planning

Patient Experience Management: How to begin

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Here is my new post on http://www.healthsystemcio.com

Patient Experience Management (PEM) is not about Patients, but it is often designed just that way.  The problem lies with the plurality, the pesky little “s” that takes the design and implementation away from an individual patient, and places the focus on patients.

Other industries grapple with the same problem, only with them the issue comes about when designing and implementing systems and processes around customers instead of a customer.

Do you recall the talking points of the recent McKinsey survey about patient experience management?  The study made drew two conclusions.  First, ninety percent of hospital executives responded that improving PEM was their first or second priority within the next three to five years.  Second, those same individuals stated they did not expect much to happen regarding PEM because they did not know who in their organization ‘owned’ the PEM business problem.

Ignoring that issue, if only for the reason that almost everyone else seems to be taking the same approach, what if a hospital wanted to move forward and deal with PEM in a meaningful way—not meaningful as in the term Meaningful Use—but in a way whereby having a PEM system actually yielded something for the hospital?

Few industries have done a stellar job with Customer Experience Management (CEM).  What can be learned from their failures?  Plenty.  The failure of CEM systems originates at the get-go. The organization does a poor job of defining its business problem, deciding it needs a system to manage its customers, as though all customers are the same.  With that as its target, it goes out and finds and implements such a system.

Here is the problem from the perspective of PEM, and in some regards for EHR.  Whatever system you choose for PEM, CEM, or for that matter EHR has been designed to address thousands of individuals as a single entity called “our patients” or “our customers.”  The system is build upon managing the experiences of a core set of patient attributes.  Chances are good that whatever PEM system you select—they really are pretty much the same—will address roughly seventy percent of the functional requirements of this entity called “our patients.”

Applications vendors build solutions and hope to find a problem which matches the system they built.  If all your individual patients fit neatly into their vision of this “our patients” entity your worries are over.  If however, patients are different, which they are, they will have many needs which lie outside of the boundary of their application.  It is these set of needs—functional requirements—upon which the success or failure of your PEM will be based.  These same needs are the ones that are unmet today.  These are the ones, the outliers, which raise the ire of your patients and the ones lowering your organizations PEM scores; assuming you track this.

One way to solve this problem, in fact, to my knowledge to only way is to start by defining rigorously the functional requirements of one patient, a super-patient, which encompasses every requirement.  With this done, you have a PEM model, based on a single patient.  Now instead of having PEM requirements which lie outside of the boundaries or core competencies of what a vendor wants to sell you, you have a turbo charged set of requirements.  The diverse PEM requirements of your individual patients are contained within the capabilities of the defined super-patient.

If you approach PEM this way you have defined for yourself a solvable problem.  You now have a problem looking for a solution instead of a vendor with a solution looking for a problem.

HIT/EHR: A little adult supervision

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Among other things, EHR requires adult supervision like parenting.  My morning was moving along swimmingly.  Kids were almost out the door and I thought I’d get a batch of bread underway before heading out for my run.  I was at the step where you gradually add three cups of flour—I was in a hurry and dumped it all in at once.  This is when the eight-year-old hopped on the counter and turned on the mixer.  He didn’t just turn it on, he turned it ON—power level 10.

If you’ve ever been in a blizzard, you are probably familiar with the term whiteout.   On either side of the mixer sat two of my children, the dog was on the floor.  In an instant the three of them looked like they had been flocked—like the white stuff sprayed on Christmas trees—I guess we could call them evergreens—to make them look snow-covered.  (I just em-dashed and em-dash, wonder how the AP Style Book likes that.)  So, the point I was going for is that sometimes, adult supervision is required.

What exactly is Health IT, or HIT?  I may be easier asking what HIT isn’t.  One way to look at it is to consider the iPhone.  For the most part the iPhone is a phone, an email client, a camera, a web browser, and an MP3 player.  The other 85,000 things are other things that happen to interact with or reside on the device.

In order for us to implement correctly (it sounds better when you spilt the infinitive) HIT and EHR a little focus on blocking and tackling are in order.  Some write that EHR may be used to help with everything from preventing hip fractures to diagnosing the flu—you know what, so can doctor’s.  There are probably things EHR can be made to do, but that’s not what they were designed to do, not why you want one, and not why Washington wants you to want one.  No Meaningful Use bonus point will be awarded to providers who get ancillary benefits from their EHR especially if they don’t get it to do what it is supposed to do.

EHR, if done correctly, will be the most difficult, expensive, and far reaching project undertaken by a hospital.  It should prove to be at least as complicated as building a new hospital wing.  If it doesn’t, you’ve done something wrong.

EHR is not one of those efforts where one can apply tidbits of knowledge gleaned from bubblegum wrapper MBA advice like “Mongolian Horde Management” and “Everything I needed to know I learned playing dodge ball”.

There’s an expression in football that says when you pass the ball there are three possible outcomes and only one of them is good—a completion.  EHR sort of works the same, except the range of bad outcomes is much larger.

 

EHR: How important is due diligence?

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What was your first car?  Mine was a 60’ something Corvair–$300.  Four doors, black vinyl bench seating that required hours of hand-stitching to hide the slash marks made by the serial killer who was the prior owner, an AM and a radio, push-button transmission located on the dash.  Maroon-ish.  Fifty miles to the quart of oil—I carried a case of oil in the trunk.  One bonus feature was the smoke screen it provided to help me elude potential terrorists.

I am far from mechanically inclined.  In high school I failed the ASVAB, Armed Services Vocational Aptitude Battery—the put the round peg in the round hole test.  Just to understand how un-complex the Corvair was, I, who hardly knows how to work the radio in a new car, rebuilt the Corvair’s alternator—must not have had many working parts.  Due the the excessive amount of rusting I could see the street from the driver’s side foot well.

However, it had one thing going for it; turning the key often made it go—at least for the first three or four months.  Serves me right.  The guy selling the car pitched it as a date-mobile, alluding to the bench front seat.  Not wanting to look stupid, I bought it.  Pretty poor due diligence.  An impulse purchase to meet what I felt was a social imperative—a lean, mean, dating machine.

The last time I made a good impulse purchase was an ice cream sandwich on a hundred degree day.  Most of my other impulse decisions could have used some good data.  The lack of good data falls on one person, me.

How good is the data you have for deciding to implement an EHR?  In selecting an EHR?  Did you perform the necessary due diligence?  How do you know?  Gathering good data is tedious, and it can lack intellectual stimulation.  I think it affects the same side of our brain as when our better half asks us to stop and ask someone for directions; we like being impulsive, and have built a career based on having made decisions on good hunches.

The difference between you buying and EHR and me buying a clunker is that when I learned I’d made a poor decision I was able to buy a different car.  You can’t do that with an EHR that has more zeros in the price tag than the Dallas Cowboys front line.  Plenty of hospitals are on EHR 2.0–they also happen to be on CIO 2.0. while CIO 1.0 is out shopping for a Corvair.

The effect of poor planning

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I’ve always considered myself to be rather athletic, although I must have been on break when they handed out the coordination genes.  Perhaps that is why I tended towards individual efforts like running.

As it was, I was fairly good at ice skating as long as I was moving forward, the straighter the better.  Turning and stopping required an abundance of room, and an absence of other skaters.

Whoever came up with the notion that if you can ice skate you can roller skate was either lying through his teeth, or I became skating’s anti-matter.  At the time of my first attempt at roller skating I was unaware that ice and roller skating skills weren’t transferable.  Have I mentioned I like having an audience?  I decided to audition my roller skating skills at a public skating rink while on a first date.

The night was proceeding swimmingly.  I learned quickly that if I stayed to the edge and leaned towards the center of the rink, centrifugal force would keep me from falling.  My confidence in my abilities began to build.  Music boomed from the overhead speakers.  Several couples held hands, the more skilled ones crossed their arms in front of them and held hands.  I locked on to my date’s wrists and eased us into the first turn.  The song switched to Barry Manilow’s “I write the songs.”  To my misfortune–an the misfortune of everyone else, I knew the words, and began to serenade my date.  When an alpha-male sings Barry Manilow in front of anyone but his own shadow, only two things can happen and they’re both bad.

We hit the second turn and I began to accelerate.  We sped past a number of couples.  I sang louder, concentrating more on the words than on the task of keeping us both upright.

For those unfamiliar with the design of roller skates I should explain what I perceive to be a fatal design flaw—one which you will note has been eliminated in roller blades.  The flaw?  On the front of each roller skate about an inch from the bottom is a round rubber device that resembles a stunted hockey puck.  It serves no known purpose other than to sucker punch novice skaters.  If you mistakenly try to build speed by pushing off with the toe of your roller skate—as you do in ice skating—you are actually hitting the emergency brake.  And because the brake is at the front of the skate, the physics is such that once your feet stop, the only direction the rest of your body can go is head over heels.

I pushed off with the front of my foot; big mistake.

I looked like I had purposefully launched us over a pommel horse.  During the first few seconds of my flight I was reluctant to let go of my date’s hands.  I thought that if we fell together that there was some small chance that I could shift the blame for the crash to her.  We separated at speed and created sort of a demolition derby for those around us; bodies piling up like logs awaiting entrance to a saw mill.  For the rest of the evening it felt like people were pointing at me as if to say, “Steer clear of him, he’s the one who took us all out.”

My one mistake caused a chain reaction of bad events and a severely hematomaed ego.  Bad things rarely happen in a vacuum.  There’s cause and effect, and the effect can be disastrous.  For those of you whose EHR program is underway who may have scrimped on the planning process—you know who you are—you may as well be the captain of the Titanic throwing refrigerant in the water.  There is no recovery from bad planning.

No matter what the shape of your EHR implementation, if you find yourself humming a few bars of “I write the songs”, only two things can happen and they’re both bad.

What are the voices telling you?

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My favorite thing about healthcare is having witnessed it up close and personal both as a cancer patient in the 80’s and as the survivor of a heart attack seven years ago.

I was fortunate enough to have testicular cancer before Lance Armstrong made it seem kind of stylish.  Caught early, it’s one of the most curable cancers.  As those who’ve undergone the chemo will attest, the cure is almost potent enough to kill you.

I self-diagnosed while watching a local news cast in Amarillo where I was stationed on one of my consulting engagements.  As we were having dinner, my fellow consultants voted to change the channel—I however had lost my appetite.  I went to my room, looked in Yellow Pages—see how times have changed—and called the first doctor I found.  This is one of those times when Never Wrong Roemer hated being right.

So, yada, yada, yada; my hair falls out in less time than it took to shower.  A few more rounds of chemo, the cancer’s gone and I start my see America recovery Tour, my wig and I visiting friends throughout the southeast.  If I had it to do over, I would go without the wig, but at twenty-seven the wig was my security blanket.  I don’t think it ever fooled anyone or anything—even my house plants snickered when I wore it around them.

I owned a TR-7 convertible—apparently it never lived up to its billing as the shape of things to come, more like the shape of things that never were.  My wig blew out of the convertible as I made my way through Smokey Mountain National Park.  I spent twenty minutes walking along the highway until I spotted what looked like a squirrel laying lifelessly on the shoulder—my wig.

The last stop on my tour was at a friend’s apartment in Raleigh.  Overheated from the long drive and the August sun, I decided to take a few laps in her pool.  I dove in the shallow end, swam the length of the pool, performed a near-flawless kick-turn and eased in to the Australian Crawl.  As I turned to gasp for air, I noticed I was about to lap my hair.  I also noticed a small boy, his legs dangling in the water, with a look of astonishment on his face.

My ego had reached rock bottom and had started to dig.  Realizing my wig wasn’t fooling anyone but me, I had one of those “know when to hold ‘em, know when to fold ‘em moments” and never again wore the wig after learning it was such a poor swimmer.

Do you get those moments, or get the little voice telling you that your EHR strategy isn’t fooling anyone?  It’s okay to acknowledge the voices as long as you don’t audibly reply to them during meetings—I Twitter mine.

Sometimes the voices ask why we didn’t evaluate the EHR vendors with a detailed RFP.  Other times they want to know how that correspondence course in project management is coming along.  It’s okay.  As long as you’re hearing the voices you still have a shot at recovery.  It’s only when they quit talking that you should start to worry.  Either that, or try wearing a wig.

 

How’s the EHR vendor performing?

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Many organizations have a Program Management Office and a Program Steering Committee to oversee all aspects of the EHR.  Typically these include broad objectives like defining the functional and technical requirements, process redesign, change management, software selection, training, and implementation.  Chances are that neither the PMO or the steering committee has ever selected or implemented an EHR.  As such, it can be difficult to know how well the effort is proceeding.  Simply matching deliverables to milestones may be of little value if the deliverables and milestones are wrong.  The program can quickly take on the look and feel of the scene from the movie City Slickers when the guys on horseback are trying to determine where they are.  One of the riders replies, “We don’t know where we’re going, but we’re making really good time.”

One way to provide oversight is to constantly ask the PMO “why.”  Why did we miss that date?  Why are we doing it this way?  Tell me again, why did we select that vendor?  Why didn’t we evaluate more options?  As members of the steering committee you are responsible for being able to provide correct answers to those questions, just as the PMO is responsible for being able to provide them to you.  The PMO will either have substantiated answers, or he or she won’t.  If the PMO isn’t forthcoming with those answers, in effect you have your answer to a more important question, “Is the project in trouble?”  If the steering committee is a rubber stamp, everyone loses.  To be of value, the committee should serve as a board of inquiry.  Use your instincts to judge how the PMO responds.  Is the PMO forthcoming?  Does the PMO have command of the material?  Can the PMO explain the status in plain English?

So, how can you tell how the EHR effort is progressing?  Perhaps this is one way to tell.

A man left his cat with his brother while he went on vacation for a week. When he came back, he called his brother to see when he could pick the cat up. The brother hesitated, then said, “I’m so sorry, but while you were away, the cat died.”

The man was very upset and yelled, “You know, you could have broken the news to me better than that. When I called today, you could have said the cat was on the roof and wouldn’t come down. Then when I called the next day, you could have said that he had fallen off and the vet was working on patching him up. Then when I called the third day, you could have said he had passed away.”

The brother thought about it and apologized.

“So how’s Mom?” asked the man.

“She’s on the roof and won’t come down.”

If you ask the PMO how the project is going and he responds by saying, “The vendor’s on the roof and won’t come down,” it may be time to get a new vendor.

 

What is meant by Healthcare 0.2 and 2.0?

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Last night I was explaining to my sister-in-law my notion about healthcare 0.2 and the need to transform it to healthcare 2.0.  She had no idea what I meant.  That’s a problem—not because she’s my wife’s sister but because she an executive at one of the top children’s hospitals.

I figured that if she didn’t understand what I meant, I may have also confused others—sort of like typing with a keyboard full of marbles.

I’ve written that healthcare is a 0.2 business being forced towards 2.0—H2.0.  What exactly do I mean by Health 0.2?  It could just as easily be 0.5 or 0.7.  The idea behind the label is that there is a large gap between where the healthcare business is, H0.2, and the future of the healthcare business, H2.0.

Permit me to share how I distinguish between the business of healthcare and the healthcare business.

  • The business of healthcare—clinical, care, patients
  • The healthcare business is paper intensive and duplicative and includes support business functions like:
    • Human resources
    • IT
    • Payroll
    • Vendor relationship management (VRM)
    • Patient relationship management (PRM)
    • Registration…and so forth

Successfully bridging the 0.2 to 2.0 GAP replies equally on foresight and planning.  For the change brought about by the bridge to take hold, change needs to be an ongoing event.

To begin the assessment, healthcare leaders must undertake an honest assessment of the organization’s strengths and weaknesses.  Sounds simple.  It’s not.  Hospitals are noted for their fiefdoms, and the fiefs, run mostly by doctors, aren’t big on being told there’s a better way to do things, nor are they keen on giving away control.

To change how the business is run, to make it more effective, and thus more efficient, requires that the major business functions be retooled.  This requires Change Management, which may require a change in management.

 

 

Who was the person who put in our first EHR system?

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The first home I bought was in Denver.  Built in 1898, it lacked so many amenities that it seemed better suited as a log cabin.  There was not a single closet, perhaps because that was a time when Americans were more focused on hunting than gathering.  Compared to today’s McMansions, it was doll-house sized.

It needed work—things like electricity, water—did I mention closets?  I stripped seven coats of paint from the stairs.  Hand-built a fireplace mantle and a deck.  One day I arrived home only to find my dog had eaten through the lath and plaster wall of the space which served as my foyer/family room/ living room-cum-hallway.  I discovered the plaster and lathe hid a fabulous brick wall.

My choice was to patch the small hole, or remove the rest of the plaster.  I knew nothing of patching holes, but felt pretty confident about my demolition skills.  Within an hour I had purchased man-tools; two mauls, chisels, and a sledge hammer.  I worked through dinner and through the night.  The only scary moment came as the steel chisel I was using connected to the wiring of two sconces which were embedded in the plaster.  On cold nights I can still feel the tingling in my left shoulder.

As the first rays of dawn carved their way through the frosted beveled glass of the front door, I wondered why I never before had noticed that the glass was frosted.  I wiped two fingers along the frost.  A fine coating of white powder came off the glass leaving two parallel tracks resembling a cross-country ski trail.  I surveyed the room only to see that the air made it look like I was standing inside of a cloud.  The fine white powder was everywhere, covering my Salvation Army sofa, a semi-matching machine-loomed Oriental rug from the Far East (of Nebraska), a two-ton Sony television, and a component stereo system that had consumed most of my earnings.

Bachelor living can be entertaining.  One of my climbing buddies moved in with me.  The idea was I’d keep the rent low, and he’d help me by maintaining the house.  He didn’t help.  I made a list of duties; he didn’t help.  I left the vacuum in the middle of the floor, for two weeks and he walked around it.  I made him move out, and advertised for a female roommate—an idea I now wish I’d marketed.  A girl from church came over to see the place.  I turned my back on her to allow her to view the house with a degree of privacy.  When I returned I found her on her hands and knees cleaning the bathroom.  I was in love.  It was like having a big sister and mother.  She even asked if it was okay if since she was doing her laundry if she did mine at the same time.  Life was oh so good.

Sometimes when one approach isn’t working it’s real easy to try something else.  And sometimes the something else gives you a solution in the form of a water-walker.  Healthcare IT and EHR aren’t ever going to be one of those sometimes.  There will be no water-walkers, no easy do-overs.  There won’t be anyone walking your hallways talking about their first wildly unsuccessful EHR implementation.  Nobody gets to wear an EHR 2.0 team hat.  Those who fail will become the detritus of holiday party conversations.  Who will be the topic of future holiday parties?  I’m just guessing, but I’m betting it will be those who failed to develop a viable Healthcare IT plan, whoever selected the EHR without developing an RFP, the persons who decided Patient Experience Management (PEM) was a waste of money.  The good news is that with all of those people leaving your organization there will be more shrimp for everyone else to eat.

I’d better go.  I just noticed somebody left the vacuum in the middle of the floor so I need to get cracking before my wife advertises for a female roommate.

EHR leadership isn’t always a democracy

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Cerealizable.

That’s my new word. I coined it the last time my wife was traveling and I was in charge of breakfast and making sure nobody missed the bus. Cerealizable is what happens when you walk into the kitchen and are confronted with two hungry dogs, three hungry kids, hair that needs brushing, homework assignments that need to be reviewed, and lunches that have to be packed.

Breakfast orders are shouted at me across the room as though I’m their short-order cook; pancakes, French toast, sausage, and who knows what else. What does one do? I was quickly headed down the path of self destruction, too many tasks and not enough taskers. I needed a light at the end of the tunnel and so I created one. I cerealized the problem; simplified it–turned into something I could solve. Go to the pantry, pull out the cardboard cereal boxes, three bowls, three spoons, and the gallon of milk. Check off breakfast.

In case you’re wondering, Cocoa Puffs still turn the milk brown, just like they did thirty years ago. Lunch orders began to be shouted across the bowls of cereal. Ham and cheese, PB&J, tuna–extra mayo, no celery. Once again small beads of perspiration formed quickly on my brow. For a moment I considered calling the school and telling them that all three were sick. That would solve the lunch problem, but it would also mean that the three of them would be home all day–my own private hostage situation. What to do? My coffee remained out of reach, still untouched. That explained the pending headache. Back to lunch. Cerealize it. “Everyone is buying lunch today,” I announced above the roar.

A half hour later, the din had subsided. I made a fresh cup of coffee and collected my thoughts. What had I learned from the exercise? Three things. One, some situations require leadership. Two, three children and one grownup is not time to establish a democracy. There is no Bill of Rights. To quote Mel Brooks, “It’s good to be the king.” Three, break the problem down into bite-sized pieces, don’t try to swallow the elephant whole.

That same approach works just as well with EHR grownups; clinical grownups and IT grownups. Improving the interaction takes leadership. Large, institution-changing projects involve pulling people out of their normal routines and relationships.  Solving problems will not involve a kumbaya moment–Program management is not a democracy. To succeed, the program champion, having created a vision, will have to break it down into bite-sized pieces.

 

EHR: there’s a difference between finished and done

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The phone rang last fall. It was the school nurse asking me if I would come pick up my seven year-old son. When I inquired as to the reason she informed me he exhibited the classic symptoms of the crud; tummy-ache, non-responsive, crying. She’s the nurse, so without better information, who was I to question her diagnosis?

We got into the car and the tears started to come again. “Do you feel like you’re going to be sick?” I asked as I looked at the leather upholstery. He didn’t answer me other than to whimper. He didn’t seem sick at breakfast. I remembered that he was crying last night, but that had nothing to do with his stomach. At first I thought it was related to the thunder. Nope. He was hugging his favorite dog, a five year-old Bichon.

We had learned a few weeks prior that the Bichon is ill and won’t ever be a six year-old Bichon. The person having the most difficulty with it is my youngest. I asked him if that was why he was crying in class and he confirmed that it was. Dads know everything, at least some times.

So, here’s the deal. The school nurse had done all the right things to diagnose my son’s problem, but she stopped short of determining what was wrong. Let’s try a more relevant situation from the perspective of an EHR implementation.  The word implementation sort of suggests that when you reach the point of having implemented that there’s nothing left to do.

There’s finished and then there’s complete.  Finished doesn’t mean the task is over until the system does what it was supposed to do.  Sort of like when W landed on the aircraft carrier.  If you didn’t do a good job of defining it up front you may never know the breadth of what was intended for the EHR.  In the case of EHR, done includes change management, work flow engineering, training, and user acceptance.

The point is, if it looks like you finished the EHR implementation, double check that you have before you take a bow. Technology alone will not an EHR implementation make, it is simply a part of the overall task.