A few weeks back, a number of you sent me this article from the New York Times:
The article describes a physician who is trying to take the amount of time – the right amount of time – that he thinks is required to get a proper diagnosis for the patient. Does taking longer, reducing his short-term productivity, end up improving care and reducing costs over the long term? That’s hard to know for sure, but it makes sense.
“Dr. [Rajeev] Alexander considers it proper technique to review each mundane detail with a patient.. a hospitalist at PeaceHealth. His painstaking method of diagnosing patients’ maladies is viewed as inefficient by some who seek to cut costs… He was nonetheless unapologetic about the time he had invested” in a patient, taking 45 minutes with a patient.
The question of productivity and “patients per hour” metrics create a lot of disagreement between physicians and medical administrators. There are enough pressures in healthcare – to reduce costs, to improve access, to improve quality and patient safety (the latter being the goal that should matter most).
The article describes one way in which PeaceHealth was going to try to reduce costs:
“In the spring of 2014, the hospital announced plans to outsource its 36 hospitalists to a management company.”
A Lean thinker would hopefully realize that outsourcing work isn’t the same as improving a process and reducing waste. A management company needs to make a profit margin on top of what the hospitalists would be paid. It’s not clear that outsourcing would really reduce costs. I’ve seen hospitals choose to bring laundry service back in house because it was CHEAPER to do it themselves.
The article makes it seem like the hospital might reduce costs because they would only pay on a per-patient basis. But do the hospitalists really have that much idle time?
“[The outsourced physicians’] compensation is often tied more directly to the number of patients they see in a day.”
Some hospitalists think the maximum number of patients should be 15 per day. Is that number based on their current system and the waste that’s quite certainly there, backed into the process? They were concerned about the new goal being 18 to 20 patients per day.
How would that goal be accomplished, I’d wonder. “By what method?”
“It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists…”
The only thing that would cause (should cause) outrage is being asked to rush through your work or cut corners. How much of a hospitalists day is spend providing value versus dealing with waste?
A physician said:
“Giving me a bonus for seeing two more patients — I’m not sure I should be doing that. It’s not safe.” (A hospital representative said patient safety was “inviolate.”)
It wouldn’t be unsafe to see more patients if you made that possible by freeing up time in their day, by reducing waste. Just squeezing the shortening the patient encounter times might be counterproductive.
Aside: hospitals always SAY “patient safety is our top priority,” but that’s not always demonstrated, unfortunately.
The article says:
“Dr. Alexander and his colleagues say they are in favor of efficiency gains.”
So, that would have been a perfect chance to engage them in that process.
After the outsourcing announcing, about one third of them quit (replaced by “locums” contract physicians), and the rest formed a union. Sacred Heart scrapped the outsourcing plan.
“By March 2015, the PeaceHealth leadership, whatever its interest in efficiency gains, was apparently not pleased that one of its hospitals had a white-collar labor insurrection on its hands.”
Why were they upset? They were afraid of “assembly line medicine,” as illustrated in the Times graphic, I guess:
Lean is, of course, not about creating “factory medicine” or “assembly line medicine,” regardless of what’s said in the NEJM.
“We’re trained to be leaders, but they treat us like assembly line workers,” said Dr. Brittany Ellison, a hospitalist in the group.”
Not all assembly line workers are treated badly… there’s a difference between a Lean culture and a traditional factory culture. It’s easy for people who have never been in a factory to generalize, but they’re usually wrong.
The Value Add (or Cost) of Hospitalists
Why has there been a boom in hospitalists in recent years? Internists faced pressure to see more patients in their offices, making it more difficult to go over to the hospital.
There were also efficiency pressures on hospitals. The hospitalists were a new cost, but, “They were on hand to discharge people throughout the day, emptying beds that could generate revenue again.” So, they paid for themselves, I guess. They had freedom to spend time with patients.
“…the increasing focus on metrics like readmission rates and hospital-acquired infections had created more work for hospitalists, who are responsible for a lot of documentation.”
It’s easier to measure costs than it is quality.
“Readmission rates have been reduced — we can show it.” Costs are rising more slowly too, he said, which is no small thing in a country where many people are bankrupted by medical expenses. But, he added, “as to whether you as an individual are seeing better quality in health care — I think there’s some question there.”
Money and Incentives
The article also says:
“To work in a hospital today is to be constantly preoccupied with money…”
(where is the preoccupation with patient safety, that supposed top priority?)
Again, from the article:
“…one of the more grating features as far as the Sacred Heart hospitalists are concerned has been the administration’s celebration of “skin in the game.” That means creating financial incentives for doctors to hit performance targets — like lowering patient’s length of stay and doing well on patient satisfaction surveys.”
Are the incentives a substitute for engagement, collaboration, and leadership?
“Dr. Robert M. Wachter, chief of the division of hospital medicine at the University of California, San Francisco, says many hospitals now give doctors financial incentives to perform well according to the criteria on which the hospitals themselves are judged under the Affordable Care Act — for example, reducing hospital-acquired infections. But there is an active debate in the profession over their utility. “If at the end of the year, 10 percent of your salary is at risk based on whether you have consistently clean hands, what patients say about you, readmission rates, that can be O.K.,” he said. The counterargument is that “you could screw things up by tying everything to financial incentives,” he said. “You stomp on their intrinsic motivation.”
In response to those incentives, it was written about one doctor:
“His personal rebellion is to linger over patients as long as he thinks it’s necessary, the hell with the performance metrics that nudge him to see more.”
That totally reminds me of the dysfunctional relationship between workers and management at my GM factory, 20 years ago. It’s sad to hear about these dynamics in healthcare.
Why does the idea of “skin in the game” and incentives bother them so much?
“It really took all of my self-control to not say, ‘What the hell do you mean skin in the game?'” he said. “We have our licenses, our livelihoods, our professions. Every single time we walk up to a patient, everything is on the line.”
They’re upset about decisions being taken away from them…
“He continued: “My thought was, I’ll put some of my skin in the game if [the administers] put your name on that chart. Just put your name on the chart. If there’s a lawsuit, you’re on there. You come down and make a decision about my patient, then we’ll talk about skin in the game.”
The article raises issues about bad leadership in their hospitals.
An MD says:
“Often people with dissociative disorder become managers. You have to treat people like things. A different way of saying it is sociopath.”
Treating people like things is not what good management (or good leadership) is about.
“What’s the widget the hospital produces?” he asked at one point. “It’s the doctor-patient relationship. You don’t improve it with extra little tasks.”
How do we improve the way care is provided? Ask the hospitalists. Engage them. Work with them. Don’t just give them targets.
A new hospital leader said “targets would include how many patients they see, but would also include measures of patient health and satisfaction… “It can’t be all based on production,” he told me. “It has to be quality — safety, a good experience. If you’re the patient in the bed, it’s important to you that you’re treated as an individual, that your needs are being met.”
About the new hospital leader…
“Mr. O’Leary was especially proud of a ritual known as REAL rounds, which stands for “rounding embraced by all leaders,” in which administrators circulate through a different unit of the hospital each week and talk to doctors, nurses and other caregivers about their needs.”
REAL was the name chosen – which stands for “Rounding Embraced by All Leaders.” That’s a good concept, but th MDs found this name offensive, saying “‘Are you kidding me? Real rounds, as opposed to what we do?'”
What Problems Should We Solve?
Again, from the article:
“Dr. Schwartz said he and his colleagues have always wanted to talk about staffing — ideally, they wanted to agree on a minimum proportion of doctors to patients — and how this affected patient safety. But when they raised these issues in the past, he said, the administration frequently shut down or retreated to marginal details.”
This reminds me of a story from a few years ago, where nurses were complaining about being micromanged on marginal details like pens in the drawer when they were trying to engage leadership on safety.
Incentives and Pay
The article points out how the hospital tried squeezing the docs:
“Hospitalists now earn about $223,000 a year for 173 shifts and are paid extra for working more. The hospital offered $260,000 for a mandatory 182 shifts, and up to $20,000 in bonus pay for hitting certain medical performance targets. The hospitalists work seven days on and seven days off, so this would have effectively eliminated any time off for sick days or vacation.”
Working half the time… that’s 365 divided by 2 = working 182.5 days out of the year
“When the doctors pointed this out, the administration responded that if they missed a few days, it would make sure they got extra days to hit the required number of shifts for full pay.”
When it came down to it…
“They preferred to work less and make less to avoid burnout, which was bad for them and worse for patients.”
We need to all work together (physicians and leaders) to devise processes and systems that provide the best care in a way that’s financial sustainable and fair for all.
The article paints a picture of a situation where nobody is finding “win/win” solutions.
What’s your reaction to the article?
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