Maurice A. Ramirez, DO, CNS, CMRO

What Would They Say Today?

Eighteen months after the terrorist attacks of 9/11, America’s healthcare leadership announced that while they had not been ready on September 11, 2001, now they were. On March 13, 2003, in a much ballyhooed statement, still sited to this day, the American College of Healthcare Executives announced:

“HOSPITAL CEOs SAY BIOTERRORISM PLANS ARE IN PLACE CHICAGO

Since September 11, 2001, hospitals have faced new challenges protecting and caring for their communities, especially the threat of bioterrorism. According to a new survey conducted by the American College of Healthcare Executives (ACHE), 84 percent of hospital CEOs agree that since 9/11, their hospitals have worked more closely with public agencies (e.g. fire, police, and public health departments). Further, 95 percent of the respondents said their hospitals already have, or within six months will have, a bioterrorism disaster plan in place, developed in coordination with local emergency or health agencies.”

Little did they know the sense of false security and the cooling of momentum this assertion would cause from that day forward.

The Clear View of Reality

Since 2003, multiple independent evaluations of hospital preparedness and hospital disaster planning have found the reality in each successive year to be far below that purported in 2003. A brief survey three reports by the Institutes of Medicine in June, 2006 serve as proof that any hint of hospital preparedness is false and that momentum towards preparedness has been lost. These reports, Hospital-Based Emergency Care: At the Breaking Point, Emergency Care for Children: Growing Pains, and Emergency Medical Services at the Crossroads found a disparity between self reported preparedness on multiple association and government surveys compared to actual preparedness measured across the five core indicators of hospital preparedness.

“Evaluations of ED disaster preparedness consistently yield the same finding: EDs are better prepared than they used to be, but still fall short of where they should be”

At first blush, this seems to confirm the ACHE assertions, but the report goes on to point out that hospitals lack patient surge capacity due to cost related downsizing, nursing shortages, loss of specialists, physical space constrains and overcrowding. Failures of planning and coordination were also identified and linked to erroneous planning assumptions.

“When a disaster occurs, the normal operating assumptions about patients, responses, and treatments often must be jettisoned. Depending on the type of event, some of the nonroutine things that can happen include the following:

• Victims who are less injured and mobile will often self-transport to the nearest hospitals, quickly overwhelming those facilities.
• Casualties are likely to bypass on-site triage, first aid, and decontamination stations.
• EMS responders will often self-dispatch. Providers from other jurisdictions may appear at the scene and transport patients, sometimes without coordination or communication with local officials.
• In some cases, local facilities are not aware of the event until or just before patients start arriving. Hospitals may receive no advance notice of the extent of the event or the numbers and types of patients they can expect.
• There may be little or no communication among regional hospitals, incident commanders, public safety, and EMS responders to coordinate the response region wide.”

The Institute of Medicine reports goes on to call for improved communications and integration across disaster response services including Emergency Medical Services (EMS), community emergency operations and most importantly the implementation of the standardized Incident Command System.

“To respond effectively, hospitals must interface with incident command at multiple levels and be prepared to deal with transitions between levels, for example, when incident command shifts from the local to the state or federal level. Each hospital should be familiar with the local office of emergency preparedness and know how hospitals are represented at the emergency operations center during an event, whether through the hospital association, the health department, the EMS system, or some other mechanism.”

They Didn’t Think of That Either

Beyond the problems common to all disaster care environments, special needs populations (children, elderly, mentally and physically challenged) have needs and preparedness issues unique to them. Unfortunately, the “one size fits none” approach taken by America’s hospitals has ignored issues highlighted by the Institutes of Medicine Emergency Care for Children: Growing Pains report.

“The needs of children have traditionally been overlooked in disaster planning. Historically, the military was considered the only target of potential biological, chemical, and radiological attacks, so the focus for training, equipment, and facilities was on the care of healthy young adults.”

“Younger patients require specialized equipment and different approaches to treatment in the event of a disaster. Children cannot be properly decontaminated in adult decontamination units because they require adjustments to the water temperature and pressure (heated, high-volume, low-pressure water). Rescuers also need to have child-size clothing on-hand for use after the decontamination.”

The problems are compounded for rural hospitals. Despite the fact that many both inside and outside hospital leadership believe that rural hospitals are at lower risk and thus require less commitment to preparedness, the truth is quite the opposite.

“The focus of emergency preparedness has been on urban areas in part because of the perceived increased risk of terrorism in these areas. However, there is a danger associated with neglecting rural areas. Indeed, one might argue that rural areas may be even more vulnerable to a terrorist attack. Many nuclear power facilities, hydroelectric dams, uranium and plutonium storage facilities, and agricultural chemical facilities, as well as all U.S. Air Force missile launch facilities, are located in rural areas and are potential targets for attack. Additionally, if individuals with infectious diseases, such as smallpox, enter the country through Canadian or Mexican borders, rural providers may be the first to identify the threat.”

A Problem of Their Own Making

The greatest indictment of hospitals by the Institute of Medicine Reports however dealt with disaster preparedness training and drills finding great variability in the training of even key healthcare personnel with even less training for non-clinical hospital staff.

“Serious clinical and operational deficiencies, fragmentation, and lack of standardization exist across a broad spectrum of key professional personnel (nurses, physicians, ancillary care providers, administrators, and public health officials) in both individual training and coordination of a team response.”

This failure to provide training not only effects patient care, but hospital employee safety. Despite public statements by hospitals that “safety is worth the cost” and “preparedness is priceless” The American College of Emergency Physicians (ACEP) and the Agency for Healthcare Quality and Research (AHQR) separately found a very different financial and leadership commitment to preparedness and training.

“Many hospitals report inadequate funding to cover the attendance costs (e.g., time off, tuition, travel) of training (ACEP, 2001). At the University of Pittsburgh Medical Center, a disaster drill in the Emergency Department costs $3,000 per hour in staff salaries alone (AHRQ, 2004).”

“Additionally, the failure of hospital administrators or Emergency Department personnel to recognize the importance of training can result in a lack of support (ACEP, 2001).”

Multiple agencies, including the Institutes of Medicine have called for an increased coordinated financial commitment to preparedness on the part of individual hospitals, hospital corporations, hospital management / holding companies, as well as local, state and federal governments.

“This lack of coordination is reflected in the haphazard funding of preparedness initiatives. EMS and trauma systems have consistently been underfunded relative to their presence and role in the field.”

“States and communities should play an important role in determining how they will prepare for emergencies. To the extent that they are supported in this effort through federal preparedness grants, the critical role and vulnerabilities of hospitals must be more widely acknowledged, and the particular needs of hospitals and hospital personnel must be taken explicitly into account”

Despite this, funding for preparedness has decreased across the board including congressional cuts in healthcare preparedness funding for 2007, 2008 and again for 2009. These cuts have been mirrored in state funding initiatives; meanwhile hospitals continue to believe that they are prepared despite evidence to the contrary.

So What Should They Say Today?

Given these realities leaders in the field of healthcare and hospital management must now confront the fact that self reporting on preparedness is a failed method, no different than asking a 10 year old to grade their own final exam. With the curtain pulled back it is time for healthcare and hospitals to say:

“It is our corporate and personal responsibility to ensure the safety and preparedness of our entire staff, clinical and non-clinical as well as prepare to respond to the needs of the patients we serve every day and the patients we will serve when disaster strikes.”

The problem is that healthcare and hospital leaders have done everything in their power to quietly avoid the need to make this statement much less bring this statement into reality. In the two years since the Institutes of Medicine published their reports, hospitals have lobbied first to delay and forestall the deadlines for both Joint Commission preparedness guidelines and National Incident Management System (NIMS) compliance elements. The effect of this has been to make such things as facility beautification a higher financial priority than facility preparedness.

What is Needed?

While the Institutes of Medicine and many other organizations have made recommendations to improve hospital disaster preparedness, the sad fact is that the only way to force hospitals to properly and adequately prepare is to enforce the existing guidelines, mandate meaningful external certification of compliance and engage the public in demanding local hospitals “just do it.” There is an old adage in healthcare law:

“No change in healthcare has ever come without regulation, legislation or litigation.”

Enforcement of existing guidelines will require that the applicable government agencies including the Department of Homeland Security, FEMA, the Department of Justice, the Department of Health and Human Services and the Center for Medicare Services mandate full and complete NIMS compliance by the original September 30, 2008 deadline. Further, these agencies must be willing to use the full force of law to induce hospitals to invest in preparedness rather than pianos and fountains. Federal preparedness legislation carries with it implications of Medicare fraud, Sarbanes-Oxley violations and federal false claims issues. It is an unfortunate reality that government must all too often prosecute to create compliance.

The private sector has a responsibility to enforce preparedness guidelines as well. Joint Commission has repeatedly chosen to “partner with hospitals” rather than “punish” the recalcitrant faculties who repeatedly delay and curtail preparedness efforts. Joint Commission accreditation is a powerful force for change in hospital healthcare. The current tendency of hospitals to do as little as possible as slowly as possible necessitates that Joint Commission enforce the original preparedness compliance deadline in January of 2009 rather than permitting yet another extension.

Perhaps the best thing everyone in healthcare oversight and leadership can say to the American people is:

“We’re Sorry and We Will Do Better!

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?

Happy Thanksgiving 2007

Thanksgiving is a time for taking stock of the blessings we enjoy and the people with whom we share these blessings. It is also a time to give thanks.

Thanks for those we love.

Thanks for those we serve.

Thanks for those we protect.

Thanks for those who protect us.

Today, turn off the computer, log off the blogs, save the emails and enjoy time with those for whom you are giving thanks.

Happy Thanksgiving!

God Bless you all...

and God Bless the USA!

Know How to Stop, Drop, & Roll? Then It’s Time to Rinse, Lather, & Repeat

Over the past 2 decades, who has saved more lives in home fire?

You may be surprised to learn that more children have saved their parents than parents have save children.

Nearly two generations ago, the National Fire Safety Council created the Stop, Drop, and Roll program for kindergartners. The theory was simple: Since adult education on fire safety was failing miserably, with home fire related deaths increasing year after year, the council decided to introduce fire safety to children, hoping the children would influence their parents and take the fire safety knowledge with them throughout their life.

The plan worked. Today, the majority of adults in their thirties, and even many in their forties, know exactly what to do in the event of a fire: crawl below the smoke; touch the door not the doorknob before opening a door during a fire; and, of course, stop, drop, and roll should your clothes catch fire.

Now that deaths due to home fires have decreased, it’s time for everyone to face the next big problem: Zero Resiliency.

What is Zero Resiliency? It means that the majority of people today are dependent on the community or federal government to help them in the event of a natural disaster, even though every municipality, state, and the federal government tells people that they need to have an evacuation plan ready and they need to be able to survive for 72 hours on their own before outside help arrives. Billions of dollars have been spent in an attempt to educate people about disaster planning, but few are taking notice.

Think about it…If a natural disaster were to strike your location right now, this moment, are you prepared? Do you have your evacuation plan mapped out? Do you have a three-day supply of food and water available for each member of your family? Is your emergency backpack stocked and ready to go? For most people, the answer to each of these questions is “no.”

Unfortunately, having zero resiliency is a byproduct of our current economy. Many businesses have and promote a “just in time” mentality. Even marketers encourage consumers to adopt a “just in time” outlook. Few people these days buy a week’s worth of groceries anymore. Instead, they stop by the grocery store every night on their way home from work and purchase enough food for the evening meal and next morning’s breakfast. So we’ve gotten away from even having a week’s worth of food in the house. As such, few people can self-sustain in times of disaster.

Rinse, Lather, & Repeat: New Training for a New Era
Since educating adults about disaster planning is having as much success as the old fire safety messages that targeted adults, it’s time to shift our educational dollars to the youngest of Americans—the kindergarteners. That’s where Rinse, Lather, and Repeat comes in.

Rinse, Lather, and Repeat is a new program that seeks to duplicate the successes of the National Fire Safety Council’s Stop, Drop, and Roll program. Like its predecessor, Rinse, Lather, and Repeat is a one-week educational curriculum for kindergarten-age students that focuses on five core activities:

1. Preparation and maintenance of a three-day travel pack
2. Knowledge of where to obtain reliable news and evacuation instructions
3. The memorization of local and out-of-state phone numbers for friends, relatives, or family
4. The location of local shelters and local evacuation routes
5. The appropriate self-decontamination procedure whether at home in a household shower or at a hospital or other community facility

One of the core, hands-on activities children will engage in during the Rinse, Lather, and Repeat program is the preparation of a three-day travel pack. This kit, which the children will actually assemble, includes:

• Three days of clothing including underwear
• Thee days of energy bars or shelf-stable packaged food items chosen by the child
• Three days of water
• One week’s toiletries, including toothbrush, hairbrush, toothpaste, and toilet paper
• A two-week medication case (without medications)
• A USB flash drive containing medical records and a document inventory device
• One roll of quarters (for pay phones, which are self-powered)
• Photos of each family member
• List of each family member with age and contact telephone numbers (cell phone)
• List of two local and two out-of-state family members, friends, or relatives with addresses and phone numbers
• Backpack to place all items within.

In addition to assembling the backpack, children will review local information sources, including cable television, weather services, local access cable, local government cable and television sources, local information radio, and local print media. They will also memorize the four relatives with their associated phone numbers, as well as practice the use of the various information channels that they chose. 

Homework assignments that get the parents involved will include the location of the closest appropriate evacuation shelter for the family. In some communities this may be the family basement, while in other communities it may represent a Red Cross shelter or even a special-needs shelter established by local government or health department. Children will also learn on a map the appropriate evacuation route for their community.

Finally, children will learn the crux of the Rinse, Lather, and Repeat program, which is how to decontaminate themselves. Contamination can occur for a number of reasons, including raw sewerage if the levee breaks flooding their town, household chemicals like bleach or cleaning products may be splashed on them at home, there may be an industrial accident in their community, or even a biological or chemical weapon scare.

Unfortunately, health care workers still struggle with how to decontaminate a child. After all, we teach children never to get naked in public, so you can’t expect them to disrobe in front of people in bio-suits and walk naked through a decontamination unit. However, every child can be taught how to take a simple shower, which is really all decontamination is. They just have to learn to Rinse well, to Lather well (not just wander around in the bathtub as so many kids do), and then to Repeat the process one time.

Therefore, the steps to and logic behind Rinse, Lather, and Repeat are as follows:

1. Disrobe, thus removing 87% of all contaminants
2. Rinse their body thoroughly, rubbing all portions of their body with their hands to remove any contamination (now reducing contamination by 97 to 99 percent)
3. Lather well, utilizing soap, shampoo, or other decontamination supplies, to wash every inch of their body. This means total-body washing and scrubbing every aspect of their body well with their hands
4. Repeat the rinse, fully removing all soap or other decontamination materials

The Rinse, Lather, Repeat process can be taught utilizing comic books and/or coloring books with children in the classroom while fully dressed. In addition to providing the necessary skills to care for themselves in the event of a chemical accident, children will also learn to maintain good hygiene by learning a skill seldom taught by their parents: how to take an effective shower. This skill will also assist healthcare in the future by providing basic decontamination skills to children and ultimately to the adults that they will grow to become.

Rinse, Lather, and Repeat week will culminate with the children taking their new three-day travel packs home to be placed proudly in a closet or in the trunk of mommy or daddy’s car. Now the child is ready in the event that they must shelter in place or evacuate with the family.

Implement Rinse, Lather, and Repeat Today
Currently, no school in the United States implements the Rinse, Lather, and Repeat curriculum. And as we saw with Hurricane Katrina, that needs to change. People need to be prepared for a disaster, and Rinse, Lather, and Repeat is our best defense to drive the message home.

By implementing the Rinse, Lather, and Repeat program, within a 20-year period, we will return the United States to the same level of resilience we saw during World War II, during the Korean War, and during the early days of the Cold War, without the hysteria, and without burdening our schools. In fact, Rinse, Lather, and Repeat will solve the national problem of Zero Resiliency with almost no effort.

So the next time your child comes home with a Stop, Drop, and Roll assignment from school, ask the teacher when the next Rinse, Lather, and Repeat program will take place. After all, Rinse, Lather, and Repeat is our best opportunity to augment the level of national disaster preparedness by increasing self-reliance and the individual resilience of each American citizen.

The Unsung Heroes

On this second anniversary of Hurricane Katrina, we must not only think of those still in the recovery, those still displaced from New Orleans and Gulfport and homes and businesses all across the Gulf Coast of the United States.  Among those who were the first to provide aid and assistance to the survivors of Hurricane Katrina who were the unsung heroes of the National Disaster Medical System (NDMS).  Few in the United States have heard of the men and women of NDMS.  These healthcare professionals shied away from the public eye and publicity of any kind.  They strive to always observe the first lesson of the disaster field office: “Don’t get in front of the camera!”  Yet those who serve in the various divisions of the National Disaster Medical System are perhaps heroes in the truest sense of the world because it is these men and women who place their lives on hold often on as little as two hours notice and travel to communities not their own to help those in need, to help people whom they do not even know and will likely never see again.

The National Disaster Medical System has existed for over two decades, beginning as a single unit of field responders under the United States Public Health System.  Since its simple beginning NDMS has grown to include units dedicated to providing medical assistance to disaster survivors through Disaster Medical Assistance Teams (DMAT); domestic animals and pets through Veterinary Assistance Medical Teams (VMAT); and the respectful care of those not fortunate enough to survive a disaster through Disaster Mortuary Operational Response Teams (DMORT).

Why are NDMS teams and the people that serve on them unsung heroes?  It is because not only do they shy away from publicity, but they choose to serve rather than to self-promote.

NDMS members exist in a unique place in our federal government and our federal response to disaster.  Although they serve in uniform and operate within a command structure that closely mimics that found both in the fire service and in our esteemed military, NDMS personnel are not technically reservists.  NDMS began at the volunteer program functioning more like AmeriCorp, the Peace Corp or the American Red Cross than like a government agency.  Over time however, the need to provide these intrepid rescuers with the basic protections of workers’ compensation, liability insurance and malpractice insurance spurred the federal government to make them “intermittent part-time employees.”  At times of nationally declared disaster, NDMS personnel respond to deployment request within as little as two hours.  NDMS personnel maintain equipment that they have paid for in deployment ready condition at all times, often carrying that equipment in their automobiles and even on vacation with them.  Three months out of the year NDMS teams place themselves on call, notifying employers that in the event of a national disaster they may have to leave their workplace almost immediately. Yet unlike all other federal assets, in those times between disasters NDMS personnel receive a biweekly federal pay stub for zero dollars. They receive no benefits, no retirement, no reservist pay, none of the other benefits, discounts, or protections afforded those who serve in the United States Military, the National Guard, the Military Reserves, or as federal employees. 

While deployed NDMS personnel are protected from employer discrimination and retaliation for their service just as those in the National Guard or the Military Reserves are protected.  During times of deployment, they are full-time federal employee but they receive pay that is seldom more than 25 percent of their usual civilian wage.  For most NDMS members, each week of deployment takes 2-3 months of personal financial recovery.   Informal surveys of NDMS teams responding to the hurricanes of 2004 (Charley, Frances, Ivan, Jeanne) and 2005 (Katrina, Rita and Wilma) found that most team members were still financially recovering as of this writing in 2007. 

Because an employer is required to hold the job open but not for maintaining the employee on the work schedule, upon an NDMS team member’s return it is not unusual for that team member to spend one or even two weeks off the job waiting for the next work schedule to begin. This means that after returning from a two week deployment where they earned 25% of their usual wage, they go without pay at all until their employer can integrate them back into the schedule.  In 2004 and 2005 this meant that individuals deployed to all seven major hurricane, spent on average seven months away from work in only a 14 month period of time.  In that same time period, few made more than the equivalent of three weeks of their regular civilian pay. Despite the fact that in that 14 month period of time, every team in the nation was deployed repeatedly and most deployed for all seven events, the loss of team members across the nation was surprisingly low.

The heroes of the NDMS system are not the typical field responder that most citizens would envision.  These are ordinary doctors and nurses, respiratory therapists, supply personnel, paramedics, EMT’s, physicians’ assistants,    nurse practitioners, administrators and accounting personnel from the whole spectrum of the healthcare workforce.  They are most accustomed to working in nicely appointed offices for well-equipped hospitals.  In their civilian lives -- like most Americans, they sleep in a comfortable bed in an air-conditioned or heated home with pillows and blankets, an alarm clock and a hot shower.  However, in addition to the financial hardships that they gladly endure, they deploy into a field environment where one trip may they sleep on the floor in an airport or on the baggage conveyor belts and the next, they sleep in a tent in a sleeping bag or in the seats of vans and buses.  Although their treatment areas are air-conditioned for patient benefit, seldom if ever do they enjoy air-conditioning in their own billet or bivouac.  A once a week shower is a luxury and since resourcefulness and creativity are the hallmarks of NDMS personnel, it is not unusual to see them washing uniforms in a bucket, in the rain or even in an unmonitored dishwasher, in the first class lounge of the Louis Armstrong International Airport.

Despite the hardships and the lack of personal benefits beyond that satisfaction of having served their fellow American, an increasing number of healthcare professionals from all areas of healthcare, both clinical and nonclinical are seeking to join not just NDMS but the state equivalent medical response teams in all 50 states and US Protectorates.  Those not willing to leave their homes are joining Medical Reserve Corps Teams in order to afford themselves an opportunity to assist their own communities in the event of disaster.

But it is the members of the National Disaster Medical System, those first out the door, first in the field, first on scene, this first line of the nation’s medical and rescue response who are truly the unsung heroes and truly most deserving of our gratitude and praise on this second anniversary of Hurricane Katrina.

Healthcare Recovery for the Gulf Coast

A recent article in the USA Today stated that there was a 47% rise in deaths in the Gulf Coast states within the impact area of Hurricane Katrina as a result of the loss of healthcare professionals in those areas.  Healthcare professionals displaced by Hurricane Katrina, many laboring under the burden of student loan repayments and the daily financial needs of life assimilated themselves into their new home community as they landed in cities and towns across the United States.

Now that the cities of the Gulf Coast are rebuilding they are discovering that these healthcare professionals are not rushing home to the Gulf Coast.

Startup cost for a private medical practice vary between $100,000 and $200,000 for rent, business insurance, malpractice insurance, equipment, supplies, information systems, computers and simple office decorations.  Most of the healthcare providers in the Gulf Coast region lost well-established practices and if they were insured at all they used the funds from those insurance payments to begin again in their new communities.  Unfortunately, healthcare practices in 2007 have little resale value; particularly, when only one or two years old.  Even if these professionals were inclined to move back to the Gulf Coast region, they face significant financial hardship in accomplishing that feat.

Add to this the lack of meaningful business recovery and a decline in the number of insured patients in many of these regions.  The sad facts are that employment statistics and new business starts in the areas most affected by Hurricane Katrina are well below national averages.  Healthcare providers, now comfortable in their new homes, find little inducement to assume the responsibilities, liabilities and hardships of returning to their former practices and even when they do often find that their former patients have yet to return as well.

Physicians are not the only individuals affected in this fashion.  Hospitals that have already reopened in the Gulf Coast region are finding it more difficult to recruit nurses in a nation where there are already nursing shortages. Even when temporary staffing agencies provide nurses, known as travelers in the industry, to the Gulf Coast region to fulfill short-term contracts, most of these nurses decline the opportunity to extend their stay, take full-time positions, or return at a future date.

Much of the problem is that as healthcare has moved from the individual private doctor and the small community hospital to large corporate enterprise, it severed its relationships with its healthcare professionals seeing them more as expendable drones and less as a necessary and valued part of the healthcare delivery system.

Healthcare professionals regularly find themselves mandated to choose between maximizing patient flow and maximizing patient safety.  They are often forced to forego important family events under threat of suspension, retaliation or termination.  When the healthcare professional finds a home where they can achieve a level of work/life balance, it is difficult if not impossible to dislodge them again.  It took a hurricane to dislodge these professionals from the Gulf Coast and nothing short of another force of nature, perhaps this one favorable, will move them back.

How to Think Like Einstein

You’ve likely met some people who are the epitome of the classic absent-minded professor. You know the ones…They can’t remember facts or formulas, much less people’s names, and they need to continually reference information that others believe should be second nature. However, once these so-called absent-minded people look up the information they need, they have the uncanny ability to encapsulate very complex concepts into simple-to-understand formulas or words. They’re the conceptual thinkers—the people who create new knowledge, products, or innovations. They are the Einstein thinkers of the world.

When asked why he had trouble memorizing formulas and why he earned poor grades in school, Einstein replied, “I do not clutter my brain with facts I can look up in any standard reference within two minutes.” Instead of wasting energy with memorization, Einstein took those easily-accessed facts and created something new with them—he saw the connections among the facts and the patterns underneath the processes. As such, Einstein, who failed math, gave us the power to harness the atom and ultimately create nuclear power.

Today’s most innovative executives are a lot like Einstein. While they may have difficulty knowing precisely, step-by-step, what they do or replicating it on paper, when asked to just do it, they have tremendous success. They have the ability to find the patterns that underlie successful processes and can apply those patterns in new and different industries, thus achieving amazing results wherever they go.

5 Types of Leaders
Very few people are true Einstein thinkers. Rather, people tend to fall into one of four categories.

• The logical thinkers: These people learn from data. They must analyze data in order to move to the next decision. If they don’t have hard data, they can’t move forward. And without that data, they can’t communicate to others how to advance through the needed steps.
• The verbal thinkers: These people learn by hearing. They are more conceptual. They can process information they learn and can write it out. But while they understand the processes that others do, replicating that process in a different location is difficult for them. 
• The pictorial thinkers: These people learn by seeing. If you graphically show them how to do something, they can do it. But if they have to read instructions without pictures, even instructions that are very well written, they’re lost. They can build pretty molecule models, but they can’t do the calculations to tell you what the reaction will be.
• The kinesthetic thinkers: These people learn by doing. You can put them under the hood of a car, show them how to fix a car, and let them dig in and get greasy. Then you can line up a hundred cars and they can fix them all. But if you hand them a manual for fixing a car, and you never show them how to do it hands-on, you’d better find another mechanic to fix what they just broke. These people have to learn by doing, and they have trouble communicating what they learned.

Think of the previous four thinking styles as overlapping circles. In the center of the overlap point are the Einstein thinkers.

• The Einstein thinkers: These people have a little bit of all four thinking styles, yet not enough of one to make them extremely effective in any one realm. However, they have the ability to take a process, no matter how it’s presented—whether verbally, in writing, in pictures, or hands-on—and duplicate the process in different scenarios. Yes, they need to review the process or  calculation or formula each time, but once they review the initial process, they move forward and create new things. They read the roadmap and follow it.

Most executives are in one of the first four areas of learning and thought. Those who truly excel no matter where they lead or work are the Einstein thinkers. They have figured out the process of being a CEO or any other c-suite position, and they can apply the process in any environment.

The Process of Einstein Thinking
While thinking like Einstein is not innate for most people, you can learn how to analyze the process underneath everything you do, thus enabling you to venture into the realm of Einstein thinking. Think of it as a process for creating a roadmap, so to speak, and once you own that roadmap, you can apply it to other industries and replicate success. The following guidelines will help.

• Ask “Why?”
  Become fanatical about asking yourself “why” at every turn. This enables you to identify the main decision points in any process. Realize that there are actually very few things at a management level that are unique to an industry or company. Yes, there are facts and circumstances that are unique, but no matter what industry you’re in, you have to build relationships inside and outside; you have to comply with certain regulations; and you have to deal with a certain level of customer service. Therefore, identify how you function in each process and ask why you’re doing something, not what you’re doing.
• Know Your Decision Options
  When you come to a decision point, ask yourself three key questions:

1. Why do I make this decision at this point?
2. What influences my decision?
3. What are my choices?

Your choices are always the same at any decision point. You can either act or not act, or you can act in a series of choices. So it’s always a yes/no decision or a multiple choice decision. At this point, step away from the tendency to focus on what the question is, and instead focus on the reasoning behind the question.

Create a flow chart that details what you’re asking yourself at this point. Is it a yes/no question or is it a multiple choice question at this decision point? Then follow that up by asking, “Why do I make this decision?” If you know at a certain point that you are making a multiple choice decision, then you can reference what the choices are and what question led you to the choices. At another point in the business cycle you may be faced with a yes/no question. Follow up yes/no questions with, “What happens if I say yes? What happens if I say no? What are the questions I’m answering at this point?”

One of the basic concepts of physics is the unified field theory. The theory states that no matter what the special circumstances are, there are a set of equations or rules under which the entire universe functions. The same exists in business. There are certain things that are always absolutely true in business. When you know the truths and the processes that underlie the truths, then you are thinking like Einstein and can move from point to point in any circumstance.

• Get the Right People on Your Side
  Whether or not Einstein thinking comes naturally to you, you need to surround yourself with people who don’t think along the same process that you do. Very few people are truly like Einstein where they can write down their process so others can follow in their footsteps. However, the executives who surround themselves with those who can do the communication for them will have the upper hand. Therefore, get people on your team to interview you and get you talking about your goals and how you got from point A to point B to point C. Your team can then capture your process, encapsulate it, and put it on paper so you can read it and validate it. Doing so enables you and your company to more rapidly achieve goals.

Think Like Einstein Today
Training yourself to think like Einstein—to see the patterns and processes behind everything you do—will enable you to reach your full potential and bring new and innovative ideas to market. 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. So create your own roadmap of what you do and follow it in every situation. And if you can’t write your own roadmap, then at least learn how to read the map that others have already created. With some analysis and perseverance, you can be the next Einstein thinker.