把最好的商業想法應用在醫療領域

Bringing the Best Business Ideas to Healthcare
湯瑪斯.李 Thomas H. Lee, MD
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湯瑪斯.李解釋,如何運用麥可.波特和其他商業思想家的想法,來改正醫療業的問題。

今天我們要討論的是,如何把各產業中一些最有力的想法,用於今日的醫療業。我是個樂觀主義者。我確實認為,歷史的弧線是朝著更好的醫療體系方向發展,但這是個弧線,因為一路上有很多障礙。

不會有任何單一的神奇做法,可修正一切。我們需要一系列想法。我們需要針對市場的大構想,坦白說,我們需要針對第一線作業的大構想,像我這樣的醫生在第一線實際照顧病患,決定要如何治療他們。

現在,我要借重五位很強有力的思想家,他們對我近來的職業生活有重大影響。首先要談的是,我和許多人從麥可.波特學到的一些東西。他是哈佛商學院教授,發展出許多現代策略概念,應用在許多產業裡。

根據他的說法,策略可歸結為兩個基本問題。你必須清楚掌握這些問題,你必須很專注於這些問題。這些問題就是,你在為誰做什麼?譬如,誰是你的顧客,你如何為這個顧客創造價值?

然後第二個問題是,你要如何與眾不同?如果你和別人做相同的事情,而且用同樣的方法做,最終勢必會淪為價格戰,你無法有利潤。無論你是營利或非營利組織,都無法投資未來,以保持領先地位。在醫療領域,「你為誰做什麼?」的答案,必定是改善提供給病患的價值。這是唯一的答案,這是醫療領域裡,所有利害關係人共同的首要目標。

直到不久前,都還不需要這種策略,以便在醫療領域蓬勃發展。你以前需要的是很好的營運效能,以及出色的品牌。我們提到營運效能時,是指把你做的事情做好,而且愈做愈好。麥可和我覺得,90%的管理重點在於營運效能。

但在以前,很努力工作、營運效能、擁有受人尊敬的品牌,就足以讓你蓬勃發展。我認為,現在這些只是最基本的條件。你做到這些就只夠生存而已,你若想成長茁壯,若想蓬勃發展,就必須準備好做出選擇。你不能什麼都做。

你必須選擇要在哪裡競爭、不在哪裡競爭。但正是這種動態情況,讓我開始很關注莉摩.達夫尼的研究,她是經濟學家、反壟斷專家,在哈佛商學院任教,專精於競爭、整體市場及其運作方式。

我們需要在醫療的各個層次都有競爭。我們需要競爭之處包括:消費者選擇健康保險產品時。我們需要競爭之處還包括:病人選擇使用哪個醫療系統、選擇誰當自己的初級醫療醫師、要去哪裡接受二級醫療。我們還需要這些醫療服務供應者和病患合作,在他們選擇去哪裡接受第三和第四級醫療時,面對競爭。

我們知道沒有任何事物是完美的。法規是試圖改善品質和效率的前進道路,它可以創造基本條件,但不能產生改善。它不能促使我們持續思考,要如何變得比現在更好?它能產生能量,例如,我們能做什麼來確保我們沒問題?但我們在醫療方面需要的不僅是這些。

你需要人們想嘗試變得更好,而要做到這點,他們必須做出艱難的選擇。要做出這些選擇,他們必須感受到競爭的壓力。他們必須想贏,也必須害怕輸。我認為,這種動態情況確實能引發我們的最佳工作成果,試圖創造更好的醫療系統。為此我們參考了伯特、克里斯塔基斯和達克沃斯的研究。

隆納德.伯特是芝加哥大學的社會學家、社會資本的專家。我們都知道什麼是金融資本,有了金融資源,組織得以做到沒有金融資本就做不到的事情。我們知道什麼是人力資本,聘雇優秀的人才,這樣你才能做那些事情。社會資本是指這些人員之間的人際關係和互動,讓組織能夠做到沒有社會資本就做不到的事情。因此伯特所描述的是,為組織創造社會資本的兩種基本方法。

透過中介活動,你就可以嘗試增加組織內部的變化。你敞開心胸接受外部的新想法。今天看這支影片的人,很可能就是思想中介人。你們從組織內部培養創意和創新。這對學習很重要,你要實際去想像如何讓自己變得更好,並敞開心胸,讓別人有機會教你一些東西。

但結束也是不可或缺的一部分,如此才能實現創意中介的好處。結束就是要敲定某個想法。你檢視各種事物和不同的想法,然後說這個比較好。這是最好的。我們都要這樣做。我們要以這項實務為核心進行標準化。這些都是組織要務。這些是可衡量的。這些是可改進的。這些的重點,全都在於人們的互動方式。

這裡的重點在於你的團隊應該如何工作,組織中的人如何一起工作。主題包括合作、可靠性、尊重、團隊工作本身、優秀的團隊。今天貫穿醫療領域的最有力想法之一,是史丹利.麥克里斯托及其同事合寫的《團隊之隊》。但是,若要有絕佳的互動、絕佳的團隊,你必須有共同的價值觀。

因此我們要轉向個人層次。這些團隊的成員、這些組織的成員,這些個人會發生什麼事?克里斯塔基斯任教於耶魯大學,專長是社會網絡科學。令他全國知名的,是2008年發表在《新英格蘭醫學雜誌》的一篇文章,主題是肥胖。你就算不知道這篇論文,也知道它的發現,那就是如果你朋友的朋友體重增加,你會更有可能體重增加,即使你不認識那位朋友的朋友。

如果朋友的朋友的朋友體重增加,你的體重也更有可能增加。那是因為,肥胖雖不是傳染病,但表現得像傳染病一樣,因為行為準則在我們周遭發展,而我們沒有察覺。如果你身邊的人都在吃甜點,你就會吃甜點。如果你身邊的人都在吃超大號薯條,你吃超大號薯條的門檻就會跟著改變。就是這種因素,驅動價值觀在人與人之間傳播。

他和同事已在以下領域觀察到這種現象:肥胖、抽煙、幸福感、慈善捐贈、刺激人群。我在群醫照護系統和布里翰醫院擔任領導人時,會頒發年度醫師獎。我們會選出表現出色的醫師,像是我的初級醫療醫師,讓他們上台領獎。這基本上傳達的訊息是,為什麼你不能更像查克那樣?但這其實不是最有力的訊息。

最有力的訊息是,有一種行為準則正在發展。你讓三、四個優秀的醫生上台,傳達的訊息就是有一種準則存在。你應該努力仿效,否則你就該感到有點緊張。所以,思考行為準則時,我們必須把同理心當成核心價值觀。例如,你若是沒有表現出同理心,就會很尷尬。我們需要協調,需要溝通,需要安全,需要重視優異的表現。

這種價值觀讓我有興趣了解安琪拉.達克沃斯的研究工作,她是賓州大學心理學家,研究恆毅力的專家。她一直在研究那些長期追求高度卓越的人,不是維持幾天,也不是幾週,而是幾年、幾十年。驅動他們這麼做的動力是什麼?熱情和毅力這兩大特性。她描述了產生這種特性的心理資產。

對自己做的事情感興趣,有目的感,感覺被別人重視。練習,刻意練習你想改進的地方。你不滿足於現狀。希望,希望只要努力,事情就可以變得更好。這不是樂觀主義,認定事情會變得更好,而是一種希望,希望如果自己繼續努力,事情會變得更好。然後,貫穿這一切的是追求卓越的熱情,試圖變得比目前更好的熱情。

這種熱情是要設法做到最好,或者至少要做到可持續維持的最好程度。我們需要安琪拉的研究,才能達成莉摩想要的,也就是競爭;我們需要這個,才能去做波特希望我們做的事情,也就是要有策略,讓我們做出選擇,這些選擇可能會讓我們變得更好。若想要有效的策略,並執行這些策略,我們就需要伯特談到及教導的,也就是培養真正的團隊合作精神,讓團隊合作成為競爭的差異化因素。

為了引導我們的社會資本行動,我們必須了解什麼是策略。我們要為誰做什麼?為了讓我們的社會資本真正變成現實,我們需要出色的社會網絡科學。我們必須推廣行為準則,創造正確的行為準則,並確保用可靠的方式傳播這些準則。所有這些因素,會創造一個回饋迴圈,其中包含對改善的渴望,和我們實現目標的能力。

它可以且應該是一個良性循環。如果你們可以在所有這些層次努力,並協調一致方向,以運用這些做法來改善照護病患的價值,我們也許就能擁有更好的醫療系統,並在許多組織中擁有具競爭力的差異化。

(劉純佑譯)


Thomas Lee, MD explains how ideas from Michael Porter and other business thinkers could fix healthcare.

Thomas Lee:Today we're going to be talking about how some of the most powerful ideas from all business sectors are being used in health care today. I'm an optimist. I do think that the arc of history is toward a better health care system, but there's a reason that it's an arc, because there are a lot of barriers in the way.

There is not going to be any single magic bullet which is going to make everything OK. We need an array of ideas. We need big ideas for the marketplace, and frankly, we need big ideas for the front lines where doctors, like me, are actually taking care of patients and making decisions about what's going to happen with them.

Now I'm going to rely upon five really powerful thinkers who are my big influences as I go through my professional life these days. And, we're going to start by talking about some of the things that I and many others have learned from Michael Porter, who is the professor at Harvard Business School who developed a lot of the modern concepts of strategy used in many business sectors.

As he put it, strategy boils down to two basic questions. And you have to have clarity on these questions, and you have to really be focused on those questions. And those questions are, what are you doing for whom? Like who's your customer and how are you creating value for that customer?

And then the second question is, how are you going to be different? Because if you're doing the same thing as everyone else the same way, then inevitably you're going to end up in a price war, and you won't have a margin. And whether you're for-profit or not-for-profit, you won't be able to invest in the future, you know, stay on the cutting edge. You know, in healthcare the what for whom it has to be improving value for patients. There's no other what for whom that is an overarching goal that all the stakeholders in healthcare shares.

Until relatively recently, you haven't really needed strategy in this sense in healthcare to thrive. What you needed was really good operational effectiveness and an excellent brand. Now, when we say operational effectiveness, what we're talking about is doing what you do well, and doing it better and better and better. Michael and I feel that 90% of management is operational effectiveness.

But in the old days, where working really hard, operational effectiveness, and having a respected brand enabled you to thrive. I think today that is table stakes. You have to do that to simply survive, and if you want to flourish, if you want to thrive, then you have to be ready to make choices. You can't do everything.

You have to pick where you're going to compete and where you're not going to compete. But that dynamic is what got me to start paying a lot of attention to the work of Leemore Dafny – economist, anti-trust expert, also at Harvard Business School, expert on competition, the overall marketplace and how it should work.

We need competition at every level of health care. We need competition where consumers are picking their health insurance products. We need competition where patients are picking where they'll dock with the health care system, who will be their primary care physician, where they will go for their secondary care. And then we need those providers and patients to be working together and facing competition as they pick where they go for their tertiary and their quaternary care.

Now, we know nothing is perfect. Regulation, as a path forward to try to improve quality and efficiency, it can create a floor. But it can't produce improvement. It can't generate the constant thinking, what can we do to get better than we are now? It produces energy, say, what can we do to make sure that we're OK? But we need something more than that in health care.

You need people to want to try to get better, and to do that they have to make tough choices. And to make those choices, they have to feel the pressures of competition. They have to want to win, and they have to be afraid of losing. And that dynamic, I think, can reliably produce our best work in trying to create a better health care system. That’s where we get to the work of Burt, Christakis, and Duckworth.

Ronald Burt, sociologist at the University of Chicago, expert on social capital. We all know what financial capital is, the financial resources that enable organizations to do things they couldn't otherwise do. We know what human capital is, hiring good people so that you can do those things. Social capital are the relationships, the interactions among those personnel so that the organization can do things it might otherwise not be able to do. So what Ronald Burt describes are two basic approaches to creating social capital for your organization.

Brokerage is where you actually try to increase variation within your organization. You open yourself up to new ideas from the outside. People watching this today, you are people who are probably idea brokers. You nurture creativity and innovation from within your organization. So that is essential to learning, to actually imagining how you might get better, opening yourself up to the possibility that other people might have something to teach you.

Closure, though, is an essential part as well for realizing the benefits of idea brokering. Closure is where you nail it down. You look at the things and the different ideas and you say, this one is better. This is the best. We are all going to do this. We’re going to standardize around the practice, in fact. These are organizational imperatives. These are measurable. These are improvable. These things are all about how people interact.

This is about how your team should work, how the people in your organization work together. So themes like cooperation, reliability, respect, team work itself, great teams. One of the most powerful set of ideas running through health care today is a work from Stanley McChrystal and his colleagues, a team of teams. But then, to have great interactions, to have great teams you need to have shared values.

So let's turn to the individual level. What's going on for individuals who are members of these teams, members of these organizations? Nicholas Christakis, now at Yale, social network science. He kind of exploded onto the national consciousness with his 2008 New England Journal of Medicine paper on obesity. And even if you don't know the paper, you know the finding, which is that if a friend of a friend of yours gains weight, you are more likely to gain weight even if you don't know the friend of a friend.

And if the friend of a friend of a friend gains weight, you're more likely to gain weight. And that's because -- obesity isn't an infectious disease, but it behaves like an infectious disease because norms are developing around us without us knowing it all the time. If everyone around you is having dessert, you have dessert. If everyone around you is having super size french fries, your threshold for having super size french fries changes. And that’s what’s drives the spread of values from person to person to person.

He and his colleagues have shown with obesity, smoking, and happiness, and charitable giving, stimulus crowds. In my leadership roles at Partners and the Brigham, I would give out physican-of-the-year Awards. And we would take a fantastic doctor, like my primary care doctor, and we put them up on stage and we give them an award. And the message would basically be, why can't you be more like Chuck? But that’s not actually the most powerful message.

The most powerful message is there is a norm developing here. You put three or four excellent physicians up there, and you give the message there's a norm. And you should aspire to practice like that. And if you're not, you should be a little bit nervous. So thinking about norms, we need empathy to be a core value. Like, you're embarrassed if you're not showing empathy. We need coordination, we need communication, we need safety, we need the valuing of excellence itself.

And that value is what led me to be very interested in the work of Angela Duckworth, the psychologist at Penn, expert on grit. She’s been studying people who pursue excellence at a very high level over a sustained period of time, not days, not weeks, but for years and decades. What drives them? Passion, perseverance, those being the two big characteristics. She describes the psychological assets that lead to them.

Interest in what you're doing, a sense of purpose, the feeling that it’s valued by others. Practice, deliberate, practice where you’re trying to get better. You're not content with the status quo. The hope, the hope that things could get better if you work. It’s not optimism the things will get better, it's the hope that things will get better if you keep on working. And then running throughout all this is a passion for excellence, a passion for trying to be better than you currently are.

The passion to try to be the best, or at the very least to be the best that you can be reliably. Angela’s work is what we need in order to do what Leemore wants, to compete. Is what we need to do what Michael Porter wants us to do, which is to have a strategy where we make choices, choices that might make us better? If we're going to have effective strategies and execute on them, we really need what Ronald Burt talks about and teaches about how to develop real teamwork for working together as a competitive differentiator.

To guide our social capital efforts, we have to be informed by what is the strategy. What are we trying to do for whom? And then for our social capital to really turn into something real, we need great social network science. We need to spread norms, create the right norms, and make sure that they spread reliably. And all of these factors create a feedback loop, with the desire for improvement and then our ability to get there.

It could and should be a virtuous cycle. And if you can work at all of these levels and align yourselves around using them to try to improve the value of care for patients, we may have a health care system that that's better, and we’ll have competitive differentiation in a lot of organizations.



湯瑪斯.李 Thomas H. Lee, MD

醫學博士,普雷斯卡尼醫療顧問公司醫療長。他是執業的內科醫生、哈佛醫學院兼任醫學教授,也是哈佛大學陳曾熙公共衛生學院(Harvard T.H. Chan School of Public Health)衛生政策和管理學教授。


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