Note from Mary Pat: Please welcome my guest columnist Jim Smith, MBA who has written on the subject of change. His original article was written about the Washington State Department of Transportation, but he has been kind enough to let me change WSDOT to ABC Medical Practice, a very large and fictitious medical practice that resembles almost every practice you and I know.

Over the past twenty years many changes have been made at the ABC Medical Practice. Almost always they were changes which improved employee production and modified the then current way of doing things. I have noticed the staff employed at the practice are only interested in doing things the way we have always done it. My point is this; people are not creatures of change, do not like change, will not suggest change, and when confronted with change quite often reject change.

Reinventing healthcare and group medical practice is a mammoth task, much larger than any change efforts at a big corporation. The ABC Medical Practice has many employees and dozens of departments. How do you begin to change something so large and bureaucratic?

To begin with, you have to recognize that youre dealing not with one large organization but with lots and lots of individual bureaucracies, each of which has its own concerns and needs. Each unit must move through the change process in its own particular way. Every department is going to have to approach change on several different levels. The first step in any changeand it doesnt matter if youre running a division of GM or Kiser Permanente is to begin to ask the basic questions: What business are we in? Whats our mission? Who are the customers were aiming to serve? You must answer those questions carefully.

Then, if youre truly going to understand the most important problems and begin to look for answers, the second step is to draw on the experience of people from all organizational levels. How do the services you provide look to employees in the field? How does it feel to be a customer of your company?

In healthcare, the answers arent necessarily the same as those in business. Who are the customers of the ABC Medical Practice? Patients? Referrers? Payers? The federal government? The state government? The owners? Those questionsand their answersare important, but they arent obvious. After you have defined your mission and your customers and then learned what those customers want, you need to articulate a vision of change and sell that vision to every employee.

Look at change from four thematic perspectives: customers, consequences, control, and culture. First, you need to revamp the relationship between your organization and its customers. You have to ask customers what they want and then restructure your organization to deliver it. Second, you need to create consequences for what people and organizations do. In business, if employees cant deliver what they were hired to deliver, they leave or are fired. If the business cant make money and keep customers happy, it doesnt survive. Somehow, managers have to create a feeling that what people do day-to-day to advance the mission of their practice really is important. And healthcare leaders have to create performance measures, budgets and other systems that reward success and force weak performers to improve. Healthcare workers are no different than other employees; they want to see their efforts matter and their progress measured.

Third, you need to look at who has control. In healthcare, control is vested at the top much more than in almost any business. If you want an organization to become more entrepreneurial and alert to customers, you must give a lot more control to the people on the front lines who deal with customers and deliver the services. Thats as true of healthcare as it is of business.

Finally, you need to ensure that the culture of the medical practice supports the work that people need to do to deliver value to the customer. In the workplace, long-standing cultures have taught people to keep their heads down, stay out of trouble, and, unfortunately, they have accomplished little. The key is to craft a different kind of culture.

Conversations about the vision of the future and your mission have to start at the very top. The doctors have to get out there and talk about that vision again and again. The leaders must do the same, but they need to be more detailed-oriented and talk about specific goals. And so on down to every level.

A crisis helps enormously. Companies like Harley-Davidson and Ford have used crises in a similar manner. If you dont have an obvious crisis, sometimes you have to try to manufacture one or at least create an overwhelming sense of urgency. You can say, This is the level of performance we need to attain, and were doing a miserable job. You can talk in quantitative terms about where you are and where you want to be and involve everybody in choosing the strategies to get there. And then, when you reach the point where you hit your goals, you shouldnt be shy about trumpeting it. Successful results can protect you from the internal and external opposition youre almost certain to run into.

Until now, change in healthcare has been an either-or proposition: either quickly create economic value for owners or patiently develop an open, trusting corporate culture long term. But new research indicates that combining these hard and soft approaches can radically transform the way businesses change.

The new economy has ushered in great business opportunitiesand great turmoil. Not since the Industrial Revolution have the stakes of dealing with change been so high. Most traditional organizations have accepted, in theory at least, that they must either change or die. And even Internet companies such as eBay, Amazon.com, and America Online recognize that they need to manage the changes associated with rapid entrepreneurial growth. Despite some individual successes, however, change remains difficult to pull off, and few companies manage the process as well as they would like. Most of their initiatives installing new technology, downsizing, restructuring, or trying to change corporate culture has had low success rates. The brutal fact is that about 70% of all change initiatives fail.

In our experience, the reason for most of those failures is that in their rush to change their organizations, managers end up immersing themselves in an alphabet soup of initiatives. They lose focus and become mesmerized by all the advice available in print and on-line about why companies should change, what they should try to accomplish, and how they should do it. This proliferation of recommendations often leads to muddle when change is attempted. The result is that most change efforts exert a heavy toll, both human and economic. To improve the odds of success, and to reduce the human carnage, it is imperative that executives understand the nature and process of corporate change much better. But even that is not enough. Leaders need to crack the code of change.

To Recap:

• Each medical organization is made up of official and unofficial departments and each department will have its individual perspective, needs and culture.Who is your customer? (Examine this carefully – you might be surprised.)
• Are there any consequences for not being willing to change? Is the culture really going to change, or is it just a lot of talk?
• Are those in control the ones talking about the vision? If the doctors own the practice and they don’t truly believe in the change, neither will the staff.
• Is there a crisis? If you are in healthcare, whether you believe it or not, there is a crisis.
• Don’t overwhelm the practice with initiatives, unless they are important and not just the flavor-of-the-month.
• Celebrate successes!

One of the most valuable, if not THE most valuable, resource a healthcare executive has are colleagues and their collective experiences. The issues that we confront daily are what we need and want to discuss with our comrades-in-arms.

The listserv is the most direct way of sharing information between colleagues. I belong to a number of MGMA (Medical Group Management Association) listservs and to the AAOE (American Academy of Orthopedic Executives, formerly BONES) listserv. These listservs are amazingly helpful and I have more often been the benefactor than the provider of information there. But listservs have their limitations.

You have to be a member of these organizations to participate in their listservs. This is not unreasonable, as the infrastructure and management of a listserv is not without cost. As healthcare continues to get squeezed, however, managers will have to make harder choices about which resources and memberships they and their practices can afford. Membership requirements also screen the participants, which may be important to some. The screening, however, may limit the amount of participation and the diversity of participation. Healthcare is becoming global, as any medical practice competing for the medical tourism dollar will tell you.

Listservs can also take time to read and delete or store. I have not found an easy solution to arranging the information I want to retain, although there is always deleting the listserv emails and searching the archives later.

I am finding Twitter to be a no-cost solution to many of my needs not fulfilled by listservs. I have access to thought leaders in and outside my field, and the conversations we have can be on or off the grid. Although it was initially difficult to constrain myself, I now find the limitation to 140 characters to be very liberating.

Tweets are brief pointers to people, conversations, blogs, and resources across the world. As Kenneth Yu says on his blog MindValley Labs:

…Twitter is currently the closest app on Earth that replicates the actual thought patterns of the human mind. You see, the human mind does not really think in blog and article form. It does not think in huge chunks of information. Instead, it thinks in a stream of consciousness way, random disjointed thought layered upon random disjointed thought.

Twitter also has a number of applications designed to organize information, contacts and conversations in ways that make information easy to retrieve. To follow me on Twitter, use my Twitter name @mpwhaley. To join a brand-new community of discussions around medical practice management, use the #medpractice hashtag to search and join the conversation.

If you remember, MMP recently had a post about Twitter, and some ideas I had about the use of Twitter in a medical practice. Since then, Twitter has exploded onto the healthcare scene. Last Sunday I participated in an online Twitter online meetup discussing social media in healthcare. The Twitterati (those who twitter) included medical students, physicians, payer representatives, consultants, patient advocates, patients and me. The long and the short of the discussion was that the world of healthcare, full of traditionally slow technology adopters, has amazing potential for using social media to reduce waste, improve efficiency, allow staff and caretakers to give more time to patients, and possibly reduce healthcare costs.

Phil Bauman, “a Registered Nurse with a background in critical care, drug safety, accountancy, finance, treasury operations, and recruiting” wrote the following in his blog post of January 18, 2009:

HEALTH CARE SHOULD BE THE LEADER IN MICRO-SHARING

With 26 letters in the alphabet arranged within 140 characters, there are over 1.2 x 10^198 possible character combinations. Of course, the number of meaningful sentences is far less than that but a point stands out: theres a virtually infinite number of short pulses of (meaningful) information that Twitter can facilitate.

With that kind of power, health care should be a leader in micro-sharing, not a lagger.

Phil put together a very impressive list of 140 Healthcare Uses for Twitter. Here are a few of my favorites:

1. Disaster alerting and response
2. Maintaining a personal health diary
3. Emitting critical laboratory values to nurses and physicians
4. Issuing Amber alerts
5. Environmental alerts: pollen counts, pollution levels, heat waves, severe weather alerts
6. Updating patient family members during procedures

Click here to see the entire list, which is also available in an eBook, and in SlideShare.

Just in case you missed the first article, here is a recap on using Twitter:

• Go to www.twitter.com and sign up for FREE (choose a name and a password)
• You can use Twitter on the web or on your phone – you can look at it once a day (you don’t have to look at it and respond to it instantly.)
• Once you’re signed up, you can start “following” people and they can “follow” you. I am following people who have interesting things to say about healthcare, and also people who are writing blogs like me.
• Start by following me (@mpwhaley) and I’ll be glad to follow you.

If you’d like to use Twitter and need some help, email me at marypatwhaley@gmail.com and I’ll be glad to talk you through it.

I just moved a practice from one hospital campus to another – down four floors, across three blocks and up nine floors. I’ve done this before, but what did I learn this time?

1. Coffee & Food – whatever it takes, keep everyone caffeinated, watered and fed. It may not make things go any better, but it’s one less thing that people will want to leave the building (and thus the move site) for.

2. Elevators – the movers told me that 50% of the time when an elevator is involved, it will fail. Be prepared, know who to call, realize that movers sometimes have to move things up and down stairs despite that they tell you they’re not supposed to do this.

3. Cell Phones – practice phones may not work despite the best planning in the world. Make sure you have all employees’ cell phone numbers, and make sure you can forward the practice phones somewhere if your phone system is not available during the move or on the first days after. If you’ve installed a paging system separate from your phone system, you’re in luck, because during the move you can announce things to everyone at once.

4. Toilet Paper – the old office housekeepers dump you and the new office housekeepers aren’t ready for you. Get some toilet paper because not having any in either facility makes a lot of people very cranky. No one will thank you for having it, but you will certainly get blamed if there isn’t any.

5. Keys and Parking Cards (old and new) – this one speaks for itself.

6. Tell Everyone – no matter how well you do your job telling patients about the move and reminding them via email or phone calls, some will still go to the old location. Give neighbor practices the moving flyer and ask them to direct patients that didn’t get the message. Tape notices and maps and phone numbers on the old practice door because no matter if you sent them a flyer and reminded them when you called them about their appointment, they’ll still forget! I know, I’ve done it myself.

7. Overtime – put this in your budget and be prepared to pay it. The only way I know not to pay overtime is to close the practice to business for a few days and have everyone work regular hours. Or, you could make all your salaried people do the move themselves (not recommended.)

8. Stickers & Labels – you will never need more labels, post-its and stickers than when you move your practice. Wearing carpenter aprons with labels, pens, blue painter’s tape, a tape measure and your cell phone will save you lots of steps. It will also help to let contractors, housekeepers, security guards, staff and doctors get the message.

9. Trash Bags – buy them and stash them everywhere. You will have almost as much trash in the place you’re leaving as you will in the place you’re moving in to.

10. Low Expectations – do not expect anyone to like anything you’ve done in the old or new office. Remember that being the manager is not a popularity contest.

What are your best practices for moving your practice?

I was intrigued to interview the man behind the upcoming free webinar “Lean Six Sigma for the Medical Practice.” Frank Cohen, former Physician Assistant, Hospital CEO, and Consultant of 20 years is the Senior Analyst of MIT Solutions, Inc., and the host for this and other webinars that I think many healthcare managers will be interested in.

Cohenspecializes in data mining and statistical modeling for medical practices. His website www.mitsi.org describes their services this way:

MIT Solutions, Inc. has been leading the health care industry in the development of decision support and business intelligence tools for medical practices since 1992. Our sole purpose is to help the practice staff work faster, smarter, make more money and improve compliance. At MIT Solutions, we develop products and services that transform the way you do business.

Cohen is a significant player in the healthcare improvement world for several reasons. He worked with the AMA in 2008 to introduce the first Payer Report Cards, which focused on how quickly and accurately payers reimburse physicians for medical services.

The report card compared Medicare and seven national commercial health insurers on the timeliness and accuracy of claims processing and was based on a random sample drawn from 3 million claims. According to the AMA report, UHC ranked lowest incontract compliance with a rate of 62% of claims correctly paid per contract. Aetna ranked higher with 71% correctly paid and 98% of Medicare claims were correctly paid.You can review the payer report card here. Knowing how hard it can be to ensure that claims are paid correctly in the typical medical practice makes the feat of collating and analyzing the data on this scale impressive.

Cohen also developed CMPA, or Comprehensive Medical Practice Analysis, which includes analyses ofProcedure Code Compliance,Provider Productivity, Modifier Analysis,E & M Code Utilization Review,Correct Code Initiative (CCI) Compliance, Fee Analysis, EOB-Based Reimbursement Analysis,Procedural Cost-Accounting/Break-Even Analysis,Managed Care Contract Analysis, Relative Value Scale Studies, andStatistical Modeling by Location by Physician.

Cohen’s website hosts an array of valuable downloads available for managers to use. Here are some examples:

• Comparison of GPCI values by Location – CY2009 vs. CY 2008
• Comparison of RVU values by procedure code – CY 2009 vs. CY 2008
• Physician Compensation Model Using Work RVUs
• RBRVS Calculation Template – 4th Quarter, 2009

Like most of us, Cohen has an interest in how medical practices can continue to meet the burden of increasing costs and shrinking reimbursements. He looked to the dual programs of Six Sigma and Lean to reveal ways for practices to eliminate wasted time, energy and resources and promote efficiencies in the practice. Cohen writes:

…I obtained my Six Sigma Black Belt certification and more recently, certification as a Lean Six Sigma (LSS) instructor. Over the past few years, I have struggled with developing a process improvement model that is specific to medical practices only, vetting a host of different tools to eliminate those that have little or no application in our vertical market and customize others to work specifically within a physician’s office. I started applying these to some projects in the past couple of years and am very excited about this model and encouraged that this is one of the best ways to optimize profitability for physicians.

Cohen is providing an introduction to his Lean Six Sigma for medical practices through a free webinar on Tuesday, February 24, 2009 from 11:00 a.m. to 12:00 p.m. Eastern. Webinars are a wonderful way to spend a little time and no money to learn something. You need a phone for the audio and a computer for the video and chat functions. I’ve signed up and I hope to “see” you there.