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
Uncategorized•
on June 14th, 2010•
By Shelley Burns
Do you know …
- How many hospital-acquired pressure ulcers you had last year?
- How much additional care, in dollars, did patients with hospital-acquired pressure ulcers require?
- What are the top three DRGs contributing to your pressure ulcers?
- Which three DRGs are the biggest losers (i.e., payment is less than cost) for your hospital?
- How much money, in total, did these three DRGs lose?
These answers and more are available in the HMC Clinical Analyzer. Take the HMC Clinical Analyzer quiz to test your skills and discover more about your hospital. Participants with 100 percent correct on the quiz will be recognized in next month’s newsletter and receive a cup of coffee (Starbucks gift card) on HMC.
Want a refresher before you take the quiz? Join us on Thursday, July 24 for a Clinical Analyzer overview.
Shelley Burns is head of knowledge management at HMC.
Uncategorized•
on June 10th, 2010•
By John Whittlesey
We have a facility – that will remain nameless – which has gone through a major physical transformation over the past three years. It recently built a brand-new, state-of-the-art tertiary facility to replace its older facility, but essentially keeping the same services intact. Now prior to the move, they certainly didn’t have what I would consider to be a cost-effective model of delivering healthcare.
So, when they were planning and building this facility, I advised one of the key planner-implementers of the project to take advantage of this singular opportunity to redesign the staff’s processes, productivity, utilization patterns, clinical protocols, etc. This could allow the facility, in effect, to “reset” its cost position in a new environment. He assured me the managers were working those things into the plans. I crossed my fingers and hoped for the best.
So we’ve just finished the facility’s 2009 clinical benchmark, and I was curious to see what major changes occurred. I went back to the 2007 report to see what its cited excess was at the old facility, and compared it to the first full data set under the new facility (FY 2009). Interestingly enough, the excess was 5 percent greater in the new facility than before, its cost/case was nearly the same, and most of the same DRGs were cited for similar variation.
So, to my eye nothing really changed, except they have a new, pretty facility. Is that really good stewardship of healthcare resources?
John Whittlesey is principal at HMC
Uncategorized•
on June 7th, 2010•
By John Whittlesey
So, recently I’m talking to one of our best program coordinators, and we’re reviewing their facility’s clinical benchmark results for 2009. I comment that Dorsal and Lumbar Spinal Fusion is their highest excess DRG this year and has increased its excess over the previous year. We drill into the data and find that the cost per case in Surgical Services is very high and increasing – hence, the driver of the excess.
Volume has also increased over the past two years, exacerbating the problem. Then the program coordinator tells me the new neurosurgeon is the one driving the volume and cost increase. The coordinator also discovered, well after the neurosurgeon was in place, that he was a part owner of the implant vendor he was using at their facility! So I ask if they bothered to do any due diligence to check out the neurosurgeon’s practice patterns or background, and the coordinator said the facility was so happy just to get neurosurgery coverage that it didn’t bother.
Really! This happens so often when it comes to surgeons. For some reason, hospitals don’t think they can/should/have the obligation to check out anything more about a physician than if they have a license, any outstanding lawsuits, or have had any disciplinary actions taken against them. I say: “What’s wrong with adding clinical and economic credentialing to the professional credentialing?”
More, now than ever, hospitals have a fiduciary responsibility to make sure their physicians will manage clinical resources effectively and efficiently.
John Whittlesey is a principal at HMC
Uncategorized•
on June 3rd, 2010•
By Michelle Gray-Bernhardt
(Part two of a two-part blog)
A wide-ranging sample of nurses from various facilities’ units participated in HMC’s survey. Their responses for the greatest time wasters fell into these broad categories:
1. Charts and documentation
These topics are interrelated. Frustrations around charts include missing or incomplete charts, the necessity of charting excess information, and/or duplicating information. It also includes the difficulty in finding necessary information.
Online documentation is the number one source of inefficiency and hybrid (half paper/half electronic) systems are singled out as particularly frustrating. Nurses also noted problems with incompatible computer systems and the crashing of glitch-prone systems, which required information technology staff intervention.
2. Finding and gathering supplies and equipment
Whether supplies or equipment, time spent searching equals time spent away from patients.
3. Patient flow
Transporting, admitting, and waiting for patients is a frequently-cited inefficiency. This includes lack of exam or treatment rooms or anomalous patients in units.
4. Physician interaction
Waiting for communication with physicians (return phone calls, post-round information, medication orders, discharge orders, etc.) creates frustration among nurses.
5. Communicating with families and patient complaints
Nurses find it challenging when families call frequently and unexpectedly, particularly when there is no clear family spokesperson. The result is that multiple family members call in with the same questions, status requests, etc.
For more information
HMC clients may check out the Nursing Obstacles and Inefficiencies Survey to see a bar chart of the results and see the nurses’ comments. They’ll also learn which nurses are doing well with time management and in maximizing patient time.
Michelle Gray-Bernhardt is an HMC knowledge manager
