Tag: healthcare

Under One Roof: What Can we Learn from the Mayo Clinic?

The biologist Lewis Thomas, who we've written about before, has a wonderful thought on creating great organizations.

For Thomas, creating great science was not about command-and-control. It was about Getting the Air Right.

It cannot be prearranged in any precise way; the minds cannot be lined up in tidy rows and given directions from printed sheets. You cannot get it done by instructing each mind to make this or that piece, for central committees to fit with the pieces made by the other instructed minds. It does not work this way.

What it needs is for the air to be made right. If you want a bee to make honey, you do not issue protocols on solar navigation or carbohydrate chemistry, you put him together with other bees (and you’d better do this quickly, for solitary bees do not stay alive) and you do what you can to arrange the general environment around the hive. If the air is right, the science will come in its own season, like pure honey.

One organization which clearly “gets the air right” is the much lauded Mayo Clinic in Rochester, Minnesota.

The organization has 4,500 physicians and over $10 billion in revenue from three main campuses, and it is regularly rated among the top hospital systems in the United States in a wide variety of specialities, and yet was founded back in the late 20th century by William Worrall Mayo. Its main campus is in Rochester, Minnesota; not exactly a hub of bustling activity, yet its patients are willing to fly or drive hundreds of miles to receive care. (So-called “destination medicine.”)

How does an organization sustain that kind of momentum for more than 150 years, in an industry that's changed as much as medicine? What can the rest of us learn from that?

It's a prime example of where culture eats strategy. Even Warren Buffett admires the system:

A medical partnership led by your area’s premier brain surgeon may enjoy outsized and growing earnings, but that tells little about its future. The partnership’s moat will go when the surgeon goes. You can count, though, on the moat of the Mayo Clinic to endure, even though you can’t name its CEO.

Pulling the Same Oar

The Mayo Clinic is an integrated, multi-specialty organization — they're known for doing almost every type of medicine at a world class level. And the point of having lots of specialities integrated under one roof is teamwork: Everyone is pulling the same oar. Integrating all specialities under one umbrella and giving them a common set of incentives focuses Mayo's work on the needs of the patient, not the hospital or the doctor.

This extreme focus on patient needs and teamwork creates a unique environment that is not present in most healthcare systems, where one's various care-takers often don't know each other, fail to communicate, and even have trouble accessing past medical records. (Mayo is able to have one united electronic patient record system because of its deep integration.)

Importantly, they don't just say they focus on integrated care, they do it. Everything is aligned in that direction. For example, as with Apple Retail stores (also known for extreme customer focus), there are no bonuses or incentive payments for physicians — only salaries.

An interesting book called Management Lessons from the Mayo Clinic (recommended by the great Sanjay Bakshi) details some of Mayo's interesting culture:

The clinic ardently searches for team players in its hiring and then facilitates their collaboration through substantial investment in communications technology and facilities design. Further encouraging collaboration is an all-salary compensation system with no incentive payments based on the number of patients seen or procedures performed. A Mayo physician has no economic reason to hold onto patients rather than referring them to colleagues better suited to meet their needs. Nor does taking the time to assist a colleague result in lost personal income.

[…]

The most amazing thing of all about the Mayo clinic is the fact that hundreds of members of the most highly individualistic profession in the world could be induced to live and work together in a small town on the edge of nowhere and like it.

The Clinic was carefully constructed by self-selection over time: It's a culture that attracts teamwork focused physicians and then executes on that promise.

One of the internists in the book is quoting as saying working at Mayo is like “working in an organism; you are not a single cell when you are out there practicing. As a generalists, I have access to the best minds on any topic, any disease or problem I come up with and they're one phone call away.”

In that sense, part of the Mayo's moat is simply a feedback loop of momentum: Give a group of high performers an amazing atmosphere in which to do their work, and eventually they will simply be attracted by each other. This can go on a long time.

Under One Roof

The other part of Mayo's success — besides correct incentives, a correct system, and a feedback loop — is simply scale and critical mass. Mayo is like a Ford in its early days: They can do everything under one roof, with all of the specialities and sub-specialities covered. That allows them to deliver a very different experience, accelerating the patient care cycle due to extreme efficiency relative to a “fractured” system.

Craig Smoldt, chair of the department of facilities and support services in Rochester, makes the point that Mayo clinic can offer efficient care–the cornerstone of destination medicine–because it functions as one integrated organization. He notes the fact that everyone works under one roof, so to speak, and is on the payroll of the same organization, makes a huge difference. The critical mass of what we have here is another factor. Few healthcare organizations in the country have as many specialities and sub-specialities working together in one organization.” So Mayo Clinic patients come to one of three locations, and virtually all of their diagnoses and treatment can be delivered by that single organization in a short time.

Contrast that to the way care is delivered elsewhere, the fractured system that represents Mayo's competitors. This is another factor in Mayo's success — they're up against a pretty uncompetitive lot:

Most U.S. healthcare is not delivered in organizations with a comparable degree of integrated operations. Rather than receiving care under one roof, a single patient's doctors commonly work in offices scattered around a city. Clinical laboratories and imaging facilities may be either in the local hospital or at different locations. As a report by the Institute of Medicine and the National Academy of Engineering notes, “The increase in specialization in medicine has reinforced the cottage-industry structure of U.S. healthcare, helping to create a delivery system characterized by disconnected silos of function and specialization.

How does this normally work out in practice, at places that don't work like Mayo? We're probably all familiar with the process. The Institute of Medicine report referenced above continues:

“Suppose the patient has four medical problems. That means she would likely have at least five different doctors.” For instance, this patient could have (1) a primary care doctor providing regular examinations and treatments for general health, (2) an orthopedist who treats a severely arthritic knee, (3) a cardiologist who is monitoring the aortic valve in her heart that may need replacement soon, (4) a psychiatrist who is helping her manage depression, and (5) and endocrinologist who is helping her adjust her diabetes medications. Dr. Cortese then notes,”With the possible exception of the primary care physician, most of these doctors probably do not know that the patient is seeing the others. And even if they do know, it is highly unlikely they know the impressions and recommendations the other doctors have recorded in the medical record, or exactly what medications and dosages are prescribed.” If the patient is hospitalized, it is probably that only the admitting physician and the primary care physician will have that knowledge.

Coordinating all of these doctors takes time and energy on the part of the patient. Repeat, follow-up visits are done days later; often test results, MRI results, or x-ray results are not determined quickly or communicated effectively to the other parts of the chain.

Mayo solves that by doing everything efficiently and under one roof. The patient or his/her family doesn't have to push to get efficient service. Take the case of a woman with fibrocystic breast disease who had recently found a lump. Her experience at Mayo took a few hours; the same experience in the past had taken multiple days elsewhere, and initiative on her end to speed things up.

As a patient in the breast clinic, she began with an internist/breast specialists who took the medical history and performed an exam. The mammogram followed in the nearby breast imaging center. The breast ultrasound, ordered to evaluate a specific area on the breast, was done immediately after the mammogram.

The breast radiologist who performed the ultrasound had all the medical history and impressions of the other doctors available in the electronic medical record (EMR). The ultrasound confirmed that the lump was a simple cyst, not a cancer. The radiologist shared this information with the patient and offered her an aspiration of the cyst that would draw off fluid if the cyst was painful. But comforted with the diagnosis of the simple cyst and with the fact that it was not painful, the veteran patient declined the aspiration. Within an hour of completing the breast imaging, the radiologist communicated to the breast specialist a “verbal report” of the imaging findings. The patient returned to the internist/breast specialist who then had a wrap-up visit with the patient and recommended follow-up care. This patient's care at Mayo was completed in three and one-half hours–before lunch.

So what are some lessons we can pull together from studying Mayo?

The book offers a bunch, but one in particular seemed broadly useful, from a chapter describing Mayo's “systems” approach to consistently improving the speed and level of care. (Industrial engineers are put to work fixing broken systems inside Mayo.)

Mayo wins by solving the totality of the customer's problem, not part of it. This is the essence of an integrated system. While this wouldn't work for all types of businesses; it's probably a useful way for most “service” companies to think.

Why is this lesson particularly important? Because it leads to all the others. Innovation in patient care, efficiency in service delivery, continuous adoption of new technology, “Getting the Air Right” to attract and retain the best possible physicians, and creating a feedback loop are products of the “high level” thought process below: Solve the whole problem.

Lesson 1: Solve the customer's total problem. Mayo Clinic is a “systems seller” competing with a connected, coordinated service. systems sellers market coordinated solutions to the totality of their customers' problems; they offer whole solutions instead of partial solutions. In system selling, the marketer puts together all the services needed by customers to do it themselves. The Clinic uses systems thinking to execute systems selling that pleasantly surprises patients (and families) and exceeds their expectations.

The scheduling and service production systems at Mayo Clinic have created a differentiated product–destination medicine–that few competitors can approach. So even if patients feel that the doctors and hospitals at home are fine, they still place a high value on a service system that can deliver a product in days rather than weeks or months.

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Patients not only require competent care but also coordinated and efficient care. Mayo excels in both areas. In a small Midwestern town, it created a medical city offering “systems solutions” that encourage favorable word of mouth and sustained brand strength, and then it exported the model to new campuses in Arizona and Florida.

If you liked this post, you might like these as well:

Creating Effective Incentive Systems: Ken Iverson on the Principles that Unleash Human Potential — Done poorly, compensation systems foster a culture of individualism and gaming. Done properly, however, they unleash the potential of all employees.

Can Health Care Learn From Restaurant Chains? — Atul Gawande pens a fascinating piece in the New Yorker about what health care can learn from the Cheesecake Factory.

Charlie Munger on the Medical System

Long a fount of wisdom, Charlie Munger provided us fascinating insight on everything from energy policy and mental models to how good gamblers think and making effective decisions.

At the Daily Journal Meeting (held March 25th, 2015), Munger answered a question on Obamacare:

Of course the system of medical care, as evolved under the United States, has much wrong with it.

On the other hand, it has much that's good about it. All the new drugs and devices, and new operations, medicine has taken more territory in my lifetime than it took in the whole previous history of mankind. It's just amazing what's been done.

A lot of it is obvious and simple, like inoculating the children against infantile paralysis, scraping the tartar off your teeth so you don't wear plates when you're 55 years old, and so on. People now take those benefits for granted, but I lived in a world where a lot of children died. Every city had a tuberculosis sanitarium, and half the people who got tuberculosis died. It's amazing how well medicine has worked.

On the other hand, compared to the best it can possibly be, the American system is pretty peculiar. It's very hard to fix. One kind of insanity is to say, “We'll pay you so much a month for taking care of the people, and everything you save is yours.”

That is the system the government uses in dealing with the convalescent homes. That's a great name, a convalescent home. You convalesce in heaven. You don't convalesce them at home. [laughs] It's attempting to have a euphemistic name.

That creates huge incentives to delay care and keep the money. The government has strict rules, compliance systems, and so forth. If we didn't have that system, the cost of taking care of the old people in convalescent homes would be 10 times what it is. It was the only feasible solution.

The rest of the world is going in that direction, because the costs just keep rising and rising and rising.

If the government is going to pay A anything he wants for selling services to B, who doesn't have to pay anything, of course the system is going to create a lot of unnecessary tests, unnecessary costs, unnecessary procedures, unnecessary interventions.

Psychiatrists that keep talking to a patient forever and ever with no improvement, of course that system is going to cause problems. The alternative system also causes problems.

Add the fact you've got politicians and add the fact you've got existing players who are enormously rich and powerful, who lobby you like crazy. A state legislature, now, is just 19 percent or whatever it is of GDP going to the medical system, imagine what the lobbying is like.

We get these Rube Goldberg systems. We get a lot of abuse of various kinds. There's hardly an ethical drug company that hasn't created multiple gross abuses, which are in substance growing through the bribery of doctors, which, of course, is illegal.

You have all these ethical companies. Ethical meaning it's the designation of a drug company that has patented drugs. They’ve all committed big follies. The device makers of anything have been worse. There's been a lot of abuse and craziness, and the costs, of course, just keep rising and rising.

That's in a system that every child has been the greatest achiever in the history of the world. It's very complicated. I think it will get addressed more because…We probably will end up with systems that are more like we do with the convalescent homes.

If you look at medicine, what's happening is that more and more they're going to a system where they pay somebody X dollars and everything they save, they keep. That system has some chance of controlling the cost. If you go into a great medical school hospital today, and you're within a day of dying of some obvious thing like advanced cancer, the admitting physician is very likely to ask for a test of your cholesterol or any other damn thing. All the bills go to the government. As long as the incentives allow that, people will do it and they'll rationalize their behavior. Something has to be done along that and more than is now being done.

I think the drift will be more in the direction of the block care. I don't see any other system that would have controlled cost in the convalescent homes.

By the way, your doctor can't just walk by every bed in the convalescent home and send the bill to the government. That's not allowed by the law. But if you transfer the patient into a hospital, he can walk by the bed five times every day and send a $45 bill to the government.

If the incentives are wrong, the behavior will be wrong. I guarantee it. Not by everybody, but by enough of a percentage that you won't like the system.

I think that's enough on a subject that's so difficult. I think we can see where it's going. We may end up with a whole system that's…In the Netherlands, they have a system where the same people are giving a free system to everybody and a concierge system to the others. It's working pretty well.

Transcript Source.