ACHE Message Boards

Week 6

Question 1.

The butterflies in today’s healthcare environment  I believe are numerous.  From HMOs and malpractice insurance to technology and beyond..  Ex   the practitioner data bank  was originally developed to help consumers  in picking a physician etc. instead in turned into an malpractice  insurance nightmare.  Also the nursing situation where the average age of the nurse is approx 47 yrs old,  will have an impact in the future on healthcare.

The cost of Pharmaceuticals today and beyond will definitely impact healthcare.

Executives in their plan  MUST have  a VISION. And the executive needs to take responsibility and ownership of this vision.  The vision is how one will survive in the competitive market   what kind of niche can one grasp...  The successful executive will need to identify ‘his people”  that   are winners   people that  will promote the vision and enable change.   Actually easier said than done…..

Question #2

   How do I manage stress?  Well some days better than others…   I guess I have utilized at least one  or more of the approaches listed in our readings during different points of the day….  My vacations are very important to me  I make sure I take at least 2 good ones a year….    I love to golf  when the weather is good  but during the winter  I honestly do not have a recreation to do  except I like to go to gym. As the articles states sometimes it is hard to find the time.     One thing I do  is I list my agenda for the day, at least the top three things on my tasks to do…  I list them in my head while I am driving.  I guess that may sound dangerous  but driving usually is my best thinking time.  I also like to break and converse with the office staff and sometimes I walk around the floor  of the building my office is located.  This removes me from all scenarios for a few minutes to allow myself a regroup time.    What can an executive do to minimize the stress for his/her colleagues and subordinates??  Executives need to communicate expectations as stated in other chapters.  This helps the employee  etc.. to prioritize tasks that need to be accomplished  to meet the expectation.    Also check back with the employee on how things are going ,communicate give feedback  Encourage  employees to take  3 – 10 minute short breaks instead of 2 -15 minute breaks.    Also  strongly encourage employees to leave the work area, nurses station, or break room and have lunch off the unit.  

Quote #3    Kind of goes along with my answers   in Question 1.

We need to throw out all assumptions and start from scratch   by perceiving, listening (what is happening to others ) and resources available and possible future resources, etc.. and  develop the vision…. And persuade others .

Quote # 2 caught my attention this week:  “For the most part, change isn’t technologically difficult. Unless people make it personal and meaningful, changes will fail to become sustaining. This is the reason so many change initiatives are dead on arrival.”  Anita Ward, vice-president, Cambridge Technology Partners

There is such interesting new evidence related to change and what we know about neuroscience. Some of the newest thinking is that change requires developing new patterns and pathways in the brain. We've all heard about it takes 6 weeks to make a change, it takes 10 weeks to change, etc. Scientists now think that behavior becomes patterned in the brain and changing requires new neuronal pathways. This is another reason to practice new behaviors, learn new things and trying new ideas outside the box to take benefit of the brain's "plasticity" to generate new cells and pathways. I was cheering when I heard on CNN on the way to work that exercise has been shown to improve memory! Maybe some of our butterflies are stem cell transplant, cloning and organ regeneration!

I agree with this quote--getting involvement from individuals affected from change right at the beginning is important to make it personal and something that can be embraced and incorporated into their daily work life. Telling people to change will never work!

Question 1.

There are many butterflies in today's healthcare environment.  In Minnesota, there were a few individuals complaining to our Attorney General regarding the billing procedures in one urban hospital.  In my opinion, that was the butterfly that developed into a twenty page agreement each hospital in Minnesota now has with the Attorney General, outlining billing procedures for uninsured, collection practices, etc.  In addition, our aging workforce started as a butterfly as did the obesity problem throughout the nation.  Electronic Medical Record is another example of a butterfly.  We will certainly be able to identify more butterflies looking back. 

We need to manage through all of these changes by holding firm to our mission, vision and values.

Question 2.

I manage stress in many ways.  I am not very good at taking vacations, but I do enjoy gardening in the spring, summer and fall.  I also have several indoor plants that require care.  I thoroughly enjoy knitting and quilting.  I can loose myself (and my stress) in my sewing room and have lovely gifts to share with my family as a result.  I also enjoy baking special treats for my family and co-workers.  Treats seem to lighten everyone's day.

In general when I think of healthcare I think more in terms of teradactyls than butterflies – not only are the factors huge, but in some cases they are remnants of systems that either are or should be extinct.  However, there some subtle forces, such as the changing ethnic composition of our country, that are on the radar screen, but just barely, in many healthcare organizations.  For example, I was in a meeting yesterday where we were discussing how the decision to choose one hospital over another is made by the consumer.  We talked in particular about where people get their information about hospitals and the most effective way to reach them.  The consultants revealed that the majority of the minority populations surveyed in our area report that they get most of their information about hospitals at church – not exactly a media outlet that we target on a regular basis.  My point is that while we talk a lot about the growing diversity of our populations and our staff, I’m not sure how much effort we are really putting into understanding how that affects every aspect of our business.  We comply with the regulatory aspects, but may not have yet acknowledged the “consequences of consequences” (from our friend Everett Rogers' Diffusion of Innovations Theory).

From a planning perspective, the tool that I have found most useful in identifying and then drilling down into the consequences of a changing environment is scenario planning.  It can be used to look at one variable or at the interplay of multiple variables.  It takes time, focus and creativity, but I have found that it really does help prepare executives to be more prepared and flexible as the consequences start revealing themselves.

Question 2: 

From a personal perspective, I manage stress through consciously trying to maintain a balance between my work life and my home life, as well as a balance between ambiguous and unambiguous work tasks.  Like many of my colleagues, my day-to-day work world is pretty ambiguous – it takes days, weeks, months or years to see the results of the work effort I perform.  When I start getting too stressed at work, I force myself to take a break and review/reorganize something or complete some tasks that will only take a few minutes – the easy stuff.  It is amazing how 15-20 minutes of purging the office of things that will never get done, organizing a work task so you will be more efficient when you start it, or making a few phone calls can give me enough feeling of accomplishment to dive back into the ambiguity of the longer-term project I am  responsible for implementing. 

For others that I work with, particularly those who report to me, I try to make sure that the ambiguity is reduced through context and planning.  We talk about the big picture, plan the steps / accountabilities and stay in touch often for progress checks.  We also celebrate accomplishments with a lunch out or cake!

Quote 1:

My first quote is from an article in HEALTHCARE EXECUTIVE, written by Derick P. Pasternak M.D., “Working with Physician Executives.”  Dr. Pasternak states that, “one of the most important things healthcare executives can do to secure the success of integrated delivery systems is to overcome their own reluctance to work with physician executives.” I agree wholeheartedly with Dr. Pasternak’s statement as it relates to the relationship between execs and physician-execs in an ids setting, but I’m curious about his use of the term “reluctance.” Comments?

Our organization went through a major cultural revolution several years ago, so I think I understand what Dr. Pasternak is referring to.  Up to that point, the relationship with many of our physicians had degraded to one of mistrust.  There was no desire on management’s part to involve physicians in any decision-making process unless it was absolutely necessary.  The bias of management was that physicians were only concerned about their own well-being and that there was no way to find common ground.  To say we were reluctant to work with physician executives was an understatement.  In retrospect, I think the problem was that we did not know how to break through our own biases and initiate the discussion.  Fortunately, a consultant we were working with on our strategic plan convinced management and the board that they only way to be successful in the future was to include physicians in our strategic planning process from the beginning – and he had a process to do so.  To make a long story short, we have been able to overcome years of mistrust and move forward together on several important fronts.  Rather than losing control, we have actually found that by working with medical staff leaders as partners and increasing the infrastructure of the organization to include Chief Medical Officers and more support for medical staff functions we have more influence over and cooperation from the voluntary medical staff than ever before.  We have moved beyond including physicians in strategic planning to working with them addressing many aspects of day-to-day operations. We have finally learned to take advantage of the expertise they bring to the table to help us solve problems we traditionally would have considered the purview of management – and are better as a result.

*****

In closing, it has been a pleasure participating in this class.  The insights that all of you have provided have been very helpful.  Good luck to each of you as your career progresses.  Hopefully we will meet again some day on a different thread...

Your comments this week are excellent. They also struck me as more “personal” that I expected, given the topics of “chaos” and “change.” I’m heartened that you took the questions and put them into your personal-professional frame of mind.

The “butterflies” question seemed to take us all over the map, which is exactly what it was supposed to do. Your speculations started me thinking about all kinds of things that are seemingly unrelated to healthcare and healthcare management, but that COULD in some way, some day, have an impact on the profession and on the hospital as we know it. In fact, it may be difficult to come up with “insignificant” forces, causeing me to modify my definition slightly - a butterfly CAN be something insignificant, but it can also - I believe - reside in a setting that is obvious in its present impact, thus hiding or obscuring future implications. Think of all the possible implications in the future of the various configurations of managed care as we know it today, and the notion of “unintended consequences” should come to mind.

Shortly before the beginning of this Internet "seminar," I conducted a leadership program for the U.S. Army’s Dental Corps. Arriving at my hotel the night before the meeting, I flipped on the TV, and watched (again) the last half of Steven  Spielberg’s “Saving Private Ryan.” I was struck by two things. First, the actions of the small group of soldiers when confronting a superior force of Germans provided an excellent example of the operation and leadership of a “self-organizing team.”  Despite the odds against them, and despite the superior fire power and organization of the enemy, the Americans modified their strategy, improvised, shared leadership decisions, and ultimately prevailed.  Second, in chaos theory, we teach about the “butterfly effect” - the notion that seemingly insignificant events in a chaotic environment can lead to dramatic outcomes. At the beginning of the search for the missing Pvt. Ryan, the troopers assigned to the search detail complain about the futility of sacrificing lives from one person, especially someone virtually insignificant when measured against the millions of people involved in the allied invasion of Europe in 1944.  Yet the search for Ryan results in the army holding a key bridge while the Germans were denied a key resource. The outcome of the search mission is a fictional (but realistic) turning point in the war. And, Private Ryan IS the butterfly.

Your "butterflies" have (so far) included human genome mapping, Alan Greenspan (I'm sure he'd be "honored" to be in this category), "minor changes" in the payment methods used by state HSS departments, Federal & State reguations, changes in reimbursement law, possible state control of insurance rates, the retirement/repacement of one physician, an upgrade in the IT system, a new drug, the decision of an individual physician as to the location of a program, changes a new CEO makes in the organization structure/philosophy, and  (Judith) a 40-year-old butterfly hiding in the rafters - so it seems - just waiting to jump out and change the best-laid plans. WoW!  In my recent ACHE seminar in New Orleans (Sharpening Executive Skills), I asked them the same question about butterflies - they cited (in addition to many of yours) a closing (or closed) HMO, Medicare, eBusiness, genetics, collaborations, staff energy, rearrangement of managed-care systems, employment/unemployment, migration,  - all are clearly butterflies - some might even be gigantic moths.

People, too, can be the butterflies - often in accidental or unintended ways. In 2000, I saved several isues of TIME magazine's series on the "greatest" of the last century. One issue focused on the “greatest thinkers” of the century, including Fleming’s discovery of penicillin is emblematic of the role accident, happenstance, and serendipity play in bringing about change and fostering creativity. Thus, any of us could be a butterfly for the creativity of others. Of course, the butterflies may be "positive," “significant," " catastrophic,” or a host of other descriptors. One of your colleagues in the New Orleans seminar commented on butterflies by suggesting that “we work in a butterfly GARDEN! And, some of those butterflies in that garden seem to be wearing brass knuckles and an 'attitude.'”

The reason for asking you to think (even if briefly) about "butterflies" is to help curb a frequent tendency we have to assume a sort of "momentum," that things tomorrow will be simply "today + 2%."  This attitude, in turn, can restrict adaptability to chaotic situations.

According to Harvard Business School professor emeritus Alfred D. Chandler, Jr.(author of "The Invisible Hand," among others), quoted in the April 2002 issue of BUSINESS+SOCIETY, the Internet is a "game-changing" new infrastructure, a source of sweeping changes in the pattern and flow of goods, services, and industrial relationships. But so is the bar code reader, which in turn was as much a revolution as the railroad or the post office. In healthcare, professor Chandler suggests "DRGs," bio-technology, and the rise of "for-profits" as similarly "game-changing" butterflies.

Have any of you read Michael Crichton’s time-travel book, TIMELINES? It is a novel centered around arrogance – the arrogance of the 20th century that we’re smarter than all the generations that have come before, and the arrogance of the 15th century (where they assumed their superior armor suits would protect warriors from the enemy’s arrows, only to discover that the enemy responded by simply shooting their horses out from under them. This “arrogance,” Chrichton suggests, can be devastating to any entity facing change and uncertainty. In an interview related to his new book,  Crichton suggested that … “arrogance leads to stasis and antiquation. The way around the problem is to keep moving intellectually, no matter what the cost. If you don’t fail a certain percent of the time, it means you’re playing it too safe. You’re obligated to miss sometimes.”

And that quote leads me to STRESS!

Ah, Stress! I can’t comment on the efficacy of your many approaches to managing stress, but I do thank you for sharing them with us. Preaching stress-management to our colleagues and subordinates may be the most fruitful aspect of our role as "steward leaders." A balanced life, exercise, humor, meditation (also called "contemplation," "prayer," even "brainstorming alone"), respect for others, consistent communication (hopefully two-way communication), vacation, and venting  -  all seem to be used to profitable ends. I'm impressed with the variety and scope of your own efforts in this area.

And finally ….

We’ve added a “Week 7” thread to this course - - - DON’T PANIC, we’re not extending the course beyond your expectations. This “7^th thread” is my evaluation form - I’ve posted a few process questions, and I’d really appreciate hearing from you as to your views about them. There’s no requirement to do so, and no impact on the “credit” you receive for successfullly completing the course. Your responses, should you choose to share them, will help us as we develop new Internet courses, and revise THIS course for future offerings.

Buckner Fanning is a friend who was the pastor of Trinity Baptist Church in San Antonio Texas for 40 years. He’s known across the country for his preaching, and he loves to talk about some of the techniques preachers use to reach out and touch their congregations. Buckner says that from time to time there arises a situation or condition (such as what he describes as “…an atmosphere of general sinnin’.”) when the congregation really needs a full-hour sermon - one of those “show’em some hell-fire and then bring’em salvation” kinds of sermons. Trouble is, it usually happens on a day when those attending the 11 o’clock service are anxious to get out because the Cowboys are playing the early game on TV and they want to get to the Luby’s Cafeteria before the Methodists get all the good seats. They’ll sit still for 15 to 20 minutes of the “good Word,” but that’s it. He says he keeps them in their seats and paying attention by forcefully exclaiming every 15 minutes or so, “AND FINALLY FRIENDS…!!!” At that, half the congregation will check their watches and mutter to themselves that “…the rev’s almost done - I guess I can stay on a few more minutes.” Buckner says on a good Sunday, he can do that two or three times, and slip that one-hour sermon in on them before they even realize what’s happened.

As my comments get longer and longer (due in no small part to the quality and provocative nature of YOUR contributions), I feel like I need to use Buckner’s technique… So …

FINALLY!

A program note, if you’ll permit me:

Please complete the “course evaluation” posted for this course.

Permit me to share one final quote - one that’s been my favorite for many years, attributed to Admiral Grace Hopper (USN), co-creator of the COBOL computer language. Said Adm. Hopper,

"The things you do today that you don't have to do will determine where you are and what you are when you can't do anything about what you should have done."  

Thank you to each and every one of you for making this Internet course so enjoyable for me, and (hopefully) valuable for our colleagues. I’ve suggested many times that I hope we’ll be able to continue our contacts and our interactions via e-mail. Remember the College maintain various Executive Forums on this web-site, chat rooms designed to encourage what we’ve started here.

God bless each and every one of you.

Paul.

1-Some butterflies in healthcare are physician preference, clinical protocol, reimbursement and standardization.  Each of these can impact the cost of patient care.  A simple thing like changing the protocol for IV changes can create a supply cost savings and free up time to allow clinicians to spend time on other tasks.  Advances in technology can also produce savings in supplies used or time spent complete procedures or waiting for results.  Being able to electronically allow clinicians to view images, test results, etc. remotely can allow for more expedited patient care.  The changes in the reimbursement landscape can impact a healthcare institution’s ability to provide care.  Technology continues to change at an ever increasing rate.  One way executives can plan for these changes is to seek information.  Resources like ECRI can be tapped to provide information about up and coming technologies and potential cost benefits.  Such resources can provide indications as to whether the technology is viable and allow organizations to decide if the technology fits into their strategy and decided if they should be early adopters.

2-Change is challenging.  However, uncertainty is the root of stress.  It is important to do your homework and stay in touch with your environment.  It is important to have market research at hand, understand the political landscape and know the financial position of product manufacturers.  Having information, good information, helps eliminate some of the stress.  I find it helpful to keep my staff informed during challenging times.  I try to stay as informed as I can and relay information to my staff.  It is also helpful to have contingencies.  Being prepared is proactive and lessons the chance of being reactive.

Quote 4-Not everything is worth trying.  I believe that much can be learned by being open to new experiences.  However, sound judgement based on solid information must be applied to decisions on what to try.

franco.sagliocca@msnyuhealth.org

This was a very good program.  Thank you.

We do need to have these opportunities to refocus and challenge our current framework and perspective.

Just saw a butterfly go by....so I better go see what's in store....

Marc

Hi Paul:

Could not find the "week 7" post.

Marc

Question 1:  I think that some of the butterflies in today's healthcare environment include an aging workforce (I have read studies that predict a continuation of the nursing shortage and one that should start in the next decade for social workers.) coupled with an overall aging population.  In regard to my state (New Hampshire) I read articles about how younger people are leaving our state (making it the sixth oldest state in the nation) and that we are a highly educated state, making me wonder who will do some of the non-skilled jobs in our hospital in the future.  I also hink that communication technology is a butterfly, only because we really can't predict what will happen next.  I remember working on mainframe computers in college and being able to exchange messages (not called e-mail yet) with other users on the university network...I would never have predicted that most of us would have home computers or that e-mail would be what it is...With each advance comes new expectations...Ten years ago no one would expect me to respond to a letter overnight on a regular basis and that is essentially what we do nowadays.  I think that the only way to plan for this uncertainty is to continue to try to understand new technologies, to read adn network with others so that you know where ideas are coming from and hopefully get a better understanding of trends.  I think the biggest thing, though, is to not try and do planning without others.  No one person has the lock on the truth or can have a full understanding of what market forces and trends really mean.

Question 2:  I personally manage stress by talking to friends and colleagues who I find to be supportive and smart.  I also exercise and frequently remind myself that everyone needs help at one time or another and to use resources that are availabe to me.  For employees, I encourage use of EAP and other programs.  I even schedule trainings for people to attend on stress management.  (We have one scheduled for next month called "A Piece of Peace".)  I also monitor my employees time on the job.  If I see people putting in too many hours, I talk to them about it.  In fact, we have set up many systems at our hospital so that that is kept to a minimum.  The other executives I work with are good role models in terms of keeping an eye on stress levels for themselves and others.  I think that the most important thing to keep in mind is that none of us can solve world hunger.  You just do what you can do and try to do the right thing at the right time.

The quotes:  I liked them all.  The fourth one reminds me of one that I heard...I think it is a Chinese proverb:  "Fall down seven times, stand up eight."  For me, this implies the need to take risks but also adds that important element of courage into the equation. 

I really enjoyed this course.  It did get me to think about the basics and what I have learned over the years.  Thank you.

Paul--thank you for an interesting and stimulating course. I enjoyed the challenges of thinking about the readings and questions and learning from my colleagues. This has been very helpful to me and came at a good time to renew and refresh my learning!

I also did not find the "week 7" post for the evaluation. 

Week 6

Question 1

Butterflies in today’s healthcare environment may be disaster planning and implementation. (i.e. Hurricane Katrina). The ability or inability of healthcare institutions to appropriately plan and manage themselves in a disaster situation (environmentally or man made) will directly impact their ability to serve and survive.

How can healthcare executives plan in the face of chaos and uncertainty? I do not think anyone can plan for chaos, however, they can prepare. Preparation includes risk tolerance, flexible leadership, and a long term shared vision or goal for the organization as a whole. If an organization can include these elements in developing its staff it will be ready to take on the dynamic changes the future offers.

Question 2

Personally I try to manage my stress through exercise, but unfortunately I do not always have the structure time I need to do this. So instead I take mini breaks and go for a short walk, and/or talk to staff about non work related items. I try to get outside as my office has no windows and I lose track of daylight and weather conditions.

Don Bradshaw

I am late posting due to some of the "butterflies" at Walter Reed (moving a few soldiers in to an off-post building, mold in rooms, etc.).

 Butterflies - I am read through the postings and guess I am wondering about things we don't know that will be butterflies for health care - a shift in fuel sources that change our ability to sustain equipment across vast distances - thereby simplifying outreach to geographically isolated areas, or a change in information technology (who in 1950's thought of the WWW and implications for data transfer) to allow better monitoring and specific treatments (may be even a "Tricorder" from Star Trek), or a simple mutation of a virus in outer Mongolia that will spread a "plague".

Do not have the answer but think one of the keys is for us (or at least some in health care) to be reading, studying and interacting outside our "health care" world to sense, direct the subtle changes and help inform the rest of us.

Stress - besides managing our own think it is vital as leaders to set the example for our peers/subordinates and to be aware of the far reaching implications of our words and actions (we may be butterflies to others in our organizations).

I like to think that the lack of chaos is death.    Change is constant and risk is growth however knowing the mission, goals and core values keeps us on a forward path.  I am somewhat of a stress junkie however keeping a sense of humor and yoga keep me semi sane.   Quote 4 was told to me in a slight more folky way when I was a small child.   The tale of why the squirrel jumps from tree to tree has been with me all these years and I use it as courage to take risk.

 Sorry I was late posting but we are having a very hectic legislative session this year.  Loved your quotes and the postings of the class.

K Holzer