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

Patricia Stanfill Edens, RN, MS, MBA, FACHE

September 13, 2005

In This Article

Implementing Organizational Redesign

In the current work environment, success is enhanced if work is defined by processes, not tasks. Management structure often is cross-departmental, as middle managers assume responsibilities for multiple services within an organization. The development of service line management was a first attempt at a matrixed approach to management, rather than the more traditional hierarchical approach. As service line positions expand over several nonrelated clinical areas, the manager must find similarities in process. The move from function to process requires an education to the expectations of the role, whether management or staff (Clancy, 2003).

To redesign a job requires a shift in focus from a task, or group of tasks, to a focus on the process of work. The first step is to identify available resources that can be used to explore options. For example, a cross-functional team may come together to enhance the registration process of the outpatient with cancer who arrives twice a week in the infusion center. Having the right people involved, or on the bus, and knowing where to drive it are the keys to success (Collins, 2001). The patient should not have to wait in line in the hospital admitting and registration department at every visit. Team members from admitting, billing, the infusion center, pharmacy, and other involved departments may be empowered to redesign the process.

In one facility, the group decided to register the patient initially and have the registration staff available on call if any information changed. The patients were educated to the new process, told it was to save time and inconvenience for them, and involved in the responsibility of keeping registration information up to date. This process was not a new one to the organization because it was similar to how a patient receiving radiation is managed over four to six weeks of therapy. Any changes are electronically updated in the patient's file by the infusion center receptionist, and a copy of any changes in the insurance card is sent to registration and billing by the patient's nurse. The work redesign ultimately reengineered the process to be more patient friendly and stabilized the flow of scheduled patients who appeared at their appointment times without delays. The new process continues to be monitored to determine if correct registration and billing information is being captured. To date, the redesigned process is working for the patient and the center.

If the registration process is considered for reengineering, as opposed to redesign, the team basically is instructed to begin the redesign process with a clean slate with no discussion of existing procedure or activities. The team leader may begin the discussion by defining the desired end point and then asking the team to decide how to achieve that goal. Participants in the group must be empowered to reengineer the process after being informed of any constraints on the activity. Although it is preferred that no conditions are put on the initial discussion, this constraint may not be feasible. For example, if adding employees is not an option, team members should be informed in the initial stages of the discussion. The team leader might start the discussion by asking members of the group to define all the pieces of the admission process that need to be addressed without regard to existing procedures. By charting steps in the process, the group may visualize redundancy, bottlenecks, or immediate opportunities for productivity improvements. In a reengineering exercise, participants are not in a mode that protects the status quo or restricts creativity, rather it allows them to freely define best-case scenario.

Reengineering a process may take more time than restructuring an existing process but often provides greater benefit to the organization. A manager can redesign a bad process to be marginally improved, but reengineering is free of preconceived steps in the process. Reengineering, ultimately, may validate that the existing process is acceptable, but if that occurs too often, then opportunities are not being selected appropriately for review.

Once consensus is reached and the appropriate management review is complete, implementation occurs. Certainly major organizational changes may need to be tested before roll out to the entire facility. Depending on the process, a pilot may be indicated to validate the implementation plan (Sultz & Young, 1999). For example, electronic physician order entry may be piloted on one unit or with a single physician group to allow operational feedback to validate the theoretical process proposed by the team.

For redesign to be successful, regardless of the method used, several issues are pertinent. The team must be selected carefully to represent the skill set and knowledge base necessary to achieve the desired outcome. A management briefing related to the internal and external factors that may impact the efforts of the team is desirable, as team members may need an update on the current influences to be considered. Providing clear direction, guidance, and respect for the opinions of all team members and timelines for group work should precede any address of the topic. Because teams are cross-functional, cross-departmental, and may involve a variety of job positions, education of participants to the responsibility of team membership will contribute to the desired result.