1. Health Care Workflow Process Improvement
Concepts of Workflow Process Improvement
Welcome to the Health Care Workflow Process Improvement, Concepts of Workflow Process Improvement. This is Lecture b, Clinical Workflows.
Lecture b
This material (Comp 10 Unit 1) was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC This material was updated by Normandale Community College, funded under Award Number 90WT0003.
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2. Learning Objectives
Describe the purpose of process improvement in the clinical setting.
Identify the components of clinical workflow.
Describe the unique aspects of health care which add complexity to workflow process improvement
Identify the benefits of health care workflow process improvement and the priorities to consider when implementing changes.
The objectives for Lecture b are to:
Describe the purpose of process improvement in the clinical setting.
Identify the components of clinical workflow.
Describe the unique aspects of health care which add complexity to workflow process improvement
Identify the benefits of health care workflow process improvement and the priorities to consider when implementing changes

3. Workflow is a Process Workflow includes: How tasks are accomplished
By whom
Task order
Task priority
Task timing
Choices and decisions
Location
Information needs
The main focus of this component is workflow. Recall, a workflow is a process, it includes activities, entities (people or things that take part in the activities), and criteria that specify the order, priority and timing of the steps. Choices and decisions as well as the information needs are specified. Often, the physical location where the task occurs or proximity to performance locations of other activities need to be considered. All of these things together comprise workflow.

4. Clinical Care Activities
Interaction with patients
Physical assessment
Ordering and conducting diagnostic tests
Decision making and diagnosis
Developing a treatment plan
Assessing compliance with treatment regimen
Patient education
Follow-up on test results
Records creation and management
Determination of confidentiality / privacy requirements
A patient visit to a provider’s office, can be broken down into their component processes; these processes are composed of more detailed activities. Examples of these activities in clinical care, listed here, include interaction with patients, physical assessment, ordering tests, making a diagnosis, developing a treatment plan, following-up on test results, etc. Successfully performing workflow analysis and process redesign in health care settings requires familiarity with common clinical activities, processes and how they vary in different clinical settings.

5. Administrative Activities
Scheduling a patient visit
Registering a patient
Transporting and tracking a patient within a facility
Submitting a claim for reimbursement
Making a referral to a specialist
Sending / receiving health information to / from another provider
Food and laundry service
Clinical care also depends on administrative activities that are necessary for care. They include scheduling, transportation, documentation, billing, food service, laundry, and maintaining an inventory of supplies. These activities that impact the workflow during a clinical encounter, e.g., a visit to a provider’s office, or the flow of the visit from the perspective of the patient or provider are often considered in workflow analysis and process redesign.

6. Grouped Activities (Tasks)
Admission
Surgery
Specimen collection
Reimbursement
Discharge
Handling of inpatient emergencies
Single activities (also called tasks or steps) are grouped together, “grouped activities” into processes. Some examples of activities grouped into processes include: Patient Admission, surgery, collecting lab specimens, etc.
The point is that steps in a process can be thought of in groups of smaller steps, or as individual steps. The detail level at which one thinks about clinical workflow depends on the detail level that is needed. For example, a professor teaching a new procedure to a resident will describe each single step. However, the medical assistant scheduling the procedure for a patient will think of the procedure as one step, the procedure.

7. Examples of Roles in Health Care Settings
Providers
Medical Assistants
Phlebotomists
Receptionists
Billing Coordinators
There are several roles that are common to many health care practices. These include providers, (which can be physicians, physician assistants, nurse practitioners, and nurses), and allied health professionals. Allied Health professional roles are those “involved with the delivery of health or related services pertaining to the identification, evaluation and prevention of diseases and disorders; dietary and nutrition services; rehabilitation and health systems management, among others.” (ASAHP, 2011).
While the providers are licensed professionals, there can be overlap in the roles. For example, the nurse may weigh the patient and take vital signs and a history, or these tasks may be performed by a medical assistant. Patient education may be provided by any of the providers. Any of the providers or a phlebotomist may draw blood for lab tests. Thus, when analyzing workflow, the role that performs a task must be clear. Clinics that perform outpatient procedures and hospitals tend to have more complex processes that involve even more roles.

8. Location, Location, Location
Where tasks are performed can be important
Physical layout of a clinic impacts workflow
Patient transportation
Hallway traffic
Distance clinic staff must travel to accomplish tasks
Patient privacy
The physical layout of a clinic can impact workflow because it determines where tasks are performed. For example, can the patients be weighed on the way to the exam room, or must they go past the exam room, get weighed, then come back, creating more hallway traffic? If patients must walk down the hallway, do they pass other patients, or pass procedure rooms? Do patients have to walk past exam rooms or back through the waiting room to leave the clinic? Are printers and copiers located conveniently for clinic staff who need them?
While changes in the physical layout of a clinic may not be feasible as part of process redesign, layout and its impact on physical workflow must be taken into account.

9. Information Needs
What information is used and generated in the course of a patient encounter?
Do providers and clinic staff have ready-access to information they need when they need it?
Do patients have access to information about their health before, after and between visits?
Health care is an information-intensive endeavor, and information needs are an important part of workflow. For example, one of the Meaningful User requirements is to maintain an active medication list for patients, meaning providers are required to reconcile the information they have about medications a patient is taking at each visit. This requires that the patient knows what medications he takes, and that the provider can both access the records of medications that the patient is on AS WELL AS be able to update that list. In this situation, to better meet the patient and provider needs, this process could be improved by providing the patient information before their visit. The provider could give the patient a blank form to complete at home while they have ready access to their medications, or a pre-filled form with their medications that the doctor has on record.

10. Unique Aspects of Health Care
System of “experts”
Physicians and physician extenders are ultimately ethically, morally and legally responsible for everything that happens to a patient
Physicians have taken an oath to “above all, do no harm”
Health care usually involves personal contact
Decisions impact patient’s health and well being
Patient care involves teams of people working in information-intense situations
Patterns of fundamental clinical routines are the product of years and decades of evolution
Conducting workflow analysis and process redesign in health care is different than working in other settings because of the unique aspects of health care.
You will be working within a “System of ‘experts’” and a culture in which
Physicians and physician extenders are ultimately ethically, morally and legally responsible for everything that happens to a patient, and in which
Physicians have taken an oath to “above all, do no harm”
Health care involves one-on-one contact with people
Decisions sometimes make the difference between “life or death”, or have the potential to seriously impact a person’s health
Patient care involves teams of people that depend on minute to minute communication and large amounts of information, and
Patterns of fundamental clinical routines are the product of years and decades of evolution. This evolution involves complex interactions between members of the health care team, technology, information, external forces and organizational factors. Sometimes the result of this evolution is a process that operates optimally. Other times, processes are the relic of compromises or constraints that are no longer important. Only careful analysis can differentiate the two.

11. Complexities of Health Care
Each situation is unique
Involve multiple people and organizations
Many opportunities for delays and variability
Must take patient preference into account
Continually changing priorities
Many interruptions, options and exceptions
Have overlapping roles and responsibilities
Involves Humans and organizations
Vary from practice to practice
Subject to time and resource pressures
Other unique aspects of health care and clinical workflows that make workflow analysis and process redesign complex include the fact that clinical workflows:
Vary from practice to practice,
Involve multiple people and organizations, thus there are many opportunities for delays and variability,
Must take patient preference into account,
Have many interruptions,
Have many options and exceptions,
Have overlapping roles and responsibilities, and
Involves humans, organizations, information, and technology.
Because of the need to contain costs, health care today is subject to considerable time and resource pressure.

12. Pulling it all Together
Clinical Workflow Impacts Patients
Problems, errors and delays are not just aggravating, inefficient or even infuriating
In medicine, more than in other fields, problems, errors and delays can cause serious harm
There are many factors that differentiate health care from other industries. One looms larger than all the rest. Health Care is about life and death. Care, including preventative care, directly impacts an individuals health and wellness. Many decisions and actions taken in the course of health care involve intervening with someone’s physical or mental functioning. Things that impact the care process directly impact patients.
Problems, errors and delays are not just aggravating, inefficient or even infuriating, they can cause serious harm.

13. Common Processes in Physician Practices
Appointment scheduling
New patient intake
Existing patient intake
Exam and patient assessment
Ordering labs/receiving & communicating results
Prescriptions
Referrals out/in
Diagnostic testing
Billing
Now that we have talked about unique aspects of health care settings, let’s return to common clinical processes. Common processes in physician practices include:
Appointment scheduling,
New patient intake,
Existing patient intake,
Exam and Patient Assessment,
Ordering Labs, and receiving and communicating results,
Prescriptions,
Referrals both out and in,
Diagnostic testing,
Billing,
Reporting, and
Monitoring patient outcomes.
On the next slide, you will have the opportunity to watch some videos and identify clinical processes mentioned.

14. Confusion about Workflow
Most people are not accustomed to thinking of what they do everyday in terms of workflow
Terms used in health care that may be confused with workflow or process analysis:
Regimented care
Clinical pathways, clinical guidelines
Accreditation and audit
Most people are not accustomed to thinking of what they do everyday in terms of workflow – that is why we need people trained as workflow specialists, to facilitate this process and to help practices accurately describe and analyze their workflows.
Several terms used in health care that may be confused with workflow or process analysis are:
Regimented care,
Clinical pathways, clinical guidelines, and
Accreditation and audit.
On your own, look each of these terms up and think about the similarities and differences with process analysis. If you don’t normally think of things in terms of workflow, identify three processes that you encounter in your everyday life. Then, for each of these processes, list out the steps that you identified, including those that you may not personally witness but assume to have happened so that you have a complete process described. Consider steps, their order and timing, decisions, locations, information needs, etc. This is an easy way to practice thinking in terms of workflow.

15. Workflow Changes Must first, do no harm Must improve processes
Increase efficiency
Decrease delays and cost
Increase quality and safety
Improve the work environment
Improve ability to care for patients
Create a better overall patient experience
Workflow changes in the clinical setting, like physicians, “must first, do no harm,” and secondly must improve the following processes. Processes can be improved by:
Increasing efficiency,
Decreasing delays, errors, and cost,
Increasing quality and safety,
Improving the work environment,
Improving ability to care for patients, and
Creating a better overall patient experience.

16. Concepts of Workflow Process Improvement Summary
What a Practice Workflow and Information Management Redesign Specialist Does
Document context and process so that it can be analyzed
Analyze process
Recommend redesign options
Implement redesign
Evaluate, adjust and maintain changes
This concludes Fundamentals of Health Workflow Process Analysis & Redesign. This unit consisted of 2 lectures, lecture a, Concepts of Workflow Process Improvement and lecture b, Clinical Workflow.
In summary, the purpose of Clinical Process Redesign is to improve the safety, efficiency and overall quality of health care. Meaningful use of Health IT can help do this. The Practice Workflow and Information Management Redesign Specialist role helps practices improve the safety, efficiency and overall quality of care by leveraging Health IT. The Practice Workflow and Information Management Redesign Specialist role:
Documents context and process so that it can be analyzed,
Analyzes process,
Recommends redesign options, including opportunities to leverage Health IT,
Works with practices to implement redesigned processes, and
Evaluates, adjusts and maintains changes.
The Specialist may do these things himself, or may teach groups of practices and facilitate groups to do the analysis and redesign themselves.

17. Concepts of Workflow Process Improvement References – Lecture b
Allied health professionals. (n.d.). Retrieved December 29, 2011, from Association of Schools of Allied Health Professions:
Committee on Quality of Health Care in America and Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century Washington: National Academies Press.
Eligible provider meaningful use meaningful use core measures measure 5of 15 -Stage 1. (2010, November 7). Retrieved December 29, 2011, from
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18. Concepts of Workflow Process Improvement Lecture b
This material was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC This material was updated by Normandale Community College, funded under Award Number 90WT0003.
No audio