Succession Planning

The term “succession” contains the word “success.” In that sense, succession planning may be explained as a strategy for the organization to succeed. To some degree, succession planning has been occurring in organizations for many years. People have been groomed to take over positions through mentoring and even job-shadowing processes, but most organizations have failed to put in place a formalized structure for recognizing this tradition.

Succession planning is a process for ensuring that the vitality of an organization continues by developing potential successors for the positions identified as critical to operations. (The overall process of succession planning is outlined in Figure 9.3.) With the fluidity of positions and people in organizations, however, it is important to understand that such planning must be reviewed and revised frequently. A critical step in the succession planning model is to forecast demand and skills gaps for key positions (Blouin et al. 2006). What is critical today is no indication of what will be critical in the future, as evidenced by the rapid changes in technology and other medical advances.

  The Succession Planning Process

In many organizations, the succession planning process is done only for the top executive position. That line of thinking comes with the philosophy that only “high potential” individuals will benefit from the leadership development that is offered to support the succession planning program (Pintar, Capuano, and Rosser 2007). This mind-set is dysfunctional. Imagine an organization facing a huge wave of employees who are near retirement. No one is in line to fill the positions that these future retirees will leave vacant, because the organization’s succession planning is designed exclusively for the top executives. That scenario will cripple the organization. Moreover, it is important to recognize the value of exposing every employee, not just the “high potentials,” to the training and workshops targeted to support the development of those who were identified as successors. It is good practice to keep a list of candidates who are eligible to fill a critical position that someone will vacate or already left either through retirement or other means of attrition. Doing so ensures workplace sustainability and signifies the presence of effective leadership. The candidate list may include the names of potential successors; information related to their professional preparation, including the number of years it would take for them to be position-ready; and the competencies necessary for the position. This list can be as simple or as sophisticated as the organization requires.

Succession planning is a vehicle for social responsibility. It can be used by an organization to give an opportunity to or advance underrepresented or protected groups (Workforce Management 2005). Healthcare still lags behind other industries in terms of growing leaders within the organization—a practice that was almost nonexistent in healthcare in the past. According to a study by the American College of Healthcare Executives, the “overall promotion rate for managerial positions hovers around 64 percent,” while only 21 percent of the more than 722 healthcare institutions surveyed routinely practiced succession planning (Wilson 2005a). Health First, located in Brevard County, Florida, addressed its succession planning needs in 2007. The organization initiated a formal mentoring process, pairing up senior executives with junior managers and directors from across the organization. To make the mentoring relationships more comfortable for participants, each person comes from different business units, avoiding the conflict that can arise with direct-report relationships and allowing participants to freely express themselves (DeMarco 2007). Similarly, Martin Memorial Health Systems in Stuart, Florida, made a commitment to grow its leadership from within the organization. Martin Memorial instituted a leadership development program that uses career mapping (Wilson 2005b).

In the future, the bench strength of an organization will continue to play an important part in organizational vitality

Employee Socialization

Even before most job candidates arrive for the interview, they have already researched the organization through a website, company literature, or a current or former employee. The interview process, then, adds to the candidates’ knowledge, allowing them to piece together an overall picture and to figure out how they will fit into the larger organizational scheme. Therefore, when the new employee reports to the job for the first time, his or her socialization wheel is set in motion.

The formal orientation process provides a huge opportunity to engage the new employee in formulating expectations for a future with the organization. If a formal orientation process is not provided, then the employee will go through an informal process that involves indoctrination by other employees. Certainly an orientation by peers is valuable, but it is not sufficient. When left with only an informal orientation device, the new employee will receive inaccurate, incomplete, and even biased information. This will lead to a cause of frustration for the new employee.

The new-employee orientation is a process by which the organization satisfies many employee-centered questions. This is the opportunity for the organization to explain and educate on workplace structure; policies; processes; practices; and related information, standards, and expectations that will assist the newcomers in their development and success with the organization. During the orientation, the employee should be exposed to a balance of job-specific and organization-related information.

Content

Because each organization is unique, the new-employee orientation should be customized, not generic. On the other hand, many topics are resident in every organization’s orientation program, such as compensation, benefits, work hours, and career planning. Table 9.2 lists the areas that are commonly covered in new-employee orientations.

Table 9.2: Types of Information Conveyed in an Orientation
Open table as spreadsheet

Employee-Centered Information	Organization-Specific Information
Compensation, including pay rates, deductions, overtime, and holiday pay	Overview of organization, including introduction, history, and customs/traditions
Benefits, including insurance, holidays, leave, and retirement	Safety, including precautions and accident-reporting procedures
Facilities, including food services/cafeteria, parking, restrooms, security, first aid, security, and badges/name tags	Employee relations, including reporting sick leave, length of probationary period and limitations of activities associated with that, expectations and disciplinary practices, and grievance process
Details of job duties, including work hours, job description, and performance criteria	Policies and procedures
Department tour, including work space/office, entrances/exits, supervisor’s location, water fountains, and smoking areas	Where to find resources and who to call to report discrimination or illegal activities
Career planning, including development opportunities and resources for growth	Community activities and sponsored events

Logistics

As today’s world continues to expose us to huge amounts of knowledge, and as we try to accommodate all or much of that information in our busy lives, we have developed fast-paced ways to learn. This trend in short-length learning has been adopted in orientation programs as well. The usual healthcare workplace situation is this: The supervisor is feeling the pinch of an unfilled position. The usual management response to the situation is this: Get the new hire initiated quickly so that person can attack the learning curve.

One of the best approaches to orienting a new employee is the “eating of the apple” method—one bite at a time. In the workplace, this method translates into breaking up the orientation into brief sessions over a period of days or weeks. The employee remembers much more because the integration of information takes place as he or she adjusts into the new work surroundings, with the information presented in “bites” that the employee can digest thoroughly. This translates into a win for the organization as well, because the employee is given a chance to stay connected to the process, and this in turn may lead to the employee’s satisfaction with work and possibly to a greater probability of retention.

Best-Practice Ideas

There are many success stories of organizations that have revamped or renewed their new-employee orientation process. The Mayo Clinic in Rochester, Minnesota, welcomes new employees with balloons, upbeat music, and breakfast. The organization strives to provide a positive, lasting first impression and to keep that momentum going through the orientation process (Hicks, Peters, and Smith 2006). King’s Daughters Medical Center, based in Ashland, Kentucky, developed its orientation session around an “interactive sports-themed orientation called New Team Member Training Camp” (Finkel 2005). When new employees arrive for the orientation, music is playing, pennants with inspirational quotes are posted everywhere in the room, and the facilitator is wearing a referee uniform. How do the new employees like the theme? One hundred percent of employees said they felt welcomed, an increase from the 92 percent survey results in 2003, before the change (Finkel 2005)

Creating Customer-Focused Healthcare Organizations through Human Resources

The problem with human resources management (HRM) thinking is that it addresses only 50 percent of the “people equation,” focusing on internal customers to the exclusion of external customers. The goal should be to link the external customer’s requirement with the internal human capabilities, thereby optimizing the utility of both. Consequently, the goal of the human resources (HR) function is not to make employees happy or satisfied at work; rather, it is to make happy those employees who are making the external customers happy. Most healthcare organizations’ mission proclaims, “People are our most important asset.” Yet no one really believes such statements. What they really mean is, “People who are serving customers well are our most important asset. Others must either convert to serving customers well or leave.”

Healthcare organizations have not traditionally been focused on the needs, wants, or desires of their patients/customers. As a result of their history and reimbursement sources, they have concentrated on meeting the expectations of their medical staff and third-party payers. The medical staff have historically had the power to decide where their patients would go for services, and their provider organizations have gone to great lengths to make them happy. Because third-party payers pay the bills, organizations have also spent considerable effort in satisfying them. This limited definition of “customer” has resulted in organizations focusing only on increasing market share, decreasing costs, and expanding revenues to retain the support of their third-party payers and on providing sophisticated technology and in-house amenities to satisfy their doctors. Meanwhile, the patient has been overlooked and underappreciated as the ultimate customer. Even the term “patient” implies a passive person who patiently waits for service from experts who know what that patient needs and who often provide it without consultation with or explanation to the patient.

This paradigm has led to an increasingly unhappy and vocal patient. One study commissioned by the Voluntary Hospitals of America and another survey published in Fortune magazine report the following consumer attitudinal trends toward healthcare organizations (Alliance 1998):

Public trust in healthcare institutions has declined…with health plans losing more ground than physicians or hospitals. The decline in trust is especially pronounced among consumers age 40 to 59; those with higher income and education levels; and those who have recently changed, added, or selected a physician or hospital. Consumers gave hospitals only a 67 percent satisfaction rating, and compared with 31 other industries, hospitals rank 27th. This placed them just above the Internal Revenue Service and 10 percentage points below the tobacco industry.

Furthermore, 80 percent of Americans agree that hospitals have cut corners to save money, and 77 percent agree that these cuts endanger patients (Healthcare Advisory Board 1999). While these findings are from 1999, such dissatisfaction and cynicism from the public continue and are probably worse today. Currently, many consumers think that in the event that they become seriously ill, their health plan will be more concerned about saving money than providing the best medical care (National Coalition on Health Care 2008).

None of these findings is surprising given that the services paid for by private insurers and government are not likely to reflect consumer preferences for convenience and personal control (Herzlinger 1997, 95). The increasingly involved healthcare consumer (this term, or plainly “consumer,” is used throughout the chapter to refer to “patient”) and the newly evolved competitive market are forcing healthcare institutions to consider who their customers really are. They are starting to rethink the old paradigm of “take care of the doctors and third-party payers and all good things will follow” and follow the new paradigm of “don’t forget the patient as customer” (Ford and Fottler 2000). Today’s consumers, however, have much more knowledge and access to information about the value and quality of their healthcare alternatives. They are more savvy about what they are getting for their healthcare dollar and are increasingly involved in the decisions about how those dollars are spent. Because they have many choices when it comes to insurance coverage and healthcare providers, their voice is being heard. In addition, increasingly vocal consumer groups have changed patients’ mind-set from being passive consumers into active participants in their own healthcare decisions.

Regina Herzlinger (1997, 3–4) describes this new healthcare consumer as follows:

They want what they want, they want it fast, and they want it when they want it. Well-informed, overworked, and overburdened with child and elder-care responsibilities, they are a new breed of consumer, and their demands for convenience and control have caused many American businesses to greatly enhance their quality and control their costs…the consumer revolutionaries want their healthcare system to provide them with the same kinds of convenience and mastery they have found with Home Depot, Consumer Reports, and Nordic Track, so that their health status and costs will improve even further.

JIT Approach

Just-in-time is often seen as a way of minimizing stocks of work in progress. It assumes that the main purpose of stock is to give a buffer between operations, and allow for short-term mismatches between supply and demand. The traditional way of allowing for these is to keep stocks that are high enough to cover any likely problems. Just-in-time gives a more radical solution with the following argument.

Stocks are held in an organization to cover short-term variation and uncertainty in supply and demand. These stocks serve no useful purpose – they only exist because poor coordination does not match the supply of materials to the demand. As long as stocks are held, there are no obvious problems and no incentive for managers to improve the flow of materials. This means that operations will continue to be poorly managed, with problems hidden by the stocks.

Organizations should really try to improve their operations, find the reasons for differences between supply and demand, and then take whatever action is needed to overcome the differences. This will allow them to eliminate stocks and have operations done just as they are needed.

You can imagine JIT on a car assembly line. Just as the chassis moves down the line to a work station, an engine arrives at the same point and is fitted. This is repeated for all parts. As the car body arrives at another work station, four doors also arrive and are added. All the way down the line materials arrive just at the time they are needed, so the car is assembled in one smooth process.

ACCIDENT PREVENTION STRATEGIES

Strategies aimed at preventing accidents should be geared, firstly, to reducing the objective danger in the workplace (‘safe place’ strategies) and, secondly, to increasing people’s perception of the risks at work (‘safe person’ strategies). The twin concepts of ‘safe place’ and ‘safe person’ must, therefore, feature prominently in any company accident prevention programme with the principal objectives of ensuring compliance with the duties laid on persons at work under HASAWA.

A safe workplace

‘Safe place’ strategies are principally concerned with reducing or eliminating the objective dangers which threaten the safety of workers. These include:

1. Premises: Premises should be structurally safe in terms of stability, the soundness of floors, staircases and general means of access and egress. The duty to provide safe premises is further reinforced where members of the public may be invited into a premises.
2. Environment: Poor standards of working environment are a contributory factor in many accidents. The provision of a sound working environment implies adequate levels of lighting and ventilation, temperature control and the prevention of environmental stressors, such as noise, vibration, dust and fume emission, all of which can affect the heath of staff.
3. Plant and machinery: Legislation, such as the PUWER (see Chapter 11 for further details), requires plant and machinery to be adequately fenced or controlled in such a way that operators are not exposed to risk of injury. All new machinery and plant should be assessed for hazards prior to acquisition. Maintenance and cleaning systems should take into account the safety requirements of staff engaged in such operations.
4. Materials: Materials and substances used at work may be toxic or carcinogenic. They may emit harmful dust or fumes during processing, or represent risks of bodily injury during handling. The duties of manufacturers and suppliers of substances used at work are clearly identified in the HASAWA (Section 6), as amended by the CPA 1987, and the COSHH Regulations.
5. Processes: A work process may incorporate a number of machines, materials and differing operating skills. Such factors must be considered during process design and be subject to regular monitoring, particularly with regard to the loading and unloading of machines, the use of potentially dangerous substances in processes, the presence of injurious by-products of manufacture, and the levels of skill and supervision necessary.
6. Systems of work: The need for clearly defined and documented safe systems of work is abundantly clear in many work situations. The failure to provide such safe systems, to train operators in their use, to supervise and control those systems and to revise them where necessary, are among the principal causes of industrial accidents. Section 2 of the HASAWA clearly identifies the provision of safe systems of work as an employer’s duty.
7. Supervision and control: Good standards of safety supervision from the boardroom downwards should be indicated in the employer’s statement of health and safety policy. The specific health and safety related duties of all levels of management and workers should also be clearly identified in job descriptions.
8. Training: It is the legal duty of employers to provide information, instruction, training and supervision under the HASAWA. Attention to safety requirements should be stressed during induction training, on-the-job training, and training in specific tasks and operations, such as the operation of lifting equipment and the use of permit to work systems.

Safe persons at work

‘Safe person’ strategies include the following:

1. Personal protective equipment: Under the Personal Protective Equipment at Work Regulations 1992, ‘personal protective equipment’ (PPE) is defined as ‘all equipment (including clothing affording protection against the weather) which is intended to be worn or held by a person at work and which protects him against one or more risks to his health or safety, and any addition or accessory designed to meet that objective’.
   Employers must ensure that ‘suitable’ PPE is provided to their employees who may be exposed to a risk to their health or safety while at work, except where and to the extent that the risk has been adequately controlled by other means that are equally or more effective.
   PPE shall not be suitable unless:
   1. it is appropriate for the risk or risks involved, the conditions at the place where exposure to the risk may occur, and the period for which it is worn;
   2. it takes account of ergonomic requirements and the state of health of the person or persons who may wear it, and of the characteristics of the workstation of each such person;
   3. it is capable of fitting the wearer correctly, if necessary, after adjustments within the range for which it is designed;
   4. so far as is practicable, it is effective to prevent or adequately control the risk or risks involved without increasing overall risk; and
   5. it complies with any enactment (whether in an Act or instrument) which implements in Great Britain any provision on design or manufacture with respect to health or safety in any of the relevant Community Directives listed in Schedule 1 which is applicable to that item of PPE.
   Where it is necessary to ensure that PPE is hygienic and otherwise free of risk to health, every employer and every self-employed person shall ensure that PPE provided under this regulation is provided to a person for use only by him.
   Under regulation 6, employers must undertake assessments of PPE prior to choosing the same. Factors for consideration in a PPE assessment are:
   1. an assessment of the risk or risks to health or safety that have not been avoided by other means;
   2. the definition of the characteristics which PPE must have in order to be effective against the risks, taking into account any risks which the equipment itself may create;
   3. comparison of the characteristics of the PPE available with the characteristics referred to in (b) above; and
   4. an assessment as to whether the PPE is compatible with other PPE that is in use and that an employee would be required to wear simultaneously.
   Employees must report to their employer any loss of, or obvious defect in, PPE. The provision and use of all forms of personal protective equipment should only be considered as a last resort, ie when all other accident prevention strategies have failed or, alternatively, as an interim measure until one of the ‘safe place’ strategies mentioned above can be implemented. As an accident prevention strategy, the use of protective equipment relies heavily on the worker wearing the item of personal protection, eg gloves, safety helmet, etc all the time that he may be exposed to the hazard. Factors such as comfort, choice of the equipment involved, ease of movement, ease of putting the item on and removing it, specific job restrictions created by the equipment, the effects of high temperatures, and ease of cleaning, replacement (as with respirators) and maintenance of parts, are significant when considering the use of personal protective equipment as a means of protecting workers from hazards. It should be borne in mind that a high level of supervision and control is necessary to ensure constant use of this equipment.
2. ‘Vulnerable’ groups: Certain groups of workers, by virtue of their age, physical condition, lack of experience or even general attitude to work, may be more vulnerable to accidents than others. Such groups include: young persons, whose experience of hazards could be limited; pregnant women, where there may be specific risks to the unborn foetus; disabled persons, whose physical capacity to undertake certain jobs is considerably reduced; and that very small group of ‘accident repeaters’, who have the same type of accident regularly. Special consideration is needed in these cases.
3. ‘Unsafe behaviour’: Horseplay and other forms of unsafe behaviour can be a feature of some work situations if supervision and control are poor. This has particularly been the case with apprentices in the past. Management must take a very strong line here, with instant dismissal of offenders in extreme cases.
4. Personal hygiene: Many substances used in industrial processes can promote occupational skin conditions, in particular, dermatitis. Such substances must be properly controlled, and facilities for maintaining good standards of personal hygiene provided and maintained. This includes washing facilities, which cover showers with hot and cold water, soap, nailbrushes and adequate drying facilities.
5. Maintaining awareness: Everyone should be aware of the risks in the workplace. Hazards should be clearly identified in the statement of health and safety policy, together with the precautions necessary on the part of workers. Methods of increasing and maintaining awareness include the use of posters, training, safety competitions, various forms of safety monitoring, hazard-spotting exercises, hazard-reporting systems and the use of ‘Days Lost’ notice-boards indicating the number of days lost per month as a result of accidents at work.

Means of preventing accidents

Strategies for preventing accidents take many forms. These include:

1. Prohibition: Some processes and practices may be so inherently dangerous that the only way to prevent accidents is by management placing a total prohibition on that activity. This may take the form of a prohibition on the use of a particular substance, such as an identified toxic substance, or of prohibiting people from carrying out unsafe practices, such as riding on the tines of a fork-lift truck, climbing over moving conveyors or working on roofs without crawlboards.
2. Substitution: The substitution of a less dangerous material or system of work will, in many cases, reduce accident potential. Typical examples are the introduction of remote control handling facilities for direct manual handling operations, the substitution of toluene, a much safer substance, for benzene, and the use of non-asbestos substitutes for boiler and pipe lagging.
3. Change of process: Design or process engineering can usually change a process to ensure better operator protection. Safety aspects of new systems should be considered in the early stages of projects.
4. Process control: This can be achieved through the isolation of a particular process, the use of ‘permit to work’ systems, mechanical or remote control handling systems, restriction of certain operations to highly trained and competent operators, and the introduction of dust and fume arrestment plant.
5. Safe systems of work: Formally designated safe systems of work, with high levels of training, supervision and control, are an important strategy in accident prevention (see below).
6. Personal protective equipment: This entails the provision of items such as safety boots, goggles, aprons, gloves, etc, but is limited in its application as a safety strategy

Wha are Accidents?

How often do we hear someone say ‘It was an accident! It couldn’t be helped’? Others will take the view that an accident is an act of God over which we have no control. Generally, as far as the accident victim is concerned, accidents have the following characteristics. They are unforeseeable, unintended, unexpected and unplanned.

ACCIDENT DEFINITIONS

A number of definitions of the term ‘accident’ have been put forward over the years, indicating the differing perceptions and views that exist. The following are some examples.

1. Fenton v Thorley & Co Ltd (1903) AC 443

Some concrete happening which intervenes or obtrudes itself upon the normal course of employment. It has the ordinary everyday meaning of an unlooked-for mishap or an untoward event which is not expected or designed by the victim.

2. Royal Society for the Prevention of Accidents (RoSPA)

An unplanned and uncontrolled event which has led to or could have caused injury to persons, damage to plant or other loss.

3. American Institute of Loss Control

An unintended or unplanned happening that may or may not result in personal injury, property damage, work process stoppage or interference, or any combination of these conditions, under such circumstances that personal injury might have resulted.

4. Little Oxford Dictionary

An event without apparent cause; an unexpected event; an unintentional act; a mishap.

5. Health and Safety Unit, University of Aston in Birmingham

An unexpected, unplanned event in a sequence of events that occurs through a combination of causes. It results in physical harm (injury or disease) to an individual, damage to property, a near miss, a loss, business interruption or any combination of these effects.

It is easy to conclude from these definitions that, in addition to their resulting in many cases from a breach of the law (eg failure to guard machinery properly), most accidents represent some form of loss to an organisation. That loss can be quantified in financial terms, eg increased employer’s liability premiums, fines in the courts, business interruption types of loss, damage costs, sickness absence costs and production losses.

INCIDENTS

An incident is a form of accident or situation that does not necessarily result in injury to people. The term ‘incident’ can be defined as ‘an undesired event that could (or does) result in loss’, or ‘an undesired event that could (or does) downgrade the efficiency of the business operation’. Typical incidents could include, for instance, a minor fire, flooding of a warehouse or an adverse product liability incident involving a company’s products, which may result in those products being recalled at very short notice. This has been seen in the past with vehicles, food products and certain electrical appliances. Such incidents result in adverse publicity, recall costs and substantial costs in restoring public confidence in that product.

‘HAZARD’, ‘DANGER’ AND ‘RISK’

Any strategy in preventing accidents at work must draw a distinction between ‘hazard’, ‘danger’ and ‘risk’. A ‘hazard’ is defined as ‘the result of a departure from the normal situation, which has the potential to cause death, injury, damage or loss’. ‘Danger’ is defined as ‘liability or exposure to harm; a thing that causes peril’. ‘Risk’, on the other hand, has a number of definitions – ‘a chance of bad consequences’, ‘exposure to mischance’, ‘exposure to chance of injury or loss’, ‘the probability of harm, damage or injury’ or ‘the probability of a hazard leading to personal injury and the severity of that injury’.

Accidents, therefore, are concerned with two specific aspects – namely the actual danger that exists at a particular point in time and, secondly, how people perceive and measure risk. Typical examples of dangerous situations could include an unfenced floor opening, a badly guarded machine, a slippery floor or, in driving situations, snow on the road. However, it is not until people come on to the scene that an accident can take place. Everyone takes risks in varying degrees, and these may be associated with such factors as individual human traits, training and upbringing. The people-related causes of accidents can, therefore, include over-confidence, ignorance, carelessness, lack of training, apathy and inappropriate attitudes to danger and the risks that can be encountered. The philosophy that ‘It couldn’t happen to me!’ is encountered among many people

Difference between Public Relations and Advertising

Public relations is a business tool that often gets confused with marketing and advertising, two related but very distinct activities. In the following sections, I clear up the differences for you.

Marketing: The four Ps

Marketing is typically defined by the Four Ps — product, price, place (channels of distribution), and promotion.

• Product refers to the physical product and its packaging. With many products — fruit juice, for instance — the packaging is a key product differentiator: Juice boxes are a separate product category from frozen concentrate. Service can also be an integral part of a product. For example, L.L. Bean has gained widespread fame publicizing its lifetime guarantee on everything it sells.
• Price is what you charge for the product.
• Place refers to channels of distribution — in other words, where the product is sold. Do you sell at a retail store or on a Web site? Do customers buy the product directly from you or through an agent or distributor?
• Promotion consists of advertising, sales promotion, personal selling, and, of course, public relations.

So as you can see, public relations is a part of promotion under the larger umbrella of marketing.

Paying for advertising while PR is (practically) free

Several characteristics separate public relations from advertising, but one fundamental difference is this: Advertising is paid; public relations is free. When you run an advertisement for your company, you pay for the space; when your press release prompts a newspaper to write an article about your company, you don't pay for that coverage.

Of course, PR is not absolutely free of cost. Your public relations staff member or your outside PR agency has to be paid for services. But compared to the megadollars of advertising campaigns, PR is quite a bargain. Many small- and medium-size businesses that can afford only limited advertising (with limited results) can do much more PR — and get better results — on a fraction of the budget they'd spend on paid advertising.

So the difference in cost is fundamental. But another distinction between PR and advertising gets less attention, though I think it's equally important: Advertising is clearly identified in the media as a paid promotion — readers and viewers know that it is a promotional message paid for by a sponsor. Publicity, by comparison, is not identified as a paid promotion. Even though a story about a product or organization may have resulted from a publicity campaign, the article or report never acknowledges that fact. (For instance, you almost never see an article in a newspaper or a magazine say, "According to a press release sent by the PR department of So-and-So Corporation. . . .")

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Thanks for the lousy press coverage!

Clergymen across the United States denounced actress Sarah Bernhardt (1844–1923) as the "whore of Babylon," which, much to their dismay, generated massive attendance at her performances. After a Chicago bishop delivered a particularly critical speech against Bernhardt, which was widely reported in the press, the actress sent him a $200 check along with the following note, as recounted by Clifton Fadiman in The Little Brown Book of Anecdotes: "I am accustomed, when I bring an attraction to your town, to spend $400 on advertising. As you have done half the advertising for me, I enclose $200 for your parish."

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Four other key differences between PR and advertising are

• Control
• Repetition
• Credibility
• Attractiveness

Sometimes these distinctions mean an advantage for PR, sometimes not. In the following sections, I go into more detail on each of these differences.

Control

When you advertise, you have almost total control over the content, format, timing, and size of your message. You specify how big your ad is and when it runs. You write the copy and design the layout, and your material appears exactly as you created it. With public relations, on the other hand, you have almost no control over the content, format, timing, and size of your message as it appears in the media. You can write whatever you want in your press release, but you can't dictate to the newspaper how it is printed or used, nor can you review or approve any changes made. You provide the press with written materials that they use (or don't use) in any way they see fit. Your press release may appear verbatim in one magazine but may be rewritten almost beyond recognition in another. One industry trade journal may write a cover story based on your material; another may not publish it at all.

Repetition

Advertising is repeatable; PR is not. The same advertisement can be repeated as many times as you want in a given publication; the same TV commercial can be broadcast night after night. With PR, a media source is going to run a given press release or cover a publicity event only once. To get covered again, you have to provide the media with a new story, or at least come up with a different angle or new spin on the old topic.

Credibility

Consumers are skeptical of advertising. They tend not to believe the claims made in advertising — at least that's what many consumers say. Many people believe that if your service or product is as good as you say it is, you don't need to advertise. On the other hand, people tend to take at face value what they hear on radio, see on TV, or read in the paper. They believe that if the newspaper printed it, it must be true. Because publicity is promotion in the guise of editorial, feature, or news material, people do not identify it as promotion and are, therefore, not skeptical of it; indeed, they believe it.

In many instances, media coverage of your event or story can appear to the public to be media endorsement of your organization or product — for example, a favorable story about your charity on the evening news or a good review of your software package in a computer magazine. What's more, comments or claims that would sound conceited, self-serving, and not credible if you said them about yourself in an ad seem complimentary, flattering, and impressive when the media say them about you.

Attractiveness

Publicity must have an angle — that is, a hook or theme that engages an editor's attention — in order for it to have a decent chance of being noticed, read, and used. Therefore, it must appeal to editors and program managers, as well as to the consumers (your sales prospects and the people who read the magazine or listen to the radio show).

An ad has to appeal to only one audience: your sales prospects. You don't care whether the media like or are interested in the ad, because they have already agreed to run it in exchange for a given amount of money.

WHAT IS GOLD STANDARD MANAGEMENT?

Gold standard management (GSM) is defined as

1. an edgy attitude and unrelenting commitment to the best;
2. a complete and thorough implementation of best-management practices in every department;
3. integration and unification of various management philosophies and schools of thought so that management is an integrated system rather than a group of independent components or disconnected programs;
4. specific management objectives and accountability that put work in the hands of competent people, give freedom to make change, expect results, use tough measures, and apply consequences; and
5. a requirement that all professional and technical staff implement their specialty's standards and best practices.

Using GSM, the management team eliminates management malpractice and violations of known best practices. Managers eradicate operational sludge and do not tolerate mediocrity.

Take the Domino’s Challenge

Domino’s made the guarantee that it could cook a pizza and deliver it to your home in 30 minutes or it was free. This began a revolutionary shift in customer expectations. Google taught everyone that it could find anything you want immediately and often for free. Customers used to want better, faster, and cheaper products and services; now they want everything free, perfect, and now, including healthcare.

This shift in customer expectations is hitting hospitals as well. If Robert Wood Johnson Hospital can offer a door-to-doctor guarantee, you might consider setting the same kinds of objectives:

• 30 minutes from door to doctor in the ED
• 30 minutes from “bed requested” to patient in bed
• 30 minutes from routine lab/radiology order to execution
• 30 minutes from discharge order to patient discharged
• 30 minutes from dirty room to clean room, dirty OR to clean OR

A Faster Lab in Five Days

In a large hospital, the response time of returning lab results to the wards was reduced by a factor of 10 simply by reducing the size of the transfer batch. It turned out that the transfer batch was determined by the size of the transfer trays.

- Boaz Ronen

One 2,400-square-foot hospital lab wanted to reduce turnaround times, which would reduce ED turnaround times and reduce LOS in the nursing units. Using pedometers, the hospital tracked lab worker travel time for a week. The hospital conducted what’s known as a 5S analysis (i.e., sort, straighten, shine, standardize, and sustain) to clean the area of 10 years’ worth of clutter (Figure 1.1) in four hours, then mapped the value stream (Figure 1.2) in two hours, and redesigned the workflow (Figure 1.3) in two hours.

Figure 1.1: 5S lab trash

Figure 1.2: Lab original spaghetti diagram

Figure 1.3: Lab redesign

Using Post-it Notes and a flipchart, the lab team was able to redesign the lab to reduce

• Staff movement by 54 percent (goal 30 percent)
• Floor space by 17 percent (goal 10 percent)
• Phlebotomist travel by 55 percent (21,096 feet to about 4 miles, ~1.5 Full Time Equivalent [FTE])
• Tech travel by 40 percent (2,304 feet, 0.15 FTE over three shifts)
• Sample travel by 55 percent (23,400 feet and 7 hours of delay per 24 hours)

Some changes could be implemented immediately; others required coordination to move machinery and recalibrate. The lab got a lot faster with less than two days of effort.

If you go to www.qimacros.com/webinars/webinar-dates.html, you can sign up for a free Lean Six Sigma for Healthcare Webinar to learn more about this Lean for hospital labs projects.

Denver Health rearranged workstations and equipment in the lab to reduce turnaround times for test results by 25 percent and saved $88,000. Overall, since starting its Lean journey in 2005, Denver Health has saved $54 million in increased revenue and cost savings.

Faster Medical Imaging in Five Days

North Shore University Hospital wanted to improve patient throughput on its CT scanners to decrease LOS and increase patient satisfaction. Average turnaround time (TAT) was 20.7 hours and varied from 8 to 34 hours. The target for improvement? 16 hours. Identified problem areas included

• Manual scheduling process leading to calls from nursing units
• Time-consuming prep and delivery of contrast medium
• CT tech travel to requisition printer (6,480 feet per day)
• Transporter availability and travel (432 feet per day)

After analysis of these various issues, the improvement team implemented several countermeasures:

• The requisition printer was relocated in between the two CT scanners, saving over 6,000 feet per day of unnecessary travel.
• Dedicated CT transporter was assigned.
• An Excel-based schedule was maintained in imaging and was viewable by all nursing units (this reduced phone calls and cancellations owing to improper patient prep or availability).
• Instead of a rigid schedule with no room for STAT orders, a “pull” system adjusted the patient transport and scan to accommodate just-in-time STAT scans.
• Contrast preparation was reassigned to the evening shift, refrigerated, and delivered during the transporter’s morning run for inpatients.
• One CT scanner was dedicated to complex procedures, and the second was dedicated to routine high-volume procedures to maximize patient flow.
• Staffing was adjusted to demand.

Results

• Average TAT fell from 20.7 to 6.45 hours.
• 200 additional inpatient scans were done per month.
• 60 additional outpatient scans were done per month.
• This resulted in $375,000 in additional revenue.
• Cancellations owing to improper prep dropped from 30.6 to 22.7 percent.

At Newton-Wellesley Hospital, radiology turnaround stood at 45 minutes. After examining patient and technician flow, the hospital found that technicians spent too much time walking around. By redesigning the work flow, turnaround times fell to 25 minutes, making the planned addition of another $500,000 x-ray machine unnecessary.

Massachusetts General Hospital’s proton beam facility was fully booked, or at least so the hospital thought—until it did a little analysis. By batching patients requiring anesthesia on the same day and scheduling an anesthesiologist for that day, throughput increased from 29 patients per day to 39 patients—a 33 percent increase.

A Faster Operating Room in Five Days

Copenhagen University Hospital wanted to reduce the time between surgical operations. The improvement team found that too much time (60+ minutes) was spent

• Investigating whether the patient got the required information from the surgeon (10 minutes)
• Unpacking individual sterile disposables (30 minutes)
• Waiting for missing devices (five trips per surgery)
• Waiting for the patient to regain consciousness to be transferred to recovery (20 minutes)
• Waiting for transport to recovery (10 minutes)

With some basic analysis, the team implemented countermeasures to save 60 minutes:

• Surgeon draws an X on patient’s wristband when the patient has been informed about the operation, allowing anesthesia to begin.
• Prepackaged sterile disposables replaced individual disposables, saving two nurses and 30 minutes.
• Standard checklists ensure that all materials are gathered before the operation starts.
• Anesthetic depth was adjusted so that the patient wakes up when the operation is finished.
• Hospital orderlies move patients to recovery immediately.

SSM Healthcare reduced operating room turnaround times from 30 minutes to 15.8 minutes.

A Faster Emergency Department in Five Days

In 2009, Press Ganey found that ED turnaround times still average over four hours, basically unchanged over the last decade. In 2006, the Centers for Disease Control and Prevention (CDC) found that 40 percent of hospital EDs were overcrowded. One Harvard study found that ED wait times rose 36 percent from 1997 to 2004.

Robert Wood Johnson Hospital in Hamilton, New Jersey (RJW), winner of the 2004 Baldrige Award, receives 50,000 patients a year. In 2004, RJW had ED turnaround times of

• 38 minutes for discharged patients
• 90 minutes for admitted patients

How is this possible? How did they do it? By systematically eliminating the delays between registration, triage, examination, lab, imaging, and discharge or admission/transport.

RJW’s 15/30 Program

In 1998, RJW offered a 15-minute door-to-nurse and a 30-minute door-to-doctor guarantee. Like Domino’s Pizza, if your nurse or doctor is late, your service is free! Patient satisfaction with the ED rose from 85 percent in 2001 to 90 percent in 2004. While payouts for this policy have been less than 1 percent of ED patients, ED visits doubled! This means that for 1 percent of the revenue, RJW increased ED revenue by 99 percent.

And because ED visits doubled, hospital revenue increased as well. Seventy percent of hospital admissions come from the ED. Faster turnaround times enabled the hospital to grow by over 10 percent per year, requiring the addition of a new nursing wing.

Results

• RJW was New Jersey’s fastest-growing hospital from 1999 to 2003.
• Mortality rates for patients with congestive heart failure (CHF) declined from 8 to 2.5 percent.
• Infection rates for things such as ventilator-assisted pneumonia (VAP) fell from 10 per 1,000 vent-days to only 2 per 1,000 vent-days.
• The cardiology market share rose from 20 to 30 percent.
• The surgery market share rose from 17 to 30 percent.
• Hospital occupancy rose from 70 to 90 percent.
• Employee satisfaction with benefits rose from 30 to 90 percent.
• Employee satisfaction with participation in decision making rose from 30 to 90 percent.
• Retention of nurses rose to 98 percent.
• Employee retention rose from 80 to 98 percent.

Faster patient flow means greater patient satisfaction, better outcomes, and more money!

Studies have shown that patient satisfaction begins to decrease when ED LOS exceeds two hours. There are two populations of patients who visit the ED, so let’s separate the emergent from the nonemergent cases and look at patients who get discharged.

If it takes only a couple of minutes to see the triage nurse, a few more minutes to get registered, and a few more minutes for a doctor diagnosis, then the total time spent on any one patient is perhaps nine minutes. So why does it take most EDs over two hours to handle each patient? Sure, some patients need lab work (11 minutes) and others need radiology, but most of those tests take less than an hour. We’re still looking at 35 to 60 minutes, not two hours or more.

If we look at admitted patients, they are taken into the ED immediately without having to wait. They see the doctor immediately. Tests are done STAT. Registrations are done at the bedside. Nursing floor bed assignments take only a few minutes. Nursing reports are fast. Transport to the intensive care unit (ICU), cardiac care, or Med/Surg floor takes only 15 to 20 minutes. These patients should fly through the ED, but they take longer than the discharged patients—two to three times longer. Sure, they have to be stabilized, but why does it take hours to get them into an assigned bed?

The answer, across the board, is delay. There is too much time between activities. The admission staff is busy, so patients have to wait. The triage nurse is busy, so patients have to wait. The ED is boarding patients who should be in a nursing unit, so patients have to wait. The ED nurse can’t reach the floor nurse to give a report, and vice versa. Neither nurse can leave to transport the patient. Beds are available but not staffed. And so on.

Imagine a Faster ED

Imagine an emergency room where patients walk in and something surprising happens:

1. They use the magnetic strip on their driver’s license, insurance card, or credit card to check in and register using a kiosk. The kiosk automatically takes pictures of all these IDs and uses the data to find the patient’s medical history, validate insurance, and so on.
2. Completing registration this way triggers a “pull” signal that brings the next nurse in the queue to collect the patient from the entry area and move him or her to an exam room.
3. Entering the exam room and gathering the patient’s vital signs triggers a pull signal for the next ED doctor in the rotation.
4. The doctor examines the patient with the nurse available and requests any tests or x-rays using a handheld device that kicks off the orders.
   1. The nurse draws any blood or other samples required and either (1) sends them to the lab for processing or (2) uses point-of-care testing to get results in 11 minutes or less. (Approximately 70 percent of patients require lab work.)
   2. The nurse transports the patient to imaging, if needed. (Approximately 30 percent of patients require medical imaging.)
5. Completion of the tests triggers a pull signal to the ED doctor to collect the results, diagnose, and recommend treatment.
6. The doctor then initiates treatment. Any “teaching” material or paperwork required is prepackaged and ready for the nurse to prepare the patient for discharge or admission.
7. Initiating admission kicks off a pull signal for a bed in the appropriate unit. If there isn’t enough staff in that unit to handle the admission, a pull signal may request an on-call nurse to come to work.
8. Instead of all being done manually, as most of this is now, it’s all carefully orchestrated and technically linked to minimize delay. Many of these activities can happen in parallel, not sequentially as they do today.

A discharged patient is in and out in 30 minutes. An admitted patient is in a nursing unit bed in 60 minutes. Of course, there will be exceptions—a rush-hour accident may tie up one of the doctors—but most patients are discharged. Finding ways to handle them in “one-piece flow” will improve ED performance dramatically.

Simply speeding up discharge and housekeeping of nursing unit beds can alleviate boarding and overcrowding in the ED. Empowering triage nurses to order x-rays for possible fractures without doctor involvement can accelerate diagnosis and treatment. Scheduling radiologists during the hours of highest trauma injuries (think rush hour and Friday/Saturday night) can accelerate ED throughput. Prepackaging common triage kits can accelerate treatment.

Simple Steps to a Faster Hospital

With all the hoopla about healthcare reform, there’s one huge missing piece—healthcare is going to have to get dramatically faster, better, and cheaper to help pay for the changes. Each of the nation’s 5,700+ hospitals must find ways to cut millions of dollars in unnecessary costs over the next decade. This may sound difficult considering that half of all hospitals lose money. Most hospitals exist on a 4 to 5 percent margin. But Lean can help hospitals start getting faster, better, and cheaper in just a few days.

One of the key principles of Lean thinking is to eliminate delays that consume up to 95 percent of the total cycle time (57 minutes per hour). If you’ve ever been a patient in a hospital emergency room (ER) or nursing unit bed, you know that there are lots of delays. Over the years, healthcare has made tremendous strides in reducing cycle time in various aspects of care. Outpatient surgeries are one example: Arrive in the morning, and leave in the afternoon. No bed required. But there is still lots of room for improvement.

Goal: Accelerate the Patient’s Experience of Healthcare

In any given “factory,” there are two kinds of time: work time during a process when actual work is occurring and elapsed time—the total time a process takes (work time plus any time spent on handoffs, waiting, batches, backlog, and so on).

- Ken Miller

Over the last decade, I’ve consulted with many hospitals on all kinds of projects. Perhaps the most powerful tool that can be applied immediately to start slashing cycle times, medical mistakes, and cost is Lean. And it doesn’t have to take weeks, months, or years. With the right focus and the right people in the room, it only takes a few days to find ways to speed up any healthcare process, which, in turn, will reduce errors and boost profits.

Every hospital seems to have the same problem: patient flow. This shows up in many ways:

• Patient dissatisfaction and physician dissatisfaction
• Emergency Department (ED) divert hours (ambulances diverted because of overcrowding), patient boarding in the ED, LWOBS (leaving without being seen), and four-hour turnaround times
• Operating room (OR) delays, cancellations, and long turnaround times
• Imaging delays, long turnaround times
• Lab delays, long turnaround times
• Bed management delays
• Late discharges
• Long patient lengths of stay (LOSs)
• Lost revenue

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What one element is critical to both patient flow and satisfaction?

Time—patient wait time leading to poor turnaround times and poor patient outcomes. Patient wait times are non-value-added (NVA). This non-value-added wait time is “baked into” existing procedures and facility design, but that doesn’t mean that it can’t be changed.

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Healthcare delivery often involves complex processes that have evolved over time and that are neither patient-focused nor clinician-friendly. When systems do not work well, healthcare workers resort to creating “workarounds,” adding additional layers of “patches” and “fixes” to poorly functioning systems.

- Christopher S. Kim, M.D