HJAR May/Jun 2023

HEALTHCARE JOURNAL OF ARKANSAS I  MAY / JUN 2023 33 book Radical Inclusion: What the Post 9/11 World Should Have Taught Us About Leader- ship , articulated a vision of leadership focused on empowering others to unleash their full po- tential for achievement. Touting the need for radical inclusivity from a diverse array of partici- pants to accomplish a purpose-driven mission, Dempsey declared that inclusion is about con- centrating the what — the goal or higher pur- pose to be achieved — while simultaneously distributing the how, which involves co-creating the plan and then loosening control to allow the diverse talents of the team to develop strat- egies to achieve the desired outcome. That vi- sion is the essence of team-based care for man- agement of chronic conditions characterized by impaired social determinants of health and unhealthy behaviors. Likewise, General Stanley McChrystal, in his book Team of Teams: New Rules of Engagement for a Complex World , ad- vocated for decentralized managerial authority, which he called empowered execution. The re- sultant shift in military focus changed from rigid control, autocratic command, and operational efficiency to adaptability, collaboration, and continuous learning and improvement. If the U.S. Army can overcome entrenched hierarchy and autocracy to achieve a higher purpose, then surely my own profession and the world of healthcare can do the same. The higher pur- pose of delivering health is our mission. And to succeed in that mission, we need to recall the true drivers of health outcomes: physical envi- ronment like the water we drink and the air we breathe (10%), clinical care (20%), health behav- iors (30%), and socioeconomic factors (40%). THE FIVE T’S One of my physician colleagues, a dear friend and mentor, speaks about the three “T’s” as they relate to changing how healthcare should be delivered: talent , technology , and team . I agree completely with him that all three will occupy a prominent place toward improving experience of care and reconfiguring how to improve delivery of optimal health outcomes but will add two more of my own that become a byproduct of the first three: time and trust . Aligning the right skill and knowledge level of every provider and caregiver to each prob- lem to be solved in healthcare will translate into optimizing not only the use of talent but its development as well. Talent is a complex enough topic that it could warrant an entire article of its own, but suffice it to say that once we change the fundamental economic model of healthcare, the need for diverse types of talent increases exponentially. For example, domain knowledge and its application to spe- cific problem-solving, becomes increasingly important. While the clinical knowledge and skill possessed by every physician remains ex- tremely important, never again would I ever want to practice medicine without a licensed clinical social worker or behavioral therapist tightly integrated into my care team. While I may understand mechanisms of disease and pathophysiology that they don’t, their own ex- pertise about motivational interviewing vastly exceeds that of almost all physicians and is an essential tool for influencing human behavior. In addition, these therapists know how to ex- pertly assess self-efficacy, perform cognitive behavioral therapy, coordinate social services, and have plenty of other knowledge domains that are well beyond my own scope of practice. I would even go so far as to attest that without tightly integrated behavioral health, achieving excellent health outcomes across a popula- tion is simply not possible. The same goes for a physical therapist trained in the McKenzie method whose economic model is no longer driven by how many physical therapy visits are generated, but rather how few does it take to resolve pain, restore function, and solve the root cause problem of the patient’s musculo- skeletal problem (usually avoiding unneces- sary musculoskeletal surgeries in the process). Skill domains, like surgical, talent is also its own topic. Suffice it to say that excellent surgi- cal outcomes are not simply the result of how many operations a surgeon has performed, but rather the end result of relentless outcome monitoring that generates constant feedback and loops of continuous clinical improvement. We know from the work of Anders Ericsson, outlined beautifully in his book, Peak: Secrets From the New Science of Expertise , that volume of surgeries performed is not nearly enough to ensure good outcomes. It takes deliber- ate practice with constant ongoing feedback, learning, and tracking of surgical outcomes to deliver truly excellent surgical results. Systems that deliver health — as opposed to traditional health systems — differentiate themselves by measuring their surgical outcomes and incor- porating feedback from those outcomes to become recognized centers of excellence, not based on brand or reputation, but rather on how selective they are with regard to operat- ing only on patients likely to benefit, how few post-operative complications develop, and on how well the patients do post-operatively. As far as technology is concerned, first at- tempts at bringing healthcare into the 21st century have been met with decidedly mixed results so far. It could even be argued that cur- rent iterations of electronic medical records are responsible for many of the woes that plague our current healthcare system, an assertion with which I would wholeheartedly agree. But I would also contend that failures to date are pri- marily because these relatively early versions of electronic medical records have neither been intentionally designed for ideal user experi- ence nor to enable and empower physicians to execute workflows that deliver the most ef- ficient and effective care. Rather, these early versions of electronic medical records have been primarily designed to facilitate coding and documentation to support transaction- based billing, where volume is king and value leaves much to be desired. However, we are also seeing technology begin to positively im- pact care. Remote patient management, for which my own health system has become a pioneer, begins to optimize talent, technology, and teamwork in novel ways, where the domain knowledge of clinical pharmacists, process engineers, data scientists, and health coaches enable superior control of chronic conditions such as diabetes and hypertension in a seam- less, frictionless, convenient, and cost-effective manner. Such remote patient management fos- ters the development of continuous connected relationships, thus enhancing experience of care for patients while saving them the time and expense of an office visit, all while simul- taneously offloading work from busy primary care clinicians and improving health outcomes. Team , the third “T” in this triumvirate, just like technology, is likewise in its infancy. Traditional