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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.
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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 At the completion of this session, attendees should be able to: • Identify the core elements of workflow analysis and redesign • Identify when workflow analysis and redesign may benefit clinical practice • Identify some critical processes that may be analyzed using workflow tools and methods • Discuss techniques that can be used to maximize efficiency and quality care using electronic health systems
“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.
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 News NEW YORK | February 19, 2013, Erin McCann The EMR is the "great magnifier.“ Lessons from the Field, Homer Chin, The Permanente Journal
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
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
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.
Four Common Types of Process Maps • Simple Process Map (also known as flow chart) • Swim Lane diagrams • Value Stream Map • Spaghetti Diagram
Simple Process Map Attend Session Complete evaluation Arrive at Crossroads Conference Return Home with New Information
Workflow Symbols for Clarity of Process Terminator – Start/Stop Process step – Activity Decision – Yes/No Data Document Predefined process – policy? Connector – go to another flowchart or page
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.
Steps to Creating a Simple Process Map • Define the process • Assemble the right team • Walk the process • Discuss and map the current process • Validate with colleagues/peers Focus on the Process as it is TODAY—Current State.
A Process Map: From Words… • Patient appears at the reception window. • Patient signs-in. • Chart is pulled. • Patient called back to exam room.
From words… 3. Chart is pulled. 4. Patient called back to exam room. 2. Patient signs in. 1. Patient appears at the window. Patient Signs in Chart pulled Patient at window Called back to exam room • To diagram
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.
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
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
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”
Related Tools and Models • Root Cause Analysis • Lean Methodology • Risk Management and Compliance • IHI Improvement Model using PDCA with tests of change
Templates Help Identify Issues Sample markup of one of the ePrescribing templates
Samples to work with . . . Source: Mary Beth Mitchell and Nursing Informatics Team Nursing Workflows from Texas Health Resources
Samples to work with . . . Source: Mary Beth Mitchell and Nursing Informatics Team Nursing Workflows from Texas Health Resources
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.
ePrescribing Special characters creating issues Too many issues opting to print fax
Review Medication List Language specifications
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.
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
Notes from the field West Texas Perspective
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
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
