The Performance Improvement Blog

Leadership and Health Care Reform

The Obama administration’s health care reform legislation will change incentives, which is badly needed, but it will not improve the quality of care unless an integrated, team-based approach also becomes the way health care professionals do business. This kind of approach is what the legislation refers to as ACO (accountable care organization). However, to be successful, such an approach will require health care professionals, especially doctors, to learn new competencies and form new attitudes regarding collaboration and cooperation.

The assumptions behind the new legislation make the need for change abundantly clear:

• the cost of health care in the United States on a per capita basis is too high
• the health of the United States population is too low
• health care in the United States is not sufficiently accessible, particularly for the uninsured
• health care in the United States is not sufficiently coordinated
• the quality of health care services in the United States is too low
• the federal government, as the largest purchaser of health care services in the United States, has the right to demand high quality, reasonably priced, accessible, coordinated health care services
• the federal government should no longer purchase health care services on a fee-for-service (or a la carte) basis because it gives health care providers an incentive to order more tests and perform more procedures in order to make more money
• there needs to be a “sea change” in how health care is delivered and paid for in the United States

Shifting from a fee-for-service model to a high-quality, low-cost model will address part of the problem. Don’t get me wrong - this change is essential, though the challenge with incentives is to ensure that “low-cost” doesn’t become more important than “high quality”. The other part of the problem is managing health care organizations in a fundamentally new way. Rather than the command-and-control style of leadership that is prevalent among doctors, nurses, and other health care professionals, these leaders will need to facilitate teamwork. They will need to respect and listen to the input of other health care providing organizations and integrate diet and life-style experts into the team. They will need to manage these teams so that optimum results are achieved for patients. They will need to keep all of the stakeholders engaged. They will need to draw out the best from everyone. And they will need to do all of this in a cost efficient manner. This is a tall order for people who come to their profession because of their high need for control, for prestige, and, for many, the financial benefits.

Health care professionals can be retrained if motivated. The real transformation of health care in the U.S. will come over time as a different kind of person is admitted to the health care professions and as measures are put in place to evaluate this team-based approach to delivering health care.

 

Organizational Blind Spots

How many times in the past week have you told yourself or someone else what you would have done if you were that graduate assistant who says he witnessed a child rape in the shower room at Penn State University, or if you were Joe Paterno, their legendary football coach, or if you were the President of Penn State? The reality is, you don’t know what you would have done. We all have blind spots to the truth that prevent us from doing the right thing in certain situations.

David Brooks writes about this phenomenon in his op-ed column, Let's All Feel Superior, that he wrote for the New York Times. He says in that column:

Over the course of history — during the Holocaust, the Rwandan genocide or the street beatings that happen in American neighborhoods — the same pattern has emerged. Many people do not intervene. Very often they see but they don’t see.

Some people simply can’t process the horror in front of them. Some people suffer from what the psychologists call Normalcy Bias. When they find themselves in some unsettling circumstance, they shut down and pretend everything is normal.

Some people suffer from Motivated Blindness; they don’t see what is not in their interest to see. Some people don’t look at the things that make them uncomfortable.

Some people look, but often don’t see the unexpected. Daniel Simons and Christopher Chabris demonstrated this in their classic research on perception. Observers concentrating on completing a task did not see a gorilla walk across the screen in front of their eyes. We see what we expect to see and, literally, don’t see the things that are not usually there. Drivers in areas of high bicycle activity see the bicyclists on the road, while drivers in areas of few bicyclists don’t see the bicycle in front of their car until it is too late.

Although physical and moral blind spots are tragically apparent at Penn State, the potential is in all of us. A co-worker is running a Ponzi scheme, we don’t want to believe it, and we look the other way. The sales department inflates revenue for the year and we make excuses why it is okay to report the numbers in that way. A manager is verbally sexually abusive to members of his team and we ignore it. In all of these situations we would like to believe that we would do the right thing. However, individuals, teams, and whole organizations put up many barriers to the truth. 

 

Barriers to Learning in Organizations

Continuous acquisition and application of knowledge, skills, and beliefs by individuals, teams, and the  whole enterprise is an essential aspect of high performance organizations. However, barriers to this learning are common in organizations. These barriers must be overcome in order for organizations to have long term success. Twelve of these common barriers are:

1. Program focus – new programs and services are evaluated in isolation rather than as interdependent parts of the whole organization, e.g., a diversity workshop is evaluated by the participants at the end of the workshop, not by everyone in the organization weeks and months after the workshop
2. Limited resources – learning is not given adequate funding and support, e.g., staff are not given resources to experiment with new ideas before risking large scale implementation
3. Work-learning dichotomy – producing and selling things is valued whereas learning is merely tolerated, e.g., little involvement of supervisors in the training of their direct-reports
4. Passive leadership – leaders don’t ask themselves the hard questions and their boards and co-workers don’t question their actions, e.g., a hospital CEO continues to push for hospital expansion while nobody asks, “Is expansion in the best interests of patients, employees, doctors, and the community?”
5. Non-learning culture – organizational values, assumptions, beliefs, behaviors, and norms do not support learning, e.g., recognizing (praise, reward, promotion, etc.) individual success but not recognizing team success
6. Resistance to change – trying new ways of doing things is not encouraged, e.g., individuals are told to be creative and innovative but not allowed to implement their ideas
7. Not discussing the un-discussable – everyone has a shared but un-spoken understanding that certain issues are not to be confronted and resolved, e.g., one employee’s negative attitudes are bringing down morale of the organization but nobody will talk about this problem for fear of retribution
8. Need for control – managers intentionally and unintentionally use organization charts, policy manuals, rules and regulations, performance evaluation, compensation, budget and expense monitoring, security systems, and work-space arrangements to constrain and limit sharing and applying knowledge, e.g., lines of communication are enforced within an organization to the point that a manager in one department may not talk to a manager in another department
9. Focus on short-term, simple solutions – managers taking the most expedient course of action without solving the long term problems within their organizations, e.g., doing multi-person layoffs to reduce costs when the real problem is not offering products and services that customers want
10. Skilled incompetence – the tendency of managers to avoid embarrassing or threatening interactions, place blame on others, and not accept responsibility for problems, e.g., the leader of a team that failed to complete an assignment avoids asking himself, “What is it about what I am doing or saying that contributes to other people behaving in ineffective and destructive ways?”
11. Blame, not gain language – employees tend to use mostly language that is judgmental and punitive rather than language that facilitates learning, e.g., when something goes wrong, the first words out of a manager’s mouth are, “Who is responsible for this problem?”
12. Selective attention – not seeing (literally) and, therefore, not learning from unexpected events, e.g., two employees attend the same presentation by their CEO but understand the new organizational direction in very different ways

What additional barriers to learning have you observed in organizations?

 

Employee Engagement: What to Make of Survey Findings

In reference to a recent Gallup survey of employee engagement that shows that 71% of employees are not engaged in their work, Wally Bock, in his Three Star Leadership Blog, offers these provocative observations:

After a full decade of high-priced experts and "engagement partners" laboring away, engagement scores have not changed significantly. Maybe it's time to send the consultants packing and see if we can find a better use for the money we've been paying them…Perhaps we can do better with homebrew methods of improving engagement. Perhaps we should quit worrying about engagement per se and turn our attention to something where our investment can make a difference…Remember this common definition of insanity: Doing the same thing over and over and expecting a different result.

I think there are at least two other interpretations of the Gallup findings. One is that Gallup is not measuring  what many organizational leaders think is engagement. I have written in a previous post about the many definitions of employee engagement. Before managers can make sense of the Gallup findings, they need to know how Gallup defines “engagement” and if that definition works for them. Gallup uses the degree of agreement with 12 statements, known as the Q12™, that they have found to be strong predictors of performance in organizations. To me, the Gallup statements are more about the antecedents to engagement than the extent to which employees are committed to their work and willing to go the extra mile, which is how I define engagement.

Another interpretation is that it’s not that engagement interventions don’t work but rather it’s the way we’ve been doing them that’s the problem. My experience is that most managers have an event-mindset when it comes to increasing engagement. They believe (or they hope) that a two or three-day program will make employees engaged with their work, each other, and the organization. That’s magical thinking. Learning and performance change takes much more than a one-time event. It’s a process that requires a long-term commitment on the part of managers to developing and maintaining a culture that encourages and rewards engagement.