Healthcare Referrals are Broken

Posted on January 16, 2012 by timberezny

Imagine that you are sitting with a travel agency.  After much discussion, they recommend that your perfect vacation would be a beach side resort in Hawaii.  After filling out all the requisite paper work, the travel agent tells you:

I am going to fax this to the airline. The airline will then call you back as soon as they can. They will inform you then of the date and time of your trip.  You can probably expect your flight to leave somewhere between 6 to 12 weeks from now, but if they deem your trip to be very important you might be able to go within 7 days.

This would be crazy in the travel industry of course (or almost any other industry … except perhaps phone and cable companies). Sadly, this is what almost every referral process in health care looks like. Surgical services, community care, children’s services, mental health, you name it.

When referring patients, we usually can’t tell them: 1) when the next step is; 2) when they’ll find out when the next step is; and, 3) what the availability of the next step is. We sure can’t say what 1, 2,& 3 are for all organizations.

Everybody is so used to this approach to referrals in healthcare, but we think it doesn’t need to be this way.

The network of Community Support Services in Waterloo Wellington agrees, and have decided to do something innovative about it.  They’ve created a process where a client always knows exactly what and when the next steps are, before the referral is even complete.  More than a year into their journey and they have served over 2000 people so far. You can learn more about it here.

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When management goes wrong (and right).

Posted on July 26, 2011 by jdoleweerd

Time and again we see it. Health care managers want to dramatically improve the performance of their organization, so they go looking.  Unfortunately they often go looking in the wrong places. They go looking for a training program, scheduling software, a provincial assessment tool, or a new way to motivate employees.  For consultants, there is great money to be made in helping organizations with these tools. What is missing, and why does this search so often end in disappointing results? Why don’t we regularly see improvements in the range of 20-30% over a period of weeks? The answer is a challenge to conventional management.

Under-performance in healthcare is a story about management focus. Today, managers know a lot about:

  • staff performance appraisals
  • training (the ‘chalk and talk’ type)
  • writing proposals
  • creating budgets
  • occurrence and risk management (tracking, prioritizing, fixing mistakes)
  • managing contracts (buying units of service etc)

The problem is, these activities don’t lead to fundamental and dramatic performance improvement. Feel free to challenge me on this, but in my experience, most managers readily agree.  They are perceived as required, often by the funder or other stakeholder, and they are always time consuming. A scarcity of management resources means efforts to control and improve how care is delivered don’t get addressed.  This causes frustration and a sense of resignation among managers.

As one small example, in my earlier management career I spent many hours administering the legalities and administrative procedures of effective competitive purchasing. Meanwhile, I would dread the staff meetings where the issues of service wait times were raised, repeatedly. These wait times were caused, in part, by the procurement approach itself. We had management time available for procurement, but not nearly enough for improving the service experience.

What great organizations like Toyota understand is that the transformation is in the nature of management itself, and the set of beliefs managers hold. They create a management approach concerned with how work is designed to deliver customer value. Transformed performance comes from changing the perspective of management from top-down to inside-out. In this approach, the customer is at the centre, pulling value from the organization.

For healthcare service delivery organizations, this means leadership gets a heartfelt understanding of what patients value. They know how patient demands present to the organization, and the capability of their organization’s processes to meet demand. They are regularly finding this out…directly.

We need to rebalance healthcare management’s focus away from deploying projects and rolling out activities conceived far from the ‘gemba’.  This is hard. It sounds very intelligent to speak in board rooms of system planning, governance and funding, performance incentives, managing compliance or rolling out shared IT solutions. Conventional management, and management consulting, in health care are replete with people who can speak smartly in these areas. We think we need to find ways to shift management effort towards designing and implementing, alongside staff, systems of work that deliver value to patients.

Our greatest successes in consulting have been when we help organizations alter their management approach, while also working with them on improving care processes. We have refined a three pronged approach that resonates with managers and clinicians alike- identifying value, understanding reality, and taking action. The results are dramatic and often unexpected.

The trick is in not copying WHAT other organizations, like Toyota, do. (Unless we are building cars!)  The goal is to transform management thinking so that we focus resources on the effective design of systems that meets patient demand, without fail. This will take unlearning some of our current management habits in health care.

 

 

Posted in design, health care, patient value, Process, Quality, Technology | 1 Comment

Beautiful health care processes.

Posted on September 10, 2010 by admin

Fyodor Dostoevsky, the Russian writer, once said: “Beauty Will Save the World!”. This is a provocative statement. With health care in what seems perpetual crisis, it might be worth asking – can beauty can save health care? This is not about being pretty. If beauty saved health care it would be about artful service design. Service design that brings joy to health care providers and patients.

Processes are the things that weaves people, tools and information together in health care. Health care process design is, to a manager, what a paint brush is to an artist.

What are you doing when you are changing your health care processes? Are you improving them? Maybe you’re streamlining them, making them more efficient or more value adding?

Or do you try to make them beautiful?

Other ways of thinking about processes can fall short:

  • Making processes efficient: Efficiency is a dirty word in some circles, and can be used to justify all kinds of nasty things. Some invoke efficiency in the name of firing staff, cutting budgets or making something better for one person at the expense of another. A single minded focus on efficiency is cold. In health care, most processes are about the flow and experiences of people rather than movement and assembly of parts without waste. People deserve something more than an efficient process. A beautiful process is probably efficient, but much much more.
  • Process Improvement: Improvement is a better term, it teases at the idea of building on past success, and that we should be continuously getting better at what we do. The saying “Improvement is a journey, not a destination” is the strongest element of the “improvement” concept. However, the term “improvement” is often incorrectly used in place of the word “change”, which may or may not yield any improvement at all. Furthermore, a process can be improved … but remain a poor experience for patients and contain tremendous amounts of waste. Aiming for an “improved” process often isn’t enough.
  • Making the process lean: This term is great with people and organizations that have embraced and understand the concept. The reality is, the typical staff member doesn’t immediately know anything more about lean than a penguin knows about pineapples. Lean contains vital ideas for the quality improvement practitioner like making value flow at the pull of the customer, reducing waste, etc. People can be taught, and integrating this type of knowledge is the essence of management, but it takes time.

Your customers/client/patients interact with you through your processes. Your staff spend most of their working lives in your processes. Is it possible to make a process fun, a pleasure to be a part of, an experience to look forward to, joyful, to make it … beautiful?

I don’t think we strive to this level of achievement with processes, but we should.

No health care process is too mundane to beautify. Phone calls can be a pleasure, forms can be satisfying and communication can be enriching. Making a health care process beautiful respects the impact that it has on people and their lives. A beautiful process would deliver what people need, is not wasteful, and would be uplifting to experience.

Isn’t beauty – the experience of pleasure and satisfaction often in the presence of another – what makes life worth living? Save some room for considering beauty when designing a health care process.

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Capturing the voice of the patient

Posted on October 24, 2009 by admin

Doleweerd Consulting completed an engagement that provides important information about the experiences of people transitioning from hospital to long-term care, or back home with the addition of home care, in Ontario.

The project focused on understanding what clients value, and then determining if the health care delivery process is capable of delivering that value.
The project was funded by Change Foundation, and supported by Ontario Association of Community Care Access Centres.

So what did patients going from Hospital to long-term care tell us that they value? i.e., what was the voice of the client?

“I want help getting accurate information that I can understand at the right time and place, including viable options, so my family and I can make the right decision for us. I want to feel confident that people care and to be treated with fairness and respect.”

The reports show that this notion of value is not fully understood and acted upon in a concerted way by the many agencies providing service. Agencies do not consistently optimize the end-to-end process, as felt by patients.  This translates into unnecessary hospitalization, needless admission to long term care and confusion for families and clients. Further, it is waste the health system can ill-afford.

This project employed Doleweerd Consulting’s methods of Patient Value Analysis and Digital Current State Mapping. Clear information was created to build an understanding of what patients value and how capable the care delivery process is in delivering this. This is more than measuring patient satisfaction. This is interacting with a program’s patients, capturing themes and insightful expressions, and observing the process end-to-end, even if it spans several organizations. It not only provides remarkably clear information, it is highly engaging of staff and is a way of getting patients into the health care program ‘design room’.

When an improvement-oriented leadership team pays attention to its patients, the results are unmistakeable and remarkable. One case in point is the Home First program being deployed all across Toronto in 2009 by the Community Care Access Centre. There are many others listed in the report, and still many more opportunities for fundamental process changes. Take some time to check out the reports or, fill out our ‘got a question‘ web form if you want to learn more about transforming the care experience for your patients.

http://doleweerd.com/

Posted in Community Care, patient value, Process, process walk, Quality, vocalizations, voice of the patient | 1 Comment

Triaging in health care. Time for new thinking….

Posted on September 22, 2009 by admin

I grew up watching M*A*S*H. The last episode in the early 80′s became the most watched TV episode in American history. I have the image burned into my brain of Hawkeye running towards the 4077′th Mobile Army Surgical Hospital helicopter pad, ducking below the aircraft blades to assess the injured.

The show brought into popular imagination the drama of doing triage. Nurses and doctors working together to care for the many wounded ensuring the most severe conditions were treated appropriately.
As consultants working in health care process improvement, we see triaging happening all over the place. We most commonly think of “triaging” as an activity in the Emergency department, where a dedicated triage nurse assigns relative priority.

But it goes way further than the ER…
‘Triage’ occurs at mental health agencies, home care, addiction, hospice, primary care, community care access centres, and the list goes on. These scenarios have little in common with the battlefield triage conditions from which the term originates (apart from their sometimes chaotic surroundings).

What’s so different?
  1. It’s not war! There is no combat that drives a surge of patient activity. In fact, in many health care sectors, the pattern of patient demand is very predictable. We often know which days and which times are busy. Further, we can often even shape when demand comes in, especially when the referral source is another health professional.
  2. The supply of staff at a M*A*S*H is consistent, they live there! Not so in health care. Staff availability is often based on historical scheduling routines, collective agreements, vacation day coverage rules, training events etc. Available staff fluctuates but often without reference to demand.
  3. M*A*S*H patients are assigned to a priority based on the front line person’s content knowledge. Today in health care, patient priority categories are often created by those with positional power (e.g. ‘only needs wheel chair assessment’ , ‘ hospital ALC patient’, ‘post-hip replacement’, ‘lives in a long term care home’).

Over and over we hear “we need to prioritize because we have more people than we can serve with the resources we have.” Hard to argue with that when your are in a perpetual crisis.

One CEO recently told me “I feel like we are trying to dig ourselves out of a hole”.

The good news is that many health care organizations are trying to understand their patient demand differently. In addition to understanding the severity of patient issues, they are working to stream the patient to he right sequence of care. Typically, creating a few standard admission streams will cover more than 90% of the patients presenting in most scenarios we’ve studied. What defines each stream is a unique organization of clinicians, tools, and know-how to effectively and efficiently deliver what is needed.

The quality improvement and engineering disciplines have much to offer health care in this area. Wait times for service drop when:

1) a full knowledge exchange with the patient is followed by

2) streaming to the right set of standard work procedures that are

3) available to meet demand.

The goal is to do today’s work today, not prioritize, wait and re-prioritize tomorrow. This is what happens when we classify according to severity alone.

Just like the storied M*A*S*H 4077, health care agencies need strong interpersonal relationships, good humour, and innovation to be effective within these environments. With this, and a healthy dose of quality improvement discipline, we are writing a new story line for how health care access works in Ontario.

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