The Non-Scalability of Charisma

Early on, many social movements depend on a charismatic leader to focus attention, build a burning platform, and inspire people to action. You know when the movement has made it when it no longer needs such a leader for fuel.

The safety and quality movements have picked up tremendous steam over the past decade, but they haven’t yet hit that self-sustaining tipping point. Last week, there were two things that reminded me of this: the announcement of a new leader of the Institute for Healthcare Improvement (IHI), and a doleful JAMA essay by Peter Pronovost.

During the circus that was Don Berwick’s recess appointment to lead the Centers for Medicare & Medicaid Services (CMS), all eyes were trained Inside the Beltway. But 440 miles north, in Cambridge, MA, arguably the most important organization in the quality and safety galaxy needed to get on with its business. On July 8th, IHI announced its choice of Maureen Bisognano to become its new CEO. Maureen is a nurse and former hospital exec who has spent the last 15 years at IHI as Don’s consigliere. She is a terrific person, with boundless energy and great organizational skills – insiders will tell you that she was the reason that IHI’s trains ran on time for the past decade, as Don is the quintessential big picture guy.

Don, of course, has extraordinary strengths as a leader, particularly in visioning and communicating. His annual IHI speech is legendary, for good reason. Consider this, from a 2004 Boston Globe profile:

Just from appearance and demeanor, you’d expect the 5-foot-10 Berwick to deliver an earnest but dull PowerPoint speech. He doesn’t wave his arms and never raises his voice, which has a low, occasionally rasping quality to it…. But there is a quiet charisma about him. He knows how to simultaneously play on the emotional and logical sides of his listeners’ brains. He is also the king of metaphors. Over the years, his listeners have heard him explain health care in relation to his younger daughter’s soccer team; the sinking of a Swedish warship; the Boston Red Sox; Harry Potter; NASA; the contrasting behaviors of eagles and weasels; his wimpy Ford Windstar (a dated reference since he now drives a used BMW convertible); and his left knee.

I’ve heard Maureen speak on several occasions, and she is quite good. But she’s no Don Berwick.

So what will happen to IHI in a post-Berwick era? The Institute remains an essential resource for thousands of hospitals around the country, and will undoubtedly continue its vital role. But my guess is that IHI will ultimately need to find a charismatic physician-leader to fill Don’s humongous shoes (unless they can hold off until Don returns from CMS, which could be as soon as late-2011, if a pissed off Senate stonewalls him when his recess appointment expires). Part of IHI’s magic has been getting, and keeping, docs at the table, and I doubt Maureen will be able to do this over the long haul, notwithstanding her impressive skills. I hope I’m wrong, but I don’t think I am.

A few days after hearing of Maureen’s appointment, I read a JAMA piece by Peter Pronovost of Johns Hopkins. Peter, of course, is the Genius Award-winningarchitect of the Keystone Project, which nearly eliminated central-line associated bloodstream infections (CLABSI) in Michigan ICUs, saving hundreds of lives and millions of dollars. Based on this breathtaking success, Peter received megabucks from AHRQ and some philanthropists to roll out his checklist initiative to the other 49 states.

Peter tells me that there have been some real success stories in the first year – a couple of states have seen results comparable to Michigan’s. But the glass is more empty than full – the implementation rate in most states has been sluggish; in some, downright pitiful.

Why? In the JAMA paper, Peter writes, plaintively,

In many states, less than 20% of hospitals have volunteered to participate. Some hospitals have reduced infection rates, most have not. Some hospitals claim they use the checklist, despite having high or unknown infection rates…. Some hospitals blame competing priorities for their inattention to these infections. If these lethal, expensive, measurable, and largely preventable infections are not a priority, what is?

Pronovost sees the root cause of this poor response as an accountability gap on the part of hospital executives and physicians. That’s clearly part of the problem, but a bigger one may be that there is only one Peter Pronovost, and he can’t be in 50 states. Peter, like Don, has one-of-a-kind charisma; recall Atul Gawande’s 2007 observations of him in the New Yorker:

Forty-two years old, with cropped light-brown hair, tenth-grader looks, and a fluttering, finchlike energy, he is an odd mixture of the nerdy and the messianic… People say he is the kind of guy who, even as a trainee, could make you feel you’d saved the world every time you washed your hands properly. “I’ve never seen anybody inspire as he does,” Marty Makary, a Johns Hopkins surgeon, told me. “Partly, he has this contagious, excitable nature. He has a smile that’s tough to match. But he also has a way of making people feel heard.”

The fact that it seems impossible to export Michigan’s success to the rest of the country is particularly disheartening, since there are few other safety and quality interventions with such strong evidence of benefit; whose successes were reported in the New England Journal of Medicine, the lay media, and now two books (by Gawande and Pronovost); and whose implementation is sostraightforward – no technology or expensive equipment needed, just a 5-item checklist coupled with some leadership commitment, measurement, and a dab of culture change. If we can’t disseminate this intervention, what will happen when we try the hard stuff?

If you’ve ever spent any time with a professional investor, you’re familiar with this concept of scalability – a “desirable property of a system, a network, or a process, which indicates its ability to either handle growing amounts of work in a graceful manner or to be readily enlarged.” United Airlines isn’t very scalable – additional passengers require more planes, crews, peanuts, and fuel. Nor is General Motors. But Google and Facebook are endlessly scalable. Once they had their basic design and infrastructure down, the thousandth user added relatively little incremental cost over the 999th. Ditto the millionth. Venture Capitalist-types begin foaming at the mouth when they hear about a scalable idea, since profitability soars when you add new revenues without additional expenses.

Our problem is that Pronovost doesn’t scale, and neither does Berwick. Trying to roll out the checklist initiative without Pronovost’s cheerleading and handholding doesn’t work very well. Nor can IHI replicate the mass enthusiasm that accompanied its 100,000 Lives Campaign without Berwick at the head of the parade.

What does this mean? I fear that it means that the business case to improve quality and safety has not yet reached the point where full engagement by healthcare organizations and caregivers isn’t dependent on the personal engagement of individuals with unique leadership and communication skills. We’ll know it has when states and CEOs are asking – even begging – Peter to help them prevent ICU infections, and when IHI and similar organizations are being tapped constantly for help, even if the answer to the predictable question, “Can Don come to our hospital to kick off our initiative?,” is always “no.”

We’re blessed to have the likes of Pronovost and Berwick in the quality and safety arena – we’d never have gotten to where we are today without them. But we’ll know that we have truly arrived when we no longer depend on them to get the work done.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

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19 replies »

  1. And if we move the needle on quality and safety, are we certain that it will also move the needle on cost? Or will we need to “redefine” quality to whatever the lowering cost needle is moving towards?

  2. This all goes back to the condundrum that you won’t move the needle on quality or safety in any meaningful way without a substantial change in payment methdology from the present system yet the infrastructure that is necessary to support such a radical change is just not there & present emphasis on clinical systems on both the payer and provider side isn’t addressing the fact that their administrative systems are generally woefully outdated/inadequate to support a profound change in payment methdology.
    Why HSAs were doomed before they were even implemented because the infrastructure necessary to support them in ’03 was there and still isn’t today.

  3. Jeff’s point — ‘It’s ingrained in the culture of contemporary medicine to exclude “systemic” issues.’ — is exactly on target. This is not a case of misanthropes trying to harm people. It is a case of well-intentioned, highly trained, and dedicated people inadvertently harming people. As Lucien Leape has pointed out, there is little in the training of MDs to help them learn how to work in teams and address systemic issues. As a result, when harm occurs, people say, “These things happen.” http://runningahospital.blogspot.com/2007/03/these-things-happen.html
    But it can be changed if there are medical and administrative champions within a hospital and support and pressure from the governing body. It can also be nudged along by real transparency of clinical outcomes. http://www.businessweek.com/technology/content/sep2007/tc20070917_425882.htm?campaign_id=yhoo

  4. I completely agree with Jeff. Individualism is taken to an extreme in western culture and medicine. Everything is broken down and experts are brought in to find the one teeny tiny problem, often avoiding all other issues that could be adding to the real problem. While I think specialists are necessary because of the precision, it’s equally as important to view a person as a whole.

  5. ” It is just difficult to gather a group of people together that understand how to approach the concepts of accountability and solving system errors.”
    Ed, this is precisely what I meant when I said that M.D.’s are our own enemies. We do not know how to do this. We have not been trained to do this,but we must learn. Only then will the culture change be truly embedded and lead to improvements in care. As far as cutting back, if done right these changes cost less, not more. If the leaders don’t get that, then the culture change hasn’t happened yet.

  6. I come from the service side of health care. I see a culture change struggling to take place. The knee jerk, put out the fire and forget about it approach must end. It is just difficult to gather a group of people together that understand how to approach the concepts of accountability and solving system errors. My concern is that institutions will need to cut back aggressively to control cost and ground will be lost. I only became involved in this culture change 2 years ago so whatever is being done is working, I am just sorry it took me so long. thank you for your post

  7. Over time, as more doctors become hospital employees and fewer are independent practitioners who merely have privileges to treat patients at the hospital, it should, in theory, become easier to make care safer for patients. This assumes that senior management, starting with the CEO, embraces patient safety as a core priority for the institution. As part of this effort, it should be made clear that doctors, including department chairs, which can’t or won’t support patient safety efforts will ultimately need to look for work elsewhere. Management might need to take the risk that such a strategy could actually cost revenue in the short term especially if some high profile doctors choose to leave or are otherwise driven away. In the end, however, to the extent that at least some hospitals can achieve significant improvement in patient safety, it should enhance the institution’s reputation for quality care and it should be rewarded with more patients and, perhaps, higher reimbursement rates or quality bonuses under P4P plans.

  8. What I’m seeing, and hearing in this article and discussion is that hospital systems and namely the chiefs are not willing to discuss two critical aspects of healthcare within their systems. They are profitability and quality medicine. When people enter the profession, they are entering for one or both of those reasons. If hospitals produce more profit, then the providers at that facility should share in the benefit, thus incenting them to practice better quality. In raising quality, more patients will want to have services performed at that facility. This seems like a win-win situation to me.
    I can’t say that I agree that hospitals that improve quality don’t take over market share. They may not draw from across the country, but they can and will push other local competitors out of business. As this competition draws close to other facilities, the need to stay in business should force a change as well. This may take time, but I believe the market dynamic will force this issue around the country in the long term.

  9. Jeff, this time I agree with both of your comments, particularly the last one about powerful Chairs running academic medical centers. (This is in contrast to community hospitals where CEO’s have more power.) Mr. Levy’s last paragraph in his cited blog post seems to confirm that:
    “No, the imperative must come from within the profession. It has to be based on the underlying set of values to which doctors pledge their lives: avoiding harm to patients. The story about Atul’s study unfortunately says, in so many words, that there is much lacking within.”
    Although I used to vociferously and vocally disagree with him on this point, I am now a convert. We M.D.’s have met the enemy,and he is us. The evidence for that is accumulating. So Dr’s Jones and Techner, take heed.

  10. The most interesting thing might be how the 2014 reform changes affect the system. Reform was needed, but there is still some work to do. A new Congress might actually fine-tune a few things that might be helpful.

  11. The underlying basic problem remains this:
    If Steve Jobs builds a better phone, that is recognized by the people who pay for phones, they spend more money on his phone and RIM and Nokia go out of business (well not exactly but you get my drift).
    If the hospitals in Michigan do a better job of saving lives, they don’t benefit at all, and they certainly don’t take over the market share of the hospitals in the states that don’t bother to put in the Pronovost checklist.
    I’m nowhere near as smart as Bob but I may have read more (of German sociologist) Max Weber. Weber said that charismatic leadership was the only way to change organizational structure externally, but in general even that doesn’t work.
    Which tells me that the only way the problems of innovation not spreading in health care will be solved will be from the organizational structure changing. That relies on the financial structure changing as they’re basically the same thing.
    What can change an organizational structure? For that we need to check in with another German sociologist called Karl Marx. He said that technology change eventually broke organizational relationships (he called it the forces of production versus the relations of production).
    So the question is, is the ability of the current technology change in health care (e.g. the ability for technology to provide a truly data driven & transparent system) enough to change the current organizational/financial structure? If so, then ordinary men will become Don Berwicks, because what they preach will benefit institutions, and the ones who ignore it will go away.
    But there’s a strong possibility that the current technology revolution is not enough, and then in Bob’s terms, no number of Don’s or Peter’s can save us.

  12. Not sure which institutions people are referring to, but, with few exceptions, teaching hospitals are run by the powerful chairs of their clinical departments. Except in unusual instances where the hospital is really prosperous, those chairs basically get what they want 90% or better of the time. Most “strategy” in these places revolves around the search for new chairs, which requires recruitment packages, promises and big dollars.
    If you have the opportunity to replace a lot of chairs at once, you’ve got a chance as Dean/Vice Chancellor or Medical Center CEO to change things. Otherwise, it’s basically gridlock. Senior leadership often try to run these places like a huge, multi-lateral poker game, but unless they are very fortunate resource-wise, they don’t exercise power even remotely comparable to the CEO of a corporation. Most AHC’s are basically loose confederations of local chapters of national specialty societies united only by a common disdain for executive leadership and the parking problem. Saddam wouldn’t last ten minutes.

  13. There is not any accountability or review for hospital administrators, except by the BOD, which is often picked by the hospital CEO. So there you go.
    Most hospital administrators are in violation of JC Standards by obfuscating the causes of the injuries and deaths at their own institutions.
    Only the most egregious events become known, such as the one at MGH when a patient on a heart floor on a monitor had many minutes of bradycardia with doctors, nurses, residents, nurse practitioners, physician assistants, medical students all busy with their faces on the EMR computer terminals, as the patients lay dying. Medicare “experts” blamed “alert fatigue”. Amazingly Ha Ha.
    It is not any wonder that malpractice insurance rates are increasing due to the negligence associated with EMR use (a dark and dirty secret).

  14. John,
    I’m not entirely sure that this is the case, that doctors are pitched against the administration. One only has to look at compliance with hand washing or the surgical safety checklist.
    In both these examples patients are harmed by the breaches of safety practices but in spite of employing infection control nurses, implementing systems, having protocols and procedures compliance is still poor.
    The WHO SSCL is another classic example where, in two of my own organisations, because surgeons have issues with the published data they see no value in it, but because it is now mandatory, the completion of it is completely half arsed and done with a complete lack of interest. Throwing the baby out with the bath water.
    I think its interesting that you believe the leadership have hijacked their own institutions for their own personal gain, my experience is that its this sort of comment that creates such an adversarial atmosphere that almost nothing of note can be accomplished.
    In order to make any progress at all in improving the quality and safety of the care provided, their has to be an acknowledgement that its less than ideal, to do that people have to admit they make mistakes and are fallible and in my experience that sort of honesty is few and far between.
    I recently saw the leaders of several fairly large organisations speak on these types of issues and one of the points raised was “you cant fix something that is not broken, or people do not accept is broken” and many organisations, their leaders and clinicians do not accept that medicine is broken and therefore following the maxim of “if it aint broke dont fix it” they wont.

  15. The institutions to which Paul Levy refers, and perhaps even his own, have leadership that have hijacked their respective institutions for personal gain and prestige. They put in place “Medical Staff” leaders who are actually do nothing well paid shills for the hospital administration and do not represent the patients’ doctors. Blaming the individualized care patients need is folly.
    Historically, when doctors criticize the administration and shout out about their patients who are killed by the safety breaches and corner cutting of administration, they are fired or sham peer reviewed.
    Thus, there is what Roy Poses, MD at Health Care Renewal, describes is an anechoic effect. All are intimidated to state the facts.
    Hospital culture and power structure is “Sadam Totalitarian”. Bob, tell us the truth about what actually happened with the GE Centricity failure at UCSF.
    How many patients were injured? We want to learn so as to not make the same mistakes.

  16. It’s ingrained in the culture of contemporary medicine to exclude “systemic” issues. Look at the marginalization of public health, despite its enormous contribution to reducing disease risk. We are obsessed with individualism in our society, and the people with the highest “individualism” quotient end up in medical school. “One patient at a time” has profound consequences for how patients are treated, and thought about. There’s a powerful centripetal force to the “doctor-patient relationship”. AHC’s are still about heroism, not teamwork. It will take a generation to change that culture.

  17. Wonderful piece and true, Bob. The marvel is that these individuals and institutions have made progress on quality/safety despite the lack of a compelling business model to do so. We will remain unable to meaningfully course correct until the money is tied to delivering care well and safely.

  18. Well stated, Bob. Don and Peter and others like Paul Batalden have been toiling in the vineyards for years, and it is striking that the academic medical centers, in particular, have generally failed to take on quality and safety as strategic priorities and as areas of academic interest. Having previously been involved with other industries (e.g., energy and telecommunications) that have gone through structural changes, I am struck by the relative slowness and recalcitrance of many of the institutions and people who you would have hoped would be thought and action leaders in these realms. (More here: http://runningahospital.blogspot.com/2009/01/what-does-it-take.html

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