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CPOE UnivErsity
Dan Morgenstern, MD, MBA
Principal
Computer Sciences Corporation
Clinical Workflow Analysis - Process
Defect Identification
A CSC Clinical Excellence Service Offering
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to future state – “defect free”
Discussion
Agenda
3
Who am I?
4
Who am I?
• Dan Morgenstern, MD, MBA– MD, Albert Einstein College of Medicine
• 25 years of practice:» Private solo as well as group» Academic – US, Israel» Cardiac, thoracic, vascular, trauma and general surgery,
wound care– “Recipient” of a failed Hospital Clinical Information System
Installation - twice– MBA, Auburn University-Montgomery Al
• Major course of study: Information Systems– Left practice in 2003 – result of the malpractice crisis– Health Care Consulting since September, 2003
• Clinical Transformation• Workflow Process Analysis and Redesign• Clinical Master Plan Development• Medical and Clinical Staff Education• Clinical Issues Resolution, Implementation Support (go-live)• Vendor Selection Assistance• Clinical Content Development• Physician/Clinician Adoption
5
Who are you?
• Name
• Practice specialty
• Institution
• Role in your institution’s CPOE project
• How did a nice guy/gal like you end up in a place like this?
• Your goals for this session
6
What are We Here to Do?
• Understand what is meant by a defect in a workflow process
• Identify characteristics of a step or task in clinical care that constitute a defect
• Recognize them in clinical workflow
• Classify the defects
• Prioritize them – with appropriate input from a SME (Subject Matter Expert) as needed
• Use them as a guide in designing the “future state”
IntroductionBrief review of workflow analysis conceptsDefinition of defectsDefinition of clinical process defectsIdentification of clinical process defectsClassification of clinical process defectsExamples of defects in clinical workflowMoving from present state with defects to
future state – “defect free”Discussion
Agenda
8
What is Clinical Workflow?
• Our proposed definition– Clinical Workflow is an established
process describing• A series of tasks• How they are accomplished• By whom• In what sequence• At what priority
that accomplishes a defined step in an activity in the clinical care of patients
9
What is Clinical Workflow?
CLINICAL PATIENT CARE
ACTIVITIES
STEPS
TASKS
10
Standard Activities and Steps in Clinical Patient-Care• Examples of activities in clinical care:
– Hospital rounds– Pre-op/pre-procedure preparation of a patient– Admission, Discharge
• Examples of steps in clinical care:– Patient Evaluation
• Initial = admission• Subsequent
» Daily rounds» Transfer» Discharge
– Consultation (patient evaluation specific toexpertise/problem)
– Bedside Procedures– Specialized Procedures
CLINICAL PATIENT CARE
ACTIVITIES
STEPS
TASKS
11
Standard Tasks in Clinical Patient-Care• Locate Patient
• Gather Data
• Evaluate Data
• Examine Patient
• Synthesize Data and Examination
• Determine Next Step in Patient Care
• Document Findings and Decisions
• Direct Care of patient – Clinical Orders
• Perform Procedures as Needed
CLINICAL PATIENT CARE
ACTIVITIES
STEPS
TASKS
12
Standard Tasks in ClinicalPatient-Care
Locate PatientMaintain Patient List
• Gather Data– Visual
• Radiography• All manner of
“graphics”: EKG, EEG, EMG
• Examine specimens and microscope slides
– Aural• “Sound images”:
ultrasound, Doppler
• Gather Data– Written
• Reports• Notes in chart• Tabulated numerical
data– Oral
• Talk to colleagues• Talk to nurses,
therapists, etc
13
Example of Standard ShapesDictionary
14
Example of Standard ShapesDictionary
Flowchart Reviewing Guide – Follow the Steps Described Below
Prep
arat
ion
Valid
atio
nCurrent-State Workflow Project
Flowchart Validation Guide
TerminatorThe beginning or end of a process
Process StepA plain box
represents any general step in a
process
DecisionA decision point
where the process
branches
DocumentA task that centers around a piece of
paper
ComputerA task directly involving user interaction with a
computer system
Automatic Process
A process entirely computer controlled
Off-Page Connector(outbound)
Off-Page Connector indicating that the flow continues to another tab in the same file.
This is a Call-OutUsed to add information to a task, such as:Arrows are used to connect tasks that are
related. The arrowhead shows the direction of process flow.
No
Yes
Yes
No
Begin Process
Follow one branch of the decision at a time,
marking your path using the highlighter. Make
sure you come back and follow the other branch.
Have your flowchart print out ready for review.
Are there decisions in the
flow?
Write any corrections on the
flowchart.
Print the flowcharts you are
reviewing
Find a highlighter or colored pen.
End
Follow the steps on the flowchart (each will be a
decision point):1. Are the tasks correct?
2. Are they in the correct order?3. Are any important steps left
out?
Off-Page Connector(inbound)
Off-Page connector indicating that a flow represents the continuation from
another tab in the same file
AA
On-Page connector which flows from and to connector with same letter. These are used when drawing lines from one box to another would cause the lines to criss-cross possibly causing confusion. Process Name
“Hot Link” indicates a link to a separate process that continues the normal flow of work
Parallel Processes. Steps within these lines happen at the same time or independently from one another.
15
Standard Shapes Dictionary
• Process Step: Any general, manual step in a process
• Paper Document: Any task centered around the use of paper
Paper Document
Process Step
Manual Interface with a
Computer
• Manual Interface with a Computer: Any manual input, output or interaction with a computer system
16
Standard Shapes Dictionary
• Automatic Process: Automatic step that requires no direct human input; entirely computer driven
• Decision Point: Branching of the process due to a pair of alternatives
• Terminator: The start or end of any process
Automatic Process
Decision Point
Terminator
17
Standard Shapes Dictionary
• On-Page Connector: Allows flow of a process on the same page without needless clutter or confusion of crossing of lines
• Off-Page Connector (outbound): Indicates that the flow continues on another tab in the same file
• Off-Page Connector (inbound): Indicates that the flow is the continuation of another tab in the same file
On-Page Connector
Off-Page Connector (outbound)
Off-Page Connector(inbound)
18
Standard Shapes Dictionary
• Dynamic Connector: Connects two steps in a process
• Parallel Mode: Two steps that take place independently but simultaneously
• Call-Out Note: Used to supply additional information about a step or supply information that is not strictly speaking a process step
Call Out Note
19
Standard Shapes Dictionary
• Hyperlink Process: “Hot Link” to another process that continues the “clinical flow” of work
Hyperlink Process
Swim Lanes
Ancil
lary/C
lerk
Nursi
ngPh
ysici
an
• Swim Lane Format: Allows role segregation while showing step relations and interactions during the process
IntroductionBrief review of workflow analysis conceptsDefinition of defectsDefinition of clinical process defectsIdentification of clinical process defectsClassification of clinical process defectsExamples of defects in clinical workflowMoving from present state with defects to
future state – “defect free”Discussion
Agenda
21
Definition of Defects
• Definitions– Nonconformance to requirements or
functional / program specification – A blemish, imperfection or deficiency
that impairs worth or utility – The non-fulfillment of intended usage
requirements – Any abnormality lowering the value of a product no matter
why, when, or how it developed– An imperfection which, if great enough, can prevent an item
from working properly or being usable– A lack of something necessary for completeness, adequacy,
or perfection
22
Defects, Warranties,Guarantees, Remedies• In commercial and consumer transactions, an obligation that
an article or service sold is as factually stated or legally implied by the seller, and that often provides for a specific remedy such as repair or replacement in the event the article or service fails to meet the warranty
• In business and legal transactions, a warranty is an assurance by one party to the other party that certain facts or conditions are true or will happen; the other party is permitted to rely on that assurance and seek some type of remedy if it is not true or followed
23
Defects, Warranties,Guarantees, Remedies• In medicine, there are:
– No warranties – we never get the “Specs” on an individual– No guarantees – we don’t have the owner’s manual
• Of course, there are also – No restocking fees– No in store-credits
• It matters little if you have the receipt, you probably cannot get your appendix, pneumonia or gallstones back
24
Clinical Work and World View
• Human mistakes are not just “oops” moments
• Technology glitches are not just aggravating, inefficient or even infuriating
• Errors and “bugs” really kill people
• In business, if you fail→ you lose money
• In engineering, if you fail → things don’t work
• In medicine, if you fail → patients die
IntroductionBrief review of workflow analysis conceptsDefinition of defectsDefinition of clinical process defectsIdentification of clinical process defectsClassification of clinical process defectsExamples of defects in clinical workflowMoving from present state with defects to
future state – “defect free”Discussion
Agenda
26
Clinical Process Defects
• Not all errors and bugs kill people
• However, the domino effect in clinical care is significant
• Inefficiencies, redundancies, bottlenecks, errors– Slow down processes – and progress– Impede task completion– Reduce quality of care– Result in “unintended consequences”– Facilitate poor outcomes
• None of these are desirable when life hangs in the balance.
• Life ALWAYS hangs in the balance in healthcare –sometimes obviously, sometimes subtly
27
Definition of Clinical Process Defect• A defect in a clinical process is the
characteristic of a step or task in clinical care that– Introduces unwanted and unnecessary
redundancy– Impedes or blocks flow of required
information– Delays completion of a task or step– Necessitates needless clinical decisions and tradeoffs– Results in clinically indefensible variation– Precludes successful completion of a clinical care process– Exposes the patient or the clinical care team to
unnecessary risk
28
Definition of Clinical Process Defect• Examples:
– Introduces unwanted and unnecessary redundancy• Multiple entries of same information
– Impedes or blocks flow of required information• Clinical results not available when needed
– Delays completion of a task or step• Procedure prolonged because of poor equipment
maintenance– Necessitates needless clinical decisions and tradeoffs
• Inventory mismanagement necessitates choice between lesser quality prosthesis
– Results in clinically indefensible variation• Unavailability of correct therapeutic agent (drug, therapy,
site of care)
29
Definition of Clinical Process Defect• Examples:
– Precludes successful completion of a clinical care process• Clinical data (films, cines, angios) misplaced, miscatalogued
– Exposes the patient or the clinical care team to unnecessary risk• Patient HIV status not communicated due to information
mishandling
30
Definition of Clinical Process Defect• Note:
– We are talking about defects in process– We are not talking about defects in reasoning, care or outcome
• Mistaking a pleural effusion for an organized empyema on an x-ray may be an error» Treating the patient as such because the x-ray or its report
is not obtainable is a process defect• Choosing the wrong antibiotic may be an error
» It becomes a process defect when the culture and sensitivity is not obtainable at the appropriate time
• An untoward outcome is not necessarily indicative of a process defect» A post-op wound dehiscence may be indicative of an error» A post op wound dehiscence after-unavailability of
retention sutures represents a process defect
31
Definition of Clinical Process Defect• It is obvious from definition and examples that there are a lot of
“defects” in clinical processes
• Most are relatively innocuous and result in – Irritating delay– Needless inefficiency– Aggravating duplication
• Workflow analysis and defect recognition are powerful tools that will help identify them all
• Process redesign – independent of technology – will help reduce the number and severity of defects
• Many – but not all - can be eliminated by technology
32
Definition of Clinical Process Defect• All need to be eliminated by constant refocus on process and
analysis– These tools can and should become a permanent part of good
clinical care quality assurance
• By understanding and perfecting the “process” we can free clinical minds to concentrate on– Patient care– Excellent results
33
Identify Defects in this O.R. Scenario
MTC Sample Script for MD Operating Room Workflow
Identify as many defects as you can
IntroductionBrief review of workflow analysis conceptsDefinition of defectsDefinition of clinical process defectsIdentification of clinical process defectsClassification of clinical process defectsExamples of defects in clinical workflowMoving from present state with defects to
future state – “defect free”Discussion
Agenda
35
Example of Standard ShapesDictionary
36
Standard Defects Dictionary
• Bottleneck: A step dependent on scarce resources that – when triggered by a specific event - results in an overall process delay
• Redundancy: A step that duplicates information or an activity already accomplished in another step, process or system, resulting in an overall reduction in efficiency and productivity
• Human-Intense Activity: A step requiring an inordinate amount of human activity, resulting in decreased efficiency and productivity
37
Standard Defects Dictionary
• Delay: A step that is time consuming and slows down the completion of a process. The slow-down is a by-product of the activity itself, not other intervening factors
• Completion Barrier: A key step that when missed or improperly executed, prevents completion of a process or drastically impedes the ability to complete the process
• Failure Point: A step that aborts the process or represents a failure of the process
38
Standard Defects Dictionary
• Decision Point Defect: A decision point that– Does not achieve its goal– Is – or should be – unnecessary– Is reached with insufficient information– Is being made by the wrong individual– Is being made at the wrong time
• Other: Defects that fall outside above parameters, usually legal, regulatory or patient safety in nature. Each of these defects must be individually examined
39
Clinical Workflow (CWF) Defects
• There is overlap amongst the defect types
• There will be individual variation in their use and assignment
• These are suggestions– Feel free to adapt them to your own situations– Feel free to add or subtract from the list
• The key is consistency in examination of workflow and assignment of defects
• Be cognizant of the fact that certain redundancies– Are in the eye of the beholder (nurse vs. doctor vs. pharmacist)– Are there for sound clinical reasons
40
Clinical Workflow (CWF) Defects
IntroductionBrief review of workflow analysis conceptsDefinition of defectsDefinition of clinical process defectsIdentification of clinical process defectsClassification of clinical process defectsExamples of defects in clinical workflowMoving from present state with defects to
future state – “defect free”Discussion
Agenda
42
Clinical Workflow (CWF) Defects
43
Examples of CWF DefectsPhone Management Process
PAU
NUrs
ing
Center chart area – 5.5fte’s
Racked charts are called
Fill in needed informationE
E Patient answers?
Message left – recorded on chart
by date
Patient calls back? Yes Patient call
answered
Patient leaves answering
machine message
Obtain needed information
Can continue in closed loop fashion up to day afternoon
before surgery
ECan continue in closed loop fashion up to day afternoon
before surgery
No success with scheduled
calls No
E
No
Yes
Charts given to nurses in back phone room
Chart Activation Process
No
Yes
Chart Dungeon Process
Nurse preps the chart: pick
appropriate health history and med form, put stickers
on them; enter PMH etc as you have it. Look for age related EKG, allergies, get as much history as
possible
Wrong contact info due to MIS over-ride. Cannot
activate patient, enter orders, contact patient at all.
44
Examples of CWF DefectsPhone Management Process
PAU
NUrs
ing
Center chart area – 5.5fte’s
Racked charts are called
Fill in needed informationE
E Patient answers?
Message left – recorded on chart
by date
Patient calls back? Yes Patient call
answered
Patient leaves answering
machine message
Obtain needed information
Can continue in closed loop fashion up to day afternoon
before surgery
ECan continue in closed loop fashion up to day afternoon
before surgery
No success with scheduled
calls No
E
No
Yes
Charts given to nurses in back phone room
Chart Activation Process
No
Yes
Chart Dungeon Process
Nurse preps the chart: pick
appropriate health history and med form, put stickers
on them; enter PMH etc as you have it. Look for age related EKG, allergies, get as much history as
possible
Wrong contact info due to MIS over-ride. Cannot
activate patient, enter orders, contact patient at all.
45
Examples of CWF DefectsAntibiotic Protocol Process
PAU
NUrs
ing
Copy antibiotic order Place on clipboard Enter orders into
SCM
All required information available?
Allergies, height weight, etc
Surgeon known to “take care of it in the morning?”
Case cancelled
Chart to ASU
Patient allergy to ordered antibiotic?
Fax to PharmacyWrite ALLERGY on order sheet Office contacts
surgeon
Antibiotic ordered?
Procedure requires AB per
nursing experience?
Yes
No
Call surgeon’s office and obtain
orderYes
end
No
Yes
Yes Fax to surgeon’s office
No
No
A
A
No
Yes
ChartDungeonProcess
Chart to ASU
This occurs in ASU
not PAU
46
Examples of CWF DefectsAntibiotic Protocol Process
PAU
NUrs
ing
Copy antibiotic order Place on clipboard Enter orders into
SCM
All required information available?
Allergies, height weight, etc
Surgeon known to “take care of it in the morning?”
Case cancelled
Chart to ASU
Patient allergy to ordered antibiotic?
Fax to PharmacyWrite ALLERGY on order sheet Office contacts
surgeon
Antibiotic ordered?
Procedure requires AB per
nursing experience?
Yes
No
Call surgeon’s office and obtain
orderYes
end
No
Yes
Yes Fax to surgeon’s office
No
No
A
A
No
Yes
ChartDungeonProcess
Chart to ASU
This occurs in ASU
not PAU
47
Examples of CWF DefectsWB Charting Process
Othe
rW
ell B
aby N
ursin
g
O2 Saturation or Vital sign? Chart in SCM
Yes
Weight? YesChart in Weight
Book
No
Chart on NB Progress Flow
Form
Glucose?
No
Metabolic Screen?
No
Chart on Face Sheet
Discharge Form
Discharge FormYes
Hearing Screen?
No
Face SheetYes
Hearing Screen Book
No
Nurses’ NotesYes
Nurses’ Notes Discharge Form
Well BabyAdmission
& InitialAssessment
Process
Result Abnormal or
Inappropriate?Notify MD
Initiate Appropriate Protocol
Yes
WB PatientCare
Process
No
Trans Cutaneous Bilirubin
Glucose worksheet
Charge in SCM
Charge in SCM
Charge in SCMCalculate risk factor using INtrAnet tool
Chart on Discharge Form
48
Identify and Categorizethe Defects
• Find as many defects as you can in the following workflow diagrams– Physician Inpatient Evaluation Process– Physician Documentation and Ordering
Process
• Tag them according to our defect categorization
49
Physician Inpatient EvaluationProcess
Physician Inpatient Evaluation Process
Anci
llary
/Cl
erk
Nurs
ing
Phys
icia
n
Yes
No
No
Yes
No
Yes
No
No
No
Are appropriate vital signs in
chart?
Physician reviews any
outside documentation, results, films,
materials
Physician views labs, xray reports,
other documentation on SYSTEM
Review ChartAre appropriate
vital signs in chart?
Review bedside chart
Bedside chart
found?
Ask nurse
Physician reviews xrays on PACS
Patient found?
Patient needs
physician evaluation
Find CNA to locate Bedside
chart
Physician takes new readings of
vital signs himself
Try another patient /floor
Physician examines patient
Chart available?
PhysicianDocumentation andOrdering Process
Yes
Patient listed on “board” as in procedure?
Yes
Patient found?
Yes
End
Physician looks for bedside chart
ListMaintenance
Process
Old Chart Needed?
No
Old admission at present
patient campus
location?
Yes
Locate old chart in
record room and transport to patient’s
location
Yes
Telephone other campus and
request photocopy of
summaries, other documents
No
Physician looks for present- admission
patient chart
Yes
No
50
Physician Documentation andOrdering Process
Physician Documentation and Ordering Process
Anci
llary
/Cl
erk
Nurs
ing
Phys
icia
n
END
Physician documents in chart by hand
Physician PatientEvaluation Process
Dictated documentatio
n required/desired?
Physician dictates note
Orders stat, urgent or complex?
Physician finds and notifies
nurse of orders
Office documentation to be used as
inpatient documentation?
Office document placed in hospital
chart
Physician using
template on line?
Physician prints it out
Physician fills out template
Physician using email information
for documentatio
n?
Physician typing in
WORD for documentatio
n?
Yes
No
Yes
No
Yes
No
Physician documents in
WORD and prints out
documentation
Yes
Paper placed in chart
No
Physician finds email, cuts and
pastes into WORD document, prints out
documentation
Yes
No
Physician writes orders
Preprinted orders
available?
Order sets downloaded and printed or pulled from repository
Yes
NoNo
Yes
Template in StaffNet?
Yes
Look in Physician Email (adult Psych)
No
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to future state – “defect free”
Discussion
Agenda
52
What is the Process to Movefrom Present to Future State?• Map present state workflow
• Analyze present state workflow– Identify defects– Classify defects– Describe consequences
• Identify those amenable to non-technological “fixes”– Redundant documentation-form elimination– Consolidation of supplies, results– Elimination of the “reply to all” syndrome
• Information to those who need it and will act upon it– Assignment and enforcement of responsibility
• Little need to fax pre-op orders to 4 numbers in the hope one will “pick up” and keep them
– Geographical and temporal re-arrangements
53
What is the Process to Movefrom Present to Future State?• Design future state which will
– Eliminate defects– Ensure patient safety and excellent clinical results– Maximize efficiency
• Think “outside the box”– Don’t rule it out because you think it may be (or actually is)
expensive– Within reason, if Amazon.com, Burger King and the local bank
can do it, so can health care
54
Post Partum Care – MotherPresent State
Post Partum Care (Mother)
Othe
rPo
st Pa
rtum
(Mot
her)
PatientTransferProcess
Mother arrives from L&D Report given (oral)
Green sheet examined
& handed to PP Nurse
Mother admitted to unit
Transfer (mother) assessment per
protocol
Assessment charted in Post Partum Flow
record
Abnormal findings?
No
Document in Nurses’ notesYes
Perineal Care
Perineal Care Assessment Intervention as
neededDocument on PCR Document in
Nurses’ notesDocument under “interventions”
Site of documentation per nurse preference, habit
Site of documentation per nurse preference, habit
Site of documentation per nurse preference, habit
Procedure required?
IV, Bladder Scan, Catheterization
Bladder Scan?Charge in SCM
Yes
Perform ProcedureNo
RH incompatibility? Yes Rhogam
Protocol
Rhogam Protocol Enter order into
SCM
Medication arrives via “tube”
Administer medication
Patient ID on envelope containing medication
Actual Medication Vial has no Patient ID information
Chart in EMAR
Chart on Notes?Post
PartumTeaching
No
Daily Fall risk assessment
Document on Fall Risk Form
No
55
Post Partum Care – MotherFuture State
Post Partum Care (Mother)
Othe
rPo
st Pa
rtum
(Mot
her)
PatientTransferProcess
Mother arrives from L&D
Report given (oral)
Mother admitted to unit
Transfer (mother) assessment per
protocol
Perineal Care
Perineal Care Assessment Intervention as
needed
Procedure required?
IV, Bladder Scan, Catheterization
Charge in SystemYes Perform Procedure
RH incompatibility? Yes Rhogam
Protocol
Rhogam Protocol Enter order into
System
Medication arrives via “tube”
PostPartum
Teaching
No
Daily Fall risk assessment
No
Post Partum Nurse reviews record in EMR
Document in Nurses’ notes
Document in Nurses Notes
BCMA
Document in Nurses’ notes
56
Construct the Future State
• Convert the workflows you analyzed for defects into future state diagrams– Physician Inpatient Evaluation Process– Physician Documentation and Ordering
Process
57
Construct the Future State
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to future state – “defect free”
Discussion
Agenda
60
Discussion
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