kitchen table math, the sequel: the sorting machine

Friday, September 4, 2009

the sorting machine

I'm sick as a dog* -- who knew stress had anything to do with the immune system? 

And, on a directly related subject: Who Killed Health Care? by Regina Herzlinger is great. Wonderful! Especially the chapter on 'dysfunctional culture.' 

I've been planning for months now to write a post called "It's the culture, stupid," a concept that came to me after re-reading Richard DuFour's "Restructuring Isn't Enough." Turns out Herzlinger has a section titled exactly that: It's the culture, stupid

Before I retire to my bedroom, here's an excerpt from her book:
"You won't believe what happened to me this week. I checked an elderly diabetic into my hospital. The guy had a lot of troubles. A great guy, but he just can't manage his diabetes. I had operated on his foot a few weeks ago. And what do you know? As soon as he heals, he goes on a bender. His sugar goes out of control. He was in terrible shape. I checked him into the hospital because I suspected he had an aneurysm ... If he tested positive, I knew I had to operate immediately, the next day. That baby could blow any minute and he would bleed to death.

"Well, the PCP (primary care physician) who is my patient's gatekeeper just called me. Because he represents the HMO, the gatekeeper has to approve the bill. He thinks I should not have admitted my patient into the hospital for the tests. He questioned my judgment. He told me I was practicing bad, wasteful medicine. He threatened to throw me out of the insurer's network of doctors if I kept this up. I lost my temper. I told him in no uncertain terms that he just does not understand my kind of medicine. He's out of his league-out of his depth."


I have heard Paul's plaint many times in the course of the research I've conducted for my Harvard Business School case studies and after the lectures I've delivered to hundreds of health care groups. I know from decades of interactions with business organizations that when colleagues cannot communicate with each other without rancor and misunderstandings, when competence and motives are questioned without cause, the organizational culture has gone terribly wrong. In successful organizations, confrontations of this sort lead to intervention and analysis by upper managers, and ultimately to a plan to correct the problem ... but in most managed care organizations, this kind of culture does not exist.


Here's how a successful health care organization handled a similar problem.

Joan is the Oklahoma-based technical specialist for a firm that manufactures life-support equipment. She is notified that the device in a Louisiana hospital is not working properly. The hospital has no backup and has tried all the usual remedies to no avail. This too is a life-or-death situation that calls for immediate action. But, unlike Paul, who had to "consult" the PCP before he could act, Joan can proceed to do what she knows to do: she e-mails a request to her manager for permission to ship an expensive replacement device ASAP. Permission is expeditiously granted. She also knows that if she does not receive a response within 15 minutes, she is authorized to proceed on her own. Here, everyone cooperates: all efforts are properly focused on the right and expeditious thing to do for the patient's well-being.

Why are these two situations so glaringly different? It is not the existence of clear procedures in one case and not the other. They could have made a difference, of course. But the core difference is that Joan's organization has a culture that lends itself to the development of such protocols and Paul's does not.

People in an organization whose culture relies on a shared vision are positive and action oriented rather than negative and blame oriented. They want to work things out, find solutions, and serve their customers. ... The culture helps them realize that a confrontation is not a clash of personalities, but rather a sign that something deeper is going wrong and a signal that it must be fixed to preserve the organization's ability to perform its mission.

In health care, a productive organizational culture means finding ways to help patients. But such cultures have become rarer and rarer in managed care organizations and hospitals for reason that we will explore....

Who Killed Health Care?
pp. 29-32

That's what we're missing in so many public schools: a culture focused on making sure all students succeed. 

Here's DuFour, writing in 1995:
Ten years ago both the structure and the culture of Adlai Stevenson High School in Lincolnshire, Illinois, reflected it commitment to the traditional task of sorting and selecting students. 


In this structure, teachers saw themselves as quality control inspectors. Their job was to present information as clearly as possible, assess the aptitude of each student, and promote student success by placing students at the appropriate ability level. Assigning grades according to a bell-shaped curve was a common practice that, by definition, limited the number of students who could achieve at a high level and ensured that a certain percentage were destined to fail. The “teacher as quality control inspector” had little need to collaborate with others. There was no compelling reason to coordinate curriculum, instruction, or assessment with colleagues teaching the same course.

Teachers were not only isolated from one another but from parents as well. No active parent organization existed other than booster groups for specific student activities. Teachers were required to communicate with parents only when a student was in danger of failing. Further, the primary means available to communicate student failure was an individual letter to each parent. Thus, parents received a progress report only if failure was imminent. The majority of parents had no idea how their child was doing until they received a repot card in the 10th week of the semester. 

“Restructuring Isn’t Enough by Richard DuFour
Educational Leadership April 1995 p. 33-24

* How sick is that, anyway? I've never seen my dogs take to their beds with fever & sore throat.

All Things PLC (Richard DuFour)


SteveH said...

Our K-8 schools have a good culture. Unfortunately, it's just not centered around mastery of skills and knowledge. It's centered around full-inclusion. Differentiated instruction is supposed to make it all work, but they have no desire or means to evaluate its effectiveness. If kids don't do well, then it's a developmental issue. How many have heard the nugget: "They will learn when they are ready"?

Imagine a health care system that has no way to determine why some patients surive and some don't. They might think that some patients just don't have the will to live. Maybe they could ask them to try harder and set goals. Some patients survive, so they must be doing something right. Right?

Our high school tries to help students, but there is no culture for following problems back to their source in K-8. In education, there is no culture for quantifying anything about the process. There is no culture for knowing whether what they do really works or not. Tests are about students and not teachers or curricula.

Catherine Johnson said...

Our K-8 schools have a good culture. Unfortunately, it's just not centered around mastery of skills and knowledge. It's centered around full-inclusion.


So they're all pulling together & mission-oriented --- but it's the wrong mission.

I wonder how often that's the case?

Catherine Johnson said...

Spending those two weeks at Evanston Hospital was interesting. My impression was that the hospital is on top of its game; only once was I concerned about my mom's care. (This occurred on a weekend night, exactly the time health care professionals warn you about.)

Interestingly, the whole place has a 'hummm' to it. The guards, for instance, are friendly and efficient; so are the people at the front desk. Cafeteria workers were pretty good - efficient and usually friendly, too. (Food wasn't great.)

Remember the Gawande article on Mayo?

The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

My doctor says health care needs to be "patient-focused."

That's my phrase for good schools: "student-focused."

But of course, as you say, "student-focused" could just as easily mean "do what we do & blame the students for the failures" as "do everything we can to ensure the success of all students."

Catherine Johnson said...

good culture/bad outcomes

I may have to go back to bed.

Catherine Johnson said...

(Still sick.)

Catherine Johnson said...

(Seriously resisting the possibility of seeing a doctor so I can get antibiotics.)