Pseudo vacation time

It’s only vacation in the sense that posting will be light due to prolonged bouts of limited internet accesiblity.

Here’s some light Wednesday reading on the difficulties of pay for performance from The New York Times.

Best line from the piece: “Whenever you try to legislate professional behavior, there are bound to be unintended consequences.”

Management is a “cancerous growth?”

Biting words about administrators from a National Health System physician in the U.K.:

He calls the administrators the Stasi – nicknamed after the former East Germany police – and the management system a “cancerous growth” which would only be improved by sacking nine out of 10 managers.

He said: ‘Unfortunately I honestly believe that the service I am allowed by the Stasi to provide to my patients is not as good as it was nearly 30 years ago when I came to this hospital.

Dr. John Riddington Young has written a book on his experience.  He continues:

He dismissed suggestions that the rising number of managers have made a positive difference, such as cutting waiting times.


‘You could ask almost any working doctor and he would be of the same opinion, that administration is incompetent, top-heavy and unnecessary’, he said.

Anecdotes from foreign countries with universal health care are often used in our health care debate, both pro and con.  Regardless of your position, it’s worth listening to the dissenters.  Our (more so) market driven system probably produces the same feelings in some physicians in this country as well.  Eliminating administration isn’t the answer, but an argument can be made that we’re over-managed.

New tools to find medical information

MedPedia, a wiki for everything (read: e-v-e-r-y-t-h-i-n-g) medical, launched last week.  From MedGadget:

A group of American medical schools is working on a project to essentially collect and organize all medical knowledge in a Wikipedia-like form. Access to MedPedia will be available to all, but editing rights will be limited to M.D.’s and Ph.D.’s in relevant fields of research. Harvard, Stanford, the University of Michigan, and Berkeley will kick off the site with initial content and work with the rest of the medical community to make it comprehensive. With that in mind, the project organizers are calling on all M.D’s and Ph.D’s to register to become editors of what they believe will be the largest and most complete encyclopedia of medicine in history.

Google Knol, a tool similar to Wikipedia + Squidoo, launched last week, too.  From Knol:

The Knol project is a site that hosts many knols — units of knowledge — written about various subjects. The authors of the knols can take credit for their writing, provide credentials, and elicit peer reviews and comments. Users can provide feedback, comments, and related information. So the Knol project is a platform for sharing information, with multiple cues that help you evaluate the quality and veracity of information.

Common theme: content created, edited, and distributed by experts for the reading pleasure of all.

It seems everything old is new again.

I am a fan of MedPedia.  For physicians, being able to easily search and access information that has long been stored in medical journals is a definite improvement. I’ve witnessed physicians using Wikipedia for a quick once over of a not-often-discussed topic.  Now, not only can they do a quick refresher with MedPedia,  but they are able to make confident clinical decisions based upon the content.

I’m skeptical of Knol, but warming.  It may have its place in medical search as well.  Bob Wachter, a partner in the creation of Knol, explains its usefulness:

So if you search Google for your favorite health care topic (migraine, or MI, or leukemia, for example), you’re likely to see a Knol – at this point, undoubtedly one that I commissioned – in the search results. The Knols are layperson oriented: I asked authors to write the Knol that they’d want their mother or best friend to read if they had just been diagnosed with the illness. There are also a few Knols on broader medical issues; for example, I wrote Knols on patient safety, quality of care, and hospitalists.

Bertalan Meskó raises this contention:

So I will have to find out which Knol is better. In Wikipedia, we merge different “Knols” into one article. So the readers can only see the best version. Doesn’t it sound better?

I believe in the wisdom of crowds (maybe because I’ve been a Wikipedia administrator for years now). You can pay people to create you a database of information; you can let people fight who can come up with the better article. But it can never be as accurate as Wikipedia is.

Don’t we have enough information?  More is always better—as long as the organization of the information is functional.  Finding it, understanding it, and trusting it is what MedPedia and Knol are trying to improve.

On a related note, I’d be willing to offer that many medical information searches start with Google.  Well, a new search engine, Cuil, launched on Sunday specfically taking aim at the search giant.

The launch was laughable.

Seth Godin’s post sums up what many are thinking on Cuil vs. Google:

Once there’s an icon in place, it’s there because it’s working. It serves a purpose, it carries useful information and performs a valuable function.


Google, of course, is the Marilyn Monroe of search. I have no doubt that someone will develop a useful tool one day that takes time and attention away from Google, but it won’t be a search engine. Google, after all, isn’t broken, not in terms of solving the iconic “how do I find something online using my web browser” question.

Bringing it all together, Seth provides advice:

The challenge for organizations is this: the easiest projects to start and fund are those that go after existing icons. The search for the “next” is easy to explain and exciting to join because we can visualize the benefits. But success keeps going to people who build new icons, not to those that seek to replace the most successful existing ones.

Are these tools differentiated enough to replace Wikipedia, Squidoo, and Google?  Will they exist in a crowded competitive environment?  Or will they languish in mediocrity?

Collectively, we watch and–maybe–participate.

The Skinny on Canada (witty, right?)

I don’t know if a single payer health care system would have prevented our current obesity situation—but it’s difficult not to look at our neighbors to the north and notice significantly lower levels of obesity on this map (via Richard Florida).

David Eaves:

If Canadian provinces were ranked along side US States, they would rank 1st (BC), 2nd (QC), 3rd (ON), 4th (AL) and tied for 5th (MB) (YK) as the least obese provinces/states. Colorado would be the first American state placing 7th, with the provinces of NS in 8th and SK in 9th.

Whatever the reason, Canada is doing something right, and the U.S. is going about the obesity situation all wrong.

Searching for Answers: Try Something New

A difficult battle for me as a young health care change agent is the daily battle against succumbing to the traditional thinking of health care.  I, along with many students I know, whole-heartedly leapt into this field primarily for altruistic reasons.

Be that as it may…

Tradition is a difficult opponent.  The way we have done things for years in health care is a path-dependent monstrosity fronting as a merciless beast.  The ramifications of misplaced, misalligned incentives drive daily decision making in health care.  The axiom “no margin, no mission” is very real.

But the beast must be defeated.  Sure, a paradigm shift is possible—people can change.  Another approach has health care organizations hiring leaders from outside the industry.  I may be biased, but how about another approach: hiring relatively unseasoned individuals into leadership positions for fresh perspective and new insight to mix with the wily veterans of health care management?  Individuals who may not show the wear and tear (and thus unaware of the “way things used to be”) of the incessant health care bureaucracy.

I turn to America’s pastime, baseball.

When Theo Epstein was hired as the general manager of the Boston Red Sox in 2002 he was the youngest GM in baseball and inherited a ball club plagued by years of misery.  His leadership ended that.

The Texas Rangers hired Jon Daniels as their GM in 2005 at the ripe age of 28 to replace embattled baseball veteran John Hart.  While Mr. Daniels has yet to achieve the success of Mr. Epstein, the risky move by the Rangers could provide some transferable insight to health care.

From Fast Company:

He inherited from Hart one of the game’s biggest messes — an overpriced roster and a weak farm system. To clean that up, he transformed the front office, where the mess was made. “I like to think of myself as a collaborative decision maker, not a power-hungry boss,” he says. “I want everyone’s opinion.” By everyone, he means the members of one of MLB’s quirkiest front-office staffs — about 50% wizened baseball vets like Welke and Hart, and 50% pups like Preller, now Texas’s scouting director, and assistant GM Thad Levine, 36. “I’m obviously in charge,” Daniels says, “but a good leader knows his limitations and doesn’t try to hide them. He trusts the people around him.”

Daniels’s team building has extended, necessarily, to the Rangers’ player development. Before his arrival, Texas had one of baseball’s most barren minor-league systems and most overpaid Major League clubhouses. (Who can forget how the team, in 2000, signed free agent Alex Rodriguez to an unheard-of 10-year, $252 million contract, then finished last in the AL West in the subsequent three seasons?) Last summer, after first baseman Mark Teixeira rejected an eight-year, $140 million offer, Daniels traded him to Atlanta for five prospects. Though the Rangers signed a handful of veterans leading into the ’08 season, none was especially high-priced and none got more than a two-year deal. “We want to stockpile our system with youth,” Daniels says, “to the point where we no longer have to sign a free agent.”

While the Rangers await the fruits (wins) of the decision to hire Daniels, the strategy has transformed the organization into a forward-thinking, build from within, baseball club.  A strategy smaller market teams have been using for years (with success, think the A’s, Marlins, Twins).  And a strategy baseball’s traditionally competitive large market franchises like the Yankees and Red Sox have begun to employ.

The decisions to hire young, highly talented, individuals has paid off for the Red Sox in two World Series titles and for the Rangers in a revamped, re-energized, poised-for-future-success ball club.  Satisfying results for the present, yet transforming the role of the baseball general manager.

Health care needs a similar shot in the arm.  Not necessarily at the top.  But most definitely in some of the roles that report to the top.  Not being battle hardened can be a good thing, especially when it brings new and innovative thinking to health care’s front offices.  Thinking not biased toward past (current) paradigms.

The beast is the enemy.  It just might be worth a shot.

Organizational Obesity: Are health care organizations too fat?

I’ve recently been kicking around potential reasons for the notorious slow-to-change health care organization phenomenon (fact?).

There are many potential possibilities: slowing down the speed of change in an environment that is controllable while the rest of the world changes minute-by-minute around it.  Financial incentives.  Variability of patient needs.  Dependence upon “contractors” to send business their way.  The list is lengthy.

But here is another thought: are health care organizations too heavy administratively?  Are there too many administrators, executive vice presidents, senior vice presidents, vice presidents, directors, managers, billers, processors, assistants, communicators, marketers, analysts, information servicers, health informaticists, human resourcers, etc.?  Could organizational obesity be the ultimate contributor to the unalterable tardiness of progress?

I don’t know the answer.  But what I do suspect is that beefy administrative staffs (as opposed to beefy patient care staffs) creates a largesse bureaucracy.

Stiff and rigid bureaucratic structures created by corpulent administrative staffing reduces accountability.  That (lack of) accountability can then be passed amongst the pertinent corporate players until an initiative fizzles out, money runs out, or industry changes require movement to another objective.

If you’re shaking your head, I’d rather it be done if you know for sure that this is not the case.  You very well could be right.  Because I’m just wondering and proposing.  Heck, I’m planning a career in health care administration.  But if you’re shaking your head because you are relatively sure, I’d ask you to dig deeper.

The problem is that traditional bureaucratic organizations have more layers between the people making decisions and the people affected by those decisions.  Flatter organizations would be in tune to the needs of patients and front line staff—the people whose needs are (should be!) the organization’s focus.

But instead, this solution: add another administrator and create another department to connect with patients.  And the march toward organizational obesity carries on.  Connecting with patients is every employee’s job.  Even the employee most removed from patient care will encounter a patient sooner or later.

SSM Healthcare in St. Louis has cut its organization’s staff by nearly 200 employees in 2008.  Most recently, it was mostly hospital top managers receiving pink slips.  This editorial says:

Most losses have been part of a larger shift to make the SSM system more cohesive. Most decisions on human resources, finance and technology will be made at two regional offices or at corporate.

Efficiency matters.  Productivity matters.  SSM is looking to find a way.  Is it the beginning of a trend?  Too early to say, but the current economic situation is not helping.

Varied payer demands, complex regulatory and accreditation requirements, and complicated management needs have made larger administrative staffs necessary in health care.  But has health care staffing become too fat?

The new health care environment is pushing for more value.  Again from the St. Louis Post-Dispatch:

Hospitals are facing increasing pressure to improve care while cutting costs. Quality directives from managed-care companies and the government are coming with slight, if any, increases in payment. And lately, some hospitals are seeing fewer patients.

Higher quality, better patient care, lower cost.  Increased value is not achievable through deep cuts of direct patient care staff.  That leaves one other group.  Guess who it is.

New Name: Peyton Manning Children’s Hospital

I missed this news item last September, but on a recent trip through Indianapolis to Chicago, I noticed that the children’s hospital at St. Vincent is now named Peyton Manning Children’s Hospital.

Peyton Manning is a great quarterback, terrific pitch man, and steward for the NFL.  His popularity in Indiana is unrivaled.

Usually rebranding of hospitals includes the addition of a corporation’s name to the hospital’s handle (to the tune of a sizable donation).

While Peyton Manning has probably made some kind of financial commitment to the hospital, the size of that gift (and poential for future giving) is not likely as large as that of a corporation.


Renaming the hospital to honor a living, still-playing, professional athlete is a very interesting strategic move.  And one I am quite fond of.  Manning has the ability to leverage his fame to encourage multiple corporations (and individuals) to strongly support the hospital—not just a few.  Further, considering Manning’s popularity amongst the people of Indiana, especially in Indianapolis, this is a good move to increase patient encounters.  There are people making care decisions that will select the Peyton Manning Children’s Hospital over competition based on the hospital’s affiliation with the athlete alone.

It would be interesting to see year-to-year comparisons for the three-year period on the impact of this decision in September 2010.