Presentation on making a gourmet clinical workflow kitchen - Workflow design and workflow 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.

4. MAKING A GOOD MEAL
(WORKFLOW = [WHO] WILL [WHAT])

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

8. 1. THE CHEF

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

10. 2. THE INGREDIENTS

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!

19. 3. THE KITCHEN

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

22. 4. THE RECIPE

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

25. 5. THE TIME

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)

30. THANK YOU!