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Something’s Gotta Give, Something’s Gotta Give, Something’s Gotta Give!

November 1st, 2008

My Facebook friend, Anne Zieger, editor of Fierce Health Finance, wrote a compelling piece the other day regarding the potential demise of hundreds of hospitals. Her prediction is based upon some very valid financial realities, and we are witnessing them locally as well as nationally. Not unlike the little banks in our area that seemed to have been insulated from Wall Street’s collapse, some of these national problems seem to be washing over some of the smaller hospitals with relatively minimal damage. Yes, many of us have seen as much as a 10% decrease in elective, outpatient procedures.

In fact, while visiting a really upscale mall for a photo session with my two year old granddaughter, Lucy, an employee engaged me in a conversation about the rotten economy. About five minutes into the conversation, she indicated that there are currently 150 stores in the chain for which she works, and that only five percent of them made budget last month. Portrait pictures must fall into the category of a luxury as their business is severely impacted by this economy. More directly, however, she indicated that she needed stitches removed the other day, and that, “she did it herself” rather than spend the $20 co-pay.

So, are we seeing decreases in important tests? Are we seeing patients avoiding emergency room visits? Are we seeing patients cutting their prescriptions in half? Yes, to all of these questions. Anne, however, seemed to be talking about the “big boys,” where their millions or billions in investments have recently tanked. If you are so big that your income from running the hospital is not a major source of protection, and your income from your investments is propping you up, then the problems begin to manifest themselves exponentially.

“Some hospitals are responding by digging into their investment income more deeply than usual, using it to finance capital projects, or even meet operational needs. Others are issuing bonds with the scary codicil that they’ll buy them back if finicky investors want to dump them,” states Zieger in her column.

She further goes on to explain that “both of these situations put a huge squeeze on hospitals’ long-term viability. One robs from their long-term assets to solve medium-term problems, while the other puts the hospitals at risk of being bled dry by investors who get spooked.”

Well, wouldn’t ya know? Yes, we are seeing a few challenges due to decreased electives, but not because we were living off of our investments. The other good news is that, because we froze our fixed pensions several years ago, we are seeing very little impact upon them from the huge drop in those investments as well. Unlike many of our larger peers, neither of these issues is similar. Between the drops in the market, the loss of pension funds, the decrease in electives, and the down-grading of their viability by the bond markets, their challenges look galactic in size compared to ours.

Sometimes smaller is just safer.

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Posted in Healthcare, Hospital, Hospital Administration, Hospital Blog, Hospitals, Integrative Health, Leadership

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Quality of Care

July 31st, 2008
Back in the 70’s, competitive marching bands came into vogue in Western Pennsylvania. Let me explain the before and after of this phenomenon: Before there were competitions, bands were made up of nearly 10 times more students than they typically have today. My bands ranged in size from 120 to 185 students. Once competition came into play, the borderline students were not able to survive. Consequently, it is not unusual now to have 20 students or less in a band.

Steelcity_border

What’s happening in medicine and in health care overall? The Government is taking a three-pronged approach to improve quality in health care:

1. They are pushing quality through public reporting. (Check a website near you.)

2. Enforcing quality through the False Claims Act. (Check a prison near you.)

3. Incentivizing quality through payment reform. (Check a checkbook near you.)

Senator Chuck Grassley is quoted as saying, “Today, Medicare rewards poor quality care. That is just plain wrong, and we need to address this problem.”

HMO’s are currently embracing “pay for performance” plans for physicians and hospitals. Medicare is introducing value-based purchase plans. Medicare is proposing the linking of quality outcomes to physician payments.

As I have written before, hospitals will no longer be paid for hospital acquired conditions. That seems like a rather simple fix, but to appropriately determine if the condition was not acquired at the hospital, extensive testing must be added pre-admission at considerable costs to the hospitals.

James G. Sheehan, Medicaid Inspector General of New York said, “We are reviewing assorted sources of quality information on your facility to see what it says and if it is consistent. You should be doing the same.”

Except for the financial implications, not unlike my competitive band story, the goal was to work toward perfection. The public reporting of quality of care is intended to:

1. Correct inappropriate behavior

2. Identify overpayment’s

3. Deny payments

KirkOgrosky
The False Claims Act, on the other hand has different goals. When asked how he viewed the False Claims Act, Kirk Ogrosky, U.S. Deputy Chief for Health Care Fraud said, “You will see more and more physicians going to jail.” I guess the prisoners will be receiving better care.

Where’s it all going? Competitive band. Will it improve health care delivery? Probably, for the patients who can find the few docs and hospital that will be left? I recently had a conversation with a young computer specialist who took care of physician practices. He said, “Doctors and hospitals haven’t figured it out yet, but they are simply becoming data entry centers for ‘Big Brother’ as the facts and figures are accumulated to be used against them any way the payers decide to move forward.”

Looking back at the school year that included gym class twice a week for the entire year, rich courses in music and art, and remembering a time when priorities included those classes intended to make every student well rounded, we have to ask, “Is education today better?”

Maybe this is all too complicated to get our arms around, but if there are 78 million Baby Boomers, and the Medicare Trust Fund is heading toward bankruptcy, then we probably will see every rule in the book being applied to keep from paying out money, because there is simply not enough money to go around.

Will health care improve? Once we understand that technology is not the end all and cure all that creates healing; once we endorse prevention, wellness, optimal healing environments, and systems approaches to health and wellness, health care will improve. I’ll bet you that it will have very little to do with the rules that are unfolding right now and much more to do with the creation and acceptance of a National Health Policy.

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Posted in Boomers, Healthcare, Hospital, Hospital Administration, Hospital Blog, Hospitals, Integrative Health, Medicaid, medical errors, Medicare, Music, Wellness

A Time to Reflect On Life

June 15th, 2008

With the passing of Tim Russert, we are all made critically aware of the fragile nature of life and our need to embrace every moment as a gift.  Obviously, within a split second, every aspect of our lives can change, and, as in Mr. Russert’s case, can end.  This is not a blog about instant death, and it is not just about recognizing our mortality.  It is about preparing for our passing carefully.

Russert
Liz Szabo, a writer with USA Today described in a recent article the cancer patient experience by saying, “Patients with advanced cancer often don’t know how long they have to live or how chemotherapy will affect their lives.”  According to a study by the Journal of the American Medical Association, many physicians either don’t give patients that type of information or the patients only “hear what they choose to hear, or very often misunderstand what is said to them.”

This situation often leads to patients requesting incredibly disruptive and sometimes painful therapies that have no hope of succeeding.  According to the study, more than 20% of Medicare patients who have advanced cancer begin a new chemo regimen two weeks before they die.  Many times patients are admitted to hospice days or hours before they die.

What has been observed in cases like this was that the patient often misses the opportunity to repair relationships, get their spiritual house in order or even prepare the necessary documents such as advanced directives.

Where is this going?  Sarah Harrington, an assistant professor at Virginia Commonwealth University School of Medicine in Richmond, co-author of the quoted article, indicated that “in the last few weeks or months of life, a lot of good work can be done.”

One of the points brought up in the article was that only about 37% of physicians told patients how long they had to live. This fact was not surprising to us because we have seen dozens of patients who were admitted to hospice over the years return home and live several more months or years. This particular prediction is not always dependable. The other fact quoted in the article, however, was that many patients learned more about their cases from other patients than from their physicians.

The article concluded with the suggestion that “patients and their families may have to take the initiative in finding answers to important questions.”  Thomas Smith, co-author and Chairman of Hematology and Oncology at VCU’s Massey Cancer Center suggested that the following questions should be asked by any patient in this situation:   What are my options?  Can I be cured?  Will I live longer with Chemo?  Should I consider Hospice or Palliative Care?  Who could help me cope?  What do I want to pass on to my family to tell them about my life?

Eldercare_visit
Palliative care is not limited to cancer.  All end-of-of life diagnoses qualify patients for hospice and palliative care.  Tim didn’t need or have this opportunity, but for those who do, embrace it. The primary thing that can be delivered to the patient and their family is the comfort of having caregivers dedicated to helping you move through your transition.  It is what they do.  These amazing people, volunteers, employees and physicians are dedicated to “paying it forward.”

So, as we eventually face our own mortality, as we evaluate what it is that we want to share with our families, as we consider the legacy that we wish to leave, having a clear mind and looking to those professionals who can help us is not only necessary, it is imperative. This transition can come in the blink of an eye.

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Posted in Boomers, Healthcare, Hospital, Hospital Administration, Hospital Blog, Hospitals, Medicare

Managers, Smanagers…It’s Over

April 17th, 2008

Kenneth Cloke and Joan Goldsmith wrote a very interesting book entitled The End of Management. In this book, they assert that managers are the dinosaurs of our modern organizational ecology. They go on to assert that the “‘Age of Management’ is finally coming to a close.”  Their treatise is that “the need for overseers, surrogate parents, scolds, monitors, functionaries, disciplinarians, bureaucrats, and lone implementers is over. . . ”

End_of_management_cover_2If, by now, you managers are wondering what comes next, our authors assert that the new need, the true need in modern day business is for “visionaries, leaders, coordinator coaches, mentors, facilitators, and conflict resolvers.”

In a recent conversation with an “old school” manager/friend, I reached out to explain to him why he was alienating his subordinate.  I explained very carefully that management as a self-contained system fails to open the heart or free the spirit.  This approach has truly taken our organization to new heights.  Of course, one can only work within one’s comfort zones, and many managers, especially, old school managers, only know one approach, and that is, the industrial revolution way.

Let me suggest that you analyze the quality of the individuals with whom you work.  Then, step back and realize just how amazing those individuals are with “butterfly” qualities.

Do not penalize your charges because of your insecurities.  Build a team that “has your back” by empowering them to be all that they can be.

The revolution quoted by Cloke and Goldsmith is one of “turning the inflexible, autocratic, static, coercive bureaucracies into agile, evolving, democratic, collaborative, self-managing webs of association.”  From our perspective, the object is to allow those butterflies the freedom to fly.

How do you manage a butterfly?  Work together on the goals and then get out of its way.  Provide it with just the very basic, fundamental needs and goals of your organization, and then trust it, love it, empower it, and encourage it.

If I could possibly find one example that would clearly embrace our success as an organization, it is that of doing everything possible to kill “parent to child management.”  It is not enough to move into the 21st century with our thinking; it is most important to identify those individuals who get it and then give them the space “to do it.”

Are they traditional?  Do they do everything the way you were taught in the “dark ages of the industrialized style of management?”  Nope.  Will it drive you crazy when you look for them, and discover that they are not on the flower where you expected to find them?  Sometimes.  Will they accomplish more than you have ever dreamed if you treat them with dignity, respect, love and freedom?  Oh, yeah.

You see, it is not about control.  Control is only necessary for those who are not trustworthy.  Better than trying to control a non trustworthy individual, simply help them find work somewhere else.  If they don’t get the mission, don’t understand the philosophy, and don’t work to their capacity, they shouldn’t be there.

On the other hand, if they are loyal, trustworthy, committed, and caring, back off and allow them to soar, and you will never see results of the kind they that they will deliver to you or your organization.

If they look at it as a job, if they are only comfortable with myriad rules, time clocks and books of policies, they are stuck in the past.

Leadership means trust.

The End of Management, Kenneth Cloke & Joan Goldsmith

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Posted in Books, Healthcare, Hospital, Hospital Administration, Hospital Blog, Leadership

Random Thoughts. . . Learn From Your Mistakes

March 21st, 2008

Make sure you know the question before you give the answer.

My kids taught me a lot about this job. At age seven, my son said, "Dad, where did I come from?" I knew that question was coming, but I had not expected it that soon. "Son," I said, "Let me explain about life" As I began my meticulously rehearsed tale of the birds and the bees, I slowly explained the nuances of life, love and more bees.

I was perspiring profusely as I stumbled over these sensitive descriptions. After about ten minutes of squirming, stuttering and stammering I said, "Do you understand, son?" To which he turned to me and said, "Heck, Dad, I knew all that stuff. I just wanted to know what hospital I came from, Mercy or Windber?"

Learn to share.

Hospitals deal every day in life and death issues. They are extremely complex and multifarious places. Emotions can run very high as well as we deal with the challenges and mysteries of life. Helping people to share has been a very large part of my life. Helping them to share resources, time, space and all aspects of life is a very important contributor to our success as both care givers and human beings. When I was eight, my Aunt Mildred gave me three pieces of bubble gum. As I was walking home with all three pieces stuffed into my jaw, a group of kids jumped me, pinned me down, took my gum right out of my mouth and divided it up between them. It would have been a lot easier on me if I had just kept a few pieces out to share.

Finally, don’t repeat it if you don’t understand it.

In any organization there always seems to be someone who takes great pleasure in telling the story when they aren't really sure of its meaning. After standing near Jack, a 15 year old sixth grader at school one day, my vocabulary expanded exponentially. He talked about mysterious things that made no sense to me, but he was big and I was small. In my world, that meant that Jack knew all. That night when my mom told me, the little third grader, to get ready for bed, I looked up at her standing beside my grandmother, aunt and dad and said, "I don’t have to go to bed, you @$#%&*$@!"

My limp cleared up right before I had to walk across the stage to pick up my college diploma thirteen years later.

Learn from your mistakes.

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Posted in Children, Healthcare, Hospital, Hospital Administration, Hospital Blog, Leadership, Motivation, Weblogs