It is all about the Nurse

I have talked in my past postings about how innovation does not happen in vacuum and how one of the best ways to sharpen the value proposition of a product/service is to observe the end-user/customers “in the moment”, i.e. what they do just before, during and after they use your product/service. Focusing on observing their use and the problems they encounter during this critical window reveals insights that one would not nominally garner sitting inside conference rooms and doing brain storming sessions on white boards.

Today, our predominant end-user customer is a nurse. Here’s a glimpse of what a day-in-the-life-of-a-nurse looks like:

Nursing is one of the most stretched resources, and nurses are some of the most stressed employees in the hospital. Remember that patients who are in their care are often experiencing the scariest times in their lives and their emotions have an effect on the caregivers. Add to that there’s a country wide nursing shortage estimated at 116,000 this year, likely to increase to 550,000 in 2025. Plus, the aging of the US population has resulted in more people looking for acute care later in their life and it is little wonder why there are increasing rates of depression and stress related disorders among nurses. To top all this, nurses are also being burdened with hospital customer-service policies, privacy (HIPAA) laws which put extraordinary onus on them to complete extensive documentation for the sake of patient security, and you start to see the picture.

Against this backdrop hospital administrators, and quite rightly so, are turning to technology to their rescue—one of the reasons why Vocera has been so well received in this segment. With technology, comes increasing complexities of the hospital IT systems. There is a frenzy created by the promise of Obama Care’s $19B commitment to EMR (Electronics Medical Records) which has contributed to its own layer of chaos around how to best implement interoperability standards amongst various EMR/EHR components. Check out this hilarious spoof on EMR information technology interoperability. While it might take the healthcare IT industry many years to reach the “interoperability nirvana”, nurses who represent a third of all hospital staff have to bear the brunt of having to deal with a plethora of devices, alerts, alarms and book-keeping.

Walk through a typical hospital and you’ll hear a cacophony of alarms, bells, other tones coming from medical equipment and computer terminals. American Medical News recently cited a study showing that 16,934 alarms sounded in a medical unit during an 18-day period—translating to approximately 40 alarms an hour! Alarm fatigue is the term medical professionals often use to describe this malaise. A study of VA hospitals published in WSJ in 2007 states:

Doctors failed to acknowledge receipt of 368 electronically transmitted alerts about abnormal imaging tests, or one third of the total, during the study period. In 4% of the cases, imaging-test results hadn’t been followed up on four weeks after the test was done. Another study, published in March in the American Journal of Medicine, showed only 10.2% of abnormal lab test results were unacknowledged, but timely follow-up was lacking in 6.8% of cases.

We heard also about the recent press release by the Joint Commissions Center for Transforming Healthcare that BZ sent around yesterday which reiterated the same malaise couched in a slightly different statistic

An estimated 80 percent of serious medical errors involve miscommunication between caregivers when responsibility for patients is transferred or handed-off.

With as many alerts/alarms and stress as a nurse is subjected to each day, no wonder this profession is so error prone, and lives of our loved ones are at risk as a result.

So how is all this relevant to us at Vocera apart from the fact that there are a lot of companies chasing the limited healthcare IT dollars within the hospital? As we design products, add-on features, or integrate hand-off solutions into our product lines, we must not lose sight of the problems facing our ultimate end-user customer, the nurse. If that means that we create tiered alarm/messaging structure in our products, or improve readability of text messages, or make tweaks to our voice user interface, improve noise immunity for our badges—it must all ultimately help lower the fatigue factor and help them do their jobs better rather than have to get “trained” on yet another new device/system. Our products have the rare privilege of being worn by the nurses and we therefore own a very coveted “real estate”. Let us keep the design principle of “keep it simple stupid” to guide our product decisions going forward because nurses won’t tolerate anything less.

Spend a Day Walking in the Shoes of Your Customer

Every successful business is built on delivering some value (aka set of benefits at a cost) at a cost that is profitable. As long as this equation is sustainable the business thrives. Seems as obvious as day light, right? You will be surprised at how untrue that is. Not all successful businesses consciously choose a set of value propositions, or articulate them clearly to their customers. Business world is littered with “me-too” enterprises which either stumble into a value proposition or do not appreciate how theirs differs substantively from their competitor’s. All too often, corporations end up fighting with the same “weapons”, i.e. cost, to a point where they self destruct by commoditizing their business segment. You need to look no further than the Wintel world of PCs and contrast that with Apple.

As part of self reflection, businesses owe it to their stakeholders a very clear definition of what value they are in the business of delivering and not delivering, to defined customer segment(s). A very good way of articulating the value proposition is to spend a day in the life of your customer – a theme that I had alluded to in my last blog.

Paying attention to the customer is certainly not a new idea. If one thinks of value delivery as a chain of links, most companies focus on their immediate customers. This is a serious mistake. Each link in the chain, all the way down to the end-user, is important. Savvy companies want to add value to the customer’s value proposition, i.e. to provide benefits to their customer’s customer. Let’s reflect on this for a bit - while Vocera’s immediate customers are the hospitals (in the Healthcare vertical), we are quite cognizant of the value our customers (hospitals) are trying to offer their end customers by way of delivering better patient safety, higher patient satisfaction/experience, increased staff empowerment and improved patient flow.

How does an organization determine the value proposition of its products or services? It is certainly not by examining the product features or differentiating them from those of the competition—that is inward focused (internally driven) and rarely translates to the actual end user benefits. Let me explain this with an example. An internally focused airline¹ might decide that their true “value” is on-time departure and arrival, yet exactly because of that, they may have a lousy baggage handling record. Result: the airline protects its on-time performance; the passengers arrive on time, only to have to wait a few aggravated hours for their luggage to arrive.

An extreme opposite of inward focused businesses are those that are customer compelled. Customer compelled organizations can also routinely miss or reject real opportunities. Some of this century’s greatest products or technological advances were confidently rejected in customer surveys: microwaves, computers, cell-phones, voice mails etc., because most often, asking customers about a benefit in vacuum usually does not result in correct choices. Scott Adams was not exaggerating in a Dilbert comic strip in which he makes fun of the historical use of market surveys²:

Airline Survey (1920)

If you had to travel long distance, would you rather:

1. Drive a car

2. Take a train

3. Allow yourself to be strapped into a huge metal container that weighs more than your house and be propelled through space by exploding chemicals while knowing that one of a thousand different human, mechanical or weather problems would cause you to be incinerated a spectacular ball of flame!

If you answered ‘C’ would you mind if we stomped on your luggage and sent it to another city?

A much better approach, I believe, is to watch customers in the context of their environs, going about doing their daily activities and identify common frustrations or problems faced by them. One of the best techniques to observing your customer is to spend a day “walking in their shoes”, or as some companies do, observing them as if doing a video recording or actually doing one, and then carefully analyze them. Honda designed their car trunks by watching many hours of footage of potential customers buying groceries and watching them load it into the trunks of their car.

“Some consumers are seen struggling to get bags into the trunk as the lids keeps closing, others arrange their bags in the trunk to keep them from tipping over, and still others pause to rest the bag on the edge of the trunk as they search their pockets/purses for the keys”

Honda Engineers came up with innovations such as, keyless automatic trunk opening, removal of the trunk “ledge” and making the rear bumper level with the trunk floor, adding grocery netting etcetera, after watching end customers struggle in those videos. The motorists did not tell Honda their trunks needed the desired benefit. Honda engineers lived a part of their car experience by walking in their shoes for a day.

Successful enterprises also determine early on not only a set of benefits they will provide, but which ones they will choose to deny. As I had mentioned last time, Southwest Airline, the most profitable airline in the history of our country, chose earlier on to provide the following benefits³:

1. Flying takes less total travel time than on competing airlines (office-door to office-door)

2. Interaction with Southwest personnel is a more fun and more sincerely personalized flying experience than typical on other airlines

But they chose to deny following benefits:

1. Assigned seating

2. Meals

3. Interline ticketing and baggage

The company then went about their strategy of delivering these benefits by deciding to not use a city’s main airport, choosing instead to fly out of smaller alternate airports which were usually closer to downtown. They decided to fly out of Dallas Lovefield Airport (instead of Midway), or the Oakland or San Jose Airport (instead of SFO) as part of delivering the benefit of less total door-to-door time. I had mentioned that Southwest chose to only have Boeing 737s in their fleet to help reduce the aircraft’s turnaround time (from the time it touches on the runway, to when the same aircraft takes off) to improve the efficiency of the ground crew and the pilots who did not have to deal with different procedures and checklists because all they ever flew were 737s.

Proctor and Gamble is another remarkable company that is acutely in tune with their value delivery systems. Pringles came up with an innovative packaging for the potato chips by focusing on delivering a value proposition that allowed them to be safely transported large distances without crushing the crunchy contents. Note that they did not highlight the freshness as one of the benefits because it would be highly incredulous to think that symmetric and identically shaped chips could be correlated to freshness by any stretch.

1. Delivering Profitable Value, Michael J. Lanning

2. The Dilbert Principle, Scott Adams

3. Creating and Leading Market Focused Company: Surviving In a Deregulated Environment, Rollin W. King, Founder & CEO of Southwest Airline, 1970

Innovation

A word with magical significance—to create something new out of a collection of ideas.

Innovation is the life blood of all start-ups. In this context, there is nothing more fulfilling than creating something that solves a specific problem in the day-in-the-life of a customer (or an end user). Vocera has created not just a product, but an entire product category of wearable instant voice communication system. If you pause and think for a moment, there are very few companies that can claim that moniker. We have carved out a very healthy market and serviced it with a system, and a product category, that did not exist before.

To be a leader is hard; a copycat very easy--Apple’s iPhone versus Google’s Android Nexus-One, or Netflix versus Redbox, eBay versus uBid etc. Vocera has shown the hospitals a better way to solve their workflow problem with our unique value proposition. What we need today more than ever before, is more innovation, at a faster pace. We have opened the doors to all our competitors and exposed the workflow management problem in the healthcare space. Now everyone from Cisco, Avaya to Nuance is gunning for those markets and hoping to up-end us. One only had to be present on the HIMSS floor this year to know the extent to which copycats are out for this space.

So what is the recipe for Innovation, you might ask? I have been brewing this in my pot for a long time and here is my secret recipe:

Observation

There must be a backdrop of a problem or a set of problems that one is trying to solve. Innovation rarely happens in a vacuum. One of the best ways to innovate is to suspend any prejudgment about a solution and to immerse oneself in observing the problem. Spend a day in the shoes of the life of your end user/customer or just observe them, as if recording a video, and make mental notes of what they do (or don’t do) and play back the scenarios of what might be possible if they had our solution.

Generally speaking, asking customers a direct question as to what problem(s) they face does not result in the same solution that one would have if one simply observed them going about their daily activities. The idea of focus groups which started in the consumer products space decades ago is quite dated now because customers tend to color their answers with their own bias about the solution. It is best to watch and observe them as they go about doing their day-to-day activities (the concept of a-day-in-the-life-of-a-customer) and then visualize them doing the same thing with your new gadget/solution etc. The outcome between those two exercises is usually quite different.

When Southwest Airline (SWA) wanted to improve their fleet’s turn-around time (time between the plane touching the runway to when the same bird takes off), they methodically observed, then analyzed, all the activities that had to happen during that time period. The solution they uncovered was not something that they would have reached had they not watched and analyzed. They decided to standardize their entire fleet on one single type of aircraft (Boeing 737s) instead of a collection of 5 different fleets. By observing their pilots in-situ they realized that most of the elapsed time was being spent because pilots and the crew had to switch to a different aircraft and to get reoriented to the new cockpit and the safety procedures for that class of jets. Since SWA standardized their fleet, it has bested all national carriers with the quickest turn-around time and is the only airlines since 1971 that has NOT had a losing quarter!

Reshaping the Box

When asked about how ‘The Incredible,’ was created, Oscar winning Pixar Director Brad Bird, who was an outsider and just hired at the company, said in an interview, “Give me the black sheep. I want artists who are frustrated. I want the ones who have another way of doing things that nobody’s listening to. Give us all the guys who are probably headed out the door.” Some of the best ideas that Brad saw generated were by members of the team that were mal-content because they saw different ways of doing things but didn’t have opportunities to try their ideas out. Pixar had had 6 straight $150M+ blockbusters prior to ‘The Incredibles’ and arguably, had figured out the secret sauce. Yet, Brad was brought in by Steve Jobs to shake things up because he was paranoid that complacency might set in.

Google harnesses a similar restlessness within their engineers by allowing them to devote a percentage of their time to pursuing ideas that are of no immediate import to the projects they are on. Further, the notion of quick prototyping-and-testing is very prevalent within the Googleplex. The idea being, that especially when it comes to software, it is better to prototype quickly and test the idea with the target base than to design it fully before launching it. A lot of their search engine algorithm improvements get beta tested, in-situ, on production servers with a high dose of diagnostic monitoring and if the feature/change does not bear expected results, it is simply turned off.

Serendipity

Mishaps are the mother of invention. We all know of the story behind Pepsi (which was accidentally created in search for a cure for dyspepsia), Splenda (originally intended to be an insecticide), or two of 3M’s most successful products, the Scotch-Tape and the Post-It Notes which were both serendipitously stumbled upon when the scientists were pursuing other research.

The main point here is that to stumble upon something interesting, one has to be trying ideas in pursuit of something and be in a state of alertness because we’re thinking about solving a problem. So when Spencer Silver, a 3M scientist in search of a super strong adhesive accidentally developed a super weak adhesive, his partner in crime, who was in the singing choir at St. Paul’s North Presbyterian Church and had been looking for easy bookmarks for his song book, immediately connected the dots and thought of creating what are now the Post-It Notes.

Serendipity doesn’t happen to those who are complacent, but has to be brought about by continuing to be restless.

Innovation at Vocera

Vocerans have all the ingredients--a dash of Observation, a measure of restlessness and a healthy dose of Serendipidity, together these have morphed into some unique new approaches to solving unique new problems faced by our customer base:

· Department based inner circle – an idea that was developed by observing the data patterns collected from many customer sites about calling trends.

· B1000A microphone box design - totally serendipitous. When we left the glue to cure overnight, instead of gluing the foam to the cavity, it glued the entire mic-box to the plastic assembly.

· Whistler ANR - leveraging the design control we have on our mechanical and hardware components to optimize the confluence of mechanical, hardware and firmware design.

· TCP Genie - a unique and unconventional twist to the conventional wisdom of only using UDP for audio streaming in VoIP because the TCP latency for Genie interaction was not noteworthy.

· Staff Assignment application created by Dave Shively visiting several hospitals and spending hours observing activities around a Nurse’s station.

There are many “malcontent” Vocerans who continue to work on ideas such as: using our badges to “automagically” generate WiFi coverage heat maps; CAFI to better understand Vocera health metric; VOS (voice metrics) to measure users voice experience; or the new Care Coordination application