Wednesday, April 27, 2011

The Crystal Ball 2

“Jaded Julie, during my days in industry there was an organization, supported by the industry, whose mission was the development of knowledge regarding the industry’s impact on the environment. This knowledge was for use in the near term, and it was developed in response to process changes and proposed government regulations. Basic research was done elsewhere, and an industry association handled government lobbying.”

“That’s all very nice, Curmudge, but why are you telling it to me?”

“I thought that for once I’d start by discussing a topic about which I knew something.”

“Well, that’s a switch, and it’s better than your usual prattle. But what does it have to do with health care?”

“Fortunately, there are similar organizations—developers and purveyors of knowledge—serving health care. People in hospitals are too busy with patient care, daily management (ready-to-serve time), hoshins (discretionary time), and other local issues to contemplate a global near-term future. That has created the need for outfits like the Institute for Healthcare Improvement (IHI), The Advisory Board, Sg2, and others. They are supported by membership dues and/or fees for participating in educational offerings and consortia devoted to specific issues.”

“These groups sound valuable, Curmudge. I understand that they are staffed by highly competent people whose job is to study, think, listen, talk, and write on behalf of the health care industry. Health care administrators are probably aware of the problems they will be facing, but they might feel overwhelmed by all of the countermeasures they could be implementing. According to their literature, these specialized consultancies help support and steer our thoughts in the direction of viable results with evidence and data to support them. Can you give me more specifics about these outfits?”

“As we said once before, IHI’s web site is a bit like a supermarket. If you have a problem, push your cart down the aisle; and you might find a solution. On our crystal ball timeline, IHI deals mostly with the present. However, its teachings will help organizations improve their near-term future. ‘IHI focuses on motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals.’ IHI’s work is funded through their fee-based program offerings and services, and also through the support of foundations. Their reports, such as White Papers and Improvement Stories, are available to the public. Among the many subject areas are Office Practices and Patient-Centered Care. Here is an example of one of their forward-looking, fee-based colloquia to be held in 2011, ‘Thriving in an Era of Health Care Reform.’ ”

“Curmudge, I like your term, ‘purveyor of knowledge.’ Did you ever get paid for ‘purveying’ knowledge?”

“Not much, Julie, and any knowledge that I still have is free to a good home.”

“So what other purveyors of knowledge for the near term do we have for health care?”

“According to The Advisory Board, they are ‘the leading provider of comprehensive performance improvement services to the health care and education sectors—including operational best practices and insights, business intelligence and analytic tools, management training, unbiased technology evaluation, and consulting support.’ Note that they don’t work for health care exclusively. They have recently acquired Southwind, a ‘management and advisory firm focused on hospital-physician alignment and physician practice management.’ “

“It’s been awhile since we reminded our readers that a blog is not an encyclopedia or a textbook; all we hope to do is stimulate the readers’ interest. We can put them ashore, but they will have to explore the island by themselves.”

“For example, Julie, these are some of the programs accessible to corporate members of the Health Care Advisory Board: Strategy and Operations Research, Clinical Research, Leadership Development, Business Intelligence and Analytics, and Physician Performance. In our case, an Affinity employee can simply guide his mouse to the information of interest.”

“Curmudge, I understand that The Advisory Board has developed a lot of information on accountable-care organizations (ACOs). What’s an ACO anyway?”

“Good question, Julie, to which the answer is not completely defined. Here is the March 28, 2011 Wall Street Journal’s answer: ‘In broad outline (ACOs) propose to unite doctors and clinics or hospitals in groups that pool their resources with the goal of trimming spending while boosting the quality of care. When the group can show that it is improving care and delivers it for less than the cost projected—arrived at by crunching historical patient data for that market—a share of the savings goes to the ACO’s bottom line.’ This concept is part of the 2010 health care law and is not yet fully developed. It initially only applies to Medicare patients and, you’ll note, contains some features reminiscent of the medical home.”

“So what’s next, Curmudge?”

“What’s next will be in our next posting on this topic. Anyone who has read much about accountable-care organizations looks forward to quitting for the day, and c’est moi (that’s me). See you next time, Julie.”

Affinity’s Kaizen Curmudgeon

Monday, April 18, 2011

The Old Men's Table

“When I arrive early for the weekly meeting of our service club, I get my food at the buffet and find a spot at a table that’s occupied by other old guys who came early. Although it’s not official, this has become a sort of Old Men’s Table. Looking around the room, I can identify the unofficial Politicians’ Table, the Successful Women’s Table, and several tables of younger men and women on their way up in the community.”

“So, Curmudge, what’s so special about the Old Men’s Table? I presume that it is populated by old codgers like you.”

“Sometimes, Jaded Julie, I am the youngest. Sadly, our tablemates tend to die off. Then we hear, ‘Carl died on Saturday? But he was sitting right in that chair last Tuesday. I can’t believe he’s gone.’ Well, my wife died three months ago, and I can’t believe she’s gone. Then someone else says, ‘My wife died four years ago, and I think about her every day.’ “

“That certainly sounds depressing; but I suspect that you are headed toward some sort of lesson, so I’ll keep listening.”

“After a few more comments about Old Carl, we return to our old-guy jokes. ‘I’m so old that I have to pre-pay when I order a three-minute egg.’ ‘I never fill my car’s gas tank because I’m afraid I won’t live long enough to use it all.’ ‘Who wants to live to be 90? Someone who is 89.’ “

“Curmudge, I surely hope you live long enough to get to the point of this story.”

“Don’t leave yet, Julie. Our old-guys group is about evenly divided between widowers and those with a living wife. The outlooks of the two groups are dramatically different. Those with a wife are concerned about dying and leaving their wife to fend for herself.”

“Of course we all know that widows fare better than widowers, but it’s easy to appreciate why a husband would be worried.”

“I certainly was. My wife couldn’t even stand on a ladder and change a light bulb. And because she was almost three years younger, it never occurred to me that I might outlive her. We even joked about the traveling she would do with her second husband.”

“So Curmudge, how does one’s outlook change when he becomes a widower?”

“Death is always worse when it disrupts the ‘orderly march to the grave,’ i.e., older people are expected to die first. So when one loses a younger wife, his grief is doubled. But he also is freed from his worry about his wife living by herself.”

“Perhaps, Curmudge, that explains why you appear cheerful on the outside but are grieving on the inside.”

“Another difference in the widower’s outlook is that death has lost much of its sting. We don’t fear death as long as it is not slow. One of the ‘old guys’ recently suffered a disabling stroke; everyone fears that. But at the same time, we don’t seek death either. We are not like Job, who ‘long(s) for death but it comes not,’ (Job 3:21). We are more like my mother who said long ago, ‘It doesn’t matter when I die…but not today.’ “

“So do we have a lesson to take home, Curmudge?”

“A Muslim friend said to me a few years ago, ‘Death is a part of life.’ There will be times in your life when you’ll need to remember that simple truth.”

Affinity’s Kaizen Curmudgeon

Friday, April 15, 2011

The Crystal Ball 1

“Today we’re going to play one of our ‘Curmudge-and-Julie-make-believe’ games.”

“Ooh, Curmudge, the last time we did that I was seriously ill.”

“Don’t worry, Jaded Julie. This time the outcome will be better. Your role is to be a middle manager in a health care organization—one whose operating philosophy is command-and-control and where everything is done the way it has always been done.”

“Hey, that outfit is suffering from organizational obsolescence. They are really behind the 8-ball. Don’t they read or use computers? They must think that Google is a character (Barney Google) in a silly song. But say, Curmudge, I thought we were going to explore the future, and here we are talking about an organization living in the past.”

“We have to start somewhere, and even today there are probably command-and-control organizations out there. It wouldn’t be proper to just blow right by them. Their first need is to realize that employees are more productive when they are respected and that problems are best solved by the people in gemba…”

“…and that traditional hospitals tend to be wasteful, and that systems are best understood and improved after they are mapped. I’ve got it, Curmudge. Making these improvements is just common sense. Understanding this is where a traditional organization has to start if they want to join the rapidly changing world of health care.”

“One problem, Julie. People have their own, unique concept of common sense. We would have chaos if every person went his own way making improvements. People’s creative energies need to be harnessed and focused by using a structured program like Lean. We’ve talked about Lean in this blog for the past four years. However, for the total neophyte’s remedial reading we recommend a review of similar programs in the April 14, 2011 posting in Curmudgeon’s Wastebasket. ”

“People use lots of names for their improvement program, including those that are unique to their organization. Most of them are based on the principles of the Toyota Production System. But tell me, Curmudge, how should the wayward outfit whose role I am playing get their culture change under way?”

“Since Affinity began their Lean journey several years ago, a ton of books have been written and an army of consultants have come out of the woodwork. However, the absolute least expensive way to learn about Lean is to read Kaizen Curmudgeon. You’ll also want to benchmark organizations that have been describing their Lean successes at meetings. At some point you will probably want to contract with a sensei (honored teacher) for guidance. The best way to find such a person is to talk with people who have been where you want to go.”

“After I have done a lot of reading and become a dedicated change agent, what’s my next step?”

“Julie, leading from the middle of an organization is like pushing a rope. Nevertheless, it’s essential that those higher in the organization—especially at the top—become emotional, vocal, and physical supporters of the proposed new culture. However, your task should not be impossible if these (paraphrased) comments from a recent meeting of the American College of Healthcare Executives are valid: ‘They have heard, and hopefully understand, that they are going to have to change their organizations in major, cataclysmic ways especially if they haven’t started to do so already. Leaders in general are now much more knowledgeable about the steps they will have to take. They understand they have to adopt Toyota and Lean manufacturing strategies.’ “

“Whew! That helps. Let’s assume that I am successful and that the organization has set sail on its Lean journey. Can I sit back and relax?”

“No way! It may have taken herculean efforts to get the flywheel turning, but it is not frictionless. Maintaining a Lean program requires dogged determination and almost religious dedication. And ideally, it never ends.”

“Perhaps it’s a bit like marriage, Curmudge. You’d better hardwire the whole concept, because it’s going to be your partner for a long time.”

“In addition, Julie, as the resident futurist you will want to expand your horizon. Instead of thinking how better to organize a supply closet, you’ll want to know what’s coming down the pike that will impact your organization.”

“Wow! That’s a gigantic expansion. I assume we’ll talk about that next time. By the way, Curmudge, are you a futurist?”

“Of course I am, but for me the future is tomorrow. That’s why if I wake up in the morning, every day is a beautiful day.”

Affinity’s Kaizen Curmudgeon

Thursday, April 7, 2011

The Crystal Ball--Prologue

“Curmudge, in this turbulent world, how were you able to stay employed so long?”

“Well Jaded Julie, I kept reinventing myself. I was always looking for ways in which my experience matched my employer’s needs. Often it was difficult to anticipate what those needs would be. Ultimately I became ‘retired’ when I ran out of inventions.”

“The outlook for health care in the U.S. appears to be even murkier than what you experienced in industry. Nevertheless, are there people or organizations who are trying to foresee our admittedly cloudy future?”

“Of course, Julie. But forecasting becomes more risky as one tries to peer farther into the unknown. Let’s start with the near term. Because most everyone already knows that we must become more efficient tomorrow, next month, and next year, we can forge ahead with process improvements with no concern that we might be wasting our effort. But planning ten or twenty years ahead is much more difficult.”

“C’mon, Curmudge, at your age planning ten years into your future is overly optimistic and twenty years out would be a waste of time.”

“Regrettably, that’s true. As you already know, I don’t even buy green bananas. However, for those folks like you anticipating a long and successful career, let’s try to look ahead anyway. Of course, you are not going to make it into the future unless you can make it through today. So we’ll start by describing resources that every health care organization should be using right now. And along with being contemporary, this knowledge is used locally, i.e.; it’s applied by the workers in gemba.”

“It sounds as if you are talking about Lean, which all of our readers should understand pretty well. But why should I, a nurse, push my knowledge horizon out into the future?”

“Be optimistic, Julie. In health care, nursing can be the gateway to most anything in the organization. The business unit and corporate leaders of the future had better understand what will be going on around them.”

“I’m convinced, Curmudge. May I sign up for your trip over the rainbow?”

“Of course. Pack your carry-on; we depart in a week or two.”

Affinity’s Kaizen Curmudgeon