Category Archives: Quality Improvement

Lean Healthcare and the Great Reform Debate

I have to apologize to anyone who may have expected greater consistency in my posts. This is by far the longest I’ve gone without posting something new. Frankly, I and my partners have been buried under the weight of healthcare clients and we’ve been busy closely monitoring the Healthcare Reform debate. As healthcare tips the scales at nearly 17% of US GDP (and climbing fast) it is easily one of the most important facets of our collective experience that can and will benefit from workflow and process improvement. Whether the object of analysis and re-engineering is the health plan and the manner in which they process claims or run their customer contact center/call center or your local hospital and the manner in which they handle lab specimens, patient scheduling or operating room supply management, there is tremendous room for improvement.

Health Care Improvement – What Are We Talking About?

I’ve been involved in health care for twenty years and can assure you that the conversation hasn’t evolved much. What we’re talking about is a dire need to improve the following:

  1. Access to Services. This can mean access to affordable care, access to insurance coverage, access to culturally-relevant care, gender-specific care, quality care, or access to professionals and facilities in remote areas.
  2. Quality of Care. Quality refers to assurances that providers of care are educated and properly trained and licensed, assurances that quality measures are taken, and continuous efforts to improve quality deficiencies exist. This is a big bucket. Clinical outcomes and patient satisfaction are measures of quality. Safety issues are addressed by quality assurance and quality improvement initiatives.  Errors (common in our healthcare system) are also addressed by quality measures.
  3. Cost Effectiveness and Efficiency. This third facet involves delivering effective care (that which produces the best possible outcome) at the lowest price.  Performance-based reimbursement or Pay-for-Performance initiatives are capitalizing on this notion. In order to drive prices down and create margins of value, providers and payers alike need to eliminate wasteful practices, leverage efficiencies and drive their costs down.

No matter your political affiliation, the US doesn’t fare as well as we’d like to think along those three dimensions. We have significant access issues (hence the cry for universal coverage), rather serious patient safety concerns (infant mortality, secondary hospital infection, and medication error scores are all poorer than we care to admit), and extremely troublesome cost and efficiency problems (our healthcare costs 5-6 times that delivered in other affluent, developed countries yet delivers outcomes and quality scores ranking us in 37th place).

Lean Healthcare Machine

If nothing else, the healthcare debate in congress and the media this year could benefit from the rational and reasonable application of Lean methodologies. Frankly, “Lean Sigma” which controls for variation, quality and waste is an ideal antidote to much of what plagues us. Fortunately, the EMR and health information exchange impetus is going to lead some in the healthcare delivery system to adopt techniques and strategies that will drive waste and variation out of their practices. They will be among the more sophisticated who know enough to improve processes before automating them. Nothing is more wasteful than automating a bad workflow. Sadly, there are some who will buy EMR and practice management software off-the-shelf and try to implement it without first analyzing and re-engineering their business and clinical processes. And that will prove to be our Achilles Heel as we move forward with HIT.

I propose a National Leaning of Healthcare Initiative prior to attempting to describe the Reform solution and prior to spending $20 Billion on electronic medical records systems. I propose we take some time and apply some much less expensive strategies that answer more compelling questions first.


Non-Profits Benefit From Business Process Management and Improvements

Non-profit organizations are near and dear to my heart. I have worked for several (hospitals, social service agencies, quasi-governmental) and have volunteered as a board member for three. I am a current board president for a global organization serving children in poverty in India and Cambodia ( so this affinity for charitable organizations is fresh.  Not unlike their for-profit counterparts, non-profits want to deliver their services effectively, efficiently and produce the outcomes they’d hoped for at a cost that is at least equal to the revenue (donations) they generate. In other words, in their business model, it’s “ok”  to break even though not ideal. Reserves and income on reserves are much better than breaking even. If that equation sounds familiar to profit-seeking capitalists, it’s because it’s essentially the same equation. What’s different, of course, is the mission, customers are “beneficiaries”, and there are no shareholders to answer to…only a board of directors and donors. Quite daunting, actually.

Like investors, major donors and grantors expect to see results. The demand for performance indicators is, frankly, equal to the demand for metrics in any business. Philanthropists, after all, are almost always successful business people.

Enter BPM

All of the conditions that underlie and are so fundamental to business  – from HR and finance processes to supply-chain and customer service processes – are present in non-profit organizations. The value stream is clear, waste is common and the benefits of automation are real. The role of process improvement – driving waste and inefficiency out of processes while infusing them with information and visibility – is best evidenced in healthcare settings. Hospitals and clinics are the closest cousins to  non-profit agencies and are proving that the application of methods like Six Sigma and Lean in addition to standardizing processes for the sake of quality, compliance and shared services is in every body’s best interest. Emergency rooms around the country are now simulating changes in their workflow using BPM tools like ProModel and Visio diagrams are as common in some public health clinics as PowerPoint presentations. Healthcare has caught on to BPM.

Invest-able Change

I suspect the biggest determinant for hospitals’ and public health agencies’ enthusiasm for BPM has been their ability to pay for the consulting support they receive. It’s quite common to see firms like KPMG, Accenture, FCG, IBM, BCG and other global firms competing for BPM work with large state and federal public health entities related to Medicare and Medicaid as well as large county general hospitals who are taking great strides toward electronic medical records. The money is there so the consultants are eagerly positioned to deliver their BPM offering and support.

Most non-profits are of the social service ilk and have much shallower pockets. $300 and $500 per hour consultants in Italian suits are not an option. Similarly, top-flight MBA grads who have never imagined serving soup in a shelter or working with children in slums are not a good fit when it comes to maintaining the integrity of a process. The truth is, we’re out there. There are seasoned professionals and subject matter experts who bring to bear an abiding commitment to mission-driven work in addition to a proficiency in quality improvement and business process management.

Don’t Let The “B” Fool Ya

I think the hang-up people in the non-profit sector have with BPM is with the B.

“But we’re not a business. We’re not in business. We need to be effective, not profitable.” – I hear these refrains often and I gently remind folks that they are an organization of people, process, systems and tools organized to deliver a service or product to a consumer. And they get paid to do it (whether they’re volunteers or not, money is coming in the door somewhere). Non-profit does not mean broke. They are just as bound to a continuous need for quality improvement, safety, efficiency and measurable results. Anyone who doubts the future course of non-profits should take a look at the Gates Foundation expectations for efficiency and results. Donors care whether or not their contributions are paying for results or being squandered on wasteful practices.

BPM is in no way incongruous with the purpose, cause and mission of any non-profit. From this day forward, I pledge – when addressing the non-profits in my life – to use the term Organizational Process Management. OPM it is!

I’d love to hear how your non-profit organization benefited from or could benefit from some old fashioned OPM. Chime in…and thanks for listening.

Proof of Concept (PoC) Important to Success of Business Process Re-Engineering (BPR) and Workflow Improvement Initiatives

How’s Business?

According to, “confidence among Americans fell by the most on record and single-family housing starts hit a 26- year low, posing an increasing threat to consumer spending that accounts for more than two-thirds of the economy. The Reuters/University of Michigan preliminary index of consumer sentiment fell to 57.5 this month from 70.3 in September. The measure averaged 85.6 last year. Construction of single-family homes dropped 12 percent last month, the Commerce Department said in Washington.” It’s high-time we turn this ship around. Words like “confidence”, “sentiment”, “trust” and “fear” are at the heart of this problem. Business people (you!) play an absolutely essential and vital role in restoring trust and confidence. What does all this have to do with a Proof of Concept?

Proof Restores Trust & Confidence

It’s the innovators and those who seek to disrupt the dynamic that lead the rest of us out of the dark. Consumer confidence is a function of trust and trust is a function of your product-quality, price, brand and your market. In your zeal to disrupt and innovate OR in your more conservative endeavor to make your current operating environment more stable and predictable (also a good idea when the market is tight), make sure you employ a Proof of Concept (PoC). Now is not the time for costly mistakes that erode trust.

What About Smaller Companies, Non-Profits and Government Agencies?

I can hear some of you now: “Who does this need for PoC apply to? Do small businesses, non-profits and government agencies need to take these measures as well? Isn’t this just for technology companies and manufacturers?” – The answer is that the need for PoC or some semblance of it applies to all of us in every instance of business process re-engineering (BPR.)

There are a number of approaches to testing and proving your concept: simulation, pilot testing, prototyping, and/or developing a business case. Whatever your chosen approach, proving and substantiating your concepts in business process re-engineering and workflow re-design can save you a lot of money and time. It may also save your job. It will certainly prevent fiasco with customers.

Proof of Conceptkinda self-explanatory

What problem are you addressing and how is your re-engineered process or re-designed, improved workflow going to solve that problem? A PoC will include results or actual measures of efficacy. You need to provide your leadership team (or yourself) with sufficient data to support your claim that this concept will have the desired impact. A Proof of Concept addresses:

  • a clear definition of the problem you are solving
  • specific attributes of the solution you are recommending
  • measures of efficacy, outcome and performance and how you will measure them
  • resource requirements
  • technology requirements
  • the full range of project mgmt and implementation variables (critical path, timeline, milestones, tasks, interdependencies, etc.)
  • budget
  • logic model (or use-case scenario) that supports your assertion that “it works” and satisfies your business requirements

In essence, a proof of concept is a prototype of sorts. It allows you to roll out your proposed solution on a very limited basis and test, validate and verify your approach and results. It establishes the feasibility and viability of what you’re proposing. In manufacturing circles and among engineers, a PoC actually precedes a prototype and establishes that a prototype is a worthy next step in the R&D and product development process.

In services sectors, a PoC may include allowing your prospective customer to try a service and prove the concept to themselves. This is actually a ripe time to take this approach in your marketing and sales.

The Benefits of a PoC?

It ought to be clear by now that by developing an approach to Proof of Concept and an environment within your company that recognizes the importance of rapid testing of innovations, you can begin to shape your products and services in new, more efficient and more customer-specific ways. You do all of this and you avoid the dreaded Unintended Consequences of making changes without considering all of the implications. This goes back to pre- and post-process metrics. What happens up and down stream from a process will become apparent to you when you begin testing in a disciplined fashion.

Key Performance Indicators: Before, During & After Your Business Process

I want to make a special case tonight for the reasoned approach to Key Performance Indicators (KPIs) that involves what happens before, during and after your process. This field (business process management and analysis (and on and on with the jargon)) makes the very most sense when we stop seeing processes as discrete “events” much the same way we advocate for “seeing” tasks in relation to one another when strung together to form a process. That was a mouthful but I hope you get the point. The more holistically we see these phenomena unfolding, the better we can manage them.

We’ve Seen This Movie Before

This is rather basic no matter how “new age” it might still sound to some people. My process can be viewed and considered in relation to the process prior (which constitutes the “triggering event” and the processes immediately following it. We’ve approached the physical sciences in this fashion for a pretty long time and it works very well. Smaller phenomena are nested inside larger phenomena. They are included in yet transcended by larger phenomena. It also helps to understand that the larger has more inherent value than the sum of its smaller parts.

By studying my triggering events and measuring them accordingly, I inform the process I am analyzing. By measuring what happens downstream, I similarly inform my analysis. Suddenly, if I have metrics for Input and Output that tell me something important which translates in favor of my goals and objectives, I will know precisely how to calibrate my process in terms of its productivity, efficiency, quality, volume, throughput and so on.

I know this is going to sound remedial to some of you and I also know that others will find this concept and practice confusing. The best I can do is point you in the direction of BPMS solutions that include simulators. There are also simulation engines from ProModel that are very good.

Simulation allows you tweak your Inputs and imagine what your Outputs will look like under different conditions. This is a practice that involves rigor and discipline. Everybody around you will find it boring. That is, until you point out the impact a process design change can have on suppliers at the point of Input or the impact on customers at Output. There are top-line sales and bottom-line inventory considerations here so do make sure your teams understand that it isn’t enough to see tasks strung together as processes but they must also see processes strung together – end-to-end – to form your entire enterprise. From this vantage point, you will all make your best business decisions and manage your risks effectively along the way.

Key A Good Fit

One final note relating to the title of this post: this practice of looking downstream and upstream for metrics is what makes your measures “key”. They describe critical indicators at critical junctures. If I screw up upstream, you can bet it will ripple through your process and screw things up downstream. One critical “key” performance indicator depends on others in its “ecosystem”. Again, I know it sounds a little cheeky for some of you but others of need to keep your eyes on all of these variables throughout your analysis. This is how you manage Unintended Consequences.

Do you have any horror stories you’d like to share? Any unintended consequences in making radical process changes? We’d love to hear from you.

Business Process Management Must Include Work-Arounds

This is a test. This is a test of your ability as an analyst or group facilitator to invite people to the perverbial table in order to conduct current state analysis or design your future state. The right people need to show up, the agenda and instructions need to be ready and – this is what makes it a REAL test – they need to bring their knowledge of and artifacts related to “work-arounds” if your little shin dig’s going to be a success. You’re being judged by how authentically safe people feel it is to admit they’ve been breaking the rules. Expect tension between those leaders who expect rules and procedures be followed and those who understand that if the job is going to get done right, you have to break the rules at times – particulalry when the procedures and processes are flawed to begin with.

What’s a Work-Around?

A work-around is the un-named process people develop at their desk, usually keep secret, barely document (if at all) and stands-in (replaces), complements, supplements and generaly compensates for the existing, current, published process and procedures.

If you’ve ever managed 10-60 people in a group, you know that more than one work-around may develop. One or more may spread among the group and one may rise to the surface as the “real way things are done”.

What’s wrong with that?

There are two types of work-arounds. Those that lazy, incompetent people develop that are much more flawed than the original process and those that smart, innovative people develop than can be (and often are) better than the original. If the work-around is better than the published process, the only thing “wrong” is that it isn’t properly documented (and it’s subversive). The other thing that can go wrong with a work-around (and usually does) even if it is far superior is that, from a data management standpoint, you have zero validity and reliability when time comes to report or conduct analysis. Documentation in work-arounds often involves multiple Excel spreadsheets that tie to nothing. From an accountability and performance perspective, work-arounds can be critically dangerous.

Bring ’em if ya got ’em!

As dangerous as they are, business process analysis really can’t live without them. You have to know what people are doing and you need to know if it works. Create that safe space and invite people to bring what they have. Keep an open mind and evaluate the work-arounds that show up. Don’t expect people to be too vocal in promoting their solutions. This is an uncomfortable topic (admitting you were a renegade and broke the rules).

If you spot a real winner, frankly, recognize and reward that person. Maintain the tension between following the rules and breaking them (for the good of the order!) by creating a space where work-arounds don’t have to be subversive and stealth. If you try to keep a lid on innovation, learning and spread of knowledge in a group, you will create your own subversion and work-around climate. Let people openly break the rules by creating labs (white-boards) where workflow innovation can happen.

Workflow Integral: Broadening & Deepening Your Approach To The Way You Do Business

I want to share a brief quip based on a recent meeting with one of my clients. I think it may resonate with people who are charged with managing business operations, product lines, services and teams of people. Anyone, that is, who might be interested in improving their workflow IQ or that of their organization.

“2000 What?!”

My team had recently wrapped up a high-level study for a large public health system and one of our recommendations (a foregone conclusion) was that they would need to invest in a contemporary transaction system. Of course, one of the steps involved in deciding what kind of application to invest in is to define requirements. Requirements–functional and technical–are a product of mapping current workflows and then extending those into business processes that can be analyzed in terms of the rules that govern activities and decisions made in-process in order to develop future state or “desired” business processes. There’s much more to it that that but you get the idea. The next steps involve collecting or harvesting requirements for an application from the schemmatics or drawings you have rendered.

When we discussed these next steps, the CIO proudly declared: “We’ve already done that.” “Oh,” I said. “When?” He went on to share that “3 years ago,” his department and unit heads mapped out their workflow. “That would have been in 2005?” I asked. “No, 2004.” He replied. Further, rather than develop requirements based upon their own mapping exercises, they “borrowed” requirements from another coalition of similar agencies. “When were those requirements written?” I asked. “2003.” He replied.


You can guess (one guess only) how successful this approach to writing requirements will be. I suspect that’s why they’re 2 years behind in making this change. But the real problem in this illustration is in the eyes of the department and unit managers sitting around the room. One chirped, “I’m afraid the requirements won’t reflect what my people do everyday.” Good thinking. Another chimed in, “My people are clinicians and it isn’t in their nature to work in two systems and not be able to take notes when they’re with a client. This change risks not reflecting who we are.” Again, brilliant observation. These managers understood something seldom appreciated by technology people (especialy those who are under-resourced and several years behind the times) – people use these tools.

People are Complex Systems

We’re integral by nature so our tools need to accommodate the variety of factors that motivate our behaviors. This is more true now than it ever has been. That’s because we want our tools to encompass more and more of what we like or need to do. The iPhone is a great example. So is Google. They integrate otherwise disparate activities into a common application and single interface. That’s the point of Business Process Management. That’s the point of standardizing code and re-using data. That’s the point of understanding what all your customers want to experience.

What’s Integral?

I give Ken Wilber full credit for my understanding of what it means for something to be integral. I give myself full credit for all that I don’t understand.

  • “Integral” takes into consideration my sense of self on an internalized, individual basis. This is really my self-sense. My sense of “I”. One finds motives, emotions, intelligence, passions, beliefs, sense of purpose and mission.
  • An integral view also takes into consideration what is exterior to me in terms of discrete phenomena like all of the “it” that I am or you are. This really refers to the human body and how it is compounded from atoms and molecules all the way up to this brain sitting in this head atop this body. In work, we are surrounded by other “it”s, all external to us and all of them are organized in terms of how they are compounded or assembled. The body is what moves in relation to other bodies (and tools like desk-tops and printers and machines) to produce…a process!
  • The integral view considers the internal sense “we” share. This is the collective cultural dimension of work (and life as a human being). It considers our values, our mores, the story we tell ourselves about ourselves as a “tribe” would. In this modern age, our story trends toward pluralism and appreciating others’ perspectives (sort of). This view lets me figure out where and how I fit in with others in my group and how our group relates to other groups.
  • Lastly, an integral view considers the external social system or organization of people (the “its”) as seen from the outside and their environment all of which is less visible but still serves as infrastructure. This would include industry, trade groups, corporations, governance, nation-states, governments and all of the social apparatus they produce (like laws and schools). This, for example, explains why it takes weeks for a purchase to be approved “because of all of the red tape”.

Wilber goes on to explain that each of these four “quadrants” include lines of emerging intelligence and developmental stages. That is, they can be rather stunted or more evolved. The more evolved they are, the more they are said to be “trans-personal” and include but transcend their less evolved natures at lower levels of organization and development. Ok. Enough philosophy. Especially done this way. Trust me, if you wan to learn more, there’s plenty to read. Don’t take my word for it. This has been a rather brutal summary treatment of very exciting material.

The point is…

Using the example above, if you want to help a team of people through change, transformation and evolution from: less organized to more organized; from low quality to high quality; from paper to database; from less efficient to more efficient; from fragments to integral; then you are strongly encouraged to look back to those four bullets above and consider how the change will impact the individual (“I”), the group (“We”), the individual actor’s body (“It”) and the social system they belong to (“Its”). From that standpoint, you can account for an integral change and avoid barriers, resistance, and potential failure.

  • Will people accept it?
  • Will people feel as though they were regarded?
  • Were their beliefs and sense of purpose be upheld?
  • Will the social system support it (and fund it)?
  • What are the rules, mandates, laws, and budgets?
  • How are partners and suppliers going to react?
  • How will the body move through this change?
  • What will the new process exert on the body?
  • What is important to these people?

And for cryin’ out loud, don’t wait 3 years to apply some other agency’s requirements to your 4 year old workflows! Ask more questions, go for more depth, more span, and act quickly before the recession gets any worse.

Non-Profit Organizations & Workflow: Doing More for the Cause

Anyone who has ever worked in a non-profit organization knows all too well that slim administration and operations budgets translate into hard work. I’m not talking about gleaming hospitals and health insurance companies that meet non-profit status criteria. I’m talking about the small and mid-size social services agencies, group homes, charitable missions and advocacy programs that provide invaluable services in this country and the NGOs that do similar work around the globe.

Non-profits are staffed by intelligent, educated, experienced, mission-driven and hard-working people. The salary structures and the nature of the work do not tend to attract people who are looking to make a buck, climb the corporate ladder and get out. Similarly, because the organization is not so much “selling” something, it provides services in the trenches with whatever resources happen to be at its disposal. Slim margins mean there is little investment in technology and innovation. Not because managers, leaders and the board of directors don’t want to or don’t see the value in it, they simply can’t afford radical investments in technology to automate some of the back-breaking work.

Improved Workflow Can Stand-In for Automation (for the time-being)

While a non-profit may not be able to afford new technology-enabled tools that would drastically reinvent their delivery systems, they can afford to emulate systems and work backwards. By visiting a large for-profit that provides similar services – as a soup kitchen may be to a successful restaurant chain – the non-profit manager can learn something about how automation and systems make restaurant work more efficient and satisfactory. It may be in the way that the customer is greeted and moved quickly to a table or in the way an order for food can include some customization and accommodate allergies and diet preferences. It may be in the way that money is handled on the back-end or in the way that supplies and inventory are managed.

Bringing these lessons back to the non-profit to model the current state and the future state so it looks and feels more like the automated solution is not only possible, everybody benefits and it costs little.

Analysing and Managing Workflow for Improvement Doesn’t Necessarily Involve Information Systems

In this day and age, much of what is said in the press and in workshops and books on the topic of managing business process and workflow is spoken by software developers and consultants who can improve workflow and automate processes using technology. Often, the approach leads to new, tailored systems. That is not – by definition – the only reason to engage in workflow improvements. Workflow and business process can and will improve by applying the fundamentals to a white-board and then implementing them using sound project management principles.

Change Means Disruption – Addressing the Beliefs that Maintain the Status Quo

By virtue of their budgets and scant IS/IT resources, non-profit agencies tend to resist innovation and change. It makes sense in the context of organizations that cannot afford to develop new processes in parallel and test-mode. “Too many people would suffer in the interim. Programs might grind to a halt. What if there were mistakes? The founder’s unique approach cannot be challenged. The board will never approve it. We can’t afford it!”

All of these are the beliefs that maintain the homeostasis of things – people, processes, outcomes – and, with care, they can be “entered” and challenged for the purpose of producing a better outcome. Working with a non-profit involves challenging sacred cows that are often very different from the sacred cows one encounters in a for-profit setting. Greater care has to be exercised in challenging them because drivers of behavior like beliefs, values, vision and mission are very strong and give way only when the organization can be assured that their purpose will be met. Making the case for doing more with less and producing better quality outcomes is the best bet. Secondarily, a higher-performing non-profit does, in fact, attract greater funding but that is always secondary to the mission.