Lessons From Mayo Clinic

Leonard Berry and Kent Seltman’s Management Lessons From Mayo Clinic is a short, clear read about how a massive healthcare organization provides top-tier service. They start by describing Mayo as a three-pronged organization that focuses on patient care, medical research, and medical education.

Their goal in writing the book was to identify the ideal service experience and understand how Mayo works toward that. Typically, the authors claim, a service organization depends upon the personal energy and commitment of its people, a spark and volunteerism that fades. What’s notable about Mayo is that its values and performance have not degraded with age and growth.

As a values-driven organization, Mayo’s key principle is that the needs of the patient come first. This is a lived value embedded in all corners of the organization. While much of the healthcare industry is payout-centric, Mayo strives to be patient-centric.

There’s no single orientation course which teachers this value. It, and other values, are built into the organization’s actions and its periodic training. Mayo codified these values in 1998. This was more than a century after its founding and only in response to rapid growth and the passage of time. By the late-1990s there was no longer a first or second connection among staff to the original Drs. Mayo and the organization felt the need to write down what was previously gained by association.

While “the needs of the patient come first” is what Mayo does, team medicine and collaboration is how they do that. These two values are key to Mayo’s success. The presence of teamwork across Mayo helps people become better doctors. Teamwork isn’t optional, it’s central to their practice.

This helps set the stage for mistakes to be viewed as teachable moments rather than in a punitive light. By focusing on quick, efficient teamwork Mayo can act as a much smaller organization. They’ve found a way to benefit from their organizational size while retaining the benefits of smallness. Ultimately the alignment and joining of their what and how values are inseparable.

Based on over 36,000 surveys Mayo has found that efficiency is as highly correlated with patients’ overall satisfaction as their physician relationship or outcome of care. Related to efficiency, Mayo’s use of technology aims to solve problems in the context of the organization’s values and strategy. Saving money may be the result, but it’s not the goal.

Mayo’s committees are key to how it builds culture and consensus. It has up to 80 committees at each campus. Decisions may occur slowly but implementation is rapid as, by that point, there’s consensus. They also decouple salaries from particular leadership positions as that way there’s no financial penalty for rotating out.

Their approach to hiring is that it can only be the first step in developing the right workforce. The orientation and adaptation to the organization which occurs after hiring is as important. Their retention rate is around 80%. Their ongoing trainings result in about nine annual sessions per-employee and are oriented toward both development and keeping people up to date with medical advances.

There’s a strong focus on service clues at Mayo. They break this down into three categories:

  • Mechanic: sights, sounds, textures, etc.
  • Humanic: behavior and appearance of employees.
  • Functional: technical quality of service.

These clue categories are synergistic rather than additive. To be highly effective they must all be present. And the design of mechanic clues must match the humanic followthrough. They even screen the marble slabs used to ensure there aren’t disquieting human or disease forms in the rock pattern. The guiding questions the authors suggest around this area of service are:

  • What is it that customers want more than anything else?
  • What drives customer preference?

In short Mayo has three big ideas. To place the interests of the patient above all other interests. To pool talent as a union of forces. And to deliver clinical care with time-condensed efficiency.

Young People and New Urbanism

A recent episode of the Strong Towns podcast was a panel session from the Congress for the New Urbanism. Chuck Marohn interviews four conference attendees under the age of 30.

One of the panelists, Dan Baisden, described something that was a new idea to me: the notion of Rust Belt cities becoming intake locations for those displaced by climate change. As a result of significant population loss many of these cities and towns have more infrastructure than they currently require. As the impact of climate change is felt they could become spaces for people relocating.

Missing Middle Housing

So this two-story garden apartment scenario I’m going to talk about for a few minutes… it’s part of an idea from the last few years called “missing middle”. If we think of housing on a spectrum, from detached single family housing you see in cities everywhere to mid-rise housing, like four to six stories you might see in the central area. You’ve also got duplexes triplexes, fourplexes, courtyard apartments, townhomes, a whole array of things that have been common historically in cities everywhere, but aren’t really provided for in very many locations in modern zoning.

That’s from a presentation Michael Anderson gave in Tualatin earlier this month. The idea of “missing middle” housing wasn’t new to me, but the term itself was. It’s such a clear summation of many issues facing urban development. Another good read on a similar subject is Strong Towns’ article on developers and luxury housing. It’s all relevant here in Portland where by at least one measure rents are finally down 3% year-over-year.

Revenge of the Analog

The attraction to analog is about the totality of the experience.

Jocelyn K. Glei’s conversation with David Sax is a good 40-minute discussion of the appeal of analog tools. Sax talks about how the march of technology is not an absolute process. And that developments we once laud are things we eventually also reconsider. There’s also a very interesting discussion of a summer camp for kids which banned phones and connected devices.

The Borgias

When reading Walter Isaacson’s Leonardo da Vinci I was struck by an anecdote about how Leonardo, Machiavelli, and Cesare Borgia spent time together in the same small Italian town. Wanting to know more about what drew together three men from seemingly very different walks of life I bought a handful of books about them.

The first two of these I read are G.J. Meyer’s The Borgias and Christopher Hibbert’s The Borgias and Their Enemies. They’re an interesting contrast in books. Hibbert’s takes a more traditional view of the family and relates as historical fact the stories of foul play, nepotism, and illegitimate children. Meyer’s, though, calls some of the Borgia myth into question and points out the tenuous nature of some source material. Personally I found Meyer’s more fair and interesting, but I’m no historian.

There’s a ton from each book that I took notes on and learned. A couple general points are worth noting. Overall if you’re to read one of the two I’d start with Meyer’s.


There’s a reason Showtime ran a three-season TV show on this family. The problem is that we’re dealing with events of the 1400s. Some of the source material is dubious at best. One oft-cited source is, essentially, a 15th-century gossip.

Meyer’s book tries to dig beyond conventional wisdom. It’s not a sensationalist history and tries to be fair. I’m glad I read it first rather than just assuming the stories from Hibbert’s book were unquestioned fact. Meyer also describes the problem of historical accuracy as this:

This is the Borgia problem in a nutshell: wildly outlandish accusations accepted as true generation after generation because when taken together they add up to one of the most gloriously lurid stories in all of history. Anecdotes about murder and incest that are especially delicious because their subject is a pope, and that have become so firmly embedded in the consciousness of the whole world that to question them can seem fatuous, to challenge them preposterous.1


Cesare Borgia was a key inspiration for Machiavelli’s The Prince. Given that images of cruelty, heavy-handedness, and violence might come to mind. One thing I learned is that Cesare’s violence has to be compared to contemporary peers. And here he’s, in some cases, almost humanitarian.

Hibbert quotes from Machiavelli in describing rulers within this territory:

[these lands were] a nursery of all the worst crimes, of outbreaks of rapine and murder, resulting from the wickedness of local lords…For these lords were poor, yet endeavouring to live as though they were rich, they resorted to innumerable cruelties.2

When taking over these towns Cesare typically took a different approach. He figured that if he built a reputation of generosity and fairness he’d have an easier time taking over additional towns. Meyer writes that Cesare, “was making it his practice to deal generously with people and places whose lord he intended to remain, thereby winning the loyalty of cities accustomed to the random cruelties of sadists.”3 His plan worked as in some cases he was able to take over towns without resorting to violence. Simple persuasion of the people was enough.


Rome of this era was crime-ridden by modern standards. That in itself wasn’t that surprising to learn. There’s an anecdote in both books that stuck with me, though.

Juan, Duke of Gandia and one of the many powerful Borgia children during the late-1400s, was murdered and his body thrown into the Tiber. Eventually the pope’s forces learn that a night watchman had seen five men dump a body into the river and weight it down with rocks. When asked why he’d not reported the watchman replied, “that in the course of many nights standing guard over cargo barges he had seen any number of corpses deposited in the river, and that until now no one had ever seemed to care.”4

  1. G.J. Meyer, The Borgias pg. 174[]
  2. Christopher Hibbert, The Borgias and Their Enemies pg. 142.[]
  3. G.J. Meyer, The Borgias pg. 318.[]
  4. G.J. Meyer, The Borgias pg. 259.[]

Revolution and Rebellion in the Early Modern World

I bought Jack Goldstone’s Revolution and Rebellion in the Early Modern World after reading some of its ideas referenced in Michael Mann’s The Sources of Social Power. It sat on my shelf for a few months until a vacation earlier this year provided an opportune quiet time to start reading. It’s a dense, academic book and it’s unlikely I remember many of Goldstone’s ideas. There are a handful, though, that I want to detail and hope to remember.

Theory of revolution

Goldstone’s guiding question throughout the work is why state breakdown on a worldwide scale occurred in two waves separated by a century of stability. He focuses on demographics and looks at how worldwide population trends impact early modern states and social institutions. Goldstone ultimately ties state breakdown across Europe, China, and the Middle East to a single process: population growth leading to changes in prices, shifts in resources, and increasing social demands that overwhelm a state’s ability to cope.

The societies he details shared a handful of common traits, most notably that they all relied on an agrarian economic base.1 This tied the bulk of state revenue to direct taxes on agricultural production. It also made much of state revenue, expenses, and debt subject to the swings of population trends, disease, and climate.

Eventually these large agrarian states (England, France, China, and the Ottoman Empire) experienced population increases in excess of the productivity gains of land. They raised taxes but faced a worsening fiscal crisis. Within a century populations doubled, prices and rents rose, and elite competition increased.

Poverty and Puritanism

A shift in the nature of poverty was, at least in the case of England, a contributing factor to revolution. Goldstone writes that:

In the early sixteenth century, poverty was hardly unknown. But the poor fell into readily comprehensible groups: the aged, the mentally or physically handicapped, the widow and her family. Young men of working age and families with the male head of household present were not among the poor. Over the course of the sixteenth century, however, this situation changed. As land and employment failed to keep pace with the growth of population, substantial numbers of men and their families were unable to keep above the line of dependence on charity.2

This increase in poverty overtook the state’s ability to provide for its people. And it contributed to the increasing popularity of Puritanism, which had become a more revolutionary movement and developed into a crusade offered as a panacea to cure the nation’s ills.

France and urban taxation

Much of the state breakdown in mid-18th-century France tied to the state’s massive debt and ultimate bankruptcy. Goldstone connects this to the state’s taxation patterns. France relied on agriculture for much of its tax revenue. And during the 18th century this sector of the economy was stagnant at best. During this time agricultural production fell 4% but agricultural tax rose 95%!3

Over the same years France’s urban and commercial sector was booming. But the state had sold privileges to municipalities that allowed them exemptions from many taxes. With a declining return on agricultural taxes and a political limitation or commercial taxes the state turned to borrowing. That led to an increasing debt and interest payments that were untenable.

  1. It was the 16th century after all.[]
  2. Jack A. Goldstone, Revolution and Rebellion in the Early Modern World pg. 126.[]
  3. Jack A. Goldstone, Revolution and Rebellion in the Early Modern World pg. 207[]

The System Made Me Do It

The problem, at every level of the equation, is the temptation to excuse poor human-to-human experiences on some ‘thing’ that we call ‘the system’ that is patently beyond any single individual’s control. If it is ‘the system’ that makes you maltreat people, you have caught a tiny glimpse, according to Arendt, of how totalitarianism gets away with evil.

That’s from a recent post by James Shelley. He connects a health care conference anecdote to Hannah Arendt’s philosophy and critique of totalitarianism. Worth keeping in mind as we go through life’s daily interactions.

The Entire Way We Talk About Millennials Is Wrong

The Bloomberg Odd Lots podcast recently talked with Malcom Harris about generational categorization and millennials.

Harris highlights how marketers are the first voices we hear defining new generational cohorts. This is a relatively new trend. Baby Boomers, in contrast, were defined from demographic impact. Now we focus more on consumption patterns. That’s misguided, though, and Harris argues we should look at production patterns (work) instead.

When looked at through the lens of work what we find is a generation that grew up amid a long-term secular shift of diverging compensation and productivity. Starting in the late-1970s productivity rose while compensation stayed relatively flat. Harris points out that there’s no sign this divergence, or rate of exploitation, is closing. And while it’s common to blame millennials for expecting a better lot than their parents, that constant improvement is one of the core promises of capitalism.

Hat tip Daniel.

A Guide to the Good Life

I first read William Irvine’s A Guide to the Good Life sometime last year. It stuck with me as something I’d like to re-read, which I got around to doing last month. The book itself looks at stoicism and the main philosophers involved. Irvine’s hope is to provide the guidebook a Stoic would have written for 21st-century life.

The book is one part history one part philosophical exploration. What I want to pull out and remember are three traits of stoicism.


Stoic philosophy first came from the ancient Greeks. People like Zeno and Cleanthes taught the philosophy of a good life to their students. This was around the turn of the fourth century BC. From there stoicism spread to the Roman world. As they did with many things Greek, the Romans added elements to Greek stoicism. Core to Roman stoicism was the attainment of tranquility.

The Romans viewed tranquility as a psychological state with both the absence of negative emotions and the presence of positive emotions. Irvine details how part of the rationale in this philosophical shift was due to recruitment concerns. After all, if you’re a Roman Stoic teacher of the fourth century BC you’re competing against other philosophical schools for students. You need students in order to cover your expenses. And you need to attract students and interest them in your school of thought.

Negative visualization

One of the common practices of Stoics was to contemplate the bad things that can happen to us. As Seneca wrote, “He robs present ills of their power who has perceived their coming beforehand.”1 If we’ve already thought through the ramifications of a potentially negative event then our mind is better prepared to face that same event in reality.

These philosophers felt that negative visualization can imbue our experiences with a significance and intensity by focusing our attention on the present moment. Their goal, though, was not to change our activities. Rather it was to change our state of mind. The hope is to strike a balance. To contemplate negative events without worrying about them. And to think of tomorrow while appreciating today.


Our desire for things can be one surefire way of disturbing our tranquility. As Epictetus wrote, “It is impossible that happiness, and yearning for what is not present, should ever be united.”2 The Stoic approach was to make it our goal to want only those things we can be certain of obtaining.

Their sense of what we have certainty over was also limited. It’s really just our goals, our values, our character. When it comes to goals these philosophers advocate setting internal ones (e.g. perform to the best of our abilities) rather than external ones (e.g. win).

  1. A Guide to the Good Life, pg. 65[]
  2. A Guide to the Good Life, pg. 85[]

The End of Average

The last of the books I picked up on a whim while in Singapore is Todd Rose’s The End of Average. It’s a short, popular psychology read with a pretty simple premise: no one is average. Rose’s book isn’t trumpeting some utopian ideal where everyone is above average. Instead it’s a look at the generally shaky science and history behind our reliance on averages.

The common mistake we make when relying upon averages is to compare individuals rather than groups. He opens the book relating the story of Lieutenant Gilbert S. Daniels, who discovered that designing a plane cockpit around the measurements of an average pilot meant it fit no pilot. Rather than a reliance on averages Rose argues for three principles.


Talent, among other things, is jagged. What Rose means is that we cannot apply one-dimensional thinking when looking to understand something that isn’t evenly distributed. Much of our intelligence consists of multiple dimensions that are only very weakly related to one another.

He gives the example of Isiah Thomas, who as General Manager of the New York Knicks set out to build a high-scoring roster of players. The problem is that he prioritized scoring averages for every player. And simply having talented scorers doesn’t mean that talent translates to rebounding, defense, and the numerous other skills required to excel as a basketball team.


In explaining the importance of context Rose relates the work of Yuichi Shoda. What Shoda’s research showed was that the way we behave always depends on both the individual and the situation. For example, while we may identify as an introvert or an extrovert what Shoda’s research illustrates is that we’re really both. It’s our circumstances and our traits that determine our behavior. If you’re trying to understand someone, relying on descriptions of their “average” behavior will lead you astray.


The pathways principle that Rose describes makes two affirmations. First, that for a given goal there are numerous valid pathways for achieving the outcome. Second, that the optimal pathway depends on our own individuality. The “right” pathway, in other words, isn’t the one followed by the nominally average individual. It’s the one that’s right for us.

The most compelling area Rose relates this principle to is education. He covers the work of Benjamin Bloom, who showed that when people are allowed flexibility in the pace of their learning the vast majority will perform well. In other words, the pace of our learning does not equal our ability. No one is a universally fast or slow learner. Schools, of course, aren’t exactly set up to allow for that realization.