Redesign challenge lies in making it stick
Clarify expectations, measure improvements
It's fine, even fun, to redesign your operations, says Donna Reck, MSN, RN, CNA, of PennState Geisinger Health System in Hershey, PA, but the important question is, "How do you sustain change?"
As a key player in designing a new preadmission center, she found that while physical and system changes can happen quickly. Attitude and cultural changes, however, take more time, adds Reck, who serves as director of the surgical division for the health system.
The goal was to address delays in operation room (OR) scheduling, long preadmission visits, and the resulting patient dissatisfaction with a one-stop shopping approach, she says. "The preadmission arena was fragmented, there were lots of pieces of paper, and patients had to give the same information to five or six people just to get into the hospital."
Taking the initiative, Reck says, "We rede-signed to streamline. We located all the services to one area to allow one-stop shopping except for the visit to the surgeon, we built in time to align information with business needs and discuss any concerns with the patients, and we considered coordination of their needs, such as travel arrangements."
Identify criteria for success
After a year of battling employee resistance, misplaced expectations and skyrocketing staff turnover, the hospital identified several criteria for success and for sustaining that success, Reck notes. (See boxes at right.)
Here are some essential elements Reck says that weren't in the initial process:
1. Communication and clarification are essential.
"It's very helpful to clarify expectations upfront," she explains. "What happened with us is that we redesigned this [preadmission process] from a physician focus to a patient focus, and focused everything on the patient. We looked at all the possibilities of what we should achieve from the patient's point of view, but did not clarify the expectations of the staff, the physicians, and the different managers involved." For example, one of the proposed outcomes of the redesign was that patients would complete a preadmission center (PAC) visit in two hours or less. However, it wasn't clarified with physicians that this would be a separate visit from when the patient came to see them or whose responsibility it would be to inform the patient of the new procedure.
Miscommunication leads to chaos
As a result of this miscommunication, the hospital was sending out letters letting patients know what to expect, but the physician was telling them something different, she explains. Told by the physician their preadmission testing would take only 15 minutes or so and could be done any time before surgery, patients would show up without an appointment and/or have unrealistic expectations of how long their visit would be, she adds. Despite the letter they'd received, "patients tend to remember only what the physician says."
2. Everyone should participate.
"We learned to include everyone, including physicians," she says. "We did have physician representatives on the committee for the design process who brought back information [to their colleagues], but there was a missing link on how many people they were actually able to get to."
Physicians who didn't understand the whole picture were filling in the gaps for themselves with how they thought it should go, she adds.
There is now a core group, involved in the redesign since its inception, that goes out to the staff meetings of each medical service and explains the reasons behind the redesign changes, she says. "This is very time-intensive, but we feel it will add value." That group includes the PAC's medical director, assistant manager, and Reck.
The hospital also has initiated a monthly schedulers' breakfast for all the employees who schedule for the physicians, she adds. "The [assistant manager of utilization review and the supervisor of preadmissions] answer questions and go over pieces of process and help educate them about insurance issues. It helps [the physicians' staff] to see why certain pieces of information are so important. It also helps by putting a face to a name."
3. Improvement measures need to be identified and monitored.
"It's critical to identify upfront items you can measure to see if you've been effective and to continue to monitor them throughout the process," Reck points out. Although the hospital appointed a quality committee and identified the items to measure, it didn't actually measure them, she adds.
"One of the key [participants] was promoted to another position so the committee never got together. We had hearsay, but no data, and couldn't show where we were improving or not improving."
In November 1997, six months after the PAC implementation, the committee redefined the measures and data collection began, Reck says. "It's not anecdotal now. We can go to people and say, 'I know you feel you're doing a good job, but the numbers show you have a 15% error rate, and we really want to keep it below 3%.'"
4. One-step rather than staggered implementation would be easier on the staff.
"We phased in the [medical] implementation service by service, and it took about three months," she says. "It was very difficult and frustrating for staff in admission and preadmission because they were working with patients processed in the old way and the new way, with different [kinds of] paperwork."
In retrospect, she would have delayed implementation, conducted intensive training, and made the change all at once.
5. Set more more reasonable expectations for employees.
The primary reasons given for the staff resistance and high turnover were schedule changes and the demand for cross-training, she says. Employees were expected to rotate through five different sections, learn all the aspects of those jobs, and become more autonomous in their dealings with patients, she says. In addition, they were asked to work extra hours until new people could be hired.
"We realized that was too much," she adds. "We decided we could break that down and let people choose two or three areas [to become proficient in] rather than five."
Also, Reck says, she learned that training employees for a redesign must be continuous, with refresher sessions as the process continues to be refined.
As a result of the changes that have been put in place, she adds, employee turnover has decreased, and there is relative stability in the PAC operation.
"We're able to show staff where they've gotten better, and we're breaking down and identifying areas that need improvement and working on them one at a time."
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