The Minute

A note before we start. In field note Nº 25 I said culture is the most valuable clinical variable. In Nº 26 I worked backwards from my daughters. This one puts those two together and measures them in time. Every number is sourced on the page. Almost all of the research is from hospitals, not homes, and I’ll tell you where it stops.

01

Follow the minutes

Strip a nurse’s day all the way down and you don’t get a job description. You get minutes. Every one of them goes somewhere.

Some go to the patient and the family. That’s the work. The assessment, the teaching, the hand on the shoulder, the hard conversation in hospice that nobody else in the family wants to start.

Some go to the work around the patient. Calling the doctor, the pharmacy, the daughter who lives in another state. Necessary, but nobody became a nurse for that.

Some go to the screen. Charting, clicking, logging in, the same field filled out twice on two different screens.

And some just get lost. Waiting, driving, redoing.

If you want to know the quality of a care company, don’t read its mission statement. Follow the minutes.

02

The best argument against me

I want to give you the strongest pushback first, because I’d be making it if I were you.

Healthcare has been promised its time back for twenty years. Electronic records were going to save time. They didn’t. The newest tools look modest when someone actually measures them. A study in JAMA this year followed more than 1,800 clinicians using AI scribes across five health systems and compared them with almost 7,000 who weren’t. The scribes saved about 16 minutes of documentation a day. About 10 percent. After-hours charting didn’t change at all.

And even when a minute does get saved, a lot of companies just stack another visit on top of it. Same tired nurse, more patients.

So why would anybody believe this time is different? Here’s my honest answer. A tool doesn’t give the minute back. A leader decides where the saved minute goes. It’s a choice, and most companies make it without noticing.

03

Where the minutes go

So let’s look at where the minutes go today.

The biggest study I could find followed 767 nurses across 36 hospital units, more than 21,000 hours of watching what they actually did. About 35 percent of their time went to documentation. About 19 percent went to patient care. Less than a third of their time was spent in the patient’s room.

How a hospital nurse’s shift is spent

Documentationshare of practice time35.3%Patient care activitiesshare of practice time19.3%

Less than a third of their time was spent in the patient’s room. A hospital study from 2008.

Then the part that matters most to me. A survey of more than 80,000 nurses found that 79 percent lose time to charting that doesn’t help anyone. Nurses who lose three or more hours a shift to it reported burnout at 46 percent. Nurses who lose less than an hour, 21 percent. More than double.

Burnout by hours lost to charting

3 or more hours a shiftnurses reporting burnout46%Less than an hournurses reporting burnout21%

79 percent of nurses say they lose time to charting that doesn’t help anyone. A survey of reported time.

And burnout isn’t just a feeling. When nurses are stretched thin, patients die more often. That’s been measured across 168 hospitals. When nurses are engaged, patients notice. In the most engaged hospitals, 68 percent of patients would definitely recommend the place. In the least engaged, 54.

Patients who would definitely recommend the hospital

Most engaged nursespatients, definitely recommend68.0%Least engaged nursespatients, definitely recommend53.7%

Each added patient per nurse went with 7 percent higher odds of a patient dying within 30 days, across 168 hospitals.

Now, home health is different. Our nurses are in people’s homes, not on a hospital floor, and there’s very little real research on it. So here’s ours. At HealthView our home health nurses have help writing their visit notes now, and we’ve watched charting go from two hours a day to fifteen minutes. That’s not a study. That’s our nurses.

04

What fills a saved minute

Here’s the piece I think most people miss.

A saved minute is empty. It’s just time. Something has to fill it. And what fills it is culture.

A nurse who’s burned out doesn’t turn ten extra minutes into a better visit. She turns it into a breath, or into the next chart. A nurse who feels supported sits down. She listens. She teaches the family how to give the medication at three in the morning so they’re not scared. The minute is the same length. What happens inside it is completely different.

Let me show you what I mean. This next part isn’t a memory. It’s a picture of the day I’m working toward.

It’s twenty years from now. One of my daughters is a hospice nurse. It’s a Tuesday afternoon and she pulls up to a small house in Whittier. Inside there’s a man in a hospital bed in the living room, and his wife, who hasn’t really slept in three days.

She walks in with her hands free. While she checks his breathing and his skin and asks how the night went, nobody has to stop and type. When she sits down on the couch next to the wife, there’s no screen between them.

The wife asks the question everybody asks. How much time do we have? My daughter doesn’t look at a monitor for the answer. She looks at her. She takes her hand and tells her the truth, gently, and then she stays. Twenty minutes she would have spent charting in the car, she spends right there. They talk about his favorite songs. She shows her how to keep his mouth moist, so she isn’t scared tonight.

Then she drives home, and she’s home for dinner. A nurse who still loves the job, which means she’ll be back tomorrow.

I don’t know if my girls will become nurses. But that’s the day I’m working toward.

05

A Monday in October

So when people ask me why HealthView cares so much about culture, it isn’t a perk. It’s how the minute becomes care. And we score it from the outside, not from my office. Our team satisfaction is at 98 percent. Fortune named us one of the Best Small Workplaces in the country, and this year one of the Best Workplaces for Women.

Let me take you to a Monday in October. The Fortune and Great Place To Work awards had come in, and we pulled a Habit burger truck into the parking lot outside our office.

We put up the blue HealthView tent. Somebody tied red and gold balloons to the corners. There was yellow caution tape and an orange cone to keep the cars out, which is about as fancy as a home health company gets.

And people came from everywhere. Nurses from across the four counties we serve. Our sister communities. Our regional teams, our therapists. People who talk to each other every day on the phone and had never actually stood next to each other. For once, everybody got to put a face to a name.

I had a lot of conversations that day, and none of them were about the census or the schedule. Their kids, their weekends, what they’re going through, what they’re excited about. That’s the human to human stuff. It’s what gives us meaning. And it’s exactly the kind of minute that disappears first when everybody’s buried in a screen.

Nobody there was talking about the award. But I caught the smiles.

Now, it could have been that Habit makes a really good burger. I’ll give them that. But I think it was something else. It was time. Time to actually enjoy your team. That’s what a saved minute looks like when it lands somewhere good.

06

What the last room teaches

Working in hospice teaches you something most families don’t learn until they need it.

I was born in 1983, the year Medicare started paying for hospice. I don’t think that’s a coincidence anymore.

At the end, the minutes are finite and everybody knows it. Families don’t remember what got charted. They remember who sat with them. They remember who came back into the room when they were scared at three in the morning.

My grandma had a very unspecial death in a hospital. That’s when I knew this had to change. When I think about her now, I don’t think about the equipment or the paperwork. I think about the minutes she didn’t get.

If you work backwards from that last room, the whole thing gets simple. Every minute we can give back is a minute a family gets at the end.

It’s why HealthView’s whole mission is two words. When Monica and I worked on our mission, we questioned every word and deleted until only two survived. We stay.

We stay with the family. Through recovery, through illness, through goodbye, and through the grief that follows. In hospice that means staying to the very last hour, when there’s nothing left to bill for except being there.

And it points both ways. We stay with our people too. You can’t ask a nurse to stay with a family if the company won’t stay with her.

That’s what gave me time for conversations like the one with Nate. Our chaplain, Nate, told me he wanted to be a pastor. Through the ministry he got directed to hospice, and he ended up finding us. And he connected with our purpose.

The most human thing you can do is find your purpose. And you don’t learn that about your team without talking like a human. Not just about work.

07

Who decides

So who decides where the minute goes?

Inc. ran a story recently about Starbucks. For years they optimized everything. Push people to the app, build pickup-only counters, pull out the seats, move the next order. Somewhere in there it stopped being a place you wanted to sit. Now they’re undoing it, and sales are up 7.2 percent.

Efficiency alone didn’t win. Taking the human out cost them the reason people came. Care works the same way. Families don’t pay for our charting. They pay for the nurse who sits down and stays.

There’s an old idea from the best factories in the world. Waste is anything the customer wouldn’t pay for. A charting field nobody reads is waste. A screen the nurse has to stare at while the patient talks to her back is waste. Our job is to find it and take it out, and then protect what we give back.

08

Where I could be wrong

Here’s where I could be wrong. We could do all of this and the minutes could still leak. Into more visits, into more meetings, into a busier day that looks productive on a spreadsheet. Saving a minute is the easy part. Protecting where it goes is the hard part, and that’s on me as the CEO.

I could also be wrong that the screen can get out of the way at all. Maybe that’s just how work is now. I don’t believe that. But we’re going to measure it, and if our numbers say otherwise, you’ll hear it here.

09

The ask

If you run a care company, do one thing this week. Pick one nurse, with her permission, and follow her minutes for a day. Not her schedule. Her minutes. How many went to a person, and how many went to a screen? Then ask yourself where you’d put the ones you could give back.

And if you’re not in healthcare, the same question works in your own life. How many of your minutes today went to a person, and how many went to a screen?

Next time, I want to show you our own numbers. What our nurses’ days actually look like.

10

Right here with me

One more thing, as a girl dad. I keep coming back to my daughter’s song.

Right here with me. That’s what a family wants at three in the morning. It’s what a patient wants when the nurse walks in. Honestly, it’s what my girls want from me when I get home and my phone is still in my hand. I’m working on that one too.

Because one day my daughters might walk into a home in scrubs. And when they do, I want them looking at the person in front of them, not a screen.