PHLO

Medicare Changes Demand Hospital Makeovers

    The assault on the Medicare program now pointing toward one of the fundamental disconnects between healthcare and the rest of the business world. In the original federally controlled program, hospitals were actually financially rewarded for poor quality. They were frequently paid for the now-called "never events"

Under the new state-controlled versions, quality is no longer simply a moral imperative; now it's a real pocket-book issue for every hospital. Medicare will no longer pay for those "never events," or a lot of other things. Reforming the Medicare system to save money, has gone to the next level, demanding higher quality from service providers.

To thrive in this much harsher economic climate, hospital executives must revisit their hospitals' performance drivers and understand and anticipate how this economic change should be folded into the larger management system.

There are five areas that require close examination.

Strategy: How can the hospital's strategic direction change to make operational quality a competitive advantage in the marketplace? How can services that do not deliver superior quality be walled off or eliminated?

Process: Resist the default diagnosis that your hospital has a process problem. Most hospitals have a process control problem. Take steps to better control your processes. This isn't magic, but it does require knowledge of control systems, something they really don't teach you in medical school.

People: Now, more than ever, hospital employees must be multifaceted. Examine the hiring criteria to ensure that your hospital acquires the quality people who can deliver the quality that will drive success. It isn't trite, good people trump many problems.

Culture: Does your hospital culture tolerate the lack of discipline that leads to poor quality? Do you have a system that drives accountability throughout the organization? Do you put clear, actionable information in the hands of the people who need it? Are the targets clear and relevant to the individual? And is there a mechanism in place that instigates improvement when the organization's performance doesn't meet established standards? Does your culture serve the whole hospital?

Organization: Can the people in your hospital make decisions? A fundamental flaw in management today is the lack of importance placed on decreasing number of people who need to be involved in decision-making. A preventable problem is only preventable if people can act in time to prevent it. If you truly want your people to keep you out of trouble, they need to be able to act on information provided when and where they need it.

Changing the mindset of hospital executives and staff is a tall order, but not insurmountable. There are plenty of tools, techniques, and expertise available to put them over the top.

Expert Advice for Improving Hospital Operations

Hospital clinicians are trained to be healthcare professionals, not efficiency experts. Expecting them to become efficiency experts overnight by attending classes on Six Sigma or Lean transformation is tantamount to asking real efficiency experts to take 40 hours of medical classes to become practicing doctors.

 

Six Sigma and Lean may look simple at the conceptual level, but transforming a run-of-the-mill hospital operation into a world-class operation requires not only in-depth understanding of strategy, people, culture, organization, processes, statistics, and information technology, but also large blocks of time that most clinicians don't have to spare.

 

Yes, it may appear to be more cost effective to have those in-house Black Belts and attendant green belts, but the reality is that those people already have full time jobs. Asking them to take on another full time job – and operational improvement can be a full time job for the less skilled – takes away from the very efficiency the hospital is seeking to attain.

 

Who wants their doctor, nurse, or other healthcare practitioner focusing on how to make hospital operations work better when they should be attending to a patient's care?

 

Put simply, why would anyone go to a local engineering firm for an important surgery? The same goes for hospitals. If they want treatment for what ails their operations, why would they expect their medical personnel to be able to administer it?

Rapid Response Teams: Too Little Too Late

The best process engineers know that designing quality into a process up front is vastly superior to correcting problems afterwards. No matter the product or service, it is always better, faster, and cheaper to start with a quality process.

This universal truth makes the notion of hospitals' "Rapid Response Teams" somewhat troubling.  While the concept of Rapid Response Teams (RRT) seems logical at first glance, it doesn't fare nearly as well under closer scrutiny. When a patient deteriorates into critical condition, the RRT brings together the best available professionals in a hospital to stabilize the patient. Sounds like a good idea, right?

Maybe not.  Although Rapid Response Teams can save lives in emergencies, there is a serious flaw in the thinking that a patient must experience some sort of critical event before this medical talent is brought to bear.  Rather than investing time and talent in creating RRT, shouldn't there be more investment in preventing the circumstances that would require an RRT in the first place?  

An industry that touts prevention needs a dose of its own medicine.  But all too often, industry incumbents who simply do not have the background or experience to design quality into day-to-day work processes dismiss using prevention as a tool for improving hospital quality.

Many would argue that RRTs are absolutely necessary and save lives. IHI justifies the need for an RRT system this way: "In the old days, a nurse could struggle for 90 minutes with a failing patient…while doing all the right things, i.e., working to assess what is going on with the patient, trying to reach the physician, waiting for test results or physician's orders, etc…. she may not actually be advancing care…."

But, an RRT does not address the underlying problem: Why is a nurse left to struggle with a patient for 90 minutes in the first place?  The RRT is only a better reaction to a seemingly self-inflicted problem.  <Read how Rapid Response Teams Improve Morale>

According to IHI, through RRTs, "Nurses are encouraged and empowered to ask for help without fear of appearing incompetent." With lives at stake, doesn't the fear of being perceived as incompetent seem misplaced?   Poor outcomes from not getting help make them look even more incompetent.

In some circles, debating the RRT concept is like debating the merits of motherhood and a hot lunch for orphans.  If they are free or easy to establish, then, of course, get an RRT in place.  Unfortunately implementing an RRT is time consuming and certainly not cheap.    <it took a $1,000,000 grant at this hospital>.  

A better debate would address the RRT's place among a larger set of hospital priorities.  The time and the money expended on an RRT might be better invested by implementing ICU physician staffing, for example. < Read fact sheet >.   In a world where less than one-third of hospitals have implemented these services, you have to wonder why there is room for an RRT. Why wouldn't a hospital invest in preventing problems instead of solving them after the fact?

Consider this: If a patient is stable enough to be admitted as an inpatient, why can't the hospital provide high quality care that would prevent the critical condition in the first place? If the best available medical team solves the problem before the patient deteriorates, it eliminates the need for an RRT in most cases – saving time, money, and lives.