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Meaningful Use: A Good Earth or Scorched Earth Path

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This past week, I had the pleasure and honor to spend four hours on medical attending rounds at a major integrated health system in the Northeast I’ll call IHS. It’s top rated in several national performance initiatives with well recognized brands and, like all other great systems, publishes very respectable performance in quality, cost and access metrics.

Also, like the majority of hospitals in 2010, IHS hasn’t yet rolled out the most challenging clinical pieces of Stage One MU – inpatient CPOE and well-constructed problem lists. To its credit, IHS is a strong Level 3 in the HIMSS Analytics EMRAM, and has clearly had many tangible clinical successes leading toward Level 7. As you read on, you’ll find that IHS is a pretty healthy place for the organizational improvements that underpin MU.

I witnessed a number of great clinical practices that led me to the conclusion I would prefer having my family and friends receive care at IHS when compared to the actual care I’ve experienced at other hospitals. For example:

1. IHS has established a practice of bringing patients’ families in on rounds. Family members not only know when rounds will be, if they’re not able to attend in person, the clinician will call a designated family member from the patient’s bedside on speaker phone. Given the near ubiquity of cell phones, it wasn’t a big surprise to learn that patient and family satisfaction is high.

2. Also present throughout rounds, or at least very nearby the patient room and closely participating, are the patient’s assigned nurse and/or nurse manager, a pharmacist, and others determined to be central to care. They include other clinicians, social workers, case managers, translators and clinical administrators. This practice has been evolving at IHS and elsewhere over the decades since my residency training in the form of family rounds in ICUs and executive patient safety walk rounds. Both of which pretty much never happened as a routine when I was in training.

3. There are shared information artifacts in printed form being used personally and between IHS staff to enhance communication and efficiency. Everyone had them. I saw evidence of both harmonies and disharmonies; great stuff to feed improvement initiatives, and drive adoption and buy-in.

My reaction? What a wonderful setting to introduce enhanced problem lists and CPOE disciplines. What a great setting to further push communications and collaboration disciplines outside of the four-walls and cell phones to electronic, timely discharge documentation for not only patients and their families, but also their referring physicians and remote care providers.

Several patients were not only not in the IHS catchment, but often several states away. The “send and receive patient summaries as interoperable documents” require the kind of cultural and work flow developments that IHS is clearly piloting today. The patients getting care from longer distances will receive some of the greatest benefits from improved post-discharge care coordination.

If my dad or mom were admitted to your hospital today, would I be informed of when I was invited in for daily rounds? Would you be able to offer me phone or video conferencing at the bedside with the clinician on rounds? Would the discharge documentation look like the impersonal, Xerox paper notes with circled, vague information that I was recently given after my mom received a VVI pacemaker placement? Much to my horror, it also included discharge instructions for an implantable defibrillator, which she didn’t need or receive.

That was the best this hospital could offer; and it has implemented CPOE. Personally, I’d rather my mom had received her care where communication is correct and clear as a first priority. CPOE, although an essential safety enhancement, is beside the point when it’s not communicating accurate information to care providers and patients.
 

This past week, I had the pleasure and honor to spend four hours on medical attending rounds at a major integrated health system in the Northeast I’ll call IHS. It’s top rated in several national performance initiatives with well recognized brands and, like all other great systems, publishes very respectable performance in quality, cost and access metrics.
One hospital's good earth path to MU

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Comments

Thanks Dr Budman. I love your clarity. I think you captured the ingredients well.

In my experience, there are two areas that take continual re-dedication: bringing personal energy to ones leadership work (its often exhausting), and sharpening the saw stuff (ie learning new skills, and picking up new knowledge.) When people fatigue in those two areas, the level of visible leadership suffers first.

Thanks again for your comment.

First, the IHS program sounds like the kind of place I would prefer to obtain treatment for my loved ones. Period. (Read that as IHS competing meaningfully in the marketplace.)

Second, I almost hate to ask these questions, since the feel is so intuitively correct. But what about metrics? Certainly I would expect significant rise in patient/family satisfaction scorres. What about improvement is clinical outcomes? Costs? Decreased length of stay? Reduction in errors/adverse events. What is the cost of the program: infrastructure, team time and training doesn't come cheap?
Third, you are certainly on point with your observation about this being a fertile environment for Problem Lists.

Good stuff. Keep it coming.

Frank,
Thank you for your comment and your link to IPOP, the InPatient Operational Performance Improvement Program
(IPOP).

A decade ago, I learned about throughput, optimizing it, and the Theory of Constraints (http://en.wikipedia.org/wiki/Theory_of_Constraints aka TOC) from a former IBM'er who was around when it swept through IBM. About 1990!

Consistent with the rational laid out in your IPOP description, if you manage anything other than the bottleneck, your throughput will be unchanged. If you hope to manage bottlenecks, you'd better understand the throughput-dollar-days to make clear decisions. And, you'd better have a detection system such as the processes you described, because, ... surprise, surprise, ... bottlenecks in hospitals float. (They're not stable: the ED to admission process may be the bottleneck for 38 hours, but then it's the discharge to unavailable nursing home, or ICU operations, or any of the departments in your examples.)  Subsequent capital decisions such as the likely impact of adding observation beds, or investing in EMR tuning, management or programs like Antibiotic Assistance can only be selected as a shoot-from-the-hip, or based on last year's black swan.

Yes, I did give IHS several gifts.

Thanks again for your comment. And yes, I violently agree with your statement that installing and implementing an EMR is only a step toward the work of exploiting that technology. If it's not a project, potentially informed by IPOP, it's a kin to a powerful car with a choked off carburetor. Burns fuel inefficiently, doesn't go very fast, and frustrates its owner.  And yet, all of the tangible resources are present.  At a recent Advisory Board meeting on ACOs, they view inpatient demand to be increasing for several powerful reasons.  The time to learn to manage inpatient throughput is now.

Doc Benjamin,

Thank you for your terrific comment.  You asked me, directly or otherwise, to expand on leadership and direct observations related to leadership from rounds. Your comment is invaluable because, in the seven hundred words of the post, a blogger is forced to be a little telegraphic.

Since you, I and the attending physician described implicitly in the post are physician leaders, let me reference a wonderful two-day course I attended, titled "Leadership Fundamentals for Physicians," by the Advisory Board Company.  It's also called "The Boot Camp."  In contrast to their usual mode, i.e. membership-only, this is a retail offering.  Any physician can attend.  Here's what they consider to be critical to physician leadership.  It applies to all healthcare executives, even completely non-clinical health system CEOs:

1. Business Context (the stuff physicians are untrained or under-trained in), including the physician's impact on the revenue cycle, financial performance basics of departments and their roll-ups, and system-wide structures (capital budget decisions, board of directors, medical exec committee, etc.).

2. Interpersonal skills - structuring individual interactions, building relationships, pre-wiring meetings, varying communication styles, and the Ernest Shackleton Epic and it's lessons for disciplined inclusion.  The relationship with Up-To-Date Problem Lists (an MU requirement) is clear: Shared Goals, Activities, and Participation.  This requires the kind of leadership that may be behind the scenes today at IHS.  The fact that the participants I spoke with privately weren't aware of these is, of course, a big red flag.  That's why so many have privately resonated with this post already.

3. Building on one and two above, the Boot Camp moves on to a) guiding multilateral decisions, b) working within the system "called the organizational context" (this is hard for young physicians and those too young at heart), and c) applying all that for Quality Improvement and elevating Organizational Performance.

What I observed at IHS?  Lots of clearly committed and energetic participants, described by the behaviors in my post above.  There was little or no evidence of projects to improve care on rounds.  Doing it as a separate process is a well-known worst practice.  Those projects, if they exist, have not been incorporated into rounds.

So, for example, in Agile with Scrum, there would be a daily stand-up component of the team where each member briefly summarized yesterdays and today's process improvement-oriented work. That, in turn, would be part of a larger improvement iteration managed by the chief resident.  And that, in turn, through department based ownership of the improvement, would inform the IT department, and inform and populate the problem list strategy, the pre-work for CPOE, the daily rounding artifacts (described above), etc.

Collectively, the change management process, from the position of the residents, nurses, pharmacists, etc., would result in three, clear, visible consecutive campaigns: Awareness, Acceptance, and Commitment.  The awareness piece of current and future work would be communicated on the rounds.  Problem list work would precede CPOE work by about nine months.  Otherwise, problem-based rounding would be replaced by a hard to use and hard to adopt roll-out.  We've all seen these over the last decade.  (I'm not saying getting business owners to the front of the bus is easy; I'm just saying that the bus doesn't run it's intended route any other way.)

The alternative approach is to have IT survey the order management system, populate a dispassionate and otherwise largely ignorant enterprise EMR system at a pilot site, with empiric lists of orders, problems, and site-specific tasks.  The thinking is department focused.  Historically, this has led to dissatisfaction, significant usability challenges, and a waste of money and talent.

The point of my post is that you can have an IT-lead initiatives, with or without Leadership that's driving the spirit of Meaningful Use. That spirit explicitly includes communal learning. If it's not happening on attending and residents rounds today, you're not headed down a good earth path (solid ground).

HITmaven,

Thanks for your kind words.

IHS's public web site makes it clear that they are publicly reporting cost data from their patient accounting department. Similarly, like all hospitals, by regulation as you know, are independently capturing and reporting satisfaction data, leading to or contributing to their many awards. The "Quality" section of their website has a single short page saying "under construction."

I follow the AHRQ classification system that put safety under Quality in an organizational hierarchy. In value, I consider it a constraint rather than an objective. For example, there should be zero avoidable catheter-caused infections, no ventilator-associated pneumoniae, and more broadly, no admissions for asthma. Each is an avoidable care management issue, not an event to be minimized. Each can be dramatically improved with Checklists, which should preceed or, worst case, be contemporaneous with CPOE and problem list disciplines.

I'm not yet comfortable with public reporting on safety. Again, referring to AHRQ, I know they are funding some great work that will making safety reporting even more effective, like they did with their PSO work.

I would welcome comments from those practitioners in the field.

Dr. Joe,
Wow..this place is truly unique. All the hospitals I or my family have been admitted to during the last three years can't even tell you what time tomorrow they will do your exray procedure, can't tell you when the therapist will see you, can't tell you when tomorrow a doctor will see you...etc.
For more see: 'Would you go to this restaurant' at http://www.kelzongroup.com/IPOP.html

I hope you gave them an award or something...
Frank

Dr. Bormel,
My first thought after reading this post was, "I wonder if IHS is hiring physicians?" This hospital is not only a place where I want my family and friends to receive care; it is an institution where I'd like to practice.

I do have a question for you. Why did you not mention leadership in your post? It appears to me that the senior executives of this organization have mastered the art of being true leaders. I believe it was Grace Hopper who once said, "You don't manage people; you manage things. You lead people." The leaders at IHS really seem to get it!

So would you please take your blog a step further and explain some of the style points or techniques you observed during your visit. I'm sure many of your readers here would find this information of value. Thank you.

Doc Benjamin

Honesty, sincerity, integrity, and knowledge help to make a good physician. Compassion and concern make a caring physician. Collaborative interdisciplinary teams with enriched data and accurate, open communications make for excellent delivery of care (the promise of IT). Leaders in health care must understand this by now. What are the business and personal skills of those leaders to make this a reality?

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