Thursday, August 27, 2009

More about Primary Care in 1940

“Curmudge, what’s this more 1940 stuff? We talked about that last week. Didn’t you get it all out of your system?”

“Actually, Jaded Julie, I didn’t. I simply remembered more. My mind runs rather slowly in reverse.”

“Sure. About the same as your top forward speed. Okay, so what’s your story? Was everything better or worse back then?”

“Some of each, Julie. Remember my telling about our family doctor cutting out my ingrown toenail? Well, it got infected. It hurt like mad, and when Dr. Arnold took off the bandage, it looked ghastly. I was afraid we’d have to use gentian violet or whatever the purple stuff was that he used to treat my impetigo a couple years before. Instead, he sprinkled something called ‘sulfa powder’ on it, and it cleared right up. It was a miracle!”

“I bet it was. There were fewer antibacterial medications then; and because they were so new, the infection-causing bacteria had not yet developed resistance to them. It was good news in 1940, but now fighting many infections has become more difficult. So what else was going on then other than World War II in Europe and Jack Benny (who was that?) on the radio?”

“I recall Mrs. Arnold telling about traveling with her three children. They all became ill and needed medical attention. She told the physician that her husband was a doctor, and the physician felt obligated to treat the family without charge. It was called ‘professional courtesy,’ and then it was offered routinely. It is not as straightforward now because of legal (Stark anti-kickback laws) and insurance issues.”

“You are still making things sound pretty good in 1940, Curmudge. Other than the physicians’ limited armamentarium (see, Curmudge, I finally learned that word), there must have been some things that weren’t so great about primary care during your childhood.”

“When I was much younger, it was common for a person to become ill and die while under the care of just his primary care physician. Now in the U.S., except for extremely isolated locations, a seriously ill person is promptly referred to the appropriate specialist. The patient often studies his illness and becomes involved with more than a single caregiver in developing his plan of care.”

“I guess medical care was not always as transparent as it is now.”

“Right, Julie, and that could have been a problem in the past when medicine was often practiced in patient-one-doctor isolation. If your primary care physician had the knowledge and personality of a Marcus Welby, you experienced positive, personalized care. In the hypothetical case of a physician who was so confident of his abilities that he would not entertain discussion with anyone about alternate approaches or a second opinion, the patient would be at risk. That would certainly be the case when the physician made the statistically almost-inevitable error in diagnosis or treatment.”

“That sounds scary, Curmudge, especially when you consider that nobody is perfect.”

“The problem is compounded, Julie, when the patient as well as the physician carry the old-time image of the infallible doc. The patient says, ‘It’s okay if the doctor says so,’ and then abdicates all decisions to the physician.”

“So what do you do if the patient in this situation is your aged parent?”

“You intervene, if possible. But that’s a different story.”

“I have the feeling, Curmudge, that this is one of those very rare occasions when you know what you are talking about.”

“In this blog even the hypothetical cases are true. The only things fictional are you, Jaded Julie, and I, Kaizen Curmudgeon.”

Affinity’s Kaizen Curmudgeon

Thursday, August 20, 2009

Primary Care in 1940

“Okay, Curmudge, who cares about health care in 1940, and what does it have to do with Lean?”

“In 1940, Jaded Julie, I cared a lot. And the Toyota Production System had not yet been invented, so we won’t talk about Lean until later.”

“Proceed with your ancient history, Curmudge. I’ll just sit here in wide-eyed amazement.”

“I grew up in a small town with a population of about 2,500. We had one law enforcement officer, Marshal Bill Arnold, and one physician, Dr. Russell Arnold (no relation). Bill Arnold was the first responder for everything. When one had a minor illness or injury, they would call Bill; he would jump on his motorcycle and ride over to apply first aid. If the patient had to be transported to the hospital 10 miles away, he would summon the local undertaker with his hearse. Bill also responded to all fire calls. If the fire were serious, Bill would call Ted Kekic, who would get the town’s fire truck out of his barn.”

“It sounds as if your town lived life in the slow lane.”

“Regrettably that’s true Julie, even if your house was burning down. Dr. Arnold’s medical practice was also typical of the age. His office was in the basement of his home, his wife was his nurse and bookkeeper, and office hours were from 2:00 to 4:00 every afternoon. He did not have appointments; everyone had to sit and wait their turn. The wait was not usually very long, because he asked people requiring minor surgery, like me with an ingrown toenail, to arrive around 4:00. Dr. Arnold had only one exam room; and as a kid, I always wondered what the stirrups were for at the end of the examination table.”

“It seems that in those days primary care medicine wasn’t very complex, Curmudge. No receptionist, no laboratory, no radiology, no Medicare, no insurance, almost no referrals to specialists, and one nurse who was rarely needed.”

“That’s it, Julie. I never saw Dr. Arnold write anything, so he must have kept everyone’s records in his head. I guess he knew everybody in town, literally outside and inside. His bills would show only two items, numbers of house calls and numbers of office visits. Years later in 1978, my mother died suddenly. It was Dr. Arnold who called at 2:00 a.m. to tell me. He had arrived at my parents’ house only moments after the 911 EMTs. That was the ultimate in personalized care.”

“It sounds as if Dr. Arnold was exceptional…an early model for Marcus Welby, MD.”

“Well sort of, but back then most doctors were family physicians in a solo practice and on call 24/7. It took an exceptional person to live that way. In 1940 primary care was, by far, the major part of the health care delivery system. If your physician was clinically competent and had a good so-called ‘bedside manner,’ you had a favorable patient experience. That was especially true if you were lucky enough to get well. As I recall, personalized care was the norm.”

‘Speaking of personalized care, did Dr. Arnold meet all of the attributes of personalized care in our Affinity Brand Promise (1)?”

“Some of the attributes would have been different back then, especially for me, a six-year-old child. Dr. Arnold could not have known me better. Except for the surgeon who took out my tonsils, he was my only doctor from the moment I was born until I left home to go to college. In that era, partnering with one’s physician in decision-making was rare because he was the only one with access to health care knowledge. He always spent enough time with me to handle my problems, but frankly, as a kid I couldn’t wait to get out of the office. Thinking back, our doctor’s outstanding attributes were his willingness to make house calls and the depth of our personal friendship. He was always there when we needed him.”

“You seem to be suggesting, Curmudge, that despite the complexity of modern medicine, primary care physicians should try to duplicate the feeling of personalized care that you experienced in 1940.”

“Actually, Julie, I suspect that because of the complexity of modern medicine, what I experienced will rarely be achieved today by a primary care physician in a solo practice with his wife as both nurse and bookkeeper.”

“So, senescent sage, how can physicians today achieve this elusive personalized care?”

“I’ll conjure up a vision, Julie, and share it with you in a week or two.”

Affinity’s Kaizen Curmudgeon

(1) Kaizen Curmudgeon. The 5P Pyramid. Posted April 2, 2009.

Friday, August 14, 2009

Lean Success Stories--the Charge Capture Project

“Jaded Julie, I think it’s time for us to share some success stories.”

“If these ‘Curmudgeon Chronicles’ really do depict success, I can be certain that they won’t be autobiographical.”

“Don’t be disparaging, Julie. For some senior citizens, just getting out of bed in the morning is a success story. But we want to talk about how implementing the Lean culture and using Lean tools led to process improvements right here at Affinity. These stories will be told by the people who did the work and made things happen, or you and I will tell the story for them. We’ll start with Deb Voyles and her charge capture project.”

“Okay, Curmudge, just what is ‘charge capture,’ anyway? You know that I can’t understand the story unless I learn the language.”

“A person’s hospital bill is the summation of the charges for each treatment or service performed for the patient. This cannot be done correctly unless each service and its duration are recorded on the patient’s chart. These data are then transferred to a charge sheet, given a billing code, and sent to Patient Billing. If any step in this process is overlooked, the bill will be low; and the hospital will not receive its full payment from Medicare, the patient’s insurance, or the patient himself.”

“So what was the problem?”

“The nurses considered the charge capture process to be extra work. Their job was to care for the patients, not collect money. When Deb met with the nurses to plead for their cooperation, they—to use a common phrase—just blew her off.”

“Very frustrating! But we wouldn’t be talking about this if it hadn’t somehow become a success. What—and who—turned the process around?”

“The economy went south, Affinity instituted a margin improvement hoshin, and the hospital president provided the support necessary to put the charge capture project in high gear. Deb Voyles was appointed project leader with Stan Shelver co-leader to aid in communication and provide a director’s ‘inspiration.’ Carol Jansen was Lean facilitator. A ‘charge specialist,’ the unit clerk in each patient care unit, was designated; a new FTE was created in each emergency department to fill that roll.”

“Okay, Curmudge, we’ve got the team. Now what?”

“The first step was to change the prevailing mindset about charge capture. Deb did that by looking at charts from the previous month, computing the ‘forgotten charges,’ and posting the results on each patient care unit in the nurses’ break room.”

“That sounds like visual management. Good move!”

“She followed that up by meeting with the staff of each patient care unit to explain the financial impact of the forgotten charges and to demonstrate the effectiveness of utilizing the Universal Chargesheet. Stan joined Deb at the meetings and ‘encouraged’ the staff to begin using the new chargesheet.”

“Curmudge, as an old chemist like you would say, ‘Management provided an essential catalyst.’”

“Twice weekly, Deb would meet with charge specialist staff, training them on effective charge capture, and addressing charge issues. She made herself available to them 24/7 (via phone and email) to answer charge capture questions. The specialists would track the additional charges they found using the new charge capture process. They posted these results every week in the break room. At the end of the first month, Deb was able to pull the financial data from the monthly finance reports. She created a chart that compared the revenue per patient from the previous month to the current month. These charts illustrated the success of the new charge capture process and were posted on every patient care unit every month. The staff responded with enthusiasm, and the charge capture project gained momentum. Deb’s weekly meetings with the charge specialists became less focused on training and more focused on reviewing new procedures to develop charges. She saw a new culture emerging at the hospitals. It was exciting!”

“There is, of course, more to the story.”

“Deb continued tracking their success on a larger scale in which last year’s charges (with money left on the table) were compared with this year’s (with all charges properly captured). The three-month trial yielded a 40% increase in revenue capture per patient.”

“That undoubtedly attracted people’s attention.”

“It’s like our Flywheel posting on 3/26/08, Julie. One person with enthusiasm and determination was needed to get the project moving and to attract others to the effort. That was Deb Voyles.”

“Curmudge, despite this project’s resounding success, it didn’t seem to require many of the classical Lean tools.”

“You’re correct, Julie. The project was well defined without needing value stream mapping. It had abundant top-level support, extraordinary leadership, a team with accelerating enthusiasm, and a result that should be enduring. One essential Lean tool was visual management. Perhaps we should summarize by saying, ‘All’s well that ends well.’”

“You’ve got that right, Mr. Shakespeare.”

Affinity’s Kaizen Curmudgeon

Thursday, August 6, 2009

Information at Your Fingertips

“Despite what you read, Jaded Julie, health care is a lot better than it used to be.”

“So, Curmudge, is that your professional opinion?”

“Nope, it’s my conjecture. That’s a better word for a fictional person. Consider this example: When I was a kid 70 years ago, the doc-with-the-black-bag couldn’t drag around a medical library when he made a house call. When he encountered a patient with unfamiliar symptoms—me—he could only rely on his experience, or as we say now, he had to ‘wing it.’”

“Since you are still with us, I congratulate your parents on their choice of family physician.”

“Fast forward to the present. Everyone knows about the power of CT’s and MRI’s for diagnosis, but I was curious about what is available in the readily accessible literature.”

“By ‘readily accessible,’ Curmudge, you mean just a couple of mouse clicks away.”

“Exactly, and I found a ton of stuff for physicians, midlevel (advanced practice) providers, nurses, pharmacists, and people writing about health care. Some of these are available only by purchase, such as the Isabel Diagnosis Reminder System (1) and several from Wolters Kluwer Health [5-Minute Consult Database, Drug Facts and Comparisons®, Evidence Based Guidelines, Lippincott’s Nursing Procedures and Skills, and several others] (2). The Institute for Clinical Systems Improvement has order sets and algorithms for diagnosis and treatments available on their website (3). Closer to home, we have Affinity policies and preprinted or standing orders for hundreds of diagnoses, evidence based treatments, and procedures. To obtain this treasure trove, I just talked with a few people and rummaged around in Google. Just imagine how much more could be obtained with a literature search done by the St. E’s or Mercy library.”

“Now I know why you were huddled with your computer for the past two weeks. So what good is all this?”

“The physician with his handy computer or personal digital assistant will no longer have to ‘wing it.’ If necessary, he can check a diagnosis or medication during the patient encounter or perhaps after the fact to confirm his decisions and monitor the quality of care he provides (4). Nurses and managers can use the evidence based procedures in these resources as the basis for standard work in any of the patient care areas of the hospital.”

“I understand, Curmudge, that we are already using the preprinted orders in our hospitals. Their check-the-boxes feature serves to remind the physicians of the latest evidence based therapies. When a physician overrides a pre-checked box, it must be justified. These forms also minimize variations in provider prescribing practices and critical aspects of patient care.”

“That’s it, Julie. I hope you now agree with me that health care has improved over the years.”

“Curmudge, you were fortunate to have survived old-time medicine, but I suspect that was not always the case.”

“Here’s another personal example: The same doctor who used his vast experience to cure me of gosh-knows-what in the 1940’s also brought my mother into the world in 1899. He was at the bedside of her mother who died of gosh-knows-what in 1902. So my mother, at the age of three, lost her mother and I lost a grandmother that I never knew.”

Affinity’s Kaizen Curmudgeon

(1)
http://www.isabel.org.uk/pdf/Product_Release.pdf
(2) http://www.clineguide.com/Common/PDF/ClineguideMobileReleaseFinal.pdf
(3)
http://www.icsi.org
(4) http://www.ama-assn.org/amednews/2009/06/29/prsn0629.htm