Part 2 of 2

The Quality-Cost Connection: Improve performance by taking outsiders’ view

Patients want health care to be customer-shaped’

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

What is the purpose of your health care organization? To survive and prosper, of course. But the question is, by what method? What you need is everybody working to improve performance, and to do that, you need the means to determine how well processes are working for patients. Patients and families can only take their view of your organization from the interactions they have with you. If those interactions are positive, people are likely to return for more services and tell friends about the high-quality experience. To achieve this goal, you must understand what matters to patients and families at every step in your patient care processes.

Take, for example, the process of getting a mammography examination. Looking at it from the point of view of the patient, the process resembles the diagram, below. The manager, taking a top-down view, might think it wise to reduce staffing for the appointment desk or limit the hours in which appointments will be taken.

But go too far and prospective customers may call elsewhere for appointments. Similarly, if management focuses on increasing the number of exams that are performed each day, patients might find themselves with a long wait time in the reception area. Moving on to the post-exam steps: results reporting and billing; you often find enormous amounts of patient calls caused by "failures" of the organization to get it right the first time.

To improve performance, people must get inside the process from the patient’s viewpoint. Patients want health care to be customer-shaped. They want to do business with organizations that respond to their particular needs in ways that suit their circumstances. Only by having intimate knowledge of customers, their attitudes, habits, their work, and so on, can one start to design services that are truly customer-driven. The best way to begin a customer-driven transformation is to know the nature of customer demands on the patient care process, know what "value" is associated with those demands, and know how the process works to meet those demands. Using the same diagram, ask yourself:

  • What do you know about the patient’s experience at each point?
  • What type of demands do patients make at each point?
  • What do you know about what matters to patients (the "value") at each point?

Now go to the points of patient-organization interaction. Listen and observe. Listen to telephone calls coming in. Observe the X-ray receptionist. Undress in the changing room, and put on the cover-up supplied to patients. Spend time with the technologist, the radiologist or anybody who personally interacts with patients. At each point, look at what’s happening from the patient’s point of view.

  • What types of demand are patients making?
  • What matters to patients with respect to each type of demand?
  • Does "what matters to customers" differ by type of patient or by type of demand?
  • Ask the people who work there what matters to patients?
  • As you work on this activity, keep asking: "How do we know?"

To improve for the long term, you’ll need more than opinion and anecdote. You’ll need measures to help manage performance. These are called "capability measures" — tools for evaluating the continued success of customer-driven process changes.

Measure process capabilities

For every type of demand patients place on your organization, you’ll need measures to tell you how well you are responding. In many health care organizations, measurement focuses on meeting internal standards.

The results reveal little or nothing about how well you are meeting patient expectations. If you take a systems approach to performance improvement, you’ll want measures of how well the organization does things for patients and families. For example, time to send out reports, time to respond to requests, percentage of bills that are accurate, percent of problems solved on first call and so on. Armed with a good understanding of what is happening at each point of interaction between your organization and patients, your improvement efforts can focus on enhancing customer service.

Measures of customer-driven expectations are very powerful analytic tools. People may disagree about what you should or should not do for patients, but they cannot argue over what is actually done. It is vital to get data on the capacity of your processes to meet customer expectations before taking a look at how work flows through your organization.

Think flow

Once you clearly understand what is happening between you and your customers, then people can begin to move from "what" to "why." Measures tell you the "what" of performance, and workflow tells you the "why." Many health care facilities claim to be working on improving processes or flows, but how have they decided on the focus of these improvement activities?

If the improvement team completes an analysis of the process from the customers’ viewpoint, as illustrated by the mammography exam example, team members will have an effective starting place for actions. The core steps of the process are defined by interactions with patients and families. Performance measures tell the team how the process actually flows.

When selecting the actions intended to improve a process, the focal point for a systems view is always the customer. The process must be viewed from end to end — from the point that the patient makes the demand to the point where the patient’s need is fully met. From the map of core steps, as defined by the customer, choose one that has a high impact on overall satisfaction.

For example, suppose the team chooses the step of mammogram results reporting. As the team examines this step, it will want to look for the causes of failure from the customers point of view by asking these questions:

  • What is the purpose of this step from the patient’s point of view?
  • What matters to patients at this step?
  • What are the activities involved in this step?
  • What is the usual flow of activities in this step?
  • What might go wrong during each activity?

As the team members discuss the step, have them make a list of all the things that could go wrong from the patient’s standpoint and what might cause these failures. The objective of the team should be to change the flow and activities so that work of "value" to patients is performed. By conducting the activities analysis, the team will have a schema of the interactions with patients, and at each point of interaction, it will have data about what is currently happening. This leads to a better understanding of the flow and identification of suboptimal activities. Now the team can move on to discovering the system causes of current undesirable performance.

A better way to work

Health care organizations are facing fundamental challenges to traditional beliefs about how to design and manage patient care processes. By viewing health care services from the patient’s perspective and applying systems thinking, improvement teams can discover the root causes of ineffective workflow and processes. Getting people to think about the "hands-on" experience of patients and their families provides an important systems view that leads to lasting changes and improved customer satisfaction.