1. Quality Improvement Workflow Design Lecture a
Welcome to Quality Improvement: Workflow Design. This is Lecture a. In this first segment we will review how to assess a workflow and how to create a process flowchart.
Lecture a
This material (Comp12_Unit6a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

2. Workflow Design Learning Objectives─Lecture a
Assess decision-making requirements in health or healthcare.
Construct a work process flowchart.
The Objectives for Workflow Design are to:
Assess decision-making requirements in health or healthcare.
Construct a work process flowchart.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

3. Quality Improvement Workflow Design Lecture a
Definitions
Workflow: series of linked steps through which a process is accomplished within a given system
Workflow analysis: description of the sequence of events that are part of a process
Flowchart: the tool used to perform the workflow analysis that provides a graphic representation of the process
Workflows are a series of steps through which a process is accomplished within a given system. Through their analysis, we describe the sequence of events that are part of a process thus improving our understanding of the system this process is part of. Finally, the flowchart is a tool used to perform a workflow analysis that provides a graphic representation of the process.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

4. Use of Workflow Design in HIT
Implement existing HIT solutions/products in clinical sites
Design new HIT solutions/products for use in the health care field
Enhance and update existing HIT solutions/products
Workflow design has an important role in HIT. The majority of students taking this course will most likely require the use of workflow analysis and the creation of process flowcharts to implement existing HIT solutions in clinical sites (ambulatory or hospital sites). This is a tremendously useful tool used to adapt out of the box solutions to the needs of a specific environment. This technique affords a significant understanding of the system as a whole and of its specific processes.
Workflow design is also crucial in the design of new HIT solutions or products for use in the healthcare field. It is also important to understand the work process flow when enhancing and updating existing HIT products.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

5. Why Perform a Workflow Analysis?
Shows unexpected complexity, problem areas, redundancy, unnecessary loops, and areas where improvement is possible
Compares actual vs. ideal flow of processes
Allows team to come to agreement as to where to make changes for improvement
Identifies areas where additional data are needed
Serves as a training tool (Brassard & Ritter 1994)
A good workflow analysis allows the team to better understand the system and its constraints, thus better adapting the HIT solution to the needs of the system. The workflow analysis shows unexpected complexities, problem areas, redundancy and unnecessary loops that might not have been immediately obvious to the team. These areas allow for standardization and simplification, thus improving the process and its outcomes. For instance, you may find that a specific process is done differently in the five different floors of your community hospital. You will be able to use the HIT implementation to make sure the process is done the same way throughout the hospital. Some of these differences are obvious but others require a concerted analysis to identify them.
Workflow analysis facilitates the comparison of the actual flow and the ideal one. The way you define an ideal process depends on the general goals of the system but in general, ideal processes are those that are accomplished with the fewest steps and are accomplished with the fewest staff members.
During workflow analysis, teams can discuss and agree to the changes after having reviewed the workflow. They are important tools used to improve processes during HIT implementation periods (or during any other improvement effort).
Workflow analysis also identifies areas where additional information is needed to better understand the system. It is not unusual for a team to get together to analyze their workflow and realize they don’t really know how a specific step is accomplished.
Finally, it can be used as a training tool. Once you have analyzed the workflow you can use the results of this analysis to train new staff to the processes in the institution or train staff in the use of the new HIT solution.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

6. Workflow Analysis Methods
Qualitative
Ethnographic observation
Shadowing of individual clinicians
Surveys and questionnaires
Human-intensive; produce low-volume, high-quality data
Quantitative
Sensor technologies such as passive infrared sensors, radio identification tags, and pressure sensors
Video recordings
Allow time stamping; produce high volume abstract data
(Vankipuram et al 2010)
There are two methods of workflow analysis: qualitative and quantitative. Qualitative methods are human intensive and tend to yield a low volume of high-quality data. Such techniques include ethnographic observation, shadowing of individual clinicians, and surveys and questionnaires. Ethnographic observation is when the observer lives in and among the clinicians being studied for a prolonged period of time and participates in the daily life of the clinician, taking copious notes on the details of the clinical workflow to find patterns. Shadowing of individual clinicians and clinical groups is used more frequently to discern clinical workflow, as well as clinician surveys and questionnaires. Quantitative methods employ sensor technologies such as passive infrared sensors, radio identification tags, and pressure sensors, as well as video recordings. These methods allow accurate time stamping and produce high volumes of data that have abstract reference to clinical workflow. In addition, they are often costly and the static location of sensors can provide a limited view.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

7. Analyze Requirements: Workflow Integration Matrix
Analyze workflow
Verify and prioritize findings with clinicians
Communicate with development team
Conceptualize and evaluate design
(Jalote-Parmar A., et al, 2010)
A workflow integration matrix is a comprehensive tool specifically used to analyze requirements to build a new HIT solution. A workflow-integration matrix is built on the theory of problem solving in complex workspaces and cognitive task analysis. It aids in the analysis of the current workflow, the design of the future workflow, and creates a bridge between the current clinical workflow and the future workflow technological solutions.
The workflow integration matrix is comprised of five steps. The first step of analysis is to investigate and verify each clinical milestone. Clinical milestones are critical steps that need to be performed to complete the clinical procedure. The best people to identify these clinical milestones are the clinicians who actually perform the procedure. The second step of analysis is to analyze workflow. It provides a description of the context and conditions in which processes occur, where errors could potentially exist, and where efficiencies are possible. The third step of analysis is to verify and prioritize findings with clinicians. Since the results of workflow analysis serve as the basis for development of expert clinical decision-making systems, it is essential that we validate that each observation and clinical problem is considered critical by the clinicians for developing a technological solution. The fourth step of analysis is to communicate findings with the multidisciplinary development team. Innovative ideas, current clinical trends, and possible solutions are documented in future workflow planning. The final step of analysis is to conceptualize and evaluate the design. This design is based on current technologic feasibility and clinical viability.
Once all requirements are analyzed using the workflow integration matrix, the development teams will design a prototype and the prospective users will evaluate the prototype. The design cycle is considered human-centered because clinicians are involved in the design every step of the way to ensure that the design supports their clinical workflow and information flow processes.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

8. Quality Improvement Workflow Design Lecture a
Work Process Flow
Think about an everyday activity. You are sleeping peacefully and your alarm clock rings to wake you up for work. You may not feel ready to get up and face the day. So you hit the snooze button to catch 5 more minutes of sleep. Of course those 5 extra minutes pass very quickly, and your alarm clock rings again. So, you climb out of bed and start your day. How would you depict these activities in a work process Flowchart?
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

9. Work Process Flowchart
This is a very simplistic work process flowchart of how I rise in the morning. When my bedside alarm rings, I have a decision to make. Am I ready to get up? And if I say no (which happens more often than I care to admit), I hit the snooze alarm and go back to sleep for 5 more minutes. If I say yes, I get out of bed and proceed with my day.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

10. Work Process Flowchart
Simple diagrams
Used to define and analyze processes
Clarifies understanding of a process
Communicates how a process works
Illustrates a step-by-step picture of a process
Identifies areas for standardization or improvement in a process
Work process flowcharts are very useful in defining and analyzing processes. They help to clarify understanding of a process and communicate how the process works. They provide a step-by-step illustration of the process and how they help to identify areas for standardization or improvement.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

11. Work Process Flowchart
Elongated circle = start or stop point
Rectangle = actions or instructions
Diamond = decision-point
Arrow = connector that shows the flow
There are a wide variety of symbols that are used for flowcharting, but it is best to keep it simple. The five symbols depicted in this slide are those that are used most frequently. An elongated circle depicts the start or stop point of the process. A rectangle signifies actions or instructions. A diamond shows a point at which one must make a decision. Arrows are used to illustrate the flow of the process.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

12. Work Process Flowchart
Symbols used for more detailed flowcharts include those for documents, delays, connectors (or when a process has too many steps you need to go to another page so you use a connector to point to that page), databases, and clouds (which are used for note taking).
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

13. Work Process Flowchart
High Level
Shows 6–12 steps
Presents a panoramic view of a process
Shows the major blocks of activity
Useful in early phases of a project
Detailed
Close-up view
Presents a detailed view of process steps
Shows complexity
Useful once issues have been defined and changes are to be made
There are two broad types of work-flow-process charts. High level process charts are limited to 6-12 steps and present a panoramic view of the process. High level flowcharts show the major blocks of activity and are very useful in the beginning phases of a project. Detailed flowcharts, on the other hand, present a close-up, detailed view of process steps. These charts reveal the complexity of the process, indicating points of delay, unnecessary work, and duplication. These are useful once issues have been defined and changes are to be made to the process.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

14. Work Process Flowchart
Get the right clinicians in the room
Define the start and end points of the process
Complete a high level picture
Decide on the level of detail required
Brainstorm tasks and decisions made
Describe the process as it really exists
Here are some tips from the Institute of Healthcare Improvement (IHI) to achieve successful work-process flowcharting. First, you need to get the right clinicians in the room—those who know the process best. You want to begin by defining the start and end points of the process. At first you will want to strive for a complete high level picture, but you will then need to decide on the level of detail required. Next, you should help the clinicians brainstorm tasks and decisions made during the process. They will need to describe the process as it really exists, not as they wish it existed.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

15. Work Process Flowchart
Clearly define each step in sequence
Include problems
Identify delays or non-value added steps
Make notes about unfamiliar steps
Go back and fill in the branches
Assign action items to fill in unfamiliar steps and verify accuracy
You will want to clearly define each step in sequence. Include problems that are frequently encountered in the process as well as points of delay or process steps that do not add value. Make notes on unfamiliar steps. Then go back and fill in further details. Once you have completed the process flowchart, assign action items to fill in unfamiliar steps and to verify the accuracy of the chart.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

16. Quality Improvement Workflow Design Lecture a
Create a Workflow
Your team determines it is having issues documenting tuberculosis skin tests (PPD). This is a process that spans over three days and involves providers and support staff.
When the provider orders a PPD, the medical assistant places it in the forearm. It takes three days for the body to react, by which time the patient needs to come back to the clinic with an appointment (which needs to be made before the patient leaves).
When the patient arrives in three days, the nurse examines the result. If the result is negative the nurse documents it in the EHR. If it is positive the provider is contacted for a follow-up decision and the result is documented.
Your team determines they are having issues with the documentation of tuberculosis skin test (PPD). To address it, the team decides to create a flowchart so they can determine where the errors are occurring. This is a process that spans over three days and involves providers and support staff. You talk to providers, nurses, and medical assistants (MA). You discover the following flow:
When the provider orders a PPD, the MA or the nurse places it in the forearm. It takes three days for the body to react by which time the patient needs to come back to the clinic with an appointment (which needs to be made before the patient leaves).
When the patient arrives in three days the nurse examines the result. If the result is negative, the nurse documents it in the EHR. If the result is positive, the clinician is contacted for a follow-up decision and the result is documented, which completes the process.
Please pause the presentation and attempt to create a flowchart that reflects this process. Once you restart, we will present you with a workflow that represents this process.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

17. Flowchart: The PPD workflow
PPD workflow describes the flow in the clinic starting with the clinician ordering the PPD, followed by the MA or nurse placing the PPD and documenting, the MA or nurse giving the patient an appointment in 72 hours, nurse reading PPD, and documenting results. There is now a decision diamond asking whether the PPD is positive. If no, document decision in EMR. If yes contact ordering clinician for follow up decision and document decision in EMR.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

18. Workflow Design Summary─Lecture a
Work process flowcharts are useful in defining and analyzing processes.
Understanding workflow and information flow is required to maximize HIT use.
Lean thinking is helpful in maintaining a patient-centered approach.
The key to success is to involve those who know the process best.
This concludes Lecture a of Workflow Design. In summary, work-process flowcharts are useful in defining and analyzing processes. Understanding workflow, information flow, and clinician needs in healthcare environments can contribute to developing strategies to maximize HIT use and to enable clinicians to take full advantage of the capabilities of HIT systems. Lean thinking principles can be helpful in maintaining a patient-centered approach to workflow analysis. The key to success is to involve those people who know the process best.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a

19. Workflow Design References─Lecture a
Brassard, M. & Ritter, D. Flowchart. The Memory Jogger II. GOAL/QPC 1994
Jalote-Parmar, A., Badke-Schaub, P., Ali, W., Samset, E. Cognitive processes as integrative component for developing expert decision-making systems: a workflow centered framework. J Biomed Inform Feb; 43(1): Epub 2009 Jul 14.
Vankipuram, M., Kahol, K., Cohen, T., Patel, V.L. Toward automated workflow analysis and visualization in clinical environments. J Biomed Inform May 29. [Epub ahead of print]
Images
Slide 8: An Alarm Clock. Creative Commons. Alan Cleaver_2000. Available from:
Slide 9: Work Process Flowchart. Courtesy Dr. Stephanie Poe
Slide 11: Work Process Flowchart. Courtesy Dr. Stephanie Poe
Slide 12: Work Process Flowchart Symbols. Courtesy Dr. Stephanie Poe
Slide 17: PPD Workflow Courtesy Dr. Stephanie Poe
No audio.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Workflow Design Lecture a