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Process Improvement with Electronic Health Records
A Stepwise Approach to Workflow and Process Management
MARGRET AMATAYAKUL
MBA, RHIA, CHPS, CPHIT, CPEHR, CPHIE, FHIMSS
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
© 2012 by Taylor & Francis Group, LLC
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No claim to original U.S. Government works Version Date: 20120516
International Standard Book Number-13: 978-1-4398-7234-5 (eBook - PDF)
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Preface
Quality improvement is a cornerstone of health care. Yet managing the efficiency and effectiveness of workflow has not always been considered an integral part of healthcare quality improvement. This is especially true as electronic health records (EHRs) are being implemented. This new technology impacts clinicians in ways most never anticipated. There are many benefits from EHRs, but there have also been unintended consequences—often from lack of attention to workflows and processes and their connection points.
This book was written to overcome the paucity of guidance on workflow and process management specifically associated with EHR implementation, adoption, and optimization. Within the context of EHR then, workflow and process management is the application of a focused approach to understanding and optimizing how inputs (in any form—raw data, semi-processed data, and information from knowledge sources such as EBM) are processed (mentally or by computers using algorithms and clinical decision support [CDS] rules) into outputs (information) that contribute to an immediate effect or downstream effects (which also contribute to creation of further knowledge).
Workflow and process management for EHR focuses on mental processes, which have been described by Dr. Sam Bierstock as “thoughtflow,” performed by knowledge workers. The clinical transformation that an EHR is expected to bring about is not just the movement from paper to electronic documentation. It is technology that contributes to a fundamental change in how medicine is practiced. The original Institute of Medicine (1991) study on computer-based patient records observes that “merely automating the form, content, and procedures of current patient records will perpetuate their deficiencies and will be insufficient to meet emerging user needs.”
The chapters in this book introduce workflow and process management in health care and set the stage for a ten-step approach to applying workflow and process management principles at whatever stage a care delivery organization is in its EHR journey. Each chapter includes specific guidance and tools, as well as case studies. Healthcare knowledge workers are said to learn in a “see one, do one” mode. Stories bring reality to theory and practical advice.
Chapter 1: Introduction to Workflow and Process Management in Health Care introduces the topic to the healthcare environment, describing the clinical
transformation that knowledge workers are expected to achieve in adopting EHR. Chapter 2: Workflow and Process Management Overview defines terms and compares workflow and process management for EHR to other continuous quality improvement (CQI) methodologies and to change management.
The ten steps for workflow and process management begin with Chapter 3, Step 1: Assess Readiness for Workflow and Process Management. It urges care delivery organizations to take a critical look at their culture, to educate all stakeholders, to set goals for EHR outcomes, and to provide a workflow and process management governance structure.
Knowing what processes need to be addressed in EHR workflow and process redesign is covered in Chapter 4, Step 2: Compile Process Inventory. Care delivery organizations may well have applied CQI techniques to various workflows and processes in the past, but the EHR environment often breaks down or combines processes differently than in the traditional departmental or task approach. Workflow and process management for EHR must be patient centered, not staff or task centered.
Chapter 5 covers Step 3: Select Tools and Train Team. EHR vendors often point out that workflow and process changes that come about as a result of EHR capabilities are the responsibility of the care delivery organization itself. Even though some support and guidance from experts can be helpful, it is likewise true that the people who know the current workflows and processes best are those who are currently performing them. Workflow and process analysis and redesign actually help initiate change management.
Chapter 6, Step 4: Current Workflows and Processes dives into the specifics of documenting current workflows. It discusses the level of detail necessary for workflow and process mapping to be effective in understanding “thoughtflows” and the information needs of clinicians.
Chapter 7, Step 5: Obtain Baseline Data describes the purposes and uses for collecting baseline data. Not all care delivery organizations opt to collect baseline data as they may not have an interest in or, in many cases, the patience, for later conducting benefits realization studies. Still, such activities can be motivational—and provide the evidence that knowledge workers especially require to adopt change.
Chapter 8, Step 6: Validate Workflow and Process Maps urges care delivery organizations to step back and ensure that current maps represent reality. Improvements cannot be effected on workflows and processes if workarounds and problems associated with current workflows and processes are not well understood. It does little good to map a current workflow and process as it is supposed to be performed. Part of validation is also capturing variations. And once again, engagement of all stakeholders helps them take ownership of changes to come.
Chapter 9, Step 7: Identify Process Redesign Opportunities describes the process for getting stakeholders to create, document, and validate new workflows and processes. It may seem like many steps to get to this point, but mapping
current workflows and processes initiates changes that take considerable time to “gel.” Mapping current workflows and processes also has valuable outputs of its own—it educates about EHR and helps the organization specify EHR requirements for vendor selection. The redesign of workflows and processes actually represents third and fourth outcomes that help the organization implement EHR and gain adoption, and later optimize use.
Chapter 10, Step 8: Conduct Root Cause Analysis to Redesign Workflows and Processes is a step that should be performed concurrently with Step 7, but may also be performed some period of time after redesigned workflows and processes have been implemented. Redesigned workflows and processes may be found to not work well, or require further change as the environment changes with ever new technology, new regulations, or new clinical research findings. Root cause analysis is not new to health care, but often has not been applied to IT issues.
Chapter 11, Step 9: Implement Redesigned Workflows and Processes is the culmination of the work in all previous steps, although as noted above may well not be the last time redesign and implementation is necessary. This chapter also dives more deeply into change management, discusses how to create change agents, and offers suggestions for using a few “tried and true” change management tools.
Chapter 12, Step 10: Monitor Goal Achievement with Redesigned Workflows “closes the loop” on the book and urges care delivery organizations to use continuous workflow and process management to celebrate their successes and to view course correction as not something bad but a part of the learning process that all relatively new technology implementations require.
List of Figures
6.5 (a) Incomplete decision. (b) Decision from a reference. .............................124
6.5c Decision flow. ...............................................................................................124
6.5d Decision table. ..............................................................................................
6.6 Special symbols.
6.7 Alignment of symbols and dynamic flow lines.
7.1
7.2
7.3
7.4
8.1a Current nursing medication administration record (MAR) workflow and process. .........................................................................................................
8.1b New nursing and pharmacy workflows and processes for EMAR. ............164
8.1c Validated “as is” MAR workflow and process.
8.2 Map in need of improvement.
9.1
9.2
9.3
9.4 Documentation of “as-is” workflow and process map—with redesign technique checklist. ......................................................................................
9.5 Documentation of “as-is” workflow and process map—with key questions annotated. .....................................................................................
9.6 Implementation validation checklist. ...........................................................
10.1 Cut the root of the dandelion (and all of your neighbors’ dandelions) to eliminate weeds.
10.2a Traditional fishbone cause-and-effect diagram.
10.2b Spreadsheet version of cause-and-effect diagram.
12.1 Monitoring S.M.A.R.T. goal achievment. .....................................................
12.2 Monitoring versus measuring.
12.3 Three-pronged approach to goal achievement.
