Calling All Volunteer Directors and Managers

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I had an experience the other day that made me re-think the importance of customer service as it relates to volunteer programs at healthcare organizations. The fact of the matter is this: many volunteer programs don’t teach the skills necessary to allow volunteers to competently interact with the customer at the point-of-service. Healthcare likely presents one of the most common human-to-human interactions in the daily world. Something as common in healthcare as volunteering demands an intensive, customer-centric approach to training, one similar to those used when training employees. Yet, not all organizations do this. Last week it became clear to me (a phrase that attorneys shouldn’t use lightly) that all volunteers don’t approach the customer equally. Volunteers vary their methods of interacting with customers, person-to-person. Last week while volunteering at a prominent regional organization I witnessed a notable defect in volunteer customer service. Essentially, a failed teaching opportunity; a defect resulting from a broken process.

Quote Time:

“It is estimated that sixteen to fifty-five percent of all Americans between the ages of eighteen and sixty-four are volunteering their time. (Zweigenhaft, Armstrong, Quintis & Riddick, 1996). I’m sure that that number has fluctuated a bit over the past near-twenty years. Maybe not. No matter though, “healthcare organizations are still big players in the volunteer ‘business’.” (Shannon, 2013. … A historically-charitable institution must be a big player, right?). Of note, volunteering has motivating factors. Some are social, others personal, others business/networking related. Healthcare volunteers are commonly known to weigh all three factors into their decision to volunteer. (Zweigenhaft, Armstrong, Quintis & Riddick, 1996). (I wonder if this makes volunteers in healthcare organizations more receptive to understanding healthcare processes?)

Returning to my story:

So, I’m volunteering at the front desk. My shift begins. Gentleman comes up to the desk, motions with his right hand to the area from which he came, and turning his head in my direction says to me, “I want to make sure that I’m in the right place. The [volunteer] before [your shift] said I have to wait here. I have a billing issue. [The hospital] billed me for this amount; I don’t think that’s right. After subtracting my insurance coverage from the total cost of hospital services, the resulting amount doesn’t add-up. Basically, it appears the hospital over-billed me for services and I’d like to talk to your billing office, which I hope hasn’t closed yet. I’ve been here for nearly an hour.”

As you could imagine, the guy wasn’t too happy. Here are some other, less-interesting details:

• It was my first day.

• Prior to this, I had relatively no training for the position.

• The program did not standardize training, and a college-aged, “seasoned” volunteer conducted the training session for my newly-minted volunteer group.

• My scheduled shift is in the early evening, beginning near close-of-business when people want to return home for the day. (Factor that in with people’s general aversion to hospital settings.)

Proposed Rule:

Volunteers must know how to manage customers. It’s honestly that simple. Here’s a financial way to think about it: the opportunity cost for me to volunteer was about $100, a quarter of which went to pay for a volunteer uniform; a polo valued at $25 (yea, right). People of my wherewithal don’t just go spending $100 willy nilly. Volunteers volunteer for a reason. They give their physical and emotional sweat to attend to people in need. Volunteer responsibilities may be minimal, but there’s not much to remember. And it’s the healthcare organization’s job to teach volunteers what to remember. They shouldn’t expect volunteers to produce high-performing outcomes without proper instruction. Capisce? Moreover, Volunteer programs should be self-sustaining. They should engender communication, honesty and empathy in practice. They should be the most consistently value-added service an organization provides to its customers. On the other side of the coin, they should not exist to harm your organization’s goodwill. There’s absolutely no reasonable basis for that outcome.

From an application standpoint, it’s entirely proper to tell volunteers how to think and act when representing the hospital. In fact, volunteers must be told how to think and act. From the customer’s perspective, it makes little sense forcing customers to engage with ignorant minds. That would frustrate anyone. Ultimately, some people just want to be listened to. While heard, the customer in my story wasn’t listened to. If I was told to sit somewhere and did, trusting the agent of the organization who instructed me, and then found out I was given wrong information and wasted more than an hour of my day sitting needlessly, I would be upset! This is empathy. Volunteers at healthcare organizations need to capture what empathy feels like and they need to capture it regularly.

Innovation of the Mind

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In his recent New Yorker article, Atul Gawande talks about the time it takes for innovations to spread. From the title of the article, one can easily deduct the gist without reading it: the spread of innovations takes longer than it probably should, with this temporal gap directly affecting the health, safety and general well-being of those without access to the innovation.

Innovation isn’t new to healthcare, and it’s true that innovative practice methods, technologies, etc., are needed to facilitate much needed change within an all-important institution once centered on “concrete” principles of religion and superstition. But upon thinking of what innovation can bring to an expanding, fractured landscape like healthcare’s, it becomes clear that, paradoxically, meaningful innovation in healthcare can only be realized through the ends that innovative technology and process redesign enable–information and awareness of our surroundings.

Innovations in technology or processes won’t achieve their purpose unless healthcare–essentially, people–is willing to accept those innovations and adopt them in practice. But what is “acceptance” and how can we measure it? Here’s my take: It’s fair to assume that acceptance isn’t generated without some new appreciation. After all, one doesn’t fully “accept” something–a way of life, a truth…something–until that person develops a newfound appreciation for it, good or bad. Innovation needs acceptance before it can innovate. But is there a way we can develop acceptance before creating innovation? I think there is.

I’d like to argue that, at the most essential level, the innovation our healthcare system needs won’t come from cutting-edge technology or new delivery processes. In my years of experience I’ve never seen a band-aid heal an underlying health issue, only mitigate an adverse affect. Technology and processes are like band-aids, in that meaningful changes can only come from within the people who use them; the way those people approach their own health, as well as the healthcare system as a whole. Health is an inconstant variable in one’s existence. While people are focused on controlling changes happening around them, few appreciate the changes going on inside of them, by the minute, everyday of their lives. Essentially, the innovation that will fix our healthcare system is an innovation of the mind; the way we think, and whether we can accept ourselves as flawed, ever-changing collections of matter prone to disintegrate over time.

I look at this last point as an opportunity; an opportunity to make the best out of a dire, but inevitable outcome. Some see it differently. Others choose not to think about it at all. Nevertheless, acceptance of this basic fact of life is a necessary precursor that will drive the innovation that our healthcare system needs.

Extinction of the Rural Practitioner

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The changes taking shape in rural parts of our country are causing access issues for rural consumers. Not surprisingly, money is at the root of the problem. General practice physicians in rural areas just aren’t able to maintain the financially viable private practices they once were.

Decreasing reimbursement rates are frustrating the private practice business model. Federal reimbursement rates, most notably, have been decreasing over the past several decades, and should continue decreasing beyond next year. While these lower reimbursement rates have directly contributed to the reduction of private practices in both rural and urban parts of our country, rural physicians are having a harder surviving. Simply put, reduced reimbursement rates are making it harder for private practice physicians to do what they’ve always been doing—caring for patients while being their own boss.

The physicians in rural America have been some of the hardest hit by the reductions. To truly understand this effect, you must first understand a few points. First, general practice physicians tend to predominate the physician make-up in rural areas. Second, general practice physicians, especially those in rural areas, have limited opportunities to bill insurers and the government for high revenue-generating services. Instead, they typically spend a lot of their time and energy providing routine, low revenue services. Contrary to what some may think, practicing general medicine in a rural market is not a lucrative business today.

Compound these points with a third point—the severe recessions currently affecting rural economies—and one can more clearly see how general practice physicians are finding themselves increasingly unable to maintain private practices. Today’s economic and political climates are unfavorable to rural practitioners, and Federal reform isn’t providing the respite that many desire.

Reform prescribes that physician practices implement new technological developments (e.g., electronic health records, data management software, etc.) at risk of receiving even lower reimbursement rates than they’re projected to receive. So, why is it that private practitioners don’t adopt these measures to prevent further reductions? Well, it’s because these technologies are expensive! The initial cost for the new systems cost physicians upwards of $1 million, not including other, non-license costs (e.g., costs routine maintenance, database management, etc.). Many small practices—like those scatter throughout rural areas of our country—are effectively priced-out. To them, the decision comes down to early retirement or taking the loss.

It will be interesting to see how the younger generation of general practitioners will rise to the challenges facing rural patient populations. Of course, they can’t be expected to assume the entire caseload of the retiring physicians. A young physicians are at the beginning of a long career. They have a lot of opportunities available to them. They aren’t limited to purchasing an aging private practice. They can become part of a hospital system, in a big city, getting wonderful experience caring for a diverse patient base. What will prompt them to move to the rural areas? Will it be the prospect of taking out thousands of dollars in loans to update an aging private practices office? I highly doubt it, especially not when they’re already swimming in debt from medical school. Nevertheless, the younger generation of physicians definitely has its hands full.

Our Aging Population, as A Trend in Healthcare

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THE CHANGE IN AGE-RATIOS AMONG AGE GROUPS ACROSS THE US POPULATION
THE CHANGE IN AGE-RATIOS AMONG AGE GROUPS ACROSS THE US POPULATION.
Data from: http://www.census.gov/population/projections/data/national/2008/downloadablefiles.html

The US population is aging. Markets in the health care industry are changing as a result. People are getting older at a faster rate than children are being born. In fact, the present US birthrate is at its lowest level since 1920! According to the graph above, over the next forty years, the ratio of 0-17 year-olds and 18-64 year-olds in our population will be slowly decreasing. During that same period, the population ratio of 65-100 will be increasing, and considerably. Between the years 2006 and 2050, the US will see a 15 point fluctuation in population ratios between its “young” (18-64) and “old” (65-100) populations. Our country has never witnessed a fluctuation of this magnitude in its regularly recorded history.

The fluctuation will be protracted, but palpable. Despite having small population numbers now, older populations will experience significant growth in the future. It will be important for communities at large to consider the effects of this increase. The increase will not happen in a vacuum, out of sight from society. It will be noticeable in everyday life. In relation to health care, our country’s health care system—both private and public—will realize greater demands for geriatric care. Nursing home, rehabilitation and hospice care will see increases in their patient base. The elderly will gain a larger foothold (and, in doing so, gather market power) in the US consumer market as a result of their expanded presence.

Competition in future health care markets will be contingent on appreciating the changing composition of our country’s population. The fact of the matter is this: health care becomes a constant one’s life when someone reaches a certain age. Based on Census data, our future will bring with it more people reaching that “certain age”.  These people will demand more care than they have in the past, and we must reasonably and cost-effectively respond to meet that demand.

Pointing Fingers is Costing U.S.

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We’ve all heard it by now. We know that health care costs are increasing. We know that things will soon be “unsustainable” if our present health care practices continue. Interestingly, despite all the stimuli we receive through the mainstream media, it doesn’t appear that the US people care as much as they should.

People haven’t done enough to appreciate the cost issue. Aside from the general if-I-use-more-then-I-pay-more concept, I would guess that most people in the US haven’t looked at the connection between the use of health services and the cost of health services. For those who haven’t, it basically gets down to this: one’s unnecessary use of health care services raises both the individual cost of care, as well as national cost of care. This means that your choice to use an unnecessary amount of health services not only increases your costs, but my costs, too!

Understanding the factual basis that underlies the “cost conundrum” isn’t that simple, though. Researching the cost issue is complex, taking many hours, if not days, of research to appreciate. There are so many moving parts, and to grasp and make sense of these parts requires time and energy that, frankly, many people don’t have. In addition to raising a kid, reading for school and trying to stay ahead of life by working two or three jobs, who among the general population has the time to dive into the boring, fact-intensive literature that outlines why health care costs are such a problem in the States? I joke, but the problem is serious. The US people–the mass of health care consumers who do not subscribe to Health Affairs–cannot reasonably inform themselves about the basics of our health care (e.g., medical terminology, billing, etc.), let alone the costs of health care that have begun to financially cripple our nation. We can’t expect them to be smart consumers, but giving-up on them and telling them what to do isn’t the answer.

We must include them in the discussion. We–those thoroughly educated in health care and its associated topics–cannot continue our insulated discussions, disseminating new and important information amongst ourselves, in our own communities and journals. Doing that isn’t the answer to correcting the education gap. We need to reach out to people in the community at-large. This doesn’t mean writing an Op-Ed in the NYTimes. This doesn’t mean hosting a panel discussion on CNN. Prestigious mediums aren’t always the answer. Health care in big cities is different than health care in small cities, and health care in small cities is different than health care in small towns. All people aren’t the same, and we can expect everyone to learn and appreciate the same way. The patient-centeredness movement is a start, however, we have a long way to go before reaching a semblance of parity.

The Epic Task Ahead for Clinicians

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“But a bulldozer will do the same thing in a fraction of the time. IT was like this—speeding up dramatically work that can be done by hand.”

EPIC, the wonderful health informatics software that will revolutionalize health care, will be rolled-out in many of our Country’s top hospitals over the next few years. For those who don’t know, EPIC is an EMR database (electronic medical record) and pretty much EMRs generally, will be given a big task–to make our health system more efficient and bring it up-to-date with 21-century technology. Good luck with that!

In my experience so far, I haven’t seen the large rewards that it promises. I’ve found Epic to be another layer of paperwork. For most clinicians more paperwork is…well, it sure doesn’t make work any easier. New demands have a tendency to avert the practitioner’s focus away from the bedside.

It’s interesting to see how EPIC has affected clinical pharmacy at some hospitals. Clinical pharmacy micro-manages patient care mostly from a central or satellite pharmacy location. They review computerized physician orders. They verify medications on electronic data systems instituted by hospitals years ago, to do the same thing expected of EPIC–provide better, more efficient services.

I believe that new software should improve the manner in which a discipline practices, not change the method of practice altogether. What I mean is, it’s hard to fathom a clinical nurse being sedentary profession while the techs do all the running.

The day-to-day tasks of pharmacists seem to be following this trend. On any given day, clinical pharmacists are tasked with accesses patient information in a computer system, and then responding to gleaned data in an appropriate manor and entering their stamp of approval online. Repeat. Only when defects occur and clinically requires it (e.g., needed presence at a code) do they leave their post. Essentially, they inform most of their patient care decisions to a computer screen, not a patient, and then hope the software behind the computer screen does its job. This medium is sort of like a permeable barrier between the patient and practitioner, and is becoming ever-present on more clinical fronts.

How can we add new electronic systems without disrupting the essence of clinical practice methods? How can we maximize patient content when technology enables us to minimize it? What can we learn from pharmacy’s experience that we can use in nursing and medicine, or anywhere other field or practice for that matter? I strongly believe that professional methods of practice should not be affected. Patients need practitioners with them as much as possible for one reason: to get better. EPIC is a software, not a practice method, and the coders who created the software ultimately don’t know what is best for the patient.

Moral of the story: Keep the patient on the pedestal. Don’t replace her with something trendy. Work with the patient and find ways to use the tools to best fit her needs.

Thermodynamics and Change Management

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en·tro·py /ˈentrəpē/ (n.) Lack of order or predictability; gradual decline into disorder.

According to the Second Theory of Thermodynamics and the concept “Arrow of Time,” as one moves “forward” in time, the entropy of an isolated system — the combination of a subsystem under study and its surroundings — will increase. This means that over time disordered states are significantly more probable than ordered states. “Because there are so many more possible disordered states than ordered ones, a system will almost always be found either in the state of maximum disorder … or moving towards it.”

We in healthcare must accept that no outcome we reach will ever reflect perfection. We can work on perfecting operations for years, but those operations will never be without flaw. Nevertheless, it is essential that we work toward maximizing order in disorder. While efficiency does not equate with perfection, it is attainable through continuous improvement and daily monitoring. We must always look to improve on processes and never permanently settle on one process over another. Settling impliedly assumes constant, continuous order when order of this kind does not exist. If history teaches us one thing, it should be that maintaining the past at the expense of the future is extremely difficult, if not impossible. In health care we must accept changes. In doing so, we must identify ongoing tendencies toward disorder and use our efforts to make the present form of disorder the best for both the patient and employees. A sound understanding of managing through change is as important now as it will ever be. We must be open to new ideas. We must mitigate entropy by working alongside and with time’s ever-evolving ideals and standards.