A camel is a horse designed by committee

I was reading an article in the Financial Times this morning that referred to an old proverb that I have not heard in a while - "a camel is a horse designed by committee."  I think the proverb is trying to say that a committee isn't very effective at making decisions and coming up with unique and innovative ideas.  Committees, by virtue of the fact that they are made up of several members, each with different perspectives, viewpoints, and preferences, have a difficult time reaching consensus.  Their logic is fragmented, flawed, and prone to failure.  So, as the saying goes, if a committee set off to design a four-legged animal that was strong enough to pull a heavy load (for example, a wagon), smart enough to follow directions, and fast enough to carry a rider from one village to another in a reasonable amount of time, they would come up with something that looks like a camel, as opposed to a horse.

In this particular case, the proverb is actually a quote (supposedly) by Sir Alec Issigonis.  Issigonis was a highly innovative automobile designer who is known for the design and development of the Mini.  Clearly, Issigonis felt that most committees, at least in regards to innovation and design, were completely useless.

What can we say about the camel, though?  Is a camel really that useless?  Actually, the camel is perfectly designed for the harsh desert climate of the Sahara Desert.  When I was young, I was led to believe that camels stored water in their humps - this is actually not true.  The hump is actually where the camel stores its fat.  This particular adaptation allows the camel to withstand the hot temperatures of the desert climate.  Fat is a perfect insulator - if the camel's fat stores were distributed evenly all over its body, they would not be able to withstand the hot desert temperatures for very long.  The camel's thick coat of hair protects it from the intense sun in the desert.  The camel's intestines are able to absorb water much better than most mammals, and similarly, the camel's kidneys are able to conserve water and excrete a concentrated urine.  The camel's long eyelashes and ear hair prevents sand from irritating the eyes and ears.  Camels also apparently have a transparent third eyelid to further protect the eyes from blowing sand.  Finally, camels do not sweat.  In other words, a camel is perfectly designed for its primary purpose, just like a horse is perfectly designed for its primary purpose.

So, are committees good at innovation or not?  I happen to believe that the diverse membership of most committees is an asset, not a liability.  Different backgrounds, viewpoints, opinions, and perspectives create environments that foster innovation.  Moreover, team diversity is much less susceptible to something known as "groupthink" (more about groupthink in a later post), where members of the committee come to a consensus too early on a solution or design that is not necessarily the best.

Different personalities and experiences can, at times, be challenging to manage.  However, in the long run, if a team or committee is led by someone who creates an environment that encourages different viewpoints while at the same time pushing the team to come to a consensus, we end up with the best of both worlds - a highly innovative group that forms a consensus in a reasonable amount of time.  In other words, we end up with a committee or team that is perfectly designed for its primary purpose - we get a camel if we are in a desert and a horse if we are anywhere else!

Peace on Earth, Good will to all.

I have been reading the Horatio Hornblower series by C.S. Forester.  There are eleven books which tell the story of Horatio Hornblower, a fictional Royal Navy officer during the Napoleonic Wars.  The Hornblower series is actually the second book series that I have enjoyed about the British Navy during that era - I have also read Patrick O'Brian's Aubrey-Maturin series (the 2003 movie, Master and Commander: The Far Side of the World, starring Russell Crowe and Paul Bettany was partially based on three of the Aubrey-Maturin novels).  What has impressed me about both of these book series is the fact that whenever an opposing ship is captured, the officers hand over their swords to the victors and pledge not to fight or try to escape.  In many cases, the captured officers are left free to wander around either the ship (if still at sea) or the countryside (if captured near shore).  War was apparently vastly different during the Napoleonic Wars compared to today, and perhaps "honor" was more meaningful and more significant.


I am reminded of an event that I first learned about while watching a Paul McCartney video for his song, called Pipes of Peace.  The setting of the video is the Western Front, 1914 (World War I).  On December 25, 1914, French, German, and British soldiers crawled out of their trenches, crossed "No Man's Land," and joined together to celebrate Christmas.  They exchanged food and souvenirs, sang carols, played football (soccer), and drank a toast to peace.  Christmas brought out the best of humankind on that day.  After several months of grueling, hand-to-hand combat, in the middle of the "War to End All Wars," there was peace.  Men who merely hours earlier were killing one another, joined hands, broke bread together, and enjoyed a few quiet moments on Christmas.  On that Christmas night, the guns were silent, bringing special meaning to the Christmas carol, "Silent Night" that they sang.


How beautiful would it be to have a peace like that on this Christmas Day?  It is difficult, if not impossible, to imagine a similar scenario occurring in these times.  But I still have a hope and belief that peace on Earth is within our reach.  World peace must start with peace here at home.  World peace must start with compassion and good will to all, no matter what gender, sexual orientation, race, ethnicity, or religious background.  World peace must start with all of us, here and now, joining together as a community in the common bonds of humankind.  "And now these three remain: Faith, hope, and love.  But the greatest of these is love." (1 Corinthians 13:13)  


World peace will only come if we open our hearts to everyone.  Merry Christmas.  Peace on Earth and Good will to All.

Do women make better physicians?

My oldest daughter tells a story that she remembers when she was younger.  Her sisters and brother were playing with their cousins at my parents' house over summer vacation - the boys all wanted to play "army."  They had built a fort in the basement, complete with an army field hospital!  The "field hospital" was a small tent, complete with one of my old toy doctor's kit mixed with some of my old medical instruments.  My oldest nephew (who happens to be the oldest cousin) told my daughter and her sisters to go into the tent, "You can't be soldiers.  You are the nurses."  My daughter responded that she wanted to be the doctor!

I am old enough to remember that male nurses were once exceedingly uncommon.  Thankfully, that has changed.  While I still think that female nurses outnumber male nurses, my impression is that the gap is closing.  I am also old enough to remember when female physicians were not very common either.  Thankfully, that has changed.  In fact, nearly half of all medical students starting medical school this year will be female.  In my own field of pediatrics, there are more female pediatricians graduating from residency training programs than there are male pediatricians.  Even in the traditionally male-dominated field of surgery, there are more females becoming surgeons (even though males still outnumber females).  It is a trend that is long overdue.

Why is this important?  Well for one, I think that medical profession should reflect the greater society as a whole.  Patients generally want to be treated by physicians who are like them.  More interesting to me are the studies showing that female physicians spend more time listening to their patients, ask more questions about their patients' overall well-being (focusing on healing the mind, body, AND spirit), and encourage more shared decisionmaking.  Female physicians are also more likely to follow clinical guidelines and order preventive tests compared to their male counterparts.  All of this is very interesting.  However, just last week, a large retrospective study of over 1.5 million Medicare beneficiaries over age 65 years admitted to the hospital over a three year period from 2011-2014, showed that patients treated by female physicians had a significantly lower 30-day mortality rate compared to those treated by male physicians.  These differences persisted even after controlling for 8 specific medical conditions and adjusting for severity of illness.  While this is a retrospective study, it is the first study of its kind to show that some of the differences in care between female and male physicians discussed above appear to matter! 

There are probably two major lessons here.  First, we should NEVER discount the ability of our female colleagues to practice excellent medicine.  Female physicians are not only good doctors, they may even be better doctors than males!  Second, we should try to learn what things that female physicians are doing to provide better care - and then model that behavior!  I think many physicians entered the profession of medicine to take care of patients.  Most physicians would like to spend more time with their patients.  The data discussed here potentially suggests that we, as health care administrators, should figure out how to foster these behaviors and how to provide ample time for physicians to actually listen to their patients.

I mentioned this study to my daughter just the other night.  It turns out that she had already heard of the study.  I think she was going to call her cousin and let him know about it as well!

Stop. Point, and Cross

A few months ago, I had the opportunity to tour the Toyota Motor Manufacturing Kentucky, Inc. (TMMK) plant in Georgetown, Kentucky.  Toyota builds the Lexus ES350, Avalon, and Camry at this plant.  TMMK is Toyota's largest automobile manufacturing plant in North America - the plant itself covers over 7.5 million square feet (that's about 156 football fields, according to the website) and is staffed by over 7,000 employees.  The Toyota team builds nearly 2,000 vehicles every day!  The tour is completely free to the public - it is a popular field trip destination for local schools. 

I was very impressed with the amount of traffic inside the plant!  Employees and managers were either walking around or riding on bicycles, golf carts, or forklifts.  Our tour was riding around on a long tram.  The intersections were as busy as any intersection in America!  As the tour guide stated in his introduction to the plant, safety is the main priority at this plant.  He specifically asked us to look out for employees when they came to an intersection.  Look for the employee to "Stop, Point, and Cross."  Every time a worker came to an intersection, he or she would stop, look both ways, point in the direction that he or she was going to move, and then cross the intersection.  What impressed me the most was that the workers did this each and every time.  Every time I looked, they did it!  It was so in-grained that they didn't stop to think about NOT doing it.

I started thinking to myself - health care is so very different.  We can never quite reach above 90% on our handwashing compliance - at either our hospital or even throughout our industry.  What is Toyota doing that every worker universally and without fail, "stops, points, and crosses"?  Why can't we get this same level of compliance in health care when it comes to handwashing? Several of us on the tour noticed this level of compliance and asked the same question.  My only response is that the culture is very different, perhaps, at TMMK.  I later found out that workers are incentivized (or in some cases, penalized) for complying with this particular safety initiative.  However, I don't think that is quite sufficient.  There is something deeper there.  Several hospitals that I know use employee incentives to encourage compliance with handwashing - yet, compliance is never quite 100% (and in some cases, it is actually far lower than 100%).  It has to be the culture at Toyota!  It has simply become an expectation of everyone who works at the plant.

How do we build this kind of culture in healthcare?  I suspect that Toyota started by being relentless about their "Stop, Point, and Cross" initiative.  Employees were accountable not only to themselves, but also for their fellow employees (something that has been called "200% accountability").  Whenever someone forgot to "stop, point, and cross" - they were called out for not doing so.  How many times in the hospital does a physician get "called out" by another physician or a bedside nurse for not washing his or her hands?  We simply need to do better.  We need to make handwashing automatic, just as TMMK did for "Stop, Point, and Cross."  But it all starts with culture.

Successful Successions (or not)

There has been a lot of talk about transitions lately.  The peaceful turnover of power from one President to the next is one of the hallmarks of our democracy, and regardless of which side of the political fence you spend your time on, this time should be no different.  Coincidentally, I happened to have a meeting just yesterday with some members from Human Resources about succession planning.    Succession planning happened to start the day I first stepped into my new administrative role about 18 months ago.  Was I nervous?  After all, here I was just starting in a new position, and I was already being asked to identify a few individuals who could replace me and under what circumstances they could do so.  In full disclosure, I wasn't nervous at all - in fact, I view succession planning as a key part of what leaders should be doing.  Why wouldn't you want to assure that the work that you started and the culture that you have helped build on your team continue after you are no longer in the position?  Succession planning is not only the right thing to do, even on day one of your job, but it is also a key part of talent management, which every leader should view as his or her responsibility.


So all of this talk about leadership transitions and succession planning got me thinking.  Has their ever been an example of a "good" transition of Presidential leadership in which the previous President hands off to one of his (unfortunately, we have still yet to have a "her" as President) hand-picked successor, one that he has played a major role in developing and placing in a position to be successful?  Well.... I started with our first President, George Washington.  He certainly handed off power to another member of his party (the Federalist Party), but even if you believe that John Adams was a successful President (and I do believe that), one could certainly argue that he wasn't necessarily "developed" or mentored by President Washington.  In fact, John Adams was famously said to have described the Vice Presidency as "the most insignificant office that ever the invention of man contrived or his imagination conceived."  Okay, strike one.  How about one of Franklin D. Roosevelt's (FDR) Vice Presidents?  John Nance Gardner, who served as FDR's Vice President from 1933 to 1941 was once quoted as saying, "The vice-presidency isn't worth a pitcher of warm piss."  Ouch.  Not really what I would call a ringing endorsement.  Strike two.  What about Harry Truman?  He was FDR's Vice President in 1945, but he only became President of the United States after FDR died in office (actually, he only was Vice President for 82 days!), so he doesn't really count.  But we could say that Truman was fairly successful.  Let's skip ahead a few Presidents to George H.W. Bush.  He served as Vice President for two full terms under President Ronald Reagan, but as much as I hate to admit it (when I was in the Navy, all I heard was what an incredibly nice, friendly man President Bush was), Bush 41's presidency was not all that successful either.  Strike three.


So, it would seem that succession planning plays no major role in arguably the most important office in the world!  Very disappointing.  How about in the sports world?  I like sports analogies, and I think there is a lot that we can learn from successful sports teams.  The quarterback position is one of the most important positions on any football team - we often hear of NFL teams drafting quarterbacks out of college and then having them sit on the bench to learn from the coaches and be mentored by the veteran quarterback.  Once the younger quarterback has had time to develop, the veteran quarterback steps aside and continues to mentor and coach the quarterback from the sideline.  Sounds great, right?  Succession planning at its finest!  But again, as I think about some of the great quarterbacks, even if they "mentored" younger quarterbacks for a few years (think Joe Montana and Steve Young, or Brett Favre and Aaron Rogers), the veteran quarterback usually leaves the team to go play somewhere else, rather than sitting on the bench to watch the younger quarterback play.


But absolutely my all-time favorite succession story (in this case, perhaps not altogether successful, but certainly not a failure either) from the sports world comes from the Tour de France!  Greg LeMond was the first, and after the last two Americans - Floyd Landis and Lance Armstrong were declared ineligible due to doping violations - the only American to ever win this grueling bicycling race.  Greg LeMond was a promising cyclist, finishing first in the 1983 World Road Racing Championships and third in the 1984 Tour de France, recruited by Bernard Hinault ("The Badger") to race for his Team La Vie Claire in the 1985 Tour.  Hinault was chasing history by trying to win his fifth Tour de France (only three other men have won five Tours - Jacques Anquetil, Eddy Merckx, and Miguel Indurain) and needed strong riders on his team to help him win (in bicycle road racing, there is usually one rider who is the designated team leader - everyone else on the team rides to help the leader win).  Hinault convinced LeMond to join him, partly by promising that he would work just as hard for LeMond the following year as a member of his team (they would, in essence, switch roles).  Again, succession planning perhaps as it is designed to work! 

During the 1985 Tour, Hinault had trouble and fell behind.  At one point (I remember watching this live on television), LeMond found himself in a position where he could easily have taken the race lead and worn the vaunted Yellow Jersey for one day.  The Team Director told him that he must not do this - he was riding for Hinault and not for himself.  LeMond agreed (very reluctantly, I might add) and Hinault eventually won his fifth Tour.  Hinault again publicly promised that he would ride as hard for LeMond the following year as LeMond had done for him at the 1985 Tour.  Well, to make a long blog post a little shorter, I will summarize the 1986 Tour.  LeMond won his first Tour de France and the Badger came in second.  Hinault had challenged LeMond throughout the race, and to many it seemed as if he was actually trying to win the race.  Hinault later claimed that he was only pushing LeMond so that he would win.  So, maybe this example still meets our definition of successful succession planning?

Unfortunately, I don't have a lot of great examples of successful successions from either the sporting world or from our nation's Presidential history (at least today - maybe in a future blog post!).  Suffice it to say that I still think succession planning is absolutely vital to an organization's success.  Succession planning is an important aspect of talent management, and it assures a safe, effective transition of leadership for the future. 

Peeling away the layers of the onion - "first principles thinking"

I like metaphors and similes.  When I was younger, some of my favorite stories were myths, fables, legends, and folk tales.  The common thread in all of these stories was the so-called "moral of the story" - lessons that we, the readers, could learn from the characters in the stories on how to act, how to respond to challenges in life, how to relate to others, and what to do in certain situations.  I am still a big believer in the power of stories to teach and to learn.  We often learn in this manner - cognitive psychologists would call this method of instruction, "analogous learning." 

A recent blog post from Michael Roberto called my attention to a completely different way of thinking.  As it turns out, the great innovator and entrepreneur, Elon Musk (of PayPal, Space X, Tesla Motors, and SolarCity fame), believes that we should spend more time learning from a method called first principles thinking as opposed to analogous learning.  First principles are basic, foundational, and self-evident ideas, propositions, or assumptions that cannot be deduced from other ideas or principles.  In mathematics and physics, first principles are known as axioms or postulates.  Conceptually, first principles come from the writings and teachings of the Greek philosopher, Aristotle.  Aristotle defined a "first principle" as "the first basis from which a thing is known."  In philosophy, first principles are "a priori" rather than "a posteriori" (they are simply assumed to exist, without question).

First principles thinking involves de-constructing an idea to its simplest elements or the fundamental truths.  Once you are there, you can develop your ideas more fully and reach an entirely different plane of understanding.  "First principles" thinking forces us to "think outside the box" and develop new and different ways to attack a particular problem.  There is a famous quote by Henry Ford (whether he actually said it or not is not known for certain) that I believe illustrates what happens when we get stuck in traditional modes of thinking.  Ford said, "If I had asked people what they wanted, they would have said faster horses."  Ford was a "first principles" kind of thinker, which allowed him to step "outside the box" and improve upon the design of the early automobile.

All good - but it is difficult to get away from analogous learning.  I even found an online article that uses an analogy to explain first principles thinking!  The article described the process of de-constructing an idea down to its first principles as if you were peeling away the layers of an onion.  The heart of the onion is the first principle.  The first question you ask peels away the outermost layer of the onion - and you keep asking "why?" (i.e. peeling away another layer) until you reach the inner core of the onion.  Only then have you found the first principle!

FDR's "Day of Infamy" Speech

Today is the 75th Anniversary of the surprise attack on Pearl Harbor.  On December 8, President Franklin D. Roosevelt stood before a joint session of the United States Congress and requested a formal declaration of war.  We remember all of those who gave their lives on that fateful day 75 years ago and during all of the days of war that followed thereafter.

Below is the text of the speech that President Roosevelt gave, now known as the "Day of Infamy" speech.  During times of crisis, leaders lead. 

Vice President, and Mr. Speaker, and Members of the Senate and House of Representatives:

Yesterday, December 7, 1941—a date which will live in infamy—the United States of America was suddenly and deliberately attacked by naval and air forces of the Empire of Japan.

The United States was at peace with that Nation and, at the solicitation of Japan, was still in conversation with its Government and its Emperor looking toward the maintenance of peace in the Pacific. Indeed, one hour after Japanese air squadrons had commenced bombing in the American Island of Oahu, the Japanese Ambassador to the United States and his colleague delivered to our Secretary of State a formal reply to a recent American message. And while this reply stated that it seemed useless to continue the existing diplomatic negotiations, it contained no threat or hint of war or of armed attack.

It will be recorded that the distance of Hawaii from Japan makes it obvious that the attack was deliberately planned many days or even weeks ago. During the intervening time the Japanese Government has deliberately sought to deceive the United States by false statements and expressions of hope for continued peace.

The attack yesterday on the Hawaiian Islands has caused severe damage to American naval and military forces. I regret to tell you that very many American lives have been lost. In addition American ships have been reported torpedoed on the high seas between San Francisco and Honolulu.

Yesterday the Japanese Government also launched an attack against Malaya.

Last night Japanese forces attacked Hong Kong.

Last night Japanese forces attacked Guam.

Last night Japanese forces attacked the Philippine Islands.

Last night the Japanese attacked Wake Island. And this morning the Japanese attacked Midway Island.

Japan has, therefore, undertaken a surprise offensive extending throughout the Pacific area. The facts of yesterday and today speak for themselves. The people of the United States have already formed their opinions and well understand the implications to the very life and safety of our Nation.

As Commander in Chief of the Army and Navy I have directed that all measures be taken for our defense.

But always will our whole Nation remember the character of the onslaught against us.
No matter how long it may take us to overcome this premeditated invasion, the American people in their righteous might will win through to absolute victory. I believe that I interpret the will of the Congress and of the people when I assert that we will not only defend ourselves to the uttermost but will make it very certain that this form of treachery shall never again endanger us.

Hostilities exist. There is no blinking at the fact that our people, our territory, and our interests are in grave danger.

With confidence in our armed forces—with the unbounding determination of our people—we will gain the inevitable triumph- so help us God.

I ask that the Congress declare that since the unprovoked and dastardly attack by Japan on Sunday, December 7, 1941, a state of war has existed between the United States and the Japanese Empire.

HRO: Deference to Expertise

I recently picked up an old book about the game of chess the other day.  I never really was all that good at chess, but I have always wanted to be better.    It really is an amazing game and is much more complex than most people think.  I was talking to my son (who is a much better player than me) who suggested that I learn about some of the classic opening moves.  Standardization has been on my mind a lot lately, and I thought perhaps I could develop a few "standard opening move" sequences, depending upon the moves that the other player made in response.  Perhaps I could even develop a playbook of sorts - if my opponent does this, then I should do this in response.  So I actually started to right down some possibilities in a small notebook.  This was going to be great!  I was finally going to be able to play chess like the pro's!  However, while I was doing some research on the Internet (looking for tips and pointers), I came across an article that stated there are 20 possible opening chess moves (16 possible pawn moves plus 4 possible knight moves - the rest of the pieces can't be moved until one of the pawns has moved out of the way) for the first player, the White player.  Similarly, White's opponent (the Black player) also has 20 possible opening moves.  Once Black has moved, White is now faced with 400 possible moves.  Once White has moved a second time, the Black player has 5,362 possible moves.  After that, the numbers get really out of hand (see the calculation here).  In other words, even if I did want to write down all the possible moves, I would need more than just one notebook!  I would probably need an entire library of notebooks.  There is just simply no way to be able to follow a specific kind of algorithm that takes into account every possible contingency.  As much as I would like to plan out all my possible moves in a "chess playbook," it is just not possible.

High reliability organizations (HROs) have already figured this out.  It would be really great if the leadership team of a HRO could script out the desired response for every single contingency that the rest of the organization could face in the future.  Unfortunately, just like in my game of chess, it is just not possible to cover every possible contingency.  The very nature of the environments that HROs exist in precludes any kind of script, checklist, or playbook that covers every possible issue.  So how do HROs deal with this issue?  They push decision making, especially in times of crisis, as much as possible to the frontline leaders and managers.  The true experts - the individuals who know their systems the best - are found on the frontlines and not in the board room!  Moreover, there is no way that an executive leader can have a full understanding of all the information that is at the frontline.  Even with the best communication plans and systems, the individuals who will have the most up-to-date and most accurate information will be the ones on the frontline.  The military has a term for the rapidly evolving, chaotic, confusing, and unpredictable nature of combat known as the "fog of war."  I think this concept applies to what most HROs deal with on a daily basis!  As a famous Marine Corps general once said, "Once the shooting starts, all plans fall apart."

The military has developed a variation on the "deference to expertise" theme known as "commander's intent" (based upon an earlier concept developed by the German military during the early days of World War II, called "auftragstaktik").  Frontline leaders (who are usually far removed from their commanding officers) are provided with a set of orders and instructions that describe the overall goals and objectives of a particular mission, the tactics and strategy that will be used, and the resources that will be immediately available.  In other words, the frontline leaders are given a rough blueprint of the battle plan and are then told to go and complete the mission.  "Commander's intent" is a really beautiful example of the last defining characteristic of a high reliability organization - "deference to expertise."

I am not against standardization in health care - in fact, I think we need to standardize, as much as possible, as many key processes that lend themselves to standardization.  Used in such a manner, standardization can and will improve outcomes and reduce costs.  However, I do think that we need to be careful not to over-script and over-plan for every possibility - there is just no feasible way to do that.  We would be much better off taking a cue from the military ("commander's intent") and other HROs, who leverage their frontline experts as much as possible.  Do these frontline leaders have specific and detailed instructions?  Yes - absolutely.  Do these frontline leaders have guidelines and guardrails within which they are free to make decisions?  They sure do.  Developing these concepts will require education and training - over and over and over again.  It is the right kind of investment to make though, and it will make a significant difference for our patients.  For now, I guess I better go back to learning more about the different kinds of chess moves and practice, practice, practice!