In my last blog post, I outlined a Business Process Mapping model that allows organizations to gather vital information about their day-to-day operations. The model was a variation of Six Sigma’s SIPOC tool, with 8 detailed points to be recorded about each step in every process:

  1. Data Elements Recorded/Processed/Viewed
  2. Data Validation Rules
  3. Step Duration (Min, AVG, Max)
  4. Step Cost (Min, AVG, Max)
  5. Step Controls
  6. Step KPIs
  7. System/Platform Used
  8. Policy & Procedure

Today, I will present one approach that addresses how to convert that information into knowledge that will help you monitor the organization’s performance & quality of service. Lastly, I will briefly discuss how to prioritize what processes you should work on improving first, since various factors may limit you from addressing all problems at once. I will use a hospital’s Operating Room in this hypothetical analytical scenario.

Consider that we have already documented all the processes of the OR per our template. What comes next is how to convert that information, specially the time, controls, and KPIs into A) Policies & Standards, and B) Monitoring System (Manual or Automated) to ensure compliance with established policies. Let’s focus on the Intra-operative step of the surgery process for now. Before the patient is even brought to the OR, there are standard check-lists that must be filled out to ensure that the OR has all the required equipment, and everything has been sanitized to reduce the rate of infection. The question here is (assuming that we are using an OR Management System to manage the workflow), how can we ensure that the checklist has been filled out before proceeding to the next step. Well, from a technical point of view, the answer is very straight-forward; If the check-list is not filled out, don’t allow the user (e.g. circulating OR nurse) to proceed to the next step in the system. Of course, further physical measure (which should still be recorded by the system), could be put in place to ensure the identity of the patient.

Let’s jump ahead a little to the end of the surgery, where an unfortunate complication has been identified, and was related to improperly filling out the check-list. Our monitoring system should allow us to link the two variables together, and once this link is established in the system, we can generate reports correlating checklist complication rates to many other variables including, but not limited to, Surgery Name, Surgeon, Nurse, time of surgery, number of surgeries physician/nurse participated in prior to this surgery, and so many other variables. Such correlation reports provide high value retrospectively, and help us pinpoint problematic areas in the OR. Yet, the highest value in using an electronic system to track all that data is the availability of those indicators in real-time. If we monitor such indicators on a daily, weekly, and monthly basis, we can rapidly identify areas to improve.

Another example of a KPI that should be tracked in the OR is the time of the surgery, procedure-specific of course. Let’s assume that we have 10 pediatric ophthalmologists who perform Strabismus Surgery. Factors that we need to document would include the different muscle alteration methods used (Loosening, tightening, transpositioning, etc). For each method, if we electronically track the details of the surgery in a structured manner (each data element entered in its own field instead of in a narrative report), we will be able to correlate complication rates to specific methods, and specific surgeons in real-time, not forgetting of course the time factor. Tracking the duration of the procedure per surgeon and analyzing that information helps us identify the most efficient surgeons, and well, the not so-efficient ones too, and thus take corrective measures in real-time to train the slower surgeons. Moreover, having that data in such high detail will help use better test new procedure and make educated decisions on which procedure to use as a standard.

Now, how do we tie all this into increasing the utilization of the OR, while at the same time, reducing medical errors and complication rates? If we follow a Total Quality Management (TQM) approach, we can improve all the potential areas and collectively A) Reduce Total Surgery Time, which translates into reduced cost (since we adopted Activity-Based Costing when we tracked the cost per step/process), and B) Reduce complication rates, which means decreased hospitalization time (decreased cost and decreased wait time for patients who are on the waiting list).

Development of Dashboards with auto-alert are the key take-away point here. Know your indicators (per step, process, department, and individual), collect data electronically in the right structure (the most important point in order to allow seamless Business Intelligence analysis), and be transparent in sharing this information across the organization with those who can help fix problematic areas. Having such dashboards that provide real-time information about your operation will help you know where you stand, and if the dashboards are intelligent enough, they would allow you to run process simulations to estimate the impact of both minor and major process changes on your organization over a day, week, month, quarter, or a year. By impact I mean cost savings as the bottom line. Consider that one of your dashboards shows you the rate of revision surgeries (a second surgery performed for the same patient because the first surgery was not a complete success) performed per year, along with the total cost of those surgeries, and the added hospitalization days, in this case, you can easily test the impact of introducing new measures that will reduce or eliminate the need for revision surgeries. Again, by impact I mean cost cutting, and also in this specific case, the freed up hospitalization days, which will allow you to admit more patients from the waiting list.

The last point I will discuss today is prioritization. Assume that we performed the Business Process Mapping project and identified the potential room for improvement in various processes, how do we decide which processes to invest in improving first. I’m sorry to tell you there no straight-forward answer to that question as many factors may affect this decision. I will, however, attempt to outline the primary factors that top management needs to consider, and finding the right balance differs from one organization to another.

  1. Funding: Funding is always a key hurdle to many projects (even to conducting the Business Process Mapping project in the first place). If costs are estimated for each process improvement including system implementation and training costs, a decision could be made to start with “some” of the least costly processes to improve. Such pilot projects can be used as proof of concept, and if they yield the desired results, they can be used as a strong bargaining chip for further funding.
  2. Organizational Politics/Culture: This is the classic topic of Change Management. Various internal factors and power plays may affect the level of enthusiasm with which such projects are met. Since re-engineering processes usually means reducing or changing the responsibility, and in some cases, the authority of individuals/groups within the organization, top management can try and gauge the initial response of middle management and staff to the “idea” of change. From there, you can start with the least resistant departments/processes, and again, use the success as a proof of concept to attract the rest. Canada Health Infoway created a brilliant document on Change Management in Healthcare. It is worth the read.
  3. Non-Financial Resource Availability: Just because you may be able to obtain the funds, it doesn’t mean that you might have the skill-set needed on staff to manage such a project internally. However, and from personal experience I could not stress this anymore, ALWAYS have permanent staff working closely with every member of the vendor’s team, and go as far as demanding it to be a part of the contract. The vendor will leave once the project is done, and outsourcing the management of your system will significantly limit a hospital’s ability to run ad-hoc reports among many other things. That doesn’t mean that you shouldn’t outsource the entire system (e.g. technical support), but the access to your database and the ability to run custom reports and create dashboards should always reside within your organization. TQM should be an on-going process, and having full-time staff who are knowledgeable and dedicated to it can prove beneficial as technology is rapidly evolving, and you need someone to always be on the lookout and who understands your hospital’s culture, i.e. what works for us and what doesn’t.
  4. Community Feedback: Never underestimate the value of community feedback (patients & relatives) while making decisions on what processes to improve first. With patients being more involved in their own healthcare management, and also patients being more vocal and active on social media, hospital administrators should never loose sight of why a hospital exists in the first place; to serve patients. One thing to consider though, if your hospital lacks transparency with its patients, problems that patients identify may not be problems with your business process, but rather miscommunication or worst, lack of communication on your hospital’s part. When prioritizing which processes to start improving, you should always include a couple of the processes which were identified by your patients as “important” in your first phase. This will help your hospital improve its reputation, and help you attract more patients, and consequently, more funding.

Lastly, for those who don’t know where to start with a BPM project, click here to view a sample Project Charter that will guide you from start to end of the project.

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