Spring Cleaning

August 29, 2014

CHW LogoWe got our house back last week.  Our sons, who have been storing most of their belongings in our garage and basement for the better part of the past three years, both settled in to new apartments, taking their stuff with them.  Now we just need to sweep up the debris and voila!  No more squeezing past a futon to get my bicycle, or climbing over cartons of books to get to the rake.  It’s like pouring Drano into a clogged sink.

Those who have seen my office know I can’t stand clutter.  This is as true of my virtual space as my physical one.  Which is why a recent article from the Economist resonated with me so much. “Decluttering the Company” describes an unfortunate tendency among business organizations to accumulate structures and processes that simply clog the place up, making it difficult to get anything of value done.  The author lists some of the usual culprits: committees and other governance structures, meetings, and emails.  The problem is not so much with committees or meetings per se.  All these things are to some extent necessary.  The problem is their kudzu-like indestructibility.  Once a committee is formed, or a meeting is scheduled, it is nearly impossible to get rid of.  The result is redundancy, wasted time, and excess complexity leading to lack of clarity about where responsibility and accountability lie.

Organizations that find themselves cluttered up should consider a spring cleaning.  Time to sort through the committees, governance boards, management layers, and standing meetings, and decide which ones still provide value, which ones need to go to the landfill.  Even better is to prevent the clutter in the first place.  Committee charters could include a planned sunset date, unless the members strongly believe that there is still value in it.  At the very least, organizations should build a regular spring cleaning into their processes.  A friend of mine who lived in the same apartment in Chicago for 20 years used to move out and back in again every three years, as a way to force herself to declutter.

Think about our organization.  We have a great deal of activity that creates value for us and for our patients and families.  But we have to admit we have a lot of clutter.  I still have work to do on my garage.  When I’m done, what should I work on next?


Decisions, Decisions

August 22, 2014

CHW LogoRaisin Bran or Honey Nut Cheerios?  Standing in front of the pantry, faced with five boxes of cereal, I was paralyzed with indecision.  I could not for the life of me choose which one to have when I got home from my overnight shift.  It was completely ridiculous: I had just spent nine hours effortlessly making, in some cases, literally life-and-death decisions in the ER, and now I pathetically could not pick among a few not-terribly-different, nutritiously marginal, food-like products.

It turns out, I was suffering from what has been termed “decision fatigue.”  Some really innovative and fascinating behavioral and neuroscience research in recent years has shed light on what is a common phenomenon, and one with widespread implications.  Perhaps the most famous study is one of parole decisions by Israeli judges: investigators analyzed over 1100 cases in a ten month period.  One of the strongest predictors of granting parole was when in the day the case was reviewed.  Prisoners whose cases were heard at the start of a session had a roughly 65% chance of being granted parole, whereas parole was almost never granted to the last cases reviewed.  Parole was far more likely at the start than the end of a session even after controlling for severity of the crime, length of time served, prior criminal history, and ethnicity.

Other research has demonstrated that after a period of repeated decision-making, subsequent decisions become harder.  This is manifest as either indecisiveness (e.g., Raisin Bran or Cheerios), or deferring a decision by defaulting to the fall-back position (e.g., not granting parole).  Not only do people with decision fatigue find it hard to make choices, they also show decrease in willpower, leading to bad choices.  It’s why we often eat or drink too much at the end of a tough day.  These findings are consistent with a theory first proposed by Freud, known as “ego depletion.”  In essence, voluntary mental effort, including making choices and resisting urges, draw on a pool of mental energy.  When that pool is drained, quality of mental efforts is diminished.  Intriguingly, food plays a role; decision fatigue is ameliorated by glucose.  (It’s not just the act of eating – artificial sweeteners do not have the same effect.) For example, parole rates for the Israeli prisoners went up after a morning snack, then drifted down again before lunch.  And back up again after lunch!

The notion of decision fatigue has numerous implications.  Most obvious is for the way we do our work.  Intellectual performance falls off after a period of time.  Potential remedies include frequent breaks; spreading meetings requiring decision-making over the course of a day rather than stacking them back-to-back; not trying to make critical decisions when you are mentally tired or hungry.

Another implication is a societal one.  Self-control is at a low point when ego depletion sets in.  Poor people, who frequently have to make trade-offs that those with more means don’t have to worry about, may be more prone to this.  They make more, and more challenging, decisions in a given day than others.  Choices that may seem trivial or irrelevant to me are depleting to someone who is counting every dollar.  Studies suggest that poverty is not caused by bad choices; rather, bad choices are a consequence of living in poverty.  But we are all potential victims.  It’s one of the reasons supermarkets put all that candy at the checkout line.  It turns out, shoppers who have just spent a half hour choosing among a dazzling array of products are much more prone to give in to the temptation.  (It’s also why, for example, car salesman offer the ridiculous undercoat protection after you’ve had to select the model, color, interior décor, sound system, and various other options.)

Well, picking a cereal for breakfast this morning was easy.  But deciding on dinner is going to be a challenge.


Back to School

August 18, 2014

CHW LogoAt the ripe old age of 18, my mother was a newly minted RN, fresh out of a two-year diploma program.  Not too many nurses got bachelor’s degrees back then.  Years later – while continuing to work two jobs and raise two kids – she went back to get a bachelor’s (in psychology, not nursing), and eventually a master’s in health administration.  Why?  In large part, I think, because of new requirements.  I certainly don’t think she believed the additional years of school made her a better nurse (she was already an awfully good one).

A study published this year in the Lancet suggests otherwise.  Looking at 300 hospitals across nine European countries found two nursing factors that correlated most strongly with mortality rates.  One was the nurse:patient ratio.  The other was the proportion of nurses with a bachelor’s degree.

Knowing how important the quality of nursing is to the overall quality of care, this is perhaps not surprising.  Nurse education is one of the many criteria evaluated by the American Nurses Credentialing Center’s Magnet Recognition program.  (CHW was verified as a Magnet hospital for the 3rd straight time in 2014, a distinction held by only about 1% of all hospitals in the country.)  Over 76% of direct care nurses at children’s have at least a bachelor’s degree, and nearly a quarter have some form of national specialty certification.  Among our nursing leaders, 72% have a graduate degree.  This is one of the reasons we are able to deliver the best and safest care.

Not only are our nurses well educated, many of them are educators themselves.  I recently read through our annual advanced practice nursing report, which presents an impressive array of teaching and research being done by our many talented APNs.

The Lancet study doesn’t show why nurse education level is associated with better outcomes, but some speculation includes a greater ability of university-trained nurses to interpret sophisticated monitoring data, and a greater willingness to question the traditional hierarchy to raise safety concerns.

My mother is certainly proof that one doesn’t need a bachelor’s degree to be an excellent nurse.  (She’s also proof that you don’t need a degree to challenge authority.)  But when it comes to education for nurses, the data show that more is better – and kids deserve the best.


Do This, Or Else

August 1, 2014

CHW LogoA couple of years ago I was visiting another hospital.  In the course of a day, I separately witnessed two senior leaders stop to pick up a small piece of litter on the ground.  I was immensely impressed that a busy executive would literally stoop to that, and I told each of them so.  The first one replied, “I really can’t stand to see things like that.  I know it’s a little thing, but it feels good when the place looks neat and clean.”  The second executive said, “It’s important to set a good example for others.”

At the time, I thought both spoke to a commitment to excellence.  But now I wonder about the differences in motivation, and the implications for all of the work we all do.  The first response spoke to an internal motivation, self satisfaction, while the second was an external motivation – what others would think.  A lot has been written about the relative impact of different sources and modes of motivation, with an emerging consensus that much of what we do to drive changes in behavior is at best ineffective and potentially harmful.

As a clinical epidemiologist, I like to define everything in life as a series of 2 by 2 tables.  Here it is for motivation:

External Internal
Positive If you finish your book assignment, I’ll give you $20 I can’t wait to finish the book assignment – I love to read
Negative If you don’t finish your book assignment, you’re grounded this weekend I’ll never finish this book – reading is so boring

Conventional practice (at least in America) in business, and increasingly in education and other fields, is to rely on external motivations – rewards and punishments – to drive results.  Among external (also called instrumental) motivations, it is generally believed that positive is more effective than negative: you attract more bees with honey than with vinegar.  But increasingly, research shows that external motivations for individual performance are at best modestly successful.  One recent study of West Point cadets found that not only is internal motivation a better predictor of success than external, but that even among those with strong internal motivation (e.g., belief in service to country), the addition of an external motivation (e.g., wanting to please a parent, desire for free education) was correlated with worse performance.

In health care, there is a growing shift toward “pay for performance,” and results so far have been mixed.  Some even worry that adding this external motivation can undermine the intrinsic motivation to do the right thing for patients that virtually all providers embody as a core principle.

Rather than devising rewards and punishments for performance, we need to leverage the intrinsic desire to do good (benefit to others) and to do well (personal excellence) that most of us have.  It’s the difference between compliance and commitment.  But even the latter can be broken down further.  Fred Lee, in his book If Disney Ran Your Hospital, talks about a hierarchy of motivations.  At the lowest level is compliance: doing what someone makes you do.  Even doing something for a reward is a form of compliance, albeit one with a smiley face instead of a frowny one.  The next level up is willpower, or doing what you believe you should do.  This is what that second trash-cleaning executive did.  It’s a step toward commitment, but not as far as imagination, which is doing what you want because you feel like it.

The vast majority of people in health care are motivated by imagination, by deeply wanting to give our patients great care and a great experience.  Certainly we like to be recognized when we do good – it’s one way to know we are doing well.  But we must be cautious about using external motivators, whether positive or negative.  I want to be part of an organization where everyone would stop to pick up a piece of litter, even when no one is looking.


Hidden Costs of Health Care

July 25, 2014

CHW LogoMy father (who was a cost accountant for a big pharmaceutical firm), used to say “If you think medicine is expensive, consider the alternative.”  Although we didn’t use the term “value” much in the context of health care back then, I think he was trying to get at that concept.  The real question isn’t the cost, it’s what are you getting for it.

Our awareness of the importance of the cost part of the value equation has outpaced our ability to measure the cost.  Oh, we’re getting quite good at determining the cost from the perspective of the provider and the payer.  We talk about fixed vs. variable costs, and direct vs. indirect costs.  While health care costing is complex, there are some very sophisticated systems for measuring those components.  When someone wants to know why a hospital charges $8 for an aspirin that can be purchased at Walgreen’s for $0.03 (as an aside, notice how keyboards no longer have the ₵ symbol?), we can explain that the price includes not only the direct cost of the materials, but also the indirect costs for handling, storage, documentation, administration, etc., much of which is mandated by regulations.  People may still feel the price is ridiculous, but at least it’s understandable.

This works if we’re trying to calculate the value of health care services to the individual who is paying.  It doesn’t work when we determine the value of health care to society.  A basic tenet of health economics is that any cost-effectiveness (i.e., value) analysis must specify the perspective of the analysis.  Much of what we do, especially at the more expensive academic health centers, benefits society as a whole.  But in addition, much of what we do also has costs to society that go beyond what typical cost accounting measures.  There are a host of what economists term “externalities” – essentially, unaccounted for costs.

Charles Bitmann illustrates this concept in a New York Times article called “The True Cost of a Cheeseburger.”  The price of a burger includes direct costs (e.g., ingredients, labor for preparing and serving) and indirect costs (e.g., rent and utilities for the restaurant, advertising), and of course a profit for the vendor.  Among the externalities, however, are things like the maintenance of the highway system used to transport the ingredients, and the cost of caring for illnesses that may be the result of consuming too many burgers.  Because these costs are not incurred by the restaurant owner, they aren’t included in the price.  But someone has to bear those costs.  Most often, they are spread out across society at large.  In the context of a for-profit business, ignoring externalities inflates the profit by passing on the costs to someone else.  Bitmann’s calculation is that the true cost of a cheeseburger would be 15-50% higher if these costs were accounted for.

In the context of health care, there are other implications.  First, in the debate over the cost of medical care to society, things may be even worse than we believe.  Instead of 17% of GDP being spent on health care, it would be substantially higher.  Second, our mission is not to make a profit.  It is to heal people or keep them well, to improve the health of society.  Some of the externalities we ignore may have the opposite effect.  While undoubtedly there are many such externalities applicable to health care, I want to consider two.

The first is the cost of our environmental impact.  Hospitals are among the most energy intense buildings around.  Our carbon footprint is enormous.  There are highly variable estimates of the cost of controlling carbon emissions and dealing with the related climate changes, but they run into the many trillions.  In the current state, those doing the emitting do not bear any of those costs.  (This could, of course, change if there were a carbon fee or tax, but that’s unlikely in the US any time soon.)  At the Milwaukee Regional Medical Center, our heat and cooling come from a coal-fired thermal plant.  This will eventually be converted to natural gas, which has about half the carbon emissions, but they are still substantial.  Since there is no cost to the hospital for those emissions, there is no financial incentive to do something to eliminate them (e.g., geothermal).  But should we be looking more broadly at the cost to society, from an economic perspective?  Or the health impact, from a moral perspective?  Some health systems, notably Gundersen Lutheran in La Crosse, WI, have done so in a big way.

The second externality is lost productivity to patients and families due to unnecessary waiting.  I have never seen anything about this in print.  But the amount of time people spend waiting in our facilities is simply extraordinary.  Societal-perspective economic analyses typically include an estimate of the monetary value of lost time.  Imagine what the cost of an ER visit would look like if it included not only the usual direct and indirect costs, but also the 120 minutes of lost work for the parents?

Research, education, public health, preventive care: these are an important part of the quality part of the value equation.  Payers, policy makers, and individuals need to be reminded that when they think about what health care costs, this is part of what they are getting in return.  We, in turn, need to be mindful that we actually cost even more than we know.  As my father might have said, “If you think medicine is expensive, it’s worse than you thought.”


Less is Less

July 17, 2014

CHW LogoA few months ago in the emergency department, I saw a child who had been getting only half as many puffs of their asthma controller medication as prescribed.  The mother, hoping to make the $185 inhaler last longer, figured some medicine was better than none.  For many people, living on the financial edge, life is a series of trade-offs – medicine vs food vs clothing vs transportation – that most of us are completely unfamiliar with.

Health insurance is supposed to minimize the need to include medical care as part of that zero-sum equation.  The Affordable Care Act, by expanding coverage, should therefore increase access to care.  But one of the changes that has accompanied the ACA is a huge increase in cost-sharing, not just for people covered by policies acquired through the ACA, but for everyone.  Over 20% of all health plans now are high deductible plans, and they are growing far faster than any other type of coverage.  We are now starting to see some of the effects of this shift of financial responsibility for health costs away from insurers and toward patients.  Back in the 1970s, the RAND Health Insurance Experiment randomized people to high vs. low deductible plans.  Their main findings were that those who had to pay higher out-of-pocket costs used less medical services, both necessary and unnecessary, and that overall there was no demonstrable difference in health outcomes.  Many have since latched onto this as evidence that cost sharing can decrease spending without harming health.  But dig into the details and you’d see that among those people with lower incomes and poorer health to start with, there were adverse effects of greater cost sharing (specifically, higher mortality among those with hypertension).

In the July issue of JAMA Pediatrics, researchers from Boston report on the effect of cost sharing on children with asthma.  Similar to the RAND study, forgoing needed care (including medications and emergency department visits) was more common among those families with higher cost sharing who were also below 250% of the federal poverty level.  Moreover, such families reported worse asthma control.  They also were more likely to have to borrow money (33.3%) or defer other necessities (17.6%) than families who either had less cost sharing in their health insurance, or higher family income.

At present, children covered under Medicaid have very little cost sharing.  Indeed, in the JAMA Pediatrics study, children covered by Medicaid fared reasonably well.  However, those families who have employer-provided insurance, or those obtaining coverage via the public exchanges, may well fall into that combination of modest income and high cost sharing that leads to forgoing needed care for their children.  We as health care providers need to be aware of the kinds of Sophie’s choices they are faced with.  How can we support them?  We can ask them if they are having trouble making ends meet, if they are having to trade off food for medication.  We can be sensitive to the cost of the care we provide, and consider less expensive alternatives when appropriate.  And we can be non-judgmental when we find out they missed a clinic visit, or didn’t refill a prescription.  Instead, we can be curious.


Recharging the Batteries

July 3, 2014

CHW LogoJuly 1 is the traditional start of the medical academic year.  The hallways are bustling with eager, young (and getting younger each year) physicians with seemingly limitless enthusiasm.  Yet by the end of the year, surveys show that at least half of them will have some signs of burnout.  This is not unique to health care. A 2013 Gallup study found that just 30% of American workers are engaged at work.  This is remarkably consistent across sectors of the economy (health care is actually at the higher end, with 34% of physicians and 33% of nurses engaged), and is a figure that compares favorably with the global average of 13%.

The usual leading suspect is lack of work-life balance.  But that is only a part of the picture. Research shows that there are four core needs that, if met, contribute to a feeling of satisfaction and engagement (or burnout, when these needs are not met):

  • Physical – opportunities to regularly refresh and renew at work (e.g., taking breaks) and away from work
  • (work-life balance)
  • Emotional – feeling valued and appreciated for one’s contributions
  • Mental – ability to focus in an absorbed way on the most important tasks, and determining when, where, and how to get the work done
  • Spiritual – doing what you do best and enjoy most, and feeling connected to a higher purpose at work

A survey of over 12,000 workers (95% of them “white collar”) showed that of these, it was the ability to focus and to think creatively that was most often felt to be missing.  A sense of meaning or significance to one’s work, and doing what is most enjoyed, were also lacking.  I suspect that part of why health care professionals are somewhat more engaged than others is the strong sense of mission we have and share with the organization as a whole.  We all want to feel that what we do is important, enjoyable, and appreciated.  I am very fortunate that, for most of my career, I have been in jobs that are exactly that.

Satisfaction is more a function of the organization than of the industry.  A common thread among those organizations with a highly engaged and satisfied workforce is certain characteristics of leaders: personal energy level, showing appreciation, and leading by example when it comes to creating focus and renewal.

Hoping to cast a positive shadow of leadership, I am getting ready to renew myself physically and mentally on a family vacation.  No email, no work reading, and no blog next week.


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