by Susan E. Daniels, editor at large
In 50 Words or Less:
- A process improvement team used lean Six Sigma tools to improve member contact rates at a healthcare support company.
- The contact rate went up 65%, improving member outcomes and return on investment.
- The effort earned the team a silver award in ASQ’s International Team Excellence competition.
A team dedicated to improving member contact rates at Healthways pulled just about everything from its lean Six Sigma toolbox for the project. For its efforts, the team earned a silver award in ASQ’s International Team Excellence Award competition at the World Conference on Quality and Improvement held last May in
The list of tools included house of quality, project charter, supplier, inputs, process, outputs and customers (SIPOC) analysis, measurement system analysis, stability analysis, normality tests, muda walk, process capability test, fishbone diagram, benchmarking, brainstorming, the five whys, process mapping, process assessments, capability analysis and t-tests.
Healthways' contractual requirements typically focus on its ability to decrease healthcare spending for members, while improving quality of life. Its programs cover areas such as smoking cessation, nutrition, fitness, lifestyle management, health risk assessments and disease management.
With a vast amount of data available to measure overall performance, Healthways already knew member satisfaction in the area of member contacts was an opportunity for improvement.
To assist in project selection, the team used a method that draws on lean Six Sigma tools and its five-phase define, measure, analyze, improve and control method as a systematic approach to process improvement.
House of quality tool
In the define phase, the team used the house of quality tool to obtain insight into the voice of the customer (see Figure 1). Among critical-to-quality customer requirements, telephone interventions were identified as being the most important.
The team was confident that a project focused on telephone interventions directly supported corporate strategic objectives, specifically the ability to "Deliver on customer promises, and assure scaled delivery."
A drilling down to key inputs of the telephone process revealed the member contact rate—the effectiveness of a call—as the most important aspect of telephone interventions. Key stakeholders agreed Healthways could improve its member contact rate while supporting the company’s business model and objectives.
The project was submitted to the quality committee for final approval. This committee ensures representation across the entire organization, using an impact and effort project scoring system that helps screen and select the projects that are most closely aligned with company strategies and goals.
The committee approved the project, and a core leadership team of stakeholders, suppliers and customers was assembled to ensure alignment and buy-in for improvement within Healthways.
Project charter tool
The team used a project charter tool to clearly define the scope and improvement opportunity for the project. The success metrics were established as clinician performance, clinician availability and call quality.
At Healthways, the word clinician is used to describe telephone workers who are typically registered nurses, but they also can be respiratory therapists, registered dieticians or licensed practical nurses. According to Mike Davis, vice president of quality for Healthways, they routinely interact with members and use evidence-based guidelines to provide health information and support designed to promote health behaviors.
The two anticipated impacts were defined as increased member contacts that decrease healthcare spending for Healthways’ member population and an estimated cost avoidance of $3 million related to improved efficiency of resources.
The team’s target compared with the company’s standard was 100% or better, but baseline data revealed current performance of key metrics at:
- Clinician performance: 60% of standard.
- Clinician availability: 97% of standard.
- Call quality: 84% of standard.
The team then conducted a high-level SIPOC analysis to identify the potential key internal and external stakeholders and to validate the process scope.
After assessing each potential stakeholder for level of involvement in each of the major process steps, the team identified types of potential stakeholder impacts, including strategic alignment, colleague morale, customer satisfaction and cost of execution. Stakeholder analysis then identified the project impact, change position and influence strategy on each key stakeholder.
Root cause analysis
To analyze the root causes of the current situation, the team used a variety of lean Six Sigma methods and tools: measurement system and stability analyses, normality test and muda (waste) walk.
The team’s muda walk with its clinician focus groups identified a variety of wastes, including excessive documentation within member records.
To validate the accuracy of the reporting system, the team completed its measurement system analysis and compared data from the reporting application to actual observed telephone interaction (see Figure 2).
Stability analysis determined the mean and variation were stable and allowed the team to move forward in its analysis and process improvement initiatives. The team performed a normality test on the rate of calls per clinician per hour and verified the data had a normal distribution. This allowed the team to use statistical analysis tools designed for normal distributions.
Many stakeholders, each bringing a unique perspective, helped identify potential root causes. This set the stage for performing an overall process effectiveness test and determining that the biggest impact on improving the member contact rate could be made by focusing on the calls per clinician per hour.
Taking a deeper dive to understand the extent of the opportunity, the team performed a process capability test on its baseline data, comparing current performance with the desired standard. This analysis revealed only 7.7% of clinicians exceeded Healthways’ standard expectation and that the current process was not capable of producing the member contact rate required to meet internal standard or customer expectations.
The team used a fishbone diagram to identify key inputs to the success metric of calls per clinician per hour, which included:
- Talk time.
- Time to end the call.
- Unsuccessful call management.
To validate its final inputs and contributing factors, the team went back to the house of quality tool to prioritize improvement initiatives. The significant contributors to productivity were clear performance expectations and visibility of data results using the right tools. Again, the team validated its findings with key stakeholders to see whether its list of contributors to productivity agreed with stakeholder needs. All stakeholders agreed the team was on target.
Just The Start of The Journey
I was honored to be the champion of the cross-functional member contact rate team from Healthways that received the silver award in ASQ’s International Team Excellence competition.
The team’s successful journey used the Healthways to Excellence improvement method, which includes lean Six Sigma tools, as part of a systematic approach to process improvement.
The majority of Healthways’ services are delivered by telephone. Our data showed that in the area of member contacts, we had an opportunity to improve. The team needed to identify creative ways to do so to meet the needs of our customers and members.
A key success factor for this project was involving and receiving input from a wide variety of stakeholders including:
- Account managers.
- Call center management.
We benchmarked other internal improvements projects and interviewed team members to identify best practices and lessons learned. Without this support, many improvement ideas would not have been identified or implemented.
In addition, the team studied operational data and conducted root cause analysis to develop a list of potential solutions. This allowed us to focus on factors that influenced our success metrics and pointed us to potential interventions to address these opportunities.
The project’s success was outstanding and set the stage for a companywide rollout of these improvements across all of our care enhancement centers.
Preparing for and winning the Silver Award at the 2008 ASQ International Team Excellence Competition was a tremendous learning experience for all involved.
It brought great visibility to the project internally at Healthways and proved to us all that what we are doing in the area of quality and process improvement can compete against what anyone else is doing anywhere in the world.
At Healthways, our goal is to make the world a healthier place, one person at a time. The type of work done by the contact rate team is an important piece in making that a reality.
We are extremely proud of this accomplishment and look forward to competing again at this year’s team competition during ASQ’s World Conference on Quality and Improvement, May 18–20, in
Vice president, quality and process improvement
To identify potential solutions, the team:
- Benchmarked other successful internal productivity improvement projects and interviewed involved team members to identify best practices and lessons learned.
- Conducted interview and brainstorming sessions with stakeholders to gain buy-in and identify potential improvement ideas.
- Took a five-whys approach to help identify root causes and provide insight into actions for improvement.
- Performed site visits to gain insight into other productivity initiatives across Healthways.
One identified root cause was related to ineffective computer skills during calls. This information led to the creation of an improvement initiative.
To select the final solutions, the team’s criteria looked at impact on success metrics, ease of execution, impact on clinician satisfaction, likelihood of success and impact on corporate strategic objectives. Each metric was given a rank of high, medium or low.
The solutions with the highest scores were selected and included process guidelines, supervisor support tools and communication tools. The team enhanced and added details to its final solutions using methods such as:
- Process mapping to identify specific process guidelines that were needed.
- Process assessments to identify specific areas of need related to training, rewards and recognition, and reporting.
- A muda walk to help with specifics related to communication and supervisor support tools.
A capability analysis verified that the implemented solutions improved key process metrics. For the performance metric, 50.8% of clinicians exceeded Healthways’ standard, compared with 7.7% at the beginning of the project.
Because the performance metric standard is a median of individual clinician performance, 50.8% equated to achievement of this standard. In addition, the two-sample t-tests supported that there was a statistically significant difference between the baseline and results for clinician performance and those following the improvement effort. The team verified this by a p-value equal to 0.0.
Stakeholder involvement in the final solution selection was based on subject matter expertise. Clinicians, for example, served as the subject matter experts for the clinician satisfaction criteria.
The process excellence team and quality committee provided input related to three key scoring criteria: ease of execution, impact on the project’s success metrics and impact of strategic corporate objectives.
The team then defined specific improvement strategies and final solutions, including:
- Process guidelines.
- Supervisor support tools.
- Communication tools.
- Reporting templates.
Process guidelines, for example, included suggested call flows for specific call types and guidelines for the efficient use of the computer system.
The supervisor support tool is an example of a final solution (see Table 1) that provided close interactions between direct supervisors and their clinicians. Supervisors provided one-on-one coaching and call flow training over a specific time period.
Stakeholder team members validated the final solutions by assessing the impact of each solution on the project’s success metrics, which covered tangible and intangible benefits.
The team achieved nearly all project success metrics. Median calls per clinician per hour improved from 60% to more than 103% of the standard. In addition, Healthways saw an improvement in clinician availability to 98% of the standard. The team achieved its desired outcomes in terms of all four quality indicators, going from 84% of the standard to 100%.
In addition to achieving the project success metrics, the team realized the overall project goals, specifically:
- A 65% increase in successful member contacts within the project call center, with $3.3 million in cost avoidance.
- An increase from 49.2% to 88.3% in the overall process effectiveness.
- Call center quality improvement on all four major indicators.
- A strong correlation between the increase in call volume and a decrease in member hospitalizations and emergency room visits.
The project also resulted in the creation of new key processes, including streamlined standard call flows, transformation of supervisors to coaches and use of standard reporting templates and analysis processes.
The Healthways team made procedure, system and other changes to implement the solution and sustain the results, learning that:
- Use of data and reports is essential.
- Documentation efficiency remains a challenge.
- Change is difficult for many, requiring the why to frequently be reviewed.
- Quality and quantity must be balanced to ensure positive impact on outcomes.
- Clinician buy-in is a key to success.
- Coaching and persistence are the only ways to sustain success.
The team’s previous measurement system analysis confirmed that its reporting application was an accurate source for its key performance, availability and call-quality data. The data were tracked using control charts and bar graphs over weekly and monthly time frames.
A detailed response plan to ensure a timely correction of any process variance is an important element of the control plan. This plan uses standard reporting metrics to address results outside expectation and requires a drill-down to find root causes when targets weren’t met. Action plans are then created to address any variances.
The tangible results for the project were a 67% increase in median calls per clinician hour, an improvement in clinician availability to 98% of the Healthways standard, and improvement or maintenance of all call-quality indicators. Research showed strong correlation between increased member contacts and improved member outcomes and return on investment.
Intangible results included a significant improvement in colleague opinion survey results, achievement of a lower employee turnover rate compared to previous years and presentation of clinician metrics in a real-time format that allowed them to see how they were performing.
Importantly, the initiative set the stage for future employee-led improvement projects at Healthways.
Source from: ASQ