clinical workflow analysis and redesign
DESCRIPTION
Clinical Workflow Analysis and Redesign. Becky Jones, MSN, RN-BC , CPHQ HIT-Pro PW Texas Tech University Health Sciences Center F. Marie Hall Institute for Rural and Community Health Crossroads Conference May 2, 2013. Objectives. - PowerPoint PPT PresentationTRANSCRIPT
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
Clinical Workflow Analysis and Redesign
Becky Jones, MSN, RN-BC, CPHQHIT-Pro PW
Texas Tech University Health Sciences CenterF. Marie Hall Institute for Rural and Community Health
Crossroads ConferenceMay 2, 2013
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
ObjectivesAt the completion of this session, attendees should be able to:1. Identify the core elements of workflow analysis and
redesign2. Identify when workflow analysis and redesign may
benefit clinical practice3. Identify some critical processes that may be analyzed
using workflow tools and methods4. Discuss techniques that can be used to maximize
efficiency and quality care using electronic health systems
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
“We have reached a tipping point in adoption of electronic health records.” -HHS Secretary Kathleen Sebelius
• More than 291,000 EPs and more than 3,800 eligible hospitals have received incentive payments from the Medicare and Medicaid EHR Incentive Programs.
• Approximately 80 percent of all eligible hospitals and critical access hospitals in the U.S. have received an incentive payment.
• More than half of EPs in the U.S. have received an incentive payment for adopting, implementing, upgrading or meaningfully using an EHR.
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
Not Without Pain & Suffering
Cost, productivity top EHR concerns
Government Health IT, April 06, 2011 | Bernie Monegain,
Contributing Editor
EHR users unhappy, many switching
Healthcare IT NewsNEW YORK | February 19, 2013, Erin McCann
The EMR is the "great magnifier.“Lessons from the Field, Homer Chin, The Permanente Journal
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Some Categories of Concern• Admission, Discharge and Transfer
(ADT)• Care coordination• Care Delivery• Communication• Documentation• Medication• Patient Movement• Supplies and Equipment
Bolton, Gassert, et al ;JHIM, Fall 2008
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Hospitals Successes and Barriers to MU Reported
• Study of 2475 US hospitals, 313 hospitals received MU payments
• The study found– Meeting CPOE requirements was the most common
barrier for hospitals achieving Meaningful Use incentives during the program's first year
– In order to maximize the incentive program's effectiveness, policymakers, healthcare organizations, and EHR vendors may benefit from increased attention to hospitals’ challenges with CPOE
Harle, C.A., Huerta, T., Ford, E., Mark, D., and Menachemi, N. (2012) Overcoming challenges to achieving meaningful use: insights from hospitals that successfully received Centers for Medicare and Medicaid Services payments in 2011
Top Ten National Barriers to MU
Office of the National Coordinator: Annual Barriers Report, Aug 2012
Top Ten Measures-Specific Challenges
Office of the National Coordinator: Annual Barriers Report, Aug 2012
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Workflow Basics:How to Map a Process
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
Magically becomes this…
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
What is a Process?• A series of steps• Carried out in sequence• Creates values• Provides service or product• Makes product
Workflow is the who, what, where, when and how things get done – both clinical and administrative.
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Four Common Types of Process Maps
• Simple Process Map (also known as flow chart)
• Swim Lane diagrams• Value Stream Map• Spaghetti Diagram
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
Simple Process Map
Arrive at Crossroads Conference
Attend Session
Complete evaluation
Return Home with New
Information
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
Swim Lane Map
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Value Stream Map
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Spaghetti/Layout Diagram
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A Process Flow Map Defines
Sequence of tasks
Involvement of people
Use of documents, systems & other informationsources
Terminator – Start/Stop
Process step – Activity
Decision – Yes/No
Document Data
Predefined process – policy?
Workflow Symbols for Clarity of Process
Connector – go to another flowchart or page
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Simple Tools to Map a ProcessTools:• Flip chart or white
board• Sticky notes • Marker• Or a simple list of
tasksSteps:• Write steps on sticky note.• Draw other symbols on sticky
as required.• Place steps in order on flip
chart.• Connect steps with arrows.
Documentation Tool for Steps in a Process
Step# Process step (including decision point steps)
Staff role (e.g., front ofc, MA, physician,
back ofc etc)
Avg time (minutes)
to completio
n
Min time to
completion
Max time to
completion
Tool(s) used Notes
1
2
3
4
5
6
7
8
9
10
…
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Steps to Creating a Simple Process Map
1. Define the process
2. Assemble the right team
3. Walk the process
4. Discuss and map the current process
5. Validate with colleagues/peers
Focus on the Process as it is TODAY—Current State.
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A Process Map: From Words…
1. Patient appears at the reception window.2. Patient signs-in.3. Chart is pulled.4. Patient called back to exam room.
PatientSigns in
Chart pulled
4. Patient ca
lled back
to exam room.
To diagram
From words…1. Patient
appears at the
window.
2. Patient s
ign
s in
. 3.
Cha
rt is
pulle
d.
Patient at window
Called back to exam room
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
Sticky Note Flow Chart
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How to Map Summary
Define start and end points. Use sticky notes to post actions and
decision points in sequential order. Use arrows for direction of flow. Keep main flow straight. Use branches for alternative paths. Involve people who do the work.
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Getting Started
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When Workflow Analysis?• Prior to EHR implementation:
– Paper process now (current state)– What it will look like after (future state)– Define change that must take place
• Post Implementation:– Find root causes when not meeting Meaningful Use– Operational issues attributed to EHR implementation
• ↓ Productivity • ↑ Dissatisfaction of providers and staff
• Client MU Education
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The Quality Improvement Cycle
Institute for Healthcare Improvement Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make to improve?
Plan
DoCheck
Act
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Goal of Analysis
• Need to depict & understand “the current state” to begin to understand how to improve “the future state”
We need to understand “the current state”, core elements:
Who: People and tools involved in each steps What: Number and type of errors encountered in each step When: Time to complete each step Where: Where is the process taking place How: Total number of steps in the process
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Related Tools and Models• Root Cause Analysis• Lean Methodology• Risk Management and
Compliance • IHI Improvement Model
using PDCA with tests of change
PDS
A
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Other Sample tools that might assist your efforts…
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Templates Help Identify IssuesSample markup of one of the ePrescribing templates
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Samples to work with . . .
Source: Mary Beth Mitchell and Nursing Informatics Team Nursing Workflows from Texas Health Resources
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
Samples to work with . . .
Source: Mary Beth Mitchell and Nursing Informatics Team Nursing Workflows from Texas Health Resources
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
Post EHR Implementation• In an electronic environment, this process
results in a walk through of the EHR.• Screen shots of the EHR accompany the visual
mapping.• This process may result in opportunities to
improve the EHR use for better clinical efficiency, quality and patient safety.
• Metrics for meaningful use can be documented in the visual to help educate clinicians and end users of where these metrics are within the process.
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ePrescribing
Special characters creating issues
Too many issues opting to print fax
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Review Medication List
Language specifications
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Evaluating the Process
West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
Future State: What do we want to accomplish?
• Designing the Solution or “Future State” is focused on more efficient, effective and quality of care---fewer steps, faster tasks or less opportunity for errors.
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Applying Lean Principles• Waiting – time wasted• Motion – movement of people with no value• Inventory – any material other than what is
needed• Processing – work that adds no value for the
customer• Defects – work below standard• Transportation – movement of material, no value• Over-production – more than the customer needs
now
Patient Check-in Process – Integrated PMS/EHRFr
ont D
esk
(FIS
HBO
WL)
Patie
nt
Patient Arrives
Marks Patient Arrival
Signs in at Front Desk
Select Patient - Centricity
Does Pt Info need to be updated?
New Patient?
Yes
No
Patient completes paper forms & signs paper and electronic
signature pad
Record updates in Centricity , collect & scan insurance card
if needed
Yes
Does co-pay need to be collected?
No
Collect and enter information into
Centricity
Collect Payment & record
Yes
Give Pt. Forms to fill out, collect & scan
insurance card
No
Patient sent to clinic waiting area
New Patient Forms:Adult Health History/Family History
Bubble sheets: ROS & PFSHPatient Info Sheet
Financial Disclosure for ADCDemographic sheet
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WEST TEXAS PERSPECTIVENotes from the field
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West Texas Health Information Technology Regional Extension Center - Making Electronic Health Records a Reality -
Where We Are Now?
• Workflow analysis initially used to guide process changes during EHR implementation
• Very few providers now in implementation phase
• Most a least one year post implementation
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Most Common Current Issues• Results of poor implementation OR• Fair implementation with lack of ongoing
support and training• Clinicians never fully engaged in the process in
some cases• Still have productivity issues that are
unresolved• Duplicate processes• Staff unhappy and resistant to further change
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Workflow Analysis can help reveal:
• No strong ‘super-user’• Lack of proactive leadership• Culture of strong independence by providers does
not support standardized processes• EHR has magnified existing operational issues
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Facilitating Quality Improvement
Through Workflow Analysis, we are:• Facilitating the discussion about what could work
better• Collecting data at the point of care• Demonstrating the value of emphasis on the
process• Bringing the PDCA model for improvement to the
provider of care – And without waiting for large amounts or perfect
data
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Additional Templates
One size may not fit all.
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Acknowledgements
• Workflow Redesign Cooperative Workgroup supported by the Office of the National Coordinator
• HealthInSight REC for Nevada and Utah screen shot of workflow and stick tab exercise example
• Mary Beth Mitchell MSN, RN, BC and Nursing Informatics Team Nursing Workflows from Texas Health Resources