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.”

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Every Good Idea has Downside Implications

Medicare’s Acute Care Episode Demonstration Project (ACE) has attracted a lot of attention as a way of encouraging greater physician and hospital alignment – presumably to lower the cost of delivering healthcare.

Hospitals like the idea of ensuring that physicians share the hospital’s concerns to reduce unnecessary utilization, supply control and improving patient safety. Physicians like the idea of the potential for gainsharing. Of course, each side has concerns about control and the degree of cooperation they will face from their new partners.

Stated and Unstated Goals of ACE

That’s all well and good. But the ACE demonstration has implications beyond the stated purpose of the project. Implications that could run counter to providing better care and counter to reducing the financial impact of malpractice legal issues.

Let’s realize that Medicare’s purpose is not just to lower government costs but to place the physician and the hospital in the position of deciding what is needed to treat the patient.

On the surface, this sounds nice.

The public certainly does not want the government deciding whether a patient needs a consultation or a test. But they are giving the physician-hospital partnership the authority to make these decisions under conditions of financial influence!

How is this financial influence different from the financial influence of pharmaceutical companies and medical device manufacturers?

Reality says that financial pressures will shape decision-making, thereby taking some chances with patient welfare that might not be taken if there were no financial influence. Critics of capitation have argued that patients suffer when care is limited by financial influence on the decision-makers. Yet isn’t the government’s purpose in proposing ACE to alter decision-making by transferring financial responsibility to others?

The ACE project also has implications for patient satisfaction with both their doctor and hospital experience.

Remember that Medicare, in response to a beneficiary complaint, instituted the Important Message from Medicare process. This unfunded burden on hospitals requires that hospitals notify patients, close to the time of discharge, that the patient has a right to appeal the discharge order to the QIO if they feel they are being discharged sooner than is appropriate for the patient.

Trouble Brews When Patients Trust in Providers is Put in Doubt

Won’t the ACE payment result in an increase in the patient’s concern that their interests are being subordinated to the physician’s or the hospital’s financial interests?

How will these concerns affect the patient’s assessment of their satisfaction with the hospital?

This payment also may have an impact on the roles that physician’s play in a patient’s care. For example, some surgical specialists have gotten used to consulting hospitalists to provide non-surgical care for the patient. Will new financial constraints place pressure on surgeons to resume the former practice of assuming all care responsibility of patients?

Another intentional consequence of ACE is a reduction in the number of consultants involved in a patient’s care. On the surface, this reduces confusion and cost. But financial interests change behavior in unintended ways. Internists may reduce the frequency of referrals to subspecialists, such as cardiologists and pulmonologists. The only problem is that common sense suggests that people who specialize in cardiology have a higher level of expertise in cardiology than a general internist. Could ACE cause internists to stretch themselves beyond their expertise resulting in harm to some patients?

New malpractice liability concerns might arise from the ACE project

Tests may be conducted to identify risks that when identified, alter treatment decisions. Financial incentives are intended to influence decisions on whether the test is necessary for the patient’s care. Hospitals and physicians are likely to develop guidelines for when tests are necessary. In many cases, there is not sufficient research to inform these decisions. Yet, without guidelines, practices will vary and errors will be made. When guidelines are developed, they will probably include cost benefit analysis, which depend upon probabilistic information. As with all probabilities, sometimes a patient is the rare event. Although physicians make these judgments now, they do so without any financial incentive influencing their decision. Won’t the presence of financial incentives influence a jury trial assessing whether the physician erred in not ordering a test?

Every change has intended and unintended consequences.

The demonstration project should look for unintended consequences, as well as the intended ones. Patients are entitled to know the full effect for how such a change in the healthcare system, while seemingly benign, could well have significant impact on their lives.

Every payer is looking for ways to cut costs, and surely costs must be cut. But instituting financial incentives to care givers to favor their own income rather than delivering safe, quality healthcare to every patient needs to have plenty of professional and public scrutiny. Otherwise, the only benefactors will be the attorneys handling yet another wave of medical malpractice cases.

The unintended demons should be carefully analyzed as this demonstration project moves forward.

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It is difficult to guess the position of such a leader and revered figure but it takes little insight to predict his position: one of concern for the 44 million Americans who go without health insurance.

His keen sense of social justice would most likely be offended by the disparities rift in our current system. So perhaps in honor of his birth anniversary we should rededicate ourselves to finding a just and equitable way of delivering quality care to all Americans.

That seems a fitting tribute.

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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.”

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Can a hospital have a near-death experience? If so, what would that look like?

For Haywood Regional Medical Center, “near-death” took the form of involuntary termination from Medicare. This traumatic event caused the hospital to lose physicians, morale, and its previously good reputation, not to mention significant amounts of money. But, with quick corrective action and strong leadership, the medical center regained its Medicare certification and received a second chance to thrive.

“Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing,” the new whitepaper from Compass Clinical Consulting, tells the story of Haywood Regional Medical Center, examining some of the factors that brought this hospital to the brink of collapse and the swift, strategic action that brought it back to life.

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When an organization has a performance problem, managers seek information to identify and assess the causes of the performance failure. Similarly, an analysis of a social problem should require policy analysts to identify and assess all significant contributors to the social problem. Our public discussion on health care reform has failed to meet this expectation.

The debate about health care reform has focused on several significant issues, such as getting financial coverage for the uninsured’s medical needs, building incentives for hospitals and physicians to provide better care, and removing inefficiencies from the fragmented delivery system.

However, there is an elephant in the room that is not being discussed – personal responsibility for health. For years, studies have shown that up to 70% of disease is influenced by personal (not provider) behaviors. As such an important aspect of health care costs, this issue cannot be ignored.

Why is personal responsibility being ignored? As health care providers know, changing patient behaviors is extremely difficult. The first step is for the patient to want to make the changes and not every patient wants to change their behavior to get better. Patients who struggle with emphysema still smoke. Patients with diabetes eat cakes and candies. They choose to continue the behaviors that got them sick despite the counsel of their physicians and other health care providers. From a psychological perspective, there are many reasons why this happens. Providing better access to care is not going to change this.

Talking about the need for personal behavior change is not politically popular. When he was president, Jimmy Carter advised Americans to reduce energy consumption. This unpopular message contributed to his failed reelection bid. Admonishing people is not an effective way to build a coalition of support. Yet, the failure of individuals to adopt pro-health behaviors will cause accidents and disease that will have to be treated, at great expense, after disease or injury occurs.

The elephant has to be addressed. Can we effectively control health care costs without including individual incentives? Assigning responsibility for patient behaviors to health care providers is easier from a political standpoint. But it fails to address a known driver of health care costs. It also has the unintended potential for creating discrimination against people who struggle to control their behaviors. Providers may terminate care relationships with patients who fail to comply with medical advice. Similarly, physicians may screen patient to determine whether a new patient is likely to fail to comply with medical advice. Ultimately, these patients will wind up in emergency rooms and other venues that cannot turn patients away.

Policy makers have a public obligation to understand the complex dynamics of the health care system before they propose changes that may have adverse effects that are as undesirable as the problems within the current system. “First, do no harm” does not only apply to caring for individuals.

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By Kate Fenner, RN, PhD, Chief Executive Officer, Compass Clinical Consulting

Everyone is waiting for the shoe to drop – the impact of Healthcare Reform on hospitals. The details change daily depending upon which government plan is getting attention by various Congressional committees.

No one yet knows what shape reform may take but the predictable is being prognosticated by the pundits; we will most probably be asked to do more with fewer resources. One CEO of a for-profit system acknowledged to us recently that reform is one of the issues that is robbing him of sleep. Another CEO of a prestigious academic hospital is already taking steps to be out ahead of the game with a major workforce planning and productivity process redevelopment for when the inevitable decisions are made into law.

When you know the inevitable, why wait for details?

The cost pressures will not disappear. Increased access to high-quality healthcare must be paid for by everyone – including hospital providers.

1. Increased access brings both problems and opportunities. Problems for those not ready and opportunities for those hospitals that are getting ready to turn difficulty into advantage.
2. Cost pressures on providers likewise hang like a sword over every hospital leader, with little foreseeable advantage to community and academic hospitals. Again, however, there is opportunity for the prepared.

Smart executives can begin girding their hospitals for reform, regardless of requirements. How so? By stepping back two paces, taking a dispassionate eye to evaluating the status quo and going about the business of needed change before it’s mandated.

Several changes are predictable.

First, is the necessity of absolute efficiency. This is just a restatement of the Four Rights: right people with the right skills using the right processes in the right numbers. There will be no room for bloat, redundancy, inefficiency and overstaffing. Well-managed productivity systems and processes will be critical to preparedness.

Second, will be managing patient throughput, length of stay and case management. This requires admitting only those who need to be admitted, treating efficiently/effectively and discharging in a timely manner while minimizing waste, unnecessary care and readmission. Shaving patient days for particular DRGs will translate into millions of dollars in greater efficiency.

Third, will be managing revenue cycles with a draconian eye towards effectiveness; idle money, cumbersome systems and obscure processes must be banished.

Underlying these three critical requirements is the use of benchmarks. Valid yardsticks for measuring one institution’s performance against peers are ubiquitous; courage to dispassionately apply them is needed. But one hospitals benchmarks and targets cannot be arbitrarily dropped on another hospital. Each situation is unique and both senior and mid-management must be in agreement and take responsibility for making changes to hit the targets they collectively agree to meet.

A dispassionate assessment of current organizational state is the foundation for prioritizing and then addressing the areas above. Executives frequently have a “gut feel” that an area isn’t functioning at its optimal level. Application of measurement derived from objective industry standards permits validation of that feeling and opens the door to the necessity of corrective action. Armed with realistic targets and needed process changes, leaders can bring order to the potential chaos threatening the viability of the organization.

Don’t be a sitting duck. Smart executives aren’t waiting for reform to materialize, they are preparing now by getting their organizations lean and effective in anticipation of the requirements that are inevitable, regardless of what reform regulations become law.

For more information on hospital preparation BEFORE reform hits, visit Operational Improvement.

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The American Academy of Family Physicians predicts that the shortage of family doctors will soar to 40,000 within the next decade. Worse yet, the overall shortage of doctors is expected to climb to nearly 160,000 by 2025, according to the Association of American Medical Colleges.

“I don’t see anything in the legislation that will greatly increase the primary care pipeline,” said Dr. Russell Robertson, chair of the Council on Graduate Medical Education.

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By Cary D. Gutbezahl, MD, President, Compass Clinical Consulting:

This week, the administration of Broward General Medical Center announced that a nurse had been reusing single-use IV tubing and saline bags. This problem had gone on for years, putting patients at risk for infectious diseases. Upon learning of the problem through the compliance hotline, the hospital acted responsibly. But one can’t help but ask, “How could this happen?” More importantly, we must ask, “How could this have gone on so long?”

As we all know, sometimes things happen in hospital operations that result in patient harm. Not infrequently, the proximate cause is that one or more people are not doing what they are expected to do. Although many factors may contribute to an avoidable injury, investigations often reveal that the policy and procedures were in place, the staff was trained on and understood the policy and procedures, staffing was adequate to do the work, but people didn’t follow the policy. Upon further investigation, it is often found that this one negative event was not a unique occurrence. Rather, lots of people fail to follow the policy, this just happened to be one time when the problem was detected. So, you have to ask, “How could this happen?”

The common managerial response to such adverse events is to punish those who were caught. Executives believe that this shows leadership and sends a message to others. But does it have any lasting effect? And does it convey the right leadership message? Punishing the guilty is appropriate, but it conveys the message that bad apples are the source of problems and that getting rid of them solves those problems. In other words, it’s not the system; it’s the people. Not only is this not a humanistic management message, but it ignores the observation that many people weren’t following the policy. Furthermore, a one-time event is not likely to have a more sustained impact on behavior than the original training on the policy.

To fix the problem, executives and managers must do two things. First, you have to investigate why people aren’t doing what they know they should be doing. You have to involve people who haven’t been doing their jobs to understand their reasoning. While it may be a challenge to do this in a non-threatening way, gaining the trust of the participants is critical to developing a systematic solution to the problem. You can’t assume that the problem was due to “bad people.” People act in response to their environments, whether that means workflow interruption or cultural norms. You can’t fix the behavior if you don’t understand the source.

The second step is to fix the problem. A highly attractive, but rarely available method is to develop mechanisms that force the desired behavior to occur. These types of solutions are usually technology-driven, e.g., an alert that is only turned off after blood pressure is checked. Of course, people may find ways to circumvent such technology. People can falsify documentation so modifying documentation requirements is not foolproof.

One critical component for management, especially when implementing a corrective action, is to design and implement a management information system that monitors the desired behaviors. You can’t assume that one-time corrective actions will continue to have the desired effects. Behaviors can drift over time. You need information, and you need to be creative in thinking about how to get that information. For example, if one-time use material is being reused, one should observe unexpectedly low supply costs.

In healthcare we also have an obligation to assure the competence of our staff. People have to be evaluated not just on knowledge, but on practice. Supervisors need to work side by side with staff to observe behaviors and make sure that the staff is following the policies and procedures. If this isn’t happening, management needs to find out why.

Finally, in our work investigating adverse events, we have found episodes of mass non-compliant behavior. Undetected errors lead to patterns of errors. At one hospital, “everyone” took wheelchairs across the entrance into the MRI suite, but “this was the first time that the metal wheelchair was (violently) pulled into the magnet.” These are particularly hard issues to monitor, unless you get out and see what’s going on. MBW (or Management By Wandering around) is still a good idea – old ideas should not be discarded just because they are old. But you have to look for problems, not just socialize.

The absence of a detected problem is not evidence that policies and procedures are implemented as designed. As hospital executives and managers, you don’t want to ask, “How could this happen?” because you’ll be reading your answer in the newspaper. Instead ask yourself, “How do I know what really is happening?”

To learn more about hospital policies and patient safety, visit Executive Leadership.

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In interviews conducted with senior Chief Financial Officers of hospitals it is abundantly clear that there is a fear to pursue improved productivity / Labor Cost Management. Many hospital leaders, especially in the non-profit sector of the healthcare industry, fear productivity or are otherwise reluctant to pursue a formal productivity assessment and coordinated program to improve their labor cost management.

Among the possible causes of fear and reluctance cited are:

• Productivity has a richly deserved bad reputation based on failed attempts that executives have participated in or heard about e.g. the slash-and-burn approach
• Hospital leaders are in a precarious and insecure position: high turnover, short tenure, concern about trustee, leadership, and employee reaction
• Hospital leadership often assumes that trade-offs are necessary due to potentially competing goals e.g. Decreasing labor costs will lead to decreased quality and patient satisfaction
• Hospital leaders have a concern that if an objective assessment of hospital productivity reveals significant improvement opportunities, the result will be interpreted as a failure of management
• Many hospitals have an existing productivity measurement system in place and in the absence of an objective assessment, feel that productivity has already been maximized
• In the context of a perceived nursing shortage many executives are reluctant to pressure nursing productivity for fear of losing nurses to competing hospitals
• In some highly mission-driven hospitals, an emphasis on productivity can be seen to be in conflict with concern for employee well-being

How to help alleviate the fear:

Respect for operational and strategic realities. Any productivity target should be carefully tailored to individual departments based on a thorough understanding of circumstances, strengths and challenges of the department. These circumstances can include strategic initiatives of the hospital—for instance expanding a cardiology program—that have definite consequences for a department. This core principle makes good sense to managers. The establishment of arbitrary quartile or percentile targets is generally resented or dismissed by department managers.

Fair and all-inclusive. Another guiding principle, and one that managers find to be reassuring, is that the process of establishing productivity targets should be fair and all-inclusive; that no sector or department should be left out of the process; that politics should not influence the setting of targets. While one or two individual departments may feel singled out by this principle, the vast majority of managers applaud it.

It’s not just cuts. Although expense reduction is the ultimate goal, the credibility of the standard-setting process is enhanced by the stated willingness to add to staffing whenever it is indicated.

There are also other payroll expense reductions that are not related to FTEs e.g. overtime, premium, skill mix changes.

Respect and genuine interest. Really listen to your mangers concerns about issues in their department. How could process changes assist them in meeting a reasonable target? How can you help?

Trust building. Don’t be locked into a departmental standard for life. You will build trust with managers if you are open to changing a standard as new information evolves, changes occur within the department or new insights emerge.

Support for “managing to the numbers.” Provide tools and education to managers so that you are not only giving them the objective, but also the means of reaching the objective.

To read more about hospital productivity, see Labor Cost Management.

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When we are asked to help a hospital that has major financial or quality problems, we almost always find that these problems didn’t begin overnight. In fact, there was evidence of problems for many years. In retrospect, it is easy to point fingers at those individuals and boards that “missed the problem.” The more important issue is whether the problem should have been recognized at an earlier time, when the problem could have been corrected without significant damage to the organization.

Our experience says that while hospitals sometimes overlook indications of problems, more often, CEOs and boards tolerate a series of ineffective attempts at fixing the problem.

Why would that be?

One reason we have found is that there exists a limited understanding of the real nature of the problem. Many organizations don’t think through what is driving poor performance issues. The best way to gain an understand of the problem is to mix knowledge with novelty. We recommend bringing knowledgeable insiders together with “uncontaminated,” but capable participants. The insiders provide factual information about what is going on, while people who are uninvolved can ask questions to surface issues that might be overlooked by people involved in the issue every day.

Another cause of poor performance is an unwillingness or inability to figure out how to deal with the drivers creating the problem. For example, sometimes people are afraid of asking the medical staff to change. In reality, this should not be difficult if hospital leaders develop a good solution that meets everyone’s needs.
Again, this is a situation in which unbiased participants can spur innovative solutions. Non-participants can ask questions or challenge assumptions that prevent creative solutions. As an interim CMO, I have often approached problem physicians and achieved positive outcomes. I don’t think this was because we were both physicians since other physician leaders had made failed prior attempts. The source of my success was that as a newbie, I wasn’t afraid of approaching the physician, I showed respect and that I brought a fair and unbiased perspective.

Often, failed problem-solving begins when the wrong people are invited to solve the problem. Many hospital managers when faced with a problem of poor performance have a tendency to “round up the usual suspects” (apologies to the movie, Casablanca). Frequently, this means the very people who have been unable to solve the issue before are still asked to come up with a new answer. The people who are involved in long-standing or slowly simmering problems had plenty of time to fix the issue but have been unable to arrive at a durable solution. This is a case of what you don’t know can hurt you – and it calls for a new set of eyes to bring about sustainable improvement in performance.

To create solutions to persistent problems, leaders and managers need to think differently. That usually requires gathering new perspectives from people who haven’t been part of the problem.

Read more about how hospital leaders can impact hospital performance.

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Pressured by the prospects of mounting losses, leaders of Miami, FL, hospital expressed concern Monday that the public hospital employees had racked up almost 1.2 million hours of overtime over a 12-month period. Jackson leaders expect the system to lose $56 million this year and $168 million next year, and they’re looking to shave costs wherever possible.

Response by Shawna O’Neill, RN, MHA, and Labor Productivity Consultant at Compass Clinical Consulting:

Yikes!!

In hospitals across the country (unionized and non-unionized) we find the phenomenon of unreasonable overtime driving the cost of safe, quality healthcare out-of-control.

What the use of overtime and premium pay does to drive up health care costs is a shame, when those dollars could be put to much more productive use.

With the mandate to cut hospital costs, this is one area that is easily identifiable and fixable vs. the trauma of laying-off employees or 5% “across the board” cuts which is unfair to those departments already doing a good job. Some employees get very used to the overtime and in fact count on it in their pay check. Paying overtime to employees can never be cheaper or save the hospital money than having staff deployed according to:

RIGHT PERSON, RIGHT ROLE, RIGHT TIME, RIGHT PLACE (R4)

There are times when overtime may be an okay option in small doses. In departments where the workload is very volatile, overtime may be a better answer than having too many core staff that are asked to stay home when the volume falls. This is a delicate balance because once overtime is approved for a few departments it can easily get out of control in those departments and can then spread through the entire hospital.

HOW DO HOSPITALS OVERCOME THIS?

Determine your current percent of overtime hours compared to your total paid hours. Productive hospitals run 1% – 3% of overtime hours total paid hours.

Measure overtime by department to determine outliers. Work with those managers to find the reasons for excessive overtime (process changes to become more efficient, time management education if there are specific employees identified as consistent recipients of overtime).

Avoid casual behavior regarding clocking in and clocking out and make sure managers are monitoring and dealing with incremental overtime.
There needs to be departmental workload based productivity standards. Each department should have a staffing plan based on these standards and additional plans for increases or decreases in volume e.g. seasonal fluctuations in census. The position control should be filled with employees to meet the staffing plan – correct skill mix and adequate full-time and part-time mix must be identified. Float pools &/or per diem staffing should be built based on historical leaves, PTO, and seasonal census fluctuations. There should also be a daily staffing plan so that staff shifts as volume shifts.
The staffing plan should only have 12 hour nurse scheduled for 6 days in a pay period (0.9 FTE) so that overtime is not incurred (most hospitals have full-time benefits for 72 hour / pay period employees).

A GOOD NEVER

A good policy is to never schedule overtime.

It should only be used for emergencies (sick call, FMLA). Clear staffing and scheduling policies that are adhered to and implemented in all departments can also help to eliminate overtime e.g. the number of staff, by skill mix and shift, that are allowed to take vacation at the same time. Ensure that employees with attendance problems are progressively disciplined and that human resource policies are consistently employed throughout the organization.

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What Health Care Reform will certainly bring:  It’s difficult to predict the specifics of what health care reform will bring, but it is clear that it won’t be business as usual. We believe that three things will be certain results of the current public debate.

First, reimbursement changes are going to increase the importance of managing the cost of delivering services. Hospitals will need to pursue operational efficiencies with a vigor that has not been widespread. Labor costs, work processes, duplication reduction, and reducing unnecessary utilization will be critical for preserving the bottom line.

Second, coordinating care will become more important. The public debate has highlighted the lack of coordination of care providers. For example, the debate on readmissions has blamed the problem, in part, on poor follow-up after hospital discharge. Post hospitalization care is a responsibility shared among hospitals, physicians, nursing homes and home health care providers. Yet, no one seems to “own” coordinating care. Regardless of the structure of reimbursement changes, someone is going to get blamed (and penalized) for letting patients fall through the cracks. This requires rethinking the health system’s business design, from being a collection of provider assets to a unified, single provider that cares for a patient.

The third major change will be increased accountability for failure to ensure patient safety (as measured by results, not processes) and treatment plans consistent with best practices and evidence-based medicine. Oversights will not be tolerated. While much can be learned from investigating undesirable events, there will be much more emphasis on error prevention. After an event, staff may be motivated to prevent a recurrence and willing to make changes, but preventing an occurrence will require changing current practices when the staff may not appreciate the degree of risk.

Many hospitals will struggle with this cultural challenge. Case management should be an important part of achieving these goals. Many hospitals fear implementing an effective case management program because they perceive that case management is similar to insurance company authorization process. This is a misconception. Health system based case management should be built to optimize multiple care process outcomes (financial, quality, and patient experience). Case managers collaborate with other care providers; they don’t evaluate them. When operating properly, case managers are valued by patients, physicians and hospital staff. Case management can multiply the effectiveness of other initiatives. Smart hospitals are not waiting for new legislation. Their leaders see the writing on the wall and are steering their organizations to make changes now!

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In our experience in case management, both in hospitals and in managed care organizations, we have found many reasons why patients are readmitted to hospitals. These include medical reasons (such as a complication or instability of the disease), patient reasons (such as lonely people who don’t want to stay at home alone or patients who don’t want to eat a low-salt diet), and post-hospital care provider issues (such as nursing homes that are short-staffed and want to send “sick” patients back to the hospital). All of these are not single solution problems. The only clear fact is that hospitals are not responsible for causing these problems.

So, how can the hospital be held responsible for all this?

Because hospitals are an easy target and other more realistic solutions are harder to implement or not politically acceptable (holding patients and their families responsible for unnecessary readmissions).

The public does not realize that Medicare, under current regulations, does not pay for long hospitalizations. In fact, the DRG payment system creates financial incentives to shorten hospitalizations and creates financial penalties to hospitals that have long hospital lengths of stay. Medicare also wants patients to go home (without home nursing care) rather than to a nursing home. Medicare is no more compassionate than any other insurer.

Medicare also requires that hospitals provide patients with a list of post-hospital care providers and expects the patients to choose. Hospitals cannot, by regulation, indicate preference to their own home care company.  Doesn’t this further complicate the degree of responsibility that a hospital can reasonably assume for rehospitalization?

If this unreasonable penalty against hospitals is implemented, Medicare should allow hospitals to refer patients to their own nursing facilities and home health care agencies. This will provide better continuity of care and enable the hospital to be a true health system responsible for providing a wider scope of services to patients in their community.

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Congress: First Do No Harm

The Democrats in Congress are discussing whether to apply reconciliation procedures to passing health care redesign legislation (I would call this redesign rather than reform, since the latter term implies improvement, which is not established at this time).

Reconciliation procedures were originally created to prevent the government from shutting down over budget disagreement. They allow passage of legislation with a simple majority and prevent filibustering, which requires 60 votes to close.

Our experience as healthcare management consultants validates that the principles underlying reconciliation procedures are dangerous for organizations.

Research on conflict management shows that conflict can be beneficial for decision-making if used correctly. Conflict arises from differences in points of view. By discussing these differences in perspective, organizations can uncover hidden assumptions about a wide variety of issues, which are important considerations.

Research shows that failing to consider these types of differences results in poorer decision quality. Cutting off discussion prematurely has the same adverse effects as groupthink.

Managers can fall into the same trap as Congress by rushing an opportunity to make change.

Leaders know how hard it is to mobilize people for change. Consequently, there is a desire to seize the moment. Wise leaders use the moment to create momentum, but understand that poor preparation for change can have unanticipated and undesirable effects.

There is no substitute for planning that integrates task conflict (good conflict), and when necessary, undertakes small tests of change before widespread implementation. We have a highly visible example right before our eyes with the Massachusetts Healthcare Reform experiment. While still to early to fully assess, already we are seeing unexpected consequences that should not be ignored as we move forward with national reform.

Our political leaders are failing all of us by rushing to a pre-conceived solution and then using the reconciliation procedure to eliminate constructive conflict to arrive at a more well thought-out solution. Two tactics are being used to interfere with constructive conflict.

First, Declare an Emergency to Stop Cognitive Discussions

The first technique that people follow when they want their own way is to declare that the situation is “an emergency.” They announce that the emergency requires immediate action.

Keep in mind that an emergency is not the same thing as a need to change or reform a broken system.

Example: A person with significant coronary artery disease may need angioplasty or cardiac surgery, but the condition is not an emergency unless that person has elevated enzymes or arrhythmias. So we do more discovery and testing to arrive at the best treatment. If we do have a real cardiac emergency, medical practioners have well-tested methods for addressing the emergency.

The exact opposite is true with large-scale healthcare reform. If we concede that we are really in an emergency situation, we don’t have a well-studied roadmap for resolution.

The principle of “First, do no harm” is about not rushing into action before an action plan is well-designed. And a well-designed plan is not rushed to implementation until sufficient discussion, information-gathering, and exploration has been conducted – with people who have a range of ideas that can lead to a better, more effective implementation.

Second, Drive a Stake Deep into the Ground and Refuse to Discuss Options

The second technique to stop constructive conflict is that both sides are unwilling to see the other party’s view. Republicans refuse to agree to the legislation proposed by the Democrats.

This is a perfect example of poor conflict management.

In a successful organization, the goal of conflict management is not to force the opposition to accept the majority perspective but to encourage the opposition to explain the reasons why opposition exists.

After the reasons are identified, the organization’s leadership tries to resolve the differences of opinion (it always comes down to opinions) by discussion, seeking more data, or conducting experiments that help resolve differences of opinions.

Exploration of the conflict usually results in a better solution.

As advocates of Better American Hospitals, we want to encourage Washington to develop legislation that provides hospital managers with the ability to care for patients. We do not want to see any process put in place that will result in incomplete planning and testing before implementation.

Congress needs to act like responsible managers and ensure (not just hope) that legislative changes enhance the health care system’s ability to provide care. Do Americans deserve less than the best plan? Like good organizational leaders, in an effort to “first, do no harm”, Congress ought to ensure that a full debate on any proposed legislation occurs before any redesign legislation is passed.

In response to this type of oppositional thinking, I hope they don’t repeal “First, do no harm”.

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Emergency Room diversions continue to be an issue in the news. The Washington Post, the beltway paper, recently reported on the problems associated with ER diversions in the District of Columbia and Maryland.

Diversions are when ambulances are sent to another ER because the nearest ER is too busy and does not believe they can safely provide care.

Since everyone else reported on the potential for adverse effects caused by extra travel, I thought it might be useful to understand that the hospital goes on diversion because it has determined that patient safety might be at risk if more critical patients were added to those already at the hospital.

Adding more work beyond the capacity of the ER not only jeopardizes the new patient but puts all the other patients at risk. For example, when an ER nurse has too many ER patients, there isn’t enough time to check on their status, comfort or educate them (or their families).

You might say, “Hire more nurses.” But, there may not be enough nurses available. And financially, where will the money come from when Medicare and Medicaid pay so poorly (not to mention the many uninsured patients)?

But there is another aspect of the problem that is controllable. Many hospitals do not adequately manage hospital length of stay. Many patients can be discharged or moved to another, less expensive, care provider safely and earlier. Critical care and telemetry beds are often filled with patients who don’t need those specialized services.

One hospital scrapped plans to build additional ICU beds after implementing a more effective case management/throughput management program. By managing bed utilization better, beds are made available for quicker transfer from the ER.

Other changes that would also speed ER patient care are to do more testing on patients who might need to be admitted in observation beds (non-ER) or in inpatient units instead of waiting for all the tests to be done before the patient is admitted. To make this happen, other things need to be done – but these also are within the hospital’s control.

Similarly, many times tests done in Emergency Rooms can be done for patients as outpatients. It’s a matter of coordination of care and reallocating resources.

The fact is that things can be done to admit patients to an inpatient bed faster or discharge patients from the ER faster. When these things are done the ERs can see more patients (and provide safer care), thereby reducing the need for ER diversions.

The solution is not “either/or” but “and.” We need social policies that reduce the influx of patients to the ER and we need management practices that do the best with what we have. Health care providers must do what they can, even if it’s not the total solution.

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Too many are standing around trying to figure out how reform will impact hospitals.  Those standing still will find proactive leaders passing them by.

The smart leaders understand that regardless of how healthcare reform looks when it becomes law, the real truth is that we’ll all be getting less. Knowing this is the end-point gives us all the freedom to take action now.

Proactive hospital leaders are already assuming the conclusion and are getting to the task of cost reduction and quality enhancement in preparation for whatever change comes our way.

The strategy to thrive (who just wants to survive?) is critical, stem to stern evaluation of all processes within the hospital from operations through administration, from staffing through organizational structure.

This need not be arduous, laborious or time consuming but it must be critical, objective and structured. In fact there is much merit in a blitz approach to assessment yielding fast, reliable opportunities that can be prioritized and addressed with alacrity.

Such a rapid approach is less disruptive, more culturally respectful and garners fewer opponents capable of hijacking the process. Analysis-paralysis is prevented. In the end, nothing yells success like results that translate to the bottom line and the ability to invest in mission critical activities.

A relatively small hospital recently took action to reduce labor cost and put an extra $8 million on their bottom line without layoffs or departmental closings – a savings that will repeat year after year. Consider then, the even greater potential for cost reduction at larger hospitals. The places to look for productivity gains with dramatic results lie in improving labor productivity, increasing patient throughput, eliminating the need for facilities expansion with more efficient processes and LOS reduction.

“Waste Not, Want Not.”  Or as Ben Franklin once said: “A penny saved is a penny earned. “ Never have pennies been as important as when you are fighting a recession, healthcare reform and more aggressive regulatory compliance – all at the same time.

Read more about hospital financial performance.

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But when “reducing the cost of healthcare” by mandating lower fees to providers, this should be more carefully analyzed to prevent a future of continuous change. Best to get it right at the start instead of rushing to judgement. This will best be done if policymakers are using the right data to make wise decisions rather than picking a data point from one place and another datapoint from another place and yet another datapoint … searching for datapoints that support what they wanted to do anyway.

This excerpt from The Healthcare Value Blog indicates what I mean:

We are surprised and dismayed at how policymakers are using the findings as the map for healthcare reform in Washington, D.C. We are also frankly appalled at how The New Yorker article by Dr. Atul Gawande has seemingly become the guidepost of reform for policymakers. The reason is that the conclusions that The White House and much of Congress have drawn from The New Yorker article are, at best, suspect and, at worst, completely wrong. Reengineering 20% of the economy is a large task, in our view, and getting the facts straight is important.

So, what have we done? Instead of using an “Atlas” to analyze McAllen and El Paso, we suggest using a “GPS” to triangulate the position that hospitals played in overall excess cost and utilization. Doing so provides some critical facts that The New Yorker failed to report.

Check out the observations by Hal Andrews & John Morrow from The Healthcare Value Blog: Lost in D. C. with the Dartmouth Atlas.

That said, all of us can read enough of the crystal ball to realize that hospital leaders will need to carefully examine their own hospital systems for ways to eliminate non-value producing processes. The goal must be to reduce the cost of delivering safe, quality healthcare. As has happened at several clients we have worked with recently, hospital managers do have the potential to reduce labor cost without layoffs, and at the same time create a renewed, long term commitment by staff to achieve safer, quality healthcare for patients.

Hospitals are big, complex businesses — typically the largest employers in any city. Running such a business is no easy task. Taking cost out of such businesses must be done smartly less the wrong decision leads to patient safety issues or to unleash unintended consequences such as doctors, nurses and specially-trained staff voting with their feet and going elsewhere to make a living.

Where we might differ from some of the global directives coming from national policy is that these savings need to be delivered one hospital at a time, each with its own unique people, processes and culture. What we don’t want to see is our national system of healthcare providers flung into chaos without the time to get leaner and better.

We believe most healthcare providers understand the need to reduce the cost of delivering safe, quality healthcare and we see them already tackling this issue without being subjected to policies that might cause them to do this the wrong way.

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The Journal of the Medical Library Association, Healthcare IT News reports on a study that indicates social networking tools are rapidly being added to the curricula in medical and nursing school. It should be noted that the study included a fairly small sampling and results may be non-projectable. We include this, however, because based on our experience (see last paragraphs of this posting), social media are gaining momentum.

Hopefully, this will be a trend because physicians, nurses and hospital administrators will gain by expanding their view of professional and patient discussions that should serve to improve care at lower cost.

The study cited:

• 53% of nursing schools and 45% of medical schools include Web 2.0 tools in their curricula.
• 58% of nursing schools plan to implement social networking tools in their curricula in the upcoming year, compared with 50% of medical schools.

Although a larger percentage of nursing schools report using or planning to use Web 2.0 tools in their curricula than medical schools, medical school respondents were more likely to report personal use of social networking tools than nursing school respondents.

Student, Practitioner Demand

A separate survey conducted in 2007 found that medical students and practitioners want more training to become better users of Web 2.0 tools.

Compass Clinical Consulting Using Social Media

Compass Clinical Consulting’s decision to reach out to the healthcare community through social media fits in with a growing trend of medical and nursing schools who are now teaching students how to be proficient in using social media.

Visit our website, our social media news room and our growing list of blogs and links to our Twitter, Facebook, LinkedIn, Flickr, YouTube, StumbleUpon, and other social media.

Over 300 hospitals are now following us on Twitter and in just three months nearly 20,000 pages have been viewed on our blogs.

The goal is to become an integral participant in the discussions that impact reducing the cost of delivering safe, quality healthcare.

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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.

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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.

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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.

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A hospital team can use this concept by combining labor cost management with case management. The two together become highly strategic multipliers. One plus one equals 3 or maybe even 10. The combination enables your team to lead transformational change faster.

Improving patient throughput with effective and aligned case management maximizes the use of hospital assets – time, space, capacity, equipment, and human assets. Maximizing those assets leads to significant productivity gains. When patient flow is increased, unnecessary work can be eliminated and existing staff can process added patient volume more effectively.

Flow improvement is especially effective for hospitals experiencing or anticipating substantial growth or for hospitals approaching the limits of their capacity.

Adding labor resource technology can also further multiply results, but only if social change is part of the technology implementation. The frequent lack of success experienced by management in using these systems usually results from the inability to generate “buy-in” as well as build the management and organizational capability to change culture and processes.

Without the required social change, technology alone is a force detractor. It takes your eye off the real problems while searching for magic bullets. Systems don’t produce results . . . people who know how and why to use systems produce results.

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If necessity is the mother of invention, then it is time to pay a visit to her cousin, replication – replication, as in borrowing from the higher education playbook in generating more charitable donations from individuals and families.

Colleges and universities have traditionally placed a much higher premium on generating both annual and planned gifts than the majority of hospitals. Rather than expounding on the many legitimate reasons why this is the case, let’s focus on steps the Board, the Executive Suite, and the Chief Development Officer (CDO) can take.

Step 1: How philanthropic is your culture?

According to a survey by the Governance Institute, only 18% of hospital Boards have a written policy outlining individual directors’ responsibilities for supporting the organization’s philanthropic efforts.

·         Is charitable commitment/charitable connection a primary criterion for Board member recruitment and performance?

·         How many trustees have donor-advised funds? Are any of those funds coming to the hospital?

·         What percentage of the Board makes an annual gift, and how many gifts are five figures or more?

·         How many planned gifts have been made by the Board and C-suite? A $10,000 charitable gift annuity can be a reasonable starting point.

·         What percentage of the annual operating budget comes from charitable gifts?

Step 2: Have you done an opportunity assessment in the last 2-3 years?

Even if you are not conducting a formal campaign, consider one-on-one interviews with your 100-200 most influential constituents. Ascertain their visions for the hospital and their philanthropic commitment to seeing that vision become reality. These interviews will yield a goldmine of opportunities for generating charitable dollars for both current and long-term needs, not to mention some great ideas for new initiatives.

Step 3: Is your Chief Development Officer empowered to be a player?

A fancy-schmancy title like CEO of the Hospital Foundation means little if your chief fundraiser is perceived as a lieutenant or special events coordinator. The Chief Development Officer at a college or university is usually right up with the Provost or Chief Academic Officer on the power grid. Many higher education Presidents were CDOs in their previous positions. How many hospital CEOs do you know that came by that path?

Either empower or hire a CDO that has full access to the Board and the requisite skills to work with Trustees and the C-Suite to create a true culture of philanthropy. The pay-offs will be worth it!

Read more about hospital fund development.

Jim Mahon is a Principal at Compass Group, Inc., and has previously served as a Chief Development Officer in both the higher education and healthcare fields.

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By Jim Mahon

Target Corporation ran a contest on Facebook, giving away $3 million to charities.  St. Jude’s Children’s Research Hospital was  the winner of the “Bullseye Gives” contest in which 10 charities vied for votes from the social network’s users.

St. Jude’s, founded by the late actor Danny Thomas, received  26.6% of the 291,399 votes cast and won $797,123 from Target.

In a close second place finish came The American Red Cross with 26.5 percent of the votes and $793,942 from Target.

Contests on social media are a new and growing way for charities to raise money.  The sponsor Target also achieved its goal, with more than 97,000 new fans joining the retailer’s Facebook page during the contest, and daily views of its page increased by 4,800%. A nice win-win for Target and the charities.

According to Ed Bennett who tracks hospitals using social media, 277 hospitals are now using social media to initiate public conversations and visibility for fund raising.

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Growth of freestanding EDs, of course, are a threat to the back door of all acute care hospitals. It is another whittling of the full-service hospital. Does this mean such hospitals face the same demise as did department stores of the past that are now replaced by boutique retailers?

Modern Physician explores the dispute surrounding private, freestanding emergency departments. Private companies can operate their freestanding EDs without regulatory oversight. Hospitals argue this advantage compromises quality of care, while the Joint Commission says private EDs provide efficient and quality care. At least one private ED company welcomes more regulation, and one state is considering legislation this year that would increase oversight of all freestanding EDs.

Check out the video on The Doctor’s Channel to see further discussion via video.

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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.

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One source attributes the following poem to a poet in Texas, who claims he wrote it 20 years ago. Recently it has made its way across the Internet as a story about a crabby old man who died in a hospital or nursing home and left this poem behind. That’s how some urban legends grow.

Wherever lies the truth, the poem should speak to all of us working in the healthcare industry — we impact the lives of real people and should be darned proud of reaching out and making life better for every patient.

There’s a real person inside each of us — even the crabby, feeble and sometimes irritating ones!

What do you see nurses?  What do you see?
What are you thinking  . . .  when you’re looking at me?
A crabby old man . . . not very wise,
Uncertain of habit . . . with faraway eyes?

Who dribbles his food . . . and makes no reply
When you say in a loud voice . . .  ‘I do wish you’d try!
Who seems not to notice . . .  the things that you do
And forever is losing . . . A sock or shoe?

Who, resisting or not   . . .  lets you do as you will
With bathing and feeding . . . The long day to fill?
Is that what you’re thinking? . . .   Is that what you see?
Then open your eyes, nurse . . . you’re not looking at me

I’ll tell you who I am . . .  As I sit here so still
As I do at your bidding  . . . as I eat at your will
I’m a small child of Ten . . . with a father and mother
Brothers and sisters . . .  who love one another

A young boy of Sixteen . . . with wings on his feet
Dreaming that soon now . . .  a lover he’ll meet
A groom soon at Twenty . . . my heart gives a leap
Remembering, the vows . . . that I promised to keep

At Twenty-Five, now . . .  I have young of my own
Who need me to guide . . . .And a secure happy home
A man of Thirty . . . My young now grown fast
Bound to each other . . . With ties that should last

At Forty, my young sons . . . have grown and are gone
But my woman’s beside me . . . to see I don’t mourn
At Fifty, once more . .  . Babies play ’round my knee
Again, we know children . . . My loved one and me .

Dark days are upon me . . . My wife is now dead
I look at the future . . .  I shudder with dread
For my young are all rearing . . . young of their own
And I think of the years . . . And the love that I’ve known

I’m now an old man . . . . . . . . . and nature is cruel
Tis jest to make old age . . . .. . . .look like a fool
The body, it crumbles . . . grace and vigor, depart
There is now a stone . . . where I once had a heart

But inside this old carcass . . . A young guy still dwells
And now and again . . . my battered heart swells
I remember the joys . .  . I remember the pain
And I’m loving and living . . . life over again

I think of the years . all too few . . . gone too fast
And accept the stark fact . . . that nothing can last
So open your eyes, people . . . open and see
Not a crabby old man . . .   Look closer . . . see ME!

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Mark Levy

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