High Mortality Hospitals Cannot Afford To Pay

In a previous post I showed that most high mortality trusts did not pay bank holiday extra rates/wages to staff for the Queen’s diamond jubilee bank holiday, while most low mortality trusts paid higher wages. 

 

A friend of mine who is an academic wrote back to me and said he could not resist doing a chi square on the numbers and found the p=0.01. I am no don to argue or explain stats but irrespective of statistical significance it is important to probe if there might be a deeper meaning or relevance. 

 

It is important to understand why the high mortality trusts did not pay higher holiday rates. Are they ‘mean spirited’ as the Unite Union portrayed them?

In my mind the underlying reasons are very simple and here it is:

QUALITY IS INVERSELY PROPORTIONAL TO COST 

 

And a high HSMR is broadly speaking poor quality care.

Financial reasons?

It might be something as simple as they had no money left to pay. Now that would be a perfectly reasonable assumption to make. Trusts get paid for activity, things like hernia repairs, aneurysm repairs, cardiac stenting, the kinds of things that you do to make patients get better. As far as I know the NHS tariff system through which the trusts get paid does not include things like deaths or complications. 

But in-hospital deaths are very costly; in-hospital complications are very costly. There is no mechanism for payment for that. So a hospital/trust which has high deaths and complications will obviously not have money to do anything else.

Well, it therefore might turn out that their inability to pay higher wages had no a financial reason at all; it may well be a by product of poor quality. High cost, deficits, losses are all a function of poor quality. 

 

If you pushed them they will come out with something like ‘in this financial climate we would like to channel all our sparse finances directly into patient care’ and you know what, they sure do; their patient care must cost excessive amounts of money due to higher rates of standardised mortality and higher complications.

Cultural reasons?

Perhaps they were unwilling to pay higher rates; management might not have felt the need to 'reward' staff who are unable to produce high quality measured in terms of mortality. Another reason might have been that the money might be better spent in a high mortality hospital in trying to reduce the mortality rather than paying more to staff when the law does not demand that you do so. These are a part of the mental make up and cultural reasons of management. They are right, well, partly right. It is also just possible that well rewarded staff might be motivated to engage in improvement. Works both ways but always difficult to decide which one is right for the given circumstances.

Finally, here is some speculation

But, why did some high mortality hospitals pay staff bank holiday wages? Surely the above arguments apply to them as well. Why did some low mortality hospitals not pay higher bank holiday wages? 

 

Now I am moving into speculation something which I try not to do too often. My gut feeling is that the high mortality hospitals who paid a higher wage are probably going to find reduced mortality soon or at the best they may continue to stay where they without slipping and getting any worse and the low mortality hospitals who did not pay may find their mortality going up or at the best they may stay where they are without getting any better

 

My speculation is an extension of my theory about money in hospitals, the trusts who are doing clinically well might have the spare cash to spend it on staff. If that was indeed the case, the staff deserve it.

©M HEMADRI 

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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 
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