CPOE UnivErsity

Dan Morgenstern, MD, MBA

Principal

Computer Sciences Corporation

Clinical Workflow Analysis - Process

Defect Identification

A CSC Clinical Excellence Service Offering

Introduction

Brief review of workflow analysis concepts

Definition of defects

Definition of clinical process defects

Identification of clinical process defects

Classification of clinical process defects

Examples of defects in clinical workflow

Moving from present state with defects to future state – “defect free”

Discussion

Agenda

3

Who am I?

4

Who am I?

• Dan Morgenstern, MD, MBA– MD, Albert Einstein College of Medicine

• 25 years of practice:» Private solo as well as group» Academic – US, Israel» Cardiac, thoracic, vascular, trauma and general surgery,

wound care– “Recipient” of a failed Hospital Clinical Information System

Installation - twice– MBA, Auburn University-Montgomery Al

• Major course of study: Information Systems– Left practice in 2003 – result of the malpractice crisis– Health Care Consulting since September, 2003

• Clinical Transformation• Workflow Process Analysis and Redesign• Clinical Master Plan Development• Medical and Clinical Staff Education• Clinical Issues Resolution, Implementation Support (go-live)• Vendor Selection Assistance• Clinical Content Development• Physician/Clinician Adoption

5

Who are you?

• Name

• Practice specialty

• Institution

• Role in your institution’s CPOE project

• How did a nice guy/gal like you end up in a place like this?

• Your goals for this session

6

What are We Here to Do?

• Understand what is meant by a defect in a workflow process

• Identify characteristics of a step or task in clinical care that constitute a defect

• Recognize them in clinical workflow

• Classify the defects

• Prioritize them – with appropriate input from a SME (Subject Matter Expert) as needed

• Use them as a guide in designing the “future state”

IntroductionBrief review of workflow analysis conceptsDefinition of defectsDefinition of clinical process defectsIdentification of clinical process defectsClassification of clinical process defectsExamples of defects in clinical workflowMoving from present state with defects to

future state – “defect free”Discussion

Agenda

8

What is Clinical Workflow?

• Our proposed definition– Clinical Workflow is an established

process describing• A series of tasks• How they are accomplished• By whom• In what sequence• At what priority

that accomplishes a defined step in an activity in the clinical care of patients

9

What is Clinical Workflow?

CLINICAL PATIENT CARE

ACTIVITIES

STEPS

TASKS

10

Standard Activities and Steps in Clinical Patient-Care• Examples of activities in clinical care:

– Hospital rounds– Pre-op/pre-procedure preparation of a patient– Admission, Discharge

• Examples of steps in clinical care:– Patient Evaluation

• Initial = admission• Subsequent

» Daily rounds» Transfer» Discharge

– Consultation (patient evaluation specific toexpertise/problem)

– Bedside Procedures– Specialized Procedures

CLINICAL PATIENT CARE

ACTIVITIES

STEPS

TASKS

11

Standard Tasks in Clinical Patient-Care• Locate Patient

• Gather Data

• Evaluate Data

• Examine Patient

• Synthesize Data and Examination

• Determine Next Step in Patient Care

• Document Findings and Decisions

• Direct Care of patient – Clinical Orders

• Perform Procedures as Needed

CLINICAL PATIENT CARE

ACTIVITIES

STEPS

TASKS

12

Standard Tasks in ClinicalPatient-Care

Locate PatientMaintain Patient List

• Gather Data– Visual

• Radiography• All manner of

“graphics”: EKG, EEG, EMG

• Examine specimens and microscope slides

– Aural• “Sound images”:

ultrasound, Doppler

• Gather Data– Written

• Reports• Notes in chart• Tabulated numerical

data– Oral

• Talk to colleagues• Talk to nurses,

therapists, etc

13

Example of Standard ShapesDictionary

14

Example of Standard ShapesDictionary

Flowchart Reviewing Guide – Follow the Steps Described Below

Prep

arat

ion

Valid

atio

nCurrent-State Workflow Project

Flowchart Validation Guide

TerminatorThe beginning or end of a process

Process StepA plain box

represents any general step in a

process

DecisionA decision point

where the process

branches

DocumentA task that centers around a piece of

paper

ComputerA task directly involving user interaction with a

computer system

Automatic Process

A process entirely computer controlled

Off-Page Connector(outbound)

Off-Page Connector indicating that the flow continues to another tab in the same file.

This is a Call-OutUsed to add information to a task, such as:Arrows are used to connect tasks that are

related. The arrowhead shows the direction of process flow.

No

Yes

Yes

No

Begin Process

Follow one branch of the decision at a time,

marking your path using the highlighter. Make

sure you come back and follow the other branch.

Have your flowchart print out ready for review.

Are there decisions in the

flow?

Write any corrections on the

flowchart.

Print the flowcharts you are

reviewing

Find a highlighter or colored pen.

End

Follow the steps on the flowchart (each will be a

decision point):1. Are the tasks correct?

2. Are they in the correct order?3. Are any important steps left

out?

Off-Page Connector(inbound)

Off-Page connector indicating that a flow represents the continuation from

another tab in the same file

AA

On-Page connector which flows from and to connector with same letter. These are used when drawing lines from one box to another would cause the lines to criss-cross possibly causing confusion. Process Name

“Hot Link” indicates a link to a separate process that continues the normal flow of work

Parallel Processes. Steps within these lines happen at the same time or independently from one another.

15

Standard Shapes Dictionary

• Process Step: Any general, manual step in a process

• Paper Document: Any task centered around the use of paper

Paper Document

Process Step

Manual Interface with a

Computer

• Manual Interface with a Computer: Any manual input, output or interaction with a computer system

16

Standard Shapes Dictionary

• Automatic Process: Automatic step that requires no direct human input; entirely computer driven

• Decision Point: Branching of the process due to a pair of alternatives

• Terminator: The start or end of any process

Automatic Process

Decision Point

Terminator

17

Standard Shapes Dictionary

• On-Page Connector: Allows flow of a process on the same page without needless clutter or confusion of crossing of lines

• Off-Page Connector (outbound): Indicates that the flow continues on another tab in the same file

• Off-Page Connector (inbound): Indicates that the flow is the continuation of another tab in the same file

On-Page Connector

Off-Page Connector (outbound)

Off-Page Connector(inbound)

18

Standard Shapes Dictionary

• Dynamic Connector: Connects two steps in a process

• Parallel Mode: Two steps that take place independently but simultaneously

• Call-Out Note: Used to supply additional information about a step or supply information that is not strictly speaking a process step

Call Out Note

19

Standard Shapes Dictionary

• Hyperlink Process: “Hot Link” to another process that continues the “clinical flow” of work

Hyperlink Process

Swim Lanes

Ancil

lary/C

lerk

Nursi

ngPh

ysici

an

• Swim Lane Format: Allows role segregation while showing step relations and interactions during the process

IntroductionBrief review of workflow analysis conceptsDefinition of defectsDefinition of clinical process defectsIdentification of clinical process defectsClassification of clinical process defectsExamples of defects in clinical workflowMoving from present state with defects to

future state – “defect free”Discussion

Agenda

21

Definition of Defects

• Definitions– Nonconformance to requirements or

functional / program specification – A blemish, imperfection or deficiency

that impairs worth or utility – The non-fulfillment of intended usage

requirements – Any abnormality lowering the value of a product no matter

why, when, or how it developed– An imperfection which, if great enough, can prevent an item

from working properly or being usable– A lack of something necessary for completeness, adequacy,

or perfection

22

Defects, Warranties,Guarantees, Remedies• In commercial and consumer transactions, an obligation that

an article or service sold is as factually stated or legally implied by the seller, and that often provides for a specific remedy such as repair or replacement in the event the article or service fails to meet the warranty

• In business and legal transactions, a warranty is an assurance by one party to the other party that certain facts or conditions are true or will happen; the other party is permitted to rely on that assurance and seek some type of remedy if it is not true or followed

23

Defects, Warranties,Guarantees, Remedies• In medicine, there are:

– No warranties – we never get the “Specs” on an individual– No guarantees – we don’t have the owner’s manual

• Of course, there are also – No restocking fees– No in store-credits

• It matters little if you have the receipt, you probably cannot get your appendix, pneumonia or gallstones back

24

Clinical Work and World View

• Human mistakes are not just “oops” moments

• Technology glitches are not just aggravating, inefficient or even infuriating

• Errors and “bugs” really kill people

• In business, if you fail→ you lose money

• In engineering, if you fail → things don’t work

• In medicine, if you fail → patients die

IntroductionBrief review of workflow analysis conceptsDefinition of defectsDefinition of clinical process defectsIdentification of clinical process defectsClassification of clinical process defectsExamples of defects in clinical workflowMoving from present state with defects to

future state – “defect free”Discussion

Agenda

26

Clinical Process Defects

• Not all errors and bugs kill people

• However, the domino effect in clinical care is significant

• Inefficiencies, redundancies, bottlenecks, errors– Slow down processes – and progress– Impede task completion– Reduce quality of care– Result in “unintended consequences”– Facilitate poor outcomes

• None of these are desirable when life hangs in the balance.

• Life ALWAYS hangs in the balance in healthcare –sometimes obviously, sometimes subtly

27

Definition of Clinical Process Defect• A defect in a clinical process is the

characteristic of a step or task in clinical care that– Introduces unwanted and unnecessary

redundancy– Impedes or blocks flow of required

information– Delays completion of a task or step– Necessitates needless clinical decisions and tradeoffs– Results in clinically indefensible variation– Precludes successful completion of a clinical care process– Exposes the patient or the clinical care team to

unnecessary risk

28

Definition of Clinical Process Defect• Examples:

– Introduces unwanted and unnecessary redundancy• Multiple entries of same information

– Impedes or blocks flow of required information• Clinical results not available when needed

– Delays completion of a task or step• Procedure prolonged because of poor equipment

maintenance– Necessitates needless clinical decisions and tradeoffs

• Inventory mismanagement necessitates choice between lesser quality prosthesis

– Results in clinically indefensible variation• Unavailability of correct therapeutic agent (drug, therapy,

site of care)

29

Definition of Clinical Process Defect• Examples:

– Precludes successful completion of a clinical care process• Clinical data (films, cines, angios) misplaced, miscatalogued

– Exposes the patient or the clinical care team to unnecessary risk• Patient HIV status not communicated due to information

mishandling

30

Definition of Clinical Process Defect• Note:

– We are talking about defects in process– We are not talking about defects in reasoning, care or outcome

• Mistaking a pleural effusion for an organized empyema on an x-ray may be an error» Treating the patient as such because the x-ray or its report

is not obtainable is a process defect• Choosing the wrong antibiotic may be an error

» It becomes a process defect when the culture and sensitivity is not obtainable at the appropriate time

• An untoward outcome is not necessarily indicative of a process defect» A post-op wound dehiscence may be indicative of an error» A post op wound dehiscence after-unavailability of

retention sutures represents a process defect

31

Definition of Clinical Process Defect• It is obvious from definition and examples that there are a lot of

“defects” in clinical processes

• Most are relatively innocuous and result in – Irritating delay– Needless inefficiency– Aggravating duplication

• Workflow analysis and defect recognition are powerful tools that will help identify them all

• Process redesign – independent of technology – will help reduce the number and severity of defects

• Many – but not all - can be eliminated by technology

32

Definition of Clinical Process Defect• All need to be eliminated by constant refocus on process and

analysis– These tools can and should become a permanent part of good

clinical care quality assurance

• By understanding and perfecting the “process” we can free clinical minds to concentrate on– Patient care– Excellent results

33

Identify Defects in this O.R. Scenario

MTC Sample Script for MD Operating Room Workflow

Identify as many defects as you can

IntroductionBrief review of workflow analysis conceptsDefinition of defectsDefinition of clinical process defectsIdentification of clinical process defectsClassification of clinical process defectsExamples of defects in clinical workflowMoving from present state with defects to

future state – “defect free”Discussion

Agenda

35

Example of Standard ShapesDictionary

36

Standard Defects Dictionary

• Bottleneck: A step dependent on scarce resources that – when triggered by a specific event - results in an overall process delay

• Redundancy: A step that duplicates information or an activity already accomplished in another step, process or system, resulting in an overall reduction in efficiency and productivity

• Human-Intense Activity: A step requiring an inordinate amount of human activity, resulting in decreased efficiency and productivity

37

Standard Defects Dictionary

• Delay: A step that is time consuming and slows down the completion of a process. The slow-down is a by-product of the activity itself, not other intervening factors

• Completion Barrier: A key step that when missed or improperly executed, prevents completion of a process or drastically impedes the ability to complete the process

• Failure Point: A step that aborts the process or represents a failure of the process

38

Standard Defects Dictionary

• Decision Point Defect: A decision point that– Does not achieve its goal– Is – or should be – unnecessary– Is reached with insufficient information– Is being made by the wrong individual– Is being made at the wrong time

• Other: Defects that fall outside above parameters, usually legal, regulatory or patient safety in nature. Each of these defects must be individually examined

39

Clinical Workflow (CWF) Defects

• There is overlap amongst the defect types

• There will be individual variation in their use and assignment

• These are suggestions– Feel free to adapt them to your own situations– Feel free to add or subtract from the list

• The key is consistency in examination of workflow and assignment of defects

• Be cognizant of the fact that certain redundancies– Are in the eye of the beholder (nurse vs. doctor vs. pharmacist)– Are there for sound clinical reasons

40

Clinical Workflow (CWF) Defects

IntroductionBrief review of workflow analysis conceptsDefinition of defectsDefinition of clinical process defectsIdentification of clinical process defectsClassification of clinical process defectsExamples of defects in clinical workflowMoving from present state with defects to

future state – “defect free”Discussion

Agenda

42

Clinical Workflow (CWF) Defects

43

Examples of CWF DefectsPhone Management Process

PAU

NUrs

ing

Center chart area – 5.5fte’s

Racked charts are called

Fill in needed informationE

E Patient answers?

Message left – recorded on chart

by date

Patient calls back? Yes Patient call

answered

Patient leaves answering

machine message

Obtain needed information

Can continue in closed loop fashion up to day afternoon

before surgery

ECan continue in closed loop fashion up to day afternoon

before surgery

No success with scheduled

calls No

E

No

Yes

Charts given to nurses in back phone room

Chart Activation Process

No

Yes

Chart Dungeon Process

Nurse preps the chart: pick

appropriate health history and med form, put stickers

on them; enter PMH etc as you have it. Look for age related EKG, allergies, get as much history as

possible

Wrong contact info due to MIS over-ride. Cannot

activate patient, enter orders, contact patient at all.

44

Examples of CWF DefectsPhone Management Process

PAU

NUrs

ing

Center chart area – 5.5fte’s

Racked charts are called

Fill in needed informationE

E Patient answers?

Message left – recorded on chart

by date

Patient calls back? Yes Patient call

answered

Patient leaves answering

machine message

Obtain needed information

Can continue in closed loop fashion up to day afternoon

before surgery

ECan continue in closed loop fashion up to day afternoon

before surgery

No success with scheduled

calls No

E

No

Yes

Charts given to nurses in back phone room

Chart Activation Process

No

Yes

Chart Dungeon Process

Nurse preps the chart: pick

appropriate health history and med form, put stickers

on them; enter PMH etc as you have it. Look for age related EKG, allergies, get as much history as

possible

Wrong contact info due to MIS over-ride. Cannot

activate patient, enter orders, contact patient at all.

45

Examples of CWF DefectsAntibiotic Protocol Process

PAU

NUrs

ing

Copy antibiotic order Place on clipboard Enter orders into

SCM

All required information available?

Allergies, height weight, etc

Surgeon known to “take care of it in the morning?”

Case cancelled

Chart to ASU

Patient allergy to ordered antibiotic?

Fax to PharmacyWrite ALLERGY on order sheet Office contacts

surgeon

Antibiotic ordered?

Procedure requires AB per

nursing experience?

Yes

No

Call surgeon’s office and obtain

orderYes

end

No

Yes

Yes Fax to surgeon’s office

No

No

A

A

No

Yes

ChartDungeonProcess

Chart to ASU

This occurs in ASU

not PAU

46

Examples of CWF DefectsAntibiotic Protocol Process

PAU

NUrs

ing

Copy antibiotic order Place on clipboard Enter orders into

SCM

All required information available?

Allergies, height weight, etc

Surgeon known to “take care of it in the morning?”

Case cancelled

Chart to ASU

Patient allergy to ordered antibiotic?

Fax to PharmacyWrite ALLERGY on order sheet Office contacts

surgeon

Antibiotic ordered?

Procedure requires AB per

nursing experience?

Yes

No

Call surgeon’s office and obtain

orderYes

end

No

Yes

Yes Fax to surgeon’s office

No

No

A

A

No

Yes

ChartDungeonProcess

Chart to ASU

This occurs in ASU

not PAU

47

Examples of CWF DefectsWB Charting Process

Othe

rW

ell B

aby N

ursin

g

O2 Saturation or Vital sign? Chart in SCM

Yes

Weight? YesChart in Weight

Book

No

Chart on NB Progress Flow

Form

Glucose?

No

Metabolic Screen?

No

Chart on Face Sheet

Discharge Form

Discharge FormYes

Hearing Screen?

No

Face SheetYes

Hearing Screen Book

No

Nurses’ NotesYes

Nurses’ Notes Discharge Form

Well BabyAdmission

& InitialAssessment

Process

Result Abnormal or

Inappropriate?Notify MD

Initiate Appropriate Protocol

Yes

WB PatientCare

Process

No

Trans Cutaneous Bilirubin

Glucose worksheet

Charge in SCM

Charge in SCM

Charge in SCMCalculate risk factor using INtrAnet tool

Chart on Discharge Form

48

Identify and Categorizethe Defects

• Find as many defects as you can in the following workflow diagrams– Physician Inpatient Evaluation Process– Physician Documentation and Ordering

Process

• Tag them according to our defect categorization

49

Physician Inpatient EvaluationProcess

Physician Inpatient Evaluation Process

Anci

llary

/Cl

erk

Nurs

ing

Phys

icia

n

Yes

No

No

Yes

No

Yes

No

No

No

Are appropriate vital signs in

chart?

Physician reviews any

outside documentation, results, films,

materials

Physician views labs, xray reports,

other documentation on SYSTEM

Review ChartAre appropriate

vital signs in chart?

Review bedside chart

Bedside chart

found?

Ask nurse

Physician reviews xrays on PACS

Patient found?

Patient needs

physician evaluation

Find CNA to locate Bedside

chart

Physician takes new readings of

vital signs himself

Try another patient /floor

Physician examines patient

Chart available?

PhysicianDocumentation andOrdering Process

Yes

Patient listed on “board” as in procedure?

Yes

Patient found?

Yes

End

Physician looks for bedside chart

ListMaintenance

Process

Old Chart Needed?

No

Old admission at present

patient campus

location?

Yes

Locate old chart in

record room and transport to patient’s

location

Yes

Telephone other campus and

request photocopy of

summaries, other documents

No

Physician looks for present- admission

patient chart

Yes

No

50

Physician Documentation andOrdering Process

Physician Documentation and Ordering Process

Anci

llary

/Cl

erk

Nurs

ing

Phys

icia

n

END

Physician documents in chart by hand

Physician PatientEvaluation Process

Dictated documentatio

n required/desired?

Physician dictates note

Orders stat, urgent or complex?

Physician finds and notifies

nurse of orders

Office documentation to be used as

inpatient documentation?

Office document placed in hospital

chart

Physician using

template on line?

Physician prints it out

Physician fills out template

Physician using email information

for documentatio

n?

Physician typing in

WORD for documentatio

n?

Yes

No

Yes

No

Yes

No

Physician documents in

WORD and prints out

documentation

Yes

Paper placed in chart

No

Physician finds email, cuts and

pastes into WORD document, prints out

documentation

Yes

No

Physician writes orders

Preprinted orders

available?

Order sets downloaded and printed or pulled from repository

Yes

NoNo

Yes

Template in StaffNet?

Yes

Look in Physician Email (adult Psych)

No

Introduction

Brief review of workflow analysis concepts

Definition of defects

Definition of clinical process defects

Identification of clinical process defects

Classification of clinical process defects

Examples of defects in clinical workflow

Moving from present state with defects to future state – “defect free”

Discussion

Agenda

52

What is the Process to Movefrom Present to Future State?• Map present state workflow

• Analyze present state workflow– Identify defects– Classify defects– Describe consequences

• Identify those amenable to non-technological “fixes”– Redundant documentation-form elimination– Consolidation of supplies, results– Elimination of the “reply to all” syndrome

• Information to those who need it and will act upon it– Assignment and enforcement of responsibility

• Little need to fax pre-op orders to 4 numbers in the hope one will “pick up” and keep them

– Geographical and temporal re-arrangements

53

What is the Process to Movefrom Present to Future State?• Design future state which will

– Eliminate defects– Ensure patient safety and excellent clinical results– Maximize efficiency

• Think “outside the box”– Don’t rule it out because you think it may be (or actually is)

expensive– Within reason, if Amazon.com, Burger King and the local bank

can do it, so can health care

54

Post Partum Care – MotherPresent State

Post Partum Care (Mother)

Othe

rPo

st Pa

rtum

(Mot

her)

PatientTransferProcess

Mother arrives from L&D Report given (oral)

Green sheet examined

& handed to PP Nurse

Mother admitted to unit

Transfer (mother) assessment per

protocol

Assessment charted in Post Partum Flow

record

Abnormal findings?

No

Document in Nurses’ notesYes

Perineal Care

Perineal Care Assessment Intervention as

neededDocument on PCR Document in

Nurses’ notesDocument under “interventions”

Site of documentation per nurse preference, habit

Site of documentation per nurse preference, habit

Site of documentation per nurse preference, habit

Procedure required?

IV, Bladder Scan, Catheterization

Bladder Scan?Charge in SCM

Yes

Perform ProcedureNo

RH incompatibility? Yes Rhogam

Protocol

Rhogam Protocol Enter order into

SCM

Medication arrives via “tube”

Administer medication

Patient ID on envelope containing medication

Actual Medication Vial has no Patient ID information

Chart in EMAR

Chart on Notes?Post

PartumTeaching

No

Daily Fall risk assessment

Document on Fall Risk Form

No

55

Post Partum Care – MotherFuture State

Post Partum Care (Mother)

Othe

rPo

st Pa

rtum

(Mot

her)

PatientTransferProcess

Mother arrives from L&D

Report given (oral)

Mother admitted to unit

Transfer (mother) assessment per

protocol

Perineal Care

Perineal Care Assessment Intervention as

needed

Procedure required?

IV, Bladder Scan, Catheterization

Charge in SystemYes Perform Procedure

RH incompatibility? Yes Rhogam

Protocol

Rhogam Protocol Enter order into

System

Medication arrives via “tube”

PostPartum

Teaching

No

Daily Fall risk assessment

No

Post Partum Nurse reviews record in EMR

Document in Nurses’ notes

Document in Nurses Notes

BCMA

Document in Nurses’ notes

56

Construct the Future State

• Convert the workflows you analyzed for defects into future state diagrams– Physician Inpatient Evaluation Process– Physician Documentation and Ordering

Process

57

Construct the Future State

Introduction

Brief review of workflow analysis concepts

Definition of defects

Definition of clinical process defects

Identification of clinical process defects

Classification of clinical process defects

Examples of defects in clinical workflow

Moving from present state with defects to future state – “defect free”

Discussion

Agenda

60

Discussion