Many have argued that healthcare systems need to move away from the fee-for-service model. What these arguments often overlook is the challenge of actually managing that change. Even if a new payment system is put in place, there is no guarantee that healthcare providers will change their behavior with patients.
This is the healthcare delivery challenge we at Possible have been facing in rural Nepal. We employ 120 full-time team members to treat over 60,000 patients a year. We run a hospital, several health clinics, and a community health worker network within the existing government infrastructure. The district we deliver care in is a 36-hour drive from the capital of Kathmandu, Nepal’s epicenter of health, economic, and political power.
Almost all of our healthcare workers – 98 percent— are Nepali. They are accustomed to dealing with Nepal’s unregulated private fee-for-service medical system and its under-resourced public sector. And as in many other healthcare systems, providers are conditioned to treat patients with authoritarianism, focus on acute systems rather than chronic or preventive care, and to use inept vitamins and antibiotics to treat almost all conditions.
As in other fee-for-service models, compensation is based on charging fees for everything they do, rather according to patient outcomes. The most dramatic example of this is cesarean sections, which encompass 60% of all deliveries in some of Nepal’s urban hospitals (compared with the 5-20% rate one would normally anticipate).
Over the past seven years, we have focused on combating these challenges and building a workplace culture optimized for two things: worker behavior change and the delivery of high-quality care. Managerial discipline – something often lacking in healthcare management systems — has been essential to both.
We ensure all employees have a manager, and that no manager has more than five direct reports. Managers meet weekly with their direct reports in structured one-on-ones, which guarantee real-time learning and feedback. We invest substantial time in crafting and refactoring areas of responsibility to avoid conflicts that arise from lack of role clarity. For example, each employee has quantifiable quarterly objectives and key results (a system we adapted from Google) that are transparent to the team. These individual objectives are also aligned with larger organizational goals to ensure team members are prioritizing effectively.
These are good practices that would work in any industry. We have also done four specific things that have been particularly useful in healthcare:
Let doctors be doctors – not managers. The status quo in many healthcare institutions is to put the doctors in charge of running the operation. Yet much of what healthcare institutions need to do—facilities management, procurement, accounting, human resources—has little to do with the skills developed during medical training. We’ve removed those managerial functions from our medical team, which allows them to focus on clinical matters. Instead, we develop and recruit specialists to fill those core operations functions.
Develop standard protocols for care. Healthcare workers are particularly known for valuing individual style and intuition over protocols, even when protocols have been shown to work well. Indeed, central to the pathology of the fee-for-service revenue model is that it incentivizes “customized” care, often to the detriment of the patient. Unfortunately, this lack of standardization typically leads to erratic, costly, and ineffective care. In most cases, there is a suite of interventions that are effective for every given interaction, and anything outside of those add to cost, waste, and burden on patients. For example, we have worked to decrease excess use of antibiotics, vitamins, and steroids in chronic disease patients by developing standard protocols for prescribing these medicines.
Hold people accountable for the little things. An endemic problem in many healthcare institutions is the unfinished task. Who is accountable for stocking the amoxicillin? For making sure the bathrooms are clean? For fixing patient beds? For paying vendors? These small tasks make a big difference to the experiences—and survival—of patients. We use simple tools like pareto analysis of drug use and reports of patient-centered outcomes to hold providers and their managers accountable to the care they deliver. For example, B vitamins are widely used the fee-for-service sector in Nepal, with limited evidence except for targeted applications. It became immediately clear after first instituting monthly pareto analysis of medication utilization that our providers, schooled in that medical culture, were grossly over-prescribing vitamin B. Thus, we developed a new protocol to reduce its prescribing.
Invest in technologies that promote efficiency and transparency. We chose to invest in Asana as our project management platform—a lean system that allows anyone in the organization to see who will do what by when. While many skeptics say that computer-based project management systems are not appropriate and cost-effective technologies for rural healthcare deliveries, our experience has been that not investing in technology-based platforms is far more costly. We are already seeing ROI in terms of less waste of time, energy, and resources, which directly connects to effective care delivery. In addition to Asana, we have implemented an electronic medical record and an electronic stocking system. In 21st century healthcare, these are basic tools for effective care delivery, yet are frequently missing, even in less impoverished settings than rural Nepal.
To change employee behavior and improve care, we’ve designed our management systems to eliminate the dangerous habits created by fee-for-service medicine. We hope that by proving what is possible in one of the world’s most remote and impoverished places, others will see how important it is to change health provider behaviors as well as payment models.