5-Steps to Unlocking Your Organization’s Ability to Deliver Outcomes
By: Marj Green
Value based reimbursement is holding providers accountable for outcomes, versus paying for activity. This creates a serious problem for many organizations as their processes may not be designed to deliver to longer term outcomes. Worse yet, the organizations tend to think about solving process problems one issue at a time which not only impacts speed, but delivers lackluster results since the changes are on top of a poor process. Leaders must now change their organizations by re-designing processes that deliver to comprehensive outcomes and eliminate the sources of errors in the process.
- Decide that establishing outcome and quality focused processes are a priority.
Organizations that deliver to outcomes are hard-wired for accountability and results. If this is a priority, it will take focus to get more than incremental change. Get the right people engaged and assure that they have the time required to focus on delivering the objectives. A common mistake is to assign this to a committee that meets on a weekly / monthly basis. This is generally a recipe for failure.
As an example, leadership in one recent organization decided that their Pre-Operative Testing area was a key priority for improving outcomes. To assure rapid results they launched a cross-functional team consisting of physicians, IT representatives, nurses, mid-levels, clerical staff and process design experts to completely rethink the process. They dedicated the team full time for one-week with additional time through complete implementation.
- Clearly define outcomes to measures that the organization will hold itself accountable to.
Leaders must make their objectives tangible and clear to their organizations if they want success. In the example above the leaders clearly articulated their objectives:
- Reliably assess patient risk across financial, clinical and social factors.
- Deliver a care plan to match identified risks
- Maximize the number of patients assessed with existing resources through improved efficiency and appropriate “top of license” escalation
- Provide information required to scale the process across more services
As part of the work the team completed, new metrics were defined for process measurement so that they would know with data if they were meeting the objectives.
- Determine what the problems are in the existing process.
People inherently know that their processes have problems and maybe some issues with respect to outcomes, but often lose perspective of how inefficiently they are operating, and how poorly they are really delivering. Teaching a team to see these issues through structured observation is one of the first steps the process designers should do.
In the Pre-Op example, in 8-hours of observation 266 problems and issues were observed that spanned the internal process, connected processes and system issues. By seeing this, the team was more willing to understand why a complete white-sheet approach to process design was a better pathway than solving the problems one at a time. It also allowed them to step back and see all the issues that patients experienced, that were previously being overlooked, and helped them to rethink patient management at a much broader level. This step is crucial if your organization wants more than incremental.
- Re-design the process to deliver to the outcomes. The devil is in the details.
Start with a blank sheet of paper. Assure that your process design experts are that, and that they are not mired in the existing process. The most difficult part of this step, is preventing the team from reestablishing the existing process with some minor improvements (incremental change), rather than working through the details involved in solid design. Step back and think about what you would really like to do to assure better outcomes.
Some key items the clinicians felt strongly about, was having access to the patients more than a few days before their scheduled procedure. This would allow them to truly “optimize” the patients for their procedures as much as possible. One observer had seen a frail couple who “took care of each other” which prompted a request for Care Management to support patients in advance and manage risks more fully across their most brittle patients. The new process design also allowed for medical risk management vs. just anesthesia risk management. Efficiency was designed into the process by off-loading clerical tasks that were being completed by clinicians to appropriate levels allowing everyone to practice at “top of license.” Last but not least, the process was designed to a detailed level to assure that errors were eliminated through design. One common mistake made in design is to work at too high a level. This will lead to numerous forms of failure. The detail required to do this well cannot be overstated. Another common mistake often observed is adding layers of inspection and complexity to a broken process. Again, this will cause the process to generate even more errors and often requires more resources so this path is expensive on multiple fronts.
- Review the problem list and the deliverable list to assure the design meets the objectives.
After re-designing a process, check to assure that the majority of the problems have been eliminated with the design. If not, determine where the process has fallen short and reassess / re-design. There is no such thing as a perfect process. A well done, detailed design should eliminate about 75% of the problems and issues in the process. Once the new process is implemented and stabilized, it can be improved through performance management.
After the design was completed the original problem list of 266 problems was revisited. 78% of the non-system related problems had been eliminated through detailed process design. The remaining problems were a mix of system constraints and external processes. Further improvement should be done over time on an incremental basis in those areas once a well-designed core process exists