It is a joy to have a son in college who is still interested in speaking to me, the old fuddy-duddy born in the Last Century. He is attending St. John’s College in Santa Fe, where they study the Great Books curriculum, or as his sister says, “Oh, so you read about ideas from old dead white men?”
It so happens that his class, which started with Aristotle, has worked their way up past Copernicus (my recent post on changing world-views), and now in the sophomore year, is now reading Machiavelli, perhaps my favorite of the classics, since it so much to say about the challenges of leadership.
Over dinner last week, my son and I discussed what I remembered from reading the Machiavelli’s “The Prince” in our Physician/APP Informatics Book Club (yes, we did), and the quotes that I use almost every week at work.
Why Change is Difficult to Lead
The reason that change in an organization is so difficult, is because at best, your proponents are lukewarm, and your detractors have ALL THE PASSION IN THE WORLD –CT’s recollection of quote
And it should be considered that nothing is more difficult to handle, more doubtful of success, nor more dangerous to manage, than to put oneself at the head of introducing new orders. For the introducer has all those who benefit from the old orders as enemies, and he has lukewarm defenders in all those who might benefit from the new orders… The lukewarmness comes from the incredulity of men, who do not truly believe in new things… –Original text from Machiavelli
How to Manage Bad or Good News
If you have to manage change that people will like, be sure to do it a little at at time and take credit for every improvement, to sustain the atmosphere of good will. If you have to manage a change that people will NOT LIKE, do it all at once. In fact, hire someone to make that change, and, at the end, when they are very unpopular, BEHEAD THEM. Problem solved.
For injuries must be done all together, so that, being tasted less, they offend less; and benefits should be done little by little so that they may be tasted better.
–Original Text from Machiavelli
Application: we have a new committee, EMO (electronic medication optimization) where we are learning to remove low value medication warnings (eg: multiple stimulants in one med list – many patients have more than one Adderall pill strength needed for the right dose). Suppressing such alerts that are 90% overridden, is a benefit. Every time we reduce clicks, we Broadcast it. Take credit for every reduction, every improvement.
On the other hand, when there is something ‘bad’ we must change, we do it all at once. We have to wipe out physicians’ old radiology order preferences in order to install new radiology orders that incorporate secure chat buttons and more effective routing. DON’T get rid of them piecemeal (they will hate you every time you make a change) rip off the bandaid all at once and remove ALL the preference lists and start fresh instead. ONE painful change. But, the ONE event fades faster in memory than many smaller changes. (Yes, I know that CT Lin ruined healthcare, regardless of what he chooses).
Close readers of the blog will remember that our book club also read Leading Change and also Buy-In by John Kotter. Really practical advice on tackling the sticky issue of how to set up important changes for success.
How to Build Consensus
Back in 2009 when I invented APSO notes (a future post) I had difficulty convincing colleagues to switch to a different format of document. In brief, SOAP notes are how docs have written standard notes for 70 years. APSO puts the assessment and plan, the most important part, at the top for increased speed and readability.
However, I had failed. In our EHR (Allscripts Touchworks at that time) I made APSO a selectable option next to standard SOAP notes. Result? 16% adoption rate, even among my close friends and colleagues.
I had an opportunity in 2011 for a platform change (we were adopting Epic) and I had a committee meeting to see if I could get APSO as the default standard.
Machiavelli teaches us that, if you don’t already know how everyone will vote at an important meeting, you have not done your work.
In brief, I made 30 minute appointments with EVERY influential medical director in that 30-member meeting to discuss APSO, answer their questions and in some cases do some horse trading (this for that) to gain support. Took a couple weeks to do this ground work, for this crucial decision.
Result? I achieved consensus at the meeting. APSO notes were the default (and for a time the ONLY) format available in our new Epic EHR. Thanks, big M.
This brings us to Prince Harry. I recently listened to his book “Spare”. I had not followed the royal drama closely, and did not know that Spare was a disparaging name for himself, in contrast to “The Heir” Prince William, as in “there’s the Heir, and there is the Spare.” How awful. See last week’s blog post (below).
One presumes that the Royal education includes the reading of The Prince, for modern princes.
One also presumes that palace intrigue, public scrutiny, the fickleness of public opinion, all weigh heavily, magnified to searing intensity by social media and paparazzi (what would Machiavelli say about paparazzi?).
Similarly, those leading projects in large health systems must contend with large populations, difficulty communicating effectively, rumor, innuendo, opposing viewpoints, resistance to change (but perhaps, not paparazzi).
To bring these threads together, one sees ancient and modern examples of leadership, managing communication, remembering that smart humans lived many years ago and wrote down their ideas. It is up to us to learn history or be doomed to repeat it. Remembering my personal failures, my 16-year journey to Open Notes, my nearly-failed plan to implement APSO notes, and now our struggles to deploy, maintain, study and improve Open Results, these innovations have all been guided, in some way by Machiavelli.
CMIO’s take? Who is the historian in your leadership group? Who reads the literature, learns from the past, and gives your teams perspective? How do you ensure a diversity of opinion, of thought? How do you challenge and disrupt yourselves to avoid complacency? I worry about this all the time.