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Final presentation - workflow design and management
1. RECIPES FOR SUCCESS IN
CLINICAL WORKFLOW
MANAGEMENT
Andrea Hoffman, RN
R. Dirk Stanley, MD MPH
2. WHO WE ARE
Andrea Hoffman, RN – Nurse Informaticist who specializes in
clinical workflow design and informatics support. Design influences =
Masaharu Morimoto, Axel Erlandson, Satoshi Kurosaki
R. Dirk Stanley, MD MPH – Former CMIO and board-certified
clinical informaticist who specializes in clinical workflow design and
informatics development. Design influences = Lego, Ikea, Bauhaus, Jony
Ive, Linus Torvalds, Gordon Ramsey
3. WHAT WE DO
Promote education about front-line clinical informatics,
clinical decision support, patient safety, and good workflow
design
• Leverage common analogies as educational tools : Movies, food,
music, etc.
• “Turning marshmallows into Legos”
Passionate about developing gourmet workflows.
• If it looks and smells like french fries, people will eat them.
5. MAKING A GOOD MEAL
… You will always need five things :
A good chef
Great ingredients
A kitchen
A good recipe
Adequate time
6. MAKING A GOOD WORKFLOW
… You will always need five things :
A good chef (Informaticist(s))
Great ingredients (standards, archetypes, templates, and
documents)
A kitchen (archetype management, document management,
project management, project team, effective governance, and
resources)
A good recipe (identifying stakeholders, current state, future
state, project plan development)
Adequate time (execution of project plan)
7. TODAY’S MENU
1. THE CHEF
2. THE INGREDIENTS
3. THE RECIPE
4. THE KITCHEN
5. THE TIME
9. THE CHEF
What are Clinical Informaticists?
• Informatics = Broad, emerging field
• Patient, broad skill set, politically neutral, high tolerance for ambiguity
• HR Nomenclature challenges : “Workflow analyst”, “Clinical Systems
Engineer”, “Knowledge Engineer”, “Clinical Project Manager”, etc.
• FUTURE : Increasing formal training (certificates, boards, PMP)
• FUTURE : Increasing use of term “Informatics”
• FUTURE : Increasing embedded role in clinical areas (embedded
nurse/physician informaticists) as SMEs / change leaders / support
• FUTURE : Wider distribution of informatics skills and terminology
11. THE INGREDIENTS
To make a good meal, you need quality ingredients.
To have quality ingredients, you need standards!
• In baking = Flour, sugar, salt, kilograms, pounds, cups, degrees, minutes
• In Informatics = Policies, procedures, guidelines, orders, order sets, protocols,
clinical pathways, documentation, checklists, alerts, budgets
How to make a standard document = archetype development!
Archetypes should be designed so form serves function
• What is it called? And what does it do?
12. THE INGREDIENTS
1. Telephone Numbers = Tools to contact a person
2. Emails, Screen Savers, and Posters = Tools to help send a short
message
3. Schedules = Tools to show who is responsible at what date/time
4. Policies and Procedures = Tools to learn organizational standards and
how to achieve them (HELPFUL TIP : Procedures are workflows –
Or are they?)
5. Guidelines = Tools to help educate and guide staff towards a desirable
outcome
6. Documentation = Tools to record and transmit information
13. THE INGREDIENTS
7. Orders = Tools to document and transmit instructions to deliver care
8. Order Sets = Collections of orders used to standardize and expedite the
ordering process for a common clinical scenario
9. Clinical Pathways = Collections of order sets used to standardize care
for a common clinical condition
10. Alerts = Tools to help communicate and document a unique issue
11. Clinical Protocols = Tools to standardize and automate a clinical
process
12. Education Modules = Tools to help educate patients / staff
13. Dashboards / Reports = Tools to help measure or monitor something
14. Templates = Tools to help create a standardized document
14. THE INGREDIENTS
15. Wikis= Tools to organize information / links for a department
16. Committee Charters = Tools to assign a committee duties and
responsibilities
17. Committee Minutes = Tools to document committee activities
18. Glossary of Terms = Tool to learn organizational definitions for
common terms
19. Budgets = Tools used to plan for future resources
15. THE INGREDIENTS
Standardized templates need to be developed from these archetypes!
Documents need to be built from these standardized templates!
Why is this important?
• Effectiveness of these tools will depend on their clarity!
• Good project planning will depend on good understanding of the
development of these tools!
• Timing of projects will depend on processes used to develop, review, approve,
and publish these tools!
• Good opportunity to streamline governance and development!
16. THE INGREDIENTS
Q : Why are archetypes and documents important in developing
workflows? A : Archetypes Templates Documents Workflows
17. THE INGREDIENTS
Why are archetypes and documents important in developing
workflows? Archetypes Documents Workflows
18. THE INGREDIENTS
Common paper workflow issue : The “Frankenform”
E.g. Part order, part order set, part guideline, part documentation,
part policy, etc.
Creates extra maintenance costs and delays
Often masks workflow issues (The “Frankenflow”)
Symptoms : Unusually long documents / order sets, clunky
workflows, or paper forms that are difficult to “make electronic”
Commonly seen in complex clinical workflows, e.g. Medication
reconciliation, Medication titration, chemotherapy, etc.
Solution : Workflow redesign!
20. THE KITCHEN
The archetype management
• Need to manage centrally, with organizational buy-in, easily accessible to everyone in
the organization
The document management
• Need to manage centrally, with organizational buy-in, easily accessible to everyone in
the organization
The project management
• Need to manage in a standardized fashion, with standardized templates and
organizational buy-in
The staff participation
• Need to identify stakeholders and SMEs effectively, and budget time/resources
properly
• Familiarity comes from working on projects together (to understand roles)
21. THE KITCHEN
The governance
• The stakeholder development, teambuilding, resource allocation, and project
timelines will all depend on the organizational governance
• Tip : This is a good opportunity to streamline governance!
• OLD : Order set committee? Policy committee? Forms Committee?
• NEW : Project prioritization committee, Resource allocation committee, Go-Live
Committee, Project Management Office
23. THE RECIPE
To develop a good recipe, a skilled chef needs good communication :
• What does the customer want? Mac & cheese? Filet mignon? Beef Wellington?
To develop a good project plan, a skilled informaticist also needs good
communication :
What is the goal, and how does the order relate to the goal? Maintenance
request? Change request? Large-scale project? Before deciding, will need to
know regulations, stakeholders, evidence/literature, current state, future
state, cost data
24. THE RECIPE
After thoroughly understanding regulations, goals, needs, and costs -
will need to build a good project plan :
1. PREPARATION
1. Literature / regulatory search
2. Current / Future workflow mapping
3. Project planning, stakeholder development, securing resources
2. DRAFTING (with low-level end-user buy-in)
3. BUILDING (both electronic and paper downtime!)
4. TESTING (Unit, Functional, Integrated, and End-user acceptance)
5. TRAINING
6. DEPLOYMENT
7. MONITORING
26. THE TIME
Set realistic expectations - Important to follow good project planning!
1. PREPARATION :
• Regulatory / Literature Search (including cost data)
• Indexing of needs
• Development of List of Stakeholders
• Development of Project Team
• Mapping of CURRENT state workflows (Hint : See procedures!)
• Development of FUTURE State workflows
• Development of Project Plan and Timelines
• Securing stakeholder buy-in
• Securing time/resources for project
27. THE TIME
2. DRAFTING BLUEPRINTS – Future state workflow(s) with supporting tools
a. Low-level testing with end-users for clinical validation (user acceptance testing)
b. Securing stakeholder buy-in
3. BUILDING :
a. electronic tools and supporting documents
b. paper downtime processes (order sets AND documentation!)
4. TESTING :
a. Unit testing
b. Functional and Integrated Testing
c. End-User Testing
5. SECURING APPROVAL :
a. Governance is important!
28. THE TIME
8. EDUCATION :
a. Adequate education for go-live – What is audience? How much is enough?
b. Big question : Does this need to be added to ongoing educational effort?
(For onboarding of new employees?)
c. FUTURE : Likely 16+ hours of computer training per new employee
9. GO-LIVE :
a. Adequate support? Superusers? Do superusers still have patient assignments?
Other elbow-to-elbow support?
b. List of showstoppers for patient safety?
10. MONITORING :
a. Issues Log
b. Standard way to communicate changes and issues with end-users (2-way
communication)
29. DESSERT
Good meals come from :
• A good chef (Informaticist(s))
• Great ingredients (standards, archetypes, templates, and
documents)
• A good kitchen (archetype management, document
management, project management, project team, effective
governance, and resources)
• A good recipe (identifying stakeholders, current state,
future state, project plan development)
• Adequate time (execution of project plan)