An interdepartmental work process in a hospital is a structured set of coordinated activities among various departments in a hospital that transform inputs into outputs. Processes are the strategic resources of a hospital which if managed to deliver outputs provide a competitive advantage. Processes seldom operate in isolation and need to be considered in relation to other work processes that influence them. In some situations, processes require observance to a specific sequence of steps. Well defined processes assist an organization in defining accountabilities, internal controls and work standards for compliance and consistent performance.
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All work processes are interdependent, that means the last step of one process, starts another. For example receiving results of an investigation test makes the last step of the investigation process but it leads to the first step in the admission or discharge process. Every smaller process usually feeds into another process which is often a part of larger processes. The patient flows through a series of processes during his journey in the hospital.
A process has the following characteristics:
A starting point and an end point. This is the scope
A defined group of users who will probably be a group of patients with similar characteristics or needs. This is sometimes called the slice
A purpose or aim for the outcome
Rules governing the standard or quality of inputs throughout the process
It is usually linked to other processes
It can be simple and short, or complex and long
The reason many organizations fail to adequately address and document their processes, as it is believed that everyone within the organization completely comprehends these processes. In a complex organization as hospitals employees have a broad or high level understanding of certain process flows, and a few know definite details of a couple of processes. But seldom do all employees have a reliable understanding of any one process and how it drives the affected parts of the organization.
Work process evolve over time, with changing organizational needs i.e. employee turnover, expansion, introduction of new technology etc. It would be foolish if a doctor treats a patient without understanding the patient’s medical history. The hospitals are businesses with ever evolving work processes yet these operate without continuously assessing applicability of work processes or without understanding why and how certain work processes evolved.
Different Work processes in a Hospital?
In an organisation as complex as hospitals a number of work processes are operating at any point of time. These work processes operate at different levels as intradepartmental and interdepartmental. A work process which seems to be as simple as providing a medication by a nursing staff to the patient also involves a defined work process which if not followed can lead to serious consequences. A slight deviation in work processes leads to inefficiency at some or the other area of the process.
The work process in a hospital can be divided on the basis of functional areas such as Medical and non-medical processes. Medical processes involves all the processes which involves any level of medical or paramedical professionals and patients. Non-medical processes include all the administrative and supportive processes which contribute to the functioning of a hospital and providing care to the patients.
Medical processes include all processes such as medical consultation, nursing, medication, investigations, surgeries etc. these are the processes which contribute to the medical care to a patient. Apart from the medical processes a number of non-medical processes also operate in a hospital. These processes can be as simple as providing a suitable diet to the patient to as complex as moving a patient from ward to operation theatre. All these non-medical processes operate in conjunction with medical processes and involves all sort of professionals.
Non-medical processes also involve a number of administrative processes operating at back end of hospitals. These processes include billing, admission, patient transfers, discharge etc. All these processes also operate in conjunction with medical processes and thus a delay in either of these can result in serious inefficiencies.
The processes in the hospital can also be divided as Interdepartmental or intradepartmental. Interdepartmental processes as name indicates involve processes which operate with two or more departments in conjunction with each other. Intradepartmental processes are the processes which include all the processes within a single department.
The hospital are the most complex organisation employing people with lowest to highest educational qualification. All the employees need to work in coordination with each other to deliver efficient and effective patient care. These work processes not only involve the staff but also depend on the patient being treated. The number of work processes operating in a hospital tend to increase with increasing number of patient and technology involved. These processes also tend to change due to involvement of large number of stake holders. Thus a clear understanding about the work processes operating in the hospital is very essential for all stake holders involved in the process.
Maintaining a clear guideline for the employees about a work process is very essential to ensure an efficient delivery of service. Standard operating procedures need to be developed with minutest detail about a work process. However developing Standard operating procedures does not suffice the purpose of efficient and guided work process. Clear observation and action with slightest deviation is required to maintain quality and efficiency of care. Managers in a hospital should be able to acknowledge the change in the work process as work processes in a hospital are widespread and has a very high tendency for deviation due to involvement of numerous handoffs.
Deviation in Work processes in a hospital not only leads to inefficiency or poor quality of service but also lead to dissatisfaction among the patient who are already in the state of despair, thus slight deviation in work processes add to their dilemma. The dilemma is high if the employees involved in the process are themselves not aware about what needs to be done or who is responsible for action.
The Medical processes if well-defined results in a better clinical outcome while other processes in the hospital improve patient satisfaction. As the demand of healthcare is increasing day by day, demand for better services is also increasing at an equivalent pace. The patient visiting hospital not only demand good care but also efficient and better services. In addition to satisfy a patient for his demand of good care, hospitals are these days facing increased challenge for satisfying another cadre of customers known as attendants and visitors visiting the hospital with the patient. These people are observing each and every activity in the hospital and are very important critic about the hospital processes.
The important processes which increase the anxiousness of the patients and visitors are administrative which they can easily observe and criticize. The processes include admission process, discharge process, interdepartmental patient transfers, diet delivery etc.
Admission process starts after the consultant decides an admission for the patient for continuous observation or procedure. The moment consultant orders an admission the patient joins the queue to get admitted and obtain a suitable bed for him.
The patient at the time of admission is already anxious due to the pain or suffering he is bearing which gets increased if the admission process is slow and takes long time. The patient satisfaction score keeps on falling down with increasing delay in the admission process.
The admission process in the hospital is an entry point for the patient in an IPD which as perceived by the patient involves only the front office department. In reality the admission is a process which can be delivered with efficiency only if other departments involved in it function as expected. An efficient admission process involves better bed management which can be achieved only after understanding the complexity of the system.
Another process which proves to be a pain for the patient and attendant is interdepartmental patient transfers. This include the transfers between ICU and wards, OT and ICU/Wards, between different wards etc. The patient after receiving information for the transfer of the patient is generally in a state of anxiousness as each state has a consequence attached to it.
In case the patient has been ordered a transfer from the ICU to Wards the anxiety of the attendant and patient increases as the family members and relatives of the patient are curious to know the state of the patient. Also any patient in ICU is considered to be in a serious state endangering life. After the patient is ordered a transfer to the ward there is a relief for the family who expects their patient to be out without delays.
The interdepartmental transfers are important for the patient and the hospital in terms of finance as well. As the bed occupied by the patient in the ward or the ICU is lined up to be allotted to another patient in need. Also the charges for the bed could not be recovered from the patient if the delay in transfer is on the part of the hospital. The same is the case for the patients who do not want to lose money in case their patient recovers a downgraded care.
NEED FOR IMPROVING WORK PROCESSES
A smooth and uninterrupted patient flow is desirable for an efficient and effective utilization of resources and revenue generation in the hospitals. Renowned obstructions to “patient flow” in hospitals include:
Difficulties in gaining admission to inpatient beds (i.e. inefficient bed management or insufficient bed capacity)
The congestion in the emergency department.
Incorrect retention of patient beds.
Need for improving different administrative processes associated with patient flow arises for efficient and effective management of hospital beds and other resources. The effective management of hospital beds is essential if the growing demand of inpatient beds is to be met.
With the limited supply of the medical resources and excess of demand, the hospital beds are in short supply. As the gap between the supply and demand of the resources reduces with each passing day, efficient utilization of available resources by means of an effective bed management is the need of the hour. To ensure a steady supply of beds for incoming patients, the processes for patient flow need to be improved to attain an optimal care.
As discussed in today’s time with increased expectations of the patient for good care and better services, efficient processes leading to steady flow of the patient which contributes to an improved patient satisfaction, better reputation of hospital and a faster turnover rate leading to higher revenues for the hospital is most essential requirement.
The need to improve work processes in hospitals has arisen of late because of
Present day patients who are:
Well informed and knowledgeable: Today’s patients are not completely dependent on the healthcare provider to decide for the service or care to be provided. With increased use and penetration of internet patient are well informed and gain knowledge about each and every aspect of care. They demand to know disease profile, treatment administered and side effects. They are also curious about various other processes and of the inefficiency of these processes in terms of money and time lost.
Value seekers: today the patient ask immediate attention in services. They have become more demanding and are not ready to adjust. They voice their dissatisfactions and opinions about the quality of service in medical care but also about the non-medical areas. The availability of various forums on the internet and media has transferred the power to the consumer.
Cost conscious: patient not only compare the prices of the services provided but also compare the value they got through services. The customers are not ready to accept a low quality service at any cost it comes.
Possess preferences: patients today have a range of preferences which they expect to be addressed by the hospitals. The hospital are expected to indulge the patients and attendants in various decision making and other services.
Desire customized services: With the increasing paying capacity of the patients with increasing income and improvement in insurance coverage, they are demanding customized services from the hospital in order to make their visit and stay at the hospital more pleasant. To acquire and retain new patient hospitals are expected to deliver fast and better services.
Perform continuous analysis: Patient grade a hospital on a number of measures or factors and are in a state of continuous analysis for the same. These include
Cleanliness of the premises and facilities.
Latest and cutting edge Technology available
Staffs’ behaviour and mannerism while providing services to the hospital.
Time spent by the care givers to impart patient information.
Action taken by the hospital for the suggestion given
Clarity and transparency of the hospital billing system
Systemic nature of the work.
Profitability of the hospital increases with increase in the number of loyal paitients because:
Lower cost of services: loyal patients are easier and cheaper to serve as they are familiar with the services and facilities, thus do not demand much. They are also less likely to make mistakes.
Increased sales: loyal customers reuse the services and tend to progressively increase the consumption thus improving sales.
Less price sensitive: as the relationship between the patients and hospitals strengthened over a period of time they become less price sensitive and are willing to pay a premium for better services. They are also less susceptible to competitors appeal as they are much more satisfied with the hospital.
Favourable word of mouth: the use of advertising in the hospital industry is minimal as designing an advertising campaign for services seems to be too desperate for the patients. The publicity for the hospital can be obtained by creating a positive and meaningful experience for the patients. Word of mouth publicity is the best medium of publicity available as it clearly demonstrates the satisfaction achieved by the patients through the hospital services. This enables a hospital to create a positive brand image in the market.
What is work process mapping?
Improvement efforts in health care have generated a variety of quality improvement and risk assessment methodologies such as, Healthcare Failure Modes and Effects Analysis, PDSA cycles, Lean and Six Sigma to name a few. A common pre requisite of these approaches is to understand the existing system before implementing improvement strategies. Any organization cannot evaluate, measure or improve its performance without properly understanding of internal processes. Most effective and a pre requisite to understand all the work processes operating in a hospital is process mapping.
Before improvements can be recognised for a process, a process’s anatomy should be understood. Process mapping is therefore a central component of quality improvement efforts in healthcare. Process mapping is a visual depiction of the work process. It displays the steps involved in a work process for a better understanding of work flows or for recognizing improvement opportunities in a process to reduce cycle time, avoid duplication of effort, prevent errors and reduce handoffs.
There are different forms of process maps with different levels of detail. A process map mainly focuses on who is responsible for a step/action, in what order and how long does it takes to complete a step/process. It depicts when and where important decisions are made. It represents the entire process from start to finish at a detailed level of inspection, allowing for exploration to optimize the workflow.
Process mapping also involves data collection that is done during the mapping process and while improvements are being made. The data collected are the real power of the process map. A visual of the work process shows a sequence of steps, but capturing and tracking the data is what tells the true story.
A process map can be used to identify gaps between what is actually happening and what has been determined to be the ideal process. It is a work in progress used to track potential improvements in a process by providing visual representations of the process before and after the changes are implemented.
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Process mapping requires cooperation and coordination, and promotes a better understanding across functional areas in a hospital. Another important benefit is the communication occurring between the staff, enabling them to observe and understand how their roles are interdependent. This results in a better acceptance of the accountabilities and contributions of each staff to the process.
Process mapping can provide a clear understanding of the work process which helps to identify prospects for improvement. Important enhancements can be made to improve workflow by eliminating insignificant or inefficient steps or combining steps in a process.
Apart from depicting the present state, process mapping is a useful tool to create a diagrammatic depiction of the ideal process. Prior to implementing major system upgrades process mapping can be used to restructure or reorganize the work process to support the fulfilment of the overall goal.
Process Maps gives everyone a wider outlook of what is actually happening. It has a potential to improve team work as it promotes ownership of the process and increases staff involvement in designing of processes. It is a moderately quick and inexpensive tool to employ, the main cost being the time obligation by the individuals.
Process maps are used to improve understanding of a process, to produce ideas for process enhancement or motivate discussion, build communication, and document a process. A process map often highlights problems, bottlenecks, duplication, delays, or gaps. Process maps help to establish process margins, process possession, process accountabilities, and efficiency measures or process metrics. Process maps are effective at improving process understanding during training. Process maps are not limited to a one department or function but are required for the holistic approach to hospital functioning.
Essentials of a good process mapping
First and foremost requirement to achieve a good process mapping is that Stake holders of a process should supply the information regarding the process which needs to be mapped should understand and support the reasons for the mapping exercise. The process map thus developed should be organized in a way that it enables all stake holders to clearly understand the process. Thirdly, the information assembled in the map should be verified with the stakeholders and validated.
The stake holders work directly within the process and have a better knowledge about the facts of a process. In order to map a process cooperation from all the stake holders is the prime importance to receive good inputs required for mapping the process to a perfect precision.
Apart from knowledge the stake holders are in a better position to inform about the problems encountered in a particular process and also the solutions which need to be looked upon for improving the process delivery.
The stake holders are sometimes too afraid to inform about the process due to a fear of downsizing. It is very important for the organisation to win the confidence of the employees. The fear of losing their jobs may prevent the employees from responding to the call of process mapping. It is important to inform the key stake holders about the objective of the process mapping exercise to obtain relevant information about the process. Most of the process mapping exercises fail as these do not consider the importance of stake holders in the process and only concentrates on the observation of the process. This approach omits the important information which required to be obtained for effective results as the stakeholders are assumed to perform simple tasks which can be logically deduced without their help. This limits the mapping exercise to analytically structured display of overviews. The process maps permits managers to actually analyse a process and then deduce a new process and implement it for the work process in association with the stake holders.
Obtaining cooperation from the stake holders and learning from the facts provided by them are two different things that are required to build an effective process map. The person building the map has to deduce specifics about a process by breaking down the process into the elements.
As previously discussed specific details about a process cannot be obtained without involvement and cooperation of the stake holders. To gather specific details about a process we need to focus not only on the process but rather on the individual items that are processed.
Process maps are not detailed because of the mapping technique. They become detailed because the process is detailed. They record reality and put us in a position to effectively understand and improve that reality.
To assure that data is actually valid, we need to verify our data from the stake holder involved in that work, at the work place, one step at a time or while observing it being done. When there are a large number of stake holders involved in the same work process, data should be collected from the most skilled. If a work process is followed through each step of the process while observing it at the work place then most of the faulty data is eliminated.
Illustration of process maps
We can illustrate the process maps using the following:
System Map – Informal and Formal
Top Down Chart
Block Diagram – Logic Flow Left to Right
Block Diagram – Responsibility Matrix
Block Diagram – Cycle vs. Process
Flow Process Chart
Work Flow Diagram
Swim Lane, or Deployment, Chart
State Change Chart
The System Maps are very useful when evaluating the systemic interplay between processes.
Informal System: It provides indicators to areas that cause concerns and delivers useful margin analysis. Its powerful root cause analysis and visual links guide process improvement efforts and leads to a conclusion within a short span of time.
Formal System Map: It represents a wide view which recognizes the process and the stakeholders’ necessities. It provides an early suggestion of functional gaps and assists in arranging them. The Formal System Map explains which stake holders provide which feedbacks to the process and defines high level activities in the process. This is called the SIPOC model, for Supplier-Input-Process-Output-Customer. When developed in concurrence with a thorough gap analysis, actual data makes a convincing case for change.
Top Down: The chart provides an excellent starting place. Three to five main activities that occur in process are described in the start. These are the “macro” steps. The “micro” or detailed steps that establish each of these macro steps are then analyzed. This gives us a thorough description of what is being done in the process.
Block Diagram: It is a flexible tool. It is so flexible that unlimited variations can exist. The commonly used formats include the Logic Flow, the Responsibility Matrix and the Cycle vs. Process Time charts.
Logic Flow: It represents the work process flow from left to right. This ordinary depiction eases understanding. The employment of key decision points makes the diagram valuable. The decision shapes and arrows allows interpretation of activities to follow for decision “yes” or “no.”
Responsibility Matrix: It simplifies the understanding of responsibility for each activity. Managers use this tool to determine and allocate roles and responsibilities clearly. In the matrix, the columns represent the activities and the rows represent the functions. The Cell connects the activity and the function using a symbol such as a solid dot (full responsibility) or a circle (involved). Managers uses the letters such as R, A, C, or I for the same. These represent responsible, accountable, consulted or informed.
Cycle vs. Process: The chart indicates the difference between “clock time” and “touch time” for activities in a process. The chart combines the flow of work left to right with timing information of each activity. The chart highlights the areas where there are severe delays. The tool is simple yet supports a substantial impact for improvement and change.
Flow Process: The chart, also called an Activity chart, provides thorough task-level information. It looks at specific value-added steps and irradiates potential non-value-added steps such as transportation, delay, rework, inspection, or storage. This view provides understanding about the steps and challenges they add to the total process. In combination with the Cycle vs. Process chart, it exposes reasons for difference between elapsed time and transformation time and facilitates activity based costing.
Work Flow: The diagram demonstrates movement of goods, people or information. The tool communicates spatial relationships. It identifies the area of bottlenecks in the process.
Swim Lane: The chart, also called a Deployment chart, identifies three questions, who does what and when. It lists the functional participants on the left and clarifies what each function does and their relations. It also determines areas and timings of hand-offs. It provides a wide perspective to cross-functional teams to clear an understanding of how they interact.
State Change: The chart allows brainstorming. By capturing “what state” information of each step, it mainly focuses on the customer needs. It is Strategic in nature as it investigates the requirements of activities rather than the method of performing these activities.
Process Mapping in Hospitals
Process mapping is a simple exercise. It is one of the most potent ways for multi-disciplinary teams to recognize the difficulties from the patient’s view, and to identify prospects for improvement. The patient is the only person who experiences the entire journey of hospital visit and stay. Process mapping helps the managers to appreciate this experience and an improvement team can take improvement steps based on facts rather than their opinions about a work process.
Process mapping helps to identify the areas of improvement which will have highest impact on patients and staff satisfaction. It helps managers and their teams to set targets and measures, and identifies methods of testing ideas before implementation.
Process mapping in a hospital enables the management and staff to visualize complexity in work processes which then enables them to brainstorm and thus improve the system and processes for efficiency.
Process mapping is required for hospital to impart a clear information to the employees about work processes and thus imparting knowledge at the time of induction and training. It improves the connectivity of the staff to the work processes who then are able to deliver the same with improved efficiency.
The problems in the processes which are otherwise considered trivial by the management can be addressed and the complexity of the process can be explained, this improves the confidence of the staff in the management who earlier believed to be demanding extra without putting an effort to improve.
A clear identification of the bottlenecks and problem areas help the management take improvement steps towards implementation. It also helps management to keep a track of improvement. Regular exercise of process mapping enables them to identify the areas of further improvement.
The management can take suitable efforts by identifying key areas for improving the quality of care delivered to patients while bringing a rational approach to work processes and contain the spiralling expenses.
The hospitals can apply various methodologies available in other industries for improving the processes but process mapping is an initial step which requires to be established to understand the process completely before implementing improvement steps.
While reducing cost of services and improving revenues is desirable by management, process mapping can be used to address the issues of quality, satisfaction and safety over cost. Delay in service cost hospitals loss of quality and satisfaction in addition to monetary losses. This loss is mainly because of the absence of standardization of the process. Process mapping enables management to address the issue of standardization of processes thus enabling improvement.
As hospital is a complex organisation with a large number of departments and staff with different qualifications and knowledge working together there is a problem of duplication of efforts. With process mapping this duplication of effort can be eliminated by identifying the areas of problem.
The process mapping can also enable a hospital move towards a human centred environment involving both the staff and patients thus improving the delivery of efficient and acceptable care to all.
Process mapping also enables the staff to understand discipline and developing relationships with managers and directors which is very important for an organisation to run efficiently.
Process mapping followed by an improvement exercise can save a lot of money for the hospital which will surpass the cost of putting an effort for the same.
Thus to summarize, mapping a patient’s Journey provide us with:
A start point for an improvement project, which can be tailored to suit organisation style
An opportunity to organize multi-disciplinary teams of all areas and line of work and provides a sense of ownership, accountability and responsibility
An overview of a complete process which helps the staff to appreciate, the complication of the system for patients. For example, number of stints the patient has to wait unnecessarily or the number of Handoffs in a process.
It helps us to identify the areas for testing the ideas of improvements that are likely to have the most impact on the improvement, It motivates the staff who normally do not have an opportunity to contribute to service organisation, but who really know how things work
An event that is collaborative and involves all the stakeholders to provide their views and ideas.
A process map which is easy to understand and highly visual.
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