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The Healthcare14: U.S. Healthcare Trauma in 2008

I have screamed and shouted about customer service—to the point of physical and mental exhaustion and near collapse. I have screamed and shouted about our failure to embrace design as a rock-solid basis for differentiation. I have hissed and booed from on high and on low at the mis-direction of our education system in an age where creativity counts most. I have screamed and shouted and harangued and begged and cajoled and sworn like the sailor I once was on the topic of truly putting people first. I have screamed and shouted and been vicious and rude on the topic of women in leadership roles. I have insulted, with maximum verbal violence, every marketer I can find on the topic of inattention to the market power of women and boomers-geezers. I have pilloried every CEO I can lay voice on over the utter stupidity of 9 out of 9.1 major mergers. And I have begged and begged and begged some more on the topic of ... Stop talking, get on with it, whatever your "it" may be.

And now I'm engaged in another hysterical, and perhaps quixotic, campaign. This time the topic and target is American health"care." No doubt of it, I am the beneficiary of incredible care and have been aided by extraordinary medical devices and the skilled hands of exceptionally well-trained surgeons. (Just as I have gotten great service at the gazillion-dollars-a-night Four Seasons hotels in which I sometimes park my weary carcass.) Nonetheless, the American healthcare story is by and large a nightmare—and I don't just mean the un-insured. Below, after a dozen-years study, the last two of which have been rather intense, you will find my summary, shorthand List of American Healthcare Sins. Moreover, and most important, you will see that, in my opinion, most of these problems could be reversed without resort to either Mr McCain's or Mr Obama's Big Policy Initiatives. Using a simple, paper airline pilot-like checklist in ICUs can reduce infections and stays dramatically. Supplying simple compression socks to in-patients could avoid thousands upon thousands of deaths via deep-vein thrombosis. Clean hands—don't get me started. Scanners to certify accurate drug administration to in-patients—don't get me started.

As with customer-care and people practices, we have the wherewithal within to make Giant Performance Leaps. So when will we do so with the Total Determination the issue demands?

Tom Peters/The U.S. Healthcare14

U.S. Life expectancy rank: #45.
WHO, overall American healthcare system performance: #37 (#1 in cost).
Access: Denied to 10s of millions un/underinsured.
Unnecessary annual health-system deaths: 200,000-400,000 or more.*
Performance/top med centers: Problematic re quality of care and follow-up.*
Over-treatment (meds, tests, procedures): Pandemic.*
Use of hard evidence in medical decision-making: Spotty at best.*
Collection of evidence based on reported treatment errors: Low.*
Use of S.O.P.s in treatment regimes: Spotty.*
Incentives for appropriate care: Low.*
Incentives for inappropriate care: High.*
Emphasis on prevention and wellness: Low.*
Emphasis on chronic-care: Low.*
State-of-the-art IS/IT: Rare.*

*Fixable without legislation or major societal change—e.g., can by and large be improved dramatically without some form of mandated universal access to care and in the absence of, say, a full-fledged War on Obesity. (Evidence in support of this proposition is the fact that in every category starred above there are Pockets of Excellence—hospitals and other health-service organizations, facing the same realities as their peers, that really "get it.")

NB1: Many of these problems are equally applicable to other nations. But as is true with education issues, various nations use various approaches, so de facto generalization is dangerous.

NB2: This rant was triggered by a testy conversation with a client who inferred (in no uncertain terms) that I was being too hard on the healthcare folks. And to think, I thought I was letting them off too easily!

[Michael Millenson, author of Demanding Medical Excellence: Doctors and Accountability in the Information Age, which Tom has been quoting since its Y2000 publication, sent him this link to Millenson's 8-Day Health Care Diary (it mentions Tom, by the way).—CM]

Tom Peters posted this on 07/30/08.

Comments

How many billions are paid out for health insurance coverage that is never used -

Some becomes a "subsidy" by the well of those in need - private sector taxation and redistribution of wealth - but many of the subsidizers (who are fortunate enough to underutilize their coverage, or simply cannot afford even the deductable) purchase insurance because they feel they must as part of an employee group, and forego the cost of things such as good diet, recreation, child care, etc.

Some goes to bureaucracy; including "incentive bonuses" for what?

No dividends come back - even my auto insurance pays back dividends when they have good results.

Like in most of life, there is a four-dimensional paradox going on in healthcare, too:
- The opaqueness of the hidden;
- The transparancy of the obvious.
(To paraphrase NNTaleb)

Posted by Randy Bosch at July 30, 2008 1:31 PM

The sad thing is this: health care people know these are all problems, but many choose to ignore.

The adversarial relationship created by the realties of the TP 14 have forced stakeholders into "hunker down and fight for every inch" mode. It has created an "us vs. them" mentality.

I would be willing to bet the pockets of excellence have this in common: great communication and a commitment to collaboration. The patients truly are a common focus. Fix the disincentives and you could fix most of the problems in the TP 14. But it requires working together.

After working against each other for so long, we're experiencing the difficulty in getting back to the table.

Posted by Drew Weilage at July 30, 2008 1:46 PM

Tom, health care rants-o-plenty here, too. My son was born with a genetic illness and I know hospitals intimately -- way too intimately.

The hospital as physical plant is a dinosaur. Cooks, launderers, housekeepers, maintenance, gas, electric, water -- wasted on at least 50% of patients who could receive better care at home with fewer errors, less waste and cheaper bills.

Median salary for an RN with 20 years experience is just under $35/hour. Let's be generous and say $40/hour. One could have a nurse around the clock at home for $960 a day. Compare that to cost of spending a day in a hospital.

At-home lab work and x-rays are now available and the list is growing. Vital-signs monitoring via computer is now a reality. Lots of exciting other new technology on the horizon.

Meantime, I have two QUICK FIXES to simultaneously raise the level of health care and lower prices.

1. Pass a bill that bans health insurance.

2. Require all health care providers, including docs and hospitals, to list their prices.

Would much appreciate feedback from your readers.

best,

bonnie
USA

Posted by Bonnie Larner at July 30, 2008 5:31 PM

As a veteran ex-healthcare manager I just love your rants on healthcare Tom –thanks again – please keep rattling the cage. As you well know, here in the UK we have a universal healthcare system funded through taxation and it has its faults – now there’s an understatement! Nevertheless, and however hard it is to swallow, we have to look objectively at the advantages and disadvantages of such a system. I am not stupid and I know there is excellence in private healthcare but the question remains - can we afford such excellence for the entire population? It is not good enough to argue that the market can ‘regulate’ healthcare provision – private healthcare works for those who can afford it. The biggest question is about how we can effectively meet the healthcare needs of the ENTIRE population – not just those who can afford it. Despite my advocating for the UK National Health Service (with all its warts and wrinkles) I am not totally wedded for ever and a day to the concept of a universal healthcare system. Why I defend the NHS is because I am yet to read ANY authoritative report from ANY credible healthcare research organisation that proves a private healthcare system results in more effective healthcare care for the ENTIRE population – ‘entire’ being the significant word. And that inevitably becomes a political issue. A nation should surely be judged at least in part by how it treats the frailest members of its population. The greatest joy for me is that patient empowerment is at last seen as important on the agenda of our NHS and giving the power to patients and the front line clinicians has to be the right way forward. Randy and Bonnie raise the critical point about how we need to move money away from ‘management’ and into front line services. Too much money is still spent on ‘feeding the beast’ through unnecessary management processes and if we could just give more power to front liners that would be a huge step to improving efficiency in healthcare.

Posted by Trevor Gay at July 30, 2008 6:18 PM

Tom, I think you're annoying your clients because by presenting simple and free solutions (like the checklist), you're effectively cutting them out from multi-billion dollar opportunities. I mean, think about it. If you told bottled-water sellers that tap water works just fine, wouldn't they be annoyed?

Trevor, I completely agree with you on your point about the NHS. Although the NHS has idealistic dreams - healthcare for the ENTIRE population - it's fantastic that the UK had the guts and the drive to actually go for the dream.

I lived in the UK for over a decade and for all its flaws, I think the NHS still works. Giving up on the NHS would be, literally, giving up on life.

Posted by Chetan Dhruve at July 31, 2008 12:39 AM

The issue of digital medical records is one that gets my ire up too - I remember a couple years ago Sun Microsystems played up the use of "Java cards" in Brazil - everyone has a card that when scanned gives the doctor access to the whole medical history of the patient. Even in rural clinics doctors have access to the national medical records system, so misdiagnoses and errors are much more rare there than in the U.S. - and that's Brazil! Not exactly the most affluent nation in the world.

Further, the system is highly interoperable - something almost impossible to imagine in America, ironically.

Yikes! But I see hope as well - more and more of these systems are being created with modern architectures and standards (such as XML). This at least creates the possibility for future interoperability, even if the reality is not there yet.

Posted by Martin Koning-Bastiaan at July 31, 2008 12:59 AM

Looks like the place to start is the one that might make the hospitals/doctors more money:
"Incentives for appropriate care: Low.*"
How can appropriate care be made more profitable?

Posted by Mike L. at July 31, 2008 2:44 AM

Thanks Chetan - the NHS celebrated its 60th birthday this year a couple of weeks ago. Despite all its faults, the NHS remains a ‘sacred cow’ in the UK and whilst many people might advocate dismantling the NHS, no politician has been brave enough to seriously suggest that since 1948. It is simply a vote loser. ‘Free at the point of need’ is a fundamental principle of the NHS since it was introduced by a radical and reforming Labour Government in 1948. The founder of the NHS Aneurin Bevan famously said in 1948 that as far as our health is concerned ‘No longer will wealth be an advantage or poverty a disadvantage’ There is a lot of work to do to make the NHS work better but I remain unconvinced that a private system can in any way provide the same guarantees to the whole population that the NHS does.

I am with Martin about electronic patient’s notes and in the UK we will all have an electronic patient record in the next 5 years. This is stumbling to completion as a national project and it rightly has its critics but we will see a day soon when clinicians can access our notes electronically, wherever we are in the UK and that has to be a good thing. Thanks for information on Brazil Martin – maybe they have health as a higher political priority than either the UK or the US and that has to be a wonderful thing – there is surely nothing more precious than our health.

Posted by Trevor Gay at July 31, 2008 3:17 AM

Many American health systems are significantly underinvested in quality management Infrastructure, Process, and Organization. To achieve breakthrough improvements in quality, patient safety, and resource utilization hospitals and health systems must develop a "world class" quality management foundation that includes:

Strategy: including a clear linkage of quality and patient safety to the organizational strategy and a Board-driven imperative to achieve quality goals.

Infrastructure: incorporating effective quality management technology, EMR and physician order entry, evidence based care development tools and methodologies, and quality performance metrics and monitoring technology that enables "real time" information.

Process: including concurrent intervention, the ability to identify key quality performance "gaps," and performance improvement tools and methodologies to effectively eliminate quality issues.

Organization: providing sufficient number and quality of human resources to deliver quality planning and management leadership, adequate informatics management, effective evidence based care and physician order set development, performance improvement activity, and accredition planning to stay "survey ready every day."

Culture: where a passion for quality and patient safety is embedded throughout the delivery system and leaders are incented to achieve aggressive quality improvement goals.

My healthcare quality improvement consulting firm has assisted a number of progressive health systems to achieve such a foundation, and to develop truly World Class Quality.

Posted by Scott Hodson at July 31, 2008 9:34 AM

Not much new in your findings -
Most has been in the popular press
over the past year or so -
But I like the hospital org chart -

Posted by x at July 31, 2008 1:39 PM

"Not much new in your findings -
Most has been in the popular press
over the past year or so -
But I like the hospital org chart"

I stick with my usual retort: It's "new" until it's been implemented by, say, 25% of the target population--that is, until a critical mass is in train. [We are probably well short of critical mass on most if not all off the 14 indictable offenses listed in this post.]

What's the point of moving on to something "new new" when the original is not implemented--this is a mistake I've made 1000 times, "moving on" to be "cool" & "cutting edge" & to entertain myself before the heavy lifting on the basic ideas is even close to being locked in.

In general these days I'm moving "back" to "basics"--the truly important stuff that never ages, such as decency, listening, patient relationship development, managing by wandering around. And I'm loving every minute of it! [It is my abiding goal in life to become a true-obnoxious bore around a few things that really matter.]

[P.S., if this stuff is old hat and accepted wisdom and the evidence is incontrovertable, why did it piss off so many people in the audience?]

Posted by tom peters at July 31, 2008 7:48 PM

One reason it might have pissed people off is because they might agree with your findings, but have no idea how to do anything about them and still have a life.
Working in a place with an org chart like the one you suggested would give a sense of clarity -
- and obvious lines of responsibility and accountability -
with an org chart like that, there is no need for a 'mission statement' - the mission statment is the org chart.

Posted by x at July 31, 2008 8:50 PM

The fact that Patient-Centred Care (I mean, come on, what other sort of care is there?) is being articulated as the problem-solving methodology de nos jours would seem to indicate that for many (most?) healthworkers there now is a large or total disconnect between their daily role and any patient-health outcomes. It's system-based healthcare on the Henry Ford model, with workers doing a routine task, not creating a car/healthy patient.

How about a Director Of Making Sure That Patient Health Is A KPI/Target In Everybody's Job Description And Evaluation?

Posted by Rob at August 1, 2008 1:45 AM

Okay, meant to post that comment on Tom's "Org Chart" blog

Posted by Rob at August 1, 2008 1:47 AM

Great comment Rob – we are losing sight of the patient in the clamour for complex bureaucratic systems and processes that produce endless reports of what the problems are but add no value to patient care. Producing the reports is good stuff but the key is what are we doing about the problems identified? It’s an implementation thing again and that is about role model leadership and valuing our front line healthcare staff. In one of my crazier moments in my healthcare management career I suggested – not really tongue in cheek – a pay reward system for managers in healthcare based solely on how many patients’ problems they can prove they solved in the last month. Needless to say that idea fell on stony ground. You are so right – if we are not doing ‘patient centred care’ – what are we doing?

Ask the CEO of any healthcare organisation if they routinely build into their diary at least two hours every week when they just go and do some active listening to patient’s stories? How many do you think it would be? My guess 1% - and I am probably being generous. Therein lies part of the problem.

Posted by Trevor Gay at August 1, 2008 3:59 AM

Trevor, I remember chatting with a doctor who said that the problem with "healthcare" was that it was nothing to do with health and nobody really cared.

Posted by Rob at August 1, 2008 5:43 AM

Rob - I think I know that doctor too and sadly, I think he may be right in part.

There are hundreds of thousands of caring people at the front line in healthcare in the National Health Service. What I hear in my dealings with them is they are often frustrated with what they see as management processes and paperwork that take them away from their vocation which is the business of caring for patients. Although some of my best friends are accountants - and we cannot do with out accountants in any business - I do believe the rise in the number of accountants employed in measuring every last penny (cent) in healthcare has a direct relationship to the distance front liners now feel they are away form direct patient care. Or maybe I am just an old cynic. By the way this is not meant to be a ‘lets beat up accountants’ comment as I also know of many caring accountants. We need to get back to basics as you suggest and remember why we are here in healthcare – that is to look after patients.

I use the following slide in all my healthcare presentations – Mr Gandhi had it right don’t you think Rob? ….

Bombay Hospital Motto

A patient is the most important person in our hospital. He is not an interruption to our work. He is the purpose of it. He is not an outsider in our hospital; he is a part of it. We are not doing a favour by serving him; he is doing us a favour by giving us an opportunity to do so. - Mahatma Gandhi

Please note Mr Gandhi didn’t say …

‘A spreadsheet is the most important thing in our hospital etc. ’

Posted by Trevor Gay at August 1, 2008 8:43 AM

Trevor, I think Ghandi was right on many things, but I think even he might have struggled with large-scale national health services. I'm sure there are many caring people in the NHS; my point is that the system encourages septic focus and localised optima at the expense of more fundamental outcomes. In response to an earlier article by TP, I imagined his audience of healthcare finance managers all wondering where the problem was, because to them the numbers looked just fine. I had difficulty seeing them get to grips with anything that didn't contribute first and foremost to the financial health of their organisation - irrespective of outcomes for the patients. Multiply that by thousands of others in meta-health jobs and the stats Tom quotes become unsurprising.

Posted by Rob at August 1, 2008 11:04 AM

Senior moments abound today - that should be Gandhi...

Posted by Rob at August 1, 2008 11:06 AM

Rob - I think you could be right about Mr Gandhi and the challenge of the NHS. I can also relate very well to the ‘senior moments.’ I’ve worked all my life to be able to say I have ‘senior moments’ - great feeling isn’t it? :- )

Interesting that in the 1980’s Mrs Thatcher declared that managers in non health settings in the private sector were going to come into the NHS and sort it out once and for all ... the majority of these folks came ... took a look ... tried for a few months to change the route the elephant was walking … got covered in elephant dung and decided it was easier to make a living in the more comfortable parts of the jungle – so they went back to Tescos and Sainsbury’s to run their corner shops. I am with you totally about finance folks – what is that saying ‘knowing the cost of everything and the value of nothing.’ I believe you and I are saying the same thing i.e. that the patient must always be at the centre of our thinking in healthcare and not the system.

I’m away on holiday tomorrow for a week and I hope to have many senior moments during the next 7 days …. Maybe I might just catch up on one or two of the many books I’ve started! – Thanks for a great exchange Rob!

Posted by Trevor Gay at August 1, 2008 12:16 PM

Trevor, that quote from Mahatma Gandhi is a modified version of the original, which reads "customer" instead of patient, and "premises" instead of hospital. My guess is that a Bombay hospital customised the quote for themselves.

It might sound odd, coming from Gandhi, to talk about customers. But he's almost certainly talking about customers in the context of 'seva' (the Hindi word for service), in the sense that the purpose of business should be to serve.

Posted by Chetan Dhruve at August 1, 2008 1:23 PM

Thanks Chetan for that clarification. I was given a copy of that Bombay Hospital motto many years ago by a friend in the healthcare buinsess and I didn't realise it was a variation of a 'customer' statement from Mr Gandhi. Neverthless it makes an awful lot of sense to me in a hospital setting too. I appreciate your feedback - Mr Gandhi must have been an inspirational figure.

Posted by Trevor Gay at August 1, 2008 1:29 PM