Today I'm standing in a coffee shop because this is where much of the early phases of an organizing will usually take place. Now that I have convinced you, at least some of you, to emulate the example of Samuel Adams, you're probably asking, how do I get started? First of all, as you begin to create your campaign, you first need to ask the question, I am organizing who to do what? Once you have decided on your goal, the organizer must touch the heart through personal narrative and gain attention of the head for strategy and tactics to encourage and guide the hands to action. Next you need to deeply understand the healthcare constituency or constituencies you are planning to organize. From the standpoint of ground-level organizing, there are four major constituencies in healthcare. Patients are the most important constituency. At the present time in the US and in Canada, and I suspect in most countries, they are the least powerful constituency. Insurance companies and government insurance plans decide on payments. Because patients are not directly paying the physicians' services, they have little interest or control over how the physician manages their healthcare. Furthermore, the patient usually has little medical knowledge, and therefore must trust that the physician is doing what is truly in the patient's best interest. Finally, many patients continue to be convinced that they receive the best medical care. This false sense of security has created patient apathy. But as every student in this class now knows, quote, best is not good enough. The second major constituency is the physician. The majority of physicians chose their profession because they wanted to cure and comfort the sick. However, changes in our healthcare system have caused an inadvertent shift in the physician's perspective and mission. Modern healthcare has become more procedure and test-based. The US reimbursement systems reward quantity over quality of care. The patient too often is seen as a vehicle for billing of tests and procedures. This creates an inherent conflict of interest that undermines altruism. To compound this problem, physicians graduate from medical school with high student loan debts, necessitating they choose more lucrative, procedure based specialties. To control the continued rise in expenditures, insurance companies are increasingly attempting to micromanage physicians, requiring that procedures and hospital visits be pre-approved. Furthermore, the independent solo practitioner is becoming an endangered species, and health systems are directly employing an ever increasing percentage of physicians. These conditions have reduced the power of physicians to make decisions and to manage their practices. These changes have also weakened the doctor-patient relationship and undermined the altruistic spirit of many doctors. These conditions have led to physician discontent and make physicians prime candidates for the campaign to improve our healthcare delivery systems. The third major constituency is nurses, nurse practitioners, and physician assistants. In nearly all systems, these individuals are paid a fixed annual salary. As a consequence, these healthcare providers do not have the same inherent conflict of interest as physicians. The nurse-patient relationship remains intact, and this constituency is among the most stable and content. They continue to serve the altruistic role they envisioned when they began their training. Because the nursing supply remains limited, when dissatisfied, they can readily move to a more positive and supportive environment. Nurses tend to be well organized and have maintained their power within the healthcare system. Given their networking capabilities, and the values that align with the needs of our patients, nurses have the potential to be the leaders in any campaign designed to improve our healthcare delivery systems. A fourth constituency and the constituency that has the greatest potential to support change are our students. Health profession students have less at stake in the status quo. They are capable of more objectively evaluating our systems, and as historians and sociologists have repeatedly observed it, is the young who most often serve as the catalysts for change. They have the energy, creativity, and lack the family and financial obligations that too often lead to apathy toward and fear of system reforms. Student campaigns can also teach our students about leadership and team work, two vital skills for improving our healthcare delivery systems. There are a number of other constituencies with a potential to be organized including administrators, ward clerks, technicians, transporters, and social workers, to name a few. And depending on the goals of the campaign, they may also possess the resources and energy to bring about change. Third, before you begin, you will need to understand the three faces of power. Whenever possible, you should try to encourage an alliance with top administrators because this will assure a more rapid and sustainable change. Call me an idealist, but I truly believe that nearly everyone in healthcare wants to improve the health and well being of our patients, and that includes those who are in power, and first and most apparent face of power is seen in the board room. Who wins the policy battles and who has the most influence on hospital and personnel decisions? These powerful individuals and boards vary from hospital system to hospital system. However, before designing a campaign strategy, it is critical that you understand and appropriately address the first face of power. The second face of power is the ability to decide who sits at the table and to control what is included on the agenda. Those in power can prevent issues from being acted upon by never allowing them to be considered by committees empowered to take action, and by excluding troublemakers from their deliberative bodies. When designing a campaign, be careful not to become labeled as a troublemaker or you will have little hope of getting on the agenda. The third, and least appreciated face of power is the creation of apathy among the have-nots. When the allocation of any valued resource is determined, there will be winners and losers. Under conditions where there is a disparity of resources and power, the winners claim they deserve to win and convince the losers that they deserve to lose. As one example, when it comes to the state adoption of the widening eligibility of Medicaid benefits under the Affordable Care Act, we have heard many legislators claim that it would be financially irresponsible. And by their action, those who have no insurance are accepting this conclusion. However, these legislatures ignore the fact for every 100,000 people covered by health insurance, 120 lives are saved. Perhaps those who are uninsured should create a campaign based on this troubling statistic. If your campaign focuses on issues that directly impact patient care and you continually emphasize this goal, you are far more likely to achieve administrative support. But let me warn you. When it comes to organization ground up change, administrators can get anxious. Let me end with an interview with Marshall Ganz, who is a Harvard faculty member at the Kennedy School of Government. Marshall had devoted his life to organizing and teaching others how to bring people together to achieve a common goal in the face of uncertainty. I'm really pleased to have Marshall Ganz with me today, and he's going to discuss the challenges of organizing healthcare systems. >> Hi, Dr. Fred. [LAUGH] No, it's. One of the things about people who are called to be healers is that they have to confront the world's pain daily and have to be sources of hope daily. And that intersection of recognizing the world's pain but also having to be a source of hope requires enormous moral energy to do the work, or in other terms, commitment. Now there's a classic Harvard Business Review article that distinguishes two kinds of organizations, what are called compliance organizations and commitment organizations. Compliance organizations are all about command and control and trying to get people to comply with minimal standards in order to produce widgets. Commitment organizations require fostering, motivating commitment that is creative, that's innovative, that's adaptive. And healthcare, more than about almost anything you could think of, rests on commitment. Yet when we design organizations that are intended to produce compliance, we put healers in a box, where what draws them to the work and what makes them great at it is exactly what a lot of the organisations drive out. And so that contradiction is one of the core contradictions in the way we do healthcare. And so reorganizing the provision of healthcare in such a way that it rests on commitment and on collaboration and on the values that go with that, I think is probably one of the most important things we need to learn how to do. >> Now how can an individual bring this about? How can someone who wants to see this happen, who is not the CEO, how can they bring this about? >> Well, I mean, that's of course a big question. I mean, I think people need to find the domains and the spaces where they can begin to actually develop this model and demonstrate it. And my experience is that that's happening kind of all over the country in varieties of whether hospitals, in different practices. Because especially among the rising generation of healthcare providers there's a real understanding of the need to align organizational structure with the mission, with the requirements of the work, which is about fostering commitment. So if you can carve out a ward, if you can carve out a department, if you can carve out a district where there's enough autonomy to begin to reorganize on relational, collaborative, values-based grounds, then you begin to create on the ground a different reality. But of course, sooner or later, it's a challenge to the way we've designed these structures. And the people who run these organizations, maybe they'll just have to be new people. >> Marshall, that's very insightful and I really appreciate your eloquent description of the challenges ahead. Thank you very much. >> Thank you.
