1 2 Root Cause Analysis The Problem: Customer Service Representatives not resolving issues on a first time call Why is it happening? 1. Not properly trained: why is that? 2. Were only trained to handle minor issues: why is that? 3. Used to pushing complicated issues to other areas: why is that? 4. Leaving subscribers and providers on hold for long periods of time: why is that? 5. This in turns leaves claims inventory high with unresolved issues. Action to take: Customer Service Representatives needs to be willing to be trained on complex issues to be able to help members/providers when they call in. Another action would be for the company to set up a number of different phone lines to certain claim representatives to help when a customer service rep has issues. This will reduce the number of calls customer service receives, no more holding times for members/providers, and will also reduce the inventory in claims. Root Cause Analysis xxx MHA 505 Running head: ROOT CAUSE ANALYSIS 1 SYSTEMS DIAGRAM 2 Record documentation contains spelling and grammar errors making it difficult to understand and causing unnecessary client escalations. why R&D budget was spent on items that would prevent extra work for staff such as rules engines. why Microsoft Word also does not correctly identify and spell some medical terms correctly. We also use abbreviations and Word does not recognize common medical abbreviations. why why why why why Three significant system enhancements in 2016-2018 took priority over adding a spelling and grammar check. Development resources previously denied for this project. There is no integrated spelling or grammar check in the system Some representatives copy/paste their notes into Microsoft Word to check spelling and grammar, but there often is not enough time to complete this and make quotas, so reps skip this step leaving the grammar and spelling mistakes in the notes. English is the second language for overseas employees, so grammar and spelling mistakes are common due to where the work is being performed Invest in development time to build a spelling and grammar check into the system for the precertification team. Incomplete clinical documentation faxed to carriers on the first submission. To counter the lack of medical experience athenahealth previously provided extensive new hire training to the offshore team. Due to the recent influx in the number of new offshore employees, the length of the new hire training was reduced to accommodate more classes and onboard the staff faster. why why why why why We partner with an offshore vendor that has high customer service ratings but most of the employees have technology, bu.

1. 1
2
Root Cause Analysis
The Problem: Customer Service Representatives not resolving
issues on a first time call
Why is it happening?
1. Not properly trained: why is that?
2. Were only trained to handle minor issues:
why is that?
3. Used to pushing complicated issues to
other areas: why is that?
4. Leaving subscribers and providers on
hold for long periods of time: why is that?
5. This in turns leaves claims
inventory high with unresolved issues.
Action to take: Customer Service Representatives needs to be
willing to be trained on complex issues to be
able to help members/providers when they call in. Another
action would be for the company to set up a number of
different phone lines to certain claim representatives to help

2. when a customer service rep has issues. This will reduce the
number of calls customer service receives, no more holding
times for members/providers, and will also reduce the inventory
in claims.
Root Cause Analysis
xxx
MHA 505
Running head: ROOT CAUSE ANALYSIS
1
SYSTEMS DIAGRAM
2
Record documentation contains spelling and grammar errors
making it difficult to understand and causing unnecessary client
escalations.

3. why
R&D budget was spent on items that would prevent extra work
for staff such as rules engines.
why
Microsoft Word also does not correctly identify and spell some
medical terms correctly. We also use abbreviations and Word
does not recognize common medical abbreviations.
why
why
why
why
why
Three significant system enhancements in 2016-2018 took
priority over adding a spelling and grammar check.
Development resources previously denied for this project.
There is no integrated spelling or grammar check in the system
Some representatives copy/paste their notes into Microsoft
Word to check spelling and grammar, but there often is not
enough time to complete this and make quotas, so reps skip this
step leaving the grammar and spelling mistakes in the notes.
English is the second language for overseas employees, so
grammar and spelling mistakes are common due to where the
work is being performed
Invest in development time to build a spelling and grammar
check into the system for the precertification team.
Incomplete clinical documentation faxed to carriers on the first
submission.

4. To counter the lack of medical experience athenahealth
previously provided extensive new hire training to the offshore
team. Due to the recent influx in the number of new offshore
employees, the length of the new hire training was reduced to
accommodate more classes and onboard the staff faster.
why
why
why
why
why
We partner with an offshore vendor that has high customer
service ratings but most of the employees have technology, but
no medical office experience.
Many of the reps have no clinical experience, so they do not
understand what is being requested from a carrier when it comes
to clinical documentation.
Patients may be seen for multiple visits each with different
medical needs, so the reps pull incorrect documentation or
submit only the last visit to the carrier.
Representatives are confused on what medical records need to
be pulled from a patient’s record and think they are pulling the
correct documents.
Utilize stateside staff to help cover work queues and rotate
offshore employees in for additional training on what clinical
documentation from athenaclinical to submit to carriers based
on the CPTs ordered.
Recent delays in imaging order turnaround time.

5. why
English is a second language for most offshore reps, so when
the athena rep can’t answer the payer’s questions, we must fax
over clinical documentation. This process results in longer
turnaround times for precertification decision.
Language barriers between rep at carrier and athena offshore
rep.
why
why
why
why
why
athena terminated the contract with one offshore center recently
and had been ramping up staffing in the remaining offshore
center to replace the number of lost employees.
The recent number of new hires have resulted in faster
onboarding and less training for offshore staff.
The number of requisitions in the queue is 2 times larger than
usual.
Representaives are spending an average of 15 minutes per order
on the phone.
Representatives struggle with finding and interpreting
information when nurses at the payer ask them medical
questions found on clinical documents on the patient's record.
Part 1 - Use stateside staff to help relieve queue volumes. Part
2- Complete additional training for offshore staff on clinical
information.

6. Gemba Walk
Shan Purdy
MHA/505
June 4, 2019
Instructor Tesa Brown
Running head: GEMBA WALK
2
GEMBA WALK
5
Gemba Walk
BlueShield Company is an insurance company which offers such
services as life, personal and health insurances to its customers.
The mission of the company is to offer unparalleled insurance
services to customers, for the least possible fees and in the most
efficient and satisfactory manner. The vision of the company is
to become a leading company in the provision of insurance
services and to become a pacesetter in customer satisfaction and
organizational culture.
To find out whether or not the mission and vision of the
company are being adhered to, I undertook a Gemba Walk
within our organizational head offices. True to the definition of
a Gemba Walk, I aimed at being at the place where the real
work was being done, to see areas of strengths as well as those

7. that need to be improved (Womack, 2013). It also gave me an
opportunity to ask why things were running the way they were.
As such, the main focus was placed on the customer service
department. It should be noted that most of the communication
between customers and the company is mainly not done face to
face but rather through phone calls as well as emails. The
company has therefore built a customer service center where
these calls are answered or made and emails replied to
customers when need be. The company places a lot of
importance on this department given that it is the one that can
make or break the relationship between it and customers. I set
out into the office to see and hear what happens there.
Specifically, I laid special importance on the times that it took
our employees in the customer care department to respond to
phone calls and to emails from our clients.
When taking the Gemba Walk, I was able to record a number of
observations. The assistants whose responsibility is basically to
reply phone calls were almost always on their phones caught
between the calls from our clients mostly in the afternoons
when they were sometimes forced to hasten their services in
order to serve as many clients as possible. This means that the
amount of time that it took to respond to clients was shorter
than they would have liked. In fact, some customers were forced
to leave messages, something that the company strives to make
sure that it does not happen. In the morning hours though, the
company employees often found themselves with less pressure,
with the work being making calls themselves and replying to
email messages from our clients. Those with the sole
responsibility of writing and replying emails sent to the
company from our clients often found themselves without much
work to do most of the time since most clients preferred calling
the company to have one thing or another sorted out rather than
send emails. Therefore, those in the emailing department had
very little work to do until at the end of the month where
customers are emailed reports of the services that they have
received from the company. As such, a lot of valuable time was

8. found to be wasted by the employees working in this
department.
From the observation, the average waiting time for calls was
found to be 6 minutes which is way above the 1-minute
threshold that the company aims to maintain. A lot of customers
are forced to wait for their needs to be attended to by our
assistants and this is a problem for the company because it is
one potential cause of customer dissatisfaction. At the same
time, the phone call assistants find themselves pressured at
times which definitely affects the kind of services that they give
to customers (Gesinger, 2016). In times when the pressure is
raging high, call times are forced to be largely reduced which
may adversely affect the quality of service offered to customers.
The emailing assistants, however, find themselves with ample
time that is unproductive (Hafey, 2014). With about four
assistants, there is hardly enough work to make sure that all of
them are work in a manner that resources are used efficiently.
Simply put, it is a call times are forced to be largely reduced
which may adversely affect the quality of service offered to
customers. The emailing assistants however find themselves
with ample time that is unproductive (Hafey, 2014). With about
four assistants, there is hardly enough work to make sure that
all of them are work in a manner that resources are used
efficiently. Simply put, it is a case of a lot of pressure that has
to be handled by assistants handling phone calls while there is
just enough work to effectively waste resources for the
assistants handling emails. To solve this problem, the company
can train assistants to handle both phone calls and emails to
make sure that resources are not wasted.
In a nutshell, the following were the key takeaways from the
Gemba Walk:
i. There are a lot of resources wasted for employing four
emailing assistants while there is hardly enough work for them
ii. Waiting times for calls are very long meaning that client
service is far from satisfactory.
iii. There is more work for the phone call assistants can

9. efficiently handle.
iv. All assistants ought to be trained to handle both phone calls
and emails if the issues of undue pressure and client
dissatisfaction are to be resolved.
To streamline customer services and reduce wastage of
resources, new phone call assistants can be hired, all assistants
can be trained in both phone call and email handling and the
groups can be molded into a single department in the short run.
In the long run, the company can make use of new technology
especially chatbots to offer customer services (Bremer, 2015).
Once these opportunities are explored, the company will surely
be able to live up to its mission and achieve its mission in the
long run.
References
Bremer, M. (2015). Walk the Line. Quality Progress, 48(3), 18.
Gesinger, S. (2016). Experiential learning: using gemba walks
to connect with employees. Professional Safety, 61(02), 33-36.
Hafey, R. (2014). Lean safety Gemba Walks: A methodology for
workforce engagement and culture change. Productivity Press.
Womack, J. (2013). Gemba Walks: Expanded 2nd Edition. Lean
Enterprise Institute.