Friday, September 26, 2014

Could Healthcare use a SimHospital?

It's July, 2014. Meaningful Use Stage 2 is underway, ICD-10 has been delayed again, the Affordable Care Act is happening, and healthcare is reforming at a pace it's never been subjected to. Change is afoot. So this has been keeping me quite busy.

So I thought I'd write a bit about the potential value of gaming and simulation in healthcare reform.

As a CMIO in a community hospital, you sometimes fill a lot of roles - Physician informaticist, project manager, trainer, workflow analyst, policy writer, regulatory guru, strategist, and practicing physician all in one. I think this is one of the reasons the CMIO role continues to expand and evolve nationally - It's helpful to have someone who sees so many facets of your care delivery system.

And as an Informaticist, to help the REAL world, you end up spending a lot of time in a VIRTUAL world, with dummy patients, dummy lab tests, and dummy tools, trying to test things in a virtual TEST environment, to make them work properly before they go into the LIVE environment. Sometimes I'm very surprised at what this virtual world teaches us about the real world. (For some Hollywood context, see Gary Sinise playing astronaut Ken Mattingly in the movie Apollo 13, where they work out problems in the virtual training environment that help save the real-life astronauts.)

Anyway, with all of the change going on in healthcare, we need to identify and train future healthcare leaders who will help see healthcare through these changes. Here is where gaming comes in.

Gaming could help healthcare, by allowing our future healthcare leaders to learn strategy in a safe, dummy, TESTING environment - No real workers, no real patients, no real budgets. If pilots can practice flying and landing planes in a simulator, why can't healthcare leaders? What if they could really experiment with revolutionary efficiency and cost-cutting strategies in a safe, TEST environment, where they wouldn't have to worry about departments or hospitals shutting down?

One thing I've learned from studying workflows is that most people behave in fairly predictable ways. Most people want to do the right thing - They want to practice their trade, make a living doing it, and be proud of their work - so if you give them enough structure and reinforcements, they will do it fairly predictably. In other words, predictable things happen predictably.

So if you were designing a healthcare simulator, it probably wouldn't be too hard to develop some common clinical and administrative avatars :
  1. [ CLINICAL ] Nurse avatars
  2. [ CLINICAL ] Physician avatars
  3. [ CLINICAL ] Pharmacist avatars
  4. [ CLINICAL ] Ancillary staff avatars (e.g. Respiratory, Dietary, Rehab, Case Management, etc.)
  5. [ ADMIN ] Manager-type avatars (e.g. Nursing, Providers, etc.)
  6. [ ADMIN ] Director/Chief avatars
  7. [ ADMIN ] Executive avatars
  8. [ ADMIN ] Board Member avatar
And in this game, with simulated budgets, each of these avatars would generally conduct themselves with a predictable degree of certainty, based on what I think are a few key environmental variables, which are all related to each other
  1. Amount of Education/Training (includes everything from formal, professional education to organizational orientation to continuing ed)
  2. Strength of Operational Infrastructure (includes everything from policies to governance to committee structure to supervision to technology to organized change management)
  3. Quality of Documentation (includes everything from contracts to job descriptions to committee charters to bylaws)
  4. Efficiency and Flexibility in Finance/Budgeting (includes everything from salaries to budgets to facilities and equipment)
  5. Effectiveness of Communication (includes everything from emails to committee meetings to reporting structure to internal/external posters and publicity)
So in a virtual, gaming scenario, you could potentially build a virtual SimHospital, from the ground up, full of these avatars. And if you wanted it to be successful - Or really successful -  you would probably want your virtual avatars to have the highest amount of education, strongest operational infrastructure, highest quality documentation, most efficient and flexible finance/budgeting, and most effective communication.

But the real world doesn't work like that - you can't have the highest degree of all of them. You have to make compromises. Usually limitations come in the form of time, resources, or both. So to be successful, most organizations constantly work to maximize all five of those factors.

But the virtual avatars in this virtual hospital would all be continuously responding to these environmental variables, and in this way, one could build this SimHospital - A virtual environment in which the goal is to make a working, functional, and financially viable hospital. You make the decisions, you juggle the variables, and the avatars and budgets will respond to your decisions. You could be your own virtual board member.

Why would someone want to play this game? To learn safely. To experiment. To try new ideas without people getting hurt. Heck, you could even make it fun and award points for things like delivering a quality procedure without complications, or saving money. What if healthcare administrators played this game at home, competitively, trying to see who could get the highest score?

Let's face it, running a healthcare corporation isn't easy, with these many complex internal and external environmental variables that are constantly changing. But helping leaders to understand the these changing variables in a safe, TEST environment, would have enormous educational value to future healthcare leaders.

After all, if pilots have virtual simulators for flying a plane, why not a virtual simulator for running a healthcare organization?

The challenge with this whole gaming idea, of course, would be deciding : What would you award points for, exactly? Would it be :
  1. Financial Profitability?
  2. Quality of Care?
  3. Quantity of Care?
  4. All of the above?
Whatever the scoring schema is, a place for healthcare leaders to learn managerial and leadership skills safely, and try out new ideas without risk, would be a tremendous help in training the leadership we will need to see our industry through the next ten years.

What would you award points for? Leave your thoughts in the comments below! Remember, this post is for educational purposes only, and to stimulate discussion about new and innovative ways to help improve the delivery of healthcare. 

Sunday, June 29, 2014

My Open Letter to the New Physician Leader

So I've been in my current position for almost seven years now. I've learned a lot during that time, and I always enjoy sharing my lessons with other people, so maybe they won't have to spend as much time learning them as I did. So in the spirit of education, and with love and fellowship for other physician leaders, I share this blog post:


To the New Physician Leader,

Welcome! You're a board-certified physician who has been honored by being asked to serve some sort of leadership position in healthcare, generally either a committee chair, department chief, or physician executive. Given all of the reform and change going on, we need good physician leadership in healthcare! We need you to bring a physician's voice to the discussion, and your hours spent in the ED, OR, ICU, floors, or clinic, will help keep you honest and patient-focused. Your experience will help answer detailed questions about how to deliver great patient care. Your clinical hours are being cut with the expectation that you will step into this new role, help coordinate with other physicians, help shape the future of healthcare, and make it great.

Unfortunately, there's no great training course for this new role. Some of you got voted into your positions, whether you wanted it or not. Some of you demonstrated your skills at many long committee meetings, and eventually earned a reputation as a physician leader. And some of you obtained MBAs, MPHs, or other advanced degrees which helped to get you started in your new role.

But I'm writing to share with you some of the lessons that I've learned in my seven years as an eternally questioning physician leader, in the hope that you will use them in any way you see fit - Hopefully, to prevent you from learning the lessons as slowly as I did.

So with that, I humbly offer you these ten lessons that either I've learned myself, or that were shared with me from other physician leaders :
  1. Don't think being a doctor prepares you for this leadership role. Medical school teaches us a lot about anatomy, physiology, pathology, and histology. Residency teaches us a lot about medicine, surgery, OB-GYN, pediatrics. Fellowship teaches us a lot about pulmonary/critical care, neurosurgery, and cardiology. Experience may teach us how to do our job, or lead a clinical team to a successful surgery. That education and experience will serve you well in this new role, but there is still much to learn. Leading a clinical team through a surgery is very different than leading a whole department or a clinical service. Always be humble and thankful for the people who teach you new things. In my opinion, as physicians, we should always strive to be both teachers and students for the rest of our lives.
  2. Set high standards for yourself. You have one shot at this. Don't just be "good enough." Be "good enough for your children." Attention to detail can be the difference between success and failure, and we need you to be successful in your new role. Don't just aim to succeed - Distinguish yourself by aiming to succeed and wow. Don't just try to meet legal standards, try to meet ethical standards.
  3. Learn some basic parliamentary procedure. Buy yourself a copy of "Roberts' Rules of Order" and read it. Keep your copy in your new office. Knowing how to run a good meeting is a critical skill that not everyone has. When the opportunity arises, being able to correctly discuss the difference between a primary motion and a secondary motion is very impressive. You will also need to know this if you have to make any big changes, which will invariably involve politics and governance.
  4. Know how to write a really good committee charter, meeting agenda, and minutes. These tools are so essential to success, and still many physician leaders don't pay much attention to them. If you really care about these documents, you will be empowered by knowing how to run really good meetings where people show up and things get done.
  5. Control your documents, don't let them control you. Simply put, documentation matters. First, make sure you read your organizational chart, bylaws, rules and regulations, and policies (at least once), and make sure you understand what they all do. Physician leaders sometimes fail because they don't know or understand their governing and operational documents. Next, make sure you know how to develop a really good document - Starting from your idea, to your regulatory/policy/literature search, to your stakeholder list, to your well-designed template, to your first DRAFT, to your stakeholder review, to your final draft, to your FINAL document approval, to your document publication and monitoring - Every step is essential to making a good document. It doesn't matter how good and well-planned your idea is - If it's not properly developed and documented, then it's likely to fail. Finally, keep all of your computer documents somewhere where other people can find them. If you keep all of your tools on your local C: drive, or your email, then nobody else can see them, read them, or collaborate on them. And if you get sick or leave - They may be lost forever! A much better place to keep them is an internal, secure, shared network drive that many people in your organization have access to - It facilitates collaboration, and someone else can find things if you're sick!
  6. "Workflow" is everything. While this term is often used when trying to implement an EMR, everyone should know what it means and why it's important. Workflow is actually deceptively simple. It's a procedure. The success (or failure) of your projects and departments will depend on having good, clear, well-designed, cost-effective workflows that build best-practices into your daily routines. To document your current and future workflows, some people try to make elaborate Visio diagrams or flowcharts, but it doesn't need to be that complex, and sometimes the complex diagrams can leave out important details. You may still need expert help when trying to fix workflows, but as a start, try studying food recipes to see how easy it can be to write good procedures. By design, food recipes/procedures/workflows are generally very 'lean' (in process, not necessarily nutrition - Sorry, no pun intended!) You may still need expert help when trying to fix workflows, but you can start writing a good procedure/workflow, line-by-line, using the general format [ WHO ] will [ WHAT ] [ how ] [ when ] [ where ] [ why ], where the bold parts are mandatory and the italic parts are optional (and only used when needed.) Once you have your current state workflows documented in this manner, you'll quickly see where it can be streamlined to develop your future state.
  7. Don't just make the future good, make it excellent. It's easy to get lost in trying to preserve the past. Sure, there are some things you'll want to keep (like good patient care, compassion, and continuity), but some of healthcare was broken. Make sure you're not trying to preserve the stuff that was broken. (This is especially important when trying to go electronic - You do not want to build bad workflows into your new electronic system!) Remember - Doctors will still be doctors after healthcare reform. We may look a little different, work a little different, and even get paid a little different, but patients will still need us to help them. Plan to make the future excellent for both patients and caregivers.
  8. Finance matters. Through medical school, residency, and fellowship, most doctors don't pay much attention to financial issues (other than student debt!), but at the end of the day, clinical decisions need to make financial sense, and many hospitals close because of insufficient funds. Every penny counts. To make sure everything you do has value, and your projects are well-planned and financially sound, always include someone from finance/accounting early in your clinical discussions. Doctors have as much to learn from finance as finance has to learn from doctors. 
  9. Prepare for shared governance. Let's face it - In the old days, doctors 'ruled' the hospital, while nurses actually kept it alive and functioning. That model doesn't work anymore - You were hired because the nurses can't do it alone. Some people mourn the passing of those days. Personally, I don't. In the future, doctors, nurses, pharmacists, quality, regulatory, legal, and financial people will work together to break down silos, answer questions and collaborate on decisions. I love working collaboratively because I learn so much from these other team members. Working together, we reduce costs, avoid workflow problems, and make better decisions. 
  10. Always let the patient guide your compass to True North. I was once given this advice by another physician leader when I asked him, "How do you always know what to do?". He basically told me, "As long as you always think about the right thing for the patient, you'll always know what to do." I've spent seven years validating his advice, and I can say that so far it has served me very well.
We desperately need you to help shape the future of healthcare, and shepherd other physicians and advanced practice clinicians (PAs, NPs, etc.) through this transition process. To help our patients, we are counting on you to be both happy and successful in your new position! Good luck, share your lessons with other people, and always remember why you applied to medical school in the first place - to help people.

Humbly submitted,

- Dirk
(fellow student, teacher, and eternally questioning physician leader)

Remember - This blog is for educational purposes only, so I always welcome opinions and feedback! Do you have any lessons you would share for a new physician leader? Leave them in the comments below!