Reforming Day-to-Day Health Care Delivery
The health care reform legislation is moving ahead, with issues being tackled, discussed and consensus reached. Even with the legislation, the work is not done: the overhanging issue is that medical care is still inefficient in its organization and execution, and it's up to physicians in their practices, hospitals within their walls (and various off site centers), and every other provider to do better. Much better. Much, much better. This will take work; it will be messy, but it will be better in the end.
Writing in the Huffington Post, Dr. John Kenagy argues that we organize our delivery organizations along the lines of the factories of old – assembly lines. What we need are highly adaptive organizations that can truly customize services for each individual patient. (Kenagy, a vascular surgeon, has also worked in executive positions in a large non-profit hospital chain and taught at the Harvard Business School).
Kenagy comes at this from a broader view than I address in my writing on medical practices. A relatively simple patient inhospital stay can generate several hundred staff-patient interactions – and each interaction is a setting for a service failure. Missed or late medication. The wrong medication. A patient waits for assistance to get out of bed. And so on.
Kenagy argues that we know plenty about the issues and source of costs in healthcare. But, he suggests, we have not gotten down into the day to day delivery of care, where the cause of much of our costs lies. When I was a hospital administrator, I had several opportunties to invite officials and pundits who would be happy to talk about health care policy, but lacked the experience to be able to appreciate what happens when patient and hospital interact.
There, I discovered that I was constantly looking for better data and going to more meetings to chip away at the macro issues of a broken system -- quality, safety, financial sustainability, technology, compliance -- while staff and physicians continued to struggle with the small problems that broke the system in the first place. Those small problems, unsolved, became the big problems that not only filled the agendas of endless meetings, but also continue to fuel the waste, rework and inefficiency that drives health care inflation.
The typical physician practice is chaotic and non-learning – the same tasks need to be completed time after time, but procedures are often not sufficiently standardized to maximize the time and movements of the physician. It requires breaking down the internal patient visit process and finding places to standardize practices, tasks, and supplies. Some requires pre-planning – internal guidelines for ordering lab tests and imaging studies, the latter an expensive and overused service. Patient instruction sheets and practice websites, secure phone systems to for physicians to deliver test results asynchronously are just a few of the tools available today. Personal health devices permit more aggressive patient monitoring and health plans are starting to pay for email consultations. We force patients into predetermined blocks of time, without any real mechanism to plan for the visit itself and how much time to schedule. I have seen practices that didn’t know what to do when the patient asked for a full physical exam!
Pharmaceutical companies and hospitals have made commitments to cut costs over the next ten years, and physicians, who will see some increases, must apply the lessons of business to do a better job, and doing it in a better way. It’s hard work, but the time to start if now.
