Uncategorized•
on July 26th, 2010•
By Shelley Burns
Healthcare has long resisted learning – truly learning – from other industries. One of the first blogs I wrote was on this subject. Yes, healthcare is different. But is it so different that other industries’ ideas, best practices, and demonstrated successes can’t be adapted and applied to healthcare? So different that ubiquitous process improvement strategies don’t apply?
I don’t think so. I read Health Leaders, coverage of Captain Chesley “Sully” Sullenberger’s address to the American Hospital Association Leadership Summit. He described the evolution of aviation safety improvement – there’s no denying the data – and how the industry’s founders found practices that worked. And the key tenets can be applied in multiple enterprises, including healthcare. It’s not rocket science. Well, maybe it is … aviation science, anyway. The key takeaways from Captain Sullenberger’s presentation on quality transformation in aviation were:
- Standardize equipment and responsibilities
- Strictly adhere to checklists
- Cultivate a team culture of safety and quality – zero tolerance
- Eliminate individual blame for systemic failures
- Reframe the captain role from god or cowboy to leader
- Measure, monitor, and communicate quality – incidences, outcomes, and the cost of off-quality
Are these principles really inapplicable to hospitals because their work is so different?It’s not rocket science. That’s not to say it’s easy, that it won’t require a great deal of courage and hard work. It’s difficult, but it’s doable. And it’s the right thing to do. Hospital-acquired infections, medication errors, patient falls, and the like are not uncontrollable collateral damage. They can be prevented if we summon the will to make the seismic mindset shift that Captain Sullenberger recommends, to stop thinking of mistakes “as inevitable and start thinking about them as unimaginable.”
Shelley Burns is head of knowledge management at HMC.
Uncategorized•
on July 22nd, 2010•
By Shelley Burns
I read this article with dismay last month. Why, in a profession that prides itself on evidence-based care, does the C-section rate continue to increase?
The increasing C-section rate is *almost* a microcosm of what is happening in many areas of healthcare. This overutilization of a medical procedure is driven by misaligned incentives for nearly everyone involved – except, perhaps, the baby. Like other causes of overutilization, the drivers of C-section rates are complex and intertwined. And while the scientific evidence is clear, it’s the cultural and market issues that make reducing the C-section rate more like a wild game of whack-a-mole.
Medical advances have lowered the attendant risks of C-sections, a great boon for those mothers and newborns who need them. Mothers who don’t require a C-section understand that the risks are lower, and consequently aren’t as wary about having a C-section as they used to be. They also understand that sometimes, to prevent risks to mother and or baby, a C-section is necessary. AND you can schedule baby arrival to the minute. Mothers don’t want to add the increased risks mentioned in the article to themselves or their babies. Yet, they are faced with work deadlines and short maternity leaves, and so don’t have much time to cobble together a support network after the birth. So, many mothers feel some slight increased risks are worth it. After all, they know plenty of other women who had a C-section and everything turned out just fine.
C-sections are attractive to physicians, too. One source claims that C-sections can eliminate six of the nine most common reasons for obstetrician lawsuits. Faced with declining reimbursements and increased litigation, where is the incentive for the physicians to advocate strongly for a vaginal delivery? C-sections make their paychecks and schedules more amenable; the likelihood of litigation is reduced; and, their patients want C-sections. If the consumer is supposed to drive the care, and the physician has explained the risks, what’s a physician to do when an expectant mom wants a C-section?
Hospitals, as well, are caught in the consumer-driven care trap. Their customers, physicians, and mothers want C-sections and hospitals deliver (pun intended) what the market wants. Hospitals get additional benefit because accommodating C-sections gives them more control over delivery volumes and schedules, and they can forecast their costs and staff requirements more accurately. C-sections also generate more services from the hospital, and our reimbursement system is service-based, not outcome based. Hospitals get higher reimbursements for C-sections.
So the primary participants in the C-section decision are today incentivized to increase C-section utilization. Each person/entity in this scenario faces undesirable consequences if they do the right thing, according to evidence-based medicine. Until there are changes in the payment system, legal system, and our overall business culture, evidence-based care will continue to take a back seat to societal and market forces. And this example of overutilization typifies many of the other conundrums present in our current healthcare system.
At the beginning of this post I said that the C-section trend was *almost* a microcosm of healthcare utilization issues overall. For many other medical activities, the gorillas in the room are the drug, implant, and medical device companies. These companies’ presence in the C-section microcosm is very small; in this instance, they aren’t driving increased utilization. But for those procedures where they have a stake, add another market force incentivized to increase utilization. Another conundrum for another day.
Shelley Burns is head of knowledge management at HMC.
Uncategorized•
on July 15th, 2010•
By Shelley Burns
I read and listened with dismay over various outcries about the recess appointment of Dr. Donald Berwick as administrator, or head of the Centers for Medicare and Medicaid Services (CMS). He’s a smart, thoughtful man with a good deal of common sense. Just what we need as we attempt to tame the raging tiger that is healthcare. We’re lucky that he’s willing to serve.
As much as the next American, I’m all for learning about political appointees’ opinions and plans. I am not, however, a fan of political posturing and commissions that are only masquerading as being useful. The latest hue and cry about the recess appointment of Don Berwick puzzles me: “We need to know where he stands! We need to know what he’s going to do!”
Really? The American public, and especially Congress (supposedly well-read in healthcare issues) doesn’t know where Berwick stands or what he proposes to do? This man has written volumes and given countless speeches outlining what he thinks the United States should do. He has built a foundation that transforms those thoughts into action, helping hospitals deliver higher-quality and lower-cost care. He’s thoughtful, smart and…most worrisome to the status quo, honest. He is willing to put the unpopular positions forward for discussion. He’s right – the waste in healthcare is astounding, full of non-value added activities that sap the strength from our country.
And yes, he does want to reform healthcare because it’s broken and needs to be reformed. Our quality compared to other developed nations is slipping. Our system is fragmented, much too expensive, burdened with extraneous care of dubious usefulness, and often inaccessible. We can do better. Why wouldn’t we borrow lessons from other countries where care is better and costs are lower? I think Berwick can help remove the blinders of arrogance that keep us from objectively analyzing results, both good and bad, from other countries. This also involves compiling the ideas that work, adapting them for our purposes, and ultimately improving healthcare for all Americans.
Healthcare reform is too complex and too critical, and the problems Dr. Berwick (and all of us) are facing are too important to be relegated to a “He wants death panels!” Twitter post. We all deserve better.
Shelley Burns is director of knowledge management at HMC.
Uncategorized•
on July 12th, 2010•
By Michelle Gray-Bernhardt
Question: When is texting at work a good thing? Answer: When it’s used as a minimally invasive tool to keep nurses apprised of patient requests without leaving the patient bedside.
Intrigued? That’s the lesson learned at Sentara Leigh Hospital (SLH) in Norfolk, Va. The hospital implemented a house-wide text messaging system using Ascom wireless phones to keep its nurses at the bedside with few interruptions.
In the past, nurses at SLH were frustrated because they had ringing wireless phones that rang until the call was answered – this was problematic when the nurses were busy. In response, the SLH Six Sigma team and Nurse Practice Council proposed a new system. Now, when a patient calls, an administrative assistant answers the phone and sends the nurse a text message. The text page triggers a different beep that can be silenced with the push of a button. This allows the nurse to first complete whatever conversation or procedure they were conducting before reviewing the text.
However, if the call is not answered within two to three minutes, it continues to appear unanswered on the administrative assistant’s computer screen. The assistant then resends the text, or finds an alternate person to answer the request. The staff wears tracer tags that cancel the call bell when they enter the room so the administrative assistant knows the staff went to the room to answer the call, and no further follow up texts are required.
In cases where the patient needs help getting to the bathroom, or other simple tasks, the message goes to assistive personnel, the rounder (a special position at SLH), and the nurse. The rounder or assistive personnel would be expected to answer these requests, but the nurse is kept apprised of the situation. In situations where the nurse is needed, having a text message allows her to prioritize requests without interrupting her current task. It’s a win-win situation. The patient gets a fast response from hospital personnel, and the nurse appreciates the convenience of a text message versus a page.
Want to try this at your facility? Then consider using these tips:
*Ensure you have the telecommunications and information technology staff and resources for the roll out and for subsequent usage monitoring.
*Involve bedside staff in development and roll out phases.
* Establish process guidelines to follow, then hold bedside staff accountable for ownership and for rolling it out on their units.
A nurse manager at SLH also offered the following advice: “We had a few instances in the beginning where staff did not think we could monitor the text messages. Once word got out that we really could track use based on those few incidents, staff compliance with expectations has not been a problem.” They have also established goals around voice response and in person response, and generate weekly reports to monitor compliance.
Michelle Gray-Bernhardt is a knowledge manager at HMC.
Uncategorized•
on July 9th, 2010•
By Shelley Burns
(Part two of a two-part blog)
Anchor number two: My best practice is out there somewhere
One very popular way to avoid change is simply to decide there is nothing superior out there to help the organization improve. Managers get caught in the trap of investigating, researching, evaluating, and singling out the best practice to serve as a universal remedy. Imagine an anchored boat, scanning the horizon but not setting sail toward a new destination. Suddenly, the quest for the holy grail of best practices becomes the focus of activity instead of making organizational improvements. This type of searching rarely ever ends, nor does it lead to results. Only action brings about change.
Anchor number three: The mindless mimics
It’s easy to fall into the trap of believing that best practices are simple panaceas that easily transcend organizational boundaries. Yet, simply mimicking another hospital’s best practice in no way guarantees results. Healthcare is complicated. What works in Hospital A may be a stunning failure in Hospital B, and the reasons for this might be a combination of 12 out of the 95 potential variables. Successful best practice implementations are not “cut and paste” operations. Managers must pick and choose from the successful practices of others to create the most effective practices for their organizations.
Using best practices for sails
The quest for the best practice can easily turn into a manager’s sole purpose. Seeking out best practices is a reasonable task for a manager, if and only if the manager then takes this information and customizes it to adapt to their organization and takes action to move the organization toward the goal. It helps to follow these guidelines for successfully removing the anchors to best practices. They include:
1. Define the expectation
2. Emphasize action
3. Use it as one of many tools available.
4. Align best practices
It’s not the best practices that fail, but rather an organization’s inability to successfully execute a best practice strategy. The quest to discover best practices does not absolve managers of their actual responsibilities of thoughtful analysis, focused leadership, and excellence in execution. Do it right, and you can enjoy the summer breeze in your sails.
Shelley Burns is head of knowledge management at HMC
Uncategorized•
on July 7th, 2010•
By Shelley Burns
(Part one of a two-part blog)
It’s summer and people are sailing. So one thinks of anchors and sails.
Every day, countless managers are charged with implementing “best practices” in their healthcare organizations. Yet, many best practice initiatives are doomed from the start. Managers and administrators have unrealistic expectations about the work necessary and the strategy for successfully implementing “the” best practice for their organization. A best practice initiative is not a substitute for sound management, thoughtful analysis, or well-planned implementation.
Managers become anchored in best practice limbo when they cavalierly dismiss ideas from others; when they use “cut and paste” as an implementation method; and when the best practice search itself becomes the focus of the initiative. Organizations that regularly achieve improvements through best practice initiatives cast away these anchors by gathering wide-ranging ideas, building a customized “best practice,” and emphasizing action and execution, as opposed to endless searches. These are the keys to using best practices as sails, instead of as anchors in the quest for performance improvement.
Anchor number one: my twin, only better
Hospitals are notoriously poor at borrowing ideas from other industries, or even slightly dissimilar healthcare organizations. Anchored managers only consider best practices from acceptable learning partners – and acceptable learning partners are healthcare facilities just like their own. For some managers, there are endless criteria to determine whether it’s worthwhile to even solicit a best practice. These criteria include: same size of facility, services, structure, payer mix, trauma level, average snowfall, number of stairwells, mean temperature, and age of buildings.
And, to top the list off, this exact replica must somehow be a better performer! Does this exact (and better) twin exist? No. Rather than seeking an identical facility, recognize that these differences direct organizations towards innovative improvement opportunities.
Everyone wants to learn from better performers, but how is a better performer defined? Is it based on hospital profitability? Hospital size? Staff experience? Typically, managers focus on this global “better performer” definition and further narrow their idea-gathering opportunities by requiring a learning partner to be broadly exceptional. These managers are thinking too globally, when they should be acting locally. Talking with other healthcare professionals about their best practices is easier once managers determine more specifically the practices they need to improve.
It’s a poor use of a manager’s time to search endlessly for the identical learning partner who has the ideal best practice that you expect to make all the difference. Rather, begin the process with the understanding that there are no quick fixes. Tangible improvement comes from considering many possibilities, and carefully analyzing and adapting the experiences of others to craft a best practice that meshes with your organization. By dismissing potential learning partners, managers cut themselves off from a rich source of ideas.
Shelley Burns is director of knowledge management at HMC.
Uncategorized•
on June 29th, 2010•
By Shelley Burns
For many years, finance people have accepted steadily increasing clinical costs as “the way healthcare is.” Talking to physicians and nurses about costs resulted in glazed eyes. This was due mostly to the fact that the care processes were so complex that they couldn’t even begin to think where to start on a cost improvement project for a specific nursing unit or patient. The daunting task of gathering up all the data and then plowing through it made most nurses cringe and most physicians frustrated.
Now with severity-adjusted DRGs, hospitals have tools at their disposal to see slight and nuanced variations in cost across similar groups of patients. They can benchmark costs/DRGs with other hospitals and see whether they are more or less expensive. External cost comparisons are a powerful tool and can help hospitals see where opportunities lie.
In the past, it was easy to dismiss external cost comparisons to other hospitals as being patient driven – “We are a tertiary referral hospital and our patients are sicker.” Nowadays, it’s harder to dismiss the external comparisons, especially with severity-adjusted DRGs. True, the more detailed coding and severity adjustments make comparing external costs easy. But, it’s still hard to convince clinicians that an external benchmark is achievable. It’s hard to “know” what the practices are at the other hospitals and requires a lot of hard work to identify which practices impact cost and quality.
So where to start? Start with a look at your own internal cost variances across DRGs. Why? Because cost variance is the explicit manifestation of an underlying variance in practice. Who drives the variation in practice? Physicians. Identifying and analyzing cost variances at the DRG level within your hospital’s four walls will enable you to uncover your own internal best practices – the best outcomes at the lowest prices. And it’s much easier to do than external benchmarks because all the players know each other. It’s a lot easier for physicians to talk to one another about their practices when they are sitting together in a room, reviewing internal cost comparisons.
Make sure you have compelling, actionable, and accurate data. Then sit your physicians around a conference table and walk through the data. You’ll be surprised how much everyone will learn and you’ll pave the way for truly understanding cost variation, improving clinical utilization, and the better stewardship of our healthcare resources.
Shelley Burns is head of knowledge management for HMC
Uncategorized•
on June 25th, 2010•
By Thomas Day
Mark Chassin’s study of his organization’s quality process measures was interesting to those of us who find “process” measures typically indirect, micro-focused, and therefore misguided as an approach to improving quality. While the criteria he used to evaluate the measures seem to make sense on the surface, let’s take a step back and ask what the heck we’re trying to do, anyway – i.e., improve healthcare quality – and are process measures the way to do this?
First, the good news. Some of the process care measures seem useful – if caregivers do these things, the outcome will be better. Early intervention with blood thinners for heart attacks is a good example. Administering blood thinners as early as is practical, with today’s technology, is an unambiguously good idea, so that’s a good one, I guess. PCI within 90 minutes? Sure seems like the right thing right now, again, with today’s technology. Okay, we have two good measures covering what, one percent of all inpatient cases?
Now for the bad news. There are a lot of things that aren’t heart attacks. Only one other measure for doing something quickly has been identified: in this case “Initial Antibiotics within 6 Hours” for pneumonia. Other process-of-care measures are the bare-bones basics – “Appropriate initial antibiotic” or “Assessment of LVS Function.” Can this possibly be an effective documentation task? Not much meat on these bones, to my eye.
And then you get to Surgical Infection Prevention. Seems to me that actually measuring Surgical Infections, as AHRQ measures do, without any additional documentation burden, I might add, is the way to get at performance issues on this one. Tracking “Hair Removed Using Safe Method-Pre Surgical,” “Prophylaxis Antibiotic – Right Kind,” and “Prophylaxis Antibiotic Stopped w/in 24” seem more than basic, unspecific in their measurements, and yet inflexibly tied to current practice methods.
So to my way of thinking, the Joint Commission-directed study does little more than confirm it likes its own measures, and will continue to burden the industry with these measures, given its power position in the accreditation process.
Urging greater scrutiny of quality process measures is definitely the right idea. Mr. Chassin’s study seems to just smooth over the basic problem with the whole approach – meanwhile public data and other pathways become stronger and are leaving JCAHO’s approach in the dust.
Thomas Day is president of HMC
Uncategorized•
on June 23rd, 2010•
By John Whittlesey
(This is the second part of a two-part blog)
The second “ah-ha” moment happened on the drive to work recently. A story on NPR discussed the recent announcement that the VA would become the first health system nationwide to develop and implement new methods of classification and monitoring to decide where various inpatient surgeries should be performed. (This decision was the result of a highly-publicized story of nine deaths in one year at a single VA facility in Marion, Ill. This occurred several years ago, and forced the VA to reassess how and where it was providing care.)
Essentially, this resulted in three levels of surgical procedures – standard, intermediate, and critical. Based on the resources available, infrastructure, volumes, outcomes, and several other criteria, each VA hospital is classified to provide care on one of these levels. Each of the VA’s 21 hospital networks has developed a surgical strategic plan to ensure that veterans receive needed care during the implementation process. (In reality, there were very few changes in terms of which facilities could still perform critical procedures.)
Again, this sounds like a good business decision to standardize care to ensure the best patient outcomes and efficient use of scarce clinical resources. If this were done in the private sector, I doubt it would go unnoticed or without a long and expensive series of congressional hearings. Interestingly enough, the VA’s surgical review program is expected to be expanded to include standards for outpatient surgery in the future. Here’s the link to a related article by Janice Simmons in HealthLeaders Media, explaining more about the program.
Similarly, Don Berwick’s ”Triple Aim” concept to consolidate and integrate delivery models based on improving the experience of care, improving the health of populations, and reducing the per-capita costs of healthcare may be the model that the private sector can adopt over time. If he’s successfully instated as President Obama’s new head of CMS, it may have a chance. Read Berwick’s full article here on the Triple Aim.
So, could the VA be getting the jump on the rest of the country by adopting a uniform delivery model across the continuum of care, focused on preventative and chronic care? No one seems to be crying foul about socialized medicine and a government conspiracy to take over the healthcare systems here. This may be the largest non-secret in the government today.
John Whittlesey is an HMC Principal
Uncategorized•
on June 18th, 2010•
By John Whittlesey
(Part one of a two-part blog)
When I was in grad school – oh so many moons ago – I learned the history of the early healthcare system in the United States. There was the Hill-Burton Act to build hospitals in rural and under-served areas; the social safety nets of Medicare and Medicaid; the evil for-profit models; the even scarier “DRG” classification and reimbursement models about to be implemented; and the then-emerging managed care products, etc.
The one fact that completely surprised and dismayed me was that there were two separate and parallel health delivery networks outside of the general private health system: the Department of Veterans Affairs (VA) system, and the military health system. Over the past 25 years, my mantra has been that if I were in charge of the national health system – and it’s a good thing I’m not! – the first thing I would do would be to get rid of the VA and integrate it into the private health systems we all use. We’d use vouchers or whatever to make sure that veterans still get the full service they deserve.
Now, I’m not so sure.
Two recent developments caught my eye and have made me think differently about the situation (yes, it is possible for me to change my mind). We’ve all heard the horror stories about the mistreatment of veterans (remember Tom Cruise in Born on the 4th of July?), along with big access and quality problems, have created a general impression that the VA system just isn’t as good as the private health system. Well, over the years it seems that the government and VA leaders have stepped up their game, and cleaned up many of the structural, facility, and clinical messes.
Phillip Longman, senior fellow at the New America Foundation and author of a book about the VA called “Best Care Anywhere,” discusses how the VA has been developing a model of integrated care delivery along the continuum of care (primary, outpatient, inpatient, aftercare, and preventive medicine). He holds that the VA is now the model of choice for the country to follow under healthcare reform. “The rest of the health-care system doesn’t have a business case for quality,” Longman says.
Most of this is being accomplished through one of the largest and most comprehensive electronic medical record projects to date. It’s a way of capturing longitudinal patient information and integrating it into patient care practices. This uniform, standardized, integrated, and theoretically efficient system will sound like a good business to some; to others it may sound like socialized medicine. Score one for the VA.
(Read a related article MarketWatch article by Kristen Gerencher here.)
John Whittlesey is a Principal at HMC
