Calling All Volunteer Directors and Managers

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

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.

The Epic Task Ahead for Clinicians

“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

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.


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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