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.
Uncategorized•
on August 16th, 2010•
(This is part two of a two-part blog)
More tips for sailing the ship into harm’s way:
6. Encourage your managers to network with others who are “like” them. Yes! The only hospitals that are worthy learning partners are those who have the same mission, market, operating strategy, challenges, size, scope, organizational structure, services, volume, physical plant, and mean average temperature.
7. Require your managers to know the ABSOLUTE best practice and how to implement it flawlessly before doing a single thing. That’s right. The ONLY way for you to improve is to slavishly emulate the hospital at the target cost position without regard for your own environment, talent, mission, or goals.
8. Check on your managers’ progress at least once a year. Maybe check in at budget time when they don’t have anything else to do. Reviewing their progress more often or being involved in their plans might make them anxious or think that you actually expect them to do something.
9. Don’t hold your managers accountable for results. You really have to give people time and allow a lot of discretion about when and how they might achieve their goals. Really! Who’s navigating this ship, anyway?
10. Keep progress toward closing the gap under wraps. Oh, wait. This is a given. You didn’t define a “gap” in the first place!
Shelley Burns is head of knowledge management at HMC.
Uncategorized•
on August 12th, 2010•
By Shelley Burns
(Part one of a two-part blog)
Given it’s summer, we’ll continue with the nautical theme we started in a prior blog. So, imagine the winds of change are fierce and blowing your hospital ship toward the rocks at a rapid clip. Endlessly measuring the wind with greater precision and understanding each time you take bearings is highly satisfying, and seems a prerequisite to action. However, nothing short of adjusting your sails and changing course will prevent your ship from being dashed against the rocks.
So, if that’s your goal, consider following these tips:
1. Don’t define your “gap.” Really, senior leadership shouldn’t have to set the course for the organization. Surely, you can delegate this detail to someone less senior.
2. Make cost improvement a goal – this year.
3. Keep your managers in the dark about your expectations. Let them guess about the overall dollars you want to squeeze out of the cost structure and the amount you expect each to contribute. Lack of focus and goals are helpful for managers – they like managing to ambiguity.
4. Restrict managers’ access to data and performance improvement tools. All those numbers, graphs, benchmarks, and best practices require such an effort to comprehend. All the managers really need to know is that their costs need to be cut.
5. Join your managers in hashing out the minutiae indefinitely. Absolutely! They must be 100 percent comfortable with even the most irrelevant data before they can make a single cost improvement or suggest any ideas to streamline their processes.
Shelley Burns is HMC’s knowledge manager.
Uncategorized•
on August 9th, 2010•
By Shelley Burns
What kills a hospital benchmarking process faster than anything else? It’s what happens when the administration asks department heads to do something with the benchmark results.
HMC produces a series of benchmarks for our hospital clients on functional cost, clinical cost and utilization, quality, and patient satisfaction. Hospital managers participate in developing the benchmarks by validating the data and our procedures handling it. The benchmark results are presented, and an administrator tells the department heads: “Find out what the lower cost/higher quality hospitals are doing differently than you!”
What do the hospital managers do? They compile long lists of differences, usually focused around their albatrosses, to rationalize the cost difference between themselves and the lower cost/higher quality hospitals. They present this list of differences to administrators as explanation for the cost/quality variances, whether or not said “difference” has a measurable and commensurate impact on cost or quality.
A few examples:
• A hospital with over a million dollars in excess labor costs in environmental services maintains that its high costs are necessary for a clean hospital. Staff cleans all restrooms every two hours. Other hospitals have “lower standards” because they clean restrooms based on need – frequently-used restrooms are cleaned more often; least-used restrooms might only need cleaning once per day.
• A sterile processing manager justifies a cost/ surgical case that is three times higher than all hospitals in their group because they have over 100 physician-preference cards, the Cadillac of sterile processing systems, and a full-time RN trainer to teach techs how to use it.
• A cath lab manager rationalizes her higher costs by noting that other cath labs have shorter operating hours than her 10 hours per day. She averages less than two cath lab procedures per day, but the cath labs, prep, and recovery are staffed three to four hours per day longer than her peers.
How can you break out of this cycle? Don’t ask your department heads what OTHERS do differently, or ask them to compile lists of differences. Instead, ask your department heads what THEY can do differently to improve their costs and quality. Task them with developing strategies and implementing solutions to cost and quality problems. Put the onus on your managers to take action and make change, not lists and excuses.
A subtle mind shift to be sure, but a critical one.
Shelley Burns is head of knowledge management at HMC.
Uncategorized•
on August 6th, 2010•
By Ariana Berberich
In a recent survey, many hospitalist physicians were unable to accurately predict the cost of treating a hypothetical patient. According to the related article in Health Leaders Media, while many of the hospitalist physicians could identify the relative costs of treatments, they were unaware of the exact price tag of the treatment choices they were making.
This lack of price awareness, coupled with a culture of defensive medicine practice, encourage physicians to order excessive testing on patients. These patients, however, aren’t typically in a frame of mind to advocate for only the most economical (read: cost-for-value-added) treatment choices. However, they stand to foot the potentially inflated bill. Admittedly, the complicated hospital pricing structure, dependent on the specific payer, makes it difficult to ever accurately estimate what a final bill will be. Yet, that still isn’t a compelling enough reason to avoid educating physicians about the financial impact of their practice and utilization decisions.
HMC offers hospitals the tools to successfully educate and encourage their physicians to practice financially-responsible and evidence-based medicine. Some of the best practices around this include:
*Establishing a physician champion or medical advisory panel to lead discussions about scientific and best practice models
*Performing internal comparisons to understand the quality and cost impacts of procedure choices within ancillary and nursing costs
*Encouraging professional development conversations with all physicians about specific practice choices, including demand matching
* Reviewing the profitability of physicians, case types, and service lines
*Identifying quality issues requiring improvement
When physicians understand the costs of their practice choices, they can provide the best value of care.
Ariana Berberich is an HMC analyst.
Uncategorized•
on August 2nd, 2010•
By Shelley Burns
(This is the second installment of a three-part blog)
As I said in my earlier blog, all the stakeholders in an unnecessary C-section play an equal parts in the overutilization of the procedure. I am disappointed with everyone in this scenario. Our business culture worships productivity and wants babies delivered on a schedule, so that mom and dad can get back to work pronto. Our reimbursement incentives obviously don’t place a higher value on vaginal delivery, although it’s safer. Our litigious society looks for malpractice in every bad outcome, forcing clinicians to act directly in the process, rather than let nature take its course.
It goes on. Hospitals allow C-sections and inductions that are clearly NOT evidence-based best practice. Nurse educators aren’t preparing mothers appropriately for a normal vaginal delivery. Physicians are not protesting against this, and schedule C-sections and inductions that are not in the best healthcare interest for the mother and child. Finally, the mothers are not fighting for the best possible care and not taking the time to understand the statistics behind their decision.
There are lots of “nots” in there. Everyone involved is simply not doing the best job they could, due to the larger background forces. We’ve overcome these types of hurdles before. Once we all got on the same page about smoking, within a generation’s time, we redefined it from being a normal, almost required activity to an anti-social scourge. The concerted, synchronized voices of the public, the AMA, the legal system, the surgeon general, the AHA and countless others turned the tide on smoking in this country, to the benefit of everyone’s health. Can’t we do the same for mothers and children? Can we decide to do something about overutilization in healthcare?
Shelley Burns is director of knowledge management at HMC.
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.
U.S. News & World Report‘s 2010-11 has named Sentara Norfolk General Hospital and Sentara Heart Hospital as offering some of the United States’ best heart programs. In a recent announcement, Sentara claimed this was the 11th time it had been so recognized. The newspaper’s rankings in the heart and heart surgery category are based on death rates, patient safety, and other care factors, such as technology and patient services. Sentara also noted that it was listed as 43rd in the best hospitals category. Additionally, Sentara posts a mortality score that exceeded five of the top-ten-listed programs. Sentara stated it’s one of only two hospitals in Virginia ranked by U.S. News & World Report.
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.
