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“But the Mirror will also show things unbidden, and those are often stranger and more profitable than things which we wish to behold.
What you will see, if you the leave the Mirror free to work, I cannot tell.”​​​​​​​


in The Lord of the Rings (Book 2, Ch. 7)

One of the enduring mysteries of the human condition is our struggle to pursue that which is good for us.  It is easy to forego exercise, to have a second serving of dessert, to watch another episode late into the night, or to avoid that phone call.  I have come to realize that resistance to improvement, even when the change is recognized as necessary, is more pronounced when it comes to systems.  A health center, even more than a person, needs a large amount of energy and incentive to walk the path of the righteous.

Through value-based payment reform, we have the opportunity to achieve institution-wide alignment that will bring us closer to our mission.  The goals for which we are designing our new system are changing, and therefore we will need to change and improve much of our daily work.  Let’s take a patient who has just been discharged from hospital.  Our current conception of the patient’s episode of care is linear.  Our responsibility starts at the first contact after discharge and ends if the patient is admitted again.  In a value-based payment system, we care about the whole patient experience: the hospital stay itself, planning for the transition back home, and once home, insuring that the cycle of readmission repeats as seldom as possible.  Thinking of patient care as a loop, as opposed to a linear discrete period between two points in time, will compel us to provide novel services, collaborate differently with involved institutions, and connect with patients and families in innovative ways. The coming reform grants us a common starting point, encouraging us to work together.  It’s like throwing over a tyrannical government: it’s simple, it’s just that everyone has to decide to say, “No more!” on the same morning.

Yet, it is impossible to have the universal foresight to design complex systems entirely right from the beginning.  Therefore, the best institutions are dynamic, able to change and adapt while keeping the end goal in mind.  In healthcare, we serve individuals, not standardized units.  I often joke that Lynn Community Health Center isn’t one institution but 200 small programs.  Beyond the quip, the deeper truth I am getting at is that those doing the work are the experts who should identify and improve what serves neither patient nor staff.  The only way to improve so many interlocking workflows is for everyone to own the parts they know best and for there to be a system in place to coherently implement improvements.

The path to excellence requires both deep humility and impatience with any aspect of the system that is serving neither staff nor patients fully.  By deep humility, I mean recognizing that we each participate in dysfunctional systems, and sometimes not unwillingly.  Another very human tendency is to notice all the errors that others are committing, all the waste that is coming from a team that isn’t mine.  Your reaction might be “No, I know when something isn’t working.”  Yet, who has not had the frustrating experience of higher management coming in to impose a change for a problem that you know isn’t what is truly bothering either you, your team, or your patients?  The path to excellence requires both deep humility to truly look in the mirror and impatience with any aspect of the system that is serving neither staff nor patients fully.

Take a sincere look in the mirror as we redesign our care around the patient experience.  What workflows are you central to that might hamper the patient experience or do not contribute to improved quality of life in our patients?

Dr Kiame Mahaniah
Kiame Mahaniah


About Kiame

Inspired by a childhood divided between a war-affected third world country – the Congo – and a high performing first world one (Switzerland), as well as parents intimately involved in rural development NGOs, Dr. Kiame Mahaniah brings a deep passion for social justice and the fight against inequities to his work as CEO at the Lynn Community Health Center in Lynn, Massachusetts.

More About Kiame

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