How to empower revenue cycle employees to solve problems: a case study of Mass General Brigham 

In traditional revenue cycle structures, managers move up the hierarchy because they are good at getting work done and solving problems. However, a successful continuous improvement culture needs not only effective managers but also empowered front-line staff who can share their insights and expertise.

With this premise in mind, leaders at Mass General Brigham (MGB) in Somerville, Mass., embarked on an initiative in 2022 to develop an in-house program that would promote a continuous improvement culture within its hospital revenue cycle operations team. As of February 2025, nearly 18,000 hours of work had been saved since the program’s inception.

The initiative was led by MGB’s then director of the enterprise process improvement team (one of the authors of this article, now executive director of the MGB project management office), who worked closely with her team and with the vice president of revenue cycle on designing and implementing the program.

Eventually dubbed “Everybody Solves Problems” (ESP), the program fosters an engaging environment in which all individuals, at all levels of the organization, are continuously empowered to share and implement ideas aimed at improving their work and outcomes. This empowerment boosts employee morale and engagement, making them feel valued and trusted by MGB and instilling in them a sense of ownership and accountability, which can drive better performance and financial outcomes.

The program also was anchored around Lean management methodology, which aims to improve the quality and efficiency of services by eliminating waste.

Key steps in designing the program included:

• Creating program goals and objectives
• Securing buy-in from key leaders and executives, including the CFO
• Identifying two dedicated program managers to facilitate design of the program methodology and implementation
• Analyzing various deployment model strategies to find the right one
• Assessing ongoing maintenance and sustainment support needs

A 3-phase process

The dedicated design work culminated in a seven-month, three-phase program development process, with ESP as its brand. Program implementations were organized by the manager unit, with a focus on staff leadership to identify problems and brainstorm solutions.

The set-up phase. During set-up, two program facilitators worked closely with three front-line managers who were selected for the pilot cohort to develop metrics and targets for improvement. The facilitators also helped to train all levels of leadership in each manager’s hierarchy branch — including the vice president, directors, managers and supervisors — on how to roll out and sustain ESP for their teams.

Training topics included the importance of analyzing metrics, developing leadership skills, building problem pipelines and solving problems for creating engagement and tracking impact. Thirty front-line staff attended training, where they were introduced to Lean tools for identifying inefficiencies and waste, prioritization tools and the Plan-Do-Study-Act (PDSA) principles.

The deployment phase. The heart of the program implementation was the deployment phase, during which one of the program facilitators worked with the three pilot teams within the revenue cycle department for five months to cement the new thought processes in an empowered problem-solving culture. Staff received how-to guidance on:

• Preparing for and holding weekly problem-review meetings
• Setting priorities for addressing problems
• Performing PDSA activities

The sustainment phase. In the weekly review, the teams would use an impact-and-effort matrix to prioritize what to tackle, considering factors such as team productivity metrics, financial impact, customer satisfaction and employee engagement. A problem could either be solved, escalated up the team hierarchy or left on the pipeline if not a priority.

The teams used the PDSA approach for problem solving and documented their work on a Lean problem-solving document with a slightly simplified structure. All materials were accessible to the teams online, making it easy for anyone to contribute to the team discussion by providing updates, introducing new concerns and documenting improvement progress.

ESP shows steady workflow improvements

Together, the three revenue cycle teams saved more than 6,600 hours due to workflow improvements achieved after the initial pilot implementation rounds in 2022 and 2023 and the completion of several successful problem-solving efforts. And in 2024, the expanded program resulted in a savings of more than 11,000 hours.

Program leaders reflected on successes and opportunities to enhance the program, and they collected feedback from program participants to help drive further enhancements.

On assessing the program’s initial implementations, the program leaders identified the following lessons learned.

1 Keep it simple and provide templates. In the first design, recognizing that there are many valid approaches to problem solving, the program leaders provided multiple tools that serve the same purpose (e.g., a fishbone diagram and the 5-whys template), in case the teams found one tool was more useful than another. The leaders quickly realized this approach was overwhelming and needed to be simplified.

For example, they pared down the traditional Lean problem-solving document and added step-by-step instructions for the problem-solving process. They also created a playbook to help the facilitators plan their meetings, including sample agendas and brief instructions for all the tools and activities.

2 Tell them once, tell them twice and tell them again. All change methodologies underscore the importance of consistent and recurrent communication to promote a desired mindset. For the ESP project, communication included the following:

• Discussions at town halls and leadership meetings.
• Refinement of the revenue cycle mission and vision to explicitly link to ESP.
• Inclusion of continuous-improvement language in job descriptions.

3 Slice and dice data to create visibility and accountability. This process involved two steps:

• Collect data quarterly to track engagement and impact (e.g., problems identified, problems solved, hard and soft impacts).
• Provide roll-up and roll-down reports so leaders can see team-based and collective impacts.

The regular cadence and elevated level of visibility allowed leaders to have informed discussions with individual managers, ensuring their accountability for engaging in and tracking their problem solving.

4 Coaching is not optional. With the first cohort of teams, managers could opt out of coaching. On collecting data and performing check-ins, however, program leaders soon found these early teams were too reliant on the manager to identify problems and run the problem-solving meetings, impairing the teams’ ability to identify root causes of problems. Making coaching mandatory ensured front-line staff were both empowered and encouraged to engage more robustly in the P (planning) and S (study) of the PDSA cycle.

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ESP program’s success spurs widescale rollout

In 2024, MGB’s hospital and physician revenue cycle activities were consolidated into one enterprise structure, creating a larger scale operational footprint to consider for the ESP program. Program leaders also faced the tall task of normalizing culture in new enterprise revenue cycle teams formed as part of the organizational consolidation.

The success of the pilot implementations of ESP prompted MGB’s executive leaders to pursue a wide-scale rollout of the program, both to build on the performance gains from the pilot and to support ongoing empowerment and growth of employees.

The program’s leadership was expanded to include MGB’s new executive director of revenue cycle performance management (one of the authors of this article), and four additional staff specialist roles were created to support the program’s efforts. An ambitious three-year timeline was set for extending the base program to all staff engaged in revenue cycle work.

With the accelerated timeline for deployment, ESP program leaders were encouraged to incorporate pilot learnings and determine how the seven-month program could be delivered more efficiently. Through internal design sessions and evaluation of impact drivers, the program leaders made the following program adjustments.

1 Streamline coaching time. To keep coaching at the forefront of the program, leaders analyzed coaching practices to determine the optimum timing and delivery and identified the opportunity to reduce coaching support from five months to three months.

2 Smooth demand and capacity management. All revenue cycle teams were placed on slotted scheduling for deployment based on assessment of team readiness and the flow of annual business activities. Capacity models for program resources were analyzed and adjusted to increase the consistency of slot capacity management.

3 Increase leadership engagement. With the targeted reduction in the amount of coaching by ESP specialists, leaders supporting front-line managers would have an increasingly vital role as coaches and cheerleaders for the ESP work in a streamlined model. To accommodate this change, the revised program model incorporated an additional focus on leadership training.

4 Provide data training for front-line leaders. Program leaders decided to bring front-line leaders into the data work earlier, providing them with training support that would allow them to capture metrics more easily and consistently than in the pilot model.

Future plans to build on program successes

Deployment of the revised ESP model began in 2025. Revenue cycle leaders have leveraged the program to foster sustainable improvement and employee engagement in their teams.

In the near future, MGB executives hope to expand the program’s footprint beyond the revenue cycle to deepen its impact and foster a continuous improvement mindset across the health system. 

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