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Learn from failure to survive healthcare change

March 12th, 2014

by Kent Bottles

Healthcare leaders need to read "Code Red: Inside the nightmare launch of and the team that figured out how to fix it." Steven Brill's article in the March 10, 2014, issue of Time is a must-read for several reasons.

Every hospital system leader can learn valuable lessons about what to do and what not to do when leading large organizations in an industry that has rarely encountered so much complexity and change in such a short period of time.

In my experience, planning for such an important and complicated project--such as the launch of the Affordable Care Act's exchange website--requires clarity and agreement on the vision, skills, incentives, resources, action plan and leadership long before the actual work begins. Ignoring any one of these requirements usually results in confusion, anxiety, gradual change, frustration or false starts.


The contrast between the initial process and the "quickly assembled fix-it team" is stark and instructive. If Brill's analysis is correct, it appears the Centers for Medicare & Medicaid Services' initial planning lacked all six requirements described above, which are needed to successfully implement complex change.

In what reads like a novel, Brill describes in horrifying detail an initial CMS failure:

  • Nobody was in charge of the project
  • Multiple contractors fought with each other and nobody took ownership for any part of the project
  • Lack of coordination led to three separate war rooms at CMS headquarters in Baltimore
  • U.S. Department of Health and Human Services Secretary Kathleen Sebelius, CMS Administrator Marilyn Tavenner and White House health policy guru Jeanne Lambrew had no idea why the website was failing
  • Lambrew excluded White House Chief Technology Officer Todd Park, who had successfully launched products in the private sector, from White House planning meetings
  • CMS relied upon marketing people who did not understand the data technology and software being developed as its content experts

The second half of the article describes how Jeff Zients, a former corporate executive, and Park led an emergency six-week effort that resulted in a functioning website, which may have salvaged President Barack Obama's signature domestic achievement. They did it by:

  • Recruiting Google site-reliability engineer Mikey Dickerson to lead the rescue effort
  • Adding data engineers, like Ryan Panchadsaram, Jini Kim, Paul Smith, and Andy Slavitt, to provide the content knowledge chops missing from CMS
  • Creating dashboards to trouble shoot the problems with the website

Dickerson's leadership in saving the Affordable Care Act offers important lessons that all healthcare executives need to learn. Dickerson attacked the problems by having "stand-up" meetings that addressed the problems in a rapid fashion. He also posted three rules outside the control center:

  • "The war room and the meetings are for solving problems. There are plenty of other venues where people devote their creative energies to shifting blame."
  • "The ones who should be doing the talking are the people who know the most about an issue, not the ones with the highest rank."
  • "We need to stay focused on the most urgent issues, like things that will hurt us in the next 24-48 hours."

Few of us will lead projects as massive as the exchange website rollout. Most of us will have to successfully manage complex change for our organization to survive in a rapidly changing healthcare delivery system environment. The story of how the federal government at first failed and then fixed the rollout is instructive on many levels. Study it carefully, and look at what really happened.

Kent Bottles, M.D, is a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics.


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