Sunday, December 28, 2008

Commitment is a Team Effort

“Emergency room waits are decreasing at some Massachusetts hospitals as they prepare to comply with a new state rule that, as of New Year’s Day, will prohibit swamped ERs from turning away ambulances.”

That is the opening sentence of a story that appeared in The Boston Globe on December 24 under the by-line of veteran medical reporter Liz Kowalczyk.

Paul Dwyer, director of healthcare safety and quality, is the state health department official who issued the order. He is quoted as saying “The key is commitment from senior management.”

That statement is correct but doesn’t tell the whole story. Specifically, it ignores the essential role played by people like Dwyer himself and reporter Kowalczyk.

The problem has not been so much a lack of commitment as a lack of public support for senior hospital management that undertook to involve itself in clinical matters and to go contrary to the historical physician/hospital bias against emergency rooms.

For example, the article mentions that certain hospitals now “[suspend] teaching rounds when the ER is overflowing and doctors are urgently needed to discharge patients on the floors.” In the not-so-distant past, no senior manager would have dared to have suggested such a thing.

What now allows senior management to demonstrate a commitment to improvement is the change in public attitudes exemplified by Kowalczyk’s reporting and Dwyer’s rule-making. This reporting and rule-making – also impossible not so long ago – converts the change in public attitudes into pressure on hospital trustees, causing them to charge senior management with responsibility for corrective action and to provide support in the face of any internal opposition.

People like Kowalczyk and Dwyer need to appreciate the role they play in all this. Their function of reflecting and forming public beliefs and perceptions plays a key part in enabling hospital management and governance to implement the reforms that are so greatly needed.

It seems that commitment, too, is a team effort.

Sunday, December 21, 2008

Levy Makes History

When you are in the middle of major change, it is easy to overlook what is happening.

Regular readers of this blog will know of my admiration for Paul Levy, President and CEO of Beth Israel Deaconess Medical Center (BIDMC) in Boston.

Traveling in the car the other day I tuned in to WBUR, Boston’s NPR station, and heard Paul being interviewed about the stated intention of BIDMC to eliminate medical errors within the next few years and the progress that has been made thus far.

None of this is a secret, having previously been covered in the press, but what struck me was his personally and publicly representing a major Boston teaching hospital on a clinical matter. Twenty years ago – maybe even ten years ago – that would have gotten him fired. In those days, clinical matters were the province of the medical profession.

The consequence is that you now have a non-physician hospital CEO who is accepting personal responsibility for the clinical performance of the doctors, nurses, and all of the other health care workers within the institution he heads.

Reaching that point is an essential element of health care reform. I wasn’t sure I would live long enough to see it.

Anyone interested in hearing the interview can do so by going to


Saturday, December 13, 2008

Academic Medical Centers and Dinosaurs

What if people come to believe that the health care services provided by their local community hospitals are better and less expensive than same services provided at big academic medical centers?

That possibility is being posed by a flap now going on in Massachusetts about how hospitals get paid.

It seems that Massachusetts Blue Cross and other insurance companies are paying premium rates to Partners and to Boston Children’s Hospital, both Harvard affiliated and generally perceived to be the crème de la crème of Boston medical institutions. Everybody in the area wants to be able to use them if the need arises, which the institutions use to their advantage during contract negotiations with insurance companies. The Boston Globe recently did an article on the subject (State urged to review fees to elite hospitals, November 20, 2008) and reported that the amount of the premium ranged from 15% to 60%. In other words, for the same medical treatments, Partners and Children’s get paid 15% to 60% more than other hospitals in the area.

The premium rates are based on the implicit assumption that the care is better. Quality is now being measured, however, and it turns out that the assumption isn’t valid. Data now available indicates that for the “ordinary cases” that constitute the vast majority of patients in these venerated institutions, the care provided by community hospitals is just as good – sometimes better.

The Globe article dealt with the economic implications of this, suggesting that paying a premium for care that is no better adds to the cost of care unnecessarily.

I’d like to raise an even bigger issue.

If people become convinced that the care provided in their local hospitals is just as good as that in the big academic medical centers, why would they pay more for the right to get that care in the more remote, more expensive place?

And if they wouldn’t, would that eventually turn those huge institutions in their present form into the dinosaurs of health care – great during their day but of a bygone era?

Monday, December 08, 2008

Another Cop-Out

AHIP got a brief splash in the news last Thursday for unveiling its health reform proposals at the National Press Club.

AHIP stands for America’s Health Insurance Plans, the health insurance companies’ national association.

I have not been able to find a copy of the proposals in the AHIP web page, but according to the newspapers (The Boston Globe, December 4, 2008) they “included recommendations for insuring everyone, containing costs, improving quality, and reducing administrative hassles for doctors.”

The article also indicated that the proposals were “stated so generally that the group’s president, Karen Ignagni, said they would be impossible to price.”

AHIP addressed the cost issue by proposing that “Congress should set a goal of reducing growth of healthcare costs by as much as 30 percent over five years….through steps including eliminating unnecessary treatments and paying doctors for better care, not more care.”

The proposals called for “improving the quality of care by devoting more expertise and money to preventive and wellness care, investing in more research to determine the best treatment protocols and providing this information to doctors and standardizing technology that is used to record and transmit patient information.”

What a cop-out!!

Here you have what ought to be one of the knowledgeable organizations in health care, well enough financed to support its projects properly. One would hope for it to provide some meaningful insights into how to go about fixing what are proving to be stubbornly intractable problems. Yet what it offers does not amount to much more than a package of slogans and platitudes.

So the proposals served the purpose of getting some publicity for AHIP and its president, but that is about all.

Health care reform will progress beyond the stage of rhetoric when hospitals and doctors devise better and more affordable ways to provide care. Nobody wants to suggest it but there is no other way.

Tuesday, December 02, 2008

Bottom Up and Inside Out

An alleged pneumonia together with the aftermath of a small, silent heart attack recently won me four Medicare-subsidized nights in South Shore Hospital in Weymouth, MA and two more in Boston University Medical Center in Boston.

I’ve been a hospital patient twice before, but what struck me this time was the mind-boggling complexity of it all. Hospital operations consist of unnumbered large and small functions performed in constantly varying circumstances and each related in some way to every other. As a result, if one of those functions is changed, nobody can be smart enough to predict or understand what the effect of that change will be in other parts of the organization.

What that tells me is that it is not wise to try to reform a hospital’s operation from the outside or from the top by picking particular things that look inefficient and then telling the hospital how to change them. The changes thus prescribed are likely as not to create even greater problems elsewhere in the organization.

Pressuring hospitals during recent years to make more use of information technology (IT) illustrates the point. Responding to that pressure, hospitals have undertaken to implement particular applications, only to find that doing so raises havoc elsewhere in the operation. Patches are applied, which turn out to have unexpected consequences of their own. Budgets and schedules go out the window. Sometimes the whole effort is abandoned.

No doubt the millions upon hundreds of millions that have been spent implementing IT in hospitals will ultimately prove beneficial, but the cost has been horrendous.

Hospitals shouldn’t be pressed to implement IT. They should be expected to improve their quality and reduce their cost and to learn how the potentially powerful tool of IT might help them do it.

The lesson here is that anyone who is serious about reforming health care operations should recognize that it is best done from the bottom up and from the inside out.

This page is powered by Blogger. Isn't yours?

FREE counter and Web statistics from sitetracker.com