Clinical Workflow Implementation
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Planning the implementation of an EMR or EHR, then you need to understand the basics of defining your clinical workflow. This presentation was made at a variety of medical conferences
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Clinical Workflow Implementation
- 1. 1Clinical Workflow: The Foundation of Systems ImplementationThe impact of Clinical Workflow on the Transformation ProcessPresented by:Edward A Stern, RNed.stern@nothingbetter.com
- 2. 2ObjectivesDiscuss workflow as it relates to transformationBasic workflow elementsCurrent stateFuture stateOriginal stateWorkflow processCognitive workflow cluster theory
- 3. Clinical Transformation ProcessA never ending process to improve care delivery excellence through:Offering valueMeasurably quality improvementEnhancing services and solutionsWhile reducing costs through the effective alignment of people, process and technology. Here’s where workflow plays a part3
- 4. 4Workflow DefinedFrom Wikipedia, the free encyclopediaWorkflow (WF) at its simplest is the movement of documents and/or tasks through a work process. More specifically, workflow is the operational aspect of a work procedure: how task are structured, who performs them, what their relative order is, how they are synchronized, how information flows to support the tasks and how tasks are being tracked. As the dimension of time is considered in Workflow, Workflow considers “throughput” as a distinct measure.
- 5. 5“It’s Workflows’ Fault”Workflow is often a common “fault” area in the implementation of a technology.The problem is that it is rarely ‘the’ workflow and more probably; that the wrong flow assessment, or not enough operations and systems workflows were considered.
- 6. What isClinical Informatics Assessment ?Simply stated, Clinical Informatics Assessment (CIA) is the process in which the clinical operation if broken down into fine step by step elements using an informatics work flow approach while remembering the clinical fundamentalsThink of it as a “pulse check” for the workflow process6
- 7. More onClinical Informatics AssessmentThe focus is on clinical operations and how other business and systems elements interact with the clinical patient care environmentSystems Operations + Clinical/Business Operations = Potential Software Product and Project Effectiveness?Consider how end-user usability plays into the productThe net result is a focus on assuring quality patient care while assuring efficient use of clinical informatics solutions.7
- 8. Factors to considerwhen building your CIA planIt’s a Business Process but the Patient Comes First!ROI is a relative factor in the business model, so consider hard and soft ROIs to prove your pointThe depth of the process is relative to the complexity of the projectMarketing concepts apply too… Your patient is your client, the provider may be your client, and who else is your client…8
- 9. 9Who benefits from CIAThe Patient!Clinical needs are considered throughout the processThe BusinessBusiness process and ROI is consideredThe Clinical RealmThe needs for the clinical providers is recognized and built into the IT processes, as opposed to the clinical world having to “adapt” to the IT product.
- 10. 10How do YOU boil water?Exercise:Define the workflow for boiling water.Goal: A cup of hot waterPlease number each step you identify
- 11. 11How do YOU boil water?Exercise:Who thinks they “nailed” it?Let’s review the resultsShare your details with a person next to you.Compare your results, how far apart are they?
- 12. 12Think PlaywrightWriting a workflow is like writing a script.You have:A PlotWhat needs to happen – Goal of the flowActorsElements in the workflow; staff, equipment, policies etc..ActionsWhat the actors are doingPlot TwistsDecisions that are made
- 13. 13Test the WorkflowReenactmentWhat’s our “plot” (Goal)Select the cast while we walk through the workflowActorsActionsDecisions
- 14. 14Assess, Intervene, ReassessWhat we just did was “audit and review” a WF an Identified problems to correct.Aka – Shadow assessment of a workflowThis is a common clinical nursing process…We alwaysAssess the patientIntervene if necessaryReassess each interventionIt’s no different when building a workflowAssess the current workflow you’ve documentedIntervene to correct problemsReassess the workflow and see if it now matches your real process
- 15. 15How do YOU boil water?Simple AnswerFill Kettle with cold water Turn on KettleWait for water to boil
- 16. 16Boiling Water WorkflowWhat if we broke it down even more?Simply adding water to the kettle can be more complexTake Kettle to SinkTurn on Cold TapOpen KettleMove Kettle Under TapWait for Kettle to FillTurn off TapReturn Kettle to Work surface
- 17. 17Boiling Water WorkflowAnd… even more.How do we turn on a faucet?Grasp the tap mechanism Turn mechanism clockwise Wait until water pressure is high enough Stop Turning mechanism
- 18. 18Boiling Water WorkflowNow bring it all together:Fill Kettle with cold waterTake Kettle to SinkPick up kettleExtend arm…(more)Walk to sinkTurn on Cold TapGrasp the tap mechanism Turn mechanism clockwise Wait until water pressure is high enough Stop Turning mechanism
- 19. 19Boiling Water WorkflowWhat are the exercise conclusions?Don’t ask Ed to make you a cup of hot waterWorkflows are everywhereWorkflows can be “considered complete” at almost any stage and any degree of complexityIt’s up to the clinical informatics person to assure that patient care and business needs are met
- 20. 20Workflow ComplexityComplexity varies based on the need of the audienceHere’s where some typical clinical “assessment” and critical thinking aspects come into play.Who’s your audience?What do they need to know?What will they be doing with the information?Where will this be used?When will they need it defined?When will it need to be updated?Why do they need it documented and defined?How does this play a role in the patient care and business processes?
- 22. 22“Current State”The exercise we just went through was a “current state” definition processWe defined the current operational state for a process… “boiling water to fill a cup”The typical next step is “future state”I disagree
- 23. 23What’s Original StateYou’ll note that in the earlier “boiling water” exercise we didn’t consult any policy manual or printed instruction.We all know that the way something was “originally intended” to work as been modified by those doing the task. Sometimes that modification is dramatic.Original State: is going back to the “stone age” of processThe way it was originally intended to be donee.g. Boiling water with fire!
- 24. 24Original State Integration DecisionsReview the original policy manualDetermine how far from the documented current state the original state is.Decide if there is a need to change the “current state” or change the “original state” (e.g. update the policy)If the policy needs to be updated, you might as well wait until after the “future state” is definedDecide if there is a need to integrate the two
- 25. 25Problem, Action and ResponseAnother nursing clinical action plays a role in assessing Current and Original State: Identify the Problem, Document the Required Action and ResponseDoes the miss match of “original” and “current state” cause a problem for operations today and/or in your future?What action do you need to take now, if any?What will staff and management response be?
- 26. 26Future StateWhat you just developed is the Future StateWhen defining your future you have flexibility within the parameters of the software applicationYou need to make sure you understand the potential and assess and test your theoretic ideas
- 27. 27Future State Design PrinciplesSupport evidence-based care guidelines
- 28. Reduce duplication of effort and data
- 29. Enhance access to care information
- 30. Facilitate collaboration and communication among care providers
- 31. Support timely clinical decision support
- 32. Reduce variability of care
- 33. Drive measurable improvements in quality and safety
- 34. Support continuity of care across the continuum of services and settings
- 35. Support interdisciplinary care and model of collaborative practiceCompliments of Dearborn Advisors
- 36. Future State Design SessionsFuture StateIntegration & SignoffFuture StateDiscoveryFuture StateValidationFuture StateConsensusCurrent StateConfirmationFacilitatedSessionWork GroupSessionFacilitatedSessionFacilitatedSession(s)NursingFacilitatedSessionWork GroupSessionFacilitatedSessionFacilitatedSession(s)FacilitatedSessionPharmacyFacilitatedSessionFacilitatedSessionFacilitatedSession(s)Work GroupSessionPhysiciansWorkflow Redesign Management and CoordinationCompliments of Dearborn Advisors28
- 37. 29Documentation ProcessOutline formatPowerPointPen and Paper“Flow” toolsVisioRF Flowetc
- 38. Cross Functional FlowsheetPrimary Actors for one WF:ED Providers
- 39. ED Staff
- 40. ED Nurse
- 41. Admitting
- 42. Bed Management
- 43. Receiving
- 44. In Patient, & Surgical Services
- 45. “other”30
- 46. Example of aSimple Swim Lane FlowSend the Patient Home31
- 47. Same “Plot” but anIntegrated WorkflowSend the Patient Home32
- 48. 33Previously Separate VariableDischarge to In-Patient
- 50. Defining Workflow by Categoryin Your OrganizationFunctional Systems WorkflowsHow the software system will function in the work process“Click here, then enter this, and drag that”Business Operational WorkflowsHow the business (patient care and operations business) model operates and physically gets executed“Go down the hall, make a left, pick up the form, and complete”Integrated WorkflowsIntegrated DepartmentIntegrated Software modulesIntegrated systems and operations workflows as one.Touch PointsWhere Operational and Systems “bump” into one another35
- 51. 36Example of Integrated WorkflowOrder for CBCOrder placed in System by MDRN acknowledges order in system and notes it is a “nurse draw” Print lab specimen labelObtain blood collection suppliesDraw Blood using hospital procedure 554.123Affix completed labelsTube to Lab using hospital procedure 554.124Indicate in system blood drawn and to labWait for results in system
- 52. Example of Integrated WorkflowOrder for CBCOrder placed in System by MDRN acknowledges order in system and notes it is a “nurse draw” Print lab specimen labelObtain blood collection suppliesDraw Blood using hospital procedure 554.123Affix completed labelsTube to Lab using hospital procedure 554.124Indicate in system blood drawn and to labWait for results in systemTPOPSYSOPOPOPOPTPSYSTPOP37
- 53. Cognitive ClusterA growing trend in “micro time decision process” documentationWorkflows are relatively linear and Mind Maps® are not often structured enough for application developmentA cognitive cluster (CC) enables a way to demonstrate same time sequence decision processesIt is not a “cheat” for singular thought processes
- 54. Simple ClusterThis simple cluster demonstrates a relatively simple 3 part question
- 56. Complex Cognitive ClustersThere are times when a cluster is a “micro time decision process” so complex it can only be handled by the “human cognitive process” due to the multitude of immediate decisions42Questions?Remember a copy of this presentation is available online atwww.nothingbetter.com