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Process Observation and Measurement

Roger Gruneisen, MSSenior Manager

Quality, Safety, and Performance Improvement

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Exercise:  Process Observation

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Objectives

Describe methods to objectively see, measure or characterize a work process

Select the best tool to observe and understand a 

work process

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• Know the actual process 

• Obtain data before making decisions

• See variation in work process – presence/ 

adherence to standard work

• Ownership of tasks

• Actual time required to complete the task

• After intervention: to know if change is an 

improvement

Why We Go to See and Measure

?

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• Follow a person or a specific kind of information (e.g. physician order) to understand what or who touches the process

• Role of the observer is to note findings as they occur –analyze later with the team

Watch the flow a few times before mapping

More observations more valid results

Observation

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• Collect the evidence

•Use simple methods to explain evidence

Observation Is Not Always Straightforward

Write downwhat you see

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• Follow one patient, or one staff person

• Expose waste of motion/ transportation

• Reveals inefficient layouts

Spaghetti Diagram

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• Explain the task and rationale to the person you are shadowing and share your observations (drawing) when complete

•Do not ask questions while observing; keep the process pure

• If adding a second person to the map, change colors

Mapping One Person’s Travel Path

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Mapping the Unit Nurse

2008 Health Administration Press

Keep your pen on the paper; every 

step counts!

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Mapping the Patient and Tech in the Eye Clinic

Tech searching for doctor –Waste of MOTION

Patient evaluated, treated and transported through two identical rooms ‐Waste of TRANSPORTATION

Tech searching for supplies ‐Waste of MOTION

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•Used to measure cycle time and waiting/ walking time

• List of time and action (direct observation)

• Repeat the observation to learn most frequent cycle time (mode)

Time Stamping a Repeating Process

Log:

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Time Stamp: Patient Tracer Pre‐op Process

0615 Patient arrives in Day Surgery for 8 am knee surgery0616 Registration complete0645 Nurse calls patient to holding area0646 Patient changes into gown0654 Patient waits in holding area bay0714 Nurse pre-op interview with patient0744 Anesthesiologist pre-op interview with patient0755 Surgeon pre-op interview with patient, marks site0756 Nurse asks surgeon to update H&P0812 Patient is wheeled into OR

Time stamping  

patient flow

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• First patients were scheduled for physician at 8am but not seen until 8:06, 8:10, 8:12, 8:17

Time Stamp: On Time Starts, Room Utilization

Time Exam Room 1 Exam Room 2 Exam Room 3 Exam Room 4 Exam Room 5 Exam Room 6

7:45

7:46

7:47

7:48

7:49

7:50

7:51

7:52

7:53

7:54

7:55

7:56

7:57

7:58

7:59

8:00

8:01

8:02

8:03

8:04

8:05

8:06

8:07

8:08

8:09

8:10

8:11

8:12

8:13

8:14

8:15

8:16

8:17

8am                                                 Anticipated physician start time                       .

T + P = Tech and Patient or Patient Waiting

D + P = Doctor and Patient 

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Observe: Planned v. Actual

18 minutes late starting, but 15 minutes ahead of schedule after just 3 cases....Why?

Schedule Actual7:207:307:407:508:00 Gap8:10 Pre-Op8:20 In Room8:30 In Surgery8:40 Lx1 Lx18:509:009:10 Lx29:209:30 Lx29:409:50

10:00

Sx1Sx1

Sx2

GAP

Pre-OpPre-Op

Sx3

Sx2

Why did we schedule a gap in the OR day?

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Observe: Resource Utilization

Time of Day INF 1 INF 2 INF 3 INF 4 Utilization Waiting Room Utilization

9:50 2 0 1 2 50% 3 37.5%10:00 3 0 1 2 60% 1 12.5%10:20 3 0 0 2 50% 2 25.0%10:30 4 0 0 3 70% 3 37.5%10:40 3 0 1 3 70% 2 25.0%10:50 2 0 1 3 60% 2 25.0%11:00 2 0 1 3 60% 1 12.5%11:10 2 0 1 3 60% 0 0.0%11:20 2 0 1 3 60% 0 0.0%11:30 2 0 1 3 60% 0 0.0%11:40 2 0 1 3 60% 0 0.0%

Multi Observation Study

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•Displays movement of information

•Visualizes waste of over‐processing information

Communication Circle

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• Count people

• Count handoffs 

Communication Circle

Pre Admission Testing 

Coordinator

Supply Coordinator

OR Director

Office Admin Asst

Surgeon

Patient

Insurance Provider Hospital 

Surgical Scheduler

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Pre Admission Testing 

Coordinator

Insurance Provider

Hospital Surgical Scheduler

Patient

Surgeon

Office Admin Asst

Quantifying the Process with a Communication Circle

6 People &6 Handoffs

8 People & 12 Handoffs

Interventions: Created Standard Process & Implemented Kanban for Implants

Pre Admission Testing 

Coordinator

Supply Coordinator

OR Director

Office Admin Asst

Surgeon

Patient

Insurance Provider Hospital 

Surgical Scheduler

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Observation Guide – One Observer for One ED Patient: Check Sheet

Instructions:

Patient Acct #:

Admit Order Delays: Delay in finding chart Y/N

Delay in giving chart to coordinator Y/N

Patient needs further conversation Y/N

Doctor doesn’t have all diagnostic information Y/N

Waiting for consult Y/N

Prep for Admit Delays: Waiting for bed Y/N

Delay in writing report to unit Y/N

Inpatient RN not available to take report Y/N

Other Delays:

Adapted from: Value Stream Management for  Lean Healthcare. 2012.

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Observation Guide – One Observer for Many Patients: Check Sheet

Instructions:

Delay in

 finding 

chart

Delay in

 giving chart 

to coordinator

Patient needs 

further

conversation

Doctordoesn’t have 

all diagnostic 

inform

ation

Waitingfor consult

Searching for 

belongings

Transport 

unavailable

Waitingfor bed

Delay

in writing 

report to unit

InpatientRN not 

available to take 

report

Patient ID √ √

239990 √ √ √

190024 √ √

000345 √ √ √ √ √

689955 √ √ √

121147 √ √

720001 √ √ √

Adapted from: Value Stream Management for  Lean Healthcare. 2012.

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• Three tools

a. Spaghetti Diagram

b. Time Stamp (patient tracer or repeated process)

c. Communication Circle

Exercise:  Matching Problem and Tool

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•Why is it taking so long to transfer a patient from a PACU bed to an ICU bed? 

Exercise:  Matching Problem and Tool

Observe and Time Stamp

0600 _______________0605 _______________0610 _______________0612 _______________

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•Are the supplies in the most useful place for medical assistants to get what they need with the least amount of steps?

Exercise:  Matching Problem and Tool

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• Communication is error prone, and many calls and pages are required to make routine decisions

Exercise:  Matching Problem and Tool

Pre Admission Testing 

Coordinator

Supply Coordinator

OR Director

Office Admin Asst

Surgeon

Patient

Insurance Provider Hospital 

Surgical Scheduler

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Role of the observer is to note findings as they occur, without influencing the process.

Important to watch the flow a few times before mapping.

Spaghetti diagrams expose waste of motion and transportation and they may reveal inefficient layouts.

Visual mapping of communication handoffs illustrates the number of stakeholders of all communication in the process, displays movement of information, visualizes waste of over‐processing information.

Summary of Key Points

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Intended for internal guidance only, and not as recommendations for specific situations. Readers should consult a qualified attorney for specific legal guidance.