Process redesign part 2: process analysis.

Imagine that you are charged with finding a solution to improving the functions of a new operating room suite by leading a process redesign.

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In my previous column ("The Nuts and Bolts of Business," November-December 2003), I discussed the steps in forming the redesign team and in selecting the process for redesign. The result of our hypothetical case was to choose the Operating Room Turnover Process (ORT) for redesign. This was because the ORT process had the greatest impact on critical success factors for the operating room and the poorest performance.

In addition, changing the ORT might lead to the least resistance to change. Having completed Part 1, the next steps in redesign are to examine the "customers" of the process as well as to map and examine the "as is" process.

Customer service

The customers of the ORT process include both the patients who undergo operative procedures and the surgeons who perform those procedures.

For the patients, the anticipation of going to the operating room is an anxiety-provoking event. For most, the operating room is a completely unfamiliar environment in which they have no sense of personal control. In addition, it may be cold, noisy, and confusing adding to the patient's fears and anxiety. So, any changes in the ORT process must take these patient concerns into account.

The second customer of the ORT process is the surgeon. For the surgeon, the ORT process is non-value added time. The longer the ORT process, the greater the delay between cases. Because their time is divided between operative procedures, office visits and possible teaching and or research, any delay in operative time due to the ORT is costly to them. In addition, prolonged ORT times limit the available hours of actual operative time, which impacts elective case scheduling.

Understanding the needs of both of these customers is important in both analyzing the current process and redesigning it.

Mapping the "as is" process begins with determining where the process begins, where the process ends, as well as what it includes and does not include. The team must then map out the current process in step-by-step fashion, creating a flow diagram as seen in Figure 1.

This process as outlined has the following boundaries.

It begins when the operating room nurse calls report of the patient's status to the post anesthesia care unit (PACU) and notification to the operating room charge nurse of completion of the case. The process ends when the next patient is brought to the operating room.

The process includes all activities required to clean, supply, and check the operating room. In addition, it involves sending for and transporting the next patient to the operating room. As outlined, it excludes the surgical procedure, as well as the care of the patient in the PACU or discharge from the PACU.

These boundaries set the framework for analysis and limit discussion to the process selected for redesign.

When separated into its functional components, it becomes obvious that the current ORT process involves a series of sequential tasks with numerous hand-offs in the process. This leads to bottlenecks in process flow.

For example, the operating room scrub nurse or technician and the anesthesia technician cannot set up the instruments table or anesthesia machine until the room is cleaned. The anesthesia care provider cannot complete the final equipment set-up until the room is cleaned and restocked. The patient cannot be transported to the room until the pre-operative check is completed and the room preparation is complete.

Any component of the process that delays room set-up or patient preparation will delay the turnover process. The result is a prolonged operating room turnover.

Process analysis

The next step is to begin to analyze the current process. An Ishikawa or fish bone diagram of the root factors and contributing causes to the ORT process is diagrammed in Figure 2.

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For this process four major factors contribute to the problem:

1. Operating room cleaning

2. Operating room set-up

3. Patient transport

4. Pre-operative preparation of the patient

For each major factor there are contributing causes such as insufficient personnel and problems with communication. The root cause diagram allows the team to easily see the problem areas that need to be addressed in the redesign of the process.

One additional analysis remains. How will the stakeholders of the current process react to change?

Of the stakeholders involved in the ORT process, the operating room charge nurse and/or charge anesthesiologist depending on who is responsible for flow through the operating rooms may provide the greatest support for changing the current process, since he or she must deal with the consequences of the inefficiencies of the process.

The housekeeping and anesthesia technicians may favor change if it improves their ability to perform their functions more efficiently. The stakeholders who may be most resistant to changing the current process are the operating room nurses and anesthesia care providers.

A longer delay between cases means greater time for breaks and possibly less work, if they work on an hourly or shift basis. However, if improvements lead to earlier completion of the caseload and an earlier dismissal from work, they may well embrace the changes.

As outlined in this simple example, the ORT process is highly inefficient and time consuming. This results in delays in the operative schedule, with anxious patients and families having to wait longer before their scheduled procedure is performed and angry and frustrated surgeons having to adjust their schedules to accommodate the delays, or worse cancel cases due to lack of available time. The final outcome is the loss of revenue both for the physicians and the hospital.

Having identified the customers of the process, mapped the current process and analyzed it, the next steps are to begin to redesign it. In Part 3, we will examine redesign and implementation.

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 

By David P. Tarantino, MD, MBA