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The Importance of Beautiful(ly Thoughtful) Questions

In 1943, Edwin Land, while on vacation with his family, took some photographs of his daughter, Jennifer. Like any good three-year-old, Jennifer wanted to see the results of the picture right away. “Why can’t I?,” Jennifer asked. This simple yet powerful question led Land and his company, Polaroid, to develop products that transformed the experience of photography.

 

Why, What If, and How

In Warren Berger‘s new book, A More Beautiful Question, Land’s story is one of many used to illustrate the importance of not only questioning (itself a lost art among adults and organizations) but in also asking the right questions (primarily why, what if, and how) as a catalyst to innovation. The power of questioning is already revolutionizing fields from marketing to technology startups, and although Berger’s book has barely been out a month, I suspect it will become one of the top business books of the year.

A More Beautiful Question is particularly timely for aging services, as a confluence of forces– from payment models to demographic needs to disruptive technologies– are bringing fundamental changes quickly into focus and now, more than ever, organizations need to deeply question the core tenants of their organization as a precursor for survival.

The why, what if and how questions form the triad of powerful, leading devices for questioning. For why questions, Berger recommends the following process:

  • Step back.
  • Notice what others miss.
  • Challenge assumptions.
  • Gain a deeper understanding of the situation at hand, through contextual inquiry.
  • Question the questions we’re asking.
  • Take ownership of a particular question.

Many providers today are struggling with declining reimbursement, razor thin operating margins, maintaining quality of care, and meeting the needs and wants of a quickly changing population. Why questions can be incredibly useful in asking, “Why are we providing this service line?”, “Why aren’t we meeting these needs?” and even “Why are we here?”

If why has “penetrative power,” Berger writes, “what if [has] a more expansive effect– allowing us to think without limits or constraints, firing the imagination.” Several organizations have used the what if question to create groundbreaking innovations in aging services already: “What if we stopped building bricks and mortar?” (The CCAH model), “What if we made senior centers as appealing as Starbucks?” (MatherLifeways Cafe Plus), and “What if we combined predictive analytics with remote monitoring? (HealthSense, HealthSignals, CarePredict, and several others).

The final crucial question, how, is where results are created. Berger points to a number of examples that highlight the value of fast prototyping (Eric Reis and the Lean Startup)  and test and learn (referencing Bloomberg’s pilot programs in NYC). Both of these strategies can be incredibly useful to aging services providers, who oftentimes think an idea to death before even launching a trial. For organizations that are able to test out new ideas and programming, it’s important to measure results carefully. Ask the question “Am I failing differently each time?”, Berger writes, drawing on IDEO founder David Kelley’s observations on the subject. This is particularly useful in responding to adverse events, as the lack of learning inevitable leads to policy creep: the tendency to respond to any event by writing a new policy or creating a new form.

 

Learning Organizations

I’ve heard many providers refer to themselves as “learning organizations,” popularized by Peter Senge, et al., in the book, The Fifth Dsicipline. The reality, however, is that very few actually embark on the journey to implement the disciplines necessary– systems thinking, personal mastery, mental models, shared vision, and team learning– mainly because they aren’t adept at questioning correctly.

One of the biggest reasons I love lean thinking is the emphasis on constant reflection and continuous improvement. Aging services providers, always already trying to do too much good work with too few resources and supports, tend to aggressively justify their current operations, values and faults rather than deeply question their core work. “We’re doing the best we can for our staff,” rather than, “How can we pay our staff a living wage?” “You have to move to assisted living to get services,” instead of “What if we built up services in place by leveraging other offerings?” This is unfortunate, foremost for its detrimental impact on persons served– and will likely be lethal over the coming years to organizations that can’t make the shift. (Polaroid, itself, is a great example of why learning must be constant, going bankrupt in 2001 after underestimating the impact of digital cameras.)

 

Questioning

Peter Drucker, considered to be the father of management, famously consulted with organizations not by providing answers but by asking crucial, if sometimes rather obvious, questions. The power of questioning, as Berger lays out so clearly in his book, will indeed be one of the biggest differentiators in the field of aging services moving forward. There is great future need, for sure, but it will no longer be met by senior housing alone. The current explosion into remote monitoring, home and community-based services, and intergenerational communities is only the tip, and providers need to start now to build strong organizations suited for deep questioning.

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Balanced Scorecards and Key Performance Indicators in Long term and Post-acute Care

Are you struggling to accomplish your desired strategy? Thwarted by constant operational challenges? Your measurement systems might be able to help more– or they might even be part of the problem.

Many healthcare organizations track enormous amounts of data to guide their action and strategy. Sometimes, however, the pursuit of measures and metrics interfere with the implementation of strategy, and organizations struggle to move past the day-to-day business challenges to accomplish their long-term goals. Balanced scorecards and KPIs are two tool sets that, when used properly, can be used to facilitate both managing operations and preparing for future work.

 

Balanced Scorecard for LTC

Balanced Scorecards

The concept of a balanced scorecard was developed in the mid-90s by Robert Kaplan and David Norton (with help from  Art Schneiderman, et al.) as a response to the over-dependence on financial measures to guide organizational action. The purpose was to translate strategy into measures that could inform action by balancing financial measures with measures around the perspectives of customers, internal business processes and innovation/ learning. Over time, additional features were added, such as strategy maps to help visualize direction, and destination statements to provide more definition around goals.

A key challenge to implementing balanced scorecards is they take a significant investment of senior leadership’s time to develop. While financial measures are easy to translate across organizations (census, payer mix, days in AR and financial ratios would be common in long-term care), as well as some internal business measures (quality indicators, survey and cert. results), the customer and innovation quadrants needs to be more locally refined. Some organizations, for instance, serve specific populations, and the measures of success need to be closely aligned with those missions. Similarly, learning and innovation is important in every organization, but the actualization can vary from an interest in employee development to implementing evidence-based practices to technological adoption.

Sometimes, the challenge is having vague ideas about strategy but no clue about how to get there. I’ve worked for and with several organizations that have wanted to “be the best place to live and work” and “a teaching and learning organization.” They struggled year after year with making progress, however, because they didn’t hone in on specific measures to drive that strategy, nor did they have clear ideas about what exactly those lofty goals meant.

The Capital Care Group in Canada implemented a balanced scorecard, and there are some great lessons learned from research on that process:

“The balanced scorecard has focused on its role as a strategic management tool. The indicators and dimensions need to be customized to the organization. Senior management must be seen to be driving its introduction. It is worth spending sufficient time developing and implementing a scorecard rather than trying to rush its introduction. The scorecard needs to be integrated with existing management processes and sufficient resources must be assigned. However, success will ultimately depend on the culture of the organization being appropriate and receptive.”

Key Performance Indicators (KPIs)

KPIs were developed to focus attention on accomplishing organizational strategy by measuring discrete data points. Again, financial measures have been used successfully for quite some time, but KPIs expand the reach to things like productivity, marketing success, turnover, meaningful quality measures (ones that either impact action or reflect operational results) and the like.

When adopting KPIs, it’s important to choose a limited number so that staff don’t become overwhelmed with the measurement of data for its own sake. It’s also important to understand the tendency for measured indicators to pervert performance by allowing managers to manipulate action in promotion of measured activities even at the expense of organizational success. I frequently see this when organizations measure turnover without regard to other performance metrics. This tends to incentivize managers to keep staff regardless of performance or actions– even at the detriment of team morale and operational effectiveness. High turnover is a costly problem in long-term care, for sure, but not all turnover is bad.

 

Using Organizational Metrics Effectively

Whatever system of measurement you use, it’s important to understand the systems themselves don’t determine strategy. Measurement systems are oftentimes compared to an automobile’s dashboard or an airplane’s cockpit: but remember, you can’t tell where you’re going, or, even moreso, what you’re supposed to do when you get there, by looking at a dashboard; nor can you tell whether you should go through an intersection by staring at your dash. Instead, the dashboard helps keep you on track and can highlight problems that might interfere with your trip. Balanced scorecards and KPIs function in a very similar way: they guide action and help implement strategy– but you still need to know where you are going and what you want to do when you get there, and you must keep in mind that they are only a piece of the overall operational puzzle.

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eSSee Consulting has extensive experience developing and implementing measuring and metric systems in long-term care organizations. If you’re unhappy with your current system, or don’t have effective dashboards at all, we would love to help simplify your life by focusing on measures that truly impact performance and push you towards your desired goals.

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Google Apps for Business: Exceptional Suite for Providers

We’re a big fan of Google Apps because of the consumer-centric nature of the experience, the seamless integration across applications and devices, easy to set up security requirements and restrictions, and the ability to run analytics to improve efficiency of use. Google Apps is well-suited for healthcare, and reasonably priced for businesses of any size (especially considering many organizations in aging services lack the IT expertise to effectively and efficiently manage local resources).

So how can Google Apps drive efficiency and help your organization?

  • Gmail, which millions of people use for their email already: powerful, intuitive UI, and massive storage.
  • Drive: A shared server and secure document portal for sharing materials internally, with trusted partners, and with the general community or prospective residents. Drive also makes collaborative editing of documents, presentations and spreadsheets a snap, which can save enormous amounts of time when writing P&Ps, preparing actions plans, or creating Board presentations.
  • Calendars: Intuitive calendaring platform that’s easy to share and simple to create group and resource (e.g., room, equipment, etc) calendars.
  • Storage space: 30GB per user is included.
  • Hangouts: A fantastic combination of instant messaging, video conferencing, and outbound call manager. Video calling is particularly valuable when you need to quickly touch base with someone about a sensitive topic and want more interaction than a phone call, but don’t need actual face-to-face contact.
  • Vault: An add-on that makes it simple to archive, retain and respond to discovery requests.
  • Remote, secure access: Google Apps is easily accessible from any location, any time, securely.
  • Integrated MDM features. Provides an easy way for IT staff to manage personal mobile devices to help ensure security and compliance.
  • Google Apps Sync for Microsoft Outlook. Many people find Outlook easy to use– or at least familiar. With GASMO, you can continue to use Outlook on desktop computers to manage Google Apps email and calendar functions.
  • See a full list of features here.

Be sure to check out the use case video of SF Bay Pediatrics available here, which highlights a lot of the healthcare-specific benefits in action.

 

Google Apps for Business starts at $50/ year/ user, which easily pays for itself with most small to mid-sized organizations. For a limited time, eSSee Consulting is also able to offer a coupon for $10 off the first year of service if you would like to set up the service on your own, or a complete assessment and implementation package for organizations without the on-site IT capabilities. Contact us to learn more or to get a coupon code.

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LeadingAge PEAK 14: Missed Chances and Future Opportunities

Today, CNN ran an article about a new app called “Cloak,” which plots check-ins from Instagram and Foursquare on a map so you can avoid your friends and exes. It’s a great use of technology on the micro-personal level, but what about avoiding cancer or loneliness or anything else in health that costs society significant resources? We’ll come back to this in a second.

I just returned from the LeadingAge PEAK conference, which took place this week in Washington, DC. Speakers and providers both shared tremendous interest around innovation and technology, and it was exciting to be with hundreds of passionate, committed aging services professionals. But as folks talked about innovation in their organizations and communities, I was left rather dumbstruck: hardly anyone is doing anything new!

In a session on innovation, one provider shared how they were piloting a program to bring elementary school children to their campus. The room cheered in encouragement… and I just about choked! Intergenerational programs are fantastic, absolutely. But they’ve been occurring for decades! We already know they generally have positive outcomes for both the young and old. This mistaking replication for innovation is something I see replayed time and time again in aging services because of a lack of good information sharing, and, more so, a lack of investment in disruptive innovation.

The Sunday New York Times magazine contained an article by Yiren Lu entitled, “Silicon Valley’s Youth Problem.”  Among her theses:

1)      Current Silicon Valley startups are flush with youth and talent, the result of which has been an explosion of new apps and interfaces between technology and the world. At the same time, less of the young talent has been dedicated to innovation in the boring parts of tech: semiconductors, legacy software, and other core infrastructure. In her words, “Why do these smart, quantitatively trained engineers, who could help cure cancer or fix healthcare.gov, want to work for a sexting app?”

2)      Young startups appear adverse to age and experience, believing older tech workers are too slow, too cautious, and too boring. “The problem is that they [older tech workers] may be making more reasonable steps, but they’re making fewer steps. It’s hard to compete when you’re moving slower, even if you’re moving in a consistently correct direction.” Hardly one-sided, older workers may also feel out of place. “The flip side of the kind of cohesion I saw at Stripe is that it can be off-putting to people outside the circle. If you are 50, no matter how good your coding skills, you probably do not want to be called a “ninja” and go on bar crawls every weekend with your colleagues, which is exactly what many of my friends do.

3) The most innovative companies are combining the young and old: “As David Dalrymple, a technologist in the valley, told me, “The most innovative and effective companies are old-guard companies that have managed to reach out to the new guard, like Apple, or vice versa, like Google.” ”

Aging services is suffering from exactly the opposite challenge:

1)      An over-reliance on age and experience, leaving younger colleagues disillusioned with the slow pace of change, stifling working conditions, incomprehensible benefit offerings, and lack of entrepreneurship.

2)      A lack of true innovation, with tremendous resources wasted on duplication of efforts and replication of existing programs.

3)      A lack of quick action, agile entrepreneurship, and the inevitable frequent failures that lead to novel solutions and rapid innovation.

4)      A dearth of organizations– whether providers or vendors– consciously combining youthful tech talent and rugged industry experience in disruptive ways.

At the PEAK Expo, vendors were sharing their own new offerings:

  • An IPOD touch-based call system that connects to nothing else. (Not only is the device $150 more expensive than you need, but it doesn’t even provide an advantage over a pager and walkie talkie. What about devices that seemlessly connect to the EHR and pull forward the care plan information? That can push data back to the EHR for recording ADLs at the point of care? That could suggest an appropriate anecdote, story or question to share while assisting with care?)
  • Several EHRs still written in .NET, and with interfaces that still look like the 90’s. (Why are most apps I use intuitively designed and functional? Why can I deposit a check into my bank account or file an insurance claim after a car crash on my phone, but I can’t document skin assessments and pressure wounds in the same way?)
  • Phillips LifeLine, with their new, cellular-enabled pendant. (First, finally! And second, my Motorola Droid from five years ago had the same technology and more– so why does LifeLine still cost an arm and a leg and look like a LifeLine?)
  • The Green House Project, which is certainly better than institutional facilities, but hardly revolutionary in terms of what technology could allow us to do. (Why are we still spending millions on bricks and mortar solutions that are only marginally better than what we have today?)

And LeadingAge itself, bless their wonderful, committed hearts, talked about an important new initiative: Namestorming a new term for CCRC.

Join us in developing a new name for continuing care retirement communities (CCRC) that resonates with the next generation of older adults.  

 

New focus was given to this idea on a field-wide level following the presentation of new Mather LifeWays consumer research.

 

The research highlighted the emotional barriers the CCRC name was creating with consumers. Based on this research, Mather LifeWays, along with LeadingAge, decided to spearhead an industry wide renaming project. Introducing theCCRC NameStorm!

Please. It’s not the name that’s the problem; it’s the product. Charles Duhigg, the leadership keynote speaker at PEAK 14, shared the story of Proctor and Gamble’s almost flop with Febreeze, which seems ironically similar in this case: Febreeze almost failed not because it didn’t work (or had a bad name), but because it didn’t connect appropriately to consumers’ habits. I wonder what Duhigg might stay about the Namestorming initiative.

Writing in Forbes, David Shaywitz responded to Lu’s NYT’s piece with a thoughtful article a few days later, “What Yiren Lu’s Magnificent Portrait Of Silicon Valley Can Teach Us About Digital Health.”

“Lu’s characterization of the valley not only rings true, but also helped me better understand the valley’s approach to healthcare – or perhaps less diplomatically, why young developers’ approach to healthcare (to the extent they’ve deigned to approach it at all) seems to have generated far more heat than light, and resulted in thousands of pointless apps, and remarkably few impactful innovations.”

He continues:

I suspect that materially impacting healthcare – i.e. significantly improving care or reducing costs – requires tolerance for complexity, patience to demonstrate value, fortitude to deal with regulators and entrenched incumbents, and respect for the distinct importance of human health.  I’m not sure there are all that many hot shot web tech developers in whom these qualities bloom – though Uber’s (as I’ve discussed) andTesla’s battles with regulators and incumbents are positively inspirational.

It’s incredibly compelling to envision the integration not only of generations, as Lu imagines, but also of domains – finding a way to functionally unite fearless creative developers with experienced healthcare experts equally determined to change the world.

There is some truth to this. I’m hopeful about companies like CareMerge and HealthSense who are working feverishly in the direction of using healthcare IT innovatively to tackle issues of cost and quality. But even with those two companies, there is a lingering of something old: reporting vitals via ugly white remote sensors in the home and a care portal that is not much more innovative that a slew of collaboration tools already years old in other industries.

Take a look at Canary. This is the sort of disruptive thinking we need in healthcare now:

There are a lot of “smart home” companies out there trying to “connect” things – dishwashers, lights, fridges, TVs, crockpots, etc. At Canary we prefer to solve problems.

 

We started with home security because it’s a need shared by hundreds of millions of people around the globe. We know because we’ve already sold Canary in 78 countries, and proved through our Indiegogo campaign (the most successful ever) that there’s a real demand for affordable intelligent home security that just works. Rather than being all about preventing the bad (including fires and floods), Canary also helps out in other ways whether it’s letting users watch their kids play during the middle of the day or providing a digital neighborhood watch while they’re on vacation.

Imagine remote monitoring that provides not only the data flow we need, but addresses the real issue at hand: my mother and yours living alone in their houses. Sure I want to know she’s getting up, using the refrigerator, and doesn’t likely have a UTI (all issues addressed by HealthSense, for example). But I want to call her in HD video to say hi in the morning; I want to play scrabble on my lunch with her through her TV. I want her to be able to text me quick questions, because she’s uncomfortable bothering me on the phone with “silly things,” (I’d love to try and explain my SnapChatting to her…) and respond in a way she can easily see and understand. I want her to book medical appointments and check her records as easily as I can use Mint or AirBnB. This technology is already here, and we need to start putting it to better use.

Bill Gates said in TechCrunch this week that “Innovation in California is at its absolute peak right now. Sure, half of the companies are silly, and you know two-thirds of them are going to go bankrupt, but the dozen or so ideas that emerge out of that are going to be really important.” I agree with his point, but, in aging services especially, we will need to be more focused on fostering disruptive innovation, rather than waiting to see how SnapChat and Cloak will play out. We need to stop wasting time on replication couched as innovation; we need to stop trying to force old workflows and predilections into new technological solutions. (Looking hard at you, EHRs and remote patient monitoring!)

After all, the technology and talent is already here– and my mother doesn’t have a whole lot of time left.

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What Happens After Go-Live

You’ve spent months and months preparing for this day. Hundreds of thousands of dollars have been invested in software, technology, and internal capital upgrades to make it possible. Staff have invested dozens of hours training, practicing, and readying themselves. It’s go-live day for your EHR.

A few hiccups aside, things go well. Line staff are happy and excited about the new technology. Administration is thrilled about new ways to easily view census, incidents and other crucial operational information. Implementation looks like it has gone better than expected. So what now?

At this juncture, organizations typically go in one of two directions. Successful organizations see go-live as the mid-point in an adoption strategy. It’s a time to celebrate a significant milestone, for sure, but also a time to begin the evaluation of the system implementation, measurement of workflow improvements, refresher trainings for staff, and planning for future improvements and changes. Even more crucially, it’s a time to listen carefully to staff, to ask probing questions like, “Is there anything that isn’t working like we thought it would?”, “What tasks are easier with the EHR? What tasks are more difficult?”, and “What are some questions you’ve had and have you been able to find the answers you need?”

The other direction, unfortunately, is more common. In the chaotic environment that most healthcare organizations exist in, go-live day represents a giant relief, the end to an over-time, over-budget project that was thrust on top of many other crucial priorities. Things seem to be running smoothly, and you hear few complaints, so you close the project and move on. 90 days after go live, your vendor implementation manager calls, asks if everything is going well, and then quickly closes the implementation and passes your organization on to the support team. Done and done. You return to the everyday challenges of caring for residents.

Oftentimes, when called in to optimize an existing installation, we see the aftermath of organizations that chose the second direction. We find EHR systems that are underutilized, redundant storage of knowledge (Excel spreadsheets, homegrown Access databases, paper files), and staff that have begrudgingly accepted impaired workflows. It’s a long process to re-implement systems, rebuild staff trust in technology, and finally capture the crucial business intelligence essential to an organization’s success in today’s market.

A Better Way Forward

Here’s what successful organizations do after go-live:

  1. Begin the next phase of the EHR project. Ideally, the post-go-live phase was already built into your project plan, and you’ve already established clear goals for the system, plans to measure against those goals, and a proactive strategy to understand how the EHR is integrating into workflows and how to adjust as necessary.
  2. Commit to one place for data. Many organizations are loathe to give up their trusted Excel-based census tracking worksheets and paper-based incident tracking systems. Resist the urge to keep data in different places. To fully capitalize on the business intelligence and analytic features of EHRs, you need to have all the data in one place to properly guide future decision-making. Data analytics is quickly reshaping all of healthcare. For LTPAC providers, this means you must have accurate data on rehab outcomes, rehospitalization statistics, and efficiency of operations. If your EHR solution is a barrier, press your vendor for added functionality. Chances are good they either have a solution from another provider, or, more likely, other providers are struggling with and clamoring for the same solution.
  3. Ask staff probing questions. It’s not enough to ask, “Is everything okay?” At one organization where I served as administrator, I discovered months after implementation that some of our med aides were not following the proper procedures to chart their med pass. In researching why the staff had not mentioned the deviation before, I discovered that they had never been able to follow the process as described, but quickly found a workaround that seemed to work. When I would ask if everything was okay in the months after go-live, naturally and honestly they answered, “Sure!” Ask staff directly if things are working as expected. Ask regularly if staff are finding different ways to accomplish tasks. Encourage your superusers to report common questions and issues so you can examine whether there are organization-wide trends.It’s also crucial to note, you must approach problems with usage of the EHR with a “just” mindset. This means if staff are not following established protocols, it’s crucial to understand why in a way that doesn’t place blame on individuals when the problems are system-induced. (And in our experience, virtually all problems with EHR usage are system-induced.)
  4. Stay curious. EHRs vendors are quick to promise their system will do everything under the sun. It won’t, trust us. EHRs currently on the market are clunky adaptations of LTPAC operations. For some processes, you will ask how to do something and receive an answer of either the EHR can’t do that, or it can, but requires a complex set of steps. Push your vendor to simplify steps and improve workflows. What EHR vendors lack in user experience design and functionality, they more than make up in attention to customer needs. So be vocal about what you need and what you’d like to see. Remember Robert Kennedy: “Some [people] see things as they are and ask why—I dream things that never were, and ask why not?” Ask why not. Often.
  5. If something doesn’t work, don’t give up on it. This part is a little shocking to us, but we find many organizations that, after struggling to adopt a certain feature or workflow, simply decide an EHR can’t support this part of their business and drop it. One time, we worked with a client that had paid for the billing/ finance module of an EHR, but had completely abandoned it in favor of staying with Quickbooks because they weren’t able to get the system to bill correctly for their independent residents. Resist the temptation. If a billing module doesn’t support your CCRC model, talk openly with your vendor about what you are trying to accomplish. Take a look at your internal process, as well, and be open to reconceptualization of your processes. While current EHRs are clunky, they are hardly impotent. Don’t give up on such a big investment.
  6. Be open to—brace yourself—replacing your shiny new EHR. Most vendors work hard to ensure client satisfaction, but if you find yourself with a vendor who refuses to work with your struggles and challenges, go back to your shortlist and reexamine other vendors. The cost to replace a system is truly less than continuing to use a beast that doesn’t actually improve your operations and ability to care for your residents.

What Next?

Are you considering an EHR? Struggling with a recent implantation? Learned some other lessons? Get in touch! We’d love to hear about your experiences and talk about how we might help you succeed.

Ready to get started? So are we!