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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.

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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.

Accuracy

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

Violence

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.

Crime

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.[↩]
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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[↩]
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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.

Tranquility

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.

Desire

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[↩]
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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.

Jaggedness

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.

Context

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.

Pathways

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.

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Museums: A Visual Anthropology

I’ve always enjoyed museums. Places like the British Museum are spaces I can spend an entire day or longer. A few years ago I bought two textbook-like works about the history and structure of museums. Since then Mary Bouquet’s Museums: A Visual Anthropology has sat on my shelf. But I got around to reading it on vacation last month.

While it is a textbook, it’s also readable. Bouquet sets out to answer how museums gained their current prominence. And to look at what dilemmas they face and what lies ahead in their future.

It was interesting to learn that many academic disciplines were based in museums during the 19th century. It was only in the 20th century that these shifted to being based in a university.

She also does an excellent job detailing the role of a national museum; a place like the Louvre or Rijksmuseum. These emerged in the late 18th century. That’s right around the time when many modern nation states were solidifying themselves. At the time these states were an unfamiliar and abstract form of organization for people. National museums helped make the state real and concrete.

Early national museums were often in large, imposing buildings. That architecture, “helped to create a visible, tangible presence and cultural identity for the nation state.” The museum itself was a way of demonstrating the new state’s competence. Its ability to bring back objects from abroad (which is a whole problem in itself) was a way of demonstrating early competence and organization.

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Leonardo da Vinci

Walter Isaacson’s Leonardo da Vinci was a gift from a while back. I’d read and enjoyed a few of his earlier books and read the Leonardo biography while in Kauai last month. It’s a worthwhile read, even if you’re already familiar with Leonardo’s life.

Isaacson opens by encouraging us to be wary of applying the word “genius” to Leonardo. Instead he portrays a man who was routinely human: someone who worked hard, made mistakes, and had an insatiable curiosity. His skill and imagination were practiced crafts.

The acuteness of [Leonardo’s] observational skill was not some superpower he possessed. Instead, it was a product of his own effort.

The book is a 500-page detailing of Leonardo’s life. And rather than even attempt to summarize, I want to instead pull out a couple things I learned.

The first is that Leonardo had the good fortune, at least retroactively speaking, of being born out of wedlock. 15th-century Italy being what it was this meant he escaped, and was even barred from, any obligation as a first-born son to follow his father’s trade. His father was a successful notary. Thankfully Leonardo was not. And while Leonardo’s notebooks indicate he picked up the note-taking mindset, he was free to pursue other work.

Another aspect that Isaacson covers throughout is Leonardo’s approach to problem-solving. Given what he was able to create, Leonardo was a relatively uneducated man. He had a limited formal education, struggled to learn Latin and math, and for much of his life preferred his own experience over handed-down knowledge. And yet he was able to create and engineer works of remarkable complexity. Isaacson ties this success to Leonardo’s ability for visual thinking. He relied far more on geometry and analogy than he did formulas and math.

Leonardo da Vinci's town plan of Imola.
Leonardo’s map of Imola.

Isaacson also describes how, in the winter of 1502, a serendipitous series of events led to Leonardo, Machiavelli, and Cesare Borgia all residing in the town of Imola. As he writes:

Imagine the scene. For three months during the winter of 1502-3, as if in a historical fantasy movie, three of the most-fascinating figures of the Renaissance—a brutal and power-crazed son of a pope, a sly and amoral writer-diplomat, and a dazzling painter yearning to be an engineer—were holed up in a tiny fortified walled town that was approximately five blocks wide and eight blocks long.

As best I can tell there’s one notable book about that connection. It’s on my reading list and something I hope to dig into more.

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Grand Hotel Abyss

I first read Frankfurt School theorists in college as part of a course called Education in the Matrix. Beyond being a fantastic title, the course was also one of my favorites. It looked at the way popular culture becomes part of education, and the need that creates for a critical perspective and strong media literacy. Reading The Fear of Freedom reminded me of that course and motivated me to add Grand Hotel Abyss to my list.

The book’s title comes from a critique of the Frankfurt School. György Lukács claimed these theorists lived in a hotel, “equipped with every comfort, on the edge of an abyss, of nothingness, of absurdity.” My view of their work is a little more favorable.

What Grand Hotel Abyss covers is a history of the main theorists involved in the Frankfurt School. These are largely German Jewish men who grew up in the early 1900s and were frequently from privileged family backgrounds. Under the Institute for Social Research they came together and created a vein of philosophy called critical theory.

All this work was funded through an endowment from Hermann Weil, a wealthy German businessman. Despite both privileged upbringings and a wealthy benefactor these theorists sought to critique and condemn capitalism and mass culture.

That set up an interesting tension, one of many ironies and contradictions within the school’s work.

The Frankfurt School was thus paid for by the economic system it was established to indict, and the businessman father who bankrolled it stood for values that his son sought to destroy.

Past that, much of the theorists’ work focused on the role of what Theodor Adorno and Max Horkheimer termed the culture industry. Loosely-speaking they felt mass production led to cultural output that resembles factory-produced goods. Movies, magazines, and radio programs become industrially produced and oriented toward our pleasure and entertainment. Culture focused on objects which pacified the masses. Where capitalism dominated work, the culture industry dominated leisure and:

[changed people] from productive beings to consumers, from the Marxist dream of creatively vital humans to stupefied moviegoers all giggling at the same thing.

They worried our passive cultural consumption dulled our sensibilities toward more radical social and economic change. That may not sound all that novel today, but they were writing this in the mid-1940s.

Another key theorist, Walter Benjamin, challenged what today we might term a flow state of concentration. Focusing on the productive output of thought was a mistake in his eyes. Our thoughts are valuable for more than their economic potential. And Benjamin’s interest, particularly when it came to art, was in the disruptive, dissonant, and absent-minded nature of thought.

Capitalism and culture were the two predominant themes to this work. And the interplay between the two drew much of the theorists’ attention. To them we live in a world where we have the freedom to choose what is always the same. Mass production leads to mass, passive consumption of what is increasingly identical. Their writing is not always uplifting and can be gloomy. But they sought to understand and to challenge popular culture and our relation to it.

All-in-all the book’s an accessible overview of what’s my favorite strain of philosophy. It’s not overly academic and if you enjoy history surveys you’ll likely enjoy reading it.

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The Fear of Freedom

A great number of our decisions are not really our own but are suggested to us from the outside; we have succeeded in persuading ourselves that it is we who have made the decision, whereas we have actually conformed with expectations of others, driven by the fear of isolation and by more direct threats to our life, freedom, and comfort.1
Erich Fromm

The other book I picked up while in Singapore was Erich Fromm’s The Fear of Freedom. It’s a relatively short book that contemplates how we relate to freedom and security. Before jumping to my notes, a bit of context is helpful for understanding the book itself.

Like his contemporaries in the Frankfurt School,2 Fromm grew up a German Jew during the early 1900s. In the face of Hitler’s rise he relocated first to Switzerland and later the United States until the 1950s. This kept him safe and allowed him to continue his work. In 1942 Fromm published The Fear of Freedom which focuses on two forces: the development of capitalism plus the rise of Italian and German authoritarianism.

Much of the book is straightforward reading, though parts do skew toward the complex. It’s also remarkably relevant reading for the modern era. Economic and political developments of the last 20 years mean much of what Fromm considers has a modern application. From labor relations to social isolation to authoritarian governments there’s much that’s still top of mind in 2018.

Despite its short length the book is tough to succinctly summarize. There were, however, a couple high-level concepts I took away.

Balance

A thread throughout the book concerns how we balance freedom and security. Fromm holds that the more we gain the more we have only one choice in front of us. We can have spontaneity in our love and work, and thus face the insecurity, anxiety, and isolation that brings. Or we can embrace security, and thus impinge our freedom and individuality.

Work

Part of our struggle to balance individualism and security stems from the past feudal social order. This was thought to be a natural order of things. And we had a sense of certainty and security in our place. The dominant social order did not deprive individuals of their freedom as “the individual” did not yet exist.

With the Renaissance and rise of Capitalism we became consumed with an insatiable greed for power and wealth. Our work was increasingly done with no share in the enterprise. Work became a supreme value and there was a deep restlessness that developed alongside a preoccupation with time. Everything in life depended upon a given individual’s effort and we couldn’t even be certain about the basic supply and demand relationship in the market.

Calvanism sowed the seeds for a modern approach to work. Effort and work were not to change one’s fate, which was predetermined. Instead our frantic effort was instead a reassurance against an unbearable feeling of powerlessness. Fromm argues this may be our most important psychological change since the Middle Ages.

  1. The Fear of Freedom, pg. 171.[↩]
  2. More on them in a bit as I recently read Grand Hotel Abyss.[↩]
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Carl Jung’s Tower

When reading Deep Work I was struck by the opening anecdote about Carl Jung. In short, Jung deeply and publicly disagreed with Sigmund Freud in 1921. Given Freud’s stature and renown this didn’t exactly make life easy for Jung. And yet amidst that professional chaos, Jung did the reasonable thing and built himself a tower.

Cal Newport goes on to describe how:

[Jung] began regular retreats to a rustic stone house he built in the woods outside the small town of Bollingen. When there, Jung would lock himself every morning into a minimally appointed room to write without interruption. He would then meditate and walk in the woods to clarify his thinking in preparation for the next day’s writing. 1

That, of course, fits with much of Newport’s thesis in Deep Work. It was interesting enough, though, that I dug into the book’s bibliography. That anecdote came from Jung’s Memories, Dreams, Reflections, which is an autobiography of sorts.

The book itself is good. While written in the first person much of it stems from interviews and conversations with Aniela Jaffé starting in 1957. If you’re interested in biographies I’d recommend picking it up. Otherwise it’s the bit about the tower that I wanted to pull out in my notes.

Jung started building the tower two months after his mother’s death in 1923. At first it was just a one-room structure. Shortly after constructing that he added a second room. A room just for him. He kept the key to this with him at all times and he describes the room as becoming a place of spiritual concentration. That’s the minimally appointed room Newport writes of above.

From the beginning he writes about the tower as a place of maturation. Somewhere within which he could be his true self.

There’s no electricity nor running water (Jung pumped water himself from the well). And he describes the space as surrounding him, almost audibly, in silence.

In closing the chapter about his tower, Jung writes a long almost ranting description of society’s drive toward progress. It stuck with me as it’s easy to think the pressure of information flows, media, and speed of everyday life is a modern phenomenon. And yet here’s a man born in 1875 writing in the 1950s about the very same.

We rush impetuously into novelty, driven by a mounting sense of insufficiency, dissatisfaction, and restlessness. We no longer live on what we have, but on promises, no longer in the light of the present day, but in the darkness of the future, which, we expect, will at last bring the proper sunrise. We refuse to recognize that everything better is purchased at the price of something worse…

Reforms by advances, that is by new methods or gadgets, are of course impressive at first, but in the long run they are dubious and in any case dearly paid for. They by no means increase the contentment or happiness of people on the whole. Mostly, they are deceptive sweetenings of existence, like speedier communications which unpleasantly accelerate the tempo of life and leave us with less time than ever before. 2

  1. Cal Newport. Deep Work. pg. 107[↩]
  2. Carl Jung. Memories, Dreams, Reflections. pg. 236[↩]