A Toolkit for Redesign in Health Care: Final Report

Redesign Planning Steps

After the decision on the need for system redesign was made, steps were taken to plan for process redesign as follows:

  1. Assess readiness for major redesign.
  2. Establish the perspectives for redesign.
  3. Create a structure for the redesign process.
  4. Gather external data:
  5. Gather internal data:
  6. Choose tools to enable redesign implementation:

It should be noted that this planning process took place over a 12-month period. The duration of this planning process underscores the need for a well thought-out sequence of events, which must be accomplished before a major comprehensive redesign/system transformation effort can begin. 

Step 1: Assess Readiness for Major Redesign

Before launching a major redesign effort the leadership should address the readiness for embarking on hospital redesign or system transformation. This can be assessed in part by asking and answering the questions below:

  • What other redesign projects have been completed?
  • What were the lessons learned from these projects?
  • Does the workforce believe that there were benefits from implementing these projects?
  • Is there a compelling reason(s) for redesign?
  • Are top administrative, physician, and nursing leadership committed to redesign?
  • Can champions be identified and developed?
  • Is the culture committed to data and information sharing?
  • Does the workforce have the needed skills and tools to accomplish redesign?
  • Does the system have the resources to undertake the redesign process?

It is important for both leadership and employees to identify and examine past redesign efforts. Once past redesign projects are identified, those responsible for managing the projects should develop a document which:

  • Describes project goals.
  • Determines if goals were achieved.
  • Describes the barriers to achieving the goals.
  • Delineates the factors contributing to success.
  • Identifies lessons learned.

Sharing these past projects with everyone creates a sense that the organization has experience with successful redesign projects and therefore can successfully tackle system redesign. For example, Denver Health's previous redesign efforts include improvements in both business and clinical processes. Business redesign efforts included:

  • The transition of the entire system from a department of city government to an independent government entity.
  • The development and implementation of a comprehensive information technology strategy for the entire hospital system.

Clinical redesign efforts included:

  • Complete restructuring and integration of behavioral health with other system components.
  • Redesign of primary care processes.
  • Implementation of an open access system.
  • Diabetes disease management system.
  • Structured community outreach effort.

At the beginning of this current redesign effort the participants in these past redesign efforts delineated the lessons learned. Many of these past lessons were validated as the current planning process evolved:

  • A compelling reason to change is needed.
  • Redesign must address issues people are battling. For providers, compelling reasons are:
    • Improving their ability to provide care.
    • Improving the quality of patient care.
  • All stakeholders need to be at the table.
  • Frontline people need to be involved and heard.
  • A leader for the change is crucial.
  • Leaders of change need the skill set to define issues and accomplish the change.
  • Consultants can be very helpful in providing expertise, but internal people need to lead the change.
  • Balance is needed between acquiring data to define the problem, implementing the intervention, and evaluating outcomes within a short time frame.
  • The need for cultural change must not be underestimated.
  • A well thought-out communication plan is necessary.
  • Key message must be something everyone can understand.
  • Expect and communicate failures, holdups, etc. as well as successes.
  • Education and training are essential.
  • Appropriate infrastructure must be available.
  • Education and training are essential.
  • Sustainability requires transformation; inability to go back to the old way is the best approach to sustainability.

Many compelling reasons for change were identified. For management, a compelling reason for change is often financial, but for providers the most compelling reason is improvement in patient care or the process by which they can provide care. (This will be discussed further in Step 2.)

Both top hospital management and clinical leaders must be engaged for successful hospital system redesign; the broader in scope the project the higher the level of staff who must be engaged in the redesign process. (This will be discussed in more detail in Step 3.)

Hospital system transformation depends on democratization of data; the more comfortable the organization is with sharing and understanding data, the easier transformation will be. (This will be discussed further in Steps 4 and 5.)

It appears that most health care workers do not have the necessary skill set for implementing major redesign. Therefore, the needed skills and tools must be identified and provided. (This will be discussed in more detail in Step 6).

The system must have and be willing to commit sufficient resources to bring a project to a pre-determined endpoint. Failure to do this will undermine future efforts. 

It may not be necessary to answer all of these questions on readiness before beginning the hospital redesign process, but there should be plans to quickly address all or most of these issues.

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Step 2: Establish the Perspectives for Redesign

It is valuable to establish perspectives from which the redesign process will be viewed. These perspectives will serve as guides to the redesign effort and will help focus process changes. 

Figure 1 served as a template of the perspectives for redesign at Denver Health and has helped guide the transformation planning effort. Health care systems are very complex, and the processes of care are so interrelated that multiple concurrent perspectives seem both valuable and necessary for successful redesign. For system-wide transformation, the perspectives for redesign and the areas of activity should include: 

  • Quality.
  • Safety.
  • Customer service.
  • Efficiency.
  • Architecture/physical environment.
  • Workforce development, including physician development.

Figure 1. Perspectives for Transformation

Figure 1 shows the perspectives from which to drive transformation. They are: architecture/environment, quality, customer service, workforce development, patient safety, and efficiency. The culture of an organization is represented by an oval. Within the oval called Culture, each perspective is presented in a box beginning with architecture/environment at the top and proceeding in order clockwise with separate boxes for quality, customer service, workforce development, patient safety and efficiency.  The dotted oval inside the larger Culture oval surrounds and touches each of the perspective boxes, as culture is important to all six perspectives. Information Technology sits below the Culture oval with arrows emanating up to the oval, signifying that information technology supports the six perspectives encapsulated by Culture. Transformation emanates from all of this indicating that all of these boxes are important ingredients to system transformation. The broken lines and the dotted oval represent the feedback loops between and among the perspectives. For example, using quality as a perspective can result in transformations in processes that not only improve quality but also improve customer service.

Figure 1 shows that architecture, quality, customer service, workforce development, patient safety and efficiency all are perspectives from which to drive transformation. Each of these perspectives creates feedback loops between and within each perspective, represented by the dotted circle touching each of the perspectives and the broken line emanating from transformation back to the perspectives. For example, utilizing quality as a perspective can result in transformations in processes that not only improve quality but also improve customer service. All of the perspectives are surrounded and embedded in the culture of the organization. 

The process transformations driven from these perspectives are supported by information technology. Information technology is not the driver but rather the facilitating mechanism for achieving the desired change. However, it should be noted that Denver Health already has a sophisticated information technology system in place. 

Based on the research conducted for this project, it appears that other health care systems that have undertaken redesign/system transformation have adopted some of these perspectives and have used tools that translate these perspectives into action.For example:

  • Virginia Mason Medical Center used the Toyota Production System, or Lean, and appears to have focused on efficiency.
  • The Department of Veterans Affairs health care system appears to have utilized the perspective of safety to drive its transformation. Six Sigma tools can be used to implement redesign from this perspective.
  • Intermountain Health Care of Salt Lake City and those institutions engaged in the Institute for Healthcare Improvement's Pursuing Perfection projects appear to have adopted the perspective of quality to drive system change.
  • Baptist Hospital, Inc. in Pensacola, Florida, appears to have primarily utilized the perspective of customer service to implement system transformation. Utilization of the Baldrige criteria appears to facilitate this approach.
  • The Planetree Institute model of patient-centered care includes concepts and new ways to design healing environments in health care systems and focuses on the physical environment for transforming health care delivery.
  • Some institutions that pursue magnet status in nursing appear to focus on workforce development to achieve redesign. To some degree, the use of Clinical Microsystem approaches which emphasize team functioning is a workforce development perspective.

A number of these tools are discussed in Step 6

Clearly, these perspectives may overlap both in concept and outcome. Keeping all these perspectives in focus as one begins redesign of health care systems will help prevent suboptimization. For example, if the redesign initiative focused solely on efficiency, this could negatively affect customer service or workforce development. 

It is important to remember that system redesign or transformation must be embedded in the culture of the organization as reflected in Figure 1. Establishing an organizational culture committed to redesign or transformation cannot be underestimated. There are many approaches that help create this culture. These include, but are not limited to:

  • Giving the project an identity.
  • Communicating regularly with the workforce regarding the need for change.
  • Communicating the progress and impact of redesign efforts.
  • Actively engaging the workforce in the process of redesign.
  • Training the workforce to use tools that empower them to participate in the change.
  • Meaningfully engaging the leadership.

Jonkoping County Council in Sweden, one of the leaders in health system redesign and transformation, named a major redesign project "The Esther Project," thereby providing a human face to transforming the care process from primary care through hospital care.The Institute for Healthcare Improvement projects were called Pursuing Perfection. At Denver Health, the redesign project was entitled "Getting it Right: Perfecting the Patient Experience."

As in all change process efforts, communication is necessary. The communication approaches found helpful at Denver Health were:

  • Regular columns in the employee newsletter written by the Chief Executive Officer (CEO).
  • Lectures and discussions on the project to leadership, physicians, and middle managers.
  • An employee newsletter devoted to redesign.
  • A specific intranet site devoted to "Getting It Right: Perfecting the Patient Experience."
  • Employee forums with the CEO.
  • Employees creating a code of behavior.

These perspectives were proposed early in the course of the project and confirmed by the review of the literature, discussions with the External Steering Committee, and site visits. These approaches are discussed in detail in Step 4.

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Step 3:  Create a Structure for the Redesign Process

Three components are needed in creating a structure for redesign:

  • Establishing a point person to lead redesign.
  • Developing a team to oversee the planning approach.
  • Developing a broad-based internal group of leaders and champions.

The higher in the organization the lead person, the more likely that the redesign effort will be operationalized and sustained. All employees will understand the importance of this effort when it is led by a person of responsibility for the hospital system. At Denver Health, the CEO/Medical Director leads the redesign project.

A core project team must also be formed. This group carries out many of the actual approaches used.Its composition depends heavily on the scope of the project. However, regardless of scope, one person must assume the role of project manager.The core team must include individuals with the competency to gather, analyze, and interpret the data. The addition of an industrial engineer or operations management engineer is an important member of the project team. The Denver Health core team included:

  • Industrial engineer.
  • CEO/Medical Director.
  • Value Analysis Coordinator (a nurse with clinical expertise).
  • Director of Health Services Research.
  • Data and research analysts.

It is equally important to have broad-based operational support through the creation of an Internal Steering Committee whose members include providers and administrators at various levels of leadership in the organization and in many departments of the hospital system. This group can become the leaders and champions of redesign throughout the organization. 

The Internal Steering Committee should review information gathered at various stages of the redesign process, determine whether the information is valid and identify potential strategies for improvement. The members of this committee will also be key in assisting with the cultural change within the organization. Members can include:

  • Chief Executive Officer.
  • Chief Operations Officer.
  • Chief Information Officer.
  • Chief Financial Officer.
  • Chief Nursing Officer.
  • Chief of Human Resources.
  • Medical Director.
  • Chief of the medical staff.
  • Clinical department chairs.
  • Director of Quality Improvement.
  • Nursing Administration.
  • Pharmacists.
  • Laboratory Director.
  • Materials Management Director.
  • Nursing staff.
  • Physician staff.

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Step 4: Gather External Data

There is always wisdom in learning from others. We found there were three helpful approaches in learning from others:

Conduct a Review of the Literature 

Reviewing both the health care and non-health care redesign literature is both necessary and important.  A separate literature review, focused on redesign efforts, was conducted (Appendix A). This review utilized the six perspectives of quality, safety, customer service, efficiency, architecture/environment, and workforce development illustrated in Figure 1. Gathering this information is helpful in understanding not only current and past redesign initiatives, but also the applied theory behind the tools that have been used.

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Form an External Steering Committee

During the beginning stages of Denver Health's system transformation, it was beneficial to create an External Steering Committee consisting of leaders in health care and other industries. This committee included representatives from the following:

  • Hospitality industry.
  • Supply chain management industry.
  • Information technology industry.
  • Professional health care organizations.
  • Architecture firms.
  • Quality organizations.
  • Regulatory entities.
  • Payers.
  • Other health care organizations.

The non-health care members provided different perspectives in reviewing data and different approaches for achieving meaningful redesign.These members had specific experience related to successful redesign and process improvement. Health care representatives provided insight into strategies they had tried and lessons they had learned from health care improvement projects.

This external group met quarterly and members had individual quarterly telephone calls with the CEO. The quarterly committee meetings were structured half-day meetings chaired by the CEO. The group provided guidance regarding alternative approaches and insights into data gathering and interpretation.

Some illustrative questions posed to the External Steering Committee over the course of the year were:

  • Were the lessons learned from past projects likely to be helpful in guiding the current effort?
  • Which institutions/industries should we consider for site visits and calls?
  • Is our assessment of the lessons learned from these visits the ones which are likely to be helpful in our efforts?
  • What is the ideal balance between training all employees and highly training a subset of employees?
  • Can many small projects lead to system transformation?  
  • How many projects are enough?
  • How do we avoid suboptimization and unintended consequences?
  • What is best way to display and analyze all the process flow data?
  • What system metrics should we use to measure success?

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Conduct Site Visits

If site visits occur, one must ask where to go, whom to send, and what data to collect. It is suggested that site visits or conference calls include both health care and non-health care industries. There is much that can be learned from the non-health care industries, and it is important that they be included. Examples of industries that could be visited or contacted are:

  • Aerospace.
  • Auto.
  • Airline.
  • Information technology.
  • Manufacturing.
  • Distribution or shipping.
  • Service sector.

These industries have developed strategies and approaches to improve quality, efficiency, customer service, and safety.  Some of these strategies and approaches can be applied to the health care environment to redesign health care systems.

Health care systems have not reached the depth and breadth of redesign that other industries have achieved, but it is valuable to visit health care systems as well. Examples of health care institutions that could be visited include those that:

  • Have published or presented major redesign projects.
  • Have won awards.
  • Are magnet hospitals.
  • Are part of the Pursing Perfection project.
  • Have major new construction emphasizing a healing environment or safety.
  • Have pioneered implementation of health information technology.

Nothing can take the place of a site visit to another organization, but much can be gained by a properly structured conference call with a leader in the redesign effort at that institution. The time and dollars saved by having a conference call rather than traveling to another site can be considerable. This is particularly true for some sites that charge fees for visits.

It is recommended the team of individuals participate in the site visits and conference calls. The team should include a clinical person—a physician or nurse, an analyst and/or engineer, and a member of the Internal Steering Committee. These visits not only generate insights, but they also create organizational champions. Of note, when Virginia Mason began its system transformation effort, the entire leadership team was sent to a factory in Japan for 2 weeks to work the lines and learn first hand the Toyota Production System. This hands-on intensive approach has continued.

Before any visit or conference call is undertaken, a standard set of questions should be developed. Form A is a sample list of site visit and conference call questions.

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Step 5: Gather Internal Data

In addition to what can be learned from others, there is also much to learn from one's own organization. Internal data gathering includes the following:

Conduct Employee Focus Groups

Employee focus groups are a method for gathering data, informing the workforce, and helping create a culture to support transformation. These focus groups help to determine the status of the institution from the employee's viewpoint. To accomplish this, it is recommended that standard questions be developed and asked of all employees. Questions can be sent in advance so employees will be ready to contribute, and those who are unable to attend can send in their answers. Sample questions that can be asked of employees are listed in Form B.

It is suggested that the focus groups be divided by categories of personnel, such as housekeeping or respiratory therapists. It is best to conduct clinical and nonclinical groups separately as their issues appear to be quite different. Focus groups were conducted with the following groups of Denver Health employees:

  • Food and environmental services.
  • Ward clerks.
  • Speech Therapists.
  • Occupational therapists.
  • Physical therapists.
  • Laboratory technicians.
  • Licensed practical nurses, health care technicians.
  • Radiology technicians.
  • Respiratory therapists.
  • Pharmacists.
  • Nursing leadership, charge nurses, nurse educators, nurse practitioners, nursing council.
  • Materials management.
  • Engineering.
  • Physicians.

These focus groups should be conducted by someone at the executive level as opposed to immediate supervisors so that ideas and information can be freely exchanged. During the Denver Health project, all the groups were facilitated by the CEO. The meeting should be held at a time that will make it easy for the employees to attend, and the meetings should be no longer than 1½ hours. Minutes should be taken or meetings should be tape recorded so that common themes can be documented.

The minutes can then be sent to supervisors and executives responsible for these areas. Some employee suggestions can and should be acted on immediately even if they are not related to redesign. This immediate response will help build support and reinforce a culture for redesign of a hospital system. It is critically important to inform all participants that redesign will take time; and if they do not see their suggestions acted on immediately, it does not mean they are being ignored.

The cross-cutting issues identified by employees can help prioritize areas for redesign during the implementation phase. At Denver Health, important cross-cutting issues identified to date from the employee focus groups are:

  • Desire for respect from other disciplines and employee groups.
  • Need for effective communication across disciplines.
  • Need for clear clinical escalation processes.
  • Desire for increased autonomy of non-physician health care professionals.
  • Need for process streamlining.
  • Need for greater ease of accessing small equipment such as wheel chairs.

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Conduct Patient Focus Groups

Patient and family focus groups can provide insight into the care provided and other hospital experiences during a patient's stay. It is important to include both the patient and at least one family member involved in the patient's stay because each experiences different aspects of the care processes.

It is suggested that patient/family focus groups consist of no more than 10 patients and 10 family members. This size allows for an expected no show rate of 1-2 families and allows for each family to contribute during the 1½-hour time frame. It is best to recruit patients who have had a recent inpatient stay, such as within the previous 6 months. 

If your institution has a substantial socioeconomic, cultural, and language diversity in the patient population served, you may find it helpful to have different focus groups. For example, Denver Health had four sets of focus groups:

  • Insured English speakers.
  • Uninsured English speakers.
  • Insured Spanish speakers.
  • Uninsured Spanish speakers.

If the patient and family member agree to attend, a confirmation letter can be sent to the patient (Form C), which includes time, place, and directions. Recruiting is also improved if a stipend or gift can be offered. 

It is suggested that a set of standardized questions be developed for the focus group. As noted above, the time should be limited to 1½ hours. Form D provides sample patient/family focus group facilitator questions used at Denver Health.

If the results of these focus groups are expected to be used for research, the protocol will need to be approved by the human subjects institutional review board (IRB). Form E is an example of an IRB-approved patient and family consent form for participation. If the focus group information is to be used for operational purposes only and is not to be published or presented, IRB approval will not be necessary.

Patient focus groups at Denver Health revealed that patients want to be active participants in their care through shared information and shared responsibility. This concern must be considered in redesign.

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Observe Current Processes

It is essential to understand current processes before process redesign can begin. The value of this step cannot be underestimated both in the planning and subsequent choice of tools for the implementation phase.

There are different approaches to depict process data. Each approach can provide different insights and answer different questions. Therefore, experimentation with data presentation is extremely helpful during the redesign planning phase.

Before processes are mapped, it is necessary to identify who will conduct the observations and to define the scope of the process to be observed. It is also necessary to define a beginning, an end, and a methodology for all of the processes to be observed.

The mapping team should include a nurse and analytical person and an industrial or operations engineer from the core analytical team. Observation ability and mapping improve with time; therefore standardization of the data collection tool and consistency in members of the team may be important.

During process mapping, the following information is collected:

  • Name of process.
  • Process owner.
  • Process output/product.
  • Who is involved in delivering the process.
  • Who cares about the process.
  • Extent of the process to be mapped.
  • Activities that define the process.
  • Start point.
  • End point.

The process-flow mapping can be conducted with patients, staff, and ancillary services with the mapping of movement of people, materials, and information.It is possible to map out any process or system in the hospital. It is advisable to meet with the supervisor of the group to be observed before proceeding, both to alleviate concerns about redesign project team staff who will be gathering information from the department or unit and to ask the supervisor what he or she perceives as problems.

It is vital to monitor and document all of the important events during a patient's stay, staff work shift, or the movement of materials and information. Through this information, operational staff will be able to identify the following types of events that can be changed to improve processes:

  • Waste(non-value-added time) such as travel or waiting time, searching, and gathering.
  • Bottlenecks.
  • Redundancies.
  • Points of dissatisfaction.
  • Inefficient use of workforce skills.

Forms F and G are sample data collection tools for mapping process flows. Appendix B illustrates standard definitions for the patient and staff activities in flows.  Standardizing definitions is important to ensure that the observers are documenting activities in a similar manner, which improves the reliability of the observations. 

A selection of business processes, ancillary service processes, and clinical processes will provide an overview of the range of hospital processes. Some of the processes and departments that may be selected for process mapping include:

  • Admission process.
  • Discharge process.
  • Food service.
  • Materials management.
  • Phlebotomy.
  • Pediatric patient stay.
  • Medical patient stay.
  • Trauma patient stay.
  • Obstetric patient stay.

The admission and discharge processes are the patient entry and exit points. The clinical departments may be selected based on the highest volume clinical services. Patients, staff, and materials can be mapped for each of the relevant processes or departments.

Providers selected for observation include nurses, interns, residents, and attending physicians working in pediatric, medical, obstetric, and trauma services. It is helpful to start with a relatively simple process such as food service before attempting more complex processes such as discharge.

Forms H and I are examples of IRB-approved consent forms for participation by staff and patients, respectively. If this information is to be used for operational purposes only and is not to be published or presented, IRB approval will not be necessary.

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Present Data

The information in this section illustrates different ways of presenting data to elucidate different problems. Please note that data as examples of redesign efforts that were undertaken are not presented here; process redesign did not occur in this planning phase. 

Once data are collected, the data can be entered or scanned into a spreadsheet for presentation in a variety of ways to address different questions. Figure 2 depicts a sample of data entries using the primary data collection tool. It shows the type of data collection tool that can be used to gather information for describing processes.

Figure 2. Sample Primary Data Collection Tool: Intern

Figure depicts a sample of data entries using the primary data collection tool in table format.

Note: Data in this figure are for illustrative purposes only.

In this example, the processes of a staff member are being recorded—in this case, an intern—using start time and end time for each activity, who the intern interacted with, and the category of the activity (Appendix B). The description of the activity can take two forms:  an open-ended narrative description and a predefined categorical description. The predefined categorical description is useful for illustrating the data. This data collection tool can also be used to describe patient activities and processes. 

Time and type of activity are the major units in which processes are measured. Some of the ways that the data can be used to depict bottlenecks, redundancies, points of dissatisfaction, and inappropriate work force issues include the following:

  • Pie chart.
  • Pareto diagram.
  • Value stream map.
  • Area diagram.
  • Top-down format.

Pie chart. Pie charts are helpful in providing a visual representation of the relative size of a component compared to the whole and other components. Figure 3 is an example of a trauma resident who was followed during a 24-hour shift. Time is the unit that defines this pie chart, and the different activities define different pieces of the pie.

Figure 3. Sample Pie Chart: Trauma Resident (24-hour Shift)

Pie chart depicting sample activities of a trauma resident during a 24-hour shift, including Down Time, Sleep and Call Time versus Active Time.

Note: Data in this figure are for illustrative purposes only.

Figure 3 distinguishes between active and nonactive time using the activity categories from the data collection tool. This type of chart answers questions about staff tasks and activities during the shift and what percentage of staff time each activity takes. 

Pareto diagram. Pareto diagrams display as a bar graph the activities being studied, arranged in order from largest to smallest. This tool is helpful in displaying staff activities and in depicting the ranking of activities. 

Figure 4 is a Pareto diagram that displays the time each activity consumes.

Figure 4. Sample Pareto Diagram Trauma Nurse (24-Hour Observation)

Bar chart depicting sample activities of a trauma nurse during 24-hour observation, showing hours and minutes spent on each activity.

Note: This Pareto diagram displays activities, ranked from those activities that consume the most time to those that consume the least. For example, attending to patients consumed the most time at 5.14 hours, with charting ranking the second most time-consuming activity. Data in this chart are for illustrative purposes only.

Figure 5 displays the components of each bar as the individual activities that compromise the totality of the bar. This illustrates the total number of activities and the number of interruptions. For instance, Figure 5 shows that the trauma nurse attended to patients on 38 separate occasions. Therefore, this graph identifies job interruptions, although not all starts and stops of activities can be considered an interruption. (A value stream map, described below, can help distinguish between the natural beginning and end of an activity and an interruption.)

Figure 5. Sample Pareto Diagram: Trauma Nurse and Interruptions (24-Hour Observation)

Bar chart depicting sample activities of a trauma nurse during 24-hour observation, showing hours and minutes spent on each activity. The chart also shows the duration of a task in minutes each time the nurse performed that task.

Note: This Pareto diagram displays the same trauma nurse's activities during the same 24-hour period illustrated in Figure 4. However, Figure 5 also breaks each bar into the frequency with which a particular activity began and ended. For example, the "attend to patient" bar has 38 components reflecting 38 separate times the nurse attended to a patient. Data in this chart are for illustrative purposes only.

Value stream map. A value stream map (i.e., a value-added or non-value-added [Visio] diagram) and process flow chart allow for the depiction of information and activity flow, indicating value-added and non-value-added activities for any type of process. These tools are frequently utilized in the Toyota Production System. Different shapes represent different events, such as activity, interruption, travel, wait, and downtime.This approach can help identify bottlenecks, redundancies, points of dissatisfaction, and inappropriate workforce issues.

A value stream is all the actions (both value-added and non-value-added) currently required to bring a product (blood draw, patient discharge, patient meals, patient x-ray, etc.) through the main flows essential to every product. A value stream map takes into account the activities that make up a process and the management and information systems that support the basic process.

A value stream map is useful for:

  • Helping visualize more than just the single-process level.
  • Identifying the sources of waste in the value stream.
  • Providing a common language for talking about hospital processes.
  • Making decisions about the flow apparent so that they can be discussed.
  • Tying together Lean concepts and techniques, thus helping to avoid targeting processes that can lead to isolated islands of improvement instead of improvement in whole-production processes.
  • Forming the basis of an implementation plan.
  • Showing the linkage between information flow and patient/staff flow.

Non-value-added tasks are tasks that do not contribute to what a patient/insurer would pay for, such as tasks that do not transform the product/output (x-ray, blood draw, discharge). These include:

  • Overproduction, typically using staff or equipment faster than necessary so they will have processes to complete.
  • Waiting for a person or machine to complete an automatic process or for supplies or staff to arrive.
  • Unnecessary transportation and rearrangement of people or materials prior to processing.
  • Process design flaws, requiring staff to intervene more often than necessary.
  • Stock on hand beyond any need to support normal operations or recovery from failures.
  • Unnecessary motion for searching, reaching, carrying, or positioning of equipment and supplies.
  • Production of defective goods.

Figure 6 is a value stream map of a phlebotomist. This diagram distinguishes non-value-added activities, such as travel time, from value-added activities such as the blood draw itself.The time for value-added and non-value-added activities is represented by the "castle wall" line at the bottom of the diagram. The non-value-added activities are depicted through the high portion of the wall and the value-added activities are represented through the dips in the wall. The non-value-added time may be further distinguished into necessary and un necessary activities. The necessary non-value-added activities should be minimized and the unnecessary activities should be eliminated. Figure 6 also depicts the communication activities involved in the process from the point of receiving a request for a blood draw to creating the product of a laboratory result.

Figure 6. Sample Value Stream Map: Phlebotomy

The phlebotomy value stream map follows the phlebotomist's path from beginning to end and is a visual representation of every process in this path. The top red portion represents the flow of information and the bottom black portion represents the flow of the phlebotomist. The flow begins with the phlebotomist printing a schedule for blood draws from the Computerized Physician Order Entry (CPOE) three times in each shift. The phlebotomist then travels to the specific area, checks for requisitions and draws labs accordingly. The blood drawn is left on the unit for transportation to pick up and deliver to the lab, as the phlebotomist travels to the next area and repeats the process. However, if the phlebotomist receives page for an immediate blood draw, referred to as the STAT call, they attend to that call next. When all STAT calls have been responded, the phlebotomist returns to the area she left off and continues to sweep for requisitions while responding to pages as they come in.


Area diagram. Figure 7 depicts an area diagram and is a representation of movement of staff throughout a geographic area. This could be a hospital campus, building, or unit. This type of diagram is useful in showing excessive and unnecessary travel. 

Figure 7. Sample Area Diagram: Phlebotomy

Figure 7 is an example of area diagram of movement through a hospital building for a phlebotomist. A rectangle represents a stop at the lab. A filled circle represents a stop for a routine blood draw. A circle with a dot in the middle represents a stop for a STAT blood draw when the phlebotomist hand delivers the blood to lab. Observation at the beginning of an evening shift showed that the phlebotomist spent 60 percent of her time attending to scheduled blood draws, and the remaining 40 percent responding to STAT calls. During this time, she was responsible for 11 blood draws with an average of 9 minutes per blood draw. She traveled to the core lab area on 4 occasions to transport and drop off the STAT blood draws. The area diagram helps to depict the geography of the area traveled by the phlebotomist in just an hour and 43 minutes of her 8-hour shift.

A rectangle represents a stop at the lab.
A filled circle represents a stop for a routine blood draw.
A circle with a dot in the middle represents a stop for a STAT blood draw when the phlebotomist hand delivers the blood to lab.

Note: Data in this chart are for illustrative purposes only.

Figure 7 is an example of area diagram of movement through a hospital building for a phlebotomist. The circles depict stops and signify the start time for each activity—in this case, a blood draw. A pedometer may also be used to determine travel distance and would complement this data and illustration. 

Top-down format. Figure 8 is a top-down format map. It shows the different activities, people, and their role in a process. This particular example illustrates the steps that occur between ordering a laboratory test and recording results in the medical chart.It also shows which person does each task.

Figure 8. Sample Top-Down Format: Laboratory Test

Figure 8 is an example of a top-down format map. It shows the activities, people, and their roles in a process. This example illustrates the steps that occur between ordering a laboratory test and recording results in the medical chart. It also shows which person does each task.  The left-most column lists the steps in the process. Each row presents a separate step. The columns to the right list persons in the process. Column 2 is nurse/resident/physician. Column 3 is phlebotomist. Column 4 is transporter. Column 5 is lab tech. Column 6 is physician.  The process begins with Step 1, which is Blood draw ordered. An arrow is drawn horizontally from Column 2, which is the nurse/resident/physician who orders the test, to Column 3 which is the phlebotomist who receives the order. The arrow is then drawn vertically down through the next four steps which are performed by the phlebotomist:      Step 2 is: Phlebotomist receives blood order for printout from the POE (point of entry). Step 3 is: Phlebotomist checks with nursing station on the floor. Step 4 is: Blood draw taken. Step 5 is: Blood draw recorded. For Step 6: Blood draw transported to lab, the arrow is drawn horizontally from phlebotomist to transporter. For Step 7: Blood draw received and analyzed by lab technician, the arrow is drawn horizontally from transporter to lab tech. Since the laboratory technician enters the results in the laboratory information system, a vertical arrow is drawn from Step 7 to Step 8: Results entered into MYCIS (the lab information system). For Step 9: Results entered into patient medical chart, ready for physician to review, a horizontal arrow is drawn from lab tech to physician. This completes the process.

Note: Data in this chart are for illustrative purposes only.

This type of diagram can be helpful in understanding the number of handoffs and the number and type of staff involved in a process. This depiction can help identify redundancies and inefficient use of the workforce.

Observation of the current Denver Health process and the display of the data demonstrated that administrative, ancillary service, and clinical processes all offered many opportunities for improvement in efficiency, safety, customer service, quality, and workforce satisfaction. The observations particularly demonstrated the inefficiency in current processes including:

  • Redundancies.
  • Non-value-added activities, such as excessive travel.
  • Numerous interruptions.

Redesign must address these core problems to be of maximal value.

Return to Redesign Planning Steps 

Step 6: Choose the Tools To Enable Redesign Implementation

The majority of the health care workforce currently lack the tools needed to implement system transformation. Therefore, identifying the tools to be used in system redesign is a critical step. There are a variety of tools that have been used by both health care and non-health care systems for redesign.Many of these tools can be divided into two types:

Some of these tool sets and their key characteristics are listed below. References providing more details on these tools can be found in Appendix A. This is not an exhaustive list of potential tools but rather those that have been used by others in health care and those considered here. 

Tools That Facilitate Process Change

Plan, Do, Study Act (PDSA). This is a model for testing ideas in rapid cycles that one believes may create an improvement. When undertaking an improvement to a system, there are three preliminary questions and four essential steps which are repeated until the desired outcome is achieved. PDSA builds in recognition that, with systems, it is unrealistic to expect change to produce the right result every time because there are often complex interactions and dependencies that can be disturbed in unexpected ways.It is always necessary to check that the predicted improvement has actually happened.

The three preliminary questions are:

  • What are we trying to accomplish?
  • How will we know that a change is an improvement?
  • What changes can we make that will result in improvement?

The four steps are:

  1. Plan:
    • Who will do the work and when?
    • What equipment or training do they need?
    • How will information for assessing success be collected and recorded?
    • When will progress be reviewed?
  2. Do:
    • Do the work according to the plan.
  3. Study:
    • Study the information gathered.
    • Was the desired outcome achieved? If not what actually happened?
  4. Act:  Decide what action is needed; for example:
    • Adopt the change permanently.
    • Abandon the change.
    • Make some adjustments and start the cycle again.

Additional information can be found at:

Lean (or the Toyota Production System). Lean thinking is a way to work more efficiently and effectively while providing customers with what they want when they want it. It is a philosophy and set of tools that aims to eliminate waste from processes.It also focuses on what adds value in processes from the perspective of the customer.The frontline workers are heavily involved in this approach. 

The 10 rules of Lean production can be summarized as follows:

  1. Eliminate waste.
  2. Minimize inventory.
  3. Maximize flow.
  4. Pull production from customer demand.
  5. Meet customer requirements.
  6. Do it right the first time.
  7. Empower workers.
  8. Design for rapid changeover.
  9. Partner with suppliers.
  10. Create a culture of continuous improvement.

While the primary focus is waste, the outcomes of utilizing Lean tools are efficiency, quality, and customer service. Implementation requires a commitment and support by management and participation of all the personnel within an organization to be successful. Some institutions have implemented Lean using an onsite trainer from industry. Additional information can be found at http://www.lean.org.

Six Sigma. Six Sigma is a disciplined, data-driven process that stresses eliminating defects and reducing variation while developing and delivering near-perfect products and services. This tool includes a rigorous improvement model known as DMAIC (Define, Measure, Analyze, Improve and Control). 

Six Sigma is the goal, which means products and processes will experience only 3.4 defects per 1 million opportunities, or 99.99966 percent good. Six Sigma is a management strategy to use statistical tools and project work to achieve breakthrough profitability and quantum gains in quality. This is achieved by implementing process improvement, measurement-based strategies via Six Sigma improvement projects.

The Six Sigma approach may benefit those organizations where existing process improvement efforts may have not delivered the financial benefits promised and where productivity goals are not meeting targets. This approach fits with the safety and quality perspective of redesign. Additional information on this tool can be found at http://www.6-sigma.com.

Return to Redesign Planning Steps 

Tools That Facilitate Change in the Environment, Culture, and/or Workforce

Baldrige Criteria for Performance Excellence. The Baldrige criteria provide a business framework and tools to help improve organizational performance practices. The criteria are based on a customer- and process-centered approach that work to continually identify and improve key organizational processes with the goal of delivering better value to the customer.

The Baldrige core values and concepts include visionary leadership, patient-focused excellence, organizational and personal learning, valuing staff and partners, agility, focus on the future, managing for innovation, management by fact, social responsibility and community health, focus on results, and creating value and a systems perspective. It appears that one of its values in health care is improving market share through achieving extraordinary customer service. Additional information can be found at http://www.quality.nist.gov/.

Clinical Microsystem. Clinical Microsystem refers to the work developed by Dartmouth College which focuses on the smallest replicable unit that actually does the work. This smallest unit not only includes a team of people, but also the local information systems, client populations, space, and work designs.

Clinical microsystems are the small functional, frontline units that provide most of the health care to most of the people. These units are the essential building blocks of the larger health care system. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed. The toolset used by these systems includes the "5Ps" (Purpose, Patients, Processes, Professionals, and Patterns). 

Improvements in clinical microsystems lead to transformation of the workforce and the culture. As part of measuring the impact of this tool on workforce development, the Institute for Healthcare Improvement (IHI) has suggested the use of a series of 12 questions ("Q12") that identify staff engagement developed by the Gallup Organization. Additional information can be found at http://clinicalmicrosystem.org and http://www.IHI.org.

Talent profiling. Talent profiling differs from other tools in that it has as its prime focus the worker rather than the process. Its goal is to get the right person in the right job, based on an in-depth understanding of the talent characteristics of each person and the most critically important characteristics needed to be successful in each role. Numerous consulting firms provide talent profiling services.

Consultants and training programs that teach these tools are currently adopting some concepts from each method for improvement such as "Lean Six Sigma." Which tool is chosen may not be as important as the mere choice of a tool and the subsequent training of the workforce in the use of the tool.

Training the Workforce To Use the Tools

 Denver Health selected three tools to implement in the redesign process:

  1. PDSA, which was in current use by the workforce, would continue to be used because the workforce had extensive experience and familiarity with this approach.
  2. Lean was chosen as the principal tool set for process redesign as it appeared to best address the major issues observed in the current processes.  Its focus on waste afforded Denver Health the most opportunity to reduce expenses—a step that was clearly necessary in order to survive in face of growing numbers of uninsured and decreasing revenues.Its focus on value from the customer perspective fit the customer service need.It also fit the organization in that it appeared to require a great deal of presence on the "floor" with observation, substantial intuitiveness, rapid-cycle improvement, and broad-based employee involvement and empowerment.
  3. Talent profiling was selected as a valuable asset in matching employees with roles.This is particularly important in health care, an industry that is experiencing shortages and high turnover rates in some health care professions.

After selecting the tool, the training strategy must be developed:

  • Who will be trained?
  • Who will do the training?
  • How will the content of the training curriculum be determined?

All institutions, both in health care and in other industries (especially service and manufacturing) that have undergone substantial redesign or transformation, have committed to training the workforce in using the chosen tools. However, there are different approaches to training the workforce:

  • Intensively train all employees in using the tools.
  • Conduct "just in time" training for team members as they are assigned to work on projects.
  • Conduct general training for all or many employees coupled with extensive training of a small cadre of employees.

There are advantages and disadvantages to each approach to training the workforce. At Denver Health, training the workforce in PDSA involved general concept training prior to the beginning of this redesign project. 

For the two new tools, Denver Health will adopt the strategy of general training for many employees with intensive training of a few. For Lean training, all executive team members and all physician department chairs will receive an introduction to Lean principles and tools; all middle managers will be trained in a broad overview of the tool. 

Twenty-five employees including three physician department chairs were intensively trained to become experts in Lean production and rapid process improvement projects in order to facilitate projects. These 25 employees ("Black Belts") represent the majority of the hospital system's departments and a broad array of disciplines.

The Lean training tool was developed in collaboration with the Mid-America Manufacturing Technology Center Association (MAMTC). MAMTC is a nonprofit service organization that helps small and mid-size manufacturers increase their sales and productivity, reduce costs, and improve quality. One of the primary tools they use to help manufacturers is Lean training. Denver Health collaborated with MAMTC to adapt the Lean curriculum to health care by using examples from actual Denver Health hospital operations. 

The following courses were provided to the staff:

  • Lean Overview and Introduction.
  • Lean 101.
  • Value Stream Mapping.
  • Tools-5S System.
  • Tools-Setup and preparation reduction.
  • Tools-Standardized work.

There are various consultants and training programs available to teach Lean production tools. Some have begun to adapt their curriculum to the service industry, particularly health care.

The Denver Health workforce will be trained in talent profiling using a similar approach to the Lean training approach. There will be a broad overview of the talent profiling tools for executives, physicians, and middle managers; a group of employees who will be those primarily involved in hiring staff will receive extensive training in using the talent profiling methods. Denver Health will work with a private firm on creating these profiles for the hospital workforce.

Page last reviewed August 2016
Page originally created August 2016
Internet Citation: Redesign Planning Steps. Content last reviewed August 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/toolkit/toolkit4.html