richard[WINTERS]md

Fewer Steps

One of our scribes wore a pedometer.
She walked over 6 miles each shift.

Six miles of chasing the doctor.
Six miles of chasing the chart, the order, the nurse, the patient.

We focus on process improvement.
Reduce the number of steps.

It doesn't make sense to have the same physician take care of patients in beds 1 and 43.

You can't see bed 43 from bed 1.
There is a different nurse.
A different tech.
A different secretary.
It's a long walk. Many steps.

It's like having a barista work the same shift at 2 different Starbucks. Just across the street from each other.

"Did you hear that order for the half double decaffeinated half-caf, with a twist of lemon?"
Nope.

"Did you know they couldn't get a line or draw bloods on that patient in 43?"
Nope.

They tried to call you, but you were doing a procedure in 1. Then they did a procedure in 42. Now it's an hour later. Nothing's done.

You can't see through walls. You can't answer every phone call. You can't eyeball the treatment result of the patient in room 1 from room 43. You can't.

One of our physicians said, "I like the walk from 1 to 43. That's how I get my exercise." That's an exercise in futility.

We aim to have the nurse, the tech, the physician, the chart and the patient walk the fewest steps for each patient visit. We want each care team to control one space.

See more patients. In less time. With fewer steps.

How many Starbucks do your baristas cover in one shift?

Administration By Email

We're no longer a group of 8 sitting around a table hashing things out. We're a partnership of 19. It's hard getting the group together in one place to talk about department and partnership issues.

How do we keep everyone up to speed?
How do we make informed decisions?

We're using a lot of email. It's an excellent way to update and get things done. But it has its problems.

Writing in the past.
There's always one person who's three days behind in the discussion. They reply on a busy email thread and everyone thinks "Dude, that was 3 days ago! Keep up."

They skipped previous emails and jumped to the present. It's not that the points made by the late responders are superfluous. Their comments may be key. But the discussion starts over again. Again.

Tangents.
In the beginning it was an email discussion of consultant coverage. Then it it transitioned to personal anecdotes about specific consultants. Then a joke. Now, it's a discussion about investing in real estate.

Tangents can be easy to redirect in a meeting. They are difficult to control in an asynchronous email conversation.

Spam.
There's a fine line between spamming and informing.

My hospital email account is filled with "Adopt An Angel", "Boiler-Room Network Upgrade", and cafeteria menu emails. The H1N1 virus has transformed into an email virus. I get nascent and forwarded emails about H1N1 from the CDC, Public Health, EMS, ACEP, and Hospital Infection Control. Mixed into this institutional spam are hospital, medical staff and department policies needing review.

There is an art to deciding what to forward and what to withhold. Is this actionable information or is it spam?

Big or small.
Write one long email with lots of little points and risk not having it read. Separate a large email into multiple smaller emails and risk not having them read.

Time.
It takes time to write a well-thought email. It takes little time to write a reflexive email. If the goal is to develop and reflect upon ideas, email is a challenging medium.

Typing-challenged.
Some individuals don't like to type. Others are Luddites. While some ROFL and LOL. Others don't. Email discussions alienate some individuals.

Discoverable.
Will I be reading this email in a court of law? Will I be reading it in the local newspaper? A verbal discussion is transient. An email is forever. A forwardable forever.

Impasse.
A Harvard Business Review article cited that face-to-face negotiations more commonly result in mutually beneficial agreements, while phone negotiations result in asymmetric agreements where one party dominates. The most common result of email negotiation is impasse (>50% vs face-to-face 19%).

Positional Bargaining.
The authors of the same article found that individuals in email discussions tend to focus more on what they may be giving up, rather than what may be the best group solution. They may focus on positions, rather than interests. This "haggling", used car salesman type of bargaining is at odds with the "openness" and give-and-take of face-to-face communications.

 
The flexibility, speed, and availability of email cannot be denied. However, it is important to think about whether it is the appropriate medium for the message.

Is there a middle ground?

We could use a password-protected moderated blog to have more substantive and on-point discussions. Tangential messages could be moderated down or serve as new threads in other focused discussions. The blog would still alienate the Luddites, may be discoverable, and may sit unused.

So how about multiuser video conferencing?