Preface

Creating social capital is something that comes naturally to most people - especially people who are drawn to the good work of healthcare. Social capital is generated by creating social networks and using them to improve what we do. We tend to enjoy building connections with others in our personal and professional lives. We like to strengthen those connections, too. We value being able to work with people we like and trust.

But building social capital so that our organizations do more for our patients with high reliability and earn the loyalty of our colleagues - now, that takes work. It takes discipline. It means building real connections with everyone on the team. It means making sure everyone knows that they are on a team. It means creating a culture in which everyone - patients and colleagues - feels respected.

It means building connections across teams and across organizations. It means using those connections to spread information quickly and reliably, so we can respond to the challenges of the moment and the challenges of our times. It means creating a context in which people trust each other because they understand what it takes to be trustworthy.

Building social capital is difficult work - but it is the best work. It is the kind of work that causes you to smile gently every now and then as you drive home after a good day. Most of us feel that this is the kind of work we would do without the need for compensation. In fact, research shows that managers who are better at building social capital are valued more highly by their organizations and get promoted more quickly.

This book is written to help managers and leaders thrive by enhancing their ability to create social capital for their organizations. I don't think readers will find any of the recommendations controversial; after all, who can be against building connections among people and putting them to good use? But I hope the framing of these recommendations will help managers and leaders focus on the steps that build social capital.

I write this fully aware that "focusing" is not easy in healthcare even when the goal has obvious importance, like the building of social capital. There are so many signals coming in from so many directions in healthcare all the time, and every one of them feels like a crisis. There are health crises, like the COVID-19 pandemic. There are social crises that result from bias and inequity. There are financial crises due to the high costs of healthcare. And, of course, for each individual patient, there are their own medical crises that must be addressed with urgency.

In healthcare, we are better wired for responding to urgency than focusing on steps to build capital of any kind - financial or social. However, healthcare's current challenges demonstrate that working hard in response to crises is not enough. We need to be able to step back and understand what types of organizational changes will enable us to deliver better care and then implement them with high reliability.

My personal education on the types of organizational changes that are essential to building social capital began one June day in 2006, when I had my first real interaction with Michael E. Porter, a professor from Harvard Business School who would subsequently become my colleague, coauthor, and good friend. Porter was already widely known as one of the most powerful thinkers about business strategy, and he had just published Redefining Health Care - a book (written with Elizabeth Teisberg) that overnight had found a place on virtually every healthcare leader's bookshelf (Porter and Teisberg 2006).

I had invited Porter to lunch with me and my boss, Jim Mongan, CEO of what was then Partners Healthcare System (now MassGeneral Brigham) because he posed a problem. My job at that time was network president for Partners. I was responsible for building the network of physicians and hospitals around Massachusetts General Hospital and Brigham and Women's Hospital and improving their quality and efficiency. The goals of this work were idealistic, but they were also strategic. We were negotiating contracts with payers as an integrated delivery system, and we were getting compensated at higher levels than other providers because, in theory, the whole of our system was greater than the sum of its parts.

We were successful enough in those contract negotiations that we were attracting criticism from health insurance companies, other providers, and some government officials. Then, in the spring of 2006, we heard that Porter was saying in public remarks that Partners was not really an integrated delivery system. A powerful voice had joined the chorus of our critics.

"That's not good," Mongan said to me. "Ask him if he would come over so we can tell him all the things we are doing to integrate our care." I reached out to Porter and invited him to lunch; he agreed, and a few weeks later, I found myself sitting with Mongan across the table from arguably the most respected expert on business strategy in the world.

I had printed out PowerPoints showing how we were implementing electronic health records (EHRs) across our system. We were not only making an EHR available, but we required physicians to adopt it. We were the first network in the country to tell doctors that if they didn't adopt an EHR, we would exclude them from our network and our contracts. (We ultimately excluded about 35 doctors who refused to come along; it was not pleasant.)

Porter paid close attention, writing notes on his yellow pad. He nodded when I described the decision support that we were integrating into our EHR to help doctors make safer and more efficient choices. I paused to give him a chance to compliment us on our work.

"That's all very lovely," he said. This was the moment when I learned that if you hear the word "lovely" in a business context, you are not going to like what is coming next. He continued, "But it's not the same thing as organizing around the needs of patients."

My heart sank, because I knew immediately that he was right. We were working hard to make doctors faster, safer, and even more efficient at doing what doctors do, but we had not really done much to reorganize what they did.

Mongan made some hand motions to tell me to keep going. I went to the pages in the PowerPoint presentation that described the financial incentives we had created to reward physicians who improved on their quality metrics and/or decreased their spending for the overall population.

Again, Porter nodded. And, again, he said, "Yes, that's all very good. But it's not the same as organizing around the needs of patients."

After a few more minutes of playing defense, I surrendered. I said, "Michael, if you were us, what would you do?"

"I would make Partners the world's leaders in measuring what matters to patients," he said. "Capture those data and put them in front of your doctors. You are good people and you are smart people. You will respond and you will figure out how to make care better. But if you don't measure what matters to patients, you can't."

I was taking notes and wrote, "Measure what . " in my notebook, but then stopped. Porter was sitting only a few feet away across the narrow table and could see what I wrote. I thought that he must be wondering, "What are they paying this guy for if he has to write down that they should measure what matters to patients?"

But his suggestion was a big one. He was recommending that Partners and the rest of healthcare organize around a new focus - improving what matters to patients. We had never been against that goal, of course. But Porter was suggesting that we make it our explicit top priority and organize ourselves accordingly.

"If you want to discuss what it means to go down this road, come on over and we can continue the conversation," he said.

And the very next day, I did.

Years later, when Porter and I were making our way through a crowd entering Fenway Park for a Red Sox game, I recalled that afternoon when we had met - and told him that after he left, several of my colleagues were waiting in a conference room to hear what had happened during the meeting with him. I told them, "He said we should measure what matters to patients." They had all bent over and furiously written in their notebooks, "Measure what matters to patients."

Porter laughed. "Don't feel bad about writing that down," he said. "This is what happens in every organization among people doing real work. They get so close to it that they can lose sight of the big picture.

"I have a great job," he continued. "I come in and say the obvious thing. And then I go away, hoping that I helped them focus on that obvious stuff."

With the benefit of time, I now understand that focusing on the obvious things - the true top priorities - is one of the most important lessons that I learned from Porter. Another is the importance of organizing around the true top priorities. (I did get the chance to watch with amusement when Porter said to a classroom full of senior healthcare executives at a Harvard Business School course: "How you are organized really matters." From my place in the back row, it looked like every one of them were writing in their notebooks, "How...