Healthcare Operations Management

2008 Health Administration Press. All rights reserved.

1
Chapter 11
Process Improvement
and
Patient Flow

Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
3
Process Improvement (PI)
Measuring and improving systems
Systems
Processes
Subprocesses
Tasks
PI tools can be used at any level
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
4
PDCA
Plan: Define the entire process to be improved using
process mapping. Collect and analyze appropriate
data for each of element of the process.
Do: Use process improvement tool(s) to improve the
process.
Check: Measure the results of the process
improvement.
Act to hold the gains: If the process improvement
results are satisfactory, hold the gains. If the results
are not satisfactory, repeat the PDCA cycle.
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
5

PDCA Graphically



1. Plan your
corrective action.
2. Do it. 3. Check to make sure
it is working properly.
4. Act to maintain it.
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
6
Flow
Theory of swift, even flow
Process is more productive as:
Speed of flow increases
Variability of process decreases
Example: advanced access
Decreased time from request to appointment
(speed)
Decrease in no-shows (variability)
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
7
Patient Flow
Hospital flow is negatively affected by
variability in scheduled demand:
Surgical admissions (scheduled)
Medical admissions (emergency)
When surgical admissions have high
variability, backlogs and waiting occur
NHS study showed that at 90 percent
occupancy, only 6070 percent of
patients were receiving active care.
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
8
Actions to Improve Inpatient Flow
Establish uniform discharge time
Write discharge orders in advance
Centralize oversight of census and
patient movements (care traffic control)
Change physician rounding times
Coordinate with ancillary departments on
critical testing
Coordinate discharge with social services
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
9
Why Use Process Mapping?
Provides a visual representation that
offers an opportunity for process
improvement through inspection
Allows for branching in a process
Provides the ability to assign and
measure the resources in each task in a
process
Is the basis for process modeling via
computer simulation software
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
10
Process Mapping Basics
Assemble and train the team.
Determine the boundaries of the process (where does
it start and end?) and the level of detail desired.
Brainstorm the major process tasks and list them in
order. (Sticky notes are often helpful here.)
Once an initial process map (also called a flowchart)
has been generated, the chart can be formally drawn
using standard symbols for process mapping.
The formal flowchart should be checked for accuracy
by all relevant personnel.
Depending on the purpose of the flowchart, data may
need to be collected or more information may need to
be added.
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
11



Triage -
Financial
Complexity
End
Patient
Arrives
at the ED
Triage -
Clinical
Intensive
ED Care
Low
High
Private
Insurance
Admitting
Private
Insurance
Admitting
Medicaid
Waiting
Waiting
Yes
No
Nurse
History/
Complaint
Exam/
Treatment
Discharge Waiting Waiting
Vincent Valley
Hospital and
Health System
Emergency
Department
(ED) Patient
Flow Process
Map
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
12
Process Metrics
Capacity of a process: the maximum possible
amount of output (goods or services) that a process
or resource can produce or transform.
Capacity utilization: the proportion of capacity
actually being used. It is measured as actual
output/maximum possible output.
Throughput time: the average time a unit spends in
the process. It includes both processing time and
waiting time and is determined by the critical (longest)
path through the process.
Throughput rate: the average number of units that
can be processed per unit of time.
Service time or cycle time: the time to process one
unit. The cycle time of a process is equal to the
longest task cycle time in that process.
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
13
Process Metrics (cont.)
Idle or wait time: the time a unit spends waiting to be
processed.
Arrival rate: the rate at which units arrive at the
process.
Work-in-process (WIP), things-in-process (TIP),
patients-in-process (PIP), or inventory: the total
number of units in the process.
Setup time: the amount of time spent getting ready to
process the next unit.
Value-added time: the time a unit spends in the
process where value is actually being added to the
unit.
Non-value-added time: the time a unit spends in the
process where no value is being added. Wait time is
non-value-added time.
Number of defects or errors.
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
14
Littles Law
Average throughput time =

People (or things) in the system/Arrival rate

Example
Clinic serves 200 patients in an 8-hour day (or 25 patients per hour).
Average number of patients in waiting room, exam rooms, etc., is 15.
15 patients/25 patients per hour = 0.6 hours in the clinic

Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
15
Basic Process Redesign Techniques
Eliminate non-value-added activities
Eliminate duplicate activities
Combine related activities
Process in parallel
Use load balancing
Use decision-based, alternative process
flow paths
Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
16
Basic Process Redesign Techniques
(cont.)
Improve processes on the critical path
Use information feedback and real-time
control
Ensure quality at the source
Let customers (patients) do the work
Identify bottlenecks and optimize
(Theory of Constraints)

Healthcare Operations Management
2008 Health Administration Press. All rights reserved.
17
Advanced Process Redesign Techniques
Six Sigma (Chapter 8)
Lean (Chapter 9)
Discrete event simulation (Chapter 10)


End of Chapter 11