115
Chapter 14
Process Redesign
in Healthcare
Alexander Bohn and Sue Ann Te
What Is Process Redesign?
Process redesign is the application of process improvement methodologies to a current system to
remove waste and increase eciencies. It is a fundamental tenet of industrial engineering (IE), and
utilizes a full spectrum of IE tools to continuously improve processes or programs in any industry.
Distinct from process reengineering, which creates an entirely new process from one that is obso-
lete, process redesign seeks to improve aspects of the current state while keeping the foundation of
the process intact. Process reengineering can be thought of like the transition from cassette tapes
to compact discs, an entirely new format for playing music. Process redesign is similar to the next
generation of a smart phone, the technology is simply given more features, a more ecient proces-
sor, and a new look.
Contents
What Is Process Redesign? ........................................................................................................ 115
How Do You Employ Process Redesign? ...................................................................................116
Dening Project Scope, Resources, and Goals ......................................................................116
Current State .......................................................................................................................116
Future State .........................................................................................................................117
Continuous Improvement ...................................................................................................118
Special Considerations and Issues ........................................................................................118
Project Example .......................................................................................................................119
Background .........................................................................................................................119
Dening Scope, Resources, and Goals ................................................................................ 120
Current State ...................................................................................................................... 120
Future State .........................................................................................................................121
116 ◾ Alexander Bohn and Sue Ann Te
How Do You Employ Process Redesign?
Dening Project Scope, Resources, and Goals
Identifying the primary process and opportunity for improvement is the rst step in any process
redesign project. As frontline sta is most familiar with the daily work, one way to achieve this is
to ask the sta for their perceived areas of ineciency or opportunities for improvement. Often,
nurses, physicians, or other healthcare sta have a greater understanding of what needs to be
improved. It’s up to the process improvement (PI) team to quantify the problem and provide a
structure and approach to develop a solution in conjunction with the healthcare stakeholders and
the available resources. e team should maintain a list of potential process redesign options or
opportunities, and then develop the feasibility and potential return on each one to help identify
where to begin.
Once the targeted process has been identied, it is important to completely dene the prob-
lem, areas for improvement, and expected outcomes of the future state design. Develop an abstract
around the ineciency that describes in detail why the ineciency exists in the current state
and what the redesign aims to solve. is abstract can, if necessary, be reviewed and approved by
administration and frontline sta as a kicko agreement for the project. Clearly outline the focus
of the process redesign and be sure that the stakeholders understand exactly which aspects will
be improved upon. is will focus the eorts and guard against scope creep. Investigate if the
existing process has any metrics currently being tracked within it that can be used as quantitative
benchmarks. Finally, document a list of expected outcomes for the project. Try to be as specic as
possible with the outcomes (using the collected metrics, if applicable) and set high standards for
the hospital or department.
Current State
Current state is the term used to describe the system or process as it exists today. It may be repre-
sented by a process map, standard operating steps, or other means. It’s nearly impossible to design
an improved process without rst gaining a clear understanding of the current state model. e
current state is generally developed in conjunction with department sta who helped identify
the process to redesign in the rst place. e current state should be simple and straightforward
enough to be understood by any of the process owners or stakeholders including sta members or
senior leadership from throughout the organization.
e rst decision to make is how the current state process will be represented. If the process is
straightforward with few deviations and entry or exit points, an Excel spreadsheet representing the
steps might suce. Process mapping (such as those developed in Microsoft Visio, see Figure14.1)
can be utilized for processes with many decision points, as it more eectively displays multiple
points of entry and paths that a process can take. For very standardized, precise processes, consider
using a systems modeling software such as Arena or STELLA, to represent and see the potential
eects of process changes digitally, before implementing them.
It is imperative to obtain honest feedback while documenting the current state process to
ensure that the information is representative of the actual workow, and not simply what the
hospital policies mandate. Healthcare is dictated by strict guidelines and procedures, so sta are
often hesitant to admit if rules are being bent or shortcuts taken. Due to this challenge, make it a
priority to meet with the frontline sta personally. Ensure that the sta and management are able
to comfortably and honestly explain the details of their job, even if the ideal world and reality of
the functions have some dierences. You may even want to walk through parts of the process with
Process Redesign in Healthcare ◾ 117
frontline sta to better understand, verify, and document the process. Sta tend to speak more
candidly about their work in this setting.
It will be necessary to meet with sta and management multiple times throughout the current
state, developing multiple iterations. Use the current state to highlight potential areas for improve-
ment or key concerns that will be the focus of the future state design. ese identied points can be
developed as a separate document to be used in conjunction with the current state to help justify
the process redesign. e current state stage can also be used as another project sign-o to keep
all stakeholders engaged.
Future State
Once the current state is fully captured, this knowledge will be used to design the future state.
As noted previously, the future state is not a completely new process, but rather the current state
with key improvements to increase eciency and quality. Again, it’s important to always keep the
patient’s perspective and experience in mind when designing the future state. Building the future
state directly from the current state map or document will ensure that every element of the current
state is accounted for and the changes can be easily noted since the two processes will resemble
each other.
A very important aspect of the future state is integrating benchmarks or milestones to quantify
the improvement that the process redesign achieved. Any current state metrics should be consid-
ered as this provides a clear before-and-after picture, but it is also encouraged to establish new
milestones throughout the process. ese targets could be a time period between events, a reduced
amount of wasted resources, or a desired “defect” rate. You may even include as a target, the elimi-
nation of steps in the process for both the patients and the sta. Ensure that the milestones can be
tracked and reported accurately through software, paper logs, or other technology solutions. ese
benchmarks, while justifying the eectiveness of the redesign, also give the sta measureable goals
to meet and a sense of accomplishment once those goals are met.
Fills out pt info
on paper weekly
schedule card
Unit RN calls/
requests referral
from Wound
Care
Coordinator
Order populates
Wound Care
worklist
Physician enters
order for referral
(EMR)
Makes
recommendation
to patient or staff
& documents
(EMR)
Documents
Wound Care
assessment
(EMR)
Screens patient
(EMR)
Wound Care
Assessment
Process
Visits patient
bedside
Prioritizes pts
based on type of
order, location,
urgency
Fills out
individual 3×5
card for each
patient with
screening into
May
communicate
w/unit staff
for handoff
May assist staff
with dressing,
linen changes
Revisit?
New Referral?
At end of shift,
enters all pt
visits for that
day
(Registration)
16 15
14 13 11
8910
12
4
132
5
6
7
Yes
Yes
No
No
St. Isadore Health System
Wound Care Process
Current State Mapping
Version 1
Last Updated: 4/18/2012 – John Smith Proprietary and Confidential
= Key Concerns
= Manual Solution
= IT Solution (other)
= Hospital Defined Process
Flow
= Entry
Point
= Standard Step
= Optional Step
= Step Occurs Anytime
= Process Reference
KEY
Wound Care Coordinator Other
Figure 14.1 Wound care process ow example (Microsoft Visio).
118 ◾ Alexander Bohn and Sue Ann Te
e team should be prepared for a handful of reactions once they are ready to present the rst
draft of the future state designs. As with the current state, expect to develop multiple iterations, in
conjunction with the frontline sta, to ensure that all existing and new steps are captured properly.
Watch out for change-resistant sta to get hung up on less-signicant details of the future state
(verbiage in processes, order of the steps, etc.) in an attempt to impede progress. e PI team will
need to be prepared to explain exactly why and how the future state will improve operations while
maintaining quality of patient care. e executive support will be extremely benecial during the
presentation of the future state. A project sponsor can help keep everyone focused on the original
goals and benets of the new redesigned process.
Continuous Improvement
It’s extremely important during and after the project to stress the importance of continuing to approach
a zero-defect, waste-free, ecient environment even after the newly redesigned process is implemented.
With so many standards in healthcare today (Health Insurance Portability and Accountability Act
[HIPAA], Magnet, payer criteria, etc.) it is very easy to fall into the “good enough” trap where, once a
department or facility is meeting the minimum goals, it doesn’t focus on further improvement.
After the process has been redesigned, approved, and implemented, it will be necessary to ensure
continuous improvement utilizing some of the tools that were developed throughout the project.
First of all, establish a regular schedule for executive rounding or meetings with frontline sta in
order to continue the forum for sta-to-management communication of ineciencies and ideas for
improvement. Also, the milestones and benchmarks that were developed during future state design
can be continually monitored and adjusted as they are met to keep the entire department focused
on increasing operational eectiveness.
Special Considerations and Issues
Process redesign in the realm of healthcare also encounters some unique challenges that a PI team
should look out for. e quality of care given to the patient should always be the number one
priority of any healthcare organization. Any redesigned process cannot compromise patient care,
and in most if not all cases, should seek to improve an aspect of care. A process that saves capital,
time, or resources will likely encounter strong pushback if patient care is negatively aected or
even perceived to be negatively aected, and will need to go back to the drawing board. If this is
not addressed, the project may even be shut down. e industrial engineer’s bias may be to view
the patient as a product on an assembly line, with the goal to get the patient out the door healthy
and defect-free. is mentality can be very successful in healthcare process redesign, as long as the
team has an in-depth understanding of the aspects of a system that ensure the patient experience is
great, and improves or maintains these pieces. is is why it is imperative to partner with and have
strong clinical advocates on the process improvement team. ese advocates understand clinical
challenges and can help lend credibility to the ecacy of the redesigned process.
e term patient experience is simply dened as any aspect of interaction with or care received
by the patient. Patient experience encompasses everything that the patient and his or her family
encounter or perceive as part of the healthcare process or event, including quality of care, bedside
manner of caregivers, freshness of food, and cleanliness of facilities. Although a process redesign
may not immediately appear to have an impact on the patient experience, almost every process
can be tied back to this experience in some fashion. A PI team should always identify and work to
improve a piece of the process that will have a positive impact on patient care.
Process Redesign in Healthcare ◾ 119
An unfortunate reality of change management and process redesign in healthcare (as in many
other industries) is resistance to the unfamiliar or becoming entrenched in the trap of a “but that
is how we have always done it” mentality. One way to proactively avoid this potential road block
is to gain strong support from leadership and administration at the beginning of the project. In
addition, the more that frontline sta are involved in the potential solutions, the easier it will be
for them to accept the necessary improvements and changes. e necessary resources will vary
depending on the scope and size of the process redesign, with facilitywide processes potentially
requiring the support of the C-Suite (chiefs, vice presidents, etc.) or organization leaders. Meet
with these key management stakeholders to explain the full scope of the process redesign and what
it aims to achieve. Ensure that all of their questions can be answered and they are clear on the
vision of the project. If it becomes a hard sell to key leaders in the area of focus, then you and the
team may wish to consider other processes that could be redesigned for better outcomes.
Obtaining this administrative buy-in can swing the momentum of a project completely.
Management must understand the key aspects of the process redesign, otherwise they may be
unable to address concerns that their department may bring up. However, if sta leadership rec-
ognizes the value of the project and what can be expected to improve, they will become a much
more eective advocate for selling the future state than any outside department or resource. is
approval should be considered an integral step in a process redesign project; it can not only help
ensure success if obtained, but also lead to a complete project breakdown if ignored.
Frequent and regular meetings with department leadership at the beginning and throughout
the process redesign project can also create a forum of communication between frontline sta and
administration. Management may not be aware of certain breakdowns in processes that occur on
a regular basis. Hosting meetings that are focused on identifying these issues will often allow sta
to speak more candidly about the reality of their work, rather than continuing to work ineciently
to meet the expectations of the patient and their employer. e PI team member is uniquely quali-
ed to facilitate these discussions and the involvement of this objective resource can ensure that
the meetings lead to positive outcomes and understanding of critical next steps. Management may
also pose dierent types of questions than caregivers, and these considerations need to be given to
redesigned processes. An improvement in one department of a hospital may inadvertently disrupt
operations elsewhere, and administration may have a better picture of the entire system. e PI
professional should make sure that he or she is also keeping an eye on the bigger picture to fully
appreciate the systemwide impact of potential redesign solutions.
Project Example
Let’s look at a very straightforward process redesign project in a healthcare setting, and how
patient care should be considered.
Background
Fairview Hospital is a 350-bed facility that has been operating over or at capacity over the past 3
months. e lack of inpatient beds has resulted in Fairview having to divert patients to competitor
hospitals, a potentially signicant loss of revenue. Emergency Department (ED) boarder hours
(the number of hours patients are holding in the emergency department waiting for an inpatient
bed) have steadily increased. Last month, ED boarder hours reached a record high of 1,500 hours.
Another indicator that has signicantly increased is the facility’s average length of stay, from 5.4
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