A Great Social Asset: Our Public Health Systems
The nation’s public hospitals, once among the most shining examples of public trust in our government institutions have been battered along with so much of our nation’s safety net. In my view, these institutions today remain places of courage and commitment, as they always have.
From small rural clinics to the giant facilities in our major cities, the social asset that defines them ought to be much more of a focus of our attention. After all, with healthcare transformation well underway, more and more leaders, physicians, and front line employees are putting shoulder to the wheel to attain the Triple Aim which must be achieved in every setting if we are to achieve it nationally.
A grand experiment is underway towards this end:
All of the 2,000 attending physicians of New York City Health and Hospitals and their union, Doctors Council SEIU have established Collaboration Councils, and after just six months, these Councils in each of the system’s iconic facilities are building sustainable learning organization to create whole systems improvement. On August 2, 2016, leaders from across the largest public health system in the United States will come together to take stock and dedicate their resources, focused collectively to accelerate the improvement of the patient and physician experience.
New York City, that shiny paradox of extreme inequality…
In one of the richest places in the world exists some of the deepest pockets of poverty and poor health. The disparities between health in Manhattan and the Bronx and Brooklyn for example speak volumes about New York realities. Premature death in the Bronx is the highest of all of New York’s 62 counties, with Brooklyn not far behind. It is said that within a span of 6 subway stops, there is a difference in life expectancy of 10 years.
NYC Health and Hospitals (NYC H + H) cares for 1.4 million poor New Yorkers. I could go on and on to describe the intense mission and reality. Please read One New York, Healthcare for Our Neighborhoods, Transforming Health and Hospitals issued by the Office of Mayor DiBlasio in Spring, 2016. This remarkable report succinctly describes the challenges and the efforts underway to enable this great social asset to meet the needs of the people who need it most.
The joint improvement effort underway between NYC H + H and Doctors Council is in the center of this transformation.
The Collaboration Councils, established through traditional collective bargaining are anything but traditional.
The new leadership of the union which came into office in 2013 made a sweeping decision to transform itself from its long history as a traditional union to become a union dedicated to supporting its members to engage in the improvement of the public health system. Through wide-scale interviews and surveys with its members, the Union learned and obtained the data to prove that 98% of the members wanted the union to stand for their participation in ways to improve the system.
The member-research was followed by the writing of a White Paper which included participation of 100 union members. The White Paper was published and widely distributed in the Spring of 2014, entitled:Putting Patients First Through Doctor, Patient, and Community Engagement.
The White Paper served as the central focus in collective bargaining, and by the summer of 2015 a full agreement had been reached on the establishment of the Collaboration Councils. The agreement included an oversight System-Wide Council along with the establishment of Councils at each facility. From July of 2015 to the first launch of the Council, the parties committed to establish a working relationship with the Institute of Healthcare Improvement (IHI). This was done to establish a common language and philosophy of improvement. Council members attended a three-day orientation to the IHI Model of Improvement, and the health system and the Union jointly invested in subscriptions for Collaboration Council members to have access to the IHI Open School, a unique on-line guide to learning the science of improvement.
Through the early meetings of the System-Wide Council, the parties established actions that would enable joint decision-making, the key differentiator from improvement projects of the past. To their great credit, the leadership of the health system was quite transparent in recognition that nowhere near enough effort had been made to engage the front line clinicians. Not unlike many improvement efforts underway around the country, improvement had been led in a project-fashion through consultants acting on behalf of central administration directives.
Moving forward, some requirements of “joint-ness” include:
- Does the Facility Based Council (FBCC) have consistent co-leadership?
- Does the FBCC have consistent high attendance?
- Are preparations for FBCC meetings made jointly (agenda, outcomes)
- Are all decisions of the FBCC agreed upon through consensus?
- Are actions and activities of the FBCC communicated throughout the facility?
- Are the discussions of the FBCC a “safe environment” for dialogue?
- Has data about patient experience and doctor engagement been shared, made understandable, and serve as the basis upon which improvement projects will be developed?
- Has the facility Quality Improvement staff been integrated into the FBCC? Has the QI staff person been made aware of and supportive in word and action with the guidelines in the collectively bargained MOU?
- Is the FBCC using the Open School? Is it being used in relation to selection and implementation of improvement projects?
- Has an improvement project been selected?
- Has an AIM statement been agreed upon?
- Have PDSA cycles begun regarding the AIM statement and the goals of the project?
- Has data been collected in relation to the PDSA cycle?
- Time and human resource has been made available to undertake the work of the improvement projects
- Improvement projects are manageable in size and scale***(avoid persistence of some to try to involve too broad a project or too many departments in the first round of improvement projects)
On August 2, 2016, leaders will be able to review improvement work underway at every facility in the system, improvement work that was established through the above processes. These projects include reducing waiting time and cycle time in clinics, promotion of health literacy, enhancing doctor-patient, doctor-family communication, reduction of A1c measures, among others. Each project is constructed within the framework of the IHI Model of Improvement. Most remarkably, doctors and administration are finding the time and the means to enable the work to go on without compromising scheduling and the work of the clinics and departments.
“We are approaching whole systems improvement the right way: while our aspiration is to be the best, we recognize that we have a long way to go. Culture trumps strategy…and we are building a culture of joint responsibility, joint learning, and joint planning. We will see the culture emerge that will accelerate improvement. We must find the right ratio of urgency to patience! On the one hand, we know that time is not on our side; our patients and our clinicians deserve the finest experience possible…NOW. However, we must realize that change will take time and not become frustrated and disappointed. So, with data as our friend, we will show ourselves and our patients that we are acting with urgency every day by building improvement in small ripples that will create waves of improvement month by month, quarter by quarter, year by year.” Dr. Aycen Turkmen, an OB/GYN physician from Coney island Hospital and Second Vice-President of Doctors Council
Taking on Low Employee Engagement
Successful practice of whole systems improvement requires that improved employee engagement be at the top of its achievement goals and challenges. While it is stated dogma by many that the knowledge and experience of the frontline is essential for improvement to be achieved and sustained, employee engagement in the health care industry remains low, including among physicians.
68% of physicians feel negatively about the current state of their profession and 77% are negative about the future of their professsion (Survey of American Physicians, Physicians Foundation, 2012).
At New York Health and Hospitals we know that the improvement journey is particularly daunting (in service to a population largely in poverty and poor health, with overwhelming budget challenges, and deep competition with the private sector as the newly insured through the Affordable Care Act have new choices to make about where to receive care). So, it could easily be suggested that the odds of improvement are not high.
It is in this daunting reality that the administration and the Union have decided on a truly JOINT path. In realtively short-order, through their sustained joint effort, new, well-conceived, and jointly owned patient experience improvement efforts are underway.
Let’s all learn about this effort and support it.
Work and the Future 