Employing a Systems Approach to Customer

Continuing Education

Satisfaction Inl Vanita Bellen, MHS -

Director of Qualify Management Genesee Region Home Care

Rochester, NY Association, lnc.

Journal for Healthcare Quality is pleased to

education (CE) cred- it to those who read this article and complete the application form on page 47. This continuing education offering, JHQ21, will provide 1 con- tact hour to those who complete it appropriately. (See application form for further details.)

offer the opportuni- ty to e m ContinUine,

Objectives By participating in this indepen- dent study offering, the reader will be able to do the following:

1. Relate how each step of a sys- tems approach is used to in- crease customer satisfaction.

2. Identify ways of testing for cause-and-effect relationships within a system.

CE questions for this article can be found on page 30.

I CE I The need to meet customers’ expectations is one of the driving forces in

healthcare today. Organizations can achieve this goal most effectively by using rational and systematic problem-solving approaches. This article describes systems theory as a problem-solving method that analyzes and implements customer satisfaction data to produce the desired result of increased customer satisfaction levels and economic growth.

Today’s competitive healthcare envi- ronment requires that organizations be sensitive to their customers’ levels of satisfaction. Genesee Region Home Care Association, Inc., (GRHC) of Rochester, NY, recognizes its reliance on its cus- tomers for its viability in the commu- nity. GRHC is striving to improve cus- tomer satisfaction through systematic problem-solving efforts.

Systems Theory One problem-solving approach, typ-

ically used by industry in the past, is that of systems theory. By definition, a system is an arrangement of interre- lated parts that are designed to achieve an objective. This concept, according to Starke, Mondy, Holmes, and Flippo (1985), involves raw materials (inputs) undergoing a conversion process to be- come a product (output) (see Figure 1). If, however, one of the raw materials contained impurities, the effectiveness of the conversion process would be compromised and so, perhaps, would the quality of the item produced. The awareness that a change in one vari- able in a system can effect a change in another variable (or that a cause-and- effect relationship exists) allows a man- ager to use systems theory in making well-planned, rational decisions (Gray & Starke, 1984; Kepner & Tregoe, 1981; Starke et al., 1985).

Application: The application of sys- tems theory to problem solving relies on quantitative research tools. Statisti- cal methods increase confidence in ab- stracted data and give credence to claims of cause-and-effect relationships. Finally, systems theory works most ef- fectively with tests that are conducted repetitively. Ongoing observation and testing improve the validity and relia- bility of data.

Systems theory can be applied to problems at institutional, unit, or func-

tion-specific levels. At GRHC, systems theory is being used at the latter level to improve customer satisfaction.

Step one-gathering raw data: The first step in bringing inputs into the sys- tem involves gathering raw data, with complaints providing one source. Com- plaints are defined as unsolicited ver- bal or written communications identi- fymg issues of concern to the customer, Each complaint is investigated by the manager responsible and is reported to the director of patient services and to the quality management department. In New York, complaints must be an- swered within the 15-day turnaround time stipulated by the New York State Department of Health. Complaints at GRHC have been collected on an on- going basis, with data from a period of several years currently available.

The patient satisfaction survey also provides raw data. A simple question- naire, which focuses on clients’ satis- faction with the specific services pro- vided by the agency, is given quarterly to those patients discharged to self-care within the previous month (see Figure 2). The previous year’s experience has produced an average response rate of about 44%. The consistency of the sW- vey schedule and the high response rate gives administrators at GRHC confi- dence in the validity of the collected data.

A referral source satisfaction survey that provides data from customers 0th- er than patients or their families is con- ducted biannually. The survey focus- es on the needs of the hospital discharge planners and social workers and at- tempts to determine whether their e:- pectations are being met by GRHC home care coordinators (see Figure 3).

Compliments and commendations usually are obtained in the form of let- ters from clients and from satisfaction surveys. These comments also ‘ire Con- sidered part of the raw data.

6 JHQ . July/August 1994. VO~. 16, No. 4

Figure 1. The System

Step two-the conversion process: The conversion process, the second step in a system, typically consists of all the

data into groups. For example, specif- ic complaints and satisfaction survey results are categorized as being related

Neither Satisfied nor

Service Very Satisfied Satisfied Dissatisfied Dissatisfied

equipment and structure necessary to convert inputs into a desired product. In GRHC’s customer satisfaction ex- ample, the conversion process actual- ly comprises two phases: problem iden- tification and problem resolution.

Problem identification: In GRHC’s ex- perience, an effective way to identify problems has been to categorize the raw

V e y Dissatisfied Not Applicable

to (a) service pFovision, (b) agency sys- tem and/or process, (c) practice and duties, (d) equipment, and (e) behavior and/or communication.

The number of complaints in each cat- egory also can provide some insight into agency-wide issues; however, the sig- nificance of raw numbers is slight. T h e fore, GRHC examines data relative to an-

Overall, how satisfied are you with the care you received?

+ I

Q Q Q Q Q Q

Figure 2. Genesee Region Home Care Association

Satisfaction Survey

How did you first hear of Genesee Region Home Care (GRHC)? D Physician D Discharge Planner D Social Worker 0 Family/Friend 0 Other (please specify)

I Q l Q l Q I GRHC home care coordination (located in the hospital) Q I Q I Q

Overall, how would you rate the timeliness of the services received?

Would you recommend Genesee Region Home Care to a friend or a family member? Yes No 0 Don’t know

If we would like further details, may we call you? a Yes 0 No

(Optional) Name of Survey Respondent

Patient’s Name (Relationship to Patient)

Address Respondent’s Phone Number

Thank you for taking the time to complete this questionnaire!

Reprinted with permission of Genesee Region Home Care Association, Inc., Rochester, NY. \

JHQ July/August 1994 1 Vol. 16, NO. 4 . 7

Customer Satisfaction

Very Satisfied

Figure 3. Genesee Region Home Care Association

Home Care Coordination Satisfaction Survey

Neither Satisfied Nor

Satisfied Dissatisfied Dissatisfied I DisZTfied I Not Applicable

1 How satisfied were you with the following services? Please check the answer that best describes your feelings.

0

Li

Attitude and professionalism of GRHC home care coordinators

Timeliness with which referrals are Drocessed bv coordinators

Service

Li Li 0 Li Li

ci ci Li Li Li

ences

Follow-up information provided by coordinators on discharge patients

Coordinator’s ability to deal with

timely manner problems in an appropriate and

Li Li D Li cl Li

D Li Li ci cl Li

Coordinator’s documentation in accordance with hospital proto- I cols cl

Coordinator’s ability to coordi- nate discharges in a timely and efficient manner

Coordinator’s availability to participate in discharge confer- I 0 l o I 0 l o I 0 I 0

If we would like further details, may we call you?

(Optional)

Patient’s Name Phone Number

0 Yes No

Thank you for completing this questionnaire and helping us improve the quality of our services.

Reprinted with permission of Genesee Region Home Care Association, Inc., Rochester, NY.

other variable whenever possible, thus making the data more meaningful. For example, the number of complaints reg- istered in a month is compared to the agency‘s census for that month. By col- lecting several months’ worth of data rel- a tive to the agency‘s census, managers can establish acceptable complaint lev- els, so that in the future, if that level is ex- ceeded, a problem can be identified and appropriate action can be taken.

Satisfaction data are examined rela- tive to the number of responses received for each question. Satisfaction levels that do not take into account the num- ber of unanswered questions reduce

the reliability of the obtained values and may mask a problem that exists or incorrectly identify a possible problem.

The analysis of trends also helps to identify problems. By examining sev- eral months’ or years’ worth of data, in- vestigators may note cyclic, seasonal, or other patterns. Then, by identifymg fac- tors or variables that may have been at play during the time period, cause-and- effect relationships may be identified (Gray & Starke, 1984).

ProbZem resolution: Problem resolution, the second phase of the conversion pro- cess, may vary among organizations, depending on the goals, experiences,

and technical knowledge of staff mem- bers. At GRHC, some problem resolu- tion methods that have been beneficial include educating staff members, de- veloping new policies and standards, and developing project teams.

Administrators have educated staff members about problems and ways to resolve them by sharing with them the survey results, discussing results at team and management meetings, highlight’ ing topics on bulletin boards, and con- ducting consciousness-raising sessions. An example of this last was a retreat held by the agency’s home care coordl- nators to define their role in the adds-

8 m JHQ = July/August 1994 = Vol. 16, NO. 4

sion process and their responsibilities to both the hospital and the agency, and to idenbfy specific ways to increase their visibility and strengthen their relation- ship with the hospitals. The recom- mendations resulting from the retreat included suggestions that coordinators should regularly attend hospital rounds and take steps to increase their visibil- ity as part of the hospital team.

A number of project teams and stud- ies have been initiated at GRHC to help in the problem resolution phase. Usu- ally, these have first provided additional information and/or clarified an issue. Action plans then were developed to ad- dress the problem. For example, agen- cy systems and processes repeatedly had been identified (both through com- plaints and the results of the satisfaction survey) as problems. The specific con- cerns identified by external customers related to staff members’ accessibility by telephone and the amount of time cus- tomers spent waiting on the phone. A project team studied the agency’s tele- phone system and recommended voice mail for administrative staff members and education on message-taking tech- .niques for clerical staff members. The team also has developed call-forward- ing guidelines and has established back- up procedures. Although data are cur- rently being collected to demonstrate improved satisfaction with the telephone system, the number of complaints about the system seems to be decreasing.

Step three-realizing outputs: The third step in a system involves outputs returning to the organization’s external environment. One output of the cus- tomer satisfaction system may be growth in admissions. Although it is difficult to verify the effect of customer satisfac- tion on admissions, GRHC has experi- enced a 17% increase in admissions over the previous year. The number of pa- tients served also is being monitored; GRHC has experienced a 27% growth in Patients served between 1990 and 1992.

In addition, client satisfaction results also can be examined. For the last year, GRHC has had an overall satisfaction rating of 99% (GRHC, 1993). Repeat admissions and an increased market share of patients also are outputs that may be considered in the future.

Another observed output is increased staff involvement in problem solving. This is demonstrated by agency staff members’ initiation of focus groups, partiapation in hospital rounds, and in- creased requests for information.

Evaluating Systems Theory The question to ask at this point is,

”DO the outputs conform to the goals and objectives of the organization?” At GRHC, it certainly appears that the out- puts contribute to fulfilling the goal of improving customer satisfaction. How- ever, an even more important function of these outputs is that they serve as benchmarks and play a key role in test- ing cause-and-eff ect relationships.

Testing for cause-and-effect: In the- ory, testing for cause-and-effect rela- tionships within a system involves mod- ifying one or more variables and observing the impact of that on other parts of the system. GRHC is beginning to examine how outputs change as more, fewer, or different resources are put into the system or if different prob- lem identification and resolution meth- ods are used, for example, testing how a telephone survey, rather than a mailed survey, affects the data about satisfac- tion levels. Another example of testing for cause-and-effect relationships may be to withhold a data collection tool and see the effect this has on outputs. If the same information can be obtained from other sources, it would be in the orga- nization’s interest to deploy these oth- er resources to additional studies and data collection methods.

Summary Although the measurable results of

employing systems theory to customer satisfaction have yet to be collected at GRHC, this article has outlined an ap- proach to problem solving that can pro- vide tremendous benefit to healthcare managers. At GRHC, awareness of sys- tems theory is providing the impetus to go beyond the obvious and examine the system as a whole, thus allowing a comprehensive view of the situation. In addition, by considering that a system is simply a sum of its component parts, the agency is recognizing how those parts relate to one another and, in par-

ticular, how this perspective is benefi- cial to the problem-solving and deci- sion-making processes.

References Genesee Region Home Care (GRHC) As-

sociation, Inc. (1993). Satisfaction sur- vey. Rochester, Ny. Author.

Gray, J.L., & Starke, F.A. (1984). Organi- zational behaaior concepts and applications (3rd ed.). Columbus, OH: Charles E. Merrill Publishing.

Kepner, C.H., & Tregoe, B.B. (1981). The new rational manager. Princeton, NJ: Princeton Research Press.

Starke, F.A., Mondy, R.W., Holmes, R.E., & Flippo, E.B. (1985). Management con- cepts and Canadian practice. Toronto: Al- lyn and Bacon Publishers.

Suggested Readings Bone, D., & Griggs, R. (1989). Quality at work:

A personal guide to professional standards. Los Altos, CA: Crisp Publications, Inc.

Scholtes, R.R. (1988). The team handbook: How to use teams to improve quality. Madi- son, WI: Joiner Associates.

continued on page 30

Vanita Bellen is the director of quality management at the Genesee Region Home Care Association, Inc. in Rochester, NY. Her responsibilities there include directing quality assur- ance, total quality management, re- imbursement review, and education- al programs; and preparing for state licensure, Medicare, and Joint Com- mission surveys. She received a mas- ter‘s degree in health administration fYom the University of Toronto.

JHQ . July/August 1994. Vol. 16, NO. 4.9

Interdisciplinary Collaboration

Joint Commission on Accreditation of Healthcare Organizations (1990, May). Hospital accreditation survey. Oakbrook Terrace, E Author.

Joint Commission on Accreditation of Healthcare Organizations (1992). 2993 accreditation manual for hospitals (Vols. I and 11). Oakbrook Terrace, JL Author.

Joint Commission on Accreditation of Healthcare Organizations (1993, Jan- uary). Hospital accreditation sumey. Oak- brook Terrace, & Author.

Knaus, W.A., Draper, E.A., Wagner, D.P., & Zimmerman, J.E. (1986). An evalua- tion of outcome from intensive care in major medical centers. Annals o f l n t m l Medicine, 104,410-418.

Shortell, S. (1991). Improved management of ICUs saves lives. Journal of Quality Assurance, 23(5), 74.

CE Questions, JHQ22 (Mark your answers on the answer sheet on page 47.) continuing ICE Education

1. To clarify current knowledge, the task force a. recommended a similar com-

mittee structure. b. proposedarevisedSICU/MICU

committee structure. c. reviewed past committee min-

utes and bulletins to analyze the process.

d. avoided communicating with other healthcare disciplines.

2. Key quality characteristics of the SCU committee determined by

the task force included all of the following except a. coordination of issues common

to both units. b. collaboration of involved dis-

ciplines. c. regular attendance at meetings

that start and stop on time. d. activities that affedSICU/MICU

would be reported to two com- mitte€?S.

3. The improvement selected was to a. combine SICU/MICU into one

b. develop a Pareto chart. c. increase charges. d. maintain the current commit-

tee structure. 4. Planning the improvement re-

quired a. filling vacant committee posi-

b. a change in the committee

c. adding quality management

d. establishing a rotating sched-

5. Another improvement in the process included a. a more specific orientation for

interns and residents. b. a simplified medication ad-

ministration process. c. an improved admitting pro-

cess. d. a reduced length of stay.

committee.

tions.

structure.

staff to the committee.

ule for meetings.

for organizations that want to advertise job openings.

Contact Kerry J. Thomas at the NAHQ office for details: 708/966-9392.

Customer Satisfaction continuedfrom page 9

CE Questions, JHQ21 (Mark your answers on the answer sheet on page 47.)

1. The systems theory of problem

a. is used best with tests con- ducted retrospectively.

b. should be restricted to one level.

c. relies on qualitative research tools.

d. involves understanding cause and-effect relationships.

2. Customer issues of concern are

solving

a.

b.

C.

d.

3. A

unsolicited verbal or written complaints. of little concern to the organi- zation. staff-perceived customer com-

best ignored by the adminis- tration. Droblem resolution that

plaints.

pr&ed beneficial at GRHC was a. staff education and developing

policies and procedures. b. use of E-mail. c. revision of advance directives

d. improving the application pro- policy.

cess.

4. Using a systems approach over the past year, GRHC has had an overall client satisfaction rating in the range of a. 92%. b. 89%. C. 99%. d. 90%.

5. It is important to account for unanswered questions in surveys a. to identify the respondents to

the questionnaire. b. to ensure the reliability of the

values obtained. c. as this will identify trends. d. to ensure that appropriate ac-

tions are taken.

30 = JHQ July/August 1994 Vol. 16, NO. 4