Maurice A. Ramirez, DO, CNS, CMRO

The Unprepared Beware

Last year a High Alert, LLC white paper had raised the specter of NRP/NIMS compliance being linked to CMS (Medicare, Medicaid and Tricare) billing, the discussion had been strictly theoretical. Several federally funded training programs have now brought to the table a new and ominous implication of the NIMS Integration Center Implementation Plan for Hospitals and Healthcare. Additionally, hospitals have reported being informed that disaster preparedness will be linked to CMS reimbursement (Medicare, Medicaid and Tricare payments).

Almost immediately, a National Incident Management System (NIMS) update alert from the NIMS Implementation Center, included obscure reference to a frequently asked question (FAQ) document on the FEMA website.  This document, posted on April 20, 2007, like many documents before it was deeply buried within the FEMA website, accessible only to those who knew where to find it. 

The last two questions on this FAQ document dealt with a raging debate regarding the repercussions of failing to be NIMS compliant before the looming September 30, 2007 deadline. 

The first answered the question of whether the Joint Commission required NIMS compliance for accreditation.  The answers stated “Not at this time.”

The second question similarly was a response to inquiries regarding whether CMS required NIMS compliance for Medicare and Medicaid benefits and reimbursements.  Again the answer was “Not at this time.”

Times have changed.

On October 18, 2007, President George W. Bush signed Homeland Security Presidential Directive 21 (HSPD-21) into law establishing the new specialty of Disaster Healthcare and fulfilling many of the predictions of the original High Alert, LLC white paper. HSPD-21 is available for download here:

Download HSPD-21.pdf

High Alert, LLC published a new white paper on the implications of HDPS-21, Sarbanes-Oxley (SAR-OX) and Federal False Claims (FFC) legislation for healthcare law and disaster healthcare. The new High Alert, LLC white paper is available for download here:

Download preparedness_and_the_force_of_lawrevised_20oct07.pdf

Each of the critical infrastructure industries identified in the National Response Plan (NRP) and the National Incident Management System (NIMS) have similar HSPD’s. The correlations made regarding healthcare law can easily be extrapolated to each of these critical infrastructure industries as well.

Although the federal government has not acted on these possibilities, they are very aware of the potential. FEMA even issued a series of statements directed to hospitals indicating that FEMA has no plan to pursue SAR-OX or FFC’s action under HSPD-21. The problem is that it is the Department of Justice (DOJ), not FEMA who pursues such claims and FEMA does not speak for DOJ.

This white paper has been vetted through contacts in D.C. and while not confirmed as an active plan, no part has been refuted except in the afore mentioned FEMA statements. However, the observations in this white paper is bolstered by the recent alignment of Joint Commission guidelines with NIMS guidelines. These Joint Commission changes occurred after the publication of the white paper, but were predicted despite the insistence of FEMA that such Joint Commission changes would not occur. It is now anticipated that Emergency and Disaster Preparedness will become a Core Performance Benchmark for Joint Commission in 2009. Given that Joint Commission is now provides de facto the Medicare and Medicaid compliance inspection, these 2009 changes will complete the alignments described in the white paper.

The Unprepared Beware!

Basic and Advanced Skills for Disaster Healthcare

My company recently reviewed the existing core competency documents for disaster healthcare in light of the October 18, 2007 Homeland Security Presidential Directive (HSPD-21) which in part calls for:

“...the recognition of the unique principles in disaster-related public health and medicine merit the establishment of their own formal discipline.  Such a discipline will provide a foundation for doctrine, education, training, and research and will integrate preparedness into the public health and medical communities.”

Stakeholders in the development of the discipline described in HSPD-21 have proposed either publicly or privately a body of knowledge and skills core to such a discipline. This essential body of knowledge is codified as Core Competencies. To date the American Association of Physician Specialists (AAPS), the American Medical Association (AMA) and the American Osteopathic Association (AOA) have prepared core competency documents.

In the past, divergent core competency documents within a medical discipline such as emergency medicine or family practice have resulted in decades of division and discord within the profession and specialty. Ultimately, wherever such divergence has existed medical science and evidence based medical practice have resulted in convergence of the core competency documents and near universal agreement on the skills and knowledge that define and are essential to a distinct medical discipline.

Unfortunately, the United States and its citizens cannot afford to wait decades for the medical politicians and special interests to conclude that there is already agreement on the knowledge base and skills core to the discipline and specialty of disaster medicine. HSPD-21 places further impetus on resolving the issue of core competencies so that the disaster medicine discipline called for in HSPD-21 may advance with all alacrity.

The core competency documents from AAPS, AMA and AOA are each developed in differing taxonomy systems. This difference in taxonomy systems combined with differences in batching of skills and knowledge within documents complicated the extraction of commonly agreed upon core points of knowledge and key skills.

The complete review and core competency crosswalk is available for download here:

Download disaster_healthcare_core_competencies_review_crosswalk_25oct07.pdf

We propose a single summary core competency document presented as a “crosswalk reference” with the associated AAPS, AMA and AOA core competency documents. Given that the AOA currently has no core competencies to contribute, the crosswalk would require update when the AOA document becomes available.

It is our that this composite summary and associated “crosswalk reference” along with all three core competency documents form AAPS, AMA and AOA be recognized by the United States Department of Homeland Security (DHS); Department of Health and Human Services (HHS); Department of Defense (DOD); Institutes of Medicine; National Institute of Health (NIH); Centers for Disease Control (CDC) and Department of Education (DoE). This will establish the needed basis for the foundation of a distinct discipline in disaster healthcare as called for by HSPD-21 while bypassing the inherent delay in recognizing that all three systems enumerate the same core knowledge and skills.

Fresh Eyes for Companies that are All Heart

The CEO of a major international company falls ill for the second time in two years. The first illness, diagnosed quickly and treated effectively, resulted in little disruption in daily business operation. Executive Vice President and the Chief Operating Officer for this $50 billion per year multi national needed only to supplement the CEO’s capabilities for a brief time. The Board and the rank in file employees alike marveled at the CEO’s resilience and proudly touted the company’s loyalty to their stricken leader.

The second illness was far more impactful. After a brief 12 months of wellness, the CEO began to make erratic decisions. Profitable outlets were ordered closed, while unprofitable outlets scheduled for closure were allowed to limp along as an economic drain. Stock prices began to fall and investor confidence with it. There had always been a corporate culture that the Board likened to “family.” The management team and the Board itself were torn between the need to save the business and the desire to not abandon a colleague.

How does the business balance these two seemingly opposed ends?

Business consultants, financial consultants, business professionals, and even human resource professionals are well versed in streamlining day to day operation, supporting business processes in the face of internal and external adversities, and even in dealing with leadership issues. However when the issue is medically related and decisions regarding fitness for duty at the highest level of a corporation will may involve the review of highly sensitive personal and even devastating medical information, the most stalwart business people begin to shy away from the issue.

The Health Insurance Portability Accountability Act (HIPAA) limits the information that companies and even physicians may review and exchange regarding a patient’s health. When a corporate leader is also a patient, physicians are often renascent, even with a signed medical information release, to be fully candid. Companies are all too willing to pay for “fitness for duty” examinations often not understanding that such examinations are limited in scope and even more limited in scientific validity. In short they are legal land mines.

For those companies who understand these limitations dealing with medically impaired leadership becomes all the more difficult. In these special situations the use of a non treating independent medical adviser (NIMA) to the Board or corporate leadership is the ideal legal solution.

NIMA - The Eyes of Experience
A non treating independent medical adviser is a physician who is adept at physical examination by observation. The depth of their experience allows them to observe individuals as they move through their work day and draw conclusions about decision making ability, information retention and physical impediments. Further, a NIMA is able to assess the impact of the medical condition on the rest of the management team. A family, like any other social structure including a tightly knit management team, is equally affected by a severe or debilitating illness as the individual suffering from the illness themselves. It only stands to reason that when severe illness strikes a corporate leader, the management team and the business as a whole will suffer.

The NIMA stands with a foot in business world and a foot in the medical world. Through observation and third party interview, the NIMA can not only identify the changes that have occurred in management culture to accommodate the illness, but make recommendations for reasonable accommodations that partially or completely ameliorate the effect of the illness within the business and more importantly within the business leadership. The NIMA is also capable of documenting and validating when reasonable accommodation will not allow the organization to return to its pre-illness baseline.

Because they have no doctor-patient relationship with the stricken leader, HIPAA regulations do not apply to their observations, therefore these observations and the inferences drawn from them can be freely shared with members of the Board and the corporate leadership within the constraints of the company’s human resources rules and professional ethics. In these circumstances, the NIMA may recommend reassignment, or medical leave of the stricken individual so as to allow for normalization of business operations while continuing their employment.

Also maintaining a foot in the medical world, the NIMA can advocate to the Board and corporate leadership for action that would be in the best interest of the average patient suffering from the same illness as their stricken corporate leader. The NIMA, based on clinical experience in the treatment of real world patients, may recommend for out-coaching and out-placement of the ill individual on a temporary or permanent basis to facilitate that individual’s maximum chance for recovery of their own health. In this fashion the best interest of both the corporation and the individual are voiced and can not be served.

A Sigh of Relief
The $50 billion a year multinational corporation, hired a Non-Treating Independent Medical Adviser. The NIMA reviewed stock performances, corporate reports, memos and non-confidential corporate communications from the CEO over the preceding two years. The NIMA observed that the CEO’s Executive Assistant spent the majority of the day functioning as an uncertified nurse’s aid and an Executive Vice President reviewed every decision and every instruction made by the CEO. The CEO’s physical appearance demonstrated that the disease had caused far more muscle loss and weakness than the fitness for duty examination or the CEO’s own reports of her medical condition had indicated. The CEO took a 20 to 30 minute nap every two hours, and often ended her work day after 8 or 9 hours compared to her previous habit of 12 to 14 hours a day.

The NIMA also noted that on days when the CEO was absent, the management team was themselves far more focused and appeared overall happier and less confrontational in their interactions with each other. The NIMA reported to the Board these findings and recommended either for a temporary medical leave, under the Federal Family Medical Leave Act or for out-coaching and out-placement. Based on the recommendations of the NIMA the CEO was given both options. In these private meetings, the CEO admitted to being unable to retire despite a generous retirement package because of the CEO’s own sense of loyalty to the company. Much to the CEO’s relief, retirement was now an option as the Board voted unanimously for full retirement despite the fact that CEO was 13 months short of 30 years with counting.

Following the CEO’s retirement, a new Chief Executive Officer was named, within 6 months the non profitable divisions had been closed. The previously closed profitable divisions restarted or absorbed into existing operations. Corporate profits had returned to levels that had existed before the CEO’s illness and stock price had rebounded to its previous all time high. A year later, company’s stock price had resumed its previous continuous upward trend and the corporation had fully recovered from its own illness.

For companies trapped between their desire to support a loyal executive and the necessities of corporate responsibility, the fresh eyes of a Non-Treating Independent Medical Advisor allow these companies to continue to be all heart.

What is Your Safety Worth?

In 1999, the Institutes of Medicine asked a simple yet profound question,

“If you would not ride in an airplane flown by a pilot who had not qualified on a flight simulator, why would you allow a healthcare Professional to treat you who had not qualified on a patient simulator?”

This question went virtually unanswered despite the fact that the healthcare community paid significant attention to other questions raised in the same Institute of Medicine report. It was almost as if by diverting attention to other issues and finding less expensive problems to blame. The healthcare industry and corporate healthcare as a whole was trying to divert the public’s attention away from the fact that they did not want to utilize simulators to certify their professional.

On those rare occasions when representatives from the various associations that represent healthcare professionals, hospitals, and the other entities in the business of healthcare were cornered, they all said the same thing,

“It is too expensive and the patient simulators required for such certification do not exist.”

Nothing could be further from the truth.

Human Patient Simulation – Forty Years and Growing
In 1968, under a $1 million Federal Grant, a single animatronic human patient simulator was built. The device could respond in a means that roughly approximated normal human responses to physical examinations and even a limited number of medications and other interventions. This device even provided facial movement and a two-way intercom link so that the healthcare provider could interact directly with the machine and hear responses from the control room provided through a speaker in the simulator’s mouth. For 1968, this was nothing short of “Star Trek” technology. Unfortunately Federal funding was not renewed and the project was quickly mothballed.

This was not however the end for human patient simulation, over the ensuing decades, various other, far more limited, patient simulation devices were created. Medical schools and residency programs around the country purchased devices such as the Harvey mannequin, to teach lung sound, heart sound, and other basic physical examination skills. These relatively simplistic human analogues, were little more than speakers dressed up as a human patient. But underlying though was a significant amount of physiology and engineering.

By the time the “To Err is Human” report was written in 1999, the science of healthcare simulation had moved far beyond simple mannequin with speakers and CPR dummies. The animatronic simulators available in 1999 were far more sophisticated than the million dollar prototype created in 1968 and capable of simulating not only normal human anatomy and physiology but abnormal physiology and diseases as well. Thanks to portable computers and more sophisticated software, these turn of the millennia simulators were even capable of assisting in the training of Anesthesiologist and other professionals contributing to the safety of patients. Yet despite the fact that this equipment was readily available and cost less than 10% of what the 1968 prototype cost, the healthcare industry disavowed any knowledge of such devices. Healthcare professional associations stated that it was too difficult, too expensive, and too unrealistic to expect physicians and nurses to take time away from busy their schedules to be trained in the use of simulators and then periodically recertify utilizing these devices. Arguments were made that there were not sufficient numbers of devices available around the country and yet no one was willing to invest in the deployment of these machines.

The greatest promise of the “To Err is Human” report was ignored.

Simulator Certification Arrives at Last
Eight years later, in March of 2008, the first high fidelity simulation based certification examination utilizing human patient simulation was finally administered. The American Board of Disaster Medicine under the direction of The American Academy of Disaster Medicine provided an all day certification examination utilizing human patient simulators. These machines were neither department store mannequins nor CPR training devices. These were highly sophisticated high fidelity human patient simulators that not only had pulses, blood pressures, breath sounds, blinking eyes, and a heart beat; these were devices that could tear, sweat, and even droll. The testing environment itself was an emergency department treatment room and a room with a collapsed roof.

The simulator responded as a real patient would respond when a drug was given. Unlike a video game, where an action results in an immediate reaction, the simulators acted as real human beings and drugs took time to work. The simulator could tell if the wrong drug had been given. Although the simulators were not allowed to actually “die” during the examination, individual actions that would have killed a real patient were recorded and later graded. In short, the healthcare providers certified that day had the opportunity to crash land, recover and continue on without endangering themselves or anyone else. At days end, the physicians certified, were clearly safer, more thoughtful, and more experienced than any before them in history.

Promise and Problem
High fidelity human patient simulation based certification of healthcare providers holds the promise of elevating the level of patient safety in way never before possible in the history of modern medicine. Today, medicine has responded to safety concerns rather than proactively intervening. There has never been a reproducible standard by which healthcare providers within their specialty could be evaluated and compared.

Medical research looks to find “hard end points” such as the prevention of death and disability when testing new drugs yet when testing healthcare providers, examinations seek to find an arbitrary percentile based score on a paper examination. High fidelity human patient simulation examination provides the same “hard end point” evaluation for the provider as medication research does for new treatments. Simply put, if a provider makes fewer errors on a simulator, they are even less likely to make errors with human real lives.

So when will physicians, nurses and other healthcare professionals accept and employ high fidelity human patient simulation as a means of certification?

When the public demands it!

Simulator certification in the airline industry is an expensive and time consuming process. Airline employees must be paid for their time while training and qualifying on the simulator. Simulator leasing companies must purchase equipment and the space in which to store it. They must employ technicians to maintain and operate the equipment and have the equipment itself validated and certified on a regular basis. The airlines must pay the leasing companies for the use of the equipment and even for a reserved time unused.

The airline industry has the money and political power to do away with mandated simulation certification for its pilots and other employees, but the regulations and legislations that require this certification came from the outcries of the American public. The airline industry is wise enough to know that it would be fool hearty to challenge these regulations and legislation now and again raise the ire of the American people.

The healthcare industry on the other hand is accustomed to not paying healthcare providers for their training time or their certification time. They are accustomed to not paying for high level training or training an employee to provide perfunctory training house thus reducing the cost. The healthcare industry is relying on the fact that the American public is uneducated as to the capability of the current patient simulation technology.

The average American is unaware that equipment exists today that is capable of mimicking virtually any provider / patient interaction, virtually any treatment and most diseases. Simulation environments can be established for a fraction of the cost only 5 years ago (less than $75,000.00 per simulator) and yet other than the fact that the simulated patient is stored in a box at the end of the day, they are virtually indistinguishable from real people when it comes to their physiology and response to medical care.

The healthcare industry and healthcare professional are unlikely to invest in the future of the public safety without both legislative mandates and public funding. If the American public were to demand of their state and federal representatives, legislation requiring healthcare providers be certified on a regular and recurring basis using high fidelity human patient simulators, patient error would drop precipitously. It is impossible to eliminate human error entirely from healthcare, however it is very possible to identify gaps in knowledge, technical weaknesses and even bad habits while teaching new skills and reinforcing good technique in the safe environment of a patient simulation training room.

The question is, why are the American people unwilling to ride in an aircraft with a pilot who had never been in a flight simulator, but they are willing to place their lives in the hands of a healthcare professional who has never been certified on a high fidelity human patient simulator?

Did We Ever REALLY Ask?

Hospitals and their corporate officers live and die by customer satisfaction scores such as the Press/Ganey Survey and Harris Poll. The problem is that these “surveys” & “polls” are little more than “opt-in” commentaries. Scientific data shows that, regardless of industry, a dissatisfied customer is three times more likely to express their opinion than a satisfied customer. Given this fact, the healthcare industry standard “opt-in” model, by its very nature, should yield a 3 to 1 dissatisfaction bias. Given that this bias is not seen indicates that other, unaccounted for factors, are skewing the data.

Survey Construction
To obtain meaningful data from a survey or poll, specific criteria for data collection must be met. The first and most important is that the demographic make-up of the study group must be determined before the data is collected. Demographics includes more than gender, age and ethnicity. In the healthcare setting, treatment area specific identifiers such as time of year, triage level on presentation (ESI 1-5), initial evaluation and management level (E/M 1-5), waiting room wait time, length of stay, etc. allow for further differentiation of individual factors influencing patient sentiment and satisfaction.

These demographic groups must be strictly adhered to and once the number of a particular group is obtained for a given survey, no further survey responses are accepted in that demographic group. Further, if a particular demographic group is not fully enrolled with respondents, additional individuals are recruited in that demographic group only until the required number of responses are obtained. This is currently not done in healthcare, yet it is the key to obtaining interpretable data.

Questions Are Key
In healthcare, the rule is to ask open ended questions to obtain global information and then ask close ended questions to obtain specificity. In survey construction, specific questions must be asked before the survey is constructed. Like a scientific investigation (and all valid surveys are scientific investigations) the first question is to ask what specific and narrow question we seek to answer. Commonly, the response from corporate leaders is that they want to know if customers are satisfied, but this is not sufficiently specific. Which customers? Under what circumstances? Such a customer satisfaction question would be,

“Are customers with an ER lobby wait of greater than 4 hours (all other demographic factors being equal) more satisfied customers than those with a lobby wait greater than 4 hours?”

Once the question is narrowed to a specific single area, a null question (null hypothesis) must be formed. This is a testable question such as,

“Is there a difference between customers with an ER lobby wait of greater than 4 hours (all other demographic factors being equal) and those with a lobby wait greater than 4 hours?”

This latter question can be answered easily by having a demographically specific and identical group score their satisfaction then dividing them based on their lobby wait time. A simple comparison of the satisfaction scores between the two groups will then indicate the influence of lobby wait on satisfaction. Obviously, those with different demographic factors will respond to wait times differently and thus narrow demographic groups with large numbers must be studied to determine if lobby wait is in fact a factor at all.

Acknowledge Framing Bias
The construction of a survey or poll must also include a consideration of the bias held by those asking the questions. Failure to acknowledge even seemingly unrelated bias will inevitably skew the results due to the framing of the question. Referring back to the ER lobby wait example above, most in healthcare leadership hold the belief, based only on unscientific “opt-in” commentaries, that ER lobby wait is a key factor in customer satisfaction for all ER patients (regardless of other demographics). This bias results in customer satisfaction studies that are skewed to elicit comments congruent with that bias such as,

“Was your ER wait time short, adequate, long, excessive?”

This question primes the reader to view a long ER wait (even for a non-emergency) as excessive if it is longer than they wanted. The unbiased approach would be to determine ER wait time as a demographic factor based on the time from sign-in (arrival) to the time place in a room (door to room time). Having this information, the question would then be,

“Please rate your overall satisfaction on a scale of 1 through 5 (1 = very dissatisfied & 5 = very satisfied)”

The statistical comparison of overall satisfaction between those with an ER lobby wait under 4 hours and those with a wait over 4 hours within otherwise matched demographic groups yields an accurate reflection of the impact of ER lobby wait on overall satisfaction.

Bad Questions Yield – Bad Conclusions
Just in case there is any doubt of the influence of bias, an “opt-in” commentary invitation was placed on the internet for seven days and circulated using a professional networking service.[1] An analysis for power determined that 53 respondents were required for statistical significance.¹ Like all healthcare customer satisfaction surveys currently employed, any person having been an ER patient was included in the final analysis.¹ Over 28,900 individuals viewed the question, but only 59 “opted-in” with responses.¹ A heuristic analysis for bias was preformed to generate a question that minimized bias based influence on responses.¹ The resultant question asked,

“Given that your wait in the lobby and your total time in the ER would be unchanged, would you rather have your ER doctor come into the room 10 minutes after you are brought from the lobby to introduce themselves but do nothing else, or would you rather have your ER doctor come into the room 25 minutes after you are brought from the lobby and complete the entire interview, exam and ordering of tests/treatment?” ¹

The 10 minute option and the 25 minute option represent the current ER incarnations of LEAN and Six Sigma respectively. Pre-study review of the ER management literature found that the majority of the responses would prefer one of the other, but there was no consensus on which option would be preferred.¹

Surprisingly, out of 59 responses, 1% offered no preference, 53% preferred the 25 minute wait and 46% preferred the 10 minute wait.¹ Of greater interest, one in twenty of those who preferred the 10 minute wait stated that they only preferred it because they could “bully” the doctor into staying and completing the entire patient encounter rather than leaving after the introduction.¹ Despite respondent reframing of the options, there was still no statistically different difference between the options.¹

While each of these approaches have ardent supporters who insist that their approach is the solution to low patient satisfaction, this data suggests that the right question has not yet been asked and thus the true answer has not yet been found.

Asking a Better Question – Getting Better Answers
Asking better questions often yields surprising and useful information. Markoul, Zick and Green published a survey based study looking at how patients prefer to be addressed when they first meet their healthcare provider.[2] In most healthcare encounters, physicians greet patients by either first name or title with last name while introducing themselves with their title and last name. Conversely, nurses are taught to great patients by first name and introduce themselves by first name only. Across the board, all healthcare providers are counseled to offer a handshake at every encounter.

Answering closed-ended, narrowly constructed questions, a survey of 415 patients found that 50% the patients wanted their first name to be used when physicians greet them.² Similarly, 16% of patients preferred to be greeted by their title and last name, and 24% wanted their first and last names to be used.² As to how healthcare providers should introduce themselves to the patient, 56% wanted to hear both names; 33% wanted the provider to use just their title and last name, and only 7% wanted first names to be used.² Approximately 78% of respondents expected to receive a handshake, with older patients less likely than younger patients to want a handshake (74% vs. 87%; P < .005).² 

This data shows that the broadest group of patients would be satisfied if their provider greeted them using first and last name names (satisfying all three groups). Further, providers should introduce themselves using title with both first and last name while offering a handshake (again satisfying all groups).

Getting to the Answers Needed
Patient and customer satisfaction surveys are a fact of life in the business of healthcare. Improving these critical business benchmarks is too often linked to hastily contrived and implemented process changes. If the key to making the best decisions is having the best information and the key to having the best information is asking the best questions to the right groups of people, then before the next survey is sent out, healthcare must create better surveys.

• Determine the distinct demographic groups to be surveyed
• Determine the exact number from each group to be surveyed
• Survey exactly that number from each group (no more and no less)
• Determine the question to be answered and the null question to ask
• Acknowledge framing bias and frame the null question without that bias
• Limit conclusions to the answer for the null question
• Use inconclusive results as a guide to identifying factors without influence on customer satisfaction
• Use conclusive results as a guide to identifying actions that will improve customer satisfaction

When healthcare really asks patients for the answers it seeks, customer satisfaction scores will become irrelevant because patients will automatically get what they need and deserve.

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[1] Ramirez, M. (unpublished data)

[2] Makoul G, Zick A, Green M. An evidence-based perspective on greetings in medical encounters. Arch Intern Med 2007;167:1172-1176.

Globalization and Generation Y

The international marketing firm Youngster recently reported that for the first time in history, the market group known as Generation Y, those ages 10 to 25, is evenly divided across each of its five age based subgroups. A short to ten years ago when Generation Y first burst on to the scene, the vast majority of Generation Y was age 10 to 14. This first wave of Generation Y influenced popular culture giving us nSync and Brittney Spears.

The youngest segment of Generation Y represented over 50% of the group and they controlled the mass media market. In the 10 years that have followed, the early 10-year-olds of Generation Y became 20-year-olds filling out the top ranks of Generation Y. The relatively constant birth rate in the Western World resulted in an even distribution across all stages of the Generation Y.

The expanding size of Generation Y has resulted in the dissemination of their influence not only through popular culture as determined by those younger than 18, but also the business culture that is determined by the most innovative in the technology field, those age 18 to 25.

But, what impact will this have on globalization?

To understand the influence this group has, you must understand how Generation Y functions.

The First Digital Natives
Generation Y has been referred to as the first humans native of the digital landscape. This means that a Generation Y has never known a world that did not include the internet, cellular phones and immediately available parallel communications. All who came before Generation Y are no more than digital tourists, but Generation Y is as comfortable and capable in the digital world as in the physical world.

Any parent of a Generation Y teenager has marveled as their child adeptly talks on their cell phone, often on a three-way call, while sending SMS text messages and sending email directly from their cell phone. These amazing youngsters do all this while playing online RPG’s (role playing games) that combine video, audio, and text conferencing. An amazing six simultaneous lines of communication involving 30 or more simultaneous participants that demonstrates how Generation Y has evolved the very concepts of networking, collaboration and community.

The RPG player must learn and master no less than 70 new rules or skills. These 70 skills do not increase the player’s likelihood of success in the game, rather these 70 skills are the bare minimum to negotiate the first level of the game. To advance through the game requires the monitoring of no fewer than 100 individual incoming streams of data from 360 degrees in all three planes of three-dimensional space (X, Y, and Z axis). In addition, the most recent generations of game systems allow players to collaborate in real time with individuals not only within their country but across the internet in other countries.

These collaborations are not bounded by language differences. As a result, to work collaboratively within a given group and have that group work collaboratively against other groups, the players must learn either a language unique to the game or one utilized in common by all players within their team.

Neighborhood Y
Generation Y members utilize services such as MySpace and Facebook to serve as their digital homes. Similarly they use professional networking services such as Xing, LinkedIn, and Konnect as their digital offices. For a member of Generation Y, Facebook is a home in their personal neighborhood, while MySpace is their bedroom. It is not unusual for Generation Y individuals who initially met in a professional environment to exchange Facebook and even MySpace contact information to facilitate a larger social interaction.

Even more indicative of this tidal change is the number of Generation Y relationships that begin as personal social exchanges only to evolve into professional relationships and even business collaborations. Generation Y professionals don’t believe in going it alone. Spouses will get to know each other having never met face to face. Children will play video games and even together learn in simulation enhanced learning environments.

xBox Education
What would happen if the much ballyhooed No Child Left Behind curriculum were handed over to video game programmers and utilized as the rules, processes and systems of a series of role playing adventure video games?

• The entire K through 8 curriculum mastered in two and a half years!
• Four years of high school completed within 18 months.
• Completion of the first two years of college by the end of eighth grade.
• Recall and application in excess of 90% accuracy and proficiency.

The problem with the application of such a model within our current educational system is that for Generation Y, the RPG is not technology, rather it is a tool while for those who provide education, RPG systems represent what was once considered a “super computer”. This is a chasm almost too wide to forge.

World-Y-Business
As Generation Y, moves from their current position as entry-level managers to corporate leadership, they will bring with them these networking skills. LinkedIn is their North American office, while Xing is their European branch office and Konnect their Asian branch office. It is not unusual for a Generation Y professional to have over 10,000 direct first person contacts developed through Web 2.0 and Web 3.0 networks. This is not a collection of random business cards, but rather individuals with whom they have developed business and personal relationships, even friendships. These professionals not only discuss business ventures, successes, and failures, but seek each others advice in open mentoring opportunities and even share personal feelings in these virtual spaces.

These young professionals have truly tapped a globalized market through the use of the internet and social networking services. The only question, is the global market ready for true globalization?

Entrepreneur Heal Thyself

As the practice of medicine becomes more and more the business of medicine physicians find themselves with an ever widening view of the market based world. Some physicians retreat into practices where they need “only practice medicine” and allow others to “deal with the business side.” Other physicians choose to “take the bull by the horns” and manage their own enterprise. Others choose to diversify their entrepreneurial interests. Physicians who move from the entrepreneurial world of running a medical practice to non-clinical entrepreneurism fall into two categories:

First are those that find a non-medical outlet for their entrepreneurism. These physicians often really want out of medicine, but have spent a career contributing and do not want to feel that they no longer matter.

Second are those that find a medically allied entrepreneurial endeavor that allows them to use their hard earned knowledge and skills to support themselves without the problems and challenges of direct clinical practice.

Physicians in each category often continue to practice medicine either to supplement their income, or because the financial freedom provided by no longer depending on medicine for financial security now allows them to make the decision to practice thus restoring joy to medical practice. 

Paging Dr. Experience
The entrepreneurial life of running a medical practice is much the same as that of running a start-up business. The only significant difference is that a medical practice runs on a larger budget initially, but a smaller budget and profit margin later on. Non-medical start-ups usually begin with marginal funding and, if successful, grow as their income grows eventually reaching a point where their budget and profit margins are both quite respectable.

Because of their leadership role in healthcare, physicians are drawn to business leadership and executive positions. When it comes to physician executives, there are two types of “CEO’s.” Those whose lives present them with a never ending string of Career Ending Opportunities (CEO’s) and those who have learned to apply the skills that made them great doctors to lead organizations rather than medical teams. This latter group of physicians apply Business Triage, Customer Triage, Personnel Triage and Marketing Triage to maximize business potential in the same way they used medical triage to maximize patient care.

Physicians entering the entrepreneurial life must however observe several lessons:

• Do not assume your success in medical practice carries any weight in your new market. Be a good entrepreneur, know your market, know your strengths, know your weaknesses and know how to deliver your commitments

• Do not forget the skills that made you a good doctor. The skills that made patients love you and diseases fear you (effective interviewing, rapid decision making, pattern recognition, etc.) all are essential skills for the entrepreneur

• Don’t assume that medical training (residency) is a good model for training anyone or learning to lead. As a survivor of residency training, you are no different from a child abuse survivor and you are prone to abuse those subordinate to you as a result. If you abuse them, you lose them

• Just like a good doctor, good entrepreneurs make referrals, get consults and ask for help these are the keys to success

Physicians, despite the stereotypes, have education and experience that endows them with many of the skills of the greats of the corporate world. The key is to learn to use these skills in the new environment of entrepreneurism.

InstaDecision: 4 Steps to a "Blink" Moment

The past months have seen a resurgence of interest in the ideals of “gut reactions,” intuition and other versions of the insight methods described by Malcolm Gladwell in “Blink!” Business leaders, CEO’s, physicians, disaster field responders, professional speakers and a business consultants use both linear and non-linear decision making (logic & intuition) to create “Blink” moments daily.

Most people know the linear decision making process because t is cultivated by our educational system. It is a system based on the collection of data to support a decision (If A and B then C, but if A and not B then D). Few people realize that we are all born as innately non-linear thinkers.

What Goes Into a “Blink” Moment?

Non-linear process is a four step process consisting of:

1) Pattern Recognition

2) Acknowledging Framing Bias

3) Heuristic Introspection

4) Empathy

Pattern Recognition

Pattern recognition is seeing the patterns and processes behind everything you do and have done. Remember that those with the greatest potential are those who are the most adaptable to any circumstance. They innately understand the process that underlies any other person’s success and can replicate it with ease.

Acknowledge Framing Bias

Think about what happens before a manager goes into a meeting. Rarely will people walk into the situation “cold.” They are briefed on who they’re going to meet and what they’re supposed to accomplish. They draw certain preconceptions, which is called a framing bias.

As long as you know what your framing bias is upfront, then you can allow the situation to develop organically. You can then take away your feelings and your impressions and use them as an analytical tool. That’s the essence of heuristics—taking your feelings and impressions and using them analytically.

Before you can fully immerse yourself in another’s viewpoint, you need to shed your framing bias. First, identify what your preconceptions are about the situation. Second, once you’ve identified them, clear your mind and explore the experience for the first time. What’s your first impression? Are you reacting the way you are because of your preconceived ideas or because you are looking at the situation through fresh eyes?

Heuristic Introspection

Heuristic introspection is a non-linear thought process in which you must “be your customer”. Much like how a fine artist “knows” if a painting or musical composition “works” by going with their “gut,” your employees should “know” what a customer wants.

When you think heuristically, you truly understand the customers’ wants and needs. The next time you want to know how your customers would feel about a particular product or service, adapt a non-linear (heuristic) research approach and become a part of your study base. Your focus group of one (you) will guide your initial thought process toward reaching your customers.

Empathy

Empathy is quite literally to walk a mile in the shoes of our customers, that is to become one with your customers. Become part of the story, even if you aren’t part of the product story. Generally, people like and dislike the same things. If not, you’d never have to wait in line for your favorite roller coaster at an amusement park. What do you feel? Listen to your gut—chances are your customers’ gut would tell them the same thing. You may not identify with the problem, but you’ll know what you need to do to make it feel “right.”

How can you now translate what you’ve discovered into a reproducible decision?

If you’re developing an ad for jogging shoes, you need to think like a runner—even if you’re not one. Why do people run? What is important to runners? How does running make people feel? After you’ve collected your personal research, you’ll be able to speak in the first person as a runner. Pretend you’re one of those successful fiction authors writing under a pseudonym. Tell your story like you live it. Now your customers will be able to personally connect with you because you’ve become one of them.

Why do people underestimate the power of this?

There are two reasons that nonlinear decision making and inductive reasoning are less valued than linear decision making and deductive reasoning. Both are based on the misperception that nonlinear decision making and inductive reasoning are inherently irreproducible, unverifiable, unpredictable and thus unreliable.

1)     Despite that fact that humans are born as empathic, introspective and unbiased "pattern recognition machines," the vast majority become linear deductive decision makers. Through their educational experiences and the very basis of our scientific society, deductive is valued over inductive and linear over nonlinear.

2)     Once the nonlinear and inductive skills are atrophied, those that undervalue what they can no longer do easily (nonlinear decision making) believe that these skills are unlearnable. Nothing could be further from the truth.

Pattern Recognition is an innate human function that ensures our survival in infancy and aids in our safety in daily living. It is easily taught and augmented.

Acknowledging Framing Bias is not an innate function, but is very learnable and since it does not require the shedding of bias, is also readily implemented.

Heuristic Introspection is partially innate. All humans are born with a degree of introspection especially when dealing with ones own needs. Walking in the shoes of another is not an innate behavior, but understanding our reaction in that situation and using that information is trainable.

Empathy is yet another innate function that ensures our ability to identify and even predict the emotional impact of an event on others. Empathy is a practiced skill and the strength of one's empathy grows as one exercises that empathy.

In short the problem is not that "gut" is unreliable or "sample size of one" (intuition) is too small. The problem is in those who devalue this innate human ability.

"The fault lies not in our stars Horachio, but in ourselves."

-          William Shakespeare

Outrage or Enthusiasm: The Choice is Yours!

Businesses large and small want happy customers, happy employees and happy vendors. Regardless of whether a multinational corporation or a “Mom & Pop” store, enthusiastic supporters are a marketing asset while a single outraged person is a liability. Studies have shown that the average “satisfied customer” refers five people while the average “dissatisfied customer” finds 11 people to chase away.

Businesses and whole industries spend huge sums of money meeting customer expectations and even larger sums of money raising those expectations further. It is a never ending chase and if you lose, twice as many people will hear from the disappointed than ever heard from the content.

The key then is to manage the factors that determine the satisfaction of customers, employees and vendors with their experiences interacting with a business.

Let Your World PIVOT Around Them!

When people are born, they believe that they are the center of the universe. As children grow and mature into adulthood, they slowly learn that the world does not revolve around them. Businesses seek as part of their customer service approach to make customers feel that again the world revolves around them. Rather than reverting to childhood, a business seeking enthusiastic supporters should make the experience PIVOT around them.

The PIVOT model provides a simple mathematical approach to understanding and even predicting the societal and individual response to an experience. The PIVOT model is another lesson learned from the disaster field office. PIVOT stands for:

P = Probability

I = Impact

V = Vulnerability

O = Outrage

T = Tolerance

Each component of the PIVOT model places a numerical value on the factors that determine the response to the experience a business provides. It is a predictor of “Customer Satisfaction.” To apply the PIVOT model each component must be understood.

Probability

Probability = The likelihood of an experience occurring (0% to 100%)

Drawn from traditional risk management and actuarial sciences, the probability of an experience or event occurring is a value based on the historical frequency of an experience or event occurring. Most simply, probability is the number of times an experience or event occurs divided by the total number of possible experience and events.

Impact

Impact = The impact of an experience (positive or negative) on a scale 0 to 3

(0 = No Impact; 1 = Minimal Impact; 2 = Moderate Impact; 3 = Significant Impact)

It is often said that no event or experience is without impact, but assigning a value to the degree of impact is often complicated. The PIVOT model deals with response to an experience or event and is inherently subjective, thus Impact is a subjective measure based on past occurrences of the experience or event.

Vulnerability

Vulnerability = The susceptibility to the impact on a scale 0 to 3

(0 = None; 1 = Minimal; 2 = Moderate; 3 = Significant)

Like Impact, Vulnerability is a historically based, subjective measure of the susceptibility to the Impact. Obviously, if something has occurred previously but had not Impact, the Vulnerability is zero; however, when an Impact has occurred in the past, people have an inherent and subjective sense of Vulnerability which can be subjectively measured.

Outrage

Outrage = The perception of the experience on a scale -3 to 3

Outrage was first identified as a component of risk communications by Paul Sandman, PhD. In his model, Sandman identified two factors that influenced and predicted the need for risk communications in the event of a business debacle, Hazard & Outrage. Sandman found that while a high perceived Hazard necessitates risk communication, low Outrage mitigated that need while high Outrage necessitated risk communication even with a low perceived Hazard.

Sandman never quantitated the level of Outrage, but in the PIVOT model, Outrage is a calculated value. Calculation of Outrage requires an understanding of two additional values, Expectation and Satisfaction.

Expectation = Perception of what reality SHOULD BE on a scale 0 to 3

(0 = None; 1 = Minimal; 2 = Moderate; 3 = High)

Satisfaction = Perception of what reality ACTUALLY IS on a scale 0 to 3

(0 = None; 1 = Minimal; 2 = Moderate; 3 = High)

Understanding Expectation and Satisfaction, Outrage can be calculated:

Outrage = Expectation – Satisfaction

The interesting result of calculating Outrage is the insight this provides. Since Expectation is the perception of what reality should be and Satisfaction is the perception of what reality actually is, and given that a business cannot change people’s perception, Outrage is actually the difference between Expectation and REALITY.

Tolerance

Tolerance = The sentiment regarding the experience or event.

Tolerance is the measure degree of Enthusiasm or Anger in response to an experience or event and like the calculation of Outrage, calculating Tolerance gives tremendous insight into why seemingly bad business news results in good while seemingly good business news can become a full fledged business disaster. To calculate Tolerance, first calculate Hazard and Risk.

Hazard = Impact + Vulnerability

Risk = Probability x Hazard

        = Probability x (Impact + Vulnerability)

Having previously calculated Outrage and now having quantitated Risk, Tolerance is simply calculated, noting that if Outrage is a negative number, the positive number (absolute value) is used to calculate Tolerance.

Tolerance = (Risk)^|Outrage|

Therefore Tolerance (anger or enthusiasm) equals Risk raised to the power of Outrage.

Choosing Epidemic Enthusiasm

A look at two classic historical business examples demonstrates how accurate and powerful the PIVOT model is for influencing public and individual sentiment.

McNeil Pharmaceuticals is the textbook example of risk communications after the cyanide contamination of their Tylenol product. Applying the PIVOT model, the probability of dying from a contaminated pill 100% and the impact if such an event occurred and the vulnerability were both high thus each scoring 3 points. Calculating for Hazard and Risk yields a Hazard score of 6 with a Risk score of 6. The Expectation of the general public was also high (3 points) as there had never before been a significant problem with a McNeil product.

When the company responded by publically withdrawing the product from the market and pledging to not return to store shelves until safety could be assured, Satisfaction was moderate (2 points). But, when McNeil made good on their promises, Satisfaction was high (3 points). Outrage, which could have crippled the company’s return to the marketplace, was effectively reduced to zero.

When Outrage is zero (Expectation = Satisfaction), the Tolerance score always equal to 1. (Mathematically, any number raised to the power of zero equals 1).

The textbook contrast to McNeil / Tylenol is New Coke / Classic Coke. The Coca-Cola Company dominated the cola market for decades when market research began to show that Pepsi cola was eroding a small percentage of Coke’s market share. In a carefully researched and planned effort to regain that small market share loss, the Coca-Cola Company reformulated Coca-Cola. Again applying the PIVOT model, the probability of bringing the new product to market was 100%, but market research and focus groups had found that the Impact would be minimal (1 point) although the Vulnerability to the Impact moderate (2 points). Calculating or Hazard and Risk yields a Hazard score of 3 and a Risk score of 3.

When the new formulation arrived on store shelves, Expectation was high (3 points), but Satisfaction with the new formula was nonexistent (0 points). The Tolerance score of 27 predicts what followed. Consumers began to hoard “old Coke” and picket against “New Coke.” Re-examining the anticipated Impact and Vulnerability shows that loyalty to the taste of the “old Coke” formula meant that the both Impact and Vulnerability were actually each 3 points, thus Hazard was 6, Risk was 6 and Tolerance was 216 (highest possible score). Despite the reintroduction of “old Coke” as “Classic Coke,” it was years before the Satisfaction score rose and the Tolerance score exponentially fell.

When Outrage is a positive number (Expectation > Satisfaction), the Tolerance score is a reflection of the Anger (negative image) felt towards the business.

But this is not the end of the New Coke / Classic Coke story. An unintended, but not unexpected beneficiary of the Coca-Cola Company’s misstep was Pepsi cola. Regardless of the success or failure of the new Coca-Cola formulation, the probability of the product making to store shelves was 100%. Had Coca-Cola’s market research been correct, the Impact on Pepsi cola would have been high (3 points) and as the number two product in the marketplace, Pepsi’s vulnerability was also high (3 points). Pepsi cola had a lot riding on Coke’s reformulation with a Hazard score of 6 and a Risk score of 6.

When “New Coke” disappointed Coke consumers, Pepsi consumers were heartened by the fact that Pepsi was NOT being reformulated. The Expectation for a change in flavor was nonexistent (0 points) while Satisfaction remained high (3 points). For Pepsi cola, the Outrage score was negative (-3) yielding a Tolerance score of 216, but unlike Coca-Cola customers, Pepsi customers were predictably enthusiastic about their preferred product. Same event, same reality, different outcome based on perspective and expectation.

When Outrage is a negative number (Satisfaction > Expectation), the Tolerance score is a reflection of the Enthusiasm (positive image) felt towards the business.

Manage What is Manageable

Ultimately, Probability, Impact, Vulnerability, Perception and Reality cannot be changed. Of all the factors that determine public and individual sentiment and predict anger verses enthusiasm, Expectation is the only factor that can be changed before and to a lesser degree during an event or experience. Thus if Expectation can be preemptively made to matched reality, Outrage is changed. Through expectation management, Anger is downgraded to Concern; Concern is converted to Opportunity; and Opportunity is upgraded to Enthusiasm.

Limited Resources and Ethics

Please discuss the ethical challenge of dealing with limited resources in a mass disaster.
(Question posed via: Ask@MauriceARamirez.com)

The importance of dealing ethically with people in times of limited resources deals not only with mass disaster, but business continuity and even daily business operations. Whether the limited resource is food water, and medical care in a disaster or wages, shifts and benefits in a business down turn a goal oriented decision process must be employed.

In a mass casualty event, Continuous Integrated Triage should be employed to determine who receives care now and who waits for care based on degree of injury balanced against resources available.

To maximize the delivery of products and services during a time of scarcity, Business Triage must be applied, even by non-healthcare enterprises.

The need for triage is not an opinion, but the consensus of the vast majority of experts in crisis management, healthcare and business continuity. To determine the ethics of such an approach, several ethics boards were asked to address the issue.

Dr. Mark Pastin, President of Health Ethics Trust believes that the need for triage is the, “simple and obvious answer.” Dr. Pastin points out that there is the “risk of violating what would ordinarily be viewed as your professional responsibilities if you do triage.” Dr. Pastin posed the example of an existing doctor-patient relationship with one of the casualties. Dr. Pastin, a long time advocate for resource based standards of care in disaster healthcare points out that the lack of such standards leaves an array of questions should the care available fall below the usual standard of care. Dr. Pastin also points out that some have even wondered if euthanasia might be appropriate to those who are suffering but not likely to be treated.

Ethicist Dr. Ken Solis finds that the distribution of limited resources equitably or most effectively is sometimes “opposing priorities.” Dr. Solis observes that “most disaster plans, for example, allocate a limited resources to health care workers (and their families so the health care worker is willing to show up at work), safety officials (police, firemen/women), and public officials to keep critical infrastructures operating and so that more subsequent people can be treated - a utilitarian or effectiveness approach. After that, most models go by ‘first come-first serve’ or ‘lottery’ to try to be equitable.   Of course, those with the most means will still tend to come in earlier due to their greater resources and might even be able to cheat the lottery in some way, e.g. pay a poor person a lot of money for their ‘ticket’."

Dr. Pastin and Dr. Solis agree that, in a disaster situation, some of the norms that guide the typical provider-patient relationship will undoubtedly become difficult to sustain. The 2001 anthrax attacks and subsequent fear resulted in behavior by physicians and other healthcare providers that culminated in a nationwide shortage of Cipro (ciprofloxin) and doxycycline.

Dr. Solis echoes the concerns of many both in and out of healthcare when he reminds us of another challenge: the competing interests that a health care worker will have balancing their family versus their patients.  “Some healthcare providers will give priority to their family, especially if their absence could cause their family harm. Similarly, the healthcare provider may decide that their presence at the disaster (e.g. an infectious disease epidemic) could cause their family harm.  During the black plaque in Europe, many doctors fled to the country side, not an effective tactic, but acted based on their personal priority.”

The decisions involved in the triage and resource allocation process will result in dissatisfaction at many levels. While the first principle of medicine for centuries had been Primum Non Nocerum (First Do No Harm), it is increasingly obvious that in disaster healthcare the first principle should be “Do the Most Good for the Most People with What You Have Now.”