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 1.5
million children and women have passed through its doors. It is the fourth busiest labor
and delivery hospital in the U.S. and the largest neonatal intensive care unit in the
Southeast. And APH ranks fifth out of 5,000 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 colors on the walls, 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 the process flowchart. Staffer Diane
Bowles, who carries the ?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 operated at 130% of 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 check-in desk entrance.
2. If the baby is born en route or if birth is imminent, the mother and baby are taken by
elevator and registered and admitted directly at bedside. They are then taken to a Labor &
Delivery Triage room on the 8th floor for an exam. 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 preregistered. (Most do
preregister at the 28?30-week pregnancy mark). If she is not, she goes to the registration
office on the first floor.
4. The pregnant woman is taken to Labor & Delivery Triage on the 8th floor for
assessment. If she is ready to deliver, she is taken to a Labor & Delivery (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 alarm) 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 Labor & Delivery 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 cannot be stabilized 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.
Please turn in a paper of one to two pages (page counting does not include cover and
reference list) discussing the following 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.
Ans.
Staffer Diane Bowles is the Clinical Practice Improvement Consultant, who charts
scores of processes. Her inputs are very important for efficient room processes and

admission processes. As Dianes assistant I would first acquaint myself with the flow of
Dianas flowchart. I would take a few days to study the various inputs and the process
flows. Once this is done then I could suggest improvements if any. I feel that there is only
place where there is a scope for improvement. This would also help in getting the rooms
vacated on time without the prospect of waiting for rooms to be vacated. I would not
initiate any changes because the flow chart of processes has been very successful and
critical to the 130% capacity of the operational levels of the hospitals only would like to
improve upon the levels of floors of the various units. The process as such is maintained
very well but the floors on which facilities for labor wards for operations and normal
delivery are scattered and in case of any emergency the patient has to be shifted many
times up and down. This not only wastes critical time but also man power. I suggest that
the seventh and the eight floors be exclusively used as labor wards and operation theaters
and the rest of th4 floors be used in any order convenient for doctors nurses and other
therapists.
A mother who is expected to be operated upon needs to jump from process 1 to 7 without
any intervening steps. the process 7 would become step 2 as the mother has already
registered and ready for the cesarean .then step 6 could be followed the mother and child
sent to the ante natal care and then step 8 .in process flow chart for a mother who is to be
operated upon. she need not go through any other step as it is not required.
Pre-registration should become mandatory fro all expectant mothers. Then the order of
the flowchart would change with step 3 becoming step 1 and step 322 and others
following each other. There should be no instant admission process .since all mothers are
treated only by this hospital doctors pre-registration must become compulsory. That way
the no of patients and mothers to be admitted for delivery on any particular day can be
assessed and particularly over crowded seasons can be studied and staff arranged for
emergencies.
A process for a hospital specializing in obstetrics and child birth could be as follows:

1. Expectant mothers to pre register with the hospital either manually of electronically in
the 30th week of pregnancy.
2. The registration number to be produced during time of admission with doctors
diagnosis.
3,. If the mother is due for a cesarean, admission should take place before 6 hours and the
mother should be taken to floor 7 for preoperative care and then proceed to step 6
4. If the mother is due for normal delivery and the birth of the child can happen any time,
the mother and baby are taken by elevator and registered and admitted directly at bedside.
They are then taken to a Labor & Delivery Triage room on the 8th floor for an exam. If
there are no complications, the mother and baby go to step 6.
5. If the mother has still some more time for delivery she is asked to go around the
hospital till the contractions start and then goes to step 6.
6. The mother is taken to the labor ward and after successful child birth she goes to the
mother and child ward and then to step 7
7. After observation and mother and child found healthy they are discharged and then to
step 9
8. if the mother is found healthy and the child is found not fit enough to be discharged the
child is taken to the natal care centre and the mother goes to step 9.
9. The mother and baby discharged with dates vie fro the next check up with post natal
care dates.