20. Generous Management

No, not the budget.

Penelope Trunk at Brazen Careerist boiled down management to this: “So the first rule, and probably the only rule of management, is to be respectful. A lot of questions I get from managers can be answered the same way: ask yourself if you are really being respectful.”

How many people do you know who dislike their jobs because of their management?  Probably a lot.

At our own system, we want people to look forward to coming to work every day.  That’s a goal.  We’re realistic about the likelihood of 100% compliance.  But we will work hard to build a culture that respects our people.  It starts with how we treat each other.  Here’s an example from Brazen Careerist:

Manager: My employees are totally unmotivated. What can I do?

Penelope Trunk: Do you give them work that respects their intelligence or is the work you give them crappy?

Manager: There’s nothing I can do. Someone has to do the low level work.

Penelope Trunk: People are much more motivated to do totally boring work (as a favor to you) if they feel respected by you in other ways. So give them good mentoring and pay attention to building their skills. In return, they will want to help you, even if it means sending 400 faxes.

Penelope Trunk sums it up (notice the part about listening!, it’s important):

Real managing is about growth and caring. It’s about taking time to see what skills people need to develop to move in the direction they want to move, and then helping them get those skills. This means that you need to sit with the person and find out what matters to them. And then you need to sit with yourself and figure out how you can help the person. Most people don’t see management as listening and thinking, but that’s what it is. Because that’s what caring about someone looks like.

Principle #20: An organization that promotes respect for each other (everyone) will respect its customers too.  Our patients are most important to our own system.  Taking care of patients is what we will do best.  But in order to take care of patients well, we must take care of each other first.

Importing Quality Measures?

In an effort to one-up CMS (kidding), the NHS will publish surgical mortality rates on their NHS Choices website.

From the Guardian:

The government is preparing to publish for the first time the death rates of patients undergoing major surgery at NHS hospitals in England, the Guardian has learned.

The move will expose alarming variations in the mortality rates of NHS trusts carrying out commonplace procedures, including hip and knee replacements and surgery of the oesophagus and abdominal aorta, the main blood vessel.

It will be the first time anywhere in the world that a government has systematically exposed the work of rival hospital teams, giving patients an opportunity to choose to be treated where their lives are least at risk.

The thinking:

Ministers think publication of the figures will drive up standards by forcing trusts to improve performance or withdraw from medical specialties at which they do not excel.

The future:

At this stage the published data will give results for hospital units, not individual surgeons. But Ben Bradshaw, the health minister, has instructed that the NHS Choices website should eventually let patients compare the performance of individual surgeons and GPs, heralding a big switch in the balance of medical power in favour of the patient.

Disclosure of the mortality data of hospitals will be followed by the publication of a wider range of indicators showing the outcome of treatments across many branches of medicine.

The take away:

[NHS Medical Director Sir Bruce] Keogh added: “Some will squeal that the data is not good enough, but the only way we can improve it is by using it.

“The writing has been on the wall since the inquiry into the deaths of children at Bristol Royal Infirmary 10 years ago, [which showed how poor practice was allowed to persist because the mortality rates were not disclosed]. There has been a lot of talk about more openness, but we as a profession have not made much progress. So I am now inviting the institutions of medicine to step up to the plate and help us accelerate the process. We want their help.”

(Complete) Transparency is coming…

Free Trade in Health Care

A recent opinion piece in The Wall Street Journal: “We Need Free Trade in Health Care.

The writers break down potential trade in medical services into the World Trade Organization’s 1995 General Agreement on Trade in Services typology.  The typology:

Mode 1 refers to “arm’s length” services that are typically found online: The provider and the user of services do not have to be in physical proximity.

Mode 2 relates to patients going to doctors elsewhere.

Mode 3 refers mainly to creating and staffing hospitals in other countries.

Mode 4 encompasses doctors and other medical personnel going to where the patients are. All modes promise varying, and substantial, cost savings.

While true free trade in medical services is probably a (very) distant threat to the industry in this country, these thoughts are interesting and may hold promise if we continue down the path we are on.  Competition, real competition—not the rivalry stuff we have now, would be good for all of us.

After reading the article, read this post on the Health Business Blog by David Williams who agrees “with about half of what’s printed there.”

The Emergency Department Experience: Redux

Yesterday I expressed the need to improve/master the emergency department experience for the patient.  And I completely believe that.

It can be easy to express ideals on a blog.  In fact, I do it weekly on purpose (see 1001 Principles).  But it also can be easy to forget the realities of every day health care.  So today when Kevin MD posted link after link after link of E.D. related challenges, it was a subtle, but necessary, reality check.

Read about a day not many would choose to endure.

Read about trying to match supply and demand.

Read about being unappreciated.  And being OK with it because it’s your job.

I’m still “all in” on the need for a great E.D. experience.  I’m still “all in” on ideals.  Ideals are important.  But so is reality.  And I would suppose the best doctors, the best managers, the best organizations are constantly trying to find that balance.

Back to Listening

The Church of the Customer blog has a short interview with author Josh Bernoff, (“Groundswell: Winning in a World Transformed by Social Technologies“).

It is a good exchange on social media. The power of social media in health care organizations hasn’t yet been realized (heck, we’re just getting around to proper patient use). It’s coming.

Favorite exchange:

What’s the secret ingredient at companies that understand the value of two-way communication with customers and why is that ingredient so hard to replicate at other companies?
Most managers say they want to hear from customers. They don’t. They like the idea of a mass of consumers but individually, customers are quirky. Most companies keep them at arm’s length with phone systems and call centers and focus groups. Why are you stuck on the other side of that one-way glass? Dell is an example of a company that now gets it. Michael Dell talks in terms of 100 million customer touches per year. When you think of those touches as an asset, you’ve changed your thinking. For your company to attain that thinking, it helps to build a social application. It will slowly and inexorably change your attitudes to be more customer-centric, especially at is succeeds and spreads to other applications. It takes years, but it works.

Personalized health care is the new raison d’etre in some organizations. That’s good…when it happens. In order to personalize, a hospital must encourage individual conversations with each patient. We have some work to do. Social media will help.

Peeking Over the Pond

The Wall Street Journal again writes on potential overnight issues at hospitals.  Evidently there are many.  The Institute for Healthcare Improvement is taking lessons from England’s National Health Service:

The Institute for Healthcare Improvement, a nonprofit group in Cambridge, Mass., is adapting lessons from the United Kingdom, where hospitals also have been learning to cope with new work rules using pilot programs called “Hospital at Night.” Traditionally, U.K. hospitals were fully staffed at night with doctors who worked during the day and slept at the facility overnight. Under new rules, U.K. hospitals are trying to deliver the same care with far fewer doctors on site, with the result that many doctors are coming on for night duty who haven’t seen patients during the day. The pilot programs include new systems for identifying the most ill and deteriorating patients, and for handing off patients between shifts.

While American hospitals have never had the U.K. model of fully staffed hospitals at night, many of the issues are the same. “We’ve had to address many of the problems that have beset nighttime care for decades, which are a problem for health care wherever it is practiced,” says David Gozzard, chief medical officer of Conwy & Denbighshire NHS Trust, one of the hospital systems in the U.K. program. Dr. Gozzard, who is working in a fellowship program at the Institute for Healthcare Improvement, says the U.K. program has enabled his hospital system to reduce the number of patients who need emergency resuscitation during off hours.

Non-profit status questioned

A recent court ruling in Minnesota has sent shock waves through the non-profit world recently according to this New York Times article:

Authorities from the local tax assessor to members of Congress are increasingly challenging the tax-exempt status of nonprofit institutions — ranging from small group homes to wealthy universities — questioning whether they deserve special treatment.

If you recall (or not), the non-profit status of hospitals has been questioned in the past two (or so) years.  So this is definitely something to pay attention to.  The discussion continues.

As local and state governments endure tough budgetary environments calls for such measures may gain momentum.

Good excerpt:

“The nonprofit sector is being pressed to be more business-like and to find new ways to fill the gaps between what government will pay and what services cost, but then assessors want to treat us like businesses, which pay taxes,” said Jan Malcolm, chief executive of the Courage Center in Minneapolis and a former state health commissioner.

And this:

“We need to figure out what we mean by ‘purely public charity’ because, frankly, we can’t afford as a state to lose nonprofits providing these kinds of services,” said State Representative Paul Marquart, chairman of the property tax subcommittee. “But it isn’t going to be easy.”

Paul Levy provides a defense of the non-profit status here:

But, I think the actual question is more interesting and subtle: What do people hope to achieve by threatening to take away the tax-exempt status of current non-profits? If their goal is not actually to take away the tax exemption, then they are seeking to have these organizations do more of what they feel is appropriate in the way of public service.

An interesting discussion in the comments ensues.

The Emergency Department Experience

An emergency department visit is often a highly stressful situation.  That stress makes long waits longer, feelings of being ignored more prevalent, bad service worse.

Not often do people speak about a good experience at the E.D.  Considering the circumstances, great service in the E.D. isn’t going to make anyone enjoy the visit by any means.

Bad service makes the experience awful—and worth sharing with others.

This Letter to the Editor outlines two bad experiences separated by several months.  During the second visit “after about an hour of this unacceptable and potentially dangerous behavior” the party decided to leave the E.D. for another (read: a competitor) 25 miles away.

Admittedly, there are challenges when trying to improve E.D. experience.

However, improving patient experience is a must in the E.D.  For many it is the introduction to a hospital.  The environment is always hectic and always stressful.  Improving that experience means managing patient expectations.  It means making a concerted effort to sympathize with very ill patients (most do).  Patient loyalty should not be taken for granted.  A bad experience could mean potential patients avoid your organization—for all services.

(links h/t: Kevin MD)

Measuring Health and Happiness

From Freakonomics: this should help health care respond to community needs in the future:

The first set of results from this unprecedented survey were released on Wednesday, as the inaugural report of The Gallup-Healthways Well-Being Index, and they find that 47 percent of Americans are struggling to stay afloat, and 4 percent are suffering as a result of money woes and illness. The remaining 49 percent say they are thriving, based on their quality of life and outlook on their future.

The index will continue to be updated daily, and will eventually be able to give a breakdown of well-being by profession, commute times, even ZIP codes.

Learning by Surfing: Issue 5

Here’s some health care reading.

Dr. Benjamin Brewer in The Wall Street Journal on pricing difficulties:

Why can’t you find out how much medical care costs before you’re treated? Even though I’m a doctor, I can’t get that information when I need it either.

A fall on our family’s spring vacation trip sent my daughter to a Tennessee ER for 13 stitches. The bill was $827. I figured the ER bill would be high, but I didn’t quite expect $63.62 a stitch. After insurance paid, my out-of-pocket costs came to $291 six weeks later.

Nobody I know would be willing to buy gas at an unknown price, only to find out the damage when the tab comes a month and a half later. But between the mind-numbing complexity of health-care charges and the reluctance of many in the health system to reveal their prices up front, you don’t have much of a choice.

BusinessWeek on the myth of retirees:

Other industries have jumped aboard, too. There are target-date mutual funds, investment funds that buy up retirement businesses, and expanded offerings from a variety of leisure industries, all counting on legions of retirees to fuel their growth.

There’s just one problem: The pundits are wrong. Through at least the next 25 years (i.e., past the time the last baby boomer turns 65), the retirement market will be far smaller than the oft-cited 78 million—regardless of whether one is referring to the number of people retiring or the number of living retirees. In fact, compared with today, the growth rate of either of those two measures will be less than 4% annually for the next 25 years—and could very well be zero.

Payment reform announcement from HealthBlawg:

The federales are now pushing the latest CMS demo promoting physician hospital collaboration. In other words, CMS is having another go at gainsharing from a slightly different angle. The information available on the demo at CMS website includes the formal solicitation (applications due August 15). It’s known as ACE – the Acute Care Episode demo.

Another attempt at payment reform from Fierce Healthcare:

The project, dubbed Prometheus–for payment reform for outcomes, margins, evidence, transparency, hassle-reduction, understandability and sustainability–is funded by the Robert Wood Johnson Foundation. Payments will be built around a total amount to be paid to all providers for a patient’s condition. The project includes 12 evidence-based case rates, which included input from health insurers, employers, physicians and others through a not-for-profit collaboration.