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This presentation explores the overuse of medicine in healthcare, its impact on costs, and the quality of care provided to patients. It delves into the need for evidence-based protocols and the importance of effective leadership in improving outcomes and reducing overuse.
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Tom Peters’ Excellence. Always. The choice is yours. Health Forum and the American Hospital Association Leadership Summit/San Francisco/23 July 2009
NOTE:To appreciate this presentation [and ensure that it is not a mess], you need Microsoft fonts:“Showcard Gothic,”“Ravie,”“Chiller”and“Verdana”
___________ costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care. … Compared with patients in ________ and nationwide, patients in _______ got more of pretty much everything —more diagnostic testing, more hospital treatment, more surgery, more home care. The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in _______ than in ______, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in _______ received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography,two hundred per cent morenerve-conduction studies to diagnose carpal-tunnel syndrome, andfive hundred and fifty percent moreurine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also receivedtwo to three times as manypacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid forfive times as manyhome-nurse visits.The primary cause of ______’s extreme costs was, very simply, theacross-the-board overuse of medicine.— “Cost Conundrum: What a Texas town can teach us about health care,” by Atul Gawande, The New Yorker, June 1, 2009
“The results are deadly. In addition to the 98,000 killed by medical errors in hospitals and the 90,000 deaths caused by hospital infections, another 126,000 die from their doctor’s failure to observe evidence-based protocols for justfour common conditions: hypertension, heart attack, pneumonia, and colorectal cancer.” Source:Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Principal Management & Leadership (as opposed to Policy) Issues: • 1. Should we be doing what we’re doing? Will it work? How do we know? • Are we doing what we decide to do safely? • 3. Do we do too much—are we in the “overuse” category as determined by agreed upon standards-measures? • 4. Are we doing what we’re doing effectively? By local standards? By global standards (as determined by “best practices,” best hard evidence, and minimal internal variation) in terms of outcome, quality, safety and cost? Do we aim, for example, to be “top quartile” in terms of measurable outcomes, quality, safety and “bottom quartile” in terms of cost? • Is the institution systematically organized to very consistently deliver the goods in a more or less optimal fashion (low variation in outcome)? • Do all the bits talk to-engage-consult “obsessively” with the other bits? Is the delivery of services truly a turnkey team effort? • 7. Are the patient and the patient’s family at the epicenter of the universe? • 8. Is our institution acknowledged as a “best place to work”?
Principal Management & Leadership (as opposed to Policy) Issues: 9. Do we acknowledge that people issues-capabilities-will involving the entire staff effect outcomes far more than capital-technology issues? 10. Is sustained follow-up at least as much a priority as the “event” itself? 11. Were we/Are we successful in terms of outcome-quality of life-patient satisfaction with the overall “experience”? 12. Are all connected with all via an effective electronic network that extends from EMR to Social Networking? 13. Do we acknowledge that most of the choices involved in executing items #1 through #12 are mostly within our discretion regardless of the nature of Obamacare? (And that Obamacare or its successor will almost surely eliminate piecework compensation—which drives the immediacy of much of the above.) 14. Do we acknowledge that throughout the system there are, today, enormous variations in outcomeconcerning every one of the above issues—which can mostly (almost entirely?) be explained in terms of institutional leadership effectiveness (vision, will, systems)?
“If I could have chosen not to tackle the IBM culture head-on, I probably wouldn’t have. My bias coming in was toward strategy, analysis and measurement. In comparison, changing the attitude and behaviors of hundreds of thousands of people is very, very hard.[Yet] I came to see in my time at IBM that culture isn’t just one aspect of the game —it is the game.”—Lou Gerstner, Who Says Elephants Can’t Dance
“Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease.The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question. “I’ll be there,” the cardiologist said. Fifteen minutes later, he was. They mulled over everything together.The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day. The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.” “The Cost Conundrum: What a Texas town can teach us about health care,” by Atul Gawande, The New Yorker, June 1, 2009
“The needs of the patient come first” —not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked “When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me. “The Cost Conundrum: What a Texas town can teach us about health care,” by Atul Gawande, The New Yorker, June 1, 2009
Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care. “The Cost Conundrum: What a Texas town can teach us about health care,” by Atul Gawande, The New Yorker, June 1, 2009
“Experiment fearlessly”Source: BW0821.06, Type A Organization Strategies/ “How to Hit a Moving Target”—Tactic #1
“We made mistakes, of course. Most of them were omissions we didn’t think of when we initially wrote the software. We fixed them by doing it over and over, again and again. We do the same today. While our competitors are still sucking their thumbs trying to make the design perfect, we’re already on prototype version#5.By the time our rivals are ready with wires and screws, we are on version #10.It gets back to planning versus acting: We act from day one; others plan how toplan—for months.”—Bloomberg by Bloomberg
Culture of Prototyping“Effective prototyping may be themost valuablecore competence an innovative organization can hope to have.”—Michael Schrage
“You can’t be a serious innovator unless and until you are ready, willing and able to seriously play. ‘Serious play’ is not an oxymoron; it is the essence of innovation.” —Michael Schrage,Serious Play
Think about It!?Innovation = Reaction to the PrototypeSource: Michael Schrage
“Rewardexcellent failures. Punishmediocre successes.”Phil Daniels, Sydney exec
“We ground up more pig brains”: 100% “Mad Scientists!”
TP’s “1/40”/“We ground up more pig brains” “Experiment fearlessly” It’s all about attitude! One Big Innovation Lab! “Let 1,000 flowers bloom” (Chief Gardener?) Micro-experiment budget Hyper-quick approval process Hyper-quick prototyping (Measure “mean time to prototype”) Mini-project teams born in a flash Do everything at once No “bad ideas” except inaction Transparency/Publish everything
TP’s “1/40”/“We ground up more pig brains” “Get it right the 79th time” Reward clever/excellent failures Celebrate constantly/ Wee rewards/Recognition/ “Mad scientist club” Master “nudgery” Encourage/Reward cross-functional excellence(A special category!) Take the lid off the “best practices” travel budget/“Visit Excellence” Steal excellence everywhere! LEARN from best practices/ Allow 100% variation
TP’s “1/40”/“We ground up more pig brains” Coalition of Fearless Experimenters Ask for help in Wikiworld Social networking with peers (Board game?) “What do you think?” Listen!!!! 100% participation 100% leaders Patient participation Process ideas from all Map everything Measure but don’t stifle! Training in process improvement for 100% Training in prototyping/100%
TP’s “1/40”/“We ground up more pig brains” Training in “What do you thinkery”/100% Training in listening/100% Training in micro-team leadership/100% 100% participation in mapping every-damn-thing Check lists until you’re blue in the face “Simple stuff” Power!! Special “simple stuff” recognition “People stuff”>“Tech stuff” Pillar of “The Way we do things around here” MBWA/“You must be the change you wish to see in the world”
“Business people don’t need to ‘understand designers better.’ Businesspeople need to be designers.”—Roger Martin/Dean/Rotman Management School, University of Toronto
Little = BIG
Big carts = 1.5X Source: Wal*Mart
Geologists + Geophysicists + A little bit of love =Oil
The “XF-50”: 50 Ways to Enhance Cross-Functional Effectiveness and Deliver Speed, “Service Excellence” and “Value-added Customer ‘Solutions’”**Entire “XF-50” List is an Appendix to the LONG version of this presentation, posted at tompeters.com
6.5 feet Away =-63% “Seconds”**Plate size, etc, first serving dish
“Everything matters” -80% Source:Nudge, Richard Thaler and Cass Sunstein, etching of fly in the urinal reduces “spillage” by 80%, Schiphol Airport
“Broken windows”: Clean the streets, fix the broken windows, ticket the open-beer-can holders, etc, etc =Sense of order = Crime way down
90K in U.S.A. ICUs on any given day; 178 steps/day in ICU.50% stays result in “serious complication”Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)
**Peter Pronovost, Johns Hopkins, 2001**Checklist, line infections**1/3rd at least one error when he started**Nurses/permission to stop procedure if doc, other not following checklist**In 1 year, 10-day line-infection rate:11% to … 0%Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)
**Docs, nurses make own checklists on whatever process-procedure they choose**Within weeks, average stay inICU down 50%Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)
The Commerce Bank Model“every computer at commerce bank has a specialredkey on it that says, ‘found something stupid that we are doing that interferes with our ability to service the customer? Tell us about it, and if we agree, we will give you $50.’”Source: Fans! Not customers. How Commerce Bank Created a Super-growth Business in a No-growth Industry, Vernon Hill & Bob Andelman
Beauty! Grace! Clarity! Simplicity!
Excellence1982: The Bedrock “Eight Basics” 1. A Bias for Action 2. Close to the Customer 3. Autonomy and Entrepreneurship 4. Productivity Through People 5. Hands On, Value-Driven 6. Stick to the Knitting 7. Simple Form, Lean Staff 8. Simultaneous Loose-Tight Properties”
