Compliance with The Joint Commission's 2009 leadership standards requires an understanding of how intertwined the concepts are with a hospital's everyday activities.
"When we really think about it, the leadership things really form the foundation for everything else," said Ken Rohde, senior consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, at the recent 3rd Annual Association for Healthcare Accreditation Professionals Conference.
"If you have weaknesses in your leadership area, it's going to manifest itself everywhere," said Rohde. Strong leadership in the hospital setting is imperative to not only surviving, but thriving in today's world of changing values, regulatory issues, and economic climate, he said.
The importance of focusing efforts
Staff members and departmental managers must show leaders what they need to focus on to stay in compliance with the standards. Providing leaders with the necessary tools and convincing them to lead by example will allow a hospital to provide high-quality care and keep in line with regulations.
High-reliability organizations strive for more than compliance with standards, said Rohde. They aim to deliver the highest-quality care to every patient. However, paying attention to certain topics will ensure compliance with the standards and force hospitals to put patient care and staff cooperation first and allow the organization to focus on its priorities.
Process management
There are some leadership standards (LD.03.05.01, 04.04.03) that deal specifically with process improvement or design. A few others call for prioritization of performance improvement activities (LD.04.04.01), program management (LD.04.01.05), and organization-wide planning (LD.03.03.01).
Rohde encouraged attendees to make a list of the processes that must be improved and, from that, create a top 10 list. It's important that there be only one list so every staff member in the hospital knows the organization's focus and does not spend time tending to other issues.
"Prioritization: If you don't do that, all we're doing is making a list of 200 number one priorities," said Rohde. It is the job of leadership to decide what should and, more importantly, should not go on the top 10 list.
"It's really easy for someone to waltz into your office and tell you another 10 things to add to the list, but it's hard to say, ‘I know we have risk here and that accreditors may be looking for this, but this is just not going to happen,'" Rohde said. A top 10 list can open up valuable communication about the organization's goals too.
Part of effective process management is change management, said Rohde. This shows that leaders have considered the directions that making a process change might take.
In the Ocala Business Journal, columnist Nick Iannone delves into the relatively short history of healthcare marketing and its effect on public health. "In healthcare advertising, the traditional combination of product, price and service isn't as directly adhered to as it is for product advertising," Iannone says.
Bruce Philp, CEO of GWP Brand Engineering, lays out the top five habits of successful executives on Twitter in this article. Some executives are already using Twitter to speak directly to customers, instinctively get it right, and add tremendous value to their enterprises, Philp says, but when they get it wrong it can be damaging to the brand experience their company works to cultivate.
Eighty plastic mannequins laid in a tangled pile in a San Antonio restaurant one evening in August. The same week, at other locations across the city, seemingly healthy people lost movement on their left side, slurred their speech, and were helped by their companions. At each event, street teams passed out cards that read "Stroke Happens" and detailed the warning signs of stroke.
These slightly macabre scenes were part of an avant-garde Baptist Health System marketing campaign. The health system's marketers designed the attention-grabbing events to inform San Antonians that their city, which used to send stroke victims to Austin or other Texas cities for treatment, now had a Brain and Stroke Network center at each of Baptist Health's five area hospitals.
"As we began to plan our marketing effort, we knew that a big component needed to be education about what a stroke is, how to recognize the symptoms, and the urgency of seeking quick treatment," says Karen May, director of internal communications at Baptist Health. "Stroke is a serious health threat that the public does not understand as readily as they understand heart attack."
The marketing team quickly decided that it needed to "develop a promotional plan that would educate our community about stroke, using tactics and messages that were clear and bold," May says.
Working with a local production company, marketers gathered 80 mannequins—one for each San Antonian who dies of stroke each year—and dressed them in "Stroke Happens" T-shirts.
"People seemed genuinely shocked that the death rate for stroke was so high and asked questions about treatment," says Beverly Ingle, account supervisor at production company Guerra DeBerry Coody.
Baptist Health also hired actors to stage mock strokes to stress the importance of fast treatment. The companions who helped the faux victims were also actors. At the end of each demonstration, the performers handed out the "Stroke Happens" cards that featured the image of half of a brain fused with half of a clock, and the National Stroke Association's FAST acronym that explains the warning signs of stroke. Ingle says almost 500 cards were distributed during the weeklong campaign.
"The people who viewed the reenactments were genuinely concerned for the would-be stroke victims and offered their sympathy and support," she says. "At the end of the reenactments, those watching were relieved that the demonstration was an act."
If there were a 2,264 slice CT, would you buy it? Your answer to that question would likely depend on a number of factors. Will those extra 4,000 slices deliver a big enough clinical improvement to justify the cost? Do your competitors have one? Could being the first in your market to have the new technology be a differentiator that would bring in significant new volume?
But there are more important questions to ask when you're considering an upgrade—whether or not physicians and patients care that you have the latest and greatest piece of imaging equipment.
For physicians, the answer is a qualified yes. Yes, they want to work at or refer patients to hospitals that have advanced technology. No, they won't necessarily decide to work or refer patients to a hospital because it has a 264-slice CT instead of a 64-slice CT. On the other hand, having the more advanced equipment could give you a slight edge over a competitor that does not.
"I don't think it assures the organization of getting the best and the brightest, but certainly does help to clinch the deal. To capture these highly-desired physicians many elements need to be in place to achieve their personal and professional needs. But if all other professional offerings are market-attractive and it comes down to the choice of one organization that has and one that has not it could be the deal maker," says physician recruitment specialist Allison McCarthy, principal of the Barlow/McCarthy consulting firm.
As far as referrals go, if an organization is a tertiary or quaternary center, physicians will have higher expectations. At a community hospital, physicians will likely be satisfied with the more modest imaging alternative, she adds.
For patients, the answer is a yes . . . and a no. It shouldn't come as a surprise that more advanced imaging technology is a selling point for women's health services. It's hard to stay competitive without digital mammograms and ultrasounds, especially.
Chester County Hospital, in West Chester, PA, learned that when it conducted focus groups of women and discovered that they were well aware of which hospitals offer digital mammography—and which ones don't. "Women shop technology. They're savvy shoppers," says Colleen Leonard Leyden, director of corporate marketing and public relations at the 220-bed hospital. "And they do select their provider based on that."
Chester's direct mail and print campaigns that either cross-sold or focused on radiology and other diagnostic capabilities created a spike in volume, she adds. "It did inspire a lot of women to pick up the phone and ask for information about scheduling their mammography."
On the other hand, direct-to-consumer ads that tout high-tech equipment in other areas aren't always the best selling point, since many consumers probably don't know the difference between a 64-slice and a 264-slice CT. If the difference were 2,000 slices, they might get it. But (so far at least), the 2,264-slice CT isn't on the market.
Read more about incorporating imaging into your marketing, recruitment, and referral strategies in this month's HealthLeaders magazine marketing article, Imaging Wars.
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In 2004, I wrote an article titled "How to Pay for Healthcare Reform," which was quoted in other articles at the time on the economic crisis in escalating healthcare costs and the threat of government intervention. I authored other articles in the 1990s about how technology could help create healthcare efficiencies, and I wrote extensively in the late-1990s about how HIPAA would help revitalize healthcare and improve information for quality, efficiency, and standardization.
Here we are at the end of the first decade of the 21st century and still healthcare is inefficient, costly, in most cases terrible at customer service, and constantly in financial crisis. Since the 1970s, people have postulated that U.S. healthcare is in trouble and we need to do something to make it better. However, little has changed and the same problems have persisted since the 1970s.
Don't get me wrong, I believe we have the best care in the world. However, I also believe we have the most inefficient healthcare processes in the world, which has led to the continuing financial crisis.
I began my professional career as an industrial engineer in the early-1970s. I analyzed process manufacturing systems, inventory control, accounting models, and manual tasks performed by trained workers. What I learned from this experience, and also while studying Edward Deming and Peter Drucker, was that well meaning people can create very inefficient processes, broken systems, and costly output.
Thus, it is not the clinical care that is the problem. It is the administrative processes that surround clinical care that creates the increases in rapidly growing healthcare costs, healthcare system inefficiencies, and opportunities for error in all aspects of patient care, as well as, practice, facility, and health insurance operations.
In addition and compounding the problem, health information technology (HIT) has been proposed as a solution that can help if process change is addressed as part of the HIT implementation. In healthcare, we are not only hampered by bad processes, but in some cases we have automated bad process, and thus created faster bad process. In the banking industry, this is the old story of buying loan systems that help create more bad loans.
In order to solve this 30-year downward spiral momentum in healthcare, three rules need to be observed:
80% of healthcare is operated out of practices with fewer than five physicians and therefore these are considered small businesses.
All solutions must be simple to understand and easy to implement.
The majority of funding must be directed at this 80% of the healthcare industry, not the large payers and large hospitals or research facilities (where typically the government puts its funding resources).
No matter how much money is thrown at healthcare for technology, it may not achieve the benefits expected.
As for the estimated savings of trillions of dollars, I remember being involved in developing HIPAA when we told the government that it would also save trillions of dollars in administrative simplification. It did not, and these new healthcare reforms will not if the real problem is not addressed.
Here are the facts and fallacies about governmental promises for better healthcare broken into three categories:
Government
1. Government focuses on the wrong things and does not really understand the industry.
2. Government thinks intervention can create change, it does not.
3. Government puts the majority of the money in the wrong places (large institutions and academic research studies)
4. Government should support the industry, but not dictate to the industry as we have witnessed lately in the automobile manufacturing business. Nationalized healthcare will create more inefficiency as has been demonstrated by other governmental healthcare initiatives like Medicare and Medicaid.
Basics 1. Systems create value if they are built on sound, efficient process.
2. Systems do not deliver value if they are not implemented with new processes.
Health realities 1. Medical practices are based on processes that are more than 30 years old.
2. We have automated bad practices (patient flow, billing, lab results reporting, even EMR based on old charting processes).
3. Claims systems are old and antiquated, designed and built on manual adjudication processes that are also more than 30 years old.
4. Customer service systems still rely too much on manual intervention and low paid, well meaning people.
5. Physicians are afraid to invest in technology because they believe most have proven difficult to implement and they delivers little value.
6. Practices are usually not business process or efficiency driven; therefore, most are over-staffed and under-funded.
7. Customer service organizations in health insurer organizations are based on phone calling and manual answering processes due to inefficient claims and payment systems with poor or incomplete information.
8. Investing in good process and good technology is considered too expensive or is rarely based on a proven return on investment strategy.
9. Little emphasis is placed on the following:
Process improvement
Process quality
Return on investment tracking
Information and process integration
Provider continuum of care integration
Information engineering of lifelong medical records
Defining an efficient and effective care payment system
Bottom's up approach to healthcare efficiency in this order:
Physician
Practice
Community
Region
National
Not a top-down approach, which has failed healthcare for over 30 years.
Government should provide sound, quick funding from the following:
Immediate 100% double tax credits on costs/investments expended for process improvement, technology, and community integration (healthcare is a local issue—HIE: Health Information Exchange projects have local merit and local value)
Immediate incentives to physicians and practices who invest in the above based on bank-backed low cost or interest free loans (with government guarantees) with five-year paybacks or easy to get grants (not too much paperwork) with no payback other than proof of implemented process improvement and tangible ROI.
Tax-free investment: Dollar for dollar for the first $200,000 invested by a physician per year in process improvement through technology based on a 24- to 36-month tracking period.
Where does the money come from: Not new taxation
From a 10% surcharge on all new government projects in all areas (based on healthcare being the primary motivator for both political parties).
A 5% government surcharge on all existing government funding (because so many believe good healthcare is a right).
All investments tied to a five-year forecast of real dollar savings on process efficiencies from practice and managed care organizational process improvement. All the while being backed by a tangible study that can be tracked and reported quarterly on industry progress to Congress and the general U.S. population. All invested funds should yield a 3 to 1 ROI.
What can be accomplished If all this was accomplished and there could be a grassroots approach to process improvement and industry integration, I am convinced the following could become a reality based on what happened in other industries:
Healthcare costs would be reduced overall based on administrative cost savings by at least 20%.
Healthcare industry would improve quality through information integration and dissemination of better data.
Patient care costs would decline and premiums would be lower based on better tracking of chronic care and wellness processes.
More people could be insured due to declining premiums and more efficient processes driving real costs down.
No government intervention other than financial support for process improvement and technology investment would be necessary.
This would result in the U.S. leading in both clinical care processes and the administrative process models for high efficiency and quality.
All of the above has never occurred in the 25-plus years I have been in healthcare.
My challenge for the industry and the government is (to put their money where their mouth is) and put this processes into action and create real healthcare change that promotes:
Implementing process improvement projects and systems (bring quality into healthcare processes)
Deploying value-based health information technology based on measurable ROI
Creating measurable results tracking systems that prove real savings, value, and increased coverage for more people
Government must support the industry, but allow the industry to make the changes necessary to create a new model for healthcare.
The industry must encourage and demand change and cooperation from all providers in order to implement a new more efficient, cost effective, quality-driven health system.
Providers must take responsibility to invest in change, improve processes, and implement health information technologies to support health information exchanges, electronic health records, and patient collaboration. This is not rocket science, but looking at our progress one might be inclined to believe it is becoming a close second in the race.
We are closing out the first decade of the 21st century and we have continued to make little change. It is time for change, and it must be initiated by the industry, not the government.
Bill Bysinger, PhD, MBA, founder ofWGB Advisory, a Macon, GA-based healthcare consultant.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
The chances of a public insurance option this year seem to diminish every day, but health insurers shouldn't celebrate the idea's demise just yet. It will happen eventually. All signs point to it.
President Barack Obama and leading Democrats want a public plan, but even if it doesn't happen this year, the public option is a powerful negotiating tool. Health insurers and Republicans are so petrified of a public plan that they will likely give in on a number of other issues.
The public plan's power is already evident as America's Health Insurance Plans has agreed to change two practices that have been an individual health insurance staple—not accepting members with preexisting conditions and charging women more for coverage—as long as lawmakers require all Americans to have health insurance. There is simply too much opposition to a public plan to happen this year. Instead of a public plan, this is the healthcare reform package I expect Congress will pass this year:
An individual mandate that will require all people have a certain level of health coverage that the government will heavily subsidize to help pay for coverage of lower-middle-class Americans and will help fund by taxing mid-sized and large companies that don't offer health insurance. The individual mandate will be implemented slowly, but will require all Americans have coverage within the next five to eight years.
Similar to the Massachusetts model, the feds will create a connector program that will help the uninsured find individual insurance. This is a win for health insurers, but the insurance industry will also have to give back something (see next bullet).
The individual insurance market has been called the "wild west" because of its lack of regulations, but expect Congress to regulate the industry as a way to protect individual health insurance members. Layoffs and reduced employer health benefits have forced many Americans into the individual market, which is the one area of growth for health insurers. This growth has also caused lawmakers to focus more on that segment of the industry. Expect more regulations that go beyond the two proposed by AHIP.
The feds will reduce healthcare costs by cutting hospital and physician payments, reducing payments to Medicare Advantage, and bundling payments that pay for care coordination and quality rather than volume, and investing more money in prevention programs in hopes of reducing long-term health costs.
In the short term, the health insurance industry will avoid the public insurance bullet, but will also have to sacrifice in the areas of more regulation and less Medicare Advantage payments. That doesn't mean the public plan idea will die though. In fact, it's inevitable. Most Americans have accepted greater government intrusion in their lives.
Government is now often seen as a solution rather than a problem, which is much different than in the days of Ronald Reagan. Plus, surveys show Americans want a public option to compete against private insurers. All of this points to my belief that a public insurance plan is inevitable.
This first pass at health reform will disappoint many liberals. But the public option will return after the midterm elections—and a watered down public plan may actually become law next time around.
This scenario is a nightmare for the health insurance industry—more regulations this time and a public plan next time. It's a one-two punch that will force health insurers to find ways to set themselves apart from the public plan, but if health insurers respond by streamlining programs and reducing administration costs, maybe that's not such a bad thing after all.
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Jerry Smith, vice president of revenue cycle at St. Vincent's Health System, discusses the successful implementation of a patient financial assistance program, live from HFMA.
The vendors had long faces and the ratio of candy and pens to the high-end swag was much higher than I've seen at conferences of past, but this year's HFMA sessions in Seattle nonetheless were packed and fewer attendees were nodding off. In fact, there were a lot of energetic and impatient hands raised when it came to hot topics, such as RACs, charity care, and accelerating patient payments.
From hospital CFOs to revenue cycle companies, banks, consultants, and healthcare finance managers, this group was acutely focused on learning strategies for how to maneuver through the tough economic times of healthcare reform, frozen access to capital, a growing number of self-pay patients, and huge regulatory changes.
In dealing with all of these issues, there was much talk of squeezing extra cash out of operations, including the revenue cycle and being as efficient as possible in all aspects of the business. The growing divide between the haves and have nots was also a common topic as was the idea that healthcare is entering a time of massive consolidation due to any number of the aforementioned items.
"We need near-term solutions to stave off debt and increase cash reserves," said Jerry Smith, vice president of revenue cycle at Birmingham, AL-based St. Vincent's Health System, as he explained to a packed room how his system drove down accounts receivable days from 50 to 34 by among other things implementing a patient financial assistance program that offers a low-interest rate credit card program for patients Essentially, the credit card program, backed by U.S. Bank, enables St. Vincent's to be paid a loan for 100% of a patient's bill within 72 hours.
The credit cards come with a 5.99% interest rate, plus prime. Patients pay as little as a $10 down payment to get into the program and are not prequalified with a credit report. But there are some risks, acknowledged Smith. "When you look at the parameters around the loan program and the no qualification score, you are rolling dice and hoping the patient will come through. You can do this intelligently by monitoring your recourse rates closely," said Smith. Still, in the end if the patient doesn't pay, the debt reverts back to the system's books and it gets sent out to third-party collection.
Meanwhile, consolidation was a theme heard over and over. As one person put it, the gap between the haves and have nots is growing to the point where consolidation will occur like it did following the Balanced Budget Act of 1997. This is due to a variety of factors, including hospital margins falling, reimbursement getting squeezed and the big race for technology. The ability to invest in technology will become a real differentiator, said another person.
Coding was another topic of key concern for this audience. Out on the exhibit floor, one consultant said that the changeover to ICD10 is going to be a big problem for hospitals because it requires a much higher degree of specificity in documentation than ICD9. At lunch, I sat next to a guy from a prestigious east coast hospital, who has had made it his personal mission to improve coding. He says coding has become a lot more important over the last year and a half with the implementation of severity DRGs and the first-ever revision of the CC list (complication and comorbidities). Still, hospitals are leaving money on the table through improper coding. "There are bizarre aspects of this business and how patients are coded is surreal. The variation is not explained by anything rational."
In another session, Hector Boirie, chief capital management officer for Sisters of Mercy Health System dazzled a room with the system's comprehensive capital planning strategy. Hector said most hospitals say they have a capital planning process and tools, but really it consists of an Excel spreadsheets.
"We have to change the way we do healthcare," he said, in the midst of all the market turmoil, which includes an unemployment rate last month of 9.4%, the highest since the 1980s. To that end, the hospital system has changed its capital planning process.
"It was about individual facilities and they used a spreadsheet and we all competed for same dollars. We had four times the requests as available cash." At the same time, he said, most hospitals don't really know how much they are spending on projects because many are multi-years.
To that end, without going into a lot of detail, all of the system's capital planning processes were streamlined. The system is spending $450 million in capital planning and asset management and has $1.8 billion in planned capital expenditures over the next five years. To drive more efficiency and savings into its operations, the system has done things such as form its own GPO. It also operates its own fleet of trucks that deliver supplies to hospitals and it does bundled buys. For example, said Hector, "no imaging technologies in the health system are purchased individually." While internal stakeholders weigh in on what to buy, Hector said, there is less focus on buying certain brands and more focus on product specifications. He said this strategy saves the system $15 to $20 million a year.
Far from prompting employers across the country to cut jobs, a national "play or pay" policy for businesses would actually create many more employment opportunities and save the country money at the same time, according to two reports released Tuesday by three California health analysts.
Their studies were bolstered by a petition signed by 330 economists , business leaders, academics, and health experts advocating universal coverage in a health reform package as a way to improve the economy.
"A lot of people are saying that given the dire economic straits that we find ourselves in today, we can't afford to undertake healthcare reform," said Jonathan Gruber, a petition signer and MIT health economist who was U.S. Department of the Treasury deputy assistant secretary for economic policy in 1997. "The key point of this statement is to point out that's exactly backwards. This is exactly the time we have to act to reform healthcare in the United States."
The reports and the petition were released yesterday in a news conference organized by Campaign for America's Future, a left-leaning Washington, D.C. political group advocating social reforms, including healthcare policy change such as universal coverage.
The first report, by Phillip Cryan of the Goldman School of Public Policy at the University of California at Berkeley, said a pay or play option route to guarantee everyone health coverage will "most likely" cause significant job gains for five reasons:
1. The country will reap enormous savings by requiring employers that don't provide comprehensive health insurance to their workers to pay a new payroll tax to help fund public health insurance for those workers. Their new health insurance coverage would allow people to obtain medical care long before their health issues became so acute that they require expensive hospital care, Cryan says. And that could create jobs.
2. With more people seeking care, more jobs will be created in the healthcare sector.
3. Workers who previously had no health coverage would now be healthier and more productive.
4. Workers who want to leave their jobs, but don't because they fear losing their health coverage would now be free to do so, making the labor market more efficient.
5. Some employers who now provide expensive coverage might choose to pay instead of play.
Cryan said that with a play or pay option "at the very worst, job losses would represent a few hundredths of 1% of employed workers."
The other report, by University of California at Berkeley policy analysts Jacob Hacker and Ken Jacobs, discussed how a pay or play plan might be modeled after one now in effect in San Francisco and why two statewide attempts at broader coverage proposals failed. Special statewide constraints exist in California that may not apply at a federal level of health reform, they wrote.
One major criticism of the play or pay proposals, Hacker and Jacobs wrote, is that the public pool would be straddled with expensive cost burdens weighted by a lot of unhealthy workers. Presumably, firms with the most medically costly employees would enroll their employees in the pool.
However, the report said that assumption is incorrect.
"Although some of the uninsured are in poor health (in part because they lack insurance), many are young and inexpensive to insure," according to the report. "Past estimates suggest that the overall costs of uninsured Americans should be about equal to the rest of the population once they are covered."
