3. ï§
ï§
To Err is Human:
Building a Safer Health
System
Placed quality on the
national agenda
Need well designed and
managed âsystems of careâ
4. IOM report: the problem
A fragmented system characterized by
unnecessary duplication, long waits, and
delays.
ï„ Poor information systems: Healthcare is a
âknowledge based businessâ but information
is poorly delivered
ï„ Doctors now suffer from the âinformation
paradoxâ--drowning in information but cannot
find the information they need
ï„ Patient information is often neither evidence
based nor easily accessible
ï„
5. IOM report: the problem
ï„
A system designed for episodic care when
most disease is chronic
ï„
Health care providers operate in silos
6. IOM report: 10 rules for redesigning
health care
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Care based on continuous healing relationships--care
whenever its needed, not just through face to face visits
Customization based on patient needs and values
Patient as the source of control
Shared knowledge and free flow of information
Evidence based decision making
Safety as a system property
The need for transparency--all information available,
including the systemâs performance on safety, evidence
based practice, and patient satisfaction
Anticipation of needs
Continuous decrease in waste
Cooperation among clinicians
7. In Canada,
ï„
ï„
ï„
There are 9,200 to 23,750 preventable deaths each year.
Almost equivalent to 1 jumbo jet crashing each week with 300
lives lost.
Medical errors are now the 4th leading cause of death in
Canada.
ï„
Numerous multi-million $ projects have been launched in an
attempt to identify solutions with varying degrees of success
and failure.
ï„
One transformative initiative has been neglected. That is,
providing practitioners with robust, evidence-based order
sets with the essential up-to-date knowledge and tools to
properly treat patients at the actual point-of-care.
8. To appreciate the significance of this
transformative change,
one needs to understand how care is
typically delivered in hospitals today?
9. âEvery system is perfectly designed to
get the results it consistently achievesâ
âDr. Donald Berwick
10. Workflow Design Concepts
Think healthcare delivery
as a âsystemâ with a large
number of components
ï„ Focus efforts on reducing
non-value added activities
ï„ Reduce backlogs or wait
times & consider parallel
execution.
ï„
12. Lean Six Sigma Process
ï„
Current Lean Six Sigma Project
Methodology
Focus on âPeopleâ and âProcessâ
ï„ * Lean â eliminate waste (speed)
ï„ * Six Sigma â standardize (variation)
ï„
14. Key Steps to Optimize Workflow
Redesign
ï±Document
ï±
Your Processes
Survey and assess your practice system: Staff? Patients?
External Services? Suppliers? Others? ASK : How do we do it better?
ï±
Involve representatives of your practice system: MDs,
Nurses, ancillary services, etc.
Prioritize (Strategic goals)
ï± Select a process
ï± Workflow design tools (Flowchart the process: Microsoft
Visio; modeling software)
ï± Select a Solution: PDCA, Lean, 6 sigma.
ï±
15.
16. Documenting Workflow
START/END: Indicates where the workflow starts and where it terminates, for the
purpose of the map
OPERATION: A specific task or activity that takes place from an expenditure of
labor, a processing activity, or a combination of both.
DECISION POINT: A point within the flow of work in which a question must be
answered to determine the next path or direction for the work.
DELAY: Indicates the work or product goes into a wait line or delay.
DIRECTION: Arrows indicate the direction of the flow of information
DOCUMENT: Data that can be read by people, such as printed output
CONNECTOR: Use this to create a cross-reference and hyperlink from a process on
one page to a process on another page
ON-PAGE REFERENCE: Use this to create a cross-reference to another point on
the same page
17. Patient
Pa ti ent Check-in Paper Process
Patient
Arrives
Signs in at
Front Desk
Marks Patient
Arrival
Patient Completes
Forms
Yes
New
Patient?
Give Pt. Forms to
fill out, collect &
copy insurance
card
No
Collect and file
forms in newly
created chart
Front Desk Receptionist
Pull Paper Chart
(from staging
area)
Does Pt
Info need
to be
updated?
Yes
Yes
Record updates in
paper chart,
collect & copy
insurance card if
needed
No
Collect Payment &
generate record of
payment for billing
department
Yes
Does copay need
to be
collected?
No
Generate
Flowsheet
Put chart & flowsheet in
bin indicating patient is
ready for rooming
18. Examining Areas for
Improvement
ï„
After mapping existing workflows, the staff should ask themselves the
following questions:
ï„
ï„
ï„
ï„
ï„
ï„
ï„
ï„
What are the best steps in the process?
What makes those the best steps?
What are we doing right? (Best can be defined by practice goals and
vision, such as efficiency, client satisfying, etc.)
What steps could use improvement?
What are the least effective?
What makes those steps the least effective?
How could we improve those steps?
Use the answers to these questions to aid in planning a future workflow
with the new process.
Health Information Technology Research Center (HITRC)
19. Patient
Patient Check-in Process â EHR is Fully Integrated/Interfaced with Practice
Management System (PMS)
Patient
Arrives
Signs in at
Front Desk
Marks
Patient
Arrival on
EHR
Patient Completes
Forms
Yes
New
Patient?
Give Pt. Forms to
fill out, collect &
scan insurance
card
No
Collect and enter
information in
EHR
Front Desk Receptionist
Select Patient
from EHR
Does Pt
Info need
to be
updated?
No
Collect
Payment &
record into
EHR
Yes
Yes
Yes
Record
EHR,
scan
card
updates in
collect &
insurance
if needed
MU Objective:
Record Pt
Demographics as
Structured Data
Does copay need
to be
collected?
No
Mark âpt is readyâ for
rooming into EHR
21. Automation
Surprises!
adding automation is like adding another team
member, but one who may not speak the same
language or share the same cultural
assumptions.
When automation is implemented that does not
speak the same language as the user or share
the same mental models, it results in what is
called âautomation surprises.â
Clinical Practice Improvement and Redesign: How Change in Workflow Can Be Supported by Clinical Decision Support,
AHRQ Publication No. 09-0054-EF, June 2009
22. Testing
Test the new workflow using different clinical
and patient encounter scenarios with the
staff. This will increase the likelihood that
youâve accounted for all possible required
steps.
ï„ Once implemented, conduct time-motion
studies to determine if the new workflow is
optimal or if there could be improvements
made to the number of included steps.
ï„ Use of CPOE system may not necessarily
save time, however, improve outcomes and
safety.
ï„
23. Problems Ordering Treatments for
Patients
For each patient, the practitioner has to remember:
ï„ All of the appropriate tests, medications and treatment options
ï„ The right sequence of steps
ï„ The right drug among many similarly named options
ï„ To write legibly (if on paper)
ï„ This process of practitioners writing by hand all the treatments
required from memory poses a real challenge to the practitioner
as:
ï„ Each patient typically has many conditions that need to be
addressed
ï„ There are thousands of medical conditions the doctor must
remember
ï„ Patients can often need 60 or more orders to receive all the care
required
ï„ Modern medical knowledge is constantly evolving
24. This haphazard process understandably
results in:
Wasting of a practitionerâs time by having to
handwrite from scratch each order (if using
paper)
ï„ Medical errors
ï„ Reduced patient safety and quality of care
ï„ Ordering of unnecessary treatments
ï„ Forgetting to order necessary treatments
ï„ Longer hospital stays
ï„ Higher rate of patients returning to hospital
ï„ Lawsuits
ï„
25.
26. None of this knowledge is delivered to
the clinician when needed at the
patient
bedside!
27. The five ârightsâ
1.
2.
3.
4.
5.
The right information
The right person
The right intervention format
Through the right channel
At the right time in the workflow
28. Problem of Health Records
Current health records are:
ï„ Paper based
ï„ Disorganised
ï„ Often illegible
ï„ Lost
ï„ Scattered
ï„ Poorly linked
29. How do you think future Health
Records will be?
Electronic, lifelong, perhaps recording all
food and drink consumption, exercise, etc
Accessible from anywhere
Linked to other records, like social care
Able to show Multimedia Results
Collect information from sensors in
the body or home
30. Traditional CPOE
Automates Physician Order Writing
ï„ Focuses on Reduction of Medication
Errors as Primary Benefit
ï„ Mostly Manual Handoffs Downstream from
Electronic Order
ï„ In-house Development Resulting in a
Proprietary System
ï„
31. How can we improve
implementation of
EBM through CPOE?
32. Building a CPOE
implementation
One effective first step in the planning
process is for the team to segment tasks
into three categories:
ï„ What new work tasks/process are we
going to start doing?
ï„ What work tasks/process are we going
to stop doing?
ï„ What work tasks/process are we going
to sustain?
33. Contemporary CPOE
ï
Electronic transmission of physician orders directly to
targeted pharmacy, lab, radiology, dietary and nursing
subsystems.
ï
Re-engineering of complete service delivery workflow
Decision Support tools including:
ï§ Allergy Checking
ï§ Drug Interaction
ï§ Order Duplicate Checking
ï§ Corollary Order Checking
ï§ Weight-Based Dosing
ï§ Drug Route Restriction
ï§ Evidence-Based Order Sets
34. Corollary orders are trigger and response pairs that cause DSSs to suggest
consequent orders in response to an antecedent order.
(An example is Warfarin, prothrombin time each morning, or, âSince you ordered
warfarin, you might also be interested in ordering prothrombin time each morning.â)
A Recommendation Algorithm for Automating Corollary Order Generation- AMIA 2009 Symposium Proceedings
Page - 333
35. âCorollary Ordersâ
ï„
Randomized Trial of âCorollary Ordersâ
demonstrated that physician workstations,
linked to a comprehensive CPOE, can be
an efficient means for decreasing errors
of omissions and improving adherence to
practice guidelines.
36. Prescribing errors classification
Prescribing errors occur in 1.5-9.2% of
medication orders written for hospital
inpatient.
Adverse drug events (Level 1)
ï„ Potential ADEâs (Level 2)
ï„ Deviations from best practice (Level 3)
ï„
â Failure to deliver optimal dosing schedule
â Failure to monitor drug levels or electrolytes
according to established protocols
â Failure to adhere to local formulary
Vincent C, Barber N, Franklin BD, Burnett S.The contribution of pharmacy to making Britain a safer place to take
medicines. Royal Pharmaceutical Society of Great Britain: London; 2009.
39. Trigger Orders
Heparin infusion
IV fluids
Insulin (all kinds)
Oral hypoglycemic agents
Narcotics (class II)
Nonsteroidals
Aminoglycosides
Vancomycin intravenously
Warfarin
Amphotericin B
Angiotensin converting enzyme
inhibitions
Chloramphenicol
Air contrast barium enema, IVP, UGI
Isoniazid
Potassium supplements
Pulmonary artery catheter
Ventilator orders
Vasopressin drip
Response Orders
(1) Platelet count once before heparin started, then once in 24 hours
(2) APTT at start, again after 6 hours of a dosage change
(3) Protime once before heparin started
(4) Hemoglobin at start of therapy, then QAM
(5) Test stools for occult blood while on heparin
(1) Place a saline lock when IV fluids are discontinued
(1) Capillary glucoses (four times a day)
(2) Glycosylated HGB (once if not done in preceding 180 days)
(1) Capillary glucose (twice per day)
(2) Glycosylated HGB (once if not done in preceding 180 days)
(1) Docusate (stool softener) if not on any other form of stool softener or laxative
(1) Creatinine (if not done in previous 10 days: SMA12, BUN counted as equivalent)
(1) Peak and troughs levels after dosage changes, and q week if no change
(2) Creatinine twice per week (q Monday and Thursday)
(1) Measures of serum levels pre and post 4th dose
(2) Audiometry
(3) Baseline creatinine for dose adjustment
(1) Prothrombin time each morning
(1) Creatinine twice per week (q Monday and Thursday)
(2) Magnesium level (twice per week while on therapy)
(3) Electrolytes (twice per week while on therapy)
(4) Acetaminophen (650 mg po 30 min before each amphotericin dose)
(5) Benadryl (50 mg 30 min before each amphotericin dose)
(1) Creatinine at baseline then 2 weeks after dosage changes
(2) Potassium (q Monday and Thursday)
(1) CBC (twice per week)
(2) Retic count (twice per week)
(1) Pregnancy test (if patient is female, in childbearing years, had no hysterectomy, and no pregnancy
tests within 3 days)
(1) SGOT, SGPT (as baseline when drug started)
(1) Electrolytes once each morning
(1) Portable AP chest x-ray (when first placed to check for placement)
(1) Arterial blood gas after changes
(1) Nitroglycerin drip or nitroglycerin paste (if patient having chest pain or known CAD)
J Am Med Inform Assoc. 1997 Sep-Oct; 4(5): 364â375.
40. Working with âNewâ People
Written orders - talked to nurses and unit
clerks who talked to the ordered service
ï„ CPOE - âtalkâ to a computer which relays
questions back fromï„
Pharmacy
ï„ Lab
ï„ Every other ordered service
ï„
41.
42. Investigating Side Effects of Change
âAdopt a proactive approach: examine new
technologies âŠfor threats to safety and redesign
them before accidents occur.â
IOM report âTo err is humanâ p. 150
43. The first rule of any technology
used in a business is that
automation applied to an efficient
operation will magnify the
efficiency. The second is that
automation applied to an
inefficient operation will magnify
the inefficiency.
~Bill Gates
Hinweis der Redaktion
What ? Workflow processes must be re-engineered, including clinic policies and procedures, job descriptions, and scheduling and billing workflows.Who?Involve stakeholders from the beginning. Physician involvement is key to successFind and Remove BottlenecksIdentify constraints, exploited if possible, and removed if necessaryMove Steps in the Process Close TogetherPhysical location of people and facilities can affect processing time and cause communication problems.Use SynchronizationBy focusing on the flow of the patient through the process, each of the step can maximize efficiency.Use AutomationProcesses can be improved by the intelligent use of automation (EHR).
Health records might beElectronic, lifelong, perhaps recording all food and drink consumption, exercise, etcAccessible from anywhereLinked to other records, like social careMultimediaCollect information from sensors in the body or homeData mined
ADE1 e.g. rash when penicillin is administered to a known allergic patient