The center of the health care universe will always be the patient-doctor relationship. As mentioned here before it is also the hard target for quality and value initiatives. Decades of corporate driven health care have replaced the patient-doctor relationship with the doctor-patient transaction (Relationships Over Transactions). A quick, impersonal, mostly authoritarian and more recently technology-focused transaction. It’s what administrators and managers do so why did we expect anything else when we handed over the keys?
A healthy relationship, as in patient-doctor relationship, is built upon a foundation of components such as trust, respect, communication, patience and empathy. In a service-based relationship the communication aspect is the most important and communication requires time. None of these components are required for the current doctor-patient transaction. A recent blog post entitled “Is Lack of Time Really Why So Many Physicians Are Poor Communicators?” asserted that poor physician communication is a learned behavior taught in medical school. There was an implication that the authoritarian approach to patient interaction is part of the training. HCR believes this to not be the case. It is true that physicians in training spend a great deal of time learning about the science of the body in health and disease. And it is also true that the individual human aspect of health and disease is often overlooked. The question is: does a focus on science necessarily lead to poor communication? It is probably a safe bet that no where in medical school are students taught an authoritarian approach to patient interaction. It is also a safe bet that no where in medical school are students taught to spend as little time as possible with patients. Rather, HCR believes that the current state of the patient-doctor relationship (transaction) is a direct result of the system and environment in which physicians work and practice.
Physicians, and more importantly current and past physician leaders (A Call-Out to All Physicians In Leadership Positions), are guilty of weakness and complacency. They have slowly and overtime conceded to the business school model of health care where volume trumps quality. And driving volume means less time with each patient. The only way for that to happen if for weakened physicians to completely take over the interaction and transform a relationship into a transaction. The authoritarian nature of the transaction is a coping mechanism rather than a methodology taught in medical school.
HCR believes that most physicians leaving medical school sincerely wish to do the right thing and practice their profession with pride. HCR believes that mid to later career physicians would thoroughly enjoy recapturing their autonomy and practicing medicine without a useless administrator beating them up for their numbers each month. So yes HCR believes that more time will matter (What If Physicians Had More Time?). It will signal a return to a patient-doctor relationship rather than a transaction. With more time greater things are possible. Physicians will have more time to discuss options. More time to discuss risks and benefits. More time to listen. More time to make sure patients understand. How could health care not be better for all? Except the MBA’s.
Is there a single fix for health care? Probably not. It’s a really broken system that involves a lot of money, a lot of waste, and lot of unnecessary people, processes and rules that consume precious resources with no return. The much-needed complete overhaul frightens many because the overhaul involves the people factor. And the CFO doesn’t know how to talk to the board of directors about the people factor. It’s difficult to measure the impact of a healthy culture and health relationships on a month to month basis.
More than any other industry health care is about people and their relationships. People and relationships are more important than big data. More important than any new processes or procedure. More important than new penalties or incentives. More important than the patient experience as it is currently being described. Healthcare needs to focus on people and their relationships. The patient-physician relationship. The provider-provider relationship. The provider-payer relationship.
The physician-patient relationship is ground zero for healthcare. A high-value location with the potential for the biggest impact. It is where the greatest improvements in quality can be made. It is where cost control begins. It is the ultimate component of the patient experience. Unfortunately, corporate medicine based on business principles has replaced a physician-patient relationship with a physician-patient transaction. Volume driven healthcare with the focus on simply getting as much done as possible. And the two most important stakeholders in healthcare, patients and physicians, have allowed it to happen. Patients have lowered their expectations and physicians have cheapened the profession. Re-establishing and optimizing a physician-patient relationship is a must for value-based healthcare that focuses on quality and succeeds at controlling costs. The physician-patient relationship is the foundation of healthcare. Transitioning from transaction to relationships will be problematic in that relationships require time and in the current system the value of time is not appreciated by anyone but patients and physicians. Is it wrong to assume that healthcare will improve if we give patients more time with their physician? More time to listen. More time to educate. More time to discuss the risks, benefits and costs of all options. More time to develop a relationship.
The provider-provider relationship also needs to be addressed. A culture of collegiality focused on patient care is imperative. Everyone has an important role to play. One can’t administrate the culture. It is about getting the appropriate people in key positions and allowing them to be role models for the new culture.
Lastly, providers and payers must establish a better relationship. The current business speak describes the concept of alignment. This will require both sides overcoming years of mistrust and antagonism.
The transition from transactions to relationships won’t be easy. Administrators and payers currently focus on volume. Physicians have been rendered powerless. It may require a revolution that starts with the paying customer, the patient, to simply demand more.
So a physician recently was working through the never-ending and ever-growing list of compliance training. None of which has ever been shown to make health care better and all of which takes up precious time. This compliance supports a self-serving industry. Nothing more.
One of the compliance learning courses was intended to help providers develop a culture of health care safety. The material in this course discussed toxic cultures and how they can lead to health care errors and patient harm. So far so good. Focus on culture. Somehow the discussion then lead to a recommendation to eliminate the hierarchical structure in health care. A dangerous statement.
Now, for the record when any member of HCR interacts with the health care system there will be a preference for the hierarchical health care system. The hope is that a well-trained, well-educated physician is at the top of this hierarchy making all of the health care decisions. He/she will work very closely with a team of providers (nurses, therapists, etc. but not managers or administrators) each of whom will have a job to perform. Patient care will be discussed openly and each provider’s feedback and opinion is valued and important. But there will be a hierarchy and the patient’s physician will ultimately make decisions and assume responsibility for those decisions.
The hierarchy is not the problem. The hierarchy is a necessity. There is a reason that it takes a long time and a lot of hard work to become a physician. Any team needs to have a leader and that leader needs to be the person that is irreplaceable to the team. In the health care system that person would be the physician. The self-proclaimed and self-serving experts and advocates love to compare industries. One “pundit” suggested that the hierarchy in health care should be eliminated making a comparison to the cockpit of an airplane. The bizarre analogy was that if a pilot is going to fly a plane into the ground the existing hierarchy might prevent someone from intervening. Seriously? In this scenario the hierarchy is likely not the problem. The problem is the pilot. If a pilot is making potentially disastrous decisions and not receptive to suggestions from colleagues then he/she should simply not be flying. This does not mean that the hierarchy is inherently bad. For the record again, when any member of HCR is on an airplane the expectation will be that a hierarchy is in place and that a well-trained and well-adjusted pilot is at the top of the hierarchy.
No, the hierarchy is not the problem. A hierarchy is a necessity. No hierarchy usually means anarchy. It’s the culture within the hierarchy that is the problem.
Does everyone who collects a pay check in health care really understand the mission and their individual role? Rhetorical. It seems that over the recent decades the health care system has been more about the industry itself and less about what it was designed to do. A lot of self-serving interests.
“An organization begins to die the day it begins to run for the benefit of insiders and not the benefit of the outsiders.” -Peter Drucker
Just in case anyone has forgotten. The mission is to deliver health care to patients. Financial success is important to sustain this mission but the bottom line must be secondary. Competing with the health care system across town is important but if you focus on the mission you will win the competition.
The engine of health care is the interaction between patients and their physicians. The physicians guide and drive the care. And the best health care occurs where the best doctors practice. All others in a health care organization are support personnel. If you have never been face to face with a person asking for help for a potentially life-threatening illness then your job is to support the person who does that job. If you have never been in an operating room attempting to correct a life-threatening problem then your job is to support the person who does that job.
This is not about elitism. This is more about reality, good business principles and how to create a successful health care organization. Everyone in a health care system presumably was hired to do a job that was important to patient care. Every employee, from hospital CEO to parking lot attendant, needs to simply realize why patients walk in the door and who they walk in to see.
Health care version 1.0, run by physicians and other providers, did not work due to an unrestrained utilization of resources. Health care version 2.0, run by corporate forces, also has been a failure. For the past several decades the focus in health care has been about the business of health care. A model of corporate medicine has emerged and proliferated and it only works well for those whose job it is to manage the bottom line. Now we are told (finally) that the future of health care is value. And we are told that the numerator and denominator of value are quality and cost respectively. In theory this will be a transformational change in health care that will require a complete overhaul in operations. But unfortunately nothing is happening at the front lines. Most likely because those currently in charge know nothing about quality but rather are business people. A meaningful change in health care will begin with a substantive change in leadership.
- CCO: Chief Cultural Officer. The most important person in the C-Suite. The CCO will be the relentless agent of change. The CCO will establish the environment where quality care happens. A Donabedian disciple of quality who realizes that structure and process guarantees nothing. Care will always be patient focused. Care will always be evidence based. Sets the standards and acts as a role model for providers at every level of the organization.
- CAO: Chief Alignment Officer. The CAO will serve as the intermediary between quality and cost. Understands the importance of the bottom line which is second only to great care. Will interact with and align the providers with the payers and others whose job it is to maintain the bottom line. Will share information between the two sides on an ongoing basis so that the value equation is maximized.
- CPO: Chief Practice Officer. Possibly the most difficult job on the list. The CPO will be responsible for transforming the practice of medicine. The current model will be deconstructed and rebuilt. The medical staff will first and foremost be dedicated to evidence based practice and will be provided with all of the time and resources to do so. All unnecessary and ineffective processes will be eliminated so that providers can use that time for better purposes. It’s not about compliance anymore. The future will be about a medical staff that is self-motivated to be the best that they can be and doesn’t need high-priced babysitters to follow them around checking boxes on paper. The CPO will make sure that their medical staff is functioning at the highest possible level. The CPO will also assure that they medical staff will make every decision based upon the patient’s best interest. Always.
There will be additional new and innovative positions designed to completely change health care. These positions will all be held by physicians who have demonstrated a selfless commitment to patients and the profession. They must be innovators. Incremental change won’t work. Lastly, they must be courageous. For several decades health care has been shaped and managed by non-physician administrators who now will need to be displaced. Someone will need to help them see how little they actually contribute to the process of delivering health care. They won’t go quietly. There will be an incredible amount of self-preserving rhetoric. Keep the focus on patients, quality and care and the good guys will persevere.
The new C-Suite will meet regularly with community members to receive feedback and assure that the new model is meeting the needs of the people that they serve.
So hopefully a complete change at the leadership level will result in the transformational change in health care that is necessary: The transition from the emphasis being placed on volume to the emphasis being placed on quality with the result being value. This isn’t bad news for everyone currently in the C-Suite. Will keep the CFO. Someone needs to understand how to depreciate equipment 🙂
The “patient experience” has become a hot topic among health care providers. Why did it take so long? This initiative seems similar to the “patient focused” health care efforts which have been talked about for some time. Hasn’t it always been about the patient and their experience? Or more appropriately shouldn’t it have been always been about the patient and their experience?
An experience is a global perception of an event. There are usually both objective and subjective components that shape the global experience. The objective component of the health care experience is the provision of evidence based care which is now down to the molecular level. Sterile, complicated, cold science. It is the most important aspect of the health care experience and falling short here can not be made up elsewhere (see: “It’s Whats at the End of the Patient Experience that Matters Most“). The subjective component of health care is comprised of all the factors that humanize the process. It is a reflection of the culture of human interaction that exists at a health care entity. Physicians obviously must be in charge of the objective component of the health care experience. While there are many individuals that are now actively involved in the subjective component of the health care experience HCR believes that physicians are in fact the best to lead this aspect of health care as well. The culture that is the foundation for the patient experience must “trickle down” from the top.
When applied to economies the concept that wealth at the top will “trickle” down to others below has not been shown to be an effective strategy. However, in the field of human anthropology the concept that behavior patterns start at the top is well established. Leaders (and yes physicians should lead every aspect of health care) can shape behaviors as role models. It has been documented that people identify and attempt to emulate those who they believe are good role models. So an enthusiastic medical staff that values evidence based health care and realizes the importance of treating patients, colleagues and staff with respect is the single greatest step toward the perfect patient experience. In fact it is an absolute necessity.
Redesigning the profession of Medicine to create a culture that optimizes the patient experience won’t be an easy task. An overwhelming majority of physicians don’t enjoy their profession anymore and project this both consciously and subconsciously to all those around them. It has become a constant struggle for them for many reasons. They are burdened with an ever-increasing amount of bureaucracy little of which has been demonstrated to positively affect patient care. There also seems to be an ongoing and worsening adversarial relationship between providers and administrators despite an outward message of alignment. Physicians need to be empowered. The hours spent on paperwork (or computer work) need to be minimized. They need to be able to refocus all of their attention on mastering evidence based guidelines. They need to work in a non-contentious and non-rushed environment so they worry only about the care they deliver. They need to be able to recognize the importance of every colleague and team member and contribute to a positive work environment so that everyone can always put the patient’s needs first.
The nay-sayers will protest that all of these actions designed to make the practice of Medicine better for physicians will have no benefit to patient care. However the enlightened will realize that the path to the ultimate patient experience is in fact a redesign of the profession of Medicine. The benefits will trickle through colleagues, staff and ultimately to the patient.
Years ago physicians took the easy way out and allowed non-physicians to manage their profession. Probably seemed like the right thing to do at the time. Let someone else worry about the bottom line. Patient care was less complex. There were adequate resources and everyone was happy. However, this complex model grew and continued to devour health care resources. As resources became more limited the tensions grew those who were once in charge of managing health care finances now were impinging on the practice of medicine. Their solutions were predictable. They showed up in physicians offices on a monthly basis with a profit and loss statement. Physicians were told to see more patients and do more. With no sense of what was best for patients and the profession and with no strong leadership physicians took the path of self-preservation. And now we have a crisis.
In the practice of medicine the most important guiding principle should always be evidence-based practice. Decisions regarding patient management are/should always be based on what the data shows is best. This strategy will optimize patient outcomes and minimize cost. The result is value. With so much at stake shouldn’t the same standards be applied to health care reform and management?
In November 2013 a publication in the Journal of the American Medial Association titled “The Anatomy of Health Care in the United States” provided insight into the demographic and economic realities and trends over the past decades. HCR encourages the interested reader to obtain a copy and read the entire article so that HCR is not accused of “cherry-picking” select pieces of information.
One of the most telling pieces of data is in Figure 2 which looks at trends in health care expenditures by category. From 2000-2011 the category with the highest growth rate is in fact administrative costs with an annual compound annual growth rate of 5.6%. This was followed by hospital and other care facilities at 4.2%, prescription drugs and equipment at 4.0% and professional services at 3.6%. So the sector with the largest growth in cost over the past decade was a sector that had no direct connection to patient care. Was this growth used to make care better or more accessible? Doesn’t seem so. Rather, these data show that we have invested in making the system more complex than it probably needs to be. How efficient do these administrative costs perform? Figure 13A shows the inefficiency of health care in comparison to other industries. Health care utilizes @ 800 revenue cycle FTE’s per $1 billion of revenue. This appears to be anywhere between 4-10x that of other industries. Does this administrative excess adversely affect patient care? Most likely. Figure 13B show that @ 13% of funds spent on physician care is related to billing and insurance related costs. The money in this case isn’t even the biggest problem. Instead, if we currently spend $70B (13% of total costs) on billing and insurance related costs for physician care just think of the wasted time involved. Time that could be utilized toward making care better. Why won’t some leaders acknowledge the administrative cost and burden on health care? Naive? Threatened?
No data is perfect and it should all be scrutinized. Data is by definition historical so one must always incorporate some prognostication and educated guesses into decision-making. In addition one can not be dogmatic and rigid and allowances for situational discretion must me made. But data should always be the starting point. Leaders in the health care industry must address the issue of administrative excess. Not doing so means losing an opportunity for significant savings. It also calls into question priorities and motivations.
It seems that significant cost reductions can be achieved by reducing administrative costs. Eliminating people and processes that have done nothing but sustain the status quo must be a priority. This will result in an entirely new dynamic between providers and administration. Changing the culture is the only pathway to success.
Another hypothetical for consideration.
So imagine two competing health care systems. One is top-heavy with MBAs who view health care as another commodity. Honestly can’t blame them. It’s what they were taught in school and it’s all they know. In addition, it has been the strategy to win the bottom line grind of corporate health care over the last few decades. Every major decision is made by people who have never been in a room face to face with another human being facing a potentially life threatening illness. They can’t make decisions based on the best care because they don’t know care. And while there may be a message to the public that the organization is led by physicians this is simply a marketing ploy. The physicians are simply chess pieces. The only feedback from administrators is monthly profit and loss statement. There is no channel for feedback from the front lines. The relationship between physicians and administrators becomes contentious. How could it not? A few physicians have the fortitude to fight the good fight. The majority, however, simply begin to dislike their work environment and question their career decisions. If they don’t enjoy their profession what would motivate them to become better at their work?
Across town at the competing health system a new visionary leader has just been put in place. This new leader knows that if health care hasn’t hit rock bottom it is pretty close. This person realizes that the successful health care system of the future will look very different from the those of today. The focus will finally be on quality and not volume. This new leader acknowledges that you can’t administrate quality. Rather, the idea is to recruit a medical staff committed to quality and then provide the physicians with the best possible environment to practice medicine. A culture evolves. Financial data will be shared freely with physicians so that they can also practice cost-effective quality health care. With autonomous physicians the administrative payroll can be slashed realizing a significant cost savings. The administrative staff that remains will be committed only to helping clinicians deliver better care. They are renamed facilitators.
The new system becomes a great success. Physician from all over apply to be part of this change. More importantly, patients come from all over to experience quality and cost-effective health care. This new system is a winner simply because it has the best doctors practicing the best and most cost-effective medicine.
First and foremost it’s always about the people.
Remember the quote from Avedis Donabedian in a previous post titled “Quality, Evidence and Avedis Donabedian”:
“Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession. If you have love, you can then work backward to monitor and improve the system.”
Leaders facing problems or embarking on new initiatives spend a great deal of time and resources researching and planning. It is an absolute necessity to optimize the likelihood of success and minimize risk. At the end of the review a strategic plan is created. This plan looks great on paper. Just like every plan. Fool proof. Can hand this off to a room full of monkeys right? Good luck.
One thing that no strategic plan on paper accounts for is the people factor. And there is no industry more “people intense” than health care. There are now over 7 billion people in the world. Biochemically it has been estimated that we are all about 99.9% similar. But from a behavioral, cultural and social perspective we might as well be 7 billion different species. Frustrating to an MBA who is taught to plan and then force conformity. This was the model for corporate driven health care. However, it is not the model for quality driven health care.
The focus should at all times be placed on empowering the people who are providers to deliver the best care to the people who are the patients. Health care is a people industry and if you don’t account for the people factor your plan won’t work. The people factor always begins with good recruitmentof those who will provide care. In fact, if an organization recruits well there is often little else to do other than provide the appropriate environment (read: culture). If an organization doesn’t recruit well and/or doesn’t have the appropriate environment (yep, culture) then a great antagonism is created that diverts a great deal of energy and resources toward “management” and away from patient care.
So plan away. Do the reseach and gather the data. Analyze the data and make educated projections. But the most important planning is always keeping the focus of any health care organization on the people.
Medical homes and neighborhoods are becoming popular models for quality and cost-effective health care. The concept is right on track. A connected group of health care providers discussing cases, sharing information and working together for the best interest of the patient. But not everyone gets it.
Recently an organization in the midst of creating a new health care integrated delivery system recognized that patients were being sent out of the system for referrals to specialists or testing. Can’t ignore that this is a problem. Their answer was to assign administrators to physicians to carry out daily interrogations. Seriously! No vision. No thoughtfulness. If these are the leaders charged with creating the strategy for the future there could be big trouble looming. But what else would you expect? It is the way of corporate medicine led by non-providers. Band-aids and goon squads. A short-term, rather than long-term, view of the bottom-line.
It’s easy to be critical. But if criticism is genuinely intended to make a situation better an alternative must be offered. Enter the concept of community. Community can be defined in many different ways based on context. But the most applicable here is that a community represents a group of unified individuals with shared values. A community completes the home and neighborhood theme.
If the above mentioned integrated delivery system truly had visionary leadership they would have recognized that the fix for leakage is community building among the providers. A referral from a physician to another physician for specialty services or to a site for testing is first and foremost based on trust. In turn, trust is based on relationships. A patient who has a bad experience with a referral holds the referring physician accountable even if they don’t vocalize their displeasure. If a physician has had a good experience with a specialist why would they want to change and risk a bad experience for themselves and their patients? How do you help them transition? It’s not with daily interrogations. The better way is to help them build relationships within the community of providers within the system. It’s a process of an introduction followed by assimilation.
Community building. Like culture this concept will make some nervous. The most nervous will be the ones that think interrogation is the answer to leakage. Communities, like culture, evolve and emerge. Wouldn’t it be great if all of the physicians in an organization could meet even every week to discuss issues? Yes it would but the reality is this can’t happen. However, for the past 20 years technology has helped to form communities. Could this be the better answer for leakage? Not just a static web page for physicians but rather a site that allows for community building. One that includes robust communication channels between physicians. A site that includes forums where voices are heard. A site that forms the foundation of collegiality and trust among the providers so that referrals can be made voluntarily and with confidence.
So the leakage problem is one of many that new health care entities need to address. Some will bring out the rusty tools and grind. Not a working brain in the bunch. Others will sit and think before they act and listen to the voice of the soldier on the front line – the physician. It should be obvious which approach is more likely to be successful in the long run.