Command and control was the traditional means of management, but it is not well suited for the complex healthcare organizations of the 21st century. Healthcare today demands flexibility, transparency, and quality. Under pressure from increased regulations and declining reimbursements, healthcare needs to grab the attention of the consumer. To do this we must be transparent, efficient and, wait for it, accountable to our patients.
It seems that all the talk about accountable care organizations centers around controlling cost between hospitals and physicians. Streamlining reimbursements models, increasing efficiency and managing resources as a means of decreasing cost should not be the goal of this effort. Improving patient outcomes should be the goal; and the two are not inevitably linked. If we think back to the managed care days, the single element which caused managed care to fail was money. Managed care was all about controlling cost, and people pushed back on that model. We cannot make the same mistake with ACOs.
Don’t get me wrong. Reducing cost and improving efficiency are noble targets and worth effort, but I fear we will lose site of the patient. CEOs must be careful. Saving money is always intoxicating and can easily seduce us away from the real goal of accountable care — to be a delivery model for improving health. To accomplish this, we must approach ACOs as a quality initiative, not a cost saving initiative. If we happen to save money, as we most likely will, that is a good thing, but should not be the objective of the effort.
I once worked for a CEO who, during a leadership building session, when asked by the moderator about his fondest memory of kindergarten; responded: “Milk was 5 cents a carton.” I thought I was struck in the head with a 2×4. Was that his fondest memory? Around the room, people were talking about sing-along time, or nap time (my personal favorite) or holding the flag for the pledge of allegiance, and his fondest memory was nickel milk. I asked myself: Was that the extent of his vision? And you should ask your CEOs: I that the extent of your ACO vision? I hope not!
It is easy to fall into the money trap when faced by uncertainty. It is also easy to slip back into old styles of management such as command and control. Margaret J. Wheatley, a writer and management consultant who studies organizational behavior, wrote, “… in the past few years, ever since uncertainty became our insistent 21st century companion, leadership has taken a great leap backwards to the familiar territory of command and control.” (1)
This is the second inhibiting factor in creating an ACO. Transparency and accountability have to start as an internal initiative, and I believe they are impossible to achieve without an engaged workforce. I think today’s workforce, especially the IT work force, does not like being micro-managed. Empowered workforces need the freedom to be creative, responsive, and innovative. That type of workforce needs to be able to act on its own initiative, take personal and team responsibility deliver upon and align itself with the organizational strategies. Command and control bosses can never achieve an empowered workforce and therefore make it difficult, if not impossible, to become internally transparent. If you are not transparent, you cannot be accountable.
The third element confounding ACO advancement will be fear. Uncertain times heighten organizational risk. Individuals who are risk averse will falter and cannot embark on a bold path to blaze a new trail in healthcare delivery. Remember the goal of ACOs is to create a delivery model for improving health. You need a real vision to do this and must be willing to take on some risk. CEOs and healthcare leaders need to be risk takers. Those who do will have a better chance of success. I wonder, however, if most healthcare leaders are risk takers. A part of me says no, but that is another essay. I hope I am wrong.
We need ACOs as one of the threads to change healthcare delivery. It is a challenge full of risk, but we will never resolve these issues without embracing three important attributes: 1-Belief that ACOs are quality plays, not cost saving initiatives. 2- An empowered workforce with personal and team responsibility to deliver the goals, not managed via command and control, and 3- a leadership style willing to take risk.
ACOs are about creating an environment that is flexible, transparent, and quality based. Are our nation’s healthcare leaders up to the challenge?
(1) 2005, Margaret Wheatley How is Your Leadership Changing?, margaretwheatley.com
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