Do we dismantle the hospitals?

The Globe and Mail. (2014). Why the future of health care may depend on tearing down the hospital. [online] Retrieved from: [Accessed: 24 Feb 2014].

The article is about tearing down the hospital in favour of a network of community health-care centers.  It gives an example of a patients with comorbidities who had been in and out of the hospitals several times.  The argument being given is that the current system hasn’t helped the patient in long-term remission and the whole ordeal has been costly for the system.  The article further states that the current health care system is acute care centric and offers no additional benefits to such patients.

I would agree with the latter part, but we do need to have an alternative in place before we start tearing down these hospital.  What would have happened had there not been that tertiary care hospital?  Is our community based infrastructure ready for such patients? 

Further, the article talks about how such patients get caught up in vicious cycle of deterioration at home, only to return to the hospitals.  I would argue that this is what the hospitals are meant for.  Treatment in the community is best left for such diseases which can typically treated in ambulatory settings.  Patients with such comorbidities cannot be treated successfully in community hospitals, let alone in community health care centres. 

The article again brings to foreground that various innovative physicians have a solution, which is getting rid of the hospital to begin with.  They argue that their community based model will provide services such as physiotherapy, social workers etc.I would argue that before we think of that, we must have an alternative ready and successful.  There is no guarantee that such drastic measures will bear favourable results.  The unfortunate part is that the proponents of community based model are targeting the kind of patients that need the hospital setup the most. 

There is an argument put forward that channelling money towards home and community care without dismantling the hospitals would be counterproductive.  As this is something that will only increase the costs.  I would consider such a suggestion quite preposterous.  How can one do away with hospitals without any kind of alternative in place.  As all would agree, the transition away from the hospital has to be gradual and calculated.  The proponents, however, believe that there are many services, like tests, that cannot be administered from home, thereby contradicting themselves.  I would suggest that efforts should be made to use telemedicine more effectively in conjunction with home and community care, before efforts are made do reduce burden on the hospitals.  The articles does agree, however, that just spending money on home care won’t deliver desired results unless it is coupled with services to fully integrate the system.

The article gives an example of how the paramedics had take an intoxicated patient to the hospital, and by the time he could be admitted, he had already recovered and walked off the emergency.  I would recommend that the proponents of the community model should rather me concentrating on such patients.  We need to explore why paramedics couldn’t have taken such a patients a community based organization in the first place. 

The articles gives an example of a clinic in a homeless shelter, which welcomes patients brought by police and paramedics.  It goes back to the previous example, and elaborates how their small venture has expanded to more beds for homeless, and provide services of nurses; personal-support workers; additions; counsellors; and social workers.  I believe this would be a great starting point of integration and shouldering responsibility, rather than big ticket comorbidity ones. 

The article highlights another set of opinion that presence of a hospital based system prevents any innovation from taking place in the community.  I would argue that it is not hospitals’ fault, but lack of culture of innovation in the system.  Also, the impression in the public is that hospitals are meant for emergencies or serious conditions.  I really wonder how many really go to hospital out of choice?  I believe here lies the opportunity for making the Community Health Centres (CHC) more visible.  There should be an effort on their part to reach out to the public.  After all, do people even know what all services are available at their nearest CHC? 

Further, it elaborates on a particular shining example of innovation in community based settings at a Family Health Team (FHT).  I believe that here lies an opportunity for creating a governance structure to share such ideas.  I am not sure, but I would take the liberty of recommending this to the Association of Family Health Team of Ontario (AFHTO) to take up a leadership role in this regard.  At the time, involved LHINs so that they are aware of the ground situation, and gauge and plan any move from hospital to community sector.     


Financial efficiencies

Was reading Doing More With Less by Susan Birk in May/June 2012 edition of Healthcare Executives.  I won’t delve into why it is so important because we all know it.

Talking of structure and efficiency,  as healthcare organization move towards value-based system, two pathways become very critical: cost management and cost structure.  Cost management or efficiency pathway would mean being more efficient in what we do and not cut down the scope of services.  Cost structure pathway would mean reassessing the strategic objectives to derive efficiencies by altering size and scope of services.  It may involver consolidation of services at one place and other structural changes.  The latter approach has not been explored that much in healthcare sector.  The reasons for this are political, as patients, staff and physicians would resist change.  It is generally advised that the organization start off with working on cost efficiencies, as this will create groundwork for further change.

As a step forward to better integrate their services and to reduce cost, organizations can reduce their non-core assets – services and facilities.  The question that comes to mind is what is core and what is non-core.  Core would be activities through which more of the care pathways pass.  Non-core won’t be in line with the strategic goals, and would be something that easily handled by somebody else.  Organizations can easily divulge non-core activities, and dedicate all their resources core activity.  The article contends that more tightly the providers are able to integrate the decision making related to cost structure and management with strategic, operational and capital allocation planning and management, the more effectively they’ll be able to use resources and keep cost under control.

Another important parameter of cost is overcapacity.  It is important to measure historical and future trends so as to balance the capacity.  That can be done better if there are means to measure.  Overheads are hard to measure as they depend of expected demand.   Ways can be found by calculating true cost, measuring appropriateness, and then determining the rationale behind continuing those services.

The article takes example of University of Alabama at Birmingham Hospital.  It emphasizes the point that cost cutting efforts should be enterprise wide, and not department wide.  Else saving at one place might be counterproductive at the other.  It further goes on to day that any cost cutting efforts coupled with maintenance or improvement of quality, should involve both clinical and financial leaders.  It should be communicated upfront that cost cutting efforts are not at the cost of quality.

Talking about Faxton St. Luke’s Healthcare, they believe in creating a sustainable model.  Where sustainability and accountability work in tandem.  The idea is to use LEAN and Six Sigma based performance improvement initiatives as cost management activities.  This in turn is hardwired to their corporate goals, and cascaded down the leadership as their individual goals.

Aviation & Healthcare : Polish President Air Accident

Just finished watching an episode on Discovery Channel about aviation disaster in Poland, in which their President died.  The scenario looked so similar to errors in healthcare, about which I was reading today itself.  In that incident a Russian made plane crashed while landing at a Polish military airport.  It was flying low and brushed over trees and overturned and crashed before it could touch the runway.  It was foggy and the pilots were faced with very poor visibility.  Now, I will highlight the errors that were made on that flight

  1. Their altitude indicator was not working properly.  From the flight data recorder it was found that they were flying lower than what their instruments told.  It was found that as it was a military airport, its elevation above ground was not in plane’s database.  On top of that the pilot had deliberately set the elevation a bit higher, to avoid “nuisance” warning that go off when the plane is dangerously low.  A sure sign of over confidence by probably the best trained pilots.
  2. From the cockpit voice recorder they found that there was some unauthorized person in the cockpit.  Most likely it was some senior official as it was a VIP flight.  It could be concurred that that person was putting indirect pressure on the pilots, adding to their stress.
  3. Also, the captain of the plane was also doubling up as navigator, which added to his workload. 
  4. In addition to the altimeter, which was faultily set, the navigator also had radio altimeter.  Investigators wondered why the faulted when they had redundancy in the form of radio altimeter.  They later found that the plane encountered a valley on its approach to the runway, and then sudden elevation.  That fooled the pilots into believing that they were flying high when they were not.
  5. The investigators also wondered why the captain didn’t decide against landing in such weather, even thought it was his final call.  They wondered that he was under indirect pressure from officials in the cockpit.   Also, he has had a previous experience as a co-pilot, where the captain refused to land a VIP flight due to safety, and the latter was reprimanded for it.  Surely, this thing was lingering in his mind and didn’t want anything to affect his career.
  6. They wondered why the air traffic controller (ATC) at the airport didn’t warn the pilot against landing and suggest a go-around.  It was later found that the instruments at ATC weren’t working properly.  More importantly, even though ATC was acutely aware of the risks involved, they didn’t have the authority to divert the flight.  Had it been any other flight, they would have, but not the one with VIP onboard. 

Now coming to similarities with errors in healthcare industry.  This seems to be a classic case of “Swiss cheese” theory, where multiple errors, all happening at the same time and redundancies not working.  Interpreting each point individually,

  1. No matter how well trained and experiences a professional you are, you must not ignore the safety built into standard operating procedure.  Errors often happen by most experienced people, as less experienced exercise caution.
  2. This point emphasized the importance of stress-free environment at workplace.  Like aviation, efforts should be taken in hospitals such that staff does not get stressed.  Also, management should leave the technical stuff at the hands of the experts, and be in a more of a supportive role.
  3. Efforts should be made such that workload is evenly distributed among workforce.  In LEAN terminology, it is called leveling.
  4. It is again a case of Swiss cheese theory, where two holes were aligned and they contributed towards the accident.
  5. Clubbing point 5 & 6 together:  There was indirect pressure on both pilot and ATC.  Unlike the workers of Toyota Motor Co, who are empowered to stop the production line, they had no say in such a critical matter.

Ultimately, errors happen when redundancies built in go wrong and it is too late to act.

Trust & Confidence: Does Your Board Have These In You?

Was reading John M. Buell’s article in Healthcare Executive Sept/Oct 2010 edition about to develop health relationship between CEO and the boards. 

As we all know, board’s focus has changed over the years from philanthropic and financial oversight to bringing in expertise, accountability and community focus.  As the background of board members becomes more complex, gaining their support has become critical.  In light of this CEOs should embrace this change with positive attitude and should see this as an opportunity to seek support from more experienced people.

It is imperative that CEO keeps open and transparent communication with the board members, especially when it related to negative outcomes in future.  It generates some discussion, and helps prepare board for underperformance in future, and also serves the purpose of board education.  If the performance isn’t as bad as projected, then all the more better for the CEO.  So, always better to set right expectations.

Also, regular ongoing interaction with board members will help alleviate the fears that they will not treat underperformance fairly.  A well qualified board is generally aware of the complexities of managing an organization, and an atmosphere of open communication will further alleviate CEO’s apprehensions.

While communicating consequences of any initiatives, one would naturally communicate the benefits, but one has to convey the potential risks and downsides as well.  Any pointed question from board should be seen as an opportunity.  A full discussion on every aspect will help, as there would be no false expectations.  And there will be a level of comfort on both the sides.  While communicating the risks, it will be helpful if risk management strategies are discussed as well, even in brief.  This will convey the message to the board that the management is in control.  CEO shouldn’t be afraid that board will micromanage.  If there is great working relationship and the latter is well informed, they’ll not.

CEO don’t and are not expected to know all, and they shouldn’t convey to the board that they do.  Instead, they should be upfront with the board that they don’t know and why they don’t know.  Taking further they should both work together to be ready for unknown.  As quoted,

“By doing this, you make the board a strategic partner and have board members own some of this uncertainty, Trustees will be more forgiving, understanding and empathetic is something doesn’t go according to plan because they will be in the same position as you.  CEOs can use this sharing-the-uncertainty approach to their benefit and change the relationship for the better.”

Once the trust is established, it is needed that board members understand their roles.  This can be done via formal or informal board education.  Formal board education can be done via some short educational programs or having a consultant come in.  Informal education can be an ongoing process, at every interaction or meeting.   Board Chair can be taken into confidence whenever some course correction is needed during meetings or otherwise.  

The expanded role of board has given rise to specialized role of its members.  It may look like micromanagement, but it in fact is “microgovernance”.  When we talk of microgovernance, we mean committee structure that takes care of specialized duties like audit, patient safety & quality, community engagement etc. 

Taking example of St. Vincent Health, Indianapolis, the article talks about the ideal size of the board.  Such that members are fare mix of expertise and the number is large enough such that they can form various committees.  Also, board shouldn’t be too large such that meaningful discussions and engagement is not possible.

At Hartford Healthcare System, they give a lot of emphasis on board being constructive.  The key lies in through selection process such that only those focused on organization mission and vision are selected.  Once selected they prefer to spend good deal of time with members as it helps CEO understand their perspective and their level of expertise.  This would give the member an opportunity to develop understanding of challenges, something that cannot always be done at the meeting.  The personal relationship developed during one-o-one meetings will help the CEO speak in language most members understand.  Similarly, opportunity should be given to members to mingle and know each others perspective. 

Even after all due diligence, it is not necessary that all the steps taken would be correct.  But, as this statement puts it so aptly,

“And when a decision turns out to be unsuccessful, as the CEO I would rather say to my board that we figure out a solution together and make corrections.  Having the board help in figuring out the answers places me in a much better position that if I had claimed to have the answer and discovered the answer was wrong.  Having a board that challenges your thinking but also stands by your decision is the ultimate scenario for an effective board-management relationship.”


Dealing with B Team Members

Was reading Thom Mayer’s article in Healthcare Executive Sept/Oct 2010 edition about how to deal with B team members, and he makes important observations.  He quotes former CEO of Southwest Airlines, Herb Kelleher that it is more important to make employees happy, as that is how customers will be happy.  Carrying this point forward, the questions comes how to deal with Team B in your hospital.  By Team B, we mean those who are negative, reactive, constant complainers, and all that makes them underperformers. 

He uses the phrase “holding up the mirror” to describe the first step in dealing with such members.  In every likelihood they don’t even realize the importance of the actions.  The next step, which is counseling these members, is a real challenge.  The general approach is to begin the discussion with something positive, then give the bad news, and finally end the discussion with a good new.  It may should savvy and diplomatic, but the staff members walks out of the meeting confused.  The recommended approach is the decide beforehand what is to be conveyed, not to exchange pleasantries as it a business meeting and present facts.  This way the staff member will realize the seriousness of the meeting.  This meeting should be clear and concise, and should include attribute or behavior followed by Team A members.

In addition, such members should be buddied up with Team A members.  And lastly, leaders should have courage and conviction to replace B members who cannot make a transition to A. 

Leadership Skills for Healthcare Reforms

Was reading Tom Dolan’s article in Healthcare Executive Sept/Oct 2010 edition, about changes PPACA and the changes it will bring.  He talks about five broad points.  Even without the new legislation, these points do hold ground.

                        1. Mastery of change management and change leadership:  No matter how big a change, there are are few things that healthcare executives will always need.  They are change change management and change leadership.  Change management is the technical component of strategy and to be able to oversee their implementation.  This would include how the methodology is being applied to various initiatives, and whether staff are trained in it.  Change leadership is the human component of it, which is the belief in change management.  It includes realization and communication of negative fallout of not being able to change.  I believe this culture of reacting to change should exist well before any changes comes our way.  Else, it is just too much work in too little time.  If we are not used to coping with small changes, how would we to a big one.
                        2. Continued quality and patient safety efforts:  As we know quality and patient safety is raison d’etre of hospitals.  It is imperative that boards and senior management should be behind any effort in this direction.  If they’re not by choice, then they’ll have to be by compulsion.  It is important that executives are familiar with the tools.  What is more important is that they create an atmosphere where staff are motivated enough to find shortcomings.  They should be able to report without the fear of retribution, and have confidence those points will be looked into.  In fact there should be incentives in place for finding the most critical shortcomings.  And recommendations for all shortcomings should be made a part of standard operating procedure and effectively communicated.  Executives should ensure that the cycle goes on.
                        3. Productivity: As important as patient safety, is increasing productivity and controlling costs.  As we know healthcare is a very different kind of industry, and so it must not be at the cost of care.  Also, it must be determined how benefits gained via increased productivity are channelized.  Benefits gained in terms of executive time and resources should be deviated towards something strategic.  They could be diverted towards being price competitive, or spending time and resources becoming even more productive.  Few of the tools being used these days are Lean, Six Sigma, Predictive Analytics etc.
                        4. Public Policy: Healthcare executives are invaluable in public policy formulation.  They have access to invaluable information from their staff and community agencies. 
                        5. Interpersonal Skills: They form the cementing medium of above mentioned points.

Developing a Culture-Based Workforce: Top Healthcare Workplaces Share Best Practices

ref: Developing a Culture-Based Workforce: Top Healthcare Workplaces Share Best Practices

Needless to say how important is it to have a positive work environment, and how it impacts patient experience.  Carrying forward from the previous article about how to move from culture of accountability to execution, here we talk about the essential component that is employee motivation.  There would be the five best practices to built “culturally united, team oriented employee base”.

  1. Establish an employee culture and hire based on fit:  It is relatively easy to articulate values and communicate among employees.  What is more important is believing in them and breathing them day-in and day-out.  Else, they’re mere slogans and rapidly fade away.  In same vain, there is no point in lecturing new hires during orientation, unless such a thing exists on ground.  Key is management is true belief it in, and then it propagates naturally.
  2. Encourage employee referrals: Yes, word of mouth publicity does help to propagate culture, but if done in excess it can be detrimental to work environment.  Care should be taken that referrals are not hired at the cost of best talent.  After all, there are other ways to communicate how current employee feel.  I’ve seen hospitals using their website quite effectively to convey positive statements from staff and patients.
  3. Developing profiles of successful employees:  Developing profile not only helps prospective employees, but also conveys the message to current one about what it takes to be successful and be recognized.  It is imperative that profiles are carefully selected, such that they convey the kind of values hospital wants to propagate.
  4. Engage current employee in the interview process:  This would be the next logical step once the hospitals values are clearly articulated, communicated and tested.  Once we have employees who truly believe in them, they can be asked to be part of the interview process.  That way they’ll be better able to hire those who can fit in.
  5. Keep culture as a priority past the hiring process:  Employee culture should not be restricted to interview process and orientation.  It rather be well past that, else new employee will become disillusioned.  That’s why it is all the more important to have the culture in place, well before we allow current employee to find their kind.