Tuesday, March 20, 2007

It's about the Physician

Who has patients.....doctors or hospitals?

Somewhere along the way to the informed healthcare consumer and all that hospital advertising about how good they are, the newest piece of technology and the latest greatest renovation as well as how much we care about you as a person (or your spirit, whatever that means), we have may have forgotten about the role of the doctor.... and that is not a good thing.....

Hospitals and health systems talk about "their patients". Healthcare organizations troll for consumers and employers through a variety of marketing techniques. Some have even entered into agreements with insurance companies under capitation arrangements for "covered lives" where they are paid a certain dollar amount per month per life to provide complete care. (After learning that it's not as easy as it sounds and losing millions of dollars, most hospitals and health systems have exited the insurance business. Good move.)

Physician referral programs, RN staffed call centers, community health and wellness programs, service lines in cardiology, neurology, orthopaedics and others, quarterly magazines and newsletter mailings, advertisements and public relations aimed at creating that awareness, usually center around the hospital, clinic or health system. Sometimes, just sometimes, it does center around the primary care doctor, specialist or physician group. Those hospitals and systems that do center their efforts around the doc get it.

Its about the physician......

A contrary view no doubt. But think about this for a minute. When to go to the clinic or hospital and you need a test what do you need? A doctors order. You can't walk into the Emergency Room at any healthcare facility and just go... "My shoulder hurts, give me an MRI". You need a doctors order. Want an aspirin to treat a headache in a healthcare setting, you need a doctors order. Want an antibiotic for an infection filled at your local pharmacy (unless you live in Mexico), you need a doctors order. If the hospital wants to bill for inpatient or outpatient services, managed care aside, they need the doc to put the patient in the bed or send them to the outpatient clinic. No order, no physician involvement, no bill. No bill, no revenue. It all starts and ends with the physician.

But to hear healthcare providers tell it, I belong to them. I don't belong to anyone, but have a relationship with my physician whom I trust and will go where she directs me. It does still happen to be that way for most people. Informed consumers exist and lots of available data is there for all of us to see, but the exception to the rule is the consumer who at the end of the day, will disagree about where their personal physician will send them for care.

What can hospitals learn from this....

Its about a partnership. That partnership is a three way- you, me and my doc. Stop spending so much time figuring out joint ventures, employment options and all the rest. Yes, I do admit some of it needs to be done, any organization worth its salt will look at service enhancements. That is the natural evolution of a business. But focus on the doc. Each year dozens of seminars, books and articles appear about improving medical staff relations, partnering with physicians, strategies for working together and on and on and on. Maybe its about time we learned from that and began to practice it more.

It means putting egos aside and listening. Doesn't mean you are going to do everything the physician wants, but if you listen very closely you might find some simple ways to help the physician practice medicine more efficiently, improve their satisfaction and at the end of the day increase admissions and procedures.

Want a sure fire way to improve admissions, focus some of your improvement efforts on making it easier for the physician to practice medicine in your institution. When the nurse pages the attending physician, make sure they are there when the doctor calls back. If a physicians wants a faxed copy of their ER report, send it. If the doctors office calls Admissions, have caller ID available so the admission representative can ID the doc and respond appropriately. And improve your patient satisfaction. Patients complain to their doctor about your service and care. Docs don't want to hear it. Physicians will send their patient to those facilities where it is easier to practice medicine, where they have their needs meet and their patients are satisfied.

Don't believe me. Take a look at market share data of any provider over time. Seeing only a one or two point market share swing among competing facilities? Guess what, it is not through any great marketing, its about the docs moving patients around to different facilities.

The healthcare organization that can improve physician satisfaction and make it easier for them to practice medicine in the halls of the hospital will gain admissions and outpatient business, which in turn will generate revenue, which, well you get the idea.

I admit it is not so simple with competing medical staff, the movement of services and procedures to different settings and other providers raiding medical staffs. But at the end of the day, if you can understand that it is about the doc, you will be better, the physician will be happier and patients will hold you in a new light.

Not that much different from billing the 1960s is it?

Friday, March 2, 2007

Learning from Europe - Universal Healthcare

The debate heats up.......Again......

Much is beginning to be written about healthcare as it continues to consume an ever increasing portion of the GNP; as the medical care component of the CPI continues its rise outpacing the general CPI; as employers find operational costs increasing due to health insurance expenditures; the 2008 campaign...... Well, you get the picture.

Intense focus will be coming over the next year as the presidential campaign for 2008 heats up, with the Democrats and Republicans putting forth their proposals on fixing healthcare. State initiatives will also force the issue, cobbling together a patchwork quilt of suggestions, programs and hidden taxes to pay for the "universal" coverage. There will be some new proposals, but I for one expect much of the same. Looking at past history, nothing will really be solved until both parities engage in a discussion of two very basic questions: Is healthcare a right or a benefit and how/who pays? These are the two unspoken issues and questions which both parities skirt.

One could make the argument, that the Democrats view healthcare as a right by their proposals and the Republicans view healthcare as a benefit by theirs. Still, who pays and how? My bet is that in the end universal healthcare under a one payer system here won't happen. Too many interest groups, too much politics, and with billions of dollars at stake on all sides (forget the quality argument for a while) a universal system just won't fly. I would expect to see some kind of hybrid between universal and private, similar to what is found in Europe. That is...... if we are willing to learn from other parts of the world and not have to reinvent the wheel every time the subject comes up for debate.

European Healthcare

Having worked for a European medical device manufacturer and traveling Europe seeing healthcare in action in some hospitals, there are some true misconceptions in the American healthcare community about what is considered healthcare delivery and payment in Europe.

Not all but most senior executives don't have a clue about what is going on in Europe regarding care or payment. I doubt that the politicos do either. Not bombastic or self serving are those statements. I come from hospital senior management and am guilty of the "if its not invented here, its not worth anything" syndrome. And that attitude considering the seriousness of the topic is just not acceptable any longer. Take away the signage in different languages in a European hospital and you would never know you were not in an American hospital.

So, lets look at a couple of myths.

OK first myth... healthcare is paid solely by the government

It is not a universal one size fits all healthcare payment system in Europe. They leave that to the Canadians. There are government programs, private insurance programs, employer sponsored health insurance programs. Consumers have much higher deductibles than what we pay and a greater emphasis on personal responsibility in maintaining health and wellness. Payment is a combination of various healthcare mechanisms that we too have here in the US. It is a complicated payment maze. But everyone gets care, everyone gets primary care and everyone gets quality care at the right time, in the right amount, in the right setting.

Now in Europe they have some very real misconceptions about us as well. The most important was understanding the difference between 45 million uninsured and 45 million Americans not getting care. They equate uninsured with no care. After many long sessions, people I worked with began to understand that in America, being uninsured doesn't mean that you don't get care. Yes, the care may be inappropriate utilization of healthcare resources by individuals and families over utilizing emergency rooms, which when treated earlier in a primary care setting would have been the preferred option, but people do get care, they do get surgery, they the do get the drugs they need.

Second myth......The hospitals and health systems in Europe don't face the same operational issues we do

Sorry to disappoint everyone, but they do. Declining reimbursement, IT consuming ever greater portions of capital budgets, the need to reduce medical errors, lack of qualified medical professionals, increasing productivity and efficiency, decreasing costs, improving quality, the shift to outpatient from inpatient care, etc, etc, etc. Matter of fact, it may even be more difficult in Europe as each country has its own language, culture, regulations, payment systems, etc. One size does not fit all. On the HIT side, many countries are farther advanced on the implementation of the Electronic Medical Record that we are. Germany and France are good examples.

Third myth.....What happens in Europe or the rest of the world for that matter doesn't effect me

Yes it does. Nothing is new in healthcare. It has been done already somewhere in the world. Its more of a question of discovering the issue, what they have done, how the solution is working and what parts of their solution will work for us. Sorry to say but we are not best in breed. If we were, then why do so many American companies have difficulty in selling their HIT and other solutions oversees. Lots of issues there besides the inability to customize their solutions for different markets, but that's another Blog for another time. We could learn a bit from how Europeans have approached the healthcare coverage issue, the provision of medical care and how it all works together.

Europeans have answered those two basic questions, is healthcare a right or a benefit and who pays and how.

What this all could mean

Clearly we are at a crossroads. We already have a tiered healthcare system that is neither reasonable from a care perspective or socially acceptable. Its easy to medicalize social problems (which is what has been done) and blame the medical community for the indecisiveness of state and national leadership in addressing this issue. Our medical care system today is based on those that can pay, those can can pay some and those that can't pay anything at all.

Individuals, government, employers and healthcare providers must all come together to reach a common understanding. I for one believe that universal coverage is a possibility, but I do not for one minute believe that it is the sole responsibility of the government. It is a partnership. A solution to a societal crisis that can be based on what has happened successfully in other parts of the world.

For the future

This isn't the last writing on this topic. It's complex. Holds many unknowns,. And as the presidential campaigns become more vibrant with proposals coming forth, much more will be written on this topic.

But life would sure be a lot easier if we could learn from others like the Europeans and not make the same mistakes.

Friday, February 23, 2007

The Patient Satisfaction Imperative

As the old song goes, I can't get no....satisfaction.......

Ever wonder why in the healthcare industry that satisfaction is sometimes so hard to come by?

That is not to say that every hospital or health system has a satisfaction or service problem. There are many exemplary examples of service focused healthcare organizations that day-in and day-out deliver high levels of patient and physician satisfaction. Yet, in an industry where we "serve" individuals, we hear from consumer research that it's the other guy. My doctor and my hospital is fine as consumers report general happiness with their healthcare providers. Hospitals regularly report satisfaction in the 90th percentile. Get people outside of the hospital and you hear some pretty common complaints: the food is cold; I did not know about my test; you woke me up in the middle of the night; it was noisy; the room to cold; the room is hot; and on and on. As organizations tout the JD Powers Satisfaction Award, show great improvements in Press Ganey or NRC-Picker or other survey instruments, there is still the uneasy feeling that all was not okay. These and other survey tools are all very valid, all worthwhile, show trends and document accomplishments. With the government HCAPHS Hospital survey in play by reporting provider satisfaction as a common basis for measurement and consumer comparison, all the more imperative the focus on patient satisfaction.

Healthcare is not an easy business by any stretch of the imagination. We work with people who are patients and their families that are at various states of emotional distress, caring employees (for the most part), good physicians etc. So satisfaction for so many different groups becomes interrelated.

Why is it important?

For several valid and researched reasons.

Satisfied patients are more compliant with treatment regimens.

A satisfied patient even if the medical outcome is not good, believes that he or she had a quality medical experience.

Satisfied patients recommend you to others.

Satisfied patients return to you for care.

Satisfied patients tend to ligate less.

It's the right thing to do.

Where does satisfaction start?

No surprise here - right in the executive suite. Yep, the CEO and senior leadership sets the tone, tenor and actions by what they do or don't do. How they treat others. How they measure and hold themselves accountable in the performance evaluation process. It's either part of the culture or not. People clearly understand the organizational rationale, polices and procedures for satisfaction and are part of the program, or they see it as the flavor of the day because so and so said so.

Satisfaction is not a program or a slogan, or simply a set of behaviors codified in polices or procedures, a bar chart on the wall. It is not the notice in the hallway or patient room that if you can't rate us as very good or excellent, call this person to immediately address your needs. Satisfaction is all that and more. The defining culture of the organization. A recognition that satisfaction is every ones responsibility. It is anticipating the needs of the person or family. Taking care of the little details day-in and day-out is what creates a satisfied patient. The successful healthcare organization recognizes and understands that patient, employee and physician satisfaction are interrelated, is a process and is controllable!

The Changing Dynamic

Did you know that here appears to be a major shift in how patients and their families judge the quality of medical care? Used to be it was all based on the the hotel services, food service, housekeeping etc. Arrogantly, clinicians and hospital leaders confidently stated that patients did not have the ability to judge the technical quality of what we do.... its magic to them!

With the information available from the Internet, health and wellness programs, news stories etc, patients are very well informed and are making technical judgements of the quality of the care that they receive. Most of the time research is indicating patients technical judgement of care is on par with those of the attending physician. Now that is a dramatic change and one which is little recognized. However, it goes one step further. The dirty floor, the torn wallpaper, the piece of paper on the floor are now adding into the mix. The patient is now judging, "If they can't take care of the little things, then how can I expect them to take care of the big things...... like my treatment......... "

OK now what?

With the advent of HCHAPS, pay-for-performance, awards as well as the bragging and marketing rights in the community, patient satisfaction moves to the forefront of operational excellence. Here's the rub.... now comes the program to increase satisfaction and how to show statistically why we are better...

Here comes the program, the flavor of the day, the decree from on high....

Lies.... damn lies....and statistics........

Patient Satisfaction is a process

Patient satisfaction is a process that is controllable and understandable. It is the voice of your customer. By listening to that voice, I mean really listening to that voice, you would be surprised at the improvements that you can make in your healthcare setting. Patients, physicians and others view the hospital experience not as a set of unrelated departments where things are done to me, but as a coordinated whole in a continuous process.

Is the process of satisfaction in or out or control?

Ask any hospital executive that question and for the most part, I think they would say yes it is. Ask them to show you the data that it is in control, nine times out of ten, the subject gets changed. The simple fact is they don't know. Healthcare leadership needs to know if their process of satisfaction is in or out of control to know if they even have a satisfaction issue. A simple percentage explanation won't do that. A bar chart won't do that. A new program that is the flavor of the day for increasing satisfaction won't do that. It takes a commitment to in-depth analysis, using all the tools of Quality Management. It takes a willingness to change the culture of the organization. That is not easy. Its hard and forces some very difficult personnel decisions.

For example, say hypothetical Hospital A is dismayed about its satisfaction scores and the CEO declares, we need a 10 percent improvement in the scores. Admirable, but misguided.

If I am housekeeping and my percentage score of patient satisfaction is 70 percent, a seven point increase over time is probably doable. If I am nursing and my percentage score is 90 percent, a nine point score improvement is impossible. Flat out can't do it, not going to happen, Nada, no way. That is what happens when you only use percentage scores or a bar chart as the basis for action.

Now, had the organization been analysing the satisfaction data with the tools of Quality Management, this could have been the action on the part of leadership in a conversation in hypothetical Hospital A.

" We really need to move the culture of the organization and improve our satisfaction scores. I asked our Quality Department to do an in-depth analysis. When you look at the bar charts we see steady improvement, but regression analysis shows really not much change over time. The telling difference was when we looked at patient satisfaction scores though the use of Statistical Process Control Charts and what a story that told.

It looks like our process of satisfaction is out of control, there seems is no rhyme or reason why the scores fluctuate so much. Yes, they are all in a narrow range, but this tells me we really don't understand the process of satisfaction and how to control it. When applying this analysis to individual departments and units, we find some striking differences. Some units and departments are outperforming the organization as a whole, others could really use some improvement. I really think we need to get to those units and departments outperforming the whole and benchmark what they are doing.

So instead of everyone trying to improve 10 percent overall lets use the upper control limit of the charts as the incremental target for improvement based on historical performance. That means housekeeping you can improve 10 percent, but nursing, its really only one percent at this time. Lets make this measurement an ongoing process so that we know the point of when we designed an intervention, implemented and see the result.

What gets measure gets done, so in your goals and objectives put in place a measurement for patient satisfaction for your departments that the scores will not vary by more than 2 points plus or minus of the top score.

This isn't going to be easy. We need to really change the organization. I know we have done this before and seen some improvement. But we always fall back after a couple of months. If we go at this the right way, the employees won't see it as the flavor of the day. And we all know what that means. It may mean over time that we will lose some people. That is never good nor is it easy. But consumers, the government, payers and employers are all demanding higher performance from us. This does have a financial impact to us. As we move forward, we need to set behaviors and hold people accountable, that includes us. We need to become world class in delivering high levels of patient satisfaction."

That unfortunately is a conversation that does not take place nearly enough.

Where do we go from here

It starts with learning. It starts with an honest assessment of here is where you are. It starts in the C-suite. Commitment, compassion, understanding, listening, process control and improvement. Every hospital and healthcare provider out in the wider world has the talent, experience and expertise to do this. But what is lacking is the will. What is lacking is the understanding of the importance of patient satisfaction. Its not sexy and really hard work. For those that are willing to start, learn and change - the benefits are enormous!

If we as an industry really understood satisfaction as we claim too, do you really think that year after year dozens of books would still be published on how to improve patient satisfaction in healthcare organizations?

My Book

Okay, here is the plug for the book..."How to Use Patient Satisfaction Data to Improve Healthcare Quality", Raph Bell, Ph.D., and Michael J. Krivich, FACHE, Quality Press, January 2000, 156 pages and available on Amazon.com or from Quality Press at the American Society for Quality. Its all detailed in an easy, readable book that will assist you in reaching your satisfaction goals. Patient satisfaction is a process, it is controllable and takes work and at the end of the day, you will be better for it, your patients will be happier for it and you can outperform your competition with it.

Unless the hospital industry begins to take a more detailed data analysis and organizational approach to patient satisfaction and make it a part of the culture of the organization, we are left with lies.... damn lies.... and statistics.....

And in the end, we may be very proud of ourselves, but our patients will still have that nagging doubt about what just happened.

Saturday, February 17, 2007


Welcome to Healthcare Matters.

Yes its a play on words. Healthcare consumes a great portion of our GNP so that matters. How you are treated by doctors, nurses, dentists, therapists, other practitioners of the medical arts, hospitals and other medical providers matters. What the drug companies create and medical device manufacturers sells matters. How the government - state and federal - pays for healthcare matters. How the insurance companies create those managed care products matter. How your patient information is stored, read, managed and remains confidential - matters, really matters.

Its a complex maze of great opportunity for health and wellness. And at the same time, a world where billions and billions and billions of dollars are at stake. In the end it that matters to you, me, our families, the uninsured, taxes and all the rest. We pay, are going to pay more and when it comes right down to it - we have very little say.

I have been in healthcare for nearly 20 years now- hospitals, health systems, GPO, managed care, long term care, medical device manufacturers. Seen a lot, done a lot, yes marketed and communicated a lot. Yep, inside scoop here, how it really works, what the CEOs really mean when they're talking.

In the coming weeks and months we will explore topics of interests, maybe break a few stories, explore some misconceptions.

Interviews with healthcare leaders, profiles and trends can be expected.

The good , the bad, the ugly - what works and doesn't work in healthcare advertising.

Evey wonder why hospitals tout their patient satisfaction scores in the high 90th percentile for satisfaction, yet you leave the medical encounter wondering what just happened and why you don't feel better about it?

Think doctors believe what you tell them? Think again.

Think we are going to have national health insurance? Not till two important questions are answered and the politicians aren't even taking about those.

Think certificate of need laws reduce healthcare sending and control the delivery of services? You'd be surprised at that answer.

Add your comments, thoughts and ideas. Suggest topics for us to explore. Have a hot tip, send it along, verification is necessary as a reminder.

Thanks for reading, we'll keep it light at times, serious at others, but most of all informative and maybe, just maybe, a bit tongue in check when the time is right.

Watch this space!