EXPANDED COVERAGE CHANGES EVERYTHING

Mandated insurance coverage will change the game. Expanding coverage to currently uninsured people will cause an influx of new demand and revenue for hospitals. Although this sounds good for hospitals, there will be undesirable consequences.

First, the healthcare system will be challenged to meet the increased demand for services. Advocates for reform cited studies that showed that uninsured people seek care less often, and later, than people with insurance as an important social problem. Newly insured people, as experienced in Massachusetts, will flood hospitals and their EDs. The increased demand will cause government outlays to exceed budget and affordability (many of the newly insured will be paid for by government programs). Inevitably, this will lead to reimbursement reductions (a major concern at the AHA Annual Meeting in Washington last month).

A PERILOUS BALANCING ACT

Since Medicare is a break even business and Medicaid is an unprofitable business, future reimbursement reductions will make it harder to break even. Insurers, under pricing pressure and maybe government price regulation, will prevent cost shifting to them. Reform believers think that hospitals will be better off since more people will be paying customers. Others are concerned that the increase in the number of low paying customers will shift the payor mix and unfavorably alter hospital profitability. It’s not clear how hospitals will balance their books. Lowering pay to healthcare providers may balance the books, but what will it do to the supply, given that shortages already exist?

THREE STEPS TO HELP YOU PREPARE FOR THE FUTURE

Proactive hospitals need to prepare for the future – today.  Here are three areas you can act upon right now:

1. Tighter management of productivity while redesigning work processes

Productivity management and work processes are closely linked. If you improve productivity without redesigning work, other important outcomes might suffer. In addition, productivity gains are often short-lived if work processes haven’t changed. The stress of “short-staffing” results in declining productivity after the intensive focus on productivity evaporates.

2.  Throughput management

Another area receiving attention is throughput management, especially in acute care and the emergency department. More patients will be coming to emergency departments although ED capacity isn’t likely to expand. Hospitals that don’t figure out how to address throughput will have to address more complaints and patient safety problems. Similarly, hospitals will need to admit more patients but they won’t be able to increase beds or hire more nurses. Hospitals will need to manage care so patients are discharged when they no longer need hospital care. This may alter the perception of what is an unnecessary hospital stay.

3.  Readmissions prevention

Finally, hospitals are beginning to address readmissions prevention. Although there is no reimbursement for this service, new financial penalties will hurt hospitals with too many readmissions. And the rules may get tighter with time. Readmission prevention also makes more room for new patients.

Action today will smooth the path for tomorrow’s reform.

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It’s a familiar scene. A hospital inpatient unit chronically misses its productivity target or budget by approximately ten percent. The nurse manager for the unit repeatedly attempts to explain, but the targets remain unmet, and the financial ramifications of unnecessary hospital labor costs continue to mount.

Ingrained Attitudes Impede Improvement
In today’s hospitals, it’s not uncommon to encounter this type of defensiveness among inpatient unit managers who miss their targets. While some frustration amongst managers is understandable, the productivity losses that can accompany negative attitudes and biases pose a serious threat to hospitals’ bottom lines. So, before embarking on any hospital productivity improvement initiative, it is important to understand how misconceptions about productivity information and deep-seated biases can hinder progress.

When observing situations like the one described, we, as consultants, are not surprised to find certain attitudes and frustrations within hospital divisions like Nursing, Finance and Human Resources. Managers who think they are managing properly can begin to question the origin and validity of the data and targets contained in productivity reports and monthly financials. Likewise, nurse managers can express exasperation with relentless questioning of their productivity performance. And, attempted explanations of variances can solidify over time into institutionalized excuse-making and high hospital labor costs.

Different Perspectives Mean Different Biases
Within the Finance division, negativity regarding the motives and perhaps even the competence of unit managers who struggle with chronic productivity variances can arise. Members of hospital Finance divisions generally feel that they are supplying an abundance of valuable management information and frequently interpret productivity variances as evidence of overstaffing. In addition, those in Finance may express consternation when the request is made for a vacancy to be filled.

Similarly, members of the hospital’s Human Resources department may harbor negative misconceptions about nurse managers who have difficulty meeting their labor expense budgets. Such doubts may dampen the enthusiasm with which vacancies are recognized, posted and pursued to a speedy conclusion. Because, in general, members of hospital Finance and Human Resources divisions have little “clinical” education or background, there is a tendency for them to be inhibited about asking challenging questions that may actually illuminate the underlying causes of FTE variances and reduce hospital labor costs.

On the other hand, nursing administrators can also operate under their own set of faulty assumptions in the absence of a clear, fact-based understanding of productivity performance variance. This can lead to less time and energy spent on leadership and management development, and more emphasis on protecting managerial prerogatives. When you consider that typical hospital inpatient units are comprised of 40-45 FTEs, and their negative productivity variances can be 4-5 FTEs per unit, misconceptions and defensiveness can translate into significant, unnecessary hospital labor costs.

Positive Change from Objectivity
Constructively addressing hospital productivity means properly interpreting variance. It requires carefully examining multiple factors within the hospital as potential contributors to departures from expectations. A 4.1 FTE variance rarely means that there are four too many nurses working on a given inpatient unit, rather it is a mathematical relationship between actual and expected productivity within the hospital. Factors like overtime, incremental time, errors in scheduling, actions of the central staffing office, actions of the shift supervisor, etc. can all contribute to variances in hospital productivity measures, so it’s rarely possible to “blame” underperformance on a single factor or person.

So, when addressing hospital productivity, it is very important that analysis of data is undertaken in a neutral, objective manner, devoid of preconception or prejudice. Such efforts can help to diffuse defensive attitudes amongst hospital staff and aid members of multiple departments—like Finance, Nursing and Human Resources—in understanding the true implications of productivity data. Giving nursing managers and others the benefit of the doubt, and working to reverse negative attitudes can be crucial to the success of any hospital productivity initiative.

For more information about how to achieve improvements in hospital productivity, contact Eric Dam at 513.241.0142.

Your quality team has studied the new standard changes, updated policies, and conducted tracers to monitor compliance. What else can you do as an executive to help your hospital prepare for more rigorous regulatory surveys? Communicate with your board!Currently, the Centers for Medicare and Medicaid Services (CMS) require hospitals to have a governing body (the board) that is legally responsible for the conduct of the hospital as an institution. The board of a hospital must hire the CEO, establish a competent medical staff, and oversee key aspects of the organization, such as the strategic plan and budget. However, it’s the governing body’s role in oversight of quality care that is most commonly cited during a complaint survey.

Rather than taking an active role in ensuring patient safety, most boards feel forced into a “rubber stamp” approach to quality oversight. This is often due to a combination of factors, including confusion about how the board oversees quality and lack of adequate knowledge about patient safety. But, hospital executives can support the board in fulfilling their responsibilities. Follow these guidelines to ensure that the board is an effective resource for your hospital.

Provide your board with an orientation. While not explicitly mentioned in the standard, board orientation has become an expectation for both CMS and The Joint Commission. Board members should receive an orientation to the hospital’s operations and quality program, as well as opportunities for additional education, if needed. Orientation also provides a chance for you and your hospital’s quality team to learn more about the needs and preferences of the board. What kinds of people serve on the board? What are their professional backgrounds? What kinds of report formats would best convey information to them in a meaningful way?

Make quality information universally understandable. Hospital boards generally consist of people from a wide variety of professional backgrounds. While many members may have some knowledge of basic quality control, it is likely that they do not know very much about the hospital’s quality standards. Therefore, the hospital must inform board members about quality care in a way that makes sense to them. Reports should be written for a lay (non-healthcare) audience and emphasize meaningful information over data.

Outline and document specific expectations for board members. In order for the board to effectively oversee patient safety (or operations in general), members must be engaged, interested, and willing to ask questions. Let your board know that you expect members to challenge old ideas, and encourage inquiry when appropriate.

Hold the board accountable for oversight. Boards receive quality reports for two reasons, to gain information and to direct action. Be clear when you want the board to take action on an identified issue, state your recommendation, then allow the board the opportunity to act. Merely approving a report is not meaningful action when there are problems. Once expectations have been stated, follow up in subsequent meetings.

Maintain transparency. Keeping the board informed is extremely important, particularly if your hospital is facing financial difficulties or adverse survey results like Immediate Jeopardy. A properly informed board can be the hospital’s greatest asset when it comes to communicating with the community and mitigating the impact of financial downturn or negative survey results. On the other hand, leaving the board in the dark about poor survey results can be disastrous, not only for reversing the findings, but in the loss of trust with the board and the community they represent. For more information and the story of one hospital that learned this lesson the hard way, read “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing.”

Across the country, hospitals are finding themselves on the receiving end of unannounced regulatory surveys. Failure to be prepared for such surveys can, in the worst cases, lead to Preliminary Denial of Accreditation by The Joint Commission (TJC) or findings of Immediate Jeopardy by the Centers for Medicare and Medicaid Services (CMS). But, hospital leaders can avoid adverse survey findings and ensure patient safety by paying attention to seemingly small issues before they become big problems.

So, how do small problems grow? We have found that small problems become big problems for two reasons. They either go unseen, or are perceived to be smaller or less consequential than they actually are.

Lack of visibility is probably the most common factor that allows small problems to grow. Often, unseen patient safety issues lurk behind seemingly positive data. Executives and board members should look critically at the quality reports that they receive, not just for the information that is included, but also for the information that’s missing. Are scores for select core measures consistently reported to be in the top percentiles while others aren’t mentioned? Are certain departments regularly highlighted for good performance but there is no discussion of problems? In other words, are you getting almost entirely good news?

When it comes to quality and patient safety, no bad news can be a red flag. Given the numerous patient interactions involved in day-to-day operations, every hospital should experience some level of failure. If, as a hospital executive, you don’t routinely hear about little problems, you’re probably missing the big issues, too. You can’t improve performance if you don’t know what needs to be improved.

So, when examining quality reports, look for the following signals that problems may be hidden or their gravity underestimated.

• Compliance with select core measures is consistently in the top percentiles.
  Core measures are important; there’s no denying that. But, they rarely tell the whole story when it comes to patient safety and regulatory compliance. Hospitals with nearly perfect core measure scores can still get into trouble on survey. Focusing on boosting core measure scores can divert attention away from day-to-day care. Also, CMS surveys are focused on compliance with minimum standards. So in many cases, core measures don’t correlate to compliance with CMS standards. For example, restraint and seclusion, a classic hot-button issue on CMS surveys, is not represented by a core measure.
• Certain departments are regularly highlighted for good performance.
  Every hospital will have stand-out departments that always do a good job of ensuring quality and patient safety. But, it’s important that you have a comprehensive view of all departments, not the just the best ones. Reports should cover every department at least once a year, with emphasis on patient outcomes. This type of strategy ensures that executives and board members and objective view not only of the entire hospital, but of the most important data.
• Reports focus solely on data and activities.
  While the current trend is to focus on risk reduction by improving processes, don’t forget that it’s important to understand how process improvements translate to better care. Be wary of reports that feature lists of actions and data without providing the analysis to show how those actions or data correlate to better patient outcomes. For example, reporting on the hours of sitter use is meaningless if those hours of supervision don’t lead to reduced use of restraints and fewer patient injuries. Also, appreciate that quality indicators are linked to other important business indicators. When more sitters are used, ask how this affects hitting productivity targets and how management responds to a productivity deviation.

Bringing minor problems to light before they have a chance to grow is perhaps the most important step toward preventing big problems. By keeping a critical eye and looking for warning signs, hospital leaders can ensure quality and patient safety by uncovering these small issues early.

To learn about one hospital where small problems turned into big problems, read “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing.”

Recently, we have learned of a hospital that received an Immediate Jeopardy citation by CMS surveyors due to an employee potentially exposing patients to the H1N1 (swine flu) virus.   Other hospitals have reported dealing with an outbreak of the highly contagious Norwalk virus. 

While stressing the importance of infection control practices in the workplace, the CDC’s guidelines for preventing the spread of H1N1 flu virus recommend that sick employees stay away from work and that employers provide flexible leave policies.  

Many hospitals and their employees don’t follow these recommendations.

Besides the social pressures of not calling in sick, hourly employees, especially front line nurses, are penalized by loss of pay if they stay home when sick.   When employees work while sick, other employees and patients are exposed to increased risks, including prolonged hospitalizations and hospital-acquired infections. CMS now adds loss of accreditation or regulatory certification and legal liability to the list of reasons hospital leaders need to review their policies regarding sick employees.  

Transparency and mandatory reporting coupled with increased scrutiny of hospital-acquired infection can only worsen the cost of failing to protect patients from communicable diseases. 

We Recommend a Different Direction:

We think there is a solution for reducing the risks of employees working while sick. Encourage workers who think they may have an infectious disease to be screened by Employee Health (or they could go to their doctor).  If the employee has a communicable disease, they should be sent home with pay (and not use up a sick day).  This approach encourages workers to do the right thing while eliminating fake illnesses. Additionally, the information gathered through this process may also be useful for monitoring disease spread patterns.

While this has a short term cost impact, from a financial, regulatory and patient safety perspective it will produce a long term positive return on the investment.

When the order entry incumbent resigned without notice in November 2008, the management team began to seriously investigate the real sources of the high defect rate. A major insight was the realization that initial training of new employees was completely inadequate. Furthermore, many of the important aspects of the job were either undocumented or inadequately documented making effective training difficult.

In the first month after the new person was hired and trained the new way, the defect rate fell 72%. The next month it fell 17%. The defect rate has fallen by similar amounts each subsequent month, now five months running. As the defect rate falls to low levels, they have begun exploring the ideas behind a “zero-defect” program.

Read about their process improvement journey.

This resulted in a long stays and low levels of reimbursement.

Compass Clinical Consulting worked with this hospital to break down communication silos along the case management chain so team members would better understand each other’s roles, regulatory changes, and the financial constraints that third parties placed on the healthcare system.

In addition, a revised schedule for case managers and social workers provided for consistent coverage and appropriate case loads for all personnel involved in case management. Compass helped this organization to standardize admission and review processes, and increase communication between clinical and financial departments. These measures ensured that medical records accurately represented each patient’s condition to optimize reimbursement.

As a result of these small changes, Compass Clinical Consulting helped this organization improve reimbursement and reduce length of stay from 4.8 days to 3.6 days, achieving significant savings in associated costs.

Read more about case management and patient throughput.

Recently published research in the Archives of Internal Medicine has attracted attention because it concludes that small gifts influence physician choice of medications. I am certain that this study will be used to justify future public and organizational policy decisions.

The focus of my comments is not related to influence on physician decision making. The issue is the misuse of research findings and extending conclusions beyond the conditions of the research. That this research is publicized is evidence of the failure of our educational system! It’s time to stand up and scream “Foul!”

This research used compared medical students, not physicians, at two medical schools that had different policies about small gifts from pharmaceutical companies. Based upon psychological tests of positive and negative associations, not prescribing patterns, the researchers concluded that even small gifts influence opinions.

There are a lot of reasons to believe that there are significant flaws in drawing conclusions about practicing physicians from this study.

First, the subjects were students not practicing physicians. Relying upon them as representative of physicians would be like assessing how well students can perform laparoscopic cholecystectomies and concluding that physicians are not skilled enough in performing surgery. Is there anyone who does not recognized that medical students differ from practicing physician?  Medical students are not engaged in “self-learning” and evaluating journal articles or practice guidelines. They are passive recipients of information. Physicians learn how to become life-long learners in their residencies. In addition, medical students have not gone through the socialization processes that are part of post-graduate medical education that prepare the physician to have a more questioning attitude to what they are told. And medical students are in an economically different place than practicing physicians and might be subject to greater influence by lower cost items (determining whether that’s true is a research study, in itself).

Second, if that were not enough to debunk this study, a fundamental flaw of experimentation was overlooked. Only two medical schools were studied. While these schools differed in their policy on small gifts, it’s very likely that they varied in other characteristics also. For example, faculty attitudes toward drug expenses might be different (which would align with the differences in policies). The problem is that there may be many unknown dimensions in which the two schools differed. To overcome the unknown differences, one needs to study students from more schools. Even that might not be sufficient, depending upon what the data reveals.

More than likely, the researchers had their minds made up before they conducted the research. That is, they were biased. When researchers are biased, it influences the quality of their research design, their analysis of data and the conclusions they draw. Ultimately, their research is not research, but rhetoric. Research requires skepticism.

The same is true in management. When management seeks to confirm what they believe to be true, they begin a path down a road that leads to missing important warning signs. Good research and good management research challenges pre-existing belief. Trying to confirm what you already believe is a dangerous practice. Instead, try to disprove what you believe to be true.

Cary Gutbezahl, MD and President, Compass Clinical Consulting

Research reported in a recent New England Journal of Medicine showed:

• Almost one-fifth of Medicare patients are re-admitted to a hospital within 30 days
• Over one-third are re-admitted within 90 days
• More than three-quarters of the re-admissions were following medical admissions, suggesting that the vast majority of hospital admissions were not scheduled admissions (most medical admissions are urgent and emergent, as are many surgical admissions). 
• More than half of patients who were re-admitted within 30 days did not see a physician prior to readmission.

The implied assumptions underlying the research design are also important.

The study implies that because 50% of re-admitted patients had no outpatient physician visits (as determined by invoices), their care was sub-optimal. This logic is flawed.

The facts of this research provide important information to focus further investigations into reducing healthcare costs.  The study, however, has significant limitations.

No one seems to notice that this research reported in April 2009 is based on the patients who were admitted in the Fourth Quarter of 2003 and followed through the end of 2004.

Thus, the effects of programs to reduce complications during the past few years such as the surgical complication reduction programs, acute myocardial infarction and congestive heart program were not included.

First, physician visits are not the only way to monitor patient compliance with treatment plans and clinical status. Many patients receive outpatient treatment from home health agencies. Some patients are admitted to skilled nursing facilities which require an examination shortly after admission (it isn’t clear whether the data revealed that these patients did not see a physician, which might suggest a methodological flaw). It also isn’t clear whether re-admission was more likely in nursing home patients than patients who were discharged to home, or whether re-admissions were more likely in patients discharged home with nursing care. In discharge planning, these supplemental care resources are associated with an assessment that the patient is at higher risk for re-admission. These patients are monitored, even if the physician does not see the patient.

Second, the observation that 50% of re-admitted patients were not seen by a physician may be skewed by the distribution of admissions within the 30-day period (shorter periods between hospitalizations had higher rates of not seeing a physician). However, it is concerning that only 25% of re-admitted patients at the 30-day mark had not seen a physician.

Medicare Demonstration Project

The results published in NEJM should also be considered in relationship to the recently reported finding of a Medicare Demonstration Project that showed that most “disease management” programs did not have a beneficial effect upon preventing subsequent problems. Disease management programs provide nurses who have frequent contact with patients to monitor compliance and screen patients for early signs of deteriorating care. Nurses contact the patient’s physician when the nurse is concerned about the patient’s clinical status.

How can these the NEJM results be reconciled with the Medicare Demonstration Project?

First, there is too little information in the NEJM article to understand why re-admissions occur. No patients were interviewed and no discharge instructions or medical records were reviewed. Instead of providing data, the authors cite reports showing reduced re-hospitalization rates based on better discharge planning (one of which was written by one of the authors). By the way, these studies did not cite physician visits as a preventative intervention for re-admission.

The Potential Impact of Flawed Logic on Healthcare Policy

There are several problems with transferring the responsibility for preventing re-admissions to hospitals through changes in reimbursement. This assumes that the causes of re-admission are known and that they are preventable. Additionally, the prevailing opinion is to punish hospitals for re-admissions. This will result in less money to hospitals that are already struggling to cover their costs. Although there is no evidence that hospitals are responsible for readmissions, it seems like policy-makers are trying to push the responsibility for reducing re-admissions to anyone they can accuse.

Another issue in holding hospitals accountable for re-admissions is patient choice over home health care agencies and skilled nursing homes. How can hospitals be accountable for re-admission rates when the patient has the choice over which home health agency is used or to which nursing home that patient is admitted? Does the patient lose choice or does the hospital get stuck with the risk when there is no ability to control the post-acute care provider?

By the way, let’s not forget that patients do decline and eventually die, despite the best medical treatment.

Policy-makers are rushing to find a culprit so they can utilize penalties to cover some of the cost of healthcare reform. But flawed logic will lead to bad policy.

As Henry Mencken wrote over 50 years ago:

      “For every complex problem, there is a solution that is simple, neat and wrong.”

When we are making healthcare policy, let’s make sure we really understand the issues and when we see any evidence that some of our conclusions are flawed, let’s step back and count to ten before we make errant decisions. 

According to the CDC’s National Center for Health Statistics “National Health Care Survey.” annual of emergency department visits jumped from 90.3 million in 1996 to more than 119 million in 2006, a 32 percent increase. At the same time, the percentage of non-obstetric hospital admissions that came through emergency departments climbed from 36 percent in 1996 to 50 percent in 2006.

“This means that a lot of diagnostic work is being done in the ER, and it is prolonging ER stays,” said Stephen Pitts, M.D., M.P.H., a fellow at the National Center for Health Statistics and an associate professor of emergency medicine at Emory University, who led the study.

The study strongly suggests that the growing use of emergency departments is directly related to the shortage of primary care physicians. Without a regular and continual source of care, patients are more likely to turn to emergency departments for treatment, said Pitts in an interview with AAFP News Now.

The study also reached the following conclusions.

·         Patients with Medicaid use the emergency department more frequently than patients with private insurance — 82 per 100 persons for Medicaid compared with 21 per 100 for private insurance. Medicaid patients have a harder time finding physicians who will treat them than do patients with private insurance, which accounts for the disparities in ER visits, Pitts said.

·         The average waiting time to see a physician in the emergency department was 56 minutes.

·         The rate of visits per 100 persons was about 36 percent for whites compared with nearly 80 percent for blacks, a fact that Pitts attributed to many blacks’ lower socioeconomic status and, consequently, their decreased access to physicians outside of ERs. Cultural factors also could play a role in discouraging blacks from seeking care from places other than ERs, Pitts said.

·         The rate of visits per 100 persons for Hispanics was about 35 percent, lower than the rate for whites. Pitts said this statistic could be a result of language and cultural barriers that make Hispanics less likely to report their visits to ERs.

·         Most ER visits occurred after normal business hours — 8 a.m. to 5 p.m. on weekdays — when 63 percent of adults and 73 percent of children younger than 15 came in.

Need to learn how to use ER facilities smarter.

Blogger Kevin Pho, MD, notes in a recent post:

One-fifth of patients coming to the ED did not have conditions requiring emergency care, and another one-fifth had urgent conditions that could have been treated in a primary care setting, the report shows.

The last point has resonance. The key is primary care and specialist access. When I work in ED fast-track, there is a good proportion who come in for medication refills and the like – simply because they can’t contact nor see their primary care physician.

Uninsured and Medicaid patients in some communities might have to wait six months or more for an appointment with a specialist. But if they go to an ED, they get all their needs met in one place at any time.

“The convenience of the emergency department really offsets the long waits that are associated with it” . . .

When patients use the ER, they get immediate attention to their ailments, but then return home with no means for follow up visits … no prevention until they return again to the ER for their next episode.

The uninsured actually are underrepresented in ER units compared to the overall population—17 percent of people in our country are uninsured, but they account for somewhere between ten and 15 percent of visits to the ER. When they do come in, they tend to put it off until the last possible moment, until they’re really sick.

If today’s uninsured were insured by a government/commercial system, they could then go to a primary care physician at a cost far lower than at hospital ER units. The case management plan for addressing their healthcare problem would be planned out by the primary care physician and the individual would stay healthier. This would also decrease the number of readmissions because follow-up care is provided outside the hospital.

Just one problem: there are not enough primary care physicians and they are not always located in the right place where those currently uninsured live.

The fact that there are fewer primary care doctors mean it’s hard to get appointments. If you call your doctor’s office and you say, “I’m really sick and coughing up green stuff,” and the doctor’s office says, “we can see you in two weeks,” you might think you need to go to the ER instead. But the issue you are running into is the queue to get in an see the relatively few primary care doctors is growing – at times beyond their ability to respond in a timely manner.

Considerable research indicates that a majority of policy makers and even doctors believe primary care doctors need to be paid more – to attract more medical students to pursue internal medicine instead of the more lucrative specialties.

While addressing primary care physician compensation, policy should also be focused on how to motivate more doctors to provide care in areas not now covered – rural and urban localities, in particular.

And there are other problems that backup into the ER. There’s a shortage of nurses and in-patient beds so you might get triage in the ER and have no room in the hospital for continued treatment.

There are no easy solutions. The ER can work on throughput issues. But that’s a tiny fraction of the problem. Hospitals cannot predict how many people show up in the ER. They cannot control how soon someone can get a bed if the hospital is short on beds or nurses. You can’t blame any one part of the system. You can’t say this is the ER’s fault, or the inpatient service department’s fault, or primary care physician’s fault. If we keep pointing fingers and blaming people, we’re not going to change anything. This is a system wide problem. If we are truly in the midst of coming healthcare reform, then all parties need to tackle this as a systemic issue … if healthcare reform is just about increasing access for the uninsured and decreasing the cost of the healthcare system, then we will have missed a huge opportunity to take a holistic approach to clinical care.

Compass Clinical Consulting

For 30 years, Compass Clinical Consulting has worked successfully with executive and clinical leaders at prestigious non-profit hospitals across the nation. We are passionate about creating better American hospitals, knowing that even the best can still get better. Our experienced consultants can pinpoint opportunities with an objective assessment and a plan that will lead to dramatic improvement that can cut millions from operations while enhancing your valuable staff.

We invite you to contact us so together we can look for opportunities to improve your most critical clinical processes. Call Cary Gutbezahl, MD, at 513-241-0142.

Sharon Begley, senior editor of Newsweek and accalimed for her ability to write about complex topics so that they are clear and understandable, has another point of view, expressed in this week’s issue of Newsweek Magazine. She sees doctors as having long resisted using science to guide their practice, thus leading to a chronic pattern of overtreatment and using more expensive techniques than are necessary.

Begley writes: It’s hard not to scream when you see how many physicians, pharmaceutical companies, medical-device makers and, lately, hysterical conservatives seem to hate science, or at best ignore it. These days the science that inspires fear and loathing is “comparative-effectiveness research” (CER), which is receiving $1 billion under the stimulus bill President Obama signed. CER means studies to determine which treatments, including drugs, are more medically and cost-effective for a given ailment than others.”

Spending a billion dollars to determine effectiveness of one treatment over another will shine a spotlight on some of the issues. Then it becomes policy-making time. Does Washington through its power behind Medicare payments dictate to doctors and hospitals how to treat patients? Or do we prefer as patients selecting our own physicians and hospitals based on they go about healing us? And who will pay for the difference?  In the end, no one wants overtreatment, we just want the right treatment. Who is to say who is right?

One of the leadership team’s first moves was to craft a strategy for improving four key areas within the system: clinical quality, service quality, financial stability and community value.

Deemed the “Journey to Excellence,” the initiative set out to reach incremental, measurable goals of improvement in each of the four areas.

“Excellence is not a luxury, it’s a necessity.”

“The four components of the Journey to Excellence program were clear to us. We have to offer the right product to the right person. We have to deliver that product in an exemplary way. We have to offer affordable care but also create a revenue stream by offering the lowest cost, highest quality healthcare. And finally, we have to bring value to our community. It really is just a matter of common sense if you are truly committed to excellence,” — CEO Tom Royer.

Completing the 60-month plan to achieve excellence, defined by CHRISTUS’ leadership team as being in the 90th percentile in service and clinical quality, has not been without its stumbling blocks, however. Realizing their improvement action plans were either not being fully implemented or were not being “hard-wired” into each of the system’s regional operations, the senior leadership team ramped up its efforts at cultivating a culture in which all employees are held accountable for their actions.

“To maximize brain power and people power, we started teaching and embracing what I call ‘professional backtalking.’ We want our team members to push back and tell us honestly and openly what’s working and what could work better, so we as a team can come to a consensus about what needs to be done to improve,” Royer says, adding that he’s been able to create an environment in which employees at every level feel comfortable “talking back” by having senior leaders in place who are confident in their leadership abilities and are willing to listen to and act on constructive criticism.

The Financial Return

Since the Journey to Excellence initiative was put in place in 1999, the system has seen marked improvement in all four areas of focus. In fact, net operating income at the system–which at the formation of CHRISTUS Health was negative $146.1 million–has increased to $107 million.

After having seen such success with the first round of their Journey to Excellence program, the team decided to implement a second phase. “We expect to be at 90th percentile for all four goals by 2009. If we’ve already reached that goal, we expect to show that we’ve been able to sustain it. We will make sure we sustain those goals and have them hardwired into our system to create more of a culture of excellence.”

The American hospital is the envy of the world, and yet it could be so much more.

Every hospital – even the best of the best – could be more effective and efficient. Every hospital should deliver a positive experience for patients, physicians, nurses, administrators, staff and the private and governmental payers. The data says otherwise.

Too often, how you define a better American hospital depends on “what’s in it for me.” Different motivations between the key players at every hospital sustain cultures that inhibit the ability for everyone to work well as a team. Conflicts between these roles need to be resolved. Once we accomplish this, the doors for dramatic improvement will spring open.

Easier said than done. The same problems plaguing Operating Rooms today were at work 15 years ago. I found a scholarly document on operating room management written in 1992 that goes into detail on these problems: “multiple surgical specialties, anesthesiology and nursing — have different motivations and cultures that frequently do not work well together on a team. Strong personalities, long work hours, interpersonal coflicts and many critically ill patients make the O. R. an area of high stress.”

Problems that stick around, even across generations, are human nature. We don’t seem to learn from our predecessors but have to learn from our own pain. But not all is hopeless. We can apply solid conflict resolution techniques that melt problems away and result in better hospitals.

Objective, trained and experienced consultants may need to be called in to diagnose the issues and facilitate the cultural changes and show how everyone can work together more efficiently.

At just three months old, doctors discovered Morgan Lee had an enlarged heart. During her stay in the Cardiac Intensive Care Unit (CICU), Morgan suffered a stroke and was diagnosed with cerebral palsy. Morgan Lee’s mouth and tongue became weak, leaving her unable to eat food by mouth. Today, thanks to help from speech therapist Drew Gerwin, Morgan is now able to eat and drink without the aid of a feeding tube.

Pizza, topped with melted mozzarella cheese, pepperoni and bacon…hot, buttered popcorn…frothy strawberry shakes and rich chocolate ice cream… Just saying the words makes your mouth water in anticipation.

Now imagine not being able to eat, except through a tube in your nose that leads to your stomach. Imagine being deprived of all the sensory delights that accompany food and drink. That’s what 3-year-old Morgan Lee might have faced. But thanks for her devoted family and the expert help of Drew Gerwin, speech therapist at Cincinnati Children’s Hospital Medical Center, the little girl is able to enjoy what many of us take for granted.

A Rocky Beginning

Morgan was just three months old when doctors discovered that her heart was enlarged to three times its normal size. She spent seven weeks in the cardiac intensive care unit, during which time she suffered a stroke that left her right side weak, as well as compromising her speech and her fine and gross motor skills. She was also diagnosed with cerebral palsy.

Says Morgan’s mom, Monica, “The doctors told us her heart was ruined, that she’d have to have a transplant. They put her on the list and sent us home to wait.”

In the meantime, Morgan and her family had to deal with the devastating effects of the stroke and the cerebral palsy. Monica had breast-fed her before she was hospitalized, but now Morgan had seemingly “forgotten” how to eat. She wouldn’t take a bottle either.

Recalls Monica, “The muscles in her mouth and tongue were weak. She also had reflux which caused her to gag, even when we fed her through the tube. Several therapists tried to teach her to eat to no avail. But in early 2003, Morgan had the good fortune to be assigned to Drew.”

Hope Enters In

Drew Gerwin is a slender, sparkly-eyed spirit whose affection for her patients is obvious. Her specialty is high-risk children with eating problems. She’s been a speech therapist for nearly seven years, all of them at Cincinnati Children’s.

Monica explains, “We could see a difference the first day Drew arrived, because Morgan actually let Drew touch her mouth and put various sensory devices into her mouth to see how see would react. Morgan connected with Drew, and although her progress was slow, she showed signs of improving.”

A Long Road Back

Drew supported Morgan’s family by teaching them feeding techniques, educating them on various feeding topics and helping them deal with setbacks. Says Monica, “We’d get to a point where Morgan seemed to have mastered something, then the next week, she wouldn’t do anything. But Drew helped us understand that any progress Morgan made was good and that we needed to keep praising and encouraging her.”

Says Drew, “Morgan was learning to eat at a time that’s especially difficult for children in general. They’re teething and having lots of ear infections. It’s frustrating for families, so you really have to take it in little steps.”

A Remarkable Outcome

Morgan has made some pretty amazing advances in her recovery. For instance, in the past two years, her heart has healed on its own, making a transplant no longer necessary. “The doctors aren’t sure why or how it happened, but it seems like a miracle to us,” says Monica.

And thanks for Drew, Morgan is now able to eat and drink without the aid of a tube. Her favorite foods are pizza and M&Ms, and she is particularly partial to chocolate ice cream.

The stroke has left Morgan unable to feel hunger. But Monica reports, when she makes popcorn in the microwave, Morgan smells it and lets her know she wants some.

Drew praises the Lee family, saying, “Morgan is a testament to how much progress you can make when you’ve got a family who understands the goals for the patient. They all pitched in and worked with her every day.”

But Monica credits Drew Gerwin for her creative ideas and her persistence in working with Morgan. “We would never have seen Morgan eating again without Drew’s skills and experience. My husband and I believe in angels — those who guide us each and every day and those that are on this earth to physically help those in need. There is no doubt in our minds that Drew is our angel, and we thank her from the bottom of our hearts.”