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.

©2012 Healthcare Collaboration. All Rights Reserved.

Unconscious Competence: Viviendo la vida locums is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

Drs. Lars Stange and Mia Granberg with their sons Per and Anders

Dr. Martin Backdahl, Prefekt of Molecular Medicine and Surgery, Karolinska Institute

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.

Stockholm sunrise, 9:30 am

Stockholm sunset, 2 PM

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.

God Helg is Swedish for Happy Holidays

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.

©2012 Healthcare Collaboration. All Rights Reserved.

International Healthcare Collaboration: Stockholm Memories is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

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.

©2012 Healthcare Collaboration. All Rights Reserved.

What I learned at the Community Hospital 100 Conference is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

Fall foliage, Guilford, ME

When nurses tell me to do something, I try to follow their advice.

So, when I was seeing patients in the ED yesterday, and nurses said to me, “You’ve got to check out the covered bridge,” I paid a visit on a beautiful, 75^o sunny day.

Originally built in 1830, it is a national historic landmark.  It has been rebuilt four times after being destroyed by flooding in 1832, 1857, and 1987, a tribute to the resilience of local citizens.

National Historic Landmark sign over the Piscataquis River

I felt the beneficiary of a collaborative blessing to be notified by nurses of this bridge’s existence, to have time to see this example of local resilience despite being on call, and to have such a beautiful day to photograph it.

Fall foliage, Guilford, ME

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 Blessing is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

Communication Ground Rules for Dealing with a Medical Staff Crisis

Last week, I spent a wonderful two days with over 25 healthcare executives in New York, teaching my ACHE seminar, Practical Strategies for Engaging Physicians. Day one, we discussed differences between physicians and hospital leaders, implications of healthcare reform, and advanced strategies, tactics, and tools to engage physicians.  But, the discussion on day two taught me the most.

We discussed the management of a medical staff crisis that resulted from physicians of Asian descent feeling disrespected by the pace of change.  The following is a list of steps we came up with to display cultural sensitivity and save face with physicians from other countries who settle in the US:

• Call the physician by the formal appellation, “Doctor,” rather than by his or her first name
• Make eye contact long enough to notice eye color
• Praise publicly
• Begin a conversation with the 1% of areas of agreement rather than the 99% areas of disagreement
• Discuss concerns privately
• Avoid hot-button words, especially in front of colleagues
• Come to know other aspects of physician’s life, such as volunteer interests and hobbies
• Reach out to physician’s spouse and children, for example, writing letters of praise when the children receive awards
• Extend cultural sensitivity to dietary concerns, such as beef with Hindus and pork with Muslims
• Be aware of reciprocity of dialect and intonation: a Southern hospital speeded assimilation by teaching foreign-born physicians to say, “Ya all.”
• Be sensitive that jokes that make people feel left out have the power to offend
• Understand that for those who grew up in poverty fear of losing affluence may shape outlook and behavior

What stories can you share about cultural sensitivity that help foreign-born physicians and their families to feel welcome where they work and live?

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.

©2012 Healthcare Collaboration. All Rights Reserved.

Displaying Collaborative Cultural Sensitivity is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

It has taken me longer than usual to summarize the proceedings of this conference because of considerable activity to prepare for the June 30 launch of my newest book, Getting It Done: Experienced Healthcare Leaders Reveal Field-Tested Strategies for Clinical and Financial Success.  It has given me great pride to salute healthcare heroes at sixteen organizations throughout the US who have broken down barriers and improved care outcomes for their communities.

Clinical Integration at Advocate Healthcare

Lee Sacks, CEO of Advocate Physician Partners, discussed clinical integration, which he defined as a structured collaboration to improve healthcare quality and efficiency. What made his presentation memorable is that he worked with independent physicians, most of whom in groups no larger than 3 people, to achieve ground-breaking outcomes. Clinical integration creates value for:

• Hospitals, by strengthening loyalty and positioning the hospital for healthcare reform efforts that require true partnership, such as decreasing readmissions
• Physicians, by helping them to differentiate in a competitive marketplace, giving them disease registry data that helps them improve performance, and assisting them with managed care contracting
• Communities, by improving clinical outcomes, focusing on patient-centered efficiencies like online scheduling, and engaging patients in the partnership to improve population health

The metrics that they are using in their value index to monitor and drive down cost include:

• Readmissions
• Adjusted length of stay
• Potentially avoidable admissions
• Cost per adjusted discharge
• Global cost of care per member per month (they have 230,000 capitated patients)
• Advocate attributable cost trend
• Non-Advocate attributable cost trend

For further information on this pioneering healthcare system, please view their 2011 value report.

Healthcare Transformation at University of South Florida

Stephen Klasko, CEO, USF Health and Dean of Medicine, University of South Florida, gave an energetic presentation with the subtitle “Can I Click My Heels and Go Back to My (Patient-Centered Medical) Home. He paraphrased Woody Allen’s quote: We are at a crossroads, where one road leads to destruction, the other despair. Let’s hope we choose the right one. He advised participants to forget reform and instead think transformation to:

• Redesign care processes
• Make effective use of information technology
• Manage clinical knowledge and skills
• Develop effective teams
• Coordinate care across patient conditions, services, and settings
• Incorporate performance and outcome measurements to promote continuous improvement
• Demonstrate ability to adapt to change

A Wharton study, where he obtained his MBA, demonstrated that 78% of MBAs viewed creativity as an important part of their success in contrast to only 12% of physicians who felt the same way.  He quoted Buckminster Fuller: “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.”

He concluded with the following survival guide:

• Think into the future
• Ask each administrative and physician leader to identify one game-changing idea yearly
• Look at the technology that your kids are using as future patient care and marketing opportunities

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.

©2012 Healthcare Collaboration. All Rights Reserved.

Transforming Clinical Integration is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

“You have to cut off the head of the snake,” said another Board member

“What if the snake turns out to be a salamander or a tadpole,” I asked

An uncomfortable silence ensued.   I continued ”Amphibians, unlike reptiles, are capable of regeneration.  Firing the Medical Staff President risks alienating the rest of the medical staff further and could make the situation worse rather than better.”

“What do you recommend?” asked another Board member

“Give them collaborative options,” I said, remembering what one of my surgical mentors had told me, that all gladiators had choices.

Together, we brainstormed ways that we might meet together with a facilitator to discuss whether we could collaborate by building on past successes or finding quick wins that might bring hospital leaders and physicians closer together for the benefit of their community.  As I mentioned in a previous post, it is too early to predict the outcome.  These processes often play out over years.

For those who wonder where my analogy came from, I quip that I have amphibian DNA because, having worked in 41 states, I have encountered hidden mines and have no alternative other than to regenerate after being surprised that something that was relatively easy in one hospital presents a huge barrier to overcome in another.  It is the price we pay to have the privilege to serve healthcare professionals facing hospital-physician and/or physician-physician collaborative challenges.

• What hidden minefields have you encountered?
• How have you dealt with surprise?
• Do you agree with what my grandmother told me, that “the Lord never gives us more than we can handle, in retrospect?”
  In return, I asked her, “How will I know when I’m in retrospect?”

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.

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative DNA is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

Therefore, I return to an old favorite subject, hot-button words to avoid in healthcare.  A previous post covered “but” which negates and “just” which diminishes value.  It also mentioned that “you” messages are accusatory and that sending “I” messages is a preferable way to resolve conflict.

To watch the video for this post, please click here.

Words to avoid

“Always” and “never” increase the combustibility of “you” messages; they often trigger a search for exceptions, which decreases the potential for active listening.

“I disagree” puts the two parties in advocacy mode rather than asking questions to learn more about the other side’s interests.

Asking about cost when a physician comes in with a new idea triggers arguments about patient care vs. organizational survival and puts people into advocacy rather than inquiry; better to ask initially, “How will your idea help us to provide better care for our community” or “How will this differentiate us compared to other hospitals,” and save cost questions for a subsequent meeting.  One way of turning physicians into partners might be to ask, “Can you think of grateful patients who might be willing to defray some of our startup expenses” or “What ideas do you have to generate additional revenues or cut costs, so that we can benefit from the valuable innovation that you have described?”

The power of language

In Tongue Fu, my mentor, Sam Horn, mentioned that telling people that they have to do something triggers the 4 R’s of reluctance, resistance, resentment, and revenge.  Asking “would you please?” is  a preferable way to obtain results.

Saying to someone, “That’s not true!” freezes the comment and turns the conversation into a battle.  Asking for clarification with, “What do you mean?” or “Please tell me more,” uses inquiry to shift the burden to the accuser to clarify his/her comments.

When something goes wrong, service recovery demands taking the “A train” to apologize, agree with the physician who had something go wrong, and act to improve the situation.  The worst things to tell a physician when something goes awry are, “I can explain…”, or “You don’t understand….”

Marshall Rosenberg’s framework

I wish that Rosenberg’s book, Nonviolent Communication were required reading in grade school, high school, college, and medical school.  It emphasizes sending “I” messages based on data, as follows:

• Observation (The concrete actions that I am observing that are affecting my well-being): “Yesterday, there was a problem with…”
• Emotional response (How I am feeling in relation to what I am observing): “I’m feeling worried and concerned…”
• Needs (My needs, desires, wants, asking for empathy) “Because I am needing/ depending on…”
• Request (The concrete actions I would like taken, proposing a solution) “Would you be willing to …?”

The above comments are merely the basics.  Please let me know what communication issues you need to resolve to provide optimal patient care.  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 Language: Hot-Button Words to Avoid with Healthcare Professionals is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

Developing a Sustainable Physician Strategy

I had the pleasure of attending and presenting at  Becker’s Hospital Review Annual Meeting May 19-20.  I was impressed that even though very few of the attendees planned to file an accountable care organization (ACO) application  by January 1, 2012, all understood the importance and urgency of providing more coordinated, cost-effective care.

I. In “ACOs- A Panel Discussion,” Brian Silverstein from CareFirst (Blue Cross Blue Shield) demonstrated the variation of patients’ costs: only 3% of plan members had advanced illness, but represented approximately 29% of total cost, at an average of over $54,000 per year.  In contrast, 50% were relatively healthy, representing 7% of total cost, at an average of only $660 per year.  He believed that the highest return on investment comes from helping patients with advanced illness manage their care better.  He and his co-presenters felt that physician engagement requires a multimodal approach comprising: 

• one-on-one conversations between physicians and hospital leaders, rather than group memos
• identification of and regular communication with informal physician leaders, the physician champions who have earned the respect of their colleagues
• infrastructure (people and processes) that helps physicians use their time optimally

II. I enjoyed Bill Woodson’s (Sg2)presentation, “The Path to Becoming an Elite Health System,” characterized by:

• Trying innovations that may not work initially like value-based purchasing, telemedicine consulting, and remote monitoring (eg.weight for heart failure patients)
• Experimenting with potentially different metrics, such as disease-based forecasting and leading indicators like cycle times and new-patient visits
• Focusing on performance: monitoring disease registries, promoting seamless care transitions, and analyzing complications for systems improvement rather than blaming others
• Managing to Medicare rather than commercial insurance margins and partnering with payers in pilot studies to improve care processes and clinical outcomes
• Accelerating financial transactions to decrease accounts receivable
• Continually improving processes to strengthen physician relations
• Drilling down to gain a better sense of readmissions from home, skilled nursing facilities, and other hospitals

Mr. Woodson summarized healthcare reform imperatives for the next five years as:

• Find physicians whom you can work with
• Manage care transitions
• Decrease the cost of care without making across-the-board cuts in staff
• Take prudent risks to embrace innovation
• Strive for flexibility and nimbleness rather than investing in architecture that adds to long-term fixed costs

III. Gary Weiss, CFO of Northshore Hospital, and Adndrew McDonald, Healthcare Practice Leader at LBMC, discussed “Making Employed Physician Models Profitable.”  Although healthcare reform efforts may involve a challenging transition from fee-for-service to more outcome-focused models, several of the following steps work for both business models:

• Build a culture of physician ownership and collaboration
• Use physician peer pressure to align incentives and performance
• Put patient throughput, including scheduling and turnaround time, under the direction of physicians
• Invest in timely physician credentialing, so that physicians can begin billing for work performed on day 1
• Provide real-time physician feedback on quality of documentation, care outcomes, and profit and loss at least monthly to avoid surprises where the physician thought that s/he had no reason to change because s/he had not received any negative feedback
• Maintain flexibility, especially for women physicians who have children
• Strive to locate primary care physicians’ offices close to patients whom you want to attract

Please let me know what you think of the presenters’ ideas.
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 Healthcare Reform Issues: Highlights of Becker’s Hospital Review Annual Meeting is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

At 3:55 PM, there was time in my seminar for one more interchange. A woman said, “I have been in healthcare for 30 years, and I can tell you that a physician advisory panel will not work unless the department chairs serve as panelists.”

Feeling under attack, I said that in my experience (about a third of hers), it was more important for physician champions, who had earned the respect of their clinical colleagues, to serve regardless of their formal leadership titles. The seminar ended poorly, except for those who needed a “food fight” to wake them up at the end of the day.

I approached her after the seminar and found that she worked at Roswell Park Memorial Institute in Buffalo, NY, where I had worked as a high-school student. We had a cordial personal conversation, in which I learned that departmental leadership is an important part of the Institute’s culture, and that the chairs are indeed clinical champions.

If, instead of arguing with her, I had asked, “Where do you work,” I could have built on her insights instead of debating her.

II. “I take full responsibility for …”

At 11:45 am one Saturday, the COO, who invited me to facilitate his medical staff retreat, and I smiled at each other, pleased with the way physicians, hospital leaders, and board members listened attentively and participated enthusiastically in the morning events, themed “Moving from Me to We.” We eagerly looked forward to the CEO’s summation, because he is such a visionary leader.

He began, “Thanks to everyone for coming and to Dr. Cohn for facilitating the events. Every one of the suggestions that you have made today is in our strategic plan, and I take full responsibility for not communicating to you all the things that we are doing.”

I do not remember anything more that he said. A scan of the physicians’ body language showed that the smiles and leaning forward had stopped, replaced by frowns and arms crossed over their chests. Inadvertently, he told them that they had wasted their time, contributing nothing that he did not know already.

I wished that I could re-record the tape and replace what he said with, “You have given us valuable insights on what we need to do better. Over the next two weeks, I will get back to you with an action plan, and once we are in agreement on priorities, I will make sure that my Board sees it, to hold us accountable to delivering on our promises in a timely fashion.”

I know that the CEO realized that if physicians do not feel that their time has been respected, they feel personally disrespected. I needed to work harder to make sure that his words reflected his understanding.

III. “That would be like…”

This Board retreat had failure baked into it before it started. We spent far longer strategizing how to neutralize a rogue surgeon, who had been put onto the board by the CEO’s predecessor, than on a comprehensive approach to improve care for the community.

An hour into the retreat, the COO admitted, “A lot of times we have earned the disrespect of our physicians by saying that we would do something and playing ‘death by the slow no’. Perhaps a way to establish better rapport with our physicians would be to admit that we did not keep our promises, apologize, and move forward.”

His CEO bellowed, “That would be like Israel disarming unilaterally in front of Palestine!” Everybody in the room was speechless. I felt like a deer trapped in life’s headlights.

In Quicksilver, Michael O’Brien and Larry Shook wrote that we all 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

They mentioned 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).

In my surgical residency, I learned that good judgment comes from bad experiences. I hope that my judgment has improved, along with my focus on what really matters, as a result of that fiasco.

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.

Three Painful Collaborative Learning Experiences is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations