NO LEFT TURNS

THE RADICAL'S APPROACH TO PERFORMANCE IMPROVEMENT

This is a refresh of an article I wrote a few years ago in response to emerging pressure to accelerate performance improvement. I am revisiting it as part of a broader look at whether the good intentions to change and clamor for "finding new ways" went far enough. It reinforces my belief that we must reinvigorate our resolve to not just "refresh" but fundamentally "re-engineer" how and what we do to deliver radically different outcomes, experiences, and affordability in care.

Almost fifty years ago UPS learned that to perform better they needed to avoid turning left.  Literally.   As in their trucks being routed in ways that reduced the number of times they had to turn left across oncoming traffic to save the lost time and fuel costs associated with idling at the light while waiting for oncoming traffic to clear.

Back then the UPS effort was a manual routing exercise done on paper.  Today it is a science driven by dispatch algorithms that result in UPS drivers turning right about 90 percent of the time. 

At scale, UPS’ avoidance of left-hand turns translates into an annual savings of almost 10 million gallons of fuel.  As important are the reduction in injuries and deaths that are result at higher rates from left hand turns.   A study from the US National Highway Traffic Safety Association (NHTSA) shows that turning left is a leading "critical pre-crash events", occurring in 22.2 percent of crashes as opposed to 1.2 percent for right turns!1

What’s the lesson here for health system performance improvement? 

For one – it is critical to map the patient journey across episodes of care and to drill down on performance scores (errors, omissions and breakdowns in service) at every point in the process.  This approach allowed UPS and NHTSA to pinpoint root causes rather than simply measure aggregate performance outcomes.

Second, when solving for root cause problems it is important to consider not only what you can do different or better, but what more critically you should stop doing entirely!  Obviously, it is not possible for UPS drivers to entirely avoid left hand turns.  To do so would send trucks in circles or at least off on radically distorted routes.  But health systems can optimize their performance on critical outcomes and experience scores by minimizing exposure to root cause events.

Let’s look at an example.

Recently, a health system identified excessive noise in the inpatient setting and waiting times in the primary care physician office as major drivers of patient dissatisfaction.   Initial efforts to resolve the service performance gaps focused on obvious variables:

Reduce Noise in the Inpatient Setting

1.      Post signs reminding staff, patients and visitors to consider their voice level.

2.      Purchase quieter equipment such door hardware and fix faulty equipment (squeaky carts)

3.      Reduce noise from electronic devices such as telephones, television and overhead paging

4.      Restock supplies during the evening rather than at night when people are sleeping

5.      Analyze the use of medical device alarms and consider visual alarms where possible

Reduce Waiting Times in the Physician Office

1.      Create greater flexibility in scheduling to allow more time to “catch-up” with demand

2.      Deploy advanced practice providers to extend physicians and improve throughput

3.      Pre-register patients and allow them to complete forms prior to arriving at the office

4.      Move people out of exam rooms post-visit for purposes of discussing follow-up care  

5.      Create more care sites to decompress overcrowded clinics, especially during peak hours

All of these are viable strategies that health systems have used to achieve the goals of quieter, more restful inpatient settings and faster service in the physician office.  But do they go far enough.  What if you could wholly eliminate the root causes of the problem by making radical changes?

Consider Zappos, the online shoe retailer with the extraordinary culture, obsessive customer loyalty and explosive rates of business growth.  Zappos succeeds because it is willing to go to extremes for its customers.  For example – Zappos is committed to a call center that delivers round-the-clock unscripted service that goes beyond almost anything else offered by online retailers.  To operationalize a call center at that high level of service requires a large number of high-caliber employees.  To get that level of access to the right people, Zappos moved its entire company -- not just the call center -- from San Francisco to Las Vegas in 2004.   The move allowed the company to build a culture that employees crave.

Is your health system so radically committed to improved performance that you would go to the lengths that UPS and Zappos have done?  Would you stop making left hand turns or move the whole company if doing so eliminated a root cause vulnerability to your service delivery?

Consider the two examples given above – creating quiet and restful care settings and reducing waits in the physician office.  What if the best way to eliminate hospital noise that disrupts patient sleep was to remove the patient from the hospital?  Would you consider “in-home inpatient care” that keeps lower acuity patients in known and quieter care settings staffed by overnight nurses and equipped with remote monitoring equipment? 

What about waits in the primary care office?  Would you deploy virtual primary care Apps to allow for the diagnosis and treatment of patients on-demand, without requiring a visit to the clinic and likely “time-out” in the waiting room?

There are competitors in your markets thinking about solving for customer problems at this level.  As technology improves and patient expectations for customer service continue to rise, these strategies will increasingly reflect the standards not the extremes of experience innovation. 

How far will you go?  And what are the risks of not going at a radical pace?

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1 Why UPS Trucks (almost) Never Turn Left, by Jacopo Prisco, CNN; February 16, 2017