I don’t think anyone disagrees there are a lot of change efforts in medical practice—we just don’t agree about the value and likelihood of success from these efforts. One basic source of disagreement is whether you expect change to be gradual, evolutionary, and continuous, or abrupt, disruptive, and unpredictable. Most people probably assume the former, but I tend to expect the latter. Given that disruptive change is unpredictable, what can I say about it?
I think the most important thing we can do for our patients, our public, and our institutions, is to think deeply about the primary values of medical care, so that when we deal with disruptive change we do not lose our way. Navigating disruptive change requires some idea which way is North. So what are the primary values of medical care, and how does that relate to healthcare reform? I have not attempted a definitive treatise, but have addressed the issue in dealing with a number of different issues. Again, my hope is not to give you THE answer, but help you think about your values and purposes. The unique thing we bring to medical enterprises as practicing physicians is the experience of being in the room with our patients. Finding a way to translate those insights into the way our institutions operate is critical no matter what happens in the larger arena. It is a job that only we can do.
Healthcare Reform Articles
If asked about the greatest advances I have seen, my outside the box answer would be the insight that the quality and safety of medical care is as much about system design as it is about human performance. Current efforts to make providers financially accountable, though, threaten the utility of this insight.
Accountable Health Communities
CMS has announced funding of the "Accountable Health Communities" initiative. Creative problem solving or misguided government interference?
Medical organizations have a lot of data, much of which is not "actionable." However, if taken as a vital sign, such data can lead to important actions that indirectly improve "the numbers."
Addressing Health Care Culture
A contrary view of the culture changes needed in healthcare.
Another Case Study
An effort to redefine corporate purpose offers a parallel to efforts to reform healthcare.
Another Look at the Value Proposition
A review of published data show pay for performance programs have not impacted either cost of care or health outcomes.
Answering Strategic Questions Part 2
What happens if hospitals think of themselves as cost centers, not revenue centers?
Asking the Right Questions
Solutions for problems in health care abound, but are we asking the right questions?
Attribution is a buzz word for deciding which individual provider is accountable for the cost of a patient's care. On paper the definition seems straight-forward, but in practice it is not really possible to define it.
Balancing Money and Mission
The expose in USA TODAY March 11th of the excess COVID 19 mortality in Trilogy nursing homes is yet another example of the need to address the imbalance between money and mission in healthcare.
Capitalism in Medicine
Is capitalism, with its emphasis on markets, really the appropriate model for health care?
What lessons does building cathedrals have for healthcare reform?
Challenges to Achieving the IOM Attributes of a High-Quality Healthcare System
Most people agree the Institute of Medicine's (IOM) description of the attributes of a high quality healthcare system are appropriate and worthy of trying to achieve. But it has turned out to be quite difficult to make progress.
Changing Physician Behavior
Clinical Integration 2015: A Hospital Perspective
Health care organizations now assume "clinical integration" is necessary for economic survival, but the FTC continues to enforce antitrust actions blocking mergers and acquisitions. Furthermore, clinical integration usually means different things to hospitals and physicians. In this article I consider some immediate steps that can be done without legal complications to improve patient care and save money. All that is really required is a change in our mental models.
Clinical microsystems are composed of front-line clinicians engaged in direct patient care. Despite a lack of formal authority, they are the key to successful healthcare reform.
Coaching and Process Improvement
Can individual coaching be a key to process improvement?
The pandemic is a time of disruption. Can it be chance to "push the reset button?
Conflicting Economic Models
Providers are being forced to take on financial risk for the cost of care as shown by recent news articles.
Confronting The Quality Paradox - Part 1
Confronting The Quality Paradox - Part 2
Accounting is not simply a matter of recording reality objectively, it makes things up and changes the definition of what really matters.
Confronting The Quality Paradox - Part 3
Confronting The Quality Paradox - Part 4
There will never be authentic quality within healthcare unless the word explicitly accommodates the truth that a human being is simultaneously both a subject and an object.
Confronting The Quality Paradox - Part 5
CQI - The Good, the Bad, and the Ugly
Are the uses and misuses of the continuous quality improvement method emblematic of our times?
Unintentional injuries during hospitalization have reverted during the pandemic to levels not seen in years. Authors from CMS and CDC opine about what should be done about it.
Experimentation may seem risky, but is essential for progress. How do we do it safely in challenging times?
Fusion cells aren't a new form of fuel, but a method designed to break down institutional rigidity.
Getting to Why
Reduced government spending by definition means someone's income goes down. To mitigate those changes medical organizations need to get to "why."
If the public response to an epidemic is a play in three parts, we are currently in Act 2 and Act 3.
"Hotspotting" is a new term for an old idea, but it usually means identifying and intervening on patients who are, or at risk for becoming, superutilizers. But are we asking the right questions?
How Did We Get Here?
How did the health care payment system become such a mess?
How did you know?
How do experts know? The roles of formal and tacit knowledge are considered.
Improving Clinical Quality Under Fire
Touro Infirmary has been in the news but not in a good way. What should it do?
Knowledge management (KM) covers any intentional and systematic process or practice of acquiring, capturing, sharing, and using productive knowledge, wherever it resides, to enhance learning and performance in organizations. Which strategy for knowledge management is appropriate in dialysis clinics?
Linking Guidelines and Process Improvement
I fear working on the difficult issues of improving health care delivery and linking guidelines and process improvement won’t stop us from ramming the iceberg created by current economic realities of high inflation, low unemployment, wage growth, lack of qualified applicants for positions requiring credentials, and pent-up patient demand that was deferred by the pandemic.
Meaning or Money
The question: is health care about money first or mission first?
Measurement error is recognized in the laboratory, but not in US healthcare, which is causing problems.
Medical evidence is a four-source: guidelines, registries, data mining and " in my experience". Different clinical situations use different types of evidence and have different implications for provider behavior. These implications are considered in detail.
Everyone is opposed to wasteful medical spending, but we still don't have a robust definition of what is waste.
Money in Medicine
Money has always been part of medicine, but it seems both quantitatively and qualitatively different now.
Money and Medicine Part 2
Many physicians and hospitals have entered into employment relationships, but neither are happy with the result.
More Data on the Value Proposition
Value-Based Purchasing" is a complex program designed to improve hospital quality and outcomes by using financial leverage. A recent study by Ryan and associates suggest it has had minimal effect.
More on Variation - Part 1
Variation is not peculiar to healthcare, but is a general issue with the way the people think, and occurs whenever judgment is needed and the data are fuzzy.
Conversation is an essential step if we are to overcome the problems with our current dysfunctional health care system.
New Payment Methods
Numbers are everywhere, but we need to be conscious of both the uses and the abuses of them.
On Dying in America
The IOM report "On Dying in America" makes recommendations for change that physicians should embrace.
On Institutional Failure - Part 1
On Institutional Failure - Part 2
A central question for healthcare organizations as they face the future is what is our goal? While taking care of patients might seem the obvious answer, it is the one that is usually not considered.
Optimism or Hope
"Hope is optimism with a plan."
Organizing for Success - Lessons from Keystone
The Keystone Cooperative ICU Project obtained major improvements in safety. The "soft science" lessons need to be applied more widely.
The psychological stress test posed by the pandemic has ramifications for the future of population health efforts.
A consideration of the interactions of patient preferences, evidence-based medicine and peer review.
Paying for What We Don't Want
Do you believe the proverb "you get what you pay for"? What if you pay for what you don't want?
An expert panel has concluded less than half of current measures used by CMS to assess value for primary care services are valid. What does this tell us about current pay-for-performance efforts?
Physician Decision Making
Physician decision-making is both complex and deals with uncertainty dooming current simple approaches to changing physician behavior.
Is physician engagement a strategy to promote physician leadership, or a code word meaning how do we get the doctors to do what we want?
Playing it Safe?
Many health care organizations have become frightened—so much change is being forced upon them it seems insane to voluntarily try something different. But what it it is essential?
Population health is a phrase that disguises some hard realities as illustrated by two recent reports.
Productivity in Healthcare Part 1
Many are focused on efficiency and productivity in healthcare without a clear understanding that the two are not interchangeable. This article introduces the two concepts as they are commonly used.
Productivity in Healthcare Part 2
The conflict between productivity and efficiency is examined from three perspectives using the care of dialysis patients as the case study.
Productivity in Healthcare Part 3
The conflict between productivity and efficiency is contributing to widespread physician malaise, which has negative implications for health care improvement.
Putting Patients At The Center Of Healthcare
Putting patients at the center is crucial for healthcare organizations, but how can it be done?
Rationing is a dirty word, but a necessary part of healthcare reform. A consideration of the implication of this for practicing physicians.
CMS is in its third year of applying penalties to hospitals with excess readmissions, but almost 75% of hospitals were penalized this year. Is this a quality improvement or a surtax?
Restoring the Commons
A consideration of the interactions of patient preferences, evidence-based medicine and peer review.
Risk, Reward, and Other Reasons Patients Don't Follow Medical Advice
Patients often don't do what their doctors recommend. The problem is important and contributes to "bad" outcomes, yet we have little insight into the problem.
Shared Decision Making
A consideration about decision making at the person, group and organizational levels.
Short Term Risk For Long Term Reward
Health care executives are faced with taking major short-term risks to their organization's survival in hopes of long-term benefit. This is new territory for them, but is a common problem for physicians.
Social Determinants of Health
Social determinants of health trump many medical therapies, but can changes be made that result in better health?
Are we spending our health care dollars wisely?
Staff Shortages and Health Care Reform
Persistent staff shortages may force care re-design in ways healthcare organizations have previously resisted.
Standardization Versus Innovation
Two recent articles present starkly different approaches for healthcare organizations dealing with the stresses of the pandemic and healthcare reform.
Strategic Human Capital
Healthcare organizations need to realize the economic value of experienced teams of clinicians able to provide highly reliable care and to recognize the importance of maintaining team integrity in times of surges in patient volumes.
Strategic Questions for Physicians Part 1
Several trends are making it imperative for physicians to re-examine their idea of what effective practice of medicine entails.
Strategic Questions for Physicians Part 2
Specialist physicians also face strategic choices and no matte which is made, the future will bring major changes.
Our current cultural norms make following traditional medical advice, like eating less and exercising more, difficult for most people to do. Improving health may have more to do with modifying these forces, which is beyond the competence of health care providers and organizations.
Medicine has adopted the language of manufacturing with terms such as efficiency, reliability, and “lean processes.” An unintended consequence may be increased risk of system failure.
The 1% Solution
Efforts to constrain health care costs have not been very effective. Maybe instead of grand solutions we need a series of "1% solutions."
The Case for Physician Leadership
Why the successful healthcare organization of the future must find a way to create physician leadership if it is to achieve the IHI Triple Aim.
The Center Effect
Some dialysis units have consistently better performance than others, even after adjusting for individual patient variables, which is termed the center effect. This has important implications for hospitals and health care organizations as they respond to public reporting of data.
The Primary Care Dilemma
When people are well they want convenient care, but when they are sick they want "the best." Is that possible?
The Profit Motive
The American College of Physicians has published a new position paper on financial profit in health care.
The Public Looks at Healthcare Reform
The Tragedy of the Commons
Recognizing the Commons is critical for success in an era of rapid change.
A work-around get past a problem with addressing either the root cause or a solution. Health care abounds with work-arounds.
Trust in Physicians and Healthcare Reform
Public trust in physicians as a group is quite low, despite the high regard patients have for their personal doctor. The implications for the physician's role in the health care reform debate are considered.
“It is time…to realize that changes in culture, investment, leadership, and even the distribution of power are more important for progress toward the Triple Aim than measurement, alone, ever was or ever will be.”
Update on Value Based Purchasing
Three articles this week provide a useful update on value based purchasing.
Vaccine hesitancy is a case study with implications for what we can expect from current efforts to create "good healthcare".
Value-Based Dialysis Care
A recent flurry of reports describe real-world results of the paying for value trend. What conclusions can be drawn?
Variation in Health Care
Is variation in health care good, bad, or inevitable? The answer may determine future medical practice.
Platforming is a new buzzword for an old idea--successful organizations put the customer at the center of the business. What does that mean for healthcare organizations?
Waste and the Cost of Care
There is no doubt individual health care expenditures have grown faster than the economy. Is this due to increased intensity of service (waste)?
What Hospitals Are Doing
How are hospitals and health systems responding to change? An AHA survey provides some insights, but suggests few are really working to improve the function and resiliency of their teams, and are thus likely to fail in attaining their strategic objectives.
Why the Value Proposition is Not Selling
Why is there resistance to the value proposition in health care?