We are accustomed to believe that going slowly is the cautious approach; and by taking time to evaluate and weigh options, we reduce risks. I do not think so. In my career, I have found that a willingness to take risks, to jump into the unknown, to accept responsibility without asking too many questions, and to move rapidly, dramatically augments the achievement of that goal.
I learned this lesson first as a 23-year-old officer at the helm of a 600-ft-long US Navy guided missile cruiser. I was one of three officers on a 24-hour watch rotation responsible for “driving” the ship as we circumnavigated South America and then patrolled the Adriatic Sea off the coast of Bosnia.
Driving is a loose term; sailors had their hands on the ship’s wheel, the engine controls, the charts, and the radars. My job was to walk the bridge of the ship with binoculars, scan the horizon, review the charts, glance at the radar, and give the orders to safely navigate us to our next mission or port. If I saw a tanker on the horizon off of our port bow, I might do a quick calculation that our paths would cross in 15 minutes and order a course change.
All day long, even during gunnery exercises, helicopter operations, and underway rendezvous with supply ships, I needed to maintain awareness of all other ships and hazards on the horizon and constantly adjust course or speed to keep our ship safe and on track. At times, that job became frighteningly complex — especially in a busy shipping lane or a constrained area like the English Channel. At any one time, while moving forward at a fuel-saving 7 knots (about 8 miles per hour), I might be simultaneously watching a ferry boat cross our bow, a cruise ship pass our starboard side, a tugboat and barge approach us, and a speedboat overtake us from behind. I would watch the entire radar screen and scan all 360 degrees of the horizon around the ship with my binoculars, because, at our slow speed, we were literally at risk of being hit from all sides.
A change in thinking
My understanding of this risk changed for me one night in the Mediterranean Sea. We were in the port of Taranto near the heel of the Italian “boot” when we received urgent orders to make a high-speed run across the Mediterranean and through the Suez Canal to take up a missile launching station in the Red Sea. We made quick preparations, cast off the lines holding us fast to the pier, and then carefully navigated through the channel and anchored ships. As soon as we were clear of the harbor and safe out at sea, the captain had me bring the ship to maximum speed as the navigator plotted a course for Egypt. “All engines ahead full, Flank 3,” I ordered over the noise of the crowded bridge. We all steadied ourselves and held tight as the 10,000-ton ship as long as two football fields began pounding through the sea at more than 35 miles per hour.
At normal speeds, I would have worried about the many ships within sight of us on the open sea. What I quickly realized was that at this incredible speed, I no longer had to worry about the ships on our port and starboard sides or behind us. In fact, unless other ships were directly in front of us or within a degree or two of our bow, we were moving so fast that they all passed quickly and harmlessly behind us. Clearly, our increased speed markedly improved the performance of the ship.
“Safety in speed”
In those moments, cutting through the open sea, I learned there is safety in speed, and moving rapidly can actually increase control while reducing the need for heavy course corrections. I have since applied that knowledge to many situations in my career both in the telecommunications industry and in healthcare. Bold, rapid decision making has served me well and allowed my team and me to achieve goals quickly even as minor issues pass harmlessly behind us.
Twenty years after that experience on the Mediterranean Sea, as CIO of a $4B health system and medical group, I applied the lesson of bold speed to a $300M project to implement an EMR. Our three hospitals and 1,500 physicians used 5 different medical record systems and 3 different billing tools. Although all parties had agreed to jointly purchase and implement a common EMR and billing system, there was no model for the process to standardize on a single platform. To implement the system on time and on budget called for bold leadership and rapid decision-making.
To facilitate a 36-month goal for completion of the project, we hired and trained our project team of 150 within three months. We set a schedule for the entire length of the project, never moving any of the go-live dates. While it was easy to make bold, common decisions within the project and project team, holding each of the hospitals and physician practices accountable for shared decisions was much tougher. Academic medicine is known for patient decision-making to achieve consensus even if that means an initiative slows or even stops. Technology was not the limiting factor in this case—organizational process and culture were.
For example, each of the 3 hospitals tracked the daily OR efficiency with several metrics including one called “first case start time.” This metric measured the percentage of cases that started within ten minutes of 7 a.m. This measure is important not only for the first case, but because a delay in the first operation of the day affects each of the following surgeries throughout the day. Meeting the first case start time involves having the patient in the room and anesthetized, the full surgical team assembled, the appropriate tools and supplies in place, and a pre-surgical safety huddle to confirm the current procedure and patient. Achieving a first case start time of 95 percent across more than ten operating rooms is a major challenge.
Over time, each hospital had developed its own way of measuring first-case start time. For one, success was measured when the surgeon made the initial incision. For another, a 15-minute window allowed for leeway in the measure of success. A third hospital threw out the data for days when surgeon meetings were held, because it was known that cases would not start on time that day. Each of these methods worked for the hospitals as long as they operated independently.
When we implemented a common EMR, however, measuring first case start times differently at each hospital was no longer an option. Hard wiring a different metric into the EMR for each hospital would have negated the benefits of standardization and increased the time and cost to build and maintain. The problem was compounded by a lack of experience working together and little interest in maintaining a common standard.
Selection of a first case start time metric was one of the more than 8,000 common decisions that needed to be hard-wired into our EMR in the 12 months before bringing the shared system live. Although we strove to achieve consensus on these choices, agreement on each decision would consume a great deal of resources.
To address this potential process risk, for this decision and each that followed, we identified the decision to be made, a default solution that would work even if it was not the first choice of all parties, and the date by which the choice must be made. For first-case start time, we set a date six months before the go-live of the EMR in the first hospital, notified OR executives from each hospital of the issue that needed to be resolved, and encouraged them to collaborate to reach a common best definition. The caveat was that if they did not agree upon a common choice by the set date, our new shared definition of first case start time achievement would, by default, be the time of surgical incision.
Not every decision in the $300M project fit neatly into this framework. But by boldly declaring our project team’s decision-making process within an aggressive schedule, we established a culture in which choices could be debated and changed without holding the project hostage. Once all parties recognized that active involvement allowed them to make clinical and operational choices, while non-participation negated their influence, we had the broad participation we needed to implement the common EMR in a standardized fashion. As a result of this and many similar bold choices, we completed the project on time and $10M under budget.
Be bold. There can be safety in speed, and moving rapidly can increase control.
Daniel Barchi, Senior EVP and CIO at CommonSpirit, wrote the piece while in his previous role of CIO at NewYork-Presbyterian. To view the original post, click here.