Hospital Labor and Delivery Workflow Analysis

Arnold Palmer Hospital Labor and Delivery Workflow Analysis

The Arnold Palmer Hospital (AHC) located in Orlando, Florida is considered one of the most efficient and patient-centric healthcare providers in the U.S. due to the customer satisfaction scores the facility receives and amount of patients the hospital sees on an annual basis. The AHC has been ranked fifth in patient satisfaction out of 5,000 hospitals and sees on average 1.5 million children and women annually. It is the fourth-busiest labor and delivery hospital in the U.S. And the largest neonatal intensive care unit in the entire Southeastern U.S. AHC has also put into place one of the most thorough and well-respected continuous improvement processes in the U.S. healthcare system. With the goal of 100% patient satisfaction, AHC has created an entire quality management and improvement organization which is now a critical part of its culture.

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Of the myriad of processes that AHC relies on to operate daily, one of the more problematic is the Labor & Delivery Check-In. This process is made more challenging by the continually changing status of the patient and her imminent delivery of a baby. Healthcare processes need to be contextually relevant and have comparable time and value durations as patients in order to contribute to patient satisfaction (Ahsan, Shah, Kingston, 2010). The AHC labor and delivery check-in process is one that is very complex with ample room for patient dissatisfaction given the highly intricate nature of eight different decision points. With so much complexity there is the potential for confusion in the Labor and Delivery check-in process and frustration on the part of patients. Clearly this process needs significant improvement as the initial analysis of the workflow is shown in the first part of this analysis. Following the initial analysis of the Labor and Delivery check-in workflow, the complication of dealing with a Caesarean-section birth is discussed. Third, if mothers were electronically checked in vs. The manual process today, the workflows would change significantly. A second flowchart has been created to show the streamlined workflow as a result of the AHC choosing this alternative. For process re-engineering to be successful there needs to be a prioritization of customer-based goals first, followed by the selective use of technologies (Bertolini, Bevilacqua, Ciarapica, Giacchetta, 2011). The use of more automated means to check maternity patients in follows this best practices of business process reengineering (Bertolini, Bevilacqua, Ciarapica, Giacchetta, 2011).

Analysis of the Labor & Delivery Process

The existing Labor and Delivery Process have significant room for improvement. It’s shown in Figure 1, Existing Workflow of the APH Labor & Delivery Process. As has been mentioned earlier in this analysis, there is significant potential for improvement in the areas of the check-in process, use of Labor & Delivery Triage, and the use of the NCU. Workflows in each of these areas are very complex, time- and condition-dependent, and also lack a quantifiable level of measurement to determine just what steps need to be taken to assist a children’s progress over time. Labor and Triage and the NCU could easily become bottlenecks if not managed to a series of performance-related goals. The entire process of Labor & Delivery defies the ability to define performance metrics due to its complexity. To ensure customer satisfaction over the long-term, it would be advisable to break the registration process, Labor and Delivery Triage Area, and NCU into smaller subprocesses. Ideally a separate, more streamlined workflow needs to be created for children who are experiencing significant problems, cycling between the NCU and Mother-Baby Care areas. This area of the workflow today has significant potential for improvement and greater simplification.

Figure 1: Existing Workflow of the APH Labor & Delivery Process

Caesarean-Section Birth Workflow

When a patient and physician choose a Caesarean-section (C-Section) birth, the process workflows in the areas of ICU, NCU and Mother-Baby Care require greater coordination. As a C-Section birth requires surgery, there are the added process areas of pre-operation preparation, the operation itself and all the logistics required, and the post-operation recovery procedures. AC-section workflow would require an entirely new series of processes branching off of the Labor and Delivery Triage origination point. There would also need to be more focus on post-operation procedures in the NCU as well, stabilizing both the baby and mother. All of these would bring several layers of complexity into the workflows shown in the lower left corner of the existing process workflow in Figure 1. Integrating C-section procedures would also requite an entirely new set of recovery and release process steps and workflows for newborns and mothers as well. Lastly, as C-sections are covered in some but not all healthcare insurance programs for patients. It is critically important to get that aspect of the C-section taken care of at the very beginning, during the check-in and registration process. If a patient and physician believe there is a possibility of a C-section, that contingency needs to be planned for at the very beginning of the check-in process. With this greater level of complexity comes the need for greater quality management to ensure customer expectations are consistently met and exceeded (Whiteman, 2004). C-sections also have a mortality risk associated with them, which requires the process workflows to have thorough support for patient contingencies and life support. Best practices in managing healthcare processes that have mortality associated with them require high levels of auditability and compliance to government reporting standards (Bertolini, Bevilacqua, Ciarapica, Giacchetta, 2011).

Preregistration and Electronic Check-In

The use of electronic check-in will bring a much higher level of accuracy, agility and auditability to the entire patient and healthcare record management process in the hospital. The complex and potentially confusing existing manually-based check-in process creates many opportunities for costly errors and loss of patient confidence in the hospital. Modifying the most complex manual processes in a healthcare provider requires significant change to how people work and what their level of trust is in the systems they are relying on to do their jobs (Hellstrom, Lifvergren, Quist, 2010). For the following workflow to be successful it must take into account the change management strategies inherent in successful healthcare business process re-engineering projects (Bertolini, Bevilacqua, Ciarapica, Giacchetta, 2011). Figure 2 shows the modified check-in workflow where three critical prerequisites are defined. Due to the significant number of patients that the hospital sees every day, the level of variation in the existing process needs to be significantly reduced. To do this, there are three recommendations made in the following workflow. First, the expectant mother and physician need to have her registration in by the 30th week of her pregnancy in order to reserve treatment at APH. Second, it is highly recommended there be an orientation session with the expecting couple to brief them on the entire procedure and how it will be handled in the hospital;. There also needs to be time allocated for going over insurance coverage and forms for admittance. This orientation session is also meant to streamline the actual admittance process. Finally, this orientation session includes the definition of a date of admittance as well. This will significantly recue errors, increase customer satisfaction and lead to more effective results given the expectations being managed much more effectively than the more complex process in the past.

Figure 2: Streamlined Check-In Process

Emergency Room Process Workflows Need Re-engineering

Of the many other process workflows in a healthcare facility, the emergency room (ER) and trauma treatment are among the most complex and rapidly changing. For APH to continually attain a high level of patient satisfaction, the triage center in the emergency room needs greater simplification and streamlining. As the ER in many hospitals must deal with a very wide variety of injuries and medical emergencies, the approach to routing specific patient cases to a given area of the hospital for further treatment needs simplification and greater accuracy. Using knowedlge management systems for example, that can define the optimal treatment plan, would be useful in streamlining the process workflows in ER and trauma centers. This area of a hospital is also challenged with a workforce that includes a wide variety of disciplines, in different shifts, and in different locations. The need for optimizing processes in ER is made even more urgent when children and women whoa re expecting are involved, as the medical conditions for these patients is critical before, during and immediately following child birth.


Ahsan, K., Shah, H., & Kingston, P. (2010). Location context for knowledge management in healthcare. International Journal of Healthcare Technology & Management, 11(1), 3.

Bertolini, M., Bevilacqua, M., Ciarapica, F.E., & Giacchetta, G. (2011). Business process re-engineering in healthcare management: A case study. Business Process Management Journal, 17(1), 42-66.

Hellstrom, A., Lifvergren, S., & Quist, J. (2010). Process management in healthcare: Investigating why it’s easier said than done. Journal of Manufacturing Technology Management, 21(4), 499-511.

Whiteman, A.S. (2004). Applying quality management in healthcare: A process for improvement. Hospital Topics, 82(1), 37-37.

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