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Process, Process, Process
Process, Process, Process

Bob Luttman
First, a belated Happy Thanksgiving! Hopefully the turkey went down well.

I have been working the last couple of weeks getting ready for the next cycle in the Massachusetts Award for Performance Excellence process. I am a senior examiner in this Baldrige Award based program. I have done this for many years and it always puts me in a process kind of mind.

Not that I am ever in any other kind of mind.

Cool Pathway Tricks, or what you can really do with all those pathways?

Okay, now you've got some pathways, or at least one or two. What can you do with them?

Plenty. Enough to keep you busier than a Florida vote counter.

Think about what a (good) pathway tells you:

  • What are we doing?
  • Who is doing it?
  • When are they doing it?

    What could you do with information like this?

    Let's start with some simple ideas and work our way up to more complex things.

    Resource Utilization and Scheduling

    Take all the pathways you have for patients currently on one nursing unit.Take all the activities for each skill type, multiply each by the time to do the activity. Sum. Factor in things like breaks, lunch, fatigue, and waits (say 20%). Factor in a little more for documentation and other administrative tasks. Divide by the hours in the shift. You now know many staff of each skill you need to take care of the patients on the unit.

    Beyond this you can use this technique to understand where all those staff hours are going. Maybe make some decisions about skill mix and/or who does what. Or maybe rearrange the workload to move some of the work to less busy shifts, or days. Maybe make priorities if you're short staffed.

    Cool? Not yet. One reason for staffing problems is uncertainty in patient volume and what activities are actually performed (this is variance analysis and we'll get to that after the holidays). Most managers I have known have scheduled for the average workload. But this means they are overstaffed half the time and understaffed the other half. You can of course adjust with variable staffing (on call, per diems, overtime, etc.).

    But wouldn't it be nice to know what's coming at you tomorrow? The day after? Again pathways can help. They can provide feedforward information: knowledge about what may happend so you can reduce some of the uncertainty in your staffing.

    Extend the anaysis we just did to tomorrow, call the floors you get patients from and have them give you the same information for patients they'll be sending your tomorrow. Return the favor to units you're sending patient to tomorrow.

    Keep going. Call the ancillary departments and let them know who will need a radiology procedure or a test or a procedure tomorrow, the next day, or the day after.

    Now this is not a perfect tool. Variances occur. Patients stay and extra day or two in the ICU (sometimes anyway), patients aren't ready for a procedure when the pathway says so. Like the weather forecast, it becomes less reliable more than 3-5 days out. But at least you know whether to bring an umbrella.

    Try this little experiment sometime. I assure you that, with a little practice and updated pathways, you'll learn how to use it effectively.

    This is not radical, or even new stuff. Industrial / Manage ment engineers have been doing this kind of stuff for decades; it is the backbone of most process planning and control systems. The current buzz word is "enterprise resource planning" or ERP (great post-turkey phrase) and a lot of guys with sandals and pony tails make a lot of money selling multi-million dollar applications to do this.

    All you need is a paper and pencil. And a good pathway.

    Where Have All the Dollars Gone?

    We have also alluded to the next step up the complexity ladder. Making decisions about staffing levels and skill mix; or more broadly, cost analysis using the pathway.

    Take those same pathways and activity times. Multiply by the cost of that time. Throw in supply costs. You now have the cost of doing that activity. This is a VERY rudimentary form of Activity Based Costing (ABC). Push a little bit further and dig into the administrative and overhead costs like documentation and order entry, narcotic counting, report, etc. Maybe some little boxes at the bottom of the pathway to capture the indirect time and expenses for a week or two to get a good sample. Now you can allocate these costs to patients. This is a little less rudimentary ABC.

    Now you can look at costs from an activity view. What patient types are consuming the most money? What activities are driving those costs? Or another view, what activities are consuming the money and what patients are receiving those services?

    Again, a back of the envelope approach, or a fairly simple spreadsheet. (I am also sure somebody reading this can sell you a solution as well). This is not a lot of data to collect and analyze. And once you've got it you can do all of this wonderful stuff.

    Wrapping Up Before Christmas

    This month's column was meant to spark some creative thinking. My theory is that quality begins with process and process knowledge. If you know your process you can begin to understand its various outcomes (such as costs) and what you can do to resolve poor outcomes.

    I hope this will stimulate some thinking, and some talking. Write me if you have any questions or comments ( or 508.359.9630), or use the quality discussion we've setup for this column.

    Happy holidays to all of you and those near and dear to you.

    Until next time,

    Bob Luttman is a member and contributor of HealthBond. View his expert page on HealthBond.
    Bob Luttman is Principal Consultant with Robert Luttman & Associates, a healthcare management consulting practice specializing in clinical pathways, quality and performance measurement, process improvement, and total quality management.

    As a leading healthcare and quality management consultant Bob has written and presented extensively on a variety of topics including Statistical Process Control (SPC) in healthcare and organizational performance assessment. He is actively involved in regional and national organizations, currently serving as the Healthcare Chair of the Boston Section of the American Society for Quality Control. In the past he has served as President and Board Member of the New England Healthcare and Information Systems Society. Bob is also a Certified Examiner for the Massachusetts Quality Award, based on the Malcolm Baldrige National Quality Award.

    December 6, 2000

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