Making change happen: learning from "positive deviancts"
Comp10 unit6a lecture_slides
1. Health Care Workflow Process
Improvement
Process Redesign
Lecture a
This material (Comp 10 Unit 6) 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. This material was updated by Normandale Community College, funded under
Award Number 90WT0003.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International
License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/
2. Process Redesign
Learning Objectives
• Identify the factors that optimize workflow
processes in health care settings
• Describe how information technology can
be used to increase the efficiency of
workflow in health care settings
2
3. Process Redesign
Topics – Lecture a
• Objectives and goals of Process Redesign
• Unproductive work
• Twenty seven strategies for optimizing
processes
• An example of each optimization strategy
3
4. Individual Performance
“You can only
elevate individual
performance by
elevating that of the
entire system.”
- W. Edwards Deming
Source: Deming, 1982
4
5. Goals of Redesigning Processes
• Improving quality and safety of care
• Enhancing the patient’s care experience
• Decreasing the cost of care
• Making clinic processes more efficient
5
7. Unproductive Work
• Tasks not necessary for providing patient
care
– Waiting
– Transportation / unnecessary motion
– Doing things twice
– Errors
– Repetitive tasks
– People with higher level of training than
necessary performing tasks
7
8. Problem - Solution
• Unproductive work = problem
• Redesign strategies = solution
8
9. See Things Right
“Before you attempt to set things right, make
sure you see things right.”
– Blaine Lee
9
10. Why not just implement
technology?
• In a recent case study, introduction of
technology accounted for 25%
improvement in invoicing time
• Addition of process redesign in addition to
technology resulted in 80% improvement
• Technology is often necessary, but is
seldom sufficient
10
11. Redesign Strategies
• Automation
• Buffering
• Centralization
• Control addition
• Control relocation
• Contact reduction
• Customer teams
and case managers
• Empower
• Exception
• Extra resources
• Flexible assignment
• Integration
• Interfacing
• Knock-outs
11
12. Redesign Strategies
(cont.)
• Numerical
involvement
• Outsourcing
• Order-based work
• Order assignment
• Order types
• Parallelism
• Split responsibilities
• Task composition
• Task elimination
• Triage
• Trusted party
• Resequencing
• Specialist-generalist
12
13. Optimization Method:
Automation
• Design decisions determine the extent to
which a given job, task, function or
responsibility is to be automated or
assigned to human performance
• Consider the relative capabilities and
limitations of human vs technology
• Basing decisions solely on the capabilities
of the technology is not advised
13
14. Automation Examples
• Opportunities to use computer systems
to automate clinic processes:
– Triggering prescription refills
– Alerting clinicians to abnormal lab results
– Triggering planned assessments
– Subscribing to automatic information updates
o Rather than waiting and requesting information
when needed
o Buffering
14
15. Optimization Method:
Centralization
• Centralization can mean common
coordination of activities at multiple
locations such that they are done the
same way
• Can also mean carrying out tasks at one
location rather than having them be
carried out by multiple organizations or
individuals
15
17. Optimization Method:
Control Addition
• Control addition means adding checks in a
process
• Addition of a control step identifies errors
before they have a negative impact
• Can be performed by a human or a
computer
17
18. Control Addition Examples
• Checking
– Insurance eligibility
o Planned procedure
o Co-pay
o Prescription
Prior to sending it home with a patient
– Drug-to-drug interactions
o Prior to writing a prescription
– Drug allergies
o Prior to writing a prescription
18
19. Control Addition Examples
(cont.)
• Counting sponges and instruments before
closing a surgery site
• Double checking the name on the
medication and the patient arm band prior
to administration
• Marking the surgery site and confirming
with the patient prior to surgery
19
20. Control Relocation
• Control relocation is changing who
performs a task, triggers a task to be
done, or approves a task
• In principle, control relocation usually
means pushing control to the “front line”
or even to the customer
20
21. Control Relocation Examples
• There are several notable examples of
control relocation in health care:
– Home monitoring devices
– On-line
o Appointment scheduling
o Data entry of patient information before a visit
– Patient portals that enable patients to share
their health records
21
22. Contact Reduction
• Decreasing the
– Number of times
– Length of contact
– Other resources devoted to customer contact
22
23. Contact Reduction Examples
• Completion of patient information forms
before a visit
• Automated appointment reminders
• Pushing tasks down to the lowest level
of staff with appropriate training
23
24. Care Teams & Case Managers
• Help customers navigate complexity
• Called case managers
• Care teams are similar
24
25. Exception Handling
• Exception
– A case that is somehow different from the rest
– Is incomplete, has errors, special circumstances or
special needs
• Exception handling:
– Designing a process to handle the ordinary cases
– “Shunting” the exceptions into a different work
stream
• Frees the process to operate at maximum
efficiency
25
26. Exception Handling Examples
• Special process for contacting no-shows
and rescheduling
• When one lab test in a batch is held up,
available results are returned and others
are reported when available
26
27. Extra Resources
• Identifying those process steps that are
known bottlenecks
– i.e., Cause downstream delays
– Adding extra resources at those steps
to optimize the overall process
• Examples:
– Staffing the front desk
– Eliminating provider wait time
27
28. Flexible Assignment
• “Hedging your bet”
– Minimizing risk
• Things might not always work out
• Flexible assignment
– Not backing yourself into a corner
• Example:
– Hiring a medical office assistant who can also
do blood draws in case having nurses draw
blood causes an imbalance in workload
28
29. Integration
• Designing clinic processes so that they
mesh well with high volume/high
interaction organizations
• Example:
– Electronic interface with
o Claims clearinghouse
o Lab or high volume diagnostic service
o Local hospital
29
30. Interfacing
• Interfacing means providing common and
standard interaction points for high volume
interactions
• Example:
– All labs come through a lab interface
– On-line appointment scheduling
– All documents are received in one place and
processed
30
31. Knock-out
• Fail fast
• Decisions that decrease workload should
be made as early in the process as
possible
• Examples:
– Checking insurance eligibility first thing
– Early initiation of insurance approval
– Screening patients for issues requiring urgent
care immediately
31
32. As Few Hands as Possible
• Design processes to involve as few roles /
people as possible
– Eliminates unnecessary delays
– Hand-offs
– Communication errors
• Avoid splitting responsibilities across
departments or organizations
32
33. Outsourcing, Trusted Party
• If others can do things better or more
efficiently than the clinic, consider
outsourcing
• Examples:
– Responding to requests for records
– Using an external lab or diagnostic testing
service
– Hosting the medical record software and IT
support
33
34. Process Types
• Process analysis should have identified:
– Main clinic work streams
– Processes
34
35. Eliminate Queues and Batching
• Queues and batches cause delays and wait time
• Instead assign work as it comes in to a person
responsible for seeing it through to completion
• Example
– Same day appointment guaranteed
– Assigning a person to handle prescription refills that
are called in by patients or pharmacies
35
36. Parallelism, Resequencing
• Anything that can be done in parallel
should be done in parallel
– Rather than waiting for another step to be
completed
• Resequence process steps to accomplish
tasks as early in the process as possible
36
37. Task Composition
• Some things are better done as smaller
steps
• Other things may be easier to accomplish
as a group of steps
• Example:
– Processing incoming documents to be filed
37
38. Task Elimination
• Getting rid of steps that do not add value
• Examples:
– ePrescribing
– Getting rid of redundant work
– Automating steps
38
39. Specialist-Generalist
• Some things are more efficient if a person
handles only one type of issue
• Other situations require people who wear many
hats
• Choice, specialist or generalist, depends on:
– Training and skill level required for a task,
– How easy a task is to do when it is not a main focus
of someone's effort, and
– Practice size / volume
39
40. Triage
• Related to the specialist – generalist concept
• Means there is an initial sorting step
– Things requiring specialist attention are sent to
specialists
– Others are sent where they are most efficiently
handled
• Example:
– Triage nurse in an emergency department assures
that urgent patients get seen first, and less serious
ones wait longer
40
41. Types of Changes
• Some process changes are large:
– “Breakthroughs”
– Major shifts in the way work is done
– Great improvements in performance
– Usually takes more preparation, planning, and
innovation
• Other changes are small incremental advances
• Many of the strategies discussed here can be
either
• The former usually takes more preparation and
planning, and of course innovation 41
42. Process Redesign
Summary – Lecture a
– Goals of process redesign
– Common process problems
– Process redesign strategies to address
common process problems
– Clinic examples of redesign strategies
42
43. Process Redesign
References – Lecture a
References
Aviña, C (2010). Community Health Clinic Ole, Case Study. Process Mapping & Documentation, Pre
and Post EMR. [PowerPoint slides]. Retrieved from
http://www.rchc.net/Public/OHIT/ClinicProcessRedesign-PPT.pdf
Deming, W. E. (1982). Out of Crisis. Cambridge, MA: MIT Press.
Lee, B. (n.d.). Manager/Leader Comments. Retrieved February 27, 2012, from Virginia
Commonwealth University website:
http://www.people.vcu.edu/~rsleeth/ManagerLeaderQuotes.htm
Mansar, S. L., & Reijers, H. A. (2005). Best practices in business process redesign: validation of a
redesign framework. Computers in Industry, 56, 457-471. Retrieved from
http://www.win.tue.nl/~hreijers/H.A.%20Reijers%20Bestanden/Mansar_2005_Computers-in-
Industry.pdf
Images
Slide 4: FDA. (n.d.). W. Edwards Deming. Retrieved February 27, 2012, from
http://commons.wikimedia.org/
Slide 6: Aviña, C (2010). Community Health Clinic Ole, Case Study. Process Mapping &
Documentation, Pre and Post EMR. [PowerPoint slides]. Retrieved from
http://www.rchc.net/Public/OHIT/ClinicProcessRedesign-PPT.pdf (Link no longer active)
43
44. Process Redesign
Lecture a
This material 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. This material was updated
by Normandale Community College, funded
under Award Number 90WT0003.
44
Editor's Notes
Welcome to Health Care Workflow Process Improvement, Process Redesign, lecture a.
The objectives for this lecture are to:
Identify the factors that optimize workflow processes in health care settings, and
Describe how information technology can be used to increase the efficiency of workflow in health care settings.
The topics covered in this Lecture a, Process Redesign, include:
Objectives and goals of Process Redesign,
Unproductive work,
Twenty seven strategies for optimizing processes, and
An example of each optimization strategy.
Health care is comprised of individuals working in processes. As W. Edwards Deming stated, “You can only elevate individual performance by elevating that of the entire system” (Deming, 1982). Paraphrasing this quote, the way to consistently improve the performance of individuals is to improve the system or process. The goal of Process Analysis is to identify aspects of the process that cause or make process problems more likely. The goal of Process Redesign is to prevent, or mitigate process problems, e.g., delays, errors, wasted resources, or inconsistencies.
Process redesign is a strategic initiative to improve the quality, cost, and safety of patient care. Goals of process redesign include:
Improving quality and safety of care,
Enhancing the patient’s care experience,
Decreasing the cost of care, and
Making clinic processes more efficient.
Achieving these goals often involves replacing manual processes with processes capable of greater accuracy and higher performance and making changes in who performs tasks. An effective approach for doing this leverages Health IT to automate processes, gives patients more control, provides more useful information to providers, practice staff, and patients and shares data between providers.
In a presentation about clinic workflow redesign from Clinic Ole in Napa California, (Aviña C., 2010) the QI/EMR Implementation Coordinator, Carlos Aviña , graphically describes the goal of process redesign. His diagram, adapted above, depicts that in a typical clinic, there is a small amount of quality improvement, there is productive work and there is unproductive work. The goal of process redesign is to get rid of unproductive work and focus all effort on productive work, including increasing the amount of effort spent continually improving clinic processes, and ultimately, patient care.
In a clinic, unproductive work is effort that does not contribute to patient care, i.e., tasks that are not necessary for providing patient care. Unproductive work includes:
Waiting,
Transportation and unnecessary motion ,
Doing things twice, for example, writing a prescription and then documenting that the prescription was written,
Errors,
Repetitive tasks performed by humans, and
People with higher level of training than necessary performing tasks.
Unproductive work can be identified during knowledge acquisition, process analysis, or during redesign.
Note: By unproductive work, we are not talking about breaks, mealtime and vacation, i.e., things necessary for humans to be rested. These things contribute in important ways to patient care by making sure that providers and staff are at their best when caring for patients.
If we say that unproductive work is the problem, then redesign strategies are the potential solutions. Redesign strategies are applied to fix process problems. There are some natural matches between problems and strategies to fix them. The key to process redesign is identifying process problems (unproductive work), and applying the right redesign strategy.
In the words of Blaine Lee, one of the original founders of the Covey Leadership Center, “Before you attempt to set things right, make sure you see things right.” (Lee, n.d.)
In a recent case study reported by Mansar and Reijers introduction of technology accounted for 25% improvement in invoicing time (Mansar and Reijers, 2005). Adding process redesign in addition to technology resulted in 80% improvement. Thus, while technology is often necessary, it is seldom sufficient.
Mansar and Reijers (Mansar and Reijers, 2005) have synthesized known strategies to decrease the amount of unproductive work. Each is defined and illustrated with an example on the following slides. For the purposes of this unit, we have consolidated closely-related strategies.
A checklist of these redesign strategies can be used on the job to systematically assess clinic processes for redesign opportunities.
Strategies for redesign include automation, buffering, centralization, control addition and relocation, as well as contact reduction and use of customer teams and case managers. Other redesign strategies are empower, exception, extra resources, flexible assignment, integration, interfacing, and knock-outs. Each of these will be discussed in the following slides.
Other strategies are given here and include outsourcing, order assignments, and resequencing. It is important to understand that in the clinic setting, application of Health IT can be used to facilitate or outright accomplish many of these strategies.
Automation means designing processes so that machines, i.e., computers, can do them rather than humans.
Things that may lend themselves well to automation are those that can be completely defined, performed in identical fashion each time and are sufficiently repetitive that the automation efforts are cost effective.
Design decisions related to this allocation of function determine the extent to which a given job, task, function or responsibility is to be automated or assigned to human performance. The decisions are based on many factors. These include the relative capabilities and limitations of humans versus technology in terms of reliability, speed, accuracy, strength, flexibility of response, financial cost, the importance of successful or timely accomplishment of tasks, safety, and user satisfaction (both short-term, e.g. as comfort and pleasure, and long-term, e.g. as health, well-being and job satisfaction). Basing such decisions solely on those functions the technology is capable of performing and then simply allocating the remaining system functions to users is likely to result in an ineffective design.
There are many opportunities to use computer systems to automate clinic processes. Some examples are:
triggering prescription refills,
alerting clinicians to abnormal lab results,
triggering planned assessments, and
subscribing to automatic information updates rather than waiting and requesting information when needed. Mansar calls this buffering. (Mansar and Reijers, 2005)
Centralization can mean common coordination of activities at multiple locations such that they are done the same way. It can also mean carrying out tasks at one location rather than having them be carried out by multiple organizations or individuals.
Using a claims clearing house is often more efficient for a practice than the practice submitting claims to multiple insurance companies. Assigning one person in the clinic to answer the phone or one person to handle prescription refill requests are also examples of centralization that may increase efficiency.
Control addition means adding checks in a process. Addition of a control step identifies errors before they have a negative impact. This control can be performed by a human or a computer, i.e., it can be automated.
Control Addition examples in health care are numerous. Some examples include:
checking insurance eligibility of a planned procedure or a co-pay,
checking insurance eligibility of a prescription prior to sending it home with a patient, and
checking for drug-drug interactions or drug allergies prior to writing a prescription.
Additional Control Addition examples in health care include:
counting sponges and instruments before closing a surgery site,
double checking the name on the medication and the patient arm band prior to administration, and
marking the surgery site and confirming with the patient prior to surgery.
Control (or work) relocation is changing the person who performs a task, triggers a task to be done, or approves a task. In principle, control relocation usually means pushing control to the “front line.” Stated differently, it means empowering those closest to the customer to make more decisions or even pushing control to the customer.
There are several notable examples of control relocation in health care. These include:
home monitoring devices, i.e., patients taking their blood pressure daily and entering it into a website or using a device to transmit the data to their provider,
on-line appointment scheduling,
on-line data entry of patient information before a visit, and
patient portals that enable patients to share their health records with other providers.
Contact reduction is straight forward. It involves decreasing the number of contacts, length of contacts, or otherwise decreasing the resources devoted to customer contact.
Notable examples of contact reduction in health care include:
completion of patient information forms before a visit,
automated appointment reminders, and
pushing tasks down to the lowest level of staff with appropriate training.
Mansar and Reijers (Mansar and Reijers, 2005) call this category customer teams. In health care, these are known as care teams. Sometimes organizations can be complex for customers to navigate. One way to alleviate customer dissatisfaction and other untoward effects caused by complexity is to assign a case manager, or a group of people involved in providing services to a customer. Case managers and care teams smooth the process and increase customer satisfaction.
Examples include:
a case manager assigned to a patient who needs multiple ancillary services,
a Medicaid case manager,
a case manager for a patient’s interaction and interface with social services, and
a patient advocate.
In health care, often multiple care providers are needed including doctors, nurses, and allied health professionals. These professionals come together to provide a care team that works together to provide for a patient’s needs.
An exception is a case that is somehow different from the rest, usually involving incompleteness, errors, special circumstances or special needs.
Exception handling is designing a process to handle the ordinary cases and “shunting” the exceptions into a different work stream.
The practice of separating exceptions frees the process to operate at maximum efficiency, i.e., the process is not gummed up by special cases. Often in process redesign, it is tempting to design for exceptions.
Resist this temptation. Design for the norm and separate out the exceptions. A good example of exception handling is the drive-through at fast food restaurants. If there is something about an order that is not ready when the car gets to the window, the cashier takes the money and asks the driver to pull aside, after which, the other “normal cases” can flow smoothly, i.e., the main designed process isn’t held up because of one guy’s fries, the exception, were not ready. The process is designed so that the exception doesn’t interfere or reduce the efficiency.
Exception handling examples in health care include having a special process for contacting no-shows and rescheduling, and when one lab test in a batch is held up, available results are returned per schedule and the lab test that was held up is reported when available.
Extra resources means identifying those process steps that are known bottlenecks, i.e., the processes cause downstream delays, and then adding extra resources at those steps to optimize the overall process. An example of extra resources in health care include keeping someone at the front desk to check patients in, and maintaining sufficient medical office assistants and nursing staff so that everything that can be done before the provider sees the patient is done with time to spare so the provider does not have to wait.
Flexible assignment is “hedging your bet” and minimizing risk.
In process design, things might not always work out, or may have unintended consequences. Flexible assignment means making changes in staff for instance that don’t lock the practice should things go wrong.
An example would be hiring a medical office assistant who can also do blood draws in case having the nurses draw blood causes an imbalance in workload.
Integration is designing clinic processes so that they mesh well with high volume/high interaction organizations. By mesh well, we mean that hand-offs processes are automated and flow smoothly.
Examples include:
electronic interface with a claims clearinghouse,
electronic interface with a lab or high volume diagnostic service, and
electronic interface with a local hospital.
Interfacing means providing common and standard interaction points for high volume interactions.
Some examples include:
all labs come through a lab interface,
on-line appointment scheduling, and
all documents are received in one place and processed.
Knock-out essentially means fail fast.
Decisions that decrease workload should be made as early in the process as possible.
For example:
checking insurance eligibility first thing,
initiating the approval process for a procedures as early as possible, and
screening patients for issues that require urgent or a higher level of care immediately, for example, practice phone messages say first of all “if this is a life threatening emergency, hang up and call 911.”
It is important to design processes to involve as few roles and people as possible. This eliminates unnecessary delays, extra hand-offs, and communication errors. Be careful to avoid splitting responsibilities across departments or organizations.
This is more a design principle than a strategy with examples.
If others can do things better or more efficiently than the clinic, consider outsourcing.
Examples where outsourcing may be more efficient include:
responding to requests for records,
using an external lab or diagnostic testing service, and
hosting the medical record software and IT support.
Identifying Process Types is more a principle than a strategy, but the process analysis should have identified the main types of clinic work streams and processes.
Queues and batches cause delays and wait time. To avoid long queues and large batches of work, it is best to assign work as it comes in and to a person responsible for seeing the work through to completion.
For example:
Guaranteed same-day appointments avoid patient back-ups and
Assigning a person to handle all prescription refills regardless of whether the prescription is called in by patients or pharmacies.
Anything that can be done in parallel rather than waiting for another step to be completed should be done in parallel. Resequence process steps to accomplish tasks as early in the process as possible.
Task composition is more something to consider than a redesign strategy. Some things are better done as smaller steps, while other things may be easier to accomplish as a group of steps.
An example is the processing of incoming documents:
Processing incoming documents is more efficient and accurate when broken down into smaller steps. These steps include:
opening all the mail,
checking for document identifiers on the envelopes,
sorting in patient number order, and
filing.
This is more efficient and accurate than opening a single piece of mail, checking the envelope for document identifiers, processing and filing before opening the next piece of mail.
Task elimination is probably what most people think of first when they hear the words process redesign. Getting rid of steps that do not add value, i.e., the “unproductive work.”
Examples:
ePrescribing eliminates a significant number of steps,
getting rid of redundant work does too,
automating steps effectively eliminates tasks that humans need to do, and
control relocation also can eliminate tasks that office staff need to do.
Specialist-generalist is more of a consideration than a particular strategy that can be applied. Some things are more efficient if a person handles only one type of issue. An example would be in a large practice where one person can devote 100% of his time to scheduling external diagnostic tests or surgeries; whereas in a small practice, people wear many hats. The choice of specialist or generalist depends on the training and skill level required for a task, on how easy a task is to do when it is not the main focus of someone, and on the size of the practice.
Triage is related to the specialist – generalist concept. Triage means that there is an initial sorting step where things requiring specialist attention are sent to specialists and others are sent where they are most efficiently handled. For example, a triage nurse in an emergency department ensures that urgent patients get seen first and less serious ones wait longer.
Some process changes are large: “breakthroughs” in improving efficient, major shifts in the way work is done, and great improvements in performance. Other changes are small with incremental advances. Many of the strategies discussed above, depending on how they are applied, can be either. The former usually takes more preparation and planning, and of course, innovation.
This concludes Lecture a of Process Design. In this lecture, we have covered:
Goals of process redesign,
Common process problems,
Process redesign strategies to address common process problems, and
Clinic examples of redesign strategies.
