The Arnold Palmer Hospital (APH) in Orlando, Florida, is one of the busiest and most respected hospitals for the medical treatment of children and women in the U.S. Since its opening on golfing legend Arnold Palmer's birthday September 10, 1989, more than 1.6 million children and women have passed through its doors.

It is the fourth busiest labor and delivery hospital in the U.S. and one of the largest neonatal intensive care units in the Southeast. APH ranks in the top 10% of hospitals nationwide in patient satisfaction. "Part of the reason for APH's success," says Executive Director Kathy Swanson, "is our continuous improvement process. Our goal is 100% patient satisfaction. But getting there means constantly examining and reexamining everything we do, from patient flow, to cleanliness, to layout space, to a workfriendly environment, to speed of medication delivery from the pharmacy to a patient.

Continuous improvement is a huge and never-ending task." One of the tools the hospital uses consistently is process charts [like those in Figures 7.4 to 7.7 in this chapter and Figure 6.6 (e) in Chapter 6 ]. Staffer Diane Bowles, who carries the title "clinical practice improvement consultant," charts scores of processes. Bowles's flowcharts help study ways to improve the turnaround of a vacated room (especially important in a hospital that has pushed capacity for years), speed up the admission process, and deliver warm meals warm. Lately, APH has been examining the flow of maternity patients (and their paperwork) from the moment they enter the hospital until they are discharged, hopefully with their healthy baby, a day or two later. The flow of maternity patients follows these steps:

1. Enter APH's Labor & Delivery (L&D) check-in desk entrance.

2. If the baby is born en route or if birth is imminent, the mother and baby are taken directly to Labor & Delivery on the second floor and registered and admitted directly at the bedside. If there are no complications, the mother and baby go to Step 6.

3. If the baby is not yet born, the front desk asks if the mother is pre-registered. (Most do preregister at the 28- to 30-week pregnancy mark.) If she is not, she goes to the registration office on the first floor.

4. The pregnant woman is then taken to L&D Triage on the 8th floor for assessment. If she is in active labor, she is taken to an L&D room on the 2nd floor until the baby is born. If she is not ready, she goes to Step 5.

5. Pregnant women not ready to deliver (i.e., no contractions or false alarms) are either sent home to return on a later date and reenter the system at that time, or if contractions are not yet close enough, they are sent to walk around the hospital grounds (to encourage progress) and then return to L&D Triage at a prescribed time.

6. When the baby is born, if there are no complications, after 2 hours the mother and baby are transferred to a "mother- baby care unit" room on floors 3, 4, or 5 for an average of 40-44 hours.

7. If there are complications with the mother, she goes to an operating room and/or intensive care unit. From there, she goes back to a mother-baby care room upon stabilization-or is discharged at another time if not stabilized. Complications for the baby may result in a stay in the neonatal intensive care unit (NICU) before transfer to the baby nursery near the mother's room. If the baby is not stable enough for discharge with the mother, the baby is discharged later.

8. Mother and/or baby, when ready, are discharged and taken by wheelchair to the discharge exit for pickup to travel home.

Discussion Questions *

1. As Diane's new assistant, you need to flowchart this process. Explain how the process might be improved once you have completed the chart.

2. If a mother is scheduled for a Caesarean-section birth (i.e., the baby is removed from the womb surgically), how would this flowchart change?

3. If all mothers were electronically (or manually) preregistered, how would the flowchart change? Redraw the chart to show your changes.

4. Describe in detail a process that the hospital could analyze, besides the ones mentioned in this case.