The Challenge: To Create More Value in All Negotiations

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Welcome to Tom Peters
PowerPoint World! Beyond the set of slides
here, you will find at tompeters.com the last
eight years of presentations, a basketful of
Special Presentations, and, above all, Toms
constantly updated Master Presentationfrom which
most of the slides in this presentation are
drawn. There are about 3,500 slides in the 7-part
Master Presentation. The first five chapters
constitute the main argument Part I is context.
Part II is devoted entirely to innovationthe
sine qua non, as perhaps never before, of
survival. In earlier incarnations of the
master, innovation stuff was scattered
throughout the presentationnow it is front and
center and a stand-alone. Part III is a
variation on the innovation themebut it is
organized to examine the imperative (for most
everyone in the developed-emerging world) of an
ultra high value-added strategy. A value-added
ladder (the ladder configuration lifted with
gratitude from Joe Pine and Jim Gilmores
Experience Economy) lays out a specific logic for
necessarily leaving commodity-like goods and
services in the dust. Part IV argues that in
this age of micro-marketing there are two
macro-markets of astounding size that are
dramatically under-attended by all but a few
namely women and boomers-geezers. Part V
underpins the overall argument with the necessary
bedrockTalent, with brief consideration of
Education Healthcare. Part VI examines
Leadership for turbulent times from several
angles. Part VII is a collection of a dozen
Listssuch as Toms Irreducible 209, 209
things Ive learned along the way. Enjoy!
Download! Stealthats the whole point!
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Tom Peters EXCELLENCE. ALWAYS.Kindred
HealthcareLas Vegas/25 March 2008Part 1 of 2
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Slides at tompeters.com
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Sticking my neck out Reflecting on
healthcare Tom Peters/03.25.2008
6
U.S. Life Expectancy
7
45. Rank of U.S. life
expectancy, ltBosnia, Cuba
8
Bottom line 1900-1960, life expectancy grew
0.64 per year 1960-2002, 0.24 per year, half
from airbags, gun locks, service employment
Source Best Care Anywhere Why VA Healthcare
Is Better Than Yours/Phillip Longman
9
Americas elites are very good at attracting
money and prestige, and they have a huge
technology arsenal with which they attack death
and disease. But they have no positive medical
results to show for it in the aggregate and many
indications that they are providing lower-quality
care than the much-maligned HMOs and assorted St.
Elsewheres. Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
10
KIA Wounded
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CDC 1998 90,000 killed and 2,000,000 injured
from hospital-caused drug errors infections
12
HealthGrades/Denver 195,000 hospital deaths per
year in the U.S., 2000-2002 390 full
jumbos/747s in the drink per year.Comments
This should give you pause when you go to the
hospital. Dr. Kenneth Kizer, National Quality
Forum There is little evidence that patient
safety has improved in the last five years. Dr.
Samantha CollierSource Boston Globe/07.27.04
13
1,000,000 serious medication errors per year
illegible handwriting, misplaced decimal points,
and missed drug interactions and
allergies.Source Wall Street Journal
/Institute of Medicine
14
Hospital infections kill an estimated 103,000
people in the United States a year, as many as
AIDS, breast cancer and auto accidents combined.
Today, experts estimate that more than 60
percent of staph infections are M.R.S.A. up from
2 percent in 1974. Hospitals in Denmark, Finland
and the Netherlands once faced similar rates, but
brought them down to below 1 percent. How?
Through the rigorous enforcement of rules on hand
washing, the meticulous cleaning of equipment and
hospital rooms, the use of gowns and disposable
aprons to prevent doctors and nurses from
spreading germs on clothing and the testing of
incoming patients to identify and isolate those
carrying the germ. Many hospital administrators
say they cant afford to take the necessary
precautions. Betsy McCaughey, founder of the
Committee to Reduce Infection Deaths (New York
Times/06.06.2005)
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When I climb Mount Rainier I face less risk of
death than Ill face on the operating table.
Don Berwick
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The results are deadly. In addition to the
98,000 killed by medical errors in hospitals and
the 90,000 deaths caused by hospital infections,
another 126,000 die from their doctors failure
to observe evidence-based protocols for just four
common conditions hypertension, heart attack,
pneumonia, and colorectal cancer. TP total
314,000 Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
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1m42s
18
59
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Plus God knows how many in doctors offices,
Tom Thom Mayer
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2003, New England Journal of Medicine
publishes quality study results 11 measures of
quality compare VA and fee-for-service plans. VA
significantly better on 11 out of 11
2004, Annals of Internal Medicine, RAND
study VA vs commercial managed care VA
outperforms all other sectors of American
healthcare in 294 measures of quality
National Committee for Quality Assurance
top-rated, JHU, Mayo, Mass General In every
single category the veterans healthcare system
outperforms the highest-rated non-VA hospitals
Source Best Care Anywhere Why VA Healthcare
Is Better Than Yours/Phillip Longman
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k.i.s.s.
22
K.I.S.S./Keep It Simple, Stupid Wrong site
surgery The most effective part of the drill is
simply asking the patient, in language he can
understand, to state (not confirm) who he is, his
birth date or social security number, and what
hes in for. Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
23
The Checklist!
24
90K in ICU on any given day178 steps/day50
serious complicationSource Atul Gawande,
The Checklist (New Yorker, 1210.07)
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Peter Provonost, Johns Hopkins,
2001Checklist, line infections1/3rd at
least one errorNurses/permission to stop
procedure1 year/10-day line-infection rate
11 to 0 (43 infections, 8 deaths, 2M saved)
Source Atul Gawande, The Checklist (New
Yorker, 1210.07)
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Docs, nurses make own checklists on whatever
process-procedure they chooseWithin weeks,
average stay in ICU down 50Source Atul
Gawande, The Checklist (New Yorker, 1210.07)
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Replicate in Inner City Detroit (resource
strapped, staff cut 1/3rd, poorest patients
in USA)Nurses QBProject managerExec
involvement (help with little thingsits all
little things)Blues, small bonuses for
participating6 months, 66 decrease in
infection rate USA bottom 25 to top
10Source Atul Gawande, The Checklist (New
Yorker, 1210.07)
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Pronovost is focused on work that is not
normally considered a significant contribution in
academic medicine. As a result, few others are
venturing to extend his achievements. Yet his
work has already saved more lives than that of
any laboratory scientist in the last decade.
Atul Gawande, The Checklist (New Yorker,
1210.07)
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Beware of the tyranny of making Small Changes to
Small Things. Rather, make Big Changes to Big
Things. Roger Enrico, former Chairman, PepsiCo
30
Beware of the tyranny of making Small Changes
to Small Things. Rather, make Big Changes to Big
Things using Small, Almost Invisible Levers
with Big Systemic Impact. TP
31
And they call it science
32
stunning lack of scientific knowledge about
which treatments and procedures actually
work. Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
33
As unsettling as the prevalence of inappropriate
care is the enormous amount of what can only be
called ignorant care. A surprising 85 of
everyday medical treatments have never been
scientifically validated. For instance, when
family practitioners in Washington were queried
about treating a simple urinary tract infection,
82 physicians came up with an extraordinary 137
strategies.Source Demanding Medical
Excellence Doctors and Accountability in the
Information Age, Michael Millenson
34
400,000 heart bypass surgeries, 1,000,000
angioplasties per year Yet recent studies show
that only about three percent of the patients who
receive such operations benefit from them most
would be better served just taking aspirin or
low-cost beta blockers. Source Best Care
Anywhere Why VA Healthcare Is Better Than
Yours/Phillip Longman
35
See no evil ....
36
culture of cover-up that pervades
healthcare Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
37
Pick of the litter????
38
Generally, the more prestigious the hospital you
check into, and the more eminent and numerous the
physicians who attend you, the more likely you
are to receive low-quality or even dangerous and
unnecessary care. Source Best Care Anywhere
Why VA Healthcare Is Better Than Yours/Phillip
Longman
39
The more doctors and specialists around, the
more tests and procedures performed. And the
results of all these tests and procedures? Lots
more medical bills, exposure to medical errors,
and a loss of life expectancy. It was this
last conclusion that was truly shocking, but it
became unavoidable when Dartmouths Dr. Jack
Wennberg and others broadened their studies. They
found its not just that renowned hospitals and
their specialists tend to engage in massive
overtreatment. They also tend to be poor at
providing critical but routine care. Source
Best Care Anywhere Why VA Healthcare Is Better
Than Yours/Phillip Longman
40
The more doctors and specialists around, the
more tests and procedures performed. And the
results of all these tests and procedures? Lots
more medical bills, exposure to medical errors,
and a loss of life expectancy. Source Best
Care Anywhere Why VA Healthcare Is Better Than
Yours/Phillip Longman
41
Dartmouth Professor Elliott Fisher and his
colleagues discovered that patients who went to
hospitals that spent the mostand did the most
procedureswere 2 to 6 percent more likely to die
than patients that went to hospitals that spent
the least. Source Overtreated Why Too Much
Medicine Is Making Us Sicker and Poorer Shannon
Brownlee
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My most memorable brushes have been with an
eminent surgeon, Marjorie wrote in her
next-to-last column for the Washington Post,
whose method is to stride into the examining
room two hours late, pat your hand, pronounce
your certain death if he cant perform an
operation on you, and then snap at your husband
to stop taking notes, since he cant possibly
follow the complexity of the doctors thinking.
Source Best Care Anywhere Why VA Healthcare
Is Better Than Yours/Phillip Longman
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VA costs up 0.8 in 10 years, Medicare up
40.4 (Note VA patients older, sicker, poorer
and more prone to mental illness, homelessness,
and substance abuse ½ gt 65, 1/3 smoke, 1/5
diabetes vs 1/14 overall chronic diseases,
frailtyespecially vulnerable to medical errors
) Source Best Care Anywhere Why VA Healthcare
Is Better Than Yours/Phillip Longman
44
VA/Strengths Safety Evidence-based
medicine Health promotion and wellness
programs Unparalleled adoption of electronic
medical records and other information
technologies Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
45
IS/IT
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Some grocery stores have better technology than
our hospitals and clinics. Tommy Thompson,
former HHS SecretarySource Special Report on
technology in healthcare, U.S. News World
Report
47
Information technology group of off-the-radar
experiments, performed surreptitiously by the
Hard Hats. Dr Kenneth Dickie, 1979, brought
together, as VistA, 20,000 software protocols
originally written by individual doctors and
other professionals working secretly in VA
facilities all around the country This
unique, integrated information system has
dramatically reduced medical errors at the VA
while also vastly improving diagnoses, quality of
care, scientific understanding of the human body,
and the development of medical protocols based on
hard data about what drugs and procedures work
best. Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
48
Scanner Skunkworks project started in Kansas,
1992, hand-held scanner, idea from nurse Sue
Kinnick when she observed usage in rental-car
return area. It wound up eliminating some
549,000 errors by 2001 there was a 75 decrease
in errors involving the wrong medication, a 62
decrease in errors involving the wrong dosage, a
93 reduction in the wrong patients receiving
medicine, and a 70 decrease in the number of
times nurses simply forgot or didnt get around
to giving patients their meds. Source Best
Care Anywhere Why VA Healthcare Is Better Than
Yours/Phillip Longman
49
Our entire facility is digital. No paper, no
film, no medical records. Nothing. And its all
integratedfrom the lab to X-ray to records to
physician order entry. Patients dont have to
wait for anything. The information from the
physicians office is in registration and vice
versa. The referring physician is immediately
sent an email telling him his patient has shown
up. Its wireless in-house. We have 800
notebook computers that are wireless. Physicians
can walk around with a computer thats
pre-programmed. If the physician wants, well go
out and wire their house so they can sit on the
couch and connect to the network. They can review
a chart from 100 miles away. David Veillette,
CEO, Indiana Heart Hospital
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No good deed goes unpunished
51
Every 1.00 spent on its wellness program ended
up saving Citigroup 4.70, according to an
academic study. WSJ/0329.07
52
Quality doesnt pay 1995, Duke Medical
Center, Nurses regularly called patients with
congestive heart failure at home to monitor
their well-being and to make sure they took their
medications. Nutritionists offered heart-healthy
diets. Doctors shared data about their patients
and developed evidence for what treatments and
dosages had the best results. And it workedat
least in the sense that patients became
healthier. The number of hospital admissions
declined and patients spent less time in the
hospital. Problem By 2000, the hospital was
taking a 37 hit in its revenue due to the
decline in admissions and the absence of
complications. Ten hospitals in Utah had a
similar experience after implementing integrated
care for pneumonia. No investment in quality
goes unpunished. But there is a problem Who
will pay for it? An idealistic commitment to
best practices doesnt pay the bills. Source
Best Care Anywhere Why VA Healthcare Is Better
Than Yours/Phillip Longman
53
Planetree A Radical Model for New
Healthcare/Healing/Wellness ExcellenceTom
Peters
54
It was the goal of the Planetree Unit to help
patients not only get well faster but also to
stay well longer. Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
55
Much of our current healthcare is about curing .
Curing is good. But healing is spiritual, and
healing is better, because we can heal many
people we cannot cure. Leland Kaiser,
Holistic Hospitals
56
The most basic question we need to pose in
caring for others is this Is this a loving act?
Leland Kaiser, Holistic HospitalsSource
Putting Patients First, Susan Frampton, Laura
Gilpin, Patrick Charmel
57
Determinants of HealthAccess to care
10Genetics 20Environment 20Health
Behaviors 50Source Institute for the Future
58
The 9 Planetree
Practices1. The Importance of Human
Interaction2. Informing and Empowering Diverse
Populations Consumer Health Libraries and
Patient Information3. Healing Partnerships The
importance of Including Friends and Family4.
Nutrition The Nurturing Aspect of Food5.
Spirituality Inner Resources for Healing6.
Human Touch The Essentials of Communicating
Caring Through Massage7. Healing Arts Nutrition
for the Soul8. Integrating Complementary and
Alternative Practices into Conventional
Care9. Healing Environments Architecture and
Design Conducive to HealthSource Putting
Patients First, Susan Frampton, Laura Gilpin,
Patrick Charmel
59
1. The Importance of Human Interaction
60
Press Ganey Assoc 139,380 former patients from
225 hospitalsnone of THE top 15 factors
determining Patient Satisfaction referred to
patients health outcomePS directly related to
Staff InteractionPS directly correlated with
Employee Satisfaction Source Putting Patients
First, Susan Frampton, Laura Gilpin, Patrick
Charmel
61
There is a misconception that supportive
interactions require more staff or more time and
are therefore more costly. Although labor costs
are a substantial part of any hospital budget,
the interactions themselves add nothing to the
budget. Kindness is free. Listening to patients
or answering their questions costs nothing. It
can be argued that negative interactionsalienatin
g patients, being non-responsive to their needs
or limiting their sense of controlcan be very
costly. Angry, frustrated or frightened
patients may be combative, withdrawn and less
cooperativerequiring far more time than it
would have taken to interact with them initially
in a positive way. Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
62
Perhaps the simplest and most profound of all
human interactions is KINDNESS. But if it is so
simple, it is surprising how frequently it is
absent from our healthcare environments. Many
staff members report verbal abuse by
physicians, managers and coworkers. Putting
Patients First, Susan Frampton, Laura Gilpin,
Patrick Charmel
63
Planetree is about human beings caring for other
human beings. Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel (Ladies
and gentlemen serving ladies and gentlemen4S
credo)
64
2. Informing and Empowering Diverse Populations
Consumer Health Libraries and Patient
Information
65
Planetree Health Resources Center/1981Planetree
Classification SystemConsumer Health
LibrariansVolunteersClasses, lecturesHealth
FairsGriffins Mobile Health Resource
CenterOpen Chart PolicyPatient Progress
NotesCare Coordination Conferences (Est. goals,
timetable, etc.)Source Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
66
3. Healing Partnerships The Importance of
Including Friends and Family
67
When hospital staff members are asked to list
the attributes of the perfect patient and
family, their response is usually a passive
patient with no family. Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
68
The Patient-Family ExperiencePatients are
stripped of control, their clothes are taken
away, they have little say over their schedule,
and they are deliberately separated from their
family and friends. Healthcare professionals
control all of the information about their
patients bodies and access to the people who can
answer questions and connect them with helpful
resources. Families are treated more as intruders
than loved ones. Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel
69
Family members, close friends and significant
others can have a far greater impact on
patients experience of illness, and on their
long-term health and happiness, than any
healthcare professional. Through the
Patients Eyes
70
A 7-year follow-up of women diagnosed with
breast cancer showed that those who confided in
at least one person in the 3 months after surgery
had a 7-year survival rate of 72.4, as compared
to 56.3 for those who didnt have a confidant.
Institute for the Future
71
Care Partner Programs (IDs, discount meals,
etc.)Unrestricted visits (Most Planetree
hospitals have eliminated visiting restrictions
altogether.) (ER at one hospital has a policy
of never separating the patient from the family,
and there is no limitation on how many family
members may be present.)Collaborative Care
ConferencesClinical Guidelines
DiscussionsFamily SpacesPet Visits (POP
Patients Own Pets)Source Putting Patients
First, Susan Frampton, Laura Gilpin, Patrick
Charmel
72
4. Nutrition The Nurturing Aspect of Food
73
Meals are central eventsvsThere, youre
fed. Irony Focus on nutrition has
reduced focus on food and serviceSource
Putting Patients First, Susan Frampton, Laura
Gilpin, Patrick Charmel
74
KitchenBeautiful cutlery, plates, etcChef
reputation Source Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
75
Aroma therapy (e.g., smell of baking
cookies)Source Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
76
5. Spirituality Inner Resources for Healing
77
Spirituality Meaning and Connectedness in
Life1. Connected to supportive and caring
group2. Sense of mastery and control3. Make
meaning out of disease/ find meaning in
sufferingSource Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
78
Griffin redesign chapel (waterfall,
quiet music, open prayer book)Other music,
flowers, portable
labyrinthSource Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
79
6. Human Touch The Essentials of Communicating
Caring Through Massage
80
Massage is a powerful way to communicate
caring. Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel
81
Mid-Columbia Medical Center/Center for Mind and
BodyMassage for every patient scheduled for
ambulatory surgery (Go into surgery witha good
attitude) Infant massageStaff massage (caring
for the caregivers)Healing environments
chemo!Source Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel
82
7. Healing Arts Nutrition for the Soul
83
Planetree Environment conducive to
healingColor!Light!Brilliance!Form!Art!Mu
sic!Source Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel
84
Florence Nightingale/Notes on Nursing/patients
need for beauty, windows, flowers People say
the effect is only on the mind. It is no such
thing. The effect is on the body, too.Source
Putting Patients First, Susan Frampton, Laura
Gilpin, Patrick Charmel
85
Griffin Music in the parking lot professional
musicians in the lobby (7/week, 3-4hrs/day) 5
pianos volunteers (120-140 hrs arts
entertainment per month). Source Putting
Patients First, Susan Frampton, Laura Gilpin,
Patrick Charmel
86
8. Integrating Complementary and Alternative
Practices into Conventional Care
87
Griffin IMC/Integrative Medicine
CenterMassageAcupunctureMeditationChiropracti
cNutritional supplementsAroma therapySource
Putting Patients First, Susan Frampton, Laura
Gilpin, Patrick Charmel
88
CAM (Complementary Alternative Medicine) 83M
in US (42)CAM visits 243M, greater than to PCP
(Primary Care Physician) (With min insurance
coverage)W-Educated-Hi incDont tell PCP
(40)OTA lt30 procedures used in conventional
medicine have undergone RCTs (randomized clinical
trials) Source Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel
89
9. Healing Environments Architecture and Design
Conduciveto Health
90
Planetree LookWoods and natural
materialsIndirect lightingHomelike
settingsGoals Welcome patients, friends and
family Value humans over technology .. Enable
patients to participate in their care Provide
flexibility to personalize the care of each
patient Encourage caregivers to be responsive
to patients Foster a connection to nature and
beautySource Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel
91
SoundTextureLightingColorSmellTasteSacred
spaceSource Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel
92
Access to nurses stationHappen
tovsHappen withSource Putting Patients
First, Susan Frampton, Laura Gilpin, Patrick
Charmel
93
The Eden AlternativeElderCare
94
The Ten Principals of the Eden
Alternative1. The three plagues of loneliness,
helplessness, and boredom account for the bulk of
suffering among Elders.2. Life in an
Elder-centered community revolves around close
and continuing contact with children, plants, and
animals. These ancient relationships provide
young and old alike with a pathway to a life
worth living.3. Companionship is the antidote to
loneliness. In an Elder-centered community we
must provide easy access to human and animal
companionship.4. A healthy Elder-centered
community seeks to balance the care that is being
given with the care that is being received.
Elders need opportunities to give care and
caregivers need opportunities to receive
care.Source Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel
95
The Eden paradigm allows elders to care for
animals, birds, and children as well as each
other. Susan Eaton, Harvard/JFK schoolSource
Putting Patients First, Susan Frampton, Laura
Gilpin, Patrick Charmel
96
The Ten Principals of the Eden
Alternative5. Variety and Spontaneity are the
antidotes to boredom. The Elder-centered
community is rich in opportunities to sample
these ancient pleasures.6. An Elder-centered
community understands that passive entertainment
cannot fill a human life.7. The Elder-centered
community takes medical treatment down from its
pedestal and and places it into the service of
genuine human caring.Source Putting Patients
First, Susan Frampton, Laura Gilpin, Patrick
Charmel
97
The Ten Principals of the Eden
Alternative8. In an Elder-centered community,
decisions should be made by the Elders or those
as close to the Elders as possible.9. An
Elder-centered community understands human growth
cannot be separated from human life.10. Wise
leadership is the lifeblood of any struggle
against the Three Plagues. For it, there can be
no substitute.Source Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
98
Conclusion Caring/Growth Experience
99
Care!/Love!/Spirit!Self-Control!Connect!/learn
!/involve!/Engage!Understanding!/Growth!
De-stress!/heal! Whole patient family
friends! be well!/stay well!
100
F.Y.I.
101
Griffin Hospital/Derby CT (Planetree Alliance
HQ) Results Financially successful.
Expanding programs-physically. Growing market
share. Only hospital in 100 Best Cos to Work
for7 consecutive years, currently 6.
Five-Star Hospitals, Joe Flower,
strategybusiness (42)
102
Learn more about Planetree/ The Planetree
Alliance www.planetree.org
103
resources
104
Best Care Anywhere Why VA Healthcare Is
Better Than Yours Phillip LongmanMedicine
Culture Lynn PayerOur Daily Meds How the
Pharmaceutical Companies Transformed
Themselves into Slick Marketing Machines and
Hooked the Nation on Prescription Drugs
Melody PetersenOvertreated Why Too Much
Medicine Is Making Us Sicker and Poorer
Shannon BrownleeDemanding Medical
Excellence Doctors and Accountability in the
Information Age Michael Millenson
Putting Patients First Susan Frampton,
Laura Gilpin, Patrick Charmel The Planetree
story