Hospital

Part 2: Are 7 sigmas 8 too many?

Posted by

0

The worst part about being wrong in public is having an audience.  Yesterday marked the eight-and-a-half year point since my heart attack.  I celebrated with a six mile run.  Instead of hiding my car keys under the bumper like I always do, I stuck them in the pouch of my MP3 case.

I was back within the hour and in a hurry to get to my water bottle that I had locked in the car.  No keys.  After considerable thought and machinations of my considerable cerebral skills I decided to retrace my steps; all twelve thousand of them.  Still no keys.  I called my wife and she retraced my route.  No keys.

I had apparently out-thunk myself.  We called AAA to get them to make us a key, and waited—two hours.  After several failed attempts Sparkie finally unlocked the car.  I opened the door, placed the palm of my right hand on the keys, reached across the seat for my water bottle…

The keys, locked inside the car right where I had left them.  No need to worry about missing any subsequent MENSA meetings.  My wife simply gave me the look—men, you know the look.  It is the one that means I will not tear into you now; instead I will save this for when I really need it.

I threw all seven of my sigmas at solving a zero-sigma problem, looking for a complex solution when an easy one would have worked.

Patient Experience Management (PEM) solutions are often approached in the same manner—sigma overkill—reengineering some arcane, one-off process without taking time to understand the real nature of the problem or its outcome.

In yesterday’s blog we drew a comparison between clinical PEM and non-clinical PEM (http://wp.me/pyKA6-Ih).  We also inferred that non-clinical PEM processes are not unlike some of the process employed by hotels.

So, what might be done to improve non-clinical PEM?  What easy wins can be achieved?

When you arrive at a hotel for an event or an overnight stay where do you go?  You go to Reception or to the front desk to check in.  When you leave you go to the same place to check out, or you bypass the process and simply leave.  You can do that because you have been a guest of the hotel.

Now let us look at the same process at a hospital.  Where do you go?  You go to Admissions, and to leave you go to Discharge.  Other than hospitals, can you think of another establishment that uses the terms admissions and discharge?

Prisons.

Admission and Discharge are suggestive of many things, but the feeling that does not spring to mind is the notion that anyone working at the prison cares much about inmate experience management.  Admissions and Discharge do not evoke warm, welcoming feelings.  They do not lead you to feel that your stay is in any way voluntary.  In fact, even ignoring that the medical vernacular for the term discharge is often used with adjectives of color—the yellowish discharge—the term discharge infers that you do not have permission to leave until you are discharged.

Ever notice the big open space right next to admissions?  Know what it is called?

The Waiting Room.  What happens there?  You wait.  It is a special, nicely furnished place designed for you and others to do nothing, prepared for you to waste your time.

Your appointment was scheduled weeks ago.  You are probably apprehensive and a little worried about what may happen to you over the next few hours or days.  You have blocked out your calendar to be there—taken off from work, arranged for a baby sitter, and arranged for someone to prepare meals for the children while you are away.  You probably needed someone else to adjust their calendar to ensure you get to the hospital on time.  The hospital told you when to arrive.  You are there on time but someone somewhere is not ready for you.

Did they forget you were coming, or does the very nature of having a waiting room infer that their time is more valuable than theirs?  The hospital is not only okay with the idea that you will be made to wait, they have preplanned it as part of the patient experience and built a special place for that activity to occur.

This waiting experience reminds me of my flight arriving at the airport only to find out that there is no gate at which to park the plane or no attendant to roll the jet-way to the plane’s door.  How is this possible?  Have they not known for the last several months that every day at such and such time this plane will be arriving?

So, here we are.  We have not even been admitted and our non-clinical patient experience is already negative.

Sometimes the best solutions are the first ones overlooked.

Patient Experience Management: For Adults Only

Posted by

0

This post is the first in a series that may make you rethink everything you think you know about Patient Experience Management.

Last week I checked in to a hotel for three days; seventy-two hours.  I was at the hotel for an event that required ninety minutes; one-and-half hours.

A few weeks prior to my stay someone told me where I had to be, how long I would be there, and what I would be doing.  My reservation was made, and I sorted out how I would get to the hotel.

The check-in process was flawless.  My room was ready.  My wakeup calls were timely. The room was serviced daily.  Plates with food arrived.  Plates without food departed.  The requirements for my ninety minute event were met and I was escorted to the correct room.

On hour seventy-two I checked out of the hotel and I received a copy of my bill.  The last thing I encountered was having someone asking me how my experience was.

Try thinking the remainder of this discussion through with me.

Of the seventy-two hours I was at the hotel only two percent of it (1.5 hours) had to do with my reason for being at the hotel—the presentation I was giving at the HFMA.

So, you may ask, how did it go?  The speech or the stay at the hotel.  Two different experiences.  Let us say that my speech tanked, or that people couldn’t find the room, or that the projector did not work.  If someone asked me, how “was your speech,” I might conclude by saying, “The speech was awful, but the hotel was great.”

On the other hand, what if the hotel lost my prepaid reservation, was only able to give me one night instead of two, made me sit in the lobby for two hours because my room wasn’t ready, could not get the air conditioning working in my room, and then billed me for two nights instead of one.

If that was the case I would conclude that my experience was awful, and I would go out of my way to let everyone know about it.

To those who want to argue that a hospital is not a hotel I will concede the point.  However, I will argue that for those who actually wish to significantly improve patient experience management that much of the improvement can be made by treating it as a hotel, and by treating your patients as guests.

For the time being, let us agree to have this discussion separate and apart from the Emergency department—we will address the ED in a later post.

The patient experience, which many claim to be managing, may be grouped into two parts—the treatment, and then everything else that happens to you from the time you schedule your visit to the time when you finish paying you bill.

Most patients fully expect their experience of their treatment will be very positive—that is why they came to the hospital.  Patients know that for treatable issues they will leave the hospital better than when they entered.  Therefore, it is a given that they will rate their treatment experience as a positive one.  A positive treatment is considered de rigueur.

However positive, the patient often views their treatment experience as the result of the procedure they underwent.  If they came in for their gall bladder and leave without their left leg, no amount of explaining how well the amputation went will convince them their experience was positive.

Both inpatients and outpatients spend the bulk of their time in the hospital undergoing non-patient experiences and suffering through ineffective and impersonal processes.  All patients spend most of their time simply as visitors, as customers, as guests of your facility.  Unfortunately, few hospitals spend much time improving those processes that are common to all patients.

To improve in the area of patient experience management, break the person’s experience into two categories; clinical and non-clinical.  While there is merit in reengineering the processes around a hip transplant, doing so does nothing for everyone who did not have a hip transplant.

Over the next several posts I will suggest what can be done to improve the non-clinical patient experience in a way that can change how people view your hospital.

Is this today’s evolving healthcare strategy?

Posted by

0

Did the large provider healthcare model go from making all the ducks better to only making some of the ducks better?  Please let me know if the concept depicted below makes sense.

Thanks

Patient Experience Management

Posted by

0

Have I mentioned I am an unapologetically type A person, for the most part an off the chart Meyers Briggs INTJ? This morning I awoke feeling no more querulous than usual—that would change rather abruptly. In general, I make it a rule never to learn anything before having my first cup of coffee. Unfortunately, today wasn’t going to be one of those days. In fact, my mood was a direct result of the instrument pictured above.

These days I am using this device to make my coffee as my espresso maker’s LED screen is displaying a message telling me my grinder is blocked—sounds a little like something two tablespoons of Pepto should be able to fix, doesn’t it? Google was no help—three hits, each instructing me to send it back to the dealer for a $350 repair. Sounds more like a response you’d get regarding a car, not a coffee maker.

I brought this pot home, a gift from my client in Madrid. It works using the same principles as a pressure cooker. Water is placed in the bottom; an espresso grind goes above the water.  Steam is forced through the grind, past a metal sieve, and into the container where as it cools it is reconstituted as a liquid—coffee. Anyway, as my coffee is cooking, I notice the metal sieve sitting on the counter. It seemed like too much work to turn it off, rinse the pot, regrind the coffee, and wait the additional five minutes. I was too tired for a do-over.

Too bad for me. Now, I’m not sure if what happened next would be found under the topic of fluid mechanics, converting steam into thermal energy, or general explosives, but it would have made for an entertaining physics experiment. In what appeared to play out in slow motion—like the Challenger explosion—actually occurred in a fraction of a second. It seems the metal sieve does more than strain the grinds from the steam. It also prevents a thermonuclear reaction. Apparently when the pressure passes the fail-safe point, the reaction proceeds to the next logical step. That step, which I observed, involves coffee and grinds exiting the pot so rapidly that before I could blink they covered the kitchen walls, counters, and floors as far away as ten feet. (It was actually pretty impressive to watch.) I was informed that once I finish writing about my travails I will be attending to the mess.

The scene reminded me of one of the forensic shows on cable. I halfway expected the medical examiner Dr. Henry Lee to walk through my door to examine the splatter pattern.

The choice I faced was to do it over, or deal with the consequences. I was in a hurry, consequences be damned—it turns out that it wasn’t the consequences that would be damned. My guess is that I’m looking at at least thirty minutes of cleanup work.

It pays to invest the time to do something right the first time—I refer to that as the DIRT-FIT principle; sort of like dealing with patients. Let’s say a certain patient call takes nine minutes to handle correctly. As many of you have observed, there are two ways to go about this. You can do it over a period of several four minute calls because your people don’t want to get dinged for exceeding their handle time allotment, or you can allow the people to talk until the patient’s need is solved.

As patients, we know you prefer the first approach. Patients prefer the second approach.

What if there was no Meaningful Use?

Posted by

0

On April 16, 1912 there was an article in the Daily Register in Anytown, Nebraska titled “Local Man Drowns.”  The article went on to note that a local man was lost at sea.  I paused for a moment trying to recall from my high school geography class the name of the ocean bordering Nebraska—there is not one.

It did not take long to realize that the newspaper was guilty of being more than a little parochial.  April 14, 1912 was the day the Titanic sunk.  The man in question had been lost at sea in much the same manner that the real headline of the story had been lost by the newspaper.

I think a lot of important healthcare IT headlines are being lost, and those loses can in large part be attributed to the puppet masters at the ONC and CMS.  It is difficult to swing a dead cat in a hospital cafeteria without hitting someone discussing Meaningful Use.  On the other hand, you could swing a blue whale without hitting someone talking about ICD-10.

The headlines are both buried and misinterpreted.  Some of the HIT headlines merit being repeated—feel free to use a highlighter on your screen to be able to locate the important ones.  Trying to meet Meaningful Use:

  • Is optional.
  • Does not mean you will meet it.
  • Could require most of your IT resources.
  • Means you may not have enough resources focused on ICD-10.

While these may appear to be trivial comments, misapplying your efforts could cost a large hospital more than tem million dollars.  Then figure another ten million to rectify the mess.

Ask yourself one question before you hire a pricey consulting firm to help you figure out how to meet Meaningful Use.

“What would we be doing if there was no Meaningful Use?”

Then do that.  Meeting Meaningful Use was never a part of your business strategy—you probably will not find it written in your three-year plan.  Did anyone sign off on the notion of spending millions of dollars to complete a task that has no ROI and has a reasonable probability of failing?

If it so happens that in pursuing your original strategy you can still meet Meaningful Use that is good.  The reverse is not so good.

The Business Strategy of Meaningful Use

Posted by

2

For those interested in a somewhat irreverent presentation on the business issues of Meaningful Use who won’t be attending the New England HFMA this Tuesday, here is an advanced copy of my presentation  http://ow.ly/50etE

I’d like to know what you think…

Does it come in blue?

Posted by

0

The store for audiophile wannabe’s. Denver, Colorado. The first store I hit after blowing an entire paycheck at REI when I moved to Colorado.

The first thing I noticed was the lack of clutter, the lack of inventory. There were no amplifiers, because amplifiers were down market. There were a dozen or so each of the pre-amps, tuners, turntables, reel to reel tape decks, and these things called CD players. They also had dozens of speakers. At the back of the store was an enclosed 10 x 10 foot sound proof room with a leather chair positioned dead center.

When the ponytailed salesperson asked about my budget, like a rube I told him I didn’t have one. He beamed and took that to mean it was unlimited. It really meant I hadn’t thought of one. He asked me what I liked to listen to.

“Pink Floyd, Dark Side of the Moon.”

Within a few seconds I was seated in Captain Kirk’s chair, and Pink Floyd’s Brain Damage filled the room in pure digital quadraphonic sound. I was in love.

I lived a block and a half away. Since the equipment wouldn’t fit in my Triumph, I made several trips carrying home my new toys—gold plated monster cable, solid maple speakers that rested on nails so as to minimize distortion, a pre-amp, tuner, receiver, turntable, and stylus.

It wasn’t that I deliberately bought stuff I didn’t need. I walked in uneducated. I had never bought what I was looking at. I didn’t know how much to spend, nor what it would do for me. Looking back at that purchase decision, I bought specs I didn’t need. I didn’t realize it was possible to build audio technology that would meet performance specs beyond what I person could hear, heck beyond what anything could hear. Not understanding that possibility, I bought specs I couldn’t hear. I spent hundreds of dollars on features from which I would never receive value. You too?

It happens all the time. Stereos. Cars. Computers. Applications. Technology. Having bought it doesn’t mean it was needed, or that it was the right thing to do, or that it has an ROI, or that it meets the mission.

The cool thing is that even though I could not hear half the features of my new stereo, it looked really, really impressive.

Why isn’t EHR more successful?

Posted by

1

Grab a soft-drink—this one is rather long. Please forgive any formatting mistakes–it looked good in Word.

I have never been one who thinks hit-and-run critiquing is fair. It is too easy to throw metaphorical tomatoes at an idea with which you disagree. As such, perhaps instead of just being critical of the national EHR rollout plan, here are a few ideas which may be worth exploring in more detail.

It just occurred to me that the ONC’s role, the Office of the National Coordinator, is just that—coordination. Who or what is the ONC supposed to be coordinating—among its various functions–the providers? There are the coordinators, and their constituents—the uncoordinated. I know at least one provider who already spent $400 million on its EHR. They didn’t get coordinated. I asked one of their executives who played a major oversight role in the implementation, with whom they worked at the ONC. She was not even familiar with the acronym.

I don’t think providers are looking to be coordinated—they are looking to be led. I also think they are looking to be asked and to be heard. They are looking for answers to basic questions like; why should we do this, what is in it for me—this has nothing to do with incentive dollars.

It often seems like the ONC has developed many solutions seeking a problem, filling their tool bag in the hope they brought along the right one. This is where I think we see a good portion of the disconnect. It is better to say we know where we are going, but getting there slowly, instead of, we don’t know where we are going but we are making really good time.

People don’t buy drills because they need a drill—they buy them because nobody sells holes—say it with me—holes. Providers need holes, not HIEs and RECs.

You understand the pressures you face much better than do I. Has anyone from the ONC asked you if they should reconsider their plan, their approach, their timing? Chances are good that you are not implementing EHR and CPOE because you have a vision or a business imperative of someday being able to connect your EHR to Our Lady of Perpetual Interoperability. CIOs and their peers are not spending eight or nine figures because you want a virtual national healthcare infrastructure. The C-team is investing its scarce resources to make its operation better, to reap the rewards of the promise of EHR.

The ONC is spending its resources towards a different goal, a virtual national healthcare infrastructure. The two goals do not necessarily overlap. I am reminded of the photo showing the driving of the Golden Spike—the connecting of the Union Pacific Railroad to the Central Pacific Railroad—the final link of the Transcontinental Railroad that in the 1870’s allowed Americans to cross the US by rail. What would have happened had the two railroads worked independently of each other? They would have built very nice railroads whose tracks would never have met, tracks dead ending in the middle of nowhere. Even if they almost met, say got within a few feet of each other, they would have failed.

There are those who see the work of the ONC as a real value-add. I dare say that most of those are not hospital CIOs or physicians. Both groups define value-add and success differently.

This is not to say that providers would not accept all the help they can get. However, providers want the help to be…what is the word I am searching for—helpful—to them, to their issues. The ONC’s mission will not work until the providers successfully deliver what the ONC needs from them. How many providers must be Stage 7, Meaningful Use, Certified compliant for the virtual national healthcare infrastructure to work? Fifty percent? Eighty? Who knows.

So, the providers own the critical path. It is all about the providers, bringing fully functional EHR systems to hospitals and physicians. The numbers I have seen do not paint a promising picture. The critical path is in critical condition. Ten percent hospital acceptance and a sixty percent failure rate. Let’s say those numbers are wrong by a factor of three—thirty percent acceptance, and a twenty percent failure rate. Even those numbers do not bode well for ever achieving a virtual national healthcare infrastructure under the current plan. Subtract from those figures—supply your own if you would like—the churn figures—those hospitals that are on their second or third installation of EHR. Something is amiss.

In a more perfect world the ONC might consider shifting course to something aligned with the following:

• Segment its mission into two parts; one to build a virtual national healthcare infrastructure, and two, provide hands-on support individual hospitals’ and providers’ EHR initiatives.
• Standards
• Standards—I wrote that twice because it is important to both missions
o Let us be honest, the largest EHR vendors do not want standards. Why? Because if all else fails, their standards become the standards. They don’t phrase it this way, but one can assume, their business model calls for them to do what is best for them.
o The vendors do not want to open their APIs to the HIEs
• Do not set dates for providers which to be met require meeting rules which do not yet exist. If the government wants providers to meet its dates, the government must first meet some of its critical success factors—standards, for example.
• Mandate vendor standards for however many vendors make up ninety percent of the EHR install base for hospitals. Give vendors 18-24 months to agree to a set of standards and have them retrofit their applications.
• Use a garrote and stick approach on the vendors. Create a standards incentive program, heck, underwrite it. Pay the vendors to develop and get on a single set of standards—this will have a much more positive impact than REC and PR money. Many will say, especially those who have an incentive for this not to happen, this cannot be done. Of course it can.
• Processes. EHRs are failing in part due to not enough user involvement, not enough user authority and governance. There is no usable decompositionable process map of how a hospital functions. No Level Zero through Level Whatever You Need. No industry standard, mega-diagram, boxes and arrows, which can be laid on a table or hung on a wall that shows, “This is what we do. This is how it all ties together.”
• I am building this process map, along with a colleague. Why isn’t the ONC? It will not match you hospital. It may not match anyone’s hospital. What it will do is give someone a great base from which they can edit it. Why is this important? Because it will enable the users, IT, and the vendor to overlay the EHR application to show:

o which business and clinical areas are impacted
o the process interfaces
o duplicated processes
o processes with no value-add
o which other facilities have similar and differing processes
o where change management resources must be focused
o what needs to happen if an acquisition is made

The ONC must move from coordinating to leading. To do that they need the authority to mandate the execution of some of the items listed above.

The McDonald’s healthcare business model

Posted by

2

Sarah Palin continues to receive national media coverage.  Many hospitals continue to implement EHR without any measurable goals.  (One of those is bad.)

The year is 2014.  I had this dream the other night of having dropped my IQ when I was at the hospital, but I couldn’t remember which hospital, so off I went, hospital by hospital looking for my IQ—I realize there are those of you who believe this isn’t a great loss.

In the first hospital I visited, a photo of the new president hung behind the registration desk.  Next to her photo—surprised some of you with that I bet—hung the photo of the Secretary of Hospital Sameness.  For a while I wondered what someone in that position did day to day.  The more hospitals I visited, the more apparent it became.  The hospitals all looked very much alike, right down to dust on the fake Fichus tree next to the water fountain.  For a while I thought that maybe I was driving in circles until I noticed that even though receptionists were all named Gladys, they wore different clothes.  It was almost like visiting Stepford.

Does anyone have the sense that what reform will really accomplish is to reform away healthcare competition?  There appears to be a move afoot towards the efficiency that is created by sameness—what I call the McDonalds healthcare model.  Put one on every corner.  Make them identical.  Limit the options.  Everyone gets a burger.  Nobody gets a steak.

Eliminate waste.  Does that mean eliminate ways of operating that differ from how the government permits them to operate?  There is talk of pulling costs out of the system thereby making it more efficient.  You tell me.  Is the argument that there is so much inefficiency that by becoming efficient not only will we be able to cover everyone, but we will be able to do it at a cost below what it costs to care for far fewer people?

How do you understand it?  Are costs being removed, or simply moved?  If someone with no access to healthcare suddenly has healthcare—a good thing by almost anyone’s standards—the reasoned person knows costs have just increased.  (Healthcare theorem 1:  The cost to provide healthcare to 2 people is greater than or equal to the cost to provide it to one person.)  If costs have increased, how does one make a believable argument that the basis for reform is cost reduction?

I try hard not to be too cynical, but sometimes I think, why bother.  By the way, I found my IQ.  Thanks for asking.

Disruptive Strategies: a business imperative

Posted by

0

When you think about it, companies begin to die the day they are born.  Some last longer than others, and some are reborn after they die–think GM.  Others may be caught in a death by stagnation spiral.  Microsoft may be a good example–has their lack of innovation caught up to them, or is Windows 37.9 considered innovative?

Disruption.  If you do not like the word, here are a few others that work just as well–disassemble, dismantle, unhinge, and disengage. Disruption is only a first step.  Once you disrupt you then must rebuild. Knowing what to rebuild is the critical success factor.

My new favorite business toy is Prezi.com.  This Prezi link is for a speech I gave last year at ICSI on why disruption is not only good for hospitals, but may in fact be a survival imperative.

For those who like to read bullet points, this presentation may not be for you.  I welcome your feedback on the tool and the ideas, especially since I wrote very little text.  I approach presenting ideas by trying to get the audience to listen to what is said rather than simply reading slides–otherwise I my being there would be superfluous.  Besides, people don’t take notes at the movies, why should they during a talk.

http://prezi.com/ved_jyx95m_d/