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By Duke Rohe, FHIMSS
Performance Improvement Specialist
M.D. Anderson Cancer Center
(Editor’s note: This is the second in a two-part series on the seven levels of change in health care. In the first installment, which ran in the May 2002 issue, Rohe discussed the first four levels of change: Level 1 — Doing the Right Things; Level 2 — Doing Things Right; Level 3 — Doing Things Better; and Level 4 — Doing Away With Things.)
Having worked at St. Luke’s Episcopal Hospital, an organization known for its innovative culture, and M.D. Anderson Cancer Center in Houston, a hospital unparalleled in the care its patients receive, I have seen real-world illustrations of the seven levels of change in health care. Here are some examples:
Level 5: Do what others do well
When I was interviewing for a job at my present hospital, one administrator told me they were piloting hotel-type room service for the patients. To a cancer patient who is undergoing treatment, food is a chore — not something to look forward to. The administrator didn’t want anything in the way of the patient’s fight to beat this terrible disease, especially food. My engineering head thought, this seemed inefficient.
To the surprise of my paradigm, the hospital has taken the hotel room service concept and done one better. The hospital hired a former manager and captains of the Ritz Carlton to grow the service from scratch. The room service staff who were hired had to have restaurant service experience first, and then learn the requirements of diet restrictions. A new call center was created to field calls throughout the day and "garnish" the choice of menu items.
The cooks worked on a short order instead of a batch basis. The kitchen had to be remodeled to accommodate the short-order style. The menu ranged from grilled chicken (meat and heat as the cooks call it) to stuffed shrimp or filets.
The hospital provides call-to-order service (conditioned by diet restrictions) from 7 a.m. to 9 p.m. to its patients and its guests — and gets the food delivered in style and in an average of 32 minutes. The service is even extended to outpatients receiving transfusions or chemo during the meal hours.
The wait staff dress in serving attire and eagerly wait on their patrons. The staff has "line-up" every morning to remind them of their mission and to discuss what could be done better.
I once followed a waiter down to the kitchen to get two fresh scoops of ice cream because the ones that came up had already begun to melt; nothing was going to get in the way of treating the patients royally. Surveys of course, showed the percent of "excellent" marks jumped from 15% to 85%.
I did have the privilege of performing a study of the number of staff needed to perform a hospitalwide 45-minute room service delivery promise and found it was more expensive than traditional tray delivery. But that’s why they call it room service and not food service.
Level 6: Do things that haven’t been done
This usually happens when there are no means to do it the traditional way. The mind won’t search for an impossible answer until there is an impossible situation. They also come when someone connects two unrelated concepts into one great idea.
A hospital was attempting to transport specimens and units of blood through the pneumatic tube system. The biggest reservation was the possibility of a blood spill inside the carrier, amplifying the risk of AIDS.
All precautions were taken. The specimen tubes were switched from glass to plastic. The specimens were placed in a leak-proof, Ziploc bag. The Ziploc bag was placed in a foam-cushioned carrier that was rubber-sealed. But WHAT IF, somehow, the specimen leaked out of the specimen tube, out of the Ziploc bag and onto the cushion of the carrier? How can someone tell, by looking at the outside of the carrier, that there is a leak on the inside?
Then one of the blood collectors had a Level 6 idea: "You know, they make disposable diapers that change color so you can see they are wet before you feel they are wet. What if they had foam liners that do the same?" Now, that’s a solution the pneumatic tube manufacturer ought to run after.
Another Level 6 effort in my hospital and a prediction for the way hospitals will be managed in the future: We are looking to blaze a new trail in organizational understanding through the use of the Theory of Constraints. Treat all needed services as a series of connected flows (in pipes). A system can go no faster than its smallest bottleneck, and a flow-related improvement anywhere else than its bottleneck will not improve the overall service.
Instead of managing resources (traditional), hospitals will focus on managing flows.
Level 7: Do things that can’t be done
This comes to those who dream differently. It is discovered in the paradoxes of life. It is in those hopes that are bigger than life. I have always wanted to have a million-dollar idea. I could care less about making a million dollars, but I would love to have an idea that clever. A personal goal of mine has been to make a positive impact on health care. Everywhere.
In fact, why stop with health care? I have an unquenchable desire to create and share tools or writings that help others. Over the years, I have accumulated more than 600 tools to speed change along. I have written more than 800 spiritual one-pagers in the same light.
With the help of Duration Software, there is now a web site designed to provide free downloadable performance improvement tools — to anyone who has a computer. The tools are intuitively categorized. Fresh tools are featured monthly. The only thing missing from my dream is the rest of the world knowing about it. Internally, in my own hospital, I am learning how to "breadcrumb" the staff to the tools’ use and availability. The mere size of their number intimidates people.
Externally, I am approaching professional organizations, country web sites, to raise awareness. For the last three years, I have e-mailed to a list of subscribers "Weekly Readers" with a tool to think on. It’s quite a challenge and honor to attempt to interface with the world to make a difference.
[Duke Rohe is performance improvement specialist at M.D. Anderson Cancer Center in Houston. He may be reached at (713) 745-4433. To access tools related to this series, visit the tools site: www.durationsoftware.com, then click Improvement Tools.]