Sunday, November 09, 2008

What Was Management Doing?

We seem to have a hard time accepting that if our system of providing health services was managed, it might cost less and outcomes might be better.

The Beth Israel Deaconess Medical Center in Boston has a program called BIDMC Spirit. Employees are invited to “callout” any situation that they believe might put patients at risk or is unnecessarily costly. The “callout” is reviewed and, if it is accepted, a team is formed to work on improvement. Many hospitals are doing something similar.

The CEO of BIDMC is Paul Levy, in my mind one of the stars of health care management. He is an enthusiastic supporter of BIDMC Spirit. Paul operates his own blog (www.runningahospital.blogspot.com) in which he periodically reports successful BIDMC Spirit projects.

The most recent one had to do with the process of getting specimens from a GI procedure room to the lab. The “callout” was made by one of the persons who transported the specimens and a team was put together to work on improvement..

The results of the team’s efforts as reported in Levy’s blog were as follows:

-- A reduction of 57% in the amount of time between when a specimen was ready for transport and when transport arrived to pick the specimen up.
-- A reduction of 61% in the time it took to transport specimens to Pathology.
-- Freeing up of hours of transport time/day without sacrificing the safety associated with this task.
-- Much improved workflow for the pathology techs.
-- Improved communication between nursing and physician staff, further reducing instances of mismatched information between the specimen label and requisition.

All of that is great and everyone involved is to be congratulated.

But one might ask what management was doing during the goodness knows how many years the cumbersome and wasteful process was in the making, and why nothing was done about it until a lowly transporter pointed it out.

The answer is found in the way hospitals are organized and operated. Most likely the GI procedure room is part of the Department of Medicine and the lab part of the Department of Pathology. The process of requisitioning, labeling, recording and moving specimens overlaps the two. Medicine and Pathology are clinical departments in which management does not ordinarily interfere. The only person with executive jurisdiction over both is somewhere high in the clinical hierarchy. The practical effect is that nobody takes day-to-day responsibility for these interdepartmental processes which accrete inefficiency until something like BIDMC Spirit comes along.

That is an example of the sort of thing that has to change if we are to have meaningful reform in health care.

Saturday, November 08, 2008

An Unrecognized Conflict of Interest

Some years ago I was told by a friend working in its health care benefits section that General Motors prohibited its executives from serving on local hospital boards. The reason was that it did not want to be obligated to contribute to fund drives in support of hospital construction that it believed to be unnecessary and drove up the cost of health care.

Earlier this year I learned that Massachusetts Blue Cross Blue Shield unsuccessfully sought the support of large employers in opposition to the large increases in reimbursement being sought by local hospitals. The apparent reason was that the senior executives of those firms or their spouses were on the boards of those hospitals.

What these stories illustrate is a conflict of interest that exists when executives of companies providing health benefits to employees serve on the boards of hospitals that serve their employees. The same would be true of their spouses.

The conflict is this: as company executives, they are responsible for holding down cost. As hospital trustees, they are responsible for increasing income. Those two purposes are in direct conflict with one another.

In the days before employer-provided health insurance when hospitals were financially dependent on philanthropy, it made sense to populate their boards with potential donors, a group that would include merchants and industrialists.

But those days are long past and while hospitals continue to seek philanthropy, they have to live off of income received for services rendered.

The so-far unrecognized implication is that executives of companies providing health care benefits to employees and their spouses ought to be disqualified from serving on hospital boards because doing so constitutes a conflict of interest that makes it more difficult to control the cost of health care.

Thursday, November 06, 2008

Reform is Nobody’s Business
Waste in health care was the subject of a 10/22/2008 Boston Globe Op-Ed piece by James Roosevelt, Jr., President and CEO of Tufts Health Plan, a major Boston HMO.

Roosevelt set out in grim detail the major factors contributing to that waste, which he claims accounts for about one-third of all health care.

At the beginning of his article he said that if such a situation were to occur in a major business, “Everyone from the company’s board members to its shareholders would be outraged.”

At the end, he assigned responsibility for doing something about it to “All of us – consumers, government, industry, and the health-care community….”

If anything significant is to be done soon to correct this situation, the assignment of responsibility for doing so will have to be more specific than that.

As the old adage has it, what’s everybody’s business is nobody’s business.

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