Pauline Chen, MD, said she was inspired by the election of Barack Obama to discus racial barriers in healthcare in this New York Times column. Obama's success didn't eliminate racial barriers in healthcare, Chen says, but perhaps it will provide a catalyst for addressing race issues on a more consistent basis.
I do some of my best thinking while pedaling my bike through the streets of Chicago or the countryside of North Carolina (I confess I'm a Lance Armstrong-wannabe). I was riding along the shore of Lake Michigan recently, pondering the state of healthcare in our nation, when I had an epiphany regarding the concept of "quality" in healthcare.
I believe we've got it all wrong as to what constitutes "healthcare quality." Our mistake is in thinking that quality is a unicycle—a singularly focused discipline that measures and seeks to improve the caliber of our clinical and technical processes, thus assuring superior patient outcomes. And while these clinically oriented processes and investments are centrally important to improved patient care delivery, this singular focus compromises the real depth of what determines "quality"—particularly as it relates to patients, their families, and caregivers.
The "ah-hah!" during my ride is that quality is, in fact, a bicycle. It has two wheels, both of which are essential to a successful ride—or more appropriately, a successful patient experience. One wheel is devoted to clinical excellence, while the other is devoted to service excellence. To focus solely on clinical excellence at the expense of service excellence robs the patient and the healthcare enterprise of its soul, and to engage in service excellence at the expense of clinical excellence robs the healthcare enterprise of its purpose and the patient of their improved health.
Relevance to my hospital
OK, the point's been made. Just how does this concept apply to my hospital?
Here are some very real and tangible examples from a recent client engagement. I was retained by a four-hospital regional health system in the Midwest to conduct what I call a "customer commitment audit" designed to measure the organization's ability and resolve to deliver a compelling patient experience—particularly from a service excellence standpoint. The capstone diagnostic of this audit is to routinely assess a hospital's emergency room—in my experience, it's the most efficient and powerful way to "stress test" what any given healthcare organization stands for, both in the clinical and service dimensions of quality.
Across these four hospitals, my average wait time from portal to portal was just under three hours. However, my total elapsed time spent with the ED physician on average—just over two minutes. Following these assessments, I met with the president of the ED Group servicing these hospitals and shared the headlines of my encounters with "his?" emergency departments (set off in quotes because the physicians claimed they merely worked there—a noteworthy subject for a future article). When he heard about the extended length of the wait juxtaposed to the brevity of the professional encounter, he immediately responded with the immortal call of the healthcare wild: "But the physicians provided you with good quality care, didn't they?"
And that's the point—and the problem! As a professional field, we continue to hide behind the unicycle of clinical excellence and somehow justify the deplorable service provided to patients because we provided excellence along the clinical domain. The end somehow justifies the means.
My response to this ED physician leader: "Truth be known, it was excellent clinical care, but quite frankly, doctor, it wasn't worth the wait!" Once he got over his shock at my candor, he demonstrated tremendous leadership and asked to hear more about my experiences, some of which are highlighted below:
Having a registration clerk stare at me and do nothing because I wouldn't ring the "red bell" designed to announce my arrival.
Having another triage nurse ignore me upon arrival for several minutes (while legitimately being distracted by a much sicker patient) and then suddenly look my way and extort: "Well, find a seat; it's going to be a couple of hours!"
Being admitted to a storage closet with a gurney—in a brand new hospital.
Interacting with countless staff members who never introduced themselves, nor have their names badges flipped so I could see who they were.
Being provided with four pages of "discharge instructions" in eight-point font, but not having anyone explain how to leave the ED so I wouldn't get lost.
And I could go on and on and on. But anyone who's worked in a hospital is acutely aware of similar types of experiences. And each of you reading this list could quickly add five more vignettes equally as graphic from your own institution. And we in healthcare justify this deplorable level of service because, "Well, we provided good quality care, didn't we?"
Clinical excellence is assumed
Now the more calloused (or more cavalier) reader may respond, "Why all the fuss about service? It simply doesn't matter how nice we are to the patient—we're still going to get paid, and they're still going to come to our hospital." And truth be known, that's absolutely right—for the time being. But there are two principle reasons why more attention needs to be paid to this other wheel—one is more universal, and the other is clearly financial.
A colleague who recently had an extended interaction with several hospitals put a sharp point to this universal issue. As she explained it, the healthcare encounter is all about instilling confidence in the patient interaction—and that requires emotional intelligence, not clinical intelligence. Lay people simply don't have the requisite skills or criteria to assess clinical expertise. But they can certainly judge whether the caregiver "cares" about them and whether by their actions and their compassion they instill a sense of confidence. And she noted, without that confidence factor, the patient enters a very negative spiral, and begins to wonder: "Will I ever get out of here, and more importantly, will I get out of here alive?"
And what is it that patients remember following a hospital stay? It's not the clinical stuff—research consistently documents that patients assume they will receive excellent clinical care. However, what patients do remember, and what they share with friends and family members, is how they were treated (i.e. how well the staff responded to their needs, how well their questions were answered, to what extent did the staff demonstrate compassion, etc.). This is the "soft" stuff that doesn't matter in healthcare—or so we're led to believe.
And if that doesn't spark a response, then the emergence of pay for performance should. Starting in the fall of 2010, as much as 4% to 5% of your Medicare revenue will be at stake for both your clinical performance as well as your service performance, the latter being measured by your HCAHPS scores. There are, in fact, 10 factors that will be used to judge hospitals, but the key metric is to determine patient loyalty is:
Percent of patients who reported yes, they would definitely recommend the hospital.
This question is a powerful predictor to assess the patient's overall experience.
So now let's return to our symbolic bicycle. Have you decided yet which wheel is "clinical" and which is "service?" A colleague recently asked two simple questions to clarify this issue: "Which is the wheel the patient sees? And which is the wheel that determines the 'direction' the patient experience will ultimately take?" It's very clear to me which wheel is which.
Let's explore this further. The back wheel is "out of sight," it is far more technical and infinitely more complicated, in large part because of the gears, the shifting mechanism, the rear axle design, etc. And doesn't this begin to mirror the clinical side of healthcare? But if my front wheel is not properly aligned, doesn't have sufficient air or inadvertently gets turned the wrong way, it doesn't matter how sophisticated the gearing mechanism is on my bike, I'm certain to have a bad experience. And yes, I ultimately need both wheels to have a quality riding experience—just as a patient needs peak performance on both the clinical and service dimensions to have a quality patient outcome.
So what to do?
There's quite a lot that healthcare leaders and clinical staff members can do to immediately address this redefined concept of quality as a symbiotic bicycle. Contact me at the e-mail address below and I'll send a dozen steps and initiatives that will bring balance and symmetry to the quality quotient in your hospital—literally overnight. They are categorized along three dimensions designed to materially enhance the patients' experience: demonstrate commitment, refresh your perspective, and apply reward and recognition.
So now we've come full circle.
It all starts and ends with the patient. But how we see them is strongly influenced by the lens through which we process the world. I fully endorse the need to keep relentless pressure on maintaining the clinical caliber of our healthcare institutions. But I feel equally as strongly that the pursuit of excellence in "quality" demands a bilateral focus on both clinical and service performance. Anything short of that is either a very bumpy ride or an unnecessarily sterile experience for the patient.
So grab a bike helmet, take an objective ride through your own institution, and see how you would capitalize on this analogy.
Morley Robbins is a principal with Health Planning Source, a healthcare strategy consulting firm in Durham, NC. He can be reached at morleyrobbins@healthplanningsource.com
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Although some private practices might think of business strategy in immediate terms, it is important to think about the long-term goals, or governance, of the organization. Not doing so could prove disastrous to a practice's future business, experts say. One of the first things a private practice should do is understand the difference between governance and management.
"What you are asking governance to do is to set a strategy that will factor in to the next 10 years, and it will also shape your organization," says Michael Dugan, vice president of Health Directions, LLC, a Chicago-based healthcare strategy and operations consulting firm. "The management of that is the actual follow-through. I guess you can say governance is what you want the organization to be, and management is how you want the organization to get there."
Governance, in other words, is providing direction toward the goals or mission of the business, whereas management is implementing that direction.
The first, and perhaps most important, aspect of establishing governance is to establish a mission, a vision, and a culture for the organization. To do so, the organization's governance needs to be responsive to and aware of the resources necessary to achieve these goals. For example, it is important to specifically outline what type of treatments the office will offer, what type of patients it will see, and what short- and long-term goals it hopes to achieve.
Another important factor is identifying which roles officials will play in planning the governance of the organization, which can be difficult. "Physicians who are more financially adept, for example, should head up the finance committee, do the contracting for the group, and serve on the committee for next year's budget," Dugan says.
Sometimes, the practice's physicians might strictly provide leadership and direction and ensure that the resources are there for the organization. In addition, physicians might want to stay away from the management or daily operation of the practice and delegate that responsibility to management.
Some offices do not take the time to develop a strategy in relation to governance or to regularly review its business operations. When mistakes are made in regard to governance, Dugan suggests starting at the top and making an honest assessment of previous decision-making so the organization can learn from its mistakes. The organization needs to sit down and determine what to spend money on and what it needs to grow, as well as the areas in which it wants to grow, he says. Not taking the time to properly plan could be disastrous.
This article was adapted from one that ran in the November issue ofThe Doctor's Office, a HealthLeaders Media publication.
Everyone thinks patient safety is important. Everyone. No, I haven't spoken with every healthcare professional in the United States, but I'm going to go ahead and make that leap. I've never interviewed a hospital executive who said, "You know, we hope our patients are fairly safe when they come here, but what's really important to our organization is supply chain efficiency." I've never heard a physician remark, "You know, I think all this drama over MRSA will eventually just blow over."
Senior leaders, middle managers, doctors, nurses, technicians, frontline staff, housekeepers—they'll all tell you patient safety is critical. Organizations implement advanced technology and send staffers to classes and devise complex systems and craft grand mission statements all in the name of making patients safer.
And yet...
Well, you know the rest. Crippling infections, patient falls, wrong-site surgeries—it's a familiar list to all of you. Even as healthcare professes its dedication to patient safety, a lot of "preventable" occurrences keep right on occurring. Sure, plenty of organizations have made admirable strides in protecting patients. And exhausted caregivers inevitably make mistakes. Technology breaks down. Money is tight.
I know all that. But what is really at the root of the industry's patient safety failings?
There's no easy answer to that one, of course, but I've seen some interesting research lately that points to a problem of perception. A report from Press Ganey Associates shows a major disconnect in how administrators, managers, caregivers, and frontline staff perceive their organization's safety culture. Based on nearly 40,000 responses nationwide, the study found that senior leaders have a much higher regard for their organization's safety culture than many frontline staffers. And administrators tend to view their culture as less punitive than do caregivers, who often fear punishment if errors are reported, the study says.
"No kidding," I can almost hear the physicians and nurses among you muttering. But I wonder if the average hospital executive genuinely understands the extent of the disconnect that can build between the C-suite and the trenches when it comes to patient safety? As the report notes, such differences can stem from a variety of sources—different groups of people are privy to different information, communication breaks down, basic human nature prompts varying responses to the same set of circumstances.
But whatever the origins of the disconnect, the point is that even the most thorough, earnest, technologically supported safety programs can be undermined and solutions delayed if key groups are not aligned.
Perhaps even more significant to me is the gap in perceptions of blame. It doesn't matter what processes you implement or which technologies you utilize—if technicians are afraid mistakes will be held against them or nurses believe reporting errors will be considered "tattling" rather than a collaborative attempt to address an organizational challenge, the system starts breaking down. Senior leaders often refer to their organization as having a "blame-free culture." That's how your executive team feels, sure. But if you asked your nursing staff, would they agree?
It doesn't have to be this way. Oh, people from different backgrounds who are educated in different disciplines and are charged with performing different tasks will inevitably have varying perceptions to some degree. But when it comes to basic communication and information access, there's no excuse for failing to close the gap. How can an organization fix a problem if the components of that organization don't collectively recognize the problem in the first place?
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
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The hospitalist specialty is just over a decade old. During that time, it has seen explosive growth and now includes 20,000 hospitalists nationwide. But for many physicians, the path has not always been easy.
While some practices have grown, others have diminished or fallen apart over the past 10 years as the specialty has evolved. One of the first multi-physician hospitalist practices in the country, the IPC Hospitalist Company group in Tucson, celebrated its 10 anniversary this year.
This story illustrates the opportunities and the challenges of building a practice dedicated to inpatient medicine, while providing valuable lessons for those entering the specialty today. In the last 10 years, we have learned the following keys to hospitalist success:
1. Aim for high quality care. It's crucial to be able to evaluate ourselves to figure out how we're doing with quality indicators, such as length of stay, readmission rates, and core measures. We rely on a web-based "clinical dashboard," that allows us to log on to a computer and track our performance and patients with real-time information. It answers questions such as: Did I document CMS clinical indicator medications, such as ACE inhibitors for heart patients? Did I send all my discharge notes to the patient's PCP? The bottom line is that it gives us quality of care tools customized for each patient so we can deliver proactive patient care.
One problem for hospitalists—and all doctors dealing with hospitalized patients—is the continuity of care and communication once the patient is discharged from the hospital. The patients go home and later visit their primary care physician, but all of the information about their hospitalization does not accompany them. This situation can result in complications, even readmission to the hospital. The IPC physicians refer to this as "voltage drop."
"At first we had to call the PCPs and interrupt them," says Douglas Kirkpatrick, MD, an IPC hospitalist with the Tucson group. "But if we didn't call, they were upset that we didn't keep them informed." The hospitalists used dictation for their notes, but it could take a week or two for the notes to be transcribed and get over to the primary care physician. "By then, the PCP had already seen the patient and didn't know what was going on. It was awkward, time-consuming and certainly not good for the patient."
2. Adopt the best technology and tools possible. IPC's size, depth of experience, and intellectual capital works to our advantage. In addition to the clinical and leadership training we receive, we are supported by the company's infrastructure, which supplies us with the systems needed to practice hospital medicine effectively and efficiently.
Having local management, decisions are not made from a distant corporate practice of medicine. Although we're backed by a large company, we function as an autonomous practice that determines our own scheduling, whether or not to add moonlighters, and so forth.
With a growing number of hospitalists around the country, IPC was in a position to address voltage drop. It created an electronic patient record system called IPC-Link® that significantly improved the efficiency of transitioning patients after discharge. Hospitalists typed their notes (first on a PDA, today over a secure Internet connection) and reports were automatically generated and faxed to the referring physicians.
Today, faxes sent to the patient's primary care physician, and any specialists involved, arrive within an average of 21 minutes, alerting the physician's to the patient's status, medications and other clinical data critical to the patient's recovery.
Patient data is also sent to IPC's Nurse Call Center, which contacts each discharged patient within 72 hours of leaving the hospital. IPC-Link codifies the hospitalist's notes in a searchable data repository so that IPC callers can create a "smart" survey customized to a particular patient's situation.
3. Promote effective communication with referring physicians. To increase referrals from community physicians, it's obligatory to communicate with them regularly, providing real-time notifications, about their patient's condition, tests, medications, etc., from the time of admission to patient discharge and hand-off to the PCP. This creates a sense of trust and assurance that their patients are in good hands.
4. Hire people with a strong work ethic, and develop ownership and buy-in. Today the Tucson group is an established and thriving practice. But challenges remain. One of them is the continued recruitment of new physicians to support the opportunities for growth.
We understand that we need to work as a team if we are to survive as a practice. And that takes cultivating friendship, loyalty, cooperation and enthusiasm. It's a plus that we're able to attract qualified and motivated hospitalists with above-industry compensation and performance bonuses.
As the hospitalist specialty grew, so did the Tucson practice. After initially projecting slow but steady growth, the group found it needed to hire four more physicians in just the first year. IPC took care of practice management and billing, along with negotiations with payers. The doctors recognized that at times IPC played "hardball" on their behalf. "If it had been just us docs, we never would have done it," says Kirkpatrick. "It really worked."
A key reason the relationship worked was that IPC did not dictate to the physicians how to run the practice.
5. Don't promise more than you can deliver. We've learned to be realistic about how many patient encounters we can each manage in one day. The consequences of overextending ourselves are burnout, disappointment, and compromised patient care.
Despite being one of the most established hospitalist groups in the country, the physicians claim that they are still in growth mode. "We are in this for the long haul," says Kirkpatrick. "People here are very dedicated."
Shelli Collingham, MD, the practice group leader, recalls that when she started out, "the term hospitalist was not even being used at the time." At that time, she worked with a multi-specialty group, and the medical director asked if she would take care of all the inpatients at Tucson Medical Center, the largest facility in the area.
"The first day I had 26 patients-–I will never forget that," she says. Collingham continued on her own for 10 months, until she was joined by two other "full-time inpatient physicians," William Odette, MD, and Douglas Kirkpatrick, MD.
In the beginning, the doctors were salaried hospital employees. Over time, the hospital asked them to become subcontractors as part of its effort to reduce the number of employees. "I had always been an employed physician and the thought of going out on my own was overwhelming," Collingham says.
David Bowman, MD, is Executive Director of IPC-Tucson, IPC The Hospitalist Company, Inc.
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When workforce shortages reach a certain threshold, they often begin to feed on themselves, creating a self-reinforcing cycle that is difficult to break.
Take the primary care shortage. Many of the root causes are financial: medical students rack up enormous debt through the course of their training, and the higher salaries offered in medical and surgical specialties simply provide a better return on investment.
But a consequence of the shortage has been a strain on practicing primary care physicians, leading 49% in a study published by The Physicians' Foundation to say they plan on reducing the number of patients they will see or stop practicing entirely in the next three years. One of their chief complaints is that they have to see too many patients and can't spend enough time with each one.
It's a vicious cycle: Physicians want to practice less because of the burdens placed on them by the shortage. That in turn exacerbates the shortage.
The remaining physicians are tasked with doing more—much more thanks to an aging patient population—with less.
How is that possible?
There are many ideas being floated, and if you haven't had a chance to read the New England Journal of Medicine's six-part package on the future of primary care from last week, I recommend it. One of the approaches that keeps popping up is enlisting midlevel providers and other nonphysicians to take some of the low-level primary care workload.
By involving midlevel providers and using sophisticated information technology, primary care physicians may be able to double their productivity by 2020, according to a report released this week by healthcare intelligence company Sg2. With the help of nonphysician providers relying on evidence-based clinical protocols and standardized care plans, the primary care physicians of the future may see 8,000-10,000 patients a year, the report predicts.
While this model boosts productivity and allows the existing primary care workforce to treat more patients, it doesn't address one of the fundamental problems raised in The Physicians' Foundation survey. Physicians want to spend more time with patients, but the realities of the market may make the opposite inevitable.
"We have some things to work through that relate to how midlevels are trained and scope of practice laws in different states, but one thing's for sure: There's no way to meet primary and chronic needs of the 2020 population, or maybe even the 2012 population, with current complement of primary care physicians in a lot of markets," says Bill Woodson, Sg2 senior vice president. "So we're going to get creative."
That means incorporating not only midlevel care, but also telemedicine, remote monitoring, case management, and combinations of other approaches currently being piloted (in addition to new reimbursement models).
Those approaches may not return us to the Marcus Welby-style primary care that many doctors prefer, but to save primary care, physicians may need to adjust their notions about what it should be.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.Note: You can sign up to receive HealthLeaders Media PhysicianLeaders, a free weekly e-newsletter that features the top physician business headlines of the week from leading news sources.