Monday, February 25, 2008

How things don't get fixed

So, as we start to implement BIDMC SPIRIT, here is a classic tale of a complaint and a solution that doesn't solve the root cause problem. Note that all people involved are very well intentioned, responsive, and caring of the patient , but how -- without a little prodding -- an underlying problem would have been left unsolved. By the end, we are headed in the right direction!

Note to me from a friend of a friend:

Amy S. suggested that I write to you about the difficulty that I have had registering on the BIDMC PatientSite. Quite simply, I tried to register as a patient and received a "Confirmation of Registration Request" by e-mail on February 11, 2008. I have still not received a username and temporary password. I currently correspond by e-mail with my primary care physician here in Worcester and find it quite helpful. The BIDMC patient site seemed to offer even more in terms of usefulness to a patient. It is frustrating and a little disquieting to discover that his piece of technology does not run as smoothly as I as a patient would hope the care at BIDMC runs.

My reply:

Hi. I am forwarding this to people here who can be helpful.

Reply to me from our CIO, with a copy to the right person in his place:

Happy to help. ABC, could you check on [this patient's] registration?

Note to the patient from ABC, with copy to me:

You are now registered for PatientSite. If you need further assistance, please do not hesitate to contact me.

Note to ABC from me:

Thanks. Now, I am curious as to why it didn't work for him. Can you explain? Is there anything we need to do to help others avoid this problem?

The IS person's reply to my query:

He sent two requests to register with Dr. X in the XYZ clinic. These requests typically go to office staff, and they did not respond to his requests.

My reply to administrative director in that clinic, with copies to others.

Well, let's pursue this and get to root cause and solve it, so it doesn't happen to future patients. (Pat and Jayne, also please note and offer BIDMC SPIRIT advice and assistance to [the AD] as needed.) Remember, no blame! Solve the problem.

Reply from AD, to me alone (!):

Thank you. Will follow-up with the admin staff.

Reply to the AD from me, again with copies to all others:

But, wait: There may be lessons for other clinics as well, so please do not do this in isolation. That is why I continue to copy others on this email thread....

Jayne, the VP who was copied, jumps in and says:

Dear All,

I will call a meeting to discuss the process for signing up for patient site. It would be good for everyone to understand the full process. Once we all know the full protocol and who is responsible for what portion of the process clearly without misunderstandings, then we can improve and re-document the process and roll this out to office assistants also as appropriate. Also, we need to ensure that the physicians also understand that they too need to approve their participation in patient site as I understand that has been a concern in the past.

ABC, can you bring a process flow of how IS and offices handle requests and timelines of the process for approval. Also, how is it fully communicated to the patient, etc. Then we can discuss other components that contribute to a less than optimal response to the patient and solve to root cause, then roll out to all, the improved system so that everyone understands their roles.


Anonymous said...

Sometimes it takes some prodding.
Just making a fix around is what we are trying to eliminate and fix the problem for good.

Sounds like one issue is in the pipeline!

Anonymous said...

Paul, this is a fascinating illustration of what BIDMC, and any hospital, faces in the nitty-gritty of process improvement. Here are my observations as an outsider:

a. the initial note to you from a "friend of a friend" represents a workaround - e.g., the patient wasn't getting any response from following the rules of the system, so they had to go straight "to the top" and AROUND the system. Had they not called the clinic responsible, or did they not know whom to call?

b. everyone involved but you was just focusing on their small part of the job. I am surprised the CIO didn't recognize the bigger picture, but maybe because the IT dept isn't responsible for registering people on PatientSite? But this tunnel vision is rampant in hospitals, perhaps because no one has time to oversee the wider implications.

c. Your note to the AD implies that you expected him/her to draw in other clinics into the root cause analysis and solution. Is this within his/her authority/job responsibility, or is he/she just responsible for that one clinic?

d. Your VP finally astutely recognized that the CEO was not going to let go of this and THEN stepped forward to appease you with a broader solution. So now you've had the CEO, the CIO, and a VP of a large teaching hospital involved in what seems a routine problem. Is this a good use of C-level time and will SPIRIT solve that problem?

e. My judgment is that you "called out" the problem, if I am using your SPIRIT terminology correctly. Whose job was it to then take the lead to the solution? My judgment would be that the analysis/solution process should have originated either with the CIO or ABC in IT. Perhaps they haven't been trained yet? Or, that the AD should have recognized his/her staff was ignoring patient requests in the first place - unless PatientSite is very new.

I am not being critical of those involved. It is a system issue that people don't recognize the wider implications of one small problem, not individual laziness. I am just interested in how SPIRIT will force these problem callouts and solutions down to the managerial/staff level at which they belong.

Anonymous said...


You have it all exactly right. Thank you for that excellent summary.

Ultimately, the problems should get called out at the level they actually occur, with the solution moving along a help chain only as far as is needed. There is certainly nothing in this case that should have required the CEO or CIO to be involved -- if the problem had been detected at the operational level.

In this case, only the VP had been through the training and was able to recognize the problem and how to get people to "swarm' to solve it. In the future, we hope that someone else closer to the issue would have seen it and -- most importantly -- felt empowered to call it out, and then would have been thanked and appreciated for having done so.

Anonymous said...

As the CEO of a very-small-business, this is incredibly inspiring. My role is slowly changing from a "doer" to more of a "leader" so it's great to get tips on how to agitate/create change within the organization. Thanks for continuing to share little behind-the-scenes exchanges like this.

Chris H said...

Interesting... In a previous job, I would often ask, "how/by what manner does this come to me?", in order to determine why I was constantly seeing things that I'd thought had been previously corrected, which obviously were not. (My job, interestingly, was to correct these things. I considered that it might be beneficial if I was able to create a work flow in which these things did not need correcting in the first place. True, I'd've put myself out of work had I been successful, but that was more or less my point.)

The sad part was the more often than not, the answer to my query was that I wasn't required to know the answer, but just to fix the thing. When I'd asked if perhaps there was some way to prevent this sort of thing from happening in the future, creating a better experience and lighter workload for all, I was pooh-poohed. Sounds like I was in the wrong place at the wrong time. :)

Anonymous said...


I always joke that if I am "doing" anything as CEO, there is a problem. The job has much more to do with being a facilitator to help notice problems and help people organize around solutions.

For the CEO in a small business that is growing, this is an important transition. Many entrepreneurs do not make it, and then the business crumbles under their weight. Good for you for realizing the need to change.

Chris H,

Check website for open positions!

Anonymous said...

To me, this was a perfect illustration of modern-day customer service. Look at the high-level communications involved! Recently, the phone co noticed they had not billed my long distance for 14 mos--I never scrutinize the bill that carefully. They suddenly wanted hundreds of bucks. It took an FCC complaint, numerous calls to and from Denver, etc., but finally the oversight was corrected and while I paid some, I did not pay all. Ack! Look at the man hours...or in my case, woman hours.

Anonymous said...

Just so you know -- I joined the site a long time ago so I don't remember exactly -- but I KNOW that I was told, by the site I think, to contact my doctor because it's the doctor's office that has to set it up. Pretty simple, I thought.

My one complaint about it: while labs are posted right away, other reports are held for two weeks. I'm an adult and don't need the doctor to tell me every piece of bad news. I know this is a debatable point.

Elizabeth said...

I know it didn't happen at your hospital, but I thought you might find this post interesting to discuss in light of your focus on analyzing root causes.

Anonymous said...

It is interesting that people were quick to jump to solve the current problem but lost sight of the need to do a 'root cause analysis' and fix it so it doesn't happen again...I applaud their customer service. However, we need to address things like this so they don't continue living as workarounds....:)