Customer-Inspired® Six Sigma Methodology Reduces Report Delivery Time by 50%

by Doris Peckron, Director, Health Information Management, and Marty Herbst, Manager, Transcription

Christian Hospital faces increased competition from other St. Louis area hospitals and, in a proactive move to cut losses and improve goodwill with admitting physicians, instituted a process improvement initiative that focuses on the primary customer of each key process. One such process undergoing transformation is the delivery of transcribed reports – a process that touches every patient going through the hospital. This article describes how turnaround times were slashed in half and what further improvements are planned.

Background

Christian Hospital is a non-profit organization, 493-bed acute-care facility located on 28 acres in unincorporated north St. Louis County, Missouri. A founding member of BJC HealthCare, Christian Hospital has more than 600 physicians on staff and a diverse workforce of more than 2,500 health-care professionals who are dedicated to providing the best care using the latest technology and medical advances.

In an area of St. Louis where a lot of older residents live, 55 percent of Christian Hospital’s patients are on Medicare. This large, aging population comes in with multiple issues, which require more specialist consultations before surgery, and places a heavier burden on internal services within the hospital. In late 2004, Christian Hospital retained Shaw Resources to help launch a process improvement program to improve service efficiency, bolster patient and physician satisfaction, and boost quality throughout the organization.

Problem

The Chief Financial Officer receives a monthly report from the Transcription Department regarding history and physical, consult, and operative transcription report turnaround times and error rates. Even though the department was consistently meeting its service guarantee of 24-hour turn around times (TAT), the CFO was concerned about physician satisfaction with report availability. Additionally, the CFO was looking at current patient admission/discharge cycle times and thought that an improvement in transcription TAT would improve physician satisfaction by providing them with patient information in a shorter timeframe.

Process Improvement Approach

In June, 2005, the Transcription Department was asked to participate in the Process Improvement initiative to address report turnaround time. A cross-functional team was assembled with representatives from each of the affected departments: Marty Herbst, Manager, Transcription, Doris Peckron, Director HIM, Judy Moore, Hospital-Based Transcriptionist, Diane Williams, Home-Based Transcriptionist, Jackie Hoffman, Clerical Support, and Jerry Lohman, IS. Under the guidance of James Shaw, an outside consultant, they began gathering the data required to put together a process improvement plan.

With the patented Customer-Inspired® methodology formulated by Shaw Resources for a framework, the team followed a continuous process improvement structure similar to the Define Measure Analyze Improve Control (DMAIC) structure of Six Sigma, with one caveat: everything had to be addressed from the point of view of the customer of the process.

Define the Process

Using the commercially-obtained Process Advisor® software, the team worked through an eight-step patented process definition methodology, as follows:

1. Beginning with a process purpose statement, which explains why the process exists within the organization, the team brainstormed and established their Charter Statement: To provide timely, accurate reports to the proper location.
2. Next, a process owner had to be identified, someone who coordinates all process activities and is ultimately accountable for process performance. Marty Herbst, Manager Transcription, took on this role.
3. Working to refine the process definition, the team composed a table of outputs – what the process yields – along with identifying who the primary customer of each output is and what measures best indicated the delivery of the output to the customer. In this case, the output table is as follows:
   

   Figure 1: shows the Outputs table produced by the Process Advisor software.

4. Once the outputs and primary customers were determined, the team then established the end of the process as experienced by the customer – when the report is placed in the chart. Customers of a process can be internal to the organization, like the physicians who dictate the reports, or they can be external to the organization, such as a nursing home or other facilities. All the customers of the reports, in the case of Christian Hospital, are caregivers: whoever needs the reported information to make a decision about the care needed for that patient.
5. Working in reverse, the team then identified the inputs – the products and services or information needed to produce the outputs of the process – and who the suppliers of the inputs are. Here, the suppliers are Treating Physicians who furnish complete and understandable dictation.
   

   Figure 2: Shows the Inputs table for the Process Profile® Graphic.

6. Once the inputs and suppliers have been pinpointed, the beginning of the process, from the point of view of the primary customer, is determined – in this case, it is when the caregiver completes dictation of a report.
7. To clarify what happens in a process, a meaningful name is assigned. The Customer-Inspired methodology calls for a verb-plus-object format when naming a process; our team came up with the name “Provide Transcription Services Sub-Process.” This process name identifies all reports and tables associated with this process improvement project.
8. The final step in Defining the Process brings everything together in a high-level diagram that summarizes the process. Using the patented software, the team produced the following Process Profile® graphic:

Figure 3: The Process Profile Graphic documents the definition of the Provide Transcription Services Sub-Process.

A significant component of the Process Profile graphic is the Qualification Level, which is a formal method of evaluating and ranking a process’ performance. The Qualification Level, initially developed by IBM and later adapted to healthcare by Shaw Resources, develops a quantifiable measure for the “health” of the process so that everyone has an understanding of how well that process is performing; the lower the number, the better the performance.

The team started at level 6 – an unknown level of performance. After six months, we moved to 4.08, into the ‘Functional’ status of performance. Using the Process Advisor software checklists, the Qualification score was automatically computed.

Measure the Process

As shown in Figure 3 above, Marty and her team determined three types of measures:

• Time-related: Time from when a report is dictated until it is available. A three-month analysis of turnaround times for selected types of reports – History & Physicals, Operations, and Consultations – showed a stable process with few deviations, and none of statistical relevance (see Figure 4 below for an example chart). This same stability made it a prime target for improvement, showing that the goal was easily attained. Additionally, since the transcription process directly affects one of the primary customers of the hospital (physicians and other caregivers), any improvements will have a double impact by increasing caregiver satisfaction.

• Adverse Indicators: # of incomplete reports; # of reports that need QA; calls from caregivers inquiring about the report status; increase in the # of delinquent records; # of reworked reports; # of reports going to the wrong location; # of incomplete reports filed in the chart.
• Management costs: No resources were added and no cost increases were experienced outside those associated with increased volumes. The team delivered improved quality of service with no increase in unit cost – quality is free. Since the year-over-year cost per line was the same, the cost was actually less after adjusting for inflation.

Analyze the Process

Looking at all the baseline measures for the time from when a report is dictated until it is available (Figure 4), it was obviously a stable process with few adverse indicators (reports delivered later than 24 hours after dictation). From here, the team determined a new goal for the time-related measure, and wanted to make it a stretch goal by cutting turnaround times by 50 percent: 12-hour turnaround times for these reports.

Investigation into the causes for failing to achieve the 12 hour TAT uncovered a number of interesting sources contributing to the variation:

• Treating physicians dictate reports at all times of the night, as shown in Figure 6.

• Loosely structured Medical Transcriptionists schedule worked for 24 hour TAT, but could not meet the goal of a 12-hour TAT.
• 24/7 operation had significant gaps in it – particularly Saturday night, Sunday, midnights.
• Weekend and evening coverage was insufficient for volumes.
• Inconsistency of transcriptionists’ start times and hours worked per day, as shown in Figure 7 below.

• Home-based transcriptionists lacked information about volume of reports in the queue for transcription and who was working what hours.

Improve the Process

Initially, we identified the most pressing ‘defect’ of the transcription process as reports not printing in the correct place (going to the wrong unit/printer in the hospital). We brainstormed the causes of this process deficiency. The brainstorming revealed a surprising number of reasons behind this shortcoming (see Figure 8).

Armed with the findings from the analysis, the team made process changes aimed at improving the measures of timeliness, accuracy and printing to the correct location:

• To provide complete 24/7 coverage for physicians submitting dictation around the clock, the following changes were made to transcriptionists’ schedules.
• Specific start times and days were assigned to all transcriptionists.
• Weekend rotations were introduced to supplement existing coverage.
• Evening / weekend coverage for odd hours not initially covered was established to provide true 24/7 staffing.

The following changes were made on the dictation system in routing work to the transcriptionists:

• Sequence of report types was tailored for each individual pool. Formerly, Consults gradually ‘fell to the bottom of the pool’ as new work types were added, therefore taking longer to get done. Additionally, the number of Consults were, at a minimum, two times greater than other reports due to the number of specialists called in by the attending physician for elderly patient care. Consults were therefore ‘realigned’ to move up higher in the transcription pool.
• Set up baseline “aging” pools; this flagged older reports, allowing the reports to be prioritized to appropriately meet the new 12-hour turnaround time goal.
• Developed “Guidelines for Home-Based Transcriptionists;” these guidelines were specific about the scheduling issues of times and days that were not covered by a transcriptionist. Schedules were reworked to make the turnaround time goals happen as required. Improved communications for downtimes, time off, etc.

Information Systems-related changes included–

• Medical Record number was entered twice, one with an extra “0″ and without a room number that caused the transcribed report to be sent to the wrong location – this was corrected by IS.
• Transfer patients showed in two open units, causing the report to be directed to the wrong location. This was fixed through programming changes.
• One surprising discovery in uncovering causes for reports printing in the wrong location was that transcriptionists would select the wrong patient type at the time of transcription. This error was eliminated by moving the patient type field in the patient search screen to the top of the screen. (See Figure 9)

Control the Process

The team went even further in order to maintain control over the process and continuously improve it through benchmarking. They surveyed caregivers and contacted other hospitals, both internal to the BJC Healthcare system as well as external organizations who were Baldrige National Quality Award Winners.

Surveys tend to try to measure satisfaction, which is a temporary state of mind, and therefore not a preferred measure for quality or loyalty. So the Process Improvement Team created a survey that instead measured how well the transcription services met/failed to meet or exceeded treating physicians’ expectations.

The feedback from team members and customers (caregivers) has been overwhelmingly positive. One physician recently commented that “I dictated the report, and by the time I got to my office, the report was there.”

Additional control measures were put in place, such as adding a Weekly Production Statistics Report to track TAT, defects, etc, that helps the team manage the process more effectively.

Benchmarks against other organizations, especially against world-class Baldrige-winner hospitals, gave the team a better understanding of where the Provide Transcription Services Sub-Process stood. The team selected sister BJC Hospital Missouri Baptist Medical Center as their internal comparison; and Baldrige winners DePaul Health Center, St. Louis, MO, St. Luke’s, Kansas City, MO, and Baptist Hospital, Pensacola, FL, as their external benchmarks.

Accomplishments

In a relatively short amount of time – only six months from inception – the Process Improvement Team has learned a great deal about the Provide Transcription Services Sub-Process and made some exemplary improvements.

• Met or exceeded our goals and benchmarks of six hours for H&Ps and Consults, 12 hours for Operations, One hour for Stats.

• Manager (Marty) was set up with a home-based workstation to monitor and address the escalation process put in place (ie: fill in weekend slot, unusual number of reports backing up in the queue, or a technical problem).
• Daily emails on volume status to Medical Transcriptionists increased to three times a day made the status more real-time to provide transcriptionists with a better view of volume.
• Weekly Production Statistics Report – new report internal to the team from Marty to track TAT, defects, etc, to help manage the process more effectively.
• Medical Transcriptionists’ Work Schedule is emailed three weeks in advance, which ensures appropriate coverage 24/7. Transcriptionists previously did not see the schedule at all and now schedules are sent out nine weeks in advance to help all staff to organize vacations, and other personal time off.
• Turnaround time results/graphs discussed at monthly meetings so that everyone knows the current status.
• Transcriptionists “stepped forward” to take hours to fill the early am and late pm gaps – worked as a team to ensure that goals were met.
• Rotation schedules established for weekends – ensure coverage for all hours, and not enough people who wanted to work every weekend – so started a rotation schedule to give some people weekends off who needed/wanted them.
• AMH Turnaround Time improved as a byproduct – Alton Memorial Hospital is another institution within BJC, and Christian Hospital does their transcription as well.
• Cross-trained transcriptionists to do CH and AMH work types.
• Overall physician satisfaction with improved report delivery time has inceased. A byproduct of the shorter report delivery times is that doctors remember more of the patient interaction and are able to make better corrections, thus, improving the quality of service to the patients.
• Process Qualification Level of 4.08 – This qualification level indicates that the process is functional and all primary customer expectations are being met. The process is systematically measured, and streamlining has begun.

Next Steps

In order to facilitate continued improvements, the team identified several resources that would be required: the availability of a data resource person; capital resources to implement speech recognition and E-sign capabilities for physicians to electronically sign dictated reports; and expansion of the reporting capabilities of source system. Future objectives and challenges have been ascertained as follows:

• Implement new dictation system 2006-2007
  • Speech Recognition – This will provide additional convenience for physicians; the transcriptionists will become more like editors to improve productivity; cost savings and productivity to be determined.
  • National average age of Medical Transcriptionist = 52(average age at Christian Hospital is 50); speech recognition will help prevent repetitive injuries (carpal tunnel, etc,) that affect older workers. Additionally, the new technology may attract younger workers; a major issue is that fewer people are selecting transcription as a career option.
• Increase / decrease volumes – no prediction available – either increase or decrease can be challenging with staffing:
  • Transcribed Lines increased 2.9% 2005
  • 2006 so far is up 9.6% – continued measurement will determine whether it is a trend, or just a seasonal flux.
• Provide Electronic Signature – by second quarter 2007; this was found to be the ‘end of process’ from the treating physician’s point of view, while the transcription department considered it as a separate process. Providing this capability will decrease the time for paperwork for the physicians; also appeals to physicians who are technologically savvy, thus helping to recruit new admitting physicians.
• Provide alternate report distribution methods, i.e. email (currently using autofax, inter-office mail, US mail, pick-up) – another satisfier for physicians’ offices.
• Seek feedback/survey from customers – this is part of the continued measurement, analysis, improvement cycles of the Customer-Inspired methodology.
• Communicate service guarantee by end of Q2 2006
  • STATS — 1hour
  • History & Physicals — 6 hours
  • Consultations — 6 hours
  • Operations — 12hours
• Process Qualification Level
  • 3.25 by August 15, 2006 – the service guarantee is communicated and re-survey the customers.

Summary

Dramatic, quantifiable results have been achieved within six months. Christian Hospital has not only cut report turnaround times from 24 hours to 12 hours or less, but has increased physician satisfaction regarding timely reports.

Shorter turnaround times have enabled dictating physicians to now focus on the quality of the reports. Since they receive the report in less time after speaking with the patient, they remember more of the patient interaction and are able to make better corrections, thus, improving the quality of service to the patients.

All the quality improvements have come at little or no cost, reinforcing the adage that quality is free. The benefits will be adding up for years to come as the same process improvement methodology that the team learned for the transcription process will also serve them well in dealing with future technologies.

The process improvement would not have been started as soon as it did without the buy in and support of the CFO. It is paramount that senior executives lead the charge for process improvement within the organization, and support recommendations for future improvements. With the backing of senior management, results like the ones realized by the Transcription Department can be pushed throughout the organization, one department at a time.

Copyright © Shaw Resources, 2006, all rights reserved. (888-742-9737), email: Info@ShawResources.com; www.ShawResources.com. You may reproduce this article provided: 1) each copy you generate is of the article in its entirety, without modification of any kind; 2) you receive no fee whatsoever; and 3) this copyright and permission notice, including the contact information, must be prominently displayed on each copy produced.

by Robert L. Boyle, Jr., M.P.H., FACMPE, James G. Shaw, M.B.A. and Diane Stewart

Copyright Shaw Resources 1994

Introduction

Macro management’s days in health care are numbered. Medical group administrators can no longer rely on expanding revenues by increasing the client base, adding physicians or tweaking fees. Instead, the major challenge facing health care management today is to do more with less. Given this challenge, we at Palo Alto Medical Foundation (PAMF) began (in late 1991) to think about Continuous Quality Improvement (CQI) as an answer. A non-profit foundation formed as a partnership with an association of 150 physicians, PAMF is located in the California’s Bay Area’s “Silicon Valley,” noted for cutting-edge technologies and business practices. The CQI approach has many advocates in the Bay Area, which is home to several finalists for the Malcolm Baldridge National Quality Award and two recent winners: Solectron (1991) and Granite Rock (1992).

Shortcomings of Existing CQI Programs

To find out what some of the pitfalls in a CQI effort might be, we talked with colleagues currently involved in QI (QI) programs. Several shortcomings they reported included:

• No game plan: Without a way to integrate the quality process with business goals, the quality effort was scattershot and lacked relevance -to the organization as a whole. Employees learned techniques of QI but had no infrastructure allowing them to be put to use.
• Physician involvement: Lack of physician participation meant playing with half a team.
• Train and drain: Employee quality training was wasted when it was not put to immediate and relevant use.
• Lack of accountability: -Without clearly assigned responsibilities, QI efforts faltered. The lack of a quality process leader often meant the -collapse of the program.
• Quality “show dogs”: Isolated improvements looked good but did not significantly affect quality in ways that mattered to the -organization. Small successes were common but significant breakthroughs were rare.

Identifying Our Key Processes

After investigating some well-known QI consulting firms, we decided to retain a consultant experienced in process management, a systematic approach to QI developed in industry. This approach assumes that processes, not people, are the problem. Process management is an objective methodology that focuses on the actual work that gets done in an organization, breaking down each process into specific activities that can be analyzed and measured.

Process management had an impressive track record in manufacturing, but the question here was: would it work for a medical clinic? Using a proprietary methodology called1 Customer Process Deployment(TM), our consultant helped us develop an organization-wide plan to improve our clinic’s processes. His approach provided us with a game plan rather than a playbook. The “plays” of QI are fairly familiar; Statistical Process Control methods and Pareto diagrams are examples. But winning the quality game requires a game plan that fits the plays into an overall strategy. Our strategists, meeting weekly for one and a half hours as the executive quality council, were seven senior administrators, all reporting to the CEO, and five executive physicians. Our consultant acted as the coach, providing “hands-on” training in process management techniques. Our first task was to determine which processes would help achieve the clinic’s overall goal of high quality patient care. Since the patient is the ultimate judge of quality, this involved viewing the clinic’s processes from a patient’s point of view. Putting ourselves in the patient’s shoes, we mentally toured our clinic, identifying each process encountered. When a patient calls to make an appointment, for example, he or she encounters the process “Schedule Patient.” Our first two meetings were spent identifying those processes affecting the patient’s perception of quality, central to long-term success. These were our key processes. Once we had identified our key processes, we created a flow chart of them and their interrelationships. We also added support processes, those that maintain the processes directly related to patient care. (See Figure 1) For each box on the chart, a process improvement team, led by one or more owners from the executive quality council, is appointed. The entire organization is represented on the flow chart in terms of its processes, so people can see how they fit in. The chart serves as both an organization-wide plan and a management tool for administering it.

Selecting a Process to Improve and Assigning Ownership

We couldn’t, of course, improve all of our processes at once; we had to prioritize them. Some of our processes we knew to be working well; others we knew had problems, such as the Scheduling Patient process. We chose this process early on as one to improve, chiefly because it was an “upstream” process. Errors in an “upstream” process become repeated in subsequent processes for a costly cascading effect. The council considered the Schedule Patients process so important, the PAMF director and its physician executive director agreed to lead its improvement effort as process co-owners. Assigning ownership to a process builds in accountability and ensures the commitment of top management. Other members of the Schedule Patient process improvement team were: the medical director, the clinical area manager, four other physicians, two other administrators, a receptionist and a facilitator.

The importance of a facilitator is worth mentioning. The facilitator does not need to come from outside the organization, but he or she should be trained and without a vested interest in the issues under discussion. Our consultant and our director of quality management acted as our first facilitators, and, as we went along, they trained other managers to facilitate improvement teams outside their organizational jurisdiction.

Creating the Customer/ Supplier Diagram

The first step in improving any process involves identifying the “customers” of the process and the outputs they require from “suppliers.” After considerable discussion, the Schedule Patients process, customers and their required outputs were identified as shown in Figure 2.

The team spent considerable amounts of time discussing whether or not the physician was a customer of the process, finally concluding that the physician was a supplier of skills and resources to the process, not a customer. An exception was a physician who referred a patient to another physician. In this instance, the referring physician was deemed a customer. Next the team identified the measures used by the process’s customers to evaluate quality. Quality measures usually fall into one of two categories: cycle time -the time it takes customers to receive what they requested; and adverse indicators – defects, or the customer’s negative experiences.
The team agreed that the main cycle time measures were:

• The amount of time spent making the appointment;
• Access time, the time between the making of the appointment and being seen by the physician; and
• The time between the scheduled appointment hour and when the physician actually sees the patient.

The adverse indicators for the process included:

• The number of failed attempts to make an appointment;
• The number of complaints;
• The number of patient “no-shows;
• The number of errors in recording patient information; and
• The number of patients double-booked at the last minute because the schedule was full.

Once the quality measures were identified, the team could brainstorm the inputs needed by the schedule patients process. The team agreed that the most important input was dependable physician availability to patients. If a physician was seeing too many patients, cycle times were too long. The medical skill mix available had a similar impact. Other factors were available space, equipment and hours of operation.

At this point, the executive quality council and the process improvement team were ready to create a customer/supplier diagram for the schedule patients process. This diagram summarized the customer and supplier inputs, the process outputs and the quality measures used to evaluate the process. (A customer/supplier diagram is developed for each key process, as it becomes a candidate for improvement.). Developing the customer/supplier diagram had several beneficial results. For one thing, staff changed the way they thought about their jobs. They looked at the process objectively, in terms of its activities, and gained an understanding of how their jobs fit into the clinic’s overall operations. They also realized that they were working for the patient, not the physician. By taking the patient’s viewpoint, the team focused on the appropriate activities to improve. The diagram also clarified responsibility and accountability for the specific activities of the process and established the parameters for analyzing and collecting data.

Identifying What to Improve

To decide what needed improvement, the team created a flow chart of the schedule patients process, showing the activities and relationships. Looking at the process in this new way revealed dozens of opportunities for improvements. Next the team reviewed the feedback measures, cycle times and defects measures that generated even more ideas for ways to improve. Many involved small changes the team was able to implement right away, such as using an existing “advice nurse” group in the family practice department to speed the response to patients’ messages. It was not always necessary for the entire process team to work on an improvement either; individuals or small subteams could be assigned the task. The more significant projects, however, needed to be explored in more detail. For example, the team determined that patient “no shows” were a significant adverse indicator. The team brainstormed the reasons why a patient might fail to show up for an appointment and charted them on a cause-and-effect diagram. The cause-and-effect diagram then served as a guide in developing a series of open-ended questions for a telephone survey of no-show patients, and the answers to the questions were tallied and graphed on a Pareto diagram. As Figure 3 shows, the most common reason for no-shows was that the patient forgot about the appointment. To address this problem the team designed three different reminder systems and is currently measuring the results of each to determine which will work best. Other causes will be addressed as the team’s work progresses.

Developing a Review Process

To evaluate improvements and goals, the executive quality council set up a biannual review for each key process. Objective feedback measures include a storyboard display of improvement data (how much cycle times have been reduced, how many complaints have been received, and so on). The quality council also adopted a six-level rating scheme to monitor and evaluate progress. Each rating level has specific requirements that must be met before a process advances to the next highest rating.

In addition to establishing objective measurements of a process’s improvement, the review process provides an opportunity to recognize the contributions of team members, boosting morale and team spirit. People feel they have a personal connection to the organization, and that they are helping to make things better. The review process is also a chance to gain executive buy-in for any potentially controversial improvements.

Some Results

In our first year, we chose four processes to improve: schedule patients, register patients, enter charges and manage patient medical information. We began seeing results in only four months. For example, the number of charge sheets turned in by physicians by deadline improved 25 percent for substantial savings. We also reduced claims denials due to registration errors by 50 percent. This gain represented numerous small improvements, but larger gains resulted from single changes, too. This was the case in pediatrics, which had the longest average waiting room time in the clinic – 30 minutes. The team traced the source of the problem to “same-day” appointments, which were being shoehorned into the schedule. Upon analysis, it turned out that the number of “same-day” appointments on any given day was predictable. By allowing a certain number of slots for them, the team reduced the thirty-minute wait to 19 minutes, a 30 percent improvement. Results like these have an obviously favorable impact on our bottom line, but we feel benefits not so easily expressed in percentages have been equally important. One such benefit is the development of our in-house management resources. The members of the executive quality council have gained new process management skills that they can use in a variety of situations. And gradually, their skills are being shared with other managers, as more and more key processes become part of the CQI program. Positive employee relations and an emerging culture of cooperation have been two other results. The objective approach to processes not people minimizes finger pointing, personality conflicts and attitude problems. People from different departments working as a team get to know one another and form relationships, fostering cooperation. Because everyone on the team has an equal voice, everyone is a stakeholder. Perhaps the most important benefit of all is that we are seeing improved results all the time. The continuous in continuous quality improvement is real.

Lessons Learned

The Customer Process Deployment method we used for our CQI program avoided the shortcomings reported by our colleagues at the outset. We learned some important lessons. One was that success depends on understanding the key processes of your organization. A good rule of thumb is: don’t try to improve anything unless you can identify the process to be improved and the specific measure that will signify improvement. A QI strategy based on key processes is a game plan that encompasses the entire organization and ensures significant and relevant results. It provides a structure enabling the techniques of QI to be used to best advantage. Linking CQI to the existing management structure also builds in accountability and executive commitment. We learned that the education of top administrative and physician management in quality principles and techniques is essential for their participation and follow-through, two critical factors for long-term success. Coaching proved a very effective way to educate. People learn best by doing. As more and more process improvement teams form, more and more people gain QI skills. And they learn them “just-in-time” to be put to use, before they are half-forgotten. Physician involvement is an ongoing challenge for us. Physician attendance at weekly meetings is a significant and essential commitment. Here, the key process flow chart has proved helpful. When the physicians see how their activities fit into the clinic’s game plan, they become more interested in playing. Their attendance is always better when the issue is one in which they are invested. Sometimes we give them a choice, pointing out the importance of their participation in several processes and asking them to choose whichever one appeals to them most.

Conclusion

In developing a game plan based on key processes, we at PAMF developed a management system and culture that allows us to effectively improve quality – on a continuous basis. A new rigor of thinking directs our CQI effort, which features objective feedback measures and success indicators that can be benchmarked throughout the industry. The Customer Process Deployment method worked for us, and it can work for other medical groups too. We have a tremendous industry opportunity to tease out processes for improvement generic to all clinics – patient registration, scheduling, charts and many others. Improving key processes is the best way we know to winning the quality game, and win the quality game is the best way we know to become a competitive low-cost provider of first-rate health services.

References

1. Customer Process Deployment is a trademark of Shaw Resources.

Bibliography

1. “Can Quality Management Really Work in Health Care?” Quality Progress, April 1992, pp. 23-27.
2. Harrington, H. James, Business Process Improvement, McGraw-Hill, Inc., 1991.
3. Process Quality Management and Improvement Guidelines, AT&T Bell Laboratories, No. 500-049.

Reprinted in cooperation with Medical Group Management Association’s MGM Journal, Jan/Feb 1994, Vol. 41, No. 1.

Copyright © Shaw Resources, 2006, all rights reserved. (888-SHAWRES), email: Info@ShawResources.com; www.ShawResources.com. You may reproduce this article provided: 1) each copy you generate is of the article in its entirety, without modification of any kind; 2) you receive no fee whatsoever; and 3) this copyright and permission notice, including the contact information, must be prominently displayed on each copy produced.

A report on the Initiation of a Quality Improvement Process within San Jose Medical Group

Copyright © 1992 Shaw Resources

I. Introduction

During the 1920′s, a professional, systematic approach to quality improvement (QI) began to evolve in US manufacturing. Following WW II, American quality experts were invited to Japan to address the topic of quality improvement.  The Japanese subsequently undertook a decades long drive for Total Quality Improvement (TQI) that incorporated and expanded the ideas presented by the American experts.  By the late 1970′s, the Japanese had used quality so successfully against the US that the American electronics and automotive industries were forced to adopt a strategy of “if you can’t lick ‘em, join ‘em.”

II. San Jose Medical Group

US health care, facing severe restructuring, is reluctantly attempting to implement manufacturing style TQI.

Unlike manufacturing, health care is not faced with a major Japanese competitive threat.  The primary motivation for adopting TQI in health care is the belief that it will reduce expenses by ten to thirty-five percent or more.  This is very attractive to hospitals who, like the US railroads in times past, have seen the need for their services reduced (and experienced a corresponding loss in profits) due to advances in other segments of their own industry.  By practicing QI hospitals expect to become more efficient and thus remain a part of the industry they have led for so long.

One exception to this hospitals only trend is the San Jose Medical Group (SJMG).  The organization was founded more than thirty years ago.   It serves a patient base of 125,000 with nine locations.  It has a staff of more than seventy doctors and 350 nurse and administrative personnel.  Though their 1990 revenues exceeded $25,000,000, they experienced a significant financial loss in 1990.  This prompted the Board of Directors to bring in new management in October 1990.

The new CEO spent the first few months getting to know the stakeholders (primarily the doctors employed by the Group) and stabilizing the situation (e.g., avoiding a layoff by having the line of credit extended to provide sufficient cash for payroll in the immediate months ahead).  The results of this initial “get acquainted” effort (which included a formal survey of the doctors) showed widespread systemic malfunction.  The organization’s basic administrative processes (e.g., accounts receivable, patient registration, medical records management, etc.) were failing daily.  This, in turn, meant having to expend valuable resources doing rework.

In addition to this obvious waste, the organization was struggling to become a provider of managed care which meant they had to lower their internal costs substantially.  Consequently, they seemed like an ideal candidate for initiating quality improvement activities.  The medical and management staff were introduced to the concepts of QI.  Once oriented, they readily agreed to begin a pilot QI effort.

III. SJMG Quality Improvement Team for Medical Records

Quality improvement at SJMG involved forming a QIT and following a simple nine step plan.

The SJMG QIT followed the simple nine step plan shown in Figure A.  Team meetings were scheduled weekly for ninety minutes.  Before recounting that experience, it should be noted that a decision was made at the outset to provide “just in time” training for the team members.  That decision took advantage of the fact that the team would be led during its early stages by a seasoned meeting facilitator who also was expert in quality improvement techniques.  At the point in time the group encountered a situation that it was not trained to handle, it was the facilitator’s duty to train them personally (or arrange for their training) during a regularly scheduled team meeting.  This approach can be expensive but maximizes the probability of retaining the training material and gaining mastery of the techniques.

The QIT activities were:

1. Select the area to improve: To ensure success, an organization normally targets a “safe” (easy) process for its pilot QI effort. But the CEO felt it was critical to improve the medical records process quickly. The retrieval and management of patient medical records was particularly troublesome to the specialist doctors. Without a patient’s medical record, specialist clinical care could not always be rendered reliably. If care was given without access to the patient’s medical record, the doctor increased the risk of malpractice.

Management had taken some spot measurements that led them to believe that the care of as many as eighty patients per day were affected by this situation.

If  QI methods could be employed successfully to improve a process that was so visible to the doctors, then acceptance of QI as the vehicle for dealing with other defective processes in the organization would undoubtedly follow. Therefore, the CEO chose the medical records process.

2. Designate the team members: The medical records process spanned several functional organizations (e.g., lab, x-ray, the branches, nursing, administration, courier, the hospital, etc.) and thus presented a particularly difficult challenge regarding who should be on the QIT. Rather than attempt to address all the membership issues at once, the initial team membership was decided upon during a QI orientation presentation to personnel in the main medical records filing function. The personnel were so empowered by the idea that management would involve them in decisions about their work that the most respected among them were immediately nominated to be QIT members. Realizing that step five in the QIT plan would call for adjusting team membership, management felt comfortable launching the QIT with only the personnel drawn from the medical records functional group.

During this orientation meeting, a group discussion ensued which resulted in the formal QIT objective being defined as “Develop and implement the changes necessary to ensure that no patient is seen without a medical record.”

Since the team membership was composed of both managers and nonmanagers, the first team meeting focused on development of rules for how the members would interact with each other. They unanimously agreed on the meeting rules shown in the inset.

3. Flow chart, measure, and stabilize the process: The team members were asked to get together before the first meeting and flow chart the existing process for retrieving and filing medical records. That flow chart was the subject of the initial meeting. And, since no one person (not even the manager) knew all the steps involved in handling some chart situations, a lively discussion occurred. After several meetings, they eventually agreed upon the flow chart shown in Figure B. This step produced many ideas about possible actions to take and they were recorded by the team recorder for possible use later.

Next, it was necessary to measure the overall process.  However, that wasn’t readily possible since not everyone involved in the process was represented on the team (e.g., nursing).

Nonetheless, a group consensus existed that identified the retrieval of records from the various branches as the most severe problem.  And, since the data for five of the eight branches could be done without involving others, its collection was immediately initiated.

The measurement consisted of recording the daily volume of charts requested from the branches as well as the number actually received. Any not received were counted as “defects.”

The defect data for the first seven weeks of 1991 is shown in Figure C. The upper control limit (UCL) of twelve was computed by assuming a Poisson data distribution. (As a check, an alternative computation that yielded a UCL of thirteen was made by assuming a normal distribution existed after the outliers were discarded.) The two peaks (outliers) of eighteen and thirteen were investigated and confirmed to be due to the same special variation: the employees who process the requests in a given branch were not available (e.g., due to vacation, illness, etc.) to do the work on either of those days.

In an attempt to see if there was a correlation between the number of charts requested and the number of defects, a scatter diagram was plotted (see Figure D). Its horizontal nature shows there is no correlation. This was confirmed visually by plotting the same data on the y-axis versus time on the x-axis (see Figure E). Intuition says that if the defect count correlates to the workload (requests), then the defects should increase on days of high requests. The lack of correlation was confirmed by noting that the defect peak of eighteen coincided with a request low point of 115!There was speculation among some QIT members that the defects might correlate with the patient work load in the branch office that failed to forward the requested chart. That was noted for later follow-up.

4. Apply the customer-supplier model: At this point the group identified the inputs and outputs to the process along with the responsible party. Although it might seem obvious that the branches were suppliers, it was not so obvious that nursing was the customer. This idea required a mind-set change by some medical records personnel since relations with nursing were strained.Next, the group formalized the input and output requirements. There were three types of requests for which requirements had to be documented: routine appointments (3 days notice); adds (less than three days notice, e.g., to handle a walk-in); and, sometimes, the request was urgent (“stat” – less than two hours notice). The customer-supplier information is shown in Figure F.

5. Adjust team membership: At this point management reviewed the team membership. Initially, it had been set based on management’s guess that personnel from the medical records department should comprise the team. But now additional information had been developed about whom should participate. For instance, it was suggested that the”customer” (nursing) be on the team. As should the “supplier” (branch clinics). In addition, since there was more work than one team could handle, it was decided to split the team into two groups: one (the Branch team) to work on the branch related issues, and one (the Appointments team) to work on items related to the rest of the process. To coordinate the two efforts, two medical records personnel (one supervisor and one clerk) were assigned membership on both teams. The Branch team was expanded to include three of the eight branch managers. The Appointments team was expanded to include two nurses and, later in the project, two doctors.

To fit the schedules of the nurse and doctor team members, the Appointments team meeting time was set for Wednesdays from noon to 1:30 p.m. This, combined with the fact that there was the possibility of being assigned tasks by the team, might have dampened the desire to participate. That, however, was not true. The potential dampening was offset by the empowerment that the team members felt when asked to participate in solving a personally frustrating problem that had plagued the organization for years and that involved decision making about how their work was done.

6. Designate a process owner: SJMG was functionally organized but the medical records retrieval process was cross functional. Nonetheless, one person was assigned as the “owner” for the Branch process and another as the “owner” for the Appointments process. The assignment, however, was not declared by fiat. Instead, participative management techniques were employed to ensure maximum buy-in by all team members. The position of process owner carried matrix management powers with it but did not have the clout that goes with being a functional manager. Therefore, cooperation of all concerned was important if the person selected were to have the best chance for succeeding.

7. Identify the measures of performance: The initial measurements taken in step three had focused on the number of branch charts requested and the number received. The number not received (defects) was then calculated as the difference. This data was also accumulated for a few weeks for the Appointments process. Nursing was asked to gather the Appointments data so the team would have a “customer” perspective. However, this meant additional work for data that probably wouldn’t be used. Therefore, this approach was soon dropped in favor of only counting the defects (charts that weren’t received by nursing by the time needed). This latter approach was much simpler since a “chart request” document existed for every chart ordered by nursing. Both nursing and medical records personnel kept the counts and they were reconciled daily.

8. Identify the possible cause factors: The QITs used a cause-and-effect diagram (see Figure G) to brainstorm the possible reasons for not being able to retrieve a chart. This information was used to design a Branch check sheet (see Figure H). Room was left on the check sheet to write in additional reasons as they were encountered. Each time a defect occurred, a copy of the related chart request form was made and a notation made regarding the reason the chart had not been retrieved. This information was tallied daily using the check sheet. The data for the most recent period (usually two weeks) was then tabulated and plotted on a Pareto diagram (see Figure I).

A similar check sheet (not shown) was developed for the Appointments process with the exception that specialist doctor names were used instead of branch clinic locations. Information for a two week period was compiled in a Pareto diagram (see Figure J).

9. Continuous Improvement Cycle: After 10 weeks of QIT activity, the process was determined to be stable so it was decided to initiate The first repeated cycles of improvement.

9.1 Establish Requirements: The cost of defects (rework in this case) was estimated to exceed $50,000 annually (i.e., more than one full time employee). This estimate was based on the fact that when a chart did not arrive as requested, nursing time was expended on the phone with the appropriate branch arranging for elements of the chart to be sent via FAX to the main clinic.

In addition to the nurse time, investigation revealed that the medical records personnel often would detect the pending defect situation and, in an attempt to avoid it, would repeat the process of requesting the chart. These follow-up chart requests, even though they were handled via telephone, usually met with failure as well. The large volume of charts requiring this special handling made the total cost quite high.

Informal discussions with medical records employees revealed chart retrieval work to be so frustrating that they would occasionally take a “sick” day rather than come into work. The estimated cost of defects did not include this cost of employee absence. Nor did it include any cost associated with employee turnover even though management felt more than one employee had left because of the frustrating work environment. Neither did it quantify the cost associated with having to reschedule patients rather than administer care without the chart. (This latter situation had the potential to become lost revenue entirely.) Nor did the cost of defects include the fact that the frustration of working in a defective process lowered the self-esteem of the medical records personnel and, therefore, productivity was not what it should be. Neither was it possible to quantify accurately the cost associated with the expenditure of doctor and management time to deal with complaints by irate doctors. (One doctor who recently left the organization cited the inability to consistently obtain medical records as a factor influencing his departure.) When these additional factors are considered the cost of defects could easily exceed $75,000 annually. And to that must be added a cost associated with the risk of malpractice.

The Pareto diagram for Appointments (Figure J) revealed that more than forty percent of the overall failures were due to failures in the branch subprocess. And the previous Pareto diagram for Branch failures (see Figure I) revealed that about sixty percent of the branch failures were attributed to the branch just not responding to a request for a chart (“no response”). This was concluded to be a procedural and training issue. Once corrected, the general situation was expected to improve by more than twenty-five percent. Therefore, it was decided that the first cycle of continuous improvement should focus on eliminating the “no response” condition entirely.

9.2 Implement Changes: The team decided the primary change needed was increased awareness about the importance of forwarding a chart immediately upon request. The first step in increasing awareness was to invite more branch managers to join the team. In addition, it was decided that the data that was being collected would be published monthly to provide feedback to each branch about how well it was doing. Additional steps included half day working visits to each branch by medical records personnel. Branch personnel reciprocated by visiting the main facility and viewing the operations there.

The team also targeted the lack of formalized procedures and began to develop and implement those as time permitted. The procedure for the Branch process included the requirement that the clinic operations officer be notified immediately upon the occurrence of a “no response” condition by a branch. It was the duty of the operations officer to then personally contact the responsible branch manager for an explanation.

The detailed list of action items that had been initiated in step three began to grow quite rapidly. It now included action due dates and the name(s) of the person responsible for achieving them. The weekly meetings often became consumed with reviewing all open action items as well as the ones completed since the last meeting. Any remaining time was devoted to a review of the weekly performance data and brainstorming and new action items.

9.3 Measure Results: The measurement continued daily (see Figure K). Progress was painfully slow since no sooner would one branch achieve improvement than another one would degrade. Every time a special variation occurred, it was investigated and almost invariably found to be due to insufficient trained staffing.

9.4 Achieve Target: The Branch team achieved elimination of the “no response” condition after about fourteen weeks into the effort. Their accomplishment, coupled with other improvements attained by the Appointments team, resulted in the achievement of zero defects for the clinic as a whole (see Figure L).

Though many action items were achieved, the written procedures were still being developed at the time this report was written. In addition, only the passage of time will confirm management’s continued commitment to keeping the process in control. Thus, the final results of the first continuous improvement cycle must await a follow-up report.

Once the final step of the first cycle of continuous improvement is achieved, the plan calls for retesting the validity of the cause factors ( Step 8 ) and the measures of performance ( Step 9 ). That too must await a follow-up report.

IV. Conclusion

SJMG management did not have the knowledge needed to improve the medical records retrieval process. However, once the employees were invited to address the situation via a formal QIT setting, that knowledge became readily available. Interestingly, the team assigned nearly all the action items to the management members of the QIT. Management’s willingness to carry out these assignments not only ensured the success of the QIT but greatly improved the morale of all medical records personnel. During the two weeks before achievement of zero defects, doctors and management not included in the QIT effort commented on the noticeable improvement in the self-esteem of the medical records personnel.

The factors deemed critical to the success of the medical records QIT activity were:

1. Treatment of the team members, particularly the non managers, as peers;
2. The commitment and actual implementation by doctors and management of the tasks assigned by the team;
3. Flowcharting and measurement of the process coupled with utilization of SPC and the other technical analysis QI tools, particularly the Pareto diagram;
4. Disciplined adherence to the weekly meeting time and duration;
5. Utilization of an experienced meeting facilitator who also was a QI expert;

The idea of managing the medical records retrieval process as if it were a manufacturing production line was new to the organization. But the staff readily accepted the idea and did not need much training to implement it. The use of SPC and related quantitative tools provided undisputed grounds for prioritizing changes to implement and, later, for deciding which changes were effective. The tools involved were not difficult for the QIT members to learn in spite of the fact most were not college graduates.

A far more difficult skill to teach has been that of team facilitator. Yet, even that skill was being acquired by a couple of individuals who should become sufficiently proficient after a few more weeks to run the meetings. Once that occurs, both QITs will be able to function with only occasional outside assistance.

The success of the project was evident to management even before it was achieved and as a result they immediately initiated two more QITs: one focused on patient registration and the other focused on accounts receivable. Both these are following the same action plan, and, although not as far along as the medical records QIT, have been experiencing similar success. Word of the medical records QIT success has spread throughout the organization and, consequently, membership on these later teams has become something of an honor.

A “quality council” has been formed and is meeting once a week with the objective of integrating continuous QI into the organization as part of its permanent culture. Its membership includes two SJMG board members (both are physicians), the medical director, and two physician department chairs. It also includes the director of nursing and several executives from administration.

Copyright © Shaw Resources, 2006, all rights reserved. (888-SHAWRES), email: Info@ShawResources.com; www.ShawResources.com. You may reproduce this article provided: 1) each copy you generate is of the article in its entirety, without modification of any kind; 2) you receive no fee whatsoever; and 3) this copyright and permission notice, including the contact information, must be prominently displayed on each copy produced.

Use of Shaw Resource’s “Customer-inspired®” Quality Methodology Leads to Two Statewide Quality Awards for St. Johns Hospitals

Copyright 1999 Shaw Resources

Like many hospitals in the early ’90s, the two St. Johns Hospitals in Ventura County, California-assembled multi-disciplinary improvement teams as a step towards improving quality. And like many similar attempts in well-intentioned organizations, the teams floundered because they lacked a systematic way to identify, analyze, eliminate and prevent problems. Initial enthusiasm waned as team members became discouraged about investing so much time with what seemed to be sporadic, temporary results.

By 1997, the situation had changed dramatically – so much so that St. Johns Hospitals won two statewide quality awards: a “best-in-class” bronze designation from the California Council for Quality & Service and the Governor’s Golden State Quality Award for Community from the California Center for Quality, Education, and Development. Both awards are aligned with the criteria of the prestigious U.S. Malcolm Baldrige National Quality Award program. What made the difference? A lot of hard work by St. Johns staff…and Shaw Resources.

Finding customer focus made the difference

“Healthcare must be more customer focused because it is becoming more market driven,” says Dan Herlinger, president and CEO of Catholic Healthcare West (CHW) Central Coast, which encompasses four hospitals. “Jim Shaw demonstrated to us that every one of our activities could be adapted to a customer-inspired® quality improvement approach. Using his methodology made our teams more effective, more focused, and more results oriented.” Peter Haggerty, director of laboratory, cardiology, and neurodiagnostics, agrees. “Before we were introduced to the Shaw Resources methodology, we were flying by the seat of our pants -trying to solve problems at the point they showed up rather than identifying root causes and preventing problems from occurring. That limits results.”

The Shaw Resources patent-pending model for continuous process improvement, called Customer-Inspired Process Deployment®, identifies customers and their expectations, defines key processes, sets up effective process improvement teams, and establishes quantifiable measures to evaluate improvement. The methodology focuses on prevention by rethinking process activities to eliminate the real sources of problems and customer dissatisfaction. Shaw Resources helps the teams along the way with consultation, training, coaching, and the use of the firm’s proprietary software program, Process Advisor™. Central to Shaw’s methodology is the belief that only customers can define quality and that to be successful, an organization must meet and exceed customer expectations. The first step-and often the most difficult-is to identify and define key processes according to customer perceptions, not what management thinks is important to customers. St. Johns started with the three processes customers listed as most in need of improvement: responding to complaints, the emergency department, and diagnostic testing. Additional teams were added slowly and now St. Johns has 22 teams focused on a different key processes. “I’m impressed with how much progress we’ve made in a short period of time,” says Bill Clearwater, vice president and site administrator of St. Johns Pleasant Valley Hospital. “Our activities are much more focused and directed at making actual improvements. It is gratifying to see us making quality changes that are visible and measurable.”

Staff become motivated and “jump in with both feet”

“There’s been a lot more buy-in from staff since we started using the Shaw methodology,” he adds. “They’ve jumped in with both feet and are active, motivated and excited about new and innovative ideas.”

One way the Shaw methodology contributes to staff involvement is the use of permanent cross-level, cross-functional teams to tackle specific areas for improvement.

“Previously we had what we called ‘self-directed leadership teams’ that were trying to employ standard TQM (total quality management) and process improvement techniques, but we were only able to change operations within our own departments,” says Vicki Lemmon, director of nursing. “We were working in isolation.”

The Shaw methodology assembles teams around a process defined as the customer perceives it, not how it appears on the organization chart.

We can’t directly tie these bottomline results to process improvements but we . . . are instituting changes that make a difference to “You learn so much more when you are sitting with people who represent other aspects of a specific process,” Lemmon says. “You begin to understand that a decision in one department may create more steps in the process in another department or it may change things so that another group is no longer in compliance with standards they need to maintain. It may be a quality improvement for us, but it plays havoc in other parts of the organization.”

“Our volume went up 12% last year and we are attracting new physicians.

We can’t directly tie these bottomline results to process improvements but we . . . are instituting changes that make a difference to customer satisfaction and employee morale.”

Unlike many healthcare organizations which often focus their quality improvement programs on patients, St. Johns followed Shaw’s advice to consider the needs of all customers inside and outside the organization. This means including some not traditionally thought of as “customers,” such as physicians, families of patients, and payors. St. Johns identified physicians as a top priority and the hospital initiated a comprehensive complaint system for M.D.s to register their concerns. “They are our suppliers and partners in giving healthcare,” says Dr. Ross DiBernardo, vice president of medical affairs. “The complaint system we started for physicians gives them the opportunity to communicate their concerns in a convenient, user friendly way.”

Physician complaint system based on M.D. preferences

St. Johns was not the first hospital to launch a physician complaint system, and its team was very much aware that programs in other hospitals had failed. Other facilities were interviewed about why their efforts didn’t work, and team members surveyed a sample of St. Johns’ own physicians about their preferences. “No physician is going to take the time to sit down and fill out a complaint form,” Dr. DiBernardo explains, “but they will make a call to convey their frustration. We use a voice mailbox that’s available 24 hours a day, seven days a week to record their complaints, and we acknowledge their comments in writing within one working day.” Physicians receive a final report on the disposition of the complaint within three weeks of their original call, and a follow-up card is sent asking if the physician was satisfied with the complaint process. A “no” answer gets a personal follow-up call from Dr. DiBernardo. Our patient volume went up 12% and we are attracting new physicians,” Dr. DiBernardo says. “We can’t directly tie these bottomline results to process improvements but we can say process improvement is responsible for better communication up and down the organization. Senior management has a much clearer idea about how work is done in the organization and we are instituting changes that make a difference to customer satisfaction and employee morale.”

“A complaint is a customer giving us a second chance to make the situation right.”

Dealing more effectively with complaints – whether they emanate from physicians, patients, or others-is one of the organization’s most significant accomplishments since working with Shaw Resources, according to Herlinger.

“It is a major shift in the culture of the organization to begin to look at complaints as valuable feedback rather than something we are defensive about or want to sweep under the rug,” says Herlinger. “But a complaint is a customer giving us a second chance to make the situation right. Shaw calls complaints ‘nuggets of gold,’ and we have found them to be that valuable.”

Analysis of call light response time reveals undetected problem

A common patient complaint in most medical facilities is how long it takes hospital staff to respond to call lights. When a patient is in pain or needs a bed pan, even a few minutes can feel like an eternity. When hospitals launch a quality improvement effort, improving call light response time is frequently at the top of the list.

St. Johns was no different – except in what it discovered.

“When patients complain that it is taking too long to get a response to their call lights, it’s easy to assume there is a staff performance problem,” Clearwater says. “The Shaw methodology forces you to put aside assumptions and not to jump to conclusions, but to gather and analyze data. In the past we might have addressed this situation by training the staff. Instead, when we followed the methodology and gathered measurable data we discovered a mechanical problem in the call light system was causing a delay between the time a patient pushed the button and when staff received notification.

“Once we knew the glitch was there, it was easy to fix, but we probably would never have found it otherwise,” he says. “We would have just gone along assuming that staff needed to do a better job in monitoring and responding to the lights, while staff would be frustrated at the continued complaints because they were doing the best job they could.”

Patient transport issue is “gigantic”and affects multiple departments

Another prickly topic that frequently surfaces in healthcare organizations is patient transport – the need to have patients moved from one area of the hospital to another in a way that meets scheduling demands of several departments and is comfortable and reassuring to the patient.

“Patient transport is one of those gigantic issues where the easiest solution may seem to be to add more staff,” says Haggerty. “But we wouldn’t stay in business long if we did that every time a problem comes up.”

The “improve inpatient diagnostic testing” team took on the challenge of examining and rethinking the decentralized transportation system that wasn’t working well. The team followed the Shaw methodology including cause-and-effect and root cause analysis focused on eliminating the source of problems, benchmarking, and two-dimensional flowcharting. After looking at all the issues that needed to change and working up a detailed financial analysis, the team recommended that St. Johns switch to a centralized transport system that is automated.

“We were receiving department and physician complaints that patients were not arriving on time,” Haggerty says. “Every late transport delays exams and treatments not only for that patient, but for others that follow. With the Shaw methodology we were able to see what was going on in several departments and what needed to happen to make patient transport work smoothly for everyone.”

Software helps to calculate scores to compare “apples and oranges”

The Process Improvement Council reviews each team in detail every six months. Each team grades its own progress using qualification standards based on a detailed checklist. During the formal review, the team explains its progress and projects its next activity and qualification rating. Shaw Resources’ Process Advisor software helps the team compute its qualification score. The software incorporates a checklist of more than 75 items organized into six levels of accomplishment.

For example, a team might say it is 10% of the way towards completing a task because it has started a flow chart of the process or established a data collection system. Typical scores after two years of work might range from 4.8 to 5.3.

The ratings are useful in comparing “apples to oranges” when it comes to different processes. The organization can compare the process improvement scores of payroll and critical care independent of the work content.

Shaw Resources concepts and techniques shared inside and outside the organization

Employees at St. Johns are also using the Shaw Resources methodology on a smaller scale within their individual departments to streamline paperwork, standardize procedures, and make other process improvements that affect the quality of the customer’s experience.

Many team participants have found that they are incorporating the principles into their daily work styles. “It has helped me with my work and given me concepts and techniques I can take with me anywhere,” says Clearwater, who added that he finds himself using the Shaw methodology to approach problems in his community activities and at home.

“Continuous process improvement is slow and painstaking work and that can be difficult for healthcare people who are accustomed to instant gratification in taking care of patients,” Lemmon says. “It’s hard to see the reward while you are building a solid process for identifying issues, gathering and analyzing data.

“But the results are worth waiting for, and when you start to make significant achievements the staff gets excited and wants to be included and involved,” she says. “Process improvement is always a work in progress because the standards keep getting higher. It is St. Johns’ long term commitment to quality.”

For more information on St. Johns Hospitals or other organizations that have benefitted from working with Shaw Resources, please call 888-SHAWRES, or check the website: www.shawresources.com.

Copyright © Shaw Resources, 2006, all rights reserved. (888-SHAWRES), email: Info@ShawResources.com; www.ShawResources.com. You may reproduce this article provided: 1) each copy you generate is of the article in its entirety, without modification of any kind; 2) you receive no fee whatsoever; and 3) this copyright and permission notice, including the contact information, must be prominently displayed on each copy produced.

Process Improvement vs. Problem-Solving

by James G. Shaw

Copyright 1999 Shaw Resources

A good many organizations spend 80% of their time solving problems and 20% of their time improving processes. Shaw Resources is trying to reverse that ratio. Why?

On The Road: It Helps To Have A Map

People sometimes confuse process improvement with problem-solving. They think that if they find a problem in the process and fix it, they’re improving the process. While problem solving may be a first step, it rarely results in an improved process. Let’s look at why.

Problem-solving focuses narrowly on individual problems. Problem-solving fails to consider how solutions relate to one another, to the process as a whole, or to the outcomes of a process. Fixing a given problem may not affect an outcome at all. The fix may even create another problem, because no one has considered its effect on other activities in the process. Problem-solving is like taking a trip without knowing your destination and then wondering why you never arrived.

Process improvement, on the other hand, considers the whole process, main-taming a steady focus on the outcomes customers receive. To improve processes, you use a map, a clear depiction of the territory and the destination. When you spot something that is wrong, you still know where you are and where you are going. You locate what has gone wrong and analyze it in the context of the big picture. You assess changes according to their impact on the process and on the customer. You implement changes that will eliminate what has gone wrong and still get you to your destination, generally more efficiently than before. A map helps you plan and explore. A map keeps you from getting lost.

Design vs. Repair

Process improvement addresses the design of a process. When changes are made, they are made to the process’s design-how the process works. Just as a good highway design is essential to safe, efficient, and pleasurable travel, a well-designed process is essential to outcomes that work, are cost-effective, and please customers. Problem-solving is not concerned with design but rather with potholes and bumps in the road. Problem-solving is road repair, a matter of patches and detours. Problem-solving does not get at what is causing the potholes in the first place. That is why problem-solving is endless roadwork.

Prevent It vs. Fix

It Process improvement is preventive and pro-active, while problem-solving is reactive. Process improvement asks the question: How can we change the process to prevent this undesirable thing from happening? Analysis involves uncovering the root causes of problems. In contrast, problem-solvers ask: How can we fix this undesirable thing that is happening? The emphasis is on the undesirable thing, not how or why it is happening. Very often, problem-solving is a reaction to pressure-operational failures, management demands, deadlines, customer complaints. What gets fixed is the problem’s current symptom. There is no attempt to get at the root of the problem and prevent it from reoccurring.

Simplify vs. Complicate

The approaches of process improvement and problem-solving are also different. Generally, process improvement simplifies processes. Eliminating defects and shortening cycle times usually involve taking something out: flaws, unnecessary steps in the process, and so on.

Problem- solving, however, frequently adds activities, either to deal with the problem or in anticipation of its recurrence. Inspection activities and additional sign-off forms are examples. The aim is to correct each problem as it happens and possibly to catch it early on. The assumption underlying problem-solving, though, is that the problem will occur. Process improvement assumes the problem can be avoided for all time.

Long-term vs. Short-term Results

Because process improvement considers the design and workings of the total process, as well as the prevention of problems, changes are long-term. They are made logically, carefully, and once. Process improvement is based on a body of statistical information used to target changes that will help the organization achieve its goals and monitor results. Process improvement looks at a change to see if it is worth the investment. If it is, the change is implemented permanently.

In contrast, problem-solving results in short-term solutions. This is partly because of its narrow focus on individual problems and partly because of its “fix it” rather than “prevent it” approach. Moreover, often the numerous fixes don’t add up to significant gains because they are isolated solutions, unconnected to the overall goals of the organization-the destination. Problem-solving can be diversionary, preventing an organization from making lasting changes.

A Task vs. a Methodology

An organization engaged in problem-solving wastes effort and can even find itself moving away from its goals. To be always looking down at potholes and bumps in the road can keep you rolling along a road to nowhere.

This is not to say that solving problems is a worthless endeavor, however. Like road repair, problem-solving cannot be eliminated; it is a necessary task. But it is a task, not a methodology.

Sometimes an organization has problems so obvious and critical, they need to be fixed immediately. But you want to move beyond problem-solving to process improvement, beyond tasks to a comprehensive methodology. For problem-solving to pay off, it needs to be incorporated into the more encompass-ing scope of process improvement.

Watch Where You’re Going

To move beyond problem solving, you need a systematic method to follow, in other words, a map. Below is a general outline of the steps involved in process improvement.

• Understand the big picture. Before making changes to a process, you need to understand the whole process from start to end.
• Identify the process’  critical path-the main activities between the process’s start and end points.
• Examine the critical path for weaknesses and potential problems.
• Prioritize the weaknesses according to their impact.
• Collect and analyze data.
• Take action to prevent problems and strengthen weaknesses.

One last important point: It is essential to understand your process from the customer’s point of view. Taking the customer’ s point of view is critical, because it is the customer who decides whether your outcomes are inadequate, good enough, or superior.

Another way of saying this is to say that your destination is your customer’ s destination. You want to be where your customer wants to be. To get there, you may solve problems along the way, but it is through the process improvement methodology that you can keep your destination in clear focus. The concept is simple: If you watch where you’re going, you’re a lot more likely to get there.

Copyright © Shaw Resources, 2006, all rights reserved. (888-SHAWRES), email: Info@ShawResources.com; www.ShawResources.com. You may reproduce this article provided: 1) each copy you generate is of the article in its entirety, without modification of any kind; 2) you receive no fee whatsoever; and 3) this copyright and permission notice, including the contact information, must be prominently displayed on each copy produced.

Copyright Shaw Resources 1999

Like many hospitals, White Memorial Medical Center in East Los Angeles found itself at a crossroads in the late 90s. Its 372 beds had an average occupancy rate of 250, and the various cost-cutting and improvement initiatives put in place under a quality improvement program begun in 1989 had yielded about as many benefits as they were going to.”We had a very good program and were doing a lot of good things,” recalls Nancy McDonough, Manager of Quality Improvement. “But after ten years, we decided that we needed to move on to the next level. So we started looking at what we could do that would push us forward.”

McDonough and her colleagues found the direction they were looking for in the Baldrige Criteria for Performance Excellence, the basis for the prestigious Malcolm Baldrige National Quality Award. With the enthusiastic support of White Memorial’s executives, the hospital proceeded to use the criteria for a comprehensive self-assessment.

“We didn’t score terribly well,” says McDonough. “We saw it as a tremendous opportunity to improve in lots of ways. But we didn’t know what to focus on.”

She and her colleagues began searching for help and found it in Shaw Resources, a management consulting firm that helps organizations implement process management from the customer’s point of view.

Identifying the Opportunity

“One of the first things we did when Jim Shaw came on board was to sit down with the directors and executives and identify the key processes,” relates McDonough. Shaw defines a key process as any process essential to the organization’s ability to meet or exceed customer expectations. White Memorial’s executives and directors identified about forty. The next decision was: which ones should they concentrate on first?

With Shaw’s help, the group prioritized their key processes according to their impact on customers (patients). After narrowing the field to three, the Emergency Department emerged as the one most likely to have the greatest impact in the near term.

There were several reasons for this. One was the high volume of patients seen by the ED, over 3000 patients a month. While the average daily discharge rate from the hospital was 30 patients, the ED was seeing 125 patients. Moreover, between 50 and 60 percent of the hospital’s admissions came from the ED. So improvements in the ED would have a very high impact on patients.

Another factor influencing the decision was that White Memorial’s business strategy called for increasing the number of nearby physicians using the hospital. Improving the ED was the most likely way to help achieve this objective because White Memorial’s ED was, in effect, the hospital’s “front door.” About 35,000 patients (and their families) had passed through those doors in 1998. Improving service to ED patients would be a way of improving service to their attending physicians, too, and word would spread.

Establishing the Team

The next step was to establish a Process Improvement (PI) team, headed by a process owner. The team needed to be a cross-functional team, and representatives were recruited from all groups involved in the process of serving an ED patient: Admitting, Billing, Radiology, Laboratory Services, and so on. The director of the ED was designated the process owner. The team met every other week.

Breaking Down the Problem

A common stumbling block for beginning PI teams is the enormity of their charter. Improve the ED? Where should they start?

When the task is large, it helps to break it down into manageable pieces. White Memorial’s PI team began by categorizing ED patients into three different groups:
Level 1-patients with non-critical problems such as earaches and sore throats that did not require intervention.
Level 2-patients who needed some intervention-antibiotics or an x-ray, for example-but who were not going to be admitted to the hospital. Level 3-patients admitted to critical care.

In selecting an initial objective, the PI team chose to concentrate on Level 1 patients. These patients were often kept waiting for hours while more seriously ill or injured patients were cared for. The team wanted to deliver health care services more efficiently to these patients without compromising the care of the more seriously ill or injured.

A New “Express Care” Initiative

As the team brainstormed ideas, attention focused on an area in the ED slightly off to one side, where three gurneys were kept. What if this area were dedicated to the exclusive care of Level 1 patients? Wouldn’t this improve turnaround times?

The team decided to try. They designated the area as the “Express Care” unit. It would be open around the clock, with a dedicated doctor and nurse on duty from 12 pm to 12 am, the busier hours. The team added two chairs to the three gurneys and specified that these were to be used for Express Care patients only. When they were ready for business, the team set a goal: to see, treat, and release Express Care patients in 60 minutes or less.

Surprising Results

They are getting close. Turnaround times went from hours to minutes, currently between 70 and 75 minutes. In addition, the improvements resulted in some unexpected benefits, as well. In 1999, before the establishment of the Express Care service, 54 patients a month left White Memorial’s ED without being seen. This number went down to 11 per month with the new Express Care service, a 70 percent improvement that increased revenue by $226,405. The number of unseen patients continues to drop and is now at 4 per month.

Another surprise was that as turnaround times for Express Care patients improved, so did the turnaround times for the other two categories of patients. The fear that the new Express Care service might compromise the care of other patients proved groundless. The opposite was the case.

It almost goes without saying that patient satisfaction increased dramatically. Not only did survey results improve, but also spontaneous compliments to the staff from appreciative patients.

More Ideas

Additional improvements made by the team include portable phones for ED physicians so that the ward clerk no longer had to track them down.

The team also installed a physicians’ hot line for complaints and compliments. This should bring to the team’s immediate attention any issues the patients’ attending physicians have with the ED, such as a missing report or lab result. Not only will the hotline provide the ED with a chance to correct any errors or omissions quickly, it will also serve as an early warning system for defects in the ED’s processes. Compliments are important, too. People need to know when they are doing something right.

Although not part of the original initiative, a new computer system is proving to be supportive of the team’s efforts to improve service. The first phase of the new system, installed in December 1999, tracks a patient’s passage through triage to bed to being seen by the nurse, treated by the doctor, and finally discharged. The patient receives a printout, in Spanish and English, with the diagnosis, the ED physician’s name, the nurse’s name, medications administered, and discharge instructions. In the second phase of the system, due to be up and running in March, the patient’s attending physician will automatically be faxed a copy. Prescriptions will also be printed out, which will save time at the pharmacy and prevent errors.

In addition, the new computer system provides the PI team with data that was unavailable to them when data had to be collected manually. With technological support in place, the team is now setting some new goals. One is to deliver more timely pain management. Another is to conduct a point-of-service customer survey. The team will also be looking at ways to improve services to Level 2 and Level 3 patients.

A Refocus on Customers

Health care is not as predictable a business as the manufacture of widgets, and the PI team in White Memorial’s ED has experienced some typical setbacks. In December 1999, for example, an outbreak of flu saw the number of ED patients jump from 94 a day to 168. Not surprisingly, turnaround times suffered. But aside from these kinds of situations, the ED has scored impressive gains in the delivery of emergency health care services and should go a long way toward attracting new patients and physicians. The ED’s improvement efforts dovetail with White Memorial’s overall business objective to refocus on customers. “We’re in the process of setting new customer service standards and looking for new opportunities,” says Nancy McDonough. Taking advantage of these opportunities will help make White Memorial the provider of choice for East Los Angeles.

Copyright © Shaw Resources, 2006, all rights reserved. (888-SHAWRES), email: Info@ShawResources.com; www.ShawResources.com. You may reproduce this article provided: 1) each copy you generate is of the article in its entirety, without modification of any kind; 2) you receive no fee whatsoever; and 3) this copyright and permission notice, including the contact information, must be prominently displayed on each copy produced.

Copyright © 2005 Shaw Resources

Shaw Resources has pioneered efforts to bring process managementfrom the manufacturing floor to the healthcare industry. The firm has guided executives of a wide variety of healthcare organizations in their quest for more efficient delivery and optimal patient care.

Learning to See from the Patient’s Point of View

Most of Shaw Resources’ healthcare clients are not accustomed to thinking of patients as customers. “We had always measured our services by the clinical standards of healthcare professionals, not by the service measures of patients,” says Joann Zimmerman, Assistant Director of Nursing at Stanford University Hospital in Palo Alto, CA.

It was “a startling experience to analyze our processes through the eyes of the patient, rather than from our own experience,” says Sharon Hollander, Associate Director for Patient Care.

Most patients do not know how to judge a healthcare organization on clinical excellence, so they assess their experience on service criteria, such as how fast a nurse responds to a call bell. It’s difficult for healthcare professionals to shift to this perspective, but once Stanford began to focus on service excellence, patient satisfaction increased.

“We are seeing real change and real results that will be long-lasting because they are altering the core infrastructure of our organization,” says Hollander.

Complaints are Guideposts to What Needs to be Improved

Leaders at Dominican Hospital in Santa Cruz, CA are now true believers in the value of studying customer complaints in order to determine patient expectations and problem areas that need to be addressed.

“Managing a comprehensive complaint process, more than anything else, directly supports the hospital’s commitment to quality,” says Sister Julie, Dominican’s Chief Executive Officer.

Although Dominican had done a good job resolving individual complaints, there was no formal system enabling the organization to grasp the bigger issues embedded in the complaints. With the help of Shaw Resources, Dominican developed a new Manage Complaints system that identifies and implements changes that significantly boost patient satisfaction. Today, everyone in the Dominican organization has been transformed into a patient relations representative.

Changing the Way People Approach Their Work

One of the most important benefits clients often report as a result of their work with Shaw Resources is the change in the way people work together within the organization.

“You begin to change the culture,” says Remo Cerruti, Chief of Professional Services for Washington Hospital in Fremont. “People go from saying: “I do what I do, I do it well, and that’s my only responsibility’ to “How I do it with other people is important, too.”

When cross-communication is limited or non­existent, as it is in many organizations, there is a tendency to undervalue or overvalue what others do. Working on cross-functional teams, people gain a realistic view of what others do, and understand how their work impacts one another and the customer’s perception of quality.

Patricia Stillwill, Director of Patient Financial Service, agrees. “The Shaw method helps us in all day-to-day activities, not just what we’re doing on the teams. It makes for better working relationships. You are able to put faces with names. You understand the other point of view. And you learn that no one is making mistakes just to make your life miserable.”

Cerruti concludes: “Improving processes is not extra to the work you do. It is the work you do. It adds joy to your work, and goals.”

Cutting Costs also Benefits Customers and Quality

Customers also benefit, indirectly, from increasing operational productivity and cost-effectiveness. Shaw Resources has helped several healthcare clients cut costs by streamlining and simplifying their business processes.

A San Jose Medical Clinic team, for example, reduced the rate of missing charts in its Manage Medical Records Process to save $70,000 annually.

Another team, in a two-fold effort, first reduced an abnormally high insurance claims rejection rate from 20% to 4% by implementing new computer and registration procedures to ensure accurate patient information. The team went on to reduce the rate to 2%, an even more difficult and impressive accomplishment, because the drop reflected changes that went beyond problem solving to permanently improve the process.

Copyright © Shaw Resources, 2006, all rights reserved. (888-SHAWRES), email: Info@ShawResources.com; www.ShawResources.com. You may reproduce this article provided: 1) each copy you generate is of the article in its entirety, without modification of any kind; 2) you receive no fee whatsoever; and 3) this copyright and permission notice, including the contact information, must be prominently displayed on each copy produced.

Copyright © 1996 Shaw Resources

Shaw Resources has pioneered efforts to bring process management from the manufacturing floor to service industries and administrative and service functions. The firm has guided executives of a wide variety of companies in their quest to achieve results and a CUSTOMER-INSPIRED® perspective.

Approaching the business from a new point of view

“We have an entirely different viewpoint now about what customers demand in a quality home and what we need to do to meet those expectations,” says Lisa Kalmbach, president of Kaufman & Broad South Bay, one of the largest home builders in the San Francisco Bay Area, in describing how the company’s work with Shaw Resources is changing the way this well-established, successful homebuilder does business.

Kalmbach admits that most homebuilders are not “the analytical type,” but K&B’s search for an innovative way to improve customer satisfaction led them to Shaw Resources which specializes in helping companies achieve measurable results in improving quality.

Under the guidance of Shaw consultants, the company developed a new way of analyzing standard customer feedback that showed Kaufman & Broad the bottomline benefits of minimizing customer dissatisfaction. Unhappy homebuyers, for example, want adjustments made to the house after the close of escrow — and that means cutting into the profit margin to accommodate customer demands or arguing with subcontractors about who should pay the bill.

“We have always done customer satisfaction surveys and collected other information, but we didn’t know how to analyze the data and use it to make changes to processes and systems so that mistakes leading to customer complaints would not be repeated,” Kalmbach explains. “Although our customer approval rating was high, we now feel we have the opportunity to achieve outstanding ratings from 95% of our home buyers. That would be an extraordinary accomplishment in the construction industry.”

Another bottomline result: an increase in the number of referrals they are now receiving as a result of improved customer satisfaction.

Uncovering ‘nuggets of gold’ in customer complaints

To get a banker’s attention, talk money. Managers at California Business Bank were initially skeptical when Shaw Resources suggested that cash incentives be given to employees if they forwarded more customer complaints. But the lure of bigger “nuggets of gold” convinced the bank to give the bonus program a try.

“We had to get the attention of our people and help them think of complaints as a valuable asset to the bank,” explains Dick Conniff, bank president. “Employees had to feel that passing on customer complaints would earn them a pat on the back, not a black mark.”

Managers worked with Shaw Resources to build a system for effectively handling complaints and instituting improvements as a result of customer input. Then the bank “turned on the vacuum” to scoop up as many complaints as possible.

To help change employees’ negative feelings about complaints, the bank sponsored a monthly drawing for a $100 prize. Every employee who had submitted a customer complaint that month was eligible. Although they enjoyed the extra cash, employees were more convinced to participate when they could see changes being made as a result of the customer complaints they were reporting. Soon they were enthusiastic participants in the “Manage Complaints” process without the lure of a cash incentive.

As a result of capturing more complaints and doing a better job in analyzing them, the bank was able to do more than just satisfy one customer’s problem. It was discovering and changing the root causes of customer dissatisfaction, thus improving performance and achieving more long-lasting results.

Following up on unpaid bills

When a customer is slow to pay, many corporate accounts receivable departments assume the customer’s CFO is holding back in order to maximize cash management.

But Shaw Resources showed managers at Hexcel Corporation that what was interfering with timely customer payments and causing a cash flow crisis at their company was actually unstated customer dissatisfaction.

Shaw Resources recommended that Hexcel track credit and debit memos on a chart in order to pinpoint repeated problem areas. Soon they were able to see a pattern, trace the root cause, and change processes so that future occurrences were prevented.

This new source of information allowed Hexcel to eliminate common sources of customer irritation such as bills received before product delivery, incorrect specifications, or invoice totals different from estimated costs.

Problems caused by a lack of communication among the sales, order entry, factory, shipping, and billing departments also surfaced through AR analysis. “We would get these people together to talk about how their jobs interact and they would make statements like ‘Gee, I didn’t know that’s what happened when it left my desk,’ “says Jim Shaw who personally worked with Hexcel executives to find a solution to their AR problem. “They needed to understand that how they did their jobs affected the process further downstream.”

The results? After just five months of analyzing what was behind the scenes of their unpaid accounts, Hexcel was able to drop its account receivable total by $5 million!

As an added bonus, as accounts receivable totals dropped down, employee morale and productivity flew up as a result of continuous process improvement efforts.

Copyright © Shaw Resources, 2006, all rights reserved. (888-SHAWRES), email: Info@ShawResources.com; www.ShawResources.com. You may reproduce this article provided: 1) each copy you generate is of the article in its entirety, without modification of any kind; 2) you receive no fee whatsoever; and 3) this copyright and permission notice, including the contact information, must be prominently displayed on each copy produced.