Archivi delle etichette: Hospital management

Una lettura obbligatoria: Exponential Organizations di Salim Ismail @WRicciardi @leadmedit

Una lettura estiva (forse sarebbe meglio dire uno studio estivo) di un libro affascinante: Exponential Organizations di Salim Ismail, edito da Marsilio nella collana Nodi.

Che cos’è un’organizzazione esponenziale? Essa è un’organizzazione il cui impatto (o output) risulta notevolmente superiore – almeno dieci volte – rispetto ai competitor, grazie all’utilizzo di nuove tecniche organizzative, che fanno leva sulle tecnologie in accelerazione.

Gestire organizzazioni esponenziali focalizzate sui clienti e non sui competitor esterni e sulle strutture interne tradizionali richiede una svolta epocale, paragonata a una nuova “era cambriana”. Richiede una nuova cultura e nuove e più dinamiche competenze.

Ho raccolto alcune frasi che mi hanno particolarmente colpito! Buona meditazione a tutti noi perché molti dei temi trattati riguardano anche la sanità!

  1. L’unica costante del mondo d’oggi è il cambiamento, e il ritmo del cambiamento sta aumentando.
  2. L’accelerazione (del cambiamento) è costituita dalle 6 D: digitalized, deceptive (ingannevole), disruptive (dirompente), dematerialized, demonetized, democratized.
  3. L’utilizzo di strumenti lineari e di tendenze del passato per fare previsioni su di un futuro in accelerazione è deleterio (vedi i casi di Iridium e Kodak).
  4. Gli esperti, in quasi tutti i campi, messi di fronte ad una crescita di tipo esponenziale, continuano sempre a pensare in un’ottica lineare, ignorando l’evidenza davanti ai loro occhi.
  5. Il vecchio detto secondo cui un esperto è “qualcuno che ti dice perché qualcosa non può essere fatta” è oggi più vero che mai.
  6. Nessuno degli indicatori tradizionali quali l’età, la reputazione e le vendite attuali possono garantire la sopravvivenza di un’azienda.
  7. La legge di Moore afferma che il rapporto prezzo/prestazione della potenza di calcolo raddoppia ogni diciotto mesi.
  8. “Le nostre organizzazioni sono fatte per resistere ai cambiamenti che arrivano dall’esterno” piuttosto che per accoglierli, anche quando sono utili (da John Hagel).
  9. Le strutture organizzative aziendali esistono proprio per annientare i fattori dirompenti di cambiamento.
  10. La maggior parte delle organizzazioni complesse si basa sulla cosiddetta “struttura a matrice” … Questa struttura è efficace nel garantire il controllo, ma è disastrosa in termini di individuazione delle responsabilità, di velocità e di propensione al rischio … Con il tempo, le funzioni orizzontali acquistano sempre più potere … Per le grandi organizzazioni con struttura a matrice attuare il cambiamento rapido e dirompente è qualcosa di estremamente difficile. Quelle che ci hanno provato, infatti, hanno sperimentato che il “sistema immunitario” dell’organizzazione tende a rispondere alla minaccia percepita attaccando.
  11. Le organizzazioni esponenziali hanno la capacità di adattarsi a un mondo in cui l’informazione è pervasiva e onnipresente e di convertirla in vantaggio competitivo.
  12. I tratti comuni delle organizzazioni esponenziali sono: il Massive Transformative Purpose (Mtp), cinque caratteristiche esterne denominate Scale e cinque interne denominate Ideas. Per essere un’organizzazione esponenziale, un’azienda deve avere il Mtp e almeno quattro caratteristiche.
  13. Il Mtp non è la missione: il Mtp è aspirational. Il fuoco è su ciò che si aspira a raggiungere.
  14. Scale: staff on demand; community and crowd; algoritmi, leveraged asset; engagement
  15. Ideas: interfacce; dashboard; experimentation; autonomia; tecnologie sociali.
  16. Il concetto di autonomia non implica non rendere conto a nessuno delle proprie azioni. Secondo Steve Denning, “In un network esistono ancora le gerarchie, ma esse tendono ad essere basate sulle competenze, e fanno affidamento più sull’accountability tra colleghi che su quella dovuta all’autorità, cioè sul dover rendere conto a qualcuno perché sa qualcosa e non per il semplice fatto che occupa una determinata posizione indipendentemente dalle competenze. Il ruolo del manager si trasforma, non viene abolito”
  17. Un’organizzazione esponenziale tende a essere una zero latency enterprise cioè un’azienda in cui si annulla l’intervallo tra ideazione, approvazione e realizzazione.
  18. In passato il lavoro si concentrava principalmente sull’importanza del quoziente intellettivo (QI), oggi il quoziente emotivo (QE) e quello spirituale (QS) stanno diventando indicatori sempre più rilevanti.
  19. Un secolo fa, la competizione si giocava principalmente sulla produzione, Quarant’anni fa, invece, il fattore decisivo divenne il marketing. Oggi, nell’era di internet, in cui produzione e marketing sono diventati merci e sono stati democratizzati, tutto ruota intorno a idee e ideali.
  20. Il piano strategico quinquennale è in sé uno strumento obsoleto … Esso è un suicidio per un’organizzazione esponenziale … L’unica soluzione è stabilire un Massive transformational Purpose (Mtp), costruire la struttura aziendale, adottare un piano (al massimo) annuale e osservare la crescita, con aggiustamenti progressivi e in tempo reale a seconda delle necessità.
  21. Nel mondo delle organizzazioni esponenziali, lo scopo (Mtp) è più importante della strategia e l’execution ha la precedenza sulla pianificazione.
  22. Arianna Huffington ha detto: “Preferisco lavorare con una persona meno brillante ma che sa fare gioco di squadra ed è chiara e diretta, piuttosto che con qualcuno molto brillante ma dannoso per l’organizzazione”.
  23. In un’organizzazione esponenziale, la cultura (con il Mtp e le tecnologie sociali) è il collante che garantisce la tenuta del team nonostante i salti quantici della crescita esponenziale. Secondo Chip Conley “la cultura è ciò che accade quando il capo non c’è”. E secondo Joi Ito “la cultura si mangia la strategia a colazione”.
  24. Sta diventando sempre più facile acquisire potere, ma è sempre è più difficile mantenerlo.
  25. Consiglio ai CEO delle grandi aziende di affiancare a chi occupa posizioni di leadership i venticinquenni più brillanti, per colmare il gap generazionale e tecnologico, per permettere a questi giovani di crescere più velocemente e per innescare un meccanismo di mentoring al contrario.
  26. Se siete un manager di Amazon e un dipendente viene da voi con una grande idea, la vostra risposta di default deve essere : Se volete dire di no, dovete motivare questo rifiuto con una relazione di due pagine spiegando perché non ritenete l’idea valida.
  27. Jeff Bezos (Amazon) ha detto: “ Se sei focalizzato sui competitor, devi aspettare che siano loro a fare la prima mossa, prima di agire. Concentrarsi sui clienti, invece, consente di essere dei pionieri”.
  28. Il miglior modo per definire questa macrotransizione verso organizzazioni esponenziali è considerarla un passaggio dalla scarsità all’abbondanza … Secondo Dave Blakely “queste nuove organizzazioni sono esponenziali perché prendono qualcosa di scarso e lo fanno diventare abbondante”.
Annunci

The Precipice: Influence and Manipulation @helenbevan @leadmedit @wricciardi @pash22

BY 

In some ways, to influence and to manipulate can seem to be the same thing. After all, the intent of both influence and manipulation is to get other people to behave, think, or make the decision you want them to. But is that really the case as demonstrated by these definitions from thefreedictionary.com?

Influence:  (n) 1. A power affecting a person, thing, or course of events, especially one that operates without any direct or apparent effort. 2. Power to sway or affect based on prestige, wealth, ability, or position.  (v) 1. To produce an effect on by imperceptible or intangible means; sway. 2) To affect the nature, development, or condition of; modify.

Manipulate: (v) 1. To move, arrange, operate, or control by the hands or by mechanical means, especially in a skillful manner. 2. To influence or manage shrewdly or deviously. 3. To tamper with or falsify for personal gain.

As indicated in the definitions, the main purpose of both influence and manipulation is  to sway; however, there is a definite difference between the two. Influence is an ethical behavior; manipulation is unethical. We admire leaders who have mastered the power of influence; equally, we mistrust leaders we believe to be manipulative. They are both getting us to see things their way. Taken too far, influence can move to the other end of the spectrum and become manipulation.

The differences between influence and manipulation include the:

  • reason behind the intention to persuade another person
  • truthfulness and accuracy of provided information
  • transparency of the process
  • benefit, affect, or impact on the person.

Manipulation implies an intent to fool or trick someone into doing, believing, or buying something that leaves them harmed in some way. We view manipulators as schemers. Out to get what they want using whatever means possible, manipulators selfishly pursue their own agenda, trying to control instead of wanting to influence another person. For example:

Influence Someone offers a proposition that is beneficial to both parties.

Manipulation: Someone offers a proposition that serves their own purposes and is against the other person’s interest. They conceal a desire to move the person to their point of view in a way that will only benefit themselves. In addition, if their intention were uncovered, the discovery would cause the other person to be less receptive to their idea.

Influence: All information provided is accurate and shared openly.

Manipulation:  Information is withheld or distorted to trick or deceive.

Influence Someone is willingly led to something they want or that will benefit them.

Manipulation: Someone is led to something that will harm them or lead them to eventual regret.

Influence Requesting someone to do you a favor you believe they won’t want to do using sincere appreciation.

Manipulation: Getting someone to do you a favor you believe they won’t want to do using guilt or emotional blackmail.

Many years ago I worked with a manager who often ended his directives with, “And if I find out you didn’t follow what I said, you’re fired,” Looking back now, I assume that he was not confident in his role, his ability to do the job, and/or his effectiveness as a manager and leader. We have all known people who, like my former colleague, get others to do what they want through fear and intimidation. Using these tactics may accomplish what they want, but it does not make them leaders. Like love and hate, there is a fine line between influence and manipulation.

 

How and why do countries vary so much in their use of health services? @WRicciardi @leadmedit @Medici_Manager @pash22

BY ADAM WAGSTAFF , http://bit.ly/1e48HAI

I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.

I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?

WHS to the rescue – again

As in a recent post of mine on Let’s Talk Development, I thought the World Health Survey might shed some light on these issues. The WHS was fielded in the early 2000’s in 70 countries – spanning the World Bank’s lower-, middle- and high-income categories. The WHS enumerators asked a randomly-selected adult in each household about his or her use of inpatient care and outpatient care; in the numbers that follow I’ve focused on use in the last 12 months. As I said in the earlier blog post, the WHS does have some drawbacks: it covers some regions fairly fully, other much less fully; it’s 10 years old; and all we can tell is whether inpatient or outpatient care was received, not the number of contacts. But despite these problems, the WHS gets us quite a long way.

A lot of variation – but not necessarily what you’d expect

The maps below show the inpatient admission and outpatient visit rate – actually the fraction of people who had at least one admission or visit in the last 12 months. Green countries are above the developing-country average; red countries are below it.
For IP admissions, most of the OECD countries are above the developing-country average (6.98%). Brazil, Namibia and the European and central Asian countries are also above it. African and Asian countries are mostly below or close to the developing-country average.

The picture is different for outpatient visits. Several OECD countries are actually below the developing-country average (27.52%). And for the most part, the countries below the developing-country average are in Africa: many are considerably below it (Mali stands out dramatically); only a few are above it (Kenya and Zambia stand out). By contrast, several countries in Asia are above the developing-country average: India and Pakistan are dramatically above it, but China and Vietnam are also above it; a few Asian countries are below it – Laos and Myanmar are considerably below it, Malaysia and the Philippines less so.

Do variations in doctor numbers and infrastructure explain variations in utilization?

The maps below show data on doctors and hospital beds per 1,000 persons. I got the data from the World Development Indicators, and took the country averages for the first half of the 2000s. As before, green countries are above the developing-country average; red countries are below it. The countries above the developing-country averages are mostly those in the OECD and Europe and central Asia, though in the case of doctors per 1,000 some of them are also in Latin America and the Caribbean. Except for China, most of Asian countries fall below the developing country average.

Correlating the WHS utilization data with the WDI doctor and beds data shows that doctors and beds per 1,000 persons are positively associated with outpatient visit and inpatient admission rates. A lack of doctors and beds looks like it could indeed be part of the explanation for low utilization rates, though of course we haven’t established causality.

But a lack of doctors and hospital beds is only part of the story. Together they “explain” only 60% of the cross-country variation in inpatient admission rates, while doctors “explain” an even smaller 20% of the cross-country variation in outpatient visit rates.

Some countries – India and Pakistan are examples – are below the developing-country average on doctors per 1,000 persons, but above the developing-country average on the outpatient visit rate. Doctors and hospitals in these countries treat far more patients than one would expect given the number of doctors and hospital beds in these countries. In these countries, it doesn’t look like accessibility is the pressing issue; as research by my colleague Jishnu Das confirms, at least in India, poor quality is the bigger problem.

By contrast, much – but not all – of Africa is in the opposite camp: these countries have inpatient admission and outpatient visit rates that are below what would be expected on the basis of their doctor and beds per 1,000 figures. So it’s not just that these countries lack doctors and beds; it’s also that people are not getting the level of contacts you’d expect from the existing staff and infrastructure. Here it looks like absenteeism could well be part of the story; recent research from my colleague Markus Goldstein confirms it – pregnant women whose first clinic visit coincided with a nurse’s attendance were found to be 46 percent more likely to deliver their baby in a hospital.

Two take away messages

Message #1 is that countries differ considerably in their utilization rates. Much of Asia visits doctors more regularly than both the developing world and the entire world; India’s consultation rate is a third higher than the global average. Africa stands out as the continent where outpatient visits and inpatient admissions lag behind the rest of the world.

Message #2 is that these variations are partly explained by differences in doctors and hospital beds per capita, but only partly. The problem goes deeper than hiring more doctors and building more hospitals. Africa has lower outpatient visit rates than its doctors per 1,000 figures would suggest, while the opposite is true of India and Pakistan. In Africa, it looks like the binding constraint may well be absenteeism, while in S Asia it looks like the first-order problem is the poor quality of care that’s actually delivered.

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.

Adapting a Strategic Plan in a Turbulent Healthcare Environment @Medici_Manager @pash22

by Sabrina Rodak    http://bit.ly/15q2xtB

In the current healthcare industry, where healthcare reform measures are continually being rolled out and healthcare leaders are facing new challenges every day, maintaining a relevant strategic plan can be difficult. “Across the country, all of us are struggling to say, ‘How do we continue to provide the care for patients who need us with the massive change in the way healthcare is being delivered?'” says Cathy Fickes, RN, president and CEO of St. Vincent Medical Center in Los Angeles. She shares how St. Vincent Medical Center uses regular review and partnerships to keep its strategy aligned with its mission and the market.

Cathy FickesOne-sheet wonders: Communicating and reviewing strategies

To easily communicate and review the hospital’s strategies, St. Vincent Medical Center summarizes its strategic plan, including its mission, vision, values and goals, in a one-page document. The leaders share this one-page summary at all levels of the organization so all employees are aware of the strategic plan and can see how their role fits into the hospital’s larger strategy. In addition, a succinct statement of the hospital’s goals facilitates progress reports, according to Ms. Fickes. “We have this one summary page you can speak to and say where you’re at. We don’t have pages and pages,” she says.

St. Vincent Medical Center’s leaders review the summary monthly and adapt its tactics and goals for the year as necessary. Annually, the hospital leadership team reviews the entire strategic plan and develops goals for one, three and five years out. “Once upon a time, we used to think 10 years out. Now, it’s much more immediate; we have one-, three- and five-year goals,” Ms. Fickes says.

Staying connected within and outside the hospital
An important way to ensure a strategic plan continues to be appropriate for the organization and market overall is to be in touch with stakeholders both in and outside the hospital. “Stay closely connected with the community and doctors,” Ms. Fickes says. She also suggests hospital leaders consider partnership opportunities as hospitals begin to redefine their role in the community as population health managers instead of only healers of the sick. “We’re trying to make sure we’re in the right place to develop relationships to provide population health management and a continuum of care for the patient,” she says. “We are aware that we’re not an isolated entity; we’re part of a larger community where we can hold each other up and strengthen each other.” For example, St. Vincent Medical Center partners with convalescent homes, emergency medicine providers and other hospitals under its parent health system, Daughters of Charity Health System based in Los Altos Hills, Calif.

Optimism in the face of uncertainty
While the turbulent healthcare environment challenges healthcare leaders to be flexible in developing and adapting their strategic plans, it also creates an opportunity for innovation, according to Ms. Fickes. “Healthcare is facing a time of extraordinary challenge. In times of confusion and chaos are when the best things happen,” she says. “Tradition has been set aside and we’re all searching for new ways of dong things. I’m optimistic we will find new ways of providing better care to our patients.”

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How clinical commissioning groups are handling new responsibilities @Medici_Manager @muirgray

by Steve Kell http://bit.ly/1bxypvV

One hundred days have now passed since 1 April and the official birth of clinical commissioning groups (CCGs). As a GP and CCG chair it has been one of the most exciting, frustrating and meaningful periods of my career.

For most CCGs, delegated authority from primary care trust clusters, and therefore responsibility, had been in place for some time before April. However the process of authorisation and establishing organisations undoubtedly became a necessary distraction, with process and structure the focus.

Authorisation was essential to ensure we build robust, patient-focused organisations capable of fulfilling our statutory duties. CCGs were the only part of the new system to have been through this process, despite the number of new structures in the commissioning system. Since authorisation it has been good to get back to what we are here to do — commissioning health services and working with patients and practices to ensure we understand local services and their quality.

Bassetlaw CCG is a comparatively small CCG, with 12 practices and 112,000 patients in north Nottinghamshire. We have the same issues as many of our neighbours – high mortality and morbidity levels, areas of significant deprivation, obesity and substance misuse. We have a two-tier local authority system and we are members of Nottinghamshire health and wellbeing board. However, 90% of our patients use acute health services based in northern England – in South Yorkshire (including Bassetlaw hospital as part of Doncaster and Bassetlaw hospitals foundation trust).

Much of our time, therefore, is spent developing partnerships. Many of the commissioning organisations we work with are new, including NHS Englandpublic health teams and the health and wellbeing board. Practices and providers are important as pre-existing parts of the system, and have been essential in understanding our local health services and outcomes. We have built transparent relationships with our providers, openly discussing services, capacity and performance. We meet neighbouring CCGs regularly to discuss commissioning on a regional level such as cardiology services and networks.

Quality assurance forms a significant part of our role. Performance indicators and targets are a key part of this, but we have also reviewed issues raised by member practices and patients. Service development has been one of our most important work streams. It is essential that we seek continuous improvement in services for patients, and not simply monitor what we already have. GPs work closely with managers to improve pathways and we have successfully commissioned new musculoskeletal, dermatology, cardiac rehabilitation and community paediatric pathways for local patients.

As a CCG we have a strong sense of responsibility for our local population. Patient engagement is central to this. We have well established practice patient groups and groups within the CCG, and this role is led by our new lay member who has worked hard to ensure we have a new, meaningful approach. We have developed a series of summits with patients, carers and providers including extremely successful dementia and learning disability events.

We have a number of commissioning priorities as a CCG. Some, such as developing integration of services and pathways, have been enhanced by the development of an integrated care board chaired by the local authority. Some have arisen due to performance issues, such as A&E performance. We have worked closely with practices, visit A&E weekly and have commissioned increased capacity within the department and acute medical services with significant results. Targets are now being met and we have services with better access to senior staff over seven days and diagnostics.

There are significant challenges. Being allowed access to patient information is essential if we are to improve outcomes and commission effectively. Running cost, set at £25 per patient, is a blunt tool that does not take into account organisational size and fixed costs, or local health needs. CCGs, particularly those such as Bassetlaw, who have natural communities but are relatively small, are extremely lean organisations where clinical and managerial time is limited and we have learned to work as an efficient, effective team. It is essential that this is valued when we have assurance meetings and that reporting upwards does not distract us from our role.

We operate as just one part of a complex commissioning system. We need to ensure we are active partners alongside public health, regulators and NHS England, and that our clinical involvement and patient engagement lead to better outcomes.

After 100 days I’m optimistic. Clinical commissioning is delivering. The NHS needs it to succeed.

Dr Steve Kell is chair of Bassetlaw CCG and co-chair of NHS Clinical Commissioners Leadership Group

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

Preventing excess @Medici_Manager @pash22 @helenbevan @muirgray

by Ray Moynihan http://bit.ly/15CMup6

IN recent weeks the world’s leading medical journals have published articles about the overtreatment of mild hypertension, the risks of breast cancer overdiagnosis, and the lack of effectiveness and potential harms of general health checks.

As the studies of dangerous excess mount, so too does the effort to raise awareness about the problem. JAMA Internal Medicinenow has a regular “Less is more” feature, the BMJ has just launched its “Too much medicine”  campaign, and professional societies in the US are running the “Choosing wisely” initiative, highlighting overused tests and treatments.

In the field of mental health few could have missed the global fight over the DSM–5 and vociferous claims it will further fuel the medicalisation of normal life.

There’s little doubt that the market-based system in the US is the epicentre of excess — where health care now comprises almost one-fifth of the entire economy — but the problem affects many nations.

With breast cancer for example, estimates based on incidence studies suggest one-third of invasive cancers diagnosed by screening mammography in NSW may be overdiagnosed — in other words, the cancer would not have gone on to harm the woman.

The probable causes of overdiagnosis and overtreatment are complex — technological change, commercial gain, professional imperialism, fears of litigation, perverse incentives and our deep cultural faith in early detection. But despite the complexity and enormity of the challenge, it’s surely time to try to work out how we can wind back the harms of too much medicine.

A group of Australian researchers are a key driving force behind the first international scientific conference on overdiagnosis to be held in the US this September. The Dartmouth Institute for Health Policy and Clinical Practice is a logical host for the Preventing Overdiagnosis conference, with its proud history of medical scepticism and impeccable credentials on the dangers of too much medicine.

Resulting from a small meeting on Queensland’s Gold Coast last year, the conference is being run in partnership with the BMJ and one of the world’s most influential consumer organisations,Consumer Reports. It will feature 90 scientific presentations on the problem and its solutions, and keynote speakers include Dr Virginia Moyer, the chair of the US Preventive Services Task Force, Dr Allen Frances, chair of the DSM IV, and Dr Barry Kramer, a senior director at the National Cancer Institute, which has made overdiagnosis one of its research priorities.

Along with the research and the conferences, the time is ripe for a lot more discussion about what can be done in the clinic and the classroom, how we can communicate the counterintuitive message that less is sometimes more, and how we can develop and evaluate effective policy responses.

The aim, after all, is not just more meetings and peer-reviewed papers, but fewer healthy infants labelled unnecessarily with gastro-oesophageal reflux disease, less distress overdiagnosed as mental illness, and fewer of our elders assailed by out-of-control polypharmacy. The less we waste on unnecessary care, the more resources there are for those in genuine need.

Along with innovations in genetics and information technology, one of the exciting areas in medicine in the 21st century will be how to wind back unnecessary excess — safely and fairly.

Ray Moynihan is a senior research fellow and PhD student at Bond University, and co-organiser of the Preventing Overdiagnosis conference being held at Dartmouth, US, 10–12 September 2013. www.preventingoverdiagnosis.net

12 Steps to Create a Mission Statement @Medici_Manager

Written by Sabrina Rodak http://bit.ly/11AQiFE

AchieveIt explains a process for creating a mission statement in a whitepaper, “Mission Statements: A How-To.”

AchieveIt suggests conducting a one-day retreat to create a strong mission statement. Here are 12 steps to create a mission statement from the whitepaper:

Preparing for the retreat
1. Each participant brainstorms about why the organization exists, chooses his or her best answer and writes it in 10 words or less.
2. Participants submit their statements, which the retreat leader writes on Post-It notes.

The retreat
3. Randomly stick all submitted mission statements on the wall.
4. Participants group mission statements by major themes.
5. Participants choose a heading of three words or less for each group.
6. Participants rearrange mission statements if they no longer fit under their heading.
7. Each participant receives a number of single-color dots equal to about half the number of mission groups. Participants use the dots to vote on the mission statement(s) they think best reflects the organization. The two mission groups with the most votes go to the next stage.
8. Each participant chooses a word or phrase in any of the mission statements that inspires him or her. The retreat leader writes the three words or phrases with the most votes on Post-It notes.
9. Arrange the words and phrases with their group heading.
10. Use the words and ideas to frame the mission statement. If the chosen words do not naturally frame the mission statement, each participant writes a mission statement under 10 words using the key words and phrases.
11. Pair participants to share and combine their mission statements into one statement of 10 words or less. Combine pairs to create teams of four and combine the two mission statements into one. Repeat this process until only two teams and two mission statements remain.
12. The two teams present their mission statements and combine if possible. Otherwise, each participant votes once on a mission statement, and the statement with the most votes wins.

More Articles on Strategic Planning:

Saint Mary’s Health Care Changes Name to Reflect 2-Year-Old Partnership
LSU’s University Medical Center to Change Name With New Management

Scripps, SCL Health: Why Hospitals Are Moving to Hospice, Home Health

When doctors and patients share in decisions, hospital costs go up @Medici_Manager

Since the 1980s, doctors and patients have been encouraged to share decision-making. Proponents argue that this approach promotes doctor-patient communication, enhances patient satisfaction, improves health outcomes and even may lower cost.

Yet, a hospital-based study found that patients who want to participate in their medical decisions end up spending more time in the hospital and raising costs of their hospital stay by an average of $865.

The findings, published in May 27 issue of JAMA Internal Medicine, came from the first hospital-based study to examine how patients’ desire to participate in medical decisions affects their use of health care resources.

There are about 35 million hospitalizations each year in the United States. If 30 percent of those patients chose to share decision-making rather than delegate that role to their doctors, it would mean $8.7 billion of additional costs per year, according to the study.

David Meltzer

David Meltzer

 “The result that everyone would have liked, that patients who are more engaged in their care do better and cost less, is not what we found in this setting,” said study author David Meltzer, associate professor of medicine, economics and public policy at the University of Chicago. “Patients who want to be more involved do not have lower costs. Patients, as consumers, may value elements of care that the health care system might not.”

The researchers approached all patients admitted to the University of Chicago’s general internal medicine service between July 2003 and August 2011. Almost 22,000 people, about 70 percent of those asked, completed a wide-ranging 44-question survey.

The key multiple-choice item for this study was: “I prefer to leave decisions about my medical care up to my doctor.” More than one-third of patients (37.6 percent) definitely agreed, one-third (33.5 percent) somewhat agreed, and a little less than one-third (28.9 percent) somewhat or definitely disagreed.

Patients who preferred not to delegate decisions to their doctors—those who wanted to work with their caregivers to reach decisions—spent about 5 percent more time in the hospital and incurred about 6 percent higher costs.

“Was I surprised?” asked Meltzer. “I wasn’t shocked. It could have gone either way. Our results suggest that encouraging patients to be more involved will not, alone, reduce costs.”

In fact, the authors note, “Policies that increase patient engagement may increase length of stay and costs.”

Although this was a large study, it may not apply in every setting, the authors cautioned.

“We need to think harder and learn more about what it means to empower patients in multiple health care settings and how incentives facing both patients and caregivers in those settings can influence decisions,” Meltzer said.

Indeed, the authors looked at “hospitalized patients, for whom providers have large incentives to decrease utilization due to Medicare prospective payment, low payment rates for Medicaid and uninsured patients, and utilization review for most patients.”

They found that provider incentives were not the only predictors of care costs. Although the uninsured had slightly shorter stays and lower hospitalization costs, patients with public insurance such as Medicare or Medicaid, which pay less than the cost of care, had longer than average stays and higher costs.

As the principal tertiary care hospital on Chicago’s South Side, the University of Chicago Medicine provides care for a diverse population. Three-quarters of the patients in this study were black. More than half had a high school education or less. Nearly 80 percent were insured by Medicare or Medicaid or had no insurance.

“This isn’t about demographics,” Meltzer said. Patients with the most education had lower costs than those with the least education, the study found.

Nonetheless, the authors expressed particular concern about the tendency for older, less-educated, publicly insured and black patients to be less engaged in medical decision-making. They warned this could increase health care disparities as empowered and engaged groups, who already are more likely to receive care, gain resources through shared decision making while the national movement toward accountable care organizations increases the pressure for cost reduction.

“We want patients to be more involved, to have the richest form of interaction,” Meltzer said. “That can align preferences, prevent mistakes and avoid treatments patients don’t want. But we need to find ways to create functional doctor-patient partnerships that lead to good health as well as sound decisions about resource utilization.”

Additional authors were Hyo Jung Tak and Gregory Ruhnke of the University of Chicago Medicine. Funding for this work was provided by the Agency for Healthcare Research and Quality, the National Institute on Aging and the National Cancer Institute.

The Fundamental Problem in Management @Medici_Manager @LDRLB

Timothy Kastelle http://bit.ly/10qB0QF

The fundamental problem in management is that the world is uncertain, and people hate dealing with uncertainty.

The result of this that they go to great lengths to provide themselves with the illusion of certainty. The Bed of Procrustres by Taleb, which I discussed previously, is primarily concerned with the problems caused by false certainty.

The problem with requiring certainty is that when you do, you fail to act. If you have to know in advance whether or not your innovation will succeed, you won’t innovate. If you have to know in advance whether or not your co-workers will perform, you won’t delegate. If you have to know in advance whether or not your idea will be accepted, you won’t put it forward.

All of the bad aspects of bureaucracy come from trying to build systems that provide certainty in a world that is by its very nature uncertain.

The more businesses I work in and talk with, the more convinced I become that the single most important management skill to develop is a tolerance for ambiguity.

Successes and Failures of Health Policy in Europe @Medici_Manager @muirgray @pash22

In the last 40 years, the health of Europeans overall has improved markedly, yet progress has been very uneven from country to country.

Now a new study, Successes and Failures of Health Policy in Europe: Four Decades of Divergent Trends and Converging Challenges, draws on decades of research to examine the impact health policy has had on population health in Europe. It asks key and incisive questions about mortality trends and health policy activity and seeks to evaluate the most effective policy for the kinds of challenges Europe has faced.

Edited by Johan P. Mackenbach and Martin McKee, and based on the latest evidence-based research, this volume is an important read for policy-makers and those working in healthcare as professionals, researchers or students.

The book is a joint publication between the European Observatory and Open University Press. It can be ordered here:

How to Manage a Micromanager @Medici_Manager @pash22

This is a guest post by Simon North, co-author of the eBook How to Get the Job You Want

http://onforb.es/10L3pGN

If you’ve ever worked with a micromanager, you know how unproductive and demoralizing it can be. This control freak is reluctant to delegate, may second-guess everything you do, and can shake your confidence in your own abilities. Simple tasks that you could accomplish quickly if left to your own devices take twice as long. Your efforts may be reduced to dust as the micromanager completely re-does your work.

Sure, you may be tempted to bolt, but at a time of high unemployment, you might not have that option. So better to master the art of managing the micromanager.

Start by understanding what causes someone to act this way. Often it’s a need for control that stems from insecurity: lack of confidence, workplace instability and pressure to produce–both individually and as a team. Deep-seated psychological issues and problems at home can also influence the way people behave at work. Many of us have the propensity to be a micromanger, but some of us rein it in better than others.

With this in mind, here are eight practical steps you can take.

1. Look for patterns. As annoying as micromanagers are, they’re incredibly predictable. Watch for behavior swings. There will be certain situations, times of the day or week, when they get especially agitated. Knowing their pressure points can help you ease them.

2. Anticipate needs. Once you know what triggers them, you can stay ahead of those stressors and ease the tensions early on. Flag potential problems before they escalate and offer solutions. Always have a stockpile ready of new initiatives and demonstrate that you are proactive. This helps them curb their responses to the pressure points without slipping into micromanagement mode.

3. Show empathy. Remember, the micromanager is under pressure to produce. Show that you understand his or her plight and are willing to share the load. This could be as simple as offering to help. Tomorrow might be the day when this colleague has to take a child to school but also has an early meeting. So today ask what you can do to make life easier tomorrow.

4. Be super reliable. It’s much easier to manage an office where everyone turns up on time and meets work deadlines. This goes back to the fact that a micromanager hates feeling out of control. If some members of the team don’t deliver, the micromanager gets aggravated and makes unfair demands on everyone else. Discuss as a team what you can do to coordinate things in such a way that there’s no need for the micromanager to fret about how everything is running.

5. Be a role model. Treat the micromanager the way you would like to be treated. Give the micromanager space. Don’t smother or micromanage back. In working with other people, show how your management style is different –and gets equally good results.

6. Speak up—gently. Often micromanagers are oblivious to the effect they are having on other people. They actually think all their micromanaging is producing a better work product. Show encouragement and support for the micromanager’s strengths. Then, without being confrontational, find a way to let this person know how micromanagement affects you. A little levity could diffuse the tension. Or you might just ask how he or she thinks it feels to be second-guessed and mistrusted all the time.

7. Enlighten others. It’s not just you who should be shouldering the responsibility of neutralizing someone’s instinct to micromanage. And chances are you’re not the only one suffering either. Explain to others on your team what you’re doing to ease the micro-manager’s anxiety and encourage them to do the same.

8. Run interference. If a micromanager reports to you and has a detrimental effect on other team members, be a sounding board. Often the micromanager has a skill or quality that’s important to the organization. But it’s up to this manager’s boss to play a leading role in preventing other team members from getting squelched.

Wake Up and Smell Your Strategy @Medici_Manager @LDRLB

Max McKeown —  March 18, 2013 http://bit.ly/X5KjGX

Every now and then you need to wake up and smell your real world strategy. Strategic reality is about events, and coping, and figuring things out. Real world strategy is a living thing. Overconfidence in strategic planning has led to financial crisis, botched and illegal wars, and missed opportunities in business, politics, sports, and life. It has led to quarter of a million missing school places in the UK and over half of Spain’s youth being without work. Failed businesses from Lehman brothers to Blockbusters to Borders all had strategic plans. They all had charts and spread-sheets.

Give me time to think. In 2009 a Toyota vehicle hurtled down a highway with no brakes and a stuck accelerator and crashed into another car killing four members of the same family. In September 2009, Toyota recalled of 3.8 million vehicles but blamed a removable floor mat instead of the real cause and ignored reports of similar fatal crashes dating back to 2007. Not until February 2010 was there a full recall of 8.5 million vehicles, new parts to fix accelerator and brake problems and a public apology from the president along with a ceremonial bow criticized for being too little, too late.

Toyota is a remarkable organization. Its famed Toyota Production System (TPS) – a careful combination of process and collaborative culture – led them to the top for quality and satisfaction. Toyota’s 100 year plan had weekly strategic meetings after high level of consensus was gained from the core of Japanese managers with life-time contracts. If real world strategic failure can harm them it can harm you.

The real world is global, not local. Toyota’s strategic process involved consensus in Japan not consensus worldwide. It favoured head office ahead of the rest of the world. Senior managers forgot the Japanese principle of gemba – going to the place to understand the problem – or perhaps thought only applied to engineering.

The real world is about little things not just big things. TPS does produce quality inside but found it hard to notice important events outside that seemed less important – less urgent – less deserving of senior management attention. They were busy too looking at the big picture at a distance to see the detail that could trip them up.

The real world is about events in real time Leaders who hide away like monarchs of old – as with the ex-CEO of RBS who threatened to fire people for putting cheap pink wafers in his meeting room –  are confused by events because they minimise, attack and deny reality. Smart leaders know events matter more to real strategy than fantasy strategy.

The future is not just more of the past The future is not a simple extrapolation of the successful past. Growth will not always be growth. Quality will not always be quality. Particularly if circumstances change – which they will – and if assumptions are not complete – which they never are. Action takes place in the real world so strategy needs to take place in the real world. You need open door strategy, real time strategy,  with real people doing real things. Smart leaders consider little things, local things, and react to real world events to successfully shape the future.

9 reasons why command and control organisations despise thinking @Medici_Manager @muirgray

http://bit.ly/VMVGja

“I don’t want that academic or theoretical stuff I want something practical”

A huge number of people who work in offices are not paid to dig ditches or split logs, so if they are not paid for their brawn they must be paid for their brain?Apparently not.

People who work in command and control organisations, despite their best intentions, if they want to survive and thrive are mainly paid for the following, check which or these attributes YOU have and which you have to build on.

The ideal command and control candidate for the top:

  1. decisive. i.e .do you make decisions very quickly indeed.The shorter the gap between being presented with a need for a decision and the decision coming out your mouth, the more decisive you are.
  2. does an awful lot. The more you do, the better value you are. Everyone knows that there is only one thing worse than doing the wrong thing right, and that is not doing enough of it.
  3. walks places very fast.  Upping the pace of a walk to a fast stride is just the beginning of a meteoric career path.  You need speed to ensure dynamism. The older you get, the greater the need to gallop down corridors to maintain your aura of urgency.
  4. delivers. If you make snap decisions, do a lot of rubbish and run down corridors , it is all for naught unless you deliver. Doesn’t matter what you deliver, as long as you do. Like a postman with a heavy round at Christmas, what is IN those parcels is irrelevant, just get delivering.
  5. has a lot of staff.  The more you have, the more important you are. You must be, otherwise why would you have all those staff?
  6. has the right face.  Not much you can do about this if you don’t.  Preferably a male face.
  7. positive. Are you positive that your boss is right? Then by agreeing with him (it’s a him, you read point 6 right?)  so are you! Handy!
  8. has a good team of staff who agree with you. If your staff agreed with you  less, they would be in charge. And you are in charge, so therefore see point 7.
  9. maintains good relationships.  The currency is popularity.  Popularity among others above and alongside you. But don’t be too popular. That way lies flavour of the month, and last month was December. Don’t be a January because February comes round soon enough.

None of these attributes for success will be improved by thinking or the consequence of thinking, learning.  In fact the opposite is true. If you think, you have to slow down and stop being so decisive [point 1], you might stop doing an awful lot, as most of it might turn to be rubbish [point 2].  You  might find that your boss is wrong [point 7], or even worse, that you are.  You might start to find that it spreads, and that your team start thinking too [point 8] and then where would you be?

It is important to recognise that learning and thinking are just code-words for self-doubt and lack of confidence. Avoid them at all costs!


EDIT this post originally came out over a year ago, and I took it down from public view during one of the 4 restructures since November 2011. Now times are saner, this blog was referenced on my last application form I filled in for my own job, and the content and style went down well with the first manager I’ve had in the organisation who didn’t treat me as a problem but as an opportunity, and wants to see what we can do publicly and officially with systems thinking and all that. Hence this post resurfacing like an rusty abandoned shopping trolley in a dank park lake. And John Seddon commented on it, which pleased me no end.
Bring on the mucky faced lad!

Keep systems thinking, and have a lovely day!

Medical schools signal readiness for revolution @Medici_Manager

A robust response to an AMA initiative underscores the fact that medical schools recognize the need for a necessary update of how they educate physicians.

Posted March 18, 2013. http://bit.ly/Z14L8o

Educator Abraham Flexner’s 1910 report evaluating American and Canadian medical schools is generally credited with transforming medical education into its current modern age. Flexner shined a light on the importance of a more rigorous education so that future physicians could be trained in — and have a sharp mind for — the rapid scientific and technological advances coming out of the Industrial Revolution.

Over the last decade, numerous studies have looked at one question: Should the Flexner model be updated so medical education can adapt to the rapid scientific and technological advances of today’s information revolution? The answer is uniformly, yes, and the call for change isn’t coming only from medical and educational observers. Recently, striking evidence has surfaced that the schools themselves are ready to make a change — one as revolutionary as anything Flexner envisioned.

That evidence is their overwhelming response to a $10 million initiative by the American Medical Association called “Accelerating Change in Medical Education.” Before a Feb. 15 deadline, 115 out of 141 U.S. medical schools sent five-page concept proposals explaining what transformative changes they would like to make in teaching future physicians. Changes might include new ways of teaching and assessing core competencies, or more of a focus on patient safety or quality improvement. The proposals reflect a changing health care delivery system transformed by technology so that the skill of finding and applying information is as important — or more so — than memorizing it. Of those proposals, 20 to 30 will be chosen to write a longer request for a proposal that is the equivalent of applying for a National Institute of Health grant. From there, eight to 10 schools will be announced at the AMA Annual Meeting in June as sharing in the $10 million to help implement their ideas.

The AMA helped bring Flexner’s report to bear, with its Continuing Medical Education division. It rated medical schools at the time and solicited the Carnegie Foundation for the Advancement of Teaching — which chose Flexner — for further efforts in improving physician education. This was at a time that many schools’ quality was poor, and there were few, if any, standards for training doctors.

The AMA again has stepped to the forefront, not only with its $10 million offer but also with other efforts to promote initiatives to improve education, publishing papers on change in medical education and organizing high-level discussions in which experts talk about what the future of medical schools should be.

But unlike 100 years ago, when substandard schools closed or fired faculty to catch up to Flexner’s standards, the relationship between medical schools and agents of change is markedly more symbiotic.

Schools already are part of the discussion about accelerating the pace of instruction to three years instead of four, as a way to train more doctors and confront the current crisis of a looming physician shortage.

They have recognized the impact that the Internet and mobile technology have had as a means for doctors to quickly and easily review treatment guidelines and look up information on diseases, pharmaceuticals and procedures. Business tracks have been added at some schools to help future physicians learn about how to manage the complex insurance and financial environment they will face. There are now programs where physicians are taught how to work not only in an individual practice setting but also as leaders and members of teams that stretch across different professions, locations and practice settings.

The AMA’s “Accelerating Change in Medical Education” program indeed will fund individual schools with particularly compelling ideas, schools that a panel of experts will choose to reflect a variety of regions and projects. But the goal is not merely to promote transformations at a few schools. By including those schools in a medical education consortium, by sharing their ideas with all medical schools, and also by sharing other worthy ideas from schools that weren’t selected, the hope is that the AMA program helps facilitate creative thinking and out-of-the-box ideas across the spectrum of medical education.

The reason the AMA emphasizes “accelerating” change is that incremental changes aren’t enough to ensure that future doctors get the training they need in a world in which rapid business, population and technological changes have made being a doctor a much more dynamic profession. These have to be systemic changes, as bold and far-reaching in our time as they were in the wake of the Flexner report.

Flexner’s triumph stemmed from an era when there were many medical schools unworthy of the name. This next revolution starts from strength, solid opportunities and a well-demonstrated willingness to embrace change.

EXTERNAL LINKS

“Accelerating change in medical education,” American Medical Association (link)