Master Class II

Process Design in Healthcare

Dr. Gaurav Thukral

DNB (Internal Medicine), PGDHM, PGDMC

COO, FORTIS OP JINDAL HOSPITAL RAIGARH

NABH Assessor, Member ISQUA

Brief

• Existing Processes

• Existing Capacities

Gaps

• Gaps Between Standards & Existing and problem identification

Prequel to Process Design

Gaps identification

Design of New Processes

• For Medical

• For Non Medical

Implementation & Audits

• Provide: Resources

2

Back to basics…..

1. Policy: Set of basic principles and associated guidelines,

formulated and enforced by governing body of an organization, to

direct and limit its actions in pursuit of long-term goals

2. Processes: Sequence of interdependent and

linked procedures which, at every stage, consume one or more

resources to convert inputs to outputsresources to convert inputs to outputs

3. Procedure: A fixed step-by-step sequence of activities that must

be followed in the same order to correctly perform a task

4. SOPs: Written procedure prescribed for repetitive use as

a practice, in accordance with agreed upon specifications aimed

at obtaining a desired Outcomes

3

PDCA

• Iterative problem-solving process

• By Dr. W. Edwards Deming

• Also known as;

– Deming cycle, – Deming cycle,

– Shewhart cycle,

– Deming wheel, or

– Plan-do-study-act.

DMAIC MODEL

• The DMAIC model stands for "define, measure,

analyze, improve and control: Within every step,

there is a variety of tools used to ensure you arethere is a variety of tools used to ensure you are

working toward the best improvement

recommendation(s)

Process Design in Healthcare

• While designing a process it must be kept in mind that dependency

of the process should be less on vigilance and hard work

• Process design metrics must focus on process reliability and not on

outcomes of the process

• Process design to enable quick response to industry developments

reduced risk of human error, and improved patient carereduced risk of human error, and improved patient care

• Design to focus on cost reduction, specifically costs on non-value

added activities like re-work, rejects, repetitive complaints

• Keep a mix of robustness and flexibility so that changes may be

made based on feedback and errors reported

Financial Implications

9

Why Process Design in Hospitals?

• To maintain high-quality standard of care

• To provide clear cut guidelines to every employee for

responsibility of total care

• To establish written protocols for every step in patient care

• For effective communication• For effective communication

• For Cost Reduction

• For Waste and Waiting Time Reduction

• For Management of Resources.

10

Types of Processes

Medical Processes Non Medical Processes

Patient Care Services Direct Patient Care

Emergency Care Services Patient welfare

Patient Care Services Sales and Marketing

Front Office

Nursing Care Services Indirect Patient Care

Critical Clinical Services Administration

ICU Protocols Purchase & Store

OT Protocols Maintenance Services

Surgical Safety Protocols Medical Record Department

Cath Lab Protocols Finance & Billing

Neonatal Protocols HR Process

11

Support Services

Blood Bank Services Laundry

Laboratory Services Security

Radiology Services BMW Management

CSSD Bio Medical ServicesCSSD Bio Medical Services

Rehabilitative Services: Physiotherapy Housekeeping

Clinical Nutrition

12

How to implement the process

Standardization of Policies

Implementation

Monitoring of measurable

matricesAudit

Role of Management

Allocation of

Resources

Assigning responsibility

as per the SOPs

Implementation of Processes Re-Audit

Accreditation

13

1.

1. Standardization Policies

1.

Healthcare Guidelines

14

– Top Management

» Middle Management

2. Role of Management

» Middle Management

• Lower Management

15

– Organization’s Support

– Manpower

3. Allocate Resources

– Manpower

– Machines/Equipments

16

Manpower Acuity and Headcount

17

4. Assigning Responsibilities as per SOPs

18

5. Implementation

Process Mapping

Process Re-engineering

TrainingPilot

Implementation

Implementation of Designed

ProcessesProcesses

19

5.1 Process Mapping

Radiology

Investigation

Registration

Patients walk into the

hospital

Lab. Investigation

Pharmacy

Patients walk out

of the hospital

Injection &

dressing

Consultation

20

5.2 Process Re-engineering

21

5.3 Training:

Need Assessment

Training Module & Train the Trainer

Feedback

Training Evaluation

22

5.4 Pilot Implementation

23

6. Monitoring of Measurable Matrices

• Medical Process Monitoring System

• Non Medical Process Monitoring System

• Patient contentment Monitoring System • Patient contentment Monitoring System

24

Parameter/Indicators Particulars

Hospital Infection Rate

CLABSI

CAUTI

VAP

SSI

Hand Hygiene

Incidence of pressure sore/1000 patient days.

Medical Process Monitoring

Adverse Incidents

Incidence of pressure sore/1000 patient days.

Death with in 48 hours of any surgical and non surgical

interventions.

Rate of returns to OT with in 24 hours.

Rate of returns to ER with in 72 hours.

ICU returns with in 48 hours.

NSI

Blood Transfusion Reactions

Incidents of fall

Cautery burns in OT25

Parameter/Indicators Particulars

Demography

Mortality Rate

Rate of Live Birth

Rate of Still Birth

Notifiable Diseases Notifiable Diseases

Utilization Rate

Down time of Major equipments

OT Utilization

ICU Utilization

26

NM Processes Monitoring System

Service on time

Asset Metric Unit Apr May Jun Target

OPD Patients waiting beyond 15 mins of appnt %

OPD Doctors arrving late for the OPD patients %

PHC %age PHCs completed within defined TAT %

ER Pts with LOS > 4 hrs in triage %

Wards Discharges before 11 am %

IPD ALOS %

IPD Pre-Op ALOS Days

OT Procedure / Surgeries starting within 30 mins of

scheduled time

%

Lab Med Short lead test completed with in 1hour 30 mins %

Radiology % of CT and MRI reports within 2hrs %

Radiology USG reports within 15 mins %

Service for all

Predictable service

Score = 1 = 2 = 3 = 4

Radiology USG reports within 15 mins

X-ray reports within 30 mins

%

OPD Calls Dropped %

IPD Admissions denied %

Pharmacy % of stock outs %

OT Surgeries rescheduled %

ICUs % Step downs planned %

Pharmacy % of (first) indents delivered within 30 mins %

F&B Average TAT for Room Service Orders Mins

IPD Time taken for new Admission Mins

OT % of admission on the day of surgery %

Billing Patients with final bill more than 5% of estimate %

Wards % discharges planned %

Wards Length of discharge process Mins

HK TAT for room cleaning post discharge Mins

% SCORE

27

NM Monitoring Overview

Assets MetricCurrent

Month Target

ER Pts with LOS > 4 hrs in triage

IPD Time taken for new admission

Star Assets

Assets MetricCurrent

MonthTarget

OPDPatients waiting beyond 15

mins of appointment

Wards Discharges before 11 AM

Laggards

Losers Star performers

AssetMetric Current

Month

Previous

monthTarget

ICU

Step down

Planning

Assets MetricCurrent

Month

Previous

monthTarget

PHC

% of PHC’s

completed within

defined time

28

IPD Operations: Patient Satisfaction Scorecard May June July

1 Total Number of IPD Discharges 322 300 379

2 Total Number of IPD Feedback Forms Collected 251 281 318

3 Percent of Discharges Covered 78% 94% 84%

Patient contentment Monitoring System

4 Overall Level of IPD Service Score 2.67 3.00 3.00

5 Overall IPD Patient Satisfaction Score 3.20 3.30 3.40

6 Reputation Index 3 3 30%

7 Positive Reference Index 80% 81% 87%

Over all grade A A A+

29

• Admission vs Patients met

• Overall level of services • Nursing

• Medical

MAY JUNE JULY

ADMISSION 314 298 318

PATIENT MET 295 277 297

PERCENTAGE 94% 92% 94%

0

50

100

150

200

250

300

350

ADMISSION

PATIENT MET

PERCENTAGE

Time spent by dr.to explain

diagnosis/treatment.

Attention from our Dr.team

May 3.3 3.3

June 3.3 3.3

July 3.5 3.6

0

0.5

1

1.5

2

2.5

3

3.5

4

May

June

July

• Overall level of services • Nursing

Attention from our Nursing team

Explaination about treatment,Procedure &

care at homeEfficiency Promptness Care & Warmth

May 2.8 2.9 2.8 2.8 2.9

June 3.1 3 2.8 2.8 3

July 3.2 3 2.9 2.8 2.8

0

0.5

1

1.5

2

2.5

3

3.5

4

May

June

July

0

0.5

1

1.5

2

2.5

3

3.5

4

May June July

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7. Audit

A process audit is an examination of results to determine

whether the activities, resources and behaviors that cause

them are being managed efficiently and effectively

Audit Preparation

Conduct audit & Analyze the

Result

Findings & Recommendations

31

Medical Processes Audit Report

Area %

Confr.

% Non

Confr.

Concerns Preventive/ Corrective

action

Action

closing time. IPD 67% 31% Admission and Discharge protocols

are not followed properly. patient

identification is not provided.

Antibiotic policy not implemented.

OPD patients are treated in ER.

Implementation of policy for admission

and discharge criteria, identification of

patient, sop's of ER/ICU/OT will be

provided within 1

month.

1 month

OPD 66.60% 27.70% No separate treatment room for

injection &dressing. Transportation of

OPD patients are delayed. Sop's for

SOP's for OPD given to head patient

services. Need to start

transport wing for OPD patients.

1 month

OPD patients are delayed. Sop's for

OPD not implemented.

transport wing for OPD patients.

ER 79.10% 20.80% ER policies not yet implemented.

Narcotic drugs are not available.

ER policies will be implemented with in

a month.

(MLC/Admission/discharge/BD/Evacuati

on/ code blue. license for narcotic drugs

not yet received.

1 month

ICU 61.00% 33.80% ICU policies not present. SOP's not yet

provide. Documentation part needs

to be improved.

ICU policies and SOP's will be

implemented

with in 15 days. Regular classes are

arranged for proper documentation.

15 days

32

Area %

Confr.

% Non

Confr.

Concerns Preventive/ Corrective

action

Action closing

time.

OT 79.50% 12.20%No separate staff for recovery.

Only one set for LSCS. Need

adequate linen for ortho. OT

sop's not present.TLD badges not

provided to OT staff.

Requisition for new instrument for LSCS

&linen for ortho OT given. OT staff ratio

needs to be improved.

15days

CSSD 88.80% 11.10%Sterile goods are not transported

in dedicated closed trolley.

Biological indicator not in use.

Instructed CSSD staff to transport sterile

goods in closed trolley. Signal locks are

used to check sterility.

closed

immediately

Biological indicator not in use. used to check sterility.

MRD 42.85% 35.70%ICD coding not done. No policy to

prevent unauthorized entry in

MRD.

ICD coding to be done from 1st

May.Policy to prevent unauthorized

entry in MRD needs to be implemented.

15days.

LAB 63.60% 36.30%Work instruction not displayed.

sample collection and dispatch

of reports not displayed.

Discussed with DR Harsha ,need fully

automatic machines.

Need to be

discussed.

Blood

bank

94.50% 5.40%PPE are not in practice. Blood

bank GDA not vaccinated for

Hepatitis -b.

Discussed with Dr Harsha(blood bank

incharge.) about not practicing PPE by

blood bank staff. Immediately Hepatitis-

b vaccine given to blood bank GDA.

Educated them about the importance of

PPE in blood bank.

closed

immediately

33

Non Medical Processes Audit

Area %

Conformance

% Non

Conformance

Concerns Preventive /

Corrective action

Action

closing time.

PWD 82% 18% 1month

Dietetics 70.32% 29% 1month

Purchase 84% 16% 1month

Store 76.8% 23% 15days

Bio-medical 86.9% 12%

34

8. Re- audit

It is important to go around the audit cycle for a second

time in order to discover whether agreed actions have

occurred, changes have achieved the desired

improvements and where changes were not required improvements and where changes were not required

standards continue to be met.

35

Audit & Re-audit Comparative Sheet

Sl. No. Process Audit observation Re-audit

observation

1 Medical process

Emergency Care Services

Patient Care Services

Nursing Care Services

24

19

34

08

04

12

ICU Protocols

OT Protocols

Surgical Safety Protocols

Blood Bank Services

Laboratory Services

Radiology Services

CSSD

32

35

25

29

31

28

24

09

13

09

11

06

26

28

36

Audit & Re-audit Comparative Sheet

Sl. No. Process Audit observation Re-audit observation

1 Non Medical process

Administration

Purchase & Store

Bio Medical Services

Maintenance Services

24

19

34

32

08

04

12

09

Dietary Services

Medical Record Department

HR Process

Finance & Billing

Front office

Patient welfare

Sales and Marketing

35

25

29

31

28

24

21

13

09

11

06

26

05

26

28

37

RECAPRECAP

38

Role of Management

Top Management Middle & Lower Mgmt

Standardized Policies

NABH & QCI Standard Guidelines

Assigning Responsibilities as per SOPs

Allocation of Resources

Organizational Support Man Power Machines

39

Measurable Monitoring System

Medical Process Monitoring System

Non-Medical Monitoring SystemPatient Contentment Monitoring

System

Implementation

Process Mapping Training Process Re-engineering Pilot Implementation

Re-Audit

Medical Processes Non Medical Processes

Audit

Medical Processes Non medical Processes

40

Accreditation

ISO NABH NABL JCIISO NABH NABL JCI

41

Excerpts from our story

• Mistake proofing

• Instrument Calibration

• Post surgical infection reduction • Post surgical infection reduction

• Safe Injection Program

• RRT: Code Blue Team

42

Mistake proofing

• Patient identification

• LASA

• High Risk Medicines

• Surgical safety checklist • Surgical safety checklist

• Pre operative checklist

• Ambulance checklist

43

Equipment Calibration

• Critical equipment calibration

– BP apparatus

– Glucometer

– Weighing Machines

– Thermometers

• Periodic calibration against standards

• PMS

• User trainings

• User accountability

• Audits and review44

1. Post surgical site infection reduction

– To Reduce the incidents of SSI. (PROBLEM)

– Policy for reduction of the rate of incidents.

(Standardization of policy)

– Processes in practice for infection free environment.– Processes in practice for infection free environment.

(Implementation)

– Monitoring the incidences.

45

Scope of Policy: Projects needs to stay focused on

root cause behind surgical site infections and

recommendations to improve practices related to

infection control only and not look into other

morbidities related to surgeries. morbidities related to surgeries.

Implementation: This project will likely require

changes in processes of patient assessment and

management during the peri operative phase.

46

Process Owner Medical Superintendent

Key StakeholdersAnaesthestists, Surgeons, Nursing, Diabetologists,

Pharmacists, Housekeeping Staff

Final Customer Patients

Expected BenefitsBetter outcomes of surgeries thus improving the

quality of Healthcare delivery

47

48

Base Line DPMO & sigma Level

49

50

51

52

Safe Injection Environment

• Multicentric observational study

• Process correction for injection usage

• Patient safety

• Employee safety • Employee safety

• Disposal of sharps

• Economic efficiencies

53

– Standardization of Policy as per the guidelines from:

• CDC,

• OSHA : 2007,

US Needle stick Safety and Prevention Act of 2000,

4. BD Program: Safe Injection

Environment Assessment Overview

• US Needle stick Safety and Prevention Act of 2000,

• WHO: 2010,

• WHO/ICN,

• Infusion Nurses Society, and

• NIOSH

54

System Wide Operation

Best Practice

Observed

• Puncture resistant

plastic containers

used for sharps

containment

• Use of needle

burners, compliant

with PCB guidelines

• Active tracking of

sharps injuries

DEVICE SELECTION PREPARATION ADMINISTRATION DISPOSAL DEVICE SELECTION PREPARATION ADMINISTRATION DISPOSAL

Product &

Practice Variation

• Many different sizes of

conventional needles used

throughout the network for

reconstitution and

injection

• Variability in syringe size

selected for flushing

• Safety engineered medical

devices and blunt fill/filter

needles not readily

available

• 3-way stopcocks selected

for IV access

• No standard method of

device evaluation

•Saline bags for flushing used

for multiple patients

•Vials not routinely disinfected

prior to inserting needle

•Needles routinely actively

recapped (using 2 hands)

•Variability in volume

used to flush IV lines

•Allergy condition of

patient not always

assessed

•Inconsistent

scrubbing of hubs

prior to IV access

•Needles actively

recapped (using 2

hands)

•Low awareness

regarding methods to

reduce injection pain

• Manual separation of

needles from syringes

observed

• Sharps collectors not

found at patient’s

bedside

• Needle mutilation not

consistent

• Open sharps

containers (not NIOSH

compliant)

55

Safety Assurance Roadmap

CATEGORY RECOMMENDED ACTIONS

IMPACT

EXPECTED OUTCOMECLINICAL

OPERATIO

NALECONOMIC

1) Develop and implement

standard device selection

criteria throughout the network

for injection, infusion and

disposal devices based on

recommendations by WHO,

CDC, INS, NIOSH

� � �

Reduced variability in

device selection will allow

for higher adherence to

standardised best practices.

This can lead to consistently

high quality of care, with

improved safety, reduced

risk and lower cost

throughout the network.

2) For medication preparation,

Eliminating sharps reduces

the risk of accidental

Device Selection

2) For medication preparation,

consider switching to blunt fill

and blunt filter needles to

reduce unnecessary sharps and

to reduce glass contamination

from ampoules

�

the risk of accidental

needlestick injuries for

healthcare workers. The

BD Blunt Fill Filter needle

reduces contamination of

glass particles up to 5

microns in diameter.

3) For skin injections, consider

evaluating safety-engineered

needles to protect healthcare

workers

� �

Adoption of safety-

engineered devices can

reduce the risk of accidental

needlestick injuries, and

help avoid the costs

associated with post-

exposure prophylaxis,

investigation and treatment.

BD EclipseTM is designed

for one-handed activation,

with minimal change in

technique required.

56

Process Designing

• Follow up on observations

• Modification of SOPs

• Training

• Implementation• Implementation

• Re audit

57

2. Rapid Response Team (RRT)

• Increased mortality on floor

• Delayed response to individual disaster

• Shortage of manpower Problem

• Delayed step up

• Policy – RRT

• SOPs - ACLS guidelines • SOPs - ACLS guidelines

• Training of the identified Team

• Implementation: Cards / Coder sheets / CPR Forms and Crash carts

with Defibs and Pacemakers

• Monitoring: Mock drills & Post event analysis

• Code Blue Committee

• Improvement In ROSC and Survival

58

CPR TO ROSC

• ROSC- RESTORATION OF SPONTANEOUS

CIRCULATION

• TIME– 20 min

59

CODE BLUE COMMITTEE

• To monitor quality of CPR delivery

• To strategize the improvement initiatives

• To assess CPR forms

• To address PC/ NC• To address PC/ NC

60

Steps of Planning

• Constitute Code Blue Committee

• Code blue policy- SOPs and Guidelines

• Crash carts with Defibs and Pacemakers

• Design ACLS coder sheet and CPR forms

• Mock Drills• Mock Drills

• Train the stakeholders

• Arrange ACLS/ BLS training sessions

61

Steps of Planning

• Code blue committee meetings

• Event analysis

• Improvement strategy

62

63

64

65

CPR to ROSC

76

9

12 1213

11

1416

1819

20

24

19

24

10

15

20

25

30

CPR to ROSC

0

4 46

0

5

66

Carry Home Points

• Process has to be independent , reliable , replicable

• Amenable to feed back

• Accurate problem identification / rectification

• Measurable and Auditable

• Based on standardized guidelines • Based on standardized guidelines

• Continuous quality improvement

• Patient centric

• Enhanced patient care

67

Fortis OP Jindal Hospital &

Research Centre, Raigarh

68