Tag Archives: Workflow

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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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.

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.

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.

Spy: Small Business Process Improvements Based on Process Benchmarks

I have to admit to being a chronic process observer and critic. Every time I sit in a restaurant, go into a store, arrive at a hotel, go to the doctor or shop online I pay attention to what staff and managers are doing and I judge. Sometimes I am deeply fond of what I see and other times I am vicious in my critique. While I am a little obsessive about all this, there is some virtue in the exercise. As a consultant, it’s important to have had exposure to tactics and process that work especially well in order to make stronger recommendations for clients. It’s also important, working across sectors to develop a mental inventory of what doesn’t work, what can be emulated and what can be tweaked to serve cross-purposes. Frankly, I would hope that anyone aspiring to build a business, product or consultancy in this domain would be doing the same kinds of things.

Spy versus Spy: Lean Innovation

Welcome to the age of transparency, reverse engineering and piracy. Watching the equivalent of So You Think You Can Dance on Indian TV broadcast by satellite last night, my Indian friend quipped: “They copy everything we do”. Reading about the new film Duplicity in the latest issue of Fast Company I am reminded that the “leanest” forms of adaptation are mimicry and emulation. It’s called “evolution” folks.It’s the 100th Monkey Theory in blazing sound and technicolor. In some cases, it’s downright criminal so be careful where you draw the line.

I’m sure by now you’ve heard that the sum total information in the world is doubling every 3-6 months or something like that. Similarly, in an open information age, we have the capacity to observe, re-engineer, implement, measure and observe again at dizzying rates. Knowing that competitors are observing and mimicking us should serve as a catalyst for greater and faster innovation (and ever more patent filings).

How About A Small Business?

Small enterprises can’t afford teams of engineers and analysts that prowl the web and deconstruct rival products the way Toyota and Honda tore into the Saturn. There is no virtue in piracy so what’s a small business to do? Give observation and emulation a try. Watch what others do and then think in terms of business process. What process can you borrow and pilot in your own shop?

Process Benchmarking

A Benchmark is a standard and, for our purposes, the Gold Standard. The Best Practice. I want to advocate for an open process exchange that enables up-and-coming enterprises to learn from the best. This idea may never take root in the private sector but it might in government and non-profit sectors. For example, what can my library learn from the Pentagon? What can a Blood Drive learn from the Census? What can the EPA learn from Green peace?

As a small business owner, I can effectively identify the leader in my market, the highest quality product or the lowest priced competitor and I can start studying how they deliver their products and services. Similarly, I can go to the leader in a totally unrelated field and observe them in action.

Benchmarking

Rivals’ and leaders’ strengths my not be in their products (engineering, materials, quality and performance) alone. You can look for benchmarks in the following areas:

  • Suppliers – supply chain, quality, ethics
  • Human Resources – recruiting, hiring and retention
  • Customer Service – walk-in, online and telephone, service responsiveness policies, dress code, etc
  • Marketing and Sales – packaging, pricing, branding, placement, promotions, sales tactics and pitches
  • Finance – pricing, financing, terms

The point is, identify some leaders, grab a pad of paper and a pen and go observe what they do and HOW they do it. Imagine how you could mimic, emulate or adopt what they do.

Keep it Simple

A final word on simple. While their algorithms are crazy complex and probably cannot ever be emulated, Google stands as the single greatest example of simplicity in customer experience. That simple one-box web page with scarcely 50 words on it – as of today – owns 64.2% of the world wide web’s search activity. They are killing their rivals with simplicity. How can you do the same?

Building The Business Case For Process-Enhanced, Information-Rich Customer Service

We all need to revitalize our customer service, relationships with customers and motivate new levels of consumer confidence. That’s our job as business leaders and small business owners. Business is not a spectator sport. It is a high-speed art and science. Business Process Management offers a special opportunity to raise your customer’s experience to new heights. What I am about to suggest is not singularly going to turn things around for you but it is one thing you can do quickly. The more “mature” your organization is in its BPM development, the easier it ought to be to deploy. What I am talking about is not new. The credit probably goes to FedEx. It’s a standard in the minds of consumers and rightly so.

Take Me Through The Process

I am referring to the manner in which UPS and FedEx have incorporated tracking into every shipment. Information regarding my package can be as important to me as the package itself. Frankly, it’s common for me to feel more importantly about something arriving than is the something. For instance, the first time I used a web-based florist (flowers.com) to send my mother flowers, it was far more important that the flowers arrive on time. I was tickled to know the flowers got there and I never even saw the flowers! The same is true with my online banking. It has to perform flawlessly and reassure me that my mortgage got paid on time. I love my bank for the knowledge that my bill got paid. Every day, I get updates from my bank in my email. I am kept apprised constantly.

Information Is Service

As a customer, information concerning by business interactions is extremely important. By telling me when my dinner will be served in a restaurant, my server is allowing me to judge how long I can take discussing a proposal at the table with a client. When my Lexus dealership’s service center calls to tell me when a part will be in, I can better manage my travel schedule. When United Airlines sends email alerts that flight times have changed my kids’ flight 30 days in advance, I can rest assured that they will be safe and know where they’re supposed to be.

What’s In Your Process?

What information is embedded in your process that would add value to your customers’ lives? If a customer triggers an order, can you tell them where their order stands minutes, days and weeks later? If a decision has been made in process, how quickly and clearly do you notify them? If you must abide by certain rules in the disposition of their interaction with you, do you let them know what rule it is you are referring to? Refer to common BPM metrics (standardized in your industry) for more ideas or ask your competitors what they measure!

What Not To Do

My local hospital’s urgent outpatient unit (open for walk-in visits on weekends) treated me several months ago (May 2008). I paid the same co-pay I have for two years and went home with a prescription for an antibiotic. Very routine. HOWEVER, they failed to mention that they no longer contract with my insurer. My claim was denied by my insurer (naturally) so the hospital sent the unpaid portion of my bill to a collections agency. Said agency calls me and can’t tell me why my claim was denied. They didn’t have that information. I just owed them $113 or I could expect my credit score to take a big hit.

The story here is not the money and it is not the abysmal performance of our local hospital. The story is in the lost opportunity to manage information and contain a customer experience. I regularly refer everyone I know to their competitor.

Customer Service: Seize The Data

Look deep inside, walk through your own processes and find the valuable data. Talk to your customers (really talk to them!) and ask them what they’d like to know and why. This is basic but so few businesses actually take the time to do it. Information is relatively inexpensive so stop being so stingy! If you want my confidence, you will earn it with useful, accurate and timely information. And – by the way – I will tell you what is useful, meaningful, valuable information. I am, after all, the customer.

Is Present Reality (Current State) a Prerequisite for Design of the Future State?

Once in awhile, a riddle so obscure and enigmatic comes along that it baffles and stumps most of our brightest thinkers and deepest philosophers, qualifying as a Zen koan. Like the sound of one hand clapping or the sight of your face before you were conceived, the answer cannot really be found in any conventional sense. Well, in my humble opinion good people, the tension between current state and future state and the need to document and analyze the “as-is” prior to taking on the “to-be” doesn’t qualify as a Zen Koan or a crossword puzzle for that matter. There is no question. You have to understand the present dynamics and process in order to sensibly develop something new.

I know that I will offend some of the business process management wizards and high priests by saying as much but my position is one of firmly believing in the value of documenting and analyzing the current state to ensure a high quality future. Frankly, jumping into the design of the future state without regard for a rather precise current state is irresponsible. Not unlike asking someone how they’d like to perform in graduate school without first ascertaining whether they can read or not. Or promising someone full health without first diagnosing their diabetes. The present state in business tells a vast and deep story that shapes the possible and potential future.

Dangerous “Experts”

I attended a conference recently (devoted to the adoption of EMR in physician practices) whereupon I was able to listen to a discussion at our lunch table between a woefully ignorant doctor who wondered aloud what it would take to implement such a thing as an electronic medical record and an “expert” across the table who piped up and assured him that he needn’t worry about how things are done in in his practice today. He would only be required to imagine what life would be like with his new system. What a  load!

Notwithstanding that particular “consultant” and his advice to the good doctor, it got me wondering, “How many of my colleagues would suggest the same?” I wish I could survey all of my BPM brothers and sisters out there. Do you honestly think you can account for all of the business rules, decision-making, forms, customer preferences, suppliers, and key metrics involved in a process without concerning yourselves with the current state. Do you really think you can skip that step and begin modeling the future state without compromising quality or any other vital business attribute? I think not.

Change without consideration for the present is invention

Don’t get me wrong. I love to invent stuff and get wickedly creative when given a chance to roam free. However, invention cannot capture all of the good reasons why my system dynamics are what they are and cannot account for the benefits and value inherent in my current state without first elucidating them. Failing to harvest and capture the good, the rules, the data, the preferences, and the logic and simply launching into invention risks losing a lot including compliance with standards of all kinds. The risks involved can cause an invented business process to become fatally flawed in short order, grinding business to a halt.

Take your time and carefully document what you do today and how you do it. Inventing the wrong thing, failing and trying weeks or months later to return to an undocumented state is fools work.