Next Level - Ideas and Inspiration Around Key Healthcare Challenges

Incremental Change

Wed, 08 Feb 2012 06:00:00 -0600

While driving home last night from the office, I made one of those regrettable decisions and thought I had enough gas to drive just one exit more. You guessed it - I ran out of gas while driving on to the off ramp of a major highway and stopped dead partially blocking the lane to other drivers. I turned on the four way flashers, the interior light of the car (thought it made me for visible and therefore safer) and called the Automobile Association to confess my error and ask for help. Since I was blocking a lane of a major highway, I was considered an urgent case and help would be arriving within 30 minutes. No problem I thought - I returned emails, listened to the radio and pulled a blanket from the back seat to keep warm.

After a while when help was not so fast in arriving, the car got colder and my battery started to die along with the radio, I started to consider the drivers whizzing by me - both to see how they were managing to avoid me and to wonder if anyone might stop to help. In the 90 minutes I waited and listened to excuses from the Automobile Association, no one stopped to help nor even slow down to look.

Did I actually expect anyone to stop and help? Not really but it made me think about what it takes to have someone see something they can do to help another and either stop and help or move on.

We see it every day in hospitals where we work - eyes averted, ears closed and a driving pre-occupation with a bigger more important agenda. This is not about missing a diagnosis or a medication or a treatment, this is about placing a meal within reach of a patient, letting a waiting and anxious family know about the reason for their wait, scheduling an appointment for the convenience of the client, or replacing a blanket that has moved. It is about the little things that are really the big things.

This is not a message that is new nor revealing yet describes a situation we all see every day. I suggest that we can become quite focused on the transformational big changes that are incredibly important yet may not have meaning for everyone who works in our healthcare system. In actual fact it is those incremental small changes that are directionally positive that have a significant impact.

Our challenge as health care leaders is to make sure all members of the organization know they have a place and a role to play in this fundamental improvement effort.

Is Your Patient Flow Out of Tune?

Tue, 07 Feb 2012 06:00:00 -0600

Consider for a moment the structure of an orchestra - it is a large instrumental ensemble that contains multiple sections. The strings section is the largest group and the heart and soul of the operation. The woodwinds provide the buildup, while the brass section delivers the excitement. The smallest section, percussions, resonate a magical sound to enhance the performance. Individually each section has its own function, but every section contributes to the larger group, and when executed correctly, the collective group is in harmony and makes beautiful music.

Like orchestras, hospitals are divided into multiple sections. Each section varies in size, and serves a different function to the overall group. Hospitals and orchestras work best when each section and player executes at the right time. When this does not happen you get a lot of unpleasant "noise" in the form of staff and patient complaints. However, it is not always clear what is the root problem of the "noise" you hear. Let's examine some example situations:

What you hear - "noise"	What is causing the "noise"
"Patients in the ED/PACU are waiting several hours for a bed"	Delayed discharges on the inpatient unit Telemetry monitoring beds are not available Lengthy admissions process Decentralized patient placement process Lack of technology for appropriate and efficient patient attribute matching Staff are too busy to communicate open beds
"Patient could have been discharged today but needed a test"	Ineffective scheduling of activities and resources Poor discharge planning/communication
"It took EVS several hours to clean a room"	Inadequate communication Problems with staffing and turnaround
"Transport takes too long"	Ineffective scheduling practices Limited foresight to demand

When it comes to effective patient flow, hospitals are highly dependent on the services of departments and staff to execute functions that will deliver optimal services for patients. Ineffective systems and processes can have a crippling effect on timely patient care and patient flow and can result in:

Poor patient outcomes and satisfaction
Inefficient throughput
Increased LOS
Stressful working environment

In order to create harmony, hospitals must see through the "noise" and identify the systemic issues that cause the breakdown.

Listen closer: Is your Patient Flow out of tune? What challenges are you facing?

Change and Creating a Shared Need - Vlog

Tue, 31 Jan 2012 06:00:00 -0600

The pit falls that leaders should try to avoid when they are making huge changes are, they must create a sense of urgency around the change. If there is no sense of urgency around the change, if people don't understand this is important and critical to the mission of the hospital, the change will not be as effective. The second pit fall that organizations sometimes fall into is that they fail to create a shared need. The reason for the change comes strictly from the top, and organizations are much more successful when they involve all players in creating a shared need and a shared vision of the change. I think, most importantly, organizations are successful with change when they involve all of the key stake holders.

If you use the example of the implementation of electronic medical records, having the physicians involved and having them participate and adopt that change is absolutely critical for the success of it.

Where we could involve nurses as teams and work with nursing teams, and they will accept the process and work together, physicians are unique and individual, and they practice individually. So, identifying the individual's physician's unique needs, tailoring a support mechanism or process for them, and putting that in place, is - I think is - I believe is critical to the success of engaging physicians.

When we can identify the key stake holders and assess where they are in relationship to the change, and at least find key and huge pockets of resistance and try to understand what the issues are and work with people to at least neutralize them to the change, change is much more effective.

Who are the people in your neighborhood?

Wed, 25 Jan 2012 06:00:00 -0600

Who are the people in your neighborhood...the people that you meet each day?

My first job within health care was as a nursing assistant in Obstetrics. During that time I interacted with the nurses, doctors, dietitians, social workers, schedulers, unit secretaries, materials management, and patients. However, there were some people in my world that I was not truly aware of.

In theater the people you don't see are the costumers, the set designers, the stage managers, the props people, etc. These are all the people that make sure that everything is ready and in working order for the actor to perform. In the hospital, some of the people who do the important, behind the scenes jobs are the environmental services, central supply, central sterile, processing and distribution, and biomedical services. It is extremely important to know who these people are and to include them in some of the decisions that you make regarding care.

For example, if your hospital's Emergency Department or PACU RNs typically infuse via gravity flow and then make the decision to switch to utilizing infusion pumps, the decision affects not only the amount of pumps that will be used, but how often cleaning will need to be done, and it could result in an increase in breakage due to the increase of use. These departments need to be involved in order to be prepared for the change, and to ensure that you have what you need.

So who is the person who cleans the room between patients, the floors and bathrooms during the day and into the night? If you said environmental services, you would be correct in most hospitals!

How about the people who fix broken parts of equipment, fix big and small machines, fix computer parts of certain equipment, even fix large and small devices? These are the people who are kind of like electricians, plumbers, carpenters, mechanics, and the Geek squad all wrapped up in one! If you guessed biomedical services, you would again be correct! (Aren't you a smarty?)

Finally, how about those people who ensure that your instruments are sterile (kind of a give away, I know), your mobile equipment is cleaned, and that they are where they are supposed to be in order for you to use them? Well, I am sure you already have decided central sterile. Of course, I tricked you a bit and added processing and distribution in there as well. Sometimes these are separate departments, and sometimes they are within the same department.

All of these neighbors are part of a larger team, which supports and enables the provider to care for the patient. Quite often, their roles are forgotten, perhaps undervalued, and invisible to the eye. But think of all the times where you have needed supplies, needed clean instruments, and medical equipment that worked? Every day, right? And yet many of us do not take the time out of our busy running around schedules to notice these people and what they do until a process breaks down, or they are not there fore us.

So who are these people in your neighborhood? Do you know where in the hospital they work? And do you know how to get a hold of them when you need them or let them know that you appreciate their support? Maybe it is time to know some of the people in your neighborhood!

Avon Calling

Fri, 20 Jan 2012 06:00:00 -0600

As I write, I'm at 38,000 feet on a Southwest Flight. As I mentioned last posts, I am Pavlovian as far as the tones of an airplane. Southwest has integrated the tones into their commercials and branding. It reminds me of the doorbell tones from Avon's TV marketing in the 1960's. You'd hear the "ding dong" and you knew "Avon's Calling."

As I write, I'm a little brain dead. I have led the implementation of an Electronic Health Record system at a pilot site and anyone who has been through an inpatient deployment of an Electronic Health Record system can attest to its difficulty. There are all the usual software snags you hit during any large system implementation. The added pressure of touching fragile revenue cycle tools and the sensibilities of the practicing physicians always adds complexity and stress to the situation. All I can say is thank goodness for great consultants and wonderful residents. But, given the stakes, I think the entire project was very positive. CPOE rates were greater than >70% by the end of the first week with minor effects on revenue cycle. So I'm going to deviate a little--well a lot--from the theme of my Health Management Academy action project and blog about clinical informatics. I did need to keep some of my basic rules front and center:

Make the right thing to do the easy thing to do.
Electronic Health Records do not practice Medicine; they cannot force a physician to do or not do anything.
Clinical Content is physician currency in Electronic Health Records
Never under estimate the ability of a clinical EHR user from destroying your perfectly well conceived solution to an informatics problem.
If you think you've covered all the communication feedback loops think again. You missed at least 3 and probably 5.
Despite electronic media, internet, web portals, and remote access, fax toner still greases the axle of medical progress.
Given a large enough beer and pizza budget you can conquer the world.

I'll get back to the topic of HIE next time. Until then, wish me luck. I'm in "fix it up" mode; which for anyone in my type of business means your dodging a lot of rotten vegetables right now.

Are You Spending Most of Your Time Managing Change? - Vlog

Tue, 17 Jan 2012 06:00:00 -0600

When I go out and talk to CEOs, what I'm hearing from them is they are really concerned about whether or not their organizations can manage the changes that are going to be coming down the pike from healthcare reform, reimbursement issues, all those other types of things that are going to be affecting them. - when we discuss managing change, that is their concern. Its whether or not I'm going to be able to have my organization flex the way - what it needs to do and the kind of time that it needs in order to be successful within that kind of marketplace.

Leaders end up spending most of their time managing this change. They may be thinking, I need to be thinking about what we need to do and how that works, and that is an important part of any leader's role. But what we have found, is that most leaders not only have to come up with great ideas, but they also have to make certain that that change gets implemented across their organization, so that there aren't the kinds of problems that you would experience when there is massive resistance to those kinds of changes.

I believe that the most critical thing about making change for healthcare leaders is to make certain early on in the process that you are reaching out to all of those stakeholders - whether it's a physician, whether it's the nurses, whether it's the clerks on the floor, whether it's the - the folks in the billing office, whoever is going to be feeling the impact of this change, is getting out to them early on in the process, fully communicating what is going on, making certain that you are showing and demonstrating very clearly your commitment to this change. If you don't show it, if you as a hospital administrator do not show that commitment to that change, how do you expect all the folks with who work with you to have that same kind of commitment to the change? So, if it's nothing else, it's to show that passion and commitment and time to the change, so that sends the message out to the organization that this is something important and something they need to pay attention to.

The elephant in the room - Vlog

Mon, 09 Jan 2012 06:00:00 -0600

So, hospitals are paid more today than they'll ever be paid, and so, in the next 24 months, they need to really make conscious decisions about how are they going to do more with less? What types of tradeoffs are they going to make? There's really nothing wrong with choosing to do certain things, and making them more of a priority than other things. The shame of it is, when organizations don't acknowledge that they need to make a tradeoff, and they don't have that open discussion among different stakeholders, and do it in an aligned way.

As we look at the changes that are happening, across healthcare, really, we're just in the very, very beginning. We're just starting to feel the ramifications of changing reimbursement rates, different influences between payers, different sense of consumerism, in some cases. Most healthcare professionals recognize that they need to be more bold in acting today. This traditional wait and see approach is no longer something that's going to work for them.

And so, the best organizations realize that they can't be all things to all people. They realize that they need to find productivity gains, and to find them in a way that actually makes things easier for their customers, whether that's referring physicians or patients themselves. They're confronting the elephant in the room, and coming together as one in - tact team , and thinking at a system level, where do we really want to be excellent? What do we want to be known for, 24 months from now?

Incandescent Light Bulbs and the Innovation Piggy Bank

Thu, 05 Jan 2012 06:00:00 -0600

The venerable 100-watt incandescent light bulb is going the way of the 45-rpm record or a phone with a cord on the end. We have relied on that light bulb for 100 years and it delivered on its promise to create light, however inefficiently. But time has finally caught up with it. Killed by regulation, new technology, and consumer demand, it's being replaced by the LED, which can produce the same amount of light for a fraction of the energy cost, and generating almost no heat in the process.

The death of the simple light bulb made me think about how sluggish our healthcare delivery model has been to change. One reason may be the perception that our current model, like the light bulb did, provides the desired outcome - it improves the health of the people it serves. However, just because healing occurred, we cannot conclude that we went about achieving that outcome in the most effective and efficient manner. With the exception of government, things that are inefficient and/or ineffective cease to exist.

In hospitals of all sizes and affiliation, when I ask a simple "Why?" question, it is rare for a day to go by without hearing the answer: "because that's the way we've always done it". That may well be, but that doesn't make it right, and it doesn't necessarily make it efficient. What has seemingly served your organization well may not work tomorrow. Remember that light bulb kept making light exactly like it did yesterday, but it was killed because "that's the way we've always done it" wasn't good enough anymore.

Defining new ways of doing things, or finding your "LED" care model, takes time, hard work, sometimes courage, and involves risk; but is worth the risk. Change doesn't have to be either big or expensive, however. Changing the way we think about change and creating a culture where "because that's the way we've always done it" is the wrong answer creates a foundation for sustainability.

Consider the following in your effort to create more effective care models:

It is possible and likely for nurses, physicians and other care providers to work courageously hard as individuals without producing an optimal collective result. Ensure combined individual tasks are the right combination of inputs that will produce the best outcome.
Start an innovation piggy bank, collecting fines whenever staff or leaders defend current process with the statement or attitude, "that's the way we've always done it."
Don't just make it okay, but encourage and reward staff for challenging the status quo.
Recognize that today's best practice won't be tomorrow's. While working towards today's best practice, dedicate at least 20% of that energy towards defining and shaping tomorrow's best practice.

Healthcare reform will continue to squeeze margins and the demand for efficiency, and predictable and reliable patient outcomes will intensify. These forces aren't just the PITA du jour; they are a real wakeup call and an opportunity to reinvent ourselves and our healthcare models.

When staff buy-in to process changes is not the main issue... but management's is

Thu, 22 Dec 2011 06:00:00 -0600

At a recent client, following several successful workshops, the client project team came to an agreement on a number of ambitious process changes that they were very excited about in order to solve an ongoing problem: wheelchair availability during the day. The cause of this issue was identified to be one of accountability, with too many people touching the wheelchairs without any controls, particularly at the exits because they were so easily available.

Process changes centered around:

1) The elimination of wheelchair storage by the exits, Instead:

keep a few wheelchairs behind the volunteers' desk at the exits, for them to use to help outpatients or inpatient admissions, or visitors;
setup "official" storage areas on each of the nursing floors, to be used for discharges;
setup a central storage area where transport would take and leave the wheelchairs they use for all transfers;

2) Leverage RTLS technology to track wheelchair movement and usage

3) Set PAR levels for each storage area (central storage, storage on nursing floors, storage behind volunteers' desks).

Alas! When these changes were presented to management, they were not received with the enthusiasm the project team had expected. A few days prior, at another hospital, this hospital's CEO had been confronted with quite the ordeal: arriving at the entrance with his daughter, who was in labor, they were forced to wait for an extended period because there were NO WHEELCHAIRS BY THE EXIT. Needless to say that the group's recommendation to remove the wheelchairs storage areas by the exits was received with a cold shoulder...

Subsequently, the project team met again and designed another solution: while some wheelchairs would still be kept by each of the exits, they would be equipped with non-telescopic IV poles, making them easier to spot for the staff, and more difficult to "steal" for visitors. This little change however impacted the whole solution which the group had formerly devised.

So next time you are concerned with staff buy-in to any major process change, think broadly and know what concerns your stakeholders! The toughest resistance will likely come from where you least expect it.

Contributing author to this blog was Xaviere Michelot, who is a Senior Consultant in the Asset Management Professional Services team. Prior to joining GE, Xaviere worked on a variety of healthcare issues in France and Sweden for a private healthcare provider, Boston Consulting Group, and the Ministry of Health. Her areas of expertise include healthcare providers financing, operational excellence, and general management.

A few leading practices in patient transport

Wed, 21 Dec 2011 06:00:00 -0600

Effective management of the patient transport process is not frequently discussed in current hospital management literature but it is an essential component if a hospital is to effectively manage its patient-related processes. Where patient transport is dysfunctional, waiting lines and procedure delays increase, patient and family satisfaction decreases, staff irritation escalates and productivity is lost.

In a recent engagement, the primary objective given to us was to solve an ongoing problem with wheelchair location and availability. Wheelchairs kept disappearing from storage areas, never to come back. The transportation department was overwhelmed, while staff and volunteers tired of spending so much time either waiting for a wheelchair or chasing it across the facility.

Patient transport issues are unique insofar as they usually involve most units and departments, and impact most patient-related processes in a hospital. Beyond the transportation department, nursing, security, volunteers, materials management and hospital management all need to work together to optimize this function. In our experience, patient transport optimization needs to focus on four main goals in order to obtain a well-functioning process:

A right-sized transportation department based on demand
A controlled access to wheelchairs, e.g. for visitors
Leverage technologies, e.g. RTLS
Staff and volunteers trained to understand patient transport issues and to follow a defined process to ensure optimal use of the available equipment

This document includes some strategies that hospitals employ to manage transport and prevent leakage, with varying degrees of success. There is no universal solution to effective patient transport, some of the practices are very effective in the appropriate environment but have to be coupled with an assessment to define the demand and critical issues in order to implement potential technologies and optimize patient transport processes.

Questionable Hygiene?

Tue, 20 Dec 2011 06:00:00 -0600

Who among us hasn't taken a magazine quiz, looked at our horoscope, taken a personality test or an aptitude test? There are entire industries dedicated to the learning about why we do what we do, from dial-a-psychics to quizzes used by corporations to pick out job applicants. What is it that makes this information so addictive? It is the personal nature of the information that is received. We are complicated creatures - there is always something more to learn about ourselves, and we are fascinated by the way that we interact with the world, especially when this information comes from an impartial source.

Hand hygiene is something that is instinctive to healthcare providers. We are taught that the easiest and most effective way to prevent infections and protect ourselves, is to wash our hands. Most hospitals believe their compliance rates (usually based on secret shoppers or a gel/soap usage calculation) are roughly 90%. Our experience of baseline has been more like 35%. If this is something so integral to our own safety and that of our patients, then why is it so hard to ingrain?

A proper hand hygiene technology solution will take both of our self-preoccupation and our innate desire to do the right thing into account. It should assume that healthcare providers intend to do the right thing, but that something prevents this behavior - and should appeal to this sense of introspective curiosity about why compliance isn't occurring. This requires individual users to receive feedback in a constructive and non-punitive way, to change behaviors.

Hand hygiene technology is relatively new and the market is beginning to flood. Consider, as you decide to invest, how the solution approaches this issue - it may not be as complete as you believe...

What hand hygiene challenges are you facing? What have you tried, to make an improvement? How do you believe technology could help? I would love to hear your perspectives...

Where are my wheelchairs? (how many do I REALLY NEED?)

Mon, 19 Dec 2011 06:00:00 -0600

When we are on site at hospitals, a frequent complaint that we hear from the staff is their frustration of not having enough wheelchairs or not finding one when they need it. This issue was recently raised during a process optimization project that we were working on. At this hospital, staff and volunteers were spending an incredible amount of time daily looking for wheelchairs. The storage areas by the exits, even though full at 7am, would be empty several times a day. This meant departments often had to reschedule for later discharges or transports because staff couldn't find a chair to transport them in and/or several calls would have to be made before a wheelchair could be made available.

Generally, when it comes to improving equipment utilization, the focus is often set on process - how is your process hindering proper usage? How can your process be optimized so as to maximize utilization? Are there any steps that should be added, or suppressed? Are there any behaviors that should be promoted and/or discouraged? But in order for a process to work smoothly, we need to ascertain if we actually have enough wheelchairs to meet the demand. Indeed, not having enough equipment available is one of the key reasons why official processes stop being followed, and why people start hiding, hoarding equipment, and running their own process instead of cooperating.

Faced with this situation we took a different approach by first conducting an inventory and needs analysis along with a processes optimization exercise. Using a bottom-up approach, we assessed:

How many patient admissions, discharges, transfers, imaging and surgery procedures, family visits, outpatient procedures were there on a typical day?
Any variances on a high-volume days?
What percentage of those required wheelchair transportation?
Then, how much time did each of these transport needs involve, counting not only transport time itself but also waiting time in imaging, duration of the surgical procedure, of the typical family's visit, etc.?

Essentially, how many wheelchair hours did this hospital need every day?

Then, we made assumptions regarding the duration of the "peak activity" time: we chose to assume that peak activity lasts for 4h (e.g. 9:30am to 1:30pm), and that 75% of transport needs occur during that peak time period. This brought the conclusion that this hospital needed to increase their wheelchair inventory by 25% to meet its needs.

This was a critical step in analyzing the root cause of the problem in conjunction with recommending the process changes on wheelchair usage since we were able to conclusively define, at an academic level, the actual wheelchair demand by the hour and where it was needed.

In a future blog we will discuss some of the leading practices that hospitals have utilized in effectively managing wheelchairs.

What Do Cephalopods and Hospitals Have in Common?

Fri, 16 Dec 2011 06:00:00 -0600

Well, they're both in a fight for their lives!

Watching a NOVA episode recently, I was intrigued by the concept of parsimony in nature - how creatures are able to find the most direct path (avoid needless complication) or work out a simple solution for very complex problems. For example, cephalopods (sea creatures) use their brainpower to change the color of their bodies to mimic nearby surfaces. They have various other survival tools, but this neural processing and cognition capability allows them to recognize environmental patterns and then replicate those patterns to hide from predators such as whales and sea lions.

In healthcare, big fish aren't predators from which we must hide, but the need to survive other threats, such as troubled economies, sociocultural shifts and healthcare reform is very real. What I'm wondering is how effective are we at recognizing our own environmental patterns and adapting accordingly. Both hard and soft trends warn us of danger if we continue business as usual, but we struggle and fear changing what we look like and how we operate.

Consider your hospital's patient flow paradigm and how it affects profitability. How many years have performance improvement teams been tweaking these processes? As valuable as Lean Six Sigma methodologies are, I still see hospitals from coast-to-coast achieving marginal patient throughput gains; many of which dissolve in less than a year or have untoward downstream effects. The ER, for example, reduces their admission order to inpatient bed placement time, but it results in multiple inpatient transfers because the patient is not placed in the right bed, on the right unit the first time.

Knowing when to use what tool and in what combination (how to adapt) is what differentiates survivors from predator lunch. In the patient flow example, hospitals have focused so hard and long on fixing the symptoms of the problem, e.g., mismatch between peak admissions and discharges that they have neglected root causes such as artificial variability. In the case of addressing OR surgeon block schedules, I've even heard hospital leaders say, "it's too difficult to deal with the surgeons," so they don't. Instead of pulling out a tool that conquers the root cause, nurses beef up bed board meetings and patient flow huddles to manually treat the symptom of this fundamental upstream problem. This mindset is not sustainable!

It seems we can take a lesson from the simple Cephalopods: in order to survive, we need to recognize environmental patterns and adapt accordingly. One example of an underutilized adaptation tool is using artificial intelligence to model efficiency through simulation. It's innovative technology such as this that helps us conceptualize new possibilities and create models of care that are sustainable. The futility of trying harder or doing essentially the same thing and expecting different results is, indeed, insanity.

Designing proper satisfaction surveys for your hospital staff

Thu, 15 Dec 2011 06:00:00 -0600

Patient Satisfaction is becoming a more critical metric as the rise in Pay-for-Performance standards from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) becomes paramount to the future of ranking and reimbursements in Healthcare.

Recent studies show that the nurse work environment and nurse-to-patient ratios can directly affect overall patient satisfaction scores. * In many instances, we have conducted these surveys as a baseline before addressing new asset management workflows.

Do you have a good method to track nurse satisfaction within your facility? The below five steps discuss best practices for creating an accurate survey to assist with feedback from your staff.

Here are the top five things to consider when creating an effective employee survey:

"The Weight of Your Survey" What scale should you use to ask your survey questions? A Likert scale utilizes questions where respondents are asked to answer according to subjective/objective criteria. Likert is considered symmetric or "balanced" because there are equal amounts of positive and negative positions on either side of the respondent's decision. Most proper questions under the Likert method would use five, seven, or nine levels. This approach gives more balanced, statistically significant answers.
Timing (Seasonal, Cyclical): Are you planning to conduct your survey annually during flu season and/or during the holidays? Will you survey staff annually, quarterly, every six months? Varying survey times throughout the year can help you in getting consistent answers. If you survey staff during the short-staff holidays or a high-census flu season, you may end up hearing more "gripes" than are truly warranted. Having a plan for your next survey before rolling out the initial one is also useful. I recently spoke with a hospital executive that was surveying staff for the first time in 4 years! He shared that they planned to compare the results with the previous survey (conducted in early 2007!). Is that really a fair comparison for your staff? With all of the recent changes in healthcare, once per year should be a minimal expectation for proper survey administration.
Communication (Get the word out!) How are you going to administer your survey? Is it going to be on your hospital intranet or through corporate e-mail? Do your employees use word of mouth techniques more frequently than a technology solution? Is the technology that you want to use for rollout "new" and still in the early adoption phase? Many COOs lament their lack of hospital survey results. Alas, when we review employee feedback, many times we find that they do not use hospital e-mail and did not know there was a survey to take. It is important to over-communicate the survey timeframe, reason, and results in order to ensure that you get a proper bell-curve with your results.
Follow-Up Timeline/Expectation-Do your surveys come in like a lion and go out like a lamb? Is there a strategic timeline for the results? Do the employees at your facility feel as if they are sending answers into cyberspace with no results or feedback? Is there proper confidentiality attached to the survey and the results? All of these items should be addressed prior to survey administration.
Share the Feedback-Uh-oh, your survey results came back less than optimal. The employees are unhappy with the way you are running your facility. What do you do? When we interview staff members about what is most important to them post-survey, transparency has been valued more than any other metric. Share your results and have an action plan in place to address areas of concern. Conduct town hall meetings with key staff members to discuss the feedback and get input into possible changes. As a caution, do not just follow up with management personnel and conduct a top down strategy for addressing challenges. Pull in key front-line ambassadors to assist with changing the process and delivering the solutions to your overall team.

Attached is a sample survey that was designed to gauge feedback around equipment utilization at a 250 bed hospital. Equipment utilization was the #1 concern around nursing satisfaction prior to our involvement at this facility. This template may help you to formulate a productive survey for your hospital.

*Nursing: A Key to Patient Satisfaction, Health Affairs, 28, no.4, (2009):w669-w677 http://content.healthaffairs.org/content/28/4/w669.full.html, Accessed on 10.17.11

Value Stream Mapping is Key to Creating the Bridge - Vlog

Tue, 13 Dec 2011 06:00:00 -0600

Value stream mapping is key to creating the bridge between the strategic initiatives of an organization and the projects, the actions, the tactical pieces that they do every day, and to support those. And that's often a piece that's missing in organizations.

Value stream mapping can help a lot by aligning the projects that are done - performance improvement projects, operational improvement projects - any of the changes that they're making helps - value stream mapping helps to align those projects to the strategic initiative.

So, instead of having a hundred different projects going on without a clear line to the strategic initiatives of an organization, you have a hundred singular results - if you can map them, those hundred projects - same hundred projects up to specific strategic initiatives, three to five strategic initiatives of an organization, you can say, "look how we've made impact to just those three to five initiatives." So, you see the sum of all of those projects rather than the individual projects.

In the current economic climate for healthcare, it's incredible important to truly understand the operations of your organization. Value stream mapping is one of the tools that will help you to understand the operations, the process, the different interactions within departments, within the systems of the organization. Once having an understanding, that helps us to understand where are we going to have the most impact. So, where do you best use your resources? Because those resources are limited in healthcare today, you need to really understand, where are you going to have the most impact for those resources. So, value stream mapping is absolutely critical right now for helping to have better use of resources, to focus in, have the most impact, and ultimately achieve the goals, the strategic goals, of the organization.

Why the Executive Needs to be the Culture Leader vs. the Idea Genius

Fri, 09 Dec 2011 06:00:00 -0600

Headlines in the healthcare industry are all about change and innovation. And, for a new hospital CEO, the most important point of advice might not be which changes to make first, nor how to execute the associated projects, but how to establish an environment for innovation in her organization.

Innovation really means changing the game, itself, vs. just pushing the rules of the current. There are three aspects of innovation and change leadership that characterize many organizations known for successfully pushing into new space.

The good news is that there are things in all of these areas that are useful for healthcare to pursue:

Environment - The leader cannot always be the one with all the best ideas, if you wish to have a sustainable path of innovation and change. Numerous studies and assessment models point to the importance of leaders creating a climate that encourages innovation and creativity. John Beeson mentions this factor in his book The Unwritten Rules, "Successful executives don't have to be creative geniuses....you need the ability to form a team that includes creative thinkers who can help..."

Check the balance of styles on your teams (creative or adaptive, high or low need for structure, developer or implementer.) You can't have all idea generators or nothing gets done, and you can't have all do'ers or you'll never move forward into new space. How does the physical work environment help or hinder creativity? How do you respond to new ideas in a way that supports exploration?
Content - Vijay Govindarajan of Dartmouth proposes the Box 1, 2, 3 model of strategic innovation...Box 1 ideas are those that help you advance your core capabilities and create excellence in current activities. Most healthcare organizations work mostly, if not entirely, in Box 1 as they build strategic plans. Box 2 ideas are about "selectively forgetting the past", or being thoughtful in planning to set aside things you currently do in order to create new capabilities; and stretching current activities into adjacencies. Box 3 ideas...rare in most organizations...are about completely new space and completely new capabilities. How might you establish a strategy around growing your services to the uninsured or underinsured using completely new care design and technologies vs. just driving more revenue from the populations with employer-paid coverage? Needs citation or link to VG
Methods - Innovative ideas need a safe harbor to develop and grow. Are you cultivating or crushing new ideas and innovation with your current processes or infrastructure? Do you have a defined set of processes around business development that are built to encourage, sponsor and shepherd new ideas through the rigors of operational and financial requirements vs. leaving those with the ideas on their own to fight their way through the current systems? Is there an established set of change leadership methods in your organization so that anyone can build and drive a case for change?

You can add creative thinkers to your organizations, but even the best ideas will not emerge from them in a useful, sustainable way unless you build the entire framework of environment, content and methods to support those people and their ideas. This is the real job of the innovation and change leader.

What does your organization look like? Find out here.

It's Not a Schedule, it's a Suggestion Board

Thu, 08 Dec 2011 06:00:00 -0600

I heard an off-hand comment after a meeting I was in recently that made me laugh, and later, reflect. The meeting was regarding perioperative improvement for a hospital with many capacity challenges - notably having oversubscribed ICUs, an ineffective transfer center, and major issues in perioperative services. The comment came from a frustrated surgeon, who was describing his battle to get access to OR time to do cases. He said, "We don't have a schedule. We have a suggestion board."

While his comment certainly was steeped in sarcasm, it is a reality for many healthcare systems. The vast majority of people who work in or around an OR will go to work tomorrow morning, look at the schedule for the day and it will already be wrong. And it will get worse throughout the day: bumped first cases for patients that aren't ready due to paperwork or pre-admission issues, emergencies that arise that take priority over elective non-emergent cases, cancellations, add-ons...it's not a stretch to describe as a "suggestion" of how the day might play out. It's the best guess at what will happen in an environment with a fixed number of OR suites, with a set number of staff and resources, and no margin for error when things go south.

Becker's Hospital Review often polls experts on healthcare topics, in which there was recently an article that asked 10 experts to share one behavior that cripples the OR.¹ Seven out of the ten answers can either be categorized under leadership or communication. The remaining three have to do with scheduling and resource alignment. If we asked 100 experts the same question, we'd get a similar distribution of answers. And that is because they are all correct. Even the weighting of the answers is correct - call it 70% of the issues plaguing the majority of OR's can be tied back to misalignment, a lack of communication, and weak governance.

But even if there was a magic bullet to solve those issues, it wouldn't result in a transformation. The OR schedule would still often be just a suggestion board. That is because the other 30%, though smaller in scale, is almost equally important. This is where the scientific aspect of the system comes into play. The core composition of the schedule - the amount of time that is blocked for individual surgeons or service lines, the time that is set aside to handle emergent, urgent or add-on volume, and the time that is open for elective volume - is a delicate, complex phenomenon that changes frequently. In order to have an OR schedule that actually plays out close to what was planned, the schedule itself must be addressed. All of the streamlined communication in the world cannot fix a schedule that is inherently not designed to function at optimal utilization.

Essentially, the degree of accuracy with which a planned OR schedule plays out on a given day is a proxy for the severity of the communication and governance issues weighted against the core composition of the schedule. Tackling one of these things by itself will only result in marginal improvement. Taking them both head on is the road less traveled, but the right one to get a schedule that can be taken at face value.

1. Rodak, S. 10 Experts Share the One Behavior They Believe Cripples an OR. Becker's Hospital Review, August 26, 2011.

YOU don't have to have all the answers

Wed, 07 Dec 2011 06:00:00 -0600

I often see leaders defining a problem as the "absence of my chosen solution." As a leader you may be wondering, why is this is a problem?

Employees that are never asked to generate answers to problems, simply won't. Even worse, not engaging in problem solving has been shown to lead to non-engaged employees who are always looking to the leaders for the solution. Their input and perspective is lost.

Using a problem-solving methodology that allows employees closest to the issue/problem to be challenged by leadership to develop recommendations to address the problem can resolve this issue.

I recently worked with a Hospital CFO who felt he could capture more revenue in the OR by changing the charge structure to more accurately reflect the intensity of the services provided. He had developed a new charge structure that he wanted to implement but was anticipating meeting significant resistance to the idea. I asked him to consider investing the time of a cross-functional team to work out a solution to the problem in a facilitated meeting. He agreed and the team came up with a very elegant charge structure that resolved the intensity issue along with a detailed implementation plan that assured the buy-in, he was looking for. He was amazed by the team's well thought out plan, that was simpler, with fewer steps, with much less chance for error than his original plan. He was excited to have a team of committed employees willing to shepherd "their plan" through implementation.

So the lesson for change leaders is clear. Take a step back and recognize, if you empower those employees closest to the problem or in the case of Hospitals, closest to the patient, they bring a vast array of experience to an issue. Empowering teams to come up with solutions not only develops better solutions but also energizes and engages those employees.

Effective change leadership means you don't always have to be the one with all the answers.

Analyzing the pressures on admissions

Tue, 06 Dec 2011 06:00:00 -0600

Over the last several weeks the publicly traded hospital companies we follow completed reporting their quarterly earnings. One notable item was the continued unevenness in the trend of same store adjusted patient admissions, which have remained between a negative 0.5% and positive 1.0% for the last five quarters. Similarly, in late August, Moody's reported that median admissions in 2010 for multi-state not-for-profit healthcare systems declined by almost 11% vs. the prior year. In this environment we felt it would be helpful to review some of the forces pressuring admissions.

The biggest factor pressuring admissions is the continued high levels of unemployment, and in particular the large numbers who have been unemployed or underemployed for significant periods. Since the majority of people get health insurance coverage from their employer, as people lose their jobs they lose coverage. However, a defining factor of this economic cycle has been the large numbers of workers who have remained unemployed for significant periods thus not only losing coverage but also their ability replace coverage before extension of coverage under COBRA expires. In addition, given the damage done to family balance sheets by the combined effects of both the housing crisis and the ensuing disruption to the capital markets, some of those who have been able to find work have been required to accept positions which are not comparable to their prior positions and/or less than full time employment, often leaving them unable to afford health care coverage or obtain it through their employer, further reducing the rolls of the insured.

Another contributing factor has been the increase in health plan consumer cost sharing and the increased use of high deductible health plans (HDHPs)/consumer driven health plans (CDHPs). For example, according to the Kaiser/HRET Employer Health Benefit Survey, between 2007 and 2011 the average annual family contribution to healthcare insurance premiums and the average annual family deductible for a PPO plan have risen at annual rates of approximately 6% and 10% respectively. In addition, according to the National Business Group on Health/Towers Watson Employer Survey on Purchasing Value in Health Care, the percentage of employers offering a CDHP is expected to reach over 74% in 2013 from only 2% in 2002. As a result of higher co-pays & deductibles, studies such as one which recently appeared in the Journal of Managed Care, have found that enrollees in such plans use lower levels of medical services and preventative medicine vs. comparable enrollees. As a result, anecdotal evidence has shown that people with coverage now appear to be deferring elective procedures and even some not previously viewed as elective.

Additional pressure is also being felt as a result of the rise in observation stays, which typically require a patient be observed as an outpatient for 24 hours before being admitted or discharged. Not only are these stays not counted as inpatient admissions decreasing utilization figures but since reimbursement is at dramatically lower rates they tend to markedly impact revenues as well. Unfortunately, given the European sovereign debt crisis, the U.S. deficit debate and continued focus by employers on controlling healthcare costs as well as regulatory scrutiny on observation visits all factors appear likely to persist at least near-term.

As such it is important to carefully review capacity planning answering questions such as: Are resources devoted to observation patients aligned with reimbursement rates and differentiated from those applied to inpatients? Have you undertaken capacity reviews given the employment outlook for your local markets? Are you tracking trends in commercial plan enrollment among the relevant MCO's in your local markets?

Does your Hospital need more Tension?

Wed, 09 Nov 2011 06:00:00 -0600

Have you ever noticed how hard it is to make change stick? If you work in a hospital, my guess is you can give me several examples!

I work with healthcare organizations that have incredibly smart leaders, with vision and knowledge about what they want and need to change in their organizations. I have a bit of a unique perspective as I have witnessed this both internally from a decision-making perspective as well as from being an external consultant. What I consistently see is that these leaders may have been successful implementing changes, but many times, have been unsuccessful sustaining the new improved state.

For example, many organizations are trying to improve their inpatient throughput, reduce emergency department length of stay, improve volumes and/or boost their operating room utilization.

What is commonly absent from these situations and scenarios is the concept of tension. This is not the tension (stress) that results as an artifact of imposing change on employees, but rather the tension (having or give no slack) required by leadership to drive and sustain change.

To sustain and continuously improve performance, tension must be incorporated and held there until gains or changes are ingrained into the organizational culture and considered 'the norm'. This can take a very long time - and tension, specific to some processes, will need to be in place indefinitely.

One applicable way organizations can apply tension on performance is through strategic and consistent use of dashboards. Dashboard measurements are tied to goals outlined in the organization's strategic plan and each measure has a designated point person. In addition, departments have specific measures that support the system's dashboard. Below is a sample segment of an Emergency Department's dashboard designed to trigger specific actions (or tension).

Sample Emergency Department Metrics Dashboard: Length of Stay (LOS)

Visual coding colors - green/yellow/red - are used to easily identify if measures are on track relative to the strategic plan. Rigorous attention to dashboard measures and prompt action is required to improve performance, and achieve strategic goals.

Here is how it works - if a measure is green, the organization is on track to accomplish their goals. Yellow indicates monitoring is needed and red triggers action. Duration of a metric's status is also an indicator that a process requires tension. For example, if a measure is red for one month, or yellow for three months, the assigned point person determines the reason and develops an action plan which is monitored by a department's leader. If the measure does not return to a green status within a predicted period of time, the issue is addressed during a monthly senior leadership team review and next steps are determined. Overall, creating a culture of tension and accountability drives success towards achieving metrics. In addition, adding time frames to the dashboard is important for implementation as well as sustainability.

Consequently, tension helps organizations execute and drive necessary change. So as you think about your organization and what improvements you are trying to accomplish are you asking yourself: Where is our tension? What tension do we need and how do we measure it?

Diagnosis - Change Fatigue! Part 3 of a 3 Part ED Series

Sat, 05 Nov 2011 06:02:00 -0600

A colleague of mine recently shared an interesting care story with me. A good friend ours was going in for day surgery at her local hospital, and she offered to be with her through the experience.When she reflected on the journey, two things really stuck out. The first was that the staff was caring, and made our friend feel safe. Indeed, this was much appreciated. The second thing, however, left much to be desired. The process steps they experienced were truly inefficient! Read on...

Unlike common ED processes where services come to the patient bedside, they were directed to no less than 4 locations before our friend was settled in the pre-op bay. As they hopped from registration to the lab, to the pre-assessment area for vitals and then a second round of medical history questions, it became clear that staff were suffering in their work processes with inefficient care delivery.The staff didn't seem to recognize that multiple trips made area to area by our limping friend was an issue.It made both of us wonder why the pre-op services weren't organized at the bedside, as they surely would have been if she had been a patient in the ED. My colleague inquired about this to one of nurses, who merely shrugged her shoulders and said "That's the process - we've tried a lot of other things but they never work for long". My colleague found it interesting to see that the staff almost seemed resigned to the fact that they had to live with a broken process, and that they would continue to appear stressed and overworked.What the staff was suffering from was change fatigue - an all too common phenomenon of healthcare environments where little improvements have been realized in the pursuit of eliminating wasteful activities.

So what is change fatigue? Change fatigue occurs when staff are expected to make multiple or continued changes in workflow process and patient protocols, without seeing the benefits of those changes in their everyday work. As they are bombarded with constant change, it is easy for people to become disengaged and resistant to change.This waste reduces their capacity to spend more time engaging in direct patient care. As such, this state of affairs detracts from the patient's overall experience,as well as,the employee's sense of satisfaction in the care delivery process. If the patient begins to worry, or feels uncomfortable in their care environment, this can clearly impact their recovery and healing progress.It's unfortunate to witness healthcare professionals who become numb to the inefficiencies of their work- which in turn, perpetuates the problem.

I feel that it is important to understand the consequences of change, why it needs to occur, and the true impact that the change will have on staff and patients. Effective tools and technologies such as computer simulation - can help clinicians understand change, the inefficiencies of their work processes, and their adaptable waste throughout the entire patient journey (not just in the ED). Even more importantly, simulation generates hard data for evidence based decisions. Data gives you the comfort, confidence, and control to make solid decisions around focused incremental, sustainable improvements. By having a risk free environment to trial potential care improvements, organizations can make data driven decisions to pick the best proven solution for their work environments. . Wouldn't it be great to implement a change that actually works....and keeps working??

It is true that creating sustainable change and transforming current state operations to a future state takes a lot of thought, vision, and effort. Organizations need guidance to decide what changes to make and which changes will provide the most benefit. This is particularly true when transforming your care delivery model or building a new facility: you need data driven insight to choose the right next steps. As such, simulation provides the framework to help organizations structure these large scale changes and manage change fatigue at the same time.

Fortunately for our friend, her healthcare experience ended on a positive note: her primary nurse was reassuring, and her procedure went well. She was able to forget about the rocky start to her journey, and went home as scheduled post procedure (although she has some feedback to submit with her patient satisfaction survey that she hopes this organization will notice).

I welcome your comments on how to improve your adaptable waste and eliminate change fatigue.

"Workaround Recovery: Curing Adaptable Waste in the ED" Blog Links:
Workaround Recovery: Curing Adaptable Waste in the ED - Part 1 of a 3 Part ED Series
Workaround Recovery: Curing Adaptable Waste in the ED - Part 2 of a 3 Part ED Series

For More Information:
Case Study: New ED facility at JFK Medical Center a 'virtual' success even before construction begins
Case Study: Planning a new emergency department with confidence-Humber River Regional Hospital
Video: A focus on Hospital of the Future Implementation

Workaround Recovery: Curing Adaptable Waste in the ED - Part 2 of a 3 Part ED Series

Fri, 04 Nov 2011 06:01:00 -0600

Last week while standing in line at the pharmacy, it struck me how adaptable we are as human beings when it comes to overcoming obstacles that get in our way. In our daily workflow, we automatically look for solutions to ongoing problems we encounter as we attempt to perform tasks. We do this without even realizing we are making course corrections! Case in point: As I watched the Pharmacy Tech assist the customer ahead of me, I noticed how she made multiple trips to the opposite end of the counter to locate multiple prescriptions. It was interesting to watch her workflow. She balanced the first three bags in the crook of her arm while closing bin drawers with her knee and reaching over one printer to access another printer. She noticed my glance and said "it's crazy, but the far printer never jams - it really is easier to reach over than take the chance we'd have to reprint!" For her, the physical juggling to avoid the temperamental printer was just part of the routine. It was easier to adapt to awkward body mechanics rather than fix the problem. Obviously, this is what we would call a "workaround".

As a consultant,I work with clients that need help with their Emergency Departments.I get the opportunity to see multiple layers of complex workflow and how workarounds compete with each other. Often the workarounds are so common that they become the standard workflow - entailing much re-work, searches, and expanded travel.The workarounds impact many areas downstream in the ED system....and they are often invisible to staff who have to perform these tasks every day as they care for patients.

Watching the broken process of manual medication reconciliation is first to come to mind. Here is how this works - first, the Triage staffer makes the initial inquiry of the patient and records the patient's medications on the medication list. Then the process is repeated at the bedside by the RN, who reviews the medications with the patient again. Then, the medication sheet needs to make its way to Pharmacy whereby the unit clerk or RN faxes the medication sheet to the Pharmacy. Since it is often not readily "received"both parties end up faxing (duplicating efforts). The faxes are not very legible, so Pharmacy asks for a re-send or to speak to the MD (unnecessary communication and interruptions to the workflow). In addition, a trip into see the patient by the MD is needed to establish clarity (unnecessary travel and time delay).

All these re-work and workaround steps equal lost time: time that could have been spent delivering direct, value-added patient care. To add insult to injury, new staff members are taught this type of cumbersome workarounds as a "Best Practice", which compounds the problems as more people perform the workarounds as part of their personal routines. In LEAN terms, the workflow becomes laden with waste: wasted time, wasted effort, increased travel, mistakes and re-work. We'll call this adaptable waste!

Yet despite the wasted effort we still manage to give care and keep our patients moving through the ED, even if the flow is only a trickle. Most importantly, the workarounds don't translate into better quality or improved efficiency: they translate into inefficiencies, extended ED LOS, and staff "fatigue".

So, how can we identify these issues and the impact to the ED system as a whole? How can we get to the root cause and create a solution?

In the ED, we can use computer generated simulation of everyday workflow and patient flow to create an accurate representation of current state operations. This allows us to see the ED as a whole system, complete with the interdependencies with other departments and support services used by patients during their visit. More importantly, LEAN based simulation helps us to identify workarounds, bottlenecks in workflow,as well as potential opportunities for improvement. Simulation is the tool to use to prevent "waste" time and help turn that into increased care delivery capacity.

Unfortunately these issues/workarounds are not easily seen when you stand in the ED, and they can be the root cause of other issues such as frustration and fatigue across the healthcare continuum.

Are you experiencing frustration and fatigue in your organization due to adaptable waste? I invite you to join in the discussion.

Until next time!

"Workaround Recovery: Curing Adaptable Waste in the ED" Blog Links:
Workaround Recovery: Curing Adaptable Waste in the ED - Part 1 of a 3 Part ED Series
Diagnosis - Change Fatigue! Part 3 of a 3 Part ED Series

For More Information:
Case Study: New ED facility at JFK Medical Center a 'virtual' success even before construction begins
Case Study: Planning a new emergency department with confidence-Humber River Regional Hospital
Video: A focus on Hospital of the Future Implementation

Diagnosing the Symptomatic ED - Simulation the Tool of Choice - Part 1 of a 3 part ED series

Thu, 03 Nov 2011 06:00:00 -0600

It is often said that the Emergency Department (ED) is the front door to any healthcare system. So is it any surprise that the ED is also the center of conversation when speaking about admissions, wait times, and the need to find cost savings for a hospital? Yet, historically when building or planning to renovate the ED space, understanding and defining the vision for workflow is typically not part of the discussion. Indeed, workflow is the way we provide and deliver care to our patients. Patient Care is the core foundation of any healthcare mission. Thus, doesn't it make sense to start the conversation by talking about our workflow in the ED and its impact on the rest of the hospital system??

Consequently, I feel that I have a new grounded purpose as I write this blog - to help provide some background and clarity for organizations to start thinking about their workflow in the ED. To understand workflow in the ED, we first must identify the interactions with ancillary departments, existing care delivery processes, and the competition for precious resources such as inpatient beds. These are all key factors that impact a hospital's ability to provide patient care to those who need it, when they need it. When portions of the workflow are "broken", gaps in existing care delivery processes can lead to elaborate workarounds. These workarounds may get the job done, but result in tangible costs to staff, physicians, and patients.

We see these costs as "symptoms" of an inefficient ED. Long wait times, extended door- to-physician times, and long waits for inpatient beds result in poor patient satisfaction scores, extended ED LOS, and excessive boarding of patients who may wait hours or days to get an inpatient bed. All of these dynamics clog the flow of work for patients in the ED. Just imagine what happens to a healthcare system when you add external forces such as the aging Baby Boomer population, and the lack of available qualified staff. The impact can be exponential!

I am sure that you have lots of questions which I will continue to answer in my upcoming blogs. In the meantime, I ask you to think about this: with all of these issues at play, how are we able to continually deliver the great patient care that we do? Wouldn't it be refreshing to have some help identifying the bottlenecks and breakdowns and systemically understand our current operations, in order to make decisions based on data - and not emotion - 'Why do we feel so exhausted or so full'? Our healthcare system needs solutions, decisions, and a toolbox that ultimately translates into increased capacity, improved quality, and actual dollar savings. These are the fundamental metrics of success.

This month, GE's Next Level web-site has added an ED self-assessment tool to help you focus on ED planning and workflow. If you are contemplating an ED build, expansion, or retro fit, take the readiness test to see how your planning process measures up. In addition, we will be hosting an upcoming series of blog discussions around ED operations and the possibilities for improvements through the use of evidence based tools. Until next time!

"Workaround Recovery: Curing Adaptable Waste in the ED" Blog Links:
Workaround Recovery: Curing Adaptable Waste in the ED - Part 2 of a 3 Part ED Series
Diagnosis - Change Fatigue! Part 3 of a 3 Part ED Series

For More Information:

Tool: Care Design: Emergency Department (ED) Assessment Tool

Case Study: New ED facility at JFK Medical Center a 'virtual' success even before construction begins

Case Study: Planning a new emergency department with confidence-Humber River Regional Hospital

Video: A focus on Hospital of the Future Implementation

HITECH success means going Doc by Doc by Doc

Wed, 02 Nov 2011 06:00:00 -0600

As you well know, the successful demonstration of meaningful use deadlines (as defined and required by the HITECH act) are drawing closer. And, if you are like many healthcare organizations, you are still struggling with adoption by certain physicians. In this day and age of disappearing margins and dwindling financial resources, you and I both know healthcare organizations must get this one right!

In my work this year with two organizations who are successfully implementing new electronic medical record (EMR) and Computer Physician Order Entry (CPOE) systems, there has been one significant mechanism for forward progress. I see the ability to identify and analyze stakeholders as the fulcrum to success.

Only, identifying and supporting key physician stakeholders presents a particular challenge. While nursing stakeholders can be engaged and supported as a team (because that is how they work in the real world), organizations will be successful by identifying and engaging key physician stakeholders by considering and supporting them as individuals, as that is the way physicians practice.

Success comes from mining a full list of physicians that are associated with your organization (employed or independent), and assessing them against four criteria. Do they currently have:

Poor computer literacy skills which may hold the physician back from successfully adopting EMR and/or or CPOE
Poor personal organization skills as demonstrated by large amounts of delinquent medical records or other elements of documentation
Poor attitudes toward the EMR system chosen
Or, an issue unique to the individual

If organizations find that any physician meets the criteria above (and this does not make them bad people by the way), they should immediately plan and implement a custom strategy to support that physician individually through their transition to EMR and CPOE.

I have found that up to 30% of physicians will meet at least one of these criteria - a surprisingly large percentile and a looming element of success or failure in meeting meaningful use requirements. Support might include computer literacy classes, identification and support for correction of medical record related issues, support for transitioning attitudes (what is a win for this physician?), and uniquely focused support related to unique issues physicians might be having. Analyze, identify, and create an action plan. Get to work now, as the goal line is approaching, and this is an investment you cannot afford to ignore.

Moving Target

Tue, 01 Nov 2011 06:00:00 -0600

During a recent discussion with a small group of radiology directors, the topic of CPT code changes came up. For one person in the group, her CT productivity reports had changed dramatically due to the combination of the abdomen and pelvis exams into a single CPT code. This change reduced reported overall CT exam volume by more than 25%. This new result was a challenge because department results were showing lower from this year than last, even though the amount of patient care had not changed.

When the established metrics change, it is very difficult for a manager to keep consistent records, trend prior performance and make meaningful projections for future year budgets. The scenario above is only a single and relatively simple example of what can happen in our environments. The lesson for the rest of us is to be proactive about what is measured and reported and to settle on stable and repeatable measurements.

While it is possible to make adjustments to these statistics, or add a footnote in a report, who wants to keep track of all of these changes over time? Not me, that's for sure. Further, how helpful is this data when it is exported to an outside benchmarking company? I have seen organizations perform labor intensive pre-processing of data using "dummy codes" before the data was sent out. Wouldn't it be better to have a simple download of data from a hospital IT system? I have always been skeptical of benchmarks that use some sort of generalized metric to measure the amount of work. I am not a fan of relative value units (RVU) as an example.

Far too often I see benchmark reports that do little else than refer to units of service and find myself questioning the definitions. Are they counting charges or are these the actual number of procedures. Even "procedures" can be a source of confusion. Does it equal exams, scans, or patients or none of the above? What's the best way to measure the amount of "work effort" and/or the time it takes to complete the diagnostic tests that are ordered?

To connect back to conversation mentioned earlier, even CPT codes as a basis of measurement, has proven fallible. I do see plenty of sound reasons to track and monitor this driver of financial performance, but not a as a proxy for productivity. I have my preferred basis of measurement and plan to share more on this topic in subsequent blogs.

As a conclusion, I am interested to know if you think there should be a universally accepted way to measure productivity in radiology, a way that would allow comparison to benchmarks and ultimately the establishment of best practices. Variation is something we have lived with in radiology, but lately I have seen this word come up more frequently and with a very negative connotation. Is variation the cause for our current "opportunities?" How are we going to address variation if we do not have a common measurement basis?