Healthcare Operations Management 1

© 2008 Health Administration Press. All rights reserved.

 Chapter 11

Process Improvement
and
Patient Flow
 Process Improvement (PI)

• Measuring and improving systems

• Systems
– Processes
• Subprocesses
– Tasks

• PI tools can be used at any level

Healthcare Operations Management 3

© 2008 Health Administration Press. All rights reserved.
 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 4

© 2008 Health Administration Press. All rights reserved.
 PDCA Graphically

1. Plan your
4. Act to maintain it. corrective action.

3. Check to make sure 2. Do it.

it is working properly.

Healthcare Operations Management 5

© 2008 Health Administration Press. All rights reserved.
 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 6

© 2008 Health Administration Press. All rights reserved.
 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.

Healthcare Operations Management 7

© 2008 Health Administration Press. All rights reserved.
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 8
© 2008 Health Administration Press. All rights reserved.
 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 9

© 2008 Health Administration Press. All rights reserved.
 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 10

© 2008 Health Administration Press. All rights reserved.
 Intensive
ED Care
Vincent Valley
Hospital and
High
Health System
Patient
Triage -
Emergency
Arrives Complexity
at the ED
Clinical Department
Low
(ED) Patient
Flow Process
Waiting
Admitting Map
Private
Insurance

Yes

Triage - Private
Waiting
Financial Insurance

No

Admitting
Medicaid

Nurse
Exam/
History/ Waiting Waiting Discharge End
Treatment
Complaint

Healthcare Operations Management 11

© 2008 Health Administration Press. All rights reserved.
 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 12
© 2008 Health Administration Press. All rights reserved.
 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 13
© 2008 Health Administration Press. All rights reserved.
 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

Healthcare Operations Management 14

© 2008 Health Administration Press. All rights reserved.
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 15

© 2008 Health Administration Press. All rights reserved.
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 16

© 2008 Health Administration Press. All rights reserved.
Advanced Process Redesign Techniques

• Six Sigma (Chapter 8)

• Lean (Chapter 9)
• Discrete event simulation (Chapter 10)

Healthcare Operations Management 17

© 2008 Health Administration Press. All rights reserved.
End of Chapter 11