Getting paid for performance - Buffet does, why not healthcare?

Top performers high achievers are amazing.

Marshall Goldsmith when he coaches senior executives does not get paid for his time; Marshall only gets paid if his clients are successful in a pre-defined and measurable way as defined by pre-selected stakeholders.

Warren Buffet when he was accepting money from his associates to invest did not get paid till he realised a minimum 6% profit on the clients money; only after Warren made more than 6% for his clients he asked clients to pay his charges/fees/profit-share.

Monish Pabrai who some say could be the Buffet of the future does the same; he does not charge his clients any fees unless he first makes 6% return for them. Above 6% he takes 1/4 of the profits – like Buffet does.

IHI – clearly states that if for any reason a participant is not fully satisfied with their course/meeting/conference/etc IHI will give a full refund of the fees paid. Check their website.

It looks like they don’t get paid (or prefer not to get paid) for their time or activity – they want to get paid for their successful performance.

There is surely something to learn from these people and institutions. On wondering how they do it it seems that they first develop their credentials, they are confident of the success of their methodology and they have the conviction to back it by putting the client’s returns ahead of their own.

It is interesting to note how they got there. They had discipline. They had the discipline to agree and write out what they wanted to do in the form of a checklist (not the tick box check list that many of us often use but the explicit work order/process type of checklist) and stick to it. They had the discipline to track their successes and failures of their checklist and change the things that did not work. They then again stuck to those checklists and tracked them again. Over a period of time their checklists have become amazingly superior. They give up opportunities which are not cleared by their checklists. They work by protocol, they have a protocol when the original protocol does not work, they have a protocol on when and how to change protocols.

Agreement on the methodology – explicitly writing it down step by step (checklist) – following the checklist – tracking the results of the checklist – changing/amending the checklist on the basis or measured performance. That seems to be their methodology. Atul Gawande has written about Monish Pabrai's method in his book, the 'Checklist Manifesto'. Enough has been written about Buffet's stock screening techniques (though no one exactly knows what they are).

An extended version of this is what they do at Intermountain Healthcare, Salt Lake City, Utah. Intermountain calls it clinical protocols (and not checklist). They are obviously a very successful healthcare organisation.

Pabrai says in an interview that if only investors quite simply followed Buffet's investment decisions even after it became completely public, the investment would clearly outperform the market, but people don't. In a similar manner, if only healthcare simply followed Intermountain (or Jonkoping) principles we could all be in a better place. Never mind reinventing the wheel, we in healthcare are possibly quite passionate about reinventing the flat tyre (to misquote Berwick).

Most of us in healthcare and I am specifically talking about clinicians and clinical health delivery, neither have the discipline nor the needed nerves of steely persistence to be able to replicate what is a very well described process/methodology that has seen sustained success for more than a decade. Actually, we may have both, it is likely we have not bothered to try it out.

Clinicians do not often have local agreement, they do not like to write out explicit protocols and then agree as a group to work to those protocols. We think it interferes with our 'clinical freedom'. That is why most of us get paid for our time and would hesitate to get paid for our performance.

 

©M HEMADRI

Follow me on Twitter @HemadriTweets


My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

New Research Area: Scientific Research vs Healthcare Delivery Research

Conventional Scientific Research Vs. Health Care Delivery Improvement Research: Both are important

I write with the confidence that many of you would already know about this..........

Research is about finding out if a proposed intervention works better than the current one. Is a new drug, operation, investigation, procedure, etc effective compared to an existing one? To find that out by definition research is a must and RCTs are essential (as RCTs are considered to be the highest form of conventional scientific research). Since the question is about the proposed intervention (and not about anything else) the confounding variables are reduced to minimum (inclusion and exclusion criteria etc). That will be conventional scientific research.

We all know real life clinical practice is not delivered under controlled research conditions.

Healthcare Delivery research (operational research) therefore becomes important. The question here is, what worked elsewhere and how to make it work for us in real practice where there will be all sorts of variables. This kind of research is important for two reasons: a) to put into practice the good things discovered by research (introduction and roll out of research findings - could probably be called innovation) and b) to discover what actually works (or does not work) in our location and to see if we can do better (clinical improvement)

I believe an example is the critical care outreach teams; apparently RCTs have not conclusively shown that they work. But in some hospitals they work very well. Now, we have such outreach teams in all hospitals; however it works in some hospitals and does not in others (again so much like RCTs finding different things when variables are changed) obviously the operational variables are different in each hospital. The point though is not if critical care outreach teams have been proven by RCTs but why it works in some places and do we want to make it work in our place?

So in practice, the question for healthcare delivery research is not whether something works (as that is an RCT question); the real question would be 'it works in St Elsewhere (even though it may or may not have been proven in RCTs); how do we make it work for us?' Where we know what works it is also about how to deliver that to every patient in our care.

As a surgeon I can say that the common operation of laparoscopic cholecystectomy surged to popularity even before any strong RCTs were done.

Let me state very clearly, that I am not for a moment supporting/encouraging dubious practices. I am talking about the existence of a different branch of research in which doctors have not been engaged actively in the past. I am suggesting that for most of us practising in normal day to day circumstances clinical operational research and/or management to benefit healthcare delivery could be equally relevant in providing good care (as RCTs). Most often the ideas for operational research comes from proven conventional research findings.

I would fully understand if trainees do not engage in this due to the expectation that they do conventional research. Doctors who are not in training ie consultants, SAS and specialty doctors could consider getting involved in this kind of work (clinical operational improvement work). This is not operational research from a management or administrative perspective. This is clinical care delivery operational research. If you thought this is managerial or admin work, sorry, you are mistaken. This is as directly clinical as it gets.

Clinicians have been taught what is best. This new area of activity and research shows us how to deliver that best to every patient at all times.

You could make a start by learning more about this. Check out IHI various courses including the on-line ones, NHS Institute's courses and of course the CQI course at NLG NHS are basic starting points to kindle interest in the area. Warwick's CSI course is reputed to get you thinking in this direction.