THE ART & SCIENCE of SERVICE: INNOVATION… IS THAT ALL THERE IS?

1. THE ART & SCIENCE of SERVICE: INNOVATION… IS THAT ALL THERE IS? STEPHEN A. KATZ, MD, CPE CMO, Vassar Brothers Medical Center

2. MEDICINE: AN ANCIENT PROFESSION SHAMAN MEDICINE MAN NATURAL HEALER PHYSICIAN PHILOSOPHER BARBER SURGEON MODERN PHYSICIAN—SINCE 1800’s LOW TECH—HOUSE CALLS (LITTLE BLACK BAG CARRIED MOST AVAILABLE TECHNOLOGY) X-RAY IN ITS INFANCY

3. THE PATIENT—PHYSICIAN RELATIONSHIP HISTORICALLY, THERE HAS BEEN AN INTIMATE, ONE-ON-ONE RELATIONSHIP BETWEEN THE PHYSICIAN AND THE PATIENT. THERE HAS BEEN AN EXPECTATION THAT PHYSICIANS WILL FIND AND TREAT MALADIES AND KEEP THEIR PATIENTS COMFORTED AND WELL. PATIENTS HAVE PLACED THEIR TRUST IN THEIR PHYSICIANS AND HAVE EXPECTED THEIR CARE TO BE INDIVIDUALIZED AND SPECIFIC TO THEIR NEEDS. AS SUCH, MEDICINE IS ONE OF THE OLDEST “SERVICE INDUSTRIES.” BUT, SINCE THE 1950’s, THE DELIVERY OF THIS SERVICE HAS UNDERGONE DRAMATIC CHANGE DUE TO RAPID TECHNOLOGICAL ADVANCES AND ECONOMIC PRESSURES. CONSEQUENTLY, THE HISTORIC PHYSICIAN-PATIENT DYNAMIC IS BEING REDEFINED.

4. THE CHANGING FACE OF MEDICINE PATIENTS STILL DESIRE A PHYSICIAN WHO IS: PROFESSIONAL WELL-TRAINED, KNOWLEDGEABLE, AND UP-TO-DATE EXPERIENCED COMPASSIONATE UNDERSTANDING OF THEIR NEEDS ABLE TO DELIVER INDIVIDUALIZED CARE WILLING TO SPEND THE TIME TO DISCUSS AND EXPLAIN THE ILLNESS AND ITS TREATMENT

5. THE CHANGING FACE OF MEDICINE PHYSICIANS NOW EXPERIENCE AN EVER-INCREASING NUMBER OF REGULATORY OVERSIGHTS AND CONTINUAL DECREASES IN THEIR COMPENSATION: MANY RULES AND LAWS HAVE BEEN IMPOSED BY JOINT COMMISSION AND FEDERAL AND STATE GOVERNMENT DOCTORS NOW NEED PERMISSION FROM INSURANCE COMPANIES TO ORDER CERTAIN TESTS DECREASING COMPENSATION HAS FORCED PHYSICIANS TO SEE MORE PATIENTS TO MAINTAIN THEIR OFFICES AND THEIR INCOMES PHYSICIANS HAVE FORMED LARGE GROUPS TO NEGOTIATE FEE SCHEDULES WITH PAYORS BUT, AS A RESULT, HAVE EVEN MORE OVERSIGHT AND DEMANDS ON THEIR PRODUCTIVITY AND PRACTICE PHYSICIANS FEEL THAT THE WAY THEY ARE BEING ASKED TO PRACTICE IS IN CONTRADISTINCTION TO THEIR TRAINING. MANY FEEL COMMODITIZED AND DEVALUED; MOST FEEL EXTREMELY DISSATISFIED

6. THE CHANGING FACE OF MEDICINE THE REALITY OF TODAY’S PHYSICIAN-PATIENT RELATIONSHIP: • HARRIED, UNHAPPY PHYSICIANS WITH TIGHT SCHEDULES • EXAMINATIONS ARE BRIEFER AND/OR MORE LOCALIZED • LITTLE TIME FOR DISCUSSION/EXPLANATION • INCREASED DOCUMENTATION REQUIREMENTS • INCREASED USE OF SUB-SPECIALISTS DIMINISHES THE ROLE OF THE PRIMARY CARE PHYSICIAN • TIME AND FINANCIAL CONSTRAINTS RESTRICT ABILITY TO FOLLOW PATIENTS IN HOSPITAL

7. THE CHANGING FACE OF MEDICINE • DISSATISFIED PATIENTS WITH EXPECTATIONS THAT ARE NOT BEING MET IN PHYSICIAN’S OFFICES OR THE HOSPITAL • FREQUENTLY INTERRUPTED; NOT LISTENED TO • NO TIME TO DISCUSS CONCERNS • LITTLE PERSONAL ATTENTION • WHEN HOSPITALIZED, SEEN BY MULTIPLE PHYSICIANS WHO ARE GENERALLY UNKNOWN TO THEM • MULTIPLE CARE-GIVERS INCREASE THE POSSIBILITY OF MIS-COMMUNICATION • STATISTICALLY, HOSPITALIZED PATIENTS TODAY ARE SICKER THAN THEY WERE FIVE YEARS AGO; SICKER PATIENTS HAVE MORE NEEDS AND ARE LESS ABLE TO COMMUNICATE THEM

8. ATTEMPTS TO RESTORE THE RELATIONSHIP ATTEMPTING TO RESTORE THE PHYSICIAN-PATIENT RELATIONSHIP, MANY MEDICAL GROUPS AND HOSPITALS HAVE SOUGHT TO IMPROVE SERVICE BY INCREASING EFFICIENCY. THEY HAVE EMPLOYED TECHNOLOGY TO ACHIEVE THIS GOAL: • ON-SITE SERVICES IN PHYSICIANS’ OFFICES: • LAB • X-RAY AND ADVANCED IMAGING • ELECTRONIC MEDICAL RECORD (EMR) • BETTER PATIENT/DISEASE MANAGEMENT • IMPROVED MEDICATION MANAGEMENT • ENHANCED COMMUNICATION BETWEEN PROVIDERS • INCREASED PORTABILITY OF INFORMATION

9. ATTEMPTS TO RESTORE THE RELATIONSHIP • HOSPITAL INNOVATIONS • PATIENT SAFETY • BAR CODING MEDICATIONS • RADIO FREQUENCY (RFID) TRACKING OF MOBILE EQUIPMENT • PROSEC INFANT MONITOR • DIAGNOSTIC TOOLS • 64 SLICE CT SCANNER IN THE ED • GI CAPSULE • SPYGLASS • TREATMENT MODALITIES • DAVINCI ROBOT • THERAPEUTIC HYPOTHERMIA • TOMOTHERAPY • BARRX • STEREOTAXIS

10. HAS EFFICIENCY WORKED? THESE TECHNOLOGICAL ADVANCES ARE TREMENDOUSLY EXCITING AND HAVE ENORMOUS POTENTIAL TO BENEFIT PATIENTS, CLINICAL PRACTICES, AND HOSPITALS. HOWEVER, AS H.L. MENCKEN PUT IT, “THERE IS ALWAYS AN EASY SOLUTION TO EVERY HUMAN PROBLEM—NEAT, PLAUSIBLE, AND WRONG.”1 CARE MUST BE TAKEN THAT WE DO NOT FOCUS SOLELY ON TECHNOLOGIC EFFICIENCIES. OUR EXPERIENCE HAS SHOWN US THAT THERE IS SOMETHING MORE. 1. JOHN PETRIE’S COLLECTION OF H. L. MENCKEN QUOTES. JPETRIE.MYWEB.UGA.EDU/MENCKEN.HTML

11. HAS EFFICIENCY WORKED? SOLUCIENT/REUTERS, A NATIONAL BENCHMARKING COMPANY, HAS RATED VASSAR BROTHERS MEDICAL CENTER (VBMC) A “TOP 100” CARDIAC HOSPITAL. OUR CARDIOLOGISTS HAVE THE BEST OUTCOMES IN NEW YORK STATE: DOOR TO BALLOON TIME CORE MEASURES (27) MORTALITY RECURRENT SYMPTOMS MYOCARDIAL INFARCTIONS BUT— OUR PATIENTS RATE THE SKILL OF OUR PHYSICIANS AT ONLY THE 37TH PERCENTILE!!! CLEARLY, THERE IS A HUGH DISCONNECT BETWEEN THE SERVICE PROVIDED AND THE PERCEPTION OF SERVICE RECEIVED!

12. SERVICE IS MORE THAN EFFICIENCY IN THE MEDICAL INDUSTRY, WE ARE LEARNING THAT “SERVICE” IS MORE THAN JUST EFFICIENT CARE. IT IS ALSO CARE THAT IS SAFE, EFFECTIVE, APPROPRIATE, AND EQUITABLE. HOWEVER, SERVICE DOES NOT BECOME “QUALITY SERVICE” OR “GOOD SERVICE” UNTIL IT BECOMES PATIENT-CENTERED. THIS POINT IS UNDERSCORED BY THE FACT THAT THE INSTITUTE OF MEDICINE (IOM) NOW DEFINES QUALITY BY THE ABOVE SIX CRITERIA. PATIENTS WHO UNDERSTAND THE MECHANISM OF THEIR DISEASE AND ARE INVOLVED IN THE SELECTION OF TREATMENT OPTIONS ARE MORE COMPLIANT WITH THERAPY, TAKE THEIR MEDICATIONS MORE RELIABLY, AND HAVE BETTER OUTCOMES.

13. PATIENT-CENTERED SERVICES AT VBMC ENTIRE STAFF INITIATIVES • CLASSES BY THE STUDER GROUP—LEARNING TO TALK TO THE PATIENT (AIDET: ACKNOWLEDGE; INTRODUCE; DURATION; EXPLANATION; THANK YOU) • DEFINED CODE OF CONDUCT—DESCRIBES EXPECTED BEHAVIORS AND THE PATIENT BILL OF RIGHTS • BEHAVIORAL POLICY—UPHOLDS THE EXPECTED BEHAVIORS • CLASSES BY LIFEWINGS—ADAPTS AVIATION SAFETY STANDARDS TO HOSPITAL CARE • MANAGING-UP—MAKING PATIENTS FEEL COMFORTABLE WITH PROVIDERS THEY DO NOT KNOW

14. PATIENT-CENTERED SERVICES AT VBMC NURSING STAFF INITIATIVES • STAFF NURSE HOURLY ROUNDING—ASSESSMENT OF POSITION, FALL RISK, CALL BELL ACCESS, TOILETING NEEDS • NURSE MANAGER DAILY ROUNDING—ASSESSMENT OF PATIENT’S NEEDS AND UNDERSTANDING OF CARE PLAN • DISCHARGE CALL-BACK—CONTACTING EVERY PATIENT THE DAY AFTER DISCHARGE TO ANSWER MEDICATION QUESTIONS, CONFIRM FOLLOW-UP APPOINTMENTS, AND DISCUSS ANY UNRESOLVED ISSUES • SAFETY, OPPORTUNITY, SUPPORT TEAM (SOS)—ENCOURAGES ANY FAMILY MEMBER TO CALL A SUPERVISOR FOR CONCERNS OR QUESTIONS • NURSE STAFFING RATIOS OF 6:1 OR LESS—PROVIDES OPTIMAL CARE (POSSIBLY THE BEST RATIO IN NEW YORK STATE)

15. PATIENT-CENTERED SERVICES AT VBMC PHYSICIAN STAFF INITIATIVES • PHYSICIAN LIAISON COMMITTEE—IMPROVES PHYSICIAN, NURSE, AND PATIENT COMMUNICATION/SATISFACTION • NEW SLEEP ROOMS FOR OB ON-CALL DOCTORS—EQUIPPED WITH COMPUTERS FOR FETAL MONITORING • RAPID RESPONSE TEAM—GIVES IMMEDIATE CARE TO DETERIORATING PATIENTS • 24/7 INTENSIVIST SERVICE (CRITICAL CARE UNITS) • 24/7 HOSPITALIST SERVICE (MEDICAL/SURGICAL FLOORS) • PHYSICIAN CHAMPIONS ON EVERY FLOOR—ROUND ON ALL PATIENTS TO ASSURE QUALITY MEASURES ARE MET • MEDICAL ADMINISTRATION—PROVIDES PERFORMANCE FEEDBACK TO PHYSICIANS

16. PATIENT-CENTERED SERVICES AT VBMC HOSPITAL PROGRAMS • MUSIC THERAPY IN NICU • CHAMBER MUSIC IN THE CANCER CENTER • PET THERAPY • CHILDRENS ART PROJECT/MILL STREET LOFT GOVERNMENT-MANDATED PROGRAMS • HCAPS (HOSPITAL CONSUMER ASSESSMENT OF PROVIDERS AND SYSTEMS)—PATIENTS COMPLETE A SURVEY THAT ASKS: HOW OFTEN DID YOUR DOCTOR • SHOW YOU COURTESY AND RESPECT? • LISTEN CAREFULLY TO YOU? • EXPLAIN THINGS IN A WAY YOU COULD UNDERSTAND? THIS INFORMATION IS USED TO DETERMINE MEDICARE/MEDICAID REIMBURSEMENTS—IT HAS NOTHING TO DO WITH COMPETENCE

17. HAS PATIENT-CENTERED SERVICE WORKED? OUTCOMES-CLINICAL EXCELLENCE: • LEAPFROG (A CONSORTIUM OF FORTUNE 500s DRIVING BEST CARE)—THREE YEARS AMONG THE TOP 32 ADULT HOSPITALS • SOLUCIENT/REUTERS—TOP DECILE FOR CARDIAC AND MOTHER/BABY CARE • COMMITTEE FOR CANCER ACCREDITATION—COMMENDATION IN 7 OF 9 CATAGORIES; AMONG THE BEST IN NEW YORK STATE • HEALTHGRADES—TOP DECILE FOR CARDIAC AND MOTHER/BABY CARE • AHA—AWARD WINNER FOR CARDIAC AND STROKE CARE • ADVANCED NURSING MAGAZINE—OF 247 TRI-STATE HOSPITALS, VOTED BEST PLACE TO WORK • BECAUSE OF OUR GROWING NATIONAL REPUTATION, WE ARE ABLE TO RECRUITE TOP PHYSICIANS AND NURSES, FURTHERING OUR ABILITY TO PROVIDE EXCELLENT CARE

18. HAS PATIENT-CENTERED SERVICE WORKED? OUTCOMES—MARKET SHARE: • 75% OF OUR LOCAL POPULATION SELECT VBMC AS THEIR HOSPITAL OF CHOICE (SIX OTHER HOSPITALS WITHIN 2-30 MILES) • 83% OF BABIES ARE DELIVERED AT VBMC • 75% OF AREA CANCER CARE IS PROVIDED AT VBMC • 75% OF AREA NEUROLOGY AND NEUROSURGICAL CARE OCCURS AT VBMC • 90% OF CARDIOLOGY AND 95% OF CARDIOTHORACIC SURGERY IS DONE AT VBMC • 14TH BUSIEST EMERGENCY DEPARTMENT (ED) IN NYS— 70,000 PATIENT VISITS THIS YEAR • HOSPITAL OCCUPANCY ROUTINELY 85-105%

19. HAS PATIENT-CENTERED SERVICE WORKED? OUTCOMES—FINANCIAL STABILITY: • GREATER THAN 4% OPERATING MARGIN (NYS AVERAGE IS -1%) • AA (DOUBLE A) BOND RATING—MOODYS, STANDARD&POOR OUTCOMES—PHYSICIAN PARTNERING: • WORKING WITH OUR PHYSICIANS TO CONTINUALLY IMPROVE OUR SCOPE AND DELIVERY OF SERVICE • ACTIVELY PURSUING A DEPARTMENT OF RESEARCH AND A TRANSPLANT PROGRAM • AFFILIATING WITH A MAJOR TEACHING HOSPITAL • CONTINUING TO IMPROVE OUR CORE BUSINESSES: CARDIAC; MOTHER/BABY; CANCER; NEUROSCIENCES

20. HAS PATIENT-CENTERED SERVICE WORKED? OUTCOMES—PATIENT SATISFACTION: • OUR PATIENT SATISFACTION SURVEY, MEASURED BY PRESS GANEY, IS IMPROVING CURRENTLY AT 85TH PERCENTILE FOR LARGE HOSPITALS GOAL IS TO ATTAIN GREATER THAN 90TH PERCENTILE THIS YEAR

21. THE ART & SCIENCE OF SERVICE: INNOVATION CONCLUSIONS: INNOVATION CAN PROVIDE FASTER, SAFER, MORE EFFICIENT, MORE EFFECTIVE TOOLS THAT ARE ESSENTIAL TO PROVIDING IMPROVED SERVICE. HOWEVER, IN A “SERVICE INDUSTRY” LIKE MEDICINE, CUSTOMER SATISFACTION IS ONLY ACHIEVED WHEN THE SERVICE IS HUMANE, CARING, AND HELPFUL ON A PERSONAL LEVEL. THE TECHNICAL ELEMENTS CANNOT SUCCEED WITHOUT THE KINDS OF PERSON-TO-PERSON INITIATIVES WE HAVE INSTITUTED. FINALLY, EVERYONE WHO WORKS IN A SERVICE INDUSTRY IS, IN FACT, A CUSTOMER OF THE ORGANIZATION, WITH NEEDS THAT MUST BE ANTICIPATED AND MET. WHEN THE SERVICE PROVIDERS ARE, THEMSELVES, HAPPY, THEY PROVIDE BETTER SERVICE TO ALL OTHER CUSTOMERS.

22. FINAL THOUGHTS “…PRESSURE ON HEALTH CARE PROVIDERS TO BE MORE ACCOUNTABLE FOR THE FINANCIAL CONSEQUENCES OF QUALITY PROBLEMS …WILL INEVITABLY REQUIRE PHYSICIANS TO LEARN TO SYSTEMATICALLY REENGINEER CLINICAL WORK METHODS IN ORDER TO REDUCE ERRORS AND WASTE—A COMMON APPROACH IN OTHER COMPLEX SERVICE AND MANUFACTURING SECTORS. THIS TREND ALSO PORTENDS MAJOR REVISION IN PHYSICIAN TRAINING, GREATER COLLABORATION OF PHYSICIANS WITH SYSTEMS ENGINEERS AND OTHER CLINICAL TEAM MEMBERS, AND THE ADOPTION OF ELECTRONIC INFORMATION SYSTEMS. HOW THESE FUNDAMENTAL CHANGES WILL BE FACILITATED REMAINS AN UNWRITTEN CHAPTER IN THE ADVANCEMENT OF CLINICAL PERFORMANCE IN THE UNITED STATES….”2 YOU CAN HELP WRITE THE CHAPTER. 2. MILSTEIN, MD, MPH. “ENDING EXTRA PAYMENTS FOR ‘NEVER EVENTS’—STRONGER INCENTIVES FOR PATIENTS’ SAFETY.” N ENGL J MED 2009; 360;23:2388-2390.