© 2009 Public Health Informatics Institute Multi-State Learning Collaborative September 17, 2009

© 2009 Public Health Informatics Institute Today’s Presenters Claudia W. Brogan, MS Ed – Associate Director, Training Deb Bara, M A – Associate Director, Programs

© 2009 Public Health Informatics Institute The Institute & Improvement Part of our Mission Embedded in previous work Others are applying the methodology to quality improvement in public health

© 2009 Public Health Informatics Institute Fundamental Questions for 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 an improvement? Who will participate in the improvement process?

© 2009 Public Health Informatics Institute Collaborative Requirements Development Methodology

© 2009 Public Health Informatics Institute Collaborative Requirements Development Methodology Business Process Analysis think How do we do our work now? Define goals and objectives Model context of work Identify business rules Describe tasks and workflow Identify common task sets

© 2009 Public Health Informatics Institute Collaborative Requirements Development Methodology Business Process Redesign rethink How should we do our work? Examine tasks and workflow Identify inefficiencies Identify efficiencies with repeatable processes Refine business processes and business rules Remodel context of work Restructure tasks and workflow

© 2009 Public Health Informatics Institute Collaborative Requirements Development Methodology Requirements Definition describe How can an information system support our work? Define specific tasks to be performed for optimized business processes Describe the implementation of business rules Describe in words and graphics how an information system must be structured Determine scope of next phase activities

© 2009 Public Health Informatics Institute What is a Business Process?

© 2009 Public Health Informatics Institute Sally’s Sandwich Shop

© 2009 Public Health Informatics Institute Business Process Matrix A table that helps keep track of all the business processes you are mapping Includes, for each business process: – Goal – Objective – Business Rules – Trigger(s) – Task Set – Inputs – Outputs – (Measurable) Outcomes

© 2009 Public Health Informatics Institute Business Process Matrix Definitions Goal The major goal in terms of benefits to population health that is supported by the business process. Objective A concrete statement describing what the business process seeks to achieve, pointing to quantifiable measures of performance. Business Rules A set of criteria that defines or constrains some aspect of the business process. Trigger Event, action, or state that initiates the first course of action in a business process. Task Set The set of required activities or steps that are carried out in a business process. Inputs Information received by the business process from sources outside of the process. Outputs Information transferred out of a business process. Outcomes The result of performing a business process, which indicates the objective has or has not been met.

© 2009 Public Health Informatics Institute Example: Order Fulfillment GoalsObjectiveBusiness Rules TriggerTask SetInputsOutputsOutcomes Timely provision of food and service to the customer at the best value Accurately process food order for and receive payment from customers in a minimal amount of time FDA standards for food handling; cashier does not handle food; cashier provides greeting and acts as point of contact for all food stations Customer arrives at drive- through station or counter Greet customer; take order; process order; bill customer and receive payment; receive and deliver food to customer Food and beverage inventory; inventory of paper goods (bags, straws, napkins) Inventory orders; sales activity reports; deposits; incident reports Payments received, timeliness of order fulfillment; number of customer complaints; incident reports

© 2009 Public Health Informatics Institute Sally’s Sandwich Shop

© 2009 Public Health Informatics Institute Context Diagrams Entity

© 2009 Public Health Informatics Institute Sally’s: Order Fulfillment Payment Bill Order detail Greeting Change Sandwich Drink Side salad Customer Sandwich order Sandwich station Drink order Side order Side station Drink station Order taker

© 2009 Public Health Informatics Institute Task Flow Diagrams Task A Task B Task C Task Series 1 Task D Task E Task F Task Series 2 Task Decision Choice B Choice A Information Flow

© 2009 Public Health Informatics Institute Sally’s Task Flow Order Fulfillment Sally’s Lunch Stop Provide Payment Provide Bill Amount Complete Transaction Receive Food End Give Food Yes No Food Ready? Sally’s Lunch Stop Public Prep. Station(s ) Order Taker Customer Start Arrive Greeting Provide Order Detail Record Order Receive Order Prepare Food Deliver Food to Cashier

© 2009 Public Health Informatics Institute Questions so far? QA &

© 2009 Public Health Informatics Institute Collaboration

© 2009 Public Health Informatics Institute Stakeholder Analysis: Influence / Interest MatrixLowHigh Low High HIGH Interest LOW Influence LOW Interest LOW Influence STRATEGY: Passive relationship management STRATEGY: Provide information, status updates LOW Interest HIGH Influence HIGH Interest HIGH Influence STRATEGY: High levels of communication and attention, goal alignment STRATEGY: Active engagement, targeted communication, goal alignment, leverage influence

© 2009 Public Health Informatics Institute Choose C Measure M Examine E Redesign R Test T Business Process Redesign Steps

© 2009 Public Health Informatics Institute Choosing a Process to Redesign Is it inconsistent? Antiquated? Inefficient or redundant? High volume? High risk?

© 2009 Public Health Informatics Institute 2 x 2 Table Low Low High High

© 2009 Public Health Informatics Institute Building a Home in Mahoning County

© 2009 Public Health Informatics Institute Why Measures Are Critical Provides objective, quantifiable way to see if new, redesigned process is really better than the old one What can we measure to quantify differences in performance between the old process and the redesigned process?

© 2009 Public Health Informatics Institute Public Health Application

© 2009 Public Health Informatics Institute Examine Symptoms of Inefficiency Duplication of effort Unnecessary tasks Long cycle times Processes unclear to staff Lots of activity for an unimportant task Quality checks too distant from the process

© 2009 Public Health Informatics Institute Principles of Redesign Eliminate unnecessary tasks Streamline tasks Group administrative tasks Perform steps in parallel Use multiple versions of the process Minimize handoffs Find and remove bottlenecks Smooth work flow Avoid cumbersome translations and interfaces Use automation Help all process participants feel ownership Measure outcomes, not tasks or handoffs Eliminate unnecessary tasks Streamline tasks Group administrative tasks Perform steps in parallel Use multiple versions of the process Minimize handoffs Find and remove bottlenecks Smooth work flow Avoid cumbersome translations and interfaces Use automation Help all process participants feel ownership Measure outcomes, not tasks or handoffs

© 2009 Public Health Informatics Institute Pilot Testing Test before invest Start on small scale Gather feedback

© 2009 Public Health Informatics Institute The PDSA Cycle SOURCE: Institute for Healthcare Improvement, Improvement Guide, P 10 Present: So many of you in the room are probably familiar with this diagram and may have used the

© 2009 Public Health Informatics Institute The PDSA Cycle A P D S A P D S S A P D A P D S SOURCE: Institute for Healthcare Improvement, Improvement Guide, P 10

© 2009 Public Health Informatics Institute Questions and Discussion QA &

© 2009 Public Health Informatics Institute Thanks for attending! For more information about the Public Health Informatics Institute, visit us on the web at