21st Century Healthcare Economics: How Will My Practice Change? Kenneth H. Cohn, M.D., MBA, Facilitator CEO, HealthcareCollaboration ken.cohn@healthcarecollaboration.com http://healthcarecollaboration.com
Overview • • • •
21st Century Healthcare
Context Burnout Leadership Moving beyond malaise
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I. My Journey • • • • • • • • •
Recovering academic surgeon Valentine’s Day Massacre 1996 “I’m not ready to move!” MBA school “How will your teaching residents practice management bring in revenue?” “At least your future is the Tuck School’s responsibility.” 1st consulting job: “You need to stop thinking like a doctor!” 2nd job: Puff, the magic dragon MVA: Gretsky strategy
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Context: What We Know from the Literature Physicians are experiencing 11 distinct losses, including: •  losses of financial security, status, independent clinical decision-making, collegiality, freedom of choice of specialty and practice location, and power in hospital governance Daugird Arch Fam Practice 1996;34:497-501 Jonasson Ann Surg 1996;224:574-582 Knight, Am Surgeon 2002;68(6):519-523 Campbell Surgery 2001;130:696-705
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ACS Survey: N = 7905 • 40% met criteria for burnout • 30% screened positive for depression • 28% had lower mental quality of life score
Shanafelt TD et al. Burnout and career dissatisfaction among American surgeons. AnnSurg 2009; 250:463-471. Balch CM et al. Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg 2010; 211:609-619.
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II. Dealing with Workforce Burnout: Dx • Burnout happens when work and/or personal demands exceed one’s ability to cope: – Emotional exhaustion (“last spirochete just died”) – Depersonalization (decreased ability to empathize) – Lack of accomplishment (spinning wheels) Cohn KH, Panasuk DB, Holland JC. 2005. “Workplace Burnout,” in Cohn KH. Better Communication for Better Care: Mastering Physician-Administrator Collaboration. Chicago, Health Administration Press, 56-62.
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Burnout Dx, II • Collect and monitor data: – Patients seen during and after hours – After-hours EMR sign-ons – Committees and projects with deadlines – Patient outcome issues – Family difficulties (not weakness or tattling) – Change in appearance or affect – Ask what is going on
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Workforce Burnout: Rx • Duty to intervene before patients, families, and physician’s career suffers (vs “there but for the grace of God…”) – We all need help at some times in our life • Express support and concern: – “I may be wrong, but I am concerned that life is getting difficult for you. We all have times when we can use someone to vent to. I would like to help. Can we find a convenient time to talk in the next couple of days?” • Avoid the commodity approach: – “Suck it up or we will have no choice but to replace you!” 21st Century Healthcare
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Burnout: Rx, II Proven interpersonal remedies: • Sharing feelings with others • Showing concern for colleagues • Respecting colleagues’ time off Proven intrapersonal remedies: • Humor (TV or movie comedies, jokes) • Exercise • Meditation, periodic “bilge-pumping” breaks • Vacation 21st Century Healthcare
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Curt Marsh
http://www.imageslides.com/Sports/gallery/2313-Classic-Photos-ofthe-Oakland-Raiders#19 21st Century Healthcare
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The Healthcare Athlete Metaphor “When I came to my first NFL camp, it was like I was a tall, cold can of beer. They popped the top and all that energy and desire and ability came out…. When I was empty, when I had no more to give, they just crumpled me up and threw me on the garbage heap. Then, they grabbed a new can and popped him open, and he flowed out till he was empty.” Curt Marsh, Oakland Raiders, ‘81-86 Sports Illustrated May 7, 2001, p.62
Are we being treated like commodities? Is it time for us to rethink leadership?
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III. Leadership Leadership is a process of achieving worthwhile results, while acting with respect, care, and fairness for the well-being of all participants – Something you do with people, not to people – Best way to increase your influence is to surround yourself with people who have skills that you do not have (Collaborate for success) Blanchard, K. 2007. Leading at a Higher Level. New York: Prentice Hall.
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Analyzing Your Leadership • • • •
Are Are Are Are
people people people people
following? changing? growing? succeeding?
Maxwell JG. 2008. Leadership Gold. Nashville: Nelson Books.
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Team-Building • A team is a small number of people with complementary skills, who are committed to a common purpose, performance, goals, and approach, for which they hold themselves mutually accountable • Common purpose creates a leveling effect, decreasing the importance of titles • Leadership of a team tends to rotate based on expertise in a given area
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Team-building, II • Leaders generate trust, provide direction, focus on meeting deadlines and achieving results, and occasionally create enemies to inspire competitiveness and dedication • Interdisciplinary teams are key to process improvement Katzenbach & Smith. The discipline of teams. Harvard Business Review. March-April 1993, 111-120.
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Admitting Uncertainty Energizes Team
Leadership Styles • • • • • •
Command and control Pace-setting Visionary Democratic Affiliative Coaching Goleman D, Boyatzis R, McKee A. 2002. Primal Leadership: Realizing the Power of Emotional Intelligence. Boston: Harvard Business School Press.
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A Healthcare Professional’s Perception of Top-Down Management
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Healthcare Champions: Overview • Have earned the respect of their peers • Clinically savvy: the experts • Come from all fields of healthcare • Have a vision of the greater good • Willing to invest social capital • Want to remain invested in their communities
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Possible Roles for Champions • Present and discuss clinical data • Create a safe environment for learning • Minimize turf battles • Help to build transparency and trust • Through the process of discovery, act like owners • Leave a lasting legacy
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IV. The Challenge of Transitioning Path is unclear No one is telling you what to do Outcome in doubt Expense realities No shortage of ways to expend scarce resources without any guarantee of success • Failure not an option • • • • •
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Clinical Skills Assessment In what areas do I shine? How do I know? What strengths can I build on? What gives me pleasure? What do I want said about myself in 5, 10, 15 years? • How can I work smarter? • • • • •
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Financial Assessment How do I earn money? Where do I spend it? For what do I save? What are my annual needs? What are my wants and timetable for satisfying them? • What is my/ my family’s risk tolerance? • How can I be (more) proactive? • • • • •
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Strengths to Project • Authenticity, integrity • Excitement, passion, curiosity, can-do attitude • Active listening • Service: sense of wanting to be part of something larger than self • Comfortable with uncertainty and ambiguity
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Reflecting on Your Niche Expertise: What are you really good at? Passion: When was the last time you felt really alive?
Market: What skills that you possess do people pay you to use?
Where the circles intersect brings you closer to your niche Collins JC. Good to Great. New York: Harper Business; 2001.
Reinvention There is only one real deprivation, And that is not to be able to give one’s gifts... The gift turned inward becomes a heavy burden, Even a kind of poison It is as though the flow of life were backed up. May Sarton (1912-1955)
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Enacting Reinvention: Overview • • • •
Listen to people you are trying to serve Tune into trends outside your field Find the holes in the road and pave them Regularly challenge what made you successful in the past Leadership is finding a bunch of people going in one direction and jumping in front of them. -Willie Nelson Harari O. 2007. Break from the Pack. Philadelphia: Wharton School Publishing.
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A Ten-Step Approach to Reinvention • Assess your clinical skills, financial assessment, and strengths • Discuss your answers with significant others • Form a group to continue discussion and to promote accountability • Network to discuss your ideas with anyone who will listen • Develop and demonstrate expertise by listening, writing, and speaking
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Reinvention, II • • • • •
Chunk big projects into 2-week steps Reflect on progress quarterly Systematize your learning Celebrate all successes Enjoy the journey
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Advice from Someone Who Has Been There “Think of your current career as a spring-board to your next one, not as a prison to escape from.” Doug Patten, VPMA, Phoebe Putney Healthcare System
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Action Ideas Task
Person
Deadline
1.
2.
3.
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Recommendations • Give yourself time to adapt – 21 days/ new habit – at least 90 days/ new way of earning income • Make self-self comparisons over time, not to others • View money spent on learning as an investment • Be open to all feedback • Keep paper and pen nearby • Start NOW • Have the courage to begin and the persistence to endure Tracy B. 2007. The Luck Factor: How to Take the Chance Out of Becoming a Success. Niles, IL: Nightingale-Conant. 21st Century Healthcare
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Keys to Peak Performance • Motivation – laser-like focus on goals • Dedication – partial achievement not an option • Involvement – passion: belief in self/goals; refusal to see self as victim – willingness to take risks; fear lost opportunity > failure
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Keys to Peak Performance, II • Present orientation – recognize and limit anger (past) & fear (future) • Chunking – overwhelming tasks into smaller pieces • Judgment – self-self comparisons, kaizen, celebrations of small victories – perspective: detached self-awareness, battle joy, humor
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Reframing Our Perspective • The golden age of medicine (1965-85) was an anomaly • In 1913, the AMA estimated that no more than 10% of physicians were able to earn a comfortable living • Intrinsic dissatisfaction can lead to social good • “It’s the sand in the oyster that creates the pearl.” Zuger A. 2004. "Dissatisfaction with Medical Practice."New Engl J Med 350(1):69-75
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IV. Moving Beyond Malaise Listen to patients talk about what was good about their healthcare experience. They will often express it in terms that describe how much someone paid attention to them, really cared for them, listened to them, or improved their life on a very personal level. There is no machine that can replicate that sensation. Marcus LJ, Dorn BC. 2001. Beyond the malaise of American medicine. J Medical Practice Management;16(5):227-230. 21st Century Healthcare
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Moving Beyond Malaise, II • The pendulum has swung far from the center. What forces will it take to push it back toward a more balanced future for medicine and medical practice? • This is a time of opportunity, one in which we define a new mission and role for ourselves... Consumers want us to remain key to the workings of the healthcare system.
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Moving Beyond Malaise, III •  When our patients are facing a frightening procedure or a discouraging diagnosis, it is common for us to comfort them by offering a course of action, something that can be done to offer them a sense of hope, and with it, a future. This formula is what good medicine is about, and it is time we do the same for ourselves and for our profession.
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Possible Approaches to Current Problems Problem
Solution
Complexity
Dialogue
Victimhood
Leadership
Exhaustion
Passion
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Top Three Physician Desires N > 1500 • Meaningful work that makes a difference in people’s lives • A sense of community and camaraderie • Regular, reliable positive feedback that affirms participants’ value Wong B. A Prescription for Physician Reengagement. Futurescan 2009. Chicago: Health Administration Press, 23-26.
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Why Act Now? • Our present non-system of healthcare delivery is unsustainable • We are moving from volume-based measures of productivity to more value-based metrics • Silos are interfering with consumers’ and regulators’ demands that healthcare become more seamless • Regardless of the outcome of the 2012 election, we are facing pressures to develop more coordinated, cost-effective care • When the trap door shuts, providers who are least ready will get hurt the most 21st Century Healthcare
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Possible Reactions • Retirement • DABDA: denial, anger, bargaining, depression, acceptance • Apathy • Engagement
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Engaged Healthcare Professionals: Exceed expected level of effort Are inspired to do their best work Feel part of the greater work community Make meaningful contributions through their work • Are personally motivated to help their organization succeed • Feel valued for their work contributions • • • •
Achieving Breakthrough Engagement: Lessons from HighPerforming Organizations. 2007. Washington: The Advisory Board Company, p.14. 21st Century Healthcare
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The Collaboration Multiplier
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The Genius of Einstein
"We can't solve problems by using the same kind of thinking we used when we created them." 21st Century Healthcare
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As the portions grow smaller, table manners may deteriorate
Can we find solutions that enlarge the pie? 21st Century Healthcare
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Change • Change is disturbing when it is done to us. • Change is exciting when it is done by us. Rosabeth Moss Kanter, Professor, Harvard Business School
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Asking the Right Questions Instead of asking: – When are they going to grow up? – Who dropped the ball this time? – Who’s going to solve the problem they created? – When is somebody going to train them? – Why is this happening to me?
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Asking the Right Questions, II Substitute: – How can I help? – How can I adapt to the changing healthcare marketplace? – What can I do to develop my talents? – How can I understand better others’ challenges and frustrations? – How can I become part of the solution? Miller JG. QBQ: The question behind the question. Putnam, NYC, 2004
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QBQ Prayer God grant me the serenity to accept the people I cannot change, the courage to change the one I can, and the wisdom to know… it’s me!
Miller JG. QBQ: The question behind the question. Putnam, NYC, 2004
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Conclusion • We are facing a decade of transformation that will revolutionize healthcare delivery and dramatically change the way we practice medicine • The choice is up to us whether we shape the transformation or fall victim to the forces of creative destruction • Start now, working together to improve clinical and financial performance
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