PROTECT YOURSELF IN THE HOSPITAL

I recently read an excellent book by Tom Sharon, “Protect Yourself in the Hospital: Insider Tips for Avoiding Hospital Mistakes for Yourself or Someone You Love.” I’ve spent a lot of time in hospitals (doing my job as an IT expert and not as a patient!) and had heard about the number of unnecessary deaths that occurred in hospitals. The book’s back cover stated that hospitals are responsible for 100,000 accidental deaths and many more injuries each year. Medical News Today, a website for the medical community estimates the average to be closer to 195,000. Regardless of the number, there’s a good chance that you may have heard of or even personally know someone who has experienced a preventable tragedy. I know of several myself, including one who lost his mother to hospital error. One of my uncles suffered a severe stroke that left him a vegetable until he thankfully passed away.

Mr. Sharon is a registered nurse who started a second career as a legal consultant who advises attorneys on cases involving hospitals that have been accused of preventable deaths.

The book is a sobering view of hospitals. I now view hospitals more carefully since the book has peeled off the veil of ignorance that I used to share with the general public about hospitals. Most people don’t shop around for good hospitals and they should, says Mr. Sharon. For my part, I have worked in one hospital where I know I wouldn’t want to be rushed to in the event of an accident. The network office was located in the basement in a room that was obviously an after-thought. Best of all, it was adjacent to the morgue! We had to descend a rusted staircase and walk through a corridor that was lined with gurneys. A gurney is “a mobile bed with wheels designed for transport of patients in hospitals and ambulances.” If it came out of the morgue, it’s not transporting a live patient anymore.

The hospital has since been replaced by a more modern and larger one but who knows whether the personnel have also been replaced? I would rather be in a hospital that didn’t have the latest gadgets but had staff that cared than one with the newest technology but had a staff that was apathetic and impersonal. So my point about that hospital still stands. I wouldn’t want to be brought there.

I have reproduced three sections that might persuade you to read the book. The first section summarizes the things you should evaluate in a hospital. When you’re aware of these things you can evaluate the hospital intelligently. The second section does the same thing for a hospital floor. And the third section discusses the accreditation process. Accreditation is an important process by an industry that polices itself. The accrediting body is known as the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO for short. I thought JCAHO certification was ample proof of the hospital’s quality until I read Sharon’s account. That’s why I thought it should be reproduced.

SECTION-1: HOW TO FIND THE SAFEST HOSPITAL

For those of you who live in urban areas where there is more than one hospital to choose from, here is a list of what to look for when you engage in comparison “shopping.” This is especially important if you move into a new area. You need to choose your hospital at least as carefully as you choose your schools and place of worship. They are not all the same.

Dangerous Hospital

1. Cash-flow deficit
2. Poor labor relations
3. Equipment in corridors
4. Odor of human excrement coming from rooms
5. Care plan conferences exclude patient or family
6. Operating room closed at night with on-call staff
7. No formal nursing recruitment and retention program
8. Supervisors scramble desperately to find nurses
9. Some trauma seen as “unavoidable”
10. No expression of interest in patient satisfaction

Acceptable Hospital

1. Balanced budget
2. Good labor relations
3. All corridors clear
4. Free of foul odors
5. Care plan conferences include patient or family
6. Operating room staffed twenty-four hours/day
7. Nursing recruitment and retention program
8. Staffing prescheduled with adequate numbers
9. Zero tolerance for patient trauma
10. Patient satisfaction survey forms provided

Here's what the author said about labor relations (the second item above):

…this important factor can determine the quality of your care. Disgruntled employees are not the people I would want to rely on for safe health-care services. Moreover, hospital managers who deal with strikes by importing personnel to cross picket lines are wreaking havoc with life and limb. I have seen many help wanted ads for nurses from agencies who specialize in this endeavor. The large print says, “Nurses desperately needed for critical care, operating rooms and other areas, one hundred dollars per hour.” The small print states, “Labor dispute exists.” The hospital managers are not going to properly screen such nurses because this is not a normal hiring situation with multiple interviews and reference checks. Any nurse with a license and a warm body who is willing to cross a picket line and lacks professional ethics will be standing at your bedside. It does not take much for a physician or a nurse to inadvertently transform an intravenous medication to a lethal injection. If there is any history of a nurse’s strike in your institution, call the Nurses’ Association of your state and find out what the issues were and how the managers conducted themselves during the dispute. Again, if you cannot stay away from such a place, you should know the kind of people who are in command.

SECTION-2: HOW TO TELL WHEN A HOSPITAL FLOOR IS DANGEROUS

Dangerous Hospital Floor

1. There is one nurses' station for the entire floor. Some rooms are not within earshot.
2. Emergency equipment is missing or broken.
3. Emergency equipment is shared with another floor.
4. Some supplies are missing or stored elsewhere.
5. Skill level checks are not consistently checked.
6. Nurses are filing “unsafe staffing” reports with the supervisors.
7. Nurses refuse to answer questions.
8. Call lights flash unanswered for more than two minutes.
9. The attending physician rarely or never sees the patient.
10. Medical care is fragmented-there is no coordination.

Reasonably Safe Hospital Floor

1. All rooms are within earshot of a nurses’ station (circular design or substations).
2. Each floor has what it needs.
3. Emergency equipment is present and working.
4. All required supplies are on hand.
5. All nurses’ procedure skill levels are up to date.
6. Nurses are satisfied with staffing levels.
7. Nurses answer interview questions.
8. All call lights are answered immediately.
9. The attending physician visits with the patient daily.
10. The primary physician coordinates all medical care.

SECTION-3: THE HOSPITAL ACCREDITATION PROCESS

This description of the process came from the website of the Rhode Island Department of Health.

Hospital Information for the Public about JCAHO Accreditation

By choosing to participate in the accreditation process, an organization asks to be measured against national standards that reflect what health care professionals agree is most conducive to providing quality care in organized health care delivery settings. Achieving accreditation means that an organization substantially complies with JCAHO standards and continuously makes efforts to improve the care and services it provides.

During an accreditation survey, specially trained JCAHO surveyors evaluate the level of an organization’s compliance to JCAHO standards and identify the organization's strengths and weaknesses.

Accreditation surveys result in performance reports, or report cards, which can be utilized by consumers and health care organizations to ascertain the performance of a given health care organization. The report lists:

1. the accreditation status
2. the date of the survey
3. an evaluation of key areas reviewed during the accreditation survey
4. the results of any follow-up activity
5. areas needing improvement

The Performance Reports are available to the public. To facilitate access to these reports and comparison of hospitals with one another, the Division has created this web site. To further clarify any terms utilized on this site please visit the glossary of terms webpage.

Accreditation Duration

The time period (three-year) during which a health care organization, found to be in compliance with Joint Commission standards, is awarded accreditation. To maintain accreditation for a three-year or two-year period, satisfactory resolution of any identified issues is required.

Sounds impressive, doesn’t it?

In the last paragraph, note that the surveys are done on a triennial basis (every three years). Now, this is what the author, Mr. Sharon, said about it.

The Joint Commission Survey and What It Tells You

In most hospitals, when you enter the lobby you will see a large plaque on the wall stating that the facility was “accredited” or “accredited with commendation” by the Joint Commission on Accreditation of Healthcare Organizations. JCAHO is a not-for-profit organization whose members are hospitals, nursing homes, home-care agencies, and in-home surgical supply and medical equipment vendors. The surveyors thoroughly inspect all areas of the health-care facility for environmental safety, cleanliness, documentation, emergency procedures, patient care protocols, and credentialing of professional staff, just to name a few. They also work from a clearly delineated set of standards and rate the hospital as to its percentage of compliance with all the criteria. This system is one of self-regulation and based on the now known fact that accredited hospitals accidentally kill approximately 100,000 and injure about 300,000 people per year, it is an abject failure.

Notwithstanding the sophistication and meticulousness of these surveys, there is one major reason for the gargantuan letdown: in all cases JCAHO notifies the surveyed facilities about three months in advance of the inspection, which occurs once every three years. Therefore, any representation that a JCAHO accreditation assures quality of care is suspect. The accreditation only shows that the facility has been compliant with JCAHO standards for about thirty days before and during the survey once every three years.

Moving forward, the hospital scene during the three-month period prior to the inspection is a flurry of activity, with mock surveys, managers’ meetings, staff meetings, and scrambling to provide previously neglected in-service and to update personnel files and patient documentation. The level of management scrutiny and dedication to upholding the highest standards is at its peak during this period, and it is a time of high levels of stress and anxiety, long hours, and fear of job loss. The period that follows is one of celebration for the relief from the stress. Unfortunately, this is followed by the relaxation phase when everything slides back to the “normal” way of doing things, with the supervision becoming much less stringent. In many instances, the usual way of managing is blatantly substandard, with an illusion of propriety displayed for the surveyors during their stay. As soon as the survey is finished, the mirage evaporates.

For example, a hospital in New York City spent about $30 million building a high-tech emergency suite designated as a level I trauma center. The problem was that it was too small to serve the needs of the surrounding community. Consequently, the hospital management adopted a policy of placing two patients in each of the cubicles that were designed for only one. This was being done in violation of JCAHO standards and health department regulations. The CEO issued strict instructions prohibiting the diversion of patients to other facilities because diverting patients is equivalent to diverting revenue.

After a year of this state-of-the-art facility’s being continuously operated in the aforesaid substandard mode, JCAHO notified the hospital that the surveyors were coming in ninety days for the accreditation inspection. The management immediately instituted a hospital-wide program of mock surveys, in-service conferences, patient chart review, and examination of the professional credentialing files to bring everything up to standard. Not surprisingly, during the week that the surveyors were on the premises, the emergency department had only one patient per cubicle. This was accomplished by diverting ambulances to other hospitals during peak times and speeding up the process of admitting or discharging patients from the emergency room. In short, the hospital became generally more efficient during the survey with more staff people working overtime. The over-crowding and chaotic ambience [sic] resumed as soon as the inspectors were gone because the ambulances were no longer being diverted and the extra overtime was eliminated.

The contrast is striking, isn’t it? I strongly suggest you read the book.

PROJECT MANAGERS NEED BUSINESS ANALYSTS TO SUCCEED. WHY?

I was fortunate to have started as a Business Analyst before becoming a Project Manager. In many ways I think it’s an ideal career path to project management and, eventually, program or portfolio management. In this entry, I explain the reason for that.

Projects are everywhere. We work on them constantly even though we don’t realize it.

Typically, three types are found in anyone’s list of things-to-do. Tasks. Projects. And goals.

Tasks are straightforward activities. Clean the room. Replace the car battery. Walk the dog.

Projects consist of several tasks. Prepare the car for the long trip may consist of tasks like making an appointment with the mechanic, waiting for the mechanic to identify the parts that need to be replaced, tuned up, or repaired, and arranging an alternative means of transportation while the car is being prepared.

Goals are objectives, broadly speaking. Join the family reunion is a goal. Among its projects may be preparing the car for the long trip as well as scheduling time off from work. In this example goal, the explicit objective is to drive a safe and tuned car for the long trip. The idea is to reach the destination safely and minimize the possibility of developing car trouble during the trip.

It’s no different in business. A goal is established and projects emerge to accomplish the goal. Projects, therefore, are essential to the fulfillment of goals and, broadly speaking again, goals are established to either cut costs or increase revenue. All organizations have goals. Therefore, all organizations engage in projects. Projects, therefore, are everywhere. We work on them constantly even while we don't realize it.

ACCELERATION THROUGH TECHNOLOGY

Today, technology has sped up the pace of life. Consequently, competition is more intense. Imagine a company with a better-designed product. It must generate revenue from that product with a sense of urgency. Why? Because it’ll only be a matter of time before competitors introduce their own improved product. The very website that markets the product (technology) is also the window that alerts competitors. There are several ways for competitors to come up with an improved product. For example, it can engineer its own and do so with the same people who created the original. The competitor simply hires the company’s employees. Whether the competitor hires them directly or through a recruiter, technology in the form of email or the mobile phone enables it quickly and discreetly.

This holds true even for a company that possesses a strategic advantage—“strategic” in the sense that its advantage is major or more permanent. Take a company with a grocery store in a better location. Perhaps, it may even be the only grocery in a rural area. The combination of human intelligence augmented by technology—this time for example, in the form of targeted direct mail—can level the field.

MAKING BUSINESS PROCESSES MORE EFFECTIVE

Today, goals tend to revolve around making the organization more competitive. For example, if a hospital can forecast the peak times of its Emergency Department (more commonly known to the public as “ER,” for Emergency Room), then it can schedule its personnel more effectively. Why have four ER personnel during the Tuesday morning shift when it knows that more cases are more likely to arrive that evening? Is it possible to do this? After all, how can it predict the future? Sure, it can and with a high level of accuracy. The majority of hospitals have never applied the statistical principles of forecasting that airlines use. Even long-established methods of manufacturing (like quality control) can contribute to the forecasting.

More effective processes create cost savings, a better bottom line, and a competitive advantage. Most goals, therefore, revolve around improving these processes—re-engineering them to make them more efficient and, ultimately, more effective.

EFFICIENT & EFFECTIVE

What’s the difference between efficient and effective? The best definitions I’ve encountered are succinct: efficient means doing things right (the first time) but effective means doing the right things.

To continue, business processes are frequently a combination of workflows and IT processes. A workflow combines human action and practices. When a patient arrives at the ER, the patient’s information must be collected. Will the workflow consist of the admission clerk writing the information on a paper form or keying it into a computer?

Today, it’s mostly the latter. Data and information, therefore, are two critical components of business processes. Many projects, therefore, are IT-based.

DATA & INFORMATION

What’s the difference between data and information? This is the distinction I prefer: data becomes information when data is put in context. The numeral 2, for example, is data. However, if 1 is the code for male and 2 is the code for female, then the numeral 2, in that context, becomes information.

To continue, projects, especially ones that tinker with processes, must be carefully implemented. An important factor that improves the success rate of projects is careful preparation. In particular, the early phases of any project must be focused on understanding the requirements of the project. Requirements must be clarified in order to ensure that the objective of the project is satisfactorily met.

If the project created an accurate ER forecasting system but the project manager (and his sponsors) failed to ensure the availability of the right combination of medical staff, then the hospital may even be worse off than before. A similar situation may arise if the hospital did not adjust its resources to equip the ER with enough equipment to handle the forecast.

THE COLLABORATION OF THE PROJECT MANAGER AND BUSINESS ANALYST

Successfully implementing a project requires two persons. First is the Project Manager (PM). He focuses on leading the project to its successful completion. However, to ensure that the project’s objective delivers the intended benefit, another person is necessary. This is the Business Analyst (BA). The BA is concerned with managing the business requirements of the project. The business requirements refer to the business benefit of the objective (e.g., cost savings) and to the things necessary to achieve that objective. Poor business analysis leads to inadequate information that, in turn, generates incorrect requirements. Incorrect requirements lead to inaccurate estimates and any project that begins with an inaccurate baseline will likely fall short of its objective.

A project’s requirements span the range from understanding the business case to identifying the processes that will be affected to defining the exact outcome. The last may seem strange but it’s critical to know how the outcome will look like. Will the project objective be met when the forecasting system is in place? Or will it be considered met after the budget has been changed and approved?

Now, isn’t it obvious that a project’s requirements must be captured and fully understood before the project plan is finalized?

The BA has the responsibility of bridging the gap between the user community and the IT personnel. From the former, the BA uncovers their requirements. From the latter, the BA collaborates to design the solution.

In some ways, the BA is more essential to a project’s success than the IT experts. Technical skills can be outsourced but the BA and his skills need to be present in order to uncover the project’s requirements. With that in mind, doesn’t it appear that business analysis should not be treated as subordinate to technical expertise? Many IT experts do not possess the temperament or personality to gather, understand, and analyze business requirements from the user community. Fewer still are able to create realistic solutions that address these requirements since many solutions are a combination of technology and processes.

Many processes involve workflows and, as mentioned earlier, people are typically involved in workflows. Persuading people to change their habits is not an easy task. Changing work habits is especially difficult since workers naturally do not want to be blamed for undesirable results. So delicate and important is this that change, in today’s environment, has evolved into its own management discipline—called, appropriately enough, change management.

Many projects that fail share this condition. The project is initiated, planned, and implemented before the project team and project stakeholders understand the business requirements clearly. This is due, in large part, to our natural belief in technical wizardry and our impatience in old-fashioned techniques of surveys and brainstorming. Too often, the latter activities are rushed. Capable PMs that take over failing projects will realize the problem and force mid-course corrections. Unfortunately, even if the project eventually meets its objective, it will invariably have exceeded its original budget and schedule.

A BA makes valuable contributions in numerous ways. He has created sub-objectives from the primary objective based on a clear understanding of the business case for the project. He has gathered the requirements that the project must meet. He has analyzed these requirements with respect to risk, resources, and time. He has shared these with the PM and project team and assisted them with devise the solution.

This blogpost, I trust, should have made it clear why I think that Project Managers need Business Analysts to succeed.

Business Analysts have a professional organization of their own, like Project Managers. BAs have the International Institute of Business Analysis. PMs have the Project Management Institute.


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