Tuesday, December 02, 2008

Tipping point?

One of the nation's most thoughtful and foremost patient advocates, noticing that I had perfected the challenges of Twitter, wrote me and said,

How about a challenge that's CEO sized...
Get all other health care execs in your region to be as transparent...

I found it hard to reply in meaningful way to this offer. I already feel a bit like the beaver that has been chewing the tree in this picture. It is hard to imagine what more we could do at BIDMC to push the transparency agenda. And it is so clear that it has tangible benefits for the quality and safety of patient care. So, I feel like we have been nibbling away at this issue for quite some time, but the tipping point remains an indeterminate distance away. And, with regard to this challenge, I think that the next steps have to take place elsewhere.

Perhaps the resistance comes from those who misconstrue that this is all about competition. As I have noted, it is not.

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.

But I am starting to think that, within a short time, we might back into the competitive issues because a lack of transparency might hurt the reputation of some hospitals. Maybe that will show up as a result of a contrast with BIDMC when specific events occur. For example, if there is a wrong-side surgery in a hospital, and folks there try to downplay it instead of admitting it and learning from it, there will be an inevitable comparison made with the way we handled that kind of event.

I truly hope that things don't work that way. I hope instead that Boston becomes known as the place in which all major providers, supported and encouraged by the insurers and the state government, engage in the real-time public presentation of clinical results in those areas that are medically significant and reasonably good candidates for process improvement.


e-Patient Dave said...

Absolutely agreed, Paul.

Nothing but good can come from increased visibility into what's happening in healthcare, especially in the US. Medicine is a complex field that needs superhuman skills at times, and exquisitely precise execution at other times, and just plain precise execution at others. We'll never make it better if we try to shut out eyes that could help.

I know there are always upsets when those who've avoided transparency find themselves dragged into it. But you know, as I hear the recent news about American auto companies begging for help, I keep recalling those same companies' executives some decades back, swearing to Congress that it simply wasn't possible to make a better, safer, more reliable, more fuel-efficient car, because if it were possible, they'd know about it.

What happened instead was that the Japanese showed it could be done, using transparency and openness and a greater commitment to shared success than to protecting one's own turf.

Let's get on with it, ladies and gents.


Don't stand in the doorway
Don't block up the hall
For he that gets hurt
Will be he who has stalled
There's a battle outside
And it is ragin'.
It'll soon shake your windows
And rattle your walls
For the times they are a-changin'.


Can't believe I'm quoting 1963 Bob Dylan revolution lyrics on a healthcare blog in 2008. But there you have it.

Anonymous said...

Good for you, Dave! I think the '60's had something to say that subsequent generations have forgotten.
But to the issue at hand, I think Paul's questioner is being naive - under the current health care delivery system, to misquote Vince Lombardi - "competition isn't everything, it's the ONLY thing."
As long as hospitals are trying to gain market share at the expense of others, one CEO has zero power to affect behavior of his competitors. UNLESS they see that his behavior is accruing competitive benefits to his hospital - and then they will try to outdo him. One can only hope and wish this will occur in Boston, but I am not holding my breath.
We need mandated systematic change with national leadership, and I am becoming a tiny bit optimistic that that may happen with the new administration.


Anonymous said...

Keep On, Keeping On!

I believe that Paul is "skating to where the puck is going to be." The others, both in Boston and across the country, will try to catch up to him... when they are forced to!

Anonymous said...

As a hospital CEO in Northampton MA, I applaud the transparency of BIDMC. The sharing of results internally and externally helps everyone to know what about how care is delivered, facilitating improvement and patient/provider decision making.

The more remarkable transparency that BIDMC is exemplifying is the inner workings of care delivery, what happens when even unfortunate things happen, again opening up opportunities for improvement and decision making at BIDMC and elsewhere.

A related transparency is that of an organization with its staff and community around the impact of the economy on jobs.

At Cooley Dickinson Hospital in Northampton, the economy pressed us to reconcile the slowing of growth in patient volume, the decreasing payments from government and insurers, and the increases in costs flamed by the economic turndown. Once it became clear we'd be facing layoffs, we shared the problems with hospital and medical staff, even announcing the planned layoff date more than a month ahead. We explained the problem and sought input on ways to save funds and how we anticipated making staff changes.

While it is still early to assess the full impact, if we ever have to have another layoff, our experience points to sharing the problem, the problem solving, and the solutions with all. Rather than compromising care, everyone rose to the situation and we made far better decisions than management could have made alone. Our staff is terrific and their involvement has assured quality care, despite the sad departures of some of our friends and colleagues.

Anonymous said...

Everything we know about diffusion of innovation (Rogers, Gladwell, and a host of other smart people) says that others will follow when they see the advantage over what they are doing now. As the innovators who are transparent show off the specific benefits they realize, with evidence, the others will follow. The previous comment cites competetive advantage as one of advantages, but there are others that Paul lists. Keeping looking for and sharing the evidence that transparency makes a real difference. And thanks!

e-Patient Dave said...

Rats, I accidentally left off the first two lines of that Dylan verse - the best part!

Come senators, congressmen,
please heed the call


Anonymous said...

Paul...what about "human nature" and hospital management silos?

It seems the "three legged wobbly stool" of hospital governance has long outlived its utility to serve the community - the ostensible owners of the assets of at least the non profits.

As long as you have an arms length medical staff organization, shadowed by a hostile and paramilitary nursing staff, with ancillary departments looking for a cultural safe harbor and a general management team with little to no horizontal communication, instead favoring their silo vertical direct reporting loyalties - is it any wonder why hospitals are so insular, grossly mismanaged and inefficient?

Transparency is an opportunity, not a threat. Accountable organizations will be the Darwinian survivors in a increasingly competitive yet complex soup of health care reform initiatives.

Anonymous said...

And it needs to have the full backing of the Board of Trustees. See here, for example, http://runningahospital.blogspot.com/2008/11/no-retreat-by-boards.html

Anonymous said...

Gregg's characterization of hospital governance made me laugh out loud. Clearly he has been in the same hospitals that I have! (NOT - which is what makes it so scary.)

nonlocal MD