Workflow and Process

Redesign HIT Toolkit

Health Information
Technology Toolkit
for Critical Access
and Small Hospitals

http://www.stratishealth.org/HIT_Toolkit_hospitals
 Presenter
Margret Amatayakul
RHIA, CHPS, CPHIT, CPEHR, FHIMSS
President, Margret\A Consulting, LLC
Schaumburg, IL

Independent consultant, who focuses on achieving value from

electronic health records, HIPAA/HITECH, and health information
exchange. Developer of tools in Toolkit
Adjunct faculty College of St. Scholastica, Duluth, MN, masters
program in health informatics
Founder and former executive director Computer-based Patient
Record Institute, associate executive director AHIMA, associate
professor University of Illinois
Active participant in standards development, former HIMSS BOD,
and co-founder of and faculty for Health IT Certification

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Stratis Health
Stratis Health is a nonprofit organization that leads
collaboration and innovation in health care quality and
safety, and serves as a trusted expert in facilitating
improvement for people and communities
Stratis Health works toward its mission through initiatives
funded by federal and state government contracts, and
community and foundation grants, including serving as
Minnesotas Medicare Quality Improvement Organization
(QIO)
Stratis Health operates the Health Information
Technology Services Center for health care
organizations seeking to use health information
technology in support of their clinical transformation

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Agenda
Purpose of Workflow and Process Redesign
Steps in Workflow and Process Redesign
Workflows and processes to map
Performing workflow and process mapping
Critical success factors in workflow and
process mapping

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Purpose: Create Ah Ha! Moments
Workflow and process redesign
Starts the process of identifying improvement
opportunities with HIT
Helps users identify solutions for current problems
and todays workarounds that will form the functional
requirements for your HIT
Aids in setting expectations for achieving HIT goals
because users will now expect to see improvements
Ensures that critical controls built into current
processes are retained or enhanced
Software People Policy Process
Hardware
that directs to support that drives that helps
that enables
computer and use adoption of achieve
system use
devices systems systems results
Copyright 2009, Margret\A Consulting, LLC. Used with permission of author.

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 Workflow and Process
Process is the manner in which work to Five Rights for Right EHR
be completed to achieve a particular result
is performed Right clinical data
Example: Do you always verify the
timeliness of medication administration?
Right presentation
Work flow is the sequence of steps Right decision
and hand-offs taken within a process
Example: Is information available to
Right work processes
schedule patients for labs in advance of
a clinic visit?
Right outcomes
Workflow and process
mapping depicts the detailed nature of
the processes and workflow to enable
improvements

Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author.
EHR is Not about Automating Charts

Only automating form, content, and procedures of current patient records will
perpetuate their deficiencies and be insufficient to meet emerging user needs

EHR is about automating & using

information to improve health care
EHRs encompass a broader view of the record than today, moving from
notion of location for keeping track of patient care events to a resource
with much enhanced utility Institute of Medicine, 1991

Copyright 2009, Margret\A Consulting, LLC. Used with permission of author.

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Steps in Mapping Current Processes
1. Identify processes to be mapped; e.g., those that will be impacted
by the HIT being acquired
2. Use individuals who actually perform the process; they know it
best and need to own the impending change
3. Instruct persons on process mapping why it is being done and
how it is done
4. Map current processes. Avoid identifying opportunities for
improvement now, or critical controls built into current processes
may be overlooked
5. Validate maps to ensure they reflect current processes, all
variations, and the information payload
6. Collect all forms and reports that are part of processes to be
automated through HIT
7. Obtain benchmark data to define expectations for change
and for use in benefits realization studies
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Steps in Redesign
8. Identify potential problems in current workflows and processes
and determine their root cause
9. Identify changes that may resolve problems today
10. Educate about HIT and EHR and identify further changes that
will be possible
11. Document changes by creating improved map
12. Use new processes to create use case scenarios to identify
HIT functional specifications, and later to build out the HIT
application to achieve improvements
13. Test new workflows and processes
14. Train all on new workflows and processes
15. Incorporate changes into policy and procedure
16. Conduct benefits realization and celebrate successful
change/correct course as necessary
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 What to Map

in Hospitals
Admission
inScheduling/check-in
Clinics and check-out
Medications reconciliation Patient intake
H&P/results review/differential Results review
diagnosis
Patient assessment H&P/encounter notes
Care planning/pathways Care planning/guidelines
Provider orders Medication management: medication
Consultation management list maintenance/ prescribing/refills
Patient monitoring and charting Provider orders
Medication administration E&M coding
Surgery/recovery Charge capture
Transfer of care/care coordination Patient instructions/education
Discharge/patient instructions Patient follow up/health maintenance
Charge capture/coding Reporting/quality improvement
Reporting/quality improvement
Departmental operations
Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author.
Select Tools
Process diagram

Swim lane process chart

Flow process chart

Systems flow chart

Software is available to
aid in drawing charts, if
desired
Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author.
 Basic Systems Flow Chart
Ovals start and end
Rectangles process
Diamonds decision

Used with permission from P. S. Rudie Associates, Duluth, MN

Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author. Robert McDonald, MD and Mary Rapps
Annotating Processes
It may be helpful to capture components of processes and
workflows by simply making a list of all processes, or
Use post-it notes to record processes as they are
performed and then arrange them on a wall or
large piece of (e.g., examining room) paper

Process mapping is not new,

and not even new to health
care, but process mapping is
foreign to clinicians
Engaging clinicians, however,
is critical because EHRs are
designed for their use. It may
be necessary to start a map
for them and have them
validate it Real clinicians
really do map! Courtesy of Dr. Hinck, Bloomington Lake Clinic,
Minneapolis, MN

Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author.
 Getting Started
Refill Processing
Identify one complete
Patient
process neither to
Pharmacy Chart
Calls Calls Reviewed

large or to small Ask Pt to Call

Pharmacy
Write Rx &
Give to Pt

Identify all potential End

Request chart
Document in
chart

starting points Review chart

End

Follow each to its Ave

1 hr Nurse
No
Place in

natural conclusion Ave

OK? MD Box
No
Yes OK?

Significant delays can 2 hr

Yes
Document in
chart Document
be annotated to the Call Pharmacy
In chart
Speak to
side if desired End
Nurse

Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author.
Reflect
Variations
Medication
administration
in a critical
access hospital
with five nurses
administering
medications
Some
processes can
be corrected
immediately;
others will
depend on
acquiring an
EMAR

Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author.
 Validate Process Maps
Initial pass at a swim lane map (clinic example):

Document
RFV on Post-it

Map after
validation: Throw Post-it
away

Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author.
 Identify (Potential) Problems
Review Flow process charts help identify
current maps Nature of tasks
to identify: Key questions
Bottlenecks
Sources of delay
Rework due to
errors
Role ambiguity
Duplications
Unnecessary
steps
Cycle time

Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author.
Determine Root Cause
Use complementary
tools as needed
Statistical charts
Radar
Pareto
Relations diagrams
Tree diagram
Affinity diagram
Force field analysis
Cause & effect diagrams
Physical Layouts B
A

Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author.
 Critical Success Factors
Map processes that will be impacted by HIT, unless other reason for
process improvement
Engage persons actually performing the process. Leave bias and
blame at the door reward those who find the most warts!
Avoid getting ahead of mapping current processes, but make sure
they are complete and address the information flow remember,
information is being automated, not the staff member or the patient
Get to the root cause of problems when looking for improvements.
Address immediate opportunities; use others as key functional
requirements for your HIT
Use workflow and process mapping to create Ah ha! moments that
initiate the change process. Follow up that changes are adopted
and celebrate success once change is implemented

Copyright 2007-8, Margret\A Consulting, LLC. Used with permission of the author.
For More Support
Contact:

Stratis Health
2901 Metro Dr., Suite 400
Bloomington, MN 55425
952-854-3306
1-877-787-2847 (toll free)
www.stratishealth.org

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