I drank the Kool-Aid--and learned 24 key management lessons.

I left a full-time private pediatric gastroenterology practice officially 10 years ago. Slowly making the transition--first being a chief of staff, then taking a half-time job as a medical director of ambulatory clinics--I went into management as a full-time medical director of all ambulatory and outpatient services at Children's Hospitals and Clinics of Minnesota in 1994.

When a lot of us talk to our physician colleagues, we will say (kiddingly, of course) that we have "gone to the dark side." That's because most of our medical peers feel that once you have gone into management, you are truly not a doctor any longer--you drank from the Kool-Aid.

Having confessed this, I still want to reflect on my past 10 years, and convey some of the lessons I learned from being in medical management. Besides gaining a lot of on-the-job management experience, I have also achieved an MBA. Since 1994, I have been most appreciative of all my mentors who taught me a tremendous amount, both practical and philosophical.

In ascending order of importance, the 24 important lessons I've learned during my journey through medical management include:

1. Think like a system or chaos ensues.

The complexity of health care would lead one to believe that we are as close to chaos theory as anything else. It is systems thinking that will help us survive. As with pathophysiology, you can't just treat symptoms--there are processes and feedback loops out there that need to be understood. People who don't understand this will never be successful in management. While physicians understand this in their clinical work, we seem to forget this when it comes to the management world. Too often, we want to cure management symptoms, and not look at systems and processes.

2. Strategy is in high demand but short supply.

I see very little strategic differentiation going on in health care. Unlike many other industries, in health care you go to national meetings and talk about strategy, but the same thousand organizations continue to do exactly the same things, in exactly the same way. Why does anybody think that this will make any difference? Very few hospital systems are actually using strategic differentiating factors compared to their competitors. Rather, they are all playing the same games. There is very little creative, truly "out-of-box thinking" in health care. Few places are creating new rules.

3. There are five keys to a successful project.

When planning any kind of comprehensive program or project, you need five things:

* A vision and the ability to articulate it simply

* People with the necessary skills to carry out the project

* An understanding of the resources that are necessary and the ability to get them

* Incentives that are aligned with your goals

* Someone who is accountable, who carries with him or her the plan of action, timing, and measurements.

Without each of these components it is unlikely that you will be fully successful.

4. We simply have to understand our core business.

I don't believe we, as an industry, truly know our "core business." The prime example comes when someone asks us what our out-comes are, and we are unable to articulate them on the spot. In fact, we look like deer caught in headlights. We may know a few select outcomes for this program or that condition, but if you ask nine out of 10 administrators (or doctors, for that matter), they couldn't tell you their organization's overall mortality rates, infection rate, or complication rates without really struggling for days to get the information. Very few other industry leaders would be this naive about their business. Heck, they would be embarrassed.

5. Not everyone is a big-picture thinker, but everyone thinks they are.

We certainly want people in management who can see the forest for the trees, understand the big picture and overall strategy. But I have never actually met anyone who, when asked "Are you a big-picture person?" will answer "Why, no--but I do have a tremendous grasp of the details of my narrow world." What I have found is that most doctors believe they are big-picture thinkers, and if you are not seeing the picture as they see it, you must be dull, stupid or not creative. They also all believe that they could do marketing, fundraising and run the organization without any training, just because they are smart.

6. The blame game dies hard.

No matter how ingrained you are in the safety movement culture, no matter how committed you are to being a blameless organization, there is still plenty of blame going on. The first reaction of most clinicians to a medical accident or error is still "Let's blame the person who screwed up." When we jump this hurdle, we will truly have made progress.

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7. No one thinks they are not working hard.

You cannot tell anyone (especially a doctor) that they aren't working hard enough. No matter what you have for an impression, just saying that to someone and saying you don't think they are putting much time or effort into work will not be effective and they will want to destroy you. Unless you have the data, don't even go there.

8. Physician/administrators = love/hate.

Physicians can't seem to get out of a vicious cycle of yearning and abhorrence when it comes to leadership roles. They want physicians to be in management and running organizations, but as soon as it happens, the physician/administrator has lost legitimacy and credibility. You suddenly become one of two things as a physician/administrator--incompetent or a liar. Can we get over this?

9. We should just let go more often.

There are too many projects going on in a hospital at one time. We say this over and over again, try to prioritize, and then seldom get it right. Peter Drucker was correct, we need "organized abandonment." We seldom let go of projects or processes. We just keep adding and then complain that our plates are too full.

10. Issues may have polarity but don't have to be polarizing.

If you start with "either-or," you'll get into trouble. If you think "both-and," your chances of improving things greatly increase.

11. Money talks.

There is no doubt about it, the people who get the most response are the ones who create most of the wealth in the organization: the cardiologists, the neurosurgeons in adult hospitals, or the transplant people or neonatologists in the children's hospital. Because these groups generate the contribution margins for the system, they are the ones who get listened to first. It takes a lot of fortitude to balance this phenomenon and give heed to the smaller players.

12. Some things just don't fit into a neat package.

Halfway through my list, here are some short bites that resonate with me:

* "Doctors may not be right but they are never wrong."

* "Meetings are where minutes are taken but hours are lost."

* "Doctors never remember what you did for them, but they never forget what you didn't."

* "If you're early you are on time, if you're on time you are late, and if you're late you're toast."

* "Whether a bad or good event occurs, before you know it, it's over--so either enjoy it if it's good or forget it if it's bad."

13. Management restructuring seldom works.

We like to believe that changing the anatomy of an organization is going to make a difference, when in reality it is the physiology--the culture--of the organization that matters. Watch out for organizations that constantly restructure them-selves. They are not dealing with the real issues of their cultures.

14. Little things matter.

Over time, I've found that responding to physicians on the little issues is just as important as the big ones, as long as they know you are trying. If you can't change big things, they understand--after all, that's why big, complex problems are big and complex. But if you don't respond to their little needs, they'll just stop believing you will ever help them.

15. Unintended consequences happen.

I see this all the time. You may plan and prepare for many results, but quite often it's the unintended consequences that turn out to be the bigger issue. We are not good at being prepared for the unexpected.

16. Style does matter.

Your personality does have impact. People tend to like affable or verbal personalities, and we judge each other very easily on such characteristics as a reflection of competency. For example, negative people who criticize often come off as being smart. We need to be aware of this--they are not smarter, just negative.

17. Management tools are means, not the end.

We are enamored by new management tools and fads, whether it is TQM, CQI, lean management, re-engineering, or Six Sigma. Every year or two there is a new one out there, and we jump on it like it's a new set of 10 commandments. Remember, they are just tools. Learn to use a few of them well. And stick to the fundamentals, as my CFO is fond of saying.

18. Get used to no thank-you's.

As an administrator, everything you do will tick off somebody. The "thank-you's" will be few or non-existent. If you are in management to get them, forget it--this is not the place to receive positive feed-back. You will have to find it else-where. Self-assurance and confidence must come from within.

19. It's about power.

All physicians will tell you their motives put patients first. Thank goodness there truly are some people who believe that, but for too many it is first and foremost about power, control or money. They may use the facade of patient care, but "Who has the power?" is the elephant in the room.

20. You can't make all people change.

When dealing with physicians (and others) about disruptive behavior, I have learned that the individuals must first have insight into their own behavior. Without the ability to accept this and then show remorse, the chance of them making successful changes is very low.

21. What color is the sky in your world?

It is amazing to me how often people will make up stories to fit their personal view of the world. If they don't have the facts, they will simply create their own. Most distressing of all, they tend to think of the worst in others as they describe what is occurring. The attribution is unbelievable.

22. Culture eats strategy for lunch.

Organizational change is unbelievably hard because most organizations are made up of powerful, ingrained cultures. People who created those cultures normally don't want to change; they want to stay at their comfort level, with the status quo. In some organizations, of course, the pain of remaining the same is greater than the pain of changing. If that is the situation, people will change; if it isn't, it will take everything in your power to make the change. A culture will fight at every turn to maintain itself.

23. Leadership does matter.

Leadership has many components: trust, vision and values, to name a few. It's about managing conflict, about being willing to be held accountable. The role of leadership is to create useful change in a non-coercive manner. It's about setting direction and motivating others in the face of ambiguities and conflicting demands. It's about managing meaning more than information.

24. Trust is everything.

The most important responsibility you have as a manager or leader is to engender trust among the people you lead. Without trust, your effectiveness in managing is absolutely minimal. Having trust signifies that "I will do what I say; I will act to the best of my ability and competency." Simple things can build trust: responding to people in a timely manner and dealing with their concerns, big or small. I do believe (as Stephen Covey says) that people create emotional bank accounts, and people will allow you withdrawals if they know you and trust you. If you start in a hole, though, it's very difficult to dig out.

From this list, it may seem like I'm cynical or unhappy. If you want to know if I'm still glad I went into management--the answer is absolutely yes. I went into management because I wanted to have impact on the health of a large population of children, as opposed to one at a time.

I loved taking care of my patients and I still enjoy getting wedding announcements and thank-you notes and calls from former patients who want some advice. But no matter what hard lessons you learn in management, the impact you can have on large populations of patients in a mission-driven organization still far exceeds any of them.

I'll let you know what I've learned after 20 years (hopefully).

Phillip M. Kibort, MD, MBA is vice president of medical affairs and chief medical officer at Children's Hospitals and Clinics in St. Paul, Minn. He can be reached by phone at 651-220-6165 or by e-mail [e-mail].

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Note: The author thanks his past and present mentors for helping formulate his thoughts about medical management: Tom Marr, MD, VPMA; Blanton Bessinger, MD, VPMA; Mitch Einzig, MD, VPMA; Terril Hart, MD, VPMA; Brock D. Nelson, CEO; Alan Goldbloom. MD, president and CEO; Julie Morath, COO, CNO; Jerry Massmann, CFO; Chris Seitz, CNE; Walter Chesley, VPHR.

By Phillip M. Kibort, MD, MBA