The Future of US Healthcare

No one can predict the future, but the future is not unknowable. While no one may be able to accurately predict the future of US healthcare, we do know something about what it will look like.

Some will want to understand why we need to change the way we deliver care. This YouTube video by Dr. Barry Bittman is a helpful introduction to the challenges we face. Simply put, we cannot continue to deliver care in the same way we have for the past 60 years.

The stakes are very high. We must find a way to improve the overall health of a given population, accomplish that at the lowest possible per person cost, and in a manner that engages and satisfies the patient’s right to a positive experience. The risk of failure or inaction far exceeds the risk of change. To do nothing is paramount to accepting the economic demise of the United States.

The future of US healthcare requires redefining what healthcare means: moving away from episodic sick-care to sustained preventive care, from provider-centric care to patient-centric care, from hospital-centric care to point-of-resident care, from professional-based knowledge to consumer-based knowledge and decision making.

The path forward will include some combination of the following realities: team-based care, technology and non-physician supported chronic disease management, integrated health delivery systems, data and results-driven population management, as well as a strong patient-centric focus.

The transformation will be highly disruptive. It will result in a redefinition of the roles and responsibilities for health care providers, a deconstruction of the medicalization of US society, and a higher degree of personal responsibility.

We are moving into very interesting times, both challenging and exciting. Change is never easy, but change we must.

“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries … and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it.”

Niccolo Machiavelli, The Prince, Chapter VI, 1532


At the most recent quarterly medical staff meeting I presented the results of the physician’s satisfaction survey, the focus group, and my responses to the information provided.  Part of my response was directed at SFMC’s past effectiveness at implementing change efforts. Most often, both in the focus group and from direct communication with physicians, this has been relayed to me in a simple statement: “Nothing ever changes.” Usually that comment comes with frustration, because the physicians want things to improve. That’s a good thing. It means physicians care.

My observation is that SFMC is eager to improve anything for the patient. Likewise, the organization, meaning staff and management, want to please the physicians. They care deeply about what they think and want to be responsive and helpful.  This is a good thing. It means the organization cares.

It’s a puzzling paradox. Physicians and the organization want things to improve for the patient.  Clearly, things stay the same (if they do stay the same) not for want of desire for change.

Another premise offered by some physicians is that there is an ability deficit. It’s not that there is a lack of desire by SFMC but a lack of management skill in pulling off change. I disagreed. If that were the case, then we wouldn’t see improved patient satisfaction scores (now exceeding the 94th percentile in the HealthStreams national database), or core measures (a 6% increase improvement in 12 months), or new technology, physician services, and any number of adaptations to the ever changing healthcare environment. These things did not occur by happenstance. It took leadership to pull it off.

I don’t think it’s about ability or willingness. Simply put, most change efforts fail. They fail for everyone, in every business, including healthcare and Saint Francis. Change management and leading change are topics of textbooks. But there are key sequential steps which must be achieved in order for change to be successful and be sustained. [1] The textbox shows eight steps which must be followed sequentially in order for change efforts to be successful and to stick.

Kotter’s 8 Steps of Change

1) Create urgency
2) Form a powerful coalition
3) Create a vision for change
4) Communicate the vision
5) Remove obstacles
6) Create short-term wins
7) Build on the change
8) Anchor the changes in Corporate Culture

Think about your past experiences with major change efforts in your clinic or at SFMC. If you think of a success story, you’ll see how these steps were applied. If you think about change efforts that didn’t stick, you’ll where steps were missed.

When I hear about problems that “never change” at SFMC, it tells me that what needs to be changed is difficult and complex. These are issues that will require substantial contribution from all involved, persistence, and attention to the realities of change. Most often, as clinicians, we are tempted to shoot from the hip, give an order, or tell someone to fix something, and move on. We are trained to think this way and act this way. But that doesn’t serve us well when we are attempting to deal with complex, large problems. Then it becomes more like internal medicine than surgery; requires a rigorous scientific method-based methodology, involving teams made up of multiple disciplines, and leadership attentive to the realities of the 8 steps of change.

This reality is part of the reason why I continue to appeal to physicians to roll up their sleeves and participate in major change efforts. Without exception, physicians are part of the “powerful guiding coalition” step. Without you, change efforts will fail. With you, we have hope and opportunity for moving forward and addressing those things that have ‘never changed’ before. Join us in the journey to exceptional patient care.

[1] Kotter, JP Leading Change: Why Transformation Efforts Fail, Harvard Business Review, Jan, 2007 #R0701J-PDF-ENG

Superbugs and Threats to our Community

Recently I read a USA Today article on Clostridium Difficile (C.Diff) infections that I’d like to share. Sometimes when we read about issues in a national publication we can be lulled into a sense of security because the people affected are far from us. We don’t know them.

C. Diff. is a real threat to us in Grand Island. At Saint Francis Medical Center (SFMC) medical center we track these infections monthly. Historically this infection was caused by use of antibiotics in the hospital. Hence it was labeled as a “Hospital Acquired Condition,” is reported to regulatory agencies monthly, and we have responded by vigorous antibiotic stewardship in the hospital.

For some years our rate of C. Diff. infections at SFMC was quite low. Like most places in the United States, In the past 12 months we have seen a steady increase in the number of C. Diff. infections at SFMC. The difference from past infections is that these C. Diff. cases are coming from the community, not from within the hospital. This is concerning.

Our response needs to be a more thoughtful use of antibiotics in the community, reserved for true bacterial infections, using the right antibiotic for the right condition, and avoiding broad-spectrum antibiotics when unnecessary. Everyone has a part to play in antibiotic stewardship, including patients, families, and providers.

For the sake of us all, let’s work together to learn about antibiotic stewardship.