Tag Archives: economy

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.

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The Leaning of America: The Case for Small Business Process Management is Unequivocal

As a consultant to small and mid-sized business, non-profits and government agencies (with a particular focus on healthcare), I often engage executives on the merits of BPM. Said executives wonder aloud if their time is well-spent documenting, analyzing and re-engineering work and processes.  The common refrain is that they believe they have bigger fires to fight and that their people simply need to be managed to be more productive. Other excuses involve blaming external factors such as unfair competitors,  legislators, suppliers, and fickle customers.

There’s no doubt that the economy is in terrible shape. All of my clients are struggling. However, the data is incontrovertible: organizations that run lean, slick, flexible processes in every dimension of their operations are doing well compared to their less BPM-savvy peers.

In retail, Wal-Mart is peerless. Japanese and European automakers have survived whilst GM and Chrysler went bankrupt. Amazon continues to disrupt the entire universe of commerce. Kaiser has revolutionized healthcare and health insurance. Tata is helping India’s GDP grow while the institutionalized first-world back-slides. The tech sector as a whole has fared better than most other sectors. The only incongruities are the BPM-centric banks that demonstrated ethics, morals, risk-taking behavior and greed can and will outsmart BPM any day.  While there are many factors at play in the world of business and global economics, it pays to study the common traits among the winners and apply them at home.

Think Small and Lean

It’s simply undeniable that investments of time, energy and money in becoming process-centric will pay off in a number of important ways. It is also a fact that the US economy is a function of small business. Our challenge is not in doing more to demonstrate how swell BPM serves multi-national, multi-billion dollar, multi-tech corporations. There is no question that aerospace and supply-chain giants know what they’re doing.

The great challenge lies in packaging BPM approaches, tools and methodologies in right-size, right-time, right-cost portions for healthcare, social services, job training, housing and other sectors. Government and non-profit organizations are crucial participants in our economy and generally suffer from a lack of process savoir-faire.  This is especially true at the local level. Small government and small business must become process-enabled.

This call to action is all the more reason to simplify and de-code the way we talk about BPM. The more cryptic and foreign something sounds, the more geeky the approach, the less accessible and more expensive it becomes in the minds of government and small business leaders. Similarly, the more BPM is a product of software developers and the more is aimed strictly at automation, the less attractive it becomes. Electronic medical records (EMR) are a terrific example. Software developers sell software in a way devoid of attention to the most basic workflow and implementation issues; 60% of implementations fail; and today a dismal 2% of hospitals and 10% of doctors offices have a fully-functioning EMR in place. No matter how badly our country needs EMR proliferation, if our approach is tinged with greed (which it is), the initiative will stall (which it has). Compare that performance to the spread of VistA (the VA’s answer to open source, simplified solutions to the same problems). VistA is standard across the DoD, VA and many other public health domains today and spreading quickly.

Lean Initiative

True, government, social service, health, and non-profit sectors – who are often smothered under the weight of social and economic pressures in ways you and I can’t relate to – need to modernize, get lean and automate. However, so long as the architects of change speak a foreign language and offer up expensive software solutions, progress will be glacial. I propose that this country needs a Lean Agenda as much as it needs a Green Agenda. Frankly, we need lean to get to green. But it has to happen in all sectors, fields, industries and domains. And in order for that to happen BPM ambassadors need to come back to Earth and engage people in a multi-cultural fashion. We should all be painfully aware that big business relies upon small business and affordable health and social services. Unhealthy, unemployed, uninsured, homeless and penniless people make lousy customers. Get real.

Prioritizing BPM Projects is a Sign of Effective, Experienced Leadership

I received an email from a friend of mine today lamenting the projects he’s had to wave good-bye to. The email read: “That other process improvement stuff is nice, however, right now…revenue generation is the only process that matters. We have to keep the doors open”.  It made me think deeply about my clients and the projects we’re working on. How many of  them have leaders who’ve called emergency meetings in the past 12 months to reconsider and re-prioritize their approach and focus? None. How many of them have since been panicking and flailing? All of them. Most of them have reduced schedules and laid people off lately. Not a single one ever stopped to prioritize and shift attention when they could.

What’s a Priority?

First of all, if you’re still slogging through 4-6 month process improvement projects, you’re braver than I am. Get lean in your approach, folks. Secondly, if you don’t know how to prioritize in this economy and are struggling to choose which of your projects should “rise to the top of the list”, please ask your peers and ask the big boss. Go to the executive team and ask them to help you decide if you need help. But no matter what, show some initiative and demonstrate that you’re thinking like an executive. If not, you’re setting yourself up for disappointment.

Short answer: it’s a priority if it will immediately help us make more money (sales) or save on costs (making us more profitable). Sales are tough now so anything that can reduce costs is a big hit with executives and shareholders. If you’re a non-profit, cost reductions are popular with boards and donors. Toot your horn. If you’re a government entity, you have serious challenges too. You must get costs under control. Government doesn’t often lay people off but I have seen it happen in the past 6 weeks. I have seen it happen where people dragged their heels, hemmed and hawed, went to far too many meetings, and took too many vacation days. They complained and wondered who was in charge. They failed to prioritize and act swiftly and assertively. Now they’re looking for work.

Inventory your projects, identify the revenue generators and cost-efficiency opportunities and move them to the top of your to-do list. Everything else takes a back-seat until your executive team gives you the green light to relax and do something interesting. That may be months from now so get comfortable fighting fires.

It’s Time for Strategic Business Process Management

I am coming off several weeks’ having to reassure clients that they are doing well and that – so long as they stick to their knitting – they’ll be ok a year from now. I have others who have required some serious, adult discussions. They lack a cohesive strategic plan, therefore, they lack in the areas of discipline, direction, commitment and – frankly – workflow IQ. They struggle with change, flexibility and orientation (“where are we?!”)

The disconnect is rampant. Perhaps it’s in the name. Shall we refer to business process management (BPM) as Strategic Process Management (SPM) from now on? You heard it here first, folks.

Strategy+Goals+Objectives+Metrics

I’ve heard others call it Business Motivation Modeling and agree that we need a deeper understanding of critical business drivers. This field and the broader business interests and stakeholders it serves needs to reminded constantly of the “means”, the “ends”, and the “influences”.  By keeping a strict focus on strategic goals (building the business, becoming #1, being fastest, cleanest, safest, whatever) and tactical objectives, business analysts and process engineers ought to be able to produce the outcome they’re looking for and they ought to be measure whether they’ve achieved their goals or not.

Environmental Analysis

However, failing to manage strategy and failing to carefully and comprehensively assess what is happening economically, politically, socially, technologically, competitively and legislatively will absolutely result in painful surprises. I have seen people very proud to have hit sadly meaningless targets lately.

Strategic and Technical Advisory Groups (STAGs)

I am calling for the formation of STAGs in every organization with 25+ employees. This committee will review and evaluate business process and other organizational change from both a technical standpoint and a strategic standpoint. Strict adherence to strategy (bearing in mind that strategy – not values – can and ought to change to reflect the environment) will be their direct responsibility. There will be an executive on each STAG until and unless every organization recruits a Chief Process Officer. Perhaps then, the brilliance of BPM will have been fully activated.

Business Process Data: On Dashboards and Windshields

Reading about IBM’s “Stream Computing” in Business Week magazine this week, I am reminded of a time in a meeting several years ago when I groaned: “I don’t want a better dashboard; I want a cleaner windshield. I want to know what’s coming and a dashboard can’t tell me that. Those are lagging indicators.  At best, a dashboard tells me what I have done in the recent past. I want to know what my suppliers and customers are doing as they approach…before they get here.”

On My Windshield

I never did get my Windshield. Today, we’re lucky if we have a dashboard. It would  put many of us in a small minority if we could have near-real-time indicators of what just happened  on our desk-tops. From a business process management perspective, how would life be if I could see changes in my supply chain before they affect me? If I could see my suppliers’ dashboards, would that be enough to give me an idea of what I could expect?  If, instead of relying on marketing, I relied on interoperable business data between my company and my customers, could I see their demand before they pick up the phone and place an order? That information would help me in innumerable ways.I suspect very large companies can afford supply-chain and distribution information management and reporting but what is a mid and small sized organization to do?

Is it possible that my contracts with suppliers and customers might involve strategic dashboard exchange? Of course  it is. In a business-to-business relationship, my clients might even think they were doing business with a pretty smart guy if they knew I needed to know something about their data prior to them needing to know they need me. I bet they would be happy to give me that information in small packets called “Bugs”. Throughout the day, “bugs” would hit my “windshield” and I would know what’s coming down the road. You could have a lot of fun with this metaphor. Landscape, traffic signs, intersections, accidents, traffic jams, you name it.

Operations, Finance, Marketing and Sales: Performance Metrics During the Race

Dashboards are helpful. Don’t get me wrong. I find them especially helpful once I have arrived. I can quickly look back over the course of the trip (or the day at work) and understand where I have been, what my top speed was, how many miles I covered and how much fuel I used (plug your favorite business metrics in here). A windshield, however, lets me calibrate  what is happening in the midst of a high-speed race. As a former football player, I can tell you that my stats after the game were a lot less important to me than was knowing where the line-backer was when I pulled out on a sweep. Failure to see my adversary or my teammates often caused me great pain. Successfully anticipating blows led to touchdowns.

The Importance of Anticipation: Getting Out of the Blind Spot

We are living through the negative consequences of not anticipating what lies ahead. We’ve all become so enamored with the rear-view mirror and the mounted DVD players in our SUVs that we have forgotten to simply out the window in front of us and drive defensively.

This may all seem trite and I may sound like I am beating this metaphor to death but I think we need simple reminders these days. Look outside your vehicle and assess what is happening down the road. Many companies have done this very well and managed to keep staffing levels and inventory at quite safe levels. Other companies were so busy fiddling with their dashboards and cell phones and doing their make-up while they drove that they missed their exit and went over a cliff.

What do you need to know about the road ahead and the drivers around you? What kinds of “bugs” do you want hitting your “windshield”? This is a great question for your next executive team meeting. It’s also a great question for your business analysts and your line staff.

  • what would you need to know about your customers’ “demand behavior” that would allow you to do your job better?
  • what would you need to know about your suppliers and supplies?
  • what would you need to know about the economy?
  • political changes around the state, country, world?
  • currency and credit changes?
  • social trends and patterns?
  • legal developments?

Keep in mind that as you’re driving in LA, for example, you don’t want to know what’s happening on the roads in Brussels. Keep your expectations “close” to you. There is little true and accurate value in looking “down the road” for more than 30-60 days at a time. Conditions on the roads are changing far too quickly. Pay attention to the drivers next to you where it matters most. The next bend in the road is far more important than the bridge several hundred miles away.

Give your data needs some attention, ask your suppliers and customers for data and use it effectively. Good data makes good information. Reliable information becomes intelligence and enough intelligence used appropriately over time makes one wise.

Business Process Re-Engineering: The Enemy of Inertia, Waste and Consensus Complacency

Working with several governmental and non-profit agencies recently, I noticed a pattern emerging that is at once counter-productive and based entirely in fear. What I used to think of as intellectual sloth is giving way to wasteful complacency and what I choose to call a “consensus trance” resulting from fear of losing one’s job and identity. Who would have ever thought the BPM field would awaken so many strange psycho-social bedfellows?

Snap out of it!

I find that the best response to this trance is a tactic long employed by carnival hypnotists: snap people out of it. As an outside consultant, I have a responsibility to identify waste and recommend alternatives and solutions. In order to pull that off in an atmosphere of fear and economic uncertainty, I am resorting to a heightened assertiveness, directness and tough love. I have to point out that it is not simply a matter of process but a matter of organizational dynamics causing my clients pain. Morale is taking a direct hit as it often does when people aren’t performing in ways they know they could (given the opportunity) however, coddling people and enabling even sicker patterns to take root is not the answer.

“Will” the change you want to see in your organization

I am encouraging (if not demanding) that mid-level people and directors seek out more definitive executive sponsorship and greater political will power to enforce change initiatives. Slowly, it’s working. I am documenting decisions like never before so that I can hold people accountable. I am measuring project status at every turn. I am amending contracts wherever possible. None of this is fun but it is all so necessary. If you haven’t already done so, push hard on your Project Charter and Executive Sponsor. Then push even harder on Project Management and then hold people accountable with actual consequences.

Failure is not the end of the world

If your project fails, your process re-engineering efforts produce the wrong outcome, or people on your team fail to meet expectations, act accordingly and appropriately and move on. Dwelling on the fall-out right now will not help anyone. What we need is will, speed, and efficacy.

Let me know what works!

The Leaning of America: How BPM Can Play A Vital Role

I’m not sure what industry you work in but my chosen field – healthcare – has been on the short-list of sectors that are under a microscope AND looking at significant investment (stimulus is such a loaded term these days!). There are others: automobile manufacturers, education, border patrol, banking and finance. I frankly love the position the President has taken. He is asking for accountability and demanding an end to wasteful practices. While it’s still way too early to judge his performance, I believe he will continue to push for efficiency and better throughput and outcomes for our money.

Lean Healthcare

I have worked on all sides of this equation. As a healthcare provider in non-profit, social service, for-profit and government agencies. As a healthcare payer (insurer) in managed care and other insurance models on both the public and private sector sides. Let me assure you, there are mountains of waste to recoup in every corner. I will not suggest that a single-payer system is the answer (though it may be) but I will assert that there are scant examples of healthcare organizations in this country who run truly efficient and high-quality shops. Our system irrefutably, immutably wastes money. Our care costs much more and produces a poorer outcome than that of our global counterparts. Now that we are in a global economy, any country that can keep its workforce healthier than ours at a lower cost has a competitive advantage.

Healthcare is the last industry to “automate the shop floor”. Frankly, it’s ironic. So much information and so many processes can be automated. This country lags far behind other industrialized nations in the adoption of electronic medical records. Today, the New England Journal of Medicine reported that only 1.9% of US hospitals use a fully functioning electronic health record, for instance.

Prior to automation, however, so much can be accomplished using BPM methodologies, particularly as they relate to Lean and aspects of Six Sigma. Anyone who has ever worked in the field can attest to the waste and now, more than ever, we need to work together to eliminate all of the waste we can no longer afford. Healthcare is rapidly approaching 20% of our GDP. That’s not only astronomical, it’s unnecessary.

Wherever you are, whatever you do, whatever your motive, please spread the word and get into action. BPM and Lean methodologies can have a profound impact on the way things are done today so that tomorrow will be cost effective. If you’re not excited about the impact you can have, you should be!