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- 1. Health Care Workflow Process Improvement Facilitating Meetings for Implementation Decisions Lecture a This material (Comp 10 Unit 7) 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. Facilitating Meetings for Implementation Decisions: Learning Objectives • Describe major health care facility decisions in process redesign that includes EHR technology • Draft an agenda and facilitation plan for a decision making meeting, • Prepare a presentation to communicate findings of a workflow analysis or process redesign to health care facility decision makers, and • Document those decisions that are made and actions identified in a decision making meeting • Critique a decision making meeting agenda, facilitation plan or scenario to identify problems and how they could have been prevented 2
- 3. Topics • Making sure everyone understands how the new workflow might differ from the current processes • Identify which of the clinical workflow changes the clinic decision makers want to implement, • Prioritize these changes • Identify participant roles in the change implementation • Outline next steps to move forward based on the decisions 3
- 4. 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 plans 4
- 5. Effective Meetings “A single effective meeting will substantially change the capacity of a group to achieve 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 plan 5
- 6. Health Care Decision-Making • In the health care field, the steps of making a decision may be remembered with the mnemonic BRAND, which includes – Benefits of the action – Risks of the action – Alternatives of the prospective action – Nothing: That is, doing nothing at all – Decisions 6
- 7. “BRAND” Change Matrix Template 7.1 Table Change Matrix Template (courtesy of Dr. Meredith Nahm, 2012) 7
- 8. 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, o if resources were limited, a priority for the change would be assigned. • Review of approved changes and their priority • Next steps 8
- 9. 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. 9
- 10. The Role of the Meeting Facilitator • Facilitation – Process of designing/running a successful meeting • Practice Workflow and Information Management Redesign Specialist ’s role (as the facilitator) – Work with practice leadership to plan the agenda, – Attend to meeting logistics – Provide decision-making materials in advance – Conduct, maybe facilitate, the meeting – During the meeting, present or provide for presentation of decision-making materials – Gain agreement on next steps 10
- 11. Group Decision-Making Process • Process resulting in the selection of a course of action • Results in a “choice” • Systems – Consensus – Voting-based methods o Majority required o Plurality – Dictatorship 11
- 12. 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 needed 12
- 13. Key Elements of Success • Involvement of key personnel – Have thought through potential solutions – Results in ownership of ideas o Solutions o 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 meeting 13
- 14. Exercise • A Patient check-in (registration) is shown in a process diagram on the following slide. Assume the practice leadership wishes to use consensus among the practice manager, senior nurse, two physician extenders and the two practice partners as the decision-making style. Assume that resources are limited and the process changes will need to be prioritized. 14
- 15. New Patient Check-in: Redesigned Process 7.2 Figure New Patient Check In. (eQHealth Solutions (formerly Louisiana Health Care Review) and the Mississippi Regional Extension Center, 2012) 15
- 16. Example Topics for Agenda • Introductions • Goal of the meeting and expected products • Review of documentation of process analysis and redesign • Summary & next steps 16
- 17. Decision-Making Materials • BRAND matrix • Process diagram 17
- 18. Meeting Logistics • Making 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 them 18
- 19. 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 items 19
- 20. Documenting a Meeting • Key information to be documented – Approved / denied process changes – Priorities for approved changes – Chosen alternatives • Next steps • Action and follow-up items 20
- 21. 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 changes 21
- 22. Methods for Other Decision- Making Meetings • Decision-making meetings = BRAND matrix • EHR functionality requirements = BRAND matrix with benefits, risks and alternatives are based on having vs. not having • Candidate systems = Scoring sheet • Process change and system implementation plan = BRAND matrix with implementation alternatives 22
- 23. Facilitating Meetings for Implementation Decisions Summary • Identified major types of EHR-related process decisions • Provided strategies, tools, and aids for planning and conducting a decision making meeting • Provided tools for documenting decisions made and actions identified in a decision-making meeting • Identified professional development areas related to planning and conducting meetings 23
- 24. Facilitating Meetings for Implementation Decisions References References Bolea, A., & Scott, B. (2010). Creating effective meetings. Retrieved from Business advisors.net: http://business-advisors.net/files/dwnld/Creating_Effective_Meetings_a.pdf Group decision making. 2011. In Wikipedia.org. Retrieved from http://en.wikipedia.org/wiki/Group_decision_making Charts, Tables, Figures 7.1 Table: Courtesy of Dr. M Nahm, 2012. 7.2 Figure: Permission for use by eQHealth Solutions (formerly Louisiana Health Care Review) and the Mississippi Regional Extension Center. 2012 24
- 25. Facilitating Meetings for Implementation Decisions Lecture d 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. 25
Editor's Notes
- Welcome to Health Care Workflow Process Improvement, Facilitating meetings for Implementation Decisions, lecture a.
- The Objectives for lecture are to: Describe major health care facility decisions in process redesign that include EHR technology Draft an agenda and facilitation plan for a decision making meeting, Prepare a presentation to communicate findings of a workflow analysis or process redesign to health care facility decision makers, and Document those decisions that are made and actions identified in a decision making meeting Critique a decision making meeting agenda, facilitation plan or scenario to identify problems and how they could have been prevented
- The overall goal of a decision making meeting, of course is to get a decision made. The objectives include, outlining the decisions that need to be made, assuring that decision makers have the necessary information for decision making, and facilitating decision making. Someone in this role should be able to lead the meeting participants through a discussion to: Making sure everyone understands how the new workflow might differ from the current processes. Identify which of the clinical workflow changes the clinic decision makers want to implement, Prioritize these changes, Identify participant roles in the change implementation, and Outline next steps to move forward based on the decisions
- The major decisions in EHR-related process redesign include things like Which processes to automate or redesign Which redesign option to implement EHR functionality requirements How candidate systems measure up against requirements, and Process change and system implementation plans For 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.
- 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, and Commit 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 workflow process improvement decisions necessitating decision making meetings, and specific content for such meetings.
- In the health care field, the steps of making a decision may be remembered with the mnemonic BRAND, which includes Benefits of the action, Risks of the action, Alternatives of the prospective action, Nothing: that is, doing nothing at all, and Decisions (Wikipedia, 2012). You will see these reflected on the next slide in an example Process Redesign meeting plan.
- 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.
- 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 analysis For 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 chosen An 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 priority Next 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..
- 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.
- Facilitation concerns itself with all the tasks needed to run a productive and impartial meeting. Facilitation serves the needs of any group meeting with a common purpose, whether it is making a decision, solving a problem, or simply exchanging ideas and information. The Facilitator does not lead the group, nor try to distract or to entertain. The facilitator is there to make sure that that everyone’s voice is heard and that the goals for the meeting and project are met. As the decision-making facilitator, the role of the Practice Workflow and Information Management Redesign Specialist is to: Work with practice leadership to plan the agenda, Attend to meeting logistics Provide decision-making materials in advance Conduct, maybe facilitate, the meeting During the meeting, present or provide for presentation of decision-making materials and Gain agreement on next steps Finally, the Practice Workflow and Information Management Redesign Specialist’s role is to document the decisions in minutes or a meeting report, and to initiate progress on the next steps.
- 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 meeting participants are to: 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 needed
- 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.
- This is an exercise to help you start building a toolbox of useful documents and aids for planning and conducting decision-making meetings in the health care setting. A Patient check-in (registration) is shown in a process diagram on the following slide. Assume the practice leadership wishes to use consensus among the practice manager, senior nurse, two physician extenders and the two practice partners as the decision making style. The boxes (any color) represent steps in the “as is” process, Red boxes represent those steps that will be eliminated with the EHR implementation, and yellow boxes represent process steps that will change with the EHR implementation. Two process alternatives, one of which denotes a possible new process step are noted in clouds on the diagram. Review the diagram, pause the slides, and Create an agenda for a decision making meeting to discuss the two alternative process options (usually a decision making meeting would involve more than one process change to be prioritized or approved and more than two process alternatives) List decision making materials needed to make decisions about this process. Consider the need to gain approval for each change as well as to make a decision about the proposed alternative. Assume that resources are limited and the process changes will need to be prioritized. Afterward, restart the slides and we will talk through the results.
- The process diagram depicted shows a process for new patient check-in. The diagram format is a swim lane diagram. Shown are two horizontal lanes on the diagram, the top one represents process steps performed by the patient, the bottom lane contains process steps performed by the front office. All process steps are denoted by boxes, 9 in total shown on the diagram. The boxes (any color) represent steps in the “as is” process, Red boxes represent those steps that will be eliminated with the EHR implementation, yellow boxes represent process steps that will change with the EHR implementation; green boxes denote process steps that will not change. Two process alternatives, one of which denotes a possible new process step are noted in clouds on the diagram. The first process step (green and performed by the patient), is arriving at the clinic; the second, also green and performed by the patient is checking in at the front desk. The third and forth process steps are yellow and performed by the patient and front office respectively. They are complete new patient forms and Verify demographics & new patient forms. The cloud appearing to the left of the third and fourth process step suggests a process alternative of having the patient complete new patient forms before the visit. The fifth process step (green and the last performed by the patient) denotes the patient waiting until called to be seen. The sixth process step (green and performed by the front office) is the entry of the new patient form into the Practice Management System, or PMS. The seventh, eighth and ninth steps are red and performed by the front office. They include printing a superbill, assemble new chart, and place chart in holder. A cloud to the top of these last process boxes states, “Will need to consider plan for notifying the Medical Assistant / Registered Nurse that the patient has checked in and is ready to be seen.”
- 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
- Two main decision-making materials are needed for the meeting: BRAND matrix for proposed process changes Since the number of decisions for the meeting is small, and the format used for the example process diagram is concise and clearly shows both “as is” AND “to be” processes, i.e., the proposed changes, the Process diagram could be provided with the BRAND matrix. In this case, less text description would be needed for each change listed. As an additional exercise, you may want to complete the BRAND matrix for the process diagram used in the example. Although you won’t have real data upon which to base a cost/benefit analysis, you can indicate whether or not there is a cost or cost savings associated with the change.
- 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.
- 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 agenda Monitor the agenda / time Encourage participation from all attendees Help participants reach a decision Document decisions and Document next steps and follow-up or Action items.
- The key information to be documented from a process redesign decision making meeting include: Decisions on each proposed process change Approved / denied process changes Priorities for approved changes Chosen alternatives Next steps Action and follow-up items The 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.
- Earlier in this unit, we covered the major decisions in EHR-related process improvement. The method that we applied to a Process Redesign meeting also applies to these other types of decisions. Identifying the decisions to be made, planning conducting and documenting the meetings are all the same. What changes for the different types of decisions is the information required for making the decision. Thus, the meeting formats and planning can be the same, but a matrix, like the BRAND matrix, is needed for each. For decision making meetings about which processes to automate or redesign, the BRAND matrix can be used. For decisions about EHR functionality requirements, something similar to the BRAND matrix can be used, but the benefits, risks and alternatives (including cost benefit assessment) is based on having versus not having the functionality. For decisions about how candidate systems measure up against requirements, a scoring sheet where each system is evaluated against requirements and scored should be used For process change and system implementation plan approval meetings, something similar to the BRAND matrix can be used, but the benefits, risks and alternatives (including cost benefit assessment) are based on implementation alternatives such as go live with all providers at once versus pilot with one provider, or migrate existing data from charts to the EHR at once using a contract service provider, or have clinic front office enter the data as visits are scheduled.
- This concludes Facilitating Meetings for Implementation Decisions. In summary, this unit has Identified major types of EHR-related process decisions, Provided strategies, tools, and aids for planning and conducting a decision making meeting, Provided tools for documenting decisions made and actions identified in a decision making meeting, and Identified professional development areas related to planning and conducting meetings.
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