USWWDS site link: https://designsystem.digital.gov/maturity-model/
The General Services Administration (GSA) has published version 2.0 of its website design standards that are intended to guide Federal agencies to compliance with provisions of the 21st Century Integrated Digital Experience (IDEA) Act that became law in 2018.
Anil Cheriyan, Director of Technology Transformation Services at GSA, told reporters on Jan. 22 that the latest version of the website standards is already being used by about 40 Federal agencies for their websites. He said that creating the website design standards as a shared service “is really getting rid of the concept” of each Federal agency having to undertake website modernization on a one-off basis.
Version 2.0 of the website design standards builds on work that GSA has been doing since 2015, he said. The standards were created to be flexible and modular, and to facilitate continuous improvement, in order to allow agencies to build solutions that best meet their missions, Cheriyan said.
The newly published version says Federal agencies should use the U.S. Web Design System (USWDS) maturity model to deliver a “great digital experience.” It continues, “Agencies should use the maturity model to adopt USWDS incrementally, and prioritize implementation to align with the priorities identified in their modernization plans” and reports mandated by the IDEA Act.
U.S. Web Design System Product Lead Dan Williams said USWDS is “suitable for anything from fast prototypes to national-scale” projects, and is ideal for coordinating design at scale across multiple teams, multiple products, and multiple locations.
“Using a design system like the U.S. Web Design System is a little bit like following the rules of baseball … No two games are exactly the same, but they’re all recognizably baseball,” Williams said.
by David Blumenthal
November 26, 2019
A recent agreement between Google and Ascension, a huge national health system, is yet another sign of how the digital revolution is transforming health care. We are at the dawn of a new era where clinicians will be able to apply in real time the collective human experience in treating any particular problem to the care of every patient with that condition.
But the critical reactions to the agreement — under which Ascension will send to the Google cloud the clinical data it collects on its 50 million patients, and Google will process that data to help Ascension better manage its patients and its finances — make it clear that changes of this magnitude are never smooth. The announcement generated concerns about patient privacy and the misuse of information for the private gain of third parties. It triggered an investigation by the U.S. Department of Health and Human Services and calls from members of Congress for further inquiries. We are obviously at the beginning of what will likely be a long, contentious, and vital debate over how to manage personal health information in the digital age.
Patients have an undeniable right to privacy and control over their personal health data. Doctors and hospitals need leeway to use patient information in their care. Patients, health professionals, and the larger society have an interest in learning from our collective experience with care to better prevent and treat disease. And tech entrepreneurs want a return on their capital when they add value to the management of health-care data. The coming debate will be about how to manage these sometimes conflicting interests as health information technology revolutionizes our health care system.
Setting the legalities aside for a moment, here are the fundamentals underlying the Ascension-Google relationship: Ascension sits on troves of data accumulated in the course of caring for millions of patients who pass through its facilities. That data used to be locked away in paper records that had to be physically transported and laboriously abstracted to serve any purpose other than the care of an individual patient at a particular place and time. As a result of the near-universal adoption of electronic health records over the last decade, all that information is now stored as electrons that can flow instantly to wherever it’s needed and useful, provided that patients’ privacy is protected.
This has several immediate benefits for patients. One is that their personal histories are always accessible when they get care at Ascension (and possibly elsewhere). Another is that Ascension’s doctors and nurses can potentially learn from the experience of all Ascension’s patients with similar conditions as they care for any individual patient. And by applying search technologies and artificial intelligence, Ascension may also be able in real time to mobilize lessons of the entire scientific literature to bring to bear on individual patients. That literature is so enormous that even the most experienced, specialized clinicians have difficulty keeping up with it. Ascension’s experience may also inform medical research more broadly.
The challenge is that accomplishing these innovative uses of electronic data requires a range of informatics, analytics, and research skills that most health systems don’t possesses. One logical approach is for health care organizations like Ascension to partner with third parties that have the necessary capabilities. That’s where Google comes in. It has IT skills — including in the field of artificial intelligence — that Ascension can never hope to equal. And Google has been gobbling up nationally renowned clinician leaders and researchers to create a deep bench in health-care informatics and research.
In this, Google is not alone. IBM Watson has been in this field for some time. Amazon and Apple seem to be following suit. And there are a flock of start-ups hunting for opportunities to add value to health care by mining patient data. When health care, which accounts for 18% of the U.S. economy, suddenly enters the digital age — bringing almost inconceivably large stores of untapped data — the business opportunities are huge. Google is reportedly not charging Ascension for its services, but that is likely because of the exploratory nature of the work that Google will be doing at this point in the developing arena of health care informatics. Future customers are unlikely to be so fortunate.
The legalities, of course, cannot be set aside for long. The Google-Ascension deal will likely expose the personal health information of millions of Ascension patients to Google employees. Doesn’t this violate the Health Insurance Portability and Accountability Act of 1996 (HIPAA)? Health care providers routinely cite HIPAA as a tough, no-nonsense statute that severely inhibits their ability to share patients’ information with each other and even with patients themselves and their families.
Well, the fact is that HIPAA, despite its fearsome reputation, is full of holes, and lawyers for Google and Ascension likely found ample room in the law to support their agreement. For one thing, health care providers who are regulated under HIPAA, so-called covered entities, may share personal health information without patient consent for three main purposes: treatment, payment, and operations.
Treatment means that clinicians can discuss their patients with other treating clinicians without getting patients’ consent each time. Without this flexibility, doctors would be severely restricted in their ability to consult with colleagues for the benefit of their common patients. Payment means providers can use personal health information to get paid by insurers. And operations means that providers can use personal health information to address the critical operational needs of their organizations, including improving the quality and safety of their care. When a covered entity uses a third party to fulfill any of these purposes, that outside entity becomes a so-called business associate, and must conform to HIPAA regulations as well.
The data management activities that Google will undertake for Ascension may very well qualify as meeting Ascension’s operational needs to improve the quality of its care, and Google could, in that capacity, serve as a business associate. Under this interpretation, the sharing of patient data without patient consent could be legal under HIPAA. The U.S. Department of Health and Human Services, which enforces the HIPAA statute, is examining the relationship to see if it meets HIPAA requirements.
However, even if the relationship turns out to be technically legal, it raises significant unresolved policy issues. The lawmakers who created HIPAA never anticipated the internet, IT behemoths like Google and Apple, or the skill of hackers who seem to penetrate the most secure data systems at will. It is one thing to share a dusty old paper record with an outside entity. It is quite another to send electronic versions off into the cloud where — despite a third party’s best efforts — it might be hacked from anywhere on earth. HIPAA is likely no longer sufficient to reassure patients that their electronic health data is adequately protected.
Another question surrounds rights to the commercial benefits likely to flow from collaborations between health care organizations and IT companies. These agreements will likely produce a bounty of intellectual property that will be profitably sold without patient information (think algorithms and software) to other health care providers and even to other businesses that develop and market health care products (think pharmaceutical and device companies and health plans). Ultimately, however, these profits will be derived from the personal health information of millions of patients who will likely have no idea of how their data have been used. Should they be given the opportunity to consent to these business uses of their data? Should they share in some small way in the gains?
These and other questions will have to be addressed to realize the individual and societal benefits of the health information revolution, and we will have to sort out the multiple conflicting interests and perspectives that arise at every inflection point in human history.
There’s a bitter fight over the patents for CRISPR, a breakthrough new form of DNA editing.
by Antonio Regalado Dec 4, 2014
Last month in Silicon Valley, biologists Jennifer Doudna and Emmanuelle Charpentier showed up in black gowns to receive the $3 million Breakthrough Prize, a glitzy award put on by Internet billionaires including Mark Zuckerberg. They’d won for developing CRISPR-Cas9, a “powerful and general technology” for editing genomes that’s been hailed as a biotechnology breakthrough.
These Streptococcus pyogenes bacteria use a DNA-cutting defense to battle viruses. The system, called CRISPR, is being harnessed to treat human genetic disease.
Not dressing up that night was Feng Zhang (see 35 Innovators Under 35, 2013), a researcher in Cambridge at the MIT-Harvard Broad Institute. But earlier this year Zhang claimed his own reward. In April, he won a broad U.S. patent on CRISPR-Cas9 that could give him and his research center control over just about every important commercial use of the technology.
How did the high-profile prize for CRISPR and the patent on it end up in different hands? That’s a question now at the center of a seething debate over who invented what, and when, that involves three heavily financed startup companies, a half-dozen universities, and thousands of pages of legal documents.
“The intellectual property in this space is pretty complex, to put it nicely,” says Rodger Novak, a former pharmaceutical industry executive who is now CEO of CRISPR Therapeutics, a startup in Basel, Switzerland, that was cofounded by Charpentier. “Everyone knows there are conflicting claims.”
At stake are rights to an invention that may be the most important new genetic engineering technique since the beginning of the biotechnology age in the 1970s. The CRISPR system, dubbed a “search and replace function” for DNA, lets scientists easily disable genes or change their function by replacing DNA letters. During the last few months, scientists have shown that it’s possible to use CRISPR to rid mice of muscular dystrophy, cure them of a rare liver disease, make human cells immune to HIV, and genetically modify monkeys (see “Genome Surgery” and “10 Breakthrough Technologies 2014: Genome Editing”).
No CRISPR drug yet exists. But if CRISPR turns out to be as important as scientists hope, commercial control over the underlying technology could be worth billions.
The control of the patents is crucial to several startups that together quickly raised more than $80 million to turn CRISPR into cures for devastating diseases. They include Editas Medicine and Intellia Therapeutics, both of Cambridge, Massachusetts. Companies expect that clinical trials could begin in as little as three years.
Zhang cofounded Editas Medicine, and this week the startup announced that it had licensed his patent from the Broad Institute. But Editas doesn’t have CRISPR sewn up. That’s because Doudna, a structural biologist at the University of California, Berkeley, was a cofounder of Editas, too. And since Zhang’s patent came out, she’s broken off with the company, and her intellectual property—in the form of her own pending patent—has been licensed to Intellia, a competing startup unveiled only last month. Making matters still more complicated, Charpentier sold her own rights in the same patent application to CRISPR Therapeutics.
No CRISPR drug yet exists. But if CRISPR turns out to be as important as scientists hope, commercial control over the underlying technology could be worth billions.
In an e-mail, Doudna said she no longer has any involvement with Editas. “I am not part of the company’s team at this point,” she said. Doudna declined to answer further questions, citing the patent dispute.
Few researchers are now willing to discuss the patent fight. Lawsuits are certain and they worry anything they say will be used against them. “The technology has brought a lot of excitement, and there is a lot of pressure, too. What are we going to do? What kind of company do we want?” Charpentier says. “It all sounds very confusing for an outsider, and it’s also quite confusing as an insider.”
Academic labs aren’t waiting for the patent claims to get sorted out. Instead, they are racing to assemble very large engineering teams to perfect and improve the genome-editing technique. On the Boston campus of Harvard’s medical school, for instance, George Church, a specialist in genomics technology, says he now has 30 people in his lab working on it.
Because of all the new research, Zhang says, the importance of any patent, including his own, isn’t entirely clear. “It’s one important piece, but I don’t really pay attention to patents,” he says. “What the final form of this technology is that changes people’s lives may be very different.”
Twitter CEO Dick Costolo (far left) and actress Cameron Diaz present the Breakthrough Prize to biologists Jennifer Doudna and Emmanuelle Charpentier last month in Mountain View, California. Each won $3 million.
The new gene-editing system was unearthed in bacteria—organisms that use it as a way to identify, and then carve up, the DNA of invading viruses. That work stretched across a decade. Then, in June 2012, a small team led by Doudna and Charpentier published a key paper showing how to turn that natural machinery into a “programmable” editing tool, to cut any DNA strand, at least in a test tube.
The next step was clear—scientists needed to see if the editing magic could work on the genomes of human cells, too. In January 2013, the laboratories of Harvard’s Church and Broad’s Zhang were first to publish papers showing that the answer was yes. Doudna published her own results a few weeks later.
Everyone by then realized that CRISPR might become an immensely flexible way to rewrite DNA, and possibly to treat rare metabolic problems and genetic diseases as diverse as hemophilia and the neurodegenerative disease Huntington’s.
Venture capital groups quickly began trying to recruit the key scientists behind CRISPR, tie up the patents, and form startups. Charpentier threw in with CRISPR Therapeutics in Europe. Doudna had already started a small company, Caribou Biosciences, but in 2013 she joined Zhang and Church as a cofounder of Editas. With $43 million from leading venture funds Third Rock Ventures (see “50 Smartest Companies: Third Rock Ventures”), Polaris Partners, and Flagship Ventures, Editas looked like the dream team of gene-editing startups.
In April of this year, Zhang and the Broad won the first of several sweeping patents that cover using CRISPR in eukaryotes—or any species whose cells contain a nucleus (see “Broad Institute Gets Patent on Revolutionary Gene-Editing Method”). That meant that they’d won the rights to use CRISPR in mice, pigs, cattle, humans—in essence, in every creature other than bacteria.
The patent came as a shock to some. That was because Broad had paid extra to get it reviewed very quickly, in less than six months, and few knew it was coming. Along with the patent came more than 1,000 pages of documents. According to Zhang, Doudna’s predictions in her own earlier patent application that her discovery would work in humans was “mere conjecture” and that, instead, he was the first to show it, in a separate and “surprising” act of invention.
The patent documents have caused consternation. The scientific literature shows that several scientists managed to get CRISPR to work in human cells. In fact, its easy reproducibility in different organisms is the technology’s most exciting hallmark. That would suggest that, in patent terms, it was “obvious” that CRISPR would work in human cells, and that Zhang’s invention might not be worthy of its own patent.
What’s more, there’s scientific credit at stake. In order to show he was “first to invent” the use of CRISPR-Cas in human cells, Zhang supplied snapshots of lab notebooks that he says show he had the system up and running in early 2012, even before Doudna and Charpentier published their results or filed their own patent application. That timeline would mean he hit on the CRISPR-Cas editing system independently. In an interview, Zhang affirmed he’d made the discoveries on his own. Asked what he’d learned from Doudna and Charpentier’s paper, he said “not much.”
Not everyone is convinced. “All I can say is that we did it in my lab with Jennifer Doudna,” says Charpentier, now a professor at the Helmholtz Centre for Infection Research and Hannover Medical School in Germany. “Everything here is very exaggerated because this is one of those unique cases of a technology that people can really pick up easily, and it’s changing researchers’ lives. Things are happening fast, maybe a bit too fast.”
This isn’t the end of the patent fight. Although Broad moved very swiftly, lawyers for Doudna and Charpentier are expected to mount an interference proceeding in the U.S.—that is, a winner-takes-all legal process in which one inventor can take over another’s patent. Who wins will depend on which scientist can produce lab notebooks, e-mails, or documents with the earliest dates.
“I am very confident that the future will clarify the situation,” says Charpentier. “And I would like to believe the story is going to end up well.”
Military commanders have had to change the way they operate in the field. Corporate executives should take note.
Much has been written over the years about parallels between the military and large corporations. But what insights are most relevant for senior executives today in an age of agile organizations? With his long experience in the Army and then in business, Justin Maciejewski is unusually well placed to reflect on the lessons for business, as a former commander of the British Army’s 800-strong 2nd Battalion, The Rifles, during its vital peacekeeping mission in Basra, Iraq, from 2007 to 2008.
Maciejewski’s career in the army spanned more than a quarter of a century, taking in the years after the Falklands War, in 1982, to recent operations alongside coalition forces in Afghanistan, the Balkans, and the Middle East. It was a time that coincided with the development of a new type of leadership based on empowerment, designed to make the British Army more tactically agile and able to overcome larger adversaries through maneuvers, rapid planning, and decision making that disrupt and break down the enemy’s cohesion. This has transformed the British Army’s approach, which for generations had been based on centrally controlled, set piece battles focused on overwhelming firepower and attrition. Awarded the Distinguished Service Order for his role in Iraq, Maciejewski joined McKinsey in 2013 and was appointed director general of the National Army Museum in London in 2018.
In this conversation with McKinsey’s Rob Theunissen, Maciejewski talks about the modern army’s agile model, the balance between command and control, the importance of (good) process, and the notion of learning without blaming.
The Quarterly: Why did the British Army change the way its organization works?
Justin Maciejewski: In the Second World War, the British Army achieved success by focusing a huge amount of resources on a smaller enemy force, then wearing them down through attrition. Battles were often very static, relying on numerical superiority. The battles were designed top down; everyone knew their place. Montgomery, the great British commander of the Second World War, called this “a tidy battlefield,” and he referred to it as the orchestra of war: one conductor conducting, with all the different instruments doing exactly what they are told to do.
As the British Army got smaller in the 1960s and ’70s, it found itself at a numerical disadvantage relative to the forces it was facing in the Cold War. Nevertheless, this culture of top-down direction continued. And in the Falklands, the British Army found that soldiers were waiting to be told exactly what to do in circumstances where casualties might have been avoided had they been more proactive. At the end of that war, people asked themselves, “Why did intelligent people sit there, waiting to be told what to do? Why didn’t they just get on and do it?
“In the late 1980s, the British Army radically redesigned the way decisions were made and how officers were empowered. A new system was introduced: Mission Command, which would now be called agile, was all about giving people the tools to make rapid decisions in order to disrupt the enemy.”
In reflecting on our performance in the Falklands War, in the late 1980s, the British Army radically redesigned the way decisions were made and how officers were empowered. A new system was introduced: Mission Command, which would now be called agile, was all about giving people the tools to make rapid decisions in order to disrupt the enemy. The idea was that you could defeat a larger enemy by getting inside their decision cycle, moving so quickly that their cohesion is disrupted and they begin to fall apart.
The Quarterly: What were the big changes?
Justin Maciejewski: In Montgomery’s army, the functions—artillery, engineers, logistics, medical, intelligence, signals, et cetera—were very powerful. In the 1980s, led by General Nigel Bagnall, the notion of integrating the functions at every level took hold. Every group was tailored for the operation that it was required to do, and functions were integrated in the volumes that were needed for that operation.
That sounds easy, but it’s difficult to do. And in order for that to happen, the army had to be much more standardized about the way it planned, the way it gave direction, and the way it cascaded intent. If you’re going to be very modular and agile about the way you allocate resources, people need to be speaking the same language.
Mission planning lies at the heart of military operations, and the army came up with seven questions, which everyone now uses across the entire organization. Once you standardize like that, you create organizations in which people feel confident to make decisions and where trust grows because people know what other people are going to do even before they come up with an idea.
The Quarterly: Standardization can feel rigid and bureaucratic—it almost sounds paradoxical alongside agility. Was that not limiting?
Justin Maciejewski: The trick is to work out what process is good and fundamental to the stable functioning of an organization—and to its consistency—and what process is bureaucratic and superfluous. Don’t throw out the good stuff when you get rid of the bad stuff; organizations that have been fossilized by bad processes sometimes try to get rid of it all.
What the army managed to do in the 1990s was to get rid of a lot of bad processes but design these very solid core processes, which everyone was able to rally around. I never saw them as constraining; I rather saw them like a trellis where a plant grows up an open frame. The effort to root out bad processes was considerable and involved significantly reducing the number of operating procedures to encompass only those activities that genuinely needed to be standardized.
For me, a good process is a process that helps someone see how to think, how to find a solution, but it doesn’t tell them what to do. It doesn’t tell them the exact answer. In other words, it’s not a tick box. It’s a framework that lets people bring themselves to the problem in a way that they know they’re not going to miss anything. It’s a support—but a support that gives them the chance to be creative.
The Quarterly: Could you describe in more detail how structure, process, and creativity work together?
Justin Maciejewski: In the old world, leaders wrote down what they wanted people to do in quite a precise way. People were given tasks that fit within an overall operation or mission. A mission today is not a set of tasks, because, in a dynamic situation, people should revert to the purpose rather than the task. Situations change; the enemy’s done something. That’s my purpose—that’s what I’m going to go after—rather than in the old system, where people would literally do their task and wait to be told what to do next.
For example, in the old world, you could say to someone, “Take and hold the bridge by midnight tonight.” In the new world, you would say, “Our intention is to cross that river. To do that, I see you securing that bridge by midnight tonight. And the reason we want you to do that is because we want to put 20,000 soldiers on the far side of that river by the close of day tomorrow.”
If you imagine that philosophy being replicated across an organization of 80,000 people at every level, it dramatically changes the performance. Everyone at every level is thinking, “What if it changes? How do I respond?”
In a business environment, people often express annual targets as percentages of growth or the amount of cost they have to take out without any real articulation of how that feeds into the overall success of the business. [What they should be saying is,] “We need you to take out this much cost because we want to put that into the R&D program for the next model that’s going to win us a new market.” It’s very disempowering to have targets without any real context of how that target fits into the bigger picture.
The Quarterly: What does it take for a leader to move into this new world?
Justin Maciejewski: I grew up during this transformation, but I think it was a lot tougher for some of the people who’d grown up in the old army. One thing you have to be prepared to do as a leader is to give people space to fail, to let people spread their wings as leaders, and to trust them. Occasionally, they’ll get it wrong. And, when they get it wrong, you mustn’t crucify them. Because if you do, they won’t do it again, and then you have to micromanage them because there’s no other option. Watching people grow as leaders, by tripping over the first time and then getting up and dusting themselves down, is most fulfilling. As new leaders gain more experience, you can supervise less.
Leaders also need to understand that there is a tension between command and control. A commander may want to do something, but it may be impossible, and that’s where command has to be constrained by control. And there are other times when the commander knows something can be done and has to be done, and sometimes the machine needs to work a little bit harder to make it happen, and that’s where command pushes control. They are both critical to success, and that distinction between command and control is something I really came to value.
The Quarterly: Can you paint a picture of how you spent your time as a military leader?
Justin Maciejewski: Once the army moved to Mission Command, much more of leaders’ time was spent up front in the creative process: “What am I trying to achieve? How do I visualize this happening? What is my mission? What am I being asked to do?” It’s about making sure everyone is clear around what’s expected of them. This gives commanders much more time away from their laptops and more time with the people they are commanding. I like to think we were all frontline people.
When we first got to Basra, we had an operations room—a control tower—that had all the screens with satellites and aircraft photography coming down and data flowing in from people on the ground on their radios. It was a huge hub of information. What I actually found was, I may have had all the data, but what I didn’t have was the fingertip feel of what was actually happening on the ground.
Over time, I came to realize that the data was not the most important thing for me to see on any given day. I would get a much better feel for the operation by seeing the “customers”—the people on the streets—and the soldiers themselves who were doing the job. I would spend two-thirds, maybe three-quarters, of my time with soldiers at the front line, either talking to them or listening to them after an operation. I spent a quarter of my time planning.
That’s where the chief of staff in the army really kicks in. In business, the chief of staff is someone who organizes the CEO’s diary. The chief of staff in the army is an incredibly powerful figure and is literally the chief of the machine. My chief of staff bought me the time to be with the soldiers, talk to my Iraqi colleagues, or meet local leaders in Basra. The chief of staff also was able to triage the data and feed to me what I needed: “Be aware that this is happening.” A key thing [in the army] is that the system selects the chief of staff to work with the commander. When I look back now, I really appreciate how much effort went in to selecting the right chiefs of staff to work with the right commanders.
How you allocate your time, though, is only part of it. The army also invests a lot of time in training leaders to manage the mental and emotional states of the troops.
The Quarterly: How do you do that? How do you show up as a leader in the army?
Justin Maciejewski: When a leader shows up in the army, the soldiers immediately worry that they’re under scrutiny, that they’re being evaluated. That imposes an additional burden. So when I started in Basra, my assumption was to let the guys lead. They’ve got the enemy to worry about, and they’ve got the local population to worry about, but if you show up, they’ve got their leader to worry about as well. When a leader shows up in the right way, it’s a source of encouragement; it shows you also have skin in the game on any particular day. When the bullets are flying around, it makes the point that we’re all in this together.
One day, we had a mortar attack, and a lot of guys were badly injured on the other side of the city. The day before, someone had been killed by an improvised explosive device, and someone had lost one of their legs. So we got into our vehicles, and we drove across the city to spend the afternoon with this company and see how they—a company of about a hundred people—were getting on. I just went up there, had a cup of tea, put my arm around a few people.
“One thing you have to be prepared to do as a leader is to give people space to fail, to let people spread their wings as leaders, and to trust them. Occasionally, they’ll get it wrong. And, when they get it wrong, you mustn’t crucify them. Because if you do, they won’t do it again, and then you have to micromanage them because there’s no other option.”
The fact that we made the effort to get up there after this attack, in the same sort of vehicles that they’d been attacked in, meant a huge amount to the guys. I came to realize that showing vulnerability and presence as a leader becomes a very important way of galvanizing everyone around a particular mission. I wouldn’t go on a mission with a leader because I was worried about that leader, but because I wanted to show that leader that I was right next to him. And that mind-set change was the most profound for me personally as a leader: seeing yourself not as an evaluator but as a supporter of the people who work for you.
The Quarterly: Say more about vulnerability, because it feels such an odd concept in the army.
Justin Maciejewski: For a meeting somewhere with, say, a tribal leader or local power broker, I would turn up with my entire panoply of drivers, communicators, and bodyguards—we call it the “commander’s tac,” maybe as many as 15 people—and there might be a jet in the air over the area. That’s saying you’re the biggest tribal chief in the area.
The vulnerable bit is when you go to a group of soldiers who are being led by somebody and say, “I would like to come out with you tomorrow.” And you don’t try and command it; you just try and be with them, to walk in their shoes. The night shift, for me, was the place where you got the best conversations, turning up in a guard tower at two in the morning and saying to a young soldier, “How are you feeling?” And they’d be honest. They’d say, “I’m scared.” One could then talk about things that we were all concerned about and how we were going to tackle them.
I’m always struck by Henry V in Shakespeare, when he goes out and walks around. That is a very profound insight of good leadership. It’s in the night, when it’s quiet or when people have got their thoughts, that you can gently get alongside them.
The Quarterly: Let’s go back to teams. How does the army compose its teams?
Justin Maciejewski: My team was built by my predecessors: years of investment in developing the right talent and pushing it forward. So my regimental sergeant major had spent 20 years in the army, but he’d been recognized 15 or 16 years previously and had been pushed through the system to be ready when I needed him. I didn’t find him through advertising a job.
When I looked at this group of 800 people, I could see the sort of institutional investment in talent over at least 20 years—but, in reality, over generations. And it made me realize just how good the army is at getting and developing the right people. I had to remove a few people when I was there, but not many—a handful in an organization of 800—while everyone else stepped up and did what was required of them.
Talent selection is crucial, and being rigorous about it is important. I haven’t come across many organizations [in business] where talent selection is really rigorous. Often, it’s based on a good year’s performance, then you leap forward into the next job rather than really understanding what potential looks like versus performance. It could be that someone’s doing something they’re not actually ideally suited for, but, by God, they’ll be good for the next level. I think business is too quick to bring in talent rather than develop it internally. Endlessly looking outside creates a very transactional approach to people.
The Quarterly: How, then, do you compose teams that can shoulder responsibility?
Justin Maciejewski: People have got to complement each other. So if you have an extrovert leader who may not be very good on detail, you need to make sure they’ve got a second in command who’s bloody good at it. You mustn’t let people pick their own teams, because what you then create is an inner circle. I’ve seen this in other armies, where commanders were allowed to move with their inner circle. And when you have an inner circle around the boss, you just create a sense of disempowerment for everyone who’s not in the magic circle of power. That creates a very fractious—and, ultimately, toxic—organization. In business, I often saw an outer circle of people who were feeling very scared and vulnerable, and I don’t think that’s the way to drive successful teams.
The Quarterly: Let’s talk about the performance dialogue, where the backbone of a culture and an organization’s true beliefs always pop out.
Justin Maciejewski: [In the army,] there’s a very mature initial conversation between the person giving the mission and the person receiving the mission around how they’re going to achieve that mission. Then there’d be a dialogue around the concerns. There’s literally a piece of paper with four headings on it, and one of the headings is “concerns,” so you can’t say, “I’ve got no concerns.” That would feel a bit weird. So it takes the fear out of alignment with your boss.
You mustn’t let people pick their own teams, because what you then create is an inner circle. And when you have an inner circle around the boss, you just create a sense of disempowerment for everyone who’s not in the magic circle of power.
At the end of the operation, there’s what we call an “after-action review,” where you review performance of that operation. And the key thing about this is that it’s facilitated by an outsider, not by the person commanding the mission but by someone who’s not directly involved in the operation—for example, someone from the intelligence staff. Generally speaking, the commander comes to that process at the end and says, “That’s really interesting. These are my thoughts, reflections. And what have we learned from this?” And then someone captures what we need to learn from it, and then that gets fed into a review of how we do an operation in the future.
When a mistake is made, you do not hang someone out to dry. Sometimes mistakes are made in battle and people get killed. If you crucify people when a mistake is made in battle, they will freeze with fear the next time they’re facing the enemy, and the consequences of that are far worse. The notion of learning without blaming is at the heart of removing fear from that process.
One thing people realize in this sort of environment is that no one is without fault. No one is invulnerable to making mistakes, because the pressures are huge. People are slow to judge because they know that tomorrow it could be them. When a mistake is made, you know it could be you. I’ve been really shocked by how much fear is used as a motivator in business—in a way that I never saw it used as a motivator in the army. People are very much in a state of fear, not because they’re being shot at, but because there’s an internal fear working in terms of how people are being evaluated and watched all the time.
The Quarterly: How did you leverage values in your day-to-day work?
Justin Maciejewski: I’ve always been struck since I left the army that the army doesn’t have just values; it has values and standards. And the reason is because it wants to help people understand what those values look like in action. So courage is a value; having the moral courage to call out something when it’s wrong is the standard.
I saw this with a young soldier who came to me and said, “Sir, my commander behaved badly in a house last night in Basra. He smashed up some furniture in a search, and it was wrong, sir.” That young soldier had the moral courage to do that.
We would spend 15 or 20 minutes, perhaps half an hour, a week talking about the army’s values—courage, loyalty, discipline—and what they actually meant. Values can be a hugely powerful thing when they’re shared across an organization, but you’ve got to invest in them. You can’t just put them on a notice board or up in an office and have that be the end of the job. In business, I think, we’re still in the foothills of how we use values in the most effective way to create healthy organizations and drive performance.
“I would never call my soldiers a ‘human resource.’ They were the soldiers, the battalion, the riflemen. The term ‘human resources’ dehumanizes people.”
The Quarterly: What have you observed about the way organizations in the corporate sector look at people?
Justin Maciejewski: One thing is that I would never call my soldiers a “human resource.” They were the soldiers, the battalion, the riflemen. The term “human resources” dehumanizes people.
The army is very mindful of its people because it can’t hire them in at any level. You can’t hire in someone to be a great general on the battlefield on day one. It has to nurture, invest in, and grow talent. Specialists can come in, but the core manpower has to be grown from within; the army does not use headhunters.
A lot of industry and business relies on the fact that it can just hire and fire people, so it becomes a hire-and-fire machine rather than a coaching-and-building machine. And I think that you can hire and fire your way to a certain level of performance, but by doing that, you will never build genuine teamwork and cohesion. The new approach to becoming agile in business is based on building small, tight-knit squads. That requires trust, and trust takes time. You’ve got to bind people to the idea and the purpose and, if you like, the essence of the company you’re building or the business you’re running. You’re never going to get people to go the extra mile if, fundamentally, it’s a transactional relationship.
About the author(s)
Justin Maciejewski is the director general of the National Army Museum and a former brigadier in the British Army. This interview was conducted by Rob Theunissen, a partner in McKinsey’s Amsterdam office.
Office of the Chairman of the Joint Chiefs of Staff Public Affairs
Watch his farewell video message to the Joint Force:
By Chairman of the Joint Chiefs of Staff Gen. Joe Dunford
In the coming days, I will complete over four decades of active service and my tenure as the Chairman of the Joint Chiefs of Staff. Before taking off my uniform for the last time, I wanted to tell you what an honor it has been to serve alongside you and to represent you here in Washington, D.C. and across the globe. More importantly, I wanted to take a minute to simply thank you for who you are and what you do.
Those of you in uniform active, guard, and reserve represent less than one percent of the American people and you’ve answered the call to serve our nation during a time of war.
You chose to challenge yourself to excellence and to be a part of something greater than yourself.
You chose to make a difference.
Across the globe, you stand the watch on sea, air, and land as we simultaneously tackle the challenges associated with Russia, China, Iran, North Korea, and violent extremism.
And you are driving change to deal with the challenges of the 21st century to include those in space and cyberspace.
Like your predecessors, you are ordinary men and women who hail from across the 50 states and U.S. territories but you routinely demonstrate extraordinary courage, honor, commitment, loyalty, and self-sacrifice.
It’s because of you that I am confident that we can defend the homeland and our way of life. It’s because of you that we have earned the trust and confidence of allies and partners around the world.
It’s because of you that people believe in America.
Over the past four years, I have spoken a lot about the need for our nation to maintain a competitive advantage over any potential adversary. You are our most important competitive advantage and any adversary would think twice about committing an act of aggression because of you.
And all of these words apply equally to our great civil servants who are an integral part of the team.
I’d also like to take a minute to recognize our families. My wife, Ellyn, and I know the unique challenges and sacrifices of military families. But we also know that the U.S. military is strong because of our foundation and our foundation is our families. One of the most rewarding experiences of the last four years has been meeting with military families across the force. Thank you for welcoming us into your homes. Thank you for your willingness to sacrifice and support and thank you for your resilience.
Let me close by saying that as I depart active service, I depart with incredible pride and gratitude, not because I’m a general or the chairman, but simply because I have stood in ranks with the Soldiers, Sailors, Airmen, Marines, and Coast Guardsmen who wear the cloth of our nation.
Please know that I will remain in proud over watch following my retirement.
God bless you all and Semper Fidelis.
FALLS CHURCH, Va. — The Department of Defense is preparing for the next major step in consolidating military hospitals and clinics under a single agency, one of the largest organizational changes within the U.S. military in decades.
On Oct. 1, the Army, Navy and Air Force begin the final two years of a multi-year transition to shift administration and management of their medical facilities to the Defense Health Agency by October 2021, changes that are “transformational and far-reaching,” said Navy Vice Adm. Raquel Bono, the DHA Director (Retiring Navy Vice Adm. Bono is the former DHA director. Army Lt. Gen. Place assumed command as DHA Director Sept. 3, 2019)
“For the first time in our modern military’s history, a single agency, the DHA, will be responsible for all the health care the Department of Defense delivers to our 9.5 million beneficiaries,” Bono said. “Whether you receive your care at an on-base facility or through our TRICARE civilian networks, DHA will oversee your care. This consolidation will drive higher levels of readiness for operational and medical forces and integrate health care services to standardize practices across the entire Department, which means patients will have a consistent, high-quality health care experience, no matter where they receive their care.”
The primary driver for this change is the National Defense Authorization Act of 2017. Congress mandated that a single agency will be responsible for the administration and management of all military hospitals and clinics to sustain and improve operational medical force readiness and the medical readiness of military members, improve beneficiaries’ access to care and experience of care, improve health outcomes, and eliminate redundancies in medical costs and overhead across three separate Service-run systems. DHA will be responsible for health care delivery and business operations across the Military Health System including budgets, information technology, health care administration and management, administrative policies and procedures, and military medical construction.
Bono said that even though congressional directives mandate this change, “it’s the right thing to do.”
“We have more than 40 years of independent studies and internal reviews that demonstrate the current structure of the Military Health System is unsustainable,” she said. “What makes us unique from other health systems is that we are heavily embedded with combat forces around the world focused on operational medical readiness and the health of our warfighters. The transformational changes underway will improve that focus, support the DoD’s priority for a more lethal force, and improve our ability to deliver high quality health care to all of our beneficiaries. Improving medical readiness is the key driver of the overall effort.”
During this transition, the quality of care won’t change for beneficiaries of the Military Health System. More important, Bono said, is that over time, it will improve that care by enabling changes to improve access, patient experience, and outcomes.
“Ultimately, what this transition means for all of us in the Department of Defense is a more integrated, efficient and effective system of readiness and health, and integration of health care services that leads to a more standardized and consistent experience of care for patients,” Bono said. “Central to that is having one agency oversee MTF operations while supporting the Services’ effort to focus more on readiness.”
Since October 2018, the DHA has been operating eight hospitals and clinics as part of the first phase of what was at first a four-year transition period. In June, the overall timeline adjusted to three years to reduce the amount of duplicative management by the Military Departments and the DHA, said Dr. Barclay Butler, the DHA’s assistant director for management and MTF transition head. “The primary driver of that is to measurably and precisely coordinate the reduction of the Military Services’ Medical Department support and oversight of the MTFs to the DHA,” Butler said. “We want to create a simple and clear transfer of authority that positively impacts healthcare for our patients.”
From Oct. 1 of this year through October 2021, the transition will focus on four primary objectives:
Centralized administration and management: On Oct. 1, all hospitals and clinics in the continental United States transition to the DHA, with the Army, Navy and Air Force medical departments maintaining a direct support role. Butler said this means that while DHA assumes overall management, the existing intermediate commands of the Military Departments will continue management duties until the transfer is complete to ensure uninterrupted medical readiness operations and patient care. The Military Departments and the DHA are currently working out final plans to maintain continuity of operations.
Establish Health Care Markets: At the center of the reorganization is the creation of health care markets. The DHA will stand up 21 large markets during the transition period to manage MTFs in local areas. A market is a group of MTFs in a geographic area – typically anchored by a large hospital or medical center – that operate as a system sharing patients, providers, functions, and budgets across facilities to improve the coordination and delivery of health care services. “These markets are really key to the entire reorganization,” Butler said. “Market offices will provide centralized, day-to-day management and support to all MTFs within each market.” Readiness support is at the heart of a market’s responsibilities, Butler added, and they will ensure the clinical competency of all MTF providers within the market. The 21 large markets will collectively manage 246 medical facilities and centers of excellence.
Establishment of a Small Market and Stand-Alone MTF Organization: For stateside hospitals and clinics not aligned to a large market, this office, referred to as SSO, will provide managerial and clinical oversight. As with the large markets, the Military Departments will continue managing the MTFs until they are realigned under the SSO. There are 16 small market MTFs and 66 stand-alone MTFs assigned to the SSO.
Establish Defense Health Regions overseas: The transition period for standing up Defense Health Regions in Europe and Indo-Pacific begins in 2020. All MTFs overseas would then report to their respective DHA regional offices. The Indo-Pacific region has 43 MTFs, while the European region has 31.
(For a complete list of markets and their assigned MTFs, go to the MHS Transformation web page at www.health.mil/mhstsransformation.)
“Change can be challenging, and this is a complex transition,” Butler said. “We will see changes in reporting relationships and communication channels while instituting standardized clinical policies and procedures and business practices. We place a premium on communicating often as we move through this together with the Military Departments.”
Bono said that from a patient perspective, these changes should be transparent. “Our patients expect the same high quality care regardless of who is in charge. Doctors, nurses, and technicians will continue to focus on practicing medicine and improving their skills and readiness. In the end, this really is about the patient – integrating into one system will improve readiness for our medical professionals and result in better care and better health outcomes for our patients.”
For more on the DoD’s medical reorganization, go to the military health web site at www.health.mil/mhstransformation for fact sheets, an informational video, and more articles.
About the Defense Health Agency (DHA)
The DHA, established on Oct 1, 2013, is the nation’s military medical Combat Support Agency, a joint, integrated organization that enables the Army, Navy, and Air Force medical services to provide a medically ready force and ready medical force to Combatant Commands in both peacetime and wartime. In cooperation with the Joint Staff Surgeon and Military Department medical organizations, DHA leads the Department of Defense’s integrated system of readiness and health through a global health care network of military and civilian medical professionals, including nearly 450 military hospitals and clinics around the world, to improve and sustain operational medical force readiness and the medical readiness of the Armed Forces. The DHA supports the delivery of integrated, affordable, and high-quality health services for 9.5 million active duty service members, retirees, Reservists and Guardsmen, and their families at military hospitals and clinics or through the TRICARE network.
Launching major transformation efforts is a common way that business leaders try to get a leg up on the competition, or just keep their heads above water. But too many of these efforts fail. Change is difficult, and many people not only resist it but seek to undermine it. Unsurprisingly, then, a McKinsey study found that merely 26% of transformation initiatives succeed. Most successful transformations have one thing in common: Change is driven through empowerment, not mandated from the top.
In my research of transformative political revolutions, social movements, and organizational change, successful efforts not only identify resistance from the start but also make plans to overcome those who oppose the transformation. And it’s done not with bribes, coercion, shaming, or cajoling, but by enabling others within their organizations to drive change themselves. Here’s how they do it.
Start with a small group. Typically, leaders launch transformation efforts with a large kickoff. It makes sense: They want to build momentum early by communicating objectives clearly. This can be effective if a ready consensus already exists around the initiative. Yet if the desired change is truly transformational, it is likely to encounter fierce opposition; inertia can be a powerful force, even more powerful than hope or fear. So by starting with a large communication campaign, essentially presenting the initiative as a fait accompli, you are very likely to harden the opposition of those who are skeptical of the change.
Most successful transformations begin with small groups that are loosely connected but united by a shared purpose. They’re made of people who are already enthusiastic about the initiative but are willing to test assumptions and, later, to recruit their peers. Leaders can give voice to that shared purpose and help those small groups connect, but the convincing has to be done on the ground. Unless people feel that they own the effort, it’s not likely to go very far. For example, when Wyeth Pharmaceuticals set out to drive a major transformation to adopt lean manufacturing practices, it began with just a few groups at a few factories. The effort soon spread to thousands of employees across more than a dozen sites and cut costs by 25%.
Identify a keystone change. Every change effort begins with some kind of grievance: Costs need to be cut, customers better served, or employees more engaged, for example. Wise managers transform that grievance into a “vision for tomorrow” that will not only address the grievance but also move the organization forward and create a better future. This vision, however, is rarely achievable all at once. Most significant problems have interconnected root causes, so trying to achieve an ambitious vision all at once is more likely to devolve into a five-year march to failure than it is to achieve results. That’s why it’s crucial to start with a keystone change, which represents a clear and tangible goal, involves multiple stakeholders, and paves the way for bigger changes down the road.
That gap between aspiration and practical reality was the challenge that Barry Libenson encountered when he arrived at Experian as CIO in 2015. In his conversations with customers, it became clear that what they most wanted from his company was access to real-time data. Yet to deliver that, he would have to move from the company’s traditional infrastructure to the cloud, an initiative that raised serious concerns about security and reliability. He began by developing methods for accessing real-time data for internal use, rather than going straight to customer-facing features. That required his team to engage many of the same stakeholders and develop many of the same processes that a full shift to the cloud would have required and allowed him to show some early results.
“Once we developed some internal APIs, people could see that there was vast potential, and we gained some momentum,” Libenson told me. Experian not only successfully moved to the cloud but also launched its Ascend platform based on the new infrastructure, which is now the fastest-growing part of its business.
Network the movement. All too often we associate any large-scale change with a single charismatic leader. The U.S. civil rights and Indian independence movements will always be associated Martin Luther King Jr. and Mohandas Gandhi, respectively. In much the same way, turnarounds at major companies like IBM and Alcoa are credited to their CEOs at the time, Lou Gerstner and Paul O’Neill.
The truth is more complicated. King, for example, was just one of the “big six” of U.S. civil rights leaders. Gerstner gained allies by refocusing the company around customers. O’Neill won over labor unions by making a serious commitment to workplace safety. These examples show why, in his book Leaders: Myth and Reality, General Stanley McChrystal defines effective leadership as “a complex system of relationships between leaders and followers, in a particular context, that provides meaning to its members.”
Every large-scale change requires both leadership at the top and the widening and deepening of connections through wooing — not coercing — an ecosystem of stakeholders.
Consider the case of Talia Milgrom-Elcott, cofounder of 100Kin10. When she set out to start a movement to recruit and retain 100,000 STEM teachers in 10 years, she knew there was no shortage of capable groups working to improve education. In fact, she had worked with many people who were building myriad approaches to the issue. But they had never met one another. And so she created a platform for collaboration that brings together nearly 300 partner organizations through conferences, working groups, and networking. Today 100Kin10 is ahead of schedule to meet its goal.
Surviving victory. Often the most dangerous part of any transformation effort is when the initial goals have been met. That’s why successful transformation leaders focus not only on immediate goals but also on the process of change itself. If Wyeth had stopped at a 25% cost reduction, it would have soon found itself in trouble again. But because its employees embraced the lean manufacturing methods, the company was able to keep moving forward. In much the same way, if Experian had been satisfied with merely shifting to a new technology infrastructure, little would have been gained.
In some cases, the benefits of a successful transformation can last for decades. Remembering Gerstner’s IBM turnaround in the 1990s, one of his top lieutenants, Irving Wladawsky-Berger, told me, “Because the transformation was about values first and technology second, we were able to continue to embrace those values as the technology and marketplace continued to evolve.” After a near-death experience, the company remains profitable today.
Editor’s note: An earlier version of this article misidentified Barry Libenson as the CEO of Experian. He is the company’s CIO.
Greg Satell is an international keynote speaker, adviser and bestselling author of Cascades: How to Create a Movement that Drives Transformational Change. His previous effort, Mapping Innovation, was selected as one of the best business books of 2017. You can learn more about Greg on his website, GregSatell.com and follow him on Twitter @DigitalTonto.