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Homelessness, and the power of empathy and dignity

West Wing

I’ve been re-watching The West Wing. The first season, in particular, is simply fantastic. There’s an episode called In Excelsis Deo {IMDB Link} where the cantankerous but morally-driven Toby feels compelled to provide a Honor Guard funeral for a homeless vet. I re-watched that episode the other day and it has stuck with me for some reason.

Today, a video is making its way around the internet. It’s from Degage Ministries and features Jim Wolf, a United States Army Veteran. Jim, according to the video, has experienced frequent bouts of homelessness and alcoholism.

The video is simple, compelling and deeply moving.

I like videos like this and Cleveland Clinic’s Empathy video. They help us feel empathy. The video of Jim highlights the importance of dignity. We need these videos as tools. And we’ll continue to need them as long as we marginalize and disenfranchise parts of our society.

I wonder too, is there a place for videos like this in education, healthcare and other places where we serve all parts of society; as a way to remind us of the importance of empathy and dignity?

David Foster Wallace on the importance of every day life

If I can suggest Cleveland Clinic’s Empathy Video is a B.A. in Empathy, then I submit David Foster Wallace’s 2006 Commence Address as a PhD in the same.

There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says “Morning, boys. How’s the water?” And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What the hell is water?”

But most days, if you’re aware enough to give yourself a choice, you can choose to look differently at this fat, dead-eyed, over-made-up lady who just screamed at her kid in the checkout line. Maybe she’s not usually like this. Maybe she’s been up three straight nights holding the hand of a husband who is dying of bone cancer. Or maybe this very lady is the low-wage clerk at the motor vehicle department, who just yesterday helped your spouse resolve a horrific, infuriating, red-tape problem through some small act of bureaucratic kindness. Of course, none of this is likely, but it’s also not impossible. It just depends what you want to consider. If you’re automatically sure that you know what reality is, and you are operating on your default setting, then you, like me, probably won’t consider possibilities that aren’t annoying and miserable. But if you really learn how to pay attention, then you will know there are other options. It will actually be within your power to experience a crowded, hot, slow, consumer-hell type situation as not only meaningful, but sacred, on fire with the same force that made the stars: love, fellowship, the mystical oneness of all things deep down.

Finding & Protecting Time for Patient Engagement

If I have a healthcare-related resolution for 2013, its to be a champion and protector of empathy. As a member of the leadership team of a health system, that means making room for empathy in how we deliver care. Or, put more simply, valuing the time our providers spend with patients over raw productivity or efficiency metrics. As a blowhard healthcare blogger, it means advancing the cause to anyone else who is able to make room for empathy in patient care. Unfortunatly, while we often pay lip service to patient engagement, we usually measure and pay providers on exactly the opposite. Patient-centered communication rockstar Steve Wilkins wrote a great piece on his blog this week: The 10 Commandments of Patient Engagement. In the post, Steve lists 10 actionable steps providers can take to more meaningfully engage with patients during a visit. I agree with every single one of them.

I’m willing to bet most providers - nurses, mid-levels and physicians - would all say the things on Steve’s Top 10 List are things they do, or want to do. Then they’ll sigh and say something like: “but there’s now way we can be expected to strike up a conversation just for kicks, not with the productivity standards we are held to.” If they are self-employed, the later part of that dismay might instead be: “and still pay my bills on today’s lousy reimbursement.”

That’s where I see a very important role for leaders in healthcare organizations - making room for empathy.

Doctors are, generally, paid on a productivity basis. This usually comes in the form of a base salary plus a portion based on something called a worked relative value unit, or WRVU (often called an RVU too). Suffice it to say, it means the more cases a provider sees, or the more complex the case they see are, the more they get paid. Nurses, mid-levels and physicians are all, with increasing frequency, being held to productivity standards. Productivity is often is expressed simply, usually as a number of patients per day. If, on average, a primary care doctor can see patients in 10 minutes, and they have 6 hours of patient time allotted on their schedules per day, that means to be 100% productive they need to see 36 patients per day.

Now, most of us can recognize that’s a pretty lofty goal and one which doesn’t leave much room for longer, more complex patients. It certainly leaves very little room for meaningful interactions. And, even in a more relaxed model of say 20 patients per day, explains why doctors are so often running behind schedule.

The problem for us administrative types is that 20 patients per day looks pretty good on a spreadsheet. And, there are a lot of sources and third parties to back up high efficiency models of productivity. So we push for it. We write productivity goals into contracts, we push nurses to work faster, and we take away any time for empathetic patient relationships.

Then we try and shoehorn empathy in. We coach staff on smiling and key phrases. “Is there anything else I can do for you?” We say we value and even demand the kinds of things Steve Wilkins is asking of providers. But, in reality, we are grading and paying providers on exactly the opposite.

Here’s another example, this time pertaining to nursing. Many of Steve’s commandments are often part of the nursing intake function. So, the graphic below depicts a very simplified flow map of a nursing intake procedure:

In the image above, each step of the process is shown along with it’s approximate time. Some steps, such as listening to the chief complaint may take anywhere from 1–3 minutes. If you add up all the minimal times, this flow takes 8 & 1/2 minutes. If the steps take their maximum amount of time, the process takes over 15 minutes.

If a nurse is being held to a productivity measure which requires they complete this process in the minimum time, what gets cut? Regrettably, all too often, its the part of the process we as patients would say is the most critical - the human interaction.

So, when I write about making room for empathy, I believe we have to look carefully at two key things: our metrics and processes. In terms of metrics, we have to ask ourselves: are the goals we hold staff to consistent with what we are asking of them? In other words, does it work to script customer service phrases while paying bonuses based on productivity? We have to look at processes to see where we can make time.

I understand the need to do more with less, and to better use our resources. But patients are increasingly voting with their feet. If we want to remain viable, we have to make patient engagement a top priority. That means making room for engagment in the patient process flow.

The best way to make room for empathy is to find steps which do not add value. For instance, in the flow image above, would it make more sense for someone else to pull the chart, take the height and weight and room the patient? If we took 3 minutes out of the nursing flow, but kept the expectation at an 8–15 minute process, then we’ve added 3 minutes of face time. It doesn’t sound like much, but we know from studies as little as one extra minute of meaningful, heartfelt interaction can make a huge difference in a patient’s relationship with their provider. By the way, this same process map / time protecting idea works for physicians.

As we head in to 2013, here are my challenges to fellow leaders, administrators and health system executives:

  • Make a PDF of Steve’s 10 Commandments
  • Map out your current patient process flow, record times for each step, average them together
  • Use a LEAN process flow calculator or your own best judgement to find steps which don’t add value to the critical path. This isn’t as tricky as it sounds, it means looking at each step and asking could I cut this out or find someone else to do it and, in doing so, make room for empathy?
  • Remove the steps which don’t add value, or find someone else to do them. Yep, that may mean a hire, but cost today is better than a loss due to poor patient satisfaction. But I think most of us will find there is enough waste in our flows to more than allow for patient engagement.
  • Implement one of Steve’s commandments for everything you cut out
  • Measure marketshare, patient satisfaction and, I argue most importantly, staff satisfaction - all will improve.

From Elsewhere: Lean Blog Podcast & Making room for Empathy

One of my favorite phrases is making room for empathy. Room for empathy is about giving staff the time in their workflows to be compassionate and to deliver care which is not only clinically competent but emotionally uplifting as well. But that’s hard to do.

It’s hard because the work of providing care is increasingly complex. We’ve got EMRs with screens of data. We’ve got sign off sheets, time outs, forms, papers, phone calls, results, and, frankly, CYA work. Those things take time. So what get’s cut? Empathy. We cut out the simple things like walking someone to their destination rather than pointing. We cut out sitting with someone who looks concerned (so we look at our shoes or iPhones in the hallway). It’s a problem

There are two main ways to make more room for empathy. First, we could hire more staff. More staff (nurses, care givers, techs, managers, administrators even) mean more bandwidth. Many hands make light work. But we probably aren’t going to get more staff. Reimbursement is dropping, and there is a push to be more efficient. Hospitals are trying to see if they could survive on Medicare reimbursement rates. (Remember, Medicare pays, on average, about 80% of what treatment costs, so we have to cut about 20% of cost out of hospitals).

The other way we can make room is by eliminating work which does not add value. Productivity gurus say we should work smarter, not harder. I’m increasingly interested in the Lean methodology as a framework for evaluating how we do our work and determining if it adds value, or simply takes up valuable time. So, I’ve been trying to learn more about Lean.

I found Mark Graban’s Lean Blog which led me to his Lean Blog Podcast, a regular, downloadable audio show about Lean. In the most recent episode, Dr. John Toussaint of ThedaCare, discusses the importance Lean methodologies in healthcare.

It’s a fantastic listen and should inspire anyone looking for ways to make room for empathy and return the focus to patient and staff experience.

"to feel and be felt" Ze Frank on designing for happiness

I saw a post today on Swiss Miss the great design blog, which made my day. Ze Frank is coming back! And that bit of exciting news reminded me of this gem:

In his 2010 TED talk (warning, some adult language), Ze Frank talks about his experience running a popular blog and a video series. But that doesn’t begin to describe what Ze Frank’s world was. Fans will remember his posts and videos as so much more just than a blog.

Ze Frank’s gift is one of designing for happiness.

In the TED Talk, Frank says the most fundemental thing we can do is to “feel and be felt”. In essence, all of his work was about spinning things - existing works, people’s concerns, negitive emotions - into something positive. His daily video posts were ways to rapid prototype the outcomes of his ideas. If that’s not the essence of experience design, I don’t know what is.

Designing for happiness

I have the privledge of conduting new employee orentation for my health system. There is an excersize I ask the new hires to go through which I’ll share with you here.

Take a few moments and think about something in your life you cannot imagine being without….something where you think I don’t remember how I got along without XYZ… It can be a thing, or a place, or even a person.

What did you think of?

9 out of 10 new hires usually shout out “my iPhone”.

Sure, some folks reply with non-consumer answers such as my family, my children, or my last vacation. But for the ones who say it is their phone, what makes it such a compelling device, why could they not live without it? What they often tell me is it’s just magic, it just works. Apple’s marketing department would be happy with that response. I believe its just magical is a proxy for it was designed well.

Over the weekend I had the chance to re-watch one of my favorite documentaries, Objectified. Objectified is director Gary Hustwit’s homage to industral design and designers. The film moves from vignettes of iconic design to narritaves of personal insight from famous designers. It is a wonderful film and part of a trillogy where Hustwit focuses on asthetics and design.

In healthcare, we often think about design in a few very narrow contexts. We think about the archatecture of new buildings. Sometimes we think about the shape and styling of medical devices. Yet, that’s not how designers see the world. As Jony Ive, head of design for Apple, puts it: “it’s part of the curse of what we do… think about how everything we encounter is designed.”

In Objectified, Erwan Bouroullec, of the designers says the goal of design about creating an enviroment where people feel good.

Isn’t that sort of also the goal of a hospital or doctor’s clinic? Don’t doctors start practing medicine because it feels good to take care of people? Don’t we go to the doctor because we want to feel good?

Regrettably, so many of our processess for delivering care were designed by consensus, rather than with a goal of creating an eivnroment where people feel good.

A few months ago I wrote a post about designing for experience where I suggested many processess are designed by consensus, or created through committees which often involve compromise for political agreement or to avoid conflict.

Try my new hire exercise again only this time think about an object or process which makes you feel frustrated or challenged when you interact with it.

My guess is whatever that thing is, it was probably not well-designed. It may be the result of design through consensus or it may simply not have been designed with attention to user experience or detail.

Now, more than ever healthcare needs to begin to apply design thinking to its processes and services. Design thinking has two major benefits: first it builds things which are in empathetic towards the user. Secondly, as Bouroullec says, it makes people feel good.

Davin Stowell, a principal designer at SmartDesign discussess working with OXO, the kitchenwares company on their vegitable peeler. Stowell says it’s not as important to understand how the average person who use the vegetable peeler. What matters is the extreme usecase - the person with arthirtis in his example. “When you design for extremes, the middle takes care of itself…” says Dan Formosa, also of SmartDesign.

Healthcare has an opportunity to embrace its extreme users too.

Examples most certinally include those who identify as ePatients. ePatients want to participate in the development and implementation of their treatment plans. They often lament a lack of access to their clinical data, or even access to their physicans using modern things like text messaging or skype.

We might also look at other extemes for inspiration. What can a “frequent flier” in the ER tell us about processess in the emergency room? What can the single, working mother with three kids tell us about process in the familiy medicine clinic?

These users are all around us, yet for some reason, we fail to consider them when designing care delivery processess and services. Instead, we design for the middle, creating average offerings rather than standout offerings.

There are competitive advantages to good design. It gets more people in the door. There are also imporant humanistic aspects. If good design really does create an enviroment that makes us happy, doesn’t healthcare have an obligation to design things well?

It is not my intent to judge our entire industry unfavorably. Good design can be as ambigious as the term itself. If it were easy, every phone manufactureer would have invented the iPhone years ago, right?

Still, there are ways to learn and practice design thinking:

  • Watch Objectified - pretty good place to start. It’s on Netflix for streaming. Listen to the designers talk about the objects they’ve designed and apply their terms and language to processess and experiences in healthcare.
  • Be empathatic - Empathy might be the single most important skill for anyone working in healthcare. Practice by thinking "Today, I’m not a provider or administrator. Today, I’m the patient walking in these doors for the first time. What do I see? Riff on the idea, always challenging yourself to put yourself in the patient’s shoes. How would a patient use this service? What would a patient think of this cafeteria food?
  • Embrace extreme usecases - Identify the extreme users of your services and observe their behaviour and listen to their communications. What can you learn from them? Are your waiting room seats uncomfortable for the elderly? Do ePatients with smartphones portend the future for the entire next generation of patients? What processess would you develop or change based on the answers?
  • Engage designers - OXO didn’t re-invent the vegitable peeler on their own. They worked with SmartDesign. Healthcare providers can find local or nationally renound tallent. Sure, it comes at a cost, but think of a well designed offering as a compeitive advange. You’d pay a reasonable price for a consultant who could help you grow marketshare, right?

By the way, healthcare device manufacturers and supply vendors are no strangers to working with designers. IDEO and SmartDesign have both worked with vendors on items such as:

  • Cardinal Health Endura Scrubs

    Many hospital workers complain about the baggy, pajama-like, and unprofessional look of traditional ‘scrubs’. Furthermore, over 70% of hospital employees are women, yet they are forced to adapt to clothing that was designed for an XL-sized man. The Endura Performance Apparel Scrubs is a line of cost-effective high performance scrubs that we designed as true unisex wear with benefits for women and men alike. They are a vast improvement on their predecessors because of design innovations such as collars that don’t blouse open to over-expose females…

  • Ethicon Endo-Surgery Generator

    Equipment in the operating room environment can be complex and intimidating, prompting the need for intuitive technology solutions that help OR nurses focus more on patient care. The new EES Generator combines advanced technology, multifunctionality, and intuitive touch screen simplicity into one compact, easy-to-operate unit.

  • Lifeport Kidney Transport System

    The LifePort Kidney Transporter provides a new high-tech alternative to the conventional method of organ storage and transportation—a cooler filled with ice.

  • Finally, here’s IDEO’s Tim Brown at the 2009 TEDmed event on Designing Healthcare

We are all hardwired for empathy

Oh, they're just not cut out for a service job... You've heard someone describe someone else like that haven't you? It's what we say about someone who comes off grouchy, or unpleasant, particularly in a role dealing with customers. Maybe its a phrase like: some people have it, and some don't... or the way hiring managers word it: we hire for customer service talent. The gist of phrases like like these is that customer service is a skill some people have and other's are incapable of.

I've been mentally wrestling with that question myself. I'll take it a step further. I believe the root of customer service is a combination of empathy and ability to act on empathetic feelings. I often wonde if some people are empathetic and others aren't. Why is one nurse willing to go the extra mile and other thinks the call bell is a bother? You know the old joke about restaurants? This would be a great place to work if it weren't for the customers. Not exactly an empathetic feeling is it?

But, some people really seem to feel that way, like customers are actually an annoyance. So, are they born that way, or is there more to it?

I had a great, inspring conversation this week with someone knows a lot more about this stuff than I do. She turned me on to a video from RSA Animate - The Empathic Civilisation. It's a visually compelling look at a researcher's thoughts about empathy.

The narrator suggests we are, in fact, all born with a biological wiring towards empathy. He goes on to say empathy is what makes us special and may even be what will save civilization as we know it. I know, right? Big stuff!

I'm inclined to agree. And, if we're all hardwired for empathy, what does that say about those people we label as grouches? Maybe it has more to the with organizational culture - that's the second half of my equation: the ability to act on empathetic feelings.

Organizations, leaders and culture have to empower employees to act on their empathetic feelings towards others. The have to make room for customer service to happen. When we try to script or pigeonhole people's service presentation, it's no wonder some people react with negative attitude.


RSA Animate - The Empathic Civilisation - YouTube.