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Adrift in PolicyLand

May 1, 2009
by aguerra
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Policyland is a fun place. I like to visit, but if you stay too long, you lose touch with reality. In PolicyLand, everyone knows everyone else, luminaries continually present on panels with each other, reinforce each others’ opinions, and are incredibly polite. In PolicyLand, you don’t even need to redo your PowerPoint because you did this presentation last month, you can just tweak it. In PolicyLand, everyone co-authors papers together and endorses each others’ work, writes intros to each other’s books and congeals around the same tables at the customary conference lunch. PolicyLand is like an exclusive club — very hard to break into, but once in, it’s almost impossible to get thrown out. That’s because, in PolicyLand, nobody is responsible for making anything actually happen, by a certain date, within a certain budget. In PolicyLand, in short, there are no consequences.

To make it in PolicyLand, you need only to express a bold vision of where things need to go, you need to constantly instruct “stakeholders” to do things like “come/work together.” You need to say pithy things like, “No one group can do it alone.” You need to state incredibly obvious things like, “Electronic medical records, while critical, do not constitute a silver bullet.” In PolicyLand you want to make sure, “the bar isn’t set too low,” because, as a policy person, that’s your job, setting bars very high. (It’s boring to talk about low bars among “visionaries.”)

Then, of course, there’s RealityLand, where most of us live. In RealityLand, the bar more often refers to where you get a drink than unattainable goals set by those not responsible for reaching them.

In a fascinating turn of events, I moved between these realms this week, and the contrast was startling.

On Tuesday I listened and “Tweeted” all day from the NCVHS hearing on Meaningful Use. While there were some useful presentations, and a few nuggets in those I wouldn’t describe as such, the affair was largely a jaunt to PolicyLand. Little did I know RealityLand was about to demand equal time.

Around 3 PM I received a call from my wife, who was driving home from a nurse practitioner conference in Boston. Seven-months pregnant, she’s often in discomfort for this or that (she says I lack empathy), but during this drive she had been in excruciating pain emanating from her back and radiating around to her “upper right quadrant,” as she described it. I could hear her crying on the phone as she raced down I-95 towards home. If the pain continued, her physician instructed, she should go to the ER and get an ultrasound to check for gall stones.

I quickly grabbed my coat and headed for home, where we would meet before heading to the hospital (a prominent and well-respected hospital, mind you). At the main ER admission desk, one look at my wife’s stomach was enough for her to be whisked off to the L&D emergency room. Coming off the elevator, we were greeted by a security guard who asked her a few questions such as name and symptoms, commenting “Oh, that doesn’t sound too bad,” as she jotted the information on the margins of some manifest.

From there, we were brought into an examination room and greeted by a nurse who asked for my wife’s information (though we had been there many times) and began creating her paper chart. Within 10 minutes, an admissions representative was in the room, collecting information on a paper form and making a Xerox copy of her insurance card. That was fast. Admissions, to its credit, did have my cell phone from a previous visit as an emergency contact.

“Do we need to contact the insurance company? Since we were not admitted through the main ER, I want to make sure this isn’t billed incorrectly,” I stated.

“It couldn’t hurt,” she said. “They all bill differently. I really don’t know.”

What wasn’t fast was spending the next six hours at the hospital for my wife to receive some fluids and a 15-minute ultrasound exam. After we were told the order had been put in for the scan, we were informed there was no estimated time on how long it would take for test to be done. “One hour?” I asked, “Three hours? You can give us NO idea?”

“No,” I was told. “Ultrasound will not give us a time.”

As we waited and the hours slipped away, I heard a nurse say, “No. We’re full here. We have no more room.” The bottleneck in ultrasound, it was clear, had started reverberating.

I also heard the following exchange between two nurses.

“Where is Mrs. X’s chart?”

“The resident took it downstairs.”


I learned just how this could happen when Transport (a guy and a wheelchair) finally came to take my wife down for her ultrasound.

“I’ve got a job for you,” he said, handing Marie her chart. “You get to hold this.”

When we got down to the ultrasound department (which seemed oddly serene for a supposedly harried department), the tech asked Transport, “Where is her wristband?”

“I don’t know,” he responded.

“Did they give you a wristband,” the tech asked my wife.


“Ok, I’ll go back up and get it,” offered Transport.

So Transport duly returned with the wristband, which was applied, and the ultrasound was completed. We were then brought back up to the exam room (my wife again performing her chart-transport duty) and sequestered there for the next two hours until discharge. As it turns out, nothing was found on the scan, so we left none the wiser, though her pain had fortunately subsided.

The next day, I was dutifully back in PolicyLand, hearing about vision and dreams and goals, how things could be and how things should be and how things ought to be. But few in PolicyLand seem to understand where things are and the skills, money, and time needed to move the needle even slightly from here to there.




Great contrast Anthony. If nothing else, you are improving our ability to write. Kudos for the example you're setting.

Now, back to RealityLand.  Like you and everyone else reading this, we live in both worlds.  We need to understand the visions and articulate an achievable vision, if we are to make progress.  Per your post, there's more than PolicyLand.  I would suggest, that there's more than RealityLand as well.  Here's the summary I took from your depiction of PolicyLand.  RealityLand is well illustrated by Marie/Your experience (the consumer view.)

Attribute PolicyLand

Population: elite
Fun yes
Consequence of staying long lose touch with reality
Social Order exclusive club - reinforce, polite
Powerpoints tweaked from last time
Co-authorships and Endorsement Common
Responsibility none

hard to break-in

impossible to get thrown out

no date or budget mgmt respblty

no consequences
Entry Requirements Bold Vision
Pithy? "come / work together"

"no one group can do it alone"

"EMRs not a silver bullet"

"Bar not set too low"

Integrated awareness of skills, money and time needed scarce

In "executive leadership/management" Land, the matrix has to look like this:

What's nice about this is that PolicyLand, aka 'vision only' or vision that doesn't transmit all the way to successful change is clearly depicted.  RealityLand, as you point out, is littered with Anxiety, Gradual Change, Frustration, and False Starts.

There is a pragmatic way to use this formulation; this isn't more PolicyLand.  So, for example, relative to "Action Plan", were there any PMPs presenting at NCVHS (Project Management Professionals)?  In my experience, when they're driving the decisions of a project, the results in RealityLand are much more successful.  PMI certification, in my experience is solid Reality.  In contrast, weak or absent project management always leads to failure in all complex projects.  PMP's are part of the antidote to pure vision.

Many of the other blog posts on the HCI site directly elaborate additional antidotes.  Tim's notes on acquiring and retaining executive skill are one example.

I think making a distinction between "executive leadership/management" Land and RealityLand is useful.  All too often, reality-oriented participants are excluded from power in RealityLand.  This is more than sour grapes - it's a statement of observation of dozens of brilliant people.  People with strong planning and project skills whom I have worked with.  In RealityLand, those folks often don't do well, at least in the large corporate world.  The fact that small firms can be far more innovative than large, bureaucratic ones illustrates this effective reality. 

What does that portend of healthcare transformation?  Alot, I think.

Wow, Anthony. You make a very good point. There is a wasteland that seems to go as far as the eye can see between PolicyLand and RealityLand. I've visited and it's not pretty. Most importantly, I'm glad Marie's ok.

If you went in through the ER, EMTALA probits the collection of financial infromation until the attending physician has made a disposition. Sounds like they violated that law too!

Don't you love the old paper system!

The admissions rep was there at least an hour before the attending "resident" made her appearance.

Regarding the resident, my wife (the NP) was asking the nurse, "What year is she?" Inside baseball tell us that the third-year residents are ok, but if you get approached by a first-year resident, run!

It's mind-blowing. We speak to so many intelligent people here who are pushing the envelope with new technologies and connecting systems all over the place, but the reality is that this group makes up such a tiny percentage of the hospitals and health systems in the U.S.

With everything that is happening in this industry (and the constant cheerleading about what great shape it's in), the idea that your wife (and you) had to go through an ordeal like that is inexplicable. It just shows how enormous the divide is between the few who are making health IT work, and those who aren't.