System vs. Systemic Change - Sharpie as Management Tool?

Sometimes a systemic sea change is planned carefully, utilizing insights gleaned through months of evaluation, pages of data, and shepherded step-by-step through the implementation phase by multiple internal stakeholders guiding an organization to the next phase of evolution.

And sometimes, a small, almost unnoticed system change germinates when you put a Sharpie to a legal pad and try to write something amusing.

When I pasted this sign on my door, I was (literally) in the middle of two coworkers contentedly engaging in some good natured ribbing.

When voices started to rise a half-octave and the comments became a bit more pointed, I grabbed a legal pad, scribbled this sign, ripped off a piece of Scotch tape, and thumped it up with my palm.

Facetiously, I said something along the lines of "There. New rule. This is a place of UNIVERSAL RESPECT."

You wouldn't think a low-tech, handwritten sign that started out as a half-joking response to situational discomfort would actually influence a change in organizational behavior.

But in the weeks since I smacked up that sign (where it hangs to this day), I can't tell you how many times I've stopped comments in their tracks by pointing to the sign. I can't tell you how many times I've reevaluated my own comments, even my own internal thought processes, as a result of that yellow piece of paper.

Here's why something this simple works to change behaviors within a system.

I DO want to respect everyone who comes within feet of my office door. This text reminds me daily that when you enter, your concerns are my concerns. Your priorities are more valuable than my own. It is my job to treat you and your comments, ideas, questions, and challenges with the utmost respect by giving you my total and complete attention.

I think a coworker put it best when we were discussing the strange ripple effect of the sign (less teasing in my office, even less in our area of the hallway - coworkers who wanted to say something sarcastic literally delivered witty remarks feet from the office entrance).

He said: "Jen, you're in a constant daily battle not to be selfish."

All of us in healthcare today are fighting this same battle.

Systemic change, in some respects, is easier to influence (or easier to convince ourselves we are influencing). When we research change that we hope will create grand and sweeping improvement at the systemic level, it's easier to divorce our individual efforts and foibles from the actual daily success and/or failure of the plan.

But when we implement change on the micro level, when we make a ripple that spreads at the personal level and influences behavior within a small microcosmic system, it's nearly impossible to separate our hourly successes and failures from the goal.

I've had this photo of that sign for weeks now.

I'm writing about it tonight because today included one of those hours when I failed.

I made a sarcastic comment to a coworker that many would most likely shrug off as meaningless. But here's the rub: that sign is the first thing I see in the morning as I unlock my door. It's one of last things I see in the workplace at night before I head home.

That sign means I'll walk into work tomorrow, take off my winter gear, and go find my colleague. That sign means a "good morning" will be closely followed by an apology for not showing the level of respect I want to convey, the level of respect she deserves.

That text reminds me that nothing is more important than trying to change a faulty system within your own daily work.

If you can accomplish that, perhaps it's time to step up and pick a system within your organization that needs improvement (handwashing procedures, emergency preparedness, physician recruitment, employee recognition).

You can't realistically influence systemic change if you don't start at the level of an individual system. Grand plans are good, but small signs that generate results are even better.

How's This For A Distinctive Patient Experience?

Retail models. Consumer-directed care. User-generated tools. There's a reason I keep cycling these issues around like a scratched CD.

Sometimes to improve people's health we must stop. thinking. of. healthcare.

Start.thinking.of.people.

Who they are. Where they live. What services they buy.

Click here to read about how neighborhood barbershops in DC are reducing the impact of heart disease in the District.

Author Delphine Schrank of The Washington Post has single-handedly revived my faith in traditional journalism with chestnuts like this opening line:

"In the annals of beauty, the pompadour, the beehive and the Afro all had their day. Now comes the lifesaving haircut."

Schrank's great article begs the question of what's more important in innovative approaches to healthcare - the methodologies or finding means to employ intervention techniques that meet people where they are?

My only question after reading the article is this: Why did it take two decades for the Hair Heart and Health Program to spread virally to the District, just about 1.5 hours away from the program's birthplace in Baltimore?

Here's a summary from DCPA:

In southeast, one barber dispatched two freshly trimmed customers with hypertension straight to the emergency room. At the Divine Transformation Beauty Salon, a beautician cajoled a 300+ lb. patron into trying a fiber-rich diet. And in northeast, the owner of Fresh Cut II All About You opened her hair salon on a Sunday night to check the blood pressure of a client who had nearly fainted after learning that her daughter died in a car crash.

These three are among African American barbers and beauticians in five DC shops with blood pressure machines and digital scales tucked between hair-drying bonnets and bottles of shampoo.

They were enlisted in a program underwritten by CareFirst BlueCross BlueShield and the MedStar Research Institute to combat coronary heart disease. Modeled after a Baltimore program coordinated by U.Md.'s Department of Medicine, the DC program trains stylists how to screen clients for obesity and high blood pressure and when to urge them to follow up with a doctor. The plan is to be implemented in 12 shops by year's end.

Launched last month, the Hair Heart and Health program joins a groundswell of similar efforts across the country. All expand on the unique cultural role that barbershops and hair salons play in the African American community to raise awareness about health issues -- particularly those that disproportionately affect black Americans.

Barbershops and beauty salons are one place where African Americans meet across socioeconomic lines. They're the nerve centers where gossip is traded and racial politics is dissected. The idea to marry health care and hair styling arose in Towson, Md., in the early 1980s, when U.Md. doctors began checking blood pressure in churches, but sought to capture a wider audience.

Also read: "Barbershops, Bibles and BET: Everyday Talk and Black Political Thought" by Melissa Harris-Lacewell, an associate professor at Princeton University. For more info, read: Hair Salons, Barber Shops Become Centers of New Cardiac Care Effort in District of Columbia; Hair, Heart & Health Addresses Coronary Health Risks for African-Americans, CareFirst BlueCross BlueShield, News Release, October 1, 2007.

Amazing. If DC can encourage barbershops in cash-strapped neighborhoods to take part in community-based, consumer-centric healthcare, what can you and your organization do to address each customer where they are?

Want a Closer Look at Canadian Healthcare? Check Out "Les Invasiones Barbares"

Normally I'm not a big movie buff.

In fact, we don't own a television, a stereo, or any other large, entertainment-oriented electronics. We're pretty geekmo and highly portable when it comes to tech stuff (Blackberrys various Apple music devices abound). When I want to watch a movie, I either pack it up and head to the theater or pack it in and download something from ITunes onto my laptop.

When I took a trip to the Twin Cities this weekend, I lugged my trusty laptop Raphaella (yes, I name my computers - wanna make something of it?). I didn't plan to spend quality time with my dad watching a rental Indie flick, but we were snowed in...plus 2003's The Barbarian Invasions (a Canadian film in French with subtitles) turned out to be a sharp and touching healthcare hit.

It's got wine, drug-seeking behavior, unique *ahem* methods of combating chronic pain related to terminal cancer, end of life care debates, pasta with truffles (mmmm), healing pastoral scenery by a beautiful lakeside cabin, and enough quirky, painfully 'real' interpersonal dialogue for an Oprah's Book Club novel.

But the most interesting part was a satirical (I hope) depiction of a Canadian hospital stay. Never having gone this far north for medical care, I can't verify whether a whiff of it's accurate. On Amazon, a reviewer named Francois Tremblay from Montreal, QC Canada, calls it a "dingy and corrupt (but unfortunately realistic) portrayal of the health care system in Québec." When the father in the picture, played masterfully by Remy Girard, cannot secure a private room or advanced treatments for cancer, he and his son argue about heading down to the good ole' US of A for treatment.

Particularly amusing (depending on your point of view) are depictions of hardworking nurses, fellow patients, unsympathetic hospital administrators, and union reps. There's something for everyone - academics and B-school financial types don't escape the picture's scathing wit.

In case I haven't convinced you to spend 99 minutes of your time checking out the film, written/directed by Denys Arcand, won the Academy Award(R) winner for Best Foreign Language Film in 2003.

Cards Generate Big Bucks - So Why Aren't Hospitals Using Them?

After reading about Visa's Healthcare Gift Card (see today's earlier post), I was curious about other potential card uses in the hospital market.

These cards are big bucks. Click here to read about how the alternative giftcard market is making a lot more than chunk change for Safeway.

I can think of one very interesting application for the H/HC market.

Colleges and universities are using "onecards," cards with magnetic strips linked to a student's account. You can use the cards to pay for a meal, a triple venti skinny mocha, a CD from the campus bookstore, or a scoop of gelato from a neighborhood shop.

The cards usually have the users photo, a logo, and other information encoded or 'linked' (such as the students account including course enrollment data, demographics, etc.) via the magnetic data, a barcode or RFID tag.

In my idealized future hospital, patients (and patients' families) could charge a reusable onecard and use it at locations around the hospital to pay for things in the cafeteria, coffee shop, gift shop, perhaps even surrounding area restaurants and other local businesses (check out the model used by Virginia Tech).

Here's how you could push the card concept several steps further by linking it to an EMR system. *And if no one's doing this yet, who'll be the first hospital to implement and build on the concept?!

If your hospital employs RFID tagging, you could issue every patient 2 cards upon admission, one for their use and one that care providers use (stored in the chart). If you're using EMRs, you could swipe the patient's card before each treatment, medication administration, vitals check, procedure, when calling up records/results from radiology, etc.

Of course, this type of integrated system is useful for billing and reconciliation in current systems, but it would REALLY generate some burning ROI only if your charges are transparent and patients can compare what they're paying to a listed menu of services and corresponding costs.

To get this going, I'd take the following steps:

1. Visit a few colleges/universities in your area and view the onecard systems in action. Take notes. Ask questions. Think of challenges you might have in translating this system to your organization. Ask one of the administrators for a reference - who was their sales rep? How did they decide which vendor to select? What advantages 'sealed the deal?' How often has the system gone down (if ever)? What backup does the school have in place?

2. Contact a few onecard vendors (or get your Administrative Fellow to do it). Work through the chain until you find a salesrep that really knows their stuff. Ask them all your tough questions. They should be hopping to come onsite and show you how things might work. Walk them through your facility. If they don't ask questions, don't call them back.

3. Put out RFPs. Do your homework. Proceed with your normal vetting process. Do the CBA. Ask other hospital administrators and your personal brain trust for thoughts. Does this make sense? Will it create undue complexity AFTER the painful trial and implementation phase?

4. Pull someone you don't know well from every department, an environmental services worker, night float pool nurse, greeter, dining services representative, etc. Form an action team, not a committee. Tell them they'll be mystery shopping systems. Ask them what they think about the idea. Better yet, see Step 1. Take this delegation on the college tour with you and record their opinions. And finally, don't make the mistake of using this team in all the planning stages and then leaving them out of the decision-making process. One person on the team = one vote when winnowing down the vendors.

5. Take a deep breath and pull the trigger. If you've done due diligence, you're making the right choice.

Everybody Wants One of These Babies in Their Stocking...

Very interesting...giving healthcare as a gift?

PA-based insurer Highmark launched a healthcare giftcard in parnership with Visa. It looks like Visa is taking the program national.

The card was created to "encourage the use of medical services among certain cash-averse populations." Now, does this mean the card was designed for those who don't like to use cash, or those who don't have enough cash to pay for medical services? Apparently both.

Highmark feels seniors who pay for health services (not in cash) and cash-strapped college students are perfect market segments to target (hmmmm). They're also suggesting the card can be used to supplement high deductible plan coverage for costs incurred before the CDHP kicks in.

Customers could also use the card to foot the bill on copays in times of 'situational' need, such as when a child breaks an arm and needs multiple follow-up visits with an ortho doc.

Kim Bellard, Highmark's vice president of e-marketing and consumer relations, would "love to get a phone call from the AARP."

Visa also thinks the card is a perfect gift for friends making 'get healthy' New Years resolutions, for baby showers, and for getting back in touch.

"After all, what could be more thoughtful than the gift of health?" (from givewell.com).

If you want to give someone the gift of healthcare dollars, the Highmark card can be yours for the low cost of $4.95 (plus s/h of course). Then load the card with any amount from $25 to $5,000. (It would be interesting to see some stats on the average amount loaded...). Visa will also charge you a $1.50 maintenance fee per month.

The card can be used at any health-related business that accepts credit/debit cards bearing the Visa logo. Designated health-related businesses where the card can be used include docs, ambulance services, counselors, dentists, pharmacies, spas and gyms.

Prescriptions at Target, Wal-Mart, CVS, RiteAid, Kroger, Safeway, Sam's Club, and Costco are also covered. Not sure if you can use the card to purchase 'other' healthcare 'related' supplies at these locations. For instance, gum is essential to my daily mental health and wellbeing, so would the purchase of Orbit be covered?

You can get more info about the cards (and purchase one if you're so inclined) at www.givewell.com. You can also enter to win a $100 Healthcare Visa gift card (which I did not do, but I have to admit I was tempted...).


Click here to read the Kaiser Daily Health Policy report, or click here to read the original Pittsburgh Post-Gazette piece by Bill Toland.

Whether You Like it or Not, We're Already a Consumer-Centric System

According to this article in The McKinsey Quarterly, titled "A Better Hospital Experience:"

• Remember K.I.S.S.: We want hospitals that talk to us like we're more than bodies for cutting and keep us up to date on treatments, wait times, etc.

• A slim 20% of a patient's hospital choice is based on clinical reputation (transparency, transparency, quality outcomes, error data, and more transparency)...While just under half (41%) is based on softer, 'nonclinical' experiences (accomodations, design, patient satisfaction, etc). Still feel like laughing at Cleveland Clinic's other CEO Dr. Duffy or United Airlines new Managing Director for Customer Experience?
  

• As an industry, we've got bigger problems than arguing over whether concierge care is a passing fad or the next hospital best practice - few hospitals have "the marketing skills, the organizational structure, or the operating approach needed to deliver a distinctive experience in the way that retailing and hospitality companies do." Start looking at which hotel/hospitality chain hire you want to recruit for your next VP opening. And why they would want to come to your hospital.

• The biggest "duh" finding: "Hospitals can segment customer groups in the same way that marketers segment them in retailing." Gee, really? And don't forget to segment w/in service line structures as well. There are multiple 'archetypes' among 'cardiac' patients...how are you appealing to your top 2-5?

• And finally, whose job is it anyway? Hospital C-levels can't forget it's our calling to germinate a cultural and operational model that grows and nurtures a "distinctive patient experience."

Health Reform 2.0: What Should Happen PRIOR to Policy Design, and Why Consumer-Centric Innovation Will Drive Change

I'm going to chime in with a broadly generalized, highly qualitative op-ed here.

This blog edition will NOT be a particularly eloquent piece with tons of quotes and sources (I haven't had any coffee yet, so we'll all be lucky if I can string together graphs with some semblance of grace).

Plenty of commentators with higher IQs and many more years of involvement in various aspects of the system are providing heavy-hitting commentary (just check out a few of the writers in my blog rolls at left).

I'm not the sharpest tool in the shed, but I do have a significant personal investment in how the system evolves. Here's my simplistic, blunt-instrument look at where I think we're headed.

Plenty of us are quoting facts and figures, but my purpose this beautiful gray morning, typing from Natural Sound Studio in Minneapolis/St. Paul, is to take a step back and gut-check some basic assumptions driving the political end of the health reform debate. (For your reference, dear readers, I tend to identify with consumer/market competition-centric portions of Huckabee, Hunter, Romney, Thompson, and Dodd's proposals).

Last weekend, two uncles and I were standing around the kitchen talking some business. As we are wont to do in my family (thanks Uncle Tim), we moved the discussion from a relatively friendly overview of the market ("Cash is king until mid 08 ") to a deep and visceral healthcare debate, with comments ranging from "healthcare spending will bankrupt the system" to "it'll be a tsunami."

Talk got hot and heavy ("is the healthcare industry more interested in defeating death or maintaining quality of life?") until we backtracked; there are a few fundamental questions we had to answer before we could hypothetically design the next cocktail-napkin generation of H/HC reform.

I'm going to play devil's advocate this weekend and ask you to consider the debate in terms of broad, sweeping generalizations.

Chew things over and give me your detailed, down-to-the-nitty-gritty responses in the comments.

So here we go:

Before we design policy, we must answer two fundamental questions:

Is healthcare for US citizens a right or a privilege? Does the game change if we modify "US citizens" to read "US residents?"

Who should pay? Employers? Employees? The government? Non-profits?


My answer:

I believe healthcare is a right, but as with many other rights, citizens bear some level of responsibility for the system and their place within it. Those who can economically afford to be 'responsible' for some level of their care should be (e.g. we need an individual pay system designed using models including Sweden and Nederland as examples).

Second, the contributions of those who can pay combined with certain resources redistributed into the collective civic service bank of our government (via income taxes and other funding models) should help support those who cannot pay for care (e.g. we need a socialized or 'universal' system where everyone has access to more than emergency care provided via government funding, a la the systems in Canada and France). These funds should be redistributed through a program that provides basic services to those consumer populations who need them most, like WIC.

In addition, I expect our nonprofit sector will continue to provide some level of care for those who cannot otherwise afford to pay, creating a third slice of the H/HC reform pie.

None of the suggestions above are shockingly new. None of them are impossible to administer. The hybridization and collective efforts of these systems, however, is failing to deliver care in a sustainable, cost-effective, wellness-maintaining manner. I believe some of this failure may be attributed to of a lack of incentivization.

My soapbox:

If consumers are largely divorced from the real costs of care in the current marketplace, what incentives are we providing for people to manage their personal health and wellbeing?

Very few. Give us more market transparency. Let us see the real prices for care versus what our insurance companies are paying. Let us purchase insurance plans across state lines. Let us select healthcare services from a menu of options that includes cost and quality data.

If healthcare providers continue to provide services for patients indulging in excessive use of care and they continue to be adversely impacted personally, professionally, and economically by these experiences, what incentives do they have to continue practicing?

Very few. Let's plug the holes jettisoning docs from the system. Combat decreasing interest in primary care and other service lines/specialties that don't offer incentives to practice, such as work-life balance, timely payment for services, ability to operate in a transparent, competitive marketplace, etc. with more training in design, implementation, and care delivery.

Let's provide docs with realistic ways to set up and manage businesses (step it up entrepreneurs - we need many more firms like Athena Health to smash H/HC silos of inefficacy). Let's increase training in areas that are increasingly important in healthcare, and augment clinical coursework with patient-centric communications and general management knowledge.

Why will some aspects of a federally-funded, 'socialized' or 'citizen'-centric system work?

We pay a certain percentage of our incomes into the larger federal pot - those funds are redistributed based on the needs of the nation as a whole (or they should be).

Another working example of this model is present in many of our municipal services; in cities and states a portion of our taxes are used to pay for (subsidize) services like trash collection, the public school system, fire departments, police departments, water and other utilities, etc.

So what type of system will ACTUALLY work in the US with all of our big-gun lobbies heavily investing in candidates and thus influencing outcomes?

Do we move to an individual payer system, where the responsibility to pay for our healthcare transfers completely from employers to workers? Or do we move to a federally-funded, government-paid, socialistic, 'universal' system, where the government funds and administers healthcare at a national level?


My answer: A hybrid system is the only type that will ACTUALLY have a chance of working in the US.

A unified move to a socialized, government-paid, supposedly government administered* national or 'universal' healthcare system would collapse under the lobbying power of the HMOs, or these same firms would put so much time and money into the legislative process that the design that emerges would be advantageous to corporations rather than consumers (Exhibit A: Medicare Part D). *Portions of Medicare/Medicaid enrollment, processing, and administration are outsourced, creating a shadow industry whose operations are partially hidden behind the exposed profile of the governmental plans.

Plus, a unified move to an individual payer system would provide untenable pressures on HMOS and other insurers - these behemoths would not be able to adapt fast enough to respond competitively to the variety of demands that would be placed on the system by consumers seeking services significantly more a la carte in nature than the current employer based, broad-spectrum package deals. This means they'd put up significant dukes to stop such a move.

In addition, our consumers just aren't ready to consider healthcare options within a competitive marketplace.

We aren't teaching healthcare providers and healthcare consumers to communicate on a level that partners providers' knowledge with patients' goals for quality of life. We aren't fostering game-changing, market-morphing, Health 2.0 style movement towards innovative, user-influenced care modalities.

We aren't teaching these things yet, but some entrepreneurial types aren't waiting for the 08 election outcomes to seize opportunities. Startups following in the footsteps of consumer-centric success stories like Starbucks, Google, and Apple, will innovate ways to avert the coming coverage crisis, and change the way the industry offers care.

Oh, and they'll probably make lots of money in the process. The transformation of the healthcare marketplace may provide the next leg-up in national productivity, GDP growth, and booming small business sector employment. The space is of increasing interest to venture capitalists as well...and why not? The more users are involved in their health management, the more users there are to utilize web-based services and a plethora of other new products.

A hybrid system, driven by competitive pressures from an exploding Big Bang of market-based innovation, is the way I hope we'll go - who's with me?