March 1, 2024

Dear Interested Readers,

 

Quality Defined Us

 

I have gained a new perspective on how to structure what remains of the story of the development of my medical-moral sensibilities. The story up till now has been mostly delivered in chronological order as I have celebrated individuals and events. That suggests that challenges and opportunities occur in an orderly process one at a time, and that was true for me most of the time until February 2008 when I became the Interim CEO of Atrius Health and Harvard Vanguard Medical Associates. As the CEO of a complex medical network that stretched across most of Eastern Massachusetts, and employed more than 750 doctors and over 2000 nurses and advanced practices clinicians providing care to about 750,000 patients in more than 30 sites during a period of rapid market and regulatory evolution, I was suddenly confronted by a host of acute and chronic problems.

 

The problems included both known and unknown issues. Some like our Epic medical record that was slowing down and had become an impediment to practice had been neglected, and there were many that we never knew existed until we began to ask “why” when things did not go as planned or hoped. There were challenges and opportunities we had not considered. Our workforce was stressed and many valuable employees were unhappy. We had competitive issues with some of our hospital and specialty care partners. We depended upon some of their services even as we were vulnerable to their pricing and the reality that a referral to them often meant losing the patient. The term “co-opetition” was evolved to describe the complexity of a business relationship where your supplier is also one of your competitors. There were also some internal issues of competition, sort of like sibling rivalries or family disputes, that I needed to address between the various medical practices that participated together as Atrius. This last challenge was not new to me since similar family feuds had occurred within Harvard Vanguard over the years. The usual concerns were fairness in the distribution of resources and the sharing and use of our surpluses. Some groups favored investing in infrastructure and practice support while others had a culture of maximizing physician compensation. 

 

It is easier to make a list of our challenges and projects that were happening all at once than it is to display them in time or by relative importance. I am usually a reluctant maker of lists, but below is an incomplete quick attempt produced mostly to explain why I need to finish the story by discussing various challenges rather than following a time line. The order of the list is random; so that an issue at the top is no more likely to be “most important” than the issue at the bottom of the list.

 

• Continue to define the organization and synergies of the Atrius partners. 

 

• Consider new additions to the Atrius family of medical practices.

 

• Develop patterns of internal referral between Atrius partners to better leverage collective resources. 

 

• Expand and strengthen all internal testing from the CBCs to MRIs to enable cost reductions compared to utilizing vendors.

 

• Move all contracts toward the potential of value-based reimbursement.

 

• Develop competency and leadership in managing within the ACO structure.

 

• Improve our performance of Epic as a clinical tool and to enable management insights.

 

• Establish Lean as our operating system. 

 

• Move leaders to believe that those doing the work know best how to improve the work. Their job is to learn what the frontline knows and to guide the development of improvements based on that new source of knowledge.

 

• Review and enable every department and unit. Help select/train leadership where needed. 

 

• Have Atrius maintain a leading position in measured quality through its expertise in continuous improvement.

 

• Work with hospital partners to improve the experience of our patients by fully empowering our surgeons and medical specialists. 

 

• Develop or improve programs of care for chronic diseases.

 

• Ensure that Atrius’ voice is heard and influences healthcare policy and program development at the state and federal levels. 

 

• Continue to pursue the Triple Aim as our North Star working internally and externally with like-minded professionals and institutions.

 

• Refurbish/replace delivery sites. 

 

• More effectively use social media and the press.

 

 

The list is not complete. Many of the issues were chronic and never to be “solved,” but they all needed to be understood and managed. The idea of switching to the discussion of subjects rather than trying to give a chronological report came to me after exchanging emails with Emily Brower whose leadership of our Pioneer ACO project was the major subject of last week’s letter.

 

Emily commented in an email to me that Rick, her “best boss ever,” had sent her a copy of my letter. I thought she was referring to Rick Gilfillan, the former leader of CMMI and the CEO of Trinity Health. She corrected me by saying that it was Rick Lopez, the retired CMO of Atrius, the leader of our quality initiatives, whom she remembered as her “best boss ever.” Rick Lopez sent her the letter,

 

That clue from Emily reminded me of how the longitudinal effort to improve quality predated the beginning days of our practice in 1969. Dr. Ebert was focused on quality during the four years of planning before the 1969 launch. Quality improvement efforts were the thread that ran through everything we had ever done. Emily’s comment reminded me that for many years before I became CEO, and for long after I retired, Dr. Richard Lopez had been a force within our internal quality efforts and our spokesperson on quality to the government, the payers, and the general public. 

 

In retrospect, a shared commitment to continuous quality improvement was one of the principles that held Atrius together. Rick’s title was Chief Medical Officer of Atrius Health. Rick more than any other executive had the support from all of the Atirus groups. He coordinated the quality efforts of the CMOs from each of the participating Atrius groups including their participation in the Pioneer ACO effort.

 

I have mused that Atrius Health was held together by Harvard Vanguard’s infrastructure, but that is a simplistic analysis. Many things were part of the glue. We shared the medical record, the quality program, and external relationships with hospitals and government policymakers. We also shared a very efficient and cost-effective lab system.

 

Perhaps, I should say that the pursuit of quality utilizing continuous improvement tools was the most important bond that held Atrius together. It is easy to observe now how Rick’s responsibilities touched each of our connecting bonds. When Atrius joined the Pioneer ACO offered by CMMI, the project was going to succeed or fail on Rick’s ability to get his team to transmit enthusiasm to all of the Atrius groups. Rick demonstrated his capability for creating harmony within Atrius by recognizing that Emily was the person who could best do the job and then supporting her success.

 

The quality program that reported to Rick had been a fixture in our group long before I began to pay attention to it in the early 80s. I had seen an early quality report from Don Berwick and a detailed quality process for oncology written by Dr. Larry Shulman who would later be the CMO of Dana Farber before moving onto a professorship at the University of Pennsylvania. Improving the quality of healthcare was an objective of Dr.Ebert’s grand project. Quality was the cultural water into which HCHP had been launched. 

 

Doing much of the creative analysis that served our improvement program during most of my time was Dr. Joe Kimura. At the time I became CEO, Joe had left Harvard Vanguard to work at Kaiser in Southern California while his wife was earning an advanced degree at a nearby university. No one made an impact on an organization faster than Joe who gained fans at HCHP working as an internist and leading clinical informatics before moving to Kaiser. When I heard that Joe might be interested in returning to us, I quickly joined the group hoping he would “come home.” It was a great day when he agreed to return.

 

Working with Joe were two other very effective voices. Dr. Anita Ung was one of the doctors I felt a little guilty about because we hired her away from the Boston Medical Medical Center, our largest DSH hospital. In the interim ten years since I retired Anita has moved her practice and quality efforts to Urbana, Illinois where her husband is a professor at the University of Illinois. While trying to find an appropriate introduction of Anita to you I happened upon a recommendation that I remember writing for her for her LinkedIn page. What I wrote is indeed the way I remember her work for us. She could make dull numbers dance and sing in unison. I had written:

 

Anita Ung is a master of quality in healthcare. She has the ability to make numbers come to life and can motivate physicians, nurses, and other healthcare professionals to shoot for the stars and achieve things that they never imagined that they might accomplish!

 

Working with Rick, Joe, Anita, and a large and diverse team of analysts and clinicians, was Kate Koplan. Kate and Anita were a one-two punch. Both have incredible presentation skills and a commitment to creating enthusiasm for the work that could produce measurable results. Rick has retired and Joe, Anita, and Kate have moved on taking their commitment to supporting and improving innovations in care delivery that improve quality to other organizations. Kate is now the Chief Quality Officer for Kaiser’s Georgia region. 

 

For me, the most strategically important point of the work of those who studied healthcare delivery and finance during the 80s, 90s, and early 2000s was the assertion that somewhere between 30-40% of what we spend on healthcare is wasted. If you remember my frequent reference to Dr Ebert’s motivation you will remember that he said that more buildings, more personnel, and more money were not what we needed to improve the health of the nation. He then said that to solve our healthcare problems we needed a new operating system and a new finance mechanism. He was implying that the way we delivered care was inefficient and unnecessarily expensive while failing to deliver equitable quality for all Americans.

 

The finance proposal that Dr. Ebert favored was “capitation.” Capitation, like all forms of finance, can be abused. The blocking forces against abuses in capitated systems are effective regulatory surveillance and quality measurement. The failure of fee-for-service payment is that it can generate overuse. The potential concern for capitation is the denial of needed care or the reduction of resources to the point that proper care can no longer be provided. 

 

On my visit to Don Berwick, after he became the Administrator of CMS, he reminded me that we didn’t need more money. His message was that we already had the expertise and the tools necessary to maximize our efforts to improve quality as we innovated to reduce costs. I could believe that a focus on quality might improve costs. Could it really save 30-40% of our expenses? We were skilled at measuring the benefits of our own quality efforts and we were committed to becoming more effective practitioners of continuous improvement, but our goals had been modest and our progress in translating what we knew into improved performance had always run up against the “work of the day.” 

 

I don’t know how many people appreciate how complex turning data into policy and policy into improved performance is. Peter Drucker is known for saying, “You manage what you measure!” Apparently, he lifted the phrase from Lord Kelvin, known to his closest friends as William Thomson. But even that statement does not include knowing what to measure and how to change outcomes. An even greater barrier is gaining the trust of those whose work will change. 

 

As quality measurement became the new North Star in practice improvement and healthcare finance, our quality department was asked to measure more and more variables. Several contracts required frequently measuring over fifty things that ranged from CBCs to patient satisfaction. The professionals in our quality measurement effort recognized the dysfunction and frustration of trying to simultaneously improve dozens and dozens of metrics. What Joe, Kate, Anita, and their colleagues did was to sharpen the focus of our measurements on a few key metrics. Those metrics often drove improvement in other “downstream” metrics. 

 

I don’t know how fond you are of looking at spreadsheets. What I enjoy most about spreadsheets is having an expert use one to point out things that were not so obvious to me when they were being considered part of a larger mix. Anita and Kate were particularly good at telling the story behind the numbers and connecting the numbers to possible improvements. I believe that the effectiveness of any quality program depends upon the skill of its professionals in quality measurement plus having the skills required to pass what has been learned along to others who will devise and implement the changes that will lead to the desired improvements. “Quality” isn’t free, but money doesn’t guarantee success. Commitment to the belief that a focus on improvements driven by the analysis of data from quality measurement was the most certain path to better outcomes. I came to believe that a dual focus on the patient and the continuous need to improve the experience of every patient was the only ethical foundation for practice. 

 

An Adventure in Healthcare

 

The picture I am using for the header for this edition of the letter is a view of one of the entrances to the Dartmouth Hitchcock Medical Center which is the hub of Dartmouth Health. Dartmouth Health describes itself on its website.

 

Dartmouth Health is a system of community hospitals, clinics and healthcare services across New Hampshire and Vermont. Our system includes:

• Locally focused community hospitals and clinics in New Hampshire and Vermont.

• An academic medical center with deep ties to Geisel School of Medicine at Dartmouth.

• Dartmouth Cancer Center, one of only 56 NCI-designated Comprehensive Cancer Centers in the nation.

• Dartmouth Health Children’s, the state’s only children’s hospital; and member hospitals and clinics across the state.

• A broad community of nursing, rehabilitation, hospice and personal healthcare services.

We have forged ourselves into one, best-of-class, highly integrated, cohesive healthcare system grounded in outstanding medical expertise… and we call it Dartmouth Health.

 

I took the picture while I was enjoying a warm spring morning and waiting for my wife to get our car after my initial appointment with my spine surgeon last Tuesday. I have long been both an admirer of Dartmouth Health and from time to time, a critic of its performance, I have never questioned Dartmouth’s ethics. I am an equal opportunity critic. Dartmouth fails where most safety net and rural hospital systems fail. It’s hard to run a hospital on current levels of public funding in a fee-for-service system.  The difficulty that rural systems have with hiring can be compounded by a relative lack of local cultural opportunities and chronic healthcare workforce shortages.

 

When I was a medical student, Dartmouth had a two-year medical school. At the beginning of the third year, Harvard’s class would swell from 120 to 160 with the addition of about 40 students from Dartmouth. At the time, I think Dartmouth was a small two-year program because the old Mary Hitchcock Hospital in Hanover did not have enough patients to support teaching in the hospital. Things have changed. The current facility in nearby Lebanon is huge, and it is the hub of a system of rural hospitals that serve about half of both New Hampshire and Vermont. 

 

Since retiring I have continued to get most of my care from Atrius, but that is a 150-mile round trip to the closest office in Chelmsford and close to 200 miles if I go to our offices in Wellesley. During COVID video visits were amazing. After the pandemic was declared to be over, the use of video visits across state lines was prohibited.  When I considered everything plus the positive reputation of Dartmouth, I decided to have my back surgery at Dartmouth. Part of my confidence was also based on the excellent result I experienced using Dartmouth providers for a laparoscopic repair of a hernia, and the very successful conservative management of a torn rotator cuff.

 

Access for my rapidly evolving back and leg symptoms has been an issue, but the fact that messaging between patients and providers and between provider organizations is now easy with Epic has helped to minimize the delays that might have been worse. My Epic records at Atrius and Dartmouth are now linked.

 

My chronic back and leg symptoms intensified in mid-January. I had been walking three or four miles on most days and was riding a Peloton when the weather kept me indoors. Fortunately, I had a scheduled appointment with my neurologist when my symptoms became intolerable. She gave me two courses of oral steroids that did not result in improvement. An MRI on February 3 showed that my problem required a surgical repair. The initial referral process to the Dartmouth Pain and Spine Unit did not utilize any of the efficiencies that My Chart offers.  With the delays in processing the referral, my visit to a physiatrist at Dartmouth for an initial evaluation was on February 19.

 

After my evaluation by the physiatrist, I was given an appointment with the spine surgeon on his next available which would have been March 5. After describing progressive symptoms, I was seen last Tuesday. A CT was done on Wednesday to help with op planning, and now I am scheduled for surgery on March 18. I am told that I will move up if there is a cancellation. I am sort of pleased with the date on the 18th since I was warned that the date could be 4-6 weeks into the future. The big surprise at the start of my visit with my surgeon, Dr. Kevin McGuire, was that our paths had crossed during his ten years at the Beth Israel Hospital in Boston. He was at the BI when we moved most of our “in-town” hospitalizations from Brigham and Women’s Hospital to the Beth Israel Deaconess Medical Center. 

 

I am finding new ways of coping with my pain. My sleeping has improved.  I am not complaining about the need to wait another two-plus weeks because I have confidence in Dr. McGuire and Dartmouth Health. I do plan to take advantage of my experience in the system to note ways that it might be improved. My first “suggestion” relates to improving the referral process. A second suggestion is about signage and information in MyChart, the Dartmouth version is named “MyDH,” about getting to appointments. I was told in MyDH to arrive for my CT at 9:25 for a 9:40 appointment. What I was not told was that it was at least a quarter mile from the front door to x-ray. That was a long walk for a guy on a cane with an uncertain gait and increasing pain with each step while rushing against the clock. You can rest assured that I will be noticing and reporting the little things that could be changed to improve the patient experience. 

 

I should add that I hope not to miss a Friday letter with my surgery. There has been a letter every Friday for more than a decade. I hope that there will be one on March 22. 

 

Next week is going to be warm again. If clear skies and warm sunny days are what we will experience over the next few weeks, I will make the best of it. I hope that you will also find some pleasure in losing a month of winter.

Be well,

Gene