“Curmudge, two years ago our holiday greeting was about being politically correct; last year we shared our concerns about homeless people and those who couldn’t get home for the holidays. What will we talk about this year?”
“It beats me, Jaded Julie. I surely don’t envy those members of the clergy who have to think up a new holiday sermon or homily each year.”
“It sounds as if the priesthood wouldn’t have been a good vocation for you, Curmudge.”
“That’s for sure, and my wife and children will certainly agree…I’ve got an idea, Julie. Instead of talking about the end-of-year holidays, let’s focus on New Years and try to make some predictions for next year.”
“Give it a try, Ancient Oracle. I believe the outcomes of your tacit forecasts for 2009 exceeded some of your gloomiest expectations.”
“Let’s start with Affinity. Renovation of St. Elizabeth Hospital, guided by Lean and LEED principles, will be under way. You and I will remain proud to be affiliated with the ‘Lean Team.’”
“One’s micro-, or personal, happiness impacts everyone around them (1). What do you see as your personal happiness in 2010, Curmudge?”
“Barring health and family adversities and as long as I can continue to come in here every day and chat with you, Julie, my micro-happiness index should stay pretty high. And I will keep trying to spread it around St. E’s. This is the friendliest place I ever worked (if that’s what one calls what I do).”
“My guess is that you don’t feel as positive about our nation and the world around us. That would be macro-happiness or macro-unhappiness, right?”
“Right, Julie. Our nation’s macro-unhappiness seems to be high and rising. We are sharply divided on many issues, and we seem to be perpetually at war.”
“To refresh your memory on perpetual war, you went back to George Orwell’s classic book, 1984 (2).”
“It was required reading when I was a college freshman in 1952. Then, I considered it to be ‘only a book.’ Now I worry that Orwell might have been, in some ways, prescient. As his novel seems to suggest, we and our way of life may be the objectives of subjugation both from within and without.”
“Hey, Curmudge! That last part of your prognostication (did I say that?) was really depressing. Well, at least it’s something that we can revisit this time next year. So what is your one-word seasonal greeting for our readers?”
“’Hope,’ Jaded Julie.”
“’Peace,’ Curmudge.”
Affinity’s Kaizen Curmudgeon
(1) Prager, D. Happiness is a Moral Obligation. (March 2007) http://www.studentnewsdaily.com/commentary/printer-friendly/article/happiness_is_a_moral_obligation/
(2) http://en.wikipedia.org/wiki/Nineteen_Eighty-Four
Thursday, December 17, 2009
Thursday, December 10, 2009
"I'm from Corporate, and I'm here to help you."
“That has a menacing tone, Curmudge. Is it intended to be that way?”
“It’s a variation on the dreaded greeting from an inspector from the Environmental Protection Agency, Jaded Julie. ‘I’m from the EPA, and I’m here to help you.’ In a pulp and paper mill, an EPA inspection would wreck your day, or more likely, your week.”
“So did you ever use the greeting, ‘I’m from Corporate, etc.’?”
“Not those exact words, Julie, but one of my jobs long ago was to visit the laboratories of my employer’s pulp mills, ascertain that they were using EPA-approved test methods, and help them correct deficiencies before the EPA or state inspectors arrived.”
“That sounds pretty valuable. Did the mill people welcome you with open arms?”
“Not always. I spent the first half-day convincing the lab technicians that I was not an officious blowhard; thereafter things in the lab went smoothly. The real problem was that the mill’s environmental manager resented my looking for—and finding—problems that he or she should have already corrected. I guess it was human nature…really quite natural. I suspect that they trashed my report as soon as I left the mill. If I found too many problems, they didn’t invite me back.”
“Enough about the good old days, Curmudge. It’s time for you to share with me what all of this has to do with Lean.”
“It’s really quite simple, Julie. Put yourself in the shoes of a middle manager who has just learned that her department will be the subject of a kaizen event. What is her natural reaction?”
“’Why my department? I’ve done the best that I can for the past ten years. We’ve always done things that way.’ Her natural response would be to resent the whole idea—just like your environmental manager in the pulp mill.”
“That’s the connection with Lean, Julie. If the middle manager has hardwired her Lean training, she will acknowledge that continuous improvement is now our way of life, and it is often initiated with a kaizen event. If the event is part of a hoshin, she will understand the event’s importance and recognize the need to suppress her initial resentment. Process improvements following the event ought to put the damper on her earlier anguish.”
“Now I understand. It’s like the small child’s learning not to take the biggest piece of cake. This is all about doing what is right rather than what is natural. Our posting back on May 8, 2008 was on this topic. Why the reprise?”
“There are two reasons. The first is that character, i.e., doing what is right, is an essential part of leadership, and we are going to teach it until everyone has it hardwired. The second is that the connection between my mill lab audits and Lean just occurred to me.”
“You’ve made it clear, Curmudge, that your earlier life—even back to your childhood—is an open book. At your age, I guess you turn the pages very slowly.”
Affinity’s Kaizen Curmudgeon
“It’s a variation on the dreaded greeting from an inspector from the Environmental Protection Agency, Jaded Julie. ‘I’m from the EPA, and I’m here to help you.’ In a pulp and paper mill, an EPA inspection would wreck your day, or more likely, your week.”
“So did you ever use the greeting, ‘I’m from Corporate, etc.’?”
“Not those exact words, Julie, but one of my jobs long ago was to visit the laboratories of my employer’s pulp mills, ascertain that they were using EPA-approved test methods, and help them correct deficiencies before the EPA or state inspectors arrived.”
“That sounds pretty valuable. Did the mill people welcome you with open arms?”
“Not always. I spent the first half-day convincing the lab technicians that I was not an officious blowhard; thereafter things in the lab went smoothly. The real problem was that the mill’s environmental manager resented my looking for—and finding—problems that he or she should have already corrected. I guess it was human nature…really quite natural. I suspect that they trashed my report as soon as I left the mill. If I found too many problems, they didn’t invite me back.”
“Enough about the good old days, Curmudge. It’s time for you to share with me what all of this has to do with Lean.”
“It’s really quite simple, Julie. Put yourself in the shoes of a middle manager who has just learned that her department will be the subject of a kaizen event. What is her natural reaction?”
“’Why my department? I’ve done the best that I can for the past ten years. We’ve always done things that way.’ Her natural response would be to resent the whole idea—just like your environmental manager in the pulp mill.”
“That’s the connection with Lean, Julie. If the middle manager has hardwired her Lean training, she will acknowledge that continuous improvement is now our way of life, and it is often initiated with a kaizen event. If the event is part of a hoshin, she will understand the event’s importance and recognize the need to suppress her initial resentment. Process improvements following the event ought to put the damper on her earlier anguish.”
“Now I understand. It’s like the small child’s learning not to take the biggest piece of cake. This is all about doing what is right rather than what is natural. Our posting back on May 8, 2008 was on this topic. Why the reprise?”
“There are two reasons. The first is that character, i.e., doing what is right, is an essential part of leadership, and we are going to teach it until everyone has it hardwired. The second is that the connection between my mill lab audits and Lean just occurred to me.”
“You’ve made it clear, Curmudge, that your earlier life—even back to your childhood—is an open book. At your age, I guess you turn the pages very slowly.”
Affinity’s Kaizen Curmudgeon
Friday, December 4, 2009
It Takes More Than a Team
“It takes more than a team to do what, Curmudge?”
“To establish a medical home, Jaded Julie. It also requires an angel.”
“Angels? Aren’t those dead people with wings?”
“No, Julie. In this case angels are live people—or organizations—with money. It’s a term used in the theater to describe people who finance a new production.”
“I must admit, Curmudge, that I was puzzled at the idea of a solo-practice doc, who has to see more and more patients to keep his head above water, hiring lots more people, proclaiming his shop to be a medical home, and suddenly becoming financially viable. There must be a ton of transitional expenses; I guess they are paid by the ‘angel.’ So why should an organization support a practice’s transition to a medical home?”
“An insurance company might be a good example. They would anticipate that the medical home would take better care of their members (policy holders) so they would have fewer specialists, duplicate tests, and ED visits to pay for. Their support could be in the form of capitation, i.e., dollars per member per month. Another example would be a large health care organization that envisions the medical home to be the wave of the future in primary care.”
“Let’s assume that the medical home has recruited their team, purchased their information technology, and trained everyone as we have discussed in recent weeks. What must they do to put the operation in the black?”
“My one-word answer, Julie, is ‘efficiency.’”
“Wow! That’s the first time ever that your one-word answer was not ‘Lean.’ Of course we already know that the team members gain much of their efficiency by using Lean principles and tools. Can we look at some of the ways that the medical home improves their efficiency?”
“Let’s start with an intuitive, uncomplicated look at physician compensation (of course, there isn’t such a thing). Mid-level providers will handle routine patient care; this will enable the physician to provide higher-intensity services, as measured by relative value units (RVUs). Electronic technology will reduce the physician’s non-value-added time with each patient; he/she will not have to shuffle through chart pages, can use the decision-support tool to confirm his diagnosis and treatment plan, and can generate notes for the encounter in real time. These attributes of the medical home should permit the physician to see more patients and perform more services per day. This will enable him to increase his compensation, or alternatively, maintain his compensation while working fewer hours.”
“I assume, Curmudge, that someone has investigated the financial side of the medical home more rigorously.”
“It was studied by Spann and a long list of coworkers in 2004 (1). We won’t discuss the assumptions used in their model; the list would stretch from here to Darboy. Here are some of the features of a medical home (they called it the ‘New Model’) that they studied and the outcomes predicted by their model (not all are intuitive):
Open-access scheduling (some same-day appointments)—Fewer visits per patient, but higher RVUs for services provided.
Electronic health records—Overall increase in efficiency (after training) including more accurate billing.
Online e-visits—Presently no reimbursement. If implemented, it would be at a lower level than an office visit.
Team approach (leveraging clinical staff)—The physician can serve a larger panel of patients by using clinical staff to perform routine tasks.
Clinical practice guidelines software—Allows physicians to rely more effectively on a team approach to medicine.”
“I trust you read the more recent paper by Rosenthal (2).”
“I did. He said that reimbursement policies will require reformulation in order to institutionalize the medical home, and he reported on reimbursement models recommended by several physicians’ associations. They included:
· A fee for service, including e-visits.
· A per-member per-month management fee.
· A quality incentive that recognizes achievement of standards of care.”
“Curmudge, from the financial standpoint it appears that the team approach to medicine and the use of electronic technology are going to be the big winners for the clinic. Of course, one of your ‘angels’ will be needed to help them get through the expenses of transition. You must be pleased at the essential role played by teamwork and empowerment.”
“I certainly am, Julie. The medical home should be a viable way to practice primary care if it is implemented efficiently by committed leadership and involved staff.”
“Involved? Committed? I thought those two words meant almost the same thing.”
“Not when you consider eggs and bacon, Julie. The hen was involved, but the pig was committed (3).”
Affinity’s Kaizen Curmudgeon
(1) Spann, S.J. et al. Report on Financing the New Model of Family Medicine.
http://www.annfammed.org/cgi/content/full/2/suppl_3/s1
(2) Rosenthal, T.C. The Medical Home: Growing Evidence to Support a New Approach to Primary Care. (Sept. 2008) http://www.jabfm.org/cgi/reprint/21/5/427
(3) Hunter, J.C. The Servant, p. 120 (Crown Business, 1998)
“To establish a medical home, Jaded Julie. It also requires an angel.”
“Angels? Aren’t those dead people with wings?”
“No, Julie. In this case angels are live people—or organizations—with money. It’s a term used in the theater to describe people who finance a new production.”
“I must admit, Curmudge, that I was puzzled at the idea of a solo-practice doc, who has to see more and more patients to keep his head above water, hiring lots more people, proclaiming his shop to be a medical home, and suddenly becoming financially viable. There must be a ton of transitional expenses; I guess they are paid by the ‘angel.’ So why should an organization support a practice’s transition to a medical home?”
“An insurance company might be a good example. They would anticipate that the medical home would take better care of their members (policy holders) so they would have fewer specialists, duplicate tests, and ED visits to pay for. Their support could be in the form of capitation, i.e., dollars per member per month. Another example would be a large health care organization that envisions the medical home to be the wave of the future in primary care.”
“Let’s assume that the medical home has recruited their team, purchased their information technology, and trained everyone as we have discussed in recent weeks. What must they do to put the operation in the black?”
“My one-word answer, Julie, is ‘efficiency.’”
“Wow! That’s the first time ever that your one-word answer was not ‘Lean.’ Of course we already know that the team members gain much of their efficiency by using Lean principles and tools. Can we look at some of the ways that the medical home improves their efficiency?”
“Let’s start with an intuitive, uncomplicated look at physician compensation (of course, there isn’t such a thing). Mid-level providers will handle routine patient care; this will enable the physician to provide higher-intensity services, as measured by relative value units (RVUs). Electronic technology will reduce the physician’s non-value-added time with each patient; he/she will not have to shuffle through chart pages, can use the decision-support tool to confirm his diagnosis and treatment plan, and can generate notes for the encounter in real time. These attributes of the medical home should permit the physician to see more patients and perform more services per day. This will enable him to increase his compensation, or alternatively, maintain his compensation while working fewer hours.”
“I assume, Curmudge, that someone has investigated the financial side of the medical home more rigorously.”
“It was studied by Spann and a long list of coworkers in 2004 (1). We won’t discuss the assumptions used in their model; the list would stretch from here to Darboy. Here are some of the features of a medical home (they called it the ‘New Model’) that they studied and the outcomes predicted by their model (not all are intuitive):
Open-access scheduling (some same-day appointments)—Fewer visits per patient, but higher RVUs for services provided.
Electronic health records—Overall increase in efficiency (after training) including more accurate billing.
Online e-visits—Presently no reimbursement. If implemented, it would be at a lower level than an office visit.
Team approach (leveraging clinical staff)—The physician can serve a larger panel of patients by using clinical staff to perform routine tasks.
Clinical practice guidelines software—Allows physicians to rely more effectively on a team approach to medicine.”
“I trust you read the more recent paper by Rosenthal (2).”
“I did. He said that reimbursement policies will require reformulation in order to institutionalize the medical home, and he reported on reimbursement models recommended by several physicians’ associations. They included:
· A fee for service, including e-visits.
· A per-member per-month management fee.
· A quality incentive that recognizes achievement of standards of care.”
“Curmudge, from the financial standpoint it appears that the team approach to medicine and the use of electronic technology are going to be the big winners for the clinic. Of course, one of your ‘angels’ will be needed to help them get through the expenses of transition. You must be pleased at the essential role played by teamwork and empowerment.”
“I certainly am, Julie. The medical home should be a viable way to practice primary care if it is implemented efficiently by committed leadership and involved staff.”
“Involved? Committed? I thought those two words meant almost the same thing.”
“Not when you consider eggs and bacon, Julie. The hen was involved, but the pig was committed (3).”
Affinity’s Kaizen Curmudgeon
(1) Spann, S.J. et al. Report on Financing the New Model of Family Medicine.
http://www.annfammed.org/cgi/content/full/2/suppl_3/s1
(2) Rosenthal, T.C. The Medical Home: Growing Evidence to Support a New Approach to Primary Care. (Sept. 2008) http://www.jabfm.org/cgi/reprint/21/5/427
(3) Hunter, J.C. The Servant, p. 120 (Crown Business, 1998)
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