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TRANSCRIPT
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Fundamentals of Health Workflow Process Analysis and Redesign
Day2
Charlie McArthur BA RRT RPFTQuality Analyst
Fort Drum Regional Health Planning Organization
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Review of Last Friday
• Increasing the Value of Health Care
• Created process flow charts
• Knowledge Acquisiton
• Process Analysis
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Exercise
• Create a Flowchart for the following Clinic
Process
• Create a list of variations and possible
exceptions
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Concepts of Health Care Processes & Process Analysis
Lecture a
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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
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Process Redesign
• A strategic initiative to improve the
quality, cost, and safety of patient care
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Process Redesign
Lecture a
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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
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• The Triple Aim requires the simultaneous pursuit of:
– Improved health
– Enhanced experience of care
– Reduced cost per capita
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See Things Right
Before you attempt to set things right, make
sure you see things right.
– Blaine Lee
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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.
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PerformanceTypical Performance Goal Performance
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QI
QI
Productive
work
Unproductive
work Productive
work
“If you want something new, you have to stop doing something old”
― Peter F. Drucker
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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
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Problem - Solution
Unproductive work = problem
Redesign strategies = solution
1
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AS IS TO - BEATAMO
situation before situation after
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AS IS TO - BEATAMO
situation before situation after
The And Then A Miracle Occurs effect
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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
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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
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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
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Automation Examples
Opportunities to use computer systems
to automate clinic processes:
• Triggering prescription refills
• Alerting clinicians to abnormal lab results
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Buffering
• Instead of requesting information from an
external source, buffer it by subscribing to
updates
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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
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Centralization Examples:
• Claims clearing house
• Assigning one person in the clinic to
answer the phone
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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
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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
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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
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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
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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
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Contact Reduction
Decreasing the
• Number of times
• Length of contact
• Other resources devoted to customer contact
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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
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Care Teams & Case Managers
• Help customers navigate complexity
• Called case managers
• Care teams are similar
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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
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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
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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
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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
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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
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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
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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
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Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign
Concepts of Health Care Processes & Process Analysis
Lecture a
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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
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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
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Process Types
• Process analysis should have
identified:
– Main clinic work streams
– Processes
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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
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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
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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
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Task Elimination
• Getting rid of steps that do not add value
• Examples:
– ePrescribing
– Getting rid of redundant work
– Automating steps
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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
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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
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The devil’s quadrangle: Indicators from different dimensions usually affect each other, thus we cannot usually improve all of them at the same time
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Exercise
• Redesign your spirometry process
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Exercise
1. List the redesign strategies you used
2. Assess the impact of the change by using
the devils quadrangle
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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
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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)
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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
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ISO HCD Framework
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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).
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Integrating Process & Information Design
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Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis & Redesign
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
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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
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Process Redesign
Lecture b
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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
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Process Redesign
Lecture b
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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
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Process Redesign
Lecture b
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Design Methods cont.
Innovative creativity
• Brainstorming
• Parallel Design
• Storyboarding
• Affinity Diagrams
• Organizational Prototyping
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Process Redesign
Lecture b
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“Every system is perfectly designed to
achieve the results it gets.”
W. Edwards Deming
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Design Alignment
• Organizational structures
– i.e., Roles, responsibilities, authority
• Available talent
• Physical layout
• Information flow
• Information use
• Regulatory requirements
– Accreditation and “Meaningful Use”
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Process Redesign
Lecture b
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Three Key Considerations
Key considerations in process redesign:
• Clinical decision support
• Meaningful Use objectives
• Physical layout
• System interfaces
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Process Redesign
Lecture b
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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
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Process Redesign
Lecture b
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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
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Process Redesign
Lecture b
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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
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Process Redesign
Lecture b
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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
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Process Redesign
Lecture b
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Decision Matrix
• List the Project Objectives
• Rank measures according to importance and feasibility
Evaluate
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HIGH
MEDIUM
LOW
IMP
OR
TAN
CE
FEASABILITY
LOW MEDIUM HIGH
Evaluate
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Common Software Interfaces in Small to Mid-size Clinics
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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
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