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Using Current Reality Tree to Reduce Billing Errors for a Healthcare Client

Submitted By: Bob Sproull

In my last posting I told you I would take a look at some other performance metrics and see how they impact our improvement efforts. I’m going to delay that posting because I want to share an experience I had with one of my healthcare client’s teams. Although I won’t go into the details of the experience, I will tell you that they had proposed a change in the way a specific process is being run.

It has been said many times that the natural tendency of people is to resist change and in many ways I believe this premise. Assuming this resistance is real, why is it that people resist change? If you ask most people this question, you’ll probably get a response like, “it’s outside the comfort zone of the people being asked to change.” I know from my experiences that this is one of the most often heard responses to this question. There is an almost art to get people to change, but I’m here to tell you that it doesn’t have to be as difficult as some people make it.

When confronted with an opportunity to implement an improvement, many times we take the easy way out when we face this resistance by developing a compromise. A compromise is letting go of part of what we want and giving more of what the “changers” want. If we haven’t learned but one thing from the late Eli Goldratt it is that we should never compromise! A compromise is essentially a win-lose scenario when in fact we should only want to come away with a win-win one.

This team I mentioned earlier had a great idea about how to reduce the financial impact of missed billings. They had studied lost billings due to immunizations, but quickly realized that their solution would apply to other areas such as various medical tests and especially the more expensive tests like EKG’s, Point of Care Testing, etc.. In fact the amount of money lost due to immunization billing errors paled in comparison to these other tests.

So knowing that we have an excellent solution, the question becomes how do we present it without a compromise? From experience I know that as long as we think that the only way to handle a conflict is by compromising, such as trying to change a process, we won’t be successful in making the change. What needs to happen is that we must surface the assumptions on why we believe there will be resistance to the process change we are going to propose. And if we never think about the underlying assumptions and know how to remove at least one of them, we’ll never find the way to eliminate the conflict and “sell” our breakthrough solution. In fact, we’ll just simply lower our expectations and continue with business as usual.

The first and most profound obstacle to change is that people believe that reality is complex and sophisticated. And because we believe this, we have a tendency to believe that complex problems require complicated solutions. Goldratt introduced us to the concept of Inherent Simplicity which clearly states that complex problems require simple solutions. In other words, the more complicated the situation seems to be, the simpler the solution must be.

Earlier I mentioned that we need to develop a win-win solution, so how do we do this? The first place to start is by constructing a solution by seeking the other party’s win, but not the win that is in conflict. If we want our win to be bigger, we have to ensure that the other sides win will be bigger. In other words, we must demonstrate how by applying our solution, the side we are asking to change must see immediately that there is a win in the solution for them.

A good solution deals with the core conflict in that it changes an underlying assumption and therefore significantly changes the situation for the better. When you present your solution effectively, you immediately face a reality that is very different from the reality you’re currently in. We must first transfer ourselves into the future to realize the situation that will exist after the solution is implemented and then communicate that reality effectively. So back to our GB project.

The figure below in a simplified current reality tree that summarizes the most prominent Undesirable Effects (UDE’s) encountered by the team. In order to solve the billing error problem, the team had to identify a core problem that, if eliminated, would reduce the impact of many of these UDE’s.

The team concluded that by the MD’s not entering their immunization orders and instead gave verbal orders that the Medical Assistants (MA’s) made errors due to trying to translate what the MD had said. And if there were translation errors, then the charges would be incorrect. And when the front desk scanned the incorrect documents to the billing company, then the revenue from billing would be missing. The team then concluded that if the MD’s would simply enter their own orders (bottom entry on simplified CRT), then most of the UDE’s would disappear. The other problem stemmed from the problem that the billing documents were sometimes unreadable, so the team recommended that the billing document be redesigned to correct this problem.

So how could this simple solution (i.e. MD’s entering their own orders into the database) be a win-win. Quite simply, because of this simple change, there were other forms of paperwork that the MD would no longer have to fill out as they would now be completed by the MA’s. The result was, the MD could now see more patients. The MA’s liked this solution because they would know exactly what the MD’s orders were and they could prepare the immunizations, paperwork, etc. while the MD was still seeing the patient. The patients would like this, because their wait time would be reduced significantly. Just as soon as the MD opened the exam room door, the MA, having all that was needed to give the immunization, would simply walk in and administer the vaccine and the patient would leave. The organization would win by significantly reducing the lost revenue. So the team created a win-win-win solution that will be very simple to sell.

– Bob Sproull

Bob Sproull is the author of Epiphanized: Integrating Theory of Constraints, Lean and Six Sigma. The book is a business novel and is an attention-grabbing and fast-paced story of the transformation of Barton Enterprises, a manufacturer of fuel tanks for the aviation and defense industry. To learn more about the book, click here >>

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