INTERNATIONAL/QUALITY: Reggie will be having a fit

I’ve always been amused that the most cited example of the “focused factory” that Reggie Herzlinger perceives to be the answer to  medical cost and quality problems is the Shouldice Institute in Canada. That’s right the country where it takes ten months to get a doctors appointment if you’re pregnant, and where the state controls all health care—concepts Reggie’s not so keen on.

And of course the nearest thing to focused factories in the US are the specialty hospitals which—given our incentives—make most of their money increasing the amount of care given to a set populations (probably unnecessarily) and taking the most profitable cases away from the local community hospitals and away from their mission of care, or their fat endowments (Delete half the previous phrase based on your stance on the matter).

On the other hand if focused factories were established within a cost-constrained environment, presumably we’d get a clue as to whether they are more efficient and save money over all. Well maybe we’re going to find out.

Apparently London is going to be transformed into a city of 200 large multi-specialty group practices with what sounds like specialty hospitals to handle the acute care. This is going to be very interesting.

Meanwhile, in Southern California a doctor buys hospitals, kicks out managed care, jacks up prices and makes bank. Tthat’s real value add to the system

Categories: Uncategorized

Tagged as: , ,

10 replies »

  1. Im writing in response to the above letter. My son was killed by the procedures and policies of Prem Reddy( I hesitate to put Dr in front or behind his name). My son was in a car accident and was taken to Desert Vally Hospital. Dr Michael Manalescu was the ER doc, he is not certified in er medicine. He gave him xrays overdosed him with fentenyl and released him. He was coding at our house about 6 hours later. The paramedics took him back to Desert Valley Hospital and there as no er doc on duty, just a PA. He had no idea what he was doing, so for all intent and purposes my son died right there. They transported him to Loma Linda but he was already dead. We got a letter from the nurses from the first night and they said the were begging Dr Manolescu to transfer him to another hospital,and he refused. They said my son did not have to die. We filed a lawsuit but of course I signed a paper to not to talk about the settlement. This hospital should be closed. I have a Dodge Durango with a sign on it that says my son did not survive Desert Valley Hospital, and every day I get stopped by people who have their own stories about horrible medical care at this hospital. This man is a business man but he does not care about his patients. He is in it for the money and thats all. This so called hopital is in Victorville Ca.

  2. I am employed by Prime Healthcare and can tell you that the hospital ICU is chronically understaffed. There is a law in the State of California which says that there is to be 1 nurse for every 2 patients in the ICU “AT ALL TIMES”. That means when a nurse goes on a break, takes a patient for CT Scan, etc, there is to be another nurse to watch her patients. Well there isn’t. And we don’t get paid overtime for missing breaks, we’re told we MUST TAKE OUR LUNCH BREAKS. Nurses sometimes work 24 hours shifts because when the census goes up the local registry nurses don’t want to come work there because they don’t get paid enough money. Prem Reddy keeps all the money for himself. Sure he has upgraded our equipment but when my yearly evaluation was done I was told that I was at the top of the pay scale and was not going to get my yearly merit raise…okay, but I didn’t get a cost of living raise either, so I’m losing money compared to last year. The hospital is being remodeled and there is black soot being blown out of the ventilation system onto the ceilings in the ICU. They have changed the wage policy for the new hire staff and will no longer pay time and one-half after the first 8 hours so the managers are holding on to the old staff at all costs, even when they are incompetent and endanger patients lives. One of the ICU nurses charted false vital signs on a patient, BP readings much lower than what they really were and when it was reported nothing was done, that same nurse was reported for sleeping for an hour and a half in one of the empty rooms and was caught by the nursing supervisor, sent home and told not to come to work until he had spoken with the nurse manager. The manager wrote up a performance improvement report and had him sign it, that’s all. This nurse routinely makes medication errors, argues with the charge nurses and sneeks off to eat or sleep but the manager does nothing. The manager by the way has only a few years experience, the old manager quit. The staff of the Emergency department all quit, both day shift and night shift because of the their new manager. The new D.O.N. has no D.O.N. experience. We have nursing supervisors who have only a year or two experience as nurses and NONE as house supervisors. One in particular who is very dangerous, she routinely under staffs the ICU area, she has dispensed incorrect medications from the pharmacy and I could go on and on until you lose your hair with fear of what will happen at that place. Of course the nurses have written her up but apparently she is a friend of the D.O.N.’s wife. One recent death is easily attributable to the lack of experience of the staff and the lack of concern and competency of the remaining staff. The doctors who used to admit their patients all quit after a meeting with Prem Reddy where he talked to them about the coding system for medicare reimbursement. We (the nursing staff) only know that all but a handful of doctors (6) walked out of the meeting and we never saw them again. The patients now are all ER admits only, and the doctor assigned to them is not their regular doctor (if they have one). They are given a Prem Reddy hospitalist. There are 1 or 2 at any given time and they take all the patients. Tests, exams etc, that may have been done by the patients regular outside doctor are now repeated for the hospitalist because he has no history on the patient except what the patient or family tells him. Like I said I could go on and on. What can be done??? The hospitals owned and managed by Prem Reddy should be investigated. The labor department should make him pay all the overtime he owes his employees. He should be forced to hire and pay experienced, competent, compassionate healthcare professionals. He wouldn’t have $300.00 million in his pocket if he ran his for profit business legally and ethically I can tell you that!

  3. > My research shows that Shouldice does NOT want
    > to expand as it would reduce the excellant quality
    > control that Shouldice now has.
    Shouldice has faced a number of management issues ranging from regulatory challenges to succession planning. My research shows that expansion was being condidered at one time, that there was internal debate about what that would mean operationally, and indeed quality of care was one topic. But not the only one. In any case, its moot whether they want to expand.
    > Now some information about how Canada
    > is trying to improve service
    Let’s see: they’re trying to move from 35 weks to see the orthopod plus an additional 47 weeks to actually have the surgery down to six weeks to see the orthopod and to have the surgery five weeks after that. This sounds quite reasonable. For them, the first 90% will be easy. Maybe they can replicate this pilot program. If it doesn’t cost them too much — the little pilot cost them CDN $20M to set up.
    The self-serving quote at the end is priceless: “Many patients, [Dr. Cy Frank of the Alberta Bone and Joint Health Institute] said, simply weren’t prepared to have their surgery under such a shortened time frame.”
    Well! I guess waiting a year might not be so bad after all.

  4. “Shouldice Hospital has been operating on hernias since before World War II. The non-profit hospital has used its unique surgical technique to bring relief to more than 300,000 patients. Called the “Shouldice Technique” or “Canadian Method,” Shouldice Hospital’s approach to hernia surgeries has been admired replicated around the world.
    Located just outside Toronto on a picturesque country estate, Shouldice boasts 89 beds and impeccable patient care. In the public system, hernia surgeries are usually treated as day surgeries – the patient arrives in the morning, receives the surgery and goes home to recover. At Shouldice, patients are asked to stay in the hospital for two or three nights. They firmly believe a longer hospital stay speeds up recovery. Patients can participate in gentle exercise classes, walk around the 20 acre estate and even practice golf on a putting green. All these factors contribute to their phenomenal 99 per cent success rate. The average North American success rate is less than 90 per cent.
    Even better is that patients can get hernia surgery at Shouldice without paying a dime because its covered by provincial health plans.
    Shouldice is very proud of the efficiencies that come with exclusively operating on hernias. In general hospitals, disposable surgical supplies can cost as much as $200 to $850 per surgery. At Shouldice, disposables cost $17.82 per surgery.”
    Some more facts about Shouldice:
    My research shows that Shouldice does NOT want to expand as it would reduce the excellant quality control that Shouldice now has.
    Now some information about how Canada is trying to improve service and lower costs within the Canadian System.

  5. Dr. Prem Reddy’s business model and strategy seems, I think, to call for a legislative response that would limit the amount that could be charged the uninsured and insurers who do not have a contract with his hospitals to 125% or, at most, 150% of Medicare rates, though they could agree to reimburse at a higher percentage for certain procedures that Medicare pays poorly for as part of a contract if they think it is necessary. I believe Maryland already has a legislative limit of 125% of Medicare that hospitals can bill the uninsured.
    Hospitals have every incentive to raise chargemaster rates aggressively and persistently and many have been increasing them by 10% or more per year for a long time. Since they become part of the formula for determining outlier payments for more complex Medicare cases, the higher the list price, the more the hospital collects. Private insurers that do have contracts with hospitals pay, on average, 120% to 125% of Medicare rates according to Charlie Baker, CEO of Harvard-Pilgrim Healthcare, a well regarded Massachusetts insurer.

  6. Ah … yes. Even the kool-aid drinkers are catching on to Mr. Holt’s unfair, misleading (and often ad hominem) attacks on Dr. Herzlinger and others.

  7. I think there is a subtext to HBS’ facination with the Shouldice Institute. Besides the focus Dr. Shouldice had brought to hernia repair surgery, its also because being grandfathered-in and managing to survive in spite of the competition from the state run hospitals, Shouldice is evidently the last “private” hospital in Canada. Last I heard, the government there forbade them to expand.