Tuesday, August 31, 2010

Do Retail Health Clinics Complement Or Compete With Primary Care Physicians?

This is the same question that has been faced by many hospitals looking to start up an urgent care center. The primary care physicians usually express outrage that the hospital would compete with them. I have seen this first hand when our hospital contemplated such a move. Never mind that the hours of our center were in the evening and weekends when physician offices were closed. Also never mind that at 5pm the physician's phones shut off and patients got an answering machine that said they were unavailable and that any serious condition should be seen in the hospital's emergency room. I guess that EDs don't present the threat that urgent care centers do.

Well now there is a school of thought that supports the idea that these centers do not actually compete with primary care physicians, but actually help them. Although there may be some patients who use urgent care centers or retail clinics when available that otherwise would have gone to the primary care physician, many more are referred into primary care physicians for followup after an urgent care visit. Also the mix of patients in the clinic is different. Only 40% of these patients even have a private physician compared to 80% in the general population. Finally, because of the hours of operation, many of these patients would be going to an ED as an alternative, not waiting for the physician's office to reopen.

Overall these clinics and urgent care centers are seen as cheap, convenient and providing a high level of patient satisfaction. Maybe the physicians should not be so threatened and view them as a potential referral source that gives patients a great after hours alternative.

More on this later.

Mark Brodeur

Monday, August 30, 2010

Is There A Future For Public Hospitals?

The current economic climate for hospitals has been described as Darwinian. I think this is a fair assessment considering the current level of performance for many small, rural, community hospitals. Many of these are public hospitals that were developed years ago to provide needed healthcare services to isolated communities.

A recent article in the Wall Street Journal has identified that their current bad credit ratings combined with the expected government cuts under healthcare reform, will further cripple public hospital's access to capital needed for health IT and other infrastructure needs. In other word, banks don't lend money to hospitals that really need it, particularly after the recent banking industry crisis.

Two other characteristics of public hospitals work against them as well. Most are small and stand alone. This gives them less of an edge when negotiating purchasing and managed care contracts when compared to the larger systems. As we move to adopting more "Centers of Excellence" again the stand alone public hospital will have a disadvantage. Finally, those hospitals that have been relying on tax subsidies by their local communities will face strong pressures to see these go away completely and have no prospect of any increases.

Some public hospitals have gone from public to private in the past with no problems. I oversaw one transformation in the early 90's. The move did nothing but benefit our hospital and the community. Perhaps more hospitals will be looking at this or even face a much more devastating alternative.

More on this later.

Mark Brodeur

Friday, August 27, 2010

Admitting Medical Errors: One Hospital's Experience

Imagine a hospital that actually encourages its employees to not only admit medical mistakes but tell the patient and family the details of the mistake. In addition, if they find that a treating physician was at fault for an error related injury, they offer the patient and family financial compensation. This sounds crazy and is a bolder move than I would have been willing to try, but apparently it works.

This is not a true study since it is the experience of only one hospital and there was no control group. But according to the Annals of Internal Medicine, the University of Michigan Health System tried this and saw the following outcomes:

1) Overall legal costs went down
2) Number of claims requesting compensation went down
3) Number of claims actually compensated went down
4) Time to resolve a claim decreased

I have heard for years that being open about medical errors with patients and family is the way to address them. But the extent of information shared by this hospital as well as linking it directly to an offer of compensation is something new. I would like to see more studies but University of Michigan Health System's experience certainly supports this approach. The hospital was on a downward trend for claims before this was implemented. But claims dipped well below the tend after this program was put in place so there is clearly a connection.

The message here is that a full disclosure with offer program will not drive up liability costs as one might suspect. In this case at least it had a very positive impact in the other direction. Certainly this is worth serious consideration.

More on this later.

Mark Brodeur

Wednesday, August 25, 2010

The Cost of Medical Care Actually Dropped Last Month

Maybe its too early to get really excited because one month does not make a trend and the cost of healthcare only dropped one tenth of one percent between June and July. But still, a decrease in the cost of healthcare is a big deal. This has been the one constant in the economy that everyone could count on. Healthcare costs will always increase from month to month. We have only had a decrease like the one last month six times in the last 63 years. Maybe longer since records only go back to 1947. And the last time it happened was 35 years ago.

On the other hand maybe it is time to celebrate, at least until the August numbers come out. Of course I would feel better if we knew exactly why there was a decrease. No one seems to be able to explain that. All we know is that healthcare did buck the overall trend which showed a consumer spending increase increase of 0.3% between June and July. The Obama administration has not yet claimed this as a victory for healthcare reform. Nor have the Republicans stated that this is the beginning of Americans abandoning our current healthcare system out of fear. People like us at Compirion would like to think it is because we are helping hospitals improve their operating metrics. But the truth is that the decrease is too small to be statictically significant, at least based on one month's data.

Lets continue to look at this and see what the future months bring.

More on this later.

Mark Brodeur

Monday, August 23, 2010

Six Keys To High Performing Hospitals: Key #6

Today I finish out the list of keys to high performing hospitals as put together by Lawrence Prybil, Ph.D. and Samuel Levey, Ph.D. To say last but not least is an understatement. Today's key is perhaps the most important of all of them.

6) Healthy organizational culture

This concept has not been traditionally discussed, perhaps because it is a bit more difficult to see and measure. In fact in the study, it was cited in only 6 out of the 10 high performing systems interviewed. The culture in these systems was described as having a broad-based commitment to excellence in patient care and operating performance. It was also stated that this culture was not always with the organization but rather had to be developed over time. The culture must embrace the organization's core values and commitment to high performance.

Changing culture in an organization is a marathon, not a sprint. This is something that we work with everyday at Compirion Healthcare Solutions. To assist an organization in changing its culture requires an intense effort over an extended period of time; at least six months. Anything less than this will not have a sustained impact. Managers frequently put a spotlight on a problem area for a short period of time and are gratified to see almost immediate improvement. What they fail to do is follow up a few weeks later to see if the improvement has continued.

This list of six keys is not meant to be inclusive. There were a number of other keys mentioned such as prudent investment in facilities, services and new technology. But these six were considered the most influential on the high performance. If you achieve these six you will have attained a high level of performance.

More on this later.

Mark Brodeur

Friday, August 20, 2010

Six Keys To High Performing Hospitals: Key #5

The fifth key to high performance may seem obvious, but when looking at hospitals that are struggling on their bottom line, it is not so obvious to them.

5) Defined organizational objectives, targets and metrics.

The only surprise to me in the study is that only 6 out of the 10 high performing hospitals in the study mentioned this. It relates to the popular axiom, "If you can't measure it, you can't manage it". All hospitals have great financial measures, quality standards and customer service scores at an organization wide level. These are usually included in a monthly dashboard shared with the Board. But what about at the department level? Does your facility have metrics to track all key performance areas? And how often is this data collected?

We at Compirion Healthcare Solutions often find this kind of data lacking. And if it is collected, it is not done on a frequent enough basis. The Board level dashboard concept must be applied at the department level (and interdepartment level) for all operations. The data should be monitored on a daily basis. Looking at last month's data will not show all of the performance fluctuations that occur. Plus it is too old to be useful for making the needed adjustments.

Gathering daily metrics is only part of the necessary action to achieve high performance. Knowing where you are today is important, but you must also set the appropriate and achievable benchmark for where you want to be. There are plenty of standards out there, some of which may seem unachievable. We have found in working with hospitals that they are surprised at the high levels of performance that they can achieve. We now resort to sharing the risk and providing them a money back guarantee if together we don't achieve this level of improvement.

So first you meed to measure where you are today, then set the benchmark for where you want to be and track your progress with daily measurement. How you get from A to B is an intensive process that is a whole subject on its own.

More on this later.

Mark Brodeur

Thursday, August 19, 2010

Six Keys To High Performing Hospitals: Key #4

Continuing my commentary on the list of keys to high performing hospitals based on a study by Lawrence Prybil, Ph.D. and Samuel Levey, Ph.D., today's topic deals with the ultimate authority for a hospital's operations.

4) Committed and engaged Board of Directors

With the hospital's CEO being the one in the spotlight, not everyone realizes the critical role that the Board of Directors plays. In fact, if they are doing their job well, they will remain somewhat in the shadows as the hospital excels. Usually Board members are only in the news when a hospital is in some kind of turmoil. A high performing Board is proactive, well informed and collaborates closely with the CEO and the Medical Staff. This was identified as a must by 8 of the 10 high performing Boards in the study. I think the other 2 just failed to mention it.

It is interesting that many of the high performing Boards spoke of the journey they took to get where they are today. It is clearly a development process. They spoke of the past when they were more passive and had a limited awareness of their environment and the importance of maintaining strong relationships. I remember dealing with a Board member who was strongly opposed to physician representation on the Board. His attitude was that the hospital would run a whole lot smoother if we did not have to deal with the doctors. This kind of thinking will hold a hospital back regardless of what other positive things are happening.

So how did the transformation happen for these Boards? It starts with education and a commitment by all Board members to be engaged in the process. The hospital can not afford to have valuable Board seats occupied by members with their own agenda or passive individuals who just occupy a chair and enjoy dinner. It also involves having the Board be clear on its role versus the role of the CEO. All high performing Boards understood this distinction. Having a strong trusting relationship with the CEO is essential. Finally, much of the work of strong Boards is done through effective committees. Most Boards are too large to have the kind of in depth discussion needed for many issues. Also there are just too many issues to deal with. So having committees that do most of this before the Board meeting is important. At the main meeting, the in depth work of the committees can be summarized rather than totally rehashed. This allows input from everyone without getting bogged in the details.

The Board is the ultimate authority for a hospital. This is not to say that it is more important than a strong CEO or cohesive Medical Staff. But without this third leg of the stool, the hospital will not excel.

More on high performance tomorrow.

Mark Brodeur

Wednesday, August 18, 2010

Six Keys To High Performing Hospitals: Key #3

I have previously commented on strong value based CEO leadership and a clearly articulated mission, vision, and values. Today I want to move on to the critical importance of clinical excellence and the leadership it takes to achieve it.

3) Strong clinical leadership and capabilities

Eight of the 10 high performing systems interviewed mentioned this as essential to their success. This actually touches on several subjects. The first is my favorite mantra "quality first, finances follow". The second is the critical importance of having a competent and supportive medical staff. To achieve both of these you must have strong physician leadership. No hospital can achieve enduring success without it.

I have seen hospitals that have dissension within the medical staff and conflict between the medical staff and the board. This makes for a dysfunctional environment and will certainly hold the hospital back from becoming a high performer. The analogy that a hospital is a three legged stool comes into play here. It is supported by the Board, the Medical Staff and the CEO. If one of the 3 is missing, the stool falls over. This often requires some give and take on both sides. Some of the high performers mentioned the value of joint ventures with their physician groups. While some Boards may not be willing to share revenue with their physicians, the high performers have learned that sacrificing something in the short run will pay larger dividends down the road when strong relationships have been developed.

Strong clinical performance also extends beyond the medical staff to include nursing which is the backbone of the care provided as well as the other clinicians who provide care and support. Effective leadership in these areas is also key to high performance.

One final thought. With the advent of healthcare reform, there will be a stronger push for fully integrated care systems that include prevention, primary care, outpatient services and hospitalization under a single billing structure. Maybe we will finally see that capitated payment system that we all got ready for in the late 90's. Either way, systems that have all of these elements integrated will excel.

More on high performing hospitals tomorrow.

Mark Brodeur

Tuesday, August 17, 2010

Six Keys To High Performing Hospitals: Key #2

Yesterday I discussed the importance of strong, value based leadership to a high performing hospital. Today I comment on my experience with the second key which involves setting a clear direction at the hospital that others are inspired to follow.

2) Well understood mission, vision and values

This was covered in my previous series of posts on what makes a great leader. But it is certainly worth repeating. There is a reason it is listed under attributes of a great leader as well as keys to high performance in your hospital. When surveyed, trustees from 8 of the 10 high performing systems that were identified for the study stated the importance of a meaningful mission statement, compelling vision for the system's future, and a clearly stated set of core values. It is important that they not only be understood but also supported by all key stakeholders both internal and external.

I have seen firsthand the difference that that a clear, concise and internalized set of mission, vision and values can make on an organization. There is no right or wrong message to convey. But it must be true to the real purpose of the hospital. More importantly it must be lived by everyone in the organization. In some hospitals the mission is just words on a dusty plaque. In a high performing hospital it is the daily motto that actually motivates employees. All key stakeholders from Board members to front line staff should be able to state the essence of the hospitals mission, vision and values from memory because they have been exposed to it every day.

This does not happen easily, nor can you change the culture overnight. It takes months if not years of repeated effort to "spread the mission". I found it useful to post these widely throughout our hospital; to make them a laminated page at the beginning of every Board meeting; to begin every new employee orientation with a thorough explanation of them; and to remind employees every day why we are here.

We talk about, "no money , no mission". I add to that, "no mission, no purpose".

More on high performing hospitals tomorrow.

Mark Brodeur

Monday, August 16, 2010

Six Keys To High Performing Hospitals: Key #1

In an intensive study conducted by Lawrence Prybil, PH.D. and Samuel Levey, PH.D. which covered 123 hospitals in 40 states, they determined the short list of factors that made the high performing hospitals able to achieve that success. This study included interviews with key leadership at 10 high performing health systems. In today's post and subsequent ones I will provide my commentary on these factors. You will note that there is clearly overlap with this list and the ten key aspects of great leadership covered previously. This is no surprise, rather an affirmation of the bond between great leadership and high performance.

1) Strong values based leadership

Nine of the ten systems interviewed stressed how important it is to have strong leadership skills from the CEO. Leadership is different than management. It includes attributes such as commitment to the system's organizational mission and values, stellar communications and relationships with the board and medical staff, expertise in financial management and cost controls, a passion for continuous improvement and strategic vision.

It was also noted that the strong leadership must extend beyond the CEO position to all of the senior management team. Each of them brings their own area of expertise to the organization. Having a top leader who can attract this kind of talent and bring them together as a cohesive team is vital for the high performing hospital.

I can tell you from experience that this is more difficult than some people may assume. First you must create a culture that will be attractive to high performers. Even in today's economy with many people looking for work, high performers are difficult to attract. Then you must get these strong individuals to work as part of a team with other strong willed types. This part can be just as difficult. For some of these types, playing as part of a team is new to them. But it can be done and it must be done to achieve superior performance.

Ultimately though, it falls on the CEO to put this team together and to get them working collaboratively. If it is not happening, it is the Board's responsibility to make the necessary change in the top position.

More on keys to high performing hospitals tomorrow.

Mark Brodeur
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