A few weeks back, a number of you sent me this article from the New York Times:
“Doctors Unionize to Resist the Medical Machine“
The article describes a physician who is trying to take the amount of time – the right amount of time – that he thinks is required to get a proper diagnosis for the patient. Does taking longer, reducing his short-term productivity, end up improving care and reducing costs over the long term? That's hard to know for sure, but it makes sense.
“Dr. [Rajeev] Alexander considers it proper technique to review each mundane detail with a patient.. a hospitalist at PeaceHealth. His painstaking method of diagnosing patients' maladies is viewed as inefficient by some who seek to cut costs… He was nonetheless unapologetic about the time he had invested” in a patient, taking 45 minutes with a patient.
The question of productivity and “patients per hour” metrics create a lot of disagreement between physicians and medical administrators. There are enough pressures in healthcare – to reduce costs, to improve access, to improve quality and patient safety (the latter being the goal that should matter most).
The article describes one way in which PeaceHealth was going to try to reduce costs:
“In the spring of 2014, the hospital announced plans to outsource its 36 hospitalists to a management company.”
A Lean thinker would hopefully realize that outsourcing work isn't the same as improving a process and reducing waste. A management company needs to make a profit margin on top of what the hospitalists would be paid. It's not clear that outsourcing would really reduce costs. I've seen hospitals choose to bring laundry service back in house because it was CHEAPER to do it themselves.
The article makes it seem like the hospital might reduce costs because they would only pay on a per-patient basis. But do the hospitalists really have that much idle time?
“[The outsourced physicians'] compensation is often tied more directly to the number of patients they see in a day.”
Some hospitalists think the maximum number of patients should be 15 per day. Is that number based on their current system and the waste that's quite certainly there, backed into the process? They were concerned about the new goal being 18 to 20 patients per day.
How would that goal be accomplished, I'd wonder. “By what method?”
“It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists…”
The only thing that would cause (should cause) outrage is being asked to rush through your work or cut corners. How much of a hospitalists day is spend providing value versus dealing with waste?
A physician said:
“Giving me a bonus for seeing two more patients — I'm not sure I should be doing that. It's not safe.” (A hospital representative said patient safety was “inviolate.”)
It wouldn't be unsafe to see more patients if you made that possible by freeing up time in their day, by reducing waste. Just squeezing the shortening the patient encounter times might be counterproductive.
Aside: hospitals always SAY “patient safety is our top priority,” but that's not always demonstrated, unfortunately.
The article says:
“Dr. Alexander and his colleagues say they are in favor of efficiency gains.”
So, that would have been a perfect chance to engage them in that process.
After the outsourcing announcing, about one third of them quit (replaced by “locums” contract physicians), and the rest formed a union. Sacred Heart scrapped the outsourcing plan.
“By March 2015, the PeaceHealth leadership, whatever its interest in efficiency gains, was apparently not pleased that one of its hospitals had a white-collar labor insurrection on its hands.”
Why were they upset? They were afraid of “assembly line medicine,” as illustrated in the Times graphic, I guess:
Lean is, of course, not about creating “factory medicine” or “assembly line medicine,” regardless of what's said in the NEJM.
“We're trained to be leaders, but they treat us like assembly line workers,” said Dr. Brittany Ellison, a hospitalist in the group.”
Not all assembly line workers are treated badly… there's a difference between a Lean culture and a traditional factory culture. It's easy for people who have never been in a factory to generalize, but they're usually wrong.
The Value Add (or Cost) of Hospitalists
Why has there been a boom in hospitalists in recent years? Internists faced pressure to see more patients in their offices, making it more difficult to go over to the hospital.
There were also efficiency pressures on hospitals. The hospitalists were a new cost, but, “They were on hand to discharge people throughout the day, emptying beds that could generate revenue again.” So, they paid for themselves, I guess. They had freedom to spend time with patients.
“…the increasing focus on metrics like readmission rates and hospital-acquired infections had created more work for hospitalists, who are responsible for a lot of documentation.”
It's easier to measure costs than it is quality.
“Readmission rates have been reduced — we can show it.” Costs are rising more slowly too, he said, which is no small thing in a country where many people are bankrupted by medical expenses. But, he added, “as to whether you as an individual are seeing better quality in health care — I think there's some question there.”
Money and Incentives
The article also says:
“To work in a hospital today is to be constantly preoccupied with money…”
(where is the preoccupation with patient safety, that supposed top priority?)
Again, from the article:
“…one of the more grating features as far as the Sacred Heart hospitalists are concerned has been the administration's celebration of “skin in the game.” That means creating financial incentives for doctors to hit performance targets — like lowering patient's length of stay and doing well on patient satisfaction surveys.”
Are the incentives a substitute for engagement, collaboration, and leadership?
Dr. Bob Wachter (listen to my podcast with him) raises concerns about incentives (as would Dan Pink):
“Dr. Robert M. Wachter, chief of the division of hospital medicine at the University of California, San Francisco, says many hospitals now give doctors financial incentives to perform well according to the criteria on which the hospitals themselves are judged under the Affordable Care Act — for example, reducing hospital-acquired infections. But there is an active debate in the profession over their utility. “If at the end of the year, 10 percent of your salary is at risk based on whether you have consistently clean hands, what patients say about you, readmission rates, that can be O.K.,” he said. The counterargument is that “you could screw things up by tying everything to financial incentives,” he said. “You stomp on their intrinsic motivation.”
In response to those incentives, it was written about one doctor:
“His personal rebellion is to linger over patients as long as he thinks it's necessary, the hell with the performance metrics that nudge him to see more.”
That totally reminds me of the dysfunctional relationship between workers and management at my GM factory, 20 years ago. It's sad to hear about these dynamics in healthcare.
Why does the idea of “skin in the game” and incentives bother them so much?
“It really took all of my self-control to not say, ‘What the hell do you mean skin in the game?'” he said. “We have our licenses, our livelihoods, our professions. Every single time we walk up to a patient, everything is on the line.”
They're upset about decisions being taken away from them…
“He continued: “My thought was, I'll put some of my skin in the game if [the administers] put your name on that chart. Just put your name on the chart. If there's a lawsuit, you're on there. You come down and make a decision about my patient, then we'll talk about skin in the game.”
Bad Leadership?
The article raises issues about bad leadership in their hospitals.
An MD says:
“Often people with dissociative disorder become managers. You have to treat people like things. A different way of saying it is sociopath.”
Treating people like things is not what good management (or good leadership) is about.
“What's the widget the hospital produces?” he asked at one point. “It's the doctor-patient relationship. You don't improve it with extra little tasks.”
How do we improve the way care is provided? Ask the hospitalists. Engage them. Work with them. Don't just give them targets.
A new hospital leader said “targets would include how many patients they see, but would also include measures of patient health and satisfaction… “It can't be all based on production,” he told me. “It has to be quality — safety, a good experience. If you're the patient in the bed, it's important to you that you're treated as an individual, that your needs are being met.”
About the new hospital leader…
“Mr. O'Leary was especially proud of a ritual known as REAL rounds, which stands for “rounding embraced by all leaders,” in which administrators circulate through a different unit of the hospital each week and talk to doctors, nurses and other caregivers about their needs.”
REAL was the name chosen – which stands for “Rounding Embraced by All Leaders.” That's a good concept, but th MDs found this name offensive, saying “‘Are you kidding me? Real rounds, as opposed to what we do?'”
What Problems Should We Solve?
Again, from the article:
“Dr. Schwartz said he and his colleagues have always wanted to talk about staffing — ideally, they wanted to agree on a minimum proportion of doctors to patients — and how this affected patient safety. But when they raised these issues in the past, he said, the administration frequently shut down or retreated to marginal details.”
This reminds me of a story from a few years ago, where nurses were complaining about being micromanged on marginal details like pens in the drawer when they were trying to engage leadership on safety.
Incentives and Pay
The article points out how the hospital tried squeezing the docs:
“Hospitalists now earn about $223,000 a year for 173 shifts and are paid extra for working more. The hospital offered $260,000 for a mandatory 182 shifts, and up to $20,000 in bonus pay for hitting certain medical performance targets. The hospitalists work seven days on and seven days off, so this would have effectively eliminated any time off for sick days or vacation.”
Working half the time… that's 365 divided by 2 = working 182.5 days out of the year
“When the doctors pointed this out, the administration responded that if they missed a few days, it would make sure they got extra days to hit the required number of shifts for full pay.”
When it came down to it…
“They preferred to work less and make less to avoid burnout, which was bad for them and worse for patients.”
We need to all work together (physicians and leaders) to devise processes and systems that provide the best care in a way that's financial sustainable and fair for all.
The article paints a picture of a situation where nobody is finding “win/win” solutions.
What's your reaction to the article?
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“What’s your reaction to the article?” The medical diagnosis:
“Often people with dissociative disorder become managers. You have to treat people like things. A different way of saying it is sociopath.”
When these people are in leadership positions, they influence many other leaders and lower-level managers and create a hostile organization that is rich in performance metrics and devoid of humanity.
Whether healthcare of not, organizations devoid of humanity are terrible places to work and destined to fail.
Well said.
We’ve probably both read about how “psychopaths” are drawn to management roles far too often.
One such article is here.
Yes indeed. In my book Lean Is Not Mean, Lesson 66, People and Processes, I say:
“What greenhouses are to plants, batch-and-queue businesses are to psychopaths: a warm and comfortable environment to thrive in… Psychopathic bosses generate enormous amounts of technical and behavioral waste, unevenness, and unreasonableness… The ‘Respect for People’ principle is a repellent to psychopaths.”
Regarding the psychopath comments, I have some people tell me in my organization that “work is not a social endeavor.” What???
Oh, by the way, I work for a behavioral health organization!
Thanks for the comment, Hal. What are healthcare organizations (or businesses) other than a collection of people serving other people? To try to de-personalize or de-humanize that… I don’t get it… and I’m an engineer with an MBA.
Thanks for another interesting story Mark.
Bonuses tied to the quantity of patients seen? Gee, what could possibly go wrong with that…
Someone I spoke with recently gave the analogy of a pendulum, with power swinging to and from unions over the years. Do you think this “first of its kind” case is just an anomaly, or a sign of things to come in the US?
The whole “fee for service” payment structure is an example of pay tied to the QUANTITY of patients. Doctors are paid that way in some other countries outside the US, so that’s not just an American problem. But, its a huge problem here that people are trying to solve through payment reform efforts.
I can’t comment on broader union / labor issues, as I don’t know what the trends are recently. Long term trend is less unionization in private business and more unionization amongst government workers.
One of the things that short-fingered, vulgar oligarchs have truly despised is the elevation of the technocrats – the nerds who rule STEMI – such as physicians, scientists and engineers. Turning them into wage slaves has been a long term goal for them. I wish that I was exaggerating, but I’ve seen in in every industry in which I’ve worked, including healthcare.
But don’t get me started on the density of psychopaths in the C-Suite.
Interesting article and discussion. I have a couple of additional thoughts:
1) I’m not sure portraying hospital leaders and managers as psychopaths or sociopaths is particularly helpful or demonstrative of the respect for humanity that you have pointed out as being the foundation of Lean. Without a question leaders must show this respect and live it every day in their interactions with physicians, nurses, and other staff members. The same, however, is also true of staff members when working with hospital leadership. If the automatic assumption that any change/recommendation/statement from leadership is symptomatic of a deep seated mental health issue then you’ve both inhibited any movement towards improvement and denied that leader their basic humanity. Lean isn’t a one-way street where only one set of people involved get to have their humanity recognized and resected. All people deserve at least this much.
2) What about the patients in all of this? Thinking about the doctor who wants to spend 45 minutes seeing every patient I was left with a nagging question about his other patients? What happens to them? Are they forced to wait even longer for an appointment because the physician can only see so many patients in an eight hour day? Are they forced to see other physicians that they may not want to see but at least they can be seen in a timeframe that meets their needs?
One of the challenges with doing this work is that it is often too easy to focus on meeting the needs of doctors, nurses, and other care-givers while missing out on the needs of others involved. For some patients it’s not enough to know that the doctor felt good about how he conducted the exam that they had to wait several additional weeks to receive. There’s more than one human involved in that relationship and they both should be respected.
Likewise, hospital administrators don’t have the luxury of not thinking about the financial performance of the organization. The salaries of hospital staff don’t just pay themselves. Someone has to work to ensure that that happens. It really shouldn’t be dismissed as being the manifestation of a dissociative disorder.
Everyone involved is a human being deserving of a basic level of respect. Dismissing management as a psychotic behavior doesn’t live up to that ideal.
“Psychopath” is a clinical term and studies show that a large number of them are attracted to management roles.
https://en.wikipedia.org/wiki/Psychopathy_in_the_workplace
The term doesn’t mean they are “psycho killers.”
Being disrespectful doesn’t make somebody a psychopath. Again, it’s a particular clinical definition and not a term to be thrown around lightly.
That doesn’t mean all executives are “psychopath.”
People who are “resistant to change” or different approaches to management aren’t being labeled as “psychopaths” by me on this blog.
I can see where the term, however, is an eyebrow raiser.
Commenting on the other non-“psycho” issues…
You’re right that things have to be kept in balance. Is more time with a patient REALLY leading to better outcomes and results? Is that better care really reducing costs in the long term?
The MDs have a fair point to investigate to see if “squeezing” or rushing them means seeing more patients but not really improving outcomes or the financial position of the organization.
There’s a 100+ year old history of medicine intentionally separating business from medicine. The MDs were freed of that burden. The reality of today’s world is that they DO have to think a bit about money and executives (physician executives or non-clinician execs) need to be leaders and create alignment in the organization about all of the different “true north” objectives that matter.
Brian, psychopath is simply the wrong word to describe “management” in general terms. I would submit that to attain power in any organization thru a appraisal process, a person must, in addition to whatever skills they may or may not have, be a committed organizational participant.
At that point, whatever personal values they may have had, their actions/behavior is by and large antisocial.
I administered a rural health organization with an 18 bed hospital. The prior executive had recently mandated seeing additional patients without, according to what I was told, regularly visiting the hospital. Of course as an experienced Lean executive, that’s the first thing I did. I visited every part of the Value Chain in the hospital. I found a caring, compassionate staff, working in incredible dysfunctional systems.
After my visits, but early in my tenure, I discovered a PowerPoint that had been presented by the medical staff to administration about 9 years before I arrived, and found confirmation for the PowerPoint requests. Ruing my first conversation with the Medical Director, I talked about my approach to addressing issues at the hospital. After a 20 minute conversation, she told me that “She was over the moon.”
I spent time listening to concerns of medical staff. But I also looked every aspect of operations: Pharmacy, Laboratory, Records (EHR and paper), Billing & Coding; recruitment; maintenance; food service; Information Technology; and our rural delivery systems. I formed Leadership teams with a very clear focus. We focused on our patients. With input, the Medical Director and staff talked about changes needed to increase productivity. They wanted to do that because their patient load was so high, they couldn’t deliver quality care. Overflow patients often had nowhere else to go because we were the only provider in a huge area. It did not take long for them to buy in because I let them know that my role was to teach, coach and mentor the team into providing outstanding care.
And the PowerPoint? It addressed issues like hiring medical assistants (we had only one for 5 FT providers); a poor EHR; a severe lack of competent IT support; and a host of others. We laid out a strategy with key executives to address each issue through Kaizen. By addressing support issues for medical staff, they said they could increase productivity by about 50% without compromising the quality of their interaction with patients.
I was learning the concepts of Humble Inquiry at the time, and had a great chance to practice during my introduction to this organization. I didn’t issue mandates. I listened and reviewed what information was available to me and let our medical staff know that the time they spent with patients was their time. My goal was to create more of it by addressing every issue of support.
It takes a long time for us as executives to learn what our role is as leaders, strategic thinkers and chief relationship officers. Opening and keeping lines of communication open are critical. When that is lost, you can only struggle to do the best you can, but systems tend to deteriorate when communication breaks down. One of the goals of a process, articulated by Stephen Spear, is to facilitate flow though unambiguous yes/no communications. I use that goal when analyzing any process. It helped me break down barriers with medical staff. A simple question for me, for example, was could the addition of more medical assistants improve patient care? From my discussion with the Medical Director, I learned in the first 20 minutes that they were doing their own administrative work every day, and that we could make hours a day available by allowing them to offload work to medical assistants. Make sense? Yes. To both of us.
It’s harder to visit the workplace, walk the processes and value streams, analyze pathways tighter with the involved staff and invest wisely in what helps staff do their job. And it’s a difficult balancing act to work with a Pull System that is dysfunctional but believes its doing a good job. For an executive, there are so many moving parts to consider and improve that you risk relationships not only with the medical staff, but all of their supporting processes.
Without an experienced coach, teacher and mentor, an executive new to Lean, especially with a lay board of directors, has to walk a complicated minefield. Good guidance is important. With 8 years of successful Lean executive and strategic leadership, I still had to think and analyze a multitude of decision points every week. I made it easier on me by involving the people working in those systems do that for me where I could.
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