Saturday, February 26, 2011


Essays and Methods, Madness and Passion for Hospital Excellence

Hospitals are very complex, and they perform nothing less than miracles every day. Of all the organizations within a society, it is the hospital where the best in what we are as human beings, as a community proves itself.  Hospitals have always had a significant series of challenges. They struggle with reducing errors, improving service and satisfaction, raising the standard of health in the community while improving hospital performance. For a number of reasons, Hospitals are some of the most over-consulted and poorly led of businesses, and unfortunately, this has led many to avoid getting help when they need it.

Hospitals strive to run like businesses, but in truth the very best businesses strive in their highest ideals, in their wildest dreams to imitate what is found in every Hospital.

It is the Hospital which every minute of every day serves all humanity: the sick, the indigent, the downtrodden, the lost.  The Hospital's mission is a simple one -  life: To rescue, to save, to heal, to restore, to rebuild and set people on a better foundation for living; to trade illness, fear and threat of peril, anguish in the face of imminent threat of death, and replace these with hope, progress and life; and where that is not possible to help grow understanding, acceptance, and give comfort and peace.

In the journey to improve the quality, service, productivity and performance of Hospitals there is far more fad than fact out there about what actually works. And the issue of sustainability seems very illusive, though claims for it are common. The problem persists when people, be they consulting gurus or their "new program", or the hospital executives or employees, put themselves before the hospital.

Whenever you hear anyone say "Have you heard about the XYZ  Program! IT does great things!" run the other way.

Whenever you hear anyone say "Listen to this guy! He's a great Visionary!..." or" She's a brilliant Leader - follow her!" flee to the hills.

I started in patient flow and clinical performance improvement consulting in Emergency Departments in the mid - 1980s. The staff in my first Emergency Department were upset that it was taking 40 minutes for chest pain patients to go from Emergency Department front door to CCU bed. They wanted that time cut to 30 minutes, and they succeeded!

Today, any hospital that can accomplish as much in under 120 minutes is considered a top performer. And most take at least 180 minutes. Many take substantially more. And research verifies that the longer a patient stays in the ED, the higher their chance of infection, and the longer their overall length of stay as an inpatient in the Hospital.

In many of the most fundamental things, Hospital performance has declined.

So much for all the fads, scorecards, improvement projects;  the conversion to "for-profit" status; the implementation of DRGs; the reckless "remote control management" by insurance verifiers and better diagnostics. All these have made hospitals resource heavy at the top, often dangerously scarce at the bottom, and inefficient throughout.

And the great ideas that  lost their way in the packaging, profits and politics have come and gone, and come back again: Management by Objectives, Quality Circles, Statistical Process Control, Total Quality Management, Continuous Quality Improvement,  Reengineering, Six Sigma, Pillars of Excellence, Score Cards, Patient Centered Care, Mission Effectiveness, Vision-Setting, Patient Focused Care, Ideal Patient Experience, Lean Hospitals, Shared Governance, Revenue Cycle, Value Added, Meaningful Use, Rapid Cycle, Environment of Safety, Accountable Care Hospitals, etc..

How can all this work result in things that looked like improvement at the time, measured improvement, but which have decayed over-all quality of care over the decades?

Yet that is what has happened.

In 2011 the most innovative fad in Hospitals, enthusiastically embraced and praised as genius, is the use of a checklist and floor supervision (buzzword "rounding"). Entire national research projects have been mounted, procedures have been packaged and copyrighted, new Gurus have emerged in the great national movement to bring to Hospitals what was already there not so long ago: Things employees, head nurses, house supervisors knew about and practiced with vigor, but which have faded into obscurity.

These basic principles are not new notions, and touting them as genius, packaging them into a "program" simply draws attention from the dynamics that unraveled them, and indeed the "Program" is one of those dynamics.

Consider the Electronic Medical Record. Here is a great idea whose purpose was lost in the short-sighted financial gains of IT firms, Consultants and Hospital executives. In the rush to install electronic record and tracking systems, principally for the purpose of increasing patient charges and revenue, and secondarily to reduce errors, klunky systems have been put in place which require so much effort from nurses and physicians that their patients are neglected with all the negative correlates. The systems that existed before - paper checklists, supervision and inspection,  real-time communication, coordination and teamwork  - have been largely abandoned with nothing but weak shadows to replace them.

The paper systems engineered to support good care over many decades were tossed away. These systems could be held in your hand or put into your pocket and moved where the patient, physician, decision-maker, family were located, so that recording, management and care were seamlessly integrated. The EMR was supposed to take this much further by reducing the tedium of documentation and information transmission; providing great artificial intelligence to streamline good care, so that care-givers could spend more time, not less, with patients doing the right things better, more intelligently.

But now those systems overall take much more time than the paper. A physician often must go through ten different screens to make a single order, when once-upon-a-time they were able to make a 20 second request of the Unit Clerk.

With any given new patient or patient ready for discharge there may be a dozen such orders. This bottlenecks the whole flow of admission and discharge.  Hundreds of caregivers and techs must fight through a very inefficient process waiting hours to see the orders on the computer before they can begin. Once-upon-a-time, the MD spoke directly to the RN and the Unit Clerk at the same time for three minutes to get these things moving forward immediately.

Because the Gurus, Leaders and Tech geniuses promised this would streamline communication, people have stopped talking to one another and wait for the computer to tell them something is needed, something is ready. Their day is scheduled on the basis of NOT spending time in face-to-face teamwork with colleagues and patients. No longer making insightful physical assessments that were of equal clinical accuracy, now care-givers instead rely on batteries of diagnostic tests that are time consuming; which are completed long after the physician and caregiver have gone on to other things, and which clinically have not improved the Hospital's overall level of care.

And furthermore, because people self-select when and what to enter into the system, communication has broken down. The busy MD doesn't stop to enter the order into the computer until he or she has rounded with all their patients, hours later, batching work, piling up delay. The busy Housekeeper doesn't stop to enter the clean room into the system until they have cleaned all their rooms, causing patients to wait in the Emergency Department additional hours for an inpatient bed.

What was once a human system of teamwork and live accountability from one manager or care giver or MD to another, patient by patient, now has a non-verbal, non-live text based electronic intermediary that piles up batches before passing on the information. This has disrupted and destroyed much of the human accountability that once existed.

They have made it worse, not better. Is the Hospital able to charge patients more money? Yes. Is the electronic system reducing medical errors and improving care outcomes? No. In some cases, it is worse: A distraction causing delays, lost opportunities for care intervention, lost teamwork and communication.

Promises were broken, but that doesn't stop them from continuing to be made. Where is the acknowledgment "We did this wrong"? How can any real progress take place without that? How can any new promise hold credible hope?

Now these new systems aren't so new. They are five, eight and ten years old. But changing them has been very slow in coming.The bigger systems that talk to each other are still klunky. The tiny systems that have some utility for clinical management don't communicate well with any other centralized billing or record systems, so duplicate entry is still necessary.

It is nothing but business competition among IT firms which has created this lack of coordinated effort and fragmentation in the tragic story of the EMR.

So much time has elapsed in this story that the tools and practices of great care from the past have been lost, rather than transformed through technology and teamwork into something greater. When past Hospital executives, nuns, nurses, managers, technicians and physicians retired vital lessons were lost. No one was interested in learning to do what they thought they would no longer need to do.

Improvements in one area can be real and significant, but when they are over-sold, people are led to believe they don't need to do common sense things anymore, like walking around and inspecting work, or checking in with patients or colleagues, or double-checking a verbal request, or confirming that request was filled.

When one small thing is fixed, what is the cost to other important practices that affect patient care, safety and satisfaction?

By making the old entirely "wrong" in order to grow a career on the new, the seeds of self-destruction are planted by the very process of implementation. So then you have replaced the old with a system that doesn't actually accomplish what was being done before, and is also doomed for the scrap-heap.

This is why Hospitals are the dinosaur graveyard of information systems, and "improvement programs",  purchased and out of date by the time they are implemented. Or worse, harmful to patient flow and care.

In this way such "improvement projects", enthusiastic for a moment, create lasting distrust.

It all looks great, but like an addiction, harms the host.

There is a myth perpetuated by those who have built their careers in just this kind of short-term exploitation. It is the myth that says a great leader comes in for a short period of time, dismantles what doesn't appear to work, makes major change, and goes away, leveraging the credit they have taken for themselves into their next higher-paying job.

But what really happens is that the most critical source of support for sustained change, the leader, is now gone.

Now that "leader" learns nothing about what it really takes to sustain change. They learn far less than those who must live with change for an extended period. You have leaders who know dangerously little about sustained quality care, fixing a small problem by dismantling an entire system, leaving it in pieces.

And the next leader makes their mark by making wrong the previous leader's "accomplishment".

In contrast,  Hospitals that really do perform well over a sustained period of time have a stable leadership.

Great leaders are people you may never hear about, because they are professionals at putting other people onto the awards platform, other people's names on the publication, other's faces in the news photos: and their organizations quietly get better and better year after year.

Since they aren't searching for their next promotion, getting credit is personally useless, but giving credit is a critical strategy for sustainability.

So the good news is that there really are great approaches to doing remarkable things and some very fine Hospital executives who practice them.

But to find those methods, to adopt those, you need to be right with your own beliefs, and then versed in these approaches, at least in concept.

If you don't really love to watch great care being given, and to work long hours to help others to do better, find work in some other field, not hospital leadership nor hospital consulting.

This Blog is for those who really enjoy seeing a great patient / caregiver interaction. Those who, when they see it, feel more enthusiasm than if their favorite team won the Superbowl. Because their true "favorite team" is the team working at the Hospital. Executives and Consultants who would rather come into the Hospital on weekends to walk around and watch what's going on, and meet with the team, lunch with the team, watch the team in action,  than to sit in box seats at the world-series or court-side at an NBA championship. People who feel, not just think, that the greatest performances in the world are those of Hospital staff and MDs, and who also bring their kids in to see the miraculous works taking place. Executives who feel more pride, more elation when they see a nurse, a tech or a doctor help bring peace and resolution to a family in crisis in their hospital, than if they were surfing in Hawaii, scuba diving in South America,  skiing in Colorado or geocaching in Turkey.

And when such leaders and consultants don't feel so great, they go out and watch a tech deliver needed supplies on time; a pharmacist give a great consult to a physician; a rehab therapist carefully, lovingly ambulate a patient. This is their restoration of well-being and purpose.

This blog will serve as a public forum for a variety of methods developed and implemented in Hospital Leadership, Organizational Development, Clinical Care, Operations Improvement and Business Management over several decades. Strategies that have cut mortality rates by 30% or more; erased infection rates; that have raised patient satisfaction rankings into the top 1 percent and even to the very top position across several states; that have eliminated unnecessary readmissions; that have cut throughput by 30-70%, eradicated Left Without Being Seen,  improved productivity by up to 30% while cutting hospital costs by an equal amount; and this done without a single lay-off,  while ramping up staff and physician satisfaction to their highest levels in the history of the Hospital.

We invite everyone to share what they have learned in the spirit of service to our community.

Compirion Hospital Solutions holds no copyright on any of its materials or tools, and gives these without reservation to both our clients and anyone who asks. We only reserve the right to use such tools and methods in our future work without royalty. Our clients can and have repackaged what we have done, and that is their privilege. They do so with full ownership and authorship, and with our complete blessings.

But we believe Hospitals are a public trust, and the costs of ignorance far too great: The public is the rightful owner of whatever is developed.

We believe Hospitals belong to everyone regardless of where they call home, regardless of race, creed, religion, lifestyle, color, sex, citizenship, age or ability to pay. If they need care, the closest Hospital belongs to them. It matters not that the Hospital is "for profit" or "not for profit" because it can only be run well over a long-term period as the servant of the People. We believe the Hospital is a gift to its leadership, MDs and employees, as well as its community: And a privilege, an honor to associate with. When working there is understood to be a sacred gift, a calling that is given to each person who works there, and which must be honored with thanks, and cannot ever be adequately earned, work improves.

Hospitals belong to their purpose and no one else can claim ownership. You can pay people to work in a place. You can heal systems that are damaged. But the fact that you  also get the whole heart, body and soul of every patient, employee, MD and manager which are priceless, under your direction, and you accept these resources and the duty to lead them, means that the debt on the part of the "owner", the "executive" and the "consultant" to the employees and the community grows ever larger with each passing day.

The caregiver and the patient grow richer by far. The growing debts of the owner, leader and consultant soar by whatever they take as compensation - both tangible and intangible - which is not immediately reinvested into the operation of that Hospital.

So their only hope to help balance the scale is to assist in whatever way they can the caregiver, the patient and the community. And to beg for strength and wisdom to do so effectively; and discretion to do so without harm.

We have shown hospitals how to become more profitable by far adopting this belief; committing to it, regardless of the challenges, and working together with the whole organization to build the right answers, and avoid cutting corners for short term personal gain.

Hospitals can eliminate most all medical errors, eliminate waste, inefficiency, poor morale and  raise their satisfaction levels and their financial margins to new heights. It has already been done several times.

And while making good use of natural resources, creating value for society, and being productive are great values of stewardship anywhere in this world, they are certainly most important with human resources when human life is at stake.

We hope that the tools, case studies, methods, analysis and advice offered here inspire others to share as well, and all to reap the benefits with the objective of providing the best healing experience possible to the entire community.

Spence Tepper