Hospital Operations and My Love of Healthcare

I love healthcare. More specifically, though, I love hospital operations. Working in healthcare means that I go to work every morning looking to improve in someone’s life. No matter the role, the role of a healthcare worker positively affects the patient. The affect can be direct or attenuated, but from one-to-one care to the casual smile passing by, the smallest human interaction has to ability to transform a patient’s mood. As much as patients need hospitals, hospitals need patients. This is something that a hospital and its employees must always remember.

Transitioning from clinical to operational practice broadened my influence on the patient. As a clinician, my influence was limited primarily to the hands-on care I provided to the patient. It attached to the shift that I worked. When working nights, I influenced the patient at night. When working days, I influenced the patient during the day. While my influence periodically transferred to adjacently scheduled shifts, for the most part it stayed time-specific, focused on my time spent at the bedside. As an operational specialist, things are different. Most notably, I don’t work a shift like I did in the past. I no longer have that specific time of the day when I provide hands-on patient care. A large part of me misses this dedicated time. The corresponding trade-off associated with taking an administration role, however, is worth it. I now see patient care as it moves across the care continuum. I monitor day-to-day interactions between patients and practitioners; practitioners and administration; patients and administration. All of this provides an understanding and appreciation of health care unattainable from the clinician level. My new role gives me a new vision, and it is this new vision gives me the heightened ability to effect improvements in patient-hospital interactions.


Empowerment Isn’t The Easiest Thing to Achieve

On a very high level, my job in performance excellence is to assist hospital transformation projects that aim to spread Toyota Production System principles. Our overall goal is to create a Lean health care environment at Stanford Hospital. A big part of Lean is empowerment. Lean concepts strive to make whistleblowers of employees, and also make employees the actors and originators of transformation. What this means is that employees identify the problems, they come up with ideas to fix the problems and then they implement their ideas to bring about change. After all this, they must sustain their efforts. This last part is always the hardest. How this part usually plays out is that our team hands-off the management of the project to the unit or the department. After at point, the recipient of the hand-off is expected to run with the project and manage it into the future, making changes and/or seeking advice from our department as needed. Well, as you can imagine this isn’t always easy. At the same time employees want to be empowered to make changes, they often balk at the responsibility that follows close behind. This makes sense, considering that the duties associated with empowerment impose new daily tasks. I mean–no one wants more work, right? But this entire concept of not wanting empowerment conflicts with what we’re taught in school–or, maybe I should say what we aren’t taught. What we are [impliedly] taught is that employees want to be empowered. Yay! What a great thing empowerment is! Well, not really. Don’t get me wrong, empowerment really is great, and to efficiently run hospital empowerment is needed. What school doesn’t teach, though, [or doesn’t expressly convey] is that people are fickle and empowerment is tricky, and working to align fickle with tricky is downright difficult! Needless to say, achieving unequivocal and wanted empowerment (i.e., true empowerment) takes much longer than I originally expected. Knowing that empowerment is necessary is only the half of it. The other half is selling the idea, and that’s where effective management comes into play.

The [Only] Problem with Government Involvement

Let’s say that you offer a fee-for-service professional service. A large number of people, not everyone, want this service, so you cater to those who seek it out as they desire. Those who want this service care about its cost, as well as their continued access to it and the cost of that access. You go on providing the service for a number of years. The service works well for some, but for others it doesn’t. For some people your service doesn’t help their underlying situation, but for others it helps them live a longer, fuller life. After several years, the government looks at your service and realizes its benefits. As such, the government enacts regulations to ensure that the private service you make available to your customers will, to a certain extent, always be accessible to your customers–and possibly others–by encouraging you, through indirect incentives, to provide your professional service in situations where your involvement may not be financially beneficial to your bottom line. So, you practice in concert with the regulation for few years and things go well–which we should assume because, technically, things improve when the government involves itself in any situation. After a period of time, though, the government desires to make another adjustment because for some reason or another the regulation it passed several years earlier doesn’t do as much as the government believes it should–not enough people can realize the benefits of your service. At that point, the government identifies a class of people–a class that it feels can’t access your service readily–and decides to pay you for providing your service to that class. This goes on for a few years and things go well–which we should assume because, technically, things improve when the government involves itself any situation. This back-and-forth process continues well into the future. You provide your service; the government tweaks the regulations that affect your service to better serve their incentives. After enough time passes, this back-and-forth activity becomes common practice in your service’s industry, and because change and repeal in governmental law is hard to come by, the way that you practice your service and the manner in which the government desires that you practice your service eventually becomes one in the same. The success of your service is inherently dependent on the government, and vice versa. It’s at this point that the government begins to appreciate the public costs associated with its regulatory ventures. Some officials question whether the costs are too large; none question whether they’re too small. Accordingly, the government looks to you–the only non-altruistic party involved–and reviews your professional service, as well as the professional judgment necessary to provide your service, in attempt recover monies that it feels it wrongfully paid you for your service. The reviews take place using hindsight, and the decisions are, more or less, final. How would you respond to mitigate the losses that you may face resulting from the from this retrospective analysis? Welcome to the world of Medicare and RAC audits.


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The Trouble with Change

It’s too bad President Obama isn’t for hire. I tell you–getting people to change their ways is tough! How did he get so many people to follow him so easily? It’s almost unnatural. Usually, getting people to change their ways is like pulling teeth; no one wants to change until it’s absolutely necessary (e.g., when their job/general well-being is on the line). But why is that? And on top of that, what about people who are risk averse when faced with no actual risk? For example, say that a large group of people all agree and buy-in to change a process, hoping to effect a new outcome (assuming that the outcome has no direct effect on individual livelihood), why should someone who agreed to the change respond aversely to a risk associated with undertaking the necessary adjustments? Is risk aversion natural in this regard? What/where is the risk? What so bad about betting with house money? My guess is that these people are averse because the risk involves a loss of control. But the real question is, how do you reach these people to show them that the risk they perceive to affect themselves isn’t real? This is where coaching comes into play. The other day, the CEO at Stanford Hospital said that Performance Excellence’s real job as internal consultants is to coach fellow employees. Employees are great resources for process improvement. They are involved in all hospital processes and through this involvement they see what works and what doesn’t. When faced with change–big or otherwise–it’s imperative that we help employees work through their risk aversions to make the institution function better for all.

On Professional Development

When you’re developing your professional self, you make the effort to attend networking events. When you attend these events other attendees tend to ask you about the plans for your future. To their questions, you often respond with a general structure that outlines where you see yourself in five, ten, fifteen or whatever number of years. You’re content with this answer; so is the person who asked the question. But, why? Why is this an acceptable answer? Generally, to answer like this implies that you’ve expended energy and effort planning for the future…that’s not really true though, is it?  You only identified a dream–an aspiration, an end. “I want to be the CEO of a Fortune 500 company” — Great! So, why not tell me how you’ll get there. Tell me the steps you’ll need to take to get to a point like that, if not comparable to that. Do you intend to live life the same way as you are now? Do you plan on making any adjustments? Most people can’t provide this information, and rightfully so. It’s difficult to know each and every step that you’ll need to take to reach your professional goals or each experience you must encounter. When you think about it, though, it kind of makes sense that the means to the goal are rarely discussed. The unknown is difficult to discuss. After all, it’s unknown. But, why does it being unknown preclude us from discussing it or thinking about it? And, what causes us to focus primarily on the outcome and not the process? Is it fear? Is it difficulty thinking in the abstract? Do people not have the time? When I meet someone and ask them about their future goals, the first thing I want to know is how he/she will reach those goals. Honestly, who cares about what you want to do? What you want to do matters very little if you don’t know, or at least try to know, what you need to do to get there.

T-minus 9…8…7…6… .

Friday capped off my first full week of work. I am now 10% completed with my internship and have only 9 weeks left.  It didn’t hit me how short the summer is until one of my co-workers mentioned it in passing. “Nine more weeks remaining, James.” …Wow, I need to start producing. In support, though, the first week doesn’t really define the entire internship experience–it’s an orientation week. It’s a week where you attend the new-employee presentations and have meet-and-greets with the staff with whom you’ll be rubbing shoulders with all summer. What I find funny is that in the same period of time that it took me to learn where the coffeemaker is and the bathrooms are, employees of several patient care units around me were able to collectively reduce per-patient CT utilization time at the hospital. In one week these employees identified defects and waste in processes, and devised and acted on a plan to eliminate those defects and wastes. It truly was [Toyota] production at its finest. Seeing their outcome made me realize the power of collective drive and teamwork. Sure their job just began and they will need to continue to monitor and improve on their plan to ensure the same outcomes from hereon, but I can now see what a week–just one-fiftieth of a year–of hard work can do for a hospital and its patients. Amazing to say the least.

“That’s a great question! Thank you for asking.”

Who was it that said that hospital managers should always respond to questions, comments and other concerns or inquiries openly with a smile and an accepting manner? Something about low-tech, maybe? Something about scarves? …I wish I could remember. Anyway, Stanford has this thing–this way they teach their staff to communicate with patients, families and other staff members. They call it C-I-CARE, and its process is solely proprietary to Stanford Hospital & Clinics. Amir Dan Rubin brought the concept with him when he came to Stanford and it appears that it’s something that he swears by. Anyway, what C-I-CARE does is make the customer–the patient, the visitor, the family–the focal point of communications. When presented with an issue, the employee connects with the patient, introduces himself/herself and his/her role, communicates what he/she will do to address the issue, asks questions and anticipates needs, responds in a timely manner, and exits courteously while consideration needs and concerns. All Stanford employees are empowered to communicate like this–it isn’t just senior management. C-I-CARE is pervasive. It spreads throughout all hospital-patient communications, including the communications of billers and housekeeping. This concerted effort by all Stanford employees creates consistent, positive interactions between hospital staff and patients, providing a level of openness and transparency in hospital interactions, and making the patient feel at home and secure in the patient care setting. C-I-CARE is a wonderful approach to interpersonal intra-hospital communications. …I just wish I could remember where I heard that before.