(by Joe Flower, from H&HN [Hospitals and Health Networks] Weekly, 5/5/09)

“Turning and turning in the widening gyre,
the falcon cannot hear the falconer;
Things fall apart: the center cannot hold . . .”

                                            —William Butler Yeats

It must seem, indeed, to many, that we are come apart, that this great lumbering patchwork ad-hocracy we call a health system is finally and beyond rescue falling to ruin, strewing pieces across the landscape, hissing steam, groaning in the joints and couplings, its old iron wheels plowing great furrows in the sand before the last gasping halt.

Maybe. There is plenty of evidence. Hospitals across the country are skirting bankruptcy while the number of people who can’t pay is soaring. As of this writing, some 3.6 million Americans have lost their jobs (and often their health insurance) in this recession, half since last September. At a time when we are really starting to hurt for physicians (particularly in primary care), half of all U.S. doctors are planning to reduce the number of patients they see or to stop practicing entirely in the next three years, according to a recent Physicians’ Foundation survey.

There is, though, a different possibility: that eventually we will look back on 2009 as the great hinge point in the history of U.S. health care, the year of the great shift, the year when we took a new direction and built something magnificent.

I believe in this possibility. The seeds of this possibility are in the vast federal stimulus package known as the American Recovery and Reinvestment Act of 2009, and in the growing momentum in Washington for comprehensive health care reform. But they are only seeds. It will take leadership and strong forward thinking by those of us in the industry to turn the possible into the real.

The difficulties in health care—the high cost, the erratic coverage, the low quality—are all systemic. We cannot cure them by fighting symptoms, or blaming any one sector. The problem, and the solution, is not in the pieces; it’s in the relationships and connections and influences among the pieces.

What this means for providers: At the core of the possibilities of this oh-so-pregnant moment is the struggle of providers to gain control over their processes and to redefine their relationships with clinicians. Each depends on the other; you cannot do either alone.

Lower Cost, Better Value

Whatever its final shape, health care reform in the United States will involve a vast array of new payment incentives, structures, allowances and qualifications. It will likely bring tens of millions of Americans into a more secure coverage arrangement—but that arrangement will not be generous. These reforms may take many shapes, but it is almost certain that hospitals will not only have to cut their costs significantly to stay below strangled reimbursement rates, they will also have to demonstrate superior value.

Cutting costs and demonstrating superior value: This is one mountain, not two. There are many paths up this mountain, but they all take the same shape: vigorous control and improvement of your processes, at every level—from strategic development to pins and paper clips, catheters and infusion pumps. Digitization and automation is the first step, the gateway to deep process improvement.

The second vector for deep process improvement is teamwork. You don’t get to the World Series with a pickup team, and you don’t get to deep process improvement with random nurses off the registry and docs with privileges who otherwise have no engagement with the hospital.

The third vector is leadership: There is simply no substitute for strong leadership, creative thought and lots of plain old hard work to move beyond this hinge point.


Among the health care provisions of the stimulus bill we find the Health Information Technology for Economic and Clinical Health (HITECH) Act, providing $36 billion to digitize and automate the system as rapidly as possible. (The California Healthcare Foundation has an excellent summary.) [Peggy: please embed http://www.chcf.org/topics/view.cfm?itemid=133864 on summary.]

In the first two years we will see $2 billion distributed through a number of channels to health care providers, medical schools, labs and clinics to build and standardize IT infrastructure. The next four years (2011–2016) will see an estimated $34 billion in CMS incentive payments to acute and children’s hospitals, doctors and dentists, nurse practitioners, midwives and federally qualified health centers, for “meaningful” use of electronic health records.

The opportunity here is not only to use the HITECH funds to get digital with it, to automate and mechanize, but to employ digitization to reshape our relations with our clinicians, both nurses and doctors.

Nurses Doing Nursing

National Nurses Week is this month (May 6–12). Nurses are expensive. Our response to this over the last few decades has been to scheme continually to find ways to use fewer of them and less of their time, with dire consequences for health care. We cut staff, cut hours, re-assign shifts, degrade staffing ratios and transfer responsibilities to lower-paid staff. Nurses quit, go to work for insurance companies or long-term care facilities or physician’s offices, or give up nursing entirely in their frustration. We have a nursing shortage in a country with more than enough RNs. Of the more than 3 million RNs in this country, 25 percent work part time, and another 17 percent have left nursing altogether.

But here is a different answer: Instead of using fewer nurses, redesign the job to use less of nurses’ time doing stupid stuff, and more of their time using them at their highest value, that is, nursing. The majority of nurses’ time in hospitals is not spent nursing. It is spent foraging for supplies, conducting documentation and other tasks that take them from the bedside and take their eyes off the patient. The supplies need to be found, and most of the documentation must be done—but process r-design can make these tasks much faster and more intuitive, automate them, incorporate them into bedside care, or drop them altogether.

The best people to engage in this redesign? The nurses, at the level that the processes actually happen, usually the department.

This makes the need for stable staffing and teamwork obvious. You can’t improve a process if it is done by different people every day, if the people doing it are not well familiar not only with the process, but with each other.

Integrated Physicians

The same can be said of physicians: We have to get them on board, integrated, part of the team, one way or another. Put at least the key physicians on staff. Whether or not we can do that, we must help them accomplish seamless digital integration—which means, at the minimum, offering them free IT consultation on how to put together an inexpensive digital system.

“Inexpensive digital medical office system” is not the oxymoron it might seem to be, in an age with a rising number of stable, free or inexpensive, open-source software platforms that run on vanilla PCs and smart phones. And in early March WalMart announced that it is teaming with Dell Computers and eClinicalWorks to mass-market complete digital physician-office packages. Recent work on the “ideal medical practice” model, much of it published in Family Practice Management, has detailed exactly how to create an efficient, low-overhead, highly effective, high-quality, customer-friendly, practice, with examples from across the country.

Digitally integrating physicians is just the start: We must get them involved in teams, building standardized evidence-based workflows, because that is the only way to keep costs down and improve quality at the same time.

There is enormous resistance among some physicians to any kind of integration. For some, independence—not only from the hospital, the government and the payers, but even from their own colleagues in the form of evidence-based medicine—takes on a nearly religious aura. Yet, judging from the many physicians who have become digitally integrated and part of working clinical teams, and like it far better than what they were doing before, much of this resistance can be seen as a fear of the new, an inability on our part to help them articulate a path forward that works. And we need physicians, so we need to help them out, help them make a living, hear their concerns.

But we must always keep our eyes on the prize: We are not here, in the end, to make life easy for physicians. We are here to bring health care—convenient, assured, high-quality health care at the lowest possible cost—to those who need it. And to do that we must ease the physicians’ path into integration of some kind, changes in practice patterns and real, serious, substantial teamwork.

None of this is easy. It is not about pushing a little at the edges. It is about changing the model. “Burn down this house,” said Rumi, “the treasure you seek is beneath the floor.” We no longer have the safety of business as usual; this house is already on fire. Americans in their hundreds of millions are suffering financially and physically—even making choices that lead to death or a lifetime of pain and disability—because they can’t afford better, because we have not been able to find a way to bring it to them for less.

Making health care work better, faster and cheaper, more reliably, for everyone, is not just smart business and good management, it is a moral quest. There is a path out of this wilderness; there is a valley beyond. The stimulus package and the movement toward reform will give us tools and some help, but the real work is still up to us.