Bracing for an Uncertain Future

Richard Clarke, President of the Healthcare Financial Management Association, wrote a great editorial on bracing for an uncertain future in Modern Healthcare, January 16, 2012, page 23.  Briefly, he predicts that because of the political stalemate in Washington, the majority of the entitlement cuts will be borne by healthcare providers.  I would like to focus on his prescription for action:

One thing is clear: Providers need to start planning for the value-based system that is evolving from the volume-based system of the past. You can start by addressing five key implications of a lower-payment, lower-volume environment:

• Move from managing operating costs to redesigning your organization’s overall cost structure
• Consider your market position to assess whether horizontal integration can achieve economies of scale and vertical integration can provide more seamless care transitions
• Recognize that all providers will be held responsible for cost and quality outcomes and create a culture that supports re-engineering care delivery
• Prepare for a payment system that links a growing portion of revenue to quality, despite the challenges of measuring it
• Be ready to provide increased transparency of cost and quality data; as patients pay a greater share of the cost of healthcare, expect them to use data and act like more traditional consumers

As I wrote last May, transitions are difficult to manage, but others have blazed a trail for us to follow.  Deciding where to start is often, in retrospect, less important than beginning with an issue about which clinical champions feel strongly and allowing the process of act, learn, and adapt to manifest.  One area that can be a win for physicians, nurses, patients, and hospital leaders is improving patient handoffs and decreasing preventable readmissions.

In  “Embracing Complexity,” in Better Communication For Better Care: Mastering Physician-Administrator Collaboration, I wrote that face-to-face conversations are the only sustainable way that people can deal with complex situations  in which predictability is diminished, experience does not guarantee success, and relationships are key. 

Sensemaking is part of the Baldrige journey.  It describes the critical role leaders play in interpreting and explaining disruptive marketplace changes and framing what is required for successful healthcare delivery.  It gives us a way to understand and frame healthcare complexity, view our organizations as part of a holistic system of care,  and provide potential and hope for sustainable improvement.

What do you think?

• In bracing for an uncertain future, can we view change as an opportunity to improve rather than as a threat
• Can we overcome past perceived insults to build a safe environment for reflection and learning
• How have you benefited from the cycle of acting, learning, and adapting

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Redefining Physician Engagement

US Healthcare Issues in 2011

Introduction

During a recent ACHE faculty conference call, we brainstormed about US healthcare issues in 2011 that are likely to have an impact in 2012, including:

1) Revenue-Expense considerations:

• The growth of medical tourism and support from payers for its continuation and expansion
• Increasing community pressure to take away hospitals’ tax-exempt status
• Implications of the green movement on renovation and new facility construction, increasing initial expense but offering the possibility of decreased maintenance costs in the future

2) Computers and the Internet:

• Approaching deadlines for meaningful use compliance
• The role of health information exchanges in sharing data
• The impact of the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey on patients’ perceptions and market behavior
• The ICD-9 to ICD-10 conversion deadline of October 1, 2013
• Robotics
• Virtual physician extenders, such as e-ICUs
• Social media and the need to monitor online communication in real time
• The challenges of maintaining patient privacy and sizeable fines for lack of compliance

3) Innovation and Complexity:

• Personalized medicine- diagnostic and therapeutic implications
• Decreased spare capacity, resulting in shortages when manufacturing capacity becomes constrained, for example, drug shortages
• The blurring of clinical and administrative functions, requiring ongoing education for providers to recognize the system implications of their daily clinical routines as we become more clinically integrated
• The political polarity affecting healthcare delivery reform

Conclusion Regarding US Healthcare Issues in 2011

 Regardless of the decision of the Supreme Court regarding the individual mandate, healthcare professionals will experience increasing pressure to provide more interdependent, coordinated, and cost-effective care for two reasons: our current level of spending is unsustainable, and it is the right thing to do for patients and their families, something that we wish for our loved ones who need care.

• What do you think
• Which issues do you think will be our greatest concerns in 2012
• What issues have I left out that merit consideration

As always, I welcome your input to improve healthcare collaboration where you work.

Best wishes for a happy and productive new year, and please contact me any time that I can be of continuing service to you as you cope with multiple priorities at the same time. 

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Unconscious Competence: Viviendo la vida locums

I apologize for the delay in posting.  Although I looked forward to taking a holiday vacation, I have come to the aid of a surgical colleague at a critical access hospital in New England who had no backup. I enjoy being of service and being thought of as a solution rather than the problem.

Last weekend, I was asked to consult on a patient who fell and had a 10% pneumothorax (a small air leak in the lung into the chest cavity).  Usually, the air appears on the lateral (outside) surface of the lung, but this time it was medial, a finding that I had never seen before.  I shared my lack of certainty with the patient and encouraged her to be transferred to the tertiary hospital where they had interventional radiologists on call who could guide her treatment.

I learned later that the medial air collection was due to the lateral lung being stuck to the chest from a previous injury or inflammatory process and that a chest tube placed via the (traditional) lateral approach would likely injure the adherent lung and not evacuate the pneumothorax. 

My grandmother called these episodes her “once-in-a-whilers.”  May we all be so fortunate to have as many “once-in-a-whilers”  as she did during her 95 years.  A talented,  intuitive general surgeon commented when I did something right, “Ken, the Good Lord, she was surely watching over you.”  A cardiac surgeon quipped, “It just goes to show that even the blindest sow finds and acorn now and again.”

During residency, I learned about the journey through the four stages of competence:

• Unconscious incompetence: people make mistakes because they are unaware that they are missing information (e.g. the July 1 house officer transition)
• Conscious incompetence: usually following unconscious incompetence, they feel upset and embarrassed and question their knowledge
• Conscious competence: over time, they feel more comfortable about their skills, knowledge, and judgment
• Unconscious competence: they trust their instincts and allow those instincts to influence their decision-making, especially when something “just doesn’t feel right.”

Donald Schoen described unconscious competence as reflection in action, a series of course corrections that experienced practitioners make, often without realizing that they are making them until they are asked to think aloud by a student or resident who is shadowing them.  Whatever the explanation, I feel fortunate to work in a profession where I am allowed, and occasionally encouraged, to trust my gut.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

International Healthcare Collaboration: Stockholm Memories

Greetings from Stockholm, where I returned to visit people with whom I collaborated during residency and to promote international healthcare collaboration.  As I wrote in a previous post, despite working in a country that has a socialized medical system, practitioners in Sweden enjoy local autonomy in clinical decision-making. The government assigns a budget for healthcare and expects practitioners to live within it, but does not tell physicians and nurses how to practice medicine on a day-to-day basis.

I was pleased to learn that they too deal with issues of physician-physician and hospital-physician collaboration. They use physician champions, like the ones featured in the photos above, to influence fellow practitioners. Although I do not believe that the Swedish healthcare system can be transplanted to the US, I am proud to include them in my group of cherished co-mentors, who influenced my outlook, as I have influenced theirs.  We face similar pressures to provide more coordinated, cost-effective care and support international healthcare collaboration.

In this land of the midnight sun during the summer, I would like to believe that my visit brought some cheer during a time of national darkness.

Happy holidays to all my readers, and thanks for your readership and your insights the past year.  Please stay tuned for more information on how you can be part of the Association for Healthcare Collaboration in 2012.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Loving Austin

Recently, I served as a faculty co-presenter at an ACHE fall cluster in Austin, TX.  The mnemonic that resonated with the healthcare executives who participated in Practical Strategies for Engaging Physicians was CRITTERS, to enhance clinical integration:

• Communication: inviting physicians to provide input before any major decisions are made
• Representation: making sure that clinical champions, who have earned their colleagues’ trust, are at the table
• Incentives to improve quality and safety, as well as the bottom line
• Transparency: helping physicians understand how decisions are made and according to what timelines
• Trust: stemming from transparency, so that there are no decision-making surprises
• Engagement: meaning two sides coming together in a spirit of inquiry rather than enmity
• Reimbursement: involving ways for both sides to increase revenues by enlarging the pie
• Speed: understanding that when physicians feel that their time is not respected, they feel personally disrespected

Austin was a conducive setting to reflect, as seen in the photos of walking paths adjacent to the hotel where the seminar took place.  The lake was created by the Longhorn Dam of the Colorado River in 1960 and named after Ladybird Johnson when she died in 2007.

With its eclectic music, restaurants, and parks, Austin is a city to which I look forward to returning.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure: I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

What I learned at the Community Hospital 100 Conference

I had a wonderful time delivering the closing keynote, “Moving from Me to We: A Practicing Surgeon’s Journey to Collaboration,” at the Community Hospital 100 Conference, October 23-25, 2011.  For those who would like to learn more about the highlights of this conference by watching a four-minute video, please click here.

Leading the Health of Our Communities

The first session discussed the transition from fee-for-service to more value-based metrics. Lori Knitt, Chief Quality Officer at Aurora Sheboygan Medical Center, described her journey of giving physicians specific provider data, so that they could see how they were doing compared to peers in the same specialty.
Clinical champions encouraged laggards by constructing a mock jail cell in the physicians’ lounge and putting their photos behind bars with the caption “Most Wanted.” She feels that physician-driven innovations like these help her hospital become more nimble in dealing with disruptive innovation.

Joshua Potter of Steward Healthcare System relies on health information technology to monitor outmigration of consultations. The primary care physicians generally stay within network. Steward has facilitated conversations among specialists to foster increased accountability.

Mina Ubbing, CEO of Fairfield Medical Center, described baby steps a community hospital can take to move toward providing more collaborative (accountable) care, After her orthopedic surgeons asked for a heightened management role, she developed a co-management agreement that allowed them to improve processes and quality outcomes and to share risk with payers. She facilitated the process by serving beer on tap in her basement. The success of this process led to primary care physicians, nephrologists, cardiologists, cardiac and vascular surgeons, and interventional radiologists forming an institute to provide more collaborative care.

The Future of Independent Hospitals

John Dawes, CEO of Bothwell Regional Health Center, partners with the Federal Qualified Health Center in his area to hold health summits, improve communication, break down myths, and assist with recruiting physicians to the area.

Jill Fuller, CEO of Prarie Lakes Healthcare System, looks for disgruntled doctors who do not want to be part of large healthcare systems any longer because of loss of autonomy. She entices her physicians to participate in Monday evening conferences over dinner by offering timely discussions on focused topics of mutual interest like, “How are we going to get paid in the future?”

 Dealing with Disruptive Innovation

Clayton Christensen, Professor at Harvard Business School, said that community hospitals represented three different business models within one structure:

• Solution shop: where patients present with diagnostic problems that require treatment (eg. Emergency Department)
• Start and finish business: eg. where patients come in for elective surgery
• Facilitated networks: where people share information (eg. chronic disease registries like inflammatory bowel disease or breast cancer survivors’ groups)

Solution shops function on a fee-for-service basis, start and finish businesses can thrive on a pre-arranged fee structure (eg Diagnostic Related Groups), and facilitated networks are financed via a membership fee or monthly or yearly dues. For every doubling of pathways that hospitals provide to be a full-service enterprise, they can expect overhead to increase by 30% due to the attendant increase in complexity.

Conclusion

One of the most important investments that we can make is in our career development. I hope that those of you who work in community hospitals will consider participating in the next Community Hospital 100 Conference, October 14-16, 2012.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Collaborative Roots

Last week, I had the pleasure of returning to my professional roots and speaking with a group of physicians in private practice about ways that they could build a culture of collaboration from the ground up.

After my talk, two physicians asked important questions:

Do we really need to pay attention to Accountable Care Organizations?  Will they control the way that we practice?

I was not sure how to answer that question, since I knew that their health system was in the process of forming an ACO with physician representation. I believe that I answered:

I am not smart enough to know how the process will play out at the federal level, but as I travel around the country, I hear repeatedly that we will all need to work more interdependently to provide more coordinated, cost-effective care, not only for economic reasons, but also because it’s the right thing to do.”

The second question came from an internist who asked:

Dr. Cohn, how do we collaborate without losing control?

My mind was racing over the number of ways that I should respond to her question. First, I described the double meaning of collaboration, in which the Latin word “collaborare” means to work together, and that treason statutes make it a crime to collaborate with the enemy. Then, I asked her what she meant by control.  She said, “The ability to make decisions affecting my patients’ care.”

I told her that it was important to have conversations with her administrators about what each wanted to control.  Most physicians seek control of their time, efficiency, and effectiveness, whereas administrators with whom I have worked think about physical assets like property, plant, and equipment when they hear the word “control.”

Going back to my roots, I told her  a story about a friend who said that he felt stupid that it had taken him over 50 years to learn that by giving up (a little) control, he gained influence. Many times, I experience frustration when faced with situations beyond my control.  On my better days, I think about what is making me upset and what I can do to influence the situation. To remind myself, I frequently close talks with John Miller’s prayer from his book QBQ: The question behind the question:

God grant me the serenity to accept the people I cannot change, the courage to change the one I can, and the wisdom to know… it’s me!.

As always, I welcome your input to improve healthcare collaboration where you work.Kenneth H. Cohn© 2011, all rights reserved

Disclosure: I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

The Zen of Healthcare Collaboration

The Zen-master Hakuin Ekaku (1686-1769) taught that three things are essential:

great faith
great doubt
great resolve

One hand

Hakuin asked students, “what is the sound of one hand?” The master wrote, “When you hear for yourself the voice of One Hand, whatever you are doing, whether enjoying a bowl of rice or sipping a cup of tea, all of it you do in the samadhi of living with one bestowed with the buddha-mind.” Samadhi refers to the highest stage in meditation, in which a person experiences oneness with the universe.

The path to collaboration

As a yet-to-be-enlightened male surgeon, the sound of one hand makes me recall the mentoring of the late Dr. Frank Wheelock, who told residents, “If you don’t use both hands, the Good Lord will certainly take one of them away.”  I think of how much louder and heartier applause is when both hands clap together.

In authentic healthcare collaboration, two or more parties meet in the spirit of inquiry rather than advocacy and come to consensus on solutions that benefit patients far more than either party’s solution would do on its own.  Collaboration may take longer, but provides more lasting and sustainable solutions than command-and-control situations, as evident, for example, from:

• Chapter One, where Dr. Fried and colleagues slashed the sepsis mortality rate to 15%, saving over 200 lives, without adding or changing a single drug
• Chapter Six, where Drs. Wilson, Joshi, Schneller, and colleagues have saved millions of dollars in supply costs by collaborating with practicing physicians
• Chapter Twelve, where Dr. Mandel, OR Director, and Susan Phillips, VP of Surgical Services, turned around a moribund operating room culture to boost case volume, revenue, and clinical outcomes

These chapters receive more detailed coverage in the new ACHE self-study guide, Coordinated Care: Improving Clinical and Financial Performance, from which readers can derive six hours of category I credit until December 31, 2011.

• Collaboration is an iterative journey in which a more pleasant, effective practice environment facilitates: 1)improved clinical and financial outcomes,
  2) healthcare professional recruitment and retention,
  and 3) the development of outstanding programs that foster improved clinical and financial outcomes.

As always, I welcome your input to improve healthcare collaboration and get it done.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content.

 

Collaborative Core Values

I love working at places that live their values.  I spoke at the annual physician retreat at St. Vincent Hospital, Indiana, where as a member of Ascension Health, their core values call them to:

• Service of the poor: generosity of spirit for persons most in need
• Integrity: inspiring trust through personal leadership
• Wisdom: integrating excellence and stewardship
• Dedication: affirming the hope and joy of our ministry
• Reverence: respect and compassion for the dignity and diversity of life
• Creativity: courageous innovation

I spoke on physician engagement, giving examples of physician champions who improved care for their communities by improving clinical outcomes and slashing expenses.  I was impressed that physicians and administrators working together in their health system had dropped supply costs from 19% to 14% of  net patient service revenue.

Kerry Johson followed, talking about highly reliable healthcare.  He is the founding partner of Healthcare Performance Improvement, which was the company that Sentara Healthcare utilized to build a sustainable culture of safety.  He pointed out that the medical staff is critical to sustain safety core values and make error prevention the norm.  Errors occur most commonly in the process of patient handoffs.

Then, Ann Murtlow discussed the parallels of her turnaround of Indiana Power and Light (IPL) with healthcare challenges.  Both cultures need to reinvent themselves to survive in a climate of disruptive change.  To rebuild trust, she:

• apologized for past mistakes
• listened to people’s complaints and encouraged them to improve processes
• built a credible team with long-term relationships to the community, media, and city and state leaders
• communicate often via face-to-face, electronic, video, and print media
• followed through and kept promises
• was transparent, fair, truthful, and compassionate

She encouraged everyone in the audience to adopt as core values to:

• be courageous
• think broadly
• enable others
• deliver results

The day went by quickly because the audience and the speakers were engaged and fed off one another’s energy.  I felt proud to be part of an organization whose outlook and slope are clearly positive.

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

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