Welcome to Fundamentals of Health Workflow Process Analysis and Redesign, Facilitating Meetings for Implementation Decisions. This component, Fundamentals of Health Workflow Process Analysis and Redesign is a necessary component of complete practice automation and includes topics of process validation and change management.In one lecture, this unit, Facilitating Meetings for Implementation Decisions, covers a method and the associated logistics for conducting meetings in which health care facility decision makers review options for major process and implementation related decisions and make decisions. The purpose of the meeting is to outline the decisions that need to be made, to assure that decision makers have the necessary information for decision making, and to facilitate decision making. This unit provides the Practice Workflow and Information Management Redesign Specialist with tools for conducting decision making meetings. There are many methods for conducting and facilitating meetings. Here, we provide one method, discuss key concepts, and provide references to resources that you can use as you develop your skills and portfolio of tools for meeting facilitation.
Many professional facilitators will agree with this quote:“A single effective meeting will substantially change the capacity of a group to achieve desired outcomes.” (Bolea & Scott, 2012)To facilitate such a meeting requires good leadership, a well-planned Strategy, the appropriately selected group processes, and a good understanding of the culture of meeting participants, and finally, the coordination of these four layers. When all of these come together, the meeting enables the group to:Face the reality of the current process,Identify unused potential to improve, andCommit to action, or “Buy-in to the” Implementation Plan. There is a lot of publically available training on meeting planning and management skills. It is not our goal to replicate such training here, but we do point out managing effective meetings as an area of professional and skills development for those without prior experience and training. In this unit, we concentrate on major EHR process redesign and implementation decisions necessitating decision making meetings, and specific content for such meetings.
The tactical purpose of a decision-making meeting is to “tee up” the key decisions along with the information necessary to make them for the decision makers.The ultimate goal of the meeting is to obtain the decisions needed to move the project toward successful completion for the practice.
There are so many methods of developing group consensus through meeting management that there is actually an internet site for selecting the best fit for the meeting needs.For our purposes, it is sufficient to note the following key elements of success: Involvement of key personnel who have thought through potential solutions,Involvement of key personnel results in ownership of ideas (solutions) and develops commitment for implementation,Immediate focus on changes which will make the greatest possible contribution to improvement and “Meaningful Use”, and Initial implementation planning is begun in the next steps debriefing wrap-up session at the conclusion of the decision-making meeting.Similar to meeting management, there is a large amount of information available on facilitation and on developing facilitation skills. We will not cover this information here, but point it out as an area of professional and skills development for those without prior experience and training.
The meeting participants are to:Work within the established ground rulesReview decision-making material in advanceNotify the facilitator in advance if additional information is neededProvide “reality checks”, i.e, question options, rationale and assumptions used in cost/benefit analysisParticipate in decision-makingParticipate actively in the meetingComplete action items and follow-up as needed
Meeting logistics are important. The practical arrangements will be arranged or managed by the facilitator. It is important to consider in detail the scheduling, the location and layout of the room and assure that it is conducive to the meeting, e.g., if there will be a presentation, is a projector and power for a computer available, is the room large enough so that participants can see the presentation, making sure that necessary supplies will be available, e.g., flip charts, tape to affix to the wall, markers, etc., providing for refreshments or breaks so that people can have their own, accounting for travel time, parking, and building access, and providing materials in advance such that participants have time to review them.
At the global level, you will want to include at least the following items in the agenda: Introductions,Reiteration of the goal of the decision making meeting and expected meeting products, and Review of documentation of process analysis and redesign, - For this you may have used the BRAND template.Summary and next steps
Conducting the decision making meeting includes:Opening the meeting by stating the meeting purpose – for example, “to make decisions on which process redesigns to implement”. If you have done a thorough job at planning the meeting and preparing the participants for the meetings, everyone will be in agreement that they have sufficient information and the right people to make the decisions and that they are prepared to do so.Review and follow the agendaMonitor the agenda / timeEncourage participation from all attendeesHelp participants reach a decisionDocument decisions and Document next steps and follow-up or Action items.
It is important for the facilitator to analyze the culture and the decision-making style currently in the health care setting. Discuss decision-making with practice leadership to determine current and/or preferred decision-making styles and incorporate this information into the meeting plans for decision-making.Group decision-making is a process which results in the selection of a course of action. Decision-making always results in a “choice”. There are multiple systems of group decision-making. These include: Consensus decision-making requires that a majority of the group approve a given course of action. If the minority opposes the course of action, consensus systems require that the proposed actions be modified to remove or modify those features where there is lack of agreement until the entire group agrees on the plan.Voting-based methods appropriate for this course include:Majority voting which requires that more than 50% of the group members agree. This implies that some members of the team will not agree with the course of action; and Plurality, where the largest block of the group decides even if it is less than the majority, is not recommended for making the streamlining decisions and gaining “buy-in” of the team.A Dictatorship is, of course, the state where one individual determines the course of action.The meeting facilitator, or if not facilitated, the person running the meeting, should be clear on the decision-making system that practice leadership intends to use.
The key information to be documented from a process redesign decision making meeting include:Decisions on each proposed process changeApproved / denied process changesPriorities for approved changesChosen alternativesNext stepsAction and follow-up itemsThe decisions on each proposed process change can be documented by adding columns to the BRAND matrix for approval and priority. The chosen alternative would be documented as an approval and other alternatives would be marked not-approved.
Like “closing a sale”, the wrap-up section of the meeting summarizes the decisions.The purposes of the debriefing are:To confirm agreement and To agree on next steps to move forward with implementing approved changes.
The major decisions in EHR-related process redesign include things like Which processes to automate or redesignWhich redesign option to implement EHR functionality requirements How candidate systems measure up against requirements, and Process change and system implementation plansFor large decisions like these, especially organizations implementing EHR systems for the first time, need help identifying key decision milestones and framing up the decisions to be made with all of the necessary information for decision making, i.e., the options and pros and cons of each option.
Making decisions about changing clinic processes is a major milestone in a redesign project and an example of decisions that warrant a special meeting. Often, the team that has done the process analysis work and that is making process redesign suggestions, does not include all of the decision makers of a practice. For this reason, taking the time to have a meeting to present the analysis of the “as is” process, and the recommendations for process changes with the EHR system for the “to be” process is important. An example of a meeting outline for such a meeting would likely include:Presentation of opportunities for redesign from the “as is” process analysisFor each redesign opportunity, the following four things would be discussed:Rationale for the change: Examples of reasons for redesign may include, to take advantage of process automation from an EHR system, to streamline a process/eliminate redundancy, or to help the clinic achieve meaningful use. In cases where there are competing redesign options, the pros and cons of each would be discussed, or the analysis of multiple options may be presented to justify the option chosenAn assessment of the cost of making the change would be presented. The cost should be balanced by return on investment documented in the rationale for making the change.Lastly, a decision would be made on whether or not to move forward with the change, and if resources were limited, a priority for the change would be assigned.Synthesis or review of the approved changes and their priorityNext steps, e.g., when will an implementation plan be ready for leadership to review, list of any loose ends or action items that need to be followed-up on before the process changes can be started, such as quotes from a vendor, contracts, preparing data for migration to a new system, discussions with impacted data exchange partners, etc..
This example “BRAND” template can be used to summarize and present process redesign options during a decision making meeting. Note how the template provides little detail about the process option other than a name or short description so that the participants can see major differences. This is because their purpose is not to redo the work of the analysis and redesign, but to make decisions based on the results including the evaluation of risks/costs, benefits, and alternatives.
Welcome to the Fundamentals of Health Workflow Process Analysis and Redesign, Quality Improvement Methods. This is lecture a.This component, Fundamentals of Health Workflow Process Analysis & Redesign, covers fundamentals of health workflow process analysis and redesign as a necessary component of complete practice automation. Process validation and change management are also covered. This unit covers Quality Improvement Methods recommended for use in the Health Care Setting. Many different approaches to quality improvement have been used in the health care arena. The workflow analysts will encounter organizations and people with experience with a multitude of proven methods and fads. Thus, an awareness of the history, methods, and tools of quality improvement is critical. This unit introduces students to these elements of QI, as well as categories of mistakes seen in these methods. It is not intended to teach the student how to use these methods and tools. Component 12, Quality Improvement, teaches the students how to implement a quality improvement project in the Health Care Setting.
Remember the IOM defined Quality of Care as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality Improvement is a method of evaluating and improving processes of patient care which emphasizes a multidisciplinary approach to problem solving, and focuses not on individuals, but systems of patient care which might be the cause of variations. Quality improvement methods can be used to improve health outcomes of all types and sizes. Some examples of Quality Improvement Projects:Redesigning a Clinical Office, Reducing the time for patient intake, andRedesigning the information flow in a laboratory.Increasing access to care, for example by increasing the percentage of time patients can get same day visits when needed
In a keynote address presented at the Texas Heart Institute’s symposium “Evolving Standards in Cardiovascular Care: What Have We Learned? Where Are We Going?”(Califf, 2005)Dr. Robert Califf added three major key concepts to the thinking of the cycle of bench to bedside for performance measures. He said, “First, we do the clinical trials. Then we develop guidelines from what the clinical trials showed. Clinical practice guidelines, if properly constructed, provide the evidence to show which of our options is most effective in a particular clinical situation. Then, in order to be sure that we are exercising the ‘best option,’ we have to be able to measure what we are doing. And finally, we close the loop by providing education and feedback to the practicing community. If we are successful in all of this, outcomes can improve.”He presented three key concepts, shown in the slide. “The 1st is that quality is a measurable entity. The Institute of Medicine has defined quality in terms of six dimensions: Is it safe, effective, timely, patient-centered, efficient, and equitable? It’s no longer enough to provide quality in your own individual clinical universe, because that universe overlaps other areas. Patients are exposed to a variety of practitioners and environments during an episode of care, so the responsibility for quality includes proper coordination across practices.The 2nd concept is safety—with safety now defined in terms of “freedom from error.” Errors are definable and measurable . . . an error is defined as having the wrong plan or failing to execute the right plan. . . .The 3rd concept is something that is really being stressed by the Institute of Medicine this year: Accountability. Obviously, we must then have systems in place to document that what we are doing is the right thing.”And this brings us back to the need for efficient and accurate HIT systems.
Quality Improvement projects can be aided or impeded by the organizational culture. Regardless of size, any health care setting can improve the care it provides. It is important to understand the culture of the organization contemplating such improvements, work within it as necessary, and encourage the development or enhancement of the culture to support quality improvement.Leadership support and buy-in, the organization’s ability to adapt to change, the communication ability of the staff in the organization, and the understanding of change or need for change by all involved are important factors affecting quality improvement. Factors needed for success include making quality improvement part of the job. Leadership support is essential for quality improvement activities to succeed. There are many ways leadership can improve the results of a QI project. Ransom et al state that, “Making quality improvement part of the job can raise morale because staff and patients see that the barriers to care they face each day are being addressed, and they realize they can participate in the work to remove them.” (Ransom, 2004) They offer an example of adding discussions about quality and quality improvement to routine clinical management meetings. Involving everyone in quality improvement closes the gap that can exist between quality improvement teams and everyone else providing patient care.
Goethe, considered by many to be the most important writer in the German language, and one of the most important thinkers in Western culture, stated that:“Knowing is not enough; we must apply.“Willing is not enough; we must do.” Quality improvement enables us to move from the knowledge presented in the 1999 report by the Institute of Medicine, which “estimated that 98,000 or more people die annually in the US due to medical errors” to “doing”the improvement which must be done. (Kohn, 2000)
Health care leaders can create organizational culture that supports quality improvement; for example leadership can assure that performance data is used to improve care for patients, and can assure that it is not used in a punitive manner. (Ransom, 2004) Ransom et al list things that leaders can do to support quality improvement including the following:Creating and promoting a quality vision with shared performance goals.Increasing staff capacity to support quality improvement by training staff in QI. Training opportunities about QI should be available for all staff and part of their routine job expectations.Motivating staff to participate in improvement projects and encouraging them to make quality part of their jobs.Establishing a quality improvement team to manage this process.Involving all staff. Demonstrating support of the use of metrics to measure performance.Making sure that the ‘voice’ of the patient is heard and acted on through surveys, exit interviews, suggestion boxes or other means.Involving staff and patients in decision making.Including QI in the budget.
There are many methods for quality improvement. In this unit we focus on process improvement that is human-centered and supportive of the implementation of Health IT. For a more in-depth coverage of quality improvement in health care, an entire component, component 12 Quality Improvement, is available. Ransom et al, in their textbook of health care quality improvement present several strategies and associated tools for health care quality improvement. Among the listed methods and tools, you will find, API, Baldridge, FOCUS-PDCA, the IHI Breakthrough Series Model, ISO 9000, Kaizen, Lean thinking, and Six Sigma. (Ransom, 2004)Quality improvement methods were originally tailored for enterprises, not necessarily health care. For example, Six Sigma was designed for manufacturing but has spread to service enterprises, including health care. Each of these have met with success but application of these methods in health care has also met with challenges.
The API (Associates for Process Improvement Model) was developed by Tom Nolan and Lloyd Provost. The API model is a simple model and like so many models for process improvement it is based on Deming’s PDSA, also called PDCA, cycle. The API model uses three fundamental questions that form the basis of improvement. They are:What are we trying to accomplish?How will we know that a change is an improvement? andWhat changes can we make that will result in improvement? Focus is frequently on small improvements and on testing the results to verify improvement – an incremental approach that undertakes improvement through many small improvements to make big improvement.
Dr. Paul Batalden formed an internal consulting division for continual improvement called the Quality Resource Group in the Hospital Corporation of America in the 1980s. This group designed the FOCUS-PDCA model, also based on Deming’s PDCA cycle. (Strickland, 2003). The model entails:Finding an opportunity for improvement,Organizing an effort,Clarifying current understanding of how the process works,Understanding the process variations and capability,Selecting a strategy for improvement, andUsing the Plan-Do-Check/study-Act cycle test the strategy to determine if it results in improvement.
The International Standards Organization in 1987 introduced the initial ISO 9000 guidelines for performance improvement. Components of these guidelines include:Design and develop a QI program,Create a sociocultural environment and a structure that supports improvement,Reduce or avoid quality losses,Define QI responsibilities,Develop an improvement planning process,Develop an improvement measurement process,Develop an improvement review process,Carry out QI projects, andAnalyze the facts before you decide to do QI.
Kaizen is a Japanese term for change for the better; the common English term is continuous improvement. The term connotes ongoing improvement involving everyone and assumes our way of life deserves to be constantly improved. It also includes improvement practices such as: customer orientation, automation, and quality improvement.
Lean thinking is a way to work more efficiently and effectively while providing customers with what they want when they want it. It is a philosophy and set of tools that aims to eliminate waste from processes. It also focuses on what adds value in processes from the perspective of the customer. The frontline workers are heavily involved in this approach. While the primary focus is waste, the outcomes of utilizing Lean tools are efficiency, quality, and customer service. Implementation requires a commitment and support by management and participation of all the personnel within an organization to be successful. Some institutions have implemented Lean using an onsite trainer from industry.
Assumptions underlying Lean thinking arePeople value the visual effect of flow,Waste is the main restriction to profitability,Many small improvements in rapid succession are more beneficial than analytical study,Process interaction effects will be resolved through value stream refinement, People in operations appreciate this approach, andLean involves many people in the value stream. Transitioning to Flow thinking causes vast changes in how people perceive their roles in the organization and relationships to the product.
Six Sigma was developed by Hewlett-Packard, Motorola, and GE and comes directly from quality thinking in the 1930s. It combines established methods such as statistical process control, design of experiments and Failure Mode and Effects Analysis (FMEA) in an overall framework with the primary aim of reducing variation in the process. Six Sigma aims to reduce variation through five clearly-defined steps: Define, Measure, Analyze, Improve, and Control. These are described here.Define - Project goals and boundaries are set, and issues are identified that must be addressed to achieve improved quality.Measure – Information about the current situation is gathered in order to obtain baseline data on current process performance and identify problem areas.Analyze – Root causes of quality problems are identified and confirmed with appropriate data analysis tools.Improve – Solutions are implemented to address the root causes of problems identified during the analysis phase.Control – Improvements are elevated and monitored. Hold the gains.
For further reading, Ransom, et al created an inventory and brief description of useful tools for quality improvement in health care. This inventory is provided here for your further investigation and includes flowcharts, cause-and-effect diagrams, Statistical Process Control, Pareto charts, and check sheets are used to collect early information about processes in place in the health care setting.
CREATIVITY TOOLSAlthough this group is not known as a fixed list of specific tools-that would be incongruent with the concept of creativity, it typically includes brainstorming, mind maps, Edward deBono’s (1999) six thinking hats, and the use of analogies. These tools help one look at processes in new ways and identify unique solutions. STATISTICAL TOOLSStatistical tools are used for more sophisticated process data analysis. They help understand the sources of variation, the relative contribution of each variable, and the interrelationships between variables. Statistical process control is a graphic means used to monitor and respond to special causes of variation. “Design of experiments,” a wide range of statistical techniques that can be applied to both parametric and nonparametric data, allows the analysis of the statistical significance of more complex interrelationships. DESIGN TOOLSDesign tools, such as QFD and FMEA, are used during the design and development of new products and processes. They can help to better align customer needs, product characteristics, and process controls.
FLOWCHARTThe flowchart is a map of each step of a process, in the correct sequence, showing the logical sequence for completing an operation. The flowchart is a good starting point for a team seeking to improve an existing process or attempting to plan a new process or system. CAUSE-AND-EFFECT DIAGRAMCause-and-effect analysis is sometimes referred to as the Ishikawa, or fishbone, diagram. In a cause-and-effect diagram, the problem (effect) is stated in a box on the right side of the chart, and likely causes are listed around major headings (bones) that lead to the effect. Cause-and-effect diagrams can assist in organizing the contributing causes to a complex problem (Tague, 2004). PARETO CHARTVilfredo Pareto, an Italian economist in the 1880’s, observed that 80 percent of the wealth in Italy was held by 20 percent of the population. Juran later applied this “Pareto principle” to other applications and found that 80 percent of the variation of any characteristic is caused by only 20 percent of the possible variables. A Pareto chart is a display of the frequency of occurrences that helps to show the “vital few” contributors to a problem so that management can concentrate resources on correcting these major contributors (Tague, 2004). CHECK SHEETSCheck (or tally) sheets are simple tools used to measure the frequency of events or defects over short intervals. This tool imitates the process of information gathering, is easy to use, can be applied almost anywhere, is easily taught to most people, and immediately provides data to help to understand and improve a process.
Basic tools are used to define and analyze discrete processes that usually produce quantitative data. These four help the analyst understand the process, identify potential causes for process performance problems, and collect and display data indicating which causes are most prevalent. Unit 2 of this component, Process Mapping Diagramming Tools, provides a detailed presentation of flowcharts and other process diagrams. RUN CHART Run charts are plots of data, arranged chronologically, that can be used to determine the presence of some types of signals of special cause variation in processes. A center line (usually the median) is plotted along with the data to test for shifts in the process being studied. CONTROL CHARTA control chart consists of chronological data along with upper and lower control limits that define the limits of common cause variation. A control chart is used to monitor and analyze variation from a process to determine if that process is stable and predictable (comes from common cause variation) or unstable and not predictable (shows signals of special cause variation). HISTOGRAMA histogram is a graphical display of the frequency distribution of the quality characteristic of interest. A histogram makes variation in a group of data readily apparent and assists in an analysis of how data are distributed around an average or median value. SCATTER DIAGRAMScatter diagrams (or plots) show the relationship between two variables. The scatter diagram can help to establish the presence or absence of correlation between variables, but it does not indicate a cause-and-effect relationship. MANAGEMENT TOOLS are used to analyze conceptual and qualitatively-oriented information that may be prevalent when planning organizational change or project management.
The topics covered in this unit, Maintaining and Enhancing Improvements, fall into three categories: Monitoring processes to maintain performance gains achieved with the redesigned process, i.e., Process Control Continuing to improve the redesigned process and other practice processes, Continuous Quality Improvement (CQI), and Contingency planning for EHR downtime so that if the EHR system is unavailable, practice staff are able to provide quality care and availability of health information is maintained.
The primary concept applied in quality improvement is the simple act of deciding what to measure, measuring it, deciding what to do to improve it, implementing the improvement, and finally evaluating the improvement. This last step could also be called “measuring again”. Measurement is really the critical part of quality improvement; measurements tell you where you are and how far you have to go, like the number of miles to your final destination on a road trip. Doctor James Harrington, a long-time quality improvement expert summed it up best when he paraphrased a well known quote, stating that,“Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.”As an aside, as far as the developers of this module have been able to tell, there isn’t consensus regarding the actual source of the quote “You can’t manage what you can’t measure.” Quite possibly, it is an adaptation of a statement in an 1883 work by Lord Kelvin, William Thomson, “when you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind” (Thomson, 1883). All others may stem from this earliest recording of the sentiment, or may indeed have arisen independently.
Even before you can measure, you have to decide what to measure, and maybe even how to define it. A best practice in quality improvement is to form a quality council. The quality council is usually a group of individuals who already have job responsibility for quality improvement, or in health care, often for registries or performance measurement reporting or facility accreditation. The quality council is charged with tasks such as:Establishing or recommending (depending on the level of authority invested in the quality council) core quality standards and requirements,Identifying and defining quality metrics,Clarifying which performance measures are key to gauging actual quality improvement performance,Collecting and analyzing data to understand key variables and process drivers,Legitimizing value of QI to ensure best use of resources and measure improvement associated with these activities,Analyzing QI data and reporting quality metrics and trends, and Educating organization and training key staff.For a small practice, the quality council may consist on the practice leader and the individual responsible for performance measure reporting. Creating a quality council formalizes the responsibility and accountability for the decision-making regarding quality, often including process, improvement and performance measurement. A key function of the quality council is deciding what to measure, i.e., what data will best inform decision-making. For example, if a practice is trying to increase access to care, they may decide to measure the percent of same day visit requests that they are able to accommodate. The quality council may be the group that recommends this measure or makes the decision that the percent of same day visit requests that they are able to accommodate will be used as the or a measure of access to care.
The next several slides will address maintaining the performance achieved through process redesign. The process that Dr. Harrington lays out in his adaptation, “If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.”starts with measurement, and from that, the measurer gains understanding, i.e., real data on what is actually happening. By understanding, we mean, is the performance consistent or are there spurious unexplained variations? For example, if we are trying to improve clinic wait times, we would look at actual measured wait times to see if they varied widely from patient to patient, i.e., 5 minutes for some and 2 hours for others. We would also want to see if the average patient wait time is acceptable, or if improvements are needed.By control, we mean consistent performance of the process, in other words, maintaining the performance we achieved through process redesign. For example, if we redesigned a clinic process and reduced the average wait time from 45 minutes to 20 minutes, process control would mean that the average wait time remained close to 20 minutes, and varied within what we would expect from natural random variation. We would use QI tools to show whether or not this was indeed the case. Then we would continue to use the tools over time so that we could tell if the average wait time or the variability drifted too far, and we would investigate and possibly intervene if it did to bring the process back into control. Monitoring process performance over time can be done with by simply calculating measures of central tendency, i.e., mean (average), median, mode, and measures of dispersion, e.g., range, variance, standard deviation, and by monitoring them over time. However, without the tools of statistics, it is difficult to know whether or not the differences from measurement to measurement are due to natural random variation, or due to the process drifting or due to some other cause. Statistical process control charts can be used to help make this decision, or the aid of a statistician can be sought for an equivalent analysis and in cases where a custom analysis is required. The next few slides will cover statistical process control charts and how to use them to control clinical processes.
First, we’ll go over some terms and concepts important to statistical process control. The term process control has a specific meaning in statistics and quality engineering. The American Society for Quality, ASQ, defines process control as, “the method for keeping a process within boundaries; the act of minimizing the variation of a process”.ASQ defines an in-control process: “A process in which the statistical measure being evaluated is in a state of statistical control; in other words, the variations among the observed sampling results can be attributed to a constant system of chance causes”.The American Society for Quality defines an out-of-control process as “a process in which the statistical measure being evaluated is not in a state of statistical control. In other words, the variations among the observed sampling results can be attributed to a constant system of chance causes.” Often, the causes of variability in an out-of-control process are referred to as “special causes” to denote that they are due to causes OTHER than natural variation.The American Society for Quality defines Statistical process control (SPC) as, “The application of statistical techniques to control a process.” The term SPC is often used interchangeably with the term “statistical quality control” (SQC).
SPC is increasingly being applied in health care. SPC was developed and first used in manufacturing. In health care we have medical statistics and unfortunately, SPC is not frequently included in books on statistics in health care and medicine, thus, statisticians working in health care are less likely to have received training in SPC techniques than those working in industrial sectors. The SPC is a way of thinking, i.e., managing based on numbers, can be seen as management by objectives, increasing inspection costs, or risking local optimization (at the expense of global optimization), i.e., as contrary to best quality or management practices. These, however, are characteristics of how SPC tools are used by an organization. Using SPC in a way that increases overall production cost or using measures that incentivize locally optimal and globally detrimental behavior would be a poor use of the tools. Lastly, successful application of SPC requires that appropriate data be available. Until the adoption of electronic health records, data required for quality improvement often had to be manually collected in addition to regular care activities, thus, prior to EHRs, using tools such as SPC required too much additional effort for health care facilities.
Statistical Process Control is accomplished using special data displays, i.e., graphs, called control charts, originally developed by Walter A. Shewhart while working for Bell Labs in the 1920s. Dr. Walter Shewhart was later named the Father of Statistical Quality Control by the American Society for Quality. Statistical process control may be broadly broken down into three sets of activities: understanding the process; understanding the causes of variation; and elimination of the sources of special cause variation. Using SPC, a process is monitored using control charts to identify detrimental variation, often called variation due to special causes, and to free the user from concern over naturally occurring variation, often called variation due to common causes. This is a continuous, ongoing activity where only special causes are addressed. When special causes are identified by the control chart detection rules, additional effort is exerted to determine causes of that variance.
PROCESS DECISION PROGRAM CHARTThe process decision program chart is a type of contingency plan that guides the efforts of a team when things do not turn out as expected. The actions to be completed are listed, then possible scenarios about problems that could occur are developed. Management decides in advance which measures will be taken to solve those problems should they occur. This chart can be helpful when a procedure is new and little or no experience is available to predict what might go wrong (Tague, 2004).FAILURE MODE AND EFFECTS ANALYSISFailure mode and effects analysis (FMEA) is a method for looking at potential problems and their causes as well as predicting undesired results. FMEA was developed in the aerospace and defense industries and has been widely applied in many others. FMEA is normally used to predict product failure from past part failure, but it can also be used to analyze future system failures. This method of failure analysis is generally performed for design and process. By basing their activities on FMEA, people are more able to focus energy and resources on prevention, monitoring, and response plans where they are most likely to pay off. POKA-YOKEPoka-yoke (POH-kuh yhoh-KAY), the Japanese term for “mistake proofing,” means paying careful attention to every activity in a process to place checks and problem prevention measures at each step. Mistake proofing can be thought of as an extension of FMEA. Whereas FMEA helps in the prediction and prevention of problems, mistake proofing emphasizes the detection and correction of mistakes before they become defects delivered to customers. Poka-yoke puts special attention on human error.
Mistakes that are frequently made in quality improvement initiatives are mistakes in purpose & preparation, mistakes in planning and operations, and mistakes in transition and implementation. Mistakes in Purpose & Preparation include:Error #1: Choosing a subject which is too difficult or for which a collaborative is not appropriate.Error #2: Participants not defining their objectives and assessing their capacity to benefit from the collaborative.Error #3: Not defining roles or making clear what is expected of individuals taking part in the collaborative as faculty or participants. Error #4: Neglecting team building and preparation by teams for the collaborative.
Mistakes in Planning and Operations can be further broken down into mistakes in fostering a learning community focused on improvement, and mistakes in transition and implementation. Mistakes in fostering a learning community focused on improvement are:Error #5: Teaching rather than enabling mutual learning,Error #6: Failing to motivate and empower team, andError #7: Not developing measurable and achievable targets. A mistake in transition and implementation isError #8: Failing to learn and plan for sustaining
Welcome to Fundamentals of Workflow Process Analysis and Redesign: Leading and Facilitating Change. This component, Fundamentals of Health Workflow Process Analysis & Redesign, covers fundamentals of health workflow process analysis and redesign as a necessary component of complete practice automation. Process validation and change management are also covered. This unit, Leading and Facilitating Change, introduces the concepts of change and the impact of such change on the providers and staff within a health care facility. It enhances the understanding that workflow analysts must be sensitive to the human component as they examine and propose modifications in processes. This unit prepares the student to recognize and address common change management problems, and to work with individuals and groups to facilitate change. Importantly, we present here key change concepts and some tools to help put them into practice. The leading authors and practitioners of change management would likely say that learning how to successfully lead change in organizations requires practice, personal introspection, evaluation, and iteration. In fact, I learned these things through experiential learning in the School for Applied Leadership across a three year period of time and the decade since practicing them and learning from my mistakes, from people with whom I worked, and from several great books many referenced throughout the presentation. Within your training program, this component and especially this one unit, it is impossible to convey the whole of leading and managing change. I can only hope to convey key concepts, and to provide reference to helpful resources that you can turn to for greater development as your practice grows.
Leading and facilitating change is about working with people. If I were to sum up this unit in one sentence, it would be this Chinese proverb: Tell me and I’ll forget; show me and I may remember;involve me and I’ll understand. To me, involvement is a key concept in change management. Involving people to the extent possible does three things 1) it builds understanding, a shared pool of knowledge, 2) it offers an invitation to engage in the project and influence outcomes, and 3) it provides additional eyes, ears, knowledge, experience and perspectives to inform the work.
There has been a lot of work in change management, hundreds of books on the topic, and many different perspectives. It is impossible to cover everything in one unit. Thus, we will cover main points and provide some tools that practitioners can use. To begin, we will cover some key concepts of change and change management, more things like staff involvement. These key change concepts can be called upon by practitioners for use in future change efforts. These key concepts help explain what is it that causes the successful change management efforts to be successful, and others to fail.
From the employee’s perspective, there can be a lot of changes and a lot of changes can be overwhelming. Remember that work process change may be only one of several changes an organization is undergoing. Employees are often dealing simultaneously with regulatory and market changes that result in new job requirements, organizational changes, and process improvements all at once; expect nothing different in clinics today.
Claes F Janssen (2011) conceptualized the Four Rooms Theory of Change, also called the 4-Room Apartment. He discusses changes that are usually very negatively significant to a person. (Death or ending of an important relationship is the usual example, but this could also be something that has the perceived potential to change one’s life, including job changes, fear of loss of power, loss of importance, etc.). When one of these significant changes occurs, the individual moves from the current state of contentment into denial, then into a state of confusion, possible uncertainty about the future or about how the individual can deal with the situation. Out of confusion, once the individual has worked through the confusion, comes growth and renewal, then once again, contentment comes. Simply put, at the end of every storm, fair weather returns. It is important for people working in change management situations to understand that this is an individual process, likely dependent on how the individual perceives the change, i.e., how threatened (rational or not) the individual is. Also, each individual moves through the state at his/her own pace. Thus, when you approach a room of people, you will likely not know who perceives a possible threat or loss, and where in the process that person is.
Many puzzle over the success and failure of Change Management efforts. One reason is that change management involves humans and organizations, i.e., complex situations with many different factors. Some of these include:Organizational constraints (lack of money or people with needed skills, or just enough people),Management style (dictatorship versus democracy),Organizational goals and departmental, division, and personal goals not necessarily in alignment,Personalities, Environmental factors (for example, new regulations that force change), etc.In multi-factor situations, attribution of cause and effect is often challenging.
Organizations (governments, societies, processes, that are comprised of people) are living, changing biological systems. If you try to change the system, it will compensate. The behavior of the system and individuals in it is likely dependent on the organizational culture and level of trust in leadership and trust in colleagues.Mechanistic tools like quantitative measurement, science and engineering are valuable in providing information for better decision making and managing and must be used in the context of an understanding of the natural system. However, such reductionist treatment rarely explains the whole.
Change happens through individual choice and freedom, not through top-down control or coercion. This is not a statement that all organizations should be democracies. As we saw in unit 7, there are many different leadership styles ranging from one person making all the decisions to group decisions. What Key Concept 3 is saying is that it is imperative that every person’s right to choose at some level be respected. The choice may be whether or not to be part of the effort, whether or not to provide input, or in an extreme case, whether or not to continue working at an organization. Key Concept 3 does not say that everything is the employee’s choice, this is usually not feasible. But, change leaders should be clear about what choices employees have and should respect those choices.
John Gall, MD in his 1978 book Systemantics said it most insightfully: “Systems run best when designed to run downhill” (Gall, 1978). This is really the intersection between process analysis and redesign and change management. People will do things if they are easy. Processes that require extra steps are less likely to be followed. For example, asking staff to manually write down or note each hypertension patient for a quality improvement project is hard; versus pulling the list from the data that are captured during the visit, which is easy. If it adds extra steps, it is a problem.
I have a great example of systems running (or not) downhill. I lived in a loft in an old warehouse. There was a garden area encased in old railroad ties between the parking lot and the door. There was one place where everyone cut through the garden and it created an ugly area where nothing grew. Some insightful person bought some stepping stones and put them in the path. The garden was no longer an obstacle between the car and the door. It became a beautiful addition to our building and people automatically used the path. The person who added the stones was very insightful. Where others would have put up signs or fences, the stone putter found a way for the people and the garden to happily co-exist.Another great example of this principle is in the movie Out of Africa, the 1985 movie starring Meryl Streep and Robert Redford, set in early 1900s Kenya. The Baroness, played by Meryl Streep, is trying to start a coffee plantation in Kenya in the early 1900’s. She directs the natives to re-route a river. They plead with her, explaining that it won’t work, that “the river will have her way” in the end, but she does not listen. Toward the end of the movie, a storm comes and washes the dam out. Process design and change management is similar in that the designer has to work with and listen to people in the facility, and combine their information with best practice to find “the downhill way.”
Change starts with a deeply meaningful purpose.Which of the following would you rather be a part of?Getting a system in production,Implementing a system so your practice would get the Meaningful Use incentives, orUsing health IT to improve the health or your patients?My guess is the latter, because it is a purpose that is easy to engage with on a personal level. Improving human health is deeply meaningful work to many people.
Make and keep the gap between “as is” and “to be” visible and talk about it at every opportunity. Making gaps visible maintains a “creative tension” as Peter Senge calls it, that motivates forward progress. In the Fifth Discipline Fieldbook, Senge et al liken holding this creative tension to holding a rubber band stretched between two hands, one representing the current reality and the other representing the envisioned state. Reading from a passage from the Fifth Discipline Fieldbook by Peter Senge et al:“People often have great difficulty talking about their visions, even when the visions are clear. Why? Because we are acutely aware of the gaps between our vision and reality. ‘I would like to start my own company,’ but ‘I don’t have the capital.’ Or, ‘I would like to pursue the profession that I really love,’ but ‘I’ve got to make a living.’ These gaps can make a vision seem unrealistic or fanciful. They can discourage us or make us feel hopeless. But the gap between vision and current reality is also a source of energy. If there was no gap, there would be no need for any action to move toward the vision. Indeed, the gap is the source of creative energy. We call this gap creative tension.Imagine a rubber band, stretched between your vision and current reality. When stretched, the rubber band creates tension, representing the tension between vision and current reality. What does tension seek? Resolution or release. There are only two possible ways for the tension to resolve itself: pull reality toward the vision or pull the vision toward reality. Which occurs will depend on whether we hold steady to the vision.” (Senge et al., 1994)
We all have a natural trouble detector. If communications in your change efforts feel like a finger trap, i.e., you feel like you are selling the change, or you are pulling others along against their will, stop. Block and Nowlan, the authors of Stewardship, Flawless Consulting (Block and Nowlan, 1999),and Block, the author of The Answer to How is Yes (Block, 2002), say it best as, “it is an assault to try and change someone’s mind.” Minds change through individual choice, not through coercion or force. This is probably the most fundamental of the key change concepts, but also, unfortunately, it may be the hardest to learn and practice. A more tactical way to think about the “Don’t pull” concept is that people need to think through or reason through the reasons for and against change for themselves and come to an understanding of why change is needed. This is true for executives and for employees alike; it applies equally to anyone impacted by a change who is not directly involved in creating it. This should not be misconstrued as a statement that “everyone needs to agree with a change.” That may not be possible. It is a statement that everyone should have an opportunity to see the reasons for and against and the opportunity to think through them. A good question to ask people having difficulty with a change is, “given this situation, what would you do?”
The engagement gap is a key component in change management. Dick and Emily Axelrod present this well (Axelrod, 2000). When initiating a change, many organizations select a team of “the best and the brightest” to go off and work on the needed change. To expedite the project, the team reports to a steering committee for the change project, and the steering committee reports to a main executive. The idea is that these employees represent all employees. There is usually some requirement for communication back to and for soliciting input from their “home department”. Time and time again however, this process breaks down. The team stays engaged, and has the benefit of owning the project; they have an in-depth understanding of the constraints, etc., because they have spent many hours personally thinking and talking through all of the decisions. The rest of the organization, however, has not had these experiences, has not thought through all of the issues, and has not become engaged. Often, the same phenomena happens with the steering committee or organizational leadership. When the results and recommendations are presented, the rest of the employees respond with shock and resistance, and organizational leadership often says “this is not what we wanted”. Employees don’t trust what they haven’t thought through and leadership feels out of the loop. The Axelrods (2000), in their book, Terms of Engagement, call this an engagement gap. The only way to fix it is to give everyone the benefit of the thought process, and the opportunity to influence.
Change management is certainly not a court of law, the phrase, “…tell the truth, the whole truth and nothing but the truth…” used in the United States court system, illustrates a key change concept, transparency. Simply put, people often fail to trust what they do not see or know. People may not agree with a change, but they can understand it when provided all of the information. For example, why is the change needed, what the alternatives are, and why the proposed or decided alternative is the best.
Pulling the Key Change concepts together, change happens best when individuals have: deeply meaningful purposethe opportunity to influence or otherwise exercise personal control or choice,transparency, andunderstanding. Change is primarily impacted by:the individuals and organizations, culture and trust, and how the change project is structured.If any of these things are out of kilter, it can undermine a change effort. If all of these are in place, a change effort has a good chance to succeed. Next, we will go over some planning tools and facilitation tools to help practitioners operationalize these principles.
In Unit 7 of Fundamentals of Workflow Process Analysis and Redesign, the student is provided strategies, tools, and aids for planning and conducting a decision-making meeting,presented examples of agenda and tables for conducting a walk through of a process, and provided tools for documenting decisions made and actions identified in a decision-making meeting.In this lecture additional strategies, tools, and aids for facilitating the change process and implementation of the streamlined process redesign are provided. We also review and provide additional perspectives for meeting facilitation. The facilitation plan may be created by the analyst or by an implementation or project manager.This F plan is the first gesture of transparency and the start of building trust.It outlines what will happen and how it will be managed; it is the social contract between the change leader and the people in an organization. The transparency displayed with the F plan is the change leader’s first opportunity for input and feedback. As we go forward, we will discuss facilitation as Big F, and use little “f” to demonstrate the differences of scope, intent and effort.
Often, as in this scenario, the Process Analysis and Redesign Specialist guides the practice staff as they do the analysis and redesign, rather than doing it themselves. This scenario assumes this approach. A mid-size internal medicine practice has decided to select, purchase and implement an electronic medical record (EMR). They have hired you as a consultant for Process Analysis and Redesign. Your agreement with the practice is that you will provide instruction, training and oversight for members of their staff as they analyze their processes, redesign their processes around an EMR, and define the functionality that they need in an EMR.You have already had an initial meeting with practice leadership and have had a tour and met the 75 person staff. At your next meeting, you will present the facilitation plan and get the analysis and redesign started.Over the next several slides, we will look at “Big F” facilitation plan for the entire effort, and a “little f” agenda for the initial meeting.
The “Big F” is the plan for the entire effort. The way that I show a “Big F” is graphically and on one page; similar to the diagram above. The “Big F” communicates an overall timeline and work plan and importantly, is best when in communication with the rest of the organization, i.e., staff and providers not directly involved in the effort, as well as leadership. The purpose is to 1) get input on the overall plan and 2) make sure that the plan is communicated to everyone so they will know what to expect. Here, we have assumed that the work needed by the practice can be accomplished in four weeks. The time for different practices will vary.With 75 staff and additional providers and leadership, it will usually not be possible for everyone to be heavily involved in the effort. Here, we apply a “two-group” plan similar to those described by the Axelrods. Group one is the team that will be doing the work. Group two is the rest of the organization. Group one will spend a significant portion of their time analyzing and redesigning the practice processes, usually 50% to full time. Group two, the rest of the organization, must be kept up to date and “engaged” in the effort. In other words, group two needs to be efficiently walked through the planned process and the results as those become ready as well as the thought processes that produced them. Importantly, You and leadership will need to communicate how group one was chosen. Some do this by invitation, e.g., an email to everyone describing the commitment and what is needed and inviting interested folks to step forward. If too many, sometimes, the number that can be spared the effort will be randomly chosen. Others choose a “team” of the latter (remember the engagement gap). This depends on leadership, on the amount of effort that can be afforded, talent available, and provider and staff interests. Usually group one includes a representative from each of the major roles, or at least someone familiar with them.The most important thing about the “Big F” is that it sets expectations for regular communication so that as the team goes through the thought process, the rest of the organization, and leadership goes through the process too. For a small 10-person practice, an elaborate plan like this is not necessary, the key criterion is that everyone is informed and has the opportunity to influence the project.
The Walkthrough is a meeting with the broader organization, i.e., staff who are not on the team to keep them up to date about the project’s progress and the teams current thinking. It is also an opportunity to keep all staff engaged and to get feedback on the plan. Thus, all participants should be encouraged to talk as much as the project team! For example, instead of presenting the context diagram, cut the shapes up and get the group to put it together (pin-the-tail-on the donkey), or have them take five minutes and individually draw one, then “shout out” components. For process inventory, pass out the list, have people look at it for five minutes and identify things missed. There should be a walkthrough every time the team finishes a major project.
Don’t forget about Leadership – they need to be engaged as well. For a Leadership Agenda try:Brief review of progressPresentation of challengesReview & “what did we miss” exercisesEngaging questions:Any surprises based on what’s presented?Get help strategizing about challengesLeadership should have input into prioritizing processes for analysis and redesignDuring the project you should keep a list of things that leadership should decide or have input into, e.g., “do we want an EHR that also has Patient Management System (PMS) functionality, or should we stay on the same PMS and build an interface?” It is the team’s responsibility to make advantages and disadvantages of such decisions clear.
Welcome to Fundamentals of Workflow Process Analysis and Redesign, Component 10 Unit 10 - the Process Change Implementation and Evaluation unit. This unit covers methodology for how to plan, implement and evaluate the process changes in clinic settings. This unit focuses on helping students develop skills needed to implement and evaluate the effectiveness of changes designed to improve workflow processes and the quality of care in the health care facility. This unit prepares the student to implement a process change by covering three key skill sets: 1) develop a process change plan (implementation plan), 2) communicate a process change plan, and 3) develop an evaluation plan.
The topics covered in Unit 10 include common process changes, implementation plan components, communication for implementation, common implementation problems, and evaluating the new process.
To ground ourselves in concrete ideas of what to expect in process change implementation and in this unit, we’ll start with examples of common process changes. Some examples are:From manual to electronic prescribingFrom receptionist to web-based appointment schedulingFrom manual to automated appointment reminder callsFrom manual tracking of test results to automated result trackingFrom paper to electronic patient chartsFrom paper to electronic test ordering.While each of these is just a sentence, changes must be considered and thought through from many perspectives and eventualities. This thinking occurs in the analysis and re-design phase as each of these eventualities may represent different process design options, for example different workflows, different allocation of tasks, etc. The implementation planning stage of a project is for figuring out how the implementation, also called “go live: or “roll out” will occur. Implementation planning is a group activity that includes multiple stakeholders. Communication of the implementation plan and execution resulting in new improved process will also involve many people.
The implementation plan documents the who, what, where, when, how, and why of the process change. It serves as a map that helps the clinic staff, leadership, and analyst get from the old process to the new one.
An implementation plan contains the following components:Reason for the process change.Summary of what will be different with reference to the “as is” and “to be” documentation, where it is located in the documents or in an appendix. Where the process change is significant, this may include step by step instructions for new workflows.Sequence of implementation tasks to be accomplished. These can include walkthroughs, training, production and distribution of job aids, software changes or “go-live” of new systems. Responsible parties for each implementation task.An implementation schedule for the entire implementation phase, and statement of how the process will be managed.Contact information for who to call when problems arise and aDescription of how the process change will be evaluated (an evaluation plan).An implementation plan does not need to be a long document. Its purpose is to document what will happen, how and when it will happen in a way such that if the implementation plan is followed, the new process will become a reality. The length and detail level should be comparable to the size of the change and the number of people impacted. An example implementation plan that shows these components is included in your course materials, and will be reviewed on the next few slides. But first, we will do an exercise.
You already know enough to draft an implementation plan for an appointment reminder system. After these instructions, pause the slides and do the exercise.A practice of 50 staff and providers is implementing an automated appointment reminder system. Review the implementation plan components on the previous slide. You may want to go back and print out the slide. Take 10-15 minutes and on one page of paper, jot down your ideas for each section. Restart the slides when you are done. Pause the slides now.
At the point in a process redesign when an analyst is crafting an implementation plan, hopefully the impacted people will already know about the change or have otherwise been involved in creating the change in some way. In this case, the communication about the implementation will be easy and expected by all. If not, expect objections either to the plan or the new process, or both. In this event, the communication and implementation will take longer, and may result in changes to the process or plan. The way to prevent such a situation is to, at a minimum, keep everyone informed about a process change throughout the analysis and redesign process. The more transparency there is and even better, the more genuine involvement people have opportunity for, the smoother the implementation will be. Remember our old adage from unit 9:“Tell me and I’ll forget; show me and I may remember; involve me and I’ll understand.”
When communicating an implementation plan, it is important to keep in mind what things people need to know.As in the automated appointment reminder system implementation plan example, when the change is minor, the plan itself can be short and can double as a notice, i.e., the communication. The main goal is to give people information about:What is happening.Why is the change taking place. (Examples of this might include to enable patient self-management or control, to increase safety, quality or efficiency of care, for sustainability of the practice, or to achieve meaningful use.)How they will be affected. (This is often best accomplished by addressing each task or activity that will be added, changed or go away.)How the change will impact their job workflow or responsibilities.How will the change take place andWhat if anything different will the patient see.Communication can occur via email, posted notices, or staff meetings. In person communication provides opportunity for attendees to ask questions and for the presenter to get feedback that might increase the success of the project.
When process changes necessitate new steps or tasks, job aids may be helpful. For example, in the automated appointment reminder system implementation, the front desk receptionist needed to notify people scheduling appointments that they would be receiving a reminder call. A job aid with talking points (answers to common questions the receptionist might be asked) was provided as a job aid. Job aids might include: Talking points, check lists, written procedures, or cheat sheets (memory aids to rescue people when they forget what to do, or descriptions of new system features for common tasks). The type and extent of the job aid depend on how extensive the change is. The creation and training on job aids should be included in the implementation plan.
Welcome to Fundamentals of Health Workflow Process Analysis & Redesign, Maintaining and Enhancing Improvement. This is lecture b.This component, Fundamentals of Health Workflow Process Analysis and Redesign, is a necessary component of complete practice automation and includes topics of process validation and change management.This unit, Maintaining and Enhancing Improvement, focuses on developing the skills to maintain and build on performance improvements achieved through process redesign, and on developing the skills to design contingency, or, alternative processes for practices to use in the event that the EHR system is down. In addition, this unit utilizes general quality improvement concepts, methods, and tools, as described in the previous unit, Quality Improvement Methods. Because workflow analysts will encounter organizations and individuals with varying levels and types of quality improvement experience, a general awareness of the quality improvement concepts, methods, and tools is necessary.
Business continuity or disaster planning may seem like an odd topic to pair with maintaining and improving processes. But all three topics are about designing and maintaining a process that delivers the best possible care. That care and health information is especially needed in times of disaster, e.g., pandemic or natural disaster, when it may be the hardest to keep a practice running, and that care and health information is still needed, even if the practice itself is having difficulty, e.g., a computer system crash, local power outage, or unexpected extended absence of one or more key providers, etc. When you think about it, business continuity planning is about maintaining core processes under emergency or adverse conditions, or in the absence of normal operating resources.The Business Dictionary defines the Business Continuity Plan as a: “Set of documents, instructions, and procedures which enable a business to respond to accidents, disasters, emergencies, and/or threats without any stoppage or hindrance in its key operations.”It provides guidance for times when the organization experiences loss of use of its facility, loss of its vital equipment and systems, and/or loss of key personnel. While practices should consider Business Continuity and Emergency Planning in the broader sense, here, we are concerned with planning necessary to provide quality care when the EHR system is down.
What is affected when an EHR goes down? In short, everything that the EHR automates. As described in Unit 6 – Process Redesign leveraging EHRs automates clinic processes, for example, receipt of lab results via an electronic interface, notifications when patients are due for screening tests and other clinical decision support, routing of prescription refills for physician approval, electronic storage of entered clinical documentation, calls to patients to remind them of upcoming appointments, and transmitting health information to another provider with a referral. Any parts of clinic processes that rely on the EHR for partial or total automation will not function for the time the EHR is down.
Business continuity planning for EHR downtime is the systematic inventory of EHR-facilitated processes and contingency planning for each. By contingency planning, we mean figuring out exactly how the process will work in the absence of the EHR, including both real-time patient care, after the fact follow-up, and getting the documentation reflecting the encounter into the EHR. Some EHR facilitated processes will be easy, e.g., receipt of prescription refill requests – a possible scenario is that the sending system will detect a receipt failure and route via agreed back-up mechanism (maybe fax) instead. Following this scenario the practice, having planned ahead will know to expect and respond to the faxes until the system is back up. Further, the sending system will know not to send electronically what was faxed and responded to by the practice and WILL resend electronically once the system is up what was faxed and NOT responded to by the practice. This is an example of an EHR system downtime contingency plan for one EHR facilitated process. The EHR Downtime plan consists of a similar plan for EVERY EHR facilitated process. Many of the processes may require paper data collection forms or worksheets, e.g., data collection sheets to use in encounters that, as best as possible, help clinicians identify things that would be alerted by the EHR, possibly using patient prompts such as, I see that you are over 40, “when was your last mammogram?”In the next few slides, we’ll discuss contents of a BCP and a framework for how a practice might go about creating one.
An initial step is to assemble a Core Team to oversee BCP development, identify Points-of-Contact for organizational units, define the overarching BCP program, and develop a BCP timeline for implementation. Often this same team is expanded to direct the implementation and continued testing of the plan.
The overarching objective of a business continuity plan, as in the specific case of an EHR downtime plan, is to plan for an event BEFORE it occurs so that when it does, everyone knows what to do and has everything they need for safe and effective operation.Typical objectives of BCP plans include:Ensuring continuous performance of an organization’s essential functions in an emergency, and in health care – patient safetyProtecting essential equipment, records, and other assets,Reducing disruptions to operations,Minimizing damage and losses, - including loss of health informationAchieving an orderly recovery from emergency operations, andIdentifying alternate locations and ensuring operational and managerial requirements are met before an emergency occurs.
Key goals will likely include:Essential organizational functions, vital systems, data and information identified and prioritized,Critical elements are capable of being recovered quickly to resume operations, - i.e., processes are defined and established and staff are trained on them. Job aids such as worksheets are readily available so that staff can switch to the “downtime process” on a moments notice.People know who is in charge,Back-up personnel are trained,Alternate work locations are predefined, andChecklists are predefined to guide the organization in responding to an emergency.
Critical processes are usually defined as those processes or services that must be recovered within 24 hours after a disruption to ensure resumption of the essential function.They include all resources necessary to carry out the critical process:Personnel,Data or vital records, andSystems and equipment.
Essential functions are functions that MUST be performed to achieve the organization’s mission. Some examples of essential functions to address include:Communications,Vital Records, Systems and Equipment,Key Personnel,Alternate Work Sites, andTesting, Training & Exercises.In a practice, in the face of a natural disaster, providing patient care may not be essential. However, maintaining availability of patient’s health information so that it is available to other providers probably is. Thus, EHR downtime plans should account for how information will be accessible to practice providers who may need to provide it to other providers, accessible to patients themselves, or accessible to other providers. Having data storage and hosting redundancy or a hosted patient portal with similar features would help accomplish this, as would participating in a health information exchange.
Without proper testing, the downtime plan may fail you when you need it the most. Exercises, like fire drills, are events that allow participants to apply their skills and knowledge to improve operational readiness. The goal of the exercises is to prepare for a real incident involving an EHR downtime plan activation. There are three types of exercises,Tabletop exercise involves practice staff and leadership talking through a downtime event from start to finish – who, what, when where how does everything get doneFunctional exercise is a walk through where a process is tested Full-scale exercise is a simulated event, e.g., on a Saturday, where there are pretend patients (family members for example), and clinic staff and leadership start with the EHR, then pretend it goes down and they resume operations according to the downtime plan like it were real. Exercises are usually followed by after action reviews such as those done in the military where everyone involved talks through what happened, what went well and what went poorly – notes are taken so that the downtime plan is improved. Another method is called a Time Out Of Time, or TOOT, where during the functional or full scale exercise, at regular intervals someone calls “time” and everyone takes one or two minutes and jots down notes about what is working well and what is not working well so that the information is captured as it is happening; this information is then discussed in the after action review.
1. Fundamentals of Workflow Process Analysis and Redesign Facilitating Meetings for Implementation Decisions This material Comp10_Unit7 was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
2. Effective Meetings“A single effective meeting will substantiallychange the capacity of a group toachieve desired outcomes” (Bolea & Scott, 2012)Effective meetings:• Face the current reality and gap between “as is” and “where we want to be”• Identify unused potential to improve, and• Commit to action / implementation planHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 3Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
3. Meeting Purpose• to “tee up” the key decisions along with the information necessary to make them for the decision makers• and ultimately, to obtain the decisions needed to move the project toward successful completion.Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 4Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
4. Key Elements of Success• Involvement of key personnel – Have thought through potential solutions – Results in ownership of ideas • Solutions • Develops commitment for implementation• Immediate focus on changes which will make the greatest possible contribution to improvement and “Meaningful Use”• Initial implementation planning is begun in the next steps debriefing wrap-up session at the conclusion of the decision-making meetingHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 5Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
5. Meeting Participants Role• Work within the established ground rules• Review decision-making material in advance – Notify the facilitator in advance if additional information is needed – Provide “reality checks”, i.e, question options, rationale and assumptions used in cost/benefit analysis – Participate in decision-making• Participate actively in the meeting• Complete action items and follow-up as neededHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 6Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
6. Meeting LogisticsMaking arrangements for the meeting• Scheduling so that necessary decision makers can attend• Room size and layout• Supplies• Refreshments & breaks• Travel time & parking• Building access• Providing materials in advance such that participants have time to review themHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 7Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
7. Example Topics for Agenda• Introductions• Goal of the meeting and expected products• Review of documentation of process analysis and redesign• Summary & next stepsHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 8Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
8. Conducting the Meeting• Open the meeting by stating the meeting purpose – “to make decisions on …”• Review and follow the agenda• Monitor the agenda / time• Encourage participation from all attendees• Help participants reach consensus• Document decisions• Document next steps and follow-up / action itemsHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 9Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
9. Group Decision-Making Process• Process resulting in the selection of a course of action• Results in a “choice”• Systems – Consensus – Voting-based methods • Majority required • Plurality – Dictatorship(Wikipedia, 2012)Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 10Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
10. Documenting a Meeting• Key information to be documented – Approved / denied process changes – Priorities for approved changes – Chosen alternatives• Next steps• Action and follow-up itemsHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 11Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
11. Debriefing Wrap-up• A wrap-up debriefing at the close of the meeting summarizes the decisions• The purposes of the debriefing are: – To confirm agreement – To agree on next steps to move forward with implementing approved changesHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 13Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
12. Major Decisions in EHR-related Process Redesign• Which processes to automate or redesign• Which redesign option to implement• EHR functionality requirements• How candidate systems measure up against requirements• Process change and system implementation plansHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 1Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting 4
13. Example Process Redesign Meeting Might Include• Presentation of opportunities for redesign• For each redesign opportunity: ─Rationale for the change: ─Pros and cons of each competing redesign options, or analysis of multiple options to justify the chosen one ─Cost assessment of making the change ─Decision whether or not to move forward with the change, ─ if resources were limited, a priority for the change would be assigned.• Review of approved changes and their priority• Next stepsHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 15Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
14. “BRAND” Change Matrix Template PROCESS Benefits Risks Alternatives Nothing: Decision of the action of the of the doing nothing action prospective at all actionProcess option 1:Process option 2:Process option 3:7.1 Table Change Matrix Template (courtesy of Dr. Meredith Nahm,2012)Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 16Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting
15. Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods This material Comp10_Unit8a was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
16. Quality Improvement in the Health Care Setting• Quality Improvement – an approach to improvement of service systems and processes through the routine use of health and program data to meet patient and program needs (Chang, 1999)• Examples of Quality Improvement Projects – Redesigning a Clinical Office – Reducing the time for patient intake – Redesigning the information flow in a laboratory – Increasing the access to careHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 18Version 3.0/Spring 2012 Quality Improvement Methods Lecture a
17. Three Major Concepts1. Quality is a Measurable Phenomenon – Six dimensions : Safe, effective, timely, patient-centered, efficient, equitable2. Safety – Errors are definable and measurable – The right plan is defined on the basis of professional standards – To avoid errors, you must decide on the best plan in the context of professional standards, and the plan must be executed3. Accountability – Measurable performance with consequences – Currently lies primarily with physicians – Physicians will increasingly be held accountable for performance at the microsystem levelHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 19Version 3.0/Spring 2012 Quality Improvement Methods Lecture a
18. Plan-Do-Study-Act Cycle This simple model can serve as the foundation for every Act on the Plan the project type. Learnings Action Study the Do the Results Action Also known as: Shewhart cycle Deming cycle Learning and improvement cycle20
19. Organizational Culture• Quality Improvement projects can be aided or impeded by the organizational culture• Organizational Culture factors to consider – Leadership – Ability to adapt to change – Communication ability – Understanding of change or need for change• Factors needed for success (Ransom, 2004) – Making quality improvement part of the job – Leadership support is essential for quality improvement activities to succeedHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 21Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
20. Quality Improvement “It is not necessary to change. Survival is not mandatory” - W. Edwards Deming 1900-1993Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 22Version 3.0/Spring 2012 Quality Improvement Methods Lecture a
21. Leadership SupportLeaders can enable quality improvement in theirhealth care settings by: • Creating and promoting a quality vision • Increasing staff capacity to support quality improvement • Motivating staff to participate in QI projects • Establishing the QI teams • Demonstrating support of use of metrics to measure performance • Making sure that the ‘voice’ of the patient is heard and acted on • Involving staff and patients • Including QI in the budgetHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 23Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
22. Quality Improvement Methods• Many methods• Human-centered and supportive of the implementation of Health IT• Originally tailored for enterprises, not necessarily health careHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 24Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
23. Associates for Process Improvement (API)Model• Developed by Tom Nolan and Lloyd Provost• Simple model for Process Improvement based on Deming’s PDSA cycle• Three fundamental questions form basis of improvement – What are we trying to accomplish? – How will we know that a change is an improvement? – What changes can we make that will result in improvement?Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 25Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
24. FOCUS-PDCA1980s – Focus-PDCA model • Find an opportunity for improvement • Organize an effort • Clarify current understanding • Understand the process variations and capability • Select a strategy • PDCA cycle test the strategyHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 26Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
25. ISO 9000• International Standards Organization• 1987 – initial ISO 9000 guidelines for performance improvement.• Components – Design and develop a QI program – Create a sociocultural environment • And a structure that supports improvement – Reduce or avoid quality losses – Define QI responsibilities – Develop an improvement planning process – Develop an improvement measurement process – Develop an improvement review process – Carry out QI projects – Analyze the facts before you decide to do QI(ISO 9000, n.d.) Fundamentals of Health Workflow Process Analysis and RedesignHealth IT Workforce Curriculum Quality Improvement Methods 27Version 3.0/Spring 2012 Lecture b
26. Kaizen• Kaizen – Japanese for change for the better• Continuous Improvement – The common English term – Connotes ongoing improvement involving everyone – Assumes our way of life deserves to be constantly improved – Includes improvement practicesHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 28Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
27. Lean Thinking • Sometimes called the “Toyota Production System” • Consists of five steps: – Identify which features create value – Identify the sequence of activities, called the value stream – Make the activities flow – Let the customer pull the product or service through the process – Perfect the processHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 29Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
29. Lean Thinking• Assumptions underlying Lean thinking are – People value the visual effect of flow – Waste is the main restriction to profitability – Many small improvements in rapid succession are more beneficial than analytical study – Process interaction effects will be resolved through value stream refinement – People in operations appreciate this approach – Lean involves many people in the value stream• Transitioning to flow thinking causes vast changes in how people perceive their roles in the organization and relationships to the product•Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 31Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
30. Six Sigma DMAIC1. Define - Project goals and boundaries are set, and issues are identified that must be addressed to achieve improved quality2. Measure – Information about the current situation is gathered in order to obtain baseline data on current process performance and identify problem areas3. Analyze – Root causes of quality problems are identified and confirmed with appropriate data analysis tools4. Improve – Solutions are implemented to address the root causes of problems identified during the analysis phase5. Control – Improvements are elevated http://www.orielstat.com/lean-six- and monitored. Hold the gains. sigma/six-sigma-dmaic/overview Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 32 Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
32. Improvement Methodology: DMAIC “Backbone” Control Tools Sustain Return on Investment (ROI) Performance improvement Improvement Devise solution(s) and implement Benchmarking …and validate root cause(s) …the current process capability (get the data!) …the problem in a measurable way Project Timeline The Quality Colloquium Introduction to Track IC:
34. Why Collect Data? “Data is like garbage. We need to know what we are going to do with the data before we actually collect them.” --Mark Twain “In God we trust; all others must bring data.” W. Edwards Deming36
35. Data-Based Decisions Data and statistical thinking play a vital role in system and process improvement. It is essential to understand distribution theory especially the concepts of shape, center, spread, and outliers.37
36. Measures of Center Measures of center estimate the center of a distribution. The three measures of center we will discuss are the mean, the median, and the mode.38
37. A Distribution Curve English 300 250 Mean: 54 200 Median: 56 Frequency 150 Mode: 63 100 50 Mean = 53.78 Std. Dev. = 19.484 0 N = 4,253 0 20 40 60 80 100 English
38. The Normal Distribution CurveIn everyday life many variables such as height, weight, shoe size and exam marks all tend to be normally distributed, that is, they all tend to look like the following curve.
39. The Normal Distribution Curve Mean, Median, Mode0.025 0.020.015 0.010.005 0 0 20 40 60 80 100 It is bell-shaped and symmetrical about the mean The mean, median and mode are equal It is a function of the mean and the standard deviation
40. Measures of Spread Knowledge of spread informs us to what extent data values vary. We will discuss five measures of spread: • Range • Variance • Standard Deviation42
41. Standard Deviation The standard deviation is the square root of the variance. A higher standard deviation indicates higher spread, less consistency, and less clustering. Sample Standard Deviation Formula: S = 2 S = n • (Yi - Y) 2 i=1 n-143
42. Bell shaped curve• empirical rule for data - only applies to a set of data having a distribution that is approximately bell-shaped:• 68% of all scores fall with 1 standard deviation of the mean• 95% of all scores fall with 2 standard deviation of the mean• 99.7% of all scores fall with 3 standard deviation of the mean
43. Distribution Shapes Exercise: Describe the following distributions in terms of shape, center, spread, and extreme values. Can you think of any examples from your workplace?45
44. Types of Data Verbatims Yes/No Categorical Unordered Types of Data Count Ordered Continuous46
45. Examples of Verbatims • “I don’t like to have to wait so long in the waiting room.” • “All I want is to talk to a human being.” • “Why do they keep asking for the same information?” • “I couldn’t understand what the doctor said.”47
46. Examples of Yes/No Data • A patient history is either “updated” or “not updated” • A diversion either “occurs” or “does not occur” • A specimen is either “OK for testing” or “not OK” • A hospital room is either “available” or “not available”48
47. Examples of Unordered Categories • Billing Errors: • Employee Injuries: - Misspelling - Hand - Wrong Address - Back - Wrong Amount - Neck - Eye • Customer Complaints - Foot - Billing Mistake - Poor care - Long wait time49
48. Examples of Ordered Categories • Service Score: - Poor - Good - Excellent • Quality Rating: - Very Dissatisfied - Dissatisfied - Neutral - Satisfied - Very Satisfied50
49. Examples of Count Data • The number of errors on twenty prescription labels • The number of patient falls in a hospital • The number of sentinel events • The number of computer system failures in a month51
50. Examples of Continuous Data • Body weight • The time it takes to room a patient • The time it takes to clean an operating room • Cholesterol level • Blood pressure • Body temperature • Room temperature52
51. Basic Tools• CREATIVITY TOOLS – Although this group is not known as a fixed list of specific tools-that would be incongruent with the concept of creativity-it typically includes brainstorming, mind maps, Edward deBono’s (1999) six thinking hats, and the use of analogies – Help one look at processes in new ways and identify unique solutions• STATISTICAL TOOLS – Used for more sophisticated process data analysis – Help understand the sources of variation, the relative contribution of each variable, and the interrelationships between variables• Statistical process control (SPC) – A graphic means used to monitor and respond to special causes of variation – A wide range of statistical techniques that can be applied to both parametric and nonparametric data – Allows the analysis of the statistical significance of more complex interrelationshipsHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 53Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
52. Basic Tools• FLOWCHART – A map of each step of a process• CAUSE-AND-EFFECT DIAGRAM – Ishikawa, or fishbone, diagram – Assist in organizing the contributing causes to a complex problem (Tague, 2004)• PARETO CHART – 80 percent of the wealth in Italy was held by 20 percent of the population (Pareto)• CHECK SHEETS – Used to measure the frequency of events or defects over short intervals – Immediately provides data to help to understand and improve a process.Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 54Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
53. Fishbone Diagram (cause and effect) 3rd Largest Cause Largest Influence Cause Cause Cause Cause Cause Effect Cause Cause Cause Cause Least Influence 2nd Largest Influence Factors and/or categories of factors
54. Pareto Chart—Patient Complaints Pareto Chart for Reason 100 300 80 Percent Count 60 200 40 100 20 0 0 ns e tio ul e s ff T im are es ed cti on Sta Pa rk ait C t Qu Sch ire d ly to he r Defect ng W Po or nd an rd to or D frie n Ha rd Ot Lo du Ha Po Un Re Count 125 96 57 32 15 12 11 8 Percent 35.1 27.0 16.0 9.0 4.2 3.4 3.1 2.2 Cum % 35.1 62.1 78.1 87.1 91.3 94.7 97.8 100.056
55. 2009 Medicaid PPRs N = 268 350 100 300 250 80 PercentCount 200 60 150 40 100 20 50 0 0 Dx es s s s s Dep s o si giti C HF ete liti rug PD m ch o ur ha ab Cell u ic D CO he Psy Ne sop Di ox C e E T / s iv / a lth re s in g n He ep so ta l D Poi en M Count 142 100 32 10 9 9 8 8 6 Percent 43.8 30.9 9.9 3.1 2.8 2.8 2.5 2.5 1.9 Cum % 43.8 74.7 84.6 87.7 90.4 93.2 95.7 98.1 100.0 57
56. Example of a simple process check sheet. (attributes) Model XYZC217 Batch 1 failures 1 2 3 4 5 6 7 8 9 0 Power up 1 2 1 Boot up 6 4 2 1 2 Sink test 2 1 1 1 Case damage 1 1 2 Keyboard damage Monitor damaged 1 2 Bundled s/w included 3 1 3 Checked by a l l r a pj m jj [j m m m pj m pj
57. Basic Tools• HISTOGRAM – A graphical display of the frequency distribution of the quality characteristic of interest – Makes variation in a group of data readily apparent – Assists in an analysis of how data are distributed around an average or median value.• SCATTER DIAGRAM – Show the relationship between two variable – Can help to establish the presence or absence of correlation – Does not indicate a cause-and-effect relationship• RUN CHART – Plots of data, arranged chronologically – Used to determine the presence of some types of signals of special cause variation – A center line (usually the median) is plotted Along with the data to test for shifts in the process• CONTROL CHART – Consists of chronological data along with upper and lower control limits that define the limits of common cause variation – Used to monitor and analyze variation from a process – Use to determine if process is stable and predictableHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 59Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
58. Red Blood Cell Histogram Size of Red Blood Cells 60
59. Scatterplot of Experiment vs Control 30 25 20Experiment 15 10 5 0 0 5 10 15 20 25 30 Control
60. Scatterplot of Experiment vs Control 30 25 20Experiment 15 10 R2 = .98 5 Experiment = - 1.55 + 1.43 Control 0 0 5 10 15 20 25 30 Control
61. Run chart Run Chart 1.07 - 12.07 50 40Number 30 Median 20 10 0 1.07 2.07 3.07 4.07 5.07 6.07 7.07 8.07 9.07 10.07 11.07 12.07 Tim e Fram e (Month.Year) Graph of data over time Track performance Display & identify variation 63
62. Run chart analysis: Common cause variation only876543210 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Tim e 64
63. Run chart analysis: Runs• Run = one or more consecutive data points on the same side of the median• Excludes data points on the median 12 10 8 6 11 4 runs 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 65
64. Run chart analysis: Run length 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Time 66
65. Run chart analysis: Trends8 Special cause—trends:6 Consecutive points all4 going up or all going2 down. May cross the0 median. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Time 67 (Pyzdek, 2003)
66. Run chart analysis: Freaks1086420 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 TimeFreaks: The presence of more than one ortwo dramatic spikes suggests the process isout of control. 68
67. Run chart analysis: Cycling109876543210 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19Cycling: A zigzag or saw-tooth patternwith 14+ points in a row alternating up ordown. 69
68. Control charts 70
69. Control chart High An indication of a special cause UCL Quality Characteristic X LCL Low Time Run chart with control limits Determines type of variation Is process stable? Predictable? 71
70. Maintaining and Enhancing Improvements Topics• Monitoring processes to maintain performance gains• Continuing to improve process performance• Contingency planning for EHR downtime – providing patient care when the EHR is down – maintaining availability of health information to providers and patients in major emergenciesHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 72Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture a
71. Measurement Is the First Step“Measurement is the first step that leads to controland eventually to improvement.If you can’t measure something,you can’t understand it.If you can’t understand it,you can’t control it.If you can’t control it,you can’t improve it.” - Dr. H. James Harrington(DeMarco, 1982)Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 73Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture a
72. Quality Council• Establish core quality standards and requirements• Identify and defining quality metrics• Identify and define quality requirements• Clarify which performance measures are key to gauging actual quality improvement performance• Collect and analyze data to understand key variables and process drivers• Legitimize value of QI within the organization• Analyze QI data and report quality trends• Educate organization and train key staffHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 74Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture a
73. Maintaining Improvements Measurement Understanding Control ImprovementHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 75Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture a
74. Process Control Terminology• Process control (PC) the method for keeping a process within boundaries; the act of minimizing the variation of a process• In-control process: observed variability is due to natural random variation• Out-of-control process: observed variability is due to special causes, i.e., those other than natural variation• Statistical process control (SPC) is the application of statistical methods to control a process(American Society for Quality (ASQ), 2011)Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 76Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture a
75. Challenges to SPC in Health Care• SPC was first used in manufacturing• SPC is not frequently included in books on statistics for health care and medicine• SPC is a tool, like any tool, it can be used incorrectly or for the wrong job• Prior to EHRs data had to be manually collectedHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 77Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture a
76. Statistical Process Control• Uses special charts, called control charts• Statistical Process Control activities – Understanding the process – Understanding the causes of variation – Elimination of the sources of special cause variation• Monitored using control charts to identify variation due to special causes• Causes for excessive variation must be determined(Shewhart, 1931)Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 78Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture a
77. Benefits of Statistical Control • Stable, consistent, and predictable process results • Allows you to learn from variation • Allows you to identify special causes of variation • Provides a rational basis for predicting future performance79
78. Some Causes of Variation One thing for certain is that variation is caused. Some of the generic cause categories are: • Environment • Equipment • Methods • Materials • Measurement • People80
79. Two Types of Variation Common cause variation is the variation inherent in the process. Special cause variation is variation due to fleeting or unusual causal factors. A statistical control chart is able to distinguish between common cause variation and special cause variation.81
80. Rules for Detecting Special Causes The following are “rules of thumb” for determining whether there are special causes of variation present in the process: 1) A point outside the control limits 2) Seven points in a row increasing or decreasing 3) Seven points in a row above or below average 4) Obvious patterns Note: Special cause rules should in some cases be tailored for the metric.82
81. Common Statistical Control Charts X & M-R Charts Continuous Data X-Bar & R Charts Statistical P Chart Control Yes/No Charts Data NP Chart U Chart Count Data C Chart83
82. P Chart: Proportion of Damaged Boxes P Chart of No. Damaged 0.5 UCL=0.4369 0.4 0.3 Proportion _ P=0.2316 0.2 0.1 LCL=0.0263 0.0 2 4 6 8 10 12 14 16 18 20 Sample Tests performed with unequal sample sizes84
83. P Chart: Proportion of Patients Diverted P Chart of DIVERSIONS 0.08 UCL=0.07354 0.07 0.06 0.05 Proportion 0.04 0.03 _ P=0.02721 0.02 0.01 0.00 LCL=0 3 6 9 12 15 18 21 24 27 30 33 Sample Tests performed with unequal sample sizes85
84. U Chart: Patient Fall Rate U Chart of Reported Falls 0.014 UCL=0.01253 0.012 Sample Count Per Unit 0.010 0.008 _ U=0.00753 0.006 0.004 LCL=0.00253 0.002 2 4 6 8 10 12 14 16 18 20 22 24 Sample Tests performed with unequal sample sizes86
85. I-MR Chart: OR Turnover Time I-MR Chart of Turn Time 60 1 1 U C L=54.06 Individual V alue 45 _ 30 X=29.74 15 LC L=5.43 0 4 8 12 16 20 24 28 32 36 40 O bser vation 1 30 U C L=29.87 M oving Range 20 __ 10 M R=9.14 0 LC L=0 4 8 12 16 20 24 28 32 36 40 O bser vation87
86. Basic Tools• PROCESS DECISION PROGRAM CHART – Actions to be completed are listed, then possible scenarios about problems that could occur are developed. – Management decides in advance which measures will be taken to solve those problems should they occur. – Helpful when a procedure is new and little or no experience is available to predict what might go wrong. (Tague, 2004)• FAILURE MODE AND EFFECTS ANALYSIS – FMEA is a method for looking at potential problems and their causes as well as predicting undesired results – Developed in the aerospace And defense industries and widely applied – Normally used to predict product failure from past part failure, but it can also be used to analyze future system failures – Enables people to focus energy and resources on prevention, monitoring, and response plans where they are most likely to pay off• POKA-YOKE – Japanese name for “mistake proofing” – Can be thought of as an extension of FMEA – Puts special attention on human errorHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 88Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
87. Quality Improvement Mistakes Mistakes in Purpose & Preparation – Error #1: Choosing a subject which is too difficult or which a collaborative is not appropriate – Error #2: Participants not defining their objectives and assessing their capacity to benefit from the collaborative – Error #3: Not defining roles or making clear what is expected of individuals taking part in the collaborative as faculty or participants – Error #4: Neglecting team building and preparation by teams for the collaborative(Ovretveit, 2002)Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 89Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
88. Quality Improvement MistakesMistakes in Planning and Operations – Mistakes in fostering a learning community focused on improvement • Error #5: Teaching rather than enabling mutual learning • Error #6: Failing to motivate and empower team • Error #7: Not developing measurable and achievable targets. – Mistakes in transition and implementation • Error #8: Failing to learn and plan for sustaining.Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 90Version 3.0/Spring 2012 Quality Improvement Methods Lecture b
89. Fundamentals of Workflow Process Analysis and Redesign Leading and Facilitating Change This material Comp10_Unit9 was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
90. Working With People Tell me and I’ll forget; show me and I may remember; involve me and I’ll understand. – Chinese ProverbHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 92Version 3.0/Spring 2012 Leading and Facilitating Change
91. Change Concepts What is it that causes some change management efforts to be successful?Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 93Version 3.0/Spring 2012 Leading and Facilitating Change
92. Employee’s Perspective Project change • From the employee’s Regulatory Merger / Changes Acquisition perspective, there can be a lot of changes, Work and a lot of changes Market Changes Process can be overwhelming. Change Employee Re- • Remember that work Departmental Changes structuring process change may Requests be only one of several Personnel changes From changes an Manager organization is undergoing.Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 94Version 3.0/Spring 2012 Leading and Facilitating Change
93. Janssen’s 4-Room Apartment 95
94. Key Concept 1:• Humans and organizations are complex• Many factors that come into play – Organizational constraints – Management style – Organizational, departmental, division, and personal goals – Personalities – Environmental factorsHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 96Version 3.0/Spring 2012 Leading and Facilitating Change
95. Key Concept 2:• Organizations are living, changing biological systems – If you push on the system, it will compensate – Behavior dependent on culture and level of trust• Reductionist treatment rarely explains the whole – Measures and numbers • Are not complete • Cannot capture the complete complexity.Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 97Version 3.0/Spring 2012 Leading and Facilitating Change
96. Key Concept 3:Change happens through individual choiceand freedom not through top-down control orcoercion.Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 98Version 3.0/Spring 2012 Leading and Facilitating Change
97. Key Concept 4: John Gall, MD in his 1970’s book Systemantics said it most insightfully: “Systems run best when designed to run downhill.” Systems should work with natural human tendencies rather than against themHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 99Version 3.0/Spring 2012 Leading and Facilitating Change
98. Key Concept 4 Example: Sure, walk in my garden!istockphoto.com/nahm001, 2011.Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 100Version 3.0/Spring 2012 Leading and Facilitating Change
99. Key Concept 5:• Change starts with a deeply meaningful purpose• Which of the following would you rather be a part of? – Getting a system in production – Implementing a system so your practice would get the Meaningful Use incentives – Using health IT to improve the health of your patientsHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 101Version 3.0/Spring 2012 Leading and Facilitating Change
100. Key Concept 6: Make and keep the gap between “as is” current reality and “to be” vision visible, and talk about it at every opportunity. Making gaps visible maintains a “creative tension” as Peter Senge istockphoto.com/nahm001 calls it, that motivates forward progress.Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 102Version 3.0/Spring 2012 Leading and Facilitating Change
101. Key Concept 7:Don’t pull. “it is an assault to try and change someone’s mind.” The Answer to How is Yes (Block, 2002)
102. Key Concept 8: The Engagement Gap CEO CEO Steering Committee Team of the “Best & the Brightest”Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 104Version 3.0/Spring 2012 Leading and Facilitating Change
103. Key Concept 9: Transparency“…tell the truth, the whole truth and nothing but the truth…”Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 105Version 3.0/Spring 2012 Leading and Facilitating Change
104. Pulling it all together• Change happens best when individuals have – Deeply meaningful purpose – Sincere invitation to influence – Acknowledgement of opportunities for personal control or choice – Transparency – Shared understanding• Change is impacted by: – Individuals and organizations – Culture and trust – How a change project is structured and managedHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 106Version 3.0/Spring 2012 Leading and Facilitating Change
105. Applying All of This Facilitation Plans and Tools: Facilitation “F” Plan• A facilitation plan is an outline for how a meeting or an entire change effort will be run. A facilitation plan includes: – Description of who is included. – Description of how included individuals will be selected or invited. – Schedule or agenda. – Outline of what methods or tools will be used – Description of how the rest of the organization will be kept up-to- date – Description of how leadership will be kept in the loop• A facilitation plan should be made available to the entire organization to maintain transparency.Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 107Version 3.0/Spring 2012 Leading and Facilitating Change
106. Facilitation Plan Scenario• A mid-size internal medicine practice has decided to select, purchase and implement an Electronic Medical Record (EMR). They have hired you as a consultant for Process Analysis and Redesign. Your agreement with the practice is that you will provide instruction, training and oversight for members of their staff as they analyze their processes, redesign their processes around an EMR, and define the functionality that they need in an EMR.• You have already had an initial meeting with practice leadership and have had a tour and met the 75 person staff. At your next meeting, you will present the facilitation plan and get the analysis and redesign started.• Over the next several slides, we will look at “Big F” facilitation plan for the entire effort, and a “little f” agenda for the initial meeting.Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 108Version 3.0/Spring 2012 Leading and Facilitating Change
107. Big F Week 1 Week 2 Week 3 Week 4 Group 1 work week: Group 1 work week: Group 1 work week: Group 1 work week: Process inventory Process Analysis Process Redesign FinalizeGroup 2: WeeklyWalkthroughs 1 hourLeadershipbriefing / debriefing1 hourHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 109Version 3.0/Spring 2012 Leading and Facilitating Change
108. Little f post-Week 1 Walkthrough• Introduction to overall project – How the team was selected – What their charge is – The Big F plan – Timeline and scope• Context diagram exercise – Create one as a group – Pin-the-tail on the donkey• Process Inventory – What did we missHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 110Version 3.0/Spring 2012 Leading and Facilitating Change
109. Little f Leadership Briefing / Debriefing• Brief review of progress• Presentation of challenges• Review and “what did we miss” exercises• Engaging questions: – Any surprises based on what’s presented – Get help strategizing about challenges – Leadership should have input into prioritizing processes for analysis and redesignHealth IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 111Version 3.0/Spring 2012 Leading and Facilitating Change
110. Fundamentals of Workflow Process Analysis and Redesign Process Change Implementation and Evaluation This material Comp10_Unit10 was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
111. Topics – Component 10 Unit 10• Common process changes• Implementation plan components• Communication for implementation• Common implementation problems• Evaluating the new processHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 113Version 3.0/Spring 2012 Process Change Implementation and Evaluation
112. Common Process Changes• From manual to electronic prescribing• From receptionist to web-based appointment scheduling• From manual to automated appointment reminder calls• From manual tracking of test results to automated result tracking• From paper to electronic patient charts• From paper to electronic test orderingHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 114Version 3.0/Spring 2012 Process Change Implementation and Evaluation
113. Implementation PlanThe implementationplan serves as a mapfor everyone involvedin changing a process.It covers what stepseveryone will need totake, what to expectand what to do whenthings don’t go asplanned.Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and 115Version 3.0/Spring 2012 Redesign Process Change Implementation and Evaluation
114. Implementation Plan Components• Reason for the change• Summary of what will be different• Sequence of implementation tasks• An implementation schedule for the entire implementation phase – Responsible parties – Each implementation task• Statement of how the process will be managed• Contact information for who to call when problems arise• Description of how the process change will be evaluatedHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 116Version 3.0/Spring 2012 Process Change Implementation and Evaluation
115. Exercise• Using your project redesign• Review the implementation plan components on the previous slide• Create an implementation plan• Include each component from the previous slide
116. Communication of an Implementation Plan “Tell me and I’ll forget; show me and I may remember; involve me and I’ll understand.” – Chinese ProverbHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 118Version 3.0/Spring 2012 Process Change Implementation and Evaluation
117. What People Need to Know• What is happening• Why is the change taking place• How they will be affected – Address each task or activity that will be added, changed or will go away• How the change will impact workflow or responsibilities• How will the change take place• What if anything different will the patients seeHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 119Version 3.0/Spring 2012 Process Change Implementation and Evaluation
118. Job Aids• Talking points• Checklists• Written procedures• Cheat sheetsHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and 120Version 3.0/Spring 2012 Redesign Process Change Implementation and Evaluation
119. Fundamentals of Health Workflow Process Analysis and Redesign Maintaining and Enhancing Improvements Lecture b This material Comp10_Unit11b was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
120. Business Continuity Plan(Wikimedia, 2012)Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 122Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture b
121. What is Affected When an EHR is Down?• Receipt of lab results via electronic interface,• Clinical decision support,• Routing of prescription refills• Electronic storage of entered clinical documentation,• Appointment call reminders, and• Transmitting health informationHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 123Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture b
122. BCP for EHR DowntimeBusiness continuity planning for EHRdowntime is the systematic inventory ofEHR-facilitated processes and contingencyplanning for each.• Real-time clinical care• Care follow-up activities• Getting data into the EHRHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 124Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture b
123. BCP Team • Assemble Core Team to oversee BCP development • Identify BCP Points-of-Contact for organizational units • Define the overarching (Wikimedia, 2012) BCP program • Develop a BCP timelineHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & 125Version 3.0/Spring 2012 Redesign Maintaining and Enhancing Improvements
124. BCP Plan Objectives• Ensure continuous performance of an organization’s mission-essential functions in an emergency• Ensure safety of employees• Protect essential equipment, records, and other assets• Reduce disruptions to operations• Minimize damage and losses• Achieve an orderly recovery from emergency operations• Identify alternate locations and ensure operational and managerial requirements are met before an emergency occurs.Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 126Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture b
125. Key BCP Plan Goals• Essential organizational functions, vital systems, data and information identified and prioritized• Critical elements are capable of being recovered quickly to resume operations• People know who is in charge• Back-up personnel are trained• Alternate work locations are predefined• Checklists are predefined to guide the organization in responding to an emergencyHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 127Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture b
126. Critical Processes• Processes or services that must be recovered within 24 hours after a disruption to ensure resumption of the essential function• Includes all resources necessary to carry out the critical process: – Personnel – Data or vital records – Systems and equipmentHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 128Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture b
127. Essential FunctionsFunctions that must be performed to achieve theorganization’s mission•Essential Functions include: – Communications – Vital Records, Systems and Equipment – Key Personnel – Alternate Work Sites – Testing, Training & Exercises – Personnel – Data or vital records – Systems and equipmentHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing Improvements 129Version 3.0/Spring 2012 Lecture b
128. Exercising the Downtime Plan• Exercises are events that allow participants to apply their skills and knowledge to improve operational readiness• Goal of exercises is to prepare for a real incident involving EHR Downtime Plan activation• Three types of exercises: – Tabletop – Functional – Full-scaleHealth IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign 130Version 3.0/Spring 2012 Maintaining and Enhancing Improvements Lecture b
129. Dangers of predicting the future • I never make predictions, especially about the future. • Sam Goldwyn Mayer
130. Looking to the future: common mistakes • Making predictions rather than attaching probabilities to possibilities • Simply extrapolating current trends • Thinking of only one future
131. Looking to the future: common mistakes • People consistently overestimate the effect of short term change and underestimate the effect of long term change. • Ian Morrison, former president of the Institute for the Future
132. Why bother with the future?• The point is not to predict the future but to prepare for it and to shape it
133. IOM report: the problem• Between the health care we have and the care we could have lies not just a gap, but a chasm• A system full of underuse, inappropriate use, and overuse of care• Unable to deliver today’s science and technology; will be even worse with innovations in the pipeline
134. IOM report: the problem• A fragmented system characterised by unnecessary duplication, long waits, and delays• Poor information systems; disorganised knowledge• “Brownian motion” rather than organisational redesign
135. IOM report: the problem• A system designed for episodic care when most disease is chronic• Health care providers operate in silos
136. IOM report: six challenges for health care organisations • 1. Design seamless, coordinated care • 2. Make effective use of IT, including automating patient records • 3. Manage knowledge so that it is delivered into patient care
137. IOM report: getting evidence into health care delivery• Ongoing analysis and synthesis of medical evidence• Delineation of guidelines• Identification of best practices in design of care processes• Better dissemination to professionals and public• Decision support tools• Goals for improvement• Measures of quality for priority conditions
138. IOM report: six challenges for health care organisations • 4. Coordinate care across patient conditions, services, and settings over time • 5. Advance the effectiveness of teams • 6. Incorporate measurement of care processes and outcomes into daily practice
139. What will survive as the world changes completely:• 1. Clear ethical values• 2. Being clear about our mission• 3. Putting patients first• 4. Constantly trying to improve• 5. Basing what we do on evidence• 6. Leadership• 7. Learning
140. Conclusions• Patients will have the same access to knowledge as professionals• Self care or “rolled back care” will become steadily more important• Professionals and patients will become much more equal partners• Evidence will become steadily more important
142. 1880 New York City• 150,000 Horses• 3 Million pounds of manure/day• 40,000 gallons of urine/day• 41 deaths/day• 15,000 deaths/year