The following New York Times article points out the difficulty in writing the law that will govern the new health reform legislation concerning Accountable Care Organizations.
I have been involved in a number of national initiatives trying to define the ACO concept. One of the efforts from NCQA released an 80 page document a couple of weeks ago which describes the thinking of a number of physicians, administrators and academics on the structure of the ACO. Unfortunately, as we define the structure of the ACO and how to accredit it we may be losing sight of the actual purpose for which it exists in the new law.
That purpose is to deliver more coordinated better quality lower cost care. The focus needs to be on the patient experience as the driver for design not how many hospitals or physicians can merge together. When we focus only on structure and finances we lose the power of what the ACO can really be. It is very disturbing the push to consolidate going on throughout the country. In my experience consolidation if not done for the right purpose does not lead to good things for the customer in this case the patient.
I could not agree more with Dr. Berwick’s quote in the New York Times article. Here’s the excerpt.
Dr. Donald M. Berwick, the administrator of the Centers for Medicare and Medicaid Services, hails the benefits of “integrated care.” But, Dr. Berwick said, “we need to assure both patients and society at large that destructive, exploitative and costly forms of collusion and monopolistic behaviors do not emerge and thrive, disguised as cooperation.”
From the IOM in 1999 to the Hearst newspaper reports this year the facts continue to accumulate that America’s healthcare system is sick and making patients sicker. This new study suggests as many as 15000 medicare enrollees a month are dying of causes related to their hospital stay. From medication interactions to surgical infections.
This is not new news. It is disturbing that the industry is not making faster progress and it is exactly why the Center has been focused on facilitating the deep dive learning opportunity associated with the Healthcare Value Leaders Network. We have strong evidence and I believe strongly that learning the principles of the Toyota Production System and applying them to healthcare is the only solution to reduce these unfortunate errors.
This article was published yesterday in the Wall Street Journal. It is an interesting take on the importance of the Medicare data to understand physician performance from and quality and cost standpoint.It also describes a law suit from years ago by the AMA to block the release of physician specific data. The AMA won this suit and this has shaped CMS policy on data ever since. With the country focused on trying to reduce healthcare costs understanding physician cost performance has become much more important. Although the Medicare claims data is not perfect it can be used to begin to understand resource utilization and when combined with quality data it can shed light on value delivery in healthcare.
Orry Fiume is the former CFO of Wiremold, which at one time was one of the best lean companies in the world. He visited ThedaCare during a Center board meeting and shares reflections on “productivity” in health care.
Dr. Womack did “gemba” along with Maureen Bisognano CEO of IHI, Randy Linton M.D. CEO of Luther Middefort /Mayo Clinic, Orry Fiume author of Real Numbers and former CFO of Wiremold, George Koenigsaecker former president of Hon now HNI, and Helen Zak President of the Healthcare Value Leaders Network. These leaders visited the Encircle multispecialty ambulatory care center, the collaborative care unit at Appleton Medical Center, a live defect huddle on inpatient oncology and the senior management visual room. The next day,when this video was taken they had just listened to Friday report out during which the improvement teams for the week described what they had accomplished.
Our experience at ThedaCare has shown that convincing staff to help remove waste from care processes goes much smoother when they know their jobs are not at risk. Why would you work to redesign care and redesign yourself out of the organization?
It has been important to have a no layoff philosophy in order to get staff excited for change. This doesn’t mean we have guaranteed they would always do the same job but we have guaranteed we would retrain them if their job changed with the goal to make sure they have work which is meaningful to them and the organization.
On August 26th and 27th the Healthcare Value Leaders Network #1 visited Park Nicollet (PN). The theme was using 3P (production preparation process) to change care delivery. 50 of us toured PN’s emergency center,cancer center,eating disorders center, and other areas. My reflections follow.
PN has done a great job of involving their front line doctors and nurses in designing their new spaces using the 3P.In the operating room example we saw there were 10 mock-ups done of the new operating room before it was ever built and most of the people that actually do the work put their handprint on the blue print so to speak.
We always are looking for how noisy and chaotic care delivery is whenever doing gemba. Everywhere we toured at PN there was calm and quiet despite being very busy the day we visited. This is a sign the care delivery processes are stable and not in chaos.
We saw good evidence of one piece patient flow in several areas again a sign that the organization is incorporating the core principle of lean at the level of the patient value stream.
PN has done a remarkable job at understanding the data behind the care. This data is driving every decision whether it be to establish and design a new service or load level an inefficient staffing pattern.
Finally,there is a passion and commitment for improvement that was present in every staff member we spoke with. This is evidenced by the fact that no one at PN thought they were anywhere near finished with the work. There was acknowledgement that there were many things to improve. The purpose of these site visits is for the network members to learn from the site visited but for the site to get improvement feedback from the visitors as well. The PN team was excited to learn what the visitors thought they could improve.This genuine desire to receive outside feedback is another sign of PN’s maturing culture around continuous improvement.
Congratulations to the PN team and leaders for a remarkable set of accomplishments focused on improving quality and lowering cost to their patients.
This is a question and answer session focused on the recently released book On the Mend co-authored by John Toussaint and Roger Gerard. The interview is focused on the hard work of transforming an organizational culture to continuous improvement.
Electronic records are an important tool to improve patient care. The Rev. Will Bleodow and I had the privilege of presenting with a number of leaders from the government, insurance,provider and professional certification communities regarding the importance of the new “meaningful use” guidelines released by the Office of the National Coordinator for Electronic Health Information.
The following are the blogs Will and I published on the Health Affairs website.
The state of Wisconsin continues to score well when compared to the rest of the country on the core quality indicators for hospital quality. Admittedly many of these indicators are still only process measures but it is all we have. I would hope we can move to consumer focused outcome data such as medication error rates,surgical infection,mortality and other key indicators. Unfortunately at this point healthcare organizations cannot accurately measure and report these important outcomes.
At www.wchq.org heart surgery mortality rates for some hospitals in the state are now being reported using the Society for Thoracic Surgery(STS) data base. It wasn’t easy to get this accomplished as there was a lot of concern from many parties but this is the kind of leadership we need if we are to build a transparent reporting system for cost and quality in America. It’s also probably one of the reasons Wisconsin rates number one or two every year on the AHRQ data.
