Tag Archives: lean service

Lean Principles 2: Variation In The System

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Continuing Thoughts on Lean Service Principles. Part 1 is Here.

2. Variation is in the system, not the people -
 so watch the incentives. 

When we are looking at why some people or parts of the business just don’t seem to be improving we look to better incentive schemes, more measurement, more oversight. It’s commonplace to say “you get what you measure” but also “what you measure isn’t always what actually matters” (i.e. what matters can’t always be measured, or you are measuring the wrong thing).

But many times the nature of the work, and the nature of the workflow, means that improvement is not possible without changing the fundamentals of how the work itself is defined. In some approaches to this topic, it is pointed out that highly structured, rigidly process driven conversations are the best way to get to the customers required answer.

And there is some evidence to show that we actually feel quite comfortable in this “known and formalised process”. It feels corporate. Until it doesn’t work of course. Then it feels corporate in a whole other way. But this line of discussion also reminds me of a line that JP Rangaswami pointed out recently:

Teachers who can be replaced by computers should be replaced by computers

Formal, well understood routines, as far as they can be automated, should be automated.

Theoretically, call center and customer service are ideal “pull environments” where customers should be able to get the information and actions they need for right now. We can automate this though really good “self service” portals, good search, and good content.

When we challenge some of the fundamentals around how customer service is provided (or indeed what it is, and what it is for) new possibilities arise. For instance “call centers” are required because that’s where this work is done. The rise of the hosted contact center and the home based agent radically challenge this idea. Agents don’t always need to sit together, attached to the information-software and telephone via cubicle, and be “seen to be working” by supervisors.

So are agents custodians and curators of your enterprise knowledge bases?

As we move to hosted and cloud based solutions what has changed in the underlying logic of the systems, oversights, and permissions we use at work? Some things I can see that are potential disruptors underpinning customer service processes I see here are:

  • Extended collaboration strategies: puling the right people into a process at the right time based on what they need to do right now is a basic co-ordination capability deliverable through CEBP. In the context of this post the customer can be “pulled into” the process at the right time, in the right mode, in order to achieve the right outcome. Customers can not only be pulled into processes, but into information contexts, into applications, and even into relationships and communities. How people give and gain access to others, and permissions to access information and resources may become mediated through CEBP.
  • Business processes-as-a-service: buy or rent an entire process or micro-process. Some technical examples are emerging in this space such as RunMyProcess and Cordys. There is even a very cool micro-process example in Ifttt which neatly ties social media elements together. There are very few complete examples here but to be clear I am speaking about “process orchestration” not just outsourcing all your customer service”.
  • Mobile everywhere: new devices change “presence”, location and what tasks can be completed (i.e photo, video conference/share, ID confirmation). Circa 25% of customers now have a smartphone and we are seeing more tablet-enablements in all customer facing environments. For instance Cisco Cius is now on iPad. Workday are designing for “mobile first”. Salesforce.com have Desk.com with a totally redesigned for mobile and social customer service. That should give you an idea of the scale of disruption to come.
So if you think about how our customer service workflows are going to be connected to many more applications (because they will be hosted); we will have far more people available to us for conversations because far more people will now be connected through new Social Business Layers; Mobile will change the when, where and how much we can interact with an organisations business processes. When you look at all these many people would still think “yeah, it will be just like now, only in the cloud”. I think that how we design processes, who designs them, how we control them, who we give control to, could all change.
(Hat Tips to @GrahamHill for comments on an early draft of this, and @Jobsworth for recent posts on flows. Get yourself a cup of silver needle tea and sit yourself down for a long read.)


Lean Service: Hospital Appointments

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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

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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.