One facility I just reviewed showed the following example in their Policy Manual for Productivity Calculations for determining minutes worked, i.e. the denominator:

Example: “Therapist works 8:00 A.M to 12:00 P.M. in Facility A = 240 minutes (4 hours)”

Do you see the error already?  Think about it a minute, what’s missing?

Where is the accounting for ten minute break required by law?  This facility makes no adjustment for required breaks, there by overstating the denominator and lowering percent productivity in their performance equation.  Double this error for a standard 8 hour day, and you’re off by 20 minutes, and that’s just the beginning.  Failing to remove breaks alone from hours work will result in understating productivity by approximately 4.3%.

Still there is another thing that is missing, (though stated in this institutions policy, it was never reflected in the productivity calculation) that being Administrative Duties.  Administrative duties are actions that need to be done, that can not be attached to any specific patient or care of patients. To test for Administrative Duties, as yourself: “is my license required to perform this duty?”, if the answer is no, it’s very like an administrative task and should not be reflected in the calculation of one’s productivity.

Removing breaks and administrative duties from hours worked can easily result in understating productivity by over 10%.

Each work day, for example, begins with some process around assignments, establishing what needs to be done and perhaps in what optimal order. Though establishing treatment plans for the day may require a license to do well, printing out the list of assignments or having it immediately available every morning, is not a task requiring a license.

Administrative duties come up all throughout the day and included but not limited to: photocopying, filing, fetching results, verifying orders, as well as appropriate facility specific process documentations, and many more.  Having visited hundreds of facilities in my career, the most efficient had approximately 27 minutes of daily administrative duties.  If there are organizations with less than 27 minutes of daily administrative activities per therapeutic role, I would be delighted to know.

So what do you need to know.

That which is referred to as “Productivity” is actually “Revenue Productivity”, this is because the numerator is minutes billed.  If, for an example for the Speech Therapist, a clinical productivity number might be the number of aspiration pneumonia patients per 100 patients treated.  In this case the most productive would be the SLP with the smallest  percent of patients with right lower lobe aspiration pneumonia.  Of course, one would have to consider the possible over-ordering of swallowing studies, but that is beyond the purpose of this piece.

Each facility needs to agree upon a proper number of minutes to attach to Administrative Duties, by clinical discipline, and then include that in the calculations.  The best way to do this is to engage a consultant to perform an Activity Based Costing methodology to discovering the true number of minutes attached to administrative tasks.  Because of the “ask a fish to describe his environment, the last thing he’ll tell you about is the water” effect, processes tend to disappear because of the “that’s the way we’ve always done it” phoneme. People too familiar with the internal processes of an organization cease to see all that is truly going on.

Finally, do your own math.  For your convenience, I built a simple little spreadsheet (Excel 2007 version, back rev’d to 2003) for you to check out.

It’s important at this time to review the purpose of information which is to improve the efficiency of achieving outcomes.  Information also has four necessary characteristics, it must be accurate, relevant, timely and trustworthy and all must be present; three out of four is just noise.

Timely is an exceptionally relevant piece.  Lying at the beach one day reading, a lifeguard came up to warn us about the incoming tide, just about 3 seconds after the last wave overcame my beach towel, banana and book.  Accurate,yes; relevant and trustworthy, certainly; timely – well not so much.

Anyway, clearly a significant improvement that will soon become normative and disappear and simply the way things are.  Still for the moment, it’s worthy of some reflection as to how astounding this really is.

The downside of pen and paper is that the information contained on paper doesn’t aggregate well.  You can’t look back through it easily to assess what works and what does not.  In earlier days when a family physician took care of you from cradle to grave, it wasn’t a problem; as long as the physician stayed alive, he or she was a biologic historical database of what went on in a patients life.  Today, however, with highly specialized and fictionalized care, it’s a problem.  So why not the sluggish acceptance of EHR’s in the private sector.

To the casual observer the perception is that costs are real, and benefits vague.  These excuses are self-damaging and weak minded.  Time to get busy.

In this piece regarding Electronic Health Records and Clinical Trials from Chris Thorman of Software Advice speaks to one legitimate benefit often talked about, but seldom realized.  True, the use of practice data in clinical trials is limited, but it’s not zero, and it grows over time.   Identifying subtle changes in treatments over time, or simply identifying patients for whom detailed clinical studies are appropriate, will contribute to improving efficiency of bringing new drugs and treatments to market.  In so doing, a faster path to market results in a longer period under patent protection, and higher product lifetime valuation with lower costs.

In the end it looks like this: the medical practice of the future needs to begin now to design itself toward increasing  its efficient and percent of total annual revenue from cash.  This means providing services for which patients will pay cash along with discovering new means by which practices can contribute value and receive compensation outside the existing constraints of third party payment.  This includes EHR’s, but also means a way patients can create appointments on their own schedule 24/7, along with a means by which medical practices can keep in closer communication with their patients.

There is no stability or efficiency in health care without successful and vibrant medical practices.  It’s time for every practice to find an EHR that works for them and put it to use, along with systems and processesto build and manage closer relationships with their patients.

The difference between this statement of 5 centuries ago and today is simply the issue to which it is applied, and the date.  For Copernicus it was aimed to those who held on to the notion that the Earth was the center of the universe, today the same could be applied to the notion that government ownership, specifically health care will produce efficiency.  If this past century has taught us anything, its that governments don’t do healthcare well, still despite the evidence of our senses, our congress seem committed to its treacherous course.

Based upon the evidence of your own senses, what remains true, self-evident, observable and non-controversial is that no one else but you does your healing for you, or your dying for you.  Only you live with the results of medical practice, good or not.  There is no outsourcing, no cost-shifting, or possible means by which you can personally enjoy the benefits of healthcare while pushing the risk of its individual consequences on to someone else. You own it.

This makes the current healthcare debate personal.  It would take a delusion of universal magnitude to believe for one minute, that a greater involvement of the government into our personal healthcare is in any way be an improvement.   Of course, you are free to believe that government healthcare is better, but that would be foolish and you would be wrong.  What is being proposed is about a few people feeling good about doing something they hope may be good, knowing in the end, they personally can no’t bear the full cost of any decisions they have made.

There are many more simple though less glamorous reforms that would be so much more effective, but they lack the flamboyant appeal of what is being proposed today.  Lowering the deduct-ability threshold for out-of-pocket healthcare expenses, interstate purchasing of healthcare insurance and personal savings accounts that roll forward and accumulate over time allowing individuals to claim higher deductibles, and in so doing enjoy lower insurance premiums.  But this is about theater, not reason.

Thomas A. Coss, RN

1. Not all hospitals, clinics and physicians are equally talented and knowledgeable in the delivery of healthcare services; here are some which are simply better than others, and experience matters.
2. It’s actually pretty difficult to kill someone.  The human body is amazing in its ability to adjust to changes, whether it is the loss of a limb due to trauma, or the loss of the function of a kidney or part of one’s heart due to a heart attack.  We adapt very well, but sometimes it’s not pretty.

For example, the difference in one’s quality of life when their heart is functioning at 50% capacity verses 20% capacity is astounding, as is the effect of the loss of function of both kidney’s rather than just one.  In both cases, the effect upon the individuals quality of life  is non-linear.

The challenge with healthcare is that neither the payer nor provider of services have to live with the results, that is solely left to the patient and their loved ones.

So then, what do we have with the current healthcare reform?  Well it pretty much looks like this:

• It may provide coverage to more people (but we don’t know this for sure nor does it mean that you can go anywhere you want for care).
• It won’t save money (virtually no one believes otherwise).
• It doesn’t address the means by which we will have enough physicians and nurses to go around.
• It will not improve effieincy in the delivery of care delivery.
• It won’t address the cost of defensive medicine (which is huge).
• It won’t make you better off.
• It will lead to more taxes.

Is there anything I missed?

Thomas A. Coss, RN

Improving Labor Efficiency in Healthcare

In 2008 I began looking into capital investment in heatlhcare as compared to other industries and found some interesting results.  As expensive as healthcare has become, investments into improving the efficiency of the labor that provides those services has been poor.  Per worker capital investment in healthcare is about 35% lower than it is in general manufacturing.  How can we hope to lower the cost and expand the availability of healthcare if we insist on providing those services the same way they’ve always been done? 

A more detailed explanation is available here until I hear: Improving Labor Efficiency in Healthcare.

At the age of 48 I was diagnosed with Prostate Cancer.  As you might imagine I was stunned as anyone would be, but not by in large concerned.  As an RN who has treated patients with this condition, I knew it was caught early and that my prognosis was excellent.  It was what happened after the diagnosis that I found compelling.

First was the matter of treatment choices of which there are many.  Thankfully I wasn’t in a great hurry to treat the problem based upon a very low Gleason score, (a scoring system designed to stratify rick based cancer cell morphology) .  The ”what” part of the decision process ( i.e. what treatment choice) took about 6 months for me to work through and in the end I decide on minimally invasive surgery.  Then the challenging decision, who.

Based off of over 15 years experience as a Critical Care RN, I knew that the “who” decision is the most important decision affecting outcomes.  Certainly the treatment form plays a role, but the individual who performs and manages the treatment is the big variable.  Hence the problem, how do I find the individual who would provide me the likelihood of the best possible outcome?

When I was actively working as an RN, this would be an easy decision.  I had a pool of resources across numerous facilities and I knew who to go to for the best possible care and outcomes.  The problem I was facing is that I left nursing over ten years ago, and with that lost my “inside” advantage.  I had to do some calling around, and I did.

My research has led me to plan on going to Henry Ford Hospital in Michigan who had, at the time of my surgery, over 200 Prostatectomey’s with the DaVinci Robot.  I had followed the outcomes literature and had planned to fly from Southern California to Michigan for the surgery.  Fortunate for me, I also found another equally successful program utilizing the same approach in Orange County and ended up having my procedure there.  I was in and out of the hospital in 26 hours, one week of home limited activity recuperation and was back at work, and in the air, in about 14 days.  My outcome has been excellent and I am very grateful for the candor and skill of the surgeon.

The reason for this story has to do with choices.  If I were restricted in my choices in any manner, I would have had a much poorer outcome.  Having discussed my situation with guys older, and younger than I, my outcome is astonishingly better.  But what if I did not have the ability to choose “who”, what if I had to go to the surgeon based upon his or her seniority or availability, what then?

As we look for “fixing” healthcare, consider this story as not at all unique.  Hearing politicians use the first person proclamations: “I’ll let you choose your own plan”, or “I’ll let you go to the physician of your choosing”, are frightening.  Just the notion that the government has the power, presumed or otherwise, to dictate the choices who’s outcomes I have to live with, is unacceptable.

Know this: in the end, it is the patient who does the healing and it is the patient who does the dying, health care professionals are at best, participants, coordinators, supporters and facilitators.  Neither we nor the Government will ever change that. The value of the internet doesn’t stop at providing information in the form of content, it is also a tool to find and take advantage of expertise well outside your local area.  A national healthcare plan that encumbers one’s freedom to choose, is no plan at all.

Happy Thanksgiving.

Tom