May 1, 2014

Lon and The Joint Commission:

Yesterday, for a different purpose, I reviewed a note which I wrote to SETMA’s leadership on August 27, 1998.  Updated copies of this note were resent through the years and a final copy with corrections was sent in January, 2013.  This morning, with the Joint Commission in mind, I have updated the note again.  There has been some suggestion that The Joint Commission may place SETMA’s 40-section notebook on the Joint Commission Standards & Requirements, Medical Home Accreditation 2013, Character Seven:  leadership in the Leading Practice Library as a “Best Practice.” 

The below (a Word Document is attached) was not included in that notebook but it addresses many of the issues which I have been discussing with The Commission.  The longer this discussion continues, the more I believe that the content of The Joint Commission’s accreditation certificate is only symptomatic of the need for The Commission to change its philosophy and its approach to accreditation. 

The comment that with over 40,000 certificates from The Joint Commission in circulation and with NO ONE ever having raised the objections to the certificates which I have raised, implies that I must be in a minority of one and out-of-step with the mainstream medical community.   There is another possible explanation and that is that the very changes which I think The Joint Commission needs to make are suggested by the 40,000 to 1 ratio.  Could it be that it is as several SETMA colleagues with long hospital backgrounds suggest that the fear of The Joint Commission’s power in the past (which no longer exists) and the negative, and sometimes brutal approach of The Commission,  squelched any opposition or negative feedback.  Could it be that the surveyed organizations where just glad to get through the process.

It seems to me, and that is one out of 40,000 opinions, that The Joint Commission’s historical approach produced the same “reform” mentality that has been the dynamic of change in healthcare, i.e., put enough pressure on the organization with threats and oversight and you’ll get the desired results for at least as long as the pressure continues.  This approach neglected the power of transformation. 

The type of leadership needed from The Joint Commission and needed at the local organizational level is transformative because it is self-sustaining.  With a reform/pressure philosophy, SETMA will only pay attention to the standards of The Joint Commission after the 18-month widow of no surprise visits passes, at the end of which we’ll have to think about these things again, lest you “catch us” relaxing because the “pressure is off.”  Can you imagine the impact The Joint Commission could have if  rather than being an “overseer,” (as stated on your certificate), you embraced the organizations with which you work as the sustainers of “quality and safety” where both see each other as collaborators, colleagues and consultants rather than one as the sustainers of excellent (The Joint Commission) and the other (the practice, hospital or other organization) as the one who only pursued quality and safety as they were forced to by the oversight of The Joint Commission. 

The future of all healthcare organizations will be dependent upon their ability to adapt to that future and not just in response to pressure and demands, but as in imperative of the internalized passion, principles, ideals, standards and transformative and generative power of a vision of excellence.  No organization, whether accrediting body or body being accredited has a lock on the future.  Past successes based on past realities and responsibilities may be lost without change.

As I said before, The Joint Commission’s certificate accurately reflects how I perceive the Joint Commission’s philosophy and the image the Commission has of itself and of the bodies it is surveying.  That is why the certificates are not a trivial matter or a distraction.  If The Joint Commission does not see the accreditation process as an occasion for celebration, congratulations and affirmation, but only as an occasion to imply, “if you don’t keep your nose clean, we’ll jerk your accreditation,” then I suspect The Joint Commission’s influence will dwindle. 

Does this suggest compromise and decreasing the standards?  Absolutely not.  It does suggest that I think that SETMA’s standards are as high if not higher than The Joint Commission’s. It does suggest that The Joint Commission’s influence can grow if The Commission changes its philosophy and if it does not see itself as the only motivator for excellence.  It does mean that if the Commission only changes it certificate but does not change its philosophy, then the dwindling of influence may take place..  It does mean that if the Commission sees itself as part of the solution for excellence in healthcare and not as the only solution, then we can all benefit from a relationship.  

It is my hope that you will hear my plea.  The microscopy which I am suggestion that The Commission examines itself with, is the same microscope with which SETMA examines itself.   Welcome to the club.  If you want to join, we will all benefit.

James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com

Adjunct Professor
Family & Community Medicine
University of Texas Health Science Center
San Antonio School of Medicine 

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center 

Leadership:  Character Traits Needed for Healthcare Transformation
By James L. Holly, MD
May 1, 2014

While Kent Keith has not said such to me, it seems obvious that at the root of The Paradoxical Commandments are the virtues of personal passion, trust and hope.  It seems that the leadership required for the transformation of healthcare will embrace those commandments and will exhibit the Personal Mastery described by Peter Senge.  On August 27, 1998, I wrote SETMA’s leadership a note in which I quoted Sir Winston Churchill, who speaking to his Private Secretary, John Colville on August 27, 1940, said, “Each night, I try myself by Court Martial to see if I have done anything effective during the day. I don’t mean just pawing the ground; anyone can go through the motions, but something really effective.”  Successful leadership over a lifetime is made up of successful leadership for one day. 

I added to this note the challenge, “Try each day to accomplish something significant and in the end you will succeed in your job. As a leader, you must be true to yourself and not be disappointed with others. You must assist them in becoming all they can be.”  In that note, I quoted an editorial entitled, ‘Leadership Paradoxes,’ in which William McCumber, listed ten conclusions about people in general. He found these ideas in a newspaper article about Howard Ferguson, a wrestling coach, who purportedly initially formulated the list.  (Read on to find the ten principles and the true source of these remarkable ideas.)

The Origin of The Paradoxical Commandments

Recently, I wanted to use these ideas but was unable to find them. I searched the web and that is when I discovered that the attribution of this work to Ferguson was not correct.  This material comes from http://www.paradoxicalcommandments.com/origin.html.   “The Paradoxical Commandments were written by Kent Keith in 1968, when he was 19 and a sophomore at Harvard College. The commandments were part of The Silent Revolution: Dynamic Leadership in the Student Council, his first booklet for high school student leaders. Kent encouraged students to care about others, and to work through the system to achieve change. One thing he learned was students didn't know how to work through the system to bring about change. Some of them also tended to give up quickly when they faced difficulties or failures. They needed deeper, longer-lasting reasons to keep trying.

“In his sophomore year at Harvard, Kent began writing a booklet for high school student leaders that addressed both the how and the why of leading change. The booklet was titled The Silent Revolution: Dynamic Leadership in the Student Council, and it was published by Harvard Student Agencies in 1968. The Paradoxical Commandments were part of Chapter Two, entitled,  ‘Brotherly What?’

I wrote Kent and he gave permission to quote his work.  The following is the copy of “The Paradoxical Commandments” he sent to me for quotation:

THE PARADOXICAL COMMANDMENTS
By Kent M. Keith

1. People are illogical, unreasonable, and self-centered. Love them anyway.
2. If you do good, people will accuse you of selfish ulterior motives. Do good anyway.
3. If you are successful, you will win false friends and true enemies. Succeed anyway.
4. The good you do today will be forgotten tomorrow. Do good anyway.
5. Honesty and frankness make you vulnerable. Be honest and frank anyway.
6. The biggest men and women with the biggest ideas can be shot down by the smallest men and women with the smallest minds. Think big anyway.
7. People favor underdogs but follow only top dogs. Fight for a few underdogs anyway.
8. What you spend years building may be destroyed overnight. Build anyway.
9. People really need help but may attack you if you do help them. Help people anyway.
10. Give the world the best you have and you’ll get kicked in the teeth. Give the world the best you have anyway.  (© Copyright Kent M. Keith 1968, renewed 2001)

Why Paradoxical Commandments and Healthcare?

While Kent has not said such to me, it seems obvious that at the root of The Paradoxical Commandments are the virtues of personal passion, trust and hope.   The kind of leaders who are needed to support and successfully deploy  transformative healthcare policies and to achieve challenging  goals are those who have what Peter Senge  identifies as “personal mastery.” (The Fifth Discipline)  They are:

1. They have a special sense of purpose that lies behind their vision and goals. For such a person, a vision is a calling rather than simply a good idea.
2. They see current reality as an ally, not an enemy. They have learned how to perceive and work with forces of change rather than resist those forces.
3. They are deeply inquisitive, committed to continually seeing reality more and more accurately.
4. They feel connected to others and to life itself.
5. Yet, they sacrifice none of their uniqueness.
6. They feel as if they are part of a larger creative process, which they can influence but cannot unilaterally control.
7. They live in a continual learning mode.
8. They never ARRIVE!
9. (They) are acutely aware of their ignorance, their incompetence, and their growth areas.
10. And they are deeply self-confident!

Personal Mastery is what leaders require if they are going to persevere through the Paradoxical Commandments.  That perseverance is what is required to translate the ideals, principles and policies of national leaders into practical experience in healthcare.  These leaders will possess personal passion, trust and hope.

Commitment to excellence is an individual passion but it becomes a collective, organizational passion as two, then three, then ALL embrace from their heart and soul the same standard. Sustaining excellence is much easier when it is the product of a group's effort. Like the "three-fold cord which is not soon broken," the group sustains the one's commitment to excellence at times of fatigue and discouragement. The physics of the three-fold cord is that at the point of one cord's weakness another is strong and the reciprocal is also true. A cord which can only support 200 pounds, when intertwined with two equally strong cords, can support 2,000 pounds.

So it is with SETMA’s efforts for and commitment  to excellence. What we cannot do alone, we can do together.

The Ultimate Hope of the Future of Healthcare is Transformation

To be successful, the implementation of new polices and initiatives witch will produce the future we imagine, must be transformative which comes from within.  Transformation results in change which is not simply reflected in shape, structure, dimension or appearance, but transformation results in change which is part of the nature of the organization being transformed. The process itself creates a dynamic which is generative, i.e., it not only changes that which is being transformed but it creates within the object of transformation the energy, the will and the necessity to sustain and expand that change and improvement. Transformation is not dependent upon external pressure (rules, regulations, requirements) but is sustained by an internal drive which is energized by the evolving nature of the organization.

While this may initially appear to be excessively abstract, it really begins to address the methods or tools needed for reformation, or for transformation. They are significantly different. The tools of reformation, particularly in healthcare administration are rules, regulations, and restrictions. Reformation is focused upon establishing limits and boundaries rather than realizing possibilities. There is nothing generative - creative - about reformation. In fact, reformation has a "lethal gene" within its structure. That gene is the natural order of an organization, industry or system's ability and will to resist, circumvent and overcome the tools of reformation, requiring new tools, new rules, new regulations and new restrictions. This becomes a vicious cycle. While the nature of the system actually does change, where the goal was reformation, it is most often a dysfunctional change which does not produce the desired results and often makes things worse.

The tools of transformation may actually begin with the same ideals and goals as reformation, but now, rather than attempting to impose the changes necessary to achieve those ideals and goals, a transformative process initiates behavioral changes which become self-sustaining, not because of rules, regulations and restrictions but because the images of the desired changes are internalized by the organization which then finds creative and novel ways of achieving those changes.

It is possible for an organization to meet rules, regulations and restrictions perfunctorily without ever experiencing the transformative power which was hoped for by those who fashioned the external pressure for change. In terms of healthcare administration, policy makers can begin reforms by restricting reimbursement for units of work, i.e., they can pay less for office visits or for procedures. While this would hopefully decrease the total cost of care, it would only do so per unit. As more people are added to the public guaranteed healthcare system, the increase in units of care will quickly outstrip any savings from the reduction of the cost of each unit.

Transformation of healthcare would result in a radical change in relationship between patient and provider. The patient would no longer be a passive recipient of care given by the healthcare system. The patient and provider would become an active team where the provider would cease to be a constable attempting to impose health upon an unwilling or unwitting patient. The collaboration between the patient and the provider would be based on the rational accessing of care. There would no longer be a CAT scan done every time the patient has a headache. There would be a history and physical examination and an appropriate accessing of imaging studies based on need and not desire.

This transformation will require a great deal more communication between patient and provider which would not only take place face-to-face, but by electronic or written means. There was a time when healthcare providers looked askance at patients who wrote down their symptoms. The medical literature called this la maladie du petit papier or "the malady of the small piece of paper." Patients who came to the office with their symptoms written on a small piece of paper where thought to be neurotic.

No longer is that the case. Providers can read faster than a patient can talk and a well thought out description of symptoms and history is an extremely valuable starting point for accurately recording a patient's history. Many practices with electronic patient records are making it possible for a patient to record their chief complaint, history of present illness and review of systems, before they arrive for an office visit. This increases both the efficiency and the excellence of the medical record and it part of a transformation process in healthcare delivery.

This transformation will require patients becoming much more knowledgeable about their condition than ever before. It will be the fulfillment of Dr. Elliot Joslin's (The founder of the Diabetes Center of Excellence in Bosom, which is affiliated with Harvard Medical College) dictum, "The person with diabetes who knows the most will live the longest."

It will require educational tools being made available to the patient in order for patients to do self-study. Patients are already undertaking this responsibility as the most common use of the internet is the looking up of health information. It will require a transformative change by providers who will welcome input by the patient to their care rather seeing such input as obstructive.

This transformation will require the patient and the provider to rethink their common prejudice that technology - tests, procedures, and studies - are superior methods of maintaining health and avoiding illness than self-discipline, communication, vigilance and "watchful waiting."  In this setting, both provider and patient must be committed to evidence-based medicine which has a proven scientific basis for medical-decision making. This transformation will require a community of patients and providers who are committed to science. This will eliminate "provider shopping" by patients who did not get what they want from one provider so they go to another.

This transformation will require the reestablishment of the trust which once existed between provider and patient to be regained. The restoration of trust between the provider and patient cannot be created by fiat. It can only be done by the transformation of healthcare in to system which we had fifty to seventy-five years ago.  With that trust relationship coupled with modern science, healthcare can produce a new dynamic which we call patient-centered medical home.  In this setting the patient must be absolutely confident that they are the center of care but also they must know that they are principally responsible for their own health. The provider must be an extension of the family. This is the ultimate genius behind the concept of Medical Home and it cannot be achieved by regulations, restrictions and rules.

The transformation will require patient and provider losing their fear of death and surrendering their unspoken idea that death is the ultimate failure of healthcare. Death is a part of life and, in that, it cannot forever be postponed, it must not be seen as the ultimate negative outcome of healthcare delivery. While the foundation of healthcare is that we will do no harm, recognizing the limitations of our abilities and the inevitability of death can lead us to more rational end-of-life healthcare choices.

After thought

There is hope for the future of medicine.  It is my hope that leaders will arise, at the local level, in the private practice of medicine, who will embrace the Paradoxical Commandments and Personal Mastery.  And, that those leaders will internalize the hopes and expectations of the transformative ideals of healthcare policy.