Donald Bellefeuille

Donald Bellefeuille

Healthcare Strategist, NBBJ, @dbellef
Donald is a healthcare strategist at NBBJ with over thirty years of experience working with healthcare institutions in developing strategies and plans to solve issues, create value, and grow and improve business performance. His own blog, The StratEx Crossroad: Where Healthcare Strategy and Execution Meet, is dedicated to advancing the healthcare strategy profession as it adapts to the faster pace of change in the new era of healthcare reform. Donald is currently reading his way through In Search of Lost Time, with the occasional time out to delve into popular fiction, science fiction and poetry. He can be followed on Twitter at @dbellef and promises not to tweet a lot about Marcel Proust.

Digital and Mobile Tech Are Part of Our Healthcare Future — But Not All of It

It Takes Both Digital and Analog Solutions to Increase Community Health and Wellbeing

February 6, 2017

Healthcare Strategist, NBBJ

@dbellef

Editor’s Note: At NBBJ, we’re at the forefront of using research and technology to drive breakthroughs in healthcare, from streamlining the design process with virtual reality, to incorporating digital analytics in healthcare planning. At the same time, we know technology isn’t the only tool for solving healthcare challenges — after all, studies show the most effective care occurs when caregivers themselves are satisfied.

This week, we’re highlighting some of the human factors that must be paired with data and technology in order to bring healthcare into the future. 

 

I had the opportunity recently to conduct a workshop in Montréal at the New Cities Summit, the annual gathering of the New Cities Foundation, an organization devoted to shaping a world where cities drive economic, social and environmental progress. The theme was The Age of Urban Tech, taking us beyond smart cities to a new wave of innovation. My workshop, the only one devoted to health, asked the question: Can digital and mobile tech increase the health and wellbeing of communities?

The answer is yes, technology can do a lot but the participants of my workshop were very clear about one thing: When technology is used it should serve the person by enhancing human interactions and help to alleviate the isolation that many folks feel when they are ill or disabled.

The participants were international and multi-generational. I broke them up into three groups to consider four distinct demographic scenarios and how mobile and digital technology, ranging from smart-phone apps to wearable health monitors to robotic companions to super smart houses and anything else they could imagine, could enable better health.

 

Several Common Themes Emerged

As the groups began reporting out several themes emerged that were common to all of the scenarios:

  • Human interaction, whenever and however possible, needs to be fostered. This is especially true for people who are ill and disabled. Because of the screen-to-screen nature of technology, it can sometimes lead to more isolation rather than less, by creating a false sense of connection. So while technology in all its forms is necessary to any solution, we have an obligation to ensure it serves human connections.
  • It will take everyone — governmental authorities, non-governmental organizations, local providers, advocacy groups and empowered people — to raise the level of health and well-being in communities. This includes an assurance that a solid infrastructure exists to enable technology to work flawlessly.
  • We must avoid the easy use of broad labels for groups, which only result in misaligned incentives and inadequate solutions. “Millennial,” for example, is an easy label to apply, but not all members of this generation are the same. They have different experiences, different cultures and different economic circumstances. The same can be said for every generation, so our solutions must be tailored to very particular circumstances.

 

How Can Technology Help?

Most participants were not concerned with all the technology that monitors human physiology and the environment. They knew from their own experiences that the technology exists, is steadily improving and will be part of our healthcare lives — whether it’s a simple application or something more robust, like telemedicine or a wearable monitor that would be prescribed in the same way a drug is prescribed.

However, participants’ interest in technology was focused around the theme of community-building. For example:

  • Increasing community participation that promotes healthy living. They envisioned an application that could gather people for informal play activities, working in green spaces and community gardens, and other outdoor activities. They were trying to create more spontaneity in both play and community gathering and take the “screen” out of their lives.
  • Deploying applications that allow people to report on environmental conditions. This was striking in the case of the dengue and Zika viruses where folks are now monitoring environmental conditions like standing water and other mosquito breeding grounds. This data is uploaded and maps are quickly generated so public health officials can act. And it empowers the individual to improve their own health by acting on their local environmental conditions.
  • Creating applications to quickly report symptoms that can distinguish between “normal” illness like a cold and more severe illnesses like flu and other high-risk communicable diseases. This will help prevent overcrowding at hospitals and track the course of the outbreak so preventive actions can be taken.

 

What Non-Technology Solutions Were Suggested?

But not everything will be solved with technology alone. Here are some other recommendations participants made:

  • Create food buses that go into food desert neighborhoods on a regular schedule with healthy choices at a reasonable price.
  • Reduce housing lot sizes in exchange for more community green spaces. In older neighborhoods continue the trend of creating pocket parks by recovering abandoned properties.
  • Create social mentorship networks to raise the level of personal and civic engagement. The decline of many civic and religious organizations has created more isolation, and the participants felt these networks could help in re-establishing the needed level of civic participation it will take to increase the health and wellbeing in our communities.
  • Incentivize population health by creating a public fund for initiatives that will decrease the incidence and prevalence of disease. This would be accomplished by a portion of private and public health insurance premiums going to the local community or non-governmental authority charged with implementation. In return, premiums and out-of-pocket costs would be reduced, benefiting private, government and patient payers.

 

Is there a gap between healthcare technology entrepreneurs and the people who use the tools they develop? Judging by the workshop, there is. Much of the technology that is being developed is purpose-driven and will succeed for its narrowly defined use case. The killer app, the one that will really drive increases in population health, is not available yet. Whatever it is, it will have to remove the artificial barrier that current technology creates and enable more human interaction.

Image courtesy of Geoff Peters/Wikipedia.

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Planning, Adapting to Rapid Change in Healthcare Design

Strategies to Future-Proof Hospitals Against Obsolescence

December 12, 2016

Healthcare Strategist, NBBJ

@dbellef

Ed Note: This post was co-authored by Donald Bellefeuille and Tim Fishking. It previously appeared in Medical Construction and Design.

The Hill-Burton Act was enacted in 1946 to increase the supply of hospital beds by providing construction grants to non-profit entities. It was very successful: Between 1947 and when funding ended in 1970, about a half-million additional hospital beds were added [PDF]. What the act didn’t, and couldn’t, anticipate were medical advances that slowly rendered the Hill-Burton version of the inpatient hospital virtually obsolete.

 

Hill-Burton era hospitals were not designed to adapt because there wasn’t much to adapt to.

Hill-Burton hospitals were a major improvement over what existed: cottage hospitals and facilities with open wards, for example. Many of the new hospitals offered double-bedded rooms and better operating and diagnostic facilities. These hospitals served their purpose well but didn’t lend themselves easily to retrofitting. Most chose to add onto existing facilities to gain more square footage and utility. Cost was no object, and adaptability was not a design feature: we just kept making more Hill-Burton-like facilities.

The 70s, however, began an era of medical technology advances that slowly made these hospitals obsolete. The first free-standing ambulatory surgery center opened in 1970, at the very end of the Hill-Burton era and, while many hospital surgical departments adapted to this change and grew their outpatient surgery business, the inpatient admissions they lost were never recovered.

 

We are now in an era of rapid change, and more is coming.

Today, technological and financial pressures are shuttering inpatient units, closing hospitals and, in many markets, consolidating inpatient care into academic medical centers. And these old facilities are not easily adaptable. Consider that:

  • Single-bedded rooms, deemed better at preventing the spread of infection and offering a better experience, are practically a requirement.
  • The migration of inpatient surgery to the outpatient setting has accelerated to the point that even a lot of outpatient surgery is now office-based.
  • The need for a physician to go to the community hospital to see patients, get information or even collegiality doesn’t exist. Much better and more accurate medical knowledge is available online and increasingly built into the electronic health record, hospitalists see inpatients and collegiality is built around organizations that manage at-risk contracts.
  • Machine intelligence and robotic systems will take over more and more routine logistical functions in hospitals.
  • Knowledge systems like IBM’s Watson will perform more diagnostic work.
  • Active and passive clinical robotics will quicken inpatient and outpatient operating and recovery times, rendering overnight stays, and even the less-than-24-hour stay, unnecessary.
  • Super urgent care and free-standing emergency rooms are replacing many of the functions of the traditional hospital-based emergency department.
  • Even research and training are not immune. Dry research is superseding wet research. As the new virtual world of healthcare becomes a reality, researchers will spend more time on the data generated from personalized sensors and computer modeling than on traditional animal studies. Research hospitals will struggle to adapt. We will need to produce more medical data scientists, and their residencies won’t take place in a hospital.

 

Inpatient hospitals aren’t going away.

Even so, we still need hospitals with beds:

  • Individual traumas will happen, requiring hospitalization.
  • Major emergencies and disasters will occur, requiring facilities to treat people.
  • There will be very sick people with multiple diseases that need intensive care.
  • Treating people with highly infectious diseases requires isolation.
  • Given the advances in healthcare nanotech, future hospitals will need to have a higher level of bio-containment than ever before to ensure this nanotech doesn’t leak into the environment.
  • Almost all births will continue to be in hospitals.

 

Let’s build obsolescence into our new healthcare facilities

If we must still build hospitals, they must be adaptable and able to anticipate their own obsolescence with the infrastructure to adapt and change rapidly and economically. By adaptable, this doesn’t mean designing facilities that can be added onto in a coherent way—we know how to do that. It means designing facilities where whole units, departments or functions can be easily replaced in situ without additional square footage.

We have advanced architectural, engineering and construction techniques that enable pre-fabrication and modularization. Operating and procedural rooms of all types can be assembled and reassembled easily now with no loss of infection control and utility. Wireless technology further enables this. We can take lessons from the military and how they have containerized just about everything, including patient beds and operating rooms. We need to think more about plug-and-play units, a decade at a time, housed in a shell built for the long term.

 

Designing Adaptability and Flexibility in Room Utilization and Facility Design

We need to move past the traditional view of a building as a static object, and instead explore opportunities for designing a building as an open-ended framework of integrated components. By developing a component logic that is highly standardized, demountable and multi-functional, key areas within the framework can be repurposed, reconfigured or replaced as requirements evolve. This reduces the likelihood of future disruption and waste and increases the potential lifespan of the entire project — a breakthrough in terms of lifecycle sustainability.

Elements of this integrated infrastructure strategy might include:

  • Permanent infrastructure elements, such as public circulation (horizontal and vertical), mechanical and electrical service areas and shafts or risers, located at the periphery of large and regular floor plates that are free of major obstructions
  • Open floorplate areas based on uniform modules of space suited for many different functions
  • Universal rooms sized and configured to accommodate a range of uses
  • Modular and/or movable casework and systems furniture

Bad adaptations serve no one well, neither patients, nor visitors nor the caregivers who work in the hospital. An adaptable and flexible hospital can future-proof itself against obsolescence, changing as healthcare changes and organic to the requirements necessary at any particular point in time.

Image courtesy of NBBJ.

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What Hospitals Should Do Regardless of Who Is Elected President: General Election Update

Now that Hillary Clinton and Donald Trump Are the Nominees, What Can We Expect in Healthcare?

August 1, 2016

Healthcare Strategist, NBBJ

@dbellef

Editor’s Note: This post was originally published in The Hill.

Now that our presidential nominees are set and the general election has begun, what do our nation’s hospitals and health systems need to do, whether Secretary Clinton or Mr. Trump is elected in November? They, and their parties, offer stark contrasts, but what will they mean for hospitals?

 

Hillary Clinton: Keep, Improve and Expand

Clinton would expand Obamacare by allowing a buy-in to Medicare starting at age 55, offering a public health insurance option and continuing the drive for Medicaid expansion. The Democrats would make care more affordable by expanding a system of subsidies for the commercially insured and mandating that insurers lower premiums and deductibles.

The Effect: Consolidations and closures will continue, and nontraditional partnerships will increase.

  • The movement of reimbursement away from traditional hospitals and the leveling out of reimbursement across all payers will continue, and healthcare will disaggregate into ambulatory settings, the home, and even on and within the person — in the form of wearables and ingestible sensors — to provide lower-cost healthcare close to the patient. Hub hospitals that command large healthcare systems will survive, and some will expand.
  • Digital health, in all its emerging manifestations, will thrive as new, nontraditional providers enter the market to leverage the incentives Clinton’s policies will create, putting additional pressure on traditional healthcare providers.
  • Population health, the movement to increase the health and wellbeing of specific communities and reduce disparities in healthcare, will continue to evolve in partnerships with private, public and non-governmental organizations.

 

Donald Trump: Repeal and Replace

Mr. Trump has adopted the Republican platform, which eliminates Obamacare and replaces it with consumer-based insurance plans. These are enabled by a series of tax, insurance and government payer reforms that incentivize the free market to reduce healthcare costs and put the customer-patient in charge of their healthcare. It converts the federal Medicaid subsidy to a block grant with fixed payment amounts.

The Effect: National and super-regional consolidation of healthcare providers and payers will accelerate.

  • National and super-regional healthcare provider systems, in an effort to avoid having to accept any price for a service, will create hub-and-spoke models with distinct characteristics, some seeking the broad middle market, others the upper echelon.
  • Commercial insurance plans, seeking to maintain their leverage with national and super-regional providers while meeting the demands of the customer-patient, will develop an array of products targeted to very specific customer-patient groups.
  • As customer-patients become actual buyers of healthcare, cheaper forms of care, enabled by digital health, will develop further. They will be fostered by payers trying to undercut the efforts of providers who offer these alternatives, in an effort to maintain leverage over those providers.

 

What Can Hospitals Do Now?

Regardless of who gets elected, hospitals can do certain things immediately to improve the health of their communities and boost their bottom lines:

  • Accelerate the development of lower-cost ambulatory and digital healthcare offerings. We are moving inexorably toward a future where healthcare is highly distributed in the community, the home and the person.
  • Hold your physicians close. Under either party, physician reimbursement will change, and care will move out of the hospital, leaving less reliance on traditional settings and organizations. Be aware that physicians have more leverage and access to capital than ever before and could easily form their own care organizations.
  • Form more partnerships with community organizations and others who have deep interests in improving community health. Whether we end up with macro-population or micro-population health, community organizations will be part of the solution.
  • Seek greater operational efficiency and reduce your costs while increasing reliability and quality. Efficiency and quality go together, and we must raise the bar on both. Technologies and systems now exist in healthcare that can do this, and they should be applied to hospital and ambulatory care alike.
  • Monetize and/or repurpose obsolete buildings. Space that is not producing revenue is a negative on your books, and you should address this sooner rather than later. Consider telemedicine centers, affordable housing and community living centers, or healthy food outlets.
  • Rethink your customer-patient experience. Patients expect to be connected throughout their care journey and for all transactions to occur seamlessly. They do not expect to have to fill out three forms and sit in a waiting room, no matter how nice it is, to get care or to march down long corridors, even with the best wayfinding.

Elections matter, and while we may not see all the changes proposed by either candidate fully implemented, healthcare providers need to prepare now. These six action steps will go a long way to getting ready.

Image courtesy of Diego Cambiaso/Flickr.

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Forget the Driverless Car — What about the Driverless Doctor’s Office?

When We No Longer Have to Drive, We Can Spend Time on What Really Matters, Like Health

May 17, 2016

Healthcare Strategist, NBBJ

@dbellef

Editor’s Note: This is the second post in a four-part series about the impact of driverless cars on design and planning. On Monday, Alan Mountjoy reported how BMW is planning for a disruptive future; on Wednesday, architects and planners from NBBJ shared some surprising impacts on a wide variety of topicsOn Thursday, Alex Krieger looked at the potential downside of increased congestion.

 

I can picture the future already… I love my driverless car. Since I bought it and joined the growing ranks of commuters on the driverless-car-only lanes my stress levels have reduced and my commuting time has decreased, giving me more time with my family. They have noticed the change in me, and my work productivity has increased.

As a group driverless cars are more efficient and travel at higher speeds with no accidents. That’s not the only change: The corridor along the highway, once a dead space filled with noise and pollution, has become a cleaner, quieter place because these cars are electric. Local residents are beginning to use this linear space more for outdoor activities, and they’re getting healthier — the continuous air and noise monitoring has proven it. The city is now looking at recovering major portions of this space for local parks and recreational activities.

Now that I have some free time in my car, I scheduled my annual check-up for this morning’s commute — in my car. My wearable health monitor connects automatically to my car’s system, and my seat measures my weight and several other things. Right on time, my large screen monitor activates and my nurse practitioner is on the line. He has already downloaded all the information that is being monitored, and it is there on the screen for both of us to discuss. The car’s high-resolution camera is also doing a facial scan and comparing it to previous scans to determine if there are any other physiological indicators that have changed. Because of my reduced stress levels, my blood pressure medication is being reduced; the new prescription will be waiting for me at my office, delivered via secure drone.

I have not been in a doctor’s office in years and neither have many of my friends. The availability of telemedicine everywhere, even in your car, has turned the entire notion of routine and urgent care on its head. Many of the medical office buildings that were built during the ambulatory construction boom of 2015–2025 are now being renovated for residential use — and those apartments incorporate less parking too.

Image courtesy of Pexels.

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What Hospitals Should Do Regardless of Who Is Elected President

The Leading Presidential Candidates Differ on How They Would Change Healthcare, but There Are Some Things in Common that Hospitals Can Act on Now

February 25, 2016

Healthcare Strategist, NBBJ

@dbellef

Editor’s Note: This post was co-authored by Donald Bellefuielle and Teri Oelrich. It previously appeared in The Hill.

Our current slate of likely presidential candidates offer differing views on the future of the Affordable Care Act (ACA) and the future of healthcare, but their ideas do not split perfectly into a Democratic view and a Republican view. Based on their written and public statements, here’s how each candidate might affect healthcare and the ACA:

 

Repeal and Replace with Universal Healthcare

Senator Sanders and Mr. Trump are the most radical and, surprisingly, almost completely aligned:

Senator Sanders advocates a universal, single-payer system, “Medicare for all”: his plan covers everything, including nursing home care. He would finance it through a variety of new and existing revenue streams, and employers would still contribute their share.

In his first public statement on the issue, Mr. Trump said he would make healthcare cheaper and better by making deals with hospitals and using those savings to finance universal coverage. More recently, in a South Carolina town hall, he vaguely referred to Medicare expansion and perhaps making commercial insurance national.

The Effect: Almost everything would change.

  • Much more care would move to less costly ambulatory and digital health settings.
  • More emphasis would be placed on “hub” hospitals that provide higher levels of acute care.
  • Many traditional community hospitals that care for low-acuity patients would evolve into ambulatory centers for advanced care. Inpatient beds would occupy less space to keep capital and operating costs low.
  • Population health and its social determinants would receive greater emphasis. Organizations of all types would have greater freedom to develop healthy initiatives.

 

Partially Repeal and Replace with Market-Based Healthcare

The more traditional Republican candidates offer a range of replacement options:

Senator Cruz advocates opening insurance markets across state lines, expanding health savings accounts and delinking health insurance from employment. His reforms are aimed at the commercial insurance market.

The Effect: National consolidation of healthcare providers and payers.

  • National provider and insurance systems would develop, creating hub-and-spoke healthcare systems with distinct characteristics, some seeking the broad middle market, others the upper echelon.
  • Many systems will have multiple offerings, and their hospitals and ambulatory settings will reflect this in look and experience.

Senator Rubio would reform commercial insurance with a market-driven alternative that would expand coverage and lower costs. But he would still keep it state-based. He claims he would improve Medicare and Medicaid without saying how. He would also end aspects of the ACA, cutting Medicare Advantage, the medical device tax and taxes on health savings accounts.

The Effect: Regional consolidation of providers.

  • We’ll see further regional consolidation of healthcare providers and more hospital closures, but “hub” hospitals will thrive as inpatient volume is funneled to them.
  • Cheaper forms of care like urgent care and digital health will develop further, as consumers become actual buyers of healthcare; negatively, consumers may defer needed care.

 

Keep and Improve

Secretary Clinton is in the “keep and improve” camp. She would expand affordable coverage, slow the growth of overall healthcare costs (including prescription drugs) and help providers deliver the best care to patients. How? As far as we can tell, by ending fee-for-service reimbursement. She also emphasizes digital health, especially for rural areas, as an affordable and accessible care option.

The Effect: Consolidation and closures will continue at a faster pace.

  • As under Cruz and Rubio, “hub” hospitals will thrive and expand.
  • Digital health will thrive.
  • New non-traditional providers will enter the market to leverage the incentives Clinton’s improvements will create.

 

What Can Hospitals Do Now?

Regardless of who gets elected this November, hospitals can do certain things immediately to improve the health of their communities and boost their bottom lines:

  • Form more partnerships with community organizations and others who have deep interests in improving community health.
  • Accelerate the development of lower-cost ambulatory and digital healthcare offerings; we are moving inexorably toward a future where healthcare is highly distributed in the community, the home and the person.
  • Seek greater operational efficiency. Efficiency and quality go together, and we must raise the bar on both. Technologies and systems now exist in healthcare that can do this, and they should be applied to hospital and ambulatory care alike.

There is no greater patient experience than receiving highly reliable care at the lowest cost possible. That should continue to be care providers’ top priority, regardless of who occupies the Oval Office in 2017.

Image courtesy of PBS NewsHour/Flickr.

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Are We Creating Hospital Deserts?

Why Local Hospitals Are Closing, and What to Do About It

January 26, 2015

Healthcare Strategist, NBBJ

@dbellef

If you’ve been following the news you know that Critical Access Hospitals (CAHs), hospitals with 25 beds or fewer and located in isolated areas, have been struggling mightily in the new era of health reform. It seems this valuable resource may be headed for extinction. Modern Healthcare reported that critical-access hospitals saw 14 closings in 10 states last year. Overall, there are 1,321 critical-access hospitals in the country in 2014, down from 1,332 in 2013.

It’s not just CAHs that are affected. Urban safety net hospitals, the ones that care for a disproportionate share (DSH) of Medicare and Medicaid patients, are heading this way. The latest to report layoffs is Harris Health in Houston. Even more disturbing, here in Massachusetts two significant hospitals, Quincy Medical Center and North Adams Regional Hospital, closed suddenly and another publicly discussed the deteriorating financial conditions that may cause it to close. These were not critical access or safety net hospitals.

A number of forces are causing this. First and foremost is the reduction in DSH and uncompensated care payments. Increased insurance coverage and expanded Medicaid from the Affordable Care Act were supposed to supplant this, but unfortunately several states are not expanding Medicaid even as DSH payments decline. Then there was sequestration two years ago, which resulted in a permanent reduction in Medicare payments to all hospitals. Add to this the financial penalties Medicare has adopted for things like preventable readmissions and hospital acquired infections, and all hospitals regardless of status have been weathering a severe financial storm that is not abating anytime soon.

Inpatient utilization is changing too: care innovations, changing reimbursement incentives and technological advances will move more and more patients out of the hospital bed. This may be mitigated in some areas with a growing population, but not by much, if at all.

Because our ability to do more things on the outpatient side has increased, we really don’t need small and inefficient facilities that can’t keep up with the technology now required to provide basic inpatient care. I’ve seen proposals that these facilities should simply be freestanding emergency rooms that “pack and ship” to larger facilities.

But even providing this lower level of care and other ambulatory services requires some sophisticated knowledge these days. And many folks forget that even the most endangered rural and urban hospitals are part of our emergency response and disaster preparedness system. Without them we quickly lose a fundamental ability to respond to anything.

Are we creating hospital deserts? It depends on what you think a hospital is. In some respects hospitals are public utilities, always present and ready to respond. In other respects, especially in this new era of health reform, they are cold, hard businesses that must ensure they are financially viable; that means shutting down services and whole facilities if necessary. In other respects, we simply don’t know what a hospital is any more. The hospital of the future is more likely a number of different facilities providing services like intense acute care, intense ambulatory care, critical access and telemedicine.

We don’t have policies that address any of this right now. Instead we are letting the market decide how it all will shake out. It certainly lets policy makers off the hook, but if access to healthcare in rural and urban areas is reduced as a result, or our ability to deal with emergencies and disasters is compromised, then what?

I think we need to not only maintain a basic inventory of critical access hospitals in rural areas, but also expand the concept to urban areas so hospital deserts are not created. I have several possible solutions for this:

  • The emerging super-regional and national hospital systems should be required to maintain some of this inventory in exchange for allowing them to grow in size and scale.
  • We should leverage our VA system to also be part of this system. I know the VA has had its share of troubles lately, but they are a resource and they are national.
  • Finally, I would start looking at creating some basic primary acute care capacity in nursing homes. This would require changing a lot of physical and operating standards, but we need to consider it. Nursing homes are local, more local than hospitals, and they could serve a valuable role in our emergency and disaster preparedness response system.

We need to do something soon. A policy of not-so-benign neglect that creates hospital deserts is no strategy at all.

Image courtesy of Rod Ramsey/Flickr.

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When Will a Robot Replace Your Surgeon?

In the Hallway or the Operating Room, Automation Will Soon Be an Everyday Part of the Hospital

October 2, 2014

Healthcare Strategist, NBBJ

@dbellef

If any industry is ripe for a rapid robotic evolution it’s healthcare. It’s a data-rich environment, filled with a lot of simple, repetitive tasks on the one hand, and many finely-skilled tasks that are carried out intermittently on the other. What are robots good at? Doing one function millions and millions of times with absolute precision, or doing very precise, complex procedures occasionally.

On the simple side, imagine small swarm robots cleaning your healthcare facility. CNET recently reported on Termes, “a collective system of autonomous robots that can build complex, three-dimensional structures such as towers, castles, and pyramids without any need for central command or dedicated roles.” Robots like these can easily be modified to effectively clean healthcare spaces and equipment that need a high degree of disinfection. They could get into the nooks and crannies that human-based systems cannot.

Imagine a swarm of them divided up into special purposes. Some have arms especially designed for tiny crevices, some have little vacuums, some have cleaning fluid and scrubbers, others have driers, and some have infrared radiation or one of many other features. A swarm of hundreds could clean a room and make a bed faster and better.

Now imagine another swarm of them in the room where you clean your IV poles and pumps. The pumps move into a chamber and the special purpose swarm robots go to work. And because the poles will also be robotic, they will transport themselves to a clean room while they await orders for their next assignment.

Before you get too antsy (pun intended) about seeing robot swarms throughout your hospital, this will all happen behind the scenes. Facilities will be redesigned to include swarm ductwork that brings these devices to rooms unseen by staff, patients and visitors. When a room is ready to be cleaned, a small door will open in a back wall; in they come and out they go, cleaning the ducts along the way.

Robots will not be limited to these tasks. The necessary precursors to autonomous surgery are in many operating rooms now. Computer-assisted orthopedic surgery is not unusual these days, and the systems use a variety of image mapping to guide robotic instruments. And while da Vinci remains somewhat controversial, the machine certainly has the ability to move from human-operated to autonomous. Going one step further, NASA is developing a surgery system that will be operated by astronauts in space. It’s targeted for emergency use but you can see how this will advance technology here on earth.

It won’t take much for these systems to go from semi-autonomous to autonomous and it will happen in increments. First the “surgbot” will do openings and closings by itself, then some internal suturing, and maybe an excision here and there. As the technology advances the bot will take on more and more. And because it is more precise and operates at microscopic detail, our ability to fix more things will increase.

A robot’s learning curve is almost immediate. Program the machine once, test it thoroughly, and off it goes, whether it is building or driving your car, vacuuming your rug, drawing and analyzing blood, cleaning and disinfecting an OR, preparing and delivering a patient’s food, or operating on a patient without remote guidance. Healthcare will be profoundly changed as a result — it could even pose a solution to the physician and staff shortages that presumably will result from Baby Boomers entering old age. Only our imagination limits the potential.

Image courtesy of Eric Schmuttenmaer/Flickr.

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The Uncanny Valley of Healthcare

If Robots Are Going to Transform Patient Care, They Can’t Appear Too Human

September 30, 2014

Healthcare Strategist, NBBJ

@dbellef

I fully expect that at some point in my life I will be cared for by a robot.

I am not talking about human-guided machines like the da Vinci surgery tool. That is not a robot. It is, in principle, the same as that arcade machine in which you guide a mechanical grabber to get a stuffed animal. da Vinci needs a human operator, robots do not.

No, I’m talking about something like RIBA, the Japanese robot bear, designed to carry elderly patients to and fro. Or Pepper, an emotionally responsive robot or “emotibot” — you can just imagine its uses in geriatrics and behavioral health as a companion and comforter, replacing alert medallions and medication reminder systems, and providing remote monitoring. And there’s also Dinsow, another type of elderly care robot.

Then there’s this robotic nurse, which crosses the line into the uncanny valley, that place where robots look as close to a human as possible — but not close enough. I get completely creeped out about it. I don’t want this thing caring for me.

And that’s the problem healthcare poses for robotics. Patient care always depended on making a human connection, but designing very human-like robots to care for us won’t work. We’ll reject them because they are just way too close to us, and yet not us. That’s why RIBA, Pepper and Dinsow purposefully have an anime style to them. We know they’re not human, but they are not-human enough for us to accept them and allow them to care for us.

I recognize that many of us are not comfortable with the notion of any robot caring for us, but as Dr. Louise Aronson, a noted researcher in geriatric medicine, says, “In an ideal world each of us would have at least one kind and fully capable human caregiver to meet our physical and emotional needs as we age. But most of us do not live in an ideal world, and a reliable robot may be better than an unreliable or abusive person, or than no one at all.”

Isaac Asimov famously created the Three Laws of Robotics:

  1. A robot may not injure a human being or, through inaction, allow a human being to come to harm.
  2. A robot must obey orders given it by human beings except where such orders would conflict with the First Law.
  3. A robot must protect its own existence as long as such protection does not conflict with the First or Second Law.

For healthcare, I would add one more:

  1. A robot must not look human.

Robots have to function in a human-built world, so they will necessarily take on certain anatomical characteristics to carry out those functions. But they should not be so fully human that we reject them completely.

Image courtesy of Horia Varlan/Flickr.

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Understanding Population Health

Are You Working to Keep People Healthy? Here's How to Find Your Place in the Crowd.

July 9, 2014

Healthcare Strategist, NBBJ

@dbellef

“Population health” is one of the most widely used and least understood buzz-phrases in healthcare today. You can just imagine some CEO calling the Chief Strategy Officer to the corner office and asking him or her to explain the organization’s population health strategy. I’m betting ten such conversations result in ten different explanations.

For some, population health encompasses the broad determinants of acquiring and sustaining a healthy lifestyle; for others it’s the treatment and prevention of the very chronic diseases that were acquired because the basic building blocks of a healthy life were not available. Then there is the notion that population health is managing a very specific population — diabetics, for example —within a larger panel of patients or, for a manager of an Accountable Care Organization that has taken on the financial risk of treating patients, the top 1–3% of the “super-utilizers” of services they are trying to bring up to some level of health.

It’s a quandary many of my colleagues in the strategy and planning business face every day: many well-meaning and passionate practitioners have very good and solid reasons to invest in the wellbeing of their populations, yet resources are scarce. The strategist has to take all this in and bring purpose and cohesion to it all so good decisions can be made.

To help, I created an initial attempt at a broad classification of the different aspects of population health. Once an organization classifies what kind of entity it is, it can determine the types of patients in which it should invest its efforts, based on an objective classification rather than trying to serve a variety of competing interests. It can also guide efforts in developing partnerships to either co-care for particular populations or align different populations in one continuum.

Toward a Taxonomy of Population Health

Responsible Entity

All Jurisdictions:
Public Health

Health Insurance Plan:
Member Health

Health Provider:
Patient Health

Role

Primary and secondary prevention of major diseases — obesity, diabetes, cancer, heart disease, etc. — addressed though public initiatives.

Federal direct research and funding of research and NGO participation included.

Addresses the specifics of maintaining a healthy lifestyle and offers incentives to do so.

Manages the care of the member in all settings (can be outsourced to health providers take on risk).

Direct care of specific patient groupings that require a licensed provider to treat.

Geographic Reach

National, regional, local depending on population health profile

Insurance plan market area

Local market

Patient Risk Profile

(Percentages reflect low, rising, and high risk only. Source: The Advisory Board)

  • At risk but no active disease
  • Low risk (60%-80%) minor conditions are easily managed
  • At risk but no active disease
  • Low risk (60%-80%) minor conditions are easily managed
  • Rising Risk (15%-35%) may have condition not under control
  • High Risk Patients (5%) with complex disease and comorbidities
  • Rising Risk (15%-35%) may have condition not under control

 

The chart begins to lay out who does what, to whom it is done, and where it is done. With further development from some budding Linnaeus, it can be really specific about sub-populations within the broader classes. Of course, as strategists and planners we are not creating the health protocols a specific population will need, but we certainly are designing the overall operational and physical structure required for the population’s care, whether in a community setting or a facility. Because such a broad range of settings are possible, we need to broaden our scope and incorporate elements of facility and urban planning.

Find your organization’s place in population health by asking some basic questions: Who are we serving? Where are they located? Why are we serving them? What are their primary and secondary diagnoses? What services do they use? Do we have services close to them or do we make them come to us for care? Are we good at serving them? Can we be the best in our market at serving them? Who else do we want to serve? Why? Can we be the best in our market at serving them? Who don’t we want to serve? Why?

The answers will guide you to your place in the taxonomy and set you on the path to your strategic design. And guess what? It’s not really a population health strategy anymore. It’s The Strategy: the one goal that aligns all elements in your organization because of its far-reaching consequences.

Image courtesy of Flickr.

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Are You a Strategic Planner or a Strategic Designer?

How One Simple Word Can Redefine Our Approach to Healthcare Strategy

May 28, 2014

Healthcare Strategist, NBBJ

@dbellef

In a lot of ways healthcare planning has turned into a checklist profession. Accountable Care Organization? Yes, check. Patient-Centered Medical Homes? Yes, check. Chief Patient Experience Officer? Yes, check. And so on. We populate our plans with the requirements du jour rather than understand, in a holistic way, a designed way, what it all means.

My profession — healthcare planning — is only beginning to understand what design means as opposed to planning. Our plans often “sit on the shelf and gather dust,” yet people rally around designs and execute and adopt them. We typically think about designing products and buildings but have you ever considered that we should be designing strategy? Good design can be applied to strategy and its associated goals, objectives, and actions just like any other product or process. It’s a different way of thinking, and we are only now coming to understand it.

For instance, the iPhone is considered a hallmark of design because its sleek exterior and interface engage some underlying electronics and code that work seamlessly together to accomplish its purpose. The phone’s code is not physical though. While it may manifest itself physically in sounds, images, and tactile feel it is simply a set of goals, objectives, and actions designed in bits and bytes. I’m sure Apple could display that code visually in such a way that we would recognize how beautiful the underlying design is but the exterior speaks for itself.

Similarly, architects design buildings, they don’t plan them. And yet within each building is a plan, or code, if you will, for the structure to accomplish its purpose: how each individual space relates to all the other spaces, the vertical and horizontal circulation, energy consumption, access and egress and so on. Said another way, these are the goals, objectives and tasks that underlie the physical structure you see on the outside. The most successful buildings have a design that let you know right away that everything, inside and out, works elegantly together.

Why should healthcare strategic planning be thought of any differently?

Let’s compare the words plan and design visually:

Plan-Design

Design sits at the center of a universe that is twice as big as plan. It has words like aim, purpose, intention, conceptualize, and invention at its heart. Plan lives in a small solar system with a limited set of words like program and project associated with it. According to the dictionary a plan is a set of actions that have been thought of as a way to do or achieve something. To design, on the other hand, is to plan and make decisions about something that is being built or created. While the words are often considered synonymous, there is a big difference in intent and action. Plan implies a certain amount of passivity; the plan may or may not get implemented in whole or in part. Design implies action and movement and a cohesiveness that all parts of the design work together.

And like that iPhone or building it’s possible to visualize your strategic design. Recently on my own blog I talked about creating scenarios in a much more visual context to simplify complexity and reduce uncertainty. I suggested using 3D computer modelling to accomplish this. It is no stretch to take a finalized version of the strategic design that comes from this process and produce a physical model of it on a 3D printing machine.

This is a very visual way of thinking, and although I was not trained that way — and neither were most of my colleagues — it is simply a different and better way of thinking about complex matters in a complex environment. Imagine a strategic design that you can hold in your hand. Done right it would serve the same purpose as that phone or building and your volunteers, employees, and leadership would be able to understand it almost intuitively.

So maybe it’s time we designed healthcare strategy. Regardless of the tools or the terminology, the question remains the same: what, ultimately, is the aim, intent and purpose of strategic design, and how can we fashion and move an organization forward according to that design?

Banner image courtesy of Flickr.

Visual thesaurus created using TH!NKMAP.

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The Death and Life of Great American Healthcare

How Jane Jacobs’ Urban Design Insights Can Improve Healthcare Strategy and Planning

April 24, 2014

Healthcare Strategist, NBBJ

@dbellef

In college I was inspired by the book “The Death and Life of Great American Cities” by Jane Jacobs, and I think much of what she taught in that book applies today to healthcare strategy and planning.

About planning, she said, “The pseudoscience of planning seems almost neurotic in its determination to imitate empiric failure and ignore empiric success.” Ouch, that cuts right to the bone, doesn’t it? Of course she was referring to urban planning, but I think the criticism applies to healthcare planning as well. How often do we in health planning and strategy simply copy, or react to, what other folks are doing? Even if what they are doing isn’t all that good. Admit it, we do it all the time. And this is one of the reasons why all our organizations look the same, why our marketing is not very effective, and why it’s hard to achieve competitive advantage.

Jacobs had four urban planning principles, each of which can be adapted to health care. (I will add healthcare words in parentheses to show how these principles can be translated to our discipline.)

  1. “The district (healthcare provider), and indeed as many of its internal parts as possible, must serve more than one primary function; preferably more than two.” In our world I’ve always taken this to mean that we have to embed our functions into the neighborhoods we serve rather than making the neighborhoods come to us. This is ironic because that is how health care began. Your doctor was in your neighborhood, and a lot of communities had their own hospitals. But as healthcare changed we consolidated more and more functions to singular locations that served the provider well but not the patient. We talk a lot about scale these days, and I think we are blindly applying that to the buildings we erect. CVS has scale, but they know how to distribute it to where their customers are. We need to get back to this in healthcare and put our services in with other services. In my neighborhood the CVS is next to the post office, dry cleaner, hardware store, etc. I’d love it if my primary care provider was there too.
  2. “Most blocks (healthcare buildings and departments within them) must be short; that is, streets (corridors) and opportunities to turn corners must be frequent.” Jacobs’ point is that long streets breed neighborhoods that cut people off from each other and from the services they need. It creates sterile areas prone to crime and blight. Short streets and blocks provide natural gatherings and crossing spots that bring people and services together and provide vitality. Traditional hospital buildings, and now some of these huge ambulatory buildings, are plagued by the same things. By pulling services out into smaller neighborhoods we can create a wholly different, and wonderful, feeling in our facilities. And I bet patient satisfaction will increase.
  3. “The district must mingle buildings (departments) that vary in age and condition, including a good proportion of old ones so that they vary in the economic yield they must produce. This mingling must be fairly close-grained.” This is a follow-on to Principle 1. She was arguing here that not every function can produce the greatest economic benefit, but yet there are functions that are crucial and must be supported. So in healthcare we want to be careful to keep that department that does not produce a return in good company with departments that do. If you isolate the not-so-good service from everything else, you magnify its losses and people will begin to question its usefulness. These departments often include behavioral health, obstetrics and breast care, considered low-margin, but mission-sensitive, service lines.
  4. “There must be a sufficiently dense concentration of people (patients) for whatever purposes they may be there for…” I think this speaks for itself. We are probably taking it too far with our big buildings that are getting even bigger. Jacobs uses the word “sufficient,” which means enough or adequate according to my dictionary, on purpose. I wonder how our planning would change if we did sufficiency studies when planning new buildings instead of trying to stuff as much as possible in them?

Consider one final quote from Jacobs, with a couple of little changes in brackets: “There is no logic that can be superimposed on the [healthcare organization]; [patients] make it, and it is to them, not buildings, that we must fit our plans.”

Imagine changing the way we do things by involving patients from the ground up, rather than from the building down. Let’s ask them where, how, and when they want their healthcare provided. Let’s allow them to tell us how they run their lives and how we should fit into that. I bet we will be surprised by the results.

Image courtesy of Flickr.

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Swat the SWOT

Once We Stop Focusing on Threats, We Can Begin to SOAR

March 25, 2014

Healthcare Strategist, NBBJ

@dbellef

The SWOT analysis is a part of any strategist’s tool kit. SWOT, of course, asks an organization to identify its Strengths, Weaknesses, Opportunities and Threats. Yet, imagine starting a conversation with someone, when half of what you want to discuss is negative in nature. It’s a tough conversation to have, asking them where they are weak and what threats are facing them. It probably feels more like an interrogation or an intervention than a conversation. It’s part of human nature to go down to that dark place; the problem is, it’s very hard to get back out.

Now, imagine having that same conversation based on the positive aspects of their life. It changes the dynamic completely and moves the conversation forward. That’s why I took the SWOT analysis out of my toolbox some time ago and replaced it with SOAR.

What is SOAR? It stands for Strengths, Opportunities, Aspirations and Results. Let’s compare the positive and negative words in SWOT and SOAR:

SWOT
SOAR
Weakness: A disadvantage or fault
 
What is wrong with your organization?
Aspiration: A hope or ambition
 
Why did you choose this line of work?
What do you aspire to be?
Threat: A thing likely to cause damage or danger
 
What are you afraid of?
Result: A satisfactory outcome
 
What is your goal?
If you fell asleep and woke up three years from now, what would you see if you fulfilled your vision?

 
Can the substitution of two words make any difference at all? Yes, a huge difference. Imagine two scenarios:

  1. You do your SWOT analysis and discover disadvantages in the face of threats that are likely to cause damage probably kicking off an organizational fight or flight response. If you choose to fight you will have to use up strength to win while not taking advantage of opportunities. You may or may not win and any depletion of organizational strength is a loss regardless of the outcome. Choosing flight is akin to entering into an undesired merger or consolidation, jettisoning service lines, laying off employees, etc. Probably not the satisfactory outcome you were seeking.
  2. You do your SOAR analysis and you discover your organization’s hopes and ambitions and, building upon its strengths, you take advantage of the opportunities and reach a satisfactory outcome. Resources are not depleted, in fact they are added to, because you have engaged the culture in a positive movement. You do not have to flee; you stay put, build, and perhaps, enter into partnerships that augment your strengths.

I’m not being as Pollyannaish as you might think. Using a positive approach is founded in solid research that has been around for years and has proven itself in all sectors of business, including healthcare. The Positive Principle, as stated by Cooperrider and Whitney, is:

“Building a sustaining momentum for change requires large amounts of positive affect and social bonding – things like hope, excitement, inspiration, caring, camaraderie, sense of urgent purpose, and sheer joy in creating something meaningful together. We find that the more positive question we ask the more long-lasting and successful the change effort. The major thing a change agent can do that makes a difference is to craft and ask unconditionally positive questions.”
 

It’s not that we ignore threats. We perform an environmental assessment and data analysis, but then we focus on developing the organization’s strengths, in order to derive a strategy for thriving in a highly competitive environment. Organizations are like people, and if you focus on the positive, then you are likely to get a better result; it can make or break your strategy. Who wouldn’t want to be part of a strategy process that has the Positive Principle as its basis?

There is a certain comfort in doing a SWOT analysis. It’s what we’re used to and somehow, oddly, people feel comforted by going to the dark place of weakness and threat. It’s that “feels like flying” sensation, “for a little while.” Rather than emphasize the negative, though, let’s just jump right out and SOAR.

A version of this post originally appeared on Donald’s blog.

Image courtesy of Flickr.

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When Culture Fights Back

How to Keep Organizational Culture from Undermining Your Strategy

February 18, 2014

Healthcare Strategist, NBBJ

@dbellef

“Culture eats strategy for breakfast.”
Peter Drucker, writer, professor and management consultant

Let’s say you’re a top company, seeking to transform your operations. You paid a hefty sum on management consulting, and now you have a fresh approach to your business. But when it comes time to execute the new strategy, you find it impossible to get traction. Why? What’s holding you back? Management guru Peter Drucker posed one possibility: it’s your culture.

So what is this culture thing then? For me it’s simple: culture is what people say and do every day. It’s the stories they tell each other that may or may not reinforce what you’re trying to accomplish. It’s the facial expressions they make as you roll out yet one more improvement plan. It’s the workarounds they create to get their jobs done. It’s the five or ten minutes late they come in as some form of silent protest.

Within the larger culture are smaller cultures: in the ambulatory care center ten miles away from the hospital; in the offices of your employed physicians; in your ICU; and in your home health organization. Every place there are people working together there is a culture, and it’s very likely these smaller cultures do not line up with the organizational culture you are trying to change. In fact they may actively work against it.

So you do your leadership rounds and tell people what the organization is up to. You have the weekly employee newsletter. You send out emails. And despite all of that you can’t seem to get everyone onboard. Maybe you aren’t on the same page. As Marcel Proust, one of the greatest observers of the human condition, noted: “In general the people to whom we speak draw from within themselves the meaning they give to our words, and … this meaning is very different from the one we put into them.”

To get a person to say something that reflects the strategy you’re trying to create, you need to get the person involved in the creation of that strategy. Once they are involved in the doing they’ll start changing what they are saying; your meaning and their meaning will line up. The culture will begin to shift, and the execution of the strategy will begin.

How do you get everyone involved in the doing? Start by asking them what needs to be changed. No doubt you will find this easier in smaller organizations, but there are a lot of techniques from the organizational development world that have been used successfully in larger enterprises. I am a particular proponent of Appreciative Inquiry, which holds that all organizations were formed to solve a problem, and the strengths that formed the core of the organization still exist and can be tapped into to solve present-day problems.

If you build on the strengths that are inherent in the organization then culture and strategy will dine together. And the people you involved with developing the strategy will execute the strategy by what they say and do every day. Your organization will move forward in ways you didn’t think were possible.

A version of this post originally appeared on Donald’s blog.

Image courtesy of Flickr.

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