Archive for the ‘Leadership’ Category

EHR Journey 1.2

July 23, 2008

Once embarked on an EHR journey, Ministry needed to develop supporting corporate infrastructure, tasks such as finding a Chief Information Officer (CIO) and Chief Medical Information Officer (CMIO). While those efforts were underway, we pulled together a team of clinicians and staff who were using or had used an electronic medical record in the past. This team gathered virtually on a regular basis to develop a joint vision of what practicing clinicians need in an EHR.

I have found clinicians who have used EMRs in the past possess unique insights as to how an EMR can be used to improve provision of care. Clinicians who have not used an EMR, tend to develop workflows duplicating their paper flows rather than finding new processes to leverage the technology.

We gathered over the noon hour once a week via a telephone conference. We generally talked about a topic and flushed out our functional specification.  Offline, we developed representative screen shots depicting the functionality we desired. Screen shots and functional requirements were shared using PowerPoint Presentations sent via our internal e-mail server. Today we would collaborate using WebEx as the communication tool.

 

By the time Ministry had hired a CIO and CMIO, the clinicians had formed a very clear vision of our functional specifications.

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Electronic Health Record 1.0

July 13, 2008

Where does one start on the EHR journey? At the beginning.  Where is the beginning?  The beginning should be squarely focused on the business needs of the organization.

Our journey grew out of series of strategic development sessions.  Our two major medical groups had been acquired within the past 10 years and each had developed a business model centered on a regional hospital.  Each regional business unit had developed the basics necessary for a functional EMR but there were no true links between the units.

A number of tactical initiatives grew out of our strategy sessions. We discussed how we might achieve the various initiatives and came to the conclusion a system wide EHR was a prerequisite.  

Lesson: The EHR (or any other initiative) has to be based on the business needs of the organization.

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PowerPoint, Keep it Simple

July 2, 2008

PowerPoint is an essential ingredient for many presentations. Remembering it is an ingredient and not the whole meal can be the key to successful communication. We communicate to transfer ideas, an overly complicated PowerPoint diverts attention from the presenter to the medium and reduces knowledge transfer. When it comes to PowerPoint, less is more.

Keeping It Simple:

  • Pick a simple format and stick with it
  • Use no more than four to seven lines per slide
  • Simplify the wording of each line
  • Reduce lines of text when including images
  • Rarely use animation, it usually distracts the audience
  • Rarely use sound, sound as well can distract the audience

Your audience can read text on the slide, you do not need to read it to them. Your verbal presentation should amplify each slide’s context adding depth and understanding.

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Addressing the Medical Staff - Disruptive Behavior

June 30, 2008

In previous posts, I have presented an interview with one of our administrative clinicians outlining how he deals with disruptive behavior and the Principles of Partnership we have with Ministry Health Care clinicians. We also must deal with this issue at our hospitals, most of which have independent physicians.  Regardless of the setting, we have to establish the baseline for acceptable behavior. One of our hospital medical staffs formed a Respect Committee that then interviewed a number of individuals.  The interviews uncovered numerous examples of respectful behavior and a few examples showing disrespect.  The Committee then produced a PowerPoint presentation that has served as a cornerstone establishing respectful behavior.  The basic contents of the PowerPoint is listed below. Examples of respectful and disrespectful behavior has proven to be helpful on many occassions.

 

Ministry Health Care:  Values Behavior

  • Treating Others with such a sincere regard that each person  feels important and worthwhile
  • Recognizes others for their achievements and capabilities
  • Provides honest, non-judgmental feedback to others
  • Creates an environment where frustrations and concerns can be expressed without fear of repercussion    

 

Ministry Medical Group Professional Practice Standards

  • We believe each patient, customer and staff member is important.  …. we strive to treat each person in a respectful nature that honors his or her importance and worth.

 

Cultural Assessment Questionnaire:

  • Ministry-wide and local norms 
    • Physicians in this organization treat other staff members with respect
    • Employees Treat Each Other with Respect

 

What Additional Data Did We Want to Gather?

  • Are there recognizable characteristics of “Best Practices”?
  • Are there characteristics of the opposite?
  • What makes staff feel that they are respected?
  • What makes staff feel that they are disrespected?
  • Can we show improvement in staff perception of respect over time?
  • Can we change behaviors to achieve this end?

 

Respect Committee Intentions

  • This is NOT a disciplinary committee
  • Emphasize the POSITIVE, the IMPROVEMENT
  • To be EDUCATIONAL, not punitive
  • To provide TOOLS for the Medical Staff  and MMG Clinic Divisional Chairs to  improve RESPECT
  • To EDUCATE all employees regarding respect issues and holding ALL WHO WORK here to the same standards
  • Try to learn something about SUCCESSFUL physician/nurse and physician/employee relationships that can benefit all.

 

WHY

  • IT HAS DIRECT CONSEQUENCES AFFECTING PATIENT CARE

Intimidating and verbally abusing nurses and pharmacists may lead to patient harm:  Institute for Safe Medication Practices (ISMP) Survey of Nurses and Pharmacists

  • 7% involved in medication error where intimidation played a role
  • 49% said history of intimidation altered the way they asked for clarification of medication orders
  • 40% said at least once in past year a concern was overlooked in order to avoid confrontation

Types of Behavior :

  •     Condescending language 21%
  •     Impatience 19%
  •     Verbal Abuse 48%
  •     Threatening body language 43%

 

AMA News: Sept 2004

  • Staff Less Tolerant of Rude Doctors            
  • Survey of Physician Executives :
    •      One physician can taint the culture of the unit
    •      83%  problems with physician behavior involve disrespect
    •      50%  problems only reported when doctor completely out of line and serious violation occurs
    •      95%  met with disruptive physician in last two years
    •      40% said physicians who generate high amount of revenue are treated more leniently than doctors who bring in less revenue    OUCH !

 

What We Did

  • Focus groups were interviewed  with representatives from Clinic and Hospital  departments with high and low respect scores. Included  nursing and  clinical staff,  administrative, and non-clinical employees.
    • Confidential
    • Qualitative
    • Individual Responses                                   
    • Highlight the most pressing and prevalent problems

 

Questions Asked

  • What are some examples of times you felt very respected by physicians?  What specific behaviors caused you to feel this way?
  • In general, is this behavior on the part of most or all physicians? Or is it more specific to a minority of them-but a minority who have a significant impact on others?
  • What are some examples of times you felt you were not respected by a physician? What specific behaviors caused you to feel this way?
  • In general, is this behavior on the part of most or all physicians? Or is it more specific to a minority of them-but a minority who have significant impact on others?
  • What physician/employee situations have you heard of?
  • How many times have you heard about situations versus times you actually experienced them?
  • How frequently does this behavior occur?

 

Sample of Comments Regarding Positive Respect  

  • MAJORITY of physicians
  • Has IMPROVED over couple years
  • HOSPITALIST program has decreased call issue complaints and a change for the better, hospitalists working together
  • LISTENING and taking  suggestions.                                      
  • INCLUDING nurses as part of a team by discussing plan of care and asking for input
  • ACKNOWLEDGE skill level, opinion and judgment
  • RECOGNITION for good patient care
  • THANKING YOU  for asking questions, bringing patient concerns to the attention of the physician
  • APOLOGIZING  when a mistake has been made
  • Basic MANNERS…thank you, acknowledgement in hallways even if just say “hi”, using pleasant voice, eye contact
  • ASKING rather than telling
  • Creating a learning environment
  • There are no “dumb” questions, no belittlement
  • Performance is improved by physicians who teach
  • Errors are handled non-judgmentally
  • Physicians act upon being called
  • Compliments in front of others and patients
  • Positive outweighs the negative

Sample of Comments Regarding Disrespect

  • Minority, some departments
  • Dismisses what you (staff) are doing
  • Expecting problem to be immediately fixed
  • Complaints about other departments/doctors
  • Belittling in front of patients or peers
  • Inappropriate comments about other physicians to patients
  • Not dealing directly with the issue
  • Yelling, hanging up phone
  • Taking out frustration on wrong people
  • Using sarcasm or intimidation
  • Requests to move patients to other areas without discussing reason
  • Unavailable, not answering page
  • Personal things taking precedence of work related duties
  • Being told not to call for certain reasons by on-call physicians and reprimand for calling
  • Unapproachable, avoid connecting
  • Being asked to lie/give excuses when physician is scheduled to be in two places at once
  • Taking out anger on staff for being awoke or called while on call
  • Criticizing staff for not being as prepared or skilled as another unit
  • Poor communication of treatment plan
  • Physician behavior differs between hospital and clinic
  • Heard about disrespect more than experienced it

Interview with Dr. Norm Chapin

June 20, 2008

My name is Dr. Norm Chapin. I am the Medical Director for Columbia Memorial Hospital in Hudson, New York. 

How big is the hospital?  They are currently staffed for 120 beds. 

Can you describe for me some of the steps you’ve made in rising through the leadership ranks?  I graduated from my residency in 1985 and for the first 5 years from 1985-1990 I practiced clinical emergency medicine.  In 1989, I was assigned responsibilities related to EMS education and ED quality management.   In 1990, I took a directorship position of a very small Emergency  Department near Detroit, Michigan and I worked there for about a year. I realized that I had taken that position maybe a little bit sooner then I was ready. I felt like I did not have adequate administrative experience.   My wife and I were looking to move out of Detroit at the time so we moved out of Detroit in 1991.  I went back to just practicing clinical medicine and emergency medicine again. 

Then a couple of years later I was given the opportunity to assume responsibility for the Quality Management Program in the Emergency Department.   I started doing some administrative work again and in 1996 when I accepted a position as Assistant Director of an Emergency Department near where I had been working. 

At that time, how much time was split between clinical practice and administrative practice? At that time, our normal clinical commitment was 144 hours per month, 12 - 12 hour shifts and I was doing 120 hours of clinical and 24 hours a month administrative time. 

As time went on did you do anything in particular to improve your leadership abilities or management abilities?  At that time, other than having a mentor I really didn’t take any formal courses in administration and leadership. Most of my CME classes were straight clinical courses.  I was doing more teaching all the time and I was learning more about how to present data to people but it was pretty much seat of the pants learning.  I really didn’t get into any kind of formal education at that time. 

When did you get into any kind of formal education?  In 1999, I was promoted to the Chief of the Department and I joined the American College of Physician Executives and I began taking some of their courses. I took my first course from them in 2000.  I also joined the ACPE list serve and began receiving their publications.  I was initially going to get my CPE Certification through ACPE and I took approximately 50 credit hours or so toward that but never completed it. 

You are enrolled in a more formal program now.  How did you decide to do that?Well, between 1999 and now I had assumed additional administrative roles.  Within the hospital I was elected as Secretary and Treasurer of the Medical Staff. The Emergency Management Group that has the contract at our hospital had branched out and I had taken a leadership role in getting two new contracts for the group. I was involved in negotiations with 3rd party payers, involved in negotiating with hospital administrators about contracts, I was doing a lot of recruiting, a lot of human resources types of things and I just realized that I needed to have a better background on the business side of medicine and healthcare in general. I’ve been interested for the past 4 or 5 years and going for my masters degree I had been challenged to really find the time to do that.  I had looked at several programs that were completely self study.  There was a little bit of a deadline to them but most of them were studying on your own, taking full on-line courses with no residency periods and that just didn’t work for me because it was too easy for me to push off the deadlines and I didn’t stick with any of those and didn’t think they would be a good fit for me just knowing my own personality.

A couple of years ago I met Mike Stahl who is the Director of the Physician Executive MBA Program at the University of Tennessee.  I talked with him. I was very interested in the program. It had a good track record.  We got a new ED contract shortly after my initial contact with Mike and I became totally immersed in the start up. Last year, 2007, I met Mike again at a national emergency medicine conference and applied to the program. I t was just very good timing for me. I applied and was accepted at the MBA program. I’m not quite half way through yet but it’s going very well. 

In your current position what percent clinical are you and what percent administrative?  Right now, I am only doing about 24-30 hours a month in the Emergency Department and the rest of the time I am Administrative. 

Do you see your clinical time further decreasing or staying about that level?  Emergency Medicine is a pretty demanding specialty and I still feel comfortable clinically right now but I when I became the Director, I went to half time clinically. That was back in 1999 and there was probably only one or two months in there that I actually only worked half time.  I was always picking up shifts for people because of scheduling problems and things like that so I always felt like I maintained a pretty good comfort level with clinical medicine. In the last year my clinical time has gone down to 2 or 3 shifts a month it is getting harder for me to maintain my comfort with practicing there.  I think over the next year as my administrative role continues to evolve, I’ll probably stop clinical medicine completely.

What advice would you give to young physicians who are considering being involved in leadership activities?   I would discourage young physicians from making a decision regarding full time administrative too early in their career.  I think my first mistake was taking on an administrative role before I really matured enough as a clinician to sustain that.  I don’t think I had enough maturity to deal with physicians who have been practicing for 20 or 30 years.  I don’t think I had earned my stripes so to speak.  I also think I tried to go from a position where I had very minimal administrative responsibilities when I was a director of a department too quickly.  So I think the best advice is to go slowly, make sure that you enjoy doing the administrative things, make sure that you gain enough experiences clinically so you can really be assured that your skills and your understanding of how healthcare works either in your specific specialty or throughout a multi specialty physicians organization or a managed care organization or a hospital organization which ever your practice has placed you.  M ake sure that you really do understand the organization well before you decide to take a real significant role there.  Committee participation, involvement in medical staff affairs, participating in performance improvement projects in the organization are each excellent opportunities to gain leadership experience.

What special skills or unique insight do you think physicians bring to the leadership table than non-physicians would not?  Well, I think we really understand other physicians better than non-physicians do.  I think we also understand patients in a way than non-physicians don’t, because we have really been with them through a lot of medical crisis.  We really understand their fears and their concerns.

I think we understand what physicians and what patients expect of physicians in a way that non physicians might not understand.  I think that gives us an advantage when discussing strategic initiatives within a healthcare organization or discussing  the vision or mission of a healthcare organization.  We have a different perspective of the complexity and how difficult it is sometimes to meet patient’s expectations and needs.  There are also aspects of healthcare as a business that we don’t understand or have a very different perspective of.  I think a team where both of those perspectives are represented at the Senior Executive level ,   gives  organizations a huge advantage in   responding  to some of the pressures that they face. 

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Mistakes Are Good

June 18, 2008

Communicating can be frightening, especially if you worry too much about making a mistake.  Of course you strive to be accurate, but you will eventually make a mistake.  It is good when a mistake is pointed out to you because:

  • At least one person heard your message
  • The issue was important to them
  • You engaged them
  • They cared enough to point out an error
  • Thank people who point out mistakes and empower them to become involved in the improvement process.  Restat your mistake and what the correction will be and ask if you got it right.  Make sure to follow through and correct your mistake.  In future presentations you can even thank the individual for how they influenced the process. 

     

    Life Expectancy is Now 78

    June 16, 2008

    A government report has announced U.S. life expectancy has now surpassed 78 years.  Good news.  The report suggests the main reason for the rise is less flu deaths and a reduction in the death rate of chronic diseases. If we have the best health care system in the world, why is our rising life expectancy still less than what is experienced in 30 other countries?  Answer: health care only makes a small contribution to life expectancy.  

    Experts estimate our health care system only has a direct effect on about 10% of the factors causing death. While our average life expectancy is not world class, your chance of surviving cancer, a heart attack or any catastrophic life threatening event is best in the good old U.S of A.  

    Our health care system has developed partly due to economic reality. We have desired high quality acute care and have paid for it preferentially as compared to preventive, wellness, primary or even office based chronic care. In my neck of the woods, health care reimbursement policies have resulted in free standing surgical centers, orthopedic centers, cancer centers and MRI centers while primary care is often thought of as a loss leader feeding providers of highly reimbursed procedures.

    The upcoming Presidential election will include a health care debate. My intent behind today’s post is not to provide the answers to the debate, but is to make a few observations which may well lead us to the answers. 

    1. Our health care organizations make a lot of money when patients are admitted to the hospital or the various outpatient procedure oriented facilities.
    2. Our health care organizations loose money when patients receive care and live a lifestyle allowing them to stay away from hospitals and outpatient procedures.
    3. Our communities will spend less money on health care with the same results by increasing or establishing reimbursement for services that keep patients out of the hospital.
    4. If we are interested in improving life expectancy, you will get a good bang for buck by concentrating on improving lifestyle behavior that impacts health.

     

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    e-iatrogenesis

    June 12, 2008

    I recently had the opportunity to listen to a presentation by Joan Ash, PhD, MLS, MBA; Associate Professor of Medical Informatics and Clinical Epidemiology at Oregon Health and Science University in Portland, Oregon.  She has been part of a long term effort investigating computerized physician order entry (CPOE).  You can review the result of the work done by this team at http://cpoe.org. If you are considering CPOE, the website is well worth the effort of review.  If you know the experiences of others, you will be better prepared to minimize or mitigate the inevitable surprises of implementation.

    Dr. Ash and her team have found asking users about their surprises rather than the unintended consequences of CPOE will result in a richer discussion.  She has also discovered that if you want to know how a process is working, go to the source and observe it.  Observing and asking questions results in far more accurate data than sitting in an office and reviewing the results of surveys.

    I did learn of one specific example of a CPOE surprise that was new to me:

     

     http://www.timesonline.co.uk/tol/news/uk/health/article753765.ece

    It seems as if there were no complaints from patients who had received Viagra in error.  Perhaps their thoughts of smoking were transformed into something else.

    Please do not consider all surprises to be negative.  When we implemented electronic Rxs in my outpatient office, patients could actually read and interpret our prescriptions.  They became empowered in the process, read the Rxs,  pointed out address errors, asked for greater quantities  and even asked for more refills.

    Any new useful technology solves old problems but introduces new ones.  A term has been recently coined, e-iatrogenesis, to label any patient harm caused at least in part by the application of health information technology.  

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    Clinical Reference Resources On-Line

    June 9, 2008

    Increasingly, doctors are turning to on-line resourses for clinical information. I first noticed the trend when we installed computers in each of our exam rooms with  connectivity to the Internet.  We found Google was a great tool to find information and direct us to sites we trusted.  I was amazed at how quickly each of our clinicians complained to me when our connectivity was interrupted. I even heard clinicians stating they could not provide quality care without connectivity to the Internet.

    The trend continued when our local hospital (St. Michal’s Hospital in Stevens Point, Wisconsin) started a digital library and provided MedConsult and UpToDate access.  Our collection of books began to get dated as we turned to online resources containing the latest information.  About the only books we updated were radiology and dermatology references.

    In late 2006, our system developed an enterprise level Library Without Walls. Our local hospital library was moved offsite since most services were provided on-line.  Use of these resources has been increasing at a steady pace.  Below you will find the number of topic views per quarter for just one resource, UpToDate.

    I expect the trend to continue since online resources are more current than printed textbooks and are far easier to search.

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    Prinicples of Partnership

    June 5, 2008

    This post contains the Principles of Partnership referred to in last week’s interview with Dr. Sockochoff.  The document establishes the standards of behavior for the organization.

    Ministry Medical Group

    Introduction

    The Medical Staff and Employees of Ministry Medical Group recognize their considerable interdependence in the rapidly-changing health care environment.  They acknowledge that providing high-quality, cost-effective health care depends in large part upon their ability to develop trust, communicate well, collaborate effectively, be mutually supportive, and work as an effective team.

    Medical Staff and Employees further acknowledge that there are many participants in the process of effective health care, including patients, their families, Allied Health Professionals, and others, and that working harmoniously with them is a necessary aspect of modern health care.  Both parties affirm that everyone, both recipients and providers of care, must be treated in a dignified, respectful manner at all times in order for their mutual goal of high-quality health care to be accomplished.

    Medical Staff and Employees further affirm that it is their mutual responsibility to work together in an ongoing, positive, dynamic process that requires frequent, continual communication and feedback.  Both agree to devote the necessary time and resources toward achieving these goals.

    Principles

    In order to accomplish these goals, Medical Staff and Employees agree to the following principles and guidelines.  Both parties agree to work collaboratively to promote them in the organization and in the community.

     1.      Respectful Treatment

    All members of the health care provider team (physicians, hospital employees, Allied Health Professionals, vendors, contract personnel, etc.) and all direct and indirect recipients of health care (patients, their families, visitors, etc.) shall be treated in a respectful, dignified manner at all times.  Language, nonverbal behavior and gestures, and attitudes shall reflect this respect and dignity of the individual at all times.  Medical Staff and Employees also agree to exercise commonly-accepted principles of social interaction and courtesy in their dealings with others. 

     2.      Language

    Medical Staff and Employees agree to use respectful language and demeanor, and not to use language that is disrespectful, profane, vulgar, intimidating, degrading, sexually suggestive or explicit, or prejudicial (racially, ethnically, religiously, etc).

     3.      Behavior

    Medical Staff and Employees agree to behave respectfully toward others at all times, and to refrain from any behavior that is disrespectful, profane, vulgar, intimidating, demeaning, harassing, humiliating, or sexually inappropriate.  This includes but is not limited to:  obscene gestures, violation of reasonable personal space, yelling, throwing of objects, menacing gestures, unwanted or sexual touching, degrading or sexually-oriented jokes or comments, or requests for personal or sexual favors.  It also includes making inappropriate comments regarding physicians, hospital employees, other providers, or patients.

     4.      Confidentiality and Privacy

    Medical Staff and Employees agree to maintain complete confidentiality of patient care information at all times, in a manner consistent with generally-accepted principles of medical confidentiality and HIPAA.  The parties also recognize that practitioners and hospital staff have the right to have personal or performance problems and concerns about competence discussed in a confidential manner in a private setting.  Medical Staff and Employees agree to maintain this confidentiality and to seek proper, professional, objective arenas in which to deal with these issues.  It is particularly important that patients, families, and other hospital visitors not overhear such discussions.

     5.      Respectful Communication and Feedback

    Verbal and written communication, including chart notes and other documents, should be respectful and professional in language and tone.  Communication about a physician or employee should be made directly to that person, in a constructive manner, in objective, behavioral terms, without impugning motives.  It is not appropriate to make critical comments about others to a third party or to relay gossip.

    Medical Staff and Employees recognize the need for an organizational chain of command, in order for the Medical Center to run smoothly and efficiently.  Both parties recognize the need for each others’ input regarding quality and performance.  Employees recognize the importance of Medical Staff in the education of employees.  However, significant concerns about performance need to be made through appropriate channels, i.e. to supervisors, and not directly to employees.  Medical Staff agree to take these concerns about employee performance or hospital issues through the appropriate chain of command.  Both parties agree to engage other parties in constructive and timely dialogue and to work collaboratively to address these issues.

     6.      Supporting Rules and Regulations

    Medical Staff and Employees recognize the need for certain rules and regulations for all to follow, in order to assure the smooth, harmonious, and safe functioning of the Medical Center, both clinically and otherwise.  Both parties agree to abide by these regulations, including such things as relate to safety, scheduling, confidentiality, documentation, parking, traffic, HIPAA, and the like.

     7.      No Retribution

    Medical Staff and Employees agree not to engage in any behavior that could reasonably be considered retribution, such as:  making implied or direct threats, physically-intimidating behavior, withholding information, refusing to speak to coworkers, attempting to find out who might have registered a complaint, etc.

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    Disruptive Behavior