Its What’s at the End of the Patient Experience That Matters Most

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We start with a hypothetical situation.  You have just been diagnosed with a serious but not urgent medical condition and have been given two options for care.

Option A involves a health care system in which the administration just launched a patient experience campaign of which they are very proud.  You call for an appointment and the phone picks up on the second ring.   A very bubbly receptionist schedules you for an appointment tomorrow.  You arrive in the office which has been meticulously designed and apportioned with the finest furniture.  Calm music plays in the background.  The atmosphere is relaxing.  You are promptly escorted back to an examination room and placed in a very comfortable gown.  You can’t help notice the great art on the walls and wonder how much this must have cost.  In walks your new doctor and right from the start your relaxed state begins to change.  He seems nervous, rushed and unprepared.  Really doesn’t listen much.  You never become engaged in a dialogue.  There is no education.  What you don’t know is that he has thrown up the white flag and surrendered to the corporate model of medicine years ago.  He just wants to see as many patients as he can today.  The other thing you don’t know is that he hasn’t picked up a book or read a journal article in years.  Maybe goes to a continuing education meeting a year in a nice resort town.

Option B is next.  You call for an appointment and the very polite office person tells you that the next opening is a  day next week.  When you show up the office is clean but a little dated.  No music or art.  As you are led into the examination room you begin to get a little anxious about the entire “feel” here so far.  In walks your new doctor.  The visit begins with an introduction and a few minutes of small talk.  The doctor does a lot of listening and you feel engaged in your care.  You get the feeling that this person is genuinely interested in helping you.  What you don’t know here is that this doctor has refused to give in to corporate medicine model.  Even more importantly, this doctor realizes that knowledge is the foundation of quality health care.  He spends at least 2-4 hours per week keeping up with the ever-changing medical literature within his specialty.  You will receive the latest evidence based care.

So is your choice option A or option B?  Of course the goal is to have the best of both and the two are not mutually exclusive.  However, the focus of current health care leadership seems to be on everything but helping doctors practice better medicine.  Do they not understand where the most important improvements in health care quality are to be made?  Do they really think that pretty offices and timely appointments define quality health care?  Is this what the general public believes or are they smarter?

Hopefully this extreme dichotomous example will help those in leadership focus on what it really important.

Adaptive Leadership and Health Care

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Honestly.  Did no one really see this coming?  Did those in leadership positions just chose to ignore the signs?  Maybe they saw the warning signs and just didn’t know what to do.  The story might be comparable to the auto industry here in the US.  Ignored external pressures.  No willingness to change or adapt.   Anyway here we are.  Our health care system is now in full crisis mode.  The system doesn’t deliver care as well as it should.  The two most important stakeholders, patients and physicians, are very unhappy and fed up.  And now the external environment has changed dramatically with the Affordable Care Act.  In all likelihood the current health care crisis was preventable if there were thoughtful leaders in place.

Adaptive leadership is a strategy that dates back to a 1994 book titled “Leadership Without Easy Answers” written by a Harvard professor by the name of Ronald Heifetz.  Professor Heifetz has studied and written about leadership, adaptation, systems and change.  The publications describing his work are available at his website (http://www.cambridge-leadership.com).  The foundation of adaptive leadership is change that enables the capacity to thrive.  The concept is analogous to the process of evolution.  A quote from Charles Darwin at the website states: “it is not the strongest who survive but those who are most adaptable”. Professor Heifetz notes that we are in an ever-changing environment that requires leaders to appropriately respond.  He states that one of the key issues that enables the capacity to thrive is the ability to distinguish technical problems from adaptive challenges.  Technical problems are those that can be solved with an organization’s current structure and processes.  Two + two equals four.  Technical problems can be fixed by an organizations existing authoritative expertise.  An adaptive challenge is significantly different.  As the title of his book suggests there are no easy answers.  The solutions to adaptive challenges involve “changing people’s priorities, beliefs, habits and loyalties”.  To HCR this sounds like a culture change.

Some of the key points of adaptive leadership outlined by Professor Heifetz may be uncomfortable for traditional leaders.  The first is that organizational adaptation occurs through experimentation.  Not too many leaders responsible for a bottom line are comfortable with experimentation but when you think about it every new initiative is an experiment.  Second, adaptive change takes time.  This is another way of saying that we need to plan for the long-term not just short-term profit and loss statements.  Other key points of adaptive leadership would seem to be less stressful for traditional leaders.  Adaptive leadership does not require a complete overhaul of an organization.  Leaders must identify and preserve what is working and identify and change what is not working.

Health care take notice.  The leadership of the health care system in the US has spent decades applying technical fixes to adaptive challenges.  Leadership did not see, or chose to ignore, the adaptive challenges that were in front of them.  It is now time for thoughtful leaders to make adaptive change that will allow the health care system to thrive.

Culture as a (the Only?) Sustainable Competitive Advantage

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The patient care case for culture is easy.  The providers on the front line of health care get it.  For decades the focus of health care leadership has been on efficiency as opposed to quality and patient care.  Health care organizations, top-heavy with MBAs, have applied all of their efforts toward cutting excess.  Definitely a necessary mission.  But with the health care system in crisis it is time for a change.  The drive for efficiency has crossed the equilibrium line and care and quality have started to be compromised (references available).  And where have the savings gone?  Certainly not passed along to patients or providers.  Providers and patients want the future to be about quality, outcomes and value.  And the foundation for quality and value is culture.  But not everyone is on board with culture.  That top-heavy leadership still would rather grind the bottom line.

So what about a business case for culture?  What can a focus on organizational culture do for you?  According to a post by George Bradt at Forbes.com in 2012 corporate culture is the only way that an organization can develop a sustainable competitive advantage: “Corporate Culture: The Only Truly Sustainable Competitive Advantage”.  Not buying it?  Well the argument that Mr. Bradt makes is as follows.  Competitors can hire away top employees.  Competitors can reverse engineer your product and duplicate your services.  Culture on the other hand is more complex.  Mr. Bradt makes a very unique analogy between music and culture.  He notes that all music is composed from the same 12 notes but there is good music and bad.  All culture is based on the same 5 components and of course then there are good cultures and bad.  Mr. Bradt states that all culture is comprised of: (1) behavior (2) relationships (3) attitude (4) value and (5) environment.  It is the association of these components that defines a winning culture that provides a sustainable competitive advantage. It’s the people and their interactions.  It is very reminiscent of a previous post where winning culture was likened to making 2+2=5.

The leadership of health care organizations should pay careful attention.  It’s time to get rid of the top-heavy health care system where minions spend every waking moment on efficiency while completely ignoring quality.  The game is no longer about initiatives that result in small incremental improvements.  Any room full of monkeys can do that these days so there is no great advantage.  Efficiency can now be looked at as a commodity.  Mr. Bradt’s post provides an eye-opening argument on how culture provides the only sustainable competitive advantage for an organization.

 

Faster Care and a Spa

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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

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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.  HealthCareRedux.com 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

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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

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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

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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.

The Valuation Process in Health Care

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One of the reasons that the health care system in the US  has been incredibly difficult to administer is that it is influenced by many different and often disparate forces.  There are economic forces at work.  Is this an industry that can/should be managed strictly by free market economics?  Is the presence of the middle man (insurance companies) a necessity  There are social/political/moral forces at work.  Is health care a right or a privilege?  Does an advanced civilized society have an obligation to provide health care to every citizen or can it comfortably allow the less fortunate to suffer disease, disability and death?

All of these forces complicate the ability to actually place a value on health care and decide what health care should cost.  Don’t be fooled by any current valuation system.  With respect to physician reimbursement Medicare uses a formula known at the Physician Fee Schedule.  Almost half of the payment for a provided service is based on what is known as a work relative value unit or wRVU which in turn are part of the resource-based relative value scale or RBRVS.  However, relative is a relative word.  The relative in RBRVS is used to compare various services that are delivered by providers.  An example would be an office visit by a primary care provider vs a knee replacement by an orthopedic surgeon.  This does not address the true value of health care in society.  To really assess the economic value of health care services wouldn’t it be better to compare the office visit by a primary care provider to tickets to an NFL football game?  Or the knee replacement to the cost of a vacation?  So a more meaningful resource-based system would evaluate health care services relative to the resources in the entire economy.

Do the current middle men (insurance companies) in the system provide value or do they just add a complicated expense?  Some say that the impending health care reform is in reality health insurance reform.  The importance of insurance companies most likely arose in response to the inability or disinterest of providers to manage the economics of the industry.  Is is possible to develop a culture wherein physicians became responsible stewards of the resources so that the middle man becomes obsolete or at least less of an adversary to both patients and physicians?

This is not meant to be an arrogant rant on the importance of health care and the professions of medicine.  HCR believes that health care is a service that an advanced and civilized society can and should provide to all citizens.  A totally laissez-faire approach is not feasible in that a large segment of society is likely to be left without service.  HCR also believes that when we finally get it right we can do it in a way that meets the needs of all involved.  Idealistic over optimism?  We need to think big.

 

A Call-Out to All Physicians in Leadership Positions

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If you are a physician who has been in a leadership position any time over the last 20 years then chances are you have contributed significantly, with acts of commission or acts of omission, to the current problems in health care and the profession of medicine.  Not all of you but most of you.  Maybe not all of the time but most of the time.

There is no plausible denial.  No pointing fingers in another direction.  Look in the mirror.  It’s about personal responsibility.  You helped to get health care where it is today.  And that’s not a good place.  Physicians in leadership positions should have been leading the charge of advocacy.  Advocating for patients.  Advocating for physicians and the practice of medicine.  It hasn’t happened.  In fact, rather than resisting the pressures that have created the current corporate  model of medicine an argument could be made that physicians in leadership positions have in fact allowed themselves to be used as tools to take health care where it is today.

Some, if not most, of  the guilty physician leaders have had a pedestrian existence with just local toxic influence.  However, others have had positions of national prestige.  Icons within their respective fields.  Department Chairman and leaders of national organizations and societies.  In both scenarios the position of leadership was more often used for self-serving purposes rather than strengthening the profession.  While young physicians were looking for mentors, advisers and advocates they instead were left with physician leaders beating them on the nose with rolled-up newspapers like bad puppies.  While patients were looking for a strong presence to defend their interests they instead were left to deal with the forces of corporate medicine alone.

Is there an explanation for why physician leaders have historically forsaken patients and the profession?  Was a leadership position simply an easier path?  Did leadership provide better compensation?  Ego?  Maybe they entered the position with good intentions and then realized they lacked the courage, fortitude and know-how to fight the good fight.  The reason is irrelevant.  The bottom line is that they were in a position to make a difference and they did nothing to help the cause of patients and their doctors.  Hopefully future physician leaders will realize the importance of their position.  Their obligations lie first and foremost in preserving health care as defined as the exchange of services from a professional to a person in need.  Although a corporate entity may sign the paycheck they

Physician leaders of the past 20 years get to claim today’s health care system as their legacy.  They haven’t provided a solution so that means they have been part of the problem.  It’s what they helped create.