Healthcare Reflections, Insights, and Lessons: Proactive/Reactive

Copyright © 2019 by Steven J Sobak.

Library of Congress Control Number:   2019913483

ISBN:       Hardcover                      978-1-5437-5394-3

                 Softcover                         978-1-5437-5392-9

                 eBook                               978-1-5437-5393-6

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"A good practical textbook of healthcare management should not only lay down the standard principles of management, but also seek to impart general knowledge of real-life experiences across the contexts of health care settings. Steve Sobak has done this in his publication, which gives rich personal insights that goes beyond many common concepts with the thoughtful considerations of the practitioner. He presents not just practical issues but gives concrete hands-on ideas relating to all aspects of healthcare management, from strategic planning, operations, financial and human resource development, to dealing with providers and patients, and health information systems.

He brings into this book his thoughts and experiences from fighting in the trenches (wards and clinics) to executive boardrooms of healthcare institutions, towards delivering efficient, financially sound and sustainable quality of care, at various levels and settings. Like his earlier monograph with the late co-author Art Ouellette (2014), An Investor’s Guide to Developing a Private Hospital: Ten Considerations before Committing, this current volume contains pearls of wisdom, born out of his many years of health care administrative experience in the private sector and privatised public hospitals in Singapore and elsewhere all over the world."

Prof Phua Kai Hong

Visiting Professor

Graduate School of Public Policy

Nazarbayev University

Adjunct Faculty

Lee Kuan Yew School of Public Policy,

National University of Singapore, and Singapore Management University

Former Associate Professor and Head, Health Care Division, Faculty of Medicine,

National University of Singapore

PREFACE

This book is based on a series of observations and anecdotes gained from my experience, exposure, research, and understandings gathered from working in healthcare systems of at least five different countries and compressed into Reflections, Insights, and Lessons statements for the purpose of being able to easily remember, but more importantly, share with you. Over the years, we have had the opportunity and privilege to manage and be a Mentor to a number of individuals who were recruited with related backgrounds in finance, operations, and other areas, and needed to be oriented and trained in application of their background within healthcare industry. Many of my mentees have risen, and assumed more senior roles, i.e. becoming CEOs/MDs, CFOs, and COOs who are now in the position to lead their respective organizations, and hopefully become Mentors as well, preparing future generations of healthcare professionals. For that reason we wish to assist and stimulate that process by sharing meaningful observations, with interested individuals.

Explanations follow each Reflection, Insight, and Lesson statement to provide context, background, or insight of the statements, and in certain instances, solutions considered and/or adopted, to make them more meaningful. The Reflective observations shared here are applicable across the healthcare industry spectrum, both in the Private and Public sectors. Certain observations appear obvious, and may have already been addressed by a particular healthcare facility; however, most facilities, depending on geographic location are at different stages of development and maturity, ranging from pending/considering implementation, to various stages of completion. Further, given the number of Reflections, Insights and Lessons highlighted in this book, there will be information overlap in various instances, which is useful as it reinforces other statements, and provides consistency and continuity in what is being shared but balanced so as to avoid being boring.

Each Reflection, Insight, and Lesson shared in this book should become the basis for expanded thinking, generating additional ideas that can be applied as enhancements or modifications, specific to your organization, making the Reflection, Insight, and Lesson even more meaningful and relevant, while perhaps triggering a recall of similar memories and experiences you may have previously encountered.

Certain Reflections, Insights, and Lessons have relevance in other industries experiencing similar situations. I am confident many may have already been identified by other authors, motivational and management speakers; however, this compendium of selected observations for consideration relate specifically to the healthcare industry and may be more relatable to you, but all offer learning and transfer of knowledge opportunities to improve both your management skills and operational insight!

Initially, this book was targeted toward middle and more senior level healthcare management positions; individuals who have experience and can relate to various lessons and can reflect on them, as this lends credibility to other statements in the book which they have yet to experience; however, two additional targets have emerged.

My secondary target are students and others just entering the healthcare industry to give them a flavor of the types of situations that may occur, and complement any formal educational training they have received with realistic and practical insights.

The last, but not least target is the general public; those who are curious and have questions and/or want to learn more about what drives healthcare decisions, operations and practices within the industry. Even healthcare individuals and professionals may want more insight about various topics, to gain a better understanding and broaden their perspectives about operational responsibilities, as well as members of the journalistic and legal professions, and especially those who are contemplating undertaking healthcare projects.

The observations that form the basis of my Reflections. Insights, and Lessons have been collected during my years in healthcare having had the privilege to be appointed to lead roles of CEO, COO, CFO, at various healthcare facilities, and equally as many supporting roles. Many observations being shared were common in all the positions; others, were more focused to a specific role, but surprisingly, most are similar regardless of the countries worked in, i.e., US, Saudi Arabia, Philippines, Malaysia, China, Singapore, and India. We must also share there were times when we personally faltered and learned hard lessons but managed to recover and was made stronger. Therefore I am able to reflect upon and share many of the learning experiences with that legacy perspective so others can avoid making the same or similar mistakes. While I have been in the healthcare industry for many years, there are many more learned individuals, and those with more experience and insight from whom I can continue to learn, and respect.

Before we close off the Preface, I want to highlight three themes present in the book. The subtitle "ProActive/ReActive connotes many of the Reflections, Insights, and Lessons are a result of proactive learning i.e., studying historical activities and reports, reading about different countries healthcare delivery systems, attending Conferences and Seminars on selected topics, networking with peers and being exposed to new concepts, able to discuss best practices" and use of them to improve our performance. On the other side, many observations have their genesis in Reactive conditions, as result of internal or external questions, observed behavior, editorials, legal actions or situations that have challenged us and caused us to think of different solutions (sometimes out of the box) on ways to improve.

Another theme, I wish to focus upon is that of Knowledge. To be a successful Senior Administrator, one must take time to learn the business from the ground up. This does not mean one must have spent their entire career in healthcare, but it does mean the Administrator must take time to visit Departments in their organization and observe front line activities, to learn and develop an understanding and appreciation of what is happening which will allow Administrators to relate with and support their staff when difficult issues or questions arise. Interestingly enough in the process, through insightful questions Administrators can even identify archaic practices still in effect offering no value add that can be eliminated. If one is a Department Manager, learn everything you can about your business, treat it as if you were an independent Owner-Operator and your livelihood depended on it. As you move up the hierarchy, you should adopt the same principle but take on new, wider perspectives.

The final theme I want to mention is that of Finance and Accounting. At the most senior levels, everyone needs to have attended, at least, a basic Executive Level orientation course in accounting and finance so as to develop an understanding of key terms. Learn how to read a Profit and Loss Statement, Balance Sheet, and able to focus on the critical line items, ratios and metrics. Many financial and accounting terms will be used in the Board of Directors/Trustees Meetings, Budget preparation and reviews, and when sharing new concepts and ideas for implementation consideration, so as a Senior Administrator, avoid embarrassment regarding basic terminology and meanings. Your Chief Financial Officer, or equivalent, can take the lead when delving into details and financial reporting compliance; however understanding the basics both in the private and public sector is essential.

Whether you are a seasoned healthcare professional or just starting out on your middle to senior level healthcare administrative career, these observation based learning points about strategy, management, finance, and operations in the healthcare industry will be meaningful. The explanations offered provide insights which you can nurture, develop, and implement, but most of all, ENJOY!

Any comments, further elaborations, or sharing of different experiences are always welcome. Healthcare is a dynamic industry and requires continuous learning and upgrading by its professionals, at all levels. If we can assemble enough meaningful additional reflective observations and lessons, we can consider publishing a follow-up book in the future.

Steven J Sobak

September 2019

Contact: [email protected]

Also by:

Arthur R Ouelette and Steven J Sobak, An Investor’s Guide to Developing a Private Hospital, Ten Considerations before Committing, (2014)

Dedication

To

Prof Cheng Heng Kock who encouraged me to collect, and share my experiences from over the years………..

And To

Theodore Gaston my first Mentor and Supporter in Healthcare

ACKNOWLEDGEMENTS

I would like to recognize the following individuals who took time from their respective busy schedules to read my draft versions and offer helpful and constructive comments, and support to improve understanding and interpretation. I have tried to incorporate all that I could.

(Mr) Boon Yeow Chew

(Dr) Jennifer Lee

(Dr) Yoong Siew Lee

(Dr) Eillyne Seow

And a Special Thanks to (Dr) Goh Hsin Kai for his clever Cover design and Illustrations

CONTENTS

PREFACE

We have divided the Reflective, Insight, and Lesson observations into four general categories; however, the content and placement within each category is subjective and I take responsibility for the selection. Even within categories, topics are mixed to keep the reading easy and hopefully interesting.

I      PATIENT RELATED OBSERVATIONS

II     HEALTHCARE FACILITY RELATED

OBSERVATIONS

III   OPERATIONAL RELATED OBSERVATIONS

IV    COMMON SENSE RELATED OBSERVATIONS

CLOSING

SELECTED TERMS AND DEFINITIONS

USED IN THE BOOK

SUBJECT INDEX

PATIENT RELATED OBSERVATIONS

1 Front line professionals, doctors, specialists, nurses, therapists and any other individuals interacting with the patients, should demonstrate good hygiene practice, show interest, engage them, making eye contact, talking to them (not at them), and asking open ended questions to obtain feedback from the patients on professionals understanding of their conditions, understanding of instructions given, and an understanding of what they want.

Unfortunately many patients meet with the Doctor, Specialist, Nurse or other service professionals, and after the meeting feel overwhelmed, or may fail to understand what transpired and what they need to do. This is particularly true for elderly, and patients who cannot communicate or interact with staff when medical services are being provided. So, use of body language, communication, visual supports (pictures, drawings, and pamphlets) should be the standard techniques used to engage the patients, caregivers, and family.

Doctors, Specialists and any staff who will be assisting, or touching any patient should make washing their hands before engaging the patient visible to the patient. Further, staff should look at the patient during the consultation or treatment, and avoid exclusively looking at the computer screen or writing without achieving eye contact with the patient. It is important to project interest in the patient’s condition and making efforts in communication. Before closing off any Outpatient Clinical Attendance or Service Appointment, ask the patient, caregiver, family member to repeat the key tasks they need to perform, or symptoms that require immediate medical attention, to ensure they understand what was communicated. The best way is by using a series of open ended questions. If the patient cannot answer or has difficulty, then there is a problem that must be resolved before the patient leaves; otherwise they will be unable to convey what transpired or remember what they need to do after leaving the consultation room. Special instructions may need to be written down, or they be given a prepared instruction sheet to assist them in what to do. Ensure each patient facing staff is educated, never allow a patient to leave their care without the patient/caregiver knowing what needs to be done, from taking medicine, to returning for follow-up service.

Similarly for inpatients, in addition to the above Observation points, all professionals (Specialists, Nurses, Therapists, etc.) should visit the patients, engaging the patients by asking certain open ended questions, specifically How do you feel today, How can I help you, to make you feel better, What do you want or need, and listen to the responses, respond accordingly. Finally, take time to explain what activities and treatment plans are scheduled, and any changes that may occur for the day to keep them updated to manage their anxiety.

2 Dress and Act like the professionals we are supposed to be; then, we will be respected for who we are.

Doctors, nurses, therapists, administrators are all professionals in their respective areas of expertise. As such, the patients and their families have perceptions and expectations on how the professionals should be dressed, as well as generally accepted professional attire of the industry. Correct dressing promotes a professional image of the individual, and reflects on the standards of services being performed. Nurses often have healthcare facility specific standardized uniforms that they normally wear, and designed to be able to delineate their rank, so this group is the easiest to identify in the organization, but even their uniforms need to be neat and tidy, especially when reporting to work. Understandably, during the course of the day they may get stained, but you can still tell they are part of the nursing team.

The attire of doctors over the years has been evolving. From a time where once the white lab coat was their trademark with a stethoscope around their neck, and having a bit of an antiseptic, clean smell from the frequent handwashing with germicidal soap to their current wardrobe. Unfortunately, many New generation doctors wear conventional street clothes, and the only visible item to distinguish them as a doctor is their stethoscope, and normally a badge, making it difficult to differentiate them from patients, general staff, family or visitors. To further raise concerns and confusion, is that many of the newly minted doctors often look very young, so it is difficult for older patients, and their family/caregivers be comfortable in sharing and discussing certain personal, sensitive information and grasp that the youthful looking individuals are both trained and capable in managing their condition (perception management). Some doctors even come to work wearing clothes as if they came directly from a party or some other activity, which makes the situation more complicated. While medical staff dress code requirements may be changing, there should still be clear standards drawn up by the Medical Board, that all must comply to project a proper image of themselves and the important roles they perform, to promote confidence with the patients, caregivers, families, and organization to gain and be given the respect they deserve.

Clinical support staff (Lab Techs, Imaging, Pharmacists, Dieticians, Therapists, etc.,) tend to be the most identifiable as they all normally wear a Lab coat with their identification, so they meet most patients, and caregivers expectations as professionals.

Finally the administrative group must always be dressed conservatively, particularly those interacting and in direct contact with patients or their families to present a professional, and responsible appearance.

3 In the service related industry, a SMILE, is Free to Give and generates INTEREST AND APPRECIATION but costs much if saved, resulting in DEPRESSION AND RECESSION, primarily your own.

This observation is often given by patients while making complaints, particularly when they perceive they are being given less than the required level of attention they believe is deserved. How many times have we heard, so and so always showing a black face; so and so does not acknowledge or recognize me, and I have been standing in front of them for so long; so and so begrudgingly gave me service and did not appear happy about it; or many of variants of the same theme.

Basically we need to teach all the front line staff, or any staff having face to face contact with patients to display a more cheerful, but a situation appropriate, countenance. This includes all level of staff, from the clinical side (e.g., doctors, nurses, assistants, therapists, aides, pharmacists, imaging, etc.) as well as, all the support staff (e.g., patient transport, kitchen and meal attendants, drivers, housekeeping/environment, laundry, building maintenance etc.), all the way through to the Administrative staff (e.g., Admissions, Business Office, Registration and Front Desk, to Cashier, Human Resources, Finance, etc.).

We must never forget helping and treating patients are the reasons the healthcare facility is in operation, and we have a duty to provide the best care possible given the resources available. Patients must always feel they are appreciated, and given recognition regardless of the conditions that brought them to seek healthcare services. As such, we should make every effort to offer a simple but sincere smile, with a how may I help you attitude to start building a relationship, and communicating. Failure to make a simple connection will often result in negative feedback being given, and usually containing a litany of many other items causing dissatisfaction which will result in a substantial amount of time and effort from many parties to placate and salvage a relationship. In the meantime staff involved/tasked with investigating and preparing responses become frustrated and they become depressed – always seeing the negative side of people.

4 Always give a Non-Attackable lead in explanation to any change, it will reduce negative comments and facilitate the change.

Change is always difficult, and it is made more difficult if one fails to be tactful and considerate when attempting to provide an explanation. Being aware that the initial reaction of the individual(s) involved will most likely be defensive, it is important to provide proper explanations that are both logical and to which one can relate.

Often time, the opening lines of the conversation must be structured to allow for listening for any feedback before offering any explanations or background conditions leading up to the necessity for change. For example,

The organization tries to manage costs at point of sale locations. A decision is taken requiring items to be paid or settled at the checkout counter, rather than the organization billing for the services. Billing adds additional backroom costs to collect the money, as well as contributes to bad debt which then results in higher costs for the service or product. As the organization, wishes to manage costs for the benefit of the patients or customers, it is easier to convey the reason or rationale for the change and then seek to obtain their understanding, but it may take a longer time for people to appreciate the underlying principles and develop an acceptance. However, this type of change should be followed after highlighting different methods of payments the facility has made available, such as: cash, tap debit cards, credit cards, new cashless bank payment features, applications (apps) using smart phones and other devices so individuals can appreciate the efforts.

Once this is done, attempt to obtain understanding from the individuals by asking questions structured to develop a series of yes responses. I am sure you do want the charges to be the lowest they can be?, You do understand that it costs more to bill and send out statements, i.e. accounting, printing, postage, manpower, bad debt?.

Another example. I once had an elderly (80++) gentleman come storming into my office to complain about the high cost of the pacemaker recently implanted, stating the hospital was overcharging and trying to take advantage of the patient, government, or insurance, whoever was paying. After listening to him, I shared the hospital obtained specifications and features for pacemakers from the cardiologist specialists, and then called for quotes from reputable manufacturers offering a range of different models that met the clinician’s needs. Qualified pacemaker brands and models were evaluated and made available to the Specialists for use in their procedures and ensure the best medical outcomes. After I listened to him and gave an explanation, I then asked him if he preferred a higher quality pace maker, versus a much lower priced one without features the Specialists wanted, or a pacemaker with marginal, poor, or unreliable outcome record for his implant. If the lower quality pacemaker failed to perform, then I told him we would not be having this conversation. He finally left with the comments he was only concerned about the high costs, and wanted to ensure patients were fairly charged which we appreciated.

The same principles can be applied to making changes to policies and procedures within the organization, as they should always be to provide clarity, consistency, and standardization in performing tasks and managing most situations. Front line staff must be kept informed and provided with necessary background information and armed with a series of Questions and Answers (Q & As) developed in advance to facilitate responses.

The same approach can be used for both face to face conversations, as well as, written responses to any query, it just needs to be structured to lead and create understanding.

There may still be individuals who still have objections. If so, ask the individual(s) to provide alternative, practical solution(s) that satisfy their objectives leading to the changes but must be fair and equitable to all parties, and not just their special interests.

You may be surprised, and obtain some great ideas!!

5 Avoid the use of negative words (no, not, regret to say, cannot) as much as possible whenever responding to patient/customer feedback, and PARTICULARLY in the opening lines.

Be careful when