Starting With Curious

Thanksgiving is one of the few holidays that, despite the emphasis on consuming to the point of gastric distress, has not lost its original significance of an occasion for giving thanks.  In our culture work we’ve used the “Mood Elevator” to depict the range of states of mind that can affect our thinking and actions:  at the very top of the elevator is “gratitude.”  It occupies that spot because the act of expressing gratitude reflects how utterly dependent we are on the people and world around us for everything that matters.  When we are grateful we are not alone.  If appreciation is the glue that holds an organization together, gratitude is the glue that holds us together.

For some time now, I have ended each day by thinking of three things I was grateful for that day.  It’s always easy to come up with one or two, though sometimes three is tough without cheating by falling back on overly used standbys (my wife, my children, Gilles’ custard).  But requiring three forces me to really consider the events, people, and interactions of the day and their value to me.  Here are some of the work-related things I’ve had on my list lately:

Colleagues who inspire me to excel, by their examples of dedication and commitment, clinical expertise, and inquisitive spirit.

A CHW leadership group that, in every way, truly exemplifies a team.

A work environment that is supportive, challenging, meaningful, and fun.

A short commute.

Those of you reading this can’t claim any credit for that last one, but as for the rest, I offer my thanks.  Upon leaving at the end of the day I sometimes think, to paraphrase a former minister of ours, “We haven’t just been to Children’s, we ARE Children’s.”  This organization is nothing more than the sum of all of us, and its success reflects on us all.

Here’s a statement that could be a set up for a high school debate team or one of those shows on cable news: “The US has the best healthcare in the world.”  I have debated this with myself many times.  The pro argument emphasizes the role of research and technology, the availability of tests and treatments that may have seemed like science fiction not too long ago.  But I usually land on the con side, thinking of our dismal overall statistics on life expectancy, child mortality and health status, coverage, and costs.

Sometimes, though, anecdotes trump statistics, as I learned the other day when I had the opportunity to spend the morning rounding in our operating suite.  First, I observed the set up in OR 3 for a Norwood procedure, a now standard operation for an otherwise fatal congenital heart condition, hypoplastic left heart syndrome.  They were getting a heart-lung bypass machine ready for a 1 week old infant.  Although it is done in many centers now, our hospital has one of the highest volumes, and literally some of the best outcomes in the world.  For a condition that was once uniformly fatal – standard treatment at most centers when I was a resident was hospice  – today at Children’s Hospital of Wisconsin about 90% of children survive.

Next, I went to OR 6, where an EXIT procedure was being performed.  EXIT stands for ex utero intrapartum treatment, and it’s an acronym that actually has some intrinsic meaning.  It was developed for when a mother is carrying an infant with some kind of anomaly (in this case, a giant cyst in the neck) that would make it impossible for the infant to breathe after birth.  A Caesarean section is done, but only the baby’s head and shoulders are brought out – a partial exit, if you will.  A team of ENT and general surgeons then works to establish the baby’s airway before delivering the rest of the baby.  Technically, the baby is being operated on before it is actually born (the moment of birth is when the cord is cut), and the mom serves as a type of heart-lung bypass machine.  This is a highly complex, technically difficult procedure, requiring enormous coordination (there were at least 20 people involved), and only done at a handful of institutions, including ours.  Even at that, this is only the fourth one we’ve ever done.

But wait, not done yet!  As I was leaving the successful EXIT procedure, I passed OR 8, where a team of neurosurgeons was doing our first ever, apparently oxymoronic  “minimally invasive neurosurgery,”  to treat a young child with a brain tumor that might otherwise have been inoperable.  Using a specialized guidance device in the OR, the neurosurgeon placed a laser-tipped catheter into the child’s brain.  The patient is then moved to MRI, where the tumor can be zapped with the laser.  MRI guidance allows the surgeon to see exactly where the laser is, and to monitor the temperature of the surrounding tissue so that only the tumor is targeted.  And get this: at the end of the procedure, the catheter is removed, the wound in the scalp is closed with a single stitch, and the patient can go home within 1-2 days.  After brain tumor surgery!!  This isn’t exactly Dr. Leonard McCoy with a tricorder, but it’s darn close.

Three children who when I was in training would almost certainly have died – three families left with an unfillable hole – who instead will all go on to soil thousands of diapers, enjoy kindergarten, create adolescent havoc, and perhaps have their own children.  On the one hand, this was thanks to Star Trek-type technology that really highlights our value of innovation.  Yet I was also struck by just how routine, how normal it all seemed.  A casual observer might not have been able to appreciate how groundbreaking some of this was, because the physicians and staff were just so – I guess “controlled” is maybe the best word.

I, on the other hand, was floored.  Three children saved from fate.  Yes, we still have too many children who do suffer or die, many from things that are easily prevented.  And the kinds of things I witnessed are very expensive; having them is wonderful, but if only a small handful of those who need them can get them, that’s not good enough.  Yet the look of hope and joyful anticipation I saw on the face of the mother about to undergo the EXIT procedure forced me to acknowledge that the answer to the question of whether the US has the best healthcare in the world is an ambiguous one.  The debate goes on.

I now know that the five most disquieting words in the English language are “This is not a drill.”

As some of you undoubtedly know from national news coverage, we had a shooting at Children’s Hospital of Wisconsin yesterday.  Police, responding to a report of a visitor who was armed and dangerous, shot the suspect (not fatally) and gained control of the situation.  From around noon until 2 pm, the hospital was in a lockdown situation.  During that time, the other leaders and I were in a command center; much of our time since then has been spent in analyzing what happened and our response, and most important, in supporting all of our patient families and staff that were affected.

Thanks to our planning and procedures, and the outstanding work of our staff and law enforcement, no patients, families, or hospital staff were injured.  In retrospect, things went as well as one could reasonably expect, maybe even better.  I mean let’s face it, education and drills notwithstanding, there is no way to really rehearse for the real thing.  Adrenaline and neurotransmitters are running rampant, time becomes completely elastic, people get hungry.

You might think an actual situation like this would be less choreographed, more chaotic than the drills.  (We actually had an active shooter drill within the last couple of months.  It was kind of boring.)  Although I was never in danger myself, it was certainly nerve-wracking.  And going around to all the care areas after, behind the modest words I could sense that many people had been frankly frightened and concerned for others.  But what I saw everywhere was not chaos, but calm.  Even when communications were spotty, or procedures unclear, there was no panic.  It was almost surreal.  At the time, I was mostly relieved and appreciative (and a bit hungry).  I chalked it up to the supreme professionalism of the people I work with.

But reflecting now after 24 hours, that wasn’t quite it.  Not that there wasn’t extraordinary professionalism, it’s just that that isn’t enough.  What I saw was skilled professionals living out our values of being At Our Best:

1.  Purpose – We act in the service of patients and their families.

The nurses who shepherded families to safe locations in the clinics, and the nurses who stayed with the patients who couldn’t be moved.

The code team that despite the lockdown responded to not one, but four different emergency (“code”) situations, including to assist the man who was shot.

2.  Integrity – We build confidence and trust in all interactions.

Althea, the administrator on call who took charge as the incident commander and calmly directed activities.

The CHW security staff who  worked with four different law enforcement agencies to control access, provide escort to personnel who needed to move about, and provide a sense of confidence that all was under control.

3.  Collaboration – We work together to care for children and families.

The administrative team in the command center who during the incident and in the hours after worked together to return the hospital to normal.

The off duty security officer who happened to be in the hospital with his child for an appointment, who stepped in to help.  And the clinic staff who watched his child in the meantime.

4.  Innovation – We commit to breakthrough solutions with continuous learning.

The many people who made creative suggestions of ways we can make our response even better should we ever need to in the future.

The communications team who use various means to get information out via email, Intranet, Twitter, etc. to try to keep people informed.

5.  Health – We are at our best.

The behavioral health providers who canceled clinics to be available as a resource for staff, along with social workers, human resources, etc.

The environmental staff who within minutes of the “all clear” were out making sure our facility was clean and ready.

Every single person who stopped to ask someone else if they were OK and if they needed anything.

As the swarm of media vans and news helicopters attests, this is the kind of incident that draws a lot of attention.  News is, by definition, what doesn’t happen every day – it’s what’s not normal.  Our values, though, are a constant.  Not terribly newsworthy.  But as the attention fades, as we get back to our routine, I’m reflecting on how grateful I am to be part of an organization that lists and lives those values.  That’s our normal.

When asked what I do, I still reply “I’m a pediatric emergency physician,” but honestly, these days I’m mostly an administrator.  I’m a suit.  I deal with things like contracting and billing, staff productivity measures, even surgical inventory management.  {That’s a thing?}  Which sounds, frankly, less noble {and less “sexy”} than the first answer.  So I want to try on a new answer:  I’m a steward.

Stewardship is “the activity or job of protecting and being responsible for something; the careful and responsible management of something entrusted to one’s care.”  The term is often applied to finance and natural resources, but has also been used to refer to pastoral care.  I like this definition because it emphasizes not only the actions of making careful decisions and avoiding waste.  It also encompasses the special relationship between the steward and the resources being managed, the elements of trust, of accountability.  All healthcare providers are, in essence, stewards – we are entrusted to care for our patients and to manage their health.  But even those who wear scrubs rather than suits to work are stewards in the business sense.

I realize that referring to medicine as a business gives many healthcare providers hives.  But the fact is, while I believe medicine is more than a business, it is still a business.  If you are wondering if what we do is a business, ask yourself, “Do we charge money for what we do?”  The answer, of course, is “Hell, yeah.”  Albert Schweitzer may not have been in the business of medicine, but the rest of us are.

Stewardship is critical on two levels.  The first is the organizational one.  Many of us are in the non-profit sector of healthcare.  The gap between the revenue we get for the services we provide and the expense of providing those services {salaries, supplies, mortgage, utilities, etc.}, is our margin, which we hope is a positive number.  {These days, accountants don’t use red ink for bad numbers, they use parentheses – parentheses are bad.  That’s why I’m using brackets instead.)  The margin doesn’t go to executive bonuses, or to pay off shareholders.  That extra revenue is what we have available for two things.  It supports those parts of our mission that we don’t get paid for {charity care, injury and illness prevention, community engagement, research and education}.  It’s also what we rely on to invest in new and replacement equipment, facilities, and programs.  It is a cliché to say “No margin, no mission,” but that doesn’t make it any less true.

Our hospital and health system is a tremendous asset to our community, one that has been entrusted to us.  Our vision is that the children in Wisconsin will be the healthiest in the nation, and I truly believe that our community would be less healthy if we were not here.  We are challenged by many changes in the healthcare environment.  Spending on healthcare has reached unsustainable levels, and while it is leveling off, we will continue to get paid less for what we do.   Which is why all of us need to be good stewards.  By focusing on making what we do cost less, we will ensure that the margin that supports our mission can be sustained.

We also must be good financial stewards for the sake of our individual patients and families.  One of the most striking effects so far of the Affordable Care Act is the acceleration of employer sponsored consumer-directed plans, also known as high deductible health plans, in response to the ACA’s tax on so-called “Cadillac” health plans starting in 2018.  While only 4% of employer health plans were HDHPs in 2006, they were over 20% in 2012.  For 2014, over 40% of employees in our system selected an HDHP {including me}.  Ironically, this is a solution that has long been promoted by free-market health economists.  The idea is that by having patients have more “skin in the game,”  in the form of high deductibles and hefty cost-sharing, they will shop more carefully for health care services.  While the several thousand dollars of out of pocket expenses are going to make me think twice about what services I seek and where, for many of us they are an inconvenience.  But for many of our patients and families, it’s more than that.  A parent may be deciding whether to have their child’s tonsils out or save for college.  It may be a choice of filling a prescription or having a meal.  We may find the idea distasteful, but it’s reality.  If we don’t control our costs, families will either be forced to go elsewhere, or go without.

Our hospital, our patients – these are things that have been entrusted to our care.  We say “kids deserve the best.”  Let’s be good stewards, so they can have it.

…is another one’s treasure, as the saying goes.  This is an important principle to bear in mind as the US tries to get a handle on healthcare spending.  As health economist Uwe Reinhardt notes in a recent New York Times blog, value is often in the eye of the beholder.

The 2012 Institute of Medicine report, “Best Care At Lower Cost,” examined the estimated $765 BILLION in “waste” (of the total $2.5 Trillion in annual spending on health care), and broke it into six categories:

1. Unnecessary services – $210 Billion
2. Excess administrative costs – $190 Billion
3. Inefficiently delivered care – $130 Billion
4. Excessively high prices – $105 Billion
5. Fraud – $75 Billion
6. Missed prevention opportunities – $55 Billion

This table leads to some finger pointing.  Physicians can blame pharma, insurers can blame docs, and everyone can blame those who commit fraud.  It’s tempting to think we can make significant progress without having to do much ourselves.  Take administrative costs.  (Please.)  We’re all familiar with the statistics – a recent estimate, for instance, that the typical US physician spends nearly $83,000 in her or his time dealing with administrative issues, four times as much as their Canadian counterpart).  And we have our own frustrating experiences: when I started as a faculty member at AI DuPont Hospital in Wilmington, DE – with a catchment area that included parts of four states – I had to complete a 7 inch thick stack of insurance enrollment forms for the over 60 different payers we had contracts with.  Our own clinical practice services at MCW – the folks who do the billing and collections for our professional fees – employ around 500 people, or nearly 1 for every 3 providers!  Why focus on “unnecessary services” when we could shave nearly as much by eliminating the non-value added “administration.”

But every one of these categories, seen as waste from the system perspective, benefits someone.  Even fraud.  So any effort to decrease these will face some resistance, on top of any other barriers.  Decreasing administrative costs by, say, having a universal credentialing process and single claims platform, would costs tens if not hundreds of thousands of jobs.  And decreasing “unnecessary” utilization means less revenue to providers, meaning less resources to take care of the needy and advance knowledge.

It  does seem like a zero sum game.  But there’s one perspective we haven’t yet considered – the patient’s.  If we streamline the insurer bureaucracy, it might mean some of those people paid to deny claims may not be needed, but the hospital gets paid faster.  But more important, patients are more likely to get the care they need. If a $100 brand-name albuterol inhaler can be replaced with a $15 generic, it hurts the manufacturer, but it helps the patient who can perhaps afford to buy both that AND a controller med to keep from getting ill in the first place.  And yes, if I order fewer CT scans in children at sufficiently low risk after head injury that it’s almost certain to be negative, my bottom line suffers.  But the child is less likely to have a radiation-induced malignancy later in life.

One person’s trash is another person’s treasure.  But to the person who should be at the center of all of this – the patient – it’s all trash.