Whether you’re the CEO of a multibillion-dollar system or a $200 million organization, you live with intense scrutiny and accountability from your board, your staff, the rating agencies and a well-read public. Driving this scrutiny are highly visible metrics: figures and scores for net income, safety, readmission and patient satisfaction.
Each of these metrics is generated from the point of care. Maximizing these metrics is fundamentally dependent on the convergence of essential basics, that is, the primary support services that five to 10 departments are expected to routinely provide 24/7, if needed, such as supplies, information, test results, patient rounds, pillows or a home health visit two days after discharge.
Invisible to the CEO and of staggering effect on these metrics, however, is the fact that one or more of the essential basics are not always available at the point of care or point of clinical decision when they are needed, or in the required quantity and expected level of quality. This invisible failure is called a “fractured convergence.”
For example, emergency services is a system of care that depends on the convergence of basics such as nurse triage, lab and imaging results, transport, tongue depressors, working blood pressure machines, computers, physician assessments, and medications. How well these basics converge at the point of care drives the departmental metrics for productivity, cost, quality and patient satisfaction. One or two micro fractures, such as a delayed reading of images or an offline computer, can diminish the quality of care on that day, even though lab, supply and nursing services have been precise with their provision of the essential basics.
From $750,000 to $1 million annually in salary per nursing unit is being paid out for nonvalue-added time, a significant portion of which is related to fractured convergence. That’s according to national cost accounting research at several hospitals conducted by Judy Storfjell, R.N., et al. and summarized in “Non-Value-Added Time — The Million Dollar Nursing Opportunity” in The Journal of Nursing Administration in January 2009. According to this research, staff at these excellent institutions thought time spent covering for the fractures at the points of care was actually a part of their job. Only when the cumulative time was calculated was the reality of millions of unnecessary dollars and the effect on quality, staff and patient satisfaction realized.
Preliminary findings from a recent survey we conducted with two colleagues, Kathy Zavaleta and Jeffrey Thompson, indicate that fractured convergence is often viewed as “just the way health care works.” The executives interviewed for our survey strongly believe that vice presidents excuse clinical and operations managers for poor quality or major delays in providing service when managers say, “We were understaffed, have vacancies or people were out sick.”
Middle managers also perceive that executives’ internal politics frequently result in a failure of vice presidents to directly address service issues with their peers. This same level of excuse, however, is not tolerated when a manager is routinely over budget or not meeting productivity standards.
When presented with our survey findings, one clinical leader of a nationally renowned medical center said, “Of course, everyone knows this happens, but they are not going to do anything about it.”
To justify fractured convergence and patch the points of care, four myths have emerged.
“Health care is so complex that we can't predict it. We just have to tolerate some poor performance.” This myth is used to excuse poor performance and ignore fractured convergence. Embedded in leadership’s mental model is that health care is so complex we must frequently excuse fractures in operations and clinical departments related to basics (such as a routine lab test delivered on time). Despite the work of countless committees designed to collaborate and solve these types of issues, fractures are accepted as the norm in too many organizations.
"The role of executives is to manage the big picture, delegate and stay out of the weeds." Since the 1980s, hospital leadership has migrated into a more corporate health care role. “Point of care” and “essential basics” are perceived as “the weeds” by many senior leaders. So, executives who focus on the details of providing test results, supplies or medications at the point of care are viewed as micromanaging or perceived as not as high-powered as those who work on mergers, physician relations and other strategies.
"No department director or vice president is good at everything. Cut them some slack. They run a tight ship.” This myth creates fractured convergence while perpetuating “silo masters” — department leaders who are celebrated for top budget and productivity benchmarks but who shave off services to meet financial and productivity goals. Their behavior frequently but subtly slows or decreases the provision of essential basics to the point of care. Rewarding a leader’s financial performance while not also looking at the "little data" and delivery of day-to-day basics can thereby contribute to a larger financial drain in the long run.
For example, a clinical executive at a Baldrige top-ranked medical center recently said, “The materials system executive and director get kudos from the CEO in meetings and give national presentations on cost reductions, while clinical units continually run out of supplies and pay a $65,000 nurse to hunt and gather basic supplies on the weekends and evenings.” When a point of care is dependent upon the timely convergence of contributions from five to six silo masters, fractures are inevitable and silently eat away at the critical metrics.
“If all is quiet, all is well.” This myth is perpetuated by doctors and staff who have a built-in tolerance for dysfunction but who periodically blow up when dysfunction has a major effect on a patient. This occurrence is then seen as an isolated event by leadership. The myth that “all is well” is also fueled by big-data averages and trends that don’t capture these fractures, making them silent and invisible even though they can be extracted from the electronic health record.
For example, in an open lunch discussion with a CEO, a surgeon unloaded months of frustration with broken instruments, poor room turnaround and scheduling breakdowns in the operating room.
The CEO said, "Why, in the last year, haven't you told me about this?"
The surgeon replied, “I would live in your office every day."
Busting your myths
Health care leaders can prevent fractured convergence by allowing that the convergence of multiple essential basics at the point of care is not “the weeds” at all, nor is it too low a level of management responsibility for the C-suite to take on. For example, it is ludicrous for senior leaders to excuse a department that doesn’t consistently provide a surgeon with his or her operating room trays with all the necessary instruments in good working order in case after case. Expecting each department to reliably do what it is set up to do 24/7 is a fundamental tenet of leadership for maximizing convergence.
Leaders should also build a systems-of-care framework to counterbalance the organization’s financial framework for managerial discipline. It would be professional suicide for a vice president to tell his or her CEO, “My areas can only meet financial and productivity standards five days a week or when fully staffed.” Our research shows, however, that these same excuses are frequently tolerated in the C-suite for fractured service delivery.
This is not an indictment of CEOs or vice presidents. Current structures for human resources, information technology, work standards, big data, management development and employee orientation do not support the levels of expectations, measures and accountability that have become standard for the financial framework.
This is not an overnight build, nor is there a three-month, quickly implemented silver bullet to establish convergence of multiple basics at the point of care. Building a framework and applying it sequentially to a few systems of care — such as emergency services, surgical services, a key disease-management system or inpatient medical-surgical unit — is the most realistic approach. Leadership must establish a disciplined framework for the systems of care with the same level of discipline, data and accountability that have become standard for the financial framework.
Focusing on 'little data'
"Little data" is the magic sauce for convergence. Little data is discrete actionable data that in 60 seconds identifies specific points of fractured convergence and leads to specific, immediate actions for remediation.
Little data is one core of a framework for systems of care. Traditional data give averages, such as “87 percent of lab tests were performed on time in the emergency department this week.” However, within that 87 percent, the fractures are invisible, so the actions in response to them would most likely include finger-pointing or having random conversations.
The reality is that the little data could, in 60 seconds, show the exact points that drove the fractures in the ED labs. Were they created by a delay between the order and the blood draw, or by the time for the blood to reach the lab? Did the blood lie on the accession table before being run? Or were results available in the computer, but there were delays of 17 minutes before the technicians verified the results?
Little data goes to the immediate action point. Frequently unrecognized by leaders is that the EHR has this data in various fields and that the data can be automatically extracted into simple reports that rapidly point to fractures. Actionable data can be created for most essential basics such as supplies, pharmacy, patient rounds and delays in the OR.
Developing little data is not an isolated silver bullet but must be integrated as a critical component of a framework for systems of care.
Maximizing your success metrics will continue to be driven by convergence of essential basics at the point of care. The four myths that have given us comfort must now give us concern.
Elwood Headley, M.D., is executive vice president, clinical affairs, and L. Rita Fritz is president of Systems Inc. in Chicago.
The survey research from which preliminary findings were drawn for this article is being called “Tolerance or Accountability for Inconsistent Performance in Daily Operations and in Financial Performance.” The research team includes Kathy Zavaleta, principal health systems engineer at the Mayo Clinic, and Jeffrey Thompson, director of operations performance management at United Surgical Partners International, in addition to Headley and Fritz.