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
West Texas Health Information Technology Regional Extension Center
- Making Electronic Health Records a Reality -
Objectives
At the completion of this session, attendees
should be able to:
1. Identify the core elements of workflow analysis and
redesign
2. Identify when workflow analysis and redesign may
benefit clinical practice
3. Identify some critical processes that may be analyzed
using workflow tools and methods
4. 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
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Not Without Pain & Suffering
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
West Texas Health Information Technology Regional Extension Center
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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
West Texas Health Information Technology Regional Extension Center
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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
Workflow Basics:
How to Map a Process
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This….
Magically becomes this…
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This is where the idea for the new EHR starts getting a little
complicated.
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.
West Texas Health Information Technology Regional Extension Center
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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
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Simple Process Map
Arrive at
Crossroads
Conference
Attend
Session
West Texas Health Information Technology Regional Extension Center
- Making Electronic Health Records a Reality -
Complete
evaluation
Return Home
with New
Information
Swim Lane Map
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- Making Electronic Health Records a Reality -
Value Stream Map
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Spaghetti/Layout Diagram
West Texas Health Information Technology Regional Extension Center
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A Process Flow Map Defines
Use of
documents,
Involvement systems & other
of people
information
Sequence
sources
of tasks
West Texas Health Information Technology Regional Extension Center
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Workflow Symbols for Clarity of Process
Terminator – Start/Stop
Process step – Activity
Decision – Yes/No
Document
Connector – go to
another flowchart
or page
Data
Predefined process
– policy?
Simple Tools to Map a Process
Tools:
• Flip chart or white
board
• Sticky notes
• Marker
• Or a simple list of
tasks
Steps:
• Write steps on sticky note.
• Draw other symbols on sticky
as required.
• Place steps in order on flip
chart.
• Connect steps with arrows.
West Texas Health Information Technology Regional Extension Center
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Documentation Tool for Steps in a
Process
Avg time
Staff role (e.g., front
Min time Max time
Process step (including decision point
(minutes)
Tool(s)
Step#
ofc, MA, physician,
to
to
steps)
to
used
back ofc etc)
completion completion
completion
1
2
3
4
5
6
7
8
9
10
…
Notes
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.
West Texas Health Information Technology Regional Extension Center
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A Process Map: From Words…
1.
2.
3.
4.
Patient appears at the reception window.
Patient signs-in.
Chart is pulled.
Patient called back to exam room.
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From words…
Patient at
window
Patient
Signs in
Chart
pulled
To diagram
Called back
to exam room
Sticky Note Flow Chart
West Texas Health Information Technology Regional Extension Center
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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.
West Texas Health Information Technology Regional Extension Center
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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
What are we trying to
accomplish?
How will we know that
a change is an
improvement?
What changes can we
make to improve?
Institute for Healthcare Improvement Model for Improvement
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Act
Plan
Check
Do
Goal of Analysis
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
• Need to depict & understand “the current state” to
begin to understand how to improve “the future state”
West Texas Health Information Technology Regional Extension Center
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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
A
S
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P
D
Other Sample tools that might assist
your efforts…
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Templates Help Identify Issues
Sample 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.
West Texas Health Information Technology Regional Extension Center
- Making Electronic Health Records a Reality -
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
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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.
West Texas Health Information Technology Regional Extension Center
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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
West Texas Health Information Technology Regional Extension Center
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Patient
Patient Check-in Process – Integrated PMS/EHR
Patient Arrives
Patient completes
paper forms & signs
paper and electronic
signature pad
Signs in at Front
Desk
Yes
Marks Patient
Arrival
Give Pt. Forms to fill
out, collect & scan
insurance card
New Patient Forms:
Adult Health History/Family History
Bubble sheets: ROS & PFSH
Patient Info Sheet
Financial Disclosure for ADC
Demographic sheet
New Patient?
No
Select Patient Centricity
Does Pt Info
need to be
updated?
Front Desk
(FISHBOWL)
Collect and enter
information into
Centricity
Yes
Record updates in
Centricity , collect &
scan insurance card
if needed
No
Collect Payment &
record
Yes
Does co-pay
need to be
collected?
No
Patient sent to clinic
waiting area
WEST TEXAS PERSPECTIVE
Notes from the field
West Texas Health Information Technology Regional Extension Center
- Making Electronic Health Records a Reality -
West Texas Health Information Technology Regional Extension Center
- Making Electronic Health Records a Reality -
Top Ten West Texas Challenges to
Reach MU
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
West Texas Health Information Technology Regional Extension Center
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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
West Texas Health Information Technology Regional Extension Center
- Making Electronic Health Records a Reality -
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
West Texas Health Information Technology Regional Extension Center
- Making Electronic Health Records a Reality -
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
West Texas Health Information Technology Regional Extension Center
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Additional Templates
One size may not fit all.
West Texas Health Information Technology Regional Extension Center
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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
West Texas Health Information Technology Regional Extension Center
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Questions & Discussion
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