Your Employees Are Your Most Important Asset

Numbers, metrics, sales, service, results, outcomes, profit, loss, success or failure is all due to something that employees create, and affect – “affect” being the operative word here.  An organization’s brand is built, or broken by the people who represent the organization.

I have been reading a lot about employee engagement lately, and I’m glad to see that people are talking about it, especially during these challenging times.  The articles that I have been reading basically all agree that billions of dollars are lost each year due to employees who are disengaged with their work, and their organization.

Some articles blame a lack of leadership (I would agree), and some blame a lack of direction (I would also agree).  There are those who have come up with a “metric” driven solution (there’s probably something of use there), and others point to a lack of communication within organizations that create an environment of “I don’t know what’s going on so I don’t care” employee (yep, I see that as a major issue as well).

Common sense would tell us that if employees are not engaged, bad things are going to happen.  Critical resources (time and creativity) will be wasted if you have employees who just go through the motions each day while at work, creating the impression of “work.”  Anyone can come into an office (for the most part) and make it look like they are working, but it takes a person who has that fire and drive in their gut to make a real difference in an organization.

Disengaged employees drive mediocrity.  Just getting by each day and staying under the radar is a conscious, and unconscious goal of these types of employees.  A culture of mediocrity is a natural outcome due to this type of behavior, and it spreads like a disease across an organization.

Employee engagement does not have to be complicated, or take up a lot of expensive resources.  Basically, educating employees about, and getting them involved with the business is a good start.   Check out my website (www.archofchange.com) for some great ideas about how to build a more engaged workforce.

Often we mistake technology with innovation! Technology is a vehicle and many people just admire the new vehicle but don’t do the adjustments and changes that come with it. Why? People are afraid of changes - aren’t you?

My 7 years old daughter loves the story of “Who Moved My Cheese!” (for kids) by Spencer Johanson. A graphical tale of 4 characters in search of the magical cheese; their different characteristics, dreams, challenges and fears. I love the book and it analogy and I often use it when discussing change management at business.

Yes we are afraid of changes! We get used to do things, arrange our schedule around the routine and if it works, we keep the status-quo. We need huge motivation to go out of this state and very often we give up on incentives just to keep ourself in the current balance state.

In the many sessions and workshops I had I always faced this, if not from all participants then from the majority. So before changing anything at your business acknowledge the individuals who will need to bear it first – your employees.

Business Changes are great if they are managed properly.

When designing a change you should consider the following steps – not necessarily in this order – some may be recursive or repetitive:

1. Motivation
   • What is the justification for this change?
   • Most reasons for changes are visible to individuals in the upper management team. You will need to make sure that the reason for the change – Motivation – is well-known throughout your organization (top to bottom, left to right).
   • Using current business analysis workshop – focusing on the desired topic can help promote motivation.
2. Umbrella
   • Why do you think your partners and co-managers will support you?
   • Many changes in one department may result in changes in other departments; resource changes, routines and processes and often budget allocation.
   • Make sure that you have a ‘lobby’ of managers to support the change – you’ll need it.
   • I call it the Umbrella you will use when the rain will start purring!
3. Agents
   • How do you think to successfully implement the change if you don’t have your ‘man-on-the-street’ to be your eyes and mouth?
   • Every change needs change agents – trustees. These are often lower level managers or employees who will need to bear the changes on their day-to-day activities.
   • They can be selected – elected - volunteered - or compensated – as long as yo are convinced they are YOUR agents and not double agents (:-()
   • You will learn that these guys will contribute to the goals and often be willing to go the extra mile for this effort – when they believe in it.
   • Facilitating workshops with a neutral party (3rd party or vendors) often helps to identify good candidates
4. Plan
   • Make a detail plan of the implementation
   • Include in your plan – training, technology, communication, check points and exit criteria.
   • Don’t forget you opposition! they will need your attention in the planning.
   • Don’t forget every plan has risks – see risk management
5. Quick hits
   • Physical changes needs ENERGY! build up this energy with quick hits.
   • Quick hits are those small wins that can be accomplished easy – even if they do not mark milestones in the major change they will reward the participants and keep them buy-in to the grand process.
   • Plan your quick hits throughout you grand implementation plan.
6. PR
   • It can’t be a secret! you need to make a commotion.
   • Posters, Slogans, Competitions, Rewards, and Nominations – are common PR tools.
   • Often send out communications on the change progress, next steps and challenges you had overcome.
   • Keep remind the business the WHY and the GOAL.

I remember one of the largest implementations my company was involved (over $150M). Instead of utilizing the vast business knowledge and progress using the new software technologies – we surrendered to the customers requests and developed the new software based on the old clerical processes they had in place. The business assumed that leaving the old processes in place will reduce the cost of change. Needless to say they ad paid almost 1:1 for the implementation as they did on the software engineering.

S.W. Foss wrote an ageless poem on this subject. It always inspired me and it is good stuff to share with the team. enjoy

Peleg Forman

Hello World Changers!

November 22nd, CYW event day,  was a 17-hour non-stop preparation for the tour.

We’re only able to tell you a glimpse of it today, because this morning (23 Nov), with 4-5 hours of sleep, 1a.m. and Relent, with some Penang Change Agents, while everyone is still asleep, went to Rifle Range to help the poor community. In case you do not know, Rifle Range is the high density, low cost, and ghetto-like flats, home to protitutes, gangsters, and one of the poorest community area in Penang. We will share with you more about this in the next post!

We just wanted to say a big thank you to all who believed and supported Change Your World. You are the Agents of Change. The tour was a blast because YOU made the decision to believe in CHANGE.

We hope this is a beginning of a new relationship where we can grow together to see change, not only in Penang, but in the whole of Malaysia.

Follow us in the next few days with more updates including pictures and videos of the event and the venture.

1a.m. & Relent

Listening to yourself  is quite a trip.  Getting the pulse of your persuasion is pretty easy when you tune into hearing the tone of your voice, choice of your words, and the timing of your delivery.  Becoming a master of your daily speech takes only a little bit of consideration. What do you want the listener to go away with after hearing you?  How do you want them to feel, what do you want them to know, and when is the best time to tell them your thoughts?  How much of our conversation is missing the mark…and how much is actually benefiting the receiver?    Our words are powerful change agents…what kind of impact do you want your words to have…having said all that??

6 word stories and films are a NEW form of Graphic recording.

It involves capturing, —in words, images and colour—people’s ideas and expressions in both words and images

It is a perfect tool to illuminate how we as people connect, contribute, learn and make meaning together.

6 Word stories as a graphic recording tool adds life to meetings,  helping all participants visualise the problems and see the solutions.

Recorders capture, through 6 word stories and images, essential ideas. Everyone can start thinking outside the box!

Contact us for more information on how we can custom make a program to suit your needs

When you would use 6 Word Story films:

• Conferences
• Workshops
• Strategic Visioning
• Team Planning Meetings
• Project Team Launches
• Focus Groups
• Brainstorming
• World Café Conversations

Benefits of using 6 word story films:

• Captures the conversation of the group in an engaging way
• Helps people SEE their ideas in real time
• Brings people together so they are on the same page
• Enhances a groups understanding of their own story
• An on going engagement tool
• Conference evaluations
• Community voice

Inspirational Cinema can also produce the  6 word stories into a variety of different products including post cards, posters,  screen savers, movies for the use on websites, e-newsletters and mobile phones.

It does a soul good to have this question asked of it periodically:  What am I holding on to?

In my years of congregational life as an adult, I have often observed a strong tendency to hold on to things that do not merit such tenacity.  I have been guilty, too.

There is One worthy of our clinging, though . . . one holy Being that deserves our stretching, our grasping, and our gripping.  The past, the present, and even the future are not to be iconized.  Only our God should be clutched tightly to our hearts.

Change, as we all know, is often resisted.  Though many of us are in favor of Godly change, even we tend to resist it.

It is unfortunate that change is so uncomfortable.  Change requires energy, devotion, and thought.  But Godliness is not inextricably associated with comfort, and true discipleship is not a bedfellow of lethargy, lukewarmness, or mental inactivity.

God needs us to be adaptable.  He needs vessels of a malleable material.

And so change should be a mode, a habit.  (If we are ready at any moment to adapt as we hear Him saying important things to us, then we will have no trouble being flexible with less important matters such as assembly patterns and other weekly, congregational matters.)

Hold on to God!  Be willing to let go of anything else if He wants you to.  Be changeable and open.  But hold on to God.

This week I have been meeting clients who all face significant challenges in helping change their large and complex organistions. One is a government department and one a large bank. In discussion with clients, either leading or planning to lead change that affects the whole organisation,  we discussed how people are reacting to what seems like obvious and well planned changes. Bare in mind that both organisations are staffed by smart, intelligent, motivated people.

So describing some initiatives I have been involved in with other organisations in the past, their eyes showed sparks of recognition, nods of agreement and smiles of complicity. I was talking about the folly of organisations trying to implement change from a systems only or perfect plan approach rather than engaging staff in the whole process and using staff as the lever for real embedded change. I mentioned the stupidity of thinking because a senior leader had sanctioned it, that change would happen, and I talked about the lunacy of thinking that a  coercion strategy would deliver long term staff support. Nods and smiles of ” we understand cos we do that”.  So what is going on here?

Two very large, complex and old organisatons where smart people are smiling in recognition of major flaws in their plans to deliver lasting change? Why do we know that things are doomed to fail, can agree with other examples , share our own stories of such madness  - YET fail to challenge and act differently ourselves? What will it take for the small boy in us to tell the emperor that he is naked !!

Change agents, consultants, internal project managers, project leaders, change catalysts … whatever the title you must be prepared to take the risks needed to get things seen for what they are. Faced with the right thing or the safe thing to say you MUST say what is right.  No change agent worth his fee, salary or bonus – should be afraid of being a heratic. All great ideas are treated as madness when first voiced.  BE THAT HERETIC.  Be sure to be challenged and maybe have a shorter career with that company.

It’s not that I am saying change is easy to implement, that is not the case.. but starting from the mechanics and not the people will not help get real behavioural change into a complex organisation.  As a good and wise friend of mine says, ” polishing a turd is not clever ,even when it shines its still a turd “. If the process is broken planning to do it more efficiently or effectively is not smart – do something else instead, almost anything else. My advice – start with people.  What would make you change your way of working for the better? What would convince you, your colleagues and your staff that changes are  worth it?

Answer why first and how second and see what a difference it makes to getting change in place.  Good luck and remember you need to be taking more risks to be a real change agent !!

On this page, you will find updates from each of our communities as well as information about applied community change and conservation. This is a resource we are using to remain in communication as a learning community together but also with a much broader global community. We welcome your input and wisdom on these very diverse subject within the broader context of our field as community change agents.

Upturn a Downturn!

Challenging economic times require challenging the status quo.  Even when times are tough there are many low-cost opportunities to build, and nurture positive customer relationships that can help an organization accelerate through, and uphold the brand’s reputation.

Don’t Panic

When faced with an economic downturn many organizations resort to panic and reactive strategies.  Taking a reactive approach can cause a management team to frame action through a negative lens, and place focus on what’s wrong, instead of what’s right.

The goal becomes survival at any cost — as long as it doesn’t cost any money. Many organizations stray from logic by reducing headcount, cutting back on services, and eliminating customer perks. In an attempt to drive costs down, they drive customers to the competition.

These types of actions exacerbate the issue, and create a vicious circle of compounding problems.  Service quality drops, and customer satisfaction takes a dive.  As customer complaints increase, the cost and resources to handle the complaints increase as well.  Negative word-of-mouth advertising impacts sales, and that leads to additional costs in marketing, and customer retention.

Don’t Forget About The Employee Experience

Challenging times impact the employee experience as well.  Organizational changes affect employee morale, productivity, and confidence in the organization that in turn affects the customers’ experience.  Frustration can lead to employee attrition that drive up costs associated with hiring and training replacements.

In the preface of his book The Loyalty Effect author Frederick F. Reichheld states, “the fact across a wide range of industries is that a 5 percent improvement in customer retention rates will yield a 25 to 100 percent increase in profits.”  The key word being retention!  It costs less to retain customers and employees than to replace them.

Simplicity is Key

In challenging times, think simple, but simple with an impact.  You don’t have to drive up costs to WOW a customer; in fact, it’s just the opposite. Most customers understand the challenges that organizations face, but they still want value for their money, and to feel appreciated.

The goal is to let customers know that you appreciate and value their business.  A sincere “thank you” from a customer service representative, or an employee that goes that “extra mile” to provide outstanding service will not only pleasantly surprise a customer, but will start a chain of word-of-mouth advertising.  Even a small token of appreciation in the form of a note, an email, phone call, or text message can do wonders do build a brand on a budget.  Most of the time it’s the smallest gestures that make the greatest impact, and help to enhance customer loyalty.

Imagine receiving a note, email, or text message from your mortgage, credit card, or telecommunications provider  saying something like:  “We want to take this opportunity to thank you for your continued support,” or “We know that these are challenging times, and we want to thank you for paying your bill on time.”  For a minimal investment you would get a maximum return on customer perception, and good will.  That’s advertising you can’t buy!

This Too Shall Pass

The good news is better days are ahead, so go ahead and challenge the status quo! Take a challenge as an opportunity to differentiate yourself by surprising your customers, and building your brand.   Not only will it help you get through the leaner times, it will help you build a brighter future.

I believe that the key issue that most organizations face today people have no idea where their organization is headed, and how they are supposed to help it get there, what I call Strategic North.

I have found this to be a critical part of a customer experience strategy, and essential to execution.  The entire organization has to understand what the new strategy is, how each department, division, team, and individual affects the strategy, and their role in the execution.

I have used an analogy in the past that has helped leaders understand how to help align their organizations and get employees to head down the same path.

Don’t Ask Alice!

In Lewis Carrol’s Alice in Wonderland …Alice comes to a fork in the road and spots a Cheshire cat in a tree.  “Which road do I take?  Where do you want to go?  I don’t know, Alice answered.  Then, said the cat, it doesn’t matter.”

A lot of organizations are like Alice.  They are going somewhere, but collectively don’t know where, or the destination is constantly changing.  That in turn causes confusion, frustration, wasted time and resource as employees think they know where they’re headed, but end up going in the wrong direction.

But Dorothy Had The Right Idea

Where are we going?

“We’re off to see the Wizard.”

How will we get there?

“Follow the yellow brick road.  Follow the yellow brick road.  Follow, follow, follow, follow, follow the yellow brick road.”

What’s the difference between Alice and Dorothy?

Alice was going somewhere but didn’t know where so it didn’t matter what road she took to get there.  Dorothy on the other hand was very specific about where she was going, and how she was going to get there.  But even more important, Dorothy repeated it to her “team” over, and over again.

Repetition is critical if you want people to understand the goal.  Organizations can learn a great lesson from Dorothy.  Be very clear about where you are headed, and repeat it over, and over again.

And let’s not forget …in the end, Dorothy arrived at her destination.  :-)

A company I recently met with is trying to get its people to accept the fact that their business is changing and they might have to also. Three things immediately pop out in the conversation:
1. We really don’t know how to change—not much practice or training, so what do we do to make the future better than today, and hopefully more like the past.
2. How will we know if what we are trying to do is going to be really better than what we are doing now?
3. When the economy returns we want to be ready for it, as if it is going to come back as it was before.
The same discussion is happening so often it seemed like a great series of blog posting that might open up the ideas and stories to share.
My thoughts first for today are about Change, the Pain of Change and How to start to enjoy Change. I will take on the other two dilemmas over the next few days.
First, it is true that as you age your brain is less receptive to new things. On the other hand, the brain is much more plastic that you might imagine. And you really do know how to learn and experience new things. But Change is truly Pain.
The part of the brain, the prefrontal cortex or working memory that goes into high gear when you are learning something creates chemical actions that feel like pain. And it is a high energy activity and we don’t have much affection for change because it is work. Neither do we have much practice doing it.
But we once knew how to learn and accepted, even enjoyed the process. When we were younger we knew we didn’t know, a state we’ll call “Conscious Incompetence,” and we had a teacher or professor or tennis coach to teach us. We slowly became more capable and “Consciously Competent” in whatever we were learning and started to do it really well ourselves. No longer were we the new graduate with limited experience and a lot of book learning. Before we knew it we were really good at what we were doing, “Unconsciously Competent,” and just did it without really thinking much about it—a lot more intuitively and habitually than when you have to think about it.
That is where you are now—you don’t have new habits or behaviors for a new time and your old daily and business behaviors don’t seem to right any more-regardless of whether you are CEO of the company or a key person in bookkeeping or sales. The logic says you have to try new things but you aren’t sure what.
But if you were going to learn a new golf swing or a tennis stroke you wouldn’t try to do it alone. So why are you trying to change you company on your own? The role of the coach is to keep watching you and pushing you forward, showing you how to improve your swing or adjust your strategy or build a better putt. So now it is a good time to find that consulting or change expert who can help you quiet your mind, open up your thinking and begin to help you see a new way to move forward in these tough times.

First, you have to know where you’re headed.  If you don’t know where you’re organization is headed  it will  end up in many different destinations.   It’s critical for an organization to develop a vision and strategy, but it’s even more critical for the leadership of the organization to not only effectively communicate the vision and strategy to its employees, but to continually reinforce the vision and strategy so it remains relevant, and guides the actions of every employee.

Keep it Simple

Simplicity is key to success. Getting rid of the corporate mumbo jumbo and fluff that nobody understands or takes seriously adds credibility to any change effort. If you want to move an organization ahead you have to challenge the status quo – and you have to move out of your collective comfort zone.

The Employee Experience

Research has shown time and time again that there are many benefits to enhancing the employee experience.  First, the employee experience has a direct affect on the customers’ experience. Happy employees typically equal happy customers. Second, major (an many times overlooked) employee costs such as lost time, productivity, morale, and attrition all affect the collective health and bottom line of an organization. These costs can be positively affected by improving the employee experience.

Billions of dollars are lost each year due to lack of employee engagement. According to Michael Hughes (2008) Executive Director, Strategy and Engagement at The Brand Union, “many companies fail to engage their employees with the brand. In the U.S., disengaged employees cost the economy $300 billion a year in lost productivity costs and this figure is growing rapidly.”

Most employees show up each day hoping to make a difference and to contribute to the organization’s success, but they can’t make a difference unless they know where the organization is headed, and how to help it get “there.”  I find that most employees don’t have a clue about how they affect the organization’s brand, but every day through their work they either build the brand, or damage it.  Now add the customer to the mix.  Do your employees understand the customer experience strategy, and how to deliver the desired experience that supports the brand’s promise?

Strategic North (see previous post) not only helps engage employees from a brand perspective, it adds seven additional areas of focus: the organization’s vision and values, the roadmap (how we get “there”), how the organization makes money, how the organization spends money, the brand promise, the customer experience strategy, and how employees affect the brand and the customer experience.

Strategic North is not a leadership/organization development philosophy per se; it’s an effective framework that any leader can follow to help overcome two major organizational challenges: alignment and employee engagement.  Strategic North takes eight points of focus that when combined help people understand critical aspects of the organization, as well as their job.  It keeps people focused and headed toward the vision of the organization as a deliberate and cohesive group.

That’s the beginning to employee engagement and organizational alignment; helping employees understand the basics about your organization.

Taking it to the next step from my previous post, if entrepreneurs make less money compared to working for someone else then why get into this field. More so why did the new breed of Social Entrepreneurs come up? Well Social Entrepreneurs (as I understand) are there to bring about a Social Change. There are some Social Entrepreneurs for who money doesn’t matter but to sustain and bring about a change it’s necessary. As I have maintained before, entrepreneurship shouldn’t be about money (be it Social or otherwise) it should be about bringing about a change (be it Social or otherwise). If your idea is good (not even great) money will come, as part of your revenue model or as grants, as long your idea is sustainable and claims to bring a change.

But where is Social Entrepreneurship headed now a days? The number of Social Enterprises in on the rise and the amount been funded is huge. The pool of socially responsible investment dollars in the United States has now grown to $2.34 trillion.  As Vinod Khosla said that most VC’s work (or rather their business model) revolves around making profits. So why would a VC come forward for a Social Enterprise where the return is less and more so less likely to come by quickly. What needs to change is how the money is being poured in, is it the same VC’s funding it or has their thought process changed. The Social Enterprises need to be valued based on the social impact.

Have the things really changed, I’m a bit skeptical about the same. Last month when I was presenting at one of the IIM’s on Social Entrepreneurship one of the students asked me if it’s ‘That kind of work’. Why is Social Entrepreneurship linked with ‘That Kind of work’ I ask and even if it is why should one shy away from it. Social enterprises is NOT ‘that kind of work’ and neither are all Social Enterprises Not-for-profit, there are many social enterprises that are for profit. As C K Prahalad said, if we stop thinking of poor as ‘poor’ but rather start identifying them as consumers there is a whole new market to be explored.

There are a new breed of entrepreneurs that are coming up. What has changed in the last few years? Why has Social Entrepreneurship gained significance in the last few years? Is it because people have started to realize that it’s not just Money that will change the world but you actually need Change Agents to bring about a change?

I studied leadership and organization development in graduate school, and over the years have read hundreds of books, articles, and theories about leadership and organizational change. Each author offers different perspectives and models that promise to take organizations, and those that lead them to new levels of success.

Some authors make the argument that leaders are born or made, while others offer complex charts and diagrams that are designed to help people “see” how to lead.  I find that most books on organization development attempt to create a pseudo science based on theoretical models instead of real-life executable advice.

I believe that the best education comes from being an active observer of organizational life, and learning from great, and not so great leaders. The knowledge and experience I gained from working in many different types of organizations helped me to design a holistic organization development framework based on a more right-brained leadership approach (people and customer-centric).

The basic concept is to engage a workforce by educating employees about the organization’s brand, basic business knowledge, the customer experience goals, and the organization’s vision and strategy; in other words, getting employees involved with the business.

My theory is that when employees are armed with critical information about the business they will be more engaged in their work, and the knowledge about the business will help them to think, and act more strategically.

Every day I work with, and/or observe far too many people who are physically present, but mentally absent due to lack of caring and involvement with an organization. In addition, I see employees with the best of intentions going off in the total opposite direction of the organization’s goals and vision because they are not given the tools, and/or knowledge to work toward similar goals.

“Somewhere in your organization, groups of people are already doing things differently and better. To create lasting change, find these areas of positive deviance and fan the flames.”

—Richard Pascale & Jerry Sternin,
“Your Company’s Secret Change Agents,” HBR

We all need to be Architects of Change. The world needs Architects of Change, and organizations need Architects of Change.  We need people who think different and challenge the status quo – people who get it, and are willing to take risks, challenge mediocrity, and create positive organizational change.

This blog explores unique ideas and models that include leadership and organization development, employee and customer experience strategies, as well as training and development models that are definitely outside of the excepted norms.

Challenging the status quo will be an obvious theme throughout this blog. Looking at the world through a static lens sustains the definition of madness: doing things the same way over and over again expecting different results.  It’s time to remove the old lenses and create new and exciting models of change that will help to address the unique needs of today’s organizations.

Get ready for bumpy ride …nobody said change was going to easy!  :-)

 

Think new, act new …

“Change Agents is a youth leaders training conference. It is a place where youth leaders of diverse cultures come to discuss changing ministry in a changing world. Change Agents was originally an extension of the first SACLA conference – indeed, the first few Change Agent’s were also referred to as SACLA – as well as a successor to Youth for Christ’s National Youth Leaders Training Conference.

We’ve set up this site as a centre of conversation around ministry and the changing youth ministry landscape in South Africa; the leadership is also using it to host their discussions around the different areas of responsibilty they must fulfill so that the August conference can happen.

We’d love your input too, since the discussion around youth ministry is not something reserved for a few elite people but a grassroots thing. The site is divided into groups – some of which are restricted to certain people to allow for privacy, and some of which are open to allow for conversation (we’re hoping to extend these to the Connect groups soon). We encourage you to join.”  [Emphasis added]

[DTW note:  oh, pick me, pick me, I have some input:  how about preaching the Gospel of Jesus Christ as it was preached 2000 years ago and stop trying to change it using brainwashed little 'change agents'.]

Change Agents is run by Roger Saner from EmergingAfrica.   This is what Roger had to say on his facebook setup regarding repentance of sin and that telling someone to “Stop sinning and follow God” is almost an insulting statement and is NOT the gospel. 

Read here:

http://66.147.244.150/~discern3/2009/08/22/ee-mmergency-releasing-christian-youth-into-the-fire/

Albert Einstein said: “Insanity: doing the same thing over and over again and expecting different results”. Said another way, by a less articulate and less wise man (me): “if you want to create something truly new and unique then you gotta break a little glass”. By glass, I’m talking about the invisible mental constraints we put on our thinking, as well as the external forces that maintain the status quo, and hence are inherently designed to stifle innovation. So, to be innovative, break some glass.

Here are six methods for breaking glass, or catalysts for creating change. Choose your method wisely depending on your temperament and situation:

1) The Mazel Tov: This is rare, and to many only comes along once in a lifetime. When this method occurs, it is well planned, and involves a wholly bought-in team who celebrate embracing change together. You may know this technique by other names such as the New Boat Launch, and the Barack Obama.

2) The Bull in the China Shop: This occurs when someone runs in and smashes through all traditions and creates change in one sweeping run. You typically see this when a change in management occurs, or by the improbable promotion of someone inexperienced and likely insensitive. Although sometimes just steamrolling in can be effective and warranted.

3) The “oops”: Accidental breakage can occur where an unintended change is made without anyone really expecting it. So this really comprises the true innovation accidents like microwaves, post-it notes, or penicillin…but as we know most “eureka” inventions are the product of a really, really long process. So it’s often imitated, but hardly duplicated.

4) The Table Flip: More prevalent than you may think, most change agents result from sheer frustration with the status quo. You’re sitting there in a cubicle, silently seething about the way things are done until one day you cant take it any more and go out with a blaze of glory. The result is you channel that frustration into something more constructive.

5) The Axel Foley: Almost the Table Flip, but in this case the frustrating entity gets to you before you can get to it. Your frustration results in negativity to the point where they throw you through a glass window (i.e. fire you). The consequence is that the throwee is given a new lease on life to be creative and inventive, and perhaps fueled by a touch of revenge. For those of you too young to know this reference, see Beverly Hills Cop with Eddie Murphy – here’s the scene (go to 1:45).

6) The Opera Singer: This approach is where you have to scream long and loud to get people so worked up such that you break them down and incite them to go along with your way of thinking. This is not for everyone, as it takes lots of guts and the ability to not get booed off stage (i.e. fired) before you can break any glass.

What ways do you suggest that we can break some glass and shake things up?

I am a fan of the rock band Talking Heads. Not only their music, but their lyrics. Some of which I find incredibly provocative to this day. Actually – most of them are ahead of their time and almost only starting to make sense to me now almost 30 years on.

One song called Seen & not seen is almost spooky. At no time in history have we been able to transform ourselves like we can now. Both socially and intellectually. As entrepreneurs – that’s our journey. Becoming an entrepreneur is all about social and economic evolution as a person. it’s about unlearning the lessons of school and previous jobs we’ve held. But more so it’s about having a vision and transforming our mind, and maybe, just maybe our physical disposition.

Read these lyrics – and just think about it. I’m not trying to be weird – rather to open your mind.

He would see faces in movies, on t.v., in magazines and in books….
He thought that some of these faces might be right for him….and
Through the years, by keeping an ideal facial structure fixed in his
Mind….or somewhere in the back of his mind….that he might, by
Force of will, cause his face to approach those of his ideal….the
Change would be very subtle….it might take ten years or so….
Gradually his face would change its shape….a more hooked nose…
Wider, thinner lips….beady eyes….a larger forehead.

He imagined that this was an ability he shared with most other
People….they had also molded their faced according to some
Ideal….maybe they imagined that their new face would better
Suit their personality….or maybe they imagined that their
Personality would be forced to change to fit the new appearance….

this is why first impressions are often correct…
Although some people might have made mistakes….they may have
Arrived at an appearance that bears no relationship to them….
They may have picked an ideal appearance based on some childish
Whim, or momentary impulse….some may have gotten half-way
There, and then changed their minds.

This song is worth a listen to as well if you can find it on itunes or the net.

CODE RED (kōd rĕd) n.

1. A system of hospital codes used world wide to alert staff to emergency conditions
2. Codes intended to convey essential information quickly with minimal understanding
3. “Code Red” typically implies catastrophic, life threatening emergency

I had the privilege to meet with Phil Longman several years back at a cafe in Washington DC when he was researching out information for his landmark piece on the Vista EHR developed by the VA. The report was so successful that Phil ultimately turned it into a book. I was interviewed at length for the book and was able to provide some of the good source material on the history of Vista from some of its luminary developers.

Phil recently contacted me for his most recent bombshell, “CODE RED – How Software Companies can Screw Up Obama’s Reform Plan“. It will appear in this months Washington Monthly to be released later this week

Cover from the new Washington Monthly. Phil Longman follows up with a power punch to the bottom line of proprietary HIT vendors.

The full article is contained below for review. In essence, Longman makes the case that the open source community has been making for nearly a decade – we can accelerate the growth, interoperability, functionality, performance, and capabilities of HIT software in the proven collaborative open source fashion faster than we can in the current silo’ed, fragmented, and non-interoperable world. In every other industry, we have seen how standards and sharing of common platform issues has dramatically increased the ability of information to flow. There is no data lubrication layer within healthcare, and hence we remain so far behind other industries.The stimulus bill would codify, and cement into practice, the current system.

Conversely, the stimulus bill could be used to mandate the standards, the information sharing protocols, privacy laws, and other infrastructure components that could help us get to the data liquidity that we all seek and absolutely must have as we transition to a next generation health system. I believe it is called CODE RED because Alarm Bells should be sounding in everyone’s ears regarding the unprecedented opportunity to get there with the stimulus bill. It is provocative, insightful, and hard hitting piece – all typical for Longman piece. I look forward to its impact in the ongoing debate.

Washington Monthly
Code Red – How software companies could screw up Obama’s health care reform.

By Phillip Longman

The central contention of Barack Obama’s vision for health care reform is straightforward: that our health care system today is so wasteful and poorly organized that it is possible to lower costs, expand access, and raise quality all at the same time—and even have money left over at the end to help pay for other major programs, from bank bailouts to high-speed rail.

It might sound implausible, but the math adds up. America spends nearly twice as much per person as other developed countries for health outcomes that are no better. As White House budget director Peter Orszag has repeatedly pointed out, the cost of health care has become so gigantic that pushing down its growth rate by just 1.5 percentage points per year would free up more than $2 trillion over the next decade.

The White House also has a reasonably accurate fix on what drives these excessive costs: the American health care system is rife with overtreatment. Studies by Dartmouth’s Atlas of Health Care project show that as much as thirty cents of every dollar in health care spending goes to drugs and procedures whose efficacy is unproven, and the system contains few incentives for doctors to hew to treatments that have been proven to be effective. The system is also highly fragmented. Three-quarters of Medicare spending goes to patients with five or more chronic conditions who see an annual average of fourteen different physicians, most of whom seldom talk to each other. This fragmentation leads to uncoordinated care, and is one of the reasons why costly and often deadly medical errors occur so frequently.

Almost all experts agree that in order to begin to deal with these problems, the health care industry must step into the twenty-first century and become computerized. Astonishingly, twenty years after the digital revolution, only 1.5 percent of hospitals have integrated IT systems today—and half of those are government hospitals. Digitizing the nation’s medical system would not only improve patient safety through better-coordinated care, but would also allow health professionals to practice more scientifically driven medicine, as researchers acquire the ability to mine data from millions of computerized records about what actually works.

It would seem heartening, then, that the stimulus bill President Obama signed in February contains a whopping $20 billion to help hospitals buy and implement health IT systems. But the devil, as usual, is in the details. As anybody who’s lived through an IT upgrade at the office can attest, it’s difficult in the best of circumstances. If it’s done wrong, buggy and inadequate software can paralyze an institution.

Twenty years after the digital revolution, only an astonishing 1.5 percent of hospitals have integrated information technology systems. Almost all experts agree that in order to begin to deal with the problems of the health care system, this has to change.

Consider this tale of two hospitals that have made the digital transition. The first is Midland Memorial Hospital, a 371-bed, three-campus community hospital in southern Texas. Just a few years ago, Midland Memorial, like the overwhelming majority of American hospitals, was totally dependent on paper records. Nurses struggled to decipher doctors’ scribbled orders and hunt down patients’ charts, which were shuttled from floor to floor in pneumatic tubes and occasionally disappeared into the ether. The professionals involved in patient care had difficulty keeping up with new clinical guidelines and coordinating treatment. In the normal confusion of day-to-day practice, medical errors were a constant danger.

This all changed in 2007 when Midland completed the installation of a health IT system. For the first time, all the different doctors involved in a patient’s care could work from the same chart, using electronic medical records, which drew data together in one place, ensuring that the information was not lost or garbled. The new system had dramatic effects. For instance, it prompted doctors to follow guidelines for preventing infection when dressing wounds or inserting IVs, which in turn caused infection rates to fall by 88 percent. The number of medical errors and deaths also dropped. David Whiles, director of information services for Midland, reports that the new health IT system was so well designed and easy to use that it took less than two hours for most users to get the hang of it. “Today it’s just part of the culture,” he says. “It would be impossible to remove it.”

Things did not go so smoothly at Children’s Hospital of Pittsburgh, which installed a computerized health system in 2002. Rather than a godsend, the new system turned out to be a disaster, largely because it made it harder for the doctors and nurses to do their jobs in emergency situations. The computer interface, for example, forced doctors to click a mouse ten times to make a simple order.
Even when everything worked, a process that once took seconds now took minutes—an enormous difference in an emergency-room environment. The slowdown meant that two doctors were needed to attend to a child in extremis, one to deliver care and the other to work the computer. Nurses also spent less time with patients and more time staring at computer screens. In an emergency, they couldn’t just grab a medication from a nearby dispensary as before—now they had to follow the cumbersome protocols demanded by the computer system. According to a study conducted by the hospital and published in the journal Pediatrics, mortality rates for one vulnerable patient population—those brought by emergency transport from other facilities—more than doubled, from 2.8 percent before the installation to almost 6.6 percent afterward.

Why did similar attempts to bring health care into the twenty-first century lead to triumph at Midland but tragedy at Children’s? While many factors were no doubt at work, among the most crucial was a difference in the software installed by the two institutions. The system that Midland adopted is based on software originally written by doctors for doctors at the Veterans Health Administration, and it is what’s called “open source,” meaning the code can be read and modified by anyone and is freely available in the public domain rather than copyrighted by a corporation. For nearly thirty years, the VA software’s code has been continuously improved by a large and evergrowing community of collaborating, computer-minded health care professionals, at first within the VA and later at medical institutions around the world. Because the program is open source, many minds over the years have had the chance to spot bugs and make improvements. By the time Midland installed it, the core software had been road-tested at hundred of different hospitals, clinics, and nursing homes by hundreds of thousands of health care professionals.

The software Children’s Hospital installed, by contrast, was the product of a private company called Cerner Corporation. It was designed by software engineers using locked, proprietary code that medical professionals were barred from seeing, let alone modifying. Unless they could persuade the vendor to do the work, they could no more adjust it than a Microsoft Office user can fine-tune Microsoft Word. While a few large institutions have managed to make meaningful use of proprietary programs, these systems have just as often led to gigantic cost overruns and sometimes life-threatening failures. Among the most notorious examples is Cedars-Sinai Medical Center, in Los Angeles, which in 2003 tore out a “state-of-the-art” $34 million proprietary system after doctors rebelled and refused to use it. And because proprietary systems aren’t necessarily able to work with similar systems designed by other companies, the software has also slowed what should be one of the great benefits of digitized medicine: the development of a truly integrated digital infrastructure allowing doctors to coordinate patient care across institutions and supply researchers with vast pools of data, which they could use to study outcomes and develop better protocols.

Unfortunately, the way things are headed, our nation’s health care system will look a lot more like Children’s and Cedars-Sinai than Midland. In the haste of Obama’s first 100 days, the administration and Congress crafted the stimulus bill in a way that disadvantages opensource vendors, who are upstarts in the commercial market. At the same time, it favors the larger, more established proprietary vendors, who lobbied to get the $20 billion in the bill. As a result, the government’s investment in health IT is unlikely to deliver the quality and cost benefits the Obama administration hopes for, and is quite likely to infuriate the medical community. Frustrated doctors will give their patients an earful about how the crashing taxpayer-financed software they are forced to use wastes money, causes two-hour waits for eight-minute appointments, and constrains treatment options.

Done right, digitized health care could help save the nation from insolvency while improving and extending millions of lives at the same time. Done wrong, it could reconfirm Americans’ deepest suspicions of government and set back the cause of health care reform for yet another generation.

Open-source software has no universally recognized definition. But in general, the term means that the code is not secret, can be utilized or modified by anyone, and is usually developed collaboratively by the software’s users, not unlike the way Wikipedia entries are written and continuously edited by readers. Once the province of geeky software aficionados, open-source software is quickly becoming mainstream. Windows has an increasingly popular open-source competitor in the Linux operating system. A free program called Apache now dominates the market for Internet servers. The trend is so powerful that IBM has abandoned its propriety software business model entirely, and now gives its programs away for free while offering support, maintenance, and customization of open-source programs, increasingly including many with health care applications. Apple now shares enough of its code that we see an explosion of homemade “applets” for the iPhone—each of which makes the iPhone more useful to more people, increasing Apple’s base of potential customers.

If this is the future of computing as a whole, why should U.S. health IT be an exception? Indeed, given the scientific and ethical complexities of medicine, it is hard to think of any other realm where a commitment to transparency and collaboration in information technology is more appropriate. And, in fact, the largest and most successful example of digital medicine is an open-source program called VistA, the one Midland chose.

VistA was born in the 1970s out of an underground movement within the Veterans Health Administration known as the “Hard Hats.” The group was made up of VA doctors, nurses, and administrators around the country who had become frustrated with the combination of heavy caseloads and poor record keeping at the institution. Some of them figured that then-new personal and mini computers could be the solution. The VA doctors pioneered the nation’s first functioning electronic medical record system, and began collaborating with computer programmers to develop other health IT applications, such as systems that gave doctors online advice in making diagnoses and settling on treatments.

The key advantages of this collaborative approach were both technical and personal. For one, it allowed medical professionals to innovate and learn from each other in tailoring programs to meet their own needs. And by involving medical professionals in the development and application of information technology, it achieved widespread buy-in of digitized medicine at the VA, which has often proven to be a big problem when propriety systems are imposed on doctors elsewhere.

This open approach allowed almost anyone with a good idea at the VA to innovate. In 1992, Sue Kinnick, a nurse at the Topeka, Kansas, VA hospital, was returning a rental car and saw the use of a bar-code scanner for the first time. An agent used a wand to scan her car and her rental agreement, and then quickly sent her on her way. A light went off in Kinnick’s head. “If they can do this with cars, we can do this with medicine,” she later told an interviewer. With the help of other tech-savvy VA employees, Kinnick wrote software, using the Hard Hat’s public domain code, that put the new scanner technology to a new and vital use: preventing errors in dispensing medicine. Under Kinnick’s direction, patients and nurses were each given bar-coded wristbands, and all medications were bar-coded as well. Then nurses were given wands, which they used to scan themselves, the patient, and the medication bottle before dispensing drugs. This helped prevent four of the most common dispensing errors: wrong med, wrong dose, wrong time, and wrong patient. The system, which has been adopted by all veterans hospitals and clinics and continuously improved by users, has cut the number of dispensing errors in half at some facilities and saved thousands of lives.

At first, the efforts of enterprising open-source innovators like Kinnick brought specific benefits to the VA system, such as fewer medical errors and reduced patient wait times through better scheduling. It also allowed doctors to see more patients, since they were spending less time chasing down paper records. But eventually, the open-source technology changed the way VA doctors practiced medicine in bigger ways. By mining the VA’s huge resource of digitized medical records, researchers could look back at which drugs, devices, and procedures were working and which were not. This was a huge leap forward in a profession where there is still a stunning lack of research data about the effectiveness of even the most common medical procedures. Using VistA to examine 12,000 medical records, VA researchers were able to see how diabetics were treated by different VA doctors, and by different VA hospitals and clinics, and how they fared under the different circumstances. Those findings could in turn be communicated back to doctors in clinical guidelines delivered by the VistA system. In the 1990s, the VA began using the same information technology to see which surgical teams or hospital managers were underperforming, and which deserved rewards for exceeding benchmarks of quality and safety.

Thanks to the stimulus bill, $20 billion is about to be poured into buggy, expensive, proprietary software that will not bring the benefits the Obama administration hopes for. Rather, it will amount to a giant bailout of a health IT industry whose business model has never really worked.

Thanks to all this effective use of information technology, the VA emerged in this decade as the bright star of the American health system in the eyes of most healthquality experts. True, one still reads stories in the papers about breakdowns in care at some VA hospitals. That is evidence that the VA is far from perfect—but also that its information system is good at spotting problems. Whatever its weaknesses, the VA has been shown in study after study to be providing the highest-quality medical care in America by such metrics as patient safety, patient satisfaction, and the observance of proven clinical protocols, even while reducing the cost per patient.

Following the organization’s success, a growing number of other government-run hospitals and clinics have started adapting VistA to their own uses. This includes public hospitals in Hawaii and West Virginia, as well as all the hospitals run by the Indian Health Service. The VA’s evolving code also has been adapted by providers in many other countries, including Germany, Finland, Malaysia,
Brazil, India, and, most recently, Jordan. To date, more than eighty-five countries have sent delegations to study how the VA uses the program, with four to five more coming every week.

Proprietary systems, by contrast, have gotten a cool reception. Although health IT companies have been trying to convince hospitals and clinics to buy their integrated patient-record software for more than fifteen years, only a tiny fraction have installed such systems. Part of the problem is our screwed-up insurance reimbursement system, which essentially rewards health care providers for performing more and more expensive procedures rather than improving patients’ welfare. This leaves few institutions that are not government run with much of a business case for investing in health IT; using digitized records to keep patients healthier over the long term doesn’t help the bottom line.

But another big part of the problem is that proprietary systems have earned a bad reputation in the medical community for the simple reason that they often don’t work very well. The programs are written by software developers who are far removed from the realities of practicing medicine. The result is systems which tend to create, rather than prevent, medical errors once they’re in the hands of harried health care professionals. The Joint Commission, which accredits hospitals for safety, recently issued an unprecedented warning that computer technology is now implicated in an incredible 25 percent of all reported medication errors. Perversely, license agreements usually bar users of proprietary health IT systems from reporting dangerous bugs to other health care facilities. In open-source systems, users learn from each other’s mistakes; in proprietary ones, they’re not even allowed to mention them.

If proprietary health IT systems are widely adopted, even more drawbacks will come sharply into focus. The greatest benefits of health IT—and ones the Obama administration is counting on—come from the opportunities that are created when different hospitals and clinics are able to share records and stores of data with each other. Hospitals within the digitized VA system are able to deliver more services for less mostly because their digital records allow doctors and clinics to better coordinate complex treatment regimens. Electronic medical records also produce a large collection of digitized data that can be easily mined by managers and researchers (without their having access to the patients’ identities, which are privacy protected) to discover what drugs, procedures, and devices work and which are ineffective or even dangerous. For example, the first red flags about Vioxx, an arthritis medication that is now known to cause heart attacks, were raised by the VA and large private HMOs, which unearthed the link by mining their electronic records. Similarly, the IT system at the Mayo Clinic (an open-source one, incidentally) allows doctors to personalize care by mining records of specific patient populations. A doctor treating a patient for cancer, for instance, can query the treatment outcomes of hundreds of other patients who had tumors in the same area and were of similar age and family backgrounds, increasing odds that they choose the most effective therapy.

But in order for data mining to work, the data has to offer a complete picture of the care patients have gotten from all the various specialists involved in their treatment over a period of time. Otherwise it’s difficult to identify meaningful patterns or sort out confounding factors. With proprietary systems, the data is locked away in what programmers call “black boxes,” and cannot be shared across hospitals and clinics. (This is partly by design; it’s difficult for doctors to switch IT providers if they can’t extract patient data.) Unless patients get all their care in one facility or system, the result is a patchwork of digital records that are of little or no use to researchers. Significantly, since proprietary systems can’t speak to each other, they also offer few advantages over paper records when it comes to coordinating care across facilities. Patients might as well be schlepping around file folders full of handwritten charts.

Of course, not all proprietary systems are equally bad. A program offered by Epic Systems Corporation of Wisconsin rivals VistA in terms of features and functionality. When it comes to cost, however, open source wins hands down, thanks to no or low licensing costs. According to Dr. Scott Shreeve, who is involved in the VistA installations in West Virginia and elsewhere, installing a proprietary system like Epic costs ten times as much as VistA and takes at least three times as long—and that’s if everything goes smoothly, which is often not the case. In 2004, Sutter Health committed $154 million to implementing electronic medical records in all the twenty-seven hospitals it operated in Northern California using Epic software. The project was supposed to be finished by 2006, but things didn’t work out as planned. Sutter pulled the plug on the project in May of this year, having completed only one installation and facing remaining cost estimates of $1 billion for finishing the project. In a letter to employees, Sutter executives explained that they could no long afford to fund employee pensions and also continue with the Epic buildout.

The VA’s open-source software allowed a nurse in Topeka, Kansas, to adapt for her own work a bar-code scanner she saw used at a rental-car agency. Her innovation cut the number of medication-dispensing errors in half at some facilities, and saved thousands of lives.

Unfortunately, billions of taxpayers’ dollars are about to be poured into expensive, inadequate proprietary software, thanks to a provision in the stimulus package. The bill offers medical facilities as much as $64,000 per physician if they make “meaningful use” of “certified” health IT in the next year and a half, and punishes them with cuts to their Medicare reimbursements if they don’t do so by 2015. Obviously, doctors and health administrators are under pressure to act soon. But what is the meaning of “meaningful use”? And who determines which products qualify? These questions are currently the subject of bitter political wrangling. Vendors of proprietary health IT have a powerful lobby, headed by the Healthcare Information and Management Systems Society, a group with deep ties to the Obama administration. (The chairman of HIMSS, Blackford Middleton, is an adviser to Obama’s health care team and was instrumental in getting money for health IT into the stimulus bill.) The group is not openly against open source, but last year when Rep. Pete Stark of California introduced a bill to create a low-cost, open-source health IT system for all medical providers through the Department of Health and Human Services, HIMSS used its influence to smash the legislation. The group is now deploying its lobbying clout to persuade regulators to define “meaningful use” so that only software approved by an allied group, the Certification Commission for Healthcare Information Technology, qualifies. Not only are CCHIT’s standards notoriously lax, the group is also largely funded and staffed by the very industry whose products it is supposed to certify. Giving it the authority over the field of health IT is like letting a group controlled by Big Pharma determine which drugs are safe for the market.

Even if the proprietary health IT lobby loses the battle to make CCHIT the official standard, the promise of open-source health IT is still in jeopardy. One big reason is the far greater marketing power that the big, established proprietary venders can bring to bear compared to their open-source counterparts, who are smaller and newer on the scene. A group of proprietary industry heavyweights, including Microsoft, Intel, Cisco, and Allscripts, is sponsoring the Electronic Health Record Stimulus Tour, which sends teams of traveling sales representatives to tell local doctors how they can receive tens of thousands of dollars in stimulus money by buying their products— provided that they “act now.” For those medical professionals who can’t make the show personally, helpful webcasts are available. The tour is a variation on a tried-andtrue strategy: when physicians are presented with samples of pricey new name-brand substitutes for equally good generic drugs, time and again they start prescribing the more expensive medicine. And they are likely to be even more suggestible when it comes to software because most don’t know enough about computing to evaluate vendors’ claims skeptically.

What can be done to counter this marketing offensive and keep proprietary companies from locking up the health care IT market? The best and simplest answer is to take the stimulus money off the table, at least for the time being. Rather than shoveling $20 billion into software that doesn’t deliver on the promise of digital medicine, the government should put a hold on that money pending the results of a federal interagency study that will be looking into the potential of opensource health IT and will deliver its findings by October 2010.

While a few large institutions have managed to make meaningful use of proprietary health IT, these systems have just as often been expensive failures. In 2003, Cedars-Sinai Medical Center in Los Angeles tore out a “state-of-the-art” $34 million proprietary system after doctors rebelled and refused to use it.

As it happens, that study is also part of the stimulus bill. The language for it was inserted by West Virginia Senator Jay Rockefeller, who has also introduced legislation that would help put open-source health IT on equal footing with the likes of Allscripts and Microsoft. Building on the systems developed by the VA and Indian Health Services, Rockefeller’s bill would create an opensource government-sponsored “public utility” that would distribute VistA-like software, along with grants to pay for installation and maintenance. The agency would also be charged with developing quality standards for opensource health IT and guidelines for interoperability. This would give us the low-cost, high-quality, fully integrated and proven health IT infrastructure we need in order to have any hope of getting truly better health care.

Delaying the spending of that $20 billion would undoubtedly infuriate makers of proprietary health software. But it would be welcomed by health care providers who have long resisted—partly for good reason—buying that industry’s product. Pushing them to do so quickly via the stimulus bill amounts to a giant taxpayer bailout of health IT companies whose business model has never really worked. That wouldn’t just be a horrendous waste of public funds; it would also lock the health care industry into software that doesn’t do the job and would be even more expensive to get rid of later.

As the administration and Congress struggle to pass a health care reform bill, questions about which software is best may seem relatively unimportant—the kind of thing you let the “tech guys” figure out. But the truth is that this bit of fine print will determine the success or failure of the whole health care reform enterprise. So it’s worth taking the time to get the details right.

Phillip Longman is a senior fellow at the New America Foundation and the author of Best Care Anywhere: Why VA Health Care Is Better Than Yours as well as The Next Progressive Era: A Blueprint for Broad Prosperity.