44. The Levy Rule

A regularly linked-to (by this blog) health care CEO provides sage advice from previous non-profit work:

If a member of our Board proposed that we should do something, it became that person’s responsibility to get it done. 

The rule may hinder idea formulation at the get-go.  (Which may be a good thing; health care has plenty of ideas, the implementation part is where many hit the skids.) However, it will improve accountability (by proxy, execution) down the road.  And because our culture is based upon participation, those keeping quiet on the necessary changes need no longer be a part of the team.

Harsh?  Hopefully not.  It has the ability to empower the change makers in the organization, to free them from the everyday barriers preventing progress in health care organizations.

Principle #44: Your suggestion, your responsibility.

43. Rethink

It’s not that a full-court press has never been used in the game of basketball (for it has, quite effectively); it’s where the thought to do so comes from.  Coaching decisions to apply a full-court press originate because it has been, proven by the past (Digger Phelps, Rick Pitino), to be an effective way to disrupt the offensive team’s efforts.  But in this case, as described by Malcolm Gladwell in The New Yorker, has been absolutely rethought:

(Vivek) Ranadivé was puzzled by the way Americans played basketball. He is from Mumbai. He grew up with cricket and soccer. He would never forget the first time he saw a basketball game. He thought it was mindless. Team A would score and then immediately retreat to its own end of the court. Team B would inbound the ball and dribble it into Team A’s end, where Team A was patiently waiting. Then the process would reverse itself. A basketball court was ninety-four feet long. But most of the time a team defended only about twenty-four feet of that, conceding the other seventy feet. Occasionally, teams would play a full-court press—that is, they would contest their opponent’s attempt to advance the ball up the court. But they would do it for only a few minutes at a time. It was as if there were a kind of conspiracy in the basketball world about the way the game ought to be played, and Ranadivé thought that that conspiracy had the effect of widening the gap between good teams and weak teams. Good teams, after all, had players who were tall and could dribble and shoot well; they could crisply execute their carefully prepared plays in their opponent’s end. Why, then, did weak teams play in a way that made it easy for good teams to do the very things that made them so good?

Lots of things have been rethought in health care.  (e.g. Hospital gownsSurgical checklistsCare delivery.)  Welcomed by some, others not.  There have been successes and failures.  But a desire to improve the status quo is what drives these changes. There is plenty more to rethink: patient experience, care across the continuum, general hospital specialization, billing process, delivery models (again), reimbursement, facilitity design, communication…

To change is to rethink.  To rethink is to improve.

Principle #43: Rethinking will be a daily activity at our own system.  It drives our incessant desire to improve.  The easiest way to rethink?  Bring in outisders.  The heart of diversity.  Ranadivé rethought basketball using his experience from cricket and soccer to coach an “inferior” 12-year-old girls basketball team into a national championship game.  Designers rethink with their design expertise.  Engineers with engineering.  Teachers with teaching.  Young people with a lack of expertise.  Experienced folks with an abundance.  Encourage the dissent, embrace the noise.  Etc.

42. Green = Go

Happy St. Patrick’s Day.

Organizations need people who are always moving, always on the go.  The type of people who drive the long way to a destination because the short way means waiting in traffic.  Always need to be moving.

Moving means progress.  Granted, the wheels are going to spin at times.  It might even mean it takes a little longer to get where they’re going.  But this is for certain: once they reach an endpoint they begin their search for the next.

Now is a time for action.

Hospitals are looking for ways to decrease costs, to be more efficient, to utilize resources more effectively.  During a time when “all is fair game” the possibilities are limitless if the barriers are removed.  Let the folks who like to move, move faster.  More at bats gives the organization more opportunities to find success (that from Tom Peters).  Try lots of potential solutions in semi-controlled environments.  If it works, spread it.  If not, scrap it.  From the Institute for Healthcare Improvement:

An important tool in creating a successful pilot and spreading change throughout an organization is rapid-cycle testing. Rapid-cycle testing allows organizations to test and refine ideas quickly and on a small scale.

As Tom Peters says, and as rapid-cycle testing allows, “Ready. Fire. Aim.”  Start trying.  Go!

Principle #42: We’ll empower our workforce to start testing and encourage them to not cease.  Enjoy the day of celebration. Believe it or not, the day means something.

41. Ask for input

Watching the crowds gather for today’s inauguration is amazing.  It is evident that people care again.  Today’s events are the culmination of a massive exercise in participation.

People want a say in the every day realities that affect their lives.  It’s as true in the work world as it is in government representation.  The Barack Obama campaign and transition teams understood this and provided an outlet for people to participate by asking for input.

my.BarackObama.com was the foundation of organization for the campaign: it allowed supporters to interact with each other through an online social network.  More importantly it provided the opportunity for over a million people to express themselves with the perception (reality or not) that the campaign was listening to their thoughts.

After the election the transition team launched Change.gov—again, asking people to provide input.

Your Seat at the Table allowed the American public to comment on transition team work that traditionally was held behind closed doors:

This means we’re inviting the American public to take a seat at the table and engage in a dialogue about these important issues and ideas — at the same time members of our team review these documents themselves.

Health and Human Services Secretary-designate Tom Daschle asked for participation in the health care reform process through discussion parties held during the holidays that encouraged particpants to report back with suggestions on moving the debate forward.  Aside from health care, any number of issues can be commented on.

Most recently the Obama transition team announced the Citizen’s Briefing Book which is a tool that allows citizens to prepare briefings.  The briefings are voted upon by others with the highest-rated briefings being placed in a book for review by the White House.  Another opportunity to provide input.

Hospitals can do the same and the internet makes it all possible.  Provide a platform for employees, physicians, patients, community, etc. to express their thoughts.  Allow stakeholders to provide input and devise a strategy for addressing any concerns they may have.  It’s a simple idea, really; but it has powerful possibilities.

Principle #41: People enjoy being a part of something.  our own system will give them the opportunity to do so.  Engagement, empowerment, and excitement all become possible when you allow people to particpate.  Just ask.

Bonus: Wired has a great story on the challenges the Obama campaign faces in continuing its trek to bring government into the social media world.

40. Continuous Feedback

With a multitude of tools available for constant and continuous interaction with each other, why should the annual review wait for its once-a-year drudgery?  Not many (no one?) likes them anyhow.

Feedback is important—vitally important for the high-performing organization.  But what good does it do an employee when she finds out six months from now that her performance on the new business plan was exemplary?  What good does the staffer gain from a constructive critique of his less-than-satisfactory interaction with patients?  In either case, little.

Feedback that is instantaneous (or at least within a workable time line) allows a co-worker to improve a lacking skill (with the organization’s help, of course), especially with the insufficient performance as an example fresh in her memory.  It notifies the up-and-comer that his new ideas are appreciated (and implementable).  Think about how much easier nurses could offer helpful critiques of physicians.  Or how much easier physicians could do the same for administrators.  Examples given not needed: imagine the possibilities throughout the organization.

Rypple (currently in private beta) has developed a platform to institute continuous review.  Its service allows users to ask for feedback from co-workers.  From Springwise:

Employees can use the system for specific concerns, for example the impact of a presentation, or for more general issues such as areas of performance to focus on in future. Questions can be tagged with keywords, helping monitor progress in specific areas over time. Rypple’s digital interface lets it foster open and honest responses that might not be given face to face: feedback can be given anonymously, only to be viewed by the person who requested it.

Of course a digital platform isn’t necessary for continuous feedback, but it certainly makes it easier (and perhaps more comfortable for all involved).  There’s room for improvement in the model, too: we can’t expect that every organization stakeholder will be so in-tune with their performance as to always be asking for feedback (overload?) or that everyone will be so engaged with the initiative as to actually ask for feedback.

We can make it clear, however, that continous feedback is important in our provision of quality health care.  Continuous feedback is a component of outstanding communication.  Communicating outstandingly with each other is a fundamental component of an open (read: transparency on steroids) health care organization.

Principle #40: We’re opening the communication lines (all of them).  We’ll talk to each other to help.  Helping each other improve will not only improve our culture, it will improve the quality of care we provide.

39. Common Sense

…has been lacking in all too many arenas lately.

Examples given:

  1. Less than a week after the federal government committed $85 billion to bail out AIG, executives of the giant AIG insurance company headed for a week-long retreat at a luxury resort and spa, the St. Regis Resort in Monarch Beach, California, Congressional investigators revealed today.AIG documents obtained by Waxman’s investigators show the company paid more than $440,000 for the retreat, including nearly $200,000 for rooms, $150,000 for meals and $23,000 in spa charges. (ABC News)
  2. The global economy may be undergoing a significant downturn, but the White House’s dinner budget still appears flush with cash. After all, world leaders who are in town to discuss the economic crisis are set to dine in style Friday night while sipping wine listed at nearly $500 a bottle.According to the White House, tonight’s dinner to kick off the G-20 summit includes such dishes as “Fruitwood-smoked Quail,” “Thyme-roasted Rack of Lamb,” and “Tomato, Fennel and Eggplant Fondue Chanterelle Jus.”To wash it all down, world leaders will be served Shafer Cabernet “Hillside Select” 2003, a wine that sells at $499 on Wine.com. (CNN)
  3. The CEOs of the Big Three automakers reportedly flew private luxury jets to Washington to plead for a $25 billion taxpayer bailout to save their debt-ridden industry — ringing up tens of thousands in charges even as they cried poverty.Recipients of eight-figure bonuses in 2007, the corporate cowboys used their executive perks — which for GM’s Rick Wagoner include the run of a $36 million Gulfstream IV jet — to arrive in style as they went begging before Congress.Wagoner, whose flight reportedly cost $20,000 round-trip — about 70 times more than a commercial airline ticket — told Congress he expected about $10-$12 billion from the requested bailout. (Fox News)

Now is certainly the time to cut back on excesses with the worldwide economy in a free fall.  It’s not just these one time occurrences that leave questions, either.  Are these decisions representative of the way these groups have conducted their previous business dealings?  Aside from the AIG debacle, the other two examples represent pennies in comparison to the larger dollar figures being debated.  That’s not the point.  It’s the principle of making such decisions in light of what is being discussed.  After all, perception is reality.

Translating this to health care is easy.  Remember the checklist debacle?  How often is common sense part of the discussion in decision making?  Hopefully it is often.  It should be always.

A friend recently flew to interview for a health care position.  Round trip airfare on short notice approached $1000.  It just so happened that the friend had another interview with a second organzation only a short distance from the first the next day.  Both destinations were within driving distance.  So the friend asked the first organization if they would be willing to take on an extra night in a hotel and half of the cost for a rental car (the other half being picked up by the second organization), total cost no more than $600.  The response?  Sorry, organization policy only allows us to pay for one night’s stay in the hotel.  But, the first organization responded, we would be more than willing to pay for a one-way ticket and one night in the hotel if the friend was willing to pay for the rental car and the second night’s stay.

Come on!  Common sense!  Dollars would be saved!

As finances get tighter and our operating environment gets tougher it is time to insert common sense decision-making at every opportunity.

Principle #39: One would like to think that common sense is common sense, but that’s not always the case.  Decision-making at every level of our own system will be driven by common sense.  What’s best for the patient?  What’s best for providers?  What’s best for the organzation?  To determine the answers we’ll use common sense.

38. Change!

It doesn’t take an extremely enlightened person to realize the challenges that hospitals are facing today.  They’re cutting staff.  They’re experiencing drops in demand.  They’re taking care of more non-paying patients.

Payer, patient, and government pressures are only increasing.  The solutions are diffuse and unpredictable.  Preparing for the future becomes much more difficult when preparing for tomorrow reigns in importance.  But we need to prepare for the many possibilities that tomorrow, next week, next year, and beyond hold.  Because one thing is for certain: we are unable to continue on our current path.  While health care likes to think that it deals with change on a continuing basis, it doesn’t do it particularly well.  And that needs to change.

Health care is responsible, in part (a significant part), for the gloomy forecasts of our economic future.  To think that this industry won’t be targeted to cut domestic spending is naive.  To think that hospitals won’t be significantly affected by economic ship-righting would be simpleminded.

In developing our strategy for adapting to change we not yet know, there are several principles we’re borrowing from a recent notable presidential campaign and the requisite transition planning.

1. Be realistic.  This isn’t going to be easy.  We know the mountain is tall and there’s nothing we can do as an individual health system that will put health care on the right track.  But we can set attainable, yet strenuous, goals.  Transparency to the Nth degree to improve patient safety.  Reducing organizational waste to enable flexibility with our dollars.  Empowering front line employees and providers to solve problems.  It’s a laundry list but it’s time to get the house in order.

2. Bring people together.  Enable all organization stakeholders to meet and work together.  No more separate units within the organization.  We are one.  The interactions will lead to innovation and problem solving like nothing we’ve ever seen.  It will also improve our culture.

3. Be consistent.  Our approach, our message, our solution will be consistent with making the organization ready for whatever will come.

4. Be inspirationally optimistic.  There’s no doubt we’re in for some hurt.  A health policy solution that works (read: lower costs) means our bottom line will be (optimistically) flat or (a little more optimistically) rising only slightly.  But if we prepare now–and do it correctly–our exposure will be minimized.  The real optimism comes with preaching a message of preparation.  We can and will succeed in our efforts of creating the ultimate in flexible hospitals.

5. Execute.  Easier said than done.  Also required.  Get the right people on board (everyone).  Get the right people in positions where they can be effective (everyone).  Give them the empowerment they need to get things done (everyone).

Principle #38: Change is most definitely coming.  We can either be the recipient of change or we can lead it.  It is time to prepare.