A Toolkit for Redesign in Health Care: Final Report

Redesign Planning Steps

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.
• Conduct patient focus groups.
• Observe current processes.
• Present data.

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 (20 KB) 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. 

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 (10 KB) 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 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 (10 KB) is a Pareto diagram that displays the time each activity consumes.Figure 5 (11 KB) 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.)

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 (14 KB) 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.

Area diagram. Figure 7 (9 KB) 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 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 (9 KB) 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.

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.

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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:

• Tools that facilitate process change.
• Tools that facilitate change in the environment, culture, and/or workforce.

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:

• http://www.tin.nhs.uk/index.asp?pgid=1130.
• http://apiweb.org.
• http://www.ihi.org.

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.

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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.

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