Former CareGroup hospital system CEO James Reinertsen reflects on the challenge of getting individual hospitals to function as a true system. Not probing deeply enough into leaders’ seemingly unanimous and enthusiastic support for going forward as one meant that unspoken dissent was not revealed or processed. The veneer of agreement had consequences for both the CEO and for the confederated hospitals’ ability to coalesce as a system.
James Reinertsen: In 1998, I went to Boston to take the role of CEO of a six-hospital system, CareGroup. I’d had a big flagship hospital at Beth Israel Deaconess, which was in itself a merged hospital between two very different hospitals, the BI and the Deaconess, but five other hospitals as well, and this system was more of a loose aggregation than a real system. Everybody understood that, were quite honest about it. Basically it went out and borrowed money together, but otherwise behaved as six independent hospitals. As I realized this, I thought it would be important to get clarity about what their long-term intentions were. Were we going to become a real system, or were we just going to be a gaggle?
I was now about 3 months into my job as CEO, and it was such an important question for me, because everything we organized and did would depend on the answer, and besides, I actually didn’t want to be the CEO of a gaggle. I realized that as well. So, it was important for me personally. After a lot of planning and discussion, we got some 60 of the most senior leaders of this entire system, of all six hospitals — the board leaders, the executive leaders, physician leaders — into a very small space called the Design Shop in Cambridge, a crucible for working out stuff like this, and we spent I believe 3 days, some 16 or 18 hours a day, all together in this space trying to work out an answer to this question: Do we really want to be a system, or are we going to be content to be a loose collection?
At the end of the 3 days, I in effect called the question, “What are we going to do?” Every single person stood up on a stage and declared in a very enthusiastic way, “We are going to be a care group.” There were songs. There were skits. People had fun. There were hugs. It was unanimous, and I drove home that evening around midnight, and I remember a feeling of disquiet. But I thought, “Wow. We are really going to do this.” And the next day, literally the next day, I started implementing the things we had decided to do, because we had to ask the question, what would it mean? And they had to have a plan. So, I put the plan out for everybody to see, and started going forward with it.
Within 24 hours after that, the undermining and dismantling of this plan began, in not rare instances led by some of the very people who were in the room, involved. And the profound lesson for me as a leader from this one was, first, that it put me in a very awkward spot. I’m up there now publicly saying we’re going to do this, right? Some of the very people who had helped me come to that conclusion — unanimously, let me remind you — were saying, “No, no, that’s not what we said,” or whatever. The leaders I’m reminded of when I tell that story to people are both Alfred Sloan and Abba Eban. Abba Eban said, “A consensus is when everybody says publicly what nobody thinks privately.”
And Alfred Sloan said something that I should have known at the time I did this. If I had seen this statement from him and thought about it, I would’ve done the right thing, but I didn’t. He said, to the board of General Motors, “Gentleman, it appears that we are in complete consensus on this issue. Therefore, I suggest that we table it, and wait for 2 or 3 weeks so we can develop some disagreement about the issue so that we can understand what it’s really about.” I did not say, “People, let’s just take a pause and develop productive disagreement,” which would have exposed some really interesting issues I should have known about. I would have done things very differently, had I actually exposed them.
I think we learn more lessons from failure than we do from success. This was a lesson I learned from failure, and a very important one. The question really remains, “What could I have done differently?” I suppose, in the moment when this consensus was now overwhelming this group.
And it would have been hard for somebody who really disagreed to actually, at that moment, late in the process, say, “No, no, no, I think this is lousy.”
There was kind of a crowd mentality, not in a riotous way, but in a unanimous way. Somebody in the room — it could have been me, it could have been somebody else — needed to raise the question, “People, is there a crack in this someplace? Is anybody in this room feeling uncomfortable right now?” That might have been a question I could have asked, and, “If so, please speak up, because we need [to hear it],” and do it in a way that’s not calling them out as somebody who’s deviant from the rest of the group, but as an important source of information for us.
If you look at the adaptive leadership model of [Ronald] Heifetz, in his model is to seek out the voices of disagreement, the ones that people aren’t listening to, and bring them out, because they often are speaking the truth. And I failed to do that. I teach Heifetz’s model. Ron and I worked together with our management team on this kind of stuff, and I failed to eat my own dog food in this particular, didn’t even use what I knew should have been done. And I think I was seduced by the same way — it was fun to realize, “Wow, they’re really committed to this, and they’re behind me, and good.” That’s sort of what I wanted them to say, so I wasn’t actually trying to bring out the other voice that was in there. So, yes, I’ve got a lot of personal responsibility for it, not having generated the productive disagreement.
I should have done what Alfred Sloan said, just, “Okay, folks, that seems great. Let’s wait 2 weeks and see if it sounds as good 2 weeks from now as it sounds now.”
This story was recorded at the Institute for Healthcare Improvement’s 28th Annual National Forum in Orlando, Florida, on December 4–7, 2016 by Mary Jane Kornacki on behalf of NEJM Catalyst and originally appeared on the NEJM Catalyst website on February 28, 2017. We wish to thank IHI for support of this project, especially Madge Kaplan for her technical advice and guidance. Click here for more Lessons in Leadership stories.
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Tyler Smith
I'd like to hear more about where you went from here. As a very recently retired (and somewhat disillusioned) employee of a health care system in Colorado, I found the momentum leadership generated in favor of system building discouraged questioning, not so much through overt hostility but rather through the underlying message that the changes were inevitable. It seemed that fundamental questioning of the decisions was pointless.
March 06, 2017 at 8:02 pm
Jim Reinertsen
Tyler, one of the most important principles about "systemness" is this: in order for a system to perform optimally, one or more parts of the system must be sub-optimized. In the case of CareGroup, this meant that some hospitals or other parts of the system would need to either close or face radical change, so that the whole system could perform at its highest potential. This proved to be very difficult to implement, despite the apparent consensus from all leaders saying "we want to be a system." The lesson here is that when it appears you have consensus to do something this difficult, it's the responsibility of the most senior leaders to ask for dissenting opinions. If they're not willing to hear them, they're putting their heads in the sand, and are going to face serious risks going forward.
In my case, I was able to implement SOME of the plans, such as some serious restructuring of governance to reflect a system perspective. But other changes--e.g. selling one hospital's physical campus and moving that hospital to another campus to be a "hospital within a hospital" were never achieved, due to intense local opposition. (I'm told that idea has resurfaced, almost 20 years later, so maybe it was before its time, but still...it would have caused one hospital to be "suboptimized" in order to optimize the whole system.)
The key idea: don't accept consensus that's too easily achieved. There are always voices of opposition. Bring them out. Listen to them. Sometimes, they are right. Sometimes, they're wrong. But bring them forward, and consider them.
March 07, 2017 at 8:13 pm