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?

Concepts help active critical thinkers organize their thinking. Sometimes the simplest of concepts work the best.

Reflect on the reality of workers in the healthcare system. I don’t care who you think about – it could be a doctor, a nurse, a technician, or an administrator. These workers are talented and dedicated and eager to do the right thing (most of the time). However, they “live” in the smallest box of a series of nested boxes.

It would be wonderful if the boxes fit in perfect alignment. However, the reality is more like:

Leaders at all levels in the system should be searching for answers to the following questions:

• How will the economy (and its slow recovery) affect the healthcare industry?
• How will your company respond to changes in the industry?
• How will jobs have to change to respond to changes in company strategy?
• Will the leaders and the workers have the skills needed for the job changes?

Most of the workers “in the trenches” simply want to do a good job, feel satisfaction, and have security. It’s up to the leaders in the government, the industry, the hospitals, the companies, etc. to make sure the people actually doing the work know why their jobs have to change.

Think about the turmoil surrounding healthcare; think about nested boxes. This is “creative destruction” at work and the system WILL (eventually) realign itself. What “pinch points” can you forecast as we reflect on the reality of changes to the system? What

The foundation to good critical thinking is coming to grips with the issue at hand. Saying that “the system is broke” is meaningless until you define system and all of its components. To rail against “Obamacare” is meaningless unless you can explain what you mean by Obamacare. So, what’s the issue?

I’ve been reading T.R. Reid’s excellent overview of healthcare, The Healing of America, wherein he compares healthcare in Germany, France, Japan, the U.K., Canada, and the United States and his framework is very instructive for considering “the issue” about healthcare. His framework is composed of four factors: coverage, quality, cost, and choice. With just these four words, you can start to better define some of the many issues.

• For the 30 to 45 million uninsured, it really is all about coverage. However, for the business owner coverage means added cost.
• For the well-to-do, or the retired person pondering Medicare Part D, it may be about choice so as to maximize benefits. However, for the insurance company with a near lock on a state, choice is the last thing they want.
• I want to know exactly how much an operation is going to cost, but my doctor has no way of knowing until after the fact!
• All of us want “the best” but someone (“not me”) has to pay for it.
• And on, and on, and on.

And here is the nasty part of trying to define “the issue.” We can be pretty sure that some blend of the four factors is going to change. We just don’t know what the blend will be.  So what is a healthcare executive to do? As I said in response to an earlier post comment, the answer is not to stand still and react after-the-fact.

Whether you are a hospital exec, an insurance exec, a doctor, an employer, a supplier or an individual the issues are explored and defined by knowing what is in your control and what is not and then determining what it will take to remain viable as the system changes. Here are some hypothetical responses to possible futures of healthcare. Consider the plight of a hospital exec if…….

• Universal coverage is enacted – How much will ER capacity and staffing go down if patients see docs earlier?
• Electronic medical records are legislated to improve quality – How many older docs will take retirement rather than make the change?
• Patients can choose from hundreds of insurance funds – How many billing clerks will have to be added unless standardized forms are used.

You get the picture. We know the system will change. We don’t exactly know what will change. It’s a human tendency to wait – but that may be too late.

OK, I’m not foolish enough to think that healthcare executives are reading this blog. So let’s make it personal. MY issue with healthcare is simple – since my wife and I are on an individual policy and can be dropped or priced-out if either of us dare to get too sick, our actions are to exercise and eat healthy and hope Medicare is there in a couple of years. It’s my responsibility to stay out of the system, because I know I can’t afford to get sick. Depressing, but true.

See if you can define YOUR issue with healthcare. They say that all politics are local, and nothing gets more “local” than health. Consider Reid’s factors of coverage, quality, cost and choice.

My last post considered ways to think about the healthcare system and I offered five snippets addressing ways to think about the future of the health care system. The fourth of the five snippets was a simple statement to “think critically.” Easy to say; hard to do.

This is the first of eight posts that will take a deeper look at that simple piece of advice. Today I’ll provide an overview of seven components of critical thinking and in subsequent posts I’ll dig deeper into each of the components.

I’ve decided to focus on health care for a few reasons: (1) it’s REALLY important to a lot of people; (2) the “debate” has been highjacked by people (left and right) with very strong opinions who do not want us to actually think about healthcare, just follow their line of thought; and (3) I’m having a hard time getting my mental arms around this issue and feel that maybe a little writing will help me clarify my own position. I need your help here.

CRITICAL THINKING: It’s the process of figuring out what to believe and then what to do about your beliefs. It starts with “figuring out what to believe,” which takes time and is darn hard work. It’s easy to parrot a talk-show host; it’s uncomfortable to examine your own beliefs and figure out if they are built on a good foundation.

As you work on figuring out your beliefs, here are seven components of critical thinking to consider:  

• What’s the ISSUE and how does the issue look from various points of view. From a moral perspective do you believe that everyone has a right to quality healthcare? From a fiscal perspective, who should pay for this right? For that matter, what about our individual responsibility to live a healthy lifestyle. Should I pay for your smoking habit and should you pay because I like to eat a lot? Paying for the system has come front and center, but it’s not the only issue. Step One of critical thinking: get clarity about the set of issues and work at prioritizing them.
• What QUESTIONS bring clarity to the issues? And the most important question to ask is: Are we solving the real problems? With upwards of 90,000 people dying every year because of mistakes, misuses, and care-acquired illnesses, is the main issue about payment or quality? We have LOTS of smart people who can answer questions. Are we asking the right questions?
• What CONCEPTS are we using to organize our thinking? I’ve had healthcare executives (angrily) tell me that “We are not a factory making widgets!” True. But the concept of standardization seems to work in every other industry. Might it be applied to some of the issues affecting healthcare? Concepts help us organize our thinking and then explain it to others. What’s your concept of a hospital? (Remember, in the late 1700’s they were literally “a place to go to die.”)
• As we think about the health care system what are the ALTERNATIVES to today’s practices? The general hospital was right for medicine at the beginning of the 20^th century because it did everything for anybody. A hundred years later is it still the right way to deal with injury and sickness? For that matter, what are the alternatives to staying healthy and never having to use a hospital?
• ASSUMPTIONS are the foundation of all strategy and all plans. And when assumptions degrade, the plans are usually out of line with reality. What assumptions underpin the insurance industry? What assumptions are the foundation of the “medical home” concept being touted? What assumptions are employers making about their role in keeping employees healthy? What assumptions are you making about your health needs as you age?
• “Truth” often depends on your POINT OF VIEW. What does the system look like from the point of view of a retiree who is in the Medicare system? What does the system look like from the point of view of the owner of a small business? What about a self-employed bloke like me? Who’s right? All of us. Who’s wrong? All of us.
• As I write this all I know for sure is that Congress is going to do “something.” Not sure what it is; but I do know that whatever they do will have both intended and unintended CONSEQUENCES. People following an ideology tend to see the intended consequences of their actions and “get surprised” by the unintended consequences.  All of us should think about “what else” were getting when we take an action. It will play out – but later.

HELP!  I really want to get my arms around this and I need a conversation. Please comment – challenge – add-to – etc. Please pass this on to friends and colleagues who are in the system. What does it look like from the inside?

(Jodi, if you’re reading this it’s time to comment.)

OK, now it’s your turn.

The healthcare system is fascinating because it will touch EVERYONE at one time or another. You may work in the system, or supply the system, or use the system – but it will touch you, one way or another, over the course of your life. I have friends who never fly and, therefore, don’t care about the airline industry. I have friends without cars who don’t care about the car industry. But I don’t have any friends who have never been sick or never needed medical help.  Healthcare is one of a few systems that touch all of us. So we had better think about its future.

Many people have written about healthcare as a “broken system.” I think of it as a rapidly evolving system that that is affected by a lot of strong forces, from technology to demographics to political posturing. In other words, the future of our healthcare system is uncertain.

How did we get here?  Well, the system that serves us today is the result of the predominant targets of the healthcare system in the past. Consider the role of doctors, nurses, and other healthcare professionals as they responded to the following:

• 1850 to 1900: Epidemics are prevalent. Food, water, sanitation and other aspects of city life cause health problems for masses of people.
• 1900 to World War I: Individual trauma (wounds) and infections are the focus
• World War I to World War II: tuberculosis, malaria, pneumonia, venereal disease and industrial hygiene are big issues to be resolved in the United States.
• World War II to 1980: We are living the “good life” and heart disease, cancer, and strokes are on the rise.
• 1980 to Present: Chronic diseases, emotional and behavioral conditions, terror, war, and genetic inheritances come to the fore.

Now think about the next age of healthcare and consider the forces that will hit the system in the coming years: more and more people are uninsured or underinsured at exactly the same time as families have become smaller and more dispersed. The massive Boomer generation is aging. There are fewer people moving into healthcare. More and more healthcare has become a “for profit” business. The bottom line is that the system and its participants will be stressed in ways we have never precisely encountered before.

That said, this system has evolved in the past and is not a stranger to new ways.

The overriding challenge is for people affected by the system to think about its future and take appropriate actions. Doctor, administrator, nurse, patient, taxpayer – ALL have a stake in the future of this sytem.

The future of the healthcare system

Esteemed doctors, academics, economists, and consultants have written a great deal about their view of and prescription for healthcare and healthcare providers. However, much of it is built on a particular point of view and, when taken in total, a contradictory picture arises. Some see the future of healthcare providers operating in the context of a “consumer- driven” system. Some see the future of providers in the context of information-empowered “personalized medicine.” And others see the entire industry changing as we move (in their view) to a single-payer system. GE Healthcare sees a fundamental shift in the nature of the healthcare provider as the system moves from “late disease” to “early health.” Because all of these points view are about the future, all we know for sure is that no one is right and no one is wrong – yet. We are uncertain.

Healthcare is filled with smart and well-educated people. And that single fact is a cause for hope and concern as we face the future of this vital industry. Because we have so many smart people, we hope that we will be able to “figure it out” as the system changes. However, because we have so many well-educated people, we may be trapped into the viewing the evolving system through mental models that may no longer be appropriate.

As you reflect on the position you want to take in the current “debate” about the future of a system that affects all of us, I suggest that you might want to consider one or more of five ways of thinking.

• Think about the speed of industry evolution. Our hospitals and providers have to keep up with the speed of evolution (on a global basis) or risk becoming irrelevant.
• Think about the larger system. Our hospitals are part of a larger system and the answer to the question “Why is my hospital changing?” is always found in the larger systems of healthcare and economy.  
• If you work in healthcare, think about your business model. Whether you are a solo practitioner or a team leader or the CEO of a hospital you have customers and they will the ultimate arbiters of your value.
• Think critically. The world is loaded with people who have opinions. Are your opinions well founded on accepted principals of good thinking? Or, heaven forbid, are you simply repeating someone else’s opinions as “fact.”
• Think across time. The past can inform actions we take in the present. All present day decisions have a “futurity,” both good and bad. And thinking about the future forms the visions we create for our organizations today.

When you think about OUR healthcare system do you throw your hands up in the air and say it’s too confusing? Don’t – your health depends on it.

Today’s New York Times has an OpEd piece by Paul O’Neill (http://www.nytimes.com/2009/07/06/opinion/06oneill.html?th&emc=th) that made me sit back and think about looking at problems from multiple points of view. Many of the articles about our “broken” health care system lead off with a statistic about the incredible cost of the system (more than any other country in the world on a basis of percent of GDP) and then launch into expensive, big-picture solutions to consider. And everyone asks “Where will we get the money?”

O’Neill’s article was about the small-picture. Infections, medication errors, patient falls and other preventable problems add up to about a trillion dollars of annual “waste.” And the kicker is that we already know how to reduce every one of these without a massive new program! And here is the kicker in his article: “What policymakers tend to forget is that only the people who do the work can make this happen. Legislation can’t do it, regulation can’t do it, infection-control committees can’t do it, financial incentives and disincentives can’t do it. ….. Where it works, the common denominators are strong leadership and a committed work force.”

And for those of us with a bit of grey hair, this has the ring of déjà vu. When the U.S. auto industry was shocked by the quality of cars coming from the Japanese auto companies we were “shocked” to find out that it was not fancy automation and wiz-bang technology, it was leadership and a dedicated (and trained!) workforce that made the biggest difference.

I’m not saying that we don’t have to proceed with big, system-wide issues; but maybe the first place to start is to fix the problems we already know how to fix. And the solution can be found in the team we already have. But it will take real leadership and that will not to be found in a government program developed by people far removed from the real problems. Improving the health care system or any system often comes down to plain hard work.

Now go visit your boss and demand some real leadership.  The future of your organization is at stake.

The Fifth Discipline was a business book phenomenon in the very early 1990s. Written by Peter Senge from MIT it launched a whole movement (that, unfortunately, turned into a buzzword) for organizations to aspire to become “learning organizations.”

The titled fifth discipline was, and is, the discipline of systems thinking and in my opinion we need it more than ever. We especially need it to properly position the heated debates and warring camps associated with “fixing our broken health care system,” or words to that effect.

The foundation of systems thinking is that we operate within systems possessing both detail and dynamic complexity. In other words, there are lots of parts and most are changing all the time.

Chapter Four in Senge’s book enumerates the eleven laws of the systems thinking. Here they are, with a bit of commentary about our health care system and attempts to fix it.

1. Today’s problems come from yesterday’s solutions. In the WW II era, big businesses used company sponsored health insurance as a way to get around wage controls to capture and keep the best workers. Now the costs are onerous and harmful to our competitive position in the world market.
2. The harder you push, the harder the system pushes back. A current proposal to deal with the shortage of general practitioners and family doctors is to cut the Medicare reimbursement to specialty docs, since they make the most money. Gee, do you think they might push back?
3. Behavior grows better before it grows worse. Politicians will be tempted to enact some simple solutions to appease interest groups (hard to believe!) and costs might actually go down for a short period. However, if they don’t consider the larger system, they may not see the delay in feedback that will (later) add costs.
4. The easy way out usually leads back in. Universal health care might seem like a humane response to the needs of the uninsured and underinsured and might appeal to a majority. However, if the system is not made more effective or efficient we will find that we cannot afford the humane solution.
5. The cure can be worse than the disease. As we put policy and technology in place we have to ask how “the burden” is shifting and to whom.
6. Faster is slower. My concern about health care reform is that it will get connected to an election cycle and our friends in Washington (after watching this thing go from bad to worse of decades) will rush legislation to show that they are doing something. Point solutions will slow the repair of the system.
7. Cause and effect are not closely related in time and space. So, for example, let’s say that they legislate the wholesale switch to electronic medical records. Will they think through the long-term impact on costs, privacy and integration?
8. Small changes can produce big results – but the areas of highest leverage are often the least obvious. If we focused on wellness we might not have the costs of dealing with sickness. Unfortunately, the system is not designed to make us healthy; it’s designed to fix us when we’re sick.
9. You can have you cake and eat it too – but not at once. New information technologies may make the system more cost effective over time – but the upfront costs will be significant.
10. Dividing an elephant in half does not produce two small elephants. The private healthcare system is not separate from the government (VA, Medicare) system. Trying to keep them apart is senseless. 
11.  There is no blame. Give me a break! That’s all Congress knows how to do!

So, what if we resurrected a good idea from the very early 1990s and give it another shot? Which of the laws do you think we might use? Which are useless in this situation?

My buddy Brad has suggested that I occasionally post something with a little “heft” to it. So, inasmuch as I’m working on a book project to help people become better prepared for the future of healthcare, I thought I’d point out the need for people to be better prepared for the future. Comments, please.

I collected articles and newspaper clipping about the world of healthcare providers. Here’s a sample and thoughts that try to go beyond the simple facts of the story and address the issues of being prepared.

·         “Medicare Won’t Pay Hospitals for Errors,” chicagotribune.com, February 18, 2008. The lay person reads this and says “Darned right!” Healthcare professionals think about the reality of dealing with human bodies and the near impossibility of taking these incidents to zero. A person who takes the time to think about the future wonders about the unintended consequences of this action.

One of the truisms of systems thinking is that all solutions inevitably create a new set of problems. Furthermore, these problems usually show up later and in different places. People prepared for the future have to consider the system of which they are a part and how that system reacts (predictably) to bending and breakpoint forces.

·         “Innovation in health care: An interview with the CEO of the Cleveland Clinic,” McKinsey Quarterly, March, 2008. The article explores an interview with Toby Cosgrove, MD, the CEO of the renowned Cleveland Clinic. In the article Dr. Cosgrove explains the three seismic shifts he sees in health care. The first is prevention; the second is the drive for value for dollars spent; and the third is that healthcare providers are being judged on the patient’s total experience, not just the clinical outcome. In order to address the third shift, he hired a chief experience officer “whose entire responsibility is to look at the hospital experience from the eyes of the patient and to translate that message back to the caregivers.”

Some hospitals have a tax status of “for profit;” others a status of “not-for profit.” But all hospitals are a business that competes for patients. Healthcare providers prepared for the future will consider their “value promise.” Why should patients come to your organization? Transparency of the total experience will only increase in the coming years, especially with the generation who “Googles” everything.

·         “Health Care that Puts a Computer on the Team,” The New York Times, December 27, 2008. The article describes the Marshfield Clinic an early adopter of health information technology and how it is a forerunner of medicine’s “digital future.” Much of the article goes onto explain the advantages of electronic medical records and how the Obama administration sees them as necessary. However, midway in the article it shifts to an examination of “predictive medicine” and the impact that it could have on the health of the population and the reduction of health care costs.

We’ve been down this technology road before and should know to think about the second and third order effects of a new technology. Leaders who are prepared for the future often have a great sense of the past.  The invention of radio did more than replace local singing groups – it enabled changes that ranged from national advertising to Blitzkrieg warfare. Electronic medical records will do more than replace paper records; and predictive medicine is only one of the more obvious effects. Be prepared for the future by learning how to “look across time” and really learn from history.

·         “How to Revive Health-Care Innovation,” Harvard Business School Working Knowledge, March 9, 2009. Clayton Christensen is a respected innovation guru and he has recently set his sights on evaluating the world of health care. He states that business model innovation, one of the three enablers of industry disruption, was common in health care until about thirty years ago. If he’s right, and we think he is, the current ranks of managers and executives are only beginning to feel the pressures of industry-wide disruptive innovation.

Leaders can prepare for the future of changes in their industry by analyzing the changes that other industries have experienced before them. Health care leaders like to remind us that “they don’t make widgets.” True; but human nature is pretty consistent, irrespective of the nature of the work to be accomplished. Do you want to prepare for the future health care innovation? It might not be a bad idea to analyze the reactions of people in industries ranging from automotive to consumer electronics to newspapers. Patterns emerge that might be helpful.

·         “Scalpel, suture and tweet: Surgery in 140 characters,” Chicago Tribune, April 8, 2009. The article explains how a spokesperson for a hospital in a Chicago suburb tracked the progress of an operation and sent “tweets” to a group of “followers.” Why? Because the hospital is experimenting with social networking as a marketing tool. Think this is silly? Questions came in from as far away as Switzerland.

Like it or not, different groups want different styles of communication. In a broader, more connected world, prepared leaders will have to flex to the needs of their stakeholders. Great thinkers always consider multiple points of view and what you see may not be comfortable. Like it or not.

·         “Virtual colonoscopy at center of policy debate,” Los Angeles Times, April 18, 2009. This article presented the pros and cons of paying for virtual colonoscopies and whether or not they are effective and saving money. Toward the end of the article the author explains that some studies have shown it to be pretty good but others “have suggested that it is not as good as detecting some smaller polyps.”

Ask yourself another question: “Is this as good as it will get?” Remember your first “car phone” or bag phone? How fast did they progress? Preparing for the future requires the ability to develop “impact maps” of current technologies and mentally play-out paths of progress. Die hard technologies generally assume the impact of a new technology sooner than it actually happens. But many of us get “surprised” by how fast technology progresses. Learning to assess varying “winds of change” is essential to thinking about the future. And technology is one of the winds affecting health care.

·         “Health care options focus on paying hospitals and doctors for quality, not quantity,” StarTribune.com, April 28, 2009. This was an AP article that gave an overview of the announcement of the Senate Finance Committee as they prepared to go into closed door discussions. In the announcement they quoted Senator Max Baucus, the Finance Chairman: “The key to healthcare reform is delivery system reform – reimbursing providers on the basis of quality, not volume.”  Here are our questions: How would a liberal interpret that sentence? What about a conservative? What about the CEO of a hospital? Without solid critical thinking skills that sentence is wide open to interpretation.

Now is not the time for uninformed opinions. Now is the time to think about the future and preparing for the future requires solid critical thinking skills. A key skill is the ability to ask GREAT questions. What assumptions are being used? What’s the scope of the “delivery system?” How does he define “reform?” He’s presented the problem in terms of a solution. What’s the real problem and what are the root causes of the problem? And on, and on. Preparing for the future requires an understanding of today and that requires more than opinions.

·         “A doctor in your pocket,” The Economist, April 18, 2009. The article explains how cell phones are being used in sub-Saharan Africa and part of Asia. The applications are simple, such as self-reporting and getting messages from a health care provider. However, the power of the story comes at the end when the article mentions the cell phones as part of a “global surveillance system” that can be used for prediction.

We have no data from the future. However, we have been blessed with imaginations. Unfortunately, many adults have disconnected their imagination in search of “the numbers.” Being prepared for the future requires a fertile imagination and adults need to rebuild what they had aplenty as children. Not only can it be done, it has to be done.

Healthcare will account for over 15% of GDP in the coming years.  What do you think they need to do to be prepared?