44. The Levy Rule

A regularly linked-to (by this blog) health care CEO provides sage advice from previous non-profit work:

If a member of our Board proposed that we should do something, it became that person’s responsibility to get it done. 

The rule may hinder idea formulation at the get-go.  (Which may be a good thing; health care has plenty of ideas, the implementation part is where many hit the skids.) However, it will improve accountability (by proxy, execution) down the road.  And because our culture is based upon participation, those keeping quiet on the necessary changes need no longer be a part of the team.

Harsh?  Hopefully not.  It has the ability to empower the change makers in the organization, to free them from the everyday barriers preventing progress in health care organizations.

Principle #44: Your suggestion, your responsibility.

43. Rethink

It’s not that a full-court press has never been used in the game of basketball (for it has, quite effectively); it’s where the thought to do so comes from.  Coaching decisions to apply a full-court press originate because it has been, proven by the past (Digger Phelps, Rick Pitino), to be an effective way to disrupt the offensive team’s efforts.  But in this case, as described by Malcolm Gladwell in The New Yorker, has been absolutely rethought:

(Vivek) Ranadivé was puzzled by the way Americans played basketball. He is from Mumbai. He grew up with cricket and soccer. He would never forget the first time he saw a basketball game. He thought it was mindless. Team A would score and then immediately retreat to its own end of the court. Team B would inbound the ball and dribble it into Team A’s end, where Team A was patiently waiting. Then the process would reverse itself. A basketball court was ninety-four feet long. But most of the time a team defended only about twenty-four feet of that, conceding the other seventy feet. Occasionally, teams would play a full-court press—that is, they would contest their opponent’s attempt to advance the ball up the court. But they would do it for only a few minutes at a time. It was as if there were a kind of conspiracy in the basketball world about the way the game ought to be played, and Ranadivé thought that that conspiracy had the effect of widening the gap between good teams and weak teams. Good teams, after all, had players who were tall and could dribble and shoot well; they could crisply execute their carefully prepared plays in their opponent’s end. Why, then, did weak teams play in a way that made it easy for good teams to do the very things that made them so good?

Lots of things have been rethought in health care.  (e.g. Hospital gownsSurgical checklistsCare delivery.)  Welcomed by some, others not.  There have been successes and failures.  But a desire to improve the status quo is what drives these changes. There is plenty more to rethink: patient experience, care across the continuum, general hospital specialization, billing process, delivery models (again), reimbursement, facilitity design, communication…

To change is to rethink.  To rethink is to improve.

Principle #43: Rethinking will be a daily activity at our own system.  It drives our incessant desire to improve.  The easiest way to rethink?  Bring in outisders.  The heart of diversity.  Ranadivé rethought basketball using his experience from cricket and soccer to coach an “inferior” 12-year-old girls basketball team into a national championship game.  Designers rethink with their design expertise.  Engineers with engineering.  Teachers with teaching.  Young people with a lack of expertise.  Experienced folks with an abundance.  Encourage the dissent, embrace the noise.  Etc.

42. Green = Go

Happy St. Patrick’s Day.

Organizations need people who are always moving, always on the go.  The type of people who drive the long way to a destination because the short way means waiting in traffic.  Always need to be moving.

Moving means progress.  Granted, the wheels are going to spin at times.  It might even mean it takes a little longer to get where they’re going.  But this is for certain: once they reach an endpoint they begin their search for the next.

Now is a time for action.

Hospitals are looking for ways to decrease costs, to be more efficient, to utilize resources more effectively.  During a time when “all is fair game” the possibilities are limitless if the barriers are removed.  Let the folks who like to move, move faster.  More at bats gives the organization more opportunities to find success (that from Tom Peters).  Try lots of potential solutions in semi-controlled environments.  If it works, spread it.  If not, scrap it.  From the Institute for Healthcare Improvement:

An important tool in creating a successful pilot and spreading change throughout an organization is rapid-cycle testing. Rapid-cycle testing allows organizations to test and refine ideas quickly and on a small scale.

As Tom Peters says, and as rapid-cycle testing allows, “Ready. Fire. Aim.”  Start trying.  Go!

Principle #42: We’ll empower our workforce to start testing and encourage them to not cease.  Enjoy the day of celebration. Believe it or not, the day means something.

41. Ask for input

Watching the crowds gather for today’s inauguration is amazing.  It is evident that people care again.  Today’s events are the culmination of a massive exercise in participation.

People want a say in the every day realities that affect their lives.  It’s as true in the work world as it is in government representation.  The Barack Obama campaign and transition teams understood this and provided an outlet for people to participate by asking for input.

my.BarackObama.com was the foundation of organization for the campaign: it allowed supporters to interact with each other through an online social network.  More importantly it provided the opportunity for over a million people to express themselves with the perception (reality or not) that the campaign was listening to their thoughts.

After the election the transition team launched Change.gov—again, asking people to provide input.

Your Seat at the Table allowed the American public to comment on transition team work that traditionally was held behind closed doors:

This means we’re inviting the American public to take a seat at the table and engage in a dialogue about these important issues and ideas — at the same time members of our team review these documents themselves.

Health and Human Services Secretary-designate Tom Daschle asked for participation in the health care reform process through discussion parties held during the holidays that encouraged particpants to report back with suggestions on moving the debate forward.  Aside from health care, any number of issues can be commented on.

Most recently the Obama transition team announced the Citizen’s Briefing Book which is a tool that allows citizens to prepare briefings.  The briefings are voted upon by others with the highest-rated briefings being placed in a book for review by the White House.  Another opportunity to provide input.

Hospitals can do the same and the internet makes it all possible.  Provide a platform for employees, physicians, patients, community, etc. to express their thoughts.  Allow stakeholders to provide input and devise a strategy for addressing any concerns they may have.  It’s a simple idea, really; but it has powerful possibilities.

Principle #41: People enjoy being a part of something.  our own system will give them the opportunity to do so.  Engagement, empowerment, and excitement all become possible when you allow people to particpate.  Just ask.

Bonus: Wired has a great story on the challenges the Obama campaign faces in continuing its trek to bring government into the social media world.

39. Common Sense

…has been lacking in all too many arenas lately.

Examples given:

  1. Less than a week after the federal government committed $85 billion to bail out AIG, executives of the giant AIG insurance company headed for a week-long retreat at a luxury resort and spa, the St. Regis Resort in Monarch Beach, California, Congressional investigators revealed today.AIG documents obtained by Waxman’s investigators show the company paid more than $440,000 for the retreat, including nearly $200,000 for rooms, $150,000 for meals and $23,000 in spa charges. (ABC News)
  2. The global economy may be undergoing a significant downturn, but the White House’s dinner budget still appears flush with cash. After all, world leaders who are in town to discuss the economic crisis are set to dine in style Friday night while sipping wine listed at nearly $500 a bottle.According to the White House, tonight’s dinner to kick off the G-20 summit includes such dishes as “Fruitwood-smoked Quail,” “Thyme-roasted Rack of Lamb,” and “Tomato, Fennel and Eggplant Fondue Chanterelle Jus.”To wash it all down, world leaders will be served Shafer Cabernet “Hillside Select” 2003, a wine that sells at $499 on Wine.com. (CNN)
  3. The CEOs of the Big Three automakers reportedly flew private luxury jets to Washington to plead for a $25 billion taxpayer bailout to save their debt-ridden industry — ringing up tens of thousands in charges even as they cried poverty.Recipients of eight-figure bonuses in 2007, the corporate cowboys used their executive perks — which for GM’s Rick Wagoner include the run of a $36 million Gulfstream IV jet — to arrive in style as they went begging before Congress.Wagoner, whose flight reportedly cost $20,000 round-trip — about 70 times more than a commercial airline ticket — told Congress he expected about $10-$12 billion from the requested bailout. (Fox News)

Now is certainly the time to cut back on excesses with the worldwide economy in a free fall.  It’s not just these one time occurrences that leave questions, either.  Are these decisions representative of the way these groups have conducted their previous business dealings?  Aside from the AIG debacle, the other two examples represent pennies in comparison to the larger dollar figures being debated.  That’s not the point.  It’s the principle of making such decisions in light of what is being discussed.  After all, perception is reality.

Translating this to health care is easy.  Remember the checklist debacle?  How often is common sense part of the discussion in decision making?  Hopefully it is often.  It should be always.

A friend recently flew to interview for a health care position.  Round trip airfare on short notice approached $1000.  It just so happened that the friend had another interview with a second organzation only a short distance from the first the next day.  Both destinations were within driving distance.  So the friend asked the first organization if they would be willing to take on an extra night in a hotel and half of the cost for a rental car (the other half being picked up by the second organization), total cost no more than $600.  The response?  Sorry, organization policy only allows us to pay for one night’s stay in the hotel.  But, the first organization responded, we would be more than willing to pay for a one-way ticket and one night in the hotel if the friend was willing to pay for the rental car and the second night’s stay.

Come on!  Common sense!  Dollars would be saved!

As finances get tighter and our operating environment gets tougher it is time to insert common sense decision-making at every opportunity.

Principle #39: One would like to think that common sense is common sense, but that’s not always the case.  Decision-making at every level of our own system will be driven by common sense.  What’s best for the patient?  What’s best for providers?  What’s best for the organzation?  To determine the answers we’ll use common sense.

38. Change!

It doesn’t take an extremely enlightened person to realize the challenges that hospitals are facing today.  They’re cutting staff.  They’re experiencing drops in demand.  They’re taking care of more non-paying patients.

Payer, patient, and government pressures are only increasing.  The solutions are diffuse and unpredictable.  Preparing for the future becomes much more difficult when preparing for tomorrow reigns in importance.  But we need to prepare for the many possibilities that tomorrow, next week, next year, and beyond hold.  Because one thing is for certain: we are unable to continue on our current path.  While health care likes to think that it deals with change on a continuing basis, it doesn’t do it particularly well.  And that needs to change.

Health care is responsible, in part (a significant part), for the gloomy forecasts of our economic future.  To think that this industry won’t be targeted to cut domestic spending is naive.  To think that hospitals won’t be significantly affected by economic ship-righting would be simpleminded.

In developing our strategy for adapting to change we not yet know, there are several principles we’re borrowing from a recent notable presidential campaign and the requisite transition planning.

1. Be realistic.  This isn’t going to be easy.  We know the mountain is tall and there’s nothing we can do as an individual health system that will put health care on the right track.  But we can set attainable, yet strenuous, goals.  Transparency to the Nth degree to improve patient safety.  Reducing organizational waste to enable flexibility with our dollars.  Empowering front line employees and providers to solve problems.  It’s a laundry list but it’s time to get the house in order.

2. Bring people together.  Enable all organization stakeholders to meet and work together.  No more separate units within the organization.  We are one.  The interactions will lead to innovation and problem solving like nothing we’ve ever seen.  It will also improve our culture.

3. Be consistent.  Our approach, our message, our solution will be consistent with making the organization ready for whatever will come.

4. Be inspirationally optimistic.  There’s no doubt we’re in for some hurt.  A health policy solution that works (read: lower costs) means our bottom line will be (optimistically) flat or (a little more optimistically) rising only slightly.  But if we prepare now–and do it correctly–our exposure will be minimized.  The real optimism comes with preaching a message of preparation.  We can and will succeed in our efforts of creating the ultimate in flexible hospitals.

5. Execute.  Easier said than done.  Also required.  Get the right people on board (everyone).  Get the right people in positions where they can be effective (everyone).  Give them the empowerment they need to get things done (everyone).

Principle #38: Change is most definitely coming.  We can either be the recipient of change or we can lead it.  It is time to prepare.

37. Mission and Vision Implementation (Walking the Talk)

It’s a simple change, really.

The strategic planning/business development group at our own system is now the Department of Mission and Vision Implementation.  Why?  Because a not-for-profit hospital has one meaning for existence: fulfilling its mission.  Mission and vision statements are easy to craft, much harder to follow.

The stories of hospitals who fail to mission and vision implement are plentiful (ask your family members the next time you get together to tell you about a disappointing health care experience, be wary of the can of worms being opened).

The strains upon our health care system are such that fulfilling the mission and vision have become increasingly difficult, that’s no reason for retreat (in fact, make it a call to arms).  Questions of quality remain as hospitals say they are dedicated to providing the highest quality care.  Charity care is questioned as hospitals promise to provide for the community’s needs.  Treating patients with dignity and respect continues to be a challenge.

It’s akin to the marketing department at a corporation whose lone function remains advertising.  Marketing is their business.  Fulfilling the mission and pursuing the vision is ours.

How often is your hospital’s mission and vision considered in decisions made at meetings?  Not often (ever?)?  Big problem.  If the mission is our purpose then every (every!) decision we make regarding the here-and-now will be guided by the mission.  If the vision is our road map to the future then every (every!) decision we make about the future will be guided by our vision.

Principle 37: If you want to be the best, then make an effort to be.  From here on out, it’s about one thing: mission and vision implementation.  Always.  Simple task with potentially staggering results: read the mission and vision before every meeting.  Every meeting.  And don’t let up until all of the organization’s actions align with these very important words, for words are words apart from action.

36. Get out of health care

The complications of delivering health care often demand customized solutions.  But that doesn’t mean we need to depend on the ideas inside of our walls for inspiration.  We could do a lot to improve ourselves if we just looked beyond our doors.

Memorial Hospital and Health System in South Bend, Indiana has been doing just that for years.  There are plenty of examples of organizations getting out of this industry to improve what’s going on inside.  Here are a few.

Memorial has taken an innovation model from industry:

Back in 2000, [CEO Phil] Newbold and Memorial’s Vice President of Marketing, Diane Stover, searched for innovation models within health care and found none. “There was a time, a change would come from Medicare or another funding source and our leadership team would react rather than stick to a plan,” Stover stated. “We launched this initiative to spark positive changes and increase control of our destiny.” Newbold led the charge to engage all 3,800 employees in an understanding of the many challenges facing them and of a commitment to innovative thinking and solution prototyping. The first step was visiting innovators like Whirlpool, 3M, DuPont, W.L. Gore, GE, and Procter & Gamble.

Others have taken checklists from pilots:

In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

Some have borrowed barcodes from grocery stores:

The next time you need medication at Medical Center Hosptial don’t be surprised if a nurse asks you to hold out your arm. This month, nurses started using a new bar-code technology to make sure the right medicines get to the right patients.

“All that information is right there on the computer so they don’t have to go back out to the nursing unit and gather that information from a paper chart,” Sharon Nash, the Horizon Admin-Rx project manager, said.

Memorial calls them inno-visits.  You can call them what you want.  The important lesson here is that we realize the extraordinary benefits that come with looking beyond health care, the inspiration that comes with a change of scenery.

The problems of health care are many, so numerous that one could sit in an office the entire day reading and prophesying about nothing but health care.  Time better spent would be to visit/read/listen/do/join/experience anything outside of this industry.  Your next great idea may come from an experience at a NASCAR track, in the chat of an art historian, from the pages of a great book, or on a visit to Method.  Seriously.

Principle 36: Every decision maker at our own system will be “strongly encouraged” to get out of health care, if only for moments on a daily basis.  The concept of looking beyond our walls will play a significant role in transforming our health care system, indeed it already is.

35. Ask the patients!

Patient satisfaction is all the rave in health care.

Ahem, finally.

PSFK brings news of Best Buy’s effort to incorporate customer wants into its products:

The giant electronics retailer has been working on a program that actively incorporates customer feedback into the design process of future products. The “Blue Label” line features notebook computers from Toshiba and HP that come with ideas sourced from Best Buy client input.

It’s great to see a large cooperation like Best Buy being flexible, responsive and actually paying attention to the real needs of people.

It certainly is great.  The real needs of people. Hospitals should be doing the same thing.  Start a Patient Experience Force today.  Not a task force, a force: a group of patients (past and present) tasked with making your hospital’s experience the best it can be.

From I4U News:

“As the leading consumer electronics retailer, Best Buy has millions of interactions with consumers each year. We listened to our customers and learned that they wanted more from the feature set on available laptops so we went directly to manufacturers to fix that,” said Wendy Fritz, senior vice president of computing, Best Buy.

Why can’t hospitals replicate such a program for its services?  They can, and should.

Ask the Force everything.  Experiences with parking, navigating your facilities, interactions with physicians and employees, services offered, billing…etc.

Oh, and then exploit their opinions to make your health care facility better.  It’s that simple.

Principle #35: We will involve patients in all of our patient experience decision making (which, by the way, is almost all of them).

34. Nice comes standard

Have you ever had an unpleasant customer service experience in a health care setting?  Not saying it happens everywhere or every time but such an experience has been known to occur.  All too often at some organizations.

Seth wants to know the price of nice:

So, here’s the question: if all I want, the only extra, is for someone to be nice to me when I visit your business, how much extra does that cost? How much extra to talk to a nice person when I call tech support? How much extra to find a nice receptionist at the doctor’s office? Would you pay $9 extra for a smile when you dealt with the Social Security bureaucrats and were filing a form?

The occurrence of unkindness is inexcusable, really.  No one (at least the sane no ones) expects anybody to go above and beyond in every service opportunity.  But patients should insist upon a pleasant interaction every time; a smile would be a good touch, too.

Some patients are willing to pay extra for it, they shouldn’t have to, but they are.  Insurance complicates (per usual) this thought in the health care world, but think of it like this: would you be willing to drop a five-dollar bill in a collection plate as you enter the organization’s door in order to be treated nicely throughout your visit?  Many would.  It may be surprising what people would be willing to pay for enjoyable service.

Seth finishes:

I think there’s a huge gap between what people are willing to pay for nice (a lot) and what it would cost businesses to deliver it (almost nothing). Smells like an opportunity.

Principle #34: An opportunity it is.  At our own system nice comes standard.  It’s not even (entirely) about the financial opportunity that comes with being nice, it’s (mostly) about the way people should be treated in their time of need.  We will include “will be nice to everyone” in the first paragraph of the job description.