Monthly Archives: September 2013

Faster Care and a Spa

HCR is still trying to determine the author of the following: “you can tell a lot about an organization’s culture by what people are talking about”.  So true.

In health care there is still no one talking quality!!!

Recently, a physician executive approached a physician about making improvements within a certain specialty service line of health care.  The physician executive presented a very well thought-out and researched process map and timeline of particular care path.  Then came the disappointment.  Rather than focus on how the outcomes at the end of the process map could be improved the physician executive asked how people can move through the process faster.  Honestly?  Is this the priority of every health care executive?  Why wasn’t the talk about outcomes and quality?  Is the health car system really committed to action on quality or is the quality talk just talk?  Maybe quality is just too difficult and no one wants to really do the heavy lifting.

It is understandable that patients would like their health care to proceed as expeditiously as possible.  In some scenarios in health care rapidity is a medical necessity.  In other scenarios however rapidity is honestly just a luxury.  Is it a luxury for which we are willing to pay?  Like any other metric in health care the time it takes a patient to complete a particular pathway of care can be optimized.  Also, like any other metric the optimization will require resources. Resources such as time, people and money.  As we stand at a crossroads between the old way and a potential new and better way the smart allocation of resources is imperative.  So who will make the call?  In this particular scenario one option would be to invest extra resources into the pathway so that patients move through faster.  If patients are getting slowed down in the testing process then just add extra hours of testing with the additional people and equipment.  Those who now are focused on quality would say that those resources could be better spent.  The alternative is to expect more from the current resources.  So just have the current providers and equipment work faster.  There is an obligatory loss of personalized care in this instance.  Also, shouldn’t health care be one of the industries where people are encouraged to work smarter not harder?

The entire issue of getting people through the system as quickly as possible is a great example of how patient’s expectations should be managed.  The timeliness of care should, like everything else, be evidence based and patients and physicians need to commit to this principle.  Do we want to invest precious resources on getting people through the system faster as a remedy for anxiety or do we want to invest those resources into quality and outcomes.  Education is a much better and inexpensive fix for anxiety.

As the meeting with the physician executive came to a close it was also noted that in addition to the initiative of getting people through the system faster the institution would be allocating resources to a spa.

Fixing the Four Ring Problem: Driving Uniformity and Mediocrity

So do non-physician leaders and executives really know how to drive quality in the health care system?  Is the focus correct and do they really understand patient care?  The premise here at HCR is that most do not.  This is not an elitist stance.  It is just impossible to manage something so complicated without ever having done it.  A recent example follows.

A health care organization noted that it had an issue with patients getting timely access to the physicians.  There are some conditions that require urgent but not emergent care.  And from a business aspect if a patient can’t get a timely appointment with a physician then they may end up at a competitors place of business.  The problem is an important one.  The problem of access to physician care is complicated and there are multiple layers.  The administrative fix is a four ring rule.  If a patient calls a physicians office and does not get a person and an appointment in four rings then the call will get forwarded to a call center where a call center person will insert that patient into a slot in some physician’s template somewhere.

The first issue to get off the table is that, like in all occupations, there are physicians who simply want to do the least amount of work and collect the highest possible salary. has acknowledged the importance of physicians taking responsibility for restoring the profession of medicine (see: “Nobility Obliges” and “Guilty as Charged”).  The first place to look is always into the mirror.

The problems and issues that affect timely access to physicians are not uniform.  It is likely that there are four groups.  The first group (Group 1) are physicians who have built practices that realize the importance of getting patients into the office quickly and have the people and processes in place to make that happen.  The second group (Group 2) are physicians who realize the importance of timely access but do not have the people or processes in place to allow for it to happen.  The third group (Group 3) are physicians who don’t currently recognize how important timely access is but can be educated and are willing to change.  The fourth group (Group 4) are physicians who don’t acknowledge the importance of timely access and likely never will and are resistant to change.  One could obtain the distribution of the groups with the appropriate data mining.  The optimal fix for the access problem would in fact be four separate fixes.  Complicated but precise.

The alternative is a generic, universal fix applied to all physician offices.  A centralized call center and a rigid physician template.  All calls not answered on the fourth ring to a physician’s office would then be forwarded to a 100 person call center where a person who likely has no medical training will answer the phone.  The call center person will likely listen for key words from the caller-patient and then insert them into one of thousands of physicians templates that have been created.  It’s the M.B.A. fix.  It looks great on paper.  But it will only partially correct the problem of patients not being seen in a timely manner.  And at what cost?

The problem with this or any generic fix is the unintended consequences.  And also, these generic and universal fixes usually result in uniformity and mediocrity rather than the ultimate goal of best practice management.  Have the following issues been considered?

1) The physicians who are now performing well with respect to patient access are potentially penalized.  What if these physicians get most but not all calls on the fourth ring?  And what if the patients who gets a recording are called back very promptly?  Those patients who would have been called back are now likely to be inserted into another physicians template.  This could adversely affect the physician’s practice.  Even though the patient was accepting of the process.

2) Patients are often referred to a certain specialist based on a referring physician developing a level of trust with the specialist.  That trust is based on the specialist providing quality care and maintaining communication with the referring physician.  The incentive to do so by the specialist will be diminished and the previously invested hard work becomes negated.

3) Physicians have become specialized and sub-specialized.  Can an untrained person in a call center really connect a patient with the best person to provide best care within the larger group of physicians?  And if a bad outcome occurs because of an inappropriate referral is it justified because the four ring metric was hit?

4) And honestly, will this generic fix do anything to make the unmotivated physician be more receptive to change?

Applying a one-size fits all fix to problem is never the well thought about fix.  Does it make sense to break down practices that may be working fine to help others that are broken? Uniformity and mediocrity or best practices?  Four rings of the phone or quality outcomes?  Fixing health care is much more complicated than four rings of the phone.

The Long View on Health Care

Quality endures.  Investing the resources necessary to establish a solid foundation always pays off in the end.  Always.  The foundation of health care is the delivery of health care services from a physician to a patient.  Over time layers of excess have been added to the foundation.  The layers did not strengthen the foundation but rather weakened it.  The additional layers not only weakened the foundation of health care, the doctor-patient relationship, but added cost with little in return.  As layers of excess were being added to the foundation the external environment was changing as well.  The system was appropriately deemed no longer financially sustainable and cut backs in funding were implemented.  A disastrous situation.

Enter the corporate model of health care management.  While there are some institutions in the U.S. that are managed by physicians (actually the more successful ones) in most health care systems the top 5 layers of leadership have never practiced medicine because they were trained to be business people.  They don’t know what its like to be face to face with another human being who has just been diagnosed with a terminal illness.  That is not and should never be looked at as 15 minute new patient visit.  They have never experienced the frustration and self-doubt that follows when a physician has apparently done everything right and a patient still has a bad outcome.  They have done nothing to fix the broken foundation of health care because they were never trained to do that and don’t know how.  Rather, the corporate model of health care knows one thing: fix the bottom line.  So for years health care administrators have had a singular focus.  They have spent decades, as the saying goes, putting lipstick and perfume on the pig.  The focus has been on how to make this month’s balance sheet look better than last month’s balance sheet.

Now it would be naive to think that there was no fat to be cut out of the system.  And one can never discount the importance of operational efficiencies.  But for years the crumbling foundation has been ignored, layers of waste have been added to the foundation and the focus had been simply on making the bottom line look better.  No one saw this coming?

Every decision in health care now has to be made with one question in mind:  How is this going to help physicians provide quality health care to their patients?  And the layers of weight on the foundation need to be reassessed.  Is there value there?  Re-establishing the doctor-patient relationship requires re-establishing the culture of health care.  The profession of medicine must be redone.  Physicians should first and foremost realize that they in the business to provide a very important service to society not purely for self enhancement.  Physicians should be encouraged to read, read and read some more rather than work, work and work even harder.  Isn’t that one of the key differentiators between a profession and a trade?  The patients need to become more engaged and set the bar higher for their physicians.  They should expect an encounter with a highly educated professional who does as much listening as they do talking.  The encounter should be educational.  It should be personal.

Health care doesn’t need more myopic fixes on the bottom line.  Someone needs to have a plan with the long view.


The 2013 Fantasy Health Care Draft

With little fanfare or media coverage the 2013 Fantasy Health Care Draft was held this past weekend.  There was great excitement as a sold-out crowd watched every citizen in the United States fill the 10 roster spots for their personal health care teams.   The eligible draftee pool was deep.  Included were insurance executives, hospital and health care system administrators, politicians, health care quality leaders, drug company and medical device executives and many others who walk around hospitals in nice clothes.  Oh, and their were physicians and nurses as well.  The draft order was derived via a lottery system.  Parents made roster choices for their children under 18. Each draftee could be on multiple rosters as the number of citizens far out numbered the draftees.  As expected, there was a significant amount of pre-draft maneuvering to obtain a higher position in the draft order.  Based on some early surveys the people of the US apparently spend a great deal of time doing research in the hopes of assembling a winning team.

The expectations were high for the potential draftees in the newly created accountable care organization executives.  Also expected to do well were those who have never practiced medicine a day in their lives but who tell those who do provide care how to do it better; the health care quality people.  The festivities began with a video presentation of the history of the health care system in the United States.  This was followed by another video that demonstrated how the Affordable Care act has been terribly politicized.  Finally at 9:00 am the first citizen came to the microphone and made their first roster addition.  It was a primary care physician.  One after another the people of the US came to the podium and 313 million people later every first round choice was a primary care physician.  As the draft moved through rounds 2-10 the anxiety among the non-provider draftees became evident.  The citizens of the US filled their rosters with various specialist physicians, nurses and other providers such as chiropractors, physical therapists, nutritionists and even EMS personnel.

At the conclusion of the draft after no non-provider personnel were drafted a formal complaint was filed on behalf of all non-providers questioning the integrity of the draft and the sanity of the American public.  A full investigation will be carried out and a report is expected within the next few months.

Culture Emerges

If culture is such an important component to a successful organization why then isn’t it a major focus of every C-suite?  The answer to this question is related to several fundamental aspects of human nature itself.  First, we prefer the concrete over the abstract.  Second, we prefer instant gratification over delayed gratification.  And lastly, uncertainty makes us very nervous.  We would much rather live the in the world of formulas, business plans, and reports.  Also, some believe that the bottom line drives the business.  In reality it is the business, and more specifically the people and the culture, that drives the bottom line.

Most businesses are driven by a monthly profit and loss statement and knowing that 2+2=4 provides them with something to follow and manage.

The concept of culture is a completely different universe.  Many have written about the importance of culture in successful organizations.  The number of “cultural illuminati” continues to grow.  While many understand the importance of organizational culture as the “secret sauce” of success no one seems to have the recipe for the sauce.  One of the cultural illuminati is Bernard Rosauer.  Mr. Rosauer is currently the president of the Wisconsin Compensation Ratings Bureau.  He has had a successful 30 year career in the data-intense insurance industry.  At one point in his career he was assigned the responsibility of organic corporate growth and customer retention.  He developed an incredibly insightful approach which is detailed at his website ThreeBellCurves.  A free white paper is available for download at the website and Mr. Rosauer lectures and provides executive training based on the Three Bell Curves concepts.  It is a great read that helps leaders maintain focus on the three most important aspects of business culture: the customers (patients for the health care industry), the work, and the employees.

The Three Bell Curves white paper also has a great introductory paragraph regarding culture.  In one paragraph Mr. Rosauer elegantly describes culture as an emergence.  He uses a definition that describes the essence of culture and at the same time demonstrates why the term culture induces anxiety in most managers:

“An emergence is a novel, complex and often immeasurable state resulting from the combination of two or more simple ingredients.”

He then goes on to describe an emergence as:

“In simple terms, an emergence can be explained as those times when 2+2=5.”

An emergence.  That is a difficult sell to those who believe that the bottom line drives the business.  Even for those who understand that the business drives the bottom line the cultural emergence is a challenge.  There is no step wise process to manage.  Rather, establishing the foundation for cultural emergence begins with a simple combination of good people who have a laser focus on the appropriate priorities.  With the appropriate support and patience a very successful culture then emerges over time.  This organically grown culture differentiates the organization from all competitors, provides stability in the face of challenges and fads and then ultimately drives the bottom line.