How to improve profitability of the OR

Ever wonder why it is so easy to make fun of everybody else’s business?  We have no problem picking on the phone company, the hardware chain store, and the airlines.  Do you suppose those people do the same thing when it comes to healthcare?

The airlines make it quite easy for us to pick on them.  After all, nobody knows what it costs to fly from Philadelphia to Atlanta on different airlines.  Heck, nobody who works for the airline or even the people on the same flight can tell you what it costs.  There is probably a higher likelihood that you and the person in the seat next to you have the same birthday than there is that you paid the same price to fly to the same place.

How far away is elective healthcare from adopting the airline’s business practices?  In many offices, we already have built-in delays, just like on flights.

I am thinking it would work something like this.  I call the hospital to schedule to have my ACL repaired.

The scheduler asks me when I would like to have the procedure, telling me the possible dates. “If you book it on-line, I can offer you a five percent discount.  Two weeks in advance takes off another ten percent.  There is a ten percent surcharge for Mondays and Wednesdays, and it is twenty percent more if you request a surgeon with more than ten years experience.  Surgeons from Ivy League schools are an additional three percent provided they graduated in the top fifty percent of their class.”

“If you have been cut on by us before, your hospital points may entitle you to free cable television or a fruit cup with your breakfast.”

“You should be aware that this is a very popular operation, so we may over schedule the OR—that means you may be bumped.  However, we also have had a number of no-shows which is why we require payment at the time you book the procedure.  Of course, that is not refundable.  Alternatively, there are other less popular procedures you may wish to consider.”

“Come again?” I asked.

“Something like a face lift, appendectomy.”

“But I don’t need an appendectomy.”

“That is a person problem, Mr. Roemer.  We are not permitted to discuss that with our patients.”

“What will this cost?”

“I can’t tell you.”

“Is this like I can’t tell you or I will have to kill you, or is it, ‘I can’t tell you?’”

“I can’t tell you.”

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Is your mission statement web site parsley?

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 its purpose merely website parsley, 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

To participate in the creation of healthier lives within the community. * To provide healthcare services in a fiscally responsible manner which contribute to the physical, psychological, social and spiritual well being of the patients and community which it serves. * To provide assistance to the whole person in a Catholic spirit of equality and interfaith serving all regardless of age, color, creed or gender.

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.

Here’s my attempt at writing a concise mission statement based on the business models I’ve seen.  We will buy every piece of technology and hire any specialist so we can treat any problem.

Hospital mission statements are very inclusive.  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.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The mathematics of change

“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 physician 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 knowing 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.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The Monty Hall hospital business strategy

The Monty Hall problem is named for its similarity to the Let’s Make a Deal television game show hosted by Monty Hall. The problem is stated as follows. Assume that a room is equipped with three doors. Behind two are goats, and behind the third is a shiny new car. You are asked to pick a door, and will win whatever is behind it. Let’s say you pick door 1. Before the door is opened, however, someone who knows what’s behind the doors (Monty Hall) opens one of the other two doors, revealing a goat, and asks you if you wish to change your selection to the third door (i.e., the door which neither you picked nor he opened). The Monty Hall problem is deciding whether you do.

The correct answer is that you do want to switch. If you do not switch, you have the expected 1/3 chance of winning the car, since no matter whether you initially picked the correct door, Monty will show you a door with a goat. But after Monty has eliminated one of the doors for you, you obviously do not improve your chances of winning to better than 1/3 by sticking with your original choice. If you now switch doors, however, there is a 2/3 chance you will win the car.

I think selecting a business strategy along those same lines is at least as productive as whatever business strategy your organization has chosen.  Let us assert that behind two of the doors are bad strategies, and behind a 3rd door is a winning strategy.  Your current strategy is behind whichever door you select.  On your behalf, I reveal to you what is behind one of the two remaining doors—a strategy destined to fail.

The question becomes, do you stick with the strategy you’ve selected knowing that you have a 1/3 chance of it being a winning strategy, or do you switch your choice to the strategy behind the door not chosen, knowing with certainty that doing so improves your chances of being correct to one in two?

Most people, like most businesses, stick with their original choice.  Change is difficult.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Why business strategies are so rigid

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.”

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Can HIT solve the healthcare cost problem?

The following is my new post in HealthsystemCIO.com http://ow.ly/1JLmO

What do you think about the idea?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Are hospitals causing themselves to go broke?

In our prior home we built a magnificent 1,600 bottle mahogany wine cellar with an in-laid brick floor, a nine-foot high antique door, a cigar humidor, and a tasting table.  We discovered that hexagonally shaped ceramic chimney flue pipes were the perfect building material.  They stacked like honeycomb and helped keep the wine chilled.

Our idea was to enjoy the wines we had collected over time.  There is a trick to being a successful wine collector—one must collect more wines than one consumes.  The principle of buying three and drinking four made our cellar always look brand new—empty.

The same principle applies to business strategy.  One must ensure that inputs exceed outputs, that cash in exceeds cash out.  Wax on—wax off.

If service “A” sells for a hundred dollars and it costs eighty dollars to deliver, that is a sustainable model.  You get to pocket twenty dollars.

If service “B” costs a million dollars a year to be able to offer the service and you can only charge eighty thousand dollars per patient, and fewer than twelve patients require the service, that model is not sustainable.

What happens next?  You have to start borrowing money from somewhere.  Often it comes from those twenty dollars you pocketed from the other services.  Then what happens?  Each time you take the profits away from service “A” to underwrite service “B” you have made both services unsustainable.

Cross-pollinate this concept across a five hundred bed hospital, a hospital whose model already requires it to offer “loss leader” services like caring for the indigent and ER and you can see the model has problems.  It may be possible to keep the model on life support by charging eight dollars for each Tylenol, but sooner or later that model will fail.

While we are at it, let’s look at what happens to service “A”.  The hospital stops performing “A” because they no longer find it profitable.  Then what?  Service “A” gets picked up by a clinic who can deliver it at a cost of forty dollars instead of the eighty it cost the hospital.

It is never the service that is the problem, it is the business model behind the service.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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What if in five years? Ten years?

As if we don’t have enough problems already.

Just curious to hear if you think any of these are viable. What happens to the hospital business model if we see this type of vertical or horizontal integration?  Primary care doctors outsource their up-market needs to hospitals, why can’t hospitals do that and move down-market?  What if:

* Payors buy hospitals then “outsource” the care back to the hospitals
* Hospitals also serve as payors
* Hospitals buy specialists way outside of their network and create a “branch healthcare” model similar to that of branch banking.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Strategy–The land of small ideas

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.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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My pre-mortem examination of the hospital business model

  • encyclopedias
  • newspapers
  • movie rentals
  • theaters
  • airlines
  • magazines
  • libraries
  • broadcast television
  • wireline phone companies
  • record companies
  • DEC
  • Xerox
  • department stores
  • SUN
  • H-P
  • GM
  • A&P
  • Circuit City
  • Most US hospitals

In his book, “How the Mighty Fall,” Jim Collins describes the path to a business failing.  His five phases are:

  1. Hubris born of success
  2. Undisciplined pursuit of more
  3. Denial of risk and peril
  4. Grasping for salvation
  5. Capitulation to irrelevance or death

To those, I add a sixth, right between 3 and 4, “Dumping Ballast.”

  1. Hubris born of success
  2. Undisciplined pursuit of more
  3. Denial of risk and peril
  4. Dumping ballast
  5. Grasping for salvation
  6. Capitulation to irrelevance or death

Dumping ballast is the elimination of key components to lighten the ship.  Perhaps you remember seeing the movie version of Jules Verne’s novel,  the Mysterious Island.  In it, prisoners of the Civil War escape in a hot air balloon.  The balloon is ravaged by storms and looks like it will go down in the sea.  To keep it aloft the crew tosses everything overboard, things they would need if they reached land.

I think most hospitals in the US are concurrently working on stages 3 and 4.  The first step is to quit denying that they have a problem.  The second step is to recognize that some of what they discarded will prove critical to their chances of survival.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer