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Selling Your Soul: Part Three

December 29, 2009
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By now, many of you are probably thinking, “What exactly is Harvey on about? It sounds like he’s grumbling about outsourcing gone wrong. How bad could it be?”

Well, let me tell you…

I mentioned earlier that I’ve spent quite a bit of time lately looking at “facts on the ground” inside some acute care hospitals. The conventional wisdom is that it’s the hospitals that really have it all together when it comes to managing IT. It’s not hard to find hospital and integrated delivery systems that have done an exemplary job of leveraging IT to excel at providing care and returning value to their bottom line.

But I’m also struck by the extent to which there are the “haves” and the “have nots” among those systems.

Why is it that we see hospitals of all sizes, but especially in the mid-size to large category, that appear to have more money than they know what to do with, that are building palatial facilities, and that are gobbling up competitors at will; while others struggle to keep the doors open? Why do some have IT operations that would be the envy of any business anywhere, while others are a train wreck? Is the latter the cause, or the effect of the former?

I am legitimately interested in others’ insights regarding the disparities. As we seek to build a healthcare delivery system that properly balances costs and outcomes, it will be increasingly important for us to understand the dynamics of the haves and have nots.

If I were doing a scholarly study of the issue, I’d begin with the hypothesis that the biggest difference between the haves and the have nots would be the overall quality of their management and leadership. And that’s where we come full circle to leadership’s commitment to IT as a key tool and enabler of organizational success.

Let me paint you a picture of an organization that has sold their soul and will pay the price accordingly. The scenario that I’m describing is a composite and does not portray any one organization, but I’ll assure you that all of these circumstances do occur in the wild.

Leadership is under qualified, isolated, and inbred.

Perhaps the organization experienced rapid growth in years gone by and outgrew the leadership’s ability to manage. Maybe the leadership style worked for the organization when the healthcare environment was different, but as the industry has experienced tumult and upheaval, leadership was not able to adapt themselves and their organization to the change.

Add to this a lack of leadership accountability. The relationship between the board and executive leadership is overly cozy. The chief executive may have actually come from inside the board to begin with and continues to lead a board that is basically self-perpetuating.

Qualifications? You’d be surprised at how many community hospitals are run by people with limited experience or education in healthcare management. The scenario above of the board member ascending to CEO? That person is more likely to be a successful banker or business owner than an experienced healthcare executive.

That does not preclude them from being successful, but it does mean that they have to force themselves to get out- get involved in industry groups, see how people that are recognized leaders in the industry approach the issues, make sure that they know and understand what the issues are today and are likely to be next year. Take another degree if necessary.

Those who are unwilling to humble themselves and admit what they don’t know will almost certainly refuse to hire talent that threatens them. Developing internal talent is great and should be the rule, but it’s also important to cross pollinate new ideas into the organization from time to time. And if your strategy is to develop your people from inside, you better be developing them. Not making sure their abilities stay one step behind yours.

Leadership is playing outside of what expertise they do have.

Suppose that the organization has managed to find someone who’s a pretty good finance person. They know how to read a balance sheet and have a good understanding of cash flows, expenses, and how third party payments work in healthcare. They become an effective CFO.

Oh, yeah, Mr. CFO, did we mention that IT is also part of your portfolio?

I know that some people will assume that I’m just being self-serving here, but the traditional idea of IT being an afterthought, and an appendage of the organization’s finance division just doesn’t get it anymore- especially in health care and especially when clinical systems are growing more critical.

I love finance guys. If I was stuck in a business foxhole, I’d want our CFO right by my side. But their brain works differently than mine does. You don’t want me making sure that we make payroll. It’s a rare CFO that you want guiding your EMR selection process.

There are exceptions; organizations where IT is part of Finance and is apparently functional. Bo Jackson was a good football player AND a good baseball player.

Bo doesn’t come along very often.





Very recognizable scenarios you've painted. Like reading a book of Dilbert cartoons, your bullets are almost too painfully recognizable to digest in one sitting!

Implicit in many HCIT software platforms from all ReallyBigCos is that the in-hospital product life cycle is between ten and twenty years. Annual releases often do add functionality but there are a lot of patches in there as well. After four to seven years, your core platform hasn't changed that much.

That's not built in obsolesce; that's pretty much never the driver. These systems are designed to be long-term IT infrastructure.

When thought of like a bridge or a building, it's generally okay to plan for a ten or twenty year life. When thought of like a road, now carrying more weight and volume than planned, and being exposed to pothole-inducing elements, ten years is a very long time. In our parlance, 'meaningful use' takes some dirt paths (some leading up to rivers with no bridges) and says, plan on a highway here.

I think you eloquently captured the management challenge. There are long term problems that are being addressed with short term solutions and often with short cuts. Short cuts that most people tacitly know wont work and aren't part of thoughtful, four to seven to ten year strategies.

Your SAN story really hit home. Probably ten percent of my clients have relatively new CIOs to their organizations. More often than not, they're very competent.

That said, the people who trained on, built, and rolled-out the existing system have left the organization. Often in frustration and anger (from abandonment of prior organizational commitments) these people often cannot be re-hired. So, the CIO's train has already left the station, with less than a skeletal crew, and with inadequate provisions even if they negotiated staffing up as part of their condition of employment.  And, the folks who left were forced to make unsustainable short cuts before they abruptly departed.  Key training and build work simply didn't happen.

In my experience, working for multiple vendors, it's this long product life cycle that's not being managed to. The majority of my clients do understand this. Their staff turn-over is low, they invest in their people, value analytic capabilities, make accommodations so that employees can work part time (especially with young families).  They deal directly with staff conflict (as opposed to avoidance.)  They elaborate their options as a team, rather than letting a bulldog or let short-staffing lead to bad decisions.

Their senior execs clearly are humble and clearly do want and cater to direct reports who are smart, smart, smart. They do this with their own leadership smarts and grace (the management trinity), without abdicating their own fiduciary responsibilities. The minority that don't do these things do have high, unplanned CIO turn-over. They need external help to "re-vision," i.e. remember what their system can do. They need their vendor to re-demo their system to them every 2-3 years. They've lost the internal competency to own that.

These organizations (again, a minority) never bought their souls in the first place. They began effectively with a "muddle through" mandate from their BODs and CEO, who, as you pointed out, were not HCIT literate.  For this minority of folks, I think your series is right on.  For the majority who have been getting the basics right, your cautions are well stated.  And, as other bloggers have noted, HCIT is going to get more challenging for everyone.