Why consultants use PowerPoint … and other pearls of wisdom from 26 years in the healthcare management consulting industry.

Neil Seeman interviews Neil Stuart . . .

Why consultants use PowerPoint …

With a newly minted PhD in health policy from Brandeis University, Neil Stuart joined Price Waterhouse as a fresh-eyed consultant in 1983. “It seemed like a good place to be for a short while – I’d learn a lot and maybe figure out how I could get a ‘real job’.” Twenty-six years later he would emerge as one of Canada’s most respected strategic advisors and health policy visionaries. The world of consulting has changed dramatically since 1983, Neil Stuart recently told a large gathering of former colleagues, clients, and mentees upon his retirement from IBM Canada’s healthcare consulting practice. (We would have needed a Hubble-powered fisheye lens to jam every well-wisher there into a single photograph).

1. How would you define the business of “healthcare consulting”?

Neil Stuart: “Any consulting to health care organizations that in some ways is about the business of health care or health care delivery – assisting with studies, plans, reviews, evaluations, solving problems, designing or implementing new approaches.”

2. What sorts of character traits make somebody well-suited to the healthcare consulting business? Who is not suited for it?

Neil Stuart: “To be a good consultant, exceptional analytical, problem-solving and communication skills are essential. But the thing that really distinguishes a great consultant from the rest is an ability to see things from the client’s perspective to understand their issues – the consultant who really figures out what the client is looking to deal with and focuses their energies and imagination on this. In my experience, one of the most common scenarios for consulting jobs getting off track is when a consultant gives a client something they did not ask for or sets out to solve the wrong problem.

If someone is the kind of person who already has the answer or who is “on a mission”, they might find consulting a frustrating path to take.”

3. How has the business changed over the last 25 years – for the better, and for the worse?

Neil Stuart: “The big consultancies have become much more sophisticated with well developed consulting methodologies and more refined tools for running their business. Twenty-five years ago, consultants were more likely to be ‘flying by the seat of their pants’. The contracts and scale of projects have grown too. A lot more of the work is related to information technology. Twenty-five years ago much of what consultants did was advisory in nature, e.g. reviews that led to recommendations. Today, there is much more hands-on work with bigger projects where consultants are involved in building and implementing large solutions and helping to manage associated change processes.

With bigger consulting projects, bigger teams and bigger practices, the roles in these consulting practices have become more specialized – with some individuals focused just on selling consulting work, some on project management, some on change management, some on process redesign, some on IT architecture and so on.”

4. How do these changes affect how and when healthcare organizations should hire consultants?

Neil Stuart: “Health care organizations need to be clear on why they need the help of a consultant. Is it for an independent or expert opinion? Is it to do a job for which they lack the specialized resources internally? Is it because they are in ‘trouble mode’ and need outside help? There are many different kinds of consultants and consulting skill sets. Health care organizations should make sure they are clear on what they are looking for and be sure to hire the consultant or consulting team that can meet their needs. If in doubt, would-be clients should check with others who have used consultants recently for similar work and learn from them.”

5. How do you respond to the critics of healthcare IT consulting who complain about some projects going over-time and over-budget?

Neil Stuart: “More often than not these situations could have been avoided if there was greater clarity on the project requirements. It is true that some times when consultants are competing to win projects, they can over-promise. This is where the client has to be crystal clear on what they are looking for and what they are contracting for.

In the case of IT related projects, it is really important that there be a clear focus on the health care benefits of the IT. There must be meaningful business reasons for introducing new IT. The health care leaders (not just the people in the IT group) must be involved in and driving these initiatives. They have to believe that health care itself will be improved by the IT. And as the IT solutions are being designed, built and implemented there must be an overriding emphasis on realizing these health care benefits.

Ontario is currently poised to try a very different approach to procuring large e-health solutions. They are looking to Infrastructure Ontario to help channel such procurement through consortia that include the IT vendors and consultants, but also include a party who will finance the project. They have called this approach Alternative Financing and Procurement (AFP). It offers a way of addressing many of the risks traditionally associated with big IT initiatives.”

6. In all your years as a trusted advisor to healthcare leaders, what qualities do you think make the best leaders shine?

Neil Stuart: “Vision, an ability to inspire their team, a grasp of the critical strategic issues – all have to be at the top of this list. Many of these qualities touch on being able to anticipate new opportunities and mobilize organizations to prepare for the future.”

7. What qualities make for dysfunctional healthcare leadership?

Neil Stuart: “Maybe the biggest pitfalls lie in becoming too focused on the narrow interests of one’s own health care organization and losing sight of what is good for patients and what the bigger health care system needs to be taking on.”

8. Why do consultants use PowerPoint presentations so often? Will the madness end?

Neil Stuart: “You have a point – no pun intended. PowerPoint has been a great tool to help consultants quickly summarize their analyses and findings and pull together a presentation. But PowerPoint can also be a real handicap if people rely on decks that are just an amalgam of slides originally prepared for other purposes. And there are some downsides in getting caught presenting from slides someone else has prepared. PowerPoint is often a used as shorthand to frame a richer, more detailed story. The presenter has to have the story and if they don’t, PowerPoint will not give it to them.”

9. What was your best experience as a management consultant and leader in the industry?

Neil Stuart: “Consulting gives one an opportunity to assist client organizations at some of their most exciting and formative moments, as well as sometimes their most vulnerable moments. Consulting can sometimes give one an opportunity to contribute to breakthrough changes and real innovation. This can be very fulfilling. But the consultant’s role is often beneath the radar. It will always be the executives in the health care organizations, or sometimes government, who own the initiative and deservedly wear the success.”

10. Would you recommend consulting as a career or even a career step for a young professional entering the health care world?

Neil Stuart: “Absolutely, I can think of no other place a fresh MBA or MHA graduate could go where they could get the same variety of experience, the insights, the chance to be part of so many innovative projects, to be in an environment that so values learning, and (if they are good) to move ahead so fast.”

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College, University of Toronto.

Neil Stuart may be reached at: neil.stuart@sympatico.ca

This Just In: Systems Designed to Fail, Fail

By Steven Lewis

First there is the disaster that comes to light long after the fact. Then there is the inquiry. Then there is the scathing report that meticulously unearths the causes of the disaster. Then there is the apology (they’re allowed now – it’s the law!). Then there is restitution. Finally there is the commitment: never again. And then the same thing happens, somewhere else, again, and again, and again.

Canadian medicine – it is quite different in some other jurisdictions – is organized around four fundamental premises. First, doctors are highly trained professionals whose license to practice needs no expiry or renewal date. Second, initial certification exams are reliable guarantors of lifelong competence and consistent, high quality practice. Third, it is both unnecessary and unsporting to subject the autonomous judgments of professionals to rigorous and regular scrutiny. Fourth, professional self-regulation is the ideal mechanism for preventing harm.

To quality improvement and harm reduction experts in every other industry, these premises are not merely dubious, but laughable. Yet they persist in medicine, and the inevitable result is that people get hurt. Radiology and pathology are high-stakes diagnostic professions where errors can kill. When massive failures occur, as in the Newfoundland and Labrador breast cancer testing debacle of 1997-2005 (!), or the Charles Smith forensic pathology fiasco of 1981-2005 in Ontario (!), the root causes turn out to be depressingly pedestrian. That’s what makes them as pathetic as they are tragic.

Even more damning is the repetition. The lid has just come off Quebec’s breast cancer diagnostic breakdown. Saskatchewan is cleaning up after a pathologist who may have put thousands of people at risk over 5 years. It will cost millions of dollars to have every one of his 70,000 images reread out of province, and perhaps tens of millions to settle the malpractice claims (the notorious Regina lawyer Tony Merchant has already launched a class action suit). The only difference between these jurisdictions and those so far untouched by the contagion is that the time bombs are on different schedules.

Despite the repeated revelations of system errors that demand system solutions, nothing has fundamentally changed to guarantee safer health care and prevent the birth of gestating misadventures. When push comes to shove, the right to practice shoddy medicine trumps public safety; no one gets to cancel the flight or shut down the assembly line without definitive proof of repeated incompetence. A health region or regulatory body that moves aggressively to suspend a practitioner pending investigation of suspicious results will be harassed and condemned for violating due process. The first reflex will not be to acknowledge the problem or seek mentorship; it will be to lawyer up. The medical association with go to bat to keep the practitioner in the saddle. Physicians and others in the know who would not send their own kids to an incompetent colleague either can’t or won’t stop yours from ending up in his care.

It’s not just a conspiracy between the guilds and the law; it’s a systematic failure to manage risk. Built in redundancy, rigorous peer review, structured continuing education, and mandatory recertification are cornerstones of safety. The higher the stakes, the greater the need for vigilance and tightly organized quality control systems. Geographically isolated professionals are obviously at risk, and many will fail without carefully designed, reliable supports in place. But everyone needs audit, feedback and peer support to perform reliably over time. In medicine it is well-documented that performance declines with age. The response to this chilling reality has been to let the chips fall where they may – the pathology of denial.

The Saskatchewan case is especially instructive. There were suspicions about the radiologist’s competence 3 years ago. With the regulatory noose tightening around his neck, he volunteered to go for remedial education. No educational program in western Canada stepped up to the plate. After he spent 3 months at McMaster, the Saskatchewan College received a perfunctory and brief report on his progress and skills that it rejected as inadequate. He returned to practice, and on the evidence to date, his interpretation of every 20^th image may have put someone at risk.

The system is designed to fail, and it must be redesigned to succeed. The solution is not to expect physicians to look furtively over their colleagues’ shoulders and snitch to the authorities. The remedies must be systemic, obligatory, and woven into the fabric of medical education, ethics, and organization. Among the obvious requirements are:

• Mandatory review of randomly drawn samples of diagnostic interpretations. The frequency and intensity of the scrutiny should be commensurate with the complexity of the practice, known error rates, and the consequences of mistakes.
• A formal, standardized protocol for addressing competency problems. The first signs of problems should trigger mandatory supervision and intensified case reviews until performance is demonstrably up to snuff.
• Beyond certain thresholds of error, automatic suspension followed by the launch of a remediation algorithm.
• Specific additional support, review, and continuing competency assurance procedures for isolated practitioners.
• Transparent reporting to the public of performance results.

It is delusional to believe that everything is now out in the open, with nothing more to uncover. It’s not just the outliers who cause harm; because medicine is so fraught with unjustifiable variations in practice, it is certain that the errors resulting from “satisfactory” practice far outnumber the misdeeds of the visibly incompetent. The graveyards are filled with anonymous victims whose stories will never surface in a public inquiry. Until professionals take their collective obligations seriously and embrace a culture of safety, prevention will fail, detection will be late, and the victims will pile up. If they view peer review, recertification, and remediation as violations of sacred entitlements, sleepwalking through mandated processes won’t accomplish much.

Sad to say, for radiology and pathology our salvation may come from machines. It is foreseeable that computerized pattern recognition software will be able to diagnose more accurately and consistently than specialists in all but the most unusual of cases. If that day comes, we can be sure that these highly reliable machines will be programmed to self-diagnose and identify anomalies in their own findings and performance at regular intervals, and will be examined, refurbished, and re-tested according to strict protocols. In other words, we will treat them and their needs with care and respect, governed by the duty to put patients first. Too bad that we don’t do the same for fallible diagnosticians and their victims.