Experiences of Accessing Medical Care by African American Men with Hypertension

I am pleased to present the ABSTRACT of  the Ph.D. Dissertation prepared and presented by Dr. Sandra Grosvenor to Walden University, September, 2012.

Abstract

Experiences of Accessing Medical Care by African American Men with Hypertension

by

Sandra Grosvenor

M.H.S.A., University of St. Francis, 2004

B.S., University of St. Francis, 2000

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Health Services

Walden University

August 2012

Abstract

The challenges and barriers that African American men with hypertension experience when accessing medical care on the Gulf Coast of Florida was the focus of this qualitative study. More than 50 million African Americans are affected by hypertension or high blood pressure. Still, many African American men may not understand the relationships between their social habits and their medical condition or how treatments such as receiving medical care for high blood pressure and eating certain foods could help improve their overall health. This descriptive qualitative study explored the lived experiences of working poor and indigent African American men between the ages of 25 and 55 with hypertension. Becker’s health belief model and Bracht’s health promotion model were used as conceptual frameworks to guide the research. Research questions were: What are the experiences of African American men when they access medical care for high blood pressure? How are African American men managing their blood pressure? What are some culturally acceptable ways to reach and competently treat African American men with high blood pressure? Four sources of data were analyzed and included questionnaires, surveys, interviews, and field notes.  A community center where African Americans frequent daily was utilized for the study. Findings showed that many African American men were not managing their high blood pressure, and had some challenges getting health care. The implications for  social change are that the health beliefs and perceptions of individuals,  have the potential to reduce the high incidences of hypertension through effective health services directly at the community level.   

Divided Government: Fiscal Cliff & Future of Reform

Credit for this article goes to author Haydn Bush, 11/9/2012 Health & Health Networks/ For use in Doctoral Research Forum.REH

 Divided Government, Fiscal Cliff and the Future of Reform By Haydn Bush H&HN Senior Online Editor November 07, 2012 The focus in Washington moves from the election to the fiscal cliff and the implementation of reform. What will that mean for hospitals? The grueling, seemingly endless presidential campaign is now a memory, and with no changes to control of the White House, Senate and House of Representatives, attention now shifts in earnest to the looming Fiscal Cliff. To be sure, there will be some time for celebration by the Obama camp and soul searching by the GOP, but those are bound to be short-lived. Even before we all sit down to gobble up turkey, stuffing and pumpkin pie in a couple of weeks, lawmakers are sure to stake out positions on the contentious issue of sequester and the 2 percent cuts in Medicare reimbursements that are slated to take hold next year. Oh, and hospitals, physicians and insurers eagerly await a slew of expected rules on the Affordable Care Act that were essentially put on hold during the last weeks of the campaign. "The election has been decided and the time for politics is over," says AHA President and CEO Rich Umbdenstock. "It is now time for governance. We must address the serious issues facing our country and have conversations that address real reform to improve the nation's health care system for patients and communities. Cuts to hospital care are not real reform. It is now clear that implementation of the ACA will move forward and we will continue to improve and build on it to advance quality of care and reduce cost." In a statement, Jeremy Lazarus, M.D., president of the American Medical Association, congratulated the president while focusing squarely on the projected cuts to physician payment scheduled to take effect next year. "The AMA is also committed to working with Congress and the administration to stop the nearly 27 percent cut scheduled to hit physicians who care for Medicare patients on January 1," Lazarus stated. "It is time to transition to a plan that will move Medicare away from this broken physician payment system and toward a Medicare program that rewards physicians for providing well-coordinated, efficient, high-quality patient care while reducing health care costs." Many experts, however, believe that in the short-term, the president and Congress will delay action on these issues well into next year. "My gut tells me that they punt the tax rates, the sequester and the debt ceilings," says Christopher Condeluci, who served as tax and benefits counsel to the Senate Finance Committee during the crafting of the Affordable Care Act and now is an attorney with the Washington, D.C.-based law firm Venable. While it's unclear at what point the federal debt limit would have to be raised — forcing action to alleviate a default — Condeluci guesses that action to move those conversations into February or March could occur, creating a new deadline of the August 2013 Congressional recess to make meaningful progress on a grand bargain around federal spending and taxes. Reform Moves Ahead In the meantime, the president's reelection means that implementation of key provisions of the ACA will continue. Most notably, open enrollment in health insurance exchanges is slated to begin Oct. 1, 2013, to prepare for coverage under the exchanges at the start of 2014. And while the final rules on the exchanges are out, Condeluci says there are a slew of other insurance market reform issues that still need to be resolved. "There will be an onslaught of regulations issued by the end of the month, and the end of the year," Condeluci says. Allowing time for the public comment process, he says, the rules could be in place by February, giving health insurance carriers eight months to prepare for open enrollment. From a longer-term perspective, of course, that means hospitals will need to continue preparations to care for the estimated 32 million Americans who are anticipated to have new access to health coverage. That means hospitals will have to carefully anticipate shifts in utilization and the impact on ED use, says Steve Valentine, president of the health care consulting firm Camden Group. One potential scenario: the potential growth in primary care offered by federally qualified health centers could contribute to a reduction in hospital utilization, he says, adding, "Inpatient use will get squeezed." And while it will take years, if not decades, to sort out all of the impacts of reform, Valentine says that in the short term participation in the Centers for Medicare & Medicaid experiments around cost containment and quality improvement, including its bundled payment and shared savings ACO programs, may not be high enough to hit the expected cost savings associated with those programs. Ultimately, the success or failure of those initiatives will trickle out to providers, he adds. "The goals of the Obama administration are not being met in terms of people in bundled payment [programs] and ACOs," Valentine says. "He's overestimated the savings, so taxes will have to go up or payment will have to go down. That's a wake-up call." 'Hospitals Will Double Down' Beyond the Beltway, of course, the health care industry is already in the midst of a major internal transformation outside of government reimbursement and oversight, from consolidation of hospitals and physician groups to the advent of insurance innovations like "narrow networks," or health plans linked to services offered by a single or handful of providers. Both Condeluci and Valentine expect these trends to pick up speed, with Condeluci predicting continued movement in the private market to embrace narrow networks, even if the plans may not initially pass muster for inclusion in the health insurance exchanges. And regardless of how federal changes to health care spending and ACA implementation shakes out, Valentine says the movement in recent years to aggressive cost containment — an issue we've covered extensively in our Fiscal Fitness series — will continue no matter what happens in Washington. Ultimately, Valentine says, that means more scrutiny for all nonclinical positions, the reevaluation of operations as they relate to the hospital's mission and a renewed focus on fundraising. "Hospitals will double down on squeezing more expense out," Valentine says. "There is no getting around this." The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

Magical Thinking in Health Care

Complete credit for this article is given to author Ian Morrison,11/6/2012 Health & Health Networks Daily. Magical Thinking in Health Care By Ian Morrison November 06, 2012 From numbers that don't add up to faulty assumptions about patient behavior, many in health care believe in the impossible. We all do it. Magical thinking is about engaging in causal fallacies. It is comforting. Otherwise we'd spend our entire lives going: "Say what?" But in our national political discourse (and in health care in particular) we have elevated magical thinking to our basic operating model for the future. Bad stuff will happen, then we will do something to [insert simple idea here], then magical thinking happens and the world becomes a better place. Easy. Magical Thinking in Politics Both parties have demonstrated an astonishing capacity for magical thinking in the run up to the election. Republicans confidently assert that cutting tax rates for the wealthy will simultaneously grow the economy and not add to the deficit, even though the dismal economic performance from 2000 to 2007 suggests that precise strategy failed. (It would also be nice if the closed loopholes were specified: namely, mortgage deductibility and health insurance deductibility. Instead, the loopholes are left to the imagination, and magical thinking, about how the deficit can be reduced by cutting public broadcasting and foreign aid, both minuscule shares of the budget.) Similarly, Democrats argue that raising taxes on the rich spurs middle class job growth and returns the middle class to prosperity, when in reality the forces of globalization and technology (beyond the control of even presidents) continue to widen gaps between rich and poor. Magical Thinking in Health Care In health care, we have raised magical thinking to an art form. Our legislative process creates incoherent mishmashes of unintended consequences, even when the laws are well-intentioned and directionally correct. There are too many examples of magical thinking to cover, but here are a few: Rich people happily subsidize poor people. For five years I have been arguing that the central question in health reform is: "Will rich people write a check to cover poor people?" This whole election was really about that. You will know the answer shortly. But, no matter who wins the election, America must solve the riddle that majorities support government taking action to cover the uninsured, but those same majorities are unwilling to pay the taxes to make it happen. This is what scholars call the principle-policy gap. Budget delusions. The deficit matters; national debt in excess of 100 percent of gross national product matters. We can krugman in the short run ("krugman" is a verb I just invented to mean "run big government deficits to avoid depression, as the Nobel laureate and New York Times columnist Paul Krugman advocates"); but even John Maynard Keynes recognized you can't run these deficits forever. Both sides in the budget debate are delusional. Eventually, we have to cut spending and raise taxes (on everyone), and health care has to be a big part of the new austerity — otherwise the arithmetic doesn't work (even with magical thinking). Repeal and replace. It is extremely unlikely that anything would replace Obamacare if it were repealed. And even then, the proposed solutions are magical. My personal favorite is buying insurance across state lines. Apparently, my favorite out-of-state health plan, Blue Cross Blue Shield of Tennessee, can have enormous contracting clout with my doctors at the Palo Alto Clinic. I just don't understand this. States as laboratories for bad science. As the contrast between Massachusetts and Texas demonstrates, states are very different in their politics and culture. Massachusetts' health reform took place in a small, affluent, highly educated state with very low numbers of uninsured and relatively generous Medicaid and uncompensated pools. In contrast, Texas has more than a quarter of its citizens who are uninsured, and the state seems unlikely to aggressively pursue coverage expansion even if federal money for Medicaid expansion and exchanges are available. Imagining that all states eventually will look like Massachusetts seems like magical thinking, given the Supreme Court's green light to states' rights on Medicaid expansion. Single payer. Another area of magical thinking, common on both the right and left, is the idea that eventually we will have a single-payer system because either private-based reform fails or Obamacare creeps toward a socialist takeover. A true single-payer system requires massive income transfer from rich to poor and a standardized fee schedule delivered in a global budget framework. Put that way, it seems unlikely in the current American political context. Vermont, the only state really considering this, has yet to be specific about how the money would be raised to pay for the proposed single-payer plan but, as far as I can tell, it does not involve state-based income tax increases, but rather magical thinking about flows of funds from employers and the federal government. Exchanges. The clock is ticking for the exchanges to get up and running. The vast majority of states will not have a functioning exchange up and running on the due date, even with Obamacare intact. Even the states that are ahead are figuring out quickly that it is tough to design a health plan that can simultaneously fit through the precious metal aperture of affordability specified in the ACA, and be affordable and attractive to the humans who will be mandated to purchase these plans. In my state, California, we are further ahead than almost anyone, yet leaders in the state are ruminating that no HMOs beyond Kaiser can fit through the aperture of affordability and that the default plan will be a very, narrow-network, very, high-deductible PPO offering. Folks, we may be headed to that future anyway through the widespread creation of private exchanges which have all the features providers hate about state-based exchanges (narrow networks, low effective provider reimbursement through consolidated purchasing and competitive bidding, and high deductibles and the resulting bad debt problems). It's Obamacare without the subsidies. Low-income folk will sign up. Massachusetts had an aggressive social marketing campaign to explain to the uninsured that they should avail themselves of coverage. It worked well. But it takes some magical thinking to assume that 15 million-plus newly eligible citizens will sign up in every state across the country, especially when in many states there is no aggressive outreach, no social stigma to forgoing coverage, and no state leadership behind coverage expansion. Block grants. When you hear the phrase "block grant," it is code for "less money." Few people propose block grants with more money. It defeats the purpose. One battle to watch for after the election is reframing block grant proposals for Medicaid as self-imposed per capita caps on Medicaid spending (states would agree to a cap on federal contribution). This sounds sensible to me, but it may be magical thinking to assume that conservative politicians will take that deal if spending increases as enrollment in Medicaid increases. Spending the Medicaid managed care dividend before you've earned it. Across the country, states are converting their Medicaid programs to managed care. Others, like California, are aggressively pursuing waivers to expand managed care to special needs populations, the disabled and dual eligibles. While I applaud the move, many states (including California) seem to be banking the expected savings before they actually earn them. As one CEO of a local Medicaid plan in California told me last month: "I'll eventually get the 30 percent savings, but it may take three years to get all the care coordination, medical home and population health infrastructure in place for these patients." Dual eligibles present a special opportunity (and challenge). Many commercial players (including health plans and at-risk provider groups who thrive on Medicare Advantage) are salivating at the prospect of managing these dual eligibles. Plans and providers can deliver better care at lower costs and benefit financially in the process. But the magical thinking comes when you have to deal with all the segments of the dual-eligible population. The target population of dual eligibles for these commercial interests is what one local plan CEO dubbed "the nice old," namely the little old ladies with chronic conditions that can be managed much better in a coordinated care platform. The commercial players are less interested in the disabled, the institutionalized, the seriously mentally ill, and those with serious substance abuse issues, which represent significant subsegments of the dual eligibles. The recent transfer of special needs populations into managed care as part of California's Medicaid waiver provides a small window on this problem nationally. Players in the field estimate that costs for caring for the population were 10 to 15 percent higher than anticipated by their actuaries. The Smith conundrum. My friend Mark Smith, M.D., M.B.A., CEO of the California HealthCare Foundation, has identified a key conundrum in American health policy. The paragons of delivery excellence for value, whether it be Kaiser or at-risk medical groups, cannot make money on the Medicaid level of reimbursement. So the question becomes: What is the delivery model for the bottom third of the income distribution when Kaiser and other high-value delivery models to which we aspire lose $100 per member per month on these patients, and no one is volunteering to make up the difference in taxes? Reimbursement reform. Everyone in Wonk World agrees that changing the reimbursement system to align incentives is the key to system transformation. However, Harris Interactive surveys of physicians and hospital leaders consistently show extremely low levels of enthusiasm for new payment models such as bundled payment, global budgets and capitation. Let's face it. Fee for service is like crack — it's tough to get off it. Accountable care organizations. Hospitals and doctors are huddling together for warmth as they face the new future, many under an ACO umbrella. But reality is dawning on these fledgling new organizations, in particular, that structure doesn't automatically confer performance. Just because you are legally a clinical integration organization doesn't mean you are integrated clinically. That actually requires hard work … or magical thinking. Shared savings. Much of the transition from the first curve to the second curve, from volume to value, is enabled through shared savings models. What happens if there are no shared savings, only shared losses? What if a combination of budget cuts at the federal and state levels, organizational intransigence, and poor management fail to yield savings? If that's the case, where is the fuel for transformation? Right now, the principal fuel for much of this is provider-based reimbursement (you pay a cardiologist more in facility fees when the practice is owned by a hospital), which seems to me to be a policy accident waiting to happen. Patient-centered medical homes. We all should have a medical home with a highly integrated team of caring professionals hovering over our medical record, ready to pounce on any deviation from health. Well, that is magical thinking. Even the fathers of the movement concede that really what PCMHs are about is creating the mother of all triage systems, where you identify and concentrate resources on the heavy users to improve care, while automating the primary care and wellness initiatives so that the nagging to maintain health is done by your iPhone, not by the entire cast of Grey's Anatomy. It's all about segmentation and focus. Migrating the Business Model All these examples point to the critical challenge we keep cycling back to in recent columns, and that is migrating the business model. It needs to be done systematically but urgently, with compassion for those we serve and commitment from those who deliver care. We need to make the system work better and we need to be clearheaded about this transformation. And not just succumb to magical thinking. Ian Morrison, Ph.D., is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express. The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

The Frustrations of Sick Americans

The Frustrations of Sick Americans By Susan B. Frampton June 13, 2012 Patient-centered approaches to medical care can lead to better outcomes. In May, National Public Radio, the Robert Wood Johnson Foundation and the Harvard School of Public Health released the findings of a poll that asked Americans how they view the quality of health care and its cost. The findings inspired a weeklong series on NPR called "Sick in America." The poll randomly surveyed 1,508 adults across the nation. A little more than a quarter of them required "a lot of medical care," or overnight hospitalization within the past 12 months. The report illuminates how our current health care system is letting down those it is intended to help, specifically people who have a serious medical condition or who've spent time in the hospital. Three of four people who were sick said cost is a very serious problem, and half said quality is a very serious problem. It is not breaking news that there are shortcomings in our health care system, but this survey provides valuable insights into precisely what is and isn't working for sick Americans. There is also encouraging progress to report. Many health care providers around the country have adopted patient-centered approaches to care that are addressing many of the problems highlighted in the poll. Poor Communication Among people who have required a lot of care recently, significant proportions say their treatment was poorly managed, with nearly a third complaining of poor communication among their caregivers. Survey respondents' emphasis on communication (or lack thereof) as a determinant of their perceptions of health care quality was not a surprise to me or to my colleagues at Planetree. The Planetree model of care originates with the voices of patients, families and caregivers. Time and again, in focus groups held by Planetree across the globe, patients express the added confidence they feel when clinicians actively include them as part of the care team — and conversely, how dehumanizing it is to be spoken about instead of spoken to. They also consistently bemoan the fragmentation of the health care system and express a desire for an open exchange of information that will equip them, as well as their loved ones who may assist with their care, with the knowledge they need to take an active role in managing their own health and wellness. In hospitals committed to patient-centered care delivery, open exchanges of information are prioritized. Patients are encouraged to review their health record with their doctors and nurses and to contribute progress notes. Patients are given literature, tools and resources to understand their diagnosis and treatment options. Daily goals are discussed with the patient and captured in laymen's terms on a communication board in the room. Loved ones are invited to be official care partners, and visiting hours are eliminated to encourage loved ones' presence and participation. Practices like these that foster engagement and nurture a trusting relationship between caregivers and patients also yield improved clinical and organizational outcomes. When caregivers partner with patients and their loved ones, medication errors can be avoided, and patients better understand their condition so they can manage their care successfully at home and avoid a readmission. Insufficient Information A quarter of sick Americans report that all the needed information about their treatment or prescriptions was not provided. According to the Institute of Medicine, "Stable, trusting relationships between a patient and the people providing care can be critical to healing or managing an illness." Time is central to such relationships. During a shift change, for example, a nurse learns about each patient's needs and has an opportunity to clarify details of the care plan. Including patients in this conversation empowers them and reinforces the crucial role they play in meeting their own health and wellness goals. The nurse's role as educator is a central focus of the profession. This isn't necessarily an easy proposition. Some patients are simply too sick to learn or are in denial about their conditions; others are depressed or anxious. Patient-centered hospitals implement a range of educational techniques to ensure that patients get the information they need in a way they will comprehend it. Educational materials written in plain language, DVDs, websites and the teach-back method can be combined to meet patients' needs. As families continue to shoulder more of the responsibility for caring for loved ones, it is essential that accommodations be made to include them in patient education activities. Poor Care Coordination Nearly a quarter of patients had to see multiple medical professionals, and no one doctor understood or kept track of all the different aspects of their medical issues and treatments. Focus group data collected by Planetree underscores the challenges patients encounter when they try to coordinate care from one episode to the next and in different care settings. When systems don't "speak" with one another, patients become the primary point of continuity, but many report feeling ill-equipped to navigate through such unfamiliar and high-stakes territory. Personal health records help patients coordinate their care. As an ongoing record of the patient's health history, medical conditions, test results, treatment plans, medication lists and wellness goals, PHRs can demystify the health care experience. Because the owner of the PHR is the patient, it transcends provider silos, equipping patients with a practical tool for assuring all their caregivers understand the patient's care needs and priorities for their health. This information can be maintained electronically with password protection, while other PHRs are paper-based. Whatever the format, the function is the same: communicating consistently with providers when transitioning from one care setting to another.In a small-scale study recently completed by Planetree, using a PHR was found to provide an avenue for patients to raise concerns and for clinicians to address topics that would have been overlooked. Silo Thinking Three in 10 sick Americans say that a doctor, nurse or other health professional did not spend enough time with them. Additionally, a majority of sick Americans want their encounters with their physicians to involve discussions about broader health issues, rather than a specific medical problem. The role of hospital leaders and front-line staff is changing, and it requires caregivers to think beyond discharge — to be collaborators across the health care continuum, from home care to long-term care provider teams. Additionally, patient-centered organizations recognize the interconnectivity of health and the importance of respecting a patient's cultural, spiritual, intellectual, biological and socioeconomic individuality. To encourage sharing of information, one approach taken by Dorothea Wild, M.D., of Griffin Hospital, a Planetree-designated hospital in Derby, Conn., is to ask a simple question, "What else?" three times. Listening and asking "What else?" draws out additional — often significant — information from patients about chronic conditions, emotional or economic issues and even substance abuse. Letting Patients Lead To move from a health care system that primarily treats the sick in America to one that actively promotes wellness in America, we must follow the lead of the poll by National Public Radio, the Robert Wood Johnson Foundation and the Harvard School of Public Health and first listen to patients. What do they need from health care providers and the health care system to help them successfully understand their treatment, manage their care and meet their personal wellness goals? They will be our guides in designing a health care system that supports meaningful patient partnerships and true patient-centered care. Susan Frampton, Ph.D., is the president of Planetree in Derby, Conn. The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

Cultural Transformation in Health Care Settings

Complete credit for the following article is given to author Joe Tye. Joe Tye, M.H.A., M.B.A., is the CEO of Values Coach Inc., a health care consulting and training firm in Solon, Iowa. He is also a member of Speakers Express. Cultural Transformation in Health Care Settings was published in the February 21, 2012 issue of Hospitals & Health Networks magazine.

Cultural Transformation in Health Care Settings
By Joe Tye February 21, 2012

Think like a physicist to effect change in your organization.

In The Dancing Wu Li Masters, Gary Zukav writes, "The way that we pose our questions often illusorily limits our responses … . The way we think our thoughts illusorily limits us to a perspective of either/or." My goal in this article is to use the laws of physics to help readers think in new ways about shaping the culture of their hospitals. If it's true that culture eats strategy for lunch, then a cultural plan is more important than a strategic plan. Used as a metaphor, Zukav's Wu Li Masters can help you think in new ways about cultural transformation.

But first, an important point: The laws of physics are morally neutral. The momentum of a speeding garbage truck will cause it to ram into a school bus full of children or a prison bus full of convicted killers with equal certainty. Likewise, corporate culture is morally neutral. Enron had a powerful culture, but it was a culture corrupted by greed.

That said, here are some thoughts on the laws of physics and their implications for corporate culture:

Nature abhors a vacuum. Every organization has a culture. Just as physical nature moves to fill a vacuum, so human nature creates cultural traditions, practices and expectations within organizations. The question is whether this culture is allowed to morph haphazardly, or is guided by principles and a plan that are clearly defined and well communicated.

Inertia is best overcome by engaging informal leaders. A body at rest tends to stay at rest, and absent deliberate management intervention, corporate culture becomes stale and stagnant. In an inertia-bound culture, you hear things like "We tried that and it didn't work" and "We've always done it this way." The larger the organization, the more energy it will take to begin the cultural transformation process, similar to the way it takes more energy to move a bowling ball than it does a pool ball. But, unlike pins passively awaiting the crash of a bowling ball, a hospital's leaders can strategize the most appropriate cultural response to health care reform, whatever form it eventually takes. Resorting to a top-down, command-and-control process (e.g., cutting staff with layoffs) is a Newtonian "organization-as-machine" approach; whereas, training employees on the personal skills of ingenuity, courage and resilience is more consistent with the paradoxical relationships evident in quantum physics.

Friction is inevitable and must be overcome. The first thing you encounter when you seek to overcome inertia is friction. The greater the change required, the greater is the resistance. Knowing that friction is inevitable can help you fortify yourself with the determination to forge ahead in spite of it. And just as a snowball gains mass as it overcomes friction rolling down a hill, once the transformation process begins, you will find that the skeptics of yesterday have become the champions of tomorrow.

Critical mass is essential to sustain change. To spark significant cultural change, you must have a critical mass of people buying into the desired change. Researchers suggest that about 30 percent of a population is sufficient to reach critical mass in launching a movement. So, for example, when a third of us decided we would no longer tolerate being poisoned by other people's cigarettes, the movement to ban public smoking became unstoppable. At Tri Valley Health System in Cambridge, Neb., a group of about 50 people meet every morning for several minutes to collectively recite that day's promise from The Self-Empowerment Pledge. According to CEO Roger Steinkruger, that one simple group action has had a positive impact on the hospital's culture, and it is now spreading to other parts of the community.

Escape velocity is generated by staff commitment. A spaceship headed for orbit must first attain sufficient speed to break free of Earth's gravitational pull; the greater the mass of the spaceship, the greater the speed required. To achieve cultural transformation, you need a sufficient number of people (mass) who are sufficiently galvanized (emotional velocity) to escape the inertia, pessimism, cynicism and toxic emotional negativity of the past. Fillmore County Hospital is a critical access hospital in Geneva, Neb. As part of a hospitalwide values training initiative, its leaders asked every employee to think about his or her personal values, then published a beautiful booklet with the responses. Patient satisfaction scores have improved in 27 of 30 measures, which the leaders attribute to having achieved the "cultural escape velocity" caused by a sufficient number of people making the commitment to act on those values.

Momentum assures ongoing progress. A body in motion tends to stay in motion. One of the things that struck me when researching All Hands on Deck: 8 Essential Lessons for Building a Culture of Ownership is the extent to which cultural momentum carried each of the market-dominating companies featured in the book long after charismatic founders like Walt Disney, Ray Kroc, Mary Kay Ash, Bill Hewlett and Dave Packard had departed. In the strongest organizations, cultural momentum is a powerful form of leadership. Organizational structures like Hamburger U at McDonald's ensure that cultural norms are transmitted to each new generation of future leaders.

Randomly intervening variables can foster new solutions. Natural evolution was profoundly altered when an asteroid slammed into Earth some 65 million years ago, leading to the dinosaurs' extinction. In cultural terms, outside factors including the economy, politics, competition and other variables inevitably complicate culture change. But as Margaret Wheatley points out in Leadership and the New Science, "Disequilibrium is the necessary condition for a system's growth." When a group of physicians in Kearney, Neb., announced plans to build their own hospital, leaders at nearby Good Samaritan Hospital feared the doctors would recruit nurses from their hospital. So Good Samaritan evaluated potential sources of employee dissatisfaction and took actions to enhance loyalty. Though the physicians' hospital is not yet completed, Good Samaritan built a stronger and more positive culture as a result of the challenge.

Entropy is the enemy of progress. Culture does not maintain itself; it requires constant attention. When Columbus (Ind.) Regional Hospital was inundated by a flash flood in June 2008, it appeared likely that entropy would set in. Basic services were shut down, the hospital was closed for five months, no revenue was coming in, and the hospital knew its "best places to work" culture and high-performing workforce were at risk. The executive team and board made a decision to keep everyone on the payroll for five months, at a cost in excess of $30 million — money that had been set aside for a new patient tower and emergency department. The hospital reopened with staff intact, continues to be rated as a best place to work, and enjoys a growing reputation for excellence. Its most recent national recognition was for its innovation center — a facility made possible as a result of flood-related rebuilding.

Black holes must be confronted and marginalized. Scientists recently have discovered a black hole estimated to be the mass of 21 billion stars the size of our sun. Black holes literally suck the life out of any objects that come too close. Organizations, unfortunately, have people like that — emotional vampires who suck the life out of people with whom they work and, eventually, out of organizations for whom they work. Marginalizing these human black holes is a fundamental leadership duty. (I shared 14 strategies for doing this in my previous H&HN Daily article, "A Positive Approach to Negative People.")

Quantum leaps are created by inspired leaders. One of the most surreal aspects of quantum theory is the notion that an electron can skip from one orbit to another without ever traversing the space between — the quantum leap. During the mid-1990s, under the leadership of Ken Kizer, M.D., the Veterans Health Administration made a rapid transition from widely being seen as a caregiver of last resort to an organization about which Phillip Longman could write a book credibly titled Best Care Anywhere. Today the VHA is going through a similarly radical cultural transformation to promote Veteran-centered care. Belying the notion that transforming a huge organization is like turning a battleship, the VHA has achieved substantive change at a quantum-like pace.

The problem of measurement requires new thinking. Even more than in management, with its mantra that "what gets measured gets done," physics is a science based on measurement. But there is also an acute awareness of the limitations of measurement. According to the Heisenberg uncertainty principle, the simple act of trying to measure something affects that which is being measured. A manager might believe that he or she is improving patient satisfaction by giving employees a script and a happy face pin, but the way that script is delivered can have a perverse effect. The things that most matter to patient satisfaction are notoriously difficult to measure with traditional metrics. Compassion, enthusiasm, pride and other "soft" qualities cannot be measured, but they certainly can be observed. Like physicists trying to understand the magnificent complexity of the universe, one of our challenges is finding new ways to assess those things that cannot be measured in the traditional manner.

Culture is a force field to be understood and galvanized. In physics, the concept of the force field explains how gravity, electricity and magnetism can cause two entities that are not in physical contact to have a physical effect on each other. Culture is a force field in which attitudes and behaviors in one part of the organization are transmitted across space and time via invisible forces like rumor and gossip; example and expectations; stories and traditions. And like gravity, culture is no less real for being invisible. Mapping out the vectors that transmit culture is a useful way of employing these forces to bring about desired cultural change.

Elegance defines the best work settings. When it evolves according to nature's laws, the universe tends toward elegance: From the Grand Canyon to photographs taken by the Hubble space station, there is beauty in the natural order. The same can be said for organizations that dominate "best places to work" lists: They have beautiful and functional corporate cultures. The Tao of Physics by Fritjof Capra was one of the first books to look at physics from a social sciences vantage point. Capra highlights similarities between modern quantum physics and ancient Eastern philosophical traditions, saying, "The further we penetrate [into modern physics] the more we … see the world as a system of inseparable, interacting, and ever-moving components, with man as an integral part of this system." More recently, in The Elegant Universe, Brian Greene describes how string theory almost makes the universe feel like a gigantic musical instrument. That's a beautiful metaphor for the culture of an organization known for being a best place to work and a best place in which to receive care.
Culture Can Change

There is, of course, another essential difference between the laws of physics and the principles of cultural transformation: The laws of nature are immutable while cultural practices are fluid and malleable. Nevertheless, thinking in terms of physical laws of the universe can provide a useful metaphorical tool for promoting a more positive and productive culture in your organization.

Joe Tye, M.H.A., M.B.A., is the CEO of Values Coach Inc., a health care consulting and training firm in Solon, Iowa. He is also a member of Speakers Express.

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

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Better Ways of Thinking about the Future

The author ... Joe Flower is an internationally known futurist and consultant to health care executives. This represents his posting of 1/24/12 in H&HN Daily. I highly recommend this article by him to all of my students.
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Better Ways of Thinking about the Future
By Joe Flower January 24, 2012

How do you learn to "Think Different," as Steve Jobs' famous ads put it?

Let's think about the structure of thought for a moment. The great experimental psychologist Daniel Kahneman, in his recent book Thinking, Fast and Slow, shows how much of our thinking and decision-making is driven by illusions and assumptions, such as the "illusion of validity" (the false belief in the reliability of our own judgment), the "availability bias" (a biased judgment based on memories that are more easily available or more vivid) and the "endowment effect" (the tendency to value something more highly when we own it than when someone else owns it).

This makes sense. Kahneman's analysis resonates strongly with my experience working with executive health care teams, including providers, health plans and suppliers, and with governments in North America, Europe and China over several decades. Smart, seasoned executives can make seriously poor judgments, especially when the environment changes.

Curiously, these illusions, biases and assumptions are driven by our experiences. So, being more experienced does not necessarily exempt us from illusion, unless something in our process constantly and directly tests the results of our judgments (as, say, a robust retail market does on price setting). Even if the judgments are correct, they are based on an environment: in the jungle or the savanna, in a controlled market or a retail market, in a risk-bearing business arrangement or an endowed business arrangement. When our environment shifts, the illusions and biases and assumptions persist, even though they may be dangerously out of date.

We are in a rapidly shifting environment. Over the next several years, all health care leaders will be called on to make numerous strategic decisions and tactical choices that fundamentally will be different from decisions they are used to making. But they will be making those decisions with a mental apparatus formed in the old environment.

A Thought Exercise

How do we rethink our assumptions? How do we approach the unfolding situation with a continually fresh mind?

Here is a basic and enormously useful thought exercise. Take some time to write down a number of basic facts and beliefs about your organization, anything from facts such as "We own XYZ Home Care" to opinions such as "Tom's a lousy communicator." Then take one of these "truths" and find several ways to form an opposite of it.

An opposite of "We own XYZ Home Care" could be "We don't own XYZ Home Care," "Our crosstown rivals own XYZ Home Care," "XYZ Home Care owns us," or "We keep XYZ Home Care's assets, but farm out the management," or even "The business we now think of as 'home care' disappears and becomes something else," for instance.

The opposite of the opinion "Tom's a lousy communicator" could be "Tom's a great communicator," "I'm a lousy listener to Tom," or "There's really no need for Tom to be a great communicator."

Entertain one or another of these opposite assumptions for a while. Treat it as if it were true. Assume that, in some way, it actually is true or could be true. How does that feel? In what ways might it actually feel true? What would be the consequences if it were true? Explore it; give it room to grow.

This is not a test of your original assumption, but a way to ferret out different assumptions and give them room to play in your judgment. Your original assumption may be correct, or it may be correct for now, or it may be as correct as some of its opposites. Maybe Tom really is a lousy communicator, but you're also not so good at hearing what Tom is on about, and in Tom's job it's not so important that he be a good communicator. In making your assumptions explicit and overturning them, you can find other truths — and in a deeply shifting strategic environment, we will need to find lots of new truths.

Overturn Assumptions

In this year of thinking dangerously, here are some assumptions to entertain that may be counter to the way you are thinking now. Try them on for your organization and your environment. See if the act of taking them, experimentally, as true turns up other thoughts that might add to the power of your judgment in the changing environment.

Assume brevity. Assume that your current product lines, business models, revenue streams and business structures have a short half-life — that they are not permanent but will disappear. Many businesses (such as consumer electronics) have this assumption built into their DNA. In health care, we make the opposite assumption: If we have a cancer program, if we make our margin on the employer side, if the sleep center is a good revenue stream, we assume permanence until proven otherwise. Assume brevity — actively search for, create and incubate alternatives.

Assume common ground. Assume that your business adversaries and rivals can be allies. The health plans, your crosstown rivals, or the city government may be making life difficult for you now. But under different business assumptions, for particular product lines, revenue streams or business structures, your strongest rivals may be your natural affiliates.

Assume all form is classical. If you are thinking of some new business direction, something that seems radically new to you, assume that somebody somewhere is already doing things this new way, is doing it well, and has learned something about how to do it. Assume that, rather than start from scratch, you can beg, borrow, pirate, buy or copy their expertise and experience — and then improve on it.

Assume new capacities. Assume that your organization does not have the capacities that it will need in its evolving environment.

Assume new abilities. Assume that your organization has latent abilities to learn, change and create that you have never tapped; that it is possible to tap them; and that you could learn how from other organizations.

Assume heterodoxy. Assume that there is no one right way to do health care, even for you to do health care in your market with your organization, but that there are many partially right ways.

Assume exotic provenance. Assume that the answers are not all in health care. As the business environment changes, we will increasingly find that we can learn things from other industries, that other industries represent a "target-rich environment" for new business ideas, revenue streams and risk structures that we can use in our organizations.

Assume the fruitfulness of challenge. Assume that a leader's most important task is to pose the unanswerable questions, the true challenges, to subordinates. Any question that actually has an answer is a technical question, not a leadership question. Leadership deals with the unanswerable, with where we could be and where we might go. Being the smartest person in the room and having the right answer is the smallest part of the job — and can actually get in the way of finding the best answer and the greatest intelligence the organization can manifest.

Assume curiosity. Curiosity is much more valuable than answers. Questions are far more useful than fixed opinions. Foster curiosity in your subordinates, in your customers, in your allies and potential allies. An organization displays and feeds curiosity by starting pilot programs, fostering new product lines, seeking out new allies and relationships, then seeing what works and pruning the rest.

Assume ruthlessness. Don't fall in love with what you create. It's a new environment. You have to try new things — and you have to kill off what does not work.

Assume competition. Assume that in a changing business environment, if an opportunity shows up, someone will take it. It could be you or it could be a competitor. The opportunity could be something not yet invented in your market, or it could be something you already do that someone else finds a way to do better, faster or cheaper.

Assume the bottom of the pyramid. Assume that there are opportunities on the low end, that there are ways to find margin even serving the least well-insured and the least well-employed. The reason is simple: The changes in the health care business environment likely will increase, rather than decrease, your exposure to the low end of the market, and will decrease the ways that you can offset losses in serving it. You have to find margin, and you will not find it if you assume it is not there.

Assume ignorance. Assume that you do not know enough about your own organization and its environment to make the best decisions: how much particular processes cost you, which of those costs are flexible, which are even unnecessary, where your revenue streams actually come from, who the true decision-makers are, both in incurring costs and in becoming customers. "Big data," the ability to drill down into the masses of information your organization produces and come up with answers to such questions, could be your friend.

Assume decision-making from ignorance. Assume that you will never really know enough, and you will have to make big decisions anyway.

Assume that it's always a decision. Assume that to make no decision, or to delay a decision, is itself a decision.

These are a few examples of the ways we must continually overturn and test our thinking, expose our illusions and bring a fresh mind to our strategic judgments. No matter how smart or how experienced, the mind whose expertise was formed in business models of the past decades is ill-equipped to make judgments in the Next Health Care as it forms and re-forms over the coming several years. When the mind of the leader learns to change first, then the organization can learn and change.

Joe Flower is a health care futurist and CEO of The Change Project Inc., and its health care education arm, Imagine What If. He is also a regular contributor to H&HN Daily and a member of Speakers Express. His new book,Healthcare Beyond Reform: Doing It Right for Half the Cost, will be published in March 2012 by Taylor and Francis.

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.