Integrated Delivery

Innovating Leadership for Outstanding Healthcare Outcomes

David Stehlik

• Publisher: Business Expert Press
• Year: 2021
• ISBN:
  9781953349576
• Topic: Negocios y empresa
• Subtopic: Sector de servicios

The 2020 pandemic proved past best practices too brittle for future challenges. An integrative model of leadership, synergizing the competing values and approaches of other models, is needed. This book focuses on the innovative leadership framework that can support emerging best practices in health care organizations. The practices of innovation and strategic management are indispensable.

Within, you will read about: •Health care's past, present, and future trajectory, •How innovation is related and required for ongoing success (and the different kinds of innovation at a leader's disposal), and •The components and practices of strategic management, and how they integrate into the three modes of leadership: anticipatory, strategic, and administrative. Each is highlighted and the attributes of supporting tools summarized.

Unlike other leadership books, this one offers a systemic and sustainable perspective. This approach is not simply a "sustain the moment and worry about tomorrow later" approach. It is a "sustain the future, integrating it into our present paradigm now" approach. Especially important is the effort taken to explain and apply matters related to uncertainty, anticipation, as well as approaching future readiness.

CHAPTER 1

The Changing Healthcare Landscape

What’s Behind the Door?

The changing healthcare landscape is our first point of contact with the conception of an integrated delivery of innovative leadership processes for the sake of outstanding healthcare outcomes. When we talk about healthcare today, even though we want to be optimistic, we are talking about a system on fire, under fire, and underwater. It is changing, being criticized and condemned, and sinking the nation financially. But, it is also necessary for the public good, incredibly complex in makeup and integration, and one of the best available in the world. Moreover, I think most readers practicing or leading in the United States are proud of what we have built and that other nations prove their systems against ours and train their people in ours, and that we have a unique opportunity to shape the sector’s next lap. In that respect, it is better to nourish rather than berate and bury the opportunity. Yet, on the whole, our healthcare system has problems. Those within and without the sector see and bemoan the failures, whether it may be the inability displayed in identifying patients correctly, quickly, consistently, and “fairly;” promoting or obstructing transparency in quality, outcomes, costs, rates, and competitive advantages; or providing quality consistency for service at all capacity levels, to both patients, staff, and additional stakeholders.

As healthcare grows, expectations grow with it. That is the nature of authority’s expansion alongside reliance and dependency. The notion that you cannot meet an expectation is often considered for the first time when it happens. The double-edged sword is that we want our stakeholders to believe we are reliable and can meet those unvoiced expectations. Such confidence keeps both parties loyal. Like with romance, there is a level of comfort and there is a level of mystery. Comfort makes us feel welcome, and mystery makes us feel special. But, is it not a bit presumptuous to think we can fool our stakeholders into thinking we are invincible–unless, of course, we have a plan and the resources to execute upon it, proving we at least supersede what they could otherwise expect from the industry? We may not be impenetrable, but we want to give them confidence that we are their best bet, and that is only one of the peaks of success. The chief end is to climb higher than realistic expectations and provide better services across the board for the long run.

Our industry also struggles with matters of fiscal responsibility, expansion, and governmental involvement. Questions constantly surround the institutions of Medicare and Medicaid and the enigma that is the Affordable Care Act. What do these three and their offspring mean for the future of payments, the nature of the insurance industry, how fees will be structured, and whether corporate healthcare will become something other. Of course, as the government becomes more involved, the problem area of public health becomes more prominent. Something that has dominated the European system while the American system has focused on private care becomes far more significant when payments are increasingly subsidized by the taxpaying constituency. Such issues will not be addressed for solutions in this book, as I do not want us to focus on policy as much as on practice. But, it is important for the sake of later considerations of anticipatory leadership: that we lead with our eyes and hearts open to the sounds of cultural angst and policy revolutions in order to rightly navigate our ships in the churning seas of change. Remember, there are only a few productive ways to interact with change: start it, amplify it, manipulate it (redirection) and oppose it. Of course, you can be carried along by it, but you likely do not see that as a leader’s best approach.

Pertaining to fiscal responsibility, we are already aware of management practices from big business applied to healthcare operations, which grate against the “do whatever it takes” mentality many have in regard to the healing profession. What we are facing is a radical notion that fiscal concern may have a legitimate place in the waiting room and operating room. For some, this is audacious: that lacking resources could be a legitimate reason for not providing care which is scarce but “available.” Certainly, proponents might argue that care is available on loan, meaning the organization is indebted for the access until someone comes along who is both in need and can pay (whether on their own or through a policy under which they are enrolled with an insurance provider). In that sense, the case made by proponents is that expensive care resources (the ones which are exhaustible and not just those with high fixed costs and near-zero variable costs which might be depreciated overlong lifespans) are at hand for access but not use—just like banks are nearby and accessible for loans, but only for eligible members. Still, when it comes to life, this seems brutish until you introduce a two-victim, one cure dilemma. Even then, when the life of an organization is considered, and that payments lead to organizational sustenance that supports the care of far more individuals, the reality of having to choose remains a highly volatile, unethical, and predatory paradigm. One thing is sure, we need to affirm that ethics matter, and so in our decision-making and leadership paradigms, we do not want to fall into the false notion that logical, value-creating decision making is ever better by not considering ethics and morals. Ethics, rightly understood, ensure our decisions protect what is truly valuable rather than discard it for things less worthy. Never forget this. It will keep you like a crown on your head.

You Know, It Wasn’t Always Like This

Surely you are familiar with the concept of not being able to know where you are going until you first know where you have been, the idea being that self-awareness and destiny are encrypted, and only reflection can help decipher and provide a right orientation for the fulfillment of your potential. Whether you believe that or not, it is helpful to understand the process by which the present state of healthcare emerged. It has taken hundreds of years to progress and entrench itself in the American way of life according to its current structure and systems. In this regard, we would be do best to receive instruction from Paul Starr (1984), author of the Pulitzer winning history, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. Starr provides the key components and framework for understanding healthcare’s evolution in the States. After he introduces readers to the origins of the concept of professional sovereignty and how authority is structured, he expounds upon how the historical beginnings of medicine in the colonies and frontiers, like in other cultures, was a mixture of religion and womanly wisdom. Bluntly, the work of medicine and well-being was considered a lesser-than role, and it was “relegated” to the work of the still considered lesser gender of women. In some respects, it might have been that men were uninterested on the whole in promoting the field for financial gain, because there was no systematization by which one could assure results of the medical practice. Without that key ingredient—the semblance of authority and expectation—there was little opportunity. In societies where men necessarily would be bread-winners, medicine was not a hot prospect for middle and lower classes, at least not for a little while longer. Until then, the only medical practice with any honor was among the elite nobles for whom the study of medicine was more related to scientific inquiry for the sake of knowledge than the bloody and dirty involvement in the affairs of “common people.”

In fact, the American system’s change away from that perspective over time due to no small swath of social, environmental, economic, and political changes, helps explain some of the main differences between the American system and the European systems that exist to this very day. Starr (1984) writes,

In early American society, medicine was relatively insignificant as an economic institution. Insofar as care of the sick remained within the family and communal circle, it was not a commodity: It had no price in money and was not “produced” for exchange, as were the trained skills and services of doctors.¹

He adds, in relation to the nineteenth century’s dramatic changes in the field of medicine across America,

The advocates of economic liberalism believed that in the care of the sick…private choice should prevail—hence their support for the abolition of all medical licensing…On the opposing side of the issue, seeking protection from an unconstrained market, medical societies tried to limit entry into practice and commercial behavior, like price cutting and advertising…medical aid to the indigent and, after the turn of the century, government and professional regulation of the drug industry. In different ways, professionalism, charity, and government intervention were efforts to modify the action of the market, without abolishing it entirely.²

Additionally, the market expansion that occurred included the transportation and communication revolutions, increasing the area of accessibility for medical care. First, this decreased the time spent to make a visit or call, so that doctors could visit and advise more patients per day. Second, this decreased the expense to families who paid the physician fees, which dropped as a result of the first’s effect on price competition. Later on, the same forces would have the effect of decreasing costs for patients visiting doctors instead of the reverse. Another expansion factor was that prior to the Civil War, the number of physicians rose faster than the population rate. A driving force of demand was the increasing urbanization that took place alongside the change from agrarian to industrial culture. One result was the distancing of work from the home, which had an additional effect of making it more difficult to attend to the sick within the family. Hospitals emerged in greater numbers in such a climate, for the sake of medical education’s growth, the general welfare of the communities and the replacement of formerly low-to-no care locations housing the sick poor, and to meet the demand for new spheres of medical influence among different practitioners who could not find opportunities to reach their medical aspirations among existing hospitals.

Starr makes the case that from after the Civil War until around 1930, the American medical sector underwent a massive shift toward professional consolidation. During this time, he argues that medicine as a profession, distinct in making rules and standards for itself, began a significant fusion process. It took decades and was at times rancorous in nature, as power structures were affirmed or denied. Intense jockeying occurred to determine who would be at the forefront and “on top” after the dust of the field’s restructuring settled. To make that work, consensus had to be established, and this struck at the heart of the social class hierarchy which was itself present among the ranks of physicians. To that end, the unification most positively impacted middle-class physicians who operated outside of the noble favor of well-to-do institutions that favored particular physicians’ heritages. The lower-class physicians, the ones more aligned with pseudo-science—especially as modernism and the emergence of faith in scientific empiricism took hold in the late nineteenth and early twentieth century—began to find themselves further exiled from the community. The middle fought for their place at the table and the upper realized their own impotence to keep professional medicine from collapsing without the middle’s support and the lower’s removal.

In too simple of terms, the lower-class physicians brought reproach on the field and did not support the emerging authority—displayed in their adherence to unapproved, unlicensed practices. This kept the upper-class physicians’ respectability from rising, for their field was one in the same. As it is said, a teaspoon of tar can pollute a barrel of honey. From a field with relatively low incomes to one where incomes progressively beat the average and would later far outstrip the rest of society, status became a major factor in the field’s rising importance to American life and how fees and incomes shifted. Starr notes, the shift of great consequence was the one in which the field slowly ceased to be competitive and became more corporate. Citing James Burrows 1963 organizational history of the American Medical Association (AMA: Voice of American Medicine), Starr (1984) points to evidence that the number of physicians who had joined the AMA had reached 60 percent of all physicians in the country by 1920, dating that period forward as “organized medicine.”³

The establishment of medical societies and the large memberships they gathered helped the medical field establish self-regulation and assert itself against remaining competition, specifically the authority of the pharmaceutical makers. Physicians gaining credibility through respectable education apparatus gave way to the doctor as gatekeeper and trusted advisor of health. This increased dependency on doctors resulted in what Starr (1984) called a retreat of private judgment.⁴ With the transfer of care, best judgment, and authority from the home to the hospital, medicine was primed for a new status at the heart of American society. Scientific developments at the biological, chemical, and technical-tool level forced a wave of advancement upon the profession. And, “by providing more accurate diagnosis, identifying the sources of infection and their modes of transmission, and diffusing knowledge of personal hygiene, medicine powered the improved effectiveness of public health.⁵” Furthermore, the nature of hospitals themselves changed, shifting from communities to approximate more formal business organizations. Starr points out,

Early hospitals had a fundamentally paternalistic social structure; their patients entered at the sufferance of their benefactors and had the moral status of children. The staff, who often resided as well as worked within the hospital, were subject to rules and discipline that extended into their personal lives. A steward and matron, who might be husband and wife, presided over the hospital family. As the hospital has evolved from household to bureaucracy, it has ceased to be a home to its staff, who have come to regard themselves as no different from workers in other institutions.⁶

Perhaps the most significant change that occurred was that which dealt with the philosophy of diagnosis in general. Prior to the shift in technology and instrumentation, Starr (1984) points out, “physicians depended in diagnosis primarily on their patients’ account of symptoms and their own superficial observation; manual examination was relatively unimportant.”⁷ Thus, over time, the medical profession took on a status of being mindful of and privy to a special class of understanding, which tethered vital information to the complicated operation of particular tools and machines and the difficult and deft interpretation of the tools’ results. From the patients’ perspective, the separation of diagnosis from either their own (patient’s) explanation or the doctor’s capability to observe without aid, promoted a sense that medicine was unquestionably accurate. We can probably see here that such logic is powerful, for you cannot argue with machines that simply perform their task without prejudice. What we did not account for, however, was that such machines only produce results in keeping with our paradigm and only operate according to assumptions upon which they were built. Still, they have had great effectiveness and advanced the field significantly, supporting the healing, saving, and protecting of countless lives in the process.

Hopefully, this brief synopsis of some of the radical shifts that helped construct the medical complex of the twentieth century proves an important lesson as how various forces will result in significant industry changes—many of which may be unpredictable. However, unpredictability does not mean devastating or need to be fear-inducing. It does mean we need to have a better eye on what shifts are taking place in society that may or may not have any semblance of direct relationships with healthcare. Just as the telephone and automobile changed the locus of medical authority and venue of medical service from home health to private practice and eventually the rising hospital system superstructures, so too can mobile phones, medical information databases, virtual reality, 3D printers, and other technologies (not to mention social issues!) press forth their own agendas. That kind of awareness is anticipatory, and it should be a crucial component to our leadership docket. Moreover, it needs to be conducted in the right way. Many can say they keep abreast of issues and monitor changes in their sectors and some beyond them, but that is not foresight in the sense needed. That is more helpful than not doing anything, but it is insufficient to be considered a profitable leadership practice. We will discuss that more in chapters 4 and 5. First, we will first look at where leading experts believe the industry is headed. From their launching pad we can make headway toward a responsive strategy.

The Map Says We Are Here, but Where Is Here?

I present the following findings from credible analyses of the shape of American medicine in 2015 and what that might mean for how much was changing and has changed since. To start, we will consider Bain and Company’s Front Line of Healthcare Report 2015, which pointed out from its survey of 632 physicians across specialties and 100 hospital procurement administrators in the United States, that:

• There has been a noticeable shift toward management-led organizations by physicians who have changed employment,
• Emergency medical record (EMR) use had dramatically increased, along with treatment protocol use,
• Some areas within the country are susceptible to a faster pace of change than others (citing Massachusetts compared to Mississippi and Alabama respectively),
• Physi...