Transcript Tom Peters’ Excellence. Always. The choice is yours. Health Forum and the American Hospital Association Leadership Summit/San Francisco/23 July 2009

Tom Peters’
Excellence.
Always.
The choice is yours.
Health Forum and the American Hospital Association
Leadership Summit/San Francisco/23 July 2009
To appreciate
this presentation [and ensure
that it is not a mess], you need
Microsoft fonts:
NOTE:
“Showcard Gothic,”
“Ravie,” “Chiller”
and “Verdana”
seven thousand dollars more per person each
year than does the average city in America. But not, so far as one can tell,
because it’s delivering better health care. … Compared with patients in
___________ costs Medicare
________ and nationwide, patients in _______ got more of pretty much everything —more diagnostic
testing, more hospital treatment, more surgery, more home care. The Medicare payment data
provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost
fifty per cent more specialist visits in _______ than in ______, and were two-thirds more likely to see
ten or more specialists in a six-month period. In 2005 and 2006, patients in _______ received twenty
per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent
two hundred per cent
more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five
hundred and fifty percent more urine-flow studies to
more stress tests with echocardiography,
diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee
replacements, breast biopsies, and bladder scopes. They also received
two to
three times as many pacemakers, implantable defibrillators, cardiacbypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for
five times as many home-nurse visits. The primary cause of ______’s
extreme costs was, very simply, the across-the-board overuse
of medicine. — “Cost Conundrum: What a Texas town can teach us about health
care,” by Atul Gawande, The New Yorker, June 1, 2009
“The results are deadly. In addition to
the
98,000
killed by medical
errors in hospitals and the 90,000
deaths caused by hospital infections,
another 126,000 die from their doctor’s
failure to observe evidence-based
protocols for just four common
conditions: hypertension, heart attack,
pneumonia, and colorectal cancer.”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Principal
1.
2.
3.
4.
5.
6.
7.
8.
Management & Leadership (as opposed to Policy) Issues:
Should we be doing what we’re doing? Will it work? How do we
know?
Are we doing what we decide to do safely?
Do we do too much—are we in the “overuse” category as determined
by agreed upon standards-measures?
Are we doing what we’re doing effectively? By local standards? By
global standards (as determined by “best practices,” best hard
evidence, and minimal internal variation) in terms of outcome,
quality, safety and cost? Do we aim, for example, to be “top quartile”
in terms of measurable outcomes, quality, safety and “bottom
quartile” in terms of cost?
Is the institution systematically organized to very consistently
deliver the goods in a more or less optimal fashion (low variation in
outcome)?
Do all the bits talk to-engage-consult “obsessively” with the other
bits? Is the delivery of services truly a turnkey team effort?
Are the patient and the patient’s family at the epicenter of the
universe?
Is our institution acknowledged as a “best place to work”?
Principal Management & Leadership (as opposed to Policy) Issues:
9.
10.
11.
12.
13.
Do we acknowledge that people issues-capabilities-will
involving the entire staff effect outcomes far more than capitaltechnology issues?
Is sustained follow-up at least as much a priority as the “event”
itself?
Were we/Are we successful in terms of outcome-quality of lifepatient satisfaction with the overall “experience”?
Are all connected with all via an effective electronic network
that extends from EMR to Social Networking?
Do we acknowledge that most of the choices involved in
executing items #1 through #12 are mostly within our
discretion regardless of the nature of Obamacare? (And that
Obamacare or its successor will almost surely eliminate
piecework compensation—which drives the immediacy of much
of the above.)
14. Do we acknowledge that throughout the system there are,
today, enormous variations in outcome concerning
every one of the above issues—which can mostly (almost
entirely?) be explained in terms of institutional leadership
effectiveness (vision, will, systems)?
“If I could have chosen not to tackle the IBM culture head-on, I
probably wouldn’t have. My bias coming in was toward strategy,
analysis and measurement. In comparison, changing the
attitude and behaviors of hundreds of thousands of people is
[Yet] I came to see in
my time at IBM that culture
isn’t just one aspect of the
very, very hard.
game —it is the
game.”
—Lou Gerstner,
Who Says Elephants Can’t Dance
“Most of the patients, like those in my clinic, required about twenty minutes.
But one patient had colon cancer and a number of other complex issues,
The physician spent an hour
with her, sorting things out. He phoned a
cardiologist with a question. “I’ll be there,”
the cardiologist said. Fifteen minutes later,
he was. They mulled over everything
together. The cardiologist adjusted a medication, and said that no
including heart disease.
further testing was needed. He cleared the patient for surgery, and the
The whole
interaction was astonishing to me. Just
having the cardiologist pop down to see the
patient with the surgeon would be
operating room gave her a slot the next day.
unimaginable at my hospital. The time
required wouldn’t pay. The time required just
to organize the system wouldn’t pay.”
“The Cost Conundrum: What a Texas town can teach us about
health care,” by Atul Gawande, The New Yorker, June 1, 2009
“The needs of the patient come
first” —not the convenience of the doctors,
not their revenues. The doctors and nurses,
and even the janitors, sat in meetings almost
weekly, working on ideas to make the service
and the care better, not to get more money out
“When doctors
put their heads together in a
room, when they share expertise,
you get more thinking and less
testing,” Cortese told me.
of patients. I asked
“The Cost Conundrum: What a Texas town can teach us about health
care,” by Atul Gawande, The New Yorker, June 1, 2009
Grand Junction’s medical community was
not following anyone else’s recipe. But, like
Mayo, it created what Elliott Fisher, of
Dartmouth, calls an
accountable-care
organization. The leading doctors
and the hospital system adopted measures
to blunt harmful financial incentives, and
they took collective responsibility
for improving the sum total of
patient care.
“The Cost Conundrum: What a Texas town can teach us about
health care,” by Atul Gawande, The New Yorker, June 1, 2009
Single
greatest act
of pure
imagination
“Experiment
fearlessly”
Source: BW0821.06, Type A Organization Strategies/
“How to Hit a Moving Target”—Tactic #1
“We made mistakes, of course. Most of them were
omissions we didn’t think of when we initially wrote the
software. We fixed them by doing it over and over, again
and again. We do the same today. While our competitors
are still sucking their thumbs trying to make the design
perfect, we’re already on prototype version
#5.
By the time our rivals are
ready with wires and screws, we are on version
#10. It gets back to planning
versus acting: We act from day
one; others plan how to plan—
for months.” —Bloomberg by Bloomberg
Culture of Prototyping
“Effective prototyping may
the most
valuable core
competence an
be
innovative organization can
hope to have.” —Michael Schrage
“You can’t be a serious
innovator unless and until
you are ready, willing and
able to seriously play.
‘Serious play’ is not an
oxymoron; it is the essence
of innovation.”
—Michael Schrage, Serious Play
Think about It!?
Innovation =
Reaction to the
Prototype
Source: Michael Schrage
“Fail .
Forward.
Fast.”
High Tech CEO, Pennsylvania
“Reward
excellent failures.
Punish mediocre
successes.”
Phil Daniels, Sydney exec
“We ground up
more pig brains”:
100% “Mad
Scientists!”
TP’s “1/40”/“We ground up more pig brains”
“Experiment fearlessly”
It’s all about attitude!
One Big Innovation Lab!
“Let 1,000 flowers bloom”
(Chief Gardener?)
Micro-experiment budget
Hyper-quick approval process
Hyper-quick prototyping
(Measure “mean time to prototype”)
Mini-project teams born in a flash
Do everything at once
No “bad ideas” except inaction
Transparency/Publish everything
TP’s “1/40”/“We ground up more pig brains”
“Get it right the 79th time”
Reward clever/excellent failures
Celebrate constantly/
Wee rewards/Recognition/
“Mad scientist club”
Master “nudgery”
Encourage/Reward cross-functional
excellence (A special category!)
Take the lid off the “best practices”
travel budget/“Visit Excellence”
Steal excellence everywhere!
LEARN from best practices/
Allow 100% variation
TP’s “1/40”/“We ground up more pig brains”
Coalition of Fearless Experimenters
Ask for help in Wikiworld
Social networking with peers
(Board game?)
“What do you think?”
Listen!!!!
100% participation
100% leaders
Patient participation
Process ideas from all
Map everything
Measure but don’t stifle!
Training in process improvement for 100%
Training in prototyping/100%
TP’s “1/40”/“We ground up more pig brains”
Training in “What do you thinkery”/100%
Training in listening/100%
Training in micro-team leadership/100%
100% participation in mapping
every-damn-thing
Check lists until you’re blue in the face
“Simple stuff” Power!!
Special “simple stuff” recognition
“People stuff”>“Tech stuff”
Pillar of “The Way we do things
around here”
MBWA/“You must be the change
you wish to see in the world”
“Business people
don’t need to
‘understand
designers better.’
Businesspeople need
to be designers.”
—Roger Martin/Dean/Rotman Management School,
University of Toronto
Little =
Big carts =
Source: Wal*Mart
Geologists +
Geophysicists +
A little bit of love =
Oil
The “XF-50”: 50 Ways to
Enhance Cross-Functional
Effectiveness and Deliver
Speed, “Service Excellence”
and “Value-added
Customer ‘Solutions’”*
*Entire “XF-50” List is an Appendix to the LONG version of
this presentation, posted at tompeters.com
6.5
feet Away =
6.5 feet Away =
-63%
“Seconds”*
*Plate size, etc, first serving dish
“Everything matters”
-80%
Source: Nudge, Richard Thaler and Cass
Sunstein, etching of fly in the urinal
reduces “spillage” by 80%, Schiphol Airport
“Broken windows”: Clean
the streets, fix the
broken windows, ticket
the open-beer-can
holders, etc, etc
= Sense of order
= Crime way down
90K in U.S.A. ICUs on any
given day; 178 steps/day
in ICU.
50%
stays result
in “serious complication”
Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)
**Peter Pronovost, Johns Hopkins, 2001
**
Checklist
, line infections
**1/3rd at least one error when he started
**Nurses/permission to stop procedure if doc,
other not following checklist
**In 1 year, 10-day line-infection rate:
11% to …
0%
Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)
**Docs, nurses make own
checklists on whatever
process-procedure they choose
**Within weeks, average stay in
ICU down
50%
Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)
Socks =
10K/UK
(DVT)
-fold!
Lisbon/New Biz:
Weeks
to …
Minutes
(!!!!)
The Commerce Bank Model
“every computer at commerce bank has a
special red key on it that
says, ‘found something stupid that we are doing
that interferes with our ability to service the
customer? Tell us about it, and if we agree, we
will give you $50.’”
Source: Fans! Not customers. How Commerce Bank
Created a Super-growth Business in a No-growth
Industry, Vernon Hill & Bob Andelman
Beauty!
Grace!
Clarity!
Simplicity!
“one line
of code!” Axiom
The
1982
Excellence1982: The Bedrock “Eight Basics”
1.
2.
3.
4.
5.
6.
7.
8.
A Bias for Action
Close to the Customer
Autonomy and Entrepreneurship
Productivity Through People
Hands On, Value-Driven
Stick to the Knitting
Simple Form, Lean Staff
Simultaneous Loose-Tight
Properties”
2007
Siberia
Why in the
World did you
go to Siberia?
An emotional,
vital, innovative, joyful, creative,
entrepreneurial endeavor that
elicits maximum
Enterprise* ** (*at its best):
concerted human potential
in the wholehearted service
of others.**
**Employees, Customers, Suppliers, Communities, Owners, Temporary
partners
2007
Sydney
… no less than
Cathedrals
in which the full and
awesome power of the
Imagination and Spirit and
native Entrepreneurial flair
of diverse individuals is
unleashed in passionate
pursuit of … Excellence.
“You have to
treat your
employees like
customers.”
—Herb Kelleher,
complete answer, upon being asked his “secrets to success”
Source: Joe Nocera, NYT, “Parting Words of an Airline Pioneer,” on the occasion of
Herb Kelleher’s retirement after 37 years at Southwest Airlines (SWA’s pilots union
took out a full-page ad in USA Today thanking HK for all he had done; across the
way in Dallas American Airlines’ pilots were picketing the Annual Meeting)
The four most important words in any organization
are …
“What do
you
think?”
Source: courtesy Dave Wheeler, posted at tompeters.com
“The deepest
human need is
the need to be
appreciated.”
William James
“Courtesies of a small and
trivial character are the
ones which strike
deepest in the grateful
and appreciating heart.”
—Henry Clay
none!
139,380 former
patients from 225 hospitals:
Press Ganey Assoc:
none
of THE top 15 factors
determining Patient Satisfaction
referred to patient’s health outcome
P.S. directly related to Staff Interaction
P.P.S. directly correlated with Employee
Satisfaction
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
“Kindness
is free.”
“There is a misconception that supportive interactions require
more staff or more time and are therefore more costly. Although
labor costs are a substantial part of any hospital budget, the
interactions themselves add nothing to the budget.
Kindness is
free.
Listening to patients or answering their
questions costs nothing. It can be argued that negative
interactions—alienating patients, being non-responsive to their
needs or limiting their sense of control—can be very costly. …
Angry, frustrated or frightened patients may be combative,
withdrawn and less cooperative—requiring far more time
than it would have taken to interact with them initially in a
positive way.” —Putting Patients First, Susan Frampton,
Laura Gilpin, Patrick Charmel
The 9 Planetree Practices
1. The Importance of Human Interaction
2. Informing and Empowering Diverse Populations: Consumer
Health Libraries and Patient Information
3. Healing Partnerships: The importance of Including Friends
and Family
4. Nutrition: The Nurturing Aspect of Food
5. Spirituality: Inner Resources for Healing
6. Human Touch: The Essentials of Communicating
Caring Through Massage
7. Healing Arts: Nutrition for the Soul
8. Integrating Complementary and Alternative Practices
into Conventional Care
9. Healing Environments: Architecture and Design Conducive
to Health
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Access to nurses station:
“Happen to”
vs
“Happen with”
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Griffin:
Music in the parking
lot; professional musicians in
the lobby (7/week, 3-4hrs/day) ;
5 pianos
volunteers (120-140 hrs arts &
entertainment per month).
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
;
Give
good
tea!
“Allied commands depend on
mutual confidence
[and this confidence]
is gained, above all
development
of friendships.”
through the
—General D.D. Eisenhower,
Armchair General*
*“Perhaps his most outstanding ability [at West Point]
was the ease with which he made friends and earned the
trust of fellow cadets who came from widely varied
backgrounds; it was a quality that would pay great
dividends during his future coalition command
Ike: An American Hero, Michael Korda:
“grin
that was to become so
famous” “got along famously” “goodwill was
“infectious grin and great charm”
“nice face”
spontaneous and easily recognizable” “good impression that
Ike had made in six weeks” [newcomer junior general to supreme commander,
Torch; Marshall-ADM King-Roosevelt-Churchill-British Chiefs of Staff]
“least rankconscious of generals” “Men were happy to serve under Ike,
even British admirals and generals who might easily have
raised objections. His sincerity and lack of ceremony made it
difficult, even impossible, to refuse him, and enabled him
very rapidly to pull a team together …” “Ike was
gregarious, rarely had anything bad to say about anyone,
and, on the surface at least, was relaxed and good natured.”
“Whereas Ike’s good humor was genuine, unaffected, and
affectionate, Monty’s [Field Marshall Montgomery] was cruel and
mocking and always carried a sting”
“Mandela, a model host [in his prison hospital room] smiled grandly,
put [Justice Minister Kobie] Coetsee at his ease, and almost
immediately, to their quietly contained surprise, prisoner and jailer
[It had mostly]
to do with body language, with the
impact Mandela’s manner had on
people he met. First there was his
erect posture. Then there was the
way he shook hands. The effect
was both regal and intimidating,
were it not for Mandela’s warm
gaze and his big, easy smile. … Coetsee
found themselves chatting amiably. …
was surprised by Mandela’s willingness to talk in Afrikaans, his
knowledge of Afrikaans history.” Coetsee: “He was a born leader. And
he was affable. He was obviously well liked by the hospital staff and
yet he was respected even though they knew he was a prisoner.”
Source: John Carlin, Playing the Enemy: Nelson Mandela and the Game that Made a Nation. (Mandela
meets surreptitiously with justice minister after decades in prison—and turns on the charm)
Excellence.
Always.
The choice is yours.
Geisinger Health System, in Danville, Pennsylvania; the
Marshfield Clinic, in Marshfield, Wisconsin; Intermountain
Healthcare, in Salt Lake City; Kaiser Permanente, in Northern
California. All of them function on similar principles. All are not-for-profit institutions. And all
have produced enviably higher quality and lower costs than the average American town
enjoys. When you look across the spectrum from Grand Junction to McAllen—and the almost
you come to realize that we
are witnessing a battle for the soul of American
medicine. Somewhere in the United States at this moment, a patient with chest pain,
threefold difference in the costs of care—
or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is
whether the doctor is set up to meet the needs of the patient, first and foremost, or to
maximize revenue.
There is no insurance system that will make the two
aims match perfectly. But having a system that does so
much to misalign them has proved disastrous. As
economists have often pointed out, we pay doctors for
quantity, not quality. As they point out less often, we
also pay them as individuals, rather than as members of
a team working together for their patients. Both
practices have made for serious problems.
“The Cost Conundrum: What a Texas town can teach us about health care,” by Atul Gawande,
The New Yorker, June 1, 2009
*No option: “Culture change”
*Experimentally-driven,
zero-based “Innovation machine”
*“Little big things”/K.I.S.S.
*Soaring aspirations driven by
towering human-development
goals
*Thoughtful human interaction, the
glue and key to “culture change”—
and, thence, organizational
effectiveness
*Choice/Excellence
Synonyms
Purity
Transcendence
Virtue
Elegance
Majesty
Antonyms
Mediocrity
“Excellence can be obtained if you:
... care more than others think is wise;
... risk more than others think is safe;
... dream more than others think
is practical;
... expect more than others think
is possible.”
Source: Anon. (Posted @ tompeters.com by
K.Sriram, November 27, 2006 1:17 AM)