All Part of The Process

4 January 2010 Dr D J Brown

Improvements in process can deliver the efficiencies demanded by today's economic climate. That's the view of Dr D J Brown, who in this extract from his book The Meaning of Careful, outlines five guiding principles for implementing processes that will free-up staff to better respond to 'customer' needs.

John was the accounting departmental leader for a multinational oil firm in a developing country. A period of growth and a merger had left him with a multitude of accounting systems, some confused staff and – most seriously – an enormous backlog of unpaid invoices. When I met him, his best estimate of the average time that it took for an invoice to be paid was over 90 days. Let's be clear, this was not policy – it was the reverse of what the company wanted. It was politically embarrassing for one of the world's largest companies to be effectively borrowing money from small, third-world businesses to finance its operations. This company was the biggest in the country and it was unintentionally putting some of its suppliers out of business. The accounting department itself was also daunted by the scale of the problem, which got in the way of their other duties and caused friction and difficulties with the rest of the organisation. The accountancy team was despondent and unhappy.

It didn't take long to realise that there was a fundamental problem: every invoice was processed in a different way. Suppliers didn't know how to get paid, so some gave their invoices to the person who had supervised their work, some sent them to head office, some to the local operations plant. The invoices went by a myriad of different routes before they arrived at the accounting department. And then the fun started. Different parts of the team processed the invoices in different ways, depending on what they had previously been taught. Not surprisingly, it was a mess. What was worse, it was clear that simply driving down the backlog using overtime wasn't going to prevent another one from developing the next month. In fact, the department had employed several more full-time staff and the problem had become worse, not better. So my consultation company was hired to sort out the problem.

The first job was to help the suppliers understand how to get paid. John agreed with all the suppliers how and where to present all future invoices. This took a while because there were thousands of suppliers and changing their habits was not easy. Together, the department agreed on what should happen to the invoices when they arrived in the department. John took the opportunity to create new sub-teams, which dealt with different sizes of invoice (and therefore took care to process 'small business' invoices more quickly – the opposite of what had been happening before).

After a year of effort, using an 'action team' run by one of his deputies, John reported that the average time it took to process an invoice had fallen, and he knew exactly by how much because part of the plan was to measure results. The last time we spoke it was down from 90 to 28 days and was still falling.

I use this story of a relatively simple, non-clinical situation because it highlights some important principles about process:

1. Processes exist only inside the heads of those involved

"Properly pursued, process improvement creates enormous efficiencies and saves money."

People tend to follow their own idea of the process, rather than what's in the instruction manual. This has two implications – if a process is to be followed, first it must be simple enough to remember; and second, you have to teach correctly to everyone the part of the process in which they are involved. The invoices in our story were sent to pretty much anyone in the entire business because the suppliers didn't understand their role. The same thing applied to the invoice processing department. To make the process work, all the suppliers and all the staff needed to learn that invoices had to go to Point A for payment and absolutely nowhere else. Making processes so simple and obvious that everyone remembers their own role correctly is the key. Only then does everybody do the right thing. This is critical to improving processes. Having a complicated process is worse than useless, unless you can find a way to get people to follow it, which is hard. If people don't remember their part of the process, they will simply make it up as they go along, and will get it wrong. Bundles of invoices end up in the wrong place. By analogy, our patients may go missing or be wrongly treated.

2. Processes need to be measured if they are to be improved

In my example of John and his invoices, we established the average time to payment as the key measure we were going to use. Everything else was subsidiary to this number – even the daunting backlog. I've said this before, but will repeat it here: numbers give people a way to concentrate on what is important and to solve problems. Numbers provide a measure of success, which can be celebrated.

3. All your processes matter, not just the clinical ones

Simple processes, such as that of paying invoices, can affect your organisation's financial performance and your reputation just as much as, for example, the sexy clinical pathways. It's no good bringing someone to endoscopy if you've failed to pay your suppliers and there's no equipment. I met a doctor who invoiced a London hospital for some work and it took them more than three months to pay him. In effect, he was financing the NHS – which seemed unfair. So he switched to using a locum agency and the hospital now pays 30% more for his time. There is a huge amount of unnecessary cost in healthcare that is hidden in this way.

4. The problem is always beyond where you can see

If one person could see the whole of any process then problems would soon be resolved. Unfortunately, all processes cross boundaries inside and outside your organisation, so most people see only one part of the process. The bigger the organisation, the truer this is. The solution is to simplify and clarify the process. This is also one of the reasons for using cross-functional 'action teams'.

5. Real improvement takes time

Hitting John's backlog with a huge overtime effort would have solved the problem in just a few weeks. Changing processes, solving problems, incrementally improving things – these take time and real collaboration, which is why, again, you have to put people before processes.

The benefits of uniformity

A uniform organisation:

  1. Performs its repetitive tasks correctly – first time, every time.
  2. Continually measures and improves its processes to generate better results.
  3. Standardises its processes where possible.
  4. Describes and communicates its processes clearly.

The benefits of uniformity are threefold. The first is obvious – by creating a culture of continuous process-led improvement, results will improve. Properly pursued, process improvement creates enormous efficiencies and saves money.

Secondly, performance ownership begins to develop as staff see the connection between their actions and the published performance figures. This improves motivation and staff retention, and improves the human capital value of the organisation.

The final benefit is more subtle and initially counterintuitive. Uniformity actually allows more flexibility in the way that patients are treated and the way in which non-process aspects of care are delivered. Paradoxically, standardisation allows for more individualisation.

Let me explain. I am privileged to have an educational supervisor who is not only enthusiastic and supportive but is also a formidable diagnostician. We were talking about processes the other day. "Everybody's illness is as individual as their thumbprint," he said. "And you can put that in your book." And I have, because the point he makes is an important one. The unending variability between patients and between episodes of illness for each patient, added to the incompleteness of our knowledge about the individuals and their conditions, makes true 'standardisation' across all patients not only undesirable but impossible. They are all different and they all need to treated as individuals.

However, pursuing uniformity where it is possible delivers huge efficiency gains. It allows the carers some time and headspace to give the right level of individual attention to patients – the 'service on top' that I mentioned earlier. It's clear that if we spend our time as clinicians on the phone or on the computer chasing inefficient processes, we get stressed among the muddle. Sadly, as a clinician I spend much of my time on the shop floor doing just that: chasing up blood results, calling other doctors to ask them to see the patient and so on. Yet it needn't always be so. Just recently one of my hospitals introduced a system of automatically calling porters. Prior to that, every time we wanted to move a patient we had to bleep the porter, wait by the phone for their return call, explain what we needed, put a written request in a box... and so it goes on. Now, we just type a request into a computer and (by magic, it sometimes seems) a porter appears and takes the patient to where they need to go. This probably frees up at least 20 or 30 minutes of my working day. With this time, I can more easily talk to patients and their relatives and give more thought to their problems, which is what I should be doing.

Looking back at John and his invoice processors, I remember that when I first met them, they were unable to answer queries on the phone because they were so busy being inefficient. By the time the process was sorted, they had a dedicated help-line for suppliers, which was manned for 12 hours a day. This responsiveness was possible only because of their new, efficient processes.

For further details or to receive a copy of The Meaning of Careful for review please ring: on +44(0)207 209 4543 or email