Cover Story--AHA Chair-elect
From health care reform to institutional stewardship, Thomas Priselac, president and CEO of Cedars-Sinai Health System in Los Angeles and chair-elect of the American Hospital Association, believes it’s time to set aside ideological perspectives and make an honest, fact-based assessment of our health care system.
As told to Mary GraysonI grew up in Turtle Creek, Pa., a classic Pittsburgh-area mill town of 11,000 people. As a biology major at Washington & Jefferson College in Pennsylvania, I knew I was interested in health care, but didn’t have a particular focus. I just had a sense that doing something on a larger scale—on a community or a public health basis—would be more interesting to me.
I went to a career night at school and heard the staff from the Graduate School of Public Health at the University of Pittsburgh make a presentation on their hospital administration program, as well as their health planning program. This was in the early 1970s when the Health Planning Act was in full swing.
Following that, I enrolled in the health planning program and later did a required three-month internship at Montefiore Hospital in Pittsburgh. I stayed on at Montefiore as director of ambulatory care services, where I also worked on strategic planning. That’s when I met some remarkable people in a remarkable institution and knew that being part of a teaching institution was what interested me.
The opportunity to be part of the creation of new knowledge on the research side and witness the explosion in science that has occurred in recent decades has been both stimulating and challenging. It creates a work environment where you feel you are constantly pushing yourself and the institution to do better and better.
People at Montefiore, such as Irv Goldberg and Dan Kane, instilled the values in me that it is the obligation of people in leadership positions in the field to contribute to the dialogue and to debate the issues. Those same values drive my interest in association work, be it the American Hospital Association, the California Hospital Association or the Association of American Medical Colleges.
Putting Ideology Aside
Health care reform is clearly one of today’s most debated issues, with far-reaching effects. The AHA is an important voice that needs to be heard as an active participant, and our plan is strategically well positioned. But there are other voices that need to be heard as part of any effort to craft improvements to America’s health care system. This is critically important because nothing will occur if the diverse group of stakeholders in this issue cannot reach consensus.
Americans are concerned not just about the cost of health care, but about quality and safety as well. And I think people are genuinely worried about whether there is access to care in an equitable manner. Our success will lie in whether or not the AHA is able to work with other stakeholders to craft some solutions that are responsive to all these points.
But we as individual leaders also have a role. We should think globally, but act both locally and globally. Obviously health care reform is a national issue, but the complexities of making these changes are more likely to be resolved sooner at the local or state level than at the national level. From my experience, it’s clear that people in general—as well as in the business community—do not understand the multiple roles hospitals play, especially the provision of essential community services that don’t fit the business model of health care.
Many in the business community do not understand how health care is financed. What they see are rising health care costs and skyrocketing commercial insurance premiums. This is their concern, not the Medicare program. When they connect the dots—understanding how underfunding government patients contributes to the cost of commercial health insurance—they become more active in discussions about how to close the gap and eliminate cost shifting to the private sector.
California is representative of the struggle and ideological conflicts in other parts of the country. It is relatively easy to get everyone to agree on what needs to be done, yet very difficult to get people to agree on how it should be done. For example, several years ago the California Legislature expanded access via a pay-or-play obligation for business. The business community did not feel that costs were adequately addressed and organized a successful ballot referendum campaign to overturn the legislation.
Today in California, there are many different solutions being offered, ranging from a single-payer system to an expansion of a market-based approach, and everything in between. Where we will end up is not yet known; it is even possible that nothing will happen or that whatever the legislature passes will end up in the courts. A similar situation could also happen on the national level.
The real question is: Can enough leadership be exerted to set aside ideological perspectives and look at the realities of cause and effect? Facts, not perceptions or ideological interests, should drive policy positions.
Trust and Leadership
One’s ability to be a leader is directly related to the trust that people have in that individual. If you lose that trust, your ability to be an effective leader is fatally compromised. When leaders lose trust, it’s usually because people feel that at some point the individual was not sufficiently honest with them.
Within an organization, leadership means a willingness to openly acknowledge and celebrate the things that are good. But more importantly, it is being able to acknowledge our weaknesses and engage the organization in a discussion about how we can work together to overcome those problems.
The overall dynamics of the health care system reflect examples where confronting situations honestly would have led to better outcomes. For example, the relationship between hospitals and health insurance companies represents one of the great missed opportunities in health care. Historically, both sides have viewed the relationship at times in an adversarial way that suboptimizes both. In some respects, hospitals and health insurance companies have allowed the market pressure for short-term success to distract them from initiatives that could result in substantial improvements in quality and cost. By definition, these efforts take time.
A brave-new-world opportunity for hospitals and health insurance companies is information sharing. We could work together proactively on the relative performance of hospitals and physicians, but not in a Darwinian way that sets up a survival-of-the-fittest scenario. Rather, it should be approached with a mind-set to improve the quality of all providers. This requires an honest dialogue to identify opportunities for improvement followed by focused efforts to make changes in a variety of areas, such as utilization of resources and admission practices, to name just two.
Health insurance companies have concentrated on developing products with tiered hospitals, narrow networks and various pay-for-performance plans in response to customer demands to bring down costs. Our concern is that the tools used to implement such programs be accurate, meaningful and reliable, in the same way that hospitals and physicians are expected to provide efficient, effective quality care. The tools generally in use today by the health insurance companies—particularly regarding efficiency—do not meet that standard. While I understand the urge to move forward quickly in this area, everyone involved should recognize that inaccurate or misleading information is worse than no information.
In the end, sharing information with individual hospitals or physicians about their performance will result in a substantial amount of improvement. Physicians and others in health care want to do the right thing, and if given information on their performance relative to recognized norms, they will generally act to meet those norms as quickly as possible.
Connecting Clinicians to IT
Information technology is often mentioned as a solution to many of the difficulties facing hospitals in America, and we are called out for not implementing at a faster pace compared with other industries. While there has been some progress in health care IT generally, we must also be cognizant of the fact that the practice of medicine and the care of a patient in a hospital setting is one of the more complex human endeavors; it certainly is not a bank transaction.
Health care doesn’t have the same degree of organization and functional uniformity as other industries. Sixty percent of physicians are in individual practice. We’re not talking about automating just 5,000 hospitals but rather tens of thousands of physicians in individual locations.
Many hospitals do not have sufficient capital for major IT initiatives, but the focus on quality and efficiency has helped create the business case to move IT projects more quickly—and there is evidence that people are upping their investment substantially.
The implementation side is also more complicated for the health care field. In 2002, Cedars-Sinai experienced a high-profile failure of a [computerized provider order entry] system. We have been an IT leader for many years and, in some respects, our past success caused us to let our guard down. We did not pay enough attention to involving a broad spectrum of physicians and others in our medical center to address the unique issues surrounding CPOE. Now, we make sure that physicians and others are intimately involved throughout the entire process, including a broad and deep review of alternative systems, the selection process and downstream implications. We won’t rush the process, and instead will take the time to make sure it is done right.
Physician-hospital relations in general can be a source of tension, but it really depends on the external forces in health care and how they are playing out in individual communities. It is a very local question.
The key lies in the process: Is the hospital engaging in meaningful dialogue with its medical staff leadership? Is the hospital investing in physician leadership development? At Cedars-Sinai, we started this many years ago. It has enabled us to sit down with our physicians and have a conversation around areas of common interest, to talk about those things that are pulling us apart, identify ways we can work together more closely, and what investments we’re willing to make both in time and money to see results.
In the end, some physicians may still want to compete with the hospital for their own reasons, which should be respected. On a broader policy level, the issue is the need to ensure a level playing field when it comes to competition.
As in all relationships, respect is absolutely essential. For the last 28 years here, I’ve had the privilege of watching physicians work and seeing what they do for patients. So much emphasis—and rightfully so—has been placed on patterns of care, procedures, standards, variations and evidence-based medicine that we forget the tremendous judgments physicians are called upon to make each and every day. I worry that in our current environment we are in danger of undervaluing the full scope of their skills, as well as the art of medicine.
Nursing is equally important, and I am very proud that Cedars-Sinai was one of the first Magnet hospitals. Our nursing program is reflective of our broader view of employer-employee relations efforts in general, but applied to the specific needs and interests of nursing.
Leadership must recognize and deal with the obstacles that are in the way of people doing what they are trained to do best. Answer the resource questions, answer the system questions. Start with the belief that the nursing staff and others on nursing units are in a unique position to see where the opportunities for improvement are, engage them in a dialogue about how to make it happen, and match that up with available resources.
The heart of it is patient safety, quality of care, meeting the right process-of-care measures, and improving efficiencies in the institution. All of these are tied directly to the resources and the work systems available on the nursing units. By linking work improvements with quality and patient safety initiatives, we are achieving our employee relations goals while making progress on our quality, safety and efficiency goals.
The relationship between nurses and physicians can’t be ignored, as it directly affects quality of care and a good working environment. If that relationship is antagonistic or abusive, leadership must confront the situation. We were one of the first hospitals to establish a physician code of conduct, which grew out of direct, open communications with both groups. The standard is one of mutual respect with mechanisms to deal with people on either side who deviate from behaviors consistent with the code.
We also created physician-nurse collaborative projects on each nursing unit that identify obstacles that interfere with taking better care of the patients, and these units identify and implement solutions.
Searching for Solutions
Obviously, the health care landscape has changed considerably since I started my career in strategic planning. Today, some consider planning irrelevant, but I don’t know how an executive or a senior executive team can lead an organization without effective tools. Successful strategic planning in today’s environment recognizes that it is a fast-moving world with objectives set in a shorter time frame, that the process must involve the right people, and should include an effective monitoring process.
Strategic planning can’t happen in a communications vacuum. The plan has to feel right to people and be communicated organizationwide. Staff has to see the connection between the plan and the work that they do, which in turn requires necessary, but repetitive, communications. The actual results may deviate from the plan, and if so, staff needs to know why the plan will or will not change.
Strategic planning in the teaching hospital environment may seem daunting because new knowledge is constantly being created as part of the academic environment, but the development of new knowledge and technology must be incorporated into the organization’s overall strategic plan.
We are all searching for solutions to the big problems that face health care today. My fear is that we all have a tendency to latch on to one thing or another as the magic-bullet solution: Consumer-driven health care is the solution.… Information technology is the solution.… Evidence-based medicine is the solution. The truth is that none of these alone is the solution. Together, however, they have potential.
While we should pursue solutions with great enthusiasm, we should also be respectful of their limitations and not oversell ourselves or the American public on any one solution as the answer.
The answer will only be found after an honest, factual and multifaceted evaluation of ourselves and our health care system.
This article first appeared in the October 2007 issue of H&HN magazine.