Of Efficiency and Effectiveness

by Academy of Clinical Excellence on November 5, 2013

I have been to several meetings recently where the topic of discussion is ‘how we can be more like the Mayo Clinic’. Mayo Clinic is held as a paragon of efficiency. Patients are seen quickly, consultations are performed rapidly, and diagnoses are made universally. It is not surprising that Johns Hopkins would be interested in emulating their model of success.

However, the Mayo Clinic differs from Johns Hopkins in many key cultural aspects. If you talk to the clinicians from the Mayo Clinic; the culture and the way that they attack diagnoses is entirely different from what we do at Johns Hopkins. Most significantly, there is only a small Inpatient Service. While St. Mary's Hospital is nearby, it is technically separate from the Clinic itself and does not enjoy the same infrastructure. Second of all, the conceptual model of clinicians at the Mayo Clinic is, “we all practice the same,” and, “don’t do anything crazy.” Any clinician at Johns Hopkins knows that this is not the culture at this institution. Finally, patients apply to be seen at the Mayo Clinic. It is rare that a patient without insurance is seen, and patients can be turned away when there “is no other intervention to be offered,” based only on the review of the record. Johns Hopkins prides itself on providing the highest quality of care to any individual in need.

Not only are many of the cultural aspects different than those at Johns Hopkins; the Mayo Clinic has the unique infrastructure to excel as a highly efficient, clinical service. Their medical record system is excellent, outpatient consults can be obtained within a 24-hour period, tests are done and read in a very short period of time, and every patient leaves with a diagnosis, even if the diagnosis is simply the presenting complaint. In reviewing patients of mine who had been previously seen at the Mayo Clinic, I have found that an enormous battery of tests was performed and the diagnoses were often determined through “sheer brute force of testing.

The John Hopkins and Johns Hopkins Bayview are not an ultra efficient hospital. You cannot obtain complete outpatient consultations within 24 hours, or testing at a rapid rate with rapid interpretation of the results. This inefficiency seems at odds with our stance that we are the number one hospital in the country. But I think it is actually the explanation for ranking. Clinicians at Johns Hopkins Hospital are the best in the country at the “work around” and deal with multiple levels of inefficiency: scheduling inefficiency, testing inefficiency, consultation inefficiency, billing inefficiency, and grant administration inefficiency. But, by struggling to overcome these challenges, the faculty are more able and willing to “think outside the box”, troubleshoot, problem solve, and consider “crazy solutions” to clinical and administrative problems. It is this pressure that helps us innovate in a way the Mayo Clinic never has. This makes us an effective organization.

Schwinn can produce hundreds of bicycles at a low cost, and with decent quality. The old Italian man who labored in his basement painstakingly crafting the custom bikes for Lance Armstrong, worked at high cost with outstanding quality, innovation, and “out-of-the-box” thinking. Companies should be careful about switching from one type of service line to the other. The most recent example is Mercedes-Benz, who produced extremely high-quality luxury cars here in the United State. Presently, most people who buy luxury cars by Lexis or BMW, because there was a falloff in quality Mercedes-Benz as they attempted to increase the efficiency of their production at the expense of effectiveness. There are dozens of examples of this in the business world.

As a general rule, if you want to increase the number of a certain type of product, you make that creation of that product as efficient as possible. To that end, the application of grants and administration of research funding is one thing at Hopkins that should be of the highest level of efficiency. With the goal of obtaining as many funding opportunities as possible to allow us to carry out the cutting edge research that has made us great, the institutional application process should be as easy as possible rather than an added obstacle. Unfortunately, this is not the case for many departments. Our lack of efficiency in grants management is a cause for concern.

It is a private practice model to see as many patients, get as much testing, and bill at as high a level as possible for patient care. I see many patients for second opinions in my outpatient clinic. Increasingly, I encounter relatively straightforward diagnoses that can be determined through a comprehensive history and physical examination, that were missed by expensive and invasive testing. Private practice is, and must be, an extremely efficient process, seeing huge numbers of patients, making relatively simple diagnoses, and instituting treatments. Our role as a tertiary care center has always been the more careful evaluation of patients. The ability to think critically about our patients and narrow the differential prior to ordering a multitude of tests, has been a privilege that should not be taken for granted. Once the basic work-up is unrevealing, at that point we move forward with testing in a measured fashion, and with treatments that are outside everyone else's experience. This has always been our role. Increasing the number of patients seen, and approaching them with “brute force” efficiency, especially as second or third opinions, may decrease our overall effectiveness, and cause us to lose that we value most. This concept is in line wth Dr. Zeiglestein’s call to reduce expensive testing, I applaud this attempt not only at cost cutting but also to return us to our strengths.

 Before we consider changing our approach to patients and the fundamental concepts that have made this hospital the number one hospital in the nation for over 20 years, I would suggest a careful evaluation of which aspects within our institution we would like to be efficient, and those we must ensure are effective.

-Raf Llinas, MD

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