Workplace Reengineering, Reorganization, and Redesign From Nursing Management: Principles and Practice

Patricia Stanfill Edens, RN, MS, MBA, FACHE

September 13, 2005

In This Article

Reengineering Measures

Management engineers tend to use quantifiable indicators, whereas clinicians tend toward qualitative measures. For example, a clinician might describe the appetite of the patient, whereas a management engineer will define caloric intake. Being able to identify a task and determine the measure of success requires the ability to complete a productivity analysis. Managers may be expected to reengineer a process or task as part of their job responsibilities. The following steps provide the nurse manager, without the support of a management engineer, with a guide to conduct an initial productivity analysis (Wolper, 1999).

The first step is to determine if the process or task is necessary. Why are you doing what you are doing? Is it because nurses always have been assigned to the task of giving baths since the inception of primary care? If it is determined that the task is necessary, then define the objective and the outcome. For example, if the objective is to decrease labor dollars per man-hour, could a different skill mix deliver greater hours of care at a lower cost without sacrificing care quality? Secondly, the manager should gather data such as staff hours, patient load, patient satisfaction, staff satisfaction, and outcomes on the unit or on a comparable unit. Involve the staff or other appropriate parties, and brainstorm around the topic of how might the unit decrease labor dollars per man-hour without suggesting any ideas to the group. Allowing free and open discussion may stimulate ideas that the manager had not considered. This may be all that is necessary to quantify what can be done to enhance productivity, define an action plan, and implement it.

Tools used in reengineering measures include smoothing, quality control, benchmarking, and, in some instances, statistics that may be incorporated into the analytical process to further validate the reengineering process. Tools to measure reliability or validity are useful as the level of management expertise develops. Recognition of bias in the analysis is also important. For example, the manager who favors an employee even though his or her performance is not up to par can invalidate a productivity analysis because workloads are not equal. Another approach with application to reengineering is smoothing. Given a set of tasks, are all completed in the morning and none left for other times in the day? Implementing something as simple as spreading patient care tasks among staff at varying times of the shift can reduce workload. Not all baths have to be given in the morning. Patients who usually bathe in the evening may prefer that to a frantic morning bath in between procedures and trips to radiology. Smoothing also can refer to management levels. Are multiple layers of management really necessary, or can fewer levels accomplish the same work and free up labor dollars? Clinicians often are promoted based on their clinical skills, when in reality, management skills are critical to the success of the organization. Once management skills are enhanced, they can be applied across the organization regardless of the clinical expertise of the individual.

Quality control is another management engineering tool that may be useful to the manager. By setting indicators and measuring on a scheduled basis, the manager can take corrective action before a situation gets out of hand. In the example given previously, reviewing labor dollars per man-hour each payroll period would prevent costs from escalating because corrective action can be taken promptly. Conforming to set labor hours or skill mix is similar to manufacturing standards, ensuring all widgets are alike over time. If policies are followed, outcomes should be the same to the point that patient variables allow. Benchmarking is another tool that is useful in quantifying performance measures between processes or facilities. A manager in a health system interested in comparing volume, revenue generated, and length of stay between facilities in the network could develop a comparison table (see Table 20-1 ) to benchmark the facilities against each other. By identifying the best performer, the manager can delve more deeply into what the facility is doing to provide more net revenue per case or shorten the length of stay.

Too often, healthcare providers say they provide good quality care, when, in fact, this is a nebulous description unless it can be quantified. Is quality defined as timeliness and accuracy of medications or a decrease in the nosocomial infection rate? Is it monitored over time? Are measures implemented to take corrective action? Whether it is called quality assurance, total quality improvement, benchmarking, or quality control really is not the issue. The issue is to define indicators, track them over time, and be prepared to take corrective action to deliver the optimal outcome.

Reengineering implies a much more involved process, beginning with a blank slate and defining new actions that may or may not include any of the current activities. Implementing an organizational redesign may be less complex but uses many of the same principles.