As I wrote in Collaborative Engagement, engaged workers strongly agree with the following statements:

• This organization really inspires the very best in me
• I am willing to put in a great deal of effort beyond what is normally expected to help this organization be successful
• I talk up this organization to my friends as a great organization to work for

(Achieving Breakthrough Engagement: Lessons from High-Performing Organizations. 2007. Washington: The Advisory Board Company, p.3.)

Engaged workers:

• Exceed expected level of effort
• Are inspired to do their best work
• Feel part of the greater work community
• Make meaningful contributions through their work
• Are personally motivated to help their organization succeed

(Achieving Breakthrough Engagement: Lessons from High-Performing Organizations. 2007. Washington: The Advisory Board Company, p.14)

They liked the idea embodied in Appreciative Inquiry, of building on the goodwill engendered by previous efforts, such as preparing for a Joint Commission visit that went well and their move to a new hospital facility.

The goal they share is to build on the efforts of physician champions to move the majority of practicing physicians from renters to owners, rekindling their passion for medicine despite disruptive changes in their lives. They liked the story of the orthopedic surgeon I worked with in the pogo epiphany, who moved beyond blame-storming when he realized that every time that he pointed a finger, three others pointed back at him.

I know that they will engage, collaborate, and succeed. They make me proud to be a fellow-physician.

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.

Engage, Collaborate, and Succeed 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

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

At the beginning of June, I traveled to Buffalo to celebrate my mother’s 85th birthday.  It was a joyous occasion that brought together nieces and nephews who have not seen each other in nearly a decade.

Then to San Diego, to present Physician Engagement: Moving from Me to We at the Governance Institute Annual Conference for CEOs, Board Chairs, and Physician Executives.  From there, to a midwestern hospital whose physicians issued a vote of no confidence in the CEO.  Our listening sessions were like a truth and reconciliation committee for both sides.  Many of the physicians were of Asian descent and felt humiliated by public comments, from which we can all learn insights, such as:

• Calling a physician by his/her formal appellation to show respect (i.e., Dr.) rather than by first name
• Beginning a conversation with the 1 percent of areas of agreement rather than the 99 percent of areas of disagreement
• Praising people publicly and discussing concerns privately face-to-face, rather than via email
• Demonstrating flexibility
• Understanding that for those who grew up in poverty, fear of losing affluence may drive their outlook

Before I left, I made a video of a frequently asked question, “What are MEC-MAP differences, i.e. the differences between the Medical Executive Committee (MEC) and a Medical Advisory Panel (MAP).  To watch this three-minute video, please click here.

The two groups are complimentary, not competitive, with the MEC focusing on quality, safety, peer review, and credentialing.  The MAP’s strength lies in gathering  physician champions to come to consensus on clinical priority setting and strategic planning.

Specific Medical Advisory Panel Projects at hospitals where I have worked include:

• Consideration of what services will go into a newly constructed hospital
• Medical staff models that align incentives and foster financial collaboration
• Ways to decrease supply costs, especially implantable devices and drug formulary expenses
• Succession planning for critical physician sections and departments
• Physician burnout and retention issues
• Ways to improve hospital-wide throughput, for example in perioperative and ICU care
• Crisis management, such as when physicians no longer admit patients to the hospital

Please send me questions on hospital-physician relations that you want answered.

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.

MEC-MAP differences: Possible Uses for the Med Exec Committee and a Medical Advisory Panel is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

Ideally, branding creates a right-brain, visceral connection with listeners.  The trust I had in Mark’s insight, wit, and ability to deliver knowledge in the face of uncertainty created that visceral connection.

In an era of ratings-driven TV personas, Mark was authentic, clearly comfortable in his own skin.  If  legacy emanates from leveraging knowledge, wisdom,and experience to make a difference in people’s lives, Mark has left a lasting legacy.

As always, I welcome your input to improve healthcare collaboration.  Let Mark’s sudden passing rekindle a desire in all of us to tackle stretch goals as a reminder that none of us know how long we have left on this planet.

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 Legacy: Remembering Mark Haines 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

1. Use a task force of employed and independent physician champions to suggest ways that the hospital can streamline processes and optimize care, so that everyone can be more productive; when doctors feel that they are making their time count, magical outcomes happen that improve care for the entire community
2. Develop multidisciplinary institutes and medical staff models that permit a variety of practice infrastructures; for example, centers of excellence in cancer care could promote the benefits of one-call coordination to all patients to arrange appointments with an oncologist, radiation therapist, and surgeon regardless of whether their referring physician is independent or employed by the hospital
3. In areas of documented community need, a hospital can help both independent and employed physicians to hire new physicians
4. A multidisciplinary taskforce on physician retention can recommend ways to improve the practice environment before independent and employed physicians leave out of frustration
5. Hospital leaders can subsidize the costs of electronic health record implementation for independent and employed physicians; for more suggestions on how to engage physicians to adopt and implement health information technology, please click here.

In Collaborative Culture, I quoted Dr. Michael Perry, CEO of Freeport Health Network, llinois, where 95% of physicians are employed or under contract to make the point that intetgration of physicians into the hospital or health system requires continual effort to improve the practice environment:

The high percentage of physicians employed by the system by no means indicates that our physicians are any closer to achieving consensus with administration, and we must be intentional about aligning our organizational goals with those of the doctors. The same skills of communication, aligning strategies and goals, and decision making are needed in our situation as are needed in organizations with fewer employed physicians.

As always, I welcome your input to improve healthcare collaboration.  Please continue to share your questions with me, so that I can serve your evolving needs.

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 Assistance: How to Help Independent and Employed Physicians at the Same Time is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

I do not usually make the time to read 371-page books, but found myself showing up early to doctors’ appointments to arrange protected time to finish this book.  It is well-organized and contains a treasure trove of practical information for healthcare organizations at every level of readiness.  In fact, a table on page 153 shows key concepts and actions to consider for organizations that are considering forming an Accountable Care Organization (ACO):

• Interested organizations should engage physicians in designing and managing integrated clinical functions, such as service lines, and in collaborations to improve operational efficiency, for example, reducing length of stay and readmissions;
• Engaged organizations should reward introduction of care pathways in common clinical areas and build physician management in the ambulatory environment
• Committed organizations should focus on strengthening inpatient and ambulatory care coordination and implement medical home pilots in partnership with payers

I wrote a big exclamation point next to page 362, where the authors wrote:

While much attention will be paid to organizational structure, it is best to think of the structure like a sports arena.  It’s the venue, not the game.  Organizational structures do not ensure success, though an ineffective structure can make success much more difficult to achieve.

Those who read my post Collaborative Culture know that I also agree with the point the authors made on page 363:

While culture is often referred to as the “soft side” of healthcare, it is clear that the “hard” outcomes of quality, safety, patient satisfaction, and business performance are dependent on the “soft” elements of organizational culture.  Many leaders are quick to discount organizational culture because it is difficult to understand and even more difficult to influence.  But culture will ultimately be the difference between success and failure.

The authors encourage us (page 323) that there is no predictable timetable that will work for all organizations and to think of the process as a flywheel that gains acceleration.  Once it spins fast enough, the process will reach a self-sustaining speed and will generate confidence on its own.

I enjoyed the case study (p. 265-70) that described  the steps that a payer went through to move to value-based contracting:

• The payer began by engaging individual specialties in conversations about trends in insurance premiums, administrative costs, utilization, and reimbursement
• The data helped all parties address the objectives of maximizing value for patients and their families, the rationale for acting now based on trends of lowered reimbursement, demand for more cost-effective care, and the need to work together to achieve cost and savings targets without compromising quality and safety
• The payers and providers established a set of ground rules that assured that all parties would have a voice at the table and that financial bonuses and direct investments to promote quality and efficiency would be made
• In return for providing clinical resources to manage care transitions (case managers and infrastructure to support a patient-centered medical home) and administrative simplification, the payer expected providers to manage the total cost of care over time and to commit to achieving access, quality, affordability, and productivity targets in accord with multidisciplinary, evidence-based, team metrics
• A year into the initiative, trust and transparency have increased, and momentum is building to support additional investments in improving the practice environment

I encourage all healthcare organizations to buy this book, make reading each chapter part of a monthly ACO journal club, and above all, to use the process to build a safe environment for reflection and learning that will improve care for our communities. 

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

Kenneth H. Cohn

© 2011, 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 Accountable Care: New Book Review is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

“Heck no,” I replied. “It is changing way too fast for anyone to feel like an expert.  The word ‘Facilitator’ appears after my name,  to clarify my role as someone who brings data for group discussion rather than someone who acts as the sage on the stage.”

With that purpose in mind, I traveled to Connecticut last week to speak to a group of physicians, hospital administrators, and Board members on Making Sense of Healthcare Reform: Moving Forward in the Face of Uncertainty. The Vice-President of the Medical Staff invited me to help him dispel myths, like “Healthcare reform will be overturned, it will only apply to Medicare,  and it will take decades before disruptive change comes to this part of the state.”

I divided my talk into three parts:

• Historical context: In 1943, facing union-led strikes during a period of wartime wage and price controls, Congress and the Internal Revenue Service agreed to allow companies to provide healthcare benefits to employees as a tax-free benefit that companies could expense as a tax deduction; so began our healthcare non-system
• Organizational implications: As I mentioned in Collaborative Culture, 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.  A few physician champions can transform a culture once they see that they are making their time count and that they are making a difference in their patients’  lives.
• Personal implications: I believe that disruptive change calls for personal reinvention; unfortunately, the pathways that are so clear for becoming a physician are anything but transparent when it comes to transitioning; as my mentor, Dr.Paul Batalden, said, “Change feels like failure when we are in the middle of it,” which can lead to feelings of isolation and despair

 Two questions from the audience remain with me:

1) From the Board Chair: “What should be the role of the Board in supporting healthcare reform?”
I replied that the Board should be a convener of respectful conversations among members of the medical staff, hospital leadership, and the community.  In complex times, communication based on active listening can help us act, learn, and adapt.

2) From an orthopedic surgeon: “How can we avoid reinventing the wheel?  There has to be a model out there that works, and people like you need to tell us what doesn’t work.” 
I empathized with his feeling that nobody wants to relive the difficult situations of the previous century occasioned by capitation and reengineering.  I also mentioned that orthopedists in the 40 states where I have worked have told me, “When you have been to one hospital, you have been to one hospital.”  Physicians with whom I have collaborated have preferred being active participants to having change imposed upon them.  Healthcare reform involves an iterative journey, in which we accept setbacks in order to move forward.  Learning is never failure.

Personal Implications of Healthcare Reform

The Collaboration Multiplier

I believe that we are in an exciting phase.  The changes that we are making now may have implications for decades.  We need to feel that we are not alone, that collaboration can improve clinical and financial outcomes, and that a spirit of inquiry rather than advocacy can guide us in the face of uncertainty.  As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

Although I was paid to speak on “Making Sense of Healthcare Reform: Moving Forward in the Face of Uncertainty,” I have not received any compensation for writing this blog post. 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 is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

Flowering cherry trees in Georgia

Last weekend, I had an early taste of spring, as I facilitated a medical staff retreat with hospital leaders and Board members.  We discussed:

- physician leaders who have improved quality, safety, and service
- building a culture of collaboration from the ground up
- career-saving strategies to prevent frustration and burnout.

We also discussed how we could move forward despite national uncertainty about the future of healthcare reform

I know that they will achieve their goal of becoming a top-tier hospital system because they have an engaged group of medical leaders, a visionary CEO and CMO,  and a culture of mutual respect.

I felt proud watching the group come together on the need to make a personal commitment to improve quality and safety rather than blaming others.  When discussing a model for timely implementation, we recalled from residency the process of making a daily rounds ”scut list” of the task, the deadline, and the person responsible for getting it done.  As the authors of Crucial Confrontations  wrote, “There is no we in accountability.”

Like many of us who were not taught communication skills in medical school, residency, or fellowship training, they welcomed the opportunity to learn how to manage conflict and confront people in a way that improved rather than threatened team cohesion, as summarized in Crucial Confrontations :

• Start from a position of safety
• Maintain respect
• Use contrasting to reassure what is not going to happen
• Establish mutual purpose
• End with a question, as illustrated below:

I am concerned about a problem that is affecting all of us.

I feel that our 5% rate of hospital-acquired infections is too high.  I find it hard to tell patients that one of twenty will suffer harm from being here.

This is not a witch-hunt. I value your service to the hospital. I would like to understand better what I can do to foster a safe dialogue on how to improve care for our community. I welcome your suggestions.

Is there a time in the next two weeks when we could come together to discuss this situation further?

As always, I welcome your suggestions on how we can improve healthcare collaboration and our service to patients, for whom we maintain a sacred trust.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

Although I received compensation for facilitating the medical  staff retreat, 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 Uncertainty is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations