Subject: [SHC] Dr. Gene Lindsey's Healthcare Musings Newsletter 29 Sep 2017

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29 September 2017

Dear Interested Readers,


Washington Watch: Opportunities and Apprehensions At the End of September

I was very happy to hear the announcement on Tuesday that Mitch McConnell would not bring Cassidy-Graham to a vote, but I did not have the same sense of triumph or relief that I had experienced when John McCain turned down his thumb on the “skinny repeal.” McConnell’s many attempts at gutting Medicaid under the guise of repealing and replacing a “failing ACA” have left me weak and weary. I feel that many share a sense of fatigue from needing to be constantly vigilant to protect the ACA from those who falsely preach that it is failing even as they actively promote its failure by administrative sabotage.

What will happen next is unclear. We do know that open enrollment for the exchanges begins on November 1 and will not get the usual administrative support. I can expect that under Tom Price and Seema Verma little will be done to insure that there is an effort to enroll all who are eligible. The mandate will remain the law for now, but will the law be enforced by those who have taken an oath to enforce even the laws that they do not like? Before he disengaged because of the activity around the Cassidy-Graham bill, Lamar Alexander’s committee was reportedly close to a set of compromises that would have guaranteed the payment of the critical CSR payments and perhaps have done other things to improve the finances of the ACA. According to Senator Chris Murphy, Democrat of Connecticut and member of the HELP committee, there is some hope now that they will return to the task. The Cassidy-Graham bill also diverted attention from the renewal of the children's health program (CHIP) which expires tomorrow. It seems that there is a high cost to being continuously on the defense against those who really do not see getting everyone covered as their major concern.

It is when we are feeling weak and weary and are looking for a reprieve that we often need to try the hardest to preserve our gains. The Senate can and must find a bipartisan way that responds to the needs of the millions of people who are depending on the exchanges for their care. It will be hard work. A bill that comes out of the Senate will need to pass the House and will require the signature of the president. “Miracles” can occur, especially when what appears to be a miracle is in reality the outcome of hard work and coordinated efforts. If the department of Health and Human Services is not going to expend effort to advertise and promote the open enrollment period who will fill that void? I hope that the social media, churches, civic organizations, and the traditional media will get out the word. When you see your friends ask them if they are covered. In your practice or in contact with people at work do not be shy. Ask people if they are covered. If the answer is “No,” or “I am not sure,” or “I don’t know what to do,” become your brother’s or sister’s keeper and follow their answer with, “I can help!”


Another Insightful Epistle from Gawande

We are a country of deep divisions that do not need to remain permanent. I think that what can heal us is near and that through all the cacophony of the moment we are slowly moving in a positive direction. There are efforts to understand and move forward from where we are. In the current issue of The New Yorker Atul Gawande has published another “must read article” entitled Is Health Care a Right?: It’s a question that divides Americans, including those from my home town. But it’s possible to find common ground. That is a very long title for an important essay. Gawande’s article is a straightforward presentation of the views of several people who were his classmates and neighbors in his hometown of Athens, Ohio. The characters that Atul introduces to us bear similarities to the folks you met if you read J. D. Vance’s Hillbilly Elegy, George Packer’s The Unwinding, Matthew Desmond’s Evicted: Poverty and Profit in the American City or Arlie Russell Hochschild’s Strangers in Their Own Land.

You do not need to read any of these great books if you read Gawande’s article because the picture he presents is consistent with the theme of despair and confusion in conflict with cultural and personal values that these books reveal. He adopts much of Hochschild’s picture of the mindset in red states and draws heavily on Strangers in Their Own Land. Most importantly Atul explains how this moment arrived by looking back at the evolution of the finance of our system of care. He then looks forward to an eventual resolution of what divides us and describes our role in the evolution. To look forward, he looks back at a little known moment in our history from 200 years ago when we passed, and then repealed, an act that provided smallpox vaccine to everyone for free, for a while.

These days, trust in our major professions—in politicians, journalists, business leaders—is at a low ebb. Members of the medical profession are an exception; they still command relatively high levels of trust. It does not seem a coincidence that medical centers are commonly the most culturally, politically, economically, and racially diverse institutions you will find in a community. These are places devoted to making sure that all lives have equal worth. But they also pride themselves on having some of the hardest-working, best-trained, and most innovative people in society. This isn’t to say that doctors, nurses, and others in health care fully live up to the values they profess. We can be condescending and heedless of the costs we impose on patients’ lives and bank accounts. We still often fail in our commitment to treating equally everyone who comes through our doors. But we’re embarrassed by this. We are expected to do better every day.

The repeal of the Vaccine Act of 1813 represented a basic failure of government to deliver on its duty to protect the life and liberty of all. But the fact that public vaccination programs eventually became ubiquitous (even if it took generations) might tell us something about the ultimate direction of our history—the direction in which we are still slowly, fitfully creeping.



Finally, It’s Here!

In the nearly ten years that I have been writing these letters I have relied on your patience and stamina as I have hoped that you would read through a lot of words. I estimate that there have been about 1,500,000 words counting all that I have copied and pasted. At least a million of those words are mine although the number is inflated by my tendency to be redundant and then justify redundancy as a learning methodology. All of this is to explain that what follows as the main section of this letter is about 1600 words that are the most concise expression I have made of the issues that I think are fundamental to our way forward toward the Triple Aim. You are right to think that it could not have been done it without a little help. I needed a specific objective and I needed the help of a coach and editor. Thank you, Eve Shapiro.

The specific objective of what follows is to inform you, if you did not already know, that a book that I have eagerly anticipated for more than a year has finally been published. The Patient Centered Value System: Transforming Healthcare through Co-Design by Anthony M. DiGioia, MD and Eve Shapiro was published earlier this month. The forward to the book was written by Don Berwick. I had the honor of authoring the preface. Getting a book into print takes a while so when I received my copy of the book this week I was eager to examine the final product. It is a terrific book that I feel honored to have helped in a small way. It was fun to have a really good professional writer, Eve Shapiro, help me shape my ideas. I hope that you will read the preface which is the main section of this letter and become enthusiastic about exploring further whether or not a focus on The Patient Centered Value System might be the link between the way you have always wanted your efforts in care delivery to be experienced by the patients you serve and the improvements that must occur before we achieve the Triple Aim.

I have known many healthcare thinkers and doers. I know of no other clinician who has has worked harder in his specialty or thought more about the optimal delivery of care based on the highest ideals of professionalism than Tony DiGioia. I met Tony several years ago on a rainy and chilly Saturday morning at a Starbucks coffee shop near Copley Square in downtown Boston. Tony had been a recent speaker at one of our leadership academy exercises. He was back in town for a brief visit to the IHI offices and to confer with some people at the Harvard Business school about some ideas he had been generating. I had not heard him speak, but he had generated a lot of enthusiasm and I wanted to meet him. In less than an hour it became clear that we shared a very similar view of the future of healthcare. In the years since we have stayed in close contact and my respect for his work has been directly and indirectly reflected in these letter. Tony and Eve Shapiro have now distilled the essence of those ideas into a workflow or process that I think administrators and clinicians across the country can quickly incorporate into their current improvement efforts. I hope that you will read the book with colleagues and then become enthusiastic about forming a “guiding coalition” of enthusiasts in management and practice to enable these ideas to help you transform care where you work.

I need to comment on the forward by Don Berwick. First, if Don Berwick is enthusiastic about this work, it should be a clue that you should look at it also. Second, as usual, what Don writes is both inspiring and insightful.

Don begins:

Excellence in healthcare depends on the quality of relationships with patients and families---really listening to what they want and need--- and remembering the values that led healthcare professionals to their calling in the first place. Gone are the days when the simple view that “the doctor knows best” suffices. Now, if we listen carefully and with open minds to what patients and families tell us, we can find the best compass toward improving our delivery of care and their care experience. This is healthcare “co-design,” and it is the wave of the future.

Don goes on to point out that understanding what patients and families want and need is our starting point, but the spiraling cost of care needs to be understood and “brought under control for the benefit of patients, families, communities, providers, and organizations.” He reminds us that none of us know the true cost of care. Our knowledge is limited to “charges and reimbursements” and we are not very transparent about those items. His conclusion is that, “Providers and organizations need to know what it really costs to deliver care if they are to reduce costs while at the same time improving quality and experiences and providing real value.”

Both Don and I endorse the concepts and methodology of this book. The Patient Centered Value System: Transforming Healthcare Through Co-Design represents a significant step toward the Triple Aim. Don ends his forward by telling us:

The Patient Centered Value System as the new operating system for healthcare points the way to personal and professional satisfaction and the experience of joy in work while helping patients and families become true partners in care through co-design.


Preface to The Patient Centered Value System: Transforming Healthcare Through Co-Design

The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.

—Robert Ebert, Dean, Harvard Medical School, 1965

In the more than 50 years between that statement and this moment we have been on a frustrating journey, searching for an operating system and finance mechanism that could “provide optimally for the health needs of the nation.” In 2007, the Institute for Healthcare Improvement (IHI) crystallized Ebert’s vision as the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

More recently that terse description has been given greater meaning by being restated as,

“Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.”

Institute for Healthcare Improvement Leadership Alliance, Year 2 (September 2015 - August 2016)

Since recasting Ebert’s description of the “deficiencies in healthcare” into a pursuable objective that we can all accept and understand, we have diligently searched for easily spreadable methodologies in pursuit of the Triple Aim. Many of us have tried hard to adopt and spread Lean as this operating system and some have succeeded, but always there has been significant resistance as clinicians struggle to see how methodologies developed in manufacturing can be applied to the care of people.

Healthcare professionals have often been unable to connect the industrial methodologies of process improvement to their work without a sense that they are losing the essence of why they became clinicians in the first place. The “adaptive work” of continuous improvement, which seems to require them to give up what they value most, has often felt like a poor fit. Many a Lean transformation has stalled because of the perceived tension between clinical values and continuous process improvement toward the Triple Aim.

Since 2006, Anthony M. DiGioia, M.D. and colleagues at Magee-Womens Hospital, University of Pittsburgh Medical Center (UPMC), have been working to bring clinicians and medical institutions a continuous performance improvement methodology that has its roots in the values of good clinical practice. This book presents the outcome of this work, called the Patient Centered Value System. The Patient Centered Value System is a comprehensive approach to healthcare delivery that comprises three essential tools: Shadowing, the Patient and Family Centered Care Methodology, and Time-Driven Activity-Based Costing--- while complementing and fully embracing current process improvement efforts such as Lean and the Toyota Production System as described later. The Patient Centered Value System integrates the scientific method, clinical values, and the science and objectives of continuous improvement. Reading about the Patient Centered Value System should feel familiar to anyone interested in quality, safety, efficiency, and the traditions of professionalism. The Patient Centered Value System feels as though it has evolved organically from a desire to improve the experience of care by seeing the entire care experience through the eyes of patients and families.

Section I of The Patient Centered Value System: Transforming Healthcare through Co-Design uses the technique of storytelling to quickly connect with readers facing new and challenging learning curves of their own. Over the course of a long career I have played many of the roles depicted in the story: the enthusiastic CEO, the physician leader, and the reluctant and skeptical clinician. The roles that I have not played I have observed in others in numerous efforts to improve care and advance the mission of our organization against significant internal resistance and harsh externalities. I can testify that the characterizations in the story are effective presentations of the many ways that real people react to the challenges of change. The story demonstrates that adaptive change is both an interactive process and a challenging learning curve that must be climbed for both individuals and groups.

The book begins with a story that demonstrates the principles and objectives of Shadowing in action. As a former leader who has struggled with introducing the need for change, the dialog and the actions described in the story feel realistic. It is easy to recognize the leadership challenges and the need to build a guiding coalition of diverse stakeholders. What is most powerful about the story, for me, is how the CEO of Exemplar Memorial Hospital, Dr. Ben Highland, keeps bringing the reasons for change back to the best care of the patient, the hospital’s mission, and the foundational principles of professionalism. As he introduces his colleagues to the what, why, and how of the Patient Centered Value System, the reader learns right along with them. The detail that Dr. Highland presents is so complete that readers should be encouraged to introduce the Patient Centered Value System in their own organizations simply by emulation.

Sections II and III, serve as the didactic resource written in the usual tradition of the medical literature that Dr. Ben Highland might have used in leading his colleagues to understand the power of the Patient Centered Value System. The story portion of the book and the technical portion cover the same issues in a highly complementary way. Repetition and review are the keys to learning.

The information in the Introduction is so useful to understanding the evolving state of healthcare and the theory and science of continuous change that it deserves special mention. If the book just began without some set-up to the story many readers might miss some of the messages that the story delivers. The Introduction should not be quickly glossed over. It has great merit as a stand-alone piece.

My favorite chapter is Chapter 8, “Time-Driven Activity-Costing in the Patient Centered Value System: A User’s Manual,” which demonstrates how to use shadowing long with the costing approach developed by Robert S. Kaplan and Steven R. Anderson (2007) to determine the true cost of care delivery. Any organization that hopes to lower its costs to succeed in the era of value-based reimbursement needs to develop consistency in combining Shadowing with Time-Driven Activity-Based Costing. This “monograph” within a book makes the subject easy to understand and demonstrates nicely how it can be implemented.

Chapter 10, “Patient Centered Value System + Lean or Other Process Improvement Approaches = Rapid Improvement,” is also of particular interest because it explains how to add the Patient Centered Value System to other process improvement approaches you may already be using to accelerate the pace of change. Lean is a management philosophy in continuous evolution. Just as the English language has continuously become richer and more effective by adopting new words and expressions from other cultures and languages, Lean too has always been in a process of continuous acquisition. Ever since a rainy Saturday morning when I first met Dr. DiGioia in downtown Boston to hear about the Patient Centered Value system, I have stressed how compatible his work is with our Lean efforts. How does “going to the gemba” really differ from Shadowing? The projects that are chosen as the focus for improvement in the Patient Centered Value System are quite similar to kaizen, or rapid improvement, events.

What is different about the Patient Centered Value System is the explicit focus on the patient and family as the core concern. In this book, the elimination of waste and the improvement of the care process are articulated more clearly as an extension of our professional accountability and values than often comes through to clinicians as they struggle with their prejudices against Lean as a form of “medical Taylorism.” In Chapter 10 the authors embrace this compatibility between their methodology and other forms of continuous improvement, including Lean. This is huge!

Perhaps the two greatest barriers to success with any improvement methodology are “today’s work” and the time and effort that individuals must devote to learning how to use any new methodology. Competent and committed leadership that extends deep into the enterprise can lower those barriers, yet patients and families who are given the opportunity to co-design the healthcare experience are the true catalysts for change.

Two additional barriers to change in many organizations are the costs of consultant help in managing the change process and revenue lost when frontline staff is required to learn the methodology. If one considers the broad spectrum of healthcare organizations across the nation, it is easy to realize that many just do not have the resources to invest in consulting and their staff doesn’t have time to read and digest the message of a long technical treatise describing a new approach to practice. The authors of The Patient Centered Value System: Transforming Healthcare through Co-Design definitely were considering these realities as they wrote this book. An interested reader can easily consume several chapters at one sitting and it is quite possible to cover the whole book over one weekend. It is easy to imagine a group of concerned clinicians or a senior management team going through this book in preparation for a strategic retreat that is scheduled when collectively they realize that the time has come when they must recognize that business as usual is in its eleventh hour.

Read it as a story. Read it as a resource. Read it as a training manual. Just read it. This is a must read for anyone who cares about the future of healthcare.


Summer Encore

Between Saturday and Wednesday it was “deja vu all over again" for summer. I was profusely sweating after an almost six mile walk with a friend around Pleasant Lake, the lake on the other side of my town, when I took the picture which is today’s header. I could have taken the same picture on the Fourth of July. I knew that the moment would not last because the weather woman on TV had convincingly predicted that the temp would be at least twenty five degrees lower on Thursday, and she is usually right. She was right. Thursday was beautiful, but nobody but me was swimming in the lake. I want to keep up my daily dip until at least Columbus Day.

In a way, I was just a little upset with the encore of summer, and I am really apprehensive about the long range predictions that it may make second and third curtain calls. I had embraced fall in all its glory, and now summer keeps showing up like an old girlfriend that did not get the message that everyone should move on. It’s also true that I am not a climate denier, and the encore seems like a reminder of grief to come even though I know that “normal cause variation” is the most likely explanation. It is true that every now and then for a few days at the end of September the temp is ninety degrees in New Hampshire. I will think about this some more, and perhaps you should also, on a walk with a friend in whatever weather blows our way this weekend.
Be well, take care of yourself, stay in touch, and don’t let anything keep you from making the choice to do the good that you can do every day,

Gene
Dr. Gene Lindsey
The Healthcare Musings Archive

Previous editions of the "Healthcare Musings" newsletter, by Dr. Gene Lindsey are now archived and available to you at:

www.getresponse.com/archive/strategy_healthcare

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