Sunday, January 08, 2006

Pizza Without the Cheese

The New York Times just published an interview with Gordon N. Bethune, retired chief executive of Continental Airlines, and arguably one of the more succesful leaders in the airline business. He made some pithy points points that seem to easily translate into the health care arena, providing some useful lessons for improving the management of health care organizations.

His major messages were:

"If you are going to be in the watch business, it helps to know how a watch works." In the airline context, Bethune's message was "that the airline business has been mismanaged by executives who do not really understand what matters to customers...." This criticism has clear parallels in health care. Although there seems to be no systematic data on the training, experience, and credentials of executives of health care organizations, it seems that few have had any direct experience caring for patients. (For example, see posts here and here.) Thus, few seem to understand the context of health care, much less internalize its values. The lesson is that health care organizations should be lead by people who understand the health care context and its values, either by direct experience and training, or by seeking extensive input from people with such experience and training.

"If you are being rewarded for findings ways to make pizza cheaper, eventually you'll take the cheese off. You'll make it so cheap that people won't eat it." In summary, do not let economic considerations over-shadow the organization's primary mission. Again, this has clear parallels in health care. The cost-cutters in the federal government (at the Center for Medicare and Medicaid Services, or CMS), managed care, and hospitals have zealously cut reimbursement for the basics of health care, e.g., nursing care in hospitals and reimbursement to patients' personal physicians for office visits. But no one seems to balk at paying huge amounts for new drugs and high-tech gizmos. (See post here.) The lesson is that we should be cutting frills, and paying less for over-priced goods and services, while supporting basic health care services.

"I asked an executive at an energy company once what he rewarded, and he said R.O.E. - return on equity. I told him if you asked someone on the second shift what roe was, he'd probably say fish eggs." In the medical context, we have discussed the latest pay-for-performance fad, and the pitfalls of the the proposed measures of performance. (See post here.) The lesson is that you should measure quality and performance, but with metrics that make sense. "You should tell people how to keep score, and reward them for it. But you better make sure you're using the right scorecard."

"You need to gain the trust of your employees." We have posted on numerous instances of conflicted and even corrupt leaders' deception and intimidation of their employees, including highly-trained nurses and physicians. Far too many health care leaders see their employees as interchangeable cogs in the machine. This may be a major reason for the dissatisfaction of physicians and nurses, and a contributor to quality problems and medical errors. (See post here.) The lesson is that all employees and staff should be treated with the respect deserved by every human being, and that trained professionals should be regarded as the essential resource of health care, not machine parts.

Good lessons.... Let's see if any health care organizations take them to heart.

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InformaticsMD said...

You write, "the lesson is that you should measure quality and performance, but with metrics that make sense."

Does that include the directive in pharma that I experienced from a VP to cut scientist access to specialty databases for drug R&D based on a metric I had to compute of "cost per user per database?"

A metric whose computation was made more difficult (and more meaningless) by the fact that some of the databases were used by *applications*, the output of which was then used by a shifting set of individuals or teams of shifting makeup over time...

Oh, this was a VP with no background in medicine or biomedical research. Nada. Now works for a computer gaming company.