After a busy month of traveling and work, I had a chance to sit lazily on the couch and plow through some mindless television on a recent Sunday evening. But I soon found myself flipping back-and-forth between Cesar Millan’s “Dog Whisperer” on NatGeo and “Beyond the Tank” on ABC – a spinoff of the popular “Shark Tank.” As the proud – if not exasperated – owner of Ellie, a 14-week-old Vizsla, I was intrigued with Cesar’s strategies. I also found it interesting listening to the “Sharks” work with the people with whom they’ve invested.
Ellie, well, she could care less.
Several of the visits we made in April to different sites and trainings across the country talking about integrated care implementation were really workshops on leadership. As we’ve discussed in this forum previously, a common misstep organizations make is treating the transformation to an integrated practice as a project, rather than a process. As such, very little planning and strategy is developed to support the transformation. Typically a few key staff, perhaps a few bucks for training, and the services of some consultant are allocated for the project. Someone might even be promoted (vertically or horizontally) to the title of “Director of Integrated Care” and off and running they go. It’s usually around the 90-120 day point when the first real frustration pangs are felt as progress has slowed. It seems impossible to engage providers, available trainings and grants are few and far between, and the task of collecting data seems daunting – especially with an EMR that doesn’t seem to support integrated care. Not to mention the head scratches you get when talking to payers about this. So usually around day 120, the air leaks out of the motivational balloon and what was once a great idea starts to decay on the branch before it is even given a chance to bloom. Excuses are made – “Well, the timing just isn’t right to do this right now,” or “We have too many other things going like PCMH to focus on this at this point,” or “the state environment isn’t friendly to this, we need to wait until after the next election.”
It occurred to me while watching Cesar is that he would probably have a very interesting take on this. We’re making this the dog’s problem; or more specifically, we’re letting the project wag the dog. When he works with “problem dogs,” Cesar almost never initially focuses on the dog, but rather the owner. Usually within a few minutes of his introduction to the dog, he has the dog in a submissive, calm state – and it’s done with nothing else but his confidence, awareness, and presence. Or leadership. Author Malcom Gladwell recognized this in Millan and wrote about him in What the Dog Saw. Please understand I’m not making the leap of comparison of employees to dogs, or that staff need to be calm and submissive. This is in reference to leadership, and the lack of it in failed transformations. Dogs are packs animals, and they desire to be lead – even “alpha dogs” can be lead. Processes require strong, consistent, confident leadership – or some alpha force such as frustration, apathy, or “this is the way we’ve always done it” will invariably take over.
Ellie shrugs and says “that’s about right.”
Over on “Beyond the Tank,” one of the Sharks was working with a mother and son duo who, coincidentally, were selling all-natural dog treats. The Shark investor saw something in them and invested, and as part of her partnership negotiated a deal with a national chain retailer to sell the product from coast-to-coast. This would require significant increases in production, distribution, and infrastructure – and exactly what the Shark had in mind when she invested. However, she had serious reservations in the mother’s ability to lead this transformation. Mom was a great baker and could manage the regional sales using QuickBooks, but recognized that she was about to be batting much higher in the order than what she was prepared for. In order to see through the transformation, they needed to hire an experienced operations expert to handle the specific tasks of expansion. This new alpha dog, though, still needed leadership and to understand the vision – which now became mom’s job. She became a talent scout and guardian of the mission and vision.
The value of leadership and planning when taking on practice transformation cannot be understated. Likewise, it is as important to understand that when you’re talking about an integrated care practice, you are really talking about practice transformation, and it’s the practice in whole – administration, financing, operations, and clinical.
Ellie shrugs, yawns. “Yeah, that’s about right.”