Process redesign Part 1: process selection.

Imagine that your hospital recently opened a new operating room suite at a cost of several million dollars.

The strategy is that new facilities and equipment will improve patient flow, increase surgical volume and improve surgeon and patient satisfaction. The result will be a positive return on investment due to the enhanced revenue.

Unfortunately, the hospital has found that although the facility and equipment are new, the same underlying problems exist. The nursing staff and operating room administration insist the problems lie with the physicians. The physicians claim it is a nursing and administrative problem. You are charged by the hospital's CEO to find a solution.

Scenarios like this go on in hospitals across the country on a daily basis. How does the physician executive approach the problem? Before attempting to tackle any solutions, it is important to realize the operating rooms are not an isolated entity within the organization, but an integral component of the total system.

Systems thinking means determining the critical success factors for the organization and examining--and possibly changing--the processes to find solutions to problems.

Enhancing revenue through increased surgical volume is an obvious critical success factor for this organization as evidenced by the large commitment of capital made to up grading the operating rooms.

However, as is often the case, facility improvements alone do not solve the problems. The answer may lie in redesigning the processes that form the critical success factor of increasing surgical volume and operating room revenue.

Enter the physician executive

Where does the physician executive charged with finding the solutions begin with the process evaluation and redesign?

The first step is securing the full backing of the CEO to undertake the redesign process. This should be made public so that all parties understand that the initiative has the full support of the senior management team.

Next, a multi-disciplinary team representing the key stakeholders of the operating rooms is brought together.

This team includes:

* Surgeons

* Anesthesiologists

* Operating room and post anesthesia care unit nurses

* Surgery unit admitting nurses

* Operating room technicians

* Operating room administrators

* Housekeepers

* Operating room schedulers

The membership of the group will vary from one organization to the next. However, it should be large enough not to exclude any major stakeholders, but small enough to be manageable and productive.

Next, ground rules must be established and agreed upon by the team. For example, a common ground rule for a multi-disciplinary team is to have everyone referred to by first name rather than tide. This tends to level the playing field and reduce any feelings of intimidation.

Another common ground role is to have members agree that no discussion of the redesign project be made public knowledge until the project is completed. This creates a sense of unity among the participants and prevents any outside influences from sabotaging the project before it is completed.

Identify success factors

The team's first task is to identify the critical success factors required to increase surgical volume for the operating room and the processes underlying those critical success factors.

Success factors might include:

* Ease of scheduling cases

* Ability to accommodate emergency and add-on cases

* Efficient operations

* Prevention of cancellations and delays

The underlying processes may include:

* Elective, add-on, and emergency case scheduling

* Pre-operative patient preparation

* Patient transport to and from the operating rooms

* Operating room turnover

What process does the team select for redesign? A Process Selection Matrix can help determine what to do.

The matrix is constructed by determining the impact each process has on the critical success factors, as well as by the current performance of each of the processes. The impact of each process is scored from 0 to 5, with zero being no impact and 5 being the highest impact on the success factor.

Current performance is turned from 5 to 0, with 5 being the poorest performance and 0 being the highest performance. The total score is determined by adding the products of the impact score and the current performance score far each process.

For example, in Figure 1, the total score for the scheduling process is determined by multiplying the impact score for ease of scheduling and the current performance score (5 x 3) and adding it to the products of ability, to accommodate add-ons/emergencies and current performance (5 x 3), prevent cancellations and delays (3 x 3) and OR efficiency (5 x 3).

This gives a total score for the scheduling process of 54 (15 + 15 + 9 + 15). Once completed, those processes with the highest scores are those that have the greatest impact with the poorest performances and should be considered for redesign.

In our example, operating room turnover and scheduling have the highest scores. Which should the team choose to redesign?

Other factors to consider

Based on the pure numbers of the Process Selection Matrix, the operating room turnover process (ORT) would seem the logical choice, yet other factors also must be considered. These include which process may have the greater impact on the ultimate goal of increasing case volume and revenue, as well as the ease with which the team believes a redesign can be implemented.

There is nothing wrong with going for the low hanging fruit if the ultimate objective is achieved.

For example, if resistance to change by surgeons were anticipated as a major obstacle to implementing a redesign, then it would make sense to choose the operating room turnover process rather than the scheduling process, since the ORT implementation may involve the least change for the surgeons.

In addition, if the new ORT process increases available operative time, they may well embrace the redesign, rather than resist it. Therefore, having gone through the selection exercise, let us assume that the team has chosen the ORT as the process to examine for redesign.

Now that the selection is made. in Part 2, we will discuss how to analyze the current ORT process and begin redesigning it.

Figure I: Process Selection Matrix

Impact: 0 to 5 : 0= No Impact; 5 = Greatest Impact
Current Performance: 0 to 5: 5= Worst Performance; 0=Best Performance

Impact on Critical Success Factors

Process          Ease of      Ability to     Prevent Delays/
                Scheduling    Accommodate     Cancellations
                                Add-ons

Scheduling          5              5                3
Patient Prep        1              1                5
Patient
Transport           0              0                0
Room                1              5                5
Turnover

Impact on Critical Success         Current      Total Score
Factor                           Performance

Process         OR Efficiency

Scheduling            5               3             54
Patient Prep          5               2             24
Patient
Transport             5               1              5
Room                  5               5             80
Turnover

David P. Tarantino, MD, MBA is the executive medical director of Shock Trauma Associates, P.A., a 50+ physician, multispecialty practice associated with the University of Maryland School of Medicine. In addition, he is the chief executive officer of The MD Consulting Group, LLC, a health care management consulting firm in Baltimore. He can be reached by phone at 410-328-2036 or by e-mail at [e-mail].