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

1. 1 Clinical Workflow: The Foundation of Systems Implementation The impact of Clinical Workflow on the Transformation Process Presented by: Edward A Stern, RN ed.stern@nothingbetter.com

2. 2 Objectives Discuss workflow as it relates to transformation Basic workflow elements Current state Future state Original state Workflow process Cognitive workflow cluster theory

3. Clinical Transformation Process A never ending process to improve care delivery excellence through: Offering value Measurably quality improvement Enhancing services and solutions While reducing costs through the effective alignment of people, process and technology. Here’s where workflow plays a part 3

4. 4 Workflow Defined From Wikipedia, the free encyclopedia 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.

5. 5 “It’s Workflows’ Fault” Workflow is often a common “fault” area in the implementation of a technology. 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.

6. What isClinical Informatics Assessment ? 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 Think of it as a “pulse check” for the workflow process 6

7. More onClinical Informatics Assessment The focus is on clinical operations and how other business and systems elements interact with the clinical patient care environment Systems Operations + Clinical/Business Operations = Potential Software Product and Project Effectiveness? Consider how end-user usability plays into the product The net result is a focus on assuring quality patient care while assuring efficient use of clinical informatics solutions. 7

8. Factors to considerwhen building your CIA plan It’s a Business Process but the Patient Comes First! ROI is a relative factor in the business model, so consider hard and soft ROIs to prove your point The depth of the process is relative to the complexity of the project Marketing concepts apply too… Your patient is your client, the provider may be your client, and who else is your client… 8

9. 9 Who benefits from CIA The Patient! Clinical needs are considered throughout the process The Business Business process and ROI is considered The Clinical Realm 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.

10. 10 How do YOU boil water? Exercise: Define the workflow for boiling water. Goal: A cup of hot water Please number each step you identify

11. 11 How do YOU boil water? Exercise: Who thinks they “nailed” it? Let’s review the results Share your details with a person next to you. Compare your results, how far apart are they?

12. 12 Think Playwright Writing a workflow is like writing a script. You have: A Plot What needs to happen – Goal of the flow Actors Elements in the workflow; staff, equipment, policies etc.. Actions What the actors are doing Plot Twists Decisions that are made

13. 13 Test the Workflow Reenactment What’s our “plot” (Goal) Select the cast while we walk through the workflow Actors Actions Decisions

14. 14 Assess, Intervene, Reassess What we just did was “audit and review” a WF an Identified problems to correct. Aka – Shadow assessment of a workflow This is a common clinical nursing process… We always Assess the patient Intervene if necessary Reassess each intervention It’s no different when building a workflow Assess the current workflow you’ve documented Intervene to correct problems Reassess the workflow and see if it now matches your real process

15. 15 How do YOU boil water? Simple Answer Fill Kettle with cold water Turn on Kettle Wait for water to boil

16. 16 Boiling Water Workflow What if we broke it down even more? Simply adding water to the kettle can be more complex Take Kettle to Sink Turn on Cold Tap Open Kettle Move Kettle Under Tap Wait for Kettle to Fill Turn off Tap Return Kettle to Work surface

17. 17 Boiling Water Workflow And… even more. How do we turn on a faucet? Grasp the tap mechanism Turn mechanism clockwise Wait until water pressure is high enough Stop Turning mechanism

18. 18 Boiling Water Workflow Now bring it all together: Fill Kettle with cold water Take Kettle to Sink Pick up kettle Extend arm…(more) Walk to sink Turn on Cold Tap Grasp the tap mechanism Turn mechanism clockwise Wait until water pressure is high enough Stop Turning mechanism

19. 19 Boiling Water Workflow What are the exercise conclusions? Don’t ask Ed to make you a cup of hot water Workflows are everywhere Workflows can be “considered complete” at almost any stage and any degree of complexity It’s up to the clinical informatics person to assure that patient care and business needs are met

20. 20 Workflow Complexity Complexity varies based on the need of the audience Here’s where some typical clinical “assessment” and critical thinking aspects come into play. Who’s your audience? What do they need to know? What will they be doing with the information? Where will this be used? When will they need it defined? When will it need to be updated? Why do they need it documented and defined? How does this play a role in the patient care and business processes?

21. Workflow States Current Original Future

22. 22 “Current State” The exercise we just went through was a “current state” definition process We defined the current operational state for a process… “boiling water to fill a cup” The typical next step is “future state” I disagree

23. 23 What’s Original State You’ll note that in the earlier “boiling water” exercise we didn’t consult any policy manual or printed instruction. 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. Original State: is going back to the “stone age” of process The way it was originally intended to be done e.g. Boiling water with fire!

24. 24 Original State Integration Decisions Review the original policy manual Determine how far from the documented current state the original state is. Decide if there is a need to change the “current state” or change the “original state” (e.g. update the policy) If the policy needs to be updated, you might as well wait until after the “future state” is defined Decide if there is a need to integrate the two

25. 25 Problem, Action and Response Another nursing clinical action plays a role in assessing Current and Original State: Identify the Problem, Document the Required Action and Response Does the miss match of “original” and “current state” cause a problem for operations today and/or in your future? What action do you need to take now, if any? What will staff and management response be?

26. 26 Future State What you just developed is the Future State When defining your future you have flexibility within the parameters of the software application You need to make sure you understand the potential and assess and test your theoretic ideas

28. Reduce duplication of effort and data

29. Enhance access to care information

30. Facilitate collaboration and communication among care providers

31. Support timely clinical decision support

32. Reduce variability of care

33. Drive measurable improvements in quality and safety

34. Support continuity of care across the continuum of services and settings

35. Support interdisciplinary care and model of collaborative practiceCompliments of Dearborn Advisors

36. Future State Design Sessions Future State Integration & Signoff Future State Discovery Future State Validation Future State Consensus Current State Confirmation Facilitated Session Work Group Session Facilitated Session Facilitated Session(s) Nursing Facilitated Session Work Group Session Facilitated Session Facilitated Session(s) Facilitated Session Pharmacy Facilitated Session Facilitated Session Facilitated Session(s) Work Group Session Physicians Workflow Redesign Management and Coordination Compliments of Dearborn Advisors 28

37. 29 Documentation Process Outline format PowerPoint Pen and Paper “Flow” tools Visio RF Flow etc

39. ED Staff

40. ED Nurse

41. Admitting

42. Bed Management

43. Receiving

44. In Patient, & Surgical Services

45. “other”30

46. Example of aSimple Swim Lane Flow Send the Patient Home 31

47. Same “Plot” but anIntegrated Workflow Send the Patient Home 32

48. 33 Previously Separate Variable Discharge to In-Patient

49. Specific Factor flow

50. Defining Workflow by Categoryin Your Organization Functional Systems Workflows How the software system will function in the work process “Click here, then enter this, and drag that” Business Operational Workflows How the business (patient care and operations business) model operates and physically gets executed “Go down the hall, make a left, pick up the form, and complete” Integrated Workflows Integrated Department Integrated Software modules Integrated systems and operations workflows as one. Touch Points Where Operational and Systems “bump” into one another 35

51. 36 Example of Integrated Workflow Order for CBC Order placed in System by MD RN acknowledges order in system and notes it is a “nurse draw” Print lab specimen label Obtain blood collection supplies Draw Blood using hospital procedure 554.123 Affix completed labels Tube to Lab using hospital procedure 554.124 Indicate in system blood drawn and to lab Wait for results in system

52. Example of Integrated Workflow Order for CBC Order placed in System by MD RN acknowledges order in system and notes it is a “nurse draw” Print lab specimen label Obtain blood collection supplies Draw Blood using hospital procedure 554.123 Affix completed labels Tube to Lab using hospital procedure 554.124 Indicate in system blood drawn and to lab Wait for results in system TP OP SYS OP OP OP OP TP SYS TP OP 37

53. Cognitive Cluster A growing trend in “micro time decision process” documentation Workflows are relatively linear and Mind Maps® are not often structured enough for application development A cognitive cluster (CC) enables a way to demonstrate same time sequence decision processes It is not a “cheat” for singular thought processes

54. Simple Cluster This simple cluster demonstrates a relatively simple 3 part question

55. Complex Cognitive Clusters