RECIPES FOR SUCCESS IN CLINICAL WORKFLOW

MANAGEMENT

Andrea Hoffman, RN

R. Dirk Stanley, MD MPH

WHO WE ARE

Andrea Hoffman, RN – Nurse Informaticist who specializes in clinical workflow design and informatics support. Design influences = Masaharu Morimoto, Axel Erlandson, Satoshi Kurosaki

R. Dirk Stanley, MD MPH – Former CMIO and board-certified clinical informaticist who specializes in clinical workflow design and informatics development. Design influences = Lego, Ikea, Bauhaus, Jony Ive, Linus Torvalds, Gordon Ramsey

WHAT WE DOPromote education about front-line clinical informatics, clinical decision support, patient safety, and good workflow design

• Leverage common analogies as educational tools : Movies, food, music, etc.

• “Turning marshmallows into Legos”

Passionate about developing gourmet workflows.• If it looks and smells like french fries, people

will eat them.

MAKING A GOOD MEAL(WORKFLOW = [WHO] WILL [WHAT] )

MAKING A GOOD MEAL

… You will always need five things : A good chef Great ingredients A kitchen A good recipe Adequate time

MAKING A GOOD WORKFLOW

… You will always need five things : A good chef (Informaticist(s)) Great ingredients (standards, archetypes, templates, and

documents) A kitchen (archetype management, document management, project

management, project team, effective governance, and resources) A good recipe (identifying stakeholders, current state, future state,

project plan development) Adequate time (execution of project plan)

TODAY’S MENU

1. THE CHEF

2. THE INGREDIENTS

3. THE RECIPE

4. THE KITCHEN

5. THE TIME

1. THE CHEF

THE CHEFWhat are Clinical Informaticists?

• Informatics = Broad, emerging field• Patient, broad skill set, politically neutral, high tolerance for

ambiguity• HR Nomenclature challenges : “Workflow analyst”, “Clinical

Systems Engineer”, “Knowledge Engineer”, “Clinical Project Manager”, etc.

• FUTURE : Increasing formal training (certificates, boards, PMP)• FUTURE : Increasing use of term “Informatics”• FUTURE : Increasing embedded role in clinical areas (embedded

nurse/physician informaticists) as SMEs / change leaders / support• FUTURE : Wider distribution of informatics skills and terminology

2. THE INGREDIENTS

THE INGREDIENTSTo make a good meal, you need quality ingredients.

To have quality ingredients, you need standards!• In baking = Flour, sugar, salt, kilograms, pounds, cups, degrees,

minutes• In Informatics = Policies, procedures, guidelines, orders, order

sets, protocols, clinical pathways, documentation, checklists, alerts, budgets

How to make a standard document = archetype development!

Archetypes should be designed so form serves function• What is it called? And what does it do?

THE INGREDIENTS1. Telephone Numbers = Tools to contact a person2. Emails, Screen Savers, and Posters = Tools to help

send a short message3. Schedules = Tools to show who is responsible at what

date/time4. Policies and Procedures = Tools to learn

organizational standards and how to achieve them (HELPFUL TIP : Procedures are workflows – Or are they?)

5. Guidelines = Tools to help educate and guide staff towards a desirable outcome

6. Documentation = Tools to record and transmit information

THE INGREDIENTS7. Orders = Tools to document and transmit instructions

to deliver care8. Order Sets = Collections of orders used to standardize

and expedite the ordering process for a common clinical scenario

9. Clinical Pathways = Collections of order sets used to standardize care for a common clinical condition

10.Alerts = Tools to help communicate and document a unique issue

11.Clinical Protocols = Tools to standardize and automate a clinical process

12.Education Modules = Tools to help educate patients / staff

13.Dashboards / Reports = Tools to help measure or monitor something

14.Templates = Tools to help create a standardized document

THE INGREDIENTS15.Wikis= Tools to organize information / links for a

department16.Committee Charters = Tools to assign a committee

duties and responsibilities17.Committee Minutes = Tools to document committee

activities18.Glossary of Terms = Tool to learn organizational

definitions for common terms19.Budgets = Tools used to plan for future resources

THE INGREDIENTSStandardized templates need to be developed from these archetypes!

Documents need to be built from these standardized templates!

Why is this important? • Effectiveness of these tools will depend on their clarity!• Good project planning will depend on good understanding of the

development of these tools!• Timing of projects will depend on processes used to develop, review,

approve, and publish these tools!• Good opportunity to streamline governance and development!

THE INGREDIENTSQ : Why are archetypes and documents important in developing workflows? A : Archetypes Templates Documents Workflows

THE INGREDIENTS

Why are archetypes and documents important in developing workflows? Archetypes Documents Workflows

THE INGREDIENTSCommon paper workflow issue : The “Frankenform” E.g. Part order, part order set, part guideline, part

documentation, part policy, etc. Creates extra maintenance costs and delays Often masks workflow issues (The

“Frankenflow”) Symptoms : Unusually long documents / order

sets, clunky workflows, or paper forms that are difficult to “make electronic”

Commonly seen in complex clinical workflows, e.g. Medication reconciliation, Medication titration, chemotherapy, etc.

Solution : Workflow redesign!

3. THE KITCHEN

THE KITCHENThe archetype management

• Need to manage centrally, with organizational buy-in, easily accessible to everyone in the organization

The document management• Need to manage centrally, with organizational buy-in, easily accessible to

everyone in the organization

The project management• Need to manage in a standardized fashion, with standardized templates

and organizational buy-in

The staff participation• Need to identify stakeholders and SMEs effectively, and budget

time/resources properly• Familiarity comes from working on projects together (to understand roles)

THE KITCHEN

The governance• The stakeholder development, teambuilding, resource

allocation, and project timelines will all depend on the organizational governance

• Tip : This is a good opportunity to streamline governance!• OLD : Order set committee? Policy committee? Forms

Committee?• NEW : Project prioritization committee, Resource allocation

committee, Go-Live Committee, Project Management Office

4. THE RECIPE

THE RECIPE

To develop a good recipe, a skilled chef needs good communication :

• What does the customer want? Mac & cheese? Filet mignon? Beef Wellington?

To develop a good project plan, a skilled informaticist also needs good communication :

What is the goal, and how does the order relate to the goal? Maintenance request? Change request? Large-scale project? Before deciding, will need to know regulations, stakeholders, evidence/literature, current state, future state, cost data

THE RECIPEAfter thoroughly understanding regulations, goals, needs, and costs - will need to build a good project plan :

1. PREPARATION1. Literature / regulatory search2. Current / Future workflow mapping3. Project planning, stakeholder development, securing resources

2. DRAFTING (with low-level end-user buy-in)3. BUILDING (both electronic and paper downtime!)4. TESTING (Unit, Functional, Integrated, and End-user

acceptance)5. TRAINING6. DEPLOYMENT7. MONITORING

5. THE TIME

THE TIMESet realistic expectations - Important to follow good project planning!

1. PREPARATION : • Regulatory / Literature Search (including cost data)• Indexing of needs• Development of List of Stakeholders• Development of Project Team• Mapping of CURRENT state workflows (Hint : See procedures!)• Development of FUTURE State workflows• Development of Project Plan and Timelines• Securing stakeholder buy-in• Securing time/resources for project

THE TIME2. DRAFTING BLUEPRINTS – Future state workflow(s) with supporting tools

a. Low-level testing with end-users for clinical validation (user acceptance testing)

b. Securing stakeholder buy-in

3. BUILDING : a. electronic tools and supporting documentsb. paper downtime processes (order sets AND documentation!)

4. TESTING : a. Unit testingb. Functional and Integrated Testingc. End-User Testing

5. SECURING APPROVAL : a. Governance is important!

THE TIME8. EDUCATION :

a. Adequate education for go-live – What is audience? How much is enough?

b. Big question : Does this need to be added to ongoing educational effort? (For onboarding of new employees?)

c. FUTURE : Likely 16+ hours of computer training per new employee

9. GO-LIVE :a. Adequate support? Superusers? Do superusers still have patient

assignments? Other elbow-to-elbow support?b. List of showstoppers for patient safety?

10.MONITORING :a. Issues Logb. Standard way to communicate changes and issues with end-users (2-

way communication)

DESSERT Good meals come from :

• A good chef (Informaticist(s))• Great ingredients (standards, archetypes,

templates, and documents)• A good kitchen (archetype management,

document management, project management, project team, effective governance, and resources)

• A good recipe (identifying stakeholders, current state, future state, project plan development)

• Adequate time (execution of project plan)

THANK YOU!