From mathematics–In a Nash equilibrium, no player has an incentive to deviate from the strategy chosen since no player can choose a better strategy given the choices of the other players.
My rewording of the corollary, “No employee who disagrees with the corporate strategy remains an employee.”
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.
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.
Did the large provider healthcare model go from making all the ducks better to only making some of the ducks better? Please let me know if the concept depicted below makes sense.
Thanks
On April 16, 1912 there was an article in the Daily Register in Anytown, Nebraska titled “Local Man Drowns.” The article went on to note that a local man was lost at sea. I paused for a moment trying to recall from my high school geography class the name of the ocean bordering Nebraska—there is not one.
It did not take long to realize that the newspaper was guilty of being more than a little parochial. April 14, 1912 was the day the Titanic sunk. The man in question had been lost at sea in much the same manner that the real headline of the story had been lost by the newspaper.
I think a lot of important healthcare IT headlines are being lost, and those loses can in large part be attributed to the puppet masters at the ONC and CMS. It is difficult to swing a dead cat in a hospital cafeteria without hitting someone discussing Meaningful Use. On the other hand, you could swing a blue whale without hitting someone talking about ICD-10.
The headlines are both buried and misinterpreted. Some of the HIT headlines merit being repeated—feel free to use a highlighter on your screen to be able to locate the important ones. Trying to meet Meaningful Use:
While these may appear to be trivial comments, misapplying your efforts could cost a large hospital more than tem million dollars. Then figure another ten million to rectify the mess.
Ask yourself one question before you hire a pricey consulting firm to help you figure out how to meet Meaningful Use.
“What would we be doing if there was no Meaningful Use?”
Then do that. Meeting Meaningful Use was never a part of your business strategy—you probably will not find it written in your three-year plan. Did anyone sign off on the notion of spending millions of dollars to complete a task that has no ROI and has a reasonable probability of failing?
If it so happens that in pursuing your original strategy you can still meet Meaningful Use that is good. The reverse is not so good.
I wrote this in response to some comments I received on my piece in HospitalImpact.org.
I do not advocate assembly line medicine, especially at a hospital. I go out of my way to stay out of the healthcare business–the clinical side of healthcare–an area in which I have no background other than having been a patient. There seems to be an inability to answer basic business questions relating to how the business of healthcare is run.
On the care side there is a need for the independence and the je ne sais quoi nature of care. However, the business of healthcare and the healthcare business can coexist in a more business-like manner. There are hospitals which get it right, and those which get it much less right.
Some of the ineffectiveness of running a hospital like a business has to do with costs, some with waste–wasted time, wasted opportunity, some with inefficiency, and some with poor planning. If one hospital can do procedure X for thirty percent less than another, it is worth exploring what accounts for the delta. If another hospital can perform twenty percent more procedures with the same level of resources, that is worth investigating. There is no point keeping metrics unless one is willing to improve them.
I am not big on efficiency. In most cases, efficiency implies speed. It is possible to perform poor processes at a speed which will make your head spin. Lots of hospitals are toying with Lean. Lean works best with a valid set of processes. Without a valid set of processes–best processes–there are not enough Sigmas to justify the expense. To those lauding how many Six-Sigma professionals they have employed, what have they done for you? Are you better off than those hospitals who only have Five-Sigma specialists? Would you be better served if you cranked it up a notch or two to Seven or Eight-Sigma gurus?
Then there are the cost cutting advocates. Cost cutting alone is a dead end strategy. Every manager can cut costs–less than one in a hundred can increase revenues. What do you do when there are no more costs to cut? Are you more effective, or net-net did you simply replace the brewed coffee with Folgers? Want to cut costs? Lock the doors. But that does not solve anything.
If none of these questions can be answered today, what happens in five years? New entrants will have gobbled up many profitable services and will be able to do so because they do not have “Big Box” overhead. Reform will have forced another business model on large providers. Payors and pharma will continue to battle for their share of each healthcare dollar.
I think hospitals can grab an even larger portion of that dollar, but I do not think they can do it without changing how they approach the business of healthcare.
Margaret Thatcher said, “Anyone who finds themselves on public transport after the age of 26 must consider themselves a failure.” There’s probably some sort of corollary for anyone twice that age that spends part of every day writing to imaginary people on the web.
When I write I like to pick a side and stand by it instead of standing in the middle of the road where you can get run over by the traffic from both sides. Likewise, I don’t look for consensus around an idea. Consensus is the process of everyone abandoning their beliefs and principles and meeting in the middle. When was it decided that meeting in the middle is beneficial? So, achieving consensus about a problem is nothing more than that state of lukewarm affection one feels when one neither believes in nor objects to a proposition.
Having this approach to solving business problems tends to yield a high number of critics. I don’t mind critics; those are the same people who after seeing me walk across a swimming pool would say that my walking only proves that I can’t swim. I rather enjoy it when someone offers a decidedly personal attack on something I wrote if only because it means they can’t find a legitimate business principle on which to base their argument. I love the debate, and I don’t expect anyone to agree with me just because I say it is so.
In trying to promote a different way of looking at the large provider business model, I’ve learned that it’s not possible to lead from within the crowd. The “as-is” hospital business model (how the hospital is run) was created over time, by followers. I may be wrong, but the most innovative alteration I have seen to the hospital business model in the last decade has been the addition of mini Starbucks, and the revamping of their lobbies to make hospitals look more like hotels. The future will be created by someone who believes the strategy of how hospitals run can be done better. I believe firmly in the notion that improving the business model by building off the current one is like trying to cure a cold with leeches.
The approach that has been used to grow the business for the last fifty years is that the hospital is responsible for everything. And yet, who is responsible for the hospital? Who is accountable for the fact that the business model is obsolescing itself? We have loads of new stuff—expensive stuff. No other industry can tout new and improved services better than healthcare. However, in those industries new and improved means faster, smaller, cheaper–it means adding services to reach significantly more customers, not fewer.
Each new and improved procedure with its more costly overhead has application to a smaller percentage of the health population, thereby allocating that overhead across fewer patients. In turn, that makes the low-margin services unprofitable. Those services will be cut lose, picked up by new entrants with lower overhead. Those entrants will make a good business out of services discarded by hospitals. The cycle will repeat, as it has for decades. The profitable new entrants will move up-market.
Is it a question of scale versus scope, or scale and scope? What happens if instead of continuing to repeat the cycle, large healthcare providers were to invert it? What makes them more relevant, adding the capability to perform a procedure used once a month or one used once an hour? Which is more important to the future model, inpatient care or outpatient care? I suggest that “in” or “out” will become irrelevant.
Those phone booths in the photo used to be the way to make public calls, now you can’t even find a booth. Maybe some day someone will take a photo of a group of hospitals stacked next to each other in a vacant lot.
As I walked through the offices of one of my clients last week I kept passing errant lines of code that had fallen to the floor throughout the hospital. Each time I passed one I retrieved it and dropped it in a folder. Eating lunch in the cafeteria, I laid the lines of code in front of me on the café table—HIE, EHR, Meaningful Use, HIPAA, and one bit of code on Accountable Care Organizations—not sure how that one got in there; probably written by a healthcare futurist with a pet unicorn.
I was reminded of the time a purchased an unassembled gas grill—why pay an extra hundred dollars to have someone connect Part A to Part B? As I learned, the reason to pay the hundred dollars is so that at the end of the process you are not left with parts K and Q and no idea where they go. The grill started just fine. Apparently, parts K and Q had a lot do with turning off the grill—the lid melted seven years ago, and the grill has served as our home’s eternal flame ever since.
I dare say there are many organizations whose systems are missing important lines of code. Maybe that is why more than half of the large providers will soon discover their EHR functions more like a multi-million dollar scanner than an EHR.
A major problem for healthcare information technology (HIT) is the disruption it has brought upon itself. If we are honest about HIT, it was not working all that well before we started disrupting it. EHR was not a natural fit on the prior architecture. To make EHR fit required that bits of the old be cut away and new applications had to be hammered and welded into place. Many chasing Meaningful Use have to take short cuts to meet it. Getting something to fit is not the same as getting something to function.
Once the EHR is in place, out come the hammers to get EHR to meet Meaningful Use. The code and interfaces are chiseled away, and functionality is sacrificed. Now leaders are trying to figure out what must be sacrificed to get ACOs hammered into place.
The old architecture was never architected to support an EHR or an ACO. That means that many, many hospitals are a few months or one or two years away from having to rethink their EHR strategy. The short cuts and dropped lines of code will have degraded the EHR’s performance to such an extent that it will have to be replaced.
The next trend in HIT will not be ACOs. Instead it will be large teams of outside consultants swarming like locusts to provide disaster recovery on hundred million dollar EHRs.
One size fits none, or is it one. The patient rarely buys what the hospital is selling. The hospital sells a hip replacement—the patient is buying the ability to play golf for ten more years.
Clayton Christensen conducted a study which showed that seventy percent of today’s patients would have been in the ICU thirty years ago, and seventy percent of the patients in today’s ICUs would have died thirty years ago. The question the study seemed to leave unaddressed is who is now caring for those patients who were not in the ICU and who didn’t die. Wanna’ bet most have been outsourced to non-hospital care givers?
There was a successful business model in that group of patients when they were treated at the hospital thirty years ago. There is an even larger business model today for that same set of patients; only it is no longer owned by the hospital. Neither are the associated revenues.
Hospitals have more high-end capability—and cost—than the average patient will utilize—sort of an 80/20 rule on steroids. Each successive clinical breakthrough enables the hospital to solve a problem for a mere handful of patients; one that will have no application to 99% of patients in their service area.
What if instead of continuing to expand the reach for the stars model ad nauseam, the hospital flipped the model on its side and catered to the ninety-nine percent? What if the business model centered on serving mainstream customers? But then who or what would handle the other one percent of the cases? An autonomous business unit could be established to serve those cases, or they could be outsourced to a group which did.
Being a blogger is not too dissimilar to being a failure’s biographer. Unless you simply repeat the ideas of your contemporaries, good blogging requires a certain avidity to oppugn those who revel in the notion that theirs was the only good idea. To me, their Sang-froid calmness has all the appeal of a cold omelet. Good writing requires that you make intellectual enemies across a range of subjects, and that you have the tenacity to hold on to those enemies. So let us step off Chekhov’s veranda and bid farewell to the sisters of Prozorova.
The Kübler-Ross model, commonly known as the five stages of grief, was first introduced by Elisabeth Kübler-Ross in her 1969 book, On Death and Dying. I heard a story about this on NPR, and it made me think about other scenarios where these stages might apply.
My first powered form of transport was a green Suzuki 250cc motorcycle. My girlfriend knitted me a green scarf to match the bike. One afternoon my mother walked into the family room, saw me, and burst into tears. When I asked her what was wrong, she told me that one her way home she saw a green motorcycle lying on the road surrounded by police cars and an ambulance—she thought I had crashed. I asked her why, if she thought that was me lying on the road, she did not stop.
My girlfriend’s mother, didn’t like my motorcycle—nor did she like me. Hence, my first car; a 1969 Corvair. Three hundred and fifty dollars. Bench seats, AM radio. Maroon—ish. It reminded me a lot of Fred Flintstone’s car in that in several places one could view the street through the floor. Twenty miles per gallon of gas, fifty miles per quart of oil.
Buyer’s remorse. We’ve all had it. There is a lot of buyer’s remorse going around with EHR, a lot of the five stages of grief. I see it something like this:
The five stages of EHR grief. Where are you in the grieving process?
True, there are a handful of EHR successes. Not nearly as many as the vendors would have you believe. More than half of hospital EHR implementations are considered to have failed.
If you are just starting the process, or are knee-deep in vendor apathy you have two options. You can bring in the A-team, people who know how to run big ugly projects, or you prepare to grieve.
If it was me, I’d be checking Facebook to see if I was still on my vendor’s list of friends.
Pale Rhino Consulting 