Category: Healthcare

"Management" and the Affordable Healthcare Act

The implementation of ACA/Obamacare is a fiasco. PERIOD. It is so silly-bad that I've shied away from commenting on it—even though I'm supposed to know a bit about management. Well, I decided to "sorta" break my silence via Twitter. What follows is completely incomplete. It is not a theory or overall statement. It is merely a few thoughts on the topic of implementing the ACA. The original tweet is followed by a brief commentary in brackets [ ].

Herewith:

Because of tangles in legislation/existing regulation, not clear God could have implemented Obamacare. [Could it be impossible to implement? Maybe not a silly question. The law is the start—a unique hyper-complex hodgepodge, even by low legislation standards, in part because of the number of compromises made to get the votes needed for passage. Add to that the existing jungle of regs from hither, thither, AND yon that must be made to dovetail with the new legislation—this ain't no
Social Security or Medicare/Medicaid implementation; those were largely greenfield efforts, this is maxi-muddyfield implementation.]

Obamacare implementation should have been out of OMB, not HHS. ["All" agree that this administration has singularly failed to get excited about management issues—especially reflected by appointments. Nonetheless, taking this out of HHS and putting implementation on the back of the "management" agency would have been a help. Obamacare is NOT an HHS issue—it is a national issue of the highest strategic order.]

Only human being I can think of who could have implemented Obamacare on time: Lou Gerstner. [The former IBM turnaround boss is a management genius, tough as nails, "accountability" is his first/last/middle name, insanely smart, tech-savvy, used to minefields, experienced at managing hundreds of thousands of people, not afraid to speak truth to power, a mechanic who gleefully dives in four levels down as much as a strategic thinker. Among other things.]

Day full-bore implementation of Obamacare should have begun: Morning after bill signing. [The magnitude of the management challenge should have been immediately acknowledged and addressed. Frankly, we're still not there!]

Principal piece of "software" to guide implementation of Obamacare: Paper and pencil. [Of course a jillion lines of code are required, etc., etc., but the discipline of paper and pencil is to keep the top of the project management pyramid understandable.]

No acronyms at any level. [Talk English, not Bureaucratese. 100% of the time.]

Deadlines galore, at a micro- as well as macro-level. [Define/measure or bust.]

Obamacare project mgt should be: "Insane" on topic of rapid partial prototyping. Several demos demoed each week with top boss; repeat at every level of organization. [Keep it real. Keep it bite-size. Can be done, regardless of size/complexity of overall project. The bigger the project, the smaller the demoed bites.]

Implementing Obamacare: Any project's master plan and goals and deadlines can be reduced to two pages. [I fervently believe this.]

Hierarchy rules! [Yes, I'm an avowed fan of far less hierarchy than has been the norm—major reduction thereof is not optional given the speed of marketplace change. Nonetheless, in this project "clarity" and "accountability" are the watchwords. We need to know who's on first. Hence an org chart, no matter how frighteningly complex, is a necessity.]

Prime contractor should perhaps have had less rather than more government experience. Subcontractors should be minimized. [Subs on top of subs decrease implementation likelihood exponentially. I have the sense that the current contractor knows the Beltway too well. Frankly, I would have liked to have seen perhaps IBM as prime contractor.]

Daily Obamacare senior implementation review: No PowerPoint. No paper. Learn to reduce the hyper-complex to simple, Hemmingwayesque sentences.

Deadlines clear as a bell and readily definable/measurable and big consequences for missing them. [Penalty for inflating what's been done: firing after one warning of those involved, and major contractor penalties.]

Implementing Obamacare: Lou Gerstner in charge. Office in West Wing. Weekly report to President modeled after President's morning intel brief.

Project team main office on virgin turf. [Make this business-as-unusual. And keep it physically away from extant bureaucracies.]

The text here is also available in PDF format.

Engaging and Empowering Patients

Tom has been very outspoken about problems with the healthcare industry (a few examples). In August, he spoke at Harvard on a panel called Engaging and Empowering Patients for Quality and Safety, which was part of the Eleventh National Quality Colloquium: The Leading Forum on Patient Safety, Quality Enhancement, and Medical Error Reduction. His fellow panelists were Michael Millenson, author of Demanding Medical Excellence and president of Health Quality Advisors, Rajni Aneja, EVP of the Joslin Diabetes Center, and "e-patient Dave" deBronkart, former cancer patient and patient care activist. (To see the speeches, go to the end of this post for the links.)

All of the panelists are working toward a common goal, well summarized by the title of Millenson's book: Demanding Medical Excellence. Medical Excellence includes reduction of medical errors, greater quality of care, improved communication between patients and healthcare professionals, increased decision making power for patients, as well as the ability to manage their own care. While Excellence is an aspirational word, the current state of the healthcare industry demands more than interest in lofty goals. The statistics on medical errors are not improving, and it is extremely difficult to change the habits and practices of an entire industry. Not to mention the fact that you'd be hard pressed to find anyone who hasn't been frustrated or angered by a healthcare experience whether its their own or their loved one's.

(more…)

I Do NOT "Have It In" for Mass General Hospital! (Or at Least, Not Much)

Lunch at the Harvard Club in Boston. First time. Age 68. Friend in publishing. I idly mention I'm vaguely thinking about a book on "patient safety." Words barely out of my mouth when a story explodes from her about a relative who'd recently suffered a series of blunders, some agonizing, at a "leading med center" in Boston.

A week before I'd paid a visit to a company I work closely with in Washington D.C. Chatting with the president about this and that. Healthcare came up because I was in the area for a couple of medical appointments. Kaboom! From her mouth explodes a horror story regarding her 90+ mom at a "leading med center" in Northern Virginia, which, like Boston, is chock-a-block with "leading med centers."

And then there was the recent dinner with fellow-sorta-oldies when health arose. (As it usually does these days.) In a flash, pretty much unbidden by me in this instance, every one offered a story of rather recent major med center f___-ups. (This may have been the 10th time this ritual has occurred—so far, alas, I'm batting 1.000. EVERY ONE in my un-scientific sample has offered a RMHFS/Recent Major Hospital F___-up Story involving themselves or someone close to them.)

My own: At a "leading med center" in Boston, was seeing an internal medicine guy of significant repute. Go over everything in an hour-plus intake interview—including, obviously, my pacemaker.

He calls up my electronic records (hooray!) and finds a heart test with questionable results. He wants to follow up ASAP, and, at 5:30 p.m. orders an MRI for 7 a.m. the next morning. Some of you will sputter at that. I didn't (great responsiveness on his part, novel indeed!); or at least I didn't until midnight when I woke up with a start and did sputter, "Holy shit, pacemaker patients can't have MRIs." I quickly went on Google and confirmed what I was 99% sure of; we can have MRIs if a cardiologist is in attendance and if, as I recall, the pacemaker has been turned off‐otherwise a high chance of fry city!

Oh, and I forgot one other thing. As I said the test the EMR system spit out indicated a problem. Well, another doc who'd ordered that test a year before had immediately ordered a follow-up which had been clean. But, um, the EMR system which had coughed up the 1st test had inexplicably failed to spit out the results of the follow-up test which was clean—at the same hospital, of course. Hence, the doc who subsequently ordered the unsafe test for me was dealing with incorrect (incomplete) data provided by the electronic medical record system.

A twofer. Screwed-up EMRs. Dumb-ass "famous" doc at "leading med center" who'd ordered a test that could have caused significant harm. He is no longer my doc. One of my friends who is a leading cardiologist was appalled—he suggested that I "do something about it," but I declined.

(But back to the Harvard Club. I'd come to Boston from Vermont for a med visit. A 350-mile round trip. Office I'd been to before. A small procedure to be done. Except, though it was in my records, they'd forgotten to write me an order for the monster antibiotic I needed to take before I came. Must do it to prevent problems that might occur, thanks, again, to that pacemaker. Whoops, 350-mile round trip pissed away!)

Enough!

I've been studying patient safety for going on 10 years. The story is appalling. Hundreds of thousands of unnecessary deaths each year in the USA alone. And the story overseas, as far as I can tell, is much the same. And then there are the millions of blunders that are not fatal. And the millions of mis-recorded or mis-interpreted prescriptions. And the recent article that says we under-count med errors by a factor of ... 10. And the un-recorded more jillions of blunders in doctors' offices.

(I've also studied the failure of docs to follow standard protocols, which comes more or less under the heading of "evidence-based medicine"—lack thereof.) (And I've studied unexplained bizarrely high differences in procedure rates from one town to the next with similar demographics.) (And I've studied over-testing and over-treatment that in the USA causes huge harm, not to mention over a half-TRILLION dollars in annual healthcare costs/waste.) (And studied the charming practice of "inventing diseases" followed upon occasions by pharmaceutical companies.) (And, speaking of pharmaceutical companies, one of my wife's best friends, at Johns Hopkins, is a/the leader in the effort to get pharmaceutical companies to report all their trials data, not just the data from the trials that support their pre-ordained conclusions.) (Etc.) (Etc.)

Often I have to pinch myself, the stories are so horrendous. Sometimes I tear up. And I am, I admit, pissed off 100% of the time. Yup, I was long one of the dumb-assed bastards who was nutty enough to think that the folks in the white coats had their collective heads screwed on right—or at least screwed on.

(Oh, meant to tell you I had leukemia one weekend about a year ago. Yup, the lab had blown the blood work. Re-test fine. Phew. And did I tell you that my doc hasn't suggested to me—age 68—in two years that I might want to have a physical? Well, stupidly, I haven't had one, though on my own I have a doc pal prescribe blood work about every nine months which he then reviews.)

Back to "leading med centers"—the evidence shows that they rank high on the lists of sinners on these issues. They often are chock-a-block with genius specialists who indeed perform near miracles (good on them!!!), but I always wonder if, on net, these famous places do more harm than good. It may not be true, but it's not a wholly lame hypothesis.

(NB: Don't get me wrong, I'm sure most healthcare workers "care." But so did the UAW guys who were making defective cars in the 70s. Caring is nice. Caring is not enough.) (Well, sadly, I'm not all that sure on the "most care" dimension. My wife's mom was just at a "leading med center." Her assessment: "They got the work done, but there was nary a sign that they cared about what they were doing"—but that's just one datum.)

At any rate, the night after the wasted 350-mile trip and the productive and enjoyable lunch at the Harvard Club, I stayed at Boston's Liberty Hotel, which happens to be about 50 yards from Massachusetts General Hospital. The next morning I went out for papers, and as I came back to the hotel I found myself amidst a shift change at Mass General. The folks looked lively and intelligent. Nonetheless, I got to wondering—maybe triggered by the lunchtime tale of woe and/or the futile 350-mile trip. And I turned my "got to wondering" into a series of rather harsh, though from the heart and not unwarranted, tweets.

Herewith:

See employees pouring into Mass General: Wonder how many will be party to NON-patient-centric, UN-safe acts?

Employees pouring into Mass General: Will help-to-harm ratio be > 1.0?

Employees pouring into Mass General: What % docs will treat nurses, techs as the equals they are?

Employees pouring into Mass General: Wonder how many will be party to UN-necessary tests per statistical likelihood of usefulness?

Employees pouring into Mass General: Wonder how many will be party to UN-necessary surgeries per statistical likelihood of usefulness?

Employees pouring into Mass General: Wonder if ER will be as ILL-managed as usual?

Employees pouring into Mass General: Wonder how many specialists will give two thoughts to the rest of the patient's body?

Employees pouring into Mass General: Wonder how many WRONG-med-doses or WRONG-meds-per se will be administered?

Employees pouring into Mass General: Wonder how many arriving non-ambulatory patients will be accompanied by some sort of advocate?

Employees pouring into Mass General: Wonder how many patients will be given courses of treatment IN-consistent with generally agreed-upon evidence?

I have NEVER BEEN a patient at Mass General. Hence these queries (which all, in effect, start with "I wonder") are not aimed at Mass General per se. As I said in a follow-up tweet, if I'd been staying at a hotel near some other "leading med center," I would have said the exact same thing with its name substituted. (NB: One close observer of this scene suggests that if you want the best results on safety, go to "St. Elsewhere." Or, I'd add, if you qualify, a VA hospital—the VA is perennially tops in almost all patient safety categories.)

(Fact: I've only had ONE de facto direct Mass General encounter. I must say, in all fairness, it was ... HORRENDOUS. It was my wife's ER experience following her slipping and breaking her ankle. Five hour mid-day wait—she was told by a tech, and I do not jest, that she was lucky the wait was so short. All five hours on a gurney in a charmless/chaotic/very public corridor amidst very sick people and ceaseless hubbub. Virtually no staff contact other than less than two minutes with a harried staff doc who said, "We'll have to get an x-ray"—for that she went to med school? Extreme pain, five hours with no palliative—not even water for the 1st two or three hours. Subsequent X-ray guy on loan from another hospital's staff; he was (VERY) un-necessarily rough. And nobody who really seemed to give a shit—don't get me started on "patient-centered care," virtually total lack thereof. I am, of course, dead certain that July 2009 experience does not color in any way my view of Mass General. At an American Hospital Association meeting a few weeks after my wife's "experience," I said I thought the "leading med center"—I didn't ID them, though everybody figured it out—CEO "ought to be fired." ERs are a bitch and lose money, I acknowledged, but the dude signed up to be CEO of the whole hospital, so it's his problem 100%.)

Enough! I could write a book! Maybe I will. Title already picked, taking off from In Search of Excellence: Lessons from America's Best Run Companies. This one: In Search of Excellence: Lessons from America's Safest Hospitals"—yup, there are some who do this stuff incredibly well!!

(FYI: My favorite response to the tweets came from a friend I'd sent the set to. He is one of the USA's most renowned docs. Said he'd laughed and laughed and that he and his wife had picked their favorites, which he sent on to me. Nice!) (No, it wasn't Don Berwick, more or less father of the patient safety "movement," but it sure as heck might have been. Currently, Dr. Berwick is trying, as top dog, to introduce this stuff into Medicare-Medicaid. My favorite Berwick-ism on the topic of patient safety: "When I climb Mount Rainier I face less risk of death than I'll face on the operating table"—Berwick's safety crusade was largely triggered by mistreatment his wife received at a "leading med center" in, uh, Boston; he was a Harvard Med School guy.)

I am pretty ineffective in declaiming on this topic. To be an effective speaker one must follow the dictum of John Knox: "You cannot antagonize and influence at the same time." I ordinarily slavishly follow that rule—but on the topic of patient safety I have no sense of humor at all.

Idiosyncratic reading list:

Best Care Anywhere: Why VA Healthcare Is Better Than Yours, Phillip Longman
Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe, Sorrel King
Safe Patients, Smart Hospitals: How One Doctor's Checklist Helped Us Change Healthcare From the Inside Out, Peter Pronovost & Eric Vohr
Putting Patients First: Best Practices in Patient-Centered Care, Susan Frampton & Patrick Charmel
Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, Shannon Brownlee
Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson
Hardwiring Flow: Systems and Processes for Seamless Patient Care, Thom Mayer and Kirk Jensen
Inviting Everyone: Healing Healthcare Through Positive Deviance, Arvind Singhal, Prucia Buscell, and Curt Lindberg

NB: Ho hum, and just off the wire, as I write this, from the Journal of Internal Medicine: "Medication errors are the second-leading cause of accidental death, and the only kind of accidental death that is increasing over time." As I said, ho hum.

Little BIG Video #40
Strategy: Sock Solution

In video number 40 from The Little BIG Things Video Series, Tom asks us to look for solutions that are astonishingly powerful, yet astonishingly unsexy.

You can find the video in the right column of the front page of tompeters.com or you can watch the video on YouTube. [Time: 2 minutes, 54 seconds] You can also download a PDF transcript of the video's content: Strategy: Sock Solution.

The Grameen Lesson?

When Nobel Peace Prize winner Muhammad Yunus began his micro-lending efforts at Grameen Bank in Bangladesh, he had no preference as to whether loans went to men or women. To make a long story very short, male recipients often frittered the money away (alas, drank it away in many instances), while women overwhelmingly devoted their loan proceeds to their business, their family, and their community. As a result, through trial and error, Grameen has ended up with over 90% female recipients. (This is all the more startling given that Bangladesh is a Muslim country.) (And the story has been repeated, pretty much chapter and verse, elsewhere by Grameen and others.) (In the NGO aid-dispensing business, it's a given that getting the local women's network on your side is a 100.00% necessity.)

All this got me thinking about the controversial new healthcare bill. Women pretty much everywhere are the principal decision makers in family affairs. And, among other things, they make upwards of 80% of family healthcare decisions. (Actually about 90%, but I'm being conservative.) Moreover, the old saying goes, as you get older you had better hope that you had a daughter; when it comes to old-parent affairs, "boys" are notoriously, uh, not "girls." (I've observed this numerous times; and I am stepfather to two boys; and I am non-young.)

Oddly, most of the polls on the healthcare legislation were not divided by gender. But the two readings I did get, courtesy Newsweek and Princeton Research Associates, did not surprise me. In short, women were 12% more favorable in one case and 20% more favorable in the other (in the latter, women were +14%, men –6%). Also, alas, it doesn't take a genius to recognize that most of the intemperate public remarks came forth from the mouths of males. (The most memorable women's quote on the House floor, to my mind, went more or less, "With this bill, being a woman will no longer be a 'pre-existing condition.'" Insurers in several states, nine as I recall, tag spousal abuse as a pre-existing condition.)

There is honestly no "bottom line" to this post; but as I have been vociferously championing women's issues (women as underserved market opportunity #1, women in leadership positions in greater numbers to match market power) for about 15 years (pretty much the only "guru" to do so), I simply wanted to see how it played out in healthcare legislation.

(NB: God knows, I'm not claiming that men don't care about their families. I am suggesting that men are less likely, far less likely, to be decision-makers concerning family issues.) (In the Grameen case, it's, of course, a little more extreme than that.)

Dear God!

So my aunt, age 94 (??), being treated for a little lung goop with meds. (No such thing as "little" at that age.) Apparently it's getting better but not 100%. She goes to see a doc and he says she'll need surgery. (Big deal for any of us, VERY big deal at her age.) She insists on X-rays first. X-rays performed. She goes back to doc, asks if she needs surgery. His answer: No.

Why the hell did he quick trigger on a major diagnosis for a 94-year-old w/o "simple" evidence? Bastard!

Same aunt, some joint trouble. (Ain't it true of all of us post-55.) Referred to physical therapist. Referring doc says she'll need to stay in med facility for several days, not return to her small condo in assisted living center. She sees therapist, asks why she can't go home, describes her place in great detail. He says, "Of course you can go home."

What I've just described is inexcusable medical practice, especially for a 90+ patient, where odds of problems from surgery or significant in-patient stay are sky high; hence one should be twice as careful in making diagnosis.

Classic-garden variety outcome where overtreatment would most likely have been the result if she'd not been at the top of her game. Most, half her age, wouldn't have made the enquiries she made.

Alas, health reform package barely touches on this.

Health Care:
Must Read

Winter at the Farm

Best thing I've read so far. T.R. Reid, The Healing of America: Global Quest for Better, Cheaper, and Fairer Health Care. Reid takes us on a global tour. Among other things, in many countries with "universal access," the programs are anything but "socialist"—available choices often beat ours, and the free market plays the lead role.

(Above: Winter "on the farm" in VT ... the real thing!)

Maybe …

Maybe all the bitching about the ephemeral economy is justified. And the death of non-virtual (real) stuff, that is, manufactured stuff that absorbs lots of jobs, is a fact-of-life.

Yesterday, the Wall Street Journal (I think—four consecutive midnights in the air, remember) reported the amazing and wildly increased share of our gross domestic profits that come from financial services. Today's Financial Times comments on new cars, labeled by the headline writer "a shiny new software appmobile." The author, Chris Nuttall, reports "a new iPhone app from Ahamobile allowing drivers to record 'Caraoke' [sic] singalongs to the car radio and post them straight to their Facebook page."

Dear God—that's, in effect, Mr. Nuttall's response as well.

I read awhile back an analysis that suggests that our "age of abundance" only dates back perhaps 40 years. That is, in the OECD nations at least, we've pretty much all got all the stuff we need and are "reduced" to consuming non-necessities. Maybe that's it, an economy that produces mainly, mostly, almost totally ephemeral things we don't need. Hence huge amounts are spent on healthcare (with not much improvement in health), financial services scarfs up huge bucks for, often, doing absolutely nothing (derivatives of derivatives of derivatives) and "high tech" that lets us "record 'Caraoke' singalongs to the car radio and post them straight to their Facebook page."

Think about it.
I am.

(NB1: When I landed in Boston at about 1:00 a.m. yesterday, literally, at 1:00 a.m., all 9 people I could see were checking their email within 30 seconds of wheels-on-the-tarmac. [Yes, no kidding, 9 for 9—and me feeling bad because I wasn't.] I'm right, right: Talk about the absolutely-totally-completely un-necessary! Age of Abundance indeed!)

(NB 2: A friend had prostate surgery recently, a bright and technologically brilliant guy. He went on and on about the robotic surgery he'd decided upon. Statistically minimal side effects, etc. Well, yesterday's Boston Globe reported a new study from the Harvard Med School concluding that nasty side effects from the robotic procedure are twice as prevalent as side effects from old-fashioned knife stuff. One more time our medical profession's passionate love affair with very sexy stuff scores. This time, incontinence and impotence are the winning lottery ticket.)

AHA Redux:
A Matter of Leadership!

I began my remarks to the American Hospital Association last week with an outline of the situation as I saw it. I called the outline "Principal Management & Leadership (as opposed to Policy) Issues." That is, it was-is my contention that hospital leaders have a choice; they are beset with constraints (aren't we all?), but such constraints do not keep some enlightened folks from performing miracles—management and leadership miracles!

Herewith my outline, also included in the slides attached to my previous post:

1. Should we be doing what we're doing? Will it work? How do we know? [In a surprising # of cases, it's not clear whether "X" or "Y" is the most effective treatment for a particular problem—e.g., my 2005 ablation vs taking a pill. "Evidence-based medicine" and "comparative effectiveness" research, ticketed to receive major federal funding, are part of the answer. And controversy is huge; i.e., who's to judge?]

2. Are we doing what we decide to do safely? [Various studies suggest that in the U.S. there are several hundred thousand preventable hospital deaths per year—again, some of the stats are very controversial.]

3. Do we do too much—are we in the "overuse" category as determined by agreed upon standards-measures? [It is "generally agreed" that perhaps $750 billion is spent annually on unnecessary tests and treatments—a "piecework" ethos, by the procedure payment, is the major culprit.]

4. 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? [This ought to be a "no brainer"—it's not. A revolution is required here—and it has damn little to do with the insurance payment process, though some would disagree.]

5. Is the institution systematically organized to very consistently deliver the goods in a more or less optimal fashion (low variation in outcome)? [There are a thousand experiments in process, but true systemically organized processes with clear measures and accountability are, alas, rare.]

6. Do all the bits talk to-engage-consult "obsessively" with the other bits? Is the delivery of services truly a turnkey team effort? [Cross-functional communication is arguably enterprise issue #1; in healthcare it's about as bad as it gets—the normal problems are compounded by the hospital "class system," with docs at the tippy-top, and no one else even a close second.]

7. Are the patient and the patient's family at the epicenter of the universe? [Bizarrely, the answer is a resounding "no" in 9 cases out of 10.]

8. Is our institution acknowledged as a "best place to work"? [13 of the top 100 places to work in the U.S., per Fortune, are healthcare institutions—i.e., it is possible!!]

9. Do we acknowledge that people issues-capabilities involving the entire staff affect outcomes far more than capital-technology issues? [For lots of reasons, re-imbursement included, many hospitals are "technology crazy"—owning the latest stuff is more important than ascertaining its usefulness.]

10. Is sustained follow-up at least as much a priority as the "event" itself? [Post-op follow-up and chronic-care are both poor cousins in general in the hospital system setting. Again, the payment system is a culprit—but some manage to do it.]

11. Were we/Are we successful in terms of outcome-quality of life-patient satisfaction with the overall "experience"? [This obviously should be the primo concern—for a host of reasons it's not.]

12. Are all connected with all via an effective electronic network that extends from EMR to Social Networking? [Still not the norm!]

13. 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.) [Of course, a health bill changes things—but, fact is, if the determination is there, and it is in some instances, a committed leadership team can move miles and miles down the road specified 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)? [SOME ARE DOING IT DAMN WELL UNDER TODAY'S CONSTRAINTS—AND THEY ARE IN AWFUL SETTINGS AS WELL AS BETTER OFF SETTINGS. "IT" CAN BE DONE—IT IS BEING DONE!]

Health Forum/American Hospital Association

On Thursday I had the great privilege of being a keynote at the Health Forum/AHA conference in my beloved San Francisco—putting "feet on the ground" there always sends my spirits soaring. While the health bill, or the likelihood of something, was on every mind, my job was to talk about leadership, regardless of the shape of any legislation. In fact I obsessed on the idea of "your choice"—the idea that incredible amounts of progress were possible in any case. Proof more or less positive is the variance that exists in the system we have today, in spite of existing ass-backwards incentives that reward "piece work" (pay-per-procedure) rather than outcomes and quality-safety. Organizations like Geisinger in Danville PA, Mayo in Rochester MN, Dartmouth-Hitchcock in Hanover NH, and Griffin in Derby CT do wonders already in terms of quality, safety, minimization of unnecessary tests and procedures, and putting the patient and patient's family first.

My main thrust was "controlling what you can control" and creating an "experimentation machine"-"innovation machine" (and a "culture" that supports it) devoted to "letting 1,000 flowers bloom" as the way forward in creating and designing systems that promote 100% employee involvement, patient-patient family engagement, safety, quality, elimination of variation in outcome, and the like. I avoided my usual hectoring (the nature of the likes of quality-safety is now more or less accepted), and urged "getting on with it" ASAP.

I have rarely felt so engaged and have rarely so enjoyed myself—as to impact, the proof will be in the doing. (Glenn Steele, CEO of Geisinger, was immeasurably helpful—he joins my "hero entrepreneurs" shortlist, next to the likes of Teach For America's Wendy Kopp!)

Attached you'll find my PowerPoint presentation; it's less helpful than usual, since so much of the tone was beyond the slides.

PPT is attached.