redesign unit 6 repaired

Fundamentals of Health Workflow Process Analysis and Redesign

Day2

Charlie McArthur BA RRT RPFTQuality Analyst

Fort Drum Regional Health Planning Organization

Review of Last Friday

• Increasing the Value of Health Care

• Created process flow charts

• Knowledge Acquisiton

• Process Analysis

Exercise

• Create a Flowchart for the following Clinic

Process

• Create a list of variations and possible

exceptions

3Health IT Workforce Curriculum

Version 3.0/Spring 2012


Concepts of Health Care Processes & Process Analysis

Lecture a

4

Process Workflow: Spirometry Test (MEDENT EHR, BREEZE Spirometry software)

1. From the MEDENT EHR, lookup Patient by name and verify patients identity

2. MEDENT: check orders

3. Click on Spirometry Lab Test order to send to BREEZE

4. Transfer patient to Test Room

5. Open orders in Breeze Spirometry Software

a. Find the Correct Lab order b. If order is not available then click ‘Refresh’

6. Perform Test(s)

7. Enter Test Quality Comments into BREEZE

8. Go to ‘Quick Print’ to print out pdf results to the screen and ‘Exit’ BREEZE Software

9. Send the pdf result to the spirometry results folder on the Network Server

10. From the MEDENT EHR, search and locate pdf from Network Server and import into

MEDENT’s lab results section

11. Nurses should manually enter spirometry results (FEV1, FVC, FEV1/FVC) in the Lab Order

Detail Screen section of MEDENT, in the structured data fields so disease registry

interface can pull data for spirometry quality measures

Process Redesign

• A strategic initiative to improve the

quality, cost, and safety of patient care



Fundamentals of Health Workflow Process Analysis & Redesign

Process Redesign

Lecture a

Goals of Process Redesign

• Improving quality and safety of care

• Enhancing the patient’s care experience

• Decreasing the cost of care

• Making clinic processes more efficient




Process Redesign

Lecture a

7

• The Triple Aim requires the simultaneous pursuit of:

– Improved health

– Enhanced experience of care

– Reduced cost per capita

See Things Right

Before you attempt to set things right, make

sure you see things right.

– Blaine Lee




Process Redesign

Lecture a

Why not just implement technology?

• In 1990, Michael Hammer, a former

professor of computer science at

MIT, published an article in the Harvard

Business Review, in which he claimed that

the major challenge for managers is to

obliterate forms of work that do not add

value, rather than using technology for

automating it.

10

PerformanceTypical Performance Goal Performance

11

QI

QI

Productive

work

Unproductive

work Productive

work

“If you want something new, you have to stop doing something old”

― Peter F. Drucker

Unproductive Work

Tasks not necessary for providing patient care

• Waiting

• Transportation / unnecessary motion

• Doing things twice

• Errors

• Repetitive tasks

• People with higher level of training than necessary performing tasks




Process Redesign

Lecture a

Problem - Solution

Unproductive work = problem

Redesign strategies = solution

1




Process Redesign

Lecture a

http://www.google.com/url?sa=i&rct=j&q=solutions&source=images&cd=&cad=rja&docid=XItbSpgFLBWy0M&tbnid=cel0fT7uWvRgjM:&ved=0CAUQjRw&url=http://www.123rf.com/photo_12253140_spehere-with-the-word-solutions-on-white-background.html&ei=yOI0UfzmOcrX0QGdr4GgDg&bvm=bv.43148975,d.dmg&psig=AFQjCNEyyWPMw6OWe_lvUL3zZKNl42Jszw&ust=1362506806095848

14

AS IS TO - BEATAMO

situation before situation after

15

AS IS TO - BEATAMO

situation before situation after

The And Then A Miracle Occurs effect

Redesign Strategies

• Automation

• Buffering

• Centralization

• Control addition

• Control relocation

• Contact reduction

• Customer teams and case managers

• Empower

• Exception

• Extra resources

• Flexible assignment

• Integration

• Interfacing

• Knock-outs




Process Redesign

Lecture a

Redesign Strategies(cont.)

• Numerical involvement

• Outsourcing

• Order-based work

• Order assignment

• Order types

• Parallelism

• Split responsibilities

• Task composition

• Task elimination

• Triage

• Trusted party

• Resequencing

• Specialist-

generalist




Process Redesign

Lecture a

Optimization Method: Automation

• Design decisions determine the extent to

which a given job, task, function or

responsibility is to be automated or

assigned to human performance

• Consider the relative capabilities and

limitations of human vs technology

• Basing decisions solely on the capabilities

of the technology is not advised




Process Redesign

Lecture a

Automation Examples

Opportunities to use computer systems

to automate clinic processes:

• Triggering prescription refills

• Alerting clinicians to abnormal lab results




Process Redesign

Lecture a

Buffering

• Instead of requesting information from an

external source, buffer it by subscribing to

updates





Lecture a

Optimization Method: Centralization

• Centralization can mean common

coordination of activities at multiple

locations such that they are done the

same way

• Can also mean carrying out tasks at one

location rather than having them be

carried out by multiple organizations or

individuals




Process Redesign

Lecture a

Centralization Examples:

• Claims clearing house

• Assigning one person in the clinic to

answer the phone




Process Redesign

Lecture a

Optimization Method: Control Addition

• Control addition means adding checks in a

process

• Addition of a control step identifies errors

before they have a negative impact

• Can be performed by a human or a

computer




Process Redesign

Lecture a

Control Addition Examples

• Checking

– Insurance eligibility• Planned procedure

• Co-pay

• Prescription

– Prior to sending it home with a patient

– Drug-to-drug interactions• Prior to writing a prescription

– Drug allergies• Prior to writing a prescription




Process Redesign

Lecture a

Control Addition Examples(cont.)

• Counting sponges and instruments before

closing a surgery site

• Double checking the name on the

medication and the patient arm band prior

to administration

• Marking the surgery site and confirming

with the patient prior to surgery




Process Redesign

Lecture a

Control Relocation

• Control relocation is changing who

performs a task, triggers a task to be

done, or approves a task

• In principle, control relocation usually

means pushing control to the “front line” or

even to the customer




Process Redesign

Lecture a

Control Relocation Examples

There are several notable examples of

control relocation in health care:

• Home monitoring devices

• On-line

– Appointment scheduling

– Data entry of patient information before a visit

• Patient portals that enable patients to share

their health records




Process Redesign

Lecture a

Contact Reduction

Decreasing the

• Number of times

• Length of contact

• Other resources devoted to customer contact




Process Redesign

Lecture a

Contact Reduction Examples

• Completion of patient information forms

before a visit

• Automated appointment reminders

• Pushing tasks down to the lowest level

of staff with appropriate training




Process Redesign

Lecture a

Care Teams & Case Managers

• Help customers navigate complexity

• Called case managers

• Care teams are similar




Process Redesign

Lecture a

Exception Handling

• Exception– A case that is somehow different from the rest

– Is incomplete, has errors, special circumstances or special needs

• Exception handling: – Designing a process to handle the ordinary cases

– “Shunting” the exceptions into a different work stream

• Frees the process to operate at maximum efficiency




Process Redesign

Lecture a

Exception Handling Examples

• Special process for contacting no-shows

and rescheduling

• When one lab test in a batch is held

up, available results are returned and

others are reported when available




Process Redesign

Lecture a

Extra Resources

• Identifying those process steps that are

known bottlenecks

– i.e., Cause downstream delays

– Adding extra resources at those steps

to optimize the overall process

• Examples:– Staffing the front desk

– Eliminating provider wait time




Process Redesign

Lecture a

Flexible Assignment

• “Hedging your bet”

– Minimizing risk

• Things might not always work out

• Flexible assignment

– Not backing yourself into a corner

• Example:

– Hiring a medical office assistant who can also do blood draws in case having nurses draw blood causes an imbalance in workload




Process Redesign

Lecture a

Integration

• Designing clinic processes so that they

mesh well with high volume/high

interaction organizations

• Example:

– Electronic interface with

• Claims clearinghouse

• Lab or high volume diagnostic service

• Local hospital




Process Redesign

Lecture a

Interfacing

• Interfacing means providing common and

standard interaction points for high volume

interactions

• Example:

– All labs come through a lab interface

– On-line appointment scheduling

– All documents are received in one place and

processed




Process Redesign

Lecture a

Knock-out

• Fail fast

• Decisions that decrease workload should be made as early in the process as possible

• Examples:

– Checking insurance eligibility first thing

– Early initiation of insurance approval

– Screening patients for issues requiring urgent care immediately




Process Redesign

Lecture a

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Health IT Workforce Curriculum Version 3.0/Spring 2012



Lecture a

38

As Few Hands as Possible

• Design processes to involve as few roles /

people as possible

– Eliminates unnecessary delays

– Hand-offs

– Communication errors

• Avoid splitting responsibilities across

departments or organizations




Process Redesign

Lecture a

Outsourcing, Trusted Party

• If others can do things better or more

efficiently than the clinic, consider

outsourcing

• Examples:

– Responding to requests for records

– Using an external lab or diagnostic testing service

– Hosting the medical record software and IT support




Process Redesign

Lecture a

Process Types

• Process analysis should have

identified:

– Main clinic work streams

– Processes




Process Redesign

Lecture a

Eliminate Queues and Batching

• Queues and batches cause delays and wait time

• Instead assign work as it comes in to a person

responsible for seeing it through to completion

• Example

– Same day appointment guaranteed

– Assigning a person to handle prescription refills that

are called in by patients or pharmacies




Process Redesign

Lecture a

Parallelism, Resequencing

• Anything that can be done in parallel

should be done in parallel

– Rather than waiting for another step to be

completed

• Resequence process steps to accomplish

tasks as early in the process as possible




Process Redesign

Lecture a

Task Composition

• Some things are better done as smaller

steps

• Other things may be easier to accomplish

as a group of steps

• Example:

– Processing incoming documents to be filed




Process Redesign

Lecture a

Task Elimination

• Getting rid of steps that do not add value

• Examples:

– ePrescribing

– Getting rid of redundant work

– Automating steps




Process Redesign

Lecture a

Specialist-Generalist

• Some things are more efficient if a person

handles only one type of issue

• Other situations require people who wear many

hats

• Choice, specialist or generalist, depends on:

– Training and skill level required for a task,

– How easy a task is to do when it is not a main focus

of someone's effort, and

– Practice size / volume




Process Redesign

Lecture a

Triage

• Related to the specialist – generalist concept

• Means there is an initial sorting step– Things requiring specialist attention are sent to

specialists

– Others are sent where they are most efficiently handled

• Example:– Triage nurse in an emergency department assures

that urgent patients get seen first, and less serious ones wait longer




Process Redesign

Lecture a

The devil’s quadrangle: Indicators from different dimensions usually affect each other, thus we cannot usually improve all of them at the same time

Exercise

• Redesign your spirometry process

49

Exercise

1. List the redesign strategies you used

2. Assess the impact of the change by using

the devils quadrangle

50

Types of Changes

• Some process changes are large:

– “Breakthroughs”

– Major shifts in the way work is done

– Great improvements in performance

– Usually takes more preparation, planning, and innovation

• Other changes are small incremental advances

• Many of the strategies discussed here can be either

• The former usually takes more preparation and

planning, and of course innovation




Process Redesign

Lecture a

Human-Centered Design (HCD)

HCD is an approach to systems design and

development that aims to make interactive

systems more usable by focusing on the use

of the system and applying human factors/

ergonomics and usability knowledge and

techniques. (ISO, 2010)




Process Redesign

Lecture b

Human-Centered Design PrinciplesISO 9241-210

a) The design is based upon an explicit understanding of users, tasks and environments

b) Users are involved throughout design and development

c) The design is driven and refined by user-centered evaluation

d) The process is iterative

e) The design addresses the whole user experience

f) The design team includes multidisciplinary skills and perspectives




Process Redesign

Lecture b

ISO HCD Framework




Process Redesign

Lecture b

© ISO. This material is reproduced from ISO 9241-210:2010 with permission of the American National

Standards Institute (ANSI) on behalf of the International Organization for Standardization (ISO).

Integrating Process & Information Design




Process Redesign

Lecture b

Technology-centered design

As-is care

process

model

Information

architectures

Improved

process

models Sensitivity

analysis

S/W

implement

ation

models

Trade-off

analysis

Better care

process

Cost-effective

HIT systemInformation usage

Risk & cost

Value to care

Care-centered design

LEAN

Source: Figure from Butler 2011, used with permission

Design Solutions

Consider:

• Sources of ideas

– Using and further developing other designs

– Logical progression from previous designs

– Innovative creativity

• Perspectives

• Patients, Providers, Staff, external orgs

• Alignment

• Regulations and Organizational Goals




Process Redesign

Lecture b

Design Methods

Leveraging and further developing other designs

• Design guidelines and standards

• Best practices from other industries

• Other clinics which have implemented EHR

• Other clinics which have a proven process that

doesn’t depend on EHR

• Prior quality improvement projects at your clinic

• Problems with current clinic workflows




Process Redesign

Lecture b

Design Methods cont.

Logical progression from previous designs

– Gap Analysis between as-is and clinic’s ideal

– Leveraging technology, i.e., automation

– Workflow diagram analysis




Process Redesign

Lecture b

Design Methods cont.

Innovative creativity

• Brainstorming

• Parallel Design

• Storyboarding

• Affinity Diagrams

• Organizational Prototyping




Process Redesign

Lecture b

“Every system is perfectly designed to

achieve the results it gets.”

W. Edwards Deming

60

Design Alignment

• Organizational structures

– i.e., Roles, responsibilities, authority

• Available talent

• Physical layout

• Information flow

• Information use

• Regulatory requirements

– Accreditation and “Meaningful Use”




Process Redesign

Lecture b

Three Key Considerations

Key considerations in process redesign:

• Clinical decision support

• Meaningful Use objectives

• Physical layout

• System interfaces




Process Redesign

Lecture b

Impact of CDSS on Workflow

• Information must be available when providers and staff need it– i.e., At the point of decision making

• Are they logged into the system?

• Do they need to be or will they be in front of a computer to

get the alert?

• Do they need to be with the patient?

• Do they have what they need to act on the alert?

• Decision must be supported– Representation

– Information

• Right place, right time, right resources




Process Redesign

Lecture b

Impact of Physical Location on Workflow

• Location of computers

• Other office hardware

• Office layout:

– Patient, provider and staff flow

– Traffic congestion

– Number of steps

– Standing or sitting




Process Redesign

Lecture b

Impact of System Interfaces on Workflow

• Common interfaces

– Practice Management System for billing

– Local lab systems

– Imaging

– Local hospital

– Local Health Information Exchange

• Interfaces impact what information will be

available electronically and when




Process Redesign

Lecture b

Review of New Process

• Providers and Staff look for:

– Points of failure

– Potential confusion

– Bottlenecks

• Design Team considerations

• Technology Vendor’s determinations:

– Technology Leveraged

– Pot holes




Process Redesign

Lecture b

Decision Matrix

• List the Project Objectives

• Rank measures according to importance and feasibility

Evaluate

HIGH

MEDIUM

LOW

IMP

OR

TAN

CE

FEASABILITY

LOW MEDIUM HIGH

Evaluate

Common Software Interfaces in Small to Mid-size Clinics




Process Redesign

Lecture c

Clinical

Practice

EMR

Practice

Management

System

Claims

Clearinghouse or

3rd party payer

Central Lab

Central Lab

Information System

Patient Portal

Local HIE

Interface with local

health care Facilities

Imaging device

PACS

Pharmacies

redesign unit 6 repaired

Documents

safety of patient care

following clinic process

leverages health

manual processes

andmaking clinic processes

spirometry lab test

spirometry test medent

spirometry results folder