Nick Jacobs, head of Windber Medical Center and Windber Research Institute, posted earlier this week about an expansion project at his organization.  In an era of new heart towers and exponential bed growth, it’s good to hear about an expansion project that benefits the community in a way other than providing more bed capacity.

The future (now!?) of hospitals will be the value they can provide to the communities they serve.  What better way than to become a community gathering place, a place for “at risk kids (those in danger of problems brought on by obesity),” for researchers to video teleconference, for employees to interact, for support groups to meet?  Applause to Windber for this terrific addition.  It’s something you would expect from an innovative hospital.

The possibilities are truly endless.  Becoming a centerpiece of community development and sustainability is a role that can be fulfilled by hospitals.  This concept is easier to imagine at smaller and rural hospitals, but it’s one that everyone should be incorporating in new expansion projects.

The primary role of a hospital will remain, it’s the peripheral roles that will define what we become.

USA Today had an article recently on the shortage of surgeons across the country, writing the shortage is particularly hurtful to the 54 million rural Americans.

The article goes on to say what many already know: more medical students are choosing specialty care and “‘fewer and fewer are going into family medicine and primary care,’ says James King, president of the American Academy of Family Physicians. And ‘many are not willing to go’ to rural areas.”

The problem, they say, was rooted in 1980s and 1990s when medical schools capped enrollment.

The solution?

To address the problem U.S. medical schools admitted nearly 18,000 students last year and the ultimate aim is to increase enrollment by 30% over 2002 numbers by the year 2015.

Whether or not we need more doctors is a matter of debate, but that’s not my argument here. There’s a reason medical students aren’t choosing career paths like primary care and general surgery and it’s easy to understand.

I was talking with a medical student who will shortly begin his intern status. We were talking about primary care; he indicated his $200,000 debt (!) and the fact that he will be in his early 30s before he makes his first real paycheck prevent him from even thinking about about general medicine as a career. So I asked, if a primary care physicians made $100,000 more than they currently make, would you at least consider it?

“Yes.”

That’s wrong. Primary care physicians are an important element of our current system, future reform may hinge on their abilities. It’s one thing to say that we will have a shortage of physicians with the solution being to train more and an entirely different matter to convince/persuade them to train for needed primary care roles.

Paying them more is a start.

Addressing the lack of physicians in rural areas will take more creativity. Training more physicians and “hoping” they will choose underserved areas to serve is a bit naive. Maybe we could start with tuition forgiveness programs for serving in rural/underserved areas?

What does a magazine from 2006 in your waiting room say about your organization?

A lot.

What if there is more than one?  And even a Hancock Fabrics catalog from 2004?

A lot more.

Being unable to display (somewhat) current issues of magazines is a problem.  It’s almost to the point that an organization is trying to be that bad.  Patients who bring in their own magazines and leave them behind should be better able to keep the stack refreshed.  But what reason would hospital waiting rooms have to keep patients reading about Google’s purchase of YouTube or the World Cup in Germany?

Beside reminiscing about the good ol’ days of health care spending in the United States, nothing. (Well, I guess you could prevent them from reading well-intentioned, yet slightly misleading articles, like this.)
It’s a culture problem.  It shows how your organization feels about its most important customers.  It’s (all!) about the patient experience: and at any appointment (like many of us have experienced) waiting is a key component.  And in a competitive market, it’s reason enough to try the guys down the street next time.

Lots of “transparency” items on the interweb recently. Promoting this discussion is always a good thing.

“As more of the responsibility for health care is pushed down to individuals through insurance products like high-deductible health plans and health savings accounts, more and better information — and access to it — becomes critical. Patients and families can become smarter consumers, capable of exerting market pressures that improve quality and lower cost, if given the chance,” writes Christopher Parks in a Tennessean editorial. He continues, “What is needed is greater transparency” (emphasis mine).

Parks is the co-founder of change:healthcare, an organization dedicated to transparency. “The company is charged with developing and providing people with the tools and information they need to make the best decisions possible as a healthcare consumer.”

Another take on transparency, although decidedly more pro-transparency for the organization’s sake of which I have blogged here before.

InsureBlog has a recent transparency update as well.

But it seems this news item really got the transparency debate going. What, you say does Facebook have to do with transparency in health care? Plenty…

APM’s Marketplace brings us this great commentary: “It’s a transparent society, so get naked” by teen CEO (futile attempt at word creation) Ben Casnocha.

Will universal transparency happen in health care in the next few years? Let’s hope so, but probably not. But I can tell you it will happen when the Facebook and MySpace crowd is in charge. It’s the world we’ve grown up in. It’s what we know.

As Mr. Casnocha says:

And transparency isn’t all-or-nothing. Today’s networks have detailed privacy settings you control. As blogger Jeff Jarvis has put it, “Publicness is good so long as we decide how public we want to be.” Like it or not, the transparent society is here.

Most of my friends are out on the Web, where we tell the world who we are and what we think. Those who are still fully clothed shouldn’t be surprised if folks start asking, “What are you trying to hide?”

Only the question will be: what’s your hospital trying to hide?

Just over a month ago, checklists in medical care = big topic. While some of us may have forgotten the surprising debate, a very interesting David and Goliath battle developed, checklists vs. The Office for Human Research Protections.

Well, according to Wachter’s World (via Health Beat Blog) David won: The OHRP “has concluded that Michigan hospitals can continue implementing a checklist to reduce the rate of catheter-related infections in intensive care unit settings (ICUs) without falling under regulations governing human subjects research.”

As I continue to study (learn is probably more palatable) health care, one of the things that continues to amaze me is how reluctant hospitals (in general) are to learn from other industries–even other hospitals. While eventually hospitals come around (think six sigma, lean production) to at least give (relatively) new ideas a try, it can take exorbitant amounts of time to get there (ah, electronic medical records).

So imagine my surprise when I read an article in the latest issue of Fast Company (web link) by Dan Heath and Chip Heath. Other industries can learn from hospitals? This is good stuff!

“Checklists help us avoid blind spots in complex scenarios. Hospitals have saved thousands of lives by following a simple five-step process for inserting IV lines. Where could your business benefit from a checklist?”

Yesterday, the post was about medical homes. An integral part of that strategy is the primary care physician–a role many experts see a shortage of in the near future.

From Newsday, “The General Accountability Office said Tuesday that as of 2006 there were 22,146 American doctors in residency programs in the United States specializing in primary care. That was down from 23,801 in 1995.”

In that same article Senator Bernie Sanders said, “There are simply not enough primary-care providers now and the situation will become far worse in the future unless we do something.”

There may be a multitude of reasons that fewer medical students are choosing primary care as a career path. But I am going to go out on a really fragile limb here: the problem is money, specifically the lack of it.

The role of a primary care physician is extensive, we expect them to be knowledgeable about, well, everything. But we’ve seen specialist reimbursements rise inordinately compared to primary care physicians.

Robert Berenson at Health Affairs Blog writes of the problems being created by Medicare reimbursements for PCPs:

When physicians receive less than 1 percent fee increases year after year, we can expect physicians increasingly to stop seeing Medicare patients, at least those whose clinical expertise does not depend inordinately on the disabled and seniors. Already many PCPs have stopped accepting new Medicare patients, whether or not national surveys have detected the phenomenon. Many physicians who continue to serve Medicare patients are themselves approaching Medicare age and will soon retire, leaving patients without a personal physician and little likelihood that younger physicians will fill the void.

Mr. Berenson continues, “Payment for generalist physicians needs to increase. Payment for niche specialists can safely be reduced, perhaps with a redesigned expenditure target approach. Additional funding sources will need to be found to get out of the SGR budget hole. And there needs to be a process for shifting funds across provider silos.” Mr. Berenson provides good detail on a multitude of topics, I suggest you read it, and not just take my brief summation as the catch-all for the entire post.

The day previous Paul Ginsburg wrote of Medicare reform on the Health Affairs Blog (it’s a series that has a few more posts so stay updated by visiting the Health Affairs Blog), “Primary care physicians are most impacted by the lack of increase in Medicare (and private insurer) payment rates. Physicians in many other specialties can more readily accept declining payment rates because of productivity increases for newer procedures and the ability to increase the number of profitable procedures.” I suggest you read Mr. Ginsburg’s post as well, he lists some potential solutions to the Medicare reimbursement issue(s).

Anyway, we know there is a problem with reimbursement for primary care physicians. Research indicates better medical care if a patient sees a primary care physician when he or she enters the health care system, not to mention cost savings. As always, however, there are varying opinions, and with varying opinions come endless ideas for solutions.

While doing some research today for a project on the use of persuasive advertising messages by hospitals in patient success stories (that’s a working description, I’ll work to make it a bit more succinct) mixed in with my daily blog reading I came across this post by the always thought provoking Tom Peters (a business idol of mine, as well as an inspiration/influence on my writing style). My enemy is me. Our organization’s enemy is our organization. As Mr. Peters quotes Mr. Walt Kelly “We have met the enemy and he is us.” Combine these two serendipitous moments with my earlier post about the patient-is-first focus in today’s hospitals and is/will continue to be the rallying/battle cry for our health services organizations…and I came up with a little far-from-scientific experiment/information-gathering-session.

You can very subjectively do this (I did it, so you don’t have to): Visit US News and World Report’s Best Hospitals 2007 Honor Roll. Then visit every hospital’s website on that list to see what the first clickable link is. (I didn’t explore the mission/vision/values/raison d’etre, but let’s assume (reasonable assumption) that these 18 hospitals rank patient care pretty high on the list of importance.)

Here’s what I found to be the first clickable link on the websites:

About Us: 9 hospitals
Medical Specialties: 4 hospitals
Appointments: 2 hospitals
Find a Physician: 2 hospitals
Patient-Centered Advertisement: 1 hospital

An argument could reasonably be made that only five of eighteen hospitals directly target patients with their first link on their website. What does that mean? The majority of honor roll hospital websites are more concerned with telling the world about themselves (US! US! US!) then a potential patient’s first interaction with the health system. Most of the hospitals (they are all huge) on this list are academic medical centers (meaning complicated campuses) and many of us can imagine our grandparents’ struggles with navigating the many buildings–one of only many foreseeable issues with a first visit (there are so many more opportunities for website improvement, use the comments section to add your thoughts).

My point: if you are reading this blog, the importance of websites as a marketing tool needn’t be expressed. Let’s fully commit to making patient experience with our health systems the most important aspect of our organization’s existence, starting with a hospital website fully dedicated to the patient.

It has been about a month since Dr. Atul Gawande’s article “The Checklist” appeared in the New Yorker (if you go there to read the article, be prepared…it’s lengthy, but worth the time). If you don’t have the time check out Maggie Mahar’s slightly shorter summary here at Health Beat Blog.

The basic point of the story is this: Dr. Peter Pronovost instituted checklists while working at Johns Hopkins Hospital in critical care. And guess what happened? Dramatically improved care. AND it even saved money.

Dr. Pronovost proceeded to export his checklists throughout the state of Michigan and again a substantial number of patient lives were saved to go along with significant cost savings.

These great results were published in the New England Journal of Medicine and then checklists were rolled out across the country, right? You would think so. But it didn’t happen. In fact, as Ms. Mahar puts it: “In December of 2006, the results were published in The New England Journal of Medicine. How many U.S. hospitals have adopted checklists since? None.”

Why? Well it seems the answer is written here in an op-ed by Dr. Gawande in the New York Times. Ms. Mahar provides her always insightful analysis here and here. The federal agency Office for Human Research Protections is preventing the use of checklists.

That’s a tough pill to swallow. Here we have a health care innovation that saves lives and delivers significant cost savings but is unable to cut through government bureaucracy.

And then after all of that, in a slightly different vein, Reuters has a story from Hong Kong on the use of checklists.

UPDATE: Some more and more on checklists.