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Move over teamwork: other forms of co-operative working? @pash22 @leadmedit @muirgray

Taken very broadly, there are two kinds of management or business research thinking when it comes to teams: perspectives that think teams are a decent functional way to organise workers to work effectively, and perspectives that are much more critical of the very concept of teamwork.

Instinctively, anecdotally, and from much research over the last few decades – we all know that teams often don’t work. ‘Dream teams’ of exceptional individuals can turn out to be nightmare units, groupthink and other faulty decision-making biases can make the whole less than the sum of its parts, and sometimes people end up in too many teams or don’t even know whether they’re in or out. I would argue that this is because teams are relatively artificial constructs; they are often no more than idealistic ‘boxes’ that exist unevenly only in the minds of some managers and workers.

Frequently, organisations are not like traditional sporting events or the inside of rowboats – they are much more variable, overlapping, organically changing configurations of people. Being inside a team or outside a team is not a neat shift from one state to another – teams or groupings vary continually in how ‘groupy’ or cohesive they actually are. Most management research, however, has focused on teams as neat boxes or islands that sometimes conflict a bit, but generally agree in their perceptions, have stability of membership, and have a relatively fixed relationship with their external environments. In short, it has been a romance of teams, a science of convenience, and an exercise in wishful thinking.

However, none of this is to say that teams are always doomed or flawed. With the right culture, tasks, and aligned sets of HR practices, teams can innovate and achieve highly effective working patterns. As with all social and workplace issues: it depends on the context and getting the conditions and circumstances right. However, many of these favourable initial ingredients or conditions for optimising teamwork either remain elusive or appear in an implausibly long list. It is no mean feat to ensure the selection of diverse members, extensive team-building and clear unifying goals. Teams themselves are also a moving target; in general they are changing: members come and go more often, technology encourages collaboration over almost any distance, and traditional hierarchies have become much flatter.

What I wish to say is that teams should be considered more dynamically as sitting within a broader spectrum of many cooperative working options simultaneously; as one work arrangement among many. The guiding word here being cooperation. There are multiple ‘building blocks’ of cooperation, from small-scale to large-scale, guiding how people work together, that managers can consider as part of a broader, customisable repertoire. I tend to refer to them as a ‘cooperative value chain’ or a ‘high-cooperation HR menu’. This cooperative toolkit consists of the five following components:

1) The individual. I want to be alone. Many job descriptions, rewards packages and other parts of the psychological contract bestowed via HR practices still revolve around individuals and their needs or talents. Many artists, technical problem-solvers, leaders and so on, may find they work most effectively as a demarcated, unique individual. Western, individualistic cultures may also favour personalised working this way, for at least significant portions of employees’ time, as proactivity, autonomy, and flexibility are emphasised in their roles. Single individuals are still cooperating, but in their own reflective way; they may also occupy special positions in social networks (see below) or fulfil boundary-spanning roles, where they are the individual link bridging units of cooperation that would otherwise have no way to interface.

2) The dyad. Two heads are better than one, but three’s a crowd. Some work roles explicitly involve pairs – software programmers check each other’s work, police officers patrol in pairs, and mentoring and other partnerships can occur in this way. But more exploitation of this unique two-person unit may be possible in workplaces than is currently realised. Some would argue that a dyad/couple is a small team, but I would argue it constitutes a special relationship. Two people cut a fruitful compromise, a middle ground between the egoistic isolation of working alone and the potentially biasing social pressures of a larger group.  Of course such pairs need to be carefully matched to each other and the workflow to get the most out of the pairing.

3) The classic team. The whole is greater than the sum of the parts – go team! As discussed above, in some situations, a neatly bounded, interdependent team with a clear goal may be possible. But a team charter or checklist should be carefully put in place to ensure the key conditions are right before proceeding with what is a larger, more elaborate cooperative endeavour in terms of the numbers of people involved. Social and task criteria to keep it working effectively together will need to be addressed, including a meaningful shared purpose, a differentiated mix of suitable members, clear rules or norms, wider resource-based support, and adequate coaching. Leadership, technology, lifespan, and competing teams or other boundary memberships in the wider environment will need to be addressed, in line with the other cooperative options above and below.

4) The multi-team system. Teams don’t exist in a vacuum, but in a ‘team of teams’.Beyond single teams, research is increasingly considering multi-team systems (MTSs) or ‘teams of teams’. Army, Navy, and Air Force; or Police, Ambulance, Fire would be obvious examples, but of course most organisations contain multiple groups, divisions, functions, layers etc. with potential for forming and/or recognising MTSs. One commanding team might lead several subsidiary teams, or teams with specific goals might come together to achieve a higher goal. As with single teams, structures need to be made crystal clear and cooperative flows and linkages choreographed and monitored carefully. People may need to be cross-trained, or to attend multiple team events, but without taking on too much workload. The relationship between the immediate goals of one team and the higher goals of the set of teams need to be clarified, as well as prioritised in various scenarios.

5) The social network. The wisdom of crowds. In a sense here we come full circle as individual employees occupy distinctive positions within collaborative networks, but in an increasingly interconnected world with more permeable communication boundaries, anyone can be meaningfully connected with up to 150 others at any one time. We enter the realm of crowd-sourcing, flash mobs, consortia, and other self-organising forms of social movement or widespread cooperative organisation. The boundaries of entire businesses and sectors may be transcended, co-operators may never meet or be totally aware of each other, and finished products may be complex mosaic or snowball outputs, difficult to link directly back to the inputs and processes of diverse contributors. Yet impressive tasks and economies of scale can be achieved, sometimes on goodwill and intrinsic motivation alone.

In conclusion, HR practitioners should try to take advantage of mapping this broader array of cooperative building blocks simultaneously. Rather than simply asking ‘to team or not to team?’ they should consider offering employees a greater range of performance opportunities via these other cooperative value chain options, enabling them to work more naturalistically and fully unlock their talents.

http://www.hrzone.com/feature/people/move-over-teamwork-what-about-all-other-forms-co-operative-working/141116

Coaching or telling. Which works? Here’s the evidence… @leadmedit @muirgray @helenbevan

Given the name of my company, Head Heart + Brain you won’t be too surprised to learn I like to have an evidence base for what I do. The ‘brain’ part of the name represents understanding the science behind leadership and change. This links to my curiosity about ideas that ‘seem obvious’ to me but that don’t get traction. I talked about this in my article on Emotional Intelligence. I feel the same about coaching. Whilst many companies use external coaches to work with senior people HR find it harder to gain traction for the manger as coach. Companies we work with still have many managers who adopt a ‘command and control’ style; that is telling people what to do. What is the evidence of which works best; coaching or telling? Is coaching actually more effective than just telling people what to do especially in complex change? I will look at some of the evidence which may help to understand which will maximise performance.

Brain basics

Let’s look at how the brain works in an organisational context.

The brain functions by making connections and associations, linking what is happening now and what has happened in the past, the memories both conscious and unconscious. This combination creates a kind of map of connections in the brain. No two maps will be the same even though the biological process for creating them is. The maps are created by making over a million new connections every second. This gives you some indication of the complexity. The brain likes order so seeks to connect new information to what is already known, to categorise it. Gerald Edelman developed the Theory of Neural Darwinism which provides a physical explanation for how our mental maps compete for resources.

The way the brain seeks to predict and make connections is explained by Jeffrey Hawkins in On Intelligence. He says our prediction abilities differentiate us in the animal world. When we first encounter something we are relatively slow to understand it. Like this article we need first to get the foundations in place. In learning a new skill for example it takes a while, maybe a few minutes or days depending on the complexity, for it to become familiar, that is create the map. The more embedded these maps the more we free up mental resources. We call this process forming a habit. Habits are run by the older more energy-efficient parts of the brain. This process of shifting activity, including thinking, from the high energy, relatively inefficient, prefrontal cortex to the more efficient areas is a basic operating mode for the brain.

Linked to this is neuroplasticity. Expert Norman Doidge, in The brain that changes itself points out, there is substantial evidence we can “rewire our brains with our thoughts.” Hebbs Law states that ‘neurons that fire together wire together’. So the more you focus on something the deeper the neurological connection. When we delve into and analysis a problem we are reinforcing the connections in the brain. This occurs through a process called myelination, the more a pathway is used, the stronger it becomes. When we repeat an action, a fatty covering called myelin coats the neural pathway, making connections stronger and more secure. Because the default is to go with the pathways that are developed it is hard to change habits but easier to create new ways of working. But it is still difficult to change without focused support and intentional effort.

The other relevant question is whether there are distinct functions responsible for emotional, as opposed to general intelligence. Research by Reuven Bar-On isolated these regions by studying people with damage to the brain in areas correlated with diminished ability in understanding self and understanding others. His findings clearly point to brain areas which relate to understanding self and others, that is Emotional Intelligence, which are distinct to areas associate with general intelligence.

So with this understanding as background let’s look at the impact of telling someone to change verses coaching them to change.

Telling versus insight

A premise of coaching is that people work things out for themselves. The difference between being told and having insight is all about creating new mental maps. If you are thinking about something like how a new process will work or the reaction of your team to a new strategy you are creating a mental map. These new thoughts are energy consuming from a brain perspective so you often do this when your brain is freed up from other activity like in the shower or on the walk to work. This type of thinking creates what we call an ‘aha moment’ or an insight. This is literally new connections happening, a new map or part of a map is formed. If you are told how to carry out the new process or what the strategy means for your job you still have to create that mental map. So coaching insight is more brain-savvy than telling an employee the answer. To take any kind of action people have to think it through for themselves. They can do this for themselves and immediately create the map when the coach/manager asks questions that create insight or they do it later after they have been told. The additional issue with telling is that it is more likely to set up a threat response (see more in the CORE video) as the individual’s predictions and connections are different to what was expected. As we have observed before, this difference creates an error message and a sense of pain in the brain. This in turn moves people away from the new information and increases the likelihood of resistance.

Managers who tell rather than coach not only waste their own energy but they are potentially making it more difficult for employees to accept a new idea. Are your managers and coaches creating insight or giving advice?

Transferring skills

You will have experienced that an insight comes with a burst of motivation or energy but this quickly dissipates if not reinforced. Reinforcing the insight creates new connections and potentially new behaviour. Because this type of action and thinking is hard work, because it takes more brain energy, people may avoid it or give up too soon before a deep map is formed. But people are also adaptable and can find shortcuts.

new study provides strong evidence for a “flexible hub” theory of brain which has implications for using skills. “Flexible hubs are brain regions that coordinate activity throughout the brain to implement tasks – like a large Internet traffic router,” suggestsMichael Cole, the author of the study.

By analysing activity as the flexible hubs connected during the processing of specific tasks, researchers found unique patterns that enabled them to see the hub’s role in using existing skills in new tasks. Known as compositional coding, the process allows skills learned in one context to be re-packaged and re-used in others, shortening the learning curve. By tracking and testing the performance of individuals the study showed that the transfer of these skills helped participants speed their mastery of new tasks, and use existing skills in a new setting.

Are your coach/managers focusing people on transferring existing skills to the ‘new world’ to speed up change?

Moving to action

Conventional wisdom, in many businesses, is that if people understand rationally why they need to do something the change will occur.  Kevin Oschner estimates 70% of what we do is habitual and that includes your job. As previously mentioned habits are run by the older parts of the brain, the basal ganglia. Because habits operate out of our conscious awareness our rational understanding is not enough. Coaching on why the new behaviour matters to the individual and designing a strategy might work.

Several things need to be in place to achieve behavioural change. Matt Lieberman says we must go beyond conscious systems and use our unconscious or “reflexive” systems. Goals for the new behaviour tend to be created in the conscious reflective system but we need to also control the unconscious habit system by managing triggers that generate the old behaviour. Elliot Berkman studies goal setting and achieving new behaviour and his research suggests there are several elements that must be aligned.

For example in new habit formation there is a sequence:

  1. cue;
  2. when to act,
  3. routine;
  4. the steps to take,
  5. and reward.

Are coach/manages working with both systems? Are they creating new behaviour by creating new routines and rewards? Are there strategies to manage the triggers that will prompt old behaviour?

We are social

The science shows social needs are primary in the brain, something many forget at work. Social pain activates the same regions as physical pain. When someone is put down, or their ways of working are controlled, or they are told what to do, especially publically, a threat response is activated reducing the ability to think clearly. You know that feeling – “I’m just blank, I have no mental space.” The frontal cortex is drained as the limbic system hijacks the energy. Again, a strike against telling!

This evidence base may go some way to persuading reluctant managers to adopt a different style.

But I am not going to fall into the same trap – and will practice what I preach.  So far be it for me to tell you that telling doesn’t work.  I’ll leave you with a few questions to generate you own insight.  What reaction have you experienced when telling someone to change? When has telling someone to do something differently worked?  What has been the benefit for you of creating insight in others?  What, good, surprises have you got from asking questions rather than telling?

A New View Of Leadership @leadmedit @WRicciardi @muirgray @pash22

By Nigel Nicholson http://bit.ly/1d2urwz

For every Winston Churchill, there is a Fred Goodwin. What makes some leaders soaraway successes, while others crash and burn?

When a flock of birds simultaneously takes to the air or when a herd of buffalo wheels and turns as one, it is a miracle of coordination. Who is leading? This is a very human question and presumption.

Sit in a packed stadium and watch the crowd rather than the sport and you will see waves of emotion and expression, uncoordinated except by the spontaneous urges of people infecting each other with thought and feeling. Not a leader in sight.

Picture the scene: I am working with a group of executives and the topic is teamwork. I ask them what the critical factors are to getting high performance out of a team.

It is only a matter of time before one person says that the group needs a leader. Lots of heads nod in agreement around the room.

At this point, I assign them randomly to groups to perform a task, and when we analyse what transpired, it is evident that the best performing team turned out to have no designated leader, and the groups that made a point of appointing a leader performed indifferently.

Look closer and you will see that teams lacking a recognisable leader do not lack leadership. It is present, no less than in the flock or herd, but it may be hard to pin down.

Leadership is not a thing but a process. It is something that helps systems to function; coordinating and directing effort. Yet, clearly, we are infatuated with leadership, which is why more space on business bookshelves is occupied by the subject than any other topic.

So why yet another book – mine?

Although there are lots of great leadership recipe books and stories of leadership success and failure, what I couldn’t find was any analysis that connected our biology as a species that loves to be led with what we see going on around us in business.

Cometh the moment, cometh the man or woman. History teaches us that just when we are in our darkest hour, a hero emerges to show us the way – Winston Churchill and Nelson Mandela in politics, GE’s Jack Welch and IBM’s Lou Gerstner in business.

Smart businesses and societies organise themselves in ways that help these leaders to emerge, but history’s parade contains as many disappointments and disasters as successes.

In the new frontier of postDarwinian thought, this turning wheel of adaptation and maladaptation is called co- evolution.

What’s special about leadership is that leaders can be game changers; rewriting the conditions under which success and failure are defined. Leaders are the tools of historical forces, and the makers of history.

What comes out of this view is what I call the Leadership Formula. To be effective, a leader has to be the right person, at the right time and place, doing the right thing. This has some simple implications and some tricky ones. The simple ones are that there are many ways of being a leader, and there are many leadership situations.

But leaders need to watch out, for situations change faster than people do.

This is where it gets tricky. It turns into a strategic challenge of whether or not leaders can bend the situation to their will or be versatile enough to ride the waves of change.

One of the smartest things Nelson Mandela did was to quit while he was ahead, climbing off the turning wheel of history before it crushed him, making way for a technocrat successor, Thabo Mbeki, to move the country to its next stage of development.

With our leadership infatuation we have to beware of the football manager syndrome, replacing leaders as soon as things go wrong. Rather, succession should be strategic, to meet the needs of changing times.

Now let us climb into the mind of the leader to see how the process of leadership actually works. What you find is an interdependent triangle of being, doing and seeing.

Being – who you are – determines what you do. In leadership, character matters because we view the world through a prism of identity. Many leaders succeed and then fail because who they are filters how they see the world and scripts the actions they take. Look at Kenneth Lay, architect of the Enron disaster.

Doing – what you do can shape your character. This is especially true of malleable people not troubled by strong instincts and impulses. They can be conditioned. Tony Blair’s account of his ‘journey’ through his premiership seemed to involve a lot of development and discovery by doing, but it was seeing – his analytic capabilities applied to experience – that informed his choices.

Seeing – this is the most fundamental starting point for leadership, and the least regarded. It is the vision of leaders that drives them and us on. They see the world as it is and how they wish it to be. The challenge they face is to keep pace with the environment and the effects of their actions.

Being openminded does not guarantee you will see what is truly important. Perspective matters, and is the key to leadership effectiveness. Openmindedness is a mark of the new generation of leading-edge business leaders, people such as Larry Page, Sergey Brin and Eric Schmidt at Google or Mark Zuckerberg at Facebook.

How Being, Doing and Seeing work together can be illustrated by thinking about change. Did you ever try to influence someone – like a spouse, a boss, or, worse, a teenager? Often we try to do this by direct attack on the Being part – ‘Get your mind right will you, please? If possible, be like me’.

Does it work? Does it hell! OK, next tack – try changing the Doing part, say by forcing a person down a new route, with the aid of rules, rewards and punishments.

Does this work? Sometimes, but it can take time. The mind has to play catch-up with behaviour, as was the case with banning smoking in public places.

Want instantaneous change? Seeing is the key. Reframe safety as threat, danger as opportunity, desire as dependence and people can switch their goals and their actions in a flash.

That’s the thing – the only person that can change you is you. This is a special human gift: the ability to change our lives and states of being in an instant, like Saul on the road to Damascus.

It is an unfortunate tribute to human persistence and optimism that we are forever trying to change people by the hardest and most impossible routes.

Great leaders know that seeing – vision – is the key to influence. Steve Jobs enveloped people in his ‘reality distortion field’ (a Star Trek concept applied to him by a colleague) and Jack Welch was a master storyteller.

Let us now apply my leadership framework, which I call the Situations, Processes and Qualities model (SPQ) to unlock the secrets of why certain leaders emerge, and why others fail.

There are many different kinds of leadership situation – every time you get promoted, take on a new assignment or employ new people, your leadership situation changes. Look at financial services, where an almost nonexistent leadership culture with everyone contentedly churning inside a bubble of self-inflating growth now finds itself struggling to be reborn and crying out for a new style of leadership.

Fred Goodwin was more a dealmaker than a leader, who expanded RBS to gargantuan proportions, until its collapse revealed the fatal absence of a coherent vision that met the needs of a changing world.

The first lesson of the SPQ model is to read the world and understand how it is changing. This might sound simple, but it is fraught with difficulty, not least the problem that people around leaders inhabit the same reality bubble.

They only see what the leader sees, and those with a different perspective get scant air time or are suppressed. The more powerful and successful leaders are, the less likely they will be to hear dissenting voices.

Leaders like Robert Maxwell, Goodwin, and Al ‘Chainsaw’ Dunlap (of Sunbeam) were surrounded by likeminded supporters in a climate where bad news was often suppressed. Leaders have to go undercover in their own organisations, engage in counterfactual thinking and allow their vision to evolve with a changing reality.

The second lesson of the SPQ model is the importance of doing what is needed for the situation. In principle, anyone can learn how to craft and deliver a powerful message, practise the skills of empathy, build a team, and so on.

It just takes time, discipline and desire. The last of these – desire – is the Achilles heel of doing what’s needed. If your backhand is weak, you may find it easier to run round and play a forehand, rather than work on your weakness.

There is also a capacity problem, and here we are bedevilled by the lonely leader problem – where leaders are isolated, insecure and obsessively meddling in every detail. What is needed is not just a strong team and the ability to delegate but what I call Critical Leader Relationships – a handful of trusted confidants who can be eyes and ears, helpers and advisers, and sources of support and honest feedback.

Michael Eisner, Steve Jobs and Bill Gates enjoyed their greatest successes at Disney, Apple and Microsoft respectively through their partnerships with people with complementary gifts, who advised, challenged and supported them when needed.

The third lesson of the SPQ framework is that leaders have to know themselves and control themselves. Unfortunately there are major disincentives to self-control.

Leaders often find their narcissism and arrogance and unfettered displays of their identity – a surfeit of ‘authenticity’ perhaps – are not just rewarded but revered by followers longing for the magical protective power of heroism and charisma.

Indeed, at the heart of leadership lies a dilemma or rather a balance to be struck between instinct and insight, between shaping and versatility, and between innovation and adaptability.

On the one hand is the need for leaders not just to respond to the forces around them but to shape them, as Steve Jobs famously did. Power is not just an opportunity but a duty to make elements of their world follow their vision. Leadership is about taking charge. This goes beyond accountability.

The performance of your boss and your peers is not your remit, but if you can help them and share your vision with them you should do so.

On the other hand is the need for deep insights into the leadership situation – to anticipate the waves of change and ride them with agility and versatility. Welch’s virtue as a leader resided in his ability to change his strategy to match the new realities he had created.

There are many forces that the leader cannot control but must navigate with skill. To do this, leaders need to develop techniques of inquiry.

Asking questions is the least developed skill in management. Too many leaders see their role as being advocates, declaimers and speech-makers.

All useful at the right time and place, but reading other people is an equal need – using what I call the art of ‘decentring’ – knowing what the world looks like through the eyes of others.

Management-by-wandering-about is another time-honoured insight technique – mostly practised by new leaders when they are finding their feet, but too often neglected as their in-tray piles higher over time.

What leaders need most of all is clarity of vision founded on a secure sense of personal and business identity, and which can be communicated with passion. This does not mean speechifying from a podium but storytelling in ways that are simple, compelling and that make sense. People need a narrative that makes sense of their experience and connects the past, the present and the future. People need to see the logic of the journey and to be reassured that if the future is not going to be like the past, it is connected in ways that are also a part of their story.

There are four stories, actually, that all leaders need – not necessarily to tell but to keep in their hearts and minds in how they act and communicate:1. Who am I and why I am here? This is not a recital of one’s CV but is about how to be real to people around you and show that you have chosen to be where you are for a purpose.

2. Who are we and what do we stand for? This is the ‘I’ of identity, that declares the purpose and raison d’etre for the part of the organisation the leader is responsible for.

3. Where are we going and why? This is the mission story, hard to tell when the future is shrouded in fog, so often a message of commitment, hope and determination.

4. Why we must change – this is the call to people on the journey to let go of the past and embrace the future. The ‘I’ of leadership is also the eye of leadership – identity plus vision, communicated with passion.

Nigel Nicholson’s The ‘I’ of Leadership: Strategies for seeing, being and doing, is published by John Wiley & Sons at £18.99.

 

What Makes an Authentic Leader? @Medici_Manager @WRicciardi @LeadMedIT @pash22

http://bit.ly/1hyuiVk

We listen to someone on stage. The message resonates yet we wonder if this person is really authentic.

We listen to an interview and the conversation seems authentic. Yet we wonder if a similar tenor of exchange happens in the privacy of their home or office.

We call individuals to be an authentic leader yet there may be as many definitions on what authenticity is as there are perspectives.

We hear someone bluster on and we grow tired. Yet being brash is who this person is. They are being authentic.

We hear of a leader really believing that working in an office is better for the organizational culture than working from home. We disagree. Yet this is the individual’s core belief. They are being authentic.

We want authentic leaders yet whose definition of authenticity applies?

What Makes an Authentic Leader?

With authenticity, we think:

  • Trustworthy
  • High integrity
  • Genuine

Each is a characteristic and each is important. Who defines authenticity though? With some research, I found a TED Conversation in which the following question was posed – What does it mean to be authentic? There were 108 responses! There are varying views on authenticity.

In a recent Forbes blog by Jan Bruce, she highlighted three things leaders must do to stay authentic. Each are important elements. Actions define authenticity. For me, there needs to be more to define what makes someone authentic. A group of diverse individuals could outline many other actions authentic leaders should take. There isn’t a set standard of actions for authentic leaders.

Characteristics are important to being authentic, just as actions are. Interpretations vary though. What one finds authentic, another may not. The key may be found in how authenticity is realized. Authenticity needs to be a part of our very being. Interpretations may come and go. Distractions will definitely come and go.

What needs to be steadfast is our authentic being. We need to have an authentic intelligence about who we are as a leader and person. We need to be smart in how we engage and maintain our authenticity.

What Makes an Authentic Leader? 4 Ideas for Authentic Leadership Intelligence

There is a smartness to authentic leaders. Smartness does not mean all-knowing; it does mean approaching your leadership craft with an authentic intelligence, knowing the impact of how you lead. To develop this intelligence, highlighted below are four ideas to consider in building your authentic leadership capabilities.

Embedded empathy. Authenticity needs to be other-centered. If it is all about an individual, then the self-centeredness will eventually harm many more than any potential good done. In other words, authenticity needs to connect to others, understand one another, and raise each other up to do more in better ways. Authenticity and active empathy need to be tied tightly together. Empathy raises a leader to consider what works best for more than just one.

Enabled community. Empathy leads to a leader’s embrace of community. How a leader enables a greater community raises their authenticity because it moves from a one-dimensional view to a multi-dimensional one. More than this, whatever action we take as a leader has a multiplier effect. The multiplier effect needs to be an enabled community working toward a higher-purposed mission or goal. An enabled community holds a leader accountable and keeps their focus on what is best for a broader base of people.

Empowering beliefs. Every leader has a certain set of beliefs, whether defined or not. To be an authentically intelligent leader, the beliefs should be empowering, not limiting. Beliefs pursued by a leader need to pass a test of:

  • Do they make others better?
  • Do they call on others to raise their game in how they work, live, and lead?

Authentic leaders embody a belief system that empowers all to look beyond themselves and foster a respect-filled and trust-filled environment.

Preventing harm. Another key authentic leader idea is to always say and do things to prevent harm. The old principle of “do no harm” is as valid as ever. Authentic leaders do not incite others to act in harmful ways. Authentic leaders keep environments safe for honest, meaningful interactions and build cultures to encourage problem-solving, innovation, and productive working relationships.

Questions to Check Authentic Leadership Intelligence

This post is a work-in-progress. It is one of the reasons they are called ideas rather than principles of authentic leadership intelligence. I do believe we need to be open to how we view a leader’s authenticity. I also believe we need to think through what enables us to claim to be an authentic leader. If we don’t understand what our authenticity consists of, then we will likely get off track and become inconsistent and inauthentic. Our trustworthiness is put at risk.

To begin to sort through the state of our authentic leadership intelligence, we may need to begin with these questions:

  1. What percentage of our inner circle thinks very differently from me? When they do offer differing ideas, do I really hear and understand them? What practices do I have in place to really understand others and make connections outside my comfort zone? (empathy)
  2. How do my actions enable other worthy actions? What am I doing to gain positive momentum in moving initiatives forward? (community)
  3. What are my core belief? Which of my core beliefs raise others up in taking positive action? How am I setting an example of leading with my beliefs? Be specific. (beliefs)
  4. How am I ensuring no harm is being inflicted on teams in undertaking their goals and objectives? How am I building a culture of innovation and problem-solving? (do no harm)

More than actions and characteristics, I believe we need to have an authentic being and intelligence on what makes us real, positive, consistent influencers. So, the question is clear: What makes someone an authentic leader?

– See more at: http://www.thindifference.com/2013/12/14/what-makes-an-authentic-leader/#sthash.X0uat6QF.dpuf

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

Posted by:

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?

 

From The NHS Change Agent

Helen Bevan is chief of service transformation at the NHS Institute for Innovation and Improvement. From 1 April 2013, she will be joining the delivery team of NHS Improving Quality. All views are personal.

Mindfulness can improve leadership in times of instability @leadmedit @muirgray

A mindful leader can respond to change with focus and clarity, and avoid repeating the same mistakes

by Cheryl Rezek http://bit.ly/15M4lLs

What does the ancient eastern practice of mindfulness, often associated with orange-clothed chanting monks, have to do with the fast-paced, performance-driven style of western leadership? In tough times, it could act as an influential asset in the public service’s fight for survival.

Mindfulness is about paying attention to what is happening in the present moment, a moment in time. It is about focusing attention on the present in a way that allows that moment to be experienced and observed closely. It involves developing the skills to allow yourself to engage actively with whatever is happening at the time, as well as concurrently viewing that moment from a more strategic standpoint.

Developing a more aware and considered approach helps leaders to respond to situations (whether internal thoughts or external events), rather than react to them. It encourages a less critical view which, in turn, creates a more flexible and attuned response. When there is less clutter and fewer distractions within one’s own head it is easier to gain clarity and perspective; mindfulness allows one to both notice more detail and see the bigger picture.

A mindful leader can reduce disorder by bringing focus and intent to the situation. By acknowledging and accepting change, the leader can step back, observe and respond with composure and purpose.

Sometimes our past experiences or immediate reactions will interfere with our ability to view the present in an unbiased way. Once we acknowledge this, we can quieten internal commentaries and assumptions. This process of stepping aside from ourselves allows us to decide what approach will best support the situation at hand, and the agendas and strategies of the organisation.

Dealing with change

If leaders realise that change is inevitable, they can encourage sufficient resilience in individuals, teams and organisations. To lead knowing that change is inevitable – though unpredictable in its timing – allows for flexibility, and a realisation that what worked in the past may not necessarily be appropriate today. This helps to safeguard an organisation from disillusionment and destruction by enforcing outdated rules and processes.

Research on mindfulness suggests that it can also help to:

• reduce the cost of staff absenteeism caused by illness, injury and stress

• improve cognitive functioning, memory, learning ability and creativity

• improve productivity and improve overall staff and business wellbeing

• reduce staff turnover and associated costs.

Mindful leadership is not a patronising fad implying that, if we are calm, everything will be fine. The reality of our working world is that all may not be fine. What mindfulness can do is develop a thinking, emotional and instinctual mind so that the leader can do the best for self, team and organisation.

 

The full version of Cheryl Rezek’s article can be accessed free-of-charge by Public Leaders readers for a limited time on the International Journal of Public Leadership.

Dr Cheryl Rezek is a consultant clinical psychologist, workshop leader and author of Life Happens: Waking up to yourself and your life in a mindful way and Brilliant Mindfulness: How the mindful approach can help you towards a better life.

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Solving the high rates of hospital readmissions @kevinmd @Medici_manager @pash22

By  , http://bit.ly/1abkQiX

Statistics show that about 1 in 5, or 20 percent of all Medicare patients are readmitted to hospital within 30 days of discharge. That’s a staggering number, not to mention all those patients that are readmitted frequently during the course of a year, but not necessarily within 30 days.

The problem of frequent hospital readmissions is actually one that exists all over the world and not just in the United States. Health care systems everywhere are seeking solutions to keep their patients healthier and away from hospital. Any doctor practicing at the frontlines will be able to tell you what a big issue this is right now. We regularly see the same patients on something of a merry-go-round of frequent hospital admissions, often with the same illness.

Why does this happen? This issue is complex. In my experience as a hospital medicine doctor, there are number of factors in play, falling into different categories according to the type of illness, availability of definitive treatment, and the social circumstances of the patient.

Severity of illness. Certain chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), when in their advanced stages, are very labile and prone to exacerbations. As much as doctors try to control these with medications, it’s a very difficult task, as it only takes a slight precipitant such as a minor infection or dietary indiscretion to push somebody over the edge. By their very nature chronic diseases tend to get worse over time. And with an aging population, these conditions are increasing in prevalence. Unless we find definitive cures, hospitalizations are always unfortunately a possibility.

Social situation. Patients who have inadequate family support tend to be admitted to hospital more frequently for a couple of reasons. Firstly, their threshold for being able to cope at home with their illness is much lower. Secondly, they will not be able to co-ordinate their regular follow up care so easily. We see the effects of this all the time at the frontlines — two patients with the same level of illness severity; one will be managed at home, the other will require hospital admission for several days.

Lack of follow-up. Many studies have shown that lack of follow-up with a primary care physician in the weeks after discharge can lead to a higher likelihood of re-hospitalization. Seeing a doctor quickly post discharge allows for any potential problems to be “nipped in the bud”. It also allows for care co-ordination and medication reconciliation. Sadly, a large number of patients do not have a regular primary care doctor (mostly for insurance reasons). They therefore tend to use the emergency room as their first point of contact when they feel unwell again.

Suboptimal discharge process. By its’ very nature, the process of discharging a complicated patient from hospital is one that is fraught with possible problems. The discharge process needs to be thorough, seamless and diligent. Areas for improvement in most hospitals include medication reconciliation, clarifying follow-up appointments, follow-up laboratory tests, and making sure that the patient and family is clear about these instructions. Too often, this process is rushed and glossed over. Nothing beats having the doctor sit down with the patient and their family, spending time reviewing all the pertinent information.

Low health literacy. Many patients are not fully educated and informed about the nature of their illness and how best to manage it at home. This can be dealt with by regular reinforcement and utilizing home nursing services to keep on checking in with the patient post-discharge.

Certain very obvious patterns do exist in how patients tend to be readmitted to hospital. Several initiatives are underway across the country to try and improve the situation. Primary care doctors, specialty clinics, home nursing services, and even social workers are all being utilized as part of a team-based approach. The strategies broadly involve:

  • Identifying high-risk patients early
  • Educating the patient and involving family members
  • Having very close follow-up with a collaborative care team

As part of health care reform, hospitals are also facing financial penalties for consistently high readmission rates. But financial penalties alone aren’t the answer, especially for “safety net” hospitals that struggle more with this problem. It’s important to remember that the drive to reduce readmissions is not just about saving the health care system money, but ultimately about keeping our patients healthier and stronger. Whatever can be done to keep them at home enjoying life as much as possible instead of lying in a hospital bed, can only be a good thing.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

Clinicians do not have the luxury to not care about costs @kevinmd @Medici_Manager @WRicciardi

by  http://bit.ly/1g8rOt3

In a large lecture hall of fellow clinicians-to-be, I was told that my job as a physician is not to be concerned with costs but rather to treat patients. My wrist, moving frantically left to right on my page taking notes, stopped. I looked up and my mind wandered: What an odd message to tell those who will be listening to ill people’s symptoms, prescribing medicine, ordering tests and orchestrating people’s care to not worry about.

We have set up this dichotomy of treating the patient or being concerned with costs. We have soaked medicine with the belief that cost-conscious care is rationing at the bedside and the public fear messages that clinicians who care about costs are limiting their care.

How can we teach future clinicians to be so out of touch with one of people’s greatest concerns when seeing a clinician? We know that people forgo medications because of high prices, medical bankruptcy plagues many and some cannot seek care due to cost. What other industries allow someone so crucially involved in controlling costs immunity from worrying about them? Does medicine’s unique role of saving lives exempt it from keeping an eye on the register? Is good care not cost-conscious care?

Clinicians do not have the luxury to not care about costs. The American Medical Association and the American College of Physicians realize this and are blurring the line between the “treat patient” or ”be concerned with cost” dichotomy. They are framing the argument of physicians caring about costs as an ethical issue of the stewardship of limited resources and of providing parsimonious care by using health care resources wisely.

This is a good first step, because bringing costs of care out of the dark eliminates this taboo, hush-hush culture of who’s paying the health care bill when it arrives at the table. Programs across the U.S. recognize this, too, and are weaving into their curriculum how physicians can be aware of costs in medicine. Research is advancing in this area as we explore in greater detail why prices vary so much: implementing comparative effectiveness research, continuing consumer-driven health care efforts and piloting interventions to control health care costs, like holding health communities accountable for the care that they provide.

National campaigns like the American Board of Internal Medicine Foundation’s Choosing Wisely call attention to unnecessary care. We have seen health care costs become more exposed with Steven Brill’s Time article revealing the rates that hospitals bill to patients or use as a starting point for negotiations with insurance companies. And the Centers for Medicare and Medicaid Services made public charges for 100 of the most common inpatient services and 30 common outpatient services, displaying variations in charges across the country for services.

This is not enough though. We need to continue to build this cost-conscious culture in the exam room where medical decisions are made, including both the patient and clinician, because 1) people care about costs; 2) the medical industry is not exempt from concerns about costs; and 3) good care is cost-conscious care.

People care about costs. People have premiums to pay, co-pays to fork over, deductibles to reach, prescription drugs to purchase and co-insurances to manage. This is a lot of financial information for people to keep straight and to be in charge of on top of the responsibilities they have to manage an illness or care for a loved one. We worry about how much health care services will cost us. In May 2012, the Henry J. Kaiser Family Foundation reported that a quarter of polled people had difficulty paying medical bills in the past year. Six in ten have “cut corners” to avoid health care costs, such as skipping a recommended medical test or filling a prescription medicine. As one might imagine, it’s even worse for those who are uninsured, have lower incomes and are in poorer health. Clinicians need to be on the same page as their patients: Costs for their health care matter to them, and people may be afraid to talk about them with a clinician and do not have the tools to know what constitutes a reasonable price for care.

Medicine’s unique ability to save lives is not exemption status from a cost-conscious culture. Just because medicine saves lives, it is not stamped “exempt” from having to think about costs. A good amount of health care is not emergency care, but rather preventive care and treatment of illness. Though health care may be a unique good in our society, the system should not be excused from having to consider sustainable models of spending. When the costs of health care are not transparent to both patients and clinicians, the temptation/decision to limit care may be hidden behind closed doors of obscure insurance policies. Other sectors of society save lives – police departments, prison systems, national security measures – and we still have to consider the costs of financing these services.

Good care is cost-conscious care. Was it worth it or should I buy it? We constantly, prospectively and retrospectively, evaluate how we spend our money: taking that vacation, buying a car, eating out. Was that a valuable use of our money compared to what we gained (pleasure/utility) and would we do it again? Though fewer choices may be available in some emergency situations or medically necessary circumstances where the decision process is accelerated or removed, we still can assess whether the care that we received is worth the cost. Have I been feeling better taking this medication? Has the pain subsided and is the out-of-pocket cost manageable? Has my health improved since seeing my doctor for “X”? These questions tumble around in our minds during our treatments and after in recovery.

Tools for clinicians and tools for health care costs. We are chipping away at this culture of unaccountable spending, of “running dad’s credit card,” when it comes to health care costs. But we aren’t giving clinicians and people the tools they need to partner together to take on this dragon of costs. Partly because people and clinicians don’t know how much health care services cost. Resources like Healthcare Blue Book are slowly becoming places where people can get estimates of how much their care will cost and insurance companies can give rough estimates prior to care. But these are outside of the exam room and can vary considerably.

If we continue to make the standard of treatment a more expensive option when cheaper, equally effective alternatives exist, tools need to be developed for the clinical encounter, in the exam room, where the clinician and patient can participate in shared decision making by incorporating costs: “No, I don’t want that medicine if it costs that much out of pocket,” or “I’d rather try treatment ‘X’ if it will save me that much money.”

Though having these conversations in the exam room may be a tall order for some, neglecting to include such an important issue is bad care. Sending someone home with a fancy procedure and large out-of-pocket costs may not have improved his health, but rather increased anxiety and stress over having to pay for his care. He may have chosen a different course of action had he known in advance the price he’d be paying for years to come. Likewise, prescribing a medication that a person will not pick up because it costs too much does nothing to help improve that individual’s health.

We have a long way to go in delivering cost-conscious care that incorporates the patient’s and the clinician’s views. Evidence-based tools need to be developed for both the clinician and patient to be able to weigh the risks and benefits of a test, procedure or course of treatment, and conversations need to be started between clinician and patient about costs.

I want a cost-conscious clinician who is aware of what I’m being charged and in touch with the challenges I face in paying for my health care. I want to be part of system that acknowledges people’s concerns with costs. People should demand from their clinicians this aspect of their care, and clinicians should demand from their health care organizations the tools to be able to deliver this information. Let’s stop clinicians from passing the buck on the costs of care, and let’s teach future and current clinicians to care about costs.

Patients already do.

Sarah Jorgenson is a medical student who blogs at the Prepared Patient blog and the self-titled site, Sarah R. Jorgenson.

A right to a personal health budget @tkelsey1 @Medici_Manager @pash22

Luke O’Shea, NHS England’s Head of Patient Participation, explains why a “quiet ministerial announcement” is so significant.

http://bit.ly/1h4VSr0

Last week in Parliament, ministers quietly made an announcement : From October next year, thousands people in receipt of Continuing Health Care funding will gain a new legal ‘right to have’ a Personal Health Budget.

The announcement went largely unnoticed by the media, patients and professionals.  Usually Personal Health Budget announcements generate Marmite-like reactions – either heralding the end of the NHS as we know it, or being seen a panacea for a person-centred NHS. But last week there was little reaction.

However, this is a significant announcement for a group of people who have less ability than most to determine the path their lives take.  The hope is that Personal Health Budgets will change that. But will they?

It made me reflect on an important experience I had working as a commissioner in the NHS. It was a trip to meet a man about my age receiving Continuing Health Care.  I think about him quite a lot.

He’d been given a diagnosis of ‘treatment-resistant schizophrenia’ and had been moved around the country for over 10 years because of his complex needs.   After a three hour drive, I arrived at the care home where he had lived for the last five years.  We got on well and talked quite a bit.  We sat in the kitchen and I asked him about his hopes for the future.  He wanted a flat of his own.  However, he’d been told for a long time that they were hoping to sort out a flat, with little sign of progress.  He was stuck.

For the NHS, the care home placement was a success.  He was high risk but had had no hospital re-admissions in recent years.  But it did not offer him what he wanted most, to build a normal life.

When the Personal Health Budget announcement was made it occurred to me that his placement budget would have paid for a flat, a full-time support worker and employment support or training, with some left over.  I wondered whether a right to have a Personal Health Budget would have started a different conversation that day I met him.

For me, the announcement on Personal Health Budgets is part of a wider historic movement where people whose lives have been constrained by the state have been offered greater self-determination.

Why would the NHS not want people to actively determine the path of their own lives?  Should people be allowed to choose and buy their own care?

Well, there is a tension.  They might choose services that fit round their lives and not what suits the NHS.  They might decide a job is more important to them than managing the likelihood of hospital re-admissions.  But what does the evidence say?

The University of Kent controlled trial of Personal Health Budgets, involving 2,000 people, showed patients with PHBs out-performing the control group, and even had fewer hospital admissions.  It seems that patients can be experts too.

The Lancaster University Poet Survey also showed significantly improved well-being for most carers, who tend to bear a huge personal responsibility for this group.  It’s rare that we measure the impact of an intervention on families of patients, but here we have.

So we need a bigger debate about Personal Health Budgets and personalisation in the NHS.  The evidence is good, but there are tensions and the implementation challenges are significant.

Personal Health Budgets are not a panacea, but they do start a different kind of conversation.  And they are not going away.  This announcement is part of a wider historic shift towards personalisation and greater self-determination across public services, which once introduced is very hard to go back on.

So let’s hope this announcement is one small step towards a time when everyone, regardless of health need, is given the chance to determine the course of their own lives.


luke-osheaLuke O’Shea is Head of Patient Participation at NHS England.

He has previously worked in national policy and strategy roles at the Department of Health and as a commissioner in a local authority and the NHS.

Prior to that he worked in a range of government departments including leading work on early year services at the Prime Minister’s strategy unit, as a private secretary to a children’s minister and leading cross government working on ageing.

He describes as his proudest achievements his “modest role at the inception of Family Nurse Partnership in the UK and of my work on ageing”.

Value-Based Health Care Is Inevitable and That’s Good @Medici_Manager @pash22 @leadmedit

by Toby Cosgrove  http://bit.ly/17GkMG7

Vaccines. Anesthesia. Penicillin. Bypass surgery. Decoding the human genome. Unquestionably, all are life-saving medical breakthroughs. But one breakthrough that will change the face of medicine is being slowed by criticism, misunderstanding, and a reluctance to do things differently.

That breakthrough is value-based care, the goal of which is to lower health care costs and improve quality and outcomes. It will eventually affect every patient across the United States. Not everyone, however, is onboard yet, because part of the value-based equation is that hospitals will be paid less to deliver better care. That’s quite a challenge, but one that Cleveland Clinic is embracing as an opportunity to do better. Others must, too.

How the Health Care World Will Change

We all know that U.S. health care is too expensive, too inefficient, and the quality is too varied. The goal of value-based care is to fix that.

A major component of the Affordable Care Act is to change the way hospitals are paid, moving away from a reimbursement model that rewards procedures to one that rewards quality and outcomes. No longer will health care be about how many patients you can see, how many tests and procedures you can order, or how much you can charge for these things. Instead, it will be about costs and patient outcomes: quicker recoveries, fewer readmissions, lower infection rates, and fewer medical errors, to name a few. In other words, it will be about value. And that is good.

Whether providers like it or not, health care is evolving from a proficiency-based art to a data-driven science, from freelance physicians to hospital-employed physicians, from one-size-fits-all community hospitals to vast hospital networks organized around centers of excellence. Each step in this process leads to another.

When hospitals employ physicians on an annual salary as we do at Cleveland Clinic, a doctor is paid the same no matter how many patients he sees, how many procedures he performs, or how many tests he orders. One-year contracts hold our doctors accountable, with yearly performance reviews that include each doctor’s quality metrics, clinical outcomes, and research. And having all your doctors on the same team makes it easier to coordinate patient care among different groups of specialists.

As more independent physicians begin to be hired by hospitals, the opportunity for large group practices and hospital consolidation grows. As consolidation expands, data and transparency become increasingly important, as a way to ensure that caregivers across the system are providing comparable care.

All of this, of course, leads back to quality, which requires an effort to achieve standardization, reduce variation, and eliminate unpleasant surprises. It’s analyzing processes, measuring outcomes, and changing practices until you get it right.

To remain viable in today’s rapidly evolving environment, health care systems must reduce costs while continuing to improve quality and outcomes.

The Cleveland Clinic’s Journey

In the October issue of Harvard Business ReviewMichael Porter and Tom Lee cite six components of high-value care-delivery systems: integrated practice units; cost and outcomes measurement; bundled payments; integrated care delivery across facilities; expanded services across geography; and an information technology platform to enable those processes.

As they note, Cleveland Clinic is one of two medical centers worldwide that has implemented all six, beginning with integrated practice units, which we call “institutes.” A patient-focused institute combines medical and surgical departments for specific diseases or body systems. All of our institutes are required to publish outcomes and measure costs. With bundled payments, we combine all the services provided before, during, and after a complex procedure like joint replacement, into a single charge. We have integrated care through shared protocols and the electronic medical record at all of our 75 care-delivery sites. And our expansion across Northeast Ohio into Florida, Nevada, and overseas allows broad geographic access to our services.

What makes Cleveland Clinic different stretches back to our founding 92 years ago as a physician-led group practice that runs a hospital – not a hospital that employs doctors. This distinction is important. Decisions from the CEO on down are made by physicians based on what is best for the patient.

Mining Data

As a leader in the electronic medical records, we have a wealth of data that can tell us what’s working and what’s not. For instance, we were able to comb through data of heart-surgery patients to find that those who received blood transfusions during surgery had higher complication rates and lower long-term survival rates. This finding – mined from our own data – changed the way we do things; we now have strict guidelines in place to limit transfusions.

We’ve made similar strides in many other clinical areas, using data to drive quality. By collecting data on provider performance and making that data transparent, central-line infections have decreased by more than 40%, while urinary-tract infections have dropped 50%.

Data can help identify variations in clinical practice, utilization rates, and performance against internal and external benchmarks, leading to improved quality and a sustained change in culture. Last year, we established a values-based care team, which seeks to eliminate unnecessary practice variation by developing evidence-based care paths across diseases and to improve comprehensive care coordination so that patients move seamlessly through the system, reducing unnecessary hospitalizations and ER visits.

Lowering Costs Without Compromising Quality

American health care is on an unsustainable path. Health care spending topped $2 trillion in 2011. The Centers for Medicare and Medicaid Services predicts that without major change, it will account for more than 20% of GDP by 2021, up from 5.2% percent in 1960. What that means is that if we continue on our current path, $1 in every $5 spent in the U.S. economy will go toward health care.

We can choose a different path, though. At Cleveland Clinic, we’ve been engaged in an ongoing effort to trim costs across the entire system. Through a concerted focus on our supply chain, we use rigorous value-based purchasing protocols, market intelligence, and business analytics to examine every purchase from the standpoint of value, utility, and outcomes. Over the past two years, this has resulted in cost savings of more than $150 million.

Our electronic medical records are also programmed with a “hard stop” function to reduce unnecessary duplicate tests. This led to a 13% reduction in blood-gas determinations, generated $10,000 in monthly savings for laboratory tests, and resulted in savings of $117,000 in just the first month for genetic testing.

A key part of the cost solution is to educate all caregivers, including doctors, about what items cost. Earlier this year, we created a Cost Repositioning Task Force to work with all caregivers across the entire Cleveland Clinic system to assess everything we do and everything we spend. Now, as part of the purchasing process, dozens of doctors gather to discuss the merits of certain products: Which ones provide the best outcomes for patients? How many are needed? How much does it cost?

Traditionally, knowing the cost of a stitch or a catheter or a bone screw — or any of the thousands of other supplies used during surgeries — hasn’t been part of doctors’ medical consciousness. To remedy that, we’ve taped price lists to supply cabinets in some ORs. In others, posters remind everyone to choose supplies carefully, stressing this message: “Without compromising quality, consider cost-effective alternatives.”

As health care reform kicks into high gear, providers are facing a difficult challenge: being paid less to produce better outcomes. We must view this as an opportunity, not a burden. After all, the providers who make the transition early will be rewarded with more satisfied patients, lower expenses, and pride in a job well done.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us athealtheditors@hbr.org, and sign up to receive updates here.

6 strategies hospitals should steal from the airline industry @Medici_Manager @pash22

by Jonathan H. Burroughs  http://bit.ly/15CSWz6

The Institute of Medicine, in its landmark report “Better Care at Lower Cost,” concludes at least $750 billion of the total national healthcare budget of $2.7 trillion represents waste as a result of poor IT infrastructure, supplier- rather than patient-centered reimbursement, lack of quality and transparency, and inefficient operations and flow.

Wasteful operations may include: delays, over-processing, redundant work, poor inventory management, inefficient transport, unnecessary motion, over-production (push instead of pull), and defects that cause harm and re-work.

The airline industry has worked on these problems for decades and although its operations and flow patterns are significantly less complex than healthcare, it has mastered basic elements we can learn from to give us a jump-start on mastering and taming a difficult but necessary component of operational design that will lead to improved outcomes at lower costs.

1: Air traffic control is managed as a system, not a place

Flow through the airport affects and directly result from flow outside the airport, and air traffic control does not make any distinction. We often treat emergency department or intensive care unit flow as an isolated problem whereas every aspect of an individual’s care from inpatient, to post-acute, to ambulatory has a direct impact on the other. As it turns out, what happens to an individual outside of a hospital has a greater effect on length of stay and flow than what happens inside. Thus, we will never master hospital flow until we master the flow of the entire system.

2: Airport operations function 24/7

Airports function 24/7 and so should healthcare systems. Flow should be managed around the clock and utilization managers should be replaced with flow coordinators who hand off their oversight continuously based on time of day and setting of care. For instance, when a plane takes off, airport air traffic control transfers responsibility to regional air traffic control, and oversight of the flight is continually monitored from control station to control station until the flight terminates at another airport.

Similarly, a flow coordinator should orchestrate a patient’s non-emergent arrival, the admission process, the inpatient care, the discharge planning process and then transfer responsibility for the patient to an outpatient flow coordinator to ensure appropriate follow up and continued optimal care. Ideally, the term “discharge” should be replaced with “care transition” so we stop thinking of moving from one environment to another as a beginning or end.

3: All departures are scheduled in advance

The three most common bottle-neck areas in a healthcare organization are the emergency department, the intensive care unit, and the surgical areas (pre- and post-operative). The vast majority of delays in these expensive settings involve the discharge planning process as patients in these areas often have no place available to go, thus backing up operations throughout, delaying treatment for others waiting to come in, reducing patient/staff satisfaction and increasing costs. Ironically, most discharges are predictable to within one hundredth of a day based upon risk and severity-adjusted length-of-stay data bases (e.g., Premier) for each diagnosis-related group.

Therefore, most discharges should be scheduled at least 24 hours to 48 hours in advance (ideally when the patient arrives) with arrangements made for nursing home or ventilator beds, physician appointments, home health on the day of admission in anticipation for discharge. Many healthcare organizations are purchasing or contracting with nursing homes, home health services, psychiatric facilities and physician practices to gain greater control and ease of scheduling by extending the chain of its operations into the outpatient setting.

4: All arrivals are scheduled in advance

One healthcare myth is that emergent arrivals are unexpected. As it turns out, if emergent ED, surgical, or ICU admissions are tracked over time, the vast majority are predictable. For instance, most emergency department admissions arrive between 3 p.m. and 11 p.m. with the fewest arrivals between 4 a.m. and 9 a.m. There will be rare disasters, which require special resources through a disaster planning process; however, these can be managed and illustrate the difference between random (uncontrollable) and non-random (controllable) variation in flow.

Truly random variation can and should be managed by policy whereas non-random variation should be eliminated by standardizing flow to accommodate predictable admissions in a predictable way through optimum staffing, resource allocation (including beds) and standardized admission processes.

5: Flight schedules are smoothed throughout the day and week

An airport only can handle its capacity of arrivals and departures at any point in time and so it manages the schedule to ensure a consistent schedule of flights throughout the week and time of day. Emergency departments, surgical facilities, and intensive care units can be similarly managed so that non-emergent patients who arrive at the ED can be transferred to lower acuity areas during peak hours, elective surgical schedules can be scheduled evenly throughout the week to avoid demand surges, and ICU admissions can be coordinated based upon regional transfer agreements in compliance with EMTALA to ensure appropriate stabilization and safety.

The system needs to be viewed holistically so all of the units and outpatient facilities coordinate flow in a synchronized and synergistic way to accommodate flow throughout the system and not within a unit alone.

6: Delayed flights are taken off of main runways and taxiways

When air traffic control delays a flight, the delayed flight does not block other flights but is directed to another area to await further instruction and movement. Delayed discharges, transfers and admissions should not sit in beds blocking patient flow but should be immediately moved to a comfortable and appropriately supervised holding area where they can be safely managed and not delay the timely diagnosis and treatment of non-stabilized patients.

Most patients waiting for beds are stable and should no longer receive top priority or undermine the overall efficiency and effectiveness of the system. Similar holding areas can be utilized for admissions, transfer, and discharges if beds are interchangeable and staff is cross trained to handle a broad range of diagnoses and conditions.

Conclusion:

Although air traffic flow is simpler and easier to manage than healthcare, the industry can offer many lessons that will enable us to treat patient flow systemically as a 24/7, inpatient/outpatient, continuous operation that requires continuous management and oversight to standardize processes, exploit bottle-necks, manage random variation and eliminate non-random variation. By doing so, we can reduce costs, improve quality/safety/service and successfully compete globally for high quality-low costs services.

Jonathan H. Burroughs, MD, MBA, FACHE, FACPE is a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives. He also is president and CEO of The Burroughs Healthcare Consulting Network.

Renewing the dialogue between the medical and nursing professions @kevinmd @Medici_Manager

  http://bit.ly/1eRzDVZ

A recent post observed that the “highly charged scope-of-practice” fight between the medical and nursing professions has resulted in social media hate speech – too often, from physicians directed at other physicians. “Like bees to nectar, a post on the topic is sure to draw dozens of anonymous, hate-filled comments” write the authors.  They propose the following “principles for civil discourse” which I believe should apply more broadly to all social media commentary, not just on the physician versus nurses conflict:

“Anecdotes are fine, but avoid drawing generalizations from one story. (‘We had that dumb NP once. She didn’t know where the gallbladder is located. So NPs must all be dumb.’)

Identify the underlying emotion of a comment that irks you, and name it when you respond. (‘Doctor Strangelove, it sounds like you’re frustrated that NPs have fewer hours of training and are asking for the same salary as MDs. Here’s my take: ….’)

Name-calling is out. Polite, respectful comments are more likely to be taken seriously, and to stimulate a productive conversation. ( ‘SJ, I appreciate hearing your viewpoint. Here is WHY I disagree with you.’)

Own your comments. Instead of making broad generalizations, make it clear that you are offering your opinion. (Rather than saying, ‘NPs simply should not be practicing without some sort of physician supervision,’ say ‘I don’t think NPs should practice without any physician supervision.’)

Consider phrasing your comment in the form of a question. (‘I’m troubled by the thought of NPs working in a rural area with no access to collaborating physicians. Does anyone have experience with that?’)

Go for the win-win. (‘The demographics, economics and politics of health care reform suggest there’s enough pie for all of us in the primary care world. We are all undervalued and overworked. By uniting in cause and working with each other, both groups stand to gain in terms of creativity, relationships, and (dare we say) income.’)

Find the best alternative to a negotiated agreement (known as “BATNA” — taken from the classic tome, Getting to Yes). (‘NPs are here to stay, with increasing autonomy across more and more states. Let’s find a way to work together — whether you’re a doctor or NP, our end goals are the same.’)”

If such principles were broadly accepted by all of us involved in social media commentary, they would result in a much better informed, respectful and constructive discussion than name-calling and personal attacks. Civil discourse, though, by itself won’t be enough to end the uncivil war between the nursing and medical professions.  What’s needed is a way to get to the “win-win” point where the legitimate interests and concerns of both professions are recognized and addressed.

Recently, the Annals of Internal Medicine, ACP’s flagship peer reviewed journal, published a paper titled, “Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper” which I believe could become the basis of such a win-win outcome. (Full disclosure: I am the principal author of this paper, along with my co-author and colleague Ryan Crowley, which was written by us on behalf of ACP’s Health and Public Policy Committee and Board of Regents).

Our goal in developing the paper was to constructively address the legitimate concerns of both professions as a step toward renewed dialogue between them.  Nurses have legitimate concerns about being held back by restrictions on their licenses and physician supervision arrangements that limit their ability to provide care to patients, that is within nursings’ skills and competencies.  Physicians have legitimate concerns that their unique and more extensive years of medical training are being devalued by the calls to substitute independently practicing advanced practice nurses for primary care physicians.  Both professions assert that their views are based on what is best for patients.

Our paper asserts that professionalism is the answer to resolving such differences. “Professionalism” we wrote “requires that all clinicians — physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals — consistently act in the best interests of patients, whether providing care directly or as part of a multidisciplinary team. Therefore, multidisciplinary clinical care teams must organize the respective responsibilities of the team members guided by what is in the best interests of the patients while considering each team member’s training and competencies.”

The goal, then, must be to assign, “specific clinical and coordination responsibilities for a patient’s care within a collaborative and multidisciplinary clinical care team should be based on what is in that patient’s best interest, matching the patient with the member or members of the team most qualified and available at that time to personally deliver particular aspects of care and maintain overall responsibility to ensure that the patient’s clinical needs and preferences are met. If two team members are both competent to provide high-quality services to the patient, matters of expedience, including cost and administrative efficiency, may contribute to division of that work.”   While we affirm the importance of, “patients having access to a personal physician who is trained in the care of the ‘whole person’ and has leadership responsibilities for a team of health professionals, consistent with the Joint Principles of the Patient-Centered Medical Home” we also state that, “Dynamic teams must have the flexibility to determine the roles and responsibilities expected of them based on shared goals and needs of the patient.”

“Although physicians have extensive education, skills, and training that make them uniquely qualified to exercise advanced clinical responsibilities within teams…well-functioning teams will assign responsibilities to advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals for specific dimensions of care commensurate with their training and skills to most effectively serve the needs of the patient.”  We observe that, “especially in physician shortage areas, it may be infeasible for patients to have ‘an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care” and that, “in such cases, collaboration, consultation, and communication between the primary care clinician or clinicians who are available on site and other out-of-area team members who may have additional and distinct training and skills needed to meet the patient’s health care needs, are imperative.”

On the debate over each profession’s role in solving the primary care workforce shortage, our answer is, “a cooperative approach including physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals in collaborative team models will be needed to address physician shortages.”

And on the most divisive issue — state regulation of nursing scope of practice — we state that, “Clinicians within a clinical care team should be permitted to practice to the full extent of their training, skills, and experience and within the limitations of their professional licenses as determined by state licensure and demonstrated competencies. All clinicians should consult with or make a referral to other clinicians in disciplines with more advanced, specific, or specialized training and skills when a patient’s clinical needs would benefit from such consultation and referral.”  We assert that,  “Licensure should ensure a level of consistency (minimum standards) in the credentialing of clinicians who provide health care services” and called on state legislatures and licensing authorities, “to conduct an evidence-based review of their licensure laws” and “consider how current or proposed changes in licensure law align with the documented training, skills, and competencies of each team member within his or her own disciplines and across disciplines and how they hinder or support the development of high-functioning teams.”

Now, I know that the paper will not please everyone in the medical and nursing professions, but we hope that it can be the starting point of a renewed dialogue between the professions.  We end the paper by noting that, “ACP offers these definitions, principles, and examples to encourage positive dialogue among all of the health care professions involved in patient care—in the hope of advancing team based care models that are organized for the benefit and best interests of patients. ACP also hopes to inform policymakers to ensure that regulatory and payment polices are aligned with, rather than creating barriers to, dynamic team-based care models. ACP encourages discussion of dynamic clinical care teams that puts patients first.”

Let’s get this dialogue started — with civility, of course.

Bob Doherty is senior vice-president, governmental affairs and public policy, American College of Physicians and blogs at The ACP Advocate Blog.

We are spending billions to train the wrong kind of doctors @kevinmd @Medici_Manager @WRicciardi @pash22

  http://bit.ly/1991PRY

Earlier this year, the physicians at my academic family medicine practice met with two senior officials from our parent health care organization to be oriented to its new initiatives and projects. Their presentation documented the organization’s ongoing investments of many millions of dollars into renovating subspecialty care suites and purchasing new radiology equipment that was likely to be highly profitable, but provide dubious benefits to patients.

Two of my colleagues asked why, given the expected influx of millions of newly insured patients into primary care starting in 2014, and an estimated shortfall of more than 50,000 primary care physicians by 2025, the organization had not identified expansion of primary care training as a financial priority. Where exactly did they expect to find family physicians to staff all of the new community offices they planned to open? An awkward silence ensued, followed by some polite hemming and hawing about how this was a complicated issue, and that supporting generalist training would likely require additional funding that was perhaps beyond the organization’s limited resources.

Additional funding required? How about $9.5 billion? That’s the approximate amount that that Medicare spends each year, with no strings attached, to subsidize the cost of training physicians in U.S. residency programs. Noting that the federal government doles out these dollars without requiring any particular outcomes from the institutions that benefit from them, some have called for Medicare to hold institutions more accountable for meeting America’s physician workforce needs.

If we have a surplus of radiologists and a shortage of general surgeons, why not tie funding to training more of the latter and fewer of the former? Given the decentralized nature of the U.S. health system, though, that has been easier said than done. In particular, it is challenging to follow the money trail and determine which institutions end up producing which types of doctors.

new study in Academic Medicine by health services researchers at George Washington University and the Robert Graham Center fills this information gap. Painstakingly assembling and cross-checking data from several sources on actively practicing physicians who completed their residency training from 2006 to 2008, they were able to identify residency-sponsoring institutions that were top producers of primary care physicians, that produced lower proportions relative to all physicians, and that produced none at all.

Notably, they conclusively disproved “The Dean’s Lie“ that counts all internal medicine residents as going into primary care (when only 1 in 5 actually plan to do so), demonstrating that at some institutions fewer than 1 in 10 internists become primary care physicians. They also identified a large funding discrepancy between the top and bottom primary care producers.

The top 20 primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates (41.0%) and received $292.1 million in total Medicare GME payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates (6.3%) and received $842.4 million.

In short, where physician production is concerned, you get what you pay for. In this case, Medicare pays a disproportionate amount of its nearly $10 billion per year in subsidies to institutions that produce mostly subspecialists, even in specialties where supplies are plentiful, at the expense of training sorely needed family physicians and other generalists whose presence has been shown time and again to deliver better health outcomes.

That’s the big picture. Since all politics is local, policymakers who want to know what types of physicians their teaching hospital or health system is training can use the Graham Center’s free GME Outcomes Mapper tool to find out. And if enough of them do so, maybe we can all have a serious national conversation about moving beyond guaranteed health insurance coverage to ensuring that the care (and the workforce) that coverage is paying for will actually help us to live longer or better.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

Medical societies’ role in improving leadership in medicine @kevinmd @leadmedit @muirgray @Medici_Manager

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The greatest good you can do for another is not just to share your riches but to reveal to him his own.
– Benjamin Disraeli

In 2009, when I was president-designate of the American College of Chest Physicians, a prominent physician, educator and outstanding mentor, who had recently died was honored by her colleagues. One of her junior colleagues, who had never met her but took over her patients, spoke of the profound influence she indirectly had on his life. She was his mentor in absentia, someone he looked up to as his guiding star, someone he sought to emulate.

This example serves to highlight the power of mentorship. Mentorship is inspiring and guiding others to reach their full potential.

The ACCP and other professional medical societies bring together professionals at different stages of their careers, for example medical students to senior and renowned experts in his or her specialty. They have the potential to foster powerful mentorship and leadership programs benefiting members in all career stages.

As ACCP president, the more I interacted with ACCP members, the more I realized that a track for leadership development and mentorship was a pressing need. Medical students wanted to hear of the opportunities that the specialty offered. Fellows and young colleagues wanted to get involved with the organization but did not know where to begin and how to get their “foot in the door.” Members wanted to seek advice from senior colleagues to guide them in their research or for their academic advancement. Some wanted a certificate of participation in leadership courses offered by the organization. Finally, many members, both domestic and international, wanted to know how to climb the leadership ladder within the organization.

The ACCP board of regents enthusiastically supported a leadership and mentorship initiative. A task force was developed to spearhead this effort. The task force comprised the cross-section of ACCP membership who would be involved either as a mentor or a mentee.

Over the past 2 years, the task force has had several accomplishments. Some of those major accomplishments include:

  • An annual orientation course for all new leaders of the ACCP.
  • A leadership development course for members held throughout the year.
  • The creation of the ACCP e-Community, a closed group where members can interact and learn from one another, similar to Doximity.
  • A leadership development course for future leaders. We work with program directors to identify and grow these leaders.
  • Live mentorship programs incorporated into our annual meeting.

Our organization has come a long way — and, we have a long way to go. We have identified a need to improve and enhance our leadership development, and we feel that enhancing leadership will lead to well-rounded members who will not only excel as physicians but also as leaders both at the ACCP and in their own careers.

How have your own institutions, societies, or organizations worked to expand mentorship and leadership initiatives?

Suhail Raoof is immediate past president, American College of Chest Physicians.

Science alone can’t make tough decisions for us @kevinmd @Medici_Manager @pash22

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On April 14, The United States Preventive Services Task Force concluded that women with an elevated risk of breast cancer – who have never been diagnosed with breast cancer but whose family history and other medical factors increase their odds of developing the disease–should consider taking one of two pills that cut that risk in half. The Task Force is an independent panel of medical experts who review the medical literature to estimate the pros and cons of preventive interventions. This is the same Task Force that in recent years raised questions about the benefits of mammograms in 40 to 50-year-old women, and PSA tests for men of all ages, tests that screen respectively for breast and prostate cancer. Despite the popularity of both of these tests, the Task Force concluded that their harms often outweigh their benefits.

The irony now is that with this report on breast cancer prevention pills, the Task Force has switched from rejecting something patients believed in to endorsing something most patients will reject.

The seemingly strange way the Task Force ping-pong’s between popular and unpopular recommendations is inevitable, because these kinds of recommendations must necessarily go beyond the medical facts – it is impossible to decide what preventive measures people need without making value judgments.

To understand the way facts and value judgments get mixed together in these kinds recommendations, let’s take a closer look at these breast cancer prevention pills.

For many years now, doctors have been prescribing tamoxifen as secondary prevention to women who have already undergone treatment for breast cancer, in an attempt to thwart any breast cancer cells remaining in their body. In women whose breast cancer cells express “estrogen receptors”, tamoxifen reduces the chance that this cancer will recur, by attaching itself to those receptors, in effect crowding outestrogen. In breast cancer cells, any estrogen landing on these receptors will spur that cell to divide and multiply. But when tamoxifen lands on these receptor sites, it does not stimulate cell growth.

Raloxifene is a close cousin of tamoxifen, which has primarily been used to treat women with osteoporosis. Like tamoxifen, it competes with estrogen for the attention of estrogen receptors. Also like tamoxifen, it slows down breast cancer by preventing estrogen from stimulating cell growth. As it turns out, both raloxifene and tamoxifen also have the strange property that when they collide with bone cells, they don’t fight against estrogen, but seem to mimic estrogen, and thereby improve bone health. (Because these drugs and sometimes act like estrogen and other times act like anti-estrogen, they are called selective estrogen blockers.)

Two very similar drugs, then. Both slow down breast cancer cells while stimulating bone cells. Each drug has been shown to cut the risk of a first breast cancer in half for women with a high risk of experiencing this disease. In what is known as the P1 trial, for example, women who faced an average five year risk of breast cancer of 6% saw that risk drop to 3%, if they took tamoxifen.

Sounds like a good deal, yes? Take a pill for five years, and cut your risk of breast cancer in half. But keep in mind, most women do not face a 6% chance of breast cancer in the next five years. Women with this kind of risk are generally retirement age or beyond, and usually have a bad combination of family history, early onset of menses, and late age of first pregnancy. It is these women the Task Force believes should talk with their doctors about whether to take these medications. And how did the Task Force reach this conclusion? By determining that for some women, at least, the benefits of these pills outweigh their harms. Before looking at this harm benefit ratio more closely, let’s put this Task Force conclusion into context.

The Task Force essentially produces three kinds recommendations, which I have taken the liberty to name.

  1. NADA: When it concludes that the harms of an intervention outweigh the benefits, the Task Force recommends that doctors and patients avoid the intervention. Think: ultrasound screening for pancreatic cancer.
  2. OUGHTA: When the Task Force concludes that the benefits outweigh the harms, it pushes to make the intervention standard of care. For example: routine screening for colon cancer in people 50 years or older.
  3. UP TO THE INDIVIDUAL: When the Task Force concludes that the benefits of an intervention potential outweigh the harms, depending on the patient’s individual preferences, it leaves the decision up to individual patients and their doctors to weigh. This is the recommendation the Task Force made both for mammography in 40 to 50-year-olds, and for tamoxifen and raloxifene to prevent breast cancer.

When making NADA or OUGHTA recommendations, the Task Force essentially makes its own value judgment. It looks at the risks and benefits of an intervention, and concludes that no sensible person could decide differently from the Task Force. In this third type of recommendation, however, the Task Force concludes that reasonable people could make different choices, based on how they weigh the risks and benefits of the interventions.

In the case of tamoxifen and raloxifene to prevent a first breast cancer, I expect the vast majority of women will conclude that the risks of the pills outweigh the benefits.  In the past two years, I have collaborated with a team of researchers at the University of Michigan (led by Angie Fagerlin, a decision psychologist in their medical school), to help women decide whether to take either of these pills. We developed an Internet-based decision aid, a tool designed to help patients weigh the pros and cons of their medical alternatives. (I write about the history of decision aids in my book, Critical Decisions.) Our decision aid provided women with individualized estimates of their odds of developing breast cancer in the next five years. We only directed women to the decision aid whose risk was high enough to have qualified for the P1 trial.

In the decision aid, we described the benefits of both drugs – the reduced risk of breast cancer and the strengthening of their bones. We also laid out the risks – a very small chance of endometrial cancer, a slightly larger chance of heart attack or stroke, a modest risk of cataracts, and finally a very strong likelihood of experiencing menopausal symptoms such as irregular menstrual bleeding and hot flashes. We actually provided them with precise numerical estimates of these side effects, with pictures illustrating the risks to make them easier to comprehend.

Women pondered the pros and cons and concluded, almost unanimously, that the side effects of these drugs outweighed the benefits.

The decision whether to take tamoxifen and raloxifene is no doubt a personal one, and the right choice will vary depending on how a given person weighs the respective risks and benefits of these medicines. For a woman with an extremely high risk of breast cancer over the next five years – say 10% or more – cutting that risk in half might very well be worth the hot flashes and the chance of experiencing blood clots. But very, very few women faced a five year risk is highest.

Consider, instead, a woman with a 3% chance of developing breast cancer over the next five years. That risk is much higher than average – most women face a five year risk of less than 1% – but is it high enough to justify taking one of these pills? For such a woman, tamoxifen and raloxifene only reduce that risk by 1.5%. Over five years. Five years with possible hot flashes. For a cancer women have not experienced yet. These modest benefits simply do not loom large enough to interest most women in these pills.

You might wonder at this point whether our decision aid biased women against these medications. As a physician trained in behavioral economics, I’m constantly on the lookout for decision biases. In the case of our study, however, we designed our decision aid in a manner that allowed us to test for well-known behavioral economic biases. For instance, research has shown  that when people face a choice between three options and two of the options are similar, they often opt for the more different alternative even if the other options are better. In other words, a person might believe that A > B, and A’ > B, but still choose B over A and A’, because they cannot decide between A and A’.

Aware of this problem, we created several different versions of our decision aid. In one version, we presented women with a choice between tamoxifen, raloxifene or no pill. Three choices in other words, two of which – the two medications – are quite similar to each other. In another version of the decision aid, we simply presented women with the choice between pill or no pill. We thought this simpler choice would increase women’s interest in these pills, by minimizing the difficulty of choosing between the two of them. But instead, this reframing of the decision did not increased women’s interest in either of these preventive medicines.

We also designed our decision aid to take account of another well-known decision bias, what are known as recency effects. When people learn about the risks of a medication and then learn about its benefits, that order of information leads them to look favorably upon the medication, because the information they remember best, the last information they receive, is about the pill’s benefits. By contrast, people who receive the same information about this medicine, but in the opposite order, like the pill less, because the last thing they learn about are the pill’s risks, and this information sticks in their minds. To make sure this recency effect was not influencing women’s decisions, we varied the order of information across women. We discovered that this did nothing to change their willingness to take either of these medications, mainly because whichever order women received information in, they did not like the idea of taking either pill.

If these pills are so unpopular among well-informed women, why would the Task Force come out in favor of them? It comes down to judgment. The Task Force concluded that a reasonable person could look at these risks and benefits and decide that the hot flashes and blood clots are acceptable prices to pay to reduce the chance of breast cancer. The majority of women don’t have to agree with this view for the Task Force’s recommendation to be correct. Even if only a small percentage of women decide these pills are worth taking, at least they have the freedom to make that choice. And at least they know that medical experts have concluded that such a decision is a reasonable one to make.

The same goes for whether to start mammograms before the age of 50 in women at normal risk of breast cancer. The Task Force never said that women shouldn’t start mammograms at this earlier age. They just said that it was a tough judgment call, and that some women, perhaps the majority even, might conclude that the harms of early screening – the anxiety caused by false negative tests, the pain caused by unnecessary biopsies – aren’t worth the modest benefits of screening at this age.

If the Task Force is going to leave all these tough decisions up to individual patients and their doctors, why should we care about their recommendations? For starters, you will have a hard time finding a more thorough and levelheaded evaluation of the pros and cons of these kinds of interventions. These people are very good at what they do. In addition, anyone reading through Task Force reports will be forced to recognize that science alone can’t make tough decisions for us. Ultimately, science can only provide us with the facts. The rest of us eventually need to make tough judgment calls. In effect, the Task Force is doing us a huge favor, by showing us which judgments are close calls, and which ones are no-brainers.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.