The Popovich Effect

Every year, at least for the last several years, before the start of the new NBA season, Nate Silver and his team at FiveThirtyEight analyze the statistics for every player on each team and run a series of simulations (over 10,000 simulations of the entire NBA season schedule) to come up with a projected win-loss record.  The 2014 NBA Preview "The Rise of the Warriors" revealed something very interesting.  They went a little further into the statistics and analyzed all of the NBA coaches' wins above expectation, by career, from 1980-2014 (consider some of the names of the coaches during this period of time - Phil Jackson, George Karl, Don Nelson, Pat Riley, just to name a few - the list is pretty impressive).  However, one coach stood out among all the rest - Gregg Popovich from the San Antonio Spurs.  Over the course of his career, Coach Popovich beat the computer's predicted wins by 117 wins over his 18 seasons with the Spurs.  His wins above expectation beat out second-ranked George Karl by 33 wins and nearly 62 more wins than legendary coach Phil Jackson.  In other words, Coach Popovich's teams always seem to do far better than what everyone expects (well, perhaps most people now expect that the Spurs will perform better than expected).  Here is the graphic from the 538 article:



Pretty amazing, right?!?!?


How does Coach Popovich do it, every year?  How does he get the most out of his players?  It's not through fear or intimidation.  Don't get me wrong, Coach Popovich has his moments (at referees, at his own players, and at post-game press conferences).  He does it through strong leadership.  Just take a listen to some of the things his players have said about his leadership style (see here and here and here for the original articles):


"He has the ability to keep egos in check by running a fair system that any professional athlete can respect.  His willingness to confront his star players as he would his role players.  It sends a balanced message to all." [from former player, Samaki Walker]


"He's not afraid to say what he believes and stand by it.  He genuinely cares about his players.  It's more than basketball." [from former player Malik Rose]


"He doesn't believe in having a superstar and having one person greater than the whole." [from Spurs superfan Spurs Jesus]


"You know where you stand with Pop.  He treats everyone equal." [from former player, Speedy Claxton]


"A lot of coaches can yell or be nice, but what Pop does is different.  He delivers two things over and over: he'll tell you the truth, with no BS, and then he'll love you to death." [from Assistant Coach, Chip Engelland]


"Hug 'em and hold 'em.  We gotta hug 'em and hold 'em." [from Coach Popovich himself]


In a word - he values his players.  All of them.  Not just the superstars.  And not just for their skills on the basketball court.  He values what they do their whole life.  He takes a genuine interest in them personally and professionally.  He cares.  His coaching is built on mutual respect, passion for life and the game of basketball, and 100% commitment to his team and their mission.  There's a lot we can learn from Coach Popovich. 

Make it stick

One of our pediatric cardiologists just ran a marathon in Montana.  I bring this up because this just happened to be the last state in the U.S. he needed to run a marathon in to complete his goal of running a marathon in all 50 states!  Pretty amazing!  I asked him the other day if he was going to go for all of the U.S. territories too - he laughed and responded that he was thinking about hitting all 7 continents next.  Good luck!

There is no question that running a marathon takes a lot of hard work, commitment, and dedication.  Perhaps most importantly, you have to really like running (I mean, really like it!).  Over the last few years, I have really started to enjoy running.  It's a nice getaway and provides time for me to just think.  Unfortunately, I have been dealing with an Achilles issue the last several months, so I haven't been running at all.  So, I have been walking instead.  A few weeks ago, my wife convinced me that I should start swimming again.  I was on my high school swimming team (I wasn't very good) and played club water polo in college for a couple of years.  Over the years, I have periodically gone back to swimming as my form of exercise.  And, just like running, swimming laps in a pool gives me some time to think.

Except for the last couple of weeks, all I can think about when I swim is my two high school swim team coaches.  I keep hearing their voices, telling me to "Finish your stroke!" or "Keep that elbow up!"  It's like they are coaching me through every stroke.  Swimming is all about technique.  Swim with bad technique and you are swimming slow and inefficiently.  Swim with good technique, and you will swim much faster and use less energy per stroke.  Technique was important, so our coaches used to really work hard with us to improve our technique.  We did stroke drills every single practice.

No matter how hard I try to get their voices out of my head and think about something else, I just can't do it.  It's almost as if I were back in high school during one of the many early morning swimming practices.  The memories are so vivid and real to me.  Why, after all of these years, have these memories stuck with me?  Both of our coaches were great mentors.  It didn't matter whether you were the best swimmer on the team or the worst one - they both would spend time with all of us, making sure that each of us got their best coaching.  They cared very deeply for each and every one of us.  I remember having to hand over my report card to my coach as soon as I received it - my coach saw it before my parents did!  Luckily I never had trouble in school, but my coaches would always ask about how I was doing and if I thought I could be doing better in one or two of my classes.

The reason I remember their coaching so vividly after all of these years?  Easy - they made it stick.  They were both great coaches because of the things that they taught - not just about swimming and swimming technique, but about life in general.  Taking care of yourself, working hard, being a good teammate, committing to something greater than yourself.  I remembered all of these things, because my two coaches made their lessons stick.  The two business writers (and brothers), Chip and Dan Heath wrote a book called Made to Stick that talks a lot "stickiness" as a concept, which was first raised by Malcolm Gladwell in his book, The Tipping Point.  The Heath brothers use an acronym (SUCCESS with the last "S" omitted) to describe how to make an idea or concept "stick":

• Simple – find the core of any idea
• Unexpected – grab people's attention by surprising them
• Concrete – make sure an idea can be grasped and remembered later
• Credible – give an idea believability
• Emotional – help people see the importance of an idea
• Stories – empower people to use an idea through narrative

As I look over these characteristics, I can maybe see some parallels with how my two swim coaches used to coach us.  However, what I think was perhaps most important was that they made all of us feel valued.  They both thought it was important to coach each of us to the best of their ability.  They gave each of us their all.  They had that ability to make us all feel that we were the most important swimmer on the team, even if we weren't.  And because we felt valued, we gave 100% back.

Leaders can certainly learn a lot about "stickiness" from Mr. Gladwell and the Heath brothers.  And, if you happen to read both of these books, I guarantee that you will be glad that you did and that you will take away something that can help you be a better leader.  But the most important thing (at least in my opinion) about stickiness was not mentioned, at least explicitly, by either Gladwell or the Heath brothers.  The one thing that a leader can do to make his or her team give their all - the kind of effort that is required to run a marathon in all 50 states or to remember the lessons taught by your high school swim coach almost 30 years later - is to make the individuals on the team feel valued.  That's it.  That's what makes it stick.

The cost(s) of quality

First things first.  I have a couple of confessions to make.  I love quality improvement and what it has done for health care.  Quality improvement changed my entire professional life.  There was a time in my early career that I stated rather emphatically that I would NEVER go into administration (in fact, one of the reasons that I left the Navy is that promotion, at least as a pediatrician, didn't seem very likely unless you had some significant administrative role).  One of my mentors encouraged me to give administration a try (he asked me to be the Associate Medical Director of our PICU) and convinced me to take one of our internal quality improvement training courses.  Nine weeks later, I was hooked!  And my career changed tacks, I found out that I really enjoy health care administration, and the rest as they say is history.


Okay, here's why I made my confession.  I recently came across a paper published in the Joint Commission Journal on Quality and Patient Safety entitled "The Cost of Quality: An Academic Health Center's Annual Costs for its Quality and Patient Safety Infrastructure".  Basically, one academic health center investigated how much money they spent on an annual basis to maintain its quality and safety infrastructure.  For the purposes of their analysis, they included all of the costs associated with regulatory compliance, hospital accreditation, licensing, credentialing and privileging, maintenance of certification, data collection and analysis for quality/benchmark measures and public reporting, and improvement (which included training clinical staff on improvement science).  What these investigators found is astounding (but in reality, not that surprising) - this particular academic health center spends $30 million on direct costs to maintain their quality infrastructure every year!  The majority of these costs (actually, 82%) were associated with mandates by regulatory bodies, accreditors (such as the Joint Commission), and payers.  Close to half of these costs supported efforts for public reporting on required measures.


I would add that all of these things - regulatory compliance, accreditation, licensing, public reporting, etc - have significantly contributed to the unbelievably rapid growth in the number of health care administrators (compared to the growth in the number of physicians, as a proxy for the actual providers of health care).  You've seen the graph, but here it is again:





There is no question that the administrative costs associated with billing, payer relations, utilization review, compliance have also contributed to the growth in the number of administrators (as well as the cost of health care in general).  However, there's more to this story.  There is an online search engine called Google Ngram Viewer that can chart the frequency of any set of search terms using a yearly count of N-grams (basically, think of n-gram as a string of words for this example).  Google Ngram Viewer searches all of the printed sources of text published between the year 1500 and 2008 and plots the frequency in which the designated N-gram appears.  I played around with the program and searched for the terms "metrics", "benchmarks", and "performance indicators":





Okay, that looks a little like the graph above.  But here is what I found when I searched for the string "quality improvement":



This particular graph looks eerily similar to the first graph above.  In other words, the growth in the number of health care administrators over time mirrors (fairly closely) the increase in frequency of the number of mentions for "quality improvement," and to some extent, "benchmark", "performance indicator", and "metric" in the available published literature!  It is tempting to speculate, then, that some of the costs of quality are attributed to the labor costs for having individuals to collect data and report it to regulatory and accreditation agencies, as well as building the quality infrastructure to try to improve care.  Again, in the aforementioned study, the salary and benefit costs for the number of FTE's engaged in quality and safety activities actually accounted for nearly 90% of the direct costs (i.e., the $30 million per year) for quality and safety activities paid every year by the academic health center.


I know what you are thinking - and you are right!  Holy cow! 


I would argue that some of this is our own fault.  Let me explain.  The United States spends far more on health care compared to countries such as Australia, Canada, France, Germany, Japan, and the United Kingdom (actually, we spend almost twice what these other countries spend).  Health care spending in the U.S. approached $3.3 trillion in 2016, which is roughly equivalent to $10,348 per person (see Hartman M et al. Health Affairs, 2018; 37:150-160).  At the current rate of growth, total spending on health care in the U.S. will reach 20% of the overall economy by the year 2026 (see Cuckler et al. Health Affairs, 2018; 37:482-492).  Unfortunately, despite spending almost twice the amount that other countries spend, the U.S. fares much worse on typical quality outcome measures, such as life expectancy and infant mortality (one argument is that we spend our money in the wrong place - for example, see the excellent book, The American Health Care Paradox: Why Spending More is Getting Us Less by Elizabeth Bradley and Lauren Taylor).  However, part of the impetus for the quality improvement, regulatory compliance, public reporting, etc (i.e. all of the things that the academic health center in the aforementioned study spends $30 million on per year) was the relatively poor performance of the U.S. health care system compared to other countries. 


So, what are we to conclude by all of this?  First, I think that investing in quality and safety is certainly an appropriate and (hopefully) worthwhile investment for a hospital.  The impetus is on us to demonstrate that this investment translates to improvements in quality and safety, and to some extent, I think we have done and are doing just that.  Second, I think we need to separate out or distinguish in some way the amount of money that is spent on actually improving quality and safety (for example, training clinical providers on quality improvement methodology) from all of the money spent on forced regulatory, accreditation, and public reporting requirements.  I get it - some of the regulatory and public reporting things theoretically could lead to improved outcomes, but I think we need to establish that link.  Third, if we are going to put a magnifying glass on health care expenses in general, we absolutely have to include the administrative costs in that analysis.  Do all of these regulatory requirements and administrative fees associated with insurance really make our health care system better, in terms of improved outcomes?


I am 100% in favor of quality and safety efforts.  I just think we need to be cognizant of the associated costs and make sure we are reaping the appropriate benefits.  We owe it to our patients to improve the care that we deliver, but we also owe it to them to do so at the lowest possible cost.  Right now, we are probably not accomplishing that objective.