Transparency is K-I-N-G: Redux

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?

Transforming hospitals: from HR to Talent

Search any hospital/health system/practice group human resources job listings and you may realize the challenges in keeping a health care organization fully staffed. If not, search Google for nurse shortage, physician shortage, or read stories like this and this.

Trend: difficult human resources issues.

Some organizations are trying different kinds of benefits, others are trying referral programs, others are trying…

Those types of solutions may be important, but, turbulent times call for new solutions. Well, maybe it starts with Seth’s suggestion of renaming the department to Talent. It could be a difficult maneuver in the traditionally stodgy health care environment, but that’s the point here: this kind of disruption, this fundamental change in how we do business, how we approach opportunities and solutions, how we treat employees, has the potential to excite (it does for me!) people. Talk to someone who works at a new Pebble Project hospital and find out many people applied for the limited number of jobs: the facilities, ideas, and approach to care are different and that brings droves of applicants onto the scene.

But we don’t have to build a new hospital to approach health care in a different way.  Seth (as always thoughtful and completely insightful, and if you haven’t started reading his blog, you need to start, today) says:

Like it or not, in most organizations HR has grown up with a forms/clerical/factory focus. Which was fine, I guess, unless your goal was to do something amazing, something that had nothing to do with a factory, something that required amazing programmers, remarkable marketers or insanely talented strategy people.

Hmm, health care is an industry in deep trouble.  Thinking differently is going to help us get out of the mess: doing something(s!) amazing is the strategy.

Checklists, checkmate.

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?”

Hospitals and YouTube

We’ve seen the lack of support in blogging in hospitals…

…but that still doesn’t (completely) explain the general neglect by hospitals of YouTube, and other online video tools.

Possibilities are endless for what hospitals and health systems could do:

1. Hospital tour – if you work in an organization where it’s easy to navigate the facilities, your patients are extremely lucky (and your organization is probably small or your leadership understands the need for navigation ease). A search of “hospital tour” on YouTube returns 582 results. Helping patients find their way around the hospital by familiarizing them with the facilities before they arrive will ease tension on what could be an emotional visit.

2. What to expect when you arrive at our facilities – when a patient arrives for a visit (giving birth, heart surgery, emergency room, etc.) confusion has the potential to reign, and a familiarity with where to park, where to go, who to seek, etc. that comes through the use of YouTube could be quite helpful.

Here’s an example from a foreign land…

[youtube:  3. Get to know providers, care givers, and staff – sticking with the familiarity theme, familiar faces on a stressful day can be helpful in reducing tension. Interviews with employees and providers could help patients get to know them and humanize health care just a little more.4. Health information on popular conditions and treatments – as a community service, provide information on common diagnoses and treatments, or other public health needs/concerns.

5. Other possibilities that you may suggest in comments.

Not to mention the inherent marketing value all of these suggestions hold…

Found this post, that comes from waaay back in 2006. Over 10,000 then, about 162,000 now. On the first page, however, most videos have to do with humor, history, and (General) Hospital (the tv show), not any of the above thoughts. The idea that hospitals need to be on the offensive when it comes to online tools is an argument of note.

But if a hospital or health system really wanted to stretch its comfort zone, it would start an online “tv” network through tools like Mogolus, blogTV, and Kyte. What would you put on a live channel? Well, there are a few suggestions above, but the possibilities are surely endless.

Au contraire…

A couple of observations from interweb reading this weekend…

We’ve heard/read/thought much about the impact of technology and preventive medicine on health care costs. That they will force them down. And they likely can (and will). But some contrarian thoughts exist…

First, a great thought posted at e-patients: “Technology is always framed as an end and it is not. It is a means. The “end” for most people is getting the information and care they need.” Good stuff.

Second, from the New England Journal of Medicine about preventive medicine (hat tip: Health Populi):

Some preventive measures save money, while others do not, although they may still be worthwhile because they confer substantial health benefits relative to their cost. In contrast, some preventive measures are expensive given the health benefits they confer. In general, whether a particular preventive measure represents good value or poor value depends on factors such as the population targeted, with measures targeting higher-risk populations typically being the most efficient. In the case of screening, efficiency also depends on frequency (more frequent screening confers greater benefits but is less efficient). Third, as is the case for preventive measures, treatments can be relatively efficient or inefficient.

Anyway, as you know if you listen to presidential stump speeches or just catch the highlights on CNN/MSNBC/FOX News/etc. when candidates speak of their health care reforms they tout the benefits of technology investments and preventive medicine. It’s always good to hear something from the other side, especially when thoughts are provided with evidence.

5. The workplace of choice

Somewhere (probably many places) someone has found the components of the perfect workplace. And while no company has reached perfection, many are working hard to get as close as they can.

But what makes a company great to work for? Google has its ideas (they seem to be working, BTW). Specifically, what makes a hospital great to work for? Fortune released its annual list not (too) long ago and ten hospitals made the list (and provided the data for the examples below). Hospital Impact has the complete rundown and some observations on the list.

The problem with this question is that the answer is going to be different for everyone. There are many things that go into making a place great to work. Becoming a workplace of choice is a culmination of hard work from all departments in the organization, not just human resources. So let’s borrow some ideas, add some of our own, and try to come up with the outline of a workplace of choice.

Benefits and wages are important. Obviously the availability of health insurance as a benefit is decreasing, so providing that service is of high importance. Fair and decent pay is an obvious need as well. Griffin Hospital in Derby, CT., received “6,691 applications for 180 open positions in 2007” because of the organization’s benefits and customer service supremacy. Although benefits and wages matter, their importance is often forgotten on a daily basis–and so less relevant in the discussion on great places to work.

Care for people. I’ve written before on Methodist Hospital System‘s “No One Dies Alone” program. As a hospital, we need to care for our patients–that is job number one. Most hospitals do that. But what separates a middle-of-the-pack hospital and a hospital that employees want to work for is how the organization cares for its employees. Are voices heard? Is communication encouraged? Are concerns acted upon? The Golden Rule applies. Every day.

Facilities can be an important aspect of a great place to work as well. Clean floors. Well-cared-for grounds. Investment in physical facilities. Innovative purchases of information technology (remember the training, lots of it!). These kinds of things can help to make employees proud of the organization they work for.

Rewards for high performance and involvement, like how OhioHealth rewards their employees for “customer service, community service, stars of the month, and perfect attendance,” amongst others. The company also rewards long-time employees with shopping trips at a local mall. It is important to reward for the right reasons, however. Reward systems have the potential to become competitive and could ultimately send employee satisfaction in the wrong direction.

A good measure of how employees feel about their workplace is the referral rate for open positions. With the current state of health care worker shortages a reality and predictor of what is likely to come, referrals may be the all-important factor that keeps our FTE openings limited and separates our own system from the competition. Children’s Healthcare of Atlanta has a referral rate for open positions that approaches 50% and many of its employees count ten or more years of service for the organization. Keeping current employees employed (satisfied!) is a great way to keep openings minimal. The Mayo Clinic has a goal to hire for life,”17% of its workforce has been there for 20 years.”

Training, constant training, for employees. Promoting within and educating the workforce to enable them to acquire the skills necessary for advancement within the organization is a very good thing. We will all become experts in customer service. Southern Ohio Medical Center “engages all employees in caregiving: Even housekeepers are urged to ask patients how they can be of help.”

Obviously there are some great hospitals listed here. There are likely even more great hospitals to work for that are not on the list. The components of a great workplace are nearly limitless. And while all the above components are important, when they come together in an organization, they create culture. Culture is the most important component of a workplace of choice.

It’s not always explainable, rarely definable, but definitely consequential.

Tony Chen at Hospital Impact writes, “Hospital culture isn’t some warm fuzzy thing that only consultants talk about – it is the unwritten norms of behavior and the frank conversations. Of course, this means that the people trust the leader enough to share!”

Principle #5: Being a workplace of choice is not an easy task to accomplish. Heck, it’s even difficult to talk about because we all have different opinions and ideas on what “great” is. But if we encourage the discussion, actively listen, and work incessantly to improve, our goal of being the best hospital to work for is achievable.

The Need for More…Primary Care Physicians

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.

Medical Homes

It’s not a new concept. In fact, I would be willing to bet that if you ask older individuals and those living in rural areas most of them would tell you they have a family physician or primary care physician. Believe it or not, patients actually call and make appointments with one physician for every medical problem they encounter. That physician then treats or refers. Easy concept. The family physician or primary care provider serves as a gatekeeper to the rest of the system. Difficult today for a variety of reasons.

This article on the American Academy of Family Physicians website says the medical home “is both old-fashioned and thoroughly modern – a blend of the personalized, comprehensive care that family physicians have been offering for decades and coordinated care that capitalizes on new technology and helps patients make sense of the increasingly complex health care system.”

Medical homes are gaining traction in the here-and-now. And for very good reason. When you read this editorial by Dr. Benjamin Brewer at the Wall Street Journal I think you will see why.

Recently, the Illinois Medicaid program decided that nearly every recipient of public aid needed something called a “medical home.” The idea is to provide an accessible, lower-cost point of entry into the health-care system than a hospital emergency room. A practice that agrees to provide the home makes a commitment to take an active, integrated approach to coordinating a patient’s medical care.

The American Academy of Pediatrics “describes the medical home as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.” Their website can give you a comprehensive rundown of medical homes.

Dr. Brewer goes on:

Patients and their doctors have 24-hour access to the information or advice from us by phone or email. We provide prenatal care, delivery services, child and adult care in the office and the hospital. We measure our quality quarterly by looking at some key indicators. We don’t avoid patients of any age or gender or those with chronic, pre-existing conditions. We maintain a list of available specialists and coordinate referrals and follow-up.

All for around $2 per patient per month in addition to office visit fees for services. It seems impossible in our $2 trillion health system. But Dr. Brewer says he is doing it. The care that was once provided free is now being reimbursed.

What’s missing in the debate over our nation’s health-care crisis is that primary care is cheap. Cheaper than your cellphone bill. Cheaper than a tank of gas. Cheaper than dinner and a movie. It’s so cheap the average person doesn’t value it properly. I could have covered my salary for 2007 and the costs of all my staff and overhead for less than $20 per patient per month, including maternity and hospital care.

I’ve blogged about private industry making change in health care on this blog before and have referred to this article as well, but it is worth noting again–a group of employers is partnering with Bridges to Excellence to pay doctors for creating medical homes for patients. “The initiative is the latest and perhaps most far-reaching effort by Bridges to Excellence, a program backed by big employers and health plans and a big player in the movement to provide physicians with financial incentives for taking better care of patients.”

But considering how often we introduce new ways to deliver care and then how quickly those innovations disappear the implementation and effectiveness of the medical home is dependent upon a variety of factors.  According to the AAFP article, “Whether the concept takes root may depend on two key issues: whether payers can be convinced of the value of medical homes (and the need to pay more for them) and whether physicians can deliver what the medical home promises.”

The concept is not new. But it seems to have been forgotten. If it can help the uninsured, stymie health care costs, and make us healthier, it should be obvious that we need to explore this option further. Any thoughts?

Some more reading here that debates some pros and cons.

is working to implement the medical home concept through its mission “The mission of TransforMED is to lead and empower medical practices in implementing the new model of patient-centered care — thereby improving health care for their patients, as well as the success of their practices.”

If we all were great presenters the world would be a better place

This may be a bit of a digression from the usual on our own system, but some ideas are just so important…

How to present…well.

It is not an easy thing, but being a good presenter can be a powerful tool. And in this information age we live in there are countless tools available, for free. In fact, some of the best give their ideas away because they can’t stand to see any more bad presentations.

It starts with preparation, and a lot of it. Garr Reynolds gives us plenty of help in this area, here, with ten steps to guide our planning. An excerpt from step No. 7, Dakara nani?, which roughly translates into:

So what?” — always be asking yourself this very important, simple question. If you can’t really answer that question, then cut that bit of content out of your talk.

Your presence during a presentation is key. Mr. Reynolds strikes again with ten more great tips to help with delivery.

If I had only one tip to give, it would be to be passionate about your topic and let that enthusiasm come out. Yes, you need great content. Yes, you need professional, well designed visuals. But it is all for naught if you do not have a deep, heartfelt belief in your topic.

And finally, the software program which has become the crutch of most presentations–and make your presentation an instant failure even if you have prepared well and are a competent deliverer, PowerPoint.

Seth Godin has a great post titled Really Bad PowerPoint, and how to avoid it with four components of a good presentation. Mr. Reynolds provides ten more tips on this subject.

And putting it all together, Guy Kawasaki, who listens to many a presentation, works hard to evangelize the 10/20/30 Rule: “It’s quite simple: a PowerPoint presentation should have ten slides, last no more than twenty minutes, and contain no font smaller than thirty points.”

Here’s Mr. Kawasaki on the 10/20/30 Rule:

And the best way to get better is to learn from others who present well. The TED website is a great opportunity to do just that, TED is a yearly conference that stands for Technology, Entertainment, Design where individuals come together to give “Inspired talks by the world’s greatest thinkers and doers.” There is some really good stuff here.

For tips on a regular basis, Mr. Reynolds’s Presentation Zen blog is great.

OK, so great presentations take a good amount of time to do. But it’s worth it. As an audience member, please, please take the time.