Tag 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.


Taking Care of Business: Why Context and Need are at Heart of Business Process Design

For those of you who don’t know, my BPM consulting work focuses on the healthcare field. Nowhere is the answer to the question “Why?” more striking and evident. When people begin (and I do mean begin) to think in terms of “Why do we do this?” and “Why do it that way?”, the answers inherently gush with reasons that make you sit up and take note. And nowhere have I paid witness to answers and reasons that are so incomplete as to send shivers up and down my spine. If you’re not sure what I mean, give up an afternoon of your time, sit in your local emergency room and watch how people there do their thing. It’s free, entertaining and the best open source forum for organic, dynamic examples of workflow and process in action.  You won’t be sorry. Mortified at times but certainly not sorry.

From this healthcare standpoint, let me say a few things about context. First of all, if you’re relatively new to BPM, BPR, BPA and all of the other acronyms, you should become aware and fluent in context diagrams. Context models and diagrams allow you to illustrate (simply) understanding of the transactions between stakeholders or entities and the outcomes that are expected as a result. For instance, if a hospital submits a billing to an insurance company, the expected outcome is a payment. These diagrams also take into account indirect interactions. In doing so, they begin to conjure SIPOC diagrams but are different in that they take a very broad Business Process Overview that includes all of the possible stakeholders (direct and indirect) and display – at once – all of the interactions in simple, straight-line fashion.

Business Process Overview – The Bird’s Eye View of Context

By illustrating all of the transactions and expected outcomes possible over an entire array of workflow and activities in a highly simplified diagram, the reader gains immediate insight into the context and the needs of all of the stakeholders (my expected outcome is directly related to my need). This may sound elementary but I promise you that in this highly inter-dependent and inter-connected world, few people grasp and understand the value and relationships involved in the working world they inhabit. Again – from the healthcare field – how many people understand that the answers, information and data they harvest are being used by Immigration, CDC, Public Health, Policy and Legislative, and Insurance officials simultaneously for vastly different reasons?

Taking Care – Taking Heart

When people understand fully the value of their work product, when they can see themselves and their activities in full view of the context, then they grow more intimatley connected to the people and stakeholders they are in exchange with. It isn’t a matter of giving you what you asked for. It  is a matter of helping you satisfy a goal or a need. If I work in a restaurant for example, the meal I serve may be the context for a marriage proposal, a landmark business deal, a birthday or the only respite a couple will get from their hectic schedules. That meal may be what restores patience or hope. If I work in a clinic and I have to enter data today, I may be entering the data that enables an epidemiologist to spot a viral outbreak or I may be entering the data that assures my patient of full and prompt insurance coverage. I may be avoiding a medication error and saving their lives. If it sounds dramatic, context reminds us that  it is.  Take pride in the work you do, my friends.

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 (www.lotusoutreach.org) 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.

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.

Workflow & BPM for the Sake of Crisis Management and Business Continuity

You may have heard the story and seen the headlines this week: Largest Recall of Meat in US History. You may have seen the other headline: FEMA Trailers Spewing Toxic Fumes in Louisiana. Both stories, and countless like them every year, reflect one of the oft-overlooked reasons to manage workflow and analyze business process: improving quality for the sake of safety and avoiding crisis.

Had the California-based meat processing plant assigned a workflow analyst and – more importantly – had they had the integrity to fully-implement a food safety and quality program, they could have avoided the embarrassment of being outed by a Humane Society undercover video sting that captured illegal employees on tape shoving disabled and handicapped cows into slaughter. School kids across the country eat that meat for lunch. Had FEMA had any quality controls in place and contracted with a supplier that managed its processes in accordance with standards, 30,000 trailers – home to Hurricane Katrina victims – wouldn’t be victimizing their inhabitants a second time – with toxic fumes, no less.

Crisis Management Planning Core to Business Continuity (Survival)

I have conducted crisis management planning with organizations and was always surprised at how little forethought went into it. It’s symptomatic of leadership and personnel at all levels. I became convinced early on that the very best way to spot potential crisis before it hits the headlines is to apply workflow and business process analysis tactics and principles. An organization that doesn’t know what its employees are doing is ripe for crisis. An organization that doesn’t see process issues and risks as a high-priority is setting itself up for disaster. Failure to examine and analyze anything more than the bottom-line is failure some companies frankly deserve.

Crisis management planning often involves scenarios that managers need to respond to answering questions like: what would you do if the phones were dead? What would you do if the power went out? Who will handle the press relations if there is a violent death on-site. Little to no attention is paid to the glaring and obvious opportunities to assess how quality of work can cause a crisis and how easily it can be mitigated by re-engineering workflow. ISO 9000 and other standards help industries by offering best practices and some industries are vigorous in their audit of quality controls. Sadly, enforcement is weak in many industries and self-induced adherence to best practice is a discipline many organizations lack.

The irony is that, of all things that could go wrong, workflow-related phenomena are easily identifiable, easily modified, easily monitored and measured and the consequences of failure to do so can mean complete ruin. FEMA’s reputation and that of their supplier is in serious trouble. I would imagine their supplier will be crippled by this. The meat processor is not only hiring illegal workers which reflects a breakdown in HR and personnel workflow but these workers are afraid for their jobs when their input and output aren’t maximized by leveraging a supply of sick and crippled cows. I would imagine this business is counting days till their doors close permanently. They should be.

What Crisis is Waiting to Happen in Your Shop?

All of us are responsible for risk management. When workflow and business process analysis become the domain and tool of IT only, nobody else knows how to detect workflow-related issues and risks with any precision. If you’ve gathered issues and risks as a function of developing requirements, what have you done with them since the day you gathered them? As a business or systems analyst, do you bring them back to the attention of management with any frequency? Do they become quality improvement initiatives? Is there a project manager assigned?

Management by Crisis

I have a particular disdain for management by crisis. Waiting until something happens as a strategy for prioritizing workflow and process re-engineering is a mistake. This is where analysts and developers need to step up and invite risk management folks and corporate counsel to meetings and raise red flags. When I meet analysts who tell me “this is a disaster waiting happen” and managers who say “if anyone outside this building knew how shoddy this process is, we’d be done for,” I cringe.

Healthcare Crisis

Let me give you an example. At a recent community healthcare meeting, healthcare leaders were reflecting upon the fact that most citizens believe their doctors and hospitals have access to their medical records across organizational boundaries. The fact is, with the exception of 0.1% of the population, that’s not true. Fragmented health information and barriers between healthcare partners that prohibit exchange are at the root of America’s healthcare quality chasm. Sadly, the public has no idea. As a result, healthcare is a dangerous pursuit for all of us. The risks are great. Hospitals are full of quality and patient-safety landmines. Rather than allowing public misunderstanding to persist, we should be honest and get to work more openly. I think people would be willing to support initiatives to develop workflow and processes that lead to integrated healthcare information if they only knew how badly disjointed systems are today. When these projects are limited to technology and systems staff, we’re luck to crawl across the finish line. These are NOT technology projects.

A Good Reason for Funding

Workflow and process design are not free and they’re not cheap. Business leaders looking for a cost-benefit analysis and ROI ought only look as far as FEMA and the meat processor this week to know that weaknesses, issues and risks must be mitigated. Planning and prioritizing that doesn’t resolve blatant risks – risks brought vividly to graphic life in a simple workflow diagram and in basic performance measures – can shut company doors overnight. Without warning, poor construction, manufacturing, HR, hygiene and customer service risks can cause instant implosion.

In some cases, folks, there may not be enough warning to suddenly prioritize an issue and launch a project. Think way ahead and allocate resources carefully.

Competition and Cost of Quality

When I beat this drum, business leaders tell me they cannot fund quality improvement initiatives because their competition doesn’t do it. If they were first, their prices wouldn’t be competitive. I say, make higher prices for quality products a competitive advantage. Sell your product on the basis of its quality. The recent troubles faced by Chinese toy manufacturers may bear out the wisdom of this approach. Suddenly, toys from China aren’t expected to be so cheap anymore. And remember, the next time you think cheap is competitive, the top-selling Christmas gift in 2007 was a $300 video game. People buy quality.

BPR and BPM: Some Important Distinctions

The BPM (business process management) space is very active, populated by sophisticated software vendors, led in part by talented engineers and consultants and financed largely by IT budgets. Entire suites of BPM and BPA (business process analysis) applications are broadening into SOA (service-oriented architecture) capabilities. All of this is very exciting, enabling rapid transformation of enterprises and radically folding what used to be “IT” – the distinct geek department – into a business services environment. All of this is also IT-intensive and relatively expensive. I say “relatively” because BPM-mature organizations with revenues greater than $500M are not going to be particularly intimidated by BPMS (BPM Suites) that can run $3,500-$10,000 per seat (and then some). The rest of us are going to think twice. That’s what concerns me.

BPR (business process re-engineering) is about discovering opportunities for value-creation, efficiency, quality improvement and – yes – even automation. However, it is not strictly in service to software and application development. That isn’t to say that BPMS is strictly in service to software development. That would be an over-simplified conclusion. My experience and some persuasive research by Nathaniel Palmer (www.bptrends.com) gives the impression (not a scientific conclusion) that BPMS is tending and trending toward being an IT tool much more so than it is an operational improvement tool. At least that’s how large organizations are tending to use the tools. In essence, the tools are not gaining as much traction among operations and management teams as one would think. Having used some of these tools as an operations type, I find it a shame but it is what it is.

What to do?

Don’t lose sight of the value of workflow analysis and BPR! Your organization may not count itself among the bigger, richer shops that are equipped with BSAs (analysts) and BPMS sophisticates. That’s not a reason to abandon workflow documentation and process improvement. From an operations standpoint, there are dozens of fabulous reasons to adapt to your constraints. Simplest among them is hiring a well-equipped consultant to do it for you. Secondly, you can invest a few hundred bucks in Visio and do it yourself.

Simplified Workflow Analysis and BPR

If you happen to work in an organization that doesn’t see the value in process improvement, business rule management, value creation, efficiency gains and the like, then I suppose you have an entirely different task ahead of you. Send your leadership some books for Christmas. If the interest to improve is there but the budget isn’t, develop a keen sense of the reasons why your organization ought to pursue the skills and tools. Above all, develop the culture and discipline.

Create a Workflow and BPR Circle of Excellence

Call it what you want – a Circle of Excellence, SWAT Team, Process Improvement Team, Workflow Design Ensemble – the point is, you’ll need a cast of champions that cut across organizational silos and functional areas. Select your SMEs (subject matter experts), send them to training (1-2 days should do the trick) and have them do a little homework on the web (Wikipedia is a great resource if you’re on a budget). Buy at least one Visio license for every major functional area (finance, IT, customer service, sales, operations, etc.) and learn together. You might designate one person as the “super-user” to run ahead of the curve and serve as a mentor for others.


Challenge yourselves to learn the language of BPR, integrate the principles into your strategic planning, measure impact, pilot various projects and recognize/reward improvement. When you’re beginning to climb the learning curve, remember to accept failure as opportunity. Don’t allow cynics to pull the plug on your initiative simply because you encountered failure.