When Being Right Mattered

An American journalistic icon passed away yesterday. Ben Bradlee was the editor of the Washington Post during Bob Woodward and Carl Bernstein’s investigative reporting that was to become Watergate. Bradlee was the quintessential well-heeled news junkie with one foot on a banana peel and the other cemented firmly on the first step of the Lincoln Memorial: “with firmness in the right as God gives us to see the right.”

Bradlee was infamous for making it known that being, “right” is what mattered more than the means to knowing you were right. Getting it right wasn’t easy, and it wasn’t without mistakes. But getting it right mattered more than anything else.

Who can watch any news network today and feel even the slightest bit of confidence that getting it right is what really matters? Getting it first matters. Getting it with images matters. Getting it in a surreptitious fashion matters. Getting it right? Sure, why not if that doesn’t cost any more.

In the 1976 movie, All the President’s Men (based upon Woodward and Bernstein’s book of the same name) Jason Robards won an Academy Award for his performance portraying Mr. Bradlee. Last year Bradlee was awarded the Presidential Medal of Freedom.

I know I am being scornfully satirical and disingenuous in discounting the many journalists who still emulate Bradlee’s commitment to getting it right. Their inability to attract a larger audience that shares such an interest is a cultural reality beyond their control.

And yet how ironic is it that as we sit here in 2014 some of us are nostalgic for one of the darkest periods in American political history because we long for the truth – even when the truth might not be something we want to hear, or accept.

Cheers,
  ~ Sparky

A Choice to Live

147391Participants at this year’s LeadingAge Annual Meeting in Nashville were treated on Sunday evening to the premier showing of Glen Campbell: I’ll Be Me. A documentary of the legendary country artist’s life with Alzheimer’s disease, the venue and audience chosen for the premier could not have been more perfectly selected.

The film artistically yet with faithful realism explores the many emotions that Alzheimer’s disease evokes – in the individual afflicted, as well as those who share life with that person. It chronicles what began as a 3-week goodbye tour turned into a 151-show theatrical phenomenon that became much more about celebrating life in whatever form it humanly manifests than succumbing to the sadness and regret of disease.

Alzheimer’s disease is unique in its ability to impact loved ones of the individual having the disease while stealing away that person’s ability to understand or empathize with those feelings. Glen Campbell and his family determined in 2011 that they would use their shared experiences to help build greater awareness and understanding of the disease.

Nationwide screenings of the film are set to launch this weekend. Grab yourself a box of tissues and go see it.

Cheers,
  ~ Sparky

More to Learn Than Fear From Ebola

ebolaEbola is scary. Though I try to allay my fears with practicality and common sense, I am – like many Americans – very concerned. The unknown is always scary. I wanted to start with that assertion to place the rest of my observations in context.

We will, I expect, ultimately pull through this latest threat to our lives better than our current fears would predict. Assuming we do, when the dust settles and the national media moves on to cover the next threat to our lives we are going to be left with some very useful case studies that we (hopefully) can use to assess how and why the healthcare industry continues to be unable to effectively embrace and utilize quality process improvement.

Of course, we will have to get past the blame game, name-calling and talking heads wanting to put the fault upon political philosophy rather than where it rightly belongs: the human beings that are involved in the promulgation of guidelines and regulations, the implementation of guidelines and regulations and the adherence to guidelines and regulations.

Already today pointed fingers are flying around Dallas like roof shingles might during a Texas size tornado. Texas Presbyterian hospital administration is accusing the media of sensationalism (go figure). A nurses union is blaming the hospital for not protecting its workers. The CDC blamed – then didn’t – the hospital for not following protocols and guidelines. How George Bush is avoiding blame down there I can’t figure.

Finger pointing in times of crisis is an innately human characteristic that only few people can avoid. Those folks that do avoid it tend to make very good leaders, and unfortunately apparently have an abhorrence for public office. But in a very real sense the finger pointing underscores how far the US healthcare delivery system has to go to change the systemic cultural aspects that impede progress toward quality improvement.

As I have shared in this space before, my colleague Nathan Ives and I wrote a white paper a while back: Aligning Healthcare Organizations: Lessons in Improved Quality and Efficiency from the Nuclear Power Industry. I believe it is informative and particularly relevant today to compare the relative safety records of both the nuclear power and airline industry safety records to healthcare. The potential wide scale impact of an epidemic raises our collective consciousness to view healthcare safety on a par with tragedies in those other industries in a way that one death at a time simply does not, however right or wrong that may be.

Though somewhat dated, there was an interesting journal article written in the December 2003 issue of Quality and Safety in the Healthcare: Applying the lessons of high risk industries to health care. In it the author notes the exemplary safety performance achieved in the oil and gas and aviation industries. And then examines why healthcare – an industry with comparable high risks – has not done nearly as well.

As the author notes, “health care has always taken medical dangers seriously, so the culture cannot be pathological. The lack of systemic risk management suggests that the culture is, at best, reactive, even though there may be the occasional proactive area.” Though we have seen the industry try and address these inherent cultural differences over the past decade since this research was conducted, we only need to look at the flying fingers in Dallas to realize not much progress has been made.

Organizational process improvement leading to the type of sustainable quality and safety that has been achieved in other industries and disciplines cannot and will not be achieved through regulatory compliance alone. It requires a paradigm shift in the thinking and attitudes of healthcare industry participants who have been effectively able to resist change for a long time. If you are looking for a silver lining in this scary period we are living through, it could be that Ebola accelerates that paradigm shift. I do believe we have more to learn than to fear.

Cheers,
  ~ Sparky

P.S. See you at the LeadingAge Conference in Nashville! We’ll be in booth 1829.

New Payment Models’ Impact on Innovation

getimageThe backdrop for this week’s feature article in Modern Healthcare by Jaimy Lee and Sabriya Rice is last week’s annual conference of the Advanced Medical Technology Association. Known as AdvaMed 2014, it is the leading MedTech Conference in North America, representing more than 1,000 companies. Commensurate with the event, AdvaMed released a new white paper that expresses concern over the potential impact risk-based payment models could have on provider adoption of emerging medical technologies.

The “Show me the data” headline connotes the growing demand of private insurers, as well as policymakers and governmental agencies, that the efficacy of such technologies be supported with evidence. And while AdvaMed, ”generally supports the movement toward new payment models that encourage providers to reduce costs through greater coordination of care,” its not too thinly veiled concern, of course, is whether and to what extent the demand for data will serve as a tactical smokescreen supporting cost control at the expense of patient care – as well as those companies’ financial success. Regardless of the relative priorities of those two objectives, pressure to control costs under risk-based contracting will certainly affect future provider decision-making impacting the adoption of un (or, at least, under) proven technologies.

I don’t think one has to belie their political persuasion to reasonably understand the pragmatically challenging conflict of this discussion. The overwhelming trends of transparency and evidence-based care in healthcare necessitate that manufacturers make the required investment to understand and be able to articulate their product’s cost/benefit story (i.e., the value proposition). The MH article shares the experience of Medtronic, a medical-device manufacturer whose research uncovered a tangential benefit of being able to reduce hospital readmissions that it could use to enhance market value.

But we also know from experience that data supporting patient benefit often trails substantial initial investment, trial and error and the ability to assess that benefit over years of a patient’s life. In a delivery system that has been able to support waste and largesse the need for patience has been a tolerable frustration. In a system where a major focus of all participants is now cost containment there’s a lot less patience.

The recurring policy challenge, as if there was just one, is in cutting through the individual agendas of industry participants to try and find some sense of balance between cost reduction and what is in the best interest of patients while not artificially stifling the enormous benefits we have enjoyed in this country from medical technology.

In Malcolm Gladwell’s latest jewel, David and Goliath, he profiles the work of Dr. Jay Freireich in the mid-50s through mid-60s. Freirech and his colleague, Dr. Tom Frei, pioneered the treatment of childhood leukemia by first transfusing patients with platelets to stop chronic bleeding. Following that they advanced the then novel approach of chemotherapy to include multiple drugs rather than a single drug.

In both instances, Freireich and Frei didn’t have to contend with whether or not insurers would underwrite the cost of their efforts. Rather, at the time they could not even get the support of their academic and clinical colleagues, so outlandish and absurd were their unorthodox approaches, which often caused great pain and hardship to their young patients. Except that in 1965 they published, “Progress and Perspectives in the Chemotherapy of Acute Leukemia,” in which they described their successful treatment of childhood leukemia. Today the cure rate is greater than 90 percent, and thousands of children’s lives have since been saved.

Is AdvaMed right to warn us against the impact risk-based payment models will have in the name of cost containment? Could the next Freireich & Frei team of innovators be kept from achieving a dramatic life-saving achievement because cost-containment will trump the patience needed to evidence results? Or is AdvaMed understandably overstating the case in doing what it is expected to do: advocate for the members funding that organization’s existence?

Cheers,
  Sparky

Mental Illness Awareness Week

The Policy Pub wishes to share with our patrons Mental Illness Awareness Week sponsored by the Substance Abuse & Mental Health Services Administration. Mental and behavioral health concerns are growing in awareness across the country. MIAW’s aim is to “help educate all Americans on the needs of individuals with mental illness—including serious mental illness—and their families.”

According to SAMHSA, of the approximately 10 million adults with a serious mental illness, less than one-half of those individuals will receive the services and care they need. Social stigmas continue to be a significant barrier in this regard. As part of its week long effort to continue bringing awareness and education combating stigmatization SAMHSA recommends:

  • supporting individuals with mental illness by helping them understand they are not alone;
  • becoming educated on ways to prevent mental illness, particularly by proactively screening and addressing potential issues during childhood;
  • building greater awareness that effective treatments of mental and behavioral health disorders are available; and
  • celebrating that very often those treatments make a tremendous difference in the quality of life of the individual: People do recover.
  • The SAMHSA website is a fantastic resource on a wide variety of knowledge and information on mental and behavioral health issues and concerns – from advocacy to education to emergency assistance. I encourage you to take a moment to become familiar with what is available there and share with others who might benefit from knowing where to turn – whether because they are seeking to help a loved one, someone they’ve never met, or themselves.

    Cheers,
      ~ Sparky

Only Innovation Will Reduce Readmissions

Body, Mind, Soul, And Spirit ConceptAs reported on yesterday in Kaiser Health News, over 2,600 US hospitals – the most to date – will have their average Medicare reimbursement rates reduced over the period October 1, 2014 through September 30, 2015, due to the Hospital Readmissions Reduction Program. The overall reduction is projected to realize $428 million in savings to Medicare – i.e., translated as lost revenue to hospitals.

For anyone still unfamiliar with the reductions program, in a nutshell it is an attempt to use public policy to achieve more efficient alignment between patent care requirements and the overall cost of care provided – particularly to the extent costs are driven by care setting. Or, more pragmatically, Medicare does not want to pay the comparatively higher overhead costs associated with acute care settings if a patient’s readmission to that setting could have been avoided.

Of course, there’s the rub that will eventually have to be reconciled if the program is to remain: can we really objectively and often times arbitrarily determine what’s avoidable? The primary reason this is so difficult is because of the myriad environmental considerations that impact patient recovery and sustainable treatment away from the acute care setting. Where someone lives (housing), their neighborhood, their human support network, access to transportation, cognitive state and capacity for engagement, recognition of comorbid considerations such as anxiety and depression – the list goes on.

Hospitals and their clinical teams are taking the readmission program seriously. A three-percent reduction in revenue from your largest source when you are already struggling with narrow margins has that effect. New efforts to forge relationships with post-acute/long-term care providers, patient communication strategies, multi-provider think tanks, post-discharge follow-up programs, transitional care planning, utilization of telehealth and telemonitoring technology, targeted disease intervention – these primarily represent the extension, or repurposing, of core clinical capabilities.

Not to discount the importance of these initiatives, but by and large there is nothing all that innovative here when compared to the fundamental nature of the problem we are trying to solve. And there is a limited ability to address the fundamental challenge driving hospital readmissions: the environmental obstacles shared above. Worse yet, these tactical approaches fail to embrace the holistic reality that is patient treatment and recovery.

That’s where innovation efforts have to be focused: not on keeping someone out of the hospital but on removing the environmental obstacles that drive readmissions as a consequence of undesirable recovery and sustainability. As Toby Cosgrove, President and CEO of the Cleveland Clinic wrote earlier this week, “as my friend Professor Michael Porter of Harvard Business School says, innovation is the only solution to … long term issues faced by American healthcare.”

And it will ultimately be the only solution to lowering hospital readmissions.

Cheers,
  ~ Sparky

NQS 2014 Annual Report

Quick hit to let Pub patrons know that the U.S. Department of Health and Human Services has released the 2014 Annual Progress Report on the National Strategy for Quality Improvement in Health Care. This is an initiative led by the Agency for Healthcare Research and Quality (AHRQ) and contains some interesting Priorities in Action – summaries of programs across the country seeking to leverage the NSQI platform.

For those seeking the snapshot . . .

Three aims

  • Better care: think patient-centeredness, reliability, accessibility and safety
  • Healthy people/healthy communities: think health & wellness, population health management and proven interventions
  • Affordable care: think value

Six priorities:

  1. Continuing to reduce unintentional harm associated with healthcare delivery
  2. Patient engagement
  3. Care coordination via “effective” communication
  4. Emphasis of prevention and treatment priorities for leading cause of mortality conditions
  5. Community-targeted best practices encouraging healthier lifestyles
  6. Encouraging new delivery and business models that can increase value (better outcomes/cost)

Cheers,
  ~ Sparky

QAPI From the Front Lines

One person lifts the word Compliant and others are crushed by non-compliance, as the winner follows This is the PolicyPub’s first post by a contributing author. I have recently written on the upcoming QAPI mandate included in the Affordable Care Act and the impact that will have on nursing homes – particularly those unprepared (which I am coming to realize appears to be the majority).

I am thrilled to have my Artower colleague, Terri Durkin Williams, R.N., L.N.H.A., share her practical experiences with QAPI.

The Nursing Home industry is being challenged to develop quality programs that consistently maintain regulatory compliance. This shift in continuous improvement will require organizations to self-assess their operational performance. In turn, this will move organizations from the established routine of monitoring systems to self-assessments.

The federal government has mandated a Quality Assurance and Performance Improvement QAPI standard under the Affordable Care Act. This mandate was to be established and implemented in nursing facilities by December 31, 2011. As yet, regulations implementing the QAPI program have not been released by CMS.

The purpose of the QAPI program is to develop best practice in providing services and care to nursing home residents. This should be the mission of all health care providers. Waiting for the government to lead us in our business is jeopardizing organization survival both financially and in the delivery of services and care.

QAPI is not a new concept: it has been widely used in healthcare organizations for quite some time. The nuclear power industry has embraced this process to assure quality controls, safety, maintain regulatory requirements, increase efficiency and enhance the reputation of individual power plants. Achieving these goals requires a significant commitment of organizational time and personnel.

Given the tremendous cost pressures and narrowing reimbursement, however, management often judges such commitment as an unaffordable expense. The tendency is to not proceed with an in-depth evaluation of organizational functions. This is too often unfortunate short-sightedness of executive management. It leads to undesired consequences such as, poor care resulting in litigation, staffing turn-over, declining census, fines due to regulatory deficiencies, dissatisfied customers and increase in regulatory over-sight to just mention a few potential outcomes.

A common current practice in quality assurance programs is to monitor a task that is being performed by personnel. The evaluator observes the personnel and uses a check list to determine if the standard being monitored is compliant. The pitfalls of this approach include:

  • Observers not being trained in a manner that results in the consistent application of standards used to perform the evaluation; i.e., the evaluation is based on the observer’s personal biases;
  • Personnel performing to the standard while being observed;
  • Personnel documenting what is required, but not assuring that care was delivered according to the established standard;
  • Monitoring as a snapshot observation; it does not tell the entire story;
  • Organizations using limited information that is gathered in the monitoring process to determine compliancy – this can give a false sense of success and prevent the exploration of best practices
  • Monitoring that  does not guide the organization to the root cause(s) of problems, does not allow for personnel to explain their performance and fails to obtain what knowledge the personnel have of the standard being monitored:

  • limits the beneficial involvement of all personnel in the process;
  • is often viewed by personnel as a punitive measure; and
  • creates a disconnect in communication throughout the entire organization.

Poor preforming organizations tend not to take time to complete a comprehensive assessment of their operational issues and challenges. They may feel that they do not have time for a comprehensive assessment. This causes them to guess at what the problem is and just perpetuates a poor practice.

Example Case
I was recently involved working with an 84-bed nursing home that had seven (7) “immediate jeopardy’s” for a period of six and a half months. Their approach to quality assurance was to have nursing managers spend several hours a day monitoring and documenting problems. But there was no understanding of the root cause(s) of those problems. They received fines from CMS of over a half million dollars. This organization would have benefited from a self-assessment program.

The alternative to this chaos is planning for cultural change that will lead to best practices. The embracement of the self-assessments program exemplifies this and is characterized by the following:

  • Supported by organizational leadership;
  • Involvement of personnel at all levels within the organization to promote professional growth;
  • Effective and efficient communication – a team working together and respecting each other;
  • Focus on evaluating the most important aspects of the people, process, and technology;
  • Comprehensive understanding based upon a collection of observations, record reviews, personnel interviews, benchmarking data, and other ongoing assessment information measured against specific criteria;
  • Identification of performance deficiencies and potential causes, organizational strengths and weaknesses and opportunities for improvement
  • Evaluates performance against established best practices;
  • Provides opportunities to change the culture of the organization;
  • Stabilizes daily operations, by consist expectations, policies and procedures and
  • Establishes a culture whereby organizations control their business activities based on mission and purpose.

Key components of a successful self-assessment program include:

  • Executive management and board leadership’s passion for excellence;
  • Identification of an individual that is supported by leadership as the Team Leader in championing the Art of Quality.
  • Entire self-assessment team educated on the organization’s mission and leadership’s expectations – and they are accountable for their actions;
  • Defined sequence of the self-assessment process;
  • Evidence based standards;
  • Requisite IT support that facilitates the collection of relevant data, analyzes information and provides benchmarking; and
  • An ability to have fun, learn and celebrate successes.

To explore how your organization can implement Artower’s EviQual™ Self-Assessment Program using evidence based practice contact me at twilliams@artoweradvisory.com or 216.244.2923.

  ~ Terri

Accelerate! ~ Or Be Eaten

sparkyartower:

Originally published in November 2012.

Originally posted on Sparky's Policy Pub:

John Kotter makes his latest contribution to an already authoritative body of work on organizational change management in the article,

that form the backbone of a strategy network, which he suggests should work in parallel with an organization’s existing operations. The accelerators differ from the eight steps in their being nonlinear, more organizationally encompassing and ideally facilitated independent of the traditional organizational hierarchy.

), while the other is a network framework that is able to leverage the organization’s group genius in ways that facilitate rapid strategy deployment.

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Culture Change at the Core of QAPI

This past Friday I attended the 2014 Katz Policy Lecture at the Benjamin Rose Institute. Peter Kemper, PhD, Professor Emeritus of Health Policy, Administration and Demography from Pennsylvania State University gave the lecture on Expanding Culture Change to All Nursing Homes: Challenges and Policy Approaches.

Professor Kemper acknowledged early on what is often the opening salvo of critics of culture change – that defining exactly what it is can be a formidable challenge. In fact, as he noted, it may be preferable to think of culture change as a movement instead of a model. This perception would be consistent with the concept of continuous quality improvement where it is recognized that while operational perfection is inherently unachievable, evidence shows its pursuit drives measurably better outcomes.

Cutting through the theory and research, at its core culture change is the ability to create an organizational environment in which individuals are empowered, trusted and valued: and this must be true for both patients and the workforce caring for them. What does this look like? Well, in listening to the lecture I found that we need look no further than the five elements of Quality Assessment Performance Improvement (QAPI).

Element 1: Design and Scope: Culture change can only take place if there is a shared commitment to be cognizant and aware of how each individual’s role and responsibilities support achievement of the organization’s future state vision. To accomplish this there must be an understanding and pragmatic recognition that the approach needs to be comprehensive, inclusive and constantly evolving.

Element 2: Governance and Leadership: It is the organizational leadership’s primary responsibility to create the environment by owning (without controlling) the design and scope process, while the role of governance is to ensure sustainability and accountability of that environment once created.

Element 3: Feedback, Data Systems & Monitoring: The old adage of you can’t manage what you can’t measure, however incomplete in its ability to capture the full essence of organizational behavior, nonetheless is the primary means of incenting desired behavior while discouraging unwanted behavior (i.e., accountability). This must be a fundamental element of culture change, particularly from the standpoint of sustainability.

Element 4: Performance Improvement Projects: The key concepts attributable to culture change here are prioritization and ability to impact. The important nuance that many PA/LTC organizations have difficulty understanding is that PIPs don’t have to be directed retrospectively. They can (and should) be borne out of a comprehensive design and scope process (i.e., Element 1). This is a key element of intersection between culture change and QAPI programming that must be embraced and understood.

Element 5: Systematic Analysis and Systemic Action: Socrates noted that, “the unexamined life is not worth living.” I contend that an organization committed to culture change will continuously assess and examine whether and how well it is able to achieve its vision while fulfilling its mission and always reflecting its core values. This brings us full circle to the concept of continuous quality improvement noted at the beginning of this post.

As Professor Kemper also noted during his lecture, there is nothing necessarily innovative or revolutionary about culture change in PA/LTC. My observation is that it is really a matter of borrowing – or adopting – proven best practices of organizational behavior from other industries and research that dates back to the early 1900s. But going from theory and research to realized benefit takes the type of leadership that isn’t as easy to import. That’s where a lot more work needs to be done before either culture change or QAPI can achieve meaningful and lasting improvement in patient outcomes and life enrichment of the individuals served.

Cheers,
  Sparky

 

 

Picture Credit: Provider Magazine

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By Dr. Bill Thomas

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