Stakeholder Health – Page 3 – garygunderson Blog

Runaway heart

My daughter Lauren is about to give birth to my second grandson, which, with her sense of dramatic timing will probably happen on Mothers’ Day. This also kicks off Nurses’ Week in hospitals. My wife and my (now former) first wife are both clinical professionals and moms. Most of my staff in the FaithHealth Division are women and the men are in touch with their feminine side or they couldn’t do their work of care for the bio-psych-social-spiritual dynamics of the thousands about whom we care. For ninety years our largest partner–the NC Baptist State Convention–uses Mothers’ Day to collect an offering for our most vulnerable patients.

So I’ve been thinking about the expansive caring going on; and the unknowable, but real limits to our reach.

Last Saturday it was my turn to lead the Medical Center’s daily “safety huddle”—the mundane miracle in which every operating unit of the health system from chief medical officer to security to food services and everything in between gathers to report on whether each of us has an event, concern or need to report. Even if we don’t, we have to say so out loud to our colleagues. Usually it moves fast, but sometimes it just stops the heart. Someone reported a situation with a runaway kid who had been compelled to come to the ED by her mom, who promptly run away herself, leaving the kid in our care. Except then the kid ran away from us, too. Everyone hurt hurt. We all dealt with our sense of profound limitations even when the 14,000 hospital people were multiplied by the police and social services. I couldn’t get it out of mind, so the next morning slipped in a prayer amid all the operational chatter:

As Jerry Winslow has noted, it takes a lot of sawdust to find the second life of a tree.

“Mother God, we pray today with thanks for the big heart and strong muscles you have given us so that we might be healers amid so many lives. Every morning we see how big a family of colleagues we have that is constantly present to do what is possible for all who come. Today we pray for all events that raise our concerns for all the needs we cannot satisfy that we cannot get out of our minds, hearts and bones. The runaway kid from yesterday with the runaway mom who left her. All the husbands without words sitting next to their wives with cancer about to leave the whole world behind. All the people who have lost their way to any hope except for the medical miracles that lie beyond us, too. Keep our hearts tender like a mother for all that love lets in. But keep it beating and open for each other and your great spirit so that we might be smart, gentle and kind for this one more day.”

The first cut through the pith lays open the astonishing grain of the burl.

The British Medical Journal has been thinking about this, too, although in grim language of “multimorbidity:” “Across the world healthcare systems are struggling to cope with increasing demands and costs. Rising life expectancy has been accompanied by an explosion in the prevalence of long term conditions and multimorbidity.

“Clinicians are working within legacy systems that were developed to deal with 19th century problems—they provide specialised responses to acute illness and infection. At the same time daily practice is strongly influenced by an ever expanding array of disease centred guidelines that don’t map neatly to the realities of clinical practice, in particular the ubiquity of multimorbidity. The result is fragmented, poorly coordinated health services for those most in need—vulnerable patients with multimorbidity. Today’s healthcare professionals are faced not only with rising disease-disease, drug-drug, and disease-drug interactions in multimorbid populations but with the increasingly evident consequences of socioeconomic disadvantage.

The rough and twisted bark hints at the pattern.

“Meanwhile, patients, their families, and their extended social networks experience not only the burden of symptoms but the burden of treatment. This is an emerging but underi-nvestigated phenomenon. It has received increasing attention recently, and interest has been growing in how to define and better understand the concept.” ( (BMJ Published 10 November 2014)

We could join the public chorus of complaint and rage about what the world is doing to us and demanding of us, as if expanded life span were a mean trick on all of us. Or we could work on what lies between us, the weak ties that could be strong, the empty spaces that could be filled with compassion and carefully tended connections. Even in our mean and stupid time, we are witnessing the dramatically hopeful emergence of webs of trust where you’d think they would be impossible—North Carolina, where you can’t even pee without the government telling you how or where. Good grief. But even here—maybe especially here, where powerful elites have told stigmatized and despised people where they could drink water and pee for generations—webs of compassion spring up on the bitter soil like desert blooms in random rain. Don’t ever be surprised by what a privileged but anxious elite will do badly. And don’t ever be surprised by the fruits of compassion, either. That’s what we are coming to call the North Carolina Way and it is big, strong and unafraid of tough neighborhoods and runaway everything.

When I hurt myself last June, I was drawn into being a partner in the healing of my own body. I have been learning in wonder how we – even me!—are made for healing. Of course we are, since we are also made to be bruised, wounded and broken. All of us, sometimes at others’ hands, but usually a mélange of our own mistakes along the random human way. (That dumb overreaching tennis decision wasn’t my only one!). I’ve been learning to turn wood on a lathe as I healed and found myself drawn to the wonder of hardwood burls, the growth that emerges where a tree has been broken or violated with some sort of trauma. The wood in the burl has a weirdly complex grain pattern, twisty, dense and wondrous. The mysteriously beautiful grain reduces me to respectful awe as the smooth cherry takes a beeswax polish. I think, of course, of Lauren’s pain and that of every woman in my life, of every nurse in every hospital, of every broken heart that manages to stay tender to the pain of the world.

No mom I know stops at the pain. They lend their life and every fiber to what remains possible for those they love. They never cease forgiving and hoping. They teach us not to stop at lament even though so much of what we see is deeply lamentable. They teach us that compassion is the heart of prophesy, of lovingly holding up what remains possible for each person, neighborhood and peoples alive.

The burl is what grows around the trauma experienced by the tree.

Faith with

Across the street from The Garfield Conservatory, a block away from the L, a gaggle of geese find their away amid the urban mysteries. — Across the street from The Garfield Conservatory, a block away from the L, a gaggle of geese find their way amid the urban mysteries.

There were years when I was across the ocean that I would tell people I was from Canada to avoid explaining US politics. People in more normal countries dumbfounded my people would be found dumb enough to vote for a California actor obviously reading someone else’s lines to fill the most intellectually demanding job in history. Some Americans still talk of him with reverence, which is hard to explain. But since we elected our Harvard lawyer, it’s been a lot easier to travel.

Its not any easier being a Christian than an American. I work in fields with lots of science going on so am occasionally held to account for my faith. Nobody cares enough enough to hurt me for it, as in olden days. But for those who otherwise like me (sometimes including my children), it bears explaining how an apparently intelligent person would identify as a member of Jesus’ or any tradition of faith. Like claiming Canada next door, it is easier to say something vaguely ethical rather than saying I go to that most odd of all human assemblies, a church.

Francis has helped. But even in a week in which it would really hard to screw up being a Christian, we have had nutters from Arkansas chattering away near microphones embarrassing generations of Christians. If Francis watched any TV while he was here last week, he probably thought about taking his robe off to just blend in with the homeless.

We think of programs as independent and accountable, but actually they weave, influencing each other and shaping the whole. — We think of our traditions and learning groups as independent and accountable, but actually they weave, influencing each other and shaping the whole.

I think of our traditions—mine being Christian—as learning groups more than knowing groups. My most powerful relationships are like that, such as the Africa Religious Health Assets Program (ARHAP) led by Jim Cochrane, Steve DeGruchy, Paul Germond and now Jill Olivier. A whole literature has emerged from its thoughtful journey, now thousands of pages. Groups don’t learn in a straight line and sometimes wander into dead ends (especially when they put on conferences with papers). But if we keep our learning grounded, we can find our way back out. AHRAP accumulated epic stories of finding, naming and mapping. But its most useful tools are those for optimistic searching (such as the assets mapping now about to be trusted by hospitals, public health and community partners in Tacoma).

That curious community spun off another one pursuing just one of its questions, about the Leading Causes of Life. Those Fellows cross the strangest boundaries of intellect and miles, as great questions always have and will draw us.

Stakeholder Health was originally the “Health Systems Learning Group” and remains useful when in learning mode. We’ve are drawn to the questions that lie in between hospitals and their neighborhoods, borrowing and bending the language of clinical, public and population health. The questions look technical, but draw us into deeper waters.

Technical kinds of answers are not the most interesting or obvious thing being learned. Along the way we have been learning about the defining characteristic of our group—most of us as both individuals and institutions were of faith. But not all of us are officially faith-ish, which is what makes the whole group so interesting. We’ve talked and sometimes argued about whether Stakeholder Health is “based” on has “faith.” What we mean by those words? Is it important? Does Henry Ford Health System have enough to count just because it has among the very largest network of faith community nurses in the nation? It reflects the man named Henry Ford, not Jesus, but sustains an often sacrificial mission finding innovations where a mere corporation would flee. What’s the name of that driving spirit? Most hospitals with religious names on their buildings don’t think or act any differently toward their patients, neighbors or employees—and many much worse—than massively profitable Cancer Centers of America. But some do find the wells of compassion to give their life away decade after decade. Iconic little Bon Secours in West Baltimore sure does and, yes, those are nuns all over that history, just as surely as the Pope is Catholic.

Many of our organizations are now merged and morphed—Brooklyn Lutheran part of staunchly secular academic NYU. The blended hospital and medical school called Wake Forest Baptist Medical Center will discover the cure for cancer before we figure out what to do with that middle word in our name. These complicated relationships are being carried by what we are learning, not by what we are based on; faith more like a sail to catch the spirit than anchor to hold us back.

We are who we walk with along our learning way. (Kevin, TC and me. Jim Cochrane holding the camera.)

People from outside hospitals notice that interesting things are happening inside. Peter Berger edited a special edition of “Society” looking at the complicated dynamics of faith in modern hospitals. Some of the pieces are not brilliant, even borderline snarky. But Berger’s introduction is tantalizing as he speaks of those of working inside the places: “They cope with reality in both secular and religious terms and they find ways (not necessarily coherent theoretically) of applying the two discourses in different parts of their lives. Is that feasible? We already know it is. The interesting question is how it is done! The question suggests a fascinating research agenda.” (Society, October 2015, Volume 52, Issue 5, pp 410-412)

Last week the learners of Stakeholder Health convened in the Garfield Conservatory in West Chicago, which for more than a century has protected space for the flowering of learning about plants. Its human story is as exotic as the plants, especially how they won’t quit when surrounded, literally, by gangs or rapacious politicos. Or when only a year after the massive dome was built, thousands of panes of glass protecting the tender palms had to be replaced because the wood frames were rotting (cheap wood). You’d think God would protect arboretums along with fools, but it turns out not.

It often takes a learning community decades to flower, especially when the questions outlast the curious. Jerry Paul, who led Deaconess Hospital in St. Louis and then its equally faithful foundation, formed when the hospital was no longer needed and lent his intellect to the founding of ARHAP, died suddenly in May of fast-moving cancer. Steve DeGruchy died in fast moving water before he even wrote his real book. Larry Pray has lived through another and then another and another stroke stealing his memory even as his spirit is defined by poetic appreciation for life. I’m not so young myself.

Faith is a fellowship, not just a bundle of ideas; marked more by with, than what.

We find life in the questions that outlive our answers.

We are defined by those with whom we seek.

We are what we find in each other.

We are what we think about and how we help each other learn.

We are what we ask of each of other.

We are what we notice in other groups also finding their way, by how we lend and borrow.

We are not the first or smartest humans to do all this.

We find nobility in humility before faith and its mysteries, complicities and community formed and still forming across the years.

It’s Sunday morning after the two big storms have passed; I think I’ll head up to church.

Improbable Lessons

This palm was planted at the Garfield Conservatory in 1926. It takes time and tending over generations to get something like this. — This palm was planted at the Garfield Park Conservatory in 1926. It takes time and tending over generations to get something like this.

Between Pope Francis and the nine Charleston “Saints” whose deadly witness held us just as rivited a few months ago it is obvious to all that faith is not synonymous with stupid, mean and irrelevant. They are helping us see through the stars, bars and blather to something real. If you need forgiveness, intelligence, mature compassion, it is a reasonable idea to look toward an institution where faith has been nurtured over a few centuries, or, in the Pope’s case, millennia. If something lasts longer than one lifetime, or even a season in one lifetime, it is likely that there is a tradition involved, ecology not just of one, but many institutions. The Pope, for all his evident virtues, did not invent or elect himself to the role of Pope. The very institution that has been so egregiously, yes, criminally, complicit with some of the worst imaginable abuses of power and privilege turned around, found its best possible self and—who could imagine it—found a guy to fill the role that has electrified the nuns, nones and nearly anyone with a heartbeat. The Saints of Charleston who died–and the hundreds more that lived to forgive–were not a random gaggle of what really good people, but a fellowship born and formed with those easy-to-dismiss rhythms of bible study, song and prayer that turned out to be—when tested on a horrible afternoon—to be stronger than speeding bullets.

The Zaban Room at The Carter Center has held hundreds of creative, improbablyy hopeful meetings. This one anchored by Ray Fabious, CareNet and Ron Mandershieim on integrating Spirit into Population Health. — The Zaban Room at The Carter Center has held hundreds of creative, improbablyy hopeful meetings. This one anchored by Ray Fabius, CareNet and Ron Manderscheid on integrating Spirit into Population Health.

On Wednesday a small group of experts in behavioral and population health gathered at The Carter Center (named for a Baptist deacon who knows about formation even unto the edge of death). The “we” included Ron Mandersheid and Ray Fabius, who has literally written the textbook on population health (second edition!) before most of us heard the term at all. He was with us after gaining specific permission from his mom so that he could travel on Yom Kippur, a day held sacred across not two, but four millennia and counting. Why? Because the subject was how to integrate the sacred, the Spirit, into the work of behavioral health as it is integrated into large-scale population scale programs. One of the questions alive in the room was how to accelerate and shift “health” from being all about disease and preventing toward the positive dynamic we hope for.

What does “faith” know about that, given that from the outside, the institutions of faith seem to be mostly about not doing things? What does faith know about life that could be integrated into—maybe even illuminate—population health? The answer isn’t in the tricks of faith-based behavior modification that drizzle a bit of ritual razzle-dazzle over the dreary goop that “wellness” programs use. It is about the practices, disciplines—traditions—that shape we humans over the complexities of life together on this spinning and wobbly planet. Those traditions help us adapt to unpredictability, with a huge toolbox relevant to failure, forgiveness, resilience and hope. And the traditions themselves adapt—as Pope Francis is modeling in real time brilliant humility.

Dr. Kimberly Dawn Wisdom of Henry Ford Health System is one of the springs of intelligence within Stakeholder Health.

While the Pope was doing his best to tend to America’s soul one Speaker at a time, the leadership of Stakeholder Health was working in Chicago, where the FaithHealth movement was born, reborn and reborn many times, with another FaithHealth infant in the birth canal as I type. Stakeholder Health is a learning group of those who are living institutional lives, trying to find the shared intelligence, courage and community needed to nurture another round of transformation. What we want to learn the most is how to find and release the deep practical nobility found in the birth story of these hundreds and hundreds of faith-inspired healthcare organizations. Stakeholder Health includes a number of institutions that are not faith governed. Some of those, like Henry Ford and Nemours, spring from the social conscious of a vastly wealthy industrialist; others like ProMedica, MultiCare or Kaiser, express another community of social imagination. But all of us know we are drawing on more than our own toolkit of techniques and clever people. And we know we are doing so for a greater purpose than ourselves. All of us have an ear for the inconvenient cries for mercy rising up from the streets and neighborhoods we were born to serve. We know—as does anyone who has ever attended a church committee—that our institutions are deeply complicit with the banal evil of every status quo. Yet, we also know they are capable of nobility and of giving the moral energy of thousands of employees and their partners a chance to express itself at a scale unimaginable by one, two or a group of individuals.

This is what a man looks like, paralyzed as a teen-ager now giving his life twenty years later to interrupting the cycle of violence: "don't tell me you're too tired." — Levon Stone is what a man looks like: paralyzed as a teen-ager now giving his life twenty years later to interrupting the cycle of violence: “don’t tell me you’re too tired.”

We heard about the miracles born of wrenching change—the closing of Advocate Healthcare’s Bethany Hospital—with angry wounding community protests about broken trust. Out of which came the Advocate Bethany Community Health Fund, structured for transparency and partnership, to steward a million dollars a year into carefully defined West Chicago neighborhoods to strengthen the non-profit and faith organizations closest to those tough streets. We heard the radical simplicity of CeaseFire Chicago, which blends the power of ER chaplaincy (embodied by Richard James) with the brutally won integrity of one who has lived the life of violence and its paralyzing fruits (embodied by LeVon Stone). The “golden hour” is that which follows the bullet’s impact, doing all to break the cycle of retribution. If not forgiveness, maybe grace, at least resilience. It doesn’t always work; but it is almost the only thing that does work.

Dr. Carrie Nelson and Dr. Bonnie Condon unpack the complexities of aligning thousands of physicians for the health of the community.

And we learned from Dr. Carrie Nelson of the mammothly hopeful and excruciatingly complicated task of turning 4,500 Advocate Health physicians toward the work of health in exactly the same way that got Ray Fabius on the plane to The Carter Center. How exactly does that come to be, not just outside the walls of the hospital, but also outside the doctors’ exam rooms and maybe even on the streets in between?

We learn of each other’s best attempts, still caught and partial, filled with frustration and inertia. We become braver, not just smarter. We look at our little lives and decide to risk our reputations as professional grown-ups on things that have never yet worked before. So, all across the vast warren of Chicagoland streets, dozens of hospital are working together to coordinate their community health needs assessments, struggling with the insane arcana of cleaning and aligning data so it can be made coherent at large scale (sort of like making oil and watercolors blend in one painting!). It seems just impossible. But then it is possible, at least enough to encourage those in the heart of it to try a bit harder, to invite a few more partners (let’s paint with acrylics, too!). It isn’t smart enough, yet. But certainly wiser than anything ever before.

Even naming a collaborative learning document with seventy authors is hard! Stakeholder Health will find a way.

There are some thing that one can absorb by listening and others that only become known through the laborious process of writing. And some by the even harder process of collective writing. Stakeholder Health is working on a second “collaborative learning document” that can help us name and claim the land we are in now. We wrote the first before the Affordable Care Act had passed through the valley of shadows known as the Supreme Court. We are in a truly new place drawing hospitals over their institutional moat and public health into partnerships only dimly imagined (with hospitals????). Stakeholder Health knows that one of the greatest and most hopeful unknowns is whether and how the quiet innovations among congregations and faith networks can be woven into the fabric. Like weaving behavioral health and Spirit (surely, we can do this!), weaving congregational intelligence and energy looks obvious until one tries. Even in Memphis where it has been nearly institutionalized, it has failed to become adapted across the full spectrum of competing hospitals (or competing faith ministries!). We need to learn more and far more quickly about integrating the full spectrum the hopeful arts of faith and health. So we are writing a not-book quickly emerging from the field, ready for the field with ten (or is it 11) chapters marking our learning edges.

This is holy and profane work, the only kind we get to do on this planet. It is the only kind any humans have ever hoped to do. We think in these days of Dr. King’s hopeful counsel about the arc of history bending toward justice.

Martin Luther King as a potential student to Colgate Rochester Seminary, long before he came to know of arcs of history and mountaintops.

Gene Matthews, who was the General Counsel for the Centers for Disease Control ended the recent meeting of the NC Citizens for Public Health with the quote behind Dr. King’s quote. Among his genius was King’s eye for the shards of wisdom born of previous battles, this one given in 1853 by Theodore Parker to a Congress on Abolition, an earlier chapter of the work still calling us beyond disparities: “I do not pretend to understand the moral universe;

The arc is a long one, My eye reaches but a little ways; I can not calculate the curve and complete the figure by experience of sight; I can divine it by conscience.
And from what I see, I am sure it bends toward justice.

City of Light

Carolos Latuff, one of hundreds of visual jounalists speaking into the horror of Paris.

Every religion is dangerous. Like fire, wind and water, religion is a fundamental element of human life that can drown, blast and burn. Religion guides our fear and frames our shame. And it can also strengthen our capacity for the courage shown in generosity, compassion, kindness and decency. It can be a wicked brew and also be like warm French cider on a bitter Winter day.

What are those of us who find our hopes in faith to do this week? What do we do when faith has been the language for nearly unspeakable acts? Do we just huddle behind the soldiers, or is there any place for our own actions to be as brave and relevant as the cartoonists like Carolos Latuff poking his pencil into the muzzle of terror?

Can mercy be brave as violence?

Although it filled up the CNN cash register this week, violence between religions is relatively rare and getting more unusual year by year. I’ve quoted the finding of Daniel Pink in earlier blogs, but worth remembering that all forms of violence continue to decline year over year over year. Most religious violence is between those who share a religion but find its variations deeply threatening.

While dozens died in Paris because of their secular differences from Islam, hundreds, probably thousands of moderate Muslims died last week because their 1,500-year-version of Islam embodied the radical hospitality, kindness and sacrificial generosity that fills up the pages of Islamic sacred writings. This is true of every religion. John Calvin burned–literally set fire and watched die–Christian theologians that it would take another theologian to figure out the minor differences in doctrine they were arguing about. He killed Christians not Muslims. I’m a liberal protestant writer who not have survived a week in Geneva. I thought about this when worshipping down the hill from Calvin’s towering grey church with an ecumenical gaggle of english-speaking Christians last July. He would have locked the doors of the World Council of Churches, torched the whole place and everyone in it….and than sung a hymn about it. And Presbyterians are relatively nice people. I’m a Baptist…….which I’m just guessing is more common among the Klan than their up-market Christian cousins.

It is always safer to have a radically different idea about god than a moderately different one using the same language. ISIS kills many more moderate Muslims more eagerly than Christians or those who believe in no god at all but humor. Every now and then they may travel to Paris for some especially flamboyant act of horror. But their every day killing is focused on the vast majority of fellow Muslims they find nearby who understand Islam as a faith of mercy and healing.

There is not much a Christian can do about radically violent Islam. But it would help to avoid accidentally strengthening the most despicable by implying they know anything about Islam. The “terrorists” aren’t radical about Islam, which is a religion of hospitality and charity; they are radical about their own projected fears, insecurities and delusions which are then wrapped in a weird and horrible way in the vocabulary of Islam. Christians know all about this process. Christian politicians are masters at wrapping their reptilian greed with Jesus’ words. But we don’t say of our nutters “those folks who blew up the Federal building in Oklahoma sure were radical about following Jesus!”

Do something to strengthen the moderate Muslims, for whom this is a special time of danger, not only from their traditional nut-cases on the far boundaries of Islam, but now from those of other faiths, including secularity, that will fear anyone they think is a Muslim no matter where they’re from (including Sikhs who stupid Americans confuse with Muslims all the time because of their turbans)(Oh, good grief…..).

Sprouts find their way through the bullet holes in an old refrigerator in North Georgia.

TC and I took a check over to our friends at the Muslim Free Clinic on Waughtown Street that I’ve mentioned in my blog before. They were today, as they do twice every month, caring for whoever walked in from the neighborhood that needed healthcare, medical counsel or a clue about where to their pill prescription renewed. It is very mundane, as most mercy tends to be. The physicians and volunteers show up and do it because their faith has thought them to do so. They aren’t aiming for martyrdom; just happy to settle for basic grown-up integrity. They are, as a Christian philosopher once said, “grabbing the near edge of a great problem and acting at some cost to themselves.” It is all a Christian, Muslim, Jew, Sikh, Bhuddist, Zoasterian or cartoonist can hope to do with their lives.

Do this.

Soak in the TV, then turn it off and go find someone who isn’t of your tribe, class, color, faith or opinion and be kind to them in some practical way.

Do this.

And the God known by every name any human has ever uttered in hope will heal your fears and count you among the living.

Do this.

New blade

Six decades later I can still hear the screaming whine of this saw as my dad crafted cabinets with it.

I peered through a hole in our basement wall into a cloud of sawdust where my father fed a piece of wood into the spinning blade. The sound was painfully high loud and powerful, such that I can still hear it, now almost six decades later. I was two or so and learned later the wood was pine, as was all the rest of the cabinets in the home I grew up in, crafted with a mixture of love and parsimony by Dad. The saw, made by Rockwell, eventually became mine and used for most of my adult life as I, too, ripped, spliced, joined and paneled every place I’ve landed. The saw was a primal link to Dad, but over time whined, smoked and wobbled more and more. Once, back when I was earning my living with it doing remodeling, I was moving it from a job site when it bounced out of my nearly-as-old pickup truck, breaking on the pavement. Ken Sehested, knowing my despair, found a friend to weld the key cast iron gear back together, so it lived to wobble on in my life. But eventually the damn thing could no longer hold an angle, sometimes cutting a perfect 45, but more likely 50 or, the other day, 60 degrees. This makes very ugly joinery.

Now wobbling, smoking and whining, the saw prevents, not enables, good work. Dad would not be happy.

Dad would have hated the crappy quality the saw made inevitable and surely would have found any link with him something of an insult. I finally had to distinguish between clinging to nostalgia and actually honoring my Dad’s woodcraft. So I went to Lowe’s, channeled his spirit, and bought a solid Kobota table saw. I’m in the last stages of a new bathroom in TC and my condo near Old Salem and now have a chance at doing the finish work in a way that the Moravians and Dad would find acceptable.

Our lives are filled with the artifacts of those in whose shoes we walk, feeling our feet slightly too small for the journey. Just before Christmas I met with the ethics committee of the medical center, which had been established by the iconic surgeon, Eben Alexander, decades ago (he’s the dad of the recently famous one who wrote about “proof of heaven.”) The committee he started is still appointed by the chief medical officer, also a surgeon. Although medicine and the health sciences are less and less about what happens inside the medical hotel called “hospital,” the focus of the ethics committee continues to be almost entirely at the surgeon’s elbow. It thinks mostly about what the doctor should do or stop doing. Our current model of bioethics is not looking at the CFO’s spreadsheet, or COO’s deployment plans, or the Board’s capital decisions voting millions to build another office in the burbs, even those decisions shape the life and death for thousands of people over time. One can imagine Dr. Alexander shouting, “I started it; you go the next step!”

Surely dad is glad I finally put down the nostagia and picked up a decent tool for work that honors him. — Surely dad is glad I finally put down the nostalgia and picked up a decent tool for work that honors him.

Every nook and cupboard among the health field is filled with guilds, national associations (with local chapters!), honoring this and that habitual practice and committee that made some sense long ago. They all have founders and officers—and sometimes even endowments(!)—but have long lost their capacity to cut cleanly or make useful connections. They have not moved with the science that gives more and more power to the integrated strategies managing conditions over time outside the professional enclaves. We live a long time now mainly because of better food and pharma not because we get surguries frequently. So there are way more ethical implications in the price of drugs than when or whether a surgeon does a procedure. They obstruct and no longer aid the joining of good science to good intentions. We need to honor our moral legacy with a new set of intellectual tools nearly as much as I needed a new saw.

We honor those who have given us life by acting with the creative courage they showed in their time; not by doing the same things their courage demanded then, but doing what courage demands now. We grown-up humans build things out of brick and steel. And we craft habits and patterns of power that guide the flow of money and time to the new glass towers. All these artifacts look solid and lasting, but they are as blowing sand at the beach.

Twice a day the tides wash the in-between land of the marshes.

I am typing this at St. Helena Island, South Carolina watching another morning tide move another day’s load of sand a few feet up the shore. These are called barrier islands because they protect the vital salt marshes which the tides wash twice a day, nurturing its wildly generative life. Very little important happens on the beach; all the life stuff happens in the muck and goop where the shrimp and a zillion other things are born and nurtured before heading to sea. The sand islands protect this vitality because they constantly move and adapt dynamically to the next big storm and even the next shift in climate rising the level of the seas.

Old maps tell the tale: the beaches move; the marshes live on.

In the handful of centuries white humans have settled here, the islands have moved miles. From the top of the 132 foot high light house you can see a few miles to the waves north east where the old one once stood. This new one (1889) is built to move again. Geologists know the whole chain of islands have moved back and forth for millennia. They last because they are dynamic; they serve life because they change. They are like tools built for a season of good craft.

The scope points 8 miles away and a quarter mile off shore where the lighthouse once stood.

Those of us holding positions of influence in institutions like to think our work and our organizations are the key to the life of our communities. Smart people at Stanford play to this pretense by suggesting adaptive change is dependent on “collective impact” organized by “anchor institutions.” These ideas are not just wrong, but dangerously misleading. Living communities don’t need to be impacted, but nurtured; they don’t need more anchors but heart, muscle and guts that serve movement. They do need protection from the raw tides, heavy winds and bitter storms, but protection in the service of change, not protection from it.

What else does any leader have to do that protect the creative energy so that it generates life? Do we have something better to do than that. Whether we are stewards of a church or hospital or public health agency or community health center, the life does not come from the edges, but the heart. I learned in Memphis that if I could protect the creative space for those who usually don’t have much power, they would craft beautiful and useful structure perfectly joined to the possibilities the neighborhoods needed. That process is the “Memphis Model” not the specific apparatus that emerged at that point in time. Don’t confuse the craft (mercy and care) for the cabinet (the structure) and certainly not the wobbly saw (me).

Leaders give life a chance by protecting the generative spaces in which life emerges, especially when those spaces need the complex processes over time. Any human community is way more complex than any salt marsh.

This is almost exactly the opposite of the role big institutions want to play. The leaders of the big things like hospitals can always rent consultants who are happy to tell us to tell the neighborhoods how they should live and how they should change, not us. The model for this is the old way that beach engineers tried to build concrete barriers to stop the tides and the natural shift of the sand (sort of like the one now under 40 feet of water a quarter mile from shore). The more we think like anchors, the more we’re in the way of life, which will most certainly have its way with us.

Roots are a kind of anchor that serve for a time and then not.

This is why I find surprising hope in the small stirring of faith and faithfulness in the faith-inspired healthcare systems of Stakeholder Health. Just about the time when you think smart and cynical are the same thing, along comes life to surprise us. In reality sometimes, large institutions such as foundations and hospitals can provide some shelter amid the raw power of the market forces (the “hurricane” in my extended metaphor). We can be barrier islands against the forces of raw money power, preserving the neighborhoods’ function as the salt marsh where life flourishes and creates the next generation. It actually does happen sometimes. It could happen more.

Francis Rivers Meza, one of our faculty in the FaithHealth Division, shared an article by Patricia Fernández-Kelly (2012): “Rethinking the deserving body: altruism, markets, and political action in health care provision,” in the journal Ethnic and Racial Studies. (click here for the article). She explores the way that religious organizations, including the huge ones such as hospitals, sometimes choose to act against the logic of the capital markets, providing crucial buffering for neighborhoods of poor and often stigmatized people. And they do this on purpose with craft and skill year after year. The authors cite one of our stakeholder health friends, Baptist Healthcare of South Florida and their long term work in Homestead Florida, a place that knows all about the need for barriers against storms.

Life finds a way, Jonas Salk liked to say. Jason McLennan, writing in Yes! Magazine this month says, “If there is one thing that’s certain, it’s that the future hasn’t happened yet.” Bingo! Honor both past and future by helping life finding its next way, not by protecting our old way.

The lighthouse just across the inlet above the gull. Everything moves; life finds a way.

Warren, Kenny and Barney

Warren G is a 43-year old rapper looking for a new song. He should not be confused with Kenny G.

Fred Smith is a Harvard-SMU-Emory PhD and United Methodist preacher. He grew up tough in Oakland playing football. When he and I were walking around Jack London Square Thursday night after a nerve-fraying couple of days, we went looking for some music at the jazz venue just a hundred yards from the water. Up we walked, me in REI garb and blue jean uniform and Fred dressed as Fred. We glanced at the ticket booth and saw Warren G, who we thought, without really thinking very hard, was….Kenny G. In we went, found ourselves seated way in the back looking like two poorly constumed narcs in a room of about 400 …. self-medicating socially complex consumers.

Warren and Kenny did not come from the same G family, nor do they share any musical dna. At all. Soon I realized that Warren wasn’t going to pull out Kenny’s jass flute thing. The wildly appreciative audience knew every syllable of every profane lyric and not-hard to discern hand motions with a rain of language probably not heard outside the Oakland Raiders huddle in a losing game. He couldn’t make it halfway through a sentence or musical phrase without a MFGDSht!??!??!?@#$%@@@@!!!MFGDSht kind of cadence. The audience, including the four young oriental women in the table in front of us and the two Indian couples next to us rocked and danced and shouted along. . I would show you a picture, but it just didn’t seem like a time to whip out my iphone and capture the moment.

I had the impression that Warren wasn’t really the bad ass MFGDsht dude he let on. I’m a Baptist and I know role play when I see it. The whole thing reminded me of one of those mind-numbing praise music servicesthat I witness in the small town Baptist meetings I find myself in from time to time. Warren used MFGDsht sort of like some Christians use Jesus, more as a sound to mark the beat and help everyone now they are in the right show—the one they know the words to.

We all sing songs that, as we age and gain life experience, may not be quite as authentic as they once were.

Kenny G is a very talented jazz musician know for his mellow music. I have no idea how anyone could confuse him with Warren G.

Warren is 43 years old now and probably has a couple daughters. He wants wants a new song. Being from Oakland, he thought his home town adulating fans would like to hear his newest song. They did not. That’s the main point of his new song, which is exactly why his old fans didn’t like it. It was like they turned the fire sprinklers on.

Most of us do not like it when our cultural, religious or intellectual idols sing new songs because it suggests that we may should consider singing something new, too.

The next day I went down to LA with the Association of Professional Chaplains, a more honorable group I cannot imagine. It was a KennyG kind of crowd until the dozens of newly certified chaplains received their certificates marking the end of years of their grueling and sometimes gruesome process. Board Certified Chaplains complete three years of seminary, been ordained and then begun 1,600 hours of intensive and invasive reflective practice in a hospital before going through rigorous and, again, invasive review of written and personal interviews. So at the end of the process they do not want to lie prostrate before the bishop on the cathedral stone. Nope. It is more like WarrenG,;“chaplains gone wild” as one APC organizer names it. A conga line whooping, shouting, yes even sort of dancing.

The Conga line marked an ending; where does it go next? Rev. Valerie R. Storms laid out with devastatingly clarity that the line leads away from all that has been the chaplains’ norm into a new world. Chaplains, because of the radical changes in their medical world context AND in their religious world context need a new song.

Barney Fife and Andy Taylor of Mayberry, modeled on Mt. Airy, just north of Winston-Salem, NC

What is the kind of learning and knowing that helps us find the new tune when we can’t just pick up the beat from our elders?

We need Barney Fife research. We know about Barney because he and Andy lived in Mayberry, modeled after Mt. Airy just about 30 minutes north of Winston-Salem.

You can recognize Barney Fife data it because it offers up proof of the value of the old ways. It honors the crackling exoskeleton left hanging on the tree long after the living body of the insect has found new form and life. Barney found meaning, purpose and value by showing compliance to an extrinsic standard of behavior. He did the right thing by complying, and was scandalized when that right thing failed to be useful in real life. Hospitals need real help in finding their way to a new song, so are unimpressed and dissmisive of proof of mere compliance to their old life even when they pretend to honor it.

Anxious guilds and technology providers invest in research designed to prove their value in terms of the current business model. Of course, they do; the new business model doesn’t exist, yet. But that’s the one that actually matters most. That’s where the conga line is going.

Andy is comfortable with the complex messy pathos of humanity. He always looked for the truth and thus often found it in inconvenient places and unlikely people. Sometimes the truth didn’t make him look good, but he never blinked and made the choices that helped people do the next right thing. In technical research terms, Andy did “formative evaluation” which is designed to evaluate as the process lives, not after its finished and done. It fits what Tom Peters (via Tom Peterson) calls the “permament beta” we live in. The more fluid the situation and creative the process the more you need Andy and the less you need Barney.

A hint at what might be worth knowing comes from the very latest Institute of Medicine roundtable on accelerating the movement to health and health equity. With bold humility it looks at past social movements—many religious—in seek of wisdom to guide the movement we all know we need to seize the opportunity 21^st century science and policy opens up. They are looking for a new song, indeed : ><http://click.newsletters.nas.edu/?qs=0303e74e5f82782dc8ae27ef1e77b6dcc341581cc00a5d2976e414ffa228bb3db9b9a4653daf7745>.

Reverend Dr. Fred D Smith an authentic man of Oakland. — Reverend Dr. Fred D Smith, an authentic man of Oakland.

Our work in North Carolina is about adapting the long legacy of faith and health to a new place and time. We know we are singing a new song and we are tuning all of our tools and techniques to it. We are using a wide array of learning tools and methods to give us as much short-cycle feedback as possible. We are stopping to look carefully at each cohort of a hundred patients we are seeing in our various lines of work; dialysis, Supporters of Health, FaithHealthNC in Lexington. We are beginning the always surprising process of participatory mapping of community health assets using the African model (now on its 7^th iteration). We are doing deep data dives into the full patient populations from 2012 using two radically different analytical models. We are driving and walking the neighborhoods where we know our most vulnerable patients live. We are talking one-on-one to dozens of clergy and the care teams in their congregations. We are allowing all this to form us, not prove us.

The Chawumba event in Winston-Salem July 25-28 is a time for us to find an authentic song for our work and time. We want one that can disrupt our complicity to the old world so far from our hopes. Who knows what song will find voice?

(If you want to be part of Chawumba, it’s not to late to register. Go to StakeholderHealth.org. Or email dhall@wakehealth.edu)

Redefining Redefining

Life is messy, more like the picture on the left. From time to time healthcare helps, but life is not about health….care.

It is important to remember this amid the policy maelstrom and the basic fact that the healthcare industry absorbs about 18% of all economic activity in the US economy. I talked about this with a dozen very bright Wake Forest MBA students last week. Len Preslar, the former CEO of Baptist Hospital, leads the class which opened with a review of one of Michael Porter’s landmark analyses of the healthcare industry (http://hbr.org/2013/10/the-strategy-that-will-fix-health-care/ar/1#comment-1084800628 ). We just have to do better or MBA students 40 years from now will still be reading articles about redefining healthcare.

The problem is obvious to everyone outside the industry: healthcare is not a self-contained industry–it is just part of life.

Porter believes that healthcare can be redefined by optimizing the focus of competition among providers so that each incident of treatment is provided by the organization expert (and cheap) in that procedure. This is a good idea, but utterly misses the opportunity.

There is a persistent myopia in a vision of larger conglomerations of providers rationalizing their services as the way provide better value to patients and payers. This helpful but inadequate view of healthcare ignores the larger community context. The good news lies in what Porter leaves out.

Quietly over the past two years a growing number of faith-based and community-oriented healthcare systems have been meeting to ask a basic question: can they actually achieve their founding mission to care for the whole community, not just the insured? Most of these systems predate the birth of health insurance. They were founded by visionary religious bodies or people like Henry Ford, who saw in modern medical science a powerful tool for social justice. Is that vision a delusional relic? The learning group discovered that even amid the half-built policy scaffolding and confusion of state-level politics, we can do what we were intended to do—if we adopt an ensemble of practices very different from Porter’s list because we need more stakeholders to play critical roles. That’s why the group is now moving under the name of Stakeholder Health (you can sneak an official peak at the website stakeholderhealth.org).

Actually, the healthcare sees life even more simply that I was giving them credit for. — Actually, the healthcare consultants see life even more simply that I was giving them credit for.

The first step is to move toward the people (who are only sometimes patients) and the places where social and environmental conditions play a significant role in limiting economic opportunity, dashing the hopes of young people, and perpetuating negative health behaviors. These also happen to be the same communities where much of the Medicaid expansion will be concentrated. We must take focused action, and do so in serious partnership with the panoply of organizations (mostly not healthcare)
which care about these communities. This includes thousands of faith congregations and nonprofit organizations, as well as a growing number of business leaders—all totally invisible if you limit your focus to the healthcare sector.

You can see life whole by looking back on it, here in God's Acre, Old Salem. — You can see life whole by looking back on it, here in God’s Acre, Old Salem.

We must focus on proactive, compassionate problem solving rather than reactive charity. Omitted from Porter’s management view is the fact that the largest single item in the operational budget of almost every health system is charity care. In the case of Wake Forest Baptist Medical System, the total is $68 million last year. While we can’t predict exactly which person will need charity care, we know the census tracts where they likely live. If we engage those complex communities in real partnerships—including with our own lowest paid employees who live there—we could improve outcomes and provide the profound value we were founded for. We have to see the larger system and the full array of stakeholders. The good news is precisely in the larger team that cares about…..life.