Wednesday, July 25, 2007

The Toxic Side Effects of Change

It is obvious that significant change in the U.S. health care system will be required to correct the quality inefficiencies and simultaneous paralleling rising cost that we are observing today. This redesign also must be part of any successful presidential candidate’s plan, since the voices of change (government, business owners/employers and now patients and their families), are yelling their loudest in decades that both the quality of care and its related cost are unacceptable.

However, with change—whether it be in the clinical arena where treatments are being modified constantly, or in the administrative arena where processes and procedures must be updated to address these redesign needs—toxic side effects of change are inevitable. Therefore, it is prudent for us as health care leaders to predict these toxic side effects in advance so that when they occur, we will not have to face the ever-oppressing question, “Have we made a mistake?”

Such an example in the clinical arena would be the hair loss that occurs in a cancer patient when we are giving them what we hope will be curative chemotherapy. After two weeks of chemotherapy when we walk in to a patient’s room and find him or her bald, we do not say, “Oh no, what have we done?!” We rather say, “Oh, the treatment is working!” In this way, the toxic side effect of treatment proves to us that our ends are being achieved and the patient’s body is undergoing changes as a result.

We must apply the same logic in the administrative decision-making processes we undertake each day to facilitate the changes necessary for creating excellence. In this way, when we observe these side effects, we can say, “Yes, our strategies and initiatives are making a positive difference.”

One example of this would be CHRISTUS’ opening of many urgent care clinics (most are located in Mexico). Clearly, in advance of these openings, we predicted that a toxic side effect would be pushback from some physicians because they believe—inappropriately so—that we are providing poor quality of care and taking patients away from their practices.

Indeed, we have seen this pushback from the American Academy of Pediatrics and now the American Medical Association. The reality is that these clinics, staffed in Mexico by physicians and by nurse practitioners in the U.S., are providing patients with access to care for a limited number of illnesses which are carefully managed by evidence-based protocols that have been designed with strong physician input. Therefore, in no way has quality been decreased.

In fact, quality of care has been enhanced because patients can get access to care more quickly in the course of their illness and therefore more serious side effects can be prevented.

In addition, these clinics are open on evenings and weekends when most physician offices are closed. Physicians are always given the opportunity to work in our clinics, but they obviously must accept the salaries which make these clinics cost-effective. This payment level is readily acceptable and in fact is the standard for physician reimbursement in our international operations. It has been our experience that in America, physicians are not willing to do such.

In addition, we find very few physicians in America who are willing to open their offices in the evenings and on weekends. If they are willing to do so, we would be happy to partner with them to provide our urgent clinics in a joint venture methodology. We must always be willing to joint venture with physicians when they share our mission, vision, and values, and our goal is always to create win-win physician health system alignments. Working collaboratively with physicians has been and will always be a necessity for an excellent health care delivery system.

Another toxic side effect of these clinics is physicians’ fear of losing patients. In fact, the contrary is true in our clinics, where we generate primary care and specialty referrals for patients who do not meet the clinic criteria or do not improve with the therapies that are instituted and therefore require specialty consultation. So, in fact, we like to partner with both primary care and specialty physicians to provide a second level of care if it is necessary.

So as is often the case when changes are made, toxic side effects quickly make themselves known and in fact may turn out to have positive responses rather than negative effects. This of course does not mean that we overlook debriefing to decide what has worked and what has not, but identifying these toxic side effects beforehand will prevent Monday morning quarterbacking, feelings of “Oh my goodness, what have we done?”, etc. This is why before any significant change is made, considerable time and reflection should be spent determining the toxic side effects of a decision so that when they become apparent, there is no second guessing or scrambling to cater to opposing voices.

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