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Clinical Workflow Implementation


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Planning the implementation of an EMR or EHR, then you need to understand the basics of defining your clinical workflow. This presentation was made at a variety of medical conferences

Published in: Technology, Business

Clinical Workflow Implementation

  1. 1. 1<br />Clinical Workflow: The Foundation of Systems Implementation<br />The impact of Clinical Workflow on the Transformation Process<br />Presented by:<br />Edward A Stern, RN<br /><br />
  2. 2. 2<br />Objectives<br />Discuss workflow as it relates to transformation<br />Basic workflow elements<br />Current state<br />Future state<br />Original state<br />Workflow process<br />Cognitive workflow cluster theory<br />
  3. 3. Clinical Transformation Process<br />A never ending process to improve care delivery excellence through:<br />Offering value<br />Measurably quality improvement<br />Enhancing services and solutions<br />While reducing costs through the effective alignment of people, process and technology. <br />Here’s where workflow plays a part<br />3<br />
  4. 4. 4<br />Workflow Defined<br />From Wikipedia, the free encyclopedia<br />Workflow (WF) at its simplest is the movement of documents and/or tasks through a work process. More specifically, workflow is the operational aspect of a work procedure: how task are structured, who performs them, what their relative order is, how they are synchronized, how information flows to support the tasks and how tasks are being tracked. As the dimension of time is considered in Workflow, Workflow considers “throughput” as a distinct measure. <br />
  5. 5. 5<br />“It’s Workflows’ Fault”<br />Workflow is often a common “fault” area in the implementation of a technology.<br />The problem is that it is rarely ‘the’ workflow and more probably; that the wrong flow assessment, or not enough operations and systems workflows were considered.<br />
  6. 6. What isClinical Informatics Assessment ?<br />Simply stated, Clinical Informatics Assessment (CIA) is the process in which the clinical operation if broken down into fine step by step elements using an informatics work flow approach while remembering the clinical fundamentals<br />Think of it as a “pulse check” for the workflow process<br />6<br />
  7. 7. More onClinical Informatics Assessment<br />The focus is on clinical operations and how other business and systems elements interact with the clinical patient care environment<br />Systems Operations + Clinical/Business Operations = Potential Software Product and Project Effectiveness?<br />Consider how end-user usability plays into the product<br />The net result is a focus on assuring quality patient care while assuring efficient use of clinical informatics solutions.<br />7<br />
  8. 8. Factors to considerwhen building your CIA plan<br />It’s a Business Process but the Patient Comes First!<br />ROI is a relative factor in the business model, so consider hard and soft ROIs to prove your point<br />The depth of the process is relative to the complexity of the project<br />Marketing concepts apply too… Your patient is your client, the provider may be your client, and who else is your client…<br />8<br />
  9. 9. 9<br />Who benefits from CIA<br />The Patient!<br />Clinical needs are considered throughout the process<br />The Business<br />Business process and ROI is considered<br />The Clinical Realm<br />The needs for the clinical providers is recognized and built into the IT processes, as opposed to the clinical world having to “adapt” to the IT product.<br />
  10. 10. 10<br />How do YOU boil water?<br />Exercise:<br />Define the workflow for boiling water.<br />Goal: A cup of hot water<br />Please number each step you identify<br />
  11. 11. 11<br />How do YOU boil water?<br />Exercise:<br />Who thinks they “nailed” it?<br />Let’s review the results<br />Share your details with a person next to you.<br />Compare your results, how far apart are they?<br />
  12. 12. 12<br />Think Playwright<br />Writing a workflow is like writing a script.<br />You have:<br />A Plot<br />What needs to happen – Goal of the flow<br />Actors<br />Elements in the workflow; staff, equipment, policies etc..<br />Actions<br />What the actors are doing<br />Plot Twists<br />Decisions that are made<br />
  13. 13. 13<br />Test the Workflow<br />Reenactment<br />What’s our “plot” (Goal)<br />Select the cast while we walk through the workflow<br />Actors<br />Actions<br />Decisions<br />
  14. 14. 14<br />Assess, Intervene, Reassess<br />What we just did was “audit and review” a WF an Identified problems to correct.<br />Aka – Shadow assessment of a workflow<br />This is a common clinical nursing process…<br />We always<br />Assess the patient<br />Intervene if necessary<br />Reassess each intervention<br />It’s no different when building a workflow<br />Assess the current workflow you’ve documented<br />Intervene to correct problems<br />Reassess the workflow and see if it now matches your real process<br />
  15. 15. 15<br />How do YOU boil water?<br />Simple Answer<br />Fill Kettle with cold water <br />Turn on Kettle<br />Wait for water to boil<br />
  16. 16. 16<br />Boiling Water Workflow<br />What if we broke it down even more?<br />Simply adding water to the kettle can be more complex<br />Take Kettle to Sink<br />Turn on Cold Tap<br />Open Kettle<br />Move Kettle Under Tap<br />Wait for Kettle to Fill<br />Turn off Tap<br />Return Kettle to Work surface<br />
  17. 17. 17<br />Boiling Water Workflow<br />And… even more.<br />How do we turn on a faucet?<br />Grasp the tap mechanism <br />Turn mechanism clockwise <br />Wait until water pressure is high enough <br />Stop Turning mechanism <br />
  18. 18. 18<br />Boiling Water Workflow<br />Now bring it all together:<br />Fill Kettle with cold water<br />Take Kettle to Sink<br />Pick up kettle<br />Extend arm…(more)<br />Walk to sink<br />Turn on Cold Tap<br />Grasp the tap mechanism <br />Turn mechanism clockwise <br />Wait until water pressure is high enough <br />Stop Turning mechanism<br />
  19. 19. 19<br />Boiling Water Workflow<br />What are the exercise conclusions?<br />Don’t ask Ed to make you a cup of hot water<br />Workflows are everywhere<br />Workflows can be “considered complete” at almost any stage and any degree of complexity<br />It’s up to the clinical informatics person to assure that patient care and business needs are met<br />
  20. 20. 20<br />Workflow Complexity<br />Complexity varies based on the need of the audience<br />Here’s where some typical clinical “assessment” and critical thinking aspects come into play.<br />Who’s your audience?<br />What do they need to know?<br />What will they be doing with the information?<br />Where will this be used?<br />When will they need it defined?<br />When will it need to be updated?<br />Why do they need it documented and defined?<br />How does this play a role in the patient care and business processes?<br />
  21. 21. Workflow States<br />Current<br />Original<br />Future<br />
  22. 22. 22<br />“Current State”<br />The exercise we just went through was a “current state” definition process<br />We defined the current operational state for a process… “boiling water to fill a cup”<br />The typical next step is “future state”<br />I disagree<br />
  23. 23. 23<br />What’s Original State<br />You’ll note that in the earlier “boiling water” exercise we didn’t consult any policy manual or printed instruction.<br />We all know that the way something was “originally intended” to work as been modified by those doing the task. Sometimes that modification is dramatic.<br />Original State: is going back to the “stone age” of process<br />The way it was originally intended to be done<br />e.g. Boiling water with fire!<br />
  24. 24. 24<br />Original State Integration Decisions<br />Review the original policy manual<br />Determine how far from the documented current state the original state is.<br />Decide if there is a need to change the “current state” or change the “original state” (e.g. update the policy)<br />If the policy needs to be updated, you might as well wait until after the “future state” is defined<br />Decide if there is a need to integrate the two<br />
  25. 25. 25<br />Problem, Action and Response<br />Another nursing clinical action plays a role in assessing Current and Original State: Identify the Problem, Document the Required Action and Response<br />Does the miss match of “original” and “current state” cause a problem for operations today and/or in your future?<br />What action do you need to take now, if any?<br />What will staff and management response be?<br />
  26. 26. 26<br />Future State<br />What you just developed is the Future State<br />When defining your future you have flexibility within the parameters of the software application<br />You need to make sure you understand the potential and assess and test your theoretic ideas<br />
  27. 27. 27<br />Future State Design Principles<br /><ul><li>Support evidence-based care guidelines
  28. 28. Reduce duplication of effort and data
  29. 29. Enhance access to care information
  30. 30. Facilitate collaboration and communication among care providers
  31. 31. Support timely clinical decision support
  32. 32. Reduce variability of care
  33. 33. Drive measurable improvements in quality and safety
  34. 34. Support continuity of care across the continuum of services and settings
  35. 35. Support interdisciplinary care and model of collaborative practice</li></ul>Compliments of Dearborn Advisors<br />
  36. 36. Future State Design Sessions<br />Future State<br />Integration <br />& Signoff<br />Future State<br />Discovery<br />Future State<br />Validation<br />Future State<br />Consensus<br />Current State<br />Confirmation<br />Facilitated<br />Session<br />Work Group<br />Session<br />Facilitated<br />Session<br />Facilitated<br />Session(s)<br />Nursing<br />Facilitated<br />Session<br />Work Group<br />Session<br />Facilitated<br />Session<br />Facilitated<br />Session(s)<br />Facilitated<br />Session<br />Pharmacy<br />Facilitated<br />Session<br />Facilitated<br />Session<br />Facilitated<br />Session(s)<br />Work Group<br />Session<br />Physicians<br />Workflow Redesign Management and Coordination<br />Compliments of Dearborn Advisors<br />28<br />
  37. 37. 29<br />Documentation Process<br />Outline format<br />PowerPoint<br />Pen and Paper<br />“Flow” tools<br />Visio<br />RF Flow<br />etc<br />
  38. 38. Cross Functional Flowsheet<br />Primary Actors for one WF:<br /><ul><li>ED Providers
  39. 39. ED Staff
  40. 40. ED Nurse
  41. 41. Admitting
  42. 42. Bed Management
  43. 43. Receiving
  44. 44. In Patient, & Surgical Services
  45. 45. “other”</li></ul>30<br />
  46. 46. Example of aSimple Swim Lane Flow<br />Send the Patient Home<br />31<br />
  47. 47. Same “Plot” but anIntegrated Workflow<br />Send the Patient Home<br />32<br />
  48. 48. 33<br />Previously Separate Variable<br />Discharge to In-Patient<br />
  49. 49. Specific Factor flow<br />
  50. 50. Defining Workflow by Categoryin Your Organization<br />Functional Systems Workflows<br />How the software system will function in the work process<br />“Click here, then enter this, and drag that”<br />Business Operational Workflows<br />How the business (patient care and operations business) model operates and physically gets executed<br />“Go down the hall, make a left, pick up the form, and complete”<br />Integrated Workflows<br />Integrated Department<br />Integrated Software modules<br />Integrated systems and operations workflows as one.<br />Touch Points<br />Where Operational and Systems “bump” into one another<br />35<br />
  51. 51. 36<br />Example of Integrated Workflow<br />Order for CBC<br />Order placed in System by MD<br />RN acknowledges order in system and notes it is a “nurse draw” <br />Print lab specimen label<br />Obtain blood collection supplies<br />Draw Blood using hospital procedure 554.123<br />Affix completed labels<br />Tube to Lab using hospital procedure 554.124<br />Indicate in system blood drawn and to lab<br />Wait for results in system<br />
  52. 52. Example of Integrated Workflow<br />Order for CBC<br />Order placed in System by MD<br />RN acknowledges order in system and notes it is a “nurse draw” <br />Print lab specimen label<br />Obtain blood collection supplies<br />Draw Blood using hospital procedure 554.123<br />Affix completed labels<br />Tube to Lab using hospital procedure 554.124<br />Indicate in system blood drawn and to lab<br />Wait for results in system<br />TP<br />OP<br />SYS<br />OP<br />OP<br />OP<br />OP<br />TP<br />SYS<br />TP<br />OP<br />37<br />
  53. 53. Cognitive Cluster<br />A growing trend in “micro time decision process” documentation<br />Workflows are relatively linear and Mind Maps® are not often structured enough for application development<br />A cognitive cluster (CC) enables a way to demonstrate same time sequence decision processes<br />It is not a “cheat” for singular thought processes<br />
  54. 54. Simple Cluster<br />This simple cluster demonstrates a relatively simple 3 part question<br />
  55. 55. Complex Cognitive Clusters<br />
  56. 56. Complex Cognitive Clusters<br /><ul><li>There are times when a cluster is a “micro time decision process” so complex it can only be handled by the “human cognitive process” due to the multitude of immediate decisions</li></li></ul><li>42<br />Questions?<br />Remember a copy of this presentation is available online at<br /><br />