Sunday, April 26, 2015

NHS & Mayo Clinic: Spring!

Spring & hope:



© Am Ang Zhang 2014
At the Mayo Clinic Hospital in PhoenixArizona, they are in the best two per cent in the country. It is an impressive hospital, with piano music playing in the lobby and sunshine streaming into the rooms.
And around the hospital are signs extolling their ethos: the patient comes first. To this end they have introduced a number of safety systems, including a check and recheck system between the pathology labs and the operating theatres.
For years they have had multi-disciplinary team rounds in which everyone from the consultant to the physio, from the nutritionist to the social worker is involved in the care of that patient.
It means better communication. Everyone is treated as an important part of the team, rather than deferring, in the traditional way, to the consultant.Professor Richard Zimmerman, a neurosurgeon at the Mayo Clinic Hospital, acknowledges that this can be labour intensive with a dozen or more people involved in each round for each patient, but he said it is cost efficient in the end.
"It is less expensive than having a lot of deaths and having admissions that last longer because you don't do it right the first time," he said.
Nevertheless, critics will say that it is difficult to compare the American hospitals with the NHS and it is true that in the US more money is spent on equipment, drugs, staffing levels. And it has an expensive, much-criticised insurance-based healthcare system.And yet, American hospitals results are better. They have more per staff per patient, for instance. But what stood out at the Mayo was the attitude to mistakes or near misses. Staff are actively encouraged to report these. Whistleblowers are welcomed. Because they do not want these mistakes repeated.
"If you go to the States doctors can talk about problems, nurses can raise problems and listen to patient complaints," Professor Jarman said.
"We have a system whereby for written hospital complaints only one in 375 is actually formally investigated. That is appalling, absolutely appalling."

This is a re-working of a previous post on The Mayo Clinic: a sincere plea to the government to look closely at what could be done. The NHS had all the ingredients in place for a world class Health Care System.


The main features:

The needs of the patient come first. 
An Egalitarian Culture.
Healthcare is not a commodity.

A Fully Integrated System.

Private or Charity Patients are Equal.

No over treating at Mayo.

Competition does not serve patients’ interests.
Disincentive system that works.

What Makes the Mayo Clinic Different?

by Maggie Mahar October 21, 2008
The needs of the patient come first. 

“At Mayo the focus is on the patient. The needs of the patient come first.  I think one of the Mayo brothers originally said it—and here, that really is the case,” says Patterson. “We also do high quality research at Mayo, and we have a graduate school of medicine.  But research is not the primary focus.

At Mayo, on the other hand, stardom is frowned up. “Mayo has been, from the beginning, a group practice,” says Patterson. “You really have to be a team player. People in administrative positions understand that everyone is an important member of the team.”

An Egalitarian Culture

You may have heard that at Mayo, doctors collaborate. But did you know that after their first five years all physicians within a single department are paid the same salary?  During those first years, physicians receive "step raises" each year. After that, they top out ,and "he or she is paid just the same as someone who is internationally known and has been there for thirty years,"  says Patterson. ("Most could earn substantially more in private fee-for-service practice." he adds.) 

“It doesn’t matter how much revenue you bring in,” Patterson explains, “or how many procedures you do. We’re all salaried staff—paid equally.

“Turnover is very low. It’s unusual for people to leave here, and when they do, many like me, wind up coming back.  You would be surprised—we celebrate many 35 and 40 year anniversaries. That fact that people stay so long is important to the success of the organization.”

Patterson does not sound as if he’s boasting. He didn’t found Mayo. He didn’t create the culture. He merely works there—and he is telling me why he likes it. 

Yet I believe that there is much that health care reformers can learn by studying how Mayo operates.

There is, after all, a difference between healthcare and hamburgers.  Healthcare is not a commodity.
                                                                                                     
Healthcare is not a commodity!!!!!

Yet—and this is key—although Mayo’s doctors are not worrying about the dollar value of what they do, they are not more extravagant than other doctors  in dispensing care.  Quite the opposite:  Extensive analysis of Medicare records done by researchers at Dartmouth Universityreveals that treatment at the Mayo Clinic in RochesterMinnesota costs Medicare far less than when very similar patients are treated at other prestigious medical centers.


Yet no one would suggest that Mayo scrimps when treating patients. The Clinic received stellar marks on established measures of the quality of care, and both patient satisfaction and doctor satisfaction were higher than at UCLA. 


…………when it comes to healthcare, lower costs and higher quality often go hand in hand. Mayo’s patients are not hospitalized as long as patients at other medical centers—and don’t see as many specialists—because resources are used efficiently, and diagnoses are made quickly.

A Fully Integrated System

“Here at Mayo, we can do things in a week that take several weeks to organize in New York,” says Patterson.  This is because Mayo is an integrated medical center.

For example, “In New York, each division has its own staff to make appointments.  If I wanted several specialists to see a patient, I had to go through each of those divisions. At Mayo, we have a pediatric appointment office that makes all of the appointments for pediatric patients.”


Meanwhile, at Mayo, “We have a unitary medical record and a very effective IT department,” says Patterson.  “We developed our own software, and we can we dictate notes—we don’t have to type.” (This is a boon because, believe it or not, many doctors don’t know how to type.) 


“In the hospital, what we dictate can be transcribed within about an hour.” Patterson adds. “In the clinic, it’s done by the next half-day. In the meantime, if someone needs to access your notes, they can dial in and listen to the dictation.”


Private or Charity Patients are Equal

The Mayo Clinic in Minnesota sees many local patients.  “And like New York, we have minorities—just different minorities.”


Like most academic medical centers, Mayo treats a fair number of patients who cannot afford to pay their bills. In 2007 it spent $182 million providing charity care and covering the unpaid portion of Medicaid bills—plus another $352 million on “quantifiable benefits to the larger community” which included “non-billed services, in-kind donations and education.”


That year, 100,000 benefactors gave the Clinic a record $373 million—enough to pay for the benefits the Clinic provided for the community, but far from the amount that would be needed cover the charity care Mayo provided.


When it comes to serving Medicaid patients, Mayo is generous with its time and talent. “Here, there is no distinction between Medicaid patients and other patients,” says Patterson. “I wouldn’t know whether they are on Medicaid, or have insurance from their employer. The business office knows that.”


At many academic medical centers, Medicaid patients are seen mainly by residents in a separate clinic. “At Mayo no one is seen only by residents. And we routinely spend 90 minutes with a new patent —going through X-rays, and a complete examination,” says Patterson. 


No over treating at Mayo.
It also is  important to keep in mind that, “contrary to popular assumptions, it’s the volume of services, not the price per service, that accounts for most of the variation in Medicare spending” observes Dr. Jack Wennberg, the founder of what is now known simply as “the Dartmouth research.” And as more than two decades of Dartmouth research have shown, it is the supply of hospital beds and doctors that drives volume—not patient demand. When more resources are available, as they are at UCLA, patients spend more time in the hospital and undergo more procedures. Yet outcomes are no better; often they are worse.


“UCLA knows it has a problem,” Wennberg confided in an interview last year. “But what are they going to do—close down beds and fire doctors? They need that stream of revenue that comes from the beds and doctors to service their debt.”  So Medicare spends more at UCLA—and some patients are over-treated. 



Competition does not serve patients’ interests.

The Mayos also made it clear that patients’ interests were not well served if doctors competed with each other. Late in life William emphasized that in addition to making a commitment to the patient, doctors must make a commitment to each other:  “Continuing interest by every member of the staff in the professional progress of every other member,” would be essential to sustaining the organization’s future.


More than one hundred years later, building a health care system that adheres to such a collective vision of its mission may be difficult. Perhaps it can only be done in Minnesota.


In the end, Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower. Isn’t this what we want?


Disincentive system that works.
Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. One surgeon refers to this tradition as a ‘‘disincentive system that works.’’ Adds another surgeon: “By not having our economics tied to our cases, we are free to do what comes naturally, and that is to help one another out. .  .. Our system removes a set of perverse incentives and permits us to make all clinical decisions on the basis of what is best for the patient.”

These are values that can be traced directly back to William Mayo and Charles Mayo, who, together with their father, William Worrall Mayo, founded Minnesota’s Mayo Clinic in 1903. The Clinic was one of the first examples of group practice in the United States. As Doctor William Mayo explained in 1905: “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary…it has become necessary to develop medicine as a cooperative science.”

Read the full article: What Makes the Mayo Clinic Different?

From: Leadership Lessons from Mayo Clinic


T e a c h i n g  f o r  T  o m o r r o w ’ s  P a t i e n t


Mayo’s combination of culture and technology is potent. The culture makes it okay for highly-trained providers to ask for help; the technology makes it easy to provide the help.
A Mayo Rochester internist speaks to the cultural influence: ‘‘The strong collegial attitude at Mayo allows me to call any Mayo  physician at any time and discuss a patient in a tactful and pleasant manner. I do not feel afraid or stupid when I call a world renowned Mayo surgeon. We respect each other. We help each other. We learn from each other.’’

A Mayo surgeon recalled an incident that occurred shortly after he had  joined the Mayo    surgical staff as the most junior member. He was seeing patients in the Clinic one afternoon when he received a page from one of the most experienced and renowned surgeons on the Mayo Clinic staff. The senior surgeon stated over the phone that he was in the operating room performing a complex procedure on a patient with a difficult problem. He explained the findings and asked his junior colleague whether or not what he, the senior surgeon, was planning seemed appropriate. The junior surgeon was dumb-founded at first that he would receive a call like this from a surgeon whom he greatly admired and assumed had all the answers to even the most difficult problems. Nonetheless, a few minutes of discussion ensued, a decision was made, and the senior surgeon proceeded with the operation. The patient’s problem was deftly managed, and the patient made an excellent postoperative recovery. A major consequence was that the junior surgeon learned the importance of intra-operative consultation for the patient’s benefit even among surgeons with many years of surgical experience.

No Internal Market, no silly cross charging.



Dr. Charles H. Mayo and Dr. William J. Mayo

“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”

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