Learning the Ropes - Back to Basics

I have to apologize for the extended absence - these past three weeks I've been busy learning the ropes at a new job.

We provide health care, 3 squares a day, and various other body-and-soul-sustaining treatments to men (and a few women) without homes. This afternoon we had a Ping-Pong tournament. Thursday I'll visit the Poetry group.

I've seen a lot in the past 3 weeks.

This may just be the understatement of a lifetime.

Going from hashing out concierge care plans with hospital execs to chowing down on lunch served cafeteria-style to a group of patients who call our treatment facility home is an eye-opening experience.

This is the kind of job (and maybe some of you can identify) where you don't change the job - the job changes you.

While I won't blog about specific patients, I will blog about what the group and certain individuals are teaching me.

I will blog about how a genuine smile that crinkles the corners of your eyes can change someone's day. How bestowing a nickname is a right of passage.

I will blog about how showing you care by holding open the door, standing and talking to someone out in the halls (despite your own feelings of inadequacy and/or embarrassment) and sharing your experiences matters more than you can believe to your coworkers, your patients.

I will blog about how there are places that reawaken the idealist inside.

There are places in the healthcare community that are giving, literally, all they have to make a patient's health their primary concern.

So what are your primary concerns?

On a day-to-day basis, what are you doing to show staff and patients that THEY are your mission?

The writing can certainly be posted on the wall (who we are and who we serve looks pretty typed and framed in the hall) - but are these words the only thing expressing the meaning of who you are, who you serve? Is this attitude of service ingrained in every action?

There are a thousand things competing daily for your attention. Minor and major projects line up one after the other in a never-ending queue.

The essential question is this: Which of these "priority" projects truly serve your patients? Which of these serve your administration? Which of these serve an internal need to achieve? To succeed on a personal/professional level?

Make no mistake - we are in the service business. If, as a healthcare administrator, patient service is not your primary concern, perhaps your priorities are out of order.

Get to work a few minutes early.

Hold the door for someone tomorrow morning.

Smile, ask how their day is going. If no one is there immediately as you enter, wait outside. Look around. Think about what you're doing there, and why.

When someone arrives for work, maybe running late, thinking about the day ahead, comment on the weather or any other mundane thing to get the conversation going.

You may just learn what sustains another person - and that's what healthcare is all about - things that sustain us - body and mind.

I'm relearning the ropes, and finding my former list of "must do's" had a whole lot to do with my goals and very little do with my patients.

Which of your goals are self-centric and which are patient-centric?

Reorganize that to-d0 list and you may just be surprised at how getting back to basics streamlines the number of things you "must do" today.


Price Transparency: Become a Positive Deviant Part III

Let's continue the conversation on effecting positive change by communicating pricing/quality data to patients, staff, and community stakeholders.

For transparency to work, both docs and patients must buy in to an evolving view of efficient modern health care as a process and partnership that requires the active and engaged participation of both parties

And yes, patients, I mean you - how many of us can't even recite the names/doses of current prescription medications or dates/diagnoses related to care in the past five years?

Without this view, hospitals releasing numbers will just be spinning the wheels.

ranted, the rest of us will have some nifty high-deductible-based pricing tools to play around with in the meantime.

And hospital executives, although patients may be telling you they want info on prices, don't discount the fact that "all this readily gleaned customer feedback can lead you astray (from Freeman, Inc. Magazine July 07 "Ask and You Shall Be Misled" - link below).

Don't let demands for pricing outpace a well-designed strategy for releasing cost/quality data. Freeman makes a great point that if you're not used to soliciting feedback from customers, you may overreact when faced with a mountain of complaints about pricing and quality info.

Some of these complaints may arise from simple misunderstandings - successful transparency campaigns also requires rising levels of patient literacy...without improved patient education programs we'll just be spouting data many customers aren't equipped to incorporate into individual treatment goals.

There's a great article by David H. Freeman in the July 2007 issue of Inc. Magazine (page 63 of the print edition) titled "Ask and You Shall Be Misled: Customers can tell you a lot. But sometimes they don't know what they're talking about." Hospital/healthcare CEOs should read it, especially given recent industry flack about listening to customers and incorporating consumer feedback.

Transparency is important yes, but perhaps not the vital primary issue in healthcare. So how does transparency play in to the current single-payor/UHC debate?

Universal health care is a different animal entirely than universal health coverage.

The former will require multilevel participation from patients and caregivers, while the latter will make sure that everyone's &(%$#@ and esophogi are covered.

I'm going to go out on a limb and argue putting health care under either 'universal' umbrella doesn't matter if patients still don't have access to care based on information about provider pricing and quality.

Take a breather, because we're just getting started.

If and when you get patients to buy in to the idea that price/quality data is important, you have to explain the small print.
Using a generalized price transparency tool like that at the WVa website is a bit like signing up for a mobile phone coverage plan.

You agree to plunk down 59.99 a month for service, but when you get your final bill there are ALMOST ALWAYS additional hidden or unanticipated charges related to usage variations.

With any medical procedure, costs will vary, sometimes significantly, based on the patient and her particular set of circumstances (including complications).

In addition, early iterations of pricing estimators available to consumers may not take into account all 'true' costs related to the procedure - and related recovery process, which can add significantly to costs incurred.

With a TKR for instance, does the fee listed include surgical workups, preop anesthesia assessments, labs, and extra costs incurred during the hospital stay such as parking, prescription copays, etc.?

What about ambulance transport home if needed, a quad cane, a shower chair or other equipment indicated by a PT, RT, OT, ST, or social worker/case manager prior to discharge?

And what if something goes awry in the OR and an additional surgeon is called in, increasing the cost of the procedure? What if the patient develops a condition during surgery that requires additional follow-up care? Or becomes infected with a nasty bug circling the halls?

Currently, sites don't include pricing tools for ancillary services or programs related to follow up care.

Take physical therapy after TKR for example, which can add quite a hefty chunk to total costs related to the procedure. Competitive pricing information, hours of operation for the hospitals rehab medicine department, etc. would allow a patient to make a more informed choice when selecting related care providers.

The issue is a toughie. But there are basic structural must-dos to get the process started.

  • Hospitals - provide pricing info for your docs. Use examples already at work "in the field" such as CompareCareWV.
  • Patients - request hospitals and docs make price information easily accessible in house and on the web. Acknowledge that you will need to follow up with your insurance provider to confirm coverage/approximate costs.
  • And med schools/residency programs, for goodness sake - start training your docs on how to handle pricing requests and, better yet, increased levels of patient engagement/involvement. Docs, Nurse Practitioners, Nurses, and Physicians' Assistants will be the frontline advocates for increasing levels of patient health literacy.

Transparency is a team effort, and there's no I in team.


Price & Quality Transparency: Become a Positive Deviant Part II

We've built a system that encourages the medical care team to make almost all necessary tough calls in patient care (followed by efforts to gain patient consent based on predetermined courses of treatment), and saddled this same team with almost total responsibility for outcomes.

Of course, just because pricing and quality data emerges doesn't mean we'll face total patient-driven anarchy - medical professionals have the knowledge and the skills - this is the reason we call you docs and trust you with life and limb. I'm not advocating patients run amok through the halls screaming "Carpe diem" and docs rush from the rooms yelling back "Patients, heal thy damn selves!"

For price transparency trends to truly impact the continuum of care though, some population of patients (I won't go so far as to suggest a majority) must become active, engaged partners who are willing to select the level of information required to have some sort of understanding of their care - and make informed decisions.

Monkey see, monkey do: Once patients can see data, some of us begin to make choices based on that information (Shocking right? But have we thought about what this really means? What if our Cancer Center of Excellence turns out to be not so excellent? Will certain facilities shunt poorly performing service lines if patients don't choose to come in for treatment based on price/quality data?).

This leads us to perhaps the largest stumbling block of all - patients will share, to some small extent, the responsibility for outcomes.

If we begin to choose our doctors, our hospitals, based on how much they will cost and their quality rankings on some sort of national or per-patient scale, we now carry some of the burden inherent in making these choices.

At this point, it becomes difficult to predict how this sort of responsibility ("If I'd elected to take my daughter to the number 5 cystic fibrosis facility in the U.S. instead of the 35th, would she have lived to see 40?") will transform our system - from the patient side, from the provider side, from the legal/regulatory side.

Before planning a process to release pricing and quality data, we must first ask the essential "whys:"
  • Why should I care how much it costs for patients?
  • Why should I care who's already doing it and what their transparency campaigns look like?
  • Why should I consider making decisions based on this information?
  • Why should I provide pricing/quality information at all?
  • Why should I consider sharing it with staff first?
  • Why should I consider taking the time/money to gather this information for release?
  • Why should I consider sharing this level of information with patients?
  • Why would it do any of us any good?

Asking these "whys" may seem like an exercise in futility, but the more questions you ask before a transparency campaign, the easier it will be to answer questions from the peanut gallery after you release pricing/quality data.

Answering the "whys" is, undoubtedly a far more insidious process than it appears in a simple blog posting, requiring a complex, multifaceted revision of many current patient education processes. You'll also have to perform some undoubtedly unpleasant and onerous internal data gathering procedures to get your hands on the figures.

And after you get the data, and get internal buy-in, there's the far more challenging issue of convincing patients why they should care.

Some patients undoubtedly don't wish to change their roles from passive receivers of prescribed care to active, informed participants.

In an ideal world, all patients would be proactive and capable of deciding for themselves, but medicine, though somehow miraculous, is not an ideal world.

Proxy caregivers will sometimes need to make these calls, and medical staff will still need to communicate risks and benefits of treatment - so how do we make such information available for thorough review?

The web is, of course, a good start, but we then also need to make sure hospitals are wired to allow internet access at all points of service (gasp).

In addition, we need to be sure transparency data is communicated in a variety of ways that is not inherently prejudiced - we need to offer it in a manner that doesn't prohibit certain patient populations from accessing it (illiterate, impaired, non-English speaking, etc).

A well-planned transparency campaign that releases information (both pricing & quality) will need to attack three main fronts by providing answers to the "whys" above:

1. Internal & External web-based media/editorials including blogging, online news, etc.
2. Internal stakeholders including employees, Board of Directors, donors, etc.
3. External stakeholders including patient populations (past, current and future), media, community organizations, suppliers, etc.

Of course, the first group that must demonstrate unilateral buy in and understanding of the "whys" is the executive/administrative team - if you aren't all on the same page regarding the transparency campaign rally the troops before proceeding.

Price & Quality Transparency: Become a Positive Deviant Part I

Today begins a more detailed, multi-part editorial examining pricing/quality transparency.

On 6.26.07 we took a gander at West VA's price transparency site, CompareCareWV.

I used the hypothetical example of a total knee replacement (TKR) to take the site for a spin.

Now let's step back and take the larger issue out for a test drive.

One could argue, perhaps quite successfully, that there's no such thing as an average price for a TKR, and that WVa's tool, while interesting and helpful, is still in the Stone Age devlopmentally and as such should be used only as a starting point for patients to discuss options with prospective care providers.

Let's try a little experiment based very loosely on anectodal evidence.

How many of you, dear readers, have ever asked your doctor how much XYZ is going to cost? (or, if you are a doc, how many have asked yourselves how much XYZ will cost your patient?)

If you've done a bit of interrogating, were you met with a stare, an "I don't know, you'll have to call the hospital, your insurance company?" or a friendly pat followed by some variation on the standard issue "Don't worry about that now, let's just get you better?"

If you haven't yet asked a medical care provider about cots, give it a whirl. Whatever the response, the results will be interesting (expect near hysterical laughter in approximately 23.4689 percent of cases).

The essential point is this: We can talk about transparency (especially in the hospital setting) until we're blue in the face, but for it to work, some percentage of both consumer and physician populations must buy in to the benefits of shared decision making.

And this is a lot of buying in to do - especially based on the rabbit-warren-like complexities of our current system and medical culture, which embraces a physician-driven "Prescribe, Accept, Perform" process.

The questions price and quality transparency advocates must consider from the provider side include the following:
  • How does making very generalized pricing structures available to consumers change the amount of time spent/pattern of current patient interactions? (i.e. will average appointment times increase once patients begin to question docs about costs?)
  • If docs have to answer questions related to pricing as well as process while with a patient, how much longer will preop appointments take? Annual physicals? OB/GYN exams? (I think you get the idea - each service line will need to measure and analyze how time spent with patients morphs after cost/quality data is released - staffing models may need revision as a result).
  • What is the planned process for releasing quality and pricing data? In-house release followed by online rollout on the hospitals website? Does the hospital's marketing/PR/community relations department then follow up by arranging interviews, open seminars, coverage in the local press, etc.?
  • What is the planned process for analyzing results of transparency? Which departments will gather & distribute this information? Where does the information "live" and can both internal and external constituencies provide comments/suggestions via a simple, easy to use format?
  • At what point will transparency saturate every area of operations, for instance - during preadmission phases...at what point will our facility begin providing basic lists/pricing along with consent forms?
  • What incentives, other than altruistic motives to keep patients actively engaged in their own care processes, are needed to foster widespread adoption among different internal populations (nursing staff, physicians, lab, etc.)?
  • How will you handle consumers who choose to stay in the dark about specifics of their care, those who just want you to fix it and don't care about the names of their meds, the specifics of their care, OR the costs involved?
  • How do you communicate the benefits of active patient engagement and accepting personal responsibility for self advocacy in terms patients will understand and value, such as reduced medical errors, increased engagement/interest among care providers, earlier ID of potential complications, etc.?
In the next posting, we'll examine potential impacts of transparency on patient involvement.


All Hail the Lap Desk - Happy 4th

For poetry nuts, "The Writer's Almanac" with Garrison Keiller provides a daily dose (available via email or at Publicradio.org).

I'll spend much of this week 'catching up' on the must-read stack standing ready at the bedside, and in honor of Jefferson's contributions (lap desk??? the man was brilliant, despite ah, certain failings) thought I'd share this nugget (from today's TWA post). Apologies in advance to readers from across the pond:

"Today is Independence Day, celebrating the day in 1776 that the Second Continental Congress unanimously adopted the Declaration of Independence, and the United States officially broke from the rule of England.

Thomas Jefferson wrote the Declaration of Independence in a second-floor room on Market Street in Philadelphia, on a little lap desk that he had designed himself. He described the task in a letter to a friend, saying, "The object of the Declaration [is] not to find out new principles, or new arguments... but to place before mankind the common sense of the subject, in terms so plain and firm as to command their assent, and to justify ourselves in the independent stand we are compelled to take.... [It is] intended to be an expression of the American mind."

To blogging friends in the medical sector - may you be blessed this day with a markedly low volume of cases caused by conspiracy theorists, sunburn, alcohol, 'happy pills (and every other kind)', and pyrotechnic displays gone awry.


Hospital of the Future: The Super-Informed Patient

On Saturday, The Petri Dish posted a great review of Michael Moore's SiCKO here. Relax, I'm not about to go off on another cinematic rant.

The post makes a great point: Many of the stories contained in the shockumentary communicate an unintended tangential lesson, namely this...

In our current health care rodeo, tales of loss and tragedy are underscored by a deficit in patient knowledge about our conditions, as well as the systems in which we must orchestrate self-care.

After viewing the movie, Petri asks of the patients shown: "Did many of them bring their situation on themselves? Probably. Are many of these people confused and ignorant of why such circumstances came about? Probably."

It's a good point, and one not often made, at least from the consumer-advocate side.

Medicine is, at some essential level, about caring for those who do not have the skill or expertise to care for themselves, those who lack the knowledge and training to diagnose and determine an effective course of treatment. In some instances it's social work with a scalpel (or a shovel).

As Petri says, "medicine is fundamentally linked to helping those that cannot help themselves or don't know better and it is very difficult to extricate medicine from that belief."

I'd like to think many of us, or at least the self-selecting 'super-informed' patient category (which is where unrepentant Type A bloggers belong) have done our homework before arriving at the hospital for prep on the day of a surgical procedure, for example.

Note: I'm picking surgery as an illustrative example for patient involvement because it's a pretty aggressive intervention, and if you don't prepare yourself for surgery, well, you're probably not going to be actively engaged in ensuring your annual physical is a 'two-way' conversation either.

Like voting at the age of 18 in national elections or the awe-inspiring option of doing our own taxes, in the current U.S. system choosing our level of involvement in medical care is a responsibility and - dare I say it - almost a right.

We can pick our docs (to some extent), we can pick our hospitals (to some extent), we can even pick how much or how little we want to know about what's going on in our bodies. And speaking of "universal care," we can walk into an ED just about anywhere and receive care, regardless of our ability to pay.

As more talented bloggers have pointed out with a great deal more eloquence, this viewpoint largely allows us to jettison responsibility for our personal health and rest the burden of care decisions on medical caregivers (and then sue them later if we don't like the results).

There's no doubt in my mind that current patient education efforts fall woefully short. Our system does not teach patients to self-advocate or be knowledgeable about care.

And even in instances where we want to be involved in the care process, the purchasing, decision-making, and payment/reimbursement minutiae make individual involvement largely prohibitive in terms of personal ROI.

Our system also doesn't teach us about the large role we can play in improving patient safety by taking some level of responsibility for informed involvement.

If I had a dollar for everything I wish I knew before a surgery (or every question I knew to ask, every supply I should have had waiting in the cabinet at home post-discharge), I'd be a rich woman.

Granted, there are some rare birds who take it upon themselves to involve patients in the treatment process, but such efforts currently transpire at the singular rather than system level.

Other patients are blessed enough to have a doc or nurse or PA or NP (or other medical acronym) in the family who becomes a hospitalist shepherd, guiding us through the murky waters of managed care.

Even if the caliber of your patient education program is excellent, however, patients must opt-in to 'owning' a piece of their treatment territory - and even with prompting, statistics, and soft incentives, NOT ALL will choose to become active participants in their care.

It's vital to remember that to some extent, there will always be four categories of patient populations:

Category 1: The Super-Informed. This category knows their meds, can spout appropriate medical terminology (may even be a doc, nurse, or medical professional), and will be aggressive in seeking 'cooperative' follow-up care in concert with their treatment team. They'll be early adopters of PHR, EMR, consider choosing a hospital based on publicly available pricing and quality data, and generally be those considered 'pains in the asses' by some care providers who dislike sharing the dias. AKA: Know-it-alls (or, even worse, "Think-they-know-it-alls.")

Category 2: The Semi-Informed. These patients may know someone who knows someone who had "this type of heart surgery." They may have a list of meds, but may speak in general terms about care, expectations for functionality post-procedure, etc. They obviously comprehend the bigger picture about their condition, but aren't interested in the specifics. Likely to bring cookies to the nurses and have lots of visitors. AKA: "The nice ones."

Category 3: The Selectively Non-Informed. Although capable of understanding basic factors contributing to their care plan, these patients just don't want to know. They want to rely completely on the medical team to "do what needs to be done." They don't ask what medications they're being given, and when pushed may refer to them as "my heart pill" or "the little blue one." They often look to either a strong primary caregiver (spouse, parent, guardian, paid provider) to make decisions or outline their care on a strictly "need to know" basis. Usually want out of the hospital fast, as in yesterday, and may demonstrate acute discomfort when faced with complicated decision-trees. AKA: "The quiet ones."

Category 4: The Non-Informed.
For some reason or another, these patients are not capable of understanding care. Perhaps they're minors, developmentally disabled, etc. Perhaps they're overwhelmed by the system or have had terrible experiences with a loved one dying, etc. They may not have ever experienced a hospital stay/surgical procedure, and perhaps are in the hospital as the result of an emergency room admit/trauma/accident where there wasn't time for them to review care options. AKA: "Those poor things."

Another point: Based on changing life circumstances, patients may move selectively in/among the four categories above.
For instance, someone receiving palliative care for cancer may choose to move from Category 1 to Category 3 based on an end-of-life viewpoint.

Regardless of a patient's interest level in care participation (1-4 above), each patient should know and carry certain basic information with them prior to a surgical procedure.

In an ideal world, my required preop patient prep kit would include the following:
  • Doctors info (including surgical team)
  • Patients info (including insurance, home/work addresses, contact numbers, etc.)
  • Schedule (what time patient is due to go into surgery - but signed awareness statement that this often changes due to rotations, emergent cases, etc.)
  • Current medications/allergies/sensitivity list - if you get a rash with the use of surgical tape or have a sensitivity to morphine, include it here
  • Advanced Directive (if completed), Living Will (where applicable), DNR orders (again, if applicable), emergency contact (qualified to make end of life care decisions or communicate patients wishes in case of adverse events).

No matter our selected level of involvement in care, we should know our doctors names (surgeon, anesthesiologist, PCP/referring physician, etc.), and, GASP, have them written down.

We should also have a list including their office addresses, phone, fax (and pager/beeper) numbers in case there should be an at-the-wire problem with insurance verification or approval. Note: I once waited 18 hours for an ortho surgery to commence because someone had typed an "OP" instead of an "IP" on the insurance forms for a 2-site bone grafting procedure (left iliac crest harvest to right talar dome).

We should all have a list of relevant insurance information, including the customer service line and copies of any necessary referrals.

We should all have packed a bag with comfortable clothing (washed with nonscented detergent/softener as sense of smell may be a bit whacky postop), plenty of books/magazines/CDs/Ipod etc, as well as something to do in case temporary vision changes preclude reading/typing.

We should all have a list of allergies and current medications (!!!).

We should ALL not rely on the above information to be included in our chart and available for our exclusive access pre-op. This is a busy time for your caregivers, and we should be helping them operate as safely and efficiently as possible by being responsible for some level of self-preparation.

This is just a start, but you get the idea.

So who should be in charge of revamping patient education efforts and instituting new patient preparation procedures?

Like patient safety initiatives themselves, in order to succeed, patient education reform needs buy-in from staff at every level.

However, the new Chief Experience Officer would be a logical position to champion this crusade. Some hospitals are using videos with docs as narrators explaining 'common' surgical procedures so that patients have more knowledge about what to expect.

But are these patients also being told to start prune/fiber use the day after GA, stock the cabinets with bland foods, and have a "phone a friend" available in case of non-emergency complications or needs?

Before surgery, I'd like to see a relatively humerous or light-hearted video with medical staff explaining "100 things I wish I thought to ask before surgery" sharing "inside" tips in a confessional or reality TV-type format.

In fact, I'd pay to buy one...or, if I was a hospital Chief Experience Officer (or Chief Executive Officer) that wanted to get my hospital's patient education efforts out swirling in the www-ether, I'd take the following steps:

1. Make the video.
2. Post portions on YouTube and other file-sharing sites.
3. Post the video on my blog.
4. Solicit an open-comment period - former patients (from around the world) would probably contribute plenty of wisdom nuggets we didn't think to include.
5. Revise the video.
6. Explore an arrangement with the production company to modify/customize the video for other hospitals and systems, with a royalty fee structure in place. Also consider purchasing the production company or a stake in the company to smooth the path for future revenue-generating partnership offerings.
6. Release!