By Brian Lucas
Main Line Health is a shining star of agility in Southeastern Pennsylvania’s health care industry. In fact, it is one of the most progressive health care organizations in the country. Main Line Health is not a small enterprise; it is suburban Philadelphia’s most comprehensive healthcare resource, offering a full range of medical, surgical, obstetric, pediatric, psychiatric and emergency services. At the core of Main Line Health are four of the Southeastern Pennsylvania region’s most respected acute care hospitals—Lankenau, Bryn Mawr, Paoli and Riddle and one of the nation’s premier facilities for rehabilitative medicine, Bryn Mawr Rehab Hospital.
They are especially recognized for their cardiac, orthopedic, oncology, rehabilitation and women’s clinical services. More than 10,000 people are part of the Main Line Health family, making them one of the largest employers in Southeastern Pennsylvania. Main Line Health is an award winning organization. The American Nurses Credential Center has awarded three of Main Line Health’s acute care hospitals—Bryn Mawr, Lankenau and Paoli—“Magnet” status in recognition of their nurses’ skills, professionalism and commitment to superior patient care. A number of their physicians have earned superior national and international reputations as leaders in their specialized fields. Many have been recognized by local and national publications as well as their peers for being among the finest medical professionals in the Greater Philadelphia region.
These achievements speak volumes about Main Line Health’s enlightened management. David Francavilla, who is an incredibly natural agilist, is a Sr. Property Manager at Main Line Health – Property Management – 255 Lancaster Avenue, MOB 1, Suite 104A in Paoli, PA 19301.
LUCAS: Dave, have you ever had any formal training in agile?
LUCAS: In fact, agile as it is being used today as a methodology, is a new term for you?
FRANCAVILLA: Absolutely, my educational background is in Business Management, with a degree is in Business Administration. Of course I was aware of the concept of business agility. However, the true depth of the adaptability of an enterprise to change and the empowerment of teams and individuals to accomplish mission critical initiatives was not something I was exposed to formally in any way.
LUCAS: Tell us a bit more about how you think and how this evolved in you.
FRANCAVILLA: Over the years, I found that I had a natural ability to perceive things, systems, and processes as they really are in their most fundamental sense. I can identify changes or adaptations to make them faster, more efficient and improve the quality of the results with reduced labor. Processes are, in themselves, very unimportant; its SUCCESSFUL results that count. In my career, I was able to take the spirit of what I had learned in my education and go far beyond it to effectively adapt to circumstances that were radically different from what I studied. The key is that I always thought about what I was doing while I was doing it.
LUCAS: How far back does that thinking go in your life?
FRANCAVILLA: Interestingly enough, for me this goes back long before school, to when I was growing up. I was always looking for a better way to do something, not through elaborate efforts, but simple ideas implemented in little short term experiments. Adaptation has always been a part of my physic makeup. For example, I have had extensive martial arts training in very formal schools where the kata was ritualistically taught. However, in most altercations off the mat you have to make considerable adjustments to your form in order to avoid being hit and hurt and, of course, end the confrontation as soon as possible.
When I went into business I carried that mentality with me. It is something that was always with me since I was a kid. I understood that you had to have the basic facts and a fundamental understanding of something, but I often noticed that many people didn’t know what facts were important or were able to really look at something in terms of the goal they were trying to achieve.
LUCAS: So your natural adaptability is something that was with you since you were a child. You said something here that was really important. You just didn’t do and adapt – you constantly THOUGHT about what you were doing in terms of additional knowledge you were gaining as you were working. You also focused in on the goal being important – not the process.
FRANCAVILLA: In reality, as long as there are no ethical violations, it’s the ends that justify the means – not the other way around. Too many people blindly follow a process and won’t speak up, even when they know it isn’t working, because they are afraid of being remonstrated or putting their job in jeopardy. What they don’t realize, is that the anonymity they practice is putting the enterprise in a precarious position since actions that don’t achieve a desired “profitable” result are not sustainable for a company.
It is interesting, but it is really only recently, in hearing you speak about agile at a business exchange meeting, that I have really reflected back on my career and contemplated this adaptability that has enabled me to be successful in different parts of my career. Since that meeting, we have had some very interesting conversations. You have made me think and look at things differently. You have enabled me to consciously realize things that were previously only subliminal for me.
LUCAS: I appreciate that. It is really serendipitous how we think alike in some areas. It makes it easy for me to understand what you are saying and thinking. For example, we both don’t take things on face value.
FRANCAVILLA: Exactly! I remember when we talked about the Internet revolution. I was a young and fairly inexperienced president of a real-estate company in New York at the time. I had leasing directors coming to me with deals for Internet start-ups that looked lucrative on paper because of the amount of money they were prepared to pay for space. It occurred to me however, that contrary to all the boom thinking that was going on, having a stable company in a location for a 10 year lease at a regular rate was more profitable than having a mercurial one paying a higher rate go bust after a year or two. As it turned out, whenever the directors listened to me the results were positive. Where we accepted the so called flash-in-the-pan clients; the expenses of having to recondition and refit the areas after a year or two and getting new clients, were far greater than the higher rents they were paying. We later found software that we were able to use to make these kind of projections and it bore out exactly what I thought.
LUCAS: It seems that a large part of your adaptability is based on a visualization of your goal and predictive analysis. Though your initial understanding is not something that you are married to; and you constantly find ways of revisiting your understanding and assumptions and verifying your facts. I remember you relating how your father would tell you to do something. You always did it in a different way in half the time. For example, I remember you telling me your father did carpentry work and would always tell you to bring out a tool and put it back right away. You however, would always bring out all the tools for the job ahead of time and then put them back one at a time when there was no more use for it. That saved a lot of time running back and forth. You were bucking-the-system, as it were, even at that time. How old were you?
FRANCAVILLA: As early as nine years old, and when I really came into my own as far as agile reasoning was concerned was 12 or 13. I remember playing sports like football. We would strategize ahead of time about a team that had a particularly big or good player. We would put two kids on that player, but if he wasn’t performing well that day. I would suggest we move our coverage back to a man-on-man profile or double cover someone else if they were hot that day. This was always plainly evident to me, but it was hard for me to get the rest of the team to understand; after all we were just kids.
LUCAS: It really doesn’t sound as if agile was something that developed in you. It appears to be something that you were born with. You seem to naturally be able to observe phenomena. You look at the bigger picture and are not confined to what is in the immediate space around you. You see things relative to their interaction with other elements. While you emphasize speed, you never seem to sacrifice quality in whatever you are doing. The time you are saving actually enables you to put greater quality into your effort. A lot of people mistakenly think of agile in terms of quick and dirty, but that’s not true for you.
FRANCAVILLA: Absolutely, when I was a kid and throughout all my adult life, doing the best possible job and having the most productive and satisfying outcome was always foremost in my mind. I think most people build task lists for accomplishing something one task at a time. They start out with the first task they need to do and then the next in a very sequential order. I visualize the end goal and then reason backwards from it to where I am now. I find it enables me to understand the target better by focusing my mind on what is to be rather than where I currently am. It often enables me to skip a couple of the preliminary steps and expend more quality effort on the more critical ones.
Once you have a vision in place, working together in harmony is most important. So very often I have seen situations where people were assigned to a project or initiative and only a few were totally focused on a goal. Maybe as little as one in three persons were dedicated to the successful accomplishment of the goal. Others added no value to the effort and worst still there were those who were actually hindering any progress. In order to work well together, you have to be able to pass information around effectively and efficiently. I have never known of an effort that required collaboration that succeeded without good communications. Motivation is probably the key to both of these. If those involved don’t share a common motivating factor like basic survival or job retention or shared financial success they usually won’t try to work together or communicate with each other.
LUCAS: You introduced a lot of subjects there; motivation or shareholder stake, good communications and teamwork. These are all basic critical success factors for agile. Your experience in the personal securities industry which you related in an earlier conversation, demonstrates when a person’s basic survival is at stake, and they know it, that they are more likely to hone these agile skills successfully. When the threat is greatest – a person’s situational awareness is greatest. That is similar to the concept of tachypsychia.
FRANCAVILLA: And sometimes being agile or adaptive is about getting back to basics – if that is the need. Often people don’t really focus on the right need or goal. For example, it is not important that you cover yourself with a paper trail; because no paper trail will ever produce a satisfying result or achieve an end goal of customer satisfaction. The most important thing; is to accomplish what you set out to do. THAT is what will lead to customer satisfaction.
I remember years ago, I a friend in New York came to me with a business problem. He ran a security service business. He was such a good salesman, that he had reached a point, where his business could not keep up with the work demand. He was starting to have failure rates and it was taking months to train new employees. He knew if he started to turn customers down that it would be disastrous. So I analyzed his entire business processes. From how he got his leads, to who sets up his meetings, to how the results of a meeting are communicated with others, to how the office sets up an account for the new client, to how all the supplies are ordered to service this new client.
What I discovered was that he spent so much time on marketing, and he was such a great marketer; that no one had spent time on the operational end of the business. He was not taking advantage of automation or leveraging computers to his advantage. His fulfillment process was long and meandering. No two people understood the flow in the same way. Also his business was fraught with turnover in a few areas that seemed trivial, but were actually critical to smooth business operations.
So I worked with him to streamline his processes and establish a basic and very simple documentation set on how the business operated. They were actually able to reduce their throughput time so much that their fulfillment issues, even with increased business, disappeared.
Here is a simple example of the kind of improvement I am talking about. Suppose you open mail one piece at a time, and then date stamp it, and then file it. You could do the same work in half the time by opening all the mail, then date stamping it all in one pass, then sorting it into categories for filing it and finally filing it. This very simple change could allow your mail room to shift from being a hold up in the process to being ahead of the demand.
LUCAS: Just to recap, throughout your entire life – you have applied your agile thinking in whatever you have done – whether it was business or personal life. In fact, it seems as if you have a burning need to reinvent whatever surrounds you or whatever situation you are in – using your agile method. I am sure that you have run into considerable resistance in the past, but I am curious as to how things are working out for you at Main Line Health.
FRANCAVILLA: I started at Main Line about three years ago. When I first came into the company, I focused on absorbing what their processes were and what was actually happening. I did not want to come in as a bull in the china shop and change everything right away until I understood what was really going on, the reasons for it and perceived a real need for change. So in the first year I asked a lot of questions, listened very intently and observed very carefully.
The traditional process of office or facility management in the health care arena, we work in, goes like this. A doctor comes in looking for an office or is looking to revamp his current office. We then go out and hire an architect or engineer or both and have them evaluate the current space to see what it needs to meet the tenant’s requirements. They create a set of documentation which we then go out and price. A contract is then negotiated between us and the doctor to see who is paying for what. We will then build the space to specifications and hand it over to the doctor.
In the past our focus was in keeping the upfront expense, like those of architectural and engineering fees, to a minimum for previously occupied spaces. Our thinking was that if the space was good enough for the previous tenant; it was in rentable condition. Well architects and engineers are not going to say no to a lower fee, but they will not do much due diligence if their fee is capped. For example, they will generally only see the facility one time briefly. When I came on board I was handing keys to doctors for office spaces that were freshly painted, newly carpeted and lamped to a doctor. He was initially happy because he was able to move in and start his practice. Later I would get a call from them at two o’clock in the afternoon on a hot summer day saying they were dying because the air conditioning was insufficient. When it was winter I’d get a call in the morning saying it was freezing in the offices.
LUCAS: In this instance being agile actually meant to adopt a strategy of more upfront planning. I know that will sound contradictory to some agile purists, but adapting to the needs successfully is the most important agile principle.
FRANCAVILLA: That’s right, getting complaint calls from clients is a serious problem. What I did was go to the call system and mine it for the information about complaints made from previous tenants. Sure enough I found patterns of HVAC, plumbing, electrical and lighting insufficiency that were addressed tactically, but never dealt with in a strategic sense by reengineering the system. Every time we had to address these complaints it cost us time and money usually at a high rate. The onsite technicians knew of these problems, but did not communicate them with the people who marketed the space. In turn, the people marketing the space did not call the onsite people to see how satisfied the previous tenants were with the space.
The fact is that maintenance of these utilities is very difficult, inconvenient and costly to perform when a tenant is occupying the space. It is far easier and less costly to perform between rentals. So I prepared documentation showing that this was a problem and that in order to stop having the problem we would have to institute a policy change in our upfront refurbishing costs. I proposed that a team be formed of an architect, an engineer, a property manager and an onsite technician as well as the space marketing people to review a facility and its history after a tenant announced they were leaving. I developed a spreadsheet checklist that covered all the historical problems that were reported for the facility and see what was necessary to address them strategically. Our records showed that it was far less expensive for us to correct these issue once-and-for-all during a tenant transition than to fix them temporarily on the fly. Furthermore, our tenants would be much happier when they occupied the space and were able to focus on their business, not facility issues.
LUCAS: What was your management’s reaction to the proposal?
FRANCAVILLA: Management at Main Line Health was progressive enough to recognize this. Their intent had been to actually save the doctor or tenant money, but it turned out that the policy did not have a positive effect. When I presented my case, they recognized the facts immediately. They very quickly adopted a new policy and supported me fully in formulating this change. What surprised me the most, was how receptive Main Line Health’s management was to accepting recommendations early on and how quickly they responded to them.
Since I came in as a senior manager, I was invited to the leadership assemblies. All the senior management would come. There would be hundreds of us. The CEO and the Chairman would tell us about the business plan for the year. They would always present these plans in a clear and direct fashion. Their style was open and friendly and they put great emphasis on presenting to us, not just giving a presentation; their communication skills were superb. Quite frankly their attitude was refreshing and amazingly agile, which I have found to be rare in a company of this size.
LUCAS: I agree with you that it can unfortunately be rare in larger organizations. You just drove home two important agile points again; great communication and open to new ideas. It sounds like these come straight from the top at Main Line Health.
FRANCAVILLA: Jack Lynch, the chairman takes the time throughout the year to send out very well thought out emails. They covered subjects like health care reform, clearly articulating the challenges that Main Line Health faces and even issues that affected the industry in general. He then sets the vision, goal and strategy on how Main Line Health will deal with these challenges. It shows an amazing focus on proactivity and solid strategic planning – balanced with responsiveness to change. He also reports on progress very much in an inverted pyramid fashion where he makes us feel as if his number one goal is to enable us to do our best.
He tells us how we currently rank in the industry. For example, every one of our hospitals is ranked in the top 100, but that we need to do better and what specifically our goal is. He always identifies what our focus should be and these always revolve around quality first and profitability second. He will talk about the importance of infection control for the clinical people and identify key specifics about the process that we need to concentrate on.
LUCAS: What is your relationship like with your immediate management?
FRANCAVILLA: I report to two phenomenal managers; Lisbeth Grossman, the System Director for Real Estate and JoAnne Magnatta, the Head of Real Estate Facilities Design and Construction. They are both very accomplished individuals. Often when you work for people who have achieved as much as they have, there is little room for self-expression or outside ideas. You do things their way and that’s it. These two people made it very clear up front that they expended a great deal of effort in the positions that they fill – looking for people who can think for themselves and bring new strengths to the enterprise.
What really took me by surprise however, is that not only did they listen to me on matters relating to facilities management, but they also embraced ideas I had that were generally not the purview of a property manager. For instance, way finding on a hospital campus; I noticed when I started work that people were having trouble finding their way to the office where they had an appointment. They were fumbling along, sometimes they were exasperated or having physical difficulty with mobility. I started to investigate what we had in terms of signage and way finding and found it to be less than adequate. The signage had grown in an organic fashion without a thought to overall traffic navigational needs.
LUCAS: How did you go about solving the problem?
FRANCAVILLA: I sat down and thought about how I could get a handle on this issue. Direct observation seemed to me to be the best answer. I stood in the lobby from 7 to 11 in the morning with my employee badge clearly displayed that says I am the property manager. If anyone appeared to look inquisitive or lost I would ask if I could help them. It was amazing what I learned. First off, there was a tremendous variance in the information people possessed when they were trying to find their doctor’s office or other destination. Some had everything including a script, a business card and appointment instructions; others only knew the doctor’s last name. Some could not even remember the actual doctor’s name, but knew his specialty.
It became evident that an overall solution had to be devised. It needed to help all types of people; from those who knew exactly what their destination was; to those who possessed minimal information. I knew instinctively that we needed commonality to make this easy to use by various types of people through various entrance and exit points. This meant we needed an orientation map that was ubiquitous and color coded. To make this work, we needed to take the color scheme and follow it throughout the facility. To be economical, we needed something simple like a backdrop on all the signs with a reveal that carried the color theme. This would give us the best of both worlds; continuity in color coding making it easy for patients even on a subliminal level to navigate by color, and freedom for the facility to maintain and remodel areas based upon esthetics that were pleasing to our clients and their customers as well. Lastly, it needed to be implementable in a very simple fashion like using 8 1/2” by 11” holders with plastic sheaves so that they could be easily updated without going to an expensive sign shop.
I very quickly put together a concept and I went to Lisbeth Grossman my immediate manager. I presented to her and asked what she thought. Her reaction was superlative. She didn’t reject it and she didn’t rubber stamp it. She asked very intelligent questions. Then she was good enough to take the time out of her busy schedule to come out and stand with me in the lobby to see the situation first hand. She didn’t delay her decision or action either. When we got back to her office she was immediately planning on how to implement this new signage program. This is now fully in place at the facility I work at and we have received very positive feedback both from our tenants and their customers about the ease of finding offices. People have even gone so far as to inquire when we would implement this at all Main Line Health facilities and now we are starting to do that.
LUCAS: That’s a nice example of enlightened management. Is it common throughout the organization?
FRANCAVILLA: Main Line Health has a term we commonly use which is to guide all our actions. It’s called “The Superior Patient Experience”. It’s a mantra that helps rally and bring everyone in the entire enterprise to a common focus.
LUCAS: That’s a beautiful articulation.
FRANCAVILLA: It’s our code of conduct. Everything is about the patient and we are only as good as our last patient feels we were. For example, if you did a great job within the building, but as the patient is leaving, he has a bad parking lot exit experience, that a problem. Main Line Health not only encourages improvement, but acts quickly to free up funding and fully supports these types of initiatives. That goes right up to the CEO and the board of directors. They are approachable.
If you can demonstrate you have an idea that advances the concept of “Superior Patient Experience”; they are very agile in getting a program off the ground and implementing it. Every month we have a leadership meeting at each one of the hospitals and the hospital president runs this meeting. They present all the financial and operational information and its net effect on the enterprise. Furthermore, they encourage us to share this information with those who don’t attend these meetings. They have a very strong concept of transparency and open communications. It’s really refreshing to know that senior management is working as diligently, or more so, than anyone else in the company and that they are flexible in recognizing that the environment is always changing and that they need to be a step ahead.
Once in a meeting I attended at Bryn Mawr hospital – the room was strewn with hospital gowns, bandages, bed sheets, etc. – just all over the place. The president took over the meeting and said I am sure you are wondering what is going on around you with all the hospital supplies lying about. Well we stock each room to the brim with supplies without consideration as to what the specific patient who will occupy the room needs will be. We did a study and found out that these are the supplies we are throwing away each day, because when a patient leaves a room whether you used the supplies or not they all have to be removed and thrown out. We need to get to the point where we are not wasting supplies like this. It is money down the drain for us and our patients. It was a great to make the point. Paoli hospital has become one of the top ten hospitals and has been asked by the medical community to communicate how they have accomplished this in various conferences. This in turn has led to tremendous financial success.
LUCAS: Well Dave we have come full circle. You started with success being important not processes and ended with that. It really sounds as if a natural agilist has found a home at Main Line Health because they have a “Healthy” attitude towards agile. The health care industry should look to companies like Main Line Health to see how to adapt to the new health legislation, the changing nature of the patient base and the new economy in which we are now fully immersed.
Note: At the time of publication the author never worked for nor had any financial interest in Main Line Health.
Tachypsychia is a neurological condition that alters the perception of time, usually induced by physical exertion or a traumatic event. It is sometimes incorrectly referred to by martial arts instructors and self-defense experts as the Tachy Psyche effect. For someone affected by tachypsychia, time perceived by the individual either lengthens, making events appear to slow down. It is believed that tachypsychiais induced by a combination of high levels of dopamine and norepinephrine. Upon being stimulated by fear or anger, the adrenal medulla automatically produces the hormone epinephrine released directly into the blood stream. This has various effects on bodily systems, including increased heart rate and blood pressure. It is common for a tachypsychia subject’s pulse to rise to between 200 and 300 beats per minute. Dilation of the bronchial passages also occurs, permitting higher absorption of oxygen. Pupils dilate allowing more light to enter, and visual exclusion, or tunnel vision, occurs allowing greater focus. Glucose is released into the bloodstream, generating extra energy by raising the blood sugar level. It is common for an individual to experience auditory exclusion or sensitivity. It is also common for individuals to experience an increased pain tolerance.