Cayman Islands Corruption Trial, Day 2

Last week, I testified in court about a corruption trial in the Cayman Islands. Below is a summary of my testimony that originally appeared in the Cayman Compass newspaper.

CarePay trial: Contract was 'highway robbery,' witness says

Fees that were expected to generate more than US$2 million a year for a Jamaican company providing services to the Cayman Islands public hospital system under the CarePay contract were called “highway robbery” by a Crown witness who testified Thursday in an ongoing criminal trial. 

Former Health Services Authority chief information officer Dale Sanders also told the jury in the trial of Canover Watson and Miriam Rodriguez that he “suspected” there was a corrupt relationship between the Jamaican contractor, AIS [Advanced Integrated Systems] and Watson, a suspicion that Mr. Sanders said eventually forced his exit from the authority. 

“I felt very strongly and actually quite sadly [in June 2011] that there was some form of corruption that existed between AIS and Mr. Watson and that it was time for me to leave,” Mr. Sanders said Thursday. 

Those allegations of “corruption” were made by Mr. Sanders in July or August 2011 to Cayman Brac and Little Cayman MLA Moses Kirkconnell and his sister Nancy Kirkconnell-Ewing on a trip to Cayman Brac. It was stated that Mr. Kirkconnell and now-government Minister Osbourne Bodden met with Mr. Sanders in mid-2013 regarding his allegations during a trip to Washington D.C.  

Defense attorney Trevor Burke, QC, suggested that Mr. Sanders appeared to have been given a lucrative consulting contract with government following that 2013 meeting. 

Mr. Sanders’s commitment to the implementation of the CarePay swipe-card contract for the local hospital system was also questioned by Mr. Burke during cross examination Thursday.  

Mr. Burke said Mr. Sanders had failed to attend a key meeting regarding the hospital contract bid recommendations in November 2010 because he was picking up his girlfriend at the airport, and later suggested that Mr. Sanders had attempted to sabotage the whole project. 

“That’s not true. I would never do such a thing,” Mr. Sanders said. 

It was after the non-attendance that Watson removed Mr. Sanders from a technical committee’s decision in evaluating bids for the hospital contract, a move Mr. Sanders said he thought was “inappropriate.” Mr. Sanders had earlier testified he missed only 15 minutes of the meeting due to an IT emergency at the Cayman Islands Hospital. 

Watson is accused by prosecutors of using his position as Health Services Authority board chairman to direct the hospital contract to AIS Jamaica and its sister company, AIS Cayman Ltd. 

Prosecutors allege that Watson and his business partner Jeffrey Webb controlled the local arm of AIS from behind the scenes using “sham” directors. The two men then funneled profits made by the local company to other accounts they owned or controlled, the Crown alleges. 

In addition, both Watson and Rodriguez are accused of transferring criminal property, namely earnings from the CarePay contract, to Webb. Both Watson and Rodriguez have pleaded not guilty to all charges. 

4 percent ‘robbery’ 

The initial contract between the local public healthcare system and AIS called for the Jamaican-St. Lucian company to set up an electronic system that would first verify a patient’s health insurance coverage and then “adjudicate” their claims – to determine how much the patient’s insurance would pay and how much the patient owed. 

The plan was for both of these functions to be performed through a single “swipe” of a hospital patient’s “CarePay card” – which worked much like a credit card. 

For these services, AIS would receive a 4 percent “transaction fee” for every patient card swipe. So if a patient’s insurance was charged $100 for a doctor’s visit, $4 would go to the contractor providing the service. 

“This amounts to highway robbery,” Mr. Sanders said of the 4 percent per transaction fee. “This is an atrocious, excessive amount for claims processing. Normally you would expect to pay pennies on a per-claim basis.” 

In the U.S. healthcare system, for example, Mr. Sanders said, a provider would charge 20-25 cents per transaction, regardless of the services billed. 

Mr. Sanders testified that he had never seen the original CarePay contract between AIS, the Health Services Authority and the Cayman Islands National Insurance Company before it was signed and only discovered the details months afterward. He said he repeatedly had to demand a copy of the contract before it was given to him. 

Mr. Sanders further testified that no one else on the technical committee that evaluated the AIS bid would have known about standard norms for such charges in the healthcare industry and that his input on the contract for such a technical operating system should have been sought prior to approval of the contract. 

As time went on and the initially scheduled implementation date for the CarePay swipe-card system looked less and less likely, Mr. Sanders testified, hospital staff and managers were under significant pressure from Watson to make “something” happen with the project by July 1, 2011. 

“Mr. Watson continued to invoke the interest of the premier and [health] minister in this project,” he said. “We had to have something by July 1 … so that they could declare a political victory.” 

It was at this point that Mr. Sanders sent an email to an undisclosed individual or individuals that stated his concerns about corruption in the AIS-CarePay project. 

Despite these concerns, Mr. Sanders agreed at Watson’s request to stay on and finish the implementation of the CarePay project, prosecutors said. 

“I had no proof of [the corruption], so I was still trying to be a positive member of the community and finish a project that HSA and CINICO had committed to,” he said. 

Meeting in Washington 

Mr. Sanders testified that, shortly before he left the Cayman Islands in September 2011, he traveled to Cayman Brac to tour Faith Hospital and to meet with Nancy Kirkconnell-Ewing, who was involved in Brac Informatics – another company that had wanted to bid on the hospital contract. 

During this visit, Mr. Sanders said he made what he regarded as confidential allegations to Mr. Kirkconnell, Mrs. Kirkconnell’s brother, about the corrupt actions of several figures he believed were involved in the CarePay deal. Those individuals involved included Watson, former Health Minister Mark Scotland and former Premier McKeeva Bush, Mr. Sanders said. Following Cayman’s general election in May 2013, Mr. Kirkconnell’s political party, the Progressives, was elected as Cayman’s government. 

In the summer of that year, the court heard, Mr. Sanders was in Washington on other business and, during the trip, met with Mr. Kirkconnell – now the deputy premier – and Minister Bodden – then the minister of health. 

“What did they want to talk about?” Mr. Burke questioned. 

“They wanted to talk about this situation [referring to the CarePay contract issues] and Minister Bodden wanted to talk about the development of this strategic health plan,” Mr. Sanders said. 

Mr. Burke asked, “Did the deputy premier promise you a … consultancy agreement if you helped them?” 

Mr. Sanders replied, “No, and I was not interested in that. Now, advising Minister Bodden on his strategic plan [for healthcare]. I would be interested in that.” 

Mr. Burke pressed Mr. Sanders on whether he was actually given another contract with the current government, but Mr. Sanders said he could not recall or could not provide the details of any payments. 

Asked whether he had provided reports of corruption to the Royal Cayman Islands Police prior to leaving the islands, Mr. Sanders replied that he did not “know who to trust” and that he was worried about his family’s safety while they remained here. 

He alleged that he feared certain individuals might try to “plant drugs” in his Cayman residence or “put pornography” on his computer in order to discredit him.  

Commitment 

It was Mr. Sanders’s stated commitment that drew rapid-fire questions from Mr. Burke during cross examination Thursday. 

“Did you buy into this enthusiasm [for the CarePay project] really?” Mr. Burke asked. 

Mr. Sanders said the concept was revolutionary and that he was “excited” by it. 

Why then, Mr. Burke asked, had Mr. Sanders – as a member of the technical evaluation committee for the project – been absent from the entire presentation about it from AIS Jamaica? 

Mr. Sanders said he recalled that Nov. 17, 2010 committee meeting and said he was only absent for about 15 minutes to deal with an IT emergency in the hospital’s radiology department. 

“Nonsense,” Mr. Burke said. He indicated records obtained by the defense noted that Mr. Sanders had gone to Owen Roberts International Airport that afternoon to pick up his girlfriend. 

“You missed the entire AIS presentation [at the meeting],” Mr. Burke said. “You weren’t at any emergency at the hospital.” 

Mr. Sanders said he could not remember the exact dates and if what Mr. Burke said was correct, he apologized. However, he noted that he felt it was still unfair for Watson to exclude him from the bid committee’s recommendations. 

That exclusion, he said, had cost the HSA and CINICO in terms of determining what was best for health services in the Cayman Islands. 

Cayman Islands Corruption Trial, Day 1

Last week, I testified in court about a corruption trial in the Cayman Islands. Below is a summary of my testimony that originally appeared in the Cayman Compass newspaper.

CarePay trial: Witness says 'half dozen' companies wanted CarePay deal

About “half a dozen” companies, both local and international, had expressed interest on bidding for a Cayman Islands public hospital patient swipe-card contract prior to the contract being awarded to a Jamaican-St.Lucian firm, according to the former chief information officer for the local Health Services Authority.

Dale Sanders testified via video link Wednesday that he was “reprimanded” by former Cayman Islands Health Services Authority board chairman Canover Watson in late 2010 when Watson learned Mr. Sanders had put government bid request documents on his healthcare blog.

Mr. Sanders said he wanted to expand the bid process as much as possible so that the HSA and the Cayman Islands National Insurance Company could “benefit from that competition.”

Mr. Sanders said Watson called him into a meeting later and reprimanded him “quite harshly” for putting out the contract bids for a real-time healthcare claims verification system in such a way. Mr. Sanders said he was told the bids were intended only to be advertised locally.

However, one of the interested companies, Brac Informatics, was a local firm on Cayman Brac. That firm, along with several other companies that had contacted him, were unable to bid because of what Mr. Sanders referred to as an “unprecedented” short turnaround time on request for proposal documents.

Watson has been accused by Crown prosecutors of personally benefiting from the eventual award of the CarePay swipe-card contract to St. Lucia’s Health Adjudication Systems and its local partner, AIS (Advanced Integrated Systems) Cayman Ltd. – an award he is alleged to have directed as chairman of the HSA board.

Watson and his business partner Jeffrey Webb are alleged to have set up AIS Cayman Ltd. as a front company to cover up their involvement in the scheme.

In addition, Watson and his former personal assistant Miriam Rodriguez are accused of transferring criminal property, namely funds from the CarePay contract, to Webb. Both Watson and Rodriguez have pleaded not guilty to all charges.

During court testimony Wednesday, Deputy Director of Public Prosecutions Patrick Moran revealed that another company, Caribbean Network Solutions, had expressed interest in the hospital contract. Mr. Sanders said he was unaware of this particular company, although he did list the names of several others.

Questions posed by that company in relation to the government’s request for proposals on the hospital contract were sent to Watson, Mr. Moran said. These were technical questions which, Mr. Moran said, an IT expert like Dale Sanders would have been able to assist Watson in answering.

Reviewing the list of questions from the Caribbean firm, Mr. Sanders said: “These are good questions. I’ve never seen this before.”

Dismissed

Referring to AIS Jamaica’s (the sister company of St. Lucia’s Health Adjudication Systems) eventual bid on the hospital contract, Mr. Sanders described it as “terrible.” He said responses given by the company were vague, non-specific and incomplete.

“It was by far the worst response, on paper, of any of the proposals,” Mr. Sanders said.

During a November 2010 evaluation of the two competing bids that were received for the hospital contract, Mr. Sanders said he was dismissed from a technical committee meeting by Watson after he stepped out of the proceedings for “no more than 15 minutes” to deal with an IT emergency at the public hospital’s radiology department.

Mr. Sanders said he thought this was “inappropriate,” and that he attempted to stay in the room following a break in the meeting.

“We went back into the committee and Mr. Watson announced that I would be dismissed,” Mr. Sanders said. “I felt it was completely inappropriate and would not benefit [the process of making] a good decision for HSA or CINICO.”

Watson’s attorneys had not cross-examined Mr. Sanders as of press time Wednesday. However, his defense team has suggested during other witness testimony that the CarePay claims adjudication system offered by AIS Jamaica was a “unique” system that offered precisely what the local healthcare industry required.

Lawyer’s advice

The final contract for the CarePay patient swipe-card system between the HSA, CINICO, the Jamaican-St. Lucian company and its local partner AIS Cayman Ltd. was never reviewed by government lawyers in the solicitor general’s office, jurors heard late Tuesday.

Instead, the contract was perused by then-HSA board member and Maples law firm partner Wanda Ebanks, who testified Tuesday that she was asked by Watson to look at the agreement “as a member of the board” to assist her fellow board members.

Ms. Ebanks, under prompting by Mr. Moran, testified that she was surprised to get the contract “at the last minute,” but denied suggestions by defense attorney Trevor Burke, QC, that she received the contract because she was Watson’s “go-to lawyer.”

Mr. Moran said the proposed contract between AIS Cayman Ltd. and the health services agencies appeared to “bind the hands” of the public hospital system, requiring it to spend more than US$13 million over five years and requiring another five-year renewal unless either party issued a termination notice a year prior to the contract’s end.

Ms. Ebanks testified that she had written a note during her examination of the AIS contract that indicated “it’s even worse than Cerner” – the U.S.-based firm that previously handled HSA’s patient information services.

Mr. Burke objected, stating that Cerner’s previous contract could not be compared to AIS because the AIS deal provided a “get out” clause for both parties where Cerner’s did not. He also alleged that Mr. Moran was “leading” Ms. Ebanks to her answers. “This is just not an appropriate examination of the witness,” he said.

At this point, Judge Michael Mettyear intervened in the proceedings, seeking to clarify what would have been expected to occur if AIS Cayman did not agree to contract changes Ms. Ebanks suggested.

“I would expect it would have been sent back to the board,” Ms. Ebanks said, stating she did not review it in detail again. A version finalized on Dec. 5, 2010 was approved by the HSA board on Dec. 7 and signed by government on Dec. 21.

Living a Conscientious Life

Amazing...This is a picture of Vic Sundquist, 95 years old, in the log cutting contest at the Dolores, Colorado Escalante Days celebration last weekend. A better man and person, you'll never meet. 

He and our dad worked together in the logging camps and mountain forests above Dolores, affiliated with the now-underwater logging town of McPhee. In their time, logging was the gold rush... the dot com era of their generation... where young risk-taking men could make their fortune. All of those young men would later take that same courage and toughness into WWII. Poor Germans and Japanese didn't stand a chance.

As kids, we had the blessing of being able to sit around and listen to their stories. Those stories shaped our perception of what it meant to be men, husbands, and fathers... And especially what it meant to live a life with a mischievous sense of humor, a sense of adventure, and live life in such a way that you have memories and stories to tell... like having the gumption to join a log cutting contest when you're 95 years old and cut through that log in 22 seconds. "Live your life the right way, not half-assed. For hell's sake, get up early and make your bed the right way. Tuck in your shirt and wear your hat the right way. Mend the fence the right way. Set the water the right way. Stack the hay the right way. Feed, water and take care of your horse the right way, first, then yourself. Drive your car and truck and take care of them, the right way. Open the door for women. Love and protect everyone's children, not just your own, at all costs. Grab for and fight over who pays the check at the restaurant. Wave gently to oncomers when driving on backcountry roads. Hunt and fish because you love Mother Nature, not because you love a trophy to yourself. Climb a mountain so that you can see, not so everyone can see you. It's ok to stretch a tall tale once in awhile, but never, ever lie or cheat. Help someone who needs it, but be very reluctant to accept help yourself. Stay strong and independent." These are not their words, but their actions. I guarantee that Vic Sundquist oiled, tightened, and sharpened the blade on that chainsaw, himself, the right way.

This is conscientious living.

Much later in life, after Vic's wife and our dad passed away, our mom and Vic struck up a mini-romance, mostly just a deep friendship, that never ended. Mom would often say, "He is such a good and interesting man." And that he is. And that they were.

To Do List for a Healthcare CIO

I was searching through some files today, looking for something else, when I came upon this. It's my "CIO Watch List" from November of 2012, while I was CIO for the Cayman Islands Health Services Authority.  One of the fun things about being a CIO in any industry, healthcare or not, is being able to learn from and interact with virtually everything that goes on in an organization. Information systems, software, and data are the backbone of all modern companies. The CIO knows a little bit about virtually everything in the company, and a lot about a few things.

Here's the list. I won't even try to describe the entries, but rather leave it up to the reader to have a crossword puzzle opportunity to decipher them.

0-6 Month Priorities

Infrastructure & Technology

1. Telephone Modernization
1. Updates to messages and tree
2. Physical and environmental audit of closets
3. Automated Call Attendant -  Contact Center Software
4. Call Accounting Reports - TIMS
5. LCR Update
6. Conference Bridge
7. Unified Message (Voicemail)
8. SIP
2. Mobile technology options for clinicians - iPads
3. CCTV – Project 
4. Disaster Avoidance Modernization
1. Sign Points of Failure – ASA Firewall and Core Switch
2. SQL Server (Upgrade)
3. Full DR test
4. Citrix DR with BIC
5. Desktop Modernization: PC metrics - PC-to-Staff ratio
6. Network Modernization:
1. Fibre to Clinics (BT and WB)
2. Active Directory Reengineering & auditing
3. Reengineer the IP schema
4. VPN/Firewall enhancements
5. Network Authorization Control
7. Printer Modernization:  Metrics, maintenance contract
8. IT Policies Update
9. CUC Downtime enhancements (Printer Bank ,Hubs, Ref. Office, Phones)
10. Equipment Depreciation Plan (Switches, PCs, UPS etc...) 
11. Network assessment 

Clinical Systems

1. Pharmacy System Modernization
2. Cerner Re-Tender
3. BMJ/Chronic Condition Management Project
4. Mobile Clinical Strategy
5. APACHE scoring in CCU (Hold)
6. Semantic text search
7. Dynamic Documentation - Nursing
8. Software for Dr. Clem

Financial and Administrative Systems

1. CarePay Project
2. Reprocessing
3. Lock Box for Self Pay EPOs
4. 835 Interface
5. HSA Web Site Modernization
6. Maintenance Management System - FMIS
7. Centralized Admissions
8. Cerner scheduling and registration in clinics
9. E-Billing/E-Payment
10. HSA Intranet Upgrade
11. Charge Master management: Craneware utilization
12. Configuration control, pricing methodology defined with CINICO
13. PAIN Management Project
14. OR Requests (Intranet)
15. HR Intranet Forms

6-12 month priorities

Infrastructure & Operations

1. Patch Management: Windows, Java, Adobe, Office, IE 9
2. Storage Management Metrics and long term growth strategy
3. Autologon to PCs in certain areas; Cerner auto logoff in OT
4. PCLA tested and working to new Service
5. Windows 7 Upgrade
6. Enterprise intrusion and vulnerability scanning
7. Dedicated Private Line vs. MPLS
8. Upgrade Citrix remote access network connection from Logic 2M
9. Hosted email strategies: Brac Informatics, Microsoft Outlook

Clinical Systems

1. Cerner optimization or implementation of new system
2. Medication Order Entry
3. Bedside bar coding
4. Nursing supplies and medication dispensing & management system (PICIS)
5. Easier, faster logon for clinicians
6. Document scanning & multimedia image storage in Cerner
7. Finish deployment of Web cams in outlying clinics and specialists
8. Telemedicine strategy
9. PACS web link in Cerner
10. IMO for Procedure implementation

Financial & Administrative Systems

1. ICD10 migration
2. End of Shift & Bank Deposit Reports
3. Gold Standard Reports
4. GL interface from ProFit

Longer Term Priorities

Clinical Systems

1. FetalLink/Partograph
2. Mobile results 
3. Personal Health Record
4. Cerner Fax Server Assessment
5. E-Prescribing
6. Cerner LightsOn Utilization
7. Convert Surgery spreadsheet to a database
8. GE PACS ADT Integration with Cerner
9. Dental Medical Record and Billing system

Financial & Administrative Systems

1. Automated envelope processing
2. Migration to ICD10
3. 1500 Interface developed
4. Procurement and Materials Management System

Healthcare Data Governance in Collaboratives and Partnerships

The number of mergers, acquisitions, and collaborative partnerships in healthcare continues to skyrocket. That's not going to change for the next few years, unless the FTC decides to be more restrictive. In all of these activities, older generation executives (I can say that because I'm older) have underestimated the importance and difficulties-- technically and culturally-- of integrating and governing data in these new organizations, and the difficulties are exponentially more complicated in partnerships and collaboratives that have no formal overarching corporate governance structure. In 2014, one-hundred percent of Pioneer ACOs reported that they underestimated the challenges of data integration and how the lack of data integration has had a major and negative impact on the performance of the ACOs.

After 33 years of professional observations and being buried up to my neck in this topic, especially the last two years as the topic finally matures in healthcare, I'm convinced that the role model organizations in data governance, practice it seamlessly. That is, it's difficult to point a finger directly at a thing called "Data Governance" in these organizations, because it's completely engrained, everywhere. It reminds me of the US transition in the early 1980s when organizations finally realized that product quality was not something that you could put in an oversight-driven Quality Department, operating as a separate function. Quality must be culturally embedded in every teammates' DNA. Data governance is the same, especially data quality.

This week, one of my teammates sent me an email, paraphrased and anonymized below:

"We are headed to John Doe Health Center Network next week to talk to them about how we can help them with analytics/quality improvement. This organization provides managed care services to 8 community health centers in their county and our main champion is fighting for a shared analytics platform. Since they do not own any of the health centers, they are struggling with how to establish data governance with this type of environment (rather than a single entity). 

Do you have any recommendations or talking points that we should make clear with this group as to how they may find success with this model?"

Here is my response:

"It's the soft side of trust and leadership that makes these things possible. The [anonymous] project that I've been working on in [another country] has firmly crystallized in my mind that the success of these data sharing initiatives comes from 90% diplomacy, 10% technology; and genuinely finding a way for the contributors of data to the platform to receive more value from their contribution of the data than if their data were not shared. That's data synergy.

The facilitator/leader of the data sharing initiative has to wriggle their way through all the participants' motives-- that leader has to craft a strategy and broker the personal relationships that provides compelling and attractive data value back to each of the participants. The participation in the data sharing initiative must scratch every organization's need for increasing the mastery of their mission; increasing the organization's autonomy to execute their mission without having to coordinate and ask for more permission from members of the initiative; and the data has to feed the organization's desire to be a part of a purpose that is larger than themselves.

In this sort of setting, you can start by chartering a steering and governance committee that is comprised from volunteer representatives in each organization. Simple things get complicated quickly, but can be solved. For example, who has voting rights on the committee (Biggest data contributor has the most voting rights or is this going to be a Senate model?) and who is going to chair the committee that is trusted and respected by all members?  Who is going to contribute money to development and operations of the shared data platform and how are you going to calculate those relative contributions?  What are the subcommittees and working groups and who is going to lead those? Long term, in these settings, you need to plot a trajectory towards creating a separate legal entity and small company that can manage the asset, manage the funding, leverage the asset to the value of the organizations, and handle liability, data commercialization, etc. issues that will eventually emerge.

"Fighting" for a shared analytics platform won't be successful. The leader has to sell the vision of data sharing… the data synergy that comes with it… and "what's in it for us?" so that organizations are fighting to get in, not fighting to stay out. The mantra I use in these situations is: Stop convincing and start connecting."

Data governance in healthcare today feels like the quality movement of the US in the early 1980s. Data governance cannot act or feel like a separate, technology-driven entity. Successful data governance is culturally embedded and in those cases where sharing data is important to loosely affiliated organizations, the leader of the effort to bring that data together and leverage it for the benefit of the participants must be a data-savvy version of Henry Kissinger.

Leadership in the Participation Age

First things, first, I want to acknowledge fellow-Coloradoan Chuck Blakeman for inspiring me to write this blog. His philosophies about business leadership resonate with me, and much of the content of this blog, below, are a direct reflection of his insights. For years, I've thought that my philosophies about corporate culture and beliefs were too unusual to practice openly, but Chuck motivated me to come out of the closet.

This blog is an amalgam of thoughts and feelings related to corporate leadership and culture, and it starts with my basic belief that 95% of all humans are great people who, if given the right environment... the right soil... they will flourish on their own, with very little needs-- give them a caring, compassionate, supportive environment, then get out of their way and let them grow. As Mr. Blakeman explains, we have transitioned from the Industrial Age to the Participation Age-- from employees to stakeholders and those stakeholders are running the corporation, not the other way around. The average Fortune 500 company grows 110% over 10 years. Jim Collins "Good to Great" companies grow at 316%. Participation Age companies grow at 1,025%.

The underlying business premise here is this, as recently described by Paul Girouard, former President of Google Enterprise Apps: "All things being equal, the fastest company in any market will win", and all companies operate at the Speed of Trust. Decision speed matters and is largely determined by the degree of trust that exists between members of the company.

Below is a verse from the 17th century priest and poet, John Donne, that beautifully describes the philosophy of human "connectedness"-- that we are not disconnected individuals, but rather all part of the same ecosystem. What happens, good or bad, to one of us, somehow ripples through all of us. We are all participants in the same inseparable network of humanity, just trying to get along and get through our lives with as much fulfillment and happiness as possible. You will recognize this poem as the inspiration behind Ernest Hemingway's, "For Whom The Bell Tolls."

No man is an island,
Entire of itself.
Each is a piece of the continent,
A part of the main.
If a clod be washed away by the sea,
Europe is the less.
As well as if a promontory were.
As well as if a manor of thine own
Or of thine friend's were.
Each man's death diminishes me,
For I am involved in mankind.
Therefore, send not to know
For whom the bell tolls,
It tolls for thee.

Participation Age organizations understand this sense of human connectedness. Operationally, below are some of the characteristics of these organizations, as summarized by Mr. Blakeman:

1. Email is an interrupt, task driven, first generation technology tool for collaboration. In Participation Age companies, email has been replaced entirely or significantly by third and fourth generation collaboration and project management tools.
2. Meetings have been dramatically reduced or eliminated; communication occurs through collaboration tools.
3. There are no managers, managing people. Managers have been replaced by leaders and mentors.
4. There are no personnel evaluations.
5. They believe that the art of leadership is how many decisions you don't have to make. Every decision you make as a leader is a lost opportunity for mentoring, learning and leadership development.
6. They believe that managers focus inappropriately on processes. Leaders focus on results.
7. Managers delegate tasks. Leaders delegate authority.
8. In the Industrial Age, we traded time for money. In the Participation Age, we trade money for time. Give people control over their own time. Focus on results.
9. ​Trust in adult behavior.
10. ​Everyone's work rhythm varies according to when, how, and where it works best for them. Acknowledge and allow for that whenever possible.
11. Question EVERY decision with at least three Why's?
12. Allow and encourage stakeholders/teammates to bring their whole messy, creative person to work. Make no false distinctions between personal and professional lives.

I suspect there are many of you, like I was, who are afraid to be "outed" for believing such crazy philosophies. If enough of us come out, we become the majority and crazy becomes the norm. That's how significant change in human culture always happens. What was once crazy is now the norm.

Make it happen and have fun doing it.

Very Cool Company: healthfinch

I almost titled this blog, "The Efficiency of Delegation: What US Healthcare Can Learn From The US Military."

For those who read my blog, it will come as no surprise that I often mention the incredible lessons learned and experience gained during my Air Force career. I wouldn't trade those years for anything, in no small part because my military service was the best training for a business career to come. In the Service, the guiding principles of honor, respect, teamwork, discipline and persistence are critical when building highly competent teams who can take on any mission, big or small. One of the reasons that the troops in the US military function so very well is the cultural strategy that places enormous emphasis on effective delegation of authority to the lowest levels possible to achieve a desired mission, and likewise, a culture that recognizes the need for rapid upward escalation when a situation requires it.

Recently I learned of a company called healthfinch, which makes Care Redesign applications that bolt on to EMRs (they are best integrated with Epic, but also working with Allscripts and will soon have products for Cerner) to automate, delegate, and simplify clinical workflow tasks. Currently, managing these clinical tasks, like prescription refill requests and laboratory results, most often falls on physicians who end up spending 2-4 hours per day sifting through hundreds of inbox messages. The sheer volume of these non-reimbursable, routine and repetitive tasks has become toxic to physicians, and is oft cited as a chief reason that nearly 88% of physicians are burnt out. Ironically, as reported recently by Bain, physicians who work in physician-led organizations are even less satisfied than their counterparts. We are at risk of losing one of healthcare’s most valuable resources.

As great organizations and the US military know well and healthfinch has figured out, delegation of tasks to the most efficient venue of completion is the most efficient way to run an organization. In the military, each person has training and a rank that comes with a defined scope of authority and they are expected to execute based on their role. Commanders set the strategy and delegate the planning to their top brass. The top brass creates a detailed plan and then they delegate tactical execution to the junior ranks, and so on. This workflow, in which all parties have well defined roles based on their authority (read: credentials), creates order, efficiency and, one could argue, ensures the safety of everyone on the team. Would it make any sense for the highest-ranking commander to get “into the weeds” and call in strike coordinates or type up a memo? No, and during the Vietnam War our US military learned that the hard way.

We must think in these terms in healthcare too, specifically regarding clinical workflow.  We need to respect the authority and training of each healthcare professional in the “chain of command” and make sure that they are working to the absolute top of their license—yet not above it or below it. Physicians are healthcare’s general officers-- our chief strategists if you will-- and should be available for managing the most complicated and high risk patients. They must be empowered to delegate routine patient care and clinical tasks to their staff, like physicians’ assistants and nurses. And then, those individuals must be able to delegate further to medical assistants and health coaches. If a physician is spending 2-4 hours per day on managing routine clinical tasks, the delegation system is broken, resulting in huge inefficiency and uncertainly in roles, staff unhappiness, escalated costs, and poor patient care. I’ve spent a fair amount of time in international healthcare settings the past few years, where clinical outcomes are higher and per capital healthcare costs are much lower. One of the common traits in these other countries is delegation of decision making and patient care to the most efficient venue. They empower nurses, PAs, and pharmacists, in particular, to care for patients and make clinical decisions that the US system constantly escalates unnecessarily to physicians. Part of the problem in the US system is the fee-for-service economic model that encourages this escalation. As soon as we become a margin and quality-driven economic model—and we are getting there-- I’m sure that delegation of tasks will be more widely accepted as the norm. Over 80% of physicians now “agree” or “strongly agree” that controlling costs is part of their clinical responsibility; we need to give them the systems and technology to enable that.

healthfinch gets it. They see the undeniable value and inevitable trend towards delegation and automation of tasks in healthcare. They get a “Very Cool” endorsement from me because they are taking delegation and top-of-license performance very seriously. Their flagship application, Swoop™, an app that automates the prescription refill process, has transformed workflows in many client sites. Physician inbox tasks for refills have been reduced by 70%, freeing them up for more direct patient care. They delegate more to nurses, who are now empowered to handle on-protocol requests in a matter of seconds, not minutes. And patients are receiving responses to their refill requests in less than 24 hours instead of 72 or more in a traditional manual approval model.

healthfinch is able to accomplish these efficiencies through automation, but only because their clients: (1) Recognize that their staff must be given the authority needed to do the job, and (2) Safely delegating the right tasks to the right people makes sense.

If your organization is seriously thinking about redesigning care delivery, I suggest you talk to the folks at healthfinch. They’ve got the right idea, and the right product, at a time when healthcare needs it most. I think you will be impressed. Physicians will be really impressed and relieved to see the emergence of this type of company and product.

I receive no reward or compensation of any kind for endorsing-- or criticizing-- companies or their products, including healthfinch.

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