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Unpacking the HealthCare.gov crash

by amiel · Dec 17, 2013

On November 22, the New York Times ran a long article detailing the organizational and managerial problems behind the crash of HealthCare.gov. Art Kleiner, editor-in-chief of strategy+business, calls this “one of the most important articles on management this year.” I agree. Kleiner goes on to suggest that the Affordable Care Act (ACA) is a test case for the idea that the private sector needs effective government, and that the way to get effective government is to free it to learn and reform. In short, let’s demand and support effective management in our public sector agencies.

What exactly does it mean to manage effectively in the public sector? And how do you produce accountability? In recent posts on this blog, I’ve begun introducing the practices of promise-based management, like making effective requests and reliable promises. The recent experience of HealthCare.gov as described by the Times presents a brilliant opportunity to illustrate these practices through a real-life example that everyone is talking about. Let’s give it a shot.

Knowing how long it would take to complete and test the software, the company’s officials and other vendors believed that it was impossible to open a fully functioning exchange on Oct. 1….Government officials, on the other hand, insisted that Oct. 1 was not negotiable.

Why do books about talent ignore management?

by amiel · Dec 16, 2013

There is a big gap in the recent literature about developing talent through conscious practice: minimal attention on leadership or managerial skills. For example, Malcolm Gladwell’s Outliers describes how the Beatles and Bill Gates became extraordinary at their technical crafts by practicing repeatedly over time. The book popularized the 10,000 hour rule named by psychologist Anders Ericsson. Similarly, Daniel Coyle’s The Talent Code and Geoff Colvin’s Talent Is Overrated reveal the rules of deep practice and deliberate practice, respectively, mostly through the examples of athletes, musicians, and teachers. On an individual level, they talk about breaking skills into chunks, practicing the chunks slowly, and correcting mistakes along the way. On an organizational or cultural level, they talk about apprenticing young people to masters and igniting talent hotbeds that inspire them to commit to long-term deliberate practices.

This is exciting and powerful stuff. Unfortunately, none of these books talk in depth about how to apply deliberate talent practice to management or leadership. OK, I lied: the Epilogue to The Talent Code contains two pages on business, specifically Toyota’s use of kaizen events to continuously improve processes and create high quality products. But, other than this, there is very little about the skills of management. Why the gap? [Read more…] about Why do books about talent ignore management?

Accountability and reliable promises, pt. 3

by amiel · Dec 16, 2013

Part 3 in a 3-part series

In part 1 and part 2 of this series, we used the example of nurses filling foam canisters in hospitals (to increase the odds of hand washing that protects patients from infection) to demonstrate what it takes to build accountability in an organization. Accountability requires promises, which in turn require effective requests (or offers) and acceptance of those requests. If the goal is for everyone involved to follow a similar process, i.e. standardized work, then it’s important that they all explicitly promise to do this. But what do you do if a nurse isn’t following standardized work? According to Mark Graban, the first thing to do is to ask why. He proposes asking the following about a surgeon who fails to follow “universal protocol” before a surgical case, but the same applies to nurses who fail to refill canisters.

We can ask:

Is it a case where the person CAN’T do the work properly?
- Do they not know how? This might be a systemic training problem. The individual can’t be held accountable for that.
- Does the person not have the right resources? Maybe they WANT to do it right, but they just can’t. Leadership needs to help eliminate those barriers.
Is it a case where the person WON’T do the work properly?
- Is the situation one where the person truly has a choice and they made a bad choice?

Accountability and reliable promises, pt. 2

by amiel · Dec 16, 2013

Part 2 in a 3-part series

Read part 1

What does it mean to have accountability? As we observed in an earlier post, piggybacking off of Mark Graban, if a hospital manager expect nurses to be responsible for filling foam canisters to increase the odds of hand washing to protect patients, there needs to be an explicit promise between that manager and the nurses. Such a promise requires both a clear request (or offer) and an acceptance. Promise = Request + Acceptance.

Now, what can we say about the components of an effective request or offer? Let’s make explicit what was partly implicit in the above example. An effective request or offer consists of the following:

Clear conditions for satisfaction. There needs to be a shared understanding of what it means to restock a canister.
Clear timeframe or deadline. What days and what times of day will the nurse restock the canister—or at least check to see if it needs restocking?
A specific speaker. What do we mean by this? If a vague pronouncement comes out from “management” about who is responsible for restocking the canisters, there is not a specific speaker. The nurse doesn’t have anybody to respond to (by accepting, declining, counter-offering, or promising to promise). Another way that a speaker can be “missing” is if a manager holds uncommunicated expectations; they want the nurses to refill the canisters, and maybe even mention it in passing, but never actually make a request.
A specific listener. On the other hand, let’s say a particular manager makes the request but communicates it vaguely to a full team of nurses. Now, we have a specific speaker but not a specific listener.
A shared “background of obviousness.” This is a fancy way of saying that when the manager says “restock the canisters in the middle hallway”, both the manager and the nurse understand which canisters these are and which hallway is the middle hallway.

How I wrote my book in three weeks

by amiel · Dec 16, 2013

A friend recently wrote me this email:

I love your practice with surrender. I am about to spend a week in NYC alone to move the dissertation forward. I will remember your counsel.

She was referring to a recent letter I sent describing what allowed me to write the first draft of my book last summer in three weeks:

It was one of those singular experiences where words pour forth without effort once you put your body in the proper place.

Now that I know she is about to embark on her own period of intensive writing, I want to round out the picture. Surrender played a big part in writing fast. Here are several other factors: [Read more…] about How I wrote my book in three weeks

Accountability and reliable promises, pt. 1

by amiel · Dec 13, 2013

Part 1 in a 3-part series

What do we mean by accountability? In a recent post, I suggested that it’s silly to hold someone responsible for fulfilling a promise when they never actually made a promise. After all, request + acceptance = promise.

Let’s connect this to an insightful take on the same question provided by Mark Graban of Lean Blog. He suggests that it’s unfair to hold accountable someone who isn’t responsible and quotes Deming’s advice to “fix the processes, not the people.”

Can we hold nurses and other staff accountable for not always following proper hand hygiene procedures when coming in and out of patient rooms?

Let’s say the foam canisters are empty outside a few rooms in a row (something I’ve seen recently). We can’t hold the nurses accountable. This is a system problem. “Writing up” or punishing the nurses would be counterproductive. We need to ask why the canisters are empty? Is there somebody to hold accountable for not restocking the canisters? Maybe not – what if it’s a bad process, where there’s no “standardized work” and no clear cut assignment of who refills the canisters (“everybody?”).

Accountability requires authentic promises

by amiel · Dec 5, 2013

When it comes to building accountability in organizations, what differentiates good from great? Many leaders wrestle with this question. The wrestling typically sounds like this: Why don’t people follow through on their commitments? I don’t like to micromanage, but how else can I ensure things get done?

I love hearing these questions for two reasons. First, they reveal a commitment on the leader’s part to managing effectively and delivering results. It appears as a complaint, but behind the complaint is this deeper commitment to excellence. Second, there is a body of management theory and practice devised specifically to handle this situation. It’s called promise-based management or speech act theory. The basic idea is that human beings make things happen through language. Words don’t just describe reality; they actually bring it into being. There are particular ways to talking—conversations for action—that are the vehicles through which we act. If we want to become more competent at such conversations, it helps to understand the key elements that comprise them. We call these “speech acts.” [Read more…] about Accountability requires authentic promises

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