I know from conversations with some of you that this is a trying time and empathize with the challenges that you are facing.  As I wrote in Collaborative Confessions, change feels like failure when we are in the middle of it, something that achievement-oriented professionals are programmed to resist. 

It reminds me of a time February 1996 we nicknamed the Valentine’s Day Massacre, when I lost my job at a VA hospital because of a budget cut, along with four other part-time physicians and surgeons because as part-timers, we had no seniority rights.  Because my wife wanted to remain in New England, I applied to the Dartmouth Tuck School MBA program, so that we could continue living in our home.  None of my male colleagues thought that what I was doing was a sound idea.  One admonished me, “It sounds like you are jumping off a cliff, hoping that you will find your wings before you crash to the ground.”

In contrast, all ten women with whom I spoke told me that as one door was closing, several more would open up with opportunities that took advantage of my talents more than my present job as Associate Professor of Surgery and Chief of Surgical Oncology at the VA.  I asked the tenth woman why she thought that there was such a difference in replies:

Men derive most of their self-esteem from their careers and fear change, while we women are hardwired to deal with change.  We go to high school and college, some to graduate school, some get married and have children, but whatever we do, change is a part of our lives every single day.

The next time that I heard the term “hardwiring” was in Quint Studer’s book Hardwiring Excellence, in which he defined hardwiring (p.2) as ingraining systems and tools that recognize what is right and what is working well.  Its importance is to serve as a method for sustaining gains after a leader leaves an organization (p.18).

Through this journey, I learned that results come from hardwiring agendas, evaluations, communication, training, selection, discharge phone calls, thank you notes, and more.  This way, the hardwired behaviors drive the system even if the leaders change.  This is crucial since most staff and physicians will work at a facility longer than the average CEO.  Hardwiring excellence supports the organization’s values and sustains the gains. 

Part of Studer’s journey was turbulent.  He recalled (p.12) a friend who listened to his complaining about problems at a hospital where he worked and handed him an envelope with three decals to post on mirrors in his home, car, and office that said, “You’re looking at the problem.”   It brings to mind the recently deceased Michael Jackson song, “Man in the Mirror” which he sang at the 1988 Grammy Awards.  Change is indeed difficult, as Studer recalled (p.12):

I had heard that I was part of the problem before in the early 90’s, but I just didn’t believe it…. I said to Tim, a housekeeping employee, “This place looks terrible.” He looked back at me and said,”The fish starts rotting at the head.” I didn’t know what he meant then.  I thought that was because I didn’t do much fishing.  Now I know he was speaking about leadership.

I summarized in Collaborative Confessions my own recent struggle with change as I found what I do had become a “discretionary expense.”  I bypassed denial and went straight to anger, but by admitting that I did not have the answers and obtaining coaching assistance, I have emerged at a wiser, more sensitive, and more accepting place.  A surgical colleague who is now a hospital Chief Operating Officer lamented,”It took me over half my life to recognize that by relinquishing control, I gained influence.” 

I have learned, as Christopher Cornue alluded in, “Where did all the strategists go?” that:

• We all face danger of extinction in this troubled economy
• Making myself indispensable requires active, ongoing effort
• Email alone is insufficient for staying in touch with a rapidly changing marketplace
• Pain can be a powerful motivator
• Daily exercise boosts serotonin and can keep depression manageable
• Forcing myself to write down three things for which I am grateful every night helps me keep my  helplessness in perspective
• I can permit myself to grieve (briefly); as a colleague advised, “It’s OK to visit pity city as long as you don’t live there.”
• More importantly, I can reward myself at the time and place of my choosing, which has helped the local ice cream parlor thrive despite difficult times
• I can be in touch with the majority of my body composition that is liquid and flow in occasionally different directions when a customary route is dammed
• In “The Question Behind the Question”, John Miller points out that the only question that matters does not begin with “who” or “why,” but “what can I do?” or “how can I help?”; perhaps my experience is teaching me to substitute “I” for “they” when I form the words, “If only….”

What do you think of my mentor’s comment that change feels like failure when we are in the middle of it?

• Do you agree with Michael Jackson’s lyrics, “If you want to make the world a better place, take a look in the mirror and then make that change.”
• What are you grateful for
• How difficult is it for us men whose self-esteem derives predominantly from our careers to access our 23 maternal chromosomes that are hardwired to deal with change
• Where do we turn next

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

Thank you for the contact; however, at this time, I do not seem to have need of your expertise.  What practices I don’t own already in the community don’t readily lend themselves to collaboration.  They are staunch, stand-alone, small, independent practices that don’t want to change anything about the way they operate.

I empathize with the way he feels.  My father was a solo-practice neurosurgeon from 1952-77.  One of our favorite stories was that while his car was in the repair shop, he stood at the bus stop and noted colleagues waving to him, but none slowed down to offer him a ride.  When he arrived at the hospital, he complained to colleagues in the physicians’ lounge who told him, “George, you need to learn to hitchhike with your thumb rather than with your middle finger.”

An article helped me think about ways to deal with physicians in small practices (Christensen CM, Marx M, Stevenson HM. 2006. The tools of cooperation and change. Harvard Business Review. 84(10):73-80).  The authors lay out a graph in which the x-axis represents the perceived way the world works (cause and effect), and the y-axis represents what people want (vision for the future).  Near the origin of the graph (where the x-axis and y-axis equal zero) lies a circle labeled “Balkanized States,” e.g. Serbia and Bosnia-Herzegovina, where the desire for autonomy outweighs the benefits of working together.

The authors state that this group responds to power tools, including:

• Command and control
• Threats
• Setting an example

It reminded me of the way that I dealt with my adolescent children, with limited success.  On my better days, I gain inspiration from ways that healthcare leaders who take my seminar have taught me to deal with physicians who do not want to be engaged.  In Collaborative Control, I saluted a CEO who when confronted by his Board Chair with, “Does it bother you to cede control to your physicians,” smiled and replied, “Heck no, I never had control in the first place.”

Here are some replies from practicing physicians to, “What can we do to engage physicians who do not want to have anything to do with us?”

That will only happen if they perceive that you have nothing to offer or they do not trust you….To me it is all about building trust and identifying areas of passion for them, and areas where you can improve their lives (processes) or their incomes (JV’s etc)….you have to come up with something of interest to them…what can you do for them, not what they can do for you

If they do not want to have anything to do with you, ask them why not!!…..that is a definable set of reasons and (mis) perceptions you might have to dig out of them, realizing that you might not like and may not want to hear what they say, but once understood gives you something to work with

We all have crosses that we need to bear. Asking me for my input in helping you solve problems, sharing data with me that will improve care for my patients, or best yet, helping me make my time count are ways to get my attention.

An additional strategy involves getting to know the physician’s assistant, nurse, and/ or practice manager and ask their input on engaging that physician.  As I pointed out in Collaborative Etiquette, active listening requires:

• Concentrating on the speaker, maintaining comfortable eye contact
• Listening with one’s eyes as well as ears to be mindful of body language
• Opening one’s stance to convey receptivity
• Suspending judgment to maintain objectivity
• Empathizing, trying to put oneself in the speaker’s frame of reference, using summary questions, such as, “Do I understand you to say….,”

We all have our own data points, but Brian Wong’s survey of over 1500 practicing physicians (A Prescription for Physician Reengagement. Futurescan 2009:23-26) revealed that the majority of physicians seek:

• Meaningful work that makes a difference in patients’ lives
• A sense of community
• Regular, reliable, positive feedback that affirms their value

I wrote in The Tectonic Plates Are Shifting: Cultural Change vs. Mural Dyslexia that:

• both hospitals and physicians are facing rising expenses, burdensome regulations, heightened consumer pressures, and stagnant or declining reimbursement
• the response to global economic pressures and the need to improve clinical and financial outcomes can bring hospitals and physicians together

Miller wrote, “God grant me the serenity to accept the people I cannot change, the courage to change the one I can, and the wisdom to know… it’s me!” (QBQ: The question behind the question. Putnam, NYC, 2004).

What do you think?

• Do you agree with Tom Atchison that much of physician-hospital relations involves executing basic blocking and tackling
• Do these troubled financial times offer us the opportunity to work together more collaboratively
• Do you have any collaborative examples that you are willing to share in the blog comments section

As always, I welcome your input to improve healthcare collaboration.  Happy Father’s Day.

Kenneth H. Cohn

© 2009, all rights reserved

Through Executive Book Summaries to which I subscribe, I came across a provocative recently published book, The Innovator’s Prescription: A Disruptive Solution for Health Care, by Clayton Christensen, Jerome Grossman, and Jason Hwang.  Although I do not usually summarize books that I have not read in their entirety, the content motivated me to alert readers to this 441 page tome, in the hope that others will agree that perfection can be the enemy of good, to paraphrase Voltaire.  I give thanks to the beeper gods and godesses who permitted me to read the summary and write a blog post while providing general surgical coverage in Maine this weekend.

Warning: something in this book is bound to upset and unnerve all of us who may not realize how invested we are in the present non-system of care.  What I write should be viewed more as confessional than prescriptive.

The premise is that the need to transform expensive, complex offerings into higher-quality, lower-cost offerings is not unique to healthcare.  For example, Dell’s entry into the personal computing marketplace forced IBM to reevaluate its business model and focus on providing value-added business consulting services rather than building personal computers as its primary source of revenue.

According to the authors, healthcare provides two distinct services:

• Solution shop: activities that focus on diagnosing patients’ problems
• Value-adding processes: activities that fix problems that have been diagnosed in solution shops

 The reasons that the two services must be separate is that solution shops need to be paid on a fee-for-service basis; they require advanced technology and specialized expertise.  However, value-adding processes are outcome-driven,  can sell their output for a fixed price, and (for example, Geisinger Clinic’s Proven Care for heart bypass grafts and hip replacements) can warrantee results.  Only when the organizational resources, processes, and business model are focused around a job-to-be-done, can they be integrated and optimized to obtain outcomes as close to perfection as possible.

Therefore, the authors recommend that hospitals build distinct facilities (or at least a hospital within  a hospital) to deconstruct their activities operationally into solution shops and value-adding processes.  In the future, general hospitals will no longer be able to subsidize low-volume non-standard solution-shop (diagnostic) services with high-volume value-added work (procedures).

The authors feel that only a minority of chronic diseases, such as Alzheimer’s, Parkinson’s, lupus, epilepsy, and infertility necessitate a multidisciplinary solution shop.  The majority of chronic illnesses are rule-based, meaning that they can be competently managed by an individual caretaker; rule-based diseases include hypertension, osteoporosis, HIV, type I diabetes, and myopia.  The rules for treating many rule-based illnesses are so widely accepted that nurse practitioners can care for these patients without compromising clinical outcomes.

We cannot count on traditional physician practices to police patients to enforce compliance with therapy.  The business models that can help patients succeed are different from those that diagnose and prescribe the original treatment plan.  The authors cite as examples disease management companies like OptumHealth and Healthways.  That only a fraction of patients are cared for by disease management companies and integrated providers like Kaiser Permanente and Geisinger suggests an opportunity for those willing to embrace change rather than cling to familiar models. 

The Patient-Centered Medical Home represents an opportunity for primary care physicians to provide systematic, patient-centered, coordinated care management processes.  The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

The authors feel that quality results from proper integration of care and that lower costs come from focus that promotes lower overhead.  Large employers are initiating disruptive change by outsourcing the care of patients to coherent solution shops for diagnosis and to integrated providers for patients’ treatment plan and compliance monitoring. 

Similar technologic disruptive forces introduce patients to devices that have provider experience built into their logic circuits, which will allow patients to monitor their own health in an improved fashion, for example scales and blood pressure cuffs, that wirelessly transmit patients’ daily weight and blood pressure to nurses experienced in the management of patients with congestive heart failure, that help patients thrive outside expensive hospital settings.

I ask with anticipation, “What do you think,” because a book like this lends itself to wide-ranging discussions on a variety of topics, including:

• Do we need a more coherent business model to guide 21st century US healthcare
• What are the strengths, weaknesses, opportunities, and threats implicit in The Innovator’s Prescription
• When is the ideal time and where is the ideal place to start

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

The photo, which I received this week from the American College of Healthcare Executives (ACHE), shows me accepting the Dean Conley Award from Chris Van Gorder, President and CEO of Scripps Health and Chairman-Elect of the American College of Healthcare Executives.  The Conley Award, which honors ACHE’s executive director from 1942 to 1965, is granted annually to recognize the contributions made to healthcare management literature and to encourage healthcare executives to write and publish articles. “The Tectonic Plates Are Shifting: Cultural Change vs. Mural Dyslexia” was selected by ACHE’s Article of the Year Awards Committee.

I wrote the article with Professor Leonard Friedman and Dr. Thomas Allyn to point out that:

•  a rapidly changing healthcare marketplace
• a variety of new business models
• increased global economic competition, and
• the need to improve clinical and financial outcomes can bring physicians and hospitals together rather than drive them farther apart.

This article outlines strategies hospital leaders can use to engage physicians and work more interdependently, such as positive deviance and structured dialogue. I concluded with a ten-step guide to engaging physicians and improving care:

1.Encourage practicing physicians to articulate future clinical priorities to increase their sense of shared ownership and to improve clinical outcomes.

2. Include doctors who are users of radiology, anesthesiology, pathology, and emergency services when drawing up contract specifications and monitoring performance to improve service; physicians may pay lip service to administrators but listen to other physicians who refer patients to them.

3. Establish a hotline for process improvement issues that is tracked at least monthly in senior management meetings to make sure that the communication loop is closed.

4. Treat the top 20 percent of physicians (by volume or revenue) as partners, and visit them at least quarterly regardless of irascibility.

5. Ask “go-to” docs, “What can we take off your plate?” at least semiannually to monitor
and reduce burnout; a recent poll of over 24,000 surgeons showed that approximately 40% met criteria for burnout.

6. Map out policies and procedures to improve effectiveness and refine handoffs, especially when people complain that they are short-handed. Staff creep often results from workarounds created by inefficient processes. Inefficiencies can be identified and improved by putting each step on a Post-it note and asking members of a group to remedy the gap between what should be happening and what is actually occurring.

7. Have the chief information officer and programmers round periodically with physicians to see how physicians struggle with information technology and how the physicians could use their limited time more productively.

8. Develop a hospitalist surgical service to off-load call burdens for physicians and to diminish the need to pay stipends to physicians for carrying a beeper.

9. Celebrate and reward all healthcare professionals who exceed their job descriptions. Stories of such professionals can become the basis of a positive culture that strives to improve outcomes and service to patients and family members.

10. Establish a pool with fines for using hot-button words (such as “you,” “always,” never,” “but,”) and killer phrases (such as “let’s appoint a committee to study that some more”) and use the money to support a worthwhile service or pay for a celebration.

Those who want to read “The Tectonic Plates Are Shifting: Cultural Change vs. Mural Dyslexia” in its entirety may do so by clicking the link.  I will also discuss its implications, including how to recognize and stop the dance of the blind reflex, use healthy competition to avoid the “herding cats” mentality, develop sustainable medical staff models, implement proactive physician recruitment, retention, and contracting strategies, deal with Emergency Department call-pay, and support healthcare innovation at a 2-day ACHE seminar, Practical Strategies for Engaging Physicians, July 15-16, 2009 in Lake Geneva, WI.

I empathize with the effects of the recession and the limits placed on travel to acquire continuing education.  I hope that the rewards for investing in improving physician-hospital relations will reemerge soon.

What do you think?

• Do you feel the tectonic plates shifting where you work
• Does change feel like failure when we are in the middle of it
• Are any of the ten steps listed above relevant to your work setting

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

I owe the inspiration for this post to two people:

1) Catherine Henderson, a Graduate Medical Education Consultant with Partners in Medical Education, Inc. reminded me that a decade ago, the Accreditation Council for Graduate Medical Education (ACGME – the organization that accredits all allopathic residency programs) mandated that residents demonstrate competence in the specific knowledge, skills, attitudes, and behaviors required in all six General Competencies:  medical knowledge, patient care, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills.  No longer will residency programs retain their accreditation by proving that they teach residents how to care for patients – they must also demonstrate that residents have learned the skills and behaviors in all six competency domains.

2) However, the ACGME did not point out how facilities can make sure that residents and faculty teaching the residents demonstrate the 6 competencies.  For insights into this journey, I am indebted to Ruben Azocar, Program Director, Department of Anesthesiology, Boston Medical Center, for his talk entitled, “Bringing the Six Core Competencies into the OR” at the 5th Annual Ellison Pierce Symposium: Positioning Your ORs for the Future, April 30-May 2, 2009, where we served on the faculty.

I will focus on the last competency, interpersonal and communication skills, not only because of my interest in the field but also because the Joint Commission on Hospital Accreditation has raised awareness of this issue by mandating zero tolerance for behavior that undermines a culture of safety.

Dr. Azocar’s presentation elucidated the skills that underlie the ACGME mandate that practitioners must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, families, and professional associates, including:

• Creating a relationship with patients
• Using effective listening skills
• Eliciting and providing information
• Working with others

Evaluation of these six competencies should be part of a rotation-by-rotation rating (such as “displays these behaviors: always, usually, sometimes, or rarely”) with a signed action plan for remedying deficiencies.  In addition to rule-based indicators, we may also see rate-based indicators that track practitioners’ clinical outcomes relative to their peers with appropriate thresholds (eg central line infections).

I was fascinated by the assessment tools to help physicians monitor and improve performance, extending beyond written and oral examinations to 360-degree feedback, direct observation (as with shadowing mentors or actors playing mystery patients), and after-action reviews of clinical simulations in which faculty assess resident performance not only for correct diagnosis and treatment but also for situational awareness and clarity of communication and follow-up measures.

He referenced a fascinating operational matrix developed by Bingham and Quinn from MD Anderson Cancer Center, in which interpersonal communication skills (“What should we say?”) could be tracked along the dimensions of the recommendations by the Institute of Medicine that care be safe, effective, patient-centered, timely, efficient, and equitable.  An important feature of the matrix is that it encourages users to close the loop; if a remedial action plan is not documented at the bottom of the matrix, problems have a high likelihood of recurring.

Dr. Azocar predicted that in the future, a physician’s portfolio will include not only a list of places worked, publications, and committee assignments, but also evaluation forms and action plans demonstrating improvement.

In “Collaborative Leadership at Academic Medical Centers” (Cohn KH. Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives. Chicago: Health Administration Press. 2006, 149), I wrote that leadership derives not only from the people in charge but also from processes that foster transparency, trust, accountability, and collaboration.  The development of emotional intelligence that broadens residents’ skills beyond command-and-control is critical because, unlike practice management, interpersonal communication skills must be learned and not delegated. Furthermore, improved communication can decrease readmissions, as discussed in Collaborative Handoffs.

The questions that the competency-based approach to residency education raises include not only how do we measure competency but also who will assess competency, what remains confidential, and how do we train faculty assessors as well as residents.  Apparently, the competency evaluations are here to stay, we are on a journey of discovery, and the potential for improving communication and patient care is exciting. 

What do you think?

• Will 21st Century residents trained under the system of the general competencies and simulation change medical practice
• What collaboration is needed to make these changes possible
• Will competencies make a difference in the quality of medical care
• How will we know when we are “there”

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

Think about the potential if we approached leadership development as a long-term investment rather than as a short-term cost. Hospitals are hubs where patients receive care, but in the process, we exchange information (eg via electronic health records) and train leaders and managers.  The rationale for investment in leadership development is clear: successful companies recognize that effective leadership is their only sustainable competitive advantage (p.1).

I remember in business school that we studied General Electric when Jack Welch was CEO.  We concluded  that GE was fundamentally a leadership development and management training company, not a portfolio company of loosely related businesses. The authors quoted Welch, “I spend all my time on developing people… the day we screw up the people thing, the company is over.” (p.8).

This concise, well-written book comprises eight lessons:

• Establish leadership development as an organizational policy
• Define desired leadership values and behaviors
• Formally assess employee career potential
• Emphasize speed and diversity in leadership development
• Create structured leadership education and development programs
• Develop depth charts and succession plans for key positions
• Provide formal oversight of the leadership development process
• Foster high-potential talent streams

The authors encourage healthcare executives to take a four-step approach (p.14) to:

• Identify personal values
• Leverage personal values to create organizational value statements
• Assess present leadership behavior against the desired future state
• Develop strategies to eliminate the gap

Merely posting job vacancies does not promote effective employee development (p.24). Instead, the authors recommend that someone in senior management assess each employee’s career because immediate supervisors do not have the perspective to recognize performance at significantly higher levels of management.

The key components of a formal leadership development program are that it (p.43):

• Be strategy-driven and focused on 1-2 top goals
• Encompass all levels of employees
• Be comprehensive
• Use diverse methods to achieve its goals
• Involve senior executives for sponsorship and training

The authors evaluate the success of leadership development programs in terms of (p.72-3):

• The reaction of participants to formal training sessions
• The participants’ evaluation of how much long-term learning took place
• A 360-degree feedback assessment of how colleagues believe that participants have behaved differently as a result of their training
• Quantitative and semi-quantitative performance metrics, such as financial performance, employee satisfaction, and compliance with core measures

What do you think?

• Does your organization invest in leadership development training
• Do you have a succession plan for senior executives
• If no, why not
• If yes, how successful is your leadership development program, and how has it changed individual behavior and organizational performance

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

When they agreed, I asked , first in small groups, then the group as a whole, to discuss the following questions:

• What ethical considerations  involve physician-hospital relations
• Where does the responsibility lie in addressing these issues
• What should be our next steps

The first group took the courageous approach of looking into the mirror and saying that ethics were fundamental to transparency, which is the building block of trust.  They felt that, in addition to providing care, hospital leaders needed to share information openly, not just the information that supported  their viewpoints.  Implicit in this approach was the imperative of tactful candor, to say no if they were unable to implement a suggestion from a physician rather than to euthanize the suggestion with ”death by the slow no.”

The second group explored approaches that they had taken to deal with financial conflicts of interest, including:

• requiring vendors to make appointments to visit the hospital, sign in at the securitydesk, and wear a badge that said “vendor” when they were on hospital premises
• abolishing “free lunches” provided by drug and device companies
• requiring off-label treatments to be approved by the Institutional Review Board
• performing random  reviews of charts by a team of physicians and nurses to identify patterns of unnecessary care

The third group discussed end-of-life care.  Members of this group had implemented a palliative care service and utilized a multidisciplinary end-of-life committee to discuss personal opinions in the context of providing optimal patient care.  They found that the resources invested in these items brought a high return because they made families and caregivers feel that their concerns mattered.

I had been uncertain of what would result from this discussion.  I was pleased not only with the insights  but also with the intra-group bonds that formed from sharing personal viewpoints.  Their input provided a context for subsequent teaching sessions involving active listening, medical staff integration models, and physician retention strategies.

When I asked the group, “Should a discussion of ethics be part of future seminars on physician-hospital relations,” they agreed unanimously.

What do you think?

• Have discussions of ethics come up in physician-hospital interactions where you work
• If so, what issues did you discuss
• What were the outcomes

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

I admit that in previous posts( Gotcha and Uncollaborative Insurance ) I have complained about what I felt were arbitrary regulations on physical therapy for cancer survivors like me who sustained spine injuries and back and neck pain as complications of lifesaving therapy.

I cheered the decision that sent $6.6 million from Aetna to business owners due to a violation of Maine state law that requires small-group insurers to spend at least 75% of premiums on medical claims [Modern Healthcare 39(17)16].

Yet, today, in the spirit of Mother’s Day, I have chosen to focus on what I agree with in Karen Ignani’s article [Uniquely American Solution: Collaboration, leadership required to bring change. Modern Healthcare. 39(17)20-21]. Anticipating criticism from readers who become as frustrated as I do with caring for patients amid denial codes, telephone calls, and burdensome paperwork and regulations, I disclose that I have received no money from anyone in the health insurance industry. On the contrary, I send Harvard Pilgrim Healthcare nearly $17,000 in annual premiums.

Here are points from her recent article on which I agree with Ms. Ignani:
1) Successful reform will require a comprehensive cost-containment strategy: I hope that physicians and hospital share with insurers, pharma, and device manufacturers in the sacrifices required to bring costs down considerably. I support insurers converting to a universal claim form which will save providers time and administrative staff costs.  I also support regulations that increase transparency for physicians and organizations who receive payments from drug and device companies for research, consulting, and speaking.
2) Preventive care and screening reduce future catastrophic outlays. I would be willing to sign a 5-year contract with my insurance company in return for a guarantee that premium costs would not rise more than the agreed upon amount, so that they could reap the benefits of their investment in my wellness
3) Investing in anti-obesity and anti-smoking campaigns can improve the health of the nation and reduce related costs. Even though I am not overweight and do not smoke, I support these efforts.
4) Providing scholarships and loan forgiveness for physicians specializing in primary care will help provide and sustain the workforce necessary to achieve the above objectives. In the Southern Surgical Association Presidential Address, Dr. James O’Neill stated, “I believe that the reason many students are selecting so-called “lifestyle specialities” characterized by shift work, is because these fields are relatively protected in terms of reimbursement under Medicare and other insurance reimbursement.  This is primarily because of enormous student debt, now averaging close to $200,000 and rising, an insidious influence…  Currently, no one is taking responsibility for this and it is up to us.” [Journal of the American College of Surgeons. 208(5),659.] The sooner we institute this reform, the better. 
General surgeons, especially those who work in rural settings, deserve to be included in the primary care category; without our active assistance, emergency departments, intensive care units, and medical wards cease to provide comprehensive care.  General surgeons allow a hospital function as an acute-care facility that can provide life-saving care to our communities.
5) All of us can do better. Amen
6) Acting now to identify reductions in all sectors can provide significant relief to purchasers of healthcare insurance, improve the solvency of the Medicare trust fund, and free up resources to finance healthcare reform. No disagreement here either.

The following are some ways that we physicians can make it easier to reach a sustainable equilibrium:
1) Invest in interoperable electronic health record software that allows us to share data without the need to re-enter it into our computers
2) Use software displays that show us clearly the results and date of previous laboratory testing and imaging studies, so that we avoid duplication
3) Obtain palliative care consults for patients entering the intensive care unit to avoid squandering limited resources on patients at the end of their lifespan for whom there is little hope of extended survival. Questions about rationing need to give way to questions about how we can deploy scarce resources more effectively
4) Support legislation that requires patients to fill out living wills signed by their next of kin and power of attorney when they apply for/ renew their health insurance coverage. This is especially important for aging patients before significant cognitive decline occurs
5) Play a greater role in health education not only for individual patients but also in schools and public forums
6) Be more pleasant and rethink conspiracy theories to cultivate mutual respect. As I wrote in Facilitating Physician Engagement, breakthrough innovation occurred at the Pittsburgh Regional Health Initiative once participants moved from an accusatory, “Why don’t you …” approach to a more welcoming, “What if We …?”

What do you think?

• What reforms do you support in the upcoming healthcare reform debate
• What can we do better
• As you look into the mirror, what would you like to change 

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

• I was in Chicago last month attending the ACHE Congress, where I received the Dean Conley Award for the best article appearing in a healthcare management publication; that article, “The Tectonic Plates Are Shifting: Cultural Change vs. Mural Dyslexia” is available on my website
• I attended The System Seminar on Internet marketing, where I implemented a new tool, Kampyle, that allows visitors to my website to offer constructive feedback; please use it to hep me serve you better by clicking here
• I revised my slides for my upcoming ACHE seminars on Practical Strategies for Engaging Physicians May 6-7 and July15-16, 2009; the seminar  includes new material on physician employment contracts and engaging healthcare professionals in innovation
• I participated in 6 radio interviews and 1 television interview on general topics relating to healthcare; you can listen to them by clicking here (note, the TV interview was taped to air June 6, 2009; more details to come soon)
• I traveled to my mother’s house in Buffalo, NY for Passover, the subject of this post

As many of you know, Passover celebrates the Jewish people’s escape from Egyptian bondage.  To me, it represents the hope of Spring and the potential of transforming current difficulty into triumph:

“On this night, long years ago, our forefathers hearkened to the call of freedom.  Tonight, that call rings out again, sounding its glorious challenge, commanding us to champion the cause of all the oppressed and the downtrodden, summoning all the peoples throughout the world to arise and be free.”

Our family’s tradition is for my mother to read about the four children, summarized below (the “he” is intended to refer to both male and female children):

• The first kind of child is the wise child.  He loves Passover; he is eager to celebrate the holiday exactly as it ought to be celebrated, and he asks his father, “What are the decrees, the statutes and laws which the Lord our God has commanded concerning Passover?”
• Another kind of child is the irreverent child, who is scornful and does not feel as though he is part of the whole celebration.  He asks his father, “What does this service mean to you?”
• The third kind of child is the simple child who is naive and very shy.  He would like to know what Passover means, but does not know how to ask about it.  So he asks merely, “What is this all about?”
• The fourth kind of child is the one who does not even realize that something unusual is going on.

Although my mother refers to me as “the curious child,” in truth, I have been all four children at various times of my life.  One of the pluses of being a cancer survivor is that my faith has been tested and strengthened in the process.  For me, Passover is a time to reconnect with family and celebrate what unites us rather than being consumed by our differences.  I leave with a sense of hope that extends to my work and is especially important in these challenging economic times, where the outcome is certain (we will prevail), but the timing is everyone’s guess.

In the spirit of Passover, what are your thoughts?

• Can you allow yourself to feel any optimism as flowers and trees bloom
• Do you escape from bondage as you complete a task that has been oppressing you
• Can you celebrate the child in you that asks questions, regardless of whether they are wise, irreverent, or naive

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

The author, Sam Horn, is a cherished mentor who led the Non-fiction Writing course at the Maui Writer’s Retreat, where I began to write Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives. Now that I have disclosed my relationship, let me tell you why I found her book riveting.  Sam is an award-winning speaker and communication/ creativity consultant who helps people craft memorable messages.

POP stands for messages that are (p.4-7):

• Purposeful: articulating the essence in a way that remains imprinted on people’s minds (e.g. “You’re in good hands with ____.”)
• Original: novel, something that people have not heard before
• Pithy: precise, concise communication that prompts people to say, “Tell me more.”

Because we are bombarded by hundreds of messages every day, messages that do not stand out end up being ignored, deleted, and forgotten.  Think of the implications for patient safety if a detail that really matters to a patient’s treatment suffers a similar fate. 

At the risk of being typecast, “What can Madison Avenue tell us about patient care,” I submit that it is our moral responsibility to learn to communicate so that our messages resonate with our co-workers rather than being dismissed as dull or boring.  Sam’s book tells us how.

Don’t be dismayed by the 221-page length of the book; it is a pleasurable read, with lots of examples to prove her points, such as:

• using the Valley Girl technique, “It’s like …” to link the unfamiliar with the familiar to create an “Aha” moment (Like a good neighbor, …, p.52-3)
• giving people an image that moves people from a logical, left-brained mental state to a right-brained state to which they can connect emotionally, as with the word “Aflac” (p. 81)
• employing alliteration to give our minds a memory hook, as in “Weight Watchers” (p. 146-7)
• rhyming, as with Tuckman’s Four Stages of Group Formation: forming, storming, norming, and performing (p. 159-161)
• telling stories about a hero’s journey, where someone succeeded despite what appeared to be overwhelming obstacles, rather than lecturing people (p. 191-4)

The question remains, “Once you have won people’s attention, how do you get them to do what you want them to do?”  Sam writes that one way to prompt people to act is to begin a sentence with phrases like, “Next time,” “From now on,” or “In the future,” which helps people convert a message into an action plan (p.214).

In Collaborative Leadership, another mentor, Tom Atchison, wrote that trust is the glue that holds a culture together and reduces friction during stressful times.  Meaningful interactions, characterized by active listening, are the basis of trust.   POP facilitates listening and thus helps to build trust.

What do you think?

• Can you remember a time when improved communication could have improved a patient’s outcome
• Is communication a journey that we can  improve by using techniques mentioned in POP
• Are you ready to start now

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved