavior we observe directly...

...a common sense that a person’s mind corresponds directly to that person’s actions, a systematic sense that psychologists refer to as the correspondence bias...

Failing to calibrate our sixth sense to recognize the power of the broader context can create considerable misunderstanding, from assuming that accidents were intentional to crediting people for successes beyond their control… Common sense suggests targeting people’s minds to change their actions, but many of these solutions are useless because they misunderstand the cause of the problems.

Egocentrism exaggerates the extent to which others’ minds match one’s own. Stereotypes can highlight differences at the expense of similarity. And others’ actions can prompt oversimplified assumptions about the minds behind them. These heuristics provide simple shortcuts for understanding the minds of others, but they come at the cost of oversimplifying them. Others’ minds are more complicated than your sixth sense often suggests.


In How to Win Friends and Influence People, one of the best-selling books of all time, Dale Carnegie lists a series of principles for how to do what his title promises. Principle 8, he writes, is a “formula that will work wonders for you.” The formula? “Try honestly to see things from the other person’s point of view.”...

The weakness of perspective taking is also obvious: it relies on your ability to imagine, or take, the other person’s perspective accurately. If you don’t really know what it’s like to be poor, in pain, suicidally depressed, at the bottom of your corporate ladder, on the receiving end of waterboarding, in the throes of solitary confinement, or to have your source of income soaked in oil, then the mental gymnastics of putting yourself in someone else’s shoes isn’t going to make you any more accurate. In fact, it might even decrease your accuracy… Overthinking someone’s emotional expression or inner intentions when there is little else to go on might introduce more error than insight. What’s more problematic is that if your belief about the other side’s perspective is mistaken, then carefully considering that person’s perspective will only magnify the mistake’s consequences. This is particularly likely in conflict, where members of opposing sides tend to have inaccurate views about each other...

We’ve now looked many times for evidence that perspective taking— actively trying to imagine being in another person’s circumstances— systematically increases mind reading and have yet to find any supportive evidence… The main issue is that carefully considering another’s perspective is no guarantee that you’ll be able to do it accurately...


Recognizing the limits of your sixth sense suggests a different approach to understanding the minds of others: trying harder to get another person’s perspective instead of trying to take it. As the old reminder to doctors trying to understand their patients goes, “The patient is trying to tell you what’s wrong with him. You have to shut up and listen.”

Consider an example of how perspective getting might work. In 1993, the U.S. government signed the “don’t ask, don’t tell” policy into law, banning gays and lesbians from serving openly in the military. By 2010, the Obama administration was considering the consequences of repealing the law. Moral implications aside, knowing how current soldiers felt about this repeal was essential for assessing its practical consequences. This is a textbook mind-reading problem, with at least two approaches to solving it.

One is exemplified by the 1,167 retired military officers who used their perspective-taking ability to imagine the consequences for current soldiers of repealing the law. In an open letter to President Obama and members of Congress, they expressed their strong opposition. “Our past experience as military leaders,” they wrote, “leads us to be greatly concerned about the impact of repeal on morale, discipline, unit cohesion, and overall military readiness. We believe that imposing this burden on our men and women in uniform would  …   eventually break the All-Volunteer Force.” Elaine Donnelly, president of the Center for Military Readiness, argued that this opposition must be taken very seriously. “They have a lot of military experience,” she said, “and they know what they’re talking about.”

The Pentagon took a second approach to this mind-reading problem. Its officials asked the soldiers their opinions directly by surveying 115,052 soldiers and 44,266 of their spouses in one of the largest studies in military history. The soldiers themselves expressed relatively few concerns. In fact, 70 percent believed that the repeal would have no effect or a positive effect on the military. More telling, roughly the same number (69 percent) said that they had worked with a gay service member already. Among those, 92 percent said it had no effect or a positive effect on the unit’s ability to work together. From these responses, Defense Secretary Robert Gates concluded that the repeal “would not be the wrenching dramatic change that many have feared and predicted.” Gates pushed for its repeal.

Who was right? In 2012, one year after the actual repeal of “don’t ask, don’t tell,” the military released a study of its consequences. The answer was clear: soldiers could speak their minds when asked directly, but the retired officers who’d imagined the soldiers’ reactions were wrong. The title of the press release says it best: “First Study of Openly Gay Military Service Finds ‘Non-Event’ at One-Year Mark.” Getting the soldiers’ perspective by asking them for it enabled understanding.

We communicate the contents of our minds primarily through language. As Daniel Gilbert writes in Stumbling on Happiness, “If you were to write down every thing you know and then go back through the list and make a check mark next to the things you know only because someone told you, you’d develop a repetitive-motion disorder because nearly everything you know is secondhand.”  This is why William Ickes, an expert on empathic accuracy, finds that “the best predictor [so far] of empathic accuracy appears to be verbal intelligence.” Knowing others’ minds requires asking and listening, not just reading and guessing...

The gains that come from getting perspective directly instead of guessing about someone’s perspective can be big...

Months before an explosion on the Deepwater Horizon oil rig caused the largest spill in history, a confidential survey of rig workers uncovered serious safety concerns but strong fears of reprisals for reporting those concerns. According to a report in the New York Times, “only about half of the workers interviewed said they felt they could report actions leading to a potentially ‘risky’ situation without reprisal.” One worker surveyed said, “The company is always using fear tactics. All these games and your mind gets tired.” To hold on to their jobs and avoid punishment, workers routinely kept quiet about obvious risks, even faking data in the company’s safety system to make the rig appear more stable than they knew it was. Under these conditions, the rig passed an internal safety inspection just one month before the disaster. Would this disaster have been averted if the company’s executives had been willing to hear what their employees knew? I’d bet on it.

Doctors have even discovered that opening up their minds and admitting their mistakes can actually reduce one of their biggest fears: litigation. In 2001, the University of Michigan Hospitals began a medical-error-disclosure program in which doctors openly admit their medical mistakes in meetings with patients, explain what led to the mistake, and then offer fair compensation. Compared to the no-disclosure policy practice in the six preceding years, this open-apology system cut malpractice lawsuits in half (from 39 per year to 17 per year) and reduced the time to resolution by roughly 30 percent (from 1.36 years to .95 years). According to the lead doctor reporting these results, “Everybody worries that disclosure will lead to liability going through the roof, but here’s one institution that set up their disclosure program privately and independently, helped their patients avoid using the courts and tort system, and did not sustain the skyrocketing claims and costs that others might have predicted.” In fact, this program actually reduced overall liability costs by roughly 60 percent. The bigger problem had been requiring patients to imagine what their doctors were thinking, or having to sue to find out, rather than just allowing doctors to explain how a mistake happened.

Reducing litigation is good, but what the disclosure program really does, according to the medical center’s chief risk officer, Richard Boothman, “is give permission to doctors and other caregivers to do what’s important and what they want to do— take care of the patients and make sure the same error doesn’t ever happen again in the future.… When you break that paradigm of litigation and give patients the chance to understand the human element of the other side— of the doctor and what they are struggling with— you find that people are far more forgiving and understanding than has been typically assumed.” Now, that’s something your sixth sense might never have imagined...

Managers know what their employees think when they are open to the answers and employees feel safe from retaliation, not when managers use their intuition… If we want to understand what’s on the mind of another, the best our mortal senses can do may be to rely on our ears more than our inferences… Knowing the limits of our brain’s social sense does not always mean that we can overcome them to understand others better. Sometimes a sense of humility is the best our wise minds can offer, recognizing that there’s more to the mind of another person than we may ever imagine...

But even our greatest abilities are far from perfect, and our sixth sense’s mistakes also cause some of our life’s greatest pains. Broken relationships, failed organizations, stalled careers, and needless conflicts are common casualties… When we’re indifferent to others, it’s easy to overlook their minds altogether, treating such people more as relatively mindless animals or objects than as fully mindful persons… If understanding is your goal, then you know how to do much better.

Only by recognizing the limits of our brain’s greatest sense will we have the humility to understand others as they actually are instead of as we imagine them to be.
Indeed. Note from the foregoing the nuanced take on "empathy." You cannot simply intuit, infer others' states of mind, others' motives, thoughts, feelings, and needs. You mostly have to ask to get it right. Which goes to Humble Inquiry (Schein) and "Help Them Grow..." (Kaye & Winkle-Giuglioni). Openness and beneficent motives, while certainly necessary, are not enough. You need Leadership-nurtured Just Culture for a thriving high-engagement healthcare workforce. The high cognitive burden workflow processes (including those of health IT) and the demands of complex, rapid decision dx and px/tx are unlikely to get any simpler or easier.

In sum, I repeat: The stool needs three strong legs. One of them being a psychosocially healthy workforce.

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


Well, the full article is firewalled. You can get at it via registration with The JAMA Network Reader, but the text there is not copyable. Suffice it to say that this is one small, weak, equivocal study. It was conducted across a 3 month period in 2012 at Brigham and Women's and their affiliated ambulatory clinics.

Of course, the red meat headlines will blare that "MU does not improve quality and wastes taxpayer dollars." This "study" does nothing whatsoever to buttress that claim.

More to come...

Monday, June 23, 2014

Friday, June 20, 2014

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…


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…


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.


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 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…


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.


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.

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.

Saturday, June 14, 2014

On healthcare system improvement: are the Feds proposing the building of a two-legged stool?

Recall my June 9th post regarding ONC's "ten-year plan" for HIT Interop.

Well, we should also consider the latest PCAST Report (pdf).

Executive Summary
In recent years there has been success in expanding access to the health-care system, with millions gaining coverage in the past year due to the Affordable Care Act. With greater access, emphasis now turns to guaranteeing that care is both affordable and high-quality. Rising health-care costs are an important determinant of the Nation’s fiscal future, and they also affect the budgets for States, businesses, and families across the country. Health-care costs now approach a fifth of the economy, and careful reviews suggest that a significant portion of those costs does not lead to better health or better care.

Other industries have used a range of systems-engineering approaches to reduce waste and increase reliability, and health care could benefit from adopting some of these approaches. As in those other industries, systems engineering has often produced dramatically positive results in the small number of health-care organizations that have implemented such concepts. These efforts have transformed health care at a small scale, such as improving the efficiency of a hospital pharmacy, and at much larger scales, such as coordinating operations across an entire hospital system or across a community. Systems tools and methods, moreover, can be used to ensure that care is reliably safe, to eliminate inefficient processes that do not improve care quality or people’s health, and to ensure that health care is centered on patients and their families. Notwithstanding the instances in which these methods and techniques have been applied successfully, they remain underutilized throughout the broader system.

The primary barrier to greater use of systems methods and tools is the predominant fee-for-service payment system, which is a major disincentive to more efficient care. That system rewards procedures, not personalized care. To support needed change, the Nation needs to move more quickly to payment models that pay for value rather than volume. These new payment models depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign processes of care around the patient and bring community resources, as well as medical resources, together in support of that goal.

Additional barriers limit the spread and dissemination of systems methods and tools, such as insufficient data infrastructure and limited technical capabilities. These barriers are especially acute for practices with only one or a few physicians (small practices) or for community-wide efforts. To address these barriers, PCAST proposes the following overarching approaches where the Administration could make a difference: 

  1. Accelerate alignment of payment systems with desired outcomes, 
  2. Increase access to relevant health data and analytics, 
  3. Provide technical assistance in systems-engineering approaches, 
  4. Involve communities in improving health-care delivery, 
  5. Share lessons learned from successful improvement efforts, and 
  6. Train health professionals in new skills and approaches.
Through implementation of these strategies, systems tools and methods can play a major role in improving the value of the health-care system and improving the health of all Americans.

...In addition to ensuring that care remains affordable, there is a need to center health care on patients, families, and population health. That objective requires action on multiple fronts, as stated well by the Institute of Medicine: care should be safe, timely, effective, efficient, feasible and patient centered. There are opportunities to improve in each of these areas. For example, recent reviews suggest that over one-quarter of Medicare patients experienced some type of harm during a hospital stay, and other research finds that between one-fifth to one-third of all hospitalized patients experienced a medical error. Almost half of these errors were likely preventable. Other studies suggest that patients are not routinely involved in decisions about their treatments or managing their conditions. And anecdotal evidence and studies highlight the impact inefficiencies have on patients—long waits for appointments, information not transmitted between clinicians, and patients with complex diseases feeling lost trying to get the care they need.

These shortfalls are occurring even as most clinicians work tirelessly for their patients. Their work is frustrated by processes that contain unnecessary burdens and inefficiencies, with some studies suggesting that almost one-third of front-line health-care workers’ time is wasted. The current stresses on clinicians mean that improvement initiatives cannot simply add to a clinician’s workload or rely on the clinicians finding time to participate in additional initiatives. Rather, successful and sustainable improvement must involve reconfiguring the workflow and overall environment in which these professionals practice, which can help to reduce the burden of work while improving the performance of the system.

Making such changes in an integrated manner is the essence of systems engineering. Recent policies, deriving from the Affordable Care Act and the American Recovery and Reinvestment Act, have laid the groundwork for wider use of systems engineering through new care models that promote integrated care and rapid adoption of electronic health records. The National Quality Strategy identifies areas for improvement in health-care quality and outcomes that systems-engineering initiatives need to address. The current policy environment and advances in technical capabilities combine to make this the right time to focus on expanding systems methods and tools throughout health care.
What's not to love with respect to any of this? All good and necessary stuff. "Systems Engineering"? You can just hear the clucking sounds of approval among my gearhead colleagues at ASQ.

Factors Limiting Dissemination and Spread of Systems-Engineering Principles
Barriers to greater use of systems methods and tools include the lack of quality and performance measures and the misaligned incentive structure of the predominant fee-for-service payment system, which encourages a fragmented delivery system. To support needed change, the Nation needs to move more quickly to payment models that pay for value. These approaches depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign the process of care around the patient and bring community resources, as well as medical resources, together in support of that goal.

Another challenge is an organization’s leadership and culture, which determine people’s commitment to improvement efforts. [emphasis mine -BG] For example, one systems-engineering initiative achieved some success by using checklists to reduce infections among severely ill patients, but significant improvement did not occur until there was a culture where everyone felt they were able to speak up about potential safety concerns.19 Other barriers include technical challenges, workforce capabilities, and limited knowledge about what works.
The siloed nature of the health system, in which clinical care is separated in an uncoordinated fashion across multiple specialties and settings, presents another challenge that can limit the use of systems approaches. Clinicians often focus only on the activities in their particular silo, as opposed to considering the broader concerns of the patient. Moving away from the current siloed state requires systematic knowledge of the many processes and providers involved in a given patient’s care, as well as a cultural shift toward team-based care where all work together to address a patient’s needs...
Goal 6: Train Health Professionals in New Skills and Approaches
Given changes in the way health care is delivered and an improved understanding of the many factors affecting a patient’s health, health professionals of the future will need new skills to succeed. They will need effective communication and collaboration skills to work in teams, a commitment to lifelong learning to manage the flow of new evidence, and an appreciation and understanding of routine improvement methods. Expertise in systems engineering is especially critical as such tools can rarely be applied in a cookbook fashion, but rather need to be tailored to local circumstances to have the greatest chance of success.
Because systems science and systems engineering are central to improving health outcomes and health care’s performance, system sciences and systems engineering need to be much more firmly and formally embedded in the training of all health-care professionals. It is crucial that both the knowledge of systems science and the skills of implementing the principles in health care are emphasized. To this end, education must involve opportunities for interprofessional problem-solving and for building capacity for collaboration that facilitates practice change.

At present, clinical education and training falls short of this vision. Most clinicians were not trained in using systems-engineering approaches, and many clinicians may not even recognize that systems methods and tools could be helpful for improving care. Yet there are reasons for optimism. Several universities are leading the way by incorporating systems engineering directly into the curriculum for health professionals of all kinds (see Box 9 for an example of integrating systems engineering in nursing education). In addition to training clinicians about systems engineering tools, there is an opportunity to teach engineers about applying their tools in a health care environment. Some institutions have started internship opportunities for undergraduate and graduate students to work in hospitals and health systems, and others have begun joint classes where engineers and clinicians learn together about applying engineering concepts to care. More broadly, organizations such as the Accreditation Council on Graduate Medical Education (ACGME) have already taken steps under their New Accreditation System and the Clinical Learning Environment Review to spotlight the need for trainees to develop competence in systems-based patient safety and quality improvement related tools. The Association of American Medical Colleges (AAMC) is addressing the need to develop skills related to systems engineering in medical schools; the American Association of Colleges of Nursing (AACN) includes organizational and systems leadership as an essential element of nursing education, particularly at the graduate levels; the American Medical Association (AMA) has launched an Accelerating Change in Medical Education Initiative to expand training in systems based practice and practice based improvement; and multiple clinical certifying boards have included practice-improvement modules in their maintenance-of-certification process. These are all positive developments and lay the groundwork for further improvement...
Again, all good and necessary stuff. Systems Engineering? Check. "Interoperable" Health IT? Check. OK, what might be missing here?

Hint (from above):
"Another challenge is an organization’s leadership and culture, which determine people’s commitment to improvement efforts."
What is "culture" in the organizational context? How much does it matter?

"The way we do things around here"? That's a popular, succinct summary, one I first heard proffered by Dr. Brent James 20 years ago during our HealthInsight IHC healthcare QI training in Salt Lake City.

Dr. James also noted that "healthcare is both high-tech and high-touch," going on to state that patients are much less likely to litigate in the wake of an adverse outcome stemming from medical error if they feel they've been accorded the caring, "high-touch" component of treatment.

To the extent we fail to successfully address the myriad issues of "culture" dysfunctionality all too prevalent in healthcare, we will be stuck with a wobbly two-legged stool, irrespective of its technological, scientific, and "systems re-engineering" brilliance. See, e.g., some salient elements proffered my prior post "dx Machina."

Healthcare is necessarily a high-stress, endlessly high-cognitive-burden enterprise. There's no getting away from that fact. Moreover, it is likely to become ever more stressful, given the expected new demands on the system as money gets tighter, clinical science advances, populations age, and the PPACA brings new patients into the fold, and in light of the orders-of-magnitude increases in data availability wrought by Health IT (someone has to find time to turn data into clinically beneficial insights).

Healthcare -- at least on the clinical and administrative sides -- is also a milieu wherein there are relatively few entry level positions. "Human resources" (I hate that phrase), consequently, are literally precious. Misuse and turnover of talent comprise a significant, frequently crippling waste.

Recall Dr. Toussaint's "eight wastes" within the Lean model.

He added "unused talent" to Lean's traditional "seven wastes."
The 8 Wastes of Lean Healthcare
  1. Defect: making errors, correcting errors, inspecting work already done for error
  2. Waiting: for test results to be delivered, for a bed, for an appointment, for release paperwork 
  3. Motion: searching for supplies, fetching drugs from another room, looking for proper forms
  4. Transportation: taking patients through miles of corridors, from one test to the next unnecessarily, transferring patients to new rooms or units, carrying trays of tools between rooms
  5. Overproduction: excessive diagnostic testing, unnecessary treatment
  6. Over processing: a patient being asked the same question three times, unnecessary forms; nurses writing everything in a chart instead of noting exceptions
  7. Inventory (too much or too little): overstocked drugs expiring on the shelf, under stocked surgical supplies delaying procedures
  8. Talent: failing to listen to employee ideas for improvement, failure to train emergency technicians and doctors in new diagnostic techniques
Toussaint, John (2012-05-28). Potent Medicine: The Collaborative Cure for Healthcare (Kindle Locations 909-918). ThedaCare Center for Healthcare Value. Kindle Edition. 
My only lament here is that #8 does not get sufficient attention with respect to the broad, deep, and critical nuance it implies in terms of what I call the relative "psychosocial health" of healthcare organizations. You cannot effect and sustain high-performance teamwork in the healthcare delivery space where the culture is burdened by dysfunction ranging from the "bully culture" on down to the "merely" autocratic and/or "FUD" environment (Fear, Uncertainty, and Doubt").

apropos -
The Bullying Culture of Medical School
NY Times, August 9, 2012 12:00 pm
Powerfully built and with the face of a boxer, he cast a bone-chilling shadow wherever he went in the hospital.

At least that is what my medical school classmates and I thought whenever we passed by a certain resident, or doctor-in-training, just a few years older than we were.

With the wisdom of hindsight, I now see that the young man was a brilliant and promising young doctor who took his patients’ conditions to heart but who also possessed a temper so explosive that medical students dreaded working with him. He had called various classmates “stupid” and “useless” and could erupt with little warning in the middle of hospital halls. Like frightened little mice, we endured the treatment as an inevitable part of medical training, fearful that doing otherwise could result in a career-destroying evaluation or grade. But one day, one of our classmates, having already been on the receiving end of several of this doctor’s tirades, shouted back. She questioned one of his conclusions in front of the rest of the medical team, insisted on getting an explanation, then screamed back when he started yelling at her.

The entire episode unnerved us all; and over the next few weeks, we marveled at her courage and fretted over her potentially ruined career prospects. But there was one aspect of the event that disturbed us even more. One classmate who had witnessed the “screaming match” described how our fellow medical student had raised her voice and positioned her body as she threatened the doctor. “It was weird,” he recounted. “It was like watching her turn into him.”

For 30 years, medical educators have known that becoming a doctor requires more than an endless array of standardized exams, long hours on the wards and years spent in training. For many medical students, verbal and physical harassment and intimidation are part of the exhausting process, too.

It was a pediatrician, a pioneer in work with abused children, who first noted the problem. And early studies found that abuse of medical students was most pronounced in the third year of medical school, when students began working one on one or in small teams with senior physicians and residents in the hospital. The first surveys found that as many as 85 percent of students felt they had been abused during their third year. They described mistreatment that ranged from being yelled at and told they were “worthless” or “the stupidestmedical student,”  to being threatened with bad grades or a ruined career and  getting hit, pushed or made the target of a thrown medical tool...
While this example is by no means exemplary of all of healthcare, nonetheless the prevalence of psychosocially toxic healthcare workplaces is widespread enough to deserve much more of our attention (dictatorialism and "shame and blame" still rule in far too many circumstances). At its worst, it poses patient safety issues. Unduly stressed workers make more mistakes. At its most banal, it inexorably wastes talent -- Lean Waste #8. Workers will not be inclined to speak candidly and offer ideas for improvement in an environment where one speaks truth to power at one's peril, nor will they be motivated to become fully engaged members of the "high-performance team-based care" that simply must become the norm in the new healthcare space.

In the face of a dysfunctional healthcare work culture, the best talent will take their skills elsewhere at the first opportunity. A psychosocially healthy workplace, then, is a significant profitability and sustainability differentiator.

Let me repeat that.
A psychosocially healthy workplace is a significant profitability and sustainability differentiator.
The stool needs three legs. Perhaps the best that government can do is provide the technical assistance recommendations and resources and policy guidance legs, but the stool needs three legs. Period.


From my never-ending, endlessly growing reading list of late.

Maccoby's books caught my eye while I was attending the IHI 25 Forum back in December. I would make it and the other two depicted above required reading for every healthcare executive, manager, and physician. David Marx is the founder of the "Just Culture" methodology. It is not some touchy-feely Kumbaya thing. Marx is both an engineer and a lawyer, nationally respected in both aviation safety and patient safety. Bowles and Cooper are well-known authorities on organizational engagement.

to wit, from "The High Engagement Work Culture"
When we look at the cultures within our organizations, we cannot help but wonder how they affect day-to-day work life for hundreds of millions of people who work in them. To give just one example, if the “individual is hero,” how does that affect people who might be very good at their jobs but very poor at being “heroes”?

To examine these issues we have to look at what culture is within an organization, how it comes about and how it ultimately will determine whether or not our workers engage. This is a topic that is enjoying an explosion of attention around the world, from government reports on the subject, to fast-growing online communities, and for very good reason:

Work environments can be much improved, workers’ lives can be healthier and happier, our productivity can be raised and our standard of living protected … at the very least … if we become far more conscious at managing the culture, or “the way we do things” at work. Specifically, if we make that culture much more “engagement-friendly.”

Industry sector and culture 

An organization culture that might be successful in one industry could be a disaster in another. We would expect a hard-charging and risk-taking culture to be prevalent in the financial services industry (but with some changes to which we have already alluded) but such a culture would be bad news for the operators of nuclear power plants or hospitals. In the hospital, strict adherence to rules and procedures (such as infection control, triage, etc.) are key; not that the culture of medicine is one of no risk, but it is a carefully controlled risk. So we see the need to match the culture to the business one is in, leaving room for the unique features that leadership always brings to the table. This is why Dell is not Apple and Virgin Atlantic is not British Airways.
An organization’s culture rests on the shoulders of its top leaders, whether or not they created it in the first place.

If an organization wants to change its culture, it usually must change its leader( s). Time and again, we have seen new leaders come into organizations and completely turn around their cultures and their organization’s performance. We have also seen new start-ups forge what are clearly high engagement cultures from scratch, because of their leaders’ vision, force of personality and the most important (and most misused) factor of all: values.


With leadership and management levels, we looked at the structure of the organization and its relationship to organizational culture. But no culture comes into existence via structure alone: instead values breathe life into the structure and shape how things will be done. Values are one of the most important factors in any organizational culture and those values start at the top. Every organization has values whether they are written down or not. Some values are distributed widely and not just within the organization: for example, on every Starbucks Coffee Company cup and sleeve there are statements about the company’s commitment to “doing business in ways that are good to each other, coffee farmers and the planet.” Other organizations may have values that are unwritten and even unspoken but drive the internal culture nonetheless. The fact that some organizations have values that are regularly expressed verbally, written down and distributed widely such as on materials used by customers or in annual reports, does not always mean much: those values may not be lived at all. Not uncommon is the company that states a particular value, but when we have surveyed those people, we find just the opposite. Such things can make one cynical, and can also be the subject of wickedly accurate cartoons such as that by Garry Trudeau’s Doonesbury, which is well worth a click-through due to its timely connection to the financial services Crash! 4 Values, then, are easier said than done.


As a living and breathing thing, culture therefore both affects and depends on whom you bring into it. Far better to take the time and pick someone who will fully support your culture from day one, rather than compromising and think that that person will “come around” with time. Smart organizations know this and go far beyond talent and skills in their recruitment activities. Picking the right people to work for you, and picking or promoting the right ones as managers, coaches, supervisors, mentors, whatever you call them, is a crucial cultural effort that will pay big dividends going forward. It will be an incredibly important determinant of whether your organization’s culture can be successful. When the factors driving culture in the organization reach the workforce, the stage is set for whether those people will engage or not, which is something we will expand on extensively further. This in turn will serve to enhance— or detract from— the performance of your organization.


Work culture and worker engagement are a core part of the makeup of those places where we spend so much of our lives, and ultimately determine much of how we feel at work and whether we and our organizations are successful. Inevitably national cultures have an impact, as we have seen, but this is less and less as globalization creates the situation where our organizations straddle the boundaries between countries. India-born managers show up in the UK as they do in the US, and bring their fresh ideas and experiences with them. Young US and British workers go to Bangalore for a unique experience and the invaluable learning that occurs when one leaves one’s own culture. Chinese companies and their managers are showing up around the world, like their Japanese counterparts did decades ago, as China extends its influence. We all learn from each other, and find out that no one national culture has all the answers when it comes to organizational culture and engagement.
What we do know is that all work cultures are not created equal: we see the Apples, Googles, Virgins, Tata Motors and others, and know that they have something special, which goes beyond engineering or finance or strategy. They have a culture that produces and sustains that great engineering and marketing and customer service and makes their people excited to work there and to contribute.

Worker engagement is no simple topic, involving as it does the rich mosaic of contributing factors we have examined. Some of these can be controlled (whom we hire or promote, the culture we create inside our organizations), others we can only work with, react to and mitigate (the economy, national cultures, etc.). But even in reactive mode such as during the 2008 Crash we have choices, some of which will themselves be creators of favorable environments for engagement, and some will not. As we have seen, most countries not in the emerging areas of Asia have their work cut out for them, in regard to worker engagement. Levels of engagement are not especially high across large areas of the developed world, and many have slipped as the effects of the Crash played out; we have also seen why this is so important, in terms of lost productivity and competitiveness. This is hardly the time to be slipping, as competition heats up to unprecedented levels.

While we have covered the drivers of work culture and engagement in some detail as we moved from national to organization to individual levels, we have only hinted at one of the most significant ones, playing its role relentlessly and often outside of many peoples’ conscious awareness. It occupies a unique space in that it can clearly be said to have played a role in both the Crash, and in ongoing low worker engagement around the world. It is the ego.

Bowles, David; Cooper, Professor Cary (2012-05-31). The High Engagement Work Culture: Balancing Me and We (pp. 20, 24, 25, 29-30, 5454). Palgrave Macmillan - A. Kindle Edition.

David Marx:
Whack-a-Mole is also a metaphor for modern life. It’s a game we play with each other—particularly here in the U.S. It’s how we respond to predictable human fallibility. It’s how we set expectations of each other, how we respond when our fellow human being makes a mistake. Whack-a-Mole...
The mole in these examples is the adverse event, those outcomes in life that just don’t seem to be what we wanted. They’re created most often by the mistakes we make, missing that stop sign seemingly hidden behind an old elm tree, addressing that sensitive e-mail to the wrong person, forgetting that the gas nozzle is still connected to the car when we pull away from the gas pump. In the aftermath of these mistakes, both catastrophic and relatively benign, we take the easy route: How bad was the harm? Who touched it last? Who is to blame? Who is to pay? As adults, we push our need for “justice” to the point that every adverse outcome in life must have an accompanying blameworthy human behind it. It’s the game of Whack-a-Mole. 

It’s a game that costs us dearly. We’re all poised to pounce, caught up in the adult version of Whack-a-Mole, with the media all too willing to help swing the hammer even before the investigation has started. Bad outcome must mean bad actor. Whack that bad actor and the game is won...
The statistics are these. You have a one-in-21 chance of dying from accidental causes in your life. That’s a one in 1,600 chance of accidental death per year. It’s a one in 584,000 chance you will accidentally die today, all things being equal. 

The greatest threat to your inadvertent demise is a medical mistake—one of our hard working doctors, nurses, or pharmacists making a mistake. Some reports say medical errors lead to 200,000 lives lost per year in the U.S. alone. Consider this: for every one person who dies in war, four will die in automobile accidents. And for every person in the U.S. who dies in an automobile accident, four to five will die from a preventable medical mistake. Nowhere in life’s endeavors does our human fallibility lead to so much harm. 

On January 25, 2000, Dr. Lucian Leape, a Harvard professor of health, testified before Congress on what he saw as the state of healthcare safety in the U.S. He told Congress that the single greatest impediment to error prevention in the medical industry is that “we punish people for making mistakes.” A co-author of the Institute of Medicine’s (IOM) report, To Err is Human, Leape cited that study’s estimated 44,000 to 98,000 annual deaths that are caused as a result of medical error alone. He said that healthcare providers would often only report what they could not hide. The process is simple: doctors make mistakes, professional boards take licensing action, and newspapers demonize the dedicated professional who made the mistakes. Case closed. Problem solved. Mole whacked—although we haven’t learned anything about what we can do better...

Whack-a-Mole may be addicting for its simplicity, but it’s not a productive way to deal with adverse events. Whether it’s our attitude toward spilt milk at the dinner table or our attitude toward the airline pilot who misses an item on a checklist, we simply cannot believe that an expectation of perfection will get us the results we want. We spend far too much time looking at the severity of the adverse outcome (how bad was it?) and who was the unfortunate soul to be closest to the harm. In turn, we spend far too little time addressing the system design that got us there and the behavioral choices of the humans in those systems that might have ultimately contributed to the adverse outcome. It’s called Whack-a-Mole... the hectic, fast-paced world of healthcare, thousands of patients suffer from adverse drug events every day. Some of these events are simply the statistically predictable side effects of the drug/human interaction. Others, however, are the result of error. 

Human error. Your doctor may write down the wrong drug or the wrong dose. She might write the order for the wrong patient. A pharmacist might make the medication mistake and dispense the wrong drug or dose. Nurses can draw up the incorrect dosage into a syringe or deliver the medication to the wrong patient. Or it may be the patient who does not read the medication label, or even after looking at the instructions, makes a simple measurement mistake that leads to the adverse drug event. 

The healthcare industry refers to those events involving human error as “medication errors.” They occur every day around the world. In some cases, patients and their doctors will never know they’ve experienced a medication error due to the body’s ability to adjust to the unintended drug or dose. In other cases, it may mean an extended hospital stay to correct this new healthcare-caused condition. In the worst cases, the patient dies as a result...

What do we do when things go awry? We face a two-fold challenge: 1) hold those who caused the event appropriately accountable, and 2) make fixes to prevent future events. What we will see is that these two goals are often at odds with each other. And when Whack-a-Mole rules the day, the prevention of future events takes a back seat. As Lucian Leape said, the single greatest impediment to safety is that we punish people for making mistakes. In healthcare today, as with any industry, from aviation to children’s day care, potential responses to the individual who makes the mistake run the gamut from termination to license revocation, from criminal indictment to civil lawsuit. 

Marx, David (2012-06-06). Whack-a-Mole: The Price We Pay For Expecting Perfection (Kindle Locations 64-174). By Your Side Studios. Kindle Edition.

Marx in a nutshell here:
  • Console the human error.
  • Coach the at-risk behavior.
  • Punish the reckless behavior.
  • Independent of the outcome.
It’s a path that we see innovative regulators and corporate managers beginning to take. It’s known in high consequence industries, such as aviation and healthcare, as a “just culture.” We teach our employees that we are all fallible human beings. We expect them to learn from their mistakes, to help us design the safest possible systems around them, and we expect employees to try to make the safest possible choices in those systems. It’s about setting aside the severity of harm and the actual inadvertent errors, and looking instead to the quality of the systems we have designed and the quality of the choices made in those systems. Console the error, coach the at-risk behavior, punish the reckless. Then, get on with the task of building a better system: changing performance shaping factors that subtly alter the rate of human error; adding barriers to prevent some classes of error; adding recovery steps to catch errors downstream before they lead to harm; and incorporating redundancy to minimize the impact of a failing system—these are the efforts that are going to produce better outcomes... (Kindle Locations 636-647).
You just have to study the entire book. It's excellent.


Michael Maccoby's book could serve as a graduate semester text in "Leadership for Healthcare QI." Among other things, Maccoby and Marx are Deming 101.
Learning and Continuous Improvement 
People on all levels of an organization may have ideas to improve processes, increase efficiency, or cut costs. In most organizations, they don't communicate their ideas, because they don't believe anyone is listening. Typically, suggestions put into a suggestion box don't lead to results. A lower-level employee opens the box and has to decide about passing the suggestion up the hierarchy. If the suggestion means criticizing someone or changing their practices, it is better not to stir a hornets' nest. The suggestion goes nowhere. 

All too often executives are surrounded by courtiers who flatter rather than challenge them. An example: a CEO was presented with survey findings that reported wide distrust of top management by the rest of the organization. He turned to his VPs and said, “This can't be true. I go around and talk with people all the time, and no one has told me this.” The VPs, who knew that no one, including themselves, dared to bring bad news to the CEO, all agreed that there must be something wrong with the survey or the way the questions were phrased. 

Furthermore, experts will often resist new knowledge that devalues their experience and expertise, and few experts are willing to learn from anyone other than a certified subject matter expert. Maccoby was once introduced at a meeting of telecom engineers as an expert on leadership, with the implication that anything he said on any other subject should be discounted. 

Being open to ideas regardless of their source can lead to improvement innovation. When Maccoby visited a Toyota factory in Nagoya, Japan, a supervisor told him that he had received an average of fifty ideas for improvement per year from each member of his team and 85 percent were implemented. This remarkable result was achieved by instituting a process whereby all ideas were evaluated weekly by a team of supervisors. Ideas might be as simple as improving illumination or expanding a particular job. When ideas were implemented, workers received points which could be used for rewards such as dinner for a couple. 

You cannot expect that experts at any level will transform themselves and become respectful to nonexperts and be willing to learn from them, whether they be employees, customers, or patients. To learn from everyone in an organization, you must establish processes for continuous improvement that are integrated with the organizational system and the practical values that further its purpose. 

People will also resist change when it challenges their values or interests. They become closed to learning, and they ignore or find reasons to distrust evidence that conflicts with their beliefs. Some physicians at a medical school refused to consider changing their practice to adopt proven pathways, saying that the vice president who was promoting evidence-based medicine was only interested in saving money, not caring for patients. To overcome this resistance, the vice president had to clarify his philosophy, emphasizing that his purpose was both better care and cost savings and that the practical values needed to achieve this purpose included evidence-based practice and continual learning. 

Of course, people can also resist knowledge that threatens their interests. Typically, product managers at companies resist learning about and supporting innovations that will draw customers away from their products. IBM had to create a new business for laptop computers located far from the managers of mainframes who felt threatened by the new product and who argued that it had no future. In similar fashion, a Norwegian oil company had to create a new company to protect ships that explored for oil from the managers of the much more costly platforms who saw the ships as a threat to their control of oil exploration. 

Fear— whether of losing money, power, status, or of being punished for mistakes— blocks learning. Health care providers learn from morbidity and mortality rounds, but they will resist reporting mistakes and learning from them if they are punished for honest mistakes. 

Organizations will learn only if, as Deming emphasized, leaders drive out fear...

Maccoby, Michael; Norman, Clifford L.; Norman, C. Jane; Margolies, Richard (2013-07-29). Transforming Health Care Leadership: A Systems Guide to Improve Patient Care, Decrease Costs, and Improve Population Health (Kindle Locations 3611-3645). Wiley. Kindle Edition. 
The Leader as Learner and Teacher 
The best leaders are passionate learners. When needing to decide about developing a new product or acquiring a company, GE CEO Jack Welch wanted to learn everything he could about the matter. He would take what he called a “deep dive” into the available material. Microsoft CEO Bill Gates took two weeks off each year to study a new area. When he heard of a new surgical technique, William Mayo would go to where it was being practiced and stay there until he had learned it. He would then return home to teach the technique to the surgeons at his clinic. 

However, in a complex health care organization, leaders cannot know everything they would like to know to solve problems and make decisions. They need to combine humility with confidence. Humility means that they don't have to know more than anyone else, that they are willing to learn from others. It is also recognition that they may never have all the information needed to make a rational decision. But leaders also need to develop confidence that they can learn enough to make good decisions, and to modify their theories if necessary. 

The leader of a learning organization will be a mentor and teacher who motivates others to learn by driving out fear, welcoming new ideas, and instituting processes that facilitate learning. These include open dialogue where no one fears punishment or humiliating put-downs. Also, experiments that test new approaches will be encouraged. Everyone in the organization will learn that all work is a process that includes planning, doing, evaluating or checking, and acting or adapting according to what has been learned. More important, everyone should learn how their work processes and roles contribute to the achievement of the organization's purpose. 

The leader will communicate a philosophy with values that determine decisions. But he or she also will be a principled pragmatist who tests these values to make sure they further the organization's purpose and produce the expected results. And if they don't, the values will be modified. In this way, the leader will model the qualities essential for continual individual and organizational learning. 

Information in a bureaucracy is supposed to flow upward to the executives who should make decisions. The leader in a bureaucracy is supposed to be the person who has all the answers. In contrast, information in a collaborative knowledge organization is constantly accumulating on the front lines. The challenge for executives is to learn from people who are closest to the customers, patients, and clients. Leaders will not learn unless they are able to ask useful questions and use the learning to help design effective processes... (Kindle Locations 3808-3830).

Recognizing successful use of systems engineering— 
Baldrige Performance Excellence Program

The National Institute of Standards and Technology (NIST) Baldrige Performance Excellence Program is a U.S. public-private partnership program designed to recognize and promote performance excellence. The program was established to identify and recognize high-performing companies, develop criteria for evaluating improvement efforts, and share best practices broadly. The Baldrige program raises awareness about the importance of performance improvement and provides tools and criteria to help organizations undertake that work. The program was expanded to include health-care and education organizations in 1999 and to nonprofit/government organizations in 2005. 

There are seven categories of criteria to help organizations identify their strengths and opportunities for improvement: leadership; strategic planning; customer focus; measurement, analysis, and knowledge management; workforce focus; operations focus; and results. The criteria focus on results—not procedures, tools, or organizational structure—in order to encourage creative, adaptive, and flexible approaches. Most importantly, the criteria support a systems perspective both to align goals across an organization and to encourage cycles of improvement with better feedback between improvement initiatives and its results. 

Over the past decade, an increasing proportion of these awards has been to health-care organizations. Last year, all of the winners were from the health-care and education sectors, which shows the appetite for improving the ways health care is organized and delivered.

From the current Baldrige Health Care Criteria document. Below, note the areas of [1] Leadership, and [2] Workforce Focus (annotation mine).

1. Leadership (120 pts.)

The Leadership category asks how senior leaders’ personal actions guide and sustain your organization. It also asks about your organization’s governance system; how your organization fulfills its legal, ethical, and societal responsibilities; and how it supports its key communities...

1.2a(2). The evaluation of leaders’ performance might be supported by peer reviews, formal performance management reviews, reviews by external advisory boards, and formal or informal feedback from and surveys of the workforce and other stakeholders.

1.2b(2). Measures or indicators of ethical behavior might include the percentage of independent board members, instances of ethical conduct or compliance breaches and responses to them, survey results showing workforce perceptions of organizational ethics, ethics hotline use, and results of ethics reviews and audits. They might also include evidence that policies, workforce training, and monitoring systems for conflicts of interest and proper use of funds are in place.

 5. Workforce Focus (85 pts.)

The Workforce Focus category asks how your organization assesses workforce capability and capacity needs and builds a workforce environment conducive to high performance. The category also asks how your organization engages, manages, and develops your workforce to utilize its full potential in alignment with your organization’s overall mission, strategy, and action plans...

5.2. “Elements that affect workforce engagement” refer to the drivers of workforce members’ commitment, both emotional and intellectual, to accomplishing the organization’s work, mission, and vision.

5.2a(2), 5.2a(3). Understanding the characteristics of high-performance work environments, in which people do their utmost for their patients’ and other customers’ benefit and for the organization’s success, is key to understanding and building an engaged workforce. These characteristics are described in detail in the definition of high-performance work (page 46).
5.2a(3). Compensation, recognition, and related reward and incentive practices include promotions and bonuses that might be based on performance, skills acquired, and other factors. Recognition can include monetary and nonmonetary, formal and informal, and individual and group mechanisms. Recognition systems for volunteers and independent practitioners who contribute to the organization’s work should be included, as appropriate.

5.2b(2). In identifying improvement opportunities, you might draw on the workforce-focused results you report in item 7.3. You might also address workforce-related opportunities based on their impact on the results you report in other category 7 items.

5.2c. Your response should include how you address any unique considerations for workforce development, learning, and career progression that stem from your organization. Your response should also consider the breadth of development opportunities you might offer, including education, training, coaching, mentoring, and work-related experiences.
I served on a HealthInsight team in Nevada in 2006 that performed a state-level program Baldrige model assessment of a hospital, for the "Nevada Governor's Awards for Performance Excellence" (a program I co-founded), so I can attest first-hand that Baldrige Criteria are comprehensive, exhaustive, and useful for assessing the health of an organization.

Were an enterprise to synthesize a Maccoby/Marx/Bowles-Cooper methodology for "Workforce-Focused, Just Culture Leadership," it would likely sail right through these sections of the Baldrige Criteria assessment with high scores.

More importantly, it would likely also have a big leg up on the competition.


With regard to all of the foregoing, it helps to recall some of the questions posed by consultants and authors Julie Winkle Giulioni and Beverly Kaye:
Do you want to
  • Raise engagement levels?
  • Uncover and activate previously unknown or underutilized talents that can help the business?
  • Establish a culture of continuous learning and development?
  • Build the skills and knowledge needed so employees will be prepared when broader moves become available?
  • Generate loyalty and the kind of leadership reputation that will have the best talent standing in line to work for you?
Then "Help Them Grow, or Watch Them Go."


More to come...