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I Can Do That Case In 45 Minutes!

March 20, 2011
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Accurate data can be very persuasive, especially for physicians

"I Can Do That Case In 45 Minutes!"

Part of the joy of my job as a CMO at a vendor is sharing observations with and helping CMOs and CMIOs at provider organizations. The challenges almost always start as recognizable stories. Let me share a recent one with you.

A surgeon asked the OR staff to fit in a case that “ will take no more than 45 minutes.” The staff mentioned this to their manager who pulled up the statistics for that surgeon and that case type. He had not completed that case type in under two hours according to more than a dozen relevant, recent cases with time-stamped performance data. The surgeon was humbled, gracefully stood corrected, and was, hopefully, quietly impressed with the professionalism of management.

This story illustrates a few things worth calling out. As we all know, accurate data can be very persuasive, especially for physicians. Physicians are specifically trained to have a very strong and healthy skepticism for unproven methods; the counter corollary is that they are strongly influenced by proof data. In fact, there's a hazard of being too easily influenced by factual but misleading framing of data. For more on this, you might find value in this interview ( link to Drs. Mercola/Golomb interview).

The second point illustrated by this story is more generally applicable to all people, not just docs. Quite simply, there are at least three relevant, concurrent and necessary perspectives for realistic self-management, as well as helping others to structure their work. The three perspectives are:

1) what we think we do,
2) what we say we do, and
3) what we actually do.

They are almost always different from one another.

In my story, the surgeon said and thought he could do the case in 45 minutes. Historical performance was greater than two hours, and, of course, included his actual time, as well as setup, buffering, cleanup and other process considerations outside the surgeon's view. To some degree, all of us have a level of self-centeredness that blinds us to our actual behavior in the real world. And when we're into work we find interesting, consuming or stimulating, we all lose track of time. That's just part of being human.

I think there are but a few ways to enhance our self-awareness to up our games: feedback (e.g. access and orientation to the performance data), coaching, and introspection (sharpening our own self-management saws, in part by simply scheduling stop-and-think time!).

What do you think? How long do you think it took you to read this post? How long did it actually take? I actually have that data. It averages 2-3 minutes.

Joe Bormel, M.D., MPH
CMO & VP, QuadraMed
This Post: http://bit.ly/icandothatcasein45minutes
Recent Prior Posts:
BlindSpots part one, two, three, four, and five

“Healing is a matter of time,
but it is sometimes also
a matter of opportunity.”

Photo credit: istockphoto.com



Doc Benjamin,

Thank you for your comment.  It tickled me that you were able to get the word "timely" into your first sentence, since this post really did focus on time.  I agree with your observation that understanding costs, associated patient flow and service management in general is crucial to healthcare's future, be that under ACOs or our current volume-based models with declining reimbursements.

I don't agree with your generalization that "we simply don't know the associated costs."  Some providers do.  As shown in the graphic above, the ED costs for physician assessments, as well as all other costs have been tracked and managed by many provider organizations.  These slides were take from the pioneering work done by Dr David Eitel et al at Wellspan in York, Pennsylvania many years ago.

If you'd like to make the generalization that there's not enough use of Corporate Performance Management (CPM) suites among healthcare providers, with an adequate focus on Time-Driven Activity-Based Costing, you will find a lot of agreement there!  Shown below is a roll-up of the same patients shown above, contrasting the General Ledger view with the Activity Based Costing view. 

I agree with your implied statement that not enough providers manage their services this way.  There is relatively little penetration of scorecards, BI dashboards, performance modeling, forecasting and other CPM suite component capabilities in daily use (typically limited to the Davies award winners) in healthcare.  Recent analytics market growth is nearly nonexistent, according to several authoritative sources (personal communication and proprietary commercial consultancy documents.) 

The providers that are managing from the data, like Sentara Healthcare, are able to show the value.  I had the pleasure of attending Sentara Healthcare CIO Bert Reese's presentation at the HIMSS AMDIS 2011 meeting last month.  Their story highlights, among other things (BI Dashboards, Go-live and ROI tracking, etc), their focus on cycle time reductions.  You can find a nice elaboration of their story in Healthcare-Informatics, here.  Want more?  Bert has a book chapter in Ken Ong's most recent (2011) executive primer on informatics, here, where he walks through Sentara's BI dashboard accomplishments in detail.

On the vendor side, the integration leaders, including Oracle and IBM had prominent exemplars on display of CPM suites at HIMSS.  Strong software pure-play companies like SAS Institute seem to struggle to tell their story in healthcare.  That's particularly unfortunate for healthcare because SAS' Activity-Based Management application is their most widely deployed CPM application in industries (other than healthcare that is.)  There are intriguing options from a lot of other vendors as well as related consultancy services.  My point is that there is a lot going on despite the relatively low penetration at provider organizations.

Thanks again Doc Benjamin.  Your perspective of the importance of time measurement and analytics for quality and service improvement is a dimension that I didn't emphasize.  Thanks for calling that out.

There is a variant of that theme about consultants, blaming their clients for failing to execute their brilliant strategies. The take-home lesson from this recent review of the problem ( http://hbr.org/2010/07/the-execution-trap/ar/1 ) is that management problem solving isn't a ready-aim-shoot situation. In that framing, aim is strategy formation and shoot is execution.

In real management situations, it's cycling through aim-shoot-measure, followed by aim-shoot-measure, etc. And "measure" isn't simply recording something like the elapsed time. The minimal analytic tool is a control chart. To your point, when is the last time you saw one of them in use, outside of published research?

In our example here of the surgeon's 45 minute case time, a control chart display would make it intuitively obvious to the most casual observer if their times were stable at 2 hours, or improving or worsening. Analytic tools don't have to be expensive.  Analytic initiatives do need to contain three steps: 

1) get the data,
2) find actionable opportunities (using tools like control charts), and
3) take action.

And, of course anything short of doing this work in the context of authentic leadership and development of trust is simply a non-starter.

Dr. Bormel,
This is a very timely post, and it makes an important point. That point is no one in healthcare knows what an encounter of any kind costs! Whether it's a simple visit to a physician's office all the way to transplant surgery, we simple don't know the associated costs.

With what appears to be the advent of ACOs, if you like it or not, knowing the costs associated with providing quality care to our patients is of tremendous importance. Yet we don't seem to be making much headway in this area. That does not bode well healthcare as a whole, and physicians in particular.

Healthcare self-awareness must include business savvy. I know that was not really the original point of your blog, but you opened a critical door. We need to understand that the first business of every business is to stay in business!

Doc Benjamin

Dr. Bormel,
Thanks for correcting me. There are a number, although somewhat small, of organizations that can and do track their total costs. Unfortunately, mine is in the majority. We do not. I suupose the pun is, someone needs to be held accountable!

About your vendor-side comment, I have considerable direct and tangental experience with integrators. I can tell you from experience, and well documented huge numbers of failed federal government projects will support this, that too many integrators will tailor a response to an RFP, while having no real idea as to how to meet the organization's goals. It's a characteristic of the beast.

Doc Benjamin