Scott MacStravic, PhD
When I read the interim report on the results so far of Medicare’s Health Support demonstration project, evaluating the impact of chronic disease management programs offered by vendors, providers and insurers, I found the same “mixed results” that have characterized previous scientific studies of health management by government insurers. While some of the projects delivered clearly positive results, there was a lack of “statistical significance” to most, due to small numbers of participants. Indeed, recruiting and retaining enough participants seemed to be a major problem for most project participants.
The report was lengthy, as you’d expect with a government study document, and about as exciting as you’d expect it to be. But included among the hordes of statistics was a table that provided what may be an explanation of the limited success achieved so far. The average fees for the fifteen project participants, covering a range of different and sometimes multiple chronic conditions being managed, was roughly $220 – per month! Moreover, the selection of patients who participated in the projects was sometimes such that their personal medical costs per year were not as great as the fees charged. [“The Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years” Mathematica Policy Research, Inc.(www.mathematica-mpr.com/publications/pdfs/mccdfirsttwoyears.pdf)]
While I claim no great financial expertise, I still vividly recall Macawber’s discussion of the immutable low of economics in Dickens’ David Copperfield. If money out is more than money in, the result is misery and disaster. And if the fees on average equal roughly $2600 a year, and as much as over $5000, the projects started with a serious handicap. There certainly have been cases where a well-managed patient with a chronic condition generated more than $5000 in savings in a given year compared to patients whose conditions were out of control, these are more the exception than the rule.
This suggests two things that may be particularly difficult in government-sponsored studies. First is that providers of health management initiatives should carefully select whom they choose to manage, to ensure that there is room for net savings, given the prices they intend to charge. This may be difficult if payers insist on random selection for intervention and control groups in order to achieve scientific validity.
Second is that perhaps prices should be based on a “leaner” approach to health management so that prices can be set at a level where positive ROI is at least mathematically possible. HCOs everywhere are being forced by payment stinginess to become familiar with lean management of sickness care. If random selection in health management requires managing the health of low-cost as well as high-cost patients, then the ways by which health is managed should be varied for individual patients, on the basis of risk/reward potential.
There are widespread examples of “customization” of health management interventions based on risk/reward potential. The Duke University Health’s “Duke Prospective Health Program”, for example, offers all participants a set of basic support services, while reserving more intensive and expensive services such as case management, personal coaching and risk-specific programs like smoking cessation, to those who represent a real potential for positive savings. (www.dukeprospectivehealth.org)
HealthMedia, Inc. offers automated computer customization based on Health Risk Assessments that virtually ensure that every participant gets feedback tailored to the individual. Its proactive health interventions are widely used by insurers, including Kaiser Permanente, as well as over 200,000 employees whose productivity as well as health can be improved, thereby increasing the savings to employer clients. [“Revolutionizing Behavior Change: Achieving and Measuring Productivity Improvements” HealthMedia.com Oct 11, 2006]
The fact that thousands of employers are continuously and increasingly investing in employee health management, while most insurers invest in member health management may indicate any mix of misguided or successful investments in the non-government sector. Results by local governments, such as the dramatic savings achieved by Asheville, NC in reducing costs associated with patients diagnosed with diabetes, suggests that success is not impossible. [J. Mahoney & D. Hom Total Value/Total Return GlaxoSmithKline 2006] Once investors get the costs closer to the lean management level, we may see some positive results reported even by the federal government, to the relief of lots of taxpayers.
Dan DeLaySenior Vice President, VHA, Inc.
When I tell people at cocktail parties, "I’m into analytics," they frequently either ask me if I know Tom Cruise, can help them with their taxes, or if I wanted to do something else, but it didn't work out. However, I can now hold my head up high. The Wall Street Journal recently published a review of a book titled, Competing on Analytics (Harvard Business School Press) that shows why analytics is the new science of winning.
Written by two individuals who are respected in both academia and the consulting world, the book points out that one of the key obstacles to becoming an analytical organization is cost--mainly the cost of hiring people who understand that analytics is not just data. People who are really knowledgeable about analytics get paid six figures, easy, in most industries. Now you know why I'm not a practicing lawyer anymore. To become an analytics-driven organization means having access to complete and accurate data, as well as having people on staff who can analyze this data and understand what it means in your existing environment, the ability to interpret where trends are taking you, and the ability to guide senior management to make decisions based on that data, rather than gut feelings, past performance, or fuzzy strategic visions.
This sounds awfully cold to people in health care, but it's actually the best way to make sure that health care organizations aren't forced into making decisions that are really cold, such as eliminating services because the hospital has run out of money due to poor planning.
I believe several billion dollars are wasted each year in our nation's hospitals because managers don't have access to information to help them make smarter decisions. That's easy to understand, since the amount of data being produced internally and externally is growing at a faster rate than the organization's ability to process and consume it. Therefore, hospital executives must look only at the data that is critical to support the organization from day to day, with no visibility into data that can signal trouble down the road. To get there, health care leaders must begin to hire CIOs, CFOs and materials managers who understand analytics and who can help their organizations develop analytics as a competency. That's part of the challenge....there aren't a lot of people working in analytics in health care. People with this skill set make a lot more money in other industries -- more than hospitals want to pay. First, we have to set up a way to train health care workers in analytics, rather than tacking this responsibility onto the job responsibilities of buyers and materials managers. Next, I think hospitals will have to bite the bullet and look at the value that seasoned analytics people bring to their organizations and pay them what they are worth.
However, analytics as a discipline can't be owned or siloed into any one area. Health care organizations must develop the processes to disseminate analytical data so it can be used, really used, by everyone. This doesn't mean simply circulating another management dashboard report. Those reports frequently don't contain actionable information.
No industry needs analytics quite as much as health care, yet it continues to bury its head in the sand and ignore the opportunity that analytics presents. Until the industry takes a good look around and recognizes the value of analytics, things are destined to remain the same.
A recent ruling by federal agencies that regulate the practice of paying incentives to employees for better health status or behavior makes it necessary to pay those who do nothing different. With three different agencies involved (Departments of Health & Hospital Services, Labor and Treasury), it is probably no wonder that some strange regulations have emerged, but this may be one of the strangest – though it also may also make sense.
The new rules recently announced require employers to manage their incentive programs in ways that give every employee equivalent opportunities to earn incentives. This includes employees that have no health problems to begin with, and those that make no health progress despite participating in a wellness effort – in other words, employees who do nothing that could improve their health and thereby deliver any value to their employer.
When employers offered a $250 incentive just to smokers, for example, for participating in a smoking cessation program, this motivated a number of their non-smoking peers to take up the habit merely to qualify for the incentive. Smokers who participate, but cannot seem to quit due to the strength of their addiction, deserve being paid the incentive for trying, says the government.
Given the addictive nature of overeating, plus possible genetic causes for overweight, the government has ruled that employees who try, but fail to gain weight, or gain it back once lost, still deserve the incentive for trying. Healthy employees should be able to gain rewards just for staying healthy, as well, while unhealthy ones should not be shut out if they try but fail to make progress. [MP McQueen “Wellness Plans Reach Out to the Healthy” Wall Street Journal Mar 28, 2007 D1, D3]
How Stupid Is This?
Normally, employers understandably focus on employees who have significant risk/reward potential because of their health status, risk behaviors or conditions, or existing chronic diseases. But increasingly employers are looking to relatively and even perfectly healthy employees as well, to keep them from becoming at risk and contracting chronic or acute conditions that would cost the employer money. And that is a significant risk.
It has been shown many times that, left alone, employees tend to increase their risk status and contract disease over time, even if they start out healthy. Some of this may be due to aging, but often it is simply the result of employees tiring of healthy behaviors and giving up on efforts to maintain their health, absent new or increased motivation. If their peers are eligible for and obtain rewards for reducing their levels of “unhealth”, healthy employees may report that they have a risk merely to become eligible for similar rewards, and HIPAA regulations prohibit the sharing of individually identified health information, so such reports cannot be verified.
Quest Diagnostics promoted participation of its employees in an annual health risk assessment (HRA) survey, with an 18-page individualized report and recommendations for change to each participant. If found that at the end of the first year of this program, 37% of employees had reduced their risk level from high to low. But 13% of employees had increased their risk level from low to high in that same year. [S. Solovich “Employers Market Good Health to Cut Insurance Costs” East Bay (CA) Business Times Mar 9, 2007 (eastbay.bizjournals.com)]
Not only is health risk status unstable, the sheer number of health risks employees have makes a big difference to their productivity, as well as their health care costs. For example, one analysis found that employees with no health risks at all had an average productivity impairment of 1.8%, while those with eight or more risks had an impairment of 24.2%. On average, adding one risk increased impairment by 2.8% each. [W. Lynch “Evidence of the Expanded Economic Value of Good Health” Controlling Costs through Effective Human Capital Investment Integrated Benefits Institute Conference Nov 19-23 2003 (www.ibiweb.org)]
Since the average compensation of employees in hospitals is roughly $60,000 per year, this means that each risk added represents a productivity impairment cost of 2.8 % of $60,000 = $1680. With the average multiplier effect (reflecting the impact that the absence or lower productivity of one employee has on peer productivity) of 1.4 for nurses, the major employee category in hospitals, this means a total impairment effect of 1.4 x $1680 = $2352 per risk factor. And if the true value to the organization is as little as two times the compensation paid each employee, the negative value impact would be 2 x $2352 or $4704 per risk factor per employee per year.
While there is no way to determine what combination of factors might cause the kind of significant risk increase reported by Quest Diagnostics (whose employees are similar to those in hospitals) in just one year, its example illustrates the logic of focusing at least some attention on healthy employees, just to keep anything bad from happening. When the “gaining” one risk factor can reduce productivity as much as 3 percent, and cost the organization as much as $5000 per risk added per employee per year, it is surely worth plenty to pay employees merely to maintain their health/risk status where it is. Hence, there is some logic to “paying them for nothing”.
Of course, if HCOs wish to avoid paying incentives merely for trying or participation, with no evidence of positive change or effects, they have the option of creating a performance-based compensation system, or even bonuses for attendance vs. absence. Since improved employee health is known to improve their productivity and other performance measures, by paying only when these improve, HCOs can avoid the paying for nothing problem. Since healthy high-performing employees are at risk for becoming unhealthy, offering them wellness programs for maintaining their health may succeed even without extrinsic rewards, as long as employees see the connection between their health and their compensation.
I can remember the days when there were no CEOs in hospitals, only “administrators”. Now many have a wide variety of C_Os, with middle initials related to “Experience”, “Financial”, “Information”, “Marketing”, “Nursing”, “Operations”, and other domains important to success and survival. Perhaps it is time for some to consider adding a “CPO” (already suggested by some as meaning a Chief Privacy Officer”) where the “P” stands for “Performance.”
This does not mean the HCO’s overall performance, since CEOs and COOs are responsible for that. It relates specifically and exclusively to workforce performance across the entire organization, and aims at continuous analysis and improvement thereof. It would include at least four major approaches to promoting improved performance:
1. Improving work environment and culture could involve focusing on the HCO’s vision, mission and accomplishments to stimulate enthusiasm, commitment and motivation among employees. It could also include greater employee self-determination and autonomy, with respect to work processes, hours, even places of work (for those not involved in direct patient care). Best Buy, for example, achieved an immediate 36% improvement in productivity, while reducing turnover from 16.6% per year to zero by enabling its corporate office employees to choose their own places and times to work, as long as they produced up to standard.
2. Improving employee health has been shown to improve worker quality of performance, on both technical and service dimensions, in HCOs as well as other industries. Higher productivity thanks to reduced absenteeism, presenteeism, and turnover has been widely reported where these are measured, along with increased customer satisfaction and new business. Of all industries, health care should probably be leading the realization of the performance improvement potential in employee health.
3. Selective incentive/reward systems include all methods that pay employees differently depending on their measured performance, as individuals or teams. This has been shown to improve performance in two distinct, though related ways: a) stimulating employees to perform better for the greater rewards it can bring them; and b) stimulating high-performing employees to remain and low-performing employees to look elsewhere for employment. This shifts the mix of performers over time toward a higher proportion of high-performers, and thus improves overall performance.
One company, for example, switched from a standard hourly wage system to a productivity-based “P4P” system. If achieved a 44% increase in productivity in the first year the new system was in place, with an average increase in wages of only 10%. It also found that in the second year of the new system, turnover among low performers increased significantly, while turnover among high performers dropped by 21%. [E. Lazar “Performance Pay and Productivity” American Economic Review 190:5 Dec 2000 1346-1361]
4. Selective recruitment/retention systems aim at improving the mix of employees hired and kept through non-financial means. More systematic testing and interviewing of prospects as well as the use of current employee referrals, and looking for candidates as much like existing high performers as possible can help in this reward, and is helped, in turn, by pay-for-performance systems. The better the tools are used in assessing prospects, the more the “quality” and performance of new-hires, and thus of the entire workforce over time, are likely to improve. [C. Handler & S. Hunt “Estimating the Financial Value of Staffing-Assessment Tools” Workforce Management Mar 2003 (www.workforce.com)]
General retention can be improved by a wide range of means, including the integration of benefit programs and customization of benefit packages to individual employee preferences. Selective retention includes any mix of non-financial methods used to increase retention of high-performers and to get rid of low-performers. Recognition and development of higher performers can reinforce the effects of differential rewards, for example.
As for selective removal of low-performing employees, simply firing low-performing workers has been recommended by many leaders as an essential “weeding out” process that enables higher-potential replacements to be identified and recruited. Jack Welch, former CEO at GE recommended firing the lowest 10% of performers annually, for example. But this may cause internal unrest and interfere with the development of teams.
On the other hand, it has been shown to have measurable positive impact on overall workforce performance. So-called “forced distribution rating systems” that identify and fire a set percentage of low-performing workers can work. In general, the average annual improvement in performance was found to be roughly 16% in the first two years of application, though this fell to 2% in the sixth year and 1% in the tenth. Actual results in specific situations would depend on the rate or overall turnover, for example. [S. Scullen, et al. “Forced Distribution Rating System and the Improvement of Workforce Potential” Personnel Psychology 58:1 Spring 2005 1-32]
The only reason for suggesting a CPO as the basis for integrating or at least coordinating all four approaches to performance improvement is that this can overcome the kinds of “silos” that may otherwise prevent recognition and management of the interconnections across all four methods. Since HCOs are in a unique position, thanks to increasing P4P revenue they can gain as for their overall performance, the better that employee performance can be managed, the better is will be for HCOs, and they will have the financial data to prove it.
Dan DeLaySenior Vice President for Supply Chain AnalyticsVHA Inc.
Of all the professional sports, baseball is a true game of numbers. Have you ever stopped to think about the amount of information that is taken into consideration in the game of baseball? With some quick research, I found 29 different statistical categories a manager can use to determine a players performance against a pitcher on the other team. For example, I discovered that in 2006, David Ortiz from the Boston Red Sox had an on-base percentage of .413, a slugging percentage of .636 and 119 walks. Talk about having the information you need to make informed decisions!
Thanks to technology, this information is available at a moment’s notice to anyone who is interested in stats about their favorite team, favorite player, or is a fantasy baseball fanatic.
It might be hard to relate health care to America's favorite pastime until you look at two key components--analyzing performance and having access to information. Just as a manager needs to consider how his players perform in different situations, such as against a left-handed pitcher, on artificial turf or with runners in scoring position, hospitals need to understand how their supply operations are performing. From automating purchasing processes to managing supply costs and charges together, from ensuring that purchases are made on contract to being able to identify funding for capital projects, these issues can all be addressed by fully utilizing technology so you have access to data you need to make better decisions.
As cost pressures continue to rise, hospitals need to continue looking for ways to accelerate their financial and clinical performance. That is why incorporating analytics into health care is so important--it combines essential data elements, analytical expertise and the latest technologies to provide insight into your supply operations, allowing you to use information to quickly focus on your hospital’s most important issues.
Analytics play an important part of the game of baseball, and thanks to the challenges we face in health care today, it is becoming an essential part of our industry's story. Even though health care “ain’t what it used to be,” to paraphrase baseball legend Yogi Berra, we have the opportunity, the resources and technology to make it better.
Robert FrombergEditor-in-Chief, HFMA
Essayist, screenwriter, and director Nora Ephron is a chronic reviser.
Here is her process: She types the first paragraph of the piece, stops, and reads it. Next she retypes that paragraph, revising as she types, and then types a second paragraph. She stops, reads the two paragraphs, then retypes them, revising as she goes, and adds a third paragraph.
She continues in this fashion until she has a complete piece, the beginning of which has been revised 20 or 30 or times, and the last paragraph of which is virtually unedited.
Ephron wrote an essay describing this process in response to an invitation to contribute to an anthology about revision. Unfortunately, Ephron’s revision process is such that she did not complete the essay until two years after receiving the invitation.
Contrast this approach to that of my grandfather, an anthropologist who wrote numerous books. I once asked him how many times he revised his manuscripts. “None,” he replied. “I sit in front of the typewriter and think about the first sentence until it is perfect. Then I type it. Then I think about the second sentence until it is perfect. Then I type it.” I hate to imagine his response should a colleague or editor suggest changing one of his “perfect” sentences.
Contrast both these approaches to the following situation. I wrote an e-mail message asking the recipient to choose one of two mutually exclusive options. The response, received 90 seconds after I sent the message, was one word: “Yep.” (I interpreted that to mean I could choose whichever option I wanted.) Too much revision was not this person’s challenge.
The drawbacks of all three examples above are obvious. So I’ll skip them. Instead, let’s look at the virtues. After all, these are three very successful people. Nora Ephron has great energy and ideas. My grandfather demonstrated a single-minded dedication to a desired outcome. And the person who provided the one-word answer showed a let’s-get-it done spirit. Imagine what it would be like to get those three people together to work toward a common goal.
As you may have guessed by now, this post is not about revision. The different approaches to revision popped into my mind as I was reading two pieces in this issue of hfm magazine. Each piece deals with the challenge of getting temperamentally different people to work together constructively--a challenge that healthcare financial executives know very well.
The April cover story in hfm magazine, “Dollars and Sense: Engaging Physicians in Supply Cost Reduction” by Jeni Williams, gives several examples of how savvy organizations are combining the clinician’s craving for clinical data and the financial executive’s craving for financial data into collaborative projects to control supply costs. And in “Bridging the Gap Between Nursing and Finance,” HFMA Chairman Joe Fifer writes about his efforts to understand the mindset of nursing by swapping roles at a recent presentation, at which Joe spoke about nurse staffing ratios while his organization’s chief nursing officer spoke about financial ratios. “The swapping of stories was more than symbolic,” Joe writes; “it represented an honest respect for each other’s role and disciplines.”
People with vastly different styles often are put in situations where they must set aside their differences to achieve the same goal--whether they be writers collaborating on a piece for publication or financial leaders and clinicians working together to ensure the success of a hospital. If Nora Ephron, my grandfather the anthropologist, and the one-word e-mailer were in a room together, there would be gnashing of teeth and rolling of eyes. But if they got beyond that stage--as has happened in the examples in this month’s magazine--the results would transcend revision.
The healthcare industry has long been accused of being subject to the “law of the hammer”, or reflecting the fact that when you have a hammer in your hand, a lot more things begin to look like they need nailing. It is well known that the kind of treatment you get for whatever ails you is greatly influenced by the particular specialist you go to, for example, and that the higher-tech academic medical centers tend to deliver more intensive and expensive care for similar conditions, without necessarily producing better results.
When hospitals and physician practices invest in new or upgraded facilities and equipment, they presumably do so in order to improve their capabilities in quantity, quality or both. But they automatically also increase their fixed cost overhead and need to generate added revenue merely to cover the additional costs. There is always the risk that the capability will be accompanied by a compulsion to use it, since otherwise the hospital or practice may not prosper or even survive.
I recall one multi-specialty practice I worked with that used what seemed on the face to be a rational and conservative policy regarding investments in new technology. Whichever of its specialties requested the investment became at risk for ensuring that the investment paid off. If the new diagnostic or treatment technology did not generate enough revenue to cover its costs, those particular specialists would have to take an income cut in order to make up the loss.
This policy would clearly tend to make the physicians more careful when proposing new investments. But it would also make them feel even more pressure to see to it that the “hammer” was used often enough, and potentially move them toward over-prescribing its use in marginal cases. The combination of not wishing to be perceived as mistaken in making the investment recommendation, not wanting to harm the practice’s performance, and wanting to avoid an income reduction could combine to create a powerful compulsion.
The perception that this potential exists clearly prevails among patients and payers. In a recent example, Whole Health Management, Cleveland, Ohio, for example, a healthcare organization devoted exclusively to onsite medical clinics and wellness centers that promote employee health and productivity, enjoyed a significant advantage when competing with a local hospital that was also bidding for an employee medical clinic contract.
Whole Health could fully align the interests of all parties, the employer, the patients, and itself as provider in pursuing and achieving the results the employer desired – healthcare cost reductions plus productivity improvements. By contrast, the hospital’s “…inherent need…to obtain use of its services and fill its beds…” created conflicting interests. [L. Butcher “The Workplace Doctor Is In” HealthLeaders Magazine Mar 2007 (www.healthleadersmedia.com)]
For example, when the City of San Angelo, Texas opened an onsite medical clinic for its employees, in its first year of operation, employee ER visits were cut by 85%. The risk manager for the city, originally skeptical about the value of the clinic now works as a consultant for CareHere, LLC, another developer of onsite clinics that is promoting such sources of care for governments and school districts throughout the country. While Whole Health focuses on large employers with 1000 or more employees at one location, CareHere aims for those with only a few hundred. In any case, there appears to be the potential for many thousands of such clinics in the US, which will not only compete with but reduce the demand for traditionally sickness-focused hospitals and physician practices. (www.carehere.com)
It is certainly a legitimate question – whether traditional providers can compete in the proactive health management market, encumbered by their capability/compulsion mix in the reactive sickness care market, which will, after all, persist even if proactive health management efforts succeed, though at a lower level than otherwise expected. There are hundreds of traditional providers already competing in this market, proving that the encumbrance is not totally debilitating, and the missions not incompatible in practice. But there is likely to be at least a perception of potential conflicts of interest when traditional providers compete with the growing number of organizations that are specializing in the proactive market.
John Britt and Karen ProctorHealth Sciences Advisory Services, Ernst & Young LLP
Clinicians generally favor routine over the dramatic, protocol over chance and predictability over variance. Their clinical training has helped to shape a conceptual framework that has quality patient care at the nucleus. In the healthcare industry, pressures to improve financial performance can create tension between senior managers who are facilitating initiatives to improve revenues and/or reduce costs and clinicians who may view such initiatives as a potential threat to how they care for patients.
While senior managers often view change initiatives as opportunities for themselves and their business, clinicians view change as disruptive and intrusive. The meetings, manuals and mandates only serve to draw the clinicians’ attention away from taking care of patients. The frustrations are intensified for those clinicians with a productivity standard. They may begin to believe senior leadership has placed unrealistic expectations on their time and thus the gap between senior managers and clinicians widens.
To obtain the clinicians “buy-in” to the change initiatives, senior managers must understand the currency and exchange rate of clinicians; that is, what has value for the clinicians and what are they willing to accept in exchange for changing their work behavior. What senior managers offer must be at least to equal to or greater than the value the clinicians perceive from the status quo. If senior managers want to influence sustainable change in clinicians’ work behavior, they should be prepared to answer these two questions:
Patient Care
In most healthcare organizations, the mission drives reinvestment of at least some of the profits back into the organization. Unfortunately, senior management does not consistently articulate this to clinicians in a personal and meaningful way. The unwritten rule is that the details of the financial performance of the organization belong in the board room or are at least stalled at the management level just as the condition of the patient is confidential and protected at the clinical setting.
The interdependence between producing good clinical and financial outcomes can hardly be argued. Senior managers must be poised to communicate the “change effort request” in the context of financial outcomes which, in turn, can have an impact on patient outcomes. Clinicians who can envision how changes in their day-to-day operations can ultimately lead to increased or better resources which can have a positive impact on patient care are more likely to abandon the known, current work method or behavior for an unknown work method or behavior. In essence, clinicians will calculate a return on investment (ROI) of their time and energy much the same as a banker would calculate the ROI of a cash investment. The perceived reward must be greater than the perceived risk.
Example: Dr Jones, a hospitalist employed by the hospital, admits and follows a large portion of the patients admitted to the hospital. An audit clearly reveals that Dr. Jones is under-documenting which leads to under-billing. Since the hospital employees Dr. Jones, the opportunity cost (dollars unrealized) associated with the under-billing belongs to the hospital. Dr Jones acknowledges his opportunity to improve his documentation but couches any intended change of his actions in perceptions of overwork, high volume of patients and limited resources.
The intended change for the hospital in this scenario is improved documentation leading to improved coding and thus improved reimbursement. Dr. Jones has calculated the ROI of the proposed change and has determined that the time and energy to improve his documentation, in short, is time spent that could have been spent managing the care of his patients.
One potential solution to this dilemma is for the hospital to run a pro-forma which estimates the anticipated increase in the revenue had the physician had complete documentation. With these additional revenues, the hospital could consider potential additional resources to leverage the physician’s time (physician assistant, nurse practitioner or perhaps refined documentation tools) which leads to a sound financial ROI for the hospital and a sound patient-centered ROI for the physician. It is this type of thinking and communication in which senior management can legitimately influence clinicians’ work behaviors.
The Clinician
Clinicians are not immune to personal motivators. Once the question of how the proposed change will affect the patient care has been cleared, the clinician will naturally consider the impact of the change personally. This question of, “what does this change mean for me” must be addressed as senior managers consider the introduction of change. Areas to consider in regards to motivating the clinician on a personal level include their:
Calendar. The point here is that time is a precious resource to the clinician and should not be squandered. While the creation of buy-in is important, senior managers should exercise caution in how they approach clinicians who are, by and large, very intelligent people. A straightforward approach with attention to the clinicians’ opinion demonstrates respect. In the face of a proposed change effort, clinicians will want to know how fast (urgency) and how much (quantity) of their time will be required.
Curriculum vitae. The curriculum vitae is a metaphor for the psychological dimension that should be considered in a change effort. An organization with a system (formal and/or informal) of recognizing employees and others for their commitment to the organization (including change efforts) find that this practice can be an effective motivator or, at least, reinforcer of work behavior change. Be careful not to trivialize the psychological rewards. Overuse may lead to a feeling of superficiality actual become a de-motivator for the clinician.
Wallet. Money motivates some people. Agreements that equate dollars to performance are not uncommon. In the healthcare arena, such proposed agreements should be removed by the organization’s attorney prior to memorializing the agreements and the issue of parity should be considered. Money could also become a de-motivator so make sure the terms of the expected work behavior or outcomes are clear and easily measured.
Summary
Change management requires-well management. While this article has dissected what change means for the patient and the clinician in the mind of the clinician, the two concepts are, in fact, inextricably linked and not so easily separated functionally. In healthcare, when the change spills over into the clinicians’ arena, senior managers must be cognizant of the medium of exchange (currency) and the relative value to the clinician. A business case for change is appropriate for clinicians but it must be a business case that does not stall in the category of profitability but one that circles back to relate the benefit in a currency with an exchange rate that is worth the clinicians’ investment in change.
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The views set forth herein are those of the authors and do not necessarily reflect the views of Ernst & Young LLP.
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