Collaborative Quality

Last week, I had the privilege of facilitating the Health Care Roundtable for Chief Quality Officers, where I also presented on engaging physicians to improve quality and safety outcomes.

The passion and dedication of the members of this group impressed me.  Despite being firmly in the middle of resistant practitioners and rapidly changing federal, state, and local mandates, they proudly showcased ongoing efforts that have improved care for their communities.

Their activities reflect the art and science of blending processes and people skills because of the importance of persuasion and influence and lack of effectiveness of command and control.

We spent considerable time discussing advances in health information technology because, as one participant said, “Behaviors that aren’t hardwired into order sets don’t persist.”

Through this facilitation effort, I learned that chief quality officers are a relatively new group of passionate physicians and non-physicians connected by a common desire to make a difference in patients’ lives.  They are true front-line warriors for collaborative quality.  I encourage all my readers who know quality officers to send them a link to this post, so that they will consider joining this roundtable and sharing their insights.  Anyone desiring more information about the next meeting November 8-9, 2012 in Las Vegas should contact emilydye@earthlink.net.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content.

Collaborative Anticipation

Next month, I expect to be home only three full days.  I quip that this is a marital protection strategy, now in its 28th year and give kudos to my family for supporting my passion to reach out to disgruntled doctors and hospital leaders, listen to their issues, and help them solve their problems through improved communication, engagement, and collaboration.

I call this process collaborative anticipation as I brainstorm ways that I can:

• connect with people’s pain and aspirations
• help them depersonalize their differences
• make their time count
• help them leave a lasting legacy

For example, I travel this week to Chicago to facilitate a 2-day discussion of quality and safety issues, which will give me the opportunity to learn from experts and share with them the insights in a chapter that I coauthored with Gary Yates and Carol Sale in Getting It Done on the pioneering work at Sentara to improve their safety culture. To deal with inadequate communication, inattention to detail, noncompliance with policy, and failure to recognize high-risk situations and use error-reduction techniques, they implemented four strategies to promote the practice of safe behaviors:

• Expectation setting: developing behavior-based expectations (BBEs)linked to techniques for error prevention for all hospital staff, hospital leaders, and physicians
• Operational focus: establishing “red rules” to focus employees’ attention on high-risk procedures that can result in patient harm if not followed exactly (e.g., positive identification prior to any action with a patient, site verification before surgery)
• Effective tools: developing an enhanced root-cause and common-cause analysis process that was more timely and geared toward producing long-term, systems-oriented changes
• Streamlined rules: adopting an approach for simplifying policies and procedures (e.g., identifying and standardizing key steps in a checklist)

Proof of their success lies in their results:

Staff increased their use of expected communications behaviors (such as using repeat-backs and clarifying questions) by 42 percent. Ventilator-associated pneumonias were reduced by 92 percent (6.15 to 0.42 per 1000 ventilator days) from January 2002 through December 2009, and the device-associated bloodstream infection rate fell 93 percent (3.68 to 0.42 per 1000 central line days) from January 2002 through December 2009.

Additionally, symptomatic catheter-associated urinary tract infections within the critical care units fell 66 percent (1.86 to 0.60 per 1000 foley catheter days) from January 2007 through December 2009. Total compliance to proper hand hygiene increased to 96% by December 2009.

What seems unique about the Sentara experience is that Dr. Yates was not satisfied with healthcare-specific benchmarks, so he looked to industries like nuclear power and aviation to improve quality and safety.  What do you think?

• What is unique to your situation that benchmarks do not address adequately
• What can you learn by making “apples-oranges” comparisons with leaders in other industries
• Where can you benefit from collaborative anticipation, disrupting your thinking and your routines in order to improve care for your community

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure: I have not received any compensation for writing this content.

Collaborative Ecosystems

I apologize for going nearly six weeks without writing a blog post here and have no idea where the time went.  Like a proud papa, I announce the birth of a new website, The Association for Healthcare Collaboration, which I have dedicated to putting experts from a wide variety of fields under one URL, covering leadership, financial and legal matters, and social media.

I have also reviewed approximately 30 books related to healthcare and leadership, the newest being The Wide Lens by Tuck Business School Professor Ron Adner.  Prof. Adner cites the health information technology industry as an example of ecosystems in dynamic change.

By 2009, only 9% of hospitals had implemented electronic health information systems because the incentives were misaligned: insurers benefit from the increased ease in sharing information, hospitals benefit from improved billing, patients benefit from the decrease in complications, and radiologists benefit from being able to look at films from home, but for most doctors, nurses, and physician assistants, the burden of increased training time and decreased initial efficiency seeing patients, to say nothing of the costs of entering information into the record, made the costs outweigh the benefits.

The process did not take off until federal legislation introduced a carrot-and-stick approach, paying physicians who received reimbursement from Medicare up to $44,000 ($63,750 for doctors who treated Medicaid patients) until 2015 when penalties begin for lack of compliance with meaningful electronic information use standards.

In Getting It Done, Joel Berman and Michael Green, who have been working in health information technology since 1997, offer suggestions to improve physician adoption of health information technology (HIT):

• Most physicians care more about the institution’s mission than its margin; therefore, financial arguments carry less weight than care-related calls to action.
• In a physician’s hierarchy of needs, workflow (in the long run) trumps all other considerations. HIT initially slows physicians’ workflow.
• Most systems are in their adolescence. They are not plug-and-play but must be custom designed for an institution by physician-led multidisciplinary teams.
• The use of computerized information systems poses cognitive challenges to physicians who are not comfortable using computers.
• Standardization of provider workflows and order sets across an organization presents significant cultural challenges to physicians of all generations.
• Health information technologic challenges are 80 percent sociological and 20 percent technological . Unwavering physician leadership is essential to solving sociologic challenges. The Concord Hospital group used John Kotter’s model (defrosting activities) to set the stage for sustained success.
• Change and its associated transitions often prompt physicians and members of their care teams to put up emotional walls. Concord Hospital’s Office of Organizational Development periodically offers change and transition workshops to help physicians recognize and address negative emotions at an early stage, before they become problematic.
• Begin with the end in mind. What do you want this application to do for you in one year? In three years? Work backward to design it to deliver what you want.
• Optimize provider workflow so that quality improvements are not achieved at the expense of provider efficiency.
• Because electronic applications convey more information than paper systems do, physicians can drown in data. To effectively manage this data deluge, encourage physicians to transform their individual care delivery to team-based approaches.
• Before deploying HIT, communicate the message that most errors are due to bad systems, not bad physicians, and that paper-based order entry is a poor system, leading good physicians to make mistakes. Make this message stick by using local stories rather than national data.
• Deployment of HIT will be one of the most challenging initiatives your organization undertakes. Allocate resources accordingly.

I hope that you will register at no charge to join The Association for Healthcare Collaboration and tell friends and colleagues about this exciting new resource.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

The Blessings of Healthcare Collaboration

Ten days ago, I had the pleasure of facilitating my ACHE seminar Practical Strategies for Engaging Physicians.  What made it so enjoyable was the mixture of senior- and mid-career healthcare leaders who shared their experience with my two faculty co-presenters, Dr. Robert Schott, a cardiologist/ physician executive, and Mr. Peter Pavarini, a lawyer and thought leader in financial collaboration strategies.

A healthcare leader with 38 years of experience told me that he still makes time to go to the Operating Room and watch surgeons perform operations.  At the end of the procedure, he asks, “Doctor, did you have all the resources that you needed to perform the operation?”

No one has ever refused his request to watch an operation.  When surgeons mention something that would help them do the procedure better or more safely, he makes sure that his staff acts upon it immediately. Such processes build transparency and trust using quick wins.

I find it gratifying that someone with 38 years of experience still makes time for face-to-face dialogue with his physicians and admits that there are subjects on which he does not have all the answers and can benefit from co-mentoring.  As my kids tell me, “Dad, ASSUME makes an ass out of U and ME.”

The blessings of healthcare collaboration, as spelled out in the newly formed Association for Healthcare Collaboration, are in the following diagram which depicts the virtuous cycle of collaboration producing improved financial and clinical outcomes, easier recruiting and retention, and outstanding programs, people, and facilities that enhance collaboration:

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Collaborative Governance

At a combined retreat that I facilitated last month, a Board chair commented on the challenge of collaborative governance and lamented her steep learning curve: “It took me two years just to learn the vocabulary.”  For people who do not have healthcare backgrounds, imagine the challenges of being responsible for hospital strategy in these rapidly changing times, with the viability of a valuable community resource resting on their decisions.

For this reason, I recommend that new Board members receive a copy of Houle & Fleece’s latest book, The New Health Age: The Future of Healthcare in America. This 311 page book comes with a glossary of healthcare abbreviations and 17 chapters divided into three parts: History and Context, The Dynamics of The New Health Age, and The Landscape of The New Health Age.

The flow dynamics of The New Health Age are:

• How we think about health care, moving from sickness to wellness
• How we deliver health care, moving from a reactive, episodic non-system to a  more proactive system focused on providing coordinated,holistic care
• The economics of health care, in which we shift from volume-based, procedural reimbursement to more value-oriented metrics, based on quality, safety, and patient satisfaction scores.

By gaining an awareness of these dynamic flow changes, the benefits of change become clearer. For example,who would attack being more proactive to improve poor health care outcomes and reduce costs?

For those people who feel trapped in the headlights of life, not knowing where to start, I offered five “evergreen” suggestions for collaborative governance that will remain viable regardless of the outcome of the Supreme Court decision later this year:

1. Improve communication around hand-offs: one of the biggest reasons for hospital readmissions is failure to communicate a plan for patient needs across the care continuum.

2. Call patients after discharge: Waterbury (CT) Hospital has instituted a program where every patient receives a call from a healthcare professional within 48 hours of discharge. This process benefits the hospital in several ways. First, the patient is less likely to be readmitted to the hospital because of inadequate follow-up care, saving healthcare costs. Second, the patient feels a personal connection to the hospital and is more likely to recommend its services to family and friends. Third, the hospital catches medical issues more rapidly and is able to treat them with less-extreme options than if adverse drug reactions or signs of infection fester.

3. Look at long-term value as well as day-to-day needs: Often, we focus so intently on day-to-day and month-to-month department budgets that we forget to step back and look at the overall cost structure. For example, using mid-level providers to facilitate physicians’ discharging their patients earlier in the day and on weekends can drop overall length of hospital stay dramatically.

4. Eliminate as much non-value-added care as possible: Approximately 40 percent of the medical care provided in the United States may not add value, based on reports from The Dartmouth Institute for Health Policy and Clinical Practice. A good way to streamline healthcare practice is to use post-it notes and write down every step in the patient care process. Then put all the post-it notes on a wall, step back and determine which steps are unnecessary, consolidating the steps to make sure that each is adding value.

Medical centers in Indianapolis collaborated on quality and safety measures that would improve care and found 23 non-value-added steps they could remove and thereby decrease cost and improve outcomes. The likelihood of error increases with every step added to the care process.

5. Encourage patients to make better decisions about their health: A 2002 Health Affairs study that found that the contribution of medical care to longevity is only about 10 percent, compared to 40 percent for patient decisionmaking. The biggest contribution to patient longevity involved the decisions patients make about exercise, food intake, tobacco, seatbelt use, and whether those with multiple partners use protection.

Patients need to be reminded at every encounter that they have the biggest impact on their own health.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have a material connection because I received a review copy that I can keep for consideration in preparing to write this content.

Bracing for an Uncertain Future

Richard Clarke, President of the Healthcare Financial Management Association, wrote a great editorial on bracing for an uncertain future in Modern Healthcare, January 16, 2012, page 23.  Briefly, he predicts that because of the political stalemate in Washington, the majority of the entitlement cuts will be borne by healthcare providers.  I would like to focus on his prescription for action:

One thing is clear: Providers need to start planning for the value-based system that is evolving from the volume-based system of the past. You can start by addressing five key implications of a lower-payment, lower-volume environment:

• Move from managing operating costs to redesigning your organization’s overall cost structure
• Consider your market position to assess whether horizontal integration can achieve economies of scale and vertical integration can provide more seamless care transitions
• Recognize that all providers will be held responsible for cost and quality outcomes and create a culture that supports re-engineering care delivery
• Prepare for a payment system that links a growing portion of revenue to quality, despite the challenges of measuring it
• Be ready to provide increased transparency of cost and quality data; as patients pay a greater share of the cost of healthcare, expect them to use data and act like more traditional consumers

As I wrote last May, transitions are difficult to manage, but others have blazed a trail for us to follow.  Deciding where to start is often, in retrospect, less important than beginning with an issue about which clinical champions feel strongly and allowing the process of act, learn, and adapt to manifest.  One area that can be a win for physicians, nurses, patients, and hospital leaders is improving patient handoffs and decreasing preventable readmissions.

In  “Embracing Complexity,” in Better Communication For Better Care: Mastering Physician-Administrator Collaboration, I wrote that face-to-face conversations are the only sustainable way that people can deal with complex situations  in which predictability is diminished, experience does not guarantee success, and relationships are key. 

Sensemaking is part of the Baldrige journey.  It describes the critical role leaders play in interpreting and explaining disruptive marketplace changes and framing what is required for successful healthcare delivery.  It gives us a way to understand and frame healthcare complexity, view our organizations as part of a holistic system of care,  and provide potential and hope for sustainable improvement.

What do you think?

• In bracing for an uncertain future, can we view change as an opportunity to improve rather than as a threat
• Can we overcome past perceived insults to build a safe environment for reflection and learning
• How have you benefited from the cycle of acting, learning, and adapting

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Redefining Physician Engagement

US Healthcare Issues in 2011

Introduction

During a recent ACHE faculty conference call, we brainstormed about US healthcare issues in 2011 that are likely to have an impact in 2012, including:

1) Revenue-Expense considerations:

• The growth of medical tourism and support from payers for its continuation and expansion
• Increasing community pressure to take away hospitals’ tax-exempt status
• Implications of the green movement on renovation and new facility construction, increasing initial expense but offering the possibility of decreased maintenance costs in the future

2) Computers and the Internet:

• Approaching deadlines for meaningful use compliance
• The role of health information exchanges in sharing data
• The impact of the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey on patients’ perceptions and market behavior
• The ICD-9 to ICD-10 conversion deadline of October 1, 2013
• Robotics
• Virtual physician extenders, such as e-ICUs
• Social media and the need to monitor online communication in real time
• The challenges of maintaining patient privacy and sizeable fines for lack of compliance

3) Innovation and Complexity:

• Personalized medicine- diagnostic and therapeutic implications
• Decreased spare capacity, resulting in shortages when manufacturing capacity becomes constrained, for example, drug shortages
• The blurring of clinical and administrative functions, requiring ongoing education for providers to recognize the system implications of their daily clinical routines as we become more clinically integrated
• The political polarity affecting healthcare delivery reform

Conclusion Regarding US Healthcare Issues in 2011

 Regardless of the decision of the Supreme Court regarding the individual mandate, healthcare professionals will experience increasing pressure to provide more interdependent, coordinated, and cost-effective care for two reasons: our current level of spending is unsustainable, and it is the right thing to do for patients and their families, something that we wish for our loved ones who need care.

• What do you think
• Which issues do you think will be our greatest concerns in 2012
• What issues have I left out that merit consideration

As always, I welcome your input to improve healthcare collaboration where you work.

Best wishes for a happy and productive new year, and please contact me any time that I can be of continuing service to you as you cope with multiple priorities at the same time. 

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Unconscious Competence: Viviendo la vida locums

I apologize for the delay in posting.  Although I looked forward to taking a holiday vacation, I have come to the aid of a surgical colleague at a critical access hospital in New England who had no backup. I enjoy being of service and being thought of as a solution rather than the problem.

Last weekend, I was asked to consult on a patient who fell and had a 10% pneumothorax (a small air leak in the lung into the chest cavity).  Usually, the air appears on the lateral (outside) surface of the lung, but this time it was medial, a finding that I had never seen before.  I shared my lack of certainty with the patient and encouraged her to be transferred to the tertiary hospital where they had interventional radiologists on call who could guide her treatment.

I learned later that the medial air collection was due to the lateral lung being stuck to the chest from a previous injury or inflammatory process and that a chest tube placed via the (traditional) lateral approach would likely injure the adherent lung and not evacuate the pneumothorax. 

My grandmother called these episodes her “once-in-a-whilers.”  May we all be so fortunate to have as many “once-in-a-whilers”  as she did during her 95 years.  A talented,  intuitive general surgeon commented when I did something right, “Ken, the Good Lord, she was surely watching over you.”  A cardiac surgeon quipped, “It just goes to show that even the blindest sow finds and acorn now and again.”

During residency, I learned about the journey through the four stages of competence:

• Unconscious incompetence: people make mistakes because they are unaware that they are missing information (e.g. the July 1 house officer transition)
• Conscious incompetence: usually following unconscious incompetence, they feel upset and embarrassed and question their knowledge
• Conscious competence: over time, they feel more comfortable about their skills, knowledge, and judgment
• Unconscious competence: they trust their instincts and allow those instincts to influence their decision-making, especially when something “just doesn’t feel right.”

Donald Schoen described unconscious competence as reflection in action, a series of course corrections that experienced practitioners make, often without realizing that they are making them until they are asked to think aloud by a student or resident who is shadowing them.  Whatever the explanation, I feel fortunate to work in a profession where I am allowed, and occasionally encouraged, to trust my gut.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

International Healthcare Collaboration: Stockholm Memories

Greetings from Stockholm, where I returned to visit people with whom I collaborated during residency and to promote international healthcare collaboration.  As I wrote in a previous post, despite working in a country that has a socialized medical system, practitioners in Sweden enjoy local autonomy in clinical decision-making. The government assigns a budget for healthcare and expects practitioners to live within it, but does not tell physicians and nurses how to practice medicine on a day-to-day basis.

I was pleased to learn that they too deal with issues of physician-physician and hospital-physician collaboration. They use physician champions, like the ones featured in the photos above, to influence fellow practitioners. Although I do not believe that the Swedish healthcare system can be transplanted to the US, I am proud to include them in my group of cherished co-mentors, who influenced my outlook, as I have influenced theirs.  We face similar pressures to provide more coordinated, cost-effective care and support international healthcare collaboration.

In this land of the midnight sun during the summer, I would like to believe that my visit brought some cheer during a time of national darkness.

Happy holidays to all my readers, and thanks for your readership and your insights the past year.  Please stay tuned for more information on how you can be part of the Association for Healthcare Collaboration in 2012.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

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