Across the industry, as we move into spring 2010, the strongest desire I hear is to get back to some kind of “business as usual,” to breathe a big sigh of relief that we are past all that sturm und drang, all that public trauma and threat to our bottom lines and corporate structures, get a good night’s sleep for once, and get back to the way things were, with maybe a few adjustments.

Maybe it even seems that we are there already. After all, a year ago half the hospitals in the country were operating in the red, and today we are pretty much back to where we were.

This is a comforting illusion, one that threatens to become an industry trance. We are not back where we were. There is no going back.

Time to Stop Dreaming about the Future

Before the 2008 election, before 2009, there was a sense that reform was coming. Efforts and thinking and hopes went into how to shape that reform, how to shape ourselves to deal with that reform—but it was all off in the future.

Now, among the wrack and effluvium of that desperate year, we find ourselves in a completely different mind-set. We got what we got out of that year, leaving the system a mess wrapped in a kludge fastened with zip ties and spit.

But it is important to recognize that our customers have been through the same trauma. Their expectations have been repeatedly raised and dashed. The daunting demographics of aging boomers (and the aging boomers among your work force) are only more advanced than they were. There is more trauma to come in a welter of lawsuits and constitutional challenges, state and federal regulation changes in a “patch patch patch” effort to fix the system—and every attempted repair job would make life more difficult, less comfortable, less profitable for somebody, whether malpractice attorneys, long-term-care insurers or hospitals.

Hospitals survive in a very political world. At the very time that we have needed our political weight, new narratives have arisen about who we are and what we do. And the power to name is the power to frame the whole discussion. What we know is that the fuel hospitals really run on is empathy. Our story is that we are struggling mightily to bring life-saving medical attention to everyone, and all our efforts to build our institutions are bent to that end.

But as obvious, as existentially true as that story may be to us, we can no longer assume that everyone else buys our story. In one new competing narrative that has arisen, the industry is revealed as a racket in which hospitals and health plans abet unscrupulous doctors who churn patients through every unnecessary test and procedure that they can get approved, all for simple profit. Another story portrays us as sloppy, uncaring, bureaucratic monsters eating the suffering of the sick. An alternative narrative, powerful for some, casts hospitals as cooperators in an industry that is rapidly becoming an oppressive, intrusive arm of an increasingly socialist state.

Our opinion as to the truth of these alternative narratives is irrelevant. What is relevant is that those stories are being told now, and are competing to frame the political discussion in which we continually seek support.

Exacerbating every one of these factors, we can expect all costs in health care to continue to rise even more vertiginously than before the annus horribilis of 2009. The specter of cost controls, real or not, is scaring suppliers, insurers, niche providers and pharmaceutical companies into what they see as defensive price rises wherever they can get away with them, forcing general providers to raise their prices just to keep the bottom line the right color.

Time for “What If?” Thinking

In this land without comfort, this landscape with no easy shelter, what can you say, what can you think, about the future of your own institution?

It’s time to say, “Focus, people.” This is not the time for hunkering down, muddling through and hoping for the best. This is time for big vision, for thinking thoughts you didn’t dare think before, for imagining what if you tried this new tactic, that new alliance, what if you shut down this other project and shifted that budget in a different direction.

It is time as well for a really solid ground game. It’s time for street smarts, people skills, business skills, deal-making skills. It’s time to communicate communicate communicate. It’s time to keep our eyeses on the prizes, which are two: 1) serving the people, and 2) keeping our organizations alive and healthy and full of options to serve the people. Usually—usually, that is—these two goals are the same goal. They are rarely in actual conflict, and that is the great virtue and wonder of running a hospital or health care organization. Our true goal is helping people toward a healthy birth, a long and healthy life, and a good death. Everything else—working with the docs, getting the budget right, building the work force—is valuable and important, but ultimately instrumental to what we are truly here for.

I’ll tell you a secret, something you might find surprising. It has to do with words like “hero,” words like “courage.” I’ve been around this business for 30 years now, and still . . . when I see the adulation given to someone like Captain “Sully” Sullenberger, who brought his crippled airliner to a safe landing in the Hudson, or the firefighters who rushed into the doomed World Trade Center towers on 9/11, or a soldier or Marine given a medal for rushing to save his or her comrades under fire, I think, “What a great thing! What a fine human being! How skilled and brave and true!” And at the same time, every time, my thoughts turn to the people running our great health care institutions.

In those moments, I don’t think particularly about those who are turning the crank on “business as usual,” picking up another paycheck and coasting toward retirement. In those moments I think about the people I have met repeatedly all across this business who have found the fortitude to take those instants of decision, those months of politicking and deal-making and implementation, those years of persistence that lead to bringing some lifesaving medical help to people who need it and can’t get it, doing it cheaper so that medical help does not bankrupt people and take their homes, doing it better so that we kill as few people as possible, so that we do no harm.

I think of the people who have struggled to bring health care back to New Orleans after Katrina destroyed so much of the health care infrastructure of that city and the surrounding parishes. I think of the leaders of major urban institutions who have said, as Bill Schneider, CEO of Northwest Hospital in Seattle, did, “Let’s build some free clinics—partly because it’s the right thing to stanch the flow into our ED, but mostly because it’s the right thing.”

I think about the leaders of ThedaCare, a four-hospital chain based in Appleton, Wisc., who said, “We need to benchmark some place that understands ‘lean manufacturing.’ We can’t afford to go to Japan for courses in kaizen. But look, here’s a local snowblower factory that’s doing it. Let’s talk to them.”

I think of Carlos Olivares, head of the Yakima Valley Community Clinic in eastern Washington, who convinced a group of local doctors to open an after-hours clinic to capture all the farm workers who were going to emergency rooms out of the area, and in the process brought down the cost of care for the farm workers at the same time that he increased the income of the docs.

I think of Brent James at Intermountain Health in Salt Lake City, repeatedly challenging clinicians to standardize and study what works, standardize and study again—a process that has saved thousands of lives over the years.

I think of Peter Pronovost of Johns Hopkins, who asked, “What would it take to reduce central line infections to zero?” and pushed to find answers to that question, and to test and implement the answers through years of study and roll-out, in ways that stand to save thousands of lives and billions of dollars.

A Habit of Excellence

Everybody has to have heroes. These and the thousands like them in health care are mine. There is an undeniable heroism in the extreme effort, persistence, creativity and calculated risk that it takes to make health care work better. There is a kind of warrior stance, an absolute focus, a willingness to collaborate and persevere amid the messy personal and political swamp of any real organization, coupled with an unwillingness to settle for the ordinary, the expectable, the ways we have always done things.< /p>My expectation is that we are going to see more of this heroism in health care. The times will call it out in people, especially in people who have never felt heroic, never felt certain that they had it in them to do something different and difficult and good.

As Aristotle famously shaped it, “We are what we repeatedly do. Excellence, then, is not an act, but a habit.” We will not get the health care that we want. We will not get the health care that we deserve. We will get the health care that we settle for. We will get the health care that we build, where we are, with the tools that we have, with the courage and compassion and collaboration and hard insistence on excellence that lies within us.