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Implementation and Evaluation of Revised CDS Tool

January 8th, 2008

LEADERS SYMPOSIUM“Strategic Planning to Inform a Funded Project onhow to Achieve Workflow Integration in Developing and Implementing CDS for CRC Screening”

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Key Informant Interviews of site-specific best-practices for integration of colorectal cancer screening CDS into workflow

Direct Observation of colorectal cancer screening CDS for barriers and facilitators to workflow integration

Implementationin primary care clinic after simulation study

Rapid Prototyping of CDS design alternatives based on Phase 1 findings

Simulation Study to test impact of CDS design alternatives on efficiency, usability, and workload

Evaluation in primary care clinic after simulation study

Figure. Project Overview

Phase 1 Phase 2 Phase 3

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Implementation/Evaluation Overview Following simulation study (months 18-21),

implementation of the revised CRC CDS tool will occur in two primary care clinics at the Indianapolis VAMC.

Measures used to evaluate the impact of the improved CDS, such as efficiency, usability, and workload, will be used as surrogate measures of workflow integration.

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Implementation Oversight Project Steering Committee

Project champions and sponsors from each of the participating clinics, and the co-I’s on the AHRQ project.

Responsible for project direction, goals, and objectives related to colorectal cancer screening CDS.

Administrative Oversight Working Group Project champions from the implementation site, primary care clinic

leader or manager, Co-I’s on the AHRQ project, and the project manager Responsible for the site specific tactical, operational, and administrative

activities of the implementation, including: Coordinating the implementation team structure Review/Approval of the implementation plans Communication of the project activities among site level participants

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Implementation Oversight (con’t) Implementation Teams

Front-line staff, including physicians, nurses, nurse managers, other clinical practitioners directly involved in care delivery, and the systems engineer assigned to each team.

Tasked with partnering with systems engineering faculty to learn lean principles and applying systems engineering methods to redesign clinical workflow processes supporting effective and efficient screening for CRC

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Lean Process Design…Identifying and Eliminating Operational Barriers within Patient Treatment ProcessesMaterials

Step 3

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Reducing sources of variation…Every step in the patient treatment process contributes to the:

•Patient Outcome•Patient Satisfaction•Cost of Treatment

Every caregiver and staff member must be active in reducing variation.

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What factors impact Diffusion?

1. Perceived Benefit - organizational and personal

2. Compatibility with existing systems, values, beliefs, current needs

3. Simplicity – Simple innovations spread faster than complicated ones due to the role of adaptation in spread of innovation.

4. Trialability – Changes should be tested and verified prior to full implementation.

5. Observability – Tests of change should be conducted in such a way so as to be readily observable by other ‘early adopters’.

Berwick DM. Disseminating innovations in health care. JAMA. 2003 Apr 16;289(15):1969-75

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Implementation Teams in Action

Courtesy Peter Woodbridge

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Goals: Define current workflow issues

associated with CRC screening Baseline current workflow processes

related to CRC screening Utilize Lean tools and methodologies to

identify operational barriers and process failure modes

Apply Lean tools to develop and test ‘future state’ clinical processes

Implement control strategies to insure long term sustainability of process improvements and spread adoption

Implementation Teams

DevelopFuture State

Process

Process Control

Strategy

Baseline Current

Processes

Identify Operational

Barriers

Define the Problem

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Expected Outcomes:

Plan for test pilot of process redesign to ensure that the new clinical processes supporting CRC screening meet project objectives (including economic objectives), timeline and project deliverables

Development of team members’ proficiency in use of systems engineering tools to enable long term sustainability of improvements and application in areas outside of the initial project focus (spread adoption).

Implementation Teams

DevelopFuture State

Process

Process Control

Strategy

Baseline Current

Processes

Identify Operational

Barriers

Define the Problem

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Lean Tools

DevelopFuture State

Process

Process Control

Strategy

Baseline Current

Processes

Identify Operational

Barriers

Define the Problem

Process Observation Worksheet

Spaghetti Diagram

5S, Visual Controls,

Constraint Management

Process Map

Check sheet

Process Control Plan

Project Charter

Voice of the Customer

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Example Implementation Team Schedule

Week #1: Define the Problem Week #2: Baseline Current Processes Week #3: Identify Operational Barriers Week #4-5: Develop Future State Process Week #6: Process Control Strategy Week #7-10: Pilot Implementation

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PDSAPDSA

Plan

PDSA

Do

Study

ActPlan the process change, collectBaseline Output data

Try out the test, collectOutput data from the newprocess

Examine theprocess/data to determinefailure modes

Refine thetest, basedon failuremodes

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Where is PDSA used within the Lean Cycle?

DevelopFuture State

Process

Process Control

Strategy

Baseline Current

Processes

Identify Operational

Barriers

Define the Problem

PDSA PDSA PDSA

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Evaluation Workload measures will be provided by the computerized

version of the NASA-TLX used earlier in the simulation phase.

A computerized version of the TLX rating scale will appear on the participants screen in a sample of approximately 30 volunteers after the colorectal cancer screening CDS is used

Three measures--efficiency, usability, and workload– will be used as indicators of costs and benefits of the redesign

Comparisons of workload will be made between the two primary care clinics implementing the new CDS and the three remaining clinics using the standard CDS tool.