Friday, April 24, 2009
A key principle of relationship and communication is that a person can --and will--change. The change may be profound as in moving the center of their life. In relationship, it is best to assume the best possible motivation for the other person and, at the same time, give them room to make mistakes. It is just possible that, even if we share a common center, are motivated by the same high purpose, and are both "good people", that we might not take exactly the same path to the goal.
In the best of all worlds, we would be attentive to each other and aware when we seem to be diverging. When we see this happening, we would talk about the divergence and the reasons for it. At this point, there have been no mistakes, no recovery is needed. All we need to do is realign ourselves with our shared goal. The path chosen might be mine or yours or some new one created out of the improved understanding derived from our conversation.
These principles are as applicable to groups as they are to individuals. Many a "leader" has brought disaster to himself and his followers by becoming focused on the problem in front of his nose and losing contact with the overall objective. This happens when the leader's center either moves inside of himself (glory, revenge, hate...) or was there to begin with (advancement, wealth, recognition...).
Don't lead your followers into a trap. Keep (or move) your center outside of yourself.
Thursday, April 23, 2009
What do you think of this sentiment? Would it help to know more about Herr Hochhuth?
I believe that a significant portion of humanity operates as though these two statements were true. I'm sure there are many reasons for this, but the root of all the reasons is fear. Fear is such a powerful emotion in us that many can't even acknowledge it--even to themselves. The result is that it transforms and appears (I like the word manifests) as another emotion altogether.
Earlier I posted regarding controlling personalities and said that insecurity and low self-worth, two manifestations of fear, were at the root of the need for control. When I saw this quote on MSN today, I immediately went back to the control issue. These two statements nullify everything we teach about collaboration and teamwork. If they ring true to you, may I suggest that you ask yourself why.
This isn't a casual investigation. You're not going to be truthful with yourself at first. You'll have to do the kaizen "seven whys" and do the seven whys repeatedly because, if you hope to help yourself and are attempting to be honest with yourself, you will get different answers each time you get to the seventh why. One day you will name a specific thing that is the cause of your fear and you will feel good because knowing is better than not knowing. But this is just the first plateau.
Now you have to ask why this particular thing is producing fear in you.
Each time you reach a new plateau, you will look around and see your world differently.
Do you recognize in yourself the need for control? Do you share your vision, plans, objectives freely and listen to the responses? Do you say what you believe and believe what you say?
How can your company, organization, team function productively if you answered no to any of these questions?
Tuesday, April 21, 2009
It certainly does help to have an idea of what kinds of technology benefits you are looking for and the types of technology that might help to deliver those benefits BEFORE you begin to design the change management program. Countless technology implementations costing untold millions (or billions) of hard-won capital dollars have been scrapped or have taken so long that the purchased technology was obsolete before the implementation was completed. The reason (and the solution) is in these two paragraphs.
Best Practice is the survey of how others are doing whatever it is that we would like to do, picking out those that seem most successful, and documenting how they are doing it.
Best is an objective determination, based upon comparison, and using some standard of comparison, of several alternatives within a context.
Humans being what they are, we always have to carefully define the context we are working in. Humans being who they are, the definition is never quite good enough to resolve all doubts. I am cursed with the gift (cursed with a gift--who's with me?) of immediately seeing similarities and differences. Show me a rule and I'll find the exceptions. Show me several random situations and I'll show you the similarities. It's a gift in that I find it very useful--a curse in that it drives other people crazy.
I'll get right to the bottom line. A best practice effort is only going to produce results for you if your investigation examines contexts as well as process, tools, governance... To put it another way, do you have the same history, culture, experiences, skills and attitudes as the organization you're comparing yourself with? If not, that doesn't mean there's no value for you in their practice. It does mean that you're going to have to know more about them and about yourself before you can put your own version of that practice into effect.
As far as best goes, it's time that we gave up on the idea of supremacy. Best in a particular competition among equally matched competitors is still only good for the moment. That's why we have continuous improvement. It's why there are frequent surprises at playoff time.
The best you can find is still just the best that you can appreciate. When we know better, we'll do better.
Monday, April 20, 2009
I saw a piece on the Today Show this morning in which one of those being interviewed made a statement to the effect that agism or age-based discrimination, is to be found at both ends of spectrum. That rang true for me. I guess the only question to be answered would be the placing of some scale on the spectrum so the appropriate remediation planning could be done.
We seen many articles and interviews regarding the characteristics of various generations from Gen Y to Baby Boomers (pretty much the endpoints of the employment spectrum). I always have to remind myself that these "portraits" are generalizations only. It's easy to latch on to a singe trait within a generational portrait and, having seen that trait exhibited by at least one member of that generation, apply it to all within the age group. Then it's only another small step to say, well, if that one is true, they're all probably true.
It's also good to remember that tendencies are statistics. An average (or a tendency) requires that some be above and some below. It isn't necessary for any individual to be average for there to be an average for a population.
This is all on my mind because I have been following some discussion forums recently and have begun to form some opinions about abilities of generational groups based on the content of the posts. I'm struggling against this because, when I stop to reflect, I know I'm making a statistical mistake.
Here's the thing: If it's happening to me, it's happening to anyone (everyone). It's very dangerous to attribute knowledge or maturity-related issues to age. Every young person is not immature or ignorant and every older person is not mature or wise. So this is a reminder that each person must be appreciated for who they are and the unique contributions they are able to make.
There's a corollary: You can't really know a person until you've met that person face to face and have shared some of his/her life. Do you know me because you're reading this or because we've exchanged emails or tweets? There are hard limits to what can be accomplished remotely, without personal contact. Some younger people know this and many older people do.
If you happen to run a company, you have a bigger labor pool than you need right now. This won't be the case for long, especially if you're in a scientific, engineering or high-tech market. People pushed to the side now and left to rust away may not be able to step back in after several years (or even several months) have passed. When you push people out of one end of the pipe without making sure there are people entering at the other end, eventually you will find that your pipe is empty. How will you adapt your business then? The knowledge, creativity and energy that created your business will be needed to transform it. It won't be about age. It will be about maturity, wisdom, creativity and energy.
Friday, April 17, 2009
I have a vision that can only be fulfilled from the office of the CIO. This vision is characterized by
- The patient of one is the patient of all
- The history will be available wherever and whenever the patient presents
- The patient may know immediately about the services delivered and the charges for those services.
- The revenue cycle can be reduced to same-day for covered (under contract) services
- Costs can be reduced by as much as 50% through attention to the quality of the information captured and used within the system
- People will accept a system of standards when they see that their own interests are satisfied
- The people in health care are highly motivated and need only a shared vision to be fully productive
- Alignment is possible when the vision is clear
- Good, reliable, current information is the key to all of this and getting that will demand the careful cultivation of cultural and attitudinal changes.
I firmly believe that this vision can come to pass with blinding speed in an environment of openness and honesty in which people are encouraged to care about and for each other.
There are two areas in which it seems necessary to ignore the Wizard. One is in the nature of "healthcare" itself. Most spell checkers refuse to recognize healthcare as a valid word, suggesting "health care" instead.
Clearly, spell checkers have not been sensitized to the politics involved. Since the dawn of the HMO nearly 30 years ago, health care has gradually given way to healthcare. What does that mean for you and me? I don't know if you've noticed, but even the physicians have been shifting attention away from their own role toward the insurance end.
More than 15 years ago, I attended a software engineering conference in Chicago at which [former] Surgeon General C. Everett Koop was a keynote speaker. I became disturbed during his speech when he made comments seeming to grant insurance companies a gate-keeping role in health care. When I got back home, I wrote him a letter mentioning my impressions and asking whether that was his intent. Some weeks later I received an envelope with Dr. Koop's return address and which contained my letter. My "gatekeeper" question was circled (red pencil) and "NO!" was written (large) in the margin.
Today, physician leaders don't even blush when they tell us that the solution to our healthcare problem is better access to [insurance] coverage.
Health care can be linked to medicine. Healthcare is a business, pure and simple. When people are talking about money and where it will come from, they aren't talking about health care.
I do not question the motives of individual physicians in health care, but I question everyone's motives in healthcare unless they are talking about profits. Even the insurance companies are being edged out for control. Today, healthcare cost is controlled by third-party (neither doctor nor patient) vendors of everything from pharmaceuticals, to technology--especially technology. This isn't necessarily a bad situation--it all depends on what the goals are. Pick your favorite goal from this list (or suggest another):
- return on investment
- market dominance
- a healthy populace
- access to medical care
- giving back
Thursday, April 16, 2009
I can almost hear the snorts of disgust. Many in healthcare will be quick to dismiss the last post by telling themselves that "we have standards." I can't allow them to let themselves off so easily.
Of course healthcare employs standards. I was, for a brief time, part of a newly formed HIMSS task force on standards. Healthcare has a wealth of standards, none of which are truly standards in that all use words such as should and unless and if possible.
Healthcare has not seen fit to develop a framework for standards and no ontology by which to bring sense and meaning (and thereby value) to the hundreds of standards vying for attention. In truth, anyone in healthcare can say without fear of contradiction that "we have standards" and none of those assertions mean anything.
If n people or organizations are doing the same work using n (or even n-1) standards, it cannot be said that the work is being done in accordance with standards. This is said routinely by each of the workers but to those who view the work from an objectifying distance, it is quite clear that n standards is no better than no standard.
Measurement of process in healthcare has a long way to go before SPC principles can be applied.
How, by what process, can healthcare practitioners be brought to believe in the power of process standards through which measurement standards can be developed? Whose interests are satisfied by the status quo?
Wednesday, April 15, 2009
Healthcare in general and from top to bottom seems to have an absolute dread of standards. Physicians (many if not most) will flop about like a fish on a hook whenever the word comes up. They fight no matter how the subject is introduced. Whether it be "guidelines", "pathways" or even "best practice", it doesn't matter. As an interested consumer, I find this disturbing on several accounts.
- It demonstrates such a me-first, tunnel vision mentality that, if I were given a clear choice, I would run as fast as I could away from this and toward anyone who could demonstrate that they do, in fact, adhere to standards.
- It has a huge--and negative--effect on everyone else in the healthcare organization. The physician role is so central in healthcare that, if there is no reliable standard (process) for the physician, then nursing, registration, coding, billing, systems developers..., no one can predict from one day to the next or from one patient to the next what they're going to be asked to do.
- It holds the practice of medicine back to a level not much different than was seen in the 18th century. Oh, sure, we have better drugs now and diagnostic magic is performed many times a day using the lastest technology, but the outcome for me, the patient, is so dependent on the physician I see that "bedside manner" often seems to be the most critical factor in outcomes.
In my 60+ years of life on this planet, I have seen that humanity can be put into two groups--those who appreciate standards and those who do not. Further, it has always seemed that the second group is the cause of problems not ony for themselves, but for everyone. Let's take a kind of standard that we're all familiar with--traffic laws. Those who flout the traffic laws are a hazard to everyone else on or near the road. And note that consistency and predictability are key. Traffic laws work because they produce consistency and the ability to predict with some assurance what the other guy is going to do. Those two principles keep everything flowing smoothly and with minimal (and manageable) disturbance.
We do not realize fully, the value of the standards we employ in this country. John Adams is the one who noted that we are governed by laws not men. Bribery is a recognized way to get things done in many parts of the world. Imagine having to find the right person (how do you do that?), paying to get their attention, then finding out that they weren't the right pewrson after all and having to start again. We sometimes go through that with building and remodeling contractors and it makes the evening news. Healthcare isn't much different EXCEPT that we don't get as heated about it because someone else is paying.
I constantly wonder at the inability of the insurance companies to get provider organizations to create and use standards.
Today, we are being told that technology is the key to the healthcare crisis (which is a crisis of out-of-control costs). I am going on record here that technology will only drive costs up unless the healthcare "system", beginning with physicians, learns to cherish standards, utilize standards, trade on standards.
We, the patients, must demand a system in which we can rely on standards to produce outcome and efficacy data allowing comparison of physicians and organizations. It's a sad system in which the only statistics available for comparison are mortality numbers.
Sunday, April 12, 2009
An example may help. Suppose you are the city planner. You could take one of two approaches.
- You could develop a comprehensive plan for the city that takes into account various expansion directions and encourages some while discouraging others. The plan would include both residential and business expansion.
- You could attempt to satisfy each request that comes before you. You could allow various developers and politicians to set the agenda for the next six months and continuously play one against the other for priority.
In the first approach, remarkably modest effort goes into an expansion model. Productive and non-productive alternatives emerge. The productive ones are fleshed out and the unproductive are set aside for contingencies. Potential streets, sewers (storm and sanitary), gas, electric, phone, Internet, and other necessary utilities are blocked in. Alternatives and contingencies are identified and capacities are established. With all of this in place, it is now relatively simple to budget for the next year's projects and all will be well as long as we don't cave into to political expediency and begin to allow projects outside the scope of the plan.
There is no problem as long as all negotiation goes on in broad daylight. If a particular out-of-scope project has popular appeal, it will be a simple matter to say, "OK, here's what it will mean for our other projects, for our long term plan and for the budget. If it's still popular, we do it.
Back to I.T. capabilities; server capacity, mass storage capacity, network bandwidth and access points, space, cooling—these are all obvious capacity planning considerations and for that reason they are at least on the radar for everyone. More subtle but no less important considerations include the architectures (technology, network, data, and communications) that we want to have, skills required as we work within the architectures and, not least, the standards architecture that will be the governance glue that holds everything else together.
Depending on your own experience as a technology worker (rather than as a manager), you may not have a "feel" for the people, skills, and experience that will be required, nor even for the implications of various architectures. Again, this is no place to guess. Get your direct reports together. If they don't seem sure or can't tell a story that is meaningful to you, then get some outside advice. The skills and attitudes required for a successful SOA (service-oriented architecture) are much different from those needed in a more "traditional" approach.
If you intend to rely on vendors for everything, you will still need to be able to tell which vendors fit into your architecture and which don't. They will tell you that they are "architecture-agnostic" or that they can fit into any architecture--don't believe it. Know about the characteristics of things that will fit and things that won't. Attempting to force-fit something that doesn't belong is the quickest way to throw everything you've built into turmoil.
If you're uncomfortable, I apologize for being so open. The answer to getting comfortable isn't avoidance, though, it lies in making a concerted effort to bootstrap yourself. No budget, no resource plan, no allocation discussion--management of one thing is not the same as management of anything. Technology is to big, too complex, too fast-moving to be brought into line by the classic "cost management and allocation of resources" approach. It needs a team approach because there's just too much for one person to know.
Do what you're able to do and know what your boundaries are. Be honest with yourself first of all and with your peers, reports and management. You may wonder if you are the only one at times, but it is not possible to manage technology without honesty. Unlike people, technology can't be coerced or manipulated.
Saturday, April 11, 2009
It is a fact that, in the history of computing (I.T.), no application or system has ever been delivered to universal acclaim (despite what the marketing people tell you). Medicine has more than its share of curmudgeons and you're going to have to let them become part of the background noise. If you're afraid of losing your job because of the indignation of a few people then you're probably on the wrong career path.
I hope you knew that already, but it can be reassuring to hear it from an "outsider".
Now, if you're still reading, you may be wondering about what the right thing is that you should do. The first thing is to get your priorities squared away. Then you you will have to work very hard to get your priorities into the cognitive space of the rest of your organization's upper management. What are your priorities? What are your 1, 3, 5 year or long term objectives? Are they written down and visible to others? If your answer is no, then your job just became much more difficult. By the way, if you are a CEO, and the only I.T. objectives you know about are the ones you handed out, you may want to re-think your approach to I.T.
What does an objective/priority look like for I.T.?
The big rocks (the ones you put into the container first) are capabilities and alignment. In my career, the most pervasive problem I have seen is that healthcare CIOs invariably focus their attentions outward from their I.T. organization. In nearly 15 years, I have yet to see a single initiative directed at developing or improving capabilities come from the top of the I.T. organization. When such things have happened, they seem always to arise from the introduction of a new application or a new technology. Just once, maybe we could spend some time to actually imagine the kind of I.T. organization we think will be needed five or more years from now. Capabilities, in the healthcare I.T. world come about by accident. The current best case is when there are a few people within the organization doing this kind of thinking on their own.
Of course, when there are uncoordinated pockets of effort, you don't get the other big rock, alignment. By the way, if one of your objectives is something like "reduce or contain costs", you may want to rethink. Cost management is like breathing if you're a manager. To call it a priority or a goal is to divert attention away from the big rocks. Similarly, any objective that includes the word "continue" is a waste of paper. Holding the gains must also be at the level of breathing for managers. You will want to keep measuring to make sure there is no backsliding and take action if there is, but holding onto gains has to be part of the original planning process and should be automatic.
Alignment begins with a picture of your organization now and five years from now. Every manager and supervisor/lead within I.T. must share that picture and understand their own specific role(s) in it. This is something best accomplished as a team. You can't mandate alignment. You will want to decide how you will recognize and/or measure the alignment within I.T. How will you know when you have it? Everyone should understand and be on board. This is the first step.
It is up to the CIO to bridge between the business strategy and the I.T. strategy to make certain that as alignment develops within I.T. it is congruent with (aligned with) the business' strategic plan.
You are fortunate in that your direct reports want all of this as much or more than you do. All they need in the way of motivation is the belief that you are committed to seeing it through. If you don't feel confident that you can produce the I.T. vision, don't attempt it on your own. This is the place for leadership that is confident and sure-footed. Start with a clear and concise vision--it has to be your vision or you won't be able to commit to it, but you can get help to create it.
Healthcare I.T. cannot get where the nation wants it to go as long as are dissociative in our thinking. Things aren't the way we want them to be simply because we say so in a presentation to the CEO or the Board. You know that buying and installing a new system is only the first step of implementation. What we're talking about here is very similar. Forming a committee or naming a Director is only the first small step. If you want to know if you have actually achieved your goals of capability and alignment, I would recommend strongly that you bring in an outside person or group to conduct an audit.
Good luck! You are the leading edge.
Wednesday, April 8, 2009
A bit of reflection reveals that these are all somewhat solitary pursuits involving individual dedication and a large degree of creativity. Of all of these career paths, software development may be the most accessible and the most remunerative. Pair this with the tendency of many socially gifted personalities to throw up their hands when confronted with technology or mathematics beyond what can be done on an adding machine and the corresponding inability or unwillingness to grasp qualitative differences in abstractions such as software, and you get a recipe for significant problems.
People who are intimidated by the technology of a personal computer or laptop are glad to grant credibility to the first person who can make the technology perform the desired tricks. The non-IT parts of the business have come to terms with this and simply compartmentalize I.T. so that as few as possible must have anything to do with those people.
Now add an additional dimension: the belief (common these days) that a good manager can manage anything. This may be true, but having worked with and come to know many developers (programmers), the credible manager is an absolute rarity in I.T. Just ask any developer (or network admin, server admin, DBA...). You'll find that a manager who enjoys the credibility and respect of the "troops" is the very definition of raris avis.
The bottom line is that software developers and the associated technology disciplines comprise people who have had to figure things out for themselves and who know that their bosses don't understand what they do. The combination of these two (an ability and an awareness) produces people who have an approach to life that is similar to that of a cowboy or possibly a farmer. They are independent and like it that way. They won't turn from a challenge, even if that challenge is doing something that they believe is appropriate despite known management objections and even obstacles. They simply know that when it works, everything will be forgiven.
And it is.
I am disheartened when I follow discussion boards on the Internet. A provocative question is posed concerning methods and the discussion immediately goes to tools. Terms that have been around for decades are redefined without any acknowledgement of the accepted definition. Adding insult to injury, this is done even by data architects who, more than anyone else, should know better.
What I am seeing in these discussion boards is a playground full of gifted five-year-olds with absolutely no supervision. They are capable of amazing feats, but at what cost? If you are the CEO or the CIO of a company, do you have ANY idea what it costs--not in salary, but in uncontrolled complexity and corresponding maintenance costs--to allow this?
You can't blame the five-year-olds. They aren't the problem. They are doing exactly what they were put there to do. If you can't find managers who are capable of establishing some level of respect and control, then you must at least find leaders among the children and give them a mentor.
Even mathematicians respond to this. Remember the Manhattan Project? This project produced the atomic bomb that ended WWII. Dr. Robert Oppenheimer was the mathematician/physicist leader who guided the work and Gen. Leslie Groves of the Army Corps of Engineers was the administrative mentor. One mathematician, no matter how capable and creative, could not have developed the weapon in the time available. But 5000, without leadership could not have done it either.
Data is available through the Software Engineering Institute at Carnegie-Mellon University on the cost benefit of a managed development team using defined processes. Once the processes have been defined (which takes leadership), the manager has only to believe in and rely on the processes in order to achieve predictable, low-cost results of known quality.
Whatever path you choose, it is you, the executive leader, who is responsible.
Monday, April 6, 2009
- meaning (semantic) understood
- applicability (use/utility) understood
- currency (timeliness) understood
- source/lineage/pedigree understood
Clearly, none of these is about allocation of resources. Just as clearly, resources will have to be allocated to create and maintain those characteristics. The point is that management skills do not come into play until the organization has decided that business intelligence is a capability it must have.
Prior to this, we have also discussed three distinct functions that are typically thrown together in the basket labelled "management." They are
- Leadership: moving an organization in the best direction by motivating change
- Management: making the organization effective by managing costs and productivity
- Governance: keeping the organization's productivity high by ensuring consistency and stability
Creating, developing and maintaining the four essential characteristics of business intelligence is going to demand all three of these functions. Leadership will be required to define and effect necessary changes. People accustomed to doing their job as they see fit, may need help in adjusting from that paradigm to one of "best for the organization." In many cases, managers have interpreted "organization" to mean the group for which I am responsible. They will need some leadership to make the adjustment to thinking of the the good of the organization as a whole. The scope of organization will vary depending on the process under discussion.
By now, you may be entertaining doubts. The doubts may center on the organization's ability to carry this off. They may concern whether the right people, experience, skill sets are available. They may also be about whether this business intelligence thing is worth the effort. I can't answer any of those doubts for you, but I can say, without equivocation, that getting to business intelligence is going to demand change and that the change will demand strong and consistent leadership.
The people within an organization are fully capable of governing themselves. Indeed, the United States of America is founded on that premise. We are "a government of laws and not of men" said John Adams. In the corporate world, laws are known as standards. Employees representing various business functions and sub-functions will be the best ones to define the standards that they will follow as long as leaders keep before them the corporate interest. There is a long history of failed attempts to impose standards on people, including those by King George V that resulted in the American Revolution. There is no need to repeat those failures.
Once the standards have been defined and agreed to by those affected, and once they have been reviewed for costs and efficiency by the managers, then what remains is to establish the equivalent of legislative subcommittees to monitor their consistent use and consult with the parties when the standards must be improved or abandoned. The cost lies in the change that produces the standards, not in the governance of the standards. In fact, many organizations already have a function dedicated to the monitoring of standards application. Quality Assurance has frequently been given a bad name because it is charged with creation of the standards as well as their monitoring.
Do you want business intelligence? Do you need current, unambiguous, actionable information with provenance, or can you be satisfied with really cool charts and graphs in three (or more) dimensions and lots of colors? You will have to decide.