Thursday, September 30, 2004

What Doctors (and Hospital Managers) Want (but Can’t Have)

The July/August 2004 issue of Healthcare Management included an article titled “What Doctors Want.” It dealt with the often-strained relationships that exist between doctors and hospital managers, comparing the situations in the U.S. and the U.K. Neither the results reported nor the authors’ recommendations for improvement were particularly surprising.

I did, however, find two comments both interesting and revealing. The first was the following quote from the March 22, 2003 issue of the British Medical Journal, which was devoted to this same topic:

“The fundamental problem is a paradox between calls for a common set of values and the need to recognize that doctors and managers do and should think differently. If managers suddenly became preoccupied with the needs of an individual patient, irrespective of the consequences for others or for their budget, then the health system would collapse. If doctors decided that their principal concern was to ensure the smooth running of the system and the delivery of policy irrespective of the consequences for the patient in front of them, then both the quality of care and public support would collapse.”

The second, as follows, was directly from the article:

“The independence of doctors from corporate control and the autonomy of doctors to admit patients to any hospital (where they have admitting privileges) and to be free to use any pharmaceutical, prosthesis, or medical device regardless of cost have been widely accepted values in American society since the early twentieth century.”

If one recognizes, as I do, that the realities of modern health care are causing hospitals and their managers to accept, however reluctantly, responsibility for supervising medical practice, then the traditional roles of doctors and managers as described in these two quotes cannot be sustained. Furthermore, trying to sustain those roles may well be the most important cause of strained relationships between them.

It is unavoidable that the needs of the institution and the needs of an individual patient will sometimes be in conflict. In practice, the conflicts are always resolved. In the traditional setting, each resolution emerges out of the particular characteristics of the doctor and the hospital and the power relationships that happen to exist between them. Predictably, the results vary widely.

The alternative is for hospitals and their managers to accept responsibility for managing both the institutional and clinical components of patient care, and to learn how to do so in ways that optimize benefits to individual patients and the health of the institution.

This approach is essential to bringing costs under control and achieving high and uniform levels of quality. It is central to the successful redesign of the health care system.

The medical profession understandably wants to maintain the professional independence it has enjoyed for so long. Hospitals want not to take responsibility for supervising clinical practice. Unfortunately, neither can have its want satisfied.

Wednesday, September 22, 2004

Ford on Patient Safety

The following is from Dan Ford. Some of you may remember a longer piece from him some months ago relating a personal story involving medical error.

I have frequent discussions regarding medical errors, physicians and leadership with executives in our industry. This includes many superb and well-qualified risk managers and others who are trying to do the right thing when unanticipated outcomes happen to patients. Their hands are too frequently tied in cultures with mixed messages, passive/resistant/non supportive CEO leadership, reticent physicians, traditional/historical staff behavior, the restrictive influence of insurance companies and legal counsel and the threat or reality of litigation.

As a search consultant, I have placed many hospital CEO's over the years, continue as a student of industry leadership and gotten inside the heads of many CEO candidates. I love this industry and am a strong industry supporter. There are many barriers, but there are CEO's willing to establish cultures of integrity and compassion in dealing with patient safety issues. My gut tells me we still have too many CEO's who are unable to establish true cultures of truth telling and accountability, genuinely believe they have such cultures, give lip service to such cultures, and/or may simply not understand that they are not personally heavily influencing positive human behavior inside their organizations --- even with a positive bottom line.

Some may have read the very thoughtful and pointed article by Nancy Berlinger in the Nov/Dec 2003 issue of the Hastings Center Report 33, no. 6, pp 28 - 36: "Avoiding Cheap Grace: Medical Harm, Patient Safety, and the Culture(s) of Forgiveness." She talks about 'avoiding the abuse of the unequal distribution of power between a physician and an injured patient, which may be further skewed by gender, race, income, age, culture, disability, or other factors. Relevant abuses of authority would include making a patient complicit in error by labeling her "non-compliant"; conflating error with "complications"; or taking advantage of a patient's religious beliefs --- "It was God's will" --- to conceal or minimize error.'

Having experienced this as a spouse, even as an industry insider, I can easily say that this behavior is very real. Unanticipated outcomes are going to happen, hopefully much less in the future with all of the positive changes taking place. Perhaps this playing field can be leveled with hospitals and physicians embracing accountability, telling the truth and doing the right thing.

This personal journey of mine, in giving patient safety presentations at the invitation of providers and serving on patient safety and quality committees has impacted my health care executive search practice. However, I am more than willing to continue to take this risk. Positive industry changes require people willing to stand up and constructively confront that which needs changing.

Thursday, September 16, 2004

Health Care – Planned Economy or Market Economy?

Nancy Schlichting, CEO of Henry Ford Health System (HFHS) in Detroit, has kindly allowed me to remain on the mailing list for her monthly Trustee Update publication.

The July/August 2004 issue reported a recent judicial ruling that appears to have cleared the way for HFHS to transfer 300 of its licensed beds to a new facility to be constructed as part of its existing ambulatory care center in West Bloomfield, a northwest suburb of the city. The ruling also allowed St. John Hospital and Medical Center to transfer 200 beds to Southfield – another northwest suburb.

The litigation arose out of Michigan’s Certificate of Need program, together with some specific legislation that permitted these projects. Several hospitals serving the northwest suburban area contested this permission in court.

Commenting on the decision, the Detroit News (Detroit’s conservative newspaper) stated that the judge had “sent a message to the health care industry: you can’t use state laws as a shield against competition.”

Of course, competition is precisely what Certificate of Need legislation is intended to prevent. This the Detroit News apparently understands, closing its commentary with the statement that Michigan should “scrap its out-of-date licensing rules.”

Redesigning our health care system requires that we address the question of whether health care should operate in a planned economy – the concept that underlies Certificate of Need – or a market economy in which hospitals would be in open competition.

The Detroit News straddled the issue by basing its opinion, at least in part, on the need for more hospital beds in the communities where HFHS and St. John’s propose to build – which is a planned economy argument. But if we are to have a market economy in health care – which seems to be the direction in which we are leaning – straddling won’t get it done. And if we are to have a market economy, we need rules for the game that accommodate the special characteristics of health care.

Physicians – Hospital Staff Members or Customers?

In commenting on its annual list of the 100 “Most Wired” hospitals, the journal H&HN (Hospitals and Health Networks, July, 2004) pointed out that in the most wired hospitals, “nearly 27% of medication orders are electronically entered by physicians.”

That caused me to wonder whether the airlines, when they went to computer-printed baggage tags, kept records on the percentage of their baggage checkers who used them instead of filling out the old ones by hand.

Not a fair comparison, you might object. A better one would be with the percentage of passengers who make their own reservations electronically and print their own boarding passes. No doubt that is a number the airlines watch very closely.

The difference of course, is that baggage checkers are staff members and passengers are customers.

In which category are the physicians who do and don’t enter their medication orders electronically? Are they staff members or customers?

The malpractice courts that regularly assess judgments upon hospitals for the mistakes of physicians and the various quality measurement agencies that rate hospitals act as though they are staff members. If they are right, then there is no excuse for anything much less than 100% compliance on entering medication orders electronically.

But H&HN (and, most likely, the typical hospital) acts as though they are customers who must somehow be enticed into entering their orders.

Uncertainty about whether the most important decision makers in hospitals are staff members or customers is a major barrier to meaningful redesign of our health care system.

It also goes far to explain why the dealing with the cost and quality problems in health care has proved so difficult.

Wednesday, September 08, 2004

Drake on Dysfunctional Hospitals

Responding to my comment that HHS might do more for IT in health care by getting hospitals to be better organized and managed, the following comment came in from David Drake, erstwhile AHA staff bigwig, now retired:

I agree with your statement about hospital management and professionals, but if you expect a federal bureaucracy to fix it, you're dreaming. The federal government is the only organization in America that is more dysfunctional than hospitals--markets not bureaucracies provide organizational efficiency and effectiveness. Unfortunately, hospitals and most other health care organizations and providers don't compete in an effective marketplace because of the way government has screwed up health insurance with its tax system and federal health programs.

Saturday, September 04, 2004

More on IT in health care

I see that in Modern Healthcare’s annual search for the most powerful people in health care, first place went to Dr. David Brailer, the national healthcare IT coordinator in the U.S. Department of Health and Human Services (Modern Healthcare, August 23, 2004).

It reminded me that for our recent trip to Europe, I was able to make our airline reservations, print our e-ticket, pay for it, and print our departure boarding passes – all in the comfort of home by means of my trusty little PC. Furthermore, while in Europe I was able to make a cash withdrawal from my hometown bank in Harlan, Iowa using an ATM machine in Moscow, Russia. I was also able to read e-mail and send some messages from a small Internet Café on an obscure side street in St. Petersburg.

As far as I know, none of that was owing to the efforts of any national IT coordinator working as part of a Department of the U.S. Government.

So how does it happen that we have one in health care?

I suggest that it is because of deeply rooted weakness in the way health care is organized and managed. If any organization is to optimally exploit the potential of IT, somebody has to be in charge. Hospitals being institutions with nobody in charge, productive use of the technology is limited to activities (like accounting and human resources) that are peripheral to their core patient care functions. Furthermore, health care managers are not operationally oriented. Instead, they live or die professionally according to how well they manage the internal politics of the organizationally amorphous institutions in which they work. Tinkering with patient care operations only raises political issues, of which there are always too many already.

If the Department of Health and Human Services was willing to address this problem, it might do a lot more to promote the utilization of IT in health care than by appointing a national coordinator.

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