Lawyer and author Cass Sunstein coined the term mud refer to situations in which the design of a specific process consistently prevents individuals from performing the intended action. A huge amount of sludge exists in healthcare processes. In this article, three senior Ascension executives share how they identified four approaches that can help other healthcare systems remove sludge from their processes.
Too often, patients face barriers that prevent them from effectively managing their healthcare. These typically include excessive wait times, redundant and confusing documents, and other processes that can be daunting and exhausting. These charges, primarily administrative, act as a “tax on time” and can significantly disadvantage our most vulnerable patients by reducing their commitment to looking after their own health, often resulting in delayed or delayed care. American jurist and author Cass Sunstein coined the term mud to refer to those types of situations in which the design of a specific process consistently prevents individuals from performing the intended action. We believe there is a significant opportunity to improve health care by paying more attention to sludge disposal. This process has become known as sludge audit — a systematic approach to identify the presence and cost of sludge and determine how to dispose of it.
In December 2021, President Joseph Biden took steps to address this issue within the federal government by signing an executive order directing agencies to redesign the customer experience to eliminate the sludge. The order outlines 36 improvements to be made, including several that focus on healthcare-related processes: a single, integrated and fully inclusive digital platform for military veterans to manage their healthcare and benefits in line ; allowing women and children in the Special Supplemental Nutrition Program to shop online rather than in person to improve access to healthy food; and the expanded use of telehealth options to enable patients to have better access to health care.
As clinical leaders at Ascension, we launched an initiative in June 2021 to apply principles from behavioral sciences and psychology to improve patient care and employee engagement in our healthcare system. We asked program managers across the health system to identify opportunities where we could help them increase their engagement to, for example, increase program enrollment or improve care utilization recommended. An Executive Steering Committee comprised of leaders from Clinical Operations, Technology, Strategy, Innovation and Assurance has been established to set priorities. Starting with the highest priorities, we worked with clinical and technology stakeholders to perform sludge audits to determine if each component of a given program likely facilitated the process or if it was sludge that l have hindered. Where possible, sludge costs were calculated both financially and in terms of engagement impact. Once the audit was complete, we made recommendations to these stakeholders on how to reduce sludge, and then helped implement them.
Since the beginning of the initiative, she has helped reduce sludge in several clinical programs and health insurance plans. Our efforts continue, but we have already identified four approaches that can help other health systems improve their processes.
1. Reduce the number of steps
When a new program to help engage a population in managing their health has been implemented does not meet expectations, resist the temptation to immediately add a new component such as additional communications or staff to the program. old approach. Instead, first investigate if the problem is that there are too many steps in the existing process.
Ascension discovered this need when employees were asked to submit a copy of their Covid-19 vaccination cards. The initial approach was based on downloading the documentation from a computer. This meant that most employees had to take a photo of their vaccination card with their phone, email it to themselves, download it from their email to their computer, and then upload it to the Ascension system. Due to these additional steps, many vaccinated employees did not upload their documentation. Our response was to create a new process for associates to directly upload their vaccine card from photos to their smartphone. With this change, the number of vaccine cards downloaded doubled in the first week after implementation.
2. Add a digital option
When the first step in a process depends on a phone conversation, it can often create a bottleneck. A process that relies solely on verbal communication over the phone requires manual effort from staff and often leads to excessive waiting (eg, being on hold or playing on the phone). In many cases, the remedy is to introduce a more automated digital channel and make it the primary option.
For example, at Ascension, our employee health plan made a change to its primary prescription coverage that required most members to update their information and enroll at a new pharmacy or risk paying more than their pocket for medication. The initial process required members to call to update their information, but attendance was low. So our pharmacy benefits team started making outbound calls. But the process was very staff-intensive, and team members were often unable to communicate with members by phone. Some employees did not respond; others had outdated phone numbers in the system. For every 1,000 phone calls made, approximately 100 members signed up, a conversion rate of 10%.
To solve this problem, we ran a pilot project: we selected around 1,000 members and sent them an email with an embedded form that they could edit and submit. The form was pre-populated with information we had previously collected such as their name and contact details. This meant that if the data we had was already correct, these members did not have to enter it again. In just one week, the conversion rate jumped to 72%. Ascension has since created an online form that health plan members who prefer a digital process can access at any time.
3. Remove roadblocks
Patients are often asked to complete a set of forms before they can make an appointment or access health care. But too often, documents unrelated to the visit are added to the mix, overwhelming patients and forcing them to reschedule appointments. Removing these unnecessary barriers should lead to better access to care.
Ascension is trying to do this in its online method of collecting patient-reported outcomes for joint replacement surgery. Patients will receive an email or text message with a link to take a short survey about their health and mobility. Before emailing or texting patients regarding health information, we will obtain their consent to receive communications through these channels. But because trying to obtain consent would create a barrier for patients who need to access care, and because these forms of communication are not necessary for the surgeon’s initial patient assessment, we decided to contact patients only after they are scheduled for surgery. . They will then receive an SMS or an e-mail containing a link to the consent form and asking them to accept or refuse it. If they give their consent, they will immediately receive an SMS with a link to complete a survey about their health and mobility. After their surgery, patients will be contacted every three months for a year for updates.
4. Offer virtual options
To expand access to care, healthcare systems should look for opportunities to replace processes that require in-person visits with virtual options. Many patients have to take an entire day off work or find a daycare center to get to an appointment with a clinician for a visit that may only require 15 minutes of actual conversation. While some healthcare engagements such as a physical examination of the heart and lungs, minor procedures such as a skin biopsy, or the administration of vaccines and intravenous medications require in-person interactions, many others such as advice on medications, diabetes management, or the interpretation of test results does not; these could be completed in a fraction of the patient’s time through a virtual visit.
There are many opportunities to improve healthcare delivery by removing sludge. This will make it easier for patients to access and manage healthcare.