Joe Alhadeff's Profile

I would anticipate that one of the first priorities would be to reach out to the various facilities and determine what exactly their perceived problems and needs are. In a new role, no one is going to have any idea what it is that person is supposed to be doing or how that new role is going to impact them. I would advocate for choosing one or two issues and solving them first before taking a more broad approach, where it may be more difficult to achieve success on individual projects. You are going to have to come up with a few “wins” or successes to justify the continuation of the role. I think another important aspect would be to figure out how you are going to interact with the individual pharmacy directors. It seems like there would be some risk of having competing agendas.

Psychiatric services in the US are mostly a mess. Underfunded and irregularly spread out. Most physicians that I know are appreciative of the support of psychiatry services and would welcome help from a more specialized unit. Perhaps developing care protocols in conjunction with the primary health care units to provide clarity as to what services they should offer, and when it is more appropriate to refer. That works with some other specialities, I’m not sure if it is as applicable to Psychiatry.

We have used mostly smaller consulting firms with mixed success. There is a paradox for hospitals, we want to know what has worked in other places, but then we also all believe that we are different than other hospitals. Identifying and understanding what it is about each hospital system that makes it think it is different would be integral in developing any change strategies.

Parking is always a hard sell to the management because there is little perceived financial benefit from building any kind of parking and it is always a large expense. I agree with Neil – what got our Board to make a decision on the parking issue was the inclusion of parking problems on our patient experience surveys. They were far and away our worst scores, so that presents an easy win for a management team to improve those scores, even though there is an expense associated. Once parking becomes associated more closely with the patient experience, it garners much more attention.

I would think one of the first priorities for the PSC would be to establish the parameters of who is going to do what and where? Which services will be offered in the various locations and who is going to be doing the billing? Is it going to be a cooperative billing process where the revenue is divided between the organizations, as in a bundled payment model, or are the different hospitals going to bill separately for the services they provide. Unfortunately, so much of how our healthcare is organized in this country is based upon how we get paid.

I think you answered your own question in your last sentence – “we are just putting out small fires as opposed to strategically developing a plan to truly help our employees find a common ground to navigate the changes we are experiencing.” If you are just making small changes in multiple departments with no overarching strategy it will always feel like you are chasing your tail. You need the big vision of what you want first – then go after the small wins to build to it.

We do very well on our HCAHPS surveys. We have a number of things we do to improve this number.
1. we contracted with a survey company to give us more feedback and more data to work with so we could track the change in scores better.
2. we start the patient education process preoperatively for elective surgeries, and immediately after surgery or admission for others.
3. We rewrote all of our discharge information to simplify it. Much was incomprehensible to the average patient before we started. The average reading level in the US is 5th grade!
4. We make sure that everyone is telling the patient the same information – if the physician says one thing, the nurse something else and the pharmacist something else, it confuses the patient.
5. We have nurses and pharmacists call the patient, 24-72 hours after discharge to ask if they have any other questions.
6. We have preprinted cards with all of the common medications that we prescribe to patients with the reason for the medication and common side effects clearly stated.
7. We use videos in the patient’s rooms to go over additional teaching. This makes sure the teaching is consistent.
8. Prime the patient to answer the survey questions – make sure that someone asks them before they leave “Have we provided you with all of the discharge education that you think you will need?”
9. We invite former patients back for meetings and focus groups to ask them what we could have done better.

In a bundled payment model, all should be able to share in the savings.
There are some very good “generic” implants out there now that are comparable to the major vendors. Revision implants are where there is still a large difference.
The hospital can use the money that it saves to hire one of the now unemployed reps, to be the hospital’s implant coordinator, managing inventory, communicating with the surgeons to make sure all the desired equipment/implants are available, and even helping staff in the OR when needed.

We don’t have many beds, so we have to manage our discharges aggressively since we don’t really have the ability to board patients. For us discharge planning starts on admission, when are they anticipated to leave and where are they going. I realize for some patients this is an unknown, but for many, you can estimate pretty accurately. Communicate with physicians the day before discharge to encourage them to fill out the necessary paperwork or computer work ahead of time and not on the day of discharge. Most EHR’s let discharge information be filled out in advance. Encourage physicians to round on patients that are to be discharged that day first, so that the process can start and then round on the patients that are not leaving yet later.
I love the idea of to go lunches from jjmurray.

You can’t have efficient OR’s if they are not fully staffed. What are the reasons that there are so many open positions and why is it difficult to retain staff?

I am not in favor of front end rules. While this works to help decrease readmissions and complications, it is an imperfect science and there are still many patients that may fall outside of the established criteria that will do very well. To use the obesity example, although there are increased risks for hip and knee replacement patients with increased body mass, the success rates in those that are obese are still quite good, with more than 90% reporting good to excellent results. Some of these are going to be younger patients that are still working, and who may not be able to work if they don’t have the surgery, then they fall into the ranks of the unemployed and we end up paying for them in someone else’s budget. I don’t like the idea of denying or rationing care, it sets a bad precedent and where do you draw the lines?
I think there has to be a component of patient responsibility, either financial or otherwise, and even more of one if they have modifiable risk factors that they have not corrected. If you smoke or are obese, etc., it will cost the patient more out of pocket.

Doctors, or at least this doctor, want to spend more time interacting with patients, talking to them, examining them, making a diagnosis, establishing a course of treatment – instead of entering information into a computer. Doctors will embrace technology if it helps them do their desired tasks better or more effectively, and they will resist when technology takes them further away from the patient.

Are there any cases or patients that you can send to the community facilities? Community hospitals fear that it will become a one way referral street with all of their paitents getting siphoned off to the larger academic center. If some patients or cases that can be better managed at community hospitals are referred to them, there is more of a feel of a give and take relationship that can be more symbiotic. There are often cost savings that can be realized at community hospitals compared to larger medical centers.

Has your leadership met with the director in question and given him/her a clear goal, and direct ownership, of improving physician productivity within his division to whatever the desired number is? Even though it may be obvious to others, it sounds like this director may not be aware that his department is languishing compared to the expectations of others. We have some within our group that are perfectly happy with the 25th percentile, they have their own justifications for why that is an acceptable number, we don’t see as many patients, but we do more research, or we have better patient satisfaction scores, or we didn’t go into this to make the hospital more money etc.

This is the most glaring weakness of Value Based Care – Patient Attribution. How do we decide which physician or which hospital is responsible for specific patients? And for how much of their costs and care over the course of a year? Many of the initial ACO’s struggled with this concept. They could manage costs well within their system, but patients had the ability to go outside of the system and then there was no cost containment. Right now patients are attributed to physicians for the purpose of Value Based Purchasing and now MIPS and many of us don’t even realize it. Value based care requires closer contact with a PCP who can effectively manage a patients chronic problems, but patients don’t necessarily want that, they want the convenience of seeing whoever they want, when they want. We can’t give patients choice of who they want to see, and then make a specific physician responsible for that patient’s care and costs over the course of a year. I think CMS is hoping it all averages out, but I don’t think we have a solution to this problem yet.