Archive for the ‘Hospital’ category
In Their Own Words: Patients, staff and physicians on their experiences at Nick’s Planetree hospital
October 5th, 2008Think Global and Act Local
October 1st, 2008Over the years people who’ve liked me have referred to me as a real visionary, but, in all fairness, the people who thought that I was an incompetent also called me a visionary. One group called me that as a compliment. The other group used the description as a put down. Considering that my physician discontinued my prescription of Atromid S medication back in the late 70’s because he said the it caused early cataracts, I’m not all that sure about my actual vision.
As a kid it was fair to say that my approach to any problem that came my way was, well, it was just different. In fact, I’d spend hours trying to come up with unique solutions to problems that otherwise might have only taken a few minutes to solve the normal way. It was my thing.
In fact, my problem solving skills could only be described as journeys down the “Road Less Traveled.” Kind of the McGyver approach. What can I do to meet this challenge by using a Zippo, some thread, a chewing gum wrapper, and piano wire? Of course there were sometimes periodic episodes of near tragedy from this approach, you know, like the time I watched the front right wheel on my wagon roll past me as my journey took me down the 80% grade that my parents called the backyard. Thank God the axle dug in just enough to stop me before the approaching cliff. (The bobby pin didn’t hold.) Between Evelyn Wood’s Speed Reading course and Cliff Notes, I read Moby Dick in about 13 minutes.
By the time college rolled around, it was clear that my addiction had spread from alternative methodologies of problem solving to a pure and simple love affair with anything that was new, cutting edge, leading (or even bleeding) edge or avant garde. “Contemporary” was the catch word all those years ago. From art films to modern music, there was no end to my attraction to new and novel things.
Well, Inside Healthcare ran an article by Clay Sherman that was entitled Think Global and Act Local that contained some great tips for survival in healthcare. Mr. Sherman talked about the Joint Commission the way that most hosptial CEO’s would like to, but do not have the guts to do so. He described the Joint’s role as one of minimalism, and that was where his description stopped. His suggestion was to drop the Joint and to engage some larger, more aggressive organizations like NCOA or Leapfrog. His words of wisdom here were, “Either embrace a rigorous standards process, or watch your successor do it.”
Mr. Sherman went on to suggest the need for us to embrace best practices methodologies, new standardization techniques, online communities for patients with similar diseases, and he closed by saying “Stay centered focused in building human assets — its their brains that are going to get you there.” Hmmm? Sounds a little like last week’s blog.
Quality of Care
July 31st, 2008Back 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.
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
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.
A Time to Reflect On Life
June 15th, 2008With 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.
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?
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.
Knowing Enough About Systems to be Dangerous
May 30th, 2008From the age of about eight until 20 years ago, my entire life was immersed in music, education, the arts and, in a very pure way, people in general. It was a complex world that required a deep, intuitive understanding of the human condition on multiple levels. In a very general way, that life, (pre-health care management) was all about systems.
Obviously, it was never just about one or two individuals, and it was not about life and death, but it was magnificently complex in its own way. It involved working with people to do something that was extremely challenging, that required incredible hand/eye co-ordination, and an ensemble mindset of co-operativeness that was paramount to success. Most importantly, it required them to listen intently to each other so as to find the perfect balance, blend and intonation.
The nuances of taking a systemic approach to the creation of music through the efforts of an ensemble in many ways have escaped our world of healing, at least until now.
At a recent visit to my dentist, he and his hygienist were talking about the fact that the doc had just taken a continuing medical education course. When he was asked if anything new had evolved from his class, he smiled and said, "Well, for the first time in 28 years of practice, they admitted that the mouth is connected to the body." He went on to elaborate about the fact that each and every day he sees the destruction caused by inflammatory disease of the gums, and then told me about his attempts to communicate that information to a physician friend several years ago. "It just didn't register," he said.
What little we know about inflammatory disease has us dutifully brushing our dog's teeth to prevent a heart condition, yet we still do not have direct lines of communication between our primary or cardiac physicians and the the dentists who see these problems as they manifest themselves in our body.
Someone once told me that Descartes' Treatise of Man played a major role in the imposed medical and emotional separation of the brain from the body, as it clearly took the stand that "Hospitals and physicians should take care of the body while the church takes care of the mind and the soul."
One of our scientific collaborators, Dr. Lee Hood, is famous for his work in Systems Biology. Another collaborator, Georgetown University, is involved in the creation of a medical school program revolving around Systems Medicine, and finally, our Optimal Healing Environment collaborator, the Samueli Institute, is focused on Systems Wellness. In spite of these wonderful leaps into what would have to be considered common sense approaches to health and life, we still sometimes miss the ensemble approach.
My recommendation?
Maybe it would help our healers to take their place on the podium, look at every one of the 30 plus lines of music on the score, raise the baton and begin to direct their way through every nuance, inflection, and harmonious signature present in a score of music with the appropriate rhythm, intonation and accents just to remind themselves that; we human beings are basically all made up of systems as well, and those systems will not function smoothly if one is completely out of sync with the other."
This is something that we all know intuitively. Maybe immersing ourselves in that world for a while will help bring that concept totally back into focus. It's all about harmony, balance and nature's perfection, and a disjointed approach to health is as potentially harmful as a disjointed approach to life.
$4.3 Trillion in U.S. Health Care Spending?
May 9th, 2008“Money doesn’t make you happy. I now have $50 million, but I was just as happy when I had $48 million.”
–Arnold Schwarzenegger
According to an article in Internal Medicine News by Mary Ellen Schneider, spending on health care in these United States is projected to reach 20% of the gross domestic product on the one hundredth anniversary of my father’s birth, 2017. Of course that projection is only an estimate made by CMS, the Centers for Medicare and Medicaid Services. That estimate is, of course, based upon a continued escalation of nearly 7% each year for the next nine years. In lay terms, that escalation would mean that the total dollars spent on health care would hit $4.3 trillion…Whatever a trillion is? I still can’t fathom a billion of anything.)
We all should realize by now that this spending in the public sector, Medicare and Medicaid, will increase due to the first wave of Baby Boomers entering the Medicare system in 2011. My 78 million peers, like the lemmings, are working their way toward the proverbial wall, and for those of you who will have to carry the load until we are wearing our wings, that is not a pretty financial picture.
The same economists from CMS are predicting a decrease in reimbursements to physicians over the next several years while Home Health will likely grow faster than most other sectors except perhaps prescription drugs.
What does it all mean? We are spending more on health care in the United States than any industrialized country in the world and, truthfully, our overall age of death is significantly surpassed by many of those “spending less” countries. How can that be? Well, for one thing, we have 47 million uninsured citizens in this country and no one really knows how many illegal aliens. Why so many uninsured? They don’t vote. The vast majority are young, single mothers with small children, and this does not take into consideration the illegal aliens who are also not insured.
Back to the answer. . . prenatal care is inadequate and infant mortality in the United States is still an embarrassment. A few of the countries that do better than us in the world in infant deaths per thousand are: Australia, Austria, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Ireland, Japan, South Korea, New Zealand, Norway, Portugal, Spain, Sweden Switzerland and the United Kingdom. Hmmmmmm? Could it be because we spend 30% of our annual health care dollars on the last thirty days of life, and less than 4% of our monies on preventative and wellness care?
Of course, Hospice would be a tremendous help. We could reduce expenditures on end of life care, properly care for our babies with the excess funds, and ensure that our uninsured are properly covered as well, but what politician is willing to touch that electric third rail of the electorial subway tracks?
We could begin by putting in a network of sidewalks, bike trails, and walking trails. We could actually walk once in a while and treat our bodies like a true temple, not the “Temple of Doom.”
One of the least often heard issues revolving around these expenditures is the continuation of our archaic hospital system. It is based on the acute care model, and the vast majority of our diseases are chronic. We rush the victim to the hospital, patch them up, send them home and then rush them back again without any commitment to behavioral modification. I have seen individuals reverse their heart disease from diet, exercise, and stress management. Why can’t we embrace this concept, reward these activities, and change our society? The millions of bicycles in Europe are no accident.
So, as I’ve quoted in some other blogs, “Change or Die,” or just spend ourselves into oblivion as we attempt to prop up a system that should have gone out with the Industrial Revolution. Good luck kids, your ole man needs you to keep working to cover my health insurance.
Managers, Smanagers…It’s Over
April 17th, 2008Kenneth 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. . . ”
If, 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
Random Thoughts. . . Learn From Your Mistakes
March 21st, 2008Make 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.
