October 1, 2007

Stop Using Band-Aid Solutions
By Patrice L. Spath, BA, RHIT
For The Record
Vol. 19 No. 20 P. 36

If your HIM department bleeds inefficiencies, it’s better to take a systems analysis approach rather than patch the problem areas.

While dictating a discharge summary, a physician complains to HIM department staff that he has found two lab reports in the patient’s record that belong to another patient. The clerk apologizes for the mistake and quickly fixes the problem.

A few days later, a nurse in the medical unit telephones the department to inquire about a missing consultation report that the physician says was dictated several days earlier. The report is located in the “to be filed” stack in the HIM department and taken to the medical unit. While both problems are quickly resolved, the underlying system breakdowns that caused the problems still remain.

In today’s hectic work environment, immediate solutions are often favored over long-term system fixes. Immediate improvements can be had when band-aid solutions are used to put out the fires, but these fixes rarely last. More time must be spent in discovering the fire’s source to reduce the inevitable future work disruptions caused by underlying process faults.

A systems analysis approach is needed to stop the periodic problem manifestations. Systems analysis involves a better understanding of the process so that improvements can be made. To do this, users—the people who work in the process and the customers of the process—need to be interviewed to gather insight into the process and how it fits the department’s operational needs. By gaining a better appreciation of what users need, the process can be redesigned to prevent recurring problems. Solutions often can be discovered by simply asking users, “What do you recommend?”

Involve Users
The first step in systems analysis is to learn as much as possible about the problem, which can be accomplished by interviewing or surveying staff members and customers. By asking simple questions, you can gain a better understanding of the process and its problems.

Suppose, for example, that transcribed reports for hospitalized patients are occasionally misplaced into the “discharged patient” stack of reports to be filed. Although the problem happens infrequently, when it does occur, it can have a significant impact on patient care. Thus, it’s imperative to fix the process using a systems analysis approach. First, the present system must be defined. By interviewing transcriptionists, file clerks, and supervisors and observing the area’s physical layout, you can develop an understanding of the current process, such as the methods of sorting typed reports, factors affecting filing accuracy, staffing, etc.

Use a 5WH (why, what, where, who, when, and how) approach to get the answers. Each of the following questions presents a different focus on the process because it requires the responder to further clarify the system.

• Asking “Why do transcribed reports for in-hospital patients have to be charted as soon as possible?” will document the need for the process. Asking why each step is necessary may determine how the answers are to be used in making process improvements.

• The question “What is happening?” documents the method of report sorting and filing.

• Asking “Where is it happening?” helps to define and understand the physical area and its potential limitations.

• Asking “Who is doing it?” documents the staff performing the report sorting and filing.

• Asking “When does the process occur?” documents that the typed reports are first sorted into two different stacks, and then the in-house reports are delivered to the nursing units.

• Asking “How is the sorting and filing process accomplished?” documents how it is determined whether the patient is still hospitalized, what unit the patient is in, and how the typed report gets to the correct unit.

Getting answers to these 5WH questions and documenting the answers using flowcharts and narratives clarifies the process under review. The draft document can be reviewed with interviewees to elicit feedback and clarification.

Once the process is understood and defined, another series of questions can assist in the analysis. With input from the people being interviewed, it often can be determined if the system and process steps are necessary in their current state. Examine each component of the narrative and flowchart to determine if you can do the following:

• Eliminate: Is it really necessary for the typed reports to be placed in one stack by the transcriptionist and then later sorted by a clerk?

• Change: Can a clerk sort the reports every hour rather than the current process of every four hours?

• Combine: Can the transcriptionist do the sorting by identifying in-hospital patients immediately upon completing the report?

• Simplify: Can the reports be sent electronically to the inpatient units?

Next, ask the interviewees to make recommendations for changing the process. This can be a powerful and insightful question. Often, the answers are obvious to those closest to the process. By asking users and those ultimately responsible for the process for their thoughts and recommendations, a list of alternative solutions can be compiled. Most importantly, the users now have been included in the solution process by having their ideas solicited and considered. If the users’ ideas are accepted, they are more likely to embrace process changes.

There are several ways of obtaining information about the problematic process to gain a clearer understanding of what exactly is going wrong. The best method is to interview the users and customers; however, other techniques can be useful complements to this questioning technique.

In some situations, observation may be needed. Watching the process in the users’ own environment or getting a demonstration of the process can provide insights not uncovered through questioning alone. Sometimes, it is helpful for the systems analyst to actually perform the function to get a sense of the users’ experiences.

Another option is a survey. A person completing a brief questionnaire (ideally less than five minutes) may disclose problems, issues, processes, or solutions not reported through other data-gathering techniques. Use various techniques to continually ask questions until the process or problem is defined from all perspectives—users, management, and others affected. With each technique be sure to ask, “What do you recommend?”

Systems Analysis Case Study
Below is a case study of how a systems analysis approach was used in an integrated health system to solve a data management problem. The organization’s conversion from a manual to an electronic patient incident reporting system had focused on data storage relative to individual departments. However, the cross referencing and analysis of patient incident data needed for organizationwide decision making was unavailable. Thus, decisions relative to patient safety improvement initiatives were still intuitive based primarily on the risk managers’ personal experiences.

If improvement projects were to be targeted on those areas with the most problems, all department managers needed to be brought into the decision-making process. Managers, however, had minimal experience in the analysis and synthesis of department-specific patient incident data. What was needed was organizationwide integrated patient incident data.

The first step was to get the executive leaders, managers, and risk manager involved in open dialogue. A facilitator with systems analysis experience interviewed each user individually. During the interview, the facilitator challenged the user to think beyond the electronic incident reporting system to the organization’s ultimate needs. The facilitator then detailed the ways in which patient incident data stored in individual departments could be integrated and used organizationwide. The user was then challenged to refocus his or her thinking from specific department needs to global organizationwide decision making using incident data synthesized from each department’s database.

Once users began to look at the incident reporting system beyond its ability to collect data, a new realm of possibilities opened. During the interview, the user began to consider how the incident data could be manipulated to furnish the information needed for organizationwide patient safety improvement purposes. Once this insight was reached, the user was ready to discuss how technology could be a better partner in the organization’s patient safety efforts. The user and facilitator then engaged in 5WH using the following questions:

• Asking “What decisions do you need to make?” documented the way in which patient incident data could be manipulated to provide the reports needed for organizationwide decision making. It focused the user’s thinking on what aspects of data collection were essential to the organization’s efforts.

• Asking “Why are these decisions critical to patient safety improvement?” refocused the user’s thinking from individual departments to organizationwide analysis.

• Asking “Who will be involved in the decision-making process?” documented which individuals and committees must receive aggregated patient incident data.

• Asking “When will the information be needed?” documented when reports will be generated.

• Asking “How should the information be presented?” documented the format in which the reports are to be generated.

When it came time to talk about solutions, the facilitator brought everyone together in a room. Immediately, the users became engaged in a chaotic and unstructured “What do you want?” discussion. The facilitator turned the discussion around by asking users to refocus on what they need. Solution brainstorming could now be productive. Users began to think of the patient incident information system in terms of the top 10 needs. Easy access, minimal input required, reliable data, fast turnaround, and integrated with other information systems all came to the forefront in terms of what they and the organization really did need.

An important lesson from this case study is that the facilitator only posed questions—not solutions—to the users. The solutions came as the result of the facilitator challenging the users with 5WH (what can be combined, eliminated, simplified, and changed) and eliciting recommendations for meeting the organization’s need for patient incident data.

Training: A Band-aid Solution?
When process problems arise and it is discovered that staff are not properly following procedures, managers often turn to training to fix the problem. But training frequently is just another band-aid solution that won’t resolve the situation.

Generally, the reason staff are not adhering to the procedure is because it doesn’t work well. More often than not, staff members know what they are supposed to do but find that doing it differently is better. Staff training cannot make up for poorly designed work processes. Take a look at the processes in your department. How many have been jerry-rigged to meet regulatory or accreditation requirements or to accommodate a shortcoming? Has staff developed work-arounds that make it quicker to achieve the goals? In most instances, employees know perfectly well what they should be doing, so lack of skill isn’t their problem. Instead, staff members often find that the process is not working for them, so they devise some other way to get the job done. This situation won’t be resolved by training.

Don’t use training as a replacement for individual corrective actions. This may happen when managers are uncomfortable confronting an employee who is not following desired work practices. Instead of initiating a corrective action plan with the offending employee, everyone is required to attend a training session. For example, if a few people are having a problem with coming back from lunch on time, don’t make everyone in the department attend time management training. The people who follow the rules will be frustrated, and the employees who are not following the rules probably won’t think the training is directed at them.

Employee performance expectations are the real drivers of staff performance. When properly formulated, performance expectations encourage staff to engage in desired work behaviors. People respond to the environment in which they work— they tend to do what they are rewarded for and not do the things that are ignored or punished. You can train and retrain staff, but most likely, they won’t use the skills you are teaching them unless expectations are established and performance is monitored. For training to be more than a band-aid solution, the following conditions must be met:

• Staff must lack skill in the area in which training will be provided. If people don’t know how to properly perform a task, then training can teach them how to do that. But if there’s some other reason that staff aren’t behaving in a certain way, training won’t help.

• Performance expectations have been clearly set, and the training that’s provided clearly helps staff meet these expectations.

• There’s a plan for ensuring that staff have the tools, resources, and support to use the new skills when they return to the job. How many times have you participated in training for a new software program three months before the program was loaded onto your computer?

• Work processes have been adjusted to incorporate the use of the new skills. If staff members are being taught how to use a new filing system, then the use of the system should be embedded in their daily work. If they are being taught specific telephone etiquette techniques, then work processes should support staff in being able to use their new skills.

If these conditions are met, then staff training is a worthwhile solution. If not, then you need to rethink what needs to be done to correct the process problems.

Where to Start
Departmental improvement efforts should be focused on making changes that produce tangible benefits for all users. Asking staff is the best way to find out which processes are most in need of improvement. The worksheet in Figure 1 can be used by staff to rate the core processes in the HIM department. Customize the worksheet for your own situation.

The survey findings are used by staff members to choose what to work on improving. When improvement projects are selected from a list of the most problematic processes, you can be sure that successful projects will benefit both the department’s performance and the customer’s perception of the quality of your services.

— Patrice L. Spath, BA, RHIT, is a healthcare quality specialist, author of Leading Your Health Care Organization to Excellence, a partner in Brown-Spath & Associates (www.brownspath.com), an assistant professor in the department of health services administration at the University of Alabama in Birmingham, and a contributing editor at For The Record.