Paving the road to hell: why change programs ultimately fail. (Positively Influencing Physicians).

IN "CULTURE AND Communications: A Critical Part of Reengineering," (1) Lisa Hirsh views cultural alignment as necessary for successful reengineering. Culture is "a pattern of beliefs, values, and expectations shared by members of an organization that powerfully shapes the behaviors of Individuals and groups within the organization." This is a theoretical ideal that would lead one to assume change is possible once realignment has been accomplished.

In reality, most organizations are composed of disparate groups whose "beliefs, values, and expectations" are often in opposition. Executives of health care organizations are beholden to stockholders (2) and have goals that are anathema to physicians (limiting services and payments versus maximizing services and payments). Employees, having learned there is no reward for corporate loyalty, are suspicious of physicians and health care executives, believing the latter's positions offer a level of security unavailable to ancillary staff. (3) Nowhere is this misalignment more apparent than in health care reengineering programs.

Putting out one fire after the next

Corporate culture is not that difficult to understand once you've been around It for awhile. Many senior people want to believe they are the next Jack Welch without having the slightest idea what that requires. At best, they will make some key decisions that will not blow up in their faces, but the desire to maintain an illusion of complete control usually gets in the way of any meaningful progress. At worst, their need to "do something" leads to "Ready. Fire. Aim." I've worked for several organizations and none of them were proactive. All suffered from crisis management. Middle and upper management spent most of their time putting out one fire after the next, often not realizing they were the only ones with matches.

In one of Hirsh's workshops, the participants identified, "It's not what you know, but who you know" as a cultural rule. One senior member objected and the group modified the rule to "Excellence is not a core value." Hirsh believed this was the path to enlightenment:

"Why was this distinction important? As we have said, cultural rules drive behavior, and the assessment pro vides a foundation on which to build new cultural values and norms. But it is important to articulate the right rule. For example, if the rule had remained "It's not what you know, but who you know," the organization would have focused on changing the performance appraisal process to prevent favoritism. This narrow interpretation would not have resolved the fundamental cultural issue.

When the rule was reformulated, it meant that the organization had to attack a larger problem- the lack of excellence throughout the organization, from the way halls were swept to the way patients were cared for."

If excellence were truly important, management's actions would reflect ITS concern for both employees and customers. Instead, the reputation of many health care organizations is "they're only in it for the money." Despite protests to the contrary, customer service is usually very low on the priority list. Why else would an organization put up with Dr. Shortfuse, the general surgeon who treats his staff poorly and is curt with other physicians, but generates a great deal of income? Why else would organizations create member service departments whose staff do not have the power to solve a patient's complaint or dilemma, only to reiterate corporate policy?

Change requires three elements

Change requires conviction, money, and effort. Without all three, any attempt at change is doomed. Many health care executives have the conviction, but are unwilling to spend the money or expend the effort. Some lack conviction, despite having money; the effort is merely spinning wheels with no forward motion. Often all three are lacking, despite an outward appearance to the contrary--the result of management delusions.

1. Conviction

Many efforts fail because senior management really doesn't want change and is unwilling to face that reality. The conviction is, at best, superficial and for display only. Senior management wants to give the illusion it is doing something. Middle management goes along with the sham, bringing it back to the employees with much fanfare, only to be greeted with cynicism. The managers are quickly labeled toadies; there is often token acceptance just to pacify middle management. Corporate communications (teams, newsletters, "open-door policies," elaborate campaigns, expensive posters and displays) are perceived as an executive mouthpiece for spreading propaganda.

Sometimes corporations spend a great deal of money and effort is expended to cover the lack of conviction. A staff-model HMO for which I'd worked for several years got a new CEO. The old CEO was known for being contentious and bucking the parent organization when one-size-fits-all policies didn't meet the reality he lived every day. The new CEO made a spectacular entrance, glad-handing, backslapping, and conversant in management speak. Buzzwords flowed from his mouth like honey-progressive, empowerment, change agents, diversity, win-win.

The organization had a history of using consultants to obtain obvious information. It spent $5,000 on a consultant who determined the employees at one site were unhappy because the building was inadequate and the pay was low-something the employees had been telling the administration for years for free. One of the major problems for the new CEO was declining revenue. He commissioned a major consulting firm to "completely examine every aspect of our operation" for $500,000. The move was met with skepticism when the young consultants admitted they had never worked with a staff-model HMO.

One inefficient telephone system was replaced with another. The optometry department was extensively remodeled, then closed within six months, diverting $150,000 a year in business to community optometrists. The mental health department was remodeled, then closed because "the numbers weren't good." The running joke was, "If you see maintenance measuring your area, you are next on the chopping block!"

Three years were spent training staff for a "new" computer system, which was widely acknowledged to be a dog but was a political payback. (The system was scrapped before conversion was complete.) We were exhorted to "improve our performance," despite not having any reliable parameters or tracking system. The company spent $200,000 on a physician profiling system, which, among other deficiencies, lumped the performance of one general surgeon in with four obstetricians.

Unfortunately, the CEO either was oblivious to or deliberately ignored the one problem that plagued the HMO from its inception and continually eroded membership: poor customer service. Patients complained about long waits (up to 20 minutes) on hold when trying to schedule an appointment or talk to a triage nurse about concerns. Referrals and coverage for treatments were denied frequently, sometimes with disastrous results. (A local TV station aired the plight of one patient, ending the segment with a phone number to call if viewers had similar experiences.) The HMO lost a $960,000 contract with the local electric company, not to a competitor in town, but to a university health system 60 miles away.

As revenue declined, layoffs increased. One round was dubbed "Black Friday:" another was the "Monday Morning Massacre." Despite numerous pep rallies in which employees were assured, "You can make a difference," morale continued to decline, along with revenue and patient satisfaction.

He left after three years, only to be replaced by a faceless, part time CEO who also covered another division. Market share has dwindled for the past five years. My OB department, which once delivered 750 babies a year, does 15 deliveries during a good month with three obstetricians and two nurse-midwives. Ancillary services have been curtailed; urgent care has closed; many have left for more secure jobs in the community. Those who have stayed wait for the other shoe to drop.

2. Effort

"The road to hell is paved with good intentions" and "the devil's in the details" are two cliches that are particularly well suited to many efforts at change. I'm reminded of a cartoon from the 1980s. Two scientists are standing before a blackboard filled with mathematical equations, in the midst of which is the phrase, "And then a miracle occurs." One says to the other: "I think you need to be more specific here." Such is the stuff of which many change programs are made.

Change does not happen magically by itself. Some well-meaning plans fail because of impatience. The goal is clear but the path is fuzzy. Some people are surprised to find out change involves hard work and time. A new physician practice may take two to three years to break even under the best of circumstances. Entrenched attitudes and resistance ("We've always done it this way") can undermine any program to the point that it ultimately dies of neglect. Laying the groundwork is often more tedious and important than actually implementing a program. (4)

A 39-bed hospital in rural New Mexico was taken over by a large for-profit hospital management corporation. The new CEO hired several primary care physicians, a general surgeon, and an obstetrician-gynecologist to "bring back the paying customers, who were seeking care at two other facilities 60 miles to the north and east. He promised, among other things, to renovate several areas of the hospital, which was badly out of date, including the surgical suite, the obstetric suite, and the general medical floor. The hospital was in the process of renovating a historic building in the downtown area for physician offices. The CEO promised, "You'll be so busy in six months you'll need a partner."

Within two months the physicians realized the CEO lacked the will to follow through. Money was poured into a sports medicine/rehabilitation complex. The administrative offices were renovated twice while the OB and surgery suites languished. The proposed office building renovation was six months behind schedule; the new physicians were placed in inadequate temporary quarters.

The majority of patients who used the hospital were indigent. Many of them had bad experiences in the emergency department and did not trust the hospital or many of the physicians in town. The established physicians were hostile, assuming the new physicians were intended to displace them.

3. Money

Another well-worn maxim is, "It takes money to make money." When faced with declining revenues, many companies will address the problem by increasing market share through designing a better product and decreasing operating costs, Often that requires long-term investments: newer or better technology, more money for R&D, better marketing, a more responsive sales force.

In 1981, Jan Carlzon took over SAS at a time when all airlines were losing money, promising a turnaround within 12 months. He began by determining his target market: the business traveler. Money was poured into services that were essential to meeting the target, while scrapping those deemed unnecessary. He went to the board of SAS and asked for (and got) $45 million. He missed his deadline by one month and became the only profitable airline in the world in 1983. (5)

Health care organizations, on the other hand, usually only look at cost-cutting, with little thought given to who their target markets are. "Frills" are stripped out, employees go through rounds of layoffs, service suffers. Patients vote with their feet and go elsewhere--resulting in declining revenue, which triggers another round of cost-cutting. The end point is going out of business or, more likely, merging with a more financially solvent entity, which brings its own set of problems.

A 200-bed hospital in a town of 18,000 in Northern Michigan was concerned because the insured obstetrical population, like the town in New Mexico, was seeking care at two competing hospitals one hour in either direction. Ironically, in the mid-1970's the hospital's OB unit had become well known across the state for its patient-friendly atmosphere. The physicians had instituted practices now considered common, such as ambulation during labor, fathers in deliveries, and letting patients make decisions about pain medications, Twenty years later, the physician staff had changed, but the OB unit hadn't. The other hospitals had invested heavily in new "birthing centers" with considerable marketing efforts to attract patients.

The physicians and administration met in 1992 to discuss the problem. The administration attributed patient migration to poor customer service on the physicians' part, and refused to consider any changes to the physical plant until patient complaints decreased, The physicians, in good faith, made a considerable effort to address their interpersonal skills and three years later had improved markedly.

The physicians and administration met again in 1995, along with the labor and delivery nurses. The hospital presented results of a survey that showed 80 percent of the hospital's patients were satisfied with their care, but they were unable to gather information from people in the community who went elsewhere. The nurses reported many patients had talked with friends about the birthing centers at the competing hospitals and had considered transferring. The administration was unwilling to consider any changes to the physical plant, although they acknowledged the physicians had done their part. Four years later, the hospital merged with one of the competing health care systems.

Prerequisites to implementing change

Reorganization, reengineering, right-sizing--call it what you will. Change by any other name is still change and still frightening. Change based on deception is destructive. People are not FTE's, tangible assets, necessary evils, covered lives, or interchangeable cogs in the machine. They are individuals with families to feed, bills to pay, and responsibilities to meet. They are also quick to see through misleading and insincere schemes.

Plsek compiled a list of reasons TQM and reengineering efforts fail, which includes: "lack of top management commitment; failure to understand and address resistance to change; lip service to principles, with action and organizational culture that are inconsistent with those principles." (6) In my experience, administrators are wildly enthusiastic about change as long as it is cheap, painless, and effortless, They begin to back away when reality sets in, and are invariably resistant to the notion they might be part of the problem.

Honesty from the outset will serve you well, even if the goal is less than desirable. If your goal is, like Avis, to be Number 2, don't pretend you want to be Hertz. If your niche is serving the indigent, don't aspire to attract heavily insured patients if you have nothing to offer and have no intention of competing effectively. If there is no money in the budget for renovation, don't display architects' renderings along with nebulous timeframes. If you are not going to survive without sacrifices and layoffs, don't promise what you can't deliver. And don't expect people to be fiercely committed if they know they'll be laid off in the next quarter.

On the other hand, if your goal is to become the dominant entity in the community and take no prisoners, don't disguise your intent with lofty mission statements and new age television ads. In Chicago, the Blues' promise to "be your insurance company, not your doctor," (7) contradicts the reality of the health care system where insurers make financial decisions under the guise of "medical necessity." (8) If your goal is to be the best, figure out what that takes and then, as Nike says, "Just do it."

Initiating change programs merely because it seemed like a good idea at the time is foolish, especially if your only goal is to "reengineer" something, rather than making a difference in how you do business. If you are not serious about change, don't do anything. Save your money, your breath, and your employees' time. They may not thank you for it, but they will respect your honesty.

References

(1.) Hirsh, L. Culture and Communications: A Critical Part of Reengineering, Reengineering Health Care, Lenz, PR and Sikka, A. Eds. Tampa, Florida: American College of Physician Executives, 1998.

(2.) Colle, R. Changes for Physician Executive in the Millennium Marketplace. The Physician Executive, 25(1):8-13. January/February, 1999.

(3.) Personal communications.

(4.) Gilbert, J. The Need for Executive Alignment for Successful Change. Reengineering Health Care, Lenz, PR and Sikka, A. Eds. Tampa, FL: American College of Physician Executives, 1998.

(5.) Carlzon, J. Moments of Truth. New York, New York: Harper Perennial Ed., 1989

(6.) Plsek, P. Total Quality Management and Reengineering: Similarities and Differences. Reengineering Health Care, Lenz, PR and Sikka, A. Eds. Tampa, Florida: American College of Physicians Executives, 1998.

(7.) 1998 Chicago area radio ad campaign.

(8.) MDs vs. Insurers: Who Decides Medical Necessity? Ob. Gyn. New 34(9):34-35, May 1, 1999.

RELATED ARTICLES: Why did the TQM Effort Fail?

Reasons why TQM and reengineering efforts fail include:

* Lack of top management commitment

* Failure to understand and address resistance to change

* Lip service to principles, with action and organizational culture that are inconsistent with those principles.

--Plsek, P. Total Quality Management and Reengineering: Similarities and Differences. Reengineering Health Care, Lenz, PR and Sikka, A. Eds. Tampa; Florida: American college of Physician Executives, 1998.

Old myths die hard.

James D. Rusin

Legend has it that physicians are not 'team players.' Numerous articles expound this as fact and enumerate obvious reasons for this broad class imperfection.

* It is a genetic trait. Medical schools purposely select new doctors with doctors with large egos who are independent thinkers and lack an understanding of or interest in interpersonal dynamics.

* Physicians are bitter over their loss of prestige with the coming of managed care. The 'natural response' is to opt out of the system and refuse to cooperate. "You cannot even talk to them".

* Physicians are dinosaurs living in the past and are unwilling to change. They are unfit for the future.

* Physicians are greedy and only concerned with preserving and enhancing their incomes. Any change is considered a threat.

* Physicians want to be the leader of every group or 'they will take their bat and ball and go home'.

These pundits have drawn the wrong conclusions concerning physicians and team dynamics because they started with the wrong assumptions. A lot depends on your definition of team player. If being a team player means you leave your mind somewhere and unquestioningly follow the leader it is probably correct that physicians are not never will be team players. If on the other hand being a team player means you want to be part of something larger than yourself you have the good of the group foremost in your mind and you want the endeavor to succeed then you want physicians on your team.

Why should I care?

Physicians have a lot to contribute and they can make some of the best team players if one takes the time to understand their motivations and address their concerns. The extra time laying the groundwork will pay big dividends later. Correctly motivating doctors is probably no different than motivating anyone else but doctors are less likely to suffer in silence. For those you wish to enlist on your team the primary question that must be answered is. "Why should I care?"

The key to being a good motivator is an intense focus on the goal at hand. In every endeavor I have been involved in we never seemed to suffer from an excess of intellectual curiosity unique perspectives, determination, or old fashioned 'sweat equity'. Think about it doctors have spent a good portion of their young adulthood preparing for the service of others. Show them the way your goal meshes with their desire to help their patients and you have their soul.

* Respect them for what they know and what they have to offer and you have their minds.

* Paint your goal in broad colorful, flourishing strokes that excite them and require them to stretch. They will be intrigued and give plenty of effort.

* Get them involved in the effort early on. Everyone is more motivated if they feel they have had the opportunity to contribute and the result reflects their effort.

* Provide them with colleagues because doctors are definitely a social species. They seem to function better in a group that has shared similar experiences.

WAYS TO TURN OFF PHYSICIANS

On the other hand, it is not hard to turn off physicians.

* Be sure to express the attitude one HMO executive relayed to me: 'Doctors are no different than janitors. They are a labor factor and I will treat them as such!'

* Separate them from their patients. As one clinic administrator told me. 'Quit talking about your patents. You do not have any patients. They are all clinic (or plan) patients!'

* When as an HMO executive you are selling your plan to an employer, don't forget to blame physicians for all that is wrong with the health care system. Finish off your presentation with a promise to save their company from those greedy doctors. 'Don't worry, the doctors in your plan will never be the wise!'

* Let the physicians know that they are not really wanted when it comes to decision making. Condescend with a comment like, 'You just practice medicine and let us take care of the rest!'

* Keep them in the dark. Let the rumor will churn. Wait until your marketing plan is underway and your brochures are printed before you inform the physicians as to what you are doing. It really impresses them when they find out about what is going on in the clinic or the plan from their patients or staff. If they do not buy in at this point, it is obvious it is because they are not 'team players'.

* Don't forget to make promises you do not intend to keep. Promise them better salaries and working conditions with fewer hours or call days. Do it right and make it a point not to write down your promises. That way, when you do not deliver ('Things have changed!') it is your word against theirs.

* When you have misled the physicians numerous times, ask them to trust you one more time. "This time it will be different." You cannot lose. If the physicians follow you again and you let them down again well silly them. If they reject you and your latest plan and the plan fails, blame it on them.

Whichever way you choose to go, 'Happy trails!'

JAMES D. RUSIN, MD, MBA, FAAFP, is a practicing physician in Minneapolis, Minnesota. He can be reached by calling 612/421-6993 or via email at [e-mail].

David A. Rivera, MD, FACOG, is a writer and locum tenens physician living in Lombard, Illinois. He can be reach by calling 630/495-1199 or via email at [e-mail]