Breaking the ‘Wicked’ Healthcare Barriers

One of the great frustrations of PATIENT FRIENDLY BILLING^® is that we know what a great patient experience looks like, and we know that it’s better not just for the patients, but also for us-the providers.

Why is it so hard to consistently realize that great patient experience vision? At HFMA’s 2008 Revenue Cycle Conference, revenue cycle leaders collaborated to articulate the barriers to achieving a positive patient experience.

We started by considering the story of Jack, a patient in the future who enjoys a truly great healthcare system experience.  

Most of the revenue cycle leaders participating in this session were not in an organization whose patients are getting this type of seamless, prompt, easy experience, but all wanted their patients to have it. Some people believed they had the ability to make this happen in their organization, but most did not.

If everyone wants their patients to have a great experience, then the question put to the participants is: Why don’t patients have this experience?

Barriers to a Great Patient Experience – A Wicked Problem

An essential clue to this question is the very nature of the problem in itself. Building a great patient experience is a “wicked” problem – one that is complex, fragmented, and involves many groups of people. Under these conditions, the people involved with the problem have difficulty even defining it, let alone agreeing to a solution.

In Dialogue Mapping: Building Shared Understanding of Wicked Problems, Dr. Jeff Conklin summarizes the aspects of wicked problems.  Below we consider several of these key characteristics as they apply to hospitals.

1. A wicked problem has many causes, is tough to describe and doesn’t have a single right answer.

This description certainly fits the question addressed in the session. Although people throughout the hospital system recognize that patients’ experience needs to be better, most would find it hard to even describe what would have to change for Jack’s experience to occur in their hospitals.

2. When you try to solve a wicked problem, there will be unintended consequences, some of which will make the situation worse. 

A common example is when hospital financial leaders try to implement new ideas, only to find that they have alienated doctors or stepped on a department head’s toes? As a result, the leaders may blame themselves for not communicating well enough, or the clinical staff for not cooperating, and everyone is reluctant to try again.

3. Wicked problems have no end point.

There isn’t a set of answers that will definitively “fix” patients’ hospital experiences. In our example, how will we know when our patients’ experiences are “great” enough? In wicked problems, solutions are implemented indefinitely until some relatively arbitrary threshold is reached (for example, a threshold of “good enough” is set, or leaders must focus on a different priority).

4. Wicked problems don’t have clearly defined alternatives.

When working with a diverse group of stakeholders (and healthcare is a prime example of diverse stakeholders!), there are no right or wrong answers. Leaders must explore many options for addressing the problem in ways that find the best balance and trade off of everyone’s values and priorities. To do that, leaders must be creative and use good judgment in selecting good approaches to their problems.

The Patient Friendly Billing Approach to Wicked Problems

Keynote presenter Terry Allison Rappuhn, Project Leader for Patient Friendly Billing, believes the way to achieve the vision of great patient experiences like Jack’s is to consider how the patient is affected by every choice you make. For example:

• If you need a new scheduling system, will patients find it easy to interact with it?  
• When you are updating your employee training program, is customer service excellence a part of that training? 
• When planning capital expenditures, are alternatives evaluated for how they will improve patients’ experiences? 

There is no magic bullet that will enable a hospital to give its patients Jack’s experience, but there are many, many opportunities to intentionally work toward this vision.

The 300 revenue cycle leaders attending this session worked to identify the barriers and some of the solutions to the problem of building a positive patient experience.  Their comments were captured using dialogue mapping, which is a method of building a shared understanding of a wicked problem by systematically capturing the collective intelligence of the group, and bringing clarity to diverse players’ perspectives.

Here’s how dialog mapping captured the final portion of this session, in which participants were asked the question “What are the barriers to a great patient experience?” 

View the session dialog map and tips for reading dialog maps.

Summary

We care about the patients we serve, and don’t want to perpetuate a system that causes them difficulty. But fixing this complex problem can feel like an insurmountable task. Jeff Conklin’s book describes it as a sense of futility that comes from expecting things to be one way and repeated banging into a different reality.

It is important, and empowering, to remember that when you repeatedly bang into problem after problem, it’s not because you’re crazy or incompetent, and it’s not because the other people you work with are crazy, or incompetent, or uncaring. The nature of the problem itself is causing the difficulties you experience.

Use the output from this session to validate what you have already accomplished and determine whether or not you are on the right track. Keep in mind that you are not looking for one right answer—you are looking for a selection of better solutions that will improve your customers’ satisfaction, and in the process will improve your revenue cycle, too!

You can do this if you think about how your patients are impacted in every decision you make.

• Be creative.
• Be intentional.
• Make good decisions, and your patients are in good hands!

Contacts

Terry Rappuhn: terryrappuhn@bellsouth.net

Jeff Conklin: jeff@cognexus.org

Resources

Patient Friendly Billing Project

CogNexus Institute

CAQH CORE Project