The art of execution: Identifying and mitigating risks in healthcare provider organizations

When it comes to effective execution, elegant plans and high-level blueprints are not enough. Moving a healthcare provider organization from ideas to actionable solutions requires powerful change management that demonstrates leadership’s commitment to seeing the initiative through and prepares the organization for successful implementation.

Moving from design to action

Putting a newly designed process, structure, policy, or system into action requires a methodical and intentional approach to change management.

The most effective initiatives are exemplified by the following:

• Clarity in the goals, reasons, and benefits of the change
• Alignment with culture—understanding how the values and behaviors of an organization affect and are reflected by the initiative, including how decisions will be made, degree of team empowerment, and tolerance for risk and failure
• Focus on capabilities—the people, processes, and technologies required to operationalize the change
• A course that is flexible to navigate the challenges, risks, and learnings along the journey, yet still leads toward the desired future state
• Calibration throughout the process (via scorecards, metrics, and incentive systems) to ensure that performance targets are being measured and achieved
• Courage to raise difficult and unpopular issues that impact achievement of outcomes
• A communication program that promotes bi-directional conversations.

An operational readiness review that identifies an initiative’s key operational impacts; discovers gaps in people, processes, and technology; and develops workflows, policies, and training to address the gaps, is a highly effective way to manage the change process and ensure new designs are sustainable and embedded into the fabric of the organization. Critical is a structured approach that engages and empowers clinical and operational work groups to test and refine designs and develop solutions to mitigate identified risks. Depending on the scope of the initiative and specific organizational needs, key operational readiness activities may include the following: 

• Identifying high impact work flows
• Defining clinical, revenue cycle, financial, and operational risks associated with high-impact workflows
• Mapping current versus future state workflows
• Conducting demonstrations to ensure clear understanding of changes
• Working with leadership to develop and execute risk mitigation plans including developing or revising policies and procedures aligned with workflow changes, modifying job descriptions and/or training staff, and adjusting workflows
• Identifying key performance indicators to monitor impact

Engaging frontline managers, staff, and clinicians is key to determining the “how” and “who” of making change happen on a daily basis, as well as identifying the risks and unintended consequences that could derail implementation. Carefully selected frontline users—typically well regarded, thoughtful operational leaders, managers, and staff closest to the impacted processes and areas—test how the new design will impact all aspects of the organization—jobs, roles, training, and education; process steps and workflows; policies and rules; and information flow and system modifications.

These readiness groups identify gaps, test assumptions, surface risks, ask tough questions, define metrics, and begin devising solutions for what needs to be done to operationalize the designed changes. The groups also meet regularly with key stakeholders to align operational and business priorities and ensure systemwide readiness.

Operational readiness in action: Examples from the field

The examples below—patient access, revenue cycle, IT system implementation—highlight the importance of engaging frontline staff through an operational readiness program to test, refine, and execute designs to ensure their real-world viability, efficacy, and value. 

Patient Access. A large Midwestern health system sought to improve patient access and transform its approach to primary care. Successful implementation of key recommendations, such as open access scheduling, would involve significant changes to provider schedule templates and centralized call center staff workflows. In preparation for implementation, workgroups identified all new design impact points and conducted readiness assessments in each clinic focused on role and template changes. 

Working with the site-based leadership team, a gap analysis was conducted and a profile for each provider was created that detailed the specific changes required to achieve the new standards. For example, care team changes were created to help clinicians and the clinic stay on schedule. Workgroups also defined training requirements for the centralized call center. Using the readiness assessment results as a guide, the new standards, templates, and roles were carefully rolled out clinic by clinic. Following implementation, the organization has seen impressive results in improved access. For example, visit volumes have grown by 7 percent.

See related tool: Sample provider profile with recommendations for change

Revenue cycle: The CFO and emergency department (ED) director of a large Southeastern community health system were concerned that ED bad debt represented 35 percent of overall hospital bad debt and quickly initiated a revenue cycle improvement process. Workgroups comprised of revenue cycle staff and ED clinicians were charged with improving the process for copayment collection, registration, follow-up appointments, and financial counseling, without disrupting patient flow or clinical care. A primary recommendation was the implementation of a discharge desk to check-out patients after their visits. Reviews with key stakeholders also identified three improvements: changes to staffing levels to cover the required patient contact locations; a notification built into the ED bed board to facilitate bedside registration; and a new process for escorting patients to the discharge desk prior to exiting.

Early clinician engagement was critical, particularly in gaining agreement on using floor space for a discharge desk, establishing accountability for escorting patients to the discharge desk, and identifying new communication mechanisms between clinicians and registration staff to support full ED patient registrations and collections. 

IT system implementation. An integrated East Coast healthcare system underwent a large-scale IT system implementation to replace acute, ambulatory, and revenue cycle systems impacting more than 9,000 staff and providers. In preparation, leadership launched 30 work groups comprised of assistant vice presidents and directors from across three hospitals to support best practice adoption. Work groups identified changes required in existing workflows, processes, policies, procedures, and roles, as well as potential clinical, revenue cycle, and operational risks associated with implementation of the new system and changes in high-priority workflows. Potential performance risks/impacts included the following:

• Accounts receivable (A/R) and discharge not billed (DNB)
• Charge capture and revenue integrity
• Patient registration and check in
• Operating room utilization and scheduling
• Utilization management/care management communication and coordination

The work groups partnered with leadership to develop and execute multi-step risk mitigation plans to address the identified risks and concerns. The integration of clinical operations and revenue cycle staff within the work groups was an important factor in identifying and addressing how clinical changes would impact billing. Also, critical to success was representation and participation from all three hospitals in the work groups to promote consistent workflows, processes, and procedures across locations. Work group leads were responsible for regular communication with frontline staff through a variety of communication mechanisms, such as huddle notes and monthly flyers. Six months after implementation, the organization has seen an increase in professional billing average daily revenue of 23 percent and daily collections of 28 percent.

See related tool: Sample risk mitigation plans 

Is Your organization ready? Assessing and addressing implementation risks

As your organization moves from design to execution, it is critical to engage frontline users to identify and proactively address the issues that will detract from successful, sustainable implementation. Consider the Operational Readiness Assessment questions outlined below:

Clarity. Do managers, clinicians, and staff at all levels understand what we are trying to do and why? Have we effectively made the case for change?

Culture. How do our organizational values and norms support the change? How are we empowering our managers, staff, and clinicians to make needed decisions and changes in behavior, policies, and processes?

Capabilities.How will this change impact our organizational staffing and roles; foundational workflows and processes; mandated policies and standards; and integrated technology? Have we thoroughly examined these impact points and documented new roles, policies, workflows, and configurations to impacted technology?

Course. Do we have a comprehensive plan that aggregates the identified impact points and assigns accountabilities and timelines, phased in an optimal manner to support the upcoming changes? Have adequate lead times (e.g., recruiting, policy revisions, approvals) and acknowledgement of dependencies been built into that plan?  Can any of the remediation steps for these impact points be tested and fine-tuned prior to the planned change?

Calibration. How will we know if we are successful? How will we measure progress against our goals?

Courage. What are the difficult or controversial issues that must be addressed to reach our desired outcomes? How are we supporting our leaders and staff to take on these issues?

Conversations. Do we have adequate forums/mechanisms/opportunities in place to promote ongoing, bi-directional communication and honest feedback?

Moving forward

An effective operational readiness program that identifies and addresses the impacts, risks, and unintended consequences of new designs—on roles, skill requirements, processes, policies, technology—can help leadership effectively manage change from design through execution and ensure improvements are sustainable and lead to full realization of benefits.