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  • Developed and presented by Bobby Gladd, Senior Meaningful Use Project Coordinator, HealthInsight, Las Vegas
  • Drawing on the late Steve Jobs’ “stuff” slide. The atomistic logic of workflow.
  • Workflows can get ostensibly “complex,” “nested” contingently to the “nth degree,” but it’s really no more complicated than this in terms of logic flow.
  • Patient visit, door-to-door. 20+ times per day, day after day.
  • Think race “relay lanes” and “hand-offs.” In the outpatient setting, it’s more than just an analogy, it’s an endless race against the clock.
  • KISS principle. Keep It Simple.
  • Times to completion and error tracking are typically overlooked.
  • Really just rapid cycle, but experimentally sound improvement method.
  • Fancy [Fishbone” 1
  • Fancy “Fishbone” 2
  • I wrote my responses right into Excel as I was interviewing. Had I a Dragon install, I could have simply talked them in.
  • Talk to the visual constraints of trying to get it all on one page, in a way that’s easy to follow. Again, this just depicts the logic, not the time consumption and error loci.
  • The beauty of this brainstorming method is in the ease of revisions as you talk your way through the process.. Then just take out your iPhone, snap a pic, and launch your graphics app (e.g. ,Visio, SmartDraw, OmniGraffle, etc) to put on the lipstick.
  • Turns out this was a “DOQ-IT” presentation, and, consequently, was public domain after all.
  • Reduction is opportunities for error.
  • What we really need to do is to display process steps in proportion to the time they consume (perhaps along with color-coding error risk loci). Think Mac “Garageband” display, with time on the x axis.
  • Improve this step by perhaps taking the data in using Dragon.
  • KISS principle
  • Most organizations can get along just fine without a “Six Sigma” QI Priesthood. KISS.
  • Thanks!


  • 1. “Workflow” demystified
  • 2. When you really think about it,even “complex” processes justboil down to this.
  • 3. "Workflow analysis" is really just about fully recognizingand documenting all of the task steps (“stuff”) you and yourfellow staff must take to complete your work (and to seehow well it actually “flows”). Between the "begin" and "end"points, there are really only two types of process steps:[1] straight input/output tasks (typically depicted by a squareor rectangle), and[2] decision point tasks (the "diamond" box) where the outputpath is the result of having made some decision froma set of alternatives.
  • 4. Individual process tasks are sequential, one after the other,often with "hand-offs" between people. Unless you work alone,work tasks typically run in parallel, i.e., different staffersperforming different tasks at the same time (and wherehand-off misalignments result in “bottlenecks”).We are really just interested in a small number of basic thingsrelated to process tasks: The total number of steps/tasks in a process; People and tools involved in each step; Time to completion for each step (min/average/max if possible, to capture variability); Number and type(s) of errors encountered in each step.
  • 5. We first seek to understand and depict our "current state"processes. Only after doing so can we begin to understandwhere things might systematically be changed for the better(e.g., fewer steps, faster task completion, fewer errors) usingThe “PDSA” cycle in order to verify that we are in fact makingthings better. Making “stuff” Better.
  • 6. A quick real world example from a clinic staffer phone interview (Depiction in a flowchart graphic on the next page.)
  • 7. It doesn’t have to be fancy to get going. Sticky notes on a whiteboard will do.
  • 8. Another real world example: Rx refill process Before EHR: Rx refill request process. 15 steps between begin/end, 11 steps in the shortest path to completion. Note also that 13 of these task steps are physical tasks. Courtesy and S.A. Kushinka
  • 9. After EHR: Rx refill request process.Now only 5 steps between begin/end,only 3 steps in the shortest pathto completion.Fewer steps means quicker taskcompletion in general, and feweropportunities for error.Think about it; unless every step in aprocess works perfectly every time,each additional step increases thelikelihood of a mistake.Note also that while some of the tasksare still “physical,” they are less so,involving the use of the computerrather than moving paper aroundthe clinic.One caution: moving from a paper chartprocess to an EHR can result in“information flow misalignment” if we’renot careful to analyze our processes andreorganize tasks where warranted. Courtesy and S.A. Kushinka
  • 10. Another process diagramming approach, the “swimlanes” map.
  • 11. Clinic _______________________________________ Process _______________________________Date ________________By ___________________________________ (Photocopy and use additional pages as needed.)
  • 12. Basic workflow diagram symbolsWhile there are dozens of “formal”workflow mapping symbols,we advise that youKeep It Simple.Also, pay attention to taskcompletion times and types andrates of errors. The standardworkflow diagram is really a“process logic map,” which,while important, doesn’t capturetime and error information, butthose too are critical fortrue process improvement.
  • 13. A few thoughts about “Lean” methods for workflow re-designAdvocates of “lean” process re-design classify tasks as 1. Value adding, 2. Non-value adding but necessary, and 3. Unnecessary (i.e., “waste”)We want to maximize time spent on #1, minimize time spenton #2, and eliminate tasks in category #3.In the context of your clinic, “point of view” must be considered.For example, only the provider “adds value” in terms of beingthe only person who whom services can be billed. All othertasks are either necessary support or waste.From the point of view of the patient, that which eases or curesher medical problem is the source of “value.” Time spentwaiting or filling out the same forms repeatedly is waste.
  • 14. Some useful links: This material was prepared by Bobby Gladd for HealthInsight in the course of his work with the Regional Extension Center for Nevada and Utah, under grant #90RC0033/01 from theOffice of the National Coordinator, Department of Health and Human Services. 9SOW-UT-2010-00-112