Zen Project Management–Rule 1, don’t steal the plants

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(I sometimes find it helpful to recite my blogs using different voices, like Neil Diamond.  You?)

Do you ever look back with amazement on how naïve you were in your first job?  You walk in, your head so full of knowledge it feels like it should explode.  You’re just waiting for that first opportunity to release the pearls of wisdom accumulated during all those years of schooling.  I was pretty sure I knew almost everything that needed knowing.

With my newly minted MBA, I worked as the assistant to the CFO of a large petroleum services firm in Fort Worth, Texas.  Lot’s of visibility, lot’s of people watching my every move.

My first day on the job, I was expected to attend a meeting at 7:30 AM.  Overtime.  I brought donuts, knowing how hungry everyone must be because they hadn’t had time to eat breakfast.  As I soon learned, the others in the room had been there since 6 AM for another meeting—they were not impressed by my offer of donuts.  My boss walked me over to an east-facing window an pointed at the orange ball of light floating above the horizon.

“That’s the sun,” he said.  “It’s been up two hours—so have we.  It comes up this time every morning.  Get used to it.”

That went well.  I noted later that five PM had come and gone and nobody made any attempt to rush the doors.  I decided to leave around seven.  As I waited for the elevator I noticed that two very large plants in very attractive pots were being thrown away.  They’d be perfect for my barren apartment.  It took me several trips to get the plants and pots situated in my TR-7 convertible.  Over the next several days I noticed that next to the elevator bays on the other floors were identical plants in identical pots.  What was the likelihood that these were all being thrown away?  Probably zero I surmised–if you steal something without knowing you were stealing, is it really stealing (think Limewire)?

So, my first day on the job I unknowingly stole the company’s plants.  What would day two offer, a walnut credenza, brass lamps?  Gonna’ need a bigger car.

Do you know people like that on your project, those who portend to know everything that don’t?  Plant thieves.  Sometimes they masquerade as program managers, sometimes as vendors.  They hide what they don’t know behind a flurry of meetings, a full calendar, reams of emails.

It’s easier to spot the plant thieves than it is to stop them from adversely affecting your project.  It’s easy to observe, easier to complain about.  What to do about it?  Why are you asking me?  That’s why they pay you the big bucks.

 

Patient Relationship Management-Master of the Jedi Order

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They don’t call me Yoda for nothing. This little rant is for those acolytes drinking the Kool Aid of disbelief, the recipe that says one day, if we stay the course, this will all get better.  These are those who believe the light at the end of the tunnel isn’t a train.
For the next few minutes try and disassociate yourself from your responsibilities at work and become a patient.  Recall a time when you’ve been a dissatisfied patient and afterward felt the need to interact with your provider. If you’re totally honest, the forthcoming interaction should quicken your pulse. Cold beads of sweat appear on your forehead, your palms feel a little clammy, and you feel an unexplained need to microwave your neighbor’s cat.

The transition is faster than Clark Kent in a phone booth. A mild mannered and pedestrian acolyte transformed into a right-winged, Myers-Briggs INTJ A-Type with a passion for metaphorically devouring the unfortunate person awaiting your phone call.

As you think about managing the equity of your patients think about it from the perspective of the patient, goodness knows they do. That relationship is black and white—there are no shades of gray. It’s good versus evil, Yoda versus Darth Vader.

Patients Experience Management versus Patient Experience Management.  See that little ‘s’ tacked on to the word patient?  One letter makes a world of difference.  Patients do experience the decisions of your hospital’s management, and oftentimes that experience is unpleasant.  That experience can involve a broad range of issues–billing, insurance, dispute management, scheduling, prescriptions.

I think with most patient interactions the patients believe that the person on the other end of the line (think hospital customer service person) is incented to make them go away as quickly as possible and at the lowest possible expense to the provider.

For most patients, patient loyalty is a thing of the past.

With whom do you do business? Why? For any product that is even close to being a commodity, I deal with the firm who I find to be the least offensive, the one that will irritate me the least. That’s why I buy cars on eBay so I never again have to hear the phrase, “What’s it going to take to get you into that car?” If you find yourself doing that, why is it such a stretch to believe so many patients feel the same way? That said, could it be rather naïve to believe your hospital’s current approach to patient relationship management will make any difference?

Patients Experience Management-why not think like one?

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I met last week with a number of 1st Year MBA students who have a consulting club to help them figure out if they are suited for this noblest of all professions–supposedly the second oldest profession. “How can you tell if you’ll be any good at it?” They asked.

As far as I can tell, there are two basic requirements. One, you have to be a bit out of kilter, a strong dose of ADHD doesn’t hurt either. You have to hate repetition.   Second, it helps if you have a belief that there is almost nothing you couldn’t figure out how to improve. While thinking it doesn’t make it true, the attitude is a critical success factor.  It will also require being rather thick-skinned as some clients will require you to yell “unclean, unclean” as you walk their halls.

For example, last week I was at the post office.  Noon on the Wednesday before the holiday–lunch time rush hour.  I’m standing in a long line underneath a banner with a message emphasizing quality.

There are two clerks, postmen, postpersons, postladies–I’m not sure which one is most appropriate, but as we both know, I’m not going to lose any sleep over it either. The line is out the door. Clerk ‘A’ tells clerk ‘B’, “I’m going on break.” At which point I turned to the person next to me and uttered, “And I’m going to UPS.”   It’s not that difficult to improve.  Not letting half of your customer-facing employees go on break during your busiest time would be a good way to start to improve things.

It’s not rocket surgery. The title of the piece is not a typo.  Patients really do experience management, at least they experience many of their ill-conceived processes and rules.  Patient Experience Management, Patient Equity Management. Whatever you call it, big inroads can be made.  Quit thinking like an executive and start thinking like a patient and you’ll have plenty of ideas.

 

Today is not a dress rehearsal, or is it?

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Or is it? Who makes that determination? This is probably the one area of your job over which you still have the most control.

CIO shift, happens–or shift happens

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Another comment of mine to Barbara Quack’s post; http://ducknetweb.blogspot.com/2010/12/cio-confidence-in-meaningful-use-drops.html#comment-form

I think you hit the nail on the head.  I think a lot of this can be attributed to the fact that stuff rolls down hill and that shift happens.

In healthcare, as in every significant industry, part of the problem seems to come from the fact that CIOs are often considered to be part of the C-suite in name only.  There are several notable exceptions to this observation, CIOs who drive business strategy instead of merely implementing the business strategy that was developed in the “real” C-suite.  Many C-suiters perceive the real role of the CIO is to apply technology to accomplish what they (the C-suite) want done.

Many executives, CFOs, CMOs, COOs, and CEOs regard the position of CIO such that the “C” (chief) and “O” (officer) are honorariums; officers in name only, officers with commensurately sized offices located on the third floor or in an offsite location.  Responsibility often without authority.

I think the issue of Meaningful Use is a clear example of how the practice works.  I worked with a large group of hospitals whose CIO had a detailed IT strategy and plan—projects, ROIs, resources, and capital.  His plan was tied to the business plan which he helped author.

He did EHR and CPOE before EHR was de rigueur.  Then along came Meaningful Use.  Without any understanding of the business issues or consequences associated with meeting Meaningful Use, the C-er’s and the board decided that not meeting Meaningful Use was not up for discussion.  The analysis was thorough, but unimportant.

In a nutshell, the organization which had already implemented EHR and CPOE because of his thought leadership—and long before DC got into the EHR thought leadership business—was instructed to meet Meaningful Use, all else be damned.  The “all else” included whatever it was that eighty percent of his IT staff would have worked on during the next three years.

For the sake of a check, the IT strategy was sacrificed, and the IT strategy’s alignment to the business strategy was sacrificed.  Did they get the check?  Will they pass the Meaningful Use audit?  IT will be blamed if they fail to meet Meaningful Use.  They will be blamed when they fail to deliver all of the other parts of their original plan.  And, they will be blamed if the standards shift in mid-stream.  Why?  Shift happens.  Responsibility often without authority.

“Memo from the CFO: How’s that whole ICD-10 initiative coming?  Holler if I can do anything.”

And guess what’s coming around the corner?  The new hot topic to roll down hill will be the decision that comes out something like this; “Memo from the CEO: The board decided we need to be seen as an Accountable Care Organization by the end of 2012.  Holler if I can do anything.”

Information Technology—IT.  “That must be where we keep all the technology in case we need it.”  Just send out a request and one of those technology guys will put it in for us.

There is only one thing that will stop this train from making the office of the CIO the bucket into which the downhill water is running.  Lead.  Plan.  Instead of planning for what technology and IT resources you need to deliver to meet their orders, draft a healthcare strategy instead of an IT strategy.  Bring forth a business plan addressing business problems that uses technology as a solution to solve the problems.

Define what is needed, on top of what you already need, to meet ICD-10.

Define what is needed, on top of what you already need, to make ACOs viable.

If you wait to respond to their IT orders, it will be too late.

Healthcare Hero

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Hero is such a disposable word.  I thought it might be of interest to share the meaning of the word from the eyes of a ten year old.

Forgive me for stealing a minute of your time for these few paragraphs.  Although I rant about the healthcare system, and independent of whether it needs changing and how to change it, I am quite a fan.

Two years ago my 10-year-old son was given a writing assignment to draft a paragraph about his hero.  He wrote the following about an event that happened when he was 4,  which I subsequently framed and placed on my night stand—the spelling errors help authenticate the narrative:

“An amblence driver is my hero. He saved one of my familys members lives, My Dad. One late night my dad had a hart attack (I had a horrible ear ake.  We called the hospital and an amblence came to take my dad.  The driver took him to the hospital (it takes 30 minutes to get there going 60 miles an hour.)

I love to read and write, and as you know, I can be critical of those who do and don’t, but this is the best piece I’ve ever read.

 

What is troubling hospitals? What isn’t?

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I wrote this as a comment to Barbara Duck’s fine post in her blog, http://ow.ly/3tFPx

Part of the problem, at least in my mind is that many of the large and small provider business models are trapped in what any MBA student would label an 0.2 model. The two biggest adversaries to provider’s success and limiting their ability to change, the two industries constraining the providers’ ability to run a profitable business, pharmaceuticals and the payors, exercise power that comes from their scale.

Add to that complexities brought to bear by other large external influencers—the rule-makers, makes it almost impossible to know what business model to build and under which to operate because providers must build strategies designed to hit unknown and moving targets; reform, regulation, and Medicaid, Medicare. Whatever strategy they design will be ineffective by the time it is implemented.

It is important to note that healthcare providers represent the only industry which does not know the cost of ninety percent of the services they deliver. They do not know what something costs, but they do know what they charge. Even the identical procedure at the same hospital will produce a different bill. How does one run a business suing those pricing models?

You may or may not know that Shakespeare spelled his own name five different ways. While that worked out okay for him, using that as a pricing model—I know this analogy is a stretch—makes no sense.

Compare hospital pricing to McDonald’s who knows how profits will be impacted if they so much as add another pickle to a hamburger.
Nobody can tell you what a tonsillectomy costs, or the profit earned from the procedure. Even for hospital IDNs, the same service will be priced differently, will be charged differently, and will be reimbursed differently.

Through acquisition and mismanagement many hospitals have multiple occurrences of large business processes; to name a few—admissions, IT, HR, payroll, pharmacy.

The time has come to separate the hospital business model into two components; the business of healthcare—how it is run, and the healthcare business—the care component. Care is delivered using a best-process model, whereas some will argue the business of healthcare is often managed no better than a lemonade stand.

There are no measures used by hospitals that allow them to calculate the ROI of a patient or a physician over five or ten years. There is no Patient Equity Management process to reduce patient or physician churn.

Large hospitals have spent more than $100,000,000 to implement failed EHRs—sixty percent of them fail. Hospitals are rushing through their implementations to try to secure minimal ARRA payments. Many hospitals are on EHR 2.0 thinking that by changing their EHR vendor they will have a better chance of succeeding. To that model they hope to incorporate ACOs.

Maybe before they boldly go where no man has gone before, they should pause and come up with a real plan of attack.

Patient Experience Management: Who is your Chief Patient Officer?

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(This column is not outsourced to Mexico.)

How many chiefs can you name? C-Levels, not Indians. I found these–COO, CIO, CTO, CMO, CMIO, CEO, CAO, CFO, Chief Purchasing Officer, Chief Network Officer, Chief Engineering Officer, Chief Benefits Officer, Chief Development Officer, Chief Brand Officer, Chief Staff Officer, Chief Health Officer, Chief Legal Officer, Chief Quality Officer.

Besides who gets the corner office, these titles demonstrate a firm’s commitment to those areas of their business, and these positions provide that business sector visibility all the way to the top of the firm. There’s a certain cachet that comes from having your sector of the business headed by a C-Level. Those are the ‘in’ jobs, the jobs to which or to whit one is supposed to aspire. You never see anyone clambering for a B-Level position. B-Level is the repository for all non C-Level jobs.

Remember Thanksgiving dinner when you were a child—apologies to those of who aren’t from the colonies. Anyway, if yours was anything like mine, there were two tables, the nice dining room table for the adults, and the smaller card table for the children, the B-Level guests.

So what does this have to do with patient care? You tell me. Let’s go from the premise that the C-Level positions are an accurate reflection of you firm’s focus. Why are we in business? If you go from the premise it must be because of finance, marketing, IT, Purchasing, or any of a dozen other things. The only thing missing in this view of the firm is the patient. The only entity without a seat at the grownup’s table is the person in the firm responsible for the patient. It seems to me a firm’s very existence, it’s raison d’être, is the patient. If that’s true, when do they get to eat with the grownups?

McKinsey published a study conducted with 1,000 CEOs and COOs to rank their top 5 initiatives over the next five years.  Ninety percent of them ranked Patient Experience Management as either their first or second priority.  The punch line of the study was that they did not know who in their organization “owned” the patient.  How is that for leadership?

If they don’t own the patient, I am willing to bet the patient owns them. If that is the case, Social CRM, S-CRM, will not be doing these executives any favors.

 

EHR: Children of the Corn

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Not in the Stephen King way.  During the late fall, my middle school friends and I would play among the withered corn stalks; capture the flag, building forts, and on occasion being more adventuresome.  On those more adventuresome occasions the adventure included matches.

It went something like this.  We would stand among the seven or eight foot tall sepia colored stalks, and remove several ears of corn, corn that had been allowed to dry on the husk.  We would peal back the leaves on husk, and strip the kernels from the bottom two-thirds of the husk.  The end product would look similar to a WW II German hand grenade—the stripped husk became the handle, the kernels on the top third were the “explosive” part, and provided the weight needed to make the grenade travel when thrown, and the dried leaves were the fuse.

The leaves were lit, closed our eyes, and let it fly.  Then we would rush through the stalks looking for signs of smoke.  By necessity, we were in a hurry.  The object of the game was to locate the grenade among the hundreds of corn stalks before it set the field on fire.  We were successful every time but one—must have been a pretty good throw.

I remember my mother asking me why my corduroy jacket smelled of smoke.  I didn’t have the courage to tell her it was because we were using our jackets to try to beat out the flaming stalks.

Segue, albeit not much of one.  A lot of healthcare providers are also in a hurry to implement EHR.  The fuse is burning away.  The fuse is the timeline to get the ARRA incentives, or at least to avoid the penalties.  That means implementations are being rushed, which in turn means implementations will fail.

If anything can be stated with certainty it is the following; it will cost much more to revise a failed EHR implementation than whatever incentive money may have been received had it worked.  Speed is costly.  So is putting in an EHR that does not do what you need it to do.  There are no business benefits to getting the EHR box on your to-do-list “checked.”

When your haste to implement EHR causes you to fail to meet Meaningful Use, how will you explain to your mother why your jacket smells like smoke?

 

Why should HIEs be scrapped, and what else might work

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“Just because Jimmy’s mom lets him do it does not mean I am going to let you do it.  Would you jump off a cliff if he did?”

This argument is the best one I can make extolling the merits of the Healthcare Information Exchanges (HIEs) and the National Health Information Network (N-HIN).  The strategy behind the HIEs and the N-HIN are somewhere between killing a mosquito with a tank.  As the camel is a horse designed by a committee, so may be the goal of having HIEs serve as the cog of the N-HIN.

Why?  Because I think the architecture needed to make this happen exists in a far simpler form.

For example, let us look at iTunes.  To be transparent, I do not have the knowledge to describe or explain the technical underpinnings.  But what if we look at the business strategy around what makes iTunes work for Apple and its customers, perhaps there is something relevant worth borrowing.

Like physics for librarians, permit me to oversimplify the idea to see if a similar set of underpinnings could work in healthcare.

For purposes of explaining the analogy as a business network, what if we equate the major components thusly?

  • Apple (iTunes)                                  Government

o   HIEs

  • The tunes                                            Patient records
  • The Internet                                      N-HIN
  • Customers                                          Patients

While it is never as simple as it seems, especially given Apple’s success with iTunes, here is the simplified version.

There a millions and millions of songs (patient records).  For Apple, the songs exist digitally—ones and zeroes—and are stored digitally.  No LPs, no tapes, no CD (no paper charts).

Apple never physically touches a single song.  What does Apple do if it doesn’t sell CDs?

  • Apple brokers the entire transaction to its customers
  • The tunes move securely and unaltered from one entity, Apple, to one customer, millions of times
  • Apple secures all parts of the business

o   Nobody has hacked into Apple to steal tunes

o   Nobody has stolen customer information

o   Nobody who does not own the songs has been able to alter their content wheter they are in transit or with their owner

  • In the iTunes business model the iPod is no more important than a toothbrush has to do with Crest’s business model
  • The business model’s success is based upon a new delivery system for music
  • Apple’s business model did not necessitate creating hundreds of disparate and separate distribution systems to link tunes from Apple to its customers.
  • Apple did not create a new way of moving ones and zeroes from virtual point A to millions of virtual Point B’s.
  • Apple was successful using and existing, and inexpensive transportation network, thereby keeping overhead much lower than it would have been

So, if we equate the two paradigms, and buy into the fact that a model such as iTunes—if you prefer you can substitute aspects of financial services, airline ticketing, GPS (On-Star), EBay, and Amazon—in its most basic form, is nothing more than the secure transport of billions of ones and zeros, it is not a big stretch to see how one can argue that the transport of millions of electronic health records may not require a solution as complex as the HIE—N-HIN model.

And if that is true, can a business argument be made to justify building hundreds of HIEs?  I do not believe it can.  The HIEs are designed to act as middlemen.  Their purpose is to hand ones and zeros from one network node to the other, and they way they will do this is by building more nodes.  They will not so much as add a one or a zero to a patient record.

Rule One of engineering a business process is that if a process does not add value to the whole, the process adds cost and complexity without adding any value.  Under the current national EHR rollout, I think HIEs are such a process.

Before discounting this notion, what would be required to make an iTunes’ model work for electronic health records?