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THE ART & SCIENCE of SERVICE:
INNOVATION…
IS THAT ALL THERE IS?
STEPHEN A. KATZ, MD, CPE
CMO, Vassar Brothers Medical Center
The Art & Science of Service: Innovation
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June 17 – 19, 2009
MEDICINE: AN ANCIENT PROFESSION
SHAMAN
MEDICINE MAN
NATURAL HEALER
PHYSICIAN PHILOSOPHER
BARBER SURGEON
MODERN PHYSICIAN—SINCE 1800’s
LOW TECH—HOUSE CALLS (LITTLE BLACK BAG CARRIED
MOST AVAILABLE TECHNOLOGY)
X-RAY IN ITS INFANCY
The Art & Science of Service: Innovation
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June 17 – 19, 2009
THE PATIENT—PHYSICIAN RELATIONSHIP
HISTORICALLY, THERE HAS BEEN AN INTIMATE, ONE-ON-ONE
RELATIONSHIP BETWEEN THE PHYSICIAN AND THE PATIENT.
THERE HAS BEEN AN EXPECTATION THAT PHYSICIANS WILL
FIND AND TREAT MALADIES AND KEEP THEIR PATIENTS
COMFORTED AND WELL. PATIENTS HAVE PLACED THEIR
TRUST IN THEIR PHYSICIANS AND HAVE EXPECTED THEIR
CARE TO BE INDIVIDUALIZED AND SPECIFIC TO THEIR
NEEDS.
AS SUCH, MEDICINE IS ONE OF THE OLDEST “SERVICE
INDUSTRIES.” BUT, SINCE THE 1950’s, THE DELIVERY OF
THIS SERVICE HAS UNDERGONE DRAMATIC CHANGE DUE TO
RAPID TECHNOLOGICAL ADVANCES AND ECONOMIC
PRESSURES. CONSEQUENTLY, THE HISTORIC PHYSICIANPATIENT DYNAMIC IS BEING REDEFINED.
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June 17 – 19, 2009
THE CHANGING FACE OF MEDICINE
PATIENTS STILL DESIRE A PHYSICIAN WHO IS:
PROFESSIONAL
WELL-TRAINED, KNOWLEDGEABLE, AND UP-TO-DATE
EXPERIENCED
COMPASSIONATE
UNDERSTANDING OF THEIR NEEDS
ABLE TO DELIVER INDIVIDUALIZED CARE
WILLING TO SPEND THE TIME TO DISCUSS AND EXPLAIN THE
ILLNESS AND ITS TREATMENT
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June 17 – 19, 2009
THE CHANGING FACE OF MEDICINE
PHYSICIANS NOW EXPERIENCE AN EVER-INCREASING NUMBER
OF REGULATORY OVERSIGHTS AND CONTINUAL
DECREASES IN THEIR COMPENSATION:
MANY RULES AND LAWS HAVE BEEN IMPOSED BY JOINT COMMISSION
AND FEDERAL AND STATE GOVERNMENT
DOCTORS NOW NEED PERMISSION FROM INSURANCE COMPANIES TO
ORDER CERTAIN TESTS
DECREASING COMPENSATION HAS FORCED PHYSICIANS TO SEE
MORE PATIENTS TO MAINTAIN THEIR OFFICES AND THEIR INCOMES
PHYSICIANS HAVE FORMED LARGE GROUPS TO NEGOTIATE FEE
SCHEDULES WITH PAYORS BUT, AS A RESULT, HAVE EVEN MORE
OVERSIGHT AND DEMANDS ON THEIR PRODUCTIVITY AND
PRACTICE
PHYSICIANS FEEL THAT THE WAY THEY ARE BEING ASKED TO
PRACTICE IS IN CONTRADISTINCTION TO THEIR TRAINING. MANY
FEEL COMMODITIZED AND DEVALUED; MOST FEEL EXTREMELY
DISSATISFIED
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June 17 – 19, 2009
THE CHANGING FACE OF MEDICINE
THE REALITY OF TODAY’S PHYSICIAN-PATIENT
RELATIONSHIP:
• HARRIED, UNHAPPY PHYSICIANS WITH TIGHT SCHEDULES
– EXAMINATIONS ARE BRIEFER AND/OR MORE LOCALIZED
– LITTLE TIME FOR DISCUSSION/EXPLANATION
– INCREASED DOCUMENTATION REQUIREMENTS
– INCREASED USE OF SUB-SPECIALISTS DIMINISHES THE ROLE
OF THE PRIMARY CARE PHYSICIAN
– TIME AND FINANCIAL CONSTRAINTS RESTRICT ABILITY TO
FOLLOW PATIENTS IN HOSPITAL
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June 17 – 19, 2009
THE CHANGING FACE OF MEDICINE
• DISSATISFIED PATIENTS WITH EXPECTATIONS THAT ARE
NOT BEING MET IN PHYSICIAN’S OFFICES OR THE HOSPITAL
– FREQUENTLY INTERRUPTED; NOT LISTENED TO
– NO TIME TO DISCUSS CONCERNS
– LITTLE PERSONAL ATTENTION
– WHEN HOSPITALIZED, SEEN BY MULTIPLE PHYSICIANS WHO
ARE GENERALLY UNKNOWN TO THEM
– MULTIPLE CARE-GIVERS INCREASE THE POSSIBILITY OF MISCOMMUNICATION
– STATISTICALLY, HOSPITALIZED PATIENTS TODAY ARE SICKER
THAN THEY WERE FIVE YEARS AGO; SICKER PATIENTS HAVE
MORE NEEDS AND ARE LESS ABLE TO COMMUNICATE THEM
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June 17 – 19, 2009
ATTEMPTS TO RESTORE THE RELATIONSHIP
ATTEMPTING TO RESTORE THE PHYSICIAN-PATIENT
RELATIONSHIP, MANY MEDICAL GROUPS AND HOSPITALS
HAVE SOUGHT TO IMPROVE SERVICE BY INCREASING
EFFICIENCY. THEY HAVE EMPLOYED TECHNOLOGY TO
ACHIEVE THIS GOAL:
• ON-SITE SERVICES IN PHYSICIANS’ OFFICES:
– LAB
– X-RAY AND ADVANCED IMAGING
• ELECTRONIC MEDICAL RECORD (EMR)
– BETTER PATIENT/DISEASE MANAGEMENT
– IMPROVED MEDICATION MANAGEMENT
– ENHANCED COMMUNICATION BETWEEN PROVIDERS
– INCREASED PORTABILITY OF INFORMATION
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June 17 – 19, 2009
ATTEMPTS TO RESTORE THE RELATIONSHIP
• HOSPITAL INNOVATIONS
– PATIENT SAFETY
• BAR CODING MEDICATIONS
• RADIO FREQUENCY (RFID) TRACKING OF MOBILE EQUIPMENT
• PROSEC INFANT MONITOR
– DIAGNOSTIC TOOLS
• 64 SLICE CT SCANNER IN THE ED
• GI CAPSULE
• SPYGLASS
– TREATMENT MODALITIES
• DAVINCI ROBOT
• THERAPEUTIC HYPOTHERMIA
• TOMOTHERAPY
• BARRX
• STEREOTAXIS
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June 17 – 19, 2009
HAS EFFICIENCY WORKED?
THESE TECHNOLOGICAL ADVANCES ARE TREMENDOUSLY EXCITING
AND HAVE ENORMOUS POTENTIAL TO BENEFIT PATIENTS, CLINICAL
PRACTICES, AND HOSPITALS.
HOWEVER, AS H.L. MENCKEN PUT IT, “THERE IS ALWAYS AN EASY
SOLUTION TO EVERY HUMAN PROBLEM—NEAT, PLAUSIBLE, AND
WRONG.”1
CARE MUST BE TAKEN THAT WE DO NOT FOCUS SOLELY ON
TECHNOLOGIC EFFICIENCIES. OUR EXPERIENCE HAS SHOWN US
THAT THERE IS SOMETHING MORE.
1. JOHN PETRIE’S COLLECTION OF H. L. MENCKEN QUOTES. JPETRIE.MYWEB.UGA.EDU/MENCKEN.HTML
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June 17 – 19, 2009
HAS EFFICIENCY WORKED?
SOLUCIENT/REUTERS, A NATIONAL BENCHMARKING COMPANY,
HAS RATED VASSAR BROTHERS MEDICAL CENTER (VBMC) A
“TOP 100” CARDIAC HOSPITAL. OUR CARDIOLOGISTS HAVE
THE BEST OUTCOMES IN NEW YORK STATE:
DOOR TO BALLOON TIME
CORE MEASURES (27)
MORTALITY
RECURRENT SYMPTOMS
MYOCARDIAL INFARCTIONS
BUT— OUR PATIENTS RATE THE SKILL OF OUR PHYSICIANS
AT ONLY THE 37TH PERCENTILE!!!
CLEARLY, THERE IS A HUGH DISCONNECT BETWEEN
THE SERVICE PROVIDED AND THE PERCEPTION
OF SERVICE RECEIVED!
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June 17 – 19, 2009
SERVICE IS MORE THAN EFFICIENCY
IN THE MEDICAL INDUSTRY, WE ARE LEARNING THAT “SERVICE”
IS MORE THAN JUST EFFICIENT CARE. IT IS ALSO CARE
THAT IS SAFE, EFFECTIVE, APPROPRIATE, AND EQUITABLE.
HOWEVER, SERVICE DOES NOT BECOME “QUALITY SERVICE”
OR “GOOD SERVICE” UNTIL IT BECOMES PATIENTCENTERED.
THIS POINT IS UNDERSCORED BY THE FACT THAT THE
INSTITUTE OF MEDICINE (IOM) NOW DEFINES QUALITY BY
THE ABOVE SIX CRITERIA.
PATIENTS WHO UNDERSTAND THE MECHANISM OF THEIR
DISEASE AND ARE INVOLVED IN THE SELECTION OF
TREATMENT OPTIONS ARE MORE COMPLIANT WITH
THERAPY, TAKE THEIR MEDICATIONS MORE RELIABLY, AND
HAVE BETTER OUTCOMES.
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June 17 – 19, 2009
PATIENT-CENTERED SERVICES AT VBMC
ENTIRE STAFF INITIATIVES
• CLASSES BY THE STUDER GROUP—LEARNING TO TALK TO THE
PATIENT (AIDET: ACKNOWLEDGE; INTRODUCE; DURATION;
EXPLANATION; THANK YOU)
• DEFINED CODE OF CONDUCT—DESCRIBES EXPECTED
BEHAVIORS AND THE PATIENT BILL OF RIGHTS
• BEHAVIORAL POLICY—UPHOLDS THE EXPECTED BEHAVIORS
• CLASSES BY LIFEWINGS—ADAPTS AVIATION SAFETY
STANDARDS TO HOSPITAL CARE
• MANAGING-UP—MAKING PATIENTS FEEL COMFORTABLE WITH
PROVIDERS THEY DO NOT KNOW
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June 17 – 19, 2009
PATIENT-CENTERED SERVICES AT VBMC
NURSING STAFF INITIATIVES
• STAFF NURSE HOURLY ROUNDING—ASSESSMENT OF
POSITION, FALL RISK, CALL BELL ACCESS, TOILETING NEEDS
• NURSE MANAGER DAILY ROUNDING—ASSESSMENT OF
PATIENT’S NEEDS AND UNDERSTANDING OF CARE PLAN
• DISCHARGE CALL-BACK—CONTACTING EVERY PATIENT THE
DAY AFTER DISCHARGE TO ANSWER MEDICATION
QUESTIONS, CONFIRM FOLLOW-UP APPOINTMENTS, AND
DISCUSS ANY UNRESOLVED ISSUES
• SAFETY, OPPORTUNITY, SUPPORT TEAM (SOS)—
ENCOURAGES ANY FAMILY MEMBER TO CALL A SUPERVISOR
FOR CONCERNS OR QUESTIONS
• NURSE STAFFING RATIOS OF 6:1 OR LESS—PROVIDES
OPTIMAL CARE (POSSIBLY THE BEST RATIO IN NEW YORK
STATE)
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June 17 – 19, 2009
PATIENT-CENTERED SERVICES AT VBMC
PHYSICIAN STAFF INITIATIVES
• PHYSICIAN LIAISON COMMITTEE—IMPROVES PHYSICIAN,
NURSE, AND PATIENT COMMUNICATION/SATISFACTION
• NEW SLEEP ROOMS FOR OB ON-CALL DOCTORS—EQUIPPED
WITH COMPUTERS FOR FETAL MONITORING
• RAPID RESPONSE TEAM—GIVES IMMEDIATE CARE TO
DETERIORATING PATIENTS
• 24/7 INTENSIVIST SERVICE (CRITICAL CARE UNITS)
• 24/7 HOSPITALIST SERVICE (MEDICAL/SURGICAL FLOORS)
• PHYSICIAN CHAMPIONS ON EVERY FLOOR—ROUND ON ALL
PATIENTS TO ASSURE QUALITY MEASURES ARE MET
• MEDICAL ADMINISTRATION—PROVIDES PERFORMANCE
FEEDBACK TO PHYSICIANS
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June 17 – 19, 2009
PATIENT-CENTERED SERVICES AT VBMC
HOSPITAL PROGRAMS
•
MUSIC THERAPY IN NICU
•
CHAMBER MUSIC IN THE CANCER CENTER
•
PET THERAPY
•
CHILDRENS ART PROJECT/MILL STREET LOFT
GOVERNMENT-MANDATED PROGRAMS
•
HCAPS (HOSPITAL CONSUMER ASSESSMENT OF PROVIDERS AND
SYSTEMS)—PATIENTS COMPLETE A SURVEY THAT ASKS:
HOW OFTEN DID YOUR DOCTOR
» SHOW YOU COURTESY AND RESPECT?
» LISTEN CAREFULLY TO YOU?
» EXPLAIN THINGS IN A WAY YOU COULD UNDERSTAND?
THIS INFORMATION IS USED TO DETERMINE MEDICARE/MEDICAID
REIMBURSEMENTS—IT HAS NOTHING TO DO WITH COMPETENCE
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June 17 – 19, 2009
HAS PATIENT-CENTERED SERVICE WORKED?
OUTCOMES-CLINICAL EXCELLENCE:
•
LEAPFROG (A CONSORTIUM OF FORTUNE 500s DRIVING BEST
CARE)—THREE YEARS AMONG THE TOP 32 ADULT HOSPITALS
•
SOLUCIENT/REUTERS—TOP DECILE FOR CARDIAC AND
MOTHER/BABY CARE
•
COMMITTEE FOR CANCER ACCREDITATION—COMMENDATION IN 7
OF 9 CATAGORIES; AMONG THE BEST IN NEW YORK STATE
•
HEALTHGRADES—TOP DECILE FOR CARDIAC AND MOTHER/BABY
CARE
•
AHA—AWARD WINNER FOR CARDIAC AND STROKE CARE
•
ADVANCED NURSING MAGAZINE—OF 247 TRI-STATE HOSPITALS,
VOTED BEST PLACE TO WORK
•
BECAUSE OF OUR GROWING NATIONAL REPUTATION, WE ARE ABLE
TO RECRUITE TOP PHYSICIANS AND NURSES, FURTHERING OUR
ABILITY TO PROVIDE EXCELLENT CARE
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June 17 – 19, 2009
HAS PATIENT-CENTERED SERVICE WORKED?
OUTCOMES—MARKET SHARE:
• 75% OF OUR LOCAL POPULATION SELECT VBMC AS THEIR
HOSPITAL OF CHOICE (SIX OTHER HOSPITALS WITHIN 2-30
MILES)
– 83% OF BABIES ARE DELIVERED AT VBMC
– 75% OF AREA CANCER CARE IS PROVIDED AT VBMC
– 75% OF AREA NEUROLOGY AND NEUROSURGICAL CARE
OCCURS AT VBMC
– 90% OF CARDIOLOGY AND 95% OF CARDIOTHORACIC SURGERY
IS DONE AT VBMC
• 14TH BUSIEST EMERGENCY DEPARTMENT (ED) IN NYS—
70,000 PATIENT VISITS THIS YEAR
• HOSPITAL OCCUPANCY ROUTINELY 85-105%
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June 17 – 19, 2009
HAS PATIENT-CENTERED SERVICE WORKED?
OUTCOMES—FINANCIAL STABILITY:
• GREATER THAN 4% OPERATING MARGIN (NYS AVERAGE IS
-1%)
• AA (DOUBLE A) BOND RATING—MOODYS, STANDARD&POOR
OUTCOMES—PHYSICIAN PARTNERING:
• WORKING WITH OUR PHYSICIANS TO CONTINUALLY
IMPROVE OUR SCOPE AND DELIVERY OF SERVICE
• ACTIVELY PURSUING A DEPARTMENT OF RESEARCH AND A
TRANSPLANT PROGRAM
• AFFILIATING WITH A MAJOR TEACHING HOSPITAL
• CONTINUING TO IMPROVE OUR CORE BUSINESSES:
CARDIAC; MOTHER/BABY; CANCER; NEUROSCIENCES
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June 17 – 19, 2009
HAS PATIENT-CENTERED SERVICE WORKED?
OUTCOMES—PATIENT SATISFACTION:
• OUR PATIENT SATISFACTION SURVEY, MEASURED BY PRESS
GANEY, IS IMPROVING
CURRENTLY AT 85TH PERCENTILE FOR LARGE
HOSPITALS
GOAL IS TO ATTAIN GREATER THAN 90TH PERCENTILE
THIS YEAR
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June 17 – 19, 2009
THE ART & SCIENCE OF SERVICE: INNOVATION
CONCLUSIONS:
INNOVATION CAN PROVIDE FASTER, SAFER, MORE EFFICIENT,
MORE EFFECTIVE TOOLS THAT ARE ESSENTIAL TO
PROVIDING IMPROVED SERVICE. HOWEVER, IN A “SERVICE
INDUSTRY” LIKE MEDICINE, CUSTOMER SATISFACTION IS
ONLY ACHIEVED WHEN THE SERVICE IS HUMANE, CARING,
AND HELPFUL ON A PERSONAL LEVEL.
THE TECHNICAL ELEMENTS CANNOT SUCCEED WITHOUT THE
KINDS OF PERSON-TO-PERSON INITIATIVES WE HAVE
INSTITUTED.
FINALLY, EVERYONE WHO WORKS IN A SERVICE INDUSTRY IS,
IN FACT, A CUSTOMER OF THE ORGANIZATION, WITH NEEDS
THAT MUST BE ANTICIPATED AND MET. WHEN THE SERVICE
PROVIDERS ARE, THEMSELVES, HAPPY, THEY PROVIDE
BETTER SERVICE TO ALL OTHER CUSTOMERS.
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June 17 – 19, 2009
FINAL THOUGHTS
“…PRESSURE ON HEALTH CARE PROVIDERS TO BE MORE
ACCOUNTABLE FOR THE FINANCIAL CONSEQUENCES OF
QUALITY PROBLEMS …WILL INEVITABLY REQUIRE
PHYSICIANS TO LEARN TO SYSTEMATICALLY REENGINEER
CLINICAL WORK METHODS IN ORDER TO REDUCE ERRORS
AND WASTE—A COMMON APPROACH IN OTHER COMPLEX
SERVICE AND MANUFACTURING SECTORS. THIS TREND
ALSO PORTENDS MAJOR REVISION IN PHYSICIAN TRAINING,
GREATER COLLABORATION OF PHYSICIANS WITH SYSTEMS
ENGINEERS AND OTHER CLINICAL TEAM MEMBERS, AND THE
ADOPTION OF ELECTRONIC INFORMATION SYSTEMS. HOW
THESE FUNDAMENTAL CHANGES WILL BE FACILITATED
REMAINS AN UNWRITTEN CHAPTER IN THE ADVANCEMENT
OF CLINICAL PERFORMANCE IN THE UNITED STATES….”2
YOU CAN HELP WRITE THE CHAPTER.
2. MILSTEIN, MD, MPH. “ENDING EXTRA PAYMENTS FOR ‘NEVER EVENTS’—STRONGER
INCENTIVES FOR PATIENTS’ SAFETY.” N ENGL J MED 2009; 360;23:2388-2390.
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