If you want to be up on the latest in management trends and buzz, the place to be is at MIX, Gary Hamel’s latest website – a derivation from MLab I think. For those not aware of who Gary Hamel is, think modern day Drucker.

MIX stands for Management Innovation eXchange, and the website is pretty quickly building up a lot of good management content.

The premise of the site is that management in its current form is getting stale, if not already outright rotten. Taking on the 25 Moonshots for Management, MIX aims to leverage its users to collaborate openly on how to reinvent management.

I love the idea of reinventing management. However I sometimes wonder if part of the problem with management is that us management nerds think that every leader in a business needs to be a good manager. What I mean is – when I work with my clients, often they are experts at their craft and captains in their industry, but I show up and immediately try to transform them into good business managers.

I could certainly argue both sides of this concept, but MIX could argue it better! Check it out…

Thanks,

Rick Maher

Booz & Co (top tier global strategy consultancy) runs one of my favorite websites, Strategy + Business, where they share their latest thinking and tons of great business and industry analysis.

Recently they published an article entitled Putting Strategy into Practice which is good in and of itself, but it has an amazing bonus! Click the link just below the byline of the title to download Harvard Business Review’s “Must Reads on Strategy” anthology as pdf.

If I’m not mistaken, this anthology would normally cost a decent chunk of change, and until June 15, 2010 Booz is picking up the tab!

While I’m at it, here are a few more plentiful business management websites:

• McKinsey Quarterly – by McKinsey & Company
• Knowledge @ Wharton – publishings from Wharton School at University of Pennsylvania
• Focus – Ideo’s “thinkings” – if you don’t know who Ideo is, I suggest you learn – NOW.
• Manager Tools – by the firm of the same name which has mastered executive coaching with a twist – it’s unbelievably practical. I HIGHLY recommend downloading and listening to their entire Manager Tools Basics podcast series.

What else is out there?

A friend and I were talking about an experience he deals with in his business. Basically he finds that his customers fall into three categories:

1. Happy Customers
2. Unhappy Customers Effective at Rectifying their Unhappiness
3. Unhappy Customers Ineffective at Rectifying their Unhappiness

We were analyzing how customers control their own destiny in achieving their category, but that the behaviors that lead to achievement of the categories are not behaviors that are taught in any classroom either of us had ever been in.

Some call these behaviors “people skills,” others call it “savvy,” but I call it “social engineering.”

It’s the behaviors that a person uses to interact with other people in order to get what they want.

I witnessed a situation at the airport this past weekend that I think demonstrates the key principles:

My flight was delayed and after boarding and sitting on the plane for an hour, all the passengers were forced to get back off the plane and arrange a new schedule with the airline representative.

The first few passengers worked quickly, and methodically through their options with the representative. Then the next passenger took a different approach.

When he was told his flight options, he began screaming at the representative that her airline was causing him a terrible inconvenience, not to mention lost money, etc.

As you can imagine, he had a very difficult time arranging for a new flight schedule.

I am asserting that his difficulty in arranging a new flight schedule was not primarily due to his particular needs being greater or more difficult than the other passengers, but rather due to his inability to engineer the social interaction between himself and the airline representative.

What I learned from the effective social engineers (first few passengers in line):

• Asking pointed questions politely allows the representative a guilt-free opportunity to add on options that she previously failed to identify
• Offering empathy toward the representative’s stressful task of having to reschedule an entire plane full of passengers without any help was quickly reciprocated in the representative being empathetic to the inconvenienced passengers social engineers
• Openly disclosing to the representative that the social engineers were also leveraging the assistance of their travel agent via phone put the representative slightly at ease, and simultaneously sparked a sense of urgency for the representative – almost as if the rep wanted to beat the travel agent to the solution in a little race!

What I learned from the ineffective social engineer (the screaming passenger):

• Speaking loudly and rudely to the representative drew attention from all sorts of people in the area, and caused the representative to become openly / loudly defensive, distracting her from the ultimate task of finding the best alternative flight schedule
• Hiding efforts to identify a solution with a travel agent from the representative led to confusion by the representative and hesitation to pull the trigger on booking the best alternative flight selection
• Making big body movements such as dramatic paces to and from the representatives station tempted the representative into moving on to service the next passenger in line who looked to be less intimidating and therefore more appealing as someone to serve, again slowing and hampering progress of finding the best possible flight schedule.

These lessons learned I think really boil down to a few key principles that you need to know and understand in order to be effective as a social engineer.

1. Recognize what is flexible and what is rigid – in this example, flights around the world are not going to reschedule themselves to accommodate one passenger.
2. People like being a part of a solution, but hate being a part of a problem – the representative wants to be the one that saves the day by finding a flight schedule that you are happy with, but hates to be the one drawing attention at the center of an angry screaming person
3. People operate within their normal constraints unless shown how not to – the representative assumed that everyone’s final destination was that of the final destination in her airline’s reservation, but when a customer said “I can fly to XYZ instead of ABC if there are good options,” the representative was able to open up a whole new set of potential solutions

Social engineering can do a lot more than minimize your travel delays in case of a flustered airline representative. Here are a few other recent instances of how I think being an effective social engineer has helped me:

• Politely thanking an administrative assistant by name evoked her to offer “next time you need xyz, just let me know I have access to the calendar!” Had I not thanked her, she would most likely not have even verbalized a goodbye as I walked past.
• Surprising my fiance with a small bouquet of flowers seemed to buy me some lee-way in chowing down on sweets which she normally would harass me about.
• Asking “is everything ok?” of someone who forgot about a scheduled appointment (instead of getting angry at them over it) spurred them to fit me in quickly rather than just cancel the appointment.

Although, sometimes social engineering requires being stern, perhaps even loud and borderline rude:

• As a soccer referee, if a tactical foul was made early in the game I would purposely establish my presence and control by exclaiming loud enough for all the players to hear, “NOT TODAY!” in attempt to proactively prevent repeated offenses.
• On many consulting projects I rudely pointed out errors in peer’s work in order to embarrass my peer into fixing the errors prior to the client seeing them and discrediting our collective efforts.

Here’s the bottom line: consciously considering multiple behavior options in interpersonal communication can yield great results. Social engineering FTW!

I want to start a business. Usually that statement evokes one of two responses:

1. Why don’t you?
2. So do it!

I respond similarly for both:

• I have a ton of business ideas that I think are viable and could be lucrative, but I don’t love them, and can’t imagine dedicating myself to them at this point
• I don’t have or don’t want to risk the cash that would be necessary to start the business

Those that know me, know that I’m a big proponent of transparency, and in that nature I’m going to risk riches by posting a few of my Big Ideas for businesses here for the world (honestly I get about 10 visitors per day to the site…) to read.

I’ve mentioned before that I believe there to be an opportunity to revolutionize postal service by implementing a scan & email alternative in order to slash physical transport of mail therefore smashing down costs.

Another idea that I’ve been kicking around for a long time is that of revolutionizing wallets – specifically all the plastic within them. I mean ALL the plastic within them.

UPDATE: Cool! I just used PlanCruncher to create a simple business plan for One Card (pdf).

Here’s a list of all the plastic in my wallet right now:

• Driver’s License
• Old Student ID (for scamming student discounts out of various vendors)
• Debit Card
• Credit Card 1
• Credit Card 2 (I would imagine that many people have more than 2)
• Hotel Room Key
• Frequent Flier Card (I actually have about 15 of these things, but only one in my wallet at this moment – the rest are in my brief case)
• Grocery Store Discount Card (grocery store clerks finally cracked down and stopped letting me use one they had handy)

That makes 8 cards currently in my wallet. On each of them is a magnetic strip that contains some amount of information about me.

Other people have different / more cards:

• gift cards
• employee id & office security access cards

Here’s the crux of the business idea – sell a card that allows people to compress all of these cards into one card. When you open an account with a credit card / bank, get a room at a hotel, sign up for a frequent (flier / diner / shopper) account, join a club, etc. you would be able to add that information to your “one card”. Maybe via a magnetic strip reader that you hooked up to your computer via usb, maybe via a web interface that you could access with your iphone…

How to Make Big Bucks!

I think there are a few ways to generate revenue in this business.

1. Subscription Charges
2. Credit / Interest
3. Vendor Transaction Charges
4. Vendor Credit Account Manager
5. Arbitrage
6. Concierge
7. Analytics

Subscription charges

This seems to be the simplest and cleanest way to generate revenue. The idea being that you charge “one card” holders some amount per year. Basically this is emulating a credit card annual fee.

Credit / Interest

Again, emulating current credit card revenue channels, grant “one card” holders a line of credit and charge interest greater than the cost of capital on their balance.

Vendor Transaction Charges

Noticing a pattern? In the same manner as credit card companies, charge vendors a percent of every transaction.

Vendor Credit Account Manager

Here is a new revenue channel idea! Sell a service to small businesses whereby you allow them to use your account with each of the major credit card companies (visa / mc / amex / etc). Scale a large enough network of vendors and earn profit by offering these vendors transaction rates lower than they are able to get from the cc companies alone.

Arbitrage

This is my favorite – albeit possibly the most far-fetched idea. It mostly centers around gift cards and affinity points / miles. Let me illustrate the idea using a possible scenario:

Christmas Day – John gets a $50 Best Buy gift card and loads it into his “one card” account

December 26 – Sue charges a $100 Best Buy purchase to her “one card” account

December 26 – “one card inc” pays best buy with john’s $50 gift card and $50 cash transfer

December 26 – “one card inc” bills Sue for $100 cash

Eventually – Sue pays off her $100 balance, and “one card inc” accrues interest on the $50 that came off the top from John’s gift card

Eventually – John uses some / all of his Best Buy gift card credit and “one card inc” loses the ability to accrue interest on the cash paid by Sue

Possibly – John never uses some / all of his gift card, one card enjoys accruing interest forever!

Inevitably – Retailers (e.g. Best Buy) would revolt! You’d be stealing their game! This arbitrage is exactly what they do! This arbitrage model would be hitting them from both sides: gift cards would be redeemed much sooner, and in full. A friend well versed in the retail industry tells me that gift cards on average still have 30% of their value after one year.

Also – run a similar scheme with frequent flier miles!

Concierge

Back to the old credit card revenue stream model – offer “one card” holders a service to purchase anything through “one card”. Ideally “one card” adds value beyond what is available through other channels – faster service / delivery, access (e.g. tix to sold out events), cost (e.g. through scale – credit card companies are doing this now with services such as credit monitoring).

Analytics

Credit card companies are trying to do this now, but seem to really suck at it. The idea is that as a hub of consumer activity, you would know a LOT about consumer preferences and tendencies, and that this knowledge is valuable. The key would be making it saleable beyond the junk mail machines that are currently at work. For example, waive the card holders’ annual fee in exchange for them linking their facebook / foursquare / etc. accounts to their “one card” account thereby adding an additional layer beyond pure purchasing and demographic info. Or allow customers to pay off their balance through viewing (targeted) advertisements on their account webpage.

In Response to the Haters:

Here are a few of the arguments commonly puked out by haters when I tell them this idea:

• What if you lose the card? You’re screwed!
• Actually, if you lose your wallet with all 8 cards in it you’d be screwed. Do you have all 8 card issuer phone numbers on speed dial to cancel quickly? I bet if you only had to make one call you’d be happy.
• While you try to build a credit card transaction network large enough to make this profitable, one of the big players will smash you!
• Indeed this is one of my fears, but if you launch with a compelling enough value proposition, I think you could carve out a nice segment then put up targeted fights with the big guys… or maybe even sell out to a big guy and hit the links!
• Credit cards are a dead media! Haven’t you ever heard of “cube”????
• YES!!! One thing I would love more than going from 8 to 1 pieces of plastic in my wallet would be going from 8 to 0! If you created “one card inc” you would be exceptionally positioned to transition to “consolidated accounts and virtual payments inc” – I promise
• Retailers / airlines / etc. would never allow the arbitrage idea
• Maybe not verbatim in the manner that it was presented, but what if as “one card” you gave Best Buy $50 gift card plus $50 cash plus $x for the gift card acceptance enticement. So long as you were confident that you could earn greater than $x in the interest, it’d still be worth trying. Perhaps eventually “one card inc” could become a “gift card administrator” with strategic partnerships with retailers.



Executive Summary – Patient Flow Improvement Cuts Length of Stay (LOS)

As a management consultant, I worked with a client hospital emergency department to reduce Average Length of Stay by 10%. Specific improvements implemented include patient arrival time and volume modeling, aligned clinical team scheduling, standardized nurse / doctor communication practices, and innovative charge-nurse-esque patient outflow coordinator.

As a management consultant I completed a wide range business improvement projects with world class companies in tons of industries. I have profiled a few of my projects here on RickMaher.info, but out of respect for my clients confidentiality, I have excluded their names and have changed some material facts and figures.

Situation

My client, was a health system that operated three hospitals each of which with one sizable main facility and numerous satellite facilities. This client was focusing on a growing trend in hospital operations – patient flow – or the optimization of patient movement through the various stages of care in a hospital in order to optimize the quality of care in tandem with hospital bed utilization. Under this focus, projects were conducted at each location, and scoped to include significant projects within many discrete departments at each location. This profile will highlight the work that I did in the adult emergency department (aka emergency room) of an 800 bed (large), university medical school, teaching hospital.

The emergency department was faced with growing demand due to community population growth and aging, and was struggling to maintain their high service level standards. In short, patients were experiencing longer wait times, and reporting reduced satisfaction in the quality of care and attention they received. As the only level I trauma center within reasonable commute, the department was also facing pressure from the state department of health to ensure constant available capacity in case of a sudden surge in trauma patients.

A capacity expansion project was being planned, but would not be ready for ~3years due to the need for a significant construction project to expand the physical space.

Task

In a management consulting role, I was brought in to identify and implement process and management improvements to increase the capacity of the emergency department within its current physical space and set-up. Further, the client insisted that patient care not only must be maintained, but indeed must be improved along with the throughput improvements. Finally, while the client and the university medical school generally worked well together, the doctors were not employees of the client and therefore were identified as a gray area in terms of in/out of scope. The core group of project stakeholders included hospital management and clinical support staff (e.g. nurses, techs, transporters, etc.).

Action

As with all of my projects, my first step was to get to know the key people, and develop a feel for the culture. The culture itself however, was absolutely unlike any other. If you’ve ever thought the chaos shown in emergency rooms TV must be dramatized, you’d be wrong. The level of activity and movement was every bit as fast and varied as I’d seen on TV, and I saw things that I will never forget – ranging from funny to scary and sad to joyous. Fairly quickly though, I realized that the level of activity was not at all chaos, most of the time it was just fast and varied. This was a key learning in getting to understand the culture and identifying opportunities to improve patient care.

Patient In-flow Patterns

In the process of getting to know the people in the department, I heard them say over and over, “you never know what is going to come through the door.” And while I came to understand their sentiment, and agree that the clinical details and demographics of patient was extremely varied, I looked to the data to uncover the real truth. In fact, as with most businesses, customer trends (in this case patient trends) are quite predictable. I was able to identify that patient arrival volumes and times were fairly predictable based on the time of day, the day of the week, and the week of the year. Further, while the clinical specifics of the patients were not very predictable, the acuity (the health severity and the amount of care resources required) of patients, by definition, was fairly predictable.

This was the first half of the story – by understanding when patients typically arrived, I was able to develop an improved staffing schedule to ensure that there was appropriate resources to address patients and prevent a significant backlog. We implemented this quickly, but saw almost no improvement.

Patient Outflow – The Real Root Cause

It became very clear that the inflow was only half of the equation, and that the outflow of patients from the emergency department was the real root cause of the long wait times. A common performance metric of hospitals and emergency departments is Length of Stay (LOS) or Average Length of Stay (ALOS). This metric is calculated by figuring the amount of time between when a patient first arrives, to when the patient departs. On aggregate, if 100 patients come in to the ED in a day, the ED Average Length of Stay for that day is the sum of each of the 100 individual Lengths of Stay divided by 100.

While the Length of Stay includes time that the patient spends sitting in the lobby waiting for care, the bulk of most patients’ LOS is accrued “in care,” the time from when they are brought to a bed from the waiting area until when they are moved out of the emergency department. Patients generally are moved out of the emergency department through two unique channels:

1. Discharged – patient care is complete and the patient leaves the hospital
2. Admitted – patient requires admission to hospital for more care, further diagnoses, further observation, etc.

In fact the mix between these two outflow channels was about 50%/50%.  Recognizing that patients admitted to the hospital often faced delays due to a similar capacity constraint in appropriate hospital beds, I focused on identifying solutions that would expedite the progression of patients to be discharged. The first solution was create a standard procedure where the physician and nurse team assigned to each patient would discuss the likely outcome as early in care as possible: discharge or admit. By identifying patients in this manner, understanding that the disposition of the patient could change at any time, the team could track progress and eliminate idle time in any likely discharge patient’s process. For example, if a patient was identified as a likely discharge, and the doctor determined that the patient should be given a dose of medicine then observed for improvement, the administrative tasks related to that patient could be completed during the observation time such that as soon as the observation was complete, the patient could be quickly and safely discharged.

Care Team Communication – The Patient Flow Jackpot

This small change of forcing the doctor and nurse to talk directly to each other turned out to hit right on the real constraint in the process. While there was rarely a situation where the doctor and nurse were not communicating with each other, a surprising amount of the communication was indirect (e.g. notes in the patient chart) or left un-said, each side assuming the other was “on the same page.”

Next, communication delays were identified within the physician team. The physician teams, depending on time of day, were made up of 4-15 residents reporting in to 1-5 attendings. A phenomenon became apparent that residents were sometimes reactive or inactive in communicating up to the attending until the attending or a group of attendings called an update meeting. These update meetings would commonly go 3, 4, even 5 hours in between each, but within the 15 minute update meeting, there would be a batch of often 10+ patients that were suddenly cleared for admission or discharge.

To cut down on the physician batching I worked with the ED management to create an innovative nursing role. The position of charge nurse is common in hospitals and emergency departments, and in this busy ED, was fully occupied in managing the inflow of patients. Typically the charge nurse would work with the triage nurses to identify the patients waiting and their priority, then when a bed became available, the charge nurse would bring the patient to their bed, perform any minor immediate care tasks, and would assign a nurse to care for the patient and communicate the patient’s vital information to the nurse. We created a role that nearly mirrored the charge nurse, but was responsible for patient outflow. For example, if a care nurse was busy attending to patient A, but patient B appeared ready for discharge or admission, the outflow nurse, or Patient Flow Coordinator as we titled the role, would prod the physician to give next steps, or would assist the patient in preparing for discharge and exiting.  The Patient Flow Coordinator also became an advocate for resident – attending conversations. Using tactics from gentle hinting to blunt commanding, the PFC recognized the importance of keeping a patient’s care progressing, and if a patient’s care was complete, expediting that patient’s discharge so that patients in the waiting room could receive care.

The Patient Flow Coordinator also filled a missing role in being the collaborator of all patient cases in the emergency department that were to be admitted to the hospital. Previously when two or more patients were admitted from the ED at about the same time, the first admission into the system received the first available appropriate bed. However the PFC was able to identify opportunities to increase quality of care by designating which admitted patients would be best served at the moment a bed became available.

Finally, I coached the Nurse Managers to create a regular routine of getting out of the office and administrative activities that tended to tie them down, and to work with the PFC and Charge Nurse to remove barriers to safe patient flow. Usually this meant that the Nurse Manager would identify any patient who had been in the ED for >6hrs and to convene a quick briefing on the patient with that patient’s care nurse, the resident, and the attending. In this meeting the Nurse Manager would identify the root cause of the delay and work with the care team to create a specific action plan to ensure that the patient received the appropriate care… Generally a patient in the ED >6hrs would receive better care if they were admitted to the hospital.

This active management by the Nurse Managers also kept them close in tune with any delays caused by hospital support services. For example, if the imaging department was on a backlog, the Nurse Manager could communicate that to the entire ED allowing the care teams to make clinical decisions as necessary.

Results

The Emergency Department Safe Patient Flow Project was a success. Operational improvements were measured as follows:

• Adult ED Average Length of Stay decreased from 5:05 to 4:36
• Average Pre-Care Wait Time was cut from 40 minutes to 25 minutes
• Reduced Average Daily Elope Rate from 7% to 2%
• Improved % Patients with LOS >6:00 from 45% to 27%

By reducing the strain in ED, the ED was able to accommodate patients to be admitted for a longer LOS when the hospital was at maximum capacity and unable to take in further patients from the ED.

The creation of the empowered Patient Flow Coordinator broke down the culture of doctors dictating patient care progression.

Nurse Managers performing regular and targeted Active Management rounds, prevented isolated variances from becoming crippling roadblocks for the entire ED.

More Information & References Available

If you are interested in learning more about this project or the work that I have done, please call me by clicking below:

I can also be reached via email at rickmaher@gmail.com, and would be happy to share client references upon request.

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