Physician Leadership: An Interview with Dr. Joseph Cooper

Dr. Joseph Cooper is a practicing board-certified ophthalmologist and a member of the American College of Physician Executives. He has been a member of the medical staff of Marietta (OH) Memorial Hospital for more than 25 years and has held numerous medical staff positions including department chair, credentials chair, and president of the medical staff. He has also served as a hospital board trustee and chaired the board quality council. For the past eight years, Dr. Cooper has consulted with various medical staff on governance, credentialing and peer review.  Recently he has also begun working with the Physician Leadership Institute as part of the Center for Transformation & Innovation (CTI). He consults with hospitals and medical staffs across the country in the areas of medical staff organizational functions, governance and bylaws, peer review, credentialing and privileging and leadership training. He is a physician leader who brings more than 25 years of experience in medical staff functions and affairs to his work with physicians, hospitals, and healthcare organizations across the country.   

How do you view physician leadership?  Can physician leadership be taught?

Definitely. There are some people who are born with it, but most people probably aren’t. Just like any skill, it has to be taught otherwise most people I don’t think would have it.

Have things changed in your day-to-day activities as a result of taking physician leadership from the Physician Leadership Institute?

Definitely.  In medical school the problem is that you’re not exposed to any leadership whatsoever.

You’re exposed to clinical activity. You pick up either good or bad habits from the people you get taught by. And a lot of them don’t have leadership skills either. So it’s kind of catch-as-catch-can.

Most people get into a position starting to assume leadership and really have no training, with no insight whatsoever because it’s not something that we’ve been exposed to for all those years.

They don’t have classes or courses about leadership or teamwork. Maybe that world is changing now, maybe some of that is going to occur now. I know medicine is becoming more of a team sport compared to twenty years ago but still I don’t think they get much leadership in their formal training.  I know my son  just graduated med school, and there certainly wasn’t anything like that for him.

Most doctors aren’t exposed to leadership tools like we were in the Physician Leadership Institute unless they’ve also undergone an MBA or an MMM program. I think for the average doctor these things are very new.  The leadership training is very valuable in that once you get exposed to it, it changes the way you approach and work with others.  You start using different styles of interaction depending on the type of person you’re dealing with. This is not something we were taught before.

In calm moments, we’re humans.  But in emergencies, we do become more technical – trying to make the best decisions to save a patient.  All doctors have to learn to balance their emotions and their clinical skills.

In your opinion, who should enroll in these physician leadership programs?

If just the people at the top are the only ones trained, it doesn’t work as well. What you need is a culture of leadership and responsibility. Anybody can benefit from leadership training because everyone is a leader at one point or another. You see the benefit in interactions with others.

Doctors are autonomous animals, we were taught to do things by ourselves, make decisions on the fly all the time, as I said. But to be a team player and look for consensus, that’s sometimes an alien world for even some very good doctors. Of course there are some doctors who may say something like I don’t have the time for this, but sometimes those are the very folks that need this training the most.

What would you tell someone who is skeptical of the idea of physician leadership?

I would tell them that there are benefits beyond simply your job. The benefits extend to your practice, whether it’s a group or individual practice, your day-to-day interactions with everyone you come into contact  with. The life skills we learn we also use with our families and friends.  It is a transformative process not just for the
organization but for individuals as well.

Did you notice an impact on business performance after the leadership training?

Because ours was  a diverse group, I think the biggest changes you would  see are in the groups that work together in the same organization or practices.  Also, in  teams that work together on action projects.  Because of the personal coaching, you create specific plans for interactions with specific people.  This was very helpful for me personally. I would hope that even my son would take a class like this so he could benefit from it for his future career.

Jim Collins: 13 Questions to Take You from Good to Great (Part II)

In the previous blog post, we went through the first six questions, now let’s continue with the discussion of Jim Collins’ 13 questions.

7. How can we better blend empirical creativity AND fanatic discipline, and thereby scale innovation?

Collins describes a tripartite formula for success in another one of his bestsellers - Great by Choice: Uncertainty, Chaos, and Luck–Why Some Thrive Despite Them All:

Fanatic discipline: extreme consistency of action—consistency with values, goals, performance standards, and methods (remember the 20 Mile March?); utterly relentless, monomaniacal, unbending in their focus on the goals.
Empirical creativity: decisions are made primarily on empirical evidence, based on direct observation, practical experimentation, and direct engagement with tangible evidence. Bold, creative moves are derived from a sound empirical base.

Productive paranoia: maintain hyper-vigilance in order to detect and react to threats and changes in their environment, even when—especially when—all’s going well. Assume conditions will turn against them, so they channel their fear and worry into action, preparing, developing contingency plans, building buffers, and maintaining large margins of safety.

Great innovators fire “bullets” first and correct their aim before firing big fire balls to hit their targets.

What is a bullet? For Collins, a bullet is “an empirical test aimed at learning what works and that meets three criteria: 1. A bullet is low cost. Note: the size of a bullet grows as the enterprise grows; a cannonball for a $1 million enterprise might be a bullet for a $1 billion enterprise. 2. A bullet is low risk. Note: low risk doesn’t mean high probability of success; low risk means that there are minimal consequences if the bullet goes awry or hits nothing. 3. A bullet is low distraction. Note: this means low distraction for the overall enterprise; it might be very high distraction for one or a few individuals.”  Thus, innovation is not about home runs, it starts with singles!

How do you accomplish this in healthcare?  By creating a culture of curiosity, testing, and improvement – with the discipline to stay the course.

8. What is our BHAG – our Big Hairy Audacious Goal?

In their book Built to Last: Successful Habits of Visionary Companies, Collin and Porras state:  ”A true BHAG is clear and compelling, serves as unifying focal point of effort, and acts as a clear catalyst for team spirit. It has a clear finish line, so the organization can know when it has achieved the goal; people like to shoot for finish lines.” An example of a BHAG is SolarAid‘s mission: to eradicate the kerosene lamp from Africa by the end of the decade.

In healthcare, a now famous BHAG for the entire industry was Dr. Ezekiel Emanuel‘s “limit per capita cost to 0% + GDP by 2020.”  

Has your organization developed a meaningful BHAG that resonates at every level of the company?

9. What is the right 20% to change, so as to best Preserve the Core and Stimulate Progress?

Collins advice here is to stimulate progress and innovation, while retaining your core purpose and values.

The Yin and Yang approach, as Collins describes it, makes organizational values the exacting standards that drive the organization.  These principles are the DNA of an organization.  Change is embraced, but only as it furthers organizational purpose and values.  The tension between these two forces is what keeps an organization healthy.

This is a great way to approach the healthcare transformation.  How else is meaningful change possible?

10. How can we increase our Return on Luck (ROL), adapting our strategy to both good luck and bad?

Most companies have their share of good and bad luck. What matters is what they do with their opportunities.  It’s called Return on Luck (ROL).

How can you get a high return on luck at work? Here’a an answer to that question from Collins’ co-author Morten Hansen.  The point: “prepare intensively, commit all the resources you can, and be maniacal about execution when the good-luck moments arrive!”

11. Do we show any signs of the Five Stages of Decline, and what should we do about them?

Collins explains why it’s a good idea to know where your organization stands on the road to doom and gloom:

“With a road map to decline in hand, institutions heading downhill might be able to apply the brakes early and reverse course. We’ve found companies that recovered—in some cases, coming back even stronger—after having crashed down into the depths of Stage 4.”

Where do you stand?

12. What should we Stop Doing?

If you have to-do list, then you should also have a NOT-to-do list!

An exercise worth doing: take your long to-do list (both at home and at work) and divide it into the following categories:

  1. Start doing
  2. Stop doing
  3. Continue to do
What have you learned?  Remember, saying no to something actually is saying yes to the things that matter most.

13. How will you Change the Lives of others?

This is the promised bonus question that is not on Collins’ website.  How will you Make A Difference today?  (I call it “go MAD”!)

The best leaders find ways to be useful with real people in the present. Think beyond your life as a physician. As a leader, how do people feel that you changed their lives? How can you be helpful, useful to others?

Remember, people don’t care how much you know until they know how much you care.  It was John Quincy Adams who said: “If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”  The job of the leader is to serve.

And now for some criticism. There has been some criticism of Collins’ Good to Great, most notably from Phil Rosenzweig, a professor at IMD, Lausanne.  In his book, The Halo Effect, he explains that the problem with business books like Good to Great is that they are based on faulty data. Rosenzweig urges leaders to develop their critical thinking skills, and be driven by evidence, not stories.  Here’s his take:

How does the halo effect manifest itself in the business world? Imagine a company that is doing well, with rising sales, high profits, and a sharply increasing stock price. The tendency is to infer that the company has a sound strategy, a visionary leader, motivated employees, an excellent customer orientation, a vibrant culture, and so on. But when that same company suffers a decline—if sales fall and profits shrink—many people are quick to conclude that the company’s strategy went wrong, its people became complacent, it neglected its customers, its culture became stodgy, and more. In fact, these things may not have changed much, if at all. Rather, company performance, good or bad, creates an overall impression—a halo—that shapes how we perceive its strategy, leaders, employees, culture, and other elements.

In our experience, we find that despite the criticism, the Good to Great model does serve as a useful transformation blueprint for most organizations.  Of course each organization does need to examine its own case, its own circumstances, and act accordingly.  But that is another story – we call it terrain-based strategy.

Jim Collins: 13 Questions to Take You from Good to Great (Part I)

A short while back, I met Jim Collins at the AMGA conference where he was a keynote speaker. I’ve always had tremendous admiration and respect for his work over the years, and now his message applies to our industry more than ever.

What makes a company great? In his landmark book Good to Great, Collins argues that great companies share certain attributes, among them:

    • Level 5 Leadership: Leaders who are humble, but driven to do what’s best for the company.
    • First Who, Then What: Get the right people on the bus, then figure out where to go. Finding the right people and trying them out in different positions.
    • Confront the Brutal Facts: The Stockdale paradox—Confront the brutal truth of the situation, yet at the same time, never give up hope.
    • Hedgehog Concept: Three overlapping circles: What lights your fire (“passion”)? What could you be best in the world at (“best at”)? What makes you money (“driving resource”)?
    • Culture of Discipline: ”Rinsing the cottage cheese” (a practice named after Dave Scott, the triathlon champion, to eliminate excess fat from his cottage cheese).
    • Technology Accelerators: Using technology to accelerate growth, within the three circles of the hedgehog concept.
    • The Flywheel: The additive effect of many small initiatives; they act on each other like compound interest.

Collins asks us 13 questions (his website lists 12 so the 13th question is a bonus) that help us think things through. Let’s look at each of these questions through the lens of the healthcare industry.

1. Do we want to build an enduring great company (or social sector enterprise), and are we willing to strive for Level 5 Leadership?

Level 5 Leadership is how Collins describes leaders who are humble, but driven to do what’s best for the company. You know you achieved level 5 leadership when people are willing to follow you when they have the freedom not to follow you. At the Physician Leadership Institute (PLI) we’re dedicated to developing level 4 and Level 5 Physician Leadership in healthcare. At Level 5 Leadership, the crucial factor is the selfless dedication to organizational purpose, cause, and legacy. In the PLI, we recognize that purpose is the critical factor of leadership and it is one of the five factors of physician leadership.

2. On what core values and enduring purpose will we build our culture for 100 years?

Organizational core values and belief define organizational culture. Jim clarifies that culture is strategy.  Our alignment model has demonstrated that lasting success requires leadership development that is well-targeted, high quality, delivered and embedded on-site, and customized to the unique needs of physicians and the organization. The goal is to transform physician leadership at all levels and build the next generation of physicians to successfully lead healthcare transformation.

3. Do we have the right people on the bus, and are 95% of our key seats filled with the right people?

Organizations that succeed are continuously assessing their talent.  At the top, its about getting the “right people on the bus” and the “wrong people off the bus.” Often times, organizations create difficult situations in remote areas or in a hard-to-recruit specialty, ending up with the wrong person on the bus. This sort of recruiting based on scarce talent is extremely destructive. Think: what message are we sending our team members when we hire someone with the wrong values fit? Great leaders have the ability to make superb people decisions by assessing who is best fit for the organization culture and purpose. Your company is your people. It is always about “the who.”

4. What are the brutal facts, and how can we better live the Stockdale Paradox?

The Stockdale Paradox is named after Admiral Jim Stockdale, the highest ranking US military officer imprisoned in Vietnam.  As a POW,  Stockdale was repeatedly tortured over 8 years – his shoulders had been wrenched from their sockets, his leg shattered by angry villagers and a torturer, and his back broken.

Collins writes about a conversation he had with Stockdale regarding his coping strategy:

“I never lost faith in the end of the story, I never doubted not only that I would get out, but also that I would prevail in the end and turn the experience into the defining event of my life, which, in retrospect, I would not trade.”

When Collins asked who didn’t make it out of Vietnam, Stockdale replied:

Oh, that’s easy, the optimists. Oh, they were the ones who said, ‘We’re going to be out by Christmas.’ And Christmas would come, and Christmas would go. Then they’d say, ‘We’re going to be out by Easter.’ And Easter would come, and Easter would go. And then Thanksgiving, and then it would be Christmas again. And they died of a broken heart.

Stockdale then added:

This is a very important lesson. You must never confuse faith that you will prevail in the end—which you can never afford to lose—with the discipline to confront the most brutal facts of your current reality, whatever they might be.

What are the brutal facts in healthcare? The brutal facts include:

- the transformation from volume to value – and the relentless requirement to drive down cost

- the need to work collaboratively in teams

- the need to manage population health and not episodic care

- disruptive innovations that alter the way we deliver care

- the consumerization of healthcare

- retail healthcare is a reality, quality and cost are expected to be demonstrated. What got us here, will NOT get us there!

These trends driving radical change in the industry are the brutal facts in healthcare. Physician leaders must understand, prioritize, and create a transformational road map based on existing and future organizational capabilities.

5. What do we understand so far about our Hedgehog Concept—what we are fanatically passionate about, what we can be the best at (and cannot), and what drives our economic (or resource) engine?

Collins uses the fox vs. hedgehog analogy to describe a company’s commitment to its core business. A fox knows many things while a hedgehog knows one thing and does it well.  Collins gives us three overlapping circles: What lights your fire (“passion”)? What could you be best in the world at (“best at”)? What makes you money (“driving resource”)?

Healthcare is a complex system and the prevalent temptation is to try to be good at everything versus great at fewer things. Big does not equal great and great does not equal big. How are we focused on what matters most?  Are we saying “no” to the right things?  What do we say “yes” to?  Is it technically and economically sustainable?  What do we have to change to get there?  These are the questions the Physician Leadership Institute (PLI) helps clients answer as we work with them to build a high-performance culture defined not by platitudes, but by results.

6. How can we accelerate clicks on the Flywheel by committing to a 20 Mile March?

Collins uses the story of the race between Robert Falcon Scott and Roald Amundsen to reach the South Pole. Both were accomplished leaders, but Amundsen’s team made it to the South Pole and back in time, whereas Scott’s team got there second, and perished on the way back.

\Why? What was the difference between the two leaders?

Scott displayed courage, perseverance, and determination in the face of obstacles but was unwilling to adapt his strategy when conditions changed; he neglected to learn from those who best understood the terrain; he used a command and control leadership style and failed to inspire his team or gain their trust and commitment.

Amundsen, on the other hand, was all about discipline and committing his team to a 20 Mile March on a daily basis. His success factors included:

- Terrain-Based thinking: Amundsen was willing to learn from others (he lived among the Eskimos to learn keys to survival and success in that terrain using dogs and sleds)

- Thought strategically

- Inspired and motivated people

- Managed the process with discipline (20 mile/day)

Ask: What’s my 20 Mile March? What are our organization’s disciplined goals? Is everyone on board and aligned?  What will it take to achieve commitment at every level of the organization?

In the next post we cover seven more questions raised by Collins and look at the criticism that some have leveled against the Good to Great approach.

Engaging Doctors in The Health Care Revolution

The June issue of Harvard Business Review includes an article titled Engaging Doctors in the Health Care Revolution*, by Thomas H. Lee and Toby Cosgrove.

The authors start by affirming the core philosophy of the Physician Leadership Institute, namely:

Fixing health care will require a radical transformation, moving from a system organized around individual physicians to a team-based approach focused on patients. Doctors, of course, must be central players in the transformation: Any ambitious strategy that they do not embrace is doomed.

The authors ask the all important question: how can leaders best engage physicians to redesign care?  

They make an important distinction between cooperation (an agreement not to sabotage) and collaboration(engagement in relentless improvement).

They also point out a fundamental flaw in the current approach healthcare organizations are employing:

Many organizations hope that they can win over physicians by combining good intentions with a few broad interventions, such as putting doctors in leadership roles and creating financial incentives for desired behavior. But as we have seen too often, such uncoordinated, piecemeal efforts are insufficient.  

The remedy?  The authors give us a motivational framework adapted from Max Weber’s typology of social action:

In our experience at the Physician Leadership Institute (PLI), this framework may not be enough to create the transformation. We need physician leadership to motivate, align and engage physicians. This corresponds with our Physician Leadership Model:

Leading with Strategy and Results: We believe engagement is like a muscle that needs to be exercised. After appealing to a common and higher purpose, physicians want to engage in a meaningful, relevant and tangible problem solving. Physicians do not dispute the need to focus on the patient; many believe that they already do. Our Physician Leadership Institute (PLI) gives physician leaders direct, hands-on training via our action projects that strive to solve real world strategic problems. These are  collaborative projects that build engagement and leadership simultaneously. One of our most popular projects asks: “How do you engage physicians in owning patient satisfaction?” A team of physicians work together for the duration of the Institute (12 months) to analyze why physicians are typically not engaged in efforts to enhance and improve patient satisfaction. The objective is to identify obstacles and to develop sustainable solutions.

Typically we discover, through surveys and interviews, that physicians believe in the false notion that they already deliver patient satisfaction. This is a real obstacle to meaningful change.  Over time they realize that the patient (and their families) judge their experience on the total visit and not the 10 minutes with the provider. The ultimate power of this approach is that physicians share their stories along with data-driven findings. This peer-based sharing of best and next practices is far more powerful and stimulating than simply watching videos or taking a traditional leadership course. For example, at Quincy Medical Group the initial team of physicians tasked to explore “physician engagement in patient satisfaction” where very skeptical of the process. At graduation, not only were they enthusiastic converts, but they led the training for all the physician groups (more than 200 providers) instead of hiring an outside speaker. Since then, patient satisfaction has topped 90th percentile on the AMGA survey and the organization was recognized as the most improved physician group by AMGA.

Leading People: the importance of peer-to-peer communication and influence cannot be stressed enough. PLI dedicates its mission to developing physicians into physician leaders that understand how to proactively use the power of language to influence and address the concerns of their peers. They learn how to tailor their communications to influence not just behavior, but outcomes.

Leading Self: At PLI, we provide individual physicians with a personal coach that works with them one-on-one to improve self awareness. Physician get to reconnect with their life purpose and connect it to their work. The physicians learn that their behavior has the tremendous power to influence others. They realize the impact of what they say and do could accelerate or derail a transformation.

Finally, the HBR article does not address the fundamental underlying challenge of physician engagement – trust.

Far too many physicians do not trust their organization’s administrators. We believe the techniques we use to engage physicians and administrators allow them to build trust and see the world from a shared perspective. It’s the age-old alignment conundrum. Purpose drives strategy, and strategy must be linked to operations. Operational policies must be relevant and guide the everyday actions of staff, physicians and administrators.

What is required is physician leadership at every level.

What do you think?

See also:

Why Leadership Development Programs Fail
Physician Engagement: The Outcome of Physician Leadership

————–
* Engaging Doctors in the Health Care Revolution, Thomas H. Lee, Toby Cosgrove, Harvard Business Review, June 2014

The Road to Transparency: Sharing Insurance Healthcare Data on Price and Quality

The march to healthcare transparency continues. Previously, we had seen how transparency in Medicare had raised a storm of controversy. Imagine the day when we’re able to shop for healthcare online just like we search for travel deals on Expedia.

Well, we’re getting closer with this latest announcement. The Health Care Cost Institute (HCCI) has announced that it will work with three of the nation’s largest health insurance companies, Aetna, Humana and UnitedHealthcare, to develop and provide consumers free access to an online tool that will offer consumers the most comprehensive information about the price and quality of health care services. The independent, not for profit HCCI will create and administer this information portal, which is expected to be available in early 2015. The health benefit companies will provide information on health care costs to HCCI, which will maintain and manage access to the information in a secure, protected environment. Other major carriers have expressed interest and HCCI expects additional carriers to participate in the near future and be part of the initial release in 2015. Participating insurers will continue to offer their own cost transparency tools and solutions as well. The cost data will be supplemented with quality and other information to provide consumers a transparent and comprehensive destination to make more informed decisions about health care.

Health care costs have been rising more than three times as fast as wages. Official estimates project that U.S. health spending will reach $4.7 trillion by the end of the decade – an 80 percent increase from $2.6 trillion in 2010 – underlining the need to better understand the prices of health care services to help make decisions and choices about purchasing care.

The new transparency tool that HCCI is developing will aggregate pricing data from commercial health plans, as well as Medicare Advantage and Medicaid health plans, if the states agree. The information will be available to consumers, purchasers, regulators and payers in an accessible, comparable and easy-to-use format.

• For consumers, this will provide consistent and accurate transparency in the shopping experience with the most comprehensive cost data and quality information; uninsured individuals can access more reliable information about the relative prices of care, treatments and procedures;

• For employers, this will foster more employee engagement in managing health care costs regardless of payer, health plan or plan design. This will provide a seamless experience regardless of payer;

• For care providers, this provides timely and accurate information about costs and quality and allows them to see information on other providers as well;

• For regulators, this provides a single source of information to support market studies, including evaluation of market efficiency and accurate review of cost drivers. This will help inform geographic rate adjustments and provide guidance for addressing important public policy issues;

• For payers, this provides the most accurate and timely data to meet customer needs and protects proprietary data while allowing customers access to multi-payer information.

Is your organization ready for radical transparency?  It’s coming, and if trends are any indication, it’s coming soon. What will be your strategy? Defensive? Wait for information to be out and then react? Or will you develop and post your own pricing information and let the market react to you!? Where to start? The Physician Leadership Institute is here to help.

Physician, Disrupt Thyself!

Traditional healthcare is being disrupted by new entrants – upstarts that are shifting the balance of power by changing accepted business models almost overnight.

Over ten years ago, Professor Clayton Christensen warned us:

Dominant players in most markets focus on sustaining innovations—on improving their products and services to meet the needs of the profitable high-end customers. Soon, those improvements overshoot the needs of the vast majority of customers. That makes a market ripe for upstart companies seeking to introduce disruptive innovations—cheaper, simpler, more convenient products or services aimed at the lower end of the market. Over time, those products improve to meet the needs of most of the market, a phenomenon that has caused many of history’s best companies to plunge into crisis. **

Now, the time is upon us.  Institutional disruption is here:

As is disruption of the profession itself:

A recent report from PWC brings home the reality:

The New Health Economy represents the most significant re-engineering of our health system since employers began covering workers in the 1930s. It goes beyond the recent period of convergence in which business roles blurred. Yes, siloes are coming down as providers, insurers and life sciences companies begin to coalesce around the pressure to demonstrate value. But in the New Health Economy, as the money flows from consumers to new players, today’s siloed disease treatment industry will be replaced by a wide open health marketplace. 

Of course, traditional healthcare providers are justifiably nervous, but the choice is clear. Either disrupt yourself, or be disrupted.  

And the customer/patient is ready for change. Every service you currently provide will be disrupted.

The consumerization of healthcare will bring a sea change in the market. Here are a few questions to ask at this point:

- How will we disrupt ourselves?

- Do we know where to begin?

- What are the strategic priorities?

- Do we have a framework for innovation that produces results?

- Do we have capable physician leaders to drive the transformation?

Stay tuned.

Why Horses for Leadership Development?

by Karen Kendrick
Karen Kendrick is the founding partner of Discovering Your Way and a physician leadership facilitator of the equine coaching practice we’ve integrated into our curriculum for the Physician Leadership Institute

Our approach to leadership and building strong teams using horses is uniquely different. The horse provides honest un-biased in the moment feedback to you as a leader and team member that you won’t get from a classroom setting. In their feedback they become your master teacher in the quest to be more present, integrated, congruent, and authentic leaders.

Highly Tuned Prey Animals

Horses are prey animals, with a strong flight response. They spend the majority of their time in their reptilian brains where they are sensing and feeling what is happening in their environment. Their senses have remained highly tuned where their bodies become acoustical instruments reading all that is around them. In addition, their eyes are on the sides of their heads giving them a wide view of all that is occurring.

As humans we spend the majority of our time in our neocortex, many times disassociating from or ignoring information coming from our Limbic or Reptilian brains. Our eyes are in the front of our heads, looking forward, making thing happen, focused on our goal in a linear fashion.

As humans we may ignore what our body system is telling us about a person or situation and rely only on what our neocortex is processing. The result is we cut ourselves off from accessing all the information available to us. Learning to lead in a horse like manner gives you access to a broader range of information and a wider view.

Just as horses can finely tune into their environment, they will tune into you and your team and “read” what is going on with you and respond immediately. Without judgment or agenda, the horse may choose to move away, not move, connect with you, walk with you, or ignore you completely and provide a changing mirror of how you are leading moment by moment.

When your body language is showing you are afraid, frustrated or angry, but you try to “put on a happy face” that is incongruent, you will have an involuntary rise in blood pressure, muscle tension and emotional energy. Horses sense this happening and will often mirror the suppressed emotion. They only calm down when a person recognizes that the feeling is there. The emotion doesn’t have to go away. It just needs to be acknowledged.

The moment the mask is removed and authentic feelings are acknowledged, an agitated horse will sigh, lick its lips or show some other sign of release. Horses have a keen emotional sense and cannot be easily manipulated or lied to; they are only comfortable when authentic feelings and motivations are being acknowledged.

So, with a horse you can’t demand their cooperation, finesse your way through, or hope they will just do what you say because you are nice to them. Horses ask us to step up and be congruent, present, clear, and authentic individuals and leaders.

A Strong Herd Mentality

A horse’s survival depends on its ability to sense any incongruence in its environment and respond appropriately. They highly value their social structure and their ability to work as a team. Without it their survival is threatened.

In the herd there is a clear hierarchy of leadership where the herd leader (many times a boss mare) is responsible to remain on alert, allowing the rest of the herd to rest and eat. Horses work out their positions in the herd through a process that is much like a dance about who can come into another horse’s space and move their feet. Once their positions are clear, and respect is earned, then they relax and work together as a team.

In a similar way, when we work with horses, we become our own herd. A horse wants to know if you will be the leader or they will be the leader in a particular moment. For example, if your body language communicates that you are incongruent, not clear on what to do, or are not confident you will get there, they will take over and do what they choose. As you change those factors, they will change their response to you, allowing you to practice new strategies, beliefs, and approaches.

How It Works

The Equine Facilitated Learning and Coaching model helps you learn by participating in experiential education activities with horses. Once you have completed an exercise you then process what happened, your discoveries, what behaviors and beliefs contributed to the experience, and what actions you want to take as a result. These activities are set up to relate directly to your present leadership opportunities, so the learning is directly applicable back to your workplace.

The types of questions that horses help us answer or see more honestly are: do I believe I am a leader? Do I know where I am going? Can I hold a picture of my goal in my head and focus on reaching that goal when things go wrong? How did I plan? Did I think about the things that could go wrong? Can I come up with creative ideas to try when I feel stuck and nothing is working? How do I relate to others in a team?

Through an exercise with a horse you can gain insight into your own leadership as well as how you are functioning as a team. Here are a few examples of discoveries made in a recent physician leadership training with horses:

One physician shared:

When we couldn’t get the horse to work with us in that exercise I just walked a little away from the horse and the group. I understand now that when I can’t accomplish a task right away I get frustrated and angry. I check out either by walking away or just leaving the room in my mind. When I do that I’m not able to be in the present moment looking for possibilities and creative solutions.

So, when I realized I was doing this, I took a deep breath, chuckled at myself, and helped the group came up with different strategies, which we tried and they worked! I now see how my tendency for flight makes me give up too easily with challenges at work and my team gets left without a leader. I also learned how my body tenses up and checks out so I can be aware of the signs that I’m ‘leaving the building’ – laugh. I can now make better choices for my team and myself.”

Another team member shared:

“We jumped in there with only one piece of the strategy figured out, our energy was low, we were confused, and we kept doing the same thing over and over again even though it wasn’t working!

Then when we strategized again we worked from our strengths, got clear on our strategy, raised our energy, created a clear picture of what we want in our heads, and kept tying different ideas when one didn’t work and we finally got to be a herd the horse wanted to be with.

Wow, how many times do we get angry with our team for not following us when we have no clear strategy or vision ourselves? When we kept doing the same thing over and over again, it looked so silly, but that is just what we do at work and then conclude it can’t be fixed or it can’t be done. (Laughs) Now we know when we feel that frustration we need to take a breath, back up, and look at other possibilities.”

Our training is created to relate specifically to the goals and objectives of a team and their workplace. Here is what you will take away from attending a session with horses:

1. A deep and over arching awareness of self and others,

2. The ability to receive and give effective feedback and to fully understand the dynamic nature of relationships,

3. The ability to take timely and appropriate action that springs from awareness and feedback, and

4. The capacity to develop somatic intelligence or the ability to integrate information at the physical, mental, emotional and spiritual levels.

 

Transparency and the Medicare Physician Data Controversy

On April 9, both the Wall Street Journal and the New York Times made waves with articles on transparency and Medicare.

Here’s the NYT:

A tiny fraction of the 880,000 doctors and other health care providers who take Medicare accounted for nearly a quarter of the roughly $77 billion paid out to them under the federal program, receiving millions of dollars each in some cases in a single year, according to the most detailed data ever released in Medicare’s nearly 50-year history.

And here’s the WSJ:

The top 1% of 825,000 individual medical providers accounted for 14% of the $77 billion in billing recorded in the data.

The long-awaited data reveal for the first time how individual medical providers treat America’s seniors—and, in some cases, may enrich themselves in the process. Still, there are gaps in the records released by the U.S. about physicians’ practice patterns, and doctors’ groups said the release of such data leaves innocent physicians open to unfair criticism.

The impact on the healthcare industry will be felt for years to come. In fact, we can predict that, in all likelihood, this represents a game changer for the industry:

Fraud investigators, health insurance plans, researchers and others will spend weeks poring over the information about how many tests were ordered and procedures performed for every provider who received Medicare payments under Part B, which excludes payments to hospitals and other institutions. The Centers for Medicare and Medicaid Services is making the data publicly available on Wednesday. While total Medicare spending — including hospitals, doctors and drugs — is approaching $600 billion a year, payments to individual doctors have long been shrouded in secrecy. For decades, the American Medical Association, the powerful doctors’ group, and others have blocked the release of the information, citing privacy concerns and the potential for misuse of the information. But a federal judge ruled last year that the information could be made public.

According to The New York Times,  2 percent of doctors account for about $15 billion in Medicare payments, roughly a quarter of the total.

And the best paid specialties are as follows:

The American Medical Association, which chose not to try to block the release of the information, questions the “usefulness of these payments to assess doctors.” Dr. Ardis Dee Hoven, AMA president asserts: “It’s raw claims data. This gives us no window into quality or anything of that nature.” While patients may know who performs a high number of procedures, like hip replacements, for example, they will not be able to tell anything about whether the patients needed the surgery or whether they benefited from the surgery.”

According to the reports, Dr. Hoven also cautions that doctors were not able to review the data, and some of the information being made public could be wrong. Specifically, the AMA points out several reasons why the data should not be taken too literally:

Errors
Data being released may contain errors because there is currently no mechanism for physicians and other providers to review and correct their information.

Quality
The data does not include explicit information on quality of care provided or quality measurement. It solely focuses on payment and utilization of services so it cannot be used to evaluate the value of care provided.

Number of Services
Residents, physician assistants, nurse practitioners and others under a physician’s supervision can all file claims under that physician’s National Provider Identifier (NPI); the data may not properly detail the services performed and who performed them. Additionally, there are several instances in which it can appear that two surgical procedures were done when in fact there was only one. For example, when there are co-surgeons or an assistant at surgery, the procedure should be counted as only one surgery, not two.

Charges vs. Payment
Medicare and other payers pay fixed prices for services based on fee schedules; therefore the amount paid to physicians is generally far less than what was charged and is not an accurate portrayal of payment.

Patient Population
The data being released is an incomplete representation of the services physicians provide, as it is not risk adjusted. Additionally, it does not include care for private insurance patients or Medicaid beneficiaries, making it a limited view of the patients a physician cares for.

Site of Service
Payment amounts vary based on where the service was provided. To reflect a difference in practice costs, Medicare pays physicians less for services provided in a hospital outpatient department than for services in the physician’s office.  However, for services in the outpatient department, another payment is made to the facility to cover its practice costs so that, in reality, the total costs to Medicare and to the patient may be higher when a service is provided in a facility setting.

Provider Comparisons
There is a lack of specificity in specialty descriptions and practice types in the data, which could be misleading when making comparisons between physicians. In some cases, physicians who appear to have the same specialty can serve very different types of patients, thus impacting the mix of services provided.

Missing Information
The data does not account for patient mix and demographics or drug and supply costs.

Coding and Billing Changes
Any analysis using the data should take into account changes in Medicare’s coding and billing rules that may be different over time and across regions of the country (e.g., local coverage determinations).

What does this mean going forward?  This is a time for leadership.

A few thoughts:

We have a choice: we can react or we can lead. Transparency is here to stay. The healthcare industry is going to have to prepare itself to face radical transparency the likes of which it has not faced before.  Like other industries that were transformed because of transparency, we can expect more of this in our industry. It will be best to not fight it, but rather to champion it. Physician leaders will work hard to demonstrate the entire value equation, not just focusing on costs, but showing outcomes and lifetime value.

Leading institutions including the AMA and AMGA must get better at creating self-regulating metrics and benchmarks that are meaningful in terms of outcomes, not merely costs. This is a key flaw in the current measurement regime.

Physician leaders must embrace and lead the focus on value delivery. As we pointed out in a previous blog post, achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent.

The Rx is Physician Leadership. In the words of Harry Truman – “Progress occurs when courageous, skillful leaders seize the opportunity to change things for the better.”

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