Facilitating mtgs fri aft [repaired]

Fundamentals of Workflow Process
Analysis and Redesign
Facilitating Meetings for
Implementation Decisions

This material Comp10_Unit7 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 IU24OC000024.

Effective Meetings
“A single effective meeting will substantially
change the capacity of a group to
achieve desired outcomes” (Bolea & Scott, 2012)
Effective meetings:
• Face the current reality and gap between “as is” and
“where we want to be”
• Identify unused potential to improve, and
• Commit to action / implementation plan

Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign
3
Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting

Meeting Purpose

• to “tee up” the key decisions along with the
information necessary to make them for the
decision makers
• and ultimately, to obtain the decisions needed to
move the project toward successful completion.

4

Key Elements of Success

• Involvement of key personnel
– Have thought through potential solutions
– Results in ownership of ideas
• Solutions
• Develops commitment for implementation
• Immediate focus on changes which will make
the greatest possible contribution to
improvement and “Meaningful Use”
• Initial implementation planning is begun in the
next steps debriefing wrap-up session at the
conclusion of the decision-making meeting
5

Meeting Participants Role
• Work within the established ground rules
• Review decision-making material in advance
– Notify the facilitator in advance if additional
information is needed
– Provide “reality checks”, i.e, question options,
rationale and assumptions used in cost/benefit
analysis
– Participate in decision-making
• Participate actively in the meeting
• Complete action items and follow-up as needed

6

Meeting Logistics
Making arrangements for the meeting
• Scheduling so that necessary decision makers can
attend
• Room size and layout
• Supplies
• Refreshments & breaks
• Travel time & parking
• Building access
• Providing materials in advance such that participants
have time to review them

7

Example Topics for Agenda

• Introductions
• Goal of the meeting and expected
products
• Review of documentation of process
analysis and redesign
• Summary & next steps

8

Conducting the Meeting

• Open the meeting by stating the meeting purpose
– “to make decisions on …”
• Review and follow the agenda
• Monitor the agenda / time
• Encourage participation from all attendees
• Help participants reach consensus
• Document decisions
• Document next steps and follow-up / action items

9

Group Decision-Making Process

• Process resulting in the selection of a course of
action
• Results in a “choice”
• Systems
– Consensus
– Voting-based methods
• Majority required
• Plurality
– Dictatorship

(Wikipedia, 2012)
10

Documenting a Meeting

• Key information to be documented
– Approved / denied process changes
– Priorities for approved changes
– Chosen alternatives
• Next steps
• Action and follow-up items

11

Debriefing Wrap-up

• A wrap-up debriefing at the close of the
meeting summarizes the decisions
• The purposes of the debriefing are:
– To confirm agreement
– To agree on next steps to move forward with
implementing approved changes

13

Major Decisions in EHR-related
Process Redesign

• Which processes to automate or redesign
• Which redesign option to implement
• EHR functionality requirements
• How candidate systems measure up against
requirements
• Process change and system implementation
plans

Health IT Workforce Curriculum Fundamentals of Workflow Process Analysis & Redesign 1
Version 3.0/Spring 2012 Facilitating Implementation Decisions Meeting 4

Example Process Redesign
Meeting Might Include

• Presentation of opportunities for redesign
• For each redesign opportunity:
─Rationale for the change:
─Pros and cons of each competing redesign options, or analysis of
multiple options to justify the chosen one
─Cost assessment of making the change
─Decision whether or not to move forward with the change,
─ if resources were limited, a priority for the change would be assigned.

• Review of approved changes and their priority
• Next steps

15

“BRAND” Change Matrix Template

PROCESS Benefits Risks Alternatives Nothing: Decision
of the action of the of the doing nothing
action prospective at all
action
Process option 1:

Process option 2:

Process option 3:

7.1 Table Change Matrix Template (courtesy of Dr. Meredith Nahm,
2012)

16

Fundamentals of Health Workflow
Process Analysis and Redesign

Quality Improvement Methods

This material Comp10_Unit8a was developed by Duke University, funded by the Department of Health and Human Services,

Quality Improvement in the
Health Care Setting
• Quality Improvement – an approach to improvement of
service systems and processes through the routine use
of health and program data to meet patient and program
needs (Chang, 1999)

• Examples of Quality Improvement Projects
– Redesigning a Clinical Office
– Reducing the time for patient intake
– Redesigning the information flow in a laboratory
– Increasing the access to care

Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign
18
Version 3.0/Spring 2012 Quality Improvement Methods
Lecture a

Three Major Concepts
1. Quality is a Measurable Phenomenon
– Six dimensions : Safe, effective, timely, patient-centered,
efficient, equitable
2. Safety
– Errors are definable and measurable
– The right plan is defined on the basis of professional
standards
– To avoid errors, you must decide on the best plan in the
context of professional standards, and the plan must be
executed
3. Accountability
– Measurable performance with consequences
– Currently lies primarily with physicians
– Physicians will increasingly be held accountable for
performance at the microsystem level

19
Lecture a

Plan-Do-Study-Act Cycle

This simple model
can serve as the
foundation for every
Act on the Plan the project type.
Learnings Action

Study the Do the
Results Action

Also known as:
Shewhart cycle
Deming cycle
Learning and improvement cycle
20

Organizational Culture
• Quality Improvement projects can be aided or
impeded by the organizational culture
• Organizational Culture factors to consider
– Leadership
– Ability to adapt to change
– Communication ability
– Understanding of change or need for change
• Factors needed for success (Ransom, 2004)
– Making quality improvement part of the job
– Leadership support is essential for quality
improvement activities to succeed

21
Lecture b

Quality Improvement

“It is not necessary to change. Survival is
not mandatory”

- W. Edwards Deming
1900-1993

22
Lecture a

Leadership Support
Leaders can enable quality improvement in their
health care settings by:
• Creating and promoting a quality vision
• Increasing staff capacity to support quality improvement
• Motivating staff to participate in QI projects
• Establishing the QI teams
• Demonstrating support of use of metrics to measure
performance
• Making sure that the ‘voice’ of the patient is heard and
acted on
• Involving staff and patients
• Including QI in the budget

23
Lecture b

Quality Improvement Methods

• Many methods
• Human-centered and supportive of the
implementation of Health IT
• Originally tailored for enterprises, not
necessarily health care

24
Lecture b

Associates for Process
Improvement (API)Model
• Developed by Tom Nolan and Lloyd Provost
• Simple model for Process Improvement based
on Deming’s PDSA cycle
• Three fundamental questions form basis of
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
improvement?

25
Lecture b

FOCUS-PDCA

1980s – Focus-PDCA model
• Find an opportunity for improvement
• Organize an effort
• Clarify current understanding
• Understand the process variations and capability
• Select a strategy
• PDCA cycle test the strategy

26
Lecture b

ISO 9000
• International Standards Organization
• 1987 – initial ISO 9000 guidelines for performance
improvement.
• Components
– Design and develop a QI program
– Create a sociocultural environment
• And a structure that supports improvement
– Reduce or avoid quality losses
– Define QI responsibilities
– Develop an improvement planning process
– Develop an improvement measurement process
– Develop an improvement review process
– Carry out QI projects
– Analyze the facts before you decide to do QI

(ISO 9000, n.d.)

Fundamentals of Health Workflow Process Analysis and Redesign
Health IT Workforce Curriculum Quality Improvement Methods 27
Version 3.0/Spring 2012 Lecture b

Kaizen

• Kaizen
– Japanese for change for the better
• Continuous Improvement
– The common English term
– Connotes ongoing improvement involving
everyone
– Assumes our way of life deserves to be
constantly improved
– Includes improvement practices

28
Lecture b

Lean Thinking

• Sometimes called the “Toyota Production
System”
• Consists of five steps:
– Identify which features create value
– Identify the sequence of activities, called the value
stream
– Make the activities flow
– Let the customer pull the product or service through
the process
– Perfect the process

29
Lecture b

Work Flow Diagrams

© 2004 Bluefire Partners
30 Rapid Action Workshops, Session 1, Wave 4, Licensed by Immanuel St. Joseph’s

Lean Thinking

• Assumptions underlying Lean thinking are
– People value the visual effect of flow
– Waste is the main restriction to profitability
– Many small improvements in rapid succession are more
beneficial than analytical study
– Process interaction effects will be resolved through value
stream refinement
– People in operations appreciate this approach
– Lean involves many people in the value stream

• Transitioning to flow thinking causes vast changes in
how people perceive their roles in the organization and
relationships to the product
•

31
Lecture b

Six Sigma DMAIC
1. Define - Project goals and boundaries
are set, and issues are identified that
must be addressed to achieve
improved quality

2. Measure – Information about the
current situation is gathered in order to
obtain baseline data on current
process performance and identify
problem areas

3. Analyze – Root causes of quality
problems are identified and confirmed
with appropriate data analysis tools

4. Improve – Solutions are implemented
to address the root causes of
problems identified during the analysis
phase

5. Control – Improvements are elevated http://www.orielstat.com/lean-six-
and monitored. Hold the gains. sigma/six-sigma-dmaic/overview

32
Lecture b

Measurement: Comparative Analysis of
Process Capability

DPMO IRS - Tax Advice
1,000,000 (phone-in)
(140,000 PPM)
100,000 Restaurant Bills
Doctor Prescription Writing
10,000 Payroll Processing

1,000
• Order Write-up
Journal Vouchers
Wire Transfers
Airline Baggage Handling
100 Purchased Material Med Error
Lot Reject Rate
Best-in-Class
10
1 Average Domestic Airline Flight
Company Fatality Rate (0.43 PPM)

1 2 3 4 5 6 7

Sigma
© 1994 Dr. Mikel J. Harry - V4.0

The Quality Colloquium
Introduction to Track IC:
Six Sigma as a Healthcare Quality Initiative

Improvement Methodology: DMAIC “Backbone”

Control Tools

Sustain

Return on Investment (ROI)
Performance improvement
Improvement
Devise solution(s) and
implement

Benchmarking …and validate root cause(s)

…the current process capability
(get the data!)

…the problem in a measurable way

Project Timeline

The Quality Colloquium
Introduction to Track IC:

Quality Improvement Tools

Quality Improvement Tools
– Flowcharts,
– Cause-and-effect diagrams,
– Statistical Process Control,
– Pareto charts,
– Check lists

© iStock photo, used under license

35
Lecture b

Why Collect Data?
“Data is like garbage. We need to know what we are
going to do with the data before we actually collect
them.”
--Mark Twain

“In God we trust; all others
must bring data.”
W. Edwards Deming

36

Data-Based Decisions

Data and statistical thinking play a vital role
in system and process improvement. It is
essential to understand distribution theory
especially the concepts of shape, center,
spread, and outliers.

37

Measures of Center

Measures of center estimate the center of a
distribution. The three measures of center we
will discuss are the mean, the median, and the
mode.

38

A Distribution Curve
English

300

250

Mean: 54
200

Median: 56
Frequency

150

Mode: 63
100

50

Mean = 53.78
Std. Dev. = 19.484
0 N = 4,253
0 20 40 60 80 100
English

The Normal Distribution Curve

In everyday life many variables such as
height, weight, shoe size and exam
marks all tend to be normally
distributed, that is, they all tend to look
like the following curve.

The Normal Distribution Curve
Mean, Median, Mode
0.025
0.02
0.015
0.01
0.005
0
0 20 40 60 80 100

It is bell-shaped and symmetrical about the mean
The mean, median and mode are equal
It is a function of the mean and the standard deviation

Measures of Spread

Knowledge of spread informs us to what
extent data values vary. We will discuss five
measures of spread:

• Range
• Variance
• Standard Deviation

42

Standard Deviation

The standard deviation is the square root of the variance.

A higher standard deviation indicates higher spread, less
consistency, and less clustering.

Sample Standard Deviation Formula:

S =
2
S

= n
• (Yi - Y) 2
i=1
n-1

43

Bell shaped curve
• empirical rule for data - only applies to a set of
data having a distribution that is approximately
bell-shaped:
• 68% of all scores fall with 1 standard deviation
of the mean
• 95% of all scores fall with 2 standard deviation
of the mean
• 99.7% of all scores fall with 3 standard
deviation of the mean

Distribution Shapes

Exercise:
Describe the following
distributions in terms of
shape, center, spread,
and extreme values. Can
you think of any
examples from your
workplace?

45

Types of Data

Verbatims Yes/No

Categorical Unordered
Types of Data

Count Ordered

Continuous

46

Examples of Verbatims

• “I don’t like to have to wait so long in the waiting room.”
• “All I want is to talk to a human being.”
• “Why do they keep asking for the same information?”
• “I couldn’t understand what the doctor said.”

47

Examples of Yes/No Data

• A patient history is either “updated” or “not updated”
• A diversion either “occurs” or “does not occur”
• A specimen is either “OK for testing” or “not OK”
• A hospital room is either “available” or “not available”

48

Examples of Unordered Categories

• Billing Errors: • Employee Injuries:
- Misspelling - Hand
- Wrong Address - Back
- Wrong Amount - Neck
- Eye
• Customer Complaints - Foot
- Billing Mistake
- Poor care
- Long wait time

49

Examples of Ordered Categories

• Service Score:
- Poor
- Good
- Excellent

• Quality Rating:
- Very Dissatisfied
- Dissatisfied
- Neutral
- Satisfied
- Very Satisfied

50

Examples of Count Data

• The number of errors on twenty prescription labels
• The number of patient falls in a hospital
• The number of sentinel events
• The number of computer system failures in a month

51

Examples of Continuous Data

• Body weight
• The time it takes to room a patient
• The time it takes to clean an operating room
• Cholesterol level
• Blood pressure
• Body temperature
• Room temperature

52

Basic Tools

• CREATIVITY TOOLS
– Although this group is not known as a fixed list of specific tools-that would be incongruent
with the concept of creativity-it typically includes brainstorming, mind maps, Edward
deBono’s (1999) six thinking hats, and the use of analogies
– Help one look at processes in new ways and identify unique solutions

• STATISTICAL TOOLS
– Used for more sophisticated process data analysis
– Help understand the sources of variation, the relative contribution of each variable, and the
interrelationships between variables

• Statistical process control (SPC)
– A graphic means used to monitor and respond to special causes of variation
– A wide range of statistical techniques that can be applied to both parametric and
nonparametric data
– Allows the analysis of the statistical significance of more complex interrelationships

53
Lecture b

Basic Tools
• FLOWCHART
– A map of each step of a process

• CAUSE-AND-EFFECT DIAGRAM
– Ishikawa, or fishbone, diagram
– Assist in organizing the contributing causes to a complex problem (Tague, 2004)

• PARETO CHART
– 80 percent of the wealth in Italy was held by 20 percent of the population (Pareto)

• CHECK SHEETS
– Used to measure the frequency of events or defects over short intervals
– Immediately provides data to help to understand and improve a process.

54
Lecture b

Fishbone Diagram (cause and effect)
3rd Largest Cause Largest Influence
Cause Cause
Cause
Cause
Cause

Effect
Cause Cause
Cause Cause

Least Influence 2nd Largest Influence

Factors and/or categories of factors

Pareto Chart—Patient Complaints
Pareto Chart for Reason

100

300
80

Percent
Count

60
200

40
100
20

0 0
ns
e tio ul e s ff
T im
are es ed cti
on Sta Pa
rk
ait C t Qu Sch ire d ly to he
r
Defect ng
W
Po
or
nd
an
rd
to or
D frie
n
Ha
rd Ot
Lo du Ha Po Un
Re
Count 125 96 57 32 15 12 11 8
Percent 35.1 27.0 16.0 9.0 4.2 3.4 3.1 2.2
Cum % 35.1 62.1 78.1 87.1 91.3 94.7 97.8 100.0

56

2009 Medicaid PPR's N = 268
350
100
300
250 80

Percent
Count

200 60
150
40
100
20
50
0 0
Dx es s s s s
Dep s o si giti C HF ete liti rug PD
m ch
o ur ha ab Cell
u
ic
D CO
he Psy Ne sop Di ox
C e E T
/ s iv /
a lth re
s
in
g
n
He ep so
ta
l D
Poi
en
M
Count 142 100 32 10 9 9 8 8 6
Percent 43.8 30.9 9.9 3.1 2.8 2.8 2.5 2.5 1.9
Cum % 43.8 74.7 84.6 87.7 90.4 93.2 95.7 98.1 100.0 57

Example of a simple process
check sheet. (attributes)
Model XYZC217 Batch

1
failures 1 2 3 4 5 6 7 8 9 0

Power up
1 2 1

Boot up
6 4 2 1 2

Sink test
2 1 1 1

Case damage
1 1 2

Keyboard damage

Monitor damaged
1 2

Bundled s/w included
3 1 3

Checked by a l l r a
pj m jj [j m m m pj m pj

Basic Tools
• HISTOGRAM
– A graphical display of the frequency distribution of the quality characteristic of interest
– Makes variation in a group of data readily apparent
– Assists in an analysis of how data are distributed around an average or median value.

• SCATTER DIAGRAM
– Show the relationship between two variable
– Can help to establish the presence or absence of correlation
– Does not indicate a cause-and-effect relationship

• RUN CHART
– Plots of data, arranged chronologically
– Used to determine the presence of some types of signals of special cause variation
– A center line (usually the median) is plotted Along with the data to test for shifts in the
process

• CONTROL CHART
– Consists of chronological data along with upper and lower control limits that define the limits
of common cause variation
– Used to monitor and analyze variation from a process
– Use to determine if process is stable and predictable

59
Lecture b

Red Blood Cell Histogram

Size of Red Blood Cells 60

Scatterplot of Experiment vs Control
30

25

20
Experiment

15

10

5

0
0 5 10 15 20 25 30
Control

Scatterplot of Experiment vs Control
30

25

20
Experiment

15

10 R2 = .98

5

Experiment = - 1.55 + 1.43 Control
0

0 5 10 15 20 25 30
Control

Run chart
Run Chart
1.07 - 12.07
50
40
Number

30 Median
20
10
0
1.07 2.07 3.07 4.07 5.07 6.07 7.07 8.07 9.07 10.07 11.07 12.07
Tim e Fram e
(Month.Year)

Graph of data over time
Track performance
Display & identify variation

63

Run chart analysis:
Common cause variation only
8
7
6
5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Tim e

64

Run chart analysis: Runs
• Run = one or more consecutive data
points on the same side of the median
• Excludes data points on the median
12

10

8

6
11
4
runs
2

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
65

Run chart analysis: Run length

8

6

4

2

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Time

66

Run chart analysis: Trends
8
Special cause—trends:
6
Consecutive points all
4 going up or all going
2 down. May cross the
0 median.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Time

67
(Pyzdek, 2003)

Run chart analysis: Freaks
10

8

6

4

2

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Time

Freaks: The presence of more than one or
two dramatic spikes suggests the process is
out of control.

68

Run chart analysis: Cycling
10
9
8
7
6
5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Cycling: A zigzag or saw-tooth pattern
with 14+ points in a row alternating up or
down.
69

Control chart
High
An indication of a special cause
UCL
Quality Characteristic

X

LCL

Low
Time

Run chart with control limits
Determines type of variation
Is process stable? Predictable? 71

Maintaining and Enhancing
Improvements
Topics
• Monitoring processes to maintain
performance gains
• Continuing to improve process performance
• Contingency planning for EHR downtime
– providing patient care when the EHR is down
– maintaining availability of health information to
providers and patients in major emergencies

Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis & Redesign
72
Version 3.0/Spring 2012 Maintaining and Enhancing Improvements
Lecture a

Measurement Is the First Step

“Measurement is the first step that leads to control
and eventually to improvement.
If you can’t measure something,
you can’t understand it.
If you can’t understand it,
you can’t control it.
If you can’t control it,
you can’t improve it.” - Dr. H. James Harrington

(DeMarco, 1982)
73
Lecture a

Quality Council

• Establish core quality standards and requirements
• Identify and defining quality metrics
• Identify and define quality requirements
• Clarify which performance measures are key to
gauging actual quality improvement performance
• Collect and analyze data to understand key
variables and process drivers
• Legitimize value of QI within the organization
• Analyze QI data and report quality trends
• Educate organization and train key staff

74
Lecture a

Maintaining Improvements

Measurement
 Understanding
 Control
 Improvement

75
Lecture a

Process Control Terminology

• Process control (PC) the method for keeping a
process within boundaries; the act of minimizing the
variation of a process
• In-control process: observed variability is due to
natural random variation
• Out-of-control process: observed variability is due to
special causes, i.e., those other than natural variation
• Statistical process control (SPC) is the application
of statistical methods to control a process

(American Society for Quality (ASQ), 2011)

76
Lecture a

Challenges to SPC in Health Care

• SPC was first used in manufacturing
• SPC is not frequently included in books on
statistics for health care and medicine
• SPC is a tool, like any tool, it can be used
incorrectly or for the wrong job
• Prior to EHRs data had to be manually
collected

77
Lecture a

Statistical Process Control

• Uses special charts, called control charts
• Statistical Process Control activities
– Understanding the process
– Understanding the causes of variation
– Elimination of the sources of special cause variation
• Monitored using control charts to identify variation due to
special causes
• Causes for excessive variation must be determined

(Shewhart, 1931)

78
Lecture a

Benefits of Statistical Control

• Stable, consistent, and predictable process
results
• Allows you to learn from variation
• Allows you to identify special causes of
variation
• Provides a rational basis for predicting
future performance

79

Some Causes of Variation

One thing for certain is that variation is caused.
Some of the generic cause categories are:
• Environment
• Equipment
• Methods
• Materials
• Measurement
• People

80

Two Types of Variation

 Common cause variation is the variation inherent
in the process.
 Special cause variation is variation due to fleeting
or unusual causal factors.

A statistical control chart is able to distinguish
between common cause variation and special
cause variation.

81

Rules for Detecting Special Causes

The following are “rules of thumb” for determining
whether there are special causes of variation present in the
process:

1) A point outside the control limits
2) Seven points in a row increasing or decreasing
3) Seven points in a row above or below average
4) Obvious patterns

Note: Special cause rules should in some cases be tailored
for the metric.

82

Common Statistical Control Charts

X & M-R Charts
Continuous
Data
X-Bar & R Charts

Statistical P Chart
Control Yes/No
Charts Data NP Chart

U Chart
Count
Data C Chart

83

P Chart: Proportion of Damaged Boxes

P Chart of No. Damaged
0.5

UCL=0.4369
0.4

0.3
Proportion

_
P=0.2316
0.2

0.1

LCL=0.0263
0.0

2 4 6 8 10 12 14 16 18 20
Sample
Tests performed with unequal sample sizes

84

P Chart: Proportion of Patients Diverted

P Chart of DIVERSIONS
0.08
UCL=0.07354
0.07

0.06

0.05
Proportion

0.04

0.03 _
P=0.02721
0.02

0.01

0.00 LCL=0

3 6 9 12 15 18 21 24 27 30 33
Sample

85

U Chart: Patient Fall Rate

U Chart of Reported Falls
0.014

UCL=0.01253
0.012
Sample Count Per Unit

0.010

0.008 _
U=0.00753

0.006

0.004

LCL=0.00253
0.002

2 4 6 8 10 12 14 16 18 20 22 24
Sample

86

I-MR Chart: OR Turnover Time

I-MR Chart of Turn Time
60 1
1

U C L=54.06
Individual V alue

45

_
30 X=29.74

15

LC L=5.43
0
4 8 12 16 20 24 28 32 36 40
O bser vation

1
30 U C L=29.87
M oving Range

20

__
10 M R=9.14

0 LC L=0
4 8 12 16 20 24 28 32 36 40
O bser vation

87

Basic Tools
• PROCESS DECISION PROGRAM CHART
– Actions to be completed are listed, then possible scenarios about problems that could occur
are developed.
– Management decides in advance which measures will be taken to solve those problems
should they occur.
– Helpful when a procedure is new and little or no experience is available to predict what might
go wrong. (Tague, 2004)

• FAILURE MODE AND EFFECTS ANALYSIS
– FMEA is a method for looking at potential problems and their causes as well as predicting
undesired results
– Developed in the aerospace And defense industries and widely applied
– Normally used to predict product failure from past part failure, but it can also be used to
analyze future system failures
– Enables people to focus energy and resources on prevention, monitoring, and response
plans where they are most likely to pay off

• POKA-YOKE
– Japanese name for “mistake proofing”
– Can be thought of as an extension of FMEA
– Puts special attention on human error

88
Lecture b

Quality Improvement Mistakes

Mistakes in Purpose & Preparation
– Error #1: Choosing a subject which is too difficult or which a
collaborative is not appropriate
– Error #2: Participants not defining their objectives and assessing
their capacity to benefit from the collaborative
– Error #3: Not defining roles or making clear what is expected of
individuals taking part in the collaborative as faculty or participants
– Error #4: Neglecting team building and preparation by teams for
the collaborative

(Ovretveit, 2002)

89
Lecture b

Quality Improvement Mistakes
Mistakes in Planning and Operations
– Mistakes in fostering a learning community focused on
improvement
• Error #5: Teaching rather than enabling mutual
learning
• Error #6: Failing to motivate and empower team
• Error #7: Not developing measurable and achievable
targets.
– Mistakes in transition and implementation
• Error #8: Failing to learn and plan for sustaining.

90
Lecture b

Leading and Facilitating Change


Working With People

Tell me and I’ll forget;
show me and I may remember;
involve me and I’ll understand.
– Chinese Proverb

92
Version 3.0/Spring 2012 Leading and Facilitating Change

Change Concepts

What is it that causes some change
management efforts to be successful?

93

Employee’s Perspective
Project
change • From the employee’s
Regulatory Merger /
Changes Acquisition
perspective, there can
be a lot of changes,
Work
and a lot of changes
Market
Changes
Process can be overwhelming.
Change
Employee

Re-
• Remember that work
Departmental
Changes structuring process change may
Requests
be only one of several
Personnel
changes
From changes an
Manager
organization is
undergoing.

94

Janssen’s 4-Room Apartment

95

Key Concept 1:

• Humans and organizations are complex
• Many factors that come into play
– Organizational constraints
– Management style
– Organizational, departmental, division,
and personal goals
– Personalities
– Environmental factors

96

Key Concept 2:

• Organizations are living, changing biological
systems
– If you push on the system, it will compensate
– Behavior dependent on culture and level of trust
• Reductionist treatment rarely explains the whole
– Measures and numbers
• Are not complete
• Cannot capture the complete complexity.

97

Key Concept 3:

Change happens through individual choice
and freedom not through top-down control or
coercion.

98

Key Concept 4:

John Gall, MD in his 1970’s book Systemantics
said it most insightfully:

“Systems run best when designed to run
downhill.”

Systems should work with natural human
tendencies rather than against them

99

Key Concept 4 Example:

Sure, walk in my garden!

istockphoto.com/nahm001, 2011.

100

Key Concept 5:

• Change starts with a deeply meaningful
purpose
• Which of the following would you rather be
a part of?
– Getting a system in production
– Implementing a system so your practice
would get the Meaningful Use incentives
– Using health IT to improve the health of your
patients
101

Key Concept 6:

Make and keep the gap
between “as is” current
reality and “to be” vision
visible, and talk about it
at every opportunity.

Making gaps visible
maintains a “creative
tension” as Peter Senge
istockphoto.com/nahm001
calls it, that motivates
forward progress.
102

Key Concept 7:

Don’t pull.

“it is an assault to try and
change someone’s mind.”

The Answer to How
is Yes (Block, 2002)

Key Concept 8:
The Engagement Gap
CEO

CEO

Steering Committee

Team of the
“Best & the Brightest”

104

Key Concept 9: Transparency

“…tell the truth, the whole truth and nothing
but the truth…”

105

Pulling it all together

• Change happens best when individuals have
– Deeply meaningful purpose
– Sincere invitation to influence
– Acknowledgement of opportunities for personal
control or choice
– Transparency
– Shared understanding
• Change is impacted by:
– Individuals and organizations
– Culture and trust
– How a change project is structured and managed

106

Applying All of This
Facilitation Plans and Tools:
Facilitation “F” Plan
• A facilitation plan is an outline for how a meeting or an entire change
effort will be run. A facilitation plan includes:
– Description of who is included.
– Description of how included individuals will be selected or
invited.
– Schedule or agenda.
– Outline of what methods or tools will be used
– Description of how the rest of the organization will be kept up-to-
date
– Description of how leadership will be kept in the loop

• A facilitation plan should be made available to the entire
organization to maintain transparency.

107

Facilitation Plan Scenario
• A mid-size internal medicine practice has decided to select,
purchase and implement an Electronic Medical Record (EMR). They
have hired you as a consultant for Process Analysis and Redesign.
Your agreement with the practice is that you will provide instruction,
training and oversight for members of their staff as they analyze
their processes, redesign their processes around an EMR, and
define the functionality that they need in an EMR.

• You have already had an initial meeting with practice leadership and
have had a tour and met the 75 person staff. At your next meeting,
you will present the facilitation plan and get the analysis and
redesign started.

• Over the next several slides, we will look at “Big F” facilitation plan
for the entire effort, and a “little f” agenda for the initial meeting.

108

Big F

Week 1 Week 2 Week 3 Week 4

Group 1 work week: Group 1 work week: Group 1 work week: Group 1 work week:
Process inventory Process Analysis Process Redesign Finalize

Group 2: Weekly
Walkthroughs 1 hour

Leadership
briefing / debriefing
1 hour

109

Little f post-Week 1 Walkthrough
• Introduction to overall project
– How the team was selected
– What their charge is
– The Big F plan
– Timeline and scope
• Context diagram exercise
– Create one as a group
– Pin-the-tail on the donkey
• Process Inventory
– What did we miss

110

Little f Leadership Briefing /
Debriefing

• Brief review of progress
• Presentation of challenges
• Review and “what did we miss” exercises
• Engaging questions:
– Any surprises based on what’s presented
– Get help strategizing about challenges
– Leadership should have input into prioritizing
processes for analysis and redesign

111

Process Change Implementation
and Evaluation


Topics – Component 10 Unit 10

• Common process changes
• Implementation plan components
• Communication for implementation
• Common implementation problems
• Evaluating the new process

113
Version 3.0/Spring 2012 Process Change Implementation and Evaluation

Common Process Changes

• From manual to electronic prescribing
• From receptionist to web-based
appointment scheduling
• From manual to automated appointment
reminder calls
• From manual tracking of test results to
automated result tracking
• From paper to electronic patient charts
• From paper to electronic test ordering
114

Implementation Plan

The implementation
plan serves as a map
for everyone involved
in changing a process.
It covers what steps
everyone will need to
take, what to expect
and what to do when
things don’t go as
planned.
Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and
115
Version 3.0/Spring 2012 Redesign
Process Change Implementation and Evaluation

Implementation Plan Components
• Reason for the change
• Summary of what will be different
• Sequence of implementation tasks
• An implementation schedule for the entire
implementation phase
– Responsible parties
– Each implementation task
• Statement of how the process will be managed
• Contact information for who to call when problems
arise
• Description of how the process change will be
evaluated

116

Exercise
• Using your project redesign

• Review the implementation plan
components on the previous slide

• Create an implementation plan

• Include each component from the previous
slide

Communication of an
Implementation Plan

“Tell me and I’ll forget;
show me and I may remember;
involve me and I’ll understand.”
– Chinese Proverb

118

What People Need to Know

• What is happening
• Why is the change taking place
• How they will be affected
– Address each task or activity that will be added,
changed or will go away
• How the change will impact workflow or
responsibilities
• How will the change take place
• What if anything different will the patients see

119

Job Aids

• Talking points
• Checklists
• Written procedures
• Cheat sheets

Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and
120
Version 3.0/Spring 2012 Redesign
Process Change Implementation and Evaluation

Fundamentals of Health Workflow
Process Analysis and Redesign
Maintaining and Enhancing
Improvements
Lecture b
This material Comp10_Unit11b was developed by Duke University, funded by the Department of Health and Human Services,

Business Continuity Plan

(Wikimedia, 2012)

122
Lecture b

What is Affected When an EHR is
Down?
• Receipt of lab results via electronic interface,
• Clinical decision support,
• Routing of prescription refills
• Electronic storage of entered clinical
documentation,
• Appointment call reminders, and
• Transmitting health information

123
Lecture b

BCP for EHR Downtime

Business continuity planning for EHR
downtime is the systematic inventory of
EHR-facilitated processes and contingency
planning for each.
• Real-time clinical care
• Care follow-up activities
• Getting data into the EHR

124
Lecture b

BCP Team

• Assemble Core Team to
oversee BCP
development
• Identify BCP
Points-of-Contact
for organizational units
• Define the overarching
(Wikimedia, 2012) BCP program
• Develop a BCP timeline
Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis &
125
Version 3.0/Spring 2012 Redesign Maintaining
and Enhancing Improvements

BCP Plan Objectives

• Ensure continuous performance of an organization’s
mission-essential functions in an emergency
• Ensure safety of employees
• Protect essential equipment, records, and other assets
• Reduce disruptions to operations
• Minimize damage and losses
• Achieve an orderly recovery from emergency
operations
• Identify alternate locations and ensure operational and
managerial requirements are met before an
emergency occurs.

126
Lecture b

Key BCP Plan Goals

• Essential organizational functions, vital
systems, data and information identified and
prioritized
• Critical elements are capable of being
recovered quickly to resume operations
• People know who is in charge
• Back-up personnel are trained
• Alternate work locations are predefined
• Checklists are predefined to guide the
organization in responding to an emergency

127
Lecture b

Critical Processes

• Processes or services that must be recovered within 24
hours after a disruption to ensure resumption of the
essential function
• Includes all resources necessary to carry out the critical
process:
– Personnel
– Data or vital records
– Systems and equipment

128
Lecture b

Essential Functions
Functions that must be performed to achieve the
organization’s mission

•Essential Functions include:
– Communications
– Vital Records, Systems and Equipment
– Key Personnel
– Alternate Work Sites
– Testing, Training & Exercises
– Personnel
– Data or vital records
– Systems and equipment

Maintaining and Enhancing Improvements 129
Version 3.0/Spring 2012
Lecture b

Exercising the Downtime Plan

• Exercises are events that allow participants to apply their
skills and knowledge to improve operational readiness
• Goal of exercises is to prepare for a real incident
involving EHR Downtime Plan activation
• Three types of exercises:
– Tabletop
– Functional
– Full-scale

130
Lecture b

Dangers of predicting the
future

• I never make
predictions,
especially about the
future.

• Sam Goldwyn Mayer

Looking to the future: common mistakes

• Making predictions rather than
attaching probabilities to possibilities

• Simply extrapolating current trends

• Thinking of only one future

Looking to the future: common mistakes

• People consistently overestimate the
effect of short term change and
underestimate the effect of long term
change.

• Ian Morrison, former president of the Institute for the
Future

Why bother with the future?

• The point is not to predict the future
but to prepare for it and to shape it

IOM report: the problem

• Between the health care we have and the
care we could have lies not just a gap, but a
chasm
• A system full of underuse, inappropriate use,
and overuse of care
• Unable to deliver today’s science and
technology; will be even worse with
innovations in the pipeline


• A fragmented system characterised by
unnecessary duplication, long waits,
and delays
• Poor information systems; disorganised
knowledge
• “Brownian motion” rather than
organisational redesign


• A system designed for episodic care
when most disease is chronic

• Health care providers operate in silos

IOM report: six challenges for health
care organisations

• 1. Design seamless, coordinated care
• 2. Make effective use of IT, including
automating patient records
• 3. Manage knowledge so that it is
delivered into patient care

IOM report: getting evidence into
health care delivery
• Ongoing analysis and synthesis of medical evidence
• Delineation of guidelines
• Identification of best practices in design of care
processes
• Better dissemination to professionals and public
• Decision support tools
• Goals for improvement
• Measures of quality for priority conditions

IOM report: six challenges for health
care organisations

• 4. Coordinate care across patient
conditions, services, and settings over
time
• 5. Advance the effectiveness of teams
• 6. Incorporate measurement of care
processes and outcomes into daily
practice

What will survive as the world
changes completely:
• 1. Clear ethical values
• 2. Being clear about our mission
• 3. Putting patients first
• 4. Constantly trying to improve
• 5. Basing what we do on evidence
• 6. Leadership
• 7. Learning

Conclusions

• Patients will have the same access to
knowledge as professionals
• Self care or “rolled back care” will become
steadily more important
• Professionals and patients will become much
more equal partners
• Evidence will become steadily more important

1880 New York City

• 150,000 Horses
• 3 Million pounds of manure/day
• 40,000 gallons of urine/day
• 41 deaths/day
• 15,000 deaths/year

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