The opportunity, as I see it, is that front line health care workers, the folks in the trenches delivering care on a daily basis, haven’t been properly empowered.  There’s too much up there, top-down, ideas from on high management going on.  In hospitals the decision making process is largely centralized.  That is no good.  It won’t work in the long run.  The benefits of decentralized decision making (yes, I understand the concerns) are too important for the sustainability of our organizations to overlook.

Hospitals are amazingly hierarchical.  Talk to a health care worker and a major concern that arises is communication (especially with administration).  A serious holdup is the number of individuals a message has to go through before reaching the intended receiver.  By the time that message reaches a front line worker it has been stripped of reasoning, portraying management as heavy-handed (or disinterested, or out of touch, or etc.).  The solution is flatter organizations.

The definition of a flat organization depends on the source.  BNET’s definition is good because our flattening doesn’t need to be drastic, but a process of delayering: “a slimmed-down organization structure, with fewer levels between top and bottom than a traditional bureaucracy, that is supposedly more responsive and better able to cope with fast-moving change.”

Flat organizations encourage constant innovation.  And constant innovation is only possible through empowered employees.  Take this as an example from The New Yorker:

The answer has a lot to do with another distinctive element of Toyota’s approach: defining innovation as an incremental process, in which the goal is not to make huge, sudden leaps but, rather, to make things better on a daily basis. … And so it rejects the idea that innovation is the province of an elect few; instead, it’s taken to be an everyday task for which everyone is responsible. According to Matthew E. May, the author of a book about the company called “The Elegant Solution,” Toyota implements a million new ideas a year, and most of them come from ordinary workers. (Japanese companies get a hundred times as many suggestions from their workers as U.S. companies do.) Most of these ideas are small—making parts on a shelf easier to reach, say—and not all of them work. But cumulatively, every day, Toyota knows a little more, and does things a little better, than it did the day before.

Need a hospital example?  Check out this work on central line infections.

The transition will be difficult.  But change is necessary.  Nick Jacobs of Windber Research Institute and Windber Medical Center writes on the end of management:

The revolution quoted by Cloke and Goldsmith is one of “turning the inflexible, autocratic, static, coercive bureaucracies into agile, evolving, democratic, collaborative, self-managing webs of association.”  From our perspective, the object is to allow those butterflies the freedom to fly.

How do you manage a butterfly?  Work together on the goals and then get out of its way.  Provide it with just the very basic, fundamental needs and goals of your organization, and then trust it, love it, empower it, and encourage it.

If I could possibly find one example that would clearly embrace our success as an organization, it is that of doing everything possible to kill “parent to child management.”  It is not enough to move into the 21st century with our thinking; it is most important to identify those individuals who get it and then give them the space “to do it.”

Are they traditional?  Do they do everything the way you were taught in the “dark ages of the industrialized style of management?”  Nope.  Will it drive you crazy when you look for them, and discover that they are not on the flower where you expected to find them?  Sometimes.  Will they accomplish more than you have ever dreamed if you treat them with dignity, respect, love and freedom?  Oh, yeah.

You see, it is not about control.  Control is only necessary for those who are not trustworthy.  Better than trying to control a non trustworthy individual, simply help them find work somewhere else.  If they don’t get the mission, don’t understand the philosophy, and don’t work to their capacity, they shouldn’t be there.

On the other hand, if they are loyal, trustworthy, committed, and caring, back off and allow them to soar, and you will never see results of the kind they that they will deliver to you or your organization.

It would be foolish to think that we could flatten hospital structures by removing a few layers and believe that business would go on running smoothly.  No, we need to experiment with new ways of delivering care and that includes new approaches to administrative functions.  Self-directed teams, interdisciplinary teams, virtual teams—heck, maybe teams aren’t event the appropriate vehicle.  The point is that it is up to hospitals to find the best way to deliver care as part of the constant process of innovation.  And the best are already experimenting.

The more influence that patient satisfaction has on reimbursement levels and return visits, the more this will become a central issue for hospitals.  It is too bad that it takes those incentives to get it right: the patient deserves (and is beginning to demand) an enjoyable health care experience.  One that is possible only through employee empowerment.

Start a conversation about electronic medical records and the topic of privacy is sure to come up…if you’re talking to someone over 30.

I’m not sure it’s a good thing, but I get the feeling that individuals who were fortunate enough to have been in college when Facebook went viral care little about privacy. Yes, it’s possible to only share your profile with friends, but if you have over 1,000 friends, I’m not sure there’s much difference between your network and the world.

The point here is that our concerns with privacy have led, in part, to inaction on the implementation of an electronic health record. And the larger point is this: enough already.

Jen McCabe Gorman has a wonderful post at Health Management Rx on exactly this topic (so, it’s safe to say my post was inspired by her post). Here is an (relatively giant) excerpt, but go read the rest:

We need to stop pretending healthcare is the industry in which our vulnerability opens us up to the most potential for avaricious theft and misuse of data.

This is a naive, overly simplistic excuse used to dismiss the end value of using personal health records and giving consumers shared control over the co-creation of a personal health narrative.

Get over it. We already co-create our personal health narrative – what do you think a history and physical interview consists of? The doc asking questions, the patient giving largely subjective answers, and then that information being ‘objectified’ and codified into that provider’s medical record.

What slays me is that we do this over and over and over.

Talk about inefficiencies and misaligned incentives rampant in our healthcare system…we have to recreate meaningful interactions and establish a solidified platform of shared data at the beginning of EACH and every visit with a healthcare provider.

And it’s not new information, building on backstory to establish timely relevance, it’s the same old H&P data that’s stored 500 other places in disjointed medical records.

If my doc could access my personal health narrative and then ask questions directly relevant to my history (“Still having trouble falling asleep?”) we might actually get somewhere in the 2.45 minutes she has to sit and talk with me before tearing off a prescription sheet.

This is an old, tired argument.

Warnings of privacy issues with medical records. Calls for more security measures with online records. Concerns with health information falling into the wrong hands.

We get it. But it’s never going to be perfect. That’s the price we pay for instant accessibility. So just deliver us a product that we can use, want to use, something we can’t (literally) live without.

It can be said that when it comes to introducing business innovation into practice, the health care delivery industry is usually behind the business world by about 10 to 15 years. Think electronic medical records, organizational structures, service delivery models. While it is easy to look at the negative aspects of such a reality, there are two sides to this coin. Watching business-changing trends take hold in other industries years before they affect health care can allow the health care industry to plan and prepare for drastic change.

Well, here is an opportunity: the globalization of health care delivery.

It’s happening. While some American hospital-affiliated organizations may be involved with health care delivery overseas, like in Dubai’s Healthcare City (official site here), it is not necessarily required. The best of American health care has set up shop in the Gulf region: the Mayo Clinic, Cleveland Clinic, Harvard Medical School. But countries like Thailand and India (and pretty much everywhere else) are luring Americans toward destination health care at organizations with little American affiliation.

In an era of rapidly rising health care costs, diminishing insurance coverage, and increasing value expectations, seeking care overseas has increasingly become a viable option. The term medical tourism has been around for a few years. Widespread diffusion of the idea is expected. And why not? Patients can seek care from U.S. trained physicians at a fraction of the cost (round trip airfare included).

According to this article in Fast Company, “As many as half a million Americans streamed abroad last year in search of affordable alternatives for hip replacements or prostate surgery.”

Worldwide health care delivery will not just be an option for the uninsured or the financially strapped American. American insurers are knee-deep in the trend:

And if all this sounds a bit outlandish, brace yourself: The big insurers are already looking into it. “Once they understand the ramifications of this, you’ll see the larger players start crafting policies that allow people to receive treatment overseas,” Ori Karev, CEO of UnitedHealth International, the global arm of the UnitedHealth insurance conglomerate, told me. “I think you’ll find most of us exploring this. We are a business at the end of the day.”

What does this mean? It means we need to get our health care house in order. The best medical care in the world takes place in this country. It just doesn’t happen everywhere in this country. We must take steps (NOW! so yes that may mean individually by each care organization) to ensure the highest quality, highest value medical care in every medical instance in the U.S.

So go read the entire article if you haven’t already. This trend will have a major impact on health care in the future. Worldwide health care delivery networks are a very realistic possibility (and that’s not necessarily a bad thing).

Let us take a lesson from the auto industry on the impact of global competition. While U.S. auto makers move manufacturing out of this country, foreign auto makers move production into the U.S.

It is time to get competitive on value, not just with the hospital down the road, but with the hospital over the ocean. Globalization creeps. Before you know it, it may have the U.S. health care industry in its grasp.

I had to get my car serviced today at the dealer’s service center. It was about as enjoyable as you could expect a 90 minute wait to be. But as I was waiting for the paperwork to be completed I noticed a sign in the lobby of the service shop that read (I snapped a picture with my phone, but its quality is too poor to post, further, all the grammatical errors were on the original sign):

Attention: Please

We work hard to provide you with the best possible service we can give you. Part of this endeavor includes a follow up survey conducted by XXXX on your experience with us. In essence this is our grade card.

Please keep in mind that XXXX considers Yes and 10 an acceptable or passing grades. Any and all other responses are considered unacceptable and / or failing grades.

If for any reason you feel you would not be able to grade with a Yes or a 10 Please call Our Service Manager XXXX XXXX.

Thank you,

XXXX XXXX Service Manager

Couple things:

1. If your service needs to be a Yes or a 10 to “pass” survey inspection, you probably shouldn’t be reminding me to give you that score. Make my experience with your organization a Yes or a 10. Your service should be so excellent that the customer needn’t reminding. Period.

2. What is the point of customer satisfaction surveys if it is pass/fail? You know, my service wasn’t that bad, but it wasn’t that great. And since I’m willing to comply with your request, I’ll give you a 10 or a Yes. But does that ever help make your service improve? I’m willing to bet your service is generally pretty good and you get very few negative responses. So while your service is going to generally be very good, what help is it to your organization to not use customer satisfaction surveys for improvement? Your service today may be good enough, but in the world we live in, good enough today probably isn’t going to be good enough tomorrow.

This happens in health care, too. It has happened to me. I went to a clinic lab to get my blood drawn a few months ago and the lab tech asked me to fill out a customer satisfaction survey before leaving. He stood over me as I filled it out and reminded me that anything lower than a 5 (on a 1-5 scale) was considered failing.

I understand we don’t want to fail. I understand that we want our customer service to be rated highly. But what is the point if it is just a mirage? If you’re going to collect data, collect it with a purpose. Your customer satisfaction is a very important component of the patient experience. Don’t set yourself up for failure by polluting the data and setting subjective benchmarks.

Kreuziger’s experience is shared by most Americans: They want the convenience of e-mail for non-urgent medical issues, but fewer than a third of U.S. doctors use e-mail to communicate with patients, according to recent physician surveys.

“People are able to file their taxes online, buy and sell household goods, and manage their financial accounts,” said Susannah Fox of the Pew Internet & American Life Project. “The health care industry seems to be lagging behind other industries.”

That, from this story. Commentary here.

The blame can’t be placed entirely on physicians. The fact that we don’t pay them for a much less expensive patient encounter (even preventive in nature, depending on how you want to look at it) is completely arcane.

“Medicine is very conservative. It changes slowly.”

Too slowly.

The Point (think Malcolm Gladwell’s “The Tipping Point“) “helps groups of people, large or small, coordinate action and solve the problems they share.”

With any activity that involves a group of people, we want to know that enough others are participating for our contribution to make a difference. Once participation crosses that “tipping point,” people are more than happy to take action. So, on The Point, each user-generated campaign is only “activated” when the tipping point is reached.

The possible uses of The Point are limitless. Form an ultimatum against an unsatisfactory company. Raise money for a group purchase or charity. Broker an agreement between a group of people. Plan an event with your friends. Those are a few we’ve thought of, and you will think of many more. The Point facilitates any situation where people want to know that enough others are committed before they are willing to commit. Now you can know if your contribution will make a difference before you lift a finger or spend a dime.

From Springwise:

To do this, The Point takes the notion of the tipping point—that point at which group action will produce a clear result and inevitable change—and applies it to organizing group efforts. Those who join a campaign pledge to take specific action—to boycott a company, for example, or donate funds toward a cause—but no one actually acts until the campaign reaches its preset tipping point, or number of pledged participants. When that point is reached, however, the action is triggered and participants make their donations, attend the event or boycott the organization. The Point can also be used to organize anonymously until a campaign builds to a level that provides safety in numbers and allows people to reveal their identities comfortably.

It’s a wonderfully cool idea. But you could end up on the wrong side of coolness. Hospitals could be affected in a number of ways: community benefit concerns, organizing providers, unhappy employees, disgusted patients…

What would happen if hospitals competed on quality?

Competition is rare in health care. Really. Health care is full of rivalry. There’s a difference.

From the trusty Merriam-Webster OnLine: competitor: “one selling or buying goods or services in the same market as another;” rival: “one of two or more striving to reach or obtain something that only one can possess.”

I would suppose that rivalry is similar to what Porter calls zero-sum competition.

Competition is healthy and it should force prices down while improving the product delivered. Here’s the problem: prices are not decreasing. And quality is improving—because it is the right thing to do—not because of the forces of competition.

It may be possible to compete on price at some point in the future. But until health insurance is reformed so that patients know how much health care really costs, I just don’t see it happening. If we’re really interested in competition, and competition sooner rather than later, it is going to have to be quality of care that leads the way.

This isn’t a new idea, but I like it, and I think it could go somewhere.  The prevailing question has been “will competition improve quality?” But why not just compete on quality since we’re having such a difficult time competing on price?

CMS is working toward a quality comparison solution.  But its development is slow and functionality minimal.  Quality measures are difficult to agree upon for comparison purposes.  Difficult is the key word here, it is not impossible.  It is another opportunity to be proactive about positive change.  Hospitals are already late: Health 2.0 companies are pushing the comparison tools forward.  Thankfully.

Here’s the question: is your organization hiding behind a rock or leading the way in quality reporting?  Competition on quality could very well be the future.  And if so, the transition will be swift (it won’t be phased in by CMS, it will be forced in by outside forces).  Will you be ready?

A friend was describing her hospital workplace culture recently.  Problem: people rarely smile.

The power of a smile.

The winter months do get long.  Gray is gray is gray.  But I think there is a much larger problem here.  How can we make people truly happy when they come to work in the hospital?  How do we get people to care about the vibe an organization conveys?

(sidebar: check out Gretchen Rubin’s The Happiness Project)

We have to make people care.  (For a relevant metaphorical blog post, read this one by Ben Casnocha)

I believe it goes further than great wages and good benefits.  Those are important, no doubt.  Crafting an enjoyable work environment is vitally important.  Responding to employee needs.  Asking for employee input (secret to success: acting on employee input).  Truly valuing employees is key.  Saying we value employees isn’t it.  Employees that feel valued…is…it.

Not having been in management, I’m unaware of the difficulty in building an employees-are-valued environment. But having worked in a plethora of organizations my list of things not to do is long.  Let’s just say there is plenty of room for improvement.  The thing is, many organizations are not trying to improve.  And that could be a fatal mistake.

It does start at the top.  Step 1: smile when you’re in the building (not every event in a hospital calls for a smile, but make it your default facial expression).  Step 2: ask employees how they are doing and if they need anything to help them do their job better.  Step 3: ask patients if you can do anything to make their visit more comfortable. Step 4: repeat! repeat! repeat!

I do know the first step in making a hospital a warm and inviting place for patients: the workers inside the hospital need to be warm and inviting.  Not groundbreaking.  But I’ve yet to find a place that is perfect.  And if your organization isn’t perfect, why aren’t you working on being so?

Hospitals have most likely responded (let’s hope) to CMS’s decision to not pay for a number of medical problems arising from hospital mistakes.

Good news. CMS has come out with a proposal to not pay for nine more preventable conditions.

Is quality getting the attention it deserves at your hospital?

My guess is (and probably dependent upon your role in the organization) that the answer is “not really.” We all know it is important. BUT! Some hospitals take quality very seriously. Most are just trying to figure out how to prevent the conditions CMS won’t reimburse for. And some hospitals probably shouldn’t be in business. It’s the bell curve. We need to shift that curve to the right.

Hospitals have been entangled in an epic struggle to stay clean since the days of Semmelweis (maybe a few years later). We’ve all seen the posters, maybe participated in a class, possibly evaluated the data. It’s been going on for years.

We know what hand washing (or alcohol sanitizing) can do. Here’s quick refresher if you have forgotten. Yet compliance rates are still poor. What is the problem? My take: accountability.

It’s time to stop paying lip service to quality. High quality is not adding a sentence to a mission statement. It’s not reporting required data to CMS. It’s not telling employees that quality is our top priority.

It is action. As an extreme, think of how good hand washing compliance would be if the person in charge said, “You will wash your hands at every appropriate moment or you will not have a job tomorrow.”

I’m a big fan of a blame-free environment. Report, report, report! But there needs to be balance. From the the New England Journal of Medicine, “But if we really are serious about making care safer, I would argue that we need to find the right balance between blaming mistakes on systems and holding individual providers accountable for their everyday practices.”

We must find the resources to make quality our top priority. Period. In an era when patients will demand to know everything quality-related about our services, we must be ready and willing to comply. CMS has provided the “business case” by ending reimbursements for hospital mistakes (and are working to reinforce the issue by extending the list). The question is, do you want to lead the way (and by proxy, define what high quality is) or slowly follow? The right side of the curve will be filled with leaders. Organizational success will follow.

UPDATE: Coincidentally, two quality related stories today: Cigna is following the CMS lead and the GAO says the feds haven’t done enough to establish quality and infection control guidelines in hospitals

From the Akron Beacon Journal, “Alliance Community Hospital wants to pay you $100 or more to find out how much your health insurer paid for care you received at rival hospitals.”

Hospital’s stated motivation:

Alliance Community Hospital Chief Executive Stan Jonas said the offer is part of the hospital’s attempt to provide consumers with more information about the true cost of medical services.

The hospital plans to share the information eventually on a new Web site.

”We feel that consumers should be able to compare prices before they buy health-care services,” Jonas said. ”We are doing this because we want to prove our value in the marketplace and to provide meaningful comparisons with our own pricing, as well. So in order to help inform consumers, we are seeking information about procedures performed at other hospitals.”

Typical insurer response:

”To the best of my knowledge, this appears to be a new type of initiative,” said Richard Waldron, director of provider networks for Medical Mutual of Ohio. ”While we support the concept of transparency, this initiative seems problematic. Looking through EOBs from unrelated facilities poses issues of data collection, interpretation and validity. Moreover, there may be numerous legal issues inherent in such an effort.”

It would be terrific if transparency is the true motivation. But a hospital isn’t going to shell out that kind of money just so patients can compare prices between hospitals. I have a feeling a competitive market is at least a factor in the decision…

This gem also from the article, “In recent years, ”transparency” has become a buzzword in the medical industry as patients are being forced to foot a higher percentage of the bill.”

Ahh, shouldn’t high quality care be reason number one for transparency?

UPDATE: InsureBlog covers the story and adds a tidbit I was too careless to find: the hospital’s CEO has a blog.