Have you ever had anyone send you a weird electronic file and when you click on it you get a list of programs from which to choose to open it? If its a graphic-heavy file, obviously you’re not going to select Excel, yet there it is as one of the options. Ever click on Excel just to see what happens? If you put your ear real close to your keyboard you can actually hear the circuits laughing. You’ll get some sort of error message that might mention something about incompatibility with the file.
I mention this because it’s becoming more evident to me that when embarking on an integrated care effort we often leave the gates doomed for frustration and failure. See, we don’t get the benefit of that error message; we humans have to go through a series of trials and errors to figure it out. A couple of blogs back I mentioned the difference between project management vs. process management. I think its important enough to circle back and build a little more on that thought because it is of such fundamental essence that it alone has enormous impact on the success of your implementation in terms of the planning, implementation and final results. To be clear, the implementation of an integrated practice is a process. Nothing short of that. It changes EVERYTHING.
Let’s also be clear about some basic definitions; first of Project Management (Stanleigh, M., Process Management vs Project Management. Business Improvement Architects, www.bia.ca/articles/pj–pm-vs-pjm.htm):
- A temporary endeavor undertaken to create a unique product, service, or result.
- Time-bound and has a customer.
- Has clear beginning and end dates.
- Follows a specific cycle of initiation, definition, planning, execution, and close.
Now, Process Management (Friedman, D., Program vs Project Management. Project Management Consulting. http://proj-mgt.com/PMC_Program_vs_Project.htm):
- Combines the ability and resources to define, plan, implement, and integrate every aspect of the comprehensive program.
- The coordinated management of a portfolio of projects to achieve a set of business objectives.
Friedman goes to more specifically spell out the differences:
1. (Processes) encompass a series of projects that in aggregate achieve an overarching set of objectives, where projects have a specific and more singular objectives. In this sense, the difference is driven by scope and scale.
2. (Process) management involves more than oversight of a set of projects. It includes application of common standards and processes to the execution of the projects.
You might be surprised to learn that here at Cherokee Health Systems, where we have been working on an integrated care practice for nearly 40 years, that we still don’t yet consider ourselves done with integration. We’re constantly chasing it. Stanleigh describes a process as “on-going with no clearly defined beginning and end dates, customer driven, and repeatable.” In fact, he would probably best describe integrated care as “Business Process Reengineering.” He defines it as “a fundamental re-thinking and re-designing of a business process in order to exceed customer and quality requirements.” What he’s describing is a process that has dexterity, flexibility and responsive to change – changing customer needs and changing environments – yet has those “common standards and processes” that Friedman mentions. Sound familiar? Anyone hear of healthcare reform?
What does this mean for us? I guess the first question is to figure out what your commitment to this is going to be. To be sure, it is going to be a process. Dr. Edwards Deming, known as one of the world’s most renowned experts on management and efficiency, makes the point quite clearly, “If you can’t describe what you are doing as a process, you don’t know what you are doing.”
During consultations, Joel Hornberger, Cherokee’s Chief Strategy Officer, often walks people through a change management cycle. It is vital because organizations very often short-sell themselves on what is going to be involved if they truly want to become an integrated practice. It is often treated as project, such as EMR implementation – where there is a clear beginning, an implementation phase, and then a completion (often with a nod to ongoing maintenance). An integrated care practice process includes:
- Clear, explicit, and present leadership from the organization’s CEO
- A profound re-thinking of the organization’s mission to reflect this new approach
- A clear understanding of the systemic and program level impact (often including advocacy and lobbying effort at the state level for payer reform)
- The ability to manage a portfolio of projects and subprojects along the way which may include the development of behavioral templates on the EMR, training on the use of new codes by providers and billing agents, facility redesign, patient flow reconfiguration, screening and scoring tools, etc.
- Development and adherence to a set of clear set of core standards by which all providers and clinicians will operate under
- If you are using contractors or partners to supply providers and clinicians (for example, if in partnership with a community mental health provider) that they understand and adhere to your standards, expectations and mission
Shifting to an integrated care practice is nothing short of tectonic. You are shifting the plates of your very foundation to become more responsive to patient needs by repositioning resources, changing key roles, and rerouting workflows. This simply cannot be done by a mid-level administrator who lacks influence equity and who may function as a lateral colleague, or worse yet may report to those to whom he is responsible for changing. This is best led from the top down – clearly, decisively, explicitly, frequently, and with ultimate responsibility and accountability.
What strength are you willing to commit to this? If Dr. Richter were to measure your impact would he give you only a 4.5 (noticeable shaking, some rattling), or will your impact be along of the lines of total disruptive innovation of 7.0 and above?