4 ways to remove “sludge” from healthcare processes

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Legal scientist and author Cass Sunstein coined the term sludge to refer to situations where the design of a specific process consistently hinders individuals from completing their intended action. An enormous amount of sludge occurs in care processes. In this article, three senior Ascension executives share how they identified four approaches that could help other health systems remove sludge from their processes.

Advice from three senior managers at Ascension. †

All too often, patients face obstacles that prevent them from efficiently managing their healthcare. These typically include excessive wait times, redundant and confusing paperwork, and other processes that can be daunting and exhausting. These mostly administrative burdens act as a “time burden” and can significantly disadvantage our most vulnerable patients by reducing their involvement in taking care of their own health, often leading to delayed or delayed care. American lawyer and author Cass Sunstein coined the term sludge to refer to situations like this where the design of a specific process consistently prevents individuals from carrying out their intended action. We believe there is a great opportunity to improve healthcare by paying more attention to sludge removal. This process has come to be known as a sludge audit – a systematic approach to identify the presence and cost of sludge and figure out 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 ordering agencies to redesign the customer experience to remove sludge. The order describes 36 improvements to be made, including several that focus on healthcare-related processes: a single, integrated, and fully inclusive digital platform for military veterans to manage their healthcare and benefits online; the ability for women and children in the Special Supplemental Nutrition Program to shop online rather than in person for groceries to improve access to healthy nutrition; and extensive use of telehealth options for patients to improve access to healthcare.

As clinical leaders at Ascension, we began an initiative in June 2021 to apply principles from behavioral science and psychology to improve patient care and employee engagement with our health system. We asked program leaders across the health system to identify opportunities where we could help them increase their engagement, such as driving program enrollment or improving the use of recommended care. An executive steering committee composed of leaders from clinical operations, technology, strategy, innovation and insurance was established to prioritize. Starting with the highest priorities, we, along with clinical and technology stakeholders, conducted sludge audits to determine whether each part of a given program was likely to facilitate the process or was sludge impeding it. Where possible, the costs of sludge, both financially and in terms of impact on engagement, have been calculated. After the audit was completed, we made recommendations to those stakeholders on how to reduce sludge and helped implement them.

Since the inception of the initiative, it has helped reduce sludge in several clinical programs and health insurance plans. Our efforts continue, but we have already identified four approaches that could help other health systems improve their processes.

1. Reduce the number of steps

When a new program to help a population manage their health doesn’t live up to expectations, resist the temptation to immediately add a new component, such as extra communications or staffing to the old approach. Instead, first investigate whether the problem is that there are too many steps in the existing process.

Ascension discovered this need when employees were asked to submit a copy of their Covid-19 vaccination cards. The initial approach was based on uploading documentation from a computer. This meant that 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. Due to these extra steps, many employees who have been vaccinated have not uploaded their documentation. Our response was to create a new process that would allow employees to upload their vaccination card directly from photos on their smartphone. With this change, the number of uploaded vaccine cards doubled in the first week after implementation.

2. Add a digital option

When the first step in a process depends on a telephone conversation, this can often lead to a bottleneck. A process that relies solely on verbal communication by telephone requires manual effort on the part of staff and often leads to excessive waiting (for example, standing on hold or playing a phone tag). In many cases, the remedy involves introducing a more automated digital channel and making it the primary option.

At Ascension, for example, our employee health plan made a change to primary prescription coverage, requiring most members to update their information and enroll at a new pharmacy or risk paying more out of pocket for medications. In the initial process, members were asked to call in to update their information, but adoption was low. So our pharmacy benefits team started placing outbound calls. But the process was staff-intensive and team members were often unable to contact members by phone. Some employees did not answer; others had outdated phone numbers in the system. For every 1,000 calls made, about 100 members signed up – a 10% conversion rate.

To address this issue, we piloted about 1,000 members and emailed them with an embedded form that could be edited and submitted. The form was pre-populated with information we had previously collected, such as their name and contact details. This meant that if the data we had was already correct, those members wouldn’t have to re-enter it. Within just a week, the conversion rate rose 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 complete a series of forms before they can make an appointment or access healthcare. All too often, documents unrelated to the visit are added to the bundle, overwhelming patients and delaying appointment scheduling. Removing these unnecessary blockages should lead to greater access to care.

Ascension aims to do this in its online method of collecting patient-reported results for joint replacement surgery. Patients will receive an email or text message with a link to complete a short survey about their health and mobility. Before emailing or texting patients about health information, we will obtain their consent to receive communications through these channels. But because trying to obtain consent would create a roadblock for patients who need access to care and these forms of communication are not necessary for the surgeon’s initial evaluation of the patient, we decided not to reach out to patients until after they have been diagnosed. scheduled for surgery. They then receive a text or email with a link to the consent form and are asked to accept or decline it. If they consent, they will immediately receive a text message with a link to complete a survey about their health and mobility. After their surgery, patients will be contacted every three months for updates for a year.

4. Offer virtual options

To expand access to care, health systems need to look for ways to replace processes that require face-to-face visits with virtual options. Many patients have to take an entire day off from work or seek childcare to travel to a clinician appointment for a visit that takes as little as 15 minutes of conversation. While some healthcare activities, such as a physical examination of the heart and lungs, minor procedures such as a skin biopsy, or the administration of vaccines and intravenous medications require personal interactions, many others, such as medication counseling, diabetes management, or interpretation of test results are not; these could be completed in a fraction of the patient’s time via a virtual visit.

There are many opportunities to improve care delivery by removing sludge. Doing this makes healthcare easier for patients to access and manage.


This post 4 ways to remove “sludge” from healthcare processes was original published at “https://hbr.org/2022/03/4-ways-to-remove-sludge-from-health-care-processes”

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