Moments of truth

Jan Calrzon is a legend in the business world. Well known for having turned around the failing SAS airlines in the 80s, his strategy for success was simple....focus on what he calls the 'moment of truth' which is the few seconds when a customer or passenger interacted with the airline. He called it so because he believed that those few seconds were a unique opportunity for the airline to make a positive and lasting impression. His clarion call to every employee eventually led to a transformation of the organization which soon reached the top ranks in customer satisfaction. This kind of leadership with an obsession for patient satisfaction and a strong belief that this is achievable only through team work is hard to find in healthcare.

Finding the right match

I was going through a case study on the hiring process at SG Cowen, a successful investment bank. I found in their hiring process the reason for my encountering dissatisfied employees at all levels in every healthcare organization i worked with. Cowen's hiring process was based on using technical skills as merely a qualifying criteria. The rigorous process they had devised was instead focused on finding the 'right match". The right match almost sounds matrimonial...it had be love for the job/groom and a proper fit into the groom's 'family'. But look at the hiring in our hospitals and clinics. The degrees and the technical skills matter. The rest is mostly ignored.

Making money from better care

Numerous studies show that patients drop out of IVF treatment because of the psychological burden associated with it...i see 2 important inferences from this. One is that there is a business case to provide as much comfort to the patient as possible. There would be more cases being done if the patients are kept happy and not necessarily pregnant. Second is that the one of the performance measures of a clinic should be drop out rate.

Would i be better off with some more flab around my waist?

So we all want to change for the better whether it is in the way we make dinner or the way we play football. But how do we usually go about it. Well imagine you wanted to improve your health. It is highly likely you will run off to the bookstore to buy a health guide, surf the net or use the accumulated 'television' knowledge on what is good for you. Let me guess..your solution would likely to be to try loosing the extra flab. How do I know? Well that's a solution which anyone living on this modern planet would think as obvious. Even if you didn't go to school you would have seen the weight loss preachers on TV. So next step..go for a radical diet or exercise all you can or a mix of both. You could be more 'scientific' and follow professionally crafted weight loss programs.
My point is not that all these weight loss plans are misguided but that we actually went from the idea of improving health to weight loss programs. Did we actually stop to think whether improving your health means lower figures on the weight scale? How did we form that link? Or is that link really consistent with your own physical-mental status. And once you reach that magical figure on the scales, are you any healthier? Who says so? Why? And how did you decide on the figure?
So what is my point? Well here goes...when you are trying to improvise, first be clear on what we are trying to accomplish. Improving health could mean a lot of things for you not just some flab you may have. It could mean feeling better or meaning you could take the stairs without gasping for breath. Be clear on the goal. Second, the goal isn't always a numerical target so you have to decide what exactly is the measure which will help you determine that the change made by you is resulting in a clear and positive change towards that goal. Thirdly, you now have to figure out what is the change that you will execute to do this?
But remember that the change initiated by you may not result in a desired shift in the measure..it may even worsen. Or you might have achieved just miniscule improvement. So what? The measure still gives you information on whether to upgrade whatever you were doing to improvise further or you realise that you are totally in the wrong direction. And then you try something else and you could go on until you reach the desired goal.
Above I have just elaborated on 2 fundamental and essential themes to remember when working on quality improvement. One is the 3 fundamental questions that must be answered when executing a change exercise. Second is the cyclical process of undertaking experiments to improvise until you achieve what you set out to do. Technically you could call it the PDSA or Plan-do-study-act cycles.

Changing pains

Change is a traumatic experience or so it may seem if you were to sit at the busy mumbai airport terminal. Over the years lot has been done in airports and by airlines around the world to make air travel a more pleasant and stress free experience. Those of us who travel around the world will have experienced the exceptionally well planned Changi airport to the less glamorous but comfortable european airports. Many of us are not so good observers of the nuances of travel. But there is one thing you could not have missed or you would have had to be deaf. In Mumbai airport it seems a noisy environment is sought to be created by constant reminders to check-in, security etc while airports across the world even those having much greater frequency of flights are so quiet you could sleep off in the waiting areas. This I think is a practice from decades earlier when flights were much fewer and most travellers were unfamiliar with the airport environment and what they needed to do. This is not the case today when most people are not first time travellers and the frequency of flights is such that reminders could continue without a pause.Sitting and waiting for the flight becomes a stressful experience. So why does mumbai airport management continue with this practice? The only reason could be that it is just too difficult for airport management to think about stopping something that has been going on for years. It probably seems to many up there that it is critical for these reminders to continue..how else will passengers know what to do? Stopping these announcements probably seems akin to removing traffic signals...dangerous and disruptive. And how would top management know what is good for the customer unless there was a structured process by which management would source ideas for improvement from the customer (in this case the traveller)? But just stop to think..have you ever asked patients whether they like the smell in the rooms or the difficulty of standing in queues?

Do numbers lie?

I once led a hospital quality improvement project team to execute a data collection plan that involved recording the time it takes for patients to leave the hospital after being medically cleared for discharge. The 2 week long exercise seemed to go well and when I looked at the numbers I found a pattern. The pattern wasn't related to the problem we were trying to solve but that each floor seemed to have its own distinctness with regard to the timepoints. I was sure something went wrong. So I brought the nurse heads on the different floors all together and asked them what it is they were actually measuring. It turned out that everybody had a different definition of the timepoint they were required to record. While for some it meant the time the patients had cleared all their bills and obtained their take home medicines, for others it meant the point when patients were handed over the discharge summaries. And then there were others with slightly different definitions of their own. While you make be thinking it was a poorly planned exercise, the fact is that definitions were clear to those on the project team but not to those on the frontline. These kind of communication flaws are not news to managers. However what is important to understand is that the flawed data gathering could have led to the wrong inferences and thereby wrong solutions to the problem at hand. And this is not just happening in quality improvement but in clinical and managerial audits as well.
So beware...always look for the story behind the numbers!