HIT Toolkit Workflow and Process Redesign Health Information Technology Toolkit for Critical Access and Small Hospitals

Presenter Margret Amatayakul RHIA, CHPS, CPHIT, CPEHR, FHIMSS President, Margret\A Consulting, LLC Schaumburg, IL Independent consultant, who focuses on achieving value from electronic health records, HIPAA/HITECH, and health information exchange. Developer of tools in Toolkit Adjunct faculty College of St. Scholastica, Duluth, MN, masters program in health informatics Founder and former executive director Computer-based Patient Record Institute, associate executive director AHIMA, associate professor University of Illinois Active participant in standards development, former HIMSS BOD, and co-founder of and faculty for Health IT Certification 2

Stratis Health 3 ●Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities ●Stratis Health works toward its mission through initiatives funded by federal and state government contracts, and community and foundation grants, including serving as Minnesota’s Medicare Quality Improvement Organization (QIO) ●Stratis Health operates the Health Information Technology Services Center for health care organizations seeking to use health information technology in support of their clinical transformation

Agenda Purpose of Workflow and Process Redesign Steps in Workflow and Process Redesign Workflows and processes to map Performing workflow and process mapping Critical success factors in workflow and process mapping 4

Purpose: Create Ah Ha! Moments Workflow and process redesign –Starts the process of identifying improvement opportunities with HIT –Helps users identify solutions for current problems and today’s workarounds that will form the functional requirements for your HIT –Aids in setting expectations for achieving HIT goals because users will now expect to see improvements –Ensures that critical controls built into current processes are retained or enhanced 5 Software that directs computer devices People to support and use systems Policy that drives adoption of systems Hardware that enables system use Process that helps achieve results Copyright © 2009, Margret\A Consulting, LLC. Used with permission of author.

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. Workflow and Process Process is the manner in which work to be completed to achieve a particular result is performed –Example: Do you always verify the timeliness of medication administration? Work flow is the sequence of steps and hand-offs taken within a process –Example: Is information available to schedule patients for labs in advance of a clinic visit? Workflow and process mapping depicts the detailed nature of the processes and workflow to enable improvements Five Rights for Right EHR ●Right clinical data ●Right presentation ●Right decision ●Right work processes ●Right outcomes

EHR is Not about Automating Charts 7 “Only automating form, content, and procedures of current patient records will perpetuate their deficiencies and be insufficient to meet emerging user needs” EHR is about automating & using information to improve health care EHRs “encompass a broader view of the record than today, moving from notion of location for keeping track of patient care events to a resource with much enhanced utility” Institute of Medicine, 1991  Copyright © 2009, Margret\A Consulting, LLC. Used with permission of author.

Steps in Mapping Current Processes 8 1.Identify processes to be mapped; e.g., those that will be impacted by the HIT being acquired 2.Use individuals who actually perform the process; they know it best and need to own the impending change 3.Instruct persons on process mapping – why it is being done and how it is done 4.Map current processes. Avoid identifying opportunities for improvement now, or critical controls built into current processes may be overlooked 5.Validate maps to ensure they reflect current processes, all variations, and the information payload 6.Collect all forms and reports that are part of processes to be automated through HIT 7.Obtain benchmark data to define expectations for change and for use in benefits realization studies

Steps in Redesign 8.Identify potential problems in current workflows and processes and determine their root cause 9.Identify changes that may resolve problems today 10.Educate about HIT and EHR and identify further changes that will be possible 11.Document changes by creating improved map 12.Use new processes to create use case scenarios to identify HIT functional specifications, and later to build out the HIT application to achieve improvements 13.Test new workflows and processes 14.Train all on new workflows and processes 15.Incorporate changes into policy and procedure 16.Conduct benefits realization and celebrate successful change/correct course as necessary 9

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. What to Map in Hospitals in Clinics Admission Medications reconciliation H&P/results review/differential diagnosis Patient assessment Care planning/pathways Provider orders Consultation management Patient monitoring and charting Medication administration Surgery/recovery Transfer of care/care coordination Discharge/patient instructions Charge capture/coding Reporting/quality improvement Departmental operations Scheduling/check-in and check-out Patient intake Results review H&P/encounter notes Care planning/guidelines Medication management: medication list maintenance/ prescribing/refills Provider orders E&M coding Charge capture Patient instructions/education Patient follow up/health maintenance Reporting/quality improvement

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. Process diagram Swim lane process chart Flow process chart Systems flow chart Software is available to aid in drawing charts, if desired Select Tools

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. Basic Systems Flow Chart Ovals – start and end Rectangles – process Diamonds – decision Used with permission from P. S. Rudie Associates, Duluth, MN Robert McDonald, MD and Mary Rapps

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. Annotating Processes Courtesy of Dr. Hinck, Bloomington Lake Clinic, Minneapolis, MN It may be helpful to capture components of processes and workflows by simply making a list of all processes, or Use post-it notes to record processes as they are performed and then arrange them on a wall or large piece of (e.g., examining room) paper ●Process mapping is not new, and not even new to health care, but process mapping is foreign to clinicians ●Engaging clinicians, however, is critical because EHRs are designed for their use. It may be necessary to start a map for them and have them validate it – Real clinicians really do map!

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. Getting Started Identify one complete process – neither to large or to small Identify all potential starting points Follow each to its natural conclusion Significant delays can be annotated to the side if desired Refill Processing No Yes Place in MD Box Patient Calls Ask Pt to Call Pharmacy End Chart Reviewed Write Rx & Give to Pt Document in chart End Ave 1 hr Ave 2 hr Pharmacy Calls Request chart Review chart Nurse OK? Call Pharmacy Document in chart End No Yes Document In chart Speak to Nurse OK?

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. Reflect Variations Medication administration in a critical access hospital with five nurses administering medications Some processes can be corrected immediately; others will depend on acquiring an EMAR

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. Validate Process Maps Initial pass at a swim lane map (clinic example): Map after validation: Document RFV on Post-it Throw Post-it away

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. Identify (Potential) Problems Review current maps to identify: –Bottlenecks –Sources of delay –Rework due to errors –Role ambiguity –Duplications –Unnecessary steps –Cycle time Flow process charts help identify –Nature of tasks –Key questions

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. Determine Root Cause Use complementary tools as needed –Statistical charts Radar Pareto –Relations diagrams –Tree diagram –Affinity diagram Force field analysis –Cause & effect diagrams –Physical Layouts A B

Copyright © , Margret\A Consulting, LLC. Used with permission of the author. Critical Success Factors Map processes that will be impacted by HIT, unless other reason for process improvement Engage persons actually performing the process. Leave bias and blame at the door – reward those who find the most warts! Avoid getting ahead of mapping current processes, but make sure they are complete and address the information flow – remember, information is being automated, not the staff member or the patient Get to the root cause of problems when looking for improvements. Address immediate opportunities; use others as key functional requirements for your HIT Use workflow and process mapping to create Ah ha! moments that initiate the change process. Follow up that changes are adopted and celebrate success once change is implemented

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