Chief Expectations Officer

Preface to Book I:  Chief Expectations Officer

This book is written for the heroes, role models, and mentors who built the bench strength for America‘s competency in life saving.  My intent is to describe indelible systems & structures for life savers.

Rather than exploring the federal mandates for how 330,000,000+ medical charts were still fragmented haphazardly across 950,000 physicians’ panels, 6,100 hospitals, and 5,700 certified ambulatory surgery centers - I have explored what matters to real people in healthcare & outside healthcare:  Perfecting the local supervision through the local chief expectations officer for their local brand of American medicine.  

This journey begins with the guarantees and assurances within healthcare professions and across to patients.  These promises did not originate from federal mandates.  Americas physicians sacrificed their youth and treasure for idealistic zeal to care for others, to improve themselves, and to join a tradition of excellence.

Healthcare organizations are first and foremost medical science enterprises; Medical evidence for causality is a distinction between what we do & our peers in retailing or a manufacturing.

Healthcare leadership must therefore draw from the best of medical science; many of the prevailing theories of redefining Healthcare, value-based care, and virtuous cycles have not been provided rigorous peer review.  It should matter that these ideas have been proven to work where we are not spending less on healthcare nor are we living longer; Frontline employees in the trenches persist heroically despite these flawed ideas like floats in a parade.

Post WWII Germany is a relevant historical case available to America due to head to head comparison of the East and West divide, the traditional pursuit of medical science (Chapter 2) on both sides, consumer Brands (Chapter 3), and ongoing healthcare expenditures higher than peers.  I happen to have studied German language, history, and culture.  The life expectancy rates between East and West Germany (Chapter 3) are instructive for the role of government.

The federal mandates in the old East Germany did not keep pace with medical science, with life expectancy progress, or with brands in West Germany.  This was intervened by proportion of East German physicians in private practice eroded from 35% down to 2%.  These gaps can still be detected from space 30+ years after the Berlin Wall came down.  Meanwhile the proportion of private physicians in American has declined from perhaps 75% when the wall came down to 46% in 2018 and falling; why did we fight the Cold War if we wanted East Germany’s health system, federal debt, & lagging life expectancy figures?  The East Germans chose the West German model.

The Supervisor on Duty arose from my observation that many organizations experienced turnover at the very top with the CEO role and add very front line roles in frontier clinics; these two types of roles have one very big thing in common which is they are the chief expectations officer for the facility whether large or small.  

Every local healthcare facility demands a local chief expectations officer.  The story of the chief expectations officer arose from my observation that the top accountable individual of each & every clinic and every hospital in America seems to be among the most vulnerable to job turnover.  

Turnover of people is debilitating to medical science & customer service; Patient emotions are reversible, employee reassurances to each other are reversible, & happy loyal engaged employees make for happy patients.  

Leading Expect!

Preface to Book II

Leading Expect (Chapter 6) occurred to me; I became troubled that the Hippocratic movement has not moved life expectancy upward in one direction, that American life expectancy has recently waned, and this math does not have a mind of its own.  It must be led by humankind. 

I choose the term Leading Expect because like Wayne Gretzky said “I skate to where the puck is going to be not where it has been.”  Healthcare organizations need to be out in front of what their customers expect.

I choose the word Leading as an action verb & I choose the word expect for many of it’s organic connotations in professional services where we are people serving people.  

Leading Expect is human centered system design that differentiates bridges that are directional in a process, repeatable in a cycle, or reversable in a topology (Chapter 2).  Leading Expect is transitive in that it is open to possibilities and integrates changes in medical science, intransitive in that it is focused not just on extending life but making things better for the next generation.  Leading Expect makes the promise to extend life; The Marathon of efforts to extend life expectancy; Leading Expect reduces the demand for Firefighting literally & figuratively. 

Mark Twain wrote of adventures on The Crossing of the Mississippi; my RAFT (chapter 3) are the bare minimums for customer service that anyone can learn. 

Leading Expect is crossing of non-physician work until bridges are built:  curing illness, eradicating disease, and increasing life expectancy.  We are amid this dredging of a channel up the river against the prevailing current of nature towards a fabled fountain of youth.  Abraham Lincoln saw it; he both invented an instrument for lifting all boats, made a promise to do so, and enforced it. 

The Mayo Brothers, Andrew Carnegie, The Four Horsemen of Johns Hopkins built this great medical science dynasty, made certain of it sure because it was their reputations at stake.  The point is that caring – altruism for lack of a better word - is good until a person cares for others to the point they cannot care for themselves (Chapter 8).  Altruism is functionally right because satisfied customers will return, refer others.  Altruism is right in an intransitive sense in like “Boyscouting the campsite” of an institutional programs better than you found them.  Appealing to the Patient Emotional Topology further softens patients to the teaching & motivational interviewing to extend their life; the Brand may improve medical science outcomes but it is not necessarily so.

Seize the opportunity for getting paid for caring, for saving lives, or helping those that do.  If we do it well someone will still be there still for you when it is your time on the brink.  Altruism is replicable through a brand learning topology, it multiplies, and altruism is the essence of what we consider intelligent life.  And altruism may not just perfect the brand of American medicine, but in the intransitive sense increase the life expectancy of the indispensable Brand we call the United States.

You own the dynasty of American exceptionalism in medical science.  That's right, you, the operator, the nurse, the physician.  And your reputation is being sullied by like 1961 East German bureaucracy, non-operable electronic medical records, the disembodiment of patients into “Lean manufacturing” or to 6σ which is brought to you by the cell phone makers that missed the smart phone.  Let that set in; we have let the Mr. Magoo of the cell phone industry guide health policy.

At the dawn of the increasing life expectancy era our country was a not just a top industrial power & a beacon of hope for the sick the poor the huddled masses the world over, but there was accountability to the Seven Topologies (Chapter 3). 

One thing I do know is that the Congressional Budget Office projects we will run a deficit of $3.3 trillion this year; little of that is going to the licensed physician.

Will Rogers said, “if pro is the opposite of con then what’s the opposite of progress?”  Congress.  “Health Economists” point to Europe for models but the European Union has no plan to underwrite a single payor for the continent; the divided U.S. Congress means we don’t have one either.  California could do Italy, New York could do Germany, but Texas won’t spontaneously become France.  Everybody knew we’d have a single private payor or Medicare-For-All; what this book presupposes the extension of Life Expectancy in the event that we don’t.  Theodore Roosevelt, Harry Truman & John Kennedy attempted federal systems and failed.  A glance down the roster at the U.S. Capitol and we are without a Lincoln, Roosevelt, Truman, or JFK – thus the real reform is the heroic work Leading Expect integrated into what you do every day. 

Not hardwiring, nor good to great, nor foreign car makers, nor domestic cell phone makers, nor malpractice lawsuits, nor federal mandates have saved our healthcare system.  What this book presupposes is that Leading Expect predicated on a financial management and medical science with life expectancy central is the thing that will; this union is physically possible as the distinction between finance & quality is an illusion.

Patient Compliance (Chapter 9) is a larger problem for life expectancy than physician inaction; Leading Expect includes a mission of The Brand proactively exploring for patients in distress using Distress Recognition (Chapter 8) and applying Actuarial Medical Science (Chapter 12).

The Furtive Fallacy (Chapter 9) distracts policymakers from where life expectancy is waning.  Hold the components of the system SUSPECT:  system, units, seconds, the Process, Expect, a Cycle, or a Topology then framing a promise of a future event and functioning as framed

The Truth of Physician Sacrifice (Chapter 9) is that this profession has Saints lost to medical science; Leading Expect is human design that considers what is unreasonable, reasonable, due, or necessary “expected hard work from medical students.”  

At the Ritz Carlton they were famously ladies and gentlemen serving ladies and gentleman.  We're not here to indulge merely in romantic fiction but in medical and scientific reality.  America is in danger of becoming the second most indispensable nation.  Our federal deficit is ballooning while our life expectancy is declining.  Private physicianship is approaching East German rates from when the Berlin Wall went up. 

There are lessons to be drawn from A Bridge Collapse:  Federal Mandates, Fundamental System Failures such as holding people SUSPECT instead of holding non-human components SUSPECT, Fundamental Science Errors such as false positive errors (doesn’t have disease), Fundamental Brand Errors such as opportunity for leadership to articulate Brand Learning Topology, Fundamental Operational Failures such as lack of acuity-adjustment to forecasting, Fundamental Individual Errors like failing RAFT audits, and Fundamental Facility Plan-Asset Topology Failures (Chapter 9)

I’ve grown increasingly troubled by the centralization of operating functions into departments (private and government see Chapter 3), from local policy to federal policy, from leading expect to the cogs & machinery of mandates over the same period of time that life expectancy has declined.  Medical scientists, nurses, & physicians should have control or ownership or influence over these operating, centralized departments.

There is a tragic flaw in the false dichotomy of quality control and finance.  Finance does not capture the patient’s temperature – a patient could be 72 degrees and they would not notice this distress in any financial report.  The Quality department could rule that patient out from the denominator of any many or all reports of quality improvement for frivolous administrative reasons, to make their numbers look good, or no reason.  This misses the whole point of a healing operation of people by people and for people along the Topologies of medical science (Chapter 2), The Brand (Chapter 3).

The policies that have come down the Potomac derive not from Mark Twain’s dream, nor from Abraham Lincoln’s promise, and not from medical science, and not from the traditional brands like Mayo – Johns Hopkins; recent policies could have been imagined by an animated remake of The Lorax in a Dr Suess cartoon where the villain is myopic, ham handed Mr. Magoo who persists only through a streak of luck.  These policymakers while well intended have proven to be frightened pilots of a vast machine they do not understanding calling in experts asking which buttons to push.[1]

We must beat on embrace Leading Expect (Chapter 6), a Human Interface of Expect (Chapter 7), Distress Recognition (Chapter 8), or we face a future of Unexpect (Chapter 9) where medicine is reduced to a computer talking to a computer delegated to attorneys or accounting.

[1] Credit to William S. Burroughs

Brand Inurement

Preface to Book III

Perfecting the Brand of American Medicine includes Brand Inurement.  Theodore Roosevelt warned against “The things that will destroy America are prosperity at any price, peace at any price, safety first instead of duty first, and love of soft living and the get-rich-quick theory of life.”  Let’s unpack that as it pertains to Seven Topologies of medical practice. 

“Prosperity at any price” can be seen in the concentration of control to the detriment of physicians and patients.  It is an imbalance in the net asset topology to the detriment of medical science (Chapter 2), The Brand (Chapter 3), and operations. 

“Peace at any price” can be seen in the ham handed inaction in the face of 480,000 annual deaths due to tobacco & 40,000 due to diversion (Chapter 14); at a time we are expending billions measuring sometimes miniscule differences in physician panels.  Accounting is the profession that if Brand Expectation Topologies – the BETs and assurances were honest should have detected & intervened in preventing the Diversion (Chapter 14) of opioids from manufacturers, pharmacy wholesalers, hospitals, government programs, and on down the line.  How did all those audits fail to detect the diversion of opioids that costs over 40,000 American lives every year?  This is like Mr. Magoo where accounting is myopic and persists only through a streak of good luck.

“Safety first instead of duty first” can be seen where malpractice is part of the problem and not part of the solution.  We have not litigated ourselves into being more safe.  Defensive medicine (Chapter 9) creates costs along the Seven Topologies that could be better deployed towards things we know save lives. 

“The love of soft living” can be seen in the general inactivity of our day to day lives, the rise of Chronic Disease (Chapter 13) where Lean manufacturing (Chapter 12) has us counting footsteps (Chapter 12).  Effectiveness is more important than efficiency; we have become more reliant more on prompts from technology than personalized meaningful connections.

“The get-rich-quick theory of life” can be seen in how some unethical bitotech manufacturers,, the pharmacy wholesalers, the EMR vendors, the retail pharmacies who caused diversion (Chapter 14) and the accountants that sold audit services to all of them & failed to detect diversion with their audits.  That’s what audits are supposed to do; and yet it has been see no evil, hear no evil, and speak no evil of diversion (Chapter 14).

Retail pharmacies now show signs of trying to run collocated physician enterprises.  Physicians have often expended directly or indirectly more on audit services than expended on their medical education. 

Despite not being publicly traded Physicians have often spent more in their career on a certified public accountant than they did on medical school though CPAs are neither medical scientists, nor brand inurement experts (Book III), nor actuaries, and missed the diversion in their attestation of audits of biotech, pharmacy wholesalers, and retail pharmacy.  The tail has been wagging the dog. 

There is no Hippocratic Oath for accounting; it brings me no pleasure to bring to your attention that it is apparent by the results.  The mandates for publicly traded companies were caused by fraudulent accounting certainly not to the benefit of physicians nor for operational needs such as cost accounting, benchmarking, or decision support.  Regulation & lobbying from accounting has restrained the simple third grade actions of addition and subtraction. in ways that have changed the economy; this regulation arose from accounting fraud by certified accountants. 

Accounting Scandals

·        Waste Management (1998)

·        Enron (2001)

·        WorldCom (2002)

·        Tyco (2002)

·        HealthSouth (2003)

·        Freddie Mac (2003)

·        American International Group (AIG) (2005)

·        Lehman Brothers (2008)

The rise of non-public entities particularly in healthcare, technology, & private equity pose a challenge for the accounting profession which has historically lobbied to restrict the practice of “certified public accounting.”

Like  Notable frauds originated from in the accounting profession rather than being deterred by the profession.  Accounting is the profession that should have detected & intervened in the Diversion (Chapter 14) of opioids from manufacturers, pharmacy wholesalers, hospitals, government programs, and on down the line.  All those audits failed to detect the diversion of opioids that costs over 40,000 American lives every year? 

The Revenue Cycle revolution was created at a Big 4 accounting firm where on the 5th floor they provided “independent” audit to the shareholders of the single largest private health insurance company in the world, and on the 4th floor accounting revolutionized the delay of care physicians know as prior authorizations & denial of care, and then on the 3rd floor they sold this information to healthcare providers who were their own client's sworn enemy.  Physicians deserve confidentiality from their finance. 

The Accounting profession has foretold its own demise; the AICPA predicts like a 90% decline in the profession due to technology replacement.  Now is the time in Perfecting the Brand of American Medicine to reach for Brand Inurement if your accounting function:

There is a comedic flaw in the accounting complacency in measuring a roster (Chapter 10) of people merely as numbers illuminated by the Abbott and Costello bit “Whos on first.”  “Whats on Second.”  This misses the whole point of a healing operation of people by people and for people along the Topologies of medical science, The Brand.

There is a myth of a doctor that’s never lost a patient, or an attorney that’s never lost a case, but it is commonplace for accountants to audit operational work they have never done.  It defies two or three of the components of SODOTO “see one do one teach one.”  We should not inure like the teaching or vision for interoperative navigation of neurosurgery to accruals from blind moles reading tickertape from yesterday. 

Medical Competency Gaps

·        Has not operated a medical practice

·        does not orient front line leaders to the fallacies in authority

·        does not have solutions for Brand inurnment

·        does not understand quality or how to integrate quality into finance

·        does not know the history of sub specialization of medicine then how can they provide insight into administrative functions

·        is not trained in calculus

·        cannot compute actuarial math justifying your relative value units to Medpac, your federal elected officials, or your statehouse 

Medical Intelligence Gaps

·        does not have a medical science background and what insight can they provide into brand that is first and foremost a clinical enterprise; it makes more sense for physicians to sit on the board accounting firms and draw on monthly fee for advising them on medical costs than it does for physicians to put a CPA on their board

·        cannot provide insight into the right size or design of facility

·        does not provide insight into the optimal roster for your medical practice

Myopia or Backward Looking

·        does not provide insight into volume forecasting on an hour by hour basis at every facility

·        does not know how a local brand becomes national

·        does not know how to contest intrusions of mandates at your local state house

·        has not insight into how to increase The valuation of your brand without just telling you to do more work

·        cannot construct primary and secondary prevention strategies for your diagnosis of interest

·        cannot monitor prescribing

What professions will replace accounting?  I believe they are the professions of Brand Inurement: 

·        Roster management (Chapter 10)

·        Brand valuation (Chapter 11),

·        Actuarial (medical) science to eradicate disease (Chapter 12) rather than merely forecasting budget

·        Administration of chronic disease (Chapter 13),

·        Brand inurement (Chapter 11) which is best practices for deterring fraud (why hire forensic experts after when you should get it right the first time),

·        Cyber security (referred elsewhere such as Hans Loven our air traffic control expert),

·        Diversion Prevention (Chapter 14)

·        Facility Design (Chapter 15)