High Performance Health Care

The American Society for Quality (ASQ) recently held its World Conference on Quality and Improvement in Minneapolis, including three days of meetings of the health care section of ASQ. Dr. Jody Crane of the Fredericksburg Medical Alliance presented an outstanding workshop on the use of Lean tools to transform a poorly performing emergency department into one with “no waits.”

Dr. Crane opened his workshop with this question – “Do you have a hidden ED within your ED?” In other words, he believes that most emergency departments have significant opportunities to uncover hidden productivity by evaluating their operations and making changes based on Lean principles.

Steps to a No Wait Emergency Department

Dr. Crane recommends the following actions:
• Establish a measure of patient demand by hour and design a system to handle it.

• Consider using team triage. This process involves quickly assessing, registering and processing through team triage, and then allocating or sorting the patient to either a treatment area or a results-waiting area.

• Appropriately capacitate triage processes and systems. Triage should collect only enough information to determine patient severity or segmentation grouping.

• Use a system for patient segmentation and establish distinct processes for different patient segments.

• When segmenting patient flow, be willing to examine your current triage protocols. For example, by switching to a "see-and-treat" model, EDs will have one in-process queue, where patients wait just one time for a one-stage assess, treat and discharge process.

• Design and fully optimize a fast track. The fast track should serve as a carve out for easy-to-treat patients,

• Commit to dedicated physician, mid-level, and nurse staffing, point-of-use supplies, and radiology and lab services. In addition, a results waiting area should be available close to triage and the fast track which can be used to buffer long radiology and lab turnaround times without consuming bed resources.

• Devise a method of tracking patients and results. Deploy a willing staff with a passion for their work. Leverage clinical talent and time. Always put the best team on the floor—play your varsity squad—and always put a full team on the floor.

Results and Implications
The results of these changes were stunning. The walkout rate dropped from 6 percent to 2 percent and the volume of visits increased from 78,000 per year to 100,000. This was a 28 percent productivity increase with essentially no change in staffing.

As health care reform moves forward, President Obama has asked the health care industry to provide a plan to save $2 trillion in expected health care inflation over the next ten years. Industry leaders initially agreed to this goal but recently have encountered significant challenges in presenting specific details to the White House.

However, here is a start on this goal - courtesy of Dr. Crane. If every Emergency Department in the United States could achieve a 28% productivity gain for the 115 million annual visits in this country, and each visit is worth about $500 you can save $16.2 billion per year. Over ten years this is $162 trillion. Just think what the rest of the system could save using these same tools.

Reference:
Jensen K, Crane J. Improving Patient flow in the Emergency Department, Healthcare Financial Management 2008 Nov;62(11):104-6, 108

Posted by Dan McLaughlin at 11:26 AM | Permalink | Comments (0)

As part of the Health Care UST MBA policy course, we led 25 students, faculty and staff to Washington, D.C., for an intensive three-day seminar. During their time in Washington, the group had the opportunity to meet with a wide range of policymakers, elected officials, journalists and senior administration representatives. These individuals were actively in the process of shaping health care reform and the final version will clearly have elements that have been shaped by them. We were especially impressed by our meetings at the White House with Nancy-Ann Min DeParle and the presentation by Dr. Carolyn Clancy, who heads the Agency for Healthcare Research and Quality. Dr. Clancy has just been named the most powerful doctor in America by Modern Healthcare.

The one consistent question for each speaker was: "How in the world are you going to get this done - especially with this very divided Congress?" Although there were differences, a number of common elements seemed to be present. Here are my impressions on how health care reform will evolve from three days of discussions with these policy leaders and stakeholders.

• Medicare will stay pretty much the same with an increased emphasis on value purchasing, which may help us in the Midwest.
• Medicaid will probably not change much either, but the categorical programs may be eliminated and income will be the only criteria for eligibility.
• Large employers providing health benefits will continue to contract with private health plans, but some portion of this benefit may become taxable.
• The big change will come for small businesses and individuals who will purchase their health insurance through a subsidized exchange – similar to the current Massachusetts system.

The remaining controversies are the sources of funding for the subsidies and whether there would be a “public” plan offered as an option in the exchange. Even though the speakers had quite different points of view, it appears that compromise and solutions are achievable to truly make significant change in the system.

I highly recommend listening to some of these audio recordings as you can get a very interesting and colorful flavor of the debate on some of the very technical elements of reform. We have converted these recording to the MP3 format so you can download them and load them onto an MP3 player (e.g. iPod.) Click here to go directly to these recordings and slides from the presenters.

Posted by Dave Durenberger at 01:45 PM | Permalink | Comments (0)

In February, the University of St. Thomas’ Health Care MBA and former Senator Dave Durenberger welcomed Guy Clifton, M.D., to campus to discuss his new book, Flatlined: Resuscitating American Medicine. Dr. Clifton is a neurosurgeon, clinical investigator, administrator and health policy advocate.

In his talk, Dr. Clifton highlighted some of the most pressing problems facing the health care industry and offered solutions to address them. (The video and PowerPoint of his presentation is here.) He identified the rising cost of health care as an urgent and underlying problem. At the current rates, Medicare will be insolvent by 2050 and the federal government will be facing a major tax problem within the next eight years. It is crucial to get health care costs down.

There are two ways to decrease costs: become efficient or cut prices. Dr. Clifton focused on what he calls a “roadmap to value,” which would increase quality in order to decrease cost. He identified three broad categories of unnecessary spending in health care: inefficient hospitals, poor management of chronic disease, and unnecessary procedures. Improving quality in these areas, he argued, would also decrease costs in the long run.

Dr. Clifton suggested three specific ways to achieve decreased costs by increasing quality:
• Anchor yourself to one primary care doctor of your choice
• Pay providers for the quality, not the quantity, of their care
• Establish, measure and report benchmarks of quality medical practice

Dr. Clifton stressed the need for benchmarks to standardize medical practice. The first step is to determine best practices. The second is to establish benchmarks of quality: Who needs to see a specialist? Who needs to be hospitalized? Which diagnostic workups are appropriate? He argued that we can no longer have such large populations being treated with massive variations in care. We need to establish benchmarks and offer doctors malpractice protection for following these standards.

Dr. Clifton estimates that hospital inefficiency accounts for 15-40 percent of hospital spending. When patients are admitted to a hospital for a procedure, costs are almost double if they experience complications. As an example of how benchmarks of quality can help reduce costs, Dr. Clifton described how the LDS Hospital in Salt Lake City, Utah, was able to reduce the hospital-acquired pneumonia rate. The nurses in the critical care unit designed a protocol to monitor and control blood glucose levels in patients. As a result, they had a four-fold decrease in the pneumonia rate and, ultimately, reduced their costs as well.

Another large source of unnecessary spending, according to Dr. Clifton, is poor management of chronic illness. The medical home can be an effective way to treat patients with chronic disease and reduce overall costs. The LivingWell clinic in Gallatin, Tenn., is an example of how quality primary care can result in decreased costs. At this clinic, 12 general internists collaborated to treat 1,400 Medicare Advantage patients. The insurance company agreed to pay a 30 percent bonus if they hit the 90th percentile for quality and reduced the cost of care. The keys to their success were being the first point of contact for the patients, spending more time with each patient, being available to the patients 24/7, practicing standardized management and monitoring quality. At the end of two years, the doctors in this clinic had not only improved quality but also had savings of 20 percent.

Throughout his presentation, Dr. Clifton stressed the need for immediate action to reduce health care costs by improving quality. He argued that improving efficiency and quality is the best means to reduce health care costs. This can be achieved by focusing on primary care, paying providers for quality not quantity and establishing benchmarks for quality care.

Posted by Erica Lyons at 03:47 PM | Permalink | Comments (0)

The health care sector is not exempt from the financial restructuring affecting most industries. Health care managers have to think more strategically in order to cope with current economic trends but still have reason to be optimistic about the economic health of the sector.

Some current trends in our region include:

•Consolidation of facilities into large, integrated systems which are driven by cost controls.
•A decrease in patient volume due to high-deductible health plans that demand larger out of pocket expenditures from the consumer and to an unwillingness (or inability) of patients to take leave from work during these difficult economic times. As a result, elective and, perhaps, necessary procedures are delayed.
•Receivables are rising because providers are getting lower reimbursements from health plans and individual consumers are slow, or unable, to pay.
•Health IT projects are somewhat on hold due to uncertainty in standards and levels of government assistance.
•The health care sector has been growing at a slower rate than it has grown in the past and has experienced its first decrease in hospital workers since 2004.

Reasons to be optimistic:

•Health care reform is now a national priority with a commitment from the federal government to address it.
•Health care institutions are becoming more deeply committed to excellence in business practices and are using those business skills to complement clinical skills.
•Initiatives such as evidence-based medicine and comparative effectiveness research are bringing together stakeholders from across the sector to jointly address the ways to deliver higher quality at lower costs.
•More savvy health care leaders are emerging in the public eye. As a result, there is greater trust in proposed solutions.

The Health Care MBA at the University of St. Thomas recently sponsored a workshop on careers in health care. The panel was comprised of Brad and Cindy Chandler from the Chandler Group, an executive search firm that works in the health care sector; Liz Swanson, vice president of Human Resources at HealthPartners; and Linda Sloan, director of Graduate Business Services, Opus College of Business, University of St. Thomas.

We were particularly interested in the portion of the presentations and subsequent discussion that centered on the skills needed to manage health care organizations in these tough, uncertain times. The nature of these is no surprise, yet their presence in health management seems to be scarce. The most prominent skills are:

•Innovation – developing new ways to deliver better value in the health care system. Creating new products and services that draw the consumer into participation in their own care is a growing area. Consumer-based activities are a vital part of any marketing initiative, yet the challenge of consumer involvement in health care is unique because of the very personal nature of that involvement.
•Operational enhancement – finding and implementing models that better deliver the health care experience in ways that reduce costs and improve outcomes.
•Financial skills – risk management and debt collection are becoming more and more important in the current health care system. Understanding cost structures and demonstrating fiscal prudence—“the ability to do a lot with a little”– are critical skills.
•Technology development – data driven processes have to be blended with care delivery in a way that care delivery quality and patient satisfaction is improved.
•Leadership – change management is essential in tough times. People need to be properly focused and motivated to deliver quality outcomes while maintaining the financial viability of the health care system. Excellent communication and team-building skills are always crucial.

The perception of the panel was that these skills are scarce, but in demand. As health care providers are increasingly rewarded for providing value and creating efficiencies, we are confident that these skills will be needed more and more at all levels of health care organizations.

We are interested in comments from our readers. How can skills that are prominent in other industries be translated to health care? What are the obstacles to developing these skills to a greater degree in health care?

Jack Militello and Cindy Lorah
Health Care UST MBA

Posted by Jack Militello at 01:42 PM | Permalink | Comments (0)