Thoughts as I go through the night prepping for my regular colonoscopy (OK, more than you want to know!) which allows me to be up even earlier than usual and make some observations. I can't yet blame the soon-to-be administered Demerol for any incomprehensible wanderings, and I promise not to write the next post until that wears off.
Atul Gawande has yet another beautifully written article in the New Yorker about health care costs, this time focusing on a particular city in Texas that has remarkably high costs compared to the rest of the country. Of course, he need not have travelled so far. The points he raises have been published for years by our colleagues at Dartmouth, and have been discussed by Brent James and others. And the kinds of numbers he cites, although perhaps not as extreme, also typify health care costs here in Massachusetts.
Brent summarized some of these issues in a talk he gave here about a year ago:
-- Well-documented massive variation in practice based on local medical myths.
-- High rates of inappropriate care.
-- Unacceptable rates of preventable care-associated patient injury and death. (Hospitals are actually the #4 or #5 major public health problem in this regard!)
-- A striking inability to "do what we know works".
-- Huge amounts of waster and spiraling prices that limit access.
While Atul focuses on national policy in his article, let me bring the discussion back to strategic planning for hospitals in general and academic medical centers in particular. It seems to me that there are three overwhelming public policy trends in America:
1) A desire to set an annual budget per person for health care;
2) A desire to limit the growth of that annual budget to a rate equal to or less than the overall rate of inflation; and
3) A desire to reduce the amount of harm caused to patients during hospitalizations.
The successful hospitals (and their associated physicians) will be those who learn to live within these broad formulations, and the most successful with be those who wholeheartedly embrace them. Further, they will need to create integrated networks of care -- whether by ownership or strategic alliances -- with people in other parts of the health care delivery system who have similar beliefs. Finally, they will need to engage in process improvement of the type discussed by Steven Spear to squeeze waste out of the system on the "factory floor."
In Massachusetts, there is only one integrated delivery system characterized by ownership of enough entities to engage in this kind of strategic approach, but that system has not yet demonstrated an ability to deliver care at a lower cost. Indeed, just the opposite. For a place like BIDMC, we will have to rely on finding multi-specialty groups, community hospitals, and others who share our vision of success through improving the quality and efficiency of our service, delivering care in the most appropriate settings, and constantly striving to be "the best at getting better."
Many of you have watched our progress here on this blog and on our corporate website as we feel our way along this path. One of our management techniques is transparency. It is based on a philosophy that you can't get better and you can't hold yourself accountable unless you are exceptionally public about what you do wrong, as well as what you do right. As I have noted elsewhere:
Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.
In this sense, transparency is a necessary but not sufficient element in bringing about transformational change in an organization. But the actual implementation is not easy. You've seen our stories about BIDMC SPIRIT and Lean process improvement here. We view ourselves as babes in the woods in these arenas, but we view part of our role as an academic medical center to share what we have learned with others. We will also ruthlessly borrow good ideas from others in our quest to do better for our patients but also for ourselves as an organization facing the three policy imperatives set forth above.