Process redesign part 3: implementation.

In my previous columns (The Physician Executive, The Nuts and Bolts of Business, November/December 2003 and January/February 2004), I hypothesized that you, as a physician executive, have been charged with finding a solution to improving the functions of a new operating room suite by leading a process redesign.

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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. We then proceeded to examine the needs of the customers of the process, to examine the "As Is" process and to create a cause and effect diagram to analyze the components of the "As Is" process.

Now, we turn our attention to developing a new vision for the ORT process and redesigning it.

Through the "As Is" process, several obvious areas for improvement became apparent. These included communication and the need for either additional personnel or the more efficient use of existing personnel. How do we incorporate these findings into the redesigned process?

A new vision for the ORT must be developed by determining key characteristics for success.

1. For example, one characteristic might be to meet a national standard for ORT, such as 15 minutes. So, the vision of the redesigned process will include cleaning and set-up to be accomplished within this national standard.

2. A second key characteristic might be patient safety. Achieving the 15-minute national benchmark cannot occur at the expense of patient safety.

3. Finally, the incorporation of technology to enhance communication may be a third key process characteristic of the redesign.

Performance measures must reflect the key process characteristics of the redesign.

The first is measurement of operating room turnover time as it compares to the national standard benchmark. A second performance measure may be postoperative infection rates, reflecting the safety standards for room cleaning.

Other performance measures might include: number of case delays, number of elective cases performed after hours, patient transport time, number of operating room minutes utilized as compared to minutes available, and patient and surgeon satisfaction.

Equally important are the potential barriers to implementation of a new process.

One barrier to implementation may be lack of incentive to change by operating room personnel. If the personnel are accustomed to long breaks between cases due to inefficient room turnover and are working on an hourly shift basis, (as may be the case with the OR nursing staff), greater efficiency may result in more work without the reward of increased compensation. As a result, resistance may be high.

A second barrier may be the cost of additional personnel or technology required to achieve the redesign. With rising costs and declining reimbursement, the hospital may not have the funds available to fully implement the redesign.

Let the redesign begin

Once this analysis has been completed, it is time to move on to the main focus of our project--the redesign of the ORT process. Just as with examination of the "As Is" process, the "To Be" process (Figure 1) begins by defining the process boundaries.

While the "To Be" process has the same end point (the next patient being brought into a cleaned and stocked operating room), it has a new starting boundary.

While the "As Is" process began at the conclusion of the surgical procedure, the "To Be" process begins 30 minutes prior to the conclusion of the case. This allows adequate time for the patient to be transported to the holding area.

Several other changes are apparent in the "To Be" process. When the circulating nurse notifies the charge nurse of the pending completion of the case, he or she notifies the charge nurse of the cleaning status of the room.

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If the case involved a patient infected with a resistant organism or excessive blood or fluid spillage, then the charge nurse may designate a "new" operating room be used for the next patient to prevent cleaning delays.

Other changes include the use of dedicated house cleaning personnel, transportable anesthesia carts that are stocked between cases, and use of two-way radios to enhance communication between nursing, anesthesia, housekeeping and transporters.

To track actual room turnover time, bar code technology is added so that anesthesia technician and housekeeping functions can be recorded. The new process attempts to solve the problems elucidated in the analysis of the "As Is" process by performing activities in parallel, enhancing communication and dedicating personnel to the turnover process.

Cost of implementation

The final components of the project include a financial analysis and implementation plan. The financial analysis should include looking at the cost of implementation, as well as projecting increases in revenue resulting from the improved efficiencies.

Implementation will involve hiring additional personnel, purchasing new equipment, as well as training that may be required for new technology.

Implementation will also depend on the size and configuration of the operating rooms. Small facilities with few operating rooms may choose to implement the changes all at once. For larger facilities with many operating rooms divided into functional service pods, implementation might occur in steps, choosing one area to pilot the new process.

Finally, the new plan must be communicated widely to all parties and must be championed and embraced by all senior administrators, nurses and physicians.

While the steps in undertaking a process redesign may seem simple and straightforward, this is rarely the case. Multiple obstacles to implementation often occur, ranging from lack of financial resources to lack of buy-in from senior personnel.

Consultants experienced with process redesign and implementation are costly, yet may be invaluable in assisting in all phases of the redesign process.

In the end, understanding how to approach a process redesign and the steps involved are valuable tools for the physician executive.

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]

By David P. Tarantino, MD, MBA