Saturday, February 22, 2014

Why should our industry expect success?

Several of us are lucky to be on a weekly email message list from Gene Lindsey, former CEO of Atrius Health, the largest multi-specialty group in Massachusetts. Drawing on a variety of life situations, Gene is always able to make connections and comments about the state of our health care system. Although he generally refers to issues in the US, his comments are applicable to other jurisdictions as well. This week, he asks and then answers a question, and then he offers a concise summary of the attributes needed in health care delivery organizations. Let's consider his advice after reviewing two descriptions I have offered elsewhere:

After her fifteen year-old son Lewis Blackman died from a series of preventable medical errors, Helen Haskell diagnosed the problems in the hospital by saying, “This was a system that was operating for its own benefit.” 

What she meant was that each person in the hospital was unthinkingly engaged in a series of tasks that had become disconnected from the underlying purpose of the hospital. They were driven by their inclinations and imperatives rather than by the patient’s needs. Indeed, they were so trapped in that form of work that they could not notice the entreaties of a seriously concerned mother as her son deteriorated.

Or that of a Harvard business professor who described the financial imperatives of many hospitals in a less personalized, but analogous fashion. He called hospitals “business cost structures in search of revenue streams.” 

What he meant was that the business strategies of the hospital had become detached from the humanistic purposes that had led to the creation of the hospital. There was thus a parallel to the individuals’ behavior noticed by Helen.

Gene put it this way:

Why should our industry expect success when we consistently put our own concerns and fears before the needs of our patients? At a minimum, we must align our skills with their problems even if our motivation is pursuing our own interests and financial well being. This is a truth that real service industries take as a given. Many in the traditional professions like medicine, education, law, and even the clergy are beginning to see the need to approach their relationships in a way that is more cognizant of the concerns of their customers who are now armed with enough information to have the courage to push back and ask “why." 

And then he offered the following, taken from Crossing the Quality Chasm:

The Ten Descriptors of A Better Health Care Organization
1)    Care based on continuous healing relationships: Care should be given in many forms not just face-to-face encounters. The system should be responsive 24 hours a day.

2)    Customization based on patient’s needs and values.

3)    The patient as the source of control. Encourage shared decision-making.

4)    Shared knowledge and the free flow of information: Unfettered access to medical records with effective communication between patients and clinicians.

5)    Evidence based decision making. Practice should not vary illogically from clinician to clinician.

6)    Safety as a system property.

7)    The need for transparency.

8)    Anticipation of need.  

9)    Continuous decrease in waste.

10) Cooperation among clinicians.


Anonymous said...

No one could have said it better. I have observed more than once, since being a patient myself and tending to my elderly mother, that doctors are treating themselves these days rather than their patients. They blindly recommend courses of treatment which make no sense in the context of the individual patient, but protect them against fears of malpractice or are knee-jerk responses to a situation.

And, regrettably, the current system possesses zero of his 10 attributes. I fear it will take a whole new physician generation for meaningful change.

nonlocal MD

Barry Carol said...

From a patient’s perspective, I wonder about the following: (1) how much difference does it make if the doctors treating the patient are salaried hospital employees or independent contractors with admitting and practice privileges, (2) do the doctors have access to easy to use electronic records to see what’s already been done or not, (3) is the hospital paid to fix mistakes like treat hospital acquired infections and preventable readmissions, (4) would the treatment approach change if the hospital were paid on a bundled payment or capitated basis instead of a DRG, case rate or per diem basis, (5) how much difference does it make if there is a culture of collegiality and collaboration within the hospital as opposed to an every person for himself silo approach (6) would it make a positive difference if the hospital controlled the entire continuum of care as the lead entity in an ACO and (7) to what extent would sensible tort reform be helpful?

In short, is the issue here one of culture, leadership, perceived fear of litigation, economic incentives or some combination of all of those?

Anonymous said...


I cannot answer the numbered specifics of your question as I am no longer in practice, but as for the summation - my ex-husband, an ethical orthopedic surgeon who used to regularly turn down surgery he felt wasn't indicated (even if the patient wanted it like backs), hurting himself economically - viewed the deterioration of medical practice with the same dismay I did. His oft-repeated statement hit it in a nutshell - "Doctors have given up medicine."
Meaning, they have given up trying in a chaotic system, they have given up trying to be patient-centered, they have given up trying to be intellectually rigorous, and they have apparently often given up trying to be ethical. So, I vote for 'all of the above and more' in your final question.


Paul Levy said...

Sorry to disagree with my esteemed commenters, but the issue fundamentally is one of leadership. Don't get distracted by the policy and business fads of the day. All of the items Gene mentions can be achieved under a variety of ownership and employee relationships, under different payment regimes, specialty and full-service health systems, and the like.

The proof is that it is happening in select locations in the country. It happens when the CEO and board and senor clinical leadership are aligned and view themselves as being in service to their community and their employees. As we have seen described elsewhere, "There is no secret ingredient."

Anonymous said...

Paul, I think your ingredients are necessary but insufficient.

And I haven't missed the irony of us two essentially switching positions since 2009. (:


Anonymous said...

I think this is one of the epic posts I will keep and refer out, as a main reference article that couldn't be better written. Sums up a lot of things.


Paul Levy said...

Thank you, Vic.

Barry Carol said...


While I agree about the importance of strong and appropriate leadership here, I think it would be a lot easier to get buy-in from physicians if they were salaried employees as opposed to independent contractors with admitting and practice privileges. It would be easier still if the hospital made it a point to only hire doctors who could work well within a collegial and collaborative culture. It would also be helpful if bonuses paid to doctors were based on something other than relative value units billed.

Paul Levy said...

There are certainly examples that support your points, Barry. There are also examples of hospitals with just the opposite--non-employed, fee-for-service--where significant successes have occurred along the lines noted by Gene.

I'd hate to think that a CEO of a place with the latter chacateristics would give up on the direction stated here--because it is possible to achieve. Indeed, it is probably easier to achieve than trying to move doctors to an employed status or engaging in a wholesale change in reimbursement and compensation issues.

You have to work with the hand with which your a dealt. The point is that, under either regime, excellence is possible with good leadership. Likewise, with poor leadership, both types of organizations can fail.

The Medical Contrarian said...

Great post. Can you tell me where the list is published?

Regarding the advantages of salaried physicians, this is not a panacea. I work within multiple health systems which ostensibly use salaried physicians. However, they also use "productivity" measures linked to RVU activity. These measures do not measure whether you bring value to patients, only that you are busy and are doign things that bring value to your health system.

Paul Levy said...

It's from Gene's email. If you post a comment here with your email, I'll forward it to him (and not print your comment.)

Anonymous said...

It is past time to change the mantra to : No Mission....No Money.
CEO's and Hospital leadership must see themselves as servant leaders.
I hold up Balridge winner North Mississippi as an example. They have narrow margins but huge commitment to the community. This is perfect alignment.

Paul Levy said...

Well put!