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John Toussaint Reflections – What Comes First Technology or Process?

What comes first technology or process? As lean thinkers we know it’s always the process first. Healthcare is not wanting for technology. We’ve spent the last ten years implementing electronic health records, replacing legacy financial systems, and building information flow systems that allow caregivers to have access to real-time data at the point of care. No one would go back. The fact is the technology continues to evolve and can support more and care designs. The problem is health care processes are not keeping up.

Making a poor process electronic-only makes the errors occur faster. Many EHR installs did not go well because leaders didn’t understand this. Those that chose to review and change care processes before implementation did the best and have continued to turn on more and more features of the EHR as they have continued to improve and redesign care processes.

The good news is that more than 60% of hospitals in the US have recognized that a commitment to improving care processes is important. Those that robustly embrace lean management principles see lower readmission rates, higher profitability, lower cost, better HCAP scores, and fewer unnecessary tests ordered. In other words, better care processes lead to better value for patients. Read more in The Join Commission Journal on Quality and Patient Safety.

Technology has a major role to play in delivering better patient processes but it’s not a leading role. Instead, it is a supporting role. I’ll explain using the example of a model cell.

The model cell is where radical new ways of thinking should be embraced. The goal of model cell performance should always achieve a 50-100% improvement over the existing process. There are two ways to approach creating a model cell, both involve clinical redesign.  The most common is breakthrough value stream improvement. This approach involves front-line teams that are doing the work. The staff are convened to map the current state of care processes and information flow. A new ideal state is imagined, and the design of the new state is mapped by caregivers. A model cell area then tests the new design and creates standard work in rapid experiments. Careful measurement of the new processes confirms whether preestablished goals are met. During this process, IT professionals are consulted to determine what features of the EHR or other technology could support the new process. IT staff should be members of the design team because they can help the caregivers understand the technology that exists. This knowledge has a bearing on the possible design of new processes. Sometimes new care processes can stretch the development of new technology as well. When I was CEO, quite a few years ago, team-based care was not on the radar. But our team developed a new model of inpatient care deemed Collaborative Care ™. This model required that all care givers use a single plan of care for each hospitalized patient. The problem was the EHR did not have a single plan of care documentation process. Our IT staff worked with the vendor to build a single plan of care that every staff member including physical therapy, respiratory therapy, nutrition, nursing, physicians, etc. all accessed and worked with together in an integrated fashion. This is standard process today.

The second approach to model cell development New Care Model design. In other industries, this is R and D. A new care model is created by an innovation team as opposed to a frontline team and is based on deep customer research. New Care Model design is used when there is a need for a completely different and new care model. One that hasn’t existed before. It takes several weeks to gather the interview data and to understand what customers are telling us. The research is required because we tend to jump to conclusions based on our reality rather than truly understanding customer reality. An exploration process includes activities such as one on interviews, visits to customer environments, and observations of how existing processes impact the customer. The innovation team analyzes full transcription of interviews looking for descriptive phrases to identify true customer needs.  Once this information is collated ideas emerge for New Care Model development.

One such idea emerged from work done at Atrius, a multi-specialty physician group in Boston. Following deep customer research, a patient told the team “I’d rather die than go to the hospital”. That concept eventually led to Care in Place, which is a successful home care model. Nurses visit the patient’s home when they call the clinic with concerns. Rather than the medical assistant simply telling the patient to go to the ER the home care nurse visits the patient at home immediately. This new care model was tested in a model cell clinic and resulted in a 50% reduction in ER visits and much higher patient satisfaction. It subsequently was spread to all primary care clinics. Technology was clearly a supporting enabler. Care in place required technology support from the EHR for home care nurses, a phone triage system that identified callers, and an electronic follow-up system to assure the patient was doing well at home. But any one of those systems would have been useless if the new care model hadn’t been clearly defined including the roles and responsibilities of each team member.

The process comes first, the technology then supports the process. The decision of whether to use breakthrough value stream mapping or New Care Model Development is the first decision. That determines the makeup of the team and the process and nature of the work ahead. The team should include IT team members, but everyone should remember technology is not going to save us from doing the hard work of creating a better care model.

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