Wednesday, February 07, 2007

Change must come from within

A personal observation after five years on the job and in this field:

The biggest managerial conundrum facing hospital administrators is how to bring about constructive and lasting change in these large, complex organizations that are known as academic medical centers. People often say that AMCs are behind the times with the application of managerial techniques that are in wide use in other kinds of organizations. That may be so, but I do not think it is an accident or for lack of trying. I think there is something fundamentally different about these hospitals that requires a different point of view and approach.

The first difference is that we do not produce a single product or service. Every patient is different, and every patient expects and deserves personalized service and individualized attention. Not so different, you might argue. There are plenty of businesses that offer service tailored to the individual, and they have learned how to provide that service consistently and efficiently. And it is true that, in medicine, there are general rules and appropriate clinical responses for many patients with one or another disease. For example, I have discussed below the use of clinical pathways to make care decisions more routine, and I have discussed protocols that can be used to avoid ventilator-associated pneumonia, central line infections, and other harm. But, at its core, effective treatment really does require due attention to the individual biology of the patient, his or her state at the exact time of treatment, as well as related factors like family and home situations. It is as much art as science.

The second difference is that the key players in the delivery of medical care -- the doctors -- are not employees of the hospital. They are essentially independent contractors who have chosen one or another AMC for a particular mix of clinical care, research, and teaching that gives them personal satisfaction. Further, they have been taught through medical school, residency training, and their history of academic professional advancement that they will ultimately judged by the results of their personal efforts, not by the progress of the institution within which they work. In baseball parlance, they are all free agents. I do not say this with any inclination to diminish the dedication, expertise, or integrity of these doctors. I offer it, though, as a sociological context for their perspective on the world. (And please, I recognize that I am generalizing a bit here, so I am shortening the description of what is a broad continuum of individuals.)

Red Sox fans know what I mean when I say, "That's Manny being Manny." Our left-fielder is a brilliant baseball player who sometimes lets his individual inclinations interfere with the well-being of the team, but who is admired, respected, and even beloved for his overall contributions on the field. Even when his actions confuse and confound and annoy us, we put up with him because he is a hard-working person usually devoted to doing the best he can -- and because his results in the batter's box can be stunning and change the course of a game or even a season.

Doctors in AMCs are not all "Manny being Manny", but they are thoroughbreds in their own way. Sometimes their behavior can be confusing and even infuriating to hospital administrators. But let us remember: Even those doctors who truly care about the interests of the hospital must make individual decisions in the batter's box when seeing a patient. They know they will ultimately be judged by others -- and by themselves -- for their specific performance in an exam room, an operating room, or on a patient floor. The same holds true for their performance in the research lab and in instructional sessions with medical students or residents.

The rest of us in other jobs think we are being judged as acutely for our own performance, but our performance is often measured in terms of our effectiveness as team members or by our interpersonal skills or by the overall progress of our organization. But now think of how we expect our own doctors to get results. How often have you heard, "Well his bedside manner isn't very good, but he is a great surgeon. If I have to choose, I want a great surgeon." It is not that we intentionally are enablers of bad behavior: It is that we selfishly want good results for ourselves or our loved ones -- and we expect the doctor to deliver it notwithstanding the economics of the health care system, the productivity of the hospital, or any other ancillary concerns.

Here at BIDMC, we are engaged in an experiment, trying to mold the hospital to your expectation of a great hospital experience. As one of my folks put it yesterday, we are trying to be "aggressively patient centered" so that every person is treated as though he or she were a member of our own family. How can we do that, you might ask, if what I say above is true? The answer lies in part in our own history as an organization, a legacy of the underlying values of both the New England Deaconess Hospital and the Beth Israel Hospital. But there was another factor.

Because our hospital went through an exceptionally bad period after the merger that created BIDMC and then almost literally rose from the ashes, those doctors, nurses, and others who stayed with us and have since joined us have an extraordinary degree of loyalty, optimism, and enthusiasm about our ability to work together to deliver the kind of care I describe above. They are collaborative to an outstanding degree. Yes, the doctors are still free agents, but they recognize that even their individual advancement can be enhanced by teamwork and cooperation.

In the postings below entitled "What Works", I have given some examples of their attempts and accomplishments. But here is the key message: Not one of those initiatives was driven by me or other members of the senior management team. The desire for change and improvement came from within, from those very free agents who are viewed by some industry observers as so troublesome.

So here is the five-year takeaway. My management philosophy is remarkably simple. My job as CEO is to help create an environment and provide the resources within which the native creativity of our doctors and other staff can flourish. I don't practice an iota of medicine, but when I do my job right, they are better able to do theirs right.

There is a joke that, "You've seen one AMC, you've seen one AMC." Maybe what I say would not apply elsewhere. We will also get to see if it works even here for the next five years! The jury is still out, but so far, we appear to be headed in the right direction.

17 comments:

David Harlow said...

Paul --

I'm wondering whether your institution has had the experience, in the course of dealing with any physicians' "Manny being Manny" antics, of disciplining "disruptive physicians" under the applicable rules of the MA Board of Registration in Medicine and the Entity Formerly Known as JCAHO? (I appreciate that you may not be able to comment on specific situations.)

I'd also be interested in your thoughts regarding the new JC draft standard. (See my post including the standards at: http://healthblawg.typepad.com/healthblawg/2007/01/disruptive_phys.html).

Harold Solomon said...

It amazes me when we overlook the little things which are the true measures of "perceived quality".. A patient sees a specialist who asks said patient to make an appointment for follow-up in two months. At the front desk, the secretary tells the patient the next available appointment is in 6 months. Who fixes this disconnect?
The patient call to speak with the doctor, and the operator has no way to know how sick the patient is. So the likelihood that the patient will get to the doctor at the appropriate time is very small.
BIDMC compete affectively by being "as good as" are competition. Partners is simply too good at what WE do, so we must plan notes and crannies of quality improvement. You have been able to get rid of your Blackberry, but these have not been able to rid the hospital of maddening answering machines with difficult menus. The level of problem solving competence of the ultimate phone answerers needs an overhaul. On an occasion, I call, reached a live voice, who solves the problem seamlessly. This event should not be rare but should be routine.
When our patient's call the BIDMC, they are not thinking about statistics, outcomes, bottom lines, but how to solve their problems and the shortest amount of time. We have a ways to go.

Paul Levy said...

As always, Dr. Solmon is right on target. We are working on improving many of those many points. Stay tuned, and hold us accountable.

On Mr. Harlow's question, there are specific procedures for discipline. See one of my early postings in August or September on this very point.

Anonymous said...

Paul,

I agree with your point that it is all about the culture we create and empowering people to not only do their best, but feel that they can suggest/make changes to improve the hospital.

I'd be interesting in hearing specific things that you feel create the environment that is so important.

Alexis said...

While it's true that there are many businesses that offer "tailored service" to the individual, the scope is far more limited than the tailoring that must necessarily go on in a hospital, making the application of such managerial practices even harder. Having come from the corporate world to the medical world, I am now getting to watch the hospital experience from the eyes of a medical student for the first time, and it's a vastly different place than from my outside corporate perspective. A client walking into an investment firm, for example, may have a million individual differences from another client, but in the end, there's only a set number of financial options for them. A patient comes in to the hospital with a set of highly individualized symptoms, often obtuse, and the medical team must discern between a huge cascade of narrowing options in order to pinpoint the correct treatment. While there may also be a set number of treatments, it's a much longer list and takes much more time to choose from - and of course, the more steps involved, the higher the probability that something will go wrong. Moreover, the necessary detail needed for such decisions is often far greater than what's needed for the choice between annuities and trusts (for example).

To me, it seems that the main need for business-model streamlining is in the field of bioinformatics. I don't know what BIDMC does, but here the transition from paper to electronic is bumpy, as it is in many places. Savvy patients will bring print-outs of their medications, which will promptly be lost in the flurry of white coats that accompanies a teaching hospital. Electronic lists of such things are often out of date and applied preferentially, to the detriment of patient care.

Ideally, I would like to see a national bioinformatics system of some sort (which may, of course, be a pipe dream), but I would also like to see a bioinformatics coordinator as part of the medical team. Just as pharmacists are taking a bigger and bigger role in direct patient care (because of the exponential increase in medications), a bioinformatics coordinator could help streamline the paperwork for patients, so that the attending, specialist, surgeon, nurse, etc, all have the same, accurate, information for the patient, rather than a mish-mosh of possibly out-of-date pieces of paper.

Steve Pashley said...

Paul,
Two points re your 2nd difference, doctors not being employees.

Here in the UK hospital-based doctors are employees and, in my opinion, it doesn't really make that much difference to their orientation to the organisation. They still (and rightly probably)pretty much continue to see themselves as independant professionals.

Second, I think the way you describe your role is a trend that effects leaders in lot's of sectors (the new Hollywood model for movie creation if you like). Lots of groups of employees are now much more orientated to their work/profession than their organisation. Providing an appropriate physical 'shell', creating and sustaining a supportive culture and orchestrating relationships is now the role for lots of organisational leaders these days. Although, paradoxically, I think NHS leaders are not as good at this today as they were 15 yers ago.

PS I wrote recently about this growing divide between clinicians and managers in the British NHS. I'd be interested in your thoughts.

Regards Steve

Steve Pashley said...

Paul, sorry, the link i gave in my reply was not picked up in full by blogger. It should have read http://stevepashley.squarespace.com/changing-thoughts-nhs/2006/11/2/mind-the-gap-managers-and-clinicians-in-the-nhs.html

Anonymous said...

"A personal observation after five years on the job and in this field:"

A very nice post and I believe you hit the nail on the head!

pgbMD

marty diamond said...

I've just read your blog for the first time and compliment you on your openness and willingness to share your views directly with the reader.

As one who's worked in the field for many years, I was impressed to see this relatively new form of communication employed by a senior health care leader.

I concur with your observations in "Change from Within".

I look forward to reading more of your posts. Congratulations on your 1st five years of service the BIMC.

Marty Diamond

Richard Wittrup said...

Then there is the opinion of Paul O'Neill, retired chairman of Alcoa and President George W. Bush's first Secretary of the Treasury. He says that in order to achieve adequate performance in the areas of safety and quality, a hospital CEO has to accept personal responsibility for every infraction of standards in his institution (as he says he did for industrial accidents at Alcoa).

That is probably not practical so long as a hospital's physicians are independent private practitioners. But we need to understand and accept that the lack of accountability that results from this bifurcation of institutional and professional roles is a major cause of the seemingly intractable issues of safety, cost, and quality in health care.

BC said...

How do you handle the occasional less than stellar doctor who accounts for more than his or her fair share of malpractice litigation that results in payouts?

Paul Levy said...

We are part owners of a captive insurance company for the Harvard hospitals. That company reviews the risk experience of all of the doctors in the broad Harvard system. When they notice trends -- either doctor specific, hospital specific, discipline specific, or procedure specific -- they initiate educational or remedial programs.

But, we recognize that malpractice claims are not necessarily related to level of competence, so it is important to distinguish the two questions.

jessica lipnack said...

The Manny post brought up this single phrase for me: "independence with interdependence."

The docs need the autonomy (and have structured it into their contracts) but they're not able to perform without an interdependent relationship with the institution and their colleagues.

Too much independence and you've got renegades who are disruptive; too much interdependence and you stifle the creativity evident from, say, your head of neuro.

Getting the right balance is the key; when the little bubble is smack in the middle, you've got a vibrant, self-correcting organization.

Mark said...

I have a question for anyone who ends up reading my post. I am the director of admissions at a small free standing psychiatric hospital in Texas. I've been part of and am currently responsible for several process improvement initiatives throughout the hospital. What I have found so discouraging and frustrating in attempting to promote change is the lack of open communication within senior leadership. In particular, the apparently divergent opinions between the COO and the Medical Director. I'm new to my role, but have been with the hospital for 5 years and I've been watching the political environment for some time.

What I would like to know is how to bridge the divide I find between the bottom line minded COO who is less experienced in the medical and legal ramifications of change and the Medical Director who has allegences to our residency programs which by their very form and function appear to be at odds with the kind of efficiency being demanded by the bottom line.

Any thoughts or comments appreciated.

Paul Levy said...

Please explain more about the kinds of problems you are seeing.

Chegui said...

I am sure I cannot the first one to write to you about this, but my MBA class in Capella University is in the midst of dissecting a HBS case study where you are taking us through your first six months on the job.

Based on the discussions I have seen within our class, your leadership style is having a positive impact outside of your hospital.

It was really exciting to read your impressions five years down the road.

Thank you for the inspiration.

Anonymous said...

I think Jessica makes an excellent point about striking a balance between independence/creativity and teamwork to optimize physician and AMC effectiveness. Having been at several other AMC's before joining BIDMC, my impression is that teamwork is poorly implemented in at least one Department due to a rather extreme "silo" structure wherein each physician is managed as an individual entity, with all emphasis on individual physician bottom lines and little to no consideration of team-based efficiencies, shared infrastructure, or the value of academic contributions. Part of the problem may lie in the nearly invisible impact of Harvard Medical School as an meaningful entity. At top AMC's, the medical school typically provides significant infrastructure support to the faculty, that serve as a catalyst for team-based initiatives/processes. The absence of Harvard Medical School in day-to day efforts to promote the academic component of our AMC is shameful. Will new leadership at Harvard and HMS provide an opportunity to improve synergy between the University and its AMC's?