by Nick Jacobs

If the Material's Management Director receives a favor in the form of a trip or a gift from a vendor, and that gift is beyond a limited value, that may be considered problematic for the organization. If a senior officer, though, is flown to a reception in the vendor's corporate jet, wined and dined, and then taken to a professional sporting event in an attempt to influence that officer into using that company's product, does that present the same problem? If a U.S. Congressman is flown at no cost by a lobbyist, that now is considered problematic, but if the lobbyist is from an academic institution, that is considered okay.

If a board member puts undue influence on an executive to do business with his company, how does that play out? Sarbanes-Oxley sends a very clear message that the business community is expected to do things differently than the way they have been done in the past, but I've already heard of cases in health care governance where specific board members have required the calculation of just how much business is too much business to be pushed to the extreme before the law kicks in for non profit corporations.

According to the Columbus Dispatch, in 2000, 13 of central Ohio’s corporate boards were dominated by insiders — company executives, consultants and lawyers. Some owned jets that they leased to their companies. Others owned office buildings that their companies rented. Still others were relatives of the CEO.

Bottom line? Corruption by any other name is often called doing business in many countries, and in some countries, it is truly considered an art form. Who do you know? How do you take care of your friends and the friends of your friends? What financial favors do they do for each other? Unfortunately, in many cases, if you don't play by the rules of the GOB's (Good Ole Boys), there can be a heavy price to pay, unemployment.

So, for all of you who are looking at a high powered future, study the rule books and stick to your guns, but, unless you work for an absolutely wonderful board, hold onto your hats because situational ethics can be very difficult to surmount.

Regarding ethics in the military, Robert Prentice, a professor of business law at the McCombs School, said, "Nobody up the line is taking responsibility. Everyone is trying to pin it on the little guys." Remember, that little guy could end up being YOU.

Final thought, putting on make-up or shaving in the morning usually requires one to look in the mirror, and that can become challenging for those who are better known as the players. Of course, that depends on the situation.

by Jeff McKune

Having attended a couple of Joe Tye’s seminars, I was eager to read The Healing Tree, a book he first published in 2005. The book is now in its second printing.

The story begins with an evening with Mark and Carrie Anne Murphy and the tragedy that enters their lives. Carrie Anne’s struggle towards recovery is one thread that is carried through the narrative. But a deeper and richer fabric is found in her personal awakening, guided initially by young Maggie, a fellow patient at the hospital who provides unique therapy to Carrie Anne and other patients. Carrie Anne’s despair eventually leads to her discovering a new path for her life, more meaningful and rewarding than anything she had previously imagined. The story alone touched me, and I found myself sometimes both uncomfortable and inquisitive with the introspection it created in me. That alone made the book worth the reading.

It was impossible for me to ignore the glimpses that Joe provides into the healing environment that was a part of the fictional Memorial Hospital. I wondered how some of the innovations Joe discussed would ever get past a Board of Directors. But clearly Memorial Hospital was a hospital focused on much more than physical healing. The hospital’s ongoing transformation was a result of visionary leadership. One phrase that I cannot forget is “the soul of the hospital.” What is the soul of your hospital? How do your efforts contribute to the development and sustaining of that soul?

Throughout the book, Joe also reveals some thoughtful insights into nursing and those that serve in caregiver roles. The bidirectional aspect of the nurse-patient relationship is developed in a discussion between Carrie Anne and Maggie. And toward the end of the book, the hospital CEO reminds us that patients are not the only ones that need healing. Joe is a strong advocate of nursing, and it is no surprise to see this emphasis in The Healing Tree.

I consider The Healing Tree to be one of those books that takes a hospital administrator beyond mechanics and methodology – it invites and encourages visionary and transformational leadership. A section containing discussion questions is included at the end of the book for the purpose of initiating dialog regarding that transformation. Also, there is a website for the book at www.healing-story.com where you can download the companion workbook Healing the Hospital, which I understand has been popular at caregiver and leadership retreats. If you want to spark discussions as to how your hospital can better serve both patients and staff, I invite you to read and share this compelling book.

by Nick Jacobs

The World Congress on Cardiology is meeting this week in Belgrade, Serbia, and, as an invited speaker, we are going to be exploring the efficacy of the coronary artery disease reversal program currently being studied at our research institute. One of the most unique findings of our studies, as identified by our lead researcher on this topic, Dr. Darrell Ellsworth, is a major reduction in measurable depression scores. After having personally gone through the program nearly ten years ago, it is very clear to me exactly why this is the case.

When any type of serious medical reality hits us, be it a cancer, heart disease, or neurological dysfunction, we are thrown into a spiral that feels irreversible. All of our lives, we have worked very hard to ensure that we had as much control over our personal situation as possible. At the same time, we tend to live in denial of our own mortality until we are staring it directly in the face.

What we/I have found with programs like the Dean Ornish Coronary Artery Disease is that, not unlike the old factory experiment directed toward seeing if low lighting or bright lighting made the employees happier, the outcome was that either worked equally well because the act of changing the lighting demonstrated that someone was paying attention to them.

In our research, a group of highly trained medical professionals work carefully with each participant to explain his or her condition, risks, challenges and alternatives. The most important outcome, however, is that the patients are taught how NOT to be victims of their disease anymore.

It is my deep belief that every human being would benefit from this type of exposure to medical professionals, people who take the time to help us sort through our personal situations, to give us hope and to ensure that we will have mental and physical support while working toward improving our health both mentally and physically.

by Jeff McKune

Tony posted an entry about HealthVault, and it looks like Microsoft has multiple healthcare irons in the fire. HealthVault appears to be more of a consumer oriented PHR platform, while Azyxxi is a data warehousing and query tool that is directed at healthcare organizations such as hospitals. It should not be any surprise that the healthcare industry has caught the eye of one of the world's largest information technology companies. We hope to see a demonstration of Azyxxi soon, and one of us will provide an update with additional details at that time.

To add to the discussion regarding using generalized networking tools such as Facebook in a healthcare context, we should mention the Joint Commission's most recent efforts. The Joint Commission has started a wiki called WikiHealthCare based on the TWiki enterprise collaboration and knowledge management solution. A wiki is a tool that allows knowledge to be shared and edited by multiple contributors. Wikipedia is good example of a very popular wiki.

It looks like smoking cessation was the sprout from which WikiHealthCare grew, and it now includes the following general discussion categories:

Quality Improvement Discussion & Solutions
Smoking Cessation Counseling Programs
Smoke Free Hospital Campus

Standards Development & Research
The Transfer of Health Information
Pharmacist Review and Use of Protocols for Contrast Agents in Radiology
Microsystems and Patient-Centered Care

WikiHealthCare was announced on September 12 and in less than a month, there are 2,774 registered users of the system.

It would seem that the vision of online collaboration using multiple information technology tools and covering a wide variety of consumer and management healthcare topics is unfolding as we discuss this. So what will the future bring as these systems develop? The key concepts of integration, consumerism, transparency, and quality will no doubt shape these systems. Will there continue to be separate and distinct physician, hospital management, and patient wikis, blogs, and networking tools? These are growing now, but I believe that we are not very far from a time when patients, physicians, and hospital administrators will be sharing information, expectations, challenges, and collaborative solutions using these online tools. You may be seeing some of this already at your hospital.

The technical walls for sharing information are, for all practical purposes, non-existent. The expansive school of hard knocks, coupled with business models that demand trust (HealthVault won't stand a chance if there is a breach), are forcing companies to more stringently address online security issues. It's not technical and security bricks in these walls - it is more likely legal and cultural issues that hinder open communications.

The pieces are falling into place. How will this change health care when we all sit down at the virtual table and talk on a global scale? It sounds sci-fi, but it isn't. It's happening.

by Nick Jacobs

It dawned on me the other day that several of my recent posts have been about problems, but many of them do not prescribe solutions. This one has a solution. If your doctor doesn't give you alternatives, fire him. If he or she doesn't encourage you to get a second or even third opinion, get another physician. If, as a man over 40, you have not had your prostate checked, question your physician's ability to practice. If you're a female over 40 and you are not receiving advice relative to your breast or pap exams, your physician is not doing his or her job.

Where is this coming from? Over the past twenty plus years, it has been my very bad experience to have known a number of physicians who are completely driven by finance. The goal of these physician is to do the fastest, least thorough medicine possible, just above the lawsuit level. It is their challenge each day to get as may patients through their practice as humanly possible, and skip the details. We've all known people like this, but in medicine they can be lethal.

When questioned about the percentage of patients recommended to have mammography each year from one of these practices, the reply is short and sweet. "Don't know, don't care. Takes time to write prescriptions and make arrangements. Probably less than 10% of those who need it."

When asked how much can be made by selling drugs to patients from an in-house pharmacy, though, you will receive a price quote per pill, per ounce, per patient or per hour. If there is a piece of equipment for which this physician can receive a professional fee on the property, every patient possible will be run through it as often as insurance will allow. Chest x-ray? Stress tests? Halter monitors? If it's part of the financial base, it will be part of your bill. In chiropractic they call these practitioners churners.

Somewhere along the way docs like this get off the Hippocratic path. They stop remembering what medicine is about, and many times stop caring about those people who have placed their lives in their hands. Nothing infuriates me more than a physician in a meeting who ignores three pages and three cell phone calls. It makes me ask the question, “What if that page was about someone that I loved?” These physicians usually avoid admitting patients to a hospital for even severe situations, and they are most often extremely rich.

Watch out for the signs of greed displayed by your personal physician because they are not always materially visible. Sometimes it's ownership of a lot of land, a place in Aspen, the newest Porsche, more diamond rings on their fingers than could be mined in a week; but, most often, it's a detached, cold, fast paced, business-like approach to you that makes you feel more like a widget than a person.

If you experience this, say, “Thank you doc. Please give me a copy of my medical record,” and then run like hell.

by Jeff McKune

My Dad and I were recently discussing healthcare issues, and he told me that he argued healthcare topics when he was on his high school debate team. In fact, in 1947 he was given the debate topic "Should the Federal government provide a system of complete medical care available to all people at public expense?" Sixty years later, the question of government's involvement in healthcare is still a hot topic, and it is one of the leading topics of the 2008 presidential race.

A little over a week ago, John Stossel hosted a 20/20 program titled "Sick in America: Whose Body Is It, Anyway?" One of the things I liked most about the program was the way that Stossel covered some challenging issues such as the linking healthcare insurance to employment, over utilization, and the profit motive. He also had a nice segment comparing the system in the United States with those in other countries, specifically Canada. I found the whole program to be refreshingly frank.

The last part of the program focused on private solutions to healthcare problems versus government solutions, and the importance of competition and individual choice. Stossel gave a couple of examples where competition among healthcare providers has led to improved quality and lower prices, even during a time when most of the industry is experiencing higher prices. Those two examples were LASIK eye surgery and cosmetic surgery, both of which are usually not covered by insurance. LASIK prices have dropped 30%, and the quality has improved. Providers have to compete because patients are shopping around knowing they will pay for the procedure out of their own pocket.

When discussing healthcare challenges, we often focus on what does not work. But what does work? The things that work for healthcare are the things that have worked for our country in many other industries: Freedom of choice, competition, innovation, and the availability of information for potential buyers. If we know these things work, as hospital leaders, how can we best connect to these basic tenants?

by Craig Ahrens

I have not blogged in a long time and I apologize. As most of you know, I attempted to launch www.thebusinessofhealthcare.tv months ago and unfortunately had to pull back on the website official launch again until next month. Long story short, it is difficult to start any business – legally the loops you have to jump through are extreme especially when it comes to this type of business model. It has been an all consuming effort and fortunately I have partnered with individuals who are going to ensure a smooth startup. So, look for it again and I appreciate your support and welcome your ideas!

At the same time, I left the consulting world to work for one of my clients. They offered me the opportunity to work in one of the most competitive markets and service lines in the country – Indianapolis as a Neuroscience Service Line Executive Director. Normally, I would not have been interested in this position, but the chance to work in a non-CON, advanced specialty hospital, competitive market with an excellent health system was too enticing. I thought that it would be interesting to post my experiences working in a new role.

Service line executives are difficult roles to manage. They are difficult primarily because of three reasons:

1. Many of the relationships with operational staff are matrixed through Chief Nursing Executives.
2. Physicians and CEOs are used to negotiating business development opportunities minus a “middleman”.
3. Operationalizing plans and business development initiatives is difficult given the myriad of relationships to navigate.

How does one overcome these issues? In my opinion, the most important thing is for the CEO/executive team to visibly communicate to administrators and physicians that you are the go to person for the service line. Without this support, you are dead in the water with the matrixed relationships. Further, the physicians will continue to pursue the pattern of going straight to the CEO to discuss any opportunity. To some this may seem odd, but you need to market yourself internally and to be seen as the person who shepherds initiatives and gets them done through navigating the internal political hospital dynamic. I will continue with part II next week. Any comments?

Craig Ahrens, MHA, MBA, FACHE is the Executive Director of Neurosciences for St Vincent Health in Indianapolis, Indiana (part of Ascension Health System). He is also President of www.thebusinessofhealthcare.tv (due to launch in late 2007), which is the web’s first internet tv program dedicated to healthcare business news and interviews. He can be reached at info@thebusinessofhealthcare.tv

by Nick Jacobs

From MSN Money: "Patients in the highest-rated, five-star hospitals in the United States are at a 65 percent lower chance of dying than patients in the lowest-rated, one-star hospitals, according to a study released by HealthGrades, a health-care ratings company. If all hospitals included in the study performed at the five-star level, the lives of more than 273,000 Medicare patients could have potentially been saved over a two year period. Fifty percent of these potentially preventable deaths were associated with four diagnoses: heart failure, community acquired pneumonia, sepsis and respiratory failure."

From "Health Daily News:"

Today, some health care executives, insurers and physicians are . . . fully embracing disclosure and apologies, not only because they believe it will reduce malpractice claims, but also because it's ethically the right thing to do."

Larry Dossey, M.D. from "Reinventing Medicine," "For more than a century the profession of medicine has tried to become increasingly scientific and technical, because this is where we believed the future of healing lay. Now a monumental shift is occurring, empowered by the evidence that consciousness is a powerful factor in the world."

Finally, Dr. Karen Donelan, Senior Scientist in Health Policy, Massachusetts General Hospital, gave a wonderful description of her experience in the health care system. A dear member of her family received timely access when the pcp's answering service worked, the receptionist, technician and doctor all showed compassion and demonstrated their desire to be there for the family and the patient. At every step information and decisions were shared, so much so that the family felt part of the care team, and finally the doctors were highly trained and had all of the right tools. She described this as truly, significantly different care than they had ever observed with other family members. According to Dr. Donelan, "It was seamless, high quality , accessible, compassionate and expert with a fully disclosed price and plan of treatment."

It was the care that her dog, Rico was given by the vet. Surprised, don't be.

by Jeff McKune

This past week was certainly busy, and the last half of it was packed with our annual leadership retreat. My head is filled with tasks and action plans as a result of our leadership development sessions with the Advisory Board. Then Joe Tye challenged us with building the invisible architecture of our organization. I have so many action plans that I need to develop, that I may start with an action plan for my action plans!

There is a strong sense of being equipped that comes out of a retreat. With all of the collective enthusiasm that accompanies that sense, I have to wonder how much will survive the onslaught of the reality of daily operations at the hospital. There has to be more than just "retreat-speak" that follows me back to the job. Certainly there are a myriad of projects that I could attempt to tackle. However, I know that time and energy are not unlimited, and that I still have to maintain some sense of balance in my life - time for family, friends, and self (exercise, reflection, and spiritual growth).

So now that I am armed, to which efforts can I fully commit? First, I will renew my commitment to formally developing my own leadership skills. If my dream is to help build a better hospital, to have a positive impact on healthcare, I have to start with building a better Jeff. That will mean taking a critical and introspective look at my skill set, determining where the opportunities for growth are, and committing time each week to addressing those gaps. My second commitment will be to focus on bringing out the very best in each member of my staff. What are their dreams? What baggage are they carrying that I can help them overcome? What would it take to make them feel like this is the greatest place on the planet to work?

Maybe armed and dangerous is not the right phrase: How about aimed and determined!

Did you recently return from a leadership retreat or similar experience? What initiatives were you able to take back to your organizations?

by Christopher Cornue

Our organization just went through another “re-organization” and the phrase “Physician Integration” was added to my title in a slightly revised role in the Table of Organization. By raising the question of what this means, I’m being somewhat facetious (I had better be clear about it, since it is in my title after all) … but shouldn’t we all have “Physician Integration” formally, or informally, after our titles? Since we are leaders in healthcare, aren’t we all expected to integrate physicians into what we do on a day-to-day basis? So, instead of Chief Operating Officer or Vice President for Strategic Planning … the roles should read Chief Operating Office & Physician Integration or Vice President for Strategic Planning & Physician Integration. These revised titles speak more to a “matrix” style Table of Organization emphasizing the role of physicians in everything we do.

Let’s not make light of this – it is key that physicians are part of our operations meetings, service line discussions, marketing/planning, nursing leadership, etc. Too often I have heard physicians separate leadership between “physicians” and “administration.” Quite frankly, I get a little frustrated when I hear this stated … I truly believe we’ve moved beyond this “old school” style of thinking of separate accountabilities and we really need to marry physician and administrative leadership as supportive, not exclusive managing styles. Another one of my soapboxes, I guess.

While it might not be necessary to specifically identify the term “Physician Integration” in each of our titles, it is important that we remember, recognize and reinforce the importance that physicians play in everything we do. This is the true nature of a dynamic, progressive and successful organization and a moniker I am proud to attach to my new title, and any other title I hold in my future care in healthcare.

by Nick Jacobs

On my hospital blog (Windberblog.typepad.com), my entry this week was about twisted truths, not ours, but others. As the art of spin has become more and more refined, we begin to reach a point in communications where reality is whatever the loudest voiced pundit can emphasis the longest and the most intently. This practice has become true in health care as well. Especially in areas of high competition.

Last year I wrote another blog about an author by the name of S. I. Hayakawa and his book, Language in Thought and Action. As a freshmen college student my impression of the book was that it was about thought and mind control through the use of disinformation.

"The original version of this book, published in 1941, was in many respects a response to the dangers of propaganda, especially as exemplified in Hitler's success in persuading millions to share his maniacal and destructive views. It was the writer's conviction . . . that everyone needs to have a habitually critical attitude towards language — his own as well as that of others — both for the sake of his personal well-being and for his adequate functioning as a citizen.

The reality now, however, is that this art has evolved into a science, and the science has become an accepted part of our world. It is fascinating to observe the use of disinformation as a means to attract patients, to see the truth twisted just enough to confuse the public so as to appeal to their lack of technical and medical knowledge through misrepresentations that lead to business.

A few weeks ago, one of our visiting sub specialists told a patient that they had to be transferred from our facility because we didn't have the necessary equipment for his surgery. As it turned out, the piece of equipment was an orthopedic nail that, had we not had cases of them, could have been delivered almost instantly by a local sales rep. The reality is that a competitor requires each surgeon to do a certain number of surgeries each day that they have scheduled. If they do not, they will have a decreased number of slots to work from in the future that are exclusively designated for their use.

What is the definition of an Open MRI? It is not a larger bore device, it is, indeed, open. Who cares? A facility that has purchased a larger bore device cares. Say that it is OPEN, confuse the public, and take business away from the facilities who purchased the OPEN MRI. A nuance, you say? A tiny twist, you think? Well, if you have a $34,000 a month payment to make, it is just good business, right? Twist to sell.

Finally, we hear, everyday, the little whispers about skill level. Perception is reality, and unless or until total and complete transparency becomes the guiding light of health care, we will be in the same boat that we were in before "Consumer Reports."

Buy our gasoline, "It will put a tiger in your tank!" It wasn't that long ago when we believed that there was a huge difference between the quality of different brands in that business as well, at least we believed that until we were informed that all of the gas was coming from the same refinery or, in some cases, all of the stations were being fed from the same truck!

Bring on open communication, just don't let some of the major, existing evaluators take the lead. They are from a different paradigm, a world where, many times the twisted, interpreted detail is the basis for a pronouncement that has no bearing on the reality of the care.

by Christopher Cornue

Unfortunately, I cannot take credit for this very accurate description of leadership in healthcare at the moment. This was a resounding theme at a recent Health Care Advisory Board meeting I attended a few weeks ago. Supporting this assertion, the Advisory Board discussed changing reimbursement methodologies, revised DRG structure later this year, global competition for paying patients, increased costs, expected growth/volume decline, shift from inpatient to outpatient, proposed legislation forcing hospitals to absorb costs for adverse events that occur during a patient’s hospitalization, a more informed consumer, increased transparency of quality outcomes for hospitals, evolution of “retail clinics,” workforce challenges, etc. No need to go through the whole list – you get the point! While many of these issues have challenged hospital leaders for several years, it’s probably safe to say that a “perfect storm” type scenario is on the horizon, whereby all of these are impacting hospitals simultaneously. Which issue do we spent the majority of our time focusing on first? How do we manage this change going forward? Regardless of our focus, I just wanted to share this “Leading Through Disruptive Change” statement, as I think it’s a perfectly appropriate label for our efforts in healthcare at the moment.

by Nick Jacobs

A few years back while listening to a presentation from Dr. Leland Kaiser, my interest was peaked when he said, "If you are not doing genomics at your hospital, you are already behind the curve." In a recent H&HN magazine article (www.hhnmag.com) by Haydn Bush entitled "Practical Genomics," the author carefully outlines the current state of the science. He quotes Lyle Berkowitz, M.D., director of clinical information systems at Northwestern Memorial Healthcare who says, "In the near future . . .physicians will be able to integrate genomic maps, or complete, individual accounts of a person's 6 billion-piece DNA code into care."

At Windber Medical Center we have been working for six years with our partners at the Windber Research Institute and Walter Reed Army Medical Center to do just that, translational medicine. We believe that the best way to rapidly improve individual patient care, outcomes, and quality of life is by translating molecular research, driven by clinical questions, into new standards of patient care. Our primary focus is improving patient care and the quality of life for the patient and their family by rapidly translating molecular and clinical research into action.

Sound good? It will be. As the article goes on to explain, "If better genetic testing for heart disease emerges, patients with increased genetic risks could conceivably undergo more regular CT scans to check on artery blockage, while also improving their diets." We have been doing this for the past five years.

The idea is for the physician to work with the patient to start a lifelong treatment of the identified risk factors. This treatment includes stress management, diet, exercise and group support. As the article states, " . . . the physician is retooled into a lifelong coach or partner to go through your entire risk report, almost as a financial adviser would manage a portfolio."

Also as pointed out by the article, let's look at the details of why we're not there just yet. First, there aren't enough genetic counselors nationwide to achieve this goal quickly. Second, most hospital information systems have no capacity to handle genomic data. Third, the fears of most patients concerning the use of genetic data to keep them from buying insurance or worse yet, from getting a job are real and definite.

Finally, there is the question of whether the patient would embrace the steps necessary to alter the potential progression of disease. In the book Change or Die the author, Alan Deutschman, discusses the reality that when cardiologists tell their patients with heart disease that they have to "change or die," nine out of ten fail to switch to healthier lifestyles. It appears as if 90% of us would knowingly select death rather than change.

So, as we push forward with our efforts to promote behavioral change through the use of integrative health through programs like the Dr. Dean Ornish Coronary Artery Disease Program, and as we work toward making translational medicine a reality through the fusing of knowledge provided by M.D's and PhD's in our labs and hospital, we work and wait for the rest of the world to understand that the future is here and the future is now.

"If you are not going genomics at your hospital, you are already behind the curve."

by Jeff McKune

If you are looking at developing a new service line or you just want to have a better understanding of business patterns that impact your hospital, you may have some questions. What are the most prevalent DRGs in our market area? What percentage of patients in our market area are coming to our hospital? If they are not coming to our hospital, where are they going? Are we holding our own on surgeries? Are we capturing our share of cardiovascular business?

I did a quick survey of state hospital associations across the country, and it looks like most, if not all, have some means of collecting and providing admissions and utilization data for hospitals in that state. Some associations make the data available on the web, while others may provide it on CD or provide summary reports of various kinds. In Missouri, an MHA member hospital can purchase this data on CD for under a thousand dollars. It is interesting how much you can learn from data like this when you have a quiet afternoon, perhaps during some down time during business travel. In fact, each of the questions above can often be answered without a lot of effort.

Microsoft Excel has a powerful feature call pivot tables. Pivot tables allow you to easily summarize and digest large amounts of data, viewing it in different ways to answer relevant business questions. Using pivot tables with statewide hospital data can provide some valuable, and often hidden, insights. There is no programming involved, and a basic pivot table takes just a few clicks and a couple of drag-and-drops to complete. There are three steps: Determine what data you are going to use, run the Pivot Table Wizard, and drag-and-drop your row and column definitions into place.

Your data can be a list of data in an Excel worksheet, a Microsoft Access database, or some larger external database. You will need to know a little about the data you are wanting to study. For example, if you want to look at inpatient admissions you will need to make sure that the data source has that kind of data in it. The Pivot Table Wizard is found under the Data menu in Excel. It will walk you through selecting your data source and determining where you want to put your new pivot table. You will probably want to put it in a new worksheet. Finally, drag-and-drop the data fields you want to study onto your pivot table.

Do you want to understand the relationship between specific hospitals and counties where patients live? From your field list drag "Hospital Name" (or whatever the data field name is) to the left of your pivot table. Boom! Excel quickly lists all of the hospitals along the left of your pivot table. Similarly, drag "County" to the top of your pivot table. Excel will list the counties across the top of the table. Drag "Admission Date" (again an example name) to the Data area of the pivot table, and Excel will provide a count of all admissions by county for every hospital. Granted, this may be a large pivot table, but drop-down lists are provide for you to select just the hospitals and counties in which you are interested. If you want to look at DRGs or physicians, drag "County" off the pivot table and back to the list of data fields, and then drag "DRG" or "Physician" to the top of your pivot table.

Yes, there are a lot of benchmarking and data analysis services available, but it is amazing what you can discover on your own using pivot tables. If you would like some more guidance, Google "building an Excel pivot table" and you will get more than 400,000 hits. One of the links is a video that shows you how to build a pivot table in Excel 2007. Or, post a question here or email me, and I will be happy to help. If you have used pivot tables in an interesting way, be sure to share it with the rest of us!

by Christopher Cornue

Literature suggests that the “proper” Service Line model consists of all operational and other entities reporting up into a Service Line Director or Vice President. So, for example, in the Cardiovascular Service Line, the Vascular Lab, Catheterization Lab, Surgery Components, etc. would report into the Cardiovascular Service Line Director and it would be his/her responsibility to oversee the functions contained within this Service Line (e.g., physician recruiting, establishment of quality & operational metrics, operational oversight of these areas, FTE oversight, capital acquisition oversight, etc.).

But, what do you do when you are in a financially strapped institution? Furthermore, what do you do when you are in an organization that is slow to move away from the “silo” mentality toward a “matrix” one, as the previously mentioned “Proper” model would support? I have spent time in such an environment, which is moving in a thoughtful & deliberate manner from the “silo” model to the integrated “matrix” model. To support this direction, and address the immediate needs around Service Lines, I have created a structure that provides administrative support across the silos, and partners that with strong clinical (mostly RN) oversight in each of the key Service Lines in which we are concentrating. This is one approach, which obviously has pro’s and con’s associated with it. In the “pro” column – one can align individuals in an interdisciplinary manner; rally people to support a focus on a specific service line; integrate quality, financial, growth and satisfaction metrics to support the service; etc. Among those items in the “con” column – there is a lack of direct responsibility over all the components within a service line; control is more dispersed among several individuals; not all “key players” are aligned and “bought into” the efforts of the service line; and fiscal and capital priorities are more difficult to direct or influence. There are other models out there … if your organization is unable to adapt the “ideal” model, what has worked for you? Furthermore, has the implementation of the “ideal” model worked?

Regardless of which model to use … a focus on 2-3 key service lines, supported by the full organization, is probably all that should be attempted in a given period (e.g., fiscal year). A focus on more than 2-3 will dilute organizational efforts for fully supported, integrated, and successful service lines. It is clear the service line structure will continue to evolve in response to external (and internal) forces. I guess we all need to buckle up and make sure we’re able to be flexible and adapt the structure that best suits our respective organizations – and make that model successful!

by Jeff McKune

Early in my IT career, I specialized in a particular series of personal computers. One interesting feature of these systems was a self-diagnostic capability that would draw a picture of the internal boards in the computer, highlighting a defective board. It was pretty cool to watch, and I couldn't wait for my first customer demonstration. In the demo, I showed the customer how easy it was to access the boards by removing the one-piece cover. I then loosened one of the boards to simulate a "failure", put the cover back on, and hit the power switch to start the self-diagnosis process. But, nothing happened - the screen remained black. Unfortunately, it was the customer who saw the problem and spoke first: "You might want to check your connections. Looks like the power cord is not plugged in."

It would not take much to get so caught up in the administrative concerns associated with the delivery of healthcare, that we forget what connected us to healthcare in the first place. Sometimes it is a good idea to make sure we "check our connections" to remind us of our purpose.

There are a couple of things that I try to do on a regular basis to keep me connected to my team and more importantly to our patients. We handle many pediatric dental patients each week. Frequently they arrive afraid, wondering about the people in funny looking clothes and what the procedure will be like. I enjoy sitting down with these little ones and reading them a story, or playing a guessing game to take their mind off things. Making a difference to kids means a lot to me, and helping others is one of the reasons I connected with healthcare a few years ago.

I also enjoy dressing out in scrubs and helping my team. Being a former IT guy with no clinical training beyond my BLS, I cannot provide direct patient care. But I can help my team clean and make beds between patients, wheel a patient outside to their waiting family, or just help the housekeeper empty the trash. I have found that this powerfully connects me to my team like nothing else.

What do you do to stay connected to your purpose and direction in healthcare? I would be interested in hearing how you "check your connections."

by Jeff McKune

In my former life in IT, I worked on a number of biotech research projects. The company organized resources around the different portions of their biotech pipeline. For each segment of the pipeline, a user steering committee was responsible for overseeing the systems and projects that affected that segment.

These committees were comprised of key stakeholders of systems at different geographical locations, project managers, and IT representatives. Even though these were IT systems, the end users had ownership, and it showed in the ratio of users to IT staff on the committees - usually three to one.

The steering committee responsibilities were fairly comprehensive. They recommended changes to systems based on their changing business needs. They reviewed and approved all changes, including those proposed by IT subgroups such as the database team or the networking team. In short, to a great extent they controlled their own destiny with regards to their operational systems.

When I joined PCRMC early in 2006, I was pleased to see the hospital beginning to use this same structure. A "user" steering committee had been organized around the management of the complexities of the revenue cycle. The committee is comprised of several department directors, as well as representatives from coding, finance, and compliance. Having the stakeholders all in one room at one time smoothes the coordination and discussion around issues that impact each of them, and it has led to significant improvements in revenue cycle efficiency.

In what other areas could steering committees be deployed in hospitals? Would it make sense to have an admissions steering committee that managed that portion of the hospital "pipeline"? In this case, the "users" would be patients - more specifically, non-hospital representatives of our patient community. What about a nursing care steering committee, or a discharge management steering committee, each with a higher ratio of patient representatives than hospital staff? Without a doubt we would gain new insights from those we serve, and the effort would bring more meaning to patient-centric care.

Perhaps your hospital is already using steering committees in this way. If so, please share your experiences with the rest of us.

by Jeff McKune

It is interesting to visit with those at other hospitals and see commonalities between institutions. One of the first of these commonalities that I noticed was the five pillars. Sometimes the pillars are expressed as part of an organization's values, and other times they serve as a means of categorizing strategic plans. Perhaps your hospital has these same pillars, or something similar: People, Service, Growth, Finance, and Quality. Each time I have heard of these pillars, the "People" pillar is listed first, and often someone will say something like "Our People pillar is first, because we put our people first."

A quick glance at an income statement will certainly confirm that people costs - salaries and benefits - typically comprise 55 to 60 percent of a hospital's operational expenses. But do those expenses really count as investments in those all important human resources that make healthcare work? Fundamentally, healthcare, at least in the context of a hospital, is delivered by people. I won't downplay the importance of facility expansions and technology purchases that keep a hospital in the forefront of quality care. But let's remember that it is not the facilities or the technology that are actually delivering the care - it is our people.

We can look back at our institutions and remember a timeline of growth. It often goes something like this: "We added our East Addition in 1990 at a cost of $20M, increasing our capacity by 50 beds. In 2000 we added two 16-slice CT systems to our imaging department at a cost of $3M. Our new Cardiology Department has allowed us to provide new services to our community at a cost of $25M."

These are all good things, but when was the last time you heard a healthcare leader say "In 2002 we recognized a need to improve staff retention and maximize the productivity of our human resources, and we invested $3M in our new leadership development program. Seeing significant improvements in several areas, including employee satisfaction and patient satisfaction, we continued our investment in our people in 2005 by establishing an in-house university, improved tuition reimbursement for academic education and professional certifications, and mandatory annual HR training for all leaders at the director level and up - all at an initial cost of $7M with annual operational expenses of $2.5M. In addition, all of our senior staff are actively involved in our leadership development efforts, participating both as students and instructors on a regular basis."

There are ample research studies to demonstrate the benefits of this kind of HR focus in an organization. Would it make a difference in our hospitals if we really took that first pillar seriously?

by Nick Jacobs

As a leader, your days are filled with problem solving tasks. Every day your cohorts present you with their problems, and they look to you for the solutions. There have been numerous books about management that teach us to deflect those invitations to suffer with them by refusing to accept their monkeys on your back. The 4-Hour Work Week, by, Timothy Ferriss, boldly proclaims, “Escape 9-5, live anywhere, and join the new rich.” The book tells you how Tim went from $40,000 a year and 80 hrs. per week to $40,000 per month and 4 hours per week. He suggests that you find out which customers generate the most money for your company and only recruit customers like that. Easy enough. Then he suggests that you should find out which customers waste most of your time and get rid of them, however, you know for sure that Tim's not talking about hospital administration.

Having spent several college summers on the railroad in the yard master's office, it became obvious to me that the problem solving techniques established by that particular industry were primarily directed toward triage. The proposition went something like this: listen very carefully in an engaging and somewhat sympathetic manner, when possible take whatever steps necessary to help move or remove barriers that had become the road blocks to the resolution of the problem being presented, and encourage the presenter to continue to move forward to solve the problem by triaging it to the appropriate levels within the organization. When this method doesn't work, it reminds me of a picture in my office of fifteen well dressed professionals pointing at each other. It should have been entitled, "Spread the Blame."

Actually, as an act of impatience, frustration or simply boredom, I often times come up with the solution on my own, immediate, timely and definitive, and most often in a vacuum. Usually when a unilateral decision comes from me, the response is phenomenal. It starts out with a smile and a nod of agreement from the visiting party, a commitment to move forward and a sincere thank-you. Then the push back begins. Clearly, in this type of decision making situation, there is a lack of endorsement and the outward resistance intensifies like a tropical storm, ensuring damage or at the very least failure.

On the other hand, when the problem is triaged back to those presenting it in a constructive manner that offers support but not a complete solution, the results are phenomenal as well. It's about a combination of empowerment and encouragement that directs them toward embracing the scientific method. We talk through the observation phase, help them in the creation of potential hypothesis that is consistent with what has been observed, try to make predictions from that hypothesis, encourage them to modify it in the light of their results, and finally, remind them to repeat steps three and four until there are no discrepancies between theory and end result.

The amazing thing about even this method is that, if we apply it very purely, we will probably fail miserably because, for the most part, we are working with moving targets that are enveloped in emotions, politics, unpredictable outcomes and yet to be defined options, but, having said that, it is the basic premise for engaging our personal hard drives in a way that will move/triage the problem forward toward solution.

Bottom line? As I re-read this post, it is obvious at least to me that I have no real answer, no definitive solution, no optimal choice, but that some order, some persistence, some method is better than just forcing your solutions down everyone's throat, and it will help to keep at least a few more monkeys off your back.

by Nick Jacobs

As a 40ish rookie in health care management, the common conversation around the board table in the late 80's was a chorus of woeful sobs directed toward the good ole days of cost based reimbursement. That was a time when hospital CEO's could pretty much count on getting checks equal to their costs to pay for services rendered. In fact, a book entitled, The Hospital That Ate Chicago, was a good example of how hospitals could actually make a profit from the government from building projects.

Ah, to have been an Executive Director or Superintendent in that era. If you didn't golf several days a week, you were not considered competent enough to be an administrator. One of my early mentors used to say, "Son, If you want to survive and thrive in this field, you are obligated to learn to golf and play a good game of bridge."

Needless to say, I sometimes drive over a bridge, on my way back from Washington D.C.this week, I actually filled up at a Gulf station?

Today, we are seeing the beginning of an end of another era. As the tide begins to sweep the post WWII generation closer to retirement, it is clear that the System is about to change. It is about to change or die, and, once again, the ole timers will wish for better days when they actually got reimbursements that, for at least a small amount of time, would allow them to pay the bills and make a little profit for the organization.

One problem with writing a blog like this is that it's easy to criticize, easy to point out, and easy to suggest, but it will take an engaged group of hard working, deep thinking leaders to set the path for the future, a path that pays attention to the infrastructure, that will work to ensure the bridges don't collapse, the discoveries aren't curtailed, and the future becomes all that it can be. That path should be inclusive, comprehensive and for the good of mankind. Hopefully, we can help make the directional signs for that journey because, our future depends on it.

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.

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?

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 Nick Jacobs

Is it possible that we do not know everything there is to know about healing and health? In 1974 my neighbor asked me to help him with a piece of concrete that had been dislocated by the winter's frosts. We both bent over, lifted the 250 lb. slab, and his instructions were to drop it into place on the count of three. Well, at the count of three I glanced and saw his foot still firmly planted under the concrete. He had planned to pull it out. I didn't realize that, and held onto the concrete. I then could not stand up straight, and was bent like the letter L. Clearly, something had happened to my young year old back.

My neighbor carefully placed me into the front seat of his car, drove me straight to the emergency room, and the treatment began. First an x-ray where the physician asked if I had ever been a professional football player. When I had stopped laughing, I wiped the tears away from my eyes, and said, "Nope, but thanks." We can't miss the nuance of what occurred next. Muscle relaxants and the threat of what has been described as traction resulted in nothing, absolutely nothing. I couldn't walk, couldn't sit, couldn't stand, and felt as if a long hot knife was stuck in my back.

Two weeks later another friend saw me struggling to walk, put me in his car and drove me to a physician's office. This was a doctor that I was not familiar with, but he was pleasant, took my blood pressure, suggested that I have a Martini every night before dinner, looked at my feet and said, "Oh, this is simple, your sacro is out." He pulled on my right foot and said, "Okay, we're done here." I stood up and felt fine.

He was a DO, a doctor of osteopathic medicine who had been trained in manipulation. Although I was a teacher at the time, it seemed perfectly clear to me that medical professionals with varying views on treatments don't necessarily talk much.

In 1997 when I became the CEO of a hospital, my first decision was to become a Planetree Hospital and to create a menu of options for our patients. Because I am not clinical or medical, nothing was particularly sacred to me. My only concern was that our patients got better, and that we didn't fill our halls with quacks and unqualified tricksters.

Consequently, we introduced many aspects of complementary and alternative medicine, but the difference at our facility was that we used only medical professionals to deliver those modalities. We opened our patient rooms to accommodate family members 24hrs. a day, seven days a week. We placed double beds in our OB suites. We employed musicians, aroma and massage therapists. Our therapy dogs are there for the asking.

The concept is to provide a healing environment. The concept is to allow certified accupuncturists, manipulation trained DO's, PT's, OT's and others to provide those treatments chosen by our patients. The United States citizens are spending billions of dollar each year on these treatments, and many times they are administered by uncertified individuals.

It is my desire to give our patient partners choices. If they get better because their loved one is permitted to stay with them around the clock, or if a dog's love moves them back to health, it doesn't really matter to me. Just so they get better.

We use a very strenuous allied health professional credentialing process to approve these clinical specialists. We take medicine very seriously, and we pay out more than a million dollars each year on general liability and malpractice insurance but have paid out, on average, less than $20,000 a year for all claims in these areas because, if you treat people as partners, not patients, if you treat them with kindness and love, and if you don't make them leave their diginty at the door, they will be your partner. If you create a healing environment void of negative energy, mean employees and limited access to their loved ones, they will heal.

As a consumer, does it make you wonder why we all aren't embracing this philosophy?

by F. Nicholas Jacobs

The rise and fall of the Cardiac surgeon as the star around which the medical universe rotates has been an interesting phenomenon to observe. In fact, three years ago when I was approached by a physician placement agency to hire a newly graduated, Ivy League trained, cardio thoracic surgeon to fill a vascular surgery position at our acute care hospital, all of my "spidey senses" kicked into action.

Why would a multi-million dollar man, a top trained, cardiac surgeon want to come to a primary care hospital for a vascular surgery assignment? It was at that very instant that I dove into heart surgery research. As the age and acuity level of our patients had continued to climb almost exponentially, heart surgeries had dropped in our area from approximately 600 to 450 to 350 a year during the previous ten year period. Then I saw the national figures that revealed a decline from a high in 1997 of 350,000 to about 250,000 coronary artery bypass surgeries in 2004.

As the recipient of six coated stents over the same ten year period, it had always been clear to me that the new, multi-million dollar men were the invasive cardiologists. Having read the latest reports on coated stents, we Boomers with six packs in our chests are nervously taking our aspirin and Plavix and waiting for that potentially fatal clot to materialize during our next stress filled situation?

I personally was a member of that very small club of 1% that had an injury to my artery ensue during my first procedure and a near fatal misfortune take place after my last invasive procedure. So much for the 1% rule. For me it’s been a 66% complication rate, two out of three procedures, but my physicians had thousands of otherwise successful procedures to their credit before and after me.

One autumn morning I overheard a conversation between a local cardiac surgeon and an Emergency Room physician. The surgeon said, "Yeah, he has 15 stents and finally wants a bypass. The problem is, it's going to take a giraffe's leg vein to bypass all of that metal." That would be another potential complication from the “full metal jacket” rule of stent implantation.

So, as it turned out, our cardiac surgeon was looking for a medically under served area where he could work to get his Green card and eventually his American citizenship, but, in general, graduating residents are having a challenge just finding the job they want. In fact, according to a recent article in USA Today, 12% of the finishing 88 cardio thoracic residents received no job offers in 2004, and that was before the bottom nearly dropped out of the open heart surgery business.

So, what do you call a heart surgeon who finishes in the last quadrant of his program? You still call him Doctor, but, to find work, he may have to specialize in lung or heart valve surgeries instead of bypass.

Maybe someday we will discover, like Dr. Dean Ornish has professed, that diet, exercise, group support and stress management will completely reverse heart disease, or maybe, like the 1973 Woody Allen movie, "Sleeper," proclaimed, it will be determined that chocolate cake, deep fried foods and smoking will be the cure. Either way, changes continue to be a reality in the world of heart disease treatment, and, until we stop lounging on our couches, over eating inappropriate food, working too many hours a day, and not practicing regular stress management program; we will continue to add to those negative statistics.

by Christopher Cornue

As we organize services across our organizations, there are multiple strategies we use to align the various individuals affecting a specific disease-state or service. These groups and services are often referred to as Service Lines, or, as I am reluctant to actually put into writing, Product Lines. Since I am so hesitant to actually use this term, I guess I need to explain further. In the 70s and 80s, I believe the general terminology used for this structure was Product Line; however, the meaning was very different. Although I wasn’t involved in healthcare until the mid-90s, my understanding was that Product Lines focused more on marketing and growth efforts, not on the broad scope of current Service Lines. I’ve always had a hard time labeling these efforts under the scope of “Product Lines” … as the connotation is that we’re taking care of widgets, not patients.

Well, now that I’ve had my say about Product Lines … let’s talk about Service Lines and why I think it does matter to call them such. With the label of “Service Line,” we can best incorporate the broad scope of a specialty, service or line. For example, when I’ve been creating service lines at my current hospital, we make them interdisciplinary with individuals involved in a patient’s care from presentation through discharge (as much as we can). Additionally, we focus on four “foundations” that drive our efforts & services: Quality, Growth/Outreach, Fiscal Responsibility/Accountability and Satisfaction (Patient & Provider). When we align these efforts (re: services) around a specific Service Line, we have the best opportunity to have quality outcomes (that are measurable and trending), control our expenses, enhance our revenue and leverage these successes to grow our volume responsibly. E. Preston Gee, author of Service Line Success, states that Service Lines allow “an organization to better understand the dynamics at play within the subcategories of its business.” A perfect example of this is the aligning of competing forces in a Cardiovascular Service Line (no small task … but very rewarding when it works!). Furthermore, Gee suggests that Service Lines force “the organization to institute a discipline of measurement and accountability” – which I believe is key in today’s environment. I could talk ad nauseam about this topic (trust me, ask anyone who works with me!!), and may discuss further in a future posting – so beware! So, that’s why I prefer the “Service Line” moniker and for me, yes it does matter. What do you think and what successes have you had?

by Nick Jacobs

These blogs are supposed to help us move toward a better health system, a more perfect hospital. Well, a few weeks ago, I ran across a corporation that is as close to perfect as mankind is capable of delivering. It's a corporation that has been formed as a federation of like hospitals to help them survive and thrive.

What's the big deal? Well, this corporation isn't dominated by a large hospital. In fact the budget sizes range from $30 to 120 M a year. There are twelve of them, and their combined gross annual budgets hang well over $1B. They each pay monthly dues until enough money has been generated to operate the corporation, and then they don't take any more money; usually that means no dues in April, May or June.

They work together in the obvious areas like purchasing, health insurance for their employees and liability insurance. What they do that is not normal is provide their docs to each other for peer review of difficult cases. They are positioned to assist each other with virtual, telemedicine pharmacists, data repositories, a blood bank, and dozens of other creative initiatives that will virtually save each participant hundreds of thousands of dollars each year.

The beauty of this virtual organization is that it does not require the individual hospitals to give up their boards, their presidents, their autonomy, their strategic planning, their connectivity to their cities, towns and villages, their pride or their place in history.

Is it possible that all of the small and medium sized hospitals in the United States could find eleven friends to hang out with, to work together, and to help support each other? We've just applied to be hospital number 13 in this gaggle, and it is our hope and prayer that it will enable us to miss not one beat as we move into the next chapter of our history. There is absolutely a place for independent, well run, high touch hospitals, and there is a place for communities to stay plugged in to their hospital.

Find some friends and emulate this federated model of non strategic partners as they pull together to fend off the predators. Not a new idea, but a near perfect alternative model.

by Nick Jacobs

Will the next ten years provide the answers required to make our health system functional into the future? If we give serious attention to the tangible challenges presently at play, it becomes very apparent that our structure will not work without a unified, bipartisan approach to the issues in consideration. For example, the flooding of our emergency rooms with marginated patients, lack of health insurance coverage for 47,000,000 American citizens; the looming failure of Medicare; the outrageous demands of an incident by incident system aimed at intervention at a time of crises rather than a lifetime of well articulated preventative health related personal decisions.

It is well documented that, if we can embrace even a limited exercise regime, discontinue the consumption of saturated and Trans fats, and stop smoking, our country will experience a surge in the length of life.

If we, as a country, could conclude that our priorities should be directed more completely toward our own citizens’ well-being, we could end up far ahead of the game. The United States has just surpassed all other industrialized nations in the separation between rich and poor. We have now reached a ratio of rich to poor that is 500 times more pronounced than in Japan.

When asking these hard questions, it is important to realize that this is not liberal vs. conservative; it is not blue vs. red; or D vs R; it is about human beings caring about other human beings. It is about the irrefutable rights of all Americans. It is about embracing our fellow man and providing a net for those of us who are not as fortunate as others. It is about getting our collective act together as a country to put together a health policy for our country. Finally, it is about prioritizing our values in a mature, caring way.

Sorry if this ended up being a rant. Maybe that’s why I have been in nonprofit management my entire life?

by Nick Jacobs

As a first time hospital president, it was clear to me that I could not tolerate a business as usual environment. My background had included visits to plenty of hospitals that allowed me to see blood on the walls in the patient’s rooms, filthy corners, stairwells, and waiting areas with waste baskets running over, cigarette butts at the entrance ways and infection rates raging at around 10% or above. For the most part, it was not because of a lack of pride. It was because of accepted standards, history, and tradition. It was about mediocrity. It was about doing it the way it had always been done.

When you enter many hospitals, you feel fortunate if you are overwhelmed by the smells of disinfectants. At least it smells as if someone is trying to clean the place. You feel lucky if you don’t see fluids on the curtains or walls, and, if you don’t get an infection.

What do you look for in clean hospital? What questions can you ask? Well, here’s the drill. There are several very important extra steps that can take place. The first thing in the morning, the public bathrooms are thoroughly cleaned. This gives the patients time to eat breakfast before the housekeeping staff begins to clean their rooms. Having said this, however, since they are the focus of the entire hospital, the patient rooms and operating rooms are the priority for the staff.

The patient rooms are done every single day; the window, windowsills, floors, tables, telephones, telephone cords, restrooms, end tables and bed trays are sanitized. The staff uses disposable wipes for each room so that the tools used to wipe up and clean up one patient room are used only once. This ensures that each room is getting it’s own cleaning equipment. It’s more expensive, but much safer for the patients this way.

The water in the staff’s cleaning bucket is changed for every room. To ensure cleanliness and to protect from infection, any blood or bathroom accidents are handled as soon as the staff is made aware of it. If any rooms need any type of maintenance or work performed, the housekeeping staff will contact the maintenance department immediately to get the problem fixed.

Staff is always on the lookout for exposed needles in patient areas to ensure everyone’s safety. They also check out the floors for paperclips because these little organizational tools can cause slips and falls on the floor. Further, they are very careful that any hazardous waste material is disposed of properly every time to ensure safety from infection.

Most importantly, when possible, they also have an important roll in taking care of the patients themselves. If they are doing their cleaning, and the patient needs a pillow, wants propped up in bed, needs a drink, or whatever non-medical request they might have, the housekeeping staff will do all that they can to help.

If it’s a medical task; they will find the person who can help the patient. Some of these requests may seem beyond the realm of a typical job duty, but if the request is valid, they will go far beyond the norm. For example, if the patient has spilled some food or drink on their personal items, the housekeepers will even wash those items for the patient. Further, they will then return it to them pressed and cleaned. (Obviously, to avoid spread of infection, any blood borne pathogens are not included in this extra service.)

by Tony Chen

Last week, I posted an entry on the most innovative hospital in the country. Today let's see what we can learn from the most innovative retailer in the world - do you know who it is? What store makes more revenue per square foot than Tiffany & Co, Best Buy, Neuman Marcus, and Saks? You might not intuitively think that the masters of product design are also masters of retail:

Apple is the best retailer in America, making more than $4,000 of annual sales per square foot in 2006. (Tiffany's is 2nd, at a mere $2,666 per sq ft) Read this great article in Fortune on how Apple came to make the controversial decision to go into retail and how they nailed it.

One the most important things Apple did was to build a store in their warehouse for testing. In other words, they approach store concept/design the same way they approach their product design. It has to be human-centric. Among many other insights, here were a few key take-aways for me:

- They designed the store around customer needs, not around product functionality. Their first "test-store-in-a-warehouse" was laid out by product category (i.e. how their company is structured internally). Immediately they knew it wasn't going work - people don't care about the actual machine/hardware, they just care about what they can do with it.
- They learned one of their best insights from outside of retail - hotels. When asked to name the "best service experience", 16 of 18 focus group participants named hotels. So, to inject that Four Seasons flavor of friendliness/service, they added the "Genius Bar" - "let's put a bar in our stores. But instead of dispensing alcohol, we dispense advice."
- They focused only on 20 products, and cut all the other clutter. Computers are complex enough - they keep it visually simple and attractive.
- They paid a premium for the best locations. And by best locations, it is mainly accessibility and visibility. They realized most people won't invest 20 minutes to drop by an Apple store, but they may invest 20 footsteps. Once they're in, the store, the service, and products are pretty compelling.

We all know that hospitals of the future will be drastically more retail than it is now. So, what questions should we be asking as we put together a hospital retail strategy? The main take-away for me is the laser-sharp focus on the consumer. Every little detail about how the store is designed is to add value to the consumer - learning about new products, having an "aha!" moment, getting some small bug fixed. Yes, it costs more to design it, the build it, and to operate it. But their results speak for themselves - their closest competitor has to increase revenue per square foot by 50% to match them.

In some sense, hospitals have been following this advice, except that we've treated the physicians as the end-user, not the patient.

And rightfully so, as thus far, it's really the physician who has more choice and can shop around. Nonetheless, Apple has shown us that everyday consumers notice when things are designed just for them - they vote with feet and will eventually rule (or at least largely influence) the healthcare landscape.

by Nick Jacobs

In an October 1, 2005 article in the Harvard Business Review, "The Passive Aggressive Organization" by Gary L. Neilson, Bruce Pasternack and Karen E Van Nuys, we learn about the characteristics of, you guessed it, passive aggressive organizations. My immediate response to the article was something like this, "Wow, this sounds exactly like a lot of the places where I have worked." (And some of the places where I work now.) For your sake, go online and buy it for $6 because what you'll be reading here is my version of a summary that surely won't do it justice.

When you observe a few of these symptoms in your organization, you surely will know where you are working:

7 Traits of a Highly Passive-Aggressive Organization

1. Senior management leaves unclear lines as to where accountability lies.

2. Employees put forth only enough effort to look compliant.

3. Managers are absolved for almost anything they do.

4. Employees wait interminably for a "project go ahead," and then their actions are accompanied by a sea of second guessing.

5. To learn, to share and to achieve are actions that are not encouraged.

6. There is either too much or too little control at the top.

7. Employees can't understand why their promising projects can't get traction.

The article goes on to say that the lack of confrontation is only a disguise for intransigence. In many companies a failure to align incentives and goals is generally seen as a primary contributor to this culture. It further states that the observer will frequently see agreement without co-operation which leads to the impression of compliance.

It's also clear that leadership is POOR at completing employee evaluations, and, in many companies, the failure to align incentives with goals is rampant.

So, you might ask, how can this culture be fixed?

Leadership must identify, verify and admit that they have a problem, and then work in a dedicated fashion to address each of the symptoms delineated above.

The article recommends bringing in an outsider, the new sheriff in town. It also suggests creating a team of seven up and comers who are assigned the seven most important tasks needed to be accomplished during a turn around. This team must be empowered by the senior leadership members, and be permitted to fly.

It's not easy. It's not necessarily fast, and if it's not addressed, it will take the organization to the brink of failure. So, good luck.

by Nick Jacobs

We are living in a health care system that embraces episodic care, that does not reward or reimburse prevention, and that is currently on the precipice. It was the Treaty of Descartes that originally insisted upon the separation of the mind and spirit from the body in our hospitals.

As we observe the near turmoil that currently represents our health care system, we find ourselves attempting to hold onto beliefs and values that are no longer valid. This lack of validation causes concern and anger among many. Instead of just being afraid of these changes, many of us have become desperate victims as we attempt to project our past into a new, unknown future.

Although culture absolutely hates to apologize, science continues to unintentionally eat away at our values, beliefs and civilizing touch stones. Scientific truth is only true until the next discovery. Medical interventions are only valid until a more sophisticated more accurate intervention is developed. The world is FLAT.

As leaders we must create a vision for a better future, and then be able to tell persuasive stories about that vision. As leaders we must produce ideas that fit reality for the future, and those ideas must emanate from deeply engrained beliefs. It is also imperative that we truly espouse those beliefs through our daily lives, to have the integrity of commitment to responsibility, compassion and guidance. Finally, we must develop the skills to sort between what is good and what is not and then value what needs to be respected.

As we plot a course through these unknown areas and move toward a better future, let these thoughts be our starting point: In health care we must embrace the fact that we are in a kindness industry and that we should be committed to connections and to love.

by Tony Chen

Now I may be a little biased (I've met 2 of the 3 authors of this article and really respect/like them), but this article in Healthcare Design Magazine is simply the most compelling article I've read on the future of hospital facilities.

A few key take-aways for me:

- We all already know that outpatient care will grow much faster than inpatient care. Certain outpatient services will grow REALLY fast. PET/CT volume will increase 120% in 10 years! A ton of surgical procedures as well as oncology will grow dramatically.

- The 2-day hospital stay will become a mainstay. 2-day discharges will almost triple in 10 years. Should hospitals set up staffing / flow / dedicated units solely for the 2-day patient?

- Healthcare is notoriously complex and extraordinarily interlinked. Nonetheless, some services are completely unrelated. Thus, care facilities must be strategically decentralized and strategically adjacent. This is a gross oversimplication, but it's like the advice you hear about your desk & productivity. Use it everyday? Keep it within arms length. Use it monthly? Put it in a file. Use the same group of things together once a month? Put it all in a box in your drawer.

- Hospitals are typically set up by service lines. Since most service lines are dominated by inpatient care, outpatient care / strategy never gets enough attention. At best, outpatient care developments are uncoordinated. Why not put someone in charge of all OP services for all service lines (like this hospital)?

- Too many hospitals are designing their facilities with growth-limiting oversight and don't even know it. When I read this article, I couldn't help but think about Blokus (the only board game I play now - it's a game about fighting for space). Like many strategy games, every decision you make to put down a piece limits you and/or opens doors for future expansion.

- This article would make my wife really happy. She's been "an inspiration" for me to plan better.

- As they say, begin with the end in mind. The end is made much more clear in this article through all the data, so definitely read up!

Combine this strategic facilities intelligence with the Planetree philosophy, and you start getting at the ideal hospital of the future.

guest post by Amy Tenderich of diabetesmine

Tony wrote to me recently asking for some insights on what hospitals can possibly do to better treat/ encourage /help patients with diabetes. Thank you for the opportunity to air this issue, as hospital care for diabetics is (believe it or not) notoriously bad!

The core problem is terrible glucose control while hospitalized, whether the patient is conscious or not. The conscious ones are often miffed because they’re forced to follow some set protocol rather than being allowed to manage their diabetes themselves, which generally they do best. The unconscious patients often either go unmonitored, or are allowed to run unacceptably high.

At a recent seminar on diabetes patient gripes, one woman told me: “When I was hospitalized for surgery, the doctors insisted that I remove my insulin pump! Then they gave an order that I should receive 2 units of insulin for every 40pts blood glucose over 180 – but I’m extremely insulin-sensitive. One nurse was ready to inject me right after dinner! Why can’t they let me manage my diabetes? I know what I'm doing!”

Meanwhile, a nurse who comments on my blog regularly reports that the surgeons she works with like to say, “You can never have too much sex or blood glucose.” I guess keeping the patients extra-high avoids any possible risk of hypoglycemia.

Yikes!

“A blood glucose >200 mg/dL in the hospital patient causes increased morbidity and mortality,“ Dr. Bruce Bode told DCU editors last year. “In the 21st century, blood glucose >200 mg/dL in the hospital will be considered malpractice.”

What exactly can be done to remedy this? I queried a few of my expert contacts, including Kelly Close of Close Concerns and Dr. Steven Edelman of TCOYD, to compile some points that should offer a good springboard for improvement:

* Check the BG (blood glucose) of everyone who checks in, not just those who are already diagnosed, as many people are diagnosed with diabetes while in the hospital being treated for something else

* Institute a policy to allowing patients with both type 1 and type 2 on insulin to remain in control of their own insulin adjustments. Hospital rules will call for some type of protocol, but it should be one where a doctor approves the suggestions made by the patients themselves (they obviously know their diabetes better than anyone else)

* If the patient is on an insulin pump, speak to them about it if they are able to speak. Let them help decide whether removing the pump for certain treatments is necessary and/or beneficial

* Be respectful of, but not terrified of, hypoglycemia. Again, there are numerous horror stories about the very high blood glucose rates that hospital patients run. Up until a couple of years ago, the guidelines of the American Stroke Association actually recommended treating only blood glucose over 200 mg/dL (implying that any level up to that is OK!)

* Promote tight glycemic control standards. Tools like new continuous glucose monitors and software programs for intravenous insulin dosing should help. (See also the ADA’s Call to Action hammered out by the experts last year)

* Obtain the special certification for quality inpatient diabetes treatment established last year by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the American Diabetes Association (ADA)

* Pay the nurses more so that they stay in their jobs! These individuals provide the real hands-on care and advocacy, and are thus the real leaders on the tight glycemic control front

* Take advantage of that “teachable moment” during hospitalization in which patients who’ve undergone a life-altering experience may be more open and willing to consider learning how to use insulin or otherwise intensify their care.

The way I understand it, there is a boatload of research indicating the importance of tight glycemic control in the ER and the ICU (thought leader here is Dr. Greet van den Berghe) – but less evidence is gathered on the hospital "floors," where the risks seem less treacherous.

One hospital that I’m told gets high marks on tight glycemic control across the board is Providence St. Vincent Medical Center in Oregon, led by Dr. Tony Furnary, who’s referred to as “the father of tight glycemic control.”

Thank you, Father Anthony, for your efforts – ‘cause the hospital can be a terrifying enough place for us patients without having to worry that our glucose control will go haywire. Bottom line is, if the patient is conscious and willing, please let them take diabetes monitoring into their own hands!

* Amy Tenderich is co-author of the new book, Know Your Numbers, Outlive Your Diabetes.

by Nick Jacobs

Okay, so here's the list: The infection rate at our hospital dropped to 1% or below seven years ago and has never risen significantly since then. Even with an acuity rate that hits 1.7 and above periodically, our length of stay hangs in at around 3.4 to 3.5 days per patient. Mortality rates for adjusted acuity is below many peer hospitals. The very unique thing that is going on at our facility is an openness to creating a healing environment that is sometimes against conventional wisdom. It's a philosophy of care.

It's not about too many FTE's for adjusted occupied bed or spending too much money on decorative wood or fountains, live plants or skylights. It's about creating a healing environment that embraces family and friends as visitors 24 hours a day seven days a week. It's about music, aroma, massage, reiki and pet therapy. It's about double beds in the OB department, complimentary access to the work out center for patient families in hospice and OB, bread breaking in the hallways, popcorn in the lobbies and staff members that demonstrate their genuine love for the families and visitors in hallways. It's about dinner buffets in the hallways, live music, beautiful environmental design and live plants from our greenhouse.

This is not brain surgery. It is not overspending or creating the Taj Mahal. It's a philosophy of loving, caring, nurturing and respecting people as fellow human beings and, as leaders, it's about understanding that you can improve your bottom line by improving your commitment to what you know is correct. "Do unto others as you would have others do unto you."

For more on Planetree, see Nick's previous posts:
No one is a number
Now that I'm a hospital CEO, time to pursue my dream
Planetree - touchy feely or just good common sense
What happened in 1974 that makes me so passionate about Planetree
Implementing Planetree
Implementing Planetree II: Demystifying healthcare

By Nick Jacobs

Pierre Abelard:

The beginning of wisdom is found in doubting; by doubting we come to the question, and by seeking we may come upon the truth.

I've come to learn that the truth is where we seek it, and part of the problem with extremely high intelligence can be that it sometimes gets in the way of progress. All of my former valedictorian, senior leaders were so wrapped up in perfection that failure for them was an A-. They were terrified to make the wrong decision, and analysis paralysis was not only the norm, it was an obligation. Don't try new things. Be the 1000th person to do it. Don't ever take a chance. Don't make a decision that could come back to haunt you. Health care's herd mentality to the maximum.

Instead, failure to those of us who "live on the edge" is a way for us to grow and accomplish what we need to accomplish. It is important to realize that every accomplishment is preceded with plenty of failures. The key is to keep focused on the ball. To move it forward and to make sure that you surround yourself with winners.(For a sample of this discussion in the paraphrased words of one of my greatest mentors, Leland Kaiser)

Edward de Bono:

It is better to have enough ideas for some of them to be wrong, than to be always right by having no ideas at all.

by Nick Jacobs

Colonoscopies are no joke, but these comments during the exam were quite humorous.... A physician claimed that the following are actual comments made by his patients (predominately male) while he was performing their colonoscopies:

"Find Amelia Earhart yet?"

"Can you hear me NOW?"

"Are we there yet? Are we there yet? Are we there yet?"

"Any sign of the trapped miners, Chief?"

"Hey! Now I know how a Muppet feels!"

And the best one of all... "Could you write a note for my wife saying that my head is not up there?"

by Nick Jacobs

A few weeks ago, it was my pleasure to have lunch with a 68 year old, retired CEO who had, in fact, seen it all. Let me begin by cautioning you that his suggested management decisions might not fit very well in the hospital setting, but, as you will read, they are just FUN.

Example Number One: A group of PhD's assigned to create specific technology that would change the face of imaging were occupy a beautiful, new building in the middle of a wooded industrial park. Our veteran CEO is called to the task of straightening up what appears to be a hopeless situation, a total lack of productivity.

He enters the conference room filled with superior talent and queries them as to their accomplishments. After about 45 minutes of unsuccessfully attempting to uncover some project that they have brought to fruition, something that is useful, he leaves the room, goes to the master mechanical room and pulls the main circuit breaker. All power is now off in the building. At this point he goes to his office and begins to work with paper and pencil.

Within a few minutes there are several PhD's asking him what they are supposed to do without computers, lights or air conditioning. His reply was, "Whatever you want to do, you're not accomplishing anything here anyway." To which they continued to query him. He explained that, "As long as they weren't coming up with anything that was productive, he couldn't afford to keep the electricity on, and, for all he cared, they should go outside and sit in the grass."

The power was not reinstated until two days later, and it was about ten minutes after that the group revealed some meaningful ideas that resulted in such progress that they eventually landed literally hundreds of millions of dollars worth of contracts.

Example Number Two:

He was called into a company filled with engineers who did not talk to each other. There was a long hallway with engineers on both sides, but, except for an occasional bathroom stop or a nod at the coffee pot, there was no conversation between offices. Our CEO observed that situation for about two days, went to the main server area and had the local e-mail turned off. Almost immediately the engineers emerged from their dens and began to talk to each other. It took him six months, but the discontinuation of the e-mail was the tipping point that allowed progress to begin.

My Inspiration: On Friday I called a group of managers together, handed each of them an envelope with their name typed on the front and a pink piece of paper inside. I asked them to hold the envelope up to the light. One sheepishly responded that, "It looks like a pink slip." To which I replied, "It is." Then I said, "It's a pink slip of blank paper, but consider this a dress rehearsal for next month. If we, as leadership, do not get our act together regarding our perceived productivity, we will all be replaced."

I'll let you know how that one turns out, but it certainly created some serious flow of conversation.

by Nick Jacobs

The book, Change or Die by Alan Deutschman, tells a story of three very different situations that prove that the title can, but rarely does happen. The author quotes the fact that, although we may be faced with the alternative of changing or dying, we are plagued with the reality that only about 10% of us are truly ever able to personally make that change. Mr. Deutschman takes us through three examples of an organization, a leader, and a physician who have helped hundreds of us beat those odds: Heart Patients, Criminals and Workers.

He examines the patients of Dr. Dean Ornish's Coronary Artery Disease Reversal Program (which has been in place at Windber Medical Center since 1999), the criminals who are participating in an effort to rehabilitate themselves under the guiding principles established by Dr. Mimi Silbert at Delancey Street in San Francisco, and the members of the United Auto Workers who were employed at a GMC plant at Fremont that was so hopeless mired in its own controversy that it was closed by GM. It was later re-opened by Toyota as a successful manufacturing plant equipped with the same basic tools and machines and 50% fewer employees, but the vast majority of them were exactly the same union employees who worked in that same failed factory for GM.

It's an interesting journey into human nature, the circle of failure and hopelessness, and the promise of hope that has always been a part of achievement and growth, of success and positive persistence, of debunking old myths and replacing them with empowerment. He embraces the three keys of relate, repeat and re frame to help us make positive changes in our lives.

If, like me, you are a little overweight, have high blood pressure, high cholesterol, a lousy set of genes and are a mouse potato (sit around too much with your computer), you might want to read this book and then, like the journey that I began in 1997 under Dr. Ornish's direction either "Change or DIE."

By Jared Johnson

The latest public hospital data Web site has made it to the Lone Star State, but the jury's still out about just how helpful it will be to consumers. Texas Price Point, sister to Price Point sites in at least 8 other states (IA, NH, NM, OR, UT, VA, WA, WI), is due to go live at the end of February. Most, if not all, are products of those states' hospital associations in an effort to "allow users to view and compare pricing information on common inpatient services."

I was able to take a test drive this week and it felt like I was handed the keys to the car and told to drive wherever my heart pleases. Some call this freedom or empowerment; others might say it's plain intimidating. Price Point includes median hospital charges for over 60 procedures, and they give you turn-by-turn navigation to find the ones you want.

Reaction has been mixed in other states (see Jeff Sturgeon in The Roanoke Times and Heidi Toth in The Provo Daily Herald). The following editorial from the Clinton (IA) Herald on February 1, 2007 is the best assessment I've seen:

In a free market society, it may seem ideal to let patients treat hospitals like a retail store, shopping around for the best price in order to save a buck here and there. However, medical care is much more complicated than that…

…It ought to be clear by now that this isn't the same as knowing how much a gallon of milk costs at Hy-Vee, Jewel and Fareway.

But still, Web site's [sic] like PricePoint are an important step in helping the consumer make educated choices. Health care is something everyone needs and one of the biggest headaches for the state and federal governments. The insurance business is a behemoth that sometimes appears too big for its own good, but it's the only real system we've got and can't be abandoned until a better solution is found.

The topic is confusing, to be sure, but having these conversations and exposing the many factors that boggle the mind are the best way to work toward getting everything cleared up for future generations.

I am rooting for Texas Price Point, and I hope it meets its objectives. My main question is how Joe Consumer will use this information. I can see him deluging the billing office with questions about why his charge is different than what's listed online. It opens more than a can of worms — more like a 50-gallon drum.

Still, the father of Price Point — Wisconsin Hospital Association's Stephen Brenton — pointed out to the House Ways and Means Subcommittee last summer that hospitals are doing their part to make prices available to consumers. That's one reason Price Point doesn't have to be all-inclusive. It is an effectual step toward transparency, not the ultimate answer.

Count me on the bandwagon.

This is the first hospital I know of to use guerrilla marketing tactics.

EDIT: and speaking of firsts, check out the firsts that Paul Levy's been bringing up that are ruffling some competitor CEO feathers. My favorite quote from that globe article: "What a blog?" - Hospital COO.

Guest post by Carolyn Kent

I'm going to venture into contentious territory and address what can be a touchy subject for hospital administrators: the application of lean manufacturing to a hospital setting.

First, a brief review. There are 5 basic principles to Lean (continuous process improvement):
1. Define value from the customer's perspective
2. Identify the value stream
3. Eliminate waste
4. Flow the process
5. Pursue to perfection

Is this management style transferable to a hospital environment? Cynics are quick to squash this idea, citing reasons such as "We don't make cars; we treat patients." (Harvard Business Review: Virginia Mason Medical Center) These individuals support personalized healthcare; after all, every patient is unique and by virtue of being such, deserves distinctive care. (No argument here)

Since, according to the cynics, achieving a lean state in a hospital is impossible due to the obligations to provide personalized care to every patient, one could naturally conclude that the hospital's management style should be one directed at increasing the quality of service, optimizing the patient experience, and improving customer satisfaction.

Again, cynics remind us that while this may be nice in theory, consistently delivering superior service across the board can be inefficient, as this approach to service consumes more personnel and time resources - things that are already limited.

So it appears that we are at an impasse. Lean process v. superior service quality - it's got to be one or the other in a hospital setting. Achieving lean presupposes standardization, which is nearly impossible in a hospital. Delivering superior service necessitates employee training, personal attention, significant time investments, regular performance measurement, et,c. all of which are counter to lean, right?

Let's revisit the first principle of continuous process improvement: Define value from the customer's perspective. It appears that lean and superior service delivery are inextricably linked thanks to the customer. Does this mean that they can co-exist after all? Is it too much of a stretch to assert that they may even complement one another?

How would we impart both continuous improvement and superior service quality into our process? Here are 7 quick steps to merge these seemingly dichotomous objectives:
1. Management must commit to the strategy
2. Determine the product line/department to start with
3. Gain a good understanding of lean (Lean Enterprise Institute)
4. Draw the current-state map of your selected process (MAMTC - Lean Building Blocks)
5. Determine the goals to strive for and the metrics to monitor
6. Draw the future-state map of your selected process (see "Lean Building Blocks")
7. Implement with a specific plan that includes benchmarking

Is it possible to achieve continuous process improvement in a hospital environment?

Is it possible to consistently deliver superior service to patients?

Is it possible to do both?

Carolyn Kent is Creative Strategy Specialist at Cleverley & Associates.

by Nick Jacobs

From an article in USA Today entitled “Health System Struggles with spiritual care,” comes the following quote: “For patients who are dying of cancer, few things are as profound as their relationship with God.” Later in the article there is reference to Tracy Balboni’s study on the spiritual needs of dying patients. “She found that 88% of terminal cancer patients said religion was at least somewhat important to them. And about half had been visited by clergy. Yet Balboni’s research also suggests that hospitals, doctors and even religious communities fail to support the spiritual needs of their cancer patients at the end of life.”

The article went on to say that 70% of the patients’ spiritual needs weren't being met by hospital chaplains or others in the health care system.

As a zealot in total support of palliative care and hospice programs, these numbers were not a shock to me, but were, in fact, a further signal that our current national health care system is NOT meeting the needs of our patients.

Those individuals who felt that their spiritual support was adequate also reported that their quality of life on a fifty point scale was nearly 15 points higher than those without that spiritual care.

Far be it from me to suggest that we force religion on anyone, but, having said that, there is no reason why spiritual support is not more readily available to our patients. There are hundreds of reasons why our peers don't do this; HIPAA, fear of imposing religious beliefs on patients, or just a lack of belief in the entire concept of the contribution that spiritual care brings to a patient’s care, but we here at Windber Medical Center know profoundly what the true contribution can be from spiritual involvement to all of our patients. We typically deal with hundreds of thousands of patients each year, and one of our commitments to them is the availability of clergy, Eucharistic ministers, and spiritual professionals in our facility or available to our patients 24 hours a day, seven days a week.

In God we trust, whomever or whatever you believe that God to be. It is not our intent to confine your beliefs, to restrict your beliefs or to attempt to change your beliefs. It is purely our intent to help to support our patients’ beliefs. Is your facility supporting your patients?

by Tony Chen

Even though it's been almost 2 years since I posted the now-infamous 8-part series of "If Disney Ran Your Hospital," I continue to get impassioned comments (just got another one yesterday). Below are some criticisms of the book from hospital impact readers - mostly from seasoned administrators, experienced nurses, or former disney employees. See all 29 comments here.

Here's a long comment from Rick. If you don't want to read the whole thing, the summary: "The last thing I need is another hospital administrator yapping about the latest book craze"

from Rick...

I remember my wife and I taking my kids to Disney World. I had given my notice at one well-respected academic medical center to leave for another in another city, and this vacation provided a break in the stress of all the change affecting all and each of us.

I doubt that if I had been moving from one Disney location to another, I would have taken my family to a world-class hospital to relax.

When I was an undergraduate I worked in a consumer electronics business for almost three years. Part of my job involved home service of their televisions. Like those who believe they learned everything they ever needed to know in kindergarten, I believe I learned enough about customer service from what my parents and other adults taught me. I sure as hell didn't need to pad some writer's pockets back then to learn how to respect a fellow traveler, and I sure as hell don't now.

That said, a number of years ago I surveyed customers of a group I supervised regarding what they expected and appreciated about our services. As I expected, what they appreciated most was our professionalism, but key to that was the expectation of technical expertise. Professionalism, i.e., customer service, was of little value in the absence of competence.

My guess is the expertise involved in portraying a duck, mouse, Snow White, etc, hasn't changed much in recent years. Ditto cooking a hmaburger, managing a ride, picking up trash before it hits the ground, etc. But the rate of change of health care is off the scale and accelerating. When I entered the field, computers were just showing up at the nurses' stations of ICUs. Now there are easily ten or more in the equipment at the bedside of a single patient.

Over the years, those of us in the field have heard how we should adopt 7 Habits, TQM, CQI, and now MIC KEY MOUSE. Every time, when we reply that we need tiome to learn how do it, other than for a pilot project here and there, there is simply no time in which tio fit it in. Why? Because we'd need money for that, and one thing that people will not part with to make health care work is a bigger slice of GNP. The same people who will hop on a plane amd throw thousands of dollars to spend a few days in a Magic Kingdom, the same people who would throw everything they at getting care for a family member suffering with a possibly terminal illness, these same people go nuts when they hear their health care premiums are on the rise.

Here are the choices:

1) Keep spending the same amount of money and treading water as the system continues to devolve under the pressures of accelerating technological and social change

2) Throw the money instead at gurus to teach us to say the equivalent of "Would you like fries with that?" and permit the system to devolve even faster than it is now?

3) Examine what we get for each incremental health care dollar and make the tough decisions whether the interventions and services we can provide are worth it. It would be a huge leap forward if we could move the economic discussion from guns-or-butter to health-or-entertainment. But that would require will and discipline that we seem to have lost from the days when we set out to build the health care system capable of what it is doing today. Now it's more "What have you done for me lately?"

Many people in this business know what needs to be done. We've figured out how to treat heart disease, cancer, and stroke among others; we can do this. Just let us know what you really care about by not only telling us what your choices are but putting your money where your mouths are.

The last thing I need is another hospital administrator yapping about the latest book craze. Five dysfunctions, indeed. After thirty years, I've learned it best to view MBA prattling with a Christian perspective: Forgive them, for they know not what they do.

Here's one from Dave who highlights that the ideas at Disney are not transferable to hospitals, given the vastly different environments.

from Dave... The idea that Disney has anything to teach us about how to run hosptials is a stretch, at best, and a more likely a counterproductive fantasy. A hospital is not a luxury resort, an operating room is not a ride, a surgeon is not a cute tour guide in a uniform. Nobody dies if they can't afford to go to Disney World. There is a lot that can be improved in our hospitals and our healthcare system, but I hope we can find better role models than the Walt Disney Corporation.

Dave, I agree that these are vastly different universes. Nonetheless, we are still serving the same market - people. Disney has transferable insights about how people feel safe, respected, and delighted - regardless of who those people are and what environment they are placed in.

from quade... Having worked at Disney for 29 years, lemme just say that the LAST thing you'd want a medical facility to be run like is a Disney theme park.

For example;

1. Perceptions > Reality

Perceptions are greater than Reality? Really? Isn't that what they call in the medical profession the Placebo Effect?

Quade - I'm not saying that we "fake" good care in order to somehow "trick" the patient. Good care is essential, but not all good care seems like good care to the patient.

from Lisa... About 10 years ago, I worked at an emergency department in an inner city. The Disney organization was paid to come to our facility to "teach" customer care. Needless to say I thought this was ridiculous, how do you compare an emergency dept with Disney World? There is no comparison. The E.R. is a place where emotions run high, life or death situations are a constant and patience by the patients is worn thin, not to mention the many, many people who use the E.R. as their doctor's office. What is the worst thing that can happen at Disney? Can it at all compare to death of a loved one? The Disney people who were recruited to come to our facility could barely speak to one another, never mind our patient clientele, they were in a word, shocked by what they had encountered. The staff at the ER had already been through sensitivity training, and are some of the most caring, compassionate, empathetic people I had the pleasure to work with, not to mention, not easily shocked. People do not need a book or a Disney staff to teach customer care, what they need is to look at how they'd like to be treated, "do onto others as you would yourself."

I wouldn't be surprised at this. Talk about culture shock. I have mucho respect for those folks who spend a career in the ER. How do you keep from getting jaded, bitter, calloused when you've seen it all?

other comments, criticisms? Let's keep the conversation going.

by Nick Jacobs

Bigger is better? Better is bigger?

The most incomprehensible part of this theory of business to me is that we spend billions of dollars on small, boutique experiences every day in this country, yet we have begun to look away from our most precious nonprofit's, small and medium sized hospitals. Could it be that health care is so complex and we are so confused about the nuances of this health care world that we embrace the herd mentality? Or is it that, we are so enamored by the lore and promise of technology that we assume that all smaller facilities cannot afford to purchase in order to keep up with the Jones of the medical industrial complex.

We should take a lesson from the War in Iraq where the most heavily funded war machine in the world is disrupted day after day by cell phones and IED's, a.k.a., roadside bombs.

Conversely, it is amazing to me that the simplest of things, a stethoscope, in the hands of a talented physician, can diagnose, more than any of the most sophisticated diagnostic technologies, complex ailments that don't always appear in digital depictions of that affected area of the body.

Cottage Hospitals are still embraced in England, and spa hospitals are the norm throughout Europe. Why is it that we are beginning to reject the fact that there is a place for small and medium facilities in our country? If your goal is to have an infection free surgery, ask about the infection stats at the various hosptial's where your doctor is credentialed.

Yes, of course this is personal, but it is amazing to me that our society continues to embrace the mega Systems as the only way to fly as we are many times pushed, tugged, stacked, ignored, and infected in some of our health care factories.

In a recent conversation with a former cardiac center employee from one of our nation's finer facilities, I explained that I had personally watched one of my closest friends forgo the opportunity to be treated locally so as to ensure their safety and to enjoy the professionalism afforded them at this institution. He died from an infection contracted. After describing this to him, he nodded and replied, "Yep, they have a bad bug there that they just can't seem to get rid of . . . " Could it be that sometimes smaller is better?

by Nick Jacobs

The hospital is full. There was one, male bed available today in the entire hospital, one. The emergency room has been packed this week-end, and each and every employee has been pushed to the maximum to continue to provide Planetree quality care to our patients and their families. We have not had any respiratory influenza this fall or winter, until yesterday, but it was only one case. This may be a preview of the next several weeks.

As we made rounds this morning, department by department, it was clear that we were dealing with the "A" Team. It was like observing the insides of a well-oiled machine. We contacted dietary and had their parent company deliver hundreds of large cookies that we personally distributed through the hospital to the employees to thank them for doing a great job.

We watched each department and each floor to ensure that we had appropriate coverage, and every patient and family member with whom we came in contact were queried as to their care, their feelings about their care, and how we could assist them.

After going home we continued to call in throughout the evening to check on the status of the medical center and our employees.

It worked today because we love our employees. We care about them, and we don't hesitate to let them know. No one is taken for granted. No one is a number. Everyone of them can feel it, and understand that it is real.

It's taken me a lifetime to get here and a lifetime to have the opportunity to prove that raising your voice, being dictatorial, tramping on people to get what you want, and causing people to shake and hate is NOT the way it needs to be. It's about "Doing unto others as you would have others do unto you." It's about working together for common goals. It's about caring for the people who do the job because they will take care of the people who need the care. That's what health care could be. That's what health care should be!

By Nick Jacobs

Well, the temperature was 16 degrees and it was snowing when I left Pittsburgh. By the time I arrived in Ft. Lauderdale, it was 74, down from a high of 83 degrees. The trip was for two days and for 12 credits toward continuing certification as a Fellow in the American College of Healthcare Executives. The classes were held in an overly air conditioned room with dark shades drawn over both windows. For all intents and purposes, it could have been held in Erie, PA. The course was on Managing Change for the 21st Century, and the instructor John Sena, PhD, a professor at Ohio State University, was truly an expert in his field.

Although I could share numerous tidbits from this course that would help each and everyone of you manage change, I'll just say, spend the $1000 and go take it. That would be good for both John and for the ACHE continuing education program.

What I will talk about briefly in this blog is that, in spite of the wisdom present in the room represented by both the instructor and the participants, it was painfully clear to me that the field of healthcare management in the United States has not made much progress since 1990 when I first started taking these courses.

The sad thing about that statement is that everyone in the room acknowledged it in one way or the other through the two day course. If the clocks were turned back to 1990, and the instructor was changed, and most of us were still wearing neckties and jackets to this business casual course, not much of the dialogue, admissions or observations had changed.

We discussed healthcare's approach to business delivery, customer service, business development, patient centered care, and physician relationships all in relation to managing change. Except for the fact that I have less hair, the conversations could have been audio taped from 17 years ago. No, we have not adapted the Ritz Carlton model for patient care/customer service. No, we have not adopted the Hertz model for registration. No, we have not embraced the concepts utilized by Google for employee satisfaction or Microsoft or 3 M for strategic planning. No, we have not made much progress with our food service or our room service. Unlike utilities and other industries, we have not made our billing practices transparent. We have not embraced the model develop by . . .

Well, you get the point, and, as the future closes in on us with LPN's in Wal Marts and stand alone specialty hospitals, we will pay the price for our lack of responsiveness, our inability to get even a little bit out of our comfort zone and our "herd mentality" approach to doing business. Our populations are diverse, but our healthcare leadership was primarily made up of guys like me: old, white, and conservative. Okay, well, I am old and white!

by Tony Chen

It's been a little nutty recently. I thought I would have more time to blog after my CHE exam. Alas, the boards I am on are kicking into high gear. Nonetheless, I wanted to share a few articles that I found that provoked some good thinking:

- There is a whole new generation of Google copycats coming. Imitation is best form of flattery, right? Makes you wonder if someone will try to carve out healthcare out of google. I think Revolution Health has a shot at it. Imagine all the best healthcare content without all the buy-viagra clutter. As always, content will drive eyeballs will drive ads.

- Check out the Top 10 innovations coming in 2007. A bunch are medically related and will have impact on hospitals down the line. Just think, one day we will implant bones made out of cow bones, we'll have lunch-hour lipo, and we'll have to deal with generic-only drug plans.

- Finally, I put this one to use immediately: The Art of the perfect voicemail. We've all received that 180-second voicemail that could have been 30. And honestly, we've all left voicemails before where we hang up and immediately regret how badly we did so. The best tip: scope out & specify your request for them with a time frame - "I just need 15-20 minutes of your time to ..."

By Lavinia Weissman
Managing Director: WorkEcology a Community of Practice
Journalist: Strategy & Business -Leading Ideas, a web based journal
Executive Coach

Recent entries in Hospital Impact related to the payer system, organization, leadership, being a CEO – all of these entries made me think how can the “healer heal thy self.” The most recent remark that “people complain about “health care,” and not their personal physician” got me thinking. It is clear to me when we talk “health care” we objectify a system that we work at mechanically based on driving down costs and doing more with less.

So within that equation you have to ask, how can the people, who work in health care gain control? And what would control mean? And could people taking control over their lead initiatives for innovation and positive change? I then reflected what it would mean in some “systems” to actually call “time out,” and invite people to begin new conversations.

I returned to Boston in 1999 for some personal reasons and a hope that I would return to working in health care. I came back to a health care region, which was steeped in layoff and cost cutting measures. One day after I called an old boss at my former employer, Harvard Pilgrim, I opened to the Boston Globe and found in the headline, “HPHP $98M and in state receivership”. Based on my very limited view a lot of good people I knew had not stopped and declared “time out” and problems that existed when I worked there had multiplied.

With Charlie Baker’s appointment much has changed that is good at HPHP and other good changes are occurring in many places in the city. Yet, Massachusetts has the highest premium for health insurance and it remains to be seen how our universal health insurance system will be implemented. Many citizens in Massachusetts do not have access to the quality care a few get and rumor has it that we have a primary care physician shortage. I am not certain if that relates to being a State in which more people move out than in because we have the highest cost of living and a resident completing his residency cannot afford to pay back school and get decent housing.

What I don’t see are people taking “time out,” and opening up to conversations that are not mechanical and structured in the same old way. So if we assume good things are done each day in health care by physicians and many others, maybe what we have to heal is how we work together and hence relate to the patients and our administrative and budget leaders.

So I invite people reading this entry to comment here and declare an imaginary “time out” that others might take serious and join you in, and start off by stating powerfully, what kind of group you would like to convene and what kind of innovation would you like this group to foster?

In the management literature today, much research has proven that good innovation comes with very little investment. As Art Kleiner, editor-in-chief of Strategy and Business recently stated
in an email introducing a report on this topic:

“New York, December 14, 2006 -- Booz Allen Hamilton's second annual study of the world's 1,000 largest corporate R & D budgets shows that investment can't buy success. The Global Innovation 1000 study identifies 94 "high-leverage innovators," including Black & Decker, Dentsply, and SanDisk, that consistently spend less than their competitors on R & D yet outperform their industries across a wide range of performance metrics. The study provides insight into how to get the most bang for your corporate innovation buck.”

For more on this topic, read this report:

Smart Spenders:
The Global Innovation 1000
by Barry Jaruzelski, Kevin Dehoff, and Rakesh Bordia

To read the full Resilience Report:
http://www.strategy-business.com/resilience/rr00039:

So maybe change in health care is not about the lack of resources and money, and maybe it’s about how we relate with each other and how we engage or don’t engage our time. If this can happen in industry, why not health care?

Guest article by Jared Johnson

I have been going through an unexpected process while revisiting our hospital's online strategy. I should have seen it coming since it's at the core of what we do in the health care practice. Still, it evaded my thoughts until our forward-thinking CEO shed some light on it.

I refer to the process of thinking about every detail of our business from the perspective that matters most: the patient's. The context that brought about my awareness may seem trite, but it likely will stick with me for a long time. Over a three-month period, I had been working with our marketing and IS directors to lay the foundation for a Web content redesign. We started by brainstorming ways to engage users more meaningfully. We were throwing mud on the wall, and a lot of it was sticking. We had some true epiphanies in those moments, and the future for our little Web site seemed bright.

I got right to work creating a site blueprint, but soon I became bogged down in the details. Necessary details, mind you. Anyone with a drop of tech blood in their veins will tell you that you can't go live without considering a host of things like browser compatibility, back-end functionality, security risks, validation, aesthetics, etc., etc., etc. After several weeks of project planning, our CEO requested a status update meeting in the board room. I readied the new design template, the content plan and a host of other technical data to woo and impress him.

But I was the one who was impressed. We had scarcely fired up the projector when our CEO scanned over the new design and asked,

"What would the patient want?"

The question hung in the air as he elaborated. What information and functions would the patients want that would improve their experience at the hospital? How could we possibly make their lives easier and more pleasant? Why can't we let them start the pre-admission process early by posting the forms online? Wouldn't that save them some time when they arrive? Why couldn't we list our staff oncologists on the cancer care page? Wouldn't that help them find a physician in a time of need?

In that short meeting, I understood why our CEO is who and where he is. He had been humanizing something that is not normally regarded as personable, to make it another part of the patient's experience. That fits every definition of hospital leadership I've ever read.

I'm pleased to say that we incorporated more than a dozen new ideas that came out of that meeting. When our new public-facing site goes live a month from now, patients and potential patients will be able to schedule outpatient tests, download a personal medication card, fill out pre-admission forms and much more. And I made sure to add a note in my strategic planning process to ask that patient question throughout the entire process next time.

The full meaning of "What would the patient want?" is unclear to me. Maybe it means that sometimes we get buried in the processes, the scores and the data and forget to think as if we're the ones being admitted. Or maybe it serves as a reminder that "patient-centric" is more than just a buzzword. Implementing change is no easy thing, but it can start with small instances. Things like adding the words "Your Hospital Visit" and "Patient Care" to our Web navigation. Will it translate to higher patient satisfaction scores? Will it drive volume? I'll let you know, but I have a feeling you already know the answer.

By Nick Jacobs

The fundamental needs of your workforce revolve around their ability to be heard, their access to leadership and recognition of their contribution to your organization. This particular list is not a complex list. It is not an impossible list. It is not an expensive list and it is not, above all, uncommon sense. Once again it is the MOST common of sense.

Back to the old book, I'm OK. You're OK. It involves a non controlling approach to management, the Golden Rule, common sense, adult to adult interaction, as opposed to the parent to child interaction that is typically embraced in many healthcare venues.

How can you engage your workforce? First, ask your employees "what they think." Ask them all the time.
Tell your staff that you love them . . . Seriously, take time every week to write something nice about one of your associates/employees. Like Colin Powell says in his presentations, a great deal of his time was spent recognizing those with whom he worked, those individuals upon whom he counted to be successful as a leader. WRITE THEM RECOGNITION NOTES.

If you're a Planetree Hospital, take some time to hug them, or, in our case, send the massage therapists to the floors to give neck or foot massages, too.

MAKE ROUNDS. Be out there. Be visible. Ask for their input and take time to recognize them for that input.

If you follow these simple suggestions, your life should continue to improve.