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November 2013

HBR OnPoint on "Find Your Focus"

HBROnPointWinter2013The Winter 2013 issue of Harvard Business Review's OnPoint (which gathers selected articles from HBR around a common theme) is on "Find your focus: get things done the smart way". We could all use a refresher once in a while, so here are a few articles that particularly caught my attention.

Extreme Productivity, by Robert C. Pozen. This article outlines 6 principles to get more done:

1. Know your comparative advantage. This is not what you do best, but what you do well enough that can most help the organization. In other words, your comparative advantage also depends on the skills of the people around you.

2. It's not the time you spend but the results you produce. This one is self-explanatory, but professions like law (which Pozen mentions briefly) continue to value employees by the number of hours they log, and it is easy to judge people by the fact that they always seem to be working at their computer while others have long left.

3. Think first, read or write second. Pozen explains: "To be a speed reader, you have to be very clear in your mind about why you are reading." He gives the example of reading the Financial Times after the Wall Street Journal: in that case, he's only looking for news coverage that the WSJ hasn't provided.

4. Prepare your plan, but be ready to change it. This is true of people about to give speeches (speakers who prepare their speech sentence by sentence and then read it from the lectern tend not to engage their audiences as much as speakers who jot down a list of 4 or 5 key points and a concluding paragraph), but also of anyone who prepares a plan for the next day's work.

5. Let others own their space. Give them ownership in the outcome of a debate, let them agree on the to-do list and the deliverables. Pozen writes: "For instance, instead of assigning detailed tasks, you can present general priorities for the upcoming year and let your reports formulate specific ways to implement those priorities along with the metrics for measuring success."

6. Keep things short and simple. "The presenter at a meeting should circulate materials in advance to all participants. These should always include a one-page executive summary and the explicit norm should be that everyone reads at least the summary before attending the meeting."

Beware the busy manager, by Heike Bruch and Sumantra Groshal. This article distinguishes between purposeful managers and the others: the procrastinators, the disengaged and the distracted, and describes how to create purposeful managers using the example of the Lufthansa turnaround. The secret in a nutshell: "Give [your managers] meaningful challenges, then let them decide how to meet them. Empower them to turn compelling visions into reality. Stress how essential their contributions are."

Make time for the work that matters, by Julian Birkinshaw and Jordan Cohen. The authors provide the following guidelines:

  • Identify low-value tasks: How valuable is this activity to the firm? To what extent could I let this go? How much personal value do I get from doing it? To what extent could someone else do it on my behalf?
  • Decide whether to drop, delegate or redesign.
  • Off-load tasks.
  • Allocate freed-up time.
  • Commit to your plan.

Management time: Who's got the monkey by William Oncken, Jr and Donald L. Wass. This article was originally published in the November-December 1974 issue of HBR and was republished with a commentary by Stephen Covey in November-December 1999. The "monkey" is the burden that subordinates put on the manager's back when they give back an issue to the manager and make it his problem, instead of solving it themselves. 

The authors recommend for managers to develop their subordinates' initiative. "For example, when an employee tries to hand you a problem, clarify whether he should recommend and implement a solution, take action and then brief you immediately, or act and report the outcome at a regular update." In summary: encourage employees to handle their own monkeys so that you free up time to do your own job. The authors also give more specific recommendations to return monkeys to their proper owners.  

The most fascinating part of the article, I thought, was the 1999 commentary by Stephen Covey, entitled "Making time for gorillas", which places the previous article in the context of the 1970s, where management styles were much more rigid and hierarchical. But I find the monkey problem as present as ever in academia, especially at institutions where the faculty has PhDs from better schools than the one they work at, and doctoral students know their PhD advisor would do the work much faster and much better if they decided to do it for their students. (There are additional incentives that work against the PhD advisor, such as the pressure to graduate students within a certain time frame, publish papers, etc.)

Resisting the impulse of doing the work for the student who shows up with little done, pretending she's read papers but is stuck although she hasn't even set up the problem is not as easy as it would first appear: the PhD adviser would want to see some output for the research assistantship's money, hit certain milestones before the end of the semester, and since there remains 55 min of the time allotted for the meeting, it is tempting to just get the work done to at least make progress. (This is where I developed a unique ability to talk and talk while writing equations so the student wouldn't be too bored watching me write, although in hindsight it might have been better to let her get very, very bored.)

When I started my faculty position, we had an orientation and a discussion on what the best teachers do, but frankly the two-day session lacked the slightest discussion on what good managers do, and that's most definitely what I needed the most. (Does a place where so many students think it's ok to type away at their laptop or check the messages on their phone throughout the lecture in small classrooms [not large, anonymous auditoriums, mind you] deserve the best teachers to begin with? I think not. But I digress.) PhD advisers are managers, first and foremost, and negotiating the transition from student to manager is a particularly difficult one. But you learn to give the problem back to the people who have brought it to you, develop their skills and help them grow (or accept they are lost causes, but not do their work for them). Nine years on, I like to think I've become a good manager in my trial by fire. This issue of HBR OnPoint serves as a great reminder of what managers should do.


Why the US healthcare system must change, in one table

Click on the table to see it full size.

HealthcareComparison-KDavis-2013

Source: K.Davis et al, Mirror Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2013 Update, Commonwealth Fund, forthcoming.

From the Commonwealth Fund website: "Karen Davis is the Eugene and Mildred Lipitz Professor in the Department of Health Policy and Management and director of the Roger C. Lipitz Center for Integrated Health Care at Johns Hopkins University. She served as president of The Commonwealth Fund from 1995 through 2012."

And from its mission statement: "The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults."


The Affordable Care Act: Summary and Implementation

HealthcarelogoIf you want to make sure you understand the Affordable Care Act, I can't think of two better resources to recommend than the summary by the Kaiser Family Foundation (13 pages), and a short, visual document put together by the American Public Health Association [APHA] about selected provisions of "Obamacare" (2 pages). APHA also authored a 1-page cheatsheet on "Why do we need the Affordable Care Act?" that concisely articulates the main reasons behind the healthcare reform. Seriously, if you have any interest in healthcare reform, you have to have read those.

Much has been written about the flawed implementation of Obamacare by now, so I won't repeat what has been said before, but what shocked me the most in the press coverage was to learn that the administration had needed a McKinsey report, back in March, to show them the difference between what they were doing and the accepted best practice, known as "waterfall". (Apparently the lesson didn't stick.)

Frankly, it shouldn't have taken McKinsey for them to know that, given what was at stake, launching at scale was a terrible idea - and since CMS did launch at scale, I can only suspect that basic project management concepts that seem obvious to engineers like me sound highly esoteric or downright ridiculous to some people of high rank. Of course you never launch such a high-visibility project at scale. You start by opening the exchanges in a small state (Delaware?) and then perhaps a second one, fixing the bugs as you go in the most inconspicuous manner. Obviously you don't get the "drama" moment and the PR exposure of the all-in, large-scale launch approach, but you don't get the falling-flat-on-your-face part either.

Rosabeth Moss Kanter summarizes it beautifully in a Harvard Business Review blog post on the fact that "good management is not just details left to technocrats." The slide of the McKinsey review posted online is worth reading, especially for the two columns about the "ideal large-scale program development" and the "characteristics of this program", which comes across as a game of opposites, answering each other in neatly stacked bullet points. This is probably as close as genteel McKinsey ever came to screaming in horror the politically correct equivalent to "what in the world is wrong with you people, thinking you can get the project to succeed that way?" Fail small. Always fail small. And don't believe there will be no bugs in a tech project. 

I am also disappointed by how the conversation has evolved into health reform being mostly about helping uninsured getting coverage, so "doing the right thing for another segment of the population", instead of keeping the focus on the fact that the health reform is motivated by very real cost growth concerns that will threaten providers' financial viability down the road as well as the affordability of care for all, and thus affect everybody.

Having an uninsured person seek emergency care at your hospital means your hospital won't get paid for the services it provides - services that are more expensive to begin with than if the person had sought treatment when his disease was a more manageable state. This can't be good for the system as a whole. But even the Lexington column in the Economist describes the current situation regarding the healthcare reform as an "insider-outsider problem", instead of asking the higher-level question, of how the ACA ended up reduced to this one feature in the public's mind.

This is an issue that was noted for instance by a pollster of the Kaiser Family Foundation at a health policy workshop I attended in October: people like most provisions of the Affordable Care Act except the individual mandate, but they tend to be less aware that the provisions they like are indeed part of the ACA - and very, very aware that the individual mandate is part of the health reform. How the ACA was shrunk to the controversial individual mandate in the public opinion will certainly be the topic of many PR books to come.

Finally, for a sneak peek into the flaws of a real-world implementation, the WaPo article "Maryland struggling with technological problems with online insurance exchange" provides an important cautionary tale about a state that supported the ACA from the start. Some of the lessons learned include offering bare-bones websites instead of more complex - and more unreliable - ones, as well as pursuing strenuous outreach efforts.

I heard Rebecca Pearce - Maryland's exchange director - talk at that health policy workshop I mentioned earlier, and she struck me as a highly competent woman with sound project management skills. I remember for instance how she said she had instructed some of her staff members to create accounts on the exchanges so that they could better understand what would-be enrollees saw and the challenges they faced - exactly the sort of things that a good project manager in charge of such a daunting initiative would do.

If Rebecca Pearce was not able to extract satisfactory performance from the Maryland exchange's main contractor, as the WaPo suggests, then we also have to consider the fact that, in some cases, some contractors may be much more to blame than the administration, whether the government officials are good managers or not. But pointing the finger at tech companies with obscure names might not attract as much attention in the press.

Watch Rebecca Pearce talk about the Maryland Health Exchange in these two videos (crank up the sound for the Vimeo one):

Rebecca Pearce - Overview of the Maryland Health Benefit Exchange from The Hilltop Institute on Vimeo.


Kidney exchange and integer optimization

Here is a great video by Sommer Gentry and Dorry Segev explaining their work on operations research models (integer optimization and graph theory) for the kidney exchange problem. [Disclosure: I know Sommer from graduate school. We graduated from MIT within a few months of each other.]

This problem arises when friends or relatives of someone in need of a transplant want to donate their kidney but find out their loved one is not a match. If someone else's would-be donor is a match, the kidneys can be "swapped" and both patients in need of a kidney can receive one. In order to find compatible matches, the whole transplant centers have to work together when deciding who matches with whom, in order to maximize the number of transplants.

The short documentary does a fantastic job explaining operations research to the general public. I loved Sommer's definition of OR in the video as "the discipline of applying advanced analytical methods to make better decisions", and hopefully the engaging format and wonderful animations (they make graph theory and optimization seem so simple!) will help better convey to non-specialists what OR really does.

Dorry and Sommer are a husband-and-wife team based in Baltimore - Dorry as a transplant surgeon at Johns Hopkins and Sommer an Associate Professor at the United States Naval Academy. When they are not optimizing kidney exchanges, both are well-known in the lindy hop community for their dancing skills and their popular classes at the Mobtown Ballroom. Learn more about them at OptimizedMatch.com or in the Baltimore Sun magazine.


Undergraduate education and residential learning

Given the growing interest in Massive Open Online Courses (M.O.O.C.s) and the never-abating debate about college's rising costs, I strongly believe more and more universities are going to emphasize outside-the-classroom learning, and in particular residential learning, as a way to keep competitors at bay and change the framework of the tuition debate. Perhaps it is not entirely a coincidence that the two American universities that exemplify residential learning consistently find themselves at the top two spots in the rankings: Harvard and Yale. 

The November-December issue of Harvard Magazine has an excellent article about Harvard's residential houses, currently in the process of being renovated. They include faculty and staff housemasters as well as resident and nonresident tutors, with each house serving as the on-campus home of 350 to 500 undergraduates and having its own amenities such as dining hall. No less than 97-98% of Harvard undergraduates live in one of 12 such houses. The renovated houses include smart classrooms, seminar rooms and new community spaces and point toward an even more blurred line between academics and extracurriculars, or, shall we say, the fact that learning opportunities exist far beyond the traditional course environment.

A few student quotes:

  • "[A]cademics make up a tremendously small portion of what going to college is about. Most of what I learned came out of interacting with my fellow students and friends."
  • "If you don’t engage in the social aspects of college, you’ll lose 80 percent of the potential to grow and mature as an individual."

The future of brick-and-mortar higher education is clearly on the mind of Stanford's administrators as well, as evidenced by the Stanford Report on Undergraduate Education, where the authors freely admit that, in spite of the many residences, themed and non-themed houses, language or culture houses and fraternities/sororities (98% of Stanford undergraduates choose to remain on campus for all four years), Stanford could do a better job turning its residential system into "learning communities." (This is going to become the new buzzword in higher ed. Mark my words.) Issues include loss of shared space in residence halls due to overcrowding - called "stuffing", i.e., singles converted into doubles etc - and low number of tenured faculty willing to serve as Resident Fellows, Stanford's term for housemasters: 14 out of 62 RFs, the others being non-tenure-line faculty or staff. The report recommends investigating additional ways to engage faculty with residence spaces, such as giving talks, as well as developing more "integrated learning environments" for first-year students. 

The tone of the Stanford's report is refreshingly honest, for instance in the way it describes many seniors electing to live on The Row, "a collection of student-run houses that is also the heart of campus social life": "But for many seniors, the appeal of the Row clearly has less to do with self-government [students learning to handle their own affairs, a form of residential learning] than with the opportunity to host parties with less stringent supervision than in non-Row houses. More broadly, the current system means that most seniors have no contact with residentially based faculty - Row houses do not have RFs - at precisely the moment that they are making major decisions about their intellectual and professional futures." 

The report makes a number of recommendations that seem to fall far short from sweeping or groundbreaking ("explore the possibility of creating new residential options for upper-class students, including a residential research college designed to accommodate and support students pursuing honors theses and other capstone projects"), and thus may not achieve the momentum needed to turn residential learning into a signature program at Stanford at this time, but this is clearly a goal that will remain on administrators' minds.


Other good articles in HBR October issue

In addition to the article by Michael Porter and Thomas Lee on how to fix healthcare, which was the topic of my previous post, I also recommend the following articles in the October issue of Harvard Business Review.

Chobani's Founder on Growing a Start-Up Without Outside Investors. This is a fantastic story about an entrepreneur who bought an old yogurt factory in upstate New York to produce the Greek yogurt of his boyhood, and turned his fledgling venture into a billion-dollar brand with zero money from outside investors - only bank loans. 

Corporate Venturing. This article is about a current trend of companies launching venture-capital funds to identify new products or techniques without having to use their own R&D labs, in order to move faster and more cheaply. This strategy is more effective when the chosen start-ups are aligned with the parent company's goals.

Rethinking the Decision Factory. That article struck me as a little odd - the author seriously argues that companies don't realize knowledge workers don't do the same work day in and day out, and he also argues that these knowledge workers pretend to look busy when they have downtimes because the real unit of work should be project-based not full-time-based, and projects come and go, leaving many workers inefficiently idle. I have yet to meet a single person in the enviable position of being idle at work (perhaps I'm in the wrong kind of knowledge work?), but the article gets better once the link with two other HBR articles becomes clear: "The Rise of the Supertemp" and "Tours of duty: the new employer-employee compact," which I both strongly recommend. 

Ferguson's Formula. This conversation between a HBS professor and the former manager of the soccer club Manchester United, Sir Alex Ferguson, whose tenure at the helm spanned no less than 26 seasons, provided a welcomed respite from the pure-business articles in the magazine and tackled people-driven leadership, with eight important leadership lessons:

  1. Start with the foundation
  2. Dare to rebuild your team
  3. Set high standards and hold everyone to them
  4. Never, ever cede control
  5. Match the message to the moment
  6. Prepare to win
  7. Rely on the power of observation
  8. Never stop adapting.

The principles may sound a bit trite or dry when enumerated so quickly, but the article complements these principles with real examples drawn from Sir Alex Ferguson's distinguished career as a coach, which made it very enjoyable to read.

Finally, this month's subject of the last-page interview ("Life's work") is Nobu Matsuhisa, of Nobu Restaurants fame. His experience of failure and despair, and the slowness with which the business venture with Robert deNiro - which ultimately brought Nobu tremendous success - developed are a reminder that not every entrepreneur realizes his dreams quickly and easily. Always a good lesson to keep in mind.


Michael Porter's strategy to fix health care

ThumbnailThe October issue of Harvard Business Review has an excellent article on how to fix health care by Harvard Business School professor Michael Porter (of Competitive Advantage fame) and Thomas Lee, the chief medical officer at Press Ganey and the former network president of Partners HealthCare. In it, they argue that the goal should be maximizing value for patients, in a redesigned patient-centered system built around their conditions and measuring the outcomes they care about. They describe a strategic agenda with 6 components:

  1. Organize into Integrated Practice Units (IPUs), i.e., organize around the customer and the need: the patient's medical condition, following the successful example of the Virginia Mason Medical Center for low back pain,
  2. Measure Outcomes and Costs for Every Patient, going beyond the most easily measured and least controversial indicators (process measures) to truly gauge quality - for instance, how many diabetes patients lose their vision, have a heart attack or stroke, or undergo an amputation - building upon the Fertility Clinic Success Rate and Certification Act of 1992, which required all clinics to provide their live birth rates and other metrics and led to substantial improvements in a short amount of time,
  3. Move to Bundled Payments for Care Cycles (they already exist in countries such as Germany, where they incorporate all hospital inpatient care including physician fees, and for procedures such as organ transplant in the US),
  4. Integrate Care Delivery Systems, to shift from loose confederations of largely stand-alone units that duplicate services to true integrated delivery services, 
  5. Expand Geographic Reach, either through a hub-and-spoke model with a leading center and satellite facilities, or through clinical affiliation, similarly to the Cleveland Clinic's Heart and Vascular Institute,
  6. Build an Enabling Information Technology Platform, using common data definitions and encompassing all types of patient data.