Saturday, September 24, 2011

Hope where we forgot to expect it

Dr. Jeffery Brenner, of "hotspotters" fame lights up the room at The White House meeting Tuesday with laser-sharp data about the illogical waste in the health system of Camden New Jersey (and pretty much everywhere). Katherine Gottlieb of the South Central Foundation (Nuka) in Alaska had just finished laying out that stunning model. Bobby Baker and Teresa Cutts opened the hopeful trifecta explaining the "Methodist Memphis Model of hundreds of community partners."

At least 100 people--more than 20 of which were CEO's of major health systems--crowded the room. I'll post links to the extraordinary power points and summaries of the meeting when they are ready.

I had the privilege of giving opening comments in place of Gary Shorb, Methodist Healthcare CEO, whose mother had emergency surgery. Here are my comments:

We come to this White House aware of our many roles: we are citizens, believers, administrators, healers, sons of mothers, sisters, neighbors and, yes, even policy wonks. We will speak out of that complexity in different ways as together we try to catch a vision of what is practically possible and how we can help each other make the possible come quickly.

Why are we here? This is a mean and bitter time in public places; the poor and the sick resented by the powerful for making inconvenient claims of mercy. So it is curious that this Tuesday morning this small group of faith and community based hospitals meet with government partners at the White House to do some opportunity solving. The focus is on how to weave the extraordinary 21st century technologies with the tenacious capacities of the love-based, justice-seeking institutions still accountable to faith or community.

This is no time for happy talk, as health organizations and government face uncertainties too numerous to list. We usually forget that the most disruptive uncertainties are good news, not bad, including the most obvious; successful policies and partnerships have resulted in most of us living inconveniently long.

Technologies today let physicians see blockages in arteries in real time 3-D allowing robotic surgeries quite recently unimaginable. Every specialty rides a wave of technical innovation that propels it almost faster than can be described. The disruption comes because the technologies that change the possibilities also change the relationships between specialized roles rooted in the previous technologies, back when nothing was digital, everything on film or paper. This kind of positive disruption dominates the attention of Washington because it changes who gets paid by whom.

Let's be clear what we are not doing: we are not pleading for our burden to be less; we want to be accountable for the effectiveness of our close working partnership with government so that together we bear the fruit we are intended to bear in health (Rev Dr Don Stiger of Brooklyn Lutheran not pleading...).

In Memphis, Methodist LeBonheur Healthcare reports $156 million dollars of "community benefit" including $104 million of the actual cost of charity care and another $21 million of cost for patients only partly covered by government. A similar amount goes to pay for training health professionals in partnership with publicly funded Universities in Memphis. We do not wish the amount to be less; we want it to be more effective.

All of the hospitals here today far exceed the level required by government. We are not trying to get around the system, we want to know how to form more powerful alignment between public, private and faith driven partners to generate more health.

Most of us are committed to do this in very tough communities, each of which we think is tougher than anyone else's. Memphis is a vortex of snarly, intractable challenges of race, class and ill health. But it is not any tougher than Jacksonville, Alaska, East LA or Brooklyn. And, truth be told, we love Memphis; we are here on purpose; and we want it healthier. Just as you do your community. So we are not here to complain; we want to learn with other partners who can help us be the institutions our communities need.

The most profoundly positive disruption of all may be the new relationship possible between hospitals and neighborhoods, especially illuminated by the bright light of 21st century science. Most diagnoses are no longer death sentences; not even AIDS, cancer or CHF. We live with conditions that would have killed us only recently, but we live in greater dependence on a web of partners. We obviously still need healthcare: insurance, pharmaceuticals, physician, other providers and, from time to time, hospitals. But now the journey of life includes family, congregation, social services and a host of wellness-enhancing helpers including community health workers. These are brains on the ground, not just boots on the ground. Our communities are filled with answers and assets, which we can work with, if we become teachable by those we previously only saw as liabilities and needs.

In a time filled with swagger and spit, venom and vanity you will find this room filled with the cool breeze of humility and the refreshing tone of adults trying to act like adults (two of them, Joshua Dubois of the White House and Fred Smith of Wesley Seminary pictured). The result is not predesigned to be revealed at the end of the meeting. Nothing will happen today that we ourselves do not create. It will come out of our conversation with each other about how we could be together to help us do the right thing in our own community, informed transparently by others trying to do similar work. That would help us in Memphis, so we hope for some ongoing relationship, especially in the practical spirit embodied in the Partnership office's work.

The quality of teachableness is what links three innovative health models held up like a lens: the way that Nuka in Alaska has built a highly efficient, broadly comprehensive system by listening with unfeigned respect to their native American members receiving their services; the radically useful intelligence Dr. Jeff Brenner discovered by following his most expensive patients home to the apartment buildings where they taught him the reality of their lives; the 376 covenant congregations of Memphis who are shifting outcomes data the hospital previously found inscrutable and intractable. These are disruptive models that decenter the hospital and drag the accountants outside the lines of their spreadsheets.

In a cynical time of diminished expectations from nearly everybody, hope simmers and bubbles as we ask, "How do we bring these disruptions to full bloom?" Innovation. Community scale. Faithful. Bold. Today.


- Posted on the journey

Monday, September 19, 2011

Reversing History

Most weeks going to the White House for an all day meeting would be pretty much the biggest part of the week. This week it is at least arguable that being part of a plenary panel for 1,500 wonks 10 miles North of 1600 Pennsylvania Avenue may be more significant. The panel kicks off the annual meeting of the Agency for Healthcare Research and Quality, a federal unit which sets much of the agenda about what and how the government measures what matters in health organizations. This year the focus is on how innovation and collaboration in healthcare can change disparities, access and quality of care.(ahrq.capconcorp/ahrq)

Not very long ago Memphis would be the negative case study because we get all three of those wrong so often. In recent years our quality inside the walls has gotten pretty respectable. But our patients don't live inside our walls; they live outside most of the time. And when they step one foot onto the sidewalk they can be back, not ten or fifteen, but 150 years, when race and class created vast differences in life expectancy and unnecessary suffering. Unraveling the mystery of why could take the full-time career of all 1,500 of my fellow-wonks.

Hospitals were rarely equitable in their healing effect on the community, since they were largely created out of the power and largess of the dominant political and philanthropic culture, which in Memphis was largely white. Employment, privileges to practice and basic access where unequal, even among the faith-based hospitals like Methodist Healthcare. We have worked very, very hard to reverse that history, but it does not help to deny it. (The picture is of Nelson Mandela's sleeping mat in his cell on Roben Island.)

The hope of healthcare is to for the powerful instituions to become teachable, not just by battalions of wonks and researchers, but by the mothers, brothers and neighbors who know the other part of what we need to understand about life in our tough city. They may not know the detailed etiology of diabetes, but they know about the lives in which that disease must be lived. The most powerful gain from our covenant with 376 congregations is to bring the hospital into an appropriate relationship where we can be taught and guided by them. Not all are "minority" (should be called majority in Memphis). But the blend of cultures and class is rich in wisdom and practical tactical insight. We all become teachable so that the blend of intelligence comes alive.

Not many data wonks will thrill at the previous paragraph. What measures and metrics? Gathered with what assurance of objective credibility? Translated exactly how across the different cultures? With what clinical processes administered by what credentialed individuals taught by who? Albert Einstein said that " if we knew what we were doing, we wouldn't call it research." I'm with Albert on this. But all the research questions must be pursued and answered and tested. That is how these organizations move, change and, eventually, change the bitter history into something that looks more like what God had in mind.

- Posted on the journey

Sunday, September 18, 2011

White House 2: DNA

The US News and World Report recognized our little hospital system in Memphis as the best in the region for the second year in a row, a fact which makes us very proud. The list of specialties in which we excel runs down the side of our largest hospital for four stories, as you can see. But if you look closely, "improving the health of the community" is not on the list. And it would not be on the list of any of the other hospitals the magazine honors. It is simply not something that anyone expects a hospital to be good at, much less excellent. But back a hundred years ago when our (and most every other) faith-based hospital was founded it was assumed that a great hospital would in fact, inevitably lead to a healthier community. It turns out to be harder than that.

The idea was that government would take care of public health prevention and surveillance (watch the movie Contagion, if you are wondering whether you need that....). And faith and non-profit agencies would get tax breaks to provide charity care. Nobody imagined it was possible to make a profit running a hospital and even it it was possible, it was a bad idea to try. Until this past year it was childishly easy to pretty much make up numbers proving that the tax waiver was justified, so gradually there emerged a whole category of hospitals that should be called Not-Not-For-Profits but Senator Grassly largely closed that loophole. Last month the State of Illinois, not known for its virtuous government, took away the tax break for a number of hospitals that were simply beyond the pale.

But nobody quite knows what to ask of the hospitals in terms of their role in generating the health of the community. The hospitals don't really know what to ask of themselves beyond taking care of a lot of people who can't pay. Should they also be expected to be a creative partner in advancing community health? How exactly would they do that and how would anyone know if they were good at it?

On Tuesday The White House and Department of Health and Human Services will convene a small group of health organizations to explore how communities are crafting partnership and programs that work for the good of the whole. The meeting is organized by Mara Vanderslice, Director of the federal Center for Faith Based and Community Initiatives ( The Center has a long bipartisan history, officially created by President W Bush and tweaked under President Obama. But the faith-government partnership has been gathering steam since Carter, Bush 1.0 and Clinton. Once could argue it has been in and out of fashion for 250 years, an acknowledged part of how America works since de Tocqueville wrote in 1835 (pictured).

The current meeting has blended DNA, part of which traces to the Interfaith Health Program at Emory ( and its long work with the Centers for Disease Control and Prevention. They jointly hosted a meeting at The Carter Center on the role of the "strong partners" years ago. It was curious about the role that faith-based hospitals (and the foundations that were sometimes created when they were sold) could more systematically contribute to the health of the public--not just their patients. That was the first time the phrase "religious health assets" was coined. And the meeting noted that "If you follow good science to the root causes of disease and injury, you will find more than a long list of individuals awaiting admission: you will find yourself struggling in a community with social incoherence." ("Playing to Our Strengths," Carter Center 1995)

The idea of religious health assets was later elaborated and deepened by the scholars of southern Africa, especially the late Steve DeGruchy (pictured) and Jim Cochrane, then the World Health Organization, especially Canon Ted Karpf and then hundreds of others, even in Memphis.

The other streams of DNA of the current discussions trace through the many particular histories of the hospital systems and the different way that science, faith and human communities combine and morph along their journey. Neither personal or organizational DNA is destiny, however. Genes are triggered by environment and in this case leadership, community and family. Sometimes a gene can be recessive for generations and then find its time has come. I think that's what happening Tuesday. The small set of hospitals coming to the White House Tuesday have in common the fact that are not afraid of the flux and tumult of our time, they are expressing their deep DNA. They are strong and while challenged, led by people who want their systems to fulfill the promise their founders--and their governmental partners--intended.

To do that the hospitals will need to learn from each other and government experts, as both also learn from the communities about what works and what is possible. That won't all happen in six hours, even at the White House. But in this mean and bitter time in Washington, it signals that it is a bit too early to give up hope that we can be the people our communities need us to be.

- Posted on the journey

Saturday, September 17, 2011

White House 1

On Tuesday morning about 20 health organizations, mostly large hospitals like Methodist Healthcare, will meet at The White House for a day of opportunity solving. We will not be coming to complain that we are facing harder challenges than any generation since humans figured out how to walk on two feet. It is a group of grown-ups trying to do what grown-ups are supposed to do--work together in the interest of those that depend on us to do the right thing.

These are tough times in more ways than can be listed in a blog. Government and health organizations facing radical changes driven by technology and global interconnectedness that has bound us together in ways we don't even know how to manage. We are swimming--almost drowning--in more information that we we can make any sense of. That's the new normal. But this is not entirely new, which is why I began with the picture of one of the bronze carvings on the front door of Grace Cathedral in San Francisco.

It is also still normal that adults try to make decisions to work with what we have to give hope a chance. When you fill up a room of 15 or 20 faith and community-based healthcare organizations and federal experts, you have a LOT to work with. Even one of the more modest systems--our own in Memphis--has 10,000 employees providing care to 64,000 inpatients and another quarter million outpatients every year. About 8% of our total revenue covers those who pay nothing, with another 2% only partly covered by the government and we still give another 2% to our University partners to train medical professionals. We absorb that $156 million and still have an A+ bond rating. It is quite a feat of skilled--faithful--management, but we and others like us do that. It is not a small point to note that these faith-based institutions accomplish this in very tight relationship to the federal, state, county and local governments beginning with the very large portion of our payments that come from Medicare or Medicaid, not mention the grace in not having to pay taxes. That's what we were designed by an earlier generation of grown ups to do and it works pretty well.

We are meeting at the White House because we think it could work even better.

Warren Buffet knows you make you most profitable investments when the market is paralyzed by fear. The most significant social investments are also made in times when things seem to be falling apart. You can make different connections and alignments precisely because the pieces are apart. When the ground shifts, new things are possible.

The picture is of the rock bent into gorgeous new shapes just north of San Francisco, which sits above the fault line. The earthquake shaking health organizations these days is the fundamental shift in science that has shaken our wall to the point they are almost irrelevant. The wall has collapsed between the old idea of public health (prevention, surveillance) and healthCARE (treatment, disease management). We all tend to live inconveniently and expensively long, precisely because of earlier success in both public health and the treatment organizations (hospitals).

Our common challenges are conditions we can live with over time, sometimes shockingly long periods of time even with AIDS, diabetes and many cancers that only recently were death sentences only demanding lament (hence the picture of the poignant AIDS Interfaith Chapel inside Grace Cathedral).

These high-capacity organizations built in one paradigm now have to re-organize ourselves around these new opportunities to extend the promise of 21st century science to our communities. That's really what is happening on Tuesday; not pleading, but planning how to be together in a new way so that all the assets are aligned to serve what is now possible.

That sounds so naive, doesn't it? But it is the cold truth that many billions of dollars of health assets will be in the room that are owned by and accountable to faith or community. Their adult leaders are paid pretty well to make sure those assets provide a maximum return on the investment measure in the health of the communities that have trusted them with such extraordinary possibilities.

From time to time it is still normal for adults to do the right thing. The United Nations was formed in the aftermath of the catastrophic events of World War Two, partly as a result of fervent prayers offered up and still remembered in Grace Cathedral (marked by this wall just inside the front door). Adults to that kind of thing. And they still can.

Tuesday's work is far less ambitious for we already have all the institutions we need. We just have see new ways to learn from each other and work with each other. We don't have to invent water, just rearrange the plumbing so that health--and maybe a bit of justice--can flow down as it is intended to do.

- Posted on the journey

Thursday, September 8, 2011

Dust and mist

Beneath hot blue sky,
baked green canvas,
shimmering air and
flowers laid
on polished copper
held above the open grave
by dull grey metal and webbing
they knelt by mounded dirt.

Jeff, then Sally,
Brother, Sister,
then John, Lauren
(son, daughter)

let the grey dust of Melinda
through their fingers
into the light
stealing sideways
under the tent
(as it sometimes does
through clouds after
a Delta storm).

Melinda drifted in
the last emptiness
between Jean and
Mike below

The grave breathed in.
And then, as gentle as a
memory of a smile
nearly lost,

Free as steam rising
from coffee on a cold day
sister dust
lifted as dry promise
into the beam
a last and only time
to wrap
over and around the family
entirely blessed
before the preacher said a word.

- Posted on the journey