A Toolkit for Redesign in Health Care: Final Report: Redesign Planning Steps

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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:

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 (19 KB) 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 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 literature review.
Form an External Steering Committee.
Conduct site visits.

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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