“Why Work Sucks and How to Fix It: No Schedules, No Meetings, No Joke–the Simple Change That Can Make Your Job Terrific” (Cali Ressler, Jody Thompson)

As a leader in an organization, imagine reading this description of an employee’s workday:

A typical day for me includes waking up when my room is too bright from the sun and I can no longer sleep. I check my e-mail to make sure there are no pressing issues and respond to anyone who needs my input. I will typically watch an episode of South Park on the Internet, then walk to my local grocery store and buy some breakfast, even though it’s closer to lunch at this point. After eating I will work in front of my television with ESPN on in the background. At this point I will choose to go into the office or continue to work from home, or maybe not even work at all and go for a bike ride or jog. If there is still work to do later that night, I’ll do it then and it’s no big deal.

I’ll admit it - it kind of made me gulp when I read it.

At the same time, though, I have been in a lot of conversations with a lot of personal and professional colleagues over the past 3-4 years or so, where the question we’re asking ourselves is, “Is this how work life is supposed to be?” Spoken or unspoken, the answer is “we don’t think so.” Various companies’ data also show a trend toward less vacancy in their physical locations.

In the middle of that self-discovery, I read about BestBuy, Inc., (see “Smashing the Clock“). This is the book about their journey.

It’s time to let go and see what our employees can really do - BestBuy Manager

A Results Only Work Environment (ROWE) is as it says - one where results are measured, not time spent. There are no timeclocks, no discussion of time, and no “Sludge” as the authors refer to it. “Sludge” are the comments people make to each other about time, whether it’s about being late to a meeting, or working late at night. Simply put, the authors state, an employer is trading work for money. Why not give them what they pay for?

Reading beyond the BusinessWeek article was very useful - this is not flextime, it’s not “working from home,” it’s a different philosophy altogether. That includes the vignette above. Totally allowed, if you have the results to show for it. The concept can appear challenging; however, it makes sense, in the context of strong leadership committed to respecting employees and customers. That’s where I found similarities to the work I have done.

About respect

When I first read about this work, I asked about how this was similar or different from the LEAN transformation I participated in, in the area of health information technology. Some of the things were consistent, some seemed less so, like having technology teams physically present alongside doctors and nurses, guiding care and feeding of an electronic health record system.

My reconciliation of all of this rests with not comparing individual tools/approaches between ROWE and LEAN. What they both have in common is respect for the customer and staff, and strong leaders. It’s impressive that at the heart of the ROWE movement was (at the time) a 24 year old employee of BestBuy (Cali Ressler), who was dissatisfied with the status quo. The authors also explicitly reject war analogies in business as I have. In my own situation, there was not just a desire to change the way we worked, it was clear that not changing would be unsafe. Healthcare organizations across the country are now learning this, thankfully, but it’s a slow transformation, and the transformations that are happening are nowhere near as radical as ROWE, which is why I am interested in the movement (not because I want to be radical, but because the threats to our patients and their families’ health are so significant).

Just because you can no longer be late doesn’t mean you can be lame

Preliminary data from the University of Minnesota’s Flexible Work and Well-Being Center are showing that voluntary terminations are down, involuntary terminations are up.

Mea culpa and, as usual, I see analogies to health care

I liked the concepts in the book a lot, and have done a self-inventory of my own sludge and the sludge that’s been directed my way. The kind of sludge I get nowadays is really from people who want to understand better how technology can be used to help patients stay healthy. I welcome it as an opportunity to teach and learn. As the authors discussed, people can learn to live sludge-free, and they really want to live sludge-free. It starts with us.

I could see myself promoting ROWE in health care settings, and I think physicians, primary care ones especially, would benefit. The work I do to change health care is completely connected to the idea that health is a means, not an end, and people who go into health care want to support our patients where support is needed, mostly where they live, work, and play. I don’t believe people in health care are any more attached to time than Cali and Jody’s (former?) colleagues at BestBuy are. When I read the stories of BestBuy employees before and after, I reflected on some of the conversations I have had with health professionals (at all levels) who have really been challenged to juggle their passion for helping people and their ability to provide for themselves and their families, physically and emotionally. What would it be like for a family medicine or internal medicine specialist to provide their cognitive services to patients and families using a combination of virtual tools and office (or even home presence) when the situation called for it? Look at what HelloHealth is doing. It’s possible.

A Results Only Patient Experience (ROPE)?

A came upon this table in the book, and curiously, I found it extensible to our health care system. I hope I won’t get in trouble for using it to think about what our health care system were like if our patients experienced it the way a BestBuy employee experienced their work life. The edits are mine.

I admit, that maybe, once or twice in my past, I may have used convening and convener in less than flattering terms, much like I used to use “process” in unflattering terms. I learned through LEAN, though, that process isn’t bad, bad process is bad. And so I have learned the same thing about convening, now that I have done it a couple times this summer, with the California Healthcare Foundation.

The most recent time was yesterday, when Veenu Aulakh, MPH, and I brought together Safety Net health care organizations, and national experts in patient online access and social impact of the Internet to talk about (you can guess…) “Patient Online Access in the Safety Net.”

These being the first convenings I have co-led, rather than participated in, I have learned a ton, and have gotten a good understanding of doing this for a purpose, which both situations have had. In the event we hosted yesterday, in Oakland, I put together an A3 document before we invited anyone, which included the background, the goals, and most importantly, the “why?” we were doing this in the first place. It was really helpful to have created agreement around the “why?” - I referred to this many times in the planning.

At the event itself, I got a new perspective that I had not had as a participant previously. It was one of listener/observer - even when I was doing the talking, I was interested to see reactions and learn what people and organizations are capable of. It made me think that when I have been a participant in convenings in the past, this is what my hosts were doing - learning what myself or my organization was capable of doing to solve a problem, as much as they might have tapped me as an expert. Interesting to have this happening in my brain.

Sharing information happened, too, courtesy of some of the most innovative organizations in the U.S., including Cambridge Health Alliance, University of California, San Francisco’s Positive Health Program , New York’s Primary Care Information Project, Institute for Family Health, and Kaiser Permanente.

In addition to all of this, there were a few nice moments of recognition for people’s work, such as when Jim Kahn, MD, thanked Kate Christensen, MD, and her team at Kaiser Permanente for their support and assistance in the launch of the myHERO patient portal for HIV patients cared for at San Francisco General Hospital.

…and a little something for me, a follow-up conversation with Hilary Worthen, MD, from Cambridge Health Alliance, about his study and pathway to discover and implement LEAN in primary care at CHA. He told me that for him, this is a transition from thinking about exam rooms and staff to “work that you need to get done, defined by doctor and patient.” I love hearing about how people apply their creativity and copy the thinking of LEAN to do exceptional things for their patients.

This being the second time I have done this, I don’t know if it was perfect. We tried a lot of things I’ve not done in meetings before, and I am still working to integrate social media before, during, and after. I am definitely sold on my philosophy of supporting any and all technology use (”if you need or want to use your device, use it”) - I have not, in my conveningness, come around to the “turn your devices off” philosophy, as I have written about previously.

Oh, and I learned that a 60″ table seats 8 people.

Here are a few images from yesterday. I’ll follow up with my slides in a separate post. Click on any to see larger size.

• Strategy Execution and the Balanced Scorecard (HBS Working Knowledge) - Excellent article with another reminder that strategy deserves its own bandwidth, and should be tied to operations, back and forth, in other words, always checking that what we're doing every day matters. Nice nod to leadership: "There are two key issues. First is leadership. Without strong visionary leadership, no strategy will be executed effectively." This can be challenging in healthcare. Luckily, our patients and their families want to help.

I looked online for a definition of the phrase “Ford-Talk,” so maybe it was a term that was coined internally within the last organization I worked for, or the broader Toyota Management System community.

It refers to a culture where managers who are called into a room by their boss give positive assessments of how their areas are doing. This was ascribed to an American carmaker, but I think it could apply to many American companies, relative to their Japanese analogues, where it is expected that failures are pointed out, so they can be fixed. As it is said, an assembly line that is reported as being 100% functional is one that is not functional because it is not finding mistakes and fixing them.

I thought of Ford-Talk when I read This article, which talks about the failure of managers to tell the CEO that things weren't ready. and this article, which dissects the CEO’s memo about the failures to staff and does a nice job of bringing Steve Jobs’ talents in working with the public to light.

However, if articles like this one alluding to the inner workings of the company (“The Economist: Jobs’s Job”) are to be believed I think there may be a different perspective than, “the managers did not report that there were problems and luckily Steve owned the problem publicly so the company could regroup and succeed.”

What I have learned is even the most innovative environments may operate with a command-and-control approach, not by purpose, but by neglect. When that happens, the failure may be not to listen, rather than not to speak.

Did that happen here? I don’t know. The comment about managers failing to tell the boss something caught my eye as a Toyota Management System/LEAN aficionado and made me wonder if there was more to learn.

I am interested in stories like this because I’ve been working in healthcare to improve the listening. When we go from telling people, “You won’t hear anything from us if everything is normal (the ultimate Ford-Talk),” to listening to the question, “I just got my lab report and I have a question about this specific number” we’re more likely to pick up mistakes. It’s better to be embarrassed and change course quickly than wait in these individual cases, and when there is a bigger problem to ask “why?” the problem happened, five times. There may be more than a simple answer…..

• Human Resources and Lean - Commentary on what HR is. And what it could be - the foundation for renewal and success in organizations, instead of a compliance function.

• Essay - Fed Up With the Frustrations, More Doctors Change Course - NYTimes.com - I am sympathetic, and this is the reason I champion LEAN wherever I go - the processes we use in health care can be changed, and we can involve patients and our families so that everyone works together to be healthy. The challenge for physicians is that we are not trained at all in process improvement, so we usually enter environments with broken processes, and manage these situations with the training we have been given, which doesn’t lend to collaboration. See this blog entry for examples of extreme challenges in our medical education system today. I sometimes say that we’re all actors in a play that has a script we didn’t write. Let’s rewrite the script (patients and their families included).

  If anyone wants to collaborate on a medical student rotation looking at LEAN concepts / process improvement / patient centered care / respect for staff and customer, let me know. This presumes that there’s a medical school either teaching this or interested in this. Is there?

• Lululemon’s Next Workout - Profile of a company who's CEO wants to be close to her customer. A great true north - "elevate the world through health and fitness." My own experience finding their expansion strategy - the showroom concept - could be useful to health care organizations

• A New Group Goes to Gemba (Going to Gemba) - Seattle's Children's Hospital is sending a large contingent of staff to Japan to learn LEAN.

A3 (Project Plan). Click here to learn more about what an A3 is

This post contains the A3 Document, or the Project Plan, for Connectivity for California Consumers. I have been posting some of the data that supports this plan on this blog (click here to see them all). In addition, I have been working with staff at California Healthcare Foundation and potential stakeholders to improve the plan.

For those of you unfamiliar with the A3 format, it is designed to (a) tell a story and (b) incrementally improved to the point that the actions are clear at the time a project is launched. It may be revised once a day or even more often. The process of discussing the project and making improvements is called “nemawashi.” I am using this blog for extended nemawashi, so please post your comments.

Since an A3 tells a story, starting on the left, going down, and then on the right, I will summarize the story here. Feel free to print out the A3 and follow along (A3 means “11 x 17″ paper. You may have to shrink to fit on letter size).

Issue & Focus

1. The California Healthcare Foundation is dedicated to the improvement of the lives of Californians managing chronic illnesses.
2. There are many community stakeholders involved in supporting this goal; their work could be improved by making connections to each other that are meaningful for patients.
3. This is part of a broader strategic plan to support the objective of involving patients and families in all aspects of their care. This is the identified gap to be closed through this work.
4. California Healthcare Foundation is seen as catalyst and partner for patient engagement in California

Current Condition

1. There are well known gaps the care of people with high blood pressure
2. The impact of these gaps is distributed across stakeholders differently compared to other chronic illnesses, which includes a strong productivity-loss component, due to the high prevalence of the condition in employed populations (see charts).
3. There are examples of employers and technology companies approaching these gaps in hypertension and other chronic illnesses that can be studied.

Problem Analysis

1. Lack of access to care accounts for only 10% of poor blood pressure control; there is a physician component in setting goals, and a patient component in operationalizing those goals, that may not be accomplished in physician visits alone.
2. Patients who are not seen at least every 12 months are at greater risk for non-adherence
3. The societal costs of inadequate management are spread diffusely; few organizations are able to to see the total harm from this perspective
4. There are few models outside of integrated care systems of using non-visit-based approaches to managing chronic illness.
5. We are just entering an era of interoperability, with many solutions not yet integrated into the value chain of patients and payers

Target Condition

This pilot seeks to create a functioning ecosystem that supports chronic disease management across the lifecycle, with the best candidate being hypertension

Action Plan

We began by interviewing example employers, health care providers, and technology providers to understand which approaches and components appeared most promising. At this time, it seems most reasonable to approach this first from the employer perspective.

Next step will be to convene a group of potential partners in June or July, 2008, at California Healthcare Foundation, to discuss how pieces would fit together.

A presentation would be made to the CHCF Board in the fall, with funding and activity to begin in 2009.

Cost / Cost-Benefit / Waste Recognition

There are recognized wastes, which include unnecessary visits for blood pressure monitoring, inadequate medication therapy, and inadequate use of the health system, for patients who have not been seen in the past 12 months.

There are costs including, technology costs (although the goal is not to build anything new), and realignment of incentives to support non-visit-based care.

Followup / Unresolved Issues

Points of concern and planned countermeasures

1. What is the metric for patient access? (Pacific Business Group on Health is working on an employee engagement survey; metrics for patient access to their health data may need to be developed)
2. How can this complement the launch of both a P4P measure for blood pressure management, and a HEDIS “Relative Resource Use for Uncomplicated Hypertension” measure for 2008?
3. Data for presenteeism and productivity loss does not seem intuitive (I have reviewed this in depth and we can bring in clinical champions to verify)
4. Partners and aligned interests (will do due diligence to support cooperative business models of partners)
5. How to engage patients in things like biometric monitoring and blood pressure control (will look at plan design options, but most importantly will go to the factory floor, and will bring an employee/patient advisor on to the team)

So that’s the script that goes with the story, more or less. Comment away, and keep in mind that each comment will change the A3 a little every time.

May 10th through May 13th:

• Be Well Mobile, Patient Engagement Software that works - cell phone platform for disease management
• Medical Advances—Through Your iPhone? - Portable applications in health care that the iPhone could enable.
• Scientific Misconduct Blog: LSD and the corruption of medicine (Part III): Naming names - A chilling account of experimentation on US citizens without consent
• Texting may help teens remember meds - CNN.com - Cell phones as a tool in medication adherence.
• The Open Secret of Success: Financial Page: The New Yorker - One of the best summaries of what Toyota does well that I've seen.
• ITIF: Explaining International Broadband Leadership - Summary of broadband access in the US and other countries
• Ruthsarian Layouts - Some helpful CSS layouts for blog design