1.2 workflow and_process_redesign

HIT Toolkit
Workflow and Process
Redesign
Health Information
Technology Toolkit
for Critical Access
and Small Hospitals
http://www.stratishealth.org/HIT_Toolkit_hospitals

Presenter
• Margret Amatayakul
RHIA, CHPS, CPHIT, CPEHR, FHIMSS
President, MargretA Consulting, LLC
Schaumburg, IL
• Independent consultant, who focuses on achieving value from
electronic health records, HIPAA/HITECH, and health information
exchange. Developer of tools in Toolkit
• Adjunct faculty College of St. Scholastica, Duluth, MN, masters
program in health informatics
• Founder and former executive director Computer-based Patient
Record Institute, associate executive director AHIMA, associate
professor University of Illinois
• Active participant in standards development, former HIMSS BOD,
and co-founder of and faculty for Health IT Certification
2

Stratis Health
3
● Stratis Health is a nonprofit organization that leads
collaboration and innovation in health care quality
and safety, and serves as a trusted expert in
facilitating improvement for people and communities
● Stratis Health works toward its mission through
initiatives funded by federal and state government
contracts, and community and foundation grants,
including serving as Minnesota’s Medicare Quality
Improvement Organization (QIO)
● Stratis Health operates the Health Information
Technology Services Center for health care
organizations seeking to use health information
technology in support of their clinical transformation

Agenda
• Purpose of Workflow and Process Redesign
• Steps in Workflow and Process Redesign
• Workflows and processes to map
• Performing workflow and process mapping
• Critical success factors in workflow and
process mapping
4

Purpose: Create Ah Ha! Moments
• Workflow and process redesign
– Starts the process of identifying improvement
opportunities with HIT
– Helps users identify solutions for current problems
and today’s workarounds that will form the functional
requirements for your HIT
– Aids in setting expectations for achieving HIT goals
because users will now expect to see improvements
– Ensures that critical controls built into current
processes are retained or enhanced
5
Software
that directs
computer
devices
People
to support
and use
systems
Policy
that drives
adoption of
systems
Hardware
that enables
system use
Process
that helps
achieve
results
Copyright © 2009, MargretA Consulting, LLC. Used with permission of author.

Copyright © 2007-8, MargretA Consulting, LLC. Used with permission of the author.
Workflow and Process
• Process is the manner in which
work to be completed to achieve a
particular result is performed
– Example: Do you always verify
the timeliness of medication
administration?
• Work flow is the sequence of
steps and hand-offs taken within a
process
– Example: Is information
available to schedule patients for
labs in advance of a clinic visit?
• Workflow and process
mapping depicts the detailed
nature of the processes and
workflow to enable improvements
Five Rights for Right EHR
● Right clinical data
● Right presentation
● Right decision
● Right work processes
● Right outcomes

EHR is Not about Automating Charts
7
“Only automating form, content, and procedures of current patient records will
perpetuate their deficiencies and be insufficient to meet emerging user needs”
EHR is about automating & using
information to improve health care
EHRs “encompass a broader view of the record than today, moving from
notion of location for keeping track of patient care events to a resource
with much enhanced utility” Institute of Medicine, 1991
≠
Copyright © 2009, MargretA Consulting, LLC. Used with permission of author.

Steps in Mapping Current Processes
8
1. Identify processes to be mapped; e.g., those that will be impacted
by the HIT being acquired
2. Use individuals who actually perform the process; they know it
best and need to own the impending change
3. Instruct persons on process mapping – why it is being done and
how it is done
4. Map current processes. Avoid identifying opportunities for
improvement now, or critical controls built into current processes
may be overlooked
5. Validate maps to ensure they reflect current processes, all
variations, and the information payload
6. Collect all forms and reports that are part of processes to be
automated through HIT
7. Obtain benchmark data to define expectations for change
and for use in benefits realization studies

Steps in Redesign
8. Identify potential problems in current workflows and processes
and determine their root cause
9. Identify changes that may resolve problems today
10. Educate about HIT and EHR and identify further changes that
will be possible
11. Document changes by creating improved map
12. Use new processes to create use case scenarios to identify
HIT functional specifications, and later to build out the HIT
application to achieve improvements
13. Test new workflows and processes
14. Train all on new workflows and processes
15. Incorporate changes into policy and procedure
16. Conduct benefits realization and celebrate successful
change/correct course as necessary
9

What to Map
in Hospitals in Clinics
• Admission
• Medications reconciliation
• H&P/results review/differential
diagnosis
• Patient assessment
• Care planning/pathways
• Provider orders
• Consultation management
• Patient monitoring and charting
• Medication administration
• Surgery/recovery
• Transfer of care/care coordination
• Discharge/patient instructions
• Charge capture/coding
• Reporting/quality improvement
• Departmental operations
• Scheduling/check-in and check-out
• Patient intake
• Results review
• H&P/encounter notes
• Care planning/guidelines
• Medication management: medication
list maintenance/ prescribing/refills
• Provider orders
• E&M coding
• Charge capture
• Patient instructions/education
• Patient follow up/health maintenance
• Reporting/quality improvement

• Process diagram
• Swim lane process chart
• Flow process chart
• Systems flow chart
• Software is available to
aid in drawing charts, if
desired
Select Tools

Basic Systems Flow Chart
• Ovals – start and end
• Rectangles – process
• Diamonds – decision
Used with permission from P. S. Rudie Associates, Duluth, MN
Robert McDonald, MD and Mary Rapps

Annotating Processes
Courtesy of Dr. Hinck, Bloomington Lake Clinic,
Minneapolis, MN
• It may be helpful to capture components of processes and
workflows by simply making a list of all processes, or
• Use post-it notes to record processes as they are
performed and then arrange them on a wall or
large piece of (e.g., examining room) paper
● Process mapping is not new,
and not even new to health
care, but process mapping is
foreign to clinicians
● Engaging clinicians, however,
is critical because EHRs are
designed for their use. It may
be necessary to start a map
for them and have them
validate it – Real clinicians
really do map!

Getting Started
• Identify one complete
process – neither to
large or to small
• Identify all potential
starting points
• Follow each to its
natural conclusion
• Significant delays can
be annotated to the
side if desired
Refill Processing
No
Yes
Place in
MD Box
Patient
Calls
Ask Pt to Call
Pharmacy
End
Chart
Reviewed
Write Rx &
Give to Pt
Document in
chart
End
Ave
1 hr
Ave
2 hr
Pharmacy
Calls
Request chart
Review chart
Nurse
OK?
Call Pharmacy
Document in
chart
End
No
Yes
Document
In chart
Speak to
Nurse
OK?

Reflect
Variations
• Medication
administration
in a critical
access hospital
with five nurses
administering
medications
• Some
processes can
be corrected
immediately;
others will
depend on
acquiring an
EMAR

Validate Process Maps
• Initial pass at a swim lane map (clinic example):
• Map after
validation:
Document
RFV on Post-it
Throw Post-it
away

Identify (Potential) Problems
• Review
current maps
to identify:
– Bottlenecks
– Sources of delay
– Rework due to
errors
– Role ambiguity
– Duplications
– Unnecessary
steps
– Cycle time
• Flow process charts help identify
– Nature of tasks
– Key questions

Determine Root Cause
• Use complementary
tools as needed
– Statistical charts
• Radar
• Pareto
– Relations diagrams
– Tree diagram
– Affinity diagram
• Force field analysis
– Cause & effect diagrams
– Physical Layouts
A
B

Critical Success Factors
• Map processes that will be impacted by HIT, unless other reason for
process improvement
• Engage persons actually performing the process. Leave bias and
blame at the door – reward those who find the most warts!
• Avoid getting ahead of mapping current processes, but make sure
they are complete and address the information flow – remember,
information is being automated, not the staff member or the patient
• Get to the root cause of problems when looking for improvements.
Address immediate opportunities; use others as key functional
requirements for your HIT
• Use workflow and process mapping to create Ah ha! moments that
initiate the change process. Follow up that changes are adopted
and celebrate success once change is implemented

For More Support
• Contact:
Stratis Health
2901 Metro Dr., Suite 400
Bloomington, MN 55425
952-854-3306
1-877-787-2847 (toll free)
www.stratishealth.org
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