Spilling Tea–Why Your Business May Be Failing

Years ago the word Lubyanka was enough to bring normal Russians to their knees in terror.  Lubyanka is known best for being the headquarters of the Soviet secret police, then called the KGB.  The basement of Lubyanka housed a prison which had one hundred and eleven cells, cells that were used to hold and interrogate political prisoners during Russia’s purge.

Two times each day the prisoners were given tea.  A prisoner in each cell would place a teapot outside the cell. Another prisoner, carrying a bucket filled with tea, would pour tea from the bucket into the teapot.

Tea spilled on to the floor.  The prisoner would clean the spilt tea with a rag.

Lubyanka’s prison operated for twenty-seven years.  Tea was served to the one hundred and eleven cells and spilled in front of each cell twice a day, seven hundred and thirty times a year per cell.

Two million one hundred eighty-eight thousand spills during those twenty-seven years.  The same number of cleanups.

Someone somewhere made the decision that it was easier or cheaper to spill and clean the tea 2,188,000 times than it was to use buckets with spouts on them.

What are the buckets in your company?  What dumb, wasteful, redundant activities and processes have been left unchanged?

The most obvious one for most companies is customer care.

It is easier to take 2,188,000 calls each year about a given problem than it is to fix the problem.

And do you know where the fallacy in the argument is?  The fallacy comes from the erroneous belief that by having a call center, by answering calls you are actually providing your customers a service.

You are not.  All you are doing is wiping up spilt tea.

 

Poor Project Planning–Musings of a drive-by mind

It takes a lot of energy to dislike someone, but sometimes it is worth the effort. It is not easy being a consultant.  One client required me to shout “unclean, unclean” as I passed through the hallways.  Maybe that is why I leave newspapers scattered around the floor of my desk, so nobody can sneak up on me without me being able to hear them.

I have a knack for complicating simple things, but the voices in my head tell me that is better than simplifying complicated things.  Either way, I appreciate those of you who continue to play along.  Just remember, if you choose to dine with the devil it is best to use a long spoon.

You’ve probably figured out that I am never going to be asked to substitute host any of the home improvement shows.  I wasn’t blessed with a mechanical mind, and I have the attention span bordering on the half-life of a gnat.

I’ve noticed that projects involving me and the house have a way of taking on a life of their own.  It’s not the big projects that get me in over my head—that’s why God invented phones, so we can outsource—it’s the little ones, those fifteen minute jobs meant to be accomplished during half-time of a football game, between pizza slices.

Case in point—touch-up painting the trim in your house.  Can, brush, paint can opener tool (screwdriver).  Head to the basement where all the leftover paint is stored.  You know exactly where I mean, yours is probably in the same place.  Directions:  grab the can with the dry white paint stuck to the side, open it, give a quick stir with the screwdriver, apply paint, and affix the lid using the other end of the screwdriver.  Back in the chair before the microwave beeps.

That’s how it should have worked.  It doesn’t, does it?  For some reason, you get extra motivated, figure you’ll go for the bonus points, and take a quick spin around the house, dabbing the trim paint on any damaged surface—window and doorframes, baseboards, stair spindles, and other white “things”.  Those of us who are innovators even go so far as to paint over finger prints, crayon marks, and things which otherwise simply needed a wipe down with 409.

This is when things turn bad, just as you reach for that slice of pizza.  “What are all of those white spots all over the house?”  She asks—you determine who your she is. if you do not have one I can let you borrow mine.  You explain to her that it looks like the way it does simply because the paint is still wet—good response.  To which she tells you the paint is dry—a better response.

“Why is the other paint shiny, and the spots are flat?”

You pause.  I pause, like when I’m trying to come up with a good bluff in Trivial Pursuit.  She knows the look.  She sees my bluff and raises the ante.  Thirty minutes later the game I’m watching is a distant memory.  I’ve returned from the paint store.  I am moving furniture, placing drop cloths, raising ladders, filling paint trays, all under the supervision of my personal chimera.  My fifteen-minute exercise has resulted in a multi-weekend amercement.

This is what usually happens when the project plan isn’t tested or isn’t validated.  My plan was to be done by the end of halftime.  Poor planning often results in a lot of rework.  There’s a saying something along the lines of it takes twice as long to do something over as it does to do it right the first time—the DIRT-FIT rule.  And costs twice as much.  Can you really afford either of those outcomes?  Can you really afford to scrimp on the planning part of IT?  If you don’t come out of the gate correctly, it will be impossible.

Back to my project.  Would you believe me if I said I deliberately messed up?  Maybe I did, maybe I didn’t, but the one thing I know with certainty is that I now have half-times all to myself.

A whimsical solution to illegal immigration

Another week of conventions got me thinking.  What is all this discussion concerning illegal migration and Borders?

Some people want to build a wall; some want to be the wall.  On one end, Mexico, the problem is illegal immigration.  On the other, Canada, the problem that is not being addressed is legal migration.  However, if not for Canada, we would have fewer comedians and television news anchors.

Here’s my take on the matter, an approach I think that has been overlooked.  If the problem is too difficult, reframe the problem to make it easier to solve.  The government defines the problem as one requiring the US to defend five thousand miles of borders.  Their idea—build a wall.  Perhaps we could outsource the solution to the Chinese, have them build The Great Wall, Version 2.0,  turn it into a sight-seeing opportunity, sort of a destination hot spot, and use the tourism dollars to pay back the Chinese.  This way, English-speaking people from around the world could come see the Wall, take in the Grand Canyon, and Hoover Dam, and leave their tourism dollars in the US.

Instead of wrestling with how to defend five thousand miles of border, what if the border was shorter?  How?  Buy Mexico, and bring the troops home from Afghanistan and overthrow Canada.  If we owned Mexico, it solves two problems.  One, the border we would then need to defend becomes just a few hundred miles, Guatemala and Belize.  They could get all the supplies needed for that wall from Home Depot.

Second, why do people from Mexico sneak into the US?  Because they want to come to America.  If we bought Mexico, Mexicans would already be in America, hence, there would be no need to come to America.  I realize this argument is a bit existential, but the argument might work.

Looking north, if Canada became the fifty-first state—of course we would try to force France to take Quebec—the northern border becomes the Arctic Circle.  At that point, the only people we would need to defend against would be the Intuits and Santa Claus.   If we were to get Canada, our petroleum reserves would increase, and we’d be able to purchase prescription medicines for less money. Heh?

Maybe the feds could learn a few things about security from Borders, the bookstore.  The security at their stores far outstrips the security at our borders.

Your EHR: Is it Well & Good?

There were four of us, each wearing dark suits and sunglasses, walking uniformly down the street, pausing at a cross-walk labeled “consultants only”—I think it’s a trick because a lot of drivers seem to speed up when they see us. We looked like a bad outtake from the movie Reservoir Dogs. We look like that a lot.

Why do you consult, some ask? It beats sitting home listening to Michael Bolton or practicing my moves for So You Think You Can Dance, I tell them.

Listening to the BBC World News on NPR whilst driving, there’s one thing I always come away with—they, the British, are always so…so British. No matter the subject—war or recession—I feel like I should sit up straight and having a proper pot of tea and little cucumber sandwiches with the crusts removed; no small feat while navigating the road.

Today’s NPR conversation included a little homily about the Gordian knot with which the company Timberland is wrestling, questioning whether as a company Timberland should do well, or do good. (Alexander the Great attempted to untie such a knot, and discovered the knot had no end (sort of like a Möbius strip, a one-sided piece of paper–pictured above. (For the truly obtuse, among which I count myself, the piece of paper can be given a half twist in two directions; clockwise or counter-clockwise, thereby giving it a handedness, making it chiral—when the narrative gets goofy enough, sooner or later the Word dictionary surrenders as it did with chiral.))) I’m done speaking in parentheses.

Should timberland do well or good? Knowing what little command some have of the English language, NPR’s listeners must have wondered, why ask a redundant question. Why indeed? That’s why I love the English, no matter the circumstances they refuse to stoop to speaking American.

Back to Gordo and his knot. That was the point of the knot. One could not have both—sorry for the homonym. Alexander knew that since the knot had no end, the only way to untie it was to cut it. The Gordian knot is often used as a metaphor for an intractable problem, and the solution is called the “Alexandrian solution”.

To the question; Well or good. Good or evil. Are the two choices mutually exclusive? For an EHR? They need not be, no matter how intractable the EHR. The question raised by the BBC was revenue-focused (doing well) versus community or green-focused (doing good). My question to the reader is what happens if we view EHR with this issue as an implication, a la p→q.Let’s review a truth table:

if P equals if Q equals p→q is
define requirements increase revenues

TRUE

play vendor darts increase revenues

FALSE

ignore change management increase revenues

FALSE

no connectivity increase revenues

FALSE

new EHR software increase revenues

FALSE

change processes increase revenues

TRUE

eliminate waste increase revenues

TRUE

decrease redundancy increase revenues

TRUE

Strong PMO increase revenues

TRUE

From a healthcare provider’s perspective the answers can be surprising; EHR can be well and good, or not well and not good.  The Alexandrian solution for EHR is a Alexandrian PMO.

Have your people call my people–we’ll do lunch.

Spilt Tea: Why companies choose to fail

At one time the single word Lubyanka was enough to bring normal Russians to their knees in terror.  Lubyanka is known best for being the headquarters of the Soviet secret police.  The basement of Lubyanka housed a prison which contained one hundred and eleven cells, cells used to hold and interrogate political prisoners during Russia’s purge.

Tea was provided to the prisoners twice each day.  A prisoner within each prison cell would place a teapot outside the cell. A prisoner, carrying a pail filled with tea, would pour tea from the pail into the teapot.

Tea spilled on to the floor.  The prisoner would clean the spilt tea with a rag.

Lubyanka’s prison operated for twenty-seven years.  Tea was served to the one hundred and eleven cells and spilled in front of each cell twice a day, seven hundred and thirty times a year.

Two million, one hundred eighty eight thousand spills.  The same number of cleanups.

Someone somewhere made the decision that it was easier or cheaper to spill and sop the water 2,188,000 times than it was to make pails with spouts on them.

What are the pails in your company?  What dumb, wasteful, redundant activities and processes have been left unchanged?

The most obvious one for most companies is call centers.

It is easier to take 2,188,000 calls each year about your bills than it is to fix the bills.  It is easier to take 2,188,000 calls each year about the bills than it is to get rid of the bills.  The same argument applies to a number of other processes.

And do you know where the fallacy in the argument is?  The fallacy comes from the erroneous belief that by having a call center, by answering calls you are actually providing your customers a service.

You are not.  All you are doing is wiping up spilt tea.

Who lost the ‘R’ in EHR’s ROI?

This is my latest post in healthsystemcio.com.

http://healthsystemcio.com/2011/07/14/standardization-lies-beyond-the-clinical-realm/#

As a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Let’s agree for the moment that workflows can be parsed into two groups—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs). (I read about this concept online via Sigurd Rinde.)

An example of an ERP industry is manufacturing. Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work—artistes.

Then there are the ERPs.  Remember The Flintstones and I Love Lucy?  Fred Flintstone was looking at a job advert for someone to put cotton in pill bottles; and Lucy got a job boxing bon bons.  ERPs are the easy business process to map, model, and structure. They are the perfect processes for large enterprise software vendors to automate.

EHRs contain both types of business processes, BRPs and ERPs.

How can you tell what type of business processes you are trying to incorporate in your EHR? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss ERP and BRP in the same sentence with EHR?  The reason is simple. The taxonomy of most, if not all EHR systems, is that EHRs are designed to support ERPs. Unfortunately, most of the business processes that the EHR has to model are one-off processes, BRPs.  Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to fit BRPs into an ERP system.

Since much of the ROI in the EHR comes from being able to redesign the workflows, it stands to reason that the ‘R’ in ROI will be sacrificed, and the ‘I’ will be much higher than planned.

On the other hand, if one looks at a hospital’s non-clinical business processes almost all of those are ERPs.  Many of them are some combination of being outdated, duplicated, and rework.  If you are looking to recover your ROI and to decrease cost, these ERPs offer a good opportunity to do both.

What do you think?

 

EHR: The 40-chicken crocodile

Got a couple hundred million burning a hole in your pocket?  Why not buy an EHR?  Indeed.

Riddle me this Batman, “What is a 40 chicken crocodile?”

It is the number of chickens you have to feed it each day to keep it from eating you. What is the crocodile at your hospital?  Is it your EHR?

Let me recount to you a true story about the details of one of the EHR “success” stories.  A major hospital who selected their EHR from among one of what I like to call the oligopoly EHR Flavor of the Month Club.  You know the suspects.

Permit me to throw a wrench to those clairvoyants who think they know where this is going before I’ve even written it.  Admittedly, I have a tendency to throw metaphorical tomatoes in one direction—that of the vendors.  That’s because, they are often easy targets.  Slow down Pepito.

This hospital, and from what I was told, the vendor, did it right.  I am not sure I would have differed from the approach of either.  The hospital spent a few years in its vendor selection process, and they were very thorough.  They spent two years building their process maps, ensuring the vendor implemented the EHR to meet their needs, not the other way around.  Operations led the nine-figure project.

They implemented many of the support functions and a few of the specialty functions.  Here come the chickens.  After implementation, cash flow dropped by 80 percent for several months due to significant issues they encountered cleaning up the revenue side.  Doctors were instructed to cut their hours by fifty percent to allow them to learn to use the system.  Hours are still down by twenty percent, well more than a year later.  Users use about one-third of the functionality, even after a rigorous training program.

The hospital held off doing most of the clinical implementations for two years.

I asked for some recommendations.  What would you have done differently?  Here’s what I learned.  If you have a research organization you need to spend extra special attention to their workflows.  Managing post-go-live was a big issue to begin to offset productivity losses. Without a continuous process improvement program the EHR would not have been accepted. Do not pick a go-live date at the outset of the project as it causes the organization to be paralyzed simply to hit the date.  Testing was compromised to meet the go-live date. The post go-live issues are still being fought.  Do not let the design or build teams skimp on either reporting or testing, they are still playing catch-up.

So, after doing a pretty bang up job, at least from where I sit, there are still a lot of chickens being fed to the crocodile.  Wonder how many chickens it would have taken had the users not been as involved as they were.  How many had the users not spent two years pre-build defining processes?  A lot.  Now comes the rest of the clinical effort.  See you at the poultry counter.