The Gov. Juan F. Luis Hospital is once again threatened by decertification from the Centers for Medicare and Medicaid, and, once again, it has been given a very short window in which to prepare a response. There is an inevitable and urgent focus on the "what" and "how" to avoid the death sentence.
But at some point in the near future, it would be very useful to ask "why." The "power of why" has become an invaluable tool for explaining success. It can also have great value in explaining deficiencies and failure, and in laying out a path to a more successful future.
Here are some basic "why" questions. Why does JFL Hospital exist? Why do Virgin Islands public agencies perform more poorly than their peers elsewhere? In this specific case, why is JFL faced with the rare threat of CMS decertification?
There appear to be three standard responses to these "why" questions. The first involves denial. This response takes several forms: one is that "they" are just picking on us – or change is coming but it takes time. The second is a more pernicious form of denial. It is that "outsiders" come in, try to tell us what to do and make a mess of things. Just leave us alone. And finally there is the eternal favorite: we lack resources. Just give us the money and everything will be fine.
There may be kernels of truth in each of these explanations but they all obscure a much bigger problem. That problem is that, when a community service – whether it is health care, education, public safety or some other important function – becomes more of a jobs program than a service, quality is inevitably crowded out by the goal of protecting the jobs of those who have them now. Part of JFL’s problem is that it is just harder to hide the negative consequences in health care than in other areas.
Jobs are a divisible benefit. There are a limited number of them and their value increases in a bad economy. Health care, on the other hand, is an indivisible benefit. Why is the hospital there? To serve everyone in the community, at least in theory.
So when jobs become the primary – even if unstated – answer to the "why do we exist" question, and someone in the hospital doesn’t perform, the thought is, what will happen to them if they get fired? Rather than what does this mean for patient care? This is especially true in a community with few other options. So let’s keep them employed.
And at some point, the poor performers begin to set the norm, overall standards erode and accountability goes out the window. The same is true at all levels and, for senior staff, people begin to see their positions as property, instead of as a responsibility.
The final piece in the puzzle involves elected officials who use these agencies and institutions to reinforce their own base and for other bad purposes. Result: the threat of decertification.
How do you get at and solve this kind of problem? A good starting point is to understand that they are problems to be solved and not questions of good and evil. And not simple problems. They are really hard because people’s livelihoods are at stake.
Few people in leadership positions in the territory view things this way, rarely asking "why" and "what if" questions, the evidence being weakness across the board in execution and managing change. The JFL crisis is just one example of this weakness.
To solve these problems in anything approaching a successful manner requires acceptance of two simple equations. The first is that “success = execution/ change management.” You have to be able to master the discipline of getting things done.
The second equation is that “execution/change management = a clear and effective strategy + the right people in the right jobs + basic systems, information management and work processes that are effective + a culture of performance, trust and accountability + project management and implementation tools.”
Use the items in the equation as a checklist for JFL Hospital or for other Virgin Islands agencies and you have both a framework for future progress and a daunting action agenda.