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Fundamentals of Workflow Process Analysis and Redesign
Facilitating Meetings forImplementation Decisions
This material Comp10_Unit7 was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Effective Meetings
3Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
“A single effective meeting will substantiallychange the capacity of a group toachieve desired outcomes” (Bolea & Scott, 2012)
Effective meetings:• Face the current reality and gap between “as is” and
“where we want to be”• Identify unused potential to improve, and• Commit to action / implementation plan
Meeting Purpose
• to “tee up” the key decisions along with the information necessary to make them for the decision makers
• and ultimately, to obtain the decisions needed to move the project toward successful completion.
4Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
Key Elements of Success
• Involvement of key personnel – Have thought through potential solutions– Results in ownership of ideas
• Solutions• Develops commitment for implementation
• Immediate focus on changes which will make the greatest possible contribution to improvement and “Meaningful Use”
• Initial implementation planning is begun in the next steps debriefing wrap-up session at the conclusion of the decision-making meeting
5Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
Meeting Participants Role
• Work within the established ground rules• Review decision-making material in advance
– Notify the facilitator in advance if additional information is needed
– Provide “reality checks”, i.e, question options, rationale and assumptions used in cost/benefit analysis
– Participate in decision-making• Participate actively in the meeting• Complete action items and follow-up as needed
6Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
Meeting Logistics
Making arrangements for the meeting• Scheduling so that necessary decision makers can
attend• Room size and layout• Supplies• Refreshments & breaks• Travel time & parking• Building access• Providing materials in advance such that participants
have time to review them
7Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
Example Topics for Agenda
• Introductions
• Goal of the meeting and expected products
• Review of documentation of process analysis and redesign
• Summary & next steps
8Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
Conducting the Meeting
• Open the meeting by stating the meeting purpose – “to make decisions on …”
• Review and follow the agenda• Monitor the agenda / time• Encourage participation from all attendees• Help participants reach consensus• Document decisions• Document next steps and follow-up / action items
9Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
Group Decision-Making Process
• Process resulting in the selection of a course of action
• Results in a “choice”• Systems
– Consensus – Voting-based methods
• Majority required• Plurality
– Dictatorship
(Wikipedia, 2012)
10Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
Documenting a Meeting
• Key information to be documented– Approved / denied process changes– Priorities for approved changes– Chosen alternatives
• Next steps• Action and follow-up items
11Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
Debriefing Wrap-up
• A wrap-up debriefing at the close of the meeting summarizes the decisions
• The purposes of the debriefing are:– To confirm agreement– To agree on next steps to move forward with
implementing approved changes
13Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
Major Decisions in EHR-related Process Redesign
• Which processes to automate or redesign• Which redesign option to implement • EHR functionality requirements • How candidate systems measure up against
requirements • Process change and system implementation
plans
14
Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions Meeting
Example Process Redesign Meeting Might Include
• Presentation of opportunities for redesign • For each redesign opportunity:
─Rationale for the change: ─Pros and cons of each competing redesign options, or analysis of
multiple options to justify the chosen one─Cost assessment of making the change ─Decision whether or not to move forward with the change,
─if resources were limited, a priority for the change would be assigned.
• Review of approved changes and their priority• Next steps
15Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions
Meeting
“BRAND” Change Matrix Template
PROCESS Benefits of the action
Risks of the action
Alternatives of the
prospective action
Nothing: doing nothing
at all
Decision
Process option 1:
Process option 2:
Process option 3:
7.1 Table Change Matrix Template (courtesy of Dr. Meredith Nahm, 2012)
16Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation
Decisions Meeting
Fundamentals of Health Workflow Process Analysis and Redesign
Quality Improvement Methods
This material Comp10_Unit8a was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Quality Improvement in the Health Care Setting
• Quality Improvement – an approach to improvement of service systems and processes through the routine use of health and program data to meet patient and program needs (Chang, 1999)
• Examples of Quality Improvement Projects– Redesigning a Clinical Office – Reducing the time for patient intake– Redesigning the information flow in a laboratory– Increasing the access to care
18Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture a
Three Major Concepts
1. Quality is a Measurable Phenomenon– Six dimensions : Safe, effective, timely, patient-centered,
efficient, equitable2. Safety
– Errors are definable and measurable– The right plan is defined on the basis of professional
standards– To avoid errors, you must decide on the best plan in the context of professional standards, and the plan must be executed
3. Accountability– Measurable performance with consequences– Currently lies primarily with physicians– Physicians will increasingly be held accountable for performance at the microsystem level
19Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture a
20
Plan-Do-Study-Act Cycle
Plan the Action
Do theAction
Act on theLearnings
Study theResults
This simple modelcan serve as the
foundation for every project type.
Also known as:Shewhart cycle Deming cycle Learning and improvement cycle
Organizational Culture• Quality Improvement projects can be aided or
impeded by the organizational culture• Organizational Culture factors to consider
– Leadership– Ability to adapt to change– Communication ability– Understanding of change or need for change
• Factors needed for success (Ransom, 2004)– Making quality improvement part of the job– Leadership support is essential for quality
improvement activities to succeed
21Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
Quality Improvement
“It is not necessary to change. Survival is not mandatory”
- W. Edwards Deming
1900-1993
22Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture a
Leadership SupportLeaders can enable quality improvement in their health care settings by:
• Creating and promoting a quality vision • Increasing staff capacity to support quality improvement • Motivating staff to participate in QI projects• Establishing the QI teams• Demonstrating support of use of metrics to measure
performance • Making sure that the ‘voice’ of the patient is heard and
acted on • Involving staff and patients • Including QI in the budget
23Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
Quality Improvement Methods
• Many methods • Human-centered and supportive of the
implementation of Health IT• Originally tailored for enterprises, not
necessarily health care
24Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
Associates for Process Improvement (API)Model
• Developed by Tom Nolan and Lloyd Provost• Simple model for Process Improvement based
on Deming’s PDSA cycle• Three fundamental questions form basis of
improvement– What are we trying to accomplish?– How will we know that a change is an improvement?– What changes can we make that will result in
improvement?
25Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
FOCUS-PDCA
1980s – Focus-PDCA model• Find an opportunity for improvement• Organize an effort• Clarify current understanding • Understand the process variations and capability• Select a strategy• PDCA cycle test the strategy
26Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
ISO 9000• International Standards Organization• 1987 – initial ISO 9000 guidelines for performance
improvement. • Components
– Design and develop a QI program– Create a sociocultural environment
• And a structure that supports improvement– Reduce or avoid quality losses– Define QI responsibilities– Develop an improvement planning process– Develop an improvement measurement process– Develop an improvement review process– Carry out QI projects– Analyze the facts before you decide to do QI
(ISO 9000, n.d.)
27Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
Kaizen
• Kaizen– Japanese for change for the better
• Continuous Improvement– The common English term– Connotes ongoing improvement involving
everyone– Assumes our way of life deserves to be
constantly improved– Includes improvement practices
28Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
Lean Thinking
• Sometimes called the “Toyota Production System”
• Consists of five steps:– Identify which features create value– Identify the sequence of activities, called the value
stream– Make the activities flow– Let the customer pull the product or service through
the process– Perfect the process
29Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
30
Work Flow Diagrams
2004 Bluefire Partners Rapid Action Workshops, Session 1, Wave 4, Licensed by Immanuel St. Joseph’s
©
Lean Thinking
• Assumptions underlying Lean thinking are– People value the visual effect of flow– Waste is the main restriction to profitability– Many small improvements in rapid succession are more
beneficial than analytical study– Process interaction effects will be resolved through value
stream refinement– People in operations appreciate this approach– Lean involves many people in the value stream
• Transitioning to flow thinking causes vast changes in how people perceive their roles in the organization and relationships to the product
•
31Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
Six Sigma DMAIC 1. Define - Project goals and boundaries
are set, and issues are identified that must be addressed to achieve improved quality
2. Measure – Information about the current situation is gathered in order to obtain baseline data on current process performance and identify problem areas
3. Analyze – Root causes of quality problems are identified and confirmed with appropriate data analysis tools
4. Improve – Solutions are implemented to address the root causes of problems identified during the analysis phase
5. Control – Improvements are elevated and monitored. Hold the gains.
32Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
http://www.orielstat.com/lean-six-sigma/six-sigma-dmaic/overview
IRS - Tax Advice (phone-in)
(140,000 PPM)
7
Sigma
1,000,000
100,000
10,000
1,000
100
10
1
DPMO
•
Restaurant BillsDoctor Prescription Writing
Payroll ProcessingOrder Write-up
Journal VouchersWire Transfers
Airline Baggage Handling
Purchased Material Lot Reject Rate
Domestic Airline Flight Fatality Rate (0.43 PPM)
Best-in-Class
Average Company
3 4 5 621
© 1994 Dr. Mikel J. Harry - V4.0
The Quality ColloquiumIntroduction to Track IC:
Six Sigma as a Healthcare Quality Initiative
Measurement: Comparative Analysis of Process Capability
Med Error
The Quality ColloquiumIntroduction to Track IC: Six Sigma as a Healthcare Quality Initiative
Improvement Methodology: DMAIC “Backbone”
…the current process capability (get the data!)
…the problem in a measurable way
…and validate root cause(s)
Devise solution(s) and implement
PerformanceImprovement
Benchmarking
Control Tools
DEFINE
MEASUREANALY
ZEIM
PROVECONTROL
Sustain improvement
Project Timeline
Retu
rn o
n I
nvestm
en
t (R
OI)
Quality Improvement Tools
Quality Improvement Tools– Flowcharts, – Cause-and-effect diagrams,– Statistical Process Control, – Pareto charts, – Check lists
35Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
© iStock photo, used under license
36
Why Collect Data?
“Data is like garbage. We need to know what we are going to do with the data before we actually collect them.”
--Mark Twain
“In God we trust; all others must bring data.”
W. Edwards Deming
37
Data and statistical thinking play a vital role in system and process improvement. It is essential to understand distribution theory especially the concepts of shape, center, spread, and outliers.
Data-Based Decisions
38
Measures of center estimate the center of a distribution. The three measures of center we will discuss are the mean, the median, and the mode.
Measures of Center
A Distribution Curve
0 20 40 60 80 100
English
0
50
100
150
200
250
300
Fre
qu
ency
Mean = 53.78Std. Dev. = 19.484N = 4,253
English
Mean: 54
Median: 56
Mode: 63
The Normal Distribution Curve
In everyday life many variables such as height, weight, shoe size and exam marks all tend to be normally distributed, that is, they all tend to look like the following curve.
The Normal Distribution Curve
00.0050.01
0.0150.02
0.025
0 20 40 60 80 100
It is bell-shaped and symmetrical about the mean
The mean, median and mode are equal
Mean, Median, Mode
It is a function of the mean and the standard deviation
42
Knowledge of spread informs us to what extent data values vary. We will discuss five measures of spread:
• Range• Variance• Standard Deviation
Measures of Spread
43
The standard deviation is the square root of the variance. A higher standard deviation indicates higher spread, less consistency, and less clustering.
Sample Standard Deviation Formula:
� (Yi - Y)2n
i=1
n-1
S = S2
=
Standard Deviation
Bell shaped curve• empirical rule for data - only applies to a set of
data having a distribution that is approximately bell-shaped:
• 68% of all scores fall with 1 standard deviation of the mean
• 95% of all scores fall with 2 standard deviation of the mean
• 99.7% of all scores fall with 3 standard deviation of the mean
45
Exercise:
Describe the following distributions in terms of shape, center, spread, and extreme values. Can you think of any examples from your workplace?
Distribution Shapes
46
Types of Data
Verbatims
Categorical
Count
Continuous
Yes/No
Unordered
Ordered
Types of Data
47
• “I don’t like to have to wait so long in the waiting room.”
• “All I want is to talk to a human being.”
• “Why do they keep asking for the same information?”
• “I couldn’t understand what the doctor said.”
Examples of Verbatims
48
• A patient history is either “updated” or “not updated”
• A diversion either “occurs” or “does not occur”
• A specimen is either “OK for testing” or “not OK”
• A hospital room is either “available” or “not available”
Examples of Yes/No Data
49
• Billing Errors:- Misspelling- Wrong Address- Wrong Amount
•Customer Complaints- Billing Mistake- Poor care- Long wait time
• Employee Injuries:- Hand- Back- Neck- Eye- Foot
Examples of Unordered Categories
50
• Service Score:- Poor- Good- Excellent
• Quality Rating:- Very Dissatisfied- Dissatisfied- Neutral- Satisfied- Very Satisfied
Examples of Ordered Categories
51
•The number of errors on twenty prescription labels
•The number of patient falls in a hospital
•The number of sentinel events
•The number of computer system failures in a month
Examples of Count Data
52
• Body weight• The time it takes to room a patient• The time it takes to clean an operating room• Cholesterol level• Blood pressure• Body temperature• Room temperature
Examples of Continuous Data
Basic Tools
• CREATIVITY TOOLS
– Although this group is not known as a fixed list of specific tools-that would be incongruent with the concept of creativity-it typically includes brainstorming, mind maps, Edward deBono’s (1999) six thinking hats, and the use of analogies
– Help one look at processes in new ways and identify unique solutions • STATISTICAL TOOLS
– Used for more sophisticated process data analysis– Help understand the sources of variation, the relative contribution of each variable, and the
interrelationships between variables
• Statistical process control (SPC)– A graphic means used to monitor and respond to special causes of variation– A wide range of statistical techniques that can be applied to both parametric and
nonparametric data– Allows the analysis of the statistical significance of more complex interrelationships
53Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
Basic Tools• FLOWCHART
– A map of each step of a process
• CAUSE-AND-EFFECT DIAGRAM
– Ishikawa, or fishbone, diagram – Assist in organizing the contributing causes to a complex problem (Tague, 2004)
• PARETO CHART
– 80 percent of the wealth in Italy was held by 20 percent of the population (Pareto)
• CHECK SHEETS– Used to measure the frequency of events or defects over short intervals– Immediately provides data to help to understand and improve a process.
54Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
Fishbone Diagram (cause and effect)
Largest Influence
2nd Largest InfluenceLeast Influence
3rd Largest Cause
Factors and/or categories of factors
Effect
Cause
Cause
Cause
Cause
Cause
Cause
Cause
Cause
Cause
56
8 11 12 15 32 57 96125
2.2 3.1 3.4 4.2 9.016.027.035.1100.0 97.8 94.7 91.3 87.1 78.1 62.1 35.1
300
200
100
0
100
80
60
40
20
0
Defect
CountPercentCum %
Pe
rce
nt
Co
un
tPareto Chart for Reason
Pareto Chart—Patient Complaints
57
Count
Perc
ent
Dx
Count 6Percent 43.8 30.9 9.9 3.1 2.8 2.8 2.5 2.5
1421.9
Cum % 43.8 74.7 84.6 87.7 90.4 93.2 95.7 98.1
100
100.0
32 10 9 9 8 8
350
300
250
200
150
100
50
0
100
80
60
40
20
0
2009 Medicaid PPR's N = 268
Example of a simple process check sheet. (attributes)
Model XYZC217 Batch
failures 1 2 3 4 5 6 7 8 910
Power up1 2 1
Boot up6 4 2 1 2
Sink test2 1 1 1
Case damage 1 1 2
Keyboard damage
Monitor damaged 1 2
Bundled s/w included 3 1 3
Checked bypj
am jj [j
lm
lm
rm pj
am pj
Basic Tools• HISTOGRAM
– A graphical display of the frequency distribution of the quality characteristic of interest– Makes variation in a group of data readily apparent– Assists in an analysis of how data are distributed around an average or median value.
• SCATTER DIAGRAM
– Show the relationship between two variable– Can help to establish the presence or absence of correlation – Does not indicate a cause-and-effect relationship
• RUN CHART – Plots of data, arranged chronologically– Used to determine the presence of some types of signals of special cause variation– A center line (usually the median) is plotted Along with the data to test for shifts in the
process • CONTROL CHART
– Consists of chronological data along with upper and lower control limits that define the limits of common cause variation
– Used to monitor and analyze variation from a process– Use to determine if process is stable and predictable
59Health IT Workforce Curriculum
Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods
Lecture b
Red Blood Cell Histogram
60Size of Red Blood Cells
Control
Experi
ment
302520151050
30
25
20
15
10
5
0
Scatterplot of Experiment vs Control
Control
Experi
ment
302520151050
30
25
20
15
10
5
0
Scatterplot of Experiment vs Control
R2 = .98
Experiment = - 1.55 + 1.43 Control
63
Run chartRun Chart
1.07 - 12.07
0
10
20
30
40
50
1.07 2.07 3.07 4.07 5.07 6.07 7.07 8.07 9.07 10.07 11.07 12.07
Time Frame(Month.Year)
Nu
mb
er
Median
Graph of data over time
Track performance
Display & identify variation
64
Run chart analysis: Common cause variation only
0
1
2
3
4
5
6
7
8
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Time
65
Run chart analysis: Runs
• Run = one or more consecutive data points on the same side of the median
• Excludes data points on the median
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
11 runs
66
Run chart analysis: Run length
0
2
4
6
8
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Time
67
Run chart analysis: Trends
0
2
4
6
8
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Time
Special cause—trends: Consecutive points all going up or all going down. May cross the median.
(Pyzdek, 2003)
68
Run chart analysis: Freaks
0
2
4
6
8
10
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Time
Freaks: The presence of more than one or two dramatic spikes suggests the process is out of control.
69
Run chart analysis: Cycling
Cycling: A zigzag or saw-tooth pattern with 14+ points in a row alternating up or down.
0
1
2
3
4
5
6
7
8
9
10
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
70
Control charts
71
Control chart
Time
Qu
alit
y C
ha
rac
teri
sti
c
Low
High
UCL
An indication of a special cause
LCL
X
Run chart with control limits
Determines type of variation
Is process stable? Predictable?
Maintaining and Enhancing Improvements
Topics• Monitoring processes to maintain
performance gains
• Continuing to improve process performance
• Contingency planning for EHR downtime– providing patient care when the EHR is down
– maintaining availability of health information to providers and patients in major emergencies
72Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing
Improvements Lecture a
Measurement Is the First Step
“Measurement is the first step that leads to control and eventually to improvement.
If you can’t measure something,
you can’t understand it.
If you can’t understand it,
you can’t control it.
If you can’t control it,
you can’t improve it.” - Dr. H. James Harrington
(DeMarco, 1982)
73Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing
Improvements Lecture a
Quality Council
74Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing
Improvements Lecture a
• Establish core quality standards and requirements• Identify and defining quality metrics• Identify and define quality requirements• Clarify which performance measures are key to gauging
actual quality improvement performance• Collect and analyze data to understand key variables
and process drivers• Legitimize value of QI within the organization• Analyze QI data and report quality trends • Educate organization and train key staff
Maintaining Improvements
Measurement
Understanding
Control
Improvement
75Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing
Improvements Lecture a
Process Control Terminology
76Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing
Improvements Lecture a
• Process control (PC) the method for keeping a process within boundaries; the act of minimizing the variation of a process
• In-control process: observed variability is due to natural random variation
• Out-of-control process: observed variability is due to special causes, i.e., those other than natural variation
• Statistical process control (SPC) is the application of statistical methods to control a process
(American Society for Quality (ASQ), 2011)
Challenges to SPC in Health Care
77Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing
Improvements Lecture a
• SPC was first used in manufacturing • SPC is not frequently included in books on
statistics for health care and medicine • SPC is a tool, like any tool, it can be used
incorrectly or for the wrong job• Prior to EHRs data had to be manually
collected
Statistical Process Control
78Health IT Workforce Curriculum Version 3.0/Spring 2012
Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing
Improvements Lecture a
• Uses special charts, called control charts• Statistical Process Control activities
– Understanding the process– Understanding the causes of variation – Elimination of the sources of special cause variation
• Monitored using control charts to identify variation due to special causes
• Causes for excessive variation must be determined
(Shewhart, 1931)
79
• Stable, consistent, and predictable process results
• Allows you to learn from variation• Allows you to identify special causes of
variation• Provides a rational basis for predicting
future performance
Benefits of Statistical Control
80
One thing for certain is that variation is caused. Some of the generic cause categories are:• Environment• Equipment• Methods• Materials• Measurement• People
Some Causes of Variation
81
Common cause variation is the variation inherent in the process.
Special cause variation is variation due to fleeting or unusual causal factors.
A statistical control chart is able to distinguish between common cause variation and special cause variation.
Two Types of Variation
82
The following are “rules of thumb” for determining whether there are special causes of variation present in the process:
1) A point outside the control limits2) Seven points in a row increasing or decreasing3) Seven points in a row above or below average4) Obvious patterns
Note: Special cause rules should in some cases be tailored for the metric.
Rules for Detecting Special Causes
83
Statistical Control Charts
Continuous Data
Yes/No Data
Count Data
X & M-R Charts
X-Bar & R Charts
P Chart
NP Chart
U Chart
C Chart
Common Statistical Control Charts
84
Sample
Pro
port
ion
2018161412108642
0.5
0.4
0.3
0.2
0.1
0.0
_P=0.2316
UCL=0.4369
LCL=0.0263
P Chart of No. Damaged
Tests performed with unequal sample sizes
P Chart: Proportion of Damaged Boxes
85
Sample
Pro
port
ion
3330272421181512963
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0.00
_P=0.02721
UCL=0.07354
LCL=0
P Chart of DIVERSIONS
Tests performed with unequal sample sizes
P Chart: Proportion of Patients Diverted
86
Sample
Sam
ple
Count
Per
Unit
24222018161412108642
0.014
0.012
0.010
0.008
0.006
0.004
0.002
_U=0.00753
UCL=0.01253
LCL=0.00253
U Chart of Reported Falls
Tests performed with unequal sample sizes
U Chart: Patient Fall Rate
87
Observation
Indiv
idual V
alu
e
403632282420161284
60
45
30
15
0
_X=29.74
UCL=54.06
LCL=5.43
Observation
Movin
g R
ange
403632282420161284
30
20
10
0
__MR=9.14
UCL=29.87
LCL=0
11
1
I-MR Chart of Turn Time
I-MR Chart: OR Turnover Time
Basic Tools
• PROCESS DECISION PROGRAM CHART– Actions to be completed are listed, then possible scenarios about problems that could occur
are developed.– Management decides in advance which measures will be taken to solve those problems
should they occur.– Helpful when a procedure is new and little or no experience is available to predict what
might go wrong. (Tague, 2004) • FAILURE MODE AND EFFECTS ANALYSIS
– FMEA is a method for looking at potential problems and their causes as well as predicting undesired results
– Developed in the aerospace And defense industries and widely applied – Normally used to predict product failure from past part failure, but it can also be used to
analyze future system failures– Enables people to focus energy and resources on prevention, monitoring, and response
plans where they are most likely to pay off • POKA-YOKE
– Japanese name for “mistake proofing”– Can be thought of as an extension of FMEA– Puts special attention on human error
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Lecture b
Quality Improvement Mistakes
Mistakes in Purpose & Preparation– Error #1: Choosing a subject which is too difficult or which a
collaborative is not appropriate– Error #2: Participants not defining their objectives and assessing
their capacity to benefit from the collaborative– Error #3: Not defining roles or making clear what is expected of
individuals taking part in the collaborative as faculty or participants – Error #4: Neglecting team building and preparation by teams for
the collaborative
(Ovretveit, 2002)
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Lecture b
Quality Improvement Mistakes
Mistakes in Planning and Operations– Mistakes in fostering a learning community focused on
improvement• Error #5: Teaching rather than enabling mutual
learning• Error #6: Failing to motivate and empower team• Error #7: Not developing measurable and achievable
targets. – Mistakes in transition and implementation• Error #8: Failing to learn and plan for sustaining.
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Lecture b
Fundamentals of Workflow Process Analysis and Redesign
Leading and Facilitating Change
This material Comp10_Unit9 was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Working With People
Tell me and I’ll forget;
show me and I may remember;
involve me and I’ll understand.
– Chinese Proverb
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Change Concepts
What is it that causes some change management efforts to be successful?
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Employee’s Perspective
• From the employee’s perspective, there can be a lot of changes, and a lot of changes can be overwhelming.
• Remember that work process change may be only one of several changes an organization is undergoing.
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Change
RegulatoryChanges
MarketChanges
DepartmentalChanges
Personnelchanges
RequestsFrom
Manager
Re-structuring
WorkProcessChange
Merger / Acquisition
Projectchange
Employee
Janssen’s 4-Room Apartment
95
Key Concept 1:
• Humans and organizations are complex• Many factors that come into play
– Organizational constraints – Management style– Organizational, departmental, division,
and personal goals – Personalities– Environmental factors
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Key Concept 2:
• Organizations are living, changing biological systems– If you push on the system, it will compensate– Behavior dependent on culture and level of trust
• Reductionist treatment rarely explains the whole– Measures and numbers
• Are not complete• Cannot capture the complete complexity.
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Key Concept 3:
Change happens through individual choice and freedom not through top-down control or coercion.
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Key Concept 4:
John Gall, MD in his 1970’s book Systemantics said it most insightfully:
“Systems run best when designed to run downhill.”
Systems should work with natural human tendencies rather than against them
(Gall, 1978)
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Change
Key Concept 4 Example:
Sure, walk in my garden!
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Change
istockphoto.com/nahm001, 2011.
Key Concept 5:
• Change starts with a deeply meaningful purpose
• Which of the following would you rather be a part of?– Getting a system in production– Implementing a system so your practice
would get the Meaningful Use incentives– Using health IT to improve the health of your
patients
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Key Concept 6:
Make and keep the gap between “as is” current reality and “to be” vision visible, and talk about it at every opportunity.
Making gaps visible maintains a “creative tension” as Peter Senge calls it, that motivates forward progress.
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Change
istockphoto.com/nahm001
Key Concept 7:
Don’t pull.
“it is an assault to try and change someone’s mind.”
The Answer to How is Yes (Block, 2002)
Key Concept 8: The Engagement Gap
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Change
CEO
}Steering Committee
CEO
Team of the “Best & the Brightest”
Key Concept 9: Transparency
“…tell the truth, the whole truth and nothing but the truth…”
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Pulling it all together
• Change happens best when individuals have – Deeply meaningful purpose – Sincere invitation to influence – Acknowledgement of opportunities for personal
control or choice– Transparency– Shared understanding
• Change is impacted by:– Individuals and organizations– Culture and trust– How a change project is structured and managed
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Applying All of ThisFacilitation Plans and Tools:
Facilitation “F” Plan
• A facilitation plan is an outline for how a meeting or an entire change effort will be run. A facilitation plan includes:– Description of who is included.– Description of how included individuals will be selected or invited. – Schedule or agenda. – Outline of what methods or tools will be used – Description of how the rest of the organization will be kept up-to-
date– Description of how leadership will be kept in the loop
• A facilitation plan should be made available to the entire organization to maintain transparency.
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Facilitation Plan Scenario• A mid-size internal medicine practice has decided to select,
purchase and implement an Electronic Medical Record (EMR). They have hired you as a consultant for Process Analysis and Redesign. Your agreement with the practice is that you will provide instruction, training and oversight for members of their staff as they analyze their processes, redesign their processes around an EMR, and define the functionality that they need in an EMR.
• You have already had an initial meeting with practice leadership and have had a tour and met the 75 person staff. At your next meeting, you will present the facilitation plan and get the analysis and redesign started.
• Over the next several slides, we will look at “Big F” facilitation plan for the entire effort, and a “little f” agenda for the initial meeting.
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Big F
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Change
Group 1 work week:Process inventory
Group 1 work week:Process Analysis
Group 1 work week:Process Redesign
Group 1 work week:Finalize
Group 2: Weekly Walkthroughs 1 hour
Leadership briefing / debriefing1 hour
Week 1 Week 2 Week 3 Week 4
Little f post-Week 1 Walkthrough
• Introduction to overall project– How the team was selected– What their charge is– The Big F plan– Timeline and scope
• Context diagram exercise– Create one as a group– Pin-the-tail on the donkey
• Process Inventory– What did we miss
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Little f Leadership Briefing / Debriefing
• Brief review of progress• Presentation of challenges• Review and “what did we miss” exercises• Engaging questions:
– Any surprises based on what’s presented – Get help strategizing about challenges– Leadership should have input into prioritizing
processes for analysis and redesign
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Fundamentals of Workflow Process Analysis and Redesign
Process Change Implementation and
Evaluation
This material Comp10_Unit10 was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Topics – Component 10 Unit 10
• Common process changes
• Implementation plan components• Communication for implementation
• Common implementation problems
• Evaluating the new process
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Implementation and Evaluation
Common Process Changes
• From manual to electronic prescribing• From receptionist to web-based
appointment scheduling• From manual to automated appointment
reminder calls• From manual tracking of test results to
automated result tracking• From paper to electronic patient charts• From paper to electronic test ordering
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Implementation and Evaluation
Implementation Plan
The implementation plan serves as a map for everyone involved in changing a process. It covers what steps everyone will need to take, what to expect and what to do when things don’t go as planned.
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Process Change Implementation and Evaluation
Implementation Plan Components
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Implementation and Evaluation
• Reason for the change• Summary of what will be different • Sequence of implementation tasks• An implementation schedule for the entire
implementation phase – Responsible parties– Each implementation task
• Statement of how the process will be managed• Contact information for who to call when problems arise• Description of how the process change will be evaluated
Exercise
• Using your project redesign
• Review the implementation plan components on the previous slide
• Create an implementation plan
• Include each component from the previous slide
Communication of an Implementation Plan
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Implementation and Evaluation
“Tell me and I’ll forget;
show me and I may remember;
involve me and I’ll understand.”
– Chinese Proverb
What People Need to Know
• What is happening• Why is the change taking place • How they will be affected
– Address each task or activity that will be added, changed or will go away
• How the change will impact workflow or responsibilities
• How will the change take place• What if anything different will the patients see
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Implementation and Evaluation
Job Aids
• Talking points• Checklists• Written procedures• Cheat sheets
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Process Change Implementation and Evaluation
Fundamentals of Health Workflow Process Analysis and Redesign
Maintaining and Enhancing Improvements
Lecture bThis material Comp10_Unit11b was developed by Duke University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Business Continuity Plan
(Wikimedia, 2012)
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Improvements Lecture b
What is Affected When an EHR is Down?
• Receipt of lab results via electronic interface, • Clinical decision support, • Routing of prescription refills • Electronic storage of entered clinical
documentation, • Appointment call reminders, and • Transmitting health information
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Improvements Lecture b
BCP for EHR Downtime
Business continuity planning for EHR downtime is the systematic inventory of EHR-facilitated processes and contingency planning for each.• Real-time clinical care• Care follow-up activities• Getting data into the EHR
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Improvements Lecture b
BCP Team
• Assemble Core Team to oversee BCP development
• Identify BCP Points-of-Contact for organizational units
• Define the overarching BCP program
• Develop a BCP timeline
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and Enhancing Improvements Lecture b
(Wikimedia, 2012)
BCP Plan Objectives
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Improvements Lecture b
• Ensure continuous performance of an organization’s mission-essential functions in an emergency
• Ensure safety of employees• Protect essential equipment, records, and other assets• Reduce disruptions to operations• Minimize damage and losses• Achieve an orderly recovery from emergency
operations• Identify alternate locations and ensure operational and
managerial requirements are met before an emergency occurs.
Key BCP Plan Goals
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Improvements Lecture b
• Essential organizational functions, vital systems, data and information identified and prioritized
• Critical elements are capable of being recovered quickly to resume operations
• People know who is in charge• Back-up personnel are trained• Alternate work locations are predefined• Checklists are predefined to guide the
organization in responding to an emergency
Critical Processes
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Improvements Lecture b
• Processes or services that must be recovered within 24 hours after a disruption to ensure resumption of the essential function
• Includes all resources necessary to carry out the critical process:
– Personnel– Data or vital records– Systems and equipment
Essential Functions
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Functions that must be performed to achieve the organization’s mission
•Essential Functions include:
– Communications
– Vital Records, Systems and Equipment
– Key Personnel
– Alternate Work Sites
– Testing, Training & Exercises
– Personnel– Data or vital records – Systems and equipment
Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing Improvements
Lecture b
Exercising the Downtime Plan
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Improvements Lecture b
• Exercises are events that allow participants to apply their skills and knowledge to improve operational readiness
• Goal of exercises is to prepare for a real incident involving EHR Downtime Plan activation
• Three types of exercises:– Tabletop– Functional– Full-scale
Dangers of predicting the future
• I never make predictions, especially about the future.
• Sam Goldwyn Mayer
Looking to the future: common mistakes
• Making predictions rather than attaching probabilities to possibilities
• Simply extrapolating current trends
• Thinking of only one future
Looking to the future: common mistakes
• People consistently overestimate the effect of short term change and underestimate the effect of long term change.
• Ian Morrison, former president of the Institute for the Future
Why bother with the future?
• The point is not to predict the future but to prepare for it and to shape it
IOM report: the problem
• Between the health care we have and the care we could have lies not just a gap, but a chasm
• A system full of underuse, inappropriate use, and overuse of care
• Unable to deliver today’s science and technology; will be even worse with innovations in the pipeline
IOM report: the problem
• A fragmented system characterised by unnecessary duplication, long waits, and delays
• Poor information systems; disorganised knowledge
• “Brownian motion” rather than organisational redesign
IOM report: the problem
• A system designed for episodic care when most disease is chronic
• Health care providers operate in silos
IOM report: six challenges for health care organisations
• 1. Design seamless, coordinated care
• 2. Make effective use of IT, including automating patient records
• 3. Manage knowledge so that it is delivered into patient care
IOM report: getting evidence into health care delivery
• Ongoing analysis and synthesis of medical evidence
• Delineation of guidelines• Identification of best practices in design of
care processes• Better dissemination to professionals and
public• Decision support tools• Goals for improvement• Measures of quality for priority conditions
IOM report: six challenges for health care organisations
• 4. Coordinate care across patient conditions, services, and settings over time
• 5. Advance the effectiveness of teams
• 6. Incorporate measurement of care processes and outcomes into daily practice
What will survive as the world changes completely:
• 1. Clear ethical values• 2. Being clear about our mission• 3. Putting patients first• 4. Constantly trying to improve• 5. Basing what we do on evidence• 6. Leadership• 7. Learning
Conclusions
• Patients will have the same access to knowledge as professionals
• Self care or “rolled back care” will become steadily more important
• Professionals and patients will become much more equal partners
• Evidence will become steadily more important
144
1880 New York City
• 150,000 Horses• 3 Million pounds of manure/day• 40,000 gallons of urine/day• 41 deaths/day• 15,000 deaths/year
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