Harvard Business Review: What Makes Gen Xers Tick?

HBR Ideacast is a great service - free and you can listen to it on your computer while you're answering emails, etc.

This week's topic is a perfect tie-in to today's post about recruiting Gen X and Yers to your Board...

Click here to listen - it's 17 minutes well spent.

"A Change Would Do You Good" - Thanks Sheryl

Today marks my last official day of work as a consultant for a research firm.

On Monday, July 9th I'll join the healthcare nonprofit world full time here in Washington, DC.

Wish me luck!

(And many thanks to Lisa Haneberg - you and Hazel are my ambassadors of kwan, and helped make this breakthrough possible).

Why You Need Gen X & Yers on the Board

In a board meeting yesterday, fellow officers and I spent at least 30 mins discussing ways our nonprofit could increase the number of people served.

We chewed over whether a series of 'outreach fairs' held in concert with existing events would be an ideal way to reach new audiences.

When the issue of marketing these fairs directly to prospective patients arose (we're working with a negative marketing budget), I suggested a quick series of posts on Craigslist.

Out of six members, only the board chair (who has two children in their 20s) knew what I was talking about.

How many of you know about Craigslist.org (I hope the answer is near 100%)? How many of you are using this site's online classified section to recruit?

Posts in many geographic areas are free, although some (NY and DC) charge a small fee per posting ($25 per DC job listing).

You can select from 'medical/health,' 'nonprofit,' 'admin/office,' and a host of other categories.

The Craigslist mention is a trite example of why recruiting younger directors is beneficial: Most bring an ingrained web-centric knowledge base to the boardroom, along with an infusion of energy and passion for continued industry improvement.

Despite a deficit of industry experience relative to other directors, younger board members bring a wealth of Web 2.0 knowledge to the table. They also provide much-needed insight into how to design internal succession planning and leadership development programs successful with the 35 and under set.

Of course, the most important factor in BOD composition (and thus recruitment) is still balance - you don't want a board overrun with newbies or one that lacks gender/cultural diversity.

You may need to push slightly outside of your comfort zone to source/recruit younger board members, but this effort may not be as onerous as you think.

Chances are promising candidates are already in your employ, or have been awarded scholarships by your hospital to attend nursing school, etc.

You can also look for board members among the ranks of active volunteer organizations, such as Rotaract, or on the pages of professional-social hybrid networking sites, such as the Young and Successful Network (ysn.com, and yes, I'm listed here).

In addition, you can post a 'wanted' ad on BoardNetUSA - it's free and easy and boasts some nice stats - over 85% of users seeking candidates found directors they wouldn't have sourced otherwise.

The good news? Promising candidates are out there.

The bad news? Many have not been given exposure to Boards, and may not have a good grasp on roles and responsibilities. You shouldn't expect them to spring into immediate action as confident, involved directors.

Most will have no prior BOD experience, and will need training on the basics of trustee duties. Younger candidates may need encouragement that their ideas are valued prior to offering contributions, but they may also lack restraint typical of more experienced directors.

But taking the time to recruit and train younger board members places your organization at the forefront of succession planning. And after juicy salaries and nice benefits packages, what's one of the most important criteria Gen X and Yers use to select a workplace and prioritize demands on time? Development opportunities.

A good blog to read if you're interested in developing the younger set is Employee Evolution.

Develop your talent set by expanding your board demographics...and you might have a fighting chance of designing and implementing constructive change.


Price Transparency: West Virginia Gets It Done

At some point in the future, I'll need a total knee replacement (TKR).

The patchworked result of an MVA, Franken-knee has already cost me (and various insurers) a pretty penny. So it's reasonable to wonder how much more me and the ol' insurance card will be shelling out (approximately) for a major joint replacement surgery.

Now, I could spend many moons beating my head against the wall trying to make sense of old billing statements from MD/DC hospitals.

Or I can pony up, jump on the healthcare consumerism bandwagon, comparison shop and arrange for a little medical tourism. Where would I consider heading for a TKR? West Virginia.

I'm in good company - WVa Governor Manchin had knee replacement surgery last year.

And you read that right - ol' WVa shot to the top of my list this week (top 10 at least) when I read this article by Eric Eyre, published in The Charleston Gazette and summarized in the Health IT Strategist daily HITS e-newsletter.

With five minutes (or less) of web browsing, I can find out how much a 'common' major joint replacement surgery may cost (an 'average' price, not an 'exact' one) at hospitals across the state.

The West Virginia Healthcare Authority developed the list of procedures and pricing, complete with hospital websites and phone numbers. It's easy to use (and also a bit addictive).

Why publish this information? According to CompareCareWV the number one reason is that "consumers are requesting it." Click here to read the complete info section for health professionals.

Although the site doesn't currently include quality ratings (just links to outside sources reporting QRs like Leapfrog, WVa Hospital Association, and AHRQ), WVHA plans to add these later.

Here are the steps I followed to get a very rough major joint replacement 'quote' of "Average Total Charges" ranging from $21,356.00 (St. Joseph's Buckhannon) to $47,070.00 (Raleigh General).

That's a difference of $25, 714. Click here to view my results.

1. Visit www.comparecarewv.gov.

2. Choose either "Procedure" or "Hospital" from the opening paragraph - click through.

3. I chose "Procedure," and then selected "Muscles, Bones, and Joints" from the dropdown menu under "condition, body part, or system affected."

4. I chose "Major Joint Replacement" for "specific medical service" (another dropdown menu - it didn't allow me to specify shoulder, knee, hip, etc).

5. I entered my zip code (outside WVa), clicked on the circle for "any" distance away, and then selected "all" the hospitals that appeared in dropdown menu 4, "Select WV Hospitals by Name."

Where is the data coming from?

"The average gross charge is calculated from State payor claims data including PEIA, Medicaid and other state payors. We have utilized publicly available claims grouping software tools to aggregate procedures to commonly termed reimbursed items. These groupers include the CMS Diagnosis Related Group (DRG) grouper and the AHRQ Clinical Classification Software (CCS) grouper.

Data are dependent on the accuracy and completeness of the data submitted by the payors. Data collection may not be the same for all payors. There may be some variability in assigning diagnoses and categorizing the amounts for the claims."

What should facilities expect as a result?

"Facilities may receive inquiry about gross charges from consumers or other professionals. These contacts may be an opportunity to expand the patient base or to initiate patient services activity within the revenue cycle. Providers can view this publication as a tool to assist patients and professionals with decision making."

How does your hospital's pricing transparency compare?

If an entire state can mobilize resources to make this data available, can't you?


Patients' Patience - Virtue or Untapped Value?

Anyone who's spent time in a hospital or doctor's office in the last five years knows the wait is likely to be:

A. 77x longer than expected, especially if you have an urgent car repair/child care/real estate/or circuit court appointment;

B. Interrupted by noise pollution from a CD, radio station or TV set at a volume that makes its squawking audible to all within a 55.876 mile radius;

C. Punctuated by complaints from the hyper-caffeinated, business-monkey-suit-wearing, Blackberry-toting crowd (guilty as charged) who were silly enough to take only half the day off for this visit and are pissed because they neglected to bring their laptops;


D. All of the above.

On June 22nd, BusinessWeek published this article, by Catherine Arnst, titled "The Doc's In, but It'll Be Awhile."

It's a good piece that pulls together research, quotes, and a bunch of 'pop' H/HC news, including the obligatory SiCK0 mention. Based on my sister's experience, I perked up reading a UCSF nugget that a patient with a possibly cancerous mole waits an average of 38.2 days to see a dermatologist.

Even more frightening than the 2-year old selection of motorhead periodicals left via natural selection in waiting areas across the country is the fact that we aren't even keeping track of how much productivity is lost as a result of increased wait times.

Who is getting paid for all this time? And why aren't people generating capital by providing patients with things to do while they wait?

So who's getting paid? Not the doctors. Not the hospitals. Patients? Perhaps, if they are using PTO.

Granted, this is an extremely tricky thing to measure, as it's certainly not ethical to ask employees which doctor they're visiting, or whether it's for a new vs. preexisting condition (even if you're really trixsy and colloquial about it).

You could have your HR/Benefits dept. try to approximate calculations on lost productivity based on average PTO taken for docs visits (if you record this and employees volunteer the information), but this enterprise may be more painful than trying to remove your fingernails with kitchen tongs.

Where we're examining wait times analytically at all, we're examining delays in the medical system from the aspect of the hospitals, and doctors, who are certainly not getting paid for the 3 hours of time a patient waits for a 30 minute appointment.

We're only examining what these wait times do to the continuum of care, or how much our D&T, throughput, and output percentages change. The strain on EDs is particularly severe, as people use ER visits as an alternative to a primary care/family practice appointment.

Almost no one denies wait times are an issue.

They impact care. They impact throughput. They impact patient satisfaction. They may increase exposure to viruses during flu season and spread infectious diseases if waiting areas are not cleaned regularly.

And to be honest, who here has seen waiting rooms cleaned with the same frequency and intensity as patient/exam rooms?

Patients certainly want to be in and out. Medical staff want patients to be in and out (let's be optimistic).

Administrators want patients and families to be happy and healthy upon discharge, and throw open the exit doors spouting the gospel of good, fast treatment, which means - that's right, say it with me - in and out.

But what to do? What if we're going at reducing wait times the wrong way?

We're looking at reducing wait times from the supply side, while demand continues to grow. Yet we're not harnessing demand to create additional market share, and many are not even looking closely at what drives demand at our individual facilities.

As an industry, we're not being overwhelmingly successful in recruiting new staff to drive the patient/staff ratio down, as shortages illustrates (yes, there are some bright points - shop around for a magnet hospital).

We're not expanding facilities fast enough because we're operating on shrinking margins (when merely 'being in the black' is part of your 10 year strategic plan, it's difficult to free up multi-million dollar chunks of capital for an expansion project).

So let's take a stab at reducing wait times from an oppositional hypothetical angle.

What if we opened up wait times to a free market, capitalistic system?

It could look a bit like an airport gate area just prior to boarding, with the "Premium Plus" members cycled through quickly while the A, B, and C acuity levels wait their turn to be herded through the 'coach' continuum. Think concierge/executive care on speed.

Oh, but I'm forgetting one pesky little thing - acuity. You can't triage and then cycle patients with potentially life-threatening health problems through the system by whether or not they'll PAY more Jen!!!

But wait, aren't we sort of doing this now? Don't we ALREADY treat patients differently based on whether or not they can pay? Make decisions about treatment based partially on what type of insurance they have?

We're also not calculating the drain on energy (including electricity, waste removal/recycling, water use, etc) nor the cost of resources used by all those waiting in pre-appointment purgatory.

If we threw all the resources used, all the hours patients spend waiting instead of working or pursuing other personally meaningful activities into the kit, the opportunity cost of all these lost hours looms writ large.

So, today's recommendations:

1. Businesses: Hire a 'housecall' PCP to come offer exams at your place of business. Assure employees visit records are protected and that management, your coworkers, the janitor, etc. never see them. Pay everyone's copays. Follow up the exam day with a nice massage and/or office lunch and you'll also be more attractive to millenials looking for unique benefits packages.

2. Hospitals & Docs Offices: Put in things for patients and their families to do during long waits. At the bare minimum, have coloring packets for kids, a bookshelf for adults, a television. Consider having fixed computer workstations with internet access (with privacy controls if you wish) and printers for use (with a time restriction). Consider innovative ways to make a buck and keep people occupied, including a pay-for-use video game system complete with earphones (hospital waiting room DDR anyone?)...vending machines with board games, etc. The Japanese sell just about everything in vending machines, why can't we?

But wait, you say - wouldn't this be counterproductive? Wouldn't some people come and hang around just to use the facilities?

Of course some would - when I worked in an ED we had some patients come for a meal and/or complimentary bus pass. But don't let those who work the system keep you from improving the system.

Now, wouldn't this be something? People actually choosing your hospital/office over another based on what you offer.

Next step, hire a Chief Experience Officer like M. Bridget Duffy a la the Cleveland Clinic...then let her loose on your waiting areas.


Quote of the Week: Look Ahead

"Look before or you'll find yourself behind."

-Benjamin Franklin


Competitive Case of the Week: Joint Replacement Center

Even 'hospitals of the future' that successfully (and quickly) reorient themselves around patient and physician centric business practices will face pressure from increasingly creative new H/HC business models.

Highly specialized ambulatory care/surgical centers are just one example.

Here's a sample business case to provide food for thought.

Three of your top orthopods announce they are leaving the hospital to start a specialized joint replacement center located 21 miles from your facility. They have not yet announced a partnership with a hospital (yours or a friendly competitor).

Their planned model is somewhat similar to a local maxillofacial surgery center and a laser vision eye center.

After being notified of their resignations, but prior to impending press coverage in the local newspaper, you talk over the coming defection during a meeting with your Chief Medical Officer, who seems a bit concerned.

You ask the CMO to elaborate, as you know only one of the docs personally from prior BOD involvement.

These docs are well-established within your community, have ties to nonprofit organizations, volunteer on committees, and one is a former Board member.

In addition, two enjoy reputations as being 'top' in their field locally - one renowned for sports medicine and 'weekend warrior' surgeries and the other for garnering rave reviews performing hip and knee replacement surgeries on the "55 alive" patient segment. This doc's careful and considerate treatment of geriatric patients and the time she spends with families is remarked upon by both the medical and nursing staff.

The third is a newer doc who has only been on staff at your hospital for 2 years, but is extremely active (you know he's a marathon runner) and has a good reputation. Last year he had a bit of a conflict with one of your more territorial physicians, and your CMO thought the issue had been smoothed over with few lasting effects.

The docs have leased space, hired office staff (including some people they worked with in your hospital), and secured forthcoming press coverage touting the speed and quality of care patients will find at New Hope Joint Replacement Center.

They're offering 'after hours' care by staggering shifts, have hired 3 PAs and 2 Nurse Practitioners (one from your staff, one recruited from a large regional Academic Medical Center), and have Saturday appointments. For an extra fee, patients can arrange for transportation to and from the center so they don't have to drive after procedures or rely upon a family member/friend.

Their reception area design drawings mirror the look/feel of a four-star hotel lobby, and the front desk area is staffed with a receptionist, concierge, and patient advocate (who is also an LPN). Guest registration occurs in small private rooms off the central reception area.

Following registration, each patient is introduced to his/her Dream Team - the doc, the NP/PA, the anesthesiologist (or nurse anesthetist), RN, and CNA who will be responsible for wellness management during their stay. All are present for the preop meeting, unless the patient specifically requests other arrangements.

They've partnered with a minute (retail) clinic chain to provide pharmacy services. The clinic will be located next door, and the two facilities are conjoined like Siamese twins - the pharmacy portion acts as a portal through which patients and their families can access the clinic portion, where they can obtain preoperative exams and other simplistic assessments.

They have also partnered with a local physical therapy provider which occupies space in the same leasing complex.

How do you handle the announcement? How would you position your hospital relative to the New Hope Joint Replacement Center - as competitor or partner?

What internal resources and information do you utilize as you explore a partnership with the doctors and New Hope Center? What immediate actions do you take to broach the subject of a potential partnership?

Do you consider waiting a year to see if the business model bears low-hanging fruit and begin planning an offer to acquire the facility?

How do you mobilize the hospital's public relations, communications, and marketing team to handle a 'counter' message?

How do you feel when faced with the additional information about how New Hope will operate (which is, by the way, probably far more competitive data than you'd realistically be able to gather prior to in-depth partnership talks)? Threatened? Curious?

Do you believe they have a chance of success, and act accordingly, or begin by trying to shut them down, criticizing their model immediately to a variety of audiences ?


Ideal Hospital of the Future: Make Believe

Warning: This is a shamelessly idealistic post, containing healthy doses of sarcasm, imaginative design, and other neat, unrealistic stuff that'll probably never show up within hospital walls.

Say I had carte blanche to design my ideal hospital. For the purposes of this exercise, cost and time are not applicable. Luckily, there's no better place to throw off these constraints than in the blogosphere, where they can't impact operations or fog up the rose-colored glasses.

In this post I'll focus on the 'soft' side, or aesthetics and design. In later posts I'll focus on service aspects and the continuum of care. Not sure what I'd name this dream hospital...anything but "Valhalla." For now I'll call it "Salutis."

Hospitals are environments of caring for the sick, the dying. Salutis would provide a comprehensive environment of healing focused on both acute care and wellness management, using the Wellness Pyramid (mental, spiritual/emotional, physical).

I'd want to see green out my window (healing gardens, water fixtures, a green eco-roof), not flying out of my wallet (although if a hospital looked like any of the environs below, I'd gladly cough up the cash).

With fifteen ortho surgeries under my belt, trust me - the view matters far more to your patients (the conscious ones anyway) than you'd like to admit. Of course, if your house isn't in order, the window dressing won't matter much.

So - arrival/parking. No sooner would the car door close than a volunteer or candidate hired out of retirement (including those who win the AARP model contest) would zoom up in a complimentary transport vehicle. Candidates with mobility issues would also be encouraged to apply. Some hospitals are already doing this (not the AARP model thing, the boomer-volunteers-or-employees-in-golf-carts-thing).

Either that, or you'd steer the wheels to a complimentary valet parking area. Some hospitals are already doing this as well.

To enter Salutis, you'd walk through a spacious, light and open atrium (think UCSD Academic Medical Center).

Entering your room, you breathe "ah, this looks like (insert the environs of your choice from the list below):"

1. The Ritz.
2. A Restoration Hardware showroom.
3. Ernest Hemingway's writing studio (ok, so I'm getting a bit carried away here, but that would sure be MY ideal hospital room).
4. One of the Kimpton Boutique hotels.
5. Disneyland/something Nickelodeon would concoct.
6. A spa in Taos or some other remote, pristine area of New Mexico.
7. A fashion-forward restaurant/bar/hotel straight from the streets of London (Womb chairs and all).
8. "A super Best Buy!" yells my husband, an IT guy.
9. The command deck of the Starship Enterprise.

Dream Team design roster I'd hire:

1. Architecture/blueprints by RTKL Associates, the genius team behind The Heart Hospital, Baylor Plano Texas.
2. Team behind Apple's iPhone.
3. Designers from Swedish home powerhouse Ikea.
4. Designers from Droog.
5. Uniforms and guest/patient attire (bathrobe style) by Isaac Mizrahi and Michael Kors. Hey, if Izaac can do it for Target, he can do it for Salutis.
6. Fixtures by Michael Graves (also a Target talent extraoordinaire, which means he can work with mass production systems and leverage economies of scale).
7. Furnishings by Karim Rashid, Philippe Starck.
8. Bed linens by Tord Boontje.
9. Complimentary weird + ugly dolls on each bed (holding a customized greeting and goodie) by BabyGeared (I'm partial to Pig-Pig).
10. Food/menu by Sobo Cafe chef (Baltimore's Inner Harbor/Federal Hill).
11. Drinks by (of course) Starbucks, Jamba Juice, Honest Tea, and Jones Soda.
12. Payment systems & back office design by Jonathan Bush, Athena Health.
13. Identity/Operations Critique (Chief Identity Officer, Chief Talent Officer, Chief of Running Smoothly) & Vision Research, Design, & Implementation (formerly called PR) by Matthew Holt (The Healthcare Blog) and Paul Levy (if I can hire him away from Harvard).
14. Guest Relations Teams designed and trained by yours truly with a Patient Advocate, Concierge, CNA, on every floor, with a centrally located desk area easily accessed from the elevators (they also get a very snazzy uniform, perhaps something by J Crew or Brooks Brothers).
15. "Recharge Room" (one per floor) design by Jonathan Adler.
16. RFID tech, including automated medication systems, by Savi Technologies. Salutis Hospital would become a preeminent center for health IT, medication/equipment/supply tracking and management, etc.
17. Poetry Therapy/Poets on the Wards program designed by John Fox, CPT, Rafael Campo, and Lucille Clifton.
18. Portable DVD players (I'd do away with fixed televisions completely) and laptops (by Dell) available via the Guest Relations Team for checkout by patients and visitors (ever been sitting in the corner of a hospital room bored to tears while your loved one is sleeping the sweet dreams of the heavily medicated? portable DVD player + earphones = window to blessed release).
19. Aquarium Design (what can I say - aquariums are among my favorite places, calming, soothing, tranquil) by Aquarium Design Group.

Employees, called "the talent" by admins, are thrilled to work at a magnet facility with:
  • free coffee/tea/water
  • a chapel
  • a meditation room
  • yoga/pilates/cardio onsite in the Optimal Wellness (rehab medicine) center
  • onsite childcare & lactation rooms
  • free parking/weekly car washes
  • onsite drycleaning (Texas Scottish Rite Children's Hospital)
  • an internet lab with free access
  • free weekly continuing education/professional advancement groups a la Toastmasters
  • 1 day off per month (minimum) for volunteering/social wellness activities
  • a restaurant (Akron City Hospital) with gourmet offerings in 30 minutes or less - employees and family entitled to 1 complimentary meal a month
  • an art gallery with periodic community shows by local artists and themed exhibitions (free)
  • strolling musicians (guests can request a musician from a menu modeled after dietary options - I'd call it "Creative Time Killers")
  • recorded or 'canned' music provided by local choral groups and orchestras, as well as bands
  • onsite massages for staff, 1 every 2 weeks

How much would this systemic vision of idealistic design cost? Who knows? Probably a few billion.

The problem with hospitals today isn't systems, it's that systems have overwhelmed people.

Systems for payment. Systems for reimbursement. Systems for hiring and firing. Systems for benefits. Systems for purchasing. Systems for scheduling. Systems for operations. Systems for licensing and certification. Systems overwhelming people.

People who work, people who heal, people who are sick, people who need surgeries, people who guide/lead/boss/mentor/manage, people who struggle to pay. People who die when the system doesn't work. People who die when the system does work.

So how do you attract people? People to work, people to check in, people to notice and comment? People to heal and evangelize? Overhaul your systems. Revolutionize your design. Become a 'hospital of the future.'

If you build it, they WILL come. I sure will.


PHRs: Are We Giving Them Spoons Instead of Shovels?

Why low-tech hurts....

In the June 16th print issue of The Economist, there's a good piece on the behavior of crowds and politics, describing why 'The electorate is irrational (p.42).'

The piece includes a story about an economist who goes to China and sees hundreds of workers using shovels to build a dam. The economist asks why the workers aren't using a mechanical digger.

"That would put people out of work," says the foreman. The economist replies "If it's jobs you want, take away their shovels and give them spoons."

Are we giving our nurses and docs spoons (outdated paper-record keeping systems), and withholding the shovels (electronic or web integrated medical/health records and systems)?

The question we're all trying to answer: In terms of productivity at our respective organizations, how much would better 'tools' in the form of EHR systems reduce the workload and pad the effects upon our healthcare system of baby boomers as well as looming nursing and doc shortages?

Yesterday Vince Kuraitis, author of e-Care Management (another must-subscribe H/HC blog), put up a great post.

Vince provided his spin on Google Health & the tech giant's potential plans to dominate the personal health record (PHR)/electronic health record (EHR) market.

Put aside 20 minutes for this must-read post (including the Comments section).

Imagine the spin-off opportunities that may be created by an integrated and multipartite EMR/PHR system, with various compenents controlled by "users" or patients (portable or web-based PHRs) and managed EHR systems integrated across hospitals and docs offices.

These records would then be coordinated and accessible through either web-based applications and/or servers within the docs offices and hospitals (see my comment on Vince's post for further explanation of what such a system might look like).

In this scenario everyone wins, because the products that are developed are oriented around how different market segments will use them, but the health information inputs, whether 'commercial' or 'consumer,' can still 'talk' to each other.

End-use is the penultimate goal - and not everyone wants to use a PHR/EMR for the same purpose. Marketing would be audience appropriate, designed to appeal to reducing inefficiencies on the hospital/physician side, and in obtaining/maintaining 'control' and access over personal health and wellness information for consumers.

Think of the telecom/mobile phone market. Many providers have sprung up to provide ways for people to talk and email on portable devices. Other firms were founded to provide commercial services and plans.

The point is that in telecommunications, we can all pick the providers and plans that have the most relevance to our needs/wants. Shouldn't we be able to do the same in the EMR/PHR market? And yet whether you use a Blackberry, Verizon services, a Cingular phone, or a landline, we can all 'talk' to one another regardless of what vendor we're using. Of course, I'm vastly simplifying the process for the sake of this exploratory analogy.

If PHRs are both web-accessible (personal health URLs as Vince posits) and remotely portable (ie thumb drives), companies that provide 'skins' similar to those available for Ipods are just one possibility of future entrepreneurial activity.

Picture animal-shaped skins, complete with colored lanyards, for patients at Children's hospitals, for example.

Is there potential for a new Apple offering here? For an Apple/Google PHR partnership? Google provides the PHR web-based access and Apple provides the peripherals, designed with the company's flair for innovative aesthetics?


Green Hospital: Dell Children's MC of Central TX

A Seton hospital, Dell Children's MC is now 92% complete.

Built by White Construction Co. of Austin, the 195-bed Dell CMC rings in at 470k sq/ft, and cost a pretty penny at $200M (Seton shelled out about $125M, the Dells put in about $50, and fundraising accounted for about $25M).

Warning: Place something beneath your chin to catch any errant drool that may result from viewing the Dell CMC gallery.

here for some amazing renderings of the exterior, including grounds.

Seems someone is finally listening when designers and architects tout the benefits of organic and representative design. On the renderings (link above), note the functional and metaphorical "hub and spoke design."

After the JCAHO "Hospital of the Future" convention in Lake Buena Vista FL this past April, a colleage and I braindumped some very rough hospital designs on a cocktail napkin. The goal was to stop thinking of hospitals as hospitals, and instead reimage facility design based on our personal ideal healing environment.

My cocktail buddy, a JCAHO consultant, laughed at me politely as we chowed down on the cheese and grapes. I'll be sure to point out this post to him when we have lunch next and give him a bit of the old I-told-you-so.

My favorite looked like a series of sunflowers, with curved perspectives. The goal was to take forms from nature (sunflower=fibonacci sequence) and relate how they may apply to organic facility design/aesthetics.

Why waste time drawing something like this? Well, the merlot may have had something to do with it, but freeing ourselves to imagine our ideal 'hospital of the future' is the first step to bringing these designs into the present.

Kalsberger Architects, who designed Dell CMC, are my H/HC Progressive Heroes for the week.

Seton details green building guidelines used here.

"Green" highlights:
  • 3 acre healing garden
  • 5 interior "lungs" or open-air courtyard that allow the hospital to "breathe"
  • even the brownfield building site is 'repurposed' land at the 750 acre former Robert Mueller Municial Airport, and the building is part of the City of Austin's Smart Growth Initiative
  • rainwater collection system
  • grounds are designed using xeriscaping and native flora
  • solar energy/panels
  • low VOC (volatile organic compounds)
  • efforts to design for maximum natural daylight exposure, which may promote healing (may promote healing? does chocolate taste good???)
  • low-flow toilets
Here are the major players, as in this McGraw-Hill Construction Magazine piece:
Key Players
Owner: Seton Healthcare Network, Austin
General Contractor: White Construction Co., Austin
Architect: Karlsberger Architecture Inc., Columbus, Ohio
Structural Engineer: Datum Engineers Inc., Austin
Civil Engineer: Bury+Partners Inc., Austin

Say you have the impossible blessing of designing your ideal hospital. Cost, space, and time constraints have been removed from the equation.

So what does your ideal hospital look like? I'd love to hear from you...more on this thread tomorrow.


Want to Go Green? Check out TerraPass

With experiences of this trip weighing heavy, today I'll go in for a bit of glass-half-full.

"Green" business (especially within our H/HC industry) is a particular interest. Tomorrow I'll share a Children's Hospital that's taken eco-friendliness to a whole new level.

With significant time spent in the friendly skies this year, I started thinking about ways to 'buy back' a bit of the trips' environmental impact.

Google "offset emissions" and you'll stumble across a veritable smorgasboard of companies offering programs to reduce the carbon emissions you generate via air travel, the daily commute, running the hearth & home.

But none are quite as nifty as TerraPass.

These guys and gals make it almost obscenely easy to breathe easy (literally and figuratively).

Just select programs customized for home, dorm, flying the friendly skies, etc. The nifty group of folks (Stanford students) at iinnovate have a great interview with Tom Arnold, TerraPass's Chief Environmental Officer here.

Click here for more info, and here to learn more about a green business with lofty goals.

You can even turn in old cellphones (usually the past 2 years' models) for cash. Then convert the bucks to cleaning your conscience and the environment by purchasing a 'free' TerraPass.

Click here to learn more and see what RipMobile will give you for your phone; they even provide old Berrys with a final resting place (or at least a second chance to addict a new user).

If I turned my T-Mobile Pearl model in now, I'd receive a $155 credit. Although I'd have to contact an ortho doc blogger to surgically remove the keypad from my fingertips first...

Now, here's the real question - is it worth it to throw a bit of cash at the problem, or should I take the lumps, and make some strategic decisions that allow me to fly and drive less?

Does plunking down a bit of change for a TerraPass really make that much difference in the global environmental trend? Check out the site - you be the judge.

I'm not completely sold, but it sure did make me feel better to purchase a TerraPass Puddle Jumper, which offsets about 6,000 miles of flying. My roundtrip from DCA to Miami this week was just under 2k miles of flight time, so I've got about 4k 'left' on the pass.

I got a tingly feeling when I checked out (They accept PayPal? This is only costing me ten bucks???)...it felt a bit like planning to buy a hybrid, cleaning items thoroughly before recycling, or picking up errant pieces of litter left by patrons in airport restaurants.

Enough tooting the horn, but if even one of you buys a TerraPass, this post is well worth it.

Now, who will be the first hospital to buy a TerraPass covering operations/executive travel for a day? A month? A year?


Meeting Sy: Part II

It's important to note a few more things about my Dunkin Donuts encounter with Sy.

1. Sy didn't come across as a malicious malcontent...he related events in the post below calmly, with a sense of underlying wit.

His mannerisms were urbane and his speech courteous. I doubt he would have openly conversed about his experiences with someone not genuinely interested and engaged.

The conversation would not have the same impact if Sy was an angry, sue-the-restaurant-that-gives-me-hot-coffee-when-I-spill-it-on-myself type of guy.

I'd be willing to be most docs, nurses, CNAs, patient advocates, etc. have a few Patient Xs hiding somewhere in their subconscious history.

For whatever reason, these patients had such a deep impact that the memory of them drives our 'calling' home when the going gets tough.

Sy is now one of mine.

2. It was Sy's seeming resignation to the state of elder care and age discrimination (intentional or underlying) that made our talk so troubling.

Have you ever verbally or nonverbally questioned a patient's decision to undergo treatment (chemo, surgical intervention, etc.) based on their age?

Somewhere way back in the brainpan have you thought "Hey, I would never undergo that treatment at that age, why risk it?" or, worse yet, "The risks just can't be worth it at his/her age." I have.

Improvement starts with cleaning house. The next step is the addition of a cleansing agent, such as a volunteer advisory board or committee to address agism and compose guidelines for how to treat those in the "55+ Alive" demographic.

If anyone wants to extend an invitation to Sy, I know this little coffee place he frequents...

Recruiting a committee takes a bit of time, but there is something you can do tonight - check out AARPs mag. It's a must-read - I'm always impressed by the content's utility and presentation.

Erickson Retirement also has a nifty channel,
Retirement Living TV, dedicated to the late-great set - here's a quick description. Some programming is available online...find out if you can view shows on your TV at home here.

"Keep Doing Your Research"

Everyone has a hospital story - good or bad.

As a hospital/healthcare professional, you never know how a seemingly small interaction can change the way you view our business.

This afternoon in a West Palm Beach Dunkin Donuts store I met Sy.

Sy, who visits this location every day around noon for his coffee, was energetically giving the good-natured cashier a hard time. He punctuated scathingly affectionate comments with taps of his cane on the counter - who could resist jumping into that fray?

Either he smelled 'healthcare' on me or I look like a drug rep (or both), but Sy and I also ordered the same medium regular java with ice and cream, so perhaps we were just bound to start chatting.

A retired lawyer, Sy moved to the Sunshine state 15 years ago. His firm represented a New Rochelle Hospital (among others) and a small horde of docs up and down the eastern seaboard.

After we chatted briefly about electronic health records (EHRs), Sy shared his opinion of the Florida healthcare system, and his views on how they treat seniors.

Sy and his wife, in their 80s, have been treated for a variety of conditions in the last few years, including progressive bladder cancer, an aortic aneurysm, a 'male' cancer, and ortho issues.

Three years ago, Sy's wife noticed blood in her urine. Two separate specialists in Florida viewed CT results and diagnosed a cyst (without biopsy). One offered to remove the cyst in the office, another offered to perform the procedure at the hospital on an outpatient basis.

Sy's wife was uncomfortable with the situation, concerned about the blood in her urine, worried about the offhand attitudes of the doctors and also the lack of further testing. Sy asked if she wanted to go 'home' to New York state for treatment, so they arranged to see a specialist there.

In NY, the specialist performed a biopsy. Sure enough - progressive bladder cancer. Surgery commenced. Sy's wife has been cancer free for three years and is "doing just wonderful."

I wish I could say this was an isolated experience, but as anyone with a chronic condition knows, you-know-what happens. Sy told 4 more stories like this one.

The one that sticks in my gullet involves a friend and his wife.

Sy's friend was admitted as an inpatient here in Florida for hernia surgery. Just prior to discharge, the friend's wife noticed the dressing/bandage near his groin was bloody with fresh bright blood. She alerted a nurse, who changed the dressing. This happened twice more before the wife went home for the night - the doc decided to keep her husband for observation.

You may be able to guess where this is going.

Early the next morning she got a call from the hospital. Her husband bled to death shortly before 4am.

One of Sy's biggest concerns (understandably) is the influence a patient's age has on quality of care.

In his experience as a lawyer, and a patient, and a retiree living in a geriatric hotspot state, he also believes doctors are less likely to be cautious and aggressive with follow-up care for older patients. He commented "What are you gonna do? You're gonna die in a few years anyway, and all the cost - why bother? They know that."

Hefting his cane, Sy made his way to the door. Just before he left, he turned back to me.

"Keep doing your research - get in there and straighten them out."

"They need all the help they can get, right?" I was only half-joking.

Hefting his cane, Sy stepped out of the store. The few minutes he took over coffee to give me an honest assessment of the geriatric healthcare environment have the cream curdling in my stomach.

When I'm feeling glass-half-empty and the industry seems broken beyond repair, I'll remember a blue-eyed man who took the time to tell it to me straight.

Question of the Day: Why don't we have more patients like Sy on hospital advisory boards?

Thanks Sy - most valuable coffee break I've ever taken.


How to Pick a Doc - Masked Sources Tell All in New York Magazine

The following entry is comprised of commentary based on the article "What's Up Docs? A panel of anonymous physicians cough up tricks of the trade" by Robert Kolker, published in New York Magazine's "Best Doctors 2007" issue.

The premise is brilliant - a panel of five docs spill the beans on how to pick a doc, get an appointment with a specialist (pray???), and why wait times resemble Dante's trip to the inferno.

Click here to read the article, published today. (Thanks SenorBuck for the link).

The New York Magazine recruited the following docs to act as sources:

Dr. Lung
. . . . . .Pulmonologist
Dr. Heart1 . . . . .Cardiologist
Dr. Heart2 . . . . .Cardiologist
Dr. Virus . . . . . . Infectious Diseases
Dr. Baby . . . . . . .OB/GYN

Some highlights:
  • Always Bring a Family Member/Friend to Act as Personal Patient Advocate: Dr. Baby relates a horror story on page 5.
  • Don't Go to a Hospital in July, or is That July Business an Urban Legend? You decide after reading page 3 (also, try not to get admitted on a Friday after noon).
  • Flattery Always Works: Want an appointment with a top-notch specialist? Tell them you're a fan and are glad to be there.
  • Don't Refer Difficult Patients: Docs (at least some in this article) don't want your hypochondriac sister-in-law, your multi-chronicity Grammy. They may, however, want your well-paid working professional book-club friend who arrives and pays on time. To be fair, I'm carrying this a bit far - Dr. Heart1 did mention referring good patients is appreciated.
  • Drug Companies & "Low Level Bribery": Dr. Virus has a great example of a steak dinner thrown by makers of an expensive antibiotic. Dr. Heart2 describes being 'wooed' and why we might take a closer look at Big Pharma's relationships with hospital purchasing depts.
  • It's All in the Degree: How to pick a doc? Check out where they went to med school (cardiologist).
  • Yellow Pages Anyone?: Picking a doc was compared to having a personal shopper, choosing a car mechanic, accountant, and lawyer.
  • Why Brand/Image Matters: Pick a doc by selecting a hospital 'brand' you like ("I think better doctors are typically at better hospitals"). Side note: I had an experience with one of the best ortho surgeons I've ever met at a tiny community hospital in the mountains of Cumberland, MD. His care and results equaled that of some more 'branded' physicians at a top trauma center in Baltimore, MD. Can't docs, like professionals of any other ilk, have stellar reps and pick an area based on familial ties, schools, quality of life, etc.?
  • Seek Those Who Teach: If you go to a teaching hospital "your statistical risk of turning up a clown is much lower" (infectious diseases doc). I'd like to see the aforementioned stats on this, but that would sort of defeat the whole masks-on-the-back-of-the-head, secret-agent anonymous-commentary angle.
  • Why You Want the Number 2 Heart Doc: Dr. Heart1 said don't pick the tip-top heart doc at a university hospital - this MD has published papers, talks the talk, but may not be able to walk the walk.
  • Use Referrals: "There can be good doctors in small hospitals and bad doctors in big hospitals. That’s why you also want a patient recommendation." - Dr. Lung
  • You Can't Escape It -Network, Network, Network: Getting in to see a specialist is all about the referral. Oh, and what type of insurance you have and how quickly they pay.
  • The 7 Minute Rule: "If you’re an HMO doctor, the network will tell you to see, on average, a patient every seven minutes."
  • Bring Jokes & Food: Shocker - like just about any other professional under the sun, docs spend more time with people they like. "You have fun with patients you like." - Dr. Baby
Favorite (?) SiCKO worthy quote (along with each doc sharing medical mistakes):

"HMOs tell us to see more patients; malpractice insurance tells us to take all the time we need."-Dr. Baby

Good Grief, There's More:

"Research is a real problem. Doctors just make up the data." - Dr. Lung

Favorite funny quote:

"You deal with professionals who know more than you in all walks of life, and you somehow learn how to find out who’s full of shit and who’s not." -

Well, that makes a great soundbite. But how much experience with the 'system,' i.e. what level of chronicity/acuity does a patient need to have before they can pick the good docs?

The doc who compared it to picking a lawyer or accountant did have an interesting metaphor - all things being equal (meaning I could hop online and find a complete, relatively accurate listing of docs in my area with 'ratings' from 'users' a la travel site Tripadvisor.com), I'd pick a doc based on their publications, reputation in the community, standing/awards, and referrals from trusted sources, including a PCP.

NOTE: RateMDs.com, a relatively new site, is one to watch. Also check out the graphically-clumsy HealthcareReviews.com. Revolution Health's Care Providers page shows some promise to further develop a rating capability, but there's room for an aesthetically pleasing, easy to use site to enter the market.

Oh, and I'd also consider price and whether or not the office accepts cash, my insurance, etc. Do they have convenient parking? A pharmacy in onsite/in the same building? A coffee machine in the waiting room? Just kidding (kind of).

How many of us really 'pick' our doctors in the same way that we pick car mechanics or realtors?

Is it realistic to believe many of us are finding a doc, who has approx. 5-40 minutes of room-time per patient during a PAYING appointment, based on his/her background, degree, areas of research interest, etc.?

Hopefully, you learn how to find out whether or not a doc is full of shit before you really need her to step in and dirty those gloves saving your life or limb.

Paul Levy's "Running a Hospital" Links to Health Mgmt Rx

Check out the mention here - thanks Paul!

Turtle: http://runningahospital.blogspot.com/2007/06/new-links.html#links


Mayo Doc Creates Office of the Future: Walk Your Way Through the Day

On Michael Moore's SiCKO page, he recommends exercise as something consumers can do to combat the desiccation of our collective cultural health ("eat fruits and vegetables and walk around").

I'd like to see hospital administrative teams take the lead on this...let's be bleeding edge rather than reactionary on the "move it or lose it" trend.

Executive teams have a nasty habit of not adopting 'new' tech or workflow processes until they've been beaten to death by another industry (FINALLY we're getting to lean? to green design? to non-smoking campuses? how long have we been obsessed with Disney?!?)

This is how Mayo Clinic is addressing the rats-in-a-cube (or corner office) conundrum.

Dr. James Levine's "NEAT" (non-exercise activity thermogenesis) Office of the Future has:
  • 10 Plexiglass areas with standing treadmill desks/computer platforms; treadmills are set to 1MPH to work your heart (100 calories/hour) without working up a sweat
  • a completely mobile workforce - the talent wears mobile phones, and there are no desk/fixed phones
  • a two-lane walking track that brings new meaning to the phrase power chat
  • animated reminders to get up and move projected onto three walls in the work area
  • plastic carpet skates are provided so workers can travel from meeting to meeting in style
Levine is currently researching NEAT classrooms...how I would have loved to walk off some frustration during an algebra exam...

Click here for NEAT office images.

Here's another good article on the NEAT office in USA Today. And here's a good piece on the NEAT Classroom of the Future on Medical News TODAY.

How much did this healthy office cost Mayo? Try $5 to $5.50 per square foot.

But time...time is money...it would take way too much time to put this into place right? So how long did it take to implement?

6 months after Dr. Levine published an article about NEAT in Science the office was up and running (Science, Jan. 27, 2005).

Can you afford to spend this amount amount of time and money creating an environment where health and movement augment productivity and enhance employee satisfaction?

The real question is, can you afford not to?


Feds Pay for Retail Medicine: Minute Clinic Chain to Accept Medicare

RediClinic now accepts Medicare

Houston Business Journal - Wednesday, June 13, 2007

"RediClinic LLC has formed a provider agreement with the Centers for Medicare and Medicaid Services to accept traditional Medicare in RediClinic's 46 locations nationwide" including:

  • 13 clinics in Wal-Mart stores
  • 17 clinics in H-E-B stores throughout Texas
  • 16 clinics in Atlanta-area Walgreens

"The Houston-based retail convenient care company said the Medicare coverage is in addition to the Medicare Advantage coverage already in place through existing contracts with Aetna, CIGNA, Humana and UnitedHealthcare."

They're not just lobbying payment providers like crazy.RediClinic is all over the news, building a series of partnership deals that break into mainstream retail spaces.

Will these clinics replace current ongoing relationships with primary care docs or community hospitals we consider our "medical home?" (see Dr. Larry Fields' description of the 'medical home' concept here).

Who knows? Most of us are waiting to see how these systems complement the current system, and how the growth and consolidation of regional chains will affect the marketplace.

The real question, however, is whether the retail/minute clinic model will succeed in reducing the strain on overburdened quickcare/urgent/fast track clinics and ERs.

In addition, how will payors deal with claims that include same-day visits to a retail clinic and a hospital (for referred FU care the clinic couldn't D&T)? Although many of the clinics operate under care-for-cash models, how often are consumers aware of what's really coming out of their wallets? They may end up triple-paying...once for the clinic fee, once for the copay at the ED or for other FU care, and once if the services related to that condition's D&T are not 100% covered by insurance. And of course this doesn't count the dollar drain they already experience paying for insurance coverage. If anyone can augment this post with experience on how HMOs, hospital billing offices, etc. handle these claims, I'd love to hear about it - please chime in with a comment.

When I worked as a patient advocate in a small community hospital ED, we often saw referrals from the local Urgent Care Clinic. Understandably, many of these patients were frustrated that they'd waited at the UCC, been told the UCC didn't have the facilities/equipment/staff on hand to diagnose/treat them, and now had to register and wait again in the ED.

It would be interesting to see results from a study detailing the percentage of patients from retail clinics referred to EDs for further treatment, including Xrays and other relatively common diagnostic procedures.

In other words, for patient populations of varying demographics, how often can the retail clinic model meet all of their needs without additional follow-up care? What number of patients are referred to other providers (ie hospitals) for 'immediate' or same-day follow-up care? 1 in 5? 1 in 50?

For the RediClinic opening in a Richmond, VA Wal-Mart Supercenter store, RediClinic offered "$39 sports and camp physicals and our 7 Vital Tests for Women package for just $15 so everyone can experience how easy and inexpensive healthcare can be.” - Web Golinkin, chief executive officer of RediClinic

RediClinics are open Monday through Friday 8 a.m. to 7 p.m., Saturday 9 a.m. to 5 p.m., and Sunday 10 a.m. to 5 p.m. Adults and children over age two are welcome, no appointments are necessary and a typical visit takes about 15 minutes (15 minutes?!! I may take a drive to Richmond to mystery shop this visit time). RediClinic charges a flat rate of $59 for Get Well services and preventive services start at $15.

If I could walk in to a RediClinic while on the road for work and pay 15 bucks for preventative services, would I consider that visit as an alternative to waiting 4-6 weeks for a slot on my PCPs schedule? Heck yes.

Talk about your competitive advantage...

"Sicko" Leaked On Web

Perhaps it was inevitable.

Michael Moore's new movie "Sicko" has been leaked by an unknown source and is available for download online (using Pirate Bay, BitTorrent or the like). Although, by the time this post is published, many sites will probably have removed it.

Even if Moore's team or Weinstein didn't have a hand in the leak, it's a brilliant strategy...14 days before release a teaser copy becomes available and the blogosphere will be swarming with talk (guilty as charged).

Click here to read the AdAge article published this morning.

Although it's certainly tempting to get a peek at this flick before it hits the big screen nearby, I'll refrain.

I'll pull through the two week wait and enjoy planning to see it in a theater that now charges almost as much as a baseball stadium, with temperatures approximating the next ice age, a bucket of stale popcorn, a notepad, and some Tums. Also, probably a travel pack of Kleenex.

The movie is scheduled for nationwide release June 29th. According to the movie's page:

"SiCKO' is a straight-from-the-heart portrait of the crazy and sometimes cruel U.S. health care system, told from the vantage of everyday people faced with extraordinary and bizarre challenges in their quest for basic health coverage.

In the tradition of Mark Twain or Will Rogers, 'SiCKO' uses humor to tell these compelling stories, leading the audience conclude that an alternative system is the only possible answer."

Turtle: http://www.michaelmoore.com/sicko/about/synopsis

The synopsis isn't the most interesting portion of the "Sicko" webpage - here are Mike's 6 responses to what consumers can do (verbatim from the site):

1. Your organization can sponsor a screening.

2. Post a YouTube video of your health care horror story and we'll post some of them on the website. (As of 10:30am EST, 39 videos have been posted here).

Send your health care horror story to your member of congress and CC michael@michaelmoore.com.

4. Pay a house call to your local congressperson and let them know how you feel.

5. Band together with organizations to bring down private, for-profit health insurance companies.

6. Eat fruits and vegetables and walk around.

I particularly like number 6 - excuse me, I need to go grab an apple.


CMS to Use DRG Classifications?

From a Modern Healthcare alert sent last night:

"The Medicare Payment Advisory Commission told the CMS that it should adopt the Medicare Severity Diagnosis-Related Groups payment system, or MS-DRG, as proposed, but recommended that the agency make some refinements to the proposed methods for estimating cost-based weights."

Some goals (according to MedPAC):
1. improve payment accuracy
2. reduce charge compression effects

Click here to see the actual letter. I encourage you to read the whole 21 pages of gooey governmental goodness.

In burea-speak, here are the meat-n-potatoes recommendations to whet your appetite:

"For fiscal year 2008, we recommend that you:

  • Adopt MS-DRGs, as proposed;
  • Make two refinements to your proposed methods for estimating cost-based weights for MS-DRGs:

1. As a short-term step to ameliorate the effects of charge compression on the weights, adopt the RTI-recommended methods for calculating national revenue center cost to charge ratios (CCRs), for drugs, supplies, radiology, emergency room, and blood products. This would increase the number of revenue centers—groups of hospital departments in which hospitals charge patients for services—from 13 to 19; (because we all like more revenue centers right?)


2. Standardize the Medicare charges and costs used in calculating national revenue center CCRs to adjust for differences in local wage levels and the extent of hospitals’ teaching activity and service to low-income patients. (curiouser and curiouser)...This change would be consistent with your use of national standardized charges by revenue center for each MS-DRG in the other half of the cost-weight calculation;

  • Terminate the transition to cost-based weights—adopting 100 percent cost-based weights, or adopt a two-year transition period for MS-DRGs that coincides with the remainder of the current transition period for implementing cost-based weights. These actions would help to balance the payment impacts of implementing severity refinements and cost-based weights; and,
  • Adopt an adjustment that is between -1.6 and -1.8 percent per year (for at least the two years following adoption of MS-DRGs) to the standardized amounts to offset the expected impact of improvements in documentation and reporting of diagnoses.
Further comments:

  • Our analyses show that substantial differences in relative profitability would remain, on average, for cases grouped in many MS-DRGs, even if payments were based on the refined cost-based weights described above.
  • Our findings also suggest that adopting cost-based, hospital-specific relative value (HSRV) weights would result in substantial further improvements in payment accuracy.
  • In addition, CMS needs to make a sustained effort to improve the quality and specificity of the information that hospitals submit on their annual cost reports. To meet this goal, CMS
    will have to change the cost reporting form and instructions, and step up efforts to inform providers and monitor the information they furnish.
  • An effective patient classification system—in the context of a payment system—should group together clinically similar cases that have similar costs.
  • The average absolute difference for MS-DRGs was 4.8 percent lower than the average absolute difference for the current DRGs. In other words, the MS-DRGs did a better job of grouping cases with similar costs into the same category. This was expected because the MS-DRGs break out high severity (and high cost) cases with major comorbidities or complications (MCCs) into separate DRGs.
  • Under the DRG system, only 23 percent of total payments fall in MS-DRG categories that have payment to cost ratios that are within 5 percent of the national average payment to cost ratio. In the case of proposed MS-DRGs, 55 percent of payments fall in MS-DRGs with payment to cost ratios that are within 5 percent of the national target. If CMS adopted the refined version of the cost-based weights, 58 percent of payments would meet the target for payment accuracy.
  • These longer-term improvements are needed to reduce the extent to which Medicare encourages community hospitals to allocate capital to profitable services, such as cardiology, and stimulates the formation of specialty hospitals that often focus on providing profitable services and tend to care for low-severity patients.
So what does all this mean for revenues (gulp)?

  • Now that CMS is proposing to adopt MS-DRGs in 2008, continuation of the transition
    period for cost-based weights would produce payment swings between 2008 and 2009. Many of the hospitals that benefit from cost-based weights (including small urban and rural hospitals) will see their payments decline under the MS-DRGs. Therefore, some hospitals that saw an increase in their DRG weights and payments in 2007 due to the phase-in of cost-based weights will see a decrease in their weights and payments in 2008, and then a slight increase in 2009 when cost weights are fully phased in. Conversely, many of the hospitals that saw a decrease in weights and payments due to the phase-in of cost-based weights will see their payments increase under MS-DRGs in 2008 and then decline again as the cost-weight transition ends in 2009.


Competitive Advantage? What &%#@^* Competitive Advantage?!

If you don't read Running a Hospital, put down the Forbes and start off your day with a cup of java and the always-visionary Paul Levy.

Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, recently posted here asking for input on how to position his facility against the competition.

As evidenced by Paul's posting, BIDMCs administration has done significant deep-dive strategic thinking, positioning themselves as an "'Avis' to {Partners HealthCare Systems} 'Hertz.'" BIDMC has "adopted a plan to position ourselves as a low-cost and high-quality provider in this region."

If you tend to glance down your nasal passages and flare those orifices when hospital operations is tagged "the business of caring," I warn you - stop reading now.

You can squint those orbicularis oculi all you want - but believe it or not(!), hospitals are businesses, with fiscal as well as socio-ethical responsibility to care for clients, shareholders and community stakeholders.

This means profit and loss, people. This means periodically evaluating your facility relative to the competition. If you're doing this - wonderful. You get a gold star - keep up the good work.

If however you're an administrator with the following issues swirling in your left hemisphere, keep reading:
  • Price Transparency: Should we make this available to consumers? Or, if we've slapped this information up on our website, how are people using it? How many views and unique visitors does this section have per week? Per month? What conditions garner the most interest (are our conditions hyperlinked so this can be tracked with any degree of specificity?)
  • Price Competitiveness: How do our prices for 'common' conditions, DRGs and procedures stack up against those regional players we consider competition? (Note: If you're pensively wrinkling your brow over how to define your 'competition,' ignore the rest of this post and figure that out pronto).
  • Service Line Evaluation: What do we offer currently that our patients and staff are proud to talk about? What are we thinking of offering in the future? Is this feasible given what other hospitals in the area are offering? What are our current environments of excellence? Should we pump more funding into current centers of greatness or do we want to focus on 'weak' spots in the market?
  • Defining Competitive Advantage: What advantages do we have relative to other facilities? Are we providing what people want? Do we have a laser eye clinic? Are we working towards magnet status? What are the selling points that make patients want to come see us, or, alternately, choose to see the competition? Is our competitive advantage comparative, differential, or a combination of the two?
All these tricky evaluations beg the question - exactly what is competitive advantage?

The gospel according to Investopedia defines competitve advantage thusly:

"An advantage that a firm has over its competitiors, allowing it to generate greater sales or margins and/or retain more customers than its competition. There can be many types of competitive advantages including the firm's cost structure, product offerings, distribution network, and customer support.

The more sustainable the competitive advantage, the more difficult it is for competitors to neutralize the advantage.

There are two main types of competitive advantages:
1. Comparative
2. Differential

Comparative advantage, or cost advantage, is a firm's ability to produce a good or service at a lower cost than its competitors, which gives the firm the ability to sell its goods or services at a lower price than its competition or generate a larger margin on sales.

A differential advantage is created when a firm's products or services differ from its competitors and are seen as better than a competitor's products by customers. "

I know, I know. "But Jen!" you're thinking..."anyone with a dictionary, an internet connection, or a library card can figure this out!"

Of course that's true. So why are you spending time reading this blog rather than drawing up a detailed evaluation of your %$#@ competitive advantage?!


TPM = Transition Planning & Management...New Facility? Switching Offices?

Consultants Warning: Transitioning to a new facility may cause headaches, eyestrain, fatigue, irritability, and nausea. Feel free to contribute your symptoms as a comment. Oh, and did I mention occasional hair loss?

"Chances are, what you’ll remember most about a major construction or renovation project is not whether it was completed on time and on budget, but whether you were able to resume effective clinical operations from the moment the doors of the new facility opened. The problem is, most healthcare administrators don’t consider the transition until much too late in the design and construction process, if at all."

-Carolyn Pfude, Manager, Transition Group, Gilbane Building Company
Healthcare Design Magazine "Managing a Seamless Transition From Old to New"
*NOTE: This article also sports a handy puzzle-piece visual detailing components of TPM.

Basic Remedy: The Six P's
Prior Planning Prevents Piss-Poor Performance....those military-types have a clever acronym for just about everything.

The first two P's, Prior and Planning, are easier to handle when administration is in full agreement about the purpose and varied uses for the new facility.

If the COO believes you're going to reduce average LOS by .8 days, and the CFO believes 110 new acute care beds are going to increase revenue by 0.7% you've got a problem - find out if administrator's goals are competing or compatible before the construction crew is onsite.

If your team is in the initial planning stages or even reviewing RFPs, try these activities to treat conversational constipation:

1. Appoint a Chief Staff Motivator (or Team): Who will act as the chief motivator? Sometimes this role naturally fits the talents and skill set of the CEO. In other instances, a motivational team with the authority to organize small, spontaneous giveaways and celebrations is in order. Carolyn Pfude (Gilbane) emphasizes the importance of PLANNING for this capability, rather than reacting 8 months after drills have started buzzing and morale has taken a nosedive.

2. Perform an Equipment Needs Audit: What do we have? What's too old? What's new that we want to move? Do we need additional vendor sourcing? What do we want to get rid of? Do we donate it? How do we dispose of it? What is the budget for furniture, equipment, etc.? What do we want to be 'top notch'? Are we willing to lay down the dough to GET top notch?

3. The IT Monster Rears its Ugly Head: Unfortunately, moving to a new facility is also primo timing for examining existing IT infrastructure. The bitter pill of EMR implementation and systems overhaul may go down more smoothly in the midst of acclimation to other new patient care tech. Or it may simply overwhelm your staff. Each admin team should plan according to the current IT climate and staff tolerance for changes.

4. Transition Plan Composition: Each unit/department should form up that ole standby - the TPM Committee. Develop transition plans that include every staff member making the move. Be sure to note and discuss the safe movement of any hazmats listed on your Material Safety Data Sheets (MSDSs) including common cleaning products. In addition, be sure to designate a staff member as point person for specs, purchasing, procurement, transport, delivery, donation coordination, disposal etc. required for any new and existing furnishings/equipment.

5. Program for Patient Transport: No transport department? Form up a team devoted to patient movement if necessary, and be sure to include important dates/deadlines. Have the team practice, practice, practice...perhaps it takes 4 staff members to navigate a bed through certain areas of the existing facility rather than the 2 called for on paper. Volunteers may be useful in moving office supplies, but medical staff should handle this precious cargo.

5. Select Green Moving Vendors Whenever Possible: Check out usedcardboardboxes.com. Select a package corresponding to the size of your soon-to-be mobile office, then sit back and wait - packing materials, including a Sharpie, are delivered direct to your door. UCB purchases and 'ecocycles' new, used, surplus, and misprinted boxes. H2E (Hospitals for a Healthier Environment) sites pay attention: a portion of proceeds benefit TreePeople.org reforestation and citizen forestry efforts.


Welcome to the ED - Please Step Up to the...Kiosk???

Turtle: http://www.dallasnews.com/sharedcontent/dws/dn/latestnews/stories/060707dnmeterkiosk.37be576.html

Parkland's kiosks speed check-in

Parkland computer kiosks eliminate lines, frustrate some

08:02 AM CDT on Thursday, June 7, 2007

By KIM BREEN / The Dallas Morning News

After Vivian Beachum mistook anti-fungal solution for contact lens drops, her first conversation at Parkland Memorial Hospital's emergency room wasn't with a nurse.

A computer asked her where she hurt.

Instead of standing in line – sometimes for hours – just to explain their symptoms at one of the nation's busiest emergency rooms, Parkland patients now type their woes into a computer at one of three automated check-in kiosks. The idea is to keep sick folks from having to stand while waiting, and to more quickly reach patients who might not look sick but whose illness demands immediate attention.

"It was real efficient," said Ms. Beachum, who didn't have to wait in a long line or worry about eavesdroppers. "Nobody can hear."

While similar machines are popping up nationally to check in patients at medical clinics, Parkland officials said they believe they are among the first to have a system in a hospital emergency room. A donation through UT Southwestern Medical School paid for the $50,000 project.

The kiosks went up just two weeks ago, and kinks are still being worked out. Because of the people served at the public hospital – including a large indigent population – the technology can present challenges. The machines look and operate a lot like automated check-in kiosks at the airport.

"A lot of these folks don't use a computer at all," said Jamie Ensminger, a nurse in charge of the project. "They get really aggravated."

But Parkland personnel stand by to give directions and type in information for people who need help, and the hospital continues to adjust to make the system more user-friendly, he said.

Parkland's emergency services department sees about 300 patients a day, and 115,000 to 120,000 a year, said unit manager Jennifer Hay.

Before the system went in, patients could stand for hours, "like a ride at Six Flags," Mr. Ensminger said. Nurses constantly monitored the condition of people waiting – and pulled from the line people who were in obvious need of immediate help.

But some potentially life-threatening problems – like chest pain or stroke symptoms – aren't always easy to see, and some patients are too shy to complain.

At the kiosks, patients type in their name, birth date and gender before being led to myriad ailments from which they choose their chief complaint. Patients can choose English or Spanish.

If the first laundry list of problems doesn't fit – allergic reaction, homicidal thoughts, shortness of breath, and so on – patients can point on the screen to a specific body part that hurts. Certain ailments, combined with information like the person's age, are immediately flagged. Monitors in the nurses' station keep a tally of who is waiting, and blinking dots cue them to people who should be seen right away – like an older person with chest pains, for example.

"It just gives me another set of eyes," said nurse Brandon Gardner. "In theory, it's great with an ER as busy as we are."

But, he said, it also has its shortfalls. Patients who are illiterate or not computer savvy need lots of help.

Ms. Beachum, who described her age as "50-plus," said she liked the system. "I am computer illiterate," she said. Even so, "It is easy, self-explanatory."

James Jones, 68, also was a fan. "I did need help," he said, but once he got that and entered information, he was immediately called up to a nurse. "I usually have to wait hours," he said.

But even patients familiar with computers had some frustrations.

Tallan Askew, who was doubled over with stomach pain as he waited for care this week, said his fingers were too big for the screen, so he kept making the wrong selections. A staff member had to help him through the system, he said.

"I'd rather have a pen and paper," said Mr. Askew, who is 20.

Patients with less serious illnesses still must wait for care during busy times. But the long lines have been eliminated, Mr. Ensminger said.

"Our first goal is met," he said. "People are able to sit down."

While patients could always lie, picking more serious conditions when in fact they only stubbed a toe in order to get called first, hospital officials said that practice could occur even without the kiosks.

Parkland is already using the new data to analyze how long people have to wait for care. A patient's record previously didn't start until he or she made it through the first line. Now, that record starts almost immediately.

Ms. Hay said that if the kiosks are a success – and she thinks they will be – she expects they'll pop up in other hospitals.

"It could catch on really easily," she said.