The toilet test

L-O-V-E the toilet test:

Whenever I evaluate a school, my first stop is the boys’ bathroom because, without an unflushed urinal of doubt, it is every school’s least common denominator. Its sticky floors, calcified wads of toilet paper and juvenile-yet-timeless graffiti (“Here I sit broken hearted…”) are generally not what a principal shows off. Then again, I once visited a school run by the Knowledge is Power Program — which focuses on preparing students in underserved communities for college — and found fresh cut flowers next to an automatic recycled-paper-towel dispenser. At another school, there were toilet targets. (Apparently, research shows that they increase accuracy by as much as 70 percent.)

Folwell Dunbar explains his metric at Miller-McCune:

In today’s data-driven world of No Child Left Behind and high-stakes accountability, administrators and lawmakers tend to obsess over hard measures. Adequate Yearly Progress determinations and School Performance Scores are based on precise formulas — formulas made up of clean, cold and supposedly foolproof numbers. In this highly calculable place, soft measures are rarely factored in. Nonetheless, after my “inspection” discovers the good, the bad and the ugly of the boys’ john, I usually have a good sense (or scent) of how a school is doing. Though I wouldn’t necessarily hold the bathroom test up against SAT scores as a measure of school success, I do consider it a telltale sign of either problems or promise.

Oh, health care and education how you are so intricately entwined. The toilet test works in hospitals, too.  The article bullets a laundry list of “soft” tests (the soft stuff is the hard stuff…).  Ideating a few for hospitals on the decline, those areas that all visitors have access to:

  • wildly outdated reading material in waiting rooms
  • trash on the floors in main corridors
  • outdated furniture and interior decor, anywhere (though especially on the floors taking care of inpatients on services that traditionally are profitable)
  • boxy tube televisions in common areas, shared televisions in patient rooms
  • anything unkempt on a mother/baby service
  • posters/announcements/bulletin boards with aged information

There are…many, maybe even a limitless list (oh, those are fun…).  Care to share?  How do you judge hospitals or any other institution/place of business when you don’t have access to metrics/don’t care about measures?

(via Tom Kuntz)

1,000,000 health reform articles later…

About 1,000,000 health care/insurance reform articles ago, someone wrote that President Obama should be “selling” reform with a “because of explosive cost growth, if you want to keep your current insurance, we need reform” not a “with reform you will be able to keep your current insurance” tactic. (I searched to no avail, the keywords “Obama” and “health reform” return just a few possibilities, if you have a link to the article leave it in the comments)

Opinions on all of this are numerous.  It’s overwhelming.  (I even considered going on a health reform posting strike simply because its domination of my daily life has put me over capacity.  But then I realized that would be a complete cop out and akin to leaving a Rolling Stones concert before they play Satisfaction or leaving a July 4th celebration in Washington DC at 4:30 in the afternoon or walking out on Game 7 of the World Series after the sixth inning of a tight ballgame…just can’t do it.  So instead I continue my efforts to ingest, comprehend, and explain this crazy system and its intended fixes.  But maybe a posting strike would work if we could gain critical mass?  Let me know…)

Back to the topic at hand.  The mesmerizing costs of health care.  In an Atlantic article by David Goldhill currently making the internet rounds he puts the lifetime costs of insuring your family into perspective:

Let’s say you’re a 22-year-old single employee at my company today, starting out at a $30,000 annual salary. Let’s assume you’ll get married in six years, support two children for 20 years, retire at 65, and die at 80. Now let’s make a crazy assumption: insurance premiums, Medicare taxes and premiums, and out-of-pocket costs will grow no faster than your earnings—say, 3 percent a year. By the end of your working days, your annual salary will be up to $107,000. And over your lifetime, you and your employer together will have paid $1.77 million for your family’s health care. $1.77 million! And that’s only after assuming the taming of costs! In recent years, health-care costs have actually grown 2 to 3 percent faster than the economy. If that continues, your 22-year-old self is looking at an additional $2 million or so in expenses over your lifetime—roughly $4 million in total.


Rational arguments are probably the worst to use because this issue is a very emotional one.  But if there’s anything that could snap emotional folks out of their daze, it’s dollar bills.  Anyway, read the article.  It’s a bit of an investment of time but it succinctly lays out the issues we’re facing in a way that’s escaped most of the millions of articles written on the topic thus far.

1. Communication is the problem, follow-through the example

The majority of problems in health care can be broadly defined as communication problems.  If you’ve ever listened to health care people talk health care troubles, communication is often explicitly mentioned.  It’s an, almost universally used blame for many issues.  But the problems are often poorly corrected.  That says one of two things: 1) the problem has been poorly defined, assessed, or 2) execution of improvement activities has been lackluster.  Neither alternative is particularly appealing.

The first step in correcting this situation (generally, solving health care’s problems—or opportunities if you prefer optimistic rhetoric) relates to alternative one above: recognizing that the issue at hand is one of a breakdown in communication.  What better way to do that than through examples?

Example 1: Following through

Ted Eytan recently blogged about a study that concluded 7.1% of the time, on average, information was not communicated to patients regarding abnormal test results.  What makes this even worse is the “no news is good news” doctrine:

It’s impressive that in 2009, believe it or not, there really aren’t firmly established processes for handling information about test results. A lot of what is done today is bred from custom, such as the infamous “no news is good news,” which the authors found was the protocol in 8 out of 19 medical practices studied. Everyone who likes this approach to test result notification, please raise your hand…

Here’s a real example from Disruptive Women (via Ted Eytan) of a communication breakdown.  Notice that policies and procedures were in place, the lack of follow-through is where the problem rose:

One year later, as Dr. Rosenthal walked into the exam room eyeing Sam’s medical record he stopped for a moment, raised his eyebrows and then looked sheepishly at Sam. “I’m sorry,” he said, “the pathology report from your surgery showed prostate cancer. And, I am afraid I did not see the report until now.” Sam was confused as to how that could have happened. Although he had not previously requested a copy of the report, he asked for one now.

After calming down, finding a new urologist, and making plans for the testing to find out how far the cancer had spread over the past year, Sam finally sat down and read the report. Typed in large, bold type across the top of the report was the following statement: “Results telephoned in to Dr. Rosenthal on 05/05/08? … one year prior to the visit. Turns out not only did Dr. Rosenthal have a copy of the report, he also had received a verbal notification that Sam’s pathology report showed cancer of the prostate. The hospital had a strict policy of calling the surgeon, in addition to faxing and mailing a copy of the report whenever there was a finding of cancer.

Transferring culture

Noah links to this Nike article.  A nice tidbit on culture and organizational values:

It’s an inevitability that most companies the size of Nike will eventually lose touch with the core values instilled by their founders. It has arguably already happened to Google in a much shorter space of time. However, Nike’s philosophy of ‘innovation and inspiration’ is still present in absolutely everything it does.

Nike employs over 30,000 people.  Maybe it’s because of the traditionally siloed, hierarchical structure of health care organizations, but it doesn’t take size like Nike’s to lose touch with cultural values.  The inevitability of progress combined with the struggles of change make staying true to original intentions difficult.  Here’s how Nike does it:

Ekins are official company storytellers employed to evangelise about the Nike brand and its sports technology. Before being unleashed on the world, Ekins are required to undergo an almost military-like training regime comprising a nine-day rookie camp at Nike’s headquarters in Oregon and a full day’s running at the Hayward field track where Bill Bowerman worked as a track coach. Almost unbelievably, as a further sign of their devotion to the brand, each Ekin is then invited to have the Nike ‘swoosh’ tattooed on their ankle ahead of their ‘graduation’.

Hmmm, tattoos…

Sharing private medical information

Having yet (we’re all going to need care eventually) to be a patient of significance in health care, I’m extremely appreciative of individuals who share their private medical information.  There have been many and the collective good will improve awareness, medical science, and health care as Jeff Jarvis explains in his Guardian column:

By revealing my cancer, I realise benefits, and so can society: if one man’s story motivates just one more who has the disease to get tested and discover it, then it is worth the price of embarrassment. If many people who have a condition can now share information about their lifestyles and experience, then perhaps the sum of their data can add up to new medical knowledge. I predict a day when to keep such information private will be seen by society as being selfish.

Collectively, we will use the internet’s ability to gather, share and analyse what we know to build greater value than we could on our own. That is the principle of transparency that I want companies and governments to heed: that openness in their information and actions must become their default, that holding secrets only breeds mistrust and robs them and us of the value that comes from sharing.

Stop your screaming, the expert’s lesson

Seth’s sensemaking is brilliance.  But we all know that.

If you want to challenge the conventional wisdom of health care reform, please do! It’ll make the final outcome better. But if you choose to do that, it’s essential that you know more about it than everyone else, not less. Certainly not zero. Be skeptical, but be informed (about everything important, not just this issue, of course). Screaming ignorance gets attention, but it distracts us from the work at hand.

Models of success

So simple. Hoping there’s more:

Yet in studying communities all over America, not just a few unusual corners, we have found evidence that more effective, lower-cost care is possible.

To find models of success, we searched among our country’s 306 Hospital Referral Regions, as defined by the Dartmouth Atlas of Health Care, for “positive outliers.” Our criteria were simple: find regions with per capita Medicare costs that are low or markedly declining in rank and where federal measures of quality are above average. In the end, 74 regions passed our test.

It’s easy to get started assessing the patient experience

It’s easy to assess (and improve!) the patient experience in existing inpatient and outpatient facilities. Here’s how, with inspiration from Matthew May, to improve an organization’s focus on empathy.  First things first, drop the data (just for now and only for a moment…)

  1. Observe a patient(s). Ask a patient if they’re open to being followed during their entire visit/stay.  An easy way to start would be with a planned admission.  Proceed cautiously with a patient who first presented to the emergency room. Outpatient facilities should provide several opportunities in a single day.
  2. Become a patient. One way is to actually become ill and require health care services.  Sometimes that’s realistic, sometimes not.  The other is to become a patient just for the day.  Pluses and minuses for both, but an actual immersion into a patient’s shoes is the best way to experience health care.
  3. Include the patient(s). This is easy, too.  Plenty of people are willing to talk to just about anyone about their health care experiences.  Ask a patient or a group of patients to participate in a focus group.  Structure the conversation—but not too much; this is about listening to the patient’s observations, thoughts, wants, and desires.

There it is.  Three easy ways to start assessing the patient’s experience.  Start changing what can be changed tomorrow.

Updated: Back-of-the-napkining health care

Dan Roam and Tony Jones recently got together to visualize health care reform.  It’s good and easy to understand.  That’s Dan’s default—he’s the author of “The Back of the Napkin.”


Part one: Health care in America is a business (that it is, with the patient increasingly mattering less…aside from $$ brought to the system)

Part two: It’s not health care reform—it’s insurance reform (and that’s a big problem, paying attention primarily to the insurance side does little to rectify our growing problem)

Part three: What proposals are actually on the table?

Part four: Impacts and conclusions