Lean Service Principles: Costs In Flow

Lean On Me

Note: This is part 3 of our "Lean Service" topic, you can find part 1 here and part 2 here.

 ”The present style of management was a modern invention, a prison created by the way people interact” W. Edwards Deming, 1994

Imagine A New Pathway

Imagine A New Pathway

It’s the new year and we all make our resolutions: lose weight, exercise more, pursue the important goals in our lives. We give up smoking and put on more weight; we exercise but injure ourselves; we follow our personal goal only to lose something else we did not realise we had. Our bodies, our relationships, and our world are all interconnected systems and how these systems influence each other often goes unnoticed.

Systems are also dynamic also can be adaptive in ways we did not appreciate. Take a recent article “The Fat Trap” in the New York Times. Many people when they lose a lot of weight can’t keep it off because their bodies ‘readjust’ their chemical settings and trends them back towards that pre-set fat level. Looking at the weight loss problem from this point of view is an example of systems thinking.

Systems Thinking and the principles of Lean Thinking make for an interesting journey. Companies can spend a fortune on software products and training but the metrics don’t move, or the metrics move but the customers are still no more satisfied than before.

In this post I am going to present some lean service principles and I will pepper the discussion with examples of systems effects. I am very much hoping that all this ties up in some great point about how cloud communications, SaaS, and ‘next generation’ platforms could learn from delivering value as per Lean Principles.

Some Principles

1. Costs are in flow, not exclusively in the activity or scale effects
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We’ve tended to look at efficiency as being driven by “scale” and through getting subsystems and departments to the right scale through seeking the appropriate degree of focus. So we break customer service away into a call center, into a shared services center, or into an outsourcer that amalgamates the work from many other clients to achieve scale effects. Breaking work down into manageable units that can be standardised, given standardised times, that can optimised via specialisation (lower cost training). It isn’t always bad, but as a system produce suboptimal outcomes.

That’s because in service environments not all customer interaction work is “the same”. Thus applying mechanisation to what is essentially an organic (high variation) problem is bound to create failures and these failures cascade through the organisation creating unaccounted for costs (sic – I’ll return to this in a future post, this depends on an agent being able to effectively “pull the right” answer from the knowledge base. Of course, the percentage of the overall interaction work that is non-standard, or dynamic in nature, is also a factor here). But if the question and answers are standard and non-changing surely some kind of self service solution is preferred, i.e. for codified information it is best to automate.

As the nature of knowledge stocks becomes even more dynamic and rapidly changing our ability to respond to these changes needs to become more flexible. Simply put, the information we had about an issue yesterday, may not hold today. Fortunately the world is moving towards “collaborative work” and the ability to self organise and to create adaptive workflows is increasing. Many see promise in the new social enterprise layer to make a further impact here.

This is not to say that basic fundamental analytical attention to variation has ceased to add any value. Predictable failure demand is driven by “common underlying causes”. These are faults in the system that prompt us to look to the system itself and redesign. These causes can be quite simple such as having a confusing product install manual or a configuration that is prone to short-circuiting. You can address the inbound calling by removing the underlying cause of this failure; a better manual, a different product design. Of course if you are not capturing the true cost of these inbound calls you may never achieve a business case for redesigning the manual or the product.

Some root causes have been considered “small black boxes into which no one can see”. Why do people just not show up for appointments? In the hospital appointments post we saw that failure to attend an appointment was “predictable” in that X amount of people would just not attend. The unpredictable part of the equation was we did not know exactly which ones would not attend. Through proactive contact, at a low cost per contact, you insert a small feedback loop at a time closer to the event and receive confirmations. You thus remove one underlying root cause. People forgetting or people not “renewing their promise to attend”. These kinds of Nudges are now part and parcel of online commerce, service design, even policy development.

Breaking down the contexts of how, where, when, and between whom these interactions occur reveals a variety of contexts that previously “showed up” as the one “black box” in our flow. The delay in confirming an appointment, what does it indicate? can we generate more context information and re-ignite the flow of communication, co-ordination, and commitment cycle?. If we can, we introduce increased velocity to the process.

Thinking about all forms and modes of communication in terms of “jobs to be done” in a process flow reveals many opportunities to be more effective. Nudges, feedback loops, automations that can at the right time, in the right mode and context help both parties complete the job that needs to be done at the point in the process.

Indeed my friend Mitch Lieberman at Sword-Caboodle has a lovely post about the various “jobs to be done” of email. Each mode of communication can be mapped to different contexts in the customers life and in their journey “to get things done” with you.

Next post I will look at Variation in the System

Lean Service: Hospital Appointments


The 8 Wastes In Lean

The 8 Wastes In Lean Methodology

In yesterdays blog post (part one of this topic) we took a brief look at the role of failure demand in driving inbound calls. These calls are zero value-add even if you handle them very well. A great example of failure demand is when people don’t show up for appointments. “No Shows” or “Did Not Attends” are one point in the entire patient journey, but even this one area has the ability to return significant improvements through applying some lean principles.

Appointments occur in the “flow of time” and if they are missed they are gone forever. In lean manufacturing this loss of time might be called “muda“- a wasteful activity. Delayed appointments also shift out a whole range of resource queues and care managers have to readjust on the go leading to multiple bottlenecks and inefficiencies. Let’s take the example of a typical hospital appointment:

How Much Does A Missed Appointment Cost?

In the UK missed appointments cost around £600m ($930M) per year. In 2007/2008 around 6.8m appointments were missed and hospitals lost average revenue per appointment of circa £100.

Cost of Missed Appointments Distribution UK

Outpatient appointment no-shows cost hospitals £600m a year

In a detailed multi-year study conducted by VoiceSage partner HealthCom at Portsmouth Hospital Trust it was found that out of 43,000 outpatients per year Did Not Attend (DNA’s) ran to 3,300 and through a combination of missed appointments, lost capacity, and lost or delayed, cost them £4m ($6.1m) annually.

Cost of Missed Appointments at Portsmouth Hospital Trust

Cost of Missed Appointments at Portsmouth Hospital Trust

What you will notice from these results is that interventions to control variation at the root cause surfaces dramatic improvements in cost outcomes. A planned, automated and pro-active communications strategy that reaches out to patients at the right time, with the right message and re-communicates their appointment details, or attempts to reconfirm their intention to attend, removes some of the variation in attendance.

Portsmouth NHS Trust

Portsmouth NHS Trust - Impacts of Proactive Confirmation Cycles

Why Do People Miss Their Appointments?

We know that missed appointments happen but if they are so important to everyone, why do they happen and why did proactive communications make a difference?

A 2005 Study of General Practice Doctors Appointments in the UK cited the reason of ” I simply forgot” by 40% of respondents, and “rescheduling difficulty” (i.e. tried to cancel but could not/ appointment was at an inconvenient time) by 20% of respondents. These, coupled with practice specific factors were significant drivers of missed appointments. In general the younger you are, and the more socially disadvantaged your background, the more likely you are to miss an appointment.

Although there are a number of studies into appointment keeping, a 2004 Study cited three main drivers as to why people missed appointments without notifying the clinic staff:

  1. Emotions – Fear and anxiety about procedures or of getting bad news
  2. Disrespect – Patients feel that the system/ provider does not respect them
  3. Understanding – Did not understand the scheduling system itself

Rather than leave these drivers unaddressed a decent case can be made for looking at the actions, behaviors and processes that propagate them.

  1. In the case of Emotion of Fear cited above how much more care could be taken around all the communications which we send to patients?
  • If we send letters could we take more care with the language used?
  • Could we follow up the letter with a simple phone call to give assurance?
  • Could we better match patient and customer care staff to encourage communications with nervous patients?

Many sectors that VoiceSage is working with have realised significant improvements through personalising messages and tailoring them to customer types or personae and matching these to each stage on the customer-patient journey. This is where the power of flexibility and iteration shows up clearly in results and outcomes.

2. To take the second point for Mutual Respect, proactively reminding people might be seen to show you care about the appointment and that it happens. It creates a sense of being in a managed process, that you are being cared for, and progressed.

However this should be seen in the wider context that when a person shows up for an appointment that they are seen to within a reasonable amount of time. When you do not account for the financial and social costs to the patient of being in a long queue at the clinic you run the risk of being seen to disrespect the value of their time and them as individuals. It stands to reason that just getting someone to keep their initial appointment time and then keep them waiting does not encourage them to show up on time next time. Indeed it’s likely that they will tell others not to worry about arriving on time. This would be a classic example of where you get one point in the process right, only to have it’s beneficial effects dissipated elsewhere.

This “disrespect factor” showed up strongly in a recent “Cost of Waiting Report” produced by TOA Technologies with regards why such long waiting windows were experienced in general appointments and deliveries. In general when dealing with larger companies and organisations many people find that their time isn’t being respected.

TOA Cost of Waiting Report 2011 - Why The Long Wait Windows

TOA Cost of Waiting Report 2011 - Why The Long Wait Windows

Of course waiting times at the clinic are not the only driver of feelings of disrespect. Overall levels of patient care and quality of overall interaction will also drive “Did Not Attends” that have their source in this feeling of disrespect. Perhaps this is one reason why the Care Quality Commission uses these missed appointment measures as a proxy measure for overall Quality of Care evaluations, particularly in the interface with community based care and the quality of the referrals process. I should give an absolutely shameless plug to the VoiceSage Survey product here because this is an ideal example of where you can conduct a post-interaction survey to gather a Net Promoter Score (NPS) measure and tie it back to specific factors underpinning that opinion (VoiceSage won European Call Center and Customer Service Product of the Year 2011 for this).

3. Not Understanding The Scheduling System – while I expect that much user experience of computer and online systems have improved over the last few years there are still gains to be made from addressing the usability of systems. By giving patients simple interfaces online, and clear plain language communications via SMS and Interactive Voice you can present patients with clear choices and clear actions. Although it is expected that smartphones will account for nearly 10% of all phones in the very near future, higher level impacts can still be attained today through simple, well thought out communications strategies that use SMS and simple Voice Interfaces.

The Point Of Interaction In The Patient Journey

Missed appointments can be mitigated by deploying proactive contact strategies that are simple, thoughtful, and caring. People do forget to make arrangements so that they can make agreed appointment times. People do get frightened and avoid going to the appointment. People don’t always feel they are respected by their service providers in healthcare and in other sectors. As we have seen above reducing missed appointments has meaningful cost implications. What I think is worth exploring further is how these appointment confirmation events tie into a more holistic appointment experience measure and how in turn these show up in overall customer care and quality of service evaluations.

 

Lean Service

Have you ever doubled your investment in capacity only to find it eaten up by an unexpected increase in demand? Customer service and call center managers have this happen all the time. More equipment, more agents, more capacity don’t seem to show up in better customer experience performance.

Why does this happen? Over the next few blog posts we take a look at the use of “lean philosophy” within the customer service environment.
A friend of mine made a simple point: “if you want to reduce traffic jams don’t build bigger roads”. He explained that it actually encouraged more people onto the road and it quickly filled up with more cars.The supply in turn created more demand. Adding more capacity does not automatically give you the ability to do more.

Lean Start-Ups

Right now everyone is abuzz with the term “Lean Start-Up”, a phrase popularized by Eric Reiss based on some of the early work of Steve Blank. The breakthrough thought was that although agile development principles had been adapted by technical teams for some time, projects continued to fail because they had not defined the customer problem correctly. Companies don’t fail because of IT problems they fail because of customer acquisition problems. Steve Blank knew that:

  • The best place to test a product is in the marketplace with real, paying, target customers
  • Seeing the interaction between the customer and the product leads to faster feedback loops, which are then integrated into the product
  • When you have a number of target customers who want this product as it is now delivered, you achieve “product-market fit”, i.e. an addressable market.

The job of the development team in a lean start-up is to launch a Minimal Viable Product (MVP) of product features, functions, and properties that are barely acceptable to a new customer. Then you iterate, iterate, iterate until you have a real addressable problem that the customer cares about, and that your product solves better than anyone else. They key is that you have good interactions with the users of the product and that your platform is built for iteration.

Lean Service – Lean Communications

lean service

John Seddon of Vanguard uses the example of a local authority that was building endless call centers but making very little impact on the customer’s experience of their services.
The problem was that an agent would take the call and then a field service person would turn up at the property, and often, would leave the premises without the problem being fully fixed. Every call after that, every reschedule is termed “failure demand”. Failure demand adds no new value.

By looking at what it takes to get the job done first time the entire flow of activities takes on a different character. Imagine John says “if the customer called you and you let them pick a time that suited them? Imagine if you turned up at this time? If you fixed the whole job when you were there? Then customer service results would go through the roof wouldn’t they? Yes they would. If you are not examining the customer context and looking at the problem in terms of flows, you are missing the real drivers of both cost and customer satisfaction.

It also meant that the field service personnel had to be able to pull on the right resources when they were on-site; those plumbers, carpenters and other tradespeople would have to be available to assist. As a system “The Jobs To Be Done” were getting done, getting done for a lower total cost, and actual customer experience of the repairs and maintenance service had been vastly improved.

Some Thoughts

  1. Getting to the root cause of a problem is essential for resolving issues early and cheaply
  2. Companies don’t always count the down stream costs of not getting it right first time
  3. When you don’t manage the interaction points for outcomes you will drive more inbound calls, and this is failure demand
  4. You cannot deliver Customer Experience if your systems are designed to deliver internal efficiencies
  5. Achieving a change of orientation from “stocks of people” to “flows of people” is a key change in your organisation culture

In tomorrow’s post, I’ll take a look at how we did this at Portsmouth Hospital, and the day after we’ll take a look at some lean service principles.