Rationing Health Care

Before I begin my blog post today, I would like to extend my sympathy to the Kennedy family on the loss of Sen. Ted Kennedy. Regardless of one’s political views or affiliations, it is clear that yesterday, health care reform lost a great friend, and our country lost a great legislator and a bright light upon the death of Sen. Kennedy. His legislative legacy is great, but I am disappointed that the great man who fought for health care coverage for all Americans since 1966 did not live to see the current reform initiatives brought to fruition.

As the health care reform debate reaches a fever pitch, one of the constant concerns being expressed in public forums and congressional offices is that reform will bring about the rationing of health care, meaning the government or some designated body will be given the ability to control when and what services are provided to patients.

In reality, rationing is occurring in health systems in some form all across America today. People are denied access to primary care appointments, must wait in line to see some specialists, are told by some physicians that their conditions are not severe enough and should wait for further deterioration or increasing pain before a “curative procedure” will be provided, etc. In addition, blood bank supplies are not endless, and often borderline anemic patients do not receive transfusions that are given to patients who are much more critically ill or who suffer from trauma or having large procedures on their heart or vascular systems.

Clearly, as new technologies such as contrast-related MRIs and robotic surgical robots are developed, they are slowly made available as they are tested and made more affordable, during which time they are extremely limited to small populations of people who are in the right place or whose financial situations or insurance gives them the opportunity to take advantage of this service during this initial startup phase. This is one way in which rationing is a part of our health care system every day—new technologies are available only to a select few who can access and afford them.

But an even clearer example of rationing is in the area of dialysis, a much more common procedure which is increasingly utilized by a larger number of people in America in order to sustain their lives until either their kidney disease is reversed with new and more modern medicine, or kidneys become available through live or cadaver donors. When dialysis was first developed, just like the initial MRI, the procedure was only available in the very largest of health centers, and was only provided in a very high cost and intensive inpatient setting. During this development phase, there were many people who could not avail themselves of this much-needed procedure, and hence died. In addition, because the number of people who could benefit from dialysis--even at the centers that were fully operational--exceeded the staffing and machine capabilities of these centers, the patients were prioritized according to the ones who would receive the most benefit from these limited services, and the others were denied access.

Clearly, this was rationing at its best and worst. Because the life-saving technologies both proven and yet-to-be developed will never meet all the needs of every person who might benefit from them, either permanently or temporarily, those who would only receive marginal benefit from such technologies will inevitably be put on a waiting list, never reaching the point on this list where those services will be available.

Fortunately, over the years more and more evidence-based scientifically driven protocols have been developed that defined--to the best of the provider’s ability--those patients who will receive value from each and every process and procedure. Where there are excessive resources, everyone who will benefit will receive the appropriate care. However, the downside of excessive resources is that many people who would not benefit from such procedures will inevitably receive them also—the overuse of health care. This is truly the negative side of rationing.

So although the recent health care dialogue has escalated the concern that the government or a government-related entity will decide who will receive specific health care and therefore decide who will live and who will die, the fact is that rationing has been, is, and will always be a part of the health care environment. The downside is that yes, occasionally there is someone who could benefit from the care who will not receive it. This is the underuse of health care. But in my 41 years of experience, I have rarely seen a case where such occurred. A person who really needs and can benefit from a procedure will find a provider who will make that happen by utilizing, at times, referral patterns and processes that are non-traditional, much like the child in California living in a low-income home who required a highly technical lifesaving cardiac procedure who was flown by a volunteer pilots association to CHRISTUS Santa Rosa Children’s Hospital in San Antonio, where the procedure was performed free of charge, both by the physicians and the hospital.

In contrast, without the need for rationing, the misuse and overuse of health care, the major drivers of the high cost of health care, quickly occur, i.e., the cardiac cath that could be avoided, the stent that did not need to be put in the borderline patient and the MRI or CAT scan for which a simple physical diagnosis or skull X-ray could suffice for a patient, particularly a pro-football player who suffered a mild concussion.

Yes, rationing is necessary, and should be supported. The concern should be that it will be done by people who have no medical background. Necessary and good rationing can and must be done by people who are well-trained and committed to the highest quality, low cost medical care which demands that proper use rather than over-, under- or misuse is the guiding principal.

Customer Service and Patient Satisfaction

Good customer service springs from individuals within an organization. It requires compassion and understanding that it is only by putting the needs of our customers, patients and residents first during each and every interaction with them that we can hope to excel as an organization and ensure we are fully living out our mission.

By the very nature of our work in health care, we are fortunate to have the opportunity to serve others at a time when their need for compassion is greatest. We are a privileged few.

In my message to our Associates this month, I congratulated each of them who have worked so hard in exceeding our patients’ expectations to provide the kind of compassionate, exemplary service we want to be known for at CHRISTUS. Service is not something we “add” at the end of the day or when we have time. Instead, it is a specific attitude toward caring that must occur as we do our jobs and interact with patients, their families, Associates, doctors, vendors and, essentially, each and every person we interact with each day.

I also told our Associates that, overall, patient satisfaction scores at CHRISTUS Health have improved significantly over our first decade of operations in the areas of inpatient care, emergency department (ED), outpatient and ambulatory surgical services.

The system has focused intensely on improving the ED patient experience during the past year. As a result, CHRISTUS achieved its largest single-year improvement ever and exceeds Press Ganey’s national average for the first time. Satisfaction improves dramatically when patients spend less than 2.5 hours in the ED, so efforts to streamline patient flow will continue to be important. Responding effectively to patient concerns and complaints is our greatest priority for improvement across all services. Hence, this will be a key system focus during our next fiscal year.

Commitment is the foundation of CHRISTUS’ Service Guarantee. The focus of our guarantee is a pledge that we are going to succeed, by being compassionate, attending to our patients’ special needs and keeping them informed, just as we would want to be if we were in their shoes.

Taking a break from reform to talk about bringing CHRISTUS to the next level via team building

I’d like to take a week off of our focus on health care reform to blog about something that will be of the utmost importance as we move forward, regardless of the outcomes of the reform discussions on Capitol Hill.

I firmly believe that CHRISTUS—and all health systems that expect to continue providing care far into the future—will need to ensure that it has the best and most appropriate leaders in place in order to meet the challenges and opportunities of the future.

So earlier in the year, I made it clear once again to our regional leaders that they are critical to ensuring that our Journey to Excellence in the future is even more successful than it has been for the last decade. Our regional CEOs and those with whom they work are the most critical success factor in reaching our benchmark goals.

Even so, while the action of individual leaders are important, what our leaders do with their respective teams is even more critical if CHRISTUS is going to create an excellent experience for all who enter our doors. In these challenging times, the strength of the team is often weakened, and at best, not enhanced. But it is my belief that it is critical that we all focus on a process that has the potential to strengthen our teams, as well as every team, that works within the large CHRISTUS Health family both in the U.S. and Mexico.

Therefore, along with the CHRISTUS Health Senior Leadership Team, we articulated 14 Attributes of Excellent Teams, 10 of which I have used for more than 40 years in developing strong teams both clinically and administratively (which you can read about here), and four of which added in discussion with the other nine senior team members. The additional four attributes include: 1) team purpose, 2) results-driven with recognition, 3) prayerful reflection on team and performance and 4) complementary.

We then requested that our regional CEOs share these attributes with their team members in a face-to-face session and, following a discussion, have each of their team member’s rank – on a scale of one to 10 – where they perceive their respective team is on each attribute.

After calculating the team average for each of the 14 attributes, the regional CEOs and their teams were asked to develop action plans to be implemented through Fiscal Year 2010 to improve all of the attributes in which they scored a seven or less. In addition, we asked these CEOs to take accountability to continue the process so that eventually, by June 2010, every person within CHRISTUS Health, all of whom are a member of some team, somewhere, will be actively contributing to initiatives which are hopefully providing value to our ministry.

These continue to be challenging times in health care, made worse by the global economic crisis. However, as always, we find these times exciting and see multiple rainbows emerging from the clouds. Leadership in health care is an awesome responsibility, and at times, can be very lonely. Therefore, in the best and worst of times, the effectiveness of the team is critical. So in this moment in time, we are making sure that we do everything possible to strengthen our team so our Journey to Excellence continues to not only be successful, but for the most part, enjoyable and rewarding.

What Do I Do All Day?

I’m periodically asked by younger health care leaders, including physicians, what I do all day

It may seem that handing them my job description would be a sufficient to answer their query. However, what they really want to know is what general areas do I focus on—how do I spend my time--and how that might be different today compared to my leadership schedule in the past.

I quickly respond by saying that the areas I concentrate on today are somewhat different than in the past, both in description and function. My work week can generally be divided into the following areas of responsibility and accountability:
• Operationally-focused CEO Whereas CEOs of the past often relied totally on their COOs for day-to-day operational efficiencies and fiscal stabilities, today a successful CEO must be able to articulate, at least at a high level, what operations is doing, what improvement plans are in place and what future operations will look like quarter-to-quarter. Audiences ranging from the system board to bond raters and investors expect me to speak to these areas in a credible way, demonstrating a far greater depth of understanding than would have been expected in the past.
• Creating a sound vision for the future There is no question that in the increasingly challenged health care industry, keeping people focused on a clear vision/direction for the system is key. This vision must be easily articulated and understood by Associates at all levels of the organization. Much of my time is spent with management and governance teams, discussing this very topic.
• Understanding the “change” agenda Many CHRISTUS strategies and tactics have to do with maintaining the status quo while making it more efficient and effective. However, critical to our success are certain areas which must be radically changed. It is imperative that I spend as much time as possible on not only identifying these areas, but paving the way for change.
• Teaching, coaching and mentoring future leaders Prior posts on my blog have been written on this key success factor. It will always be true where we are successful, we have the right leader and where we are not, we don’t! It is our job to make sure that those to which we give responsibility are sufficiently educated to lead effectively and accept accountability.
• Balance “present” and “future” time and energy If the present does not work, there will be no future without substantial investment. The money we spent on Futures Task Force II will have been wasted if our cash flow cannot sustain current operations.
• Creating the culture of the organization For us, that has been creating a culture of excellence built on the foundation of our mission, vision and values. This is done through constant focus on the 4 directions of our Journey to Excellence, connecting everything we do to them. Because no consultant or association can pluck a culture off the shelf and make it work, I must walk the culture walk and talk the culture talk each and every day.