Part 1 of 2

The Quality-Cost Connection: Improve quality with systems thinking

By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR

Is your organization plagued by performance-improvement initiatives that fail to achieve their intended goals? Are gains short-lived? All too often, desired change takes time, and we’re on to the next project without realizing the last one wasn’t successful.

Why are plans to change people’s performance so often thwarted? If we don’t ever ask this question, we won’t learn. If we don’t learn, we are more likely to continue wasting resources on ineffective improvement projects. The cost of failure goes far beyond the price tag of the project.

Demoralization of physicians and staff involved in the project is a frequent and costly consequence of failure.

To gain success from improvement projects, we need to understand more about what actually governs people’s behavior. It’s been demonstrated over and over again that people’s actions are influenced by the system in which they work. When improvement projects fail, it generally is because the actions taken to affect performance were nonsystematic — meaning that no attempt was made to change the system in which people work.

For example, after training everyone in customer service, we expect people to do the right thing and customer satisfaction scores will improve. In practice, staff behavior in front of patients and their families is governed by the system. If the system makes it hard to provide outstanding customer service, no amount of training will change staff behavior.

This is the first of a two-part series on the fundamentals of systems thinking. By applying systems thinking, people in health care organizations can gain a better understanding of the causes of improvement project failures.

To achieve performance improvement successes, we must learn how to view our organization as a system and understand the implications of the system on the performance of individuals. A system is a whole made up of parts.

Each part can affect the way other parts work, and the way all parts work together will determine how well the system works. The Joint Commission on Accreditation of Healthcare Organizations transitioned the accreditation standards to a systems approach many years ago, and now we need to do the same in our thinking.

Traditionally, we have improved performance in our health care organizations by managing the separate pieces (nursing, pharmacy, medical staff, laboratory, operating room, etc.). Managing in this way can cause friction when parts of the organization set about achieving improvement goals at the expense of the whole.

It’s time to come to terms with the system issues that affect poor performance. Studying failure is a good way to learn how your organization works as a system. For instance, when customer satisfaction scores don’t improve following organizationwide training, determine why the system doesn’t support the delivery of outstanding customer service. Find and fix the features of the system that impact quality of service and consequently impact the behavior and attitude of frontline staff.

Changing the perceptions of patient care

Systems thinking requires that we change the way we perceive patient care services.

Traditionally, we’ve had a top-down hierarchy, with decisions about how work is performed separated from those who actually do the work. Most health care organizations are designed and managed this way.

While we have learned to think of our organizations as top-down hierarchies, they don’t look like that to our patients. Our customers have a much different view of the organization. When you look at health care services from the patient’s point of view, the organization may appear fragmented and very unproductive.

While we might think of health care services as being managed and controlled through functional hierarchies, in practice, work "flows" through the organization. System design can impede workflow; thus the first step toward improvement is learning to manage the flow. To manage the flow, you must think of how your organization should respond to the needs of patients and their families. Think of it this way: If your health care facility responds to patient demands by doing what the patient wants, your service will improve.

If your goal is to manage workflow, then you need measures that tell you about how well the work is flowing through the organization.

Here’s an example: The hospital pharmacy department receives many calls each day from nursing staff, physicians, billing office personnel, former patients, and other customers. The purpose of the pharmacy is to create value for the customers who call by providing accurate and timely information. The pharmacy manager has been measuring "time to answer" the phone. Investigation showed that more than half the incoming calls might have never occurred had people throughout the organization done what customers expected the first time. Many of the phone calls concerned billing errors originating from the finance department; failures to notify the pharmacy of a new physician order; inadequate communication between pharmacists, nurses, and physicians; and other customer service failures throughout the organization.

When it comes to measurement, we often view the health care organization in parts. We put in place performance measures that account for parts of the organization separately.

The prevailing thinking seems to be that if each part of the system performs as specified, then overall, the system will perform as expected. Nothing could be further from the truth. Some performance measures should be put in place to identify how often system failures are affecting the performance of the parts.

Change for improved performance means changing the system. Any intervention in a system which does not alter people’s thinking will produce no change. This is why quality improvement training often fails to improve performance over the long term. It’s not just a matter of learning new tools — the everyday practical matters of workflow and systems design must be dealt with. Once people have a better understanding of how work gets done, their behaviors will change.

Altering the system means taking out things that limit or damage current performance. This means that hierarchical barriers may need to be removed, control mechanisms revised, and processes refined.

Improvement actions must be aimed at putting in place the right "system conditions" to ensure that performance is managed from a strong base of workflow understanding.

When you can see your organization as a system, warts and all, you learn about the "what and why" of current performance. You can see what could be achieved, and moreover, you can see what needs to change to realize the potential improvements.

Taking a systems view is totally different view from the traditional, hierarchical view. The traditional, hierarchical view is to look at the organization as having parts or functions. The systems view is to look at the whole and understand how the parts work together.