Mashing the Right Button for Henry

By Merit Smith
Vice President
Director, Health Care Practice

Henry is the CEO of one of the best regional HMOs in America. He is a clear thinker, introverted and soft spoken with a strong Texas twang. He uses few words. He lets an issue play out, hears all points of view, and guides his management team to the point where the decision is obvious. His approach works. His health plan is nationally recognized for low administrative costs, high member satisfaction, consistent growth and continuous profitability.

When he hired Nolan to improve his utilization management process, we were excited but nervous. How we would help improve medical costs without detracting from the plan’s overall excellent performance was a challenge. Our project had been underway for several weeks, and I was visiting the plan to see the first progress review our consultant was presenting to Henry’s management team.  Nolan’s consultant showed them that there was more room for improvement than anyone had thought. They weren’t defensive about this finding, but they did probe the data until they were comfortable. And then they went on to talk about what the new insight implied for patient care and profitability. All in all, it was a great session.

As the meeting broke up, I found a private moment with Henry and asked him, “Are we covering the right things for you?”  He said, “Sure are. Just make sure we are mashing the right buttons.”  And then he walked off.

“Mashing the right buttons?” What did he mean? I had no idea. Mash…. Hawkeye and BJ? Potatoes? Kentucky bourbon? What did he mean? What do “mashing” and buttons have to do with each other? I soon learned that “mashing” is a Texas term for “pushing.”  “Just make sure we are pushing the right buttons.” Now what he had said made perfect sense to me.

On many projects, the most important value a skillful consultant brings is to make sure the client “mashes the right buttons.” Let me explain. Most frequently we help executives with problems their organization has tried to fix, but has failed to resolve. As we learn about the prior efforts to fix the problem, we frequently see these things:

Because of his management style, Henry wasn’t worried about dealing with political problems or assigning inadequate implementation resources. What he was concerned about was that the project might not correctly link causes and solutions. He knew – either by instinct or experience – that a recommendation that is not strongly linked to the cause of a problem really isn’t worth much. You have to mash the right buttons to get the right results.

Common sense. But you would be surprised at how frequently organizations implement fixes that will not solve the problem. Based on our experience, we believe that a poor linkage between a cause and problem usually involves two things:

You can’t fix a problem if you don’t know what causes the problem. Oh, I guess you could get lucky, but successful careers aren’t based on random solutions to problems!

The trick is finding the “root cause” of the problem. A root cause is a condition without which the problem would not exist. Very few problems have more than one root cause. Finding root causes is hard work. They hide under layers of “contributing problems” and “symptoms.”  A “contributing problem” is a problem that makes it harder to diagnose or fix a root problem. Improving a contributing problem will cause a temporary improvement in the problem, but it can not eliminate the problem. Novice mangers frequently work on contributing problems. “Symptoms” are noticeable negative conditions that can be seen when a problem is unresolved. Frequently symptoms are quantifiable and associated with poor quality service or excess costs. Ineffective solutions to problems – ones that result in no improvement – are frequently the result of a manager working on a symptom rather than a cause.

Nolan’s approach to mashing the right button is to provide clear and specific recommendations on the root cause, and then for each contributing cause.

We then measure the symptom as a way of measuring improvement in the situation.

For example, we might have a client with a phone service problem. The symptoms are excessive wait times and abandon rates. The contributing causes might be excessive staff turnover among the phone staff and increasing volumes of claims-related calls. After much work, we determine the root cause is a recent change to the claims processing that is confusing and unpopular.

We could add more staff to the call center. We could raise wages for the staff to reduce the turnover. But these approaches will create only temporary improvement in the symptoms. These approaches can’t improve the long-term situation because they don't deal with the root cause. In fact, they will cause short-term improvement and increased cost. And the problem will reemerge until the root cause is discovered and eliminated.

So Henry was saying: “Help us stay focused on root causes.”  Common sense, plainly spoken (once I got over the “mashing” confusion). Classic Henry.