Every health system leader has unprecedented executive management challenges facing their organization in the wake of the pandemic. More than ever, we need all the tools and help we can get to overcome the growing needs of the healthcare system. Dr. Lorissa MacAllister recognizes the need to optimize healthcare environments, leading her to found Enviah. The company helps create healthcare environments where people thrive while helping healthcare providers more effectively accomplish their mission. In this episode, Dr. MacAllister joins Dr. Roger Spoelman and Ben Sawyer to share the story and inspiration behind the development of Enviah and how it aims to align people, processes, physical spaces, and profitability within healthcare organizations. Through case examples and her expertise, Dr. MacAllister challenges traditional healthcare practices and offers a new perspective on driving revenue, improving patient outcomes, and competing with direct-to-consumer entities by optimizing physical spaces. Tune in to this episode and discover how Dr. MacAllister and Enviah are revolutionizing healthcare environments. Take the first step towards transforming your organization by unlocking the untapped potential of your organization’s physical spaces.
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Improving Healthcare Outcomes By Optimizing Healthcare Environments With Dr. Lorissa MacAllister
We are excited about this special edition because we are going to introduce you to someone and something that we are sure you haven’t pondered or considered. Ben Sawyer, my friend and colleague, is with me again.
Roger, it’s good to be here.
It’s great to see you again. Ben is a Six Sigma black belt. He is interested in all kinds of quality initiatives and improvement. He is well-read, and I love talking with him. We have been friends for many years. This is so much fun for us to do this. We are delighted to introduce you to a special friend of mine. I have known Dr. Lorissa MacAllister. She and I have served on boards. We have worked together. We had fascinating coffees together. I’m delighted to introduce her to you.
Lorissa is the President and Founder of her own company called Enviah. I’m not going to spoil it. I’m going to let her tell us what that is, but I have to tell you a little bit about her background. In addition to serving on many boards, both for-profit and not-for-profit, she got her Bachelor’s Degree in Social Work from the University of Vermont. I lived right across Lake Champlain from you at the time in Plattsburgh, New York. It is a beautiful state.
She then decided to go to the University of Michigan to get her degree in Architecture. Being an architect wasn’t enough for Lorissa because she was interested in research and combining her social work background with architecture. She found at Georgia Tech a PhD program, and she has her PhD in Architecture, Culture, and Behavior. You will see in a couple of minutes why that is perfect for what she is passionate about, why she founded her company, and why you need to know what she is doing and how it can help you. Welcome, Dr. Lorissa MacAllister. Thank you for joining us.
Thank you, Roger. I’m excited to be here and participate. I appreciate the opportunity.
Ben and I were talking about this a little bit in advance, and we had a discussion. It would be best for us to start out if you would tell us a little bit about what Enviah is. I know you started it because you felt there were some problems in healthcare that no one else seemed to be solving. Tell us about that. Would you, Lorissa?
When I started Enviah thirteen years ago, what I was finding as an architect is that architects are in the business to sell space. As an architect, I continued to run against the opportunity to sit with executives and leaders to make critical decisions within their organization and try to help them to determine what they needed within the environment.Architects are in the business to sell space. Click To Tweet
We didn’t have the right tools to assess that. We didn’t know within the physical space what was working, what wasn’t working, and what workarounds were happening on the lean side of things to get the team to work at the top of their license. Do we know when the physician is working at the top of their license or any of the clinical staff? There wasn’t an understanding of how people, process, and place were working in concert together.
As you mentioned, my background is in medical social work. Many times, I realized that the environment was letting me down in my ability to do my job. I would have to have crucial conversations in a hallway when I would be better suited to do that in a consult room. I would get different experience outcomes from those engagements.
When I sought to do my PhD, I was working to create tools and help to advance the field to better understand how all of these things work together or don’t work together. Enviah was founded on the development of a science and evidence-led strategic consulting company to build the evidence and the tools that we have a proprietary trade secret around our process and how we approach things that help to align that people, process, place, and profit to healthcare organizations specifically.
When you started the company, who did you have in mind? Did you have an ideal customer in mind to be able to solve their problem? Where did you go looking for people to share this revelation that you had?
We work with our hospital systems. The ideal client was any client that had an issue or a concern that they were thinking, “I need to add more space to solve that problem.” In the industry, if you add something more, you are going to get more of that. You are not going to get a resolution to anything. Recognizing that in any client we were working with. They had a problem or a situation. For example, maybe a patient satisfaction outcome, the likelihood to recommend is low. You want to increase the likelihood of recommending.
How would you do that? We could look at that specific streamline of that process to say, “Likelihood to recommend in what service line? Is it radiology? Is it surgery? Where is that issue? Maybe we can isolate that.” The research approach to that and understanding operationally, what is happening and what experientially is happening. How are they walking through the facility?
What we find is even taking the time, stepping back, and saying, “From the patient’s perspective, what is the trajectory of that patient through the entire system from the moment they pick up the phone to the moment they walk through the door, to the moment they enter their building and enter their clinical space, to then discharge and payment?” All of that holistically is never looked at, and how each staff member and clinician engages with that person from beginning to end. What we help our clients to better understand is the patient experience process and the tools, which are physical space, as well as technology and operational systems to assure that outcome is going to be confidently secured within their system.
On behalf of the audience, can I ask a couple of practical questions about how what you are doing relates to the acute care space, and secondly to the outpatient? With the acute care space, as everyone knows, health systems are struggling bottom line financially. The Kaufman Hall Reports have been coming out demonstrating that, on average, most hospitals are underwater in terms of net operating margin. There is a lot of focus on excess and avoidable days within that process, which is related to avoidable delays.
The first question is practically speaking, how does what you are talking about help them take a look at that through a different lens? Secondly, they are losing volumes in the outpatient side where you are dealing with direct-to-consumer because we haven’t always done direct-to-consumer well in healthcare. I know that is a bit broad. Practically speaking, can you pull out a couple of examples, one in acute and one in the outpatient setting, where the audience can go, “I didn’t even realize that was an opportunity?”
From the acute care side, if we look at major revenue generation in operating rooms, we know that an operating room has a return on investment within its capacity or ability to turn that room a certain amount during that day. The patient experience, the patient’s throughput, and the physician operations are within there as well.
Looking at that holistically, we found and have been able to explore and expose opportunities for direct margin revenue within the existing chassis of most OR facilities because of the potential workarounds within the physical space, operational inefficiencies, or even some clinical opportunities with supply chain, direct margin revenue of up to $6 million within the existing space. Looking at your operating rooms as a potential revenue generation with the realignment of surgeries, the improved performance, and alignment of that physical space to support that patient through that journey. That would be an example.
For the audience, it is taking a look at the OR, front to back, how the providers are using the rooms, the interaction with the SPA and PACU, and making sure that all of that is optimized for the patient experience and optimization of throughput. I presume that extends into the inpatient progression stay.
We are finding an additional 30% capacity in a lot of the operating rooms because of the dysfunction or not streamlining the overall capacity of their facilities. We are able to identify, without building new ORs, you can generate more revenue by looking at your own data. All of our clients were looking at their data, understanding how their environment is working and how to maximize that return on investment, putting different surgeries in different locations, optimizing the utilization of the staff and supply chain requirements, and improving the overall patient experience, and allowing that to occur in the right location.
This goes above and beyond the typical Lean Six Sigma processes they might be using.
Most of the research I have been doing in my PhD is building a correlation between patient experience and staff engagement in physical space environments. What I have been able to prove is there is a statistically significant difference in specific features within a room that I have been able to identify with improved outcomes, for example, the orientation of the hand wash sink in an inpatient room. If you are able to look at the patient while you are washing your hands or gelling in, the skill of the physician score on patient experience has gone up to 26% top box score improvements.
Those subtle changes, you don’t think operationally. You think that you can script all of this out. Those physical components and places within the space are going to increase the overall experience of care. A lot of times, what we are finding is the hospital systems don’t know the data within the room-level analysis. You are looking at unit-level analysis or system-level analysis, but drilling down to the room performance will help to better understand where there may be issues or bottlenecks.
More than likely, the rooms aren’t performing as you think they are because you are amortizing it out over the unit. You are not looking at it in isolation. When you get to the room-level performance, it is clear what may be an issue. For example, overhearing a conversation is much more disruptive than a loud noise of a lawnmower or a room next to a door slamming on a daily basis. It is going to be more disruptive and has lower satisfaction scores in those rooms than others. Thinking about how you can operationally change those to get your overall performance better is what we are looking at. It is the fine-tuning of your space to get the most out of it.
I’m a veteran of healthcare. I survived for nearly 40 years as a healthcare CEO back in the early days before COVID. I was okay. I did a good job. You talk about the environment and how it intersects with healthcare outcomes. My mind goes to things like Yacker Tracker. If it is noisy, we are going to get the Yacker Tracker. We are going to set that up. It was mainly there to sensitize our staff to be quiet and keep their voices down when patients are trying to rest.
There might be something complex if we get some respiratory diseases from a patient room. There have been cases of listeria and legionnaires disease. That is an obvious environment that impacts healthcare outcomes. Where you were was far more than just the fit and finish of the room and materials. The thing I keep thinking about, Lorissa, is you say, “Any way that we can make it easier for our staff to see our patients and our patients to see our staff.” It is the entire setup. It is a long explanation, but who in the hospital is going to get fired up about this, own this, see the value proposition, and do whatever is necessary to engage Enviah to come and do an assessment of our facility so that we can gain these improvements?
The key people we work with are the chief operating officer and the chief financial officer. If you look at it, every building physically is built to generate revenue. When you are building a new building, it pains me when I see, “We are going to spend $40 million on a new inpatient tower.” Do you know what that direct margin revenue is with that $40 million investment? Are you certain when you hire that architect that you are going to get that return on investment and that the business operations are going to be clean, smooth, and fluid? No, it is not.
That is the science and the integrity that we build into the process and operations to be able to understand that every facility is maximized. It would be similar back to what Ben was saying or requesting on the outpatient side and the retail influence of that to say that what we are trying to do is we are looking at the retail environment as the holy grail of understanding every square inch is understood what is generating revenue from the shelf level.
You know if your product is on this shelf, this is the return on investment. How many health systems know on the acute side or even on the ambulatory side what is the revenue generation by room? What is the revenue generation by that system? We should be able to know that. We need to be able to know that to compete as we move into the future. Just a 2% or 1% margin is not going to do it as we move forward. We need to maximize all of our assets. The intention here is to build that business acumen around the role the environment plays and improve that performance.
Most health system leaders would say that’s where a large percentage of the battleground is, in the direct-to-consumer space. There are not a lot of competitors that want to get into the high QA space. It is too asset-intensive and so forth. There are lots of opportunities to improve in the acute care space. They have to do that. That is their bread and butter. In this battleground, where they are competing against top-performing direct-to-consumer entities like Amazon, Walmart, and CVS, can you provide some discrete examples of what you are talking about that can help them better prepare and/or compete with those kinds of sophisticated direct-to-consumer competitors in that space?
I would give you two examples specifically in regard to an understanding of the value of that investment. If you are thinking about your existing facility, do you have access to your data and know what that facility is and how it is performing? An example is a project we worked on with a hospital system for an organization that, for over seven years, we consolidated two locations into one spot. We had the same square footage. We doubled their productivity. We doubled the number of encounters, but we tripled the revenue by square footage. We increased the top box score likelihood to recommend by 8%.
Not only was the value understood that there was increased satisfaction, improved productivity, and additional revenue generation. A lot of the health systems recognize you won’t be able to build all new. We got it, but know your baseline number, and understand what additional capacity and throughput you could get to get there, as well as improve the overall patient experience. You can’t just look at it in isolation. Ben, you can correct me, but with Six Sigma and Lean and all of these aspects, you drill down into an operational understanding when you lose sight of the person. You lose sight of the customer experience that retail does well, and even that feedback loop we were talking about. It is knowing your data and baseline.
The second example is making sure that you have a clear feedback loop that could be done on a regular basis and empowering your staff to make those changes. They all know what they need to do to make that improved experience for that patient. There may not be the capacity at the time of the day because they are working hard and running around to accommodate all they have to have done. It is difficult to accommodate that. Putting those systems in place to have a regular ability to improve care, experience, and outcomes.
When we are doing Lean Six Sigma, the challenge is there are always assumptions that you can’t modify the facility. You take that out of the equation. You are working more on process optimization, people optimization, and training. The other aspect of that is the customer feedback devices that sometimes are used in advanced direct-to-consumer environments that healthcare hasn’t been used to that aren’t factored into the improvement.
One of the reasons why this conversation is interesting to me is because it is not an area where we typically can do anything. We recognize it sometimes, but we don’t delve into it because it is what it is. We’re stuck with the facility we have. We don’t have some of the more advanced consumer feedback devices. It sounds like those are the things you guys are delving into.
This is where I will go to that to say that the environment is always a missing third variable in every equation in regard to operational improvement. It is given. We can’t do anything with it. A simple example was we went to a hospital and mapped their operational model from beginning to end. The staff was beginning to see opportunities of how they could shift their simple space and not make a lot of investment, but move a copier closer to the desk where the person was getting a copy. She wouldn’t have to be running around to get the printer or buy another printer. Even having consolidated health history forms, instead of a clinician or a patient filling out ten health history forms, we identified that you only needed two with the coordinated information.
That reduces the amount of reentry of that work for the staff. It also recognizes what that patient experience from beginning to end, where they need to stop and reposition a room to allow for consults to happen, as well as, meeting with family members or having an exam room. We have made modifications simple to allow for rooms to be multi-use. When you put large fixed equipment into things, you can’t necessarily use them at multiple different times. If you think about a room, you want that room to generate as much revenue as possible.If you think about a room, you want that room to generate as much revenue as possible. Click To Tweet
Make it as flexible and usable. Multi types of things could be done in those rooms. When you have a surge event, you are able to shift it quickly. You are able to generate the revenue and needs you have. More than not, if a lot of our solutions aren’t necessary, you have to build a brand new building. Most of the time, we are talking them out of building something new and recognizing you are not using what you have well. You can get more out of what you have and talk them out of additional spaces.
We had an outpatient facility. We did an audit for an architecture firm. We were able to end the facility. They were going to rent a space for $250,000 a year because they didn’t have enough office environment. When we came in and reconfigured operationally how things were working, we took that $250,000 annually that was going to be spent on additional space that they were renting. We incorporated it into their existing footprint, as well as gave them expansion opportunities to grow what they had by 15%. That is all in the existing footprint. A lot of times, it is just re-looking and recalibrating people, process, and place to be working together all at once.
It would be easy to misunderstand and think of this as a consultation. Lorissa, when you and I met one time for coffee, you laid out on the table this detailed process map. I was so impressed with that. We had previous conversations. You mentioned that in almost every nursing unit or every clinical unit, you asked the staff, “What is the most inefficient part of this? Which rooms are the last rooms to fill and why?”
I’m speaking to our audience. Your teams and people know this information. The problem is you are not going to hear about it. I don’t think there is a venue that has been created for you to hear about it. Lorissa, when you talk about the revenue generation per square foot, I think of the net revenue generation when I think of the expense per square foot that we unknowingly and unwillingly build into our facilities. We might get lucky and find an architect who knows a little bit about this, but typically, no. That is when the workarounds come, and the dead space occurs. All of it costs us money. You can pay for yourself by people bringing you in.
Our hope is that you have a better understanding. We would go in and do an assessment of your facility at our cost to be able to demonstrate your gained revenue potential. My hope with Enviah is to provide the tools for administrators, executives, and leaders to have it at their fingertips and to better understand what they have and what they need.
It would be wonderful if you were confident as an executive leader and owner of your health system to say, “I know for sure that these facilities are at capacity. There is no way for me to do anything more, and I need to build something new, or I need to add on the service line, and I know confidently how to do that?” That is the confidence I hope in demystifying the role the environment plays and the facilities.
A nod to retail. The retail environment will knock down a building and build a brand new building because they know it is efficient. In healthcare, we can’t do that. We know that we have enough data to tap into that understanding and say, “I’m operating 25 inpatient rooms.” More than likely, you are not using all 25. You are probably using 20 because of the 5, maybe one is too hot, one is too cold, one is not laid out properly, or something always breaks. Your ability to get a higher return on that investment of that square footage is never going to happen unless we isolate and understand why that is happening.
We only have a couple of minutes left. We would be remiss if we didn’t ask you about KPIs, input, and process measures that heretofore health systems may not even have thought about putting on their KPI dashboard as it relates to facility optimization. How would you answer that question? What are some key things that are net new KPIs or input and process metrics they should have on their KPI dashboards?
What we look at is productivity by the physician, which I’m sure are clinicians that you have, and the capacity of your physical space. We have an algorithm we work with, and we set benchmarks for the industry, but looking at the capacity of that room and the efficiency of the space. This is why I went back, got my PhD, and started Enviah.
As an architect and planner, I like to equate it as similar to meteorologists and weather forecasters. We add additional color to our square footage when we do programming for a project. We are going to add extra space to the inefficiencies of how the environment is laid out. You got an extra hallway, inefficient on how rooms are laid out, or too much waiting area. The efficiency of the square footage is loose. We could bring it into most of our space and would be most efficiently used by 30%. You could add additional revenue to your environment. It’s between 15% and 30% that most of our clients are finding.
We are able to look at the efficiency of the overall square footage and say, “Is this a highly efficient use of space?” Back to that retail model, they are going to take down a whole new building and build a brand new one because they have an efficient design layout. In healthcare, unfortunately, we can’t take all of our buildings down, but we can at least tighten up the chassis of what we have to get a higher return on those spaces.
Thank you so much, Lorissa. Our time got to an end. Hopefully, we have stimulated enough interest in our audience that they will want to get in touch with you. How best can they do that? How can they get in touch with you?
You are welcome to reach out through Information@Enviah. Environment and Motion for Health is what it stands for. Please feel free to reach out at that. The website is also Enviah.com. I’m happy to have that. Thank you.
Thirty minutes is not nearly enough to scratch the surface. Hopefully, we have stimulated people to think, “I could squeak out much more efficiency and I need to.” This could save some jobs.
Quick question, Lorissa. Was there a white paper you have worked on that may be included in the Baldrige Foundation’s LeaderDialogue blog so people could take a look at it and see a little bit more detail?
It is a response to the publication in Modern Healthcare, additionally with the advisory board, in regards to the five retail giants, how they are coming into the healthcare world, how we as non-for-profit healthcare need to reshift our thinking and focus around the consumer-centric model that’s overtaking our system, and looking at our data and understanding how we can better compete against that.
That will be wonderful for our audience to be able to review.
What a great way to stop wringing your hands and worrying about the future, be armed with some offensive information, and take control of your environment rather than complaining about it.
My hope is that everyone doesn’t build anything new until they understand fully what they have in their current cadre of spaces.
Lorissa, thank you so much. What an interesting spin on all of this. It is more than a spin. It is a philosophical shift that our audience needs to take advantage of and think about. This has been fascinating. Time has gone by quickly. We are not done discussing this. We will have to have a follow-up at some point. Thank you so much, and thank you to our audience. Thank you for taking the time. We are grateful that you have seen it fit to tune in to LeaderDialogue. Thanks for joining us, especially for this special edition of LeaderDialogue brought to you by the Malcolm Baldridge Foundation. We will see you again next time.
About Dr. Lorissa MacAllister
Lorissa is the founder of Enviah, PC a strategic consulting firm that ensures people and places are performing at their optimum. She is a researcher, speaker, architect, and writer who blends her years of experience and expertise in healthcare and architecture to pioneer a unique approach to design in the healthcare industry. Lorissa has dedicated herself to guiding organizations to the next level of integrated performance by systematically aligning operations, spaces, processes, culture, sustainability, business performance, revenue, and user experience.
Using an evidence-based model and Dr. MacAllister’s pioneered approach, Enviah ensures industry-leading outcomes by improving experiences, saving money, and increasing operational efficiencies. This work creates healthcare environments where people thrive while helping healthcare providers more effectively accomplish their mission.
Lorissa will share her perspective and insights on this important theme and topic, providing practical suggestions that can be applied immediately.
Dr. MacAllister holds a Ph.D. from Georgia Tech, a master’s in architecture from The University of Michigan, and a BSW from University of Vermont. Her research includes exploring the patient room and unit physical layouts and their impact on patient self-reported outcomes at Emory University Hospital in Atlanta, Georgia. Additional research includes the exploration of healing environments as a Senior Fellow at the Samueli Institute. She speaks nationally to help bring about transformative change that benefits stakeholders, patients, the community, and the environment.