Healthcare: More on I.T. Capabilities

I realize the need to be a bit more specific with respect to capabilities. I have seen a virtually unbroken string of capabilities discussed that related to the practice of medicine or the business of healthcare delivery, but in almost fifteen years of experience in healthcare I.T., I have yet to see a capability goal that is about I.T.

An example may help. Suppose you are the city planner. You could take one of two approaches.

1. 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.
2. 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 second approach, a deft manipulator can get by for quite a while. The city, on the other hand, will always be in turmoil and unable to staff its various departments effectively. Budget dollars will go to the current top project(s) at the time of the budget approval process. But, because project priority will be ever changing with the political situation, those projects may start and then go into hibernation. Workers with specific skill sets will find themselves with little to do while the new high priority project has tough going because there is no money to bring in the right skills. Equipment winds up sitting in a warehouse or worked far beyond recommended maintenance cycles.

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.

Advice Re; Healthcare IT

If you are a healthcare CIO or the top IT director/manager and happen to be reading this, or if someone has forwarded this post, and if you feel under some pressure more accomplished (or even to get something accomplished), I have some gentle advice. You're going to get phone calls from angry physicians no matter what you do, so you may as well do the right thing.

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.