MISSION: Improvement

Performance Improvement Tip of the Day: SMART Dialogue

2012-02-15T11:58:00.000-05:00

Referring again to Dale Carnegie's "How to Win Friends and Influence People in the Digital Age", the authors talk about the importance of dialogue (vs. monologue) as a means of connecting with "core desires".

The authors' concept of dialogue provides a great mechanism for improving "listening" skills as well, which we all agree are critical to leadership and change management. The authors define the following features of dialogue, which somehow align nicely with the "SMART" template:

Secure
Meets mutual needs
Authentic
Respectful (the authors use "considerate", but I exercised some poetic license here)
Transparent/ Builds trust

How do these concepts connect? >>> If you engage in SMART dialogue, you will increase your influence with that individual, and thereby increase your capacity to lead change.

Hospitals Decry Low Safety Rankings

2012-02-14T10:24:00.001-05:00

This article in the Boston Globe lays out the concern emerging from the hospital community over the "safety" data that was recently released publicly by CMS (http://www.hospitalcompare.hhs.gov/), and is also planned to be included in the "value based purchasing" calculations that will penalize hospitals who have low "quality scores".

Even those who fared well on the rankings note that this metric was not intended for the purpose for which it is being used. One can certainly glean some insights from the AHRQ indicators that are used to calculate the patient safety scores. Having reviewed the respective data for a particular healthcare institution, I did find it to be helpful and a reasonably accurate reflection of our patient care. However, as the billing data from which these measures are derived are not generally constructed with the delivery of quality clinical care in mind, the data cannot be presented as a highly reliable picture of the quality of care being delivered at an institution.

This isn't a question of using data, or comparing hospitals, or posting the data publicly - although each of these initiatives may independently inspire criticism as well. This isn't even about those institutions not faring well in a head-to-head competition crying foul. The central issue remains that one can't take major shortcuts in data gathering if one if trying to properly incentivize and motivate the system to improve. This doesn't work in an individual medical center or clinic - as one of the first tenets of performance improvement is to ensure that the data we share with our physicians and other clinicians is meaningful and reliable - nor does it work for the entire healthcare system.

The intention may be proper, but displaying such data publicly, expecting consumers to make healthcare decisions based upon it, and furthermore penalizing hospitals for not performing better on the same scale has the risk of coming across as a desperate maneuver to reduce costs in the guise of quality.

Reducing Readmissions through Guidelines (and other performance improvement techniques)

2012-02-09T09:09:00.000-05:00

This article in Health Leaders Media provides a wonderful example of how to utilize performance improvement tools and principles in order to reduce readmissions. "UPMC Hamot, Lancaster (PA) General Hospital, and Muncie, IN–based Indiana University Health Ball Memorial Hospital have readmission rates that beat Medicare's HospitalCompare dataset national average in three key areas: 30-day readmission rates for heart attacks, 30-day readmission rates for heart failure, and 30-day readmission rates for pneumonia." The entities attribute their success in large part to the following interventions:

Guidelines:

"We researched best practices, and we standardized those practices."... "Then we put together teams of physicians and caregivers that care for the population of patients we were focusing on and developed standardized treatment guidelines that were then put into use."
"The organization now has more than 200 guidelines in place, each created by an interdisciplinary team with a physician champion."

Checklists:

Heart failure (HF) patients receive a home health referral upon discharge.
Telehealth whenever possible.
Scale with the blood pressure monitors hooked up to the phone line.
Review weight every day.

Standardization:

Standardizing paperwork that is exchanged between hospital and after-care facilities.

Multidisciplinary (in this case, cross-institutional) Teams:

"We took it a step further when we worked on heart failure. We created a heart failure skilled care order set and met with the administrator and director of nursing to make sure what we were putting on the order set could be used anywhere."

Redesigning Care Processes:

Inpatient HF clinic staffed by nurse practitioners.
Link the specialists in the hospital to patients' primary care physicians and SNFs.
HF coach calls discharged HF patients three times within the first week to make sure they are following up with appointments and understand their medications.

A few additional PI techniques come to mind that are not mentioned in this article, but would be a natural adjunct to the initiative, and could help to ensure excellent outcomes:

Disseminate Data to Physicians, Nurses, and Other Staff to generate awareness.
Provide Feedback in the event that there is a "failure" in a process in order to ensure that individual practitioners learn of any gaps in their behavior.
Create Profiles of Providers in order to generate further awareness about team and individual performance.

Improving Surgical Quality: Tracking Emergent vs. Elective Surgery

2012-02-08T09:48:00.000-05:00

This article in Health Leaders provides an important reminder about the need for performance improvement experts to understand our data in more detail. Many hospitals formally evaluate various surgical quality measures, including the Surgical Care Improvement Project (Core Measures), complications, infections, readmissions, mortality, returns to the OR, returns to the ICU. However, these hospitals may not be differentiating between Emergency Surgery vs. Elective Surgery, a variable that can change the likelihood of complications considerably.

This research being undertaken at Wake Forest University Medical Center underscores that unless we understand the variables behind the data that we are collecting, we will likely not understand how to truly improve outcomes.

Another danger in "aggregating data" - particularly in this day of mandated physician profiling, e.g., through the Ongoing Professional Practice Evaluation (OPPE) - is that we may project individual practitioners to have higher complication rates than their peers, when in reality they may have a selective patient population. For example, perhaps some practitioners take more emergency call than their peers, which would lead them to perform more emergent procedures.

Other variables, such as delay in performing surgery, quality of OR team, communication within the OR/ preoperative timeframe, may also play a role in the outcome of the procedure. However, unless we are attuned to these variables, capturing them, and studying them, we will not be serving the cause of improvement nor will we be able to effectively engage and help our physician colleagues as actively as we would like.

Performance Improvement Tip of the Day: Influencing People

2012-02-07T12:15:00.002-05:00

Dale Carnegie's "How to Win Friends and Influence People in the Digital Age", an updated version of the "time-tested" leadership primer, lays out many simple, ayet profound concepts that apply rather well to performance improvement.

Influence is often not discussed overtly as a performance improvement tool or principle - generally bundled within "leadership" or "developing a multidisciplinary team". However, influence is clearly the key to motivating people to change behavior or processes.

Everything else we discuss in performance improvement - data, feedback, profiling, multidisciplinary team, clinical redesign - may be moot if these elements don't help in "influencing" the staff, medical staff, and leadership to support the desired change.

One of the book's chapters on "connect with core desires" delivers a particularly powerful message for how to influence people: "True change is born of an interpersonal reach that takes hold of the deepest part of an individual".

This is something that is "known" to all of us, but still manages to evade us, particularly in the plethora of media, volume of connections, and numbers of projects that we are all trying to maintain. However, the advice couldn't be more pertinent.

In the course of working on a performance improvement project, think about how to "connect with the core desires" of the staff you are trying to influence. Here are a few simple tips:

Understand the real needs of the people: Its not just a project you're managing; its change you're advocating; change affects people; and you need to understand what they're experiencing and desiring before you can try to change it.

Get out to the front lines.
Talk to the staff, and get their opinions.

Include staff opinions in the design, goals, initiatives of the project.
Capture the stories: Data is key for building a framework, but stories have the power to influence.
Be sincere about what you are trying to do: You can manipulate, threaten, or cajole, but no change is more lasting than that which comes from the "core".

Performance Improvement Tip of the Day: Better Brainstorming

2012-01-31T14:47:00.002-05:00

In the performance improvement world, we rely often on "brainstorming" as a proven strategy for generating ideas about how to overcome barriers, gaps in care, and general problem solving. A thought-provoking piece in Fast Company Design about how the brainstorming process works - or doesn't work - made me think about how we can improve our use of this technique.

The article points out the following principles which may help us brainstorm better:

need some individual time, and some group time to generate ideas
group dynamics tend to inhibit some creativity, but the prospect of criticism also improves the quality of ideas
good ideas usually come about as a solution to a readily identified problem
the most productive groups were those with a baseline of familiarity but just enough fresh blood to make things interesting
physical proximity of group members helps to encourage "serendipitous" conversations and discoveries

For performance improvement personnel, here are some thoughts on how to apply these principles:

have the group brainstorm problems first, before identifying solutions
encourage individuals to think independently about solutions before embarking on the "group discussion"
plan ways for the performance improvement team to informally network with each other in order to stimulate the "accidental discovery of ideas", e.g., dinner, bagged lunch, social hour, etc.
ensure that there is a healthy mix of experts and novices in the team

Vigilance in the Face of Fatigue

2011-12-13T08:47:00.001-05:00

The probe into ventilator deaths undertaken by The Boston Globe points to "alarm fatigue" as a key reason for failure of these systems. However, as the stories from the Detroit Free Press about patient safety concerns at nursing homes point out, there are numerous other "fatigue" issues involved with failure of ventilators and other clinical processes, including overwhelmed staff, under-competent staff, under-armed regulators, and an industry under financial strain.

Vigilance is often the byword we use in steeling ourselves to be watchful for patient safety, however, how do you ensure adequacy of vigilance in the face of fatigue - when the demand for it requires intensity, concentration, time, competence - all of which are at a premium even at the best of times. This is a complex problem which will not go away with exposes, fines, shame, root cause analyses, and disciplining of staff. Its a symptom of a system gone considerably awry, and a distressing illustration of the harm that can occur at the "sharp end".

Overwhelming as the task may seem, the solution will entail a careful redesign of care systems such that staff who care for patients on ventilators have the knowledge, training, experience, time, and support to ensure that they can deliver the care required. Relegating this to another case of "alarm fatigue" may be tempting, but it risks the thinking that we could solve it if only we had better alarms or more attentive staff. Staff will only be able combat the collective fatigue if they are placed into roles that they can manage, and provided with adequacy of workload such that patient care does not suffer.

Despite the mostly impressive drive over the recent decade to improve healthcare quality, we have largely failed to highlight and support adequacy of workload as a foundation of patient safety. All frontline nurses and doctors can readily point out that patient safety starts with a manageable workload. However, these repetitive patient safety failures demonstrate that we keep placing staff in "unsafe" working conditions and somehow expecting good outcomes. The accountability belongs to the leadership not to the staff. This complex problem cannot be addressed by the clinicians on the front lines; rather, it should be a call to leaders to design clinical systems more effectively and to put their staff in situations in which they can succeed.

The Regulator's Dilemma: Censure or Close a Nursing Home

2011-12-12T11:20:00.001-05:00

This article points out a difficult dilemma, if you close a facility because its not performing well what do you do for patient access? Healthcare is a difficult business, with some barriers to entry, as well as limited supply of particular resources (including physicians, nurses, hospital beds, and/or nursing facilities). If you shut any of these resources down, you do so with the realization that this is not an entirely "renewable" resource, and also with the realization that the free market may not spring forth to supply an alternative - particularly for the poor, elderly, vulnerable members of society.

The article is part of the "Trust and Neglect" series by the Detroit Free Press which attempts to shed light on the challenges of the nursing home industry in Michigan. The first article in the series talks about the extent of the problem and adds names and stories to make the numbers real.

Many of the cases should disturb all of us:

Staff tied a residents hands hands together with a garbage bag
Respiratory therapist forgot to connect a patient to a ventilator; and also forgot to check his vitals
Nurse fell asleep on the job allowing a patient to wander out of the facility

The reasons behind these mistakes are theoretically remediable:

Nursing homes try to cover up errors
Staff are overwhelmed
Homes don't follow their own procedures
Staff are not competent for the roles they are assigned

Some healthcare systems related issues that appear to be contributing:

Bureaucratic rules that burden homes and their staff with too much paperwork
Differences among inspectors about interpretation and application of rules
Regulatory systems dependence on "fines, surveys, and lists" to censure chronically underperforming homes

The common thread here appears to be lack of staffing, which results from low operating margins, which are only going to come under increasing pressure as the industry has recently gone through an 11% cut in reimbursement. Where will the solution to protect patient safety come from when the staff are already overwhelmed and the industry is going to face increased financial pressures?

We need more aggressive redesign of care processes, simplification of protocols, reduction of bureaucracy and paperwork. Perhaps this can lower costs of operations, and increase the amount of time that staff can spend on patient care.

Different business models have to emerge that are able to provide adequate, safe, quality care. Perhaps the "accountable care organization" model now being promulgated for Medicare patients - which rewards practitioners and facilities for reducing cost and improving quality - can provide a new financial model for facilities to improve their care processes.

A new regulatory framework also has to emerge to solve the "dilemma" posed by this report. In addition to fines, inspections, surveys, and lists, more aggressive action should be taken to ensure that staffing is appropriate to provide adequacy of care; or perhaps repeat offenders should be "mandated" to implement a structured, supervised "performance improvement system".

Should Individual Performance Reviews Be Made Public?

2011-12-06T09:39:00.000-05:00

This opinion piece posted on the USC Annenberg School for Communication & Journalism site made me think about a similar debate being carried out in healthcare

I think its become more "accepted" that physician and hospital ratings will be posted publicly, but what the content of those should be is still a matter of fierce debate. How much transparency is appropriate?

I think asking the question from the perspective of the average citizen makes it more poignant - "would you want your work performance to be publicly posted?" Advocates of privacy decry any advertent or inadvertent posting of personal data, however, what could be more personal than job performance?

Perhaps the issue here is that these are government employees? But most physicians are not government employees - should only the profiles of the ones hired by the VA be posted publicly? And then, as the article states, why shouldn't we have publicly posted profiles of highway engineers, postal workers, politicians?

Is the issue that medical (and education) professionals require more oversight and transparency? Its hard to argue that posting profiles for other professionals - politicians, bankers, lawyers, etc. - would not lead to greater accountability in those fields as well. The true power of the market could really be exerted then as the public could "vote with their feet" and support those professionals whose work was positively reviewed.

In this age of technology, social media, and consumerism, the demand for public reporting in general seems to only be increasing. And its hard to argue that it overall hasn't had a beneficial effect for the consumer along the lines of: more information = consumer empowerment = better decision-making = better outcomes. However rating an organization such as a restaurant or hotel, or rating a commodity such as a car, book, or technology, are fundamentally different functions than rating an individual - even if he be a professional. The public posting of the same has a level of invasiveness that would make many of us likely to recoil.

I'm generally a staunch advocate for public reporting of data, but public reporting of ratings for individuals seems to be crossing some ethical and intellectual lines. What is the rationale that makes it appropriate?

How Will We Reach The Tipping Point in Changing Hospital Culture?

2011-12-05T12:04:00.002-05:00

A friend and fellow healthcare leader sent me a email indicating his frustration with the "group-think" culture of leadership:

"Executive meetings of large corporations have people who have shared values and assumptions, who play a positive and necessary role in holding that group together. But when a team of senior managers suffer from collective denial and self-deception – when they can’t unearth and question their shared assumptions - they can’t innovate or make course corrections effectively. That often leads to business and ethical disasters ..."

He questioned what we could apply from Malcolm Gladwell's Tipping Point theory about how to change social culture. This theory holds that culture is "epidemic" and is sustained through "transmission" from one agent to another. Also like epidemics, it can go along at a steady state until a "tipping point" is reached which destabilizes the equilibrium. This can occur both for what we may consider "positive" or "negative" social behavior.

It occurs to me that the tipping point is a great paradigm for understanding the microcosm of an individual institution's culture. The "culture of an institution" is the collective representation of its staff, managers, leaders, as well as its clients and customers. If the institution is overrun by "nay-sayers", "defenders of the status quo", "managers by repression", the culture will be mirrored as the same. However, culture can change if a few individuals start emulating the behavior that they believe the institution needs to aspire to, ensuring that they are the positive "role models" for the change that they are espousing, and start building towards the "tipping point" by assimilating other like-minded individuals, and infecting as many others as they can.

The concept of the "critical number" to get to a tipping point can help these change agents to target a critical mass that they have to build their "culture change movement" to in order to get the culture of their institution to tip. I'm not aware of data to support what this number needs to be for "institutional culture change", and certainly there are many factors that would influence such a "number", including size of the organization, roles of people involved, depth of culture change required, etc. However, based on my experience with leading culture change at small to medium-sized healthcare organizations, 25 appears "intuitively"to be the number to target. If one can get 25 leaders, managers, staff, and physicians involved in the movement, the culture is quite likely to "tip" in favor of the change agents.

Another concept fundamental to Gladwell's tipping point is the "non-linear" nature of social phenomena: "There is no steady decline: a little change has a huge effect." There may be no output related to change activities for a prolonged period of time and/or effort, and then a little change could produce a dramatic result.

The concept of "non-linear social phenomena" is not very dissimilar from what Jim Collins referred to in "Good to Great" when he discussed "the flywheel effect". In organizations that he studied that went from being average to significantly outperforming their counterparts, there was a collective effort of "shoulders to the flywheel". There was no magic moment that suddenly led the average companies to take off, and all turns of the flywheel did not produce the same output; but consistent, cumulative efforts at turning the flywheel at some point led to dramatic results.

Perhaps further research will elucidate what the "critical number" may be at which organizational culture change "tips", however, healthcare leaders would be wise to recognize the "epidemic" nature of change, the concept of "critical mass", how "non-linear social phenomena" work, and bring all of these to bear in revolutionizing their organizations.

Should Patients Get Direct Access to Their Laboratory Test Results?

2011-11-30T09:28:00.001-05:00

I blogged recently about "breakdown in communication of test results" and subsequently saw this piece in JAMA referencing some of the same issues and discussing whether "patients should get direct access to their laboratory test results".

The authors do a great job discussing the pros and cons of this potential solution to "communication breakdown" from both patient and physician point-of-view. In the context of performance improvement, patient direct access could certainly help to reduce some communication issues. However, it may not improve outcomes if patients are not clear about how to interpret the results. It could set up a further discontinuity within the system if there is confusion about "who is responsible for following up on the results?"

If part of a well-designed system, this initiative could help simplify the process by reducing steps in the communication chain and provide redundancy to reinforce patient safety. However, if implemented without careful thought to many of the questions posed by the authors, it could increase the complexity of the communication dynamic and lead to breakdowns of a different sort.

Dangerous Assumptions & Lack of Systems: Breakdown in Communication of Test Results

2011-11-28T12:19:00.000-05:00

This article in the Washington Post points out a disturbing, yet unfortunately widespread, cause of medical errors: breakdown in communication of test results.

The Joint Commission addresses the issue as one of its National Patient Safety Goals for hospitals. However, systems at many hospitals and physician offices are not "airtight" enough to assure the reliable transmission of information and the delivery of safe care.

The "root cause" for this error generally comes down to one of a few common factors:

Staff too busy with their "day-to-day" routine.

If the result reporting process is not well-integrated into their clinical workflow, there is a high likelihood of system failure.

No clear process identified for handling of critical lab results.

This is probably the "over-arching" root cause for the issue at hand. If the process for communication is not robust, not well disseminated, and not monitored, it will inevitably lead to errors.

Miscommunication about who in the hospital/ office is handling the communication.

Results may get reported to a non-clinical staff member (such as a Unit Clerk or Office Manager) who is not the right individual to interpret the significance of the findings.

Physician was not reachable despite numerous attempts.

Sorry to say that this is probably one of the most common reasons for failure to relay critical test information, particularly in a busy hospital setting.
Lab techs, nurses, and other staff try to follow an "established process", but the process is doomed to repetitive failure because one of the key steps is not reliable.

Results get communicated, but subsequent "changes to reports" are lost.

Unfortunately, this happens often for tests that have to be "incubated" (such as microbiology reports) or "reviewed" (such as radiology reports).

Test results that cross clinical settings (such as hospital to provider office) are prone to getting lost.

Every provider and every hospital may have a different mechanism and process for communicating critical test results. This increases the complexity of the process exponentially, and makes it more prone to break down.
When there is not "one standardized process for communication" across the local healthcare system, how do we expect individual physicians, staff, and even organizations to ensure reliability?

The system described by Dr. Eric Poon at Brigham and Womens Hospital is a constructive approach to this problem:

However, this system is mostly reliant on an electronic interface, which may not be applicable to all providers in a diversity of clinical settings. In addition to using electronic systems wisely, healthcare providers should remember the key principles of performance improvement for systematically reducing the likelihood of error in this vital clinical process:

Undertake a root cause analysis for any specific errors at the respective institution
Undertake a FMEA (failure modes effect analysis) to formally assess the likelihood of systems breakdown for key processes
Ensure that a specific process is laid out and communicated widely to all staff and physicians
Build in redundancies to ensure that an "adequate safety net" is in place to catch errors before they affect a patient
Monitor data both on outcomes (errors reaching the patient) as well as critical steps in the process (such as success in test result handoffs)
Report data widely to staff, physicians, leadership
Provide feedback to staff and physicians on individual errors
Incorporate education about process into staff orientation and ongoing training forums

LED Displays in Hospitals Improve Compliance through Feedback

2011-11-28T10:22:00.002-05:00

I recently blogged about "The Power of the Feedback Loop" and then came upon this article from The New York Times about an interesting application of this concept that I thought I should share.

ICUs in North Shore University Hospital in Manhasset, NY are using LED displays to provide instant reminders and feedback to staff:

The initiative is based on a system developed by a private company called Arrowsight. It employs video-surveillance of staff as they enter and exit patient rooms. Random snippets of video are monitored by employees in India who rate each event as pass or fail. Nurse managers receive close-to-realtime information about hand hygiene rates, and the LED displays provide positive reinforcement when the hand hygiene rate for the shift meets the target.

The results:

Hand hygiene compliance has improved from 6.5% to over 80%.
Rates of hospital-acquired infection are reported to have dropped.
The culture of the institution with respect to hand hygiene appears to be changing.

The concept of analyzing video tape for compliance with clinical processes and converting that into data and feedback is highly intriguing, although privacy advocates will be duly concerned about the monitoring implications. The cost of the technology may also prove to be limiting to widespread dissemination. However, I love the innovativeness of the solution, its incorporation into the clinical workflow, and its harnessing of the power of the feedback loop in changing behavior.

Performance Improvement Tip of the Day: The Power of the Feedback Loop

2011-11-22T09:29:00.000-05:00

This article from WIRED magazine about the power of feedback loops nicely helps illustrate how this simple biological mechanism works to improve personal performance, and can be harnessed to improve the performance of teams and systems.

Dr. Joseph Kvedar, Director for the Center for Connected Health at Partners, talks about the feedback loop in this wonderful YouTube video. He talks about using the key feedback elements below to help patients change their behavior. However, the same feedback loop and elements can also be used in motivating behavior change for practitioners. When implemented wisely and within the construct of a well designed management system, this loop is a powerful contributor to improvement.

(1) Active Reflection: This occurs through the appropriate use of data, presented in a meaningful way, at the right time in order to make the intended recipient/ audience actively "sit up and take notice".

This is the concept behind the TrendWatch presented earlier.
Critical information is displayed on one page - an important concept that ensures adequate visualization of the overall initiative.
This allows individuals and a team to understand how their performance is linked to outcomes and where their collective performance sits in the context of initiatives undertaken to improve performance.

(2) Sentinel Effect: The idea that someone may be watching you can change your actions.

Monitoring data regularly, providing feedback, and generating reports all create the signal to individuals and teams that their behavior is being monitored.
In my experience, this is sufficient to drive most individuals to change "undesirable" behaviors.

(3) Social Norm Bias:

This is the mechanism that drive the power of the SMART Profile system presented earlier.
Producing a Profile and sharing it regularly with team members provides the impetus for team members to gravitate their behaviors towards the "social norm" or "team average" or "benchmark".
When combined with the monitoring of data, provision of feedback, and generating of reports, profiling helps to keep desired behaviors in place.

(4) Ability to Take Action: The individual must be able to take action to change the behavior that the feedback is intended for. Many improvement efforts fail because the feedback loop that they generate is on "irrelevant" items, or behaviors that any particular individual is unable to change, i.e., they may need to be changed at the group/ team/ systems level.

(5) Consequence: Consequence is ultimately what makes all of the above strategies successful when implemented within a "system". In most cases, consequence is a theoretical possibility and no consequential action is actually undertaken. However, the possibility must exist of consequence, which in the context of healthcare performance improvement may include the following:

Coaching
Supervision
One-to-one meeting
Letter on file
Censure
Peer review
Suspension

Can Standardization Cut Costs & Improve Quality?

2011-11-21T13:28:00.001-05:00

A couple of articles in today's USA Today identify a growing - and seemingly controversial - trend at US hospitals: standardizing approaches to clinical care delivery in order to reduce costs.

Medical cost-cutting also can improve care

Hospitals try to find savings, cut unnecessary care

There is nothing really new here to drive the controversy as numerous healthcare organizations around the country are implementing Lean, Toyota Production System, or other methodologies in order to reduce waste. Some of that waste comes in the form of avoidable costs - which it would be good to remove from the system.

The controversy lies in the insinuation that this cost reduction comes at the expense of patient care or improvements in quality. In reality, numerous organizations have demonstrated that standardization of clinical processes leads to both improvement in quality as well as reduction of costs.

Doctors worry because they feel that their decision-making authority will be taken away from them in the process of "standardization"; but if you study the improvement efforts closely you realize that the common thread is that doctors and frontline staff are integrally involved in the standardization efforts, without whom the efforts would surely fail. Once the team has determined, with a lot of careful input and thought process, that "one particular approach" makes sense for their organization in order to improve quality AND reduce waste, individual physicians and staff would certainly be encouraged to implement that approach.

As clinicians will readily point out, the "one size fits all" approach doesn't work in medicine. That's when professional judgement is truly needed - knowing when to deviate from the standard approach, and personalizing the protocol or treatment to the individual patient and the particular scenario. However, the fact that we need to deviate from a standard should not be an argument against the development of standards, merely the recognition of the limits of standardization.

The real message of the critics of standardization should be that organizations pursuing standardization need to be vigilant in also building in appropriate mechanisms for deviation from the standard.

Leadership & Business Model Failing to Support Patient Safety & Quality

2011-11-21T10:03:00.000-05:00

In this post by Paul Levy, former CEO of BIDMC, and staunch patient safety advocate, points out the failings of healthcare leadership in creating a culture of safety.

Juxtapose his call-to-arms with this Letter to the Editor written by the Illinois Hospital Association stating that "hospitals .. firmly believe in providing the highest level of safe, quality care to every patient" (which comes on the heels of a fairly damning report recently in the Chicago Tribune about lack of investigation about patient safety concerns at Illinois hospitals).

I can't think of any healthcare entity or practitioner who would not stand behind a statement similar to that issued by the IHA - after all its what we all believe healthcare should be about (and it is the politically correct statement to make). Healthcare institutions and leaders are not deceiving us when they say they believe in quality and safety, and that they are working towards improving these outcomes. Yet the industry is still collectively failing to meet the needs of patient safety and quality. How then do we explain the gap between "what we all believe" and "why we are failing"? I would point first to a few logical disconnects:

belief does not equate to action
belief does not equate to the right action
belief does not equate to primacy of belief
belief may not equate to sufficient action

We can justify our belief in patient safety by committing some resources to the activity, and undertaking a few choice initiatives. However, this does not necessarily lead to the outcomes that ultimately everyone is concerned about - demonstrable improvements in quality and safety, and organizations driven by the same. The rate of improvement that these activities can sustain may not even keep pace with the increasing complexity of the healthcare delivery system, which continues to yield unfortunately visible, dramatic signs of failing the patient.

As Paul Levy states, quality and safety have to be " internalized it into .. decision-making and process improvement efforts". However, this approach is also vulnerable to the following challenges:

quality and patient safety are as yet not adequately measured
institutional leadership is generally constrained by the rules of the industry
societal leadership has to change the rules of the game

If the primary objective for hospitals is revenues and volumes, healthcare executives will inevitably subjugate patient safety to these business drivers. Our healthcare institutions need to be rebuilt with the ideas of maximizing patient safety and quality first, and restructuring the business model around quality and safety. Pay-for-performance (P4P) programs, quality measurement, public reporting, value based purchasing are all initiatives that support the "quality and safety movement", however, are not sufficient to transform the industry and its leaders to "think quality first". They are seen by many within the industry at worst as "bureaucracy", "regulatory burden", "added costs", and at best as "nibbling around the edges". Attempts to measure additional dimensions of quality and to increase transparency are generally met with similar immediate reactions. The industry is not generally rushing forward to embrace and evolve into a quality-driven model. This is largely to be expected, as the current business model does not allow for the typical healthcare institution to be "built around quality".

The Accountable Care Organization (ACO) concept is generally a push in the right direction - at least it is an attempt to create more of a platform for quality while reducing the model's demand on volume for profitability. However, the dimensions of quality measurement as yet are significantly limited - is the patient's experience of safety truly measured by patient satisfaction surveys? are physicians' views about quality incorporated into the "core measures"? are nurses' concerns about safety incorporated into "hospital acquired complications"? And even though the ACO model changes the focus from "doing more for every patient" it subtly subverts the business incentive to "do as little as possible (within the limitations of measurable quality) for every patient" and "sign up more patients (through hiring more physicians) to join the ACO".

In order to drive real transformation of the industry - rather than just "payment reform" - a true "quality-driven" business model needs to be developed. As opposed to the "volume" or "frequency" turnstile, we have to develop a "quality and safety" turnstile. Quality and safety should be measured at the level of the individual patient, and drive the payment mechanism only if deemed adequate. Institutional leadership can only rise to the challenge if the rules of the game are changed at the societal level.

No Ego in Performance Improvement

2011-11-15T12:09:00.002-05:00

This recent blog post by David Witt in Blanchard LeaderChat stimulated me to think about the role of ego in performance improvement. There are lots of authors writing about this topic recently - my favorites being Deepak Chopra's "The Soul of Leadership" - which coincidentally talks about the potential of soul-driven vs. ego-driven leadership; and Jim Collins' "Good to Great", which talks about "level 5 leaders having a unique combination of intense will combined with personal humility".

Performance improvement is ultimately all about leadership, so one is compelled to think about the impact that ego-driven leadership can have on improvement efforts. I think the issue is the same as identified by David - ego can drive ambition and results (a la "the activated internal champion"). However, when it comes to creating sustainability, generating buy-in, and managing behavior - all critical aspects of performance improvement - its ultimately the "team-player" that wins out.

The leader (or PI Specialist or Project Leader) who can "channel her ego" into building the following performance improvement components will not only achieve success in short-term goals, but also has a greater likelihood of sustaining the gains.

Culture Aspects

"No blame"
Feedback provided constructively
Accountability provided fairly

Systems Aspects

Multidisciplinary team drives problem-solving
Platforms for awareness
Forums for education
Channels of communication

Let’s All Feel Superior: Individual Failures Require Leadership, Systems, and Culture to Bind

2011-11-15T09:10:00.001-05:00

I read this op-ed piece from David Brooks in the New York Times with great interest. While talking about the Penn State scandal, Brooks identifies several fascinating psychological constructs that we use as individuals to avoid taking the "right action":

Normalcy Bias - "shut down and pretend everything is normal"
Motivated Blindness - "don't see what is not in their interest to see"
Bystander Effect - "the more people are around to witness the crime, the less likely they are to intervene"
Self Deception - "we attend to the facts we like, and suppress the ones we don't"
Blind Spots - "when it comes time to make a decision, our thoughts are dominated by thoughts about how we want to behave; thoughts of how we should behave disappear"

His key point is that we're in denial of "the underside of our own nature", which I would have to believe is likely true. However, as Brooks also points out "in centuries past people built moral systems that acknowledged this weakness .. they helped people make moral judgments and hold people responsible amidst our frailties." I would argue that this is the real weakness. Human nature has not changed, but society has evolved into such a complex organism such that the systems to keep "human nature in check" are not functional.

But this is ultimately what is means to be a leader - whether spiritual, political, or organizational - and to create an organizational culture: help to guide human nature - despite its many failings, blind spots, self deception, and biases - to achieve a purpose and pursue actions that no individual would undertake on his/ her own.

Many of us see these individual failings consistently in our healthcare organizations, which have largely been build around the notion that failure of behavior is an individual failing. Sometimes these individual failings are just as egregious as the examples used by Brooks when staff, managers, and executives "stand by" and allow for actions to be taken that lead to patient harm in the guise of "its just the way things work around here".

However, as many industry leaders have been pointing out - particularly the stalwarts for patient safety - individual behavior may contribute to a failing, but it is not the cause. The system (i.e., culture or society) that allows that behavior to be manifest is the cause. If we want better behavior, decisions, actions or ultimately the outcomes which result from these behaviors, then we have to work with greater diligence to build the leadership, systems, and culture that will allow individual failings to be overcome or at least held in check. The likelihood of harm is just as great, and not at all excused because the victims are sometimes unknown, or because it happens within a building and not on the street.

Hospitals Reduce Bloodstream Infections: Performance Improvement in Action

2011-11-15T07:48:00.000-05:00

This article from The Tennessean provides a nice overview of gains made by hospitals in the state to reduce bloodstream infections related to catheters - a hospital-acquired condition that can be deadly. The secret to their success? They applied principles of performance improvement:

The State Department of Public Health started collecting data across institutions.
US Department of Health and Human Services established a benchmark for all hospitals to aspire to.
Hospitals started following a "safety checklist", including the following elements:

thoroughly wash hands
wear sterile protective garb
avoid putting catheters in the garb
cleanse the infection site
remove catheters as soon as they are no longer needed

Centennial and Methodist University Hospital committed to transparency by posting their numbers on their own websites.
Vanderbilt increased awareness about the initiative by posting signs counting "days since the last infection".
Vanderbilt developed an "antibiotic stewardship program" to closely monitor use of antibiotics which has helped to reduce the incidence of multi-drug resistant pathogens.

It is gratifying to see initiatives like this taking hold as other states have also been reporting positive outcomes with their collaborative efforts. However, there is a lot of improvement work to be done! Federal and state officials should provide a greater impetus to such initiatives - lead more collaborative efforts, aim for higher targets, and try to achieve the gains faster. The hospitals that have not achieved gains at the same rate as others may need more assistance from the state or other agencies in setting up their performance improvement systems.

Performance Improvement Tip of the Day: A "SMART" PI Project Checklist

2011-11-14T09:39:00.000-05:00

In this "list-obsessed" world of ours, its hardly a surprise that one would create a "Checklist for Checklists". In healthcare, the call has gone out from Drs. Peter Pronovost and Atul Gawande to introduce Checklists as "patient safety tools". They are particularly useful when dealing with complex systems, and for reminding personnel of "basic operations" that can't be forgotten. When used properly, Checklists can ensure that necessary aspects of care are delivered, and free up highly trained personnel to think about when to deviate from a Checklist, and focus on higher level decision-making.

As we make our performance improvement teams more results-oriented, the Checklist becomes a useful tool to help keep the projects themselves on track. This helps to remind our project leaders about the steps they need to take in order to ensure that project goals will be met.

The "SMART" PI Project Checklist below - in keeping with our "SMART" theme - helps to provide a relatively simple, easily implementable framework for delivering improvement. In this context, "SMART" reminds us of the following:

When designing Goals, Feedback, and Profiles, keep them "SMART" in order to ensure efficiency and minimize the likelihood of resistance or conflict. See prior blogs on each of these topics for more details.
The "SMART" PI Project ensures that we:

"Specify" ownership of the project.
"Monitor" results in an ongoing fashion, and ensure that others in the organization help us with the monitoring.
"Analyze" the current system in order to properly develop Goals, identify Barriers, and identify the Critical Processes that need to be undertaken in order to deliver results.
"Redesign" the system intelligently building in decision support to ensure reliable outcomes, and enhancing safety mechanisms to catch problems real-time.
"Train" ourselves, our staff, and our leaders to deliver better results using proven "behavioral management" techniques of Feedback and Profiling.

While this list can be individualized for the needs of particular institutions, the elements included are generally those that I find essential in delivering results. As you work through the list, you are introducing greater reliability into the system and establishing an increasingly mature culture of improvement.

"No one wants to be an Outlier" - Spine Surgeons at BIDMC Use Performance Improvement Tactics to Reduce Waste

2011-11-10T16:58:00.000-05:00

This initiative at BIDMC to reduce waste in spine surgery is a great example of a "performance improvement system" (in this case they used Lean) to improve outcomes (in this case clinical utilization). A similar "performance improvement" approach can work in improving quality, mitigating risk, and improving patient safety.

The article identifies the following "performance improvement tactics" that should be integral components of all improvement projects:

Examined how much they used and spent (review and monitor data)
Questioned why each device was being being used (ask why five times)
Studied reasons for wastage (undertake root cause analysis)
Asked surgeons, operating room personnel, industry representatives, and nurses to help them identify waste (seek multi-disciplinary input)
Compiled lists of who had been wasting more instruments than others (create profiles)
Shared lists [of waste generators] with each other (create report cards)
Awareness campaign (educate)
Physician leadership prompted change (get support from leadership)

The key behavioral drivers that project leader, Dr. Kevin McGuire, Chief of Orthopedic Surgery, identified are "physicians are competitive in nature" and "no one wants to be an outlier". Understanding these drivers is key to understanding some of the performance improvement tools and how to deploy them effectively.

Performance Improvement Tip of the Day: Hierarchy of Clinical Decision Support

2011-11-10T06:30:00.000-05:00

As we construct checklists, order sets, and various other tools to help guide clinical activity, there is a hierarchy of decision support that patient safety and quality improvement experts need to be aware of.

HIERARCHY OF CLINICAL DECISION SUPPORT
Level	Description
1	No decision support provided
2	Education provided re. clinical decision, but no decision support at point-of-care
3	Decision support provided at point-of-care, but not integrated into workflow
4	Decision support integrated into clinical workflow, but optional
5	Decision support mandatory to complete, but "opt in" required to activate
6	Decision support is the default option, with "opt out" required to de-activate
7	Decision support automatic, e.g., initiated by protocol, with parameters built in for safety

In general, as you implement higher levels of decision support, the likelihood of the "right" action being undertaken increases as the dependence on the clinician making an "active effort to choose the right action" decreases. However, at the same time, clinical autonomy in decision-making is also reduced, which is often perceived as "administrative" or "heavy-handed" by physicians. As such, it is wise to embark upon the "hierarchical" journey with caution, full support of the medical leadership, and a clear sense of what the "medical culture" and "institutional culture" will be able to support.

Over the course of future blogs, I will provide some examples of these decision support levels in practice.

Improving Surgical Safety: Time-Outs, Use of Checklists, Systems Improvement

2011-11-08T19:33:00.015-05:00

This article in Hospitals and Health Networks provides some interesting insights into successful interventions undertaken by many hospitals to reduce the likelihood of "wrong-sided surgeries" - an event so infrequent, that it is hard to muster an institution's scant resources to address. However, a number of institutions referenced in this article did exactly that.

One of the most helpful lessons from this article are the reasons that The Joint Commission found as the leading "root causes" for this "never event":

Operating Room

Lack of intraoperative site verification when multiple procedures are performed by the same provider
Ineffective handoff communication or briefing process
Primary documentation not used to verify patient, procedure, site and side
Site mark(s) removed during prep or covered by surgical draping
Time-out process occurs before all staff are ready or before prep and drape occur
Time-out performed without full participation
Time-outs do not occur when there are multiple procedures performed by multiple providers in a single operative care

Organizational Culture

Senior leadership is not actively engaged
Inconsistent organizational focus on patient safety
Staff are passive or not empowered to speak up
Policy changes made with inadequate or inconsistent staff education
Marketplace competition and pressure to increase surgical volume leads to shortcuts and variation in practice

The article also identifies the following interventions that seem to have been effective in different settings:

Implementation of the WHO "Surgical Safety Checklist" to ensure critical aspects of the impending surgery are reviewed (Safe Surgery 2015)
Implementation of "Time-Out" to ensure surgical team synchronization (Minnesota)
Improving communication regarding the scheduling of surgeries (AnMed Health Women's and Children's Hospital, SC)
Support from Hospital Association and local hospital leadership (South Carolina Hospital Association)
Insistence upon use of evidence-based standards (Pennsylvania Patient Safety Authority)
"Labor-intensive practices" - including staff support, physician support, meetings, observations, a role for everyone (Lifespan, RI)

These are great examples of "good-old-fashioned" performance improvement - get leadership involved, create a multi-disciplinary team, measure the critical steps in the process, share the data with staff and medical staff, implement the evidence-base, ensure that not implementing the evidence-base is not an option.
There are many other interventions that can also be implemented to help improve surgical safety. Some of these may not directly impact the likelihood of "wrong-sided surgery", but they can have a major impact in the greater endeavor to make surgery safer.

Pre-Operative Checklist: Helps to standardize a number of items that need to be in place before a patient is "cleared for surgery", including:

Cardiology Evaluation (required in high-risk cases to ensure patient's cardiac condition is appropriately treated prior to surgery)
Pulmonary Evaluation (required in high-risk cases to ensure patient's respiratory function is appropriately maximized prior to surgery)
Anesthesia Evaluation (identifies risk for complications of intubation, anesthesia, and surgery)
Administration of Beta-Blockers (specific medications that can reduce risk of cardiac complications)
Pre-Operative Testing, including Labs, EKG (to ensure that there are no latent underlying conditions that need to be treated prior to surgery)
Prophylactic Antibiotics (medications to prevent infection)
VTE Prophylaxis (medications to prevent blood clots)
Plan for Peri-Operative Pain Management (a proactive plan can improve pain control, and post-operative recovery)

Post-Operative Checklist: Helps to standardize a number of items that need to be implemented and monitored post surgery, including:

Monitoring of Blood Loss and Fluid Status (can be signals of underlying complications)
Monitoring of Pain (can be a signal of an underlying complication)
Monitoring of Cardiac Rhythm (can alert to underlying cardiac complications)
Monitoring of Bowel and PO Status (are signals of overall recovery from surgery)
Sepsis Screening Protocol (monitor signs to alert for impending infection)
Prophylactic Antibiotics (medications to prevent infection)
VTE Prophylaxis (medications to prevent blood clots)
Removal of Foley Catheter within 24 to 48 hours (can reduce the likelihood of a urinary infection)

Intra-Operative Pause:

The "Time-Out" is a process by which all team members stop what they are doing prior to surgery so that they can all get "into synch".
The Intra-Operative Pause similarly provides a break during prolonged procedures so that team members have a chance to "re-synch".

Severity of Surgery Assessment:

A formal means to improve communication prior to surgery about the potential for complications.

I'll provide more details about some of these interventions in subsequent blogs.

Pay-for-Performance to Improve Quality at Rhode Island Hospitals

2011-11-08T10:25:00.000-05:00

Reflecting a move underway in many parts of the country - including with the federal government - insurers are now looking to compensate hospitals and providers more on the basis of quality measures/ outcomes rather than simply for the delivery of service. Part of the drive to do this is simple cost containment - it gives the insurers a means to keep the growth of healthcare costs pegged at general inflation. The other main driver is to improve quality - despite developing a world-beating medical-industrial complex in the US, the system has become so complex, the need for coordination of care so intense, that many providers are failing in their ability to deliver high reliability for relatively simple, non-controversial, "evidence-based" clinical care processes. Many of these failures in the undertaking of "process measures" also add up to failures in "outcomes measures" (the ultimate objectives of delivering care) - including readmissions, mortality, and complications.

This article in Providence Business Journal demonstrates how Blue Cross Blue Shield of Rhode Island is working with hospitals to incentivize them for quality. One of the points that this article doesn't make is that the data for how most hospitals are doing is publicly available on a website developed by the federal government: Hospital Compare (www.hospitalcompare.hhs.gov). Its important for consumers to know this as "transparency" and "consumerism" are two of the big movements driving improvements in quality and safety in the US.

While the overall objectives of the BCBS of RI initiative are commendable, the measures that the incentive payments are targeting are mostly process measures. From a quick review on Hospital Compare, many of the state's hospitals are already doing well on these process measures. There do appear to be opportunities to improve the "patient experience of care" measures state-wide, however, whether these measures are a true reflection of quality is being actively debated.

The real need is tackle the more complex outcomes measures, which certainly appear to be an area of opportunity at some of the state's hospitals, particularly for readmissions:

The good news is that groups like Rhode Island Quality Partners and Rhode Island Quality Institute are working on improving systems to improve "transitions of care" which can lead to reductions in readmissions. More work like this needs to be supported so that the healthcare system can meet the needs of the public in a high reliability, high quality, and high patient safety manner.

Complication rates (also reported on Hospital Compare) appear to be a challenge for some hospitals in the state. I'll write more about that in a subsequent blog.

Performance Improvement Tip of the Day: The "SMART Profile"

2011-11-07T09:27:00.000-05:00

As you can gather from previous posts, SMART is a recurring acronym from our "performance improvement perspective".

The SMART Profile is a tool that can help you generate a sense of who the “top performers” are for any performance measure, who the “outliers” or “low performers” are, and how each individual practitioner ranks within his/ her peer group. When prepared with an eye to the SMART elements below, this tool can provide an important impetus to behavior change.

PPII SMART Profile Tool

Physicians in general are data-oriented and competitive. The SMART Profile comparing an individual's performance to others in their professional peer groups provides a helpful reference for the individuals to know where they fall "within the ranks". Those on the "Top Performer Reports" are supported and reinforced to continue their positive behavior, while those on the "Low Performer Reports" are motivated to improve their performance.

Performance improvement staff often worry about the negative ramifications of Profiles and the potential for "angry physicians". However, most individuals do not react negatively - particularly if the profiles follow the SMART paradigm. Those rare individuals who do get upset about the profiles generally become quite compliant once they have blown off steam and understand how these contribute to the overall improvement effort.

It is important for PI Specialists to understand that behavior cannot change unless one provides some "framework" for the same. SMART Profiles are an important means to establishing such a reference.

These Top Performer and Low Performer Report Cards were provided courtesy of Physician Performance Improvement Institute.

Performance Improvement Tip of the Day: Standardization of a PRN Protocol

2011-11-04T08:33:00.000-04:00

A simple example of standardization - a short list of PRN (as needed) medications that were most likely to be ordered for inpatients.

What led to the development of this initiative?

Physicians were frustrated that they were getting calls at all hours of the day - and particularly night - for relatively "simple issues".
Nurses were frustrated that they could not give their patients relief for "minor" and common symptoms - for which many of the medications were over-the-counter, until they heard back from the physicians. The delay in some cases could be hours.
Patients naturally bore the impact of this, not getting timely relief.

It took some work to come up with a set of medications that the medical staff and nursing staff could agree upon to be administered for most patients without a direct medical evaluation. However, once the "PRN protocol" was created, and integrated into the General Admission Order Set, it immediately led to a reduction in what was perceived by all staff to be "unnecessary phone calls".

Patients received care more promptly. The "first-line" treatments for "minor" symptoms could now be initiated by nursing judgement, and rarely led to a request for "second-line" treatments.

Standardization by using a common set of medications also improved safety by reducing the complexity of the system, by increasing clinical familiarity, and by having parameters and precautions "built-in" to the order.

It allowed the communication between nurses and physicians to rise to a "higher level of practice" rather than to consume their valuable time chasing each other about the routine.

Caveat: Even "minor" symptoms can turn out not to be minor, particularly in patients admitted to a hospital. Clinicians are right to be worried about over-standardizing care through the use of protocols, however, a well-developed protocol when balanced with continuing exercise of clinical judgment can streamline the care process dramatically.

Medication Errors Affecting 2000 Patients at Lifespan Hospitals: Need to Improve Care Transitions

2011-11-03T22:35:00.000-04:00

The issue of medication errors affecting 2000 patients at Lifespan Hospitals in RI is understandably catching the media's and public's attention.

Although the apparent explanation offered by the hospitals is "software error", the article in FierceHealthcare quotes RI State Health Director, Dr. Michael Fine: this represents a "risk in the handoff process" and requires a "more robust team approach for care transitions".

It may be a relatively subtle mistake that was made - substitution of time-release medications for shorter acting formulations, however, a robust "care transitions process" that the article alludes to could have provided a safety net to catch mistakes made by a software glitch:

At the time of discharge, it is a common expectation at US hospitals that a formal "medication reconciliation process" be undertaken.
Many, if not all, hospitals struggle with medication reconciliation due to the complexity of the task.
However, the minimum requirement that all institutions should be able to uphold is that the physician discharging the patient review all discharge medications explicitly, and indicate whether each should be continued or not.
The nurse discharging the patient should also review the medications ordered by the discharging physician, providing a "double-check" of the medication reconciliation process.
Prior to discharge, the discharging nurse (or delegate) should review the discharge medication list with the patient in order to ensure that the patient understands which medications to take and the indication for each.

While many patients may not be in a position to question a subtle substitution of formulations, the aware patient and/or representative family member can often be a "triple-check" in the medication reconciliation process.

Subsequent to discharge, the patient's primary care physician and visiting nurse (if involved) should review the discharge medication list to ensure clarity regarding each medication prescribed.

These clinicians may be at a disadvantage at determining which medications may not be appropriate since they were not involved in the inpatient care, however, their astute judgment can be a "fourth check" to protecting patient safety.

The corollary discharge documents - usually a discharge summary, medication list, and "referral form" - should be completed in a timely manner by the inpatient clinicians and communicated reliably from the hospital to the outpatient care providers. These documents can provide an essential link in the communication chain to ensure safe patient care.

For an error not to be caught by any of these "safety mechanisms" does imply that there are more serious issues than a software glitch, and Dr. Fine is right to identify that the "care transitions" process needs to be carefully reviewed and may need to be redesigned.

Performance Improvement Tip of the Day: Embed the Desired Practice into the Clinical Workflow

2011-11-03T21:09:00.000-04:00

This document illustrates a very simple improvement principle - in order to ensure that the desired practice is undertaken, embed it within the clinical workflow.

In this example, ordering of DVT prophylaxis was embedded into the tool that clinicians used to admit all patients - the General Admission Order Set. Multiple prior iterations of a separate "DVT order sheet" were tried but failed, because it was "yet another document that clinicians had to remember to grab".

Once the desired practice was built into this order set, the resultant ordering of DVT prophylaxis improved considerably. The issue in this case was not that the clinicians were unaware of the need for DVT prophylaxis nor that they were resistant to the same, but simply that the appropriate reminder (AKA checklist) was not presented to them at the time when they were most likely to write this order. A simple reminder, including the most common orders for DVT prophylaxis, provided at the most clinically opportune time gave the clinicians the precise "decision support" they needed to ensure safe practice.

The DVT Prophylaxis section is highlighted here:

We also included "decision support" on the reverse-side of the paper-based orders so that staff had an immediate reference handy to support their decision-making:

Could Performance Improvement Systems Reduce Communication Errors, Malpractice Payments?

2011-11-02T23:28:00.000-04:00

From this recent article in FierceHealthcare, failures to communicate have resulted in 40% increases in malpractice premiums from 1996 to 2003.

Some of the common reasons cited for communication breakdown: "Physicians and patients might not receive results, report findings may be delayed, and there may by lengthy turnaround time. Together, these three communication failures across all specialties totaled $91 million in payouts in 2010, compared to $21.7 million in 1991."

Automation is touted as one of the potential solutions to this issue, which it certainly is. Automation can take out the human element from the workflow equation, which generally improves the reliability of a process (as long as the workflow is otherwise designed properly). However, automation has its limitations as well:

The wrong fax numbers may be entered in the system, thereby sending documents either to wrong parties, or to a document neverland. This can create more quality and risk issues.
Changes to the system can lead to breakdowns in other parts of the system, requiring constant vigilance.
Not all parties use the same technologies thereby making the connectivity more problematic.
Automation can convey the false-sense of reliable transmission, but it is generally unidirectional, and as such, may not be able to ensure that the recipient has actually received the document (no matter if the fax machine confirms that it was sent) nor that the matter is handled with the same urgency as the sender intended.
In the "clinical emergency arena", nothing beats the direct phone call, provider to provider, to ensure that the communication and intended actions do not fall through the cracks.

Beyond issues with automation, however, the biggest opportunities to improve communication lie in developing and implementing reliable systems for communication:

Are there clear protocols for which tests and what test results are considered critical, thus, requiring "critical communication"?

Is this list as appropriately narrow as it can be, and are the cutoffs for the test results truly clinically meaningful?
Having a comprehensive list can dramatically increase the number of times "critical communication" is expected to take place, and increases the likelihood of "communication fatigue" or "overload".

Is there a clear process for "critical communication"?
Is there a reliable system for training and re-training all staff in the "critical communication" process?
Is the process for "critical communication" as streamlined as it should be?

Are there staff involved in the process that don't need to be?

Are the key steps in the critical communication process being monitored and measured?

How often do the steps breakdown in the critical communication process, and when they do, what action is taken to address the systems or staff issues related to the breakdown?

Unless an organization develops a performance improvement framework for critical communication - implementing systems, defining protocols, redesigning processes and workflow, and monitoring data - it is unlikely that any technology or automation will resolve the communication breakdown.

Tackling Delirium in Hospitalized Patients with a Structured Approach

2011-11-02T16:21:00.000-04:00

This is a great article in the New York Times by Susan Seliger about the hazards of delirium in hospitalized patients. Delirium in this setting is not uncommon, but is poorly understood and addressed by clinicians and organizations. Unfortunately it is fraught with perils for patients.

Fortunately, there are protocols and systems that can be implemented to reduce the likelihood of delirium.

Dr. Sharon Inouye, who is referenced in this article, helped to pioneer the HELP (Hospitalized Elder Life Program) that seeks to reduce delirium by increasing social interactions with hospitalized elders. The goal of this program is to return patients to home close to the functional capacity that they came in to the hospital with. One of the hospitals that I have worked with implemented this program very successfully.

Other strategies to improve delirium include reduction of the medications that can lead to delirium, improving ambulation, and attention to hearing, visual, and eating impairments.

Alcohol withdrawal - unfortunately also quite frequent in elders - is a fairly common cause of delirium in the hospitalized patient, and can be tended to with careful history-taking, as well as protocols for close monitoring.

Undiagnosed or untreated pain is often a common cause of delirium, which somehow continues to evade clinicians. Sometimes clinicians get stuck between the "rock and hard place" of treating the pain with narcotic medications which can then in turn also lead to delirium.

Ultimately, this "hospital acquired condition" can also be mitigated by taking a systematic, performance improvement oriented approach to identifying patients at risk, implementing strategies to reduce the risk, and monitoring outcomes closely to ensure that the intended interventions are indeed in place.

Performance Improvement Tip of the Day: "Outcomes Driven" Meeting Agenda

2011-11-02T13:22:00.000-04:00

The meeting agenda is probably one of the most commonly used tools in project management. However, how this tool is used can make a big difference in the effectiveness of meetings, as well as the coordination of the overall performance improvement project.

The "Outcomes Driven Meeting Agenda" template below integrates performance-enhancing features into the staid meeting agenda in order to create a powerful project management tool:

"Roles" of team members - Leader, Facilitator, Scribe, and Time Keeper - are assigned at the outset in order to keep the agenda flowing.
"Time" is allotted for each agenda item in order to guide the discussion, and to keep the team from getting "stuck" on a particular item.
"Discussion Type" is a unique element that allows the team to know what the nature of the discussion will be, so that the discussion is more directed.

Info = Share Information
Proc = Process Information
Con = Need Consensus
Dec = Make Decision

"Desired Discussion Outcomes" is my favorite feature in this tool. It allows the project leaders to envision and lead the team to the desired outcome for each agenda topic.

Adapted from Mike Hauser and Brian Stancampiano, Quality Solutions Group, Sanofi Aventis.

Respectful Management of Serious Adverse Events + Daily Safety Check-in

2011-11-02T09:00:00.000-04:00

Combine the thinking of:

the paradigm proposed by Jim Conway, Frank Federico, Kevin Stewart, and Mark Campbell of the Institute for Healthcare Improvement about a framework for respectful management of serious adverse events in this article from HealthLeaders Media

with:

the concepts proposed in this article from Patient Safety and Quality Healthcare by Carole Stockmeier and Craig Clapper about instituting a "daily safety check-in"

and you start to get the makings of a powerful real-time and retrospective risk mitigation and patient safety system, which incorporates the following elements:

Proactive, immediate, and retrospective responsiveness
Heightened awareness of risk
Early resolution of problems
Accountability
Leadership presence at the frontline
Involvement of the frontline staff in safety
Furthering the culture of safety
Team-based approach to improving safety
Development of a structured plan for dealing with safety issues
Structured risk assessment and mitigation

Thanks to the vision and insights shared by the authors above and for their leading the charge to develop a patient safety system we can all be more proud of.

Performance Improvement Tip of the Day: Providing "SMART Feedback"

2011-11-01T10:04:00.000-04:00

One of the most essential aspects of behavior modification is feedback - its critical to auto-regulation in all systems: biologic, social, and behavioral. If a practitioner does not find out that an action is undesirable, then she cannot correct it.

Most organizations are not familiar or comfortable with providing feedback. They find that it takes too much time, or the culture of the organization is not "ready for feedback", or they are not sure of how to go about setting up a feedback system, or they are worried about how the recipients will react. The purpose of feedback is not to chastise or blame, but to re-orient, teach, guide, and engage.

Feedback isn't about occasional meetings with the department head, or annual performance reviews. Those are too far removed from individual actions to be meaningful. Feedback is about providing critique about a specific action, in a time-sensitive manner so that the memory is still relatively fresh in the recipient's mind, and can be acted upon soon enough to change outcomes.

PPII has designed a SMART Feedback Tool to help performance improvement specialists structure their feedback in order to gain the greatest engagement and responsiveness from their practitioners:

PPII SMART Feedback Tool

Other "COOL" elements to add to the SMART Feedback structure:

C - Consistent - to establish a "culture of feedback" and fairness.
O - Ongoing - to ensure that the performance of a behavior is reinforced and hardwired.
O - Opportunity - for the recipient to provide further input into the issue or request clarification.
L - Learning-oriented - the best feedback provides a framework and opportunity for learning.

This SMART Feedback Tool was provided courtesy of

Physician Performance Improvement Institute.

USA Today: Medicare Inspector General - "More tracking of serious errors needed"

2011-11-01T09:00:00.000-04:00

Have to applaud this report since reporting and tracking are often the first steps towards improvement:

In an excerpt from the article - "That means that those hospitals ... don't learn from their mistakes, Inspector General Daniel Levinson writes .. No one tracks the effectiveness of policy changes or how the hospitals actually correct mistakes."

These statements get at the real crux of the matter - serious adverse events are happening everyday throughout the nation's hospitals. However, are we learning and responding appropriately to the same in order to reduce the risk of injury for subsequent patients?

In addition to reporting and tracking of the errors, we need robust risk mitigation and performance improvement systems to ensure that patient safety is being improved:

Root cause analysis of these events to get to the incipient causes of the errors.
Corrective action plans that hospitals are held accountable to in order to ensure that the root causes are mitigated.
Failure modes and effects analyses (FMEAs) to ensure that we understand all the myriad ways systems can fail.
Systems redesign to ensure that the culture, workflow, clinical actions, and behavior that led to the error are truly modified.
Auditing and Monitoring of systems and outcomes to ensure that the intended changes have gone into effect.
Real-time assessments of adverse events in order to mitigate immediate risk to the patient in front of us - in addition to retrospective analyses or prospective improvements.

As outlined above, many actions can be taken to improve patient safety. Unfortunately, as hospitals continue to be impacted by the recession - reductions in volumes, cut-backs in budgets, and cuts in reimbursement, patient safety staffing and patient safety systems are not as robust as they need to be. We can mandate more monitoring, reporting, and tracking of errors, but unless we work with hospitals to develop the infrastructure required to build patient safety systems, patients will continue to be harmed by the very systems intended to help them.

Story about the "Story Board"

2011-11-01T07:31:00.000-04:00

One of last week's Performance Improvement Tips of the Day was about the use of Story Boards to improve communication related to performance improvement projects:

In this regard, I received a wonderful story from a PI project leader related to the Story Board.

Who says performance improvement can't be exciting?

How to Address Cleanliness Violations at Hospital? New Building or Performance Improvement

2011-10-31T12:45:00.000-04:00

The LA Times posted this article about UCLA Harbor Medical Center's safety violations stemming from "lack of cleanliness".

The plan for correction: "Los Angeles County is spending nearly $323 million to construct a 190,000-square-foot building at the hospital that will replace both the surgical facilities and the emergency room. "

As some of the comments to the story point out, its not all about the facility - its also about management and leadership. I've worked with organizations that have faced even older infrastructure, and yet we have improved their cleanliness with good old fashioned management and systems:

Leadership recognized the difficult situation but resolved to address it.
Management threw its shoulder "to the flywheel" and made it turn.

A voluntary team of "cleanliness inspectors" toured the hospital on a regular basis and documented cleanliness of high risk areas - in a manner that could be measured, easily disseminated, and compared.

Performance improvement systems were installed to ensure improvement:

Pulled together a "performance improvement team" to oversee the issue.
Measured the results.
Made the measurement consistent and reliable.
Disseminated the findings.
Developed policies for cleanliness that could be adhered to by all.
Ensured accountability by reporting on the team's findings to the governing body through the appropriate oversight committees.
Made the "clicks of the fly wheel visible to all" by showing that some departments (that were just as resource-starved as the others) were able to make improvements.

Perhaps a new building is necessary at UCLA Harbor for many reasons, but in order to reform healthcare, we as a society have to start recognizing that adding costs (staffing, equipment, and buildings) to solve a problem are not sustainable interventions. Improving leadership, management, and systems are.

ADDENDUM 11/1/11: This story published subsequently in the Daily Breeze provides further details about a corrective action plan being put into place at UCLA Harbor. "Those fixes include a reorganization and restructuring of the hospital's infection prevention and control unit, identifying problems with the physical plant and enhancing efforts to assure staff members are washing their hands and practicing good hygiene." All of these actions appear to be appropriate, however, the key to real and sustained improvement from the "corrective action plan" is to ensure that the actions are monitored regularly, and that comprehensive performance improvement systems are implemented.

C-Section Rate Variability at MA Hospitals: A Tale of Culture & Performance Improvement Systems

2011-10-31T11:05:00.000-04:00

This story in the Boston Globe Magazine is ostensibly about c-sections:

However, the underlying factors leading to high rates at some MA hospitals are all related to culture and/or implementation of performance improvement systems:

(1) Hospital Culture

(2) Physician Culture

(3) Monitoring of Outcomes

(4) Sharing of Outcomes

(5) Use of Report Cards

(6) Design of Systems to Facilitate Outcomes

Performance Improvement Tip of the Day: Lesson about Motivation from Jim Collins, Author of "Good to Great"

2011-10-31T09:28:00.000-04:00

Performance Improvement is ultimately about changing outcomes - which is about either changing behavior or stimulating people to change systems - both of which can be daunting tasks in an organization already burdened with its numerous day-to-day challenges.

Jim Collins - best selling author of Good to Great - delivers a powerful lesson that can help to drive motivation for change in this short video about "letting the people see and feel the clicks on the flywheel".

These are the small victories on the path to the bigger goal. Try to capture them, measure them, and make them visible; they will in turn generate more buy-in, enthusiasm, and support from your staff.

Improving Hospital Safety at Night: Nocturnists & Systems of Care

2011-10-31T07:50:00.000-04:00

A thoughtful blog by Dr. William Mills, currently the senior vice president of quality and professional affairs for the Upper Allegheny Health System.

Thought I would post my comments here to get others' opinions on the same:

Apurv Gupta | Oct 31, 2011 | Reply

I couldn’t agree with you more Dr. Mills. Many hospitals hire physicians just to have “night-time” coverage, but they are not integrated at all with the day-time team. Often times, the night-time role is just to respond to emergencies, and not to provide care.

In addition to being part of the professional team, I think hospitals and hospitalist programs should be working to improve systems of care at night:
- what are the communication standards between nocturnists and nurses?
- which patients need to be seen and how quickly?
- how will information be handed off between daytime and nighttime staff?
- are the night-time staff well oriented to the hospital – EMR, order sets, pharmacy, nursing supervisors?
- are there regular meetings between the nighttime staff (physicians and nurses) and “daytime” leadership in order to continue problem-solving any issues that arise?

The mere physical presence of a physician will not ensure safe delivery of care, however, it is a foundation upon which the system of care can be designed.

Performance Improvement Tip of the Day: Readmissions Assessment Tool

2011-10-28T08:53:00.000-04:00

Systematically assessing high-risk patients who are readmitted to a hospital is one of the proven strategies to reducing readmissions.

The keys to implementing this tool are: discipline and structure.

Staff tend to think that "we already address all of these issues with our patients". However, if it doesn't done with discipline, its not happening reliably, and that will allow for some vulnerable patients to fall through the cracks. This form can provide structure to the readmission assessment process, and increase confidence that any issues that can be acted upon are being identified.

Structure is provided through the actions indicated by the next steps listed next to each element of the assessment. The point here is simple but very important to grasp - assessment without intervention is meaningless. This is not a data collection task, but an opportunity for improvement.

This form is a variant of a checklist integrated with a decision support tool: it reminds the user of specific issues that need to be addressed, and provides clarity as to the decisions that should be made if any items are "checked". Intelligent tool design is critical to getting a tool in use and for driving performance.

This Readmissions Assessment Tool was modified from a version being used by participants in the STAAR (State Action for Avoidable Readmissions) Initiative supported by IHI (Institute for Healthcare Improvement) and The Commonwealth Fund.

Perfomance Improvement Tip of the Day: The "Story Board"

2011-10-27T09:02:00.000-04:00

The "Story Board" represents a simple but effective way to improve communication related to your PI project.

It serves many functions:

Makes everyone aware this is a priority project.
Lays out the rationale for the initiative.
Communicates the latest data and trends.
Can be easily updated.

The Story Board above was contributed by

Physician Performance Improvement Institute.

Performance Improvement Tip of the Day: The "PI Pitch"

2011-10-26T11:00:00.000-04:00

What is it?

A short sound bite that succinctly and memorably reports on a project's success and activities. It “hooks” the listener to want to know more! It also tries to get the listener to "take the next active step" needed to make a project successful.

Why do you need it?

It provides a mechanism to engage physicians and other providers in an initiative, while respecting the limited time that most professionals have available for such interactions. It brings visibility to the project and gives team members credibility.

What makes it great?

Keep it short, make it "easy to get", and make it conversational.

Scripting (Example)

"We’ve been participating in the Diabetes Performance Improvement Project for 7 months. We're excited that lipid profile testing has improved from 42% to 57%. Our team implemented a check off for lipid profile on the General Admission order set to remind physicians to order this test on all diabetes patients if no documentation within last 12 months. What is your practice related to this measure?"

Follow Up (after initial PI Pitch engages):

-- "Do you have any questions or suggestions about this initiative?"
-- "We would love to have your participation or help (if appropriate)."
-- "I'll plan to followup with you again when I have updated results."

This PI Pitch is provided courtesy of

Physician Performance Improvement Institute.

Performance Improvement Tip of the Day: The TrendWatch

2011-10-25T12:15:00.000-04:00

The Trendwatch is a finely crafted performance improvement tool that provides a lot of "punch" in just one page.

(1) Updated Performance - helps to communicate the latest data to your team, physicians, and staff members.

(2) Barriers or Gaps to Performance - helps your team to keep their eyes on the "root causes" of poor performance.

(3) Initiatives Implemented - helps you keep track of what interventions you have tried to improve performance, along with dates of implementation.

(4) Other Prioritized Initiatives - helps you keep track of interventions that you intend to try, lest you forget some great ideas that someone brought up earlier in the process!

Those who have used the tool report that it has been a great aid to their initiatives - it keeps information organized, provides focus, and helps to keep everyone on the same "page".

This TrendWatch tool was provided courtesy of

Physician Performance Improvement Institute (PPII).

Performance Improvement Tip of the Day: SMART Goals

2011-10-24T12:45:00.000-04:00

Setting up a successful initiative starts with creating a SMART goal.

SMART stands for Specific, Measurable, Attainable, Realistic, and Timely.

I start first with Timely to ensure that the initiative you are picking is going to be of interest to others in the organization at the current time.

Timeliness results in interest, which in turn leads to support, which ensures that you will have backing to resolve difficult issues when they arise.

Next identify something Specific about the initiative that you would like to achieve.

Instead of the broad goal of “improve care of heart failure patients” it would bring more clarity to the team to say “improve accurate dissemination of discharge information to 95%”.

For clinical initiatives, it is helpful to pick a metric that has ample evidence in the literature to support its implementation. This helps to generate the buy-in required to make an initiative successful.

Ensure that your specific goal is measurable.

Success is unlikely unless you can measure where you start, where you end, and all waypoints in between.
Even subjective experiences can be measured through the use of surveys.
Auditing can be used as a technique to generate reasonable sample sizes when the entire population of study is too large.

Attainable and Realistic go hand-in-hand.

This is a time for a reality check. The goals need to stretch the limits for the team, but still need to be attainable within the scope of the institution’s resources, within a defined amount of time.

This tool is "simple", but it takes repetitive applications before you can really understand how it helps to drive performance. Practice makes perfect!

I want to thank my friends and colleagues Brian Stancampiano and Michael Hauser from the Quality Solutions Team at Sanofi Aventis for recently reminding me about the power of this tool.

Performance Improvement Tip of the Day: Performance Oriented Project Management

2011-10-21T14:11:00.000-04:00

Start with a "burning platform" - what is a critical performance issue that needs to be solved at your institution? Is your CEO staying up at night worrying about something? Is the Board requesting frequent reports on a particular topic? What information is being publicly posted (e.g., on www.hospitalcompare.hhs.gov) that represents a vulnerability for the organization?

Build your support - executive leadership and leadership. Talk to some of the key stakeholders in the project of your choice to ensure that they will support the endeavor. In most healthcare organizations, there are so many competing priorities, while the resources and staffing to tackle them are very limited, that you have to ensure that your leadership team will support the project, especially when it comes to the tough issues that will need to be dealt with.

Build your PI team - some of these may be the same executive leaders and leaders that you spoke to in the "building support round". However, many of these individuals will be frontline staff - nurses, physicians, pharmacists, therapists. The team should be multidisciplinary in order to ensure that you are getting wide-ranging input into the project. Most clinical performance improvement projects have ramifications that you may not be able to predict, or may not realize. Having a team of people from different disciplines, and at different levels of the organization, allows the right solutions to emerge, and enables effective problem-solving.

Create the project plan - one of the first things to accomplish when you get the PI team together is create a "formal" project charter, including mission, vision, goals, outcomes, meeting frequency. This can be more structured if you like, including defining team roles - team leader, meeting facilitator, note taker, and time keeper. However, I've generally found that the strict definition of these roles is not critical, particularly in an organization that is not operating otherwise with this level of structure.

There are some "outcome oriented project management tools" - such as Meeting Agenda, Action Item Log - which can be vital to success. I'll discuss these tools in future blogs.

How often will you meet? - Meeting frequency is one of the project plan parameters that is very important. Contrary to popular opinion which in general disdains meetings, significant progress cannot be made without effective meetings. Meetings allow for multi-directional sharing of information, resolving of concerns, problem-solving, and synchronization. For projects that are high priority or require sustenance of momentum, consider meeting weekly or bi-weekly. For some projects, we've coordinated daily meetings, which proved to be one of the most instrumental factors in attacking difficult problems:

Patient Flow from ED to Inpatient: Daily huddles led by our CEO, attended by all critical disciplines - particularly frontline staff - helped to identify problems "real-time" with a major change in the way that patients were being admitted to the inpatient units (admission evaluation completed on the inpatient units rather than in the ED). The direct presence of top leadership, transparency of communication, and the speed with which problems were addressed helped the frontline staff accept and adjust to the changes. This project was highly successful, leading to a reduction of time to admission by an average of 90 minutes per patient.

Communication of Discharge Documentation: Our Hospitalist Program Director and the Director of Quality & Safety moved to daily meetings to address ongoing challenges with getting discharge summaries and other documentation to primary care physicians (PCPs) in a timely and reliable manner. The daily meetings led to rapid identification of ongoing issues, and to resolution of the same in a timely manner. Information from these meetings was communicated to some of our PCPs, who reported greater confidence in our discharge communication.

Identify the PI Specialist - Although there are a number of roles, as mentioned above, that come into play in a complex project, there are none more important than the PI Specialist. This individual is the day-to-day project leader; the person who ensures that the project is moving forward, and following up in between meetings to ensure that action items are being completed.

This individual often collects data, disseminates data, provides feedback to providers, and identifies irresolute problems for the PI team to troubleshoot. I'll provide more details about these activities in upcoming blogs.

Use of Checklists Could Help Improve Transplant Safety

2011-10-21T14:00:00.000-04:00

Interesting article in the Boston Globe today about changes being made to the Lahey Clinic Transplant Program after a number of adverse events were noted in patients.

http://www.boston.com/news/science/articles/2011/10/21/lahey_clinic_revamps_transplant_program_after_kidney_failures/?page=1

Obviously hard to know from the outside all of the details of the issues and the actions taken, however, some of the writeup excerpted above alludes to changes that could be addressed by a "checklist" process, such as the simplistic sketch below:

Drs. Peter Pronovost and Atul Gawande have researched and written eloquently about the use of checklists to improve safety in healthcare. Those of us on the administrative and clinical front lines need to heed their recommendations for implementing this relatively simple tool that has the potential to prevent adverse events, improve outcomes, and improve reliability of care.

Performance Improvement Tip of the Day: Improving Performance after a Serious Clinical Adverse Event

2011-10-19T10:34:00.001-04:00

A recently published whitepaper by IHI outlines an excellent proactive approach to responding to serious clinical adverse events: http://fb.me/1h1CfU9vm

A robust improvement plan is critical to the response to a serious clinical adverse event. This is often what the patient, family, and/or staff are looking for in order to rebuild confidence in the care, systems, and institution. The issue brings to mind an example of a serious clinical adverse event that I was involved in assessing:

An elderly female patient was seen in the emergency room after falling and hitting her chest. She was admitted for chest pain, "rule out MI". However, multiple rib fractures were missed on the X-rays. She continued to have pain post discharge, and was subsequently readmitted, at which point the rib fracture diagnosis was made. Her second hospitalization was prolonged - complicated by overmedication with narcotics for pain, renal failure, aspiration pneumonia, traumatic lung injury - leading to her ultimate demise in hospital. Family members were distraught about the original "missed diagnosis" as well as several other care coordination issues ("was she being monitored appropriately?", "how could she develop all of these complications in the hospital?").

The hospital conducted a series of root cause analyses on the case - including all of the practioners involved in the care of the patient: Hospitalist, ED MD, ICU MD, General Surgeon, Anesthesia, Nursing. The root cause was determined to be "lack of awareness and systems to diagnose multiple trauma in elderly patients post fall". This was addressed through communication at staff meetings. The Chiefs of respective departments immediately pulled together a "rib fracture protocol" to help clinicians better diagnose and manage patients with low-impact trauma. Other issues identified by the root cause analyses were also tended to: improving pain management in elderly patients by increasing awareness of hospitalists and coordination with pain service; and ensuring adequate monitoring of acutely ill patients by reinforcing monitoring guidelines.

Ultimately it was the conclusion of the hospital staff that this patient's outcome would likely not have changed due to the underlying traumatic injury. However, the patient's family and all staff would have felt more confident if the right systems were in place to ensure that the right care was delivered at each interaction. The improvement plan above went a long way towards ensuring that future patients would receive the required care. The plan was communicated to the patient's family, along with other findings of the root cause analyses, and responses to their other questions. The depth of inquiry, level of transparency, open communication, and approach to improvement all helped to mitigate the family's concerns.

Performance Improvement Tip of the Day: The Importance of Giving Feedback

2011-10-17T21:31:00.001-04:00

Three recent articles all underscore the importance of the feedback function in improving performance:

Isn't feedback great: http://www.businessleaderslearning.com/archives/2011/07/18/tips/isnt-feedback-great/
How to give negative feedback: http://leaderchat.org/2011/10/17/need-to-deliver-some-negative-feedback-5-things-to-keep-in-mind/
"Taking a break" and "being slightly behind" motivates improvement: http://www.freakonomics.com/2011/10/17/call-it-a-comeback-why-performance-increases-when-were-losing/

Feedback is an important part of the "regulatory loop" without which we do not have a mechanism to self-correct. Successful change agents, managers, and performance improvement specialists all incorporate feedback actively into their repertoire as they recognize that very often behavior of their staff and colleagues needs to be modulated.

Formal feedback systems can include annual performance reviews and report cards, as well as punishment and censure for egregious behavior. However, there are often "minor" behavioral issues that do not rise to requiring this level of intervention. Some examples in the clinical setting:

medical records not signed
use of unapproved ("dangerous") abbreviations
specific performance measures - such as CHF or Pneumonia - not met
minor conflicts between staff members

In these cases, it is incumbent upon a department head or performance improvement specialist to provide feedback to the responsible clinician - usually physician or nurse - about an action that should have been carried out. When provided within a "non-blame" environment, and framed in a non-threatening manner, such feedback can "gently" suggest to the recipient that there are alternative behaviors that he/she should have undertaken.

In my experience working in numerous healthcare settings, most providers receive this feedback in a constructive manner, and are generally happy to have the assistance in identifying the "outlier" behavior.

In some cases, the recipient of feedback will engage in a dialog about why the selected episode is considered an "outlier". In most of these cases, the clinician is generally satisfied with the ensuing discussion - provided that the underlying rationale is made clear, the system for review is fair, and that the practitioner doesn't feel singled out.

In very rare cases, the recipient takes the feedback personally, and can become defensive, or offensive. The reaction can certainly be quite intense, and requires a healthy quotient of emotional intelligence in order to allay. However, even in these cases, I have found that the feedback still has its desired impact - the individual is now aware of the discrepancy in behavior, and is generally more likely to be compliant with desired behavior.

Performance Improvement Tip of the Day: Culture Drives Performance

2011-10-16T23:49:00.000-04:00

The culture of an organization determines behavior, decision-making, and ultimately outcomes. It is "baked into the design" of every (clinical) process. Therefore, in order to improve outcomes, one must understand and shape culture. This requires intricate analysis, leadership support, and a broad enough span of time to accomplish the changes required.

Within the context of most performance improvement projects, we generally think about operating "within the cultural paradigm" of the institution, otherwise many targeted interventions may get rejected by the organization.

However, in order to achieve "breakthrough performance", the organization's culture has to be changed as it is in large part the culture that is constraining outcomes. Thus, performance improvement specialists have to be adept at gauging what "cultural change" they can successfully advocate for and implement within the course of their projects in order to lead the organization to higher-level performance.

"Culture" makes its presence felt in many subtle ways. Even in the "simple" case of implementing order sets, the following are variants of interventions that can be implemented based upon "what the organization's culture is ready to handle":

use of order sets
mandating use of order sets
implementation of "opt out" orders
use of nurse or therapist-driven protocols
pharmacist or nurse "pulling the chain" to stop the process for any unclear orders

This blog from Ron Ashkenas on HBR Blog Network presents a nice, concise analysis of culture, its impact on performance, and a few tips on how to assess culture:

"Any management team can assess its culture by asking these kinds of simple questions across a range of organizational behaviors. For example: To what extent do we reward individual vs. team results? To what extent do we share information broadly or parcel it out narrowly? To what extent do we encourage or discourage risk?"

8 Common Sense Skills - for Recruiters, Managers, and PI Specialists

2011-10-12T23:22:00.000-04:00

8 common sense skills - yet not so common to find ..

http://www.ere.net/2011/10/12/8-skills-recruiters-should-have/#more-21422

This article was written with recruiters in mind, but it applies to all managerial and leadership roles. It also applies quite well to performance improvement specialists, as they need to possess many of the same skills:

(1) Listening - Can't identify gaps/ barriers without being a good listener.

(2) Sales - Need to be able to convince others to participate in the initiative.

(3) Followup - Many performance improvement projects languish because of "action-item neverland".

(4) "Hunter mentality" - Not typically thought to be a "PI skill", but the best PI specialists will be incessantly searching for new ways to drive their projects to higher performance.

(5) Big picture thinking - In order to get the organization's resources and commitment behind the project, the capable PI specialist will be thinking about how the initiative impacts the organization at the "big picture" level; for example, this can improve outcomes, which improves patient satisfaction, which improves word-of-mouth, which increases the customer base.

(6) Consultative in nature - There are many roles on a PI team, but in general the PI specialist plays a facilitation role, rather than enforcement. The idea is to get staff and physicians engaged and involved rather than feeling that they are being dictated to. The PI specialist keeps the project organized and moving forward, but is not trying to insist upon a particular format or intervention.

(7) & (8) Personable, approachable, cultivates relationship - I haven't met a PI specialist who has succeeded if they don't have a core personality that is agreeable to work with. The work of the PI specialist is "teamwork" and these skills are essential to well-functioning teams.

Moneyball in Healthcare

2011-10-12T09:02:00.000-04:00

Its tempting to draw parallels when a new paradigm emerges. Normally, one would not think of many similarities between the glamorous world of baseball and the stodgy, sterile world of healthcare. However, when it comes to the central theme of "Moneyball" - the power of data to outpredict the "instincts" of the experts - there may be many things in common. Medicine has traditionally operated much more in the "artisan" mode than the "scientist" - there is often a strong belief in the experience and instinct of the practitioner, and the practitioner often resents the intrusion of "data" or "evidence-based (cookbook) medicine" into his/her practice.

Unfortunately it has been shown time and again that experience and intuition alone are not sufficient at producing the best outcomes for a specific patient or even for a population. Intuition is often led astray by the "recall effect" - the most recent cases that a practitioner has seen, and particularly negative outcomes, can often be over-emphasized in a practitioner's mind.

Furthermore, the physician's intuition - much like the scouts in Moneyball - may be led astray by subtle biases - the way someone looks, talks, walks, color of skin, religion, etc. It happens much more often than many physicians would like to acknowledge - patients are attributed as "drug seeking" thereby leading to unnecessary struggles between the care providers about their course of treatment, emotive labels of "unfortunate" or "pleasant" are applied in the medical workup that actually have no role or meaning in the care of the patient, but may paradoxically taint the medical encounter.

In this recent posting on KevinMD, Drs. Jerome Groopman and Pamela Hartzband discuss common types of cognitive error that can contribute to undermining of logic, intuition, and experience:

http://t.co/GmntggS4

(1) "Anchoring" - fixation on a particular bit of information, which can then lead us down a particular path, closing down prematurely the possibility of other paths.

Example: A patient was admitted with abdominal pain and elevated WBCs. Abdominal ultrasound revealed some thickening of the gallbladder. The diagnosis was made of "acute cholecystitis" and patient was taken for cholecystectomy. However, the patient also had gram positive cocci in a blood culture; this finding was not congruent with the diagnosis, but was ignored because of the diagnostic path that the clinicians had taken. The patient turned out to have sepsis, resulting in a poor outcome.

(2) "Availability" - similar to "recall" bias, powerful memories tend to hold greater sway in our decision making. Patient deaths tend to have this impact, and although certainly should hold a place in a clinician's memory, they can be detrimental when they exert an undue influence.

Example: A practitioner prescribes long-term anticoagulation for a number of patients after discharge because one of his recent patients died of a pulmonary embolism after hospitalization.

(3) "Attribution" - excessive influence of stereotypes; this is a bias that all of us have to be vigilant for in our day-to-day lives, as such it should be no surprise that it also plays an undue role in medical decision-making.

Example: Countless patients are "labeled" as "chronic pain" or "frequent flyers" - in part because of their socio-economic background - only leading the providers astray from their goal of helping each patient.

(4) "Confirmation" - contradictory data is discarded in order to make a "neat" diagnosis. This error was also present in the example of gram positive bacteremia given above.

(5) "Satisfaction of Search" - stopping the search for an underlying diagnosis because we have found one potential diagnosis. This error was also found in the gram positive bacteremia example above.

Drs. Groopman and Hartzband propose a few remedies to combat these errors, asking clinicians to pose these questions:

(a) What else could it be?

(b) Does anything else fit?

While data is not something that the doctors discuss directly in this post, synthesizing data (for example from clinical trials, evidence-based medicine, systematic reviews, patient registries) into the medical decision-making process should provide a further grounding for sound decision-making.

Performance Improvement Tip of the Day: Fix the Problem, and Not Just the Symptoms

2011-10-11T11:16:00.000-04:00

Novartis CEO, Joseph Jimenez, in an interview by Adam Bryant of the New York Times talks about getting at the "root cause of a problem" rather than attempting to resolve the symptoms. This is an endeavor that needs to be pursued with greater discipline throughout healthcare. ITs tempting to think that we have identified the root cause, but we don't always exert the discipline to drive deep enough to find it. Too often we are satisfied to act - believing that action itself, or rapidity of action, or intensity of action, can suffice. Action may indeed be enough to keep regulators and overseers happy, but true improvement can only come from a deep understanding of the root issue.

One simple tool - ask "why?" five times - often helps us to persist in the diagnosis of the problem before we attempt to treat it. To illustrate:

Why1: Why did the patient with diabetic ketoacidosis die?

His condition was not recognized as severe in a timely manner.

Why2: Why was that?

Critical lab results were not called in to the right physician.

Why3: Why did that happen?

The lab followed its procedure, but there was confusion about which clinician was managing the case.

Why4: Why was there confusion?

There are no clear protocols for shared management of critically ill patients in the emergency room.

Why5: Why are there no protocols?

We haven't realized the significance of this issue before as an organization.

The inquiry can continue deeper, perhaps ultimately getting at issues of culture or leadership within an organization, however, the leaders conducting the analysis need to be clear that they are unearthing a "root cause" which if addressed will significantly reduce the likelihood of the problem recurring.

Fix the Problem, and Not Just the Symptoms

By ADAM BRYANT

Published: October 8, 2011

This interview with Joseph Jimenez, chief executive of Novartis, the pharmaceutical company, was conducted and condensed by Adam Bryant.

Marilynn K. Yee/The New York Times

Joseph Jimenez, C.E.O. of Novartis, the pharmaceutical maker, says he learned in a previous job that you can't solve a problem if you can't get to its roots.

Corner Office

Every Sunday, Adam Bryant talks with top executives about the challenges of leading and managing. In his new book, "The Corner Office" (Times Books), he analyzes the broader lessons that emerge from his interviews with more than 70 leaders. Excerpt »

Q. What are the most important leadership lessons you’ve learned?

A. One occurred when I was a division president of another company. I was sent in to turn the division around after four years of underperformance. It was a declining business. And when I got there, I completely misdiagnosed the problem. I said: “Look. We’re missing our forecast every month. What’s wrong?” I brought in a consulting firm, and we looked at what was wrong. And the answer was that we had a bad sales and operations planning process, where salespeople, marketing people and operations people were supposed to come together and plan out the next 18 months and then forecast off of that. So I said: “O.K. We’re going to fix this. We’re going to have the consulting team come in and help us make that a better, more robust process, with more analytics.”

And it turned out it wasn’t at all about analytics. Because once we did that, and we put that new process in place, we still continued to miss forecasts. So I thought, “Something’s really wrong here.” I brought in a behavioral psychologist, and I said: “Look, either I’m misdiagnosing the problem or something’s fundamentally wrong in this organization. Come and help me figure it out.” She came in with her team and about four weeks later came back and said: “This isn’t about skills or about process. You have a fundamental behavioral issue in the organization. People aren’t telling the truth. So at all levels of the organization, they’ll come together, and they’ll say, ‘Here’s our forecast for the month.’ And they won’t believe it. They know they’re not going to hit it when they’re saying it.” The thing she taught me — and this sounds obvious — is that behavior is a function of consequence. We had to change the behavior in the organization so that people felt safe to bring bad news. And I looked in the mirror, and I realized I was part of the problem. I didn’t want to hear the bad news, either. So I had to change how I behaved, and start to thank people for bringing me bad news.

Q. That doesn’t mean letting them off the hook, though.

A. Right. It’s more a chance to say: “Hey, thank you for bringing me that news. Because you know what? There are nine months left in the year. Now we have time to do something about it. Let’s roll up our sleeves, and let’s figure out how we’re going to make it.” It was a total shift from where we had been previously. So after that experience, I always ask all of my people, and I always think to myself: “Are we really fixing the root cause of this problem, if there’s any problem? Or are we fixing the symptoms?”

Mission: Improvement; a primer to guide healthcare reformers.

2011-10-10T22:49:00.000-04:00

In the upcoming weeks, I'll be blogging a series a posts entitled "Mission: Improvement; a primer to guide healthcare reformers".

Lots of books and articles have been written about project management and continuous quality improvement. Why another one? Simple, there is a need for a practical approach to improvement not a theoretical treatise. This will help you understand what to do in the trenches while fighting the battle for improvement.

Over decades of experience in the field, the author has found that most people know what needs to be done. They have read the books, attended numerous lectures and conferences, and even participated in numerous performance improvement projects. The missing link tends to be inadequate application of that knowledge, perhaps not knowing which tools to use at which time, and how all of the pieces fit together.

Similarly, in the author's humble opinion - having worked at a number of different healthcare organizations, most healthcare providers are not "knowledge poor" when it comes to implementing evidence-based medicine - rather what's missing is the knowledge of how to redesign systems in order to ensure the right outcome; what's missing is often the motivation or incentive to change. Unfortunately, the attribution of a knowledge-deficit as the critical missing element often leads most improvement teams to focus on education efforts. However, education does not lead to significant, sustainable change. Change results from redesigning systems to lead to the desired outcome; by making the default option the desired option. Secondly, change results from the collective efforts of cross functional teams; these teams produce insight about the organization's working and capacity that any one individual is not privy to. Thirdly, change results from behavior modification. Physicians and clinicians know what needs to be done; they may not make the action enough of a priority; behavior modification techniques expertly implemented within the context of a performance improvement system can lead to desired outcomes.

The lessons that I will share with you have led in real world settings to what I call "high performance outcomes":

Utilization Management:

Reduced inpatient length of stay by 25% at two facilities
Reduced emergency room length of stay by 90 minutes for patients waiting to be admitted

Diabetes

Improved patient education from 81% to 100%
Improved hemoglobin A1C evaluation from 14% to 57%
Improved lipid profile evaluation from 10% to 24%

Congestive Heart Failure

Improved communication of discharge instructions from 88% to 98%
Improved “perfect care” (patients meeting all measures) from 80% to 95%
Reduced readmissions from 18% to less than 10%

Surgical Care Improvement Project

Improved foley catheter removal within 48 hours from 46% to 72%
Improved prophylactic antibiotics given within one hour of surgery from 64% to 100%
Improved discontinuation of prophylactic antibiotics within 24 hours from 75% to 88%

Stroke

Improved LDL less than 100 or statin initiated from 50% to 100%

Pneumonia

Improved ordering of blood cultures before antibiotics from 84% to 100%

Ambulatory Care

Improved selection of prophylactic antibiotics from 55% to 92%
Improved initiation of prophylactic antibiotics from 69% to 100%

Watch this blog in the coming weeks for more discussion about the items above and expert tips on how to get the results many of us seek.

Some MA Hospitals May Have to Fund Coverage

2010-05-15T13:02:00.000-04:00

Cost pressures continue to rise in the Commonwealth, as well as indications that there may be some "redistribution of wealth" in the healthcare provider community ..

Hospitals face levy to fund coverage

By Kay Lazar

Globe Staff / May 15, 2010

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Many Massachusetts hospitals would be required to make a one-time contribution to a fund to help small businesses pay for health insurance, under legislation that the state Senate will vote on Tuesday.

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Senate President Therese Murray inserted the measure yesterday into a more sweeping bill she unveiled last month because almost no hospitals answered her call for voluntary contributions — other than Partners HealthCare, which pledged $40 million.

Murray, who formally filed the bill yesterday, hopes to raise $100 million to help small employers, who have faced double-digit health insurance rate increases. She said the money would reduce their premiums by about 2.5 percent.

“This bill will have an immediate and positive impact on small businesses that cannot be ignored,’’ Murray said in a statement. “It is not a permanent fix, but the shared sacrifice from both providers and insurers will bring necessary relief in the short-term as we continue to work on complicated, long-term cost-control measures.’’

The Massachusetts Hospital Association expressed reservations yesterday about the proposal, saying it is “concerned about the impact of the mandatory assessments this legislation levies on hospitals and how those assessments would be implemented.’’

The association said it will “continue to advocate to ensure that there is shared responsibility in addressing the healthcare cost issue that involves all stake holders — hospitals, insurers, employers, consumers, and state programs.’’

Partners HealthCare, whose Boston teaching hospitals have been blamed for helping to drive up medical spending, may end up owing more than the $40 million the health care giant already pledged, because Murray’s bill provides an exemption for small and financially struggling hospitals.

The complex formula requires hospitals that have more than a 2.5 percent profit margin to contribute money based on their patient population, with facilities that mostly treat patients who have private insurance kicking in more than those that typically care for lower-income patients on Medicaid.

Murray’s bill requires hospitals to deal directly with the health insurers, who would then distribute the refunds to small businesses over a two-year period, to be completed by September 2012. The state Division of Insurance would have to issue a public report by Oct. 1 that lists the names and the amounts to be contributed by each hospital.

Murray’s bill also includes a so-called transparency provision, which would require insurance companies to report annually to the state the rates it pays each of the hospitals for their services.

Partners, the parent organization of Massachusetts General and Brigham and Women’s hospitals, has come under scrutiny by the attorney general’s office and other regulators because it is among providers paid far higher rates than their competitors for similar services — payments Partners has been able to negotiate because of its market clout, regulators said. Partners says its higher rates reflect the complexity of the care its hospitals provide.

Kay Lazar can be reached at klazar@globe.com.

Linking Greatness - Structures within Structures

2010-05-15T09:41:00.001-04:00

At a recent discussion about applying "Good to Great" principles at our institution, one our our department leaders talked about a sophisticated structure he had built up over the years to identify and develop talent within his department. He described as a "hierarchical" model, which moved talented individuals from "field staff" to "leaders" to "gold badges". It was clearly well thought through, disciplined, and understood by all members of his department.

The key points that generated from this discussion were:

did this structure enable this department to move down the path of "greatness"? how would he know?
this structure clearly allowed him to identify the good players, however, did it help him to identify the "ones who should not be on the bus"?
and, by the same token, did the structure help him to "move the wrong people off the bus"?

Moreover, it was quite likely that this was the only department in the institution that had set up such a structure raising further questions of:

should this model be emulated by other departments?
what is the impact to the drive for greatness to have different such structures within different departments?

Questions like these allow us as managers to dive deeper into our constructs and understand better how to connect our work with the overall work of an institution and to ensure that our department-specific activities are helping to drive the overall institution to greatness.

Putting "Good to Great" in Practice

2010-05-13T21:22:00.000-04:00

A few of us at Quincy Medical Center have been engaged in a "discussion group" re. Jim Collins' bestseller "Good to Great", a fantastic book laying out some of the elements common to great companies that Collins and his team identified through research. While none of the elements are revolutionary by themselves, the framework developed by Collins is very elegant - it resonates with "management intuition", is easily accessible by all levels of management, and is fairly practical to implement (although not necessarily without rigor).

One of the ideas that our group keeps coming back to in various discussions is that the journey to Greatness begins with the right people. Many of us "know" this, but still get caught up in a race to develop "visions", "goals", "processes", or "business models". Collins' research patiently urges us to first focus on ensuring that the "right people are on the bus", and by the same token, that "the wrong people are off the bus" before we can engage in any meaningful task defining "what" these people should be doing.

Another practical application that we have developed using this framework is that, even though Collins developed his framework based on research on companies, the principles can also be applied to "departments" to help guide managers and directors in their drive for greatness. This makes the material eminently accessible to all levels of an organization.

One more concept that our group is now exploring is developing a model for monitoring the progress towards greatness. We've found that a number of individuals and departments have been persevering towards greatness for some time, but have not been able to adequately measure their progress towards the same. Our team is now developing a "performance improvement" model that can help such individuals in this endeavor.

Motivation 3.0 for Physicians

2010-05-10T22:14:00.000-04:00

Just finished reading "Drive" by Daniel H. Pink and was left pondering the ramifications in healthcare of the Motivation 3.0 operating system that the author proposes is more relevant for success and fulfillment in the 21st century. As opposed to the "carrot vs. stick" theories of behavior modification defined by Motivation 2.0, the "upgraded operating system" is built upon the intrinsic motivators of autonomy, mastery, and purpose.

For physicians, we have created numerous financial rewards and penalties, which essentially take the intrinsic enjoyment out of the work of medicine, and convert it into a system to be gamed. Therefore, we should not be surprised that the system is indeed played, and that the numerous incentives and penalties have in great part contributed to the overall dysfunctionality of the system, not to mention the relative dis-satisfaction that many practitioners now feel in their vocation.

Building a new model upon the Motivation 3.0 framework, healthcare leaders, policymakers, and administrators should attempt to cultivate true internal motivation by creating environments wherein practitioners can find autonomy, seek mastery, and develop a re-connection to the purpose that brought them to medicine in the first place.

Autonomy requires that the physician have some control over their task, time, technique, and team. External pressures from the changing healthcare landscape have impinged upon nearly all of these elements. In order to provide/ return autonomy to physicians, administrators need to observe and faciliate, not censure and command.

Physicians have generally been trained for thousands of hours in order to be "masters" in their practice. However, true "mastery" requires unlocking a deep passion for what they do combined with a desire for steady improvement in their skills. The work of healthcare institutions -efficiency and improvement - is potentially interconnected with the individual's needs for mastery. However, management needs to do a better job of ensuring that the institution's objectives are better interlaced with the professional's and that the need to achieve simplistic outcomes doesn't subvert the practitioners drive for true mastery.

Purpose may be the most ephemeral of these elements, however, this is the one that most likely drew practitioners to undertake a long road of education, training, and practice so that - in addition to making a decent living - they could also serve the common good. Many practitioners are still captivated by that drive, but are unable to connect with this purpose on a day-to-day basis, which may be overshadowed at times by financial and time pressures, difficult patients, and complex cases. Management should endeavor to help make this connection, which can in turn invoke a deeper sense of achievement, and thereby help to drive overall greater performance.

Can Small Practices Lead to Big Changes?

2009-12-11T09:58:00.001-05:00

A daunting challenge ahead for small practitioners .. at the same time may provide some insight into what's keeping the healthcare system operating at the "cottage industry" level .. the key question appears to be "can fundamental quality improvement happen without consolidation of providers into larger scale operations"?

Small Practices Face Big Challenges
Elyas Bakhtiari, for HealthLeaders Media, December 10, 2009

In Atul Gawande's latest piece in The New Yorker, the physician-author compares the current pilot-project approach to reforming healthcare with efforts in the early 1900s to improve agricultural production. Farmers at the time were struggling with analogous problems—spiraling costs, a lack of "comparative effectiveness research," poor quality rating mechanisms, and industry fragmentation—and only began to see improvements after government-initiated pilot programs spurred innovation.

Gawande, who was named one ofHealthLeaders' 20 People Who Make Healthcare Better this year, offers long-term and clear-eyed hope amidst a lot of short-term nay saying and pessimism about the future of healthcare.

But his analogy may not be very reassuring to one segment of physicians. A consequence of agricultural progress that Gawande briefly glosses over is the near extinction of the small family farmer. If healthcare follows a similar path, does the solo or small physician practice face the same fate?

Before the transformation of agriculture, the industry presented a similar economic challenge as healthcare does today. Forty percent of a family's income went to paying for food and almost half the American workforce worked in agriculture, many on small farms. Scientific and technological advancements, as well as evidence-based efficiencies, cut spending to 24% of income and 20% of the workforce by 1930, Gawande explains. Today it only accounts for 8% of income and 2% of the labor force.

Consolidation of farms and the rise of big agribusiness played a major role in that. Small farmers increasingly had trouble purchasing necessary new equipment and keeping up with productivity gains made by larger operations with more capital to invest. Sound familiar?

It's no secret that, even with the reimbursement bonuses in the HITECH Act, solo and small physician practices face a steeper climb when purchasing and implementing electronic health records than larger groups.

A new study published in the Journal of the American Medical Association highlights yet another small-practice struggle: Nearly 65% of primary-care physicians work in practices that are too small to draw meaningful conclusions about the quality of care they provide based on Medicare data. Even aggregating data over a 3-year period for each physician group failed to produce large enough sample sizes for half of the groups with fewer than six physicians.
Don Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement, offered some suggestions to improve data collection without compromising the size and autonomy of practices, such as pooling data from all payers and surveying patients about their experiences.

But measuring small-practice quality will become a more significant change if one of these payment pilot projects evolves into a full-fledged quality-based reimbursement system.
Given the general direction healthcare is heading and the financial pressures physicians face, it's likely that the proportion of doctors in small practices will continue to drop over the next couple of decades.

There are some options for the little guys, though. An independent practice can have a managed service organization run by a hospital or other entity handle human resources and administrative tasks, or a physician-hospital organization, where money matters are handled jointly. Some physicians may also look at limited or divisional mergers, where a small practice retains its individual identity but joins other practices to form a corporation.

To stay small, many practices will have to find help, and perhaps give up some of their autonomy. But that may be the only way to resist the tide of consolidation.

Health Insurers Compensate Providers Disparately

2009-12-11T04:40:00.003-05:00

While acknowledging that employer payments are not their priority, insurers also continue to pay disparately to providers. While some spread in the compensation may be rational to account for higher cost specialty services, or more payment for coordination of care within larger networks, this method of relatively arbitrary compensation continues to compromise the delivery of care by smaller physician groups and hospitals. Will payment reform in Massachusetts address this matter, or will global capitation fees continue to unfairly favor specific providers over others?

Health insurers mum on practices

State regulators’ get few answers about talks with providers

By Kay Lazar, Boston Globe Staff / December 10, 2009

Executives from some of the state’s leading health insurance companies, facing an unusual public grilling from state regulators yesterday, refused to answer key questions about why some hospitals and doctors are paid up to three times as much as others for the same services. But some of the company officials acknowledged that the affordability of coverage for employers and their workers is not a priority in negotiating contracts with health care providers. Instead, they said, provider payments are based on fierce competition among hospitals and doctors in some areas of the state, as well as employers’ insistence that a particular hospital or physicians’ group be included in their plan. The testimony was part of a monthlong probe by the state Department of Insurance into the reasons for disproportionately high health insurance rates paid by small businesses; but the agency has expanded its investigation to determine what is behind the soaring increases in insurance costs overall, including the large disparities in payments to providers. In at least a half-dozen instances, executives from the state’s second- and third-largest insurers - Harvard Pilgrim Health Care and Tufts Health Plan - declined to answer regulators’ questions. They explained their companies had signed confidentiality agreements with certain hospital or physician groups that prevented them from disclosing the information publicly because doing so would put the insurers at a competitive disadvantage. “You identified a number of answers you are reluctant to provide in a public forum,’’ deputy insurance commissioner Kevin Beagan said toward the end of an hourlong questioning of Marc Spooner, Tufts vice president of provider contracting. “Why?’’ “Some of these terms relate to confidentiality constraints,’’ Spooner said. Executives from the state’s largest insurer, Blue Cross and Blue Shield of Massachusetts, are scheduled to testify when the hearings continue tomorrow. While Tufts and Harvard Pilgrim officials did not name the providers that are getting more generous fees - and declined to identify them when asked later by a reporter - the Globe Spotlight Team reported last year that Partners HealthCare hospitals are often paid more for services than competitors. Some specialty hospitals, or hospitals with little competition in their area, also tend to get higher payments. Most of the questions the insurers declined to answer sought details about the balance of power between the insurers and the providers in their contract negotiations. For instance, the regulators asked whether the contracts allow the insurer to adjust or renegotiate reimbursement rates to a provider if the insurer obtains information about what another insurer is paying that provider. Harvard Pilgrim’s Rick Weisblatt, senior vice president for health services, testified that the insurer generally provides more generous reimbursements to large, well-organized networks of physicians compared with smaller groups for providing the same medical services. “It’s on average 45 percent higher [for a large network] than for a smaller, more loosely organized network,’’ Weisblatt said. “There can be as much as a 300 percent difference between the highest and lowest [paid provider] for the same service.’’ The sparsely attended hearing, in a drab fifth-floor conference room at the agency’s headquarters, featured mostly dense, bureaucratic answers to pointed questions. In one instance, Beagan, the deputy commissioner, pressed Spooner to explain whether Tufts considers the impact on employers when it sits down to negotiate expensive contracts with health care providers. Those contract costs are passed on to employers. “Do you start,’’ Beagan asked, “with what you think employers are willing to pay?’’ Spooner replied that contract talks with providers are “an interactive process’’ that takes into account the competition among providers. Undaunted, Beagan pressed again. “So the amount the employer would pay is not your target?’’ Beagan asked. “No,’’ Spooner said. Small-business owners say they have been clobbered by annual double-digit increases in health insurance costs for the past several years, and that increases for 2010 are the highest they have seen in years. While the state’s major insurers said in September the 2010 rate increases statewide would range from 7 to 12 percent for all employers, many small-business owners say they are getting hit with increases that are three times that amount. “These increases continue to be the worst in recent memory,’’ Retailers Association of Massachusetts president Jon Hurst said yesterday by e-mail. “Everything is in the 20-45 percent range from the feedback we are getting.’’ During a break in yesterday’s hearing, Beagan said they had yet to pinpoint anything from the testimony that would specifically explain the large disparities in insurance prices charged to small employers compared with larger companies. Beagan said testimony and data expected next week from the insurers about the amount of medical care that large and small companies use may shed light on why insurers charge different prices. Toward the end of the hearings, Joseph Murphy, acting insurance commissioner, told the insurers that state law gives his agency the authority to collect the information that the executives had declined to provide in public. He said the agency will be sending them letters demanding the information. He added that insurers’ individual answers would not be made public, but that his agency would release a report summarizing their answers in general.

Making Health Care Better - The Brent James Way

2009-11-08T12:22:00.000-05:00

a fascinating article about improving the quality of healthcare .. the key seems to be getting physicians more involved in reviewing their data and outcomes instead of relying on experience and training alone .. physician engagement needs to be a cornerstone of reform ..

http://www.nytimes.com/2009/11/08/magazine/08Healthcare-t.html?_r=1&scp=1&sq=health%20economics&st=cse

Reform Management to Reform Healthcare

2009-10-15T21:10:00.000-04:00

a compelling article discussing why current healthcare reform proposals are unlikely to yield real results .. not enough real innovation and performance improvement at the front line ..

Target antiquated management methods

By John Kenagy

Posted: October 15, 2009 - 11:00 am EDT

Everyone who has worked in a large, complex organization has run up against unmanageable “elephants in the room”—unresolved issues, major inconsistencies, or big problems that no one in the room can even acknowledge, let alone solve.

In my career, I have been a physician, healthcare executive and adviser, academic scholar, author and, perhaps most importantly, a patient once deeply immersed in healthcare with a critical injury. In each of those roles, I have seen big elephants in many rooms.

As a visiting scholar at Harvard Business School, I studied those few companies that innovated successfully when others failed to adapt, and discovered one of the most consistent indicators of success is the ability to turn unacknowledged elephants into real opportunities.

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For example, Intel saw its profit fall from $198 million in 1984 to $2 million in 1985, but then regained dominance. How? CEO Andy Grove famously identified Intel's elephant and turned it into an opportunity. Grove recognized he had successfully developed, led and grown a great computer memory company whose business model was no longer relevant in the marketplace. Rather than ignore this elephant and stay alive by downsizing and cost cutting, he identified it as an opportunity, marshaled his organization's forces, and adapted Intel's business model to a profitable focus on microprocessors.

Meanwhile, Digital Equipment Co. (DEC), another great technology company, saw its profits fall dramatically at exactly the same time, but failed to eliminate the elephant in the room. A Microsoft executive, who was formerly part of DEC's senior management team, told me this story: “I saw it happen. We formed consensus around the management table on key strategic initiatives over and over again while many around the table were thinking, ‘Here we go again, this is not going to work.' ” No one could acknowledge, or manage, the fact that DEC's previously successful business model was the problem. That's the elephant that killed DEC.

Fortunately, the key to reforming healthcare does not require eliminating a herd of elephants that silently stampede through many healthcare organizations. It requires eliminating only one—but it is a very big elephant.

Elephant No. 1 is the belief that we can transform healthcare with formerly successful, but now antiquated management methods that were originally designed for mid-20th century factories, not 21st century healthcare. “Try harder” is not the solution; it's part of the problem.

For example, let's look at the healthcare reform solutions proffered to Congress in the last few months. They generally follow this pattern: First gather and analyze the data, then assemble experts in meeting rooms to design and implement solutions and technology that “simplify administrative costs, develop new kinds of healthcare insurance, make hospitals and doctors more efficient, reduce hospitalizations, manage chronic illnesses more effectively and improve healthcare information technology.”

Data up to more meetings, then implement more solutions and technology down. Sound familiar? I've been in healthcare for 40 years and, for me, it's as Yogi Berra said: “Deja vu all over again.”

Just like DEC, we are not going to transform healthcare by trying harder with 1978 methods. Trying harder to move more data up to more experts in more meetings, who will then design and implement more solutions and technology down to the frontline, will deliver exactly what it has already delivered—less care at more cost. That's our Elephant No. 1.

Acknowledging Elephant No. 1 reframes the problem and the opportunity. Our dilemma is not a lack of technology, money, or effort by intelligent, hard-working people, and it's certainly not a shortage of meetings. It is a data up/implement down, industrial management model that has been overwhelmed by the complex, dynamic, unpredictable nature of 21st century healthcare. Our current system is not dysfunctional or broken. It delivers all it can.

Looking at business models and methods that successfully manage complex, unpredictable work delivers the solution. My Harvard Business School research and experience in the crucible of healthcare's frontline developed, tested and validated an “adaptive design” business model of innovation that eliminates Elephant No. 1.

The successful path is well-documented. Instead of moving information up to meeting rooms, a few leaders will use adaptive design methods to develop, coordinate and control new critical thinking skills and rapid, state-of-the-art decisionmaking close to the point of care.

The result? People and systems that address problems as they happen and then test, validate and replicate solutions in real time close to the patient. Everyone works every day to increasingly get patients exactly what they need at continually lower cost. Everyone is fixing healthcare.

Using the inspiration of adaptive design methods, skills and tools, a Massachusetts hospital increased surgical volume by 16% while decreasing surgical staff overtime by 14%; a Minnesota hospital nursing unit yielded a total return on investment of $1.7 million and at the same time won the award for most improved patient satisfaction in a 17-hospital system; and a Colorado hospital pharmacy generated $1.9 million straight to the bottom line by making it simpler for patients to get the medications they needed.

New adaptive design ideas—ideas that don't just try harder at old solutions—eliminate Elephant No. 1 and open the door to the true transformation of healthcare.

For example, innovation incubators inside frontline units always rapidly problem solve and simplify the work. That creates the opportunity to partner with technology companies to bring new, simple, testable and improvable enabling technologies into these frontline incubators as experiments. These new partnerships will then test, validate, improve, collect and disseminate the lessons learned to the broader healthcare community.

The broader community is now ready to learn because a few leading organizations have eliminated Elephant No. 1. They are developing people to get patients exactly what they need at continually lower cost in real time, not in meetings. That's the way to fix healthcare.

John Kenagy is a former visiting scholar at Harvard Business School, Cambridge, Mass.

Health Reform Will Make Americans Less Fat

2009-09-19T13:05:00.000-04:00

Here's an excerpt from an article by Michael Pollan in the New York Times. Interesting to note how agribusiness has developed into an economy based on cheap, fast food, which in turn leads to obesity and chronic diseases that contribute to excess healthcare costs. It may be a longshot, but plausible hypothesis that true health reform can motivate insurance companies to try to turn around this trend.

By Michael Pollan, The New York Times. Posted September 14, 2009.

"There’s lots of money to be made selling fast food and then treating the diseases that fast food causes. One of the leading products of the American food industry has become patients for the American health care industry."

http://www.alternet.org/story/142597/michael_pollan:_health_reform_will_create_a_dieting_revolution

Transparency, Disclosures, and YouTube

2009-08-27T21:54:00.000-04:00

does anyone else out there get a feeling that the pendulum on public disclosure and transparency is about to swing too far in the other direction .. is this really about doing the right thing for the patient? or is it merely capitalizing on a market trend towards consumerism and transparency?

WSJ Blogs

Health Blog

WSJ's blog on health and the business of health.

AUGUST 24, 2009, 7:43 PM ET

By Laura Landro

Pitching Patient Safety and Hospital Transparency on YouTube

After a medical error, hospitals’ traditional approach has been to retreat behind a wall of silence, on the advice of risk managers and attorneys. But some hospitals are taking a different approach, fully disclosing medical errors, apologizing and offering financial compensation up front – and inviting patients and families to participate in patient safety improvement efforts. For a look at how one hospital is working with the family of a child harmed by a medical error to improve safety, see my latest WSJ column.

While some experts have warned that the full disclosure approach could lead to more lawsuits and higher payouts the experience of the University of Illinois Medical Center at Chicago suggests otherwise. In 2004, the hospital created a consultation service to help staffers communicate quickly with patients and families about safety incidents; in 2006 that evolved into a policy of full disclosure, apology and a swift offer of financial compensation. Over the four-year period, the number of lawsuits dropped 40% from the prior five years, and there has been no increase in financial payouts, according to chief safety officer Timothy McDonald.

“How we respond to these events defines who we are as individuals, organizations and our professions as a whole,” says McDonald, who is both a pediatric anesthesiologist and a lawyer by training. “Open and honest communication between caregivers and their patients and families starts the process of healing and closure – for both the patient and the caregiver.”

The first step is creating a culture that punishes those who recklessly endanger patients but holds blameless those who are involved in errors linked to flawed systems or products. The 450-bed academic medical center uses a carrot and stick approach, praising staffers who promptly report incidents and penalizing those who fail to do so. Departments that fail to promptly report incidents see a larger share of malpractice premiums assigned to their department budget.

Those changes have led to a doubling of the number of patient safety incident reports to about 2,000 in each of the last two years; about 10% of the incidents caused serious patient harm, leading to 20 full disclosures to patients and families of inappropriate or unreasonable care. Equally important, the program has identified safety gaps that have led to nearly 200 improvements in hospital procedures, according to McDonald, who will report on the program’s findings in an upcoming edition of a patient safety journal.

McDonald and a colleague, cardiac anesthesiologist Dave Mayer, are producing a series of patient safety videos to highlight process improvements following harmful patient events and disclosure. The videos, which will be sold to hospitals for use in patient safety education programs for staffers, also aim to teach patients how they can take a more active role in their care and provide critical input caregivers may miss. The YouTube video embedded in this blog post is trailer for the first video, “The Faces of Medical Error: From Tears to Transparency,” which will debut September 24th at the University of Illinois.

TransparentHealth, that brand name you see in the video, is a for-profit patient safety education company founded by McDonald and Mayer. They say any profits will go to the foundations of the families whose stories will be told in the videos, and to fund the making of the subsequent films. They chose to go for-profit because they were unable to secure funding and saw the need for the videos.

World's Best Health Care?

2009-08-26T20:56:00.000-04:00

the mantle of world's best healthcare gets thrown around a lot .. mostly because there are many characteristics of the US system (physicians and institutions) that really shine .. however, the overall performance as evidenced by outcomes - mortality, longevity, public health - leave much to be desired .. once again a case of the haves versus the have nots .. the haves probably can access the best healthcare in the world; but the have nots - an ever growing group, including the working class, the poor, and the elderly - largely have to deal with an inferior system ..

Opinion

EDITORIAL

World’s Best Health Care

Published: August 25, 2009

Critics of President Obama’s push for health care reform have been whipping up fear that proposed changes will destroy our “world’s best” medical system and make it like supposedly inferior systems elsewhere.

The emptiness of those claims became apparent recently when researchers from the Urban Institute released a report analyzing studies that have compared the clinical effectiveness and quality of care in the United States with the care dispensed in other advanced nations. They found a mixed bag, with the United States doing better in some areas, like cancer care, and worse in others, like preventing deaths from treatable and preventable conditions.

The bottom line was unmistakable. The analysts found no support for the claim routinely made by politicians that American health care is the best in the world and no hard evidence of any particular area in which American health care is truly exceptional.

The American health care system puts patients at greater risk of harm from medical or surgical errors than patients elsewhere and ranks behind the top countries in extending the lives of the elderly. It has a mixed record on preventive care — above average in vaccinating seniors against the flu, below average in vaccinating children — and a mixed record of caring for chronic and acute conditions.

Contrary to what one hears in political discourse, the bulk of the research comparing the United States and Canada found a higher quality of care in our northern neighbor. Canadians, for example, have longer survival times while undergoing renal dialysis and after a kidney transplant. Of 10 studies comparing the care given to a broad range of patients suffering from a diverse group of ailments, five favored Canada, three yielded mixed results, and only two favored the United States.

There is no doubt that American medicine at its best can be awesomely effective. But there is clearly room for improvement. Far from threatening a superb health care system, reform should be seen as a way to improve a system whose bright spots are undercut by its flaws.

How to Mend the Hospital Safety Net

2009-08-10T17:21:00.000-04:00

this article gives support to the fundamentals of management - planning, strategy, team-building, operations improvement - in turning around a failing hospital; if these elements are implemented with diligence, patience, and rigor, much success can be achieved .. more power to all of the turnaround efforts underway at many of the nation's healthcare institutions!

THE WALL STREET JOURNAL: HEALTH

AUGUST 7, 2009, 11:53 A.M. ET

Mending the Hospital Safety Net

by ABRAHAM VERGHESE, M.D.

At a time when many public hospitals around the country are in financial peril, R.E.Thomason Hospital in El Paso, Texas, has pulled off a miracle.

In the 11 years I worked at the hospital, it always operated in the red, a poor relative to the fancy private hospitals up on the hill. Most of our patients were indigent and often were not eligible for Medicare or Medicaid. Many were probably Mexican nationals—we never asked as long as they had a billing address in El Paso. The hospital was supported by a tax district, and perennially hamstrung by a politically appointed board that did the bidding of the city council members who got them the gig. It seemed as if the cronyism, the political infighting and the chronic lack of funds would never change.

Still, as a physician, it was the most satisfying place I ever worked. I was encountering third world diseases in a first world hospital—I saw typhoid fever, amebic liver abscesses, brucellosis, and many acute illnesses in young people—not what most internists see in American hospitals. Mexico was a stone's throw from my office window. It was an incredible place to train medical students. At the end of the day, I had the great satisfaction of knowing that despite all the hardships, I was providing yeoman service to patients who had no other recourse. I left for another medical school position (and another public hospital) in 2002.

On a visit to El Paso last week, I found wonderful changes afoot. The hospital, recently renamed University Medical Center, had so many additions and remodeled areas that I got lost in corridors that had sprouted new limbs and branches. Since the arrival of the new CEO James Valenti in 2004, the hospital's bond rating has risen, and work has begun on a huge new building approved by voters.

In talking to Mr. Valenti, I was struck by how his task resembled that facing public hospitals around the country (not to mention all of American health-care): How do you fix a broken system that is horribly expensive and running out of money?

The answers from Thomason may help rescue some of the struggling public hospitals around the country that train our young physicians and care for our poor and elderly -- iconic hospitals like Jackson Memorial in Miami, and Grady in Atlanta.

This was Mr. Valenti's fifth hospital turn-around project, but his first with a public hospital. He says he did it by applying the "the private-practice business model" to the public hospital: he demanded individual accountability and financial accountability; he developed a clear strategic plan, and recruited people who could execute the plan; he changed the culture from one of inertia, defeat and pessimism, to one of excitement and belief in the future. His recipe was "local, local, local—one person at a time." He gave up to three speeches a day to different community groups, selling them the hospital's mission and strategic plan. He won over the city council, the hospital board, law enforcement and the public with his singular vision of where the hospital needed to be.

When I worked there, we physicians were employed by Texas Tech School of Medicine (and we taught the third and fourth year med students who came from the mother ship in Lubbock). Though this was the sole hospital in which we practiced, we felt disconnected from the administration—we were not on their payroll. Valenti created a physician advisory group that met each Friday. The group looked at each specialty and asked, "What do we need to become leaders in this field in a year?"

The scrutiny extended to the patients. More than once I treated patients whose bodies showed no evidence of the operations and injuries described in their old records — they were borrowing identities to qualify for free care. Now Thomason does credit checks on patients, identifying those who misrepresent their financial situation and can afford to pay.

Valenti renegotiated contracts with insurance companies, with HMOs and with state agencies. The Dean of the medical school, Manuel de la Rosa said to me, "Care was not rationed so much as a rational approach made to giving care." For example, the hospital used to carry ten different types of implantable knee prostheses. Now, the hospital carries just one model, which it buys at a negotiated discount.

Here is the lesson I took away after my visit: Just as much of the funding gap for Medicare could be plugged by cutting out waste and fraud, sick public hospitals—and so many of them are sick-- do not always need infusions of money to be fixed. Instead they need discipline, accountability, and progressive politicians and hospital boards whose actions are made very public and who are held accountable. If a New Yorker article earlier this year portrayed the city of McAllen, Texas as the poster child of excess Medicare expenditure, El Paso's public hospital, which provides some $250 million dollars a year in charity care, might well be the poster child for fiscal prudence and genuine care for its community.

Abraham Verghese is a practicing internist and a professor of medicine at Stanford. His most recent book is Cutting for Stone.

Leadership by Crisis

2009-08-02T22:08:00.000-04:00

Here is an interesting piece from the Health Care Leadership Blog, referencing a Harvard Business Review article by Ronald Heifetz about leadership in times of crisis .. keeping an organization at the "cutting edge" literally seems to require keeping it "on edge" with grim consequences on either side ..

http://www.healthcareleadershipblog.com/2009/07/post-recession-alerts-for-health-care-leaders.html

Embracing Disequilibrium

Heifetz cited Paul Levy's success as the "turnaround leader" at Beth Israel Deaconess (BID) Hospital in Boston as an example of leadership that carefully leveraged uncertainty and instability as a potent lever for engaging an organization to change its culture and sustainably pull itself out of crisis:

"...a successful turnaround was no guarantee of long term success in an environment clouded by uncertainty....Keeping an organization in a productive zone of disequilibrium is a delicate task...if [the heat] is consistently too low, people won't feel the need to ask uncomfortable questions or make difficult decisions. If it's consistently too high, the organization risks a meltdown..."

The authors go on to cite Levy's successful use of potentially unstable devices (publication of error rates) and public cultural confrontation (of unproductive cross professional squabbles) to expose the implications of an unacceptable status quo and drive the changes essential to BID's survival.

Volume Pressures Affect Entire Healthcare Industry

2009-08-02T09:21:00.000-04:00

Below is an excerpt from a recent NYT article talking about the same hospital in McAllen TX featured in Dr Gawande's New Yorker "expose" about why healthcare costs are high in some areas of the country compared to others - namely the profit motive. While the profit motive may certainly be linked to increased volume of procedures, it would be over-simplifying to think of profit as the net motive, as the increase in volume is likely in part to make up for lost compensation from reduced reimbursement and increased expenses.

It is also a distraction to focus the debate on physicians and physician-owned facilities as the profit or net income motive applies to all healthcare entities, be they constituted as for-profit or not-for-profit. All institutions are struggling with how to maintain or increase volume in order to drive or sustain revenues and net income, as the dominant source of revenues for the industry continues to be dependent on the number of encounters. The debate on this topic needs to shift to payment reform for all providers, encouraging meaningful discussion about outcomes, quality, and overall health.

Texas Hospital Flexing Muscle in Health Fight

By KEVIN SACK and DAVID M. HERSZENHORN

Published: July 29, 2009

The gleaming, well-equipped Doctors Hospital at Renaissance, which has expanded to 503 beds from 30 in six years, has become a footnote in the health care debate. It was featured unflatteringly in a June article in The New Yorker about geographic disparities in health care spending, a story that President Obama has cited repeatedly in speeches and meetings.

The article, which is sharply disputed by hospital officials, posited that physician ownership provided “an unholy temptation to overorder” tests and procedures because doctors earn not only their fees but also a share of the hospital’s profits. At Doctors Hospital, where 353 of its 452 owners are physicians, net revenue amounted to $64 million in 2008.

Leading members of Congress have long been concerned about the potential for conflicts of interest, lapses in patient safety and cherry-picking of patients with the best insurance at the country’s 230 physician-owned hospitals. Past efforts to restrict ownership by doctors have stalled, but language to that effect is currently included in health care legislation in Congress, though in ways that are unlikely to hurt Doctors Hospital.

Who Pays for Complex Care Coordination?

2009-08-01T14:06:00.001-04:00

Here's a great fundamental question posed in the WSJ. We certainly have many different criteria for determining who meets "acute level of care", without which qualification, a hospital is unlikely to get reimbursed for the hospitalization. However, how does the healthcare system take care of those individuals like the patient below who will not be able to get the care they need unless they are hospitalized. But if they are hospitalized, is it fair that the hospital carries the uncompensated burden for coordinating the complicated care required?

The issues in this case are not dis-similar from the recently well-publicized case of the Florida hospital that received court permission to deport a non-US resident patient directly to his home in Guatemala. The current reimbursement system provides very little compensation for such cases, and it is unrealistic to expect that the average community hospital with scant resources, many of which are at the brink of failure themselves, can provide this kind of care.

It is unlikely that issues like this will be significantly addressed within the current healthcare reform proposals. However, moving towards a system that provides near-universal coverage would be a step forward.

An ER Doc Grapples With ‘Unnecessary’ Hospital Admissions

Published On: July 31st, 2009

It’s all well and good to talk about reducing unnecessary hospital admissions to help control health costs. But the definition of “unnecessary” gets a lot more complicated when you’re the one doing the admitting, ER doc Jesse Pines writes in a column on WSJ.com. He describes the case of a woman with a probable case of lung cancer who needed a comprehensive evaluation. She was on Medicaid, the government health insurance for the poor, which meant she’d have a hard time finding specialists to treat her as an outpatient. So Pines admitted her to the hospital, even though she wasn’t acutely ill. In the hospital, she got a biopsy, a formal diagnosis of lung cancer and a plan for outpatient treatment. She met with a psychiatrist and a social worker. Pines argues that it was the best outcome, though more expensive than it would have been for her to be treated as an outpatient. “She was not sick enough to need a hospital bed,” he writes. “But I believe admitting her was the right decision.”

Quality of Care at VA Hospitals

2009-07-29T21:57:00.000-04:00

Something interesting to ponder .. Is the quality of care delivered at the VA better than at other hospitals? Is the care delivered through this insurer-care deliverer better than government or private insurers who contract with non-profit hospitals? what is driving the difference in quality - technology? leadership? "a single-payer-type" approach? a "HMO-type" model?

If this government system works (as opposed to Medicare and Medicaid, which are failing), then why not expand upon it to provide increased coverage to the uninsured and also to improve quality?

From Phillip Longman. (January/February 2005) The Best Care Anywhere. Retrieved on July 28, 2009 from http://www.washingtonmonthly.com/features/2005/0501.longman.html

The following is an excerpt from a 2005 article that preceded the book above.

“Yet here's a curious fact that few conservatives or liberals know. Who do you think receives higher-quality health care. Medicare patients who are free to pick their own doctors and specialists? Or aging veterans stuck in those presumably filthy VA hospitals with their antiquated equipment, uncaring administrators, and incompetent staff? An answer came in 2003, when the prestigious New England Journal of Medicine published a study that compared veterans health facilities on 11 measures of quality with fee-for-service Medicare. On all 11 measures, the quality of care in veterans facilities proved to be "significantly better."
Here's another curious fact. The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care.
It gets stranger. Pushed by large employers who are eager to know what they are buying when they purchase health care for their employees, an outfit called the National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA's seal of approval is the gold standard in the health-care industry. And who do you suppose this year's winner is: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VHA system outperforms the highest rated non-VHA hospitals.
Not convinced? Consider what vets themselves think. Sure, it's not hard to find vets who complain about difficulties in establishing eligibility. Many are outraged that the Bush administration has decided to deny previously promised health-care benefits to veterans who don't have service-related illnesses or who can't meet a strict means test. Yet these grievances are about access to the system, not about the quality of care received by those who get in. Veterans groups tenaciously defend the VHA and applaud its turnaround. "The quality of care is outstanding," says Peter Gayton, deputy director for veterans affairs and rehabilitation at the American Legion. In the latest independent survey, 81 percent of VHA hospital patients express satisfaction with the care they receive, compared to 77 percent of Medicare and Medicaid patients.
Outside experts agree that the VHA has become an industry leader in its safety and quality measures. Dr. Donald M. Berwick, president of the Institute for Health Care Improvement and one of the nation's top health-care quality experts, praises the VHA's information technology as "spectacular." The venerable Institute of Medicine notes that the VHA's "integrated health information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation."
If this gives you cognitive dissonance, it should. The story of how and why the VHA became the benchmark for quality medicine in the United States suggests that much of what we think we know about health care and medical economics is just wrong. It's natural to believe that more competition and consumer choice in health care would lead to greater quality and lower costs, because in almost every other realm, it does. That's why the Bush administration--which has been promoting greater use of information technology and other quality improvement in health care--also wants to give individuals new tax-free "health savings accounts" and high-deductible insurance plans. Together, these measures are supposed to encourage patients to do more comparison shopping and haggling with their doctors; therefore, they create more market discipline in the system.
But when it comes to health care, it's a government bureaucracy that's setting the standard for maintaining best practices while reducing costs, and it's the private sector that's lagging in quality. That unexpected reality needs examining if we're to have any hope of understanding what's wrong with America's health-care system and how to fix it. It turns out that precisely because the VHA is a big, government-run system that has nearly a lifetime relationship with its patients, it has incentives for investing in quality and keeping its patients well--incentives that are lacking in for-profit medicine.”

Increased Equity in Compensation for All Specialties

2009-07-29T06:54:00.001-04:00

The excerpt below is from a CBS Evening News Report sent to me by ACPE Digest. The cuts proposed to specialists are certainly dramatic, but given the overall financial condition of Medicare, the extreme shortage of primary care physicians, and the growing concerns that the runaway costs can only be tamed by increasing primary care services (and decreasing procedures done by specialists), some income redistribution is going to be inevitable. Even though the proposed increase to primary care is up to 8%, and the proposed decrease to some specialists is up to 40%, I believe equity in compensation is likely to drive more satisfaction among primary care physicians. For those already practicing in the field to feel that their work is valued. Physician satisfaction will drive patient satisfaction and quality. It's a relatively long term outlook, but once the practice environment for primary care improves, only then will more emerging students and residents seriously consider going into primary care fields in the numbers required to turn the tides. The need for equity is widely prevalent in many of our psychologies, and it must be recognized as well within the healthcare debate.

The Institute of Medicine identified as one of its dimensions of quality that care must be equitable. Granted that this was primarily applied in the context of the patient, however, I think it must also be considered as a key dimension with respect to physicians and the practice environment.

Paying primary-care physicians more may require pay cuts to specialists. The CBS Evening News(7/28, story 10, 3:15, Couric) reported that, in the healthcare reform debate, there is "one thing everyone involved...agrees on," and that is "there's a shortage of doctors. Not specialists, we have plenty of them. What we need more of is primary-care physicians." By 2025 the primary-care "shortage could top 40,000." CBS noted that, "on average, specialists make twice as much as primary physicians." But, as "the system begins to pay primary-care doctors more, the pressure is on to pay specialists less. Medicare just proposed a pay cut of up to 40 percent for specialists like radiologists and cardiologists and pay increases of up to eight percent for family doctors. Specialists predict the cuts will reduce their service in rural areas and still not raise enough money to recruit more family physicians." The network asked, "Does this get us to more primary-care doctors?" According to American College of Cardiology CEO Dr. Jack Lewin, "No, absolutely not. Because there's not enough, the cuts to cardiologists are devastating to them. It's not even close to helping primary care in the way they need to be helped."

Hospital Readmissions Gain Scrutiny

2009-07-26T17:44:00.000-04:00

Hospital readmissions have been in the spotlight as a recent article demonstrated that a high percentage of patients are readmitted post an acute hospitalization. There is speculation that many of the readmissions are potentially preventable thereby leading to improved outcomes and reduced costs.

Coincidentally, The Joint Commission (TJC) Core Measures for Pneumonia, Acute Myocardial Infarction, and Congestive Heart Failure are also linked to reducing readmissions by implementation of the core measures. The Centers for Medicare and Medicaid Services (CMS) recently made public on its hospitalcompare.hhs.gov site information comparing hospitals on readmission rates.

Readmissions for specific diseases are likely to be reduced by improving adhering to evidence based interventions - including medications, counseling, and education. Across disease processes, there are some common interventions that are likely to yield reduced readmissions. These include medication reconciliation, ensuring understanding of discharge medications and instructions, scheduling a followup appointment, improving communication of discharge information to subsequent care providers, and undertaking either telephonic or in-person monitoring for high risk conditions.