Silver Spring, MD-based Holy Cross Hospital's Ethnic Health Promotion Program tries to mitigate the health problems facing immigrants by having health educators, including foreign-educated doctors, help them. Through the program, preventitive health is taught in the immigrants' languages and in the context of their various cultures.
The 12 new physicians at St. Francis Medical Center in Grand Island, NE, are due at least in part to the opening of the a new patient tower addition, said hospital President and CEO Mike Gloor. The tower serves as a "big billboard" for the hospital, as it can be seen by many who travel local highways and main thoroughfares, Gloor said.
In this opinion piece from the Seattle Post-Intelligencer, Jeff Huebner, MD, and Rupin Thakkar, MD, say banning data mining would protect the patient-physician relationship, control escalating healthcare costs and reduce inappropriate prescribing.
To successfully market a medical group practice, you must begin by assessing your strengths, weakness, and opportunities. The problem is, many practices don't know their markets as well as they should. It is crucial to know the characteristics of your practice's service area. Start by asking basic questions about the service area, including the following:
Is the population growing or declining? What trends are you seeing with respect to the average age, sex, household income, race/ethnicity mix, education levels, and length of residence?
Describe the work force: Is there a predominant employer? What is the mix of retail, manufacturing, governmental, and service occupations?
What potential effect will environmental factors have on the community's physical and mental health?
Who are your competitors? How many similar physician practices serve the same population?
What is the distribution of primary care versus specialty care physicians in the service area?
Do consumers out-migrate from the service area for specialty care, and if so, why?
How do consumers/patients differentiate physician care delivered at your medical practice from what is offered at competitor practices? What attributes do they value that can be leveraged to build awareness, preference, and, ultimately, utilization of your group's service offerings?
How do consumers perceive the physician group? Is there anything truly distinctive and meaningful about the group, and if so, how is this being communicated to the marketplace?
What sources do consumers rely upon to get information about physicians and the group's clinical offerings?
How do consumers make their choices about where to go for care (e.g., health plan, employer, word of mouth, etc.)?
From where does the practice draw 80 percent of its referred patients?
Much of this information is available through secondary market research-already existing information obtained from external sources, such as the Medical Group Management Association, the U.S. Census Bureau, and local and state medical associations. It can also come from internally generated data, such as relative value units, current procedural terminology codes, and patients' ZIP codes.
Unlike hospitals, which have access to standardized inpatient market share reports, most medical groups don't have a lot of detailed information about their market share and must rely on estimates.
Don't let the wails of disapproval fool you; healthcare groups were not caught off guard by President Bush's budget proposal that would slash some $560 billion from Medicare over the next decade, according to the Wall Street Journal.
But seeing trouble on the way doesn't always help. Last fall at the annual MGMA conference I talked with William Jessee, MD, about the continual decline in reimbursement. With so many private payers piggybacking their rates on these dwindling Medicare rates and some 47 million uninsured, the financial outlook for medical groups appears bleak.
And don't discount the impact of the cost of running a practice, says Jessee. He points out that, according to the MGMA, Medicare reimbursement for 2008 is expected to decline by 1.7 percent compared to 1999, but operating costs have increased by 62 percent over that time.
"When your costs are going up 62 percent and your revenue is going down 1 percent, something's got to give," he says.
Indeed. Unfortunately what's giving might just be the number of qualified people willing to practice medicine in such an unfriendly economic environment.
As the AMA stated prior to last week's State of the Union Address, without Congressional action, physicians face a significant payment cut from Medicare this July. And a survey of members found that 60 percent of physicians would limit the number of new Medicare patients they can treat if the 10 percent cut occurs. We've seen reports like this one in the past, and Congress has come to the rescue.
The AHA was also very critical of the president's plan, saying it would have a disastrous effect on America's healthcare system. In a prepared statement, the AHA's Rich Umbdenstock says, "At a time when physicians are in short supply, this budget calls for cuts to teaching hospitals that prepare tomorrow's physicians. At a time when our economy is faltering, this budget cuts hospitals serving some of America's poorest patients. At a time when an aging America depends on modern hospital care, this budget drastically reduces funds that help hospitals keep cutting-edge technology available for communities. This budget cuts programs that help rural communities keep their healthcare, train the nurses and caregivers of tomorrow, and assist children's hospitals in training pediatricians and other specialists."
Clearly, the Bush administration is aware of the basic principles of inflation--at least when it comes to its defense budget. After all, it has increased military spending by about 30 percent since Bush came to office, even as funding for so-called entitlement programs heads downward. A White House fact sheet says cuts to Medicare and Medicaid would save $208 billion over five years and the alternative would be "massive tax increases, sudden and drastic cuts in benefits, or crippling deficits."
Scary stuff--but not nearly as frightening as the prospects of the inevitable shortfall of physicians we face and the likelihood that those we have will be hard-pressed to accept Medicare patients.
So now healthcare lobbyists will descend on Congress to right the executive office's bloated--to the record tune of $3.1 trillion--and slipshod federal budget. But I'm expecting Congressional revisions that amount to Band-Aids where sutures are needed.
When's the last time you got a good night's sleep?
There are always excuses for why we didn't get our recommended eight hours of sleep: The game ran late. I couldn't put my book down. My child had a nightmare. My husband was snoring.
For most of us, missing a few hours of sleep means that we're just a bit grumpier in the morning, but a strong cup of coffee will usually get us back to our usual selves.
For those in the hospital--particularly the ICU--sleep is crucial, and an article in USA Today this week tells us that being a patient in the ICU isn't particularly restful.
ICU patients--because of their conditions--are checked on and visited by nurses and other hospital staff members much more often than those in regular hospital units. They're hooked up to machines that have alarms and beep to notify caregivers when they're not working properly, or have to be reset. Many ICU patients are on pain controlling drugs like morphine that make it hard to sleep, the article says.
The result is patients drifting in and out of sleep--not reaching the deep levels of sleep that promote healing--says, "Quantity and Quality of Sleep in the Surgical Intensive Care Unit: Are Our Patients Sleeping?" published in the December 2007 issue of The Journal of Trauma: Injury, Infection and Critical Care.
The study was led by Randall Friese, MD, of the University of Texas Southwestern Medical Center. It studied the sleep patterns of 16 intensive care patients at Parkland Memorial Hospital in Dallas. It suggests that hospitals examine their intensive care units and assess whether providing patients with more comfortable, home-like rooms, removing unnecessary medical equipment and adjusting light levels will help patients get more of the restful sleep they need to recover.
As we get ready for HCAHPS, a quiet hospital atmosphere is a topic that many have tried to tackle. Many hospitals have engaged nurses and other caregivers in efforts to keep hallways quiet and limited the number of overhead pages that happen during the nighttime hours. But have you considered those necessary interruptions--the medication-giving, blood-pressure taking visits--could be preventing them from getting the good, deep sleep they need to heal?
As Quality Leaders, we should be thinking about how much good sleep our patients are getting--whether it be in the intensive care unit or otherwise. We know that it is in our organization's best interest to get patients well in as little time as possible--keeping costs low and quickening the turnaround of hospital beds.
Going back to HCAHPS, we also want to make sure that our patients are answering the survey in the best frame of mind. Remember that grumpy feeling I mentioned earlier? If a patient leaves your hospital feeling sleep deprived and not quite healed, it's likely they'll remember that when they record their impressions of your hospital--particularly when the survey asks about the area surrounding the patient's room being quiet at night.
Good, quality sleep is important for all of us--but particularly so for those recovering from an illness and trying to heal. What does your hospital do to ensure a healing environment for its patients? I'd love to hear about it.
Mike Reno, vice president of operations, and Andrew Eller, clinical educator in the emergency department at St. Luke's Episcopal Hospital, describe how the lean method improved quality and efficiency in the emergency department.
Step 5: Invest in Medical Staff Leadership Leadership is a developed set of competences that includes behavioral attributes, knowledge, skills and tools that enable an organization to effectively and continuously adapt to changing internal and external environmental requirements. Physicians do not learn about or develop the requisite leadership competencies as part of their medical education, and this is reflected by the cultural conflict between medical staffs and hospital administrations. Some further thoughts show that the leadership challenges for physicians include:
Commitment--effective leadership requires a major commitment of time, professional interest and energy. It cannot be done in the time available between patients or the occasional day off.
Competency--requires physicians to acquire and learn a new set of behaviors, skills and tools not taught as part of their medical education.
Cultural conflict--requires physicians to understand and be able to effectively mediate differences in values, communications and behavioral norms between clinical medicine and administrative leadership.
The key to success is physicians learning the competencies of leadership.
Step 6: Invest in Social Capital Social capital is characterized by the networks, processes and trust that help to facilitate coordination and cooperation for the benefit of individuals that are part of a larger group. Physicians and hospitals form a social unit. The strength of relationships and good will that comes from physicians, administrators and boards spending time together in social activities both in and away from the hospital can be enormous.
Step 7: Hold Regular Meetings and Retreats Successful relations are characterized by the development and implementation of multiple points of structured access between physicians and hospital. The following are some examples of best practices seen in organizations that might serve as examples to others. These include:
A biweekly lunch of the "C" suite of the hospital with key medical staff leaders to discuss issues on an ongoing basis
A bi-annual off-site retreat attended by the hospital board, administration and medical executive committee, with a portion of each meeting devoted to education on collaboration
Annually, the hospital sends a board member, a hospital administrator and physician leaders to a national meeting on medical staff and hospital governance and leadership.
Structured but informal physician-hospital social activities. Why make this investment? Trust grows from structured access. Social capital allows the resolution of collective problems more readily and in a less costly fashion.
Step 8: Establish a Written Conflict Resolution Mechanism Because of significant fundamental differences, conflict is inevitable even under the best of circumstances. A process for resolving conflicts between physicians and hospitals must be planned and agreed upon by both parties in advance of any conflicts. A formal policy should identify the process that shall occur and the leadership tools to bridge the gap.
Step 9: Maintain Excellent Communication Communication is the active process of exchanging information and ideas. An excellent communication process needs to be planned, open and frequent. Communication competencies need to be learned, practiced and implemented. Those competencies include:
Active listening characterized by the principle of listening to understand.
Observe the fundamental elements of a message in which non-verbal behaviors account for 55 percent of the message, tone of voice 38 percent and the actual words used 7 percent
Provide feedback by paraphrasing what you think you heard to check for understanding.
Ask good questions using words that are factual rather than emotional.
The success of every step in this process for improving physician-hospital relations is dependent on effective communication.
Step 10: Celebrate the Successes The journey to improving physician-hospital relations can be long and arduous. In fact, at times it can be downright contentious. But along the way, some short and long term wins have been realized. Some of the successes to celebrate include:
The first session of the newly created Medical Staff Leadership Institute with a delineated application process, a formal curriculum with external experts and attached CME hours, as well as a clear criteria for advancement.
The mechanics of a joint venture ambulatory care center have been worked through and construction is in progress. This only occurred after an intense period of discussion employing the principled negotiation approach.
It is increasingly important to celebrate the successes. A list of successes should be created--no matter how small--and examined to find ways that can be celebrated. By celebration, appropriate recognition is given to the successful improvement and by highlighting it, hopefully allows it to be repeated.
Summary and Conclusion This monograph has outlined a ten step approach developed by The Greeley Company to improve physician-hospital relations. The monograph began by keeping the end in mind. What would it look like after the multi-year process necessary to achieve different results? Let's take a look:
Step1: Acknowledge physicians are customers, partners and competitors. Physicians and hospital now have a better understanding and appreciation that the old social contract between the parties has expired and conversations about a new order can begin.
Step 2: Heal the past. Physicians and hospitals have been able to name perceived past injuries and have agreed not to play old tapes. This has allowed the physicians and the hospital to begin to work through the dynamic of impact and intent. Because of this, the healer's wounds have been acknowledged and the past can be appropriately mourned. An emerging light from this storm is that a rediscovery of the "joy of medicine" is occurring.
Step 3: Create a shared vision of mutual successes. The medical staff and hospital, having each crafted their own mission/vision statement and a joint strategic plan that is multi-tiered and flexible.
Step 4: Develop mutual expectations for physicians and the hospital. The physician-hospital "compact" has served the parties well in focusing, aligning and advancing the diverse groups in search of their mutual interest to provide better and expanded clinical care to patients and communities.
Step 5: Invest in medical staff leadership. The formalized Medical Staff Leadership Institute, with its delineated application procedures, formal curriculum and criteria for advancement, has graduated its third class of present and future physician leaders.
Step 6: Invest in social capital. Physicians and hospital have increased play together and now have a harder time fighting than those who don't.
Step 7: Hold regular meetings and retreats. Increased trust has definitely grown from structured access.
Step 8: Establish a written conflict resolution mechanism. The written conflict resolution process and the investment in training all leaders in both principled negotiation and Polarity ManagementT have helped guide physicians and hospital through multiple conflicts.
Step 9: Maintain excellent communication. Active listening has become the norm. In seeking to first understand, the parties are now are finding that they are being understood.
Step 10: Celebrate the successes. Along the way, successes were identified and celebrated in public ceremonies recognizing the change agents and minimizing the naysayer.
William K. Cors, MD, MMM, FACPE, is Vice President of Medical Staff Services for The Greeley Company, A Division of HCPro, Inc., in Marblehead, Massachusetts.
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The Maine Hospital Association recently announced a voluntary statewide initiative aimed at preventing patients and insurance companies from getting billed for the expense of medical errors that lead to longer hospital stays. But a state lawmaker says the voluntary policy doesn't go far enough and is pushing for an enforceable law that would make it illegal to charge patients or other payers for medical missteps that should never have happened in the first place.
A technician mistakes an "A" for an "O" in a drug name. A doctor misplaces a decimal point in a prescription order. A nurse reaches for a vial in a cabinet as she's done hundreds of times before, only this time the light is dim and she fails to notice that the powder-blue label is more of a sky blue. The slip-ups are often simple, and always human, and all have happened in U.S. hospitals. Each simple mistake is supposed to be countered by a recommended backup, a second or third set of eyes--in other words, guidelines to reduce human error. A lot has to be overlooked in the cascade of errors that result in serious patient harm.
