hospital impact

by Tony Chen

It's probably not every day you see someone in their late 40s in a classroom full of 23-year-olds learning about healthcare administration. But that's what happened a few years ago to Jeff McKune - our newest blogger at hospital impact. Read his previous post on hospital strategy here and his bio below:

In 1981 I graduated from Harding University with a B.B.A. in Business Systems Analysis. I worked in information technology in Dallas for several years, and it was there that I met and married my wife. We moved to Missouri in 1985 where I started a systems integration and computer consulting business serving small businesses, county governments, and Fortune 500 companies throughout the state. A number of personal and professional factors, including the illness of my parents, drew me towards healthcare. At the age of 47 I began my graduate studies, completing my Masters in Health Administration at the University of Missouri at Columbia in 2005. I then completed a one-year administrative fellowship at Phelps County Regional Medical Center with the Chief Financial Officer and the Administrative Director of Human Resources as my co-mentors. These days I serve as Director of the Ambulatory Surgery Unit at that same hospital, enjoying each day with a great team of physicians, nurses, and clinical staff. If you would like to learn a bit more about me, please visit my personal site at http://www.mckune.net.

I'm definitely excited to see what topics Jeff ends up posting on - with such a unique path into hospital management, I'm sure he'll have some fresh perspectives to share.

by Tony Chen

Sorry I have not posted in a while. Thanks for your patience.

It's a busy time at work right now. Plus, I've been preparing for out-of-town guests, getting ready to sing & play guitar at a wedding, spending time with the little one, fulfilling local board responsibilities, and fulfilling my blogger role at World Health Care Blog. Read my posts about the AMA and obesity.

I'll have more for you in the next few days, including the introduction of our newest blogger. Stay tuned!

by Tony Chen

Usually it's California that gets all the attention - the governator, progressive policies, Kaiser, and 4 of the 17 best hospitals in the nation. Nonetheless, California, in all it's glory, is fairly average when it comes to health.

One state is always near the top of the list - Minnesota. They are the #1 healthiest state according to the UHC Foundation and 3rd healthiest state in the country according to Morgan Quitno. The key metrics behind these rankings are things like: cardiovascular death rates, premature death rate, uninsured population %, children in poverty %, total mortality rate, infant mortality rate, motor vehicle deaths, and a high rate of high school graduation.

Beyond the healthier culture that seems to pervade Minnesotians, Minnesota seems to be a hotbed for medical and healthcare innovation - everything from medical devices to Mayo to retail clinics. Here are a few more facts about Minnesota:
- Largest Bridges to Excellence Program in the country (780,000 lives).
- "Smart Buy Alliance" - a collaboration between the state, union groups, big & small businesses to improve quality and affordability of healthcare (thought results have been slow).
- State employee health plan boasts a zero-premium increase for 3 straight years.
- Of course, it helps to have great hospitals like Mayo, Abbott Northwestern, and Park Nicollet.

So what is it about Minnesota anyway? What can we learn from them?

by Nick Jacobs

Senator Chuck Grassley (R) Iowa while still the chairman of the Committee on Finance, directed his staff last September to create a discussion draft of potential reforms to ensure adequate levels of charitable care from the nation's non-profit hospitals. His desire to pursue this topic was rooted in his belief made by interpretive assertions by IRS Commissioner Mark Everson and the Government Accountability Office that there is little difference between for-profit and non-profit hospitals when it comes to charity care and community benefits provided. As stated by Grassley, the staff draft of potential ideas was the beginning of a discussion, not the end. Public comments are strongly encouraged at this point. Public comment should be sent to hospital_comments@finance-rep.senate.gov by Friday August 24, 2007.

The above paragraph is the premise for this post and my submission to Senator Grassley for public comment.

Let me begin by saying that I have no personal ax to grind with the for profit world. Having stated that, however, unless you live the day to day challenges of survival in the non profit health care arena, your viewpoints cannot possibly include every aspect of the decision making process necessary to keep it all together.

Having previously worked with a half dozen former executives from the for profit health care sector, it seems to me that the current governmental leadership has missed some very important points.

As an employee of the former for profit leaders, it was perfectly clear that, at least the motivation of those individuals for whom I had worked was directed toward their salaries, bonuses, and, as they stated it to me, a solid commitment toward making money for their stockholders. How do you measure the nuances created in a system that has a profit motivation leading to the creation of wealth for owners as compared to a system that exists only to create the common good?

Their typical description of their functioning as a for profit vs a not for profit CEO was that, if the neonatal, OB, trauma or psych units were not profitable, you would be strongly encouraged to close them down. Public good vs stockholder's shares become the measure of success.

What is this about? For any government official to paint a picture depicting that the non profit motivation is the same as that of the for profits, it is clear that he is living in only the numbers that are obvious to him, not in the realities of the mission and challenges present in vast majority of small and medium sized, hospitals just struggling to stay alive.

by Tony Chen

Our warm welcome to two new health blogs to the burgeoning healthcare blogosphere. First, check out WSJ's Health Blog, which covers "health and the business of health." Recent posts cover topics ranging from chili dog contaminants to Mass. retail clinics to pharma big wigs. Their two bloggers and other staffers are posting 5 or 6 posts per day.

Also check out My Prevention Blog, brought to you by U.S. Preventive Medicine Execs Chris Fey and Briam Baum. These guys really seem to be thoughtful and sincere about wanting the American people to live healthy and get "more good years." While I'd like to see them post more often (and maybe add some shorter, quick-hit posts), I'm looking forward to what else these blue ocean strategy thinkers will come up with next. Read Chris Fey's first post on how his personal experiences made him passionate about preventive health.

by Tony Chen

Recently, I've been doing a lot of reflecting and thinking around the real impact of this hospital impact blog. I know how it's impacted me: it's opened my eyes to new perspectives and innovations, it's challenged me to synthesize and make sense of the cluttered healthcare news arena, and it's brought me to lots of interesting people and opportunities. Besides getting hacked, getting squatted, & getting plagiarized, I've had a grand ole time blogging and I hope it shows.

But my question today is this: What is the impact of hospital impact on you? What have you found to be most valuable? What's still missing?

If you want to provide feedback confidentially, email me.

by Tony Chen

Take a quick look at two conversations going on right now on the web.

21 comments and counting on my previous post on Sicko Reviews.

Also, read my post at World Health Care Blog on the Changemakers' competition on disruptive innovation in healthcare. Currently, there are 147 entries to the competition - and these aren't just ideas/concepts in a vacuum, these are real organizations with real budgets trying to disrupt healthcare as we know it. As this is a collaborative competition, go comment and add your input on any of the ideas submitted.

by Nick Jacobs

Once, while seated beside my board chair at a very elite meeting set up for only 15 board leaders and their guests from across the nation, Dr. Leland Kaiser looked out across the group and said, “Give me a creative CEO over a traditional CEO any day of the week.”

Dr. Kaiser went on to say (and I paraphrase as my memory serves me) that “If you don’t already have genomic testing in your hospital, you are already behind.” “If you aren’t looking at advanced imaging, electronic records and patient centered care, integrative health and behavior modification practices, you need to examine your leadership.”

My chairman looked at me and smiled. We were knee deep in all of these things six years ago.

We started participating six years ago in an insurance reimbursed program with Highmark Blue Cross on a wellness program that replaced heart surgery and angioplasty with a natural approach to healing, the Dean Ornish Coronary Artery Disease Program.

Yoga, stress management, no trans fats, massage, a work out facility for our employees, personal trainers, aroma, music and pet therapy but most of all, candor and respect are keys to our performance. If we can be sensitive to each other’s needs and treat patients as if they are our loved one, health care and health can change.

Innovation is indeed the key to survival. We have just completed our greatest financial year in the past 101 years, not because our facility is the biggest, not because it has the most tertiary care, or helicopters, or complex bureaucracy but because we treat our employees and patients with dignity and respect and because we embrace innovation.

To those who are waiting for the first two thousands hospitals to take the jump before they do, it's almost time. We boomers are getting impatient for the care we know you're capable of delivering.

by Tony Chen

Recently, I posted an open question to my linkedin network: "what innovative partnerships with hospitals have you seen?" The answers I got were basically summed up by one of my contacts: "that's probably the first time I've ever seen 'innovative partnership' and 'hospital' in the same sentence. what are you talking about?"

Nonetheless, this hospital CEO is out to prove you wrong. Read this HealthAffairs interview with Virginia Mason CEO Gary Kaplan. Yes, this is the hospital that periodically flies out their leaders and physicians to Japan to learn Toyota's production process improvement approach. Passionate about "getting rid of all waste" in their system, they have cut everything from unnecessary supplies to unnecessary physical steps staff members used to walk to expensive medical procedures (for a loss).

If that weren't enough, they have partnered with (gasp!) payers as well as local employers. Yes, Virginia Mason is losing money by eliminating more expensive procedures, but amazingly Aetna has agreed to pay them more for less expensive procedures.

Even though the hospital is getting the smaller slice of the pie, this seems to be a rare example in which incentives are more aligned. And maybe this provides long-term benefits that we've yet to identify - better reimbursement for a whole slew of activities (e.g. diabetes education, patient education, prevention/screening) that could really make a tangible impact on an entire community.

Add on top of that these new insurance plans that financially reward healthy living, and we could be on our way to a drastically different health culture. The risk of death typically won't change our lifestyle, but maybe $2,000 will.

by Tony Chen

Last week, my new car was parked (legally) on the street and my neighbor backed into it. She drove off, but we tracked her down and so her insurance will obviously pick up the tab.

I brought the car into this great-looking autobody shop near my house. They really had their act together - nice decor, coffee/treats for customers, toys for waiting customers with kids, a plasma screen TV, friendly staff, and even a direct link to the insurance company (think EMR). They even had one of those mini european cars in the driveway.

Anyway, everything was very impressive except for one fact. When I drove off with the rental car they provided, I looked down and saw that the gas tank was empty. Not 1/4 full, but literally empty. I was already late to work so I just begrudgingly filled it up myself.

Even if the bodywork they do is perfect, ask me if I'll refer anyone to this outfit.

It just goes to show. We can have wonderful facilities, we can have great staff, but one little mishap, one little mistake turns a "highly-likely-to-refer" customer (5 out of 5) into a "detractor" (2 out of 5). Even though the actual work (read: patient care) was exceptional, the customer experience (i.e. patient experience) was negative.

This gets back to all we've been talking about with "patient experience," "If Disney Ran Your Hospital", and seemingly small things like housekeeping.

Of course, they still have a chance to turn me into a loyal referring customer. When I go back a week from now to pick up my car and inform them of my rental car gas deficiencies, they could delight me by picking up my gas bill for my troubles. I'm not holding my breath.

Check out this week's Grand Rounds at Aetiology. Interesting post at Emergiblog on what patients owe their healthcare provider.

by Christopher Cornue

While I never profess to be an expert about acuity-based staffing models, I have dabbled a bit and have been aware of the debates in California regarding mandated staffing ratios. Several other states have attempted to pass legislation to create models for staffing that enhance patient safety and are based in the foundation of addressing the appropriate needs of the sickest patients. One such model has recently been passed in Illinois. In short, this new legislation (which was passed on 29 May 2007) will mandate that each hospital create a team to develop acuity-based staffing models. Each team must be comprised of at least 50% direct-patient care nurses. The hope is that each hospital, with the involvement of their nurses, can create a model which best suits that organization’s unique needs and challenges. Instead of me rambling on about it, interested folks can view some of the detail at the following link on the Illinois Hospital Association’s website: http://www.ihatoday.org/advocacy/state/sb867.html. A very cursory review of other models suggests that California, Kentucky, Nevada, and Oregon are among the states that have passed legislation around acuity-based models. One report indicated that more than 25 states have considered such legislation. So, what are your thoughts regarding this?

by Nick Jacobs

In a recent article from USA Today, Dennis Cauchon elaborated on numerous health related laws that are currently being implemented across the United States. According to the article; in New York City and Windber Medical Center, (I added the part about Windber Medical Center) trans fats have officially been banned.

As we look toward a generation where one of every three children will be devastated by Type II diabetes, California has officially banned soda sales during regular school hours and limits have been placed on sugar and fat content in school prepared food.

Three States have taken on the challenge of cervical cancer as Indiana and North Carolina schools must tell parents of girls about the link between human papillomavirus and cervical cancer. They must also inform them about the availability of the new vaccine to prevent this cancer. In Nevada they now require insurers to cover the costs of that new vaccine.

Colorado has banned abstinence-only sex education in all school districts but one, and they are requiring schools to teach sex education based on scientific research. They also are requiring that information on contraception will be provided to the students.

As our society is continuously challenged by professional athletes in the use of performance enhancing drugs, the state of Florida has voted to initiate a one-year, pilot program of random steroid testing with high school athletes who participate in baseball, football and weightlifting.

The Massachusetts' health care insurance law will take effect requiring everyone to have health insurance — either purchased privately or with the help of the State.

Finally, New Mexico legalized the medical use of marijuana, and Rhode Island has made permanent its medical marijuana program. Simultaneously, Vermont has expanded the use of medical marijuana from only those with terminal diseases to those with some chronic diseases, too.

So, there will be no soda in California. No trans fats in New York or Windber, vaccines in Indiana, North Carolina and Nevada, sex education in Colorado, and Massachusetts will make sure you have insurance. Florida will stop your steroids, and New Mexico, Vermont and Rhode Island will let you toke for medical reasons. Now, we only have 39 more States to get on the band wagon, or, depending on your viewpoint, only eleven to get off! Wonder where Puerto Rico is in all of this?

guest post by Jeff McKune

Andrew touched on the central point of strategy when he said that it is "where you want to be." As with solving any problem, understanding the problem is the first step. Understanding where a hospital wants to be in the future is the first step in strategy development. There is a strategy development methodology known as complex adaptive systems that overcomes some of the shortcomings to other approaches. None would question that the healthcare industry is dynamic, with players and variables changing so quickly that adapting a static approach to strategy development is, for all practical purposes, hopeless. Perhaps those more static methodologies, and the resulting frustrations, are one of the reasons why senior leadership often reverts to a more operationally focused "what do we need today" approach.

In brief, the complex adaptive systems methodology starts simply with a series of scenarios. Write several brief scenarios about aspects of healthcare in the future - just a few paragraphs for each is sufficient. Base each scenario on your current knowledge as well as trends that you see. Where will healthcare be in five or ten years? Write in the present tense, placing yourself in the new world of healthcare as if it actually existed. Select two or three of the most compelling scenarios as the seeds of your strategy. From here, the strategy development is a series of straightforward but thoughtful steps.

* Identify the stakeholders in your scenarios. What skills and capabilities do they have? How will your organization relate to them?
* The keystone organization is that organization through which other services will flow. It is the cornerstone of the socioeconomic business system - the healthcare environment in which you operate. What skills, capabilities, equipment, and other resources will you need to be that keystone organization in your scenario? Do you have the right people? This will hopefully lead to another entirely separate discussion on strategic human resources management.
* Decide how you will acquire the skills, capabilities, resources, equipment, and people that you will need. This is much more than "we need a 64 slice CT scanner". This is acquisition with intent and a clear view of where the acquisitions will place you in your future scenario.
* The plan for acquiring what you will need becomes an action plan that is the basis for your implementation plan for your strategy. Implementation is where so many organizations fall short, so developing project plans and milestones is crucial.

At least once a year, revisit your scenarios. What has changed? How have the complexities of your system reshaped your scenario? Simply restate your scenario and reiterate through the steps once again. What you learned from the previous effort and your new perspectives will sharpen your next strategic plan. This is the advantage to the complex adaptive systems approach.

When your entire organization is focused on making your hospital successful five or ten years in the future, it is much more difficult for other organizations to compete or deflect you from your target. It is like playing chess with someone who can think ten moves ahead of you - you don't stand a chance.

Jeff is Director of the Ambulatory Surgery Unit at Phelps County Regional Medical Center

by Tony Chen

Here's a roundup of Sicko reviews. Overall, everyone agrees that this is Moore's most "neutral" movie. In other words, he doesn't go as extreme in confronting people and he doesn't fudge as many facts. But he makes his point because it's an easy one to make: our healthcare system is broken. Obviously, this isn't exactly breaking news, but his method of storytelling (juxtapositioning "facts" and gut-wrenching stories) makes it real, entertaining, and memorable for the audience.

Washington Post: "Ladies and gentlemen, I think we can agree on two things: The American health-care system is busted and Michael Moore is not the guy to fix it."

AP: "Moore's 'Sicko' gives accused little say"

NYT: "Mr. Moore has hardly been shy about sharing his political beliefs, but he has never before made a film that stated his bedrock ideological principles so clearly and accessibly. His earlier films have been morality tales, populated by victims and villains, with himself as the dogged go-between, nodding in sympathy with the downtrodden and then marching off to beard the bad guys in their dens of power and privilege. This method can pay off in prankish comedy or emotional intensity — like any showman, Mr. Moore wants you to laugh and cry — but it can also feel manipulative and simplistic"

LATimes: "Moore is back again examining America's healthcare system in the aptly named "Sicko." It's likely his most important, most impressive, most provocative film, and it's different from his others in significant ways."

LATimes commentary: "Sens. Hillary Rodham Clinton of New York and Barack Obama of Illinois and former Sen. John Edwards of South Carolina all have staked out positions sharply at odds with Moore's approach. But none of them is eager to have that fact dragged into the spotlight."

Chicago Tribune: " "Sicko" represents a subtle but distinct shift in tone for Moore. Realizing he has in his mitts a great and genuinely bipartisan issue, the writer-director from Flint, Mich., moderates his attack strategy for the better."

Boston Globe: "Whatever you call his movies -- agitprop, advocacy entertainment, Commie propaganda, the Truth -- "Sicko" is built to persuade. It succeeds by making us ill with laughter and with shame."

Rolling Stones: "Does Moore cut a few corners? Sure. Some of the European hospitals he visits might be spiffing up for the camera. The drugs an American patient buys in Havana (five cents there, $120 at home) might not be up to FDA standards. And maybe the French are pushing it by doing a patient’s laundry. But the weight of evidence Moore marshals for taking the profit motive out of medicine is overwhelming. In a summer of dumb, shameless drivel, Moore delivers a movie of robust mind and heart. You’ll laugh till it hurts."

Capital Hill Blue: "Michael Moore's new movie, "Sicko," should be called "Skipo," since it skips over so many facts en route to government medicine."

Salon: There's no other way to come at Michael Moore's "Sicko" than to state upfront that his essential argument -- that it's shameful that America, the richest country in the world, fails to provide healthcare for all its citizens -- is irrefutable. No matter how you feel about Moore or his filmmaking tactics, there's little here that any sane, reasonable human could argue with: We've fashioned a system in which big corporations get rich off our illnesses, or even just off the regular preventive steps that most of us take to avoid getting sick.

Anyone see it already? what's your take?

by Nick Jacobs

Back in 1963 my philosophy professor challenged me to prepare an analysis of intrinsic (taking) versus altruistic (giving) behavior. My conclusion at that time was that there clearly was no such thing as altruism. No one did anything unless it was good for them. Even those individuals who so generously gave of their time, money or wisdom, did it because it made THEM feel a little better about themselves.

Interestingly enough, that sophomoric knowledge (I was a sophomore.) did not keep me from embracing a life in not for profit management. Throughout my career in the various nonprofit organizations with whom I have worked; education, arts, economic development, and healthcare, it has been clear to me that there are two types of people who volunteer, the givers and the takers.

When questions are raised regarding how much is personally too much to those individuals who are the takers, the answer is obvious, “You can never have too much.” But when the same question is posed to the givers, the answer is entirely the opposite, “We enter with nothing, and we should leave with nothing. We are here to serve mankind.”

Well, over the last thirty plus years, it has also become clear to me that controls are necessary in order to keep the takers in tow because, many of them have no boundaries in regards to their material needs, and not for profit organizations are not the appropriate setting for pursuing those endless needs.

After Enron there appeared to be a glimmer of hope relating to controlling these takers, and there also appeared to be a strong movement toward a Sarbanes-Oxley-type legislation for nonprofit's. That proposal has now evolved into a new proposal called the Nonprofit Accountability Bill. Unfortunately, it does not yet have enough teeth to be really meaningful.

Let’s examine carefully the rolls of our nonprofit board members and simply track back the amount of business done by their companies within the nonprofit corporation for which they volunteer. Then check to see if bids were solicited, if influence was not placed on executives in charge through board compensation committees and if the business/member excused him or herself from the meetings when these issues were being decided. The Nonprofit Accountability Bill proposed certain limitations regarding the amount of business that actually constituted a conflict of interest, but, it is relatively clear that those numbers have also not been activated.

Bottom line? Ask questions about your nonprofit boards. Thankfully, for the past ten years I have worked for a board that is free of conflict, but this clearly is not the norm.

The difficult proposal that requires you to buy board member products, embrace their services, and use their consultants in order to ensure that they will be good board members is not acceptable behavior in a world that needs our help.

by Nick Jacobs

Why 2034? It’s actually the date that my actuarial has indicated that my individual involvement in this discussion should no longer have any viability. In other words it’s the projected date of my passing, but, believe me, there will be tens of thousands of we boomers contributing to this discussion until then.

A few years ago, during a scientific mission to Boston for a conference at MIT, it was my privilege to participate in a conference directed toward the challenge of keeping our senior citizens viable, active and out of long term care for as long as possible. We met with several health care professionals, engineers, and scientists who had taken on the challenge of miniaturizing every known type of monitoring system for the human body.

They had begun the effort to successfully decrease the size of these devices to the diameter of a nickel, the relative thickness of a potato chip and a cost of about twenty five cents each. We saw demonstrations of some of these miniaturized devices in actual use. They were adapting systems for monitoring the heart, blood pressure, brain function and respiratory system. With all of the flexibility that wireless communication can deliver, the unencumbered participants would be literally, wired for sound, as they moved freely through the special apartment that had been constructed for this research.

Each and every movement could be monitored all day, every day. The signals generated from the participants various organs were sent directly to a computer that was housed at a physician’s office where any missed beat could be reported through an alarm system that immediately notified the physician in charge.

Think of it. Pappy gets up from his chair, feels a little dizzy, sits back down, and the videophone rings with a healthcare professional checking to see if all is well.

Because of the 1984 feeling that some of we 1960’s free spirits might feel from this “Big Brother” type monitoring, it was suggested that the grandparent might also like to have her sibling monitored as well, thus giving the affect that they are indeed checking on each other.

Think of it. This system could very well keep us out of some offensive, under staffed, insufficiently reimbursed nursing home for at least an additional year or two.

In closing, however, I did receive an e-mail the other day with this suggestion. If you like to cruise, it would be more fun to live on the Pacific Princess for the rest of your life than in the Sunset Valley Nursing Center. The cost is similar, and when you trip and break your hip, they will upgrade you to a suite and deliver meals to your room.