Guest Column: Use system analysis for lasting improvements
Questioning tools help find solutions
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
In today’s hectic health care environment, we tend to look for immediate solutions to problems. In our haste to "put out fires," we implement process changes that may offer immediate improvement; however, the problem that caused the fire often still exists. A more effective way to achieve lasting improvement is to use system analysis techniques when making a change in a process. System analysis involves interviewing process owners and management to gain a broader understanding of the problems so that better solutions can be developed.
The lack of a system approach by case management staff results in wasted troubleshooting efforts. Staff may not always comprehend the unique area of concern and the environment in which the process resides. That’s why involving users and customers of the process is so important when solving problems.
Question those involved
A quick and effective questioning tool that can be applied in all environments consists of a series of six age-old questions: why, what, where, who, when, and how. Use these questions when interviewing and trying to understand an existing process or problem. Comments and insights from users can be elicited simply by asking:
- Why do we need this process/procedure?
- Why do we need this method?
- Why is this a problem?
- What is the purpose of this process/task?
- Where is this process done?
- Who does this process/task?
- When is it done?
- When does it have to be done?
- How is it accomplished?
Getting the answers to the why, what, where, who, when, and how and documenting the answers with flowcharts and narratives clarifies the process being studied.
Each question presents a different focus on the process because it requires the responder to further clarify the activities in another way.
Once a process is understood and defined, another series of questions can be used to determine if the current process steps are really necessary. This is done by looking at each component of the process narrative and flowchart and asking: Can this task be eliminated? Changed? Combined? Simplified? Asking for improvement recommendations can be a very powerful and insightful question. Often the answers are in front of us. We just need to solicit input from those closest to the process. By asking users and those ultimately responsible for the process for their thoughts and recommendations, a list of alternative solutions can be compiled. This step is an important way of getting everyone involved in the solution process by having their ideas solicited and considered. Users of the process will have more accountability if their ideas are accepted.
When putting together a clear understanding of the problem, other data-gathering strategies may be needed to complement the questioning technique. One form of data gathering is observation. Observing a process in the user’s own environment, or getting a demonstration of the process or problem, combined with asking the aforementioned questions, provides valuable insights. Visit the area where the process is done and experience what people see and feel. Surveys also can reveal issues that might not be uncovered any other way. A person completing a brief, five-minute survey may disclose problems, issues, processes, or solutions not found through other data-gathering techniques.
Questioning and other data-gathering techniques provide an opportunity to continually ask questions until the problem is defined from all perspectives — process owners, management, and others impacted. And with each technique, don’t forget to ask, "What do you recommend?"
Case management application
The following case study illustrates the use of system analysis to improve a process involving case managers. The director of case management believes that case managers are not receiving timely notification of new inpatient admissions that would benefit from case management services. In some instances, case managers are not contacted until the patient is less than 24 hours away from discharge. There appears to be a breakdown in communication between the staff nurse who conducts the patient’s admission assessment and the case management department. System analysis techniques are used to help define and resolve the problem.
First, the present system of assessment and communication is defined. By interviewing staff nurses, supervisors, and case managers from different units, an understanding of the current process is developed. Asking, "Why should patients needing case management services be identified at the time of admission?" documents the need for the process. The question, "What is happening?" gets to the current method for assessing patients and communicating results to case managers. Asking, "Where it is happening?" allow people to define and understand the location and its limitations. Asking, "Who is doing it?" documents the staff doing the initial patient assessments. The question, "When does the process occur?" focuses thinking on day of the week and time of day. Asking, "How is communication between the admitting nurse and the case manager actually done?" documents the information exchange as it now exists. Answers to the above questions are documented in a flowchart showing the present admission assessment and case manager communication process. This draft document is then reviewed with those interviewed to elicit feedback and clarification.
The next step is to look at the current process to determine where improvement can be made. Can a step be eliminated? For example, is it really necessary for the nurse to complete a separate form to request a case manager consultation? Can something be changed? For example, can elective admissions be screened prior to admission to identify those needing case manager services? Can something be combined? For example, can case managers be present during the initial nursing assessment? All questions are designed to determine if a step can be eliminated or streamlined.
As people brainstorm ways to improve the process, a unit secretary who has been asked for an opinion and recommendation responds with, "We see many of the same patients over and over again. Why not set up automatic case management referrals for these patients?" A staff nurse builds on this answer by suggesting that the admissions department directly notify case managers when previously admitted patients with chronic conditions are readmitted. A physician offers an additional recommendation: "Let the patient’s family contact the case management department directly when care coordination issues arise."
When everyone involved in a process is brought together in a room to solve a problem, they often become engaged in a chaotic and unstructured discussion of quick-fix solutions. Using system analysis techniques, the leader of the discussion can focus people on what is needed to achieve lasting results. The asking of why, what, where, who, when, and how provides problem solvers with a structure for achieving the best solutions.
Questioning whether process tasks can be eliminated, combined, changed, or simplified further defines the process and can lead to a more efficient process. The question, "what do you recommend?" recognizes that those closest to a process often have the solution.
These questions lead to a better understanding of the system or problem so that the best options and solutions can be defined.
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