Wait! I Have A More Difficult Solution!!

My father is a graduate of the US Military Academy at West Point and a career military officer.  He is also one of those folks who teach life's lessons by telling stories.  Looking back, I now understand that I didn't appreciate many of those life lessons until the actual situation arose in my own life. 

One of the stories that he told countless times that I didn't understand was this:

As a student at West Point, one of the required classes for graduation was calculus.  My dad hated calculus and, as a result, didn't pass it the first time through.  So, the following semester he had to take that awful, dreadful, painful calculus again. 

The class took place in a large, old, wood-paneled  lecture hall with blackboards on 3 walls and stadium-style seating that held 300+ cadets.  Day after dreaded day, the professor would come into the packed lecture hall and, without a word, would start writing a mathematical proof on the first blackboard...then on to the 2nd blackboard...writing...drawing arrows to various integers...scribbling.... 

My father was completely, maddeningly lost.  He did his best to keep up, writing the proof number by number, trying to make sense of it all, but it was no use.

Finally, the professor would complete the proof, turn to the audience of lost cadets, and say in his best military voice:  "Gentlemen, are there any questions?"

The cadet who sat in front of my father (who's name I know well but who, out of respect for my father, shall remain nameless) would raise his hand and, having been acknowledged by the prof, would stand at attention and say in a loud voice that filled the hall:  "Sir!  I have a more difficult solution, sir!"  and proceed to explain a more complex, perplexing, convoluted means of achieving the same outcome.  Each day the scenario repeated.

Having reached the punchline of his story, my father would look me in the eyes, grin, and nod his head slightly as if to say "and that explains why the world is the way it is, son."  I probably heard that story a hundred times growing up, usually as a result of some situation my father had encountered with a neighbor, bureaucrat, fellow military officer, school official and the like.  I never got it.  Until I went to work.

And today, as I sit in endless committee meetings, deal with various state and federal regulators, confer with various consultants, go through the annual budget process, try to follow the arcane convoluted capital request process, try to make sense of the IT department's mysterious ways, try to comply with the Board's desires, listen as my Human Resources department explains our compliance policy, and confer with corporate wonks who have a complicated, redundant, intrusive answer (that will not work) for any given problem but, at the same time, can't find my hospital on a map, I visualize them in my head saying: 

"Sir!  I have a more difficult solution, sir!!!"

Onward, ever onward, my friends.

When Your Plow Is A Pencil

President Eisenhower once said, "Its easy to be a farmer when the farm is 900 miles away and your plow is a pencil", referring to the ineffectiveness of the federal government to direct farming activities from Washington DC.  My experience in healthcare has been similar.

Large, national, for-profit healthcare companies have made many positive contributions to healthcare in America by leveraging their size and capital to build hundreds of hospitals, expand hospitals into rural and underserved areas, and use competition among providers to drive efficiencies, outcomes, and patient satisfaction.  But in growing too large, a company can easily risk losing touch with each individual hospital and its unique, community-based challenges.  Former Speaker of the House Tip O'Neill used to say "all politics are local" and the same is true of healthcare management.

One of the hospital companies I worked for in the past was bought out by a larger, more national competitor...so far, so good.  However, I should have sensed the impending doom when someone called from our "new" corporate headquarters located halfway across the country to discuss information technology needs and started the conversation by asking where we were located.  I named the city and he asked "what state is that in?" and when I answered, then asked me to give him a rough idea as to what major cities were nearby.  Now this wasn't a recruiter or a consultant cold-calling for business, this was a member of "senior leadership" who could not find one of his "own" hospitals on a map...and hadn't even bothered to google us or our location.

So, okay, its a big country and this was a big company so maybe my expectations were set alittle high, but this lack of knowledge about local conditions was compounded by a corporate culture of control and centralization, i.e., "Don't make any decisions unless we give you the green light" which meant I had no authority to adjust to changing local conditions and no one at corporate had the insight into local conditions that we had...being local, after all.

It reminded me of a job I had when I was in grad school.  I was a DJ in a 50's-themed bar/restaurant in Baton Rouge that was owned by a national company based in Dallas.  Now I had been a DJ for years and had just left one of most successful clubs in the city, so I pretty much knew my way around a turntable and knew how to keep the dance floor packed.  But this company was smarter than us hicks in Louisiana and had a "national director of entertainment", based in Dallas, whose job included faxing a playlist to each DJ in the field, each day, listing which songs to play in which order...."4:01 pm:  Round Around the Clock; 4:04 pm:  Earth Angel" and so forth. 

The problem is its easy to be the DJ when your club is 900 miles away and your turntable is a fax machine.  I was forced to play the wrong song at the wrong time, time and time again, and watch the crowd drift away.  I had been warned that varying from the playlist meant instant "de-hiring" but, one day, I had finally had enough, dedicated "With This Ring" to a couple celebrating their 40th wedding anniversary and watched the dance floor fill.  My manager raced to the booth and told me if I did that again, it was my job.  I told him:  "Jack, see that record right there?  Its going to run out in about 2 and a half minutes.  Think fast", took off my headset, and walked out of that club with The Platters singing "with this ring I promise to always love you..." as I hit the parking lot.  Never even went back to pick up my last paycheck.  Moral of the story?  That company went out of business in less than 18 months.

The challenge with healthcare management is the same, I think.  In order to benefit from the opportunities a national presence affords a company, the company has to hire good local hospital operators and then learn to get out of their way.  All healthcare is local, so the management must be, too.

The Ripple Effect

In a world of six billion people, it’s easy to believe that the only way to initiate profound transformation is to take extreme action, to make some big splash. Its the same in hospitals:  The attention goes to the high profile, high impact events...a ground-breaking surgery, the construction of a new wing, the recruitment of a large physician practice, the opening of a new Center of Excellence.

Each of us, however, carries within us the capacity to change the world in small ways for better or worse. Everything we do and think affects the people in our lives, and their reactions in turn affect others. As the effect of a seemingly insignificant word passes from person to person, its impact grows and can become a source of great joy, inspiration, anxiety, or pain. Your thoughts and actions are like stones dropped into still waters, causing ripples to spread and expand as they move outward. The impact you have on the world is greater than you could ever imagine, and the choices you make can have far-reaching consequences. You can use the ripple effect to make a positive difference and spread waves of kindness that will wash over the world.

The recipient of a good deed will likely feel compelled to do a good deed for someone else. Likewise, someone feeling negativity will be more likely to pass on that negativity. One act of charity, one thoughtful deed, or even one positive thought can pass from individual to individual, snowballing until it becomes a group movement or the ray of hope that saves someone’s life. Every transformation, just like every ripple, has a point of origin. You must believe in your ability to be that point of origin if you want to use the ripples you create to spread goodness. Consider the effect of your thoughts and actions, and try to act graciously as much as possible.

A smile directed at a stranger, a compliment given to a friend, an attitude of laughter, or a thoughtful gesture can send ripples that spread among your patients, your loved ones and your friends, out into your community, and finally throughout the world. You have the power to touch the lives of everyone you come into contact with and everyone those people come into contact with. The momentum of your influence will grow as your ripples moves onward and outward. One of those ripples could become a tidal wave of positivity.

Jobs Are Like Girlfriends...

I just left a CEO position with one of the larger for-profit hospital companies in the country.  I was only with them for 3 years and I think I can say with confidence that both of us are happy I'm gone.  A headhunter asked me yesterday, "What did you like about working for Company X?"  My immediate reaction was to say something snappy like "Not much" but as I responded I found there was alot I like about my experience:  The people I worked with, the location of the hospital, what I learned in 3 years, the connections I made, the people we helped.  

Another interesting thing about the experience:  The hospital changed hands 3 times in the 2.5 years I was there.  I was heavily recruited by original owner Company V...they were supportive but gave me the authority to make changes, they trusted my experience & instinct, and we achieved excellent results.  For a few months there I was a regular healthcare rock star.

About a year after joining, Company V bought Company W, the original V leadership group that had recruited me left and I now reported to W leadership.  Totally different style, agenda, and strategy...I un-learned the "V" way and learned the "W" way.  And almost 9 months later, the entire company was bought by Company X...and another 180-degree change in focus. And 90 days later, X and I parted company.

What's the positive?  Well, in the course of 2.5 years, I worked for 3 of the biggest names in the business.  I went to school on 3 completely different yet equally successful business models.  I learned new technical systems like patient accounting and marketing systems.  And I met alot of great people.  I'm a better CEO for the experience.

It occurs to me that jobs are alot like girlfriends:  You learn something from every one of them, even the ones that turn out bad.  Margaret Ann taught me about Led Zepplin...before dumping me for her ex.  Harriet showed me the backstage at Disney where she worked...before she started dating the guitar player from the Disney band.  Alina taught me the magic of LSU football...and I married her.

Charter Medical taught me volume cures all ills.  OhioHealth taught me that innovation creates opportunity.  Baton Rouge General taught me an organization should stick with their core mission and when you forget that, trouble awaits.  River Parishes taught me to not let your medical staff get too far ahead of you.  Triumph Healthcare taught me Speed + Execution = Results.

So as I start a new position on Monday, I won't burn my bridges behind me, forgetting everything except the memory of the smell of smoke and the impression that once my eyes watered.  Instead I'll remember what I learned from each of my former employers and use it to foster success in my new "relationship..."

The Rules

PREHN’S RULES OF HOSPITAL ADMINISTRATION:

1. Simpson’s Law of Simplicity:  Either this will work out OK or it will make for an interesting story.

2. Brock’s Bylaw:  Speed + Execution = Results

3. Morrison’s Mantra:  Anytime a major charge or shakeup happens at your hospital, your staff will have 3 questions:  (1) What about me?  (2) What about me? (3) Oh, by the way, what about me?

4. Mary Ann's Mantra: Never let them see you sweat.

5. Johnson’s Judgment: Every once in a while, you just gotta throw a dead body out in the hall.

6. Viator’s Verdict: You might as well take all the undeserved praise, because you’re gonna get all the undeserved blame.

7. Morrison’s Maxim: Hospital CEOs should change every 3 years because if you haven’t created enough enemies in 3 years to get yourself fired, you’re not pushing hard enough.

8. Prehn’s Proclamation: If it ain’t working, use a bigger hammer.

9. Prehn’s Prescript (previously known as Prehn’s Rule of Free Drinks at Happy Hour): The cheaper the product, the more consumers will complain about the quality.

10. DON's Definition:  CNOs who seek equality with CEOs lack ambition.

11. The Simpson Elucidation of the Chain of Ridicularity:  The longest distance between two points utilizing as many people and forms as possible in a corporate chain of command in order to review and analyze any requested decision or action without there ever having to be a substantive decision.

12. Prehn’s Precept:  When you don’t know what you’re doing, walk fast & act worried.

13. Shane’s Sayng:  Show up, act interested.

14. McCurdy’s Maxim:  I’ll panic when it happens.

15. Jim Injunction:  Volume cures all ills.

16. Colin Powell’s Quote:  You can’t make someone else’s choices. You shouldn’t let someone else make yours.

17. Andretti’s Axiom:  If everything is under control, you’re not going fast enough.

18. Weinstein’s Wisdom:  Sometimes its paranoia, sometimes its just sensitivity

19. Prehn's Perrill:  My job ate my life.

20. Aleen's Advice:  When your boss is manic, rise to the level of their mania to communicate an adequate sense of urgency.

21. Aleen's Advice:  (to nursing staff) You will NEVER get in trouble for being nice to a patient/family member.  Get them what they need to be comfortable.

22. Harrison’s Three Laws of the Universe:

• Hurry up, get to the point, I don’t have a lot of time
•  Don’t sweat it, most of it turns out to be B.S.    anyway 
• I don’t have to be the smartest guy in the world, I just have to be the smartest guy in the room

23. Lee's Law of Timing:  If you have to have an answer right now...it's no!
 

• Corollary - Lack of planning and/or preparation on your part does not constitute an emergency on mine.

25. Prehn’s Expediency Formula:  Results are simply a matter of time & money.  The more money you have, the less time you need.  And vice-versa.  R = f [T:$]

26. Reformation of Martin Mull’s Observation:  Being a hospital CEO is like having a bowing alley installed in your head.

The Wizard of Oz

After 30+ years of leading healthcare organizations, I've come to the conclusion that organizational behavior and leadership, particularly during times of crisis & turmoil, is best illustrated by the story of the Wizard of Oz.  I won't rehash the entire story--almost everyone has seen the movie at least once--but to recap, Dorothy gets swept away and finds herself in the strange land of OZ.  She asks the Glenda, the Good Witch, how to get back home and Glenda says that only the Great Oz can help her.  So Dorothy sets out to find the Great Oz and along the way faces many obstacles but, in the end, reaches her goal.

The story has what I believe are the four key components of leadership & crisis management in healthcare organizations:  (1) CRISIS...in this case, being lost in OZ, (2) JOURNEY...in this case, setting out on the Yellow Brick Road, (3) LEADER...in this case, the Great Oz, who all believe has the power to solve the crisis, and (4) TASKS...Dorothy and her friends are given a challenge by the Great Oz--bring back the broom of the Wicked Witch--and he will grant their wishes, i.e., solve their problems.

Now let's apply the metaphor to a hospital reeling from a bad accreditation review and subsequent threat of losing their accreditation.  The CRISIS is the bad survey and the fear that it could cripple or even shut down the hospital...the Quality Department feels particular heat that their jobs may be on the line, along with the clinical leadership.  So they begin the JOURNEY to resolve the crisis but they're fearful and not sure how to solve the crisis so they go to the LEADER who, most believe, has the knowledge and power to solve their problems.

But does he?  No!  Like the Great Oz himself, the LEADER is the man behind the curtain...not all powerful and all knowing, but simply in the titular position of appearing so by virtue of his office.  But does he appear weak and unknowing in the face of the crisis?  No again.  Like the Great Oz, he listens to the plight of the staff and then suggests/assigns a series of TASKS they must undertake before "he" can grant their wishes.

So the team sets /off to complete their assigned tasks and, once completed, return to the LEADER so he can grant their wishes/resolve the conflict.  But what do they find?  Like Dorothy and her friends returning to Oz, in completing the tasks they find THEY had the power all along. 

Perhaps most of us in leadership positions hope that no one ever pulls back the curtain to reveal that we are not the Great Oz, but simply the man behind the curtain, but in understanding the dynamics of crisis management in an organization also understand the journey by which is may be resolved.

NEXT:  THE RULES

The Strange World of Healthcare

Commentator Paul Harvey once illustrated how complicated and bizarre the world of healthcare is by using the metaphor of your local grocery store:  "What if your grocery store had to operate under a system similar to how hospitals operate?" 

Imagine:

1.  Before you go shopping, you would have to enlist the help of an "expert" to determine what groceries were needed.
2. Before going to the store, you'd have to contact your "managed grocery store provider" to request permission to go to the store.  They would check and see how many times you've been recently, whether the visit was reasonable & customary, and select a "preferred grocery store" in their "network"...even if that store was in the next town over.
3. Once at the store, the "advanced practice grocer" would review your shopping list.  She'd also have to access your personal "grocery record" to assess what groceries you'd bought in the past and determine what groceries were allowed by your plan.  Generics preferred.
4. Your grocery record, by the way, would contain a list of every grocery you ever bought, what it was used for, and whether there were any negative outcomes or led to additional shopping
5. You would then make your way to the "grocery payment clerk" who would total up your groceries.  The total cost of your groceries?  $250.  Your bill?  $1,250.  Why??  Because you have to make up the shortfall caused by the last two shoppers who were on government plans that don't pay the actual cost of their groceries so someone has to make up the difference and that would be YOU.  The industry calls that "grocery cost shifting."
6. By the way, your local grocer is thinking hard about giving up groceries altogether and getting into the bar business because the red tape is driving is costs higher every year just as his reimbursement keeps getting cut.

We are, indeed, in the strange world of healthcare.  What other business can you think of in which the consumer doesn't pay for the goods & services, a 3rd party (ie, insurers or government) does?  Or a business where the major decision makers in the organization--in this case doctors -- aren't employed by the organization or, for that matter, held accountable by the organization?  Or a business increasing focused on "customer satisfaction" in which the very services we provide often cause "customer dissatisfaction"...the post-surgical pain, the painful rehabilitation following knee-surgery, blood draws, vital signs taken in the middle of the night?

...and all of this done in an industry that is the most highly regulated in the world...more highly regulated than Wall Street, the space program, or the banking industry. 

Is it little wonder that we have trouble sleeping at night?

NEXT:  THE WIZARD OF OZ