Healthcare & Technology

What is Expresso and why should I care?

A Risk Assessment is a process by which an Organization identifies:  (1) Threats to the Organization (i.e. to its Operations, Assets, or Individuals); (2) Vulnerabilities internal and external to the Organization; (3) The harm (i.e. adverse Impact) that may occur given the potential for Threats exploiting Vulnerabilities; and (4) The Risk associated with a specific Threat, Vulnerability and Impact combination.

Although a definition of Risk Assessment is helpful and required, we also need to clearly understand the cybersecurity context in which we all now operate. We have become jaded by the daily announcements of massive data breaches and their consequences. So much so that it appears that providing a hardened cyber defense may be a hopeless task. Expresso^TM takes on this challenge head on by reducing the complexity associated with performing Risk Assessments.

Expresso^TM is Software-as-a-Service ("SAAS") built upon industry best practices and a world class Risk Management Framework[1] developed by the National Institute of Standards and Technology (“NIST”)[2]. Expresso^TM takes a complex problem and clarifies its implementation so that Risk Assessments can be readily understood by the masses—without the need for the masses to become information security professional. 

To learn more, visit the HIPAA Survival Guide Expresso^TM Product page and watch the following Video.

 

[1] See generally NIST Special Publication (“SP”) 800-39 (“Risk Management Framework”).

[2] NIST is the organization that provides cybersecurity advice and guidance to U.S. Government (“Government”) agencies.

 

HIPAA Audits: OCR becoming aggressive!

OK, so why now?

The HHS Office for Civil Rights (OCR) reports that settlement payments last year were $25.6 million[1]. Subsequently, they are reporting there will be an increase in HIPAA compliance investigations. With resources from settlement fines, OCR believes the industry has had adequate time to develop complete data security policies and procedures. Unfortunately, healthcare organizations are still lagging. But take notice there will be a higher number of investigations by OCR in 2017. That’s more than enough to ruin a good day.

To make matters worse, OCR is not always consistent with its audit process. In some cases, inspections occur over years during which the rules can change. Covered Entities (CEs) and their Business Associates (BAs) must conduct Risk Assessments on a regular basis to ensure compliance. That said, there is no definition of what a ‘regular basis’ means, or what entails a ‘comprehensive Risk Assessment’. They’re not saying HOW to do it, just do it.

Not surprisingly, OCR’s perspective on compliance is “sometimes a matter of judgment on the language in pertinent regulations.[2] ” More funds collected fosters expectations that OCR may increase the number of audits with additional resources funded by received settlements.

[1] Goedert, Joseph. "Why OCR is aggressively enforcing HIPAA compliance." Health Data Management. Source Media, 1 Dec. 2016. Web. 16 Dec. 2016.
[2] Ibid.

Should healthcare be allowed to Block Information?

Update 11/18/2016   Why interoperability is crucial in radiology http://www.healthdatamanagement.com/opinion/why-interoperability-is-becoming-more-important-in-radiology

It’s not just the intellectual capital of vendor products or the need to ensure the security of PHI, or to maintain patient confidentiality; there are very real needs to share data securely among systems (and providers) for the benefit of decisions made on behalf of patients. Clearly, there is no single standard in healthcare, nor does semantic interoperability exist. What does the Security Rule say about flexibility in its implementation? HIPAA regulations for security of PHI is required. Is flexibility in the rule to enable the flow of information between providers, or integration, that can be enabled to provide improved quality of care for patients? Take a listen to Carlos on the Security Rule Flexibility Principle (and visit HIPAA Survival Guide on YouTube for other short videos).

An a recent article in Health Data Management, it stated “IT vendors are not helpful when it comes to integrating.” They either require complex Application Programming Interfaces (APIs), “flatly refuse to transmit the data,” or require additional fees for exchanging data. Also, in my experience, providers were required to purchase additional software for secure transmission of health data. Why are there so many ways to get from point A to point B? It’s expensive, time consuming and an uphill battle at best.

The Centers for Medicare and Medicaid Services (CMS) is promoting full interoperability even though it was NOT part of the attestation of certified EHRs at the onset of Meaningful Use nor its subsequent updates. CMS has sponsored “a major PR effort to get vendors to sign the toothless Interoperability Pledge” plus the MACRA rule now requires that providers attest to “not blocking information.” Providers have previously complained that EHR vendors were unwilling to share data or they charged cost prohibitive fees to make sharing possible. [i]

There are situations where the need for claims information is necessary for patient conditions, and a vendor has required significant programming efforts before enabling integration. Why continue these practices? Not only are they difficult to address, but in many cases (and in this example) may negatively impact decisions by practitioners due to lack of a complete medical history. 

Moreover, lack of common semantics is a key inhibitor to interoperability. Without a single standard at the granular level of patient data, too much time is spent assimilating data from various formats into a single standard. Health Data Management says “we’re not talking about producing breakfast cereal.[ii] HIMSS Electronic Record Association reported that “Value-based payment and delivery system reform remains the biggest driver of interoperability.”[iii] Let’s hope that is the case. 

Lack of interoperability and its resolution is long overdue. Fortunately, ONC Health IT Certification Program recently passed Enhanced Oversight and Accountability and amended the Public Health Service Act (PHSA) to create “Title XXX – Health Information Technology and Quality” (Title XXX) to improve health care quality, safety, and efficiency through the promotion of health IT and electronic health information exchange.[iv] It’s like Mother telling Child. You must do what I say or there will be consequences. Yes, the ONC can take certification away from those who do not comply. Is this what we need to exchange or share healthcare information – a big stick approach? Seems that way.

[i] Gue, D’Arcy Guerin. "HIT Think Is Information Blocking Finally on Its Last Leg?" Health Data Management (2016): n. Web. 17 Nov. 2016.

[ii] Ibid.

[iii] "Interoperability in Healthcare FACT SHEET June 2016." HIMSS. HIMSS Electronic Record Association, June 2016. Web. 17 Nov. 2016.

[iv] "ONC Health IT Certification Program: Enhanced Oversight and Accountability." Federal Register. Office of the National Coordinator for Health Information Technology, Department of Health and Human Services., 19 Oct. 2016. Web. 17 Nov. 2016.

Are you ready for your HIPAA Audit? It’s coming soon in full force.

The Office of Civil Rights (OCR) has launched Phase 2 of their HIPAA Audit Program, seeking to expand its scrutiny to a much broader array of HIPAA-covered entities and business associates. In Phase 2, OCR will contact Covered Entities (“CE”) and Business Associates (“BA”) to perform desk or onsite audits that comprehensively examine data security practices and compliance with HIPAA privacy and security rules.

Until recently, smaller CE’s have not been a primary focus of OCR attention but now, with this “across-the-board auditing,” CEs and BAs of all sizes will undergo the possibility of HIPAA Audits. This changes the game for those who have ignored the possibility of HIPAA audits in the past. Now, organizations must get their “house in order” to ensure that a Risk Assessment has been performed, Risks are identified, and mitigation policies and procedures, put in place to avoid enforcement actions – many of which can be significant. “HIPAA fines are on the rise and getting larger.”[1] In addition, CEs are required to obtain satisfactory assurances that their BAs are complying with the Security Rule.

Implementing HIPAA compliance begins with a Baseline Risk Assessment that identifies areas in which CEs and BAs have high Risk exposure due to lack of policies, procedures and Security and Privacy Rule compliance. A Risk Assessment is one of the implementation specifications of HIPAA Security Rule—but by far, arguably the most important.

In addition, subsequent Risk Mitigation includes review and implementation of security controls that mitigate identified risks. Possible items may include encryption, employee training, governance of login credentials and security. Moreover, the Security Rule requires documentation for each implementation specification and a written sanction policy. The Privacy Rule requires a log of restriction requests made by patients as well as a log of PHI, access, amendment, and disclosure requests. The Breach Notification Rule requires documentation regarding how the HHS Secretary should be notified in case of a breach. The Omnibus Rule mandated changes to notice of privacy practices and introduced other modifications to the HIPAA Rules. Suffice it to say these regulations are non-trivial. Management must make compliance, their risk assessment and its mitigation efforts, a high priority in addition to ensuring that the right solutions are implemented.

OCR is committed to transparency about the process by posting the updated audit protocols on their website.  “The audit protocol will be updated to reflect the HIPAA Omnibus Rulemaking and can be used as a tool by organizations to conduct their own internal self-audits as part of their HIPAA compliance activities.”[2] Gathering an inventory of security objects (i.e. operations, assets, and workforce members) that create, access, maintain and/or transmit PHI, is foundational to Security Rule audit preparation.

Commercial off the shelf products may be helpful to the implementation of the Security Rule’s Safeguards. If a CE or BA is out in the Risk Assessment wilderness with manual reviews or only paper documents and spreadsheets, or no documentation at all, take a look at Expresso’s Risk Assessment software and all of the Risk Mitigation products available at The HIPAA Survival Guide. “Now that the stakes have changed, those who are unwilling or unable to adhere to HIPAA data security rules threaten not just their own businesses, but those of the public, including yours.”[3] 

[1] Robertson, Cam. "Why HIPAA Audits Raise the Stakes for MSPs as Well as Providers." Health Data Management. N.p., 06 Oct. 2016. Web. 06 Oct. 2016.

[2] "OCR Launches Phase 2 of HIPAA Audit Program." HHS.gov. HHS Office of the Secretary of Civil Rights, 2016. Web. 06 Oct. 2016.

[3] Robertson, Cam. "Why HIPAA Audits Raise the Stakes for MSPs as Well as Providers." Health Data Management. N.p., 06 Oct. 2016. Web. 06 Oct. 2016.

Population Health in Crisis: Patient Care Management

Where do nurses and doctors find the time to provide care beyond the office walls? Given the fragmented nature of the U.S. healthcare system, healthcare providers have increasingly implemented Care Management programs aimed at coordinating the care patients receive to improve quality, reduce per capita cost and improve access to care. Traditionally, coordination interventions follow from several perspectives: medical versus social; short-term episodic or acute care versus chronic and long-term care; and various points of access to the patient (e.g., patient targeting to find those in need of high-intensity services, managed care organization, or physician office practice).[i] 

Care Coordinators (a.k.a. Care Managers) provide outreach to at-risk patients to ensure they receive specialized attention related to needed services. They are a key liaison between the patients and their primary care providers. The general intent is to facilitate delivery of the right health care services in the right order, at the right time, and in the right setting.[ii] Recently, care coordination programs have gained a stronghold where managed care organizations, commercial vendors, academic medical centers, and private health insurers sought to implement mechanisms aimed at controlling costs, improving disease outcomes, quality of care, and patient satisfaction.[iii]

At a high level, a 2000 report, entitled, “Best Practices in Coordinated Care,”[iv] made the following five recommendations for Care Management programs:

1. "Programs should follow the three steps: Assess and Plan, Implement and Deliver, and Reassess and Readjust for all enrolled patients;
2. Programs should have express goals of prevention of health problems and crises, and of early problem detection and intervention;
3. Disease-specific programs should incorporate national evidence-based or consensus-based guidelines into their interventions;
4. Care coordinators should be nurses with at least a bachelor's degree in nursing; and
5. Programs should have significant experience in care coordination and should have evidence of having reduced hospital use or total medical costs."[v]

Care Management software comes in various shapes and sizes. Many fill the needs of Clinically Integrated Networks of Hospitals, Clinics, and practices; others come in smaller sizes to meet the needs of small practices. One such package is Stone Health Innovation’s Idea Care. Regardless of the size, certain capabilities should be part of the care management software solution as described below.

Care Coordination Components[vi] should include:

1. The ability to perform a clinical assessment.
2. Develop a Nursing Proactive Plan of Care (POC) separate but approved by the Physician.
3. Identification of participants in the patient’s care and their roles. This also includes those who are not authorized to view or speak to clinicians about the patient’s personal health information (PHI).
4. The ability to communicate to all team members, including patients and their family.
5. Ensure secure information exchange in communications and across care interfaces. Prevention and mitigation of interface issues for transitions and handoffs between settings of care.
6. Provide the ability to monitor and adjust care goals.
7. Evaluate health outcomes – a principle target. Also, identify issues in coordination and care that may impact outcomes.
8. Ensure ability to utilize standard protocols, evidence-based guidelines, self-management programs, and routine reporting and feedback.

Information provided herein serves as development for a working definition that may be a helpful step for others attempting standardization in the area of Care Coordination. Interventions can be demarcated by type that includes not only use of software, but also educational brochures, mailings and member letters, telephonic care management, in-person care management, call centers and self-monitoring devices. Providers may find patient profiling and reports that originate from registries and clinical information systems, electronic medical records, decision support and other electronic communication systems useful. The Agency for Healthcare Quality and Research (AHRQ) published research on care management entitled “Measuring Value in a Care Management Program.“[vii] AHRQ claims that a measurement strategy is critical for determining the value of a Care Management program and to ensure effectiveness in reaching its goals.

 

[i] McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.) 2, Background: Ongoing Efforts in Care Coordination and Gaps in the Evidence. Available from: http://www.ncbi.nlm.nih.gov/books/NBK44011/

[ii] Ibid.

[iii] Ibid.

[iv] Chen A, Brown R, Archibald N, Aliotta S, Fox PD. Best practices in coordinated care. March 22, 2000 [Accessed: January 30, 2006]; Available from: http://www .cms.hhs.gov /DemoProjectsEvalRpts /downloads/CC_Full_Report.pdf. [Reference list]

[v] Ibid.

[vi] McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.) 3, Table 6: Components of Care Coordination. Available from: http://www.ncbi.nlm.nih.gov/books/NBK44012/

[vii] By Using Structure, Process, and Outcome Measures, a State Can Ensure That It Is Receiving a Complete Picture of Its Program's Value., AHRQ. "Section 7: Measuring Value in a Care Management Program." Agency for Healthcare Research & Quality. U.S. HHS: Agency for Healthcare Research and Quality, 2014. Web. 13 Sept. 2016.

Population Health in Crisis: Patient Engagement

In my first post in this series on Population Health, I stated that EFFECTIVE PATIENT ENGAGEMENT IS ALL THAT MATTERS. There is simply nothing more important than the patient if you are trying to deliver higher quality of care at a lower cost for a population of patients. When clinicians are dealing with many patients they generally do not have the time to effectively educate each individual patient in a manner that may help improve their wellness.

For example, patients with Diabetes require education about exercise and the kinds of foods that are suitable for someone with their condition. Likewise,there is a need to teach all patients, but especially those with comorbidities the importance of staying in compliance with their medications. The list can go on and on. 5-10 minutes with your doctor every three months will never suffice vis-à-vis the kind of information needed to support wellness. 

Almost everyone is using the Internet to search for articles on their conditions, however; often they may encounter information that is inaccurate for their specific circumstances. Nurse note here... “It is always best to check with your Doctor or Nurse” – but they may not be available when the patient needs a question answered. Now we have the role of the “care manager” in population health. The healthcare industry recognizes this obvious need but is struggling how to fulfill it.

One thing is certain as we have discussed before, conversations with the patient cannot take place in a multiplicity of places (e.g. patient portals for every specialist). It has to take place in one virtual space or it won’t take place at all. But, how is this possible if every doctor wants to use their own distinct virtual space to communicate? Enter a visionary startup Docola, whose platform allows the conversations to take place in a single virtual space no matter how many clinicians are treating the patient.

Using Docola’s Platform (or something akin to it) the conversation becomes centralized across all care providers. Care coordinators are able to pull the requisite patient information from multiple EHRs and other data sources to effectively educate the patient. In fact, Docola’s Platform is, among other things, a patient education platform. Now clinicians can choose from world-class clinical content publishers the educational courses that have the potential to make an enormous contribution to patient education, while at the same time ensuring that the patient conversation takes place.

The certainty of this approach for patient education is self-evident. The reason that we have not seen this type of system receive widespread success is that the healthcare industry, despite recognizing the need and potential of this type of Platform, is struggling to develop the business model(s) that would make it work. In short, the industry is struggling mightily to remove the shackles placed upon it by Fee-For-Service. However, disruption is coming.

Population Health In Crisis: Lack of Communication

It is not the Internet, or the Internet of Things, or Big Data, or analytics, or a host of other technologies that are foundational to population health that will eventually transform healthcare. These technologies may be necessary, but they are certainly not sufficient. No, what will drive transformation is the way in which the medium will improve conversations that take place between human beings (i.e. between providers and patients). The improved human dialog is the change agent.

We need to insert the patient into the equation. Although this may seem obvious, it is one that the FFS model has ignored for well over 100 years. Everything else was a distant secondary consideration. Why has the patient been left out of the equation? Because unlike almost every other market you can imagine, in healthcare the patient historically was not the entity that paid for the services. Hence, from an economic perspective, the healthcare industry was free to ignore the very people they purportedly served.

Atul Gawande spoke about the need for communication and systems thinking in healthcare. In a TED Talk, he summed it up by saying “We’re all specialists now, even the primary care physicians. Everyone just has a piece of the care. But holding onto that structure, we built around the daring, independence, self-sufficiency of each of those people has become a disaster. We have trained, hired and rewarded physicians to be cowboys. But it’s pit crews that we need, pit crews for patients.”[i]

The very reason that population health is in a state of crisis is that the focus formerly has been on a million and one potential distractions with very little attention paid to how we were going to engage with the patient, and moreover exactly where was this engagement going to take place. A premise of the population health “movement” is that healthcare has to transform its view of the patient from a “clinical thing” to be examined and studied, to a natural person with whom we want to engage in a mutually beneficial dialog.

A few thousand years ago there was a marketplace. Never mind where. Traders returned from far seas with spices, silks, and precious, magical stones. Caravans arrived across burning deserts bringing dates and figs, snakes, parrots, monkeys, strange music, stranger tales. The marketplace was the heart of the city, the kernel, the hub, the omphalos. Like past and future, it stood at the crossroads. People woke early and went there for coffee and vegetables, eggs and wine, for pots and carpets, rings and necklaces, for toys and sweets, for love, for rope, for soap, for wagons and carts, for bleating goats and evil-tempered camels. They went there to look and listen and to marvel, to buy and be amused. But mostly they went to meet each other. And to talk.

Yes, markets contain prominent conversations. The Cluetrain Manifesto[ii] propelled this meme on the world’s stage over fifteen years ago. However, very few people intuitively understand the implications, and fewer still are leveraging the idea, as a way of doing business in healthcare. Enormous opportunities await any organization that finds its voice, and through it learns to have an ongoing conversation with its patients.

Further, patients are eager to have this conversation, as long as it is no more demanding of them then their use of Facebook, or WhatsApp, or Snapchat or whatever social media platform they choose to engage with. Moreover, it is clear that the conversation needs to take place in one virtual space, not hundreds. The idea of patient portals is DOA. Why? Because a patient is not going to visit twenty different portals to engage with all the clinicians (i.e. specialists) that our currently fragmented delivery system mandates.

 

[i] Gawande, Atul, MD. "Transcript of "How Do We Heal Medicine?"" Atul Gawande: How Do We Heal Medicine? TED Talks, Apr. 2012. Web. 28 Aug. 2016.

[ii] Rick Levine et al., The Cluetrain Manifesto: the end of business as usual (Cambridge: Perseus Publishing, 2000).

Population Health in Crisis: The Any Good Manager Fallacy

A good manager can manage anything right? Take for example Jack Welch (i.e. former CEO of General Electric), who is universally renowned for his management skills. Can you conceive of a business or government project that Jack would not manage effectively? I can. Jack was a good manager, but he probably would have done a poor job of managing The Manhattan Project (responsible for building the first atomic bomb). Why?  He was a world-class executive but not a world-class theoretical physicist. He would have had a heck of a time trying to discern a great atomic bomb design from a disastrous one. And even if this feat were remotely possible, we certainly would have lost the war by the time Jack made a reasonable determination.

 If you are going to manage, let alone lead, any non-trivial population health initiative (and most trivial ones for that matter), you better be an extremely knowledgeable (i.e. a combination of clinical, healthcare information technology, and managerial expertise) and a respected member of the team. Otherwise, the troops and their respective bosses are going to chew you up and spit you out. Design sessions will turn into popularity contests or position power plays, neither of which is likely to produce great results.

No, Jack Welch, being a world-class chief executive, would have immediately recognized that he was not the right man for the job, and quickly would have gone out and hired the best available talent that money could buy. It seems obvious in this example, but over and over again I have seen individuals put into positions of management or leadership where they have, at best, a rudimentary understanding of the underlying technologies and/or subject matter domain. It is as if charm, good looks, or social graces were enough to get the job done when it comes to leading an inordinately complex population health initiative.

This is not to say that being a technically competent individual with excellent managerial skills is enough either since I have already expounded at length on the importance of leadership. But if you have these skills, at least you are qualified to be in the game!

FOR THE LOVE OF THE GAME

Most people, at the top of their profession, derive some intrinsic value from their work. It is probably one of the reasons they excel in their chosen vocation. Usually, such a calling satisfies significantly more than their financial needs. They derive an extreme sense of satisfaction, and at times, inspiration from the work itself. Ernest Newman noted:

The great composer does not set to work because he is inspired but becomes inspired because he is working. Beethoven, Wagner, Bach and Mozart settled down day after day to the job in hand with as much regularity as an accountant settles down each day to his figures. They didn’t waste time waiting for inspiration.

All the truly exceptional project managers that I have had the pleasure of working with displayed an intense passion for their craft. They got off on the work. Just like exceptional musicians get off on their music. Passion for your craft is a pre-requisite for greatness. If you want to hire the best of the best, learn to look for a certain fire in their bellies and sparkle in their eyes.

THE ECONOMIC UNIT OF VALUE CREATION

Successful projects drive competitive advantage, and in healthcare, the need for competitive advantage is growing day-by-day. The creativity that impacts activities of the value chain yielding marketplace advantages is almost always unleashed within the context of a project. Therefore, it follows that you want to staff your mission critical projects with the best available talent you can find, wherever you can find it.

Mission critical projects should define and guide your employment practices. Much of the talent you would love to hire would probably want to work on your mission critical project, given that you are willing to pay them what they’re worth, however, they may not be as interested in a stewardship role for the next five years, once the project’s objectives have been met.

In other words, there are people who love to continuously create, and there are those that create and then to nurse their creations. One is not necessarily better than the other, but they are different. To be successful, you must learn to recognize individual differences and then hire world-class players for each category. Mission critical projects will only yield sustainable results if you are astute enough to hire the right combination of both.

PAY FOR PERFORMANCE

By now just about everyone understands that lifetime employment, with the same organization, is a thing of the past. It may still happen in a very small number of cases, but the majority of workers (of whatever color collar), either out of necessity or by choice, will wind up working for many employers over their lifetime. Whether they are employed as permanent employees (whatever that means nowadays) or freelance consultants will make little difference.

One thing is certain; top talent will continue to insist on pay for performance at high market rates. They will also be in a position to negotiate more vacation, flexible hours, and anything else that the current market will bear. If organizations insist on playing thefool’s game of squeezing their best talent financially, the moment things turn a little tight economically; they will be rewarded with mass exodus when the economy improves. You reap what you sow.

“Did anybody think it would be just the people who were downsized who would start thinking like free agents? This is capitalism. If you create a free market for anything, including talent, the people with the most value to sell are going to leverage it for everything it’s worth. And that’s what’s happening. The most valuable people are leveraging their talent in the marketplace for everything it’s worth. Success now is defined by the open market, and that means that the sky is the limit. No single organizational hierarchy puts a cap on your potential. Go wherever opportunity takes you. That is the essence of the free-agent mindset.[i]”

Of course, it is prudent to point out that free agency is not without risks. You may have to accept lower market rates and/or less work whenever economic conditions dictate. It is not all upside by any stretch of the imagination. However, even in a bad employment market, free agents tend to have distinct advantages. Since they often have better skills and are economically motivated to keep them honed, they remain aggressive competitors in good markets as well as bad.

[i] Bruce Tulcan, Winning the Talent Wars (New York: W.W. Norton & Company, 2001) 24

Population Health in Crisis: Leading the Congregation

Every team member is an essential part of the team and brings unique qualities and experiences to bear in their assigned role. This is an axiom of team dynamics; however, it is a pure abstraction and is only relevant if each team member is made to feel unique. One of the Natural Leader’s primary goals is to develop this sense of uniqueness through quiet praise and various other subtle techniques, assuming, for the sake of argument, that the respective team member is indeed making unique contributions.

Effective multidisciplinary teams are mission critical if population health initiatives are to succeed. Further, it is questionable (i.e. highly unlikely) that “pure clinicians” have the breadth and depth of clinical and technology experience to recruit, build, nurture and reward a team consisting of the right players. One not so subtle technique for rewarding high-performing individuals is to create forums wherein team members get to shine in front of their peers. I have used this method with great success and go out of my way to look for opportunities that fit a particular individual. This is often most beneficial for journeyman and junior team members, who otherwise might not get a chance to lead the congregation. Can I get a witness?

Breaking Bread

There is something about sharing a meal together, in a social context outside of the work environment, which contributes more to team building than a thousand and one classes in sensitivity training. We are social animals and breaking bread together is probably the most socially rich experience that we partake in. Consider the fact that this is something usually done with family members, dear friends, and close acquaintances (i.e. except when contrived for business purposes or formal occasions) and you can begin to appreciate why it tends to have such a salutary effect.

Random Acts of Kindness

If you want to build a lasting bond between team members, then learn to do little things from the heart, often. It always seems to be the little things that someone does that makes them stand out in our hearts and minds. Perhaps it is the only way that human beings actually demonstrate their humanity. Kindness cannot be faked. It must be genuine and heartfelt, or it ceases to be.

Kindness begets kindness.

—Sophocles

Kindness inspires trust. It is probably a natural law that one cannot demonstrate kindness to another human being without wishing them well. It should not be surprising that we tend to respond favorably to random acts of kindness. Because population health initiatives require such specialized and individualized skillsets we are simply forced to “trust but verify” that individuals are producing the requisite critical path deliverable at the appropriate time. Trust help team members come forward when they otherwise might hold back for fear of criticism or worse.

Team Identity

There is clearly an accepted (and often expected) high-performance team sub-culture that has emerged over the last 20 years. Some of the key elements of this culture are hard work, creativity, and fun. Successful and innovative organizations such as Apple, Google, and Facebook work diligently at culture creation and building team identities. This effort ranges from creating T-shirts with team names and logos to providing code names for all projects. Why? Because these companies realize that having the appropriate culture contributes significantly to their bottom lines. It immensely improves their recruiting efforts and dramatically reduces employee turnover. It also creates an environment where creativity and productivity flourish.

Men and Women have an innate need to belong, to be part of something that is larger than self; this is an irrefutable historical fact. Whether the larger group is based on race, religion, political ideology, nationality, or the gang from the barrio, the specific manifestation often seems to make very little difference. The need is a powerful one and demands to be satisfied.  A relatively small team or a number of small teams working in concert, each possessing a strong identity, often conspire to bring great products to fruition. The ability to create a strong team identity is critical to the mission’s success. It is something that the Natural Leader must establish early in the mission’s planning process and continue to strengthen during its execution. Population health initiatives are by definition transformative. A “run of the mill” project team will never achieve the mission.

Whose team is this anyway?

High-performance teams, jelled teams, killer teams or in short, great teams, require a considerable amount of energy to build and sustain. However, their complete and utter destruction can happen in a matter of hours or less. This happens most often when outside forces, not understanding the team’s dynamics, impose constraints or demands that make the contracts that took so long to negotiate, unenforceable.

The quickest way to ensure the team’s destruction is to change the Natural Leader, either voluntarily or involuntarily, without any preparation or consideration for who will assume this role. Organizations must learn to have a better ear for team dynamics. In many ways the Natural Leader embodies the team. He or she created it, nourished it, and maintained and enforced the contracts. They often command more loyalty from the troops than some arbitrary organizational hierarchy that won’t hesitate to downsize them out of existence at the first sign of trouble. Given the complexity of population health initiatives, you can be sure that the team will experience more than its fair share of challenges—that’s simply the nature of the beast.

Interfere with the dynamics of a successful team (i.e. the one working on the transformation of your business model) and you may have just shot your organization in the head. Team implosions in complex projects are legendary. One minute the magic is so palpable that you can breathe it like pure oxygen, the next minute the fire you started consumes it, and you are left choking to death. Now you see it, and now you don’t.

I will pay more for the ability to deal with people than for any ability under the sun.

—John D. Rockefeller

 

Population Health in Crisis: The Mission

Almost everything non-trivial that happens in the business world, and in many other walks of life, is the result of a project. Projects have a well-defined beginning, middle and end. They always require a project plan. The plan not only defines the stages of the project but also drives its execution. I prefer the word mission because it implies motion and carries a greater sense of urgency. Given the importance of population health initiatives to their respective stakeholders, I can assure you that there better be a sense of urgency, or this initiative will wither and die on the vine.

Signing Up

You usually either sign up for the mission through pressure from your current employer or preferably, you volunteer on your own. However, signing up for a population health initiative is, for me, a much deeper commitment than is apparent on the surface. It means that you will do almost anything within your power to achieve the end game. It may make the difference between your organization thriving and prospering in the rough and tumble world of 21st-century healthcare, or becoming roadkill on the information highway.

For population health initiatives, signing up does not necessarily imply consistently working 60 hours a week for the duration of the mission. However, it does imply that you will go above and beyond the call of duty, which often entails some overtime, and/or other personal sacrifices at critical junctures. Signing up is a binary proposition, you’re either on board or you’re not. There is no acceptable middle ground. It is a contract with the rest of the team members. It is mutually binding and cannot be broken without putting the mission at risk.

Getting all team members signed up is the responsibility of the mission’s Natural Leader. On projects where I have assumed this role, I always look for opportunities to shoot on sight any team members caught sitting on the fence. They usually die a very slow and painful death, often from multiple wounds. I would rather reduce headcount than risk the mission by having to carry wounded combatants iteration through iteration. This is hyperbole of course but you get the drift.

No One Gets Left Behind (the WIIFM)

While Signing Up ensures that everyone on the project commits to everyone else by signing the same mutually binding contract, the Natural Leader also signs a personalized contract with each individual. This contract is a promise that individual, and specific, benefits will accrue to each (and every) team member in return for his or her effort during the mission. It answers the question “What’s in it for me?”  This contract is implicit between the Natural Leader and an individual team member and is not shared with other mission comrades.

Would you persuade, speak of interest not of reason.

—Benjamin Franklin

In Black Hawk Down the movie’s powerful punch was delivered not by outstanding performances from Hollywood’s elite, but by the graphic representation of the brutality of war, and the poignant relationships that are manifested in the middle of life and death situations. The motto of Delta Force is, “No One Gets Left Behind,” and I guarantee you, if the film is to be taken at face value, this is no gung-ho marketing campaign. It is a mutually binding contract that is honored at all costs. Notice that all this contract talk does not involve an organizational abstraction outside of the project team. It is widely known that soldiers in the heat of battle fight harder, and often until no one is left standing, not for God or country, but because of the personal relationships they have with those in nearby fox holes. It is the shared experience of the mission that brings out the best in us.

Natural Leaders

Natural Leaders own the mission. By definition, there is only one Natural Leader for any given mission. They can coexist with a leader that derives authority from position power but are obviously more effective when position power and natural leadership are aligned. Natural Leaders create team magic. Magic is not a by-product of serendipity. It is clear that renowned movie directors do not rely on serendipity to create the cast chemistry required for a great movie. The creation of cast chemistry is premeditated.

Good fellows are a dime a dozen, but an aggressive leader is priceless.

—Red Blaik

How do Natural Leaders do what they do? Does it require charm, superior social skills, above average intelligence, empathy, and love of humanity? Well, the truth is that no one knows for sure. Probably a Natural Leader possesses all the aforementioned qualities and still others that remain unnamed. The nature versus nurture argument is relevant, and like so many other cases where this argument is raised, the only plausible answer is that natural leadership requires some combination of both. That said, it is clear that leadership skills can be improved with practice and grow with experience.

It must be noted that leadership skills are not immutable. Change the mission context in a dramatic fashion and/or within a different domain and you are unlikely to see the same Natural Leaders emerge. Leadership is often fleeting. It is extremely context sensitive and occurs within certain space and time boundaries. That said, within a given context and domain, leadership can certainly be maintained across a relatively large number of missions. As previously mentioned, there are no scientific principles of leadership, and perhaps there never will be; yet there are some rules of thumb that have worked for me and I will share them with you in subsequent posts. These always seem to apply, despite the composition of the current team and the context of the current mission.