4 ways to remove ‘sludge’ from healthcare processes
Legal scholar and author Cass Sunstein coined the term mud refers to situations where the design of a particular process consistently prevents people from performing their intended action. Huge amounts of sludge are generated in healthcare processes. In this article, three senior managers at Ascension share how they identified four approaches that can help other healthcare systems remove sludge from their processes.
All too often, patients face obstacles that prevent them from efficiently managing their healthcare. This typically involves excessive wait times, redundant and confusing paperwork, and other processes that can be daunting and exhausting. These mostly administrative burdens act like a “time tax” and can significantly disadvantage our most vulnerable patients by reducing their commitment to caring for their own health, often resulting in delayed or delayed care. The American legal scholar and author Cass Sunstein coined the term mud refers to those types of situations where the design of a particular process constantly prevents individuals from carrying out their intended action. We believe there are significant opportunities to improve healthcare by focusing more on clearing sludge. This process has become known as mud audit — a systematic approach to identify the presence and cost of sludge and how to eliminate 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 remove sludge. The order describes 36 improvements to be made, including several that focus on processes related to healthcare: a single, integrated and fully inclusive digital platform for military veterans to manage their healthcare and benefits online; the opportunity for women and children in the Special Supplemental Nutrition Program to shop for groceries online instead of in person to increase access to healthy foods; and expanded use of telemedicine options for patients to gain greater access to healthcare.
As clinical leaders at Ascension, in June 2021 we launched an initiative to apply principles from behavioral science and psychology to improve patient care and staff engagement in our healthcare system. We asked program leaders across the healthcare system to identify ways in which we could help them increase engagement, such as increasing program participation or improving uptake of recommended care. To set priorities, an Executive Steering Committee was formed, comprised of leaders from clinical operations, technology, strategy, innovation and insurance. Starting with the highest priorities, we partnered with clinical and technology stakeholders to conduct sludge audits to determine if each component of a given program was likely to facilitate the process or was sludge that hindered it. Where possible, mud costs have been calculated both financially and in terms of engagement impact. After completing the audit, we provided these stakeholders with recommendations on how to reduce sludge and then helped implement them.
Since the initiative’s inception, she has helped reduce sludge in multiple clinical programs and health insurance plans. Our efforts continue, but we have already identified four approaches that can help other healthcare systems improve their processes.
1. Reduce the number of steps
When a new program to help engage a population in managing their health falls short of expectations, resist the temptation to immediately add a new component, such as additional communications or staffing, to the old approach. Instead, first investigate whether the problem is that the existing process has too many steps.
Ascension identified this need when employees were asked to submit a copy of their Covid-19 vaccination cards. The initial approach relied on uploading documentation from a computer. That meant most employees had to take a picture of their vaccination card with their phone, email it to themselves, download it from their email to their computer, and then upload it to Ascension’s system. Because of these extra steps, many vaccinated employees have not uploaded their records. Our response was to create a new process that allowed employees to upload their vaccination records directly from photos to their smartphones. With this change, the number of vaccination cards uploaded doubled in the first week after implementation.
2. Add a digital option
When the first step in a process depends on a phone call, it can often create a bottleneck. A process that relies solely on verbal communication over the phone requires manual effort from staff and often results in excessive waiting (e.g., queuing or playing phone tags). In many cases, the remedy is to adopt a more automated digital channel and make it the primary option.
For example, our Ascension employee healthcare plan made a change to its primary prescription requirement, which required most members to update their information and enroll in a new pharmacy or risk paying more out of pocket for medication. The initial process required members to call to update their information, but acceptance was low. So our pharmacy services team started making outbound calls. But the process was staff-intensive, and team members often couldn’t get in touch with members over the phone. Some employees didn’t answer; others had outdated phone numbers in the system. For every 1,000 phone calls made, about 100 members signed up – a 10% conversion rate.
To address this issue, we ran a pilot: we selected about 1,000 members and sent them an email with an embedded form that could be edited and sent. The form was pre-filled with information we had previously collected, such as B. Name and contact information. This meant that if the data we had was already correct, those members didn’t have to re-enter it. In just one week, the conversion rate increased 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 fill out a series of forms before they can make an appointment or access healthcare. But all too often, documents unrelated to the visit are added to the bundle, overwhelming patients and causing them to reschedule appointments. Removing these unnecessary barriers should lead to better access to healthcare.
Ascension is in the process of attempting this in its online method of collecting patient-reported joint replacement surgery outcomes. Patients receive an email or SMS with a link to take a short survey about their health and mobility. Before sending patient health information via email or SMS, we obtain their consent to receive communications through these channels. However, because attempting to obtain consent would present a barrier for patients who need access to care, and because these forms of communication are not necessary for the surgeon’s initial assessment of the patient, we decided to delay patients until after the planned surgery to contact . They will then receive an SMS or email containing a link to the consent form and asking them to accept or decline it. If they agree, they will immediately receive an SMS with a link to fill out 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 healthcare, healthcare systems should explore ways to replace processes that require in-person visits with virtual options. Many patients need to take a full day off work or find childcare to travel to an appointment with a doctor for a visit that may only require 15 minutes of an actual consultation. While some medical procedures, such as a physical exam of the heart and lungs, minor procedures such as a skin biopsy, or administering vaccines and IV drugs, require face-to-face interactions, many others, such as drug counseling, diabetes management, or interpreting test results, do not; These could be completed in a fraction of the patient’s time through a virtual visit.
There are many ways to improve health care by clearing sludge. This makes healthcare more accessible to patients and easier to manage.