| 8 May 2015
Dear Interested Readers,
Inside This Week's Letter
This week’s letter certainly is a “musing”. The first section has a provocative title and is a story of regret and personal transformation.
The second section is a celebration of the recently reported achievements of the Pioneer ACO but it morphs into a discussion of the long way we have to go on the road to the Triple Aim.
The final section before this week’s attempt at a humorous closing has its origin in one “Interested Reader’s” response to last week’s letter about obesity.
Throughout the letter you will find references to Atul Gawande’s new New Yorker article. I did not read it until yesterday while I was flying down to Newark to speak at a meeting in Short Hills today. I plan to write more about the article next week. It is his best effort yet.
Finally, my colleagues at Strategy Healthcare.com are eager to post your points of view as healthcare professionals and interested readers on any of the topics that are discussed. I know that many of you write. I read your articles and I also know that some of you who rarely write have things to say that should be shared. Drop me a line by hitting reply on this letter and I will make sure that your thoughts get on the Internet as a posting on Strategy Healthcare.com as part of our ongoing collaboration.
What I Do Not Remember Fondly About Practicing Medicine
I do not know about other retirees but one of the things I find myself doing in these early days of retirement is a lot of “replays” of my years of practice and medical group leadership. In Lean terminology it would be called “Hansei” or deep reflection. It is strange that the replays of my practice activities are daytime events. They are a major part of my reflections on my long walks. So far the replays have not invaded my dreams. I do have a lot of “do over” dreams but they usually are about high school football, old girl friends, or going to college and medical school again.
Long before I was aware of the wisdom of the question, “What part of the problem am I?” I became involved in the governance of my practice because I wanted to see changes made. Perhaps my motivations were self-serving but I had come to a fork in my own personal road and after a little experiment to briefly consider a different road, I decided that I would rather try to make a difference by becoming more involved rather than fight the progress that others were trying to make. It was not quite like St. Paul’s experience on the road to Damascus but it was definitely an inflection point in my life and it did involve a little trip.
It was ten years into my practice experience at HCHP that I realized I was dissatisfied and frustrated. I realized I needed to leave and start all over somewhere else or I needed to stay and get more deeply involved in the effort to improve the environment that I had become tired of complaining about. It was not easy to decide which way to go. Then I remembered the dream that I had years earlier. In my dream I would practice in an idyllic “our town” environment where I could walk to my office in the local hospital and I would become a member of the community of other professionals, merchants, tradesmen and citizens.
I was tired of the anonymity of the city and its endless commutes and degrees of difficulty with the simplest of life’s activities of daily living. I dreamed of someplace where people seemed to care about one another. I was looking for a world right out of Thornton Wilder’s 1938 play about life in small town America. I was looking for a place like Wilder’s little town, Grover’s Corners, where one could be part of a community and live next to “ordinary people who make the human race seem worth preserving and represent the universality of human existence.”
As fate would have it, I saw an ad in the NEJM for a cardiology position at the hospital in Peterborough, New Hampshire. Peterborough is generally accepted to be the model for Wilder’s town in his play “Our Town”. Wilder wrote the play while in residence at the MacDowell Colony in Peterborough. If you clicked on the link just before these words you learned what at least one critic of the play says that Wilder is trying to tell us. He writes, “[Wilder] is reminding the audience of how precious daily life is, because it determines our true reality…our enduring identity is not derived from the things and the events because they are familiar and repeated, but from our ever-new, ever-fresh relation to them.”
All the romance and personal discovery of Wilder’s little town fit nicely into the fantasy I was exploring as my wife and I drove west on Route 2, the “Mohawk Trial”, from our home in Wellesley toward Mount Monadnock and Peterborough. It was a good trip. The town was lovely. The hospital looked up to date and adequate. Everything looked better than I expected. I could even imagine hanging out with smarter people from the MacDowell Colony and enjoying good live music at some of the local venues after a day of fishing in the nearby streams and ponds. As we drove around more, a greater realty became apparent to us, Peterborough was not where we belonged in 1985. We belonged in Boston. Families are not so portable and I loved my colleagues and my patients. I realized that I needed to stay put and begin in some small way to try to contribute to making the practice that I was angry about become something better. My dream of small town life needed to go on a long “hold”.
That Sunday drive was a great investment. I learned much more in Peterborough than I expected. I never even applied for the open position at the hospital. I went home and reapplied myself to the work that I was seeking to avoid. From that day forward I decided to become part of my practice. Before the trip to Peterborough I was just treading water and looking at options. I had been apart in the midst of a crowd. I had defined myself as on the outside and in my mind, my way was the better way. I was the epitome of the autonomous physician. After Peterborough I realized that if I did not care enough to try to be a part of the group and participate in the effort to improve care, it was hard for me to justify any complaints.
Rather than be part of the problem, I needed to see if there was any way I could be a contributor to meaningful change. Dr. Ebert’s plan and ideas were bold. Even bold ideas take time to evolve and to gain traction. Old ways die slowly even when they are dysfunctional. Today’s work takes most of our energy and the work that will improve things must be done in and around and after what we must do in the old way until we learn the new way.
As I reflect further on those years of practice, I am a little surprised that I am losing the names of many of my patients. I saw thousands of patients in more than a hundred thousand office visits and stood at the bedside of thousands more in hundreds of tours of duty as the hospital based cardiologist on call for my practice; but now without the refresher of a recent visit even some of the most active patients are becoming a memory without a name. It is interesting to me that I can still see a patient’s face and EKG in my mind’s eye and relate minute details of their history but not have a name to go with the collection of stored data.
Losing names is not what disturbs me most as I think back over my years of practice. What disturbs me most were all of the lost opportunities even after I decided to try to be a part of the solution. What really disturbs me is how hard it was to work in an environment of waste. As hard as it is to work in an environment of waste until the advent of Lean, it has been even harder to break out of an environment of waste.
The thing that was most wasted was the time I could have been spending doing for patients what I alone could do while I was doing what a poorly engineered system required me to do that could have been done much more efficiently by another staff member. Lean talks about the basic eight wastes in systems. There are different mnemonics to describe them but I favor “TIM P. WOOD”. I have lifted a description of the eight wastes from a Healthcare Finance News interview done a few years ago with Marc Hafer, one of my Lean mentors. I did just a little editing. Click the link if you are interested in the whole article.
1. Transportation: Transportation is entirely non-value-added. "It contributes nothing to patient care. It adds to delays and increases likelihood there will be defects and dissatisfaction," Transportation includes moving patients from one department to the next, shifting supplies and equipment and moving instruments from sterile processing areas to the OR and back again – and even when patients travel to and from the actual hospital itself.
2. Inventory: Inventory can include pharmaceuticals, supplies, and patients, too, if you consider a waiting room in a hospital. The replenishment system should be based on use as opposed to some forecast. "Only what's needed when it's needed is a good approach with inventory,"
3. Motion: Unnecessary motions, reaching, bending, twisting, and turning. These motions are all ergonomic issues abundant within healthcare. Clinicians are injured because processes like transporting a patient from wheelchairs to beds aren't designed ergonomically. Staff takes time off for rehabilitation when unnecessary motions incapacitate them, which can result in a loss of productivity and enhance overall costs.
4. People: Unused human potential with all the waste that already exists in healthcare, the last thing clinicians need to do is more non-value added work, yet it happens all the time.
5. Waiting: Patients waiting for treatments, clinicians waiting for supplies... as cliché as it sounds, time is money; and sometimes it's a matter of safety, too. There are some medications that need to be administered within a certain amount of time after a reaction or a procedure. Waiting can diminish the quality of the pharmaceutical and it's effectiveness with the patient.
6. Overproducing: Overproducing is creating more of something than what's exactly needed. Sending medications to a patient's room that won't be used because the patient has already been discharged is an example. Along the same vein, this type of miscommunication between departments can also extend a patient's stay, which is another form of overproduction. Other examples include repetition of diagnostic tests and the multiple registrations a patient has to endure when checking in. It's a laborious, unnecessary process and one time should be sufficient enough.
7. Overprocessing: Creating reports that don't get read or aren't useful, administering duplicate tests – doing things where you produce 105 percent when you only needed to give 100 percent is processing waste.
8. Defects: There are countless defects within healthcare situations, such as hospital-acquired infections, early discharges that lead to readmissions, incomplete medical records or instrument kits in the ER and inaccurate medical billing. In many circumstances, these defects are covered-up through reworks and workarounds.
[In this week’s New Yorker Atul Gawande has written an article that showcases waste in healthcare. He just sums all waste up and calls it “overkill”. This story may be his best yet: “Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?” I plan to review this article in depth in next week’s letter. Among other things it gives a great review of what has happened in McAllen, Texas since the article he wrote six years ago; and he makes very big points for ACOs, the ACA and CMS.]
Just reading the list of wastes now causes me to bristle as I can remember specific moments when the time of a patient or my time was a victim of one of these states of dysfunction that are so ubiquitous in ambulatory practice. I also must admit to the sin of frequently being a part of the waste problem. As Gawande so bravely describes in his article in a vignette from his own practice, we sometimes waste resources because we think the patient needs reassurance. That was the sin I most frequently committed. I knew I was doing something that was unnecessary and did it anyway blaming the patient’s insistence or his or her inability to understand why the test or treatment was unnecessary. Sometimes I rationalized the justification for that extra stress test or echocardiogram because I needed to gain the patient’s confidence.
Some of the eight wastes may feel more important to the individual work of a clinician than others but all are important to the enterprise. Fee-for-service financed healthcare is especially prone to waste the potential of people because reimbursement is highly related to the activity of the licensed individual. If the doctor does something, payment occurs. If staff does it or if the system takes a step that adds no value out of a process, then payment is lost. The result of this volume based reimbursement system is that the wrong person is often doing activities that add no value for the patient but do generate revenue.
The two biggest wastes that aggrieved me in the behavior of others that I was frequently blind to in my own practice were over-production and over over-processing. As mentioned earlier, Gawande just lumps these as “overkill”. Many times in clinical practice we metaphorically apply six coats of paint when three does the job nicely. Clinicians order tests for a variety of reasons, some good and some not so good, the result is a waste of time reviewing data that was not needed for a cost, often shared by the patient, that added no value. We have learned some bad habits that are hard to break alone. Lean is a good way to move from practicing alone in an environment of waste to collaboration in a culture of quality. What you can’t do alone is often achievable as a group or team.
Ironically the practice at HCHP was one of the most supported and innovative practices of its day and yet even in that environment of good intentions more of my time was misused than effectively used. The same was true for all of my colleagues and sadly the same problem still exists throughout most of ambulatory healthcare even as I write today. I frequently ask physicians what percentage of their day is spent doing what they alone could do. The answers that I get are tightly clustered around 35%.
I do not regret a minute of the time I invested in patient care and in retrospect I was trapped in time and space and the way forward toward my “box 3” ideal state of practice was a slow journey that is taking longer than the time I had left to practice. It was thirty years ago that I was “converted” on the road to Peterborough. I am proud of the many efforts made by the organization and the continuing work driven by the commitment that exists in my old practice to the “Triple Aim plus one”. The “plus one” is the improvement of the professional experience of everyone doing the working of the practice; but there is still so much to do and across the country the work is just beginning in so many places.
I have always considered being someone’s doctor or being a healthcare professional working to improve the health of others as a “high calling”. I realized great joy seeing patients and struggling with the clinical problems and concerns that they brought to me. I realized even greater joy and had more confidence in our collective success at the end of my career when we began to use Lean as the core of our efforts to improve care.
As implied, Lean arrived a little late for me. I never got the plus one and the Triple Aim is still more of a goal than a reality. I am left with the regret of the lost time spent licking envelops, making calls for approvals, make calls to cajole a consult when the system had not been staffed to meet expected demands and using my one-off problem solving skills to make it through the day. I am also left with the regret that I too was often a waster of resources. Trying to improve practice without a culture of Lean thinking is much like the work of Sisyphus. You push the stone up the mountain again and again. The time I spent figuring out a solution one day rarely had a continuing return on investment the next day. My solution did not create new “standard work”. I knew that tomorrow the same problem would be there needing a different solution because there was also no standard work in the work of others and the various suppliers of the services I needed for my patients each had their own autonomous way of viewing the world.
I do not think that I ever experienced burnout but I can remember great personal stress as the result of being imbedded in a system of waste. I regret the fact that I surely transferred some of that stress to my close family and some dear friends. Work related stress was not the only factor in a marriage that did not last; but it was surely a contributor. Time wasted in an inefficient system was a burden for my patients, a loss for me and a loss for my family. I understand why it was the way it was; but I still feel that I am justified in my regret of the past reality.
During a recent conversation with Anita Ung about the success at Atrius Health with quality metrics, she surprised me by describing a senior clinician whom I respect greatly who is dismissive of participating in the efforts to improve quality metrics because he “has too much to do”. He works in an environment where there is Lean but apparently he has decided just to continue to work as he always has worked. It is sad indeed that he is not alone. Accepting changes in work flows and a redefinition of your “standard work” requires a level of adaptation that is just a bit too much of a stress for some people. I can certainly understand the clinician who thinks that he has been doing a good job for thirty years and balks when presented with data to the contrary or is invited to work with others to find a better way.
The physician that Anita referenced and I did practice in simpler times when clinical autonomy was mistakenly conceptualized as an asset. The best doctors were the most individually creative in the ambiguity of clinical practice. When clinical supports are not optimal, knowing or inventing what to do in an inadequate environment does require resourceful utilization of what is available and some creativity even as it generates waste. Ironically, as I said before, solving problems is a satisfying exercise but when the whole day is full of problems that return again and again to be solved and solved again, that can be stressful. I envy those clinicians now that have the ability to solve a problem once in a Lean environment and can expect it to stay solved.
If I could turn back the hands of time almost forty years to July 1, 1975 and make one small change to the moment when I walked in to the Kenmore office of Harvard Community Health Plan to start practicing, it would be that through some miracle it would be that I walked into a practice where my arrival had been preceded by the establishment of the Lean environment that does exist at Kenmore in 2015.
That is my story. As many times as I run the tape in my mind, the story does not change. I was born too soon. I was born before we had Lean. Sure I did get a taste of TQM in the mid nineties and it helped me and the system did get a little better. Despite being attracted to “quality in daily work life” and making many efforts at self directed improvement, my reflections now suggest to me that despite my good intensions on the road back from Peterborough, I could have done more for my patients if I had just had Lean.
The patients did not get the best that they might rightfully expect. Sadly, I also realize that I could have enjoyed practice even more than I did and I would surely have had less stress to take home with me if I had worked in a Lean culture and been able to practice in an environment of continuous improvement. It is painful for me to realize that for at least a decade now it has been possible for every medical professional to have the joy of better support working at the top of his or her license in a continuously improving environment; but very few are. There are huge opportunities to be realized.
What I Read in the Newspaper
Tuesday’s Globe published the much-anticipated results of the independent actuarial accounting of the results of the first two years of the Pioneer ACO program of CMMI.
Click here to read the whole article.
I find it impossible to read the article without wanting to comment. Many may not remember that the first accountings were somewhat different. In 2013 there was an article in the same paper and in papers across the country that essentially reported the reverse of these results. The initial results were reported on savings against a budget that was a function of previous performance. Those original budgets were highest for those systems that were most expensive and were lowest for those systems that had previously had some success in lowering the cost of care. The “rules” seemed pretty unfair. My thought at the time had been, “Once again no good deed goes unpunished”. At other times I regressed to a Southern expression of wisdom, “Oh well, thems that gots, gets” as I pondered the higher budgets of some of the most costly and wealthy medical institutions on the planet.
The release this week is fabulous on several levels. At the most important level it is a verification of the concepts behind the Pioneer ACO. Secondly, the reported successes should encourage other ACOs to examine what was done and try to build on what worked. Finally, the dedicated medical professionals that did the work deserve the recognition. I think that it is not a coincidence that Dr. Gawande’s article that touches on many of these subjects also came out the very same week. We will hear a lot more about this analysis as we all try to extract the lessons and move toward applying what was learned.
Back in 2012 there was controversy, confusion, and uncertainty about how success would really be judged and ambiguity about every aspect of the proposed objectives of the Pioneer ACO project of CMMI. How in the world would we ever lower the cost of care when patients could go to other providers whenever they felt like it? Elliot Fisher encouraged the Pioneers with his bucolic metaphor, “The best fence is a green pasture.” It is turns out Elliot was right although I would just say that businesses have know for a long time that customers are loyal to organizations that treat them with respect and provide great quality delivered with the highest levels of service and Pioneer has proven that once again.
Pioneer ACOs may not be the perfect answer to all of the dysfunction in healthcare and the exact structure of Pioneer or even the Medicare Shared Savings ACOs surely can’t be transferred to every patient population and every practice in the country but Pioneer and MSSP are moves in the right direction and if nothing else the report gives credence to what I have believed for a long time:
“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.”
The Pioneers demonstrated that more money was not necessary to improve care. Pardon the wordsmithing of Dr. Ebert’s quote: With less money spent the Pioneers did improve care with a new conceptual framework and operating system that did address the health needs of their populations.” We should all be encouraged by their success and grateful for their courage and efforts.
The Importance of Prevalence
Every writer likes feedback. I am no exception. I would go further and say that I write to get feedback. For a long time I have had a habit that has its ups and downs. I am a true extrovert in that I understand more when I write and speak and get the responses of others than when I talk to myself. I do both. My long walks facilitate conversations with myself if no one else comes along. I may have had an original idea sometime but I could not tell you when or what it was. Any idea I have had is built through collaboration and reconsideration of the ideas coming to me through what I read, what I hear and what I see. Five minutes after this letter goes out I will be checking my email to see what is coming back. I love to report to you what comes back to me. The letter last week generated some great responses and I gained an insight that was present in plain site but still deserves being underlined and emphasized.
Hi Gene,
As always, your Friday musings touch me in so many ways.
This week, I must say that the fundamental issue in US Healthcare is NOT costs. How we think about costs and payment is a primary driver of our dysfunction, of course, and eliminating waste and lowering cost is a huge and necessary task before us. However, a fundamental issue in US Healthcare is the focus on commoditizing treatment of pathologies, rather than investing in and rewarding health itself. Probably because measuring how to do this investment and reward is so SO hard!
For example, a system cannot drive down the cost of obesity treatment if it focuses only on treating people who are obese. Even if you are successful with each case AND do it efficiently (both highly unlikely), the total cost will continue to be astronomical if the rising PREVALENCE of obesity continues as it has. Instead of rewarding treatments per se, reward systems that decrease prevalence, tax systems that increase prevalence…
Single payer systems will not fix the focus on treatments for pathologies--although they might pivot faster, theoretically--we still need methods of measurement and creative incentives to reward and invest in long term bulwarks against the rising tide of prevalence of chronic disease. We need to actively invent that paradigm, and not focus on battles over paradigms of the past.
xxxx
I think the writer is on to something and it should be built into everything we do. Treating obesity in those who have it is both wise and humane; but I think the writer is dead right implying that the treatment for the population is a different question than the treatment of the individual. Perhaps HIV is an example of the concept. We develop treatments for affected individuals plus we develop population-based strategies to reduce the prevalence of the infection.
We are at the end of the era of just treating disease in individuals. The next era will be about enhancing health and reducing the prevalence of disease. We really do not have developed economic concepts that vigorously support reducing prevalence. In a way this is an extension of the thoughts that I reported a few weeks ago that were expressed by Michael Chernow in his presentation at GPIN.
My pen pal had some specific suggestions related to the relationship of obesity to the destruction of the “microbiome” that I left out of the reproduction of the letter because that subject alone quickly becomes political as would a discussion of the impact of empty calories of high fructose corn syrup that make up so much of the diet of the people who are economically drawn to cheap calories. But again the writer makes a good point and that is that the war on prevalence will go far beyond the ambulatory office and the hospital.
Many of those battles will be in legislatures and courts and wisdom will evolve slowly as we gradually move a critical mass of the electorate to a tipping point of understanding why letting everyone have it their own way leads us to a state where no one gets what they need. That story is for another day although the prequel is called “The Tragedy of the Commons”.
What Glorious Weather on Some Days
Earlier this week when I took the picture of my new friend Thunder that you can see in the header of this letter, the weather in New Hampshire was a little dull. Thunder lives about a mile and a half down the road from me on one of my favorite jaunts. I think we have a lot in common given that we both seem to be retired and have probably seen better days.
I stop by Thunder’s place and talk to him over the fence but he doesn’t say much. He seems to listen well and he never gives me the cold shoulder and does not move away. I do think our relationship will grow and even if it doesn’t it is already meaningful.
My relationship with the Red Sox is on a much more tenuous footing. I can’t bear to watch self-destructive pitching followed by the scene of runners dying on base in scoring position. And then there is Tom Brady. Has he gone the way of Pete Rose, Lance Armstrong, Barry Bonds, Roger Clemons, and Alex Rodriguez? Will all of the previous adulation become the disgust due to someone who has violated a sacred trust? I can’t talk about it now. The pain is too acute. I will walk many miles before I figure out a way to see anything good coming from the report about “deflate-gate”. I am past denial.
To end on a positive note reread the part about Pioneer or make plans now for an adventure in the outdoors because all of the reports I read suggest that it will be warm, even if it is a little cloudy, most places this weekend. We are making progress toward the lazy, hazy days of summer.
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