hospital impact

by Nick Jacobs

Kathy's husband passed away about a year ago after a short run with cancer. Hence, her kids decided that she needed a complete physical, took her to a local hospital and found out that she had a blockage leading to her kidney.

She went in for a stent and had a heart attack. A few weeks later she had open heart surgery, and the stitches leaked. Consequently, she had it again the very next day, and was then placed in a drug induced coma for about a week.

When she regained consciousness, her children had to tell her that she had a stroke during the second surgery causing her left leg and left arm to be weak. A few days later she was transferred to a specialty long stay hospital where she was diagnosed with C diff, an infection.

After about three weeks, she was transferred to a specialty care unit of a nursing home where she became less and less mobile until she could barely stand. She was nearly in a vegetative state from the fifteen different medications that her five different physicians had prescribed for her. Her weight dropped to 90 pounds. Although the MRI revealed that there were no signs of damage from the stroke she became more and more disabled.

After a series of phone calls with the children, none of whom lived near Kathy, followed by consultations with two pharmacists, two physicians and a social worker, all of whom were not directly involved with the case, Kathy was taken off seven of her fifteen meds, at least two of which were completely redundant and many directly conflicted with each other. One of the others, as noted in the literature, had severe side affects and, because two weeks into the prescription the patient was not exhibiting any signs of the progress that this drug might have produced, should have been discontinued months ago.

Today, the family is waiting and for their mother to walk again and eventually be able to leave the nursing home. The seven drugs had, according to physicians who advised in this case as friends of the family, gorked her out!

And today, I sit in my health care leadership chair, and wonder how often this scenario is repeated in the U.S. health care system.

She was not ever our patient. We were only involved as observers and friends, but we were involved. Short of being family, we tried everything to get the professionals involved to take notice of Kathy and her condition; her care givers, her physicians and the administrators. As an Insider it causes me much grief that this scenario has played out this way. Why were her medications not closely monitored? Why did her continued, non explainable deterioration not draw the attention of her care givers? How many people in our system of health care are without patient advocates and are destined to deteriorate and die prematurely due to a similar lack of interest?

by Christopher Cornue

Continuing from my earlier posting, The Commonwealth Fund recently published Bending the Curve – Options for Achieving Savings and Improving Value in US Health Spending. In it, they identified four areas of focus that, if implemented collectively and appropriately, could result in reducing national expenditures over the next decade while improving access, quality and population health. The first of these areas is to produce and use better information for health care decision-making. I believe that all of us in healthcare would agree that data & information are key to our ability to be effective in our respective roles – whether diagnosing patients, or trending our contribution margin. Similarly, I believe we’d all agree that access to this information is not easy, nor is it always complete or well coordinated. Next, translate these beliefs to our patients and other decision-makers in healthcare – how are they supposed to navigate our system and make informed decisions specific to health?

The policies recommended to “address information barriers that contribute to the inefficiency of our health system and undermine are outcomes” are grounded in three fundamental tactics:
• Promoting Health Information Technology
• Creating a Center for Medical Effectiveness and Health Care Decision-Making
• Patient Shared Decision-Making

Promoting Health Information Technology – the study focuses on the importance of widespread usage of information technology. This foundation is essential to ensuring our industry and consumers have an effective mechanism to support systemic efforts of improving health, coordinating care, and ultimately controlling costs. Among the details of the policies, they propose using 1% of Medicare expenditures in conjunction with a 1% tax on private insurance premiums to support activities to create effective healthcare technology. Additionally, they recommend federal matching funding (3:1 to help with healthcare adoption technology; and 15:1 to promote the development of Health Information Exchange Networks) for the states, with a high priority for safety net hospitals, rural providers and small practices. Examples include electronic medical records, process redesign efforts and health information exchange networks. Although the recommendation is for voluntary adoption, they suggest an alternative could be to require these efforts through Medicare’s condition of participation.

Creating a Center for Medical Effectiveness and Health Care Decision-Making – recognizing that providers need data to lead their clinical decision-making efforts, the report suggested the development of a shared public & private sector “center” to coordinate this critical information and improve decision-making among various groups. Not only would this information support the provider, but it would also be used by payers (for coverage and payment decisions) and consumers (to provide further information as they make health care decisions). Based upon research that states education to patients and the usage of clinical pathways or protocols help to reduce costs, the development of streamlined information should prove valuable. According to the report, the center would “have a mandate to produce and publicize information that identifies and encourages the adoption of best practices and authority to establish certain incentives that are consistent with that objective.” I believe this effort is similar to the “Map of Medicine” concept in England and Wales that I wrote a posting about in Fall 2007 and the larger Healthcare Commission (a topic for a future posting) in England.

Patient Shared Decision-Making – allowing a well-informed patient to be key in their healthcare decisions in consultation with (not exclusive to) their physician is a primary driver for this strategy. The study suggests the creation of patient education aids (PtDAs) prior to having high-cost, sensitive procedures (i.e., coronary revascularization for angina, mastectomy for early breast cancer, prostatectomy for benign prostatic hypertrophy, medical stroke prevention therapy, etc.). These PtDAs would be required by the CMS for fee-for-service Medicare beneficiaries. The provider would be responsible for ensuring the patient receive these documents, as part of their decision-making process, prior to their procedure.

Next for our Bending the Curve report discussion is Promoting Health and Disease Prevention.

by Nick Jacobs

Last week in the New York Times, a very creative depiction of the Red Cross flag took it in three shots from a + (plus sign) to a - (minus) as it described the challenges faced by this prominent organization and its recent announcement of its $200+ M deficit. Interestingly, as the Chairman of a local Chapter of the American Red Cross, we have had the same challenges. As the public donates specifically to a disaster, and the monies flow past the operational needs of the organization and directly toward the actual disaster, there is no cash to pay salaries, overhead and operations. The article by Stehanie Strom, tells of the challenges of this leaderless organization that has been a revolving door for prominent CEO's since 9-11. She stresses the complaints generated by the tyranny of donors as they designate the target of their gifts. They are requiring the recipients of their gifts to spend their monies exactly where they want it spent.

As a former philanthropy executive for over 10 years, it is clear that this trend of giving only to the donor's designated project completely hamstrings the charity that is the pass through for the gift. Last year 92% of the 77,000 disasters to which the Red Cross responded were house fires, which, as quoted by the writer, were not exactly "the stuff of national headlines." The Red Cross is being held captive by their own policy called, "Donor Direct," which commits to sending funds only to the donor designated areas.

What's the point of this blog? We are about to enter the largest and greatest pass through of wealth ever conceived of in this country as the 78 M Boomers begin to make plans for their personal estates. It has been suggested that Donor Direct be replaced with donation limits, i.e., if the donation is less then one to five, the moneys will be used by the charity as needed.

Bottom line? "Nonprofits need to do a better job of educating their donors about the cost of running their organizations." For every $100 that we bring in from hospital operations, we sustain about $98.50 in overhead expenses. In our philanthropy department, for every $100 generated, we are faced with, on a bad day, approximately ten dollars in overhead. Clearly, philanthropy is certainly a piece of the possible solution to the enormous, unmet needs of our health system, but exclusively "Donor Direct" is a limiting solution that attacks the very fiber of the charity.

by Tony Chen

We've been talking a lot recently about hospital culture - what makes it work? how can we change it? Another way to look at it is to look at the hospitals that made this year's list of Top 100 Companies to Work For. A record-breaking 10 hospitals made the list this year with some surprises (9 hospitals made the list in 2007 and 2006). Here's the rundown:

#10: Methodist Hospital System
#18: OhioHealth
#45: Children's Healthcare of Atlanta
#49: Griffin Hospital (was in top 10 two years ago)
#59: Mayo Clinic (check out Fortune's video on Mayo)
#63: King's Daughter Medical Center
#75: Southern Ohio Medical Center
#76: Arkansas Children's Hospital
#85: Lehigh Valley Hospital & Health Network (employees get $500 "wellness" dollars)
#94: Baptist Health South Florida

(Aside: It's unclear exactly how Fortune tallies the list, even if they did survey 10,000 workers. Obviously, there is quite a bit of subjective judgment. Nonetheless, the key criteria seem to be things like: pay, turnover, benefits/perks, and % minorities/women.

A few observations to make:
- I think employees know the difference between employers that really care versus employers that just try to appease / buy their loyalty. It takes real thoughtfulness and understanding of your employees (and the willingness to invest the $$$) to offer the types of benefits being offered to the employees on this Top 100 list. Just take a peek at some unusual perks here - everything from $ for buying hybrids to dollar-for-dollar matching of charitable contributions to 18 weeks paid maternity leave (7 for dads).
- I have to wonder whether the % women/minorities factor in Fortune's criteria gives hospitals an unfair advantage? Maybe that's why so many hospitals are on this list? Then again, maybe it's because many people in hospitals do view their jobs as truly meaningful work.
- Speaking of meaningful work, this is partly why Google is #1. Sure, it's nice to have great perks, financial security, lots of mobility, and a great campus. But Google gives employees 20% of their time (1 day/week) to work on anything they want.
- Mayo does seem serious when they say they want to "hire for life," but it does beg the question - where are the other prestigious hospitals?
- In my book, the true A-listers are those on this list AND the Magnet Status list: Mayo, Lehigh, Southern Ohio, and Baptist Health Florida. I know people have different views on the true value of Magnet, but irregardless, it does represent an organizational commitment to really invest in the nursing staff.

by Tony Chen

Over at the hospital impact social network, there have been a few very insightful comments about hospital culture:

Mike said: "Hospital cultures are very segmented as well. Not only are they segmented by profession i.e. nursing, medicine, ancillary services etc. but also intra-professionally within in each discipline i.e. Nursing - ER, ICU, Med/Surg; Medicine - Surgery, ER, Attendings Residents and the list goes on. Each group has their own expertise they bring to the table and each are jocking for position on many issues depending on the impact. Bottom line hospitals have very dynamic cultures."

Isn't it this type of culture that breeds the "not my job" type of attitude? And when the "not my job" is running point for a patient's care, devastating things happen.

Jane had an interesting solution for this particular problem:

One of my answers is..return the role of "head nurse" to its original purpose. That is, overseeing the care given to all patients on a unit, teaching nurses how to improve their practice, engaging other members of the care team in true care planning, making rounds with physicians and talking with families. Not managing a budget, finding staff, sitting on innumerable committees and spending almost no time actually on the unit.

This comes down to investing in additional resources to the head nurse with the many administrative tasks. While I like this idea, I think there are some administrative/strategic initiatives that only the "head nurse" who knows what's going on could really implement.

Speaking more generically about hospital culture, I saw this very interesting insight from Denny:

"For leaders, the most critical thing they can do to shift a "culture" is find out what the conversations are that their people are having. Not only is it important to know what people are saying to each other, but also what are they saying to themselves about the way things are. When a leader knows what people are saying about "the way it is around here," the leader then has an opportunity to address the issues and make a difference."

I like this explanation because everyone can grasp this. Hospital culture isn't some warm fuzzy thing that only consultants talk about - it is the unwritten norms of behavior and the frank conversations. Of course, this means that the people trust the leader enough to share!

by Tony Chen

Go check out this great post on the World Health Care Blog for a good wrap-up of what Deloitte, Brailer, PWC, Forrester, et al are saying about healthcare in 2008.

To summarize, here are 8 things that will increase in '08: IT investments, MDs using the internet, telemedicine, healthcare costs, employers not providing healthcare, individual health insurance, retail clinics, and hospital/physician tension. Are we having fun yet?

by Nick Jacobs

Giving people permission to care in the health care environment may be one solution to positively changing the manner in which we run our hospitals, nursing homes, clinics and ambulatory centers. If we carefully examine what the current behaviors are and how the stakeholders are punished and rewarded, it’s an eye opener. Having worked in this field for over 20 year, I know that profound caring is just beneath the surface and relatively small changes can begin a process of managing and changing expectations and behaviors.

How is this accomplished? Our first step was to provide enough information and education to every employee, physician and administrative leader so that they had no questions what-so-ever regarding the organization’s goals. We did this by offering open meetings over all shifts to every stakeholder. We then offered classes and workshops in Emotional Quotient (EQ), Disney, Planetree, and general Sensitivity training. We paid for a week-end visit to the Ritz Carlton for the head of housekeeping and maintenance, and sent four employees to Disney University.

By the second year, we had built a comprehensive evaluation matrix for patient satisfaction and patient responsiveness into our employee’s annual appraisals. We then created an opportunity for about 10 percent of the employees (including our senior leadership), to find employment elsewhere. Although this was a difficult time, it was clear that these individuals had no interest in providing the type of compassionate care expected in our organization.

Finally, each and every year for the last nine years, we have continued to enforce our commitment to the philosophy of transparency, patient and peer compassion, and spiritual openness. Integrative health, access to clergy, 24 hour visiting, and a commitment to creating an environment that encourages a nurturing attitude have contributed to making our facility a true center for healing.

by Christopher Cornue

Our friends at the Commonwealth Fund have provided us with a wonderful New Year’s present – “Bending The Curve: Options for Achieving Savings and Improving Value in US Health Spending”.

Built upon established facts that US health spending is expected to increase from 16% ($2 trillion) of the GDP in 2006 to 20% ($4 trillion) of the GDP in 2016, the authors of this detailed and unique report offer options that have the potential to “bend the curve” of this increase and keep our spending from increasing so rapidly. The options they present are in some cases radical changes in our thinking and rely heavily on changes in governmental policies; however, overall, they are plausible solutions providing an opportunity to control our healthcare spending. They assert that over the next decade, it would be possible to reduce national expenditures while simultaneously improving access, quality and population health.

The report is focused on a combination of policies that address different aspects of the healthcare industry:

• Production and use of better information for health care decision-making;
• Promotion of health & disease prevention efforts;
• Alignment of financial incentives with health quality & efficiency;
• Correction of price signals in health care markets.

Through forthcoming postings, we’ll try to examine each of these areas and policies identified by the report.

As is always the case with The Commonwealth Fund, much of their efforts are focused on promoting a national discussion around issues and solutions. They’ve accomplished this once again and over the next several postings, we’ll do the same.

by Christopher Cornue

As many of our readers know, I’m usually not short on words, but this posting is very direct and few words are needed. We spend a great deal of time discussing ways to make our healthcare system better in the States and this is an absolutely essential discussion that needs to occur, and it will continue. However, I do want to take a step back, prompted (I’m sure) by a recent hospital stay in November and other recent activities. Medicine is so amazing and our society is able to do so much to improve the health of individuals. The progress made over the past few decades (and centuries, for that matter) is remarkable and our possibilities to improve are endless. The ability to affect the lives of individuals, whether you are a front-line caregiver, physician, administrator, office worker, etc. is a rewarding and awesome responsibility. I’m so proud to be a part of this industry and to be an active contributor to these efforts.

So, with that brief pause and reflection on our industry, I look forward to our future discussions, collaboration and solutions to, as Tony puts it, make “our hospitals the best run organizations on the face of the planet” and improve the delivery of healthcare!

by Tony Chen

Straight from CNN's frontpage in the last 24 hours:
- Glenn Beck: Put the "care" back in health care. This CNN reporter experienced first-hand the lack of compassion at his hospital bed. Funny, Nick just posted on the power of empathy earlier this week.
- Should I sue my doctor? A heads-up to all risk management folks - this article recommends patients to come see you for compensation.
- Dennis Quaid, wife lash out at hospital. Movie Stars! Medical errors! A conspiracy? What more could you ask for? Coming to a theater near you: Secrets No More

A few implications for hospitals come to mind:
- As social media becomes more and more rampant, is your hospital ready for more of patients youtubing and blogging from their hospital bed?
- Do movie stars or other influential people get "better" treatment? We aren't comfortable with this 'tiering' of healthcare, but it's happening already.
- While I don't know the real story behind the Quaid's experience, I am reminded of one thing: transparency is more than providing regular metrics, it's a culture.
- Where are the touching/inspirational stories of the 100s of amazing miracles that have happened in our hospitals in just the time you read this post?

by Tony Chen

Go over to Kellogg Insight to read a research article on whether hospitals "act strategically" in a competitive market. This particular economics professor focused on EP procedures. It's very rare that I see business strategy empirical studies on hospitals. So if you enjoy economics and/or strategy, definitely read it. The conclusion (written like a true economist):

“Recognizing that hospitals, insurance companies, and doctors are economic agents reacting to the economic conditions they face would go a long way to understanding healthcare,” Dafny concludes. “This paper contributes to the mounting evidence that the Hippocratic oath does not suffice to protect patients from undergoing unnecessary but profitable treatments.”

by Tony Chen

If we really aim for hospitals that are world-class organizations, then we must aim for world-class organizational cultures. Join the discussion on how to do that at our online community forum here.

My old boss used to say - we as managers are really only responsible for two things - structure and culture. And structure is the easy part.

by Nick Jacobs

Denise Grady wrote a great Op Ed for the New York Times today about her sister's fight with cancer. In this opinion column she discusses empathy toward vulnerability. Interestingly, she quotes Dr. James A. Tulsky, director of the Center for Palliative Care at Duke University Medical Center whose study published in the Journal of Clinical Oncology found that doctors and patients weren't communicating all that well about emotions. She quoted the study as having revealed that male doctors were less than 50% as empathetic as female doctors in their responses to patients.

Ms. Grady made a point of indicating that it was not necessarily critical for the physicians to engage in long dialogue with the patients where they became psychological counselors. In fact, according to Tulsky, "Brief, empathetic responses will suffice."

A few days ago, I ended a post by quoting Maya Angelou who said, "I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."

So much of our life is spent looking for emotional support in some way, shape or form. The management schools teach us that "It's not all about the money." The attorneys tell us that "If we are kind and explain ourselves to the patients, our chances of being sued drop exponentially."

This morning we dealt with an employee complaint. It wasn't about time, money, or benefits. The complaint was that the employee was not treated with compassion, respect or dignity. It was about how one of her peers made her feel.

There are very difficult emotional challenges that come with being a chemotherapy or, for that matter, any type of cancer patient. After all, this disease can very clearly make us deal with our own mortality in a very direct, uncaring, matter of fact way. It is or it isn't. We are or we aren't; and one of the examples that we use is that "It may be your 543 rd Leukemia or melanoma or lymphoma, but it is the patient's first."

We are not indicating that our world must be one of mamby pamby, warm fuzzies that never deal with the truth. We are indicating that the people with whom we deal are human beings. I heard a comedian say last night that he had just gone through a tough divorce and lost weight. He then said, "I think I lost about 30 pounds. That's how much a soul weighs, right?"

So, as we move about in our world every day, remember Denise Grady, remember her sister, and remember that warmth, concern, compassion, and empathy are NOT bad things. The day that we found out that my father's cancer had metastasized, the doc told him not to worry. He told him that everything was okay. Then he turned to my mother and winked. That day will forever be burned in my memory. His was the wink of death.

Just remember that, "Wherever there is a human being, there is an opportunity for kindness."

by Nick Jacobs

My life has taken me to different countries, different continents, different cultures: Italy, Bosnia, Serbia, England, Nigeria, The Netherlands et al. During those travels, it is always exciting to me when my view of life is shaken by fundamental realizations that challenge my day to day beliefs.

For example, during my first trip to Europe, we crossed so many borders into so many different countries pre Euro, that money became so confusing to me that my mind locked up. 123,000 Lire, 5 Francs, £3 Sterling? What did it mean? It was during those multiple country, multiple currency visits that it hit me, at the tender age of 22, that money was just one way to get what you needed.

Nearly twenty years later, as we deplaned at the airport in Rome, we were swamped by Italians leaving for their month long holiday, and, of course, for those businesses that remained open, there will always be the break from 3:00 to 5:00 PM and those leisurely, wonderful, evening meals.

What struck me is that we, as Americans, too often see the things that happen to us on our way to our next meeting or destination as an unessential distraction. While, to those Europeans, be it in Serbia, Bosnia, France, Italy or Spain, those interruptions are life. They stop and talk. They enjoy the trip. Because the journey, not the destination, is life.

A friend of mine recently forwarded me a letter from a business associate that described the secret to being a successful leader. To paraphrase his thoughts: a successful leader has the uncanny ability to embrace both philosophies. Great leaders most often have disciplined themselves to get huge amounts of work done in very short amount of time.

They also, however, have learned to hold onto the moment, to remain receptive to those with whom they have come in contact, to keep their minds open for positive interaction and to take advantage of the serendipity that surrounds each and every one of us every day. It has been my experience that by keeping open to every possibility, we often times find solutions to our most challenging problems. So, carpe diem. As Maya Angelou said, "I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."

by Tony Chen

Has anyone else seen this article in the Atlantic? It claims that too many doctors lead to lower quality because the "coordination costs" outweigh the benefits. When every doc is responsible for one aspect of care, sometimes it gets unclear who is responsible for what (or at least, that's the theory)

From the article:

“Why would more doctors lead to worse care, and fewer doctors to better care? More tests and procedures always entail more risk, and for care that’s unnecessary, the ratio of benefit to risk is zero. What’s more, where numerous doctors, particularly specialists, are routinely involved in a patient’s case, the potential for miscommunication and confusion multiplies (bold mine). Modern medicine should be a team sport, but it is often practiced as if everybody is running a different play. Different doctors order duplicative tests, prescribe drugs that interact poorly with what the patient is already taking, and assume another physician will attend to a critical aspect of a patient’s care. A cardiologist can be a virtuoso at slipping a stent into the coronary artery of a patient in the throes of a heart attack, but if she leaves it to another physician to prescribe aspirin to her patient—one of the most effective treatments for preventing a second heart attack—that prescription might fall through the cracks.

“This is what appears to be happening in many hospitals, where the ratio of specialists to primary-care physicians is especially high. In one recent study, two Harvard economists—Katherine Baicker, of the School of Public Health, and Amitabh Chandra, of the Kennedy School of Government—examined how the quality of care in different states varied as the proportion of specialists rose. They found that measures of quality, like the percentage of heart-attack patients who received a prescription for aspirin, tended to fall in direct proportion to a rising ratio of specialists. The point, says Chandra, “is not that the specialist is inferior, but that the system is not accounting for the ‘coordination cost’ specialists are imposing.”

It's not hard to believe that this coordination isn't always done well. But it is hard to believe that this lack of coordination could outweigh the benefits of the tremendous expertise and advanced care provided by specialists.

I need to see more on this, but nonetheless, this further reinforces the notion that your hospital's organizational culture may be just as important as the organizational structure & processes.

by Nick Jacobs

The book, Birth of the Chaordic Age by Dee Hock, Founder and CEO Emeritus of VISA was recommended to me, and actually sent to me by a very brilliant guy a few months after I had attempted to explain my philosophy of management to him.

If you are a student of management, or a front line manager, you will see that there is hope. At least one CEO in the country gets it.

Dee Hock is currently founder and CEO of the Chaordic Alliance, a nonprofit committed to the formation of practical, innovative, organizations that blend competition and cooperation to address critical societal issues, and to the development of new organizational concepts that more equitably distribute power and wealth and are more compatible with the human spirit and biosphere.

Dee says plenty of things are right on target for me. "Forming a chaordic organization begins with an intensive search for PURPOSE, then proceeds to PRINCIPLES, PEOPLE and CONCEPT and only then to STRUCTURE and PRACTICE."

One of my favorite sections involves the reality quoted earlier:

"The Industrial Age, hierarchical, command-and-control institutions that, over the past four hundred years, have grown to dominate our commercial, political and social lives are increasingly irrelevant . . . They are failing . . .organizations increasingly unable to achieve the purpose for which they were created, yet continuing to expand as they devour resources, decimate the earth and demean humanity."

Willis Harman, former President, Institute of Noetic Sciences, writes: "Dee Hock describes a new organizational culture that might well spell the difference between a smooth, orderly transition to a more salubrious, sustainable society and the chaos and anarchy that some see in our near-term future."

So, as Paul Harvey says on his radio program, "And now for the rest of the story."

My entire professional career has been dedicated to attempting to create an environment that was not like the typical hierarchical organization. Unfortunately, the bullies live on, and the world is under attack in every way by their greed and their egos.

So, think about reading Birth of the Chaordic Age. For some of you, life may change. For others of you, there may be a rebirth of your spirit, and for the rest of you, understand that there is a movement to unseat your archaic beliefs, those beliefs that currently feed our wars, our pollution and our failed systems. So, hold onto your hats because change is coming.