Final Report_________________________________________

A Toolkit for Redesign in Health Care 

Prepared for: 

Agency for Healthcare Research and Quality 

540 Gaither Road 

Rockville, Maryland 20850 

www.ahrq.gov 

Contract No. 290-00-0014-7 

Denver Health 

Prepared by: 

Patricia Gabow, MD, Principal Investigator 

Sheri Eisert, PhD, Co-Principal Investigator 

Amit Karkhanis, Project Manager 

Andrew Knight, Value Analysis Coordinator 

Paula Dickson, Statistical Research Specialist 

AHRQ Publication No. 05-0108-EF 

September 2005 

The authors of this report are responsible for its content. Statements in this report should not be construed as endorsement by the 

Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. This document is in the 

public domain and may be used without permission. 
Contents

Introduction......................................................................................................................................1 

Description of Denver Health ..........................................................................................................1 

Forces Which Compel System Redesign/Transformation...............................................................2 

Redesign Planning Steps .................................................................................................................3 

 Step 1. Assess Readiness for Major Redesign...........................................................................4 

 Step 2. Establish the Perspectives for Redesign ........................................................................6 

 Step 3. Create a Structure for the Redesign Process..................................................................8 

 Step 4. Gather External Data .....................................................................................................9 

 Step 5. Gather Internal Data.....................................................................................................11 

 Step 6. Choose the Tools To Enable Redesign Implementation...........................................23 

Strategies for Translating Information Into Proposed Projects for Implementation......................28 

System Metrics...............................................................................................................................30 

Acronyms and Abbreviations ........................................................................................................44 

 

Figures 

1. Perspectives for transformation ..................................................................................................6 

2. Sample primary data collection tool: intern..............................................................................16 

3. Sample pie chart: trauma resident (24-hour shift) ....................................................................17 

4. Sample Pareto diagram: trauma nurse (24-hour observation) ..................................................18 

5. Sample Pareto diagram: trauma nurse and interruptions (24-hour observation) ......................19 

6. Sample value stream map: phlebotomy ....................................................................................21 

7. Sample area diagram: phlebotomy............................................................................................22 

8. Sample top-down format: laboratory test .................................................................................23 

Sample Forms

A. Site visit/conference call questions..........................................................................................32 

B. Employee focus group questions..............................................................................................33 

C. Confirmation letter for patient/family focus group..................................................................34 

D. Patient/family focus group facilitator questionnaire................................................................35 

E. Patient/family focus group consent form ................................................................................36 

F. Staff process flow observation form.........................................................................................38 

G. Patient process flow observation form.....................................................................................39 

H. Staff member consent form......................................................................................................40 

I. Patient consent form .................................................................................................................42 

Appendixes 

A. Review of the Literature .........................................................................................................45 

B. Definitions ...............................................................................................................................64 
1

Introduction

The broader and deeper the scope of the redesign effort of a hospital, the more likely redesign 

produces system-wide transformation. For the purposes of this project, “redesign” and “system 

transformation” will both be used to describe the desired process outcomes. 

In October 2003, Denver Health began a major effort to redesign/transform the process of care in 

the hospital in a comprehensive manner. This project was supported by the Agency for 

Healthcare Research and Quality through Contract No. 290-00-0014. 

This document presents the following information: 

• A brief description of Denver Health gives context for the redesign process. It enables others 

to identify the attributes of their system that are similar to or different from those of Denver 

Health and to assess how these attributes may influence their application of the approach to 

redesign described below. 

• Forces that compel health care systems to embark on redesign or system transformation. 

• Steps to be taken in planning for redesign/system transformation. In general, the steps are 

listed and discussed in the temporal sequence in which they occurred. Following these steps 

in this sequence will provide a robust approach for planning redesign. 

• Strategies for translating information gathered into proposed projects for implementation. 

This is presented to show the depth and breadth of activities which can emerge from the 

planning process. Some of the proposed projects which emerged from Denver Health’s 

planning process may be different from those that would emerge from another institution’s 

planning, depending in part on the forces that affect the institution and the information 

arising from its external and internal data gathering. However, delineating the projects 

provides examples for consideration. 

• Potential metrics for use in the implementation phase. The metrics would vary to some 

extent, depending on the nature of the projects to be undertaken. However, the system 

metrics that suggested here should be useful capturing meaningful change at the system level. 

The information detailed in this report provides an approach to redesign utilized by Denver 

Health. It is presented here with the intent to help others who wish to undertake the process of 

redesign or system transformation. 

The implementation phase has just begun, so this document does not provide information on the 

actual implementation of the redesign process or data on outcomes of redesign.

Description of Denver Health 

Denver Health is a large integrated, urban, academic safety net institution. Various aspects of 

this system are listed below. 
2

 Components of the Integrated System

• 911 system for City and County of Denver. 

• 398-bed acute care hospital with Level I trauma center. 

• 8 family health centers (federally qualified health centers). 

• 12 school-based clinics. 

• Public health department for the City and County of Denver. 

• 100-bed non-medical detoxification center. 

• Correctional care facility. 

• HMO for Medicaid, Child Health Plan, and commercial product. 

• Call center—regional poison center, drug line for national companies, nurse advice 

line, translation line, centralized scheduling. 

Demographics of Population Served 

• Approximately 150,000 individual users. 

• Approximately 70 percent of patients are members of ethnic minority populations. 

• 27 percent of the patients are non-English speakers. 

• 42 percent of charges are for uninsured patients. 

• $285 million in care to uninsured patients in 2004. 

Organizational Aspects of the System

• Is an independent government entity. 

• Employs 4,100 individuals, including physicians. 

• Has a formal academic affiliation with the University of Colorado School of Medicine. 

• Provides a learning environment for160 interns and residents at any given time, 

integrated with University of Colorado School of Medicine 

• Employs physicians who have a full time faculty appointments at University of 

Colorado School of Medicine 

Information Technology Structure 

• $225 million investment in information technology since 1997. 

• Integrated information technology across the entire system. 

• Single patient identifier for the integrated system. 

• Single electronic medical record across the integrated system. 

• Integration of financial, clinical, radiology, pharmacy, and laboratory data. 

• Computers in all clinic offices; chartless environment. 

• Initial phases of roll out of computerized provider order entry. 

 

All Denver Health community health centers, the hospital, emergency services, pharmacy, and 

laboratory systems use the same unique identifier for patients; thus, outpatient, inpatient, and 

ancillary service data can be linked to evaluate health services utilization, medication use, and 

provider compliance with guidelines. 

Forces Which Compel System Redesign/Transformation 

There are many reasons which compel all health care systems to embark on process 

redesign/system transformation. These include: 
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• Continued rise in hospital costs. 

• Concerns about patient safety and quality. 

• Little change in the core health care processes over decades. 

• Silos of care provision. 

• Little application of knowledge from other industries. 

• Enormous redundancies in care delivery processes. 

• Numerous patient handoffs. 

• Major workforce shortages. 

• Employee dissatisfaction. 

• Resident work hour limitations. 

• Limited involvement of the patients and their families in hospital care. 

• Patient dissatisfaction. 

 

Although the impact of each one of these factors may vary from system to system, all of these 

factors impact every health care delivery system to some degree. At Denver Health, of most 

concern at this point in time were the following: costs, safety, quality, lack of change in 

processes through the application of tools from other industries, redundancies in processes, and 

workforce shortages. This led us to focus on tools which addressed these major concerns. It is 

critically important for the leadership of a system to articulate these forces and how they 

necessitate change. 

Redesign Planning Steps 

After the decision on the need for system redesign was made, steps were taken to plan for 

process redesign as follows: 

1. Assess readiness for major redesign. 

2. Establish the perspectives for redesign. 

3. Create a structure for the redesign process. 

4. Gather external data. 

• Conduct a literature review. 

• Form an External Steering Committee. 

• Conduct site visits. 

5. Gather internal data. 

• Conduct employee focus groups. 

• Conduct patient focus groups. 

• Observe current processes. 

• Present data. 

6. Choose tools to enable redesign implementation. 

• Tools that facilitate process change. 

• Tools that facilitate change in the environment, culture, and/or workforce. 

It should be noted that this planning process took place over a 12-month period. The duration of 

this planning process underscores the need for a well thought-out sequence of events, which 
4

must be accomplished before a major comprehensive redesign/system transformation effort can 

begin. 

Step 1: Assess Readiness for Major Redesign 

Before launching a major redesign effort the leadership should address the readiness for 

embarking on hospital redesign or system transformation. This can be assessed in part by asking 

and answering the questions below: 

• What other redesign projects have been completed? 

• What were the lessons learned from these projects? 

• Does the workforce believe that there were benefits from implementing these projects? 

• Is there a compelling reason(s) for redesign? 

• Are top administrative, physician, and nursing leadership committed to redesign? 

• Can champions be identified and developed? 

• Is the culture committed to data and information sharing? 

• Does the workforce have the needed skills and tools to accomplish redesign? 

• Does the system have the resources to undertake the redesign process? 

It is important for both leadership and employees to identify and examine past redesign efforts. 

Once past redesign projects are identified, those responsible for managing the projects should 

develop a document which: 

• Describes project goals. 

• Determines if goals were achieved. 

• Describes the barriers to achieving the goals. 

• Delineates the factors contributing to success. 

• Identifies lessons learned. 

Sharing these past projects with everyone creates a sense that the organization has experience 

with successful redesign projects and therefore can successfully tackle system redesign. For 

example, Denver Health’s previous redesign efforts include improvements in both business and 

clinical processes. Business redesign efforts included: 

• The transition of the entire system from a department of city government to an 

independent government entity. 

• The development and implementation of a comprehensive information technology 

strategy for the entire hospital system. 

Clinical redesign efforts included: 

• Complete restructuring and integration of behavioral health with other system 

components. 

• Redesign of primary care processes. 

• Implementation of an open access system. 

• Diabetes disease management system. 

• Structured community outreach effort. 
5

At the beginning of this current redesign effort the participants in these past redesign efforts 

delineated the lessons learned. Many of these past lessons were validated as the current planning 

process evolved: 

• A compelling reason to change is needed. 

• Redesign must address issues people are battling. For providers, compelling reasons are: 

o Improving their ability to provide care. 

o Improving the quality of patient care. 

• All stakeholders need to be at the table. 

• Frontline people need to be involved and heard. 

• A leader for the change is crucial. 

• Leaders of change need the skill set to define issues and accomplish the change. 

• Consultants can be very helpful in providing expertise, but internal people need to lead 

the change. 

• Balance is needed between acquiring data to define the problem, implementing the 

intervention, and evaluating outcomes within a short time frame. 

• The need for cultural change must not be underestimated. 

• A well thought-out communication plan is necessary. 

• Key message must be something everyone can understand. 

• Expect and communicate failures, holdups, etc. as well as successes. 

• Education and training are essential. 

• Appropriate infrastructure must be available. 

• Education and training are essential. 

• Sustainability requires transformation; inability to go back to the old way is the best 

approach to sustainability. 

Many compelling reasons for change were identified. For management, a compelling reason for 

change is often financial, but for providers the most compelling reason is improvement in patient 

care or the process by which they can provide care. (This will be discussed further in Step 2.) 

Both top hospital management and clinical leaders must be engaged for successful hospital 

system redesign; the broader in scope the project the higher the level of staff who must be 

engaged in the redesign process. (This will be discussed in more detail in Step 3.) 

Hospital system transformation depends on democratization of data; the more comfortable the 

organization is with sharing and understanding data, the easier transformation will be. (This will 

be discussed further in Steps 4 and 5.) 

It appears that most health care workers do not have the necessary skill set for implementing 

major redesign. Therefore, the needed skills and tools must be identified and provided. (This 

will be discussed in more detail in Step 6). 

The system must have and be willing to commit sufficient resources to bring a project to a predetermined endpoint. Failure to do this will undermine future efforts. 
6

It may not be necessary to answer all of these questions on readiness before beginning the 

hospital redesign process, but there should be plans to quickly address all or most of these issues. 

Step 2: Establish the Perspectives for Redesign

It is valuable to establish perspectives from which the redesign process will be viewed. These 

perspectives will serve as guides to the redesign effort and will help focus process changes. 

Figure 1 served as a template of the perspectives for redesign at Denver Health and has helped 

guide the transformation planning effort. Health care systems are very complex, and the 

processes of care are so interrelated that multiple concurrent perspectives seem both valuable and 

necessary for successful redesign. For system-wide transformation, the perspectives for redesign 

and the areas of activity should include: 

• Quality 

• Safety 

• Customer service 

• Efficiency 

• Architecture/physical environment 

• Workforce development, including physician development 

Figure 1. Perspectives for Transformation 

 

Figure 1 shows that architecture, quality, customer service, workforce development, patient 

safety and efficiency all are perspectives from which to drive transformation. Each of these 

perspectives creates feedback loops between and within each perspective, represented by the 

dotted circle touching each of the perspectives and the broken line emanating from 

transformation back to the perspectives. For example, utilizing quality as a perspective can result 
7

in transformations in processes that not only improve quality but also improve customer service. 

All of the perspectives are surrounded and embedded in the culture of the organization. 

 

The process transformations driven from these perspectives are supported by information 

technology. Information technology is not the driver but rather the facilitating mechanism for 

achieving the desired change. However, it should be noted that Denver Health already has a 

sophisticated information technology system in place. 

Based on the research conducted for this project, it appears that other health care systems that 

have undertaken redesign/system transformation have adopted some of these perspectives and 

have used tools that translate these perspectives into action. For example: 

• Virginia Mason Medical Center used the Toyota Production System, or Lean, and 

appears to have focused on efficiency. 

• The Department of Veterans Affairs health care system appears to have utilized the 

perspective of safety to drive its transformation. Six Sigma tools can be used to 

implement redesign from this perspective. 

• Intermountain Health Care of Salt Lake City and those institutions engaged in the 

Institute for Healthcare Improvement’s Pursuing Perfection projects appear to have 

adopted the perspective of quality to drive system change. 

• Baptist Hospital, Inc. in Pensacola, Florida, appears to have primarily utilized the 

perspective of customer service to implement system transformation. Utilization of the 

Baldrige criteria appears to facilitate this approach. 

• The Planetree Institute model of patient-centered care includes concepts and new ways to 

design healing environments in health care systems and focuses on the physical 

environment for transforming health care delivery. 

• Some institutions that pursue magnet status in nursing appear to focus on workforce 

development to achieve redesign. To some degree, the use of Clinical Microsystem 

approaches which emphasize team functioning is a workforce development perspective. 

A number of these tools are discussed in Step 6. 

Clearly, these perspectives may overlap both in concept and outcome. Keeping all these 

perspectives in focus as one begins redesign of health care systems will help prevent 

suboptimization. For example, if the redesign initiative focused solely on efficiency, this could 

negatively affect customer service or workforce development. 

It is important to remember that system redesign or transformation must be embedded in the 

culture of the organization as reflected in Figure 1. Establishing an organizational culture 

committed to redesign or transformation cannot be underestimated. There are many approaches 

that help create this culture. These include, but are not limited to: 

• Giving the project an identity. 

• Communicating regularly with the workforce regarding the need for change. 

• Communicating the progress and impact of redesign efforts. 

• Actively engaging the workforce in the process of redesign. 

• Training the workforce to use tools that empower them to participate in the change. 

• Meaningfully engaging the leadership. 
8

Jonkoping County Council in Sweden, one of the leaders in health system redesign and 

transformation, named a major redesign project “The Esther Project,” thereby providing a human 

face to transforming the care process from primary care through hospital care. The Institute for 

Healthcare Improvement projects were called Pursuing Perfection. At Denver Health, the 

redesign project was entitled “Getting it Right: Perfecting the Patient Experience.” 

As in all change process efforts, communication is necessary. The communication approaches 

found helpful at Denver Health were: 

• Regular columns in the employee newsletter written by the Chief Executive Officer 

(CEO). 

• Lectures and discussions on the project to leadership, physicians, and middle managers. 

• An employee newsletter devoted to redesign. 

• A specific intranet site devoted to Getting It Right: Perfecting the Patient Experience. 

• Employee forums with the CEO. 

• Employees creating a code of behavior. 

These perspectives were proposed early in the course of the project and confirmed by the review 

of the literature, discussions with the External Steering Committee, and site visits. These 

approaches are discussed in detail in Step 4. 

Step 3: Create a Structure for the Redesign Process

Three components are needed in creating a structure for redesign: 

• Establishing a point person to lead redesign. 

• Developing a team to oversee the planning approach. 

• Developing a broad-based internal group of leaders and champions. 

The higher in the organization the lead person, the more likely that the redesign effort will be 

operationalized and sustained. All employees will understand the importance of this effort when 

it is led by a person of responsibility for the hospital system. At Denver Health, the 

CEO/Medical Director leads the redesign project. 

A core project team must also be formed. This group carries out many of the actual approaches 

used. Its composition depends heavily on the scope of the project. However, regardless of scope, 

one person must assume the role of project manager. The core team must include individuals 

with the competency to gather, analyze, and interpret the data. The addition of an industrial 

engineer or operations management engineer is an important member of the project team. The 

Denver Health core team included: 

• Industrial engineer 

• CEO/Medical Director 

• Value Analysis Coordinator (a nurse with clinical expertise) 

• Director of Health Services Research 

• Data and research analysts 
9

It is equally important to have broad-based operational support through the creation of an 

Internal Steering Committee whose members include providers and administrators at various 

levels of leadership in the organization and in many departments of the hospital system. This 

group can become the leaders and champions of redesign throughout the organization. 

The Internal Steering Committee should review information gathered at various stages of the 

redesign process, determine whether the information is valid and identify potential strategies for 

improvement. The members of this committee will also be key in assisting with the cultural 

change within the organization. Members can include: 

• Chief Executive Officer 

• Chief Operations Officer 

• Chief Information Officer 

• Chief Financial Officer 

• Chief Nursing Officer 

• Chief of Human Resources 

• Medical Director 

• Chief of the medical staff 

• Clinical department chairs 

• Director of Quality Improvement 

• Nursing Administration 

• Pharmacists 

• Laboratory Director 

• Materials Management Director 

• Nursing staff 

• Physician staff 

Step 4: Gather External Data 

There is always wisdom in learning from others. We found there were three helpful approaches 

in learning from others:

• Conduct a review of the literature. 

• Form an External Steering Committee. 

• Conduct site visits. 

Conduct a Review of the Literature 

Reviewing both the health care and non-health care redesign literature is both necessary and 

important. A separate literature review, focused on redesign efforts, was conducted (see 

Appendix A). This review utilized the six perspectives of quality, safety, customer service, 

efficiency, architecture/environment, and workforce development illustrated in Figure 1. 

Gathering this information is helpful in understanding not only current and past redesign 

initiatives, but also the applied theory behind the tools that have been used. 
10

Form an External Steering Committee 

During the beginning stages of Denver Health’s system transformation, it was beneficial to 

create an External Steering Committee consisting of leaders in health care and other industries. 

This committee included representatives from the following: 

• Hospitality industry. 

• Supply chain management industry. 

• Information technology industry. 

• Professional health care organizations. 

• Architecture firms. 

• Quality organizations. 

• Regulatory entities. 

• Payers. 

• Other health care organizations. 

The non-health care members provided different perspectives in reviewing data and different 

approaches for achieving meaningful redesign. These members had specific experience related 

to successful redesign and process improvement. Health care representatives provided insight 

into strategies they had tried and lessons they had learned from health care improvement 

projects. 

 

This external group met quarterly and members had individual quarterly telephone calls with the 

CEO. The quarterly committee meetings were structured half-day meetings chaired by the CEO. 

The group provided guidance regarding alternative approaches and insights into data gathering 

and interpretation. 

Some illustrative questions posed to the External Steering Committee over the course of the year 

were: 

• Were the lessons learned from past projects likely to be helpful in guiding the current 

effort? 

• Which institutions/industries should we consider for site visits and calls? 

• Is our assessment of the lessons learned from these visits the ones which are likely to be 

helpful in our efforts? 

• What is the ideal balance between training all employees and highly training a subset of 

employees? 

• Can many small projects lead to system transformation? 

• How many projects are enough? 

• How do we avoid suboptimization and unintended consequences? 

• What is best way to display and analyze all the process flow data? 

• What system metrics should we use to measure success? 

Conduct Site Visits 

If site visits occur, one must ask where to go, whom to send, and what data to collect. It is 

suggested that site visits or conference calls include both health care and non-health care 

industries. There is much that can be learned from the non-health care industries, and it is 

important that they be included. Examples of industries that could be visited or contacted are: 
11

• Aerospace. 

• Auto. 

• Airline. 

• Information technology. 

• Manufacturing. 

• Distribution or shipping. 

• Service sector. 

These industries have developed strategies and approaches to improve quality, efficiency, 

customer service, and safety. Some of these strategies and approaches can be applied to the 

health care environment to redesign health care systems. 

Health care systems have not reached the depth and breadth of redesign that other industries have 

achieved, but it is valuable to visit health care systems as well. Examples of health care 

institutions that could be visited include those that: 

• Have published or presented major redesign projects. 

• Have won awards. 

• Are magnet hospitals. 

• Are part of the Pursing Perfection project. 

• Have major new construction emphasizing a healing environment or safety. 

• Have pioneered implementation of health information technology. 

Nothing can take the place of a site visit to another organization, but much can be gained by a 

properly structured conference call with a leader in the redesign effort at that institution. The 

time and dollars saved by having a conference call rather than traveling to another site can be 

considerable. This is particularly true for some sites that charge fees for visits. 

It is recommended the team of individuals participate in the site visits and conference calls. The 

team should include a clinical person—a physician or nurse, an analyst and/or engineer, and a 

member of the Internal Steering Committee. These visits not only generate insights, but they also 

create organizational champions. Of note, when Virginia Mason began its system transformation 

effort, the entire leadership team was sent to a factory in Japan for 2 weeks to work the lines and 

learn first hand the Toyota Production System. This hands-on intensive approach has continued. 

Before any visit or conference call is undertaken, a standard set of questions should be 

developed. Form A is a sample list of site visit and conference call questions. 

Step 5: Gather Internal Data 

In addition to what can be learned from others, there is also much to learn from one’s own 

organization. Internal data gathering includes the following: 

• Conduct employee focus groups. 

• Conduct patient focus groups. 

• Observe current processes. 

• Present data. 
12

 

Conduct Employee Focus Groups

Employee focus groups are a method for gathering data, informing the workforce, and helping 

create a culture to support transformation. These focus groups help to determine the status of the 

institution from the employee’s viewpoint. To accomplish this, it is recommended that standard 

questions be developed and asked of all employees. Questions can be sent in advance so 

employees will be ready to contribute, and those who are unable to attend can send in their 

answers. Sample questions that can be asked of employees are listed in Form B. 

It is suggested that the focus groups be divided by categories of personnel, such as housekeeping 

or respiratory therapists. It is best to conduct clinical and nonclinical groups separately as their 

issues appear to be quite different. Focus groups were conducted with the following groups of 

Denver Health employees: 

• Food and environmental services. 

• Ward clerks. 

• Speech Therapists. 

• Occupational therapists. 

• Physical therapists. 

• Laboratory technicians. 

• Licensed practical nurses, health care technicians. 

• Radiology technicians. 

• Respiratory therapists. 

• Pharmacists. 

• Nursing leadership, charge nurses, nurse educators, nurse practitioners, nursing council. 

• Materials management. 

• Engineering. 

• Physicians. 

These focus groups should be conducted by someone at the executive level as opposed to 

immediate supervisors so that ideas and information can be freely exchanged. During the 

Denver Health project, all the groups were facilitated by the CEO. The meeting should be held 

at a time that will make it easy for the employees to attend, and the meetings should be no longer 

than 11⁄2 hours. Minutes should be taken or meetings should be tape recorded so that common 

themes can be documented. 

The minutes can then be sent to supervisors and executives responsible for these areas. Some 

employee suggestions can and should be acted on immediately even if they are not related to 

redesign. This immediate response will help build support and reinforce a culture for redesign of 

a hospital system. It is critically important to inform all participants that redesign will take time; 

and if they do not see their suggestions acted on immediately, it does not mean they are being 

ignored. 

The cross-cutting issues identified by employees can help prioritize areas for redesign during the 

implementation phase. At Denver Health, important cross-cutting issues identified to date from 

the employee focus groups are: 
13

• Desire for respect from other disciplines and employee groups. 

• Need for effective communication across disciplines. 

• Need for clear clinical escalation processes. 

• Desire for increased autonomy of non-physician health care professionals. 

• Need for process streamlining. 

• Need for greater ease of accessing small equipment such as wheel chairs. 

 

Conduct Patient Focus Groups 

Patient and family focus groups can provide insight into the care provided and other hospital 

experiences during a patient’s stay. It is important to include both the patient and at least one 

family member involved in the patient’s stay because each experiences different aspects of the 

care processes. 

It is suggested that patient/family focus groups consist of no more than 10 patients and 10 family 

members. This size allows for an expected no show rate of 1-2 families and allows for each 

family to contribute during the 11⁄2-hour time frame. It is best to recruit patients who have had a 

recent inpatient stay, such as within the previous 6 months. 

If your institution has a substantial socioeconomic, cultural, and language diversity in the patient 

population served, you may find it helpful to have different focus groups. For example, Denver 

Health had four sets of focus groups: 

• Insured English speakers. 

• Uninsured English speakers. 

• Insured Spanish speakers. 

• Uninsured Spanish speakers. 

If the patient and family member agree to attend, a confirmation letter can be sent to the patient 

(Form C), which includes time, place, and directions. Recruiting is also improved if a stipend or 

gift can be offered. 

It is suggested that a set of standardized questions be developed for the focus group. As noted 

above, the time should be limited to 11⁄2 hours. Form D provides sample patient/family focus 

group facilitator questions used at Denver Health. 

If the results of these focus groups are expected to be used for research, the protocol will need to 

be approved by the human subjects institutional review board (IRB). Form E is an example of an 

IRB-approved patient and family consent form for participation. If the focus group information 

is to be used for operational purposes only and is not to be published or presented, IRB approval 

will not be necessary. 

Patient focus groups at Denver Health revealed that patients want to be active participants in 

their care through shared information and shared responsibility. This concern must be 

considered in redesign. 

 
14

Observe Current Processes

It is essential to understand current processes before process redesign can begin. The value of 

this step cannot be underestimated both in the planning and subsequent choice of tools for the 

implementation phase. 

There are different approaches to depict process data. Each approach can provide different 

insights and answer different questions. Therefore, experimentation with data presentation is 

extremely helpful during the redesign planning phase. 

Before processes are mapped, it is necessary to identify who will conduct the observations and to 

define the scope of the process to be observed. It is also necessary to define a beginning, an end, 

and a methodology for all of the processes to be observed. 

The mapping team should include a nurse and analytical person and an industrial or operations 

engineer from the core analytical team. Observation ability and mapping improve with time; 

therefore standardization of the data collection tool and consistency in members of the team may 

be important. 

During process mapping, the following information is collected: 

• Name of process. 

• Process owner. 

• Process output/product. 

• Who is involved in delivering the process. 

• Who cares about the process. 

• Extent of the process to be mapped. 

• Activities that define the process. 

• Start point. 

• End point. 

The process-flow mapping can be conducted with patients, staff, and ancillary services with the 

mapping of movement of people, materials, and information. It is possible to map out any 

process or system in the hospital. It is advisable to meet with the supervisor of the group to be 

observed before proceeding, both to alleviate concerns about redesign project team staff who will 

be gathering information from the department or unit and to ask the supervisor what he or she 

perceives as problems. 

It is vital to monitor and document all of the important events during a patient’s stay, staff work 

shift, or the movement of materials and information. Through this information, operational staff 

will be able to identify the following types of events that can be changed to improve processes: 

• Waste (non-value-added time) such as travel or waiting time, searching, and gathering. 

• Bottlenecks. 

• Redundancies. 

• Points of dissatisfaction. 

• Inefficient use of workforce skills. 
15

Forms F and G are sample data collection tools for mapping process flows. Appendix B 

illustrates standard definitions for the patient and staff activities in flows. Standardizing 

definitions is important to ensure that the observers are documenting activities in a similar 

manner, which improves the reliability of the observations. 

A selection of business processes, ancillary service processes, and clinical processes will provide 

an overview of the range of hospital processes. Some of the processes and departments that may 

be selected for process mapping include: 

• Admission process. 

• Discharge process. 

• Food service. 

• Materials management. 

• Phlebotomy. 

• Pediatric patient stay. 

• Medical patient stay. 

• Trauma patient stay. 

• Obstetric patient stay. 

The admission and discharge processes are the patient entry and exit points. The clinical 

departments may be selected based on the highest volume clinical services. Patients, staff, and 

materials can be mapped for each of the relevant processes or departments. 

Providers selected for observation include nurses, interns, residents, and attending physicians 

working in pediatric, medical, obstetric, and trauma services. It is helpful to start with a 

relatively simple process such as food service before attempting more complex processes such as 

discharge. 

Forms H and I are examples of IRB-approved consent forms for participation by staff and 

patients, respectively. If this information is to be used for operational purposes only and is not to 

be published or presented, IRB approval will not be necessary. 

Present Data 

The information in this section illustrates different ways of presenting data to elucidate different 

problems. Please note that data as examples of redesign efforts that were undertaken are not 

presented here; process redesign did not occur in this planning phase. 

Once data are collected, the data can be entered or scanned into a spreadsheet for presentation in 

a variety of ways to address different questions. Figure 2 depicts a sample of data entries using 

the primary data collection tool. It shows the type of data collection tool that can be used to 

gather information for describing processes. 

In this example, the processes of a staff member are being recorded—in this case, an intern— 

using start time and end time for each activity, who the intern interacted with, and the category 

of the activity (Appendix B). The description of the activity can take two forms: an open-ended 

narrative description and a predefined categorical description. The predefined categorical 
16

description is useful for illustrating the data. This data collection tool can also be used to 

describe patient activities and processes. 

Time and type of activity are the major units in which processes are measured. Some of the 

ways that the data can be used to depict bottlenecks, redundancies, points of dissatisfaction, and 

inappropriate work force issues include the following: 

• Pie chart 

• Pareto diagram 

• Value stream map 

• Area diagram 

• Top-down format 

Figure 2. Sample Primary Data Collection Tool: Intern Time Start Time End Activity Duration Staff Member Interacted with Date Shift

Activity, NotesActivity Category

7:00 7:07 0:07 Intern 6/14/2004 D Writes progress note for patient Charting (progress note)

7:07 7:30 0:23 Intern 6/14/2004 D Waiting for rounds to start Waiting

7:30 9:08 1:38 Intern Physician team 6/14/2004 D AM grand rounds Rounds

9:08 9:35 0:27 Intern 6/14/2004 D Entering orders on Computer Entering orders

9:35 10:44 1:09 Intern Cardiology team 6/14/2004 D Cardiology rounds Rounds

10:44 11:00 0:16 Intern Resident 6/14/2004 D To see patient on 8 east Travel

11:00 11:02 0:02 Intern Resident 6/14/2004 D Discuss patient with resident Consult with provider

11:02 11:03 0:01 Intern 6/14/2004 D Break Down time

11:03 11:09 0:06 Intern 6/14/2004 D Entering orders on Computer Entering orders

Note: Data in this figure are for illustrative purposes only. 

Pie chart. Pie charts are helpful in providing a visual representation of the relative size of a 

component compared to the whole and other components. Figure 3 is an example of a trauma 

resident who was followed during a 24-hour shift. Time is the unit that defines this pie chart, 

and the different activities define different pieces of the pie. 

Figure 3 distinguishes between active and nonactive time using the activity categories from the 

data collection tool. This type of chart answers questions about staff tasks and activities during 

the shift and what percentage of staff time each activity takes. 
17

Figure 3. Sample Pie Chart: Trauma Resident (24-hour Shift) 

Trauma Resident

24-Hour Shift

Active vs. Down, Sleep and Call Time

Down, Sleep and Call Time

Total: 4 hours 11 minutes 

•2h 27m sleep

•1h 2m down time

•42m in call room

Active Time

Total: 19 hours 49 minutes 

•3h 54m consulting with 

other providers

•3h 7m attending to patient

•2h 42m charting

•2h 25m in surgery

•1h 45m travel

Consult with Provider

16%

Attend to Patient

13%

Charting

11%

Surgery

10%

Travel

7%

Other Active Time

26%

Sleep

10%

Down Time

4%

Call Room

3%

 Note: Data in this chart are for illustrative purposes only. 

Pareto diagram. Pareto diagrams display as a bar graph the activities being studied, arranged in 

order from largest to smallest. This tool is helpful in displaying staff activities and in depicting 

the ranking of activities. 

Figure 4 is a Pareto diagram that displays the time each activity consumes. Figure 5 displays the 

components of each bar as the individual activities that compromise the totality of the bar. This 

illustrates the total number of activities and the number of interruptions. For instance, Figure 5 

shows that the trauma nurse attended to patients on 38 separate occasions. Therefore, this graph 

identifies job interruptions, although not all starts and stops of activities can be considered an 

interruption. (A value stream map, described below, can help distinguish between the natural 

beginning and end of an activity and an interruption.) 
18

Figure 4. Sample Pareto Diagram: Trauma Nurse (24-Hour Observation)

5:14

1:43

1:301:29

1:18

1:081:06

:54

:41

:30 :27 :19 :18 :15 :12 :11 :10 :09 :09 :09 :08 :07 :07 :07 :06 :05 :05 :04 

0:001:122:243:364:486:00

Attending to Patient Charting - Flow Travel - Meds Travel Give Meds Report Consult with Nurse Charting - Meds Checking for Orders Meeting Education Procedure Equipment Waiting Computer Verbal Orders Consult with HCT Consult with Provider Gowning Assessment Review Patient Data Check on Patient Discuss Care Paperwork Telephone Discussing Care Travel - Supplies Travel - Equipment Consult with Clerk Pa

hours:minutes

Note: This Pareto diagram displays activities, ranked from those activities that consume the most time to those that consume the least. F

attending to patients consumed the most time at 5.14 hours, with charting ranking the second most time-consuming activity. Data in this 

illustrative purposes only. 
19

Figure 5. Sample Pareto Diagram: Trauma Nurse and Interruptions (24-Hour Observation) 

Note: This Pareto diagram displays the same trauma nurse’s activities during the same 24-hour period illustrated in Figure 4. Howeve

bar into the frequency with which a particular activity began and ended. For example, the “attend to patient” bar has 38 components re

the nurse attended to a patient. Data in this chart are for illustrative purposes only.

0

50

100150200250300350

attend to patient travel meds gives meds charting flowtravel consult with nurse charting med checking for orders consult with HCT telephone discuss carereport gowning review patient data equipment computer consult with provider meeting procedure travel supplies change bed check on patient consult with clerk education paging MD paperwork patient ass

t

Interval Duration in Minutes

 (38) 

 (23) 

 (21) 

 (19) 

 (16) 

 (10) (9) 

 (9) 

 (8) (6) (5) 

 (5) 

 (5) (4) (3) (2) (2) 

(2) (2) (2) (1) (1) (1) (1) (1) (1) (
20

Value stream map. A value stream map (i.e., a value-added or non-value-added [Visio] 

diagram) and process flow chart allow for the depiction of information and activity flow, 

indicating value-added and non-value-added activities for any type of process. These tools are 

frequently utilized in the Toyota Production System. Different shapes represent different events, 

such as activity, interruption, travel, wait, and downtime. This approach can help identify 

bottlenecks, redundancies, points of dissatisfaction, and inappropriate workforce issues. 

A value stream is all the actions (both value-added and non-value-added) currently required to 

bring a product (blood draw, patient discharge, patient meals, patient x-ray, etc.) through the 

main flows essential to every product. A value stream map takes into account the activities that 

make up a process and the management and information systems that support the basic process. 

A value stream map is useful for: 

• Helping visualize more than just the single-process level. 

• Identifying the sources of waste in the value stream. 

• Providing a common language for talking about hospital processes. 

• Making decisions about the flow apparent so that they can be discussed. 

• Tying together Lean concepts and techniques, thus helping to avoid targeting processes 

that can lead to isolated islands of improvement instead of improvement in wholeproduction processes.

• Forming the basis of an implementation plan. 

• Showing the linkage between information flow and patient/staff flow. 

Non-value-added tasks are tasks that do not contribute to what a patient/insurer would pay for, 

such as tasks that do not transform the product/output (x-ray, blood draw, discharge). These 

include: 

• Overproduction, typically using staff or equipment faster than necessary so they will have 

processes to complete. 

• Waiting for a person or machine to complete an automatic process or for supplies or staff 

to arrive. 

• Unnecessary transportation and rearrangement of people or materials prior to processing. 

• Process design flaws, requiring staff to intervene more often than necessary. 

• Stock on hand beyond any need to support normal operations or recovery from failures. 

• Unnecessary motion for searching, reaching, carrying, or positioning of equipment and 

supplies. 

• Production of defective goods. 

Figure 6 is a value stream map of a phlebotomist. This diagram distinguishes non-value-added 

activities, such as travel time, from value-added activities such as the blood draw itself. The 

time for value-added and non-value-added activities is represented by the “castle wall” line at the 

bottom of the diagram. The non-value-added activities are depicted through the high portion of 

the wall and the value-added activities are represented through the dips in the wall. The nonvalue-added time may be further distinguished into necessary and unnecessary activities. The 

necessary non-value-added activities should be minimized and the unnecessary activities should 

be eliminated. Figure 6 also depicts the communication activities involved in the process from 

the point of receiving a request for a blood draw to creating the product of a laboratory result. 
21

Figure 6. Sample Value Stream Map: Phlebotomy

Phlebotomy prints 

schedule for 

blood-draw 

(3 times/shift)

Phlebotomist walks 

to scheduled floor

Phlebotomist checks 

requisitions at nursing 

station

Phlebotomist walks 

to patient room

Phlebotomist 

draws blood 

from patient

Phlebotomist walks 

to transport box at 

nursing station

Phlebotomist drops 

blood sample in 

transport box

Transporter carries 

blood sample to 

core lab

Core la

blood s

PHLEBOTOMY HIGH-LEVEL VALUE STREAM 

MAP (CURRENT STATE)

Phlebotomist 

receives page

Phlebotomist 

carries blood 

sample to lab

Stat call

Phlebotomist 

calls back

4 Mins

2 Mins

1 Min

5 Mins

1 Min

1 Min

N. A.

N. 

Stat call

Nurse/Physician

Blood draw 

order is 

entered in 

POE
22

Area diagram. Figure 7 depicts an area diagram and is a representation of movement of staff 

throughout a geographic area. This could be a hospital campus, building, or unit. This type of 

diagram is useful in showing excessive and unnecessary travel. 

Figure 7 is an example of area diagram of movement through a hospital building for a 

phlebotomist. The circles depict stops and signify the start time for each activity—in this case, a 

blood draw. A pedometer may also be used to determine travel distance and would complement 

this data and illustration. 

Figure 7. Sample Area Diagram: Phlebotomy 

Phlebotomy Flow 

Main Hospital 

9

 8

 x2 

 end observation 

7

6

Western Addition 

5

4 4

3 3

1 Phlebotomist 

11 Blood Draws 

4 Lab Stops 

Total time: 1 hour 43 minutes 

Average time for blood draw and travel: 

9 minutes

2 2

Start 

111

Lab 

Note: Data in this chart are for illustrative purposes only. 

Top-down format. Figure 8 is a top-down format map. It shows the different activities, people, 

and their role in a process. This particular example illustrates the steps that occur between 

ordering a laboratory test and recording results in the medical chart. It also shows which person 

does each task. 

This type of diagram can be helpful in understanding the number of handoffs and the number and 

type of staff involved in a process. This depiction can help identify redundancies and inefficient 

use of the workforce. 
23

Observation of the current Denver Health process and the display of the data demonstrated that 

administrative, ancillary service, and clinical processes all offered many opportunities for 

improvement in efficiency, safety, customer service, quality, and workforce satisfaction. The 

observations particularly demonstrated the inefficiency in current processes including: 

• Redundancies. 

• Non-value-added activities, such as excessive travel. 

• Numerous interruptions. 

Redesign must address these core problems to be of maximal value. 

Figure 8. Sample Top-Down Format: Laboratory Test 

 Nurse/Resident/Physician Phlebotomist Transporter Lab Tech Physician 

1. Blood draw 

Ordered 

 

2. Phlebotomist 

receives blood order 

for print out from 

POE. 

3. Phlebotomist 

checks with nursing 

station on the floor. 

4. Blood draw 

taken. 

5. Blood draw 

recorded. 

6. Blood draw 

transported to lab. 

7. Blood draw 

received and 

analyzed by lab 

technician. 

8. Results entered 

into lab information 

(MYCIS) system. 

9. Results entered 

into patient medical 

chart, ready for 

physician to review. 

 

Lab Ordered and Results Recorded in Medical Chart

Note: Data in this chart are for illustrative purposes only.

Step 6: Choose the Tools To Enable Redesign Implementation

The majority of the health care workforce currently lack the tools needed to implement system 

transformation. Therefore, identifying the tools to be used in system redesign is a critical step. 

There are a variety of tools that have been used by both health care and non-health care systems 

for redesign. Many of these tools can be divided into two types: 

• Tools that facilitate process change. 

• Tools that facilitate change in the environment, culture, and/or workforce.
24

Some of these tool sets and their key characteristics are listed below. References providing more 

details on these tools can be found in Appendix A. This is not an exhaustive list of potential 

tools but rather those that have been used by others in health care and those considered here.

Tools That Facilitate Process Change 

Plan, Do, Study Act (PDSA). This is a model for testing ideas in rapid cycles that one believes 

may create an improvement. When undertaking an improvement to a system, there are three 

preliminary questions and four essential steps which are repeated until the desired outcome is 

achieved. PDSA builds in recognition that, with systems, it is unrealistic to expect change to 

produce the right result every time because there are often complex interactions and 

dependencies that can be disturbed in unexpected ways. It is always necessary to check that the 

predicted improvement has actually happened. 

The three preliminary questions are: 

• What are we trying to accomplish? 

• How will we know that a change is an improvement? 

• What changes can we make that will result in improvement? 

The four steps are:

• Plan: Who will do the work and when? 

What equipment or training do they need? 

How will information for assessing success be collected and recorded? 

When will progress be reviewed? 

• Do: Do the work according to the plan. 

• Study: Study the information gathered. 

Was the desired outcome achieved? If not what actually happened? 

• Act: Decide what action is needed; for example: 

o Adopt the change permanently. 

o Abandon the change. 

o Make some adjustments and start the cycle again. 

Additional information can be found at: http://www.tin.nhs.uk/index.asp?pgid=1130, 

http://apiweb.org and http://www.ihi.org. 

Lean (or the Toyota Production System). Lean thinking is a way to work more efficiently and 

effectively while providing customers with what they want when they want it. It is a philosophy 

and set of tools that aims to eliminate waste from processes. It also focuses on what adds value 

in processes from the perspective of the customer. The frontline workers are heavily involved in 

this approach. 

The 10 rules of Lean production can be summarized as follows: 
25

1. Eliminate waste. 

2. Minimize inventory. 

3. Maximize flow. 

4. Pull production from customer demand. 

5. Meet customer requirements. 

6. Do it right the first time. 

7. Empower workers. 

8. Design for rapid changeover. 

9. Partner with suppliers. 

10. Create a culture of continuous improvement. 

While the primary focus is waste, the outcomes of utilizing Lean tools are efficiency, quality, 

and customer service. Implementation requires a commitment and support by management and 

participation of all the personnel within an organization to be successful. Some institutions have 

implemented Lean using an onsite trainer from industry. Additional information can be found at 

http://www.lean.org. 

Six Sigma. Six Sigma is a disciplined, data-driven process that stresses eliminating defects and 

reducing variation while developing and delivering near-perfect products and services. This tool 

includes a rigorous improvement model known as DMAIC (Define, Measure, Analyze, Improve 

and Control). 

Six Sigma is the goal, which means products and processes will experience only 3.4 defects per 1 

million opportunities, or 99.99966 percent good. Six Sigma is a management strategy to use 

statistical tools and project work to achieve breakthrough profitability and quantum gains in 

quality. This is achieved by implementing process improvement, measurement-based strategies 

via Six Sigma improvement projects. 

The Six Sigma approach may benefit those organizations where existing process improvement 

efforts may have not delivered the financial benefits promised and where productivity goals are 

not meeting targets. This approach fits with the safety and quality perspective of redesign. 

Additional information on this tool can be found at http://www.6-sigma.com/. 

Tools That Facilitate Change in the Environment, Culture, and/or Workforce

Baldrige Criteria for Performance Excellence. The Baldrige criteria provide a business 

framework and tools to help improve organizational performance practices. The criteria are 

based on a customer- and process-centered approach that work to continually identify and 

improve key organizational processes with the goal of delivering better value to the customer. 

The Baldrige core values and concepts include visionary leadership, patient-focused excellence, 

organizational and personal learning, valuing staff and partners, agility, focus on the future, 

managing for innovation, management by fact, social responsibility and community health, focus 

on results, and creating value and a systems perspective. It appears that one of its values in health 
26

care is improving market share through achieving extraordinary customer service. Additional 

information can be found at http://www.quality.nist.gov/. 

Clinical Microsystem. Clinical Microsystem refers to the work developed by Dartmouth 

College which focuses on the smallest replicable unit that actually does the work. This smallest 

unit not only includes a team of people, but also the local information systems, client 

populations, space, and work designs. 

Clinical microsystems are the small functional, frontline units that provide most of the health 

care to most of the people. These units are the essential building blocks of the larger health care 

system. The quality and value of care produced by a large health system can be no better than the 

services generated by the small systems of which it is composed. The toolset used by these 

systems includes the “5Ps” (Purpose, Patients, Processes, Professionals, and Patterns). 

Improvements in clinical microsystems lead to transformation of the workforce and the culture. 

As part of measuring the impact of this tool on workforce development, the Institute for 

Healthcare Improvement (IHI) has suggested the use of a series of 12 questions (“Q12”) that 

identify staff engagement developed by the Gallup Organization. Additional information can be 

found at http://clinicalmicrosystem.org and http://www.IHI.org.

 

Talent profiling. Talent profiling differs from other tools in that it has as its prime focus the 

worker rather than the process. Its goal is to get the right person in the right job, based on an indepth understanding of the talent characteristics of each person and the most critically important 

characteristics needed to be successful in each role. Numerous consulting firms provide talent 

profiling services.

Consultants and training programs that teach these tools are currently adopting some concepts 

from each method for improvement such as “Lean Six Sigma.” Which tool is chosen may not be 

as important as the mere choice of a tool and the subsequent training of the workforce in the use 

of the tool. 

Training the Workforce To Use the Tools 

 Denver Health selected three tools to implement in the redesign process: 

• PDSA, which was in current use by the workforce, would continue to be used because the 

workforce had extensive experience and familiarity with this approach. 

• Lean was chosen as the principal tool set for process redesign as it appeared to best address 

the major issues observed in the current processes. Its focus on waste afforded Denver 

Health the most opportunity to reduce expenses—a step that was clearly necessary in order to 

survive in face of growing numbers of uninsured and decreasing revenues. Its focus on value 

from the customer perspective fit the customer service need. It also fit the organization in 

that it appeared to require a great deal of presence on the “floor” with observation, substantial 

intuitiveness, rapid-cycle improvement, and broad-based employee involvement and 

empowerment. 
27

• Talent profiling was selected as a valuable asset in matching employees with roles. This is 

particularly important in health care, an industry that is experiencing shortages and high 

turnover rates in some health care professions. 

After selecting the tool, the training strategy must be developed: 

• Who will be trained? 

• Who will do the training? 

• How will the content of the training curriculum be determined? 

All institutions, both in health care and in other industries (especially service and manufacturing) 

that have undergone substantial redesign or transformation, have committed to training the 

workforce in using the chosen tools. However, there are different approaches to training the 

workforce: 

• Intensively train all employees in using the tools. 

• Conduct “just in time” training for team members as they are assigned to work on 

projects. 

• Conduct general training for all or many employees coupled with extensive training of a 

small cadre of employees. 

There are advantages and disadvantages to each approach to training the workforce. At Denver 

Health, training the workforce in PDSA involved general concept training prior to the beginning 

of this redesign project. 

For the two new tools, Denver Health will adopt the strategy of general training for many 

employees with intensive training of a few. For Lean training, all executive team members and 

all physician department chairs will receive an introduction to Lean principles and tools; all 

middle managers will be trained in a broad overview of the tool. 

Twenty-five employees including three physician department chairs were intensively trained to 

become experts in Lean production and rapid process improvement projects in order to facilitate 

projects. These 25 employees (“Black Belts”) represent the majority of the hospital system’s 

departments and a broad array of disciplines. 

The Lean training tool was developed in collaboration with the Mid-America Manufacturing 

Technology Center Association (MAMTC). MAMTC is a nonprofit service organization that 

helps small and mid-size manufacturers increase their sales and productivity, reduce costs, and 

improve quality. One of the primary tools they use to help manufacturers is Lean training. 

Denver Health collaborated with MAMTC to adapt the Lean curriculum to health care by using 

examples from actual Denver Health hospital operations. 

The following courses were provided to the staff: 

• Lean Overview and Introduction

• Lean 101 

• Value Stream Mapping 

• Tools-5S System 

• Tools -Setup and preparation reduction 
28

• Tools-Standardized work 

There are various consultants and training programs available to teach Lean production tools. 

Some have begun to adapt their curriculum to the service industry, particularly health care. 

The Denver Health workforce will be trained in talent profiling using a similar approach to the 

Lean training approach. There will be a broad overview of the talent profiling tools for 

executives, physicians, and middle managers; a group of employees who will be those primarily 

involved in hiring staff will receive extensive training in using the talent profiling methods. 

Denver Health will work with a private firm on creating these profiles for the hospital workforce. 

Strategies for Translating Information Into Proposed Projects 

for Implementation

The lessons learned from external and internal data gathering were focused on three components 

of the system: 

• People 

• Processes 

• Communication and culture 

Therefore, the redesign projects and the system transformation which emerged from this 

extensive planning effort focus on these three areas. A strategy was developed for the approach 

to implementation of system-wide transformation through this information. The following 

describes the proposed projects for the subsequent implementation phase. 

People

• Lesson learned: The right person must be in the right role. 

o Planned response: Talent profiling. 

• Lesson learned: People should function at the highest level of their knowledge and skill. 

o Planned response: Increase role of nurses, nurse practitioners, and physician 

assistants. Expand ability of non-physician professionals in writing orders. 

• Lesson learned: Create champions. 

o Planned response: Establish cadre of employees with unique skills—the experts in 

Lean. 

• Lesson learned: Health care workers need new tools to allow them to redesign processes. 

o Planned response: Training in Lean, adoption of Clinical Microsystem concept for 

work groups, and talent profiling. 

Processes

• Lesson learned: Efficient, effective, timely, and accurate process flow requires use of realtime data on products and people. 

o Planned response: Develop mini command center for movement of materials and 

supplies and pilot test the use of radio frequency identification for one type of 

equipment. 
29

• Lesson learned: Match work teams with work demands. 

o Planned response: Change shift times and geographic distribution of workers for 

certain processes. 

• Lesson learned: System transformation is best accomplished through a balance of many, 

well chosen rapid-cycle projects and system projects. Core process redesign is best 

accomplished by those engaged in the process. 

o Planned response: The 25 trained “Black Belts” will conduct 50 rapid-cycle 

projects per year. Their process improvements projects will be focused on 

processes in their assigned and familiar areas of work responsibility. A small 

number of system-wide projects of high strategic value will be undertaken. 

Criteria were also developed to help select both system and small rapid cycle projects. These 

selection criteria are expected to help guide those trained in Lean tools in identifying projects 

and increasing the probability that these projects would be successful. Project selection will 

focus on those with: 

• High strategic value. 

• Substantial inefficiencies. 

• Identified champions. 

• A team that is ready for the task. 

• Good (albeit not assured) chance of success. 

• Institutional resources to bring project to completion. 

• Measurable outcomes. 

Communication and Culture 

• Lesson learned: Effective communication must be timely, complete, accurate, and come to 

closure. Communication can be synchronous or asynchronous. The former is necessary in 

health care, but the latter is more efficient. 

o Planned response: Develop multiple types of structured communication for 

synchronous communication, including: 

 Situation-Background-Assessment-Recommendation (SBAR) for nursephysician communication. 

 Defined escalation processes for clinical circumstances. 

 Multidisciplinary rounds with daily care plans. 

 Huddles/time outs. 

 Use of wireless devices. 

 Institute multiple approaches for asynchronous communication, including: 

 Text paging. 

 Secure e-mail. 

 Computerized provider order entry. 

 Picture archiving and communication system. 

 Feasibility assessment of single integrated (across all disciplines) 

electronic record on a clinical service. 

• Lesson learned: Create a culture of accountability and continuous improvement. 
30

o Planned response: Develop with employees a set of expected and preferred 

behaviors. 

• Lesson learned: Immediate rewards are important as incentives for improvement and 

alignment of corporate and employee goals. 

o Planned response: New employee bonus/rewards program. 

• Lesson learned: Corporate and employee goals must be aligned. 

o Planned response: New bonus/rewards program. 

 

System Metrics 

During the implementation phase of process redesign, those involved will want to know whether 

the process changes have improved the health care system. One can develop these system 

metrics from the initial perspectives that were chosen at the beginning of the process. As noted 

above, for Denver Health these were efficiency, patient safety, quality, customer service, 

workforce development, and/or architecture/environment. 

Defining the system measures before the project is started permits one to assess in advance if the 

measurement truly reflects the desired outcomes and determine if the data are available to create 

the measure. It is important to have the ability to acquire baseline (pre-project) data to measure 

the effectiveness of the change or intervention. It is important to develop a set of metrics for 

evaluating the impact of the many process improvements that will be implemented throughout 

the hospital system. In order for there to be replication of redesign efforts in other hospital 

systems, there needs to be an incentive for hospitals to invest in this effort. Both system-wide 

metrics and individual process improvement metrics need to be developed. 

Some common system metrics that can be considered are described in the following table. This 

table describes a variety of financial, operational, clinical, and employee variables and maps 

them to each of the six perspectives. For example, cost per discharge is listed as a variable and it 

maps to efficiency. Many variables represent more than one perspective, emphasizing the need 

to consider all six perspectives with system-wide transformation. Many of these system metrics 

are commonly reported by hospitals for ongoing operations and management, such as average 

length of stay (ALOS) and cost per discharge. Other metrics may require primary data 

collection, such as total travel distance and discharge process time. 

Given that there will be many concurrent rapid-cycle projects and system-wide projects, it may 

not be possible to identify which projects, singly or in combination were responsible for the 

change in a specific metric or metrics. In order to transform the system, it is not feasible to 

conduct one project at a time. However, each individual rapid cycle and system project should 

have specific metrics that address system-wide goals and perspectives. 
31

Table of System Metrics 

Measure 

Efficiency Patient 

Safety 

Quality Customer 

Service 

Workforce 

Development 

Architecture/ 

Environment 

JCAHO Core Measures1 X X 

Cost per Discharge2 X 

FTE per Adj Occupied Bed X 

ALOS (Total)2 X X 

ALOS for Top 10 Diagnoses X X 

Mean Wait Time in ED for 

Hospital Bed 

X X X X 

Physician Productivity (Relative 

Value Units) 

X 

Net Revenue X 

Medication Errors3 X 

Errors Related to 

Procedure/Treatment or Test3

 X 

Number of Cardiac Arrests (cor-0) X X 

Re-Admission Rates X X X 

Total Travel Distance X X X X 

Patient Complaint Rate X X 

Patient Satisfaction4 X X 

Discharge Process Time X X 

Risk Adjusted Mortality X X X 

Nurse Turnover Rate X X X 

Nurse Vacancy Rate X X 

Employee Turnover Rate X X X 

Employee Vacancy Rates X X 

Employee Satisfaction X X 

1 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Core Measures were designed to 

permit more rigorous comparisons using standardized, evidenced based measures in the areas of acute myocardial 

infarction), heart failure, pneumonia, pregnancy and related conditions, and surgical infection prevention. A 

description of these measures can be found on http://www.jcaho.org/pms/core+measures/core+measures.htm. 2 Metric can be compared pre- and post-implementation of process improvements and to University HealthSystem 

Consortium (UHC) benchmark. UHC, formed in 1984, is an alliance of academic health centers situated mainly in the 

United States. As a membership organization, UHC provides its 90 full members and 123 associate members with a 

variety of helpful resources aimed at improving performance levels in clinical, operational, and financial areas. 3

 The UHC Patient Safety Net is a data collection and reporting tool that allows member hospitals to identify and 

report patient safety issues. Through this system, Denver Health reports patient safety events and therefore will be 

able to identify improvements in patient safety. 

4

 Press Ganey administers patient satisfaction surveys to almost 900 hospitals throughout the country. On a weekly 

basis the hospitals send Press Ganey a list of inpatients for which Press Ganey selects a random sample to survey. 

Press Ganey calculates the percentiles and scores for these hospitals, including trends, and distributes results on an 

annual basis. Denver Health has been using this survey since 2001. More information can be obtained at 

http://www.pressganey.com/
32

Form A. Site Visit/Conference Call Questions 

Date: ____/____/____ Time: ________AM/PM 

Interviewer(s): ___________________________________________________________ 

Site/institution: ___________________________________________________________ 

Person(s) interviewed: _____________________________________________________ 

1. What was the motivation going in for a radical redesign? 

2. What are the goals for transforming your organization? 

3. What steps did you take to transform your organization? 

3⁄4 With leadership/management? 

3⁄4 With the frontline workforce? 

3⁄4 With culture? 

3⁄4 With input, from your customers? 

4. What were the timelines for this transformation for each of the steps? 

5. From your personal experience in health care, what processes would you change? 

6. What were the critical juncture points? 

7. What worked well during this transformation? What did not work well? 

8. What were the problems/issues that you confronted? What would you approach differently? 

9. Which of the components of these processes are transferable to other organizations, particularly 

health care? Which ones are not? 

10. What do you estimate were the costs of this transformation and the components of these costs? 

11. What was the role of information technology? 

12. What was the role of human resources? 

13. Where did you need to make organizational structure or key competency changes and how were 

these accomplished? 

14. Can you describe the most important end-results? 

15. Can you name the tools/concepts that you applied? For example, Six Sigma, Lean, etc. 

16. What other industries did you look at as for examples of redesign? 

17. What were the critical factors involved in maintaining the success and visibility of the projects? 
33

Form B. Employee Focus Group Questions

Date: ____/____/____ Time: _______AM/PM 

Department(s): __________________________________________ 

1. Are there parts of your job that you think someone else should be doing instead of you? 

2. Are there things you think should be part of your job that someone else is doing? 

3. What are the things that keep you from working efficiently? 

4. Are there things you see happening to patients that you think you should tell someone but you 

don’t know whom to tell? 

5. Given what you see every day, if you were a patient in the hospital what would you want to be 

different? 

6. What things would you want to do for yourself if you were a patient? What things would you 

want your family to be able to do? 

Notes: 
34

 Form C. Confirmation Letter for Patient/Family Focus Group 

Date 

Patient Name 

Address 

City, State, Zip 

Dear (PATIENT NAME): 

Re: _______________________ Patient Focus Group, April 13, 2004 

We would like to thank you and your family member for agreeing to participate in 

_________________ focus group on improving patient care on _____________, from 

____________. Please arrive by _____________ to register as a participant. The group meeting 

will held in meeting room____________________________________________ and will begin 

promptly. Doors will be closed by _________. In an effort to show our appreciation for your 

willingness to participate in this group, you and your family member will each receive snacks and $ 

________ cash. 

Below is a map to the _________________________. Parking is available in the public parking lot 

behind the building. Parking coins will be provided to you during the focus group session to allow 

you to exit the parking lot at no charge. Directions are provided below and a map is attached. If 

you have any questions, or need transportation assistance please contact 

________________________. 

Thank you, 

Directions: 
35

Form D. Patient/Family Focus Group Facilitator Questionnaire

Date: ____/____/_____ Time: ______AM/PM 

Patient group: __________________________________ 

Facilitator: ___________________________________________ 

Facilitator Title: _______________________________________ 

Questions for Patients and Families After a Recent Hospital Stay 

1. What were the most important events during your hospital stay? 

2. What were the most positive? 

3. Where there any negative events during your hospital stay? 

• How would you have changed it, or how would you have like to have seen it go? 

4. Did you receive enough information to make informed decisions? 

• Was the information presented in such a way that it was understandable? 

• What would you change? 

5. How much of their time is down time and how would they rather use it? 

6. What type of issues/events during the patient’s stay could be categorized as redundant or repetitive 

and how this affected the stay? 

7. How the patient may want to be engaged in the process of care? 

8. What types of information would you like to have access to, that would improve your stay? 

9. How would the patient like to use technology such as e-mail? 

10. Do you or your family wish to take part in your care? How would you like to participate? 

• Eat in a cafeteria. 

• Walk to other departments for tests/x-rays. 

• Assist with bathing activities. 

• Would you like to have access to your chart? 

Non-English speaking question: 

If your care provider spoke your native language would you trust them more or less than 

someone who needs a translator? 

Notes: 
36

Form E. Patient/Family Focus Group Consent Form

Project Description 

You (you equals you/your child) are being asked to take part in a research study of improving the way 

hospitals work and provide care to patients. You are being asked to be in this study because you or a 

family member was a patient in the hospital at ________________, where this study is taking place. 

You will be part of a group of ______ people. The other members of the group were also selected 

because they or their family member were in the hospital at _______________. Each member of the 

group will be asked about their and/or their family member’s hospital experience. You will be asked for 

ways you think this experience could have been improved. You will also be asked about the parts of 

your hospital experience that you thought were good. 

Up to _____ local subjects will be enrolled in this research study. 

Procedures 

If you agree to take part in this study, we will ask you to read and sign this consent form. You will also 

be asked to participate in a focus group that will take place at _____________ sometime during 

February 2004 through October 2004. This focus group will meet once, for 2-3 hours, to discuss your or 

your family’s hospital experience at __________________. 

Discomforts and Risks 

The study may include risks that are unknown at this time. 

Benefits 

This study is designed for the researcher to learn more about improving hospital care. This study is not 

designed to treat any illness or to improve your health. 

Study Sponsor 

The sponsor for this study is the _________________________________________________________. 

Cost to Subject

There is no cost to you for participating in this study. You will be paid $_____ for your participation in 

this study. If you arrive late or leave the focus group session before it has been completed, you will not 

be paid for your participation. 

Voluntary Participation and Study Withdrawal 

Taking part in this study is voluntary. You have the right to choose not to take part in this study. If you 

do not take part in the study, your doctor will still take care of you. You will not lose any benefits or 

medical care to which you are entitled. If you choose to take part, you have the right to stop at any time. 

If there are any new findings during the study that may affect whether you want to continue to take part, 

you will be told about them. The study doctor may decide to stop your participation without your 

permission, if he or she thinks that being in the study may cause you harm, or for any other reason. Also 

the sponsor may stop the study at any time. The investigator may withdraw you from the study if your 

participation in the focus group is having a negative effect on the other participants of if you arrive to 

the focus group session late or leave the session early. 
37

Invitation for Questions 

The researcher carrying out this study is __________________. You may ask any questions you have 

now. If you have questions later, you may call _________________. You will be given a copy of this 

form to keep. 

Confidentiality

We will try to keep your research records confidential, but it cannot be guaranteed. Records that 

identify you (including your medical records) and the consent form signed by you, may be looked at by 

the following people: 

• Federal agencies that oversee human subject research 

• Institutional Review Board 

• The investigator and research team for this study 

• The sponsor or an agent for the sponsor 

• Regulatory officials from the institution where the research is being conducted, to ensure 

compliance with policies or monitor the safety of the study 

The results of this research may be presented at meetings or in published articles. However, your name 

will be kept private. You will also be asked to sign a separate authorization form. This form will explain 

who will have access to your protected health information. 

Injury and Compensation

You should inform your care provider(s) if you decide to participate in this research study. If you have 

questions about injury related to the research, you may call _________________ at ________________ 

and/or your private physician. _________________ should be informed about any injury you experience 

while you take part in this study. If you are hurt by this research, we will provide medical care if you 

want it, but you will have to pay for the care that is needed. 

AUTHORIZATION: 

I have read this paper about the study or it was read to me. I understand the possible risk and 

benefits of this study. I know that being in this study is voluntary. I choose to be in this study. I 

know I can stop being in this study and I will still get the usual medical care. I will get a copy of 

this consent form. (Initial all the previous pages of the consent form). 

Signature: _________________________ Print Name ____________________ Date___________ 

 subject 

 Print Name ____________________ Date______________ 

 child 

Consent form explained by: _________________Print Name _________________ Date-

___________ 

Investigator ______________________________ Date ______________ 

 
38

Form F. Staff Process Flow Observation FormNote: Complete each field as necessary based on the staff activities observed. Observer Name: ___________________________ Department/Area: ___________________________ P Date: ____/____/____ Staff Member: _______________________________

Position Title___________________________  Time/Shift: ___________ 

Activity, Comments Interacted 

With 

Time 

Start 

Time 
39

Form G. Patient Process Flow Observation FormNote: Complete each field as necessary based on the experience of the patient. Observer Name: ___________________________ Department/Area: ___________________________ P Date: ____/____/____ Patient No.: (1) (2) (3) (4) (5) Time/Shift

Activity, Comments Interacted 

With 

Time 

Start 

Time 
40

Form H. Staff Member Consent Form

Project Description 

You are being asked to take part in a research study that is looking at ways to improve the way hospitals 

work and provide care to patients. You are being asked to be in this study because you are a medical 

staff member at _______________, where this study is taking place. You will be observed for the 

duration of your shift in the hospital. We will document where you go in the hospital and how long you 

stay there. We will also document the medical care you provide, the people you communicate with, and 

other tasks performed. The duration of these events will also be documented. 

Up to ___ local subjects will be enrolled in this research study. 

 

Procedures 

If you agree to take part in this study, your duties during you shift will not be changed in any way. We 

will ask you to read and sign this consent form only. From this point on, we will observe your 

movements throughout the hospital until the end of your shift. The information collected that could 

identify you on an individual basis will be kept in our records until ____________ and during this time 

will be kept confidential. You are being asked to be in this study because you are clinical staff that provides 

direct patient care in the _________________ Department. 

Discomforts and Risks 

The study may include risks that are unknown at this time. 

Benefits

This study is designed for the researcher to learn more about improving hospital care. This study is not 

designed to treat any illness or to improve your health. 

Study Sponsor 

The sponsor for this study is the _______________________________________________________________. 

Cost to Subject

There is no cost to you for participating in this study. You will not be paid for participation in this study. 

Voluntary Participation and Study Withdrawal 

Taking part in this study is voluntary. You have the right to choose not to take part in this study. If you 

do not take part in the study, your doctor will still take care of you. You will not lose any benefits or 

medical care to which you are entitled. If you choose to take part, you have the right to stop at any time. 

If there are any new findings during the study that may affect whether you want to continue to take part, 

you will be told about them. The study doctor may decide to stop your participation without your 

permission, if he or she thinks that being in the study may cause you harm, or for any other reason. Also 

the sponsor may stop the study at any time.

Invitation for Questions 

The researcher carrying out this study is __________________. You may ask any questions you have 

now. If you have questions later, you may call ____________ at (___)___-____. You will be given a 

copy of this form to keep. 
41

If you have questions regarding your rights as a research subject, please call the Institutional Review 

Board office at (___)___-____. 

Confidentiality

We will try to keep your research records confidential, but it cannot be guaranteed. Records that 

identify you (including your medical records) and the consent form signed by you, may be looked at by 

the following people: 

Federal agencies that oversee human subject research 

Institution Review Board 

The investigator and research team for this study 

The sponsor or an agent for the sponsor 

Regulatory officials from the institution where the research is being conducted, to ensure compliance 

with policies or monitor the safety of the study 

The results of this research may be presented at meetings or in published articles. However, your name 

will be kept private. You will also be asked to sign a separate authorization form. This form will explain 

who will have access to your protected health information. 

Injury and Compensation 

You should inform your care provider(s) if you decide to participate in this research study. If you have 

questions about injury related to the research, you may call ________________ at (___)___-____ and/or 

your private physician. ________________ should be informed about any injury you experience while 

you take part in this study. 

 

AUTHORIZATION: 

I have read this paper about the study or it was read to me. I understand the possible risk and benefits of this 

study. I know that being in this study is voluntary. I choose to be in this study. I know I can stop being in this 

study and I will still get the usual medical care. I will get a copy of this consent form. (Initial all the previous 

pages of the consent form). 

Signature:_________________________ Print Name ____________________ Date___________ 

 Subject 

Consent form explained by: _____________________Print Name ________________ Date___________ 

Investigator ______________________________ Date ______________
42

Form I. Patient Consent Form 

Project Description 

You (you equals you/your child) are being asked to take part in a research study that is looking at ways 

to improve the way hospitals work and provide care to patients. You are being asked to be in this study 

because you are a patient at ________________, where this study is taking place. You will be observed 

for the duration of your hospitalization. We will write down where you go in the hospital and how long 

you stay there. We will also write down who gives you medical care and what they do to you. 

Up to ___ local subjects will be enrolled in this research study. 

 

Procedures 

If you agree to take part in this study, your care will not be changed in any way. We will ask you to 

only read and sign this consent form. From this point on, we will observe your movements throughout 

the hospital until you are discharged and not ask anything else of you. The information collected that 

could identify you as a patient will be kept in our records until October 2004. Patients have been 

selected to participate in this study if they are admitted to the hospital or visit the emergency room at 

_____________ from ________ through ________ 2004. 

Discomforts and Risks 

The study may include risks that are unknown at this time. 

 

Benefits 

This study is designed for the researcher to learn more about ways to improve hospital care. This study 

is not designed to treat any illness or to improve your health. 

Study Sponsor 

The sponsor for this study is the _________________________________________________________. 

Cost to Subject

There is no cost to you for participating in this study. There are no procedures or drugs required by the 

study. All of the costs associated with your hospital stay will be billed to you or your insurance, just as 

they would without participation in this study. You will not be paid for participation in this study. 

Voluntary Participation and Study Withdrawal 

Taking part in this study is voluntary. You have the right to choose not to take part in this study. If you 

do not take part in the study, your doctor will still take care of you. You will not lose any benefits or 

medical care to which you are entitled. If you choose to take part, you have the right to stop at any time. 

If there are any new findings during the study that may affect whether you want to continue to take part, 

you will be told about them. The study doctor may decide to stop your participation without your 

permission, if he or she thinks that being in the study may cause you harm, or for any other reason. Also 

the sponsor may stop the study at any time.

Invitation for Questions 

The researcher carrying out this study is ______________. You may ask any questions you have now. If 

you have questions later, you may call ________________ at (___)____. You will be given a copy of 

this form to keep. 
43

If you have questions regarding your rights as a research subject, please call the Institutional Review 

Board office at (___) ___-____. 

Confidentiality

We will try to keep your research records confidential, but it cannot be guaranteed. Records that 

identify you (including your medical records) and the consent form signed by you, may be looked at by 

the following people: 

• Federal agencies that oversee human subject research 

• Institution Review Board 

• The investigator and research team for this study 

• The sponsor or an agent for the sponsor 

• Regulatory officials from the institution where the research is being conducted, to ensure compliance 

with policies or monitor the safety of the study 

The results of this research may be presented at meetings or in published articles. However, your name 

will be kept private. You will also be asked to sign a separate authorization form. This form will explain 

who will have access to your protected health information. 

Injury and Compensation 

You should inform your care provider(s) if you decide to participate in this research study. If you have 

questions about injury related to the research, you may call ______________ at (___)___-____ and/or 

your private physician. ________________ should be informed about any injury you experience while 

you take part in this study. If you are hurt by this research, we will provide medical care if you want it, 

but you will have to pay for the care that is needed. 

AUTHORIZATION: 

I have read this paper about the study or it was read to me. I understand the possible risk and benefits of 

this study. I know that being in this study is voluntary. I choose to be (or to have my child) in this 

study. I know I can stop being in this study and I (my child) will still get the usual medical care. I will 

get a copy of this consent form. Initial all the previous pages of consent form. 

Signature:__________________________ Print Name ___________________ Date________ 

 subject 

 Print Name__________________________ Date_________ 

 

Signature:__________________________ Print Name______________________Date__________ 

 legally authorized rep./proxy 

Consent form explained by: _________________Print Name _________________ Date______ 

Investigator ______________________________ Date ______________
44

Acronyms and Abbreviations 

adj adjusted 

ALOS Average length of stay 

CAT Computed axial tomography 

CEO Chief executive officer 

cor heart 

ED Emergency department 

FTE Full time equivalent 

h hour 

m/min minute 

HCT Health care team 

HMO Health maintenance organization 

IRB Institutional review board 

med medication 

MRI Magnetic resonance imaging 

PDSA Plan, Do, Study, Act 
45

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64

Appendix B. Definitions 

Staff Observation

Adjust equipment Adjusting any type of patient specific equipment such as an IV pump. 

Administrative Performing administrative or office type duties. 

Answer call light Answering a call light initiated by a patient or a patient’s family 

member. 

Answer telephone Answering the telephone. 

Answering page Responding to a page. 

Answers alarm Answering an alarm on patient-specific equipment such as an IV 

pump or cardiac monitor. 

Assessment Assessing a patient’s condition. A provider or a nurse can do this. 

Attend to patient Any nonspecific contact with the patient. 

Attending class Attending an educational class. 

Bathe patient Bathing or washing a patient. 

Calls for assistance Calling for assistance to help with a task. 

Charting Documenting in the patient’s medical record. 

Charting (flow) Documenting on the patient’s bedside flow sheet. 

Charting (meds sheet) Documenting on the patient’s medication sheet (usually performed by 

a nurse). 

Charting (orders) Writing orders in the patient’s medical record. 

Charting (progress note) Documenting the patient’s progress in the medical record. 

Checking for orders Checking the medical record for new orders. 

Cleaning Cleaning a patient room post-discharge. 

Cor-0 or Code blue Working in a code or Cor situation. 

Consult with nurse Discussing a patient’s medical care with a nurse. 

Consult with provider Discussing a patient’s medical care with a provider. 

Crushing meds Crushing or preparing medications before administration to a patient. 

Down time Time that is not used to benefit the patient, such as eating lunch. 

Entering orders Entering orders into a CPOE (computerized physician order entry) 

system. 

Gives meds Administering medications to a patient. 
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Lab draw Obtaining a specimen from a patient. 

Looking up labs Looking up laboratory results on a computer. 

Making copies Making photocopies. 

Monitors EKGs Watching the unit’s central cardiac monitor station. 

Obtain vital signs Obtaining vital signs on a patient. 

Obtains medication Obtaining medication(s) from the pharmacy or a medication 

distribution system. 

Office work Administrative duties related to the operations of a department. 

Pages provider Paging a physician. 

Paperwork Working on nonmedical paper work (e.g., payroll). 

Place page Paging other staff personnel. 

Procedure (simple) A nonsurgical procedure usually performed in the patient’s room (e.g., 

patient’s catheter). 

Procedure (invasive) An invasive procedure not performed in the operating room (usually 

performed at the bedside (e.g., a central line). 

Pyxis med station Automated medication-dispensing station. 

Report Giving or receiving report from another person, shift, or unit. 

Review med sheet Reviewing the patient’s medication sheet (usually performed by a 

nurse). 

Review chart Reviewing the medical record, checking for new orders, or checking 

for order accuracy. 

Rounds Attending patient care rounds (usually attended by physicians). 

Searching Searching for some item not readily available. 

Supplies Obtaining needed supplies. 

Surgery Performing surgery. This is done in the operating room. 

Talk to family Speaking with a patient’s family member. 

Technical problem Working on or fixing some type of technical problem, usually related 

to computer systems. 

Telephone call Making a telephone call. 

Transport Moving a patient from one area of the hospital to another. 

Travel Moving from one area of the hospital to another. 

Travel linen Traveling to a linen closet to obtain linens. 

Travel medications Traveling to a medication station or a medication room with the 
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purpose of obtaining medications. 

Travel supply Traveling to a supply station or a supply room with the purpose of 

obtaining supplies. 

Waiting A period of inactivity while waiting. 

Patient Observation 

Adjust equipment A clinical person makes any type of adjustment to patient-specific 

equipment such as an IV pump. (An example would be a nurse 

adjusting the infusion rate on the IV pump.) 

Admission process Patient undergoes any part of the admission process, such as an initial 

history and physical. 

Ambulates with nurse Patient walks around the unit with the nurse in attendance. 

Answer alarm A nurse or other clinician enters the room to attend to an alarm on a 

piece of medical equipment. 

Ask/answer questions Patient answers or asks questions of a clinical person. 

Assessment Clinician assesses the patient’s condition (may be part of a history and 

physical). 

Attend to patient Any nonspecific contact with the patient by a clinician. 

Baby assessment Assessment of a newborn by a clinician. 

Baby to/from nursery Transportation of a newborn to or from the nursery. 

Bathe Patient is bathed or washed by a member of the health care team. 

Blood draw Patient’s blood is taken either by a clinician or lab personnel. 

Care question Patient asks question(s) of a clinician regarding his or her care. 

CAT scan Patient undergoes a CAT scan. 

Check on patient A clinician looks in on the patient to make sure everything is OK but 

does not do anything specific or have actual hands-on contact. 

Cor-0 or Code blue The patient is involved in a cor or a code situation. 

Discharge Patient is discharged from the hospital. 

Discharge education Patient undergoes education before discharge (i.e., education on 

medications, wound care, etc.). 

Discuss care Patient discusses the plan or course of care with a clinician. 

Eating Patient is eating. 

Equipment 

placed/checked 

A clinician sets up and/or checks medical equipment in the patient’s 

room. 
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Evaluation Evaluation of the patient’s condition by a clinician. 

Examine patient Hands-on examination of the patient by a clinician. 

Feed baby Feeding of the newborn by hospital personnel. 

Gets dressed The patient gets dressed. 

Lab draw The patient has a specimen taken either by a clinician or lab personnel. 

Linen change Bed or linen is changed. 

Linens Linens are delivered into the patient’s room by hospital personnel. 

Monitor patient A clinician is at the bedside monitoring the patient but does not have 

any other contact with the patient. (Often the patient is unaware of this 

act.) 

No patient activity No activity from the patient. (The patient may be resting or sleeping 

during this time.) 

Paperwork Patient fills out paperwork (i.e., admission or discharge papers). 

Patient education Education of the patient and/or the patient’s family by hospital staff 

regarding their medical condition or clinical care. 

Patient leaves Patient leaves the hospital without being discharged. 

Placed on monitor Patient is placed on a cardiac monitor. 

Procedure (simple) A nonsurgical procedure usually performed in the patient’s room such 

as a catheter. 

Procedure (invasive) An invasive procedure performed at the bedside such as a central line. 

Receives food Patient receives food from hospital personnel (usually by food service 

personnel). 

Receives meds Patient receives medications from a clinician (usually a nurse). 

Recovery Patient recovers after surgery. 

Report Clinical or change of shift report at the patient’s bedside. 

Restroom Patient uses the restroom. 

Room maintenance Maintenance personnel enter the patient’s room to perform general 

maintenance. 

Rounds Medical rounds performed at the patient’s bedside. 

RT treatment Patient receives a respiratory therapy treatment (can be given by a 

respiratory therapist or a nurse). 

Shift report Clinical change of shift report at the patient’s bedside. 

Supplies Medical supplies delivered into the patient’s room. 

Surgery Patient undergoes surgery. 
68

Telephone call Patient makes a telephone call. 

Test performed Patient undergoes a noninvasive test such as an EKG. 

Therapy Patient undergoes therapy. 

Transport Hospital personnel transport patient from one area of the hospital to 

another. 

Uses call light Patient uses a call light to call for assistance. 

Visiting Patient visits with family or friends in the patient’s room. 

Vital signs Vital signs obtained by clinical personnel. 

Wait Period of inactivity while waiting. 

Walking Patient walks around the unit without assistance. 

X-ray Patient undergoes an X-ray procedure, either in the patient’s room or in 

the radiology department. (This does not include CAT scans, MRIs, or 

interventional procedures.)