Problem Statement

Massachusetts General Hospital (MGH) is the largest teaching hospital of Harvard Medical
Schoolandbestknownforconductingthelargesthospitalbasedresearchprogramintheworld,
withanannualresearchbudgetofmorethan$750million.(Wikipedia)MGHhasbeenhaving
beenstrugglingfinanciallyasaresultoftheincreasingcostofthehealthcareindustrysincethe
early1980s.
MGHperformsalargenumberofsurgeriesonadailybasis,amongwhichisCoronaryArtery
BypassGraftSurgery(CABG),whichinvolvespatientstostayinthehospital(LOS)foralmost
614days.BecausepatientscasesdifferintermsofLOSandtypeofhealthcareprovided,MGH
isuncertainoftheamountofresourcesrequiredduringeachpatientstreatment.
Asanattempttoimprovetheprocessofthehospital,Dr.DavidTorchiana(CardiacSurgeon)and
Dr.RichardBohmer(QualityImprovementAdministrator)areimplementingacarepathsolution
thataimstostandardizetheprocedureinallMGHdepartmentsandreducehospitalcostswithout
compromisingthepatientshealthcare.
ThecarepathsolutionintendstopreciselydefinetheproceduresofCABGtreatmentincluding
eachstageofthesurgery,fromhospitaladmittancetodischarge.Implementingsuchasolutionis
expectedtoreducethepatientsLOSby20to30%.
TheoldcarepathsystemimplementedbyMGHwasapaperchecklist,inwhichnursesare
requiredtorecordeachstepbyhandforeachpatient.Asthepatientisdischargedahardcopyof

completedchecklistiskeptinthepatientsfile,yetthatcarepathwasnotwellstandardized.
Dr.TorchianaandBohmerarenotintroducinganewtreatmenttechnologynorchangingthe
operatingprocedure;theyaresimplyattemptingtostandardizeprocedures,reducethepatients
hospitalstayandincreasesurgeonslevelofperformance.

Situation Analysis
Process Analysis
Step 1: Identify Opportunity
AfterevaluatingtheperformanceofMGHincomparetoitscompetitors,Dr.Torchiana
and Bohmer were inspired by the outcome of the care path implemented by the
orthopedic surgeon and saw this solution as an opportunity to improve the overall
performanceofthehospital.
Step 2: Define Scope
The scope of the care path solution could be considered narrow as the changes
implementedwouldhavenoaffectonthedeliveringvaluetopatients.Howeverwould
haveasignificantimpactonthehospitalperformanceinwhichthelengthof CABG
patientsstayinthehospitalwouldbereducedto5days.
The purpose of the care path is minimize any delay happens during the process of
admitting,treating,anddischargingpatients, optimizeresourceandcapacityutilization
whilemaximizingthequalityofcare.
Design Team

Implementingthecarepathrequiresformingacrossfunctionalteamtosetuptheprocess
ledbyDr.TorchianawiththehelpofDr.Bohmer.Additionally,allhospitaldepartments
arerequiredtocommunicateandcoordinatetocontributetothesuccessoftheproject.
Step 3: Document Process
Each step of the care path process must be well defined and documented. This
documentationwillenabletheteamtodetermineerrorsandfindwaysforimprovements.
Theleaderofthecarepathmustbecommittedtotrainandeducateallhospitalstaffto
knowtheirroleintheimplementationofthecarepath.Furthermore,inordertogainthe
patientstrustandinsurethedeliveryofqualityhealthcare,itisthedutyofthehospital
stafftoeducatepatientsaboutthecarepathprocess,throughdocumentedandvisualized
presentation

of

the

care

path

process.

Step 4: Evaluate Performance

Todeterminetheefficiencyofthenewcarepathprocess,theteammustevaluatethe
performance of the project in delivering quality healthcare and treatment, and
maintaininghighcustomersatisfactionrate.
Asuccessfulontimecompletionofeachstepinthecarepathprocessisafulfillment
oftheprojectpurposeinstandardizingtheprocessoftreatingpatients,shorteningthe
patientsstayinhospital,andoptimizingresourceandcapacityutilization.

Comparingtheoperatingcostsbeforeandaftertheimplementationcouldalsohelp
theteamvalidatetheefficiencyofthecarepathsolution.
Step 5: Redesign Process
The evaluation step of the process analysis can reveal any inefficiency occurs during
the process, and help the team find opportunities for improvement by redesigning the
process to eliminate the sources of weakness and flaws.
Step 6: Implement Changes
Implementinganychangeinworkprocessesmightfacesomeresistancefromsome
employees;thereforethecarepathteamshouldstarttheimplementationwithPre
OperativeandOperationdayonly.Afterthatcommunicatetheimplementationplan
with staff members involved in this step and define their role in the process, in
additiontoconductingsurveystodeterminethelevelofpatientssatisfaction.
Afterevaluatingtheformersteps,theteamshouldcontinuetheimplementationplan
to rest of the phases including SICU, Post operation days in Ellison 8 rooms,
dischargeandpostdischarge,andmakesuretohavethecommitmentandcooperation
ofalldepartmentsthroughtheimplementationprocess.

Total Quality Management

The implementation of the care path solution contributes to maximizing the Total Quality
Management (TQM) of MGH, as it addresses the problems of the current process and finds ways
to improve them.

The care path solution aims to reduce costs for both the hospital and patients, reduce the length
of patients hospital stay, and maximize the quality of healthcare provided, which in my opinion
would enhance the level of Customer Satisfaction as a factor of the TQM.
Another factor of the TQM is Employee Involvement, however, it is essential for the success
of the care path solution to have the commitment and support of the cross-functional teams from
all hospital departments to educate the rest of the staff and to implement the change in the current
care path.
In order to achieve the ultimate TQM, any workplace requires Continuous Improvement in
processes, services, and products. Therefore the teams in MGH must be dedicated in evaluating
the performance of the new care path solution in terms of patients length of stay, costs, resources
utilization and quality of healthcare provided, in order to find better and more effective solutions
for improvements.

What are the primary challenges in improving operating processes in a health care
environment such as MGH? Why would an outstanding hospital like MGH tackle the
resistance from first-rate professionals to pursue something like a care path?

Many MGH officials are reluctant to endure any changes in the hospital processes; due to some
primary challenges the hospital is currently facing as mentioned earlier. Among which are the
limited financial resources and the shortage of human resources that affect not only MGH, but
also the whole healthcare industry, in addition to the poor communication between departments.
(Docslide.net,2014)

How should MGH balance the tension between process standardization and process
customization? What are the hazards of standardizing the process too rigorously?
What are the dangers of allowing too much freedom to customize?

Strictly standardizing the operating process in MGH would put the whole process of healthcare
at risk and could cause misdiagnosis, not to mention the possibility of affecting the behavior of
all staff negatively.
On the other hand, allowing too much freedom to customize the operating process in accordance
to patients needs has downsides as well. Freedom in customization would increase the operating
cost of the hospital, due to improving the facilities and services in the hospital. Additionally, it
would further complicate the process of the current CABG process, and would cause confusion
between the roles of different departments.
Therefore, MGH should adopt a moderate method that is not strictly standardized, and would
allow some exceptions to the process in a way that would benefit both the hospital and the
patients.(Docslide.net,2014)

In your decision, what implementation approach should Bohmer and Torchiana select?
Be specific as to where you would start, what resources you would bring to bear, what
performance you would expect, and what timeline you would hope to follow.

Inordertoinsurethesuccessofthenewcarepathsolution,Dr.BohmerandTorchianashould
chooseasmallpreliminaryprogramasanapproachtoimplementthecarepathmethodinCABG
andstarttheimplementationinJanuary.Staringthroughthissmallapproachwouldhelphospital
stafftorecognizethebenefitsofthecarepathandthereforeapplyittoallhospitaldepartments.
Theresourcesinvolvedintheimplementationofthenewcarepathprocessincludehuman
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resources (surgeons, doctors, nurses, physicians, and other hospital staffs.), hospital funds,
medicalandadministrativeequipment.
Implementing the care path solution is expected to improve the quality of the healthcare
provided,standardizethehospitalprocesses,reducethelengthofpatientstayabout20%to30%,
andreducetheoverallcostofthehospital.
Theexpectedtimelineforfullyimplementingthisapproachinthehospitalisthemonthafter
January2011,whichwillbethepreliminaryimplementationperiod.(Docslide.net,2014)

Stepping back from this particular care path, what recommendations would you make
to MGH regarding its longer-term improvement efforts?

For longterm improvements in MGH, I would recommend adopting database software to

manageandtrackpatientsinformationincludingtreatmentplansandbillinginformation.Such
databasesoftwaremusthavehighqualityfeaturestosupportthecarepathprocessandtoinsure
theconfidentialityofthemedicalrecords.

IwouldalsorecommendMGHtousetheirhumanresourcesmorewiselytoreducetheextracost
onthehospital.Medicalassistancecouldbeassignedfunctionsthatareperformedbyhighlypaid
employeessuchasnursesandtechnicians.(Docslide.net,2014)

Alternatives
ProcessFocus:oneoftheoptionstheMGHhastoimprovetheiroverallperformanceistofocus
on standardizing their processes, one of which is implementing the new care path process.
Undertaking this option would help reduce the operation cost and length of patients stay.

However,thecarepathsolutionwouldnotresolveissuesrelatedtooverflowofpatients,lackof
bedsinEllisonroomsorshortageofstaffinSICU.

ProcessRedesign:MGHcanconsidermakingradicalchangesbyredesigningsomeareasofthe
hospitalincludinghospitallayout,paymentmethods,patienttrackingsystem,andoutsourcing
radiology.Thisoptionwillimprovethehospitalperformanceinthelongrun.However,thecost
ofthesechangeswouldbehuge,andthechangeinthelayoutwouldbeinconvenientforthestaff
andthepatients.

Improve The Technology: MGH could adopt some new technical equipment that would
incredibly increase the productivity of the hospital. For instance, acquire robots to perform
surgeryandautomatedguidedvehicles(AGVs)totransportcleanlinensinhospital,andmonitor
patientsandnursesusingRFID.However,obtainingthesetechnologiesisahugecostonthe
hospital and would not resolve the main problems the hospital is facing. (sridharbalas,
Studymode,2013)

Managingdemandandcapacity:MGHcouldconductsomeresearchesestimatingthedemand
andhighlighttheareasofproblemintheprocessflowdiagramsuchassurgeryroomandEllison
8rooms.Theoutcomeoftheseresearchescouldhelpthehospitalmanagetheresourcessuchas
staffandfacilities,howeverwouldntresolvethecurrentissuesofthehospital.
Nochange: MGHcouldacceptthefactthatthecostofthehealthcareindustryisincreasing
everyyear,andsimplydonothingaboutit.However,embracingthisoptionhasnoadvantages,
asMGHwouldntbeabletosurvivewithoutmakingachangeintheirprocesssystems,and

improvingtheirfinancialconditions.(sridharbalas,Studymode,2013)

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