by Thomas H Lee
Greater sampling increases the utility of the data by providing sample sizes needed for better performance measures at smaller breakout levels.
In summary, the clear direction is toward collection of data electronically from as many patients as possible. More data obtained more quickly help dispel some of the reasons clinicians might offer for ignoring recommendations that are based on patient experience data. To accelerate these trends, many organizations are starting to use point-of-care data collection, for example, using tablet computers to collect data from patients much more frequently, such as every day or even every shift during a hospitalization. These data can be used to overcome some of the challenges in attribution of information to individual clinicians.
Advances in Data Analysis
Collecting more data from more patients in a more timely fashion is the beginning of an ambitious agenda, not the end. Once those data are collected, they must be analyzed, put in context, and reported in ways that have an impact. As has been noted, the normal human response to feedback is to look for reasons why the findings may be wrong if those findings suggest the need for improvement. Even if patient experience and other types of quality data were collected from 100 percent of patients every day or every shift during hospitalizations, there would still be justifiable concerns about the use of those data to compare providers and decide who is best, who is merely average, and who is doing poorly.
Patients are individuals, of course, and just as two people may give drastically different reviews of the same movie, patients can walk away from the same healthcare experience with different impressions. One implication of this is that healthcare providers need to tune in to their patients as individuals and understand each of their needs and try to meet them; in other words, they need to practice empathy. Another is that healthcare providers need data on many patients so that the wisdom of crowds can be applied to the data and random errors caused by variation among individuals will cancel out.
However, just as individuals vary, so do groups. New Yorkers are tougher customers than Midwesterners. Younger patients are less likely to give top ratings than are older patients. Asians give fewer top grades than do European Americans. There are also complex systematic differences in interactions between groups of patients and groups of clinicians, for example, between patients and providers of different races or different genders.
The result of this complexity is that gathering tons of data doesn’t automatically mean that apples-to-apples comparisons are easily done. Life is complicated, and so is healthcare. However, the fact is that benchmarking is valuable. It helps providers learn where there is opportunity to improve because someone out there is doing better. It helps providers learn when there is an imperative to improve because the data suggest that they may be doing worse than their colleagues.
The implication that emerges from Press Ganey’s experience is that lots of data from lots of providers are necessary to do good benchmarking. National comparisons and benchmarking set the stage for understanding relative performance in a rapidly moving and increasingly competitive industry. Comparing groups of similar organizations—academic or community hospitals, organizations within the same state or city, organizations of like size or volume—refines the ability of providers to put their own performance in perspective. Similarly, using benchmarks that are specific to physician specialty or the type of care being provided can help account for differences in the underlying patient population, including their complexity, needs, and severity. The findings and trends may not change drastically with more detailed analyses, but they are often needed to overcome resistance to the feedback.
That said, even sophisticated analytics are not necessarily enough to drive improvement in performance, which requires feeding back data to units of accountability and units of improvement. Units of accountability are those which recognize responsibility for performance. Units of improvement are those which have the personnel and other ingredients needed to create permanent change for the better. Ideally, performance measurement provides the incentive and the road map for these units to improve.
To date, patient experience data are most effective when the units of accountability and improvement are the same, such as an individual physician in the outpatient setting. When individual physicians understand that they alone are responsible for demonstrating empathy to their patients and they get data and comments showing that there is room for improvement, there is a good chance that they will improve.
However, there are many issues that are important to patients for which individual clinicians do not feel accountable. For example, waiting time is a topic that often annoys physicians who are already working as hard as they can. (Their reaction is “What am I supposed to do? I am already seeing patients as quickly as I can for 12 hours a day.”) Also, there are important issues such as the coordination of care, which depends on the actions of so many others, for which individual clinicians do not feel fully able to drive improvement.
For such issues, the problem is less the measures and the data and more the organization of care. A common observation these days is that healthcare is a team sport. But often the teams do not actually exist or the team members do not know that they are part of a team. In other words, there is no individual who feels accountable for performance, and there is no identifiable team either. Patient experience data can be collected, but when they are sent to healthcare organizations, they might as well be returned with the stamped message “Addressee Unknown.”
An example I have observed at several hospitalist programs around the country goes something like this: The individual hospitalist physicians say that they want to be held accountable for their performance as individuals. However, in general, patients are surveyed at the end of a hospitalization, and the data are analyzed on the basis of the last physician who was overseeing the patient’s care. The discharging physician may have been responsible for much of the patient’s care or for very little. Frequently, the real action of the hospitalization occurred on someone else’s watch.
Two potential solutions seem obvious, and both are needed. One is for the group of hospitalists to feel collective responsibility for their performance and to recognize that they are a team in which no individual’s performance stands alone. The other is to collect more data throughout a hospitalization so that patients can be asked to give feedback on the care of the physicians, nurses, and other personnel with whom they have interacted during the last day or even the last shift. Some organizations are already moving in this direction, using tablet computers with photographs of the various personnel to help patients identify them.
The attribution challenge exists almost everywhere in medicine because teamwork is so essential to state-of-the-art healthcare delivery. In emergency departments, for example, patients with problems of any complexity often require care for more than one shift of clinical personnel. The response rates are already lower for emergency department patients than they are in other settings. Physicians can be irritated at getting feedback on a small number of patients for whom they don’t feel ownership.
In such settings, cultivating the sense of group ownership is critical, and for patient segments with similar shared needs, a powerful new concept of the group is emerging. Integrated practice units (IPUs) are emerging in healthcare systems around the world in which multidisciplinary teams work to improve the value of care for patients with specific conditions such as prostate cancer and headache or those who need to undergo major surgical procedures such as cardiac or orthopedic operations.
These IPUs meet frequently and are often a more important focus for organizational identity for the clinicians than are the hospital departments that reflect their expertise. These teams exist to meet patients’ needs and to do so efficiently. They hunger for data to help them, including the following:
• Patient reported outcomes measures (PROMs)
• Traditional quality metrics on the reliability with which key processes are occurring
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• Cost data
• Personnel “engagement” data that capture how well the team is working as a team
All these types of data are important, and they interact with one another to influence patients’ overall outcomes, experience, and costs. For example, more engaged teams are less likely to have turnover of personnel and thus avoid the costs and disruption of hiring and training replacements. Thus, creating real teams and giving them a fully integrated package of the data that they need to improve value are important goals for forward-looking organizations. Consolidating care of patients with target conditions with these IPUs will make the data more robust and increase the impact of such teams.
In sum, recent years have seen marked advances in the ability to measure what matters to patients. More data can be collected more quickly, and there is increasing clarity about their importance and how they should be analyzed. Nonetheless, the fact is that data are necessary but not sufficient to drive improvement. There has to be an organization and individuals within the organization who want to use the data to improve. These dynamics are the focus of the remainder of this book.
CHAPTER
5 Social Capital and Social Network Science Come of Age
WE KNOW THE problem: the chaos and the resulting loss of empathy that are so common in modern medicine. We understand the strategic business imperative to improve: we are entering a healthcare marketplace driven by competition on value to the patient. That marketplace demands relentless efforts to improve the effectiveness and efficiency with which providers meet patients’ needs. We grasp that empathic care is critical to meeting the needs of patients and appreciate that the science and technology related to measuring those needs is advancing. We know what we need to accomplish, and we are getting much better at measuring how we are doing.
But how do we actually do it? How do we spread the values that are reflected by what we are measuring? How do we make empathetic, coordinated care the norm rather than something akin to stars coming into alignment? How do we help individuals and groups of individuals in healthcare be at their best consistently and live up to their own aspirations for the care that they deliver to every patient every time?
Making progress toward this lofty goal requires understanding the importance of social capital, and amassing social capital requires thoughtful use of social network science. The insights that flow from research in both areas can strengthen the ability of healthcare organizations to compete and thrive in the new healthcare marketplace while bringing professional pride to their personnel and driving an epidemic of empathic care.
Social Capital
When healthcare organizations talk about capital, they are usually referring to financial capital: the monetary resources that enable organizations to erect buildings, buy equipment, and accomplish other goals that otherwise would be beyond their reach. They also may be referring to human capital, which is the intellectual quality of their doctors, nurses, and other personnel. Social capital is about coordinating the two. Social capital describes the advantages created through the structure and function of relationships both within the organization and with others outside the organization. Those relationships enable an organization to do things it couldn’t otherwise do, such as reliably deliver care that is compassionate and coordinated.
Social capital explains why some organizations do a better job than others at meeting patients’ needs and why other organizations so often fall short even though their personnel are every bit as intelligent and work just as hard. The higher-performing organizations do a better job and are more reliable because of the ways in which their personnel relate to one another both formally and informally. Teamwork is not an abstraction but a core part of the professional lives of their personnel.
Those medical professionals know what they are supposed to do as individuals and also what others are expected to do. There is trust among them, so rework can be minimized. There is a shared goal, so the most efficient way to accomplish that goal can be pursued collectively. There are norms that are not likely to be lightly violated, and one of those norms is putting the needs of patients above all other priorities.
A clear and useful framework for thinking about social capital can be found in the work of the University of Chicago sociologist Ronald S. Burt. Burt describes two basic ways in which organizations increase their social capital: brokerage and closure. Brokerage describes the way organizations learn and actually increase the variation in how they do things. Closure describes how they reduce variation and achieve consistency in working together in an effective and efficient way.
Organizations need both types of functions to drive an epidemic of empathy. They need to learn what others are doing to redefine what it means to meet patients’ needs, such as using transparency with patients’ comments to drive improvement, doing root-cause analyses when patients suffer a loss of dignity, and providing communications training programs to help clinicians learn what messages best encourage and convey empathy. That is information brokering. After learning about and piloting new ideas, personnel need closure to make those ideas the local norm.
Brokerage
Healthcare organizations are made up of people, and even though some people leave the organization every year and new ones enter, there is a history to the group of people. Within the organization, there are subgroups, and there are other organizations in the great beyond, all with their own histories and norms.
At my hospital in Boston, my colleagues and I are dimly aware that the Mayo Clinic has a social norm in which everyone answers his or her beeper right away. We don’t talk about it every day. It comes up a couple of times a year after someone has visited Mayo Clinic. He or she will say, “Do you know that they all answer their beepers immediately?” “Really?” we tend to say. “I think I’ve heard that before.”
We have also heard that Cleveland Clinic asks every patient who calls seeking an appointment whether he or she would like to be seen that day. We point out that we see a large percentage of our patients on the same day they call and believe that we find a way to squeeze in virtually everyone who needs care urgently. But we do not guarantee same-day access, and we don’t ask all patients if they want to be seen the same day. Nevertheless, we are aware that Cleveland Clinic and some other places in other cities are doing just that.
We were startled when we heard that the physicians at University of Utah Health Care were posting all their patients’ comments on their find-a-doctor pages on the Internet. I remember that I was in the back row of a classroom at Harvard Business School in January 2013 when I first heard that from its CEO, Vivian Lee. My actual words to her were “You are kidding me!” (In my mind, I put an expletive before the word kidding.) Some of us went to the website to see if it was true. It was.
Although those examples were impressive, we didn’t try to emulate them. We went back to the hard work of doing our job the way we always did it.
My colleagues and I tend to get a bit more concerned when we hear about different ways of doing things among colleagues closer to home, especially in the Boston area. After all, they are our competitors and our friends. Our children go to school together. Our patients live in the same communities and often go back and forth among our institutions. Therefore, when one hospital, Beth Israel Deaconess, began giving patients full access to their medical records through a program called OpenNotes, the clinicians in other hospitals could not help but sit up and pay attention.
My colleagues at Boston’s academic medical centers are aware that there are organizations around the country that are a lot like ours. My colleagues at Brigham and Women’s Hospital take note when they hear about changes in the design of care at academic medical centers such as Johns Hopkins, Yale, and Stanford. My colleagues at Boston’s safety-net hospital, Boston Medical Center, are in touch with their counterparts around the country. My colleagues at Dana-Farber Cancer Institute are carefully watching what goes on at other comprehensive cancer centers. We are all aware
of the community in which we work and the broader communities that are relevant to us. There is variation in the way things are done within and across these communities. Some ways of doing things are better than others in meeting patients’ needs effectively and efficiently. Some are clearly best practices.
Variation provides an opportunity to improve by learning. How quickly and reliably are these various practices compared, and how quickly and reliably do the best practices emerge and spread? The efficiency of this market of ideas is determined by organizations’ effectiveness at information brokering.
As attractive as the idea of spreading best practices sounds, the reality is that the barriers to doing this are considerable. Burt writes, “When people specialize on their immediate tasks to the exclusion of adjacent tasks, they lose track of other groups and the external environment. Variation in belief and practice develops between groups. People here do it differently than people over there. In fact, in-group communication can create barriers to information inconsistent with prevailing beliefs and practice.”1
In other words, the more intense and inward-facing a culture is, the harder it is for information from the outside to penetrate. That observation is consistent with a self-deprecating joke about the medical community in which I practice: “Over the years, many great ideas have come out of Harvard, but very few have gotten in.” The problem of insularity demands a conscious, systematic effort to learn from the outside.
Burt writes about people working in clusters and the importance of bridges between those clusters so that information can reach them. It is one thing to hear that the physicians at Geisinger Health System do things a certain way; it’s another thing to actually go to Danville, Pennsylvania, and see them in action. In the former context, it is too easy to dismiss the description of some best practices with the casual remark “They are organized differently from us.”