I think many of you would agree with me. The world, and in particular, health care seem overwhelming. At the beginning of the pandemic, the world shut done. While this had serious negative consequences on the economy, it at least afforded us all the opportunity to focus on managing the pandemic and keeping each other and patients safe. As the course of the pandemic has evolved and we have better resources to screen, test, prevent (vaccines) and mitigate the risks of COVID 19 (adequate PPE), we are now simultaneously trying to manage subsequent surges of COVID 19 while continuing necessary clinical care. This has been exacerbated by a wave of patients flooding the ER and clinics with sequelae of poorly managed chronic disease or new illness that we normally would have seen at an earlier stage making diagnosis and treatment more complicated. There are many factors that explain this “perfect storm” and include staffing shortages across the health care continuum, patient choice in delaying care because of the pandemic, resistance of part of the population to public health measures, and for many of us, a generalized fatigue with the pandemic. These factors build on each other to make circumstances worse as we see the great resignation, retirement, and migration occurring amongst employees in all sectors of the economy, and more staff developing and exposing others to COVID (including patients) making staffing issues even worse. Many hospitals and health care organizations are buckling under the strain of high volumes of medical and COVID care along with a staffing crisis that won’t be solved by more money.
Even before the pandemic, health care was becoming increasingly onerous to staff, nurses, and providers. Whether internally from the organization or externally from payers or other regulatory bodies, everywhere we turn there are more requirements placed on all of us to accomplish the same tasks. Let me give you a small example. Ten years ago, when I saw a person in clinic and wanted to schedule them for the OR, I talked to my scheduler at the end of the day or the next morning and gave them a list of who needed to be scheduled and for what. This past Thursday, I saw one patient as a video visit who needed surgery. They struggled with the video and I called them and talked them through how to make it work. Next, the films were not available so I had to step out of the room and ask my medical assistant to call the hospital so that the images could be sent via VPN. Already running behind, I then spent 15 minutes discussing options and reviewing potential risks and benefits. Family was with the patient and they had several questions. By the time I was done with the visit, I had three patients waiting in clinic and had not completed any of my documentation. By the time I finished clinic at 5:30 PM, I then had to check my email that I had neglected for the day, make several phone calls, and pick up my son from practice. After helping everyone with homework and eating dinner, I sat down at 9 PM to click through meaningful use, complete my notes, and place orders for my cases. I got through about ½ of my notes by 11:30 PM and called it quits and spent another 2.5 hours the following evening calling back patients, answering portal messages, and completing notes.
This summary is not intended for anyone to feel pity for me. Many of us go through this. Some of you are much more efficient than me and can complete everything during clinic or have figured out a way to make your clinical practice very efficient. I would say that I am moderately efficient but have enough competing interests and don’t do that well with multitasking and this is the best I am going to get. My point is that we have continued to add more and more to the plate of everyone in healthcare without clear relevance to the patient or the provider. I’ve written about this previously but over the weekend I had something of an epiphany as I thought about the extreme duress I see many staff, nurses, and providers buckling under in our current health care environment. How do we figure out what to stop doing so we can make things better?
I want to start out with a caveat. First, electronic medical records are a great thing. They have improved our ability to provide safe care by reducing transcription error and have allowed better access to information to patients across the health care continuum. Take for example imaging. Even when I don’t have a CT scan available to me, 95% of the time, I can get it through the other organization sending it through a VPN to a viewer system so that I can make decisions in real time. In the past, patients would show up with discs that were hard to open or even in the more distant past, sheets of x-rays that had to be looked at on a lightbox. Or even worse, I had to send the patient away and have the images Fed-ex’ed to me and then call the patient back to continue our discussion.
Second, the intention of our health systems, payers, and regulatory bodies is more good than bad. Sure, everyone is trying to contain costs and that pressure seems to rest on the people doing the work, but for those organizations that are driven by a value proposition, cost containment is only one component of the picture. Many of these efforts are focused on the STEEEP objectives that were outlined in the Institute of Medicine report- safe, timely, efficient, effective, equitable, and patient-centered care. The big question for all of us to answer is how do we move toward a goal of value-based care without crushing the system and those who deliver the care. One clue lies in our current staffing crisis.
As most of us know, our ability to care for the increased volume of patients has been constrained by staffing shortages. Over the last several weeks, I have spoken to other CMOs both within the Trinity System and outside our system and they are all experiencing the same issues. We can’t keep up financially with the market for labor. Nurses can make much more and work less taking a travel contract than staying with the organization that they have worked at for years. In some cases, these nurses take a travel contract for much more than what the organization normally pays and are placed at the hospital they normally work at. Similarly, other job categories can make more in service or food industries with lower risk than staying at their job at the hospital even for more financial compensation.
The answer to our troubles in health care is giving people more time back to themselves. There are several ways that this can be done. First, we can hire more people if we can find them. The biggest problem with this is that hiring more people with associated benefits, training, etc… is not sustainable financially for any organization. When we talk to younger employees, they want it all- good pay, good benefits, and flexible and good hours so that they can pursue other activities in life.
The other solution is to try and reduce the amount of work that people are doing in their jobs. This makes sense because if people are allowed to focus their efforts on meaningful work and eliminate activities that do not add value to the task, themselves, or the patient, then this would result in reduced effort with hopefully the same or even better outcome. This is not a novel solution. If you have ever studied Lean or other quality improvement systems, they talk about reducing waste. That waste can be in the form of supplies, but it can also be in the form of employee or customer time. You may be more familiar with a popular representative of this concept. About a year ago, my wife watched the series Tidying Up with Marie Kondo. Marie Kondo is a Japanese consultant who has built a career on helping others organize their lives and personal items. I don’t typically watch these types of programs (I prefer fiction when I am in my leisure time) but I sat through one episode thinking about how these same concepts apply to the work we do in health care. The idea is not necessarily how to determine what you want to get rid of but rather what you want to keep and then eliminate the rest.
And there is the epiphany. How do we examine what we do and determine what is valuable to keep doing and try to eliminate activities that don’t add value. While simple in concept, the reality is harder than it sounds. First, we all have to agree with what defines value and because there are multiple stakeholders in health care, there are competing interests. But one place that we can start is agreeing on values and how values apply in health care. From a health care economics standpoint, value is simply Appropriateness of care x Quality/Cost. The STEEEP criteria further refine both appropriateness and quality ensuring that our care is safe, timely, efficient, effective, equitable, and patient centered. I think that if you looked at a lot of Health System or Hospital Vision, Mission, and Value statements, you would find that there is very little conflict between these criteria and the individual organizations. Organization A may talk about Stewardship and this aligns with efficiency and cost. Organization B might incorporate innovation into their values which is critical to improving safety and the effectiveness of the care we deliver.
Let’s take, for argument’s sake, that the STEEEP criteria serve as our universe of value in health care. The next step is to keep the activities that support these values. Who decides what to keep? That is our next tricky question but fundamentally it should be the people delivering the care and the patients receiving it. I believe most of us know the right things to do to care for patients. The problem is that we have abdicated control to payers and policy when it comes to care delivery. That’s a bold and contentious statement but I am going to flesh it out further. As a physician leader, it is important to maintain the integrity of clinical care while engaging in the broader process of health care delivery. I believe many physician leaders do this but the further we get away from hands on patient care, the more we assume the mantle of administrative priorities. Those administrative priorities are important- they are what keeps the lights on and keep us out of trouble BUT without the constant reference to the values and the why, a physician leader and the overall organization can drift into activities that become counterproductive.
Its hard to untangle what we are already doing but the first place an organization can start is to have the front-line health care delivery folks weigh in when a new process or activity is going to be added. Does it meet our values? Will it improve patient care or provider care? If it does, then the next question is what are we going to stop doing to make room for this new activity? This is not a zero sum game because adding a new process that gets us to better care is additive while taking something away that does not need to be done any longer is also additive. Once we build the muscle for new activity, then we need to break down our current work and decide what adds value and see where we can eliminate those areas that do not. This allows us to both give people back time which I believe is the most valuable commodity in the current work force and also allow people to devote more time to the valuable activities which helps us provide safer, more effective, more efficient, more equitable, and timelier, and more patient-centered care.
Of course, there is an elephant in the room and that is that a lot of what we do and how we do it is dictated by payers, policy, regulation, and even law. Even though I’ve done my e-learning on infection prevention or fire safety every year for the last 20 years, I can’t stop doing it because it is a requirement. I can’t stop doing my peer to peer calls for denials because either my patient won’t get the scan or test I think they need or they will get a huge bill for that service that insurance won’t cover. Rightsizing the regulatory burden requires a different approach. We all have memberships in professional societies. Those organizations are supposed to advocate for their members. This has done us all a disservice because it has made physicians look like we are looking after our best interests over our patients. We need to pressure our Medical leadership to focus on the values outlined above to force discussions on how new and existing policy and regulation improve the value proposition and develop mechanisms to eliminate policies and regulations that don’t accomplish these goals. Leveraging other organizations such as State/County Medical Societies, interactions with elected officials, and even leveraging the lobbying arms of various medical organizations to be the champion of STEEEP and value-based care and away from self-interest will allow us to simplify the way we deliver care to focus on our time and effort that benefits patients and eliminating activities that only add wasted time and effort to the system. If a hospital or health system could accomplish this in collaboration with their physicians, providers, and staff, they would be one of the most desirable places to work and most sought after for patient care. I’ll be honest, I may have the idea but lack the experience to start this but if you are interested and have ideas, please reach out to me.
You Are Not Alon (But I Am) 