33. Live the Service, Improve the Service

How do you know when service is broke?  Do you listen to patients?  To staff?  Is it a gut feeling?

There’s only one way to know for sure: experience it.

The Chicago Sun-Times brings news of a county sheriff willing to do just that (via Freakonomics Blog):

Lake County Sheriff Mark C. Curran Jr. sentenced himself today to a week in his own jail, saying he believes spending time behind bars will make him a better cop and a better person.

“I believe that I can be a better sheriff by having a better understanding of jail operations from the perspective of an inmate in the Lake County Jail,” Curran said before being locked up. “I believe that I will receive significant introspection from staying in the jail with inmates for a week.”

Jail.  JAIL!  If a sheriff is willing to experience one week in a jail, surely a hospital executive would be willing to experience a night in the hospital.

His plan:

Curran plans to live in a cell, eat jail food, mingle and talk with other inmates in common areas, while also attending numerous programs offered in the facility, including substance abuse counseling, parenting and educational classes, along with religious services.

That immersion, he said, should give him more insight into everything from safety issues to what programs may be needed help inmates straighten out their lives and avoid future crimes.

“My experience in the jail will help me to better understand our existing programming, as well as any possible unmet needs that exist in our programming,” said Curran, a 45-year-old former prosecutor elected sheriff in 2006.

An inpatient stay is the new hospital report card.

Do it all: arrive through the ED, register, be wheeled to a room on a gurney, wear the robe, talk to doctors and nurses, be transported to radiology (and everywhere else), wait for food, try to eat that food, use the restroom, take a bath, try to sleep next to a roommate separated only by a curtain, use the telephone, use a cell phone, enjoy the television, tug the pull cord, etc…all just like a patient in the hospital (surgery not required, though it medically necessary, all the better).

The insight: valuable.

Granted the service that a hospital executive receives will be biased.  But that’s not the reason to do this, not for aspects of service that can be easily observed.  No, this time is meant for those aspects of service that can only be experienced.

Would you be willing to spend time as an inpatient in your hospital?  Be careful how you answer. If the answer is anything close to “no,” it’s time to get moving and start improving.

Principle #33: At our own system all senior leaders will be required to spend time in the hospital: live the service, improve the service.  If someone is unwilling to comply with such a requirement, well, that says about all a patient needs to know about our hospital.

32. “Don’t just do something, sit there”

Have you ever walked through the halls of a medical center and noticed the busied nature of all the people inside?  Their rushed existence to get from point a to point b?

As the great John Lennon espoused, “Life is what happens to you while you’re busy making other plans.”

Health care happens while we plan for the future.

In a health care system with many big, challenging issues, it’s easy to forget the problems that plague us on a daily basis.  The forgotten hand wash.  The misguided patient.  The uneasy interaction of a stressed doctor and a busy nurse.  The elements of health care that affect direct delivery to the patient.  They’re overlooked for the hundreds of thousand square foot tower expansion, the hiring of the latest super specialist, and the acquisition of the greatest MRI machine.

Health care takes place between the big decisions.  And sometimes those who lead health care forget that.  There are a lot of small improvements organizations can make on a daily basis that will improve the health care we deliver, it will improve the satisfaction that patients have with our organizations, and it will help us improve our financial situations.

But how do we do that?  How do we find the areas that we need improvement?  We notice, or rather, super notice.

Steve Portigal and Dan Soltzberg published a dialog in Gain (via kottke) “about the importance of being aware and the advantages of tapping into your ‘super-noticing power’ in practicing design and specifically in user research.”

Mr Soltzberg:

It is ironic: people don’t notice that noticing is important! Or that they’re already doing it. It’s kind of like breathing—we’re not usually that aware of it. It’s much easier to recognize more “outbound” activities like brainstorming, testing, designing, refining. But noticing is just as important—it’s really where everything begins. There’s a funny Zen saying about that: “Don’t just do something, sit there.” It’s a reminder to let yourself take things in as well as output them.

In the hustle bustled, go-go-go environment that is health care today, it’s easy to stop noticing the issues that plague us on a daily basis.  But those daily issues are how we can improve health care today.  The issues that we don’t have to wait for anyone else to fix.

But noticing is a concerted effort.  It’s a process of pattern finding as Mr. Portigal comments:

This process of noticing once and then noticing again is how you start finding patterns and uncovering themes.

To embrace the power of super-noticing we must release ourselves from our ideas and thoughts and preconceptions of what’s going on.  We must notice, super notice, bias free.  See what is happening.  Experience what is happening.  Do something about it.

Mr. Soltzberg:

Which really supports what we were talking about earlier, that it all begins with noticing. There’s another classic Zen concept that everything you need to know and experience is already happening and present, but you need to get your old ways of thinking out of the way so you can experience it. Doing contextual research is like using “super-noticing power” to peel back those layers of preconception, culture and habit. When you do that you get to something fundamental and then you’ve got a really solid platform for developing new concepts.

Principle #32: Spend time super noticing.  Do it every day.  our own system will make a commitment to finding the everyday problems that prevent us from becoming a superior health care delivery organization.  We’ll also do something about them.  Planning for the future is important, too.  However, we must not forget the now.  Health care happens in the trenches, we need to focus on solutions that improve those conditions.

31. Grow Our Own

A major workforce transition is on the horizon.

Health care worker shortages have been well documented.

Complicated systemic problems require talented individuals to fix.

What’s a hospital to do?

Grow its own.

From BusinessWeek:

The war for talent. The coming brain drain. Mismanaged succession. In recent years, judging by steady increases in spending on talent management, workforce challenges like these have become top of mind for most companies, large and small.

The Millennials will only complicate matters.  Their lack of organizational commitment makes retention difficult.  That makes the Talent Management Department’s job that much harder.  But, not impossible.

A dedicated talent management program is the first step to retaining the talent a hospital requires.  BW reports on a recent joint study between IBM’s Institute for Business Value and Human Capital Institute:

Researchers found that large companies—defined as having 10,000 to 50,000 employees—do not only manage their existing employees more efficiently, but they are better equipped to plan ahead for the number of people and types of skills they will need to bring into their organization in the future. “Smaller competitors who haven’t done this work really scramble in a lot of cases when it comes to filling holes in their workforce,” says Schweyer.

The business world is truly in an intense competition for talent.  If health care is to dig itself out from an unsatisfactory situation, it will have to compete with the rest of the business community for the best employees.

BW again, “All nonprofit industries studied—government, education, and health care—lagged behind the private sector in virtually all areas of talent management.”

Principle #31: For a sustainable health care future, our own system will focus on talent management.  Bringing talented individuals on board and keeping them in the organization is a difficult task.  A dedicated, workable, efficient, productive, etc., Talent Management program is a first step toward hospital-level transformation.

30. Strategy vs. Startegy

Strategy vs. Startegy

From strategy (via Ted Eytan, MD):

We don’t advocate abandoning an intense focus on operations and their improvement. But we do advocate planning strategy, not just describing it as important. The senior management team needs to have regular, probably monthly, meetings that focus only on strategy. We describe in the book the different roles, frequencies, participants, and agendas for operational review meetings and strategy review meetings.

From startegy (via TP Wire Service):

When faced with a blank sheet of paper, we tend to spend too much time engaged in discussions about strategy, otherwise known as “strategery”, and too little time learning by doing.  In this context, talking a lot about what to do and why is inappropriate because we don’t know enough about context and constraints. When you’re getting out in to the world and starting things, guiding evidence has a way of surfacing in a way which doesn’t happen within the cloistered confines of meeting rooms.

Interesting.  Less talk, more action.

Principle #30: Health care, for far too long, has employed strategy alone.  In an industry in much need of positive change, it is time for health care organizations to widely embrace startegy, too.  Learn by doing.  We’ll pioneer the effort at our own system.

29. The environment of expectation

A scene that has become the status quo for the fans of Major League Baseball’s Minnesota Twins: a team that was thought to be no better than a second-to-last finish is challenging for the Central Division title.  After losing a Gold Glove outfielder, a Cy Young pitcher, and even an award-winning general manager from the year previous, the Twins have again cobbled together a winning team.  This season’s iteration is currently one half-game out of first place.

The Twins’ run began in 2002 and includes four division championships in six years with only one losing record (79-83 in 2007) during that span.  Exactly zero players from the 2002 40-man-roster currently play for the team.  Two from 2003.  Eight from 2004.  Ten from 2005.  Fourteen from 2006.  Sixteen from 2007.  Out of 40.  The players, on the majority, change from year to year.

How do they do it?  They don’t have the best players, or the best facilities, or the biggest budget.  Aside from a few shrewd front office moves, it’s consistency from manager Ron Gardenhire.  It’s never sacrificing values.  It’s making few mistakes.  And for the mistakes that are made, there’s an option up the sleeve for quick recovery.  It’s expectations.  It’s the culture.  It’s the environment.

David Heinemeie at 37signals wrote last week:

In my experience, we’re all capable of bad, average, and good work. I’ve certainly done bad work at times and plenty of average work.  What I’ve realized is that the good and the exceptional work is at least as much about my environment as it is about me. Average environments begets average work.

The Twins have excelled at creating an exceptional environment.  An environment expectant of winning.

Praise from your competition may be the greatest testament to an organization’s efforts.  Take, for instance, the words of first place Chicago White Sox manager Ozzie Guillen when questioned why he routinely heaps praise upon the team he has dubbed “The Piranhas” for their style of play:

Why? Tell the people in Chicago how many playoffs the White Sox have and how many the Minnesota Twins have since I’ve been managing and since I’ve been playing. I give people compliments when they need to or when they have to. … They build good players. They play the game good. They’ve been playing the game like that since I was playing. And that’s why I do it. People in Chicago don’t like it? That’s not the first time people don’t like what I say. When I say it, I mean it. We come here to kick their butt, but they are here for a reason.

Mr. Heinemeie puts it bluntly:

So if you want your team to excel, quit thinking about how you can land a room full of rock stars and ninjas (note to recruiters: even if these terms weren’t just misguided, they’d be tired by now anyway). Start thinking about the room instead!

And concludes masterfully:

But most importantly, stop using the perceived quality of your team as an excuse for why you can’t try or follow new ideas. That’s a self fulfilling prophesy that’ll never fail to disappoint. Humans are incredibly eager to live down to low expectations.

The Twins were targeted for retraction in 2002.  If they had believed in their perceived quality then, they wouldn’t have made the playoffs. A World Series Championship has eluded the Twins during the run since 2002 (they have two, 1987, 1991).  There’s no doubt they expect to be there every year, though.  But being in the mix as a perennial contender gives the team a chance.  A chance is all a true fan can ask for.

Principle #29: our own system will help it’s team reach its fullest potential by focusing on the environment.  Make it an environment expectant of winning.  Hold people accountable, establish expectations, enjoy the results.

28. “Getting It”

Erik Karjaluoto at ideasonideas has a wonderfully entertaining post on a recent back-and-forth he had with a public relations firm.

The moral of the story: the world changes, and yesterday’s way of doing things don’t always continue to work.  Instead of adapting, some people keep trying the old ways over and over and over.  They just don’t get it.  You can imagine the success rate of such a ploy.

The problem happens in every industry.  Think Medicare’s fee for service in health care.  Sure, CMS tries new iterations of the payment system but the meat of the approach continues as it has for years.  What we’re left with is the problems of yesterday, only worse.

This can happen at an organizational level, too.  A favorite notion of health care folk is that change is constant.  A traditional approach to the health care change issue is to ignore it until ignoring the problem manifests into something requiring action.

Wait, wait, wait, wait, wait, wait, wait, wait, wait…hurry up and solve.  Example given: the primary care shortage, er crisis.

It doesn’t have to be like this.

Organizations that “get it” and make proactive attempts to embrace change can be successful in this hectic, ever-evolving world.

“Getting it” is difficult to define.  The problem with a definite definition of “getting it” is that it’s much easier to describe what it’s not.

Eric writes this about those who don’t, “Again, the problem is that they’re completely stuck in an old paradigm.”

There’s a way around not getting it, and that’s to get it.  Prophetic.

Realistically, the solution is diversity.  Diversity of thought, diversity of opinion, diversity of background, diversity of experiences, diversity of race, diversity of age.  Diversity etc.  Having all these people around influencing individual decision making will improve your organization’s chances of not getting stuck in an old paradigm.

Here’s the secret: utilize that diversity.  The dialog created between all this diversity will help an organization “get it.”  Listen to those with dissenting views, they may be right.

Principle #28: It all comes back to this: You either get it or you don’t.  Getting it means incorporating diversity.  It means being proactive toward change, listening to dissenters.  It means learning never stops.  Just because something worked yesterday has no bearing on its effectiveness today.  Organizations must approach each day with this notion in mind.  And we’ll do that at Our Own System.

27. Community Activi(ty)sm

A new survey released by the Centers for Disease Control and Prevention pegged the percentage of obese adults in the United States during 2007 at 26 percent.  That number is down from 34 percent in 2006.

We’re getting skinnier!

Not so fast.

Heights and weights were self reported.

From the Associated Press article:

CDC officials believe the telephone survey of 350,000 adults offers conservative estimates of obesity rates, because it’s based on what respondents said about their height and weight. Men commonly overstate their height and women often lowball their weight, health experts say.

The CDC conducts a more reliable study in which researchers “actually weigh and measure” participants.  That is where the 34 percent number comes from—its much more indicative of actual obesity levels.

Another AP article reports that we can do something about our staggering obesity issues.  An analysis by the Trust for America’s Health and several public health groups says that if we spend $10 per person over five years we would have the capital necessary to fight obesity resulting in significant annual cost savings.

Here’s the math: $10 x 300,000,000 American population x 5 years = $15,000,000,000.

The end result: reduced obesity levels resulting in annual savings of $16,000,000,000.

Full disclosure: research has been conducted suggesting that treating obesity doesn’t save money.

Regardless, the point is that this is about making Americans healthier.

Some local programs have already been implemented.  Read the article for examples.

It is time for all hospitals to jump on board.  A public health focus will be better for all of us.

Principle #27: Our Own System realizes the role of health care in a community is to help people be healthy.  Most of the time that means caring for patients with medical conditions.  It can also be about promoting healthier lifestyles before they arrive for treatment resulting from unhealthful behaviors.  The hospital’s job is to do both.  Promoting healthful activity is the basis of community activitysm.

26. Attack on Every Pitch

Ben Casnocha wrote last week on a conversation he had with a friend who works for an NCAA Division I baseball program.  As Ben writes, “a lot of the staffers [baseball team] sign off emails with “AOEP” which stands for Attack on Every Pitch.”

He explains:

It’s a pitcher’s mantra. It doesn’t mean the pitcher has to throw strikes every pitch — a pitcher can still attack a hitter’s weakness by throwing out of the zone. It simply means that each pitch should have a purpose.

Recent posts on this blog have discussed frustrating bureaucracy and strategies to bust through it.

In bureaucratic non-profit organizations some activities can become part of the “way it’s always been done” mantra.  Phrases like “my boss told me to” become part of the everyday lexicon.  Activities can become wasteful.

Purpose is a powerful word.  Purpose can become a powerful activity.  In performing a job function, if you can’t answer the simple question, “what’s the purpose of this?,” there is a problem.  Speak up if you report to someone.  Listen if you’re reported to.  And end the purposelessness when necessary.

It’s a part of the Attack on Every Pitch philosophy.  Have a purpose.  Know the purpose.  Apply the purpose.

Principle #26: Too much waste.  Too many barriers.  Too much dissatisfaction.  Start breaking through by attacking on every pitch.

25. Separate Work and “The Rest of Life”

Constantly connected.  The demands of the “modern” workplace have made weekend emails standard operating procedure.

Sending email on the weekends has consequences.  Often, it demands a response from the person receiving the email.  When higher-level managers send an email, a subordinate may feel compelled to respond quickly—to the point that it interrupts “the rest of life” (those precious hours outside of the office).

Separating the two worlds is important to feeling refreshed come Monday.  It has everything to do with job satisfaction.  It has everything to with keeping employees engaged and productive during their time on the clock.  It has everything to do with creating a work environment conducive to enjoyment.

Principle 25: No email on the weekends.  Holidays included.  Enjoy your 4th of July holiday weekend.

24. Benchmark to Perfection

In my eyes, part of the problem with the lack of progress in health care is due to the fact that health care organizations delay implementation of innovative ideas until some other organization does it first.  It just makes it easier, the argument may go.

Message to the world: the World Health Organization has endorsed the idea of using checklists to reduce patient harm.

It goes beyond waiting, however.  Often (or always) we benchmark our data (quality, patient satisfaction, outcomes, etc.) to similar organizations.  That’s fine.  But it doesn’t go far enough.  And our worries about our peer group distracts our focus on becoming the best we can be.  It distracts our attention from focusing on what matters most: the patient!

Tom Peters says: “Don’t let the “enemy” rule your life.”

He also uses this quote by Howard Mann to help prove the point:

Obsessing about your competitors, trying to match or best their offerings, spending time each day wanting to know what they are doing, and/or measuring your company against them—these activities have no great or winning outcome. Instead you are simply prohibiting your company from finding its own way to be truly meaningful to its clients, staff and prospects. You block your company from finding its own identity and engaging with the people who pay the bills. … Your competitors have never paid your bills and they never will.

I understand our obsession to compare.  No, wait, I really don’t.  Be better!  Period.  Strive to be THE BEST. Benchmark to the only competition that matters: Perfection! Seriously, move the entire industry forward.  Because if you benchmark to perfection, the peer group will benchmark to you.  And, pulling this all together, if they benchmark to you, they will be benchmarking to perfection, too!

Don’t be afraid to try something…different.

Look what Aetna is doing: creating a lottery where patients can win cold hard cash if they adhere to treatment plans.

Or at least foster a discussion starting with a question like “Chronic care: Do we need an entirely new model of delivery?

Answer: resounding Y-E-S!

It’s a simple decision really.  Choose to be different.  Choose to be the best.  The implementation is the difficult part.  But don’t back down from difficulty.  Get the people in place to make it happen.  It really is possible…

Principle #24: our own system will benchmark to perfection.  It’s the only measure that matters.  Try new things.  If they don’t work, well try something else.  And if that doesn’t work, we’ll try something else.  And we won’t stop until it’s the best alternative.  Then we’ll keep on trying, because it won’t be best for long.  It really is possible, and we’re going to work our tails off to make it happen.  Benchmark…to…perfection.