The Doctors Resource Group identified the top three complaints employed physicians have about their current practices:

1. Lack of Job Security
2. Changes in Compensation
3. Call Schedule is too Burdensome

While call schedules are likely to be a source of frustration no matter how happy a doctor is, compensation structure and job security are important factors to bear in mind when considering moving to a new practice.

Why Doctors are Seeking New Employment Opportunities

Ericksson Physician Search, a physician recruitment agency, surveyed 1,200 doctors currently working at independent and hospital-owned groups but in search of new employment opportunities to learn why they were looking at other jobs. Not surprisingly, the most common motivation for physicians was to find financial security. According to the survey, 57 percent of the physicians in the market for a new practice were looking for job and financial security. This isn’t too surprising, considering the strain that student loans present for doctors: 18 percent of those surveyed indicated that their student loans were the major source of financial stress in their life. In addition, 52 percent were also driven by their dissatisfaction with their current practice environment. It is worth noting that doctors looking for new employment were not solely motivated by their frustrations – 42 percent also indicated that they were motivated by lifestyle changes like divorce or family needs.

Many doctors frustrated with having to deal with the business side of healthcare or wanting more job security are looking to hospitals for employment opportunities, but do hospitals really have what these physicians need?

Do Hospitals have Greener Grass?

As the number of patients needing medical care in the United States grows steadily, hospitals are increasing the number of physicians on staff. But as healthcare becomes an industry dominated by the bottom line, the need for increased physician employment is taxing hospital finances. And with the recent Medicare reforms and the impending compensation reductions starting in 2013, many already strained hospitals will be facing severe economic hardship without a change in structure or billing practices. Any way you slice it, hospitals are under pressure to cut costs while boosting revenue.

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Physicians should keep this in mind when they are looking for new jobs. A survey by QuantiaMD, an online physician community, found that 49 percent of the 136 physicians surveyed had not had a salary increase in the past two years. Even more concerning, they found that 18 percent of respondents had actually had their salaries cut. More and more hospitals are adopting a pay for performance structure for physician compensation. Capturing lost charges and improving medical coding and billing are more important for hospitals and practices than ever before.

What’s the take-home message for physicians looking to change jobs? Don’t forget that hospitals are businesses, and most are struggling. Changing where you practice does not guarantee job security, and more and more hospitals will be embracing a pay for performance compensation structure.

The Clarkson Centre for Board Effectiveness (CCBE) has tracked CEO pay and performance alignment for firms on the S&P/TSX Composite Index (TSX Index) since 2004. Overall, data shows that CEO pay and share performance move in the same direction in the long-term. This trend is, however, less apparent in the short-term. To better understand pay and performance alignment in the short-term, this report focuses on a crucial observation period: the 2008 financial crisis; a year where total average TSR of the TSX Index plunged to -32%.

In an era of increased shareholder scrutiny enhanced by the introduction of corporate governance practices such as, “Say on Pay,” this paper examines patterns in CEO pay and performance alignment in the short-term and whether tenure on the S&P/TSX Composite Index influences compensation behavior. For the purposes of this report, CCBE looked specifically at how TSX Index boards reacted to the 2008 financial crisis. How did long-tenured firms align their CEO pay with financial performance relative to short-tenured firms and firms with eventual-tenure?

Like this one from a parent, in regards to the new teacher evaluation process:

“My children should not represent dollar signs to a teacher. My kids will be in 1st and 4th grade. I do not want their teachers thinking about profit.”

Soooo…..that means what? You’d rather your children’s teachers have no absolutely no incentive to ensure your kids are learning? You’d rather just trust that the 99% of teachers who were rated effective by their principal last year were actually effective? If profiting off of children’s achievement means kids learn more in the end, I say bring on the moolah! The assumption is that the teachers are, at least in part, responsible for their students’ success, right? If that isn’t the case then we have a much bigger problem on our hands.

How about this statement: “My house should not represent dollar signs to a contractor…I do not want my contractor thinking about profit.” Well, if he’s not thinking about profit, then he’s either a) so wealthy he doesn’t need the money or b) an idiot. But the bottom line for the homeowner is that dollar signs are exactly what motivate the contractor to do a good job.

I have heard all the arguments against pay for performance systems and I understand why many teachers are upset about it. It is a scary thing to suddenly change the way you receive your paycheck after so many years in the profession—decades for some teachers. So I get the fear that teachers have.

Here’s what I will never understand—why would parents be against a system that rewards the most important people in their children’s lives (next to themselves) for doing a great job?

The next day she called to tell me I was right. Her original fears were unfounded. Her performance review was excellent and met all her expectations. Clearly the seller (my sister’s current employer) wanted to convince the buyer the people were excellent.

Was that performance appraisal really about her or about the sale? Most performance appraisals are not really about the people but instead about some other motivation or intended outcome. This can include things such as a bias, a manipulation, poor leadership, justification for a raise or bonus, justification for a firing, and justification for a promotion or a demotion. Aren’t performance appraisals supposed to be about improving the performance of the individual? If so, why would leaders misuse the policy for their own selfish motivations?

The current performance appraisal process really doesn’t work well and there are two basic reasons why:

1. The basic assumptions behind the current appraisal are flawed

2. The appraisal process is most often manipulated to justify some motivation other than its original purpose e.g. justifying a raise (or bonus) to keep a high performer happy or justifying the firing of a poor performer.

The main assumption of the current appraisal process is that improving the quality of the people will improve the organizational performance. This describes our desire to analyze the parts of a whole in order to understand the whole. This is inconsistent consistent with systems thinking and leaders must embrace systems thinking in order to achieve predictable organization improvement.

Most leaders now assume that poor organizational performance is rooted in poor employee performance. Nearly ninety percent of organizations conduct performance appraisals and that is its main purpose. This is merely a dysfunctional yet sophisticated form of blame. Additional assumptions that follow from this are:

· Individuals have control over the results of their work and the factors that allow them to achieve their goals. This is false. There are always many factors that contribute to the success of a goal.

· Managers can evaluate individual performance separate from the contributions of others and the influence of the work tools, environment etc. This is false. Managers cannot separate their bias (either positive or negative) from their evaluation.

None of these are true because they are inconsistent with systems thinking. Instead, the correct assumption is: “the quality of the interactions between employees (and departments) is more important for improvement of the organization than improving the quality of the people.” In other words, you can’t separate the evaluation of the person from the quality of the interactions that person has with their co-workers and the working environment. If this is true one must conclude that the typical appraisal doesn’t evaluate the individual. It evaluates their interactions. It is not about the person it’s about the interactions of that person in that particular environment.

Leaders often manipulate the appraisal process to serve their own purposes. Just as with my sister, the owner manipulated the process to make all employees “look good” so the new buyer would be impressed. This compromised the opportunity to receive real feedback for improvement. It compromised the truth.

Leaders very often will compromise the process to achieve some short term goal. The appraisal then becomes more about achieving the goal and less about the person receiving the appraisal.

That performance appraisal with your name on it is really NOT about you. It is really about how you are able to interact with others and environmental factors outside of your control.

Luckily I have “TRIPLE A” membership. I called and requested a tow.  The nature of the breakdown caused the front end to be nearly touching the pavement. I cautioned the “TRIPLE A” agent to send the right kind of tow truck to handle such a situation. She assured me “all our service stations are knowledgeable professional shops”.   Of course, you guessed it, when the truck arrived the driver proclaimed, “I brought the wrong kind of truck.  I will need to get a different one.”   He suggested I call “TRIPLE A” and report the error and gain approval for him to implement the new action.

I took his advice and called “TRIPLE A”.  When a woman answered, a different person from the original customer service representative, I realized the explanation was going to be challenging and the accountability for the error was non-existent.

It took a while but the driver returned with the correct truck and I was off to have my car repaired.  On the way to the shop I was wondering how, and if, “TRIPLE A” could learn from this situation.  I tried to warn the first customer service person to avoid a mistake.  The mistake still happened and it caused wasted time for “TRIPLE A”, the tow truck driver, the towing company and the customer (me).  What was the root cause(s) of the error and how could “TRIPLE A” learn to avoid it in the future?  Unless accountability is set up into the system the answers to these questions will be elusive and the mistakes will likely reoccur.

Accountability means to be responsible and it requires four elements.  First people need to be aware of the situation or problem.  Second, they must understand a specific process to follow.  Third, they must agree to follow the process.  Finally, there must be feedback (data or consequences) if the process fails.  It is a leader’s responsibility to set up the system so that all four elements are present.  Without these elements a leader just ends up blaming people for mistakes and learning is compromised.

In my story all four elements were missing.   The initial customer service person was clearly un-aware of the need or the meaning of the information I provided her regarding the condition of the car and the type of truck needed.   In addition, she had no clear process (I am guessing because of my impression) to handle this information or request.  Third, she obviously made no agreement to follow such a process.   Finally, it seems there was no feedback to either her or any other customer service person regarding the mistake (again I am guessing).

Are you setting up accountability or just blaming people for mistakes when they occur?  If you don’t set up accountability then you are stealing the opportunity from people to optimize their learning.  Perhaps if there was a process to escalate the call to a supervisory level when a puzzling or challenging question was asked that might have begun to set up the accountability system in “TRIPLE A”.   Perhaps if the telephone system was set up to quickly escalate the call, as needed, to a knowledgeable technician. Perhaps if the customer service person was trained to recognize the opportunity and to transfer the call, the second element of accountability would be met.  Perhaps if there was a feedback loop to report wasted time for tow truck drivers it would create the forth element of accountability.  Perhaps if there was a team of knowledgeable process experts who could study the root causes and therefore modify the process or change the training processes (consequences and feedback) the mistake would not be repeated.

It is a leader’s job to set up the accountability system.  In the 15 years of consulting rarely have I seen an organization with a robust accountability system.  Instead, leaders tend to look for mistakes, guess at root causes on their own, and use a performance appraisal process to punish the employee who unfortunately found him or herself in the middle of a dysfunctional system.

Are you stealing accountability from your organization and from your people?  Stop now and set up the four key elements.  Stealing accountability is wasteful and it creates victims not leaders.

My daughter Emily is a junior in college and works part time for a catering company.  She drives to one of the catering company clients to serve dinner to elderly customers at a Senior Living facility.  Her boss rarely sees her.  He does little more than schedule the workers.  He is rarely at the location because the students work well as a team and need little or no supervision.  The process for serving dinner is very predictable and relatively easy to learn and implement.

After working a year for this company Emily was scheduled for a raise.  The company policy required she receive a performance review before she could be approved for her raise.  This policy was an attempt to treat all employees fairly by insuring all employees who receive a raise in fact deserve one.  It sounds reasonable and necessary however, there is a problem.  The boss is rarely, if ever, available to observe her performance.  He therefore must guess.  There is no predictable process in place to access Emily’s performance.  The policy exists but there is no way to carry it out because the process can’t deliver it.

The boss and Emily met.  He explained his rating of “3.2” on a scale of 1 to 4.  In this company’s performance management policy the “1” rating is unsatisfactory and requires immediate dismissal; the “2” required immediate improvement with a performance plan; the “3” means “meets expectations”; and the “4” means “exceptional”.  The boss explained that “no one ever” receives a “4” rating because he doesn’t believe in it.  Everyone can improve and therefore the rating of “exceptional” is unreachable and unattainable.  The boss had his own way of interpreting the policy.

My daughter was disappointed in her rating because she had never missed a day of work scheduled, had filled in for other employees when they called in sick or needed an evening off multiple times, and the clients loved her. She continually received unsolicited accolades and even gifts from the seniors.  She was not only disappointed but also appalled by his explanation.  She felt de-motivated and discouraged.

She decided to speak up asking, “How can you rate my performance, you are never here?”   “That’s not true” he replied.  “Occasionally I arrive at the end of the shift in time for me to see you mopping the floor.”  Policy alone cannot deliver fairness nor can it deliver engagement.  An event that was intended to increase engagement actually damaged it.  Policies don’t deliver fairness, processes do.  Without predictable processes, based on sound theory, fairness will be non-existent and engagement will be damaged.

While all employees need to understand policy it is not the policy alone that delivers the outcomes.  It is the process.  Employees also need to be treated as individuals.  Their individual needs, characteristics, skills all need to be addressed to honor their unique make-up.  The current performance appraisal process doesn’t deliver this (nor will it ever be able to do so in its current form).  Although my daughter’s story is a bit unusual in its detail, the outcome is very common, i.e. a disengaged employee after a “good” performance review.

Policy alone cannot deliver fairness and engagement.  A process that is both flexible and clear is needed to manage the variation in desired outcomes.  Too often a leader “sends down” edicts to the masses and expects compliance.  It just doesn’t work that way.  That is an unsophisticated way of achieving engagement and the results show it.

In January of 2009 “Sully” Sullenberger landed a USAIR flight in the Hudson after both engines shut down from a bird strike.  He was honored by everyone including the President of the United States, his hometown, and 60 Minutes.  He was called a true America hero by many in the press.  His actions were called a miracle.  He claimed that he and his crew were only doing their jobs.  He said, “But I know I can speak for the entire crew when I tell you we were simply doing the job we were trained to do.”  Sullenberger followed processes based upon solid and proven principles.

Why is it so often that our heroes are so modest and downplay their star qualities and give away their accolades?  They know something that we often forget.  They have a system supporting them.

In the case of Sullenberger the flight crew was thoroughly trained to react quickly and decisively in an emergency situation.  Sullenberger took control of the plane and instructed his co-pilot to read through the appropriate check lists.  The check lists and the cooperation of the co-pilot did as much to save all 155 people as did Sullenberger.  They all played a significant role in the coordination of a successful heroic event.  Sullenberger did NOT act alone. He could not have possibly done it alone yet we still want to hold him up as some super natural champion.   Heroes understand systems.  The general public doesn’t yet appreciate the influence a system has on performance.  We don’t yet think in terms of systems.

There are three reasons why we should not treat star performers differently whether it is in the military, the airlines or in our organizations.  First, doing so ignores the overall system interactions that helped contribute to the successes.  We can forget the catcher who snags a wild pitch to save a perfect game for the star pitcher.   We ignore the co-pilot’s role of reading and fulfilling the emergency engine start-up check list or the flight attendant who keeps the passengers form panicking even though they need to stand on the wing of a jet in the middle of the Hudson River.  System interactions contribute greatly to a hero’s success.  Acknowledging this helps us engage others and understand a bigger picture.

Second, treating “stars” differently prevents us from duplicating successes in the future.  By giving all the credit to one person that event becomes a “person dependent event” not a system dependent event.  If the success is great don’t we want to duplicate it as much as possible?  Sullenberger is now retired.  Does that mean we cannot teach others to duplicate his actions?  Why can’t we have 100 heroes in USAIR and not just one?

Finally, treating heroes and stars differently prevents us from learning.  It creates a barrier to learning. Aren’t we are saying, “We just couldn’t have done it without them?”  Instead, isn’t it more important to acknowledge their accomplishments and the system interactions and ask, “What can we learn from this?”  Isn’t it just as important to learn from our successes as it is to learn from our mistakes?

So much time and effort is spent now on looking for ways to keep our star performers in our organizations.  We court them, provide opportunities for them, we lavish them with praise and bonuses just to be sure we them happy.  The next time you see a star being honored think about what we might be missing.  What other system interactions need to be honored and who else needs to be engaged?  How can we duplicate that same set of circumstances and interactions such that we duplicate the success?    Finally, ask, what can we learn?   If we want continued success and continued engagement in our organizations we need to stop treating our heroes so differently.

I waited until September to take action because I know from experience that is the best month to re-grow grass.  I asked my lawn guy to prepare the soil with an aeration treatment, growth fertilizer, and power seeding.    I carefully watered his good works and the grass is coming back nicely.

All I did was create the proper conditions and allowed nature to take over.  This is an important lesson for leaders.  Don’t focus on improving individuals.  Use your energy resources to create the right conditions for performance.

I didn’t attempt to accelerate my lawn repair by conducting motivational speeches or placing posters of motivation on the surrounding trees and bushes.  Nor did I offer additional “rewards” in the form of additional fertilizer or water to encourage faster growth from those high performing seeds.  I also didn’t threaten to withdraw those goodies form those seeds that were slower to grow.

That approach would have been ridiculous.  Just as ridiculous is leaders who use performance appraisals and pay for performance and expect long term sustainable improvement without creating the proper performance context.  Performance, like grass will naturally grow when “good seeds” are planted in the proper conditions.  Nature takes over.

A leader’s first job is to create that context.  The proper context in an organization includes the following five key items:

1. Values
2. Vision
3. Mission
4. Management Theory
5. Strategy

This is lesson number one for leaders.  What have you done lately to reinforce the clarity of the Values: How we want to behave regardless of the situation; Vision: how w want to look as an organization in the future; Mission: Why the organization exists; The Management Theory: Do you believe people want to do a good job or do you believe people need to be pushed to work?; Strategy: What differentiates you from other organizations in your industry?

The second lesson from nature is autonomy.  Nature allows choices to be made.  Make the right choices and you succeed.  Make the wrong choice and you lose (or you experience pain).  Nature does not control.  Nature encourages autonomy.

When organizational leaders rely on methods of control to manage, they impair the organization’s ability to respond or adapt to change. To be successful in this fast-paced business climate, leaders must learn to cultivate a context that empowers and encourages informed and rapid decision-making.

A good metaphor for this type of responsive decision-making is a flock of birds in flight.  It is a most mystifying phenomenon. As a group, they have no leader to tell them when to turn left or right, or when to slow down or to speed up; yet as a group, they change direction as effortlessly as a single organism.  How is this possible?  It is possible because, flocking birds naturally follow three basic principles: first, they fly in the same general direction as their closest neighbors; second, they fly at the same average speed as their closest neighbors; third, they fly at the same average distance from their closest neighbor and avoid colliding with them at all costs.  Following these three basic principles, they are able, as a group, to respond to their fast-changing environment with rapid, precise adjustments.

Flocking birds are what’s called a “self-organizing system”.  Organizations can achieve the same agile capabilities if the leader clarifies the vision and the organizational objectives, and teaches clear effective principles. In doing so, the leader establishes trust and increases his/her influence, while empowering each individual to make the right decisions at the right time.  In the presence of a clear vision, clear objectives and sound principles, individuals participating in a self-organizing system learn how to adjust to a fast-paced environment.  Like the birds, people will respond quickly, appropriately and in the best interests of the “flock”, without needing a controlling authority to tell them what to do.

The creation of this performance context allows autonomy.  The birds are free to make choices within the context of the principles.  A leader can create the conditions and then trust employees to operate autonomously within that context.   So doing will create the best response to change and the greatest possibility of high performance.

Stop trying to control the seeds or the birds.  Create the proper conditions instead and let them perform.  It is the natural thing to do.

They unintentionally damage employee engagement

Employee engagement is one of the hottest Human Resources topics today. Study after study demonstrates that when an employee feels a positive emotional connection with their team and organization they consistently contribute toward increased productivity, customer service quality, and they are more loyal.
The typical manager damages this engagement and they can’t help it. Their responsibilities and way they have been taught to carry them out clashes with what employees need for engagement. To optimize employee engagement a work environment should have these five elements: a clear understanding of how their work contributes to the benefit of the whole organization and the customers it serves, a sense of autonomy in their decision making, a sense of challenge that matches the employee skills, consistent feedback, and a sense of progress toward a desired result.

The typical environment is set up so that the manager is the only conduit for these elements. The manager is the parent and the employee is the child who cannot be fully trusted to act on their own. These manager dependent environments prevent the achievement of these five engagement elements.
For example, employees are most often assigned tasks. They have little or no choice in them. If they are lucky they are told the strategy of the organization. More likely they are merely told what their goals are and they have little choice in their creation. Their feedback is dependent upon when a manager wants to give it and often it is delivered poorly.

They unknowingly stop innovation

The manager dependent environments send subliminal messages about the difference in status between an employee and a manager. The message is “the manager is the parent and the employee is the child.” Naturally if you treat someone like a child it increases the probability they will act like one. Organizations need adults who are innovative not children who comply. The typical manage stifles risk taking and innovation because they are responsible for evaluating their employees. Manages are also evaluated by their managers and so on all the way to the top.
This hierarchy of criticism makes the reward for being truly creative small in comparison to the damage one mistake might make to a career or reputation. Furthermore, that mistake will go in the file and everyone who considers that employee for a future position will be able to read it and know how and why they messed up. This fear of failure, and the label the employee might carry, stops innovation in its tracks.
Managers are told to evaluate employees. They do it and unknowingly damage the very thing that could improve the organization’s competitive advantage.
They accidentally impede adaptability

Today increasing the capacity for change is necessary to match the the speed of change in the global economy. For example, just a few years ago Research in Motion dominated the cell phone market. Today they are dwarfed by Apple and Google. The ability to adapt is probably more important than ever before yet our managers accidentally slow the pace because they are focused more on themselves and less on the elements that create adaptability.
The war for talent contributes to this inability to adapt. Focus is given to improving the parts of the organization (the top talent) while the adaptability of the organization’s system suffers. In the war for talent managers compete with each other for attention and success. These intelligent individuals are often able to manipulate their own success while creating unintended negative results in another part of the organization, e.g. selling more than the operations can deliver or over promising to meet a performance goal. Usually the setting of numeric goals that must be achieved to receive either a pay for performance bonus or a “results oriented reputation” are the root causes of this behavior.
The focus by senior leadership on attracting and retaining talent can accidentally damage the organization’s ability to adapt because the focus is on those individuals and not on encouraging the cooperative effort to detect the subtle important changes that need to be made to continuously respond to changing customer needs and wants. Focus on the wrong things accidentally damages adaptability.

Summary

Managers are consistently rated poorly by employees and employee engagement scores are stalled. Why? It’s because managers are being asked to play a role that is irrelevant for the current needs of employees and the needs of the organization. The typical manager unintentionally damage engagement scores, stops creativity and prevents adaptability. Senior leaders need to recognize that the typical manager must be replaced with a facilitator who understands how to lead people to greatness while optimizing a system. Managers need to be supportive facilitators not bureaucratic overseers because bureaucratic overseers are now irrelevant.

Remedy? In short: Let corporate performance be based on an increased desire to understand the values of performance stakeholders (Customers, People, Society) and on the increasing ability to design concepts to be successfully introduced into the same. Let performance be measured on understanding the commercial, ethical and social responsibilities. Let financial remuneration be based on people’s actual competencies and management of the whole person, as well as their support of their organizations’ sustainable health.

This sounds straight forward and common sense.
It is relatively straightforward, but it is not common sense because it runs counter current wisdom on so many levels. However this change would go a long way towards a systematic cure of the current malaise and dramatically increase the sustainable performance of not only our financial institutions but our enterprises in general.

A “bundled payment” groups and coordinates all of the charges associated with a surgery and recovery together for one pre-negotiated price. This means an individual can quickly and easily understand their potential out-of-pocket costs before surgery and results in greatly reduced paperwork for all involved.

“Think of a bundled payment like a restaurant offering a complete meal for $20 deal,” said John Foley, regional vice president of Provider Engagement and Contracting for Anthem Blue Cross and Blue Shield in Wisconsin. “You know if you choose that option that you will get a great experience that you will get a great experience that includes an appetizer, entree and dessert, and you know what it’s going to cost before the bill hits your table. That’s a bundled payment.”

“The alternative is an a la carte meal, where each item you order goes on your bill separately. This can result in some surprises by the end of the meal — especially if the prices aren’t printed on the menu.”

Anthem Blue Cross and Blue Shield’s bundled payment agreements extend beyond the costs associated with the actual surgical procedure to also include recovery and rehabilitation services, such as physical therapy. Additional peace of mind and cost certainty is provided through a performance guarantee similar to a warranty.

“The purpose of these bundled payments is to deliver high quality care and a high quality experience to Anthem Blue Cross and Blue Shield members,” said Foley. “If any additional medical services are needed within 90 days of the surgery to make the procedure a complete success there is no additional cost to the patient, so long as they return to the doctor who performed the bundled procedure.

“This cost protection is completely unique to these bundled payments. In almost any other case, patients who undergo additional procedures would be subject to additional costs in the form of deductibles, coinsurance and copays, depending on their insurance policy.”

Bundled payments are reflective of a larger trend within health care that is working to align payments with the value of the care, rather than the volume of health care services delivered.

Here are common compensation mistakes to avoid:

• Neglecting to benchmark pay practices
• Failing to align all the organization’s goals
• Using limited pay-for-performance differentiation
• Not calibrating performance management data
• Avoiding transparency in the pay system
• Moving too quickly
• Failing to empower managers

When pay practices are not consistent, employees may feel that they are not compensated fairly. They may think their compensation is not reflective of their qualifications and performance level.  When it comes to pay for performance, there needs to be enough differentiation between pay increases among your top and poor performers.  If everyone is getting a 3% increase, often referred to as the “peanut butter” approach, then there is little incentive for employees to improve their performance.

- Javier Gonzalez, Research Associate

I am a member of a board of directors for a local non-profit charity.  A recent fund raiser attracted only 65% participation by the membership.  The last board meeting was dominated by an emotional discussion about how these are the same people who never fully participate in anything.  Some board members even suggested we should take action to encourage their removal them from the membership ranks.  Blaming these people was convenient for some of the board but I interpreted this problem differently.  I interpreted this as an opportunity to improve our leadership skills and the motivational environment of the non-profit.

Ask yourself; is the lack of participation a symptom or a root cause?  I believe it is mostly a symptom of poor leadership and not a reason to blame people.  Unfortunately, many leaders faced with poor participation, poor engagement, or poor performance will tend to go for the easy answer, i.e. command and control of people.  Although challenging problems call for sophisticated solutions, leaders often go for the easy answer with increasing regulations and/or using contingent reward systems to create compliance.  Forced compliance is not voluntary commitment.  These command and control policies cannot create commitment and leaders want voluntary commitment because that creates the highest levels of performance and creativity for an organization.

There are two reasons why leaders tend to blame the people when change is not embraced.  First, it’s easier.  Instead of looking at their own leadership techniques it’s easier to blame others for your own shortcomings.  Blaming others means you don’t have to take responsibility, work hard, and/or take a risk to solve a complex problem.  Secondly, we have been immersed in the command and control techniques all the way through school and very few of us really know anything else.

It is easier to blame others

If we are waiting for others to change we may have to wait forever but that is OK because it means we won’t have to make an effort to change.  Unfortunately, to be truly effective, leaders must change their behavior first before they can expect others to change.

Gandhi was once asked by a Mom to help her son to give up sugar for health reasons.  He thought for a moment and told her to come back in two weeks.  When she approached him after the two weeks was up he finally agreed to help.  She asked him why she had needed to wait.  He told her that he had to give up sugar first before he could be a credible source of influence for her son.

Leaders must take responsibility for the current policies and behaviors that they created if they want to make significant and long-term change to stick.  The policies of command and control often influence others to have poor behaviors and/or poor performance.  Leaders must accept responsibility for uncovering these hidden causes.  It is not an easy task.  It’s hard work and it requires a different understanding of the world.  This “different understanding” is not what most of us have been taught.  This brings us to the second reason leaders often blame others, i.e. we have been immersed in the command and control techniques.

We have been immersed in the command and control techniques

With the best of intentions we have been immersed in Frederick Taylor Scientific Management thinking.  Frederick Taylor Scientific Management helped organizations in the late 1800’s and early 1900’s to become more efficient by identifying the very best process to perform a job, breaking the job into small specific steps, and using pay-for-performance behavioral control techniques to force employees to comply with those specific steps.  This way of thinking has dominated our school system for 100 years.  We use standardized testing, grades, specific curriculum to control our children’s learning.

This command and control thinking no longer works well for us yet we remain immersed because it is all most of us know.  Unfortunately this way of thinking now longer works well.  The world has changed but our thinking continues to be the same.  We now find ourselves in the knowledge economy where require creativity, critical thinking, and problem solving skills and more important than ever.  These are not important in a command and control environment like Scientific Management.  Memorization and compliance is more important than freedom and creativity in the world of Frederick Taylor.   Even so, that theory is all most of us know.  Our schools are failing and our children continue to fall behind in these new skills because our system is set up to reinforce Frederick Taylor thinking.

Summary

If you are a leader and you see poor performance and/or poor participation in your change initiatives, please stop blaming people.   Blame won’t help you make improvements.   Look instead at how to create a motivating environment. Evaluate how you are thinking about people and problems.  Stop thinking that people are the root cause of these problems.  Instead, realize there are opportunities to think differently about change and to act differently as leaders.  Realize that these options will help people to become more enrolled in the changes you seek to make.

“Health data is no longer a government initiative. It is an American initiative.”  Such were the words spoken by U.S. Chief Technology Officer, Todd Park, at this week’s Health Datapalooza.  Organized by the Robert Wood Johnson Foundation, the California Healthcare Foundation and HHS, more than one hundred applications and websites, all powered by open data, took center stage at the exposition.

As Derek Newell,  CEO of Jiff,  illustrated in a recent Forbes article, mHealth has the ability to revolutionize healthcare delivery by providing the following:

• Improved access to care
• Improved patient engagement
• New provider of business models
• Reduced medicare fraud
• Improved patient safety

Absent Medicare fraud, I daresay that without patient engagement…the other four will likely fail in this business model. And while I applaud the pioneering  efforts of this growing movement, I also wonder what will it take for patients to truly embrace these applications?

One innovative solution, mRx, has been developed by Happtique, the first mobile health store for healthcare professionals by healthcare professionals.  Utilizing the mRx technology, physicians can ‘prescribe’ apps and send them directly to the patients’ mobile devices, thereby increasing the likelihood of download and implementation.

While drawing a causal relationship between patient and provider is critical, is it not equally important for the patient to be incentivized to adhere to the ‘prescribed therapy’?  According to Joanne Wu, MD, MPH, the answer is a resounding yes.  In her article, Rewarding Healthy Behaviors—Pay Patients for Performance, Dr. Wu asserts that rewarding clinicians in the form of pay-for-performance (P4P) has produced lackluster results due to the challenge of patient behavior modification.  Instead, she proposes that patients be rewarded for achieving evidence-based health goals.  Rewards would be issued in the form of discounts towards co-payments for doctor’s visits, procedures, and medications, thereby potentially reducing cost and compliance issues.

There is no denying that the efforts of the Healthcare Data Initiative Forum III, aka Healthcare Datapalooza, are  truly innovative.  And now that the data has been liberated, shouldn’t we be turning our attention to how it is being utilized?  While the definition of the provider role is changing, it remains the fulcrum for healthcare service delivery.  With  the development of certification and standardized processes, these tools could one day be required CME training for physicians, allied health and nursing personnel.  And only when the federal government and payers take an active role in the design of a payment system bearing incentives will we move mobile health to the next frontier by aligning patients, physicians, healthcare providers and payers.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

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The NCLB was a reinstatement of the Elementary and Secondary Education Act of 1965 initiated by President Johnson as part of his “war on poverty” policies.   We can conclude that we have had 47 years of standards-based education reform and it has failed 80% of the time.

Recently the Governor of CT doubled down on standards based education reform with his own version of this type of legislation.  He even added an extra bell and whistle by including mandatory performance evaluations for teachers.  This too will fail miserably just as previous versions have failed for nearly 47 years.

It’s time we moved away from standard-based education.  It’s time we moved to a system that allows students to freely develop their passion with teachers who are facilitators of learning and not the “shovels” of facts into the brains of our children for the purpose of memorization and test scores.  We must stop forcing every child to comply with the same curriculum at the same time with the same grades.  It’s costly and dysfunctional.  Isn’t 47 years of failure enough time?  No Child Left Behind should be renamed the 80% failure.

What makes leaders to continue to embrace dysfunctional policies that damage performance?  It’s their defective beliefs that cause them to make the same mistakes over and over at our expense and at the expense of our children’s future.

I submit there are three beliefs that cause our leaders to continue to embrace failed policies.  Beliefs are hard to change but I think it’s time we examine these to question their validity.  I ask you to examine your own beliefs and I hope you will be willing to be open to a change.  Without this a re-examination we might all continue our dysfunction.

People must be held accountable to measurable goals

Leaders who think people need to be held accountable to measurable goals believe people by nature are basically lazy.  Goals don’t create performance success.  Effective and efficient processes create performance.   The reason the performance standards in our schools are not being met is not because of a lack of effort or laziness.  It’s because the policies and processes are flawed.  These flawed processes and policies are based on the false belief that people are naturally lazy.  The belief creates polices that damage natural motivation and therefore the belief becomes manifested in reality.

Managers must evaluate employees (teachers)

Evaluating and improving the parts of a system will not improve the performance of the system.  It’s the quality of the interactions between the parts that improve the performance of the overall system.

I recently rented a very expensive car just for fun.  It started to rain. I looked for the windshield wipers and couldn’t find the control for a good minute.  I nearly had to pull to the side of the road to find the control.   Although the control worked fine, and was obviously of very high quality, the interaction between it and me (the driver) was more important for safety and function of the car than the quality of the unit.

Having talented individuals in the organization is not enough for predictable performance.  Talent means little if the quality of the interactions between the individuals is poor.  Evaluating individuals is also much less important, if not irrelevant, to the functioning of the overall system.  Quality interactions will contribute more to the performance of the whole than talented individuals.  It’s always a team effort and the team members are interdependent.

People need performance pay to be motivated

Money is not a motivator.  It is best to pay people enough money so they forget about pay and focus on improving their processes and their interactions.   This strategy is the only way to generate predictable profitability and customer loyalty.

Beliefs are hard to change but I think it’s time we examine these to question their validity.  Defective beliefs cause leaders to make defective decisions.  These defective decisions will take the form of a policy or procedure that will eventually fail.  I ask you to examine these three beliefs.  Do you embrace them?  If so, please just do a little more study.  There is a good deal of evidence that these defective beliefs cause unintended consequences and poor performance. Contact me if you want to know where to find the research.

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Yan Feng, Ada Ma, Shelley Farrar and Matt Sutton

Research Paper

“In April 2006, payment thresholds were raised for GPs who participate in Scotland’s Ouality and Outcomes Framework.  GPs were required to meet new, higher thresholds on some indicators to receive maximum levels of payment.  In this paper, OHE’s Yan Feng and her colleagues examine whether this change in fact improved GP performance and whether the impact differed across GPs. Specifically, they examine whether low-, mid- and high-performing GPs changed behaviour and, if so, to what extent.”

Perhaps you don’t believe my rating data.  Perhaps you think your leadership is effective.  If so, consider this additional data.  According to Watson and Wyatt only 39% of employees trust their senior leadership; only 31% of employees rate internal communication effective at their companies; only 52% of employees can see the connection between their jobs and the company strategy; only 25% of employees think their rewards system is effective; only 29% of employees are considered fully engaged.  According to Bersin Associates, only 18% of mid-level leaders and only 37% of senior leaders are rated excellent by their direct reports.  I could go on.

We all know the typical definition of insanity namely, doing the same thing over and over again and expecting a different result.  Although this definition is memorable I offer a different definition from the dictionary: foolishness or lack of good judgment.  I believe many leaders are acting foolishly with their actions and decisions about policies that no longer make any sense.  I believe there are the three major conditions that cause this insanity.

An inability or unwillingness to understand and appreciate “Systems Thinking”

Systems’ thinking is the art of looking at the world as a whole and avoiding the analysis of the parts.  A system is a set of interdependent processes that work together cooperatively to achieve an aim.  We have not been taught effectively how to think deeply about systems.  Our public schools systems are competitive and attempt to improve the parts of that system (the students and/or the teachers).  Our organizations search for talent as if that talent exists separately from the whole and will create organizational success just by being present.

Systems’ thinking requires a focus on the quality of the interactions between the parts of the system and avoids evaluation of the performance of the parts.  Systems’ thinking takes into account how the system can impact the performance of that individual when looking for solutions to problems. Systems’ thinking requires a synthesis of parts and not a separation of them.  It helps answer questions about why people behave the way they do and not just analyze what and how they do it.

Leaders today tend to ignore systems’ thinking and this hurts their ability to solve problems quickly and for good.  This lack of effective problem solving hurts their leadership ratings making them look foolish.

An inability or unwillingness to understand and improve trust

I believe every organization must understand how to continuously improve trust.  Trust is the oil in the pistons of innovation, performance, and adaptation to change. A lack of trust results in fear, poor learning, an inability to adapt, and stagnation in improvement.

In their book Credibility: How Leaders Gain and Lose It, Why People Demand It, James Kouses and Barry Posner describe the key characteristics of a credible leader.  They list the top four characteristics as honesty, the ability to be forward-looking, the ability to inspire others to action, and the ability to be competent. These top four characteristics were chosen by up to 87% of the 1,500 survey respondents who were asked to define the characteristics crucial to leadership.

Coincidently, there is an alignment between these four characteristics and the four elements of trust included in the International Association of Business Communicators definition of trust.  The IABC define trust as the willingness to be vulnerable with another due to the presence of integrity (honesty), concern and respect (inspiration), shared objectives (inspiration and the ability to be forward looking), and competence (ability to be competent).

Leaders lack credibility and this is why they receive low ratings from their followers.  Managing the key elements of credibility and trust would provide improvement and healing.  This lack of focus on the key elements of trust causes followers to mistrust their leaders and make them appear foolish.

A senseless and foolish embrace of the past

Frederick Taylor’s Scientific Management influenced everyone’s belief system about management.  His beliefs about people and work are still embraced today and we can see examples in our school systems and organizations.  Unfortunately, his beliefs, and the controlling policies that follow from them, have reached their limit in their ability to improve productivity and performance in the knowledge age.  Taylor methods do not create employee engagement and that is one reason why we are doing so poorly on that front.

Many leaders (if not most) still embrace policies and practices that are consistent with Frederick Taylor Scientific Management thinking.  Contingent pay for performance and the typical performance management system are examples of those policies.  These polices prevent employee engagement and act as barriers to improving leadership credibility.  These policies place leaders in a dominating position over employees.  They rob employees of autonomy and create victims.  Victims will not rate leaders highly.  Victims will not willingly follow leaders because they feel controlled.  Victims are created in environments of leadership insanity.

Healing our leadership insanity is essential to our future success.  We can’t continue to be led by foolish and senseless policies and procedures and expect a significant improvement in results.  To heal we must acknowledge our insanity and shift our focus and our behaviors.

We are seeking survey responses from those engaged in the management and administration of or who are members of such physician organizations as IPAs, PHOs and MSOs.

For your participation in this brief survey, we will send you free an executive summary of the analyzed results.

What are the ‘looming’ challenges? Any opportunities? What is the most pressing concern from your perspective?

The survey only takes a few moments. You do not have to identify yourself if you choose.

As you know, survey results are reported in the Managed Care Information Center reports, in our Managed Care Weekly Watch, as well as the MCIC Blog, Facebook and Twitter and are posted at our website.

To participate in this survey, go click on this link now: http://bit.ly/JhFn9o

If you are connected with executives of members of PHOs, IPA or MSOs, please let them know about this survey.