This article appears in the August 2012 issue of HealthLeaders magazine.
I n the mid-2000s, Sharp HealthCare was on two somewhat overlapping journeys, those grand goals that define health system improvement for large organizations. One was to fulfill its own self-appointed vision of the Sharp Experience, a service mission stated as "Become the best place for employees to work, the best place for physicians to practice medicine, the best place for patients to receive care, and ultimately the best health care system in the universe." Along the way Sharp also undertook the self-examination and improvement required for the Malcolm Baldrige National Quality Award, which it eventually achieved in 2007.
One of the core learnings along the path was that Sharp, for all its effort and lofty goals, still struggled to understand process, says Nancy Pratt, senior vice president for clinical effectiveness at Sharp HealthCare. "What is a process? What is a standard process versus a one-off process? Because in healthcare and in our organization we had a lot of individual processes that were not repeatable, and so you don't get the consistent results when you don't have a standardized, repeatable process," Pratt says. "There were some things that we needed to have on that consistent basis across the enterprise, whereas other things could vary for very good reasons. But to just have everything different because everybody feels like having it different wasn't going to make us successful."
It was important to make the distinction between what was an unorganized "collection of activities" and the goal of an "orchestrated process," Pratt says.
"People didn't understand that this collection of activities was a process and that we could map it as a flow. Just in defining it in a flow diagram, we could often see immediately what was wrong," Pratt says. Throughput in the emergency department was among the first processes to go through process mapping, and what they found was that physicians and nurses were not working in tandem as well as they could and that much of the patient experience was waiting.
"What we needed was an orchestrated process driven by a team where everybody understood everybody else's roles," Pratt says. "They knew what they were going to do. They knew the rough time frame they were going to do it in, and they accomplished it and got to a conclusion. And it happened so much faster because of that."
Blind process improvement for the pure sake of efficiency, however, is not the goal. Often process improvement efforts identify process waste that has an underlying patient safety or satisfaction reason, such as duplicate time spent with patients to make certain they understand their follow-up care plan. What has made the results sustainable has been that all process improvement is weighed against "what is value-added and what is not value-added to patient experience," says Susan Stone, vice president of patient care services and chief nursing officer for Sharp Memorial Hospital.
"What we did was really focus on reducing all the waste from the patient experience and what happened was that we saved our own time, saved our own redundancies and duplications of effort," Stone says. One of the biggest wastes identified was "multiple communications to multiple people," she says. When redundancies were eliminated and processes were standardized to optimize the patient experience, ED throughput was reduced from an average of 5 hours to 2.8 now. As a corollary, patient satisfaction jumped from the 30th percentile to the 96th, Stone says.
"The overall patient experience is so much more purposeful and the team members are more satisfied because what they're doing is meeting the needs of the patients and themselves while they're at it. It's kind of one of those things where we were looking at it from the patient experience, but we're also going to be thoughtful so that it makes sense for us, too. At this point in time with healthcare reform … and reimbursements going down, we all need to work smarter, not harder. But while we do that, we can focus on what's most important—providing the best patient care experience possible."
What blocks many healthcare organizations from sustainable process is complexity. The thought of mapping hundreds if not thousands of distinct processes is daunting. What helped Sharp to map processes from the ED to ICU and beyond was rooting those processes against a handful of "critical functions," Pratt says.
"There are a core set of critical functions that we do on every patient. That was kind of the nugget of truth that allowed us to simplify this to what's real," Pratt says. "Those common processes occur across the entire healthcare delivery system and all of those processes we identified key requirements for. When you do it at the macro level, then people can understand how it works for their individual jobs."
Those processes broke down into four stages:
Registration process: "Every patient that comes to our health system has a registration process, and there are critical things that have to happen there from a safety perspective to properly identify the patient," Pratt says. "There's an expectation that that happens at a rate of speed that's commensurate with what their needs are."
Diagnostic assessment: "There is an assessment process that needs to be done thoroughly and accurately by the right providers," Pratt says. "Even if it's a health maintenance activity, we're going to do some kind of diagnostic assessment. Those are critical processes that all have requirements to be safe, patient-centered, timely, efficient, and equitable."
Treatment process: "All of those patients are going to have some kind of treatment, whether it's health maintenance or to cure some process of illness that they have. So there's a treatment modality there, and there are critical requirements to that treatment process," Pratt explains.
Disposition/education: "Every patient is going to have some sort of education piece. If they're an outpatient, they're going to have some kind of instructions that they leave with. If they're an inpatient, they're going to have some instructions that they leave with," Pratt says.
Having consistent processes allows for an essential foundation of patient-centered care: customization. Susan Frampton, president of Planetree, a not-for-profit membership organization working to implement a comprehensive patient-centered model of care, says standardization and customization are not enemies.
"It all comes down to setting up systems up that allow for choice," says Frampton. "For example, every hospital has an admissions process. There's quite a bit of information that's collected at that time. And in a more traditional sense, it's always been information that clinicians think is important to have. A patient-centered approach would be to say, 'What aspects of the experience can we provide choice to patients around that will work for them and work for us? And what sort of systems do we have to have in place to support that?' "
An example would be patient-directed visitation. "You know, you add one question to that admissions paperwork that says, 'Who would you like to have available to you, and when would you like them to be able to be here?' And that information then gives the patient some choice about, 'Who is my support system, who do I need to have here?' If you have a system then where that same information goes into the care plan that the nursing staff is working with, and it's right up there with other important pieces of information—the nurses can really use that to help manage the patient."
This article appears in the August 2012 issue of HealthLeaders magazine.
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Jim Molpus is the director of the HealthLeaders Exchange.