Upstream Learning & Downstream Dysfunction: How to Train Leaders for a New Future

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“The arrogance of success is to think that what you did yesterday is sufficient for tomorrow.” – William Pollard

In health care right now, lots of people are talking about innovation as a generic way to describe the new holy grail to some of medicine’s biggest problems. Of course this line of logic might lead some to think medicine is in some state of “innovation-deficiency,”¬† a condition for which innovation replacement therapy is the clear and sole treatment. While this obviously isn’t always true, introducing new technologies and processes, if done the right way, can certainly help minimize waste, control cost, improve efficiency, and introduce equity into existing public systems.

So if medicine needs to up its innovation game, as many are suggesting, who’s it going to turn to? Where is the pipeline of leaders to fill the holy grail and how do you turn on the faucet of new and better ideas?

I’ve been thinking a lot about these questions over the past few weeks as I start my Fall semester at Harvard’s TH Chan School of Public Health. And no that wasn’t a name drop. It was a point of reference drop, to help place the problem I am about to describe, into context.

For the past 3 weeks I’ve been taking a pretty stand out course on quality improvement¬† taught by the incomparable Maureen Bisognano and her enviable squad of colleagues and friends. For a bit of background, Maureen is the President Emerita of the Institute for Healthcare Improvement, basically a healthcare innovation incubator based in Boston, and her friends include people like Don Berwick, Atul Gawande, Brent James, Ellen Goodman, and Derek Feeley, to name a few of the powerful speakers who inspired us. For 3 weeks, we reviewed international examples of ways to radically redesign the US healthcare system.

And then, I had fall registration.

Excited to push the boundaries of existing systems, I was eager to take classes across the University, and like Maureen showed us, find examples from other industries, sectors, and disciplines that could be applied to the great challenges facing medicine and build solutions that translate across public systems and private incentive structures. But to my surprise, that inter-sectional, open learning, not only wasn’t a requirement, but was incredibly difficult to find. And if it is hard to find at places branded on leadership, I worry it may be symptomatic of a larger issue.

Which got me thinking, just how are we going to train this next level of leaders when the educational pipeline through medicine looks remarkably similar to what was suggested in the landmark Flexnor Report in 1910, that established a system of medical education, that with few exceptions, continues today.

Courses continue to be divided by discipline, learners are isolated to their field of study, and for those who select to learn outside that box, they do so singularly, as a function of personal interest or a non-degree program rather than systematic integration of agents and ideas. Then is it any wonder why our systems remained silo’ed with divergent (and sometimes antagonistic) incentive structures despite overlapping public interests?

Don Berwick is often quoted as saying, “Every system is perfectly designed to get the results it gets.” In medicine, as we move upstream in our interventions for disease, to target root causes rather than downstream effects, we must do the same thing for the education pipeline. We have to challenge ourselves to teach future leaders how to think, reason, and execute rather than prescriptively guiding them, formally and informally, to reproduce the same system, with the same challenges we already have.

It has been more than 100 years since the last massive shift in professional medical education, perhaps parting with apprenticed dysfunction and practicing principled disruption is a good start.

 

 

 

Fighting for Failing Care: How Hospital Closures May Impact the Safety Net

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In the post-Affordable Care Act healthcare landscape, sweeping hospital closures have created new barriers to access in a system already criticized for its fragmentation and saturation. Looking back over the past 20 years, urban hospitals, and urban trauma centers in particular, bore the brunt of this impact, closing at the highest rates in the country. Now, evidence suggests the impact of urban hospital closures may disproportionately affect those living in poverty, racial and ethnic minorities, and the uninsured.

This concerning trend begs an important question:

If urban hospitals are a trusted point of access for low-income communities of color, does their closure undermine the national safety net OR does it create opportunities to deploy lower-cost, higher-quality delivery models for vulnerable populations?

To answer this question, let’s look at the contentious 2007 closure of Martin Luther King Jr. Harbor Hospital in Los Angeles.

As a bit of background, MLK-Harbor opened in the wake of the 1965 Watts riots and general unrest regarding the lack of sufficient public investment in communities of color in South Central (now termed South LA). The hospital was to provide healthcare in one of the poorest and most violent neighborhoods in LA. At the time of its closure, it remained the only public hospital to serve a large part of South LA, treating more trauma patients than almost all other hospitals in the region. Its closure was prompted by a series of egregious medical errors that eventually threatened the hospital’s accreditation.

Mounting quality concerns aside, what was most notable about its closure, was the staunch community protest. In the face of unquestionably dangerous medical practices, the community rallied to protect their safety net; even garnering the support of Congresswoman Maxine Waters, who rose to the cause’s defense in 2004. Despite their efforts, the trauma center was shut down in 2004 and the general acute care hospital closed thereafter in 2007.

So why would a community fight for the failing care of their discredited hospital? Is the safety net worth protecting when it is offering poor care or is the community’s advocacy tacit admission that poor care is better than no care at all? And ultimately, does “no care” threaten the safety net or does it provide an opportunity for something better?

Let’s dissect these questions piece by piece.

First, it is a basic human instinct to protect what you perceive as yours. Even if what you have is broken. Now superimpose on that instinct, a history of having no say in what is taken from you; a history of abandonment by public institutions charged with investing in your community infrastructure; and a history of displacement driven largely by resource scarcity and discrimination. When viewed in this structural context, the motivations to fight to protect resources become obvious.

Second, let’s explore the idea of fighting for “failing” or “poor” care. Here, the assumption is that low-income communities of color either don’t understand or don’t want, quality. Why else would they protest the closure of a bad hospital, right? In this case, I think we’ve got the assumption wrong. Americans love a deal. We want more for less. Whether it’s super-sizing our french fries or buying into the housing market at the right time, we want quality and we want it at a bargain price. In this way, quality is an American value that translates across the economic spectrum. But sometimes, “the deal” trumps quality. So the real question is, what is the “deal”?

In the case of MLK-Harbor, if there is not another medical facility near your home and public transportation is unreliable, or if you are uninsured and you cannot afford a second opinion, or if the medical specialty you need is only available at your local provider; then the deal is access, the deal is cost-savings, the deal is specialization. This is why low-income populations are vulnerable. Because their lack of resources offers them a bad deal, around which there is little leverage.

So it is not that poor care is better than no care. It is that no care should no longer be an option, but for many, that is the deal they are left with. So as engineers of the system, we have to create something better.

And herein lies the answer to our initial question. It does both.

Because urban hospitals are a trusted point of access for low-income communities of color, their closure undermines the national safety net AND creates opportunities to deploy lower-cost, higher-quality delivery models for vulnerable populations.

In attempting to forge a better healthcare system in the midst of our broken one, every failure is an opportunity for improvement.* As the Affordable Care Act re-organizes the medical landscape into regionalized, micro-systems that are accountable for local populations, it provides the opportunity to consider our past failures and the global impact of shifting costs and shifting care on the vulnerable.

The tension between eliminating inefficiency, maintaining quality, and controlling cost while elevating the voice of the community and prioritizing the needs of the under-served, remains. These are the challenges that loom at the forefront of a healthcare system that seeks to cut costs and maximize quality for all. But this is a cause worth fighting for and I’m all in. Are you with me?

* To see how MLK-Harbor (now MLK Community) is improving their system to re-open in 2015, click the link.