Response to week at Harvard Kennedy School of Government

From Jan. 27 through Feb. 1, 2013, I participated in an executive education program titled “Shaping Healthcare Delivery Policy” at the Harvard Kennedy School of Government in Boston, Mass. In more than 54 hours of case studies, presentations and dialogue, we examined creative approaches to solving complex healthcare problems, including ways of fulfilling the Institute of Healthcare Improvement’s Triple Aim: improving care, improving health and decreasing cost. We interacted with visionary leaders of healthcare including former Center for Medicare and Medicaid Services (CMS) administrator Dr. Don Berwick, who first defined the Triple Aim.

On Friday afternoon, Feb. 1, Saturday morning and Sunday morning, I wrote responses to participations in this meeting. They included the following. Friday, I said:

“Individually, and collectively, I have benefited from the generosity of your minds and spirits. Heraclitus of Ephesus (540-480 B.C.) reminded us that we can never traverse this same river again; neither will we ever be the same and neither will we forget. In Europe, the entrance into the lecture hall of an esteemed teacher elicited a vigorous stamping of the feet. The thunderous vibrations of the wooden floors were the professor’s richest reward. To our teachers, we offer the metaphorical stamping of our collective feet in honor of them.

“Having enjoyed the week, I expected today (Feb. 1, the last day of the conference) to be anticlimactic and perhaps even superfluous. Nothing could be farther from the reality. Sheila’s (one of the two co-directors of the program and an adjunct lecturer at the Kennedy School) case study presentation was the crowning event of the week. Surely, I thought, Amitabh’s (Amitabh Chandra, Ph.D., professor of public policy and director of health policy research at the Kennedy School) “wrap up” will be perfunctory. My favorite medical articles are grand summaries that bring together the state of current knowledge. I did not expect such a summary for this meeting.

“At the beginning of the last session, I was briefly distracted by patient care in Beaumont, but shortly after Amitabh’s summary began, my attention was captured and I was dazzled, literally, by his brilliant integration of our week-long experience. I was genuinely awed by his performance. Thank you, Sheila and Amitabh. In the midst of visionary leaders like Don Berwick and David Blumenthal, you shined through as the stars.

“I would hope to join such a group again — it is too much to imagine the same group re-gathering — but if that is not to be, it will be my purpose to aggressively pursue the “moral test” – the care of those in the dawn of life, those in the twilight of life, the elderly and those in the shadows of life, the poor, the needy and the handicapped — the “Triple Aim” and the transformation of healthcare. It is that resolve and commitment which will honor the privilege of being “one of the forty-nine (the number of conference attendees).”

“In the context of your values, blessings upon each of you. It was an extraordinary week — and it did not end with a weary whimper but with a triumphal crescendo. I am impressed and grateful. I will always carry these memories in my heart and mind.”

On Saturday morning, after rounding at the hospital, I wrote a second note to the conference members. “On the four-hour flight home last night, I though more about our week together. I realized after experiencing the emotion of the group yesterday, that what had been happening all week was that a group of strangers were becoming a team. The critical step in healthcare transformation is that each transformative unit must become a team. We began that process this week. It has been interrupted and as a ‘group of the 49,’ we cannot continue, but we can take that experience with us to our respective organizations and continue it.”

The experience brought to mind Peter Senge’s comment in his book “The Fifth Discipline”:

“Most of us at one time or another have been part of a great ‘team,’ a group of people who functioned together in an extraordinary way – who trusted one another, who complemented each other others’ strengths and compensated for each others’ limitations, who had common goals that were larger than individual goals, and who produced extraordinary results. I have met many people who have experienced this sort of profound teamwork – in sports, or in the performing arts or in business. Many say that they have spent much of their life looking for that experience again. What they experienced was a learning organization. The team that became great didn’t start off great – it learned how to produce extraordinary results.”

“That process began with our sharing personal histories and stories which communicated to others who, what and why we are. It continued with us tackling problems together. We began to learn and we experienced the fact that learning really has very little to do with taking in more information but it has everything to do with metanoia – “changing our mind” (Senge) about how we relate to other members of the healthcare team, and about why are relating and what our goals are.”

In his book, Senge identifies five new “component technologies” that are gradually converging to innovate learning organizations:

1. “Systems Thinking – endeavors bound by invisible fabrics of interrelated actions, which often take years to fully play out their effects on each other. Systems thinking is a conceptual framework, a body of knowledge and tools that has been developed over the past fifty years, to make the full patterns clearer, and to help us see how to change them effectively.

2. “Personal Mastery – the discipline of continually clarifying and deepening our personal vision, of focusing our energies, of developing patience, and of seeing reality objectively – the learning organization’s spiritual foundation.

3. “Mental Models – deeply ingrained assumptions, generalizations, or even pictures or images that influence how we understand the world and how we take action. (This) starts with turning the mirror inward; learning to unearth our internal pictures of the world, to bring them to the surface and hold them rigorously to scrutiny. It also includes the ability to carry on ‘learning-ful’ conversations that balance inquiry and advocacy, where people expose their own thinking effectively and make that thinking open in to the influence of others.

4. “Building Shared Vision – When there is a genuine vision (as opposed to the all-too-familiar ‘vision statement’), people excel and learn, not because they are told to, but because they want to…Given a choice most people opt for pursuing a lofty goal, not only in times of crisis but at all times. What has been lacking is a discipline for translating individual vision into shared vision – not a ‘cookbook’ but a set of principles and guiding practices. The practice of shared vision involves the skills of unearthing shared ‘pictures of the future’ that foster genuine commitment and enrollment rather than compliance.

5. “Team Learning – How can a team of committed managers with individual IQs above 120 have a collective IQ of 63? The discipline of team learning starts with ‘dialogue,’ the capacity of members of a team to suspend assumptions and enter into a genuine ‘thinking together.’ The discipline of dialogue also involves learning how to recognize the patterns of interaction in teams that undermine learning. The patters of defensiveness are often deeply engrained in how a team operates.

“This is what we were experiencing in Boston, which is why we may have a hard time putting our finger upon an idea or a fact which we will ‘take home with us.’ What we experienced was parts or all of these five steps. The case studies that we ingested and then digested aided this process. …

“Have you ever noticed that you have begun many things which you never finished, but that you have never finished something which you did not start? The key to success is to begin – that carries with it the risk of failure but it also brings the opportunity for success. Such a team has the ability to perform near miraculous transformation in the lives of those we serve. Have you ever seen a client or patient who threatened to kill someone? Listen in your heart to the following story:

“Ultimately, it is in the collection of thousands and of millions of stories like this that we will know that we have transformed healthcare. The outcome is worth the difficulty of the process because whether it is the ‘moral test’ or the ‘triple aim,’ it is the result that is seen in the lives of those whom we serve that

“As I finish this note, I realize there is another on in the offing. That note will contain my recommendations for future meetings both as to structure, content and ‘dynamic.’ But, I will save that for another day. Thank each of you for the gift of your sharing of your ideas.”


Dr. James L. Holly is CEO of Southeast Texas Medical Associates, LLP (SETMA) in Beaumont.