"Is this another April Fool's joke?"

"The story you are about to here is real.  The names have been changed to protect the innocent..."  All joking aside, this is not another April Fool's story.  During my research for my recent post on Goodhart's Law, I came across a story that sounded a lot like an April Fool's joke.  They say that anyone who believes everything that is posted on the Internet is a fool - but this is Wikipedia after all!  Everything on Wikipedia is true, right? 

As it turns out, there was a link on the Wikipedia page for Goodhart's Law that referred me to a page on Campbell's Law (very similar concept - I discussed this one in my post as well).  I decided to look up more information on Campbell's Law and was referred to a Wikipedia page on the so-called "Cobra effect".  The "Cobra effect" is basically another name for something that is called the "Law of Unintended Consequences."  As the story goes, during the British colonial rule of India, there was a big problem with cobras - they were killing a lot of people.  The British government decided to control the cobra population (smart administrators that they were) by offering a bounty for each dead cobra that was brought to the local authorities.  What a great way to encourage the local population to take matters into their own hands, right?  Well, unfortunately, the plan backfired.  The local entrepreneurs started breeding cobras so that they could turn more cobras in to the government authorities and make a nice profit!  The government caught on fairly quickly and abandoned the program.  The entrepreneurs released the cobras that were bred in captivity into the wild - and the cobra population increased to even higher numbers than before the program started! 

The Wikipedia page on the "Cobra effect" also mentions the "Rat effect."  The time and place this time was the country of Vietnam under French colonial rule.  The French government wanted to control the local rat population and offered a bounty for each rat tail that the locals brought in to the authorities (thinking that to get the rat tail, the rat would have to be killed).  Again, in this particular case, the locals would cut of the tail and release the rat - the rat would then be free to breed and further increase the rat population (more tails = more money). 

I don't know if these stories are true or not.  However, I am reminded of a similar story that seems beyond belief, but I know it to be true.  I was stationed at the Naval Hospital in Guam right after my pediatrics residency training.  Guam is known for a lot of things.  For example, Guam is home to the largest Kmart store in the world - it's true, look it up!  The citizens of Guam are the number 1 per capita consumers of Spam in the world (also true).  But did you know that there are more snakes on Guam than there are humans?  At some point during World War II, a supply ship brought (by accident and unbeknownst to the crew and local authorities) the Brown Tree Snake from Papua New Guinea to Guam.  The Brown Tree Snake is venomous - the Brown Tree Snake does not have fangs like a rattlesnake.  It injects its venom by chewing repetitively on its victim (similar to the North American Coral snake).  The Brown Tree Snake has no local predator - it completely wiped out Guam's indigenous bird population (there are no exotic birds on Guam!).  The snake is also responsible for very frequent power outages, and the local authorities are always concerned about snakes "sneaking aboard" another ship or plane and wreaking havoc on the bird population of another island, such as Hawaii.  Well, to make a long story short, there have been a lot of outlandish schemes to try to control (or even eliminate) the Brown Tree Snake population.  The strangest that I have heard so far?  Apparently the over-the-counter medication, acetaminophen is highly poisonous to the snake.  The U.S. military apparently placed pellets of acetaminophen into dead mice, attached parachutes to the mice, and dropped the mice by plane over the jungle canopy with the hopes that the mice will get caught in the trees, where they will be ingested by the snakes.  Sounds like a crazy, far-fetched April Fool's joke, but it is completely true (look it up or just read the article here.  I can't imagine what the "Law of Unintended Consequences" would have to say about this one, but I guess we will just have to wait and see.

The moral of the story for today - beware the "unintended consequences." 

National Doctor's Day

Happy National Doctor's Day!

National Doctor’s Day is celebrated every year on March 30^th.  The first Doctor’s Day was observed more than 90 years ago, on March 30, 1933 by the Alliance to the Barrow County Medical Society in Winder, Georgia (for those of you who don’t know Georgia geography, Winder is a small town located east of Atlanta).  Members of the Alliance to the Barrow County Medical Society selected the date to honor all physicians on the anniversary of Dr. Crawford W. Long’s first administration of anesthesia in 1842 (Dr. Long used ether during surgery to remove a tumor from the neck of James Venable) in the following resolution:

 

WHEREAS the Alliance to the Barrow County Medical Society wishes to pay lasting tribute to the Doctors, therefore, be it RESOLVED by the Alliance to the Barrow County Medical that March 30, the day that famous Georgian Dr. Crawford W. Long first used ether anesthesia in surgery, be adopted as "Doctors' Day," the object to be the well-being and honor of the profession, its observance demanding some act of kindness, gift or tribute in remembrance of the Doctors.

 

The first Doctor’s Day was observed by sending cards to all the physicians and their spouses, and a red carnation flower was placed on the graves of deceased doctors.  Through a series of resolutions in the years that followed, Doctor’s Day was widely celebrated throughout the southern United States, with sponsorship by the Southern Medical Association.  Eventually, a resolution was adopted and approved by both the U.S. House of Representatives and the U.S. Senate on October 30, 1990 and signed by President George H.W. Bush, designating March 30 as “National Doctor’s Day” in the following resolution:

 

WHEREAS society owes a debt of gratitude to physicians for the contributions of physicians in enlarging the reservoir of scientific knowledge increasing the number of scientific tools, and expanding the ability of health professionals to use the knowledge and tools effectively in the never ending fight against disease and,

 

WHEREAS society owes a debt of gratitude to physicians for the sympathy and compassion of physicians in ministering to the sick and in alleviating human suffering: Now, therefore, be it

 

Resolved by the Senate and House of Representatives of the United States of America in Congress assembled, That;

 

1. March 30, 1991, is designated as "National Doctors' Day"; and
2. the President is authorized and requested to issue a proclamation calling on the people of the United States to observe the day with appropriate programs, ceremonies and activities.

The red carnation remains as the symbol of Doctor’s Day. 


To all Doctor's - thank you for what you do, each and every day!

Dealing with the Divos and Divas

The urban dictionary defines a "diva" as a female that "has to have her way exactly, or not at all."  The male version of a "diva" is called a "divo."  But that is not really what I wanted to talk about.  I am reading a book on two of my favorite subjects - history and the American Civil War - by the author and historian, Douglas Southall Freeman.  Freeman wrote multi-volume biographies of Robert E. Lee and George Washington, both of which won him a Pulitzer Prize.  He also wrote an accompanying three-volume history to the biography on Lee, entitled "Lee's Lieutenants: A Study in Command."  I just started the first volume, and I was struck by how much time President Jefferson Davis and Robert E. Lee (he was the senior military advisor to Jefferson Davis during the first year of the American Civil War and only later rose to fame as the General of the Army of Northern Virginia) spent massaging the egos of the various Civil War generals.  During the first year of the war, various military leaders in the Confederate Army argued back and forth about who was senior to who, both on the battlefield (at times with disastrous consequences) and while in camp.  There were several instances in which one General would refuse to carry out an order until it was verified by either Lee or Davis that the order came from them and not some other General.  I am finding the book very interesting, as I had never realized that some of the troubles experienced by President Abraham Lincoln with his generals (there was a long succession of "divo" generals before U.S. Grant took over, most of which translated to a long succession of losses on the battlefield) were also experienced on the other side.  Personalities clashed, egos were bruised, and tantrums were thrown, on both sides apparently.

While reading about these "divo" generals, I can't help but recall similar experiences that I have had over the years.  How do you deal with members of your team with big egos?  There is no question that ego can get in the way of success - just look at some of the most talented sports teams that have fizzled over the years.  I remember my own beloved 2004-2005 Indiana Pacers basketball team.  The team was loaded with personalities (some would call it "charisma") and talent (led by Reggie Miller, Jermaine O'Neal, Ron Artest, and Stephen Jackson) and was highly favored to win the Eastern Conference.  And then there was the brawl with the fans in Detroit ("Malice at the Palace"), which resulted in the suspension of several of the Pacers players for the rest of the season.  The team never recovered and went on to finish the year as the sixth best team in the Eastern Conference, losing to the Detroit Pistons in the second round of the play-offs.  There are many, many more examples, and not just in the world of sports.

So how do you deal with the divos and divas on your team?  The Harvard Business Review has published several articles that I have found helpful in this regard.  John Baldoni wrote an article "Managing Big Egos so the Entire Team Wins" and offers three key recommendations.  First, leverage the power of big goals ("nothing motivates talent like a big goal.").  Second, encourage spirited (but respectful) competition between the various egos on the team (Baldoni says to "rub egos together").  Third, make sure that the goals of the team supersede those of the individual.  Finally, when all else has failed, respectfully ask the person with the ego to find another team. 

Baldoni makes some great points.  I would add a few more.  First, at least in my experience, the individuals with the biggest egos like to be recognized, rewarded, and praised too.  I think at times that we tend to neglect praise for our superstars.  We can praise the so-called divos and divas without creating problems for the other members of the team, as long as we do it consistently and equitably.  Second, and maybe tangentially related to Baldoni's recommendation to leverage big goals, superstar talents like to be challenged.  If they insist on being treated special, acquiesce by giving them a challenging assignment ("I am giving you this assignment, because I know you will do a great job.").  Lastly, I think it is a good idea to sit down with the superstar separately and have a heart-to-heart discussion on what your expectations as the team leader are and what behaviors will just not be tolerated.  Do this in a respectful way, ideally before the rest of the team starts working together.  Establish the ground rules, and explain how you would like to leverage the superstar's talent and expertise to accomplish your shared goals. 

I am by no means an expert in this area.  I expect no one really is - especially if Abraham Lincoln had difficulty dealing with his "divo" generals (and apparently Robert E. Lee did too).  And like just about everything, a little bit of knowledge and lots of practice will do wonders in the end. 

Forced Ranking - Goodhart's Law redux?

In my last post, I talked about Goodhart's Law (and a related concept, known as Campbell's Law).  In essence, both Goodhart's Law and Campbell's Law say the same thing (Goodhart's Law was first described in economics, specifically in monetary policy, while Campbell's Law comes from the social sciences) - once an organization starts to use a quality measure as a target, the measure ceases to be useful as an indicator of quality.  As I stated in reply to a comment to my original post, I think part of the explanation for Goodhart's Law is that when we tie individual metrics to some kind of incentive, whether it is monetary (e.g., pay-for-performance) or something else (e.g., college ranking in the annual U.S. News and World Report), we have essentially substituted extrinsic motivation for intrinsic motivation.  Extrinsic motivation tends to "crowd out" intrinsic motivation - in other words, by linking achievement of a certain level on a quality measure with some kind of reward, such as a pay bonus or recognition by an external agency, we have discouraged employees from doing something because it is the right thing to do (doing good for its own sake). 

Several years ago, the legendary management guru, Jack Welch started to use a technique known as forced ranking at General Electric, Co.  Forced ranking is a management technique in which managers rank individual employees every year based on their performance.  Fair enough so far, correct?  The top 20% of employees are the "A group", the middle 70% of employees are the "B group", and the bottom 10% of employees are the "C group."  Importantly, the C group employees may actually be good employees who are achieving performance targets every quarter; however, they still rank at the bottom of the organization in terms of their performance.  Jack Welch was a strong advocate for providing financial rewards, praise, and recognition of the "A group" employees, while "B group" employees were provided with coaching and mentorship.  Welch often said of the "C group" employees, "They have to go."  By ranking employees, Welch and others believed that employees would compete with each other and the organization as a whole would benefit. 

Even if forced ranking is not followed exactly as Jack Welch originally described, we see certain elements of it in almost every performance management system used today.  For example, many organizations use the "Fails to meet expectations," "Meets expectations," and "Exceeds expectations" in their performance management system, which is essentially ranking employees by whether or not they achieve certain performance metrics.  Moreover, in some cases, forcing managers to rank employees is a way to address "grade inflation" with performance ratings.  For example, when I was in the Navy, a simple five-point scale was used to rate every sailor in approximately five to six categories.  Even though a "3" was equal to "average" or "meets expectations", getting a "3" was essentially a career killer.  Hence, most commanding officers gave a lot of 4's and 5's, and if a sailor was up for promotion, a "5" was absolutely essential (and usually provided, as long as the individual was a hard worker and motivated to excel). 

Forced ranking certainly has its supporters - there are definite advantages, but in many cases, these are outweighed by the significant disadvantages!  Think of how difficult it would be every year to have to terminate your bottom performers!  What forced ranking is saying is that the "C group" employees aren't even worth the effort to try to rehabilitate or "coach up" to the "B group."  While some level of competition is okay, the kind of cut-throat competition that many companies that used forced ranking was counterproductive in the end.  Think of how competitive pre-med students are and you will have a good idea of what I am talking about.  Teamwork, at least the kind of teamwork that is necessary in today's environment, just doesn't happen when employees are competing this much with each other.  Finally, by linking promotion (and termination) with performance, forced ranking has essentially created the conditions described by both Goodhart's Law and Campbell's Law.  By making a performance evaluation a target to achieve for each individual employee, the performance evaluation has ceased to be useful as a measure of the quality of an individual employee's work production. 

It is no wonder that a number of organizations (including, by the way, General Electric, Co.) that previously used forced ranking have stopped using this management technique.  For all intents and purposes, forced ranking, at least in the form that Welch described, has fallen out of favor.  However, as I mentioned above, we still have some vestiges of forced ranking with most of our current performance management systems, especially when they use classifications such as "Meets expectations" or "Exceeds expectations."  Goodhart's Law would suggest that even this simple classification should not be used.  Maybe Goodhart was right...

Your quality measure is no longer useful!

I came across an interesting concept the other day called "Goodhart's Law" that states, "When a measure becomes a target, it ceases to be a good measure."  The economist, Charles Goodhart, first described the concept in 1975, stating more technically that "Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes."  While originally applied to monetary policy, Goodhart's Law has now been applied in a number of different contexts.  Let me give a few examples. 

The "quality" of an academic journal today depends upon its so-called Impact Factor, which is essentially the average number of journal citations in a given year divided by the total number of articles published in the journal during the same period.  In other words, more citations for articles published in the journal lead to a higher Impact Factor, which increases the journal's credibility and importance.  Investigators who publish their scientific articles in journals with high Impact Factors are more successful at getting promoted and have a greater chance of receiving grant funding for investigators.  In other words, a journal's Impact Factor has become a quality target.  Given the importance that academic institutions and grant funding agencies place on journal Impact Factors, journals with higher Impact Factors often receive a greater number of high-quality manuscript submissions from prestigious investigators.  Publishers therefore are motivated to do what they can to increase their journal's Impact Factor.  I have heard of some journals that encourage (in some cases, require) investigators to cite other articles from the journal when they submit a manuscript.  Investigators often cite their own articles or encourage their colleagues to cite their articles to increase the number of citations for their articles.  The journal Impact Factor, which was originally designed to serve as a measure of the quality of a journal's publications, has become a target (the publisher's goal is to increase the journal's Impact Factor).  Once the quality measure becomes a target, investigators and the journal itself can try to "game the system" to "help" increase the journal's Impact Factor.  In other words, the Impact Factor as a measure of quality has become useless and irrelevant.

High school seniors who want to go to college are required to take either the SAT or ACT during the admissions process.  A higher SAT or ACT score is required at more prestigious colleges.  Similarly, colleges with higher average SAT scores or ACT scores for their admitted students are generally perceived as "better colleges" to apply to by high school students.  The original intent was to use the SAT or ACT score as a measure of the "quality" of the student.  The quality measure, however, has become a target.  There is an entire industry of ACT and SAT preparation classes, books, practice examinations, and private tutors that high school seniors use in order to increase the chances of getting a higher score on their test.  In addition, colleges often use a method called "superscoring" to report the average SAT and ACT score of their admitted freshman class.  "Superscoring" essentially means that the college uses the best parts of the SAT or ACT score (for example, the Verbal and Math scores of the SAT), even if the scores were from different testing dates (most high school seniors take the test multiple times to get their best score).  Again, due to gaming of the system, the SAT and ACT score has become essentially useless as a measure of quality.

As a last example, think of customer satisfaction scores in any of a number of different industries.  How many times have you been told by a retail salesperson or customer service representative that "We strive for perfect tens on our customer satisfaction surveys, and if I get all tens, I get a bonus!"?  Customer satisfaction scores were designed to be used as measures of the quality of customer service.  However, companies use higher customer satisfaction scores as targets or goals.  Again, once something has become a target, it ceases to be relevant as a measure of quality.

How often do we see examples of Goodhart's Law in health care?  Several years ago, the rate of ventilator-associated pneumonias (VAP) was used by a number of organizations as a measure of the quality of care received in the Intensive Care Unit (ICU).  Insurance organizations started lowering reimbursement (i.e. penalizing) hospitals with higher than average rates of VAP, while increasing bonus payments to hospitals with lower than average rates of VAP in their ICUs.  Once the VAP rate became a target, hospitals were encouraged to work on lowering the rate of VAP in the ICU through quality improvement techniques and safety initiatives.  I know of some ICU Medical Directors who would "argue" to try to downgrade the classification of a VAP to something that didn't quite meet the definition of a VAP.  In my own institution, we observed a significant decrease (near-elimination) of VAP with a concomitant increase in the incidence of ventilator-associated tracheobronchitis (widely considered a precursor condition of VAP - these patients do not meet all of the defining criteria for VAP).  I suspect that the work directed at VAP created conditions in which patients that previously would have developed a VAP now developed tracheobronchitis (notably the risk factors and pathogens were exactly the same between the two conditions).  However, I can't say with 100% confidence that the way we classified cases as either VAP or VAT (the defining criteria are notoriously poor and highly subjective) was always right either.  Our quality metric became a performance goal, and from that moment ceased to be relevant as a marker of quality.  Incidentally, several organizations have dropped VAP as a quality measure altogether.

Goodhart's Law states simply that once a quality measure becomes a performance goal, especially if there are incentives to reaching that performance goal (money, prestige, or promotion), the measure is no longer relevant as a quality measure.  There are a number of regulatory agencies and government organizations who would like to use market forces to improve health care delivery.  As an example, so-called "pay for performance" (P4P) programs are being tested to determine whether monetary incentives can lead to improvement in specific performance metrics.  Charles Goodhart would tell us to be very careful here.  Perhaps quality measures should just be left alone and used for their original intended purpose - as a measure of quality and not as a performance goal or objective.

"The problem with airlines is..."

Well, we made it back from Switzerland last night (see last blog post for details on the trip "We are more alike my friends...").  We flew on an airline that I usually don't fly, for multiple reasons (Reason #1 - I have a frequent flyer account built up on another airline; Reason #2 - I have had multiple issues with this particular airline in the past; Reason #3 - I happen to like the airline that I usually fly).  Well, the airline, which shall remain nameless for the moment, did not fail to disappoint.  They met my very low expectations yet again.  One member of our family got to the airport in Zurich and didn't even have a ticket to go home (the airline canceled the return flight when we had to re-schedule our flight to Switzerland due to the blizzard in the Northeast last week).  Luckily she did end up getting on to the plane without too much trouble.  We were late pulling away from the gate because they had to search and remove some baggage from another party that missed their connection and were not on the flight.  Once that was squared away, the auxiliary power gave out and had to be repaired and inspected (never mind that the airplane we were flying on was built well before the turn of the century!).  We ended up leaving an hour late, which meant that two of us had to race through customs and immigration, baggage (which took forever!), and TSA to get to our gate, just in the nick of time.  It turns out that two other members of our party had issues with their connecting flights as well.  What a mess.  I guess we did all make it home, and we all got our baggage - so not a complete failure.

Why am I blogging about all of this?  Well, as it turns out, there were two things that really struck me as pertinent to hospital operations.  First, my daughter mentioned to me while we were sitting on the tarmac in Zurich, "Do you think maybe they should have known about a failure in auxiliary power long before the moment that they were getting ready to pull away from the gate?"  She was absolutely correct - shouldn't this have been something that they picked up during their initial pre-flight checklist?  I don't know too much about planes, but "auxiliary power" sounds pretty important.  You would hope that a failure in a system of this level of importance would be identified much earlier than right before pulling away from the gate.  I hear of cases all the time at hospitals in which pre-procedural time-outs are not followed, either because the physicians are too busy or the procedure is being performed emergently.  We have checklists for a reason - they are there for exactly the times when we are rushed because we are busy or the procedure is emergent.  Things like a failure in "auxiliary power" should not happen with airplanes, and pre-procedural time-outs should never be skipped because we are too busy.

Second, when we landed in New York's John F. Kennedy International Airport over 60 minutes later than expected, we were greeted by airline representatives dressed in purple jackets (the flight attendants told everyone as we were getting off the plane to talk to the "people in the purple jackets" if you have a connecting flight).  Those people in the purple jackets had our connecting information and a bright orange card that said "Express Security" with our connecting gate information and a back-up plane ticket if we missed our connecting flight.  We essentially were taken to the head of the line for customs and immigration and for TSA, and the individuals told us exactly how to get to our next gate and how long we had.  My first impression was, "Wow, what great service recovery."  Again, one of my daughters commented, "They really have this down - it must happen all the time!"  She was absolutely right!  The airline had developed a complete work-around for something that should be a rare occasion (a late flight).  Do not get me wrong, no airline is perfect.  We should never hold an airline accountable for bad weather (case in point - the recent blizzard that hit the Northeast United States last week causing a number of flight delays and cancellations).  We should not expect that airlines will be on time 100% of the time.  However, when you are late so many times that you develop a work-around system for service recovery, I think that is a problem.  How many times do hospital staff develop and perform a work-around for something that shouldn't be allowed to happen?  It happens more than it should, and that's a problem for two reasons.  When hospital staff develop work-around processes, they usually fail to notify anyone of the problem that necessitated the work-around in the first place, so no learning occurs and the problem never gets fixed.  In addition, work-around processes are usually slower and less efficient than how a process should work, which compounds inefficiency and can lead to additional problems down the line.  We shouldn't need "people in purple jackets" in our airports or our hospitals!

I am amazed again on how much there is to learn through simple observation of other industries outside of health care - both the good, as well as the bad.  We have learned a lot from commercial aviation, and our hospitals are safer as a result.  But there are some things that we should never learn from the aviation industry, and yesterday gave me two clear examples of what not to do in health care.

"We are more alike my friends..."

I am visiting Bern, Switzerland this week - I was honored to speak at the 12th European Postgraduate Course in Neonatal and Pediatric Intensive Care Medicine.  The blizzard in the northeastern part of the U.S. caused us to change our travel plans somewhat, so we actually flew into Geneva and took a train to Bern.  The Swiss countryside is absolutely beautiful, and the city of Bern is amazing.  Anyway, we did some sightseeing today, and I was struck by the fact that despite our differences, we are really not that much different.  There are some amazing things in Bern that I wish our country would adopt (free public transit for one), and the Swiss health care system really is great.  Our cultures are different, but I was reminded again how great people can be to one another.  I am certain that we stick out like sore thumbs ("silly Americans" is our running joke), but the people here have been wonderfully helpful, kind, and gracious.  I wish our respective governments were like that - there really is so much that we can learn from each other, if we would only take the time to do so. 

This week, I was reminded again that our diversity is truly a gift.  Teams that bring together different personalities, as well as different areas of expertise, knowledge, and skills generally are much more successful than teams that are made up of individuals with the same background, personality, and skillset.  If "teamwork makes the dream work" is really true, then it is only when we have diversity in our teams.  There is a great series of articles in this month's Harvard Business Review called "The new science of team chemistry" that delves into this issue further.  As it turns out, the management consultant company, Deloitte, analyzed personality data from over 20,000 individuals, both working inside and outside their company, and determined that there are four different personality types that are prevalent in any organization - Pioneers, Drivers, Integrators, and Guardians.  Teams that are well-balanced with individuals from these four groups are less susceptible to groupthink, though the authors are careful to point out and emphasize that leading these four different personality types takes some skill and forethought.  Again, when left with a choice between a diverse team and a similar, uniform team, give me the diversity. 

Finally, my trip to Switzerland reminded me again of another poem by Maya Angelou called the "Human Family".  Apple recently used the poem in one of their commercials, which I think was played for the first time in this year's Super Bowl.  It really is a great poem, and I think it solidifies my thinking on diversity.  Our diversity does make us stronger, but in reality, "we are more alike, my friends, than we are unalike."