Systemic Complexity in Service Creates More, Well, Complexity

People are having serious difficulty understanding the selection/purchasing process for vital products/services.

Exhibit A: The subprime mortgage meltdown (hold on to your 401ks ladies and gents -we'll revisit the issue in Q3 of '08).

Housing is one of the biggest investments we can make, and some of us are bumbling it in our semi-blind pursuit of the American Dream -accepting more risk than we can reasonably afford with ARMS and negative amortization plans.

Exhibit B: A hospital stay.

This isn't yet a right (still a privilege for those who can pay except for "emergency" care), but it will be interesting to see how politicos in the coming year frame healthcare for all. If the founding fathers wanted to tack something else onto the Constitution, it might read life, liberty, the pursuit of happiness, and the pursuit of health. Our physical/mental/spiritual health influences every aspect of our lives, and yet most of us are woefully out of touch with how to keep our bodies tuned up and running like a well-oiled machine.

What do the mortgage market and the H/HC market have in common?

If you look at the two markets on a conceptual level, similarities emerge.

First, both are services we undoubtedly need. And there are plenty of providers for those with money to spend.

Second, both the mortgage lender and the hospital may 'talk' consumers into products and services based on a one-size-fits all approach that doesn't suit the needs of each individual.

Third, both industries are under fire. Some point the finger of responsibility for crisis at the lenders and hospital systems, some comment that consumers aren't taking enough responsibility for the weight of their own choices. Both observations are partly correct.

The reality is that there's plenty of blame to go around, and blaming is usually an exercise in futility. Yes, these systems have problems - big ones. Yes, consumers need to take more responsibility for educating themselves about the choices they make. Yes, providers must take on additional time/expense burdens related to creating a more knowledgeable, informed base of customers.

Can you educate all consumers all the time and expect each to make logical decisions prior to purchasing? Heck no...not in theory, and certainly not when it comes to hot ticket items like homes and health. However, it also doesn't mean you stop trying.

Complex services and markets require complex solutions. Hospitals don't have an invisible hand of oversight similar to that of the Federal Reserve which pulls market-controlling strings, although The Joint Commission is certainly trying to achieve similar lofty status.

So what to do? Educate, educate, educate.

Make information available to your consumers. Have staff dedicated to shepherding them through the process. If I was an MBA student right now interested in a healthcare career, I'd seriously consider a business plan for outsourced patient advocate corps that could be replicated at hospitals nationwide (if anyone's interested, let me know - this is a concept I'd love to flesh out). Read this great post by Dr. Malpani, aka The Patient's Doctor, for one idea of how to bring this concept from page to stage.


A Week's Worth of Must-Reads

Every once in a blue moon so many good H/HC articles pile up in my Inbox that I can't address all of them in a timely fashion.

So here are a few of this week's (and last week's) best for your edification:

1. Aging Japan Struggles to Rein in Healthcare Costs
(aka The US Outlook in 10 Years)

"Other ageing nations will be watching closely to see how far the heavily indebted
government can rein in costs especially as the number of elderly in Japan creeps up with
projections that 40 percent of the population will be aged 65 and over by 2055."

2. One-Third of US Lacked Health Insurance
(aka The Reason We Need More Organizations Like MEDBANK)
Blogger's Full Disclosure (aka Always Read the Fine Print: I sit on the BOD at Medbank of MD)

"The report found that more than 79 percent of those without insurance were in families in which at least one person had a job, 70.6 percent were themselves employed full-time, and 8.7 percent were employed part-time."

3. Do You Know Where Your Next CEO Is?
(aka Well Punk, Do Ya? Forget Having Two Successors Handpicked - Try 4 Per

If you're having difficulty recruiting administrators/execs/BOD members from outside the industry NOW, imagine the conundrum you'll have 10 years from now when those with the most desirable experience have been promoted to C-level positions at established
organizations before the age of 40...try snapping us up then.

4. 70% of Churches Provide Healthcare Services
(aka Forget Retail Clinics - Churches May Be Your Biggest Competition...and If You Thought JCAHO Was Tough, Just Try Taking on an Active Congregation)

...churches said that they provided counseling or support groups for mental health or
substance abuse problems, tests for medical conditions such as hypertension and high
cholesterol, flu vaccinations and sponsorship of health clinics for members or the community. In addition, 65% of churches said that they provided health care education
programs, and
51% said that they offered financial assistance for medical bills.."

An Invitation, Dear Readers...

You may have noticed the Innovation Challenge judge logo on the left frame of Health Mgmt Rx recently.

The good news? Idea Crossing wants more talented judges - I'd love for you to get involved, dear readers.

Each year, top MBA teams from all over the states gather at the Darden School of Business (UVA) to address business-case issues for 5 top organizations at Idea Crossing's "Innovation Challenge."

The thinking is team-based. Resultant plans are creative and implementation-oriented. This is one of those great opportunities where teams learn by planning (and presenting) in a pressure-cooker atmosphere.

If you like HBS case studies, McKinsey Quarterly Articles, and Trump's show The Apprentice, judging The 2007 Innovation Challenge is a great way to spend a few evenings.

There's a dinner for judges at the conclusion of the contest and other perks, including HHonors points. Plus, the judge who recruits the most OTHER judges wins a lesson on a Harley. In addition to my altruistic motivations, and in the interest of full disclosure - let's be honest here - I'd love that ride...

2007 sponsors include:
Hilton Hotels
OPEN from American Express

Hope to see some of you at Darden in November...any takers?

www. innovationchallenge.com


Random Schtuff II - Wellness Plans

Why are many businesses, especially hospitals and healthcare orgs, waiting to design wellness programs?

We already have much of what we need on-site or close at hand...fitness facilities (Rehab medicine, etc.), dietary plan assistance (dining/food services and dieticians), a large area to walk (indoor walk plan, doing stairs, etc.), etc.

If complications related to chronic conditions eat up 90 cents of each healthcare buck (according to Dr. Feld's blog here), and the American Journal of Health Promotion metrics show you might expect a 3 to 1 payback on each dollar spent on a wellness program, what are we waiting for?

The Journal studied the plans of 200 companies and set average 3- to 6-year return on investment on those plans at 348 percent. THREE HUNDRED FORTY EIGHT PERCENT.

Provant Health Solutions says a firm will see improved absenteeism in the first 6 to 18 months of putting a wellness plan into action, according to HR Daily Advisor, an e-newsletter published by BLR.com.

If I was interviewing, I'd also count a company with a wellness plan as a top-notch competitor for my work-time and talent. They make me healthy, I work well for them - that's a partnership I can live (and work) with.

Cost improvements aside, don't we as H/HC business leaders and managers have an obligation to manage our resources efficiently (paying attention to the overall 'health' of our organization) and demonstrate ethical concerns for the health and well-being of our employees?

Am I being hopelessly idealistic here or does enacting a wellness policy represent best-practice good management?


Random Schtuff I

Random Schtuff #1:

According to Investor's Business Daily (some issue from last week that was a soggy delight of a pile on my stoop today), the Boston Museum of Fine Arts is the first US museum
making money repurposing its collection as cell phone art. Talk about a brilliant stroke of
newtech marketing. For a buck ninety-nine you can download a single copy of famous works
Houses at Auvers by van Gough (for all of you out there in the mental health field) or
Monet's Water Lilies. If that's not enough culture for your celly, for less than a latte and
muffin at Starbucks ($4.99) you can get a months subscription with five backgrounds.

Next gen hospital advertising is only a nanostep behind; I can see the hospital silhouette backgrounds now...and if I was really ambitious I'd figure out how to put a
cool xray image of my ankle with an ex-fixator on my Berry background.

Also if I was on staff in charge of acquisitions on Ebay I'd get in on this yesterday...

Couldn't Have Said it Better Myself...

Yesterday Carolyn, a loyal reader and commenter (thank you!) who is enrolled in an MBA program somewhere out there in brick-and-mortar land, left this comment.

I'm posting it as a stand-alone entry because it sums up proper consumer behavioral research processes perfectly.

Before postulating what your consumers want/will use/will buy, you need an accurate snapshot fleshed out with quantitative metrics to back up your theories.

CK - I couldn't have said it any better:

"It sounds as if a lot of quick assumptions are made about consumers without any sort of market research behavior to support or refute such assumptions. Any successful customer experience begins with first knowing your customers (demographics - literacy levels would be included in this category), and then understanding them (psychographics - behavior patterns and expectations).

Until you have a solid grasp on these two items, you should never presume to know what consumers would do and what would succeed/fail."

Point taken Carolyn - Research first, blog/talk and implement later.


Underestimating the Consumer

It's true - Parkland Hospital in Texas has installed airline-type kiosks in its ED area.

I'm not sure I'd go that far...in my vision of a dream hospital yesterday I imagined using these self-check in machines for surgery pre-registration.

Criticism from the medical community in the blogosphere has raised several key points about the use of consumer-controlled tech in the hospital setting, namely:

  • What are they NUTS? Asking ED patients to self-identify and map out symptoms? They might as well put out a candy jar with pre-signed scripts for Demerol...
  • Patients with 'true' emergencies will be bleeding all over the touch screens, and I can just see the sentinel event/M&M report now: "Patient expired trying to type last name while bleeding out post MVA."
  • Non-emergency patients with communicable diseases, nasty flus, flesh-eating bacteria, or other disgusting things will smear their grossness all over the screen, making it unusable for anyone else (hello? have you people SEEN the public bathrooms in EDs lately?)
  • And my personal favorite (drum roll please)..."Consumers" with an average literacy level little above a middle-schooler will not know how to use this new-fangled technology, so it won't work.

All are interesting points, no doubt about it.

And obviously if you're using kiosks in the ED, a patient's self-entry of symptoms shouldn't supercede a good ol' fashioned triage.

But it's the last bullet I want to focus on for now; the one that assumes consumers will not be able to figure out the system and employ it efficiently.

This is the worst kind of hypocrisy from medical staff members who use a 1-10 pain scale with emoticons and expect consumers to successfully navigate the managed care environment and rabbit warrens that are most hospital floor plans.

To those who underestimate consumers, I offer these examples that 'overestimated' consumers and successfully innovated for new products and services that have become market leaders (or just pretty darn nifty):

  • Starbucks: Who the heck would order a double whip skinny triple whatever with sugar free vanilla before this Seattle chain took over the world (literally)? They created a market for 'luxury' coffee drinks where consumers were happy (relatively speaking) with convenience store sludge. If you build it they will come...
  • Apple: I-what? Who wanted a mini player that just regurgitated songs you'd already bought in a random order? The Shuffle and other iPod models again created a market where one didn't exist. And guess what? The consumers figured it out just fine.
  • Google Earth: Pictures of the planet? Outside a National Geographic back-issue? Google Earth has enthralled thousands with satellite images of our Big Blue and Green. Does it make them money? Who knows. Who cares? It's pretty darn cool.
  • Your local library: Now most of us can hop online for free at local libraries and renew books, search the card catalog, and bypass that tricky Dewy Decimal thingie. Pure brilliance. This faculty was formerly available only to highly educated librarians, who have masters and doctorates related to all this good bibliophile stuff. But even elementary-schoolers who are first generation Americans and speak very little English are picking up this system using foreign language versions (Spanish).
Let's simplify things a bit though.

No matter whether you can read or write in English (or speak), all of us not visually impaired can head into a McDonald's and pick what we want from the menu and order. And there are systems to accomodate the sensory-challenged.

How? Using the most basic of human communication - picture and point.

With check-in kiosks we just switch up the format a bit...it's not picture and point but rather picture, point, and click.

For us to believe consumer based innovations in the hospital setting won't work is a form of underlying elitist bias that underestimates the consumer and simultaneously reduces the chance of patients and consumers advocating for system-level change.

Give us our fair share of responsibility. Or, if you prefer, give us more thingies to buy. With choices we've never seen before we tend to reach for wallets faster. Even with bloody fingers.


For My Next Trick...

I took a nasty little tumble from my bike two weeks ago and banged up my right leg pretty good.

Since this is the 'hurty leg' that looked like a Bloomin' Onion seven years ago following a nice MVA, I was a bit worried and went to see my wonderful ortho doc for xrays and an exam (Disclaimer: University of Maryland Ortho rocks).

Luckily it's nothing a little physical terrorism won't fix. It did, however, get me thinking.

I do spend an inordinate amount of time thinking about hospitals, as I've spent some time in a few and want to spend my future career hanging around the industry.

Next time I need surgery for my puzzle-piece ankle, this is the kind of hospital I'd select.

Well, I'd select it providing it actually existed. Which it would SOMEDAY if H/HC entrepreneurs & docs/nurses/PAs ran the world hand-in-hand with a patient advisory committee and designed a specialty ortho dream team showpiece.

My hospital:

  • Allows me to view and preschedule surgery times with my ortho doc online. I can IM his assistant and ask her a question about the Friday 11am slot. I can select my PA and even request the same anesthesiologist who did my pre-surgical consult last January (That guy was a character and tried to sell me on a popliteal block. He put in a great effort, but I wasn't having it - after upwards of 15 surgeries I know what works for me). I can also request the Ogee pump (thank God for Ogee...)
  • Offers free valet parking so my mom/husband/etc. doesn't have to lug stuff in after dropping me off at the front with crutches, pillow, etc.
  • Lets me check in via an automated kiosk a la the airlines (but this one hardly ever breaks - hey, while I'm dreaming of a physician-owned, consumer-focused specialty ortho hospital I may as well dream big).
  • After I check in, I pick up a flashing light/beeper thingie like they hand out at Olive Garden from a very nice Patient Advocate, a local college kid who's studying pre-med. This will buzz and be generally annoying when it's time for me to register and hand over my life savings, I mean my insurance card, but gripping it tightly and constantly asking it "Are you alive in there? Is it my turn yet?" will make me feel like I'm doing something constructive. Plus it would look REALLY cool. Unless they call me a psych consult. Maybe it would have a special color tag that coordinates with my arm band to communicate if I have, say, an allergy to drape adhesive.
  • When I'm gathering up said buzzy-thingie the Patient Advocate would offer me some things to do while I wait in the nice, open airy room to be summoned by a recovery room/OR nurse. This would include some volunteer activities like copy editing a draft of the Ankle Patient e-newsletter, knitting an extra large footie that will fit over a Bledsoe boot for an uninsured patient, etc.
  • While I'm sitting in the waiting area, having finished my edits and handed in the draft signed "Red Pen Was Here," I select from a pre-paid "menu" of options. This looks like the itemized quote they give you at Jiffy Lube or the vet's office prior to performing services. For instance, I know I won't care whether or not I'm in single patient room immediately post op, as I'll be shaking and shivering and yelling and blissfully unaware of all this afterwards, except feeling as if my bones are freezing from the inside out. Thinking of this, I check the box that lets me request a down blanket for $10. It will be waiting on my bed. For an extra $100, I can have the twin size monogrammed and use it to tuck my nauseous self in for the car ride home.
  • I preorder a snack for recovery, knowing I'll want Saltines and Ginger-Ale as soon as the anti-emetic takes effect. I check the med they recommend and discover it's different than the one they used last time (flipping backwards to an itemized list of services/products they used in prior surgeries - which I could also select NOT to receive if I wasn't extremely anal and a medical geek and didn't want to know this kind of stuff), which took two doses to work. Goody.
  • I realize I'm pretty nervous about this surgery and my recovery program/return to work timeline, so I request a Physical Therapy consult via button on my beeper thingie. The PT on call, part of my integrated care team, is chairside in under 15. That's what I call service. I could also have requested a counselor, a chaplain, or a nurse to speak with and allay my concerns in a private therapy-type room just off the main waiting area.
  • Just as we're finishing up, my beeper goes off and I head back for my preop prep. My progress is calm and unhurried but I'm moving along, especially since I know I've requested my mom's favorite tea be delivered bedside before I go under and I'll have use of an IPOD playing Enya as they wheel me back to OR-land.
Yes, this is pretty crazy. Some of the ideas are completely outlandish. Others not so much. Some are already in use in the hospital setting, including 'concierge' care type options and meal delivery choices.

I imagined Rapid Response Teams as the precursors to Integrated Care Teams (or PS Teams, for Personal Service).

All the fluffy service options won't REALLY cause me to forget I'm going in to have surgery, and there are risks, and I will be in pain. And things may go wrong. And then many of the desires above will seem trivial. But that's life, and medicine.

But these things sure can lessen the sting of preparing for surgery, and being ready helps patients feel like we're involved in our care processes, and perhaps a few baby steps closer to having some control over our own health and wellness.

As doctors, nurses, hospital administrators, fellow patients - which is more important in the long run, and more transformative to our system? Stopping us from getting sicker, or teaching us how to live well?


Out of Your Element - Leadership on Any Given Sunday

Teamwork is good. Accomplishing strategic goals as a team is even better. Unfortunately, it's taking H/HC a bit longer to catch on to the values of a team-based culture than some other industries.

There are literally hundreds of blogs offering teamwork and leadership tips and hints.

With the variety of definitions and recommendations swirling in the online ether, sometimes it feels like you're more liable to get a head ache than get ahead.

In honor of it being the weekend, and a gorgeous day, and just because I'm not feeling verbose, let's simplify things a bit. Here are some not-so-brilliant definitions of managing and leading:

If you're a successful manager or executive, people do what you say because they have to.

If you're a successful leader or coach, people do what you say because they want to.

Can you be both a successful leader and manager? Probably. But that's a talk for another time.

Now, if you want to learn about leadership you can read a book, a blog, or go to a workshop/conference.

If you want to see leadership in action, get out of your element. Go out to a local sports bar any given Sunday.

I'm sitting in the midst of fans from both conferences at a Northern Virginia Steelers haunt now (long story and not usually how I spend my weekend).

Fans here polarize around their favorite teams, but at each color-blocked table a captain emerges. This person leads the cheers and tablemates follow.

The table captain may be self-selected or emerge from a more stable base of similarly engaged fans. But why do the fans at the rest of the table tend to join in?

Why? They all want the team to do well. They all want the team to win. The leader is simply the most vocal about communicating this desire, and team members lend vocal chords to the effort. Everyone wants to be involved and engaged.

If more of our hospital 'table captains' showed 1/100th the passion, devotion, and enthusiasm of these fans (or their analytical acumen - I've been approached multiple times to verify a statistic using my laptop), maybe healthcare would have a hope of successful reform after all.


Means and Ends

On Tuesday the great suits of the Senate heard testimony related to H/HC IT practices, universal healthcare, and other great stuff.

Kudos to the voice of reason, aka Henry Aaron, at the Brookings Institution.

HITS, the Health IT Strategist e-newsletter, ran this priceless quote:

Henry Aaron, a senior fellow at the Brookings Institution, told members of the Senate Budget Committee that increased use of electronic health records, e-prescribing and other high-tech tools "is a means, not an end," and then chided Congress for not providing nearly enough funding for the effort.

"The end is replacement of the traditional view of physicians as solo, all-knowing managers of each patient's care with a new model of healthcare as a team activity involving many specialist providers who work together," he said.

Henry's philosophy applies to many more areas of healthcare than IT.

Let's take overuse/abuse of the ED by frequent flyers, for example. Not the most PC of terms, and if you're not familiar with it, go ask one of those all-knowing ED nurses or docs to share the definition as used in common practice.

People who use/abuse the ED to indulge in drug-seeking behavior are a segment of the hospital population I consider "customers" (because I can't use the terms I'd like to employ on a PG blog) by and large, rather than "patients" - that is unless they're ODing or detoxing as they come down off an overdose of meds or possibly having a severe and very interesting allergic reaction to narcotics. But I digress.

In advocating for designing service lines that call to customers, I'm by no means excusing or encouraging this type of behavior. Nor am I a cheerleader for hospitals' continued treatment of non-emergency conditions in the ED.

Nurse and physician bloggers far smarter than I have posited a great solution: staff your ED with a triage professional full time (RN, PA, MD) who will refer those patients who are not acutely emergent following triage to another facility.

Some brilliant Einstein-like minds have even called for a deductible payable in cash or via credit card UP FRONT - funny how if you charge someone that 100, 300, or 500 bucks before you'll register them after the triage exam they'd suddenly find their condition wasn't an emergency after all.

Of course, there would be true emergencies that are rushed through triage to immediate care - acute diabetic ketosis, alcohol poisoning with LOC, etc. These "lucky" patients get billed later for lifesaving services rendered.

This new "are you an emergency or not" system may sound great, and be cathartic to suggest, but is excrutiatingly trixsy for several reasons.

First - let's just admit it. We're all scared to death of being sued.

Second - we will make mistakes and miss some cases that don't present in the traditional way (heart attacks, CVAs, etc) and people will suffer.

Third - this requires the hospital in which we are practicing to have a subacute or "step down" ED unit, such as an onsite Urgent Care center, Fast Track, etc. This means mucho dinero to design, build, staff, and advertise, because this is a unit that will serve "customers."

Fourth - this requires the hospital in which we are practicing to embrace that catchy MBAschool teamwork lingo and have an executive team that supports our decision and promotes an "emergency care for emergency patients only" view from the inside out, at EVERY LEVEL of the culture. If we are going to be specialist providers who work together as a team, let's start acting like it.

This won't be easy to do (understatement of the month) in a culture that does tend to think of emergency healthcare (based on personal rather than medical determination) as a right rather than a privilege.

This won't be easy to do in a culture where hospital administration is a four letter word that (some, not all) medical professionals view as a bloated, bureaucratic yes-team. We may have rightfully earned that stereotype in too many H/HC organizations.

The full-time "weed out" triage pro and emergency treatment for emergency patients are means to an end, rather than the end itself.

Even if all of these trouble spots magically vaporize into thin air however, we still won't have successfully arrived at a sustainable "end."

The end is less crowded EDs.

The end is quicker service for life and limb threatening injuries and conditions.

The end is the return of emergency medical professionals who are burnt out and tired of selfish customers who slurp up resources patients should be receiving. They signed on to save lives people, not to babysit and bus cafeteria trays.

The end is a wider range of health-improving, wellness-maintaining, money saving options for care targeted towards desired sectors of medical "consumption" by customers with non-emergency conditions.

The end is a system that works, makes some money for some people, and self-selects to offer low or free care to those who are truly disadvantaged, like my new employer.

We don't seem to have much problem envisioning the ends - now where are the minds and leaders who will design and implement the means?


"Customers" vs. Patients - Economics and Enabling

ER Nursey and WhiteCoat Rants, two of my favorite bloggers, had great posts earlier this month. With Migraine Rants, ER Nursey jumped on the great "users versus abusers" and "are they customers or are they patients" debate, while Dr. WhiteCoat provided a comprehensive view of our enabling culture here.

As both bloggers and medical professionals, a certain amount of weigh-in on the "patient" side is inevitable. However, I can't shake the feeling that our system has moved way past the point where most patients are merely, well, patients.

In allowing patients to choose their level of care and have relatively unrestricted access to services, we are indeed "enabling" (and yes, encouraging) them to become customers.

We are, either directly or indirectly (via HMOs and other coverage) consumers of healthcare, and this puts us solidly in the "customer/client/guest" realm.

However, just because we're now consumers doesn't mean we make "good" consumptive choices. Similar to the subprime lending fiasco and the mortgage crisis fallout currently smacking our economy in the face, this means some customers make "bad" or self-centered choices about how to individually access resources. We're not concerned with saving the system; we're concerned with saving ourselves.

Dr. WhiteCoat has selected a great example in the ambulance services market.

Anyone in this country may dial 911 (please note I don't use "can..." here - I'm not assuming everyone in the country is physically/mentally capable of dialing 911) and be transported to an emergency room for care. The minute these patients come through the front or back doors of your ED, they morph into customers.

The issue isn't really whether or not we consume H/HC but whether or not we are EFFICIENT consumers of healthcare. Having worked in an ED myself, the answer to that question is a booming NO, at least as it pertains to 'emergency' services.

Unless we are in no physical or mental condition to make choices, we select from a variety of treatment options when seeking 'emergency' medical care. Again, this makes the vast majority of us "customers."

How many "customers" come into the ED not for an emergent, life- or limb-threatening condition, but because they can't get in to see their PCP for a week? Because they're out of pain meds? Because they are scared, uninformed, and/or uninsured?

Unfortunately, many patients (and their worried families/friends) treat the ED as a 24 hour doc's office, rather than a place for emergency healthcare.

No doubt about it - at most hospitals the ED is a service line that bleeds cash rather than generates it.

There are, however, service lines that contribute regularly to a hospital's bottom line (with traditional, average profitability a paltry 4-6 percent) - these include Ambulatory (Elective) Surgery and OB/GYN.

The patients who select a hospital based on the perceived strengths of certain departments are certainly customers making conscious purchasing decisions. Shouldn't they be treated as such?

This is a dividing issue I haven't heard much chatter about in the blogosphere, much less the 'mainstream' industry media...I'm concerned about the internal fragmentation between medical staff who view patients as "patients" low on the traditional medical hierarchy and administrators who view patients as "customers" who need to be wooed with well-designed marketing campaigns.

The opposing views are generating plenty of conflict in individual departments. They're certainly contributing to employee churn and burnout, but the debate isn't surfacing at the system/management level where it may have some small hope of resolution (or at least facility-specific improvements).

Why am I so concerned with this dichotomy of perception...there are plenty of other things to worry about the the H/HC market right? Right.

However, the way varying members of the organization view the patients/customer population determines what services are provided. This can make or break a hospital in terms of revenue generated.

And let's face it; money is the bottom line - it keeps the doors open, the lights on, and the staff paid (hopefully) saving lives. Hospitals are businesses, and patients are customers. It's a noble business of course, but a business nonetheless.

We're really talking around the issue though - try to put aside ruthless, self-centered enabling and multiple abuses of hospital resources by frequent flyers, just for a moment.

Let's revisit the issue using economic terms: needs versus wants. Hospitals have two distinct population groups...those who NEED care and those who WANT care. Those who NEED care are patients; those who WANT care are customers.

Will the need-versus-want divide prove too large? Will the hospital/healthcare market eventually fragment according to the acuity of varying conditions?

Dr. WhiteCoat articulates the crux of the issue well...we suffer from a fragementation in access in addition to level of consumptive options - economically disadvantaged "customers" have disproportionate access to healthcare (especially preventative care). As the good doc puts it:

"The health care system in the US is broken for a lot of reasons.
One of the biggest reasons is that the costs of providing healthcare to this nation’s
citizens outpace the resources available to provide those services. Like it or not,
rationing already exists. And unfortunately, that rationing disproportionately
affects the poor."

After speaking with a psych nurse about the customer vs. patient issue, a scary vision of the future popped into mind.

If the schism in industry perceptions deepens and we refuse to reinforce the concept that the majority of our patients are customers, we may end up with an irrevocably divided care environment.

Imagine this environment (a few decades from now): Politikos have yielded to popular opinion that access to "lifesaving" care be added to the Bill of Rights. They establish federally funded, state administrated facilities similar to the hulking, inefficientVA system. These behemoths are ward-like emergency facilities that provide ONLY emergency care and then discharge patients.

Patients discharged would then morph into total H/HC consumers, selecting a specialized facility based on their own ability to pay, their personal preferences and the type of care needed.

Similar to other consumer markets, there would be great variability in the offerings; think of airlines, auto makers, and hotel chains. Some hospitals would be tailored towards bare-bones consumers, some would act as 'massclusivity' economy lines, and some would be luxury facilities.

We'd revert to a class/caste system of healthcare, where customers are the "haves" and patients are the "have nots..." and how is that so different from the broken system we have now?


We Remember...

To all those who lost jobs, family, friends and lives, and to all those dealing with health issues that may be related to serving at Ground Zero - we remember; you will not be forgotten.


Rural, Suburban Primary Care on the Cutting Edge?!

I received an interesting letter size envelope in the mail today, with an abstract graphic on the return label.

The sender was "Lasting Impressions Aesthetic Center, Leonardtown, MD."

Since the information originated from my old home town, I opened the letter rather than placing it in the circular file. I'm glad I did. Seems some providers are catching on to the idea of conspicuous consumption and how it relates to service line expansion.

Inside was this letter from my former PCPs office (although now I'm considering driving the 1.5 hours each way to stay on their active roster).

I'm taking a page out of Paul Levy's book and relating the contents en total:

Dear Mrs. McCabe Gorman,

There have been exciting new developments with St. Clements Medical Care and Chesapeake Family Healthcare. We have recently expanded our services to include laser treatments and aesthetic care. You are already familiar with how our quality medical care keeps you feeling your best; now trust our physicians and providers to assist you in looking your best.

Your experience will begin with the confidence of knowing your service is being performed by a medical professional. Our Gemini Laser utilizes state of the art technology to ensure gently, effective treatment. Enjoy relaxing in a comfortable atmosphere while the laser continually cools and precisely targets your problem areas. Our laser can treat acne, leg veins, brown spots, facial redness, rosacea, wrinkles, shaving bumps, and unwanted hair (Blogger's aside: Why didn't they call it the "Eureka! Laser?").

We have also had successful results with aesthetic injectables over the past year. Our office offers Restylane and Cosmoderm, which are dermal fillers for the temporary correction of wrinkles, folds and scars. We also offer Botox injections for relaxing wrinkle-producing facial muscles. Revaleskin, a line of skin care products which have been featured in Shape and Allure magazines and are only available through medical professionals, will be available for sale at great introductory rates, along with other quality skin products.

If you have ever thought about doing something for yourself (Blogger's aside: And really, who hasn't? What's next? PCP gift cards for a little pre-New Year's Botox?)we encourage you to call Lasting Impressions Aesthetic Center at 301.997.1562. Although there are variations among individuals, what we are offering is faster, easier, less painful and more effective than almost anything else available. The technology has moved a long way {sic} in the last few years. Call us today for your personal consultation with your favorite medical professional. If you call before October 1, 2007, you will receive a free consultation and a low introductory price for your services (Blogger's aside: I may have to try this just to see if the services live up to the hype...and, um, I could really use a facial...).

We would also like to invite you to attend our OPEN HOUSE on September 29, 2007, from 1:00 to 4:00 PM, at the above address. Enjoy refreshments, receive a sample of Revaleskin products, view a laser demonstration DVD (Yowza!), and meet the providers performing the laser procedures to ask questions of what we can do for your Lasting Impressions. Find out how we can help define your own lasting impression.

We look forward to working with you!


Dr. Jennifer Schmidt, DO
Dr. Mia Finkelston, MD
Dr. Karen Tucker, MD
Jennifer Cheeseman, PA- C (went to high school with Jennifer)
Marie Tarleton, CRNP (one of the best practitioners I've ever met)

I have to admit I'm excessively curious to hear how my doc's office came up with this plan...and even more curious about how well the center will do. I'm betting it becomes their top revenue generating service line within the next 16 months.

It's a good reminder that sometimes industry chatter is exactly that - chatter. There's no doubt PCPs are in trouble in many areas, but these ladies seem to be doing just fine. Their letter sure made a lasting impression on me.


JCAHO Top Compliance Issues for 2006

The Joint Commission just released top compliance issues for last year...how do you stack up?

58% of hospitals did not improve the effectiveness of communication among caregivers, having problems with verifying verbal orders, using prohibited abbreviations, communicating critical test results, and standardizing hand-off communications

46% of hospitals did not accurately and completely reconcile medications across the continuum of care

44% of hospitals did not properly and safely store medications

30% of hospitals are not properly following the Universal Protocol to prevent wrong-site, wrong-procedure, wrong-person surgery

Issue 1: Communication.

Issue 2: Medication reconciliation.

Issue 3: Medication storage.

Issue 4: Surgical Errors.

Take another look at the first issue...it impacts each of the following three, particularly surgical errors.

What communication development programs do you have in place?

If the answer is "zero," convene a communication improvement committee this afternoon - there's no better time to start the process of clarification.

JCAHO has made their expectations for improvement clear - have you communicated the urgency of these efforts to your team? Do you regularly monitor (using quantitative AND qualitative methodologies) improvements and internal benchmarks?

And for the purposes of self-awareness, take 15 minutes and use the free Alpha Assessment to clarify your leadership and communication strengths (and weaknesses).


Microinsurance Startups: A Possible Solution?

Very interesting Forbes article here.

Could a regional or municipal based microinsurance startup concept work in the US?

What about a nimble, adaptable microinsurance company without much overhead (eg all employees telecommute) organized around sales to a specified patient populations (ie young professionals in their 20s with no dependents living high-volume in cities such as NYC, DC, LA, etc.)?

You'd probably want to pick a patient population group that, similar to the Indian farmers mentioned in the article above, has statistically low incidences of high-cost procedures, such as inpatient surgeries, per 100 or 1,000.

Wonder who will be the first to figure out just how much you'd have to charge a 20-something to get a basic, mid-level deductible plan going...and how many you'd have to enroll to turn a profit.


Hospital Admin or I-Banker? Hmmm...

I read the following account in FierceMarkets' FierceFinance e-newsletter with some interest...

"According to a recent government report, investment banking pay is hitting absurd levels. The weekly pay in the profession is $8,367, compared with $841 for all private sector jobs. Are investment bankers worth 10 times more than everyone else? Let the debate begin."

Here is a NYTimes article detailing extreme disparities in pay - we pay those who work with our money more than we do those who work to teach our children, those who work to improve our health.

But we also must be seeing the law of supply and demand in action...many more MBAs want to work in the NYC market atmosphere than toil as a hospital executive. Money talks, apparently.

But what else talks to promising candidates looking for a career?

Money of course, but I-banking and other financial/consultancy positions deliver a gift wrapped package that may turn out to have a grenade inside. Take a look at the comments section following the NYT article for a good old-fashioned, gloves off back-and-forth debate.

Despite the big-bang paychecks, the sector can be fraught with competitive pressures where honing your skills is an hourly affair, necessary for survival. All that living on the edge gets tedious and carries a high risk of burnout.

However, I have to admit that were I an MBA evaluating my options, weighing the costs and benefits of different industries, I'd cast a favorable eye on several perks the banking/financial industry offers:
  • Strong cultural norms ('good' or 'bad');
  • Visible company identities that emphasize cohesiveness of total results in addition to personal competitiveness - and these identities are shaped by a strong management/exec team;
  • "Very handsome bonuses" that are performance/productivity based;
  • The opportunity to access continuing education/development in the form of scholarships, tuition assistance, and mentorship programs (for instance, if I could find a firm willing to pay for graduate school, or one that offered a scholarship competition to cover the costs of higher higher ed, I'd stay with them through my doctoral program and most likely 5 years beyond); and
  • The opportunity for advancement, furthering leadership skills, and possible inclusion in succession planning if I really demonstrate the right stuff.

However, take a good look at the list above - all of these are areas hospital and healthcare organizations can develop to attract promising candidates.

H/HC organizations are suffering due to a lack of aggressive searches for new executive talent. We need new blood, and we're not doing enough to revamp the supply.

Of course, it's a vast oversimplification to say many financial, consultancy, and research firms aggressively recruit/rewards young talent while many hospitals don't, but - well - think about it.

Do you send a representative to all regional college career fairs? What about high schools? Is there information about your scholarship programs in high schools statewide?

Do you have forums for young staffers to develop leadership AND managerial skills?

Are you providing them with opportunities to volunteer for BOD committees, become involved in the operational heirarchy as talents/needs permit? Could you personally name 2-3 promising replacements at multiple experience levels within your organization?

Promising candidates with much to offer our industry ARE out there, but they won't stumble across your doorstep by accident.

Similar to performing a comprehensive service line evaluation, you have to figure out what to offer that will bring them knocking, portfolios in hand and suits neatly pressed.


Servant Leadership? Drop the Chalupa!

My new home city (Washington DC) has recently garnered the dubious distinction of having the number one obesity rate for youth in the USA.

Click here for one of many articles detailing our gluttonous ways.

Good for us DC...taxation without representation and now some kids with too much to eat (or not the right food to eat, certainly) and not enough exercise.

I wouldn't have believed this possible in the nation's capital (bad naive idealist! bad! bad!!), until I stood on the stairs of one of our facility buildings and watched children gather in front of a boarded up school building. In groups of about 20, the students finished snacks and climbed the few stairs to cushy seats on coach buses.

I learned from a coworker and some residents that they've been bused to and from a local college to attend classes for three years while their beautiful old building sits "under construction."

They leave this neighborhood each day, and instead of walking to school or riding bikes, many are dropped off or take a Metro bus to this coach bus stop.

I wonder what sort of incentives we'd have to offer them to take a more active means of transportation to and from school. What sorts of public works initiatives would we have to enact to make the streets safe for kids to walk? skip? Ride bikes and scooters? What awareness campaigns would we have to develop to engage parents and allay concerns?

With the elimination of recess in many districts, and the shortened physical education times, the desire to do something new may hold its own attraction.

At least that's what finally tipped my coworkers and I off the couch...

After many pithy comments from the staff peanut gallery, some of us wondered why we weren't getting certain parts of our anatomy moving more often.

A few of us started cycling regularly (I finished my first 25-miler on Saturday), and two other colleagues are going running tomorrow morning before work.

The first steps toward higher levels of fitness are faltering, but they are movement forward. With almost 23 percent of the District's children overweight, any efforts toward improving even basic fitness levels (1/2 mile of walking per day) would be a step in the right direction.

As servant leaders in healthcare settings, how can we provide additional examples of paths to increased wellness?

Can we partner with area schools to provide 'safe' places to walk? Can we send teams of volunteer staff members to lead recess hours? And pay them for this time?

Do you have any innovative suggestions for getting your people, your communities, moving? Bodies and minds work better in tandem...


Labor of Love

Last week I was talking to a new nurse - 3 months out of school - who has chosen to work at our facility.

Her first clinical 'job' experience and she's spending it caring for homeless clients with high levels of acuity, multiple conditions, behavioral and social deficits - the list goes on.

Needless to say the respect I feel for a staff member with the maturity and guts to take on this type of assignment is almost off the charts.

We had a rare few minutes to chat at a welcome function, and were hashing out the typical who are you, where are you from, what-do-you-want-to-be-when-you-grow-up type questions.

When I mentioned my goal of entering hospital administration, New Nurse paused for a moment, put her hand on my knee, and said with a completely straight face "oh Jen, I'm so sorry to hear that." (As you can probably infer, she's doing just fine with our tough crowd of patients using that sarcastic wit).

After some laughs, we talked about how New Nurse really hates hospitals, and was dreading working in the hospital environment right after school. Luckily for all involved, she found us - an alternative environment of care that will allow her to develop one-on-one relationships with patients in a supportive setting.

Her ultimate goal is to care for patients who can't care for themselves - to be a medical partner for those who are underserved. Perhaps the most valuable part of our conversation (for me) included a discussion about how a focus on the end (caring for the underserved) rather than the means (nurse in a hospital versus a clinic setting) allows you to not become bogged down in searching out your next step on the career ladder, but rather seek out opportunities that help you get closer to your 'end.'

We talked a bit about her feelings of discomfort and from whence they arose. Some of the things she mentioned had me up late at night thinking about why I love hospitals, and how that drives me towards wanting to get my hands on one and shake things up a bit.

I've arrived at the conclusion that I probably am a bit crazy to 'want' hospital administration as my 'end' - in these times of multiple challenges and relatively low rewards compared to other administrative/executive paths, you'd have to be a bit on the strange side to think you can ride in on a white charger and organize methods of positive system growth/change.

But perhaps all labors of love germinate from an unwillingness to let the difficulties sway you from your 'end.'

In honor of Labor Day, let's head back to the concrete for a moment - examples of some things that create an 'undesirable' hospital feel but that you can labor to change include:

1. Focus on sickness/dying.
2. Lack of privacy.
3. Lack of respect for individual personhood and decision making - not involving a patient in their continuum of care via full disclosure of DX and treatment options - ie not taking time to really talk to our patients because we're so busy performing the 'technical' functions of healing (med administration, dressing changes, etc).
4. Yes, the food.
5. Lack of activities for patients who are relatively awake and aware to continue pursuit of their personal goals.

What components of your facility's operations/approach contribute to the undesirable portion of the "hospital feel?"

Can you modify any of these things to create a more constructive healing environment? The answer is probably yes - just ask some of your new nurses...they've got plenty of valuable ways to help you achieve your 'end.'