Time Over Target and the Law of Unintended Consequences

Author: Brian Taylor, Au.D.

This issue of Audiology Practices is devoted to efficiency. Everywhere you go these days you encounter efficiency. Automobile makers are on a constant quest to make cars more fuel efficient and builders strive to make homes and offices more energy efficient. Health care is trying to become more efficient in how they take care of patients. Fortune 500 companies hire so-called efficiency experts to reduce waste. You even hear talk of NFL teams trying to run more efficient offenses. Efficiency is about trying to work smarter, rather than harder. In our quest, however, to optimize profitability or satisfaction, while reducing the amount of wasted time or expense, it is entirely possible to create unintended consequences.

Efficiency is not limited to energy consumption and Aaron Rodgers moving the Green Bay Packers quickly down the field to score another touchdown. As farmers have employed new technologies over the past hundred or so years, food has become much more plentiful and cheaper. But, improved efficiency has a dark side. In the case of more efficient farming, it is unprecedented amounts of obesity and diabetes due in part to the abundance of low cost, super-sized meals.

For audiologists, efficiency is really about “time over target.” In other words, how much time does the practitioner need to spend with each patient to optimize outcome? From an operational perspective, time over target would entail the amount of time spent on marketing, business planning and managing to maximize profitability. Given the complexity of patient care and management of your practice, optimizing efficiency is bound to lead to better patient care, improved profitability, but also some unintended consequences.

There are hundreds of ideas out there that can lead to better efficiency. Here is one example from a 2009 study published in JAAA. Catherine Palmer, Ph.D. and colleagues asked 805 patients the following question during the pre-fitting in-take interview:

On a scale from one to ten, one being the worst and ten being the best, how would you rate your hearing ability?

This question is a helpful way to evaluate your patients’ self-perception of a hearing problem. My guess is that most audiologists talk about motivation and self-perception of a possible hearing problem with their patients, but most us probably don’t directly ask our patients to quantify it in such a way. The results of this study suggest that the answer to this one simple question has the potential to improve one facet of clinical efficiency, which is the counseling and recommendation phase of the pre-fitting appointment. The authors assigned participants’ responses into three buckets. If the patient answered 8 to 10 (minimal hearing problems), there was less than a 20% chance of each patient using amplification. If the patient answered between 1 and 5 (a strong likelihood that a hearing problem is perceived) there was a better than 80% chance that each patient would use hearing aids. Finally, for approximately one-third of patients that responded to the question with a 6 or 7, there was a 50-50 change that they would use amplification – even though this group had essentially the same pure tone average as the patients who answered the question with a 4 or 5 rating. As you may have guessed, quantifying the answer to that question along a 1 to 10 continuum can lead to greater efficiency in the clinic. According to this study, patients responding with an 8 to 10 answer are extremely unlikely to purchase hearing aids, so the appointment becomes more educational in nature. Patients responding with an answer between 1 and 5 can be quickly and efficiently brought into the hearing aid selection process. No need to convince these patients that they need your help; simply go to work finding the best solution to their hearing loss and lifestyle. The golden opportunity rests with the patients who responded to the question with an answer of 6 or 7. Palmer et al’s data would suggest that doing something different with this group; perhaps conducting some type of comprehensive hearing aid demonstration would lead to increased utilization of hearing aids. After all most of the patients in this bucket have a substantial hearing loss and need hearing aids. They just need a little push from you.

Of course, both patients and clinics are complex systems. The law of unintended consequences suggests that improving clinical or business efficiency to any complex system is likely to lead to some unpredictable outcomes. As you read the articles in this edition of Audiology Practices, think about how each tool or idea could improve time over target in your practice. Automated audiometry has the potential to save a lot of time on the mundane aspects of conducting a hearing assessment. Hearing kiosks and disease state marketing have the potential to make our marketing efforts more efficient. Changing the way you conduct a case history or the use of apps for auditory training have the potential to help you optimize time over target. All are interesting tools and concepts. Do they have an unintended downside?

The unbridled quest for better efficiency is sure to have some unintended consequences. Frederick Winslow Taylor (1856-1915) is considered the world’s first efficiency expert. With the use of a stop watch he was able to improve the overall efficiency of automobile production. This led to lower production costs and, eventually, higher pay for workers. It was his seminal ideas that fueled McDonald’s obsession with counting how many burgers are flipped each hour and the phone company’s penchant for monitoring the number of calls each operator is expected to handle each day. These are practices that lead to better efficiency, yet have the tendency to suck the soul out of the employees. Ultimately, the challenge for audiologists is to become more efficient, while not losing the soul of our practices. Not an entirely easy combination of tasks to juggle in 2012.

Palmer, C., Solodar, H., Hurley, W., Byrne, D., Williams, K. (2009). Relationship between self-perception of hearing ability and hearing aid purchase. Journal of the American Academy of Audiology, 20(6), 341-348.