Warning to readers: This post, like a previous post, Gotcha: A surgeon dissects patient-centered care, contains more rant than reason.  Those who feel passionately that Congress is doing a great job dealing with the people’s healthcare should look elsewhere for confirmation of their views.

In An Interview with Stuart Altman, this distinguished healthcare economist mentioned Altman’s Law, that  advocacy groups seek to preserve the status quo rather than adopt another plan that might disadvantage their interests.

January 21, 2010, in Citizens United v. Federal Election Commission, the Supreme Court voted 5-4 to remove limits on contributions from corporations and unions for “electioneering communication.”  Hailed by some as a victory for the First Amendment right of free speech, to at least one skeptical surgeon, it means that free speech just became more expensive, as limitless contributions pour in to influence 535 votes.

Kudos to David Harlow for getting it right in his commentary, Holy Mackarel: Scott Brown, Health Reform Redux and What Can (Should) Happen Next: “it is time to think about other avenues towards the improvement of the health care system in this country.”  Reform efforts will go on while Congress is embroiled in partisan gridlock.  As David mentioned, states have become the learning laboratories.

Medicare demonstration grants in Colorado, New Mexico, Oklahoma, and Texas continue to investigate the merits of value-based purchasing of healthcare services.  Patient-centered medical home projects, as described in Engaging Physicians to Adopt Healthcare Information Technology, represent a continuous, proactive, consumer-directed approach to care coordination.

In My Inadvertent Oncology Fellowship: Why I Remain Optimistic About Healthcare, I concurred with fellow Massachusetts surgeon Dr. Atul Gawande, that healthcare reform embodies an iterative journey, where we test different hypotheses in our learning laboratories, because no one has sufficient knowledge to assert that one way of delivering care will work for all our citizens. Dr. Gawande concluded in Testing, Testing:

But if we’re willing to accept an arduous, messy, and continuous process, we can come to grips with a problem even of this immensity. We’ve done it before.

As I mentioned in “Embracing Complexity,” in Better Communication For Better Care: Mastering Physician-Administrator Collaboration, face-face conversations are the only sustainable way that people can deal with complex situations in which predictability is diminished, experience does not guarantee success, and relationships are key. 

Complexity facilitates interest group politics, as members on all sides struggle to convey their message in 30 seconds or less.  In Collaborative Sensemaking, I described the critical role that healthcare leaders must play in interpreting and explaining disruptive marketplace changes and framing what is required for successful healthcare delivery.

Finally, I thank my mentor, Lee Kaiser, who in Collaborative Gnosticism, wrote:

Most people and most organizations see themselves at the center of the universe, which leads to egocentric, self-interested approaches that facilitate exploiting others for competitive advantage, hardly a sustainable approach to differentiation and the service of others… There is no economic, social, or political solution to the current healthcare crisis.  Spirituality, based on abundance, collaboration, and sharing provides the only solution because it makes problems disappear.

As always, I welcome your input to improve healthcare collaboration, even if sometimes I feel (to paraphrase Churchill) that we embrace it only after we have exhausted all other alternatives.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content.  I have no material connection to the brands, topics and/or products that are mentioned herein.  David Harlow is a friend, colleague, and coauthor with me of Field-tested Strategies for Physician Recruitment and Contracting.  Please check out his HealthBlawg.

In Candid Reflections on Bad Behavior, I reflected on the recently published ACPE Doctor-Nurse Behavior Study, in which 2,124 physicians and 696 nurses participated.  Nearly 85% of respondents experienced degrading comments, 73% yelling, 49% cursing, and 38% refusing to work together.

Those of you who have been with me know that I am on a continuous healing journey from being labeled “the problem” to helping find solutions.  Please let me recount a painful lesson from my third year of residency. At 3 AM, after being up over 20 hours, I was asked to evaluate a patient with acid burns of the face, and when I said that we needed to get the patient to a shower immediately to wash off the acid, the triage nurse told me, “Our protocol does not allow an acute patient to be transported out of the ED.”

I lost it. Instead of saying, “Let’s take care of this patient’s acute needs to get the acid off his face and discuss revising the protocol in the morning,” I let her know what I thought about her protocol and took the patient to the nearest shower in the OR changing room.  When I returned with the patient, I learned that I had been reported for swearing at a nurse in front of a patient.

Caught in a “Gotcha” moment, I apologized to the nurse, her boss, the ED Director, the Chief of Surgery, and my program director, to name a few.  Through this incident, I learned that leaders need to remain calm in crises, so that team members can function at peak efficiency.  I also learned not to fight at night and told the story to all residents who would listen once I became chief resident and Assistant and Associate Professor of Surgery, hoping that they would learn from my mistake.

At the end of my residency, I presented a talk at the Society of University Surgeons, entitled “Misadventures in surgical residency: Analysis of mistakes during training” (Current Surgery 42:278-285, 1985).  It was the only talk in which I had a standing room only crowd.  As one surgeon told me, “Everyone wants to hear others admit their mistakes.” 

When asked to comment on my presentation, my program director, Dr. William McDermott, replied, “I have thought of the third year of surgical residency as the peri-menopausal year because residents are in between, no longer interns or junior residents but not yet trusted to do senior-level work.” Later, he reflected on his distinguished career in academic surgery with this wise counsel:

For all of us in healthcare, it is a privilege to be asked to serve.  It means that someone else values what we do and that we can lend a personal touch to the task which we have been assigned.  But after a while, our eagerness to please takes its toll.  We find that, like burrs, things stick to us, and we cannot get away from them without confronting people or leaving to take another job.  So, you might say that we all have the seeds of self-destruction planted within us.

Then,  he smiled at me and said:

Just because we have the seeds of self-destruction planted within us, does not mean that we need to drink Miracle-Grow.

As Thanksgiving approaches, I feel blessed to have benefited from a wonderful mentor like Dr. McDermott.  He is the principal reason that I have devoted time to teaching fellow physicians how to mentor newly hired physicians and why I was proud to write an article showing that teaching physicians to be better mentors improved physician retention significantly (The Lifelong Iterative Process of Physician Retention).

What do you think?

• Has your career benefited from others making the time to mentor you
• How have you reciprocated
• What stories can you share about the co-mentoring process, in which we learn from sharing knowledge and experiences with others

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

PS: This will be my last blog for 2009.  My son, a senior at Purdue in the Naval Reserve Officer Training Program, will begin his Naval aviator training soon.  Our focus will be on family from Thanksgiving through the end of the year.

I join with thousands of others decrying the violence that took the lives of our troops at Fort Hood yesterday.  My heart goes out to their friends and families.  I pray that something will come of this event that will prevent a similar crisis from ever happening again.

The parallel with healthcare is what compels me to write today.  Laurence Barton, who was VP for crisis management at Motorola, calls sabotage the undisclosed crime in Crisis Leadership Now: A Real-World Guide to Preparing for Threats, Disaster, Sabotage, and Scandal. 

He wrote that today’s saboteurs take many forms that are not easy to identify.  People with access to an organization pose a great likelihood of compromising safety. Colleagues may hesitate to report statements or incidents because they fear embarrassment if they are wrong or retribution if they are correct, leading to inaction until it becomes too late to prevent a tragedy,  similar to what happened at Fort Hood. 

Clearly, there is no way except in retrospect to know when a crisis will hit.  Therefore, it behooves all of us to prepare.  Ian Mitroff and Gus Anagnos wrote in Managing Crises Before They Happen that organizations should review their vulnerability in the following six major areas:

• Economic, for example,  events stemming from the current recession
• Information, for example, loss of proprietary data or protected patient health information
• Physical, for example, a machine that works improperly that puts patients’ and/or employees’ health at risk
• Human resource, for example, loss of key personnel in an accident or due to a pandemic
• Sociopathic, for example, terrorism, kidnapping, or baby abduction
• Natural disasters, for example, fire, flood, tornado, or hurricane

We need a systematic approach to crisis management because in today’s complex interlinked environment, crises in one area may spread to others, for example, a flu pandemic in which 30% of healthcare workers are unfable to work, that compromises patient safety due to inadequate staffing. 

When I traveled to China in 2006 to speak at The First People’s Congress on Healthcare Communication, I learned that two Chinese characters symbolize The English word “crisis”: danger and opportunity.  The opportunity here lies in breaking down siloed communication and providing a forum where all stakeholders, including physicians, can make their complementary views known.

What do you think?

• Although it is natural to attribute blame when something goes terribly wrong, what are the systemic things that we can do ahead of time to prepare for and possibly prevent sabotage and other crises where we work
• Have you experienced situations where one crisis led to another
• Years afterward, what positive aspects emerged from going through a crisis with your coworkers

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

As I described in Dealing with a Medical Staff in Crisis, I have witnessed the power of independent community physicians to affect hospital revenues and hiring.  The quickest way to explain how we got to this point, is to refer to Maslow’s Pyramid, where each party took a lofty view of its own goals (self-actualization, at the top of the pyramid) and a skeptical view of the other side, dismissing their concerns as selfish and disrespectful.  In retrospect, each party faced survival issues (at the bottom of the pyramid).  The community physicians cannot pay their practice expenses based on outpatient visits alone because of the payor mix in this urban community; the hospital relies on admissions from indpendent community physicians to provide inpatient care to community residents and workflow for its employed physicians and allied healthcare professionals. 

As I mentioned in Collaborative Uncertainty, hospital leaders walk a tightrope of providing leadership and reassurance in times of crisis while showing that they are listening actively and remaining open to new ways of thinking and acting.  During this engagement, I learned the importance of acknowledging past perceptions of injustices and at the same time, moving forward.  The physicians whom I interviewed stated repeatedly that they did not want to hear more words, but wanted to see action to improve their situation.

In Collaborative Revolution, I alluded to Peter Senge who wrote that rather than tell people that their thinking is outmoded, we need to reflect on our assumptions, so that we can see the underlying forces and the opportunities on which we can capitalize rather than resort to blame-storming and finger-pointing. If it were easy, there would be no need for consultants and blog posts like these.

In Collaborative Learning, I pointed out that physicians’ training to make a unifying diagnosis makes it difficult for us to deal with occasionally conflicting polarities like long-term and short-term or patient survival and organizational survival.  Becoming more comfortable with paradox is a lifetime learning journey.  Collins and Porra in “Built to Last: Successful Habits of Visionary Companies” quoted F. Scott Fitzgerald, “The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time and still retain the ability to function.”

What do you think?

• Can a modicum of physician dissatisfaction drive productive change that improves processes and care for our communities
• Is some of our current dissatisfaction rooted in non-medical issues, like the recession
• If we are all in this boat together, where do we go from here to refocus on the patients and families who rely on our teamwork

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

I had the pleasure last weekend of attending The Future of Medicine: An Expert Diagnosis, at my alma mater, the University of Rochester.  Here I am introducing Dr. Mark Taubman, the Acting CEO of the University of Rochester Medical Center.

Other Panelists included: Paul Keckley, Executive Director, Deloitte Center for Health Solutions, Daniel Sisto, President, Healthcare Association of New York State, and David Klein, CEO of The Lifetime Healthcare Companies, below.

Mr. Keckley pointed out that over 60% of our $35 trillion national debt is healthcare related.  So far, the US economy has shed over 6 million jobs during our current recession, but healthcare has added approximately 300,000 jobs over the same timeframe.  Decreasing healthcare costs by 1.5% per year for 10 years would save approximately $3 trillion.

Mr. Sisto, summarizing the events of last summer, defined a myth as a popular belief or tradiditon that serves to explain the mindset or world-view of a group.  He described politics as the manipulation of people by playing into their myths.  He described the maneuvering that is taking place, even though Democrats hold 256 seats in the House of Representatives, because 57 members of the Progressive Caucus, committed to the passage of the public option, are balanced by 52 Blue Dog Democrats, who resist activities that enlarge government.  Furthermore, 49 House Democrats were elected from districts that voted for John McCain in the 2008 Presidential election, making them wary of appearing to overreach. 

He also explained that one reason for the difference in cost of the Senate Finance Committee Bill (approximately $829 billion) and the House bills (approximately $1.2 trillion) is that the House provides a 10-year fix to Medicare physician fee cuts, but the Senate bill addresses only the first 2 years.  Without intervention, Medicare payments to physicians will be cut 21.5% in 2010.  In 2007, Medicare accounted for 17% of Federal spending, and Medicaid accounted for 7% of Federal spending.  To learn more about differences between the current House and Senate bills, please read Rehabilitating Healthcare in the LA Times October 14, 2009.

Mr. Klein pointed out that the current legislation before Congress does not provide significant cost containment.  Approximately 3/4 of the average annual family policy cost of $12,700 is borne by employers.  As Medicaid coverage expands, states face either cutbacks in other budget categories or increased income and/ or property and sales taxes to fund this expansion. 

Despite the challenges, the panelists made me feel that the future of US medicine is bright, provided that we can identify and implement ways to decrease waste and inappropriate care.  This panel summarized a great deal of data into actionable information.  I thank the panelists for traveling to Rochester to educate us on the challenges and opportunities that we face in the coming months and apologize if I have misquoted them or left out any important information in this brief summary.

What do you think?

• Do you find the current state of affairs confusing regarding healthcare reform
• Do you feel that the healthcare cost pressures we face are unsustainable
• Do you find that the opportunities for reform balance the current challenges

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

As I reflect on major insights that I have experienced over the past three decades, most have arisen from talking with women:

• In Nursing Collaboration, I celebrated Nikki who took me aside during a busy ED shift and told me, “Just because this is the 7th patient you have seen with a sprained ankle in the past hour, does not mean that it was her 7th ankle sprain.”
• In the same post, I also mentioned the 10 nurses who told me that the aim of a residency program in surgery should be to teach communication skills, not just technique and surgical judgment, which has guided my career path ever since
•  In Collaborative Gender Issues, I mentioned that I felt like I was hit by a 33-degree wave when I heard that women are socialized to value relationships for the first time in an Organizational Behavior group discussion

I felt similarly humbled a couple of weeks ago in Chicago, where I spoke on “Practical Strategies for Transitioning to Non-Clinical Careers” and mentored physicians taking the SEAK Non-Clinical Careers for Physicians course, that approximately 250 physicians attended.  I described the environment in Tip of the Iceberg? New perspectives on disgruntled doctors, in which I mentored over 50 physicians in 15-minute segments until my talk the second afternoon.

I asked a rural surgeon who came to me for guidance, “When was the last time that you felt really alive?” trying to uncover his passion.  He looked at me blankly, “I don’t know.”

I replied, “Some times, when guys can’t remember, their wives can.  How do you think your wife would answer that question?”

“I don’t know,” he replied. “Can I go back into the lecture hall and get her?”

“Sure,” I replied.  “I can’t wait to hear what she says.”  It turned out that she  was also his office business manager, which meant that they spent over half their waking hours together.  She told me, “His passion left him years ago.”  He nodded, sadly.

In the remaining 10 minutes, we talked about what he was really good at: teaching.  Gradually, I saw a smile appear on his face and some light sparkle in his eyes, as his energy began to return.  He made a decision that once he moved closer to his grandchildren, he would contact the local medical school and offer to teach anatomy to medical students.  He left feeling that he now had a reason to get up every morning, which brought him hope.  A day later, as we departed for the airport, his wife told me, “Although he still spends more time telling me what he doesn’t want to do than what he does want to do, at least after this weekend, he has at least one thing that he wants to do.  Thank you.”

As I waited for my plane to take off, I felt grateful to have a weekend “with my people.” I mused that physicians are not leaving the profession solely due to the economic costs of running a practice, as a recent CNN article stated, but also because they have lost touch with the feelings that attracted them to healthcare careers in the first place; to make a difference in the lives of patients and their families.

At a transition point in my career, when I lost my academic job due to a budget cut at the VA at White River Junction, VT and prepared to attend the MBA program at the Tuck School at Dartmouth, most of my male colleagues told me that I was wasting my  surgical oncology and reasearch training and should look for another academic job, even though my wife did not want to move.  On the other hand, at least 10 female nurses told me that as one door closed, many others would open and that I would enjoy a career where I was able to bring a variety of strengths to play that were not highly valued in my present job.  When I asked the 10th nurse why she thought that there was such a difference in replies, she stated:

Women are hard-wired to deal with change.  Some of us go from college to jobs to marriage and raising a family, but no matter what we do, change happens to us every day, so we learn to embrace it rather than fear it or fight it .”

It is times like the ones I have described in this post that make me want to celebrate the 23 chromosomes that derive from my maternal DNA.

What do you think?

• Do you work with physicians who no longer enjoy coming into work
• Have you asked them what are they really good at and what makes them feel truly alive, as Jim Collins advised in Good to Great
• If so, what did they tell you

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

In residency, I learned that it is a sign of strength to admit ignorance and ask for help.  While  writing my latest column  for the Journal of Healthcare Management on Innovation in the Face of Recession, I realized that  little has been written recently on that subject in healthcare.

 So, I asked respected thought leaders what they were doing and what was working.  I ended with the following question:

• If you could be granted three wishes, what would you request?

Their responses fell into several thought-provoking clusters:

• Regarding healthcare reform, over one third wished for a more efficient system that decreased red tape and made it easier for people to collaborate inside and outside their organizations.  Such collaboration included sharing information about outcomes and improvement programs that worked as well as aligning incentives, so that we have a system of interdependent parts rather than a collection of cottage industries.  In Collaborative Conversations, I wrote that the challenge of any meaningful healthcare reform efforts is the extent to which they engage healthcare professionals to make a difference in patients’ and families’ lives.
• The above response tied into to their wish for a nationwide information network that would help providers and organizations be more accountable for outcomes and help them integrate care throughout the inpatient/outpatient continuum.  As one respondent wrote, “Know more, act prudently, measure outcomes.”
• Physician staffing also entered into their responses, especially primary care providers and orthopedic surgeons.  As I mentioned in Field-tested Strategies for Physician Recruitment and Contracting, not only are patients aging and their care needs becoming more complex, but health care providers are aging along with them, and younger physicians tend to have different expectations about work-life balance than colleagues who were born before 1965. Of the physicians practicing in 2005, 36% were at least 55 years old and over 15% were at least 65 (Cohn KH. Harlow DC. Journal of Healthcare Management. 2009; 54(3):151-158).
• Several participants wished for patients to become more cognizant of their role in improving healthcare outcomes, specifically regarding nutrition, exercise, and safe decisionmaking related to seatbelt use, alcohol, and protective barriers in those who have multiple partners. As noted in Collaborative Business, here is an area where insurance companies and large corporations are providing innovative incentives, such as a 24-hour help line, exercise facilities, smoking cessation programs, cancer screening, diabetic education, and trans-fat free cafeterias.
• One person wished for targeted management and leadership training.  As I wrote in Collaborative Leadership Development, summarizing Growing Leaders in Healthcare by Brett D. Lee and James W. Herring, 85% of Fortune 500 companies sponsor formalized internal leadership development programs, but only 21% of US hospitals have formal processes for identifying and developing candidates for leadership positions.
• Another wished for an intellectually stimulating environment in which to work.  In Collaborative Listening, I mentioned Brian Wong’s survey of over 1,500 practicing physicians, where meaningful work that makes a difference in patients’ lives ranked as the top priority.
• Finally, about 10% of respondents made ”spiritual” wishes to restore a sense of mission, purpose, and professionalism, reconnect with the reasons they initially chose healthcare careers, and have the courage and wisdom to make correct decisions in difficult economic times.  Not only did they seek incentives to encourage cooperation and sharing, they also sought an abundance rather than a scarcity mentality to confront our current challenges.  In Collaborative Gnosticism, my mentor, Lee Kaiser, stated that most people and  organizations see themselves at the center of the universe, which leads to egocentric, self-interested approaches that facilitate exploiting others for competitive advantage, hardly a sustainable approach to the service of others. He maintains that there is no economic, social, or political solution to the current healthcare crisis.  Spirituality, based on abundance, collaboration, and sharing provides the only solution because it makes problems disappear.

 What do you think?

• Despite the strident debate over healthcare that we are witnessing in the news media, do we largely agree on the rationale for improving our clinical and financial outcomes
• If we agree on the why and and the what, can the how become a lifelong  iterative journey
• What three wishes would you like granted

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

Addendum: Anyone wishing to take the aforementioned survey and have your responses mentioned in my upcoming column, please copy the questions below, paste them into your e-mail program, and send your responses to ken.cohn@healthcarecollaboration.com by September 11, 2009.  Thank you for your input:

• How are you and your organization doing in these difficult economic times?
• What are your greatest concerns?
• What strategies have you found to be the most useful in dealing with your concerns?
• What strategies have not proven to be helpful?
• If you could be granted three wishes, what would you request?

© 2009, all rights reserved

I spent a small part of my recent vacation meeting with thought leaders in New England to discuss trends and implications for the coming year.  One of my most pleasurable meetings took place at a winery and restaurant in the Nashoba Valley, where I talked with Dr. Kate Goonan about her new book, Journey to Excellence: How Baldrige Healthcare Leaders Succeed. 

The premise of the book, as stated in the foreword, is that although there may be no magic bullets, there are rational approaches that achieve results.  The Baldrige approach that Dr. Goonan and her co-authors elucidate provides guidance and checklists to embark and persist on the iterative journey of improvement based on the LASER framework:

• Leadership consists of 3 steps: recognizing that fundamental change is necessary to achieve one’s vision, welcoming objective evaluation and “brutal facts” feedback, and commiting to build a culture based on organizational learning and improvement
• Assessment reflects the decision to systematically evaluate processes and practices to view the organization from the perspective of patients and families
• Sensemaking describes the critical role leaders play in interpreting and explaining disruptive marketplace changes and framing what is required for successful healthcare delivery (discussed in greater detail below)
• Execution refers to the focused action necessary to achieve results, which includes: formalizing informal processes, setting priorities, discontinuing unproductive activities, establishing accountability with action plans, and integrating the Baldrige process into strategic and operational planning
• Results includes strong performance on a comprehensive set of measures important to patients, stakeholders, and markets; beneficial trends over time relating to the organization’s mission; key results that show good-to- excellent relative performance on benchmarks; alignment with organizational strategies

Sensemaking

On page 102, the authors quote Karl Weick, who introduced the concept by writing, “What is good for sensemaking is a good story.”  I like this concept because it underscores the cyclical journey of improvement including assessment, interpreting feedback, learning, and implementing improvements.  In Collaborative Workout, I mentioned that the discipline of being committed to a continuous process allows an organization’s members to dive deeper into making sense of disruptive changes, using candid feedback to improve clinical and financial processes and outcomes. 

Sensemaking leads people to go beyond narrow silos to focus on processes that they need to perform well to achieve desired outcomes.  It begins with answering questions and addressing inconsistencies.  The authors cited an example of Sister Mary Jean Ryan, CEO of SSM Health Care,  regarding a disconnect evaluators noted: “You say that human resources are your most important asset, but you don’t cover them in your strategic plan.”

Once she became aware of her organization’s failure to link its vision and values with strategy development and human resource management, she was able to lead her team to breakthrough performance.  In short, sensemaking drives organizational maturity because it fosters system thinking (rather than finger-pointing and blamestorming) and facilitates team learning and collaboration.

As I mentioned in  “Embracing Complexity,” in Better Communication For Better Care: Mastering Physician-Administrator Collaboration, face-face conversations are the only sustainable way that people can deal with complex situations  in which predictability is diminished, experience does not guarantee success, and relationships are key.  Sensemaking gives us a way to understand and frame healthcare complexity, view our organizations as part of a holistic system of care,  and provide potential and hope for sustainable improvement.

 What do you think:

• Have you participated in the Baldrige process
• Are you considering being part of a structured improvement process
• What roadblocks and advantages do you see in such a long-term improvement effort

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

I just read a summary of Ram Charan’s new book, Leadership in the Era of Economic Uncertainty, a provocative strategy for dealing with recession and emerging stronger.  The author recommends that executives act quickly and decisively to prepare for the worst-case scenario, with the optimism that if they encounter a situation that is not as bad as forecasted, they will be in better shape to thrive when the recession ends.

Cash

Worst-case scenario planning requires that the cash breakeven point be lowered as rapidly as possible. The three sources of cash must be pursued vigorously:

• Earnings from operations
• Working capital (decreased inventory and expedited collection of receivables)
• Sale of assets

Mr. Charan wrote that refocusing strategy puts executives on the offensive, converting crisis into an opportunity to emerge from the recession stronger, smaller, more flexible, and more competitive.  Succeeding in this volatile environment requires deep immersion into operations, with hands-on involvement and follow-up, to obtain ground-level intelligence.  Financial targets need to move from quarterly to monthly and then weekly because volatility shortens the life span of the business model and makes strategy become obsolete more quickly.

 The role of the CEO is to provide reassurance as well as leadership despite the difficulties of economic forecasting.  Facing uncertainty and dashed hopes, many people go into denial.  Executives need to present a compelling rationale that problems can/ must be faced and solved and that their organization can emerge from troubled times in better shape than before.  A compelling vision for the future can be a source of creativity, energy, and hope.

People

Every business has a central set of invaluable assets that must be protected.  In healthcare, as in other industries, the accomplishments of top performers need to be celebrated because they give us hope for the future.  Listening to top people, regardless of their abrasiveness or irascibility, is important because it provides indispensable marketplace information. 

Mr. Charan states that now more than ever, alignment of goals and values can be a source of competitive advantage.  The art of leadership requires pointing out that our similarities outweigh our differences and leveraging  the energy of social discontent.  As a nurse mentor pointed out to me in Collaborative Fairness, “It’s the sand in the oyster that creates the pearl.”

In Collaborative Champions, I defined physician champions as outstanding clinicians who have earned the respect of their peers by caring for patients in a consistent and reliable fashion, delivering great clinical outcomes.  They are the people we turn to when we need medical care.  They are also seasoned professionals looking to leverage their knowledge and experience to improve care for their community.  Possible roles for physician champions in difficult economic times include:

• Presenting and discussing clinical data with fellow physicians
• Minimizing physician-hospital battles
• Creating a safe environment for learning
• Helping to build transparency and trust

Mr. Charan wrote that the intelligence that front-line people gather can be used to improve the value proposition, from making the registration process simpler and faster to redesigning services to suit patients’ and families’ needs better in changed conditions.  The most important point that he makes is:

Don’t let the temptation to save money persuade you that face-to-face contact is not important.

In a chapter entitled “Embracing Complexity,” in Better Communication For Better Care: Mastering Physician-Administrator Collaboration, I wrote that face-face conversations are the only sustainable way that people can deal with complex situations  in which predictability is diminished, experience does not guarantee success, and relationships are key.

In Collaborative Revolution, I mentioned that rather than telling people that their thinking is outmoded, Senge et. al. encourage us to reflect on our assumptions.  As we expand our understanding of issues (rather than blaming one another), we will see more clearly the underlying forces and the opportunities on which we can capitalize and create a virtuous cycle in which:

• An improved practice environment drives better clinical and financial outcomes
• Which make it possible to improve existing services, invest in new programs, and recruit and retain talented healthcare professionals
• Which drives an ever-improving environment in which to care for patients and their families

What do you think?

• Does the fact that healthcare is no longer recession-proof make you feel more vulnerable than in past recessions
• Do you know people who are facing or have faced job losses
• Are you working harder to do others’ jobs as well as your own
• How can we help one another succeed and avoid burnout in difficult economic times 

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

I don’t see why we should need to resort to degrading, immature tactics to get doctors to do what everyone knows they should do in the first place.

This comment, from a VP at a midwestern hospital during a discussion of healthy competition at a recent ACHE seminar that I taught, surprised me.  He was the first to protest the strategy of using competition whenever people felt frustrated by the difficulty of herding cats, in reference to physicians’ different concept of teams compared to administrators.

He was a veteran of the corporate healthcare industry at General Electric, where people performed according to expectations or disappeared.  The concept that administrators had influence but lacked control over physician behavior was foreign and still unsettling to him.

I explained that physicians are not alone in their feline DNA.  University professors also tend to display greater interest in and loyalty to their subject matter and colleagues than to the setting in which they teach.  So do most members of professional guilds, who derive prestige, income, and autonomy from mastering their craft.

We ended the discussion by agreeing that in environments in which he had worked previously, CEOs shaped the culture more by a top-down approach than by bottom-up strategies like healthy competition.  In Collaborative Culture, I wrote that most physicians prefer bottom-up processes to top-down edicts. They have told me that they much prefer being inspired to being supervised.

The only way that I know to develop a common culture is to allow physicians to play a role in shaping it.  One of the barriers to improved physician-hospital collaboration lies in overcoming physicians’ skepticism that they are invited to meetings to bless decisions rather than to provide input into making decisions. 

As I mentioned during my ACHE seminar, we can:

• Build on areas of agreement rather than argue about what we feel is right
• Focus on how we can make better use of scarce resources like physicians’ time
• Celebrate all wins to build lasting partnerships that improve patient care 

Perhaps the recent unanimous recommendation of a Massachusetts state panel to switch from fee-for-service to global payment will spur improved physician-hospital communication.

 What do you think?

• Do contentious issues like billing offer the potential to bring physicians and hospital leaders closer together
• Is some provider autonomy necessary to provide individualized patient care, mindful of the risks of heightened variability
• Do you know of any techniques more effective than face-face conversation in rectifying our differences and improving patient care

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

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