32. “Don’t just do something, sit there”

Have you ever walked through the halls of a medical center and noticed the busied nature of all the people inside?  Their rushed existence to get from point a to point b?

As the great John Lennon espoused, “Life is what happens to you while you’re busy making other plans.”

Health care happens while we plan for the future.

In a health care system with many big, challenging issues, it’s easy to forget the problems that plague us on a daily basis.  The forgotten hand wash.  The misguided patient.  The uneasy interaction of a stressed doctor and a busy nurse.  The elements of health care that affect direct delivery to the patient.  They’re overlooked for the hundreds of thousand square foot tower expansion, the hiring of the latest super specialist, and the acquisition of the greatest MRI machine.

Health care takes place between the big decisions.  And sometimes those who lead health care forget that.  There are a lot of small improvements organizations can make on a daily basis that will improve the health care we deliver, it will improve the satisfaction that patients have with our organizations, and it will help us improve our financial situations.

But how do we do that?  How do we find the areas that we need improvement?  We notice, or rather, super notice.

Steve Portigal and Dan Soltzberg published a dialog in Gain (via kottke) “about the importance of being aware and the advantages of tapping into your ‘super-noticing power’ in practicing design and specifically in user research.”

Mr Soltzberg:

It is ironic: people don’t notice that noticing is important! Or that they’re already doing it. It’s kind of like breathing—we’re not usually that aware of it. It’s much easier to recognize more “outbound” activities like brainstorming, testing, designing, refining. But noticing is just as important—it’s really where everything begins. There’s a funny Zen saying about that: “Don’t just do something, sit there.” It’s a reminder to let yourself take things in as well as output them.

In the hustle bustled, go-go-go environment that is health care today, it’s easy to stop noticing the issues that plague us on a daily basis.  But those daily issues are how we can improve health care today.  The issues that we don’t have to wait for anyone else to fix.

But noticing is a concerted effort.  It’s a process of pattern finding as Mr. Portigal comments:

This process of noticing once and then noticing again is how you start finding patterns and uncovering themes.

To embrace the power of super-noticing we must release ourselves from our ideas and thoughts and preconceptions of what’s going on.  We must notice, super notice, bias free.  See what is happening.  Experience what is happening.  Do something about it.

Mr. Soltzberg:

Which really supports what we were talking about earlier, that it all begins with noticing. There’s another classic Zen concept that everything you need to know and experience is already happening and present, but you need to get your old ways of thinking out of the way so you can experience it. Doing contextual research is like using “super-noticing power” to peel back those layers of preconception, culture and habit. When you do that you get to something fundamental and then you’ve got a really solid platform for developing new concepts.

Principle #32: Spend time super noticing.  Do it every day.  our own system will make a commitment to finding the everyday problems that prevent us from becoming a superior health care delivery organization.  We’ll also do something about them.  Planning for the future is important, too.  However, we must not forget the now.  Health care happens in the trenches, we need to focus on solutions that improve those conditions.

Neighborhood health care delivery

Wal-Mart is opening its first Marketside store (yes, that Wal-Mart).  The concept is a 15,000 square foot (much, much smaller than the Super Wal-Mart) neighborhood market.  It’s meant to compete with Tesco’s Fresh & Easy entrance into the United States.

The Financial Times reports the new concept “marks a dramatic break with the branding of the rest of Wal-Mart’s more than 3,400 low-cost US stores.”

What does this have to do with health care?

The trend.  It’s smaller, manageable, intimate, community-like.  If a Super Wal-Mart is 1000+ bed quaternary hospital, then a Marketside neighborhood market is a … to be determined.

Some may think it’s a retail clinic, but the analogy doesn’t hold here.  The retail clinic depends on the foot traffic generated by the big box retailer or pharmacy.  It’s not a specialty hospital either, not enough product offerings.  Most likely it’s a health delivery concept that hasn’t reached the masses yet, like the medical home or micro practice.

Regardless of what it actually is, the concept of neighborhood health care delivery is much more desireable than the mass production of a primary care clinic attached to a super hospital.

You have to try stuff to find winners

Jen McCabe Gorman passed along a link to a video via Twitter Tuesday.  It’s a Modern Healthcare highlight reel of the Rocky Mountain Roundtable 2008.  The theme of the short footage is generally about bettering wellness prevention and chronic disease management.

Reed Tuckson, executive vice president and chief of medical affairs at UnitedHealth Group, emphasized community solutions, especially community-based health centers for all patients.

Dr. Tuckson’s talk focused on a four-step approach to improving prevention efforts and disease management:

1. Better leadership

2. Better strategic planning

3. Support research

4. Integrate prevention into clinical care through IT

All good points.  However, his quote about step two is bothersome.  Dr. Tuckson said, “We gotta get better strategic planning, we play around with prevention. ‘I heard a good idea the other day, let’s try that.’  That’s foolishness.  We need data, information that’s locally specific that says ‘here are the problems in our zip code and here are things we need to get at.'”

If trying new ideas is foolishness, fools are what we should aspire to be.

Granted, planning around prevention would improve through locally gathered data.  It would tell us a community’s greatest needs and then we would apply proven methods to address them.  That’s fantastic.  And some day it may work like that.

But varying needs will require solutions of many different feathers.  How do we find such solutions?  When researchers, doctors, public health officials, citizens, patients, etc. say, “I heard a good idea the other day, let’s try that.”

Tom Peters:

If Randomness Rules then your only defense is the so-called “law of large numbers”—that is, success follows from tryin’ enough stuff so that the odds of doin’ something right tilt your way; in my speeches I declare that the only thing I’ve truly learned “for sure” in the last 40 years is “Try more stuff than the other guy”—there is no poetic license here, I mean it.

You have to try stuff to find winners.

It’s wonderful to hear an executive from a private insurer pushing these ideas.  But throwing out the engine (good ideas) that will create innovative solutions to solve our oppressing health care issues is unwise.

Watch out, Tom Peters is on the health care trail

It’s no secret that Tom Peters is on the health care quality trail.  Instead of a nice hike through the grasslands of a state park, his approach is more of a rampage with a machete through the rainforest of the Amazon.

Some are glad he has arrived, others should be fearful.  Regardless, expect more of this:

Could it be that the odds of a screwed-up colonoscopy are higher than the odds of detecting a problem relatively early enough to justify the risk? I don’t know the answer in this instance, but I do know that in any number of situations “Stay the f#^* away from the hospital” is the statistically correct choice.

Sad Story at Tampa General

Sad story.

The problem, which is not mentioned in the article, stems from a nationwide lack of psychiatric hospital beds (pdf).  Deinstitutionalization was a terrifically humanistic improvement.  But it also significantly reduced psychiatric beds—a problem that has manifested into patients sleeping in the hallways or spending days in the emergency department (quite possibly on a gurney in the hallway as well).

As you may have guessed, psychiatric services are not well reimbursed, which contributes to the problem as well.  Raising nurse salaries, as the lawyer in the article suggests, goes against common business sense. It becomes quite difficult for hospitals to offer services on which they don’t at least break even.

This would helpHere is an explanation.

But our entire system still boils down to a misaligned system with improper incentives for providing the appropriate care for each patient.  Until we change that, stories like the one at Tampa General will persist.

The “New Health Care:” Informed Patients

Tom Peters’ recent discussion with friends is nothing new.  This conversation is happening at dinner tables, around kitchen counters, and surrounding fireplaces the nation over.

But the question comes here: why do so few patients still not question the quality of health care?

We (health care) know mistakes are happening.  Our perception has been that patients know mistakes are happening as well.  But the “quality” of health care is in the eye of the beholder.  Perception is reality.  Patients have a tendency to perceive quality as everything but what health care experts have deemed clinical quality.

It becomes very obvious that we (health care) have failed patients in educating them about what clinical quality health care means.  Every reason being old health care.  The health care of blind trust and walls built so high in order to “protect” “us” from information slipping into “their” hands.

The new health care redefines “protect” “us” and “their.”  The new health care demands full participation.  It demands honesty, communication, and understanding.

We’ve got some work to do.  Transparency efforts are a start.

Mr. Peters brings to light why many health care organizations are fearful of complete transparency:

Make no mistake, this is a story of lousy management and sloppy leadership—not, primarily, the result of lousy health policy.

Make no mistake, this is a story of unconscionably lousy management and almost criminally sloppy leadership—not, primarily, the product of bad health policy.

If patients aren’t motivation enough to tirelessly improve quality, then a flat out indictment of “unconscionably lousy management and almost criminally sloppy leadership” is.  What are you doing to assure the highest (read: the H-I-G-H-E-S-T) quality of care is being provided at your organization?