Chapter 5 AB3

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Health IT and EHRs: Principles and Practice, Sixth Edition

Chapter 5: Healthcare Workflow and Process Mapping

Importance of Workflow and Process Improvement

Identifies opportunities for improvement

Aids in understanding functional requirements needed for health IT

Avoids unintended consequences of poorly designed health IT systems

Reduces costly rework after implementation

Helps manage change through:

Education

Team empowerment

Terminology and Methodologies

Process

Manner in which work is performed to achieve a particular result

Workflow

Sequence of steps and hand-offs taken within a process

Process mapping

Depiction of the workflow and process that is being studied

Process improvement

Analysis of current processes and workflows for efficiency and effectiveness

Also called: process redesign or process re-engineering

EHR Five Rights:

Right clinical data

Right presentation

Right decision

Right work processes

Right outcomes

Process Improvement Goals

Achieve the right way!

Old Way

New Way

My Way

Your Way

Right

Way

Process Improvement Case Study

Benefits of Process Improvement

Steps in Process Improvement

Identify processes to be assessed.

Create process assessment teams.

Select tools.

Map current process.

Validate accuracy of map.

Collect forms and reports to be automated.

Obtain baseline data.

Identify potential problems and root cause.

Identify changes for now, and with health IT

Identify other improvements.

Document proposed changes in new map.

Use new process to create use cases for health IT functional specification.

Test new processes.

Train on new processes.

Incorporate changes into policy and procedure.

Conduct benefits realization and celebrate success/correct course.

Processes to be Mapped for EHR

Process Mapping Teams & Training

Teams should:

Be composed of those who will actually implement project

Be responsible for actual process analysis

Solicit input from potential users

Include those familiar with current processes

Include a coach and access to IT resources

Teams need training on:

Process improvement purpose and goals

Process mapping tools

EHR or other health IT features and functions

Thoughtflow

Coined by Sam Bierstock, MD,

“The process by which physicians obtain, assess, prioritize, and act on information.”

Many clinical processes are not visible to another person. They are mental processes

It is the mental processing that is at the core of a clinician practicing medicine, and needs to be at the core of using an EHR and other health IT

Process Mapping Validation

Ensures process map reflects how work is actually performed today

Includes not only the chart and people, but most importantly the information payload

Most clinical process entail a significant amount of mental processing, not directly observable

Many mappers are new to mapping and new to EHR, so need coaching to ensure thoroughness

Current Map Validation

Process Changes

Allow team members the freedom to make change

Solve problems rather than symptoms

Stay focused on ultimate goal

Focus on primary customer

Study existing systems

See the big picture

Workflow and Process Mapping Tools

Process mapping denotes sequence of tasks in a process.

Process mapping charts can be simple or complex, often starting simple and progressing to the complex.

Tools

Process diagramming tools

Process Diagrams

Swim Lane Chart

Flow Process Chart

Systems Flow Chart

Use case

Document analysis

Baseline data collection

Benchmarking

Process improvement

Process Diagramming Tools

Process diagram

Swim lane chart

Flow process chart

Systems flow chart

Flow Process Chart

Free-form illustration utilizing common set of symbols

May be combined with swim lane chart to illustrate simultaneous processing in different departments

Swim Lane Process Map (Example)

Flow Process Chart

Older tool uses a list structure with accompanying symbols to illustrate flow

Very suitable for those not comfortable drawing pictures, especially physicians

Excellent for marrying process mapping and baseline data collection

Flow Process Chart Template

Basic Systems Flowchart

Most common tool for information process mapping

Terminator symbol contains information on the boundaries of the system being mapped (where process begins and ends)

Process is the performance of an operation. It should be described precisely for each and every step in a process

Decision symbol describes decisions made within an operation. There must always be at least two choices (e.g., Y/N). Three choices might reflect <, =, or >; or action A, B, or C

Terminator

Process

Decision

Basic Structure of Systems Flowchart

For Complex Decision-Making:

Choices?

Decision Table

Special Systems Flowchart Symbols

Sample Current Process Map

Use Case

Another way to describe workflows and processes; especially to illustrate roles of user and computer

Two forms:

Graphic notations following the standard Unified Modeling Language symbols

Essential use case, aka use case scenario, uses narrative that is often preferred by users not accustomed to diagrams

Use Case Diagram

Essential Use Case Example

Document Analysis

Ensures that all data needs are accounted for in the process assessment

For direct patient care

For reporting purposes

Collect all forms and reports.

Analyze their data elements.

Who collects the data, for what purpose?

Who uses, how, when, frequency?

Document Analysis

Data Element Analysis

In a database, record all data used in all applicable documents

Identify source

Identify use

Used in clinical decision making?

Intent is to capture data once and use many times to avoid repetitive work and errors.

Data Element Analysis

Compare Processes

Compare process maps drawn by people essentially performing the same process, but in different locations (such as nursing units, clinic sites).

Identify variations

Compare maps directly

Use a spreadsheet

Evaluate variations

Are some variations necessary? (such as different nursing staff may have different credentials)

How can processes be made more standardized to reduce variation and potential errors?

Process Variation (Clinic Example)

Baseline Data Collection

Purpose

Identifies opportunities for improvement

Helps set goals and expectations for what can be accomplished with EHR

Benchmark how well the EHR is performing the desired goals

Baseline Data Collection

Baseline data collection captures current:

Volume of work

Time to complete steps

Number of errors or near misses

Helps:

Identify opportunities for improvement

Set goals

Conduct benefits realization studies

Benchmarking

Process of comparing process performance against an industry best practice or industry standard

Often used in comparison with organization’s baseline data

Process Redesign

Team Empowerment

Process assessment requires teams of various skills and knowledge

Teams should be given responsibility and appropriate authority

A system of checks and balances must be established so no group can be an outlier

Group Leader

Facilitates proceedings

Keeps group on track

Encourages participation by all

Source: Schuman (2004). Reprinted with permission from the Institute of Cultural Affairs, ICS-USA, Chicago, IL

Group Facilitation

Brainstorming

Round Robin

Double reversal

Nominal group process

Probing

Opportunities for Improvement

Bottlenecks

Sources of delay

Rework due to errors

Role ambiguity

Unnecessary duplications

Long cycle time

Lack of adherence to standards

Lack of information

Lack of quality controls

Effecting Change

Change management is the process by which an organization gets to its future state

Facilitates adoption of health IT, through:

Education

Providing feedback

Reducing fear

Process assessment

HIM and IT Professionals

Frequently are trained explicitly in workflow and process mapping and can help train, coach, and facilitate

To be effective in these roles, however, they must be neutral and unbiased

Start

Choice

Action

Choice

Action

Yes

End

Basic Flowchart