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Four Key Issues in Innovation Management @timkastelle @Medici_Manager @WRicciardi @leadmedit

by http://bit.ly/1iWe5JW

Co-authored by Tim & Ralph

What are the key innovation issues facing the business community right now?

When we met up in person recently we had a great talk about this question.  We’ve continued the discussion over email, and these are the four innovation management issues that we believe people need to be thinking about right now.

Differentiated and integrative innovation concepts

Sustainable innovation cannot be achieved by one-size-fits-all and one-sided approaches. It requires a common understanding of what innovation is, classifying concepts in order to assure individual assessments as well as differentiated approaches for firms to strengthen their innovation capabilities and performance. Further, innovation is about balancing complementary, and often opposing, variables. Therefore, integrative frameworks may help to gain a more holistic perspective and direction of impact. Examples:

  • The Innovation Matrix is supposed to help assigning firms to one of nine types of innovative organizations. Depending on the characterization, a tailored approach can be developed in order to define where innovation should sit in the business model and how to drive growth.

 

InnovationMatrix

 

  • The Three Horizons Model integrates a short, middle and long term view of innovation, often being in tension to each other. It enables generating a balanced innovation portfolio, consisting of activities with different time horizons. This model can be of great benefit when it comes to mixing incremental and radical innovation activities with regard to risk and strategic alignment.
  • As outlined previously, firms need to ensure a balance of exploiting existing businesses with exploring new opportunities, i.e. they need to become ambidextrous in order to thrive sustainably. As each direction of impact requires dedicated culture, metrics, leadership, mindset and organizational setup, this is another tension to be managed. An integrative framework (below) can be useful to determine a firm’s inclination and how to move towards a balanced innovation capability. It’s important to note – particularly for leaders: Exploration and exploitation are different, but equally important!ralphmatrixStartups, typically positioned in the upper left quadrant need to move to the right direction for increased exploitation and optimization of new businesses. Bigger, established companies, in turn, aim at strengthening their exploration capabilities by moving from the bottom right box upwards. One of the main challenges for organizations to attain ambidexterity is to simultaneously enable separation and integration of both directions. While novel opportunities flourish best when they don’t interfere with core business, they must be linked to the firm’s core in order to scale successfully after validation.

A more detailed discussion of this issue is planned for an upcoming post. On a personal level, sustainable innovation requires integrative instead of either-or thinking. In order to be able to manage ambidexterity, Roger Martin suggests to balance reliability with validity by developing a design thinking mindset.

 

Walking through Lausanne, talking innovation

Walking through Lucerne, talking innovation

Reinvention and business model innovation

As the life times of business models steadily decrease and more radical innovation activities are about to enter the pipelines of most firms, the business model is the new unit of design. Indeed, research has confirmed that business model innovators outperform traditional innovators over time.

One key issue here is to establish systematic approaches to business model innovation. While most companies have proven processes for product innovation in place, only few follow process models for innovating business models. Steve Blank has recently pointed out that generation of novel and reinvention of existing business models is imperative for corporations to succeed in the time to come. Some of his points are:

  • For companies to survive in the 21st century they need to continually create a new set of businesses, by inventing new business models.
  • Most of these new businesses need to be created outside of the existing business units.
  • The exact form of the new business models is not known at the beginning. It only emerges after an intense business model design and search activity based on the customer development process.

Unlike execution of existing business models, the invention and validation of new business models is based on a scientific and emergent approach: defining and testing hypotheses through rapid iterative experimentation. This is what the Lean Startup approach is about. It also implies designing and testing solutions on a minimum viable basis to gain a high iteration and learning frequency through customer feedback.

To develop the ever more important (re-) invention and search capabilities into new fields, existing companies are challenged to consider to implement the lean startup concept. Or as Eric Ries puts it: Entrepreneurship is the new corporate function.

 

bmg

 

Another key issue for existing, in particular larger companies, will to build a structure, capable of successfully combining search (= generation and validation of new business models) and execution (= scaling and improvement of existing business models).

Co-creation through open and social approaches

Facing growing complexity, organizations are finding it increasingly impossible to be successful when entirely operating on their own. To move innovation forward more effectively and efficiently, they aim at building appropriate networks and partnerships. Findings of a recent IBM study confirm outperformers to be more inclined to innovate with external partners – including customers. It suggests a clear tendency to leverage openness, connectedness and co-creation.

Combining internal and external capabilities is becoming crucial for organizations to survive and thrive. Interorganizational partnerships and distributed value networks can be formed to pursue open business models and complementary capabilities. One interesting example is the intensified partnering between startups and larger firms to achieve sustainable innovation by combining their natural strengths. There is one simple reason behind: customer value and continuous disruption don’t care about silos and boundaries.

There is also a growing awareness of the benefits to make organizations more social. According to Nilofer Merchant, becoming social is about connecting things, people and ideas. Networks of connected people with shared interests and goals create ways that can produce returns for any company that serves their needs. This refers to both the organizational and the individual level. As for organizations, it’s all about moving from isolation to communities.

Here is Nilofer again:

The social era will reward those organizations that understand they can create more value with communities than they can on their own. Communities of proximity, where participants share a geographic location (Craigslist is an example but co-working locations are another) will allow people to organize work differently. Communities of passion who share a common interest (photography, or food, or books) can inform new product lines. Communities of purpose will willingly share a common task to build something (like Wikipedia) that will carry your brand and its offer to another level. Communities of practice, where they share a common career or field of business, will extend your offer because it extends their expertise (like McAfee mavens). Communities of providence that allow people to discover connections with others (as in Facebook) and thus enable the sharing of information, products and ideas.

On the people level, connecting individual stakeholders through social business design – particularly involving customers – is on the rise. In social organizations, people are seen as most valuable asset to make a difference. As discussed here, a higher degree of connectedness in combination with making interaction workers more effective and efficient, seems to be a prerequisite for strategic advantage over industry peers. Moreover, social designs bear significant potential to help organizations in better tackling the complexity of business model innovation, adaptability and strategic reinvention.  

Building a culture of experimentation

One of the best tools to use to improve innovation capability is experimentation.  We often think that great businesses are built on great ideas.  But the fact of the matter is that great businesses are usually built by tinkering until their great idea emerges – this is the story told in Little Bets by Peter Sims.

Experimentation is an organisational skill that underlies all of the other issues that we have raised here.  While there is no one-size-fits all innovation tool, experimenting is pretty close to being a one-size-fits all innovation skill.  It is an approach that works best when it is used to test hypotheses – so that it enables structured learning.  Experiments and hypothesis testing are an essential part of business model innovation.  If we are trying to embed lean start-up principles into larger organisations, this is a capability that must be there.  Experimenting is also central to co-creation and other social approaches.

Start-ups and smaller organisations often experiment naturally.  The issue that we would like to raise is that this skill must also be nurtured in larger organisations as well.  If you’re a manager, this means building experimenting into your organisational structure and routines. If you are reporting to someone, it means figuring out how much you can get away with, and using that scope of action to support experiments.

Other people may well come up with other innovation issues that are important, but these are the ones that seem most interesting to us right now. Now we just need to start making progress on them! Therefore, we’ll try to elaborate on these issues in the time to come, in order to provide further ideas to help make innovation more successful.

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About Ralph-Christian

Experienced innovation, technology and product management professional. Looking at the intersection of organizational and personal innovation capabilities. Integrative thinker. Boundary spanner. Author of the Integrative Innovation blog. You can follow him on Twitter @ralph_ohr.

Managing Complexity: The Battle Between Emergence And Entropy @Medici_Manager @pash22 @wricciardi @leadmedit

By Julian Birkinshaw, London Business School Term Chair Professor of Strategy and Entrepreneurship. http://onforb.es/19bAvh8

The business news continues to be full of stories of large companies getting into trouble in part because of their complexity. JP Morgan has been getting most of the headlines, but many other banks are also investigation, and companies from other sectors, from Siemens to GSK to Sony, are all under fire.

It goes without saying that big companies are complex. And it is also pretty obvious that their complexity is a double-edged sword. Companies are complex by design because it allows them to do difficult things. IBM has a multi-dimensions matrix structure so that it can provide coordinated services to its clients. Airbus has a complex process for managing the thousands of suppliers who contribute to the manufacturing of the A380.

But complexity has a dark side as well, and companies like JP Morgan, IBM and Airbus often find themselves struggling to avoid the negative side-effects of their complex structures. These forms of “unintended” complexity manifest themselves in many ways – from inefficient systems and unclear accountabilities, to alienated and confused employees.
So what is a leader to do when faced with a highly complex organisation and a nagging concern that the creeping costs of complexity are starting to outweigh the benefits?

Much of the advice out there is about simplifying things – delayering, decentralising, streamlining product lines, creating stronger processes for ensuring alignment, and so on. But this advice has a couple of problems. One is that simplification often ends up reducing the costs and benefits of complexity, so it has to be done judiciously. I have written about this elsewhere (provide link).

But perhaps the bigger problem is this advice is all offered with the mentality of an architect or engineer. It assumes that Jamie Dimon was the architect of JP Morgan’s complexity, and that he, by the same token, can undo that complexity through some sort of re-engineering process.

Unfortunately, organisational complexity is, in fact, more complex than that. To some extent, organisations are indeed engineered systems –we have boxes and arrows, and accountabilities and KPIs. But organisations are also social systems where people act and interact in somewhat unpredictable ways. If you try to manage complexity with an engineer’s mindset, you aren’t going to get it quite right.

I have been puzzling over complexity in organisations for a while now, and I reckon there are three processes underway in organisations that collectively determine the level of actual complexity as experienced by people in the organisation.

1. There is a design process –the allocation of roles and responsibilities through some sort of top-down master plan. We all know how this works.

2. There is an emergent process – a bottom-up form of spontaneous interaction between well-intentioned individuals, also known as self-organising. This has become very popular in the field of management, in large part because it draws on insights from the world of nature, such as the seemingly-spontaneous order that is exhibited by migrating geese and ant colonies. Under the right conditions, it seems, individual employees will come together to create effective coordinated action. The role of the leader is therefore to foster “emergent” order among employees without falling into the trap of over-engineering it.

3. Finally, there is an entropic process – the gradual trending of an organisational system towards disorder. This is where it gets a bit tricky. The disciples of self-organising often note that companies are “open systems” that exchange resources with the outside world, and this external source of energy is what helps to renew and refresh them. But the reality is that most companies are only semi-open. In fact, many large companies I know are actually pretty closed to outside influences. And if this is the case, the second law of thermodynamics comes into effect, namely that a closed system will gradually move towards a state of maximum disorder (i.e. entropy).

This may sound like gobbledegook to some readers, so let me restate the point in simple language: as organisations grow larger, they become insular and complacent. People focus more on avoiding mistakes and securing their own positions than worrying about what customers care about. Inefficiencies and duplications creep in. Employees become detached and disengaged. The organisation becomes aimless and inert. This is what I mean by entropy.

The trouble is, all three processes are underway at the same time. While top executives are struggling to impose structure through their top-down designs, and while well-intentioned junior people are trying to create emergent order through their own initiatives, there are also invisible but powerful forces pushing the other way. The result is often that everyone is running very fast just to stand still.

So let’s return to the leader’s challenge. If these three processes are all underway, to varying degrees, in large organisations, what should the leader do? Well, sometimes, a sharply-focused and “designed” change works well, for example, pushing accountability into the hands of certain individuals who are much closer to the customer.

But more and more the leader’s job is to manage the social forces in the organisation. And in the light of this blog, it should be clear that this effort can take two very different forms:

1. Keeping entropy at bay. This is the equivalent of tidying your teenager’s room. It involves periodically taking out layers of management, getting rid of old bureaucratic processes that are no longer fit for purpose, or replacing the old IT system. It is thankless work, and doesn’t appear to add any value, but it is necessary.

2. Inspiring emergent action. This is the equivalent of giving a bunch of bored teenagers a bat and ball to play with. It is about providing employees with a clear and compelling reason to work together to achieve some sort of worthwhile objective. It isn’t easy to do, but when it works out the rewards are enormous.

And here is the underlying conceptual point. The more open the organisation is to external sources of energy, the easier it is to harness the forces of emergence rather than entropy. What does this mean in practice? Things like refreshing your management team with outside hires, circulating employees, making people explicitly accountable to external stakeholders, collaborating with suppliers and partners, and conducting experiments in “open innovation”.

A lot of these are initiatives companies are trying to put in place anyway, but hopefully by framing them in terms of the battle between emergence and entropy, their salience becomes even clearer.

Why you should reframe your strategy as transformational @leadmedit @helenbevan @Medici_Manager @muirgray

Posted by:

In my last post, I talked about strategy as logic; that is, a system of reasoning we utilise, based on our views and beliefs, about how to achieve change.

My own strategic logic for change (and therefore my practice as a leader of healthcare improvement) has been particularly influenced by Marshall Ganz. Ganz spent decades as a community organiser, leader and enabler of campaigns and social movements before joining the Kennedy School of Government to teach, research and write about leadership of change from a social movement perspective.

It’s very helpful for healthcare leaders to reflect on Ganz’s logic and definition of strategy: how we as leaders turn what we have (resources) into what we need (power) to achieve what we want (outcomes) by focusing on clear strategic objectives. I’m concentrating on this perspective specifically in this blog and will discuss resources next time.

The Montgomery bus boycott

We can see these strategic principles in action in so many of the inspiring stories of social change. Let’s take the example of the Montgomery bus boycott which was a pivotal point in the genesis of the American civil rights movement in 1955-56. Following the arrest of Rosa Parkes for refusing to give up her seat on a bus to a white passenger, the black population of Montgomery, Alabama, boycotted the town’s buses in protest at racial segregation of buses.

By organising for civil rights, a group of largely dispossessed marginalised African Americans was able to pool resources to create collective power for change (enough people withdrawing their use of buses and payment of bus fares so that it had a profound impact). They built power both by pressing the authorities for reform through united action and growing their movement by winning other people across the nation to support and take action for their cause.

And they achieved the outcomes they sought: pressure for change increased across the country and eventually the segregation rules were deemed unconstitutional by the courts.

Ganz, along with other commentators, concludes that the leaders of social movements (“voluntary organisations”) typically have fewer levers and resources for enacting change than leaders of formal organisations have. This makes the strategic focus of leaders, to turn potential resources into power for change, even more important.

Ganz quotes James Q. Wilson:

“In most voluntary associations, authority is uncertain and leadership is precarious. Because the association is voluntary, its chief officer has neither the effective power nor the acknowledged right to coerce the members – they are, after all, members and not employees. In a business firm, the chief officer may, within limits, hire and fire, promote or demote, his subordinates…

“In most associations, power, or the ability to get a subordinate to do what the superior wants, is limited, and authority, or the right toexercises such power as exists, is circumscribed and contingent.”

Use your levers

I concur with Wilson that the kinds of levers and resources available to organisational leaders can create an easier set of circumstances for enacting change (when compared with social movement leaders who have none of these resources). However, on their own, coercion, compliance and other organisational mechanisms won’t create sustainable transformational change within and across organisations.

So I don’t necessarily agree that organisational leaders have a more straightforward task in leading change. In fact, I think that leaders of health and healthcare who are seeking radical changes across their organisations and systems in an ever more complex and unpredictable world have got more in common with social movement leaders than they have differences.

Many NHS change strategies are driven by logic based on extrinsic levers for change: incentivising payment systems, regulatory and quality assurance systems and holding leaders to account to deliver change outcomes. The strategic logic of social movement leaders is essentially based on igniting intrinsic motivation: building shared purpose, connecting with values, mobilising actions and taking meaningful action.

Transformational change across the NHS system requires both intrinsic and extrinsic factors and we as leaders need to find ways to align them and balance the tension between them. Otherwise there is a tendency to overemphasise the extrinsic factors and inadvertently kill off the energy, creativity and sense of psychological safety that people need to innovate and deliver goals for change.

Peter Drucker got it right when he advised organisational leaders to “accept the fact that we have to treat almost anybody as a volunteer”. We can learn greatly from the strategic approaches of social movement leaders who led change that succeeded because people wanted to be part of the change, not because they had to be. They have a lot to teach us about motivating, mobilising and building power for change through the assets and resources of a communitybased on common interests and a common goal, creating capacity for change from within.

Some questions to consider:

    • What is the shared purpose underpinning our change efforts? Is it framed in a way that connects with values and builds intrinsic motivation?
    • What leadership actions can we take to shift power in the system and get the outcomes we seek?
    • Think about loss and gain: what control/power might we have to surrender in a hierarchical sense to enable a more distributed leadership system and quicker, wider progress of change across the system?

 

From The NHS Change Agent

Helen Bevan is chief of service transformation at the NHS Institute for Innovation and Improvement. From 1 April 2013, she will be joining the delivery team of NHS Improving Quality. All views are personal.

How do you create a curious culture? @muirgray @wricciardi @leadmedit

How do you create a curious culture? I struggled with this question until the January 2013 issue of National Geographic landed in my mailbox with this cover theme: “Why We Explore.” Inside was a fascinating article called “Restless Genes”, written by David Dobbs. The article provided panoply of scientific evidence as to why humans explore.

“The compulsion to see what lies beyond the far ridge or that ocean – or this planet—is a defining part of human identity and success.” – David Dobbs

The article helped me conceptualize a framework for enabling a curiosity-based culture inside an organization. I learned three aspects of human behavior that encourage us to explore – why we are curious – and what we as leaders can do to unleash this in our organizations.

I discussed the first two lessons learned in yesterday’s blog post. Here is the conclusion to my thoughts on this subject.

I already knew that human hands with our five fingers, including a thumb, were a competitive advantage for Homo sapiens in the battle for resources. In the final lesson from the article, what I didn’t’ know is that societies tended to develop mythology around those people who excelled at “clever hands,” as author Dobbs refers to innovations created by those hands.

Societies tended to develop mythology around those people who excelled at “clever hands”

Mythology made it “cool” to be “clever;” a little like the adulation the Steve Jobs’ of the world receive today. The marine vocabulary of the Polynesians conferred great status on ship builders, as Dobbs says, “like today’s astronauts.” This social standing was a motivating force to continue exploring.

I recently visited Cisco’s customer briefing center in Tokyo, and as I walked down the hallway past a bank of Cisco equipment, I stopped because I saw a box that was a different color from all the others – white with red lettering. I knew right away when my eyes focused specifically on this box that I was looking at a Cisco “AGS” router; the product that was used in the first-ever commercial Internet connection. A group of us just stood there for a few minutes and talked about what this AGS box meant to Cisco – and the world. It is not an understatement to say the AGS changed the world.

I’ve always believed that culture is built on the backs of important symbols. The mythology around the Cisco AGS router is every bit in our vocabulary as the sail is in the Polynesian marine vocabulary.

Culture is built on the backs of important symbols

The lesson:  Nostalgia is what keeps an organization from moving forward, but the myths of what symbolizes the great accomplishments of your organization should be celebrated and must be front and center in your team’s culture.

“When you set sail to find new lands, you became mythologized – even if you didn’t come back.” – National Geographic Explorer-in-Residence Wade Davis quoted in “Restless Genes.”

Great accomplishments of your organization should be celebrated and must be front and center in your team’s culture

Cisco CEO John Chambers frequently says culture is the responsibility of leaders. Curiosity may kill the cat, but it may be the most important attribute of a resilient organization in a constant state of evolution to win in today’s markets. As leaders, it’s our responsibility to set curiosity free inside our organizations, in the same way the great human explorers dared to go places that others feared and few ventured.

It’s our responsibility to set curiosity free inside our organizations

“…for the larger powers we gain through culture…it gives our malleable genomes, imaginative minds, and clever hands the power to transform even the strongest forces in our environment — wind, water, current — from threat to opportunity.” – David Dobbs

http://switchandshift.com/how-do-you-create-a-curious-culture?utm_content=bufferd0e04&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer

Mindfulness can improve leadership in times of instability @leadmedit @muirgray

A mindful leader can respond to change with focus and clarity, and avoid repeating the same mistakes

by Cheryl Rezek http://bit.ly/15M4lLs

What does the ancient eastern practice of mindfulness, often associated with orange-clothed chanting monks, have to do with the fast-paced, performance-driven style of western leadership? In tough times, it could act as an influential asset in the public service’s fight for survival.

Mindfulness is about paying attention to what is happening in the present moment, a moment in time. It is about focusing attention on the present in a way that allows that moment to be experienced and observed closely. It involves developing the skills to allow yourself to engage actively with whatever is happening at the time, as well as concurrently viewing that moment from a more strategic standpoint.

Developing a more aware and considered approach helps leaders to respond to situations (whether internal thoughts or external events), rather than react to them. It encourages a less critical view which, in turn, creates a more flexible and attuned response. When there is less clutter and fewer distractions within one’s own head it is easier to gain clarity and perspective; mindfulness allows one to both notice more detail and see the bigger picture.

A mindful leader can reduce disorder by bringing focus and intent to the situation. By acknowledging and accepting change, the leader can step back, observe and respond with composure and purpose.

Sometimes our past experiences or immediate reactions will interfere with our ability to view the present in an unbiased way. Once we acknowledge this, we can quieten internal commentaries and assumptions. This process of stepping aside from ourselves allows us to decide what approach will best support the situation at hand, and the agendas and strategies of the organisation.

Dealing with change

If leaders realise that change is inevitable, they can encourage sufficient resilience in individuals, teams and organisations. To lead knowing that change is inevitable – though unpredictable in its timing – allows for flexibility, and a realisation that what worked in the past may not necessarily be appropriate today. This helps to safeguard an organisation from disillusionment and destruction by enforcing outdated rules and processes.

Research on mindfulness suggests that it can also help to:

• reduce the cost of staff absenteeism caused by illness, injury and stress

• improve cognitive functioning, memory, learning ability and creativity

• improve productivity and improve overall staff and business wellbeing

• reduce staff turnover and associated costs.

Mindful leadership is not a patronising fad implying that, if we are calm, everything will be fine. The reality of our working world is that all may not be fine. What mindfulness can do is develop a thinking, emotional and instinctual mind so that the leader can do the best for self, team and organisation.

 

The full version of Cheryl Rezek’s article can be accessed free-of-charge by Public Leaders readers for a limited time on the International Journal of Public Leadership.

Dr Cheryl Rezek is a consultant clinical psychologist, workshop leader and author of Life Happens: Waking up to yourself and your life in a mindful way and Brilliant Mindfulness: How the mindful approach can help you towards a better life.

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Solving the high rates of hospital readmissions @kevinmd @Medici_manager @pash22

By  , http://bit.ly/1abkQiX

Statistics show that about 1 in 5, or 20 percent of all Medicare patients are readmitted to hospital within 30 days of discharge. That’s a staggering number, not to mention all those patients that are readmitted frequently during the course of a year, but not necessarily within 30 days.

The problem of frequent hospital readmissions is actually one that exists all over the world and not just in the United States. Health care systems everywhere are seeking solutions to keep their patients healthier and away from hospital. Any doctor practicing at the frontlines will be able to tell you what a big issue this is right now. We regularly see the same patients on something of a merry-go-round of frequent hospital admissions, often with the same illness.

Why does this happen? This issue is complex. In my experience as a hospital medicine doctor, there are number of factors in play, falling into different categories according to the type of illness, availability of definitive treatment, and the social circumstances of the patient.

Severity of illness. Certain chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), when in their advanced stages, are very labile and prone to exacerbations. As much as doctors try to control these with medications, it’s a very difficult task, as it only takes a slight precipitant such as a minor infection or dietary indiscretion to push somebody over the edge. By their very nature chronic diseases tend to get worse over time. And with an aging population, these conditions are increasing in prevalence. Unless we find definitive cures, hospitalizations are always unfortunately a possibility.

Social situation. Patients who have inadequate family support tend to be admitted to hospital more frequently for a couple of reasons. Firstly, their threshold for being able to cope at home with their illness is much lower. Secondly, they will not be able to co-ordinate their regular follow up care so easily. We see the effects of this all the time at the frontlines — two patients with the same level of illness severity; one will be managed at home, the other will require hospital admission for several days.

Lack of follow-up. Many studies have shown that lack of follow-up with a primary care physician in the weeks after discharge can lead to a higher likelihood of re-hospitalization. Seeing a doctor quickly post discharge allows for any potential problems to be “nipped in the bud”. It also allows for care co-ordination and medication reconciliation. Sadly, a large number of patients do not have a regular primary care doctor (mostly for insurance reasons). They therefore tend to use the emergency room as their first point of contact when they feel unwell again.

Suboptimal discharge process. By its’ very nature, the process of discharging a complicated patient from hospital is one that is fraught with possible problems. The discharge process needs to be thorough, seamless and diligent. Areas for improvement in most hospitals include medication reconciliation, clarifying follow-up appointments, follow-up laboratory tests, and making sure that the patient and family is clear about these instructions. Too often, this process is rushed and glossed over. Nothing beats having the doctor sit down with the patient and their family, spending time reviewing all the pertinent information.

Low health literacy. Many patients are not fully educated and informed about the nature of their illness and how best to manage it at home. This can be dealt with by regular reinforcement and utilizing home nursing services to keep on checking in with the patient post-discharge.

Certain very obvious patterns do exist in how patients tend to be readmitted to hospital. Several initiatives are underway across the country to try and improve the situation. Primary care doctors, specialty clinics, home nursing services, and even social workers are all being utilized as part of a team-based approach. The strategies broadly involve:

  • Identifying high-risk patients early
  • Educating the patient and involving family members
  • Having very close follow-up with a collaborative care team

As part of health care reform, hospitals are also facing financial penalties for consistently high readmission rates. But financial penalties alone aren’t the answer, especially for “safety net” hospitals that struggle more with this problem. It’s important to remember that the drive to reduce readmissions is not just about saving the health care system money, but ultimately about keeping our patients healthier and stronger. Whatever can be done to keep them at home enjoying life as much as possible instead of lying in a hospital bed, can only be a good thing.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

Clinicians do not have the luxury to not care about costs @kevinmd @Medici_Manager @WRicciardi

by  http://bit.ly/1g8rOt3

In a large lecture hall of fellow clinicians-to-be, I was told that my job as a physician is not to be concerned with costs but rather to treat patients. My wrist, moving frantically left to right on my page taking notes, stopped. I looked up and my mind wandered: What an odd message to tell those who will be listening to ill people’s symptoms, prescribing medicine, ordering tests and orchestrating people’s care to not worry about.

We have set up this dichotomy of treating the patient or being concerned with costs. We have soaked medicine with the belief that cost-conscious care is rationing at the bedside and the public fear messages that clinicians who care about costs are limiting their care.

How can we teach future clinicians to be so out of touch with one of people’s greatest concerns when seeing a clinician? We know that people forgo medications because of high prices, medical bankruptcy plagues many and some cannot seek care due to cost. What other industries allow someone so crucially involved in controlling costs immunity from worrying about them? Does medicine’s unique role of saving lives exempt it from keeping an eye on the register? Is good care not cost-conscious care?

Clinicians do not have the luxury to not care about costs. The American Medical Association and the American College of Physicians realize this and are blurring the line between the “treat patient” or ”be concerned with cost” dichotomy. They are framing the argument of physicians caring about costs as an ethical issue of the stewardship of limited resources and of providing parsimonious care by using health care resources wisely.

This is a good first step, because bringing costs of care out of the dark eliminates this taboo, hush-hush culture of who’s paying the health care bill when it arrives at the table. Programs across the U.S. recognize this, too, and are weaving into their curriculum how physicians can be aware of costs in medicine. Research is advancing in this area as we explore in greater detail why prices vary so much: implementing comparative effectiveness research, continuing consumer-driven health care efforts and piloting interventions to control health care costs, like holding health communities accountable for the care that they provide.

National campaigns like the American Board of Internal Medicine Foundation’s Choosing Wisely call attention to unnecessary care. We have seen health care costs become more exposed with Steven Brill’s Time article revealing the rates that hospitals bill to patients or use as a starting point for negotiations with insurance companies. And the Centers for Medicare and Medicaid Services made public charges for 100 of the most common inpatient services and 30 common outpatient services, displaying variations in charges across the country for services.

This is not enough though. We need to continue to build this cost-conscious culture in the exam room where medical decisions are made, including both the patient and clinician, because 1) people care about costs; 2) the medical industry is not exempt from concerns about costs; and 3) good care is cost-conscious care.

People care about costs. People have premiums to pay, co-pays to fork over, deductibles to reach, prescription drugs to purchase and co-insurances to manage. This is a lot of financial information for people to keep straight and to be in charge of on top of the responsibilities they have to manage an illness or care for a loved one. We worry about how much health care services will cost us. In May 2012, the Henry J. Kaiser Family Foundation reported that a quarter of polled people had difficulty paying medical bills in the past year. Six in ten have “cut corners” to avoid health care costs, such as skipping a recommended medical test or filling a prescription medicine. As one might imagine, it’s even worse for those who are uninsured, have lower incomes and are in poorer health. Clinicians need to be on the same page as their patients: Costs for their health care matter to them, and people may be afraid to talk about them with a clinician and do not have the tools to know what constitutes a reasonable price for care.

Medicine’s unique ability to save lives is not exemption status from a cost-conscious culture. Just because medicine saves lives, it is not stamped “exempt” from having to think about costs. A good amount of health care is not emergency care, but rather preventive care and treatment of illness. Though health care may be a unique good in our society, the system should not be excused from having to consider sustainable models of spending. When the costs of health care are not transparent to both patients and clinicians, the temptation/decision to limit care may be hidden behind closed doors of obscure insurance policies. Other sectors of society save lives – police departments, prison systems, national security measures – and we still have to consider the costs of financing these services.

Good care is cost-conscious care. Was it worth it or should I buy it? We constantly, prospectively and retrospectively, evaluate how we spend our money: taking that vacation, buying a car, eating out. Was that a valuable use of our money compared to what we gained (pleasure/utility) and would we do it again? Though fewer choices may be available in some emergency situations or medically necessary circumstances where the decision process is accelerated or removed, we still can assess whether the care that we received is worth the cost. Have I been feeling better taking this medication? Has the pain subsided and is the out-of-pocket cost manageable? Has my health improved since seeing my doctor for “X”? These questions tumble around in our minds during our treatments and after in recovery.

Tools for clinicians and tools for health care costs. We are chipping away at this culture of unaccountable spending, of “running dad’s credit card,” when it comes to health care costs. But we aren’t giving clinicians and people the tools they need to partner together to take on this dragon of costs. Partly because people and clinicians don’t know how much health care services cost. Resources like Healthcare Blue Book are slowly becoming places where people can get estimates of how much their care will cost and insurance companies can give rough estimates prior to care. But these are outside of the exam room and can vary considerably.

If we continue to make the standard of treatment a more expensive option when cheaper, equally effective alternatives exist, tools need to be developed for the clinical encounter, in the exam room, where the clinician and patient can participate in shared decision making by incorporating costs: “No, I don’t want that medicine if it costs that much out of pocket,” or “I’d rather try treatment ‘X’ if it will save me that much money.”

Though having these conversations in the exam room may be a tall order for some, neglecting to include such an important issue is bad care. Sending someone home with a fancy procedure and large out-of-pocket costs may not have improved his health, but rather increased anxiety and stress over having to pay for his care. He may have chosen a different course of action had he known in advance the price he’d be paying for years to come. Likewise, prescribing a medication that a person will not pick up because it costs too much does nothing to help improve that individual’s health.

We have a long way to go in delivering cost-conscious care that incorporates the patient’s and the clinician’s views. Evidence-based tools need to be developed for both the clinician and patient to be able to weigh the risks and benefits of a test, procedure or course of treatment, and conversations need to be started between clinician and patient about costs.

I want a cost-conscious clinician who is aware of what I’m being charged and in touch with the challenges I face in paying for my health care. I want to be part of system that acknowledges people’s concerns with costs. People should demand from their clinicians this aspect of their care, and clinicians should demand from their health care organizations the tools to be able to deliver this information. Let’s stop clinicians from passing the buck on the costs of care, and let’s teach future and current clinicians to care about costs.

Patients already do.

Sarah Jorgenson is a medical student who blogs at the Prepared Patient blog and the self-titled site, Sarah R. Jorgenson.

Gartner’s 2013 Emerging Technologies hype cycle focuses on humans and machines @Medici_Manager

Summary: New technologies take time to mature, but Gartner’s annual hype cycle diagram provides a guide to whether they are being overhyped and how close they are to becoming productive. http://zd.net/1c2wvEb

The 2013 edition of Gartner’s long-running Hype Cycle for Emerging Technologies focuses on “the evolving relationship between humans and machines … due to the increased hype around smart machines, cognitive computing and the Internet of Things.”

Gartner fellow Jackie Fenn, who came up with the hype cycle idea in 1995, says “there are actually three main trends at work. These are augmenting humans with technology — for example, an employee with a wearable computing device; machines replacing humans — for example, a cognitive virtual assistant acting as an automated customer representative; and humans and machines working alongside each other — for example, a mobile robot working with a warehouse employee to move many boxes.”

Fenn’s collaborator Hung LeHong says these trends have been made possible because machines are becoming better at understanding humans and humans are becoming better at understanding machines. “At the same time, machines and humans are getting smarter by working together.”

The three main trends are:

1. Augmenting humans with technology

Companies can improve workers’ performance or the level of customer service using augmentation devices such as wearable computers. Gartner says: “Organizations interested in these technologies should look to bioacoustic sensing, quantified self, 3D bioprinting, brain-computer interface, human augmentation, speech-to-speech translation, neurobusiness, wearable user interfaces, augmented reality and gesture control.”

2. Machines replacing humans

Robots have been used on the factory floor for decades but improvements in technology mean there is still plenty of scope for automating both physical and mental procedures. Gartner says: “Organizations should look to some of these representative technologies for sources of innovation on how machines can take over human tasks: volumetric and holographic displays, autonomous vehicles, mobile robots and virtual assistants.”

3. Humans and machines working alongside each other

Gartner says: “The main benefits of having machines working alongside humans are the ability to access the best of both worlds (that is, productivity and speed from machines, emotional intelligence and the ability to handle the unknown from humans). Technologies that represent and support this trend include autonomous vehicles, mobile robots, natural language question and answering, and virtual assistants.” One example is IBM’s Watson working alongside doctors and providing natural-language question answering (NLQA).

At this futuristic level, Gartner says “enterprises should consider quantum computing, prescriptive analytics, neurobusiness, NLQA, big data, complex event processing, in-memory database management system (DBMS), cloud computing, in-memory analytics and predictive analytics.”

Hype Cycle for Emerging Technologies 2013
Hype Cycle for Emerging Technologies 2013 Source: Gartner

The point of the Hype Cycle is to give enterprises some idea how far various technologies are from the “plateau of productivity” where they can be more easily adopted. The cycle has five stages, for which Gartner uses terminology reminiscent of John Bunyan’s Pilgrim’s Progress. It starts with a Technology Trigger: a new invention or innovation. That gets the attention of the media, analysts, conference organizers etc, which drives the idea to a Peak of Inflated Expectations. At this point, disillusion sets in. As I noted in the Guardian in 2005, “The press, having overhyped it, knocks it for being overhyped, and it descends into the Trough of Disillusionment.” Successful innovations pass through the trough and start to climb the Slope of Enlightenment before reaching the Plateau of Productivity.

In the 2013 hype cycle, Technology Triggers include SmartDust, brain-computer interfaces, and quantum computing, all of which Gartner reckons are 10 years or more from the plateau. It reckons autonomous vehicles and biochips are 5-10 years away.

Technologies at the overhyped stage include “big data”, consumer 3D printing, gamification, and wearable user interfaces.

Overhyped technologies now plunging into the Trough of Disillusionment include mobile health monitoring, NFC and cloud computing.

Technologies that are climbing the slope or already becoming productive include gesture controls, biometric authentication systems, speech recognition and predictive analytics.

Gartner’s Hype Cycle for Emerging Technologies, 2013 ($1,995) “includes a video in which Ms Fenn provides more details”. Fenn and LeHong are also hosting two free webinars at 3pm and 6pm (UK time) on August 21, registration required.

Topics: Emerging TechEnterprise SoftwareTech Industry

About 

Jack Schofield spent the 1970s editing photography magazines before becoming editor of an early UK computer magazine, Practical Computing. In 1983, he started writing a weekly computer column for the Guardian, and joined the staff to launch the newspaper’s weekly computer supplement in 1985. This section launched the Guardian’s first website and, in 2001, its first real blog. When the printed section was dropped after 25 years and a couple of reincarnations, he felt it was a time for a change….

A right to a personal health budget @tkelsey1 @Medici_Manager @pash22

Luke O’Shea, NHS England’s Head of Patient Participation, explains why a “quiet ministerial announcement” is so significant.

http://bit.ly/1h4VSr0

Last week in Parliament, ministers quietly made an announcement : From October next year, thousands people in receipt of Continuing Health Care funding will gain a new legal ‘right to have’ a Personal Health Budget.

The announcement went largely unnoticed by the media, patients and professionals.  Usually Personal Health Budget announcements generate Marmite-like reactions – either heralding the end of the NHS as we know it, or being seen a panacea for a person-centred NHS. But last week there was little reaction.

However, this is a significant announcement for a group of people who have less ability than most to determine the path their lives take.  The hope is that Personal Health Budgets will change that. But will they?

It made me reflect on an important experience I had working as a commissioner in the NHS. It was a trip to meet a man about my age receiving Continuing Health Care.  I think about him quite a lot.

He’d been given a diagnosis of ‘treatment-resistant schizophrenia’ and had been moved around the country for over 10 years because of his complex needs.   After a three hour drive, I arrived at the care home where he had lived for the last five years.  We got on well and talked quite a bit.  We sat in the kitchen and I asked him about his hopes for the future.  He wanted a flat of his own.  However, he’d been told for a long time that they were hoping to sort out a flat, with little sign of progress.  He was stuck.

For the NHS, the care home placement was a success.  He was high risk but had had no hospital re-admissions in recent years.  But it did not offer him what he wanted most, to build a normal life.

When the Personal Health Budget announcement was made it occurred to me that his placement budget would have paid for a flat, a full-time support worker and employment support or training, with some left over.  I wondered whether a right to have a Personal Health Budget would have started a different conversation that day I met him.

For me, the announcement on Personal Health Budgets is part of a wider historic movement where people whose lives have been constrained by the state have been offered greater self-determination.

Why would the NHS not want people to actively determine the path of their own lives?  Should people be allowed to choose and buy their own care?

Well, there is a tension.  They might choose services that fit round their lives and not what suits the NHS.  They might decide a job is more important to them than managing the likelihood of hospital re-admissions.  But what does the evidence say?

The University of Kent controlled trial of Personal Health Budgets, involving 2,000 people, showed patients with PHBs out-performing the control group, and even had fewer hospital admissions.  It seems that patients can be experts too.

The Lancaster University Poet Survey also showed significantly improved well-being for most carers, who tend to bear a huge personal responsibility for this group.  It’s rare that we measure the impact of an intervention on families of patients, but here we have.

So we need a bigger debate about Personal Health Budgets and personalisation in the NHS.  The evidence is good, but there are tensions and the implementation challenges are significant.

Personal Health Budgets are not a panacea, but they do start a different kind of conversation.  And they are not going away.  This announcement is part of a wider historic shift towards personalisation and greater self-determination across public services, which once introduced is very hard to go back on.

So let’s hope this announcement is one small step towards a time when everyone, regardless of health need, is given the chance to determine the course of their own lives.


luke-osheaLuke O’Shea is Head of Patient Participation at NHS England.

He has previously worked in national policy and strategy roles at the Department of Health and as a commissioner in a local authority and the NHS.

Prior to that he worked in a range of government departments including leading work on early year services at the Prime Minister’s strategy unit, as a private secretary to a children’s minister and leading cross government working on ageing.

He describes as his proudest achievements his “modest role at the inception of Family Nurse Partnership in the UK and of my work on ageing”.

Value-Based Health Care Is Inevitable and That’s Good @Medici_Manager @pash22 @leadmedit

by Toby Cosgrove  http://bit.ly/17GkMG7

Vaccines. Anesthesia. Penicillin. Bypass surgery. Decoding the human genome. Unquestionably, all are life-saving medical breakthroughs. But one breakthrough that will change the face of medicine is being slowed by criticism, misunderstanding, and a reluctance to do things differently.

That breakthrough is value-based care, the goal of which is to lower health care costs and improve quality and outcomes. It will eventually affect every patient across the United States. Not everyone, however, is onboard yet, because part of the value-based equation is that hospitals will be paid less to deliver better care. That’s quite a challenge, but one that Cleveland Clinic is embracing as an opportunity to do better. Others must, too.

How the Health Care World Will Change

We all know that U.S. health care is too expensive, too inefficient, and the quality is too varied. The goal of value-based care is to fix that.

A major component of the Affordable Care Act is to change the way hospitals are paid, moving away from a reimbursement model that rewards procedures to one that rewards quality and outcomes. No longer will health care be about how many patients you can see, how many tests and procedures you can order, or how much you can charge for these things. Instead, it will be about costs and patient outcomes: quicker recoveries, fewer readmissions, lower infection rates, and fewer medical errors, to name a few. In other words, it will be about value. And that is good.

Whether providers like it or not, health care is evolving from a proficiency-based art to a data-driven science, from freelance physicians to hospital-employed physicians, from one-size-fits-all community hospitals to vast hospital networks organized around centers of excellence. Each step in this process leads to another.

When hospitals employ physicians on an annual salary as we do at Cleveland Clinic, a doctor is paid the same no matter how many patients he sees, how many procedures he performs, or how many tests he orders. One-year contracts hold our doctors accountable, with yearly performance reviews that include each doctor’s quality metrics, clinical outcomes, and research. And having all your doctors on the same team makes it easier to coordinate patient care among different groups of specialists.

As more independent physicians begin to be hired by hospitals, the opportunity for large group practices and hospital consolidation grows. As consolidation expands, data and transparency become increasingly important, as a way to ensure that caregivers across the system are providing comparable care.

All of this, of course, leads back to quality, which requires an effort to achieve standardization, reduce variation, and eliminate unpleasant surprises. It’s analyzing processes, measuring outcomes, and changing practices until you get it right.

To remain viable in today’s rapidly evolving environment, health care systems must reduce costs while continuing to improve quality and outcomes.

The Cleveland Clinic’s Journey

In the October issue of Harvard Business ReviewMichael Porter and Tom Lee cite six components of high-value care-delivery systems: integrated practice units; cost and outcomes measurement; bundled payments; integrated care delivery across facilities; expanded services across geography; and an information technology platform to enable those processes.

As they note, Cleveland Clinic is one of two medical centers worldwide that has implemented all six, beginning with integrated practice units, which we call “institutes.” A patient-focused institute combines medical and surgical departments for specific diseases or body systems. All of our institutes are required to publish outcomes and measure costs. With bundled payments, we combine all the services provided before, during, and after a complex procedure like joint replacement, into a single charge. We have integrated care through shared protocols and the electronic medical record at all of our 75 care-delivery sites. And our expansion across Northeast Ohio into Florida, Nevada, and overseas allows broad geographic access to our services.

What makes Cleveland Clinic different stretches back to our founding 92 years ago as a physician-led group practice that runs a hospital – not a hospital that employs doctors. This distinction is important. Decisions from the CEO on down are made by physicians based on what is best for the patient.

Mining Data

As a leader in the electronic medical records, we have a wealth of data that can tell us what’s working and what’s not. For instance, we were able to comb through data of heart-surgery patients to find that those who received blood transfusions during surgery had higher complication rates and lower long-term survival rates. This finding – mined from our own data – changed the way we do things; we now have strict guidelines in place to limit transfusions.

We’ve made similar strides in many other clinical areas, using data to drive quality. By collecting data on provider performance and making that data transparent, central-line infections have decreased by more than 40%, while urinary-tract infections have dropped 50%.

Data can help identify variations in clinical practice, utilization rates, and performance against internal and external benchmarks, leading to improved quality and a sustained change in culture. Last year, we established a values-based care team, which seeks to eliminate unnecessary practice variation by developing evidence-based care paths across diseases and to improve comprehensive care coordination so that patients move seamlessly through the system, reducing unnecessary hospitalizations and ER visits.

Lowering Costs Without Compromising Quality

American health care is on an unsustainable path. Health care spending topped $2 trillion in 2011. The Centers for Medicare and Medicaid Services predicts that without major change, it will account for more than 20% of GDP by 2021, up from 5.2% percent in 1960. What that means is that if we continue on our current path, $1 in every $5 spent in the U.S. economy will go toward health care.

We can choose a different path, though. At Cleveland Clinic, we’ve been engaged in an ongoing effort to trim costs across the entire system. Through a concerted focus on our supply chain, we use rigorous value-based purchasing protocols, market intelligence, and business analytics to examine every purchase from the standpoint of value, utility, and outcomes. Over the past two years, this has resulted in cost savings of more than $150 million.

Our electronic medical records are also programmed with a “hard stop” function to reduce unnecessary duplicate tests. This led to a 13% reduction in blood-gas determinations, generated $10,000 in monthly savings for laboratory tests, and resulted in savings of $117,000 in just the first month for genetic testing.

A key part of the cost solution is to educate all caregivers, including doctors, about what items cost. Earlier this year, we created a Cost Repositioning Task Force to work with all caregivers across the entire Cleveland Clinic system to assess everything we do and everything we spend. Now, as part of the purchasing process, dozens of doctors gather to discuss the merits of certain products: Which ones provide the best outcomes for patients? How many are needed? How much does it cost?

Traditionally, knowing the cost of a stitch or a catheter or a bone screw — or any of the thousands of other supplies used during surgeries — hasn’t been part of doctors’ medical consciousness. To remedy that, we’ve taped price lists to supply cabinets in some ORs. In others, posters remind everyone to choose supplies carefully, stressing this message: “Without compromising quality, consider cost-effective alternatives.”

As health care reform kicks into high gear, providers are facing a difficult challenge: being paid less to produce better outcomes. We must view this as an opportunity, not a burden. After all, the providers who make the transition early will be rewarded with more satisfied patients, lower expenses, and pride in a job well done.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us athealtheditors@hbr.org, and sign up to receive updates here.

6 strategies hospitals should steal from the airline industry @Medici_Manager @pash22

by Jonathan H. Burroughs  http://bit.ly/15CSWz6

The Institute of Medicine, in its landmark report “Better Care at Lower Cost,” concludes at least $750 billion of the total national healthcare budget of $2.7 trillion represents waste as a result of poor IT infrastructure, supplier- rather than patient-centered reimbursement, lack of quality and transparency, and inefficient operations and flow.

Wasteful operations may include: delays, over-processing, redundant work, poor inventory management, inefficient transport, unnecessary motion, over-production (push instead of pull), and defects that cause harm and re-work.

The airline industry has worked on these problems for decades and although its operations and flow patterns are significantly less complex than healthcare, it has mastered basic elements we can learn from to give us a jump-start on mastering and taming a difficult but necessary component of operational design that will lead to improved outcomes at lower costs.

1: Air traffic control is managed as a system, not a place

Flow through the airport affects and directly result from flow outside the airport, and air traffic control does not make any distinction. We often treat emergency department or intensive care unit flow as an isolated problem whereas every aspect of an individual’s care from inpatient, to post-acute, to ambulatory has a direct impact on the other. As it turns out, what happens to an individual outside of a hospital has a greater effect on length of stay and flow than what happens inside. Thus, we will never master hospital flow until we master the flow of the entire system.

2: Airport operations function 24/7

Airports function 24/7 and so should healthcare systems. Flow should be managed around the clock and utilization managers should be replaced with flow coordinators who hand off their oversight continuously based on time of day and setting of care. For instance, when a plane takes off, airport air traffic control transfers responsibility to regional air traffic control, and oversight of the flight is continually monitored from control station to control station until the flight terminates at another airport.

Similarly, a flow coordinator should orchestrate a patient’s non-emergent arrival, the admission process, the inpatient care, the discharge planning process and then transfer responsibility for the patient to an outpatient flow coordinator to ensure appropriate follow up and continued optimal care. Ideally, the term “discharge” should be replaced with “care transition” so we stop thinking of moving from one environment to another as a beginning or end.

3: All departures are scheduled in advance

The three most common bottle-neck areas in a healthcare organization are the emergency department, the intensive care unit, and the surgical areas (pre- and post-operative). The vast majority of delays in these expensive settings involve the discharge planning process as patients in these areas often have no place available to go, thus backing up operations throughout, delaying treatment for others waiting to come in, reducing patient/staff satisfaction and increasing costs. Ironically, most discharges are predictable to within one hundredth of a day based upon risk and severity-adjusted length-of-stay data bases (e.g., Premier) for each diagnosis-related group.

Therefore, most discharges should be scheduled at least 24 hours to 48 hours in advance (ideally when the patient arrives) with arrangements made for nursing home or ventilator beds, physician appointments, home health on the day of admission in anticipation for discharge. Many healthcare organizations are purchasing or contracting with nursing homes, home health services, psychiatric facilities and physician practices to gain greater control and ease of scheduling by extending the chain of its operations into the outpatient setting.

4: All arrivals are scheduled in advance

One healthcare myth is that emergent arrivals are unexpected. As it turns out, if emergent ED, surgical, or ICU admissions are tracked over time, the vast majority are predictable. For instance, most emergency department admissions arrive between 3 p.m. and 11 p.m. with the fewest arrivals between 4 a.m. and 9 a.m. There will be rare disasters, which require special resources through a disaster planning process; however, these can be managed and illustrate the difference between random (uncontrollable) and non-random (controllable) variation in flow.

Truly random variation can and should be managed by policy whereas non-random variation should be eliminated by standardizing flow to accommodate predictable admissions in a predictable way through optimum staffing, resource allocation (including beds) and standardized admission processes.

5: Flight schedules are smoothed throughout the day and week

An airport only can handle its capacity of arrivals and departures at any point in time and so it manages the schedule to ensure a consistent schedule of flights throughout the week and time of day. Emergency departments, surgical facilities, and intensive care units can be similarly managed so that non-emergent patients who arrive at the ED can be transferred to lower acuity areas during peak hours, elective surgical schedules can be scheduled evenly throughout the week to avoid demand surges, and ICU admissions can be coordinated based upon regional transfer agreements in compliance with EMTALA to ensure appropriate stabilization and safety.

The system needs to be viewed holistically so all of the units and outpatient facilities coordinate flow in a synchronized and synergistic way to accommodate flow throughout the system and not within a unit alone.

6: Delayed flights are taken off of main runways and taxiways

When air traffic control delays a flight, the delayed flight does not block other flights but is directed to another area to await further instruction and movement. Delayed discharges, transfers and admissions should not sit in beds blocking patient flow but should be immediately moved to a comfortable and appropriately supervised holding area where they can be safely managed and not delay the timely diagnosis and treatment of non-stabilized patients.

Most patients waiting for beds are stable and should no longer receive top priority or undermine the overall efficiency and effectiveness of the system. Similar holding areas can be utilized for admissions, transfer, and discharges if beds are interchangeable and staff is cross trained to handle a broad range of diagnoses and conditions.

Conclusion:

Although air traffic flow is simpler and easier to manage than healthcare, the industry can offer many lessons that will enable us to treat patient flow systemically as a 24/7, inpatient/outpatient, continuous operation that requires continuous management and oversight to standardize processes, exploit bottle-necks, manage random variation and eliminate non-random variation. By doing so, we can reduce costs, improve quality/safety/service and successfully compete globally for high quality-low costs services.

Jonathan H. Burroughs, MD, MBA, FACHE, FACPE is a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives. He also is president and CEO of The Burroughs Healthcare Consulting Network.

We are spending billions to train the wrong kind of doctors @kevinmd @Medici_Manager @WRicciardi @pash22

  http://bit.ly/1991PRY

Earlier this year, the physicians at my academic family medicine practice met with two senior officials from our parent health care organization to be oriented to its new initiatives and projects. Their presentation documented the organization’s ongoing investments of many millions of dollars into renovating subspecialty care suites and purchasing new radiology equipment that was likely to be highly profitable, but provide dubious benefits to patients.

Two of my colleagues asked why, given the expected influx of millions of newly insured patients into primary care starting in 2014, and an estimated shortfall of more than 50,000 primary care physicians by 2025, the organization had not identified expansion of primary care training as a financial priority. Where exactly did they expect to find family physicians to staff all of the new community offices they planned to open? An awkward silence ensued, followed by some polite hemming and hawing about how this was a complicated issue, and that supporting generalist training would likely require additional funding that was perhaps beyond the organization’s limited resources.

Additional funding required? How about $9.5 billion? That’s the approximate amount that that Medicare spends each year, with no strings attached, to subsidize the cost of training physicians in U.S. residency programs. Noting that the federal government doles out these dollars without requiring any particular outcomes from the institutions that benefit from them, some have called for Medicare to hold institutions more accountable for meeting America’s physician workforce needs.

If we have a surplus of radiologists and a shortage of general surgeons, why not tie funding to training more of the latter and fewer of the former? Given the decentralized nature of the U.S. health system, though, that has been easier said than done. In particular, it is challenging to follow the money trail and determine which institutions end up producing which types of doctors.

new study in Academic Medicine by health services researchers at George Washington University and the Robert Graham Center fills this information gap. Painstakingly assembling and cross-checking data from several sources on actively practicing physicians who completed their residency training from 2006 to 2008, they were able to identify residency-sponsoring institutions that were top producers of primary care physicians, that produced lower proportions relative to all physicians, and that produced none at all.

Notably, they conclusively disproved “The Dean’s Lie“ that counts all internal medicine residents as going into primary care (when only 1 in 5 actually plan to do so), demonstrating that at some institutions fewer than 1 in 10 internists become primary care physicians. They also identified a large funding discrepancy between the top and bottom primary care producers.

The top 20 primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates (41.0%) and received $292.1 million in total Medicare GME payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates (6.3%) and received $842.4 million.

In short, where physician production is concerned, you get what you pay for. In this case, Medicare pays a disproportionate amount of its nearly $10 billion per year in subsidies to institutions that produce mostly subspecialists, even in specialties where supplies are plentiful, at the expense of training sorely needed family physicians and other generalists whose presence has been shown time and again to deliver better health outcomes.

That’s the big picture. Since all politics is local, policymakers who want to know what types of physicians their teaching hospital or health system is training can use the Graham Center’s free GME Outcomes Mapper tool to find out. And if enough of them do so, maybe we can all have a serious national conversation about moving beyond guaranteed health insurance coverage to ensuring that the care (and the workforce) that coverage is paying for will actually help us to live longer or better.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

Medical societies’ role in improving leadership in medicine @kevinmd @leadmedit @muirgray @Medici_Manager

  http://bit.ly/1bjWw3L

The greatest good you can do for another is not just to share your riches but to reveal to him his own.
– Benjamin Disraeli

In 2009, when I was president-designate of the American College of Chest Physicians, a prominent physician, educator and outstanding mentor, who had recently died was honored by her colleagues. One of her junior colleagues, who had never met her but took over her patients, spoke of the profound influence she indirectly had on his life. She was his mentor in absentia, someone he looked up to as his guiding star, someone he sought to emulate.

This example serves to highlight the power of mentorship. Mentorship is inspiring and guiding others to reach their full potential.

The ACCP and other professional medical societies bring together professionals at different stages of their careers, for example medical students to senior and renowned experts in his or her specialty. They have the potential to foster powerful mentorship and leadership programs benefiting members in all career stages.

As ACCP president, the more I interacted with ACCP members, the more I realized that a track for leadership development and mentorship was a pressing need. Medical students wanted to hear of the opportunities that the specialty offered. Fellows and young colleagues wanted to get involved with the organization but did not know where to begin and how to get their “foot in the door.” Members wanted to seek advice from senior colleagues to guide them in their research or for their academic advancement. Some wanted a certificate of participation in leadership courses offered by the organization. Finally, many members, both domestic and international, wanted to know how to climb the leadership ladder within the organization.

The ACCP board of regents enthusiastically supported a leadership and mentorship initiative. A task force was developed to spearhead this effort. The task force comprised the cross-section of ACCP membership who would be involved either as a mentor or a mentee.

Over the past 2 years, the task force has had several accomplishments. Some of those major accomplishments include:

  • An annual orientation course for all new leaders of the ACCP.
  • A leadership development course for members held throughout the year.
  • The creation of the ACCP e-Community, a closed group where members can interact and learn from one another, similar to Doximity.
  • A leadership development course for future leaders. We work with program directors to identify and grow these leaders.
  • Live mentorship programs incorporated into our annual meeting.

Our organization has come a long way — and, we have a long way to go. We have identified a need to improve and enhance our leadership development, and we feel that enhancing leadership will lead to well-rounded members who will not only excel as physicians but also as leaders both at the ACCP and in their own careers.

How have your own institutions, societies, or organizations worked to expand mentorship and leadership initiatives?

Suhail Raoof is immediate past president, American College of Chest Physicians.

Science alone can’t make tough decisions for us @kevinmd @Medici_Manager @pash22

by   http://bit.ly/1bjVWDk

On April 14, The United States Preventive Services Task Force concluded that women with an elevated risk of breast cancer – who have never been diagnosed with breast cancer but whose family history and other medical factors increase their odds of developing the disease–should consider taking one of two pills that cut that risk in half. The Task Force is an independent panel of medical experts who review the medical literature to estimate the pros and cons of preventive interventions. This is the same Task Force that in recent years raised questions about the benefits of mammograms in 40 to 50-year-old women, and PSA tests for men of all ages, tests that screen respectively for breast and prostate cancer. Despite the popularity of both of these tests, the Task Force concluded that their harms often outweigh their benefits.

The irony now is that with this report on breast cancer prevention pills, the Task Force has switched from rejecting something patients believed in to endorsing something most patients will reject.

The seemingly strange way the Task Force ping-pong’s between popular and unpopular recommendations is inevitable, because these kinds of recommendations must necessarily go beyond the medical facts – it is impossible to decide what preventive measures people need without making value judgments.

To understand the way facts and value judgments get mixed together in these kinds recommendations, let’s take a closer look at these breast cancer prevention pills.

For many years now, doctors have been prescribing tamoxifen as secondary prevention to women who have already undergone treatment for breast cancer, in an attempt to thwart any breast cancer cells remaining in their body. In women whose breast cancer cells express “estrogen receptors”, tamoxifen reduces the chance that this cancer will recur, by attaching itself to those receptors, in effect crowding outestrogen. In breast cancer cells, any estrogen landing on these receptors will spur that cell to divide and multiply. But when tamoxifen lands on these receptor sites, it does not stimulate cell growth.

Raloxifene is a close cousin of tamoxifen, which has primarily been used to treat women with osteoporosis. Like tamoxifen, it competes with estrogen for the attention of estrogen receptors. Also like tamoxifen, it slows down breast cancer by preventing estrogen from stimulating cell growth. As it turns out, both raloxifene and tamoxifen also have the strange property that when they collide with bone cells, they don’t fight against estrogen, but seem to mimic estrogen, and thereby improve bone health. (Because these drugs and sometimes act like estrogen and other times act like anti-estrogen, they are called selective estrogen blockers.)

Two very similar drugs, then. Both slow down breast cancer cells while stimulating bone cells. Each drug has been shown to cut the risk of a first breast cancer in half for women with a high risk of experiencing this disease. In what is known as the P1 trial, for example, women who faced an average five year risk of breast cancer of 6% saw that risk drop to 3%, if they took tamoxifen.

Sounds like a good deal, yes? Take a pill for five years, and cut your risk of breast cancer in half. But keep in mind, most women do not face a 6% chance of breast cancer in the next five years. Women with this kind of risk are generally retirement age or beyond, and usually have a bad combination of family history, early onset of menses, and late age of first pregnancy. It is these women the Task Force believes should talk with their doctors about whether to take these medications. And how did the Task Force reach this conclusion? By determining that for some women, at least, the benefits of these pills outweigh their harms. Before looking at this harm benefit ratio more closely, let’s put this Task Force conclusion into context.

The Task Force essentially produces three kinds recommendations, which I have taken the liberty to name.

  1. NADA: When it concludes that the harms of an intervention outweigh the benefits, the Task Force recommends that doctors and patients avoid the intervention. Think: ultrasound screening for pancreatic cancer.
  2. OUGHTA: When the Task Force concludes that the benefits outweigh the harms, it pushes to make the intervention standard of care. For example: routine screening for colon cancer in people 50 years or older.
  3. UP TO THE INDIVIDUAL: When the Task Force concludes that the benefits of an intervention potential outweigh the harms, depending on the patient’s individual preferences, it leaves the decision up to individual patients and their doctors to weigh. This is the recommendation the Task Force made both for mammography in 40 to 50-year-olds, and for tamoxifen and raloxifene to prevent breast cancer.

When making NADA or OUGHTA recommendations, the Task Force essentially makes its own value judgment. It looks at the risks and benefits of an intervention, and concludes that no sensible person could decide differently from the Task Force. In this third type of recommendation, however, the Task Force concludes that reasonable people could make different choices, based on how they weigh the risks and benefits of the interventions.

In the case of tamoxifen and raloxifene to prevent a first breast cancer, I expect the vast majority of women will conclude that the risks of the pills outweigh the benefits.  In the past two years, I have collaborated with a team of researchers at the University of Michigan (led by Angie Fagerlin, a decision psychologist in their medical school), to help women decide whether to take either of these pills. We developed an Internet-based decision aid, a tool designed to help patients weigh the pros and cons of their medical alternatives. (I write about the history of decision aids in my book, Critical Decisions.) Our decision aid provided women with individualized estimates of their odds of developing breast cancer in the next five years. We only directed women to the decision aid whose risk was high enough to have qualified for the P1 trial.

In the decision aid, we described the benefits of both drugs – the reduced risk of breast cancer and the strengthening of their bones. We also laid out the risks – a very small chance of endometrial cancer, a slightly larger chance of heart attack or stroke, a modest risk of cataracts, and finally a very strong likelihood of experiencing menopausal symptoms such as irregular menstrual bleeding and hot flashes. We actually provided them with precise numerical estimates of these side effects, with pictures illustrating the risks to make them easier to comprehend.

Women pondered the pros and cons and concluded, almost unanimously, that the side effects of these drugs outweighed the benefits.

The decision whether to take tamoxifen and raloxifene is no doubt a personal one, and the right choice will vary depending on how a given person weighs the respective risks and benefits of these medicines. For a woman with an extremely high risk of breast cancer over the next five years – say 10% or more – cutting that risk in half might very well be worth the hot flashes and the chance of experiencing blood clots. But very, very few women faced a five year risk is highest.

Consider, instead, a woman with a 3% chance of developing breast cancer over the next five years. That risk is much higher than average – most women face a five year risk of less than 1% – but is it high enough to justify taking one of these pills? For such a woman, tamoxifen and raloxifene only reduce that risk by 1.5%. Over five years. Five years with possible hot flashes. For a cancer women have not experienced yet. These modest benefits simply do not loom large enough to interest most women in these pills.

You might wonder at this point whether our decision aid biased women against these medications. As a physician trained in behavioral economics, I’m constantly on the lookout for decision biases. In the case of our study, however, we designed our decision aid in a manner that allowed us to test for well-known behavioral economic biases. For instance, research has shown  that when people face a choice between three options and two of the options are similar, they often opt for the more different alternative even if the other options are better. In other words, a person might believe that A > B, and A’ > B, but still choose B over A and A’, because they cannot decide between A and A’.

Aware of this problem, we created several different versions of our decision aid. In one version, we presented women with a choice between tamoxifen, raloxifene or no pill. Three choices in other words, two of which – the two medications – are quite similar to each other. In another version of the decision aid, we simply presented women with the choice between pill or no pill. We thought this simpler choice would increase women’s interest in these pills, by minimizing the difficulty of choosing between the two of them. But instead, this reframing of the decision did not increased women’s interest in either of these preventive medicines.

We also designed our decision aid to take account of another well-known decision bias, what are known as recency effects. When people learn about the risks of a medication and then learn about its benefits, that order of information leads them to look favorably upon the medication, because the information they remember best, the last information they receive, is about the pill’s benefits. By contrast, people who receive the same information about this medicine, but in the opposite order, like the pill less, because the last thing they learn about are the pill’s risks, and this information sticks in their minds. To make sure this recency effect was not influencing women’s decisions, we varied the order of information across women. We discovered that this did nothing to change their willingness to take either of these medications, mainly because whichever order women received information in, they did not like the idea of taking either pill.

If these pills are so unpopular among well-informed women, why would the Task Force come out in favor of them? It comes down to judgment. The Task Force concluded that a reasonable person could look at these risks and benefits and decide that the hot flashes and blood clots are acceptable prices to pay to reduce the chance of breast cancer. The majority of women don’t have to agree with this view for the Task Force’s recommendation to be correct. Even if only a small percentage of women decide these pills are worth taking, at least they have the freedom to make that choice. And at least they know that medical experts have concluded that such a decision is a reasonable one to make.

The same goes for whether to start mammograms before the age of 50 in women at normal risk of breast cancer. The Task Force never said that women shouldn’t start mammograms at this earlier age. They just said that it was a tough judgment call, and that some women, perhaps the majority even, might conclude that the harms of early screening – the anxiety caused by false negative tests, the pain caused by unnecessary biopsies – aren’t worth the modest benefits of screening at this age.

If the Task Force is going to leave all these tough decisions up to individual patients and their doctors, why should we care about their recommendations? For starters, you will have a hard time finding a more thorough and levelheaded evaluation of the pros and cons of these kinds of interventions. These people are very good at what they do. In addition, anyone reading through Task Force reports will be forced to recognize that science alone can’t make tough decisions for us. Ultimately, science can only provide us with the facts. The rest of us eventually need to make tough judgment calls. In effect, the Task Force is doing us a huge favor, by showing us which judgments are close calls, and which ones are no-brainers.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

Doctor integration leads to higher costs @Medici_Manager @leadmedit @wricciardi @pash22

Integrating physicians into hospitals has been theorized to be a cost-saving measure. A new poll of physician executives indicates that such integration may actually increase healthcare costs.

The American College of Physician Executives (ACPE) polled its 11,000 members, asking them what happens to healthcare costs when a physician group or practice is purchased by their hospital or health system.

[See also: Managing clinical, financial integration is key to hospital success]

Of the 468 members who answered the question, 149, or nearly 32 percent, said that healthcare costs go up. Only 22 respondents (4.7 percent) said costs go down. Sixteen percent (75 respondents) said costs remain mostly the same. About 35 percent (163) said the question wasn’t applicable to their institution.

The poll results should be taken as an indication of a possible trend but not as rock solid evidence that physician integration results in higher healthcare costs, cautioned Peter Angood, MD, ACPE’s CEO.

“I think part of the issue that we need to try and tease out further is so are the costs directly related to the physicians ordering more tests and generating more care, or is it that the fact is in order to cover the investment of the physician purchase – the infrastructure that is needed to support them and the other personnel – are those costs getting transferred into the other expenses in terms of charges in the costs of healthcare care,” he said.

Angood believes it is the latter issue spurring the higher healthcare costs, and that those higher costs are likely a temporary situation. As the upfront investment costs depreciate, the higher healthcare costs should drop, he said.

[See also: Doctor medical groups a hot commodity]

Costs should also drop, he said, if the theory of providing integrated care results in improved quality, safety and efficiencies.

http://www.healthcarefinancenews.com/news/doctor-integration-leads-higher-costs