Client News•
on September 30th, 2010•
Norfolk, Va.-based Sentara Healthcare recently announced plans to merge with the independent Martha Jefferson Hospital, based in Charlottesville. A nonprofit, Sentara Healthcare currently includes eight Virginia-based acute-care hospitals and home care services. According to a local press article, with this move, the Sentara system will include 10 hospitals across the State of Virginia. A 176-bed nonprofit facility, Martha Jefferson plans to open a new $275 million facility next year.
Uncategorized•
on September 28th, 2010•
By Shelley Burns
(This is second of three snowclone blogs.)
These snowclones are amazing things. I wasn’t intending to blog about this topic or use another snowclone, but the HMC blog kahuna was kind of insistent.
Politicians and the public are wondering why hospitals and health systems aren’t going gung-ho into the post-reform world. Most are treading water, and administrators are waiting to see what the next big wave will bring. There’s just too much that is unknown and the parts they do know, scares them. They know that their Medicare mix is likely to increase, while the reimbursements from Medicare continue to decline. They don’t know how much, but they are betting it’s going down.
Healthcare administrators know that hospitals need to take the lead in improving the the alignment across providers – clinics, physicians, long-term care facilities, rehab facilities, home health, and assisted-living facilities. But what do the models need to look like? Where will the infrastructure costs be borne? Do you partner or purchase physician practices and ambulatory clinics? What’s reasonable for an ACO? What will HIPPA proponents sue you for as you attempt to share critical information about patient care? How much follow-up is required for the hospital to insure that patients actually follow discharge instructions? What about some accountability from the patients themselves?
Administrators know that hospitals will have to exchange data seamlessly with payers. Hospitals have an uneasy relationship with payers – it’s hard to negotiate with deep-pocket insurance companies that have lots of actuaries to develop mind-numbing carve outs, pre-approvals, and payment requirements. Hospitals are likely to take it on the chin if they can’t align more smoothly with payers, but what happens if the payers don’t want to play nice?
What about the other things on hospitals’ plates? OPPE? RHIE? EMR? CPOE? CD-10? Hospitals have committed significant resources to these systems. How will these acronyms fare in the post-reform world?
It’s the HCRA, stupid. That’s why hospitals are treading water, waiting for the waves to abate before deciding where to set sail. It’s not alphabet soup, it’s alphabet deadlock.
Shelley Burns is head of knowledge management at HMC.
HMC News•
on September 24th, 2010•
The KnowledgeWeb expands and changes with clients’ needs
NEEDHAM, MASS. – September 24, 2010 – The Healthcare Management Council, Inc. this month has marked the addition of the 8,550th solution to its KnowledgeWeb portal.
While HMC is the leading provider of actionable benchmarks and dashboards, it offers clients even more. It delivers an online platform of easily searched solutions to the challenges its analytical applications define. It doesn’t just identify such things as excess and off-quality events – it provides easy-to-follow steps to solve them. With healthcare reform, technological advances, and a myriad of other changes afoot in the healthcare industry, hospital administrators need a practical easy-to-use guide to assist them.
“The KnowledgeWeb is an archive of thousands of ideas, insights, collaborations, and events that solve real world problems,” says HMC Director of Knowledge Management Shelley Burns. “It’s not a theoretical or abstract database. This has peer-submitted ideas and recommendations that have stood the ultimate test – that of working in the real world. HMC’s insights, combined with the in-depth knowledge of on-the-ground hospital managers, is unparalleled.”
“We all know that institutions contain vast amounts of knowledge, though it is largely inaccessible on a broad basis,” says HMC President Thomas Day. “Collecting and disseminating knowledge – commonly called “knowledge management” – has such huge potential, which, despite the tremendous investment of time and energy by many people and firms, remains largely untapped.”
He says: “Most knowledge is trapped within individuals and for the most part, is thought of as expertise. A consulting firm has case teams working on similar problems, and they may be able to find some help and direction within their own firm. Healthcare providers do similar work, yet clinical variation is so profound that reducing clinical variation around a best practice is often cited as a huge cost and quality improver.”
HMC not only has gathered these solutions into a single web-based repository, but has made it accessible in the most user friendly format available. According to Day: “We’ve built some excellent methods and tools which allow us to ‘issue-ize’ our knowledge. You ask about an issue, and we share the knowledge others have used to solve that problem. Knowledge is ranked, tagged, indexed, and applied to the analytic tools to tightly integrate them. The definitions of problems allow the direct presentation of the solution knowledge to our clients.”
In addition to being a rich idea archive, the HMC KnowledgeWeb is a real-time collaboration and idea generation platform. Nurses, managers, and staff participate in ongoing web conversations around ideas and topics to add insights on a Best Practice or enter a new idea into the database. “Interaction is key,” says Burns, “to grow the collective knowledge of the group and build a thriving community around specific topics.”
She says: “If you can’t find what you need or have a challenge to solve, there are two solutions. One is to call HMC and talk to one of our knowledge consultants. If the solution is in the KnowledgeWeb, we can find it for you quickly. Two, if we need to engage other HMC Partners in developing the solutions, we can do that, too, through surveys, conference calls, and targeted inquiries.”
Expanding world of knowledge
Just what is available on the HMC KnowledgeWeb? You can learn how to streamline discharge processes; or gather staffing ideas to reduce overtime; or develop keys to building a palliative care program, and much more. Ideas and solutions are available around the clock, every day, to every member of the hospital staff.
More specifically, KnowledgeWeb contains :
Three thousand, one hundred and fifty Best Practices. HMC’s Best Practices Exchange is an online forum designed to spark discussions around real-life issues such as preventing patient falls, managing equipment service contracts, and improving patient satisfaction with environmental services. Our clients can add suggestions or vote “pro” or “con” on a given idea to help create perspective and improve decision-making processes.
Two hundred and sixty-eight Successes & Good Ideas (SGIs). HMC endlessly seeks case studies and interesting articles to stimulate thought and solve problems. Its knowledge managers are frequently adding well-written and informative pieces on every conceivable topic. These SGIs stimulate thought and help you define and solve the healthcare challenges facing you daily.
Two thousand, one hundred and ninety-six Surveys. HMC keeps its pulse on what is happening out where you are, in the actual healthcare field. HMC online surveys have yielded a wealth of data on such topics as off-quality events, nursing staff frustrations, and more. This delivers insight into what is happening in peer facilities and enhances decision making.
Six hundred and seventy-six iConferences. HMC sponsors phone and web-based collaborations called iConferences to allow peers to freely share ideas and solutions to common problems. Administrators from small regional hospitals can receive best practice suggestions from the largest and most successful systems in the country. Contrarily, large hospitals learn the creative ways small hospitals perform tasks such as cross-training staff and streamlining processes. HMC archives the results of these events for convenient access.
Two hundred and fifty Documents. These documents cover technical and clinical specification sheets, flow and organizational charts, and white papers. They include PowerPoint presentations, PDFs, and templates that can be downloaded and shared through your organization to enable you to leverage existing best practices.
HMC considers the KnowledgeWeb a work in progress that will improve and change as the clients’ needs vary. “HMC’s KnowledgeWeb has been evolving for over 10 years and will continue to develop into the future,” says Day. “And as excited as I am about where we are today, it’s an exciting and never-ending journey.”
Uncategorized•
on September 15th, 2010•
By Karen Jorge
A big “congratulations” to St. Joseph Hospital in Nashua, N.H., is in order. Over the past few weeks, as part of their work to realize some of the opportunity found during the HMC benchmarking process, their managers and directors have created more than 50 action plans!
While this number is impressive for a small-to-medium size facility, the content of the plans is even more attention-worthy. The creators of these action plans did their homework with the Functional and Clinical benchmarks. They identified the potential opportunity within the functions or service lines for which they are responsible, and developed hypotheses for the major drivers of the excess. They also identified the steps to take (along with timelines) to reduce these expenses. We’ll be rooting for them as they move forward to implement their plans in the coming months.
So how can other facilities use action plans to help turn a benchmark report into cost savings? Action plans are a great place to start, and provide structure for figuring out next steps. Of our action plan templates available for use and adaptation, some focus on hypothesis generation – figuring out what is responsible for excess in a particular area. Others are more concrete, delineating actions to be taken and assigning dollar amounts to be achieved within a set timeline. As a general guide, here are some suggestions to consider when developing action plans:
1. Identify key players. Change is easier using a team approach. Determining who will be spearheading the initiative, as well as who else should part of the process, is an important part of creating and implementing a successful plan.
2. Pinpoint the opportunity. This could be the total excess for a particular function or DRG. All of it may not be actionable, but knowing the entire dollar amount that is out there will aid in determining what is achievable. Breaking it down further to see what part of the opportunity is made up of labor and what part is non-labor will reveal what action initiatives you should focus on.
3. Hypothesize key drivers. Using the department profiles and the KnowledgeWeb can help you determine the root causes of the opportunity. Our surveys, iConferences, Successes & Good Ideas (SGIs), and document library have relevant information. If you need more information, just let us know! At this point in the process, it is also a good idea to figure out why you believe your hypothesis to be true, as well as what could be done to substantiate it.
4. Establish a timeline. Perhaps senior management has given a deadline for achieving opportunity. If not, it’s beneficial to determine an endpoint for completing plan implementation, as well as intermediate dates for accomplishing steps along the way.
5. Track progress. Keeping tabs on your progress, either through a dashboard or by another method, will show what has been accomplished and what is still on the table. If this dashboard (or other tracking mechanism) is shared with others, it will also serve as a means for accountability. In addition to endpoint goals (e.g., lowered expenses or elimination of agency use), there may be other important metrics to track – including quality, patient satisfaction, and revenue – to evaluate the broader impacts of implementation.
Karen Jorge is an HMC analyst.
Uncategorized•
on September 13th, 2010•
By Shelley Burns
Okay, I admit it – I snowcloned my title from Bill Clinton’s 1992 presidential campaign slogan, “It’s the economy, stupid.” Snowclones have entered our lexicon because their form and cadence are instantly familiar, and the relationship immediately understood. We’ve all done it: “Try my experimental casserole! I’m not a chef, but I play one on TV!”
But that’s the thing, isn’t it? I could wrack my brains to come up with a clever, pithy title, or I could build on the collective knowledge of our culture to uncover a shorthand title that instantly conveys my topic. And that’s what collaboration via the HMC KnowledgeWeb is all about – building the collective knowledge of the group for the mutual benefit of the group. (We could, I suppose, debate whether snowclones are really beneficial.) Healthcare is complex – a convoluted maze of protocols, policies, practices, people, patients, and data. Reinventing an established and proven best practice every time you need to improve a process is akin to shooting yourself in the foot – and wondering why it hurts to walk.
True healthcare reform requires collaboration on a large scale. And I’m not talking about the big collaborations – like the insurance companies suddenly deciding that they will all use the same form for hospital claims (although that would be nice, wouldn’t it?). No, I’m talking about more local, more operational collaborations. This is the sort of collaboration where EVERYONE is involved in improving their little corner of healthcare.
The nurse educator wonders if others found that online refresher courses improved performance on competency tests. The infection control manager shares strategies for increasing hand-washing compliance. The admissions clerk asks how others handle living wills and healthcare-power-of-attorney paperwork. Nurses debate the pros and cons of call lights and hourly rounding.
The HMC KnowledgeWeb empowers this large-scale, focused collaboration so that the aggregated, collective knowledge of everyone benefits…well, everyone. It’s web-based, so it’s available 24 by 7, when and where it’s convenient for healthcare workers. Also, it’s scalable – the more participation, the merrier. You can query your peers; you can submit the results of your own initiatives; you can search on archived solutions and documents; you can rate and debate ideas with others. And if you get stuck or have a question, there are live people to help you find your way.
Visit the HMC KnowledgeWeb and redefine the old slogan with: “It’s the collaboration, genius.”
Shelley Burns is head of HMC knowledge management.
Uncategorized•
on September 10th, 2010•
By Karen Jorge
(Part two of a two-part blog)
In my previous blog, I pointed out that doctors and nurses communicate differently than patients do. This can cause problems in care.
To bridge between these narrative and explanatory gaps, Kleinman advocates an approach in which the physician or provider asks the patient (and, if possible, the patient’s family) the following questions (at the very least to elicit their explanatory model):
- What do you call the problem?
- What do you think is causing the problem?
- What course do you think the problem will take, and how serious do you think it is?
- What do you think it is doing inside your body?
- How does the problem affect your body and mind?
- What do you fear the most about the problem itself?
- What do you fear the most about the treatment?
Similar questions would be asked regarding the proposed treatment. Only after the physician has explored the patient’s perspective can they use the information to discuss and negotiate treatment and care decisions. Perhaps if the cardiologists in the Globe study used a similar approach, the patients and physicians would improve their communication and understand each others’ explanatory models.
Karen Jorge is an HMC analyst.
Uncategorized•
on September 9th, 2010•
By Karen Jorge
(Part one of a two-part blog)
Over the past few days, there were a couple of interesting and related articles on hospital communications.
One was in the Boston Globe, and the other in a New York Times blog. The Globe article discussed a recent study of cardiac patients undergoing angioplasties and receiving artery-opening stents. When asked about the potential outcomes of the angioplasties and stents, more than 80 percent of the patients in the study reported that they believed the procedure could prevent future heart attacks or death from heart attacks.
Then researchers asked the same question of the cardiologists who were either performing the procedures, or had done the patient referrals. More than 80 percent of these said that it would only help ease chest pain and do nothing to prevent heart attacks. That was because the patients were stable, and not emergency cases. Obviously, there was a huge difference between what the physicians thought they told patients, and what the patients thought they were told.
The Times article (written by a nurse who regularly writes for the paper’s “Well” blog) discussed the way doctors and nurses communicate with each other. She calls this manner of speaking, with its speed and use of medical jargon, the “Rattle.” The Rattle covers the most important information about a patient and nothing more. While this method of communication is crucial to doctor-nurse interactions, it does point to a larger issue highlighted in the Globe article – doctors and patients communicate differently!
In our HMC patient satisfaction benchmarks, we often see the measures regarding communication (with doctors or nurses, or around medicines and discharge) as ones that patients do not score highly. So, while good communication between patients and their providers is vital to providing good care and ensuring positive outcomes, it remains a tricky area to navigate.
In the medical anthropology literature, there is much discussion about interactions between patients and providers. A commonly used approach for understanding how to make these interactions more effective for both parties is the “explanatory models” approach. Dr. Arthur Kleinman’s influential book, The Illness Narratives: Suffering, Healing, and the Human Condition, outlines this methodology. In essence, it demonstrates that medical practitioners conceptualize and talk about illness, diagnoses, and treatment differently than patients do.
Put another way, each party brings their own “explanatory model” to the table. The practitioner generally adheres to the essential biomedical explanations – the Rattle. However, the patient follows a more lengthy “illness narrative” that combines physical and psychosocial elements. Both models are valid and useful, but when unaligned, the models hinder communication. This can lead to care that is not only frustrating for both provider and patient, but can also be dangerous.
In the case of the Globe article, if patients have such a drastically different understanding of the procedure they are undergoing, they may subsequently choose actions (such as discontinuing medication after receiving a stent) that fit their model but are potentially harmful. Furthermore, physicians may not take the time to explain what the patient should do upon discharge from the hospital and find out if this plan fits with the patient’s own model.
Karen Jorge is an HMC analyst
Client News•
on September 2nd, 2010•
Inova Fairfax Hospital recently announced that Patrick Christiansen is its new COO. In his role, he will have executive responsibility for operational procedures, and will join the collaborative team overseeing strategic decisions for both the hospital and the Inova Health System. Prior to this, Christiansen was a senior vice president of Inova Health.
According to the announcement, Christiansen joined Falls Church, Virginia-based Inova Fairfax in 2007 as administrator of the Inova Heart and Vascular Institute. While there, he established a highly successful cardiovascular program. He became senior vice president of the system in 2009.
Uncategorized•
on September 2nd, 2010•
By Shelley Burns
(This is part three of a three-part blog)
I’ve previously blogged about the overutilization of C-sections and inductions and the misaligned incentives for everyone involved – physicians, parents, hospitals, businesses. Is it possible to overcome the cultural and market forces that drive overutilization in childbirth?
It’s a tall order, but not impossible. Since 1999, Intermountain Healthcare, an integrated system based in Salt Lake City – 19 birthing facilities in Utah, one in Idaho – has been changing the culture around childbirth, one step at a time. Janie Wilson of Intermountain has shared its journey with HMC partners, and at several professional society meetings over the past 10 years.
The staffers started with their mission – clinicians working together with other clinicians, health care administrators, and patients to develop high-quality, cost-efficient medical care for women and newborns, by incorporating evidence-based medicine into a program of continuing quality improvement.
They supported that mission by analyzing utilization and outcome data. They discovered that inductions at gestational ages less than 39 weeks resulted in longer labors for mothers, more C-sections, and higher costs. Now, everyone knew that the American Congress of Obstetricians and Gynecologists (ACOG), recommended against inductions at less than 39 weeks for healthy mothers and babies. But, due to convenience, the casual culture surrounding inductions, legal issues, scheduling, and other market forces, the induction rates at Intermountain had started to rise, mirroring trends in the rest of the country.
When Intermountain looked at the data and found it to be in conflict with its mission, it decided it could improve care – reduce non-necessary C-sections, reduce hours in labor – if it reduced elective inductions prior to 39 weeks. This is a key step. It decided it could do better.
The staff gathered and shared data on elective inductions and the consequences with admitting physicians and local OB/GYNs. They used the data and physician input to develop their evidence-based guidelines – among them, no elective inductions for less than 39 weeks. Several sites went a step further and agreed to no elective inductions for first time mothers. Imagine – they worked to convince all 20 sites and their concomitant clinics and physicians to agree on the guidelines and entreated all stakeholders to abide by them.
The results?
* Some sites have had very impressive successes; the most improvement in reduction of primary C-sections occurred in facilities that chose not to electively induce first-time mothers.
* After ten years, the elective inductions for less than 39 weeks gestational age has dropped from ~27 percent to under two percent.
* Utah has the lowest C-section rate in the nation, 22 percent. (Intermountain delivers 55 percent to 57 percent of the babies in Utah.)
* Costs are low. The HMC comparative databases show Intermountain facilities among the lowest-cost birthing providers.
Intermountain shared and continues to share the outcome and utilization data – to continually reinforce for the medical community and parents that having fewer elective inductions is indeed the best care they can receive.
However, the misaligned incentives in health care caused this success to come at a cost to the hospitals. The elective induction guidelines drove down revenues in labor and delivery services. Even though it drove reimbursements down, Intermountain continued to be a strong proponent of the guidelines, demonstrating commitment to its mission of evidence-based medicine and continuous improvement. This has had the unintended benefit of positioning the system well for health care reform – for best care and most appropriate utilization.
Intermountain discovered that increased interventions like inductions adversely impacted care. Instead of allowing that fact to be obscured by misaligned incentives that induce (pun intended) overutilization, Intermountain decided that evidence-based care should not take a back seat. They decided.
As a nation, we can improve healthcare and decrease the waste of overutilization by developing high-quality, cost-efficient medical care for everyone by incorporating outcome data into a program of continuing quality improvement. We just have to decide to do so.
Shelley Burns is head of knowledge management at HMC.
