The Quality Improvement Challenge. Richard J. Banchs

FIGURE 7‐1 The SIPOC template.

Figure 7‐2 presents a completed SIPOC diagram, for the “prescription to medication delivery” process, highlighting the suppliers, inputs, outputs, customers, and the high‐level view map or steps of the process.

FIGURE 7‐2 SIPOC diagram for “prescription to medication delivery.”

      Steps to Creating a SIPOC Diagram

       Identify the process’s beginning and ending steps.

       Add the main process steps, selecting a maximum of 4–6 high‐level steps.

       Identify the key outputs.

       Identify customers in the downstream steps, while focusing on the critical few.

       Identify the key inputs and suppliers in the upstream steps.

       Identify the critical to quality requirements for each input, process steps, and outputs.

      Example: SIPOC Diagram for St. Barnabas’ Preoperative Evaluation Clinic

The Preoperative Evaluation Clinic (PEC) at St. Barnabas Medical Center is staffed with three physician assistants (PAs) and one full‐time anesthesiologist. At a recent meeting of the Surgical Services, a number of surgeons complained about the performance of the clinic, specifically, about delays in getting patients scheduled and a high cancellation rate on the day of surgery (DOS). Cancellations negatively affect the OR throughput, surgeon’s satisfaction, and the “bottom line” for the organization. The chair of Anesthesiology decided to launch a QI project. The goal of the project was to improve efficiency by reducing the number of cancellations on the day of surgery that are due to incomplete preoperative workup. After writing a Problem Statement, and drafting their first Project Charter, the QI team decided to set the project scope and boundaries creating a SIPOC diagram (see Figure 7‐3).

FIGURE 7‐3 A SIPOC diagram for “patient evaluation in the PEC clinic.”

CHAPTER 8 Who Are the “Customers,” and What Do They Need?

      IN HEALTHCARE, WE ALSO HAVE “CUSTOMERS”

      Who Is the “Customer”?

      Improving the quality of care requires a meaningful and actionable strategy and a well‐organized approach. The appropriateness of the strategy, and the effectiveness of the approach, depend on a clear understanding of the problem from the customer’s perspective. To clearly understand the problem we should “walk a mile in the customer’s shoes.” So, who is the customer?

       The customer is the person who requires and benefits from our work product; the customer is the end user, the person who receives the output of the process we are considering.

      Before we can address a problem and understand the nature of the problem, we must identify the customer. Problems in QI can only be understood from the customer’s perspective. If we ignore the customer, it will be difficult to truly understand the issue, focus our improvement efforts, and move the project in the right direction. Problems should be defined using the lens of the people who experience them.

In manufacturing, the customer is well known, and the customer’s needs are well defined. Improvement efforts are focused on delivering value to the customer. The same happens in healthcare. Staff and providers in healthcare organizations create value for their customers. Their efforts are focused on delivering quality care and an outstanding healthcare experience. So, who are the customers in healthcare?

      Three Types of Customers

In healthcare, the patient is always the ultimate and final customer. But there may be additional customers, as we described in Chapter 3. The word customer applies to any person who receives the work product or output of a process. The customer is the end user of the process outcome. Generally, there are three main customers for a QI project team to consider (see Figure 8‐1):

       Patients. The patient is the customer. The patients’ needs must drive our improvement projects. Many of our QI efforts are launched to address our patients’ needs and expectations. Patients expect care that is safe, timely, effective, efficient, equitative, and patient‐centered (the six dimensions of the Institute of Medicine). The patient is called the external customer.

       Providers. Sometimes the customer is not the patient. Sometimes the customer is a provider. A QI project may be initiated to address the concern of a provider or group of providers. Providers need the work product of others to do their job. Providers need: reliable information, diagnostic services, lab services, imaging services, on‐time deliveries of supplies, and so on. Providers need the work product of others so they can provide effective and efficient care to their patients. Providers are called internal customers.

       Staff. The customers of a QI project can be the staff. Staff enable the delivery of care. These professionals also depend on others for information, equipment, and supplies to perform their duties and support patient care. Other people in the care value chain may be responsible for providing them with what they need to do their job. A QI project may be initiated to address their needs. Staff are also internal customers.

FIGURE 8‐1 The three types of customers in QI projects.

      Example: The Customer of a STAT Arterial Blood Gas (ABG)

       The customer of a STAT ABG is the provider. The provider is the person who needs to interpret the results to make critical decisions about patient care. If the results take too long, it may affect a timely treatment. During a crisis, the timely report of the results in the EMR may be critical. What if it takes too long? A QI project may be initiated at the request of these customers to address the issue of STAT ABGs taking too long. Staff, providers, and the organization are the internal customers. Ultimately, the patient will benefit from the provider’s therapeutic decisions and, of course, will always be the final customer.

THE “CUSTOMER CONTINUUM”

      Within the care process, the professionals who receive the end product of a process (customers) can become, in turn, the professionals who do the work and supply services for customers of the next process. Depending on your perspective and the process you are trying to improve, a person can be the customer of a process, or the frontline professional delivering a service to another