Identifying System-level Barriers Using Walk-Throughs and Other Tools

I’m part of the state SSA office; should I and how would I do a walk-through to get started doing NIATx improvements on our system?

Should I? You should do something to understand the impact a process has on others. A walk-through yields tremendous insight to the problems and potential solutions for improving system performance—but a walk-through may not be possible or the most effective way to gather this information.

In administrative environments there are basically three types of processes:

1. A direct service whether it be clinical or administrative
2. A flow of a piece of paper or information
3. The impact a rule or regulation has on those who must apply it

Let’s examine each type individually and identify specific tools to help you understand what are the challenges inherent in your existing processes.

Direct Services

If your Change Team is interested in a process that involves providing a direct clinical service (e.g., an assessment) or an administrative service (e.g., re-licensure approval) then it is likely that you will have the opportunity to perform a physical walk-through of the process.

Systems leaders need to walk through their own processes to understand what providers experience. Some walk-through ideas to consider:

• Do an intake with a provider. How much of the information requested is really necessary? What does the state really require?
• Sit down with the person who fills out the state data collection forms and walk through the process of entering data for a real person. Follow that data record through the various uploads and submissions that it is routed through between the clinician and the state and back to the agency.
• Call your office with a contract question and see how it gets routed or answered.
• Sit down with a treatment agency staff person who is trying to fill out next year’s contract forms. Experience the process from his or her perspective.
• Participate in a license review. Sit on the provider side of the table and follow up with an interview of the provider about the requirements.

Now that you have considered these options, you’re ready to conduct a walk-through.

Information Flow

If your Change Team is interested in a process that involves the flow of a piece of paper or information then there are several tools to effectively understand the process experience.

• Build a flowchart to track the paperwork process or the communication stream visually. Input from those who both execute and experience the process will offer the best understanding of the actual process.
• Do a tracer study. For example, attach a flagged form (physical or electronic) to a work request and have the staff who work on that request jot down notes. Have them time stamp the flagged form at every step so you can see how long the work takes. Consult the Tracer Studies Guide (British National Health Service) for ideas and suggestions.
• Interview staff who work on the process and ask them to just walk you through what they do. Inquire about frustrations, problems, ideas for improvement, feedback they get, etc.
• Interview customers (people working on the "next step in the process" or actual external customers) and have them describe their encounters with your process.

Regulatory Impact

If your Change Team is interested in the impact a rule or regulation has on those who must apply it, focus groups and/or in-depth interviews with those in the process yield tremendous information on the impact of a given rule or regulation. In the payer-provider partnership model, the strength of the partnership deepens when there is face-to-face collaborative dialogue on such processes. These conversations often work best at a learning collaborative’s kick-off session.

Here’s a good way to begin this conversation: Have the SSA personally ask each provider CEO to share two state-level changes that the CEO would make were he or she to become the SSA.