Richard J. Banchs - The Quality Improvement Challenge

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 valueto 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?

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

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.

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 customer: a stakeholder. The customer who receives a service (the output of a process) may become the person who supplies services for the next process. The problem you are trying to address and the process you are trying to fix will determine which customer you should consider. That is why clarity about the process’s start and end is so important . The process limits determine who you consider the customer and who are the stakeholders (the people that do the work).

Materials management receives the supplies that have been ordered from a vendor. If we consider the target the process “supply delivery to the hospital,” the vendor is the stakeholder, and materials management staff are the customers. Subsequently, patient care units’ supply rooms are restocked by materials management. Nurses use these supplies to restock carts in the hallways that are used by physicians on rounds. If the QI project aims to improve “the supply chain management for patient care units,” the customer is the nurse, and the suppliers are materials management staff. The carts are used by the physicians on rounds to provide wound care and re‐dress patient’s wounds. If the QI project aims to improve the “availability of supplies during rounds,” nurses become the suppliers, and physicians, the customers. This example illustrates the customer continuum, a chain with three “suppliers of service” and three customers receiving the output of the process. Depending on which portion of the process continuum (value stream) we focus on, the QI team changes and so do the boundaries and scope of the project .

A successful improvement project cannot be launched on the basis of our opinions, beliefs, or assumptions about the problem. It must be substantiated by a true assessment of the situation that includes a clear understanding of the nature of the problem from the perspective of the internal or external customer.

The Voice of the Customer (VOC) is the expression of the collective needs, wants, preferences, and expectations of the customers.

The first step in finding the “Right Problem” is to understand and define the problem from the perspective of the customer. The VOC uses the customer’s input to define the needs and requirements of the service or care that is being provided. As discussed previously, customers can be patients, providers, or staff. The VOC is critical to the project team because

It helps us understand the main drivers of quality and customer satisfaction.

It allow us to focus our improvement efforts.

It sets the priorities, scope, and goals for the project.

Quotable quote: “The first step in exceeding your patients’ expectations is to know those expectations.” Roy H. Williams