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Doctoring The Health Care Industry
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NFC: Your chairman, David Salsbury, said, “Today when people come to us for healthcare they are being served by team IHC.” This is the whole concept of clinical integration. IHC was really one of the first to start that, is that correct?
Spencer: We were one of the first to go anywhere with it. It's interesting—our improvement process really did start on the clinical side and over time moved into some of our administrative and other areas. It was unusual and exciting to watch.

NFC: In all the literature involving the clinical side in quality improvement efforts, a large concern is on giving physicians a sense of ownership. How did you accomplish that?
Spencer: By having doctors lead it. They were the ones providing the improvement tools. They were the ones leading the parade and providing information and saying to their colleagues, “We think this information is useful. What do you think?”

And as you identify outliers in the presentation of information, it has a wonderful effect. For example, if someone else is having great outcomes and keeping a patient for X number of days and you are keeping them in for X+ number of days, you could probably learn something.

NFC: Is it as simple as saying that the physicians will be in-charge? What were the challenges?
Spencer: The challenges were to create believers and you do that one step at a time. It's hard to bring in 500 doctors and train everyone in a new way of moving forward. It's much easier to go where there is initial interest and fertile ground, have some success, publish and share that learning. Then others begin thinking that this is something they can learn from and that they ought to perhaps look at another process or another diagnosis. It's a building block rather than a huge programmatic effort, and it has taken years.

NFC: Why do you think so many hospitals and healthcare facilities have been slow to grasp this?
Spencer: Good question. A. couple of things come to mind. One is the strong professionalism that says there is a lot of art to what we do.
Some of our initial experiences with best practices were that we would find the 16 steps that somebody did to do something. We would take these 16 steps and they wouldn't work because something is different; the environment is different. It took us awhile to realize that best practices isn't just looking at the 16 steps, but looking at the key principles and processes that make a difference and learning from those rather than trying to copy the 16 steps.

And in the health care arena that is especially true because outcomes come in so many different ways and there is a tendency to really rely on the individual art and less so on rigorous measurement and documentation over time. We are realizing that we can measure and track. We can keep a sense of the true process ingredients for making a difference.

Another component in the health care industry is that the hospitals, insurance plans and clinicians have been on different teams and still are to some extent.

There's the story about the four golfers who go golfing every Saturday and they choose balls to pair up and whoever wins the game, gets lunch bought for them. But one Saturday someone says, “Let's not choose teams until the end,” so they go through the whole golf game not knowing whether the shot that someone makes is a good one or not because they don't know who is on their team.

Well, that is sort of like health care. We don't really know who is on our team. Anybody could be on our team as restructuring occurs. Somebody who is your competitor one day could be on your team the next day.

And we've been helped a great deal by moving to an integrated system. At IHC we had our health plans early on. That brought two components together: the delivery and the health plan side working together.

More recently we've brought the physician component on board so that now we have all three components working together, which is unusual still in health care. When they are integrated you are able to keep track of things in an integrated way. When it doesn't really matter where that X-ray is given, whether it is in the doctor's office or in the clinic or in the hospital because it is all one bottom line, then you can really make a decision about how best to do that.

But as long as there are financial incentives to do it at one place over another, then it's very difficult to come up with the best way for the patient.

NFC: All employees at IHC are aligned around four key objectives. What are those objectives?
Spencer: Clinical quality, service quality, cost and market share which is the number of new enrollees in our health plans. Those are the four strategic objectives. We want to be tops in service and clinical quality and we want to do it in a way that is cost effective and we want to do it in a way that meets the needs of those we serve and that's represented by them re-enrolling with us over time.

The leadership team identifies the service quality: “What do we want to stay as status quo, how much do we want to improve or did we slip for some reason?” So they are deciding what those overall objectives are for each year, the specific objectives that will indicate achieving a system of goals: “What's our cost goal for the year, what's our service quality goal, what's our clinical quality goal?” The senior leadership team, along with doctors, insurance and delivery-side members, decide where those will be for the year?

NFC: Let's say that I'm a nurse in an Intensive Care Unit. How does that trickle down to me?
Spencer: Through department and individual discussion around how you will impact those goals, what you will do on your part with respect to those system measures.

NFC: Would my ICU team have a regular meeting to look at those?
Spencer: An annual meeting to look at that and decide on the goals for the year. And as an individual you would be responsible to spend some time doing that for yourself and sharing that with your manager and getting feedback.

NFC: How long have you been doing this?
Spencer: Not long and it's still not complete. We've got some parts of the organization that do a much better job than others, but it's been a couple of years.

NFC: If you are going to be clinical about it and look at those parts that have done well and those parts that haven't, what are the differences and why has that occurred? Why do you think that some have done it more easily than others?
Spencer: Part of it has to do with group maturity indicators. Some are more capable, not only at the leadership level but at the manager/team leader level, and that's where we focus—on building individual capacity of team members, managers and leaders.

As you build capacity you also want to build the alignment between individual and organizational goals. The more we can help individuals realize their goals are consistent and aligned, the better off we are going to be.

NFC: How do you train or develop individual capacity?
Spencer: One way is with the new employee orientation that provides the building block skills of service quality—identifying who your customers are. The orientation includes some stakeholder exercises, communication exercises and moments of truth experiences where they actually go around and experience things in the work setting, their facility or division.

We call them Bug Splats. They go out and experience bug splats on the windshield—experience things that aren't right and learn from that. So we are trying to, more than anything, build awareness on what service quality means and their role in that.

We are also trying to teach, employees, associates or anyone that you don't have to launch a full-blown study to have improvement. You can improve daily work through being aware of what you do and through experimentation—trying new things. It's a learning cycle—you experience stuff, but you learn by paying attention to what you experience. Then based on that paying attention, and it doesn't have to be formal measurement, you try new things to change your outcomes.

NFC: But no one works in a silo. Your output is very often dependent on someone else doing something as well. How does one deal with that?
Spencer: Through managers who are holding teams accountable for the kinds of things we believe in.

NFC: How do I, as a manager, hold you accountable?
Spencer: We all hold each other accountable. We identify key success factors for achieving our goals that we set up as a team. We talk about what that means for each of us and how we are going to have to behave. We decide that and then we hold each other accountable when we don't.

We set up mechanisms for recovery because we are not all going to be able to do that every time on everyday. What are the OK strategies to deal with that when it happens?

NFC: What, in your opinion, is a solution to the national health care situation? Is there one?
Spencer: My personal opinion is that we'll make progress nationally as we put more purchasing power back in the hands of the consumer. Then they will decide if they want to fly on this airline or not.

For most employees, most decisions are made by a benefits purchaser who is doing it primarily based on cost. So the fact that I can't get access to my physician or the physician I want or that I've got to go to this hospital versus that hospital is taken out of my hands for the most part.

We haven't figured out a way to get patients back in the driver's seat. And that is because of cost.

NFC: There's been in recent yearsan increase in interest about the alternative care—vitamins, supplements, acupuncture, chiropractic care and other alternative kinds of medicine. How do you see that being integrated?
Spencer: Slowly. But you have at least two choices: you can ignore it and wait until it hits you on the head or you can try and learn about it, not necessarily embrace it, but explore it and find ways that it compliments our objectives of a healthy community.

And IHC is exploring that. From all components—the insurance component, the delivery component, building new facilities, and designing task forces for making those facilities more consistent with what we already know and what we are discovering everyday—the impact of sounds, music, family care and also the alternative cares with respect to food, diet and other practices and procedures.

NFC: What about your job and your field keeps you awake at night?
Spencer: It's very hard to make perfect organizations and it's hard to make perfect managers. We foul up. Everybody fouls up, not intentionally but it happens. And I want to make and help our associates have the skills to be safe and able to deal with whatever situation they encounter so that they can surface the manager that is being harassing to them and deal with that. That they can identify a bureaucratic holdover that's creating a barrier in how they do their work and surface that. And I lay awake worrying about the employee somewhere in our organization who doesn't have the skill to either protect themselves or doesn't have the skill to surface and label and vocalize some pain or frustration they are dealing with.