Hospital

Healthcare’s pre-mortem

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I call this my premortem of the large provider business model.  The new reform law is Washington’s Anschluss of the healthcare business model—the annexation of the old way of doing business.  With change, as with writing a novel, the most difficult part is to invent the end.  It is only difficult if someone actually gets to that part, the end.  Many large providers remain mired in the first chapter.

The term Ultima Thule refers to any distant place located beyond the “borders of the known world.”  That is where we are when it comes to trying to understand the implications in the realm of the known and unknown external influences on the business model of the large healthcare provider.  I tend to have a stygian mindset about how I think these influences will play out—when Washington sneezes, it is the providers who catch the cold.

Sometimes it is a matter of asking the right questions.  Unfortunately, when one asks questions, somebody always has answers.  The bad thing about answers is they often bring closure to the process of thinking.  In the short-term there may be a modus Vivendi between us—an agreement to agree to disagree, but in the long-term limiting one’s vision to the borders of the known world will prove fatal.

Gone are healthcare’s Elysian moments when leaders thought they could keep doing what they were doing as long as they did it a little better.  At some point, there are no more costs to cut.  Providers will not be able to get any Leaner.  The time has come to square the circle—something proven impossible in 1882 by Ferdinand Lindemann.  Squaring the circle is an attempt to construct a square with the same area of a given circle using Euclidian geometry.

Trying to retrofit today’s healthcare model to meet tomorrow’s business requirements seems to me to be a similar argument.  It can’t be done; you can’t get there from here.  That it cannot be done won’t stop people from trying.  The impossibility cannot be proven.  The proof will be apparent only when hospitals start to fail.  Only then will it be possible to “walk back the cat” to diagnostically deconstruct what failed hospitals should have done.

A purpose of intelligence is the ability to assess and predict.  The application of thinking and intelligence is the ability to assign relative importance to predictions.  Here’s my assessment and prediction.

To successfully change the large provider model one must disrupt it, not simply adjust it.  It has nothing to do with asking, “How can we do this better?” disruption requires that we ask, “Do we need to do this?”

For example, last week I met with the former CFO of a group of east-coast hospitals.  Each hospital had an orthopedic department.  The group also owned an orthopedic clinic.  The clinic was ranked among the top twenty orthopedic centers in the US.  None of the hospitals’ orthopedic departments was ranked in the top one hundred.  The CFO recommended the hospitals close their orthopedic departments and service those patients at the clinic.  This would improve quality and eliminate duplicative costs.  Great idea.  Unfortunately the board liked their hospitals to be able to offer all things to all people—quality and cost be damned.

Why?

Is it time to fire Winston?

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I was reporting to the board—or bored—sometimes it is the same.  The mission: figure out what was wrong, and then fix it.

I spent weeks talking to everyone from the executives to the receptionist.  I interviewed patients and physicians.  The doctors were not happy, the patients less so.  Costs were up, charges were down, and quality was down.

Of all the gin joints in all the towns…

The problem was easy to decipher.  I presented my findings.

“What do you recommend?” asked the chair of the audit committee.

I tried to look lost in thought.  “I fired Winston,” I replied.

“Why Winston?”

“Winston was where it all led; quality, cost, satisfaction.  Winston was responsible for the failures.”

Several members of the board nodded, and spoke among themselves.

After several minutes I jumped back into the fray.  “The more I think about it, the more I think Winston may be salvageable—not in the same role but somewhere else in the organization.  The employees really like him.  Besides, it’s the holidays.  Do you really want to be the reason Winston is not able to buy presents for the kids?”

The board held an in camera discussion.  “Agreed.”

I knew they would.  I started with my actual presentation.  “There is no Winston.”  The Winstons scattered around the table looked perplexed.  They were looking for the easy answer to the problems in their organization, they were looking for themselves.

Who are your Winstons?

Strategy–The land of small ideas

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Hangin’ by a thread

“It will feel better when it quits hurtin’.” Well duh.  It will also feel better when we stop self-inflicting the hurt.

To help me understand how things work I need to decompose issues, not into small parts, but into a series of pictures or shapes.  The pictures I come up with represent my particular perspective of how things look.  That can be a far cry from how others view them.  Maybe that stems from when I was a child and enjoying putting puzzles together upside down.

Instead if hitting myself over the head with a hammer, I set aside the easy pieces—those with straight edges and the four corners.

The puzzle was equally complete no matter whether you worked with the picture or just the shapes, but the exercise was quite different.  The advantage in doing it my way is that upon staring at 500 pieces of cardboard backing I had to bring different problem solving skills to the table.  The disadvantage is that once I could picture the solution in my mind, I lost all interest in completing the last few pieces of the puzzle.

I find myself looking at coming up with a reasoned approach for attacking the large provider healthcare business model.  Puzzle pieces are scattered across my desk; some right-side up, others right-side down.

Here’s where the process breaks down or breaks up—I am sure the direction is irrelevant.  How does one change someone that either does not want to change or one who thinks change is not needed?

Just because you think you’re being followed does not mean you are paranoid—it could mean you are the only one with enough focus to know what is happening.  Charging someone eight dollars for a bag of popcorn to keep your business afloat is not insightful, frankly, it is embarrassing.  Charging forty dollars to check a bag on a plane does not earn a CEO the Baldridge Award, it only allows the airline to lose less money, to stave off inevitable bankruptcy a little bit longer.  Eastern, Pan-Am, Braniff, TWA, Republic, Northwest, Piedmont, Midway, Independence.  They proved the same thing.  Continuing to use the same failed strategy delivered the same failed result.  Just because the first five people to jump off the garage roof couldn’t fly doesn’t mean you can’t.  Or does it?  Bigger wasn’t better, was it?

What does it cost to fly from New York to Seattle?  It depends.  What does it cost to have an angioplasty on Philadelphia?  It depends.  Did the airlines adopt their pricing model from hospitals, or was it the other way around?  Does it matter?  Probably not.

The land of small ideas, like Monty Python’s silly walks.  Somebody actually comes up with these ideas.  I doubt it is someone on the board.  People who lead do not one day lose their marbles and decry, “Our model is not working, let’s start charging passengers if they sit during the flight.”

If staying afloat requires a hospital to charge eight dollars a unit for Tylenol, the land of small ideas is winning.

EHR: Going the Last Mile

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Summer vacations via car.  Makes me wonder what ever happened to station wagons—anyone who does not remember Richard Nixon may want to use Google to the term ‘station wagon’.  We had a sky blue Ford; others had the one with the faux wood-grain side panels like the one Chevy Chase drove in the movie Vacation.

I noticed last week as we drove from Pennsylvania and crossed into Maryland how the blacktop improved and that the shoulder plantings were more numerous and spiffier as though Maryland was showing off, to make you feel you are entering a better place and leaving a worse one. On the return trip the same scenario was reversed as the road for the first mile back into Pennsylvania was much nicer than was the last mile of road in Maryland.

It makes me wonder why states do not put the same level of effort into the last mile instead to make you miss the place you were leaving.

Now let us think about your healthcare IT vendors.  Remember those guys?  The ones who when they courted you took you to dinners and baseball games and golfing.  You probably have one of their coffee mugs on your desk and a few dozen of their Rollerball pens and a commemorative golf towel clipped to you golf bag.  At the get-go everything was first class.  The vendor hoard was attentive and still picking up the lunch tab.

Then they left; all of them.  You surmised the project must be over.  The vendor’s project manager no longer had you on his speed-dial—your number had been replaced with the number of his new golfing buddy, the CIO at Our Lady of Perpetual Implementations.

It makes me wonder why vendors do not put the same level of effort into the last mile of their implementation as they did the first mile.  If they did maybe your perception of them would be better.  Maybe the implementation would have gone better.

Is your mission statement merely decorative parsley?

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What is your organization’s mission, your vision, your goal?  Can you articulate it?  If yes, write it below in the space provided.

Okay.  Why do you have a mission statement?  Is it of any more value than the parsley on your Denny’s Grand Slam breakfast plate, or is it actionable?  What does it tell you to do?  Is it something to which all of your employees can contribute?  Can you measure if your actions helped meet the mission?  Does the business strategy result from the mission statement?

Here’s one you probably haven’t thought of.  Let’s say every one of your employees puts your mission statement into action.  Does that improve your organization, or does it bring it to its knees?  Your mission statement either communicates your mission or it does not.  What does it say to your employees, to your customers?  If it does not create a message that makes you unique, fix it or dump it—or say, “We are just like those other guys down the street.”  Just because it communicates, does not make your mission sustainable.

Here are some real examples of hospital mission/vision statements.  Read them and see if you begin to understand why I think the hospital business model is in trouble.  I have not published the name of the hospital, as that is not what is important to this discussion.

Providing exemplary physical, emotional and spiritual care for each of our patients and their families

Balancing the continued commitment to the care of the poor and those most in need with the provision of highly specialized services to a broader community

Building a work environment where each person is valued, respected and has an opportunity for personal and professional growth

Advancing excellence in health services education

Fostering a culture of discovery in all of our activities and supporting exemplary health sciences research

Strengthening our relationships with universities, colleges, other hospitals, agencies and our community

Provide quality health services and facilities for the community, to promote wellness, to relieve suffering, and to restore health as swiftly, safely, and humanely as it can be done, consistent with the best service we can give at the highest value for all concerned

We are caring people operating an extraordinary community hospital.

Ensure access to superior quality integrated health care for our community and expand access for underserved populations within the community. Create a supportive team environment for patients, employees, and clinical staff.

Let’s look at some of the million dollar words in the mission statements of some highly regarded hospitals.  Ensure, foster, promote, participate, create.  Comprehensive.  Involved, responsive, collaborate, enable, facilitate, passion, best, unparalleled, .  These statements were written by well paid adults.  These statements are awful.  They are awful because they are fluff—unachievable.  They are well intentioned but meaningless euphemisms.

Hospital mission statements are inclusive to the nth degree.  They also seem very similar.  If a perspective patient read your mission statement and read the mission statement of the hospital down the street, could they tell which one is yours?  Probably not.  Who among you has a mission statement which excludes anything?

So, let’s say your board is debating if you should buy the machine in Monty Python’s hospital skit—the machine that goes “Ping.”  Which of the mission’s goals does that support?

How do you make them better?  For starters, make them short. Very.  One writer wrote, “If I had more time, I would have written less.

Southwest Airline’s mission statement—be the low cost carrier.

Dramatic pause.  Something either contributes to the mission or it does not.  Leather seats and free lunches do not.

 

 

The mathematics of change

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There are three people in the ER. One of them is a physician, one of them is an executive, and one of them is a consultant. They see a machine unplugged and standing against a wall in the waiting room.

And the executive says, ‘Look, the technology in this hospital is not used.’ And the executive says, ‘No. There are machines in the hospital of which at least one is not used.’

And the consultant stood there in silence guessing neither of them really cared what he thought about the machine.

At least one.

A mathematical term meaning one or more. It is commonly used in situations where existence can be established but it is not known how to determine the total number of solutions.

How many things can be changed regarding the business of healthcare that would have a positive impact on your business model? At least one.

Wayne Newton’s 4th law of relative immobility

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Last night I was speaking with a woman at a gathering of graduates from my high school.  She got into the subject of reading glasses and then commented that she first learned she needed regular glasses since the age of four.

As she was not wearing glasses, I asked her if she’d had Lasik.  No, she said, “I always hated how I looked in them, so I quit wearing them in high school.”

“Don’t you miss being able to see things?” I asked.

“Not really.  This is how I’ve seen the world for the past thirty years.  I’ve grown comfortable with how I see the world.”

I think many business leaders have the same perspective.  They get comfortable with how they see their world—comfortable with the issues and how to address them.  Given the choice, people will stay in their comfort zone.

Do you remember your physics?  Relative motion is the branch of physics that studies the motion of the body relative to the motion of another moving body (Newton).  For example, if you are in a train and another traveling at the same speed pulls alongside you, it appears to both set of passengers that neither train is moving.  If your train decelerates it will appear to you the other train has accelerated.

Now, take the perspective of someone standing on the platform viewing the two trains.  To that person, there is no illusion.  The bystander can see exactly what is happening; who is moving forward and who isn’t.

Some business leaders get caught up in what I call Wayne Newton’s 4th law of relative immobility.  When they look out their windows at the executive in the hospital across the street, it appears they are both moving at the same speed and at the same direction.  That is how they have seen the world each day for the last several years.  They look at each other, wave, and then go about their business, knowing their competitor hasn’t passed them or changed course.

But you and I know why it looks that way to them.  The reason they have not been passed is because neither hospital is moving forward.  The reason they do not perceive a change of direction is that they are both moving in the same direction.  In actuality, there is no motion.  Only an outsider can see neither hospital is moving.

HIT: Your most solvable big problem

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Two incompatible things are a type A personality and heart disease—I speak from experience.  I usually run six miles a day, three miles out and three miles back.  A few weeks ago I started hitting a wall after two to three miles and found myself having to jog/walk back to the car.  Wednesday I hit the wall after a mile, hands on my knees and gasping for air.

The air thing bothered me because that is what happened during my heart attack in 2002.  As I tried to make it back to my car I had to stop every few steps to catch my breath.  As I made it to a field and lay down several people stopped to ask if I needed help—this is where the incompatibility I mentioned comes into play.

I did not want to impose.  One of those who stopped happened to be a cardiology nurse and she was not taking no for an answer.  Dialing 911 she stated “I have an older gentleman, 60-65 having trouble breathing.”  That got my attention—all of a sudden my age seemed to be a much more important consideration to me than whether or not I could breathe.  “I am 55,” I corrected her.

Knowing how close I was to my home I tried unsuccessfully to get the EMTs to stop by my house before going to the hospital so I could get my laptop.  After three hours of tests, and without concluding why I had trouble breathing, they ruled out anything to do with my heart and sent me home.

I think knowing when to ask for help and accepting help relates a lot to healthcare IT; EHR, Meaningful Use, ICD-10.  These are each big, ugly projects.  There are several things that can happen on big, ugly projects, and most of them are bad.  This is especially true when the project involves doing something for the first time and when the cost of the project involves more than one comma.

Now we both know there is nobody with years of experience with Meaningful Use or ICD-10, and there are not many people who have one year’s experience.  So why ask for or accept help?  The truthful answer is because there are some people who know enough to know what to do tomorrow, and from where I sit the toughest part of every project is knowing what to do tomorrow—how to get started, and what to do the next day and the day after that.

Meaningful Use–Are you following the crowd?

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I remember the first time I entered their home I was taken aback by the clutter. Spent and wet leaves and small branches were strewn across the floors and furniture. Black Hefty trash bags stood against the walls filled with last year’s leaves. Dozens of bright orange buckets from Home Depot sat beneath the windows. The house always felt cold, very cold. After a while I learned to act normally around the clutter.

There came a time however when I simply had to ask, “Why all the buckets? What’s the deal with the leaves?”

“We try hard to keep the place neat,” she replied.

“Where does it all come from?” I asked.

“The windows.”

I looked at her somewhat askance. “I’m not sure I follow,” I replied as I began to feel uneasy.

“It’s not like we like living this way; the water, the cold, the mess. It costs a fortune to heat this place.

And, the constant bother of emptying the buckets, and the sweeping of the leaves.”

“Why don’t you shut your windows? It seems like that would solve a lot of your problems.”

She looked like I had just tossed her cat in a blender.

When you see something abnormal often enough it becomes normal. Sort of like in the movie The Stepford Wives. Sort of like all the scurrying around Meaningful Use.  The normal has been subsumed by the abnormal, and in doing so has created an entire entity which is slowing devouring the resources of the organization.

Are you kidding me? I wish. It’s much easier to see this as a consultant than it is if you are drinking the Kool Aid on a daily basis. When I talk with hospital executives they are marching headstrong into the Meaningful Use abyss.

It makes me feel like I must be the only one in the room who doesn’t get it—again with The Stepford Wives.

If I ask about it they always have an answer. It all boils down to something like, “We simply can’t turn down the money.”  They say that with a straight face as though they are waiting to see if I will drink the Kool Aid.  It’s gotten to the point where no matter how goofy things get, as long as they are consistently goofy, they are not goofy at all.

This is the mindset that enables leaders to be fooled by their own activity. Busy replaces thinking.

Patient Experience Management: Why Men Can’t Boil Water

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There was a meeting last week of the scions of the Philadelphia business community. The business leaders began to arrive at the suburban enclave at the appointed hour. The industries they represented included medical devices, automotive, retail, pharmaceutical, chemicals, and management consulting. No one at their respective organizations was aware of the clandestine meeting. These men were responsible for managing millions of dollars of assets, overseeing thousands of employees, and the fiduciary responsibility of international conglomerates. Within their ranks they had managed mergers and acquisitions and divestitures. They were group with which to be reckoned and their skills were the envy of many.

They arrived singularly, each bearing gifts. Keenly aware of the etiquette, they removed their shoes and placed them neatly by the door.

The pharmaceutical executive was escorted to the kitchen.

“Did your wife make you bring that?” I asked.

He glanced quickly at the cellophane wrapped cheese ball, and sheepishly nodded. “What are we supposed to do with those?” He asked as he eyeballed the brightly wrapped toothpicks that looked banderillas, the short barbed sticks a matador would use.

“My wife made me put them out,” I replied. “She said we should use these with the hors d’oeuvres.”

He nodded sympathetically; he too had seen it too many times. I went to the front door to admit the next guest. He stood there holding two boxes of wafer thin, whole wheat crackers. Our eyes met, knowingly, as if to say, “Et Tu Brutus”. The gentleman following him was a senior executive in the automotive industry. He carried a plate of freshly baked chocolate chip cookies. And so it went for the next 15 to 20 minutes, industry giants made to look small by the gifts they were forced to carry.

The granite countertop was lined with the accoutrements for the party. “It’s just poker,” I had tried to explain. My explanation had fallen on deaf ears. There is a right way and a wrong way to entertain, I had been informed. Plates, utensils, and napkins were lined up at one end of the counter, followed in quick succession by the crock pot of chili that had been brewing for some eight hours, the cheese tray, a nicely arrayed platter of crackers, assorted fruits, a selection of anti-pastas, cups, ice, and a selection of beverages. In the mind of our wives, independent of what we did for a living and the amount of power and responsibility we each wielded, we were incapable of making it through a four hour card game without their intervention.

I deftly stabbed a gherkin with my tooth pick. “Hey,” I hollered “put a coaster under that glass. Are you trying to get us all in trouble? And you,” I said to Pharmacy Boy, “Get a napkin and wipe up the chili you spilled. She’ll be back here in four hours, and we have to have this place looking just as good as when she left.”  I thought I was having the neighborhood guys over for poker; I was wrong. So were each of the other guys. We had been outwitted by our controllers, our spouses. Nothing is ever as simple as it first appears. We didn’t even recognize we were being managed until they made themselves known.

Who’s managing the show at your hospital, you or the patients?  The answer to that question depends on who owns the relationship, who controls the dialog.  If most of the conversation about your organization originates with them, the best you are doing is reacting to them as they initiate the social media spin, or try to respond once the phone started ringing.  It’s a pretty ineffective way of managing.  It’s as though they dealt the cards, and they know ahead of time that you are holding nothing.

There are times when my manager isn’t home, times when I wear my shoes inside the house—however, I wear little cloth booties over them to make certain I don’t mar the floor.  One time when I decided to push the envelope, I didn’t even separate the darks from the whites when I did the laundry.  We got in an hour of poker before I broke out the mop and vacuum.  One friend tried to light a cigar—he will be out of the cast in a few weeks.