Healthcare Systems and Process Performance

Learning Outcomes

Learning Outcome 1: Critically analyze a healthcare organization’s structure and culture and organizational behavior.

 PC 1.1: Demonstrate critical understanding of a healthcare organization’s structure and culture, and how this affects its operational efficiency.
 PC 1.2: Evaluate the impact of organizational behavior on employee engagement.
 PC 1.3: Discuss how teamwork aids organisational development and employee engagement in a healthcare organisation.

Learning Outcome 2: Conduct a review of change management in the Healthcare delivery environment and apply it effectively to organizational development.

 PC 2.1: Discuss how to manage change and achieve competitive advantage in healthcare sector.
 PC 2.2: Research and critically review at least two of the conceptual models and principles of healthcare delivery systems.
 PC 2.3: Apply a range of ICT functions to improve healthcare delivery systems.

Learning Outcome 3: Evaluate the key measures used to assess healthcare systems and process performance.

 PC 3.1: Research the clinical and non-clinical metrics that can be used to enhance organizational performance.
 PC 3.2: Evaluate the cost benefits of augmenting patient satisfaction and process enhancement.
 PC 3.3: Critically review performance indicators by conducting an analysis of the perceived problems with healthcare systems.
 PC 3.4: Recommend solutions and develop a model for enhanced performance.

Learning Outcome 4: Critically analyze and apply lean tools to improve healthcare processes.

 PC 4.1: Evaluate at least three different lean management tools that can be used to improve Healthcare industry processes.
 PC 4.2: Apply at least three different lean management tools to a Healthcare clinic’s current processes.
 PC 4.3: Recommend changes that should be implemented to improve operational performance.

Assignment Task 1

Rapid City Regional Hospital implemented a multidimensional hand-hygiene program to improve hand-hygiene adherence in accordance with The Joint Commission (TJC) Patient Safety Goal #7: Reduce the risk of healthcare-associated infections (HAI). Root cause analysis uncovered three primary reasons for non-compliance: takes too much time; dry, cracked hands from too much washing and use of soap; and a non-supportive culture. Solutions included making alcohol hand rubs and hospital-approved lotion more available, providing education and encouragement, establishing an infection control hotline to report non-compliance, and holding physicians accountable. Hand-washing compliance increased from 57% to 91%, resulting in a 21% reduction in HAI and dollar savings of $291,450.


1- How do the characteristics of a healthcare organization and system influence performance?

2- Outline key methods to improve performance in a healthcare setting.

3- List some of the important Key Performance Indices (KPIs) that influence patient outcome and growth of a healthcare organization.


  Boersma, Beth; Keegan, J. M. ; Planning and Implementation of a Multidimensional Hand-Hygiene Program – Reduce the Risk of Healthcare Associated Infections (HAI) at Rapid City Regional Hospital (RCRH), Health Care  Division 2009

Assignment Task 2


A not-for-profit healthcare system found that adherence to clinical quality observed metrics for inpatient heart failure discharge instruction was consistently below national standards. Working toward a goal of increasing the observed rate of compliance from 45.3% to at least 90% by January 2008, the improvement team used the Six Sigma DMAIC (define, measure, analyze, improve, control) approach and Pareto analysis to identify potential failures and the vital factors contributing to the problem. Strategies developed to counter the vital signs and improve the process included standardizing the discharge process across all nursing units, standardizing the most effective type of discharge instruction, improving the knowledge level of heart failure discharge instruction elements unit-by-unit with one-on-one training, and standardizing and simplifying the heart failure discharge instruction process. Based on a three-month pilot, the project succeeded in reaching its goal of a 90% compliance rate with heart failure discharge instruction.

1- What are the tools / techniques used in operations management to improve quality? illustrate with at least three examples.
2- Analyze how lean management tools will be beneficial to the hospital to enhance the hospital discharge policy? You may use diagram to discuss the patient flow from admission to discharge. Discuss key factors that hinder smooth and effective patient discharges in any healthcare setting.
3- How can Lean and Six Sigma be applied to improve healthcare operations, considering the differences in concept and approaches of each of them.

Reference:   DeFeo, Joe; Ralston, J. Er : Increasing the Percentage of Heart Failure Patients Who Receive Heart Failure Discharge Instruction; Healthcare Division, The Global Value of Quality 2009

Assignment Task 3

Choose your own healthcare facility / or any department at chosen health care facility, critically reflect on weakness / challenges that need to be changed for better efficient and effective performance.

1- To fulfil the above given criteria, introduce your organization, show the organizational structure chart of your chosen organization, and bring out the major cultural values your organization follows. [13 MARK]

2- Reflect on Change Management and how to apply effectively to your organization development. Align with strategic management practices by doing a SWOT analysis of your chosen organization; based on weaknesses, opportunities and threats envisaged. Bring out certain major changes you would like to bring about in the chosen organization. Review how you will manage these changes, as well as resistance to change, to eventually achieve competitive advantage in the market environment. [20 Marks]

3- While bringing about the changes in your chosen organization, highlight on how will you monitor and control the changes being sought by your chosen organization, what will be the performance indicators you would like to benchmark upon, techniques to implement the changes, as well as the process and resources to manage the changes. [12 MARK]



The Novel Coronavirus SARS-CoV-2 /COVID19 has posed a direct threat to an over-burdened healthcare system worldwide. Pandemics present challenges to healthcare to calibrate the strategies in proportions.
Prepare a PPT highlighting on the following points:

  1. Key Lessons learned from COVID-19 in your country.
  2. Strategies to consider when addressing those key lessons.

You must highlight on the main following points:

  • Staffing
  • PPE & safety techniques
  • Emergency Medical Services response “EMS & Transport”
  • Emergency Department Care “ED”
  • Outpatient services
  • Alternative Systems of Care
  • Hospital Incident command (Operational periods, incident action planning)
  • Critical Care for COVID19 patients

 The presentation should not have more than 10 slides and will be presented for a maximum duration of 10 minutes, followed by 5 minutes of questions and answers session.  

Along with your PPT presentation, you must submit a written summary of the plan along with your reflections on possible limitations and challenges with the proposed plan and ways to overcome them. [300 words]

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