Physician owners know that there are four key objectives at the core of process improvement:

• To remove waste and inefficiencies
• To increase productivity and asset availability
• To improve response time and agility
• To sustain safe and reliable operations

The question is, how do we do all this? I would suggest a proven technique known as the OODA Loop.

OODA Loop figure

The OODA Loop consists of four overlapping and interacting processes. You must
Observe the current situation and form theories,
Orient the picture by setting improvement targets and determining root causes,
Decide by developing solutions, and
Act by means of implementing and evaluating

The OODA Loop can be subdivided further into an eight-step problem-solving process.



Step 1: Clarify the problem

This is a critical step. You need to recognize the correct problem and be sure it is completely understood by all. It helps to state the problem by developing a “problem statement” in terms of what, where, when, and the significance. You also need to “lay eyes” on the situation, ensuring you have first-hand observation. This will then help in drafting a flow chart that diagrams the steps of the process. Lastly, you need to conduct surveys and interviews, talking with the “customer” or end user who determines the value of the process under review.

Step 2: Break down the problem and identify performance gaps

It is tempting to jump to action but you must refrain from doing so just yet. Gather and review the key data. Understand what data is necessary and what role it plays in problem-solving. Are there gaps in your analysis? Are there bottlenecks in the process you are reviewing? Under this step, you must also look at waste in your practice as it relates to the problem. There are generally eight types of waste: defects, overproduction, waiting, overprocessing, transportation, intellect, motion, and excess inventory. You should always look for waste in your processes.



Step 3: Set improvement targets

Where do you want to be? Determine your desired outcome for the practice. Be sure to look at both strategic and tactical targets. Strategic targets are visions of what your practice strives to become. Tactical targets define the performance level necessary to make your strategic vision a reality. Remember to keep your tactical targets challenging but achievable.

Step 4: Determine root causes

This is the most vital step in the problem-solving process. All too often, practice managers find themselves addressing problems that have been “solved” many times before. This is usually due to directing problem-solving efforts at the symptoms of a problem rather than at the root cause of the problem. It often helps to do much brainstorming. When you think you understand the cause of the problem, ask what caused the problem (continue to ask “why?”).



Step 5: Select solutions

When selecting solutions, consider both quality and practicality. Be sure to also gain acceptance (or “buy in”) from those that must implement the solutions. Some key factors to consider when analyzing solutions include effectiveness, feasibility, and impact. When developing your action plan, be sure that you have created a clear and detailed plan that everyone can understand. Most importantly, build consensus with others by involving all of your team appropriately to cultivate a sense of ownership in the solution and in its success. Effective communications can be a deciding element as to whether the plan succeeds.



Step 6: See the plan through

Collect data according to the action plan. Remember the old adage, “You can’t manage what you can’t measure.” You may need to implement a contingency plan as conditions change and you need to keep the project on focus. Continue to provide required training during this step as well.

Step 7: Confirm results and process

Ensure the plan is producing the intended results. Monitor the project for performance relative to: a) the baseline developed in steps 1 and 2; b) the improvement targets established in step 3; c) where you thought you would be at this stage; and d) meeting targets by the established deadline. You should return to any step as necessary.

Step 8: Standardize successful processes

This is the most commonly skipped and under completed step of the entire problem-solving process. You can define this step by asking a series of questions: What is needed to standardize the improvements? Is the appropriate documentation in place? Were other opportunities or problems identified by the problem-solving process?

If the answer to this last question is yes, begin the process over…that is why it is referred to as the OODA Loop.

Nick Hernandez, MBA, FACHE

Nick Hernandez, MBA, FACHE,, is the CEO and founder of ABISA, a consultancy specializing in strategic healthcare initiatives.

Since founding ABISA in 2007, his emphasis has been on developing and maintaining a strong relationship with physicians and identifying areas for business opportunity and support. The company’s client list includes physician groups, hospital systems, healthcare IT organizations, venture capitalists, private equity firms, and hedge fund managers.

Nick is a graduate of the United States Naval Academy and a former Captain in the U.S. Marine Corps. He holds MBA degrees in both Operations Management and Information Technology & E-Business Management from Wake Forest University. He is Board Certified in Healthcare Management and has been named a Fellow of the American College of Healthcare Executives.

He is a frequent guest lecturer and is often quoted in the national media. He has consulted with clients in multiple countries and has over 20 years of leadership and operations experience. Nick is a Subject Matter Expert in business strategy, practice management, telemedicine, health IT, and oncology.


  1. Using just the right qualified business associates to guide the physician practice staff in the right direction allows the physician to spend more time practicing medicine – the practice owner will always have to have ultimate control and decision authority in all of their processes. But, the cost of having just right business associate doesn’t cost at all. It pays – that’s because the practice owner can spend more time driving the top line while the business associate works hand in hand with the staff to streamline, minimize overall costs and perfect operational efficiency. All of which will underpin the excellent patient care that the physician so strongly desires.


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