Wednesday, November 25, 2015

Experiences in public sector service logic - DMV vs USPS

In the US it is common to complain about the lack of service quality at the Department of Motor Vehicles (DMV), the organization which administers driving licenses, vehicle permits, and many other traffic-related permits. Everyone likes to share their stories of long wait times, crowded waiting rooms, and rude service. It often is used by stand-up comedians as the archetype of lousy public service. However, my own experiences have been very different, in fact mostly the polar opposite. Maybe my expectations were set low, but every interaction I have had with them I have found the service to be excellent, on time, and efficient. As a service organization, DMV has to handle numerous challenges that less common for most for-profit organizations. DMV needs to be able to serve every citizen, regardless of age, location, social group, language, income, disability, financial capability. They also support an extensive network of office locations, while also providing numerous on-line services. Also, as for most government institutions they need to adhere to a myriad of complex regulatory requirements. I believe much of the reputation for poor service is a relic of the past - when service possibly was far worse. In fact, it is clear they have spent considerable effort on improving the customer experience. They have shifted many services from in-person to on-line. They offer a comprehensive on-line system for scheduling in-person visit, when such in-person visits are needed, such as for a driving test. Inside the office locations, they have set up an efficient "flow system" - where customers are quickly triaged to different service clerks. They also appear to have close tracking of customer throughput and wait times, and make this information available to customers - for planning and expectation setting. This model has some similarities with supermarket checkout these days, where a customer can choose between different lines depending on number of items purchased, and their preference for self-service - but I find the DMV model to be more efficient and professional.
       For a public organization like DMV, it is not clear what may be the opportunities for extensive resource integration or co-creation. For an example of simple co-creation (but less successful), I will turn to the US postal service (USPS). In recent years they have expanded the ability for customers to print their postage using a home printer - and customer then can simply drop off the package to the post office, thus significantly reducing the wait time needed. However, while the effort is well-intended, it unfortunately works poorly in practice. I believe one of the key reasons is that it is still far too difficult for most customers to understand what postage to select when creating postage at home. The USPS maintains numerous (5+) different parallel pricing systems, depending on many obscure rules and exceptions for package size, type, dimension, weight, destination, content, etc etc.  Furthermore, while the DMV online services are excellent, the postal services' online services are confusing and hard to use. In contrast, most for-profit postage/shipping firms, such as FedEx, have excellent online services that makes the shipping process easy. The USPS service would benefit from a better integration of the pricing model with the self-service process, to achieve an overall more customer-focused experience.

Sunday, November 22, 2015

Service innovation in healthcare industry - focused on surgical services

Traditionally, most surgical services were performed in hospitals. As surgical techniques improved some procedures could be done as outpatient services - where patient could come in for just the day, and then return home before end of the day. However, even in this model doing procedures at large hospitals resulted in excess cost, and also increased risk of infection. As a result, over the last 10 years there has been a strong trend towards doing outpatient procedures at ambulatory surgical centers, also referred to as surgicenters. These centers provide a streamlined approach to perform many of the most common procedures, involving relatively healthy patients. Surgicenters often specialize in particular areas, such as orthopedics, or GI health. The core idea for a surgicenter is to have a higher productive approach, where equipment and staff is specifically focused on these types of patients and procedures. When the model is executed well, surgicenters can also offer higher-quality surgery compared with procedures done at traditional large-scale hospitals. The downside of procedures at surgicenters is that they are less ready to handle cases if the patient becomes unstabile during the procedure, or there is some other form of medical emergency. Another potential downside is the effects on the medical staff. Having worked in both surgicenter and in acute care hospital - I personally find the surgicenter model can become exceedingly repetitive, where the staff will do a large number of similar procedures every single day. At an acute care hospital the staff usually will experience a much wider set of procedures - which allows for broader skill building and job variety. Even with the downsides for the staff perspective, I believe the surgicenter model is superior for many forms of minor surgical procedures. However, then it becomes important to select the staff members who prefer a more narrow job mix, and also potentially explore ways to rotate staff between different facilities so to maintain and develop job skills - as well as for job satisfaction.

Saturday, November 14, 2015

Healthcare industry - customer experience

There is an ongoing rebirth of customer experience as a key organizing principle of health care delivery. If we go 10-20 years back - most healthcare delivery processes were structured primarily for what was easiest and most effective for the providers, but with less emphasis placed on the actual experience of the patient. I will give 2 relevant examples:

1) Major hospitals focusing on customer service: Many of the leading hospital organizations have in the last 5+ years extensively upgraded their focus on customer experience and satisfaction. Retraining of ALL employees to help everyone contribute to patient positive experience, bring in methods and processes from the hotel and travel industry. The emphasis is on offering more focus on each individual, supporting unique needs and preferences - from language, food, communication, physical ability, and more. Ultimately, these hospital chains aspire to increase their market share by providing superior customer service. Meanwhile, of course healthcare clinical quality is understood to be at least equal to that for their competitors.

2) Coordinated care of elderly: traditionally it has been challenging for older persons to access the different forms of healthcare they need - from primary care, nutrition, daily services, mental health, transportation, physical therapy, and more. The organization of services used to be organized around the healthcare PROVIDER. The patient typically had to go from one healthcare provider to the next, often wasting time, repeating test, and getting confusing or contradictory answers and advice. In recent years there is a movement to instead organize the health service around the PATIENT. This way the aim is to make it easier for individual patients to access the right type of care at the right time. The coordination of timely and cost effective care is facilitated by electronic medical records, and pro-active case management - often emphasizing preventative care as a way to hopefully reduce the costs and effort spent on high-cost intensive care models too often seen for elderly patients.
 Currently, there are efforts under way to also align incentives, payment models, and performance metrics to support this more patient-centric care model.


Saturday, November 7, 2015

Resource Integration in the healthcare industry: surgery

Resource integration in the healthcare industry - focused on surgery

Resource integration is a crucial element of successful service delivery in the area of surgery. The integration includes several types: facilities/equipment, staff/skills, and supplies, as well as close coordination with pre- and post- operative service providers.

In the hospital I work at, surgery start time is scheduled to a specific hour & minute. The expectation is that surgeries will start on time, in order to allow for effective completion of all surgeries to be done on the particular day - to make best use of operating rooms, and surgeon and other staff time.

On-time start of each surgery requires a well-orchestrated planning and management of all resources that can be involved: the patient (on time arrival, preparation, required paperwork), the surgeon(s), the anesthesiologist, the OR nursing staff (with right skill and experience for the particular surgical procedure), the right equipment & tools (some complex surgeries may involve 100s or several 100s pieces of specialized equipment and tools - all sterile and set up in a specific way), any specialized supplies - such as implants (of correct size, type, manufacturer), and other staff such as xray technicians, pathologists, and much more. Complex surgical procedures may last 4-6 hours and thus it may require several teams of nurses and technicians to cover rest and meal breaks.

Many hospitals use computerized tools to help in resource coordination, staff scheduling, and tracking of surgical procedures. However, even the most advanced such IT systems are not able to handle the sometimes subtle staff planning and job assignments among the OR nursing staff to match the best set of nurses and OR techs to each surgical procedures - and balance the needs across multiple operating rooms active at the same time - with focus on overall patient safety as the key driver. Usually, the key role of the staff planning and assignment is performed by experienced nurse managers who are familiar with the specific clinical needs for different procedures, and the experience of individual staff members - as well as the professional interests and focus of staff.


Value creation in my industry

Value creation in my industry: healthcare

I am not sure if I can point to many examples of true customer-led co creation being done in the healthcare industry at this point.

On the other hand, the hospital I work at may be a useful example of co creation between different service providers - which ultimately allow for relatively customer-specific experiences. The acute care hospital I work at is organized to provide an extensive line of surgical services, operating rooms, trained staff, and related supplies. However, the actual surgical and anesthesia services are performed by independent physicians. Here, each surgeon may bring their own specialized technique and method when performing various surgeries, using different tools, equipment, and process. Different surgeons also focus on different patient segments, such as emergency patients, pediatrics, geriatrics, women, etc. The result of the collaboration ("provider co creation") is that the hospital is able to offer very customer-centric surgical processes - and this can easily adapt as needs and priorities from customers change over time.

In a longer-term perspective, one possible area of true patient-driven co-creation in the healthcare industry may be driven by increased sharing of health related information directly from patients to healthcare practitioners. We have already started to see this at a small scale - where patients can send their vital signs and other health info over mobile phones to their providers.
 This way the providers can better prioritize and adapt the focus of their services each day/hours based on the latest information provided by their patients. There are a few physician groups in New York that are using this type of online enabled service collaboration - and this drives significantly increased value for all participants, including a) faster health service delivery, b) more optimal resource allocation, and c) reduced use of high-cost health delivery methods, such as Emergency Department visits.


Service Logic in my industry

Service Logic in My Industry,

I work in the healthcare industry - specifically in an acute care hospital, where I do surgical nursing.
My industry, as well as the majority of the healthcare area, clearly are pre-dominantly service industries. Traditionally, the healthcare field has been dominated by production logic - focusing mainly on metrics such as patient counts, room counts, room turn around, prodecure time and cost, and the vast underlying equipment and materials supply chain needed to support hospitals.

In recent years, many leading hospitals, having established a similar level of quality and cost, now are instead turning towards service logic to manage their business. Different hospitals and healthcare systems now are working to figure out what is their target patient population, and how does this relate with their unique assets and skills. Gone are the days when each hospital could "do everything". Instead, many leading hospitals work to become specialized in certain areas of medicine, or specifically targeting certain patient groups. When well executed such approach to focus allows an ability to achieve increased excellence, and create streamlined business processes - ultimately driving increased healthcare quality and enhanced relative cost position.

One major challenge in this development - is that consumers (patients) still lack much of the required tools and information to do an informed choice when selecting between different healthcare service providers. Furthermore, most patients remain relatively insulated from the actual cost level of healthcare service delivery - since the majority of cost usually is covered by insurers. Therefore, the first step towards driving increased service logic and efficiency is fueled by major insurers and govermental agencies - which now increasingly evaluate overall quality and cost between different healthcare providers, and then drive resource allocation to more capable providers.