Random Thoughts from a Restless Mind

In my day job I work in the ultimate customer service business, medicine. Ever listen to how people address folks on the providing side of the customer service continuum? Do you ever stop to listen to yourself, or think about how you will sound before you speak? Fascinating. In North America we are moving ever more swiftly to an economy that is majority a service economy; we don’t really make stuff so much anymore, we help people use stuff someone else made, or provide assistance based on a knowledge base or skill set. Listening to people on the receive side of the customer service equation is fascinating.

I’m prompted to this line of thought by three interactions at my day job, SkyVision. Three individuals not so much requesting a service but demanding it, doing so with a tone that implies not only a deep sense of entitlement but also a deeper lack of regard for the individual who will provide that service. Both in tone and content, the to-be-served make it clear to the service provider that he or she is there to serve only them. In fact, the server’s only reason to exist is to serve, as if the to-be-served were some kind of different, superior version of the species. It’s quite loathsome, actually.

I spend every waking moment of each working day on the “serve” side of the equation, whether I am at SkyVision plying my profession or CrossFit Bingo coaching. Having achieved some measure of expertise in both it’s very rare that I am on the receiving end of this type of behavior, but it does happen. More often is the case that it is someone lower on the org chart who gets this. The receptionist, phone operator, or check-out person who gets this “lower life-form” treatment, not the doctor or business owner.

Life can be hard for these front line people in a service business. There’s not only a “customer is always right” mentality on the other side of the interaction but also a sense that being a customer who will get what they want is as much a human right as Life or Liberty. That’s what it sounds like, anyway, if you are off to the side listening. No matter how frustrated one might become from a service situation gone wrong it’s important to remember that there is no continuum in the relationship when it comes to the inalienable rights, nor is there any evolutionary hierarchy across that desk or over that phone line. Being served if you are the customer is not a right at all, not even one up there with the pursuit of happiness. Server and served both have the right to life, liberty, etc.

In a funny little side note, the more effort I (and my partners and staff) make to be better at the whole customer service thing, the less tolerant I am when I am on the receiving end of poor customer service. Actually, I should be a bit more specific on this point: I am much less tolerant if I am being served by an organization that openly preens about its excellent customer care but won’t deliver. Heaven forbid if I detect a cynical lack of effort, either institutional or on a more personal level, when the expectations that I’ve been led to have are mis-met because of this. The harder we try and the better we get at providing an excellent customer experience at SkyVision the less likely I am to choke down indifferent service or a lack of effort when I’ve been lead to believe (and paid for) something extraordinary. The difference, though, is that I initially engage with the expectation that all I have to do is be polite and kind to those folks charged with taking care of me; my first shot across the bow is not to treat them like serfs.

Danny Meyer, the great NYC restauranteur, is probably closest to correct when he says “the customer is not right all of the time, but mostly right most of the time. A customer [only] has the right to be heard.” How you express yourself when you are on the “receive” side of the customer service experience is not only an important measurement of how you value the person across from you providing the service, but frankly is probably also a predictor for how likely you are to be successful in being heard. It’s instructive that none of the three SkyVision clients who made difficult (bordering on unreasonable) requests in an unpleasant manner were accommodated because doing so would have required an extraordinary effort which may not have been successful in any event. After being treated a some sort of sub-human primate, who would make such an effort?

Sorry, no pithy statement to wrap this up. In the end we all want what we want, and we all need to be heard. It helps to look at the person on the other end of the service divide as if you were looking in a mirror. Would you say that, like that, to the person in front of you then?

It’s funny how stressful situations remind one of the truisms of life. We are now Day 7 without power in the White house, our own “Little House on the Prairie” complete with fireplace and communal bed (shared by 3 dogs). The tiny generator we were able to score powers the fridge and the sump pump (we had 6 flooded basement episodes in 2011) but not the furnace. The temp just went UP to 52 in the house.

And yet, it’s OK. We have food and we can cook. We have wood and offers of more if we need it. Randy has become a wizard at building and stoking a fire. Me? Grunt work like foraging for wood and fuel, and starting an epically awful beard. The extent of my pique, such as it is, is refusing to wear a tie to work until the power is back on.

We’re OK largely because we have CHOSEN to be OK. It’s a bummer, and it’s a nuisance, but it’s the hand we’ve been dealt, one that is not nearly as bad as others in Sandy’s aftermath. Our attitude is in stark contrast with others on display. One neighbor, a city councilwoman no less, de-camped to a hotel after bitterly complaining about the noise of the generators, our “little engine that could” especially. “We just couldn’t take it anymore.” Really?

My staff and most of our patients handled stuff with an equally sanguine attitude, re-scheduling when necessary, coming in early or staying late, whatever. The few folks who copped a bad attitude stuck out so painfully it was comical. The gal who hung up on me when I told her I couldn’t examine her pinkeye without power (M’am, all I have is a flashlight and a toothpick). The patient coming for a surgical consult, appointment confirmed by automatic email Monday night by a computer that was as dark and dead as the rest of the office when she arrived on Tuesday, who screamed at us for 10 minutes on the phone on Wednesday. Really?

Our circumstances often arrive unchosen and uncontrollable, and most often we are left with no choice but to react to them as well as we possibly can. While the circumstances are beyond our control we certainly can control our attitude, our outlook. We are in control of how we will approach the task at hand. We are in control of how we will approach the person at hand.

Frankly, I don’t know if a positive attitude makes the tasks any easier, or makes it more palatable to get through something tough like this Sandy thing What I DO know is that it is always easier if I come across someone in similar straits, or someone I’ll need for help, if they are at least trying to “put a good face on.” I think this goes for everyday life, too, and making this your baseline choice (a good attitude) might make it easier to keep your chin up when the chips are down.

Attitude is a choice. Your attitude says more about you than it does about your circumstances.

Skyvision centers is a hybrid organization that brings together multiple, disparate skill sets in a medical environment. If you ask any of the staff or doctors who we are and what we do you will hear something along the lines of “we’re a customer service business; our product just happens to be eye care.” The founding principle for Skyvision was the creation of a truly patient-centered experience achieved by borrowing liberally from such customer service stalwarts as Nordstroms and the Canyon Ranch Spa organization. These practices were then layered on top of a flow process that was adopted from the Toyota manufacturing system in order to allow the doctors and staff to provide medical care that exceeded all industry standards for outcomes, safety and efficiency.

It became clear very early in the development of Skyvision that a traditional management structure would be counter-productive. Most small businesses, and essentially all medical businesses, are run using a steep pyramid set-up: doctor at the top, office manager next, and all kinds of middle management on top of the folks doing the real work of caring for patients. Command and control was exactly the wrong strategy for us. We adopted the ultimate flat organizational structure, the POND.

The Pond Theory of Management is best viewed from overhead. Unlike the pyramid of the traditional management flow chart, the Pond Structure is nearly invisible when you look from the side. Staff members “float” on the pond like overlapping lily pads. Tasks are determined initially by job description. Responsibility for seeing that larger projects are accomplished is determined by “mutual affirmation” in the overlapping individuals, and those who affirm a leader take on the responsibility of helping that task leader succeed.

With the appropriate systems in place and so much of what we think of as traditional staff management happening on something that looks like “cruise control”, what is the role of the “Boss” in a flat organization? Rising just above the lily pad-covered surface of the pond are the very few “flowers”, the leaders of the organization. If the “Tribe of Adults” is managing its own intra-staff personal relationships and taking responsibility for outcomes, what does the Boss do?

The common misperception of management in a flat organization (and in groups practicing TQM/CGI) is that there is no longer a leader or “Boss” role at all. This, of course, could not be further from the truth. The primary role of leadership in a flat organization is to make broad policy decisions and set major goals for the organization as a whole. The first of these is to choose to have a flat organizational structure! It is the few leaders who are charged with setting the general course of the business, from choosing the products or services to be offered, to determining the variables that will be measured to keep the organization on track.

Once the organization is up and going it’s important to identify the metrics necessary to maintain a tight focus on the goals that have been chosen. Monitoring these metrics and reacting to them is the responsibility of the “Boss”. From just above the Pond an effective leader is able to offer broad guidance without being involved in the minutiae of the day-to-day machinations of the business by reacting to these metrics. This also frees up the Boss’ time for critical planning, meeting with significant customers, and other larger picture tasks that will help the business grow and prosper.

It seems as if the flat organizational structure is designed to inoculate the Boss from any real staff management, doesn’t it? In reality, the only thing that the Boss might miss out on is any of the fun aspects of day-to-day interaction with employees. For better or for worse while the Boss may not do the hiring it is the Boss, and only the Boss, who must do the firing. At the end of the day, a business that chooses a flat organizational structure is not immune to any of the factors that make an individual employee an unsuitable member of the team. Remember, there are no managers, only a Boss, and no one else available to perform this (hopefully rare) task.

The role of the Boss in a Flat Organization is at once bigger and smaller than in a traditional hierarchical structure. Smaller in that the number of management tasks he is asked to perform is radically reduced. Bigger since the remaining tasks are more global and reach into every aspect of the business. Certain types of individuals are more geared to fulfilling this role (it helps to be a little more laid back and patient), and certain abilities are more helpful (delegation, data analysis, “blue-sky” planning). Indeed, the more of these characteristics one has in a leader, the fewer leaders you need!

The better the Boss, the flatter the organization.

We’ve had lots of new people around Skyvision Centers recently. Two sets of consultants have come through at our invitation, our hope being that they would help us improve our patient education process. While they certainly had lots of really good ideas, systems and protocols that have been tested and found to be quite helpful in typical eye care practices, we found that they didn’t really translate terribly well “off-the-shelf” at Skyvision.

Why? It turns out that we have a very different culture at Skyvision, and that the management structure we use to foster that culture is so foreign to traditional medical care that we had to eat up some of our consulting time teaching the consultants who we are and how we work. Oddly enough, the question that set this process off was one that probably seems to be ridiculously basic to these two groups of consultants, but one that turned out to be nearly impossible for us to answer. “Who is your office manager?” Um… well… Gee., we don’t really HAVE an office manager. “Well, who should we talk to , then?” The answer to this question turned out to be just as difficult for them to understand: “everybody.”

I should start, I guess, with a word about our culture. I described the Skyvision culture to a new employee yesterday as a group of adults behaving like adults and treating each other like… adults. I told her to think of us as a Tribe of Adults! This is all I really wanted from my staff five years ago when I founded Skyvision. My most enjoyable part of management has been “blue-sky thinking”, setting priorities, charting a course, and allowing my people to work to the absolute limits of their capacity and ability in order to bring us home. Employee relationship monitoring and management is beyond boring and only barely tolerable. Hence, a Tribe of Adults.

Unfortunately, the typical management structure in small businesses in general and medical businesses in particular is not really conducive to fostering this kind of culture. Pretty much every other medical practice that I’ve ever been involved with, either as a physician, a patient, or a consultant has been set up as a steep management pyramid. Very strict top–down management in a command and control environment. Lots and lots of rules and regulations with an equally dense layer of middle management whose prime objective appears to be applying discipline to everyone who falls below it on the pyramid. Individual initiative is totally suppressed, and even the task of managing your relationship with a coworker is given over to a manager. Yuck.

But a Tribe of Adults clearly needs to be managed in a totally different way. A group of people who are willing to take responsibility, not only for the outcomes of their work product but also for their own personal behavior and relationships within the organization is best managed with as flat a management structure as possible. The ultimate flat organizational chart would be one in which literally no management existed. This is impossible, of course, because at some point someone has to chart the course, lay out priorities, and designate goals. After that  a Tribe of Adults shouldn’t need much management!

Enter the “Pond Theory of Management.”  Unlike the top–down management of a pyramid, if you look at an organizational chart set up according to Pond Theory from the side, what you will see he is a very thin layer on the surface of the pond and a few tiny flowers sticking up a bit above the surface. The magic, though, is looking at this organizational chart from above. If you look down on the pond what you see are a number of lily pads which flow on the surface of the pond, one for each employee in the business. The flowers above the lily pads represent a small number of individuals responsible for big picture issues and those very few instances where the Tribe of Adults cannot work through an issue on its own.

How does this Pond Theory of Management really work? The key, critical difference between a business run based on Pond Theory and one that is run on traditional command-and-control principles is in the allocation of tasks. In command-and-control theory some manager assigns a worker to a task, and might even assign that worker responsibility to direct other fellow workers in the accomplishment of that task. In the Pond there are areas where lily pads overlap, tasks that could be performed and responsibilities that can be shared among two or several workers with similar skills or job descriptions. Where these lily pads overlap the responsibility and the accountability for completing this task or achieving this goal is determined by mutual affirmation of all the workers whose lily pads overlap.

The individual who now has accountability and responsibility for this task retains them as long as he or she is able to deliver the desired outcome; all of the other workers whose lily pads overlap accept this individual as their leader for this particular task. In a similar and related manner, those workers who have affirmed this individual give up any “right” to criticize how this outcome is achieved. There are certain rules and regulations that might apply, of course. In our medical world HIPPA and other government regulations are unavoidable. National, state, and local laws apply, too! Beyond this what we achieve in “The Pond” is outcomes with minimal managerial oversight,  interference, or necessity.

After two full days with us I’m still not sure the consultants really got what I was talking about, and if they did I’m pretty sure they didn’t really believe me. How about my new hire? She came from an extremely rigid practice with rules and regulations to account for pretty much every minute of her day, and a manager who monitored each one of those minutes to make sure that there was 100% compliance with all of those rules and regs. What was her reaction when I explained to her the culture of a Tribe of Adults working in an extremely flat organization, working on the Pond?

“Wow! We’re all BIG girls here!”

Uncle. I give up. Full surrender. Total capitulation. I cannot beat the takers.

It’s funny because my first three drafts of this missive started out “stop the madness”, but I can’t. It won’t stop. The “Do-Gooders” and “We Shoulders” who make the decisions because “they think” or “we feel” have beaten me. Beaten everyone like me. The white flag is up. Turns out the windmill is really a dragon, and contrary to what it says in all the fairy tales the dragon always wins.

You see I, Dr. Quixote as it turns out, thought that being right made a difference. I thought that data, precedent, FACTS would rule the day. Silly me. Silly, sorry sad little me. I thought it was about patients, patient outcomes, statistics, but all along it’s been about the system and protecting the system, protecting it from the very possibility of theoretic risk, protecting it from…patients.

Here I was looking at yet another cost being added to the experience of my surgical patients and asking why a change was being made. Why were we opening a new bottle of $13.00 eye drops for each laser patient, when each bottle held enough medicine for 100 patients? Why were we using a new vial of antibiotic to be injected into the infusion bottle of each case, when each vial held enough medicine for 5 cases? Why, indeed, when there had never…not once…been a reported case of acquired infection, ever, from using one bottle or one vial. Ever. When eye doctors in their offices use and have used, bottles of eyedrops until they can’t squeeze our a single extra molecule. Why?

I blanched at the waste. Plastic baggies of bottles full of drops carted to the trash. Vials of man’s best antibiotics less the microliters used for one surgery crowding the sharps buckets. It was unconscionable, an insult to Puritan and non-adherent alike. The amount of waste nothing short of vulgar.Did no one else see this? I mean, here we are in the supposed throes of a healthcare crisis born of excess and waste, and yet I, Dr. Quixote, flailed alone?

Data…surely data would prevail. Look at the cost, I cried. Never mind the insult to the Puritan ethic, simply look at the cost! You can’t bill the patient, though Lord knows you’ve “mistakenly” done so innumerable times. It’s a cost. It decreases “revenue in excess of expenses” (you’re a non-profit…I get it…we can’t call it profit). I even understand why you’ve spurned my entreaties about Pre-Admission Testing even though there was an article in the New England Journal of Medicine that said PAT is unnecessary. The NEJM is the only medical journal that God reads, and even SHE knew I wouldn’t win THAT one because you can get PAID for PAT. I get that one.

You’ve beaten me. Today I see it. You sent in the REAL decision maker, one of the people who make the decisions in this new age of medicine. I was still under the illusion that maybe I, a doctor, was a decision maker. That I, a doctor who looked at and liked real data, had a vote, some skin in the game. No, today you sent in The One From Pharmacy. I have seen the One With Power and now I know that I am beaten.

The One From Pharmacy has all the words. He has all the weapons. “It’s only fair that each patient receive the same freshly opened bottle/vial.” “What if we have an infection and we re-used a bottle? How could we ever face that patient?” “Here’s an article by a pharmacist that says you could possible have contamination of an open bottle.” “Should we ignore this article that discusses the theoretic possibility of infection?” I also know from prior conversations with The Hospital Administrator that The One From Pharmacy cannot abide not knowing the destination of each drop, cannot abide not having the option of charging each individual patient (if only he could) for each medicine, and that a new bottle must be opened and assigned to each patient for this purpose. This I know.

Oh, I tried. I really did. I tried to point out that each of the articles the The One From Pharmacy shared with me were nothing more than opinion pieces, essays that were little more than editorials sharing one author’s thoughts. His or her feelings. “I think,” therefore it must be. But…but…but…there’s no DATA. No evidence. Nothing to refute decades of experience in the operating room. No results or reviews showing that the status quo is dangerous, only some somebody who managed to get what “they think” into some non-peer reviewed journal.

“Doctor, are you saying that we should just IGNORE these articles? You would have us simply continue with business as usual? The governing bodies ALL say this COULD happen. Are you saying that we should ignore what they THINK?” I confess, I had no answer. I was paralyzed, caught between my horror at the thought that decades of success, as well as common sense so obvious it made stomach hurt, were to be tossed aside because of some someone’s feelings, and my fascination at the sheer revulsion registering on the face of The One From Pharmacy. Funny, he wasn’t anything at all like what I thought the dragon would look like.

I stood there for a moment, bleeding, as the realization slowly came to me that I was defeated. Vanquished. It’s a shame, really, because doctors of my generation are the last, best hope for all of us. We bridge the divide between the ancients who lived through the Golden Age of Medicine–the Giants who cured polio, discovered antibiotics, replaced joints–and the moderns, the nextgen who will live through the silicon age of medicine–Dwarfs who will serve a system, cure the economics, replace care.

I felt small, diminished, inconsequential, a failure, a disappointment. It was hard, frankly, to haul my carcass to the operating room to begin my work day. Yet that’s exactly what I did. I mounted my steed and raised my lance; slowly, ever so slowly, we rode alone to the operating theater.

A white flag, attached to my lance, waving in the breeze.

It’s become quite fashionable to call oneself “patient-centered”. It’s rather trendy, in fact. Large, quite famous medical institutions now trumpet their new “patient-centered” care initiatives. The hiring of a “patient experience officer” is front page news in Cleveland. The airwaves are choked with advertisements from doctors and hospitals alike, beaming with pride and anxious for you to know that now it’s “all about you, the patient.”

What it really turns out to be is LIPSTICK ON A PIG.

It’s the same hospital with the same staff and the same processes. The same doctors are in the same offices and get paid the same way. A new paint job and new curtains cannot hide the fact that you wait just as long sitting in the same, old chairs in the same old waiting room. No amount of  advertising or re-branding is going to magically change a 1990 Mercury Sable into a brand-new Mercedes 500SL, and if you close your eyes  you still know which one is taking you for a ride.

Since when is “it’s all about the patient” news? Isn’t that the way it’s supposed to be? Do the doctor and the nurse have a job because a patient needs their care, or is the patient there so that the doctor and the nurse can have jobs? How many times have you wondered if that big, beautiful new $100 Million hospital wing is being built to handle all of the patients who must be turned away, or if the hospital will now embark on a campaign to find patients to fill that new, superfluous edifice? Or worse yet, if the $100 Million addition is simply a way to launder all of the “revenue in excess of expenses” generated by the “non-profit” hospital?

Medicine is the ultimate consumer service business. Even more so than any other service business because the people who bring you medical care have been entrusted by a patient to do some version of the next right thing for that patient; they have been trusted to put the care of the patient before their own care and feeding. We do a wonderful job of curing disease in the United States, but we don’t do such a great job of caring for patients, lost as we are in our zeal to care for diseases. Patient-Centered Medicine means looking at the curing of diseases from the patient’s viewpoint rather than the doctors’ or the nurses’ or the hospitals’.

Patient-Centered Medicine is all about the patient’s EXPERIENCE.

Enter Skyvision Centers, a unique take on eyecare built from scratch centered around the patient experience from the ground up. Two eye doctors, an ophthalmologist and an optometrist, left a very successful practice (where very high quality eye disease care is still being offered) to start something new. Something radical. Something truly focused on the patient experience from the very beginning. We had nothing but our names and our reputations. No patient lists. No accounts receivable. Heck, in the beginning we didn’t even have an address! All we had was a blank piece of paper with “Skyvision Centers” written on it, and a picture of a patient in the middle. We built our business around that patient and her experience.

Benchmarks? Sure! We went out and benchmarked Nordstrom’s and the Canyon Ranch Spa and the Ritz Carlton to learn about the best practices in customer service. We studied the mechanics of the Toyota manufacturing methods to learn about flow processes, accuracy, and safety. We built an office that allowed us to maximize our efficiency in a setting that looks and feels more like a boutique hotel or retail setting, with lobbies rather than waiting rooms.

Every staff member went on a customer service “field trip” where we ate lunch at a Holiday Inn and dinner at a Ritz Carlton. We witnessed three of our staff members experience a makeover at the Almay counter at Dillards, and then watched three other staff members ENJOY a makeover at the Bobbi Brown boutique at Nordstrom’s. We checked into a room at the Holiday Inn to have a standard hotel experience, and then checked in and spent a night at the Ritz Carlton. All of us. The non-doctor staff and their spouses stayed on the concierge floor, the docs in regular rooms.

And then we brought it all together and made it Skyvision! Our goal is for each patient who comes through the door to have an experience that is more like the Ritz Carlton than the Holiday Inn. More like Nordstrom’s than Dillard’s. We measure every step of the patient experience and constantly evaluate our customer service just like we evaluate and measure our medical outcomes. We agonize over each sub-par visit or less than stellar service evaluation.

Why? Well, why NOT? Where does it say that providing the best possible medical care with the best possible outcomes has to be coupled with less than the best possible experience? That the most important person in the process is anyone other than the patient? We’ve all seen the check-in process at a Holiday Inn and at a Ritz Carlton. They both work, but they sure feel different, don’t they? Why is it that the majority of check-in processes at medical offices and institutions feels more like a busy airline ticket counter during a storm than the front desk at Canyon Ranch? If the cosmetics cost the same at Dillard’s and Nordstrom’s (you know, like your co-pay for a visit), why is it that you feel so much better after shopping at Nordstrom’s?

We all took a financial bath in the first four years of Skyvision Centers. Hey, starting from scratch is hard! In the end, though, we created what is one of those very rare creatures, a true Patient-Centered Medical practice. It should make you wonder how much better your experience would be if all of those busy practices and all of those hospitals building their new wings took some of the money they are spending telling people that they are “patient-centered” and actually tried to put YOU in the center. We’re pretty much an open book. We’re happy to be the benchmark. Heck, we’ll even go along on their “customer service field trips”! This Patient-Centered Medicine is more fun to provide, too.

But until they do, until all of those folks advertising their all-new, all-you, “Patient-Centered Medicine” spend some time looking at the experience of receiving medical care from the viewpoint of the patient, all of us who are those patients had better pucker up.

The pig just got her make-over.