Adaptive Strategies Blog

It’s the end of the year and the decade and I’m facinated with all of the “top ten” lists coming at me. I now know the top ten medical stories, the top ten vacation spots, the top ten movies, the top ten songs, and on and on and on.

I’d like to compile a list of the top ten individual or collective lapses in good thinking from the past decade. Here are a couple of my nominees.

• What were the mortgage companies thinking when they gave NINJA (no income, no job, no asset) loans for mega-houses?
• What was Merck thinking when it kept Vioxx on the market after it’s own studies showed it to increase risk of heart failure?
• What was management at Pontiac thinking when they introduced the Aztek? (See if that doesn’t bring a smile to your face?)

Please add to the list. What were they thinking?

For the past six years I have been conducting workshops on “critical and strategic thinking” for some of the better corporations in America. And in these workshops I cover the key attributes of critical thinking. Two of them seem to be lacking in the congressional “debates” we see played out in the news.

First, an aspect of critical thinking (or just plain good thinking) is the willingness to look at a situation from multiple points of view.  Every time I hear that congress “voted along party lines” I realize that the people who are deciding things that affect my future have abdicated their responsibility to think! This is “groupthink” at its best/worst. If all we need is a tally of party votes, we should fire all of our senators and representatives (and save a TON of money) and let a clerk tally the votes.

Second, good thinkers realize that complex problems (like healthcare, like the national debt, like the wars) do not have known or even knowable solutions – they require experimentation to discover possible part-solutions that can be combined to find a reasonable total solution. As long as both parties see this as a win-lose situation they will never undertake the bold experiments that are needed to find real solutions. They are unwilling (as seen by their actions) to risk their party reputation for the good of the country. Sorry, but that seems gutless to me.

What do you think?

One of the harder aspects of critical thinking is to be willing to accept that your point of view is only one of many points of view addressing a particular situation and that they are just as real as yours . You may not like them; you may disagree; but they are real.

The challenge you face is to consider them and take them for what they are – legitimate expressions of concern. If you ignore them, you are guilty of lazy thinking.

Consider our health care system and the many points of view that need to be considered by those attempting to improve the system.

• To people with good company paid insurance, the system is just fine and they see no need for change.
• To the uninsured, the system is divided into “haves” and “have-nots” and all that they know is they are not even in the system.
• To insurance companies, the system is part of a business ecosystem and they know that they have to keep their shareholders happy with decent profits.
• To a Medicare recipient, healthcare is a promise from our government for a lifetime of work.
• To a patient with long-term illness, the system is slowly driving them into bankruptcy.
• To a healthy young adult, the system is something they may need sometime, but not right now.
• To a hospital executive, the system is overly complicated and rife with administrative duties.
• To a doctor approaching retirement, the system is the reason to give up a lifelong passion because it’s “just not worth the hassle.”
• To a conservative, the system has no need for government.
• To a liberal, the system needs government involvement.

And on, and on, and on.

Take a look at our healthcare system and consider some of the points of view.

Now, without falling back on a predisposed ideology (which is a single point of view) consider actions “we” could take to improve the overall performance of the system.

Not so easy, is it? How would you like to be an “independent” in Washington? Must be lonely.

We need people who will think about the problems with health care, not simply use ideology to drive their position.

What do you think?

The medical community refers to high blood pressure as “the silent killer.” It’s a disease without obvious symptoms and many people, unfortunately, don’t even know they have high blood pressure until a stroke or heart attack kills them.

The “high blood pressure” of strategy is the set of assumptions that the strategy is based upon. The assumptions may have been fine at one point in time but may have degraded over time and may well be wrong when the strategy is stressed.

The roll-call of strategic irrelevancy often finds degraded assumptions at the heart of the matter.

• Manufacturing companies assumed they needed lots of raw material and work-in-process inventory until the Japanese surprised us with “just-in-time” manufacturing.
• Airlines assumed a hub and spoke system was best until SouthWest Airlines got real good at point-to-point.
• Kodak assumed that film-based cameras would have about three more years of sales than they actually had.
• The entire housing and mortgage industry assumed that the price of houses would continue to rise year after year.
• Sears assumed it had a lock on middle class Americans.

Staying with the health care theme of the last few posts, what assumptions do you see your local healthcare providers making? What assumptions do you think they are making with respect to:

• Who will control your “medical home”
• Telemedicine?
• Insurance rates?
• Your attitude about safety?
• Defensive medicine?
• Medical tourism?
• Hospitalists and surgicalists?
• Electronic medical records?
• Elective surgery?
• Patient education?

All industry “truths” are built on assumptions that were true at one time or another.

How many of these truths do you think will prove invalid in the coming couple of years?

Great thinking is built on great questions. Unfortunately, it seems to me, we have started with answers before we agreed on the important questions.

One of my favorite books is Asking the Right Questions: a Guide to Critical Thinking by Browne and Keeley. Let’s see how a few of their questions help inform the discussion about health care

• What are the issues and the conclusions?
  • Let’s stick with the issues from the last post: coverage, quality, cost, and choice. We are still wrestling with the conclusions about each of these issues. Coverage seems to be the big Democratic issue and a conclusion for many is that coverage needs to be universal. Cost and choice seem to be the big issues for the Republicans and tentative conclusions are that cost will be too high and that choice is important and will be hurt by a “government” agency.
  • Bring this down a notch and look at it from the perspective of a hospital executive: universal coverage is good; high quality is demanded; cost should “reasonable;” and choice may be bad if it adds to administrative costs.
• What words or phrases are not clear?
  • Do we have common understanding of: “rationing,” “free market,” “recission,” “Obamacare,” “level playing field,” “socialism,” or, for that matter, “health.” Think back to the days of the “quality” movement – lots of discussion by what we meant by quality.
• What are the value conflicts and assumptions?
  • Is the healthcare system run as a “zero sum” game. Does one party win at the expense of the other? Unfortunately all of the public “debate” has focused on differences and not common ground.
  • What line items should be used in a healthcare system report card? Until we have a common set of items we can cherry pick “the best system” to fit our needs.
  • There are a bunch of assumptions that have to be investigated: Will quality reduce cost (like it did for manufacturing)?
• How good is the evidence?
  • There are bits and pieces of evidence floating around, but little has been used in coming to terms with the debate.  Furthermore, when numbers are presented they are not always put in proper context nor made widely available.
  • What evidence would you want to see to come to grips with the issues of coverage, quality, cost and choice?
• Are the statistics deceptive?
  • The short answer is Yes. We have to make sure we understand the basis behind the numbers.

We have a lot of very smart people who can find answers once we have posed the right questions. From your point of view, what are important questions that no one seems to answer?