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.
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
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.
