Uncategorized•
on April 20th, 2010•
HMC has compiled a cutting-edge white paper of best practices to address the expensive and widely prevalent problem of decubitus ulcers.
Research from HMC has indicated that decubitus ulcers cost around $575,000 for an average hospital annually. A patient acquiring a pressure ulcer requires an average of $9,200 in extra care. This cost is not reimbursed by Medicare or Medicaid and in the future probably won’t be reimbursed by private insurers, either. What’s worse is that this is a preventable off-quality condition, according to Shelley Burns, HMC’s director of knowledge management.
There are solutions, however, says Burns. “Being able to readily discern patterns in your ulcer incidence increases the likelihood that you can fix your decubitus ulcer issues quickly and effectively,” says Burns. For more on this, see today’s announcement.
Uncategorized•
on April 15th, 2010•
Interested in physician performance and utilization? HMC is as well, and to facilitate this, we’re organizing a peer group that will focus on building meaningful physician scorecards. Our databases already house extensive clinical data and comparisons, and clients have asked about standard metrics or reports to find opportunities to improve utilization and quality via physician profiles or scorecards. Therefore, we are in the process of building a data pathway to allow hospitals to understand the quality, utilization, and cost impacts of their physician groups and practices. The scorecard will uncover how physician practice, utilization, LOS, and quality directly impact your bottom line, your patient satisfaction, and your market share.
This is the chance to start a productive dialog with your professional colleagues and HMC. Ultimately, it will allow you to provide input into the report characteristics – what data and format would be most useful, and what links and pathways would offer the greatest insight. Understanding and communicating these practice and utilization issues will enable your hospital to thrive. This virtual group will collaborate via the KnowledgeWeb with surveys, discussion forums, and Webinars. If you are an HMC client interested in joining our development group, please click here and start to explore the world of physician scorecards.
Shelley Burns, head of knowledge management, HMC.
Uncategorized•
on April 12th, 2010•
By Thomas Day
Recently, I read a McKinsey article titled “Making health care healthy,” by Gary Cohen. While it seemed a call for a type of change that was beyond a comprehensible and actionable scale, he did discuss some very interesting and mind bending issues that gave me real pause.
The central idea is that chronic disease is swamping us. Cohen states that “70 percent of all health care expenditures in the U.S. are devoted to treating chronic disease; only 4 percent of the healthcare budget is focused on primary prevention.”
Some supporting statistics from the article: learning disabilities impact one in six children; infertility impacts one in six couples; one in three women and almost one in two men will get cancer in their lifetimes; among children under 14, cancer is the leading cause of death by illness. Also, obesity affects almost 90 million Americans – at a cost of $147 billion per year!
Cohen notes that our exposure to hundreds of toxic chemicals in our environment is partially to blame. There are also other factors, such as food produced by a “failed industrial food system,” as well as poor individual choices. Our health care system seems to be like a machine designed to pull people out of a river, but that never moves upstream to keep them from falling in, he says. There is some evidence we can do something better. As evidence, he cites some really small wins: eliminating mercury thermometers; creating medical waste incinerators; and improving the food quality in hospital cafeterias.
Wow, if that’s the best we’ve done to date, this looks like a pretty huge problem.
Thomas Day is president of HMC.
Uncategorized•
on April 9th, 2010•
The long term benefits of using robotic machines in prostate surgery have yet to be proven, according to a new study conducted at the Sentara Health System/Eastern Virginia Medical School in Norfolk. According to Reuters, for the study, researchers evaluated 785 men who underwent four types of treatment for prostate gland cancer. The procedures included both robot-assisted surgery and conventional open surgery, as well as the implanting of cancer cell- killing radioactive “seeds,” and cryotherapy.
While advocates claim using the robotic technology reduces the risks of long-term incontinence and impotence that comes with traditional open surgery, the facts apparently aren’t there. In fact, “there were no significant differences in quality of life between men who had undergone open surgery and those who’d had robot-assisted surgery,” states the article’s author.
Given that just to purchase the machines requires a $1.5 million upfront investment, as well as surgeon training and annual maintenance fees, administrators may want to take pause before signing checks.
Uncategorized•
on April 6th, 2010•
By Karen Jorge
I had a doctor’s appointment the other day. While making small talk as he looked through my records, the doctor asked me what I do for a living. After I told him that I work in hospital performance improvement, he said that he was very concerned about healthcare reform, because it made everyone think that they had to provide an “impossible” combination of high-quality and low-cost care, with too much of an emphasis on cutting costs.
While this particular physician may have been correct that only focusing on cutting costs won’t improve care, he missed the point. High-quality care doesn’t have to cost more. It is in fact very possible to inexpensively provide high-quality care precisely because providing such care lowers its delivery costs. Poor quality is much more expensive, as it requires extra resources to fix problems, and results in longer lengths of stay and higher malpractice costs.
HMC has found that hospitals that provide the highest quality care are usually some of the lowest-cost performers. Driving organizational change through quality-improvement initiatives can ultimately lower hospital costs by avoiding expensive off-quality events, lowering length of stay, and making care more efficient. As an added bonus, approaching hospital performance improvement in this vein can be more valuable and palatable to physicians – who are primarily (and understandably!) concerned with providing the best possible care. It also can facilitate getting them on board with strategic improvement projects.
The relationship between cost and quality doesn’t have to be an antagonistic one that makes a hospital try to determine just how much money it can cut from the budget before quality suffers. Instead, by “leading with quality,” the cost drops will follow.
Karen Jorge is an HMC analyst.
Uncategorized•
on April 2nd, 2010•
By Pamela Paxton
New hospital construction – such as that ongoing in Baltimore, for instance – provides a perfect opportunity to go green at your facility. Not only are environmentally-sound practices good for the environment, they can reap big financial benefits, too. Read here about Metro Health’s successes with cost-saving green construction and practices.
Metro Health Hospital, the recent winner of the Practice Greenhealth award, has made great strides toward implementing eco-friendly practices (going green), which have afforded the hospital and its community many benefits, including increased patient safety and satisfaction, decreased costs, and a negative environmental impact.
Pamela Paxton is senior healthcare knowledge consultant at HMC.
Uncategorized•
on April 1st, 2010•
By Thomas Day
I read a very good article in the Harvard Business Review the other day, titled “Fixing Health Care on the Front Lines,” by Richard M. J. Bohmer. (While I’m not a frequent reader of HBR, a friend and former HMC’er sent it to me.) We hear lots of talk about “redesigning” healthcare, but until now, it has all sounded a little vague, very global, ill-defined, and often politically motivated to me. However, Bohmer puts together some very interesting frameworks for what a redesign actually means to providers and how to proceed.
Let me highlight some of the key insights I pulled away from the article. The very best one was the top level assessment, where he states health care providers must “excel at performing three discrete tasks simultaneously.” These tasks are:
*Rigorously applying scientifically established best practices for diagnosing and treating diseases that are well understood.
*Using a trial-and-error process to deal with conditions that are complicated or poorly understood.
* Capturing and applying the knowledge generated by day-to-day care.
Doesn’t this get at the core of the issue? Not every disease and patient requires Sherlock Holmes-levels of detective work, and these cases should be handled differently than those that are more confounding, variable, and complicated. Additionally, Bohmer notes that “more than a quarter of Americans over 65 suffer from four or more interacting diseases.” These sorts of complicated patients need different treatment processes and methods, “corralling their variability” from the more predictable patient cases.
Finally, he insightfully observes that medical knowledge comes from more than research and scientists. Rather, it comes from all directions in the daily practice of medicine. The consequence of this is far reaching – but it’s an open question about how you capture individual caregiver knowledge, synthesize it, and distribute it for use to all other caregivers.
Bohmer also offers excellent eye-opening examples, citing how “Intermountain has protocols on roughly 70 conditions that make up more than 90 percent of the caseload.” He notes how a “hospital in a hospital” can separate cases benefiting from a tight protocol from those that require careful and ongoing diagnosis, treatment, and monitoring.
All in all, this article is a real mind-bender.
Thomas Day is president of HMC.
Uncategorized•
on March 30th, 2010•
By Karen Jorge
I’ve been reading Atul Gawande’s The Checklist Manifesto: How to Get Things Right, which, as the book’s title suggests, discusses the surprisingly significant positive effects of implementing such a low-tech system (a checklist) in various fields.
Along the way, Gawande discusses how in complex situations that demand expertise from many areas (e.g., medicine), it is often most effective to farm the responsibility for decisions to the most distal areas – to the people who are actually on the ground doing the work, instead of locating it in some central decision-making body. In one anecdote, he explains that one reason for governmental failures in the response to Hurricane Katrina was that nobody could decide who should be making the decisions. The only thing various levels of government could agree on was that some centralized body should be calling the shots, even though the central body was far removed from what was actually happening. The governments chose that approach instead of letting people on the ground figure out how to best respond and adapt to the constantly changing situation.
Interestingly, Wal-Mart Stores(!) staged one of the most effective responses. The CEO decided that each and every Wal-Mart employee be empowered to make decisions that they deemed necessary, and the employees certainly stepped up. Store managers distributed food, water, and supplies to first responders, created rudimentary but effective methods to systematically hand out goods to displaced citizens, and responded to the needs they saw. In essence, they identified problems and solved them, something that couldn’t be accomplished with higher levels of centralization.
This example came to mind when I was listening to the impressive presentation given earlier this week by Kathy McCoy, Dr. John Kaiser, and their ICU team at Sentara Williamsburg Regional Medical Center. They haven’t had a case of ventilator-acquired pneumonia (VAP) in six years, which is particularly notable because VAP is the most common hospital-acquired condition in the ICU, and occurs in almost one-quarter of patients on mechanical ventilation. Six years without a single case!
As they explained how they accomplished this feat, I was struck by how many of the elements of on-the-ground responsibility that Gawande espouses in his book were also integral to the success at Sentara Williamsburg. Notably, the impetus for this project didn’t come from some higher-level quality or performance improvement (PI) department, but from patient care providers themselves. A small group of nurses, respiratory therapists, physicians, dietary staff members, and pharmacists decided to form a council, listed a number of possible projects, and chose to tackle VAP. They created a plan, implemented it, and consistently evaluated it to make sure that it was: A) followed; and B) effective. By owning it at the “grassroots” level and educating other staff members to ensure they owned it, too, they were able to achieve significant results and solve obstacles they encountered.
Of course, you still need quality and PI departments. These departments often have the requisite clout, resources, and experience, as well as a mandate to make important changes in hospitals, and we’ve seen them be highly effective. However, if all of the innovation- and change-related responsibility is centralized in these departments – if they are the only ones empowered to take on problems and solve them – then care providers on the floor might abdicate responsibility. It can cause the classic “someone else will take care of it” mentality. In reality, these on-the-ground people often have the best view of what areas need change and how to get it accomplished. The flip side is that uncoordinated, independent players can create chaos. So developing a balance between grassroots and higher-level change is crucial, and can be accomplished through quality and PI departments actively supporting and encouraging grassroots-level innovation.
Karen Jorge is an analyst at HMC.
Uncategorized•
on March 29th, 2010•
By John Whittlesey
For some years, the surgical supplies cost category has remained a most frequently cited Top 10 excess function, and with the largest excesses. It’s a complex and problematic area to manage well. Just think of all the stock keeping units (SKUs) and contracts that materials management staff and the surgical team must track. Supply chain management (SCM) concepts have done great things to help streamline and consolidate inventory handling operations, and they can help provide insights into lowering costs for surgical supplies. But what happens when you’ve driven as far as you can down those SCM avenues?
A materials manager frequently thinks that once the contract is negotiated, their job is done. They will typically review the purchase orders and inventory to make sure that the orders are adhering to the contract, and that the payments are correct. But what about utilization? A contract doesn’t even try to address that issue. Even if a contract has tiered pricing for various levels of implants (joints, spines, or even pacemakers), as long as the SKU matches the price list, you’re compliant. But SCM needs to evolve to a second generation of improvement: effective utilization. Contract compliance doesn’t assist in utilization.
I often get blank stares when I ask surgical managers how or if they track which joint implant was used and why. The surgeons know what clinical conditions the patients have, what their activities of daily living (ADL) needs will be after discharge, their comorbidities, etc. These factors influence their decision about if they should use a low- , medium- , or high-demand knee system. You know for sure that the vendors understand that decision tree better than you do, and will try to influence those decisions to upsell whenever they can, or even go off-contract to get full price.
What’s wrong with everyone else knowing that? I encourage the joint teams to sit down with the surgeons, include materials management staff, AND even the vendors. The group should establish the clinical criteria about what particular joints would be best used in which type of patient. Cost is a secondary byproduct here. Develop a decision grid, listing all the clinical criteria on the left side, and at the top, include the grade knee or hip system. Then track usage for a month, aiming for 80 percent compliance to the clinical criteria that the surgeons established.
At the monthly joint team meeting, talk about the results and why certain patients or physicians didn’t meet the criteria. If the criteria need adjustment, fine – if behavior needs adjustment, even better. The costs will drop and you’ll be in good stead for the next contract cycle.
John Whittlesey is a principal at HMC.
Uncategorized•
on March 25th, 2010•
By John Whittlesey
More and more, hospitals are finding themselves trying to figure out how to improve quality, not only for quality’s sake, but to minimize financial exposure. The U.S. Centers for Medicare and Medicaid Services (CMS) has laid the path by denying reimbursement for a host of Present On Admission (POA) conditions. If private insurers haven’t already followed suit, then shame on them.
One of the glaring holes that I see lies between a typical hospital’s quality management department and the finance department. Aside from setting the annual budget, very few managers in either area even speak to each other outside of the cafeteria line. Periodically, I ask either manager if one knows about the other’s annual performance improvement plans and goals. I also ask how these goals and plans may relate to the overall facility strategic plan. Then I get the proverbial deer-in-the-headlights stare. Intuitively, the different managers know their departments should be more integrated, but in the absence of a higher plan set by the senior team, it just doesn’t happen.
So I encourage hospitals with large cost, quality, and utilization issues to establish an annual – I’d love quarterly! – strategic summit with quality management and finance staff present to review individual strategic plans and see how they support each other. They can also look at ways to integrate their plans with initiatives meant to overcome the financial and clinical challenges facing the hospital.
Here’s a “top secret” tip: the HMC Benchmark gives you the answers, and we’d be happy to discuss it.
John Whittlesey is a principal at HMC.
