Sunday, January 7, 2018

Hospital Margin Killers: Bad Heuristics / Good Heuristics. The rules each Hospital employee, medical provider and patient live by are different rules.

With every passing month, hospital margin percentage points are whittled away silently and invisibly from the healthcare system’s margin. Where did that capital go?

It was spent on delay, duplication, loss and error.

It was drawn down in investments with questionable and lackluster return.

It was spent on too many handoffs everyone thought would make things better, but which have now proven to diffuse responsibility and focus.

It was lost in the silent daily leakage of referrals out of the system. A physician's secretary tired of the many steps to help their patient schedule an exam; Each patient's family member tired of waiting to speak to the scheduler, the nurse, the provider, hanging up and finding another clinic, another hospital; Each patient who tired of waiting in a crowded emergency waiting room, who gets up and walks out even before they are registered. This is the invisible, passive loss of revenue every day.

Once invisible. Now a source of threat.

And yet when hospital executives are asked about revenue growth they ask "where can that possibly come from? We are landlocked by insurance. If a patient leaves here, they will come back. ...."

It is customary for organizations to use their own internal teams to fix such problems. But, to paraphrase Einstein, problems cannot be fixed with the same thinking that created them. And new problems cannot be fixed with old thinking.

If the status quo has missed something, so will the solution generated by those thought leaders whose very jobs and career require leaning on an old platform of out-of-date and out-of-step thinking. Why lean? When you can stand!

Engineering more hand-offs may just mean more hands-off the patient.

When a new position or a new stage of patient flow is promoted that places the responsibility for fixing a problem on someone new, someone else's shoulders, that is a warning sign. Because everyone involved must share more responsibility, not less, for any problem to actually be fixed.

Every good solution un-managed becomes a new risk. And managed in the old way, inevitably proves the old way is best, by failing predictably; meeting the self-fulfilling prophecy of the status quo which actually demands its failure.

However better personal rules to work by, 'Heuristics', change everything. Because no matter what those rules are, everyone has them, everyone uses them. And in the absence of them, people make up what appears to work best for themselves moment by moment. The good news is that people are creating new rules and adapting to them every moment of every day. And that is also the bad news.

What is efficient for the provider, the staff member, the technologist, the executive and the patient, may be entirely different and in conflict.

For a provider who arrives at 8 AM to leave at noon, in order to get to their office hours, patients may need to stay in the hospital an extra day. But that rule they created for themselves works. Move that responsibility into the hands of hospitalists on a seven-day on schedule, hoping to get a new Heuristic, and the picture doesn't improve, because, on a seven-day schedule, you don't get 8-10 hour on-site days: You get 5 hours over seven days, plus on-call. And that first hour, often 8 AM, after kids have been dropped off at school, and the last hour, often 1 PM, is lost in email and report. So the rules inevitably form around the status quo. Patients don't get discharged on weekends because physicians, technologists, and clinical staff in the hospital, the Long Term Care facility, the DME all have lighter crews on weekends. An no one believes the financial return of doing otherwise is solid enough to proceed with real change.

Planning on Thursday and Friday for a Saturday discharge are for naught when the senior clinical management staff needed to facilitate and approve of a nursing home transfer and admission from the hospital aren't working on Saturdays at the hospital nor the nursing home. After years of service, their promotion has come with weekends off to be with their kids. It all makes sense.

And more effort in pushing against these very things pushes uphill a ball that readily roles right back down the minute a key leader is off on vacation.

We use rules all the time. So it is natural to adopt new ones that work better, if we can understand it, feel it, grow into it in a natural way. We can learn new rules, and if we are willing to try something just a little different, can discover an entirely new pathway to performance heretofore hidden. And surprisingly, this is the fastest way to generate results beyond expectations that sustain for years.  But what are the rules that naturally allign interests, that move every member of the team closer together, around the patient?

Today, the system, unsynchronized, unscheduled, imbalanced, lacking adequate supervision, with conflicting interests, runs like a car being towed, rather than under its own power.

And who is doing the towing? The CEO.

Improvement Programs Don't Work...for long. They are pasted on solutions, rather than organically grown and built from within using the natural rules of human behavior and organizational development.

Even when constructed by the system's own people the rules can be wrong. That is because the basic assumptions and rules for working together all come from the same culture, and therefore lead to the same, self-fulfilling result.

No one is more acutely aware of this  than the Healthcare system CEO. Doing a live walk through of their Emergency, Surgery, Intensive Care, Cardiac Cath, Interventional Radiology or Outpatient clinics is to see both patients and staff waiting, idle, each in  their own special and separate waiting silos.

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