Revising your work flows?

revised work flowAs 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.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process 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 they are designed to support an ERP business model. Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to get BRPs into an ERP type system. Since much of the ROI in the EHR comes from being able to redesign the workflows, I think either the “R” will be sacrificed, or the “I” will be much higher than planned.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Is your mission statement web site parsley?

What is your organization’s mission, your vision, your goal?  Can you articulate it?  If yes, write it below in the space provided.

Okay.  Why do you have a mission statement?  Is its purpose merely website parsley, or is it actionable?  What does it tell you to do?  Is it something to which all of your employees can contribute?  Can you measure if your actions helped meet the mission?  Does the business strategy result from the mission statement?

Here’s one you probably haven’t thought of.  Let’s say every one of your employees puts your mission statement into action.  Does that improve your organization, or does it bring it to its knees?  Your mission statement either communicates your mission or it does not.  What does it say to your employees, to your customers?  If it does not create a message that makes you unique, fix it or dump it—or say, “We are just like those other guys down the street.”  Just because it communicates, does not make your mission sustainable.

Here are some real examples of hospital mission/vision statements.  Read them and see if you begin to understand why I think the hospital business model is in trouble.  I have not published the name of the hospital, as that is not what is important to this discussion.

Providing exemplary physical, emotional and spiritual care for each of our patients and their families

Balancing the continued commitment to the care of the poor and those most in need with the provision of highly specialized services to a broader community

Building a work environment where each person is valued, respected and has an opportunity for personal and professional growth

Advancing excellence in health services education

Fostering a culture of discovery in all of our activities and supporting exemplary health sciences research

Strengthening our relationships with universities, colleges, other hospitals, agencies and our community

Provide quality health services and facilities for the community, to promote wellness, to relieve suffering, and to restore health as swiftly, safely, and humanely as it can be done, consistent with the best service we can give at the highest value for all concerned

To participate in the creation of healthier lives within the community. * To provide healthcare services in a fiscally responsible manner which contribute to the physical, psychological, social and spiritual well being of the patients and community which it serves. * To provide assistance to the whole person in a Catholic spirit of equality and interfaith serving all regardless of age, color, creed or gender.

We are caring people operating an extraordinary community hospital.

Ensure access to superior quality integrated health care for our community and expand access for underserved populations within the community. Create a supportive team environment for patients, employees, and clinical staff.

Let’s look at some of the million dollar words in the mission statements of some highly regarded hospitals.  Ensure, foster, promote, participate, create.  Comprehensive.  Involved, responsive, collaborate, enable, facilitate, passion, best, unparalleled, .  These statements were written by well paid adults.  These statements are awful.  They are awful because they are fluff—unachievable.  They are well intentioned but meaningless euphemisms.

Here’s my attempt at writing a concise mission statement based on the business models I’ve seen.  We will buy every piece of technology and hire any specialist so we can treat any problem.

Hospital mission statements are very inclusive.  They also seem very similar.  If a perspective patient read your mission statement and read the mission statement of the hospital down the street, could they tell which one is yours?  Probably not.  Who among you has a mission statement which excludes anything?

So, let’s say your board is debating if you should buy the machine in Monty Python’s hospital skit—the machine that goes “Ping.”  Which of the mission’s goals does that support?

How do you make them better?  For starters, make them short. Very.  One writer wrote, “If I had more time, I would have written less.

Southwest Airline’s mission statement—be the low cost carrier.

Dramatic pause.  Something either contributes to the mission or it does not.  Leather seats and free lunches do not.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Are hospitals causing themselves to go broke?

In our prior home we built a magnificent 1,600 bottle mahogany wine cellar with an in-laid brick floor, a nine-foot high antique door, a cigar humidor, and a tasting table.  We discovered that hexagonally shaped ceramic chimney flue pipes were the perfect building material.  They stacked like honeycomb and helped keep the wine chilled.

Our idea was to enjoy the wines we had collected over time.  There is a trick to being a successful wine collector—one must collect more wines than one consumes.  The principle of buying three and drinking four made our cellar always look brand new—empty.

The same principle applies to business strategy.  One must ensure that inputs exceed outputs, that cash in exceeds cash out.  Wax on—wax off.

If service “A” sells for a hundred dollars and it costs eighty dollars to deliver, that is a sustainable model.  You get to pocket twenty dollars.

If service “B” costs a million dollars a year to be able to offer the service and you can only charge eighty thousand dollars per patient, and fewer than twelve patients require the service, that model is not sustainable.

What happens next?  You have to start borrowing money from somewhere.  Often it comes from those twenty dollars you pocketed from the other services.  Then what happens?  Each time you take the profits away from service “A” to underwrite service “B” you have made both services unsustainable.

Cross-pollinate this concept across a five hundred bed hospital, a hospital whose model already requires it to offer “loss leader” services like caring for the indigent and ER and you can see the model has problems.  It may be possible to keep the model on life support by charging eight dollars for each Tylenol, but sooner or later that model will fail.

While we are at it, let’s look at what happens to service “A”.  The hospital stops performing “A” because they no longer find it profitable.  Then what?  Service “A” gets picked up by a clinic who can deliver it at a cost of forty dollars instead of the eighty it cost the hospital.

It is never the service that is the problem, it is the business model behind the service.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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What if in five years? Ten years?

As if we don’t have enough problems already.

Just curious to hear if you think any of these are viable. What happens to the hospital business model if we see this type of vertical or horizontal integration?  Primary care doctors outsource their up-market needs to hospitals, why can’t hospitals do that and move down-market?  What if:

* Payors buy hospitals then “outsource” the care back to the hospitals
* Hospitals also serve as payors
* Hospitals buy specialists way outside of their network and create a “branch healthcare” model similar to that of branch banking.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Strategy–The land of small ideas

Hangin’ by a thread

“It will feel better when it quits hurtin’.” Well duh.  It will also feel better when we stop self-inflicting the hurt.

To help me understand how things work I need to decompose issues, not into small parts, but into a series of pictures or shapes.  The pictures I come up with represent my particular perspective of how things look.  That can be a far cry from how others view them.  Maybe that stems from when I was a child and enjoying putting puzzles together upside down.

Instead if hitting myself over the head with a hammer, I set aside the easy pieces—those with straight edges and the four corners.

The puzzle was equally complete no matter whether you worked with the picture or just the shapes, but the exercise was quite different.  The advantage in doing it my way is that upon staring at 500 pieces of cardboard backing I had to bring different problem solving skills to the table.  The disadvantage is that once I could picture the solution in my mind, I lost all interest in completing the last few pieces of the puzzle.

I find myself looking at coming up with a reasoned approach for attacking the large provider healthcare business model.  Puzzle pieces are scattered across my desk; some right-side up, others right-side down.

Here’s where the process breaks down or breaks up—I am sure the direction is irrelevant.  How does one change someone that either does not want to change or one who thinks change is not needed?

Just because you think you’re being followed does not mean you are paranoid—it could mean you are the only one with enough focus to know what is happening.  Charging someone eight dollars for a bag of popcorn to keep your business afloat is not insightful, frankly, it is embarrassing.  Charging forty dollars to check a bag on a plane does not earn a CEO the Baldridge Award, it only allows the airline to lose less money, to stave off inevitable bankruptcy a little bit longer.  Eastern, Pan-Am, Braniff, TWA, Republic, Northwest, Piedmont, Midway, Independence.  They proved the same thing.  Continuing to use the same failed strategy delivered the same failed result.  Just because the first five people to jump off the garage roof couldn’t fly doesn’t mean you can’t.  Or does it?  Bigger wasn’t better, was it?

What does it cost to fly from New York to Seattle?  It depends.  What does it cost to have an angioplasty on Philadelphia?  It depends.  Did the airlines adopt their pricing model from hospitals, or was it the other way around?  Does it matter?  Probably not.

The land of small ideas, like Monty Python’s silly walks.  Somebody actually comes up with these ideas.  I doubt it is someone on the board.  People who lead do not one day lose their marbles and decry, “Our model is not working, let’s start charging passengers if they sit during the flight.”

If staying afloat requires a hospital to charge eight dollars a unit for Tylenol, the land of small ideas is winning.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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My pre-mortem examination of the hospital business model

  • encyclopedias
  • newspapers
  • movie rentals
  • theaters
  • airlines
  • magazines
  • libraries
  • broadcast television
  • wireline phone companies
  • record companies
  • DEC
  • Xerox
  • department stores
  • SUN
  • H-P
  • GM
  • A&P
  • Circuit City
  • Most US hospitals

In his book, “How the Mighty Fall,” Jim Collins describes the path to a business failing.  His five phases are:

  1. Hubris born of success
  2. Undisciplined pursuit of more
  3. Denial of risk and peril
  4. Grasping for salvation
  5. Capitulation to irrelevance or death

To those, I add a sixth, right between 3 and 4, “Dumping Ballast.”

  1. Hubris born of success
  2. Undisciplined pursuit of more
  3. Denial of risk and peril
  4. Dumping ballast
  5. Grasping for salvation
  6. Capitulation to irrelevance or death

Dumping ballast is the elimination of key components to lighten the ship.  Perhaps you remember seeing the movie version of Jules Verne’s novel,  the Mysterious Island.  In it, prisoners of the Civil War escape in a hot air balloon.  The balloon is ravaged by storms and looks like it will go down in the sea.  To keep it aloft the crew tosses everything overboard, things they would need if they reached land.

I think most hospitals in the US are concurrently working on stages 3 and 4.  The first step is to quit denying that they have a problem.  The second step is to recognize that some of what they discarded will prove critical to their chances of survival.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Why hospitals are like airlines and movie theaters

I prefer to talk about events before they take place, not after. I don’t know if that makes me a futurist or merely someone not bright enough to understand them as they now are.  I like to have a think about things that don’t seem right.  This helps me understand what I may be missing, or if I may be on to something.

I got one of my “ah-ha” moments while driving to the airport yesterday; something I have done a few hundred times.  I could drive the route in my sleep.  I know of two ways to get there, so I really never thought about needing a third.  My bad.  One of the roads I take was flooded—the rain was so hard it appeared to be raining up.  After being stuck in traffic for twenty minutes,—route number two.  Five minutes later, the drenched man by the side of the road told me the bridge was out.

I found myself out of choices, poor planning on my part.  I came to a fork in the road and took it.  I still had a reasonable amount of time to make my flight.  Then I found myself driving behind a nun who was driving a Rambler.  Really.  We never hit thirty on the speedometer.  I would have missed the flight had it not been delayed.

It occurred to me as I was stopped that I had failed to heed my own advice.  I was guilty of having no plan for what to do if things changed, guilty of having no options because, “I have always done things this way.”

I am speaking this afternoon about innovation and transformation for the large healthcare provider model (hospitals)—could take five minutes, could take an hour—we will have to see how many people brought tomatoes to throw.

The large provider business model is dying.  Play along with me for a minute.  How many different services and procedures are offered by the “average” hospital?   A couple thousand.  Some are performed hundreds of times each day, some on a somewhat regular basis, and some rarely.  Let’s focus on those done rarely.

The funny thing about having the ability to do something is you have to pay for the resources and technology whether you do it once or hundreds of times.  The less you do it, the larger the negative ROI.  Most large providers offer many services with negative ROIs.  How does one alter the business model to compensate for that?  Charge for parking; charge $7 for each Tylenol, outsource less profitable services.

It might be important to recognize that the reason many services—the ones most patients need—are marginally profitable is because those services are helping to fund the unprofitable services.

Sooner or later, hospitals cut loose the low-end services.  Others gobble them up, and make tremendous profits from offering them under a new business model.

I started thinking about other industries that operate under a similar business model.  The two I came up with are movie theaters and the large airlines—both which offer a service.  One of my early clients was the CFO of one of the country’s largest theaters.  They knew their costs down to the penny.  They lose money on every movie they show.  That is why they charge eight dollars for popcorn.  Their model is broken.  Are they changing it?  No.  Others changed it.  Blockbuster did.  Then their model broke.  Now we have NetFlixs.  They are making money without the popcorn.

Continental and United are merging.  Will that make things better?  Will they stop charging for bags?  Will they offer free meals?  More seat room?  Of course not.  Combined, they will lose even more money.  Their model is broken.  Are they changing it?  No.  What are they doing—buying even bigger planes.

You know who owns fifty-five percent of the flying market?  The pesky, disruptive regional carriers.  They make lots of money.  They have a different model, and they know their costs.

Disrupting the business model and changing the way you do something are not the same.  At some point there will be nothing left to change except for what you do.  Building a need for every sub-specialty offered by EPIC is not disruptive, it is dysfunctional.  Offering the same services as every other hospital within your coverage area is not disruptive, it is duplicative.  It simply divides the revenue pie for any given procedure into smaller slices.

Hospitals know their charges, not their costs.  They can’t pull a P&L per patient, or per procedure.  How can one price an Accountable Care model without knowing the costs?  An executive at a large children’s hospital told me they have to markup the costs of little things, like pills, two-hundred and fifty percent.  Unless hospitals are prepared to disrupt their business model, they had better buy a lot more pills.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Firing Winston

I was reporting to the board—or bored—sometimes it is the same.  The mission: figure out what was wrong, and then fix it.

I spent weeks talking to everyone from the executives to the receptionist.  I interviewed patients and physicians.  The doctors were not happy, the patients less so.  Costs were up, charges were down, and quality was down.

Of all the gin joints in all the towns…

The problem was easy to decipher.  I presented my findings.

“What do you recommend?” asked the chair of the audit committee.

I tried to look lost in thought.  “I fired Winston,” I replied.

“Why Winston?”

“Winston was where it all led; quality, cost, satisfaction.  Winston was responsible for the failures.”

Several members of the board nodded, and spoke among themselves.

After several minutes I jumped back into the fray.  “The more I think about it, the more I think Winston may be salvageable—not in the same role but somewhere else in the organization.  The employees really like him.  Besides, it’s the holidays.  Do you really want to be the reason Winston is not able to buy presents for the kids?”

The board held an in camera discussion.  “Agreed.”

I knew they would.  I started with my actual presentation.  “There is no Winston.”  The Winstons scattered around the table looked perplexed.  They were looking for the easy answer to the problems in their organization, they were looking for themselves.

Who are your Winstons?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The Kevorkian of the large provider business model

I call this my premortem of the large provider business model—I guess that makes me its Kevorkian.  The new reform law is Washington’s Anschluss of the healthcare business model—the annexation of the old way of doing business.  With change, as with writing a novel, the most difficult part is to invent the end.  It is only difficult if someone actually gets to that part, the end.  Many large providers remain mired in the first chapter.

The term Ultima Thule refers to any distant place located beyond the “borders of the known world.”  That is where we are when it comes to trying to understand the implications in the realm of the known and unknown external influences on the business model of the large healthcare provider.  I tend to have a stygian mindset about how I think these influences will play out—when Washington sneezes, it is the providers who catch the cold.

Sometimes it is a matter of asking the right questions.  Unfortunately, when one asks questions, somebody always has answers.  The bad thing about answers is they often bring closure to the process of thinking.  In the short-term there may be a modus Vivendi between us—an agreement to agree to disagree, but in the long-term limiting one’s vision to the borders of the known world will prove fatal.

Gone are healthcare’s Elysian moments when leaders thought they could keep doing what they were doing as long as they did it a little better.  At some point, there are no more costs to cut.  Providers will not be able to get any Leaner.  The time has come to square the circle—something proven impossible in 1882 by Ferdinand Lindemann.  Squaring the circle is an attempt to construct a square with the same area of a given circle using Euclidian geometry.

Trying to retrofit today’s healthcare model to meet tomorrow’s business requirements seems to me to be a similar argument.  It can’t be done; you can’t get there from here.  That it cannot be done won’t stop people from trying.  The impossibility cannot be proven.  The proof will be apparent only when hospitals start to fail.  Only then will it be possible to “walk back the cat” to diagnostically deconstruct what failed hospitals should have done.

A purpose of intelligence is the ability to assess and predict.  The application of thinking and intelligence is the ability to assign relative importance to predictions.  Here’s my assessment and prediction.

To successfully change the large provider model one must disrupt it, not simply adjust it.  It has nothing to do with asking, “How can we do this better?” disruption requires that we ask, “Do we need to do this?”

For example, last week I met with the former CFO of a group of east-coast hospitals.  Each hospital had an orthopedic department.  The group also owned an orthopedic clinic.  The clinic was ranked among the top twenty orthopedic centers in the US.  None of the hospitals’ orthopedic departments was ranked in the top one hundred.  The CFO recommended the hospitals close their orthopedic departments and service those patients at the clinic.  This would improve quality and eliminate duplicative costs.  Great idea.  Unfortunately the board liked their hospitals to be able to offer all things to all people—quality and cost be damned.

Pittsburgh has more MRI machines than Canada.  Why?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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And now for something completely different

My new favorite toy is Prezi.com.  This prezi link is for a speech I am giving Tuesday at ICSI on what hospitals should do to increase their revenues.  For those expecting bullet points, this is the wrong place to look.

I welcome your feedback, especially since their is very little text.  I come from the school of wanting people to listen to what I saw, rather than read my slides–otherwise I don’t need to be there.  Besides, people don’t take notes at the movies, why should they during a talk.

http://prezi.com/ved_jyx95m_d/

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer