Things That Won't Change

Recently, I posted an article on my blog entitled, “What You Know Just Ain’t So,” which discussed things we believe to be true but when tested over time and with deeper questioning, just don’t hold up. That type of critical thinking is necessary in order for us to accurately look at our reality – to see things as they are and not as we might want them to be.  

Yet, an analysis that shows the flaws in our thinking, doesn’t, by itself, help guide us down the correct path. After all, highlighting all the closed roads on a map won’t get us to our destination. To choose the best path for our journey, we need to know the roads that will be open when we need them. In other words, to set the right course, we must know the things that won’t change with time. 

Jeff Bezos, the CEO of Amazon, eloquently makes this point. He noted that people are always asking him about what’s going to change in the next 10 years, but they never ask him about what’s not going to change in the next 10 years. He says, “…the second question is actually more important of the two because you can build a strategy around the things that are stable in time.” Because Mercy is going through a strategic planning process, that statement made me think about what won’t change in health care over the next 10 years. 

The best way to come up with such a list is to take the perspective of our patients, since they’re the ones who will ultimately choose what has real value over time. It’s hard to imagine a future where a patient would prefer to wait longer to talk to a provider or obtain test results, have less confidence in their quality of care, have more unanswered questions about what treatment plan they should choose, pay more or have more hassles about paying their bills. In short, the best future for Mercy will be one where we seek the opportunity to be faster, more convenient, more trans- parent, higher quality and less costly. No problem, right?

Think about that challenge for a moment. What do we need to do to realize a more “customer friendly” future? To start, we’ll need to care for people where they are as patients, not necessarily where we are as providers. That will mean being accessible online and in person, on phones and tablets, at their home or work, days and nights, week- ends, holidays and vacations. When patients want information or answers, they’ll expect it to be immediately avail- able, just like the products and services they’re used to getting on demand today. When they get a test or image, they’ll expect it to be interpreted and explained in the moment, that they’ll be billed the amount they were promised up front, that the results will be easily interpreted and a plan of care established quickly. If referrals are made, the expectation will be that they’ll happen promptly and if they have problems with a service, there will be someone to listen to them and take action quickly. When a procedure or surgery is necessary, it will be scheduled promptly, performed expertly and with the least amount of discomfort possible. If it can be done in an office without anesthesia, that would be preferable but always with minimal pain, invasiveness and time away from home or work. They’ll expect to be treated with respect and in a manner that befits an organization that wants to retain their loyalty.

Perhaps that seems like a tall order for our organization, but before writing it off as fantasy, consider this...If you’ve ever tried the Uber transportation service, you may have been as impressed as I was on its simplicity, transparency and responsiveness. Through the Uber phone app, you input where you are, where you want to go, select a driver who has already been vetted by Uber, rated by prior passengers and is close to your location. Both you and the driver can see each others’ pictures and locations via GPS to know the time of arrival. Typically, within a few minutes, the driver pulls up, you travel to your destination, pay through the app, rate the driver, the driver rates you as a passenger (warning: don’t act like a jerk), and voila’ – done! It works brilliantly.

But after my last Uber experience, I was struck by one question. Why is it that suddenly, in the era of Uber, there are all these drivers just waiting to take me wherever I want? Before Uber, if you needed a taxi and were waiting at any place other than a high-traffic area, it was a hassle. Most likely you called a taxi dispatch that sent a message to a cab that may or may not be available at that moment. There was no feedback on where they were or when they’d get to you and you didn’t know what exactly to look for, nor did they. What changed?

I would submit there are two things that made Uber possible and popular. The first is technology. Uber cannot happen without GPS. With GPS, nearly anyone with a driver’s license can become an Uber driver. In the taxi era, one of the driver’s valued skills was knowledge of where places were and how to get there. Today, those skills are less valued as one doesn’t need local road knowledge to follow the directions of GPS. The passenger says where they want to go and the software takes care of the rest.

Of course the next step on this path is to eliminate the human driver all together. With self-driving cars as envisioned by Ford, Apple, Tesla, Google and others, the long-term need for drivers of any type – Uber, passenger, truck or otherwise – is questionable. But while the driver may be optional in the future, it’s the second component that makes Uber itself irreplaceable. Uber makes the experience feel safe. By showing pictures of drivers and passengers, providing feed- back on locations and time of arrival, secure method of payment, rating their past Uber experiences, tracking locations with GPS and recording all that data, the Uber experience feels safer than any taxi experience I can remember. That sense of safety is key to making Uber valuable to travelers and gives it staying power in the market.

Think about how the technology behind Uber and its popularity apply to health care. In that same blog article on “What You Know Just Ain’t So,” I discussed a company called Ayasdi that’s helping Mercy put together care paths for about 80 different illnesses, based on real data from our own patients. These are not care paths put together by wise men stroking their chins while extolling the virtues of what they believe to be best practice, but actual data. The end result of that work will be care paths that provide the best evidence on how to care for a particular disease that achieves the best outcome at the lowest cost.

Now, pause for a minute and think about this... do you need to be a physician to follow a care path? How about a physician’s assistant or nurse practitioner? How about a nurse? Nurse’s aide? If the diagnosis is correct and the care path instructions are clear, outside of an acute care setting, what’s the need for any of those traditional providers? Why wouldn’t a patient just follow the care path on their own until they ran into a problem they couldn’t solve themselves? While Uber and GPS put power in the hands of the passenger, why wouldn’t patients want and utilize that same type of power by having state-of-the-art care paths to guide them through management of their illnesses?

If, like me, you’re a provider and that last statement makes you fear for the security of your professional future, go back and think about the second part of what makes Uber successful. They make it feel safe. Managing your health when you aren’t terribly sick is not that difficult if you’re armed with adequate information and a plan. But when good health fades and more complicated illnesses loom, managing your health can be both scary and difficult. In those moments, patients want to know they’re safe and not alone. Is my health care team behind me? Can I talk to them quickly when I have questions? Will they provide good advice to me when I need to make a tough decision? When I need more than just advice, will the hospital, experts and all the technology I need be there for me?

As it always has been, Mercy’s answer to all those will be “yes.” That’s the service we’ll provide, the feeling of safety we’ll give, and the sense of value for which we’re known. That’s why we, as providers, will remain vital and why Mercy, as an organization, will thrive for generations to come.

Certainly health care has more complicated problems than that posed by an antiquated taxi system, and it’s always dangerous to apply simple solutions to complicated problems. Still, as we look to the future and contemplate what will not change, it’s sometimes the simple lessons taught by the experience of others that resonate the most. Let us vow to build a future at Mercy that serves our patients by making it something they want and are thankful to have when they need it the most. It’s an honor to be on this journey with you.

What do you think? Email me at Alan.Scarrow@mercy.net or on Twitter @DrScarrow.

What You Know Just Ain’t So

In 1937, the great American inventor and businessman Charles Kettering said, “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” My hunch is that if Mr. Kettering were alive today he would want to double down on that belief.

History is full of examples where that which was once universally accepted as the truth was eventually replaced with equal conviction of the exact opposite. In 1615, Galileo was placed under house arrest for writing that the earth circled around the sun. Today anyone alleging the opposite with conviction would be considered a lunatic.

In 1846, Ignaz Semmelweis, a physician from Vienna, was put in prison and eventually beaten to death after trying to convince other physicians that patients were dying from infections due to physicians not washing their hands. Today physicians who insisted on not washing their hands before and after touching patients would have a hard time finding employment anywhere in the world. Up until 1982, every respected physician in the world was absolutely convinced the human stomach had far too much acid for bacteria to survive. That is until pathologist Robin Warren showed that wasn’t true for the bacteria H. Pylori which, by the way, also happened to be the cause of stomach ulcers. Warren won the Nobel Prize for his discovery and has saved millions of people from suffering the pain and disability of stomach ulcers.

For those of you who are old enough to remember a rotary phone, how about these former beliefs:

• Japan will dominate the world during our lifetime due to its manufacturing and management prowess. (Today, the Japanese stock market is about the same level it was in 1985.) 
• The encyclopedia is the most important and reliable source of knowledge. (True, unless you consider this thing called the Internet.) 
• Every major city has one morning and one afternoon newspaper in addition to radio and television stations. (Raise your hand if you were born after 1980 and have either read a printed newspaper or sat down to watch the evening news in the last six months…I thought so.) 
• High inflation is a permanent part of American economic culture. (Thanks, but we’d prefer a 2 percent mortgage over a 16 percent mortgage.) 
• And finally, medical doctors have it made. (I’ll let your mind run where it wants to with that one.)

Here are some things I thought were absolutely true until just recently: 

Only a human could possibly win a game of Jeopardy! Not so much. IBM’s Watson, a question-answering computer using a cluster of 90 servers with 2,880 processors and 16 terabytes of RAM, beat the all time Jeopardy! winner Ken Jennings. 

Here’s another - health care providers are the only ones who can accurately diagnose illness. Who else, after all, can talk to patients, examine them, review labs and imaging studies, think about a differential diagnosis and make a treatment plan recommendation? Well, it turns out, the Cleveland Clinic, Sloane-Kettering and WellPoint all think Watson will eventually be better than human providers, and they’ve invested their money in Watson to do so. After Watson has a query posed that describes a patient’s symptoms and other related data, it reviews the patient’s health record for pertinent history, labs, images, notes from other care providers, treatment guidelines, clinical studies, research materials and comparisons to other similarly situated patients to come up with a differential diagnosis and treatment plan. 

If all that seems like it’s a long way from Springfield, consider this: Mercy has worked with a company called Ayasdi to review the data from our millions of patient records in Epic to come up with care paths for the diseases we most commonly treat. The result? After the Ayasdi computers combed through millions of our data points, they have created treatment plans based on a subset of all those patients who had the best outcomes under our care. The big question now is what will we do with this new information?

Now, let’s add this. Today the Mercy Virtual Care Center (VCC) in St. Louis is remotely monitoring the care of many patients who have multiple complicated medical conditions. Each of those patients has Bluetooth-enabled monitoring equipment in their home for data like heart rate, temperature, respiratory rate, oxygenation, blood pressure, blood sugar and weight, which is automatically uploaded into Epic and transmitted to providers at the VCC. When their results start to fall out of line, these patients receive phone or video calls from VCC providers who put treatment plans in place before an adverse event occurs. 

Can you see where this is going? If, like me, you believed that the diagnosis and treatment of human illness was squarely in the hands of other human beings…well, maybe what we know just ain’t so. We are in a time when many things, formerly done by thinking human beings, can be reduced to a computer software algorithm, replaced by a robot or outsourced to those who can do it better, faster and cheaper. 

But before some of you get a sinking feeling in your gut and make predictions about the apocalypse, think about these things: The biggest increases in the labor force have been in education and health services, which have doubled as a percentage of total jobs since the 1970s. During that same time, employment in professional and business services was up 80 percent and hospitality and leisure services are up 50 percent. Today, there is a clear trend toward more employment in industries that value human interaction. 

The trend toward thinking being done by computers while humans focus on social interaction is also clear. The analytic skills of math and science are ever more susceptible to low cost competition and software. College graduates with high cognitive skills are using those skills less. Since 2000, the amount of brainpower required of college graduates has decreased and in 2012 reached the same level as 1980. Cognitive skills are still important, but those who use their cognitive skills in addition to showing an ability to build relationships, brainstorm, collaborate and lead are in a superb position to thrive. 

We’ve evolved from the industrial era, to the knowledge era, to the relationship era. As people who’ve dedicated our lives to the care of other people based on our ability to use our knowledge to form a caring relationship with them, this should make us feel hopeful. 

The fact is, change is inevitable. The way we do things, how we achieve our goals, even where we carry out our service to others is going to change. Those changes don’t make us a victim, however. If we accept those changes, adapt our thinking around those changes, create and maintain meaningful relationships with each other, as well as those we serve, we become the masters of our fate. Although there is much we don’t know about our future, when we actively engage in creating that future, there is a lot less to be fearful of, and a lot more to look forward to. Just think of what we will do together.

The Culture Question

There’s a saying we frequently use at Mercy. I’ve also heard it used in other organizations with variations of the same words: “Culture eats strategy for lunch.” 

That saying, originally attributed to Prof. Peter Drucker, the man many would say invented business management in the latter part of the 20th century, essentially conveys the idea that no matter how much a group might want to accomplish together, the way they treat each other will be of far greater importance in determining what they’re ultimately able to do. And while Prof. Drucker certainly deserves his place in history for his business insights, it was Mercy foundress Catherine McAuley who observed nearly 100 years before Prof. Drucker’s birth that, “who we are together is more important than anything we will ever do.” 

It’s a rare moment of clarity when business and religious leaders come to the same philosophical conclusion like this. As such, it seems worth taking some time to think more deeply about what this means within our own organization. It’s a question of culture. 

We obviously have strategies to improve patient satisfaction, co-worker engagement and financial performance. Leaders throughout our organizations spend a lot of their time thinking about those three issues and what can be done to influence them. But do we have the culture within our organization to execute those strategies? It’s not an easy question to answer. After all, it’s difficult to see the picture when you’re inside the frame. Further, one’s perspective changes depending on the vantage point within the picture. Even coming up with an acceptable definition of culture isn’t exactly straightforward, although one I particularly like is, “It’s what happens when the boss leaves.” Said differently, it may be as simple as how we feel about the people in our organization. 

So one way or another, we have a culture, and there’s little doubt that it’s the culture we deserve – one that we have behaved our way into. Describing it is important as it says volumes about who we are. Perhaps equally important is the expression of our culture to the world outside of Mercy. That expression is known in advertising and marketing circles as our brand and it’s nearly impossible for an organization’s brand to fall far from its’ cultural tree. Thus, whatever we believe our culture to be has a natural resonance in our communities and with our patients. Surely they do not see anything different in us than we see in ourselves. 

The poet Maya Angelou once wrote, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” I’m curious when you go home to your families, what feelings do you take with you about the people you work with? In other words, how would you describe our culture? Let me know your thoughts. Email me at alan.scarrow@mercy.net.

Motivated Reasoning

In the field of organizational behavior, there’s something known as motivated reasoning – that’s when someone seeks explanations that confirm their beliefs and ignore everything to the contrary. For example, both before and after Apollo 11 landed on the moon in July 1969, the International Flat Earth Society proudly denounced the whole venture as a hoax. No amount of NASA film, television coverage, Neil Armstrong and Buzz Aldridge testimony - not even 47.5 pounds of moon rock could persuade them to believe otherwise. It was, in their minds, a myth the U.S. government perpetuated to cover up a yet-to-be-determined evil scheme.

Regardless of your feelings about the International Flat Earth Society, they were certainly not the first, nor the last, to engage in motivated reasoning. Throughout history, seemingly rational people have used motivated reasoning to explain myths. For example, the Viking warriors wore horns on their helmets, sharks don’t get cancer and tomatoes are vegetables (all not true by the way). One myth that invoked my own youthful motivated reasoning was the notion of a genie in a lamp – that somehow a very small 2,000 year-old magic woman could live in a bottle, reappear outside the bottle looking as a youthful, normal-sized Barbara Eden, and be able to provide the owner of the bottle with anything imaginable.

Laugh if you’d like but there were five seasons of superbly acted reruns to persuade a certain kindergartener of the possibility that even though he seemed small, there was a way to gain some control over the big world.

But eventually the kindergartener grows up and magical thinking is set aside in favor of that which is rational and determined. Still one can’t help but have fleeting moments when the thought of a genie’s magic would be...well, very helpful. A moment thinking, “if only…” and then a magical, irrational idea to follow. If only spinach tasted like apple pie…if only I knew then what I know now…if only Miami Beach was next to Osage Beach.

In the spirit of motivated reasoning and magical thought, I ask you to imagine that for one day there is a Mercy genie who could grant you a single wish. The wish can only happen within our hospitals and clinics and must make your job or our Ministry better in some way.

I'll help you get started. “If only…” Email me the rest at alan.scarrow@mercy.net (unless you are a member of the International Flat Earth Society in which case you can send me an encrypted letter – just to be safe).

What is an Excellent Community?

Those of us who spend time in the hospital have likely seen the addition of a feature from the automobile manufacturing floor to a number of patient care and support areas. The lean production process derived from the Toyota Production System has been adopted by a number of leading health systems including ours. 

The lean process is aimed at focusing co-worker time and energy on things that add value to our patients and reducing everything else. The “lean board” is a running scorecard for how we’re doing at fulfilling that principle and is updated each day in a huddle with team members. This board is organized with the five areas of excellence our organization is focused on: clinical, service, cultural, financial and community. Even if you’re not familiar with that list, the first four probably seem fairly obvious and straightforward. One would hope that any health system would aspire to have excellent clinical outcomes, an exceptional patient experience, an engaged group of co-workers, and to fulfill their mission while achieving financial profits to sustain the organization over the long term. 

But what does an excellent community look like and how does a health system make it more excellent? If you look closely at the lean boards, you’ll see the difficulty in answering that question. The “community” portion of the board is often blank. 

Here’s what we know: Communities with excellent health have low rates of poverty, heart disease, cancer, stroke, hypertension, COPD, diabetes, obesity, asthma and low birth weight babies and a high percentage of people with health insurance. Health insurance is a key driver of health status as lack of insurance is a primary barrier to primary and specialty care and other health services. Greene County is 2 percent higher than the rest of Missouri’s adult uninsured rate and roughly 36,800 adults without health care insurance. 

Here’s what we don’t know: How does our organization make an impact on those metrics? By growing the number of patients we care for, we’ll be able to create some new jobs but even the most optimistic would find it unrealistic for us to make a meaningful impact on the region’s poverty. Similarly many of the diseases listed above such as COPD, obesity and heart disease are the result of behavioral habits made by individuals. Even with our most idealistic glasses on, it’s hard to envision a health system capable of reaching into people’s lives to affect years’ worth of habits and decision-making. 

Which leads to this. We can’t do everything, but can do something, and we shouldn’t let all that we cannot do interfere with what we can. When we look at that blank community space on the lean boards, what should we fill it with? What should we be doing for our community to make it more excellent? I am interested in your thoughts. Email me at alan.scarrow@mercy.net.

Complex and Opposing Thoughts

F. Scott Fitzgerald, author of The Great Gatsby and considered by many to be one of the greatest writers in American history, has a quote that I’m reminded of fairly frequently:

“The test of a first-rate intelligence is the ability to hold two opposing ideas in mind at the same time and still retain the ability to function.”

It’s debatable whether it takes “first-rate intelligence” to hold opposing thoughts, but there’s no doubt that each one of us takes in all the information life throws at us each day, and then we try to create simple rules that make sense of the complexity that surrounds us.

When we generalize, we’re trying to make things more shallow and superficial. Even those of us who have chosen to specialize in one particular area have the same desire for simplification. We want to believe that things outside our specialty must follow rules similar to that which govern things inside our specialty. Either way, the desire to simplify ignores the complexity and nuance that makes up the world around us.

This desire has plagued science for generations. The first scientists of the 17^th and 18^th centuries had to solve simple problems such as what forces were at work when a cannon ball fell to earth or why the earth rotated around the sun. Later in the 19^th century came the challenge of making reliable predictions about seemingly unpredictable things like the movement of gas particles in a vessel or the transfer of heat from one medium to another. But the problems of the last century are complicated and defy simple rules and generalizations; things such as how to pull oil from rock shale miles under ground, understanding how our cells age or how our environment affects our bodies. These are problems that have and continue to require thousands of the brightest minds working millions of hours on ideas that are complicated, nuanced and bring together people with perspectives that are often directly opposite one another. This is science in 2015, and no branch of science demonstrates any more nuance and complexity than medicine.

Here’s an example. Today, for our organization to sustain itself, we must do two things simultaneously that seem at odds with one another. We must grow and reduce our costs and do so in an environment that is extremely complex. Growth is necessary for us to reach an economy of scale and maintain a full complement of sub-specialty care that our 459,000 patients need. At the same time the government, insurers and companies that pay for our services have shown us that we must lower our costs without compromising quality of the care if we expect them to choose Mercy as their provider. Meanwhile we must make certain that our 11,000 co-workers are paid competitively; and have opportunities for growth and personal accomplishment; and make sure we are in compliance with federal, state and specialty certification; and make sure our quality of care doesn’t slip; and reinvest in our hospital and clinic infrastructure; and come up with innovative ways to provide better care; and support our community with time and philanthropy; and well, you get the idea.

It’s difficult, complex and nuanced, but at the same time exciting, rewarding and filled with opportunity. With all that we have done and all we have yet to do, I believe if Mr. Fitzgerald was alive today and came to visit us, he would look around and say, “These are people with first-rate intelligence.” It is an honor to serve with you. 

Overcoming Adversity

Below is my most recent discussion as part of a Leadership Development series.