Bridging Business & Healthcare

Navigating today's risky healthcare highway

Burl Stamp — Wed, 16 May 2012 08:46:17 -0500

For those of us old enough to vaguely remember life before prospective payment, it is easy to understand why cost-plus reimbursement might be described as the “good old days.” Like a leisurely drive on a straight country road, if you paid attention, maintained a reasonable speed, and navigated the occasional slight curve, you were fine.

Changes that began in the 1990’s significantly changed the landscape. Comparable to a multi-lane freeway, the speed of change increased significantly. Dramatic shifts in hospitals’ relationships with physicians, managed care constraints and increasing risk in payer reimbursement models were like the vehicles coming on and off freeway access ramps. If you made adjustments as necessary, and adapted to the changing traffic flow, you survived.

But like driving the dramatic, curve-filled Highway 1 along the rocky Pacific Coast, today’s healthcare roadway is filled with significantly more risks – as well as potential rewards. Leaders who are in the driver’s seat of provider organizations must pay much more attention to the speed with which they implement major changes to be sure they don’t lose key constituencies along the way.

Think of it this way: if we were driving a small, high-performance sports car we could zip through the hills and curves on Highway 1 easily. But large, complex provider organizations with many constituents to bring along handle more like a Greyhound bus. If we take the curves too fast before our staff, physicians, Board members and patients understand both the “why” and “what” of major changes, we risk careening off the cliff into a devastating crash.

Given the altered terrain, following are key ideas to consider when navigating today’s risky healthcare highway.

Collaborative planning is essential

Gone are the days when a small group of executives could craft strategic plans in isolation and still successfully implement new initiatives. Today, the strategic planning process is more important than the document it produces, giving key players opportunities to both weigh-in and buy-in to critical changes in care models, cost management and clinical service line development.

Education is vital

The economic issues facing healthcare over the next decade are daunting, so it should come as no surprise that many of the changes proposed to lower costs and deliver higher quality care are extremely complex. For Board, health system, and physician leadership, a solid understanding of the incentives and risks associated with new care models is critical to crafting appropriate responses and gaining support for significant change.

Transparency has never been more important

When key partners feel as if they have been left in the dark regarding new strategies, initiatives have very little chance of succeeding in the long-term. While it may require a greater investment of time in the early stages, transparency builds the trust that is absolutely essential. Developing innovative care models that will be successful from both clinical and financial perspectives is not possible without a commitment to transparent processes and communication.

In an environment as complex and changing as healthcare today, it is unwise to abruptly step on either the brakes or the gas pedal; the former risks being run over by competitors while the later risks moving beyond the organization’s capacity to manage change and bring along key constituents. Smart, strategic organizations pay attention to adjusting their pace to appropriately respond to both the anticipated as well as the occasional unexpected curves in the road ahead.

The dangers of pursuing the "silver bullet"

Burl Stamp — Mon, 14 May 2012 09:14:59 -0500

In her remarks at the ninth annual World Congress on Health Care, Shari M. Ling, MD, deputy chief medical officer of the Centers for Medicare and Medicaid Services wisely pointed out that there is “no silver bullet” to achieve better value. As reported by Fierce Healthcare associate editor Alicia Caramenico, Dr. Ling emphasized, “When we start to talk about value, that discussion is really formulated on the foundation of quality.”

Given the daunting challenges and demands health care leadership teams face to increase quality while reducing costs, it is easy to see why looking for the “silver bullet” is so tempting. I still get asked by some accomplished, experienced health care leaders, “Isn’t there something simple we can do that will cause our scores to go up?” I see the disheartened look on their faces when I have to reply, “Not if you want real improvement in quality that’s sustainable over time.”

The real danger in pursing silver bullets goes well beyond just implementing simple solutions that produce disappointing, unsustainable results. Organizations that have a culture of only looking for quick, easy solutions undermine the very practices and competencies essential to making real progress in value-creation.

Think about this way: any object crossing the path of a bullet is impacted negatively. Sometimes the damage is reparable; often it is not. When we rely on silver bullets to solve our most important, complex issues in care process improvement and patient experience, we may be damaging — even killing — the very aspects of our culture that we need most to succeed in the future. Following are several primary examples.

Silver bullets kill continuous improvement
The concept of “continual improvement” pioneered by Edward Deming has been embraced by successful companies across industries – including healthcare — as essential to long-term success and achieving higher quality. In silver bullet-dependent organizations, staff and managers stop looking for improvements because they want to believe that they’ve found the “right” answer in a single solution. The idea of an ideal, permanent, silver bullet answer to any question is anathema in cultures that embrace the idea of continuous improvement.

Silver bullets kill innovation and critical thinking
Frontline managers and staff have the critical insights and understanding of core processes that are essential to improving care and making it more efficient. Within organizations that rely on silver bullets to solve problems, staff often simply wait for management to deliver the next solution. This type of culture not only undervalues and under-leverages the potential contributions frontline staff can make to improvement; it also places a tremendous burden on senior leadership to come up with all of the solutions to the organization’s challenges.

Silver bullets stymie effective implementation
Organizations that tend to seek out simple, silver bullet solutions also tend to overly simplify implementation. Poorly implemented hourly rounding initiatives at some hospitals are prime examples demonstrating this weakness. The idea of checking on patients more regularly to assess their needs and answer questions is a solid way to improve “care responsiveness” as measured in the H-CAHPS survey. Unfortunately, I’ve seen too many organizations simply put a compliance checklist on the wall and tell nurses, “You now have to document that you’re in each patient’s room every hour to check on the four Ps” as their implementation strategy. Conversely, hospitals that achieve the best results in hourly rounding involve staff up-front in understanding the real issue, structuring the new approach, making the improved strategy work across the team, and – perhaps most importantly – in finding ways to make the practice more successful and efficient over time.

While a simple, easy-to-implement answer may seem appealing in the short-term, the long-term impact of silver-bullet thinking in organizations can be debilitating to sustainable improvement efforts. In order to be successful in the new value driven world of healthcare, organizations must invest in developing cultures of continual improvement and collaborative problem-solving to achieve sustainable gains in quality and value over the long haul.

The Ultimate Compliment

Burl Stamp — Fri, 11 May 2012 14:07:02 -0500

It was almost nine o’clock in the evening when I finally arrived at my hotel from a long day of meetings and travel in preparation for the full-day workshop I would lead the next day. I was tired, but I was also hungry. I asked the front-desk clerk as I checked in if there was a place nearby where I could still get a quick bite. She pointed across the lobby and said, “I think Joan over in the bar can still get you something to eat.”

The bar at the suburban hotel where I was staying was not exactly a hot spot on a Monday night. There were only two other people at a small table talking when I walked in and pulled up a bar stool. Joan was busy cleaning up behind the bar but cheerfully greeted me with a menu. Our small talk quickly brought her to the question, “So what brings you to town?”

“I have a meeting tomorrow at General Hospital,” I replied.

She immediately stopped what she was doing, looked at me with the appreciative smile a mother has when you ask about one of her children, and uttered three simple words.

“That’s my hospital.”

Her heartfelt expression of what General Hospital meant to her and her family said it all. Sure, she went on to explain that “her babies” were born there and that they took wonderful care of her husband when he needed surgery. But the details weren’t necessary to convey the powerful connection she had developed with General Hospital because of the compassionate, respectful care she had received there. It was as if she was telling me about a member of her family, and she was so proud of who they were and what they had accomplished.

The expression of an institution being “my hospital” is, in many ways, the ultimate compliment and should be considered as one of the best measures of success in assessing a patient or family’s long-term experiences with our organizations. It’s tough to pose the question on a patient satisfaction survey. (Asking “Is General Hospital your hospital?” just doesn’t get you to the same place.) But we know it when we see it. And this level of loyalty and commitment is a dialogue worth having among care teams to discern what it would take to elicit the same reaction and response from all of the patients as I got from Joan.

Certainly General Hospital had done a multitude of things right over the years to build the kind of trust and connection that Joan and her family felt with the institution. But my guess is that at the heart of all of those things was the sense among frontline staff – especially nurses – of each patient being “my patient” – an individual who deserves the same level of compassion and care that I would provide to my own mother, child or very dearest friend. In a business that at its core is dependent on personal connections more than any other, that sense of dedication and accountability to each individual is what will continue to distinguish the very best healthcare organizations.

Think Small?

Mark Browne — Mon, 30 Apr 2012 14:03:50 -0500

I frequently joke with those that I work with that my dream job is to be the “Vice President of Big Thinking.” It would be great to have the time to take all of the complex issues we are facing in healthcare, sit in a room and come up with big ideas and big solutions. Unfortunately, I have not yet been able to find an economic resource willing to sponsor my dream, if not imaginary, job description. Here in the real world, it seems as if the dilemmas we are facing in healthcare- reimbursement, quality, access, legislation - are closing in on us from all sides and with no real solutions in sight and no time to take them on.

This week during the Annual Meeting of the American College of Physician Executives, I had the opportunity to have my mind stretched on this issue a bit and saw just a bit of light at the end of the tunnel. I participated in a workshop on “Little Bets.” It may be difficult to imagine a room full of over 200 left-brained, type A physician executives in “full creative mode,” but with some good facilitation it happened. After a morning of doing improv acting, playing “soundball,” and generating ideas through the eyes of Einstein, Bob Dylan, and Michael Jackson to get our right brains engaged, an interesting thing happened – it worked. We actually began to come up with solutions that we could take home and implement. And in the course of the day, I learned some important things about innovation and how we can all apply it.

Innovation doesn’t have to be big

We can all agree that our problems in healthcare are as big as they come, and most of us are approaching them from the top down with attempts at big solutions; developing an integrated delivery system, merging with another group, implementing a new IT solution. Most of us seem to be constantly swinging for the fences, and in the process, our frustration grows. Within the framework of Little Bets, the answer lies in “smallification”- starting to solve big problems by trying a bunch of little solutions, some of which will certainly fail. But at the end of the day, those failures will lead us to some solutions that will stick, allowing us to get at the big problems piece by piece from the bottom up. As the old adage reminds us; how do you eat an elephant? One bite at a time.

Anyone can do it

Many of us in leadership seem to believe that true innovation is reserved for those with lots of money or lots of time. We hear our peers criticizing ideas as too expensive, too disruptive, or too hard. Frequently, this atmosphere of “can’t do” results in unworkable solutions that we feel the need to try despite their propensity for failure. In the meantime, our wheels continue to spin in frustration.

This weekend’s creative workshop gave me hope that we can all have access to the type of creativity needed to break this cycle, but it can’t happen behind our desks in our typical work flow. No committee on the planet is designed to create, they are designed to manage. With a new set of tools, a slightly uncomfortable approach, and very little time, I watched our group of physicians create new “real” healthcare solutions that were inexpensive, scalable, and could be made ready to go live virtually immediately.

Innovation is Fun

For many, the joy of working in healthcare seems to have evaporated. The things that drew us to this profession of caring are clouded by the storms of finance and change. But as I watched our group create solutions, I saw true passion and joy rekindled in many of my colleagues. The fact that we were coming up with real workable solutions, and even having fun doing it, was a source of great satisfaction for all of us. Unleashing some of our pent up creativity may be just what the doctor ordered to help us recapture the real reasons we got into healthcare in the first place.

I know the challenges we are facing in healthcare are many, are complex, and sometimes feel downright scary. But if given the right set of new tools and the courage to make some little bets in healthcare, the whole truly could once again be greater than the sum of its parts.

The price of being human

Burl Stamp — Thu, 26 Apr 2012 11:24:10 -0500

Several months ago, I committed the mistake that strikes fear in the heart of every businessperson who is a frequent flyer: I missed a flight. No bad weather. No huge traffic jams on the way to the airport. I simply had in my mind that the flight left one hour later than it actually did. I glanced at the Eastern time zone label on my Outlook calendar instead of the Central time zone.

So your thought at this point probably parallels my initial reaction … How could I be so stupid!? To soothe my bruised ego, I reminded myself that on this particular day I was juggling even more issues and priorities than usual, got sidetracked by a last minute request that I had to respond to immediately, and was mentally preoccupied by a family issue that concerned me.

In short, my afternoon was very similar to a frontline healthcare professional’s typical day on a patient care unit. But there was one major, important difference. The personal price I would pay for my mistake – several hundred dollars to get the last seat on the last flight out that evening – paled in comparison to the potential price a clinical professional can pay for errors: the emotional burden of a patient’s physical harm or even loss of life.

Making care safe for patients – and caregivers

During the past decade, a number of the most forward-thinking healthcare systems across the country have embraced “High Reliability Organization” (“HRO”) theory as a path to developing safer cultures that minimize and contain errors. One of the most liberating aspects of HRO theory is the assumption and acceptance that because we are human and imperfect, we will make mistakes. Across the five core HRO principles, one organizational characteristic in particular emerges as requisite for achieving higher levels of reliability and safety -- teamwork. Interestingly, I don’t think it’s a coincidence that one of the most highly correlated patient experience factors to overall satisfaction also is “how well staff worked together as a team.”

Most healthcare providers publicly avow that teamwork is a priority and a core organizational value. But how often do our actions and decisions indicate otherwise? Following are several key questions for leadership teams to consider in assessing whether better teamwork is indeed a priority in the organization.

Do we model effective teamwork from the top down?

During my career, I’ve been a member of a leadership group that functioned well as a team and one that didn’t. Sometimes, to my amazement, that dysfunction was keenly recognized and directly transmitted to the frontline. Executive teams are made up of high-performing, often competitive individuals (frequently with healthy egos) who have risen largely by their own personal accomplishments. Unless teamwork is specifically identified as a non-negotiable expectation and openly discussed by the group, it often doesn’t happen naturally.

Have we prioritized privacy over safety and teamwork?

No one would argue that important gains have been made over the past 20 years with regard to patient and family privacy in healthcare institutions. But the larger and larger private rooms that sometimes necessitate longer, more isolated hallways away from common nurses’ stations mean that caregivers more often are flying solo, with less inherent collaboration among colleagues.

In his breakthrough book Why Hospitals Should Fly, author and patient safety expert John Nance depicts a new, safer patient unit design that might best be described as “retro.” In his circular pod format, rooms face a common caregivers’ station where nurses, doctors and support staff could see all patients from a central vantage point. Increases in patient privacy, Nance argues, should not be at the cost of patient safety. Is the circular pod design too radical a solution? Perhaps. But seriously contemplating its advantages may bring to the surface unintended patient safety compromises resulting from a heightened focus on patient privacy.

Is better interpersonal communication an organizational priority?

Over the past decade, healthcare organizations have spent billions upgrading electronic documentation and record-keeping systems to increase access to information. While these investments are an important step, their implementation too often is thought of as the answer to perfecting communication across the care team. In reality, blind reliance on electronic communication can have a detrimental impact on critical face-to-face interactions that are essential for good teamwork. A physician I was working with in one institution that had implemented a new electronic health record reluctantly described its impact on the culture this way: “It’s almost as if we turned on the EHR and everyone stopped talking to each other.” Patients and caregivers deserve the advantages of better electronic communication, but it can’t replace the constructive give-and-take of face-to-face interactions.

In today’s fast-paced, stress-filled world, strong teamwork has never been more important to ensure a safe environment of care for both patients and the compassionate professionals who have dedicated their careers to taking care of them. If patient safety is indeed a top priority, healthcare organizations must add an important question to their decision-making and investment considerations: How does this decision impact teamwork?

Teaching to the Test

Mark Browne — Tue, 17 Apr 2012 14:55:25 -0500

This past weekend, I got to do something I truly enjoy. My tried and true 2007 Avalon was groaning and moaning a bit more than in days past, so I decided it was time to take the dive and go buy a new car. Unlike many people, I actually enjoy the car buying process. I don’t know if it’s the thrill of the hunt, the joy of seeing all of the new bells and whistles, or just the simple pleasure of that “new car smell.” I enjoy it all. After driving the requisite number and style of cars (sports cars, luxury cars, even an SUV), I settled back in to my comfort zone with a brand new shiny Avalon. Just like my 2007 model, this new Avalon still seemed to fit my tastes just fine.

It was getting late in the day and quite honestly, I was ready to get the deal done and get home, but knew I had to be patient and wade through the requisite two trees worth of paperwork. As I began to dive in, my sales person leaned in a bit and said – “You know, I don’t like to sell cars late in the day.” OK, I’ll bite, I thought. “Why is that Frank?” I queried. “My satisfaction scores might be lower” he replied. “People are in a hurry and it doesn’t seem to matter how well I do. We’ll get you out of here; just don’t gig me on my survey – OK?”

In the auto sales and service industry, customer service – or more accurately customer service scores – are king. Every interaction is followed by a phone or email survey and every salesperson and technician is constantly showing you exactly the score they need to have. (Often, only the highest score is considered to be a “passing” score, with all other scores considered to be “failing.”) The incentives for good scores are obviously big and have taken on an almost comic sense of importance.

As we in health care move towards subjective metrics, in the world of patient satisfaction, I can’t help but wonder if we are implementing some of these same behaviors. When we focus too much on short-term, isolated tactics to improve scores, are we really improving the culture in healthcare organizations in a way that genuinely makes patients happy and enhances their overall experience?
I am not saying that patient satisfaction is unimportant, I’m just curious if we are really asking the questions and improving aspects of their experience that mean the most to the patients in terms of their satisfaction. Alternatively, could it be argued that we are simply “teaching to the test” to be sure we capture the maximum amount of revenue associated with patient satisfaction?

All this thinking made me wonder – what questions would I want to see on my own healthcare satisfaction survey? Sure a clean, quiet environment is important, but is that what would make me really satisfied? Here is my first pass at a listing of outcomes that would contribute most to my satisfaction as a patient:

I know exactly what the services will cost before they are provided. No surprises or hidden fees.
I know my doctors provide the highest quality care in my area of need, and they have the data to prove it.
I have access to all of my clinical and financial data all of the time.
My doctors and caregivers talk to each other. They all know my plan of care and execute it flawlessly in concert with one another.
I’m healthier now and have been taught how to stay that way.

I don’t know if we will see questions leading to these outcomes on a patient satisfaction survey anytime soon, but as we move toward using patient satisfaction measures more and more, I hope that we in healthcare don’t fall prey to achieving “great scores” that have no real connection at all to patients being truly satisfied.

Making Data Matter

Mark Browne — Fri, 06 Apr 2012 08:04:02 -0500

On one of my many road trips recently, I pulled over at a rest area for a brief stretch and caught a glimpse of something I’d never seen before. It almost felt as if I was getting to see the proverbial “man behind the curtain.” Sitting there in the parking lot next to me was a vehicle with an enormous and complicated camera mounted to the top – the Google maps Streetview car. Here it sat, the very low tech way that Google is creating high tech data -putting together a comprehensive map, neighborhood by neighborhood, seemingly one frame at a time by driving across country snapping pictures from the top of this simply modified car. Even though the data they went out to capture was time consuming and in small bits, their method seemed to be working.

Jumping back in my car and having a bit more time to ponder, I began to think about how we are collecting data in the world of healthcare. As the industry continues to edge closer and closer to delivery and payment models based on value, alignment, and care coordination, the mad scramble to create and capture truly meaningful data is gaining speed. The approach to find the “holy grail” of data for most appears to be integration, integration, integration. Let’s make sure every physician, hospital, payer, and even patient are all on (or have access to) the same system with the same gigantic bucket of data. If we can just get everyone to push all of their data into the same place, surely we will be able to divine the answers we seek.

Google’s approach appears to be a bit different. Rather than trying to force everyone to push data into a common place, they are going out and pulling it in, bit by bit and coming up with a very comprehensive, very usable to tool that provides direction and gives meaningful information. Our approach in healthcare to getting everyone to push their data into a common place would be like Google asking everyone in the country to please send a picture of their home to Google headquarters, hoping we all use the same size, format, color, and resolution.

How might this model look in healthcare? Each time a patient refills their blood pressure meds, what if their blood pressure was recorded at the pharmacy and sent directly back to the physician? Could this allow us to begin to track the outcomes of individual medications in a more meaningful, real time way? What if our focus was not a common electronic medical record structure that is primarily physician focused, but on creating a common portal for all patients to share data with all physicians? Would we actually be getting better and more meaningful clinical data from the field as opposed to capturing well coded data that is designed, at least in part, to maximize our reimbursement?

I understand the privacy and operational challenges that something like this would create. It would truly force us to question the model we are currently using, but isn’t that the point? If we continue to place all of our focus on building the perfect, fully integrated information system, we may be missing the opportunity to capture smaller, discrete pieces of information that may not initially provide us with the “big picture,” but will certainly give us useful direction along the way.

"I'm sorry, but our office is now closed ..."

Burl Stamp — Wed, 28 Mar 2012 10:25:40 -0500

In our conceptual analysis and debate about what really defines “patient-centered care,” healthcare organizations may be missing one of the most basic yet important issues for today’s modern family. Regardless of how compassionate, individualized and inclusive a provider’s approach may be, care is not patient-centered if it’s unavailable when the patient wants or needs it most.

I remember well my wife’s careful search for an obstetrician when we moved to a new city many years ago. In terms of criteria, healthcare organizations might guess that she would be most concerned about where the physician went to medical school, his/her hospital affiliation or office location. But as a young, practical career woman, my wife’s first priority was clear: did he/she offer Saturday hours? “When I get pregnant,” I vividly remember her saying, “I’m not going to have time to be taking off in the middle of the week to go to doctor’s appointments all the time. I won’t even consider a practice that doesn’t offer Saturday and evening hours.”

Interestingly, my wife found an obstetrician who attended a prestigious medical school, practiced at a number of the city’s leading hospitals, had a convenient office location – and scheduled patient appointments on Saturday.

Some may believe that the fact that many physician offices and other ambulatory services operate on what used to be called “banker’s hours,” can easily be minimized as simply a minor inconvenience for patients. But in an era that requires more aggressive, proactive management of all aspects of care, access limited by hours can have significant consequences.

“In the ambulatory arena, one of the things we hear from patients is that many of them are actually trying not to go back to the hospital and get readmitted, and yet they find they have very few care options after hours,” pointed out Eric Coleman, MD, MPH, Professor of Medicine and Head of the Division of Health Care Policy and Research at the University of Colorado Denver, in a recent CMS-sponsored webinar.

Regarding patients’ after-hours dilemma, he went on to explain, “In some cases there’s a recording or a person who doesn’t know anything about them or just hears that they’ve been in the hospital, and they automatically get sent back to the ED. When the ED hears that they were recently discharged, the pretest probability of getting readmitted goes up fairly substantially.”

Perhaps the commonly held belief that many patients end up in the Emergency Room because they don’t have a primary care provider only partially explains the problem of “inappropriate” emergency care. The fact that a patient’s primary care provider or specialist isn’t available may be just as important a contributing factor.

So without returning to the days when primary care providers were expected to be on-call 24/7, how can today’s healthcare organization offer care that respects the reality that families must have reasonable access outside the hours of 9 to 5? Innovative use of well-structured after-hours phone triage programs, well-trained physician extenders, innovative telemedicine applications and even emerging IT-aided patient self-prescription applications may be options. In addition, more creative scheduling of young physicians who might be more likely to trade evening hours for something less than a 50-hour-per-week schedule could be part of the solution in some practice settings.

But the most important first step? Admitting that limited hours that do not fit the needs of all patients is more than just a patient convenience issue, it is an access to care problem that needs to be solved.

An App for That

Mark Browne — Tue, 20 Mar 2012 11:19:55 -0500

As a traveling consultant, I eat at a lot of restaurants on the road and am frequently short on time when I do. I have had to learn to live with the very inefficient current model of business in restaurants. Wait to be seated, order your beverage, wait again, hear the specials, order my meal, wait some more, eat my meal, wait for the check, pay the bill, wait again, you get the picture. I love good service, but why do I have to wait to be asked and for the server to share the specials with me as if it were some big secret. Information seems to be shared only when you ask, and then only in limited amounts. Why can’t I just go online, see the menu, order, and pay when I’m done with the terminal at my table? And now..here it is – they have an app for that. An iPad at every table to put the customer in charge of his destiny. This model has the potential to upend the current service model. The dependence on those running the restaurant is gone. Now the customer is truly in control. Although servers were concerned they would be put out of a job, the opposite has happened. They now have more time to focus on actual service and spend more time with their patrons. Customer and server satisfaction has increased and tips have actually gone up. Restaurants are still reluctant to adopt this, but are cautiously evaluating its effectiveness and are studying how this just might work.

With a bit of tweaking, it seems to me that something like this would be the perfect patient centered app for hospitalized patients. One of the biggest fears and frustrations for those in our healthcare system today is the lack of information and the lack of control. How much better would the care and outcomes be if we used this type of technology to truly put the patient in the center of their own care by providing real time, up to date information? What if the “app for that” looked something like this:

Every morning a daily summary in laypersons terms of the physician’s orders and daily notes is shared that allows the patient to advance their care. “Good morning, Mark. The doctor has changed your diet this morning. Would you like to see a menu for lunch? Click here”

A summary of medication changes with links to layperson information on new medication as an educational tool appears with each medication update. “Your medicine for your blood pressure has been changed. Here is a link to information on this medicine. Click here for links to the pharmacy nearest your home with the best pricing. Would you like this link sent to your physician”

“Your doctor is running late on rounds today. He has shared with us he plans to be here around 3PM. Please let your family know.” How much more time would there be for nurses to actually care for patients if this type of communication was automatic?

“What questions do you have for the doctor today?” “When can I take a shower?” “The doctor will be happy to discuss this with you, but in the meantime, click here for information provided to us by your doctor on what to expect after this surgery.”

“There will be a live online hangout with others who have had your surgery. Some are still here in the hospital and some have had your surgery recently and are now home. Click here to reserve your spot.”

And this is my favorite – “Here is a running total of your bill to date. If you have any questions about your bill, click here to speak with a live representative now.”

I understand that this type of communication would require an enormous change in culture and in systems. The creation of the “app for that” will be necessary, but not sufficient to create this change. And much like the restaurant industry, few in healthcare would be willing to jump into this with both feet. It will take a lot of momentum for something like this to occur, but many are looking for new and better ways to re-create the healthcare system every day and as the call for true patient centered care continues to grow, the “app for that” may be here sooner than we all think.

Want more "accountable" care? Call your pediatrician.

Burl Stamp — Thu, 15 Mar 2012 14:27:57 -0500

While the individual mandate for insurance coverage has been the most hotly contested aspect of the Affordable Care Act among the general public and politicians, providers have struggled more with the development of new care delivery models such as Accountable Care Organizations (“ACO”). Opinions still vary as to how important ACOs will be in making real progress in reforming the health care system, but most experts do agree that providers must be more accountable for managing cost and outcomes – with or without ACOs.

Individual examples of breakthrough success in managing cost and quality exist in physician practices and other provider organizations across the country. But important progress in three specific strategies heralded as essential for better management of care – medical homes, patient/family partnerships, and chronic condition management – has already been largely achieved in one segment of our industry: pediatrics. Adapting key lessons from the successful management of children’s health could be very helpful in better managing care for adults.

Developing Medical Homes

While many health care professionals might guess that the development of medical homes is a reaction to current health reform legislation (or even the 1990s managed care era), the concept was actually conceived and introduced in 1967 by the American Academy of Pediatrics (“AAP”). But even if the AAP hadn’t called it a “medical home,” shouldn’t the way care is managed by a pediatric practice define the way care should be provided for everyone? Convenient, responsive access when you’re sick. Structured, preventative care to keep you well. And a long-term relationship with a health care professional who is available to answer questions about everything from nutrition to serious physical symptoms.

Pediatrics also pioneered strategies to support self-care outside of -- but in cooperation with -- the physician’s office. Dr. Barton Schmitt’s breakthrough work in the 1970s at the University of Colorado and Children’s Hospital Colorado is still the definitive source for comprehensive, evidence-based telephone triage protocols for children’s health. Hundreds of programs were inspired and shaped by his work, including this author’s launch of the Answer Line at St. Louis Children’s Hospital in 1989. The program today remains one of the most important, far-reaching things I’ve been involved with in my 25+ year health care career.

Involving Families More Actively in Care

While “family-centered care” is seen by many as a contemporary idea to better manage care, especially for chronically ill patients, the concept was developed first in children’s hospitals in the 1970s. Caregivers recognized that parents deserved to be more fully involved in decision-making and all aspects of their child’s treatment. Since that time, much research around the “patient-centered care” concept has reinforced its importance, as emphasized in the recent article “Shared Decision Making: The Pinnacle of Patient Centered Care” in the New England Journal of Medicine. Seeing family members as important partners of the care team – rather than as a distraction or burden – makes sense for all patients. This is especially true in situations where the risk of readmission is high. Family member involvement can mean the difference between effective compliance and a trip back to the hospital that may not be fully reimbursed.

Improving Outcomes and Lowering Cost for Chronic Conditions

While much work has been done across a number of diagnoses related to management of chronic conditions, none is any more impressive than the significant gains over the past two decades in asthma care and treatment among pediatric patients. Building a sense of personal responsibility and empowerment among patients are two key strategies that have resulted in the reduction of hospitalizations and emergency visits for young asthmatics. “I can control my asthma; it doesn’t have to control me,” is a philosophy that must be replicated more often in adults with controllable, chronic conditions if optimal gains in outcome improvement and cost reductions are going to be achieved. The consequences of inadequate attention to chronic disease management were highlighted last week in a news release by the Agency for Healthcare Quality and Research. The article reported that readmission rates for chronic conditions such as diabetes and congestive heart failure are significantly higher than for acute conditions. Better understanding the proven success factors modeled and implemented in pediatrics is a worthy investment of time for those adult hospitals still struggling to significantly reduce avoidable admissions.

Despite the achievements cited above, it is not unusual for successes and breakthroughs in pediatric care to sometimes go unnoticed in the adult medicine world. But in the emerging era of accountable care, ignoring the track record that pediatric professionals have amassed in the development of constructive relationships with patients and families that help improve care and reduce costs could be especially short-sighted. Indeed, this pediatric expertise could be among the most important contributions to a system of adult care that must become more “accountable.”

Building the Mirror

Mark Browne — Fri, 02 Mar 2012 14:28:42 -0500

Earlier this week, CMS announced its latest updates to their Physician Compare website. This site, required by the healthcare reform law, is designed to provide information specific to physicians related to the quality of care provided. Although it is currently not much more than a physician directory for Medicare, it will ultimately be designed to make information on physician performance publicly available. CMS is not alone in the payer world in developing access points to provide information on physician related quality metrics. With four clicks of the mouse on the BCBS website, I can find specific information on quality (and cost) for all providers by specialty. Again, the metrics are not robust, but the information is being developed and is easily available.

Seeing this growing access to quality information in the payer world made me curious to see what was happening in quality on the clinical side of the aisle. Certainly we, as physicians, were “keeping up with the Joneses” on the payer side, so I decided to start with the specialty societies. Even if I couldn’t find physician specific information, I was sure I could at least find some direction as to which metrics should be used to truly define quality in each specialty. So off to the sites for the American Academy of Family Medicine and American College of Physicians I went, confident the information would jump off the page, just as it did on the BCBS site. Alas, after 20 minutes of diligent searching, I gave up. Although both sites provided a fair amount of patient education materials, neither one provided any specific information on physician quality or how to best measure it.

As our society continues to demand access to more and more detailed information on all types of purchases, physicians are certainly not exempt. Most of the information related to quality that is currently available, however, lives with the payers and insurers in the industry. This information certainly can be valuable in assessing which physician to choose, but does it truly provide an accurate assessment of the quality of care provided?

We are all on a journey toward a system that will rely more and more on measuring quality and value in healthcare. Who will define quality is yet to be determined, but it appears that those most directly affected by these definitions have yet to fully exercise their voice in this discussion.

Here's Lookin' at You

Mark Browne — Wed, 22 Feb 2012 16:03:14 -0500

As a consultant, I spend a lot of time in the friendly skies. On a recent flight, while once again waiting on the tarmac for air traffic control to decide my destiny, I peered into the cockpit. As expected, the pilot and first officer were busy going through their pre-flight routine, but they were not alone. Squeezed ever so uncomfortably into the “jump seat” was a gentleman in civilian clothes, clipboard in hand, perched directly over the shoulders of both of the men who were in charge of getting me from point A to point B safely and without incident that morning. The captain and his co-pilot went about their normal duties, not acting as if the in-flight evaluator were a distraction, but even chatting with him and treating him as a welcome addition to their day.

As I watched this real time assessment of quality unfold, I had a great deal of comfort knowing that the people in charge of my life for the next few hours were happy and willing to be graded and assessed on their performance.

As physicians, our performance assessment is far from this model. At best we assess ourselves indirectly, infrequently, and retrospectively. We are in constant debate about the quality data that is available not really representing “true” quality of our care. I began to think what a real time assessment model might look like if we applied it to what we as physicians do daily. Could it actually work? What if rather than an annual “Maintenance of Certification” for our license, we all participated in a real time assessment by a peer through our individual specialty boards each year? What if we all agreed that this real time assessment was a much better indicator of clinical quality than a look through the medical record long after care actually occurred? What if the results of this data were reported publicly?

With any new model, of course, the devil is in the details. The issues of patient privacy, cost of assessment and training, and a myriad of others will be brought up as reasons that something like this simply won’t work. I am not here to say moving to this model would be easy and it certainly would not be popular among some. It would, however, move us away from debating about whether the data currently reported represents clinical quality and directs our energy on creating a renewed focus on getting our patients safely from point A to point B on their healthcare journey.

Comfortably Numb

Mark Browne — Wed, 22 Jun 2011 13:24:56 -0500

2,080. 40 times per week. That’s the number of wrong site surgeries still happening annually in hospitals and clinics across the US, according to a recently released study from The Joint Commission. I read the article with great interest yesterday morning as I was making my way through several airports traveling to a client site. As I walked through an airport I stopped to watch several news stations, expecting to see some outrage at such statistics. Maybe even a catchy new headline – “The War on Error”. I watched them all - CNN, Fox News, the political gamut – and saw…nothing. Not one story. Not even a passing interest.

Have medical errors become so much a part of the fabric of our healthcare system that this type of news doesn’t even merit a mention? Has getting the wrong care become not only accepted, but expected?

As healthcare reform continues to press forward, we continue to design fixes that will allow us to slowly evolve into a new delivery system, all while not changing our current system too much or too quickly. We seem to have agreed somewhere along the way that some frequency of errors is acceptable, and that we need to work on this slowly, lest we break the system we have worked so hard to create.

This study proves what we already know – our healthcare system is still broken. How long will we as a nation continue to tolerate slow and steady fixes to the system, and at what cost?

Hold the Mayo?

Mark Browne — Mon, 13 Jun 2011 10:56:22 -0500

In a nine page letter last week to CMS, the Mayo Clinic has definitely outlined its position on ACOs. Under the current proposed rules they, like many others, have publicly chosen not to participate. Mayo goes on to say that the proposed regulations are “in conflict” with the way it currently runs it Medicare operations.

Although the Mayo Clinic is only one voice in a growing chorus of dissent, I can’t help but wonder if their voice is louder than the rest. In a public letter to Senators Ted Kennedy and Max Baucus on June 2, 2010, President Obama stated that "we should ask why places like the Mayo Clinic in Minnesota, the Cleveland Clinic in Ohio, and other institutions can offer the highest quality care at costs well below the national norm. We need to learn from their successes and replicate those best practices across our country. That’s how we can achieve reform that preserves and strengthens what’s best about our health care system, while fixing what is broken." With that type of endorsement, it would hold to reason that if Mayo is a model we can all learn from and even strive to replicate, yet they aren’t going to participate in ACOs, would it be logical for anyone to participate?

I know the Mayo model is certainly not the only way to skin the accountable care cat, but they are certainly held in high esteem by most in the medical community and even more so in the political community. Although there are those who believe that one voice alone will not be enough to derail the ACO train, I do believe that Mayo’s position will significantly drive the outcome of the final rule. As a wise friend of mine once said – “Sometimes you have to count the votes, and sometimes you have to weigh the votes.”

Live Free or Die

Mark Browne — Fri, 10 Jun 2011 05:27:23 -0500

Recently as a colleague of mine and I were debating the latest developments in healthcare reform, he posed a not-so-rhetorical question. “So, when do you think the independent practice of medicine as we know it will cease to be?” Current statistics, if you are believer in statistics, suggest the answer to his question might be “Sooner than you think!” Hospital employment of physicians is up 75% from 2011 to 2012, operating costs in physician practices are up 51% over the last decade, only 25% of practices have successfully implemented a fully functional electronic medical record, all in the face of flat or declining reimbursement. The die does appear to be cast.

However, even in the face of what appear to be overwhelming odds, there still remain a large group of physician practices looking to reinvent themselves in any way needed to assure their continued independence. Although the independent practice as we know it will certainly change, many are unready to write its epitaph quite yet.

So what will it take to remain independent in today’s merger happy, consolidation focused environment? Here are a few thoughts (with many thanks to my colleague Jon-David Deeson for his contributions to the list below):

Define independence – Practices may not have to be employed/aligned/merged/acquired, but every practice will need to learn to work outside of its own four walls if they are to take advantage of new payment systems, particularly bundled payments. Even the most independent of practices will need to become comfortable sharing data, both clinical and financial, with other groups and health systems.
Measure and share your value – Living on the reputation of being the best –ologist in town who the CEO comes to see as his/her personal physician is no longer enough. Those physicians and practices who wish to survive independently must be able to objectively demonstrate their value to patients, physicians, and health systems that they desire to have as partners and customers. Once that value is shown, proactive transparency with the data will be crucial.
Embrace the new quality - There must be an awareness that the traditional ways we as physicians measure ourselves will not be adequate. Successful groups must not only show that they perform better than national benchmarks, they must also demonstrate that they perform better than others in the same specialty. Relative performance will become more important than absolute performance with regard to almost all measures of quality. In a world of reform, if you are not demonstrating quality outcomes, you may not be able to play at all. Those who wish to thrive must also realize that all quality measures will not objective. Patient satisfaction and communication have always mattered, but now your income will depend on mastering them and proving that you have.
Change your ways – Although productivity still matters, maximizing your business model around a fee for service, volume focused model will not allow practices to thrive and control their own destinies. Along with the quality focus mentioned above, physicians must learn to not only provide care, but to direct care. Developing and leading a team of providers (physician extenders, care mangers, home health providers, etc..) will differentiate a physician from the rest of the pack. This model is much different than the traditional “the-doctor-will-see-you-now” model of care most physicians grew up practicing, but mastering it will be critical for any practice wishing to succeed.

It is certainly getting tougher by the day to practice medicine independently, but for those that are willing to innovate and embrace change rather than pining for the “good old days” of medicine, there may yet be hope.

Defining the Core

Mark Browne — Thu, 02 Jun 2011 09:46:42 -0500

In its June 1 letter to CMS, the American Hospital Association outlined a litany of concerns and issues with the ACO proposed rule as it is currently written. One of the key concerns brought out by AHA was the large number of quality metrics to be tracked by participating organizations, currently set at 65 different measures. Their proposal goes on to suggest that CMS consider a “concise set of measures” be included in the startup phases of ACOs to encourage greater participation and a greater likelihood of success in improving those metrics. The AHA did not, however, define what it thought those metrics should be that would adequately define high quality care delivery.

Although there are certainly many quality metrics out there currently defined by CMS and others, most would agree that they have failed to capture the measurement of the delivery of truly high quality care. With that in mind, I am going to attempt, at least in part, to fill in the blank left by AHA. Here are my thoughts on what might constitute a few new core measures for quality.

Physician and nurse communication as a “trigger metric”. Even in the most sophisticated healthcare systems, thorough communication to the patient so about their care is not always the focus for all caregivers. No communication – no quality reward.
Percent of participating physicians using clinical decision support tools – A version of this metric currently exists in the proposed rule, but is limited only to primary care. With the rapidly growing complexity of care, not using decision support tools as they become available will become akin to not using antibiotics to treat infections. We must learn to work in new and innovative ways, using all the tools we have available, if we truly wish to improve care and lower costs.
Time to implementation of evidence based care – The medical field continues to be content with slowly adopting therapies and interventions that are known to work and save lives. As an example, the use of care guidelines around the insertion and care of central lines has been definitively shown to save lives, yet adoption across the country is not yet universal. Adoption of this type of guideline should be expected within one year of release of data deemed as “clinically significant” by a panel led by physician experts in clinical quality.

This list may not be complete and may not represent exactly the type of quality metric that CMS or AHA has in mind. However, if we as a healthcare system, cannot successfully address some of these tough issues at the very core of care delivery, we have little hope of reaching our defined goals of truly providing the highest quality of care that we know can be delivered.

Elevators and Amusement Rides

Mark Browne — Thu, 12 May 2011 15:30:06 -0500

Yesterday was no different than many other days in my life as a consultant. Two clients, three cities, and finally arriving late evening at the hotel. It had been a long day of travel and I was looking forward to getting into my room and off of my feet. As I got onto the elevator, for some reason, the inspection certificate caught my eye and I felt compelled to read it. Capacity 1750 lbs. No more than 5 passengers. Inspection good through January 2012. And then I saw it – Certified by the State Administrator for Elevators and Amusement Rides. Elevators AND Amusement Rides? Did I miss the “You must be THIS tall to ride this ride” sign? Visions of “approved” rusty carnival rides whirling in the air made me very glad to step out of the elevator and onto something a bit more structurally sound.

This week a new study from Mayo Clinic was released, outlining the volume of colonoscopies a physician must perform to demonstrate expertise as rated by an objective test of endoscopic skill. The study showed that the number of procedures needed to show competence in colonoscopy was nearly double the 140 procedures currently recommended. It also raised questions regarding many procedures and the training required to attain true expertise in performing them.

As we continue to plunge into a world of healthcare accountability based on value and not solely on volume, I have to ask the question: are setting the quality bar high enough? It is a difficult discussion for many practices and health systems to have, but the question of clinical competence must be expanded beyond performance that is simply ”greater than the state or national average.” Have we given our nurses and clinical staff the appropriate training to truly excel in caring for our patients? Are we holding all physicians to the same high standards for every procedure, in every setting? Have we allocated our financial resources to truly focus on the highest clinical outcomes attainable, not just performing better than our nearest competitor?

As the concept of measuring value and holding each other accountable for outcomes evolves, we must be cautious not to measure only what we currently can track and assume that it is good enough. We must continue to push to measure that which truly demonstrates a standard of excellence, not just a standard of competence, even if that means that some physicians or health systems won’t be able to provide that service until they can demonstrate a higher level of care. It may be difficult, but until we in healthcare hold ourselves to these new, higher standards, we will never know if we are getting elevator or amusement ride quality.

One Small Step

Mark Browne — Mon, 25 Apr 2011 15:29:07 -0500

Ask anyone who was alive in the 60’s to list the greatest accomplishments of our country and they will most certainly include the successful flight of Apollo 11 and the first moon landing. The US spent nearly $25 billion dollars to get Neil Armstrong and company to the moon and back, but what did we really see when we got there? Buzz Aldrin captured it best when he looked at Neil Armstrong and said: “OK. About ready to go down and get some Moon rock?” $25 billion dollars and over 200,000 miles to get there and we get…moon rock.

In 2008, the US government spent nearly $400 billion dollars on Medicare with another $200 million on Medicaid, and the numbers continue to grow every year. We now find ourselves facing the challenge of nearly 500 pages of new rules governing how this money will be spent and facing a long and arduous journey to find new models of care delivery to somehow make this all work in a new and different way. If and when we finally reach the promised land of Accountable Care Organizations, what will we find when we finally arrive?

The creation of new models of care delivery may be the greatest challenge healthcare has faced in decades, but where we actually end up may not be the most important part of the journey. Even though our Apollo astronauts came back with a bucket of rocks, the trip to get there had great value in and of itself. Without it we may never have had dialysis machines, CT scanners, contemporary physical therapy machines, cook/chill equipment, Mylar, athletic shoes, or even cordless power tools.

What new innovations will come from our journey to a new world of healthcare? A patient portal app that is standard on all smartphones? New medication delivery systems that eliminate the need for IV lines entirely? True real-time quality measures and interventions? - (Mr. Browne, this is your patient care coordinator. I see through your iPhone app that your BP has been above baseline for 5 days. Have you been taking your medications?) And many, many others….

The destination of the new care model as it has been currently defined may end up being no more exciting or memorable than a big pile of moon rock, but the innovations we create along the way may just make it worth the trip.

A new "ist"?

Mark Browne — Mon, 11 Apr 2011 15:01:05 -0500

Since the term hospitalist was coined in 1996, this new specialty has grown faster than any other in the history of medicine. Continued financial pressures on primary care, combined with increased restrictions on resident work hours and the desire of physicians for a more manageable lifestyle, created a perfect environment for the rapid growth of this field. The success of this model has spawned the creation of similar models in obstetrics (the laborist) and, most recently, surgery (the surgicalist). As I read through and began to digest the proposed rule for implementation of ACOs over the last week, I began to wonder if we were once again creating the perfect environment for the creation of a brand new kind of specialist….

The proposed rule has more than 50 pages dedicated to defining specific quality measures, how they will be used, and how physicians will be rewarded (or punished) based on their performance. There are 65 metrics currently outlined, the majority of which are to be measured in the outpatient, primary care setting. Metrics include seven measures on patient satisfaction in the primary care setting, rates of 30-day post discharge visits, surveys for patients on how well they understand their care plans, “ambulatory sensitive conditions” (diabetes, CHF, dehydration, pneumonia, and others) measured both on how well you manage them as well as your ability to keep patients with these diagnoses out of the hospital – and the list goes on. The rule goes on to outline that you must report on and perform well on each and every one of these metrics if you wish to participate in any available shared savings. The potential financial rewards for many organizations are great as are the adverse risks of underperforming.

Primary care has been thrust into the center of medicine once again (can anybody say capitation?), but this time it appears that at least some of this model may actually stick. Although putting the primary physician in the proverbial driver’s seat will have advantages for managing care and outcomes, there is only so much a physician can do in a day. How will primary care physicians find the time to continue to do what they have always done – diagnose, treat, and care for their patients? Ladies and gentlemen, I give you, The Preventionist.

The Preventionist will focus solely on the optimization of care as defined by CMS, BCBS, and any other outside entity or payer. They will only see patients with conditions defined as focus areas for cost and quality, nothing more. Diagnostics or other conditions? Leave that up to your family physician. Acute illness? We have a nurse practitioner that will see you now. Without this focus on the ever-rising bar we are being measured against, how will any organization be able to truly succeed? This may be taking this looming model of primary care to an extreme, but ask any internist who has practiced more than 10 years if they ever thought, when they first began, they wouldn’t be caring for their own patients in the hospital?

The new rules are upon us and I do believe they were well intentioned and designed (at least in theory) to lead to better care for patients and populations at a lower cost by charging primary care, once again, to steer the ship. However, in our haste to create a model to save money and to care for the most challenging patients, I fear we may be creating just what we are trying to avoid – misaligned incentives and a model of care that is even more fragmented than the one we have today.

Draft Day

Mark Browne — Wed, 09 Mar 2011 11:19:49 -0500

As I was getting my daily fix of ESPN this morning, something a bit different than the routine scores and highlights came across my TV. Two very talented men, both potentially bound for NFL stardom, were showcasing their talents for scouts, coaches, recruiters, and reporters – a panel of judges if you will. Although these players have certainly proved their talents in the past, these workouts will likely determine which player an NFL team will choose to build their future around. These workouts are vigorous, competitive, and very, very public. As draft day approaches, there is a running tally of whose stock is up and whose is down. Which player is at the top of Mel Kiper’s big board? Who will be drafted in the top ten? Will they succeed or be a bust?

As I listened to the reporter break down every step of Cam Newton’s latest pro day, I wondered what it might be like if physicians were put through this type of workout and evaluation before we were “chosen to play on a team?” If professional entertainers are subject to this type of scrutiny, shouldn’t we expect at least that from those of us sworn to care for the sick and “do no harm?”

I thought about the standard recruiting process for most physicians. A check of our background and training. A reference check from those with whom we have worked. An interview or two and a nice dinner. All of this is usually followed by an offer and a contract. Not exactly the NFL combine when it comes to assessment of quality.

The world of quality in healthcare is at a pivotal point in its history. Tracking of quality data and performance is certainly central to any health reform effort, but when it comes to individual physician performance, we admittedly have a long way to go. The arguments over which data are good enough and whether or not it “applies to me” continue to be the core of many discussions in many physician lounges and hospital board rooms. We may not ever get to the level of intensity seen on NFL draft day, but if we truly hope to deliver the highest level of quality for our patients, we must be more open to increasingly higher levels of scrutiny and evaluation of our performance.