Lessons from ACPE's Annual Meeting

It always takes me a few days to unwind from the intensity and new ideas coming out of our Annual Meeting. This year's meeting in Washington, D.C., and that's me in the picture with my wife, Janet, and an actor who portrayed one of the "founding doctors" during our induction ceremony for Fellows and Certified Physician Executives.

At the meeting, we heard from Dave Snowden about Complexity Theory and how it can be applied to the chaos of health care. He pretty much exploded many of the status quo ideas about a linear, predictable and manageable control mentality when it comes to improving our health care system! His analogy of parents trying to “manage” a 6 year old’s birthday party and all the unexpected twists and turns inherent in such an endeavor was hilarious.

He mentioned that we should be aware of “outliers” from the norm. Thinking about that, I met two medical students who found their way to our Annual Meeting and asked them why they came. Both were curious about physician leadership and system change. At least one has already decided he wants to be involved in system change when he graduates. I want to meet more outliers like these, and like the many young physicians who were attending their first ACPE meeting and are excited about being agents of change.

It feels like a renaissance is occurring among a growing number of physicians. No longer content to watch from the sidelines, or rail against powerful forces with major roles in health care, these physicians are excited and optimistic about the role they can play in shaping the system to better serve patients, and the professionals who work in the system. Many said they’re tired of the “us vs. them” way of thinking. They know that the strategic importance of financial statements, linking quality and safety to the business functions of medicine, and knowing how to influence organizations to change are new knowledge content that will be important.

We heard from David Cutler, a health economist, and from six leaders who gave us updates on what they expect in payment, safety, comparative effectiveness research, IT, medical home, and integration. The innovators among us – probably most of us – were imagining what new ideas can disrupt the status quo, and change the health care landscape.

Finally, I want to thank Harry Leider for his leadership as President of ACPE over this past year. He demonstrated to me, to our Board, and to our members how enlightened and effective leaders work. One of Harry’s greatest achievements was organizing seven Task Forces on key issues. Their reports were given in person to the Board. The analysis and recommendations were insightful, strategic, and very useful. You’ll be seeing more in the months to come about what ACPE is doing to implement those recommendations. Thanks to the more than 200 members who contributed to this vital work.

A Good Friend at CMS

The Obama Administration is set to disclose that Donald M. Berwick is its pick for administrator of the Centers for Medicare & Medicaid Services, according to a report from the Bureau of National Affairs.

Members of ACPE are quite familiar with Don’s work and writing as a physician, CEO of the Institute for Healthcare Improvement, and one of the authors of the Institute of Medicine’s landmark reports calling for greater safety and efficiency in our nation’s health care system. I think Don is a great choice to lead the country’s largest source of funding for health care services. If he survives the confirmation process (never an easy task), here’s what we should expect, and why he’s up to the challenge.

First and foremost, Don knows that the health system should be designed with patients and consumers as the primary focus. He’s written and spoken eloquently about his personal experiences with mistakes and poor communication among members of the health care team during his wife’s serious illness a few years ago. He’s made the impact of errors and poor communication very real to care givers and health care leaders through the voices of Americans who have lost children and spouses from medical error to the attention of the health care industry by allowing them to share their stories with us. Hearing their stories and their determination to prevent similar tragedies from happening to others should make us no less committed to a safer health system. Look for CMS to have a relentless focus on health system safety.

Consistent with his focus on consumers, watch for a spotlight to be shown on the cost of care. These federal funds for Medicare and Medicaid come from our taxes. We have every right to demand that CMS funds are being spent for essential services, delivered efficiently. Recent articles on communities that have BOTH high quality and low cost are worth re-reading. If you haven’t looked at the Dartmouth Atlas recently, you might want to see how your region or community compares to the best cost performers – and ask yourself why. Overuse of medical services will be a hot topic.

Now that insurance reform changes have been passed, I expect the next large change to come in how physicians and hospitals are paid. Many health policy experts have pointed out the flaws in the fee-for-service system when quality, safety, and lower costs are the goal of a nation’s health system. Based on his experience as a pediatrician, IHI’s experiences with promoting greater efficiency , and imagining an idealized design in which a system is perfectly designed to achieve the results it gets, we should be prepared for a transition to bundled payments, and/or capitation for large populations. This means that another wave of integration between physicians and hospitals will occur.

Recent reports suggest discussions have already begun across the country as balance sheets of independent group practices deteriorate in the recessionary economy, and health systems are seeking clinical leadership to deliver lower cost care with high quality. Add to this equation the preference of young physicians for employment by a large organization, and we’ve already got momentum for change in the alignment of hospitals and physicians.

Finally, Don has the characteristics of a “Level 5 Leader”, as described by Jim Collins in this best selling business book, Good to Great. Noting the common leadership traits that make these leaders highly successful, he describes men and women who understand from personal experience what’s happening at the front lines of their businesses or industry, like most physicians in leadership roles. They “turn information into information that cannot be ignored”. They’re ambitious for their enterprise (not themselves). They’re quick to give credit to everyone but themselves when everything is going well, and take personal responsibility when things aren’t going well. They lead with questions, not answers.

Please join me in asking what we can do to help Dr. Berwick transform our health system to one that’s more responsive to patients’ concerns about quality, safety, and cost. This is the time to use what we’ve been learning about leadership, influence, reliability and teamwork. The next few years are going to be exciting ones for all of us!

Physician Leadership: The Next Generation

I’ve had a couple of really great weeks.

I had lunch the other day with several physicians who are here in Tampa for the Certified Physician Executive tutorial. Almost all of them were in their thirties. Last week I was at a meeting with CMIOs, many of whom were in the same age group. This is a very energetic and determined group of physicians who have a whole different set of challenges than many of us have had, or are currently dealing with. I left these two separate meetings with optimism for the future of health care and a determination to make ACPE a place where they can get the help they’re seeking. Here’s what I heard.

Many of these physicians already have advanced degrees in management. They’re very articulate in defining leadership and management challenges in health care. They decided during their medical training, or before, that they wanted to be in leadership or management roles. All of them are familiar and facile with information technology as a means to improve health care. Some of them were tapped for IT roles because of the perception that they’re “technodocs”. Direct, one-on-one patient care is not their preferred career path. They want to maintain both a clinical role, and a significant leadership or management position in whatever organization they’re working with.

They note that the health care industry is extremely hierarchical. Leadership positions are usually given to physicians who are much older than themselves. They’re being pulled into leadership roles primarily because they have IT skills, and because they really enjoy the opportunity to improve a system. Unlike many mid-career or older physicians who describe being pushed into management roles somewhat reluctantly, this group is very excited about shaping the next generation of health care.

They’re interested in learning how to position themselves in the eyes of system leaders and board members as potential senior leaders – even as physicians who are still early in their careers. Because they’re young, many older physicians feel they can use their personal connections with senior leaders or board members to make life difficult for them when change management issues are not to the liking of senior colleagues. Their spouses sometimes ask them if their CMIO role will lead to anything else after the IT implementation is completed, or whether their system leadership opportunity ends with that job. I think that’s a very fair question, and one that deserves an answer.

If you’re in a high level senior leadership role at your organization, would you do anything different if you knew that the youngest physicians making an impact in your organization might be impatient for more significant leadership opportunities? Have you mapped out a career path with them that fills their needs for a satisfying career in health system leadership? What would you tell them about positioning themselves for those higher level roles if they’ve already gotten their MBA or MMM, and if you’ve been noticing how quickly and elegantly they’re able to define a thorny issue in your organization compared to older physician leaders without that leadership and management training? If you thought that one of the youngest physicians on your staff was the best leader for key organizational roles in quality, IT, safety, operations, or even the CMO role, would you discount their suitability because of their age? Can we create organizational structures for the health care systems of the future that are less hierarchical, more teamwork oriented and less age-dependent?

The Blunt End vs. The Sharp End

Clinician leadership. Integrated health system. Accountable Care Organization (ACO). These are the concepts and words being discussed, debated, and defined at our Winter Institute in Naples, FL over the past few days. They’re the same words and issues I heard last week at one of the nation’s premier MHA programs. We’re talking about strategies, structures, compensation methodologies, alignment challenges, and the economics of integration. Why are these topics at the “top of the charts” of what both physicians and non-clinical health system leaders are listening to, and talking about?

First, many health systems and physician groups are anticipating changes in payment that reward quality, outcomes, and safety – regardless of whether any health care legislation emerges from Washington. Clinicians with additional knowledge competencies in integration strategies, compensation methodologies, will be vital to successful implementation of integration strategies.

Second, for medical groups and health systems to be viable economic enterprises, the bottom line must reflect improvements in quality and patient safety. One of the questions discussed in the Advanced Quality course was, “What’s the cost of a Never Event?” The discussion included a financial analysis of Never Events and complications, AND how to mobilize clinicians to develop better communication techniques, and change the culture of the entire organization to address the cost of poor quality and outcomes.

The power and importance of clinician leadership can be summarized using a concept familiar to system safety engineering and accident investigation. It’s called the sharp end-blunt end model(1) of how organizations and the people who work in them interact. Imagine an inverted isosceles triangle representing an organization. The blunt end is where boards and senior organizational leaders develop missions, strategies, and goals for the organization. The sharp end is where the organization’s people, processes, and technology touch its customers (patients). In health care it’s what happens to a patient, in the ED, ICU, lab, radiology, ambulatory care, etc. When an organization’s mission, vision, values, and goals are translated into appropriate specific individual human behaviors and actions at the sharp end consistent with blunt end strategies, it’s performing at a very high level.

Clinicians are intimately familiar with activities and behaviors at the sharp end, because that’s where we’ve spent many years of our lives. We’ve experienced the frustration of inefficient work processes, and understand how harm can occur to our patients. Now imagine a clinician entering strategic and operational discussions at the blunt end. There’s tremendous insight and wisdom that can be contributed to decisions about what to improve, how to improve, and what observable behaviors at the sharp end will indicate that improvement is happening.

Just being a clinician isn’t enough to be effective in a leadership or management role. We have to learn about strategy, influence, basic health care finance, and organizational dynamics to really be effective in making change happen. Just as we have our own language and thinking styles, non-clinical leaders have theirs. Breakthrough change comes when new insight emerges from understanding how solving your problem can solve someone else’s problem at the same time. Ask yourself what value you can bring to an integrated system, ACO, clinic, business, or workplace in the health care sector. Maybe it’s traditional one-on-one patient care at the sharp end. Maybe it’s that, plus helping out at the blunt end to design a system that works first for patients, and secondarily for the professionals – both clinical and non-clinical – who care for them.


(1)Cook RI, Woods DD. Operating at the
Sharp End: The Complexity of Human
Error. In Bogner MS, ed. Human Error
in Medicine. Hillsdale, NJ: Erlbaum and
Associates; 1994:255-310.

Lessons from Tucson

Our Fall Institute in Tucson, Arizona, finished last week. Here are some quick “ahas” from our Board, our members and me that I thought would interest you at this time of chaos and change in health care. Tossed in this mix is a joke from 10-year-old Anastasia, which put a smile on our faces and made us more creative.

• “If you don’t like change, you’ll like irrelevance even less,” Mike Wirth, president of The Governance Institute, quoting General Eric Shinseki at the Innovators’ Panel discussion.


• “There are two types of change. Incremental change is the process applied to making existing products, services or market shares better (doing what you do better). Disruptive change is doing something different,” Eileen McPartland, COO of Allscripts, in remarks shared with our Board.


• “If I had asked people what they wanted, they would have said faster horses,” Jason Hwang, co-author of The Innovator’s Prescription, reminding us of Henry Ford’s famous quote about knowing what your customer wants – and thinking beyond.


• “We should define ourselves by the job to be done. We shouldn’t be in the business of selling ¼ inch drills – we should be in the business of providing ¼ inch holes,” Jason Hwang.


• “Don’t make hypotheses about segments of markets. Look for general themes and find common values. Segment by behaviors and buying patterns.” Bob Lokken, CEO of White Cloud Analytics, a member of the Innovators’ panel.


• “Why did the tomato blush? Because it saw the salad….dressing,” Anastasia, when asked to share her best joke.


• “I’m 100% clinical right now, but might want some other options in two or three years,” a participant, when asked his reason for attending.


• “As soon as you place a negative label on another person or group, you’ve placed a huge psychological obstacle between you and them in terms of human influence,” Charles Dwyer, a professor from the Wharton School, teaching the Physician In Management (PIM) course on influence.


• “Never expect anyone to engage in a behavior that serves your values unless you give that person adequate reason to do so,” Charles Dwyer.


• “No one has to do anything,” Charles McCabe’s Law, as quoted by Charles Dwyer in his influence course.

The attendees in Tucson were focused on getting the skills they need to lead change in their organizations and communities. They asked lots of great questions about how to get that first management opportunity or how to move on to more responsible leadership positions. We had physicians asking about roles in insurance, pharma, and employee health – and we had experienced physicians from those sectors to help answer those questions. I’m optimistic about the future of health care because physicians are learning the leadership, management, and behavioral skills that are needed to innovate and change. Combined with our clinical experiences, it is a powerful combination for change.