15. Department of The Best Start

First impressions matter.

our own system’s Department of The Best Start will be responsible for greeting and helping patients, families, and visitors when they walk into the lobby.

We borrow the job description from the blog of Beth Israel Deaconess Medical Center CEO Paul Levy:  employees in the Department will “answer all kinds of questions, give directions, escort people to their appointments, and are otherwise exceptionally pleasant and helpful.”

Simple, right?  Not always.  Smiles and hellos are not always pervasive in a hospital.  But what better to help sooth a patient’s rattled nerves as they enter a hospital than a friendly, smiling face?

The distinction between a run-of-the-mill staffed hospital lobby desk and the Department of The Best Start is a move from a static office desk dedicated to answering questions by those who approach to a constantly mobile group of individuals dedicated to the patient experience by seeking out all who walk through the front door.

Innovative patient experiences is really what the Department of The Best Start is all about.  This group will always be on the lookout for ways to improve the patient/hospital interaction.  At BIDMC, they have interpreters in over 30 languages and have “a rotating box with instructions in several languages to help people who do not speak English get the help they need.”

The Department of The Best Start will be the dedicated Relationship Builders between those entering the hospital and our own system.  If patients start with an enjoyable beginning we know that there is a better chance their entire experience will be positive.  And it all depends on communication.

As Mr. Levy writes on his blog, “Good communication is not just a pleasantry in a hospital: It can be a matter of life and death.”

Principle #15: Beginnings matter.  A lot.  As we move to a competitive hospital world where patient satisfaction actually manifests into return visits/word of mouth marketing, how we build relationships with those who enter our organizations will become vitally important.  We’re just getting a head start.

13. Doc Squad

Have you heard of the Geek Squad? From their website: “Geek Squad Agents, Advisors and Installers teach people to embrace technology fearlessly and practice the art of human interaction.”

In order to offer patients more care options (and a throwback to the days of old), our own system will deploy the Doc Squad (still deciding whether to outfit them with Beetles or not) to respond to individuals who need attention at home. These providers will be able to provide basic general practitioner duties in the patient’s home.

Jay Parkinson and a few others are practicing virtual medicine…but why couldn’t this innovative solution be employed in the hospital? Well it can. And we will.

The Health Care Blog has a good piece on Dr. Parkinson. The best quote:

“The healthcare industry is so stuck in 1994,” he says, “The only way they’ve used the Internet is to provide information. I look at the Internet as something that provides communication.”

Principle #14: 1994 or not, it’s time that we (hospitals) start deploying new business models. The Doc Squad is our own system’s version of a previous era doctor’s house call. Every decision we make should make the process easier for the patient. Period. And if you’re not innovating for the patient (or the patient’s well being) you shouldn’t be innovating. Period.

11. Evidence-Based Design Matters

Evidence-based medicine.  Evidence-based management.  Evidence-based design.

The thinking makes a lot of sense: do today with what you (and others!) learned yesterday.

The Center for Health Design is the ultimate source on this subject and they provide a much more comprehensive definition:

Evidence-based healthcare designs are used to create environments that are therapeutic, supportive of family involvement, efficient for staff performance, and restorative for workers under stress.

An evidence-based designer, together with an informed client, makes decisions based on the best information available from research and project evaluations. Critical thinking is required to develop an appropriate solution to the design problem; the pool of information will rarely offer a precise fit with a client’s unique situation.

In the last analysis, though, an evidence-based healthcare design should result in demonstrated improvements in the organization’s clinical outcomes, economic performance, productivity, customer satisfaction, and cultural measures.

As we plan and build our virtual hospital, our own system is committed to constructing a healing environment through evidence-based design.  The Center even provides a toolkit that will help us:

• Understand what patients want from the built environment
• Enhance the design process through consumer involvement
• Build patient-centered environments
• Improve design quality and consumer satisfaction

Ulrich and Zimring published a comprehensive literature review/report on hospital evidence-based design in 2004.  The Robert Wood Johnson Foundation has a nice overview/summary of the research.  We can take explicit recommendations from this research and turn them into action:

The Single Room that does it all. “This change alone will help improve patient safety by reducing patient transfers, cut the risk of nosocomial infections, enhance patient privacy, lower stress for patients and their families, and improve staff communication with patients.”

Ventilation Systems and Air Filters. “Several studies have demonstrated that identifying and fixing air-quality problems, in combination with single rooms and scrupulous hand-washing, can substantially lower infection rates at hospitals.”

Noise Reduction. Elements like carpeting and sound-reducing ceiling tiles can lower noise levels.  “Research shows that noise is a major source of stress at hospitals. At hospitals that took steps to cut noise levels, patients were more satisfied with their care, slept better, had lower blood pressure, and were less likely to be re-hospitalized.”

Natural Light. “Looking out at bright light can improve health outcomes, including depression, agitation, sleep, and circadian rest-activity rhythms.”

The “Little Stuff.” “Small changes to room layouts, color scheme, furniture choice and arrangement, floor coverings, and curtains, as well as providing informational material and displays, can improve people’s moods and physiological states.”

Easy Navigation. “It’s easy to get lost or confused trying to find one’s way in a hospital. Not only is this confusion stressful for visitors, but it also incurs a cost to hospitals.”

Work Environments that help staff do their work. “Nursing stations are hectic and stressful places where too many errors occur while updating charts, filling medication orders, and communicating between shifts.”

One more thing: the Pebble Project.  “The purpose of the work (Pebble Project) is to create a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities whose design has made a difference in the quality of care and financial performance of the institution.”  Just take a look at some of the benefits of great design: staff turnover reduced, occupancy rates increased, patient satisfaction up, etc.  And if you have an extra minute or two, enjoy the great images of proven evidence-based design.

Principle #11: Evidence-based design is beyond important, it’s item number one on the things to do list at our own system. The Center for Health Design will help us get there.

10. Green as can be

In the kind of prognostication you can only find in a bar like Cheers, serendipity ran me into a know-it-all-end-of-the-bar type several months ago that put our future environmental status in stark perspective: Mother Nature will be just fine. If we, as in humans, don’t change the way we interact with the Earth, it will be us who is disposed of; Mother Nature will have done her job: react to imbalance to ensure stability. Weird and uncomfortable as the situation was, the message resonated.

Making our own system green is a small step we can take “to do our part.” But, for a moment, let us move beyond the environmental benefits of going green and focus on our patients. An article at Building Design and Construction puts it well:

Think about this: If you were asked to identify the one building type that needed the highest-quality indoor air, the lowest levels of toxic off-gassing, the greatest access to daylighting and outdoor views for occupants, the most efficient energy and water usage—in other words, the greenest building—what would you think of first?

Hospitals, right? Sure you would. Hospitals should be leading the way in providing patients, their families, doctors, nurses, technicians, and office staff the ultimate sustainable experience. Sick people should have the greenest buildings of all.

But it’s not the case.  Hospitals have been slow to jump on the green revolution. The U.S. Green Building Council reports that only 74 hospital construction projects have been LEED certified, about 2% of all LEED-registered projects. But, as construction booms, and as we continue to build our virtual hospital, the opportunity to build green facilities is upon us.

National Geographic published an article in 2006 ranking the top 10 green hospitals in the U.S. that also discussed the challenges of building green hospitals, “Infection control requires strict cleaning procedures and frequent air changes, which increase the already-high energy costs of the 24/7 operations and sophisticated medical equipment that make hospitals among the greatest energy consumers of any institution.”

A solution.

The Green Guide to Health Care provides a 400+ page document (go to their site and register for a free download of the document) that is “the healthcare sector’s first quantifiable sustainable design toolkit integrating enhanced environmental and health principles and practices into the planning, design, construction, operations and maintenance of their facilities. This Guide provides the healthcare sector with a voluntary, self-certifying metric toolkit of best practices that designers, owners, and operators can use to guide and evaluate their progress towards high performance healing environments.”

The GGHC combines several resources to come up with their assessment principles including the Green Healthcare Construction Guidance Statement (pdf) by the American Society for Healthcare Engineering, LEED, the U.S. Environmental Protection Agency’s Labs 21 Environmental Performance Criteria, the Green Building Council of Australia’s Green Star Green Building Rating System, among others.

The aforementioned Building Design and Construction article offers 14 steps to greener hospitals and an analysis of GGHC, “This well-conceived set of guidelines goes far beyond LEED in rating hospital projects. GGHC requires integrated design, something LEED only hints at. It covers both construction and operations, and it offers specific health policy reasons for each of its credits. Unlike LEED, however, it is self-compliant: Building Teams rate their own performance, which to some is a shortcoming. Currently, 79 projects are participating in the GGHC pilot program.”

Principle #10: Building green facilities is a must. The best part: aside from being good for the environment, the elements of a green hospital are great for patients.

9. The Paperless Hospital

We’re on the verge of an extreme infusion of information technology into hospitals across the country. Electronic medical records (EMR) are the future of inpatient and outpatient record keeping. I see three fears holding back many: 1) cost of implementation, 2) technophobia, and 3) concern about purchasing the “right system.”

While information technology is not the solution to all of our problems, when implemented and used correctly it can help reduce costs and allow for continuity of care amongst providers, ultimately benefiting the patient.

The announcement of the partnership between Google and the Cleveland Clinic moves us one step further (no matter how long it took us to take that step!) toward converting our system of paper to one that is electronic.

However, our own system will go a step beyond the EMR and will be a “paperless hospital.” Being paperless means, well, no paper. Beyond the EMR, going paperless has an impact on all aspects of the hospital. Some organizations have implemented paperless systems already allowing us to learn from what they have done. Newly constructed Dublin Methodist Hospital‘s paperless system is highlighted here. Read (it’s in the first paragraph) about the paperless Baptist Medical Center South.

Vanderbilt Children’s even has a demo to show us how easy it can be:

[youtube:http://www.youtube.com/watch?v=6ueTFjcTtco%5D

Principle 9: Paperless from the start! It is best for our patients. It is best for our organization. It is best for our health system. Removing waste and reducing errors are top priorities. We can do both by going paperless.

8. Commissioned Art

“Art washes away from the soul the dust of everyday life.” –Pablo Picasso

I’ve heard that art has healing power. Whether that is true for everyone, it matters not. As one Planetree (“promotes the development and implementation of innovative models of healthcare”) component says, “Artwork in patient rooms, treatment areas and on art carts add to the ambiance (of the hospital). Volunteers work with patients who would like to create their own art, while involvement from artists, musicians, poets and story tellers from the local community help to expand the boundaries of the health care facility.”

Art’s importance in the hospital setting is a design component that can help patients and families (and staff!) feel more comfortable. Anything that helps to reverse the notion that a hospital is cold and gray is a good thing. Art adds color and warmth.

But we must be careful: I’m sure we’ve all seen those tired, old pieces that have been on display in the hospital’s waiting room for too long. our own system has a solution. Seth wrote a few months ago (I’ve remembered it this long, so it must have been good) about a truly intriguing idea: an artist in residence. We will hire an artist (or a few, even, depending on our size) that comes to work everyday to create art that will be displayed throughout the hospital. If anyone wants to buy a piece of art, they can. That piece will be taken off display and replaced with another work. Rotating art will keep the atmosphere fresh, it may even turn into something of an exhibition that we normally see at museums.

The notion of good art in the hospital is growing. There’s even a conference on The Value and Importance of Art in Health Care (be careful, it’s a PDF). And you can even get a daily fix on health care and art by reading this blog, it has some good stuff. If going all the way and hiring an artist in residence is too much for your organization here are some tips on starting an art program.

Principle #8: our own system, on its journey to try innovative ideas, will hire an artist in residence (maybe even a team!) to keep the hospital full of great art. This art will help to create an atmosphere attractive to patients, staff, and the community.

7. HEALTH care (emphasis on health)

Since the beginning of Western medicine–when a patient had a few swigs from the whiskey bottle before a procedure–the practice of medicine has been reactive. And for good reason: someone has a medical problem so a doctor would address it. Why would someone see a doctor if they’re not even sick?

Well, progress is a strange thing. Today, we don’t think twice (sadly, some don’t think about it at all) about yearly physicals or a mammogram every one to two years. Proactive health care is here (that shouldn’t be much of a surprise). Preventive medicine can help to control disease–even prevent disease in some cases.

This post at the World Health Care Blog addresses the issue by discussing whether or not hospitals are moving from a model dedicated to health instead of the more traditional sickness; it was inspired by a report published by the American Hospital Association with a section titled “Focus on Wellness.”

our own system will focus on wellness. Traditionally, the post says, “efforts often address one or two wellness initiatives, such as flu shots for their own employees and the medically underprivileged, or focus on the poor and frail, as part of their mission, PR and tax-exemption maintenance strategies.” our own system will make a concerted effort to dedicate the system’s complete efforts in order to focus on wellness. More from the blog describing that mission:

This wellness focus included the call for efforts to prevent or at least reduce the incidence and prevalence of illness and injury in the first place, along with measures to manage chronic illness once it has arisen. It addresses the health risk conditions and behaviors that employee and population health management efforts by employers, insurers, and governments have been investing in for some time. This suggests, at least, that hospitals are finally being asked to become part of the solution to the healthcare/cost crisis, rather than the part of the problem they have been up to now.

Of course, sickness care will still need to be a big component of our care for patients.  However, our own system will be the impetus for the paradigm change amongst our stakeholders required to make the shift to wellness.  The shift will take considerable patient education, third-party payer support, and physician buy-in.  As the meeting place for all three of these groups, our own system can be the uniting component of a fundamental shift in thinking and practice.

Principle #7: We will focus on the health portion of the phrase health care.  our own system will bring together key stakeholders in the delivery of care and provide the needed platform to make a complete effort dedicated to comprehensive care for our patients, with an important focus on wellness.

6. Share Our Stuff

Sharing is the way to do business.

Google (and others) allows developers to download it’s code for applications like Google Maps.  Those developers then create “mash-ups” combining ideas: a map and something else (a pretty cool example: “Time Space Map is an encyclopedic atlas of history and happenings that anyone can edit.”)  Linux is an operating system (similar to what many of you are using currently: Windows).  Only Linux is developed by anyone who wants to–the source code is freely available to anyone–developers collaborate on creation.

Some more examples:

According to Bloomberg, “Harvard University professors may publish more research online, free to readers, after the school’s arts and sciences faculty adopted a new policy.”

The University of California Berkeley has a YouTube site where you can view a number of lectures including “Physics for Future Presidents.”

Stanford utilizes iTunes for much the same purpose.

The Public Library of Science “is a nonprofit organization of scientists and physicians committed to making the world’s scientific and medical literature a freely available public resource.”

Sharing themes abound.

Ideas don’t do any good if you place them under lock and key hang onto them for dear life.  They will probably be irellevant in a year anyway.  The power of ideas comes when they are shared, when they can be thought about, utilized, and implemented everywhere.

Maggie Mahar’s “Money-Driven Medicine” brings us this vignette from Dr. Donald Berwick, co-founder of the Institute for Healthcare Improvement, “Berwick recalls phoning a hospital in Houston to learn about its reportedly successful innovations in pneumonia care, and being told that ‘the gains were enormous but that the methods could not be reported to the public–excellent pneumonia care offered the hospital local competitive advantage.'”

The book continues as Dr. Berwick says, “The enemy is disease.  The competition that matters is against disease, not one another.  The purpose is healing.”

Maybe we all need to re-visit the sharing lesson.

Principle 6: It’s not mine, it’s not yours, it’s ours.  We’re in this together (this meaning fixing our health care system).  Revolutionary ideas need to be diffused…quickly…incessantly.  our own system will share all we have to offer, from research, to innovative ways to care for patients, to the ways we do business.  It’s time we rid ourselves of selfishness and come together and share to achieve a common good.

Failure is good.

On the flipside, are you failing often enough?

Health care and schools, failing together?

Failure, per say, is subjective to each individual’s definition. Even so, reasons for their possible failure are at opposite ends of the spectrum. One doesn’t have enough resources, the other uses too much. But this article in the The Atlantic made the connection for me. How similar does this sound to the current debate in health care?

The United States spends more than nearly every other nation on schools, but out of 29 developed countries in a 2003 assessment, we ranked 24th in math and in problem-solving, 18th in science, and 15th in reading. Half of all black and Latino students in the U.S. don’t graduate on time (or ever) from high school. As of 2005, about 70 percent of eighth-graders were not proficient in reading. By the end of eighth grade, what passes for a math curriculum in America is two years behind that of other countries.

I asked Marc Tucker, the head of the New Commission on the Skills of the American Workforce (a 2006 bipartisan panel that called for an overhaul of the education system), how he convinces people that local control is hobbling our schools. He said he asks a simple question: If we have the second-most-expensive K–12 system of all those measured by the Organization for Economic Cooperation and Development, but consistently perform between the middle and the bottom of the pack, shouldn’t we examine the systems of countries that spend less and get better results? “I then point out that the system of local control that we have is almost unique,” Tucker says. “One then has to defend a practice that is uncharacteristic of the countries with the best performance.

Nationalizing our schools even a little goes against every cultural tradition we have, save the one that matters most: our capacity to renew ourselves to meet new challenges. Once upon a time a national role in retirement funding was anathema; then suddenly, after the Depression, we had Social Security. Once, a federal role in health care would have been rejected as socialism; now, federal money accounts for half of what we spend on health care. We started down this road on schooling a long time ago. Time now to finish the journey.

Maybe we could learn from education? At least in what not to do. But some places get education very right, let’s explore why.