Imagine you’re part of an improvement team that has just completed a current state process map or a current state Value Stream Map (VSM). The team has diligently included storm clouds to identify problem areas that need to be addressed. The team realizes it will be impossible to fix everything at once and that it needs to prioritize the needed improvements. Assuming this is from a strategically important area, and improvements need to be made, where should you begin?


Looking at the VSM, some team members want to address the challenges at the front-end of the process. This might be registration and initial patient assessment for a clinical process, or order taking for a non-clinical process. Their feeling is that this is the customer’s first experience with this process and that a positive impression is essential for overall satisfaction. Another group of team members thinks improvements should begin at the back-end of the process. In a clinical process, this might be patient discharge and room turnover. For a non-clinical process, this might be order fulfillment and delivery or shipping. They agree that first impressions are important, but believe addressing the challenges at the back-end of the process will create capacity and enable a smoother flow through the entire process.

Which sub-group is correct? Where would be the most effective place to begin improvements?

Clearly, the specific situation and needs of the organization should drive the prioritization of focus. However, generally speaking, I would recommend that the team begin their improvements at the back-end of the process.  There are several reasons for this:

  1. I agree with the second sub-group that fixing the back-end of a process will create capacity and enable a smoother flow through the entire process. Fixing the back-end of a process will create a true “pull” system within the process. In the clinical example, getting a patient discharged and the room cleaned will signal upstream that another patient can be brought to the room for diagnosis and treatment.
  2. This will also expose the true nature, scope, and root cause of bottlenecks and problems earlier in the process.
  3. Fixing the back-end problems will enable subsequent front-end improvements to be fully realized. If one starts by fixing the front-end processes, patients, supplies, staff, etc. may not see any difference if back-end problems persist, preventing the improvements from taking full effect. In fact, fixing front-end problems may even exacerbate back-end problems. Improving patient flow through the ED will not help if in-patient beds are filled up, and it may make matters worse by increasing the number of patient holds in the ED. It is better to fix the discharge issues, clear the beds out first, and then address ED flow.

The bottom line is to look at flow of your patients, supplies, staff, etc. through a process and begin by clearing out the bottlenecks/issues at the back-end. Then, move your improvement focus to the front-end.

So, where will you begin?


Aaron Fausz, Senior Consulting Director at HPPToday’s blog was written by Aaron Fausz, Senior Consulting Director.

Aaron brings more than 25 years of experience helping organizations align and improve their personnel and technical systems to accomplish strategic business objectives. He currently leads Lean transformation and process improvement consulting engagements for Vizient.

Aaron has consulted with leading healthcare organizations across the country, including Denver Health, Mayo Franciscan Health System, University Health Services, Vanderbilt University Medical Center, Henry Ford Health System, and many others. His areas of expertise and professional skills include guiding organizations through strategically driven changes and enhancing business performance, with significant experience in needs assessment, best practice analysis, performance measurement, process improvement, and behavioral change management. He holds a Ph.D. in Industrial and Organizational Psychology from the University of Tennessee in Knoxville, Tennessee with a minor in Industrial Engineering.

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