by Tony Chen

Recently, TIME magazine (is it still an actual magazine?) came out with the 10 big ideas that are changing the world today. As I read through this mostly fantastic (and maybe fantastical-sounding?) list, I couldn't help but think about the impact on health care for six of those big ideas.

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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 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 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.

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