Leading From the Middle, 3Rs of Success

is_150828_middle_management_tug_o_war_800x600If you are a Middle Manager like me, you know you have the hardest job in the world.  If you are going to be successful in this role I have learned there are three traits you will have to acquire:

Be Resourceful:  Since you are not at the top of your organization you cannot prioritize your initiatives.  This often means you will have to be creative and find other revenue streams, other cost savings, and creative options to make your projects happen.

Be Relational:  Many times you will not have all the resources you will need to make things happen, so you will have to rely upon relationships you have created and good will you have established with others in your organization.  This means you will have to give more than you take.  Genuine servanthood will be key to achieve things when you lead from the middle.

Be Resilient:  Despite your best efforts, sometimes your priorities will not rise to the top for the organization, or worse yet they do and you fail to make the priority successful.  It will happen if you lead from the middle long enough.  When it does you will have to brush it off and start looking for the next way you can have impact.  You cannot lead from the middle while looking backwards.


A Patient’s Progress: A Healthcare Allegory

One night, I had a dream.  In my dream I saw a man standing outside a gleaming city of tall buildings, connected by skyways.  There was a hustle and bustle of people from all walks, dressed in all manners of garments from business suit and tie, to dirty work clothes.  From beautiful middle eastern garments to “pants on the ground” gang colors.


The man stood in front of the most prominent building in the city and read a sign over the entrance that read, “City of the Infirm.”  The man was in obvious pain and distress.  With a deep breath to gather courage, he entered the grand portal and stepped inside.  He was greeted there by a magnificent foyer that seemed to extend forever in all directions, including up.  The architecture featured Mahogany and stacked stone, water features and hanging plants, but he could not determine where he should go.  There were signs everywhere, pointing in every direction, and some of them were color coded with corresponding directional lines on the floor.  People were going every which way; many of them in white coats and different colored uniforms.  They all seemed too busy to help him find his way, so he wandered…

After a time, the man stumbled upon a desk with a sign labelled “Information.”  There were several people in line at the desk and he fell in behind them, and watched for a number of minutes while a very nice older lady attempted to answer questions and give directions amid incessant interruptions from a phone on the desk.  Finally, it was his turn!  He explained that he was very sick, did not have any appointments, but needed someone to help him.  The very nice lady told him to follow the red line on the floor to the Department of Emergency and ask for the Nurse of Triage, who would tell him what to do next.


The man did as he was instructed, and, after a time, found himself at the end of a hall, entering into another large lobby with rows and rows of chairs, TV’s playing, and all manners of people.  Many of the people where crying and moaning.  Some of them had towels and bandages wrapped around injured appendages.  Others were asleep in the chairs, and yet others stared at the TV’s with lifeless expressions of disinterest.  Then the man saw another desk with several long lines.  He picked one and waited his turn while several nice clerks asked the same questions to each person.  “What is your name?”  “What is your date of birth?”, and “What is the nature of your emergency today?”

When it was the man’s turn he answered, “I am called Much Afraid”, gave his date of birth, and explained that he felt like he was going to die if he did not receive help.  The clerks told them that someone would be with him shortly, and placed on his wrist a plastic bracelet with his name and date of birth.  They told him that he is now a “Patient”  and that is what he should be by taking a seat. So, he did. He then watched as people in the same colored uniforms stepped out of a row of doors on the opposite side of the waiting room from where he entered, calling every name under the sun except his.  Then, he finally heard his name.

The man, still obviously in pain, struggled to his feet and shuffled to the one who called his name.  She told him that she was the Nurse of Triage, asked him his name and date of birth, and compared it to his wrist band.  He asked why she did that and she told him it was to keep him safe.  She said he should make sure everyone did the same while he was in the City of the Infirm.  She took him through the door and asked him to have a seat on a rather strange type of couch covered with butcher block paper, a thought which made Much Afraid, more afraid!

She then proceeded to ask many questions about him, his family, and the nature of his illness.  She put instruments in his mouth, on his finger and around his arm.  She stuck his arm with a needle and collected tubes of his blood.  Finally, she connected a machine with wires to several spots on his chest and abdomen, and the machine printed out a long strip of paper that the Nurse of Triage studied intently.  When she was done she said that his complaints were serious, so they would have a doctor see him right away.  She said she would be right back, and went out a different door than they had entered, the long strip of paper in her hand.

She returned with a man in a white coat.  The man introduced himself as Doctor E.R.  He asked Much Afraid for his name and birth date and compared it to his wrist band.  He told Much Afraid that he was in grave danger, but that he was in good hands.  He said that they needed to take him to the Laboratory of Cardiac Catheterization because his heart was in distress, and Doctor Cardiology would be the best person to see what is going on.  Then, a team of people in different uniforms swept into the room, put him on a rolling stretcher, and whisked him through the back door of the exam room.  They rolled him for what seemed like forever through many halls, through a tunnel, around many turns and up an elevator. Then the stretcher came to an abrupt halt.


Much Afraid looked around and he saw he was in a room full of machinery that looked like a mad scientist’s torture chamber one might see in a science fiction movie.  Then, as the team of people lifted him from his stretcher to a long thin table in the midst of the machinery, a lovely lady in a white coat introduced herself as Dr. Cardiology.  She asked Much Afraid for his name and birthdate and compared his answers with the bracelet.  She then explained that he is now known as Patient STEMI and that they needed to perform a procedure to save his heart and his life and asked his permission.  He told her he was Much Afraid, but she assured him that she had performed this procedure on hundreds of Patient STEMI’s and many of them had moved on from the City of the Infirm to the State of Well-Being.

Much Afraid had heard of that land and very much wanted to go there, so he consented to the procedure.  The team of people started a buzz of activity.  Clipping hairs, poking, sticking, and calling out to each other with instructions, questions and answers.  Then they put a needle in his arm and hooked him to plastic bags of liquid with long plastic tubes.  They told him he would begin to feel calm and relaxed, and he did.  Soon he awoke to the pleasant face of Dr. Cardiology.  “Patient STEMI, you did great.  We fixed the problem in your heart and you are well on your way to the State of Well-Being!  Much Afraid was ecstatic, thanked the doctor, and cried tears of joy.  Dr. Cardiology said, “get this man a new bracelet.  He is no longer Much Afraid, he is now Hopeful!” The team did as she instructed as “Hopeful” drifted back to sleep, relieved of all his burdens and cares.

When he awoke, he was in a real bed in a room that looked more like his bedroom at home, though he was still hooked to a bag of fluids and to another machine with wires.  A man entered into his room and told Hopeful he was Nurse Harried, a Nurse of the Floor, and was there to give him his medicine.  Hopeful took the medication as instructed, and made pleasant conversation with the man as he went about checking the fluid, and the machine, and writing things down.  The nurse soon bid farewell and started washing his hands at the sink when Hopeful had a terrible feeling in his chest.  Then he looked, horrified at the Nurse of the Floor and said, ” I am once again “Much Afraid,” and no longer “Hopeful.”  The Nurse looked at him curiously and then became very much afraid himself, as he said, “Is your name not Stable?”  Nurse Harried then realized his mistake.  He had given the medicine to the wrong patient.


Much Afraid remembered the instructions of the Nurse of Triage, “Make sure everyone checks your name and date of birth, it will keep you safe.”  Much Afraid could not help but laugh at the irony of surviving a heart attack and then dying from a mistake, as the pain in his chest subsided and darkness fell over him.  Somewhere in the distance he heard a loud voice calling, “Code Blue!, Code Blue!”  It was obvious he would never travel to the State of Well-Being.  He had lost his way, forever.

If you have ever had one of THOSE weeks, READ THIS!

If you know me personally, or have read my blog for any length of time, you would probably agree that I am the glass half-full guy; the can-do guy; the annoying guy at the coffee pot at 7:00 Monday morning seeming as though he’s happy to be back at work!  That being said, there is one guy that takes that kind of attitude to a level that even annoys me!

The man is Alistair Humphreys, motivational guru who has a quote that keeps popping up in many different podcasts to which I listen.  “Do what you love and you will never work a day all your life”  (by the way, I think Confucious was first to the party with a very similar quote).  Reading through his blog, he is motivating people to find their passion and get out of dead-end jobs they hate and head for the hills.  I think that is a worthy calling and applaud his endeavors.

Here is my issue.  I am a Healthcare Administrator.  I love my job.  It is my calling and I am passionate about leading and about providing world-class healthcare to people in an affordable manner. IT IS, HOWEVER, WORK!  Some days that work is easier than others, and SOME WEEKS, well some weeks are just HARD WORK!

Have you ever had a week where everything you are working on came to a pinnacle, and all the plans you had crafted seemed to evaporate and devolve into chaos? Have you ever had a week where you felt you were transported from your work place into an episode of the 1960’s TV series, “The Twilight Zone”  and found yourself in some kind of surreal carnival?  One minute you are in a “fun house” that is anything but, looking at yourself in a hall of distorted mirrors thinking, “this is not what I am, this is not where I belong,” with people jumping out from unexpected places yelling and screaming, trying to direct you further into the trap.  The next minute you find yourself stuck in the midway game, “Whack-A-Mole” as one of the moles.  You stick your head out of the hole looking for escape, only to be slammed back down by a kid with a rubber hammer, over and over again!  Finally, you are on the four tentacled ride, the “Scrambler,” in one of the four cars at the end of one of the four appendages being slung as fast as possible in one direction, and then turned 120 degrees and slung in that direction, all the while looking like you are going to crash into the other cars!  You may even like the ride at first, but in this nightmarish week it seems to never stop.  The constant changes in direction, loss of balance, and disorientation makes you sick!  You want off the ride, but it just kept going and going and going!

Finally, it stops.  It is Friday afternoon and you are able to get off the ride.  You go home and tell your wife about the horrible week and she consoles you.  You go out to dinner at a new place and enjoy each other’s company.  On Saturday, you go to lunch with your in-laws, whom you love, and later pick up your son who has been apart from you for a week of vacation with your brother’s family.  Sunday you spend the day on a mountain lake with your best friend and his family.  Life is GOOD!

The moral of this story is that meaningful work, for most of us, is still work!  I think there is much work that would never get done if everyone excluded from their consideration things that are hard some days, or weeks, or even years!  If everyone “ran for the hills” and sought work that never felt like work, there would be a lot of unmet needs in this world!  If you believe in servant leadership, as I do, please encourage each other.  Your work is important!  Do NOT give it up because it is hard at times.  If, however, you cannot go home on Friday and have a life outside the twilight zone, then you may need to run for the hills.  Otherwise, realize that the Monday following a week in the twilight zone is likely to be more normal.  As my mom used to tell me when I would get worked up, “this too shall pass.”



Goal Setting: Ready, Fire, Aim! Oops!

I never seem to get where I want to go as fast as I want to get there.  Does that mean I failed?

I work in healthcare, and things my team sets out to do have serious implications.  If we set a goal of implementing a new chest pain protocol by July 1st to reduce the length of time from door to definitive diagnosis for chest pain patients from 27 hours to 16 hours, and the protocol does not get implemented until September, and the length of time only drops to 18 hours did we fail?  Absolutely not!  But if my team’s raises or bonuses were tied to those hard numbers, and therefore the team did not get rewarded, would they feel like they have failed?  Of course!  Such is the danger with aggressive goal setting as a leader.

On the other side, if all we are looking to do as a leadership team is put goals in place that are easy to achieve so we all get bonuses, we will constantly lag compared to market leaders who take risks and innovate.  So what is the answer?

I believe the secret is all in the “aim.”  If you want to hit the target of being best in class, these three tips on aiming will help you hit the mark:

Aim High

The great motivational speaker Les Brown said, “Most people fail NOT because the aim to high, but because they aim to low and hit the target.”  Many organizations fall into this trap.  They hit their goals and make their budgets year after year, yet they fall in the middle of the pack compared to the competition.  Why?  They have no stretch in their goals.  Nothing to make them strive and innovate.  Nothing that will differentiate them from the herd.  They are the organizations of which Jim Collins wrote when he talked about Good being the enemy of Great.  If you want to be great, aim high!

Aim Small, Miss Small

My favorite movie of all time is “The Patriot.”   My favorite scene in the movie is when Mel Gibson’s character takes his two very young sons, probably 8 and 10, to rescue his older son that has been taken into captivity by the redcoats.  The 10 year-old is scared to death as his father hands him a gun and he realizes he is getting ready to shoot at soldiers.  His father stops and looks him in the eye, grabs him by both shoulders and asks, “What have I taught you about shooting?”  The son answers, “Aim Small, Miss Small.”  The wise father knew that if the boy shot at a line of 20 red coats, they could not win. But if he focused on his small target, one six- inch patch of red cloth at a time, their chances would improve.

“Aim small miss small” is good advice in business as well.  Goals need to be cascaded in a way that is focused.  Let’s say there is a facility goal of making 4% operating margin (typical for a hospital).  This principle would tell us to make goals focused on what the individual manager or team member can TRULY contribute to that goal.  For example, housekeepers may have a goal for turnaround of rooms between patients, nurses may focus on patient satisfaction to improve word of mouth and grow volume.  The business office might focus on reducing A/R to improve cash flow so we can pay accounts payable in 10 days and get a 2% discount on our payables.  Decision support might commit to developing meaning financial performance dashboards for key areas, etc.

Instead, we usually see this goal cascaded to managers as “achieve budget targets” then volume drops, managers cannot bring in business, fixed costs have to be covered, budgets are not achievable, and leaders are de-motivated by their goals.

Aim to Please

The final key to goal setting is to make sure your aim is focused in the right direction.    Too often our goals are focused on what is good for us personally or our organizations.  Actually, that is like pointing the gun at ourselves.  We all know the likely result of that activity!

Instead we need to “aim to please.”  By that, I mean “to serve.”  In hospitals we aim to please patients, for you it may be customers.  Whoever it is your business is aiming to reach, filter every goal you consider against the question, “Will that goal help us serve?”  If not, it is not worthy of your time and attention.  Eliminate it and move on to one that does.

My First E-Book is on Amazon!

Check it out:

Three R’s of Success in Healthcare


This book is about how to succeed as healthcare leaders in this complex, difficult environment.  How can we deal with Obamacare, ACO’s, and CMS penalties for things beyond our control?  By Getting Back to the Basics, of Course!

I look forward to your feedback!

Break Through the Barricades

imagesYesterday was a tough day.  It is budget season, and my meeting with leadership to discuss my capital priorities resulted in a total flip of my original rankings.  There is sound reasoning behind the decision, but it killed my main strategic priority for the next fiscal year and I was truly disappointed.

This morning, I was driving to work; still feeling defeated; replaying the discussion in my head; thinking about how I could have presented things in a more compelling manner; remembering getting side-tracked.  In short I was wishing for a do over!  I actually remember thinking to myself, “I guess I just need to let it go, and do what I can with what I have next year, and leave it at that.”  Just as I was thinking that thought, I arrived at our employee parking garage.

I pulled into the two lane entrance and there were 2 cars in each lane in front of me.  No movement.  Two cars pull in behind me.  Still nothing.  Within 60 seconds there were 12 cars lined up out into the road blocking traffic both ways.  The first two cars were just sitting there, nobody was doing anything.

So, I got out of my car, and briskly walked to the front of the line.  I swiped my badge for both drivers and the barricades lifted, allowing the first two cars to enter the garage, and the next two to pull up behind them.  I hurried to my car, and soon was in the garage myself.

As I drove to my usual parking place it occurred to me… That is my job as a leader.  I remove barricades that allow others to accomplish their work.  My failure to secure capital for next year’s strategic priority was one of those barriers.  There is work to be done. Since that work is healthcare, if I let the barricade stop us lives will be adversely effected.  I determined not to give up on the priority, but find a way to remove the barricade.

The rest of my morning I called and/or met with various leaders on how to accomplish the strategy without capital funding.  By mid morning, after some great input by people smarter than me, we had a working hypothesis that might just enable us to get where we want to go!  Further analysis is required, and approval is far from certain, but if that does not work we will go back to the drawing board and find another way.

I have done everything in healthcare from cleaning grease traps in dietary to gold shovel ground-breaking ceremonies as a Hospital CEO.  In my opinion, middle management is by far the hardest role.  You cannot set the priorities, yet all the people you lead expect you to provide them with the tools they need to do their jobs.  When that gets tough, you cannot (or at least should not) blame “Administration.”  In fact, to them, you ARE Administration!

To all of you serving in the middle, regardless of industry, thanks for the work you do. People’s jobs depend on you doing them well.  Healthcare middle managers, as you know, not only jobs, but lives depend on you!  Be proud of your role.  If you succeed in the middle, you can succeed at the top!



The World is YOUR Stage. Act II, Scene 1

There I was in the quarterly leadership meeting with 150 other leaders in my health system.  The speaker, talking about the challenge of labor force and leadership shortages, had us stand up in age groups:

Under 35 years old; my boss stood up, I did not.

35-45; the new Chief Medical Officer stood up, I did not.

45-55; I stood up.  I looked at my fellow group members.  Great leaders, lots of wisdom, men with gray hair and/or very little thereof.  I thought to myself…”It is official… I am one of the old guys.”

I turned 50 on my last birthday and I have had a lot of similar conversations with myself since that milestone.  I have been blessed in every every arena of life.  I have so much for which to be grateful.  Not far down the list is that I am engaged in IMPORTANT, MEANINGFUL WORK.

I have choices at this point in my life.  Like many of my contemporaries, I am in a position to embark on a second act career.  I could find something that is fulfilling, learn new skills, and pursue my passion.  After all, I have worked, and saved, and I owe it to myself to self actualize, right?

In my case, what all this introspection has done is reinforce how my vocation of leadership in healthcare is needed now more than ever.  My  self actualization has led me to re-awaken a passion within me to “be the change (I) want to see in the world.” as Ghandi emplored.  I am challenging myself to go outside my comfort zone, be an even better leader, and learn new skills.

In effect, I have engaged in my second act career, but chosen to do so on the same stage as my first 30 years!  I am thrilled that I have that opportunity!  I have not been booed off the stage yet, so I must be doing something correctly, right?  There may be an Act III in this play as well, but I am too busy learning my role and growing in my craft to think about that right now.

Here is a challenge to other successful leaders, healthcare or otherwise.

  • Will you continue growing in your craft, treating the applause you have worked so hard to earn as an encouragement for an encore, and not the curtain call?
  • Will you continue to step up and help society face our many challenges with your time-tested wisdom and strong effective leadership?
  • Will you consider that radical revolution may NOT be the answer to self fulfillment.  Instead, a real-time renovation inside your vocation might allow you to move forward without first backing-up.

I ran into a long-time colleague on Linked-In recently who told me she hopes her friends will tell her when it is time for her to hang it up.  I am here to tell her and others; if you can engage and rekindle your passion, this is exactly the time we need your leadership!


Part Two: 3 R’s of Success in Managing Across the Acute Care Continuum

This blog is part 2 of a guest post at http://www.acutecarecontinuum.com/Home.aspx.  Please check out their blog as well for much more on this topic.

In my part 1 post on this topic, I said that the first R of success in managing the continuum is to “Resolve what you can.”  I pointed out that we have tremendous opportunity to be more effective and efficient in managing the acute care continuum, and that it is crucial we do so in this era of shrinking reimbursement and an aging population.  If we do not, the organizations we lead are at severe risk.

In this post, we will cover the other two R’s needed to succeed in this regard.  The second R is:

Refer What You Cannot Resolve

Even if we resolve everything possible at every stage of the acute care continuum, there are still cases that we must refer.  Using the ED as an example, if the patient needs more diagnostic testing or treatment than the resources for an ED visit affords, the patient must be referred to a level of care that has the resources to render the appropriate services.  The first question is where:  observation or inpatient?  Next, to the care of whom: hospitalist, cardiologist, pulmonologist, gastroenterologist, etc.?  All of these questions stem from our initial diagnosis.  Making the right decisions on these referrals will result in efficient and effective care.  On the other hand, wrong decisions will have the opposite effect.

It does not stop in the ED.  When the patient gets to the inpatient floor and has a complication, the nursing staff has to be able to identify it early and involve the hospitalist who needs to order the appropriate testing and/or consults with specialists to address the issue.  Then, the specialist and hospitalist need to agree on what should be done before the patient leaves the acute care setting, and what can wait and be done in an outpatient environment post-discharge.


Reinforce Right Living—the Third R


Lastly, when patients are leaving our care we have an obligation to reinforce with them the things they can do to help them succeed.  We must do this even if we know that they have heard it before and failed to heed this wisdom.  This is because we never know when a patient will be ready to receive what we have to say.  Circumstances change, and life teaches everyone.

My own mother was an example of this.  She smoked one to two packs of cigarettes from her teenage years until she was almost 50 years old.  She tried to quit several times, but could not seem to “kick the habit.”  Then, her mother had a battle with breast cancer.  That flipped the switch for my mom.  It took her from the knowledge that she should quit smoking, to the understanding that she must quit smoking.  Lessons can build on each other and people who have never “got it” before may be able to get it today, tomorrow, or next month.  We never know if and when that day may arrive for the patient in front of us.  Do not let cynicism dissuade us from delivering the education and information that, this time, might get through to the patient and set him or her free from the things that are causing pain and suffering.  Do not shortcut on discharge instructions, follow-up calls, and patient education about the conditions that beset them.  Ultimately, that information, if received, is what can cause them to be able to live well.

So, healthcare reform is here and we need to keep people well and out of the hospital.  Maybe we will get there in the future.  But today, we can improve care and efficiency if we concentrate on the 3 R’s of Success in managing across the Acute Care Continuum:

  • Resolve What You Can
  • Refer What You Cannot Resolve
  • Reinforce Right Living

It will require a team effort that cannot tolerate organizational silos, egotistical or turf battling behavior, short-sighted cost cutting by out of touch administrators, or any of the other couple dozen dysfunctions that adversely impact our organizations today.  It will take a cultural revolution that truly puts the patients at the center of all our efforts, rather than trying to cycle them through our systems and processes at our convenience.

This is only my opinion, of course.  But it is an opinion built on my experience.  I have been a healthcare leader since 1985.  We have faced many challenges in my career and I do believe this set of circumstances is worse than any of the preceding ones, but healthcare will always be needed and provided.  It will always take dedicated, compassionate, thoughtful leaders to do it well.  My current mission is to encourage hard-working, experienced, healthcare leaders not to quit at this critical time of change.

Stay in touch by clicking the Follow button in the lower right corner of your screen.  Use the comment field to let us know if you agree or disagree with what you read here.  A lot of you are much smarter than I am!  We would love to hear from you.


3R’s of Success in Managing Across the Acute Care Continuum

This weeks blog is being republished from a guest post I did on acutecarecontinuum.com .  I am so glad to have the opportunity to do this guest blog.  As we prepare for the most overwhelming period of change in US healthcare, I thought I would share my views on what we must do to continue delivering the best care possible in the new healthcare environment.


I know that government payers want hospitals to spearhead networks to keep people well. The reality is that there is so much that effects wellness that will never be handled by anything a hospital can do.  So many health problems result from lifestyle choices that no amount of education can seem to change.  Who in America is not aware that smoking, overeating and a sedentary lifestyle kill; and yet these behaviors persist.  I have seen many hospital systems try to reach their programmatic endeavors into arenas to try to change those behaviors.  I truly wish them success, but I cannot advocate that acute care organizations invest much in these approaches.  Instead, I believe hospital systems need to get back to the basics of managing across the Acute Care Continuum.  Just as there are 3 R’s of Education (reading, riting, and rithmetic), so there are 3 R’s in managing patients across the Acute Care Continuum:


Resolve What You Can


Whatever stage of the Acute Care Continuum you are involved with, be it emergency department, inpatient floor, or discharge planning, you are given the charge to resolve what you can at that stage within the resources allocated by payers for that purpose.  Is that an unbelievably difficult challenge?  You betcha!  Is it going to get even more difficult in years to come? Absolutely!


That reminds me of a story…


There was a ten year old boy who loved gold fish.  When he was on vacation with his family one year at a beach resort he saw the biggest gold fish he could ever imagine.    He asked one of the hotel employees, “What are these fish called?”  “Koi,” the worker answered.  “Where can I buy them?” the boy inquired.  “You can probably go online and find a way to have them shipped to you, he answered.”


The boy went to the business center at the hotel and in a matter of minutes found an eBay ad for 6 koi.  He had an eBay account that he and his dad used to sell things they bought at yard sales.  He put a bid in, and sure enough, he won the bid.


The next day his family went home.  As soon as he could break away from the family he went to the garage, got a shovel, and headed for the back yard which was partially lawn and partially wooded.  He went about 20 yards into the woods and started to dig.  He dug and dug and dug until he had a hole to make a pond.  It was about 3 feet deep and 6 feet around.  He was so proud and could not wait until the following day!


That day came and he spent all morning on the front porch in a rocking chair.  He could hardly contain himself when the moment finally arrived and a FedEx truck pulled up out front.  The driver came bounding out of the back of the truck, pulled out a dolly and a crate, and started up the driveway toward the porch. It seemed to take forever for the driver to get there.  After the boy quit trying to talk the man into leaving the crate with just his signature, he got his 18 year old sister to sign and the man left.  The boy started ripping into the packaging over his sister’s objections and taunts of the impending doom when their parents got home from work.


Inside the crate was a foam cooler, which contained a plastic cube filled ¾ to the top with water, a battery operated aerator and, of course, 6 beautiful koi.  The boy tried unsuccessfully to pick up the crate but this was no ordinary 10 year old.  Quick as a lick, he was in motion.  He ran through the house, out the back door, and at the corner, down the stairs, he grabbed a hose and the bucket that his dad used to wash their cars.  He filled the bucket, and with the water still running made a b-line to the hole in the woods with the hose.


Thirty minutes later he returned with the end of the hose and turned off the water.  Grabbing the bucket, he went around to the front porch and freed his captive koi, one by one, using the bucket to transport the koi to the newly made pond.  By noon he was done and 6 beautiful koi swam in the small pool.  As the boy elatedly fed them, the koi chased the small food pellets that were shipped with the fish.  After they had enough to eat, the boy laid down by the pool and let his hand hang over the edge where he would occasionally feel one of the koi brush against his fingers.  The boy had never known such contentment.  The warm sunlight streamed through the mixture of evergreens, oaks and beech trees.  The boy closed his eyes and drifted to a sleep filled with sweet summer dreams.


His slumber was disturbed by the sound of an engine, followed by the screech of a garage door rising.  The boy immediately leapt up to go greet his father before his sister was able to put him in a foul mood.  The boy was successful.  He greeted his dad as the driver side door opened.


“Dad, Dad, come with me you have to see what I have done!”  OK son, OK.” the father said, “let me get out of the car first!  What is so important?”  “Just come see, in the back yard,” the boy cried, grabbing his dad’s hand and tugging him all the way to the home-made koi pool.  The boy’s youthful exuberance was suddenly cut short.  As the father and son reached the little pool, six koi were floating belly up.  The boy stood in stunned disbelief, then tear filled eyes looked up to his father to try to see if there was anything that Dad could do.  The father’s answer was not what he wanted to hear.  “I am so sorry, son.  This small still pool of water just did not have enough oxygen to sustain these six large fish.”


The lesson is this.  In healthcare, we have a limited pool of resources.  The top line of available resources is not going to move.  Profit will be made by volume/market share growth, efficient delivery of healthcare services, and effective treatments of conditions and diseases.  While some providers will be up to the challenge, most will not.  Those who are not able will go the way of the koi.  The question thus arises, which are WE going to be?  The adage “patients first and foremost” is still true, but today the care we can render is limited by the available resources , and those resources per aging person in need of care will be more scarce until the baby boomers leave this planet.  As a result, healthcare leaders have to be the ones who deliver the changes to serve our communities well.


What does that mean we need to do?  In order to Resolve what we can, we must render:


The right diagnosis, the right treatment, and the right staffing.  This is true for each stage of the Acute Care Continuum, but let’s first talk about the Emergency Department.  The vast majority of the ED patients can  right treatment,be ‘treated and streeted.’  But that requires the right diagnosis in order to deliver the right treatment.  Well over 90% of the ED visits are handled in this manner.  The problems caused by a wrong diagnosis is that there is a risk of streeting someone who needs more treatment, (thus raising liability and patient risk); or treating someone that really should have been streeted (which creates waste and throughput issues).  Furthermore, it’s possible to utilize the wrong treatments that are ineffective or contraindicated, which causes harm or waste.  Finally, we can do all of these things correctly, but just by not be staffed adequately, we can see delays that lead to waste, throughput issues, and/or poor clinical outcomes.

I will give you the last two R’s for managing across the acute care continuum next week.  You can catch it first at acutecarecontinuum.com, next Tuesday, 4-16, for those who are anxious to know what they are!

It’s Scary Out There! Healthcare Leaders Must Have Brave Hearts!

I heard a Podcast today with Jon Acuff as the guest.  John is an author, a blogger, and is having a tremendous impact on Gen Y’ers by teaching them (and a few of us old folks too!) to follow their passions without destroying their lives.  Or, as the subtitle of his Wall Street Journal best seller Quitter puts it, “Closing the gap between your day job and dream job” without creating a nightmare!

On this Podcast, John made the statement that “Fear only bothers you when you do things that matter.”  As healthcare leaders we do things that matter, EVERY DAY!  Do we face fear today?  How can we not?

If it is not enough that CMS has contracted with all the HMO’s for everything that is already discounted due to APC’s and MS-DRG’s, and further look to strip reimbursement with ACO’s and leverage the new ICD-10’s.  On top of that you have the OIG lurking around reviewing all the RAC’s hoping that they also may stumble upon improper inurement in our PHO’s and IPA’s  Next, IT dumps on us the task of preparing for meaningful use in our EHR’s and PACS in order to achieve higher scores on our HCAHPS and QI core measures.  All of which will only become 5 times more important under PPACA when we lose our ICTF and DSH funding since everyone will abandon their traditional HMO and PPO plans for one of the government sponsored plans.  Then, though we will no longer have the uninsured, we will have the under insured with high deductibles and co-pays backed up with underfunded HSA’s, HRA’s or maybe FSA’s.  So, in the end, we still will not get paid for delivering healthcare services, meaning the only way to get paid is under capitation by keeping everyone well and out of the hospital.  Only, we all know that task is beyond all reasonable hope for success!

Almost every week I hear about another physician, nurse/clinical leader, or administrator who is calling it quits.  I am not talking about people in their seventies, I mean folks in their 50’s; a decade I now relate to personally!  They are tired, frustrated, and disillusioned.  Shifting sands of reimbursement, cost cutting exercises by healthcare institutions, perennial staffing shortages, and an overall leadership vacuum in the midst of the most tumultuous healthcare environment imaginable has stolen our hope.  Why?  We no longer believe we can succeed.

I disagree.  I believe we can succeed.  Furthermore, people’s very lives depend on our success.  How can we succeed?  By doing what we can do, and not concentrating on what we cannot!  Tom Rath, author of the #1 Wall Street Journal best seller, Strengths Finder 2.0, asks the question, “Do you have the opportunity to do what you do best every day?” and goes on to point out that we often, as individuals, devote most of our time fixing our shortcomings rather than developing our strengths.  I believe the healthcare industry does the same thing.

How many hospital systems have we seen successfully help patients become compliant at home?   How many have beat the insurance companies in risk contracting?  How many have delivered customer service with the consistency of the Ritz Carlton?  Have you got your lists of all those?  I can tell you, these topics dominate conversations and literature for Hospital Administrators these days.  But I will bet your list of hospitals doing even one of these things is short to non-existent!

Now, compare that to this next list:

How many hospitals deliver great care, safely.  How many do a great job of dominating their primary market?  How many negotiate great rates with insurers.  How many control expenses within the 25th percentile of their peers.  Do you actually know of some that do all of those?  I DO!  Will hospital systems that do these things well succeed in the new healthcare environment?  Absolutely!  We need to major on the majors and see our glass is not half empty, or even half full!  It may be 60%, 75%, 90% full, but we are so worried that someone may come along and break our glass, we are locking it away in a bank vault!

Next week’s blog will be dedicated to hospital leaders specifically, and it will be about how we can succeed by operating within our strengths.  I will be blogging it from the beach, but trust me, I will be back in the trenches with you in a couple Mondays to help my hospital succeed!