A powerful tool is to translate Lean into an analogy about delivering great patient care.

You can compare the stages of evaluating and delivering great patient care to the stages in which Lean can be applied in healthcare processes. The first stage in delivering great care is for the physician to go see the patient, similar to the Lean teaching to go see the process with our own eyes. Secondly, physicians learn about a standard protocol in medical school called History, Physical, Impression, Plan (HPIP) as a systematic way to evaluate a patient. Lean also systematizes process evaluation through the application of value stream mapping, 5S and Kaizen, all standard ways of uncovering potential solutions for treating serious process problems that consume wasted time and effort. The third stage is the prescription for treatment; delivering great care involves not just treating the symptoms but addressing the root cause of the problem. In Lean, we are taught not to jump to solutions, but to take the time to understand the facts around the process. Finally, in the fourth stage, physicians are taught to make sure there is follow up with the patient, whether it is with their primary care physician or other provider. The Lean process is very focused on the follow up as learning new processes is highly challenging and a rigorous sustain plan with data is a key to successful implementations.

Try this analogy next time you are challenged to engage your physicians in participating in your Process Improvement initiatives.

9. Have an area of expertise / team up

Your health system meetings are a good opportunity to leverage your executive team as another set of audience members. When you have the support of a larger group in business meetings, you should discuss and agree on critical areas of focus in advance to maximize participation. For example, you might want to focus on determining the financial solidity of the proposals and programs, analyzing how well the presenter assumed stretch targets, leveraging the right stakeholders, setting a shared vision, mobilizing commitment, considering change controls, or other important areas. Once the audience members agree on these key aspects, it can be very helpful to determine who will question / interact in each area. A meeting becomes one-dimensional and boring when only one executive speaks and, frankly, each of the audience members should be engaged in the conversation or what is the purpose of their attendance? Determine the assignments ahead of time and help each other. Each executive needn't stick to their original assignment, as long as the dialogue is lively, engaged and relevant.

10. Say thank you

We can forget how stressful it is to prepare for a meeting with an executive. Planning how you conclude these meetings is an important consideration. I remember clearly a meeting I had with several vice presidents early in my career. I don't remember the topic we covered... in fact I could not recall what we talked about except that all of us presenters were challenged severely and were feeling a little deflated by the end of the meeting. We had worked hard for weeks on our presentation and it was based on several months of difficult work. We all had our game faces on and soberly took our feedback with all of the professionalism we could muster. It was the end of the meeting and we started to gather our things to leave. At that point, surprising us, one of the vice presidents stopped us to say a few words. He said some like this: "Hey everyone, I know you might feel like we all poked you in the eye a little as we went through this presentation with you, but I want you to know that you all handled it really well, I recognize the monumental amount of work required to do this and I think the progress you have made is terrific. It is our job to challenge you in these areas, and we do that to test you and also to learn about your work. I feel great about all of the progress you have made, keep up the good work, and thank you for an outstanding presentation." I walked out of that meeting sky high. I was so energized and could not wait to work even harder. A simple 'thanks, great job" is NOT enough for your presenters. You should try to 1) acknowledge their efforts and all of their hard work, 2) point out why you challenged them and why that is part of the process, and 3) say thank you. This minimal effort, when done with true sincerity, can pay big dividends in employee engagement and productivity.

This was the final blog in the series covering another set of leadership behaviors to leverage in your meetings that can change your organization. Performance Solutions' culture driven performance model can help your organization lead change in this and many other ways.

"Be the change that you wish to see in the world." -- Mahatma Gandhi

7. Stay out of the weeds

There is a time for drilling down and getting into the details, and there is also a time for staying on track. It's always appropriate to ask relevant questions about performance data and targets, whether financial, clinical or otherwise. These data provide informative metrics and information that are critical for understanding the business of your healthcare system. But don't get tricked into going down the rabbit hole by continuing to dwell on data to the point where you lose sight of the important strategic conversations that are a productive use of your time. Use meetings to have strategic conversations and drill down only when necessary -- and get back on track quickly. The behavior that you will inspire in your team is to know their numbers and be able to emerge from the details in order to consider strategic implications across the system.

8. Drive accountability

It is critical that your hospital leadership understands what they own in terms of results. They have accountability for operational outcomes even when they may not have authority. They should understand the broader influence responsibility that they have. This is true for facility and department / corporate leaders. In some organizations, it is the corporate and headquarters departments that can have a more difficult time acknowledging this reality. Make it clear to them. These leaders need to feel accountability for these results, regardless of their sense of control ... this is part of leadership expectation in their role and it bears re-iterating in your meetings with them. Requiring that each meeting include a recorded set of follow-up action items is a fantastic way to drive accountability, and the action list is only as good as the leader's ability and perseverance in following up. Before anyone leaves the room, each action identified in the meeting needs a definition, an owner (who is responsible), and a due date. These action items must be identified during the meeting, be sent to participants within a short time, and be accompanied by clear expectation regarding the follow up. The quicker that actions are shared with accountable parties, the greater the impact on the recipients. It is possible that you will eventually want to re-emphasize this accountability outside your meetings as well, and that can take the form of human capital practices like incentives, pay practices, merit and discipline programs. If you are going to set goals for your staff, your meetings with them, conversations, policies and practices need to reflect that they are accountable for those goals.

Look for the next blog covering another set of leadership behaviors that can change your organization. Performance Solutions' culture driven performance model can help your organization lead change in this and many other ways.

In order to move the company toward this goal, Gerstner began reorganizing IBM's management structure so the company was better positioned to drive customer solutions. Gerstner breathed life into the revised structure by creating a series of systems and structures designed to change the way the business operated and ensure the company did not go through the re-organization only to revert to business as usual. Gerstner knew that for IBM's transformation to succeed it had to extend beyond reporting lines and truly change the way people thought about their jobs.

The problem IBM faced in the 1990s is not all that dissimilar to the situation facing many healthcare executives today: in the face of a rapidly changing industry, health systems across the country are focused on moving from a siloed fee-for-service care model to a new world where all the assets of a system (Preventative, Acute, and Post-Acute) need to be focused on providing a patient with coordinated health solutions. In response to this challenge, many health systems are reorganizing their leadership team and reporting structures, as IBM did, to better align with this new model of care.

This is the right approach as traditional health system organization structures often create barriers to managing a population's health. The re-organization alone does not solve the problem, however, and unfortunately, too many systems fail to take the next step of changing their operating systems and structures to support the new organization. Organization charts are important, but if you move the boxes without addressing how people actually work together and how goals are aligned across the organization you will continue producing the same results.

To activate its new strategy, IBM instituted new operating rhythms that brought together collaborative teams from across the organization to focus on progress toward its strategic imperatives. IBM also adjusted its goal-setting and incentive compensation systems to ensure leadership was aligned around the common goals of the organization. This approach is similar to what GE uses internally, and it is the basic methodology Performance Solutions has used to drive transformations at health systems around the country.

Our experience has shown that health systems seeking a true transformation must move beyond simply re-organizing their reporting lines and focus on establishing organization-wide processes that align goals, focus work efforts around a few key initiatives, and ensure accountability for execution. While re-organizations often accompany the transformation efforts we are involved in, the clients who are truly successful are those, like IBM, who adopt strong processes for aligning goals, activating strategy, and driving accountability.

5. Listen

It's amazing to me how many people think they are good listeners. Consider the number of people who feel that they rarely experience a good listener, and we can reasonably conclude that there are some folks out there who think they are better at it than they really are. I say this merely to bring attention to the concepts that underlie good listening, and to inspire some self-reflection on your current skills. The two most commonly required changes in leadership behavior are 1) slow down and 2) show you understand. It is human nature to try to determine what someone is going to say before they finish their sentence. However, when you complete a sentence for a speaker, it can be drastically de-energizing as a listening technique, even though the speaker may feel you are demonstrating keen insight. Waiting patiently to make your point is another behavior that takes attention away from what the speaker is saying. If you are finishing sentences for others, thinking of a point that you will add, or generally jumping in to make your own point, you may need to think seriously about slowing down the conversation. Taking the time to use your toolbox of active listening techniques will pay large dividends in the form of productive conversations and overall goodwill (the term 'go slow to go fast' applies here). Showing real understanding in your remarks and having the speaker acknowledge that you are mirroring their content accurately will lead to a much richer and more robust dialogue and idea sharing. As a leader, demonstrating outstanding listening skills allows you to model behavior that you would like to see more broadly in the organization, and it can also make you seem much more approachable, which may expose you to more innovation and creativity in lower ranks.

6. Determine how well your presenter knows the material

Sometimes, you should ask a few questions that you already know the answer to. Each meeting you have with anyone in your system is an opportunity to get additional data and collect feedback. All interactions are performance reviews, so try to get the most out of each one. Don't be shy about pushing for more information and don't accept "I don't know" or "I'll need to get back to you" without an explanation, especially if it is in an area of expertise that you expect that individual to have mastered. Think of the power in knowing something more about how your staff is performing and finding out in a way that allows you to assess true operational knowledge. Don't we all want our leaders and staff to know the business of healthcare extremely well? Have they thought through applications, impacts, consequences, benchmarks, organizational considerations, and workforce planning, to name a few considerations? Are they relying so heavily on consultants that they don't understand their own business as well as they should? Your meetings are a great way to pulse and prod in this area... take the opportunity to make every interaction a source of input for your staff's performance reviews.

Look for the next blog covering another set of leadership behaviors that can change your organization. Performance Solutions' culture driven performance model can help your organization lead change in this and many other ways.

3. Demonstrate you support the right analysis and back-up

As a healthcare leader, you direct your staff in many areas. For example, you may ask physician leaders to initiate a project to implement a care model, starting with orthopedics across your system. Or create a new patient experience model and pilot it at your hospital in the southwest region. When your presenter comes to share plans and strategies for leading, executing, and sustaining this initiative, you have a unique and special opportunity as a leader. All plans or recommendations to be reviewed need to be based on tangible and logical data. Environmental analysis, benchmarking, well-informed assumptions, focus group results, and financial forecasts are examples of what you as a leader should require. It is irrelevant whether you provided the direction to go forward or not; no one's gut feel - neither yours nor your team's - is sufficient to merit acting upon. It may take several meetings of pushing on the team to supply this missing data, but don't give up. After a few of these experiences, organizational behavior will begin to change and a culture shift towards analytical verification should emerge.

4. Acknowledge work well done

While it might seem trite to say "nice job" (or a similar verbal pat on the back) any time the right work is presented, it is actually a fundamental way to help your leaders and teams understand your standards. They need to know specifically the type of work, innovation, communication and vision that you want to see and understand how it will help them work through difficult patches. The acknowledgement needs to be delivered with three unique parts: 1) indicate why it is important, 2) reflect on the impact it makes, and 3) convey how the demonstrated behaviors can be leveraged to move through other difficult areas and that you would like to see more of this level of performance. Word spreads quickly on the kind of work and behavior you are looking for... and breeds more! I strongly encourage leaders to practice this particular behavior before trying it in a meeting. It is harder than it looks to employ, probably because it seems too simple and straightforward. Don't underestimate the impact on the recipient during a meeting when this type of feedback is delivered effectively and sincerely. At that moment, many leaders see the inspiration and motivation they have been eager to drive in their organizations start to take root.

Look for the next blog covering another set of leadership behaviors that can change your organization. Performance Solutions' culture driven performance model can help your organization lead change in this and many other ways.

Getting comfortable with change is a first step. Knowing that change is a constant state of being, and leading successfully in that space, requires the ability to optimize operations while embracing the delicate balance required in managing your human capital. How many times have we had an idea for motivating our workforce (or for motivating just one member of our staff) that we planned and thought about for days? We worked on the right words, meaningful examples we would reference, our tone, and even facial expressions. But somehow, our message lost power along the way. It wasn't as impactful as we wanted it to be, and our teams (and maybe we ourselves) reverted to prior behaviors.

As Gandhi points out, our messages gain in power when they take the form of the actual behavior we model, starting with how we act as leaders in our meetings. In this series of five blogs, we'll cover 10 leadership behaviors that can inspire and maintain true change in your organization. It's this type of executive coaching that Performance Solutions can offer your organization as you address some of the human side of leading change. Everyone looks to leaders in order to guide their own behavior. Your responsibility is undeniable... how you shoulder it is up to you.

1. Start interacting right out of the gate

We've all been in meetings when the presenter, eyes down, starts to methodically walk through the bulleted items on a presentation slide or read lines of data analysis one-by-one. It can be hard to get a word in without rudely interrupting, and by the time there is an opportunity to talk, it can seem insulting and hurtful to state that they need to re-think their approach. Statements from a leader in the room, even a few minutes into a presentation, such as "we want to make this a discussion," or "let's start with some grounding on your topic," or "I'd prefer to hear some of your impressions of this analysis" can seem like a harsh judgment to the presenter. Add that to the nervousness that many presenters feel, and we've lost an opportunity to create a more positive experience for the group.

The key is to start the interaction very early in the process. Early intervention can prevent a 'speech' and encourage discussion. The responsibility for setting a tone for the interaction falls on the leader. The moment eyes drop down to a page, call attention back up by asking a pertinent question. I've even seen an executive in an audience say "I can read, so you don't need to read your slides to me. Please look up and let me know what you think." Getting a two-way dialogue started in the first 30 seconds is the key to a meeting with a different tone. Late intervention can feel like a slap, whereas early involvement feels like an expectation-setting exercise and is less confrontational. Once presenters begin to get a feel for this new style, they will begin to change their approach as they enter business meetings, and a cultural shift should ensue.

2. Be firm, but fair

Setting an environment where serious work with serious results is encouraged and recognized is harder than it looks. Being able to recognize work that was challenging yet worth it requires having a deep knowledge of the subject. People like to be complimented. And it feels good to be the one doling out the kudos. For some leaders it comes naturally while others need to be reminded to focus on the positives. The magic is in the balance. I think the key here is preparation via multiple means. Whether it means having a few short discussions with internal or external colleagues, reading up or walking the hospitals, the more you know the better you can challenge and praise in the meaningful areas of work. How you respond to the work being presented will drive all future behavior in interactions. Taking this work and this presentation seriously is a major step. Providing firm and fair perspective encourages MORE meaningful work, which can push your organization forward at the speed of leadership's drive.

Look for the next blog covering another set of leadership behaviors that can change your organization. Performance Solutions' culture driven performance model can help your organization lead change in this and many other ways.

As many private practices and hospitals are being purchased by large health systems, and many large health systems are merging with each other or payers, here are a few tips from happily married couples to consider.

1. Understand how you balance each other out - Phrases like "opposites attract" and "you complete me" are woven into our culture. There are compelling reasons why. The same sentiment is a primary driver of healthcare M&A activity: to close gaps in the continuum of care for patients, while also preparing to manage risk as organizations move to new structures such as Accountable Care Organizations. Lesson: Ensure each organization clearly understands the other's value proposition and why at the end of the day, 1+1 should equal 3.
2. Meet the extended family - When you marry someone, you are also marrying their family. Strange Uncle Earl and loud Aunt Deb come with the deal, whether you like it or not. Lesson: Many hospitals and physician practices have well established ecosystems. Seek to understand your new family and its connections before it's too late.
3. Set goals or make a bucket list - Happily married couples often work together to set goals for one year, five years or beyond. They draft the list collaboratively and work together to achieve it. Lesson: Healthcare organizations should work together on creating goals and ensure there are regular mechanisms to review progress and course correct as needed.
4. Shared values - Along with a common set of goals, having shared values is imperative. That said, there is plenty of room for different interests, beliefs and opinions. Even if you do not agree with your partner at all times, you should respect them. Lesson: With more collaboration between for-profits and not-for-profits, faith-based and non-faith based organizations, medical schools and university hospitals, providers and payers, it is critical to define a path for shared values and behaviors in order to operate as a single entity.
5. Understand each other's practices and habits - Before you "propose," you better understand how your significant other lives. For example, do you both cook and clean the same way? Probably not and stating "my way is the right way to do it" is usually not a smart move. However, if you can show why an approach is better, it often helps. Consolidating healthcare organizations face a similar challenge. Adding a "brand name" sign on the front door or stating "do it this way, because it's evidence based practice," does not magically change the way care is delivered. Lesson: Understanding how each organization operates and working together to arrive at a consistent experience is critical to success. If you approach contentious issues with an open mind and avoid a "not-invented-here" mentality, everyone will come out better for it.
6. Be willing to compromise - While compatibility and balance are vital, a great marriage always involves compromise. This can range from the mundane (picking the restaurant) to the weighty (deciding what religion to raise your child). M&A in healthcare will always include compromise as well. Lesson: The key to success is making decisions within the context of what is better for the organization as a whole - drawing on the foundation of your shared goals and values, ensuring transparency in the decision process, and clearly communicating the rationale.

While we are not marriage counselors at GE Healthcare, our Performance Solutions team has worked with healthcare organizations for the past decade, successfully applying many of the principles described above. Click here to read one of those success stories. And if you have gone through or are planning an M&A activity, I invite you to join the dialogue and share your own experiences and tips for success.

Reference

1. Saxena, S.B., Sharma, A., Wong, A. (2013) "Succeeding in Hospital & Health Systems M&A Why So Many Deals Have Failed, and How to Succeed in the Future" Leading Research paper, Booz & Company.

The ironic thing is, although most clients cite the silos as a concern, few if any have truly tried to bring their leadership together for constructive, collaborative dialogue about the organization. While almost all clients have senior leadership meetings, few have the types of structured, focused, and honest conversations that Mulally pushed at Ford using his Business Plan Review meetings. Like Ford, we know the success of hospital transformations hinge on the ability of senior leadership to have honest, collaborative dialogue with one another. When we work with clients on activating strategy we create this dialogue through the Quarterly Operating Review (QOR) process.

Quarterly Operating Reviews are template-driven meetings where each initiative team updates their colleagues on where they are relative to their targets and what they plan to do over the next ninety days to meet their goals. As the primary operating mechanism for our strategy activation process, the QORs are designed to be mandatory checkpoints where leaders and teams are held accountable for their performance. The meetings, however, are not simply report-outs, they are action-focused discussions in which leaders discuss their plans for achieving their goals while other members of the leadership team ask questions and offer assistance. The QOR process creates a culture of shared responsibility for achieving the organization's goals -- leaders are expected to share where they are falling short of their targets and their peers are expected to have candid dialogue about where they can offer assistance or who can make up the shortfall through over-performance in their area. The QORs help educate every leader in the organization on where they stand relative to their goals and they help foster candid conversations about organization priorities, interdepartmental conflicts, and staff talent.

This type of dialogue has helped GE succeed for over 100 years and is a major reason why the company is considered a world-class operating organization. Despite the success of this approach, we often find this type of dialogue to be very unsettling for our clients because they operate in very siloed environments where successes and failures are treated as secrets to be shared only with immediate superiors; meaningful, strategic dialogue between peers on the senior leadership team is neither expected nor encouraged. Even many successful clients view their organizations as a collection of individual units and goals where dialogue among the leadership team is a nice to have but only necessary in instances where the work of one unit directly affects the work of another unit. Experience has shown, however, that in large, complex environments like Ford or GE or a hospital, candid dialogue across the entire leadership team is a key to unlocking the potential of the organization.

Every week Ford's entire senior leadership team would gather to report on their progress toward the company's turnaround plan. They used succinct, data-driven, template-guided reports intended to quickly educate everyone on the team about where the company was relative to its goals. The meeting was mandatory and was designed to expedite progress on the turnaround plan, remove organizational barriers, drive cohesiveness in global operations, and ensure every member of the team was familiar with every aspect of the business. Mulally expected all members of his team to be prepared for their presentations and he demanded that they share information, both good and bad, openly and honestly. The culture of Ford had always been one that encouraged hiding failures or shortcomings for fear your peers would use the information against you, but Mulally's BPR meetings turned it into a culture where leaders freely shared shortcomings and failures because their peers were expected to offer assistance in correcting issues. The BPRs became the central operating mechanism for Ford, and during the heart of the financial crisis they were held every day to ensure every member of the leadership team had a clear understanding of where the business was and what they needed to be doing to move the plan forward. By creating a venue for honest dialogue among the leadership team, the BPR meetings helped changed the way Ford operated and helped it execute the turnaround plan that kept the company out of bankruptcy and away from government assistance.

Fostering candid dialogue among senior leaders, like Alan Mulally did at Ford, is a core principle of Performance Solutions Management Systems philosophy, and we view it as a critical component to any successful hospital transformation. In the next blog we will discuss how we apply the principle of leadership dialogue while working with our hospital partners.

Are you ready to step out of the silo?

How many of you feel your hospital operates in silos the way the Ford of 2006 operated? The silo mentality is one of the most common concerns expressed by our clients about their senior leadership teams, and it is often cited as the reason why the organization cannot get traction on its strategic initiatives and transformation efforts. Instead of working as one organization focused on common strategic imperatives, each operating unit is pulling in its own direction and following its own agenda.

The ironic thing is, although most clients cite the silos as a concern, few if any have truly tried to bring their leadership together for constructive, collaborative dialogue about the organization. While almost all clients have senior leadership meetings, few have the types of structured, focused, and honest conversations that Mulally pushed at Ford using his Business Plan Review meetings. Like Ford, we know the success of hospital transformations hinge on the ability of senior leadership to have honest, collaborative dialogue with one another. When we work with clients on activating strategy we create this dialogue through the Quarterly Operating Review (QOR) process.

Quarterly Operating Reviews are template-driven meetings where each initiative team updates their colleagues on where they are relative to their targets and what they plan to do over the next ninety days to meet their goals. As the primary operating mechanism for our strategy activation process, the QORs are designed to be mandatory checkpoints where leaders and teams are held accountable for their performance. The meetings, however, are not simply report-outs, they are action-focused discussions in which leaders discuss their plans for achieving their goals while other members of the leadership team ask questions and offer assistance. The QOR process creates a culture of shared responsibility for achieving the organization's goals -- leaders are expected to share where they are falling short of their targets and their peers are expected to have candid dialogue about where they can offer assistance or who can make up the shortfall through over-performance in their area. The QORs help educate every leader in the organization on where they stand relative to their goals and they help foster candid conversations about organization priorities, interdepartmental conflicts, and staff talent.

This type of dialogue has helped GE succeed for over 100 years and is a major reason why the company is considered a world-class operating organization. Despite the success of this approach, we often find this type of dialogue to be very unsettling for our clients because they operate in very siloed environments where successes and failures are treated as secrets to be shared only with immediate superiors; meaningful, strategic dialogue between peers on the senior leadership team is neither expected nor encouraged. Even many successful clients view their organizations as a collection of individual units and goals where dialogue among the leadership team is a nice to have but only necessary in instances where the work of one unit directly affects the work of another unit. Experience has shown, however, that in large, complex environments like Ford or GE or a hospital, candid dialogue across the entire leadership team is a key to unlocking the potential of the organization.

There is ample evidence that the demand side of healthcare has changed already and is expected to continue to shift. Inpatient volume growth is near zero often with extreme unexplainable swings. Providers are caring for large numbers of observation patients, cases which are difficult to accommodate effectively within the operational structures of many hospitals. Outpatient volumes are continuing to grow, but providers need to make vital decisions about how and where to best serve the growing numbers of outpatient consumers. Crafting strategic responses to these challenges would be difficult enough, but most providers have also identified huge amounts of costs that need to be taken out of their organizations to meet the threats to the top line. These costs targets are far in excess of what can be taken out of the organization by the usual means of curtailing discretionary spending and mass reductions in personnel.

So what responses are we seeing to these enormous challenges? Too often we are seeing leaders waiting for more certainty in their markets and the regulatory environment before acting. Further compounding the difficulty in forming an organizational response is the fact that these problems cut across many of the traditional operating structures of most hospitals. Managers throughout the organization see the problems as outside of their span of authority and don't feel they have the requisite knowledge to take on these challenges. Accordingly, little action is being taken and time is running out. What can be done to break the impasse?

My premise is that managers throughout provider organizations need to step up as winners and "ask for the ball" This doesn't mean that the leader retires into his or her office and comes out weeks later with the solutions carved in tablets of stone. Here's what I think this process of "stepping up" should look like:

1. Show that you can assemble a multi-disciplinary team of individuals from across your organization. Select your teammates wisely and not simply from the senior leadership ranks. You'll want fresh ideas and out of the box thinking. If the organization is doing annual Leadership and Talent Reviews of managers and key personnel this should be an easy task of scanning through these reviews to identify who might be ready for a stretch assignment with your team.
2. Prove that you can manage, inspire and foster a common vision of change across your team. Paint the vision of the "burning platform" for change. This is more than painting a dire picture of the future. Painting the negatives without reassuring leaders than they can succeed is counterproductive. Give the team the confidence that they are empowered to develop solutions to the daunting problems facing the organization.
3. Challenge the team with specific targets to be met. At GE we call this "start with the answer." This concept changes the dialogue from what can we do incrementally, to what we need to do to meet the needed. To use a football analogy, you don't want the team running plays that will produce a field goal when you're behind by a touchdown.
4. Be bold and work with your team to develop a firm view of the future of healthcare in your market. Don't simply accept that the "expert" view of the market will come true and fully fit your local market dynamics. With any of the assumptions that you make about the market trends don't forget to ask what it will mean if these key trends don't unroll as expected.
5. Help your team to suspend their "not invented here" tendencies and reach out to experts inside and outside the healthcare industry to collect and evaluate the best ideas for strategies that can be deployed in your organization. Engage outside assistance as needed to help develop and deploy strategies to meet the challenges of high performance in cost, quality and access. Assemble best of breed solutions to fit your view of the market and test the sensitivity of your solutions to varying market conditions and trends.

While there's no denying that the challenges are huge, I believe that the major mistakes to be made are in waiting to begin this transition. Start now, be a winner, "ask for the ball!"

For several weeks, the reason for the volume decline remained a mystery and yet it persisted.  The answer, when it became apparent, was quite surprising.  During the Spring of 2011 the hospital had implemented a new clinical information system.  While the implementation was functionally successful it did require changes in physician workflows and processes.  Physicians who had been splitting their referral volumes and sending the minority of their cases to the hospital shifted their volumes to competitor hospitals.  After discovering the cause of the volume decline, the hospital focused attention on making the workflows as efficient as possible and hired extra staff to help physicians navigate the system but volumes have not yet returned to normal.

This could never happen to your hospital, right?  While the exact confluence of factors may not be repeated at other hospitals we are seeing these market driven events across the country.  Hyper-competitive markets for physician practices are causing disruption of traditional referral patterns.  Payers are putting pressure on volumes via more stringent rules and increased audit activity.  Patients have delayed elective procedures in the face of difficult economic conditions.  Finally, business models in healthcare are changing, altering the relationships between clinicians and delivery systems.  Any or all of these factors can pop up unexpectedly to cause significant changes in the financial performance of the hospital.  So how does a hospital protect itself from these unexpected changes in volumes?

• First, insure that your leadership has a clear understanding of the historical volume trends for your organization, including any seasonal trends, referral channels, and geographic distribution. Continue to run your volume reporting and analytics on a regular basis to insure that you can detect and respond to changes in volume very rapidly.  Assemble a multi-disciplinary team to review the volume reports on a regular basis.
• Second, perform a segmentation analysis on your customer base to make sure that you have a clear understanding of the wants, needs and socio-economic position of each of the customer segments.
• Third, a segmentation analysis should be performed on your physician base.  This analysis will help you to understand the key wants and needs of each major specialty and admitter group.
• Finally, the execution of major strategy components should be accompanied by change management tools like a stakeholder analysis, 3-D's Matrix or Resistance Analysis in order to insure that the impact of any given change is handled smoothly.

The future success of any provider organization will require that the entire organization be extraordinarily focused on customers and customer service.  The ability to detect and react to markets shifts will become a key skill set for all providers.

1. The Ten Faces of Innovation by Tom Kelly describes different styles with which people innovate. Along the way, he reminds us of the nature of innovation with passages like: "most organizations have no shortage of problem solvers. The challenge is that they don't know what problem to solve." The "ten faces" in the title refers to ten different approaches to innovation and read almost as personality types. For example, "the anthropologist", the "cross-pollinator" and the "caregiver."
   
   This is usually the first book we recommend to healthcare leaders working to raise the innovation IQ of their hospital. That's because TFOI reminds us that great innovation comes in different packages. As leaders, we must be conscious to foster diversity within our teams.
2. Defence of Duffer's Drift by E.D. Swinton. Heralded as the most popular book in the world for training military officers, DODD describes a young British officer and his unit's mission during the Boer War to hold a piece of ground for a few days in order to prevent the Boers from flanking a British column. The book is structured as a series of dreams in which the young officer attempts the same mission day after day. In each dream he loses the fight and wakes up the next day with the same challenge... with one exception: he retains the lessons of each defeat and applies them the next day.
   The young officer begins, as most innovators do, with a series of well-intentioned mistakes. For example, in the first dream he allows his soldiers to rest rather than prepare the defense. When they are overrun that night he learns a basic lesson: soldiers would rather be alive than rested. From that first lesson, the unit improves every aspect of their defense and eventually wins. This, of course, makes it a story of successful innovation.
3. Beautiful Evidence by Edward Tufte. I am a big fan of Mr. Tufte. He writes and speaks about the visual representation of quantitative information (aka "a picture speaks a thousand words"). For example, in this book Mr. Tufte highlights what he describes as "the greatest visualization of the 19th century", Charles Minard's 1869 "super- graphic" to illustrate Napoleon's failed invasion of Russia in 1812 and 1813.



The purpose of the graphic was to communicate to a later generation the magnitude of loss of life in war. How to do so thoroughly and quickly in order to win and keep the attention of his audience? Minard accomplished this with two lines superimposed over a map: a brown line to track the invasion and a black line for the subsequent retreat. Here's the brilliant part: the thickness of the lines represents the number of soldiers in the army at that point in the invasion. As the lines brutally convey, Napoleon left France with an army of 422,000 and returned with only 10,000 soldiers. With the shock that follows this realization, the reader is drawn into the map and begins to explore the rich information within. That's what makes it a super graphic.

In Beautiful Evidence, Tufte shares example after example of this type of innovative genius in the presentation of ideas and information.

1. Effective and autonomous governance structures, with multi-disciplinary participation
2. Schedules that are designed to ensure steady flow and a reduction in peaks and valleys of arrivals/admissions of patients
3. Efficient workflows that support the entire system

1. Schedulers. Schedulers are among our most important touch points with our patients and physicians. Have we invested in their training, kept them current on new capabilities, and provided them with simple tools to connect the dots of need, capability and timing?
2. Tribal knowledge. Every hospital seems to have a core of nurses who have been there since... well, a long time. You know them when you see them. Too often we ask them not to "tell war stories" for fear it will undermine the latest improvement effort. There's logic to that. Then again, unlocking the knowledge of our most experienced and dedicated caregivers may be just the pinkie toe we've overlooked.
3. Block time in the OR. Most hospitals allocate blocks of OR time to either surgeons or service lines. These allocations always make sense in the moment. But, has our analysis kept up with evolving surgeon habits, OR capabilities and utilization patterns? There are very few hospitals - maybe none - that couldn't improve the pinkie toe of block utilization.
4. Mobile medical equipment. Could we better manage battery powered life support equipment so we can find them in emergency situations (e.g., power loss)? That's a pinkie toe that isn't needed every day but makes a big difference when we do.
5. Patient Safety Communities. Patient Safety Organizations, like the GE PSO, are creating virtual patient safety communities within which providers can discuss the nitty gritty reality of patient safety in a protected environment. That includes sharing with both local and global peers. This promises to unlock pinkie toes everywhere.

• Focus on process variability: One of the key lessons of Six Sigma is the importance of measuring and managing the variance in your processes. If one-half of your customers are delighted while the other half are dissatisfied has your organization really made progress? Narrowing the variance in your processes will add more supporters in your customer base.
• Develop strategies based on the "real" value proposition of your key customers segments. A segmentation analysis of your patient population may be helpful to determine disease states or geographic locations that are growing. Provider organizations should survey patients in these populations to determine what they value most in making the choice among healthcare providers. Do they want the very latest in medical equipment and treatments or do they value a high touch experience? While the answer to this last question is likely to be a combination of the two, knowing and meeting the needs of your patients will be essential to future success.
• Similarly, understanding the value proposition of your organization to the physicians in your market is just as critical. While the uncertainties of healthcare reform make it difficult to predict your specific market demand for services over the next 3 - 5 years, developing some working assumptions that can form the basis of strategic actions will likely be more beneficial than delaying action until later in course of reform. In our practice we find that a consensus building process with the leadership team which identifies what is known and the key questions to answer can guide provider organizations to the broad strokes of strategic actions. With the composition of an aligned physician group so critical to most provider strategies, having an early view on the desired specialty and geographic make-up of the physician group will help to avoid the mistakes of the last wave of physician / hospital consolidation in the 90's. Once the desired framework is established, provider organizations should build an understanding of what factors the physicians in the market use to determine which hospitals to align with. What is the relative importance of economics versus other determinants of the physician experience, such as scheduling, ancillary reporting processes, or connectivity / IT capability?
• Once the value proposition of the organization to its customers is we understood, market messages should be honed to focus on those specific areas and highlight key differences between the performance of the organization and key competitors. Given that we are in the early stages of quality and cost performance reporting, including an element of education on the meaning of various performance metrics may be beneficial to the community.
• Finally, approach insurers in order to build collaborative efforts focused on developing unique reimbursement programs such as payment bundles that incorporate physician and hospital services across the episode of care, co-branded insurance products, or provider networks. These collaborative efforts should only be undertaken once the organization's quality and cost performance is well managed and analytics can be performed to model any proposed payment methodologies.

1.  What are the stated principles of this department? (These should precede and inform the policies and procedures).
2. When was the last time we reviewed those principles? How many of the committee members were in position when that was last done?
3. Do we have the right committees in place and the right structure for those committees?
4. Do we have the right members on the committee? For example, is every specialty represented on the Block Committee and/or OR Governance Committee; is the chair an unbiased individual that commands respect; is there a mix of high volume vs. low volume surgeons and supporting vs. non-supporting surgeons and block vs. non-block surgeons?
5. Is leadership ready to address the challenges raised by these committees?
6. Are the committees tracking the right metrics and utilizing that information to make data-driven decisions?

-Calvin and Hobbes

1. Decrease controllable census variability by smoothing elective admissions.
2. Utilize historical patient data and simulation modeling to determine the right number of each type of bed that is required to treat the expected patient population.
3. Expedite critical activities on each patient's care plan with bed management workflow tools.