National Alliance for Physician Competence Discovery Workshop

Context

  • After hearing presentations on diversity and complexity science, this round of work asked participants to consider the purpose of the Alliance and to develop principles in light of the content from those presentations.
  • Short Cuts: Use these links to jump to the Reports for

Strategies for Achieving Purpose

Assignment

Context: Recall that one model of innovation recognizes three processes for generating new thinking: serendipity (mutation), combination, and extremity. Serendipity requires a bolt from the blue. Extremity deliberately removes mission-critical elements of the system and asks you to redesign without them. Combination creates a playground at the intersection of two fields or positions of thought—usually a new line of thinking intersecting with a problem to be solved. The operative word here is playground. The mind has to move rapidly and elastically from idea to idea in a playful way, periodically touching on the seriousness, or ground, of the problem to be solved. The trick with succeeding with combination is to tirelessly create a large volume of ideas, allow the ideas to let you skip mentally across many options, to refrain from judgment that might dampen creativity, and to log what you have learned. Your chances of coming up with a great idea that’s adaptable to your solution is somewhere between 1:20 and 1:100, but patience usually wins. Frustration only hampers your ability to think in an elastic way. Like a little kid, just set up the blocks, knock them down, set them up again, knock them down and sometimes put one in your mouth to chew on. Don’t forget to breathe…

Objective: Use the ideas you have just heard, distill the ideas into principles, and combine them with the purpose of the National Alliance (reproduced below) to develop answers to the following questions:

Process: You can simply begin by working through the ideas you’ve just heard or you can turn the ideas into principles and then work to apply each principle to the purpose of the Alliance. Ask yourself questions like, “what if the Alliance used this principle—what kinds of strategies might emerge?” Work quickly. You have about 50 minutes.

Exchange: Note the ideas you come up with on a marker board. Be prepared to talk through your ideas at the end of this round of work.

Resources: Here is the stated purpose from the National Alliance draft proposal for your reference.

Purpose: The mission of the National Alliance for Physician Competence is to assure the public and the health care community that individual physicians are competent to provide safe medical care of the highest quality. Through partnership and collaboration, the Alliance will 1) advocate continuity in the definition, measurement and determination of physician competence across the continuum of education, training and practice; 2) support seamless collaboration among organizations that contributes to physicians pursuit of lifelong learning and improvement; and 3) seek ways to enable reformation of the system of physician self regulation so that it is efficient and effective.

Report Outs

 

Bryan

If you have trouble hearing please move up.

Before we hear the reports from the three teams let's talk about this for a minute. Whenever we distill ideas we hope to go through iterations. You had a 50 minute conversation which you put on the marker board and then you had a 40 minute conversation and distilled that onto this poster board. It's very possible that there is a lot of information from your conversation that is missing on your poster board. Please report your poster board and something about the process as well.

Teams 1 and A:

We had a process where the scribe is also the reporter. I'll tell you what's on the board. In some ways there was more breadth in the original conversation and that allowed us to be more specific in the second conversation.

The items we talked about were reducing the existing redundancies and putting measurement on competencies to address current voids in assessment. We came up with two strategies. One was to do a lot of small experiments and disseminate the successes. There is some new language items that fits here and that is managing risks (that is something we should begin talking about). We would build confidence from some successes.

The second strategy is to define the Alliance as a place that fosters respect and minimizes rules to increase adaptability.

The second strategy is to define the Alliance as a place that fosters respect and minimizes rules to increase adaptability. Some of the earlier conversation begins to define the Alliance as something that doesn't replace existing organizations but enhances conversations and ultimately might lead to some organizations deciding that things no longer need to be done. When we started this conversation we thought that there were a lot of organizations doing similar things and because of that some people thought we might need to stop come organizations from doing stuff. Instead we talked about using the Alliance to develop simple rules to become more adaptable and flexible.

We also talked about the diversity of the input from the different organizations that make up that Alliance. The diversity might allow us to develop tools for measuring outcomes we haven't learned about yet.

Maybe we think we are diverse. We don't have the full medical community together but we are diverse enough to start small and then evolve to other groups. We talked about excellence versus the threshold and what happens below the threshold. There is a line in the sand that what happens below the threshold is not acceptable.

We don't want the Alliance being a top down group but we want it to be one of encouraging the wisdom of the crowd.

You said you were concerned about becoming a top down organization. When I talk about extremity being one option for creativity and innovation - that option of being command and control has been taken away from you.

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Teams Two and B

We started with the same dilemma that the other group did.

We want the GMP document published.

We had three strategies. We spent some time talking about who the agents are and what strategies the Alliance could employ to influence the agents. We want the GMP document published. We don't know what that means exactly at this point. It could be a wiki or it could be codified or it could be both. Once it is published then we want to promote the integration of the GMP into the agents. There are lots of agents. We want to make it part of the common culture. We want to integrate it into the work of the agents.

The third one is compromised language. We started with reduce complexity and then we talked about managing complexity and then we said we wanted to continue to collectively meet and talk about adjusting to the changing future. Having the group be diverse and continuing the conversation so we can discern the future and adapt to it.

It felt very open and collective and non-judgmental in the process. It feels fine to have come to this at this point and knowing that it will come to something else in a year or so.

One thing that is troubling is the danger of becoming an echo chamber. We are becoming comfortable with these new ideas but we are part of a small group having these conversations.

A question that arises is, "are we at some risk of becoming just one part of the alphabet soup?" Did other groups evolve because of wanting to fill a void? We don't want this group to become one more part of the litany of acronyms.

You are in this stage of the evolution of the healthcare system but if you have a good solution it is incumbent on you to bring it out. You are one agent in this system and the GMP is one part of your strategy. If you do that and demonstrate some fitness then people will pay attention to you.

If one of the attributes of the profession is self-regulation then publishing the GMP document is a responsibility. Once you start changing the vocabulary you change the way people think. That could be a leverage point to change the way people think.

There might be a need to establish some functional alliance with people that can change some of the attributes of the system that limit the expression of professional ideals.

Norm did a great job of capturing the conversation. But our agents are codified for action. If the task is to discern the emerging future then we need to focus on censoring and discernment of the emerging future.

This group may become much larger and putting these two things together might become a process. If you became masters at building relationships and telling stories you become an attractor for people that want to interact with each other. Even just mastering that little piece could be a product you deliver - a way of sustaining the dialog.

One major player that is not represented in the Alliance is the government. There might be a need to establish some functional alliance with people that can change some of the attributes of the system that limit the expression of professional ideals. We must have some kind of interaction with people that can change the regulatory environment so we can do some of the things we want to do.

I work with another group from PWC. One of the speakers came in and talked about the prospects of change in the medical system and they said it was low because no one at the government level understands enough of the complexity and no one at the public level knows enough to know what they want.

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Teams Three and C

We have sucked up to Bryan by matching the color to Bryan's short.

The goal is to have a physician in a health care system practicing safe and effective medicine. We took a look at the Alliance and we believe that the Alliance has a process that is tolerant of change. The physician is included in all these other parts of the system and they are stakeholders that need to be engaged. We also need to embrace risk. The Alliance is the sandbox that we can come and play in. You roll in the sand but it doesn't stick. We don't need another box. We need a wading pool.

In an industry R&D department they expect failure. We have this conundrum in that we cannot tolerate that kind of failure so we need a structure that allows for people to go into the wading pool and get wet and then they come back and interact with the sandbox. Defining our adaptive goals - we have to have common language and common goals. This is a small group that has been talking and we think we understand what is happening. We have to communicate and dialog with the multiple stakeholders.

This is a personal aside on the GMP publication. We are stuck on the dichotomy. Do we embrace that the GMP document is owned by the diaspora? Are we willing to make the GMP a living document and allow everyone to play and then publishing it as well since we are a bi-modal group?

The only way the 800,000 doctors engage in the system is through these organizations. Maybe there is a new way to buy in to what it means to be a doctor? Some times the most fascinating thing in Wikipedia is the dialog - the conversations going back and forth. Can we talk about this as one of those risks to throw it open to the whole body - we'd have a monitoring and editing group - but can we throw it open to the larger body?

I noticed it was difficult to keep from drifting into the Healthcare system that we could do something about.

We talked about the payer. We think they all want a safe and effective environment. What is the impact on the physician when CMS stops paying for something? Will there be a black box? Are we going to drive quality back into the dark ages?

This is a good time to have this dialog. This is the safe place to have these conversations.

One of the discussion talked about the 45 million people that don't have access to healthcare. Those people are part of the system. That perspective has to be brought into the conversation as well.

We had one group that wrote on the board in one color and voted and had things in one box. The other group had different colors and arrows and different ways of thinking about things and they came together in a nice way.

Communicating the risk is one thing we talked about. We are here representing our organizations but not really. ACGME has 24 review committees and 44 appointing organizations and they have opinions about this. The Federation is made up of 70 different boards. Those are part of the agents and they don't know much about this conversation. Maybe the wiki goes first to them and we get their feedback first? The next level of communication could be at that level.

Another way of thinking about the Alliance is thinking about the complexity of the system - the goal would be to make it more adaptable and not necessarily to change it.

We don't need to worry about the command and control structure in the alliance but our organizations have that structure. We need to simplify the rules of engagement for the interactions between the organizations. Most of the organizations have some role in the regulating structure. How do we deal with the stated goal and the reality of the tension between these things?

I've been wondering about the Alliance being an agent for moving this entire system we have now.

Some times I think that publishing the GMP is outlandish (it's terrifying) but I'm wondering if someone talked about something outlandish?

Having nurses involved. If the nursing profession was involved in the discussion because they are part of the team but then we felt there were limitations there. What if the nurses applied to the USMLE to take the test and become a 'licensed' doctor?

All of the regulation is based on the 1850s idea of getting on a horse and how do we evolve a system that accredits systems? All of the measurement is still solo dog. The best outcomes are when you have a coordinated team of practitioners delivering care. What is the risk to the people that participate? Maybe we need to evolve to a system based accreditation instead of an individual doctor accreditation.

I've been wondering about the Alliance being an agent for moving this entire system we have now. If we had a truly collaborative system we would have our own system of measuring and accrediting. Getting improvement in the health of the public might be impossible.

Maybe we should think about having the alliance bless some board and a group of physicians that want to work together to create something different?

So we're talking about figuring out some experiments and some safe places to have these conversations.

Unless we can get the government online - there is a deficiency in the current process.

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Discussion

 

Bryan

One of the outlandish ideas that is emerging is uncovering some dichotomies that have to exist side by side. There are a lot of these different examples in the presentations and you have described it as tension - it is creative tension. For researchers the tension doesn't go away but this is how they manage it.

"I do not know what I may appear to the world, but to myself I seem to have been only like a boy playing on the sea shore, and diverting myself in now and then finding a smoother pebble or a prettier shell than ordinary, whilst the great ocean of truth lay all undiscovered before me." Isaac Newton

Curiosity is not enough. The word is passion. "You must feel in yourself an exploratory impulsion - an acute discomfort at incomprehension." (an address to scientists).

You need to have both sides of the coin in play at the same time.

How are you doing about embracing new ideas? Are you backsliding? How many feel like you are leaping forward?

I feel like I am backsliding. Our next meeting is in December and I was feeling like we needed to find a structure for the alliance. What are we going to report to the group in December?

The part I encourage you to embrace is to allow the new thinking to come in and to settle down. All these people coming up with new ideas have spent time being full - until they couldn't take any more. Our job is to keep pouring things in. The consciousness will let go of solving the problem because it is too big. It will happen but it may not happen before 6PM tomorrow. I do know that adding these new ideas will eventually lead to that.

How many of you have heard of the 80/20 rule? The power curve?

A lot of people want to come up with a really big idea. They think that the big idea will emerge from a brainstorming session and then they want to go implement it. This is a power curve that says you will have a low probability that you will get the big idea. The probability of something small and useless happening is really high.

We are looking for some threshold where the new idea really matters. Maybe what you have with the GMP is a requisite size to the solution?

To get that you have to do a lot of tests and do a lot of combining. It's like the sand pile experiment. You dribble grains of sand and at some point the angle is too steep and grains start to dribble off. At some point you get a landslide. You have to keep dropping grains in order to get landslides.

The next round of work includes food.

We are looking for insights about complex adaptive systems. If you want to continue to talk about the purpose and the activities that is fine but focus first on the insights. Let's consolidate some of the things we've talked about. Let's not forget we have agents. Small outputs can create large system change. We'll come and get you for lunch. Capture your ideas on the marker boards and when we come back we'll have a conversation about it.

Scribing

 

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