I liked his insight, “Having more work than you can get done is actually welcome news…. you were hired to help. Not to get everything done, but to keep everything moving.” (p.31)

Imagine what it would do for healthcare collaboration for organizations to free up as much as 20% of people’s time by asking systematically, as though doing spring cleaning (33):

• What should we stop doing; what no longer matters
• What should we start doing
• What should we continue doing

Some times, we are so caught up in our task lists that we do not ask (35):

• Who needs this done
• Why do they need it
• What difference will it make

How we frame a problem is the problem (50).  Before we set an intention to do something, we must put it into context.  Framing “problems” as opportunities to learn and improve helps us uncover options that are not apparent in flight-or-fight mode.  As an example, he pointed out that Lazy Acres transformed the expense of ripening produce into its most profitable source of value to customers by making soup out of vegetables. 

In situations that require handoffs, we can see ourselves as victims or we can ask people on either end (78):

• What can I do to help you produce what you need
• Is there anything that I am doing that makes it difficult for you to execute and meet deadlines
• What do you suggest that we do that would help us work more creatively and productively; workarounds start when we make the first move (88)

As Michael Winston noted, “People don’t like changes made to them but don’t mind changes made by them. Just be sure to give them criteria with meaning and oversight.”

He closed by reminding us that above all we are in the education business and that our job is to help people learn (213).  “Be sure to ask yourself, ‘What can you do that requires no one’s permission other than your own?” (216)

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.

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Workarounds: Getting the Right Things Done is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

The central tenet of this book is that catastrophes, such as global economic meltdowns and NASA tragedies, are caused by normal thinking, which stems from overconfidence in our own thought processes (p.xvii).  The word quicksilver is a synonym for mercury and a metaphor for suddenness and unpredictability.  Our minds may be changing the world, but we are not changing our minds to match the world that we are creating (p.11).

I have written that conflict is inevitable in times of rapid change, but the authors take insight to a higher level when they point out that leaders stop leading when they make others responsible for breakdowns (p.67).  Dealing with a medical staff in crisis showed the extent to which community service is jeopardized by feelings of disrespect. 

To declare that something should not occur is life’s ultimate whine, aka “no fair” (p.69).  Affixing blame is impotence not leadership (p.68).  On the other hand, substituting could for should causes one to ask, “What do I want my colleagues to do, and how can I support them?” (p. 71).  Curiosity triggers creativity (p.72).  Paraphrasing Churchill, the authors wrote that the could road traverses the sunlit uplands of the eternal now (p.74).

In Three Painful Collaborative Learning Experiences,  I summarized another important Quicksilver insight.  We experience four fears (p.130):

• Appearing stupid, foolish, or idiotic
• Being unmasked as a pretender or a fraud
• Feeling like an outcast
• Looking weak, powerless, or ineffective

The authors reminded us that a leader’s challenge is to set aside his (her) story long enough to hear other people’s stories (p.147). Generous, curious inquiry enables leaders to have breakthrough conversations, where ideas rather than people are on trial (p.171). What we resist, persists (p.168).

I know that I am not doing justice summarizing this outstanding book.  Please read it for yourself and comment on what its message means to you.  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.

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Leadership: A Review of Quicksilver is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

Dr. Cohn discussing physician recruitment and retention at HCA Rural Retreat

This week was formative, as I traveled to the lovely northern foothills of San Antonio, currently the 7th largest city in the US, to speak at the HCA Rural Retreat, sponsored by Methodist Health System .  I was impressed by the sense of possibility among the participants and the way that they welcomed change as an opportunity to improve care for their communities.  At the reception preceding my talk on using physician recruitment to move from me to we, I heard about a hospital in Seguin that has used a physician advisory panel to advise on recruitment for the past decade to improve patient access. 

Dr. Cohn discussing physician recruitment and retention at HCA Rural Retreat

This data-driven process, led by physicians who have earned the respect of their colleagues, builds consensus on both the need to hire additional physicians and, once the process is underway, on whether a specific physician represents a good cultural fit for the area.  As a result, they have had 100% retention of new hires for the last five years.  

In Collaborative Culture, I described the paradox of culture.  As I mentioned in my book, Collaborate for Success! (p. xiv), culture encompasses the beliefs, habits, attitudes, and assumptions that an organization uses to cope with problems.  Executives make time to shape organizational culture because a strong culture allows leaders to delegate tasks and become more productive.

However, most physicians enjoy bottom-up processes more than top-down edicts.  They have told me that they much prefer being inspired to being supervised.  The only way that I know to develop a common culture is to allow physicians to play a role in shaping it. 

 In Collaborative Champions, I wrote that physicians can become hospital advocates if they feel that, as physicians, people are listening to them and that they are making their time count.   In that way, they can leave a lasting legacy at a time in their lives when the marginal value of seeing one more patient or doing one more procedure start to diminish. 

 The most fruitful ways to cultivate physician champions include:

• Engaging them in conversations likely to lead to results, for example:
  • What is going well for you?
  • What things are we doing that waste your time?
  • How can we improve care for our community
• Drawing up an action plan that shows meaningful outcomes at 2-week intervals
• Reviewing progress with physicians at least monthly
• Closing the loop
• Celebrating success at least quarterly

What do you think about using a physician panel of generalists and specialists to facilitate recruitment and retention?As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2010, all rights reserved

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Recruitment is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

Steel girders supporting upper floors

My grandfather, who sold commercial real estate, told me to begin a tour of a house for sale at the basement, where one can see, feel, and even smell the quality of workmanship and attention to detail.  Witness the I-beams used in construction of skyscrapers that support the top two floors of my new home.

Two healthcare analogies come to mind:

1) During my residency, an attending surgeon stayed in the Operating Room until the skin incision was closed; he told me, “If patients see perfectly approximated skin edges, they assume that their surgeon paid attention to detail on the inside. First impressions count.”

2) When I help hospitals set up Physician Advisory Panels, I encourage them to pick physician co-chairs who, based on inside knowledge, are the physicians that physicians turn to for advice and care; these physician champions create a safe environment for learning and growth that builds transparency and medical staff trust from the ground up in the same way that a home builder starts construction with a solid foundation

Imagine the potential, as we design a system to deliver more collaborative cost-effective healthcare, of being builders designing a home that we are going to live in.  For those of us at or nearing our mid-century mark, the timing could not be more favorable.

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

Kenneth H. Cohn

© 2010, 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.

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Construction: Implications for Hospital-Physician Relations is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

Stress has become something of a badge of honor in today’s society…. We are quickly realizing that people who experience stress act in ways that can be problematic for their organizations and for their own well-being.  Over the long term, what starts as a relatively minor complaint can blossom into burnout, lower performance, and even turnover and violence…. If we could help ourselves, stress would not be considered an epidemic….  The goal of this book is to put practicing administrators in a better position to address the stress of those with whom you work.

On page 108 is an interview form that contains questions to ask, including:

• What are the primary challenges you face
• How often do you face these challenges
• What do you enjoy about your job
• What suggestions do you have to make your job better

On the following page, the author writes practical guidelines for facilitating stress focus groups, such as:

• Establish ground rules (for a list of such rules, readers may consult my article on Surgeon Frustration, p. 82)
• Facilitate more than participate
• At the session wrap-up, communicate possible next steps and obtain feedback

I appreciated his answer to, “How can we sustain our work so that we don’t run into future stress-related problems?” (p.75):

• Close the loop
• Continue to reach out and make rounds at your facility
• Retain your team of stress management champions: even as your meetings become less frequent and less intense, they should continue

My only (minor) disagreement based on my experience over the past 12 years was (p.70), “Open-ended questions don’t work with physicians.”  As I wrote in Dealing with a Medical Staff in Crisis, I worked closely with the Medical Staff President to devise a survey instrument that included open-ended questions, such as:

• How would you rate your experience here?
• What is going well for you?
• How likely are you to recommend this hospital to a friend, colleague, or a family member?
• On what do you base your rating?
• What is the future of this hospital?
• What role do you see yourself playing?
• Which obstacles need to be addressed now for the hospital to thrive?
• Whom else should we interview?

Most physicians found the discussions therapeutic, an indication that someone valued their input and validation of their anger and frustration.  Momentum built and physicians who were initially too busy to participate asked why they weren’t interviewed, so I returned about a week later until we had more than 25 physicians’ comments in our database.

Dealing with stress and confronting workplace burnout allow leaders to have an engaged workforce, committed to their organization’s goals and mission as manifested by the:

• vigor that they bring to their jobs
• dedication to advancing the organization’s mission
• absorption in their work, the flow state

Dr. Halbesleben concludes by advising healthcare organizations to acknowledge and deal with stress and burnout:

You have nothing to lose.  You have only to gain a productive, safe organization with engaged employees who stay with you for the long haul- a challenging goal, but one worth pursuing.

I recommend this book because of its practical approach to acknowledge and deal with the causes of stress and burnout. 

What is the situation where you work?

• Are you experiencing an epidemic of stress and burnout
• If so, how are you and your organization dealing with it
• What measures are working

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

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have a material connection because I received a review copy that I can keep for consideration in preparing to write this content.

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Stress Management: A New Book Review is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

• In Nursing Collaboration, I celebrated Nikki who took me aside during a busy ED shift and told me, “Just because this is the 7th patient you have seen with a sprained ankle in the past hour, does not mean that it was her 7th ankle sprain.”
• In the same post, I also mentioned the 10 nurses who told me that the aim of a residency program in surgery should be to teach communication skills, not just technique and surgical judgment, which has guided my career path ever since
•  In Collaborative Gender Issues, I mentioned that I felt like I was hit by a 33-degree wave when I heard that women are socialized to value relationships for the first time in an Organizational Behavior group discussion

I felt similarly humbled a couple of weeks ago in Chicago, where I spoke on “Practical Strategies for Transitioning to Non-Clinical Careers” and mentored physicians taking the SEAK Non-Clinical Careers for Physicians course, that approximately 250 physicians attended.  I described the environment in Tip of the Iceberg? New perspectives on disgruntled doctors, in which I mentored over 50 physicians in 15-minute segments until my talk the second afternoon.

I asked a rural surgeon who came to me for guidance, “When was the last time that you felt really alive?” trying to uncover his passion.  He looked at me blankly, “I don’t know.”

I replied, “Some times, when guys can’t remember, their wives can.  How do you think your wife would answer that question?”

“I don’t know,” he replied. “Can I go back into the lecture hall and get her?”

“Sure,” I replied.  “I can’t wait to hear what she says.”  It turned out that she  was also his office business manager, which meant that they spent over half their waking hours together.  She told me, “His passion left him years ago.”  He nodded, sadly.

In the remaining 10 minutes, we talked about what he was really good at: teaching.  Gradually, I saw a smile appear on his face and some light sparkle in his eyes, as his energy began to return.  He made a decision that once he moved closer to his grandchildren, he would contact the local medical school and offer to teach anatomy to medical students.  He left feeling that he now had a reason to get up every morning, which brought him hope.  A day later, as we departed for the airport, his wife told me, “Although he still spends more time telling me what he doesn’t want to do than what he does want to do, at least after this weekend, he has at least one thing that he wants to do.  Thank you.”

As I waited for my plane to take off, I felt grateful to have a weekend “with my people.” I mused that physicians are not leaving the profession solely due to the economic costs of running a practice, as a recent CNN article stated, but also because they have lost touch with the feelings that attracted them to healthcare careers in the first place; to make a difference in the lives of patients and their families.

At a transition point in my career, when I lost my academic job due to a budget cut at the VA at White River Junction, VT and prepared to attend the MBA program at the Tuck School at Dartmouth, most of my male colleagues told me that I was wasting my  surgical oncology and reasearch training and should look for another academic job, even though my wife did not want to move.  On the other hand, at least 10 female nurses told me that as one door closed, many others would open and that I would enjoy a career where I was able to bring a variety of strengths to play that were not highly valued in my present job.  When I asked the 10th nurse why she thought that there was such a difference in replies, she stated:

Women are hard-wired to deal with change.  Some of us go from college to jobs to marriage and raising a family, but no matter what we do, change happens to us every day, so we learn to embrace it rather than fear it or fight it .”

It is times like the ones I have described in this post that make me want to celebrate the 23 chromosomes that derive from my maternal DNA.

What do you think?

• Do you work with physicians who no longer enjoy coming into work
• Have you asked them what are they really good at and what makes them feel truly alive, as Jim Collins advised in Good to Great
• If so, what did they tell you

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

Kenneth H. Cohn

© 2009, all rights reserved

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Insight: Post 76 is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

Thank you for the contact; however, at this time, I do not seem to have need of your expertise.  What practices I don’t own already in the community don’t readily lend themselves to collaboration.  They are staunch, stand-alone, small, independent practices that don’t want to change anything about the way they operate.

I empathize with the way he feels.  My father was a solo-practice neurosurgeon from 1952-77.  One of our favorite stories was that while his car was in the repair shop, he stood at the bus stop and noted colleagues waving to him, but none slowed down to offer him a ride.  When he arrived at the hospital, he complained to colleagues in the physicians’ lounge who told him, “George, you need to learn to hitchhike with your thumb rather than with your middle finger.”

An article helped me think about ways to deal with physicians in small practices (Christensen CM, Marx M, Stevenson HM. 2006. The tools of cooperation and change. Harvard Business Review. 84(10):73-80).  The authors lay out a graph in which the x-axis represents the perceived way the world works (cause and effect), and the y-axis represents what people want (vision for the future).  Near the origin of the graph (where the x-axis and y-axis equal zero) lies a circle labeled “Balkanized States,” e.g. Serbia and Bosnia-Herzegovina, where the desire for autonomy outweighs the benefits of working together.

The authors state that this group responds to power tools, including:

• Command and control
• Threats
• Setting an example

It reminded me of the way that I dealt with my adolescent children, with limited success.  On my better days, I gain inspiration from ways that healthcare leaders who take my seminar have taught me to deal with physicians who do not want to be engaged.  In Collaborative Control, I saluted a CEO who when confronted by his Board Chair with, “Does it bother you to cede control to your physicians,” smiled and replied, “Heck no, I never had control in the first place.”

Here are some replies from practicing physicians to, “What can we do to engage physicians who do not want to have anything to do with us?”

That will only happen if they perceive that you have nothing to offer or they do not trust you….To me it is all about building trust and identifying areas of passion for them, and areas where you can improve their lives (processes) or their incomes (JV’s etc)….you have to come up with something of interest to them…what can you do for them, not what they can do for you

If they do not want to have anything to do with you, ask them why not!!…..that is a definable set of reasons and (mis) perceptions you might have to dig out of them, realizing that you might not like and may not want to hear what they say, but once understood gives you something to work with

We all have crosses that we need to bear. Asking me for my input in helping you solve problems, sharing data with me that will improve care for my patients, or best yet, helping me make my time count are ways to get my attention.

An additional strategy involves getting to know the physician’s assistant, nurse, and/ or practice manager and ask their input on engaging that physician.  As I pointed out in Collaborative Etiquette, active listening requires:

• Concentrating on the speaker, maintaining comfortable eye contact
• Listening with one’s eyes as well as ears to be mindful of body language
• Opening one’s stance to convey receptivity
• Suspending judgment to maintain objectivity
• Empathizing, trying to put oneself in the speaker’s frame of reference, using summary questions, such as, “Do I understand you to say….,”

We all have our own data points, but Brian Wong’s survey of over 1500 practicing physicians (A Prescription for Physician Reengagement. Futurescan 2009:23-26) revealed that the majority of physicians seek:

• Meaningful work that makes a difference in patients’ lives
• A sense of community
• Regular, reliable, positive feedback that affirms their value

I wrote in The Tectonic Plates Are Shifting: Cultural Change vs. Mural Dyslexia that:

• both hospitals and physicians are facing rising expenses, burdensome regulations, heightened consumer pressures, and stagnant or declining reimbursement
• the response to global economic pressures and the need to improve clinical and financial outcomes can bring hospitals and physicians together

Miller wrote, “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!” (QBQ: The question behind the question. Putnam, NYC, 2004).

What do you think?

• Do you agree with Tom Atchison that much of physician-hospital relations involves executing basic blocking and tackling
• Do these troubled financial times offer us the opportunity to work together more collaboratively
• Do you have any collaborative examples that you are willing to share in the blog comments section

As always, I welcome your input to improve healthcare collaboration.  Happy Father’s Day.

Kenneth H. Cohn

© 2009, all rights reserved

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Listening: Post 70 is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

Dr. Cohn receiving Dean Conley Award at ACHE Congress

The photo, which I received this week from the American College of Healthcare Executives (ACHE), shows me accepting the Dean Conley Award from Chris Van Gorder, President and CEO of Scripps Health and Chairman-Elect of the American College of Healthcare Executives.  The Conley Award, which honors ACHE’s executive director from 1942 to 1965, is granted annually to recognize the contributions made to healthcare management literature and to encourage healthcare executives to write and publish articles. “The Tectonic Plates Are Shifting: Cultural Change vs. Mural Dyslexia” was selected by ACHE’s Article of the Year Awards Committee.

I wrote the article with Professor Leonard Friedman and Dr. Thomas Allyn to point out that:

•  a rapidly changing healthcare marketplace
• a variety of new business models
• increased global economic competition, and
• the need to improve clinical and financial outcomes can bring physicians and hospitals together rather than drive them farther apart.

This article outlines strategies hospital leaders can use to engage physicians and work more interdependently, such as positive deviance and structured dialogue. I concluded with a ten-step guide to engaging physicians and improving care:

1.Encourage practicing physicians to articulate future clinical priorities to increase their sense of shared ownership and to improve clinical outcomes.

2. Include doctors who are users of radiology, anesthesiology, pathology, and emergency services when drawing up contract specifications and monitoring performance to improve service; physicians may pay lip service to administrators but listen to other physicians who refer patients to them.

3. Establish a hotline for process improvement issues that is tracked at least monthly in senior management meetings to make sure that the communication loop is closed.

4. Treat the top 20 percent of physicians (by volume or revenue) as partners, and visit them at least quarterly regardless of irascibility.

5. Ask “go-to” docs, “What can we take off your plate?” at least semiannually to monitor
and reduce burnout; a recent poll of over 24,000 surgeons showed that approximately 40% met criteria for burnout.

6. Map out policies and procedures to improve effectiveness and refine handoffs, especially when people complain that they are short-handed. Staff creep often results from workarounds created by inefficient processes. Inefficiencies can be identified and improved by putting each step on a Post-it note and asking members of a group to remedy the gap between what should be happening and what is actually occurring.

7. Have the chief information officer and programmers round periodically with physicians to see how physicians struggle with information technology and how the physicians could use their limited time more productively.

8. Develop a hospitalist surgical service to off-load call burdens for physicians and to diminish the need to pay stipends to physicians for carrying a beeper.

9. Celebrate and reward all healthcare professionals who exceed their job descriptions. Stories of such professionals can become the basis of a positive culture that strives to improve outcomes and service to patients and family members.

10. Establish a pool with fines for using hot-button words (such as “you,” “always,” never,” “but,”) and killer phrases (such as “let’s appoint a committee to study that some more”) and use the money to support a worthwhile service or pay for a celebration.

Those who want to read “The Tectonic Plates Are Shifting: Cultural Change vs. Mural Dyslexia” in its entirety may do so by clicking the link.  I will also discuss its implications, including how to recognize and stop the dance of the blind reflex, use healthy competition to avoid the “herding cats” mentality, develop sustainable medical staff models, implement proactive physician recruitment, retention, and contracting strategies, deal with Emergency Department call-pay, and support healthcare innovation at a 2-day ACHE seminar, Practical Strategies for Engaging Physicians, July 15-16, 2009 in Lake Geneva, WI.

I empathize with the effects of the recession and the limits placed on travel to acquire continuing education.  I hope that the rewards for investing in improving physician-hospital relations will reemerge soon.

What do you think?

• Do you feel the tectonic plates shifting where you work
• Does change feel like failure when we are in the middle of it
• Are any of the ten steps listed above relevant to your work setting

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

Kenneth H. Cohn
© 2009, all rights reserved

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Steps is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

I owe the inspiration for this post to two people:

1) Catherine Henderson, a Graduate Medical Education Consultant with Partners in Medical Education, Inc. reminded me that a decade ago, the Accreditation Council for Graduate Medical Education (ACGME – the organization that accredits all allopathic residency programs) mandated that residents demonstrate competence in the specific knowledge, skills, attitudes, and behaviors required in all six General Competencies:  medical knowledge, patient care, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills.  No longer will residency programs retain their accreditation by proving that they teach residents how to care for patients – they must also demonstrate that residents have learned the skills and behaviors in all six competency domains.

2) However, the ACGME did not point out how facilities can make sure that residents and faculty teaching the residents demonstrate the 6 competencies.  For insights into this journey, I am indebted to Ruben Azocar, Program Director, Department of Anesthesiology, Boston Medical Center, for his talk entitled, “Bringing the Six Core Competencies into the OR” at the 5th Annual Ellison Pierce Symposium: Positioning Your ORs for the Future, April 30-May 2, 2009, where we served on the faculty.

I will focus on the last competency, interpersonal and communication skills, not only because of my interest in the field but also because the Joint Commission on Hospital Accreditation has raised awareness of this issue by mandating zero tolerance for behavior that undermines a culture of safety.

Dr. Azocar’s presentation elucidated the skills that underlie the ACGME mandate that practitioners must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, families, and professional associates, including:

• Creating a relationship with patients
• Using effective listening skills
• Eliciting and providing information
• Working with others

Evaluation of these six competencies should be part of a rotation-by-rotation rating (such as “displays these behaviors: always, usually, sometimes, or rarely”) with a signed action plan for remedying deficiencies.  In addition to rule-based indicators, we may also see rate-based indicators that track practitioners’ clinical outcomes relative to their peers with appropriate thresholds (eg central line infections).

I was fascinated by the assessment tools to help physicians monitor and improve performance, extending beyond written and oral examinations to 360-degree feedback, direct observation (as with shadowing mentors or actors playing mystery patients), and after-action reviews of clinical simulations in which faculty assess resident performance not only for correct diagnosis and treatment but also for situational awareness and clarity of communication and follow-up measures.

He referenced a fascinating operational matrix developed by Bingham and Quinn from MD Anderson Cancer Center, in which interpersonal communication skills (“What should we say?”) could be tracked along the dimensions of the recommendations by the Institute of Medicine that care be safe, effective, patient-centered, timely, efficient, and equitable.  An important feature of the matrix is that it encourages users to close the loop; if a remedial action plan is not documented at the bottom of the matrix, problems have a high likelihood of recurring.

Dr. Azocar predicted that in the future, a physician’s portfolio will include not only a list of places worked, publications, and committee assignments, but also evaluation forms and action plans demonstrating improvement.

In “Collaborative Leadership at Academic Medical Centers” (Cohn KH. Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives. Chicago: Health Administration Press. 2006, 149), I wrote that leadership derives not only from the people in charge but also from processes that foster transparency, trust, accountability, and collaboration.  The development of emotional intelligence that broadens residents’ skills beyond command-and-control is critical because, unlike practice management, interpersonal communication skills must be learned and not delegated. Furthermore, improved communication can decrease readmissions, as discussed in Collaborative Handoffs.

The questions that the competency-based approach to residency education raises include not only how do we measure competency but also who will assess competency, what remains confidential, and how do we train faculty assessors as well as residents.  Apparently, the competency evaluations are here to stay, we are on a journey of discovery, and the potential for improving communication and patient care is exciting. 

What do you think?

• Will 21st Century residents trained under the system of the general competencies and simulation change medical practice
• What collaboration is needed to make these changes possible
• Will competencies make a difference in the quality of medical care
• How will we know when we are “there”

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

Kenneth H. Cohn
© 2009, all rights reserved

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Competency is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

• realize tangible improvements within a short time
• reduce bureaucratic barriers that hinder decision making and implementation
• expose and overcome misalignment of incentives
• generate ideas at every level
• increase visibility
• improve accountability

I wondered why healthcare organizations did not take advantage of the concept and process until I read What Top-Performing Healthcare Organizations Know: 7 Proven Steps for Accelerating and Achieving Change ( Butler G, Caldwell C. 2009. Chicago: Health Administration Press), which reads like a survival guide for senior healthcare executives and middle managers, with a coherent rationale, data from 222 hospitals, multiple checklists, and three case studies.

The book’s  premise is that organizational success hinges on how transformational initiatives are organized for accountability and action.  Structure drives culture as much as culture drives structure, according to the authors.

The reasons that the GE Workout model is impractical in healthcare settings are that it:

• Required healthcare providers and senior and middle-level administrators to remove themselves from the work environment for 2-3 days at a time, too long to be away from a dynamically changing situation
• Expected testing and redesign to be complete within 2-3 days, too short a time considering the complexity we face in healthcare settings
• Focused on a set of projects rather than promoting an ongoing performance improvement process

Instead, the authors tailored a process for healthcare organizations called the 100-Day Quality Workout (p.29), which proved more reliable in organizing healthcare professionals for change and creating a culture of action and accountability.  I liked the way they debunked the concept that accountability conjures up notions of judgment and failure.  A strong accountability system can help leaders focus attention on results while creating regular opportunities for collaboration and information sharing across departmental silos. 

The advantages of dividing each year into 20-day planning and 100-day implementation cycles are that it:

• fosters a perpetual environment of improvement
• limits the tendency to plan at the expense of execution
• creates urgency for change
• focuses the entire organization on achieving improvements in major core processes
• eliminates unneccessary meetings and unproductive teams

A case study that I found compelling (p.113-116) involved a 300-bed community hospital that faced budget pressures as a result of Medicaid cuts.  It recognized that layoffs were not an ideal solution in this tight-knit community and embarked upon an operational performance improvement program that generated nearly $5,000,000 in cost recovery the first year but less that $1,000,000 the second year, despite considerable effort. 
Using the 100-Day Quality Workout , the hospital evaluated staffing patterns on an hourly basis.  Each manager developed a plan for transforming his or her staff.  They eliminated minimum staffing burdens, cross-trained healthcare professionals, implemented irregular shifts, and staggered 12-hour shifts to match staffing capacity more closely with demand.  During the first 100-day cycle, they saved approximately $2.1 million . 
An Internet-based monitoring system tracked progress, so that results were visible to everyone in the organization.  This system created healthy competition and opened managers’ eyes to what others were doing.

It would be impossible to summarize the lessons of this well-written book in one blog post.  I encourage readers to buy this book, set a stretch goal to read it over a weekend, and implement at least one of its excellent ideas within the next 120 days.

What do you think?

• Are 20 days of planning and 100 days for implementation sufficient to make significant changes in a core process
• Does a system like this owe its success to top-down (executive sponsorship) and bottom-up (managers define quality) measures
• Is a “perpetual system of improvement” self-energizing

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

Kenneth H. Cohn
© 2009, all rights reserved

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Workout is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.