www.33voices.

com

REAL HEALTH CARE REFORM: WILL PHYSICIANS CHANGE? ( Unplugged)

A conversation between Jim Champy & Moe Abdou
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

About Jim Champy & Moe Abdou

Jim Champy

A leading authority on the management issues surrounding business

reengineering, organizational change, and corporate renewal, Jim
Champy is also the author of the 3 million-copy international best-seller,
Reengineering the Corporation: A Manifesto for Business Revolution, as
well as Reengineering Management, X-engineering the Corporation, The
Arc of Ambition, and Fast Forward.

Moe Abdou

Moe Abdou is the creator of 33voices — a global conversation about things

that matter in business and in life. moe@33voices.com

33voices.com 1
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

As you know this is typically one of my favorite half hours. To have the
opportunity to speak with you because not only do you get my mind
stimulated and inspired but more importantly, I love your writing style. I
love the way that you not only give practical advice but give really great
examples.

This particular topic Jim, I have to just start by asking you what inspired
you to tackle this issue?

I had been thinking about tackling this issue for a long while, certainly, all of
the political debate. The debate that was going on around healthcare reform
caused me to want to really address the issue from what I think is a different
perspective and a different lens than our government. At least our political
forces were thinking about it. I really felt in all of the debate and discussion
around healthcare reform, there is not enough reality being paid to and enough
attention being paid. To what was really going to get the cost of healthcare
down and to get the quality and safety of healthcare improved although people
debating healthcare would always mention cost and safety.

Nobody was really paying attention to how it was going to get done. Actually, I
consider that a pretty dangerous condition because we put in place in our
legislation which I think we would had to put in place in order to cover all of
the uninsured. We've done it I think with some degree of naiveté about what
it's going to take to really get the job done. It's a long answer to your question
but that's what inspired to me to what to write this book, answering the hard
questions.

You did tackle it from a completely different perspective. I know that even
to the naked eye, the problems in healthcare are countless. How did you
and Dr. Greenspun start to break down the problems to boil it down to the
final product that you guys put out?

Harry has been a practitioner in healthcare for many years; very thoughtful and
very engaged in the application of information technology to healthcare,
particularly the adoption of the electronic healthcare record. Harry and I just
stepped back and said, alright what is it going to take to fundamentally rethink
the delivery of care?

That's what this book is about. This is about how to change the delivery
processes of care. But I've known from my past work that you just can't change
the processes. That is, you just can't change the work that people do, the work

33voices.com 2
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

processes that people do without paying attention to the skills and the
behaviors of the people and whose work you're changing.

Also, that in healthcare, one of the great enablers of healthcare change is

information technology. So Harry and I built a construct for this book that said,
look, in order to change the delivery of care, you need to focus on people,
process, and technology — those three elements.

By the way, if you don't cover all of those elements, we're not going to succeed
in changing how healthcare is delivered but that was the basic construct of the
book. This is about changing people, process and technology in healthcare.

Let's talk about those three issues. Let's start with people. You give
fabulous examples of people. I mean, early in the book, I think it was in
the second chapter where you talk about Zeev's model for transformation
and what he did to the Lenox Hospital. Throughout the book you talk about
some amazing examples.

Can you address this whole issue of people? Is it the examples of the type
of work that he's done? Is that what you're referencing?

First, what we're referencing around people is the issue of what I would call,
the culture of conditions in healthcare delivery. One of the big issues for me in
starting to write this book was whether the ideas of reengineering which are,
as you know, a process in work ideas that come out of business. I have
developed with my camera these ideas almost 20 years ago. Whether these
ideas could be applied to healthcare. Whether clinicians would listen to these
ideas. Whether they would be open to changing their behaviors.

The good news was that I found many examples. Again, when we write about
them in the book, of clinicians being open to change when we demonstrate to
the clinicians, to the doctor, or to the nurse, that there is actually a better
way to do work. They can do more good by doing work in one way versus
another way.

So my first question around people was answered. Will people adopt these new
methods of delivering care and will they change their behaviors? The
resounding answer so far is yes, although not easy. It's not easy to convince
clinicians that they should change the way they do their work.

Secondly, around people, what we found and this has always been the case,
that it's possible to change the behaviors of people but sometimes you just

33voices.com 3
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

have the wrong person in the job. We have a wonderful rich example in the
book, I don't know if you recall it of Novant Health. This is the organization
that actually got pharmacists to do a lot more useful work from my
perspective. And really help elderly patients once they had returned to their
homes after having been hospitalized.

One of the glaring examples early on in the book was this whole notion of
communication. How he went in and discovered that there was a broken
link — take us through that a little bit because on the surface, it seems so
little. But yet, it's magnified dramatically.

Absolutely. It's often the case when you're reengineering your process or
changing work that you get through the change and you say, “Wow, doesn't
that look simple? Why didn't we think of that?” Communication is like that.

It's Zev Neuwirth, I think you're talking about. Zev is a master at designing
change in his organization. What he first recognized was that there wasn't a
level of trust between clinicians, particularly clinicians and their own
administrative staff. There wasn't a level of respect and a level of trust. He
really worked and focused on what I would call the social engagement in order
to get people to first trust each other and to appreciate the skills and talents
of each other.

But then he began a very simple program of communication. I think very simple
programs of communication and actually integration. I mean, one of the things
that his organization did was that there had been breakdowns in
communication and workflows between orthopedic surgeons and radiologists.

You know, a person comes in with a broken bone or a strained ligament or

something. What an orthopedic surgeon does of course is send them off to
radiology; let's take an x-ray or an MRI. There were long delays in getting the
information back and there were slow downs and their work, from time to
time, just breakdowns.

What Zev's organization did was simply relocate the two organizations. Kind of
put them next to each to other, took down the walls so there could be active
negotiations between the staff of the orthopedic surgery department and the
staff of the radiology department. Now, every morning, those staffs hold a
joint meeting to talk about the work load of the day and how they're going to
manage the day; very simple techniques, very, very simple techniques.

33voices.com 4
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

Some people look at reengineering and say, “Wow, it looks frightening.”

Oftentimes, it's a very simple solution that's required to dramatically improve
the performance of an organization.

When you observed his work, Zev's work in particular, and you walk into
the hospital to the place that he was at, can you sense the difference? Can
you sense that leadership compared to some of the other institutions that
you guys have observed?

Absolutely. I actually had the opportunity to visit one of the redesign meetings
of Zev's teams inside his own organization. Actually, Zev's organization is a
very, very large physicians' practice organization. By the way, it's got clinical
capabilities. It's very sophisticated several hundred physician practice.

I had an opportunity to observe some of the teams working on the redesign of

the work. There were a couple of things that were very clear. By the way, this
was a team or group of people who were dedicated to creating better accuracy
in the results of the reports from the pathology department. They're very
critical. You send out something out for pathology, you want to get back the
right answer.

The team was actively engaged in redesigning the processes of the pathology
department in order to really be able to guarantee the accuracy of the work
that they did. A couple of things that struck me as I listened to what I would
call the readout of the teams, these are the teams presenting their work.

First the excitement in the room of people saying, we've discovered some new
way of just labeling the things that come and go that would really assure us
that we've got the right sample with the right name. It looked like simple stuff
but critical stuff in the delivery of care.

Secondly, the engagement to the people these weren't physicians or clinicians

who were necessarily redesigning the processes. These were lab people who
are doing the work. These were administrative assistants who were doing the
work. Everybody was engaged in the redesign of the processes. That's what I
like to see.

When you get an organization that is engaged broadly in the redesign of work is
when you start to see great stuff because the people are actually doing the
work, who understands where the breakdown is going to occur. They can
deliver the best results.

33voices.com 5
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

So to answer your question — a level of excitement and then the deep

engagement, the deep and broad engagement of people in Zev's organization,
very inspiring.

Well, you're the master at that. You know that's all about leadership. It's
all about effective and efficient management, just healthcare in general. I
guess it's still around this people issue. Just from a general perspective, I
mean, how would you rate the leadership from what you've observed out
there. Obviously, he's an anomaly.

You know, a couple of things. First, you have to — let's take hospitals for
example. You have to recognize that hospitals have come out of a history of
being non-profit organizations. That's the way most of our community hospitals
began. They were almost all non-profit organizations.

Now, they were community hospitals. They had local boards of directors and
without question, they were there to do good and they did good. Because there
was no profit pressure although there was performance pressure on hospitals, a
lot of them never developed the operating disciplines that you would like to
see an organization develop.

So they didn't develop what I would call the operating leadership skills. So you
can still go in to some clinical organizations, hospitals and doctors groups, and
you don't find the kind of crisp operating skill that you like to find there.

On the other hand, what you do find and what I did find in a lot of cases are a
couple of interesting phenomena. Almost every clinical organization does have
one or two or maybe multiple physician leaders. They are the really respected
great leaders from a diagnosis and treatment perspective.

If you and I had a problem, a medical problem, they are the people we'd want
to see. They're the lead clinicians. They are great thinkers. They are great
practitioners. What I found was when those people started to, let me simply
say, see the light, that there was a better way to really do their work. They
became very powerful leaders. They became very powerful evangelists for
changing work.

By the way, none of these changes that I write about, took place in any of
these hospitals or physician groups without a physician leader. Without
someone in the clinician community standing up and saying this is a better way
to do our work. The good news again was those people do emerge when you
can show them a better way.

33voices.com 6
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

The other thing that I was struck by was the number of nurses who lead
reengineering efforts very effectively. They were the leaders in a lot of these
change initiatives. The Novant case, you know, there were nurses very
instrumental in making the changes. In many of the cases we saw, there were
nurses leading the change.

Harry and I had asked the question, why is this? Why do the nurses seem to
have these kinds of sensibilities about how healthcare has to change? Maybe
better sensibilities than physicians. I think it's because a nurse lives with a
patient. A nurse is always with the patient. They see the world a lot more.
They see the patient's world. They see what patients are going through;
particularly, the complexity that patients are dealing with in the healthcare
field.

A patient in a hospital for four days actually will interact with an average of up
to 24 different people, 24 different clinicians and administrators. Just imagine
that. You're in a hospital for 4 days and you see 24 different people who are in
some way have something to do with your case. Nurses see that and they
understand that because they're always with the patient. And so they're very
good reengineers. They're very good at understanding how work has to be
redesigned. How things have to be simplified and they see it through the eyes
of the patient.

I did certainly find physician leaders but I found some great nurse leaders out
there.

You know Jim the nurses are typically the unsung heroes out there.

Absolutely.

Doctors get all the credit but they're so actively involved in all the care
that it's great to hear you say that.

You know, Moe, I was sitting in a meeting awhile back of very large hospital
system. There was a discussion of medical errors or errors in the delivery of the
right drug to a patient's bedside, errors either in terms of the wrong drug or
the wrong dosage.

There was a discussion of the executive team of this very large hospital system.
They were reporting out of where they were and someone reported that they
were at about a 2% error rate. Just think about that. That's scary as it is that

33voices.com 7
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

every two doses out of a hundred are wrong, okay, that get delivered. That's
dangerous.

But then someone said, but we're doing very well because our near-miss rate
was 11%. I said, “Oh my goodness. You think 11% of what you were delivering to
the bedside was a near error?” I said, “What made the difference between the
11% and where you got to a 2% rate? How did you get to that good a
performance from the 11%?” They said to me, “It's the nurses.” It's the smart
nurse who looks at a drug that they're about to administer to a patient and
says, either this is the wrong drug for this patient or it's the wrong dosage and
the nurse finds an error.

Again, great praise to the nurse but that's still not a condition that we want to
exist within a hospital.

You also asked the question in the book when you referenced this example
is, why not zero?

That's where we have to get but it's not easy. I don't want to be casual about
this. It's not an easy thing. I believe there are something like 17 different steps
between when a physician enters a prescription for you in the hospital and
when you get the drug. Seventeen different steps and so there are 17 different
opportunities for error. And so, we got to really look at those processes
carefully and step by step, no substitution but looking for detail, how does all
of this happen to get the error right down to the 0%.

By the way, one of the things that was going on is we are requiring doctors now
in many hospitals — but this has not happened broadly yet — to enter
prescriptions electronically. There are some hospitals that have said to
physicians unless you enter prescriptions electronically, you cannot practice in
this hospital.

That may sound like a very harsh position. There is a joke about physician's
handwriting but it's true. You just can't risk unintelligible handwriting so one of
the big steps in getting the error rate down to zero is requiring physicians to
enter all prescriptions electronically.

I used to think that they taught them that in medical school - the
handwriting had to be like that for some reason.

33voices.com 8
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

I know. Actually, I was amused. Harry and I have signed a lot of copies of the
book. Harry is a physician and you can't read his handwriting, his signature.
Mine is very clear.

You put yourself in a sole practitioner's shoes, the doctor's shoes. I have
several very close friends who are physicians. They're trying to make
sense of everything that's going on. I sense that there is a lot of
uncertainty, a lot of fear going on.

What does reengineering mean to them and how will it impact their
business. How can they say, there is probably not much that I can do to
impact Washington but there is a lot that I can do to impact my own
business?

You know, Moe, you're raising a very critical question. The lives of physicians
are really challenging. I can remember when I was growing up in my local
community outside of Austin here. They utilize physicians who were incredibly
good. They were well paid. They would work long hours at a time. They feel
very satisfied by their work. They felt they were being rewarded in their work
but a lot has changed.

By the way, I wish I could give you an answer that says the physician alone can
fix everything. The physician on their own can fix everything if they're
independent. But because they're working in what we call, you know, we call
healthcare a system but it's not a system. It's a collection of fragmented parts.

So what do I mean by that? If you are an individual physician, you maybe

dealing with 20 or 30 different insurance companies who cover your patients,
all of whom have different forms and different approval procedures for things
that you may want to do for your patients. You're billing is incredibly complex.

Secondly, we are living in this litigious environment. I really believe that a

physician who makes a negligent error should be held accountable. We've got
to do something to tame the litigious condition that's driving the cost of
insurance up for individual practitioners.

There are individual practitioners out there, clinicians, who can't make money
because their insurance is so high particularly in some fields. The insurance is
just so high it's almost impossible for them to earn a decent living for the work
that they give.

33voices.com 9
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

Thirdly, the fragmentation itself of the diagnosis and treatment with so many
specialists out there that you may be a general practitioner, GP so called, but
you're going to have a whole set of relationships with all of the specialists in
your community to make sure your patients get the care that they need.

Also, you can be working all day. This is true of many physicians. They work all
day and they fill out their reports at night.

An individual physician can streamline their own workflows and processes can
adopt information technologies in their offices to digitize or create electronic
healthcare records and create some efficiency. There are still these huge what
I call system or lack of systems phenomena that will continue to put pressure
on sole practitioners.

By the way, the other thing that's going to happen or that is happening is to pay
for this healthcare bill. The government has already declared that it's going to
reduce Medicare payments. That means that the physicians and hospitals are
going to get paid less for the work that they do.

So what I think we're going to see and we're seeing it already is many of your
friends who are individual practitioners are going to join group practices. We'll
see fewer and fewer folks who hangout their own shingle that have their own
independent offices. That it's just going to become too expensive to operate
that way. So they'll move into group practices.

Now, the advantage of that is you can move into a very good group practice.
The whole infrastructure is there to help you run your practice. You still get to
do the work you love. The processes are well designed. You may get home in
the evening. You don't have to spend the evening filling out forms and reports.

I think what's going to happen is we'll see a continuing drift of the individual
practitioner into group practices.

That's very interesting because other than hearing what's happening in

reform and the government, you know, I've kind of tuned myself out until I
got your book. If your name wasn't on it, I wouldn't have read it cover to
cover. I was surprised when I finished the book about this whole notion of
process that really is almost a lack of process innovation in this whole
system.

33voices.com 10
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

That's right and it's very fragmented. And again, as I said, that wasn't quite the
inspiration. My inspiration was we better start addressing this or else we're
going to see the collapse of what we call parts of the healthcare system.

Another inspiration I always have is when I see a fragmented environment that

can be organized into much more intelligent work that excites me. To that
point, ultimately, what we have to do in the delivery of care is to step back
and manage what we described in the book as the continuum of care.

Our care shouldn't be handled transactionally. We shouldn't be seeing 10

different physicians who hopefully will talk with each other over time. Our care
should be managed as a continuum over our lifetime. We should have a delivery
system where we have a single healthcare record, by the way, that moves with
us. That isn't owned by a doctor's office or isn't owned by a hospital but as our
record.

So wherever we move, wherever we go in this country or in the world, any

physician we're seeing can see that record and have access to that record and
can make entries to that record. It's all about managing the continuum of our
care. It won't be until we get to that that we'll really get healthcare to perform
to where I think it needs to perform.

We know there are some outfits out there primarily for high net worth
individuals. They consolidate their healthcare records and they also
manage it. I assume that that's something at some point that the entire
healthcare system will see that's a very effective way to try to manage
that.

I think you're right. You know, probably 20 or 30 years ago, there was the
answer to healthcare delivery with the HMO, the management organization.
That was a very good idea. You sort of see remnants of that kind of coming
back. I mean, I'm treated personally by a large group practice of several
hundred physicians, very well integrated. All of the physicians I see are within
the network of that practice.

You know, I'm not a high net worth individual necessarily. Somebody, thank
goodness, is helping to pay for that cost. I should tell you though, it is
expensive but my care is first rate. I don't have to worry about who has my
healthcare record. I know where it is. It's just right inside that practice and
every physician in that practice. No matter what department they're in has
access to that record.

33voices.com 11
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

I don't have to tell them 20 times what drugs I'm taking. You have that
experience when you move from place to place. It's just amazing how much
wasted time and energy there is both for the clinician as well for the patient.

It's really amazing. What role do you see that the patients can play in this
whole reengineering process you outlined?

I think to be more demanding as consumers. It sounds again simple but we have

such respect as we should for the clinicians that we deal with. That we're really
fearful to be critical of them and how they operate.

But you know, it is ridiculous to — if Amazon is shipping me a book, Federal

Express or UPS, I can track where that is at any point in time. If I go in for a lab
test, the average patient goes in for a lab test, it may take them a week before
you hear back from your physician. You know you're calling back and forth.

Let me tell you the commercial processes and the patient processes of
healthcare delivery are primitive compared to the processes that we come to
expect in other parts of our lives. I think the patient needs to be more
demanding.

The patient for better or for worse, also has to I think take a much more active
role in managing their own continuum of care because unless you're in a very
good group practice or large group practice, nobody else is going to do it for
you. So you got to manage your own continuum of care and your own well
being. But I think we can also be more demanding of the organization that
deliver us care.

Again, we would never accept the delays, the performance that we get in
healthcare delivery in other parts of our lives.

Do you see now this whole business — third issue — do you see technology
as being a catalyst and really playing a significant role in this whole
reengineering process?

It's eventually going to deliver some very important answers to us. But, as you
know, as I argue in the book, of course it's a combination of technology and
process. As we build and we put all our healthcare records on electronic system
whether it be a single system or a set of systems that we can access across this
country and maybe across the world, we start to build — we've known this for a
long while. We are building bigger and bigger base of data and information that
will allow us to relate and correlate treatment outcomes.

33voices.com 12
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

That is, we'll be able to see if whether we do X, Y, and Z. If you come into a
hospital with a cardiac problem, what result we get and what best protocols
there are for treating the illnesses and diseases. We'll have a real body of
knowledge so again we can correlate treatments with outcomes.

What that's going to mean and it's actually happening, we wrote about it in a
couple of cases in the book, it means that physicians are going to be handed
protocols again. You know, if a person comes in through the emergency room
with these kinds of symptoms and you believe it's this kind of problem, here are
the 10 steps that you take.

We actually have to get medicine to that kind of — for most illnesses and
issues, we have to be able to get to that kind of condition. You see some
hospitals already getting it. They're requiring protocols, requiring checklists.
It's all about better medicine but boy, physicians remember, have not been
traditionally taught to operate that way and work that way. But information
technology is going provide with the knowledge that will allow us to make
sound steps in that respect.Very critical.

It's not that far off. It won't take us many years to really develop the
relationships between treatment and outcomes.

I hear the same passion in your voice as I have with everyone of your other
books. I know that reengineering a corporation has kept you in board
rooms for two decades. Is this thing going to kind of shift your focus a
little bit because if somebody like you gets involved in this whole
healthcare issue, then there is a whole new level of inspiration going on.

Hopefully, I'll be able to contribute in healthcare. But my sense is this industry,

let me call it an industry, this profession, needs some stimulus. I can provide
some stimulus. I can provide some ideas. But it is a profession as well as an
industry. A lot of the stimulus has to come from within.

My real hope is that I'll be able to inspire enough clinician leaders, enough
nurse leaders so that they carry the banner. I expect it will keep somewhat
busy but I really want the nurses and doctors to do the work. That's part of the
manifesto of this book. I think nurses and clinicians have to take back the
redesign of healthcare delivery. Otherwise, by the way, government is going to
pick it up. You can see it already. You don't want governments to pick this up.
It should be the work of nurses and physicians.

33voices.com 13
www.33voices.com
Real Health Care Reform: Will Jim Champy with Moe Abdou
Physicians Change? (Unplugged)
!

My strategy here is going to be a little different than my strategy around

reengineering and business. I could be out there working in companies and
helping them. I want nurses and physicians to lead the call here and people
who run hospitals, hospital administrators. I want them to be leading the call.
That's what's important.

Well we're going to help spread this word to nurses and clinicians out
there and I have to tell you, I didn't think I would be interested or
intrigued in this project but I don't know if it's your style of writing or just
you but I appreciate what you've done. We'll do our best to get your
message out. It's always inspiring spending time with you.

Thank you Moe, I really do appreciate your interest in my work.

33voices.com 14
 www.33voices.com
FeedBack

We believe that the best version of yourself is when you don’t have to
choose between doing what you love and making a living. So if you’re stuck
or simply want an extra spark of inspiration, please tell us how we can help.

What Are You Struggling With?

ASK A QUESTION THINK WITH JIM