Maurice A. Ramirez, DO, CNS, CMRO

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.

Three Simple Rules for Media Relations

In the disaster field office there are three simple yet absolute rules to managing media relations. Businesses, celebrities, and even hospitals have created for themselves foibles and catastrophes due to a basic lack in the ability to manage media relations and the press.  These problems stem from the fact that most failed to understand that the press serves the same people that they serve.  Whether you are a corporation, a small business, a healthcare facility, or a movie star the press speaks at one time en masse to your public.  If you remember this simple fact it is then no great intellectual stretch to understand that by partnering with the press and the media you can communicate vital information to your entire market simultaneously.

Rule Number One: Don’t get in front of the camera!

This may be obvious but if it is not your job to speak to the press do not get in front of the camera. Moreover ensure that your employees and staff do not get in front of the camera unless it is their job to interface with the media.  Most media mishaps occur because the press is presented with multiple messages and good, honest reporters attempt to make some logical sense of these conflicting stories. 

Unfortunately no matter how good the reporter and how well meaning your staff when conflicting stories enter the press simultaneously nothing but bad can come of it for your organization.

Rule Number Two: Do not lie!

Now this is probably good advice in life in general, but if you lie to the press they will catch you and then they will make it their mission in life to destroy your career because you have just done irreparable damage to theirs, you have damaged their credibility.  The media succeeds because people trust them.  If they violate that trust no matter how unintended or innocent the violation they lose the public trust.  With this loss of credibility comes the loss of the ability to do their job.  Therefore everything that you say must be absolutely true and absolutely consistent with what the reporter observes.

Rule Number Three: Remember how the press keeps score!

The media does not keep score the same way that you do. 

• They do not count dollars.
• They do not count lives saved.
• They do not count how many movies they appear in. 

The press keeps score either in terms of minutes of face time on camera or inches of newsprint.  In order for the press to score they must capture 1.5 seconds of you, approximately 15 words in print, and surround it with several minutes of themselves, at least 2 inches of newsprint. 

If you know what message you wish to communicate to your market, their audience, and you must:

• Condense your message into a 1.5 second sound bite (fifty words for print).
• Ensure that message is absolutely true and consistent with what the reporter sees.
• Deliver that same message regardless of the question asked.

Do these three things and you will leave the reporter with only one choice, use your message or to not score today.  Under those circumstances the media will use your message every time because they keep score based on minutes of face time or inches of newsprint and to score they must surround your message with their voice or their prose. 

Remember these lessons from the disaster field office and your next media encounter will serve to bolster your relationship with the media and your position both with the press and the community. 

The Choice to Love

We hear the word love throughout modern society.  We are told to love our customers and that as customers we are loved.  We are told to love our neighbor as ourselves.  We are told that there is no greater gift than love.  We even have a special holiday, Valentine’s Day, dedicated to the notion of love.

Love has been described a basic building block of resilience, the foundation of the family, and in the goal of marriage.  But does love have a place in business?

Father Dan Schulte, a Catholic Priest and Philosopher, has defined love as “Love is the unifying thoughts between two people who have cared for and have said ‘yes’ to each other total being.  It implies mutual respect, freedom and trust, and seeks the happiness of fulfillment of each other as a common goal.”

Father Robert Mitchell has stated that love is an act of choice while “life” is an uncontrollable emotional response to our experience of another individual.  Father Mitchell states that while respect is a pre-requisite of love, life is not.  Father Mitchell does posit that respect is the ideal foundation for a love relationship and that from this respect “life” would ideally spring forth to form the framework of the love choice however, life is not the pre-requisite to the act of choice to love.

In the business world the admonishment to “love our customers” has been criticized as minimizing the meaning and importance of love.  As this admonishment is a pride in most businesses that criticism is quite true.  Father Schulte in his definition points out that love is a unifying response, it binds those in the relationship together trading a new individual, the love relationship itself.  In his definition those in the love relationship choose to “care for and face ‘yes’ to each other’s total being.”  Here Father Schulte and Father Mitchell agree completely, love does not require that you “like” the other individual only that you choose to love.  How many of our customers do we have the immediate emotional response of dislike?  Father Mitchell and Father Schulte prove here that we can embrace that “dislike” and still choose to love that customer.

But how can I love somebody whom I dislike?  Father Schulte’s definition answers this question as well by including that love implies mutual respect.  Just as Father Mitchell stated that respect is the foundation for love, Father Schule states it is an absolute pre-requisite.  Even if we dislike our customers we can still find in ourselves respect for them and perhaps even acceptance of them as they are and through these make the choice to love them. 

Finally Father Schulte points out that a love relationship requires that we seek the “happiness and fulfillment of each other as a common goal.”  Is this not the goal of every business?  Few of us work to be unhappy despite the fact that for many this is the end result.  Instead we speak to gain fulfillment and happiness through the work we do.  Father Schulte points out that it is not the work that creates the fulfillment and happiness but the relationships that we garner from that work.  Interestingly, when the relationships from our work provide fulfillment and happiness we need the last pre-requisite to love our customers.

But what if our customer refuses to enter into this love relationship?  What if our customer does not care for us, is not accepting of us and does not respect us, does not trust us or does not seek our happiness or fulfillment as their goal?  Increasingly in American society we find an almost schizophrenic response to the concept of customers and businesses and business people entering into a love relationship. 

When we fill the role of customer we are often impatient, untrusting, unaccepting, unloving.  Yet when we are in our own business and work environment we strive to respect, accept and even love those whom we serve.  Father Mitchell points out that because love is choice we can choose to offer love even when the requirements of a true love relationship are not there.  For Father Mitchell this is a form of self reliance and self respect.  Father Mitchell states that it is the ultimate form of self love to not allow another person to denigrate decisions and the ideal that we have set for ourselves.  This means that even though we may not like our customers, even though our customer may disrespect us we can choose to offer them love.  This is not to say that we should allow ourselves to be abused.  Nor should we allow ourselves to be exploited.  There is a vast difference between offering love and becoming a victim of our own love choice.  In offering love we are respecting our own choice to enter in to a love relationship however, that relationship becomes exploitive when it is not a unified response, when we are not cared for nor accepted.  We may offer love despite apparent disrespect but if disrespect, distrust and a failure to value our happiness and fulfillment by what we receive in return for our love choice then it is not love but masochist to remain in the relationship.

For many years it was the professional responsibility of physicians to constantly evaluate their relationship with their patient.  The doctor/patient relationship was seen as the ultimate love relationship.  In that relationship the physician along with the patient sought health and happiness, however when evaluating that relationship if the physician found that the relationship itself was not healthy either for the doctor or the patient that physician was both morally and ethically bound to end that doctor/patient relationship and assist the patient in finding a new physician. 

Unfortunately as healthcare became more a business and less a relationship physicians began to abandon this professional responsibility remaining in relationships where they were neither respected nor trusted and where they failed to respect or trust their patient.  Over time the professional decisions to find the patient a more supportive relationship became replaced with the legal decision to “severe the doctor/patient relationship”.  It is interesting to note that about the same time the number of malpractice lawsuits in the United States began an exponential rise.

In any choice to enter into a love relationship there must be the inherent choice to end that relationship if it fails to meet the basic requirements of love.  This is a prospect that is frightening too many businesses however, if a business is to be financially resilient, if it is to be able to extend the same love relationship to its employees as it frequently extends to its customers than it must obey the moral imperative to love its customers enough to seek for them the best business relationship possible even if it is with another business.  How often had a business garnered our undying loyalty by referring us elsewhere for service that they can not truly meet?

The choice to love is the basic building block not only of friendships, marriages and resilience, it is the basic building block of business.

Redundancy, Business Continuity and Lessons for Healthcare from the Disaster Field Office

The business world has learned several hard lessons over the past decade when it has come to the need to preserve business critical data. Words like “redundancy” and “continuity” have become the watch words of the Information Technology professional and the corporate CFO. The time taken to perform daily and even hourly computer back-ups is no longer perceived as a waste, but rather as time well spent. Where once computer sales people had to argue the benefits of off site storage, now corporate buyers demand such service compatibility.

Corporate healthcare too has learned these lessons, but for reasons that are inexplicable to those of us who use the systems everyday, this level of security and redundancy does not extend to the most critical of healthcare data, the patient’s medical record. To be certain, electronic medical records provide a greater level of security and data redundancy than their paper predecessors, but the type of duel storage data verification used for the most critical business information does not exist for patient medical records. In the disaster field office we have learned that if a system is going to fail, it will fail at its weakest link.

In 1999, the Institutes of Medicine published a report titled; To Err is Human and the national debate on patient safety began. The Institute of Medicine report highlighted a number of areas of concern, chief among them were medication errors and wrong site surgery. Now Eight years and dozens of regulations later, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) CEO has revealed that wrong site surgery has not declined, it has increased.

Unfortunately, healthcare professionals, despite their best efforts, are failing to create the systems that will ensure your safety in the hospital. Few people are capable of remembering the complete and detailed treatment plan for every patient in their care. Medical records exist to ensure that critical information is at the fingertips of caregivers. The problem with today’s medical records is they are based on a century’s old technology, paper. The risk of a medical error or complication increases when the medical record is incomplete or absent. Unreadable handwriting and failure to cross reference medications for incompatibility only add to the danger.

Would you give your money to a bank that kept your financial records in a dusty handwritten ledger? Would you ride on an airplane in which the captain navigated with a paper map and sextant?
Technology has come to the aid of the patient both at the doctor’s office and in the hospital. Kevin Freking, of the Associated Press recently reported on the first major corporate sponsorship of portable electronic medical records. Applied Materials, BP America, Inc., Intel Corp., Pitney Bowes and Wal-Mart will enroll employees in a central database to maintain health records in an effort to eliminate duplication, omission and error.

This is a concept that is supported by President Bush and the National Academy of Science - Institute of Medicine. Not only with the system collect medical record information and reports to a central repository, but individuals will be able to provide personal and family information to augment the record. This type of system is envisioned by the Whitehouse as a national standard by 2014 and is a requirement for implementation by medial providers by 2008. The problem with this on-line repository database is that it is Internet dependent and while accessible only from an Internet portal, it is not truly portable. You cannot carry it self contained in your hand.

So how can the medical record undergo validation at every patient encounter, particularly when patients move from doctor to doctor as required by their disease, their job or their insurance coverage?

What if this vital data where contained in a watch, pendent or wristband you wear everywhere you go?

What if every time your electronic medical record was accessed, it was compared to the data you wore and any differences required that your healthcare provider reconcile the information?

W. David Stephenson of Stevenson Strategies made the fantastic suggestion that people carry their medical records on secure U3 enabled USB drives. According to Mr. Stephenson:

"This sounds like a real win-win technology that hits my sweet spot, and in a disaster, a literal and figurative lifesaver, because you'd not only have your medical records in hand, but also all of your critical applications and business files as well."

Thanks to the falling cost of computer memory and USB Flash drives, the first 1 Gigabyte Portable Health Record (PHR) wristband has arrived on the market. A Personal Health Record is a software/hardware solution used to store personal information, insurance data, medical records and medical images. In the event of an emergency, or even a routine medical visit, the healthcare professional places the drive in the USB port of any compatible computer. With a Personal Health Record, your medical information is available where you and your healthcare provider need it.

Currently there are 25 companies selling Personal Health Record solutions. Although all 25 companies claim password protection for the user interface, only one of the systems uses encryption to safeguard the data files from direct access by other software. Encryption is an essential feature for a Personal Health Record.

Also needed is the ability to ensure that the patient does not deliberately or accidentally alter the records, especially if they record includes notes from medical professionals as several of the systems do. Another nice feature would be the ability to synchronize with the Electronic Medical Record (EMR) at the doctor's office. With this type of synchronization capability, a central repository serves not only as a primary data source, but an ideal back-up for the USB data.

When choosing a Personal Health Record look for:

• An Emergency Information screen that appears immediately when the PHR is activated
• Password protection with encryption for information stored on the PHR
• Image import and storage for x-rays, EKG’s and personal documents
• Storage for a several emergency contacts (including local contacts and employers)
• Storage for all your insurance information (medical, dental, travel, vehicle, business, liability, worker’s compensation, etc.)
• Lists of both your primary doctors and your specialists
• Lists of both current and past medications
• Lists of Allergies and Reactions
• Lists of Hospitalizations, Surgeries, Past and Current Medical Conditions
• Journals where doctors, nurses and you can record notes for future reference
• Synchronization with your main computer and an online data repository
• Synchronization with Electronic Medical Records at the doctor’s office or hospital
• Tracking of Changes made to maintain data integrity
• USB Drive Capacity of 1 Gigabyte or more

Arnold Goodman, CEO of My Medical Records, LLC plans to give away a basic Personal Health Record on his company’s website (www.TheOriginalMyMedicalRecords.com) beginning in May of 2007. Mr. Goodman and his team have been involved in Medicine and Medical Information Systems for a cumulative 54 years. They developed both a “Lite” and a full featured “Pro” version of their Personal Health Record. Their “Lite” version has all the features of its 24 other competitors. Why give away what your competitors charge full price for? Mr. Goodman has a simple answer:

“We have seen the effect of not having critical medical information available when it is needed. The free “Lite” version of our software will ensure everyone has a minimal level of safety.”

In the coming seven years, all of healthcare will by necessity and regulation convert their centuries old paper technology to modern electronic medical records. The use of Portable Health Records for data validation is the logical next step in this evolution.

What a wonderful merger of form and function that could now save your life!

When Worlds Collide

John, a veteran of the Fire Department of New York had “retired” to his southeastern home several years ago. Unable to sit and fish all day, John soon joined the county fire service and became a resource for his department and his community. Loved by everyone for his jovial nature John was admired by the rookie firefighters.

One bright summer day, a chemical tanker truck caught fire in front of the regional trauma center. The trauma center was upwind and in no direct danger when fire and hazmat teams arrived. The fire was quickly contained and the hazmat team set about the work of clean-up.

As operations began, John’s first duty was to establish contact and coordination with the hospital. Smiling he turned to the rookie assigned to him for training and said,

“This will be fun, watch their reaction when we ask to speak with their Liaison Officer. They won’t have a clue what I’m talking about.”

John and the rookie walked into the hospital still smiling and asked the security officer at the front door to contact the Liaison Officer. Much to John’s surprise, the security officer immediate called for the Liaison Officer to come to the front lobby. Moments later, a young woman arrived and introduced herself to John.

Unfortunately, John’s experience is still the exception rather than the rule when community response services interact with hospital services. Too often these interactions are seen as either a threat to hospital autonomy or as a public relations exercise. As with most problems of culture and communication, the fault lies on both sides of the relationship.

Hospitals are for the most part private businesses with the duel mission of providing care and delivering a profit. Unfunded mandates and social pressures have created a complex web of regulation and oversight that is largely resented by those in the healthcare professions. Any aspect of the business that is not regulated is seen as an opportunity to distinguish oneself from the competition and is thus jealously protected. Until this year, that included hospital command structure during a disaster.

Fire/Rescue has been steeped in a system of command and control born of the need to ensure that lives and property are not placed at undue risk. Unlike healthcare professionals, Fire/Rescue professionals know that a breakdown in command decision making will cost their life or the life of one of their colleagues. There is no room for individuality or customization of the system in the mind of the Fire/Rescue professional.

These worlds collide in the modern era of disaster preparation and response. By mandate, hospitals and healthcare facilities are now required to use the same incident command system that Fire/Rescue has used for decades. The relationship is further complicated by the fact that this mandate reverses the traditional lines of authority and knowledge in which Fire/Rescue has always taken instruction and guidance from healthcare as regards Fire/Rescue’s medical operations. Now healthcare must take instruction and guidance from Fire/Rescue.

As with any realignment of a relationship, the integration of hospitals and healthcare institutions with the larger community response will ultimately strengthen the system and the nation’s preparedness. Until then professionals on both sides will do their best when their worlds collide.

Business Continuity and Healthcare Disaster Planning

The Business Continuity profession has seen rapid and explosive growth in the days since 9/11. On that terrible day, the significant difference between those businesses housed in the World Trade Centers that would reopen and those that would close was the degree of business process resilience that business possessed.

The years since 9/11 have seen businesses large and small implementing not only data redundancy, but continuity planning for all critical business processes. To be sure, healthcare has also implemented data redundancy and business process continuity planning for business and administrative activities, but what about the true business of healthcare?

Business continuity planning is designed to preserve those critical business processes that must be preserved to maintain operations and profitability. For an investment company, those processes include data storage, client accounting and real time financial processing to mention just a few. Healthcare business contingency planning is directed at supporting such processes as data storage, client accounting and real time financial processing; but does this support the mission of healthcare?

An investment company is in the business of managing money and markets; their business continuity planning supports that mission. Healthcare is in the business of delivering medical care. Currently healthcare business continuity is split between two professionals, the business continuity professional and the medical contingency planner/safety officer. The business continuity professional is charged with ensuring that the financial and administrative processes of the healthcare business are maintained. The Medical contingency planner/safety officer is charged with ensuring that the delivery of healthcare continues uninterrupted. But the does this split approach support the mission of healthcare?

Healthcare business continuity planning must preserve those critical business processes required to maintain operations and profitability. This by necessity includes both critical medical services and critical financial and administrative processes. However, most healthcare institutions in the United States are private sector businesses. These businesses do not meet their operational budgets with emergency medical services or even general hospital admissions. This was borne out in the late 1970’s and early 1980’s when the losses in emergency medical services caused hospitals to either close or restrict services in the emergency room. In an effort to stop this trend, Congress passed the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA). In 2007, healthcare institutions subsidize the unfunded EMTALA mandate with outpatient services. These are the very services that most medical contingency planners/safety officers close when disaster strikes.

Like business contingency planning, healthcare disaster planning begins with a vulnerability analysis; however, unlike the business vulnerability analysis which focuses on identifying critical business processes, the healthcare vulnerability analysis focuses on quantitating external threats. Healthcare disaster planning is based on an “All Hazards” approach. Despite the apparent emphasis on external threats, an “All Hazards” approach is meant to be “Process Hazards” approach.  Here in is the challenge for the medical contingency planner/safety officer and the new market opportunity for the business continuity professional.

Healthcare desperately needs a planning professional who can combine the healthcare vulnerability analysis with the business process vulnerability analysis. The average daily revenue loss for a hospital that closes outpatient services following a disaster is a quarter of a million dollars. In addition, financial losses occur as a result of process failures in registration, charge entry and billing. The delivery of healthcare services frequently suffers as a result of process failures during disaster that cause a backlog of patients and a loss of efficiency. Healthcare disaster planning based on standard healthcare vulnerability analysis combined with process vulnerability analysis would not only address the business process continuity, but would highlight medical process vulnerabilities allowing limited medical resources to be concentrated on medical process continuity. Finally an attention to business continuity focusing on the primary mission of the healthcare institution to deliver healthcare and maintain profitability would support the business processes and the medical processes while quickly returning to normal operations to restore all streams of revenue.

There is No Nursing Shortage

An interesting conversation took place recently between a 45 year nursing veteran and her family. The topic of the day was the nursing shortage and the veteran nurse surprised all by announcing, “There is no nursing shortage, there is a hospital nursing shortage.”

She went on to explain that in the home health and non-institutional nursing fields, there is an adequate supply of nurses willing to work for employers who respect and value their services. According to this nurse who had worked in hospitals for much of her career, the problem today is that hospitals and other institutions see nurses and other professionals as replaceable rather than precious.

“No nurse my age is going to work for some young supervisor who believes that you manage people by threatening them or their license. There are too many jobs out there to deal with that nonsense.”

This veteran nurse struck on the key factor in any employee shortage, the relationship between employer and employee. Two contrasting examples of the value of the employer/employee relationship demonstrate the promise and peril facing healthcare in the future.

Steeley Corporation:
One of the two largest employers in a north Florida community, Steeley Corporation had once been one of the two most reliable employers in the region. Steeley Corporation was the unrivaled market leader in their niche and pay at Steeley Corporation was second only to pay at the paper mill. Steeley Corporation management was exclusively hand picked individuals who had proven their willingness to follow any order given by the company president. Steeley Corporation management believed in an authoritarian management model and the lack of other good paying jobs ensured that employees remained despite the poor employer/employee relationships.

As the economy of the area shifted from manufacturing to tourism, Steeley Corporation began to suffer financial difficulties. Convinced that the company could be profitable again if the employees would stand with the organization, mandatory overtime and shortened breaks were instituted to “save jobs.” Employees unwilling or unable to work past the end of shift were terminated and management further retaliated by giving poor references. As the company spiraled downward, payroll checks began to bounce and managers began threatening licensed employees with “reports to the state.” Employee resignations skyrocketed and families began leaving the community. Finally, the company collapsed and disappeared overnight. In the aftermath, hundreds of employees were owed millions of dollars.

Intuit:
The early days of the “dot-com” craze were characterized by a many great ideas that would flounder for years until rediscovered by a bigger company. Small software houses would create a fantastic product, but without the funds to run a start-up business, these products would either disappear or be purchased by larger companies. Microsoft was the biggest buyer of such innovative technology. It was into this environment that a small company with an electronic checkbook was born. Intuit began in a garage and grew quickly on money borrowed by the founders.

The brightest days for Intuit were quickly followed by sudden financial darkness. As larger software developers entered the “personal finance” market, Intuit found itself in financial trouble. The company founders made the employees an extraordinary offer based on the value they placed on the employees and the relationship with each as a person. The employees were offered an opportunity to work for partial ownership of the company. Those who chose this option would become shareholders with the potential of making millions if the company survived to be a publicly traded company. Employees who could not afford to forego being paid received a guarantee that their job would be available if they chose to return when the company was again solvent.

Intuit management had cultivated caring relationships based on mutual respect with each employee. There was no “management by intimidation” at Intuit and the company was rewarded when financial disaster loomed large on their horizon. Most key company employees opted to stay, unpaid, in exchange for ownership. A small group of employees were unable to forego an income. Intuit management guaranteed their jobs and honored these guarantees when these employees returned. Over time, Intuit became the dominate personal and business finance software manufactured (Quicken and QuickBooks), even staving off a take over attempt by Microsoft.

Healthcare has become a split marketplace with institutional care (hospitals and nursing homes) separated from non-institutional care. Nurses are gravitating to non-institutional care despite lower pay because of the factors that Intuit and others have come to appreciate. Employees care more about the relationships than the money. Veteran nurses remember being respected and appreciated for long hours and selfless dedication. It was not expected or required, it was given freely and accepted graciously. Even in a “materialistic society” people want to be loved and cared for, respected and valued.

There is no nursing shortage, there is a relationship shortage.

No More Wrong Site Surgery

In 1991, a major medical training hospital made the national news after the wrong leg was amputated twice in one week. Despite “an abundance of care” two unfortunate people entered the hospital expecting to lose one leg and walk out with a prosthesis and ended up loosing both legs and leaving in a wheelchair.

In 1999, the Institute of Medicine published a landmark report on patient safety titled: To Err is Human and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) began championing the cause of patient safety and the prevention of wrong site surgery. Over the past 16 years, hospitals, doctors, nurses and many, many others have developed and implemented procedures designed to stem the rising tide of tragic errors.

In 2007 at a conference on patient safety, the CEO of JCAHO disclosed that despite tremendous effort, expense and study, the number of wrong site surgeries has risen unabated and exponentially since 1991. Every attempt to change this horrific reality has failed!

How can this be?

The title of the 1999 report summed it up: To Err is Human.

Think about modern surgery. You, the patient, are moved to an operating room. Your identification band confirms that you are the patient scheduled for surgery.

This is the first possible point of error, wrong name on the surgery schedule.

Once the operating room staff ensures you are you, the site of surgery is confirmed in the chart and marked. You may even be asked to confirm that they are marking the correct spot.

This is the next possible point of error, wrong site listed in the chart or told to you.

Once your surgery site is marked, you receive medication (if you didn’t earlier). Your surgery site is washed and “prepped” further entrenching this as the “correct side.” Then your entire body is covered by surgical drapes and other items that reduce you to an unidentifiable pile of cloth with a small window of skin.

This is an opportunity to reinforce prior error by eliminating the ability of the surgeon to recheck each of the above steps easily.

The surgeon arrives and prepares to begin cutting. The surgeon confirms that you were identified and the correct surgical site was marked. The amputation is completed and the surgery team removes the surgical drapes and discovers your diseased leg was NOT amputated!

So is there a solution?

Perhaps, imagine if you could mark the surgical site days or even weeks before surgery without risk of changing the marking. Imagine a pre-operative marking system that provided a unique identifier for the surgical site that is not affected by the process of washing, prepping and draping. Imagine a patient and surgical identifier that can be checked repeatedly from the point of admission through the pre-operative procedure, during the operation and even after the correct limb were amputated.

Impossible?

Technology has the solution. Implantable RFID chips are currently in use as unique medical record identifiers for patients and disaster responders world wide. Contrary to popular myth, there is no GPS tracking system or other privacy issue created by these passive electronic numbers.

RFID chips are biologically inert and implanted through a small needle as easily as giving an antibiotic shot. These are the ideal characteristics for a wrong site surgery solution.

Think about RFID assisted surgery. You, the patient, see your doctor weeks before the surgery. Your regular doctor has determined that you require surgery. An RFID chip is implanted in the fat of the diseased leg and you are sent to see the surgeon.

You see the surgeon several days later, but your medical records have not yet arrived. Instead of rescheduling your appointment, the surgeon scans your leg with an RFID receiver and gets your medical record number. You authorize immediate release of the medical records and your surgeon schedules surgery.

You are admitted to the hospital and the first human error occurs as your healthy leg is entered into the medical record as requiring surgery.

The day of your surgery, the second human error occurs as your roommate is moved to the operating room. Instead of amputating the wrong leg from the wrong person, your roommate is scanned for an RFID chip and the unique identifier reveals that you and your roommate received the same wristband.

You are moved to the operating room. Your identification band confirms that you are the patient scheduled for surgery. Once the operating room staff ensures you are you, the site of surgery is confirmed in the chart and marked. You may even be asked to confirm that they are marking the correct spot. The chart indicates your healthy leg is the surgery site. You have already received medication and agree as a result of the sedation.

Once your healthy leg is marked, your healthy leg is washed and “prepped” further entrenching this as the “correct side.” Then your entire body is covered by surgical drapes and other items that reduce you to an unidentifiable pile of cloth with a small window of skin.

The surgeon arrives and prepares to begin cutting when the final RFID chip scan is performed. No RFID chip can be found in the leg about to be amputated. The surgery team immediately removes all the surgical drapes and scans your diseased leg. The RFID chip is found and the correct leg is washed, prepped, draped and amputated.

Tragedy averted!

To Err is Human – RFID may be Divine

Relationship Leadership

Jim Cathcart developed and characterized “Relationship Selling” as a system to describe and teach the paramount importance of the interpersonal relationship in business and the conduct of business around the world. Mr. Cathcart has transformed the business world by instilling the values of simple human kindness and contact back into the conduct of the business day. Too bad Mr. Cathcart doesn’t teach disaster preparedness.

When I look at my market today, I am as amazed as Jim Cathcart was decades ago when he looked at his market and I draw the same conclusion, what is needed are relationships. I know that those in healthcare value relationships with customers, but what relationships are developed with vendors, employees, nurses, doctors and competitors. Are these relationships nurtured in the good times?

Everyone in Disaster Planning, Preparation, Education, Response and Recovery should be true disciples of Jim Cathcart and Relationship Selling. The lessons taught in that simple system will build the type of healthcare system resilience that American desperately needs.

But there is more to nurture than just business relationships; as healthcare prepares in an “All Hazards” manner, Relationship Leadership is needed.

What is Relationship Leadership?

Relationship Leadership is the use of interpersonal skills beginning long before a disaster looms to create an environment of mutual trust and respect to influence others to work towards common organizational goals. This means permanently abandoning healthcare’s current dependence on the power and control (demand and threat) method of leadership.

Nurses would be the first to benefit from this process change. Rather than threatening nurses with loss of licensure or disciplinary sanction if they must leave at the end of a shift in a disaster, imbue undying loyalty by showing undying loyalty in the “good times.”

Nurses would not be the only ones to benefit however. After Hurricane Francis, Cape Canaveral hospital needed a new roof. Many of their employees also needed new roofs after 2 hurricanes. When the hospital hired a roofing contractor, the hospital included “front of the line” roof replacement for all hospital employees who needed it. 95% of the hospital employees lived within 1 mile of the coast so the hospital went a step further. The hospital added that the “front of the line” status for hospital employees would be perpetual.

The roofing contractor was thrilled by the long term hospital contract and the “guaranteed work” that the “front of the line” clause represented. The hospital employees loved it because it showed that the hospital genuinely cared about the employee’s safety and the safety of their families. Interestingly, the hospital saw a surge in new employee applications and a drop in attrition. The cost to the hospital was nothing more than the effort to demonstrate Relationship Leadership.

Relationship Leadership requires that those in positions of “power” surrender power to the relationship and leave their ego permanently at home. Relationship Leadership is a unifying process between two equals who care for and about each other and the organization. Relationship Leadership is based on mutual respect, freedom and trust and seeks the happiness and wellbeing of each other and the organization as a common goal.

Relationship Leadership is a great challenge, but for those who implement it, the benefits are limitless.