1. Healthcare Operations Management © 2008 Health Administration Press. All rights reserved. 1

2. Chapter 11 Process Improvement and Patient Flow

3. 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

4. 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.

5. 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.

6. 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)

7. 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 60–70 percent of patients were receiving active care.

8. 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

9. 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

10. 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.

11. Healthcare Operations Management © 2008 Health Administration Press. All rights reserved. 11 Vincent Valley Hospital and Health System Emergency Department (ED) Patient Flow Process Map

12. 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.

13. 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.

14. Healthcare Operations Management © 2008 Health Administration Press. All rights reserved. 14 Little’s 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

15. 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

16. 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)

17. 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)

18. End of Chapter 11