Management Experiments

Northwell Health aspires to be among the best places to work, and our efforts to make it so are closely linked with a broad institutional effort to improve the experience of our patients. The theory goes – and I believe – that it takes engaged and committed employees to provide great care. To that end, we survey our employees regularly to gauge our progress and to identify opportunities to improve their work life.

I am proud to say that my team, the roughly 100 people who make up the administrative core of Northwell Health Physician Partners, is a highly engaged bunch, but we recently instituted two programs that I hope will make a good situation even better.

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Can We Talk?

Mental illness causes great suffering for the afflicted, profoundly affects families and loved ones, and is highly prevalent. As I share stories of my own family, I am routinely struck by how many people have similar stories of their own to tell – really  heart-wrenching stories about their children, or their parents, or their siblings, which have shaped their own lives as well as the lives of their loved ones. And yet, we don’t much talk about it. It is like a great shared silent burden. Keeping these stories in the shadows compounds the pain of those affected and further stigmatizes mental illness and its sufferers.

Fortunately, I have seen recent signs that this conspiracy of silence is starting to change. Maybe it is a consequence of the “radical sharing” of the Facebook generation (no, I still don’t have an account), and partly a consequence of more effective treatment for serious mental illness. Whatever the cause, people are starting to talk. Here are a couple of examples, just from this last week.

The first was a two-part podcast produced by WNYC as part of the “Only Human” series that explored intergenerational conversations about mental illness. Part one focused on immigrant communities, and how children raised in America faced difficult conversations with their parents raised in other cultures. Part two was about a medical student who challenged her school and her teachers with an open approach to her own mental illness. Both are well-worth listening to, and may challenge your own thinking.

The other was a video produced by the Washington Post about a young composer, Rachel Griffin, who is developing a musical about mental illness to de-stigmatize her own story. I am proud to say that my daughter, Emily Nash is in the cast, and helping to bring the work to life.

These seem to me to be good signs of progress on a long road. What do you think?

Hippocrates and the Internet

The Hofstra Northwell School of Medicine recently graduated its second class. The commencement was a wonderful “feel-good” event, complete with beautiful weather, happy graduates and proud families. The ceremony closed with the newly minted physicians rising to their feet and reciting the oath of the physician. In a nice touch, the other physicians in the audience were invited to renew their commitment to the profession by joining in. I found the whole thing joyous, and the opportunity to publically take the oath again was a moving reminder of what doctoring is all about.

Coincidentally, I also had the opportunity this week to lead one of the sessions in Northwell’s Physician Leadership Development Program,  part of a half-day session with Sven Gierlinger, our organization’s Chief Experience Officer, and Jill Kalman, the Medical Director of Lenox Hill Hospital, devoted to the voice of the patient.  My bit was about our “transparency project”to publish our physicians’ patient experience scores on our public website.  I used the story of how and why we did that as a case study that tied together the themes of physicians driving change and of improving the care we provide to patients and their families.

It was only after the fact that it occurred to me that there was a profound connection between the two events.

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Sound Familiar?

I am reading a really interesting book entitled Team of Teams written by (naturally) a team, which includes retired United States Army General Stanley McChrystal. McChrystal, you may recall, was the commander of US and coalition forces in Afghanistan before he got sacked for comments he and his staff made to a reporter for Rolling Stone. Prior to taking command, he served as the head of US Special Forces in Iraq during the Sunni insurgency, and this book is about how he and his deputies restructured that “Task Force” to meet the unprecedented challenge they faced.

Early in the book, he discusses the rise of “efficiency” as an organizing principle for industry and, by extension, other forms of human endeavor. He tells the story of Frederick W. Taylor who, late in the 19th century, introduced the idea of organizing activities in a factory so that the workers could produce “more, faster, with less.” Taylor also popularized the means of doing so by standardizing processes to reduce wasted time and effort and by optimizing each element of production. He was, one could say, the Lean production maven of his day. Here’s the passage from McChrystal’s book that really caught my attention, describing Taylor’s experience in a factory in 1874:

Taylor became fascinated by the contrast between the scientific precision of the machines in the shop and the remarkably unscientific processes that connected the humans to those beautiful contraptions. Although the industrial revolution has ushered in a new era of technology, the management structures that held everything in place had not changed since the days of artisans, small shops, and guilds: knowledge was largely rule of thumb, acquired through tips and tricks that would trickle down to aspiring craftsmen over the course of a long apprenticeship.

That transformation from artisanal workshop to organized enterprise, and from “tips and tricks” learned through apprenticeship to standardized work that can be specified and taught, sounds to me exactly like what medicine is going through today.  In fact, the changes in medical practice that have been advocated as the pathway to better, less expensive care have been described using the very same language.

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Population (Heart) Health

I had a great time at the national meeting of the American College of Cardiology (ACC) this past weekend.  I hadn’t been to “the meetings” in a few years, in part because my professional focus is no longer primarily clinical and well, I never really liked going even when it was. I generally believed (and still do) that I get more valuable information about new developments in cardiology by reading journals than by shlepping around some gargantuan convention center and listening to a few talks while dodging the barrage of drug and device manufacturers. Now that the results of “late breaking” clinical trials are instantly available (complete with slides and expert analysis) within hours of their presentation, I find the whole convention thing even less compelling.

So (with a nod toward the upcoming Passover holiday) why was this meeting different from all other meetings?

First, I had the pleasure of hearing my brother, David Nash, founding Dean of the Jefferson College of Population Health, deliver the Simon Dack lecture. As I said to him when he first told me he was invited (and wanted to know if it was a big deal), this is a big deal. It is the opening keynote for the conference, and is intended to set a tone or theme for the meeting, which draws almost 20,000 people from around the world. Here is a picture of him being introduced by the President of the ACC:

Nash_ACC

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Capitation? What Capitation?

Policy makers who are responsible for shaping how the federal government (the country’s biggest payer of health care services) pays physicians are pushing CMS on a rapid path away from traditional fee-for-service (FFS). As I discussed last year, CMS intends to have 50% of its payments flow through “alternative payment models” such as ACO’s and bundled payments by 2018, with nearly all of the rest of the FFS payments linked to quality measures.

While I believe this is generally a good thing, I pointed out recently that changing how the dollars flow is not the same as changing how the care gets delivered. Changing payment models facilitates redesigning care, but it doesn’t automatically create new care models. That only happens when physicians, liberated from the constraints of FFS, lead the way to do the right things for patient.

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Transparency 2.0

I had the opportunity recently to speak about our practice of posting patient comments and survey scores on our physicians’ web pages. The conference at which I presented was devoted to “transparency and innovation” and it became clear to me that making patient satisfaction scores public, while innovative today, will be universal pretty soon. The same forces that convinced us to go this far – rising consumerism among care-seekers, the ubiquity of ratings and information for other goods and services, and the evolution of payment models away from fee-for-service – will compel us to provide more and more information to patients and potential patients.

What might that look like? Here are a few possibilities.

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Incentives and Capabilities

The idea that we have to “change incentives” for physicians is all the rage. Oceans of ink are being spilled over the transition away from the traditional fee for service payment model to a menagerie of value-based ones. At the core of much of the discussion about how to make the transition is figuring out how risk-bearing organizations like large physician groups, health systems, ACOs and the like are going to provide appropriate incentives to the individual, front-line physicians who are providing the clinical care. It is not a trivial problem to solve.

The usual explanation of the challenge goes something like this: In the old days, when organizational success was defined by the number of “heads in beds” in hospitals or patient encounters in the clinic, it was pretty straightforward to “share” that success with physicians. The more patients they saw (or procedures they did) the better it was for everyone, and rewarding “productivity” floated everybody’s boats. Under alternative payment models, the measures of success of the organization are different and more complex – generally combinations of quality measures, patient satisfaction, efficiency, etc. – and translating that into new physician payment models is not so easy. If you continue to reward productivity, then it may defeat organization efforts at efficiency; make the payment model too complex by including many different performance metrics, and physicians don’t get invested in any of them; make the model too simple, and physicians will be insulated from the organizational goals.

Lost in all of the details of how to create the illusory “perfect” physician incentive program is the fact that incentives are only a part of picture. Combinations of carrots and sticks only work where the capability to respond exists. It is not helpful – to patients, doctors, or anybody else – to implement incentive programs that reward or punish physicians when the systems of care in which they work have not been redesigned to achieve the new goals. For example, tying a physician’s compensation to cancer screening rates in a primary care setting without designing a system to identify appropriate candidates for screening and facilitating the testing is just a demoralizing punishment for the physician.

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Test Responsibly

I got a heads up the other day that our organization had been dissed by a CNN reporter who was frustrated by her inability to get tested for Zika. You can read her original piece and the follow-up here. Short version is that she was upset that it was difficult for her to get tested after returning from a vacation to Costa Rica where she encountered “a good amount of mosquitoes” and later developed a mild febrile illness.

I won’t defend that she was made to feel like she was getting the run around, and it seems like – at the very least – we could have done a better job of communicating with her. But what she seems to dismiss, even though it goes to the core of her encounters with all of the medical providers she contacted, is whether she should have been tested at all. Continue reading Test Responsibly

More Public Reporting

Readers of this blog know that I am a fan of public reporting of performance data. I believe that data transparency helps fulfill an obligation to our patients to be honest about the care we provide, and is also a potent stimulus for improvement. There are obvious conditions that ought to be met before any sort of data – about quality, patient experience, finances or anything else – is shared in this way. The data should be meaningful (pertaining to something that patients are likely to care about), valid (the data actually measure what we say it measures), reliable (vary consistently with performance) and presented in a way that patients can easily make sense of it.

Our own efforts to report the patient satisfaction scores of Northwell Health Physician Partners physicians has been well received by our members and the press because it meets all of these criteria.

Some of the other public reporting efforts, such as recent reporting of surgical complications by Pro Publica, have been criticized for failing to meet the standards of validity and reliability, although I and others have been supportive of their efforts.

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