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- BobbyG

On healthcare system improvement: are the Feds proposing the building of a two-legged stool?

Recall my June 9th post regarding ONC's "ten-year plan" for HIT Interop.

Well, we should also consider the latest PCAST Report (pdf).

Executive Summary
In recent years there has been success in expanding access to the health-care system, with millions gaining coverage in the past year due to the Affordable Care Act. With greater access, emphasis now turns to guaranteeing that care is both affordable and high-quality. Rising health-care costs are an important determinant of the Nation’s fiscal future, and they also affect the budgets for States, businesses, and families across the country. Health-care costs now approach a fifth of the economy, and careful reviews suggest that a significant portion of those costs does not lead to better health or better care.

Other industries have used a range of systems-engineering approaches to reduce waste and increase reliability, and health care could benefit from adopting some of these approaches. As in those other industries, systems engineering has often produced dramatically positive results in the small number of health-care organizations that have implemented such concepts. These efforts have transformed health care at a small scale, such as improving the efficiency of a hospital pharmacy, and at much larger scales, such as coordinating operations across an entire hospital system or across a community. Systems tools and methods, moreover, can be used to ensure that care is reliably safe, to eliminate inefficient processes that do not improve care quality or people’s health, and to ensure that health care is centered on patients and their families. Notwithstanding the instances in which these methods and techniques have been applied successfully, they remain underutilized throughout the broader system.

The primary barrier to greater use of systems methods and tools is the predominant fee-for-service payment system, which is a major disincentive to more efficient care. That system rewards procedures, not personalized care. To support needed change, the Nation needs to move more quickly to payment models that pay for value rather than volume. These new payment models depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign processes of care around the patient and bring community resources, as well as medical resources, together in support of that goal.

Additional barriers limit the spread and dissemination of systems methods and tools, such as insufficient data infrastructure and limited technical capabilities. These barriers are especially acute for practices with only one or a few physicians (small practices) or for community-wide efforts. To address these barriers, PCAST proposes the following overarching approaches where the Administration could make a difference: 

1. Accelerate alignment of payment systems with desired outcomes, 
2. Increase access to relevant health data and analytics, 
3. Provide technical assistance in systems-engineering approaches, 
4. Involve communities in improving health-care delivery, 
5. Share lessons learned from successful improvement efforts, and 
6. Train health professionals in new skills and approaches.

Through implementation of these strategies, systems tools and methods can play a major role in improving the value of the health-care system and improving the health of all Americans.

...In addition to ensuring that care remains affordable, there is a need to center health care on patients, families, and population health. That objective requires action on multiple fronts, as stated well by the Institute of Medicine: care should be safe, timely, effective, efficient, feasible and patient centered. There are opportunities to improve in each of these areas. For example, recent reviews suggest that over one-quarter of Medicare patients experienced some type of harm during a hospital stay, and other research finds that between one-fifth to one-third of all hospitalized patients experienced a medical error. Almost half of these errors were likely preventable. Other studies suggest that patients are not routinely involved in decisions about their treatments or managing their conditions. And anecdotal evidence and studies highlight the impact inefficiencies have on patients—long waits for appointments, information not transmitted between clinicians, and patients with complex diseases feeling lost trying to get the care they need.

These shortfalls are occurring even as most clinicians work tirelessly for their patients. Their work is frustrated by processes that contain unnecessary burdens and inefficiencies, with some studies suggesting that almost one-third of front-line health-care workers’ time is wasted. The current stresses on clinicians mean that improvement initiatives cannot simply add to a clinician’s workload or rely on the clinicians finding time to participate in additional initiatives. Rather, successful and sustainable improvement must involve reconfiguring the workflow and overall environment in which these professionals practice, which can help to reduce the burden of work while improving the performance of the system.

Making such changes in an integrated manner is the essence of systems engineering. Recent policies, deriving from the Affordable Care Act and the American Recovery and Reinvestment Act, have laid the groundwork for wider use of systems engineering through new care models that promote integrated care and rapid adoption of electronic health records. The National Quality Strategy identifies areas for improvement in health-care quality and outcomes that systems-engineering initiatives need to address. The current policy environment and advances in technical capabilities combine to make this the right time to focus on expanding systems methods and tools throughout health care.

What's not to love with respect to any of this? All good and necessary stuff. "Systems Engineering"? You can just hear the clucking sounds of approval among my gearhead colleagues at ASQ.

Continuing...

Factors Limiting Dissemination and Spread of Systems-Engineering Principles
Barriers to greater use of systems methods and tools include the lack of quality and performance measures and the misaligned incentive structure of the predominant fee-for-service payment system, which encourages a fragmented delivery system. To support needed change, the Nation needs to move more quickly to payment models that pay for value. These approaches depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign the process of care around the patient and bring community resources, as well as medical resources, together in support of that goal.

Another challenge is an organization’s leadership and culture, which determine people’s commitment to improvement efforts. [emphasis mine -BG] For example, one systems-engineering initiative achieved some success by using checklists to reduce infections among severely ill patients, but significant improvement did not occur until there was a culture where everyone felt they were able to speak up about potential safety concerns.19 Other barriers include technical challenges, workforce capabilities, and limited knowledge about what works.

The siloed nature of the health system, in which clinical care is separated in an uncoordinated fashion across multiple specialties and settings, presents another challenge that can limit the use of systems approaches. Clinicians often focus only on the activities in their particular silo, as opposed to considering the broader concerns of the patient. Moving away from the current siloed state requires systematic knowledge of the many processes and providers involved in a given patient’s care, as well as a cultural shift toward team-based care where all work together to address a patient’s needs...

Goal 6: Train Health Professionals in New Skills and Approaches
Given changes in the way health care is delivered and an improved understanding of the many factors affecting a patient’s health, health professionals of the future will need new skills to succeed. They will need effective communication and collaboration skills to work in teams, a commitment to lifelong learning to manage the flow of new evidence, and an appreciation and understanding of routine improvement methods. Expertise in systems engineering is especially critical as such tools can rarely be applied in a cookbook fashion, but rather need to be tailored to local circumstances to have the greatest chance of success.

Because systems science and systems engineering are central to improving health outcomes and health care’s performance, system sciences and systems engineering need to be much more firmly and formally embedded in the training of all health-care professionals. It is crucial that both the knowledge of systems science and the skills of implementing the principles in health care are emphasized. To this end, education must involve opportunities for interprofessional problem-solving and for building capacity for collaboration that facilitates practice change.

At present, clinical education and training falls short of this vision. Most clinicians were not trained in using systems-engineering approaches, and many clinicians may not even recognize that systems methods and tools could be helpful for improving care. Yet there are reasons for optimism. Several universities are leading the way by incorporating systems engineering directly into the curriculum for health professionals of all kinds (see Box 9 for an example of integrating systems engineering in nursing education). In addition to training clinicians about systems engineering tools, there is an opportunity to teach engineers about applying their tools in a health care environment. Some institutions have started internship opportunities for undergraduate and graduate students to work in hospitals and health systems, and others have begun joint classes where engineers and clinicians learn together about applying engineering concepts to care. More broadly, organizations such as the Accreditation Council on Graduate Medical Education (ACGME) have already taken steps under their New Accreditation System and the Clinical Learning Environment Review to spotlight the need for trainees to develop competence in systems-based patient safety and quality improvement related tools. The Association of American Medical Colleges (AAMC) is addressing the need to develop skills related to systems engineering in medical schools; the American Association of Colleges of Nursing (AACN) includes organizational and systems leadership as an essential element of nursing education, particularly at the graduate levels; the American Medical Association (AMA) has launched an Accelerating Change in Medical Education Initiative to expand training in systems based practice and practice based improvement; and multiple clinical certifying boards have included practice-improvement modules in their maintenance-of-certification process. These are all positive developments and lay the groundwork for further improvement...

Again, all good and necessary stuff. Systems Engineering? Check. "Interoperable" Health IT? Check. OK, what might be missing here?

Hint (from above):

"Another challenge is an organization’s leadership and culture, which determine people’s commitment to improvement efforts."

What is "culture" in the organizational context? How much does it matter?

"The way we do things around here"? That's a popular, succinct summary, one I first heard proffered by Dr. Brent James 20 years ago during our HealthInsight IHC healthcare QI training in Salt Lake City.

Dr. James also noted that "healthcare is both high-tech and high-touch," going on to state that patients are much less likely to litigate in the wake of an adverse outcome stemming from medical error if they feel they've been accorded the caring, "high-touch" component of treatment.

To the extent we fail to successfully address the myriad issues of "culture" dysfunctionality all too prevalent in healthcare, we will be stuck with a wobbly two-legged stool, irrespective of its technological, scientific, and "systems re-engineering" brilliance. See, e.g., some salient elements proffered my prior post "dx Machina."

Healthcare is necessarily a high-stress, endlessly high-cognitive-burden enterprise. There's no getting away from that fact. Moreover, it is likely to become ever more stressful, given the expected new demands on the system as money gets tighter, clinical science advances, populations age, and the PPACA brings new patients into the fold, and in light of the orders-of-magnitude increases in data availability wrought by Health IT (someone has to find time to turn data into clinically beneficial insights).

Healthcare -- at least on the clinical and administrative sides -- is also a milieu wherein there are relatively few entry level positions. "Human resources" (I hate that phrase), consequently, are literally precious. Misuse and turnover of talent comprise a significant, frequently crippling waste.

Recall Dr. Toussaint's "eight wastes" within the Lean model.

He added "unused talent" to Lean's traditional "seven wastes."

The 8 Wastes of Lean Healthcare

1. Defect: making errors, correcting errors, inspecting work already done for error
2. Waiting: for test results to be delivered, for a bed, for an appointment, for release paperwork 
3. Motion: searching for supplies, fetching drugs from another room, looking for proper forms
4. Transportation: taking patients through miles of corridors, from one test to the next unnecessarily, transferring patients to new rooms or units, carrying trays of tools between rooms
5. Overproduction: excessive diagnostic testing, unnecessary treatment
6. Over processing: a patient being asked the same question three times, unnecessary forms; nurses writing everything in a chart instead of noting exceptions
7. Inventory (too much or too little): overstocked drugs expiring on the shelf, under stocked surgical supplies delaying procedures
8. Talent: failing to listen to employee ideas for improvement, failure to train emergency technicians and doctors in new diagnostic techniques

Toussaint, John (2012-05-28). Potent Medicine: The Collaborative Cure for Healthcare (Kindle Locations 909-918). ThedaCare Center for Healthcare Value. Kindle Edition. 

My only lament here is that #8 does not get sufficient attention with respect to the broad, deep, and critical nuance it implies in terms of what I call the relative "psychosocial health" of healthcare organizations. You cannot effect and sustain high-performance teamwork in the healthcare delivery space where the culture is burdened by dysfunction ranging from the "bully culture" on down to the "merely" autocratic and/or "FUD" environment (Fear, Uncertainty, and Doubt").

apropos -

The Bullying Culture of Medical School
By PAULINE W. CHEN, M.D.
NY Times, August 9, 2012 12:00 pm

Powerfully built and with the face of a boxer, he cast a bone-chilling shadow
wherever he went in the hospital.

At least that is what my medical school classmates and I thought whenever
we passed by a certain resident, or doctor-in-training, just a few years older than
we were.

With the wisdom of hindsight, I now see that the young man was a brilliant
and promising young doctor who took his patients’ conditions to heart but who
also possessed a temper so explosive that medical students dreaded working with
him. He had called various classmates “stupid” and “useless” and could erupt
with little warning in the middle of hospital halls. Like frightened little mice, we
endured the treatment as an inevitable part of medical training, fearful that
doing otherwise could result in a career-destroying evaluation or grade.
But one day, one of our classmates, having already been on the receiving end
of several of this doctor’s tirades, shouted back. She questioned one of his
conclusions in front of the rest of the medical team, insisted on getting an
explanation, then screamed back when he started yelling at her.

The entire episode unnerved us all; and over the next few weeks, we
marveled at her courage and fretted over her potentially ruined career prospects.
But there was one aspect of the event that disturbed us even more. One classmate who had witnessed the “screaming match” described how our fellow
medical student had raised her voice and positioned her body as she threatened
the doctor. “It was weird,” he recounted. “It was like watching her turn into him.”
 
For 30 years, medical educators have known that becoming a doctor
requires more than an endless array of standardized exams, long hours on the
wards and years spent in training. For many medical students, verbal and
physical harassment and intimidation are part of the exhausting process, too.
 
It was a pediatrician, a pioneer in work with abused children, who first
noted the problem. And early studies found that abuse of medical students was
most pronounced in the third year of medical school, when students began
working one on one or in small teams with senior physicians and residents in the
hospital. The first surveys found that as many as 85 percent of students felt they
had been abused during their third year. They described mistreatment that
ranged from being yelled at and told they were “worthless” or “the stupidest
medical student,” to being threatened with bad grades or a ruined career and
even getting hit, pushed or made the target of a thrown medical tool...

While this example is by no means exemplary of all of healthcare, nonetheless the prevalence of psychosocially toxic healthcare workplaces is widespread enough to deserve much more of our attention (dictatorialism and "shame and blame" still rule in far too many circumstances). At its worst, it poses patient safety issues. Unduly stressed workers make more mistakes. At its most banal, it inexorably wastes talent -- Lean Waste #8. Workers will not be inclined to speak candidly and offer ideas for improvement in an environment where one speaks truth to power at one's peril, nor will they be motivated to become fully engaged members of the "high-performance team-based care" that simply must become the norm in the new healthcare space.

In the face of a dysfunctional healthcare work culture, the best talent will take their skills elsewhere at the first opportunity. A psychosocially healthy workplace, then, is a significant profitability and sustainability differentiator.

Let me repeat that.

A psychosocially healthy workplace is a significant profitability and sustainability differentiator.

The stool needs three legs. Perhaps the best that government can do is provide the technical assistance recommendations and resources and policy guidance legs, but the stool needs three legs. Period.

LEADERSHIP, "JUST CULTURE," AND ENGAGEMENT

From my never-ending, endlessly growing reading list of late.

Maccoby's books caught my eye while I was attending the IHI 25 Forum back in December. I would make it and the other two depicted above required reading for every healthcare executive, manager, and physician. David Marx is the founder of the "Just Culture" methodology. It is not some touchy-feely Kumbaya thing. Marx is both an engineer and a lawyer, nationally respected in both aviation safety and patient safety. Bowles and Cooper are well-known authorities on organizational engagement.

to wit, from "The High Engagement Work Culture"

When we look at the cultures within our organizations, we cannot help but wonder how they affect day-to-day work life for hundreds of millions of people who work in them. To give just one example, if the “individual is hero,” how does that affect people who might be very good at their jobs but very poor at being “heroes”?

To examine these issues we have to look at what culture is within an organization, how it comes about and how it ultimately will determine whether or not our workers engage. This is a topic that is enjoying an explosion of attention around the world, from government reports on the subject, to fast-growing online communities, and for very good reason:

Work environments can be much improved, workers’ lives can be healthier and happier, our productivity can be raised and our standard of living protected … at the very least … if we become far more conscious at managing the culture, or “the way we do things” at work. Specifically, if we make that culture much more “engagement-friendly.”

Industry sector and culture 
An organization culture that might be successful in one industry could be a disaster in another. We would expect a hard-charging and risk-taking culture to be prevalent in the financial services industry (but with some changes to which we have already alluded) but such a culture would be bad news for the operators of nuclear power plants or hospitals. In the hospital, strict adherence to rules and procedures (such as infection control, triage, etc.) are key; not that the culture of medicine is one of no risk, but it is a carefully controlled risk. So we see the need to match the culture to the business one is in, leaving room for the unique features that leadership always brings to the table. This is why Dell is not Apple and Virgin Atlantic is not British Airways.

Leadership
An organization’s culture rests on the shoulders of its top leaders, whether or not they created it in the first place.

If an organization wants to change its culture, it usually must change its leader( s). Time and again, we have seen new leaders come into organizations and completely turn around their cultures and their organization’s performance. We have also seen new start-ups forge what are clearly high engagement cultures from scratch, because of their leaders’ vision, force of personality and the most important (and most misused) factor of all: values.

Values
With leadership and management levels, we looked at the structure of the organization and its relationship to organizational culture. But no culture comes into existence via structure alone: instead values breathe life into the structure and shape how things will be done. Values are one of the most important factors in any organizational culture and those values start at the top. Every organization has values whether they are written down or not. Some values are distributed widely and not just within the organization: for example, on every Starbucks Coffee Company cup and sleeve there are statements about the company’s commitment to “doing business in ways that are good to each other, coffee farmers and the planet.” Other organizations may have values that are unwritten and even unspoken but drive the internal culture nonetheless. The fact that some organizations have values that are regularly expressed verbally, written down and distributed widely such as on materials used by customers or in annual reports, does not always mean much: those values may not be lived at all. Not uncommon is the company that states a particular value, but when we have surveyed those people, we find just the opposite. Such things can make one cynical, and can also be the subject of wickedly accurate cartoons such as that by Garry Trudeau’s Doonesbury, which is well worth a click-through due to its timely connection to the financial services Crash! 4 Values, then, are easier said than done.

People
As a living and breathing thing, culture therefore both affects and depends on whom you bring into it. Far better to take the time and pick someone who will fully support your culture from day one, rather than compromising and think that that person will “come around” with time. Smart organizations know this and go far beyond talent and skills in their recruitment activities. Picking the right people to work for you, and picking or promoting the right ones as managers, coaches, supervisors, mentors, whatever you call them, is a crucial cultural effort that will pay big dividends going forward. It will be an incredibly important determinant of whether your organization’s culture can be successful. When the factors driving culture in the organization reach the workforce, the stage is set for whether those people will engage or not, which is something we will expand on extensively further. This in turn will serve to enhance— or detract from— the performance of your organization.

Conclusions
Work culture and worker engagement are a core part of the makeup of those places where we spend so much of our lives, and ultimately determine much of how we feel at work and whether we and our organizations are successful. Inevitably national cultures have an impact, as we have seen, but this is less and less as globalization creates the situation where our organizations straddle the boundaries between countries. India-born managers show up in the UK as they do in the US, and bring their fresh ideas and experiences with them. Young US and British workers go to Bangalore for a unique experience and the invaluable learning that occurs when one leaves one’s own culture. Chinese companies and their managers are showing up around the world, like their Japanese counterparts did decades ago, as China extends its influence. We all learn from each other, and find out that no one national culture has all the answers when it comes to organizational culture and engagement.

What we do know is that all work cultures are not created equal: we see the Apples, Googles, Virgins, Tata Motors and others, and know that they have something special, which goes beyond engineering or finance or strategy. They have a culture that produces and sustains that great engineering and marketing and customer service and makes their people excited to work there and to contribute.

Worker engagement is no simple topic, involving as it does the rich mosaic of contributing factors we have examined. Some of these can be controlled (whom we hire or promote, the culture we create inside our organizations), others we can only work with, react to and mitigate (the economy, national cultures, etc.). But even in reactive mode such as during the 2008 Crash we have choices, some of which will themselves be creators of favorable environments for engagement, and some will not. As we have seen, most countries not in the emerging areas of Asia have their work cut out for them, in regard to worker engagement. Levels of engagement are not especially high across large areas of the developed world, and many have slipped as the effects of the Crash played out; we have also seen why this is so important, in terms of lost productivity and competitiveness. This is hardly the time to be slipping, as competition heats up to unprecedented levels.

While we have covered the drivers of work culture and engagement in some detail as we moved from national to organization to individual levels, we have only hinted at one of the most significant ones, playing its role relentlessly and often outside of many peoples’ conscious awareness. It occupies a unique space in that it can clearly be said to have played a role in both the Crash, and in ongoing low worker engagement around the world. It is the ego.

Bowles, David; Cooper, Professor Cary (2012-05-31). The High Engagement Work Culture: Balancing Me and We (pp. 20, 24, 25, 29-30, 5454). Palgrave Macmillan - A. Kindle Edition.

David Marx:

Whack-a-Mole is also a metaphor for modern life. It’s a game we play with each other—particularly here in the U.S. It’s how we respond to predictable human fallibility. It’s how we set expectations of each other, how we respond when our fellow human being makes a mistake. Whack-a-Mole...
The mole in these examples is the adverse event, those outcomes in life that just don’t seem to be what we wanted. They’re created most often by the mistakes we make, missing that stop sign seemingly hidden behind an old elm tree, addressing that sensitive e-mail to the wrong person, forgetting that the gas nozzle is still connected to the car when we pull away from the gas pump. In the aftermath of these mistakes, both catastrophic and relatively benign, we take the easy route: How bad was the harm? Who touched it last? Who is to blame? Who is to pay? As adults, we push our need for “justice” to the point that every adverse outcome in life must have an accompanying blameworthy human behind it. It’s the game of Whack-a-Mole. 

It’s a game that costs us dearly. We’re all poised to pounce, caught up in the adult version of Whack-a-Mole, with the media all too willing to help swing the hammer even before the investigation has started. Bad outcome must mean bad actor. Whack that bad actor and the game is won...


The statistics are these. You have a one-in-21 chance of dying from accidental causes in your life. That’s a one in 1,600 chance of accidental death per year. It’s a one in 584,000 chance you will accidentally die today, all things being equal. 

The greatest threat to your inadvertent demise is a medical mistake—one of our hard working doctors, nurses, or pharmacists making a mistake. Some reports say medical errors lead to 200,000 lives lost per year in the U.S. alone. Consider this: for every one person who dies in war, four will die in automobile accidents. And for every person in the U.S. who dies in an automobile accident, four to five will die from a preventable medical mistake. Nowhere in life’s endeavors does our human fallibility lead to so much harm. 

On January 25, 2000, Dr. Lucian Leape, a Harvard professor of health, testified before Congress on what he saw as the state of healthcare safety in the U.S. He told Congress that the single greatest impediment to error prevention in the medical industry is that “we punish people for making mistakes.” A co-author of the Institute of Medicine’s (IOM) report, To Err is Human, Leape cited that study’s estimated 44,000 to 98,000 annual deaths that are caused as a result of medical error alone. He said that healthcare providers would often only report what they could not hide. The process is simple: doctors make mistakes, professional boards take licensing action, and newspapers demonize the dedicated professional who made the mistakes. Case closed. Problem solved. Mole whacked—although we haven’t learned anything about what we can do better...

Whack-a-Mole may be addicting for its simplicity, but it’s not a productive way to deal with adverse events. Whether it’s our attitude toward spilt milk at the dinner table or our attitude toward the airline pilot who misses an item on a checklist, we simply cannot believe that an expectation of perfection will get us the results we want. We spend far too much time looking at the severity of the adverse outcome (how bad was it?) and who was the unfortunate soul to be closest to the harm. In turn, we spend far too little time addressing the system design that got us there and the behavioral choices of the humans in those systems that might have ultimately contributed to the adverse outcome. It’s called Whack-a-Mole...

...in the hectic, fast-paced world of healthcare, thousands of patients suffer from adverse drug events every day. Some of these events are simply the statistically predictable side effects of the drug/human interaction. Others, however, are the result of error. 

Human error. Your doctor may write down the wrong drug or the wrong dose. She might write the order for the wrong patient. A pharmacist might make the medication mistake and dispense the wrong drug or dose. Nurses can draw up the incorrect dosage into a syringe or deliver the medication to the wrong patient. Or it may be the patient who does not read the medication label, or even after looking at the instructions, makes a simple measurement mistake that leads to the adverse drug event. 

The healthcare industry refers to those events involving human error as “medication errors.” They occur every day around the world. In some cases, patients and their doctors will never know they’ve experienced a medication error due to the body’s ability to adjust to the unintended drug or dose. In other cases, it may mean an extended hospital stay to correct this new healthcare-caused condition. In the worst cases, the patient dies as a result...

What do we do when things go awry? We face a two-fold challenge: 1) hold those who caused the event appropriately accountable, and 2) make fixes to prevent future events. What we will see is that these two goals are often at odds with each other. And when Whack-a-Mole rules the day, the prevention of future events takes a back seat. As Lucian Leape said, the single greatest impediment to safety is that we punish people for making mistakes. In healthcare today, as with any industry, from aviation to children’s day care, potential responses to the individual who makes the mistake run the gamut from termination to license revocation, from criminal indictment to civil lawsuit. 

Whack-a-Mole...

Marx, David (2012-06-06). Whack-a-Mole: The Price We Pay For Expecting Perfection (Kindle Locations 64-174). By Your Side Studios. Kindle Edition.

Marx in a nutshell here:

• Console the human error.
• Coach the at-risk behavior.
• Punish the reckless behavior.
• Independent of the outcome.

It’s a path that we see innovative regulators and corporate managers beginning to take. It’s known in high consequence industries, such as aviation and healthcare, as a “just culture.” We teach our employees that we are all fallible human beings. We expect them to learn from their mistakes, to help us design the safest possible systems around them, and we expect employees to try to make the safest possible choices in those systems. It’s about setting aside the severity of harm and the actual inadvertent errors, and looking instead to the quality of the systems we have designed and the quality of the choices made in those systems. Console the error, coach the at-risk behavior, punish the reckless. Then, get on with the task of building a better system: changing performance shaping factors that subtly alter the rate of human error; adding barriers to prevent some classes of error; adding recovery steps to catch errors downstream before they lead to harm; and incorporating redundancy to minimize the impact of a failing system—these are the efforts that are going to produce better outcomes... (Kindle Locations 636-647).

You just have to study the entire book. It's excellent.

Maccoby

Michael Maccoby's book could serve as a graduate semester text in "Leadership for Healthcare QI." Among other things, Maccoby and Marx are Deming 101.

Learning and Continuous Improvement 
People on all levels of an organization may have ideas to improve processes, increase efficiency, or cut costs. In most organizations, they don't communicate their ideas, because they don't believe anyone is listening. Typically, suggestions put into a suggestion box don't lead to results. A lower-level employee opens the box and has to decide about passing the suggestion up the hierarchy. If the suggestion means criticizing someone or changing their practices, it is better not to stir a hornets' nest. The suggestion goes nowhere. 

All too often executives are surrounded by courtiers who flatter rather than challenge them. An example: a CEO was presented with survey findings that reported wide distrust of top management by the rest of the organization. He turned to his VPs and said, “This can't be true. I go around and talk with people all the time, and no one has told me this.” The VPs, who knew that no one, including themselves, dared to bring bad news to the CEO, all agreed that there must be something wrong with the survey or the way the questions were phrased. 

Furthermore, experts will often resist new knowledge that devalues their experience and expertise, and few experts are willing to learn from anyone other than a certified subject matter expert. Maccoby was once introduced at a meeting of telecom engineers as an expert on leadership, with the implication that anything he said on any other subject should be discounted. 

Being open to ideas regardless of their source can lead to improvement innovation. When Maccoby visited a Toyota factory in Nagoya, Japan, a supervisor told him that he had received an average of fifty ideas for improvement per year from each member of his team and 85 percent were implemented. This remarkable result was achieved by instituting a process whereby all ideas were evaluated weekly by a team of supervisors. Ideas might be as simple as improving illumination or expanding a particular job. When ideas were implemented, workers received points which could be used for rewards such as dinner for a couple. 

You cannot expect that experts at any level will transform themselves and become respectful to nonexperts and be willing to learn from them, whether they be employees, customers, or patients. To learn from everyone in an organization, you must establish processes for continuous improvement that are integrated with the organizational system and the practical values that further its purpose. 

People will also resist change when it challenges their values or interests. They become closed to learning, and they ignore or find reasons to distrust evidence that conflicts with their beliefs. Some physicians at a medical school refused to consider changing their practice to adopt proven pathways, saying that the vice president who was promoting evidence-based medicine was only interested in saving money, not caring for patients. To overcome this resistance, the vice president had to clarify his philosophy, emphasizing that his purpose was both better care and cost savings and that the practical values needed to achieve this purpose included evidence-based practice and continual learning. 

Of course, people can also resist knowledge that threatens their interests. Typically, product managers at companies resist learning about and supporting innovations that will draw customers away from their products. IBM had to create a new business for laptop computers located far from the managers of mainframes who felt threatened by the new product and who argued that it had no future. In similar fashion, a Norwegian oil company had to create a new company to protect ships that explored for oil from the managers of the much more costly platforms who saw the ships as a threat to their control of oil exploration. 

Fear— whether of losing money, power, status, or of being punished for mistakes— blocks learning. Health care providers learn from morbidity and mortality rounds, but they will resist reporting mistakes and learning from them if they are punished for honest mistakes. 

Organizations will learn only if, as Deming emphasized, leaders drive out fear...

Maccoby, Michael; Norman, Clifford L.; Norman, C. Jane; Margolies, Richard (2013-07-29). Transforming Health Care Leadership: A Systems Guide to Improve Patient Care, Decrease Costs, and Improve Population Health (Kindle Locations 3611-3645). Wiley. Kindle Edition. 

The Leader as Learner and Teacher 
The best leaders are passionate learners. When needing to decide about developing a new product or acquiring a company, GE CEO Jack Welch wanted to learn everything he could about the matter. He would take what he called a “deep dive” into the available material. Microsoft CEO Bill Gates took two weeks off each year to study a new area. When he heard of a new surgical technique, William Mayo would go to where it was being practiced and stay there until he had learned it. He would then return home to teach the technique to the surgeons at his clinic. 

However, in a complex health care organization, leaders cannot know everything they would like to know to solve problems and make decisions. They need to combine humility with confidence. Humility means that they don't have to know more than anyone else, that they are willing to learn from others. It is also recognition that they may never have all the information needed to make a rational decision. But leaders also need to develop confidence that they can learn enough to make good decisions, and to modify their theories if necessary. 

The leader of a learning organization will be a mentor and teacher who motivates others to learn by driving out fear, welcoming new ideas, and instituting processes that facilitate learning. These include open dialogue where no one fears punishment or humiliating put-downs. Also, experiments that test new approaches will be encouraged. Everyone in the organization will learn that all work is a process that includes planning, doing, evaluating or checking, and acting or adapting according to what has been learned. More important, everyone should learn how their work processes and roles contribute to the achievement of the organization's purpose. 

The leader will communicate a philosophy with values that determine decisions. But he or she also will be a principled pragmatist who tests these values to make sure they further the organization's purpose and produce the expected results. And if they don't, the values will be modified. In this way, the leader will model the qualities essential for continual individual and organizational learning. 

Information in a bureaucracy is supposed to flow upward to the executives who should make decisions. The leader in a bureaucracy is supposed to be the person who has all the answers. In contrast, information in a collaborative knowledge organization is constantly accumulating on the front lines. The challenge for executives is to learn from people who are closest to the customers, patients, and clients. Leaders will not learn unless they are able to ask useful questions and use the learning to help design effective processes... (Kindle Locations 3808-3830).

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ONE ENCOURAGING NOTE IN THE PCAST REPORT

Recognizing successful use of systems engineering— 
Baldrige Performance Excellence Program

The National Institute of Standards and Technology (NIST) Baldrige Performance Excellence Program is a U.S. public-private partnership program designed to recognize and promote performance excellence. The program was established to identify and recognize high-performing companies, develop criteria for evaluating improvement efforts, and share best practices broadly. The Baldrige program raises awareness about the importance of performance improvement and provides tools and criteria to help organizations undertake that work. The program was expanded to include health-care and education organizations in 1999 and to nonprofit/government organizations in 2005. 

There are seven categories of criteria to help organizations identify their strengths and opportunities for improvement: leadership; strategic planning; customer focus; measurement, analysis, and knowledge management; workforce focus; operations focus; and results. The criteria focus on results—not procedures, tools, or organizational structure—in order to encourage creative, adaptive, and flexible approaches. Most importantly, the criteria support a systems perspective both to align goals across an organization and to encourage cycles of improvement with better feedback between improvement initiatives and its results. 

Over the past decade, an increasing proportion of these awards has been to health-care organizations. Last year, all of the winners were from the health-care and education sectors, which shows the appetite for improving the ways health care is organized and delivered.

From the current Baldrige Health Care Criteria document. Below, note the areas of [1] Leadership, and [2] Workforce Focus (annotation mine).

1. Leadership (120 pts.)

The Leadership category asks how senior leaders’ personal actions guide and sustain your organization. It also asks about your organization’s governance system; how your organization fulfills its legal, ethical, and societal responsibilities; and how it supports its key communities...

NOTES:
1.2a(2). The evaluation of leaders’ performance might be supported by peer reviews, formal performance management reviews, reviews by external advisory boards, and formal or informal feedback from and surveys of the workforce and other stakeholders.

1.2b(2). Measures or indicators of ethical behavior might include the percentage of independent board members, instances of ethical conduct or compliance breaches and responses to them, survey results showing workforce perceptions of organizational ethics, ethics hotline use, and results of ethics reviews and audits. They might also include evidence that policies, workforce training, and monitoring systems for conflicts of interest and proper use of funds are in place.

 5. Workforce Focus (85 pts.)

The Workforce Focus category asks how your organization assesses workforce capability and capacity needs and builds a workforce environment conducive to high performance. The category also asks how your organization engages, manages, and develops your workforce to utilize its full potential in alignment with your organization’s overall mission, strategy, and action plans...

NOTES:
5.2. “Elements that affect workforce engagement” refer to the drivers of workforce members’ commitment, both emotional and intellectual, to accomplishing the organization’s work, mission, and vision.

5.2a(2), 5.2a(3). Understanding the characteristics of high-performance work environments, in which people do their utmost for their patients’ and other customers’ benefit and for the organization’s success, is key to understanding and building an engaged workforce. These characteristics are described in detail in the definition of high-performance work (page 46).
5.2a(3). Compensation, recognition, and related reward and incentive practices include promotions and bonuses that might be based on performance, skills acquired, and other factors. Recognition can include monetary and nonmonetary, formal and informal, and individual and group mechanisms. Recognition systems for volunteers and independent practitioners who contribute to the organization’s work should be included, as appropriate.

5.2b(2). In identifying improvement opportunities, you might draw on the workforce-focused results you report in item 7.3. You might also address workforce-related opportunities based on their impact on the results you report in other category 7 items.

5.2c. Your response should include how you address any unique considerations for workforce development, learning, and career progression that stem from your organization. Your response should also consider the breadth of development opportunities you might offer, including education, training, coaching, mentoring, and work-related experiences.

I served on a HealthInsight team in Nevada in 2006 that performed a state-level program Baldrige model assessment of a hospital, for the "Nevada Governor's Awards for Performance Excellence" (a program I co-founded), so I can attest first-hand that Baldrige Criteria are comprehensive, exhaustive, and useful for assessing the health of an organization.

Were an enterprise to synthesize a Maccoby/Marx/Bowles-Cooper methodology for "Workforce-Focused, Just Culture Leadership," it would likely sail right through these sections of the Baldrige Criteria assessment with high scores.

More importantly, it would likely also have a big leg up on the competition.

CODA

With regard to all of the foregoing, it helps to recall some of the questions posed by consultants and authors Julie Winkle Giulioni and Beverly Kaye:

Do you want to

• Raise engagement levels?
• Uncover and activate previously unknown or underutilized talents that can help the business?
• Establish a culture of continuous learning and development?
• Build the skills and knowledge needed so employees will be prepared when broader moves become available?
• Generate loyalty and the kind of leadership reputation that will have the best talent standing in line to work for you?

Then "Help Them Grow, or Watch Them Go."

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More to come...

Jon Stewart on the VA IT

The Daily Show
Get More: Daily Show Full Episodes,The Daily Show on Facebook,Daily Show Video Archive

Ouch.

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More to come...

The ONC Ten Year Plan, comrades

In the past decade, there has been dramatic progress in building the foundation of a health IT infrastructure across the country that is resilient and flexible to accommodate many types of change. Through deliberate policy and programmatic action, the majority of meaningful use eligible hospitals and professionals have adopted and are meaningfully using health IT. This progress has laid a strong base upon which we can build. However, there is much work to do to see that every individual and their care providers can get the health information they need in an electronic format when and how they need it to make care convenient and well-coordinated and allow for improvements in overall health. There is no better time than now to renew our focus on a nationwide, interoperable health IT infrastructure – one in which all individuals, their families, and their health care providers have appropriate access to health information that facilitates informed decision-making, supports...

This significant progress has created a growing demand for interoperability that not only supports the care continuum, but supports health generally. Electronic health information needs to be available for appropriate use in solving major challenges such as providing more effective care and informing and accelerating scientific research. Despite significant progress in establishing standards and services to support health information exchange and interoperability, it is not the norm that electronic health information is shared beyond groups of health care providers who subscribe to specific services or organizations. This frequently means that patients’ electronic health information is not shared across organizational, vendor and geographic boundaries. Electronic health information is also not sufficiently standardized to allow seamless interoperability, as it is still inconsistently expressed with vocabulary, structure, and format, thereby limiting the potential uses of the information to improve health and care. We must learn from the important lessons and local successes7 of previous and current health information exchange infrastructure to improve interoperability in support of nationwide exchange and use of health information across the public and private sector...

What's not to love? Below, graphic prediction of their model.

BUILDING BLOCK #1: CORE TECHNICAL STANDARDS AND FUNCTIONS 

Through our Standards & Interoperability (S&I) Framework, ONC will continue to work with industry stakeholders and federal and state governments to advance core technical standards for terminology and vocabulary, content and format, transport, and security. These standards will enable, at a minimum, the following essential services for interoperability:

1. Methods to accurately match individuals, providers and their information across data sources
2. Directories of the technical and human readable end points for data sources so they and the respective data are discoverable
3. Methods for authorizing users to access data from the data sources
4. Methods for authenticating users when they want to access data from data sources
5. Methods for securing the data when it is stored or maintained in the data sources and in transit, i.e., when it moves between source and user
6. Methods for representing data at a granular level to enable reuse
7. Methods for handling information from varied information sources in both structured and unstructured formats.

You can't question the necessity of any of these. But, frustratingly, what you will not find in this entire ONC paper (pdf) is the word "dictionary" or phrase "data dictionary." See my earlier tilting-at-windmills blog post on The Interoperability Conundrum.

ERRATUM

LOL From The Incidental Economist blog.
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More to come...

KHIT Blog Milestone

Thanks to everyone who keeps coming by. It's probably somewhat more than that, as I didn't even install the blogger.com javascript tracking code in the blog template source html code until about a year after launching this blog.

On toward a half million.
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MEANINGFUL USE UPDATE

Meaningful Use Program Payments Approach $24 Billion; Enrollment Still Lags Behind 2013
by Alex Ruoff

As of April, the federal government has paid more than $23.7 billion in incentive payments to health-care providers and hospitals through the meaningful use program, which pays Medicare and Medicaid incentives to providers and hospitals that adopt electronic health record systems, according to Centers for Medicare & Medicaid Services data released June 4.

Enrollment grow in the meaningful use program is slower than in previous years, however, particularly for hospitals, the data show.

In April, the latest month for which data are available, 7,057 providers and 13 hospitals newly registered to participate in the meaningful use program, according to the data. In April 2013, 4,445 providers and 38 hospitals registered to participate in the program, according to earlier CMS data reports.

The largest share of the incentive payments—$13.83 billion—has gone to hospitals, according to the data. Nearly $2 billion was paid in 2014.

Provider registrations were down compared to March and February of this year, when, respectively, 12,461 and 9,378 providers registered to participate...

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More to come...

Whither ONC?

ONC's structure gets flatter as its $2B stimulus appropriation ends
By Joseph Conn 

It should have come as little surprise that Dr. Karen DeSalvo, in announcing last week a reorganization of the Office of the National Coordinator for Health Information Technology, said she was aiming for a “flatter” reporting structure.

One reason for the reorg is obvious. A massive bulge in ONC funding is deflating because most of the $2 billion that was directly appropriated to the ONC by Congress in 2009 for health IT programs under the American Recovery and Reinvestment Act has been spent over the past four years. The appropriation was part of the economic stimulus during the Great Recession.

DeSalvo, in a recent memo to her staff, noted that the ARRA's “health IT infrastructure and program investments are ending and it is our responsibility to take this opportunity to reshape our agency to be as efficient and effective as possible, never losing sight of our primary accountability—the people of America.” There were no layoffs with the reorganization; the ONC head count remains at 191 full-time equivalents.

Back in February, in an on-camera interview soon after her appointment to head the ONC, DeSalvo talked about operating with less money than her two immediate predecessors, Drs. David Blumenthal and Farzad Mostashari, both beneficiaries of ARRA funds...

Most of that stimulus law money went to health IT workforce development programs, the Beacon Community program, state health information exchanges, higher education in health IT and the regional health IT extension center program.

Fifty-five of the 60 extension centers in the first two rounds of grants have applied for and received permission from the ONC to keep spending remnants of their funds, according to the ONC. Two other RECs in the third round of grants have requests pending for similar spending extensions. But in no case will spending continue after five years from their original grant date, the ONC maintains.

Grants for the REC program totaled $688 million or a little more than one-third of the ONC's appropriation under the stimulus law.

DeSalvo, a professed fan of the RECs, has said she'd like to see their work continue.

The original plan called for the popular RECs to be financially self-sustaining after four years, but a program to extend federal financial support to them has not materialized.

In March, Mat Kendall, who headed the ONC's REC program since its inception in 2010, stepped down as director of the Office of Provider Adoption Support.

That office did not make the cut as DeSalvo's reorganization plan pared the ONC structure from 17 offices and suboffices to 10. Those duties now fall under the new Office of Programs.

According to a survey of executives of 37 RECs published in April and conducted by the Healthcare Information and Management Systems Society, leaders were optimistic they'd achieve sustainability, but only “a handful” indicated their organizations “have already been generating revenue streams to sustain operations going forward.”

Aside from the anomalous 2009 appropriations bubble, the ONC's budget over the rest of its history has been repeatedly flattened by Congress. In fact, for the agency's first year, fiscal 2005, its budget was zeroed out by legislators.

Since then, ONC budgets have been remarkably flat, averaging slightly less than $61 million a year, according to the ONC's latest report to Congress.

For fiscal 2015, HHS' budget request to Congress is $74.7 million, well below the average request over the years at $81.6 million, with the average cut to an ONC budget request running at 22.3%. For the current year, ONC asked for $77.9 million and—after a 22% whacking by Congress—was given $60.4 million.

The great bulk of the spending on health IT under the ARRA was actually controlled by the CMS, not the ONC, coming from the electronic health-record incentive payment programs under Medicare, Medicaid and Medicare Advantage...
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As Committee Pursues Policies to Foster Health Care Innovation, Leaders Question Agency Plan to Increase Health IT Regulation and Fees
June 3, 2014
Members Question Authority and Rationale for Expanded Regulatory Approach, Underscore Commitment to Safe and Innovative New Approaches for Technology in Health Care

WASHINGTON, DC – House Energy and Commerce Committee leaders today sent a letter to Karen DeSalvo, National Coordinator for Health Information Technology in the Department of Health and Human Services Office of the National Coordinator (ONC), questioning the ONC’s authority to expand its regulatory role in the Health IT space. The leaders are concerned that a report released in April 2014 “suggests that the Office of the National Coordinator for Health Information Technology would, among other things, create a Health IT Safety Center for the purposes of regulating software and other Health IT products. In addition, the ONC 2014 budget suggests it will impose a new user fee on Health IT vendors and developers to support ONC’s certification and standardization activities.”

The leaders write, “it is not clear to us under what statutory authority ONC is now pursuing these enhanced regulatory activities, including the levying of new user fees, on Health IT.”

The Office of the National Coordinator was legislatively established in 2009 as part of the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009. Late last week, ONC announced a leadership structure that, among other things, creates an Office of Standards and Technology. As the ONC is poised to reorganize itself, committee leaders want to better understand how the agency believes it can carry out a host of new functions amid concerns that it might be overstepping its statutory authority. Fostering and promoting better integration of technology, innovation, and health care has been a central tenet of the committee’s 21st Century Cures initiative. Members are concerned that another layer of bureaucracy could hamper such efforts.

The letter was signed by full committee Chairman Fred Upton (R-MI), Health Subcommittee Chairman Joe Pitts (R-PA), full committee Vice Chairman Marsha Blackburn (R-TN), and Communications and Technology Subcommittee Chairman Greg Walden (R-OR).

Read the complete letter online here. Also, from Government Health IT:

DeSalvo on Tuesday received a letter from the Energy and Commerce committee demanding answers. Specifically, they want DeSalvo to address these four questions:

1. When the authorization for the Medicare and Medicaid Incentive program expires, under what statutory authority does ONC believe it is able to regulate health IT and electronic health records, particularly in (but not limited to) non-Meaningful Use areas?
2. The FDA is provided with the authority to regulate medical devices by the Federal Food, Drug and Cosmetic Act. What similar authority does ONC point to, going forward, to participate in regulatory activities in coordination with the FDA and FCC?
3. To what extent does ONC’s notice of proposed rulemaking on 2015 EHR certification represents a broader shift in focus from coordination and promoting efforts related to interoperability, privacy and security, and quality reporting criteria, to the regulation of data collection, functionality requirements, and other areas where market forces are more likely to promote innovation and efficiency?
4. What role does ONC plan to play moving forward on issues including, but not limited to, health IT safety and EHR certification requirements? How will the recommendations of ONC’s Federal Advisory Committees guide these plans? Will ONC’s role be limited to the scope of these recommendations?

At the heart of those questions are ONC’s intentions to create a Health IT Safety Center to regulate software and other HIT products, the committee explained, and the fact that ONC’s “2014 budget suggests it will impose a new user fee on health IT vendors and developers to support ONC’s certification and standardization activities,” as well as whether or not ONC actually has the authority to carry out its intentions.

Recall my Q&A with Dr. DeSalvo at HIMSS14 back in February. Have to wonder whether ONC is now effectively finished. Probably too early to say. Upton's hearing is not likely to do much more than his prior ones have. I think it's a safe bet, though, that if the GOP retakes the Senate this fall, Congress will do nothing beyond Impeachment hearings and related stuff like "Benghazi" -- and now the new POW trade "Berghazi" dustup.


We shall see.
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WHEN YOUR MAC CRASHES

I have been mostly offline for blogging the past few days. Last Saturday my aged 2004 desktop iMac finally gave up the ghost. I'd bought a Canon Pixma Pro 100 oversize-print (13 x 19) color printer, and after I'd installed it, I think it was just too much for the old machine to handle. It went squirrely, and then finally refused to boot up clean (it had been randomly locking up and crashing multiple times a day of late).

So, I went to the Apple Store in Walnut Creek and forked over the AMEX card for the baddest new 27" iMac they make: 32 gigs of RAM, a 3 TB hard drive, 3.5 GHz quad CPU chipset, 8 gigs accelerated graphics RAM. Brought it home, took it out of the box, set it up on the desk in my office, plugged it in, hooked it up to my 2 TB Time Capsule, turned it on, and selected "migrate."

Took about 6 hours (I had about 600 megs of apps and data on the old iMac, including my more than 40,000 photos). Pretty flawless, though I did have to engage Adobe tech support to get my subscription Creative Suite 6 working properly, and had to re-download the ~120 books in my Kindle reader.

It went about as smoothly as I could have asked for.

A 2004 iMac. LOL. A friend wagged me on Facebook: "that's like putting 500,000 miles on a Honda." 

The effective useful life on the PC side is about 3 years.

I am now more of a "Mac Snob" than ever. When I was with the REC, it always cheesed me off that there were only one or two native Mac EHR platforms.
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More to come...