What makes teams effective? (1) Not being too role-focused

I am a big fan of people in the fields of “usability” and “human factors.” These are engineering disciplines which have been applied to software engineering, more broadly to information technology and even more broadly to organizational effectiveness. Usability and human factors people focus on considering the mental and physical characteristics of users when designing systems. They make systems more intuitive and less tiring. Within this field, I am particularly fond of an organization called User Interface Engineering (UIE).  They are a software usability consultancy that works on specific software and web application design projects. They also do seminars, training, and publications. Back in about 2003, I took the entire Reward Health Sciences team, all four of us at the time, on a 3 day field trip to Boston to attend a UIE seminar. It was great. We used crayons, construction paper and scissors to construct prototypes of software user interfaces and used them for quick usability testing and redesign sessions. They emphasize a light, iterative approach. In a three hour period, we would go through 5 iterations of design and testing. The fifth iteration was substantially different than the first, clearly reinforcing the importance of not falling in love with your first design and seeking frequent input from users.

Ever since I attended that seminar, UIE has been sending me e-mails with short articles about usability. This morning, I read their most recent article, entitled “Who is on the User Interface Team?”  They studied user interface design teams that were highly successful and compared them to those that were struggling to see if they could find characteristics that predicted success.  The answer?  Successful teams focused less on their individual roles, and conceptualized more people as being part of the team.

When the unsuccessful teams were asked “who is on your team?” they responded “We have two information architects, an interaction designer, and a user researcher.” When successful teams were asked the same question, they responded “Our team handles the interaction design, information architecture, and user research for the product.” And, the successful teams were more likely to include end users, project sponsors and other stakeholders as part of the team.

I feel strongly that this research finding applies to many types of business and clinical teams.  For example, effective primary care teams don’t start off focusing on which team member has an MD, and which is a nurse, aide or clerk.   All brains are turned on.  All are invited to have ideas on all subjects.  Of course, the knowledge, skills and talents that each team member brings to the team may be very different.  That will naturally drive different people to be more influential on different aspects of the design, analysis or management problem that the team is trying to solve.  But, in my experience, the most effective teams let those differences play out naturally.  They don’t spend energy enforcing them based on titles, degrees, certifications or other such distinctions that serve as barriers to inclusiveness in the intellectual effort of the team.

This fundamental driver of team effectiveness is one of the things that sometimes gives smaller organizations an advantage over larger ones.  In smaller organizations, the “all hands on deck” principle comes naturally.  But in larger organizations, the advantage of being able to afford specialized team members can too easily turn into a disadvantage when locked down role descriptions inhibit the shared intellectual effort that makes teams successful. Fortunately, this can be overcome by cultivating a culture that celebrates decentralized creativity and that promotes inclusiveness across traditional role boundaries.  To be successful, ACOs and other types of health care organizations should actively promote a culture that is intellectually inclusive and avoid focusing too much on specialized roles.

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Why do other countries have different attitudes about Health Economics?

Wednesday morning, I attended a thought-provoking panel discussion entitled “Is Health Economics an Un-American Activity?” — a reference to the McCarthy-era Congressional committees that judged Hollywood movie directors and others considered to be communist sympathizers.  The panel presentation was part of the annual meeting of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) in Baltimore.  It featured John Bridges, PhD from Johns Hopkins, Peter Neumann, ScD from Tufts, and Jeff White, PharmD, from WellPoint.

The panel started by noting that the field of health economics has, as its fundamental premise, the rational allocation of scarce health care resources. This allocation is informed by “cost-effectiveness analysis” — broadly defined as the process of preparing estimates of both health and economic outcomes for different health care services to support decisions about which services are worth doing.  Health care services often produce a mixture of different health outcomes — sometimes extending life and sometimes affecting different aspects of the quality of life.  So, to deal with the mixed basket of different outcomes, cost-effectiveness analysts commonly combine all the health outcomes into a single summary measure called the “quality-adjusted life year,” or “QALY.”  Then, QALYs are compared to the costs of the health care service.  Based on this comparison, decision-makers determine if the service is worth doing, or “cost-effective.”

The panel noted that the United States is far less supportive of these basic concepts of the field of health economics, compared to almost all other developed nations.  In the U.S. stimulus bill, Congress provided substantial new funding to establish a Patient-Centered Outcomes Research Institute (PCORI).  But, Congress specifically forbade that Institute from using QALYs or establishing cost-effectiveness thresholds.  In the debates leading up to passage of the health care reform legislation, U.S. political leaders went out of their way to emphasize that they did not condone any type of “rationing” or “death panels.”  In contrast, the ISPOR meeting was full of presentations by health economists from Europe, Australia, Asia and elsewhere describing their government-sponsored programs to formally assess the cost-effectiveness of heath services and to use those assessments to determine whether to grant market access to drugs, biomedical devices and other health care products and services.

Although the panel discussion was enlightening and interesting, I felt they generally focused too much on QALYs and too little on the deeper cultural issues.  They made only vague comments on any evidence or theories about why there would be a such an obvious difference in attitudes between the US and other developed countries.  One presenter noted that America was founded by individuals fleeing tyranny, which led Americans to be distrustful of government hundreds of years later.  Another jokingly hypothesized that support for health economics had something to do with having a monarchy.

So why does the US see things differently?

It seems to me that there are two competing explanations for why Americans are so troubled by health economics and cost-effectiveness analysis: Entitlement and Duty.

According to the entitlement hypothesis, after a few generations of economic largess, Americans have come to feel entitled to a worry-free life.  As a result, Americans are supposedly unwilling to accept limits or burdens.  This is described as the decline of our culture.  It supposedly applies not only to health care, but also to our unwillingness to make tough decisions and sacrifices to solve the federal budget deficit, global warming, urban sprawl and even childhood obesity.  Both political parties implicitly support this view when they assert that their party will revive American exceptionalism and put the country back on the right track.  This sense of entitlement applies to both rich and poor.  Rich people hate rationing because they associate it with big government, which they equate with high taxes to pay for generous social welfare programs that transfer their wealth to the poor.  Poor people hate rationing because they fear that it will provide the pretext for the “establishment” to avoid providing them with the high quality health care to which they feel entitled.  According to the entitlement hypothesis, both rich and poor are like spoiled children, stomping their feet at the prospect of any limits to the health care they expect.

In contrast, the duty hypothesis makes seemingly opposite assumptions about the state of American culture.  It emphasizes that Americans have a strong sense of duty, and a romantic sense of chivalry, loyalty and patriotism. They note that Americans, compared to their European counterparts, tend to have more fundamentalist religious beliefs.  Americans tend to have a strong sense of right and wrong, seeing moral issues as black and white, rather than the more relativistic shades of grey prevalent in attitudes of those from other developed countries. Advocates of this hypothesis point out that Americans feel strongly about not leaving a soldier behind in battle, no matter what the risk. This sense of duty translates to an insistence that we spare no expense to rescue the sick from illness.

I can’t say I know which point of view is right.  Perhaps both forces are at work to animate Americans’ opposition to health economics.

What are the implications for ACOs?

ACOs involve providers taking responsibility for the quality and cost of care for a population.  Controlling cost requires reducing waste.  Many health care leaders would like to believe that we can control costs just by eliminating medical procedures that offer zero benefit or that actually harm patients, and by creating leaner care delivery processes so each necessary service is delivered at lower cost.  But, the elephant in the room is the far larger waste in the form of delivery of procedures that do offer some benefit — just not enough to be worth the high cost. Reducing the use of such procedures will face opposition and resistance. To be successful in the face of such resistance, ACOs must overcome the sense of entitlement.  ACOs must channel the strong sense of American duty, honor and righteousness to the act of triaging to help the people who need high value services.  The courts and churches use rituals and solemn settings to convey solemnity, seriousness and integrity.  Perhaps ACOs should use some form of ritual and a solemn setting to build a sense of rigor, transparency and integrity to the process of determining practice guidelines that direct resources to the “right” clinical needs. In this manner, the US culture of duty could potentially overcome any sense of entitlement, enabling the ACO to carry out its stewardship duties and responsibilities regarding quality and cost of care for the population.

I suspect that for-profit health care provider organizations will have a far more difficult time overcoming this resistance to health economics.  For people to internalize a sense of duty to triage, they must have confidence that when practice guidelines cause providers to say no to one patient regarding a low value service, the preserved resources go instead to provide a high value service to another patient.  If they suspect the savings is going into the pockets of stockholders, the cultural opposition to health economics will be strengthened.

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Interesting “National Strategic Narrative” on Prosperity and Security and how it relates to health care transformation

This morning I read a short article by my favorite journalist, Fareed Zakaria (who I have been reading since long before he was a CNN news celebrity).  In the article, Zakaria covers and expresses his general agreement with a policy paper published by the Wilson Center proposing a new “National Strategic Narrative” regarding prosperity and security.

The paper was written by two actively serving military officers, Captain Wayne Porter, USN and Col Mark “Puck” Mykleby, USMC.  But they signed the paper “Mr. Y” to communicate their intent for it to be considered as a proposed replacement for a very influencial paper published back in 1947 in Foreign Affairs under the pseudonym “X.”  That paper, actually written by George Kennan, was titled “The Sources of Soviet Conduct.” It portrayed the U.S. as the “leader of the free world” and argued for the U.S. to seek “containment” of its adversaries.  It provided the narrative that drove national security policy for the subsequent 40 years.  In the new paper, “Mr. Y” proposes to update this narrative to reflect a more complex and interdependent world, replacing “containment” with a goal to become the most competitive and influential country.  Even though it is written by military officers, the paper advocates for decreased emphasis on military might, increased investments in human capital (including education and health care), and increased focus on domestic prosperity, adherence to internationally-respected American values, and civilian engagement in the international “ecosystem.”  It is a readable 14 pages, including a preface by Anne-Marie Slaughter.  I recommend it.

How does this relate to health care transformation and the emergence of Accountable Care Organizations (ACOs)?

First, the content of the paper puts health services into the larger framework of prosperity and security.  Access to health care is a component of prosperity.  Freedom from disease is a component of security, which is defined as a state of mind.  This conceptualization reminded me of Don Berwick’s description of the two approaches to improving health care quality: eliminating “bad apples” (the providers at the extreme unfavorable end of the performance distribution) vs. “moving the mean” (focusing on improving health care processes to shift the entire distribution of performance in the favorable direction).  It seems that national “security” is eliminating the undesirable tail of the distribution of human well-being, while “prosperity” is shifting the whole distribution in the direction of greater well-being.

Second, the paper points out the importance of entrepreneurialism, competition and free markets to improving prosperity and security.  Regardless of your politics about public vs. private financing of health care, I think it is important to recognize that fundamental transformation and continuous improvement in the actual delivery of health care services will require the creative energy of entrepreneurs, the forces of competition and the reform of markets to create the information transparency and level-playing field necessary for free choice and fair competition.

Third, in outlining our fundamental national values, the paper includes an “environment” that provides “plentiful” water and soil and “abundant” fuel, but settles for health services that are just “adequate.”  Given our problems with health care spending that greatly exceeds the per capita cost of other economically advanced countries with little measurable increase in health benefits, I understand the authors’ avoidance of adjectives that promote further increases in the quantity of health care.  But, I found the word “adequate” to be uninspiring.  I would have preferred that they focused on the abundance of health and wellness, and went with the themes of “smart” and “sustainable” that are present throughout the paper to convey the need to use our inventiveness and practicality to get the most health and wellness while avoiding waste and preserving as much of our economic output as possible for other values and pursuits.

Fourth, the paper argues that we need to avoid “labeling” and “binning” in ways that miscommunicate our true intent and that turn off nuanced thinking.  The authors give the examples of the harms from using terms like “terrorist” and “jihadist.”  Extrapolating from this point to health care, I feel that we are poorly served by much of our terminology and labels, such as “cookbook medicine,” “rationing,” “death panels, ” “kick-backs, ” and even some seemingly positive but nuance-killing terms like “professional autonomy,” “patient advocacy,” “standard of care,” and “evidence based.”

Finally, the idea of creating a “narrative” that can transcend political parties and traditional constituencies to establish a shared vision, underscore shared values, and drive long term policy and societal transformation seems to be very applicable at this point in the history of our health care system.

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“Can I get a Fast Pass?”: Learning from Disney about health care quality

While returning from a vacation to Walt Disney World yesterday, my family and I were in a disorganized crowd at the Orlando International Airport boarding the tram that shuttles travelers between terminal buildings.  A man yelled “Can I get a fast pass?”  Everyone laughed.

Anyone who has been to a Disney park knows that a “fast pass” is a little ticket that can be obtained at the entrance to popular rides that gives an assigned time after which you can return to the ride and avoid having to stand in a long line.  They are lifesavers, particularly to families with kids on hot days.  Going through the “fast pass return” gate to a ride always makes you feel like you were lucky to win a prize or that you are a special guest.  It is a process design that anticipates a customer problem and prepares in advance to resolve the problem, thereby delighting the customer.  

Over the course of our vacation, my wife and I noted hundreds of little ways that Disney was “thinking.”  Signage that always seemed to point to where we wanted to go.   Rubber tubing inserted in the train track slots at cross walks to keep buggy wheels from getting stuck.  Masking tape applied to the pavement just before the evening parade and fireworks to mark places OK for standing and removed just before the end of the parade.   The list goes on and on.

Once aboard the Orlando Airport shuttle, after making sure my daughter had a good grip on the pole (the one with the germs of thousand of travelers!), my thoughts wandered to the business trip I had taken the week before, when I missed my return flight from Chicago because I waited for more than an hour in the security line at O’Hare Airport.  While waiting in that line, I had plenty of time to study the processes at the airport to try to figure out why they are so un-delightful.  At O’Hare, at the security entrance to terminals E & F, travelers must choose among four roped-off waiting lines.  Fifteen minutes into the line, I noticed that my line and the line next to me were moving far more slowly than the other two lines.  After another half hour of waiting and inching closer to the inspection area, I had the diagnosis.  Out of 5 x-ray baggage screening machines, Homeland Security had staffed only three of the machines during this Saturday morning of Spring Break week.  (Perhaps they lacked “intel” about school schedules in the homeland?)  Two of the waiting lines fed into their own screening machine.  My waiting line merged with the other slow line to share a single screening machine.  I finally made it up to the ID check lady.  After she checked my ID against the home-printed boarding pass (some other time we can try to figure out how that is adding security value), I politely asked if I could make a suggestion and explained the problem with the lanes and suggested that they close off one of the two slow lanes.  She looked at me with a quizzical “and you think I care?” look.  After another 10 minutes in the line, I noted that there were about the same number of staff standing and watching as actively interacting with travelers or their bags.    I overheard one of these watchers say to another “What a mess.  It’s enough to make you want to help out.”  The other watcher smiled at the joke.  After I finally got through and finished hopping on one one foot to tie my shoes, putting my belt back on, and repacking my computer bag, I realized that I missed my flight.

So, why has Disney been able to outperform O’Hare, Orlando International, and Homeland Security in customer experience?

I believe that the answer is culture.   I’m a person that usually focuses on numbers and science, and the concept of “culture” sometimes seems too vague for my taste.  But, it is undeniable that some organizations achieve a culture that emphasizes quality and customer satisfaction, while other organizations do not.  In my experience, small organizations tend to have an easier time achieving such culture, since each member of the organization is close to each other and to the customer.  But Disney is a huge corporation.  I suspect that Disney has built up their culture over many decades, attracting employees that find Disney’s culture attractive, selecting employees that already have personality and character traits compatible with their culture, training new hires in their philosophy and the processes and techniques they use to pursue that philosophy, and creating an experience for those employees that their ideas count and their effort is appreciated and rewarded.

On Sunday morning, I overheard two Disney employees talking to each other, greeting each other with cheer.  One said “I’ve got to hurry over to the mono-rail, which is backing up for some reason.”  The  Disney employee was in a hurry, but took a moment to express cheer and respect for a fellow employee.  The employee had a sense of urgency to solve a problem with customer experience.  But the last three words caught my attention.  “For some reason.”  The employee had an inherent interest in the causes of the problem, not just in the problem itself.  I was left with the impression that this employee was going to help out with the current situation, while simultaneously trying to figure out and subsequently address the reason that it happened this Sunday morning, so it does not happen again on the next Sunday morning.

So what can we learn from Disney and airports about the quality of care in Accountable Care Organizations (ACO)?

For ACOs to be successful, they must be competitive — not only to purchasers, but also to patients.  They have to create processes that anticipate the needs of the patient, and solve problems before they happen.  They need to be able to learn what works and does not work.  They need to be able to overcome the professional cultures that sometimes emphasize technical competency and physiologic outcomes to the exclusion of humanistic competency, and the satisfaction and delight of patients and their families.

The idea that we in the health care field can learn from those in the hospitality field is certainly not new.  At health care professional meetings, such as meetings of the American Medical Group Association (AMGA), I’ve been to numerous presentations over the years by executives from Disney, Marriott, Ritz-Carlton and other hospitality companies about how they select and train people, how they have huddles at the beginning of every shift, how they empower people to solve customers’ problems, and how they reward people that delight customers.  And many hospitals and physician organizations and some health plans have taken this advice to heart and made significant progress to nurture a patient-satisfying and quality culture.  But, I think everyone would agree that we still have a lot to learn and a long way to go.

 

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Atul Gawande’s articles in the New Yorker most relevant to ACOs


Atul Gawande - image link from New Yorker

Atul Gawande is a general surgeon at Brigham and Women’s Hospital in Boston, and is an amazingly compelling writer about health care issues.  He has written a series of articles in the New Yorker, blending stories of individual patients and their care providers with a larger scientific and health policy context.  Some of the most relevant of these articles for Accountable Care Organizations (ACOs) include:

December, 2007: “The Checklist:  If something so simple can transform intensive care, what else can it do?.” In this article, Gawande explains the work of Peter Pronovost, MD, a critical care specialists at Johns Hopkins who used simple checklists and an associated process to empower nurses and create a quality culture in hospital ICUs to dramatically reduce complications from central lines and ventilators, first at his own hospital, then throughout Michigan in the Michigan Health and Hospital Association’s Keystone Project (with funding from Blue Cross Blue Shield of Michigan).  The article laments about the resistance to national implementation of the checklist approach (a resistance that has at least partially been overcome in the three years since this article was published).  Pronovost argues that the science of health care delivery should be emphasized and funded as much as the science of disease biology and therapeutics.

August, 2010: “Letting Go: What should medicine do when it can’t save your life?.” In this article, Gawande describes the cultural and psychological barriers that make it difficult for patients, family members, and doctors to prepare for good end-of-life decision-making.  He reports the success of hospice programs, end-of-life telephonic care management programs, and programs to encourage advanced directives.

January, 2011: The Hot Spotters: Can we lower medical costs by giving the neediest patients better care?.” In this article, Gawande enthusiastically describes the work of Jeffrey Brenner, MD and his “Camden Coalition”  in Camden, NJ, and Rushika Fernandopulle in Atlantic City to develop intensive patient-centered care for high risk patients, and the analytics of Verisk Health focused on predictive modeling for high risk patients.  The article includes some encouraging pre-post study results from these programs, but acknowledges the risk that results could be biased due to the “regression to the mean” effect — when a cohort of patients specifically selected based on recent high health care utilization is expected to have lower utilization in subsequent time period without any intervention.   The article also points out the resistance to change in health care, evidenced by Brenner’s inability to get state legislative approval to bring his program to Medicaid patients.

Additional biographical information about Gawande, as well as a complete list of his articles in the New Yorker, are available here.

 

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Learning from Manufacturers about Culture and Technology: The Case of PLM Systems

Product Lifecycle Management (PLM) systems are software tools that are used by product manufacturing companies to support the entire lifecycle of ideation, business planning, requirements, design, manufacturing, launch, and eventual retirement of products.

They are interesting to me for two reasons: (1) they are relevant to the development of software products, and (2) they share some important characteristics with health care information technology.   PLM systems, like electronic medical records (EMR), order entry, registries, care management and analytic systems used by Accountable Care Organizations (ACOs), are systems that are mission-critical to the company.  They involve complex information.  This complex information is created and maintained by business users with some technical capabilities.  This complex information must be communicated in ways that support collaboration by many different people from different professional disciplines.  They support processes that are constantly being changed and improved in ways that can create competitive advantage for the organization.   They support design and analysis, rather than just execution.

So, what can we learn from product companies and the systems that they use that can be applied to Accountable Care Organizations?

I just read a report from the Aberdeen Group on the “CIO’s role in Product Lifecycle Management (PLM) System.”

http://www.ptc.com/WCMS/files/110940/en/Aberdeen_Report_PLM_CIO_english.PDF

The report starts by acknowledging the tendency for CIOs to view PLM system implementations initiated by product people to be “rogue” projects.  The report explores whether such system implementations should be in the “realm” of IT, rather the product people.

This article seems to be written from the perspective of the CIO.  It concludes that to be “best in class”, a company needs to:

  • Have the PLM implementation project “under IT,” rather than have it under product area leaders who have “a day job,” asserting that, if the PLM system is supported by the product area, there will be a risk to “business continuity”.
  • Have the PLM implementation project funded through the IT budget, including funding for some dedicated staff in the IT area, but justified based on a business case tied to a business initiative of the product area.  In other words, the product people are responsible for helping argue the case to the C-suite for increasing the IT budget.
  • Minimize customization to the PLM software, even if the product people argue that customization is required to maintain some aspect of the product lifecycle process that they consider to be a competitive advantage.

At the end of the article, the authors acknowledge that less than 50% of recent PLM implementations are taking this advice and formally assigning CIO responsibility for PLM system implementations.  The companies that do so tend to be large companies that “focus on standardization.”

Of course, none of these turf issues matter if the people and departments involved are fundamentally collaborative and agile and if the right talents are represented in the collaborators.  I theorize that the problem has, as its root cause, the culture of blame that sometimes develops in large organizations.  In such organizations, IT leaders routinely experience blame when IT-related things inevitably go wrong, even in situations where the problem is  largely out of the control of the IT leaders. After receiving routine beatings over a long period of time, IT leaders and IT department culture can take on a defensive posture.  This defensiveness, in turn, does three things:

  1. It crowds out collaborativeness
  2. It fosters hiring and promotion processes that emphasizes management skills (“are you done yet?”) over design insight and creativity
  3. It encourages processes to be optimized for documentation and blame avoidance rather than agility

Then, after years of experiencing IT support that, in the opinion of product leaders,  lacks design insight, creativity and agility, the product leaders insist on keeping the PLM systems under their own control.  CIOs consider this to be “rogue” behavior that needs to be thwarted.  As a result, a reinforcing loop (a vicious cycle) is created.

This general system of causes and effects seems to apply as well to other technologies that are used for mission-critical processes by non-IT people with some technical capabilities, including workflow automation, business process management (BPM), enterprise data warehouse (EDW), and electronic medical records (EMR).  Specifically in the latter case, clinical leaders that are focused on using IT to transform their actual care processes sometimes tend to associate “EMR” with “big expensive project owned by IT people that don’t understand my clinic.”  As a result, they prefer “registries,” which connotes “little project owned by the clinicians and focused on enabling the front-line process improvements we’re trying to make right now.”

The Aberdeen Group report attempts to address some practical issues regarding budgets and organizational roles.   It does a nice job of linking survey data to recommendations.  But, in my opinion, the solution to this problem — whether it be for PLM systems in product companies or care process management systems in ACOs — is not to decide who owns the turf.  It is to address the root causes.  IT and product/clinical leaders must work together in ways that avoid finger-pointing, builds trust, attracts and retains the best talent, and invites meaningful participation by all the team members with something to contribute and a stake in the outcome.  And the information systems must be designed to enable such collaboration.  Admittedly, easier said than done.

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