Fog Forces Focus

Every day I walk to the light rail to commute to work. Today was a walk in the fog – nice and thick, London-type fog.

Now, I love fog, it changes your perspective. You cannot see to the horizon and there are no mountains in the distance. You’re forced to notice what is directly in front of you. Grass pops out from grey backgrounds, sounds seem to carry further and nearby animal movement catches your eye.

Today, many would say that we are operating in a fog of regulation and change in healthcare – this is said as though it is a hazard or something to be avoided at all costs. What if we took this opportunity to change perspective? It is not possible to see clearly long term and the horizon is not visible. We need to tighten up focus and notice what is right in front of our collective eyes.

So, what should we notice?

For more than 30 years we have been talking about quality. We’ve implemented standards and methodology such as total quality management, Juran, IHI collaboratives, Lean, Six Sigma and Toyota – and yet we still struggle to reduce hospital-acquired infections, drug-to-drug interactions and other avoidable errors. In the move to value-based reimbursement we need bigger than ever breakthroughs in quality because quality, or lack thereof, is expensive.

We have been talking about costs of care since the introduction of DRGs. We struggle to know what the true costs of care are and how to properly account for care given. We’ve tried activity-based costing, updates to charge masters and inventory systems. We still have to admit that for much of the care processes we drive, we really don’t know the costs neither to us nor to our patients, most importantly. How can we take on risk in value-based care if we don’t know what things cost and why? We need think about the little things such as:

  • Where will my discharged patient go?
  • How will they get to their next appointment so time is not wasted on a no-show?
  • What does the medication prescribed cost the system and the patient over the course of treatment?
  • What alternatives exist when I order a test or refer a patient?

We have long wondered how to coordinate care, perhaps thinking that if we just changed the payment structure we’d cause change in how we organized care. It wasn’t enough. We have tried group visits, care managers, case managers, care navigators, patient education and portals. Yet, we are not quite sure where our patients are, across the care system that often comes together like a patchwork quilt, to cover a chronic condition.

  • Did they make their appointment?
  • Do they know where to go next?
  • Does the next provider have the necessary information to best treat the patient?
  • How will I know what was done and if my patient is progressing?

Yes, we are in foggy times. We can spend a lot of time speculating over the future of the ACA, whether MACRA will be delayed or how genomics will impact healthcare delivery, but that is like imagining what is behind the fog – it is fun but we may be wrong. Instead, let’s take the time to look a few steps ahead.

What one thing can we each do to improve the quality of the next patient we treat? What one thing can we notice about the costs of our decisions for the patient and next provider of care? What is the one thing we can do to be clear about where the patient needs to go next, do next, and how can we be prepared when they get there?

Let’s allow the fog to force our focus for now. We may be surprised by what we notice.

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