Greetings from Taipei! I'm wrapping up a 2-week vacation here in Taiwan, which included several visits to the world's tallest building, Taipei 101.

I won't be posting for the rest of the week as I will be stuck in an airplane for 16 hours and trying to recover from overeating, oversleeping, and the 14-hour time difference.

In the meantime, check out this week's grand rounds over at Matthew Holt's The Healthcare Blog. Instead the usual "weekly best," Matthew has solicited 2005's best - definitely check it out.

Looking forward to see how the healthcare blogosphere will continue to evolve in the new year. Thanks to Andrew Barna and Nick Jacobs for your insightful blog contributions. And thanks to all for reading, emailing, and commenting.

See you in 2006!

Hospitals are probably among the last places that you'd want to spend Christmas. But for some, there isn't much choice, and they make the most of it.

Bonnie Schmidt (right, in the picture) has been a patient since mid-November after getting a 4-inch tumor removed from her brain. Her family brought in a griddle, already-mixed batter, bacon, coffee and the other fixings from home to make pancakes topped with peaches, strawberries, whipped cream, and syrup. Pancake breakfasts are a tradition in her family.

Howard County General Hospital holds so many holiday-themed activities - including a visiting Santa, carolers, a handbell choir, a harpist, toy drop-offs and parties for employees - that it might be one of the merriest places in town. From the Baltimore Sun: "Anita Pandey can't see the Christmas tree in the hallway outside her hospital room - but she likes knowing it is there. Her 2-year-old daughter, Sarika Pandey Kapadia, keeps taking ornaments off the lower branches to bring to her mother, who is pregnant and has been on bed rest since the end of last month."

Chance Kahler, a 6-year-old boy, broke his femur sledding this past week. Worried that Santa wouldn't find him, he rewrote his letter to Santa, explaining that he was in Room 1257 in the hospital. Somehow the letter was returned by the post office, and the hospital staff decided to get everything on Chance's list.

And finally, there's nothing like a good ole fashioned Santa-sized hug (with a monkey in the middle).

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And thanks to all those who worked the Christmas shift.

Massachusetts reported this week that profits were up for 2005. While the rest of the nation continues to experience a rich-get-richer, poor-get-poorer trend, the good news in MA is that hospital profits were up across the board. Top-quartile hospitals profits were up from 3.7% to 5.6%. Bottom-quartile hospitlas were up from 0.3% to 1.0% profitability. Also, check out this cool hospital-by-hospital financial stats page via the Mass Division of Health and Human Services.

Consistent with other reports across the nation, officials cite better revenue management. Nonetheless, Mass hospitals face the same struggles as other hospitals. Though profitability is up, hospitals continue to remain at the mercy of the economy for two reasons: (1) some hospitals stayed in the black simply because of investment returns; (2) with consumer-driven healthcare, patient volume will become more and more dependent on economic conditions. Also, current margins just won't support the next wave of capital upgrades.

My question is this: what is the ideal profit range for a hospital? It's gotta be high enough for capital improvements, but it can't be too high for fear of major public backlash. This is probably more of a theoretical question for most hospitals (i.e. just getting by here! the higher the better!), but for great hospitals, this is a real factor in establishing a solid charity care policy.

Is that a patient in room 2 or is she an undercover mystery shopper? This past year, the California Healthcare Foundation hired 622 people to pose as poor uninsured patients to determine hospitals' progress in disclosing costs and access to financial assistance. The results were not so good: "Only 7.3 percent of the fictitious patients who visited a hospital in person were offered information about financial assistance policies or charity care eligibility."

Mystery shoppers in hospitals are not a new phenomenon. One firm, Mystery-shoppers, cited a 1999 example of a hospital director of surgical services who wanted to know more about how her patients perceived the care they were receiving. For $50-100/individual "patient" visit, the information was invaluable. Devon Hill Associates, offering their "secret patient services," were cited in the New York Times way back in 1997. They were also recently featured in the Pittsburgh Gazette:

"Surveys or other tools that measure patient satisfaction may give hospital administrators an idea of problem areas. But mystery shopping can further pinpoint the cause" - Barbara Gerber, President of Devon Hill Associates

Gerber is cited here in 1998. In one particular case, she charged a hospital roughly $6,000 for her services. According to a Healthleaders article, another firm, Perception Strategies, has done roughly 25,000 "shops" for hospitals and physicians' offices. Prices start at $2,500, and can go up to $100,000 (which can include greater #s of visits, quarterly testing & year-end executive summary). Many of the hospitals did make concrete changes: hiring of bilingual staff at the front desk, writing thank you notes to patients, better sales support, better lighting in hallways, etc.

Mystery shopping as a whole is a growing $600MM industry. It's only a matter of time that hospitals, more conscious of care perceptions, would join the fray.

We can plan and think. We can conduct focus groups. But sometimes, there's nothing like sending out some trained spies to experience our services first-hand. Does your hospital employ mystery shoppers?

By Andrew Barna

This past week I attended The Fourth Annual Summit on Patient Safety & Information Technology hosted by The Center for Business Innovation. While the conference was not well attended, there were some excellent speakers and quite a bit on the burgeoning field of RFID in the healthcare setting. Here are some of my take aways from the meeting.

I learned about an organization, the National Patient Safety Foundation, which I had not come across before. The Foundation’s President, Diane Pinakiewicz, shared a bit about the Foundation and how it works to improve patient safety. One of the Foundation’s central tenants is to include the patient perspective in all aspects of the care, even in the design of the care process. A great resource on the website is a series of video clips from the 7th Annual National Patient Safety Conference held this past May. In the clip from Sue Sheridan, a consumer advocate, Sue gives a poignant description of the type of leadership needed to eliminate medical errors.

One of my favorite speakers was Dr. Bob Wachter of UCSF. He spoke about some of the “over-looked” side effects of the growing role of technology (particularly the EMR and other “error mitigating technologies”) in the healthcare. One of those side-effects (my term, not his) is the changing role of the physician. Whereas in the past physicians essentially operated independently (i.e. made decisions on their own), with EMRs, and all their attendant “bells and whistles,” physicians will be operating within a system. It is a system in which they are not in charge and it may even be a system (drug interaction warnings) that over-rides their decisions. This is not a trivial change. I wouldn’t even call it a culture change – it is more along the lines of an identity change. Thus, as Dr. Wacther suggested, it is wise to implement technology thoughtfully.

Finally, I heard a great quotation, which I believe is attributed to the business scholar Ted Levitt, “People don’t want a quarter-inch drill, they want a quarter-inch hole.” This is a great reminder for us as we consider adopting new technologies. Sometimes it isn’t the tool, it’s the results that matter.

by Nick Jacobs

When my tenure began as a hospital Vice President, it was clear from day one that we were not in the hotel business. The sheets were not 400-thread count. In fact, they were practically see-through. The curtains were, oftentimes spattered with blood or worse, as were the ceilings. There were dust bunnies in every corner. The furniture was scratched, and the chairs were similar to those used in a prison. If you wanted to sleep, you slept on the prison chair.

As it became clear that this was “the biz,” my heart sank. Each day my walks through the hospital, a.k.a., “rounds,” were peppered with discoveries of dirty corners in the halls, abandoned cigarette butts on the stairs that literally stayed there for weeks at a time, filthy walls, entrance mats, and windows.

The food was regularly delivered cold, tasteless, and colorless. The most courteous messages ever delivered were “Sit over there and wait,” and “Don’t worry, honey, someone will be with you.” What wasn't said was the rest of the phrase that was “sometime today..”

The hospitals of the 80’s were not exactly user friendly, and the CEO’s were not exactly interested in the soft side of care. They were interested in reimbursements, unions, recruiting physicians, keeping budgets on target, and many other business challenges. It was and still is a tough career.

My initial thoughts were to apply the concepts learned from the hospitality industry, my previous career, to healthcare. My dream was to bring chefs, hotel managers, and house keeping professionals to the hospital. Of course, this concept was unheard of and rejected for all of the normal and customary reasons. It was the same set of criteria that probably dictated that the walls were to be painted white or that awful shade of institutional green.

We absolutely could never have a hotel manager because hotel managers don't understand the hospital business. True, but it’s absolutely also true that hospitals didn't understand the hospitality industry. In fact, when, as a hospital president, we hired our first hotel manager, it changed our hospital forever. His approach was fresh, exciting, and virtually unparalleled.

Now, house keeping was a problem. Fortunately, the only thing that we had to do was orient our housekeepers to the hotel business, and we did this through training and orientation at Ritz Carlton Hotels. They got it very quickly. The brass began to shine. The floors began to sparkle.

What in the world was it about? It was about transforming a hospital into the best of a hotel and the best of a spa. Our philosophy was not just to create something that people would like. We, in fact, were interested only in creating something that people would absolutely love.

What did that mean? As a patient, it is typical that you must leave you dignity at the door of the hospital. You are entering a world that is foreign to most of us. It is filled with scientists who typically deal in life and death issues. Hence, when they make a mistake that is serious enough it can end a life or damage a human being forever. This phenomenal responsibility dramatically changes lives, personalities, and interactions.

Patients very quickly move into a world of fear, confusion sometimes filled with employee coldness and apathy. The employees many times develop an edginess that is matched only in a federal agency. Some of it is protection from emotional involvement. Some of it is boredom, lack of communication and years and years of pent up anger coming from being managed by great technicians or nurses who many times have no real training in management. This many times represents the Peter Principle at its very best.

So, what are the answers? The answers are all based upon one universal belief, love. Love can be produced through empowerment, through trust, through humanness, through nurturing; through the very best that mankind has to offer.

Just this past month, I noticed two hospitals that announced a new "hospital within their hospital." Virginia Baptist Hospital announced their $4MM, 36-bed hospital within a hospital. Lourdes Medical Center in NJ also announced their 30-bed long-term, acute care hospital.

The common elements between the two:
- Both will have their own separate medical director, CEO, and Board of Directors.
- Both are are relatively small (30-36 beds) being planted into a medium-sized hospital (250-350 beds).
- Both tend to be focused on long-term acute-care services.

My question is this: why didn't they just open up another department? Instead, they went through all the extra work in setting up a separate governance, a separate entity albeit in the same facility. Anyone have any ideas?

Well, I spoke with two folks to get to the bottom of this one:

First, my blogging friend Bob Coffield of The Healthcare Law Blog. Basically, Bob explained that these hospitals are considered LTACHS (Long-term acute care hospitals) - they cover the "no-man's land" of hospital care - patients that are too sick to go home (or a nursing home), but too healthy to be in an ICU. Enter LTACHS, where average length of stay is 25-30 days.

Here's the catch: Medicare requires these to be governed separately, w/ separate board, CMO, CEO, etc. Also, if you set one up within a hospital, 75% of the volume has to come from outside that facility (or else the reimbursement changes big time).

Enter David Adams, VP Senior Services of Virginia Baptist (mentioned above). For them, out of their 26,000 - 27,000 discharges every year, about 1,000 were eligible for LTACH care. So the go/no go was simple. But they faced this decision: (1) build a separate building for the LTACH; (2) set up the hospital w/in the hospital and figure out this reimbursement stuff. In David's case, they chose #2 (#1 required too much capital). Not surprisingly, they chose to put the LTACH into their smaller facility so the other hospitals within the system could meet the 75% quota.

David informed me that there are probably ~400 LTACHs in the country now, about half are hospital within a hospital. Kindred is obviously the big stand-alone player with HealthSouth starting to come in as well.

Is your hospital ready for a hospital within a hospital LTACH? Maybe, if there isn't one in your community already. But if you are in a one-hospital kinda town, then chances are, you'd have to build a separate facility or just shunt out somewhere else.

Starting this week, I will only be posting this News wrap-up every other Friday instead of every Friday. After some reflection and talking to a few readers, I think there are too many "weekly news wrap-ups" out there already. Since I'm still posting 1 entry per weekday, I think there's plenty of good ole hospital impact posts that would be a better use of this space. So, on the "off" Fridays, expect to see a "normal" breath-taking, insightful, mind-bending, awe-inspiring post that you've come to expect here every day at hospital impact. Plus, the hospital impact news scoop will be the only semi-weekly news wrap (or warp, which ever you prefer) in the industry.

12.16.2005

The word of the week is slow
According to a study done by the Center for Health System Change, physicians have been slow to respond to pay-for-performance. Only 2 of the 12 representative healthcare communities they visited had P4P in place.

According to a study released in JAMA, Hospitals have been slow in addressing patient safety issues. Straight from the article: "Development and implementation of patient safety systems is at best modest" and "Data are consistent with recent reports that patient safety system progress is slow and is a cause for great concern. Efforts for improvement must be accelerated."

Just so no one feels left out, according to the UnitedHealth Foundation, our nation has been slow in realizing gains in healthcare. What are they doing in Minnesota? 10 times since 1990, MN has been the healthiest state of them all. And more disturbingly, why is there such a disparity in health from state to state?

Slowing hospitals down or increasing quality (or both)?
Given the negative news on CPOE from last week, some have asked: if medical devices and pharmaceuticals are regulated, why aren't CPOE systems regulated as well?

You are finally ready for the JCAHOites, you are getting ready for HCAHPS, but are you ready for ISO 9001 accreditation? This company wants to accredit hospitals for quality control/customer satisfaction using the well-known international ISO 9001 standards.

Finally, are some hospitals going a little too fast (or is this savvy cost savings)? - using one-time-use devices over and over again.

Continuing our series on hospital strategy, I read a very timely article in November 2005's edition of HFM on getting serious about hospital strategy. I may be a little biased, but I highly recommend HFM articles because they are the perfect combination of strategy & tactics. This article is no different. It goes through how to properly do a SWOT, how to close the gap on our perception of the environment vs. reality, and how to judge the quality of an organization's strategy.

I particularly like how this article talks through strategic trade-offs. No hospital can be all things to all people. Inevitably, the hospital has to say no in at least one of three dimensions:
(1) service variety - How much service (and how much variety of service) you offer
(2) customer need - How deep each service goes to meet customer needs
(3) customer access - how easily accessible your services are

Check out this quote that elaborates this point using Idea and Jiffy Lube as examples:

"Two well-known industrial organizations are illustrative. Ikea, a company that sells unassembled furniture, focuses on many customer needs, but offers limited access and has a limited range of products. Jiffy Lube, by contrast, has made its trade-offs by focusing on broad access to some very limited services, meeting very few customer needs."

Unfortunately, most hospitals haven't thought through trade-offs in these terms. Our hospitals end up either in the middle (and completely undifferentiated) or trying to be everything for everyone (and not doing a good job at any of it). Yes, there are many restrictions and regulations in healthcare, especially for critical access and rural hospitals. And granted, there's not as much "room" to differentiate as in other industries. That may very well be true, but look at the Mayo Clinic, the Rehab Institute of Chicago, and Shouldice Hospital (exclusively a hernia surgery hospital). They have chosen to differentiate themselves by being the best at #2, not care much about #1, and not care at all about #3. They are so successful precisely because of focusing on being the best in just one aspect. These are extreme examples, but maybe there is more room to play than we originally thought?

The other way the article talks about trade-offs is to decide whether to be the "low-price" good-enough provider or the "premium-price" niche player. More and more, we are finding that healthcare is big enough for some hospitals to offer Toyota Corolla-type products while others offer the Hummer H2-type products.

by Andrew Barna

One of my favorite internet resources for what is happening in the world of business is strategy+business (hereafter s+b). Given our recent focus on hospital strategy, I thought it would be appropriate to share s+b’s recently released “10 most enduring ideas” of the past decade.

1. Execution
2. The Learning Organization
3. Corporate Values
4. Customer Relationship Management
5. Disruptive Technology
6. Leadership Development
7. Organizational DNA
8. Strategy-Based Transformation
9. Complexity Theory
10. Lean Thinking

I find this list to be truly interesting. In my short tenure in healthcare, I have seen each of these ideas applied somewhere in the industry. Corporate values (tax-exempt status, billing issues) and customer relationship management (HCAPS and CDHP) are leading topics right now. Leadership development has been a big issue in Catholic healthcare. I even have books on how to apply complexity theory and six sigma (related to lean thinking) to healthcare. And disruptive technology is happening all over healthcare (e.g. – drug eluding stents, virtual colonoscopies).

I have to say I am pleased to see execution at the top of the list. I was speaking recently with the COO of a very successful hospital in San Francisco and he emphasized how important execution was to the well-being of his organization. In his tenure with the hospital, he has had to discipline a manager on only one occasion for missing budget. This discipline of execution, according to the COO, is the base on which the organization can do the “fun stuff” of quality improvement and patient satisfaction.

Any of the ideas on the list can provide the fodder for organizational insight or strategy, just make sure that at the end of the brainstorming and visioning retreats, you remember to execute. That is where good strategy so often fails.

by Nick Jacobs

What should the ideal health care environment be? A health care environment dedicated to the creation of a healing philosophy that leads to reduced mortality rates that are not only achievable, but also a necessity.

Each year thousands of people are almost harmed, seriously harmed or even killed due to normal human mistakes that occur in our nation’s hospitals. Sometimes these mistakes are related to medication errors, physician or nursing misjudgments or fatigue. Sometimes they are caused by a combination of all of these elements.

The majority of the time, however, these situations can be avoided by watchful observance of patient care, by education, and by active participation in their treatment by a selected team of care partners.

In my decade and a half in healthcare senior management, hundreds of these mistakes have crossed my desk for my input and acknowledgement, and each time I pen my name to the forms describing these mishaps, it brings home the reality of those near misses or nonfatal interventions.

Efforts directed toward patient centered care ironically allow you to survive the world's most incredible, most effective, most advanced healthcare system.

The key, however, is that these people are just that, people, human beings, and as human beings, as they do their work each day, mistakes happen. Unlike a widget factory, six sigma perfection is somewhat more challenging when the human body and human biology are involved both as a caregiver and a patient.

The laws of probability and statistics will demonstrate time after time that one in 1000 carpal tunnel surgeries will go poorly, that one in 100,000 people will be totally paralyzed for a short amount of time by certain types of anesthesia, that one percent of the time during a heart catherization the catheter may puncture and sometimes penetrate the right descending coronary artery causing damage that will later lead to another blockage or that may even require an instant trip to the open heart surgery suite.

One of my favorite lines from one of our top surgeons was, “Major surgery is anything that happens to me!” Well, hospitalization is major when it happens to you. We live in a society that spends more on healthcare than any other in the world. We live in a society with the finest and fastest care available to anyone in the world, but it’s not perfect. We need to work everyday to PERFECT our world any way that we can. There aren't enough flight simulators in the world to protect our patients. Education, training, and positive reinforcement will help.

Last spring it was my turn in the barrel. The procedure was quick and simple, but one nurse didn't follow directions from one physician, and my blood pressure dropped to 60/30. Perfection is the only way this works. DON'T CUT EDUCATION in your facility. This is a matter of life and death.

As a continuation from my previous post about what hospital CEOs are like, last week, Deloitte released its 10th annual hospital CEO Survey Results. Here are the highlights:

Biggest Concern: The uninsured (is this a surprise? what about P4P and CDHP - or are these issues still too early to say?)

Current Focus: More focused on revenue enhancement rather than cost control (don't worry, in a few years, it'll swing back to a focus on cost)

60-70% said: (1) their institutions are profitable (66%); (2) that their boards are worried (66%); (3) they can only invest in quality measurement/improvement if it pays for itself financially; (4) Medicare accounts for more than 40% of their revenues (66%)

80-90% think: (1) Clinical/quality outcome data should be publicly available (86%), (2) Education/Training & standardization is in the "top 5" among activities with the greatest potential to reduce medical errors (85%)

Here's an interesting one: 73% reported that their ERs are unprofitable, but only 1% is willing to close their ER

Click here some 15-20 quotes from hospital CEOs surveyed. My personal favorite:

"The future is very fuzzy! We need to concentrate on our financial viability while maintaining patient satisfaction! - CEO of rural hospital in Georgia

Anyway, I would recommend downloading their 52-slide powerpoint presentation - this is a rare and fairly comprehensive inside look "into the mind of the hospital CEO."

FYI - if you want to see how things have changed (and how things have stayed the same, too), check out their 2002 report as well. To give a taste of how things have changed:

What % of CEOs singled out financial viability as an important issue for their Board members?
2000 8%
2002 65%
2005 66%
$ got important quick and has stayed top of mind ever since...

12.09.2005

EHR Emergency?
A Study in the journal Pediatrics showed that after the implementation of a CPOE system, mortality rates for children transported into specialized care almost doubled. Also, the ER at Navapache Regional Medical Center reported that they abandoned their EHR system and cited dissatisfaction with the system.

Before we sound the siren and abandon EHR altogether, let's slow down. These two early data points give us some insights into the two big (and very well-known) challenges in implementing any system: (1) potential short-term drop in quality; and (2) lack of buy-in from physicians. Especially read the comments section in this abandoned EHR article - someone from the hospital actually disputes the reporters story. The "failed implementation" was caused by "a few difficult doctors," not necessarily the system itself. We don't just need IT experts, we need change management experts.

Not surprisingly, Cerner came out with some good news & good results for its CPOE system from The Nemours/Alfred I. duPont Hospital for Children.

Blue Cross Blue Shield Bank?
Following up on the BCBS Visa Card I posted on 2 weeks ago, this week BCBS announced the formation of its own bank that will handle health savings accounts and other financial tools.

And while we are on the topic of Consumer-driven healthcare...

"During Your Hospital Stay...?"
As I posted yesterday, the HCAHPS questionairre is out. Ready or not, slowly but surely, the world will begin to know how patients felt about your hospital's service. Coincidentally (or not), Press Ganey just released the results of a massive study: Hospitals that provide excellent customer service also achieve excellence in clinical quality.

And speaking of patient satisfaction...

Lower Satisfaction with Consumer-Driven plans Or at least, that's what the 1,000+ respondent survey results showed, according to the Commonwealth Fund. Not surprisingly, the survey also uncovered a common criticism of CDHP - a doubling of missed or delayed healthcare.

Weird Police Station/Hospital Linkages
We've all heard of racial profiling, but what about patient profiling (or more accurately "efficiency profiling")? It's kinda unfair to put these into the same light, or is it?
we've all heard of undercover cops, but what about undercover patients (who are really consultants)?

Or, more precisely, is your hospital ready for your patients to answer these 22 questions about your hospital and for the world to know the results? (the last 5 out of the 27 are patient demographic questions, leaving 22). As I mentioned in last week's Weekly News Scoop, the HCAHPS Survey is out (Thanks to Laurie for providing the link). You can read the 50-page report on how they came up with the questions, how to measure, when to measure, their research recommendations, etc in this PDF.

But, at last, here are the 27 questions that we will all become much more familiar with very quickly:

1. During this hospital stay, how often did nurses treat you with courtesy and respect?
2. During this hospital stay, how often did nurses listen carefully to you?
3. During this hospital stay, how often did nurses explain things in a way you could understand?
4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?
5. During this hospital stay, how often did doctors treat you with courtesy and respect?
6. During this hospital stay, how often did doctors listen carefully to you?
7. During this hospital stay, how often did doctors explain things in a way you could understand?
8. During this hospital stay, how often were your room and bathroom kept clean?
9. During this hospital stay, how often was the area around your room quiet at night?
10. During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan? (if no, go to 12)
11. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?
12. During this hospital stay, did you need medicine for pain? (if no, go to 15)
13. During this hospital stay, how often was your pain well controlled?
14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
15. During this hospital stay, were you given any medicine that you ahd not taken before? (if no, go to 18)
16. Before giving you any new medicine, how often did hospital staff tell you waht the medicine was for?
17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?
18. After you left the hospital, did you go directly to your home, to someone else's home, or to another health facility? (if other health facility, go to 21)
19. During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?
20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
21. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital?
22. Would you recommend this hospital to your friends and family?
23. In general, how would you rate your overall health?
24. What is the highest grade or level of shool that you have completed?
25. Are you of Spanish, Hispanic, or Latino origin or descent?
26. What is your race? Please choose one or more.
27. What language do you mainly speak at home?

so, what do you think? Is this scary or what?

A post by Andrew Barna

After reading Tony’s first post on strategy, I was struck that he was asking some really fundamental questions about hospital strategy. What is a good hospital strategy? How can a hospital differentiate itself? Who has good strategies? Do healthcare executives know how to create and execute upon strategies? I think these are some great questions to explore further. For me, the first step in this process is thinking about strategies in and of themselves.

In the past few years of focusing on hospital strategy, I have come to believe that strategies are a means to an end. Strategies take you from your current state to where you want to be. The tricky part for hospitals, I have found, is knowing what you want to accomplish and then committing to do what ever it takes to get there.

Setting the goals or the vision is really the key to strategy. What exactly is success to your organization? Is it meeting certain financial, quality, or patient satisfaction targets? These are laudable goals, but I haven’t found them to be compelling enough or differentiating. In my opinion, a more compelling vision is about the identity of the organization. I recently learned that Stanford University Hospital and Clinic’s vision is to be the “Best Medical Center in the Nation.” Now that is a compelling vision and, almost as important, it is, perhaps, attainable for Stanford.

With a vision set, I think most hospital executives believe they know what they need to do to succeed. The key is keeping them focused on the goal and then it is all about execution.

For me, strategy is all about asking and answering the right questions. Who do we want to be? What can we do that will set us apart in the market? What steps do we take to get there from here? Answering these questions creates strategies.

Continuing from my previous post, I'm doing a series on "hospital strategy." Just like any other organization that operates in a competitive environment, hospitals need to nail down their strategy in order to survive and thrive.

One healthcare system has been grappling with hospital strategy quite a bit recently. Baptist Health System in Alabama is undergoing one of the most dramatic turnarounds in the country. They improved their financial performance in fiscal year 2005 by $40MM and expect a similar improvement for FY2006.

Unlike many of the hospital turnarounds that I've blogged about previously, this turnaround isn't a "operational improvement" turnaround, this is truly a strategic turnaround.

Bleeding $56MM in 2004, Baptist really did some soul-searching. They looked at all of the things that they were involved in and made some tough decisions about what they really needed to focus in on. In some sense, they really had to think about 5-10 years down the line, what would their health system look like? What would be their core competency?

I can't say for sure, but I'd be willing to bet that Baptist realized that their core, their greatest strength, their best source of competitive advantage is their concentrated presence in Birmingham. That's why they essentially sold off everything except their core 4 hospitals in Birmingham area. That is strategy 101: to know your organization well enough to realize what the "core," the best source of advantage of the organization really is. Is it a technology? a hold of a particular market (in strat terms, an "established base") some economies of scale factor? a valuable brand? What is your hospital's greatest source of strength?

Interesting that whether we see it or not, strategy (even hospital strategy) is actually all over the news and all around us. We just don't normally think of it that way.

Just last week, Jim Collins published a monograph: Good to Great and the Social Sectors: Why Business Thinking is Not the Answer

(Taken from a review I wrote for amazon.com)
As a non-profit leader, I've been waiting for this monograph to be published for several months, and Collins did not disappoint.

In a lucid style that only Collins can deliver, he masterfully explains the subtle (but seismic) concepts of good to great for the social sector. Similar to his previous books, he effectively uses a broad array of real-life examples (e.g. the NYPD, a church, the Girl Scouts, the Cleveland Orchestra, a high school science dept), helpful graphics, and a very readable, conversational tone. Even though the monograph is only 31 pages, he contributes his clear thinking on numerous issues that will be very familiar to social sector leaders:
- how to measure success in non-$ metrics
- how to recruit and motivate a passionate (and poorly-paid or unpaid) staff
- how to think differently about "restricted funds"
- how to transcend systemic / external problems.

I particularly enjoyed his discussion on "legistative" leadership (versus "executive" leadership in the business world). Collins predicts a dramatic reversal - that one day non-profit leaders, who have mastered legistative leadership, will be wooed away to lead for-profit businesses. Also, he says that the true difference is not between for-profit vs. non-profit, but good vs. great - regardless of organization type.

This monograph does stand on its own. However, I think you would have to be fairly familiar with the concepts in Good to Great to fully appreciate the value of this monograph.

Regardless, I would recommend this to every hospital leader. For $9-10, you really can't go wrong.

by Nick Jacobs

As a little boy it was always fascinating to me that when my grandparents, neighbors or friends were sick or injured, the undertaker would drive up to the house in a white Cadillac ambulance to drive them slowly to the hospital. Since then it’s been clear to me that life is filled with inappropriate incentive arrangements that should be more readily questioned by society on an ongoing basis.

Other examples of this phenomena? The architect who gets paid more when he causes project over runs because his fee is a percentage of the overall cost of the project. How about the contractor who experiences a greater financial reward by not putting in as much rebar or concrete as called for in the plans?

Once while running a tourism agency we convinced a group of Travel Writers to visit our area. The river was secretly stocked an hour before their trout fishing trip. Nice articles were written, tourism increased, jobs were created and life was good. (Situational ethics.)

It was pretty clear to me as a child that life was not just. Everything depended upon who was making the decision. The employee who is not permitted to make a long distance call on a company phone while the CEO is flown to the U.S. Open by a potential vendor. We all are exposed to situational ethics.

Finally, there’s the physician who gets a bonus for not doing as many medical tests as he should on a patient. The for profit hospital executive who gets a bonus for decisions that hurt the overall care of the patient in order to reward stock holders. The doc who prescribes a drug that is not as effective as its competitor because of the rewards garnered from the company working to influence her.

Where is this going?

Oh, yes, the legitimacy of a situation can be rationalized by any person with a triple digit I.Q. So, look before you take . . .

12.02.2005

Well, in some sense, this was a slow week for hospital-related news. Though I could easily "fill up" this post with the usual 8-10 pieces of the most relevant news of the week, I think I would be wasting my breathe. Nonetheless, let me mention a few worthy things that happened this week:

Consumer-Driven Healthcare takes another step with the completion of the HCAHPS survey. Healthcare leaders were pleased to see the new HCAHPS Survey - a standardized, nationalized survey that polls patients' perception of care. At some point in the future, a sampling of patients from every hospital in the country will answer these 27 questions about their experience. I don't know about you, but I am dying to get my hands on these 27 questions. Using those questions as a guide, are we ready to start looking at our hospital operations/service from the patient's point of view? If you haven't already, check Press Ganey and NRCPicker for more info on this. Of course, the results of all this info will be made public on CMS's HospitalCompare website - it'll be sorta a Zagat's for hospitals. (FYI: I believe these questions will become public domain in about 5 weeks.)

6.6% profit margin for small hospitals in 2005. Relatively speaking, it has been a great year for hospitals. According to S&P, Small hospitals had a median profit margin of 6.6% and median operating margins of 4.7% in 2005, up from 2.3% and -0.5%, respectively, in 2003. Large hospitals also improved their margins from 2004. Why/How? I can't say for sure, but if you look at all the publicly traded hospital companies, they've been mentioning bad debt management and increased volume. How did your hospital do this year?

Trend or Fad? That's the question for these three new interesting developments.

Face Transplants - The world's first face transplant was performed in France.

Online 2nd Opinions - The WP reported on Cleveland Clinic's "MyConsult" (www.eclevelandclinic.org</a>). For $565, you, too, can get a 2nd opinion on any one of 600 "life-threatening or life-altering conditions."

Take 2 placebo and call me in the morning. Is this the end of pharmaceuticals as we know it? No way. Nonetheless, some studies have been completed that offer evidence that the "placebo effect" is real. One study showed that a proven painkiller didn't work as well once Alzheimer's disease took away people's ability to expect the painkiller to work. Another study had scientists causing some pain in healthy young men. As soon as the men were told they were getting a pain killer, their brain released endorphins (natural painkiller). Will this spawn a new industry that will serve the anti-pharma, all-natural, I'm-gonna-will-myself-better crowd?

In all 3 of these developments, not surprisingly, I think they will neither trends nor fads. I think most would agree that each will find their niche and their market, but never become a dominant force.

Yes, hospitals in the same town often collaborate. Yes, hospitals have noble missions to strive for and provide an essential public service to their communities. And yes, hospitals are all about compassionate caring and about each precious person that walks through our doors.

But hospitals also have to be run like businesses to survive. For some reason, some people rail against that fact. But really, it's really just another way of saying that hospitals have to make smart decisions about trade-offs. It means saying "no" to some good initiatives in order to say "yes" to what's truly best for the hospital's future. Someone has to tend to the overall view of the hospital - to think about financial, clinical, political, operational, and strategic aspects of the hospital's mission and make it all work out.

For too long hospitals have had no strategy. Far too often, hospital executives are simply putting out fire after fire. They're thinking about the monthly numbers, about one patient's story, about the next report to the board, or (at best) about the next year. All of this is good to think about, but when does anyone have time to look further than that? When does anyone even put the words "hospital" and "strategy" together at all?

Starting next week, I want to begin a "Hospital Strategy" series on how we can start thinking about and putting together our hospital strategy. I've spent a lot of time blogging here about tactics, goals, and trends - I realize that that's not enough. In this increasingly crazy operating environment, it is more important than ever that we think very lucidly about our hospital's strategy. What differentiates our hospital from all others? What is the core of our strength?

To be sure, I think every industry and every executive struggles with this. But the most successful companies (no matter what industry) I've seen are the ones who nail the strategy. One day, if our hospitals really become the best-run organizations on the face of the planet, we will know that hospital executives finally got serious about hospital strategy.

Andrew is taking today off, but will be back next week. In the meantime, I've been somewhat surprised/pleased at the different ways that hospitals have tried to increase nurse retention.

Saline Memorial Hospital is now providing a $500 bonus to nurses who achieve certification status in their particular field. In addition, they've put together a nursing career leader program as well as a Nurse Recruitment and Retention Committee.

A hospital in Memphis experienced a 30% decrease in nurse turnover after it learned "peacekeeping skills" from fighter pilots. The hospital brought in LifeWings, a company founded by a former US Navy Top Gun Instructory and that specializes in aviation-based teamwork training. Check out LifeWings other success stories here. Sometimes it's as simple (and as hard) as getting people to communicate better.

Not your cup of tea? Go the old-fashioned way - Long Beach Memorial Medical Center recently approved a 20% raise over 3 years for their nurses.

Children's Memorial Medical Center here in Chicago has seen some excellent results, thanks to their "Clinical and Organizational Development" program (run by Diana Hafler, who recently received a $640k grant to study the nurse internship/retention link). Nurse turnover dropped 50%, resulting in $500,000 in annual savings. The program stresses personal attention and operates on three tenets: (1) providing competitive compensation; (2) as much schedule control as possible; and (3) career development - in particular, mentoring.

"The nursing preceptor, who may be from a different unit or department, has the greatest impact on their [new nurses] careers. This person mentors, working side-by-side with you, helping you become acquainted with the job and the flow of care. If I had limited monies and needed to make one major investment, it would be investing in that role and supporting those nurses, because teaching someone new and managing their own patient care is a heavy responsibility and can be a stressor." - Diana Halfer

two new ones:
HITSphere, which is focused on healthcare IT
HealthVoices, which has an interesting "Open Medicine" vision about healthcare. See their healthcare blog list here.

two older ones:
Healthcareblogs stopped refreshing its feeds for a while, but now it is back on track.
MedLogs which categorizes the blogs nicely between physician, nurse, biz, etc.

so, which one is the best?

HealthVoices, MedLogs, and Healthcareblogs all segment the various healthcare blogs well. Nonetheless, I think that niche aggregators like HITsphere are going to pick up steam. Healthcare is simply much too broad to aggregate it all for anyone to make sense of it all. Besides, most people only care about one or two professionals/specialties. I can only read so many M.D. blogs before I feel a little out of place.

Then again, maybe all of these will be leapfrogged by more sophiscated RSS aggregation technology, like a TiVo for webfeeds?

By Nick Jacobs

Back in the 70's there was a popular psychology book entitled I'm OK, You're OK by Thomas Harris, M.D. That book impacted my life in so many ways from teaching, to child raising, to management that the results are impossible to describe in this short space. It taught me that bully management always has a serious price tag associated with it and that the price most often comes in the form of a gotcha.

The book talks about dealing like an adult with another adult rather than as a parent to a child. The beauty of this philosophy is that people begin to work WITH you rather than FOR you. With the parent to child management style, you may get what you want faster, but make sure you have your next job lined up because, within four years your employees will begin to do you in. It will happen at critical, mostly subtle junctures. They will leave an important task undone, let the truth drop about one of your faults, or purposefully hurt you in ways that you will feel, but may not fully detect.

If you are a bully manager, a parent to child manager, make sure you continue to cultivate your consultants and your head hunter friends because it will be just a matter of time until you need them to help you to find your next job.

In employing this OK style of management as a teacher, a nonprofit CEO and now a healthcare executive, it is my observation that many workplaces are so used to this patriarchal form, this bully form of management, that the employees interpret a kinder/gentler more mature style of management as a weakness. They are so used to employers who scream, yell and bully that when someone comes along who doesn't fit that bill, the crowd gets a little shaky.

It's a great idea to demonstrate your ability to take on the difficult issues early on by dealing with those ten percent of individuals who will not ever be part of your team. Just continue to manage and/or transfer, move or fire these employees with the same finesse and honesty that you must demonstrate in all of your business decisions.

My final recommendation in this matter is to be sincere, be real. Deal from the top of the deck. Be able to face yourself everyday. Understand that the biblical phrase "Do unto others as you would have others do unto you" is real. Understand that a team inspired by joint goals, rewarded appropriately, and, at all times, a team that is respected will out perform everyone.

Rent Seabiscuit and follow the philosophy of the trainer, Tom Smith.

Medgadget is now taking nominations for the 2005 Medical Weblogs of the Year. If for nothing else, head on over there and see what other blogs are being nominated - there will probably be a few more undiscovered blogs worth checking out.

My prediction: Hospital impact will be an underdog in one or two categories because this blog doesn't fit well into any of the categories. Just goes to show - there just ain't many hospital and/or hospital leadership blogs out there.

Plus, Dr. Helen was nominated also in one of my potential categories. Since her blog has 40x more readers than mine, and her husband's blog has 1,000x more readers than mine, with one link, we already know the results for that one! Plus, Dr. Helen is slightly more good-looking than yours truly.

[note from Tony: check out this guest entry from Shahid Shah. I haven't seen a healthcare blogger start a blog stronger than him at www.healthcareguy.com. It's daily & insightful - very hard to do both]

by Shahid Shah

As most of my readers at The Healthcare IT Guy already know, I’ve served in many consulting R & D capacities at The American Red Cross (ARC), including Chief Systems Architect for the blood collections IT system. Although it’s not commonly known, if you’ve ever given blood at any Red Cross facility, you have an electronic record of your demographics, lab results (for blood tests), and other similar biomedical information stored at the ARC data centers. If you’ve given blood somewhere else, they also manage your data but it’s not in a centralized manner like ARC’s.

I’ve long considered the ARC medical records as a solid basis for a personal health record (PHR) that could be offered to, at minimum, blood donors but could be expanded to non-donors to include any citizen. Think about what this might mean in time of disasters – something that the Red Cross helps manage with artful skill already. As you may have seen, people in disaster areas have a difficult time getting access to their medical records. For example, from the Sep 19, 2005 New York Times article “Doctors Join to Promote Electronic Record Keeping” they mentioned:

…last week, in the aftermath of Hurricane Katrina, government and private health care officials were rushing to build an electronic database of prescription drug records for hundreds of thousands of people who lost their records in the storm. Health and Human Services Secretary Mike Leavitt said the chaos wreaked by Katrina “powerfully demonstrated the need for electronic health records.

A simple “disaster time personal health record” system that would allow people to store a rough medical record such as demographics, allergies, immunizations, medications, physicians, forms etc that would be useful in a disaster. I think it’s time for the hospital and care delivery communities to request a service such as PHRs from the Red Cross. Red Cross supplies about 50% of the nation’s blood to roughly all of the nation’s hospitals. If anyone already has reach into the hospitals, it’s the ARC. And, with an appropriate technology solution put into place by the ARC they could become part of the NHIN and actually make PHRs work for a useful purpose (disaster-time). I’m pretty sure my idea will work because I know that the ARC already has most of the modern technology it needs already in place (networks, architecture, etc). And, for the other 50% of the blood suppliers ARC could manage their data for a fee for service.

Ultimately the problem may not be sheer willpower to do it but a business model (after all, ARC charges money for collecting and distributing blood and can’t do it for free). My guess is that it would cost about $3 to $7 per person per year to operate but that ARC could charge up to $50 to $100 per year per person to run the system for them. Donors could get the system for free but ARC could collect money from the government’s NHIN funds (have a PHR would be a free service for donors). If you’re not a donor but want a PHR you would be charged. Another revenue source might be to sell the service to local communities (counties, states, etc) so that ARC would run the system but charge the county for number of residents. There are many business models that might work but in any case ARC could make some decent money while doing considerable good in time of a disaster. And, ARC could definitely use the money – they do great work but don’t always have great funding.

The beauty of the system is that using their existing system ARC already has portions of medical data for millions of donors in a homogenized and centralized database (which I helped deploy). And, they’re working on upgrading this large database to take on growing information needs right now.

I’ve discussed this idea with some other ex-ARC colleagues and they think it’s a good idea, too, but we haven’t been able to convince folks within the Red Cross to take it seriously. It’s not that they think it’s a bad idea; just that it’s not a priority. Perhaps the ARC customers like hospitals and community groups or even local governments could make noise to get the idea heard and acted upon. I’d be happy to help.

Hope everyone had a happy and healthy (relatively-speaking) Thanksgiving!

11.25.2005

Electronic Health Records The Wired for Health Care Quality Act was passed in the Senate last Friday, envisioning a day of keychain medical records. Of course, anytime we talk about access, we also talk about privacy (and different levels of it for different audiences). Makes me wonder: let's watch how the banking industry handles this catch 22, and maybe we in healthcare will be there in 10 years. Check out ING Bank's log-in page - I don't know how well it works, but it sure makes me feel more secure. Then again, maybe it'll come down to implanted microchips.

Consumer-Driven Healthcare is not coming - it is here and it has been here. 31.6MM Americans use the internet for their healthcare decisions. Also, BCBSA is teaming up with Visa to offer a debit card - a plan very similar (but short of) UnitedHealth's new bank venture, Exante. LifePoint Hospitals is also starting to offer its own credit card - patients get a discount and LifePoint gets 93 cents on the dollar guaranteed from their banking partner (still a mystery who this is).

Good News, Bad News I guess it all depends on perspective, but several stories came out this week in which it was hard to decide whether to cheer or to cry. For one, healthcare costs continue to outpace inflation, but its growth slowed from last year. Still not sustainable, but getting there? The jury is still out. Similarly, the AIDS virus continues to expand its reach (now to 40 million people), but infection rates are starting to decline in some countries. Good news or bad news? Also, this past week, NY State set up a commission to rate hospitals in order to identify (and inevitably close down) the least viable ones. Maybe a fast death is better than a slow one, so everyone can move on? News stories (and especially statistics) can be spun to be mean just about anything.

Speaking of statistics and numbers, 4.4% is the number of the week. Not surprising, the docs are up in arms as CMS is ready to cut Medicare fees by that amount. Doesn't sound like much? It was enough to bring out these fightin' words by two prominent MDs:

Physicians cannot absorb the pending draconian cuts. A recent A.M.A. survey indicates that if the cuts begin on Jan. 1, more than one-third of physicians would decrease the number of new Medicare patients they accept. - Dr. Duane Cady, AMA Chairman

vs.

Medicare needs to encourage and reward efficiency and high-quality care, not simply pay for more services - Dr. Mark McClellan CMS Chief

What do you think?

Happy thanksgiving! Well, in the spirit of this holiday, I'd like to share one news story that made some shareholders very, very thankful, I'm sure.

A very weird thing happened last week. Burke Whitman went from being CFO at Triad Hospitals to President/COO at HMA. That's not particularly weird, as Burke Whitman is a highly-sought after hospital exec who just returned from serving in Iraq.

The weird thing was Wall Street's response. As a result of one man's job switch, Triad's stock lost more than 3% that day or $120,000,000 in market cap whereas HMA stock gained 8% or $460,000,000 in market cap.

No offense to Mr. Whitman, as he's a great exec and a great soldier, but $460,000,000? Assuming that Mr. Whitman will make a comparable salary to the rest of the HMA Exec Team ($570k - $1.5MM), he probably represents the best $1MM dollars HMA has ever spent.

Once in a while, you bump into people who think their hospital CFO is a turkey, but Mr. Whitman is anything but - just ask the shareholders of HMA who, I'm sure, are having a very happy thanksgiving.

By Andrew Barna

More news from the West Coast. Catholic Healthcare West (CHW) has signed a deal with medical supplier B. Braun to purchase PVC/DEHP-free IV-bags and tubing. CHW claims that this move will not only improve patient safety, but will have a positive effect on the environment. See the full story here.

This is a commendable move from one of the larger health systems in the country. Providing safe, high-quality, cost-effective healthcare is not an easy task, indeed, it is all consuming. And yet CHW has made concern for the environment one of the pillars of its commitments to its communities. All not-for-profit hospitals need to demonstrate the benefits that they provide to their communities and environmental efforts should be counted among them.

Not knowing a whole lot about this aspect of hospitals, I located the California Waste Prevention Information Exchange on the internet. It seems to be a great starting place for ideas on how your hospital can reduce and/or mitigate its waste production.

Grand Rounds 2.09 is up at CodeBlog.

Not only has Geena done a great job adding her commentary on each post (including one from hospital impact), but this edition of grand rounds marks the start of a new era in medical/healthcare blogging. Thanks to Nick over at blogborygmi (a play on the medical term borborygmi, meaning stomach growling), Grand Rounds will be picked up by medical media giant Medscape. Click here (reg req.) for this week's (and 1st ever) Medscape article on grand rounds.

by Nick Jacobs

As a first time, guest blogger to hospitalimpact.org, it strikes me as clearly ironic that a totally right brained, creative-type like me would be invited to contribute to anything associated with finance and business.

Don't get me wrong, they allowed me to get one of my advanced degrees from Carnegie Mellon University where two thirds of the students on campus clearly lean to the left due to their heavy concentration in analytically directed coursework, but I must admit that I almost crashed and burned in advanced probability and statistics.

So, let me begin by telling you, in my humble opinion, that everyone needs at least one or two creative types on their management team. Why, you ask? You did ask, didn't you?

Well, as a left brained leader, the heavens have blessed them with an uncanny desire to analyze, dissect, and analyze again. They also have been trained, not unlike the pharmacist, to count, recount and recount again. Finally, and this is the most important part of their training, it's not really there until it is really there.

Now, enter the right brainer. We often times see the finished results in our mind before the project has even begun. We can count and allocate funds over and over before the contract has even been written. We hardly ever have an exit strategy because we are confident that we won't need one. Our view of the world is one of growth, expansion, invention, sometimes a little exaggeration, and always new ideas that lead to solutions that are often unorthodox, but usually creative. We often have off-beat senses of humor because we see the rest of the world very differently, but most importantly, we have a deep belief that where there's a will, there's a way.

So, temper us, keep us on the straight and narrow, but embrace the fact that there are multiple ways to get there, and, with a balanced team, your chances of success grow exponentially. So, hug a right brainer today. It could be the best day of your life.

I'm pleased to announce that Nick Jacobs, CEO/President of Windber Medical Center and Windber Research Institute, will be blogging at hospital impact as a guest blogger, sharing his humorous and insightful thoughts on hospital leadership. You can also find his thoughts on his blog, Nick's blog, the first hospital CEO blog ever.

His background is quite interesting (as I posted previously). Among many other things, Nick was previously a high school music teacher, a director of a regional arts organization, executive director for two different healthcare foundations, a VP at Mercy Medical Center, and a chief communications officer for a health system.

What I especially appreciate about Nick is his ability to tell stories (something us financial types really need to learn), his right-brained way of thinking (check out tomorrow's post), and his approach toward leadership. It should not be lost that under Nick's leadership, his Medical Center has a 1% infection rate (9x lower than the national average) and was recently nominated as one of the top 50 places to work in the U.S.

For a full bio, check out his blog bio. Given his busy schedule as a hospital (and research institute) CEO, I especially thank him for his enthusiasm to blog at hospital impact from time to time.

UPDATE 10/2008: Nick also now blogs at askahospitalpresident.com

Welcome Nick!

Yes, the uninsured problem is still a huge and growing problem, but it's good to see individuals step up and contribute in whatever way they can. This Sunday School room at Grace Lutheran Church is now an evening clinic. This clinic in Oregon provided 7,868 patients with 16,321 clinic visits, including medical and mental health services, as well as preventive dental services for preschool and elementary school children. The Fan Free Clinic in VA, partially funded by the United Way, is the 1st free clinic in the state and provided 4,500 patients with ~8,000 visits.

It's also good to see hospitals stepping us as well. Central Kansas Medical Center set up an endowment specifically to help patients who find themselves strapped without necessary funding. A recent golf outing added $55,000 to that endowment. The major hospitals in Des Moines, Iowa also recently announced discounts to the poor and uninsured - this is representative of what many hospitals around the country have been doing, especially the last few months.

While most of the media attention is on the bitter fighting, class-action lawsuits won by patients, the 19 states taking on healthcare into their own hands, let's not minimize the value of a helping hand and a clearly thought-out & well-communicated charity care policy.

As I mentioned last week, I've started a weekly post that provides a quick rundown of the most impactful hospital news for hospital executives. Here's volume 2. Let me know if you have any comments.

11.18.05

One small step for HHS, one giant leap for healthcare? HHS announced $18.6MM interoperability pilots to Accenture, IBM, Northrup Grumann, and CSC. Don't let the relatively small number fool you - this could have monumental consequences down the line on who will become the EHR providers of choice for the next 15 years. Does this give these 4 companies an advantage? Yes - they design it, they get a head start, and they get the PR. No - the whole point of interoperability is that it will be system-agnostic. Will other players will be able to follow quickly behind? This week, HHS also announced EHR-type initiatives for Gulf States. But don't get too excited, either - just last night, the House voted down the bill that would have tripled the government's health IT funding.

More healthcare gurus (and non-gurus) weighing in on consumer-driven healthcare Michael Sachs spoke about it at a Missouri hospital association meeting, restating the obvious - when people have to pay more, they use less. James C. Robinson pondered in an Health Affairs article whether the 15-year-old lessons from managed care could help inform us on the impending magnitude of consumer-driven healthcare. Not surprisingly, non-gurus are weighing in too, including the self-exclaimed consumer-driven guy on his new blog of the same name.

CMS steals the headlines for a 2nd straight week They finally started enrolling people into Medicare Part D (and faced criticism for their hard-to-use website). They also plan to dole out $8.5MM more this year in bonuses for hospitals via their pay-for-performance programs. 270 hospitals, $8.5MM - rounds out to $30k a pop? worth it?

Quote of the Week RWJF President and CEO Risa Lavizzo-Mourey, MD/MBA, speaking about positive pay-for-performance results announced on Wednesday:

"Whether or not you believe P4P will make a significant difference, it's time for payers of health care to reward providers who are improving quality rather than turn a blind eye. Pay for performance represents the first real attempt to pay providers differently based on the quality of care they give to patients and these projects have a lot to teach others about what works and what doesn't."

Give me a raise Are you a physician executive looking for a big raise? Go for that VP Quality Job - they get the biggest raises - this past year, their salary is up 18%. But, before you make the jump, VP's of Quality still make less than CMOs.

Calling all hospital leaders The Healthcare Alliance announced the creation of a competency directory to ensure that future healthcare leaders have what it takes to lead tomorrow's hospitals. It boils down to 300 competencies in 5 domains: leadership, communications/relationship mgmt, professionalism, business knowledge/skills, and knowledge of healthcare environment. It's interesting to go down the competency list and get a sense of your own strengths/weaknesses.

After my last post on the state of hospital CEOs, I've been noticing a lot of hospital executives in the news:

- Michael Lake, the CEO of Ashford Community Health Care, is doing everything he can to prevent the county and state from shutting down his hospital. As of earlier this week, the hospital is closed, the lease is expired, and the power is shut off. The straw that broke the camel's back: an anonymous complaint last week over poor patient care, lack of supplies, the absence of a medical director in an OR, alleged piles of trash. Now, the fight begins for the $11MM trust fund.

- On the other end of the spectrum, the El Camino Hospital District board handed CEO Lee Domanico a $159,862 bonus this week, touting his excellent performance at the Mountain View facility. This is definitely a departure from their overly-secretative & protective stance on financial matters of times past.

- Andrew Lasser, former CEO of St. Joseph's in Augusta, didn't go far to his next job (reg required) - just 5 miles up the road to University Hospital. Andrew was CEO of St. Joseph's for 5 years, not atypical for CEOs (avg CEO tenure: 7-8 year). It's just unusual to jump to a cross-town rival. If physicians have non-compete agreements (e.g. 50 miles away for 3 years), shouldn't hospital execs also?

- Speaking of the CEO shuffle, Stony Brook CEO Bruce Schroffel is leaving after 4 years to head Univ of Colorado Hospital. Not really newsworthy, but representative of what normally happens in healthcare: CEOs of small hospitals become CEOs of bigger or more complex hospitals. Wanna become a small hospital CEO? Studies show most CEOs are COOs first.

- Most interesting to me was Tenet CFO Robert Shapard returning to his Utilities roots after just 8 months on the job at Tenet. I was watching his story with much interest given how rare it is for hospitals to hire executives from outside healthcare. When was the last time you saw a CEO from another industry hired in to run a hospital? Sure, accounting is accounting, but healthcare finance poses unique managerial and technical challenges that seems to require industry-specific experience.

by Andrew Barna

MatchingDonors.com – One of the biggest healthcare stories on the West Coast right now is the loss of 2 transplant programs in the Los Angeles area. First, St Vincent Medical Center closed its liver program after it was revealed that it had given a liver to a patient far down on its list. Second, UC Irvine closed its liver program subsequent to losing its eligibility for Medicare and Medicaid for poor management of the program.

This means that potentially hundreds of patients will have to find new transplant programs. Moving to new programs could change their “place in line” and thus, quite frankly, their odds of survival. This should be a very sobering thought for healthcare providers. The decisions we make on a daily basis have real and serious impacts on current and future patients. This is not a point that is lost on most hospital personnel; however, the impact on future patients, also known as “community need,” doesn’t always get full consideration when weighing costs and benefits.

One way for these patients to play a more active role in obtaining a transplant is through the website MatchingDonors.com. MatchingDonors.com provides a space for people in need of a transplant to meet people willing to make living donations. Even though this is outside of the national system for organ allocation, it has been well received as a practical and ethical alternative.

That is the tagline from this Fortune Article that features guide-to-our-crazy-healthcare-system company Subimo. Their service, www.myhealthadvisor.com, enables patients to "shop on-line" for doctors, health plans, and hospitals. And it's getting some attention - 60 million people already use it!

BusinessWeek also just named it "Best of the Web" for healthcare information. In the 16,000-response survey, Subimo even beat out WebMD and Yahoo!Health. The site contains info on 5,000 hospitals and 100 medical conditions and procedures. For $24/year, consumers get all that rich information.

I hope they don't read my blog because I'm here to say that I would be willing to pay a lot more than $24 to find the information they are providing. They are only a $10MM company (and finally profitable) serving 60 million users. I'm not complaining. But given that consumer-driven healthcare is supposedly a $16B industry (according to Forrester Research), if I were rich & smart & passionate about healthcare (I'm only one of three), I am buying this company for $40MM and turning it into a $1B enterprise. Thankfully, they are more altruistic than me.

I just paid the $24 and I love what I see. Some examples of screenshots:

A comparison of charges for a C-section

A comparison of patient safety standards

UPDATE: I was thinking about this more today. When someone calls up the hospital to ask how much a C-section is, isn't that like calling up a Honda dealer and asking how much a car is? Or calling a grocery story "how much is a loaf of bread?" I doubt that consumers will ever be able to truly compare prices. At least with a Honda, you know what options you're gonna need.

According to the University of Maryland's Center for Health Work Force Development, we will be short 1,000,000 nurses by 2015.

We already know the causes (poor working environment, abusive/disrespective physicians, long hours, inconsistent schedule, nursing faculty shortage, etc), but these new stats from the study are interesting:
- 41% of nurses are dissatisfied with their job
- 22% of nurses plan to leave within a year
- 33% of nurses under the age of 30 plan to leave within a year

Also mentioned is the unfair media portrayal of nurses, something I've posted on previously. According to the study, 90% of the decisions and activities that affect patient care are not up to physicians but are in the hands of nurses. Being somewhat of a media junkie, I admit it - that 90% figure is hard to believe.

Recently, I have been impressed and inspired by Yahoo Finance's remake, especially their exclusive columnists and their daily "best of business news". As such, I am thinking about starting a weekly entry every Friday entitled "Hospital Impact Weekly News Scoop" - a quick rundown of the 5 most impactful news stories for hospital executives for that week. Tell me what you think, is this a useful filter or is it just too superficial (or is MH's Daily Dose, etc enough already)? Email me at tony[at]hospitalimpact[dot]org or leave a comment.

11.11.05

TREND: 19 states are taking healthcare insurance into their own hands, as Washington continues to pontificate.

TREND: The number of hospitalists will double in 5 years, from 12,000 now to 25,000 by 2010. This could be a first - doctors, hospital CEOs, and managed care companies all agree - the hospitalist model works.

FIGHT: The AMA had a busy week against the CMS. First, they threatened an exodus of physicians from Medicare if cuts aren't rescinded. Then, they blasted the CMS and demanded them to cancel their Physician Voluntary Reporting Program.

READY OR NOT: Avian Flu is inevitable. Time to dust off that 3-ring JCAHO-required Disaster Recovery binder. We can plan all we want, but if it happens, will our hospitals be ready? It's good to see my employer addressing this in a meaningful way.

READY OR NOT: More than 50% of hospital execs said that our hospital facilities will not be able to meet patient-care demands over the next five years. Newer and better designed facilities are in dire need. With only 2/3 of hospitals even breaking a profit these days, who's going to fund this construction boom?

"I write, they comment, we connect. That is what it is all about." - Nick, the first hospital CEO blogger in the blogosphere.

Well, the day has finally come - the first hospital CEO has hit the blogosphere. Actually, he's been blogging since May, but I just didn't find him until now.

Nicholas Jacobs, FACHE, is President and CEO of Windber Research Institute and Windber Medical Center. His blog, informally titled Nick's Blog, covers a range of issues and honestly addresses various audiences - including employees, the community, and the board. His blog was also reviewed & profiled by the mega-popular Diva Marketing blog, who gave him two thumbs up. Her profile is a definite read, as they interview Nick on his thoughts on blogging. Turns out the idea for him to start blogging came from an 80-year-old friend.

UPDATE: Also check out the WSJ CareerJournal article that tracks Nick's career from high school music teacher to hospital CEO.

Just in case you wanted to read hospital impact in Chinese, click here

You can translate any website to a few different languages using google's language tools - the simplified Chinese translation has just been added as a beta). I'm still waiting on the Dutch to English translation so I can read the blog of Martijn Hulst, who works on internet/intranet strategy for a large hospital in the Netherlands.

I went on a search for other healthcare bloggers who happen to blog in other languages. After looking everywhere, not surprisingly I found that non-English medical / healthcare-specific blogs are few and far between. Some had potential but have sinced been abandoned. A few interesting blogs I did find:
- This one looks like a Danish blog about living with diabetes. Unfortunately, Google doesn't have Danish-to-English translation yet.
- Dr. Chong's blog (in Chinese) discusses some health-related news items. Unfortunately, with sentences like, "the menopause woman keeping in good health four wants," we start to see pretty quickly that Google's translation tools still needs some work. Makes me wonder what exactly even the words "hospital impact" becomes in other languages.

After all, the blogosphere is still nascent - even more so for the healthcare blogosphere. But with the # of blogs doubling every 5 months, I'll have to check again soon - never know when someone in China or Iran or Germany will start blogging and become the next KevinMD or Matthew Holt.

by Andrew Barna

Consult Me This – In my role, I am often the first point of contact with vendors or consultants. Not the kind that sell synthetic hips or surgery staples, but the kind that offer new healthcare services or the kind that do part of our jobs for us, only better. Consultants tend to get a bad rap for “stealing your watch and then telling you the time,” and I have encountered consultants like this. They speak at length and produce weighty reports, but in the end the organization hasn’t been significantly changed for the better. There are, of course, consultants that get it. Or at least they appear to get it. Here are a few pointers for consultants that work with hospitals.

• Nearly every consultant understands that if you can’t help an organization meet its goals, then you won’t make it past the first meeting. Frequently, consultants try to achieve this by copying your hospital’s logo from your website, adjoining it with their own (or other client hospital logos they have stolen) and reading you your own mission statement. This is a perfunctory ritual, but otherwise not much use.

• Consultants need to listen first and then put together their spiel. Company accolades or sample pro formas don’t win the contract. If you can capture the spirit of the problem that the hospital is facing and clearly outline how your company can address it, then you will put yourself in the call back pile. Hospitals don’t buy solutions to problems they don’t think they have.

• On top of this, bundle-in a distinctive service that sets you apart from the competition. Hospitals love getting things for free.

• Speaking of free…be flexible in the financial relationship. In our healthcare system, we have a medical IT guy that always negotiates in some consultant or vendor risk. Hospitals want to know that you have some skin in the game as well.

Heard of Skylight before? They equip hospital rooms with in-room media centers providing key hospital information, health education videos, satisfaction surveys, room service dining menus, and digital entertainment (movies, games, music) and communication options (email) designed to enhance the patient experience.

They seem to be capitalizing on two trends: the need to build patient loyalty via an enhanced total patient experience, the increase need for connectedness via technology. In just the last month, they announced contracts with Woman's Hospital (16th in deliveries in the U.S.), Providence St. Peter Hospital, and St. Vincent Hospital.

Studies show that the system reduces the non-clinical task load usually handled by nurses, potentially boosting nurse morale and retention. The system also enables administration to obtain instant patient feedback, allowing them to respond more quickly to service failures and deficiencies.

Check out this Advisory Board brief (PDF) (always excellent stuff from AB ) on the impact of service excellence on hospital success. One hospital using Skylight's system (page 6) is now able to (1) respond to service lapses within 60 minutes; (2) increase bedside feedback 3 to 6-fold.

Check out yet another creative grand rounds this week at MSSPNenus. Among other things, Rita reveals her childhood crush! Also, don't miss Dr. Helen's story about her heart attack experience. (and I might be wrong about this, but I believe Dr. Helen is married to regular grand-round-linker Instapundit)

Besides consumer-driven healthcare and EHR, Pay for Performance may very well be the emerging trend of greatest interest for the hospital industry.

BusinessWeek did a long article "A Big Green Pill for Healthcare?" - highlighting the bills in Congress that were to make p4p the rule instead of the exception. From what I understand, those bills are still under construction.

Just how widespread is Pay for Performance right now?
ACPE released survey results (hat tip MeetingsNet):
- 40% of doctors are currently participating in some sort of pay-for-performance
- 36% are thinking about it
- 24% aren't participating and aren't thinking about it.

Some quotes from doctors are quite telling:

Pay-for-performance programs "are an inevitable rising tsunami that will overtake us."

"Bonus pay for taking better care of patients certainly is controversial."

"It is embarrassing to have to be paid to improve quality ... our industry has been lax,"

Pay-for-performance programs "are the most recent scam to be perpetrated on physicians. Agree to them at your own peril. All physicians will regret their participation in any such program."

Also, according to research done by Harvard, this Forbes article stated that pay for performance hasn't improved quality too much. Nonetheless, more demonstration projects are underway, such as the one announced earlier this month re: end stage renal disease.

Rod Huebbers, Hospital CEO in the fastest-growing county in the country, is no stranger to adversity. When he became the CEO at Inova Londoun hospital 4 years ago, they were nearly bankrupt and was 1 week away from selling their best hospital. Rod turned it around - preventing the hospital sale, strategically opening new services in other locations, doubling the number of beds, and fighting off HCA attempts to open a hospital just a few miles down the road. Rod also lead efforts to merge with Inova in 2004, when Inova agrees to invest an additional $200MM to upgrade hospital services.

Starting Jan 1, 2006, all the Inova Hospital CEOs in the East Region will be reporting to Rod. For more on Rod's approach, read this article - Rod seems to have that perfect blend of characteristics of good-to-great leaders. He's both hard but fun-loving, focused on operational excellence but still has great vision, approachable yet no-nonsense, humble but gutsy (not many CEOs as their first act as CEO would stop a hospital sale that had been planned for many months).

oh, and yes, these pies were thrown at him by his employees as part of a United Way fundraiser.

"We believe consumers should have at least as much information about health care as they do about cars or computers," UICI CEO Bill Gedwed said.

Yes, we all know that consumer-driven healthcare could be one of the largest drivers for change in healthcare in the next 5-10 years. This report puts it into context about just how early it still is. Check out these stats:

- 56% of those who have bought cars in the last 5 years used the internet to help make the choice and spent 5+ hours doing so
- 44% of those who have bought a computer in the last 5 years used the internet to help make the choice and spent 4+ hours doing so
- 22% of those who choose a new doctor used the internet for help, and spent 2 hours doing so
- 12% of hospital patients used the internet to choose a hospital.

What this report tells me is this:
(1) Most people don't think of using the internet to look for hospital quality/pricing/info. To be honest, we can't blame them - current sites don't get much awareness. Plus, a true leader hasn't emerged.
(2) There will be many more reports like this that compare hospital shopping to computer / car / airline ticket / TV shopping. That will inevitably get more people to rethink their hospital experience.
(3) As more hospital data becomes readily available, more marketing will occur. Hospitals, the towns they reside in, and local realtors (good schools won't be enough anymore) will boast about their high rankings.
(4) Hospital leaders will see the fight for more patient volume intensify and be increasingly about "marketable quality."

Why should we care about hospitals and how they are run? The most obvious reason is that almost every American will encounter a hospital in their lifetime. You were likely born in a hospital. You may have had a broken bone mended in an emergency room or you may face your final days on earth in a hospital. In each case, you and your loved ones shared a defining moment in life. Being a patient in a hospital or visiting a patient or even hearing about someone’s experience in a hospital causes a pause and, at the least, a moment’s reflection on one’s own mortality. Hospitals can impact us the way old churches do or the way the Grand Canyon does. Hospitals are significant places.

But hospitals are more than a backdrop to life. In a culture that has an interest in all things healthy and healing, hospitals are the places where truly miraculous healing is available. I am not referring here to Divine Intervention, but I do want to draw upon the mystique of the concept. The things we do in hospitals are many times beyond common understanding – to the lay observer they are “miracles of modern medicine.” Clogged arteries, cancerous lesions, and broken hips can bring life to a halt; the future becomes foreshortened and everything in the world depends on the test or the procedure or the prognosis. At the hospital, miraculous healing restores people.

Miraculous healing is no easy task, however. Hospitals are complex organizations with (well-meaning, yet) fallible people, multi-faceted processes, technical communication, sharp needles, and potent drugs. Indeed, hospitals can be outright dangerous places when the system doesn’t perform as it is intended. Coordinating all these elements takes wisdom, attention to detail and outcome, sensitivity, and most of all, leadership. Inertia does not keep a hospital safe. Miraculous healing takes the dedication and willingness to constantly challenge the organization to improve. I truly believe that leadership is the glue that holds hospitals together. Leadership and diligence keeps the miracles coming.

These are just a few reasons why hospitals are worth caring about.

A post by Andrew Barna

by Andrew Barna

I am the guy that always sat at the front of the class. I wasn’t always the best student nor did I make the highest grades, but I was always engaged. In these early days of my career as a hospital administrator, I find myself again in the role of eager student. I am not the professor. I don’t have all the answers, but I have a long career in healthcare ahead of me and I am interested in how healthcare and hospitals evolve over the next few decades.

My front-row-sitting started at Baylor University, where I studied psychology (B.A.) and philosophy (M.A.). My interest in ethics, the experience of illness, and technology steered me toward bioethics. Fortuitously, it wasn’t until after I attended a hospital bioethics meeting that I realized that I wasn’t cut out for a career in bioethics. At that meeting, I saw the role of the hospital administrator and took a leap of faith. That led me to the University of Iowa for my MHA, where I discovered the complex world of hospitals and healthcare.

My current role, Director of Strategic Development for a hospital in the Bay Area of California, has given me a front row seat to an organization that shares many of the same challenges as other urban hospitals across the country. I have been blessed in this role to take on a number of projects around the hospital and to be a part of an executive team that is transforming a hospital. My hope is that my posts will encourage discussion on where hospitals and healthcare should be headed and how we can get there.

Note from Tony: look for Andrew's hospital leadership insights every Wednesday here on Hospital Impact (and every Tuesday at Healthcare Tomorrow). Email Andrew at andrew[at]hospitalimpact[dot]org

UPDATE 12/2005: Andrew has moved on to the next chapter in his healthcare career.

That's right - hospital impact now has another blogger - Andrew Barna. I'll let him introduce himself later this week, but I will tell you that I've enjoyed speaking with him and reading his thoughtful hospital blog, Healthcare Tomorrow. Look for his out-of-the-box insights on hospital leadership regularly on Wednesdays (and occasionally during the week) right here on Hospital Impact. Welcome Andrew!

GrandRounds is up at KidneyNotes. A couple of my favorite links:
- The best rapping nurse I've ever seen and I will ever see. This guy from UAB is hilarious. "we are ER nurses, medications we disperses..." "we treat every patient, from the womb to the tomb" "room 3 has got the flu, room 4 can't poo poo, room 5 is just cuckoo." What would you do if you were in this hospital and he was taking care of you?
- CodeBlog tells of ICU Nurses who dress up the babies on the unit for Halloween.
- GruntDoc grunting about the overhead "code blue" calls.

"Paper records are an utterly irrational national security risk." - Newt Gingrinch

"We don't want people to be saved, taken to a shelter and then face the risk of death because doctors don't know what's going on with them." - David Brailer, after Katrina

"It's a key part of saving Medicare" - HHS Secretary Michael Leavitt, referring to EHR

"This is the No. 1 issue for many CEOs. Health-care costs are going up so rapidly. Society can't afford it. You've seen a change in philosophy. The country has the political will to support this." - John Chambers, CEO of Cisco, referring to growing healthcare costs and the need for e-Health.

"There's not a single proposal to create a government-run database in the basement of the Health & Human Services Dept." - John Holamka, CIO Harvard Medical School

"It's time to modernize the health care system" - Craigg Barrett, Chairman of Intel

Healthcare IT, and in particular EHR, continues to be plastered all over the media these days. Some highlights:
- Hurricane Katrina highlighted the need for EHR
- A federal commission recommended that the gov offer financial incentives that encourage a standardized exchange of patient health information.
- BusinessWeek had a whole section on Brailer, the man who wants to heal healthcare. They also tried to balance that story with this article on the need to protect patient privacy.
- Meanwhile, some states, like Wyoming, are proposing state-wide EHRs. Michigan's got a plan to take all state medical records electronic by 2015.
- IBM has been busy! First, they announced that their employees can not access their medical info online. IBM also announced that they are making their healthcare software open source, a good step to improve interoperability. They'll also be discussing this interoperability issue with fellow big guns Cisco, Microsoft, and GE Healthcare at the World Congress.

UPDATE 1: Also, check out Matthew Holt's post today on EHR's - he's spent a lot of time thinking about these.

UPDATE 2: not just another new blog, HealthNex is a group blog by a bunch of IBM Execs (many ex-HealthLink folks). This one is also definitely worth a look.

Hosting Grand Rounds this week was quite an experience. Thanks to all who linked to it - the post was visited ~1,500 - 2,000 times! Thanks to Instapundit for contributing to about half of that traffic.

Blogging in general is growing - doubling every 5 months. Medical/Healthcare blogging may not be growing as fast, but growing nonetheless.

Grand Rounds was a modest 15-link post a year ago, and this week it was 32 links (and I had to decline a few). To all you healthcare bloggers out there, wouldn't it be cool if Grand Rounds becomes the best Carnival of them all!

Now would also be a good time to say hello to a few new healthcare bloggers.
- Healthcare IT Guy just started a week ago and is off to a strong start. I enjoyed his recent scoop of a doctor who stores medical images on his iPod. Yikes!
- Unbounded Medicine just started this week with some interesting images of chest x-rays.
- Unsolicitied Marketing Advice started August 10th. Since he does marketing for a hospital organization, he's got some advice on everything from creating good hospital signage to how to think about your hospital's various PR vehicles. And as an added feature, you can listen to any of his posts.

Speaking of podcasts, Kent Bottles over at Soundpractice has been doing a healthcare blogging pioneer podcast series. So, if you want to hear whether bloggers can speak as well as they blog, check out their podcast directory (including an interview he did with me this past week). And no, I don't speak as well as I blog (which ain't saying much!). FYI - the recording makes us sound like we all have lisps.

Greetings from the Windy City! My name is Tony Chen, I started hospital impact one fateful evening in March 2005. I work at Healthcare Financial Management Association as the Director of Product Innovation. In this role, I'm responsible for developing and bringing new products and services to hospital executives. Thus, I am constantly thinking about the business side of hospitals, especially the financial management aspects.

Given my business background, I am also very interested in all aspects of hospital management / leadership and am curious to find leadership insights and strategies from other industries. I believe that hospitals lag behind many other industries in various respects, but most importantly in the area of business leadership. Still, I believe that hospitals can be the best run organizations on the face of the planet.

Before HFMA, I was in business school at the Kellogg School of Management, where I majored in non-profit management, marketing, and finance. I also worked part-time as a healthcare equity research associate for an investment bank and was an independent healthcare management consultant. Prior to Kellogg, I worked several years at Merck as a Project Leader and Management Analyst. Back in the day, I was a Chemical Engineering major at Cornell University.

Obligatory Disclaimer: the views and opinions expressed on this blog most definitely do not necessarily reflect the views or opinions of my employer, my employer's members, my friends, my mom, my goldfish, or anybody else besides me. Hospital Impact is not affiliated with HFMA, ACHE, or any other four-letter acronym and is purely a personal endeavor. I may refer to HFMA resources from time to time, but only when I believe it benefits hospital impact readers. [add your favorite legalese here]

Drop me an email at tony[at]hospitalimpact[dot]org. Hope you stay awhile!

Check out my very first post here. Wow, I was such a young, misty-eyed blogger back then!

There have been quite a few successful hospital turnarounds recently:
- Maricopa Medical Center: $12MM in debt to $25MM in the bank in 6 months.
- Tufts-New England Medical Center: $25MM loss to break-even in one year
- Amsterdam Memorial Healthcare: $4.7MM loss to $0.4MM profit in one year
- Detroit Medical Center: $60MM loss to $9MM profit in two years
- Western Suburban Hospital: $19MM loss to break even in 1 year.

So, what's the common thread?
The common thread is that all of these turnarounds resulted from strongly-led team-based effort on several different fronts. If there is any "silver bullet," it is this vague, difficult concept of leadership. Those who led these turnarounds did these things well:
1. Rallied their leaders around them. And if they didn't have strong leaders already, they hired them. Hospital leadership is hard enough even in good times.
2. Attacked the problem on multiple fronts. They simultanously cut costs (revamped staffing practices, renegotiating their credit, renegotiating supply cost), increase revenues (rev cycle management, denials mgmt, contract negotiations, new channels for referrals, marketing new points of differentiation), and improve employee morale (see how this HCA hospital did it)
3. Focused on the key opportunities. Despite the multi-pronged approach, these leaders didn't try to solve everything at once. They focused on the high-impact areas first.

Balancing #2 & #3 is essentially a function of how well you do #1.

Welcome to today’s grand rounds. This week, instead of departmental presentations, I would simply like to read a letter from a janitor in our hospital.

To:
Hoss Pitle, CEO
Neighborhood Hospital
Sum Whear, SW

Dear Hoss Pitle CEO,
My name is Jan Itore, I am a janitor on the 2nd floor in the hospital. I am writing you today to express how proud I am to be a part of this hospital family - what interesting people we are associated with! I would like to share with you a glimpse into this fact as I was finishing my shift one evening.

As I was walking out, I bumped into Nurse Kim of Emergiblog. I love her stories, especially her EmeriAwards - I couldn't stop laughing at the funny and crazy things patients do in our hospital. As we were chatting, we saw doulicia, who had some thoughts about crazy patients - in particular, OB patients trying to manipulate labor's natural clock.

As we were walking out, we walked by radiology - and they were laughing, too. According to Sumerdoc, someone actually did a study on radiologists' brain activity as they looked at radiologic images. An analysis on the analyzers - I love it! Speaking of brains, we bumped into ShrinkWrapped, who wondered if an "ego transplant" into the brain could one day become a reality.

Like I do every Monday night, I headed over to Bar Louie for a few drinks. I love this bar - always interesting people debating interesting topics. Of course, Hank of InsureBlog and Jill of OUPBlog were there, debating national health insurance. Corpus Callosum chimed in on the worsening health insurance situation, too. Elisa of HealthConcerns had a group of doctors and moms together discussing a case of a mom disagreeing with her doctor's diagnosis of her son's development (does he have autism or not?). Dr. Andy brought up an ethical question about organ donation: does the donor have the right to specify the race of the recipient? Galen's Log also piped in on organ donation: what if a proclaimed organ donor who requests DNR can only donate if she is put on life support? CodeBlog recounted a touching story about a 12-year-old organ donor.

BarbadosButterfly recounted her first patient near-death experience. GruntDoc explained how the challenges of their newly-remodeled ER: as a nurse said, "I just act like it's a new job: I know how to do things but don't know where anything is."

Around a friendly game of pool, the folks at Health Business Blog wondered if the military would start drafting docs and dentists, given the growing shortage. Red State Moron pondered aloud about whether airlines will one day be liable for medical conditions that develop on their flights, like this case of DVT. The folks at Clinical Cases and Images Blog wondered if this new diabetes medicine is the next "Vioxx."

Multiple Mentality came in with a group that ordered calorie-free beer, and he explained the real risks of gastric bypass. Like 5% death within a year.

Rita of MSSPNexus blog came in with a group of wide-eyed 3rd-year residents. She explained the rigorous, somewhat-ridiculous process of credentialing and privileging.

The science booth in the corner was lively as usual today. Dr. Lei, of the Genetics & Public Health blog, was sharing with a group about genetic testing for cancer in African-American women. Mic of Antifaust shared about the concept of the "universal antidote." Tara of Aetiology reviewed the fact that the measles vaccine does not cause SSPE. The whole booth burst into shouts of disbelief as Dr. Emer told them that our beds may be dirtier than our bathrooms - the dust mites on our blankets produce a couple of pounds of excrement per year. Orac knows railed against the stem cell injection treatment going on in a Moscow spa.

In the next booth were the techies. The Krafty Librarian had a few doctors at the table, and she asked them whether UpToDate is really better than FirstConsult and eMedicine. Tim of Medical Connectivity talked more about Cisco's new connectivity product for hospitals.

Difficultpt came in with a group of pediatricians, sharing with them her difficult, painful childhood experience and asked them to be extra vigilant during the holidays.

Dr. Charles and KidneyNotes came into the bar at this point and bought me another drink. Dr. Charles, in a halloween mood, started telling the story of a visit to a "haunted" patient home and how office visits, for better or worse, can grossly oversimplify the patient's problems. Staying with the slightly-creepy-but-informative theme, KidneyNotes chimed in with a remembrance of Gretchen Worden, the late curator of the famous medical oddities museum in Philly.

Then, I saw Kent Bottles of SoundPractice going around table to table, offering a free drink for anyone who could explain why he is so confused about consumer-driven healthcare. The Cheerful Oncologist was offering free drinks for a month for anyone who could get through his 4-question "who wants to be an oncologist?" game show. Enoch of MedMusings then came in, and I bought him a nice glass of wine as he told some stories from his missions trip to help Katrina victims.

So, at this point, it was getting late and I already had my 2 beers, so I thanked everyone for another wonderful evening and decided to head home.

I walked home marveling at everything I had just heard about: soccer ball-sized ovaries, an ego transplant brain surgery, $3,000 genetic tests, 500,000 vaccine-preventable deaths, dust mites on my pillow feeding off my sweat and dead skin, and a drunk patient on a bed peeing 12 feet across a room.

I finally arrived home and picked up my mail. Yup, there it was - the dreaded hospital bill from a few months ago. Thankfully, the bill was not too bad, and I could actually understand it - thanks for making my bill patient friendly (and thanks Andrew from HealthcareTomorrow). My neighbors are always complaining how they wished their bill and healthcare in general came with instructions.

So, Mr. Pitle, thank you for letting me be a small part of this hospital community full of interesting and passionate people. I may "just" be a janitor, but I, too, am committed and passionate to make patients happier and to make healthcare in this country just a little bit better.

Sincerely,
Jan Itore

[I once spoke with one of the most famous hospital CEOs in America. Out of all the things he could have shared with me that day, he talked to me about a cleaning lady in his hospital. This is the story he told... A patient was in a coma and her grieving family sat around her. The patient had been completely unresponsive for weeks. Then, a particular cleaning lady unknowingly and deeply moved this family - simply by doing her job with a smile and by singing/humming a sweet tune under her breathe. The family noticed that the patient actually responded to this far-off cleaning lady's humming ever so slightly - a twitch of the eye, a tear. The family asked the cleaning lady to come in and sing to their loved one in the coma. Without hesitating, the cleaning lady put down her mop, came into the room, and sang an angelic tune. It was a tender, moving moment for the whole family - another tear flowed down the patient's face. A few days later, the patient died, but the family was so moved by the event, that they wrote the hospital, wanting to thank that anonymous cleaning lady. This week's grand rounds is dedicated to that unnamed hospital cleaning lady, and to all those in healthcare who do their job with a smile on their face and a sweet tune on their hearts.]

This concludes this week's grand rounds. Next week's host: Kidneynotes. Archives of previous Grand Rounds can be found here on Blogborygmi. For a list of submission guidelines, click here. For a flashback of grand rounds exactly a year ago, visit my post from yesterday.

Since I'm hosting Grand Rounds this week, I thought it'd be interesting to look back - what were you doing a year ago?

We know what Bush and Kerry (and the Red Sox) were doing.

what were we blogging about exactly a year ago? Here's a flashback to Grand Rounds, week 5. Code Blog hosted a 15-linker.

The Good: 14 out of those 15 contributors are still frequent and active bloggers today.

The Bad: 3 of the links don't work anymore, probably because of re-archiving, etc.

The Ugly (or the beautiful, depending on how you look at it): The issues and stories we faced a year ago are still relevant today: physician apology (from Kevin MD), crazy Red Sox fan/patients (from Blogborygmi), and the future of grand rounds (from medmusings).

Essent Healthcare bought another community hospital, with the proceeds going to a charitable foundation that will fund local health programs. If I'm in that community, I'm celebrating - the hospital's under new management AND there's a new multi-million dollar foundation that'll fund health programs for me. Two-for-none benefits.

Essent Healthcare is relatively new - this is only their 5th hospital acquisition. I previously mentioned another hospital acquiring newbie Stonebridge (their CEO is anything but a newbie).

Speaking of M&A, hospital M&A activity was $1.3B for 3Q05 (compared to just under $1B for 2Q05). As you look at this report more closely, the one thing that jumps out is the M&A for Managed Care - $17.3B. Of course, that's mostly WellPoint's buying WellChoice ($6.5B)

And finally in the international front, apparently French hospitals go for about the same amount as American ones. German hospital giant Fresenius bought hospital chain Helios Kliniken for $1.8B. 24 hospitals, 9,300 beds - so they paid ~$200,000 per bed, similar to deals in America that I've posted on previously. And even after dropping $1.8B, looks like Fresenius is really just getting started.

What does all of this M&A mean? To me, it basically means three things: (1) a lot of people think they can add a lot of value to existing hospitals; (2) a lot of people think healthcare's future growth prospects and profitability is more viable than many other industries; (3) a lot people see "niche" opportunities: finding and buying hospitals with similar characteristics.

(UPDATE: don't get too carried away, though: Evanston Northwestern was just ordered by the FTC to sell Highland Park Hospital. The reason? the acquisition "substantially lessened competition" and drove up health care costs)

"With wigs, makeup and volunteer stylists, the Claudia Mayer Cancer Resource and Image Center enables patients to live their lives as they fight their disease" (From the Baltimore Sun)

At the Claudia Mayer Cancer Resource and Image Center, cancer patients can throw a "wig party" like Stephanie Dietz did last spring. She got her friends and family together to help her pick a wig, which was then custom-styled for her. Cancer patients can also just sit back, read a magazine, and have a cookie. Or they can shop for prosthetics, bras, hats, turbans, scarfs, and lingerie. Or they can spend some time in the professional salon.

To follow up on last week's post on hospital CEOs, check out these fairly extensive survey results (reg req) on the hospital CEO and C-suite dynamics, done by Cejka search and Soluient. This is an unusual survey in that it compares Solucient's "Best in Breed" hospitals with other hospitals on various dimensions.

112 CEOs responded and said this:
- the top trait valued by CEOs is strategic thinking
- best in breed CEOs are more likely to have served as COO prior to becoming CEO.
- best in breed CEOs have advanced degrees
- best in breed CEOS are more likely to have been promoted from within
- the top 3 critical dashboard indicators are: patient volume, productivity, and average length of stay. (almost 2/3 of best-in-breed CEOs reviewed patient volume daily)
- the avg CEO become a hospital CEO at age 39.

This week's Grand Rounds are up at Diabetes Mine, maybe the best patient blog on the web.

Next week, Grand Rounds will be right here at hospital impact! Please email submissions to me at tony[at]hospitalimpact[dot]org by Monday night 11:59 EST, October 24.

Archives of previous Grand Rounds can be found here on Blogborygmi. For a list of submission guidelines, click here.

For those that are new, Grand Rounds is the weekly wrap-up of the best entries in the medical/healthcare blogosphere. Check out a few in the archive and you'll see a little bit of everything: patient stories (funny and scary), healthcare policy musings, health trends, patient/physician relationship mishaps and heroics, and the works.

Among the 133 hospitals surveyed by HCPro, 25% are using overseas radiologists and another 14% are considering doing so by 2007.

However, even though cost and labor drivers may feed this trend, a bill has been proposed on capital hill that could stifle it. Hillary and fellow Demo Markey (MA) have introduced two bills that would require patients to "okay" their info being sent and evaluated by offshore docs/technologists.

For more on this general topic, check out radlinx's site, including news on offshore radiology, a 2004 survey of 276 radiologists,

Also, check out Nighthawk's website - they are another leader in the field, based on Australia. You can see pictures/bios of their 36 radiologists on staff.

It was very flattering to be considered in the same group as Shrinkette, MedPundit, and KevinMD - all 4 of our blogs were mentioned by the MSSPNexus Blog as "big dogs." Hospital Impact apparently is worth $15,000 or so. Find out how much your blog is worth here.

Using the knowledge that AOL paid between $25 - 40MM for Weblogs, Inc, we have our first benchmark of how much a blog is worth to traditional media companies. True - Weblogs, Inc is more than just a bunch of linked blogs - it's also an infrastructure as well as a brand. AOL ended up paying $560 - $900 per link source (using Technorati). That's obviously not gonna hold for us small-time niche bloggers, but it is the 1st data point (of hopefully many to come) of how much blogs are worth.

Also, check out this self-reported database of # of visitors & monthly Adsense revenue. This guy from Malaysia makes $6,000/year from his blog.

UPDATE: by the way, has anyone else seen their traffic increase dramatically since google launched their blogsearch tool?

This hospital in Nebraska just successfuly put in the "At Your Request" Program from Sodexho. From 7AM-7PM, patients can order from a menu with full breakfast items, baked fish, hambugers, grill items, etc. Apparently, this reduces food costs, reduces waste, and gets nurses out of the food service business. Check out Sodexho's PDF Sell Sheet for more benefits.

Sodexho has put this program in place for 233 facilities. Not surprisingly, Aramark, a leader in food service (among other services) in hospitals, offers a similar menu-driven program. Also of note from Aramark was their 3/23/05 press release on hospital dining - they estimate that only 50% of employee dining needs are being met at hospitals. If hospitals could do this better, hospitals could increase revenues by $350MM/year.

UPDATE: Seems like every week, I'm hearing more and more about how hospitals are becoming more like hotels. Like I previously posted, hospital patient registration clerks need to become more like hotel check-in personnel. Andrew Barna's got a post on hospitals being "more than a hotel." Also, HealthLeaders also highlighted some lessons that hospitals should learn from the Ritz-Carlton. One example: all hospital workers, clinical or not, are "on stage" and should "maintain positive eye contact" and "use proper vocabulary."

Get ready for some more bad press for hospitals. Quoting from the article: "In the first decision of its kind in the country, Circuit Court Judge Richard Baldwin certified a class action lawsuit filed on behalf of thousands of uninsured patients of Legacy Health System ("Legacy"). The lawsuit accuses Legacy of consistently overcharging its poorest and most vulnerable patients -- the uninsured -- by billing them the highest rates without their knowledge. These prices far exceed the amounts that Legacy requires its insured patients to pay for the same exact services."

Hopefully Legacy won't go the route of Sutter Health and countersue.

If your hospital doesn't have a good charity care and discount policy (See 2/05 PFB report), a defensible pricing model, and a community benefit communications plan, now may be a good time to work on them.

A new study was released last week that shows that the percentage of Americans who are considered obese has been constant over the last 5 years. 62% of adults and 34% of kids are considered obese - and that those #s have been the same since 2001. Still, those numbers are dumbfounding - that means we have ~150,000,000 people in the United States that are considered obese. The CDC think that number is more like 90,000,000, but nonetheless, that's a lot of people.

Despite the exploding awareness levels from so many diet programs and TV shows (e.g. the Biggest Loser), the good news for me is that the numbers don't seem to be going up. (With all the new products, I just assumed that the problem was getting worse and worse.) Hopefully the increased attention especially in the last 2 years can start to turn the tide. Check out a few of my previous posts on obesity - the power of inertia in human behavior can be so strong. Also related, check out this brutally honest analysis of the obesity problem from the UK Herald. Yes, some obesity is genetically-linked. But since obesity has doubled in 20 years, we know - all fingers point back to our lifestyle decisions. This may be one case where financial drivers will force the government and corporate America to step in - make exercising cool (an ad campaign like the successful anti-smoking campaign) and make eating healthy easier (e.g. no more soda in schools).

Nonetheless, for hospitals, this means the continued supersizing of healthcare facilities and growth in the bariatric segment. We who work in healthcare also have to lead by modeling the way - we have to take care of ourselves, too. I've been fascinated by Biggest Loser Contestant Jeff, an MD, who is on the show because he can't credibly tell patients to take care of themselves unless he does so himself.

According to a report from Deloitte & Touche, hospital CEOs are more optimistic on healthcare's financial outlook. 29% (down from 32%) of hospital CEOs thought their hospitals could fail financially in the next 5 years.

hmm... actually, is that supposed to be good news? A 3% drop is good - that's probably around 150-200 more hospital CEOs who now think they're financially okay. But that still leaves 29% - 1,500+ hospitals that could fail financially. Does this scare anyone else? With such razor-thin margins, I guess anything could swing it to the negative. The report also shows that only 67% of hospitals are profitable.

Stepping back from these numbers, I think this report just reminds me of how precarious of a situation we have here. Sure, there are lots of hospitals making money, using technology well, applying supply chain best practices, bringing down denials, etc. But there are still many hospitals (maybe 1,500 to 2,000) that are just barely scrapping by - some of those are behind, some maybe made a few bad isolated decisions. Inevitably, there are also some that are doing everything right, but won't make it financially without outside help.

Everywhere you look on TV or in the movies, the typical stereotypes for doctors and nurses continue to be propogated.

Doctor lives are exciting and cool. Though sometimes they're arrogant, they're are smart and interesting. On the other hand, nurses are nice, caring, unnoticed, and constantly dumped on. Some nurses are portrayed as downright dim-witted.

It'll be interesting to see how that nurse reality TV show does. They're positioning these nurses as: "compassionate, adventurous, and heroic." They're also positioning the show as one that will "change your view about nursing." Here's the cast:

Seems like a decent mix of young/old, male/female, stereotypical/non-stereotypical.

Maybe this will be the first TV show ever where some kid will watch it and say, "mommy, when I grow up, I want to be a nurse."

We'll have to see if anyone actually watches it (doesn't seem like the show's been picked up by any networks yet). And how will they handle HIPAA?!?

StoneBridge Healthcare, a new venture formed by industry veteran Joshua Nemzoff, will partner with physician groups to buy hospitals and provide "a superior patient experience." It will be structured as a whole-owned joint venture, whereby docs own a small stake in the company (and not to mention, docs are allowed to self-refer - see Modern Healthcare article pdf). The name "StoneBridge" is to highlight what the company plans to do: to bridge the gap between hospitals and patients.

Their competitive advantage:
- let docs design everything for the patient experience, and let those who know the business side do their jobs, too (this one doesn't sound all that innovative)
- docs can self-refer, and patient volume has been shown to increase 20% within 3 months! (this one is kind of hard to believe?!)

By the way, this Joshua Nemzoff, the CEO of the company, is no stranger to hospital acquisitions. He may very well be the America's hospital acquiring expert, with more 175 transactions and $7B of hospital M&As under his belt. So, if there's anyone who can spot an easily-turned-around hospital, it's him.

That's right. A new study from Ball State University has come out that shows that we in America spend an average on 9 hours A DAY consuming various forms of media - internet, TV, radio, magazines. This constant barrage of information makes me wonder (like I have in the past), when do we have time to think?

This also makes me wonder about this blog. Is this blog helping to filter the noise or am I really just adding to the noise?

I have to admit that my entries recently haven't been as thoughtful as I would hope. Why is it that we bloggers aim to post something daily? If we have nothing good to say, shouldn't we just keep quiet? Isn't one real good insight better than 10 regurgitated pieces of news? On the other hand, the daily posting enforces a certain personal discipline to "think" about something fresh and new everyday.

One other observation about blogging on hospitalimpact: I get the most comments about medical stuff or healthcare industry stuff. In other words, it seems like the majority of hospitalimpact readers aren't the people that it's aimed at: hospital administrative folks. I'm beginning to theorize that hospital admin just don't read blogs very much, while industry and medical people do. Is this a demographic thing (are hospital admin older?)? Is this a technology thing (are hospital admin less tech savvy somehow?)? Or maybe it's just because of sheer numbers?

Why is it that there are scores, if not hundreds, of doctor blogs, while there are only a handful (maybe less than that!) hospital admin blogs? Then again, patient stories will always be more interesting than revenue cycle stories.

Turns out anesthesiologists do another balancing act in the OR besides the medicine of anesthesiology - picking the tunes. A talented OR DJ? be chosen more often for surgeries!

I'm sure we all saw the announcement last week from GE Healthcare on their acquisition of IDX for $1.2B.

Just to give you an idea of size, GE Healthcare has annual revenue of ~$14B, IDX has an annual rev of ~$0.6B. GE Healthcare has 42,500 employees to IDX's 2,400. In other words, with this purchase, GE Healthcare just got ~5% bigger.

A little more context: if you look at Healthcare Informatics Top 100 Health IT firms, IDX ranks #15. I think we all expect more consolidation as the big guns try to consolidate their strength & exploit cross-selling synergies.

Just a few weeks back, Banc of America called GE Healthcare "one of GE's best business," citing strong long-term growth prospects and strong competitive positioning. In the report, BofA also cited that hospital execs plan to increase capital spending by 14% this year. 60% of CEOs & CFOs cited clinical IT and diagnostic equipment as their top spending priorities.

UPDATE: More great in-depth coverage and debate on the acquisition at The Health Care Blog and HISTalk. Both view the acquisition is weird and somewhat un-GEish. This tells me that GE is up to something we can't see yet.

Are group doctor visits on the rise?

This report from Colorado tells us of an OBGYN that has successfully implemented group visits for his practice. Some studies has shown a 7% decrease in cost - reducing the number of hospitalizations, office visits, and calls to nurses. While some patients expressed anxiety (esp. if the pregnancy was their first), many seem to enjoy the camaderie among other patients, more time with the physician, and less time in the waiting room.

If you are interested in implementing group visits, check out this PDF. In it, check out their recommended group visit format and agenda, a sample hand-out to get patients to sign up, and potential productivity calculations.

In the last month, I've seen two how-not-to-get-screwed-by-hospital-bills articles.

This one from a Florida Newspaper is written towards seniors who have a hard time deciphering their hospital bill. They quote a startling stat (anyone know where this is from?): hospital billing errors result in patients overpaying by $1,300 on average. Aside from the typical talk about duplicate billing and length of stay, if all else fails - they recommend hiring a billing advocate that charge $30-$150/hour or a commission on the savings.

I saw a very similar article in at biz yahoo on the 8 most common hospital billing errors.

While many hospitals are still in the stone age on making their bills patient-friendly, some hospitals are taking the lead with on-line bill pay and easier-to-understand bills. Read this article from hfm and if you haven't already, visit HFMA's Patient Friendly Billing Project for resources, tools, and insights.

In the last HFM magazine, I saw a very insightful article on why hospital registration clerks need to build relationships with patients.

I think we all already know the benefit for doctors and nurses that establish relationships - more job satisfaction and less lawsuits.

This article takes that a step further to the registration clerk. Why does s/he have to be all friendly, especially to self-pay patients? This isn't about being chummy, but about truly understanding the patient's financial situation. This results in better classification of the patient (bed debt vs. charity care) and sometimes this leads to discovery that the patient is eligible for Medicaid or SCHIP.

As CDHP is on the rise and as hospitals continue to focus on the front end of the revenue cycle, this could be the end of the $9/hour registration clerk. This front-line employee will have more sophistication around revenue cycle, customer service, and even financial planning?

Not a big deal, but maybe the start of a notable trend? Memorial Healthcare System in Florida decided it was worth it to make their entire website available in Spanish. Using TransMotion technology from MotionPoint, the new spanish website will more effectively reach out to the large Hispanic communities - in Miami-Dade, Hispanics make up almost half the population.

Props to MotionPoint, which only truly entered the hospital market in July 2005, by partnering with MedSeek. Just a few months after that partership was announced, scoring just a reputable 6-facility system ain't too shabby. It seems like a superior technology.

The things that come to mind:
- Seems like only hospitals in high-Hispanic population areas (and world-class hospitals) will consider this. However, with hispanic population in the US at 14% (40MM or so) and growing fast, more and more hospitals will be considering this.
- Now that Memorial has a great spanish website, the easy part is done - do they have spanish-speaking registration personnel, nurses, and physicians to back it up?
- It's a fairly well-known fact that the uninsured rate for Hispanics is much higher than some other demographics. So how will increased volume pay for the investment in the website? Or is this viewed as a "community benefit?" (apparently so)
- While we're on the topic of language, the NY health chief is updating her state's regulations to ensure non-English speaking patients get the proper care (and privacy)

So, for my "milestone" birthday this past weekend, my wife took me to Boston & Cape Cod (and surprised me with the presence of some great friends). I also got to visit Fenway Park for the 1st time, which brought back memories of last season's thrilling and stressful run. I couldn't even watch those games last year - it was too stressful for me. Being riled up for hours at a time couldn't have been good for my heart.

Well, according to some stats from local ERs in Boston, watching the Red Sox was potentially dangerous for other reasons, too. Turns out ER visits in 6 Boston hospitals were down ~15% while Boston was in the playoffs last year - lots of people who normally would make the visit stayed glued to their TVs.

I'm still not sure why Red Nova, a science & space website, continues (to pay) to put up these interesting articles on the uninsured, hospital management, the healthcare sector, etc.

In this article, they highlight a state policy difference between Arizona and Florida. Arizona has effectively reduced its uninsured rate from 24.5% to 17% in seven years by putting in $$ to expand health insurance, getting docs to agree to provide discounts, and letting county & local officials develop discount programs.

In the same time period, Florida's uninsured rate went from 17% to 19%.

what the article doesn't address is how did AZ pay for this?

A couple of hospitals in Nashville are finding new revenue streams from... Temper-pedic, and maybe even a soft drink company pushing its water and juices.

Started in July 2005, The Enliven Partnership is pushing the envelop by selling category-exclusive sponsorships to companies who can enhance the patient experience. Hospitals get free products and funds, sponsors get product placements.

Before we dismiss this idea too quickly, read enliven's 2-page PDF that explains their approach - they are obviously also being very sensitive to the overcommercialization/those-capitalist-pigs gut reaction that many of us will have. This could truly be a win-win-win situation:
- Anxious patients get a better experience
- Cash-strapped hospitals get cash and valuable products.
- Vendors get branding

So long as the products truly fit the hospital mission of serving patients better, why not?

Are you an starving artist with no health insurance?

At Woodhull hospital in Brooklyn, no worries! Instead of paying, you can teach pediatric patients how to make sock puppets. That was the experience of Betsy Kelleher, a teaching artist at the Henry Street Settlement in NYC. As this "bartering" program is relatively unique, her story has been getting a lot of attention lately.

will we see more "will work for healthcare" type of arrangements?

--- --- ---
All of this while more unnerving news on the uninsured appeared last week:
- King County (Seattle) has a 10-year high uninsured rate of 15.5%. Furthermore, for Latinos is was 35.5% (!!) and for African-Americans is was 21.5%. (and not surprising there's more uninsured in the city of Seattle versus the suburbs)
- In Arkansas, the uninsured rate is 17%. For Hispanics, it may be as high as 50%.
- In a weird twist of irony, for these uninsured, it took a hurricane for them to get some much-needed medical care.

MCOL has launched a new consumer-driven healthcare website, www.consumerdrivencare.com</a>, for consumer and professionals in the industry. The only thing about this site that I don't like is that I wish I came out with it first - it's about time someone put together a "portal" of sorts for consumers to get this kind of information. True, the info is still light, but they have collected numerous relevant articles and provided advice to consumers.

But for a professional in the industry, the most intriguing part was their stats:
- Enrollment (graph) is up to ~3 million
- The marketshare (graph) leader is Uniprise with 30% of the market. Not surprisingly, Uniprise is a branch of mega-monster UnitedHealth.

9/11 and now Katrina. Hospitals have been spending millions upon millions in the past few years on emergency preparedness: a greater stockpile of diesel to run generators, 72 hours worth of supplies always on hand, security and communications upgrades, etc.

But as this report from Boston shows, many of the country's hospitals are unprepared. As such, JCAHO announced a guide for less affluent hospitals to be prepared. Included in this checklist are things like: safeguarding important data, finding appropriate corporate partners in the community, and linking with mental health agencies/resources. Also, check out the Hospital Association of the Greater New York Area - they have successfully linked their areas hospitals so that resources can be redirected quickly in times of emergency. This may very well be a model for the nation.

The hospital CEO position is probably one of the toughest positions in healthcare, and maybe anywhere. As passionate as I am about healthcare, I honestly do not aspire to this spot.

A few weeks ago, I highlighted the CEO of Detroit Medical Center, who has aggressively turned his hospital around.

A couple of recent hospital CEO interviews in the press recently. Here's one with Desert Springs Hospital CEO, Sandy Kaufman, who talks about the success of their partnerships and service line expansions.

Here's one with Lawrence Hospital CEO, Edward Dinan, who talks about his faith and his "best practices" in hope.

Last year, ACHE put out a very interesting piece (PDF) on CEO/CNO relationships, based on a survey of 1,000 CEOs and 776 CNOs. Among the findings: CEO/CNO relationships are good and CNOs get a lot less board exposure than CFOs.

Also from ACHE, they have been tracking hospital CEO turnover for almost 15 years - the avg turnover for the last 4 or 5 years: ~15% (1 in 7 or 8 hospitals changes CEOs every year!). New on the ACHE site is CEO turnover by state. The highest: Nevada (33%). The lowest: New Hampshire (3%). Strange that there is such a high variance - if you assume that these rates correlate with financial performance, one would speculate that state policy has a big impact on hospital performance?

And finally, since the Modern Healthcare survey on hospital CEO pay, as expected there has been some of criticism and defense. Some of that fun in Pittsburgh and Georgia (pdf).

A heart-warming and good-business move in Atlanta. Shepherd Center decided to purchase the Hawthorne Suites Hotel next door. They'll renovate the place so that patient families can stay temporarily for free. Given that Shepherd specializes in paralyzing spinal cord and brain injuries, the typical stay was 6-8 weeks anyway. Since they had already been providing free temporary housing for 30 days, this increases their flexibility for extending that time and may even reduce their overall costs.

A new RAND report suggested that computerized medical records will save the nation $81B - that's $77B in improved efficiencies, and $4B in less errors. (RAND press release here)

What I'm still trying to understand is why RAND didn't use the Bush Administration's cost estimates of $150B + $50B annual maintenance. And I can't quite figure out all their assumptions. Nonetheless, If they did use the $150B/$50B for costs, that means EHR would pay for itself in about 5-6 years ($81B - $50B = $31B in true savings/year) - remember that's 5 or 6 years after it is completely implemented - not great, but not bad either.

Now if we could just get people to agree on universal standards.

The government's hospital compare website added three more quality measures (2 involve preventing surgical infections and 1 on pneumonia) to its previous 14.

Here's a graph that I pulled up for two local hospitals, Evanston Northwestern and Northwestern Memorial (apparently, they haven't submitted this data yet):

Also, now that the site has been up for almost 5 months (launched April 1st, of all days), 70% of hospitals are now submitting data.

Apparently, bad debt has more or less stabilized in Tennessee hospitals this year. Hospitals are getting better at managing the process, but higher premiums, more high-premium plans counterbalance that.

Some useful stats:
- Community Health Sys: 10% bad debt
- HCA 8.9% (after providing more aggressive discounts to underinsured)
- Industry as a whole: 10.1%

Still, some hospitals continue to blame bad debt for their financial woes, like this one in Indiana. This hospital has simply doubled its aid program, effecting taking $ from the bad debt bucket to the charity care bucket. These 2 hospitals in Idaho are increasing their educational outreach towards self-pay patients, especially the federal CHIP program for kids.

Back in business school, one of the most amazing statistics that I learned was that organizational culture was the primary culprit in derailing 1/3 of all corporate mergers. 1/3! I was surprised that such a "soft, fluffy" thing could become such a huge factor. But it did make sense - it's why so many mergers look so enticing on paper, but end up failing so miserably.

My previous boss always used to say, "Management is in charge of really only 2 things: culture and structure." Since he didn't have an MBA at the time (and I did), I thought I'd inform him: what about strategy? competitive intelligence? what about strategic planning? He just kinda smiled and I thought I had him. But upon further reflection, I'm realizing that maybe he's right. All of those things are important, but they end up falling under structure and/or culture - i.e. strategy & intelligence & planning have to be built into the organization.

And now, thinking about hospitals - when you look at the 100,000 or so deaths that happen as a result of accidents, how many of those are really a product of a poor organizational culture? Aren't many of these errors really a result of people not communicating or people fearing the wrong things? These are org culture fundamentals, aren't they?

When we look at some of the best books written on leadership and hospital management, strangely, they take a disproportionate amount of space to address organizational culture. For example, the series I did on If Disney Ran Your Hospital was primarily about reloading the culture. Hardwiring Excellence by Quint Studer spends a lot of time trying to help you create a success-breeds-success culture. When MBA students study the success of Southwest Airlines, they come to the conclusion that "culture" is their source of competitive advantage - it's unique, it's lasting, and others can't copy it.

So why doesn't anyone in healthcare talk about this more? Especially as the tidal wave of consumerism bring more change, how much more will we have to be organizational culture architects?

Consumer Reports and Health Improvement Institute have launched a beta site for comparing consumer health websites: healthratings.org

Two things I find particularly impressive:
(1) The site provides strengths AND weaknesses for each site. For example, for WebMD, weaknesses mentioned include: "busy with distracting advertising; poor visual representation of pages."
(2) The site attempts to objective rank each website along 9 dimensions (e.g.identity, ease of use, design, coverage, etc). Maybe I'm just a sucker for harvey ball graphics.

By the way, the only hospital to make the top 20 is Mayo Clinic.

Is there a day coming when such a site would exist for hospital websites?

Versant, an interesting non-profit, is tackling nurse retention from an unique angle: providing an "RN Residency" program at your hospital. A quote from their website:

"Unable to handle the intense pressure and resultant stress, new nurses leave their first employment situations at alarmingly high rates in the first 12 –24 months of service; new graduate RN turnover currently runs between 35-60% within the first 12 months of employment"

So far 700 nurses from 13 hospitals have graduated from the program.

If you haven't already, check out MedScape's blog - numerous nurses tell their front line stories in the aftermath of Katrina. Some memorable quotes:

"The looks on some of the faces of these people will probably haunt me for the rest of my life. I already see these people in my dreams. The cries of the residents (and even some of the staff) when they are told they have nothing left to go back to and that we do not know if their families have made it, are sometimes too much to handle."

"Not one person I spoke to had on their own clothes; they were grateful for the donations. It was overwhelming and for the most part seemed unbearable, but every time I looked up to take a deep breath, the outpouring of love and humanity I witnessed gave me strength to move on to the next cot, holding the next person."

"My [8-year-old] daughter provided much-needed assistance by running paperwork back and forth to order medications or to bring me supplies. I watched her facial expressions as she gently placed stickers on the patients signaling that they had been seen by the nurse, always making eye contact and always with a smile. I knew that her life was changed forever, for the better."

Also, check out the story of this 113-bed mobile hospital.

A little under the radar screen, Intel re-orged in January 2005 into 5 units, with healthcare (now called the Digital Health Group) as one of them.

Louis Burns, a home-grown-Intel-exec and now chief of Digital Health at Intel, gave a speech a few weeks ago. What I thought was interesting:
- He made it clear that they're in it for the $$, not for "altruism"
- He eluded to the fact that they will go after home health before hospitals (is this a pilot strategy or just more closely aligned to their tech?)
- They're already working with some tech design for 3,000 hospitals in China

Burns also showed off some wireless therapy systems.

Book Review: Healing Words by Dr. Michael Woods
(4 of out 5)
An impassioned and thoughtful plea from a doctor to doctors to say "I'm Sorry"

Given all that has been recently reported on physicians saying "I'm sorry," this short, straightforward book couldn't have come at a better time. Dr. Michael Woods has written a practical, motivational book directed at physicians on the why's, how's, and what's of apologizing to patients. Drawing from personal experience, stories from other doctors, examples from other industries, and research data, Dr. Woods does not hold back in making an impassioned plea for physicians to master this tricky part of the patient-doctor relationship.

At ~82 pages, you can probably read this book in one or two sittings (In fact, I read most of it in the waiting room as I waited to see my doctor. Luckily he didn't have to apologize for anything that day). Dr. Woods moves quickly from topic to topic, breaking down just about every psychological, cultural, and emotional aspect of "I'm sorry" - why it's so difficult for physicians in particular to apologize, what a meaningful apology entails, what the patient is thinking/feeling in apology-worthy situations, how to build more authentic relationships with patients, and even what exact words you could say in difficult situations. He even advises to apologize for: "(1) being late for a scheduled appointment; (2) receiving a patient complaint about poor service from hospital or office staff; and (3) Interrupting a patient who is speaking - even if you must take an emergency call."

Overall, doctors should apologize appropriately (and probably more often)- it's the right thing to do, it's the compassionate thing to do, and if that's not enough, it might even prevent some lawsuits.

Definitely this is a book written by a doctor for doctors. For the admin readers, something to read and then pass along to your clinical leadership (and risk management dept).

I'm just sorry that I didn't read this book sooner.

As most of you have seen, a lot has been written recently on the "the power of apology" from physicians. This is an overdue & healthy development that could make a huge impact. It's a shame that it took data "that it pays to be honest" to get people's attention. But hey, regardless, this is better for the patient, better for the physician, and better for our healthcare system.

Tune in tomorrow for a book review of "Healing Words: the Power of Apology in Medicine" by Dr. Michael Woods. For today, here's a summary of what I've seen:

Physician Apology in the blogoshere:
The very prolific Kevin M.D. has posted numerous times on physician apology, but most relate to the fact that apologies actually decrease malpractice and politicians who realize its value are trying to make it less risky for physicians to do so. Red State Moron laments that sorry shouldn't be the hardest word and quotes from a popular (and highly-linked-to) article from the National Review. Dr. Tony reports that even Harvard's teaching hospitals is considering a sweeping disclosure policy, including training in apologizing. StraightFromTheDoc (I told you he is prolific) points to a case when admission of a tragic mistake led to increased quality and reduced medical error in a Boston hospital OB-GYN area.

Physician Apology in the press:
Sorry Works!, of course, has been getting tons of coverage: from Time Magazine, the New Hampshire Union Leader, the Boston Globe, the St. Louis Post, and the Chicago Tribune, to name a few.

Also, there is the now-infamous op-ed piece (reg required) in the NYT by Dr. Richard Friedman. His closing line: "In the end, most patients will forgive their doctor for an error of the head, but rarely for one of the heart." Another memorable quote: "Patients sometimes spontaneously improve despite incompetent treatment. On the other hand, a patient who receives exemplary medical care may fare badly simply because the illness is hard to treat. In other words, doctors are often praised or blamed, when the outcome is in fact a chance event."

Here's some interesting data from one malpractice insurer in Denver: "Average payments to aggrieved patients were under $6,000, compared with about $284,000 for doctors not in the program." For more eye-opening examples/stats, check out this article in RedNova.

AHA launched a new site Hospital Relief Efforts - other hospitals around the nation can use this site to offer up personnal and supplies. (Hat tip: MSSP Nexus)

I was quite excited this week when I was contacted by Andrew Barna, a hospital executive over in San Jose, CA. He just started a hospital-admin focused blog, called healthcare tomorrow. He's off to a great start with an entries on HSAs, what's right on healthcare, and (my personal favorite) the long-term potential impact of JCAHO.

Andrew - welcome to the hospital admin blogosphere! Look forward to more insights now that the JCAHOites have left the building.

Most hospitals are prepared for some emergency, but this was just too much. Read this NYT article for an inside look into how area hospitals are coping. No electricity means: diagnosing infections with your sense of smell, manual pumping of airbags for pulmonary cases, and trying not to get stung by pesky insects. Still, there's plenty of canned ravioli, peanut butter, and corn flakes to go around. A couple of hospitals remain open:

Biloxi Medical Center, the only one in Biloxi.

Oschner is still open, too

To the staff and administration of these hospitals, thank you for sticking around to serve your communities.

Hurricane Katrina has wrecked havoc. Many local hospitals have put up a valiant effort - little electricity means carrying each patient up the staircase floor by floor. But most of these folks will have to be evacuated, too...

How do I find loved ones?
There are still tons of us who don't know whether a friend/family member is okay. Check out Josh Britton's site for a good guide on how to find our loved ones.

How do I donate?
To donate to the Red Cross, click here. Better yet, you can also donate directly to Red Cross at your local Best Buy, who will match it up to $1MM. $21MM has already been donated, but more is needed. Red Cross is calling this the largest response to a natural disaster in the history of the Red Cross.

For those that need more incentive than that, you can bid on these items (like a pass to the premier of latest Morgan Freeman movie) in this charity auction. Feels a little weird/wrong thinking about movies, hollywood, and weekend getaways right now, but hey, our fellow Americans need all the support they can get. so give in whatever way you're comfortable.

How do I volunteer?
Again, check out Josh Britton's site. He suggests to go through your local Red Cross office.

What else can I do?
Give blood at your local Red Cross - blood will be in short supply. Folks in FL can conserve energy, as one of their main gas lines went through Mobile Bay, AL. Others in the region can offer up a room to displaced folks on craigslist.

A few weeks ago, I posted on a company opening a profitable chain of Urgent Care Centers in Florida.

Now, there is a former high school football coach opening up a profitable chain of OB-GYN Clinics targeted specifically for uninsured and undocumented residents in Altanta.

For $1,700, mothers-to-be get all the pre-natal care they want.

Throw out the conventional wisdom:
- that OB-GYN is unprofitable
- that serving the uninsured is unprofitable
- that the uninsured won't pay (the wife/COO says 95% pay in full)
- that hispanics don't want pre-natal care

They've got some good things going for them:
- their costs are lower, so they can charge less. They drive down costs by actually offering pre-natal care (or else pregnant hispanics show up at the hospital on the day of delivery, driving costs up)
- they know this market (The CEO is Hispanic and gathered his Hispanic OB-GYN friends to start this)
- no one else wants to compete with them
- Hispanics tend to have more babies
- word-of-mouth marketing in the Hispanic community rocks

Their biggest mistake so far: "Probably not being ready for the volume of people that showed up. We underestimated the market."

Health Buddy, created by Health Hero Network, allows patients to stay connected with their healthcare provider in the comfort of their own home. Especially for elderly patients and others will chronic illnesses, the ~$50-200/month is well worth it. 7,000 people have signed up.

The results? (From SF Gate) "In a pilot program conducted by the Veterans Health Administration, 281 veterans with chronic diseases were given home health monitoring equipment, including the Health Buddy. The results showed that hospital admissions for the group fell 60 percent, according to a study reported in Telemedicine Journal and e-Health in 2003."

All of this talk on CDHP, I decided to take a deeper look. Check out this chart below for what I've gleaned from HSADecisions summary of CDHP.

Seems that when most people say "CDHP," they're really talking about HSAs.

I'm still struggling (like many others) over how pervasive CDHP will be.

The it'll-be-huge camp: HSAs really only became available 1/2004 through MMA of 12/2003. In the last 15 months, enrollment has surpassed 1 million people. The entire 45 million+ uninsured market will benefit from this.

The its-overblown camp: HSAs have hit only 1 million folks after 15 months. That's 1 million out of 300 million. Plus, it's not the uninsured that are signing up for this - many can't even afford (or aren't willing to pay) to obtain a high-deductible health plan ($100-200/month for a single person) to be eligible for HSAs. The stats say that only about 1/3 of current HSA users were previously uninsured.

I tend to be in the "it'll-be-huge" camp. Consumerism is taking over every aspect of our society, and nothing will prevent it from spreading into healthcare. And it won't just be the uninsured getting HSAs - it'll especially be the underinsured.

What does this mean for hospitals? If you thought your current revenue cycle was complex, get ready for a whole new level. if you thought your bad debt was starting to stabilize, i've got news for you. forget travelocity, how about hospitalocity?

Also, check out this interesting podcast with Matthew Holt explaining CDHP impact on physicians. (26-min interview - mp3). Obviously a very great topic, as you can see by all the passionate comments it got.

Look at the amazing range of profit change for hospitals in Florida:

Hospital profit change (FY2003 to FY2004)

Sure, some of these were a result on one-time events and write-offs, but still! No hospitals in Florida had a profit change less than 20%. And more volatility could be coming. Hospital officials attribute this to the difficulty in forecasting volume, type of volume, and # of uninsured.

Wow - it's hard to believe that hospital impact has been up for 5 months now!

Here's what others having been saying about it:

"Great blog...links are terrific resource" - Carol Kovac, GM, IBM Life Sciences

"An interesting new blog" with a mysterious origin - Matthew Holt, The Healthcare Blog

"A great little blog...you can certainly do much worse than hospital impact...staying up to date on great healthcare news" - Cincinnati Healthcare News blog

"His personal category is perceptive and worthy of note." - Health Care Blog Law

"Refreshing to see such a well thought out approach to delivering information that hospital administrators can use to improve the business side of healthcare delivery." - from a Healthcare Facilities Services Vendor reader in Philadephia

"A fantastic site and the information has been tremendous " - Director of Patient Care Services, CA

"About time somebody takes on the voice of hospital business" - Healthcare PR Consultant in PA

Please! suggestions, comments, ideas, questions, lashings, flattery, and prayer requests welcome! tony[at]hospitalimpact.org

As a continuation to a previous series on community benefit, I thought this was a very thoughtful piece from an unique Chicago-based organization.

The Metropolitan Chicago Healthcare Council put together this very well-done economic impact report (pdf highlights or pdf full report) of Chicago hospitals on the community. Among the highlights:
- 400,000 primary and 2ndary jobs
- $23.7B in personal income for residents
- Better (and more sustainable) jobs with an average salary of $63k (~$20k more that region's average)
- $1.8B in capital spending, creating significant construction employment
- ~3,000 new hospital jobs per year through 2020.
- Every $1 in hospital wages creates $1.42 in non-hospital wages
- Every 1 hospital job creates 1.54 non-hospital jobs.

It's hard to believe that this hospital system lost $500MM 6 years ago. A few weeks ago, they just reported a $9MM profit for the 1st half of 2005. How did they turnaround their hospital? Their aggressive CEO (a formal attorney) mainly did via increasing patient volume. A well-publicized 29-minute guarantee for speedy ER service, a string of great leadership hires, layoffs, the addition of some specialists, and an organizational change in culture has upped ER visits 14% and increased overall patient visits by 5%.

I read a realy interesting OpEd piece by Richard McCartan the other day on preventable deaths in the United States. His main point was this:

"There are other, more preventable causes of death that the billions being spent on homeland security and terrorism prevention might be better spent upon. Policy makers should consider all of these factors when budgeting."

Here are some examples of preventable deaths (annual deaths):
Traffic crashes (45,000)
Suicide (31,655)
Firearm assault (17,638)
Poisoning (17,550)
Falls (16,257)
Breathing disruptions (5,517)
Drowning (3,447)
Exposure to smoke (3,159)
Accidental firearm discharge (762)
Contact with machinery (652)
Terrorism (???)

(yeah, after a while, these start to become a little depressing...)

Anyway, we all know the healthcare #s:
Medicare error: 100,000+
And a new one for me (From the RWJ Foundation) No health insurance, preventable illness: 18,000

I'm not necessarily advovating we take all of our anti-terrorism $$$ and put it in healthcare, but it's interesting just to dream for a second what I would do with $300B?

- EHR: $200B
- The coolest ad campaign ever made, on motivating everyone towards healthy living: $100B

If you were in charge and had $300B laying around to spend on healthcare, how would you spend it?

whoah, nellie, let the counterclaims begin...

what do you think?

Living Room? Nope - this is a hospital waiting room in Detroit.

Hospital administrators like it because it brings more patient volume
Doctors say that the "living room" environment calms their patients before a sometimes-stressful visit.
Patients obviously like to ambience - some even want to "wait" longer.
Critics say it's excessive / unnecessary / unwise in this environment of skyrocketing healthcare costs - a further tier-ing of American healthcare?

What do you think? Apparently, ~50% would factor it in their hospital decision, and the other half are very outwardly against it. Read some people's comments here.

Now, folks in Cincinnati will know. Aetna is making physician pricing for numerous procedures and tests public (WSJ - reg may be required) tomorrow.

From the article, "For instance, an internist in the University of Cincinnati area charges Aetna or its members $161.32 for a visit from a new patient with moderate to severe problems, while another physician a few blocks away charges $132.23 for the same office visit. The first doctor also charges $41.89 for a chest X-ray taken from two angles, while the latter's price is $34.34."

AHIP's new website, HSAdecisions.org, just published a consumer's guide to healthcare spending accounts: "what you need to know about HSAs, HRAs, FSAs, and MSAs." I work in healthcare and I still need help with this! thank you, AHIP.

Also HSADecisions site was recent news: as of 3/2005, 1,000,000+ people were covered by HSA/HDHP products. This is double from six months ago. Get ready for some more explosive growth.

If your have a heart attack, I hope you're in Boston. But if you get pneumonia, I hope you're somewhere else. Yup - for the 1st time, we have the stats to prove it: quality of care actually varies by region.

yeah, this one's random - the folks at IBN have developed an urine test that is powered by a drop of urine.

What fun it was to get a comment from Carol Kovac, IBM Healthcare's GM. She's started a new blog called LifeLines. Among her first posts are predictions that EHR: (1) will NOT evolve into smart cards; and (2) will ultimately be paid for by employers and payors.

As I mentioned in a previous post, IBM Healthcare has grown from 2 employees to 1,500 under Carol's leadership. I guess Carol has a knack for growing things as she is an avid gardener as well.

Here's a summary of the coverage we've had recently on the nursing shortage:

The media loves this story - in the matter of 2 weeks, I found individual articles from 5 states lamenting the problem. In IL, the governor just signed a bill that will allow nurses in Puerto Rico to work in IL.

Just this past week, I posted on the unique challenges that male nurses face.

Will this nursing reality TV show help or hurt the nursing profession? Answer: it won't.

Here are some good examples of how communities are dealing with the nursing shortage. Also, let's not ignore the growing trend of using traveling nurses.

With all this media coverage, let's also not forget: it's not a nursing shortage, it's a nursing faculty shortage.

At the end of the day, let's not forgot the influence one nurse can have on a patient's life.

UPDATE: here's the best article I've read on how to retain nurses. (1/30/2006)

Here's a good article on how not to treat your patients. Too often, in people's greatest time of need and sensitivity, they are treated like a #, an object, and/or a nuisance. Here's a story of one patient that was fed up:

"After one doctor slipped into the room unannounced and tried to give him an injection, Mr. Edwards decided that he had had enough, said his father, James (Red) Edwards Sr., in an interview. His son posted a sign on the outside of his door. It read:

'ATTENTION:
1) Please announce yourself when you come into my room (let me know your name and why you are here).

2) Please let me know what you're going to do and how it will feel before you touch me for any reason.

Thanks - Jim and Red'

The hospital where he was treated, at the University of North Carolina in Chapel Hill, has included Mr. Edwards's sign in a training video for its staff."

For all you folks in South Bend, IN, aren't you lucky?

Can't get to the hospital? Get the hospital to come to you. St. Joseph's Regional Medical Center is planning a "hospital on wheels" of sorts that will serve at-risk individuals who face transportation, financial, or language barriers.

Or if that doesn't work for you, just stop by the neighborhood Wal-Mart.

The 420-sq-ft clinic will treat 30 common ailments, including sinus infection, sore throat, and seasonal allergies. Wal-Mart is going to try this model in 12 locations this year. The Wal-Mart spokeswoman: "I raised five kids, and they get sick on weekends when it's not always possible to see a doctor," she said. "The mini-clinic is a growing trend and we're really excited to bring it to our customers."

Just wait to the day when we have hospital ATMs. I can picture it now: "punch in your PIN, take your meds from the bin."

Well, not really?

Remember Ben Stiller in the movie "Meet the Parents?" Oh man, the jeers, looks, and lines his character got for being a male nurse.

Turns out in real life, too, it has been somewhat difficult for male nurses. Check out Male Nurse Magazine, an on-line publication exclusively for current or prospective male nurses. Check out some of their honest discussions on:
- how they deal with discrimination
- what male nurses can do that female nurses can't (yup, more stereotypes here)
- how to deal with a nursing professor who gives single moms a break, but not this single dad
- whether male nurses should wear panties and other male nurse uniform protocol (I'm not kidding!)

Nonetheless, there has been some success stories, too. Male nurses now make up 6-7% of the nursing population (up from 3% in the 1980's).

Steel-worker-turned-RN Jim Townsend enjoys the job security, good pay, and making a difference.

For $1,500-$20,000 a year, you, too, can have the services of a concierge doctor. Here's how it works:

You probably get:
- 24-7-365 access to your physician
- "semi-exclusive" access, as most physicians limit the number of patients they manage (to "just" several hundred)
- comprehensive wellness plans
- advice on how to navigate complicated plans, which hospitals to go to, who to see, etc. (love this quote: "What the hell kind of system is this, where you have to hire a guide?" Arthur Caplan, UPenn medical ethicist)
- unhurried visits
- little or no wait times
- next day appointments
- one company (MD2, the 1st in the biz) even offers marble showers and individually monogrammed bath robes.

You probably don't get:
- some routine exams (this NYT article explains that one doctor did not offer routine GYNE exams)

Many new concierge doctors love it, and so do their patients.

Drs. Svledlow and Ryack are all smiles about spending less time working the system and more time with patients.

Most agree that this trend is growing (they have their own association now), but won't grow too big. There's probably only 500 doctors (probably w/ ~250k patients?) doing this. That's out of a pool of 300,000 primary care docs.

Business-wise, it's just smart segmentation. Nonetheless, it's controversial for obvious reasons. Country clubs are for golf, not healthcare, right? Just another service for the rich?

And experts do agree on that:

With concierge medicine, you are definitely getting better service (but not necessarily better care).

There's good debate on that topic in this article, but it comes down to this: from the patients point of view, better service is better quality.

Wow, I must be really posting some really interested entries.

Someone did an altavista video search on "you are the one- aha." The only search result was hospital impact.

Here are some of my all-time favorites searches that ended with someone visiting hospitalimpact.org:
- people fighting
- brother and sister
- one day in your life
- for you
- forum on eye bag surgery in bangkok bumrungrad hospital
- basic learn accordian
- 166
- energetic positive people
- goldfish swallowing (twice)
- music appreciation flowchart duane day

And of course, since I just posted this entry with those key words, these poor people may end up on my blog again.

Well, maybe they aren't the hottest, but in terms of revenue % growth they are. Based on Healthcare Informatics Top 100 survey (pdf), these 10 companies are obviously on to something. Even #10, Picis grew revenues by 60%.

Besides the fact that the data looks weird and the methodology doesn't seem consistent, Healthcare Informatics did a nice job profiling the top 100 (in the above pdf), Regardless, let me zoom in our the fastest growing 10

Company (Growth Rate)

1. Cardinal Health (200%) - we all pretty much know what Cardinal Health does. So we also know that to grow 200% they must have cheated... er... I mean, they made a huge acquisition in ALARIS, which prevents medication errors

2. CyMed (99%) Transcription business is good, sure, but CyMed also made a major acquisition in June 2004: Pro-Scribe Medical Documentation Solutions, a former competitor. Now their the 3rd biggest in the biz. The good news continues - just last week, AHIMA & MGMA Selected CyMed for the MTIA Beacon Award.

3. Emageon (97%) - The true #1 in my book, as they grew the old-fashioned way, closing big deals with big clients. Their one-stop shop intelligent imaging software is a hit everywhere it goes. In the middle of 2004, they had $100MM+ in backlog orders. But I'm puzzled why they're not profitable yet.

4. ProxyMed (93%) - ProxyMed supplies transaction processing services, and in 2004 bought PlanVista, a cost containment company for hospitals, about 1/2 the size of ProxyMed.

5. Epic Systems (78%) Epic rode the EHR wave, was at the right place at the right time, and signed a monster partnership with Philips.

6. US Technology Resources (71%) As long as we keep outsourcing, USTRI will keep humming away. I may be wrong, but this growth rate was their total corporate growth rate, not healthcare-specific. So, I'm not sure if this one counts, especially since their healthcare website is pretty light.

7. Spheris (70%) The 2nd med transcription company in the top 10 and now the #2 largest in the biz, Spheris serves 450 systems and 5,000+ transcriptionists. Mayo, Cleveland Clinic, and Scripps are all customers.

8. Infologix (67%) - These guys are "e-mobile integrators," providing "computer on wheels," wireless networks, RFID bands, and even e-Learning. Business is hot - they've been named #6 in Entrepreneur's Hot 100 List. But they've grown quickly also through acquisition: ViA, a provider of "wearable computing" solutions.

9. Televox Software (64%): Different than all the other "technical" IT companies on this list, Televox is positioned around "high tech human touch." They simply enable messaging, delivering messages between docs and patients, including appointment reminders and lab results. Soft soft and fluffy? Well, 10 of the top 14 hospitals are using their software (read pdf). They also acquired a competitor (SmartTalk) in 2/2004, raising their customer base by 60%. (so how come they only grew by 64%?)

10. Picis (60%) these guys only play in the high-acuity care arena. Mayo, HMA, and the UK's NHS top an impressive list of global clients. Picis merged with Ibex in 8/2004.

2 things jump out at me:
(1) I was hoping to pick out some "hot" technology, but what we really got was "hot" mergers and acquisitions! When you look at this list, only two really count! Emageon and Epic both grew by solid execution, closing deals, and finding enhanced distribution channels.

(2) There's obviously still quite a bit of fragmentation in the market. Makes me wonder - the IT vendor that we bring into our hospitals: will they be the acquired or the acquirer? And how will that effect their performance in your hospital? Kinda scary.

This was only a matter of time. Check out this story (reg required) from philly.com. The survey looked at 35 HMOs and 41 PPOs and found all of them to be satisfactory, though only 64% of respondents were completely or very satisfied with their plan. Also, check out the consumer reports page introducing the study.

Judging by the comments on Matthew Holt's recent posting on hospital price gouging, this isn't exactly a popular topic for the masses: how to increase hospital profits.

Yes, there is some price gouging (intentional and unintentional) going on out there. Yes, some hospitals are overly-aggressive with their collections practices. And yes, lots of hospitals still need to get together a coherent pricing policy (as well as a community benefit stance).

Nonetheless, hospitals also get the shaft thanks to patients who can pay but don't and government agencies that don't even pay to cover costs. To top it all off, many hospitals shoot themselves in the foot with poor medical information technology, wrong coding, poor management etc. It's these controllable revenue cycle factors that this HFMA white paper focuses on - worth a read.

A few months ago, Businessweek did a piece on the digital hospital. In this article, they used Hackensack University Medical Center as an example. With nifty robots and human-error-minimizing software, hospital CEO John Fergeson says, "We could never become a top hospital unless we were tops in tech." Check out businessweek's other articles on this topic here.

So, besides Hackensack, who else is taking the all-digital plunge?

Oklahoma Heart Hospital went all-digital.

So did Baptist Medical Center in Florida.

And so did DeKalb Medical center in Georgia.

And we can't forget Indiana Heart Hospital (watch the video news coverage here), arguably the nation's first digital hospital, using primarily GE equipment and systems.

GE, of course, ain't the only game in town. You might say that Philips' recent appetite for acquisitions is coming from a hunger to corner a bigger piece of the digital hospital pie.

Ronald wouldn't be so cheery if he faced the financial dynamics that hospitals do.

Imagine you're running a McDonalds. 100 customers come through your door per month - each customer orders a $5 Super Value Meal. Suppose each meal costs you $3.50 to make.

Out of those 100 customers:

8 can't afford to pay, so you say, "no problem."

4 refuse to pay, so you say, "oh well."

63 pay with a free meal ticket from the government. You mail those in to get $3 per ticket. The problem is 10 of those tickets were mishandled either by you or the government. So after some corrections and wrangling, 7 of those 10 get paid.

Simple math problem: how much do you have to charge the remaining 25 people to break even? It costs you $350 to provide 100 meals. So far you've received $180 from the government. You still need $170 from 25 people, or $6.80.

But that's 35% over the original price and almost double the actual cost! Price gouging!

So you've got a few avenues to address your pending bankruptcy:
1. Train your staff to ensure all those government tickets get paid. Then you only have to charge $6.44
2. Get 2 of those 4 who refuse to pay, to pay $5. Then you can charge the other 25 only $6.04. Just be careful not to confuse those who can't pay with those who won't pay, otherwise you may have to pay some legal fees.
3. Get the government to reimburse for $3.25 instead of $3. That brings down the price to $5.50.

easy enough?

Problem is you have to buy a new burger machine next year, which will cost $500. Plus, the fries machine will need a tune-up for $100 for a total of $600. So breaking even isn't good enough. You'll have to pay ~$300 of the $600 next year, meaning you need to make a profit of $25/month: that's an extra $1 per paying customer. So now you're back at charging $6.50 (even if you accomplish steps 1-3 above). How do you keep you business open?

yup, that's right.

Kim, a nurse at Jewish Hospital in Kentucky, will be monitoring 61 ICU patients... from down the street. Using technology from VISICU, she can zoom in cameras, talk to the patient, and track sudden changes in heart rate - all from one location.

The preliminary data from installations in 30 cities is positive: 26% lower death rate, 16% decrease in length of stay, and in some cases 66% increase in ICU profits.

One man sounds the alert
another gets a skin insert
two archenemies partner and flirt.

(don't worry, not quitting my day job for poetry anytime soon)

Read Bill Frist's op-ed on why we must invest in EHRs. In a nutshell, it's all the same stuff: EHR will cut unnecessary costs while improving quality.

Meanwhile, former HHS Secretary Tommy Thompson just got RFIDed. The little chip is rice-sized.

and it looks like Newt and Hillary really do agree about healthcare. Newt: "Hillary is so correct in the direction she laid out." Hillary: appearing with Newt "was a great thing to do."

As you can see, I've been adding some new blog "skins", so you can read hospital impact in various designs. Just scroll down to skins (on the left sidebar) and select your design. (my new favorite is crystalglass)

While we're on the topic of blogs, here are two good articles I ran into recently:
- A blog is born every second: some good stats on blogging today. Only 13% of bloggers update weekly.
- Don't bore me with your blog: some good advice for keeping your blog fresh and interesting.

Just when we thought that ERs were the poster child for "loss leader" (e.g. this hospital is thinking about closing theirs) this company is planning on opening 10-15 ERs next year and turning a profit. Not only that, patients are seen at a fraction of the cost of a typical ER visit.

Okay, so that's a little misleading, but not too far from the truth. Read an interview with the CEO (pdf) to get a sense of their business model and strategy. They don't want to compete with family practices, they want to augment them. So their facilities aren't open until 3PM and stay open until midnight. They envision getting up to operating 100-150 centers in metro areas.

Bush's EHR proposal would cost $150B to start up + ~$50B/year to maintain.

Just to give you an idea of how much that is, consider this: that's about $650 per person. Also, Medicare will cost ~$290B in 2005; Medicaid $193B. (For more on the HHS Budget, download this pdf). Speaking of Medicaid, check out this USAToday article on how Medicare continues to expand.

As I've mentioned previously, hospital marketing needs to kick it up a notch without getting into trouble. In this consumer-driven atmosphere, marketing is as important as ever.

Read the Rush University Hospital marketing story. In a nutshell, they were easily the #1 hospital in Chicago for decades, competitors came in and marketed aggressively, they became #4, then they launched a well-planned and well-executed marketing campaign. Now they've climbed a spot to #3, "Find a Doctor" queries are up 500%, calls to the physician referral line are up 100%, and outpatient volume is up 10%.

Also check out this healthleaders article on how to take your hospital marketing above the clutter. My favorite tips:
(1) People already assume that quality is good and your doctors are competent, so what's special about your hospital?
(2) Find those delighted (not just satisfied) patients and ask them to speak for you.
(3) Don't be reactive. Even if your competitor down the street comes out with an ad, don't one just to do one. (look outside of healthcare! check out this great blog on marketing/branding.)

Also read these articles for other hospital marketing news:
- Stats on hospital marketing levers: most used: appealing to emotion, and appealing to institution prestige
- hospital adds patient blogs to its marketing portfolio: lots of people noticed, but I don't know if it really worked
- this hospital is spending the $ to build a national brand: consumers are empowered and have more flexibility in their plans to choose, so why not market to them?
- In Louisiana, rural doctors and hospitals are collaborating in their marketing plans to keep their patients from going to bigger, newer, suburban hospitals.

vs.

The California Nurses Association has launched a blog to stop Arnold's "corporate takeover."

This comic perfectly captures the sentiment of some critics of outsourcing. While outsourcing can be extremely beneficial, some organizations have gone a little overboard.

So how do you decide what to outsource? Check out this excellent white paper from healthcare management services king Aramark. It gives a fair assessment of the right reasons, the concerns, and the value proposition for outsourcing (especially non-clinical functions that are "non-core.")

I was in contact with someone from Aramark recently - they have recently entered into a string of 5-, 10-year, multimillion dollar strategic agreements with hospitals. And the best part for hospitals is this: these agreements can be structured around delivering outcomes like cost reduction, patient throughput, and visitor satisfaction! Talk about aligning interests!

We've already seen success in outsourcing in hospital IT operations. Catholic Healthcare West has 40 hospitals and 6 IT staff: they've inked a "full-service" multiyear, mega$$$ deal with Perot Systems. Some say the hospital IT outsourcing market will hit $5.2B by 2006. Physician practices are benefitting from this as well.

Some smaller hospitals are even outsourcing some ER functions. This HealthLeaders article does a good job identifying the potential pitfalls.

And finally, make sure you do your due diligence before outsourcing even non-core functions. This HealthLeaders article gives 4 things you should do prior to making the plunge.

Dr. Mike Woods has started a very interesting blog with an unique/unusual focus: physician personal leadership. Some memorable quotes from his first week in the blogosphere:

"Medicine is a good example of an entire profession failing to commit to the obvious. The profession is filled with bright people, yet many have an almost infinite capacity to ignore basic truths that limit the achievement of excellence."

"While tort reform is a worthy endeavor, the profession conveniently ignores the fact that 80% of all claims are related to ineffective physician communication and inappropriate behavior in the course of caring for a patient."

"I do what I do because I became aware of my personal failings after I quit- yes, quit- medicine. I had become disgusted with the profession and the way physicians behaved and treated other people, including their colleagues. And a funny thing happened."

Recently, I've been pleasantly surprised to find more healthcare coverage in BAH's thoughtful magazine Strategy+Business. Here they discuss CDHP as one of the few private-sector driven trends that could significantly impact overall healthcare costs.

A little financial incentive, says S+B, force consumers to make better decisions, "balancing prevention with savings." Maybe this will work for some segments for the population, but judging by Gadfly's comments on Matthew Holt's recent post, he'd disagree: "Being overweight is health risk and decreases the quality of life in many ways: if that's not enough "incentive" to lose weight, then it's doubtful some tax break will do it. Slow suicide vs. tax break - hmmmm."

Good: consumers become more educated and informed about medical decision-making

Bad: consumers become more educated and informed about medical decision-making.

Regardless of whether it's good or bad, it's coming. And more and more info is being made available to patients on how to make decisions. Here's one by Answer Financial: 10 tips in shopping for health insurance. Also, here's a pretty comprehensive overview for how patients should choose the "right" hospital for them. Apparently, if President Clinton followed these steps, he may have chosen a different hospital for his bypass surgery.

There are some reports that hospital pricing data in California is simply not that useful. At the end of the day, does all the research and better information actually improve outcomes? Not necessarily, says this doc in WSJ. There's a reason you have to go to medical school and residency to be a practicing M.D.

Consumer-Driven healthcare might just be one of those few things in life that is good, bad, and ugly.

(Since we're doing a 60s theme this week...)

Congrats to these 8 medbloggers for making the Forbes Best of the Web List.

While we're on the topic of hospital marketing, I thought this was just too silly not to post. Norwich Union Healthcare in London went a little too far in it's hospital marketing. Citing the competitor's long wait times, they used this tagline:

"Royal Cornwall Hospital. Queues likely. Avoid the wait. Call 0800 42 42 42"

They've since pulled the ads and apologized. If anyone has access to the actual ad, I would be curious to see it.

Also, in Detriot, this hospital put up a billboard that brought out the critics.

Other ads that this hospital used indeed brought them more patients. But it also brought them 2 lawsuits.

Some lessons learned: if you appeal to emotions, do it very carefully. Don't appeal to fear (that is just too manipulative). Make sure that your facts are 100% correct.

When marketing is used effectively - for better or for worse, it can be extremely powerful. So think out of the box, but handle with care.

Finally, some folks are addressing the real problem in the nursing shortage: attracting new nursing faculty. I applaud Monster Healthcare and the AACN - we need more programs like theirs.

Alas, adding 5 nursing faculty per year is just a drop in the bucket, as 32,000 qualified nursing students are turned away annually.

Like I eluded to the other day, it's comforting (and also a little disappointing) that many of the financial and regulatory issues we face in hospitals today... we have been facing for a long, long time. Check out this archive of articles going back all the way to 1969 (and earlier!). Operating on razor-thin margins, community benefit questioning, hospital incentives controversy - apparently, we've been there before.

What were you doing in 1969?

I posted previously about a nursing reality TV show, sponsored by the traveling nurse recruiting company, Access Nurses. Well, the candidates are in and you can vote for who you want to see on the show:

A lot of questions are running through my mind: how realistic will this be? How will people decide on who to vote for? And maybe most importantly, will this help or hurt (or simply be inconsequential to) the nursing profession?

My guess: inconsequential. we don't need to attract more people to become nurses, we need to attract more nurses to become nursing faculty. how about creating a reality TV show for that?

This whole concept of running a hospital like a business is a relatively new idea. The most obvious symptom of that truth is this: hospitals are still so simplistic and unsophisticated in their marketing and PR efforts. Sure, hospitals have come a long way, but there is still quite far to go, especially in using quantitative approaches to get the most bang for your marketing buck. According to this great article by Susan Solomon, too much of hospital marketing and PR content is generic and bland.

To test that, go to your hospital's website: what % of the content could be true for any other hospital? Where's the differentiation?

Why is so much hospital marketing so boring?

Solomon says: lack of resources/focus, too much copycatting, lack of cross-functional creativity, lack of really listening to our customers.

Let's think out of the box a little bit! Selfless doctors and nurses work tirelessly around the clock in your hospital. Amazing miracles and breath-taking stories occur in your very hospital on a daily basis. Why don't we share about those? If I can almost shed a tear watching a Citi (Banking!?!) commercial, how much more should we be able to touch people and inspire our communities to root for and care about our hospitals? The loyalty Coke has with people drinking sugar water shouldn't have anything on us - in some sense, our story is much easier to tell. I just don't understand why nobody is telling it.

As a continuation from yesterday's post, it would be great for all hospitals to communicate their community benefit in a compelling and engaging way. However, maybe the issue isn't just communication, maybe your hospital needs to go to the next level.

After all, even for-profit hospitals are reporting community benefit (and include the property tax they pay). Here's one (pdf) from an HCA hospital.

There are tons of ways to expand your community benefit. Here are some ideas to get the juices flowing:
- I mentioned one hospital last week that has aggressively increasing charity care by $1MM/year.
- The Cleveland Clinic started a high-school internship program.
- This hospital (pdf) provides scholarships to those going into nursing and helps employees volunteer in the community.
- This hospital has partnered with local schools and government agencies to set up job-shadowing experiences and low-cost insurance for local kids.
- This hospital saw a need in their community and donated $200k to it.
- This hospital has ~500 classes on the schedule or the next month, including Boot Camp for New Dads, Overeaters anonymous, Orthepedic yoga, and breastfeeding.
- This hospital set up heart.nmh.org and provides online Q&A forums with world-renown heart docs and a newsletter for "heart attack alumni."
- This hospital had to discontinue a very cool and popular "Ask A Nurse" phoneline because of financial pressures.

And if you didn't catch this article from yesterday, check it out. The author, Patricia Cahill (former pres/CEO of Catholic Health Initiatives) eloquently exhorts us to tell the story and partner with other community organizations. She also lists 20 ideas for community benefit.

When and where was America's first hospital established?

Clue: Benjamin Franklin was one of the founders.

Yup, you guessed it - in Philadelphia: Pennsylvania Hospital in 1751.

Next May 11th will mark their 255th anniversary!

Much has already been said about whether non-profit hospitals deserve their tax-exempt status. In Ohio, hospitals are compared to "big businesses that don't pay any taxes." Many are also arguing that their charity care levels are no higher than for-profit hospitals. As if charity care was the only community benefit that hospitals provide?!

Hospitals, it's time to lead. It's time to communicate your hospital's true impact to its community. And equally importantly, it's also time to do some soul-searching - does your hospital do enough?

Communicating Community Benefit

The best listing of community benefits I've seen is posted by HFMA in this article. This article by the Catholic Health Association is also excellent. More importantly, take a look at one hospital who reports community benefit well: Enloe Medical Center. This 3-page PDF captures their community benefit.

I love how this is done because it provides hard numbers along with "feel good" pictures from the community. Numbers aren't enough. Neither are just pictures. Also notice that it doesn't have to be long (save the painful enumeration of everything you've done for your 990 Form). Here's another good example (pdf).

Here's an example of a community benefit report that I am less fond of (pdf). It seems that this hospital may have done just as much (or maybe even more) for its community, but this report has 2 things against it: (1) it reads like a business plan; (2) it's 42 pages long. This report is fine as an attachment to a 990, but who is really going to read this? On the flip side, here's an example of too little and too vague info on comm benefit. I can totally understand that not every hospital has the resources to put the time and thought into this. But in this day and age, this is becoming an increasingly crucial competence for all hospitals.

Finally, check out this great article on more tips to communicate community benefit. We shouldn't just communicate, we should also celebrate.

Tomorrow I'll list some interesting community benefit programs that I've found around the country.

"Good news"
Uninsured in NY? Check out this new site just for you to find low-cost and free healthcare resources. Read the news coverage here.

Here's a great story of two "competing" hospitals collaborating to better meet the needs of the uninsured in their community.

In NJ, the governor just signed a measure to expand the eligibility of the state's health insurance plan for working poor families.

This hospital is giving the uninsured a 25% discount regardless of their socioeconomic level.

"Bad News"
Here's yet another article (pointing to the same data I referenced previously) that we ALL pay for the uninsured. Also, TheStreet, in an abrupt about-face (see their glowing article from 2 weeks ago), are now not so hot about hospitals, citing the costs to treat uninsured as a major factor.

All of these charity care/tax exempt issues we are facing in hospitals are not new. Read this article from Bruce Vladeck and J. David Seay, who also wrote "Mission Matters" in 1987. In their minds, the 5 distinguishing characteristics of non-profit hospitals are the same today as they were in 1987.

* Values that reflect community commitment

* Accountability to patients and communities

* Long-term commitment in the face of short-term trends and opportunities

* A physician-hospital relationship that fosters a symbiosis of service

* Institutional voluntarism that allows institutions to be both provider and beneficiary of community service

Seay warns: "Neglect community service at your own peril."

Many of you probably saw the movie I, Robot. It envisioned a future where robots walked the dog, got our groceries, picked up our kids from school, etc...

As hollywoodistic (is that a word?) and futuristic as that sounds, robots are already being used in hospitals today.

Here an InTouch robot can move and interact with patients and staff as directed by a remote doctor.

Check out this blogger, who is a machine when it comes to bloggin about robots. He's got some great summary posts on how robots are being used in hospitals - mostly to help pharmacists and to help doctors have "remote presence."

Johns Hopkins (just named the #1 hospital AGAIN) is experimenting with robots that help doctors examine patients remotely (read another story about Johns Hopkins here).

Hospitals in the UK are cutting costs by replacing pharmacists with robots. Another hospital is using Robonurse Penelope as their scrub tech, who just successfully assisted "her" first surgery last month at NY-Pres.


Doesn't look like a "Penelope" to me; nonetheless, still effective.

Here are a few more trends to be thinking about as hospital leaders:

- Hospitals keep buying each other up. Based on this report, hospital M&A activity for 2Q05 is up 67% - roughly $900MM of hospitals were bought in the last 3 months. (Update 7/16: LifePoint buys 5 HCA hospitals)

- Hospitals are improving financially, or at least Wall Street continues to be positive on the for-profit hospital sector. Bad debt is being managed and volumes are up. (HCA's stock was hit recently, but overall is still doing well)

- Hospitals continue to suffer from a "trust epidemic." I just started Dr. David Shore's book "The Trust Prescription for Healthcare: Building Your Reputation with Consumers" and let ya'll know what I think of it when I'm done.

- More and more groups are collaborating to get better information for decision-making. This group in Wisconsin is trying to get to the bottom of healthcare costs. Meanwhile, WellChoice (with the help of WebMD) just announced personalized online health records, complete with lab test results, cholesterol levels, and health management tools.

- Supersized healthcare: a more obese nation means hospitals spending more money on supersized beds, wheelchairs, mattresses, and stretchers.

Oversized wheelchairs can cost up to 5x more than its regular-sized counterpart

This HCA hospital in Texas is getting more proactive with its preventative health programs with the community. They've partnered with Aegis Group to work specifically with large local employers, identify specific health risks, and match at-risk employees with appropriate detection, prevention, and education initiatives.

This hospital in IL is also getting more proactive about preventative health - that is, it's own health. Instead of waiting for lawsuits or bad PR to happen later, hospital leaders have aggressively grown charity care by 70% this year (~$1MM).

so, rich men are healthier?

This article mentioned that the rich are healthier. And this study talks about how women (especially uninsured ones) take care of everyone except themselves.

By now, you've all heard that HCA pre-announced some bad news regarding 2Q05, sending the stock down 8%. Looks like overall admissions were slightly lower than expected (though seasonality predicts this somewhat) and uninsured admissions were slightly higher than expected (though still lower than previous years).

Come on! $2 billion loss in market cap for that slight miss? yet another typical overreaction from Wall Street.

okay, to be fair, HCA has been seen some amazing growth in 2005, ~40% before today's drop. Maybe it was time anyway for a correction.

Here's an idea. How about we save some money on lighting?

Check out this article from Health Facilities Management (under the AHA) for a 10-step guide to a money-saving hospital lighting program. Among the very practical ideas: minimize the # of types of lamps/sockets, use light-colored wall paint, use automated control for areas of infrequent use.

And while we are on the topic on costs we never really think about, here are a few other very practical resources to save some money:

- 26 tips for non-profits to save $$ Most of this is plain common sense, but there are a few interesting ideas: window-tinting, doing an utilities audit, getting 2nd-hand furniture.

- Lots of ideas in this article for how to stop wasting money on waste. (speech from the American Society for Health Care Environmental Services)

Waste in these biohazard bags cost 10x as much to dispose of than regular solid waste. The speaker: "I´d bet my children that 50 percent of it (redbag waste) is still inappropriate, stupid, ridiculous nonsense."

- Baptist Healthcare claims they saved $8MM and 98,000 workhours by successfully implementing their idea management software. Maybe your cost savings are all hidden in your employee's heads?

to go along with yesterday's post on healthcare IT, let's not leave out the consultants. This report shows that healthcare consulting remains one of the hottest sectors in management consulting, growing to $25B by 2008 (includes pharma, providers, & health insurance).

Not surprisingly, the usual suspects (BearingPoint, BAH, BCG, CSC, Deloitte, IBM Business Consulting Services, McKinsey, and SAIC) will take 1/3 of that pie.

Download this PDF summary report (from Consulting Central), which lists the major acquisitions from the last 4 years and shows a ~10% CAGR in revenues through 2008.

based on these two posts, back-of-the-envelop calculations would suggest that for every $1 spent on IT, hospitals spend 30-50 cents on management consulting.

In South Dakota, a new law went into effect a week ago. Hospital pricing is now public - okay, not yet, but they're working on it. Check out this website, which will be the future site for consumers to do comparison shopping with hospital pricing. For now, you can call up their billing department and ask.

In trailblazin' California, some pricing is available today. For example, a brain scan at Cedars-Sinai runs about $1,650, and at Community Hospital at San Dimas for $2,800. But for all the clamor, how many people actually care? Apparently, not many, at least not yet (and not the insured).

The trend of non-healthcare companies and conglomerates getting into healthcare continues with this $7B purchase.

McKesson's stock is close to a 5-year high. Cerner is close to its all-time high.

According to this article, the healthcare IT market in the U.S. is worth $24B per year (and getting up to $34MM by 2008). That means the average hospital spent $4-5MM this year in healthcare IT?

It's no wonder that everyone is vying for position. Almost $1B has changed hands in the last few months via healthcare IT acquisitions

Philips buys Stentor $280MM
IBM bought Healthlink $250MM
Accenture bought CG Healthcare practice $175MM
ACS bought Superior Consultant Holdings $100MM
(though not IT, McKesson buys again today)

And don't forget: these Indian companies are also waiting in the wings to be acquired.

Also keep watch: a new healthcare CIO thinktank formed by Abovehealth: The Dolphin Group

We're all familiar with those kiosks at the airport that makes the checking in process so much easier.

Once in a blue moon, I'll encounter an error and the agent is there to help out. This self-service model for checking-in is great - staff can focus on more value-added activities and passengers don't have to wait in long lines.

So why can't we do that in hospitals? Well, some hospitals are already doing it.

Medikiosk allows patients to check themselves in, sign consent forms, pay co-pay fees, and see where to go next.

This hospital in NJ has installed it with excellent results. In addition, Galvanon (the creators of Medikiosk) boasts 16 high-profile clients.

What's next? Window or aisle operating room?

Yup, yet another acquisition for UnitedHealth. This time it's PacifiCare for a not-too-shabby $8.1B, adding 9 million members to UnitedHealth's 55 million existing.

This is after UnitedHealth assimilated Neighborhood Health Partnership, Definity Health, and Oxford Health Plans in the past 12 months.

The media continues to sound the nursing shortage siren, and I'm pretty sure I don't need to link to any more of these doomsday articles.

However, this article mentioned what their local foundation was doing about the problem: an outreach program for middle school students to get psyched about becoming a nurse.

Check out their Nursepower website (which can be read in Spanish, Portuguese, and Russian). They answer FAQs about salary, schooling, LPN vs. RN, etc.

Also, if you haven't seen J&J initiative to recruit nurses, visit here to discover nursing.

There's profiles of current nurses, information for folks considering different types of nursing, and info on nursing as a 2nd career.

Also, here's a previous post on how other hospitals and communities are deaing with the nursing shortage.

And if it makes anyone feel better, nurses aren't the only ones in short supply.

Every time I turn around, there seems to be another resource for people to take care of themselves. Will preventative medicine really work? Steve Case thinks so, and he's putting his money where his mouth is. Richard Branson is betting that financial incentives (like airline discounts) will get us to the gym more.

I just finished "You: The Owner's Manual"

No wonder this book is a NYT bestseller and currently #8 on amazon - this book is long overdue. Through humor, approachable illustrations, and good analogies, the two doctor-authors make very complicated medical information simple and easy to understand. I came away vowing to walk more, eat more nuts, and make more smoothies. Not because the book emotionally motivated me, but because now I know exactly how these actions effect my immune, cardio, (and yes, reproductive) systems.

(Nonetheless, based on my previous post on the difficulty of changing behavior, my chances of sticking with it are slim to none.)

Also check out this newly announced uk site Body Language that helps people take care of themselves.

"do you have stretch marks?" "do you produce excess ear wax?" "do you crave butter?" are just three of the many questions you can get health answers to here.

Finally, I also just finished Newsweek's "Your Health in the 21st Century" Special Issue.

Not surprisingly, I found articles on personalized medicine, gene tests, EHRs, new classes of drugs. However, I was pleasantly surprised to find the conclusion of one article that health is still largely up to us via how we choose to live. From Geoffrey Cowley: "In other words, medical science can light the path to optimal health. Walking it is still up to us."

Okay, now time for my daily walk. Or maybe I'll just surf the web some more.

Lots of people wonder these days whether hospital marketing is worth it. Seems like I can't get through a mall here in Chicago without seeing print ad banners for local hospitals. Or driving downtown, I can't help but notice the Northwestern Memorial Hospital billboard: "surfing the web is good for your heart heart.nmh.org"

Is it worth it? Like everything else, the answer is: it depends. And chances are, even if it does, it will be difficult to measure. Nonetheles, if it makes us feel any better, companies like Coke don't spend hundreds of millions of dollars unless they know it works.

Coke has spend billions on marketing over the years. The result: the most valuable brand in the world, worth $55,000,000,000. (click here for the world's most valuable brands)

Everyone is looking to bring up volume, increase brand equity, build reputation. if you are spending more on hospital marketing, check out this healthleaders article on how to give your hospital a PR make-over. Or maybe give George Washington University Hospital a call - they recently won awards for their TV commercial and print publications.

Healthcare continues to get more interesting, bringing a series of odd couples. Read this healthleaders article on the Medicaid/Pharma, provider/payor, and provider/lawyer coupling.

Of course, we've all seen the best odd couple yet: clintonewt

or... hillafrist

Salmon is $8 or 9 per pound.
Filet Mignon $20-25 per pound

In America, obesity costs ~$15 per pound of fat. okay, maybe that's a slight (and unfair?) exaggeration, but at $36B of obesity-related healthcare for ~85MM people, that's what it would come out to be.

Only in Vegas can you get directions to educational session from Elvis impersonators.

Well, HFMA's Healthcare Finance Conference is winding down. If you haven't checked out the HFMA Conference Blog, head on over there for little tidbits and news.

Some personal take-aways for me from the sessions:
- hospital margins are improving, especially in for-profit chains. Once they improve too much, get ready for a wave of gov cuts?
- there is a lot of unmet need out there for hospital management training and education (seems like every time I turn around, a new vendor enters the space)
- hospitals need to be much better at communicating and quantifying their community benefit. The press has effectively tied "amount of charity care" to tax-exempt status. That is simply a terrible oversimplication and a lie. The value of hospitals isn't just free care!
- Sarbanes-Oxley is for real (despite Scrushy's case). Though some hospitals have effectively rejected the S-O recommendations (or others are adopting a wait-and-see approach), it will be inevitable. Just like EHR. Just like gain-sharing?

I'll be away on vacation for the next few days (staying here in Vegas and the Grand Canyon through the weekend). I'll have more to say when I get back!

Check out this interview with IBM Healthcare GM Carol Kovac. Kovac was one of the original two employees at IBM Healthcare in 2000 and has grown the unit to 1,500 employees with an annual budget of billions. Among the highlights of the interview:
- Kovac views EHR as a certainty
- Kovac views the next few years in healthcare as a "tipping point" when unforeseen opportunities will abound.

Also meet GE Healthcare's new chief, Joe Hogan.

This Forbes interview transcript with Hogan is very interesting, where Hogan talks about personalized medicine, medical imaging costs, and previous EHR failures.

check out HFMA's conference blog - I'll be curious to see how people respond to it.

to be fair, I should tell you that I work for HFMA as their Manager of Business Strategy (finally I reveal myself!). I do reference HFMA stuff quite a bit in this blog (though probably just as much as ACHE), but only when I find it particularly helpful. And just to be perfectly clear, hospital impact is 100% my personal site and not affiliated with HFMA in any way (i.e. the stuff I write here is not the opinion of HFMA, HFMA staff, members, volunteers, etc etc - you get the picture)

Anyway, I'll be contributing a few entries to HFMA's blog this week as I take in the sites and sounds of Vegas.

(Source: Medrants)

As a follow-up to my previous posting on the nursing shortage, check out HealthLeaders article on strategies for solving your nursing shortage.

The Washington Post also highlighted an initiative in Northern Virginia in which colleges, hospitals, NGOs, and legislators are teaming up (don't see that every day!) to address their nursing shortage. $24MM has been raised for building nurse training facilities and streamlining nursing workflow with new tech.

Nonetheless, there is still plenty of press on how bad the shortage really is in Florida, Oregon, California, Connecticut, and New Hampshire.

Matthew Holt commented on this article a while back, but this is worth revisiting. Momentum is such a scary thing.

Sick of reimbursement headaches and raising office costs, some docs are choosing to forgo private practice to join large physician "companies." (reg required). Not really a surprise, as this is essentially just the inevitable next evolutionary step of physician practice management companies.

Sterling is one such company with 1,400 physicians. One doc says of his company: "We are basically small practices under one large umbrella. I don't have to call Sterling and ask permission for this or that. They're very hands off."

This trend still represents a very small % of docs, but it's enough to get the AMA mad - their board is trying to ban such corporations. (then again, seems like a lot of things haven't been going well for the AMA lately.)

Richard Branson...

and now Steve Case.

Case, former chairman of AOL, announced that he wants a piece of the healthcare pie. He has launched Revolution:

a VCish company that will buy up health care companies that "help people take care of themselves"

UPDATED: by the way, Dell just assigned a new VP for the healthcare segment, too.

who else is going to join the party?

The good news on the hospital front continues.

Today S&P forecasted a good 2nd half of 2005 on increasing volumes and improving reimbursement.

It's always interesting to see non-healthcare strategists talk about healthcare. Here is a great strategy + business article on whether a EHR national system could really work?

Lots of Fortune 500 companies are already neck-deep in strategy, marketing, product development, etc on reaching the Hispanic population with their products. They know that Hispanics are the fastest growing minority population and will make up 1/5 of our population within 1 generation. That's just simply to big to ignore.

Some estimate the hispanic healthcare market represents $70 billion in annual spending. Some health plans are already building products specifically to serve this growing population.

What are hospitals doing? A little bit here and there, with probably much more in the near future.

One hospital is trying to reach out more effectively by providing Spanish classes to staff, giving hospital tours to pregnant Hispanic women, and even cooking more Hispanic food in the cafeteria. This seems to be helping despite broad-based studies that cross-cultural training doesn't necessarily improve healthcare quality. It's an uphill battle - it's much more than just language and cultural barriers.

Hablando español no es suficiente

Good bye paper records!

With or without government help (or meddling), EHR is an inevitable reality. Now it's just a matter of when, how, and how much. Some say that 90% of hospitals will have EHR by 2020 (and that assumes no help from the gov).

How will you pitch EHR at your hospital? HFMA just released a white paper (Sponsored by Cerner) on tips to make the case, support the strategy, and smooth out the implementation. While a lot of the content would hold true for just about any major IT implementation, the paper is an excellent collection of pitfalls, tips, CFO quotes, and success stories.

Maybe a better question is this: now or later? Wait for the "leaders" to work out the tech kinks for you and be a fast follower? Or trailblaze & lead the way? I think this comes down to the opportunity cost profile for your particular hospital. What other initiatives is your hospital considering?

Who is this man and what made him one of the strongest corporate leaders in history?

This is Darwin E. Smith, and otherwise ordinary man who happened to be one of the most influential CEOs in the 20th Century. He turned Kimberly-Clark into an international consumer products powerhouse. In Chapter 2 of Good to Great, Jim Collins decides to use him as his posterboy for a Level 5 leader. Collins writes of Smith, "His awkward shyness and lack of pretense was coupled with a fierce, even stoic resolve toward life." Like Collins and his research team, I'm somewhat surprised at this unique combination of traits. We often equate shyness with weakness, fierceness with insecurity or arrogance. Yet Smith was not shy, insecure, nor arrogant.

Sure, these Level 5 leaders have to be smart, but their enduring success is more a function of their character, not their personality or abilities. Level 5 leaders have this perfect blend of humility and will.

Despite this seemingly impossible mix of traits, Collins believes that most people have the potential to develop into a level 5 leader. To that end, I would recommend the 21 Irrefutable Laws of Leadership by John Maxwell. (Collins is silent on how to become Level 5)

Reflecting on this chapter, I realized again that Level 5 leaders sincerely put the cause above themselves. That selflessness is prerequisite #1. And I'm proud to know that this rings true for many in hospital leadership.

On his website, Collins offers some other questions for our consideration:
- Which is harder to cultivate within yourself: humility or will?
- If Level 5 is about ambition first and foremost about the cause, the company, the work—not yourself—combined with the will to make good on that ambition, then how can each of us as individuals learn to take actions consistent with being Level 5?
- Think of a Level 5 you have known. How did he or she become Level 5? What can we learn from that person?
- Why do so few Level 5s get chosen for top spots in our organizations? What can be done to change this?

There has been some interesting articles in the press recently on how hospitals are coping with the continuing nursing shortage.

Many hospitals are utilizing traveling nurses, who take 8-12 week assignments in a particular hospital. For 20-30% more pay, travel expenses paid, and a chance to see the world (or at least the country), some nurses are jumping at the chance.

To face the nursing shortage, hospitals in Alaska have partnered with the University of Alaska to double the number of nursing graduates by 2006.

Albany Medical Center, in NY, is "growing their own" nurses by sending motivated staff to nursing school, all expenses paid. In return, the newly-trained nurses agree to stay on for at least 4 years. With much fanfare, the first class of 14 just graduated earlier this month.

The good news is that there is some evidence of positive progress. NurseWeek announced the results of their national survey in March 2005. From the article:

"In 2004, nurses observed a reduction in the amount of overtime. Fewer perceived a negative work environment or referred to inadequate salary and benefits as the main reasons for the shortage, although they said both were key factors that could contribute to solving the shortage."

In addition, according to the ACHE annual survey, hospital executives are less worried about labor shortages. Now, financial challenges and uninsured issues top their worry list.

I particularly like the idea of a nursing "reality" TV show (set up by Access Nurses). Though nurses are probably divided on whether the show will make or break stereotypes, I think it will bring a fresh (and can I dare say: cool) perspective on what the nursing profession is all about.

On the first page of Jim Collins' book Good to Great, he states, "we don't have great schools, principally because we have good schools. We don't have great government, principally because we have good government. Few people attain great lives, in large part because it is just so easy to settle for a good life."

Maybe I can take the liberty to add: We don't have great hospitals, principally because we have good hospitals.

Many of you will probably say that this is really just a re-hash of the 7th post in the "If Disney Ran Your Hospital" series: great leaders must foster a healthy dissatisfaction in employees in order to strive for greatness.

Yup, not only is this old news, it's a pretty simple concept. But I bring it up again to pose these questions to you: would you consider your organization good or great? How can you tell? At what point does an organization cross the good/great line?

Some may say:
- we are at the 99%ile of all the metrics we measure
- we outperform all of our competitors
- we have turned around our organization drastically

This is what I think: it's a little bit paradoxical. The moment we think we are great or great enough, we will inevitably fall back into the good category. Sure, great hospitals do achieve great results, but their culture doesn't allow them the ever rest of their laurels: great is never great enough.

1. In 2005, the yearly premiums for a family with coverage through an employer will average:
(a) $5,623
(b) $10,979
(c) $15,516

2. Health insurance premiums will cost families and employers an extra $___ on average this year to cover the costs of caring for the uninsured
(a) $572
(b) $729
(c) $922

3. Uninsured patients pay about __ of the costs of their care provided by doctors and hospitals.
(a) one-tenth
(b) one-third
(c) one-half

(Correct answers: b, c, b)
For more info, check out this CNN article or Families USA's website.

Everyone knows that hospitals remain profitable because of a whole slew of "subsidization."

Profitable private insurance patients essentially subsidize unprofitable medicare/medicaid patients. Inpatient procedures, outpatient procedures, and outpatient diagnostics help pay for low (or negative) margin inpatient medical care, ER services, and outpatient medicine.

This explains why specialty hospitals are so attractive. Keep the high-margin lower-volume stuff for yourself, and let the others deal with the loss leaders.

So, why would some hospital executives decide to invest in free-standing ERs, the posterchild for loss leaders?

Keep an eye out for Adventist, whose $7-8MM free-standing ER facility in Maryland will open in early 2006.

If this little experiment works, expect them (and others) to replicate it in target markets.

I just don't understand how they will make this work financially? Or is this purely a "brand-building" mission-driven decision?

Outside the clinic we worked at in Cap Haitien

Well, I got back from Haiti this past Sunday. All in all, it was an eye-opening and amazing experience. Later this week, I'm hoping to start posting again and to reacquaint myself with "normal" life again. Honestly, after the experience I've had, I'm also thinking through what aspects of my life ought not return to "normal."

In the meantime, I found this hospital waiting room story very touching. Sometimes, little expressions of care can go a long way.

(I'm still in Haiti, but this is another post I wrote before I left... I'll be back June 5)

If you haven't made it over to HFMA's Financing the Future Website, check it out now. They've released their 7th report on how hospitals will finance the future.

This report covers 7 Principles of Best Practices Financial Management and is actually free (just have to fill in a short registration form).

Though some may say the report covers "common sense" financial management strategies, I doubt all hospitals have these in place.

Some ideas that this triggered for me:

More than ever, hospitals need finance expertise

As obvious as it sounds, finance is becoming an increasingly necessary competency for hospital management. The stats reveal the state of affairs:
- in 41% of hospitals, depreciation outpaces capital expenditures;
- Hospital CFOs expect a marked increase in capital spending even while the % of hospitals with limited access to capital has doubled in 4 years.

Seems that all hospitals are in one of two categories: (1) they are improving financially and thus have better, cheaper access to capital; or (2) they are struggling financially and thus are finding it more difficult to obtain the necessary capital to renovate. HFMA calls this the widening gap separating the "have" from the "have not"s.

In case there was still any iota of doubt out there, let me just say it one more time: we can't look at hospitals as purely mission-oriented organizations anymore. We have to find a way to balance mission and margin.

Financial planning should be integrated w/ strategic planning & operations planning

This is pretty common sense, but for organizations that have been doing it differently, it takes a lot of energy and change to get here. It doesn't make sense for strategic planning or capital allocation or resource allocation or budget planning to take place separately. Because of the blatant interdependencies among all these processes, an integrated planning process is necessary. HFMA calls this practicing rigorous calendar management.

Everyone has to play by the same rules

GE is probably the posterchild of this - every single initiative at GE, whether it's a product or service, whether it's a domestic or international opportunity, goes through the same process and is evaluated using the same criteria (and even written using the same formats/templates). This ensures that strategic decisions aren't driven by personal agendas, the slickest presentation, or the current fad. (the hard part is getting everyone to agree on the criteria, weightings, and templates)

Getting good at saying no to good

Not only does the process / templates have to be standardized, but the evaluation of new opportunities has to occur concurrently. New opps have to be weighed against each other (not one by one). This competition of ideas and strategic initiatives forces management to make trade-offs - to say no to "good" ideas in order to focus on the best of the best. This aligns everyone in the same the direction.

For me, this is huge. More and more, I think the hardest part of management is this idea of resource allocation. It's saying "no" to really good ideas in order to maintain a laser sharp focus on the best ideas. It's why some organizations are far superior than others - everyone is marching in the same direction, and everyone is allocating their time to the most important aspects of the business.

Also makes me wonder if this principle is true about life in general, especially here in America. I often feel so distracted by so many good things and middle/upper class luxuries, that I forget about the best, most important aspects of my life: faith, family, friendship, and just being a thankful, forgiving person.

So, even though I am physically in Haiti, my heart is with you here on this blog. Okay, that's a lie. I am fully in Haiti right now and if I've been successful at putting my puzzles pieces together, I'm not even thinking about hospital impact right now. Rest assured, though, that I'll have some good medical stories from Haiti on my return.

Nonetheless, in my sometimes-useless desire to overachieve, I wrote a post last week that has been "held" until now. In the 1st of these postings, I've started a new series that I just can't seem to let go: Good to Great for Hospitals.

In pursuit of this dream of hospitals becoming world-class organizations, I can't ignore the fact that so many hospitals are stuck on this crucial rung: just being really good. Most folks have probably already read Jim Collins book, Good to Great

so my focus here is to briefly think through his concepts specifically from a hospital executive point of view. How do we take our really good hospitals and make them truly great?

If you haven't read the book or for a refresher, check out Jim Collins' website for a pretty good over rundown of the key concepts.

Well, as I mentioned previously, I'm off to Haiti today and will be back June 5th.

I'm excited
A year of preparation has finally culminated to this day, when we get on a plane to Miami and then a puddle-jumper to Cap Haitien. We've been learning Creole as best as we can. As part of the medical team, maybe the most important phrase we learned: "Se pa fom mwen" (I didn't to it on purpose).

I'm a bit anxious
Although I've been to many different countries, I think Haiti will be the poorest and least politically stable country of them all. Especially with almost-daily news about riots, prison breaks, U.N. peacekeeping politics, I can't help but be a little concerned for my own health/safety and the safety of my team. Nonetheless, as hokey as it might sound, we have felt led to go every step of the way. Plus, most of the instability is in Haiti's capital, Port Au Prince, an 8-hour drive away from Cap Haitien.

I'm thankful
This trip is possible only through the support of our church and the faithful prayers of hundreds of friends. Also, a shout out to King Pharmaceuticals for donating ~$80,000 of medicine that we have carefully packed into 50-pound luggages.

See you on the other side!

After the good news earlier in the month on public perception of hospitals, here's one more encouraging piece of news: healthcare price hikes are slowing? The BLS reported today that health insurance costs per hour worked were up 7.5% for private employers. Higher deductibles, technology-enabled shorter stays, and a shift towards more generic drugs were all cited as potential reasons for the slowing. In other words, it's (at least in part) a true slowing of healthcare cost increases, not just cost-shifting.

I was also pleased to see the positive reference to the innovative Bridges to Excellence program.

Wow, two pieces of good news - all in the same month. Don't get used to it.

hey, per my last post, you're not supposed to be reading this!! =) (and I'm not supposed to be posting)

oh well, while you're here:

So, what would it take for our hospitals to be the best run organizations on the face of the planet?

What do YOU think?
tony [at] hospitalimpact [dot] org

If you've been a regular reader of this blog, thanks! I've had a lot of fun blogging, and I hope you've had a lot of fun reading.

Now, for a weird suggestion... I encourage ya'll to take some time this week to do nothing but think. Too many people (myself included!) have lost the ability to think - to truly think out of the box (as cliche as that is). For me, information overload has caused thinking underload. Great leaders must be great distillers of information just as much as they are great learners.

It's like we all have a big bag of puzzle pieces (of information). Too often, I don't take the time to put the puzzle together - I'm too busy collecting more pieces and putting them in our bag. I'm so proud of how big my bag is even though I don't know what the puzzle is trying to tell us. What is the meaning of it all?

This week, take a break from all the blog-reading (even this one!), blogging, the craziness of work, and our hectic lifestyles. =) And actually, I won't be posting anything for the rest of this week. Here's why...

The timing actually works out pretty well. I'm going to Haiti next week on a medical missions trip with my church for ~2 weeks. Have no fear - I already have two entries that will be posted here and there (on time-delayed release). Plus, Lord willing, I come back in one piece, I'll tell ya about the medical experiences I had in Haiti, the poorest country in our hemisphere.

So, I'm going to try to follow my own advice. Instead of blogging this week, I'm going to take that time to reflect. There are too many puzzle pieces that I still need to fit together so that I can be fully ready for my trip.

It's time to take a breather and revisit the original vision that hospital impact was created for. what will it take for our hospitals to be the best run organizations on the face of the planet?

World-class organizations are sustained by world-class organizational cultures. We learned quite a bit in the If Disney Ran Your Hospital series. Your organizational culture may very well be your greatest weapon to beat out competitors, or it could be the achilles heel of your organization. With so much potential to harm or help, culture has to be treated with extra thoughtfulness by hospital leaders.

World-class organizations are run by world-class leaders. These people have to be second to none. They have to be more motivated, more wise, and more skilled than the majority of other leaders. That's why we looked at Jack Welch's take on leadership and thought through hospital implications. Leaders find a way to deal with the inherent tensions of leading - long-term vs. short-term, being positive vs. skeptical, living an example vs. relentlessly coaching others.

World-class organizations are constantly changing to stay world-class. That's why leaders have to be absolutely masterful in motivating change. if the Change Agent series taught me anything, it's that truly changing human beings may very well be the greatest challenge in business, in hospital management, and in our own personal development.

World-class leaders have world-class information at their fingertips to make their decisions. No way am I claiming that this blog is "world-class," but I hope that some of the news analysis and links have been helpful.

What else do you think is important to talk about? What have been the most helpful resources for your hospital or your organization? Leave a comment or email me at tony[at]hospitalimpact.org [at] is "@"].

Despite the hospital pricing scandals, the talk of 45 million uninsured, the great HSA/CDHP debates, the lawsuits, the questioning of non-profit status, Harris Interactive reported today that public perceptions of hospitals actually improved by 10 percentage points, hitting an all-time high for the survey. Harris partially explains this by implying that bad press on hospitals doesn't necessarily translate to bad first-person experiences in hospitals.

Why do the managed care and health insurance industries score so low? It's not just insurance-related (life insurance actually scores quite well). Only oil and tobacco are worse than HMOs - even pharma scores significantly higher.

So, what would it take for hospitals to beat out the #1 industry:

92% of respondents gave supermarkets a thumbs up, compared to 79% for hospitals.

A part of me thinks hospitals will never get there simply because of expectations. If only shopping for heart surgery was as easy as shopping for potato chips (though finding the right chips is getting harder and harder!).

Harris has done some other interesting polls - check out the results here, including this one (pdf) on what people want in doctors.

Complex car consoles means less time paying attention to the road.

In the same way, Jakob Nielsen, the "king" of web usability, recently wrote this article on how bad CPOE design in hospitals kills patients.

Some interesting news from the hospital RFID front...

An RFID cabinet of medical supplies at Massachusetts General Hospital (Source: RFID Journal)

A new report released today predicts that RFID in hospitals will hit $8.8 billion in 5 years (gut-check: that's ~$1.5MM per hospital? sounds reasonable). One hospital in Pittsburgh reports significant quality improvements through RFID and bar code systems.

We already know that IBM is getting in the hospital RFID game. And, smaller players abound and are doing well. For example, Mobile Aspects, one of the early RFID leaders for hospitals, grew 400% in 2004 and is forecasting 400% growth in 2005. Among their customers? UPMC, Mass Gen, U of Chicago, Hospital of UPenn. However, those at the Motley Fool would probably warn against investing in RFID companies - the value is certain, but the winners are not.

Users beware: check out this HIStalk post from last month - a good reminder that some "technology-driven" improvements are really process improvements. Also, Palmetto Health passed on RFID for Wi-Fi. For the same price, they said that RFID would have only got them 500 tags versus the 3,000 they have using their Wi-Fi network.

Also related, big brother FDA is currently looking at privacy concerns of implanting RFIDs into hospital staff.

I've never attended any conferences on this before, but it seems like a whole flurry are being created: the 2nd annual "Leveraging RFIDs in Hospitals" conference next week in Vegas and a series of seminars in Chicago, Las Vegas, and Hawaii by Fast Track Technologies.

A while ago, I mentioned that I started to learn how to play the accordian.

Unbeknowst to me, this is actually making me better equipped to face change.

In this final installment of the Change Agent series (adapted from Fast Company's "Change or Die" article), we go to San Francisco.

Dr. Michael Merzenich, a professor at UCSF, is a neuroscientist who has utilized his neurological-how-people-learn expertise to start two successful Bay area companies. His research shows that the human brain has a surprising ability to change and learn, as long as it is being stretched. As the old saying goes, "use it or lose it, baby." And Merzenich practices what he preaches - he employs a "5th-day strategy" at one of his companies. Essentially, one day a week, everyone in the company spends the day working on a different discipline: marketing folks give software design a shot, designers think about business issues, etc... Merzenich sees this as a productivity booster (not drainer), since people are actually rejuvenating their brain and creative abilities. Merzenich takes it one step further, "My suggestion is learn Spanish or the oboe." (or the accordian!)

Of course, I'm not saying to have your billing clerks perform brain surgery. In fact, I'm not sure how we could apply to our hospitals. How do we establish a learning culture? I take this one as more of a personal challenge. I need to examine my own stubbornness/flexibility. How good am I at learning new things and handling change? As leaders, if we do nothing else, we have to lead by example.

Change Agent Series:
101 Why preventative health doesn't work
102 Give people a new frame (not a new picture)
103 Revolutions easier than evolutions
104 Learn to play the accordian

In light of the recent discussion on hospital pricing, I thought this roundtable discussion on pricing (PDF) from HFMA was a helpful tool.

Two hospital CFOs, some consultants, and a lawyer talk it up. Among some of the interesting take-aways:
- Even the words "strategic pricing" has a negative connotation. Sounds like "pricing to make a lot of money." One participant preferred using "price transformation."
- To prevent backlash, set up an agreed set of criteria for pricing changes. Use these criteria consistently for all pricing decisions.
- Pricing is not just a "finance" issue.
- Good pricing starts with good tools: a clean chargemaster and a good market intelligence tool.
- No pricing policy is complete without a thoughtful charity care policy.

While we're at it, check out HFMA's White Paper (sponsored by 3M) of Strategic Price Setting (PDF, June 2004), where you'll find 11 pricing pitfalls to watch out for.

The rich are getting richer and the poor are getting poorer. The vicious cycle plagues the poor and the virtuous cycle benefits the rich. Momentum is hard to fight. This is true for the nations of the world. This is true for our nation's citizens. This is also true for our nation's hospitals.

Safer hospitals are getting safer, while less safe hospitals are getting less safe.

Add that to this already well-known fact that stronger hospitals have better & cheaper access to capital. Struggling hospitals (who arguably need capital the most for renovations) are finding it increasingly difficult to access capital.

Building on the previous Change Agent posting on the need to consider the emotional aspects of change, Fast Company Writer Alan Deutschman talks about the need for "quick wins." (read Fast Company Article)

You'd think that small lifestyle changes, like popping a pill once a day, would be easy to keep up with.

Unfortunately, the data tells us otherwise. 66% of folks taking statin drugs stop after a year. Why? Even though the drug may have actually treated their symptoms, they couldn't feel any difference.

On the other hand, going back to Preventive Health Research Institute, the folks going through Dr. Ornish's tough and radical program saw quick, dramatic results. Feeling and seeing those tangible results told them, "hey, this is working!" and motivated them further.

Deutschman goes on with a truth-telling research study done by management consultant gurus, Bain & Co. (Read Bain's "Rip Off the Band-Aid Quickly PDF Whitepaper) Almost all successful corporate transformations were substantially completed in 2 years or less. Early victories produced momentum, silenced the nay-sayers, and served as emotional fuel to take on the challenges ahead.

Change Agent Series:
101 Why preventative health doesn't work
102 Give people a new frame (not a new picture)
103 Revolutions easier than evolutions
104 Learn to play the accordian

Richard Branson, founder of Virgin, announced today that he is teaming up with Humana to offer a health insurance product. It will be linked to gym membership and discounts for Virgin Airlines. He believes that a good portion of the 45MM currently uninsured folks could benefit tremendously from this.

Asked about his take on the healthcare market, Branson says, "we think that by Virgin going into it, we can liven it up"

I guess it was only a matter of time that a non-healthcare celebrity leader like Branson invested into healthcare. I am intrigued by the potential for new ideas and healthy turmoil. And I love this idea of providing some incentive for people to feel better and get healthier, though I wouldn't go as far as Branson in saying that their products will be "liberating, life-enhancing and fun."

How do we change people's behavior? Fast Company writer Alan Deutschman took his search to Dr. Ornish of the Preventative Medicine Research Institute, where previously-heart-attack-waiting-to-happen patients leave every day with sustainable lifestyle changes (smokeless, exercising, and dieting). Ornish's strategy to motivate is refreshingly different than the typical "you're gonna die if you don't change" fear tactic.

Here's why scaring people with death doesn't work:

the thought of death is just too much, people go into denial, people get depressed, and then people aren't sure that living a longer (and depressed) life is even desirable.

Ornish reframes the issue, by appealing to positive emotions. He talks about the "joy of living," and encourages people to enjoy the things that make daily life so pleasurable. He has effectively "re-framed" the issue. Read the rest of the article for more examples from business (IBM, Apple, and the NYTimes).

While we're sort of on the topic of smoking, teen smoking is down. How did it happen? Check out this Slate article on how this advertising campaign got teens to stop smoking. Similar to Ornish's strategy, they didn't appeal to the fear of death (what teenager doesn't feel invisible?), they appealed to their emotional need to be hip.

For teenagers, the fear of being uncool and unaware is greater than the fear of dying.

Both of these examples help us see that when we want to change someone's behavior, we have to appeal to their most poignant emotions. It's the same facts/information, just "re-framed" in a way that connects with them. Whether you're a doc trying to get a patient to change his life or you're an administrator trying to implement a new system or process for docs, the question becomes: do we know people well enough to identify the emotional aspects of any change we desire? Maybe we're getting ahead of ourselves. do we know ourselves well enough?

Change Agent Series:
101 Why preventative health doesn't work
102 Give people a new frame (not a new picture)
103 Revolutions easier than evolutions
104 Learn to play the accordian

If you had $200MM to invest, what would you invest in?
(a) a new rural hospital company
(b) a managed care company
(c) a pharmaceutical / biotechnology company
(d) a clinical IT company
(e) are you kidding? I wouldn't invest in healthcare.

GTCR, a private equity firm, announced today that their answer is "(a) a new rural hospital company." For the investment gurus out there, yes, this question is rigged - the answer depends on where else you are currently invested, etc.

Nonetheless, GTCR is the same firm that funded Life Care Hospitals (12 hospitals down South) and Trans Healthcare (120+ facilities in the East Coast/Midwest area). Apparently, they have been successful enough in these ventures to be hungry for more. And obviously, they have confidence in the new management team, which is primarily made up of former Province Healthcare Execs.

This is interesting in light of the fact that HCA, one of the strongest performers in the hospital sector, has made a concerted strategy to focus on growing urban areas.

But isn't half-knowledge dangerous?

You guessed it. In my previous posts on new hospital comparison tools, we saw that Aetna, UnitedHealthcare, and the government all launched hospital comparison tools. Well, not surprisingly, another was launched this past week from CIGNA. Here's an example of an output on St. Anthony Hospital.

Is more information always better? Because one hospital got 1 star or 1% point higher than another hospital, would that cause you to go to another hospital?

Look what happened in San Diego. The press beat up these two hospitals because their heart bypass mortality rates were 1% more than neighboring hospitals. What's next? An e-learning session for the general public on statistical significance?

Check out this article from the Star Tribune of Minneapolis (registration may be required).

An excerpt: "Like planes on the runway waiting for takeoff, patients in the waiting room are identified on one screen by name and the severity of their condition. Other screens track progress in the operating room and the availability of hospital beds, smoothing the patient's trip from takeoff to landing."

Okay, so the previous posting on obesity & lifestyle is a long, but perfect set-up to say that preventative health has been cited as a promising strategy to deliver us from our healthcare woes. People say, "if we just get people to take care of themselves, make better lifestyle decisions, blah blah blah, the entire health care system would cost xx% less."

Kaiser Foundation Health Plan and Hospitals CEO George Halvorson wrote a tremendous article in HFM on the coming "tipping point in healthcare." He cited how taking care of 1% of the sickest among us makes up 30% of the cost. Not all of those are lifestyle-driven, but some surely are. As quoted in Fast Company, Dr. Raphael Levey, of the Global Medical Forum, noted that "even as far back as when I was in medical school [Harvard, 1955], many articles demonstrated that 80% of the health-care budget was consumed by five behavioral issues." Yeah, you guessed it: too much smoking, drinking, eating, and stress, and not enough exercise.

I love the beauty and simplicity of these ideas. Just think: if everyone in America decided to eat right, exercise, refrain from smoking, how many trillions of dollars would be chopped off?!?

Sigh... I hate bursting my own bubble. As much as I would love to see this happen, I don't have much faith in this strategy at all. People are people, and I am constantly amazed at how most people (yours truly included) never change no matter how badly we need to. The Fast Company article continued,

"Some 90% of heart-bypass patients can't change their lifestyles - even at the risk of dying."

This inability to change people's behavior has tremendous implications on our health and our hospitals.
(1) Any preventative health program rolled out at any level has to do battle with this inertia/complacency. Simple websites sponsored by the government at best are a weak start.

It might be good PR, but it isn't making any kind of impact.

(2) Related, but in a different way, any change management initiative rolled out at your hospital requires staff to work/think/act in a new way. How will you get your organization to care about / re-align towards [fill in the blank]? In fact, isn't this how you would describe leadership? Being able to influence others to change? How do we become effective change agents in our organization and in our society?

We covered some of this in the If Disney Ran Your Hospital series (book by Fred Lee). But, I think there is still quite a bit to cover. In the next few weeks, let's dissect Fast Company's article on Change or Die by Alan Deutschman. While you're there, also check out Fast Company's 5 Myths about changing behavior.

Change Agent Series:
101 Why preventative health doesn't work
102 Give people a new frame (not a new picture)
103 Revolutions easier than evolutions
104 Learn to play the accordian

Dr. McClellan, administrator of the CMS, announced at an AHA meeting today that 270 hospitals participating in their pay-for-performance program saw marked improvements.

One year into the project, the lessons learned:
-Focus on leadership and culture.
-Focus on efficient dissemination of clinical best practices.
-Focus on process improvement, with or without up-to-date technology.

[updated]
Wouldn't your hospital want to be a part of this for a piece of the $7MM pie (averages out to $25k/hospital)? On the flip side, poor performing hospitals may have to pay a penalty.

And Dilbert doesn't even have to think about HIPAA!

Have no fear, IBM has arrived!
Last month, they announced two substantial deals in healthcare IT. They bought HealthLink, probably for $200-300MM (terms were not disclosed). Plus, they partnered with University of Pittsburgh Medical Center in a multi-year $400MM deal.

Matthew Holt, in his Health Care Blog, also mentioned rumors of Oracle sniffing around the industry. Maybe Cerner as a target? Makes me wonder, since Cerner also announced an acquisition of its own today. Apparently, healthcare is the new, new thing for these IT implementation gurus.

Frost & Sullivan think that hospital IT demand will grow even faster after HIPAA implementations are done.

We will have to see how this plays out. The day that the likes of IBM, GE, and Oracle start competing for your business, innovation (and upheavel) is on the way.

The latest Grand Rounds are up! MudFud, an MD/PhD student, is this week's host. (where does she find the time to blog?) For previous Grand Rounds, check out the archives here.

The healthcare blogosphere has been active with these hot-potato topics.

Today, Matthew Holt posted another entry on whether the American health system is truly a free market. Check out his original post (4/19/05) that generated quite a few insightful and heated comments. At the heart of the issue: how do we appropriately provide incentives for people to pay for and benefit from the healthcare system?

Don Johnson (the one who disagrees with Holt) over at the Business Word is a frequent blogger on the uninsured and healthcare policy, with 58 entries on the uninsured. Don't miss Joe Paduda's post on why the uninsured effects us all.

Last week, Ezra Klein finished comparing and constrasting our healthcare system with those in other countries. Out of Canada, France, Britian, and Germany, Ezra preferred the government-provided French system with a floor (but no ceiling).

I also posted on why the uninsured are increasingly headed to private hospital ERs and why the uninsured problem will not be addressed.

And of course, Grahamazon has done a superb job putting together a 3-minute segment on why a single-payor system makes sense. Maybe some will criticize this segment for its oversimplification, but I think we need more content like this (even though I'm not sure I agree with him). His use of statistics, production, and analogies is excellent.

I went to an Advisory Board presentation at the last ACHE Congress where the presenter provided different "tiers" of possibility for healthcare change. Of course, the single-payor model was rated the least likely of them all, with only Ted Kennedy publicly supporting them. On Kennedy's Health Issue page, he links to everybody in, nobody out's webpage.

Maybe that is about to change... Enter the HMO Big Wigs...

This past Friday, Aetna CEO John Rowe announced his support for a requirement that all individuals obtain basic health coverage and for a public subsidy for those who can't afford the insurance.

Though the details of such a plan were not given, Rowe mentioned subsidies for low-income individuals and a broad-based funding mechanism. Of course, Rowe isn't pushing for a single-payor system (otherwise, his compensation in the future might be significantly less than his 2004 compensation of~$22M). But I applaud him for taking a public stand on such a contentious issue (even if it does get him and his company some PR points).

(by the way, can someone help me out - is it payor or payer?)

An apple a day may keep the doctor away, but according to a new research study, people ain't eating their applies.

This article on CNN states that only 3% of the population is following "common sense" guidelines for healthy living. Red State Moron also gives 4 other links, citing the same study.

I found this terribly ironic that just as this report came out, a group backed by the U.S. Food & Restaurant industries came out with an ad blitz saying that the obesity threat is just "hype." Here's the ad from the May 2 Newsweek magazine:

Honestly, I can't blame them for reacting the way that they have. After all, millions of Americans have went on diets (4 diet books on amazon's top 50 right now) and watched "The Biggest Loser." The CDC called obesity an epidemic, compared it to terrorism, and millions of Americans watched "Supersize Me" in awe.
.

These restaurant folks are simply protecting their own interests. In their minds, they were screwed by CDC ignorance and arrogance. But in my mind, this ad blitz would be just like if cigarette companies came out to say that the dangers of smoking is just "hype."

Now, I realize that the politics and the psychology of obesity in this country is complex and multi-dimensional. But anyone who has worked in a hospital knows the effects of obesity.

So many of the metrics that compare the U.S. health system to those in other countries show us lagging behind. yes, our health care system contributes to that lackluster performance. But is it possible that we don't fare as well also because we are less healthy to start with?

Book Review: If Disney Ran Your Hospital, by Fred Lee (5 out of 5)
This book is the "Space Mountain" of hospital management books

Many of you have been following my 8-part series on Fred Lee's book, If Disney Ran Your Hospital.

(adapted from the review I wrote on amazon.com)
Like many Disney rides, you have to wait a bit to get this book on amazon (I purchased mine directly from the publisher). But it's worth the wait. I attended the ACHE Conference in 3/2005 where the book was named the "2005 Book of the Year."

Fred Lee has written a fantastic book in "If Disney Ran Your Hospital." Not only is it a well-written book (Lee uses memorable examples, stories, and graphs to illustrate his points), but also he has chosen an outstanding topic. We need more books like this - learning from the best from other industries. Lee effectively builds the bridge, taking Disney corporate realities and turning them into approaches and strategies that hospital leaders can easily digest and apply in their hospitals.

Some of the concepts definitely stretch my current mindset on customer service (and after reading the book, you might even stop using that term). Lee talks about why perceptions are more important than reality, patient loyalty is more important than satisfaction, courtesy is more important than efficiency, and experience is more important than service. He also spends some time addressing the shortfalls of patient satisfaction surveys and competitive incentives for employees. All for the sake of his true focus of the book: to "bring out the best behaviors in workers and provide the best emotional experience for patients."

For those that are experts in services marketing or world-class hotel corporate culture, some of the concepts will be old news. Nonetheless, the way Lee specifically applies these concepts to the hospital setting is truly magical and novel.

That seems to capture the confused look I get when I tell people I work for a non-profit that has grown net profit by 80% from last year. Isn't a profitable non-profit an oxymoron? It's a legitimate question.

There has been a lot of non-profit hospital-bashing going on these days. Part of the increasing scrutiny around hospital pricing and billing practices is rooted in a misunderstanding of the world of non-profits. People aren't comfortable with that tension between mission and money. And honestly, I can't blame them. As a person in non-profit strategic planning, I've been living with that tension for almost two years, and yet I still can't always shake that feeling of uneasiness.

This is probably pretty basic for many of you, but here's what I've gathered so far...

What makes a non-profit a non-profit?

In the most basic sense, a non-profit is a legal entity that (directly or indirectly) benefits society. Under IRS Code 501 (c)(3), a nonprofit corporation may be formed to operate for some religious, charitable, educational, literary, or scientific purpose. Legally, no one "owns" the organization - there's no stocks, and thus according the HHS, "no part of the net earnings of such entity accrues or may lawfully accrue to the benefit of any private shareholder or individual."

How can a non-profit have profits?

The only way any organization, profit or non-profit, gets bigger is through profits. Through higher profits, non-profits can invest in new strategic initiatives to accomplish their mission in expanded and novel ways. We should root for profitable non-profits!

There's nothing wrong with a non-profit having profits. If anything, it could mean that the non-profit:
- has done a good job controlling expenses
- has provided goods/services that others valued enough to purchase or give
- has been smart in balancing short-term demands and long-term goals

How does a non-profit organization measure success?

Most define success by somehow measuring their impact on society. For the American Red Cross, it might be dollars donated to families. For a healthcare management association, it could be how many people attended their educational events. For a hospital, it could be how many patients they treated. Honestly, it's hard to truly measure impact - how do you measure the value of a changed life? Is one fully changed life worth the same as two half-changed lives?

Inevitably, though, financial metrics are also used to measure the sustainability of operations. That's the reality of non-profits. In my organization, we have 6 non-financial metrics and 1 financial metric. Our job is the mission, but our means is the money. Put another way, meeting the non-financial metrics means we are accomplishing our mission this year. Meeting the financial metrics means we are planting seeds for the success of our mission for the years to come.

What makes a successful non-profit manager?

Interestingly enough, non-profit managers need all the same skills that their for-profit counterparts need - finance, accounting, marketing, public relations, leadership, organizational development, you name it. But, I believe that the job of non-profit managers is even more sophisticated in these ways:
- they must balance financial goals with mission goals
- they must be comfortable with significant "service lines" that consistently lose money and find ways to stay afloat in other ways.
- they have to be more creative to "do more with less"
- they often must motivate staff and volunteers using non-financial means (you can't fire a volunteer, nor can you give them a raise or a pay cut)

It's unfortunate that the reputation of non-profit managers suffers on both extremes: many see non-profit managers as either greedy opportunists trying to cash in on others' generosity or 2nd-class businesspeople. That's probably true, but only at the fringes. I've met a lot of non-profit leaders who have 1st-rate business minds coupled with a 1st-class passion for a better world. Those are fun people to be around.

For more on becoming a great non-profit leader, go to Peter Drucker's site for non-profit leaders.

By the way, all non-profits have their tax returns available for public viewing. Visit Guidestar, register for free, and pull up your favorite non-profit.

if Disney Ran Your Hospital, actions would be more powerful than ideas.

It's easy to look at Disney's level of organizational excellence, and say "I wish we had that." It's easy to read a book called "If Disney Ran Your Hospital," then just go about our business as usual. The question becomes: what are we going to do about it?

Watching the Olympics, I heard lots of people say, "I'm gonna get in shape!" Or kids watch professional athletes on TV, and say, "I'm going to be like Mike." Sometimes I listen to a concert pianist or opera singer and am dazzled.

It's easy to forget how much work they have put in just for one brief concert, performance, or game. Sure, it takes talent, but how many talented people have not succeeded? I once heard a stat: for every minute an NFL player plays in a game, he has trained/worked out ~100 minutes. (and that doesn't even include the years of training to get to a competitive level). To be great, talent is helpful, but hard work is unavoidable.

What about our hospitals? Yes, there might be some low-hanging fruit in our organization that we can pick off pretty easily. But real transformation in organizations doesn't involve short-cuts, gimmicks, more consultant decks, and tips. It takes hard work... no, it takes hard, smart work. There's no getting around it.

Fred Lee highlights some traps that many organizations fall into in trying to close the gap between knowing and doing. Too many leadership teams delegate the management of culture and change to committees, consultants, individuals, and trainers. These initiatives are doomed for failure. The leaders have to be directly accountable. Culture and change are much too important to be delegated.

Also, too many organizations suffer from analysis paralysis. The leaders of the organization must be willing to put in the hard work in hardwiring excellence. It's good to ask "how?" but at some point, we have to roll up our sleeves and dive in.

But you may ask, this sounds a lot like "making people do things." Is Fred Lee advocating a culture driven by compliance? Isn't this in conflict with the previous post on motivating through imagination? Yes and no. Some organizations' cultures are so chaotic that the first step is to get to a culture of compliance. Once that is established, then, the next levels of motivation can be pursued.

That's it! We've come to the end of our series on "If Disney Ran Your Hospital." I highly recommend that you purchase this book. I covered the 8 most impactful lessons for me and my organization, but honestly, there were probably 30-40 other lessons I could have talked about enthusiastically. Thanks to Fred Lee for writing such a thought-provoking and lucid book.

8-Part Series on "If Disney Ran Your Hospital"

The 8 Big Impact Ideas from “If Disney Ran Your Hospital”
1. Perceptions > Reality
2. Courtesy > Efficiency
3. Patient Loyalty > Patient Satisfaction
4. Experience > Service > Product
5. Intrinsic Motivation > Extrinsic Motivation
6. Habit > Imagination > Willpower > Compliance
7. Dissatisfaction > Complacency
8. Doing > Knowing

Check out the Grand Rounds posting on Dr. Tony's blog. For the blogging newbies, this is kind of the "week in review" for the medical/hospital blogging community.

For those coming in from Dr. Tony's, welcome! Find out more about hospital impact.

(if only grand rounds could be held here instead of our hospital conference rooms)

also worthy of note today:

on hospitals
- this USATODAY article on hospital charity care lawsuits. The suits are being dismissed in federal courts, which is another way of saying "big legal showdown coming to a state courthouse near you."
- $13MM extra for 61 Indiana hospitals from BCBS pay-for-performance program
- Triad Hospitals performance beat estimates. Plus, smoother sailing ahead.

on blogs
- A Non-Stop Celebrity Megablog is born?
- Businessweek started a blog about blogs.

(Photos: CBS)

As a follow-up to my previous post on the WOW factor of Bumrungrad hospital in Thailand, check out this 60 minutes piece on medical tourism

If Disney Ran Your Hospital, employees would have a healthy dissatisfaction with their current performance.

Not that people would be first-class complainers, but they would never be satisfied with the current level of performance. They would always be thinking/ scheming/ dreaming/ striving for the next level. In some sense, this is just another way of saying what Jim Collins said in his book Good to Great:

Good is the enemy of Great

The greatest companies in the world all had to make a very difficult transition - going from good to great. How do we motivate people who are already doing a good job? How do we get them to dream bigger?

Fred Lee shares a recipe from Martin Stankard, a national Malcolm Baldridge Award examiner:

Dissatisfaction with "as is" + Dream of "could be" + knowledge of "how to" > Organizational Interia.

Part of creating a "culture of dissatisfaction" is using statistics wisely. If patient satisfaction scores are already at 95%, what motivation do people have to change? Do what Disney does. Measure the % of all respondents who are "very satisfied," the 5 out of 5 scores. That creates the kind of environment where staff don't get complacent, but get creative. Even at great organizations (e.g. Disney), that score is probably 60-70%. That's a D / C-!

Part of "dream of could be" is to help your staff envision what greatness would taste like, feel like, smell like, look like. It's gotta be vivid, clear, and it has to balance idealism with realism.

Listen or read Martin Luther King, Jr's speech. Apart from the amazing person he was, we can all learn from him on how to cast a vision. His use of stories, metaphors, and analogies is absolutely masterful. His audience had plenty of dissatisfaction, and so he wisely supplied the other two components: the dream and the knowledge.

Keep in mind that all 3 ingredients are needed. Vision alone becomes lofty ideas that are quickly forgotten and subjugated to the daily demands of the job. Dissatisfaction alone creates frustration, angst, and a destructive culture. Knowledge alone has no way of energizing and persisting in change. The leaders have to provide all three.

The golf world was amazed when Tiger Woods, during the peak of his dominance, decided to completely change his swing. Why, Tiger, why?

Read what he has to say in this GolfDigest article. This is a man who has a healthy obsession to be constantly improving. Sure he was beating the rest of the competition by 10 shots or more before the change, but he knew he could be better and more consistent. So he changed his swing. Even though his transition to the new swing has cost him a few years of losing big, Tiger seems to be back again, better, more consistent, and more amazing than before.

8-Part Series on "If Disney Ran Your Hospital"

The 8 Big Impact Ideas from “If Disney Ran Your Hospital”
1. Perceptions > Reality
2. Courtesy > Efficiency
3. Patient Loyalty > Patient Satisfaction
4. Experience > Service > Product
5. Intrinsic Motivation > Extrinsic Motivation
6. Habit > Imagination > Willpower > Compliance
7. Dissatisfaction > Complacency
8. Doing > Knowing

The Rise of the Hospitalist = docs have more time with patients, better clinical outcomes, 13% decrease in costs, and 16% decrease in lengths of stay? That's what this article on St. Charles Medical Center (Bend, Oregon) stated.

Another article (may require registration) in The Star Telegram offers more stats: there are roughly 12,000 hospitalists working nationwide, making $155k, seeing 2,200 patients per year.

In Massachusetts, this article told a patient's story of receiving better care at Holyoke Medical Center because of a newly implemented hospitalist program.

Happy birthday to hospital impact!

Well, it's been one month since I started hospital impact. and what a ride it's been! Now that I have 30 days of blogging under my belt, I can safely say that:

Blogs on hospital administration/leadership are few and far between.

There are some good medical blogs by doctors, some good health IT blogs by IT professionals, and good policy & news blogs by consultants. But by and large, there's nothing solely for hospital leaders. Is this a fluke? Am I on to something new and novel? Or maybe no one's done it before because there's just not enough hospital leaders who even know what a blog is?

Search engines are weird

Can anyone make sense of the difference between yahoo and google and ask? Notice that if you search for healthcare blogs on yahoo, hospital impact will be your #2 hit. but if you search for healthcare blog (no "s"), hospital impact will be your #244 hit. Also, Jack Welch 8 Leadership Principle is your #1 hit on yahoo, but no where to be found on google? The only thing I have figured out is that yahoo uses the key words associated with the blog, where as google doesn't.

I enjoy learning new things.

As nerdy as it sounds, blogging seems to be yet another manifestation of this inherent curiousity and desire to learn. The physical process of writing and editing clarifies the idea in my mind, helping me to learn.

Other ways this has manifested itself? Last year, my sister and I were walking down the street and passed a crafts store. We went in with no agenda, but came out with yarn, two sticks, and a "how to" book. 3 hours later, we had knit an ugly scarf. Also, I recently decided to learn how to play the accordian. Just finished learning "The Godfather."

I'm a sucker for stats.

I don't know if this is a guy thing (i.e. the popularity of fantasy sports), a geek thing, or a performance-driven thing, but I watch my web statistics way too much. I need to publicly confess that I have looked at my blog stats page and hit "refresh" to see the hits number go up one by one.

by the way, the stats:
# of visits: 2,000+
# of unique visitors: 380
# of hits: ~37,000 hits (although probably ~30,000 of those are me checking stats)

# of times I've wanted to discontinue hospital impact: 3
# of times I've mistakenly visited a "bad" site while researching for hospital impact: 3
Average # of times I edit a post after it's been published: 4-5
# of times I've blogged when I should've been doing something else: ~20
# of sites that link to hospital impact: 4
# of people who have added hospital impact to their favorites (est.): 30
# of minutes it takes me to post an entry: ~40
# of spam hits from a paxil-selling website: 60
# of days I didn't post anything: 1

Starting this weekend, I will be taking weekends off to keep fresh. Go Bulls!

# of minutes I should have spent on this post: 30
# of minutes I actually spent on this post: 90

A few weeks ago, I ranted at the silliness that Wall Street thinks that hospital stocks tend to move together, discounting the impact a good leadership team can make.

Today, one of my favorite investment websites, TheStreet, reported that hospitals are looking healthier based on HCA's surprise announcement. They beat estimates by 38% on bad debt management and higher patient volumes (i.e. flu patients on March). I was glad to see some meaningful mention of hospital management as an attribute of success.

From theStreet.com article,

"I view HCA as having the best management in the hospital sector and much further along in implementing new health care business strategies than the rest of the sector," says Peter Young, a business consultant at HealthCare Strategic Issues. "As such, I suggest others' performance will lag HCA for the year."

Why are we always talking about HCA? They're the biggest. HCA's market cap of $23 billion is more than Triad ($4b), Tenet($5.5b), HMA($6.1b), and Pacific Healthcare ($4.8b) combined.

If Disney Ran Your Hospital, employees would be motivated by their imagination instead of their obligation to comply.

Again, Fred Lee perfectly describes the human heart. In particular, what is the primary motivation of the human heart? He describes 4 levels:

1. Compliance: I do it because I have to do it. (or I'll get in trouble)
2. Willpower: I do it because I should do it (I don't like it but I know it's what I should do)
3. Imagination: I do it because I want to do it!
4. Habit: I do it because it comes naturally for me to do it.

If you're like me, then maybe the word "imagination" doesn't quite fit in there for you. Lee links imagination with compassion this way: you have to really try to imagine what the patient is going through, what the patient's family is like, what the patient is thinking. Through that imagination process, you are growing your capacity for compassion.

In fact, as weird as it sounds, that's what good actors do - they are able to relate to their characters so much so that they are truly feeling the raw emotions of their character. The best actresses who cry on screen are crying real tears - many conjure up the saddest moments of their lives and allow themselves to feel those emotions on screen. Whatever the character feels - loss, love, fear, determination - the actor draws from the emotions of their daily lives.

Ultimately, all good actors have sincere compassion for their characters. They use their imagination to feel what the character is feeling. Good acting doesn't look like acting because it's real people showing real emotions!

In the same way, Lee encourages hospital staff to imagine the emotions and thoughts of their patients. Drawing on their own life and truly seeing the patient's needs - this is the essence of empathy and compassion. A word that works better for me is "perspective" (though it overly-emphasizes the intellectual aspects over the emotional aspects). If we truly have the perspective of the patient, we will be able to treat them with better care, anticipate their requests, and meet their needs before they even realize they need it. You can read about Lee's experience going to acting school and how he's draws upon his new abilities.

Leaders must become artists - we must master the art of motivation. Carry around a bat and we can get anyone to comply. Plaster a mission statement everywhere, and maybe we can get people to feel a true sense of obligation. Capture people's imaginations, and we've got patients who will tell memorable stories about your staff over dinner (and a movie).

What motivates you? What motivates those around you?

8-Part Series on "If Disney Ran Your Hospital"

The 8 Big Impact Ideas from “If Disney Ran Your Hospital”
1. Perceptions > Reality
2. Courtesy > Efficiency
3. Patient Loyalty > Patient Satisfaction
4. Experience > Service > Product
5. Intrinsic Motivation > Extrinsic Motivation
6. Habit > Imagination > Willpower > Compliance
7. Dissatisfaction > Complacency
8. Doing > Knowing

Thanks to Matthew Holt for linking to Ezra Klein's new series on how healthcare systems in other countries work. Too often, we compare our system to other countries without even having the slightest about what those systems are really like. I'm looking forward to Klein's lowdown. So far, he's already covered England and France.

Kevin MD has put up 13 postings in 48 hours on everything from obesity to patient compliance.

Also, check out Girl Scientist's grand rounds (highlights of medical blogs from the last week or so).

MedPundit also discovered a new way to make money blogging. One particularly proficient blogger, Darren Barefoot, offered up his blogging services on ebay and got 9 bids, with the winning bid at $2,000. The winning bidder? Check out the Cincinnati Healthcare News blog.

Since I've been covering the book "If Disney Ran Your Hospital" in the leadership blog, I thought I'd just bring up the fact that this blogger got kicked out of Disney for providing unofficial tours.

And while we're talking blogging, I couldn't resist this article about why celebrities blog. Not in the mood to face the harsh realities of hospital management today? Do some productive procrastination at these blogs...

Bruce Willis, David Duchovny, Pat Sajak, and Rosie O'Donnell blogging away.

If Disney Ran Your Hospital, they would motivate employees through the mission of the hospital, not the amount on their paycheck.

Disney doesn't utilize pay-for-performance. Nor do they utilize a "forced" curve where a certain percentage of workers get higher raises than others. In environments where teamwork and lateral relationships are instrumental for success, such incentive structures don't work - and even more, they are destructive and demotivating.

I'm sure many people are familiar with the infamous, secretive "hazing" that goes on at college fraternities across the nation. Essentially, a group of new freshman eager to join the fraternity have to do some unconventional "things" to prove their loyalty and unity to the fraternity.

Though those involved are sworn to secrecy, stories abound - 10 guys stuck in a bathroom and can't come up until they finish 10 cases of beer, people swallowing live goldfish, etc.

Back in college, I thought these things were simply foolish. I understood the value of unity, but why couldn't they build unity while doing something constructive. Why couldn't they go out as a team and build a house with Habitat for Humanity?

Now I understand - to do something constructive would defeat the very purpose of the hazing. The new group had to be so sincere about joining the fraternity that they would do these things in which the only incentive to do so is to prove loyalty and commitment. If the activity had any other extrinsic motivation (like helping the community), it would defeat the purpose!

Lee also gives some good examples of this.

THE OVERZEALOUS MANAGER: One manager wanted to encourage her employees to write "letters of appreciation" to other employees in the group. Very few people actually did, so she decided to provide some incentive - for every letter, the writer would get a Pepsi. You can imagine what happens next - Not surprisingly, she yanked the whole thing a week later - $50 poorer and no one taking any letter seriously.

OLD MAN STOPS INSULTS FROM KIDS BY PAYING THEM TO INSULT HIM: I absolutely love this story, and you'll find it on page 179 in Fred Lee's book. It basically goes like this. Kids insult old man. Old man ignores them. Day after day, kids keep insulting old man. Old man decides to pay kids a quarter for each insult. The next day, tons of kids come and insult. The next day, old man says, "too many kids. now I can only pay you a penny for each insult." Kids go away insulted and stop insulting old man for good.

What a perfect illustration for how extrinic motivations can derail intrinsic motivations!

There's a fine line here. Obviously we are to be careful how we reward "compassion." We want to avoid the situation where people do compassionate things in hopes of the reward while their real sense of compassion is no where to be found. On the other side of the coin, we also want to recognize those who display compassion sincerely and spontaneously. Just as the display of compassion is spontaneous and not required/expected, so should the recognition be. Indeed, it's a fine line...

8-Part Series on "If Disney Ran Your Hospital"

The 8 Big Impact Ideas from “If Disney Ran Your Hospital”
1. Perceptions > Reality
2. Courtesy > Efficiency
3. Patient Loyalty > Patient Satisfaction
4. Experience > Service > Product
5. Intrinsic Motivation > Extrinsic Motivation
6. Habit > Imagination > Willpower > Compliance
7. Dissatisfaction > Complacency
8. Doing > Knowing

Just last week, the Nevada Assembly passed a bill for hospital pricing transparency. Last month, an opinion piece in a California newspaper argued for increased disclosure on hospital costs and financials. Several hospitals in South Carolina are being sued for hospital pricing. The suit looks for hospitals to permanently stop charging uninsured patients more than insured patients.

Have you heard of these organizations?

www.hospitalvictims.com</a>: a website for those who feel that hospitals have overcharged them. You can download videos of people sharing their stories of how overpriced hospital bills caused tremendous stress and pain in their lives.

HospitalMonitor, a Chicago-based advocacy group, has been hard at work in exposing hospitals' "double standard of care" and demanding "accountability" from hospital administration.

Oregonians for Health Security: an organization in Oregon is working for "fair hospital pricing" and leads with these three facts.

Fact: Hospital costs are the fastest growing component of health care costs.

Fact: Oregon is the fifth most expensive place to spend a day in the hospital.

Fact: Oregon hospitals made $265 million in profits in 2003.

Based on the increasing attention on the uninsured and hospital pricing discrepancies, we can be sure that the worst is still yet to come. How should a hospital respond to this? Many hospitals counter with more communication about the level of charity care and uncompensated care they provide per year. Though these amounts are significant, the dramatic story of "poor family with 6 kids being worked by money-making hospitals" is sticking into our nation's memory. This is not a problem that will go away with a slick PR campaign (though... where are the "poor family with 6 kids helped by generous hospital" stories? there is $20-25 billion dollars worth of those stories each year. And if hospitals do use a PR campaign, please please use stories, and not just numbers). Yes, hospitals need to learn how to price fairly. For a primer, try Cleverley Associates' white paper (pdf) and look at their article on "Are Hospital Prices Reasonable? (pdf)" Also check out HFMA's Patiently Friendly Billing Project for regular updates. HFMA also has numerous educational activities, including this audiowebcast on April 21. This one ain't going away any time soon:

the heart-wrenching story that everyone can relate to + the tobacco lawyers of the 1990s looking for a new battle + the increasing prevalence of being uninsured = the perfect storm?

If Disney Ran Your Hospital, Customer Experience would trump Customer Service.

In the now famous book, The Experience Economy, the authors provide an insightful commentary of where our economy is heading. Back in the 1800s, we had an economy driven by commodities - cotton, water, oil, steel, etc. Then, after the industrial revolution in the early 1900s, our economy was driven by manufacturing - i.e. clothing, cars, refrigerators, TVs. In recent years, since all products are becoming semi-commoditized, value is created through services (relaxing spa, trusted investment advice, friendly dry cleaning). The 4th revolution has begun relatively unnoticed - the customer experience.

Take coffee as an example. The theory is that every step up gives you 5-10x more value. Coffee grinds run maybe a few cents. Package it into a product? maybe 20 cents. Brew a cup and sell it - about a dollar. Cozy up in a warm sofa at a Starbucks with a grande dark roast coffee, $4.

Lee quotes the authors, and so will I: "Commodities are fungible, goods tangible, services intangible, and experiences are memorable." The main principle is that experiences are personal and individualized.

In other words, we have to stop thinking of our hospitals as providing a service or a product. We have to start thinking about our hospitals as providing an experience. What kind of an experience? As Lee puts it, an experience that "engages patients on an emotional, physical, intellectual, and yes, spiritual level." And the quality, consistency, and substance of that experience may very well become the primary differentiator of your hospital. What can we do today that will make this patient visit absolutely memorable?

Lee goes on to make some excellent points of how to implement this new mindset. Scripting has to be more than words on a page, but setting up an entire experience, scene by scene. Hiring should be done based on one's talent to engage the patient. Think of roles, not jobs. In some sense, every patient room is a stage.

Lights, camera, action!

8-Part Series on "If Disney Ran Your Hospital"

The 8 Big Impact Ideas from “If Disney Ran Your Hospital”
1. Perceptions > Reality
2. Courtesy > Efficiency
3. Patient Loyalty > Patient Satisfaction
4. Experience > Service > Product
5. Intrinsic Motivation > Extrinsic Motivation
6. Habit > Imagination > Willpower > Compliance
7. Dissatisfaction > Complacency
8. Doing > Knowing

Yesterday, an LA Times article highlighted the problem of the shifting of ER care from crowded community ERs to private hospitals. In LA, this is particularly bad, with 2.25MM uninsured residents.

One hospital in particular, Downey Regional Medical Center, has been particularly hard hit.

If you thought your hospital was struggling with the uninsured, check out Downey's stats.

In the last three years, they have experienced a six-fold increase in financial loss as the number of patients increased 25%. According to the LA Times article, the increase isn't proportional because the uninsured are waiting longer to come in for care - driving up the complexity and cost of each visit.

One other interesting note from the article: The spokesman for the Hospital Association of Southern California estimated that "at the 40 private hospitals reporting jumps in ER visits by the uninsured, the cost of caring for them rose from $63 million in 2000 to $77.5 million in 2004." Correct me if I'm wrong, but that's only 5.3% a year. If he was trying to prove the urgency of the situation, a measley 5.3% doesn't do it for me.

If Disney Ran Your Hospital, they would focus on patient loyalty instead of patient satisfaction. That's right. Disney is arguably one of the greatest organizations in the world and they don't measure customer satisfaction. But they are relentlessly looking at customer loyalty. Why? Loyalty, not satisfaction, is what drives repeat business. In patient satisfaction vernacular, loyal patients give a rating of 5 out of 5, while "satisfied" patients give a rate of 3 or more. In a famous essay written in HBR on "The Loyalty Effect" by Reichheld, customers who give a 4 rating are 6 times more likely to defect compared to the 5-raters. Patient satisfaction surveys are an odd beast. If nothing goes wrong, if nothing memorable happens, the patient would probably check off "3" or "4." Additionally, if a hospital achieves "98% patient satisfaction," why would any staff feel the need to improve? They would rest on their laurels while patients simply had a ho-hum experience. Disney aims higher. Their measure is the % of customers that rate their experience "very satisfied" (rate 5 out of 5).

For patients to be "very satisfied," something memorable, something unexpected, something worthy of a dinnerparty story, has to happen.

Now, of course! It's Disney! Not a hospital where people come in sick, hurt, afraid, and stressed! How do hospitals create "storytelling moments" (of the positive kind, of course)? Lee did some research on unsolicited positive feedback from patients. The main theme? compassion. Patients remember compassion. Heck, human beings remember compassion, especially when they are in need. Compassion can become the chief point of differentiation in your hospital. How? Again, I leave that to Fred Lee. But I will say that it can't be scripted or even "required." (Imagine a husband saying, "wife, I love you because I'm required to.") But it does have to be hired for, valued, and measured. 8-Part Series on "If Disney Ran Your Hospital" The 8 Big Impact Ideas from “If Disney Ran Your Hospital” 1. Perceptions > Reality 2. Courtesy > Efficiency 3. Patient Loyalty > Patient Satisfaction 4. Experience > Service > Product 5. Intrinsic Motivation > Extrinsic Motivation 6. Habit > Imagination > Willpower > Compliance 7. Dissatisfaction > Complacency 8. Doing > Knowing

Here's a BCBS-Illinois ad in the April 11, 2005 Newsweek.

Honestly, I don't understand this ad. At first, I thought that they were marketing the launch of a new hospital comparison tool to match the government's new tool, Aetna's newly launched tool, and UnitedHealth's updated tool.

Instead BCBS is simply marketing the fact that members can now "check claim status, view explanation of benefits, and search for doctors & hospitals." Please tell me if I am missing something (surely wouldn't be the 1st time), but I thought all of this was standard by 2003? As a member of BCBS, I got this sinking feeling that BCBS is behind the curve, not ahead of it. Or maybe they purposely chose not to pursue a hospital comparison tool?

FYI - Newsweek charges ~$200,000 for a full-page 4-color ad.

Today makes it 22 consecutive quarters of more than 30% growth. That is quite impressive.

I always have mixed emotions when I see HMOs do so well financially. Not that I want to see them fail, but sometimes their gain means hospital loss (and vice versa). Take a look at this chart, where I took 4 representative HMOs (UNH, AET, HUM, WLP) and compared their performance to 4 representative hospital stocks (HCA, HMA, UHS, TRI).

The top 4 lines are HMOs, and the bottom 4 (clumped together) are hospitals. It's hard to see, but HMOs are outperforming hospital stocks by 100, 200, 300% over three years.

So, why the mixed feelings? Maybe I'm simply jealous of all those who put their money in these stocks a few years ago (while I loss $$ on tech).

From a hospital perspective, the HMOs pay the bills. They are also vital partners in helping the uninsured. (UnitedHealth is said to be pursuing 3 million new uninsured patients) Their members are exactly the patients that boost the hospital bottom line the most (if only hospitals had 100% private insurance patients!). Yet, many hospital staff are all too familiar with the complicated and stressful managed care contract renewal process. Doesn't HMO strength mean more HMO leverage in these negotiations (and thus less favorable rates)?

Strong HMOs are both good and bad for hospitals. Their strength gives them power over hospitals, but their weakness means hospitals struggling with more fragile cash flows.

Just to give us an idea of order of magnitude - the 4 HMO companies above made $4 billion in 2004, or 20% of the total amount of uncompensated care hospitals provided last year. Not small potatoes.

As an aside, what can we learn from the business model of the UnitedHealth Group?
They have brilliantly diversified outside of their core business. They have effectively acquired competitors to establish local/regional dominance. They are obsessive about cost-cutting. And they do their business so well that their competitors pay them for their help. How's that for "best practices?"

If Disney Ran Your Hospital, courtesy would be more important than efficiency. This is another one that sounds wrong. How could courtesy be more important that efficiency?

This is true at Disney. They don't use "pillars of excellence" like many of us to in healthcare where all five priorities are balanced (and the relative importance of each is unclear). Disney makes it more blatant by using a ladder instead of a pillar - pillars don't help you prioritize, ladders do.

On Disney's ladder, safety is priority #1, followed by courtesy, then show (kinda related to perceptions), and THEN efficiency. Long ago, Disney realized this (and Lee provides a great flowchart here):

Unit efficiency focus --> Internal focus --> Turf Protection --> Compete for Resources --> Overall inefficiency

Courtesy focus --> External focus --> Responsiveness --> Share Resources --> Overall efficiency

In other words, focusing on efficiency actually makes you inefficient (and probably not too responsive) where as focusing on courtesy gets you BOTH efficiency and responsiveness.

Hear what Lee is NOT saying: He's not saying that we throw efficiency out the window. Nor is he saying that we should stop measuring cycle times and think about process improvement. But too many times, process improvement initiatives are "department-centric" not "customer-centric." These so-called improvements maybe make the department more efficient, but only because they've shifted work to other departments.

Sometimes optimizing one cog in the machine makes the whole machine slower.

Lee mentions several stories of hospitals who took the courtesy plunge and succeeded. One hospital dramatically changed their food service. They initially had the "efficient" model of meal delivery for patients at set times, 3 times a day. If patients happened to miss the meal, too bad - kitchen was closed. Wanting to provide better service, the food service department evolved to the point where it now delivers food all day long, and not just to patients, but also to staff, to physician offices, and anyone who finds themselves in the hospital. The tripling in volume + decrease in wasted food costs more than paid for the extra labor required.

I have to admit, this one still sits uncomfortably with me. But in essence, Lee is saying organizational efficiency > unit efficiency. And many times, organizational efficiency is synonymous with finding ways to provide great service for patients.

8-Part Series on "If Disney Ran Your Hospital"

The 8 Big Impact Ideas from “If Disney Ran Your Hospital”
1. Perceptions > Reality
2. Courtesy > Efficiency
3. Patient Loyalty > Patient Satisfaction
4. Experience > Service > Product
5. Intrinsic Motivation > Extrinsic Motivation
6. Habit > Imagination > Willpower > Compliance
7. Dissatisfaction > Complacency
8. Doing > Knowing

Yesterday, Ventas, a healthcare real estate investment trust, purchased 68 independent and assisted living properties from Provident. $1.2 billion for 68 properties with a total of 6,819 units (about ~$176,000 per unit). Not surprisingly, revenues from the properties are largely private-pay.

How much is your hospital worth? Take a look at some hospital acquisition transactions from Levin Associates. Based on the two examples they give, the ballpark going rate for a typical, profitable hospital is $200,000 to $250,000 per bed. Put another way, hospitals are worth ~60 - 80% of their annual revenues. These are ballpark numbers only as hospital valuations are tricky; obviously, payor mix, location, capital structure, etc all factor in.

Today, HCA President said that specialty hospitals should not be allowed to compete - to do so would be "gutting" the local community hospital. Read the MSNBC article here.

Whether we like it or not, hospitals survive on subsidization. Private patients subsidize Medicare/Medicaid patients. And specialty operations subsidize the bread-and-butter emergency room & obgyn hospital operations. Without this subsidy, hospitals would easily be out of business. An unfavorable payor or procedure mix is more than enough to tip the scales for even a well-run hospital to go in the red.

We have private, for-profit, charter, and niche schools, why can't we have the same for hospitals? Education is a mess, but if only healthcare were as simple as education! Lawmakers are still scratching their heads.

Fitch's 2005 Outlook on hospitals (registration required) lists the states that have Certification of Need (CON) regulations, which would require doctors (or anyone) to prove a level of need before opening a new specialty facility.

If Disney Ran Your Hospital, patient perceptions of care would be more important than the actual care they received.

A few years ago, while Andre Agassi was still in the peak of his career, Canon advertised their new "rebel" camera with Andre, and the tagline: "Image is everything."

Lee explores a slight variation of that: perceptions are more important than reality. Sounds weird, but hang with me.

Let's pretend you are a patient in a hospital. It's late at night and you are half-asleep in your room. The nurse comes in, checks up on you and then quickly closes the door as she leaves. How do you feel? You might think she's in a rush to get to another patient (wow, this hospital is always so packed). You might think it inconsiderate (hey, I wanted that open!). Or maybe the nurse went out to talk behind your back.

Well, the truth was the nurse knew that the next shift was coming in and it would be getting loud outside. The truth is that she closed the door to minimize the noise from the changing shift report - she closed the door because she's a considerate nurse. But you didn't know that. You're still thinking about what you did to deserve this.

Good intentions and good care don't always lead to the perception of good care.

To impact patient perceptions (and thus, satisfaction), those good intentions have to be verbalized. This isn't showing off or brown-nosing. This is simply matching up your actions and words with your intentions in order to assure the patient and to avoid misunderstanding.

The nurse could have left, asking "Do you want me to close the door? it gets kinda noisy out there during shift change. It won't be too much longer." That 10 seconds of verbalizing done over 1,000s and 1,000s of patient interactions creates a perception, "hey, these people are looking out for me."

All of us are all too familiar with this idea from everyday life. We incorrectly read into things, others incorrectly read into our actions. It's why this book on the 5 different "languages of love" is an amazon.com top 100, selling 2.5 million+. Many relationships fall apart not because the love has faded, but that the love isn't understood by the other. It's as if they are speaking a different language.

We have to see every interaction with patients from their perspective, not ours. Their perception of the care they are receiving is more important than most of us think. When we learn how to manage perceptions, customers sing our praises, and word-of-mouth starts kickin' in.

Still doesn't sit well? How can perceptions be more important than reality? After chewing on it, I think these two statements help:
- perception IS the patient's reality.
- the reality that patients experience (i.e. perception) > the actual reality of the situation.

How do we get staff trained to do this? I'll leave that for Lee to explain in his book - it definitely takes a different skill set to manage perceptions. All I'll say is this question isn't the right question because training isn't even the half of it.

8-Part Series on "If Disney Ran Your Hospital"

The 8 Big Impact Ideas from “If Disney Ran Your Hospital”
1. Perceptions > Reality
2. Courtesy > Efficiency
3. Patient Loyalty > Patient Satisfaction
4. Experience > Service > Product
5. Intrinsic Motivation > Extrinsic Motivation
6. Habit > Imagination > Willpower > Compliance
7. Dissatisfaction > Complacency
8. Doing > Knowing

It's been really interesting seeing how ya'll end up on this site. Today, someone landed on my site through a yahoo search on "healthcare blogs."

Search engines are great and invaluable, but the fact that they work on such different algorithms confuses me.

when you do a search on healthcare blogs, hospitalimpact.org is...
- #2 & #3 on yahoo search
- not even in the top 250 on google or MSN Search

But if you do a search on "healthcare blogs" (with the quotations),
- #3 & #4 on yahoo search
- #17 on google
- not found in MSN Search

while we're on the topic of somewhat useless stats, wordcount (from the maker of tenbyten.org) says that "hospital" is the 651st most used word in the English language.

hospital just beat out friends, shown, and music, and was barely beat out by poor, award, and front. The #1 word? Clue: the word is in this sentence.

This past March, I made it to the ACHE Congress, where they awarded Fred Lee with the 2004 Book of the Year Award, for If Disney Ran Your Hospital

Well, the book was sold out at the conference, but I finally bought a copy from the publisher. Not only has Mr. Lee written a great book, he has chosen a fantastic topic. We need more books and resources like this - we especially need to learn from outside of our industry. We should learn about supply chain from Wal-Mart, new product design from Apple, and customer delight from Disney.

Fred Lee calls managing today's hospital "the hardest management job in the world." In this book he focuses particularly on "those approaches that bring out the best behaviors in workers and provide the best emotional experience for patients."

And for the record, I want to state that this was one of the best business books I’ve ever read. I probably had 3 or 4 mini "A-ha’s" in each of the 10 chapters, so I definitely would recommend you purchasing a copy for yourself. Some of the concepts will definitely challenge your current thinking. After you’re done, I bet you’ll think of several people in your organization to pass it along to.

I wanted to share with you the eight biggest “A-ha’s” that I took away. I’ll dig deeper into each in the coming days.

Here are the 8 big impact ideas from "If Disney Ran Your Hospital"

1. Perceptions > Reality
2. Courtesy > Efficiency
3. Patient Loyalty > Patient Satisfaction
4. Experience > Service > Product
5. Intrinsic Motivation > Extrinsic Motivation
6. Habit > Imagination > Willpower > Compliance
7. Dissatisfaction > Complacency
8. Doing > Knowing

"How many times do you see it? One of the most powerful symbols in the world. no words, just one letter standing alone. what is it saying?

Follow me. Follow me and I will take you to a place in this town, where it doesn't matter who you are, or where you've come from, or what you have in your pocket or what terrible indignity or hurt or misforture life has visited upon you... follow me and I will take you to where the very best people in this community will surround you and will do everything in their power for you in the name of curing and caring. That's the promise behind that sign. that's the promise we keep every day. for all Americans." - from AHA Hospital care video

In our working environments where we are conditioned to just look for problems... in times when hospitals are portrayed as corporate America's evil cousin, sometimes it's necessary to take a step back and remember why hospitals are worth fighting for. Check out AHA's Hospitals Caring for Communities website.

Download their inspiring 5 minute hospital care video (11Megs) to remember why hospitals are so important - it's worth the wait. 570 million times this year, someone will walk into one of our hospitals. Each time it's someone's mother, sister, brother, husband.

The uninsured problem in America continues to grow, but as Matthew Holt says, probably not enough for the system to change.

I got that same message from an Advisory Board presentation at the recent ACHE Annual Conference. Typically, Congress only acts when crisis is imminent - i.e. when Medicare is less than 10 years away from insolvency. Looking back into the last quarter-century, it's true: Congress refrains from acting until Medicare is (on average) 4.5 years away from insolvency. And even then, the fixes are temporary bandages that will fall off in a few years.

With little hope, some states have taken things in their own hands. This week, MA Governer Romney unveiled his plan to cover all his citizens by 2009. Minnesota is trying to pass mandatory health insurance

Meanwhile, the press continues...
- "At what cost" - LA Times
- Commentary from my childhood paper on why people can't afford insurance.
- the AMA weighed in with this article
- North Mississippi Health Services got served up with this hit from a law firm. The press release calls the hospital "one of the most lucrative 'non-profit' hospitals in America." Just yesterday NMHS broke off talks.
- Some uninsured folks get really creative
- Some worry about a complete healthcare meltdown in California, as the state lost 1,400+ beds from hospital closures last year.

I was at a dinner party the other day and someone came up to me and asked for my position on "socialized medicine." Her experience in Canada was that the care is slow, but at least everyone got it. In her view, health care is a basic "right" of every citizen. That's a great concept, but it will never happen in the U.S. Period. There's not enough political will and there's too many powerful lobbyists that represent too many companies that employ too many people.

Nonetheless, there are some good resources to think through the uninsured issue. check out the upcoming Cover the Uninsured Week

Also, HFMA offers some excellent resources through their Patient Friendly Billing Project. Download their 2/2005 report (pdf) on what actions hospitals can take. Blue Cross Blue Shield is also making strides. Also take a look at some positional statements from ACHE.

ACHE's incoming chairman, Sam Odle, speaks passionately about hospitals leaders truly stepping up as leaders. Part of that is addressing this growing issue. We cannot and should not stand idly by as the unbalanced story, "big, greedy hospital beats up on poor little grandma" pervades the American psyche. Yes, hospitals should admit fault fully and honestly. But the problem isn't that hospitals are greedy (usually), the problem is systemic and much more complex. Many hospital leaders aren't the biggest fans of PR, but in this case, hospitals need to grow some PR and branding sophistication before it's too late.

And much more important than protecting hospital reputation is solving the uninsured problem itself. Never before has there been a greater need for hospital leaders to band together. Who will lead us?

well, it's been two weeks since I started hospitalimpact.org. As I've been struggling with html code, sifting through hospital news, researching blogging trends, and thinking about hospital leadership, here are some observations.

Blogging for hospital leaders: an oxymoron?

Blogging may have been the "word of the year" in 2004 (ironically, "blog" narrowly beat out "incumbent"), but still very few people are familiar with blogs. Research has shown that only 7% of the population is "very familiar" with blogs. I'm pretty sure that % is even less for hospital leaders, which begs the question: why is hospitalimpact.org a blog in the first place? is a blog for hospital leaders an oxymoron? A valid question.

Blogging is fun for me... so far...
I realized something about myself this week: when I learn, I write, and when I write, I learn. so, because I love learning (apparently one of my strengths in strengthsfinder), I love to blog.

But as one visitor mentioned, blogging is like "having homework for the rest of your life." So far, thankfully, it hasn't been like that. It's been exciting to see how people end up on this site - one site out of 8 billion+ websites (websites outnumber people 4 to 3!?). And I've felt the child-like joy of learning something new.

Bloggers don't make money blogging

Even mildly popular bloggers that get thousands of hits per day probably can't blog for a living. It's simply not enough traffic to make it worth the while for advertisers or sponsors. Back-of-the-envelope calculations tell me advertisers pay ~0.5 to 1 cent per visit. Most bloggers blog on the side or as a marketing tool for their consulting firm or their day job. Of course, blogging doesn't cost that much either. $10-20 for a domain name plus $5-10 dollars/month for hosting, depending on your traffic. It's the time commitment that's killer.

Quality vs. Quantity
Yes, I admit it, I've been weak. Pumping out quantity instead of quality. Isn't one truly original thought/idea a week more valuable than 1 semi-new idea a day? Shouldn't I shoot for one shining idea vs. several dim ones? Stay tuned.

Anyway, thanks for visiting! hospitalimpact.org has already had 500+ visits simply from word-of-mouth (though I'm still trying to figure out how many of those hits was me). any riveting comments, random ideas, half-baked thoughts, crazy questions, effusive praise, ill-willed bashing, inspiration to share, offers of sponsorship or free pizza, feel free at tony[at]hospitalimpact[dot]org

Book Review: Winning by Jack Welch (4 out of 5)
this time Welch nails it

Many of you have been following my leadership series from Welch's new book, based on the Newsweek excerpt. Turns out the rest of the book is just as good as the excerpt on leadership that I covered in depth.

It appears that (after a couple of misfires) Jack Welch has finally written a book to match his legend. It probably also helps that his new wife Suzy (and co-author), a former editor at HBR, knows a thing or two about writing. No matter what you think of either Welch (to put it mildly, they're controversial), this book is worth the price of admission.

Put "Winning" on the top shelf next to "Good to Great" and "Built to Last." In fact, Welch's "Winning" is the perfect complement to Jim Collins' two-some. Collins' work is dramatically research-based, Welch's is utterly life-based. In particular, I enjoyed his 8 leadership principles that balance soft skills (communicating vision, building trust, motivating others) and character attributes (making the tough call, being positive, being nurturing to the core). I also enjoyed how Welch answers his critics on the infamous 20-70-10 rule and his hiring frameworks.

One strength of "Winning" is in the breadth of topics covered - both in the realm of organizational leadership as well as career development. Lots of books do one well, but Welch manages to excel in both without being superficial or glossying-over (though most other books aren't 350+ pages!).

Make no mistake about it - the ideas presented are not new. For example, two of Welch's leadership principles: "exude positive energy" and "push and probe with a curiousity that borders on skepticism" sound a lot like Collins' "confront the brutal facts, yet never lose faith" principle. But it's Welch's down-to-earth writing style that helps you understand these timeless principles in a fresh way. As you're reading, you can almost picture him speaking the words in some business school auditorium or some Fortune 100 management retreat. The words are deceptively simplistic, but it's Welch's wisdom at its best - boiled down to the very essence from four decades of rough-and-tumble managerial experience.

Book Review: Hardwiring Excellence by Quint Studer(5 out of 5)
Clear, Inspirational, and Thought-Provoking

Quint Studer ain't your ordinary hospital consultant. In fact, he probably wouldn't call himself a consultant at all; he's a "Fire Starter" and a "Coach." From a high school GPA of 1.3 to Special Ed teacher to hospital President to Founder of the Studer Group, this man has a genuine passion to make a difference in healthcare and on society. In his first COO role at Holy Cross Hospital, he took his hospital's patient sat scores from 5% to 94% in one year. At his first Administrator position in Baptist Hospital, he decreased employee turnover from 30% to 12% and also founded the Baptist Leadership Institute. It's hard to argue with results like that.

The basis of his book and his work is this flywheel:

which is essentially a much more thoughtful way of saying "success breeds success." Start with passion - a passion for what you do, a passion for making people's lives better (lots of folks take this step for granted). Then implement their 9 principles (the book dedicates one chapter for each principle). And these principles lead to results in the most important areas - the pillars: people, service, quality, finance, and growth (can anyone say "balanced scorecard?"). This in turn leads to more passion, and momentum starts kickin' in. And all of this is founded on the fact that when people are given a worthwhile purpose, watch out what they can do.

In my view, this book is well-balanced between motivation and practical to-do's. In fact, I think the magic of this book is how well Quint covers both issues: the heart (the emotions/psychology, human nature) and the mind (hard-nosed focus on hard-core results). I think most hospital leaders could pick up this book and actually put some or all of the principles into practice, even in difficult working environments. And that is exactly Quint's intent.

Welch shocked some (and inspired some) by giving back many retirement perks worth millions.

If you'd like, go back to the 1st post of this series. Or go to the original Newsweek Excerpt.

Leaders Celebrate

These two quotes from Welch say it all on this one:

"Imagine a team winning the World Series without champagne spraying everywhere. And yet companies win all the time and let it go without so much as a high five."

"There is just not enough celebrating going on at work—anywhere."

Celebrate too little? Then you're missing a big opportunity to energize your team and create a positive environment where achievement is recognized. Especially in hospitals where the mindset is always to look for problems, appropriate celebrations make people feel appreciated and validated. Appropriate celebrations enable people to remember again that their work is meaningful.

Celebrate too much? Welch doesn't talk about this because few err on this side of the balance. Nonetheless, if you do overcelebrate, expect your team to become a little too informal, a little more complacent, and a little less productive. Your team begins to expect a celebration for even little things (it's my 2nd cousin's birthday tomorrow). Some people may even grow wary that management is hiding something and using "these cheap parties to keep us happy."

All that said, let's not miss the point Welch is making - good leaders take the time to party!

forgive me revealing my allegiance here...

Welch's 8:
1. Leaders relentlessly upgrade their team, using every encounter as an opportunity to evaluate, coach, and build self-confidence
2. Leaders make sure people not only see the vision, they live and breathe it.
3. Leaders get into everyone's skin, exuding positive energy and optimism
4. Leaders establish trust with candor, transparency, and credit.
5. Leaders have the courage to make unpopular decisions and gut calls.
6. Leaders probe and push with a curiosity that borders on skepticism, making sure their questions are answered with action.
7. Leaders inspire risk taking and learning by setting the example.
8. Leaders celebrate.

While I attended Kellogg, Welch spoke to us on his first book.

If you'd like, go back to the 1st post of this series. Or go to the original Newsweek Excerpt.

Leaders inspire risk taking and learning by setting the example

At the very essence of leadership is exampleship. Actions speak louder than words. Some lessons are better caught than taught. You get the idea. Welch mentions two particular areas that this is just:

(1) Risk-taking. Welch colorfully puts it this way: "Too many managers urge their people to try new things and then whack them in the head when they fail. And too many live in not-invented-here worlds of their own making. If you want your people to experiment, set the example yourself." And when you try something new and fail, take responsibility, but don't beat yourself up. Be light-hearted, and even humorous about it - others will catch the drift that they are free to try and fail, too.

(2) Learning. Not all learners are leaders, but all leaders are learners. Even as the top dog, great leaders are constantly searching to upgrade their skills, their perspective, their character. They are never satisfied with their current spot. Welch says, "Whenever I learned about a best practice that I liked at another company, I would come back to GE and make a scene."

Welch's 8:
1. Leaders relentlessly upgrade their team, using every encounter as an opportunity to evaluate, coach, and build self-confidence
2. Leaders make sure people not only see the vision, they live and breathe it.
3. Leaders get into everyone's skin, exuding positive energy and optimism
4. Leaders establish trust with candor, transparency, and credit.
5. Leaders have the courage to make unpopular decisions and gut calls.
6. Leaders probe and push with a curiosity that borders on skepticism, making sure their questions are answered with action.
7. Leaders inspire risk taking and learning by setting the example.
8. Leaders celebrate.

That's the quote from a new Consumers Digest cover story (April 2005).

I don't mean to harp on consumer-driven healthcare, I'm just writing about what I'm seeing in the popular press.

Consumers Digest talked with folks from The Leapfrog Group as well as the Institute for Healthcare Improvement (two of my favs, too) and encourages patients to understand their choices in hospitals. After some vivid examples of hospital errors as well as hospital improvements, they encourage patients to ask a lot of questions, specifically these 6:
- Is this hospital accredited by JCAHO?
- What is the hospital's overall infection rate?
- Does the hospital employ intensivists in its ICU?
- Does the hospital have a policy to ensure a safe level of nurse staffing?
- What directives are used to ensure surgical procedures are carried out as planned?
- What procedures are used to prevent infections hospital-wide?

According to the article, the source of many hospital errors is miscommunication. Donald Berwick, president of IHI, says, "injuries and errors in healthcare occur just the way they do in normal life. You drop the ball when it gets handed off... we are an industry of silos."

Overall, the tone of the article is neutral (the writer, Linda Wilson, is a seasoned ModernHealthcare freelancer). Nonetheless, I think the article instills a certain fear/wariness in the average Joe consumer - enough fear for him to do some online research. And after getting frustrated with researching, the question in his mind would be: where is the vehix for hospitals?

Would Curious George have been a good hospital leader?

If you'd like, go back to the 1st post of this series. Or go to the original Newsweek Excerpt.

Leaders probe and push with a curiosity that borders on skepticism, making sure their questions are answered with action

"When you are an individual contributor, you try to have all the answers. When you are a leader, your job is to have all the questions." - Jack Welch

Curiosity may have killed the cat, but the lack of curiosity could kill your career. This curiosity, this quasi-skepticism is the principle that balances principle #3 (Be tirelessly positive). In other words, being a positive thinker shouldn't make you a fuzzy thinker. Leaders should be thinking more clearly than anyone else. They see the big picture, they get the reports from their team, and they know exactly what questions to ask. For Welch, his questions usually start with "what if?" or "why not?" or "how come?"

Welch makes it a point to take that a step further - your insightful questions don't just generate debate, they generate action. We'll have to read his book to understand what he means here, but I'm assuming that when questions can't be answered sufficiently, someone is assigned to find out. I guess that in every good leader, there is a little bit of Curious George (I'm thinking Curious George would've been more productive than those monkeys in that careerbuilder commercial)

"King Kong on line 1"

Welch's 8:
1. Leaders relentlessly upgrade their team, using every encounter as an opportunity to evaluate, coach, and build self-confidence
2. Leaders make sure people not only see the vision, they live and breathe it.
3. Leaders get into everyone's skin, exuding positive energy and optimism
4. Leaders establish trust with candor, transparency, and credit.
5. Leaders have the courage to make unpopular decisions and gut calls.
6. Leaders probe and push with a curiosity that borders on skepticism, making sure their questions are answered with action.
7. Leaders inspire risk taking and learning by setting the example.
8. Leaders celebrate.

Welch has had to make many difficult calls in his career at GE, including divestitures, acquisitions, new initiatives (e.g. 6sigma) and layoffs. All the while, GE's market cap grew from $12B in 1981 to ~$300B when he retired in 2001.

If you'd like, go back to the 1st post of this series. Or go to the original Newsweek Excerpt.

Leaders have the courage to make unpopular decisions and gut calls

"You are not a leader to win a popularity contest- you are a leader to lead. Don't run for office. You're already elected." - Jack Welch

Cut-backs, lay-offs, and tough calls are part of the nature of hospital management. Sometimes leaders have to make the tough call.

As leaders, you have the benefit of getting all the information from your team, aggregating it, and making the decision. Others don't have the information or perspective that you have, so it's your job to explain the "big picture" view. Again, there has to be a healthy tension - explain the "corporate" view without sounding corporate. Be sensitive to their viewpoint, but tell them like it is. Days, weeks, and months later, people will still be saying, "did you hear what [leader] said about that?" so think through your approach.

It takes courage to make the tough call.

Part of becoming a courageous leader is being sure that you are standing up for something that's worthwhile. In hospitals, we make tough calls because on the whole, we are fighting for better patient well-being. We are fighting for better lives, a better society, a better world. Yes, sometimes that means that many patients will get better care at the expense of a few other patients. Yes, sometimes that means some select few employees are forced to pay a high price. No question that this can be difficult, but it is the reality of running organizations. Even the most amazing organizations in the world are are not exempt from this fact.

Welch's 8:
1. Leaders relentlessly upgrade their team, using every encounter as an opportunity to evaluate, coach, and build self-confidence
2. Leaders make sure people not only see the vision, they live and breathe it.
3. Leaders get into everyone's skin, exuding positive energy and optimism
4. Leaders establish trust with candor, transparency, and credit.
5. Leaders have the courage to make unpopular decisions and gut calls.
6. Leaders probe and push with a curiosity that borders on skepticism, making sure their questions are answered with action.
7. Leaders inspire risk taking and learning by setting the example.
8. Leaders celebrate.

As a continuation from my previous post on consumer-driven healthcare, the government joined the fray in a concrete way on April 1st by launching their hospital comparison tool. (did they have to pick April's fool's day to launch this?)

Here's an example of a screenshot comparing Northwestern Memorial Hospital with Rush University Medical Center on one aspect of care you can select from their menu.

Percent of Pneumonia Patients Given Initial Antibiotic Timing

While we're on the topic, Money Magazine (April 2005) featured Newt Gingrich in their "The Big Idea" column.

Newt is determined to revolutionize healthcare.

He founded the Center for Health Transformation. One focus is to "move the focus of health back to the individual." Part of that, as Mr. Gingrich says, is that doctors and hospitals should be required to "post prices and results."

Welch's book is less about winning, and more about leading. With this post, we're half-way through his 8 principles.

If you'd like, go back to the 1st post of this series. Or go to the original Newsweek Excerpt.

Leaders establish trust with candor, transparency, and credit

Trust - it's a word that's thrown around a lot these days, maybe to the point where it's lost it's original meaning. Nonetheless, we all inherently know what it means,

Now that's trust!

I think Welch takes it a step further. Instead of letting our character and our words "stand for themselves," we should be diligent and purposeful in establishing trust. Even if we are 100% trustworthy people by nature, we still have to be extra-careful to avoid misunderstandings. Good intentions are not enough. Gotta be smart about trust, because it is so darn fragile. It takes years to build, and can take seconds to destroy. Jack Welch, on a Newsweek webchat said, "At GE, that culture [of candor and trust] took about seven years to build."

Again, like all of Welch's principles, this is a shift in orientation/perspective/attitude more than it is a set of tactics. Armed with the right attitude, Welch speaks of two sides of the same coin:
- when things are bad, be transparent. Be candid. No suger-coating.
- when things are good, give credit where it is due.

I can't help but notice how this concept relates to the Good to Great chapter on level 5 leadership. Here, Jim Collins talks about "the window and the mirror." When things go well, great leaders look out the window and attribute the success to other factors. when things go poorly, they look in the mirror and take responsibility.

"I think we may safely trust a good deal more than we do." - Henry David Thoreau

"To be trusted is a greater compliment than to be loved." - George MacDonald

Welch's 8:
1. Leaders relentlessly upgrade their team, using every encounter as an opportunity to evaluate, coach, and build self-confidence
2. Leaders make sure people not only see the vision, they live and breathe it.
3. Leaders get into everyone's skin, exuding positive energy and optimism
4. Leaders establish trust with candor, transparency, and credit.
5. Leaders have the courage to make unpopular decisions and gut calls.
6. Leaders probe and push with a curiosity that borders on skepticism, making sure their questions are answered with action.
7. Leaders inspire risk taking and learning by setting the example.
8. Leaders celebrate.

Newsweek reports that Jack has declined CEO offers

If you'd like, go back to the 1st post of this series. Or go to the original Newsweek Excerpt.

Leaders get into everyone's skin, exuding positive energy and optimism

Great leaders are high-fivin', thumb-upin' kind of people.

Just like success breeds success, upbeat leaders end up leading upbeat people. There is a certain unquenchable optimism from great leaders - this is consistent with the findings of Good to Great author Jim Collins. Why is a positive outlook so important? Positive people, by definition, are more energetic, more creative, more driven. They're more enjoyable to work with and they are more open to change and risk-taking - they believe things will work out and that their efforts are not in vain.

Work is hard, though, especially in some environments where the demands seem endless and the work is thankless. Isn't it so easy to be a complainer (yes, right about now, you can probably picture the person in your hospital)? There is a certain gravitational pull toward negativity - it's human nature. That same person who could be so energetic, creative, and driven in a positive environment can become your #1 whiner, complainer, and bring everyone else down. It's up to you that your team stays positive. That means that you have to become a sincerely positive person, not just do positive things. The fake positive stuff can make things even worse.

So, where is the place for healthy skepticism? We'll get there on day 6, but great leaders, as Collins puts it, confront the brutal facts yet never lose faith. It seems like an oxymoron, but it's really a healthy tension that all leaders must live with. Great leaders have to press the issue on both ends - confront the facts AND never lose faith (most people tend to be biased one way or the other).

It's like sailing. If you only have tension on one end of the sail, all you have is a flag. You need to press hard on both sides of a sail to create that tension in the sail. And that tension is exactly what will get you movin'

Welch's 8:
1. Leaders relentlessly upgrade their team, using every encounter as an opportunity to evaluate, coach, and build self-confidence
2. Leaders make sure people not only see the vision, they live and breathe it.
3. Leaders get into everyone's skin, exuding positive energy and optimism
4. Leaders establish trust with candor, transparency, and credit.
5. Leaders have the courage to make unpopular decisions and gut calls.
6. Leaders probe and push with a curiosity that borders on skepticism, making sure their questions are answered with action.
7. Leaders inspire risk taking and learning by setting the example.
8. Leaders celebrate.

Okay, I'll give you some clues:
- 554 beds
- 2,000+ employees
- 850,000 patients per year
- Patients come from 150+ countries
- JCAHO accredited in 2002
- Patient volumes up 23% in 2004
- 16% profit margin in 2003
- $112MM in profit in 2003

Allow me to introduce to you Bumrungrad Hospital in Bangkok, Thailand

Okay, maybe they aren't the BEST, per se, but...

Not only do they have a world-renown heart center...

Americans, Europeans, and Australians alike are flocking to their plastic surgery center because it's the same quality at a better price.

(smart branding move: check out their website - they are creating a distinct brand just for plastic surgery center to cater to the different market segment)

Is healthcare becoming a global marketplace? Will a well-off couple take a flight to Thailand for a nip, a tuck, some curry noodles, and some sun? According to McKinsey, "Medical tourism" will hit $2B in 2012. Of course, acute care is not on the chopping block for obvious reasons, but elective surgery and check-ups? It's already happening.

Check out Bumrungrad pricing and promotions (exchange rate: $1 to 40 bahts). You can get a comprehensive check-up for ~$60.

By the way, Bumrungrad is expanding into the Phillipines, Malaysia, and maybe even China. They just shelled out $9.2MM for a 40% stake in Asian Hospital in Manila.

Welch applying principles 1 & 2 in a GE factory

If you'd like, go back to the 1st post of this series

Leaders make sure people not only see the vision, they live and breathe it

The Newsweek article isn't all that clear about this one, except that it's the leader's responsibility to make the vision "come alive." Two good suggestions:

1. The vision isn't supposed to be a secret. Too often, leaders communicate well with their inner circle about the vision. But outside of them, the people on the frontlines never hear about it.

Some hospitals struggle with this, but not in the way you would expect. They spend lots of management/board time developing a vision, a mission, a list of values, etc. They communicate it internally, they even have some PR releases. But then, nothing changes.

Vision: to forget how much time we wasted and money we paid an external consultant to come up with a vision that no one remembers.

At best, the vision becomes forgotten. At worst, it becomes a reminder of all the time and money spent on nothing but some words. Every time a hospital is burned like this, staff become more resistant to change and management takes another hit on their reputation. Make sure vision is backed up with bite-size, measurable goals and milestones.

2. Put your money where your mouth is (or where your mouth ought to be). For people to truly be motivated by the vision, Welch says you have to "show them the money." This is harder to apply in non-profit hospitals, though I've seen it done. A big hospital here in Chicago, for example, uses their vision goals as the basis for their yearly bonus - and everyone (even the janitor) is eligible.

$$$ is always a good motivator, but in many non-profits, it's the vision that really inspires people to go the extra mile. There's a famous story from NASA back in the 1960s. The night before the flight, a janitor was mopping up the bathroom floors one more time. His supervisor comes in and asks, "what are you doing?" He says, "I'm helping put a man on the moon!"

Go to Newsweek Excerpt on Welch's Book

Welch's 8:
1. Leaders relentlessly upgrade their team, using every encounter as an opportunity to evaluate, coach, and build self-confidence
2. Leaders make sure people not only see the vision, they live and breathe it.
3. Leaders get into everyone's skin, exuding positive energy and optimism
4. Leaders establish trust with candor, transparency, and credit.
5. Leaders have the courage to make unpopular decisions and gut calls.
6. Leaders probe and push with a curiosity that borders on skepticism, making sure their questions are answered with action.
7. Leaders inspire risk taking and learning by setting the example.
8. Leaders celebrate.

Never heard of us? Chances are you haven't, since this site was turned on only last week! Hospitalimpact.org was started on March 25, 2005 in Chicago by Tony Chen. We're only 6 days old and it's already been a whirlwind of a time!

Hospitalimpact.org is the first and only healthcare blog dedicated for current and emerging hospital leaders, thinkers, and enablers. The vision is simple - to answer this question:

what will it take for hospitals to be the best run organizations on the face of the planet?

We'll do that from 4 different angles using 4 different blogs. First, get some fresh perspectives on why hospitals are so important. Hospitals are worth fightin' for. If we forget that, we are done. Then, find leadership insights drawn from leaders, thinkers, and organizations inside (and especially outside) of healthcare. And since we don't need to reinvent the wheel, link up to commentary on my favorite resources, books, and websites. Also keep an eye out on the scoop on hospitals. News you can use that signals new trends and opens up new strategies. Of course, you can look at it all together, too.

Also, occasionally, check out the about blog, where I make observations on healthcare blogging, my life as a hospital blogger, and other random things that come up.

Feel free to email me with questions, comments, ideas, tips, issues to be addressed, anything at tony[at]hospitalimpact[dot]org

Hope you enjoy the ride!

Yesterday, the good news from HCA lifted the whole hospital sector. A little miffed that Wall Street would think that HCA's success meant success for others, I took a look at the 5-year trend for some of the top hospital companies.

If Wall Street is right, then these lines should look more similar. True, there are some similiarities if you really look hard, but by and large, they're different. So looks like strategy and management still make a difference after all.

Mrs. Welch, previously of Harvard Business Review, helped Jack shape this book.

If you'd like, go back to the 1st post of this series

Leaders relentelessly upgrade their team, using every encounter as an opportunity to evaluate, coach, and build self-confidence

This is probably a very familiar (and forgotten) idea. Welch is advocating that building up individuals is not an event or even a series of tasks - it is a lifestyle, a others-centeredness that pervades everything you do. We are to be constantly and relentlessly thinking about the individuals on our team - what makes them tick, what motivates them, what bugs them, how they can improve as leaders, trying to optimize their job with their gifting, what barriers still need knocking down, etc.

"Think of yourself as a gardener, a water can in one hand and fertilizer in the other"

I've had the privilege of working for leaders who are instinctive gardeners/coaches. Any moment can be a teaching moment. Sometimes weeks and months go by, and I will still be thinking about some random passing remark they made. How did they get that way? It wasn't by accident! (more on this on day 7 where we talk about how all leaders lead by example)

So you walk into the hospital tomorrow armed with this new knowledge. Here are some DO's and DON'T's for how to get started:

- DO get started, but start slowly. Especially if this hasn't been on the top of your list, it may take some time to "study" your team. Just like a doc wouldn't give a prognosis before a diagnosis, you should spend some time taking notes (mental and/or in a password-protected doc) on your team. Spend some time talking with them. Find out what drives them.

- DON'T do it in name only. After all, this is largely a shift in your attitude, not another thing to add onto your to-do list. Take some time to reflect on why this is important. Maybe even think back to a good coach in your life - what made them such good coaches to you?

- DON'T try to fix all the problems at once. Even if you know exactly what issues each of your team members has, pick your spots. Pick those teachable moments to maximize the impact. Give people time to digest feedback.

- DO encourage, recognize, care, and nurture. This helps people realize that you are on their side. They realize that you're rootin' for them. And when that happens, not only do they trust you, but also they are much more open to hear constructive criticism.

- DO this even if you are not a manager or leader yet. I think this will turn out to be true for all 8 principles. This type of orientation prepares you for the future and separates you from the pack. Management will notice - "hey, this guy already thinks like a manager. let's promote him" (if only it were that easy)

Go to Newsweek Excerpt on Welch's Book

Welch's 8:
1. Leaders relentlessly upgrade their team, using every encounter as an opportunity to evaluate, coach, and build self-confidence
2. Leaders make sure people not only see the vision, they live and breathe it.
3. Leaders get into everyone's skin, exuding positive energy and optimism
4. Leaders establish trust with candor, transparency, and credit.
5. Leaders have the courage to make unpopular decisions and gut calls.
6. Leaders probe and push with a curiosity that borders on skepticism, making sure their questions are answered with action.
7. Leaders inspire risk taking and learning by setting the example.
8. Leaders celebrate.

Taken with permission from Hardwiring Excellence, by Quint Studer

a letter from a patient's daughter

Dear [],

My father died at your hospital. It wasn't a matter of if he was going to die, but when. He was in your extended care facility. I'm his only living relative. I was all that he had. My constant worry was that I wouldn't be there when he died. I tried to be at the hospital every moment, but I simply couldn't be there 24 hours a day.

I wasn't there one day and I received a call from a nurse who said, "You need to get here right away." I jumped in my car and got caught in a traffic jam. I pulled up to the hospital and ran inside. As soon as I got to the nursing unit, they told me my father was dead.

But when I went into the room, I saw a nurse there with him. She was sitting down. And holding my father's hand. That nurse told me that my father wasn't alone when he died. She was there. she also told me that my father loved me.

Do you know what a great nurse you have at your hospital?

(Quint goes on the explain that the nurse's shift had actually ended when she decided to stay. Knowing the financial challenges the hospital faced, the nurse swiped her card and stayed with the patient on her own time. Her values would not let her leave.)

HCA 5-Day Chart

HCA shares were up significantly today because of a strong 1Q outlook and potential upside for the rest of the year(read marketwatch story). The most interesting part of the report was HCA's intention of selling 10 rural hospitals to focus on urban areas.

Quick back-of-the-envelope calculation: figuring these are 10 small hospitals, say 100 beds each, and $1MM/year in revenue per bed, we're talking $1B in revenue, or 4% of their annual revenue. Smells like the beginning of a strategic repositioning to me.

UPDATED: After Business Close, Yahoo Hospital Facilties Index

Funny that the entire hospital sector got a boost from HCA's positive outlook. Wall Street must think that hospital performance has more to do with overall environment than management talent/strategy execution. Stay tuned.

Newsweek just came out with an Exclusive Excerpt of Jack Welch's 2nd try of a book to match his legend. Maybe this time, he actually got it.

8 universal managerial principles etched from his decades of experience in one of the best, largest, most respected companies on the earth. (FYI - as last week GE retook the "largest company in the world" title back from Exxon-Mobile. Those oil prices are crazy)

For the next 8 days, let's think through one principle at a time with an eye towards how we can apply it to our hospitals.

Welch's 8:
1. Leaders relentlessly upgrade their team, using every encounter as an opportunity to evaluate, coach, and build self-confidence
2. Leaders make sure people not only see the vision, they live and breathe it.
3. Leaders get into everyone's skin, exuding positive energy and optimism
4. Leaders establish trust with candor, transparency, and credit.
5. Leaders have the courage to make unpopular decisions and gut calls.
6. Leaders probe and push with a curiosity that borders on skepticism, making sure their questions are answered with action.
7. Leaders inspire risk taking and learning by setting the example.
8. Leaders celebrate.

what will it take for hospitals to be the best run organizations on the face of the planet?

that is the question that I can't seem to let go.

these past few days have been quite humbling, I've realized how hopelessly clueless I am about putting up a presentable webpage. At times, I've felt like this dog - I can envision what I want, but I can't get there cuz I'm fenced in by my lack of web prowess.

I couldn't have done it without the forum communities of the blogging software I'm using. which actually brings me to one of the main purposes of this blog: to learn from each other. If each hospital could take the best of their knowledge and transfer it to all the others, and if hospitals could learn from the best run companies in the world, maybe hospitals could become the best run organizations on the face of the planet. that is the single-minded intention of this blog.

In the leadership section, I hope to explore topics like maximizing patient satisfaction, quantum leaps in hospital management, org culture, improving financial performance, strategic planning, influencing others, etc... by learning from other hospitals, other thinkers, other organizations. The most interesting part may very well be taking the lessons of the likes of Apple, Wal-Mart, and Southwest Airlines, and applying it to a hospital. My wife always laughs at me when we sit down at a restaurant and I "size up" the operations, branding, and competitive environment. "this is a perfectly positioned restaurant for this location," I say smugly. a little geeky? oh, yeah! I admit it. But it comes from a conviction that people (esp. leaders) have to take substantial time to think hard, process, and digest (not just learn or understand) information to really make an impact. We are a generation of news junkies and information junkies - too many have lost the ability to think original thoughts and to make the creative linkages between seemingly unrelated information.

the perspectives section aims for the same target, but goes at it from a different tact. Hospitals will never be the best run organizations on the face of the planet unless it employs the best, most motivated, most inspired, and most inspiring leaders on the face of the planet. (some hospital leaders I've met already fit this bill) Part of that is taking some time to gain perspective about why hospitals are so important, beautiful, and crucial - for individual lives as well as our society as a whole. If we forget why hospitals are worth fighting for, then we are lost.

the about section is more about this blog and about me. Blogging is a relatively new phenomenom and there is a lot to be said (and a lot for me to learn) about what makes a good blog.

the links section links you to my favorite websites, books, and resources. and the scoop section is noteworthy news. These sections are purposely focused (instead of comprehensive) and digestable. The problem in hospital management issues isn't the lack of information, it's that the information is too fragmented, too voluminous, and too disorganized to be useful. So this will be my humble attempt to prioritize, categorize, and connect.

Hope you enjoy the ride!

I'd love to hear from you! Email me with questions, comments, ideas, tips, items you want to see addressed at tony@hospitalimpact.org

"consumer-driven" healthcare takes another step?

an Aetna ad on page 45 of Business 2.0 magazine, April 2005. They unveil their new version of their hospital comparison tool. (for the overly curious, Business 2.0 ads are listed for ~$60k a page.)

Now patients can look up patient volumes, success rates, and ALOS to factor into their decision of going to your hospital or your competitor's?

This is nothing new, as UnitedHealthcare also has had a similar comparison tool for some time.

makes me wonder -
will one day report on hospitals, too? Right now, they already rate a list of other organizations with hospital report cards. They also did a 21,000-person survey on hospital safety back in 1/2003.

Gotta give props to those who have gone before me. There ain't too many hospital-related blogs out there, but check these out.

Matthew Holt - maybe one of the "grandfathers" of healthcare blogs as he started his blog 18 months ago (that's 18 years in blog-years). healthcare, pharma, managed care news and observations, updated almost every workday.

Joe Paduda - "Managed Care Matters" for news, observations, and insights into anything managed care, updated almost every workday.

Healthcare Renewal - a team of academics tackle the dyfunctionalities of healthcare, updated daily (sometimes more than once!)

Clinical IT - Healthcare IT may be more important than ever. updated several times a month.

Telemedicine - overcoming distance in healthcare, another take on healthcare IT written by seasoned healthcare practitioners. updated several times a month.

Healthcare Blogs - an eclectic aggregation of 100+ blogs in the healthcare world - students, pharmacists, house staff, MDs, etc.

the hospital I grew up with: Montgomery County Hospital, Blacksburg, VA. Back then, the building looked like a box - it didn't have that fancy semi-circle architecture. Of course, back then, it wasn't an HCA hospital.

much has already been written on the hospital's role in growing an economy, advancing society, providing peace of mind to a nation, etc. On a large scale level, all that is true. But on an individual level, hospitals are even more significant. it's hard to imagine life without hospitals. many of the most important moments of my life have happened in hospitals. new life... and new death... some of the greatest joys and sorrows, the darkest and happiest moments in life happen in the anonymous halls of our hospitals. People never leave hospitals unchanged - they are healed, fixed, broken, full of hope, fearful, relieved. somewhere between filling out the registration form and thanking the doctor, people's perspective on life changes, even if just for a moment. Our bodies are so resilient, yet so fragile. Our lives are so short, yet so precious.

strong leaders build strong organizations, and hospitals are no exception. there are some strong leaders in healthcare. unfortunately, the stereotype of hospital leaders is that they are the bad guys, the paper-pushing bureaucrats saying "no" to doctors and needy patients. More often than not, that's just not true. Most of the hospital leaders I've met have a passion for caring for patients. They might not wear stethoscopes around their neck. no, their tools to improve patient care are organizational behavior, leadership development, revenue cycle, and change management. maybe not as cool, but increasingly crucial. to be sure, they are businesspeople, yes, but their business is caring - making sure their hospitals are managed in a way to serve (and even delight) the patient. They do this while regulations change almost daily, payments from the government are erratic, billions of dollars of free care is administered unnoticed each year, and consumer groups bamboozle on their reputations. it's a thankless, complex, misunderstood, tough, and somewhat paradoxical job - they're driven by passion and profits. mission and margin.

if you are a hospital leader / thinker / enabler, this blog is for you. It'll all boil down to one simple question:

what would it take for hospitals to be the best run organizations on the face of the planet?

That is the question that I can't seem to let go. So, whether it's HIPAA, revenue cycle, quality, leadership, or whatever, I'm going on a journey to find some answers. and I have a feeling that some of those answers will come from unusual sources and unexpected places. Hope you enjoy the ride.