Keys to leadership success in getting people to act their way to a new way of thinking

April 1,2010

With the passage of new national laws pertaining to health care, and the ever changing pressures within the existing health care environment, there appears to be the need for another look at the role of leadership. With total credit to the author, John Kenagy, M.D., I want to share with my current and past students, his refreshing and successful approach to health care leadership.


Acting Your Way to a New Way of Thinking
By John Kenagy, M.D.
Understanding human behavior opens new doors for health care management.

Scientific discoveries and new technologies promise much improved patient care. But delivering on that promise means that people must think and act differently. The history of innovation shows that it is a lot harder than most people realize.

It's just like the adage "A tiger doesn't change its stripes." Throughout my career as a physician, health care executive, academic scholar, advisor, author and patient, I have seen how changing behavior can be very difficult.

For 30 years, the basic behavior change tools in health care management have been gathering data and aligning incentives. One of the constant refrains of the current health care reform effort is "We must realign incentives."

Are data and aligned incentives the key to delivering on the promise? Let's examine the evidence.

Leading Companies Often Fail to Innovate

The health system I helped manage in the mid-1990s was an industry leader in the managed care revolution. We had integrated physicians with aligned incentives, our own health plan, an electronic medical record system, lots of data and a multitude of quality improvement initiatives. But the managed care revolution failed and eventually petered out.

Puzzled by why lots of data and aligned incentives failed, I became a visiting scholar at Harvard Business School studying industry transformation. There I discovered the topsy-turvy world of disruptive innovation.

Disruptive innovation teaches us that when the world changes, many leading companies fail to innovate. Lotus could not compete with Microsoft, General Motors could not compete with Toyota and now Toyota is challenged. American and United Airlines cannot compete with Southwest, and now Microsoft can't compete with Google. Why? Changing behaviors is a lot harder than most realize, even if it means lost business, bankruptcy or the demise of a company.

That's a depressing discovery, but fortunately there is a solution. My research at Harvard focused on the few companies that were able to adapt and change when others failed—companies like Intel and Southwest Airlines. I found these adaptive companies shared a common characteristic: an organizational DNA that was "designed to adapt."

Thinking Is Part of the Problem

For the last 12 years of working with many people around the country, I have tested, validated and improved these characteristics in the complex, dynamic, unpredictable world of health care. One discovery was that data and aligned incentives are helpful but not sufficient to deliver on their promise because it is very difficult to get people to think their way into a new way of acting. Instead, people must act their way into a new way of thinking. It's action innovation, not thinking innovation, that makes the difference.

I believe most of us understand the difference. Recent research on the neurobiology of human decision-making offers the scientific explanation. The surprising first discovery is that humans are often not rational.

We do not analyze all options when we decide to do something. Instead our past experiences create predetermined pathways for behavior that we repeat, even when those actions may not be in our best interests.We have all seen it—very intelligent people making the wrong choice over and over again.

For example, in doing consulting work with Microsoft, I spoke with many brilliant people who had worked in failed IT companies before coming to Microsoft. I remember an executive explaining how it felt to be a senior manager at Digital Equipment, one of the world's greatest technology companies until it crashed and burned in the mid-1980s.

He said, "We would sit around the management team table, analyze all the data and come to a decision, but all of us had, in the back of our minds, the thought, 'Here we go again, this isn't going to work either.'"

The Science Behind the Experience

If you want to change behavior, you need more than data and aligned incentives. Behaviors are driven by beliefs. To change behavior, you must first change beliefs. This is where the neurophysiology of decision-making comes into play.

Our beliefs do not reside in some anatomic filing cabinet in our brains. Rather, f-MRI studies show beliefs are generated by complex recurrent firing of patterns of neurons accompanied by subtle but very specific changes in hormones and neurotransmitters. This brain activity is developed by experience and linked to the feelings that experience engenders.

In other words, we are not rational but we are sentient. Our brains are hardwired by experience and feelings. The stronger the positive feeling and the more frequent the experience, the more we become hardwired to respond in the same way.

To change behavior you must first use experience to change beliefs; you have to act, not think. Experience generates feelings that inform future experiences. The more positive the feelings and the more direct the link to experience, the more likely beliefs are to change. When beliefs change, behavior changes.

So, you can't think your way into a new way of acting; you have to act your way into a new way of thinking.

We have all experienced this phenomenon. I saw it in action when I worked in a Harvard Business School research project to better understand the Toyota Production System. The "thinking" approach says we will change peoples' behaviors by implementing "lean" process improvement tools. I worked with Toyota experts for two years, but I was never taught a lean process tool.

Instead, I was constantly told to go the workplace, understand the work through observation, then engage in small experiments to change the work in concert with front-line staff. This experience, experience, experience close to the work—not thinking, thinking, thinking in meetings—made the difference at Toyota. I wonder now if thinking about how to become the world's largest automaker has become part of Toyota's current problems.

Prove That Action Works by Acting

I have rigorously tested experiential change management in health care for the last 12 years in many different environments. It works. Here are the keys to leadership success in getting people to act their way to a new way of thinking:

1. Set a clear, simple and meaningful direction.
2. Develop and empower people; it's people, not technology, that make the difference.
3. Build trust and optimism through positive results in problem solving the needs of patients.
4. Solve those problems as real-time experience, close to the work, not in meetings.
5. Grow by repeating your success and relentlessly challenging the status quo.

The results are always positive. For example, in one year, staff on a Midwestern hospital medical-surgical nursing unit changed their behavior to generate the greatest increase in patient satisfaction in a 17-hospital system, while simultaneously increasing productivity 14 percent, decreasing length of stay 8 percent, and generating $1.7 million in new revenue and savings.

Action Innovation Opens New Doors for Leadership

New technologies offer the promise of wonderful improvement in patient care. But we will never achieve that promise without changing people's behavior. That means more than gathering data and aligning incentives.

Fujio Cho, Toyota's chairman, said it well: "No mere process can turn a poor performer into a star. Rather you have to address employees' fundamental way of thinking." The recent evidence that Toyota management ignored brake problems in a "culture of secrecy" for years suggests that they forgot that this lesson also applies to leadership.

Behaviors are driven by beliefs. Beliefs are formed by experience and feelings. Instead of thinking your way into a new way of acting, you act your way to a new way of thinking.

Our brains say it's so. Leading people to act their way into a new way of thinking opens new doors for health care management.

John Kenagy, M.D., is a physician, patient, former visiting scholar at Harvard Business School and author of Designed to Adapt: Leading Healthcare in Challenging Times (Second River Healthcare Press, 2009).

This article 1st appeared on March 22, 2010 in HHN Magazine online site.

Evolving Senior Care

I would like to share this interesting article entitled "Evolving Senior Care" with credit to the author ... Molly Forrest. Senior care is a high priority issue in the USA and it is refreshing to see these signs of professional leadership in the field.
Robert E. Hoye, Ph.D.
Faculty Mentor
Health Services
Walden University



Evolving Senior Care
By Molly Forrest

The Los Angeles Jewish Home is designing innovative programs to meet the needs of seniors of all stripes.

Molly Forrest

What will senior care and housing look like in the 21st century?

For starters, we know that baby boomers are living longer and better (even with chronic medical conditions) than any generation in history. We also know that, as they have done their whole lives, they will question outdated approaches and expect a new era of awareness and action. These two factors create a new world of opportunities for hospitals and other health care providers that want to be part of the solution.

But today's economic climate is causing health care organizations of all stripes to hesitate before expanding services or branching off into uncharted waters. Yet that's exactly what must be done if we want to influence how senior care and senior living will evolve. At the Los Angeles Jewish Home, one of the foremost multilevel senior living communities in the United States, we realized that standing still was not a viable option and, as a result, we are now recognizing the benefits of creative planning and proactive program development.
New Undertakings

It's one thing to be open to new ideas; it's another to execute them and be willing to commit the resources—time, money and energy—to see them through. Even though we are a nearly century-old institution blessed with many emulated business practices and successful programs, we needed to look anew to serve a growing need in a changing world.

Despite the difficult economy that we're all feeling, the Jewish Home has recently launched new large-scale programs in hospice, psychiatric care and nursing education that we believe are central to the ongoing health and well-being of our organization. We've also taken a fresh look at how health care can and should be delivered to aging boomers. We believe that any new model must begin with the understanding that there will be a growing need for highly intensive medical, rehabilitative and health care services as society ages.

All of our recent development directly addresses clear community voids that we believe our organization is best positioned to fill in unique and innovative ways. Our Skirball Hospice program, for example, expands the Jewish Home's services beyond our two campuses by taking the compassion and dignity found in hospice care directly into a person's home, providing for the physical, psychological and spiritual needs of both patient and family during the end of life.

Our new Auerbach Geriatric Psychiatry Unit addresses the special needs of seniors in a setting that makes them feel comfortable, welcome and understood, with special emphasis paid to depression and other issues that often affect this population. Our Annenberg School of Nursing—highly unusual in an organization like ours—is helping train tomorrow's health care professionals as we do our part to address the nation's severe nursing shortage.

We've also launched the Brandman Centers for Senior Care, the name for our PACE development. PACE (the federal and state Program of All-inclusive Care for the Elderly) aims to ensure that vulnerable seniors who choose to live at home can do so safely and securely while receiving coordinated and well-managed medical care, home assistance, personal needs care, meals and transportation services. With this development we believe that we have taken great strides toward providing exactly what the marketplace is telling us is needed. And, by doing so, we retain and strengthen our position as the regional leader in senior care and housing.
Lessons Learned

Our venture into new areas was driven by our organization's long-standing commitment to develop programs and services that balance the physical, medical and social well-being of those we touch. The insights we've gained from this experience are not unique to us or confined to senior care. Here are six lessons that might be helpful to other health care organizations:

Whatever you do and whatever innovations you develop, always remain true to your brand. Remember that your brand is your promise to your customers. It is what helps define your organization's unique characteristics. Never forget who you are. Never compromise your values, mission and heritage.

Look for partners who share your passion and commitment. We found other nonprofit organizations who believe as we do in the importance of treating all with the dignity and respect they've earned. What's more, they share our 21st-century vision of extending to the community the caring hands and compassionate hearts we have historically offered to our residents.

Where senior health is concerned, throw away any old notion that one size fits all. It doesn't. Often we simply bundle all older adults together into a category generically marked "senior" and expect everyone's needs will be met. Just as hospitals have become increasingly savvy in recent years in segmenting their consumer market, "seniors" and their needs must be segmented into multiple submarkets and programs planned accordingly.

This economic downturn is an opportunity to try new things and take intelligent risks. Nobody knows for sure what tomorrow's health care landscape will look like, but we do know that it will be different in the way costs are paid and services provided. That means that hospitals need to be open to change. The successful hospitals will be those that lead the change and don't just wait to be swept up in the current. In our case, we realized that by making the Jewish Home's medical specialties, geriatric services and wellness programs available to more of the community and not just the residents within our walls, we could have a positive impact in changing how elder care is accessed and specialized services are delivered.

Make sure that everyone is on the bus and make a compelling case for them to be there. That means working with a committed board, seeking and respecting the input of your community, involving your employees and helping everyone understand that new challenges mean exciting opportunities.

Finally, and most importantly, hospital CEOs and other health care leaders must recognize that the issues we collectively face are societal and that we are all in this together, along with the communities we serve. While these are momentous times, they also provide us with remarkable opportunities to enhance the life and wellness of those who often rely on us during their most vulnerable days of life.

We must seize these opportunities. There is no better time to begin than today.

Molly Forrest is a 35-year veteran of senior housing and health care and the chief executive officer and president of the Los Angeles Jewish Home.

This article 1st appeared on March 16, 2010 in HHN Magazine online site.

Collecting Demographic Data

Having worked with hundreds of graduate students in the collecting of data and information to support research projects, I was impressed with the article: "UNDERSTANDING PATIENT DEMOGRAPHICS" by Adaeze Akamigbo. She is a Senior Researcher at the Health Research & Educational Trust. This article 1st appeared on February 16, 2010 in HHN Magazine online site.

Before collecting data, I am an advocate of conducting an "environmental scan". Taking time to identify and examine the total environment in which the research is to take place. Many times, important entities are not identified, and tend to "fall through the cracks" and thus, the final results of the research might be seriously lacking in validity. The author's focus on "real data" is worth considering when constructing the research plan.


Understanding Patient Demographics
By Adaeze Akamigbo
REAL data can be an effective tool for improving delivery of care.

  

Adaeze Akamigbo
Many hospitals do not systematically collect REAL (race, ethnicity and language) data. Understanding this aspect of patient demographics can be extremely helpful in improving delivery of care. It can also help hospitals raise patient satisfaction levels and capture a larger market share.

REAL data can demonstrate that differences exist in the quality of care among different racial or ethnic groups. It is helpful for leaders to be mindful of these disparities, which are present throughout health care and can be found in almost every setting. Because the hospital is often the point of entry for many people into the health care system, gaps in hospital care and in the community can be identified and addressed by this data.

Hospital executives can play a key role in acquiring demographic data, recognizing the gaps in care, then putting the data to good use. By doing so, care in hospitals and entire communities can be more effective and safe for all patients. Mindfulness of this issue can also position a hospital as a center of quality.

Acquiring the Data

For REAL data to become useful, it must first be collected in a standardized format. The hospital executive can make an impact on quality by insisting on high-quality demographic data. High-quality data is critical to making the business case for improvement, effectively targeting needed resources and creating a plan to address the local health care community.

Appropriate data collection and analysis can help hospitals track population trends and forecast emerging changes. One example is an increase in the Spanish-speaking population. It would, of course, be helpful to offer hospital materials in Spanish and to provide translators or bilingual providers who could enhance the patient experience during a hospital stay.

Improving quality depends on accurate demographic data to help target the necessary interventions. In order to start making the business case for collecting REAL data, there are three key questions executives can ask:

Do we have data to verify that we are delivering safe and high-quality care to members of all racial and ethnic groups who come to this hospital?
If we do not have the data, how can we efficiently work with our existing infrastructure to collect standardized demographic data?
What are the key questions we want to address in collecting accurate demographic data on our patients? (For example: Do we have any evidence that our patient satisfaction scores regarding communication are impacted by our staff's language proficiency?)
Executives will find that these questions are often not easy to answer. The best intentions may give way to the limitations of current IT systems or staff members' hesitation to ask pointed questions of patients. However, there are multiple resources to train and educate staff on collecting demographic data for quality improvement. There are also cost-effective ways to collect this standardized REAL data while complying with privacy regulations.

The Institute of Medicine recently recommended the Health Research & Educational Trust Disparities Toolkit as a key resource in starting hospitals on standardizing their data collection and on using the data to make improvements. The toolkit provides ongoing training, teaching front-line staff how to interact with patients on this issue and how to meaningfully implement the toolkit. Hospital executives are invited to be full partners in this process.

Translating Data into Action

Once executives make the commitment to collect demographic data, there are many uses for the information. Much depends on the interpretation of the data. For every situation of perceived differences in quality, a solution will present itself differently.

For example, a hospital might determine that among their acute myocardial infarction patients, 30-day readmissions are higher for one ethnic group than for another group after accounting for all other personal characteristics. The hospital might then further determine that these patients do not have good access to primary care services outside the hospital. The hospital may also find that these patients typically rate their satisfaction lower than that of other patients. This may suggest that there are aspects of the hospital encounter that disproportionately affects those patients.

These are important findings for the hospital. They give executives actionable items to address. They can remove barriers within the hospital to create a more patient-centered experience for these individuals. This might include patient education sessions before discharge. It might also include a training program to help employees learn how to be more culturally sensitive to the needs of a given population. This may improve patient satisfaction scores. The hospital may also determine that it needs to engage the broader health care community to identify appropriate sites of primary care to improve continuity of care for this population.

Moving Forward with Demographic Data

Organizations such as HRET are a resource for hospitals ready to make a genuine effort to collect data and measure organizationwide outcomes. Measuring demographics—REAL data in particular—is yet another tool in an arsenal to combat factors that may adversely impact the bottom line and, more importantly, impede the delivery of high-quality health care services.

Adaeze Akamigbo, Ph.D., M.P.P., is a senior researcher at the Health Research & Educational Trust.

This article 1st appeared on February 16, 2010 in HHN Magazine online site.