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Cost Containment: The Importance of Nurses @Medici_Manager @helenbevan @pash22

by September Wallingford, RN, BSN

Due to ever increasing healthcare costs, stakeholders in the healthcare system rely heavily upon front-line workers to assist in containing costs to help make healthcare more affordable. Since nursing is the largest sector of front-line workers, the field has an opportunity to greatly impact cost containment. Currently, there are 2.7 million nurses in the workforce, with an expected growth rate of 26% over the next decade; however, there has been limited discussion on how nurses can help contain healthcare costs.

Why are nurses not usually integrated into the cost containment discussion? Why have we not been invited to the table? Likely, it is because we don’t have the power to order (or discontinue) tests, labs, or medications, all of which are major factors in the rising costs of care. Even so, a nursing perspective can be important and should be considered when doctors make treatment decisions.

For example, I recently treated a patient who had undergone abdominal surgery. Despite uncomplicated post-operative days 1 and 2, on day 3, he developed nausea, vomiting, and an increasingly distended abdomen. I administered intravenous anti-nausea medications, along with back rubs and cool cloths on his forehead. None of the treatments worked. While waiting for the doctor, I sat with the patient and spoke to him about the possibility of receiving a nasogastric tube to alleviate his symptoms. Given an understanding of the process, the patient agreed to this possibility and I paged the doctor once again. The doctor eventually placed the nasogastric tube, the tube was connected to suction, and out came a liter of gastric contents.

I then noticed that the doctor had put in an order for an abdominal x-ray to “check nasogastric tube placement.” Seeing this, I initiated a conversation with the doctor to discuss the patient’s symptomatic improvement as well as his current state of exhaustion. I assured the doctor that nurses would be at the patient’s bedside to monitor for signs and symptoms of tube malfunction. As a result, the doctor cancelled the x-ray, which not only eliminated an unnecessary test for the patient, but also reduced the cost associated with his care.

Situations like these are commonplace to nurses across the country. We witness daily that more is not necessarily better, and we are in a position to help make decisions that lower costs without negatively impacting the patient’s care. Nurses bring a unique perspective to the healthcare cost conversation, so include us in the discussions, give us a seat at the table, and utilize us as active participants in the fight against rising healthcare costs.

September Wallingford is a registered nurse at an academic medical center in Boston, Massachusetts. She is currently completing her graduate nursing education to become an Acute Care Clinical Nurse specialist.


Why you should reframe your strategy as transformational @Medici_Manager @helenbevan @muirgray

In my last post, I talked about strategy as logic; that is, a system of reasoning we utilise, based on our views and beliefs, about how to achieve change.

My own strategic logic for change (and therefore my practice as a leader of healthcare improvement) has been particularly influenced by Marshall Ganz. Ganz spent decades as a community organiser, leader and enabler of campaigns and social movements before joining the Kennedy School of Government to teach, research and write about leadership of change from a social movement perspective.

It’s very helpful for healthcare leaders to reflect on Ganz’s logic and definition of strategy: how we as leaders turn what we have (resources) into what we need (power) to achieve what we want (outcomes) by focusing on clear strategic objectives. I’m concentrating on this perspective specifically in this blog and will discuss resources next time.

The Montgomery bus boycott

We can see these strategic principles in action in so many of the inspiring stories of social change. Let’s take the example of the Montgomery bus boycott which was a pivotal point in the genesis of the American civil rights movement in 1955-56. Following the arrest of Rosa Parkes for refusing to give up her seat on a bus to a white passenger, the black population of Montgomery, Alabama, boycotted the town’s buses in protest at racial segregation of buses.

By organising for civil rights, a group of largely dispossessed marginalised African Americans was able to pool resources to create collective power for change (enough people withdrawing their use of buses and payment of bus fares so that it had a profound impact). They built power both by pressing the authorities for reform through united action and growing their movement by winning other people across the nation to support and take action for their cause.

And they achieved the outcomes they sought: pressure for change increased across the country and eventually the segregation rules were deemed unconstitutional by the courts.

Ganz, along with other commentators, concludes that the leaders of social movements (“voluntary organisations”) typically have fewer levers and resources for enacting change than leaders of formal organisations have. This makes the strategic focus of leaders, to turn potential resources into power for change, even more important.

Ganz quotes James Q. Wilson:

“In most voluntary associations, authority is uncertain and leadership is precarious. Because the association is voluntary, its chief officer has neither the effective power nor the acknowledged right to coerce the members – they are, after all, members and not employees. In a business firm, the chief officer may, within limits, hire and fire, promote or demote, his subordinates…

“In most associations, power, or the ability to get a subordinate to do what the superior wants, is limited, and authority, or the right toexercises such power as exists, is circumscribed and contingent.”

Use your levers

I concur with Wilson that the kinds of levers and resources available to organisational leaders can create an easier set of circumstances for enacting change (when compared with social movement leaders who have none of these resources). However, on their own, coercion, compliance and other organisational mechanisms won’t create sustainable transformational change within and across organisations.

So I don’t necessarily agree that organisational leaders have a more straightforward task in leading change. In fact, I think that leaders of health and healthcare who are seeking radical changes across their organisations and systems in an ever more complex and unpredictable world have got more in common with social movement leaders than they have differences.

Many NHS change strategies are driven by logic based on extrinsic levers for change: incentivising payment systems, regulatory and quality assurance systems and holding leaders to account to deliver change outcomes. The strategic logic of social movement leaders is essentially based on igniting intrinsic motivation: building shared purpose, connecting with values, mobilising actions and taking meaningful action.

Transformational change across the NHS system requires both intrinsic and extrinsic factors and we as leaders need to find ways to align them and balance the tension between them. Otherwise there is a tendency to overemphasise the extrinsic factors and inadvertently kill off the energy, creativity and sense of psychological safety that people need to innovate and deliver goals for change.

Peter Drucker got it right when he advised organisational leaders to “accept the fact that we have to treat almost anybody as a volunteer”. We can learn greatly from the strategic approaches of social movement leaders who led change that succeeded because people wanted to be part of the change, not because they had to be. They have a lot to teach us about motivating, mobilising and building power for change through the assets and resources of a communitybased on common interests and a common goal, creating capacity for change from within.

Some questions to consider:

    • What is the shared purpose underpinning our change efforts? Is it framed in a way that connects with values and builds intrinsic motivation?
    • What leadership actions can we take to shift power in the system and get the outcomes we seek?
    • Think about loss and gain: what control/power might we have to surrender in a hierarchical sense to enable a more distributed leadership system and quicker, wider progress of change across the system?

For more resources on large scale change, follow Helen Bevan on Twitter @helenbevan

Learning to do more with less @Medici_Manager @helenbevan @pash22

By Christopher Moriates, MD and Andrew Lai, MD MPH

University of California, San Francisco

The daily “Resident Report” conference at the University of California, San Francisco (UCSF) started a little differently yesterday. The Chief Resident stood at the front of the room and asked the audience, “How many of you ordered labs for a patient this morning?”

Only 2 people in a crowd of more than 20 put up their hands.

Yesterday’s lab ordering restraint was not because of our focus at UCSF over the last two years on decreasing unnecessary services and costs of care, nor the fact that our Chair of Medicine, Dr. Talmadge King, has declared “Choosing Wisely” a Departmental priority. In fact, in 2010-2011, housestaff were offered an incentive of $400 each if they were able to reduce common labs by 5% — they didn’t.

At UCSF we have been exploring listing the prices of labs on order screens, much like was successfully done at Johns Hopkins. We have tried educational programs and feedback to reduce the costs of daily lab ordering, much like was described in the memorably titled research paper, “Surgical Vampires.”

So what finally got them to not order daily labs yesterday?

It was a strike by the patient care technical workers represented by the American Federation of State, County and Municipal Employees (AFSCME), in conjunction with a “sympathy strike” by the University Professional and Technical Employees (UPTE), which occurred at all University of California medical centers. This severely limited resources with virtually nobody in the hospital to collect and process labs.  This created a situation where labs, along with imaging and procedures, could only be performed under truly urgent circumstances.  As a result, our Chief Medical Officer reported that our medical center ordered less than half the usual number of labs.

Let’s be clear: this strike was not good for patient care and resulted in cancelled surgeries and chemotherapies, as well as the inability to accept inpatient transfers from community-based hospitals despite these patients needing specialized care. But if we are to find a silver lining of this strike, it did indeed serve as a teachable moment for forcing clinicians to think more thoughtfully about our diagnostic test patterns. Our medical service leadership counseled all teams to ask themselves “Does my patient need this test?” and “Is there another patient who needs this test more?”, simple questions that should automatically cross our minds every day in our daily work flows.  It is possible that this two-day experiment may provide an impetus to ingrain this sort of reflective – rather than reflexive – ordering practices into the culture post-strike. At least for a few days it seemed to break the stronghold of routine daily labs.

After all, our Chief Resident asked a follow-up question to the “Resident Report” group yesterday: “How many of you felt that not ordering daily labs this morning impacted your patient care or outcomes?”

Not a single hand.


Christopher Moriates, MD (Twitter: @ChrisMoriates) is an Assistant Clinical Professor at UCSF. He is the Co-Chair of the UCSF Division of Hospital Medicine High-Value Care Committee. He works with the ACP, ABIM Foundation, and Costs of Care on educating physicians about healthcare value. 

Andrew Lai, MD MPH is an Assistant Clinical Professor at UCSF. He directs the Division’s Case Review Committee and co-directs the Hospitalist Procedures Service. He is a member of the Division of Hospital Medicine High-Value Care Committee, Quality Improvement Committee, and the Global Health Committee.  

The Unwritten Rules of Management @Medici_Manager @helenbevan


William Swanson’s unwritten rules of management is full of pithy advice. Swanson is the Chairman and CEO of Raytheon.

Originally a part of a presentation to engineers and scientists at Raytheon, someone asked him to write his rules down.

Thankfully he listened, the result is Swanson’s Unwritten Rules of Management.

Not all of the rules are Swanson’s. Some of them were published in 1944 in The Unwritten Laws of Engineering by W. J. King. (The book was updated in the early 2000′s by James G. Skakoon.)

In The Unwritten Rules of Management, Swanson elaborates on these rules with a paragraph or two.

  1. Learn to say, “I don’t know.” If used when appropriate, it will be often.
  2. It is easier to get into something than it is to get out of it.
  3. If you are not criticized, you may not be doing much.
  4. Look for what is missing. Many know how to improve what’s there, but few can see what isn’t there.
  5. Presentation rule: When something appears on a slide presentation, assume the world knows about it, and deal with it accordingly.
  6. Work for a boss to whom you can tell it like it is. Remember that you can’t pick your relatives, but you can pick your boss.
  7. Constantly review developments to make sure that the actual benefits are what they are supposed to be. Avoid Newton’s Law.
  8. However menial and trivial your early assignments may appear, give them your best efforts.
  9. Persistence or tenacity is the disposition to persevere in spite of difficulties, discouragement, or indifference. Don’t be known as a good starter but a poor finisher.
  10. In doing your project, don’t wait for others; go after them, and make sure it gets done.
  11. Confirm the instructions you give others, and their commitments, in writing. Don’t assume it will get done!
  12. Don’t be timid; speak up. Express yourself, and promote your ideas.
  13. Practice shows that those who speak the most knowingly and confidently often end up with the assignment to get the job done.
  14. Strive for brevity and clarity in oral and written reports.
  15. Be extremely careful of the accuracy of your statements.
  16. Don’t overlook the fact that you are working for a boss. Keep him or her informed. Whatever the boss wants, within the bounds of integrity, takes top priority.
  17. Promises, schedules, and estimates are important instruments in a well-ordered business. You must make promises — don’t lean on the often-used phrase, “I can’t estimate it because it depends upon many uncertain factors.”
  18. Never direct a complaint to the top. A serious offense is to “cc” a person’s boss on a copy of a complaint before the person has a chance to respond to the complaint.
  19. When dealing with outsiders, remember that you represent the company. Be especially careful of your commitments.
  20. Cultivate the habit of boiling matters down to the simplest terms. An elevator speech is the best way.
  21. Don’t get excited in engineering emergencies. Keep your feet on the ground.
  22. Cultivate the habit of making quick, clean-cut decisions.
  23. When making decisions, the “pros” are much easier to deal with than the “cons.” Your boss wants to see them both.
  24. Don’t ever lose your sense of humor.
  25. Have fun at what you do. It will reflect in your work. No one likes a grump except another grump!
  26. Treat the name of your company as if it were your own.
  27. Beg for the bad news.
  28. You remember 1/3 of what you read, 1/2 of what people tell you, but 100% of what you feel.
  29. You can’t polish a sneaker. (Don’t waste effort putting the finishing touches on something that has little substance to begin with.)
  30. When facing issues or problems that are becoming drawn-out, “short them to the ground.”
  31. When faced with decisions, try to look at them as if you were one level up in the organization. Your perspective will change quickly.
  32. A person who is nice to you but rude to the waiter — or to others — is not a nice person. (This rule never fails.)

Leaders are made, not born (great video) @pash22 @Medici_Manager @WRicciardi @muirgray

Great video by

Many of the system-wide issues we face won’t be solved by management processes @Medici_Manager

POSTED BY  ⋅ MAY 28, 2013

If the future sustainability of the NHS means its leaders will need to make tough decisions, how can leaders make sure they are making the right ones? In my chief executive roles in the NHS, I’ve made some difficult decisions – some clinical, some financial, many staff related. All had patient and service impact.

You could probably guess at the areas they might have covered: where to invest new resources, how to structure new organisations, which of the best people to promote, whether to reduce funding for services with limited clinical value, how to tackle the viability of a service, and so on.

They were all difficult, but they mostly related to ‘tame’ problems. I’m not being flippant, I’m using language coined by academic, Keith Grint, who says that if a problem can be solved using a process, then it is ‘tame’. The problem might be complicated, but there’s a process and we know the answers. So in the organisations I’ve worked for, we engaged with patients and the public, consulted using statutory guidance and followed organisational policies and procedures. There was process and we followed it.

Then there were the incredibly difficult problems, those which were complex, longer term, strategic, multi-dimensional and with no obvious answer or process. The sort that Grint refers to as ‘wicked’.

As chief executive of a primary care trust (PCT) in Sheffield, our goal was to reduce the 13-year health inequality gap between the best and worst outcomes in the city. We wanted to work out how best to measure the impact of our investments – either unilaterally as a PCT or as part of multi-agency approaches – so that we’d make a difference 30 years from now. It took difficult to a new level.

Do you focus on housing, social care or education? Or what about the justice system, benefits, improving NHS services or health promotion? Where will the greatest impact be made? Impossible, right? These sorts of complex problems, says Grint, are wicked. We’ve not come across them before, we don’t know the answers and we can’t solve them alone. The best we can do is to come together to try.

In Sheffield, and with support from the Health Foundation and the London School of Economics, we tried a new approach that brought together clinicians, patients and managers from across the health system to work through problems, looking at how we could combine value for money analysis with stakeholder engagement.

The approach was designed to help us move forward, not necessarily to find the answers, engaging with patients, staff and data, investing a lot of energy and staunch commitment. In short, we were working it through.

When staff are looking for solutions, when boards are holding you to account, would you be bold enough to respond “we’re working it through”? It takes someone with great leadership skills to know it’s the not only the right answer but the only answer for wicked issues. For many of the system-wide issues we face today, we won’t solve them with management processes.

We need leaders who are comfortable with the journey, who want to work in collaboration across system boundaries and who know that making a difficult decision is sometimes the wrong thing to do.

If senior leaders are always dealing with problems where there’s an answer, they’re dealing with the wrong things. Finding the right question is as important as finding the right answer.

Jan Sobieraj is managing director of the NHS Leadership Academy. Follow Jan on Twitter @JanSobieraj

5 Leadership Lessons An MBA Can’t Provide @Medici_Manager @CEOcom @muirgray

First he talked about the importance of inspiration. Then he described the power of passion. Then he shared the value of vision.

Then I almost fell asleep.

The professor was describing the traits of a great leader. I certainly didn’t disagree with his list: Vision, passion, inspiration, dedication, fairness and accountability. All are important traits of a great leader.

Still, even then I knew I wouldn’t remember almost anything he said. Platitudes are hard to remember, much less put into practice. “Inspire your team,” is great advice, but how exactly do you inspire them?

As I walked away I decided most of what I know about leadership didn’t come from business schools or conferences or seminars. The best leadership lessons are the ones I learned the hard way:

1. Information comes and goes, but feelings are forever.

Data is important. Explaining the logic and reasoning behind a decision can help create buy-in and commitment. Charts, graphs, tables, results, etc., are useful—and quickly forgotten.

But make an employee feel stupid or embarrass him in front of other people and he will never forget.

An employee made a comment in a meeting, and I instinctively fired off a sarcastic comeback. Everyone laughed but the employee. (For a long time, I was like a sarcastic-comment sniper who figured that if I had the witty shot I should always take it.)

And my working relationship with that employee was forever changed. I apologized on the spot and also later, but the damage was already done.

Spend twice the time thinking about how employees will feel than you do thinking about data and logic. Correcting a data mistake is easy. Overcoming the damage you cause to an employee’s self-esteem is impossible.

2. The best ideas are never found in presentations.

Presentations are a great way to share detailed, complex information. Presentations are a terrible way to share great ideas.

After I drank too deeply from the Six Sigma Kool-Aid I started interrupting employees who came to me with ideas by telling them to “put something together.” A few would: Then we’d whip out our multicolored belts and talk intelligently about their data, their analysis techniques, their conclusions… ugh.

Most wouldn’t bother, and looking back I don’t blame them.

Great ideas can be captured in one or two sentences. Your employees have those ideas.

All you have to do is listen. And your employees will love you for listening, because I guarantee people they used to work for never did.

3. The “volunteer penalty” kills the flow of great ideas.

Your best employees tend to come up with the best ideas, and it’s natural to assign responsibility for carrying out an idea to the person who came up with the idea. Plus, if that person is a great employee it’s natural to want them to take responsibility because they’re more likely to get things done.

Of course, your best employees are already working extremely hard, so assigning them responsibility every time they have a suggestion naturally stops their flow of ideas.

As one outstanding employee finally explained to me, “I finally realized I needed to stop suggesting things to you. Every time I did you just added another responsibility to my plate.”

Sometimes the employee will welcome the responsibility for carrying out their idea. Other times they won’t. How do you know how a particular employee will respond?


4. Sharing only the positives always results in a negative.

Imagine you’re sharing the reasoning behind a decision you made with your team. Naturally, you want to describe the positive outcomes of the decision. So you whip out your pom-poms and start cheering.

Meanwhile your employees are instinctively looking for negatives, since almost every silver lining for the business has a black cloud for at least a few employees.

I once described how a change to paper dust collection would improve the air quality throughout the plant, but I left out the fact that as a result a few employees would spend at least part of each day looking like they had rolled around in a bathtub filled with flour.

Never leave out the negatives, even if those negatives may be potential rather than actual. Talk openly about any downsides, especially when those downsides directly affect employees. Show you understand the best and the worst that can happen and what that might mean to your team.

When you freely discuss potential negatives, employees not only respect you more, they often work harder to make sure potential negatives don’t turn into realities.

5. Data is accurate, but people are right.

You’re smart. You’re talented. You’re educated. Data analysis is your best friend. Sometimes your data will lead to an inescapable conclusion… and yet you should still make a different decision.

I once moved two crews of about 30 people to a different shift rotation because I knew the resulting process flow would automatically improve overall productivity by about 10 percent. I also knew, because they told me, that most of them would hate the new rotation. But I held firm because I knew great leaders are willing to make tough decisions and do whatever it takes to get results.

It turns out I had that all wrong.

Sure, my new shift rotation worked on paper. It even worked in practice. But it screwed up the family lives of a number of great employees, and I finally pulled my head out of my [butt] and shifted everyone back to the old rotation. We found other ways to improve productivity.

Sometimes a decision should be based on more than analysis, logic, and reasoning. No decision should ever be made in a vacuum, because every decision must eventually be carried out by people.

Leadership should be data driven, but great leadership is often subjective and even messy. If your employees don’t agree with you, ask why, but don’t ask just so you can defend your position. Ask in order to learn.

You know things your employees don’t know, and they know things you don’t know—at least until you listen to what they have to say.

Richard Smith: Health and social care: lots of activity, little value @Richard56 @Medici_Manager

21 Jun, 13 | by BMJ Group

My mother is a wonderful woman but has no short term memory and drinks too much alcohol. When she’s sober her language is complex and her sense of humour magnificent. “What a terrible world,” she says, watching the television news, “I’m glad I’m not in it.” In a way, she isn’t. She’s mildly disinhibited even when sober and chats to everybody. “You’re one of the sights of Barsetshire,” I say to her, “they’ll be organising coach parties.” “Well, nobody ‘ll pay,” she answers laughing. But how much have the health and social services helped my mother?

She’s clear that she wants to live on her own as long as possible. In an age gone by, but still present in most of the developing world, she would have lived with me or my brothers. It would be unthinkable that when widowed she should live alone. But those days are finished. We couldn’t stand it and nor, I’m confident (but maybe deceiving myself), could she.

It’s fascinated me how well and for how long she has lived alone despite having no short term memory. It’s been some six years. I thought an intact short term memory essential for living alone, but I was wrong. Luckily she doesn’t cook, so doesn’t leave the gas or the oven on. She forgets to put water in the electric kettle and sometimes blows the fuses, but she doesn’t blow up the house.

Every day is much the same. She gets up at about 8.30, has a cup of black coffee, looks at the Guardian (making no sense of it), puts on her shoes, and “stomps,” as she describes it, the mile into the centre of Barset. Greeting the man in the newsagent, she buys a bottle of wine, stomps home, hailing people as she goes, drinks the wine, and goes to bed. Perhaps two hours later she gets up and does it all again. And when the days are longest, she may attempt it a third time—unaware that it’s evening not morning and unsteady on her feet after two bottles of wine. That’s why I’m sat here in Barset writing this. I’m “mothersitting.” She giggles at the term but doesn’t really like it.

Back at the beginning I thought that we ought to “get her into the system.” I thought that we’d need some support and that it would be essential to be “on the books” to receive it. So we went to the GP, which she doesn’t like. The trainee said that she should have some blood tests and come back to have “the long test for memory.” That was two trips, 140 miles driving, and when we had the appointment for the long test, the doctor didn’t have time to administer it and so simply referred her to the memory clinic. There was no value added by all this as the postman could have told us that she has no short term memory.

The adventures with the memory clinic were long and drawn out with MRI scans, psychological tests, many interviews with a variety of people, and some 350 miles of driving. My mother hated it all, but in the end she was prescribed drugs to help her memory. She forgot to take them and didn’t, I think, want to take them anyway, although she said she did to please us all. Even if she had taken the drugs there was only a small chance that they would have done any good. Everybody was charming and helpful, but no value was added by all this activity—except that the diagnosis released some state benefits.  It was bureaucratic value that was added.

Social services became involved. They came and did a long assessment. Eventually, they said, she’d have to go into a home. This wasn’t surprising. They couldn’t do anything except give us a list of services. They couldn’t recommend any service even though they presumably know which are better than others. So no value in this.

We arranged for a “sandwich lady” to come three times a week to encourage my mother to eat. But that was hopeless, and eventually my mother herself told the sandwich lady that she didn’t need her anymore.

Social services assessed her again and told us the same as before. They did arrange a bath chair, which did add a little value. Unfortunately it broke down almost immediately and took a long time to fix. Now they’ve taken it away. I’m not sure why.

We arranged for carers to come in twice a day, and they have added value. But we found them and have to pay as my mother owns her house.

What about resuscitation, the care company asked. My mother is very clear that she doesn’t want to be resuscitated. We talk about death a lot. She’s not scared of death. But we can’t have a DNR in place without having the doctor approve it. So we haven’t bothered. If the carers find her in cardiac arrest they are highly unlikely to succeed in resuscitating her anyway. Having to have a doctor determine your eligibility for a DNR seems to me a process that subtracts value.

Now things have reached a crisis. With the long evenings my mother is going out late and drunk and having all kinds of adventures with neighbours, the police, and the burghers of Barset. The care company has contacted social services worried that it might be blamed if she goes under a bus. So have some neighbours. A young man from social services rings me in a state of high excitement. He asks me things that we have told social services many times. He’s rung the GP asking for an assessment. He offers us another assessment. “What good will that do?” I ask. He’s not clear. I say that we recognise she can no longer live alone even though she insists that she wants to. We’ve started finding a home.

They can’t, it’s apparent, really do anything. I ring the GP and speak to a friendly understanding doctor. They have been contacted by social services and discussed her in their meeting. But nobody knows anything about her. A doctor has visited twice but never got an answer. Somebody is going to try again. The young doctor agrees that they have little to offer. I’ve not heard from them since.
Social services keep ringing because people are ringing them. The care company tells me that they will do anything to help but in the same call, without irony, tell me that they can’t supply somebody in the light evenings.

My brother asks who social services are serving?  Are they there for my mother or the neighbours? We recognise the strain on the neighbours, and we know most of them. Some have been very helpful. Ages ago I delivered them all a letter asking them to contact any of us if they had worries. I’m not sure why they ring social services rather than us.

Then my mother has a fall. It had to happen. Indeed, it’s happened before. This time she has a scalp wound, and we doctors (and surely most others) know that scalps can bleed generously. I was abroad unfortunately, so my brother rings 111. Risk averse, as they have to be, they recommend a visit to A and E. Nobody can be sure that she wasn’t unconscious. A young doctor thinks she might have a urinary tract infection to account for her confusion and prescribes antibiotics. They can’t be taken with alcohol. He suggests a visit to the GP in four days’ time. I say poppycock to all this when I return, and we forget the antibiotics and the visit to the GP. She is fine. So again more activity, more expense for the NHS, and no value. At least she hasn’t developed diarrhoea through taking antibiotics.

A woman from social services rang again today. She’s weary. I tell her that we are in the final stages of the bureaucracy of finding a home. She’s relieved. I ask her what she might do if we weren’t doing anything. Eventually she would have to use the law to have my mother admitted to a care home. She could arrange an emergency admission to a home, but we agree that we should do all we can to avoid having to move her twice.

My mother is unaware that the phone lines of Barset are buzzing with concern about her. She’s not keen on moving to a home but will do what we advise. Seconds after we’ve had the conversation she has of course forgotten it.

When I reflect on the saga so far I can’t see that statutory health and social services have added anything but minimal value. But there’s been plenty of activity, form filling, and expense. My mother is not that unusual. We surely need better ways to get value out of the system.
I also reflect that people who have added a lot of value are those who work in the newsagent she visits every day. She likes them, and they are not only kind to her but also let her have goods without paying when she forgets her money and arrange a taxi to take her home when she’s tired and exhausted. Perhaps we need fewer expensive professionals and a revitalisation of communities.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.


Five (and a half) lessons I learned at the IHI National Forum @Medici_Manager

Dr Alan Willson, 1000 Lives Plus @dralanwillson –

Several people will be on their way from Wales to the BMJ/IHI International Forum in London next month. While there they’ll see innovation and best practice from around the world. It’s an opportunity to meet experts in quality improvement and patient safety and bring new knowledge back to Wales.

I’ve recently been reflecting on the ideas and examples I heard at the IHI National Forum last December. Here are five (and a half) lessons I learned, recognising a huge debt to Brent James and others who willingly shared their presentations with me so I could fully get to grips with what they were saying.

Lesson 1 – The quality improvement mindset is the opposite of top down management – and that is important

The frontline is where change matters because this is where we interact with patients. To change NHS Wales we need to follow Deming’s principle: Organise everything around value-added processes on the frontline – i.e. focus on the bits that will really make a difference to patients. Change needs to start here to be really effective.

Lesson 2 – Improvement has more to do with left brain than right brain

Innovation is fun. We all like to come up with ideas and then see if they work. But Bellin Health’s ‘High Performance Healthcare’ model indicates that a scientific approach to providing standardised levels of care is important to improving quality.

We don’t always have to do something new – what is more important is making sure the right things are done at the right time, in the right place and to the right people. Then, valuable improvement energy must be focussed on business critical problems and within a clear context of measurement and alignment with what else is happening in the system.

Lesson 3 – Quality and cost saving can and must be delivered together

The evidence from the QUEST initiative in American hospitals shows that improved quality and lower costs (or better control of costs) go together. We’ve also done some work on this, publishing a white paper last year. However, it’s very important that we set out with a focus on quality, not a focus on improving costs – better quality helps reduce costs; just trying to reduce costs won’t improve quality.

Lesson 4 – There is now an evidence base for high performance

The 10 most important elements in high performance have been identified in the QUEST hospitals. In the past we have had intuitive opinions, but now we have evidence-based key features that we should be looking to replicate in NHS Wales. We are fortunate to have Eugene Nelson speaking at the next 1000 Lives Plus National Learning Event on Tuesday 11 June to describe this ground breaking work.

Lesson 5 – Reducing harm from sepsis and surgical site infections are winnable fights

Some healthcare organisations have seen mortality due to sepsis drop by two thirds. Infections after c-sections have been virtually eliminated in many hospitals. It shows that deaths and harmful events can be stopped in Wales – the ways we can make this happen are out there.

 Lesson 5 and a half – We are on the right track with Improving Quality Together (but there is still work to do!)

If we can reach the point in NHS Wales where everyone truly believes that they have two jobs – to do their job and to improve their job – then this will result in improvements being initiated everywhere by everyone.

Improving Quality Together is a way of delivering this mass participation – but we need training, coaching and data for actionable measures to keep track of the improvements taking place and to evaluate them.

Let’s keep talking

I’d be interested to hear your comments on these lessons. Do they reflect what you know about the work going on in NHS Wales? What do you find intriguing? What makes you pause and go ‘hmmm’? Do comment.

Or, if you are at the International Forum next month, 1000 Lives Plus will be running the NHS Wales stand. Please stop by and say hello. If you can’t make it, then we’ll be blogging throughout the week to keep you up-to-date!

Most CEO’s have a cautious approach to innovation and it’s not paying off @Medici_Manager @StephenClulow

Why Low-Risk Innovation Is Costly

Companies are finding it hard to churn out “the next big thing.” Instead of the disruptive products, services and business models of yesteryear, innovations coming to market today are typically line extensions.

Our recent survey of more than 500 executives revealed that, while one in five (18 percent) respondents rate innovation as their top strategic priority and two-thirds depend strongly on innovation for their long-term strategy success, more than half feel they have a sluggish innovation process. Despite increasing commitment, funding and organizational accountability, many companies are disappointed by the returns they are deriving from their investments.

A cautious approach to innovation is understandable, given the relatively disappointing results. At the same time, however, it is a potentially perilous strategy. Enterprises that restrict themselves to incremental innovation, on the other hand, risk unknowingly entering a vicious cycle in which they lag ever farther behind.

By putting formal systems in place to manage innovation, companies can protect themselves from such risk. Enterprises able to successfully innovate at a breakthrough level are far more likely to dominate and prosper in the new markets they create. They can also position themselves to master change.

Leadership, doubt and humility @Medici_Manager @muirgray

Do you ever feel secretly inadequate?  I don’t mean the confusion of not quite understanding what’s going on in a busy and demanding world.  I mean feeling out of your depth, bewildered and doubtful as to whether you can do what is asked of you in your leadership role?  Or more accurately, a deep-seated and yet suppressed and secret feeling that really – you’re not up to the job?

I have.  My presenting behaviour, my ‘brand’ if you like, is confident, assertive, and assured.  I’m sure some people might even turn the volume up on those words and call me over-confident and maybe sometimes even rude.  These are behaviours I’ve been working on for years where I try and manage the thin boundary between genuine passion and unfortunate arrogance.  However, my internal experience is different.  Sometimes I look at the expectations people have of me, and I think ‘I’m just not up to this!’  I don’t feel like this all the time – but when things are tough and my resources are low I can find myself rocked and uncertain.

am i good enoughIf sometimes you feel like me – that you might not have what it takes – then we’re not alone. This feeling is called the Imposter Syndrome – and it’s completely normal. During my leadership development and coaching practice I’ve worked closely with numerous managers, leaders and fellow developers.  Pretty much every one has at some point said ‘I’m only one page ahead of the others’ or ‘I feel that at any moment I’m going to get found out for the fraud I know myself to be.’

Despite apparent evidence of one’s competence, when the Imposter Syndrome hits you’ll remain convinced that you do not deserve the success you’ve achieved, dismissing this inwardly as luck or fortuitous timing.  Psychologists would call it a phenomenon where successful people fail to internalise their accomplishments, unable to believe they are themselves responsible for, or deserving of, the position they’ve achieved.

I’ve met some truly brilliant people who experience this hindering internal pattern.  One in particular comes to mind – a bright and brilliant talent who is by everyone’s estimation a deserving young leader full of real promise.  By everyone’s estimation that is, other than her own.

Almost every leader I’ve worked with as a coach has expressed this personal doubt.  I say almost every leader – there have been a few that were justifiably nervous and rightly aware they were out of their depth – living examples of thePeter Principle where employees in a hierarchy will be successively promoted until they reach their level of incompetence.  But these weren’t the worrying ones – they were usually helped to find more fitting employment – sometimes uncomfortably, but normally appropriately and with compassion.

No, the really disappointing leaders were the couple that had no qualms at all of their capability.  Is it that they were so ‘complete’ and personally confident that they didn’t need to doubt themselves?  Quite the opposite – they were the real imposters who serendipitously found themselves in positions of influence but lacked the humility and insight to work reflexively on their own practice, to seek genuine feedback and take a proper look in the leadership mirror.

So, assuming you’re one of the majority of leaders, of people, who experience (or suffer) the Imposter Syndrome – what can you do?  All I can suggest is the same as I have suggested to clients, and the same as I suggest to myself when the feeling hits.

  1. Believe that it’s normal.  Take a look around the office at those you admire, and know they’ll experience this too.
  2. Ask for feedback.  Since the Imposter Syndrome is really a denial of the realities of your own efficacy, seek out others who can give you a more dispassionate view.  They’ll probably tell you you’re not perfect – but that you deserve the success you’ve earned.
  3. Save up positive feedback – and use it when you need it.  Be it a patient’s ‘thank you’, a colleague’s ‘well done’, a manager’s recognition or a good appraisal.  Some people keep a ‘My plaudits’ file on their computer offering a mine of restorative nuggets to be excavated in times of need.

thumbs up

Oh, and one entreaty.  If we assume that most people at some time or other experience this feeling of doubt – let’s help them out.  Let’s pass praise around our worlds freely and liberally.  I’m not talking about adopting a leadership style of complacent acceptance of poor performance – quite the opposite – I’m all for challenging (fairly, compassionately and very directly) those that truly aren’t up to the job.  The majority of colleagues though are talented yet self-doubting people doing the best they can. An encouraging word and a positive stroke could be just the reinforcement they need to keep their imposter at bay.

Does integrated care deliver the benefits expected? @RANDCorporation @Medici_Manager @pash22

Findings from 16 integrated care pilot initiatives in England

This report is part of the RAND Corporation research brief series. RAND research briefs present policy-oriented summaries of individual published, peer-reviewed documents or of a body of published work.

Permission is given to duplicate this electronic document for personal use only, as long as it is unaltered and complete. Copies may not be duplicated for commercial purposes. Unauthorized posting of RAND PDFs to a non-RAND Web site is prohibited. RAND PDFs are protected under copyright law. For information on reprint and linking permissions, please visit the RAND Permissions page.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors.

7 Strategies For Simplifying Your Organization @Medici_Manager

Over the past several years we have heard hundreds of managers talk about the negative impact of complexity on both productivity and workplace morale. This message has been reinforced by the findings of major CEO surveys conducted by IBM and KPMG [PDF], both of which identified complexity as a key business challenge.

Agreeing on complexity as a problem is one thing, but doing something about it is quite another — particularly for managers who are already over-worked, stressed, and can barely keep up with their current workload. In fact, the Catch-22 of complexity is that most managers don’t feel that they have the time to focus on it: Having the problem precludes the ability to solve it.

With this dilemma in mind, we think it’s important for managers to have a strategic framework that they can use to address complexity in their own areas, at their own pace, in their own ways. So to that end, we would like to offer a “simple” seven-step simplification strategy. While we present these sequentially, they can be implemented in any order, depending on where you might be able to make the greatest difference most quickly. Over time however, it’s important to do all seven so that simplicity becomes a core capability of your organization and not just a one-time project.

  1. Clear the underbrush. An easy starting point for simplification is to get rid of stupid rules and low-value activities, time-wasters that exist in abundance in most organizations. Look, for example, at how many people need to review and sign off on expense reports or small purchases; or how many times slide decks need to be reviewed before they are presented. If you can shed a few simple tasks, you will create bandwidth to focus on more substantial simplification opportunities.
  2. Take an outside-in perspective. Simplification should be driven by the need to add value to your customers, either internal or external. So a key step in the process is to proactively clarify what your customers (internal or external) really want and what you can do to make them more successful. One manager, for example, took her team to visit a customer plant so that people could see how their product was actually used, which gave them ideas about how to improve it.
  3. Prioritize, prioritize, prioritize. One of the keys to simplification is to figure out what’s really important (and what’s not), and continually reassess the priority list as new things are added.
  4. Take the shortest path from here to there. Once it’s clear that you are working on the right things, root out the extra steps in core processes. Where are the extraneous loops, redundancies, and opportunities to make our processes as lean as possible?
  5. Stop being so nice. One of the patterns that causes or exacerbates complexity is the tendency to not speak up about poor practices. This is particularly true when people hesitate to challenge more senior people who unintentionally cause complexity through poor meeting management, unclear assignments, unnecessary emails, over-analysis, or other bad managerial habits. To counter this trend, use constructive feedback and conflict to keep your colleagues (and yourself) honest about personal behaviors that might cause complexity.
  6. Reduce levels and increase spans. Another source of complexity is the structural tendency to add layers of management, which often leads to managers supervising just one or two people. When that happens, managers feel compelled to add value by questioning everything that their subordinates are doing, which adds work and reduces morale. To reduce this kind of complexity and stay away from micromanaging, take a periodic look at the organization’s structure and find ways to reduce levels and management and increase spans of control.
  7. Don’t let the weeds grow back. Finally, remember that complexity is like a weed in the garden that can always creep back in. Whenever you feel like you’ve got it solved, do steps 1 through 6 over again.

In today’s global, increasingly digital organizations, complexity is a growing drag on productivity and workplace satisfaction. Managers need to develop simplification as a core leadership capability and a critical component of the business strategy. Hopefully these steps will help you get started.

Lisa Bodell is the founder and CEO of FutureThink and the author of Kill the Company.

Are You Managing Change Or Leading It? @Medici_Manager

Jim Blasingame

“There is a time for everything, and a season for every purpose under heaven.”

On its face, this well-known King Solomon wisdom, from the 3rd chapter of Ecclesiastes, delivers hopeful encouragement. But implicit in this passage is a somewhat hidden, and often troublesome paradox: A time for everything also implies nothing can be forever, and therefore, change is inevitable.

In the abstract, we accept the reality of change, but in practice we regard it like the medicine we know we need, but don’t want to take.  And knowing change is inevitable doesn’t make the pill any sweeter.

In the marketplace, it was challenging enough to implement a change when we had the expectation of not having to do it again anytime soon. But in the 21st century, the bitter pill of change has acquired an unfortunate new characteristic: a frighteningly short duration.

Organizations that enjoy consistent success will make change an abiding element in their business model, rather than an intrusion to “the way we’ve always done things.”  They’ll create a culture and environment where change can occur whenever necessary, without creating a casualty list.

Rick Maurer, author of “Beyond the Wall of Resistance,” conducted a survey of organizations that have implemented change. He identified four things they did to create a culture compatible with change.

1.  Make a strong case.

Maurer found that “when change was successful, 95% of the stakeholders saw a compelling need to change.” Change must be accompanied by evidence of its importance.  If you can’t make the case, perhaps it’s not the right thing to do — yet.

2.  Establish the vision.

Maurer’s research indicates 71% of successful changes happened “when people understood the vision of the project.” Stakeholders should see the long-term benefits of change.

3.  Sustain the changes.

The primary reason for failure, Maurer found, was “inability to sustain the change.” Sustaining change isn’t a sprint; it’s a marathon that must endure pressure from many sources and may be the greatest test of leadership.

4.  Anticipate maintenance.

Successful managers recognize that it’s not in the nature of change to be self-perpetuating.

Finally, behavioral studies have established that when something positive (or negative) is expected, that’s what is likely to happen. It’s called the Pygmalion Effect and it can be very powerful, either way.

Change will happen. And if we expect something positive, it probably will be.

Jim Blasingame is one of the world’s leading experts on small business and entrepreneurship. He is the creator and award-winning host of the nationally syndicated radio program, The Small Business Advocate® Show.  In addition to his weekly columns, Jim is the author of two books; Small Business is like a Bunch of Bananas and Three Minutes to Success.

When doctors and patients share in decisions, hospital costs go up @Medici_Manager

Since the 1980s, doctors and patients have been encouraged to share decision-making. Proponents argue that this approach promotes doctor-patient communication, enhances patient satisfaction, improves health outcomes and even may lower cost.

Yet, a hospital-based study found that patients who want to participate in their medical decisions end up spending more time in the hospital and raising costs of their hospital stay by an average of $865.

The findings, published in May 27 issue of JAMA Internal Medicine, came from the first hospital-based study to examine how patients’ desire to participate in medical decisions affects their use of health care resources.

There are about 35 million hospitalizations each year in the United States. If 30 percent of those patients chose to share decision-making rather than delegate that role to their doctors, it would mean $8.7 billion of additional costs per year, according to the study.

David Meltzer

David Meltzer

 “The result that everyone would have liked, that patients who are more engaged in their care do better and cost less, is not what we found in this setting,” said study author David Meltzer, associate professor of medicine, economics and public policy at the University of Chicago. “Patients who want to be more involved do not have lower costs. Patients, as consumers, may value elements of care that the health care system might not.”

The researchers approached all patients admitted to the University of Chicago’s general internal medicine service between July 2003 and August 2011. Almost 22,000 people, about 70 percent of those asked, completed a wide-ranging 44-question survey.

The key multiple-choice item for this study was: “I prefer to leave decisions about my medical care up to my doctor.” More than one-third of patients (37.6 percent) definitely agreed, one-third (33.5 percent) somewhat agreed, and a little less than one-third (28.9 percent) somewhat or definitely disagreed.

Patients who preferred not to delegate decisions to their doctors—those who wanted to work with their caregivers to reach decisions—spent about 5 percent more time in the hospital and incurred about 6 percent higher costs.

“Was I surprised?” asked Meltzer. “I wasn’t shocked. It could have gone either way. Our results suggest that encouraging patients to be more involved will not, alone, reduce costs.”

In fact, the authors note, “Policies that increase patient engagement may increase length of stay and costs.”

Although this was a large study, it may not apply in every setting, the authors cautioned.

“We need to think harder and learn more about what it means to empower patients in multiple health care settings and how incentives facing both patients and caregivers in those settings can influence decisions,” Meltzer said.

Indeed, the authors looked at “hospitalized patients, for whom providers have large incentives to decrease utilization due to Medicare prospective payment, low payment rates for Medicaid and uninsured patients, and utilization review for most patients.”

They found that provider incentives were not the only predictors of care costs. Although the uninsured had slightly shorter stays and lower hospitalization costs, patients with public insurance such as Medicare or Medicaid, which pay less than the cost of care, had longer than average stays and higher costs.

As the principal tertiary care hospital on Chicago’s South Side, the University of Chicago Medicine provides care for a diverse population. Three-quarters of the patients in this study were black. More than half had a high school education or less. Nearly 80 percent were insured by Medicare or Medicaid or had no insurance.

“This isn’t about demographics,” Meltzer said. Patients with the most education had lower costs than those with the least education, the study found.

Nonetheless, the authors expressed particular concern about the tendency for older, less-educated, publicly insured and black patients to be less engaged in medical decision-making. They warned this could increase health care disparities as empowered and engaged groups, who already are more likely to receive care, gain resources through shared decision making while the national movement toward accountable care organizations increases the pressure for cost reduction.

“We want patients to be more involved, to have the richest form of interaction,” Meltzer said. “That can align preferences, prevent mistakes and avoid treatments patients don’t want. But we need to find ways to create functional doctor-patient partnerships that lead to good health as well as sound decisions about resource utilization.”

Additional authors were Hyo Jung Tak and Gregory Ruhnke of the University of Chicago Medicine. Funding for this work was provided by the Agency for Healthcare Research and Quality, the National Institute on Aging and the National Cancer Institute.