Best Care, Best Future David Lawrence, MD 2014

Below is an outline of the book by Dr. Lawrence

Introduction: there are three responsibilities - => the best care, develop a competitive organization and prepare for the future. Variation impacts results and costs (C2). Kaiser is a complex, decentralized, MD driven organization, consensus oriented.  ? built to be adaptable and had significant variation. Financial losses increased the urgency for change (?).

I.                   Why ? - Care (C1) is fragmented and ? collaborative despite increasing complexity.

II.                 New Organization - need an ecosystem that is adaptive and supports improvement.

a.      Must bridge C1 and life. Health is more than treatment.

b.      Process focus - pay attention to how people move through the system, contingency planning and anticipate exceptions. Planning flow decreases variation but is controversial and resisted by clinicians. Standardization helps design flow, decreases C2, improves safety and increases reliability.

c.      Increasing need for collaboration but does decrease autonomy.

d.      Speed - ongoing cycle of ? - hypothesis, test, analyze, repeat.

e.      Coherence/constancy - based on purpose, values and stories.

III.              How Do You Lead? - organizational viability and clinical independence can => potential conflict.

a.      Need to understand the work where it is done and the people; never ending.

b.      Jujitsu - use the energy of others to move in the direction you want them to take.

IV.              Starting - how you start sets the tone. ? requires a break with the past and earning informal power. Take time to learn at the beginning, opportunity passes quickly. How you spend time demonstrates values.

a.      Carve out time for learning, be deliberate in who/how. Develop questions, reserve opinion, thank. Plan interactions in advance - id issues to explore/discussions. Assure follow up.

V.                Obstacles and Traps: ? silver bullet for transforming an organization. 

a.      Financial: Improving quality may reduce volume. Visit other organizations and take a long view. Quality is cheaper in the long run.

b.      Regulatory: complex and fluid.

c.      Bubbles: surrounded by trusted individuals filters information and alternative opinions.

d.      ‘Shiny objects’: inconsistency is a problem. Focus on the critical few, limit priorities.

e.      Hubris: leads to limited listening, dismissiveness, defensiveness. 

f.       ‘Kumbaya’: sometimes need to take a stand, won’t always be consensus, anticipate emotional response and criticism.

VI.              Health - critical to maintain personal health - diet, exercise, sleep, balance.

VII.           The Heart of the Matter - patients and their stories.

a.      Have to protect patients from the experts.

b.      Patient experience: dignity is central. Patient do ? always understand their rights, plans and participation. Need to collect patient stories and performance data.

c.      Include patients in C1 design/improvement, strategic planning and community health initiatives.

VIII.         Board of Directors - education is critical. Board has a fiduciary role and provides moral stewardship - public and institutional responsibilities. 

a.       Recommends a 9-11 member board without MD representative Does not seem to fit current trends/expectations of greater MD inclusion - VJG

b.      On-boarding process is critical. Meetings should include educational component, focus on strategic issues and only financial at the end.

IX.              Senior Leadership/Change Leadership Network

a.      Typically wait too long to make HR ?’s - believe in potential for improvement/ongoing efforts to fix. How separation is done is as important as why. Entire org is watching.

b.      Senior leadership must have a common purpose and complementary skills. Need the ability to have productive, civil discussions. Id’s need for financial, HR and IT leadership - ? id need for clinical leadership- VJG.  Emphasizes strategic thinking beyond technical knowledge - analytic and collaborative.

c.      Change Leadership Network - informal/fluid relationships that provide insight/advice.

X.                Physicians - leading MD’s - challenge. Need enough consensus to make a decision.

a.      Be prepared for things to blow up and that someone will always be angry.

b.      ? cannot be imposed. Resistance comes from training and socialization, sense of loss.

c.      Physicians are trained to care for patients - ? real world functioning. 

d.      Common ground - establish patient centrality, share data, experiment collaboratively. 

e.      There are pros/cons to formal groups vs. independent practitioners.

XI.              Workforce - can’t engage if leadership is ? engaged. Need to develop trust, takes time. Stories are a key tool. Establish fun and recognition.

XII.           Compacts - explicit agreements, but ? contracts. Are ? legally binding, ? dispute resolution. Explores commitments. Process is > important final document.

XIII.         Systems - Language: every comment tells people who you are, shapes their perception. Focus on economy and action. Tell stories. Make quality the centerpiece. 

XIV.        System - Learning: unceasing quest to find a better way. Reinforce learning environment. Start with values, help people experiment/fail/learn. Decrease variation. Measurement is critical. Have individuals teach one another.

XV.           System - Transparency: basis for trust. Patient - experience/expectations; organizational - decisions/performance; public - errors/performance/participation.

XVI.        System - Innovation: bring in new capabilities and solutions, improvement is insufficient. Requires supporting culture and structures.

XVII.      System - Information: tailor information system to needs of the organization. Complicated by legacy systems, differing constituency needs.

XVIII.    System - Prods: need to escape the status quo. Apply Institutes, external expertise.

XIX.        Accountability & Compensation - reinforces values/strategy; team focused. 

XX.           Operating Discipline/Final Thoughts

a.      Need an operating process tailored to the organization and culture. Stay focused and consistent to => results. 

b.      Complicity: if we fail to provide safe, efficient, responsive care we are complicit because we know better.