clinical workflow analysis and redesign

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


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


“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 NewsNEW 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


Workflow Basics:How to Map a Process

This….


Magically becomes this…

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

Arrive at Crossroads Conference

Attend Session

Complete evaluation

Return Home with New

Information


Swim Lane Map


Value Stream Map


Spaghetti/Layout Diagram


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


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

…


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.


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


Sticky Note Flow Chart


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.


Getting Started


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

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


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


Related Tools and Models• Root Cause Analysis• Lean Methodology• Risk Management and

Compliance • IHI Improvement Model

using PDCA with tests of change

PDS

A


Other Sample tools that might assist your efforts…


Templates Help Identify IssuesSample 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


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


Evaluating the Process


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

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


WEST TEXAS PERSPECTIVENotes from the field

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


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


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


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


Additional Templates

One size may not fit all.


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


Questions & Discussion

clinical workflow analysis and redesign

Documents

ehr concernsgovernment

reality hospitals successes

eligible hospitals

us hospitals

hospitals challenges

reality emr

critical access hospitals

workflow redesign