Happy Independence Day and sincere gratitude to all who are serving in the armed forces to keep us independent, as well as to their loved ones.  My son, who is studying to become a naval aviator, is on a summer cruise off Cyprus, and it gives our family a different perspective on the 4th of July beyond fireworks and barbecues.

In 10 Powerful Ideas for Improving Patient Care, (ReinertsenJ, Schellekens W.  2005, 35-42), the authors discussed the paradox of physician autonomy, in which individual variability of physician orders becomes a breeding ground for complexity, error, and waste, which leads to suboptimal patient outcomes and subsequent increased healthcare oversight of medical decision-making by payers and government regulators.

Reinertsen and Schellkens noted that physicians talk about evidence in groups (eg. national meetings, grand rounds, and morbidity and mortality conferences), but implement it as individuals.  They cited experience from the New England Deaconess Hospital (NEDH) in which cardiac surgeons went over a year without patients experiencing postoperative mediastinitis once they all agreed that any PACU or ICU patient with a blood sugar over 110 mg/dl would be placed on an insulin drip to maintain blood sugar between 80-110 mg/dl.  Previously, the annual incidence of mediastinitis at NEDH had been 1.2%.

In a subsequent example on multidisciplinary rounding in the ICU and the adoption of patient-care bundles, they detailed the importance of physician champions and peer-group pressure, in which adopting physicians confronted resistant physicians with, “Are you so good that you are exempt from all the evidence in the literature?” and “So are you saying that you value your autonomy more highly than the patient’s outcome?”

Reinertsen and Schellkens noted that standardizing work gives physicians more time to:

• see more patients
• spend more time with individual patients
• spend more time with thier families

Clearly, if standardization were easy, we would all have done it already.  Standardization requires:

• courage to face resistant colleagues
• knowledge of the evidence and its limitations
• confidence in one’s own performance data
• willingness to trust processes over which one has influence but lacks control

In a related post, Overly High Healthcare Administrative Costs, Dr. Kenneth Fisher makes a case for Appropriate Care Committees to leverage the local impact of physician champions.  Acknowledging the controversy, he wrote:

“There will be oversight….The question is do we want oversight from bureaucrats… who are hundreds of miles away making crucial healthcare decisions… it’s a patient’s … worst nightmare.”

Moving from independence to greater interdependence is what gives many of us hope.  We have a noble tradition of co-mentoring  fellow physicians, acknowledging that we all have knowledge, insight, and experience that add value.  Effective collaboration allows healthcare professionals with diverse backgrounds to develop new approaches to improve care based on a shared vision rather than to play the role of a victim.  As such, collaboration can help healthcare professionals to reconnect with the values that attracted them to healthcare in the first place.

What do you think:

• Do you agree with Reinertsen and Schellkens that the medical orders that flow through nursing and hospital pharmacy resemble the languages spoken at the Tower of Babel
• How have physician champions improved care where you work
• Most healthcare professionals see little value in creating another committee to solve current problems; what do you think about the questions Dr. Fisher raises about professional oversight

As always, I welcome your input.

Kenneth H. Cohn

I was moved watching Tim Russert’s memorial service yesterday.  We both grew up in Buffalo and rooted for the Bills, regardless of outcome.  We never met, but we share common values, including:

• the importance of family
• a sense of spiritual connectedness
• optimism
• a focus on communication and relationships as a central source of meaning and joy
• the pleasure of story-telling
• preservation of our child-like sense of curiosity and wonder
• intense desire to hone our craft skills

Whenever I perform surgical coverage assignments, I start the day as I leave my car, saying to myself, “Only good days in healthcare.”

What do you think?

• Does attitude make a difference in the current dynamically changing healthcare environment
• What do you do that you find helpful
• Can attitude improve our ability to collaborate and improve care for our communities

As always, I welcome your input.

Kenneth H. Cohn
 

“We’re not stupid- we just need to be trained,” a general surgery section chief confided to me a few years ago.  He had been promoted to section chief based on his clinical competence and then realized that he needed to communicate, negotiate, and resolve conflicts in ways that he had never learned in medical school or residency.

I began using the term “co-mentoring” to describe this process because I believe that each person brings valuable knowledge, experience, and wisdom to the table.  Although I was helping physicians with process skills to improve communication, negotiation, and conflict resolution, they taught me things that helped me refine my approach.  One of my physician colleagues has pointed out how important the co-mentoring prinicple is with physicians who are sensitive to hierarchy. 

Some of my most gratifying moments have been in co-mentoring relationships with physicians.  The section chief proved that he was not stupid by crafting a bold and far-reaching vision of where the section of general surgery needed to go.  The colleague who made the comment about sensitivity to hierarchy evolved from a “rock-throwing member of the medical staff to Vice President of Medical Affairs … striving to promote co-mentoring relationships.”

When I helped set up a physician co-mentoring program recently, I asked physicians, “What makes a great co-mentor?” They replied:

• Personal connection
• Passion
• Insight
• Availability
• Active listening
• Mutual respect
• Clear vision and expectations

We agreed that to set up a safe environment for learning, they needed to:

• Learn about each other’s background, training, families, and extracurricular interests during their first encounter
• Reassure each other that there are no dumb questions
• Share painful on-the-job learning moments
• Be proactive, contacting each other frequently in the beginning to ask how they could be of assistance to each other

I have found that through co-mentoring, we can create a new generation of physician leaders who can increase transparency, improve physician-physician and physician-administration collaboration, and minimize physician-hospital battles.

What do you think?

• Do you agree that physicians enjoy learning from fellow physicians
• Have you seen dividends for leadership emerge from physician co-mentoring
• Is co-mentoring a process worth the investment

I welcome your input.

Kenneth H. Cohn

 Anybody who has worked with physicians has heard the comment, “Organizing doctors is like herding cats; you just get scratched.”
When I finished business school a decade ago, a physician asked me, “What is the difference between business school and medical school?”
I replied, “There was a lot more memorization in medical school than business school. Also, 30-50% of my grade in every course that I took in business school came from team projects.”
I have asked over 2,000 physicians how much of their grade in medical school came from team projects and have heard, “Zero,” every time. However, rather than bemoan how difficult it is to get some physicians to work in teams, we can use healthy competition to advantage:

• A cardiologist kept track of start times in the catheterization lab and used healthy competition to motivate other cardiologists to show up on time. He noted, “Cardiologists are a lot like alpha dogs who, when a bone is tossed their way, are eager to fetch.”
• Another cardiologist asked for input from his colleagues. He showed simple bar graphs of procedure time for balloon dilatation and stenting by anatomic location and number of stents for each of the cardiologists by number. Only he knew which name corresponded to each number. The cardiologists agreed that they could see widespread variation.
  He continued by showing them data on who used which supplies, again showing widespread variation. He ended by displaying data on simple outcomes like myocardial infarction and death according to American Heart Association category and elective vs. emergent status, and they agreed that their practice exhibited widespread variation. He encouraged the group to share their thoughts in subsequent group meetings on how they might limit variation, improve outcomes, and cut supply costs, telling them that they would re-examine the data in another four months, hoping to see progress. If they could not come to consensus on how to limit variation and improve outcomes and profitability in six months, he would put names above the individual physicians’ numbers and post the data on a bulletin board in the catheterization laboratory in full view of the entire staff.
  The medical director’s clinical credibility, integrity, and sincerity were unchallengeable. Within four months, procedure times and outcomes for the entire six-person group were within one standard deviation, and they had decreased their vendors to two and cut costs substantially, all while improving outcomes. As one of the cardiologists explained, “None of us wanted to be an outlier, except on the positive side.”
  (Case reprinted with permission from Cohn KH, Lambert M. “Engaging Physicians in Hospital Operations,” in Cohn KH. Better Communication for Better Care: Mastering Physician-Administrator Collaboration, Chicago: Health Administration Press, 2005, 47-48. http://www.ache.org/pubs/redesign/productcatalog.cfm?pc=WWW1-2038)

What do you think:

• Is engaging physicians like herding cats?
• Do physicians respond to healthy competition?
• What stories can you share about physicians working collaboratively to improve care?

I welcome your thoughts

Kenneth H. Cohn
 

I admit feeling clueless as I travel on average 100,000 miles per year, listening to physicians tell stories about the ongoing tensions of providing care in a dynamic marketplace.  The word “hospitalist,” referring to physicians who specialize in inpatient care, was not coined until 1996 (Wachter and Goldman, New England Journal of Medicine, 335(7):514-17).  It may also be the most rapidly growing US medicalspecialty, with 20,000 estimated hospitalists by 2010 (Williams MV. 2004. The Future of Hospital Medicine. Am Journal of Medicine. 117(6):446-50).  As the following comments from several regions of the country indicate, rapid growth is only one of many reasons for the instability we currently face:

• A West-coast Emergency Department physician:“When hospitalists first started working here, I initially thought it would be great, and it was for the first few years. Now the problem is they’ve become so overworked and bitter. They’re always looking for us to send people home from the ED, or get another service to admit them. Other times, they’re annoyed if we don’t have the complete workup done in the ED. Isn’t that their job? The whole concept of facilitating hospital stays seems to have been lost. It just doesn’t feel like we’re on the same team any more.”
• A midwestern medical staff President: “So, I get awakened at 2:30 am because a gastroenterologist does not want to scope an alcoholic with a GI bleed until he knows that someone is willing to take the patient and manage the withdrawal issues.  What am I supposed to do? I can’t yank his privileges!  All 6 hospitalists where I work are looking for jobs”
• A West-coast hospitalist: “Other doctors and departments here still think hospitalist is equivalent to resident. It’s not. I’m not here to be on the beck and call of every other physician. I’m here to see my patients and, truth be told, perform billable services. I don’t want to see every patient in the hospital. I need to have a life, too.”
• A 6-year-old daughter of a midwestern hospitalist who had been caring for patients 11 consecutive days: “Daddy, I don’t see you any more.”

The stakes are high as the sociology of care changes.  Hospitalist care frees primary care physicians (PCPs) to focus on caring for patients in their offices.  How hospitalists relate to PCPs affects hospital volumes, revenues, and clinical outcomes (Kripalani et al. 2007. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians. JAMA 297(8):831-41).

Hospitalists’ practice environment can benefit from hospital leaders’ timely response to hospitalists’ suggestions (Cohn, Collaborate for Success! 2007. Chicago: Health Administration Press, 26), including:

• Interdisciplinary rounds
• Expedited credentialing for new hospitalist hires
• State-of-the-art information technology resources including computers, peripheral devices, simplified sign-in procedures, web-based storage of patient data to allow access from hospital, office, or home, and electronic health records that allow PCPs to see hospitalists’ notes and vice-versa
• Case-manager availability on weekends and holidays to expedite discharges and decrease length of stay
• Assurance that staff who page physicians have access to and know the results of patient data, including vital signs, problem list, medications, allergies, and laboratory values

Even limits to admissions, inpatient encounters, and discharge summaries are in discussion.  However, everything mentioned above may be necessary but insufficient as care becomes more complex and one person’s actions change the context for everyone else.  With complex issues, formulas have limited applicability, and expertise is important, but relationships are key (Cohn,”Embracing Complexity, in  Better Communication for Better Care. 2005. Chicago: Health Administration Press, 32.).  As the medical staff president above reflected, “We all need to work together and protect one another.”

What do you think:

• Do you feel the bathtub water swirling as old compacts break down?
• What have hospitalists recommended to improve the practice environment where you work?
• What can we do differently to work together and protect and sustain one another while protecting patients and their families from fragmented care?

I welcome your thoughts.

A friend and colleague who is an orthopedic surgeon surprised me with a 2-page response to my article on surgeon frustration. I wrote that physicians’ mastering process skills not taught in medical school or residency, like communication, win-win negotiation, and conflict resolution are key ways that they can improve their leadership skills, practice environment, and patient care. I was so impressed with the thoughtfulness of his reply that I asked his permission to reprint parts of his note in my blog. He wrote:

• I think that the medical community as you and I knew it is probably changing forever…. I fear the only way for hospitals to be successful and efficient is with a salaried (owned) medical staff. I don’t like this idea much- that’s not why I went into medicine… It seems that we are stuck with doing much of the work of medical care, but the profits go more toward the hospital (who of course cannot pass on profit because of Stark implications).
• Page 79 suggests that we MDs will need to learn to change as in learning consensus-building vs. traditional command-and-control mechanisms. I have difficulty seeing how MDs are going to buy-in to choosing teamwork over primary responsibility for medical care. Perhaps this MD mindset will change with the new generation … coming into the… marketplace.
• I think that as a surgeon, a leap of faith is required to buy into the new system. Unfortunately, my years of dealing with a divergent … administration makes it difficult at times for me to do so.

If he and I were sitting by a pool, where our last conversation took place after an Estes Park Institute conference, here is what I would say after I thanked him for sharing his thoughts with me:

• I do not know of any salaried physicians who are “owned” by their employers; physicians, like university professors, feel more of a sense of allegiance to their specialty and their colleagues than to their workplace, regardless of their year of birth
• We all rely on teamwork- in the office, the OR, and on the floor; teamwork does not need to compromise responsibility; in fact, it can enhance responsibility for clinical outcomes if we use clear communication and promptly acknowledge and learn from mistakes
• It is only possible to be passionate about the role of communication and collaboration in improving clinical outcomes if one has seen evidence of it working. As I have said before, the old separation of leaving clinical care to doctors and nurses and finance and operations to administrators does not work any longer, especially regarding never events like falls, catheter-acquired infections, and hospital-acquired bed sores that the Center for Medicare and Medicaid services will not pay for.

My friend and colleague views medicine as a calling; he has won the Distinguished Physician Award, as voted by physicians at his hospital. When he retires, it will take more than one physician to fill his shoes. The purpose of this blog post is to stimulate discussion, not to decide who is right or wrong. What do you think:

• Are hospital-salaried physicians hospital-owned?
• Is teamwork antithetical to primary physician responsibility for patient care?
• If personal change must accompany cultural change, what administrative pre-conceptions about physicians and what physician preconceptions of administrators must give way?

As always, I welcome your thoughts.

Kenneth H. Cohn

Last week, hospitals across the US celebrated National Nurses Week, which led me to recall with gratitude nurses who made a difference in my training and kept me from harming patients. What better place to start than internship?

I salute Nikki, a nurse on the 7PM to 7AM shift in the Emergency Department of a community hospital in Cambridge, MA, who had a wry sense of humor and a knack for being in the right place at the right time. During an unusually busy Sunday evening shift, I saw eight patients with sprained ankles in just one hour. People complimented me for my organizational skills and ability to minimize waiting time. I was proud to be up to the task.

Nikki surprised me by taking me aside and telling me, “Just because that was your eighth patient with the same condition doesn’t mean that it was her eighth sprain,” and just as quickly, turned away to do her next task. My ears burned with embarrassment. I was angry for moving patients through the system and getting called on it. Only later did I realize that she thought that I was trainable, and I took her advice as a compliment. I feel that she still hovers over my left shoulder at times when I am time-pressured.

Later, I relearned the lesson as I analyzed the results of a survey that I conducted as an attending surgeon. The principal question asked, “What should be the aims of a residency program in general surgery?” All 43 residents and attending surgeons cited technical competence as the primary aim. The 20 participating attending surgeons also cited judgment, compassionate patient care, and research as additional aims. However, all 10 participating nurses listed communication skills as the principal aim, followed by technical competence, holistic care, and knowledge-building. Each nurse asserted that the current system of residency training was inadequate for preparing residents to care for patients in a multidisciplinary, collaborative setting and welcomed ways in which they could reduce residents’ burden of care (Cohn K, Batalden P, Nelson E, Farrell T, Walsh D, Dow R, Mohr J, Barthold J, Crichlow R. “The odyssey of residency education in surgery: Experience with a total quality management approach.” Current Surgery, 1997; 54:218-224).

As I wrote subsequently, (Cohn KH, Algeo S. Stackpoole K, Bowkley CW. Overcoming abrasive interfaces: Implications for nurses in leadership positions Nurse Leader. 2005; 3(4):53-56), lifetime continuing education may be necessary to meet patients’ and caregivers’ needs in a way that promotes safe, effective, timely, efficient, equitable care and that provides a fulfilling practice environment.

What do you think:

• Are we managing the process of healthcare change effectively
• Are we establishing our facilities as safe environments for learning as well as safe environments for receiving and providing care
• What synergy results when physicians and nurses truly work collaboratively

As always, I welcome your input.

Kenneth H. Cohn

Last week, while I was teaching at the Estes Park Institute, I had the pleasure to listen to my friend and mentor, Lee Kaiser.  Lee is a psychologist, futurist, and provocateur with a cherubic face, booming voice, and razor-sharp intellect.  I make every effort to hear him speak because I find his insights centering and stimulating.  He helps me to put life’s disruptions into perspective.  I strongly encourage you to visit his blog, Gnostic Notes. 

Gnosticism refers to knowledge, recognition, and wisdom.  In Peeling the Onion, Lee refers to gnostics as fellow mountain climbers who come from different backgrounds but are climbing the mountain together and providing assistance to fellow travelers as needed, i.e. collaborating.

In I Am Beside Myself, he postulates that most people and most organizations see themselves at the center of the universe, which leads to egocentric, self-interested approaches that facilitate exploiting others for competitive advantage, hardly a sustainable approach to differentiation and the service of others.

Lee maintains that there is no economic, social, or political solution to the current healthcare crisis.  Spirituality, based on abundance, collaboration, and sharing provides the only solution because it makes problems disappear.

I don’t expect all of you to follow Lee like the Pied Piper.  In Junk in Your Life, he maintains that we develop strength by pushing against something.  Resistance builds strength and resilience. 

In It Will Hit the Fan, he notes, “Folks you know and associate with on a regular basis may be unable to reconcile your choices with their inaccurate image of who you are. At the very least, you will be asked to justify yourself. At the worst you may be threatened and intimidated.  You should not act in a way that encourages confrontation. However, you should not back away from it either. You do not have to apologize for who you are … Give a simple answer to your accusers and get on with your life.”

“The old control game of threat, intimidation, hurt and silence will become familiar to you as you go about your world work. You have a unique destiny to pursue. Following this destiny often cuts across the vested interests of people you know, like, or love. So, you must either fold your cards or continue to play out your hand in the game of life. If you seek to maintain harmony at any cost – the cost will be your failure to progress on the pathway of Light. So, expect that sooner or later it will hit the fan and you will have to make a choice to retreat or go forward.”

What do you think:

• Do you find Lee’s writing stimulating and unsettling
• Who is at the center of your universe
• Have you found yourself confronted
• How do we move forward to improve care for our communities

As always, I welcome your thoughts.

 Kenneth H. Cohn
 

I wanted to alert you to a provocative, well-written post by Tina Wardrop, “Sidestepping the Medical Staff Bidding War.”

The shortages of physicians, demands of a burgeoning elderly population, and economic and family-related physician time- squeeze will create a bidding war unless we create organizations in which physicians want to work by:

• offering them a chance to participate proactively in decision-making
• tear down the barriers to physicians in leadership positions
• help physicians have a life while they practice medicine by reducing the burden of practice management
• find novel solutions to deal with emergency call, such as hiring specialists or considering deferred compensation alternatives
• share information in an electronic health record that is user-friendly and links the inpatient and outpatient continuum seamlessly
• revitalizing phyisician practice networks
• improving quality and safety

In a previous post, “Collaborative Error: The Day I Nearly Quit“, I wrote that the old paradigm of physicians and nurses taking care of clinical dimensions of care and administrators keeping finance and operations to themselves does not work any more.  The decision not to reimburse for never events, such as wrong-site surgery, falls, hospital-acquired infections, and bed-sores acquired during a hospital stay requires a collaborative effort among clinical, administrative, and board team members.  So does improving patient flow, as discussed in “Collaborative Flow.”

Although much has been made about differences between baby-boomer and generation-X physicians, they both need to make their time count.  Healthcare settings can help to unite physicians and improve collaboration by systematically examining processes and policies to make sure that every step and requirement adds value to the patient’s experience. 

Merely flowing each step of a process onto a post-it note, putting the notes on a wall, and stepping back to see how a process is supposed to work, how it really occurs, and how it could work to improve the care experience can be eye-opening and decrease the need for additional employees to deal with work-arounds of inefficient processes.

What do you think?

• Are we headed toward a bidding war
• If so, what steps can we take to deal with it proactively
• Has anyone ever asked a physician, “What can I take off your plate,” rather than adding on

I welcome your input.

Kenneth H. Cohn

Most physicians that I know would agree wholeheartedly with Nick Jacobs’ post, “I hate business plans.”  A surgeon protested, “Can you believe that I went into the COO’s office all excited about a new device that would speed recovery and shorten length of stay, and do you know what he told me? ‘Fine, go write a business plan.’”

“I’m not that stupid,” he continued. “I knew that the main reason he said that was to get me to leave his office and never bring another idea to his attention again!”  As he told his buddies in the physicians’ lounge, I wondered how many other physicians learned the same lesson.

My anger over the way that the situation was handled led me to write an article (Cohn KH, Schwartz RW. Business plan writing for physicians. Am J Surg 2002;184(2):114-120 cohnbusinessplan3_31_02.pdfcohnbusinessplan3_31_02.pdf)  to demistify the process for physicians who had not attended business school and to encourage them not to be put off.  Just because they do not have the training to do the cash-flow analysis does not mean that they cannot explore the:

• unmet need that their proposed innovation will fill
• estimated patients per year their service will draw
• alternatives to their proposal and the reason that their service offers an advantage
• definition and measurement of success
• resources (labor, funds, equipment, and supplies) they will need to start
• obstacles they might encounter and how they can overcome them

 As I wrote the article, I felt that physician involvement in writing a business plan was a great way to focus, clarify, and justify a request for scarce resources.  It also offered a way to plan proactively for an uncertain future rather than to react to competitive market dynamics.  If done well, it might even improve transparency, trust, and collaboration between physicians and hospital leaders.

I tested my hypothesis with a urologist at a community hospital in Connecticut.  For two months, we met every other week for dinner and talked about his idea to accelerate diagnosis and treatment for patients with prostate cancer.  We drafted a business plan that we shared with senior leaders at his hospital.  His business plan became the blueprint for a multidisciplinary cancer diagnosis and treatment center that is currently up and running.  The case is included in the article.

What do you think:

• Can we empower physicians to write business plans
• Does joint physician-administration thinking about the concept, market, competition, strategy, finances, operations, and implementation improve our chances of success
• Would you want to work in an environment where hospital leaders helped physicians write business plans

 As always, I welcome your input.

Kenneth H. Cohn