Facilitating mtgs fri aft [repaired]

Fundamentals of Workflow Process Analysis and Redesign

Facilitating Meetings forImplementation Decisions

This material Comp10_Unit7 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.

Effective Meetings

3Health IT Workforce Curriculum Version 3.0/Spring 2012

Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions

Meeting

“A single effective meeting will substantiallychange the capacity of a group toachieve 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

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.



Meeting

Key Elements of Success

• Involvement of key personnel – Have thought through potential solutions– Results in ownership of ideas

• Solutions• 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



Meeting

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



Meeting

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



Meeting

Example Topics for Agenda

• Introductions

• Goal of the meeting and expected products

• Review of documentation of process analysis and redesign

• Summary & next steps



Meeting

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



Meeting

Group Decision-Making Process

• Process resulting in the selection of a course of action

• Results in a “choice”• Systems

– Consensus – Voting-based methods

• Majority required• Plurality

– Dictatorship

(Wikipedia, 2012)



Meeting

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



Meeting

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



Meeting

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

14

Health IT Workforce Curriculum Version 3.0/Spring 2012

Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation Decisions Meeting

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,

─if resources were limited, a priority for the change would be assigned.

• Review of approved changes and their priority• Next steps



Meeting

“BRAND” Change Matrix Template

PROCESS Benefits of the action

Risks of the action

Alternatives of the

prospective action

Nothing: doing nothing

at all

Decision

Process option 1:

Process option 2:

Process option 3:

7.1 Table Change Matrix Template (courtesy of Dr. Meredith Nahm, 2012)


Fundamentals of Workflow Process Analysis & Redesign Facilitating Implementation

Decisions Meeting

Fundamentals of Health Workflow Process Analysis and Redesign

Quality Improvement Methods

This material Comp10_Unit8a 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.

Quality Improvement in the Health Care Setting

• Quality Improvement – an approach to improvement of service systems and processes through the routine use of health and program data to meet patient and program needs (Chang, 1999)

• Examples of Quality Improvement Projects– Redesigning a Clinical Office – Reducing the time for patient intake– Redesigning the information flow in a laboratory– Increasing the access to care


Fundamentals of Health Workflow Process Analysis and Redesign Quality Improvement Methods

Lecture a

Three Major Concepts

1. Quality is a Measurable Phenomenon– Six dimensions : Safe, effective, timely, patient-centered,

efficient, equitable2. Safety

– Errors are definable and measurable– The right plan is defined on the basis of professional

standards– To avoid errors, you must decide on the best plan in the context of professional standards, and the plan must be executed

3. Accountability– Measurable performance with consequences– Currently lies primarily with physicians– Physicians will increasingly be held accountable for performance at the microsystem level



Lecture a

20

Plan-Do-Study-Act Cycle

Plan the Action

Do theAction

Act on theLearnings

Study theResults

This simple modelcan serve as the

foundation for every project type.

Also known as:Shewhart cycle Deming cycle Learning and improvement cycle

Organizational Culture• Quality Improvement projects can be aided or

impeded by the organizational culture• Organizational Culture factors to consider

– Leadership– Ability to adapt to change– Communication ability– Understanding of change or need for change

• Factors needed for success (Ransom, 2004)– Making quality improvement part of the job– Leadership support is essential for quality

improvement activities to succeed



Lecture b

Quality Improvement

“It is not necessary to change. Survival is not mandatory”

- W. Edwards Deming

1900-1993



Lecture a

Leadership SupportLeaders can enable quality improvement in their health care settings by:

• Creating and promoting a quality vision • Increasing staff capacity to support quality improvement • Motivating staff to participate in QI projects• Establishing the QI teams• Demonstrating support of use of metrics to measure

performance • Making sure that the ‘voice’ of the patient is heard and

acted on • Involving staff and patients • Including QI in the budget



Lecture b

Quality Improvement Methods

• Many methods • Human-centered and supportive of the

implementation of Health IT• Originally tailored for enterprises, not

necessarily health care



Lecture b

Associates for Process Improvement (API)Model

• Developed by Tom Nolan and Lloyd Provost• Simple model for Process Improvement based

on Deming’s PDSA cycle• Three fundamental questions form basis of

improvement– What are we trying to accomplish?– How will we know that a change is an improvement?– What changes can we make that will result in

improvement?



Lecture b

FOCUS-PDCA

1980s – Focus-PDCA model• Find an opportunity for improvement• Organize an effort• Clarify current understanding • Understand the process variations and capability• Select a strategy• PDCA cycle test the strategy



Lecture b

ISO 9000• International Standards Organization• 1987 – initial ISO 9000 guidelines for performance

improvement. • Components

– Design and develop a QI program– Create a sociocultural environment

• And a structure that supports improvement– Reduce or avoid quality losses– Define QI responsibilities– Develop an improvement planning process– Develop an improvement measurement process– Develop an improvement review process– Carry out QI projects– Analyze the facts before you decide to do QI

(ISO 9000, n.d.)



Lecture b

Kaizen

• Kaizen– Japanese for change for the better

• Continuous Improvement– The common English term– Connotes ongoing improvement involving

everyone– Assumes our way of life deserves to be

constantly improved– Includes improvement practices



Lecture b

Lean Thinking

• Sometimes called the “Toyota Production System”

• Consists of five steps:– Identify which features create value– Identify the sequence of activities, called the value

stream– Make the activities flow– Let the customer pull the product or service through

the process– Perfect the process



Lecture b

30

Work Flow Diagrams

2004 Bluefire Partners Rapid Action Workshops, Session 1, Wave 4, Licensed by Immanuel St. Joseph’s

©

Lean Thinking

• Assumptions underlying Lean thinking are– People value the visual effect of flow– Waste is the main restriction to profitability– Many small improvements in rapid succession are more

beneficial than analytical study– Process interaction effects will be resolved through value

stream refinement– People in operations appreciate this approach– Lean involves many people in the value stream

• Transitioning to flow thinking causes vast changes in how people perceive their roles in the organization and relationships to the product

•



Lecture b

Six Sigma DMAIC 1. Define - Project goals and boundaries

are set, and issues are identified that must be addressed to achieve improved quality

2. Measure – Information about the current situation is gathered in order to obtain baseline data on current process performance and identify problem areas

3. Analyze – Root causes of quality problems are identified and confirmed with appropriate data analysis tools

4. Improve – Solutions are implemented to address the root causes of problems identified during the analysis phase

5. Control – Improvements are elevated and monitored. Hold the gains.



Lecture b

http://www.orielstat.com/lean-six-sigma/six-sigma-dmaic/overview

IRS - Tax Advice (phone-in)

(140,000 PPM)

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Restaurant BillsDoctor Prescription Writing

Payroll ProcessingOrder Write-up

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Airline Baggage Handling

Purchased Material Lot Reject Rate

Domestic Airline Flight Fatality Rate (0.43 PPM)

Best-in-Class

Average Company

3 4 5 621

© 1994 Dr. Mikel J. Harry - V4.0

The Quality ColloquiumIntroduction to Track IC:

Six Sigma as a Healthcare Quality Initiative

Measurement: Comparative Analysis of Process Capability

Med Error

The Quality ColloquiumIntroduction to Track IC: Six Sigma as a Healthcare Quality Initiative

Improvement Methodology: DMAIC “Backbone”

…the current process capability (get the data!)

…the problem in a measurable way

…and validate root cause(s)

Devise solution(s) and implement

PerformanceImprovement

Benchmarking

Control Tools

DEFINE

MEASUREANALY

ZEIM

PROVECONTROL

Sustain improvement

Project Timeline

Retu

rn o

n I

nvestm

en

t (R

OI)

Quality Improvement Tools

Quality Improvement Tools– Flowcharts, – Cause-and-effect diagrams,– Statistical Process Control, – Pareto charts, – Check lists



Lecture b

© iStock photo, used under license

36

Why Collect Data?

“Data is like garbage. We need to know what we are going to do with the data before we actually collect them.”

--Mark Twain

“In God we trust; all others must bring data.”

W. Edwards Deming

37

Data and statistical thinking play a vital role in system and process improvement. It is essential to understand distribution theory especially the concepts of shape, center, spread, and outliers.

Data-Based Decisions

38

Measures of center estimate the center of a distribution. The three measures of center we will discuss are the mean, the median, and the mode.

Measures of Center

A Distribution Curve

0 20 40 60 80 100

English

0

50

100

150

200

250

300

Fre

qu

ency

Mean = 53.78Std. Dev. = 19.484N = 4,253

English

Mean: 54

Median: 56

Mode: 63

The Normal Distribution Curve

In everyday life many variables such as height, weight, shoe size and exam marks all tend to be normally distributed, that is, they all tend to look like the following curve.

The Normal Distribution Curve

00.0050.01

0.0150.02

0.025

0 20 40 60 80 100

It is bell-shaped and symmetrical about the mean

The mean, median and mode are equal

Mean, Median, Mode

It is a function of the mean and the standard deviation

42

Knowledge of spread informs us to what extent data values vary. We will discuss five measures of spread:

• Range• Variance• Standard Deviation

Measures of Spread

43

The standard deviation is the square root of the variance. A higher standard deviation indicates higher spread, less consistency, and less clustering.

Sample Standard Deviation Formula:

� (Yi - Y)2n

i=1

n-1

S = S2

=

Standard Deviation

Bell shaped curve• empirical rule for data - only applies to a set of

data having a distribution that is approximately bell-shaped:

• 68% of all scores fall with 1 standard deviation of the mean

• 95% of all scores fall with 2 standard deviation of the mean

• 99.7% of all scores fall with 3 standard deviation of the mean

45

Exercise:

Describe the following distributions in terms of shape, center, spread, and extreme values. Can you think of any examples from your workplace?

Distribution Shapes

46

Types of Data

Verbatims

Categorical

Count

Continuous

Yes/No

Unordered

Ordered

Types of Data

47

• “I don’t like to have to wait so long in the waiting room.”

• “All I want is to talk to a human being.”

• “Why do they keep asking for the same information?”

• “I couldn’t understand what the doctor said.”

Examples of Verbatims

48

• A patient history is either “updated” or “not updated”

• A diversion either “occurs” or “does not occur”

• A specimen is either “OK for testing” or “not OK”

• A hospital room is either “available” or “not available”

Examples of Yes/No Data

49

• Billing Errors:- Misspelling- Wrong Address- Wrong Amount

•Customer Complaints- Billing Mistake- Poor care- Long wait time

• Employee Injuries:- Hand- Back- Neck- Eye- Foot

Examples of Unordered Categories

50

• Service Score:- Poor- Good- Excellent

• Quality Rating:- Very Dissatisfied- Dissatisfied- Neutral- Satisfied- Very Satisfied

Examples of Ordered Categories

51

•The number of errors on twenty prescription labels

•The number of patient falls in a hospital

•The number of sentinel events

•The number of computer system failures in a month

Examples of Count Data

52

• Body weight• The time it takes to room a patient• The time it takes to clean an operating room• Cholesterol level• Blood pressure• Body temperature• Room temperature

Examples of Continuous Data

Basic Tools

• CREATIVITY TOOLS

– Although this group is not known as a fixed list of specific tools-that would be incongruent with the concept of creativity-it typically includes brainstorming, mind maps, Edward deBono’s (1999) six thinking hats, and the use of analogies

– Help one look at processes in new ways and identify unique solutions • STATISTICAL TOOLS

– Used for more sophisticated process data analysis– Help understand the sources of variation, the relative contribution of each variable, and the

interrelationships between variables

• Statistical process control (SPC)– A graphic means used to monitor and respond to special causes of variation– A wide range of statistical techniques that can be applied to both parametric and

nonparametric data– Allows the analysis of the statistical significance of more complex interrelationships



Lecture b

Basic Tools• FLOWCHART

– A map of each step of a process

• CAUSE-AND-EFFECT DIAGRAM

– Ishikawa, or fishbone, diagram – Assist in organizing the contributing causes to a complex problem (Tague, 2004)

• PARETO CHART

– 80 percent of the wealth in Italy was held by 20 percent of the population (Pareto)

• CHECK SHEETS– Used to measure the frequency of events or defects over short intervals– Immediately provides data to help to understand and improve a process.



Lecture b

Fishbone Diagram (cause and effect)

Largest Influence

2nd Largest InfluenceLeast Influence

3rd Largest Cause

Factors and/or categories of factors

Effect

Cause

Cause

Cause

Cause

Cause

Cause

Cause

Cause

Cause

56

8 11 12 15 32 57 96125

2.2 3.1 3.4 4.2 9.016.027.035.1100.0 97.8 94.7 91.3 87.1 78.1 62.1 35.1

300

200

100

0

100

80

60

40

20

0

Defect

CountPercentCum %

Pe

rce

nt

Co

un

tPareto Chart for Reason

Pareto Chart—Patient Complaints

57

Count

Perc

ent

Dx

Count 6Percent 43.8 30.9 9.9 3.1 2.8 2.8 2.5 2.5

1421.9

Cum % 43.8 74.7 84.6 87.7 90.4 93.2 95.7 98.1

100

100.0

32 10 9 9 8 8

350

300

250

200

150

100

50

0

100

80

60

40

20

0

2009 Medicaid PPR's N = 268

Example of a simple process check sheet. (attributes)

Model XYZC217 Batch

failures 1 2 3 4 5 6 7 8 910

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Case damage 1 1 2

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Basic Tools• HISTOGRAM

– A graphical display of the frequency distribution of the quality characteristic of interest– Makes variation in a group of data readily apparent– Assists in an analysis of how data are distributed around an average or median value.

• SCATTER DIAGRAM

– Show the relationship between two variable– Can help to establish the presence or absence of correlation – Does not indicate a cause-and-effect relationship

• RUN CHART – Plots of data, arranged chronologically– Used to determine the presence of some types of signals of special cause variation– A center line (usually the median) is plotted Along with the data to test for shifts in the

process • CONTROL CHART

– Consists of chronological data along with upper and lower control limits that define the limits of common cause variation

– Used to monitor and analyze variation from a process– Use to determine if process is stable and predictable

59Health IT Workforce Curriculum

Version 3.0/Spring 2012


Lecture b

Red Blood Cell Histogram

60Size of Red Blood Cells

http://labmed.ascpjournals.org/content/42/5/300/F2.large.jpg

Control

Experi

ment

302520151050

30

25

20

15

10

5

0

Scatterplot of Experiment vs Control

Control

Experi

ment

302520151050

30

25

20

15

10

5

0

Scatterplot of Experiment vs Control

R2 = .98

Experiment = - 1.55 + 1.43 Control

63

Run chartRun Chart

1.07 - 12.07

0

10

20

30

40

50

1.07 2.07 3.07 4.07 5.07 6.07 7.07 8.07 9.07 10.07 11.07 12.07

Time Frame(Month.Year)

Nu

mb

er

Median

Graph of data over time

Track performance

Display & identify variation

64

Run chart analysis: Common cause variation only

0

1

2

3

4

5

6

7

8

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Time

65

Run chart analysis: Runs

• Run = one or more consecutive data points on the same side of the median

• Excludes data points on the median

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

11 runs

66

Run chart analysis: Run length

0

2

4

6

8

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Time

67

Run chart analysis: Trends

0

2

4

6

8

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Time

Special cause—trends: Consecutive points all going up or all going down. May cross the median.

(Pyzdek, 2003)

68

Run chart analysis: Freaks

0

2

4

6

8

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Time

Freaks: The presence of more than one or two dramatic spikes suggests the process is out of control.

69

Run chart analysis: Cycling

Cycling: A zigzag or saw-tooth pattern with 14+ points in a row alternating up or down.

0

1

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

70

Control charts

71

Control chart

Time

Qu

alit

y C

ha

rac

teri

sti

c

Low

High

UCL

An indication of a special cause

LCL

X

Run chart with control limits

Determines type of variation

Is process stable? Predictable?

Maintaining and Enhancing Improvements

Topics• Monitoring processes to maintain

performance gains

• Continuing to improve process performance

• Contingency planning for EHR downtime– providing patient care when the EHR is down

– maintaining availability of health information to providers and patients in major emergencies


Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing

Improvements Lecture a

Measurement Is the First Step

“Measurement is the first step that leads to control and eventually to improvement.

If you can’t measure something,

you can’t understand it.

If you can’t understand it,

you can’t control it.

If you can’t control it,

you can’t improve it.” - Dr. H. James Harrington

(DeMarco, 1982)




Quality Council




• Establish core quality standards and requirements• Identify and defining quality metrics• Identify and define quality requirements• Clarify which performance measures are key to gauging

actual quality improvement performance• Collect and analyze data to understand key variables

and process drivers• Legitimize value of QI within the organization• Analyze QI data and report quality trends • Educate organization and train key staff

Maintaining Improvements

Measurement

Understanding

Control

Improvement




Process Control Terminology




• Process control (PC) the method for keeping a process within boundaries; the act of minimizing the variation of a process

• In-control process: observed variability is due to natural random variation

• Out-of-control process: observed variability is due to special causes, i.e., those other than natural variation

• Statistical process control (SPC) is the application of statistical methods to control a process

(American Society for Quality (ASQ), 2011)

Challenges to SPC in Health Care




• SPC was first used in manufacturing • SPC is not frequently included in books on

statistics for health care and medicine • SPC is a tool, like any tool, it can be used

incorrectly or for the wrong job• Prior to EHRs data had to be manually

collected

Statistical Process Control




• Uses special charts, called control charts• Statistical Process Control activities

– Understanding the process– Understanding the causes of variation – Elimination of the sources of special cause variation

• Monitored using control charts to identify variation due to special causes

• Causes for excessive variation must be determined

(Shewhart, 1931)

79

• Stable, consistent, and predictable process results

• Allows you to learn from variation• Allows you to identify special causes of

variation• Provides a rational basis for predicting

future performance

Benefits of Statistical Control

80

One thing for certain is that variation is caused. Some of the generic cause categories are:• Environment• Equipment• Methods• Materials• Measurement• People

Some Causes of Variation

81

Common cause variation is the variation inherent in the process.

Special cause variation is variation due to fleeting or unusual causal factors.

A statistical control chart is able to distinguish between common cause variation and special cause variation.

Two Types of Variation

82

The following are “rules of thumb” for determining whether there are special causes of variation present in the process:

1) A point outside the control limits2) Seven points in a row increasing or decreasing3) Seven points in a row above or below average4) Obvious patterns

Note: Special cause rules should in some cases be tailored for the metric.

Rules for Detecting Special Causes

83

Statistical Control Charts

Continuous Data

Yes/No Data

Count Data

X & M-R Charts

X-Bar & R Charts

P Chart

NP Chart

U Chart

C Chart

Common Statistical Control Charts

84

Sample

Pro

port

ion

2018161412108642

0.5

0.4

0.3

0.2

0.1

0.0

_P=0.2316

UCL=0.4369

LCL=0.0263

P Chart of No. Damaged

Tests performed with unequal sample sizes

P Chart: Proportion of Damaged Boxes

85

Sample

Pro

port

ion

3330272421181512963

0.08

0.07

0.06

0.05

0.04

0.03

0.02

0.01

0.00

_P=0.02721

UCL=0.07354

LCL=0

P Chart of DIVERSIONS


P Chart: Proportion of Patients Diverted

86

Sample

Sam

ple

Count

Per

Unit

24222018161412108642

0.014

0.012

0.010

0.008

0.006

0.004

0.002

_U=0.00753

UCL=0.01253

LCL=0.00253

U Chart of Reported Falls


U Chart: Patient Fall Rate

87

Observation

Indiv

idual V

alu

e

403632282420161284

60

45

30

15

0

_X=29.74

UCL=54.06

LCL=5.43

Observation

Movin

g R

ange

403632282420161284

30

20

10

0

__MR=9.14

UCL=29.87

LCL=0

11

1

I-MR Chart of Turn Time

I-MR Chart: OR Turnover Time

Basic Tools

• PROCESS DECISION PROGRAM CHART– Actions to be completed are listed, then possible scenarios about problems that could occur

are developed.– Management decides in advance which measures will be taken to solve those problems

should they occur.– Helpful when a procedure is new and little or no experience is available to predict what

might go wrong. (Tague, 2004) • FAILURE MODE AND EFFECTS ANALYSIS

– FMEA is a method for looking at potential problems and their causes as well as predicting undesired results

– Developed in the aerospace And defense industries and widely applied – Normally used to predict product failure from past part failure, but it can also be used to

analyze future system failures– Enables people to focus energy and resources on prevention, monitoring, and response

plans where they are most likely to pay off • POKA-YOKE

– Japanese name for “mistake proofing”– Can be thought of as an extension of FMEA– Puts special attention on human error



Lecture b

Quality Improvement Mistakes

Mistakes in Purpose & Preparation– Error #1: Choosing a subject which is too difficult or which a

collaborative is not appropriate– Error #2: Participants not defining their objectives and assessing

their capacity to benefit from the collaborative– Error #3: Not defining roles or making clear what is expected of

individuals taking part in the collaborative as faculty or participants – Error #4: Neglecting team building and preparation by teams for

the collaborative

(Ovretveit, 2002)



Lecture b

Quality Improvement Mistakes

Mistakes in Planning and Operations– Mistakes in fostering a learning community focused on

improvement• Error #5: Teaching rather than enabling mutual

learning• Error #6: Failing to motivate and empower team• Error #7: Not developing measurable and achievable

targets. – Mistakes in transition and implementation• Error #8: Failing to learn and plan for sustaining.



Lecture b


Leading and Facilitating Change


Working With People

Tell me and I’ll forget;

show me and I may remember;

involve me and I’ll understand.

– Chinese Proverb


Fundamentals of Workflow Process Analysis & Redesign Leading and Facilitating Change

Change Concepts

What is it that causes some change management efforts to be successful?



Employee’s Perspective

• From the employee’s perspective, there can be a lot of changes, and a lot of changes can be overwhelming.

• Remember that work process change may be only one of several changes an organization is undergoing.


Fundamentals of Workflow Process Analysis & Redesign Leading and Facilitating

Change

RegulatoryChanges

MarketChanges

DepartmentalChanges

Personnelchanges

RequestsFrom

Manager

Re-structuring

WorkProcessChange

Merger / Acquisition

Projectchange

Employee

Janssen’s 4-Room Apartment

95

Key Concept 1:

• Humans and organizations are complex• Many factors that come into play

– Organizational constraints – Management style– Organizational, departmental, division,

and personal goals – Personalities– Environmental factors



Key Concept 2:

• Organizations are living, changing biological systems– If you push on the system, it will compensate– Behavior dependent on culture and level of trust

• Reductionist treatment rarely explains the whole– Measures and numbers

• Are not complete• Cannot capture the complete complexity.



Key Concept 3:

Change happens through individual choice and freedom not through top-down control or coercion.



Key Concept 4:

John Gall, MD in his 1970’s book Systemantics said it most insightfully:

“Systems run best when designed to run downhill.”

Systems should work with natural human tendencies rather than against them

(Gall, 1978)



Change

Key Concept 4 Example:

Sure, walk in my garden!



Change

istockphoto.com/nahm001, 2011.

Key Concept 5:

• Change starts with a deeply meaningful purpose

• Which of the following would you rather be a part of?– Getting a system in production– Implementing a system so your practice

would get the Meaningful Use incentives– Using health IT to improve the health of your

patients



Key Concept 6:

Make and keep the gap between “as is” current reality and “to be” vision visible, and talk about it at every opportunity.

Making gaps visible maintains a “creative tension” as Peter Senge calls it, that motivates forward progress.



Change

istockphoto.com/nahm001

Key Concept 7:

Don’t pull.

“it is an assault to try and change someone’s mind.”

The Answer to How is Yes (Block, 2002)

Key Concept 8: The Engagement Gap



Change

CEO

}Steering Committee

CEO

Team of the “Best & the Brightest”

Key Concept 9: Transparency

“…tell the truth, the whole truth and nothing but the truth…”



Pulling it all together

• Change happens best when individuals have – Deeply meaningful purpose – Sincere invitation to influence – Acknowledgement of opportunities for personal

control or choice– Transparency– Shared understanding

• Change is impacted by:– Individuals and organizations– Culture and trust– How a change project is structured and managed



Applying All of ThisFacilitation Plans and Tools:

Facilitation “F” Plan

• A facilitation plan is an outline for how a meeting or an entire change effort will be run. A facilitation plan includes:– Description of who is included.– Description of how included individuals will be selected or invited. – Schedule or agenda. – Outline of what methods or tools will be used – Description of how the rest of the organization will be kept up-to-

date– Description of how leadership will be kept in the loop

• A facilitation plan should be made available to the entire organization to maintain transparency.



Facilitation Plan Scenario• A mid-size internal medicine practice has decided to select,

purchase and implement an Electronic Medical Record (EMR). They have hired you as a consultant for Process Analysis and Redesign. Your agreement with the practice is that you will provide instruction, training and oversight for members of their staff as they analyze their processes, redesign their processes around an EMR, and define the functionality that they need in an EMR.

• You have already had an initial meeting with practice leadership and have had a tour and met the 75 person staff. At your next meeting, you will present the facilitation plan and get the analysis and redesign started.

• Over the next several slides, we will look at “Big F” facilitation plan for the entire effort, and a “little f” agenda for the initial meeting.



Big F



Change

Group 1 work week:Process inventory

Group 1 work week:Process Analysis

Group 1 work week:Process Redesign

Group 1 work week:Finalize

Group 2: Weekly Walkthroughs 1 hour

Leadership briefing / debriefing1 hour

Week 1 Week 2 Week 3 Week 4

Little f post-Week 1 Walkthrough

• Introduction to overall project– How the team was selected– What their charge is– The Big F plan– Timeline and scope

• Context diagram exercise– Create one as a group– Pin-the-tail on the donkey

• Process Inventory– What did we miss



Little f Leadership Briefing / Debriefing

• Brief review of progress• Presentation of challenges• Review and “what did we miss” exercises• Engaging questions:

– Any surprises based on what’s presented – Get help strategizing about challenges– Leadership should have input into prioritizing

processes for analysis and redesign




Process Change Implementation and

Evaluation


Topics – Component 10 Unit 10

• Common process changes

• Implementation plan components• Communication for implementation

• Common implementation problems

• Evaluating the new process


Fundamentals of Health Workflow Process Analysis and Redesign Process Change

Implementation and Evaluation

Common Process Changes

• From manual to electronic prescribing• From receptionist to web-based

appointment scheduling• From manual to automated appointment

reminder calls• From manual tracking of test results to

automated result tracking• From paper to electronic patient charts• From paper to electronic test ordering




Implementation Plan

The implementation plan serves as a map for everyone involved in changing a process. It covers what steps everyone will need to take, what to expect and what to do when things don’t go as planned.



Process Change Implementation and Evaluation

Implementation Plan Components




• Reason for the change• Summary of what will be different • Sequence of implementation tasks• An implementation schedule for the entire

implementation phase – Responsible parties– Each implementation task

• Statement of how the process will be managed• Contact information for who to call when problems arise• Description of how the process change will be evaluated

Exercise

• Using your project redesign

• Review the implementation plan components on the previous slide

• Create an implementation plan

• Include each component from the previous slide

Communication of an Implementation Plan




“Tell me and I’ll forget;

show me and I may remember;

involve me and I’ll understand.”

– Chinese Proverb

What People Need to Know

• What is happening• Why is the change taking place • How they will be affected

– Address each task or activity that will be added, changed or will go away

• How the change will impact workflow or responsibilities

• How will the change take place• What if anything different will the patients see




Job Aids

• Talking points• Checklists• Written procedures• Cheat sheets



Process Change Implementation and Evaluation


Maintaining and Enhancing Improvements

Lecture bThis material Comp10_Unit11b 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.

Business Continuity Plan

(Wikimedia, 2012)



Improvements Lecture b

What is Affected When an EHR is Down?

• Receipt of lab results via electronic interface, • Clinical decision support, • Routing of prescription refills • Electronic storage of entered clinical

documentation, • Appointment call reminders, and • Transmitting health information




BCP for EHR Downtime

Business continuity planning for EHR downtime is the systematic inventory of EHR-facilitated processes and contingency planning for each.• Real-time clinical care• Care follow-up activities• Getting data into the EHR




BCP Team

• Assemble Core Team to oversee BCP development

• Identify BCP Points-of-Contact for organizational units

• Define the overarching BCP program

• Develop a BCP timeline


Fundamentals of Health Workflow Process Analysis & Redesign Maintaining

and Enhancing Improvements Lecture b

(Wikimedia, 2012)

BCP Plan Objectives




• Ensure continuous performance of an organization’s mission-essential functions in an emergency

• Ensure safety of employees• Protect essential equipment, records, and other assets• Reduce disruptions to operations• Minimize damage and losses• Achieve an orderly recovery from emergency

operations• Identify alternate locations and ensure operational and

managerial requirements are met before an emergency occurs.

Key BCP Plan Goals




• Essential organizational functions, vital systems, data and information identified and prioritized

• Critical elements are capable of being recovered quickly to resume operations

• People know who is in charge• Back-up personnel are trained• Alternate work locations are predefined• Checklists are predefined to guide the

organization in responding to an emergency

Critical Processes




• Processes or services that must be recovered within 24 hours after a disruption to ensure resumption of the essential function

• Includes all resources necessary to carry out the critical process:

– Personnel– Data or vital records– Systems and equipment

Essential Functions


Functions that must be performed to achieve the organization’s mission

•Essential Functions include:

– Communications

– Vital Records, Systems and Equipment

– Key Personnel

– Alternate Work Sites

– Testing, Training & Exercises

– Personnel– Data or vital records – Systems and equipment

Fundamentals of Health Workflow Process Analysis & Redesign Maintaining and Enhancing Improvements

Lecture b

Exercising the Downtime Plan




• Exercises are events that allow participants to apply their skills and knowledge to improve operational readiness

• Goal of exercises is to prepare for a real incident involving EHR Downtime Plan activation

• Three types of exercises:– Tabletop– Functional– Full-scale

Dangers of predicting the future

• I never make predictions, especially about the future.

• Sam Goldwyn Mayer

Looking to the future: common mistakes

• Making predictions rather than attaching probabilities to possibilities

• Simply extrapolating current trends

• Thinking of only one future

Looking to the future: common mistakes

• People consistently overestimate the effect of short term change and underestimate the effect of long term change.

• Ian Morrison, former president of the Institute for the Future

Why bother with the future?

• The point is not to predict the future but to prepare for it and to shape it

IOM report: the problem

• Between the health care we have and the care we could have lies not just a gap, but a chasm

• A system full of underuse, inappropriate use, and overuse of care

• Unable to deliver today’s science and technology; will be even worse with innovations in the pipeline


• A fragmented system characterised by unnecessary duplication, long waits, and delays

• Poor information systems; disorganised knowledge

• “Brownian motion” rather than organisational redesign


• A system designed for episodic care when most disease is chronic

• Health care providers operate in silos

IOM report: six challenges for health care organisations

• 1. Design seamless, coordinated care

• 2. Make effective use of IT, including automating patient records

• 3. Manage knowledge so that it is delivered into patient care

IOM report: getting evidence into health care delivery

• Ongoing analysis and synthesis of medical evidence

• Delineation of guidelines• Identification of best practices in design of

care processes• Better dissemination to professionals and

public• Decision support tools• Goals for improvement• Measures of quality for priority conditions

IOM report: six challenges for health care organisations

• 4. Coordinate care across patient conditions, services, and settings over time

• 5. Advance the effectiveness of teams

• 6. Incorporate measurement of care processes and outcomes into daily practice

What will survive as the world changes completely:

• 1. Clear ethical values• 2. Being clear about our mission• 3. Putting patients first• 4. Constantly trying to improve• 5. Basing what we do on evidence• 6. Leadership• 7. Learning

Conclusions

• Patients will have the same access to knowledge as professionals

• Self care or “rolled back care” will become steadily more important

• Professionals and patients will become much more equal partners

• Evidence will become steadily more important

144

1880 New York City

• 150,000 Horses• 3 Million pounds of manure/day• 40,000 gallons of urine/day• 41 deaths/day• 15,000 deaths/year

Documents

Facilitating mtgs fri aft [repaired]