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7 Lessons from AHA's Leadership Summit

 |  By cclark@healthleadersmedia.com  
   July 21, 2011

I got to spend a few days away from the desk this week to blitz through the American Hospital Association's Leadership Summit in San Diego.

The weather was an agreeable 70 degrees, and there may have been a disproportionate number of attendees seeking relief from the heat dome under which much of the country is withering. But the sessions served up a buffet of ideas about what healthcare leaders are thinking. So here's a sampling from some of the tracks that I thought were especially provocative.

1. Physicians should be friends and partners

The AHA on Tuesday took what president and CEO Rich Umbdenstock described as the "first step" toward building a structure to collaborate with physicians. And to introduce the concept, the AHA invited some physician leaders to a sunrise breakfast. The idea is that hospital executives need to find common ground to work with doctors and their practice groups to integrate, which of course is the magic word these days.

After all, he said, there's clearly a trend. For example, "65% of the members of the American College of Cardiology are now employed. We're going to be more integrated, more at risk, and more accountable, but we have a long way to go. We have a lot of work to do together," he said.

William Jessee, MD, outgoing president and CEO of the Medical Group Management Association, added that it will take a cultural transformation to get 25 groups of five doctors to "behave like a group of 125....There's a reason why there were 25 groups of five." And the task won't be easy, Jessee said. "It's going to be challenging and painful."

2. Insidious intimidation is a problem

Theresa Zimmerman, past president of the American Society for Healthcare Risk Management, described the emerging recognition of insidious intimidation, a type of intimidation much more subtle, and well, insidious, than the yelling and screaming or overtly threatening kind. 

This is when co-workers show "reluctance or refusal to answer questions, return phone calls, or answer pages, [use] condescending language or voice intonation, are impatient with questions and manifest other behaviors that are damaging to team effectiveness and compromise patient safety," she said.

"It's the person who doesn't answer the call light; who disappears when they know a new admission comes into the unit, and doesn't jump in as a team approach, or when they see something is not going a well as possible, [that they] conveniently take their breaks," Zimmerman added.

She went on to explain that this divisive behavior is "eating away at the morale of our teams...and is starting to threaten the actual legitimacy of our quality indicators." Now quality is being linked to payment, she emphasized, and the audience seemed to get her point on how this behavior could impact their quality scores. 

3. Surgical standardization is getting serious

Guido Bergomi, director of Project Management of the Quality and Patient Safety Institute of the Cleveland Clinic, had a story he told those gathered at a forum on surgical site infections:

"It used to be surgeons did their own skin prep of patients, and as much as surgeons standardized, they were standardized. But when we looked we found they were really doing different things in very different ways.

"The solution to that was that rather than have the surgeons do the prep, we now have nurses doing the prep, with just a few nurses who are trained in how to do it, all do it the same way every time using the same solution.

"But when it was first rolled out, one of the surgeons came in and said 'What are you talking about? I prep the patient. Why are you trying to do that? Don't do that.'

"It would have been pretty easy for the nurses to say, OK. Got it. You do it. You're the surgeon; you're in charge. But she said, 'No. This is important and this is why we're doing it. I'll get Dr. Vogel and he'll talk to you.' And she did. And he came in and told him...'Sorry you missed the communication this is what it's about.' The surgeon observed, and was on board."

Bergomi added that all too often, the "culture is such that when the surgeon says this is what you're going to do, people unquestioningly go and do it—particularly in the operating room setting. For a nurse to actually stand up and say 'No, you're wrong.' is a testament for us to sustain this over time."

4. Be less like cowboys, more like pit crews

The star of the forum was keynote speaker Atul Gawande, MD, a Brigham and Women's Hospital surgeon, and now well-known healthcare writer.

Gawande's latest catchy phrase, "Cowboys to Pit Crews," describes the dramatic change he sees necessary for healthcare to be more effective. Doctors, he argues, must behave like team players rather than individuals. In the 1970s, Gawande said, only 2.5 full-time equivalent providers were necessary to take care of a sick patient. Today it is 15.

"We're in the midst of trying to make a transition of what I call going from cowboys to pit crews," he said. "We've rewarded, hired, and trained people to be cowboys, but it's pit crews we need. Pit crews for patients. Whether we call them accountable care organizations or medical homes or just getting your staff together to go in the right direction. This is the fundamental cultural battle we're struggling with," he said.

Gawande doesn't just give speeches. In nearly every sentence, he reflects the emotion of his point with movement of his brow, a dip of his chin or a fretful look in his eye. I think that's why he's such an effective speaker. One really sees that he speaks his words with a measured, but discernible passion. 

"Fifteen autonomous free people providing care for patients with the choice of whatever they wanted to do, at whatever given moment in time, has proved to be chaos," remarked Gawande. "This is the way we all experience it when we've been sick, when our families have been sick." 

5. Cut the fat

The human resources of healthcare (the providers themselves) reflect the communities they serve, and share the same problems of diseases linked to excessive BMI. But are health providers who are fat effective at telling patients to lose weight?

At Baptist Health South Florida, leaders of the system's seven hospitals are asking that question and entering a lion's den, but one that is innovative and so far, productive.

First, as much as they want the workers to be healthier, the self-insured system also wants to control its spiraling bill for medical costs, which are $20,000 per year on average higher for a worker diagnosed with diabetes than for one who is not.

Corey Heller, Baptist's corporate vice president and chief human resources officer acknowledged that the system is "pushed the envelope a bit" with respect to the Health Insurance Accountability and Affordability Act. Baptist has been offering $150 premium credits if an employee takes an annual screening survey and submits to routine disease screenings, such as a glucose test to show predisposition to diabetes.

The system uses the results to determine interventions for workers who are at risk, even to the point of making home visits to look in their employees' pantries, to give advice on changing their diets.

"We don't make widgets; we take care of people. So let's take care of our own people and make sure that we demonstrate and model that behavior for the community," he said.

"Let's take care of them before they become our patients. Why wouldn't we want to have the healthiest workforce in America?"

With Baptist's coaching, some of the highest risk employees have demonstrated an 11-pound average weight loss and a two point drop in BMI since the program began.

6. There may be an ACO in your HMO

Roaming the hallways and ballrooms, I heard several executives fretting about how health insurers will influence the payment, quality, and alignment structures of the future.

That topic came up in one session, entitled "Chasing Unicorns: A leadership conversation around the future of ACOs."

A member of the audience asked, innocently enough, "What about commercial insurance carriers? Will they drive the ACO?"

Fred Hessler, managing director of the Health Care Group of CitiGroup in New York said, "Humana is getting into the care delivery business as much as anything with some of their acquisitions. Others are staying totally away from of it. It's not clear at all what is ultimately going to happen with the big players."

Nancy Schlicting, president and CEO of Henry Ford Health System in Detroit called this aspect of healthcare "fascinating."  

She added that in the Detroit area, dominant Blue Cross has created some pilot programs with medical home models and driven a lot of quality improvement performance. "We've seen some evidence that again, with the right integrated model with payers, that providers and payers can work together for the right ends but it's going to be complicated for awhile."

Chris Van Gorder, President and CEO of Scripps Health noted, "I think the jury is still out," but added that his organization is talking with private insurance companies "to see if there's an opportunity for partnership to use the data and information they have—if there's an opportunity to work together."

If doctors and hospitals "don't find a way to come together and create a better healthcare community, health insurance companies will come in and fill the void, for control reasons. And make a profit," he said. "It's up to us as providers to solve this problem instead of waiting for insurance companies to come in and solve the problem for us." 

7. Your ACO is delighted to make your acquaintance

Ian Morrison, futurist, author, and blogger, perhaps got the best laugh of the summit during his keynote when he described a letter Medicare beneficiaries might receive to explain an ACO.

Dear [Name Withheld to be HIPAA Complaint]:

Congratulations.

It's now official. While we have seen quite a bit of each other this past year, we just heard from the good folks at Medicare that we are now officially responsible for the quality and costs of the medical care you got this past year. It was as much of a surprise to us as it must be to you. Nevertheless, we are delighted to have you.

However, the relationship has gotten off to a bit of a rocky start. We see from your records that you had a heart attack in Florida when you were visiting cousin Mildred. To make matters worse, they did not give you an aspirin on discharge and now we won't get our bonus.

We really hope you take much better care of yourself in the coming year and don't travel so much.

Warmest regards,

The Patient Centered Medical Home Team at St. Jude the Obscure ACO 

Yes, Morrison got a big laugh. But clearly these are serious times in patient care. In the next few weeks, I hope to write more about some of the exciting and intriguing concepts that were featured here.

 

 

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