HIMSS Summit 07HIMSS Summit 07 Architects of Architects of

ChangeChangeLeadership Skills Track: Workflow Leadership Skills Track: Workflow

RedesignRedesign

June 25June 25thth, 2007, 2007

ObjectivesObjectives

Identify mechanisms to ensure effective Identify mechanisms to ensure effective and productive workflow sessionsand productive workflow sessions

Discuss the difference between the four Discuss the difference between the four cultural dimensions of organizationscultural dimensions of organizations

Understand the barriers to getting good Understand the barriers to getting good information during workflow sessionsinformation during workflow sessions

OutlineOutline

1.1. Background of ProjectBackground of Project

2.2. Mechanisms of the Workflow ProcessMechanisms of the Workflow Process

3.3. Cultural InfluenceCultural Influence

4.4. Barriers and Lesson LearnedBarriers and Lesson Learned

5.5. QuestionsQuestions

BackgroundBackground

Evanston Northwestern Healthcare Evanston Northwestern Healthcare – ENH Hospitals and ClinicsENH Hospitals and Clinics

Evanston HospitalEvanston Hospital Glenbrook HospitalGlenbrook Hospital Highland Park HospitalHighland Park Hospital

– ENH Medical GroupENH Medical Group– ENH Home ServicesENH Home Services– ENH Research InstituteENH Research Institute

BackgroundBackground

CharacteristicsCharacteristics– Admissions (Including Births)Admissions (Including Births) → → 42,00042,000– Outpatient Visits (Excluding ER) Outpatient Visits (Excluding ER) → → 454,000454,000– Total ER VisitsTotal ER Visits → → 88,50088,500– Employees Employees → → 70007000– Physicians (Professional Staff) Physicians (Professional Staff) → → 17001700

ENH Medical Group ENH Medical Group → → 500500 House StaffHouse Staff →→ 150150

Major teaching hospitals for Feinberg School of Medicine Major teaching hospitals for Feinberg School of Medicine of Northwestern Universityof Northwestern University

Ranked #1 in the State of Illinois and #10 in the United Ranked #1 in the State of Illinois and #10 in the United States among multi-specialty independent research States among multi-specialty independent research hospitals with total external grant awards exceed $115 hospitals with total external grant awards exceed $115 millionmillion

Fully integrated EMR across the NetworkFully integrated EMR across the Network

Background - EMR Background - EMR ProjectProject

2001 – Decision & Contract Signing2001 – Decision & Contract Signing

2002 – Plan / Build / Test / Training2002 – Plan / Build / Test / Training

2003 – Training / Install Epic2003 – Training / Install Epic

2004 – Make The EMR Work for Us2004 – Make The EMR Work for Us

2005 – Make The EMR Work for 2005 – Make The EMR Work for YouYou

PatientPatientDataData

PatientPatientDataData

Portfolio of EMR ProductsPortfolio of EMR Products

ONCOLOGYONCOLOGY

ICU SYNOPSISICU SYNOPSIS

HOVHOV

My ChartMy Chart

Mechanisms for Mechanisms for EffectivenessEffectiveness

Identifying the workflows Identify the participants Understand the culture of the

Organization/Departments Clear goals for the session Have something on the table Group Therapy skills Identify any standards, policies and

required actions

Identifying the WorkflowsIdentifying the Workflows

Identify all the Departments/Units and Identify all the Departments/Units and categorize themcategorize them– Revenue generatingRevenue generating– Support servicesSupport services

The Department functionsThe Department functions– Patient Patient – Service ProvidedService Provided– Interaction with other departmentsInteraction with other departments– Interaction with other systemsInteraction with other systems– DocumentationDocumentation

Drill down from thereDrill down from there

You won’t find them allYou won’t find them all

Let The Fun Begin!Let The Fun Begin!

112 High level Workflows112 High level Workflows– ADTADT– Identification of Patient cohort Identification of Patient cohort – Rounding/Assessment/TreatmentRounding/Assessment/Treatment– OrderingOrdering– Prescribing/AdministeringPrescribing/Administering– DocumentingDocumenting

– PatientPatient– EpisodeEpisode– EventEvent

– CommunicationCommunication– ChargingCharging

Physician entersmedication order into

Epic

Pharmacistverifies order

Medication sentup to unit

MedicationAdministration

Workflow

Go to Pyxis andremove

medication. I fmed not in Pyxis

then call topharmacy f or stat

prep.

Yes

Pyxis Override

RN clicks“acknowledge”

button to sign offorder in order

review

Medication appears automatically on theelectronic MAR

Medicationrequired now?

No

System performsduplicate therapy

checks and allergychecks

Physicianaddresses the

warningsaccordingly and

signs order

Physician writesmediation order onpaper order sheet

Pharmacistverifies orderagainst other

medications andallergies

Medication sentup to unit

MedicationAdministration

Workflow

Go to Pyxis andremove

medication.

Yes

Pyxis Override

I f present tubedor f axed to the

pharmacy

Medicationrequired now?

No

RN signs off/acknowledges

order on the paperorder sheet

RN transcribes theorders onto paperMAR and writes inscheduled timesfor medication as

applicapable

Problemidentified?

YesPharmacy calls

the physician todiscuss order

OrderChanged?

Pharmacy entersorder into the

pharmacy system

No

Yes

OrderCancelled?

Yes

Physician callsfloor to speak

with RN recancelled order

Physician callsfloor to speak

with RN rechanged order

No

RN checkswritten order on

the old MARagainst Printed

order on the newMAR

Medicationappears on the

MAR sent up f orthe next 24 hours

No

I f med not inPyxis then call topharmacy f or stat

prep.

Order given tounit pharmacist

Medication WorkflowMedication Workflow

Identify the Participants

Representation from all departments Representation from all departments that touch the workflowthat touch the workflow

Systems expertsSystems experts

Standards expertsStandards experts

ScribeScribe

Admission Workflow Admission Workflow ParticipantsParticipants

Nursing

Bed Coordinator

PhysicianEnvironmental service

Sysytem Analyst

FacilitatorScribe

Transport

OR Scheduler

House StaffED

Manager

Registration

Unit Secretary

Physician Office Admin

Influence of Culture Corporate SupportCorporate Support

Governance structureGovernance structure

Revenue generatingRevenue generating

Physician/Non-PhysicianPhysician/Non-Physician

ManagerManager

Organizational CultureOrganizational Culture

HierarchicalProductivity, performance,

stability, and process. Likely tofine-tune existing processes than

take innovative approaches toachieving goals. Key Words:

Information Management, StabilityControl, Rules, Security

Leadership: conservative, cautious

RationalEfficiency, uniformity, and goal

achievement. Projects more likelyapproached through planning and

goal-setting. Key Words: Planning,Goal setting, Production, Efficiency

Contract, CompetenceLeadership: directive, goal-oriented

Grouppeople-oriented, based on

flexibility and trust, andimplementation occurs through

consensus.Key words: Cohesion, Morale,

Affiliation, attachment,Leadership: concerned, supportive

Developmentalvalue organizational flexibility,

emphasis on growth and resourceacquisition and willingness to seize

opportunities.Key Words: Adaptability,

Readiness, Growth, ResourceAcquisition

Leadership: inventive, risk-taking

Peo

ple

Organization

Control

Flexibility

Adapted from Zammuto and Krakower (1991)

Identify the Goals

The system/organization requirementsThe system/organization requirements

The end result that needs to be achieveThe end result that needs to be achieve

Areas that need to changeAreas that need to change

TimelineTimeline

Have Something On The Table

Meet with the managersMeet with the managers– Identify the playersIdentify the players– Departmental culture Departmental culture

Map out the current workflowMap out the current workflow Gather the documentation/electronic Gather the documentation/electronic

tools used in the processtools used in the process Definitions and NomenclatureDefinitions and Nomenclature Standards/Policies/RegulationsStandards/Policies/Regulations

Paper World WorkflowPaper World WorkflowPhysician ordersIV Infusion D5/45

at 83 hr

Does thePatient Have

access

Order is taken off

Unit Secretary

Chart FlaggedOrder reviewed

and acknowledgedby RN

RN

Order sheet tubed/faxed to pharmacy

if a medication

Is accesspatent

No

Writes fluid on theMAR and/or

infusions sheet

Page IV Therapist

RN IV infusionsdocumentation

WF

Pharmacy wouldtranscribe order

into system

PharmacyVerification

WF

Wait for Therapistto call

Review order withtherapist over

phone

IV Therapistcomes to unit

IV therapist looksfor chart

Reviews chart

Adds patient to IVTherapy kardex

and notes onkardex when next

restart is due

Implementsappropriate action

Documents inchart

Completes IVtherapy charge

sheet

Charges enteredinto system

Physician

Pharmacy

IV Therapy

Yes

Yes

The Electronic WorkflowThe Electronic WorkflowMD Wants infusion

for patient

Pooled Inbasketmessage to IV

Nurse

IV Nurse reviewsorder

Reviews patientchart

Implementsappropriate action

Documents inchart

IV nurse goes toorder set and

drops charges,places saline flush

PRN TO and“Order IV TherapyRestart-72 Hours”

Opens order set and ordersinfusion fluid - IV Therapy -

Start IV-IP is a defaultedorder in any order set where

there are infusion fluids

Infusionautomatically

added to MAR

MedicationInfusions dropgroup on IV

Infusionsflowsheet

PharmacyVerification

WF

Nursing IVDocumenta

tion WF

Patient appears onIV Therapy Patientlist automatically

Automatic

RN

Physician

Pharmacy

IV Therapy

Charges drop

Restart reminderappears in IV

therapy Kardex48hrs later

RN reviews orderand acknowledges

Session Outline

This is where we need to beThis is where we need to be– Requirements of the systemRequirements of the system– Requirements of the workflowRequirements of the workflow

This is where we are or is it!This is where we are or is it!– Current workflowCurrent workflow– Hidden workflowsHidden workflows

This is the timelineThis is the timeline– Set a dateSet a date– Were does this fit in the big pictureWere does this fit in the big picture– What are the dependencies What are the dependencies

Session Outline con’t

Outline the areas of potential Outline the areas of potential improvementimprovement– HandoffsHandoffs– Transcribing informationTranscribing information– AutomationAutomation

Outline the areas for further Outline the areas for further investigationinvestigation– Other departmentsOther departments– Standards, policy, external influencesStandards, policy, external influences

Patient Admitted overnight

Unit called and RN informed

Patient Education>13yrs

No action

ConsentOpen order set and sign order

Lab Workflow

Colonized

Infection Control receives report

Patient into isolation and cart

ordered

Infection Control RN enters problem

on problem list

Orange alert banner fires in all

key patient summary reports

Physician orders MRSA

Decontamination kit

Central Lines or fever

Alert fires on each flowsheet filing for RN and PCT only

No action

Patient Discharged with remainder of treatment

Refused

Agreed

No

Yes

No

Yes

Flowsheet Documentation

No

Yes

User reviews Order review for

order statusOrder status

Complete Documentation

Order sent

Order entered but not sent

Obtain nasal swab

No order

Maximize Maximize compliance : compliance : One workflow One workflow with minimal with minimal

decision pointsdecision points

Group Therapy Skills

Success of our Success of our customer/patient/organization not me customer/patient/organization not me

What is said in this room stays in this What is said in this room stays in this roomroom

Education of each otherEducation of each other

No question is a stupid questionNo question is a stupid question

Introductions (everyone is important)Introductions (everyone is important)

Don’t make assumptionsDon’t make assumptions

Mechanisms for ProductivityMechanisms for Productivity

Administrative support Administrative support

Turn of cell phones and pagersTurn of cell phones and pagers

See the fruits of their laborsSee the fruits of their labors

Conflict resolutionConflict resolution

Clear GoalsClear Goals

Keep good notesKeep good notes

Stay on trackStay on track

Documenting the WorkflowDocumenting the Workflow

Who does what?Who does what?– SecretarySecretary– RNRN– TechTech– AidAid– MDMD– TransportTransport– DieticianDietician– PhysiotherapistPhysiotherapist

How does it get done?How does it get done?– Needed System Needed System

functionsfunctions– Needed Human Needed Human

functionsfunctions

Enough detail to Enough detail to support the buildsupport the build– User interfaceUser interface– Behind the scenes Behind the scenes

functionsfunctions

What you will FindWhat you will Find

Staff and managers may not be able to Staff and managers may not be able to articulate the current processarticulate the current process

Workaround on top of workaroundWorkaround on top of workaround

The policy and procedure committee The policy and procedure committee would faintwould faint

Different people do it different ways and Different people do it different ways and everyone thinks their way is correcteveryone thinks their way is correct

Staff and managers don’t understand the Staff and managers don’t understand the need for consistency and get defensiveneed for consistency and get defensive

What system function fits the workflowWhat system function fits the workflow

Barriers

Resources (Time and Personnel)

System architecture

Participants seniority

Workarounds (Undocumented features)

The sub-sub-sub-sub groupThe sub-sub-sub-sub group– Accountability defermentAccountability deferment– Clear goalsClear goals

Barriers

Culture ChangeCulture Change– VulnerabilityVulnerability– Thought process Thought process

changechange– Exposure (the walls Exposure (the walls

are gone)are gone)– AccountabilityAccountability– EmpathyEmpathy– CommunicationCommunication

Thinking “Out of the Thinking “Out of the Box” Box” – Requires Requires

Interdepartmental Interdepartmental collaborationcollaboration

– Buy-InBuy-In– Scary FactorScary Factor

Finding common Finding common groundground– PatientPatient– OrganizationOrganization

Lessons LearnedLessons Learned

Workflow walkthroughsWorkflow walkthroughs

End User validationEnd User validation

Keep the old workflowsKeep the old workflows

Don’t even open the door an inch!Don’t even open the door an inch!

Not everything fitsNot everything fits

Lessons Learned – cont’dLessons Learned – cont’d Feed the 5000!Feed the 5000!

Set dates and stick to themSet dates and stick to them

PatiencePatience

Make no autocratic Make no autocratic decisions!!!!decisions!!!!

Do not assumeDo not assume

Users educate UsersUsers educate Users

Old habits Die HardOld habits Die Hard

Workflows are NEVER FinishedWorkflows are NEVER Finished

Kate, we need to change………?Kate, we need to change………?

Kate, it used to do “x”, now its not!Kate, it used to do “x”, now its not!

Kate, we have this new procedure, Kate, we have this new procedure, activity etc.activity etc.

Success Due To:

LeadershipLeadership

Physician Physician ChampionChampion

Opinion LeadersOpinion Leaders PhysiciansPhysicians StaffStaff

Clear expectations Clear expectations of behaviorof behavior

OwnershipOwnership

TrainingTraining

CommunicationCommunication

RecognitionRecognition

RewardsRewards

TechnologyTechnology

Contact InformationContact Information  

Katherine Reynolds, RNKatherine Reynolds, RNSenior Director Medical Informatics - InpatientSenior Director Medical Informatics - Inpatient

Evanston Northwestern HealthcareEvanston Northwestern Healthcare4901 Searle Parkway4901 Searle Parkway

Suite 220, PO Box 1006Suite 220, PO Box 1006Skokie, IL 60076-8006Skokie, IL 60076-8006

  Tel: (847) 982-3999Tel: (847) 982-3999Fax: (847) 982-6986Fax: (847) 982-6986

Pager: (847) 479-0878Pager: (847) 479-0878

  email: email: KReynolds@enh.orgKReynolds@enh.org

Positive ImpactPositive Impact

H ierarch icalIn form ation M anagem ent,C om m unication, S tabi l i tyC ontro l, R ules , S ec ur i ty

Leaders hip - cons ervativ e,c autious

R atio nalP lanning, G oal setting,P roduc tion, E ffic iencyC ontrac t, C om petenc eLeaders hip - d irec tiv e,

goal-or iented

G ro upC ohes ion, M orale,

D evelopm ent of hum anres ources , A ffi l ia tion,

attac hm entLeaders hip - c onc erned,

s upporti ve

D evelop m entalA daptabi l i ty , R eadines s ,

G row th, R esourc eA c quis i tion

Leaders hip - inv entiv e,r i sk -tak ing

Peo

ple

Org

anization

Contro l

Flexib ility

Adapted from Zammuto and Krakower (1991)

Negative ImpactNegative Impact

H ierarch icalInform ation Managem ent,C om m unication, S tabi l i tyControl, Rules , S ec ur ity

Leaders hip - cons ervativ e,c autious

R atio nalP lanning, G oal setting,P roduc tion, E ffic iencyC ontrac t, Com petenc eLeaders hip - d irec tiv e,

goal-or iented

G ro upCohes ion, Morale,

Development of hum anres ources , A ffi l iation,

attac hm entLeaders hip - c onc erned,

s upporti ve

Develop m entalA daptabi l i ty , Readines s ,

G row th, R esourc eA c quis i tion

Leaders hip - inv entiv e,r isk -tak ing

Peo

ple

Org

anization

Contro l

Flexib ility

Adapted from Zammuto and Krakower (1991)