Just watched an interview by Paul Borawski with J. J. Irani or Tata Steel (India). A couple of ideas that could be applied to healthcare, if we'd allow it. Irani talked about "big Q and little q." Little q is the quality of the product or service. In his case, it meant how good was the steel? This is where our emphasis has been for quality in healthcare: wrong site surgery, hospital re-admissions, wound infections, aspirin for chest pain, etc. All those metrics that various gurus have espoused as indications of quality in healthcare services. We spend countless hours and dollars measuring these things and reporting the results to now-empty offices in Washington. It's possible to look up how your hospital ranks on many of these metrics. No one would argue that they are not important or desirable. Catheter infections are costly. Sometimes people die. But somehow, there is this nagging feeling that we are chasing the wrong tail. If we do better in all these little things, will healthcare overall be better? Are these really the problems or are they symptoms of a more basic problem.
Which brings us to Big Q. For Dr. Tata, that means quality in management. How the company is run. Asked which was more important, Big Q was an easy choice. At one point, he said he would like all his suppliers to adopt the same quality management systems that his company was using. For him, this meant adopting the principles of the Baldrige Award. His point was that it needed to be a system of management, not a tool for improvement. In other words, a way of running the organization. The Baldrige principles constitute one approach, ISO 9001 is another.
For those who aspire to exceptional excellence, the Baldrige criteria are appropriate guides. Indeed, the original concept was to identify examples of excellence for others to emulate and thus raise the quality of U.S. industry. Over time, the award has expanded to healthcare, education, and government. It has also become commercial, with a mini-industry of consultants to write the perfect application. The number of healthcare applications has been increasing steadily, without visible effect on the healthcare industry as a whole. It still costs too much money to be sick.
ISO 9001 has only recently made inroads in healthcare. DNV healthcare became a serious competitor to the Joint Commission in 2008, primarily because of their focus on Big Q. They require hospitals to become eligible for registration to ISO 9001 within three years of their original accreditation by DNV. ISO, of course, is not specific to healthcare. It is a way of running the company--any company, including a hospital. It is Big Q. A recent book documents the effective use of ISO 9001 in a private group practice and in the global healthcare operations of the U.S. Department of State.
If you have Big Q in place, other things will follow. A management system allows control of the tiller. Once the ship is headed in the right direction, quality becomes part of the culture and thus pervasive in all the activities on board.
Wednesday, August 3, 2011
Monday, June 13, 2011
When does it end?
In reviewing Paul Borawski's brief comment about quality at Ford, I was intrigued by one concept mentioned by Mr. Fowler of Ford: quality must focus on the entire customer experience. To paraphrase another sage, "It ain't over 'till it's over." Now there's a new concept for much of healthcare. How do patients get to your office? Is it easy to find? On a public transportation route? We once surveyed patients coming to a clinic in our building, and 85% said it was difficult to impossible to find. At one time, there was a sign at the main entrance, "Hard hat area. Do not enter." The response of our executive officer was, "We have signs! What's the matter with those patients that they can't read signs."
Beyond directions, how about instructions. What to bring. What to eat/drink. Does this work? Do you know? Is the process of getting into your system so easy that it never fails?
Some other thoughts from my surgery center days:
What about the experience within your system? How do your customers feel about that? Don't forget that family members are customers also. Are they kept informed? An analysis of calls coming in to the pre-op area showed over 95% were looking for a patient. "Is Mrs. Smith there?" With computer screens everywhere, it didn't take much to create a patient locator system so any employee could find any patient, tell when they arrived at that location, and how long they were likely to stay. The calls stopped.
And the exit. Which way to turn out of the parking lot. When my wife had cataract surgery, the center gave chits for 2 hours of free parking. Unfortunately, the procedure took 2 hours and 20 minutes. Somehow, I found that extra $5 for 20 annoying. The center had no idea and was not at all interested.
I received a thank-you note from a family once because our maintenance employee changed a tire for them so they wouldn't be delayed going home. How did he know? Are employees tuned to signals of a need in patients or families?
How was the trip home? Did you know there is a high incidence of vomiting in children when the car turns the first corner on the way home?
In some ways, ambulatory surgery foists the burden of post op care on the family rather than hospital nurses. Sometimes, the family needs guidance in what to expect and how to deal with it. Take pain pills before the pain starts. How long will it take to recover? Go back to work? Managed expectations. Surgeons frequently have an overly optimistic view of the post op period. Collect data.
The biggest hurdle to managing total customer experience is taking responsibility. Make it your job. If providing care is not part of your mission, be there to provide resources or inform those responsible. Learn from the Ford experience; it ain't over 'till it's over.
Beyond directions, how about instructions. What to bring. What to eat/drink. Does this work? Do you know? Is the process of getting into your system so easy that it never fails?
Some other thoughts from my surgery center days:
What about the experience within your system? How do your customers feel about that? Don't forget that family members are customers also. Are they kept informed? An analysis of calls coming in to the pre-op area showed over 95% were looking for a patient. "Is Mrs. Smith there?" With computer screens everywhere, it didn't take much to create a patient locator system so any employee could find any patient, tell when they arrived at that location, and how long they were likely to stay. The calls stopped.
And the exit. Which way to turn out of the parking lot. When my wife had cataract surgery, the center gave chits for 2 hours of free parking. Unfortunately, the procedure took 2 hours and 20 minutes. Somehow, I found that extra $5 for 20 annoying. The center had no idea and was not at all interested.
I received a thank-you note from a family once because our maintenance employee changed a tire for them so they wouldn't be delayed going home. How did he know? Are employees tuned to signals of a need in patients or families?
How was the trip home? Did you know there is a high incidence of vomiting in children when the car turns the first corner on the way home?
In some ways, ambulatory surgery foists the burden of post op care on the family rather than hospital nurses. Sometimes, the family needs guidance in what to expect and how to deal with it. Take pain pills before the pain starts. How long will it take to recover? Go back to work? Managed expectations. Surgeons frequently have an overly optimistic view of the post op period. Collect data.
The biggest hurdle to managing total customer experience is taking responsibility. Make it your job. If providing care is not part of your mission, be there to provide resources or inform those responsible. Learn from the Ford experience; it ain't over 'till it's over.
Sunday, May 22, 2011
There's No Tomorrow
Actually, no today either. In case you missed it, the world ended last week. But, if it doesn’t happen as promised, there’s another chance. This time it’s not the Christian Bible thumpers but the Mayans. The Mayan calendar will end on 21 Dec 2012. In truth, however, only the Christians have such an apocalyptical view of the world. The Mayans simply start a new calendar, so perhaps there will be tomorrows.
That ‘s good news, because the ASQ has published their view of what tomorrow will look like. Others have commented, and, of course, they’re all wrong. Let’s look at their predictions:
1. Global Responsibility. ASQ thinks “governments, organizations, and individuals” will act with “a growing awareness of the local imac of local decisions.” Waste will become socially unacceptable. Well, they certainly forgot to ask the Tea Party about this, or the Republican party in general. There are those in Congress who want to remove funding from the EPA, and any thought of a carbon tax brings laughter and derision. ASQ also talks of waste in the form of “undeveloped minds.” To turn that around, we would need to strengthen the WIC program and Pre-K enrichment programs for poor kids. Oh, but we just cancelled those things. Sorry, despite our fondest hopes in 2008, the U.S. at least, seems headed in the opposite direction.
2. Consumer Awareness. They allude to the Internet and social media as providing information to consumers to make purchasing decisions. Well, yes, some, but that’s here now. Is there some reason this practice will expand? Internet shopping is a here and now practice, not a dream for the future. Even the concept of mass customization is so, well, yesterday. What about tomorrow?
Globalization. As they say, globalization of customers and work forces is a factor in most businesses, tho more critical to larger than smaller businesses. It’s not clear from the discussion what they predict for tomorrow, so hard to argue that they’re wrong unless one could say globalization will become irrelevant. So OK, I’ll say that. Globalization will cease to be the boogey-man it once was. Cheap labor is cheap for a reason, and low wages will no longer be the driving force for location of factories. Taking healthcare as an example, there will always be a place for medical tourism, but it will never challenge or supplant traditional sources, like your Community Memorial hospital or the Cleveland Clinic.
3. The increasing rate of change. Change has certainly been dramatic in our lifetimes. Wow! I remember dial telephones. And the first TV in our neighborhood--a 6 inch black and white. So it’s easy to predict that this will continue. Easy, at least unless you’re reading the tea leaves. On a talk show the other nite, someone espoused the radical idea that technology hadn’t really done much in the last ten years or so. New gadgets, to be sure, but no dramatic improvement in our lives that could be ascribed to technology. Today’s Washington post carries a column about “life without gadgets.” So maybe not much will change in the next 5 to 10 years. Society will take that time to digest what went on in the last. And we do have a few wars to contend with. Wars aren’t over when they end.
4. The workforce of the future. I hope they’re mostly correct here, when they state that unemployment “will become a thing of the past,” but I suspect this is wishful thinking. The pressures of high wages have driven productivity ever higher. We just don’t need that many workers making widgets anymore. But without paid workers to buy widgets, we don’t need to make so many widgets, so we’ll lay off a few more workers. That’s where we are now. It’s called recession. Getting out is hard to do. Government spending helps, but that only works if you simultaneously raise taxes. Not gonna happen in the present environment, so unemployment will be with us for the long haul, and may actually get worse.
5. Aging Population. ASQ starts this discussion with a prediction that working longer may become an option “if not a requirement,” and I’ve got to agree with this one, with one asterisk. The requirement part implies extending the retirement age for Social Security. This makes a lot of sense, and there is talk of indexing the SS retirement age to life expectancy and thus return the duration of retirement to about 10 years. Current U.S. life expectancy is about 78. One of the big problems with this is that if the job demands physical effort, it’s hard to keep up when your 70. Manual laborers will lose out. ASQ talks about the high cost of healthcare for all these geriatric patients. Maybe we should revisit Soylent Green. Healthcare expenses do go up with age, but not as much as you might expect. Furthermore, the increasing number of elderly is not a key factor in the costs of Medicare. The reason Medicare is such a budget buster is the high and rising costs of individual healthcare services. Not only are our healthcare costs higher than any country in the world, we provide more of those services per patient than any country in the world. So, yes, Medicare is a serious problem for the U.S., but no, the aging population is not making it worse--not by much anyway.
6. 21st Century Quality. For this discussion, ASQ defines quality as what the customer wants. They present an interesting concept that quality has moved from production lines to process improvement to enterprise assessment. Whither goest quality as a concept in the future? Some say nowhere. In healthcare, at least, attempts to institute “quality” have not produced any system wide gains in efficiency or in quality of care. In fact, the results of data from NCQA and AHRQ show little if any improvement over the past several years. Anyone who is surprised at this should remember that any system produces the results it was designed to produce. Is “quality” an obsolete term? Has the concept outlived its usefulness? What is the meaning of quality in a service economy? Is there any place for it in the future?
7. Innovation. ASQ initially expresses some confusion over the difference between innovation and improvement, then makes no prediction for the future importance of either. Just a term they thought they should mention. Hard to argue with that.
On predicting the future: I went backpacking with the Boy Scouts, and one of our assignments was to predict the weather. For six days, there was a morning haze followed by sunny skies. We, of course, predicted more of the same for the seventh day. It rained. Poured down rain. This illustrates the difficulties of predicting the future by extrapolating from the past. That’s what ASQ has done: they picked some trends and extended the line to the next point. This doesn’t allow for unexpected events (like earthquakes) or disruptive innovation that may make your business obsolete. The C&O canal in Washington, DC was supposed to be the transportation mode of the future. Until railroads, that is.
This report by ASQ is almost totally devoid of documentation or data to support the few predictions they make. For the most part, that’s OK in this venue. However, when you make an outrageous statement like unemployment will go away, you better have charts and graphs.
Let me offer my own take on the next ten years. Mark your calendar and call me back. I’ll buy drinks if I’m wrong on more than two and ASQ was right.
1. Global responsibility: There are no incentives for either governments or corporations to be socially responsible. They will not. A few isolated examples, but generally no.
2. Consumer awareness. Has reached its peak. Certainly in healthcare, further attempts to better inform consumers will fail, partly because most patients are incapable of understanding and partly because they don’t care.
3. Globalization. No one will talk about this in ten years. No book titles. No speeches.
4. Rate of change. Will slow to a snail’s pace. We may see expansion of wireless networks to broad geographic areas, but it will be the same Internet. Lots of refinements of gadgets--better iPads--but nothing innovative.
5. Workforce. Wages will fall, mostly by a drop in benefits, particularly health insurance and retirement. Healthcare and technology will be the biggest employers, but unemployment will not be much different from today. The Very Rich will emerge as a distinct class of World Citizens without allegiance to any country. The gap between the Very Rich and the rest of us will widen.
6. Aging. The 70 to 90 year old group will become the new middle class. They have money to spend and time to spend it, in modest amounts. The health in this group will improve, and the time between sick and dying will shorten. Suicide will become a more common cause of death.
7. Quality will decline in relevance as a buzzword. In healthcare, quality will come to mean compliance to standards set by government committees or think tanks.
Maybe the world did end yesterday, and I just missed it. Catch you in 2012.
That ‘s good news, because the ASQ has published their view of what tomorrow will look like. Others have commented, and, of course, they’re all wrong. Let’s look at their predictions:
1. Global Responsibility. ASQ thinks “governments, organizations, and individuals” will act with “a growing awareness of the local imac of local decisions.” Waste will become socially unacceptable. Well, they certainly forgot to ask the Tea Party about this, or the Republican party in general. There are those in Congress who want to remove funding from the EPA, and any thought of a carbon tax brings laughter and derision. ASQ also talks of waste in the form of “undeveloped minds.” To turn that around, we would need to strengthen the WIC program and Pre-K enrichment programs for poor kids. Oh, but we just cancelled those things. Sorry, despite our fondest hopes in 2008, the U.S. at least, seems headed in the opposite direction.
2. Consumer Awareness. They allude to the Internet and social media as providing information to consumers to make purchasing decisions. Well, yes, some, but that’s here now. Is there some reason this practice will expand? Internet shopping is a here and now practice, not a dream for the future. Even the concept of mass customization is so, well, yesterday. What about tomorrow?
Globalization. As they say, globalization of customers and work forces is a factor in most businesses, tho more critical to larger than smaller businesses. It’s not clear from the discussion what they predict for tomorrow, so hard to argue that they’re wrong unless one could say globalization will become irrelevant. So OK, I’ll say that. Globalization will cease to be the boogey-man it once was. Cheap labor is cheap for a reason, and low wages will no longer be the driving force for location of factories. Taking healthcare as an example, there will always be a place for medical tourism, but it will never challenge or supplant traditional sources, like your Community Memorial hospital or the Cleveland Clinic.
3. The increasing rate of change. Change has certainly been dramatic in our lifetimes. Wow! I remember dial telephones. And the first TV in our neighborhood--a 6 inch black and white. So it’s easy to predict that this will continue. Easy, at least unless you’re reading the tea leaves. On a talk show the other nite, someone espoused the radical idea that technology hadn’t really done much in the last ten years or so. New gadgets, to be sure, but no dramatic improvement in our lives that could be ascribed to technology. Today’s Washington post carries a column about “life without gadgets.” So maybe not much will change in the next 5 to 10 years. Society will take that time to digest what went on in the last. And we do have a few wars to contend with. Wars aren’t over when they end.
4. The workforce of the future. I hope they’re mostly correct here, when they state that unemployment “will become a thing of the past,” but I suspect this is wishful thinking. The pressures of high wages have driven productivity ever higher. We just don’t need that many workers making widgets anymore. But without paid workers to buy widgets, we don’t need to make so many widgets, so we’ll lay off a few more workers. That’s where we are now. It’s called recession. Getting out is hard to do. Government spending helps, but that only works if you simultaneously raise taxes. Not gonna happen in the present environment, so unemployment will be with us for the long haul, and may actually get worse.
5. Aging Population. ASQ starts this discussion with a prediction that working longer may become an option “if not a requirement,” and I’ve got to agree with this one, with one asterisk. The requirement part implies extending the retirement age for Social Security. This makes a lot of sense, and there is talk of indexing the SS retirement age to life expectancy and thus return the duration of retirement to about 10 years. Current U.S. life expectancy is about 78. One of the big problems with this is that if the job demands physical effort, it’s hard to keep up when your 70. Manual laborers will lose out. ASQ talks about the high cost of healthcare for all these geriatric patients. Maybe we should revisit Soylent Green. Healthcare expenses do go up with age, but not as much as you might expect. Furthermore, the increasing number of elderly is not a key factor in the costs of Medicare. The reason Medicare is such a budget buster is the high and rising costs of individual healthcare services. Not only are our healthcare costs higher than any country in the world, we provide more of those services per patient than any country in the world. So, yes, Medicare is a serious problem for the U.S., but no, the aging population is not making it worse--not by much anyway.
6. 21st Century Quality. For this discussion, ASQ defines quality as what the customer wants. They present an interesting concept that quality has moved from production lines to process improvement to enterprise assessment. Whither goest quality as a concept in the future? Some say nowhere. In healthcare, at least, attempts to institute “quality” have not produced any system wide gains in efficiency or in quality of care. In fact, the results of data from NCQA and AHRQ show little if any improvement over the past several years. Anyone who is surprised at this should remember that any system produces the results it was designed to produce. Is “quality” an obsolete term? Has the concept outlived its usefulness? What is the meaning of quality in a service economy? Is there any place for it in the future?
7. Innovation. ASQ initially expresses some confusion over the difference between innovation and improvement, then makes no prediction for the future importance of either. Just a term they thought they should mention. Hard to argue with that.
On predicting the future: I went backpacking with the Boy Scouts, and one of our assignments was to predict the weather. For six days, there was a morning haze followed by sunny skies. We, of course, predicted more of the same for the seventh day. It rained. Poured down rain. This illustrates the difficulties of predicting the future by extrapolating from the past. That’s what ASQ has done: they picked some trends and extended the line to the next point. This doesn’t allow for unexpected events (like earthquakes) or disruptive innovation that may make your business obsolete. The C&O canal in Washington, DC was supposed to be the transportation mode of the future. Until railroads, that is.
This report by ASQ is almost totally devoid of documentation or data to support the few predictions they make. For the most part, that’s OK in this venue. However, when you make an outrageous statement like unemployment will go away, you better have charts and graphs.
Let me offer my own take on the next ten years. Mark your calendar and call me back. I’ll buy drinks if I’m wrong on more than two and ASQ was right.
1. Global responsibility: There are no incentives for either governments or corporations to be socially responsible. They will not. A few isolated examples, but generally no.
2. Consumer awareness. Has reached its peak. Certainly in healthcare, further attempts to better inform consumers will fail, partly because most patients are incapable of understanding and partly because they don’t care.
3. Globalization. No one will talk about this in ten years. No book titles. No speeches.
4. Rate of change. Will slow to a snail’s pace. We may see expansion of wireless networks to broad geographic areas, but it will be the same Internet. Lots of refinements of gadgets--better iPads--but nothing innovative.
5. Workforce. Wages will fall, mostly by a drop in benefits, particularly health insurance and retirement. Healthcare and technology will be the biggest employers, but unemployment will not be much different from today. The Very Rich will emerge as a distinct class of World Citizens without allegiance to any country. The gap between the Very Rich and the rest of us will widen.
6. Aging. The 70 to 90 year old group will become the new middle class. They have money to spend and time to spend it, in modest amounts. The health in this group will improve, and the time between sick and dying will shorten. Suicide will become a more common cause of death.
7. Quality will decline in relevance as a buzzword. In healthcare, quality will come to mean compliance to standards set by government committees or think tanks.
Maybe the world did end yesterday, and I just missed it. Catch you in 2012.
Saturday, May 14, 2011
Leadership in Healthcare
On reviewing Paul Borawski's writing about ideas for education, I looked for common themes--some high level principle that could apply to healthcare also. I came away with leadership. Every organization needs a strong leader--someone to point the way and inspire the troops to follow. This is true for education, and it is also true for healthcare.
Why? What do leaders do, and how is that different from managers or supervisors? There is even a Journal of Leadership in Health Services. Leaders should be visionary and determine the best direction for the organization. Take charge and accept responsibility. General George Patton is quoted as saying, "Tell the troops what you want done, but don't tell them how to do it. They will amaze you with their ingenuity."
Managers, by contrast, make it happen. They marshal resources, assign tasks, monitor progress, etc. Also needed, but a different focus. supervisors make sure everyone comes to work and has the tools to perform their assigned tasks.
So, what about healthcare? Taking the hospital as the prototypical example, healthcare organizations use a matrix organizational structure. This works best in project oriented environments where a given employee may work on different projects sequentially and there is some advantage to sharing lessons learned with others in the same discipline or carry knowledge from one part of the organization to another. The disadvantage with matrix structures is the confusion that comes with having multiple bosses and the fact that no one is ever in charge of anything. I remember the chief of the surgery clinic at the University of MI saying one day, "I'm supposed to be in charge of this clinic, but no one here works for me."
When no one is in charge, no one takes responsibility for what happens. My wife and I were waitting in a pre-op area, when she noticed a nurse putting paper into a red-bag trash can. She had heard me talk about the relative costs of red and white trash, so she knew this was wrong. "Why is she doing that?" The simple answer was that no one cared. No one was responsible for that area. No one's annual bonus depended on the efficient operation of day surgery. So they put non-hazardous trash into the red bag and paid dollars per pound instead of putting it into the white bag that cost dollars per ton.
This is a major problem with healthcare today. No one is in charge. Institutions and sections within institutions are allowed to operate inefficiently, because there is no leader to stress efficiency and cost saving as a goal. To some extent, the above examples could be explained by the lack of a profit motive in most large hospitals. A moment's thought, however, will dispel that thought. What's your favorite airline? Least favorite? Why? Where do the employees of the best airline get their attitude? Out their thumbs? Are they born that way? I was strolling up and down the corridors at Dulles airport recently, waiting for my flight, when I heard cheering and applause at a gate ahead of me. I thought it must be some group charter, but as I got closer I could see that it was just a routine Southwest Airlines flight. No one cheered at the Lufthansa gate. Someone up the food chain set the tone for those employees. That's leadership.
We recently returned from a cruise where a daily activity was getting people off the ship and on to buses on shore. One group of employees assigned bus numbers for various tours. The security group checked passengers off the ship. Another group drove the tenders to the dock. I'll let you imagine the chaos that ensued when these groups didn't talk to each other. Leadership. Someone needed to be in charge. Responsible.
This is not to say that chaining the organizational structure of healthcare institutions and assigning leaders would solve all the problems. Leaders don't always make wise decisions. However, if we determined a new direction that would solve problems, we would have a mechanism for instituting those changes--a single, responsible individual in charge.
Leadership in education, and leadership in healthcare.
Why? What do leaders do, and how is that different from managers or supervisors? There is even a Journal of Leadership in Health Services. Leaders should be visionary and determine the best direction for the organization. Take charge and accept responsibility. General George Patton is quoted as saying, "Tell the troops what you want done, but don't tell them how to do it. They will amaze you with their ingenuity."
Managers, by contrast, make it happen. They marshal resources, assign tasks, monitor progress, etc. Also needed, but a different focus. supervisors make sure everyone comes to work and has the tools to perform their assigned tasks.
So, what about healthcare? Taking the hospital as the prototypical example, healthcare organizations use a matrix organizational structure. This works best in project oriented environments where a given employee may work on different projects sequentially and there is some advantage to sharing lessons learned with others in the same discipline or carry knowledge from one part of the organization to another. The disadvantage with matrix structures is the confusion that comes with having multiple bosses and the fact that no one is ever in charge of anything. I remember the chief of the surgery clinic at the University of MI saying one day, "I'm supposed to be in charge of this clinic, but no one here works for me."
When no one is in charge, no one takes responsibility for what happens. My wife and I were waitting in a pre-op area, when she noticed a nurse putting paper into a red-bag trash can. She had heard me talk about the relative costs of red and white trash, so she knew this was wrong. "Why is she doing that?" The simple answer was that no one cared. No one was responsible for that area. No one's annual bonus depended on the efficient operation of day surgery. So they put non-hazardous trash into the red bag and paid dollars per pound instead of putting it into the white bag that cost dollars per ton.
This is a major problem with healthcare today. No one is in charge. Institutions and sections within institutions are allowed to operate inefficiently, because there is no leader to stress efficiency and cost saving as a goal. To some extent, the above examples could be explained by the lack of a profit motive in most large hospitals. A moment's thought, however, will dispel that thought. What's your favorite airline? Least favorite? Why? Where do the employees of the best airline get their attitude? Out their thumbs? Are they born that way? I was strolling up and down the corridors at Dulles airport recently, waiting for my flight, when I heard cheering and applause at a gate ahead of me. I thought it must be some group charter, but as I got closer I could see that it was just a routine Southwest Airlines flight. No one cheered at the Lufthansa gate. Someone up the food chain set the tone for those employees. That's leadership.
We recently returned from a cruise where a daily activity was getting people off the ship and on to buses on shore. One group of employees assigned bus numbers for various tours. The security group checked passengers off the ship. Another group drove the tenders to the dock. I'll let you imagine the chaos that ensued when these groups didn't talk to each other. Leadership. Someone needed to be in charge. Responsible.
This is not to say that chaining the organizational structure of healthcare institutions and assigning leaders would solve all the problems. Leaders don't always make wise decisions. However, if we determined a new direction that would solve problems, we would have a mechanism for instituting those changes--a single, responsible individual in charge.
Leadership in education, and leadership in healthcare.
Sunday, May 8, 2011
Wrong Target
Hard to hit the bull’s eye when you’re aiming at the wrong target. A recent opinion piece in the Washington Post summed up the “two monumental issues:” how to provide access for everyone, and how to control costs. The first issue—access—has been largely solved by the recent healthcare insurance reform law. However, the cost issue remains. These authors join countless others in aiming at health insurance, without targeting the systems of healthcare services that drive the cost of insurance. The premiums for health insurance merely reflect the costs of the services received by the insured population.
Everyone now views with alarm the relentless rise of healthcare costs in the U.S. Medicare, in particular, has been projected to consume 100% of the discretionary spending in the federal budget in our lifetime. No need for budget debate; it will all go to Medicare. Unfortunately, the current discussion focuses on Medicare as the insurance plan for the 65+ population. Costs to health insurance companies would be less if we provided less care to individual patients, so most cost reduction schemes seek to reduce the care provided. For Medicaid, we will reduce eligibility, so there are fewer people in the pool. For Medicare (and others), we’ll have an expert panel to decide what therapies will be covered and which will be excluded—similar conceptually to the British NICE panel. (See article in The Atlantic on “My Drug Problem.”) Still, we are left with high-cost individual healthcare services. It still costs more to have hip replacement in the U.S. than anywhere else in the world. This, of course, is the basis for the Medical Tourism industry.
Suppose, instead, we pointed our weapons at the cost of individual healthcare services by invoking price competition. We’ll still provide a hip replacement (THR) to anyone who needs it, but we’re taking bids. Yes, it’s more complex than ordering copy paper, but those are solvable problems. They have been solved in other realms and can be solved in healthcare.
What would you do on the other side? Your hospital has been doing THRs forever, but you just lost your bid to a hospital in the next town, because you charge too much. In most industries, the instinctive response would be to look for ways to reduce your cost. This would lead you to a process engineer who would use LEAN techniques to identify waste in your current processes. Estimates of waste in healthcare vary from 20% to 50% of costs, so there are enormous opportunities here. There are other tools and techniques, and there is value also in an overall Management System to organize those tools and ensure they are used effectively. (Disclosure: I’m one of the authors of this book.) These tools are not entirely new to healthcare, but price competition is a new concept.
So too is the concept of an overall management system, such as ISO 9001 to manage improvement efforts and ensure they are focused on common objectives.
Tuesday, April 12, 2011
Outmoded Concept?
Quality, that is. Has its day come and gone? There was serious question a few months ago over continuation of the Baldrige award on the grounds that it was no longer relevant. There was an article in, I think the NEJM last year suggesting that the quality movement had totally failed to produce any tangible results in healthcare. The measures of healthcare done by AHRQ and NAHQ are indeed static. Nothing is getting better.
One can (and I have) argue about the relevance of the metrics, but nothing is improving. Nothing. True, there are poster-child stories about this hospital or that doing something great, but the overall system is static. Why?
I think we have to go back to someone’s saying that a given system produces the results its designed to produce. If you want a different result, you have to re-design the production system. Healthcare was never designed to produce “quality.” P4P and other metrics were pasted on to an existing system with no provision for motivation. OK, some trivial financial rewards, but no hospital would go out of business because they failed to meet standards. No provider would lose business to a competitor who provides a better service or a lower price.
In the business world, if a competitor provides better or cheaper products than you, people will stop buying your product, and you’re out of business. So you work very hard to provide what your customers want at a lower cost than your competitor. Not true in healthcare. Pricing and purchase decisions are driven by small monopolies. Competition is for insured lives and not over price of procedures or convenience for patients.
When goods or services first enter the market, they command a premium price driven by innovation. The iPhone is a good example. The world was full of cell phones, but this was an entirely new concept in electronic communication. People bought it, and it was/is a high profit item for Apple.
Fast forward now to the point where that product has become a commodity. Generally speaking, prices come down. Dramatically. Competition is no longer about innovation, it’s about price, packaging, convenience, etc. Stuff gets cheap. Want to see a commodity? Copy machine paper. What brand does your company use? I’ll wager you don’t know or care. It’s all pretty much alike, so purchase decisions are made on price, delivery, etc. A certain basic quality is assumed--maybe even specified by standards.
Most of healthcare is a commodity today. All surgeons read the same journals, use the same instruments. Protocols drive family practice encounters. Want a mammogram? You’ll get the same exam with the same results, regardless of where you go. Where is quality in this system? Why would any provider or institution spend time or money pursuing better quality? There is no reward. It doesn’t sell. In fact, it’s difficult to define quality in a system like U.S. healthcare, beyond conformance to accepted practices.
We have been pursuing Quality as an end in itself, when it should be viewed as a tool to achieve a bigger market share. That would require the creation of a market in healthcare--real competition for goods and services, mostly on the basis of price. In such a world, everyone wins.
One can (and I have) argue about the relevance of the metrics, but nothing is improving. Nothing. True, there are poster-child stories about this hospital or that doing something great, but the overall system is static. Why?
I think we have to go back to someone’s saying that a given system produces the results its designed to produce. If you want a different result, you have to re-design the production system. Healthcare was never designed to produce “quality.” P4P and other metrics were pasted on to an existing system with no provision for motivation. OK, some trivial financial rewards, but no hospital would go out of business because they failed to meet standards. No provider would lose business to a competitor who provides a better service or a lower price.
In the business world, if a competitor provides better or cheaper products than you, people will stop buying your product, and you’re out of business. So you work very hard to provide what your customers want at a lower cost than your competitor. Not true in healthcare. Pricing and purchase decisions are driven by small monopolies. Competition is for insured lives and not over price of procedures or convenience for patients.
When goods or services first enter the market, they command a premium price driven by innovation. The iPhone is a good example. The world was full of cell phones, but this was an entirely new concept in electronic communication. People bought it, and it was/is a high profit item for Apple.
Fast forward now to the point where that product has become a commodity. Generally speaking, prices come down. Dramatically. Competition is no longer about innovation, it’s about price, packaging, convenience, etc. Stuff gets cheap. Want to see a commodity? Copy machine paper. What brand does your company use? I’ll wager you don’t know or care. It’s all pretty much alike, so purchase decisions are made on price, delivery, etc. A certain basic quality is assumed--maybe even specified by standards.
Most of healthcare is a commodity today. All surgeons read the same journals, use the same instruments. Protocols drive family practice encounters. Want a mammogram? You’ll get the same exam with the same results, regardless of where you go. Where is quality in this system? Why would any provider or institution spend time or money pursuing better quality? There is no reward. It doesn’t sell. In fact, it’s difficult to define quality in a system like U.S. healthcare, beyond conformance to accepted practices.
We have been pursuing Quality as an end in itself, when it should be viewed as a tool to achieve a bigger market share. That would require the creation of a market in healthcare--real competition for goods and services, mostly on the basis of price. In such a world, everyone wins.
Friday, April 1, 2011
When he fell . . .
When he fell and couldn’t get up, the ambulance took him to the nearby University Medical Center. Did he have a stroke? “No, but we’ll keep him overnight.”
First was the overdose of sleep medication, so he didn’t wake up the next day. Then they overdosed his coumadin, causing GI bleeding that requires transfusion. What mistake will come today? The elderly and infirm lack resilience, so my friend may not survive.
When I needed help a few years ago, I suffered at home rather than call the ambulance that I knew would take me to that same hospital. But I had knowledge and a choice that my friend did not. My bleeding stopped, and the pain stopped, and I am alive today.
But why should survival depend on knowing enough to avoid healthcare? What must we do to convince institutions to pay attention and provide acceptable healthcare that doesn’t harm patients? The knowledge is there. No one deliberately tries to harm patients, but that is what happens all too often.
Barbara looked at me with anguish and frustration. “What can I do?” We both knew there was no answer. She is losing him. Not to accident or disease, but to carelessness within the system that is supposed to help him. Prescribing Coumadin is not rocket science, but it does require attention to detail. Secretly, I was glad I am no longer working in the healthcare sector and don’t have to take responsibility for these errors. I also wonder what will happen for me next time--when I don’t have a choice.
Maybe there will be a revolution in healthcare. Maybe we’ll stop paying for poor care, and doctors will pay attention to patients. Maybe I’ll win the lottery.
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