Middle management is in a golden age. But it’s harder than ever to be a middle manager. Central Management is stories, tips, and wisdom to make it easier to be better.
This week’s guest on the Central Management podcast is Jordan Woods, heart and vascular service line director for a large healthcare system located in the Midwest.
“I enjoy the challenge of trying to be a chameleon and work well with anybody and be effective and appreciated by a lot of different types of people.”
The highlights of our discussion:
2:50 — job responsibilities of executing on executive project vision, whether he participates in developing that vision or not
8:20 — the impact of dictated quick-turnaround deadlines on manager and employee engagement when implementing projects; and the flip side of that: organizations are under pressure to get lots of things done
14:00 — Jordan enjoys his job and the challenges it presents, especially developing people (he is measured(!) on his success in helping his employees develop new skills that allow them to move into other positions in the organization)
19:30 — the biggest challenge for a middle manager is managing executive expectations about project timelines — and navigating the desires of the executive versus employee engagement (Jordan recently had a conversation with a hospital president where the individual made it clear they think managers and directors are the most important people in the organization)
26:10 — the importance of spending time as a middle manager in becoming a visionary leader involved in organization strategy; middle management, though under appreciated, is a great platform for career development
Or why your current amalgamation of programming isn’t improving community-level health measures
As healthcare delivery organizations continue to explore outcomes-based community health improvement strategies, it’s sensible to pursue one focused on “place.”
Places present the parameters for healthy decision making. The social determinants of health (WHO: the social and economic environment, the physical environment, and the person’s individual characteristics and behaviors) are heavily dependent on the concept of place.
We spend all of our time in places both in the real and abstract senses. There are two components instrumental to place in the pursuit of health improvement: the degrees to which it is 1) health supporting and 2) builds community.
Why place? The most successful behavior interventions and population health management efforts cannot be sustained if the environments (read: places) where individuals spend their time don’t support healthy living. Making healthy choices isn’t a problem when willpower and motivation are present; the difficulty comes when those personal resources are low — a tidal process nearly every individual experiences daily. Places of work, schools, and even religious institutions are beginning to offer more and more aggressive health improvement programming and, in the process, are creating health-supporting environments. Meanwhile the most important places — the home, the neighborhood, and increasingly online — remain on the sideline despite public health, hospital, and community foundation efforts.
Health occurs “out there,” outside the purview of a provider, outside the walls of even the most community-focused hospital. The vast majority of Americans — even those with chronic ailments — spend a fraction of their year under the care of a provider. While some may identify this lack of connection to the healthcare system as a problem, it actually represents an opportunity to shift health creation to the places where individuals spend their time, which, in fact, is where it should be. It behooves community health improvement initiatives to help people make the vast majority of their year healthier.
Places also happen to be where we gather, an important concept affecting both health creation and community building. The study of social dynamics has long held that individuals are influenced by each other’s behaviors and gathering is a prerequisite to the existence of community. Noteworthy programs such as Weight Watchers and Alcoholics Anonymous have leveraged both in building successful health improvement programming.
Why not an explicit focus on physical health? Because the physical manifestation of health problems are often signals of root causes. Hospitals, public health agencies, local governments, and community foundations have been working on health improvement initiatives for at least two decades and have little in quantifiable improvements to show for it. Middling attempts at a consumer-centered marketing frame of health have not achieved the widespread acceptance necessary to create impact. In the busyness of American culture, health is commonly the the “to do” left uncompleted on the “to do” list.
That busyness is as much to blame for declining health indicators as a poor diet or a lack of exercise. Declining social ties, lack of access to healthy foods, decreasing levels of spirituality, stressful workplaces, financial struggles, poor education, high rates of crime, strained family relations, among many others, are all contributors to declining health status.
The truth, often, is that physical health issues are the outcome of a complex concoction of life’s realities. But health is life; without it, none of the enjoyment that comes from being alive is possible. While the message of “health is life” isn’t likely to evoke action in the wider population — a struggle experienced by hordes of self-development strategies — it’s mandatory of a competent health improvement strategy to find a frame that resonates to encompass the essence of a “health is life” message.
Improving outcome measures like obesity rates, high blood pressure, managed diabetes, etc. through behavior change intervention is fundamentally arriving at the problem too far downstream. Those programs and interventions are necessary, to be sure, but that work becomes the focus of population health management and clinical interventions.
The future of health improvement will be based upon reimbursement and the preservation of revenue, not the work within a community benefit scope. The importance of behavior change programming can’t be left to volunteers, right place/right time programming, and an underfunded community benefit strategy. Today it requires — and the industry is coming to terms with this notion — the same level of professionalism, individualization, and reimbursement as traditional medical care to counteract the factors responsible for poor health.
Just because there are so many contributors to unhealthy living and the identified problem is deliberately defined with grandiose scale doesn’t mean a community health improvement strategy should microscopically focus on improving physical health indicators. It means the approach to community health improvement should match the magnitude and individualization of the situation. It also means that healthcare delivery systems must ask for their limited community health improvement dollars to do more. That approach is to become a catalyst for creating health supporting places.
Why a catalytic role? There are three reasons to pursue a catalytic community health improvement strategy:
The magnitude of the unhealth problem; if the definition is limited to physical health indicators the problem is massive; it only grows with the addition of the factors encompassing whole-person wellness.
The traditional consumer’s cognitive connection between health and healthcare providers. Providers can provide a respected connection to health improvement opportunities in the community.
The unique role a local hospital plays in a local community. Few, if any, corporatized organizations continue to hold special stature in local communities than “our hospital.”
The magnitude of unhealthiness — both at a national and local level in this country — is too tall a problem to expect that even the combined financial budgets of hospital community health improvement programming, local government initiatives, public health agency efforts, and community foundation grant making strategies to address.
Combine those monies in a catalytic effort with the (much more important) non-financial resources of community and neighborhood development and a recipe for true, impactful upstream change begins to appear. In short, to rival the causes of unhealth, health improvement is in need of a solution that scales: where the audience grows disproportionately compared to production costs.
This means working with households, schools, and businesses as well as local governments, spiritual institutions, and non-profit organizations to catalyze the creation of health supporting and community building environments. Individuals spend their time in an abundance of places and the extent to which their real and abstract characteristics support health and build community are varied.
What does it look like? Healthcare delivery organizations should pursue a place based health improvement strategy because places:
provide the necessary scaling opportunity;
can be crafted to be health supporting; and
are where individuals gather as groups to build community.
First, a conversation about scale. In a limited pilot, a program called Healthy Lakewood (Colorado) shows great promise in improving individual activation. In this scenario, activation is defined as the knowledge, skills, and confidence essential to managing one’s health. The evidence is clear that improved activation leads to improved health outcomes. The success of Healthy Lakewood is based upon the following tenets:
People are in need of supportive conversation more than they are in need of instruction.
Health education must be paired with an activation opportunity.
Change must be self-directed (but can be co-created).
The Healthy Lakewood program adopted a co-creation mindset: improvement driven by the individual and assisted by a supportive health guide. This community-centric model relies upon the organizational competencies of three Lakewood partners: St. Anthony Hospital, City of Lakewood Recreation Department, and the Consortium for Older Adult Wellness and connected participants to additional community services through self-management skill building and action planning.
The pilot results and growing demand for additional implementations of the Healthy Lakewood model are useful guides in the decision to expand the strategy. Given the number of people that would benefit from the program, however, the resource constraint of health coaching becomes apparent. Healthcare delivery organizations do not have, and will not have, the resources required to provide the level of assistance necessary to the number of potential participants required to create movement in population health measures.
But places do.
The true value of the Healthy Lakewood program lies in peer-to-peer conversations of support; not in the expertise of a certain class of professionals or license holders. While healthcare system investment is required to prove efficacy in initial implementations, future investment should trend toward creating and sustaining a peer-to-peer health improvement support model. This is possible given the learnings from Healthy Lakewood.
That same recipe of supportive conversation, activation, and self-direction (+ co-creation) can be applied in numerous settings to begin improving the “places” where individuals spend their time, to develop and redevelop (social dynamics and physical spaces) environments that support healthy living and behavior change interventions. Neighborhoods, workplaces, and places of worship (and Rotary Clubs, after-school programs, and yes, even the local pub, among others) hold additional value in this new community health improvement paradigm because they are essential to the creation of social capital.
The concept of social capital, defined simply as “sense of community,” is explored in Robert Putnam’s seminal work “Bowling Alone: The Collapse and Revival of American Community.” Putnam charts the decline of social capital since World War II and explores potential causes of Americans’ increasing engagement with private life at the expense of civic activities. His writings provide evidence that each generation since the pre-World War II generation has become less socially inclined; a certain problem given that communities with high levels of social capital are more successful while those with poor levels suffer social ills. While not as easily to chart, each generation since World War-II has become increasingly unhealthier, too.
The connection to health becomes clear when Putnam begins to provide the causes of declining social capital: increased television viewing (the average American now watches more than four hours of TV daily), busier families (dual-earning households, growth in youth activities, etc.), and urban sprawl (commute times, reduction in walkable urbanism, big back yards as opposed to front porches). These factors account for declining leisure time and are contributors in creating the perception of busier lives. A perceived lack of time is a major reason not to partake in health creating activities like praying, socializing, relaxation, or exercise. Levels of civic engagement and health status are linked, if only by the same causes.
Combine this reality with the steady societal transition away from a physical labor-intensive workforce, the emergence of processed foods, and an increasing reliance on modern medicine and it’s no wonder former U.S. Surgeon General Regina Benjamin remarked, “We are the last of the accidentally well.” No longer the happy consequence it once was, the pursuit of health has become a choice, rather, an amalgamation of choices. Catalyzing places to support community building in the pursuit of creating social capital is important not only because of social dynamics’ influence on individual decision making, but because community building also leads groups to improve the places where they spend their time.
Community building social capital strategies have been pursued as a means of increasing local civic engagement for a number of decades. The shortcoming of such strategies, often termed “healthy community initiatives,” has been a simple misframing of the opportunity. While health is always a component of these initiatives — along with education, economic opportunity, environmental sustainability, among others — it’s treated as one pillar rather than the overarching feature it should be.
Health is life. A person that is economically secure, educated, and lives in a safe environment is likely to be healthy. If by improved group activation neighborhoods, workplaces, and churches become more health supporting these opportunities become attainable and healthy communities will emerge. Creating places that support healthy living is different than creating healthy communities, it prioritizes the pursuit of health as an end over a means. The two approaches are similar in desire; an effort to create places supportive of healthy living can be informed by the work of those pursuing creating healthy communities. Jo Anne Schneider produced a report for the Annie E. Casey Foundation titled “The Role of Social Capital in Building Healthy Communities.” She writes in the introduction:
… fostering communities where residents have a sense of ownership for the neighborhood as a whole, as well as shared responsibility to other members, requires a complex mix of investment in individuals and institutions combined with measures to build trust and strengthen already existing social networks. Establishing healthy communities also requires that communities develop trusting connections with citywide institutions, markets, and policymakers to ensure that the neighborhood receives the resources that it needs, and that families have a bridge between their local communities and the wider society to achieve their goals.
Before healthcare delivery asks individuals to think about health differently, the industry must truly acknowledge that health is more than just the absence of disease. A reframed “health is living” concept is, at face value, important to most. If it is not important to the individual, it must become so before health improvement can commence. And that is the key to future messaging: the pursuit of health (wellness) is an individually defined undertaking. Surely every person can be encouraged to make healthier decisions but every person is also already pursuing some activities that are health creating. At the individual level, it is about recognizing what those are and doing more of them. The folly is in the expectation that a single message or approach will resonate with everyone. That is an unrealistic expectation in any setting.
The intriguing idea is this: a reframed concept of health — ”health is living” — can resonate with individuals, businesses, governments, organizations, churches, schools — places — because the presence or absence of health affects everyone. A strategy to create places that support healthy living and build social capital is the approach healthy communities initiatives should undertake.
That is the opportunity. It’s a partnership strategy to create and promote health supporting and community building “places.” It’s not about doing the work, rather, it’s about leading the work; launch the ship rather than sail it. Given the unique leadership position hospitals hold within the local community and the impetus provided by the foundations of community health improvement, pursuing a place-based strategy is the first step in ensuring healthy living becomes a way of life.
Putting it into practice
A few ideas:
Peer-to-Peer health improvement support/training as described in the Healthy Lakewood example; an organization like Centura would develop, train, and maintain the model through a network of community partners.
A self-management, activation, and organization training program for individuals to take leadership and ownership in the pursuit of place development by employing the three tenets of Healthy Lakewood
Leverage the Community Health Needs Assessment and Implementation Plan processes to create an ongoing and sustained community leadership conversation around a reframing of health, acknowledging the importance of place and the four broadly defined categories of physical, social, mental, and spiritual. This group should be empowered to lobby for impactful change efforts.
An accelerator would provide assistance to individuals and groups wishing to advance place-based-building projects such as expertise in data and analytics, community connections, project planning, capital, access to experts, among others.
The EMR falls short. IT is preoccupied and cost constrained. Middle managers need access to software. And widespread experimentation is key to transformation.
Strategy Execution Platform: Enterprise healthcare technology designed-for-the-user, won’t-bust-the-budget, and especially-for-your-need.
This is the most exciting time to be effecting change in the history of healthcare delivery. Healthcare transformation is continuously creating new operational requirements for healthcare delivery firms. Executives respond to the shifting operational requirements within healthcare delivery — both problems and opportunities — with strategies.
This is the most exciting time to be effecting change in the history of healthcare delivery.
As they have always been, middle managers are tasked with executing identified strategies. And as they have always had, middle managers use three resources to implement and execute: people, process, and technology.
Middle managers use three resources to implement and execute: people, process, and technology.
Decisions of whom to hire and promote have long been the agency of middle managers. The same goes for determining how employees do the work and customers experience the service.
Historically, however, technology decisions have been left to the IT department. Continuing this paradigm will only impede progress by creating barriers and causing frustration.
While not every problem is solved with technology, nor does every opportunity require technology, increasingly solutions are dependent upon technology. This makes it imperative to empower middle managers with it.
The responsive healthcare delivery firm provides middle managers the capability to act by empowering them with agency over people, process, and technology decisions. Responsive healthcare delivery firms allow middle managers to quickly solve problems and take advantage of opportunities by piloting as many ideas as possible.
The rigidity of the EMR and existing industry IT ideals are combining to prevent middle managers from being empowered with technology in the same fashion as they have been with people and process decisions. Fortunately, there is a solution.
The Strategy Execution Platform.
A Strategy Execution Platform provides diverse functionality, allows a sustainable support model, and is inexpensive to implement. It possesses the privacy and security features demanded by the healthcare industry. It allows IT to facilitate technology diffusion throughout an organization by focusing on governance rather than managing a project request queue. Instead of a single-record keeping system that promises everything to everyone with a single usability framework, it allows for many projects to be built upon a single framework promoting usability to match the workflow needs of the user.
Most important, a Strategy Execution Platform gives middle managers access to the technology necessary to promote widespread experimentation. Finally empowered with all three resources — people, process, and technology — middle managers are now truly enabled to implement the strategies of healthcare transformation.
A Strategy Execution Platform gives middle managers access to the technology necessary to promote widespread experimentation.
As continuing healthcare evolution has required us to inventory technology, question processes, and challenge our people, one thing has become clear: It will be the summation of many efforts that will allow healthcare to transform. With the aid of a Strategy Execution Platform, those middle managers able to pilot projects by marshaling their resources, innovating their processes, and taking advantage of new technology will be the leaders to get us there.
The Electronic Medical Record is a Brick Wall
The EMR is a necessary piece of technology. It’s the workhorse technology of healthcare delivery. It ensures stringent adherence to process. But the inherent rigidity and weight mean functionality, existing or promised, hasn’t adapted well to the requirements of an evolving operating environment. The EMR has not adapted to the flexible requirements of healthcare transformation.
Usability is terrible. It’s cumbersome for entering information and navigating existing information. The data is poorly organized. It doesn’t have a longitudinal view of information making it difficult to capture a snapshot of a patient’s context.
Speaking of data, it’s nearly impossible to get out for enterprise purposes. Creating or extracting reports, analytics, and dashboards requires an analyst, usually one that reports up through the IT function.
Customization of anything requires the consensus of a committee, is impossible at worst, and completed on a lengthy timeline at best.
The EMR controls workflow and process, rather than process and workflow being built into the technology. It offers no insight into productivity or performance. Automation, business logic, and workflow support are maddeningly absent. It recognizes no opportunities for process improvement.
Integrations are difficult or impossible. It lacks any effort to allow patients to enter information. And it doesn’t help market services, monitor health, or promote engagement.
Healthcare delivery requires a better way to become responsive to problem-solving and responding to opportunities brought about by transformation. It requires a flexible, complementary software solution that can be implemented anywhere, connect with anything, and is perpetually customizable.
The IT Department Has Become a Roadblock
The information technology department has been the most important department in healthcare delivery over the last forty years.
But IT has unintentionally become a roadblock. Technology now touches almost every aspect of healthcare delivery. Given this growth and new requests that come along with it, IT leaders have been forced to create a bureaucracy that allows only the most important and pressing needs to be addressed. This bottleneck prevents progress in an environment that is demanding more and more technology to support organizational initiatives.
The same cost-cutting and value-improving pressures facing operational departments are facing IT, too. With pressure to reduce headcount, a growing number of projects, and rising support requests, increasing needs from operational departments become more difficult to fulfill.
Technology needs of operational entities are viewed as a lower priority because IT’s focus is on other strategic priorities and enterprise initiatives like ICD-10, Meaningful Use, privacy and security, EMR replacements, technology issues related to mergers and acquisitions, clinical data integrations, etc.
Data analysis resides as a department, often within IT, instead of as a function embedded within each department. The necessary bureaucracy of the centrally managed IT function does not promote scope, scale, nor speed in new projects.
Given its support department status, IT is too far from the patient experience. Technology should be making it easier to use and consume healthcare services, not making it a more frustrating experience.
Creative technology solutions are viewed as a risk. No CIO has recently been fired for implementing Oracle or Cisco or IBM or Epic. This mentality leaves inexpensive and effective solutions to a wide variety of problems on the table.
IT must transition into a role as technology facilitator, helping to diffuse technology-supported solutions as quickly as possible. This mentality will allow organizations to take advantage of new competitive priorities and improvement opportunities. The IT department should be promoting care coordination, patient experience, team-based care, interoperability, and data sharing at every turn. IT must help other departments become more functional, not stand in the way of being functional.
This is the Golden Age of Middle Management
Where is healthcare transformation occurring?
The answer, clearly, is where healthcare is being delivered: in places like the clinic, the radiology department, the contact center, and the case management department.
Who is responsible for implementing healthcare transformation?
The answer, undoubtedly, is middle managers. The individuals charged with leading the clinics, the radiology departments, the contact centers, and the case management departments.
While executives have the enjoyable task of intellectualizing and philosophizing for the pursuit of creating strategy, it is middle management that has the responsibility to make the strategy happen. The ideas — yes, important — are the easy part. Bringing the ideas to life is difficult.
Peter Drucker, the famed management consultant, relayed it best when he wrote, “… the man who focuses on contributions and who takes responsibility for results, no matter how junior, is in the most literal sense of the phrase, ‘top management.’ He holds himself responsible for the performance of the whole.”
Perhaps a bit more succinctly but equally prescient, Herb Kelleher, the founder and CEO of Southwest Airlines put it this way: “We have a strategic plan, it’s called ‘doing things.’”
This is the golden age of middle management. An era when all the action of improving healthcare delivery is happening on the front lines under the supervision of the often maligned, but unnecessarily so, middle manager.
Middle managers are central to the success of healthcare transformation. As such, they are central to the success of healthcare delivery organizations. Maybe, just quite possibly, more important than the CEO.
But middle managers need to be empowered with the resources to make transformation happen. The job of the middle manager has become increasingly difficult: their plates are full, the velocity of industry change is increasing, and the constraints of the technology they and their staff are using are real.
Historically, with only supreme agency over people and process resources, it is time for healthcare organizations to empower middle managers with a third: technology.
As commonly held as the notion that organizations must innovate to continue to create value is, healthcare delivery organizations continue to struggle to ensure that innovation is systematically part of their culture, part of the day-to-day approach of solving problems or taking advantage of opportunities.
Charles Darwin had it right when he wrote about biology. It appears the same holds true for the modern-day business entity, too: Adaptation is key to survival. How to adapt but one step at a time?
Some ideas pontificated following the passage of the Affordable Care Act are beginning to appear. For many, though, we are still maddeningly far from knowing what is going to be the secret to success in population health, value-based reimbursement, or care coordination, among the many other elements known or unknown of healthcare reform.
Innovation is not a board room strategy, it’s a way of doing. A way of operating. Innovation only happens through experimentation with ideas. Many ideas.
While great headway has been made in finding new ways to deliver healthcare, there is truly only one way to continue to figure it out: try more ideas.
Tom Peters, the management consultant, puts it best: Whoever Tries the Most Stuff Wins.
Successful innovation is simple: widespread experimentation. That doesn’t make it easy.
Admirably, healthcare delivery has long been experimenting. It’s the essence of the scientific method, pilot projects, trial and error, Plan-Do-Check-Act cycles, Kaizen, process improvement, etc. Whatever the organization calls it, it’s imperative to do more of it.
As Malcolm Gladwell relays in his “Creation Myth” essay, psychologist Dean Simonton notes, “Quality is a probabilistic function of quantity. The more successes there are, the more failures there are as well.”
If innovation is the way into the future, and it most certainly seems to be, healthcare delivery firms must embrace widespread experimentation and make the tools, both tangible and intangible, acceptable, available, and accessible.
Strategy Execution Platform
Arthur C. Clarke, the acclaimed futurist, wrote: “Any sufficiently advanced technology is indistinguishable from magic.” That notion has been canonized as the third of Clarke’s Three Laws.
“Any sufficiently advanced technology is indistinguishable from magic.”
How does an organization empower middle managers with technology?
With the magic of a Strategy Execution Platform.
A Strategy Execution Platform provides diverse functionality, allows a sustainable support model, and is inexpensive to implement. It possesses the privacy and security features demanded by the healthcare industry. It allows IT to facilitate technology diffusion throughout an organization by focusing on governance rather than managing a project request queue. Instead of a single-record keeping system that promises everything to everyone with a single usability framework, it allows for many projects to be built upon a single framework promoting usability to match the workflow needs of the user.
Most important, a Strategy Execution Platform gives middle managers access to the technology necessary to promote widespread experimentation. Finally empowered with all three resources — people, process, and technology — middle managers are now truly enabled to implement the strategies of healthcare transformation. The ability to pilot ideas, as many as possible, in response to arising problems and opportunities and then iterating, expanding, or ending the idea is a paradigm changer for healthcare delivery.
As a flexible, complementary solution, a Strategy Execution Platform can be a standalone software system allowing software to be created for any need. It can be an overlay, a way to make existing technology more functional. It can be a way to connect technology with new or existing systems, making integrations the default and not an exception. And it can even be a solution that stands between two other solutions, drawing data from each and recombining to create something new for a related function.
A Strategy Execution Platform is the easiest answer to a problem facing more and more departments and cross-functional initiatives: information management. As organizational efforts take notice of the reality that what happens outside the hospital or clinic is as important as what happens inside, the patient journey continuum becomes a necessary concern. The four activities — acquire, connect, retain, and improve — some pursued collectively, others independently, become important considerations for a firm’s activities as a system of record.
As a platform strategy, a Strategy Execution Platform meets the goals of exponential distribution (scale), widespread experimentation (scope), and expedient implementation (speed). It can be programmed, tailored, and adapted to a department’s needs. It removes the need for IT to conduct a scoping exercise every time a technology request is made. Governance is possible but doesn’t stand in the way of progress. The system is dependable but doesn’t require excessive support. It is a multi-sided technology solution addressing the requirements of a diverse set of stakeholders.
The velocity of industry change requires an approach to solving problems and taking advantage of opportunities where there is a bias for action and an expectation of widespread experimentation. It requires a new commitment to speed and scale and scope. This notion becomes a reality only with empowered middle managers. Agency over people process, and technology decisions is their new domain.
Software allows unprecedented automation, efficiency, and the delivery of creativity.
Healthcare has never demanded new ideas to create value like it is now. Value for providers, for partners, and for patients.
Software is creating opportunities for individuals throughout healthcare delivery organizations — most importantly, those individuals on the front lines of delivery transformation — to create value in an unprecedented fashion. It’s never been cheaper, easier, nor faster to build quality software to support emerging ideas.
Software helps make ideas possible. While technology is often not the entire solution to a problem — it is usually part of the solution. Software can bring ideas to life. It can be the difference between paper and pencil, it can be the difference between having reliable and useless data, it can be the difference in creating a prototype that scales or a pilot project that languishes.
For instance, these are not difficult problems to solve:
Timely and accurate discharge information for patients leaving the hospital and being admitted to a long-term care facility (potentially preventing an unnecessary less-than-24-hour return trip to the hospital) should be the standard; instead it’s the exception.
Why can’t uninsured patients be easily targeted for a marketing campaign to become insured — good for the both the individual and the organization — based upon basic demographics and data sources readily available in other industries?
The standardized operating “rules,” “guidelines,” “resources,” and “protocols” stored in human memory, Word documents, and Excel files, should be readily available to all and logic-based for improved decision support.
Yet these problems exist in organizations around the country. My exploratory conversations with healthcare providers can be boiled down to a fill-in-the-blanks exercise:
If only we had software to __________________, we could __________________.
What a powerful notion. A notion that, until now, would have required great expense, great effort, and bountiful resources. The proliferation of software — and more importantly, the ease of which quality and inexpensive software can be developed efficiently — is changing that. The cataclysm of a world converting to software and a transforming delivery environment holds the potential to improve healthcare delivery for all participants.
That is why today’s healthcare operating environment requires a tandem approach to software: core systems and the flexible solution.
Core systems are traditional clinical software technologies like the electronic medical record, the practice management system, the PACS system, provider order entry, pharmacy information system, the lab information system, etc., etc., etc. They are in a fixed state and customization occurs at implementation. These rigid enterprise systems were built for a fee-for-service environment.
But the rigidity has created a technology gap that manifests as a barrier. By definition, the rigidity creates inflexibility.
To undertake new strategic opportunities brought about by system transformation, core systems require complementary flexible solutions. Flexible solutions are in a dynamic state and mandatory in a fee-for-value environment.
A flexible solution is a software platform that that can be implemented anywhere, connect with anything, and perpetually customizable. It is not limited to a particular function, not speciality specific, nor does it have to be expensive. It is quick to implement and easy to scale. It does not dictate workflow, it supports the best workflow.
Every enterprise requires both core systems and complementary flexible solutions. Both are necessary throughout the enterprise. Both are required to provide care across the continuum.
Accepting a broader definition of health means that a healthcare delivery organization embraces the determinants of health beyond access to care that serve a significant role in an individual’s health status. What better foundation than that for community benefit? Those determinants (behaviors, environment) are often represented by place: where people live, work, and play and the social dynamics represented within.
A traditional community health improvement approach would make it difficult to effectively insert health improvement programming into every place where people spend time. But there is usually an established entity (individual, organization, or small group) already promoting health and healthy living in these places. Accepting the determinants of health model means the industry must begin to shift community benefit spending to the determinants of health. Hospitals are unlikely (and probably unnecessarily) to create direct programmatic responses to improving these health producing factors.
But there are plenty of organizations that do. These may be arts groups, urban gardens, social entrepreneurs, community leaders, etc. An investment strategy is part of helping those organizations scale their reach and broaden their impact.
A community health improvement investment strategy uses financial resources to scale the efforts of these place-based community members. Given the expanded definition of health, the programmatic burden and need of health improvement is too large for any single healthcare delivery organization, a group of organizations, or even a group of organizations plus local government municipalities to create and sustain.
Community Health Improvement Investment (CHII) is defined as financial support provided to local organizations for the use of expanding and improving programming affecting the improvement of the determinants of health and health improvement. Converting community benefit spending to investment dollars will allow healthcare delivery organizations to improve social and environmental factors without undertaking the programmatic necessity to achieve community-wide impact.
Every organization will have to create an investment thesis depending upon its objectives to include investment targets (i.e., nature and requirements of investment will vary based upon business structure of the receiving organization), risk tolerance (i.e., tested and proven ideas vs those that hold promise), and investment principles. Several suggested principles are listed below.
Partnerships. Whenever possible a CHII strategy should promote partnership within the community by investing in collaborative efforts involving more than one organization. Multiple organizations working together toward a common goal can scale efforts of health improvement.
Built Environment. Invest in organizations and efforts that build health into expanding or redesigning infrastructure. The built environment, through health-oriented design, can promote healthy behaviors.
Culture. The characteristics (beliefs, religion, social norms, etc.) of the groups people spend their time with have a broad impact on health status. Efforts to create a culture of health — intentional effort to make healthier decisions — are worthy of investment.
Self-Management. Both on an individual and community level, the principles of self-management can lead to broad impact. Turning over the responsibilities of health improvement to individuals and communities will lead to broader reach.
Community Leadership. Social capital is the idea that social networks have value. Community involvement has health benefits, namely the building of social networks. These networks start with social participation and involvement and can evolve into community betterment efforts.
Implementation. Planning and ideation are important to realizing the creative process; however, many good ideas are never realized because of a lack of implementation. Focus investment on mature ideas ready for implementation. There are other routes to fund the important efforts of convening and idea gathering.
Scale. Promote scale whenever possible. The problem of unhealth requires efforts that reach the broader population. A major advantage of community-based health improvement initiatives over medically-based programming is their reach. Instead of one-to-one or one-to-few programming, invest in efforts that have scaling built in: where the audience grows disproportionately compared to production costs.
Community benefit strategy for healthcare delivery organizations is evolving — and for many of those organizations the Affordable Care Act is bringing the importance of having a strategy into focus. While community benefit has existed in some form since the founding of non-profit healthcare — -and really is the reason these organizations still hold not-for-profit tax status — -the function has been carried out primarily as an income statement function. Far and away the leading community benefit line item has been and continues to be charitable care and the unfunded care cost of government healthcare programs.
The United States spends most of its healthcare dollars on access to care, which accounts for only 10% of health status. (New England Healthcare Institute, 2005)
The Affordable Care Act has renewed the attention community benefit receives from organization leadership. The requirement of a Community Health Needs Assessment and accompanying Implementation Plan is propelling organizations to more intentionally affect community health outcomes. It has also renewed organizational attention to public health, particularly the determinants of health.
The vast majority of healthcare delivery organization expenditures is spent on providing medical care. Spending on the provision of medical services will continue to dominate the share of organization expenditures. And it should. It is what these organizations do best and the majority do it well.
But access to care isn’t what keeps people healthy. Access to medical care only accounts for around ten percent of the average individual’s health status. What does account for a person’s health status is where they live, work, and play.
Community benefit spending, then, should focus on catalyzing place-based health improvement. While charity care must continue to be part of every organization’s community benefit strategy, healthcare delivery organizations should be strategically spending in the following areas related to place-based health improvement:
Accepting the determinants of health model demands an expanded definition of health. That expanded definition must include the concepts of social, mental, emotional and spiritual health to accompany the traditional definition of physical health. The expansion of this definition requires a reimagined approach to community health, particularly community health improvement.
There is no better beacon of community health than that of the hospital and the provider. At a macro level it’s imperative for the combined resources of the healthcare delivery system to provide the catalytic gusto to reframe the definition of health. On an individualized micro level, the healthcare system must begin, in earnest, connecting people to the places they live and the resources those places contain to support health and health improvement.
The professional world of health improvement has an illness afflicting projects across the nation: its efforts are not reaching far enough. Organizational realities put limits on dreaming — it’s not that the profession doesn’t see the overwhelming need for a large, coordinated, and effective approach to helping people lead healthier lives — it’s that the fee-for-service business approach still dominates healthcare delivery. That institution frowns on dreaming because, up to this point, it hasn’t been measurable. An existence too beholden to reality, to the here and now (the opposite of dreaming as it were) produces small vision in abundance.
The fee-for-service perspective is predicated on a fairly straightforward approach to problem solving (i.e., value creation) in that it sets out to solve problems for which there is a relatively straightforward solution. In the fee-for-service world, business problems are solvable with traditional tools; the entire business is built upon the diagnosis and treatment of an identified problem. This is a very straightforward approach for the vast majority of medical problems. Broken arm? X-ray, bone set, cast. Breast lump? Mammogram, lumpectomy, chemo. Chest pain? Interventional radiology, cath lab, beta blocker.
These are necessary interventions. They are needed and required to produce health. But interventions like them have become the predominant way to produce health, when in reality, they should be but only part of a much grander approach to helping people be well. Contrary to perception, the collective combination of small vision solutions does not create a grand solution. The perspective must be larger.
Its within this framework that solving community health issues can be seen a problem too large to address as the siloed, traditional operations approach is insufficient to take on social issues. Combined with an unwillingness to reach outside these traditional parameters and boundaries of healthcare delivery, declining health status is an issue that continues to grow. It is this fatalistic perspective that stops the unbounded thinking and doing necessary to create healthier communities.
Health improvement is different than providing medicine, though medicine is integral to health improvement. The approaches to each are inherently different: the provision of medicine happens in an instance, or set of instances, in the clinic or the hospital. Whereas the provision of wellness happens when the individual takes knowledge from a clinic or hospital visit and activates that knowledge outside the confines of medical supervision and in common regularity. Health improvement requires the patient to do something for the patient. The traditional approach to medicine has made customary the provider intervening on behalf of the patient.
Surely health improvement must start with the individual; and it is one that must extend beyond the individual to the places where individuals spend their time. It’s a problem — or diagnosis — that healthcare delivery doesn’t currently have the tools to address. Health improvement must address the social determinants of health; its solutions will cross silos, combine approaches, and demand broader perspective taking. It is within these environments identified constraints can propel the necessary creativity to create something grander.
Addressing the unhealth problem (realistically a combination of many problems) requires dreaming and a resulting dream vision. It’s not something that medicine or healthcare delivery should or can tackle on its own. It’s a locally-based, collaborative effort requiring participation from every sector of life. It requires healthcare delivery organizations to refrain from implementing a series of small visions and take the lead in implementing a new reality, a different set of strategies and tactics.
Paradoxically, the dream vision must, too, be based in reality. Funding does not and will not appear based upon prognostications and soapbox discourse. Health improvement leaders and healthcare delivery organizations must come together to create a united effort. Health improvement must become more professionalized, uniformly committed to measurement, and address value creation for all stakeholders. Healthcare delivery organizations must show a desire and commitment to approaching the issue by appointing leaders able to establish and implement a dream vision, creating funding mechanisms to experiment and innovate, and approaching partnerships with a renewed veracity and leadership.
The approach of the past two decades to community benefit is not enough. The dream vision of health improvement must assist healthcare delivery organizations in navigating a tumultuous operational environment by providing measured value. The healthcare delivery organization must help the dream vision of health improvement by more fully becoming the community leader it so often is deemed to be.
It takes but a short drive around any metropolitan area to gauge the advertising battle between healthcare delivery systems. Rare is the advertisement promoting anything but consumption. The recommendation to consume is hidden in plain sight under the guises of new technology (come use it!), new locations (come visit!), and area locations (convenience!). It’s nothing short of a medical-arms race where a truce is seen as allowing the competition to win the battle.
But progressive healthcare thinkers recognize that advertising a medical-arms race is a losing proposition in the long term. The reimbursement models the industry is moving toward will not reward this type of marketing strategy. It’s time to realize an alternative approach is necessary. It just so happens there’s an opportunity waiting to be seized.
A productive provider/customer relationship is built upon trust. Trust isn’t created, it’s earned, and it starts with having trustworthy products and services. But more companies (in various industries) are realizing it doesn’t have to end there. Because of capitalism’s competition-driven business culture, organizations, large and small, have been embracing new marketing trust-building touchpoints in a variety of ways.
These organizations have recognized that traditional communication methods work differently than they used to, that customers feel emotional connections to the brands they purchase from, and the traditional buyer/seller relationship has become more complex. In short, companies have embraced cultural responses to a shifting market context.
Why have healthcare delivery organizations been so slow on the uptake of this emerging cultural theme?
Healthcare delivery organizations, pseudo-corporations as they are, long ago recognized that achieving balance between profits and sustainability is core to their raison d’etre. Healthcare has always had certain advantages that traditional corporate organizations have had to work hard to replicate.
The first is purposeful brands. Corporations have spent extensively trying to create positive correlations in the consumer’s mind between their brand and what it stands for. For example, Pepsi embraced a project it titled “Refresh” to express that its brand is more than soda, it’s about building community. Whole Food’s recent campaign “Health Starts Here” invites shoppers to embrace healthy eating by shopping at the retailer. Walmart’s embrace of environmental sustainability is meant to make consumption feel less foul.
The second advantage is using a marketing approach to express brand meaning in non-traditional ways to create correlations in customer’s minds “between branding channels and everyday life.” The NFL’s “Play 60” effort encourages youth to become more physically active using the sport’s superstars to encourage participation. Hershey’s (the chocolatier) Track and Field Games’s stated goal is to inspire youth to be their best by training for and participating in their competitions. Red Bull, arguably considered the movement’s champion, utilizes a variety of methods to promote its “gives you wings” tagline.
For most healthcare delivery organizations, their purpose is about being a foundational support to community by providing healthcare services in support of leading healthy lives. An inherent purpose that has remained remarkably unchanged since the advent of modern-day healthcare delivery. That purpose is their culture, their people, and their identity. These organizations have always held themselves to a higher standard, a higher purpose. Surely, they will continue to do so.
Knowing this, it makes the question “why don’t customers love healthcare brands?” all that more intriguing. “Look at us, we’re great” is limited in its effectiveness, and is declining daily. Especially when everyone else has the same. exact. message. Individuals don’t inherently want to interact with healthcare brands; they haven’t, generally, provided joy in the past. There’s little positive about what happens in hospitals and physician offices. Even in cure, there’s plenty of discomfort in diagnosis and treatment. But an evolving payment structure and a new resolve to help people lead healthier lives is granting permission to healthcare delivery organizations by finally giving people a reason to interact with healthcare brands.
How can healthcare delivery organizations leverage these inherent advantages to create brands that people enjoy interacting with?
Corporate social responsibility, as a theme, has been around for decades. In most contexts, however, it existed as either a response to negative press or a surefire method to improve the bottom line. Its social good was often a by-product, a happy consequence of circumstance. CSR programs became an addendum to doing business, not a part of doing business.
In more recent years corporate social responsibility started to become integrated with the concept of branding. Out came brand purpose: a promise bigger than just selling more product. As a result, brands softened. They’ve warmed. They’ve changed. In short, brand purpose has created purposeful brands.
Walmart, a retailer long criticized by detractors for its promotion of consumption and the negative environmental consequences that result, reversed course in 2005 when it announced three ambitious goals:
To be supplied by 100% renewable energy
To create zero waste
To sell products that sustain people and the environment
Eight years later, the world’s largest retailer is a recognized leader in environmental sustainability. Walmart’s sustainability agenda has required adopting renewable energy sources, making a wide variety of improvements to shipping methods to improve efficiency, and improving the amount of produce that is sourced locally.
Walmart now not only sees sustainability as good for business, but as a responsibility of conducting business. It’s effects are multiplying as sustainable improvements spill over to other retailers and industries. It has partnered with Daimler Trucks North America to build a hybrid electric semi-truck, worked with manufacturers to reduce packaging size, and it’s convinced 100 partners, including some competitors, to be active in the Sustainability Consortium, a collaborative industry group focused on improving consumer product sustainability. With larger initiatives reaching natural limits in helping Walmart achieve its sustainability agenda, the company introduced a Sustainability Index tool in 2011 to take the sustainability movement to the product level.
While Walmart’s brand represents various creations in the minds of individuals, it’s purpose has moved far beyond outfitting American homes with low-cost goods. It now aims to outfit American homes with low-cost goods in a sustainable, good for the environment, fashion. Walmart now is socially conscientious.
For as long as the modern-day memory extends, profit maximization has been the go-to, status-quo business strategy for stockholders. Somewhere along the way this mentality began to crowd out the source of those profits, the customer. And customers (in growing number) began to notice. It explains a renewing interest in local, in relationships, and in brands with a humanizing morality.
While the attitudes of corporations are slow to change, no one can deny that profits are important — equally so in regard to sustainability to for-profits and non-profits. However, the signs of a shift away from a “profitability at society’s cost” mentality are present. Brands with a social conscience are everywhere and they include corporate giants as well as alternative-minded start-ups. Socially conscientious brands recognize and put into action: What we do is/can be: a) good for you (personally, environment, community, etc.) and b) good for business/us. Skepticism remains (and should) at the motivations of McDonalds, Coke, Walmart, ExxonMobil, but one must acknowledge that they are doing something. And that something is improving their brand promise.
Igniting worldwide intrigue, the project was designed to “transcend human limits.” It promised new research into the world’s fascination with exploring space. Millions of people tuned in to watch history being made.
But the decade wasn’t the 1960s. The project wasn’t funded by the United States government. It wasn’t the first time man entered space.
Instead, Felix Baumgartener became the first human to safely free fall from 128,000 feet above Earth and break the sound barrier from the edge of space.
The project was funded by Red Bull, the energy drink company. It was the latest marketing effort by a company known for its non-traditional advertising, a strategy that has propelled the company into the world’s number one seller of energy drinks.
Red Bull’s marketing strategy is a literal example of Marshall McLuhan’s famous phrase “the medium is the message.” Its brand promise, “Red Bull gives you wings,” has driven the company to creatively market its product through events, projects, and ownership that, if not entirely literal, gives participants wings. Its Flugtag event invites participants to pilot homemade flying machines off a pier and judged on distance, creativity, and showmanship. Crashed Ice is a downhill ice course skating competition where skaters navigate steep turns and vertical drops. Red Bull doesn’t just sponsor professional athletic teams, it’s own them, including soccer and racing franchises worldwide.
The thousands and thousands that gather to view these events are constantly exposed to Red Bull messaging. Stratos, as the free fall jump program was titled, set a YouTube record for most live streaming views. Though Red Bull, a privately held company, doesn’t release sales figures, experts predicted the event would lead to increased sales, a category the company already leads as the world’s number one seller of energy drink beverages.
McLuhan’s “medium is the message” lives on. Many companies have begun embracing the sentiment with strategy called murketing, a portmanteau coined by Rob Walker combining marketing and murky to describe a paradigm shift that has marketers blurring the lines “between branding channels and everyday life” and “the consumer embrace of branded, commercial culture.” Putting its potentially negative connotation aside, it’s an advertising strategy that moves beyond direct messaging to customers and instead relies upon experiences, brand association, brand building, marketing buzz, brand identify, publicity, and the like.
And more and more brands are using it.
“Public Works” Tactics in Healthcare Delivery Organizations
FastCompany put it this way: “This is the new world of marketing — where the advertising efforts of brands become public works — think Nike funding childhood obesity studies and creating campaigns to get kids moving and American Express creating an initiative to get the public shopping at small businesses.”
These efforts are nothing if not the seizing of a cultural zeitgeist where some customers expect more than a consumption-only relationship from the companies they do business with. Simon Sinek captured this shift with his proclamation that “People don’t buy what you do, they buy why you do it.” Not every customer cares, of course, but corporations have decided that pursuing “public works” marketing strategies are important enough to create and continue.
It’s relatively straightforward for a company to pursue one of these strategies. Success of a “public works” marketing strategy depends on the relevance of the idea to the company’s services or products. Pepsi’s Refresh Project received attention because it was atypical; argument remains as to whether or not it increased profitability. On the other hand, Red Bull’s approach has propelled it to the leading energy drink company worldwide, in terms of market share. Walmart’s embracement of sustainability saved the company $230 million through its waste diversion and recycling efforts in 2012; whether it has created new customers is arguable. Rare, however, is the organization that can take full advantage of both.
From a strictly mission-based perspective, there are not many better corporations than healthcare delivery organizations to pursue both a purposeful brand and murketing strategy. Along with this shift in marketing, we’re entering a world where people care about their health like never before, partly out of necessity, partly because of intrinsic motivation, and partly because of shifting culture.
Health Improvement as a Marketing Strategy
This crossroads of marketing, brand purpose, and consumer interest is where health improvement can become a strategic advantage for the forward-thinking healthcare delivery organization. Instead of continuing to spend marketing dollars on a deteriorating consumption-based advertising strategy, these organizations should embrace purposeful brand and murketing tactics. The future of marketing healthcare delivery is about helping people address needs; for instance: finding a doctor, easy prescription refills, and health improvement.
What underlies any purposeful brand strategy is the utilitarian value the strategy provides to the customer. Health improvement helps customers address a need while also creating goodwill, both of which create customer loyalty. Loyalty is the reason to pursue such a strategy. Health improvement communicates a healthcare delivery organization’s commitment to the betterment of the individual.
Healthcare delivery organizations should repurpose significant portions of their advertising budget to health improvement programming. Organizations should create robust (an emphasis on robust, traditional programming efforts don’t meet the need), innovative, and wide-spread health improvement programs that have visibility everywhere in the community: in schools, households, businesses and at athletic events, community fairs, neighborhood gatherings, etc.
As a result, the organization will create more loyal customer relationships, support customers in their pursuit of addressing a need, expose the organization to potential customers, raise the organization’s profile in the community, and improve health. Given the advent of new reimbursement models that reward value over volume in a managed health environment, there is a possibility health improvement programming will create future profitability by lowering the incidence of unnecessary healthcare consumption.
As Duncan Watts has eloquently noted, “If society is ready to embrace a trend, almost anyone can start one. If it isn’t, then almost no one can.” Given the attention that healthy eating and active living is receiving from society in general, there is no better time to pursue a purposeful brand strategy in the name of health improvement. There’s power in embracing culture; most importantly customers respond to it. The opportunity to transform healthcare organizations’ brands from the sick care focus they have had to the health care they will become is immense and immediate.
It’s not just when an individual works out at the gym. Or sits down for lunch. And especially not just under the care of a physician.
It happens in those places. And every moment between.
It happens at happy hour with friends. It happens smoking a cigarette. It happens in a place of worship. It happens in the day-to-day mundane or the exceptionally engaging 9–5 of a workday.
Health is always. It’s the outcome of existence.
The University of Nebraska’s Wellness Model represents the scope and scale of Health is Always recognition: it’s elements of emotional, physical, social, environmental, occupational, spiritual, and intellectual wellness represent the totality of life.
2. Health is Personal
It’s almost too logical to state. But in a population health world, it’s too important to forget.
No situation better illustrates this reality than that of a 2009 U.S. Preventive Services Task Force recommendation for mammograms, a recommendation made on the basis of population health science. Mammograms for patients under 50 with average breast cancer risk, the USPSTF essentially said, were causing more harm than the potential good that can come from earlier screening.
Whether the science underlying the USPSTF’s 2009 recommendations supported the position mattered little when the news was met by public perception. And this is where the dichotomy of population health meets that of an individual: individuals framed breast cancer screening as a personal issue, not one of a population. Individuals care very little, if at all, about population health.
“What about me?”
That’s the pivot question, asked in a variety of ways and in differing circumstances. It’s the expression of health viewed through the perspective of an individual: Health is Personal.
Health status is determined by contextual factors such as genetics, lifestyle choices, and living conditions as in Dahlgren and Whitehead’s “Determinants of Health” model.
3. Health is Local
Health is Always and Health is Personal lie at the intersection and in the interaction of a long accepted truth: Health is Local. Health is not created by a single healthcare provider, nor the local recreation department, or a community garden in the middle of the city. It’s all of these and everything else.
For those elements of health within the realm of reasonable control (namely everything except age, sex, hereditary factors), the context of local is immensely important to the opportunities (good and bad) available. Those opportunities like where to work, where to attend school, and where to worship. Such as where to meet, where to shop, and where to spend free time. Or the air we breathe, water we drink, and food we eat. Our friends, family, and connections.
Choosing to engage in health-creating behaviors is contingent upon availability; often the most available lies within the communities where we work, live, and play.
In their book Healthy Cities: Promoting Health in the Urban Context Trevor Hancock and Leonard Duhl describe elements of a healthy community:
A clean, safe, high-quality environment
An ecosystem that is stable now and sustainable in the long term
A strong, mutually supportive, and nonexploitative community
A high degree of public participation in and control over the decisions affecting one’s life, health, and well-being
The meeting of basic needs (food, water, shelter, income, safety, work) for all the city’s people
Access to a wide variety of experiences and resources, with the possibility of multiple contacts, interaction, and communication
A diverse, vital, and innovative city economy
Encouragement of connection with the past, cultural and biological heritage, and other groups and individuals
A city form that is compatible with and enhances the preceding parameters and behaviors
An optimum level of appropriate public health and sick care services available to all
High health status (both high positive health status and low disease status)
Unhealthiness, as a relative public, has become part of everyday life. It often is the path of least resistance. This is not because of laziness or lack of willpower but because the pursuit of unhealthy behaviors has become so easy. Unhealthiness isn’t a choice any longer. It just exists.
Health is a choice.
It didn’t used to be this way.
We sit while we work. We watch hours of television. We drive from one side of town to the other, and back. We eat foodstuffs our ancestors wouldn’t recognize as sustenance.
And the reason we do these things isn’t because we set out each day to do them. It’s because it has become part of culture, part of our day, part of living. Prior to the present, we sat less at work, we watched fewer hours of television, we drove less, and we ate healthier food.
Choosing to be healthy has become the failure point. Our willpower tanks empty too quickly. Our habits and routines are difficult to alter. Until healthy living becomes a part of everyday living as it once was, health outcomes evident of a healthy society will continue to be elusive.