CPOE University
A CSC Clinical Excellence Service Offering
Clinical Workflow
Analysis - Process
Defect Identification
Dan Morgenstern, MD, MBA
Principal
Computer Sciences Corporation
Agenda
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to
future state defect free
Discussion
Who am I?
Who am I?
Dan Morgenstern, MD, MBA
MD, Albert Einstein College of Medicine
25 years of practice:
Private solo as well as group
Academic US, Israel
Cardiac, thoracic, vascular, trauma and general surgery,
wound care
Recipient of a failed Hospital Clinical Information System
Installation - twice
MBA, Auburn University-Montgomery Al
Major course of study: Information Systems
Left practice in 2003 result of the malpractice crisis
Health Care Consulting since September, 2003
Clinical Transformation
Workflow Process Analysis and Redesign
Clinical Master Plan Development
Medical and Clinical Staff Education
Clinical Issues Resolution, Implementation Support (go-live)
Vendor Selection Assistance
Clinical Content Development
Physician/Clinician Adoption
4
Who are you?
Name
Practice specialty
Institution
Role in your institutions CPOE project
How did a nice guy/gal like you end up in a place like this?
Your goals for this session
What are We Here to Do?
Understand what is meant by a defect in a workflow process
Identify characteristics of a step or task in clinical care that
constitute a defect
Recognize them in clinical workflow
Classify the defects
Prioritize them with appropriate input from a SME (Subject
Matter Expert) as needed
Use them as a guide in designing the future state
Agenda
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to
future state defect free
Discussion
What is Clinical Workflow?
Our proposed definition
Clinical Workflow is an established
process describing
A series of tasks
How they are accomplished
By whom
In what sequence
At what priority
that accomplishes a defined step in an
activity in the clinical care of patients
What is Clinical Workflow?
CLINICAL
PATIENT CARE
ACTIVITIES
STEPS
TASKS
9
Standard Activities and Steps in
Clinical Patient-Care
Examples of activities in clinical care:
Hospital rounds
Pre-op/pre-procedure preparation of a patient
Admission, Discharge
Examples of steps in clinical care:
Patient Evaluation
Initial = admission
Subsequent
Daily rounds
Transfer
Discharge
Consultation (patient evaluation specific to
expertise/problem)
Bedside Procedures
Specialized Procedures
10
CLINICAL
PATIENT CARE
ACTIVITIES
STEPS
TASKS
Standard Tasks in Clinical
Patient-Care
Locate Patient
Gather Data
Evaluate Data
Examine Patient
Synthesize Data and Examination
Determine Next Step in Patient Care
Document Findings and Decisions
Direct Care of patient Clinical Orders
Perform Procedures as Needed
CLINICAL
PATIENT CARE
ACTIVITIES
STEPS
TASKS
11
Standard Tasks in Clinical
Patient-Care
Locate Patient
Maintain Patient List
Gather Data
Written
Reports
Notes in chart
Tabulated numerical
data
Oral
Talk to colleagues
Talk to nurses,
therapists, etc
Gather Data
Visual
Radiography
All manner of
graphics: EKG, EEG,
EMG
Examine specimens
and microscope slides
Aural
Sound images:
ultrasound, Doppler
12
Example of Standard Shapes
Dictionary
13
Example of Standard Shapes
Dictionary
This is a Call-Out
Current-State Workflow Project
Flowchart Validation Guide
Used to add information to a task, such as:
Arrows are used to connect tasks that are
related. The arrowhead shows the direction of
process flow.
Terminator
The beginning or
end of a process
Process Step
Decision
A plain box
represents any
general step in a
process
A decision point
where the
process
branches
Yes
On-Page connector which flows from and to
connector with same letter. These are used when
drawing lines from one box to another would cause
the lines to criss-cross possibly causing confusion.
A process entirely
computer
controlled
A task directly involving
user interaction with a
computer system
A task that centers
around a piece of
paper
No
Automatic
Process
Computer
Document
A
Parallel Processes. Steps
within these lines happen at the
same time or independently from
one another.
Off-Page
Connector
(inbound)
Off-Page connector indicating that a
flow represents the continuation from
another tab in the same file
Off-Page Connector
indicating that the
flow continues to
another tab in the
same file.
Off-Page
Connector
(outbound)
Hot Link indicates a link to
a separate process that
continues the normal flow of
work
Process Name
Validation
Preparation
Flowchart Reviewing Guide Follow the Steps Described Below
Begin Process
Find a highlighter
or colored pen.
Follow the steps on the
flowchart (each will be a
decision point):
1. Are the tasks correct?
2. Are they in the correct order?
3. Are any important steps left
out?
Print the
flowcharts you are
reviewing
Are there
decisions in the
flow?
Yes
Have your
flowchart print out
ready for review.
Follow one branch of the
decision at a time,
marking your path using
the highlighter. Make
sure you come back and
follow the other branch.
No
14
Write any
corrections on the
flowchart.
End
Standard Shapes Dictionary
Process Step
Paper
Document
Manual
Interface with a
Computer
Process Step: Any general, manual step
in a process
Paper Document: Any task centered
around the use of paper
Manual Interface with a Computer: Any
manual input, output or interaction with
a computer system
15
Standard Shapes Dictionary
Automatic
Process
Decision
Point
Terminator
Automatic Process: Automatic step that
requires no direct human input; entirely
computer driven
Decision Point: Branching of the
process due to a pair of alternatives
Terminator: The start or end of any
process
16
Standard Shapes Dictionary
On-Page
Connector
On-Page Connector: Allows flow of a
process on the same page without
needless clutter or confusion of crossing
of lines
Off-Page
Connector
(outbound)
Off-Page Connector (outbound):
Indicates that the flow continues on
another tab in the same file
Off-Page
Connector
(inbound)
Off-Page Connector (inbound): Indicates
that the flow is the continuation of another
tab in the same file
17
Standard Shapes Dictionary
Dynamic Connector: Connects two steps
in a process
Parallel Mode: Two steps that take place
independently but simultaneously
Call Out Note
Call-Out Note: Used to supply additional
information about a step or supply
information that is not strictly speaking a
process step
18
Standard Shapes Dictionary
Hyperlink Process
Hyperlink Process: Hot Link to another
process that continues the clinical flow
of work
Ancillary/Clerk
Nursing
Physician
Swim Lanes
Swim Lane Format: Allows role
segregation while showing step
relations and interactions
during the process
19
Agenda
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to
future state defect free
Discussion
Definition of Defects
Definitions
Nonconformance to requirements or
functional / program specification
A blemish, imperfection or deficiency
that impairs worth or utility
The non-fulfillment of intended usage
requirements
Any abnormality lowering the value of a product no matter
why, when, or how it developed
An imperfection which, if great enough, can prevent an item
from working properly or being usable
A lack of something necessary for completeness, adequacy,
or perfection
21
Defects, Warranties,
Guarantees, Remedies
In commercial and consumer transactions, an obligation that
an article or service sold is as factually stated or legally
implied by the seller, and that often provides for a specific
remedy such as repair or replacement in the event the article
or service fails to meet the warranty
In business and legal
transactions, a warranty is an
assurance by one party to the
other party that certain facts or
conditions are true or will
happen; the other party is
permitted to rely on that
assurance and seek some type of
remedy if it is not true or
followed
22
Defects, Warranties,
Guarantees, Remedies
In medicine, there are:
No warranties we never get the Specs on an individual
No guarantees we dont have the owners manual
Of course, there are also
No restocking fees
No in store-credits
It matters little if you have the receipt, you probably cannot
get your appendix, pneumonia or gallstones back
23
Clinical Work and World View
Human mistakes are not just oops moments
Technology glitches are not just aggravating, inefficient or
even infuriating
Errors and bugs really kill people
In business, if you fail you lose money
In engineering, if you fail things dont work
In medicine, if you fail patients die
24
Agenda
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to
future state defect free
Discussion
Clinical Process Defects
Not all errors and bugs kill people
However, the domino effect in clinical care is significant
Inefficiencies, redundancies, bottlenecks, errors
Slow down processes and progress
Impede task completion
Reduce quality of care
Result in unintended consequences
Facilitate poor outcomes
None of these are desirable when life hangs in the
balance.
Life ALWAYS hangs in the balance in healthcare
sometimes obviously, sometimes subtly
26
Definition of Clinical Process
Defect
A defect in a clinical process is the
characteristic of a step or task in clinical
care that
Introduces unwanted and unnecessary
redundancy
Impedes or blocks flow of required
information
Delays completion of a task or step
Necessitates needless clinical decisions and tradeoffs
Results in clinically indefensible variation
Precludes successful completion of a clinical care process
Exposes the patient or the clinical care team to
unnecessary risk
27
Definition of Clinical Process
Defect
Examples:
Introduces unwanted and unnecessary redundancy
Multiple entries of same information
Impedes or blocks flow of required information
Clinical results not available when needed
Delays completion of a task or step
Procedure prolonged because of poor equipment
maintenance
Necessitates needless clinical decisions and tradeoffs
Inventory mismanagement necessitates choice between
lesser quality prosthesis
Results in clinically indefensible variation
Unavailability of correct therapeutic agent (drug, therapy,
site of care)
28
Definition of Clinical Process
Defect
Examples:
Precludes successful completion of a clinical care process
Clinical data (films, cines, angios) misplaced, miscatalogued
Exposes the patient or the clinical care team to unnecessary risk
Patient HIV status not communicated due to information
mishandling
29
Definition of Clinical Process
Defect
Note:
We are talking about defects in process
We are not talking about defects in reasoning, care or outcome
Mistaking a pleural effusion for an organized empyema on an
x-ray may be an error
Treating the patient as such because the x-ray or its report
is not obtainable is a process defect
Choosing the wrong antibiotic may be an error
It becomes a process defect when the culture and
sensitivity is not obtainable at the appropriate time
An untoward outcome is not necessarily indicative of a
process defect
A post-op wound dehiscence may be indicative of an error
A post op wound dehiscence after-unavailability of
retention sutures represents a process defect
30
Definition of Clinical Process
Defect
It is obvious from definition and examples that there are a lot of
defects in clinical processes
Most are relatively innocuous and result in
Irritating delay
Needless inefficiency
Aggravating duplication
Workflow analysis and defect recognition are powerful tools that
will help identify them all
Process redesign independent of technology will help reduce
the number and severity of defects
Many but not all - can be eliminated by technology
31
Definition of Clinical Process
Defect
All need to be eliminated by constant refocus on process and
analysis
These tools can and should become a permanent part of good
clinical care quality assurance
By understanding and perfecting the process we can free
clinical minds to concentrate on
Patient care
Excellent results
32
Identify Defects in this
O.R. Scenario
MTC Sample Script for MD Operating Room
Workflow
Identify as many defects as you can
33
Agenda
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to
future state defect free
Discussion
Example of Standard Shapes
Dictionary
35
Standard Defects Dictionary
Bottleneck: A step dependent on scarce
resources that when triggered by a
specific event - results in an overall
process delay
Redundancy: A step that duplicates
information or an activity already
accomplished in another step, process or
system, resulting in an overall reduction in
efficiency and productivity
Human-Intense Activity: A step requiring
an inordinate amount of human activity,
resulting in decreased efficiency and
productivity
36
Standard Defects Dictionary
Delay: A step that is time consuming and
slows down the completion of a process.
The slow-down is a by-product of the
activity itself, not other intervening factors
Completion Barrier: A key step that when
missed or improperly executed, prevents
completion of a process or drastically
impedes the ability to complete the
process
Failure Point: A step that aborts the
process or represents a failure of the
process
37
Standard Defects Dictionary
Decision Point Defect: A decision point
that
Does not achieve its goal
Is or should be unnecessary
Is reached with insufficient information
Is being made by the wrong individual
Is being made at the wrong time
Other: Defects that fall outside above
parameters, usually legal, regulatory or
patient safety in nature. Each of these
defects must be individually examined
38
Clinical Workflow (CWF) Defects
There is overlap amongst the defect types
There will be individual variation in their use and assignment
These are suggestions
Feel free to adapt them to your own situations
Feel free to add or subtract from the list
The key is consistency in examination of workflow and
assignment of defects
Be cognizant of the fact that certain redundancies
Are in the eye of the beholder (nurse vs. doctor vs. pharmacist)
Are there for sound clinical reasons
39
Clinical Workflow (CWF) Defects
40
Agenda
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to
future state defect free
Discussion
Clinical Workflow (CWF) Defects
42
Examples of CWF Defects
Center chart area 5.5ftes
Phone Management Process
Charts given to
nurses in back
phone room
Racked charts are
called
Fill in needed
information
Chart Activation Process
Chart Dungeon Process
Nurse preps the
chart: pick
appropriate health
history and med
form, put stickers
on them; enter
PMH etc as you
have it. Look for
age related EKG,
allergies, get as
much history as
possible
PAU NUrsing
Yes
Patient
answers?
No success
Wrong contact info due to
with scheduled
MIS over-ride. Cannot
calls
activate patient, enter orders,
contact patient at all.
No
Message left
recorded on chart
by date
Patient calls
back?
No
Can continue in closed loop
fashion up to day afternoon
before surgery
43
Yes
Patient call
answered
Obtain needed
information
Yes
No
Patient leaves
answering
machine message
E
Can continue in closed loop
fashion up to day afternoon
before surgery
Examples of CWF Defects
Center chart area 5.5ftes
Phone Management Process
Charts given to
nurses in back
phone room
Racked charts are
called
Fill in needed
information
Chart Activation Process
Chart Dungeon Process
Nurse preps the
chart: pick
appropriate health
history and med
form, put stickers
on them; enter
PMH etc as you
have it. Look for
age related EKG,
allergies, get as
much history as
possible
PAU NUrsing
Yes
Patient
answers?
No success
Wrong contact info due to
with scheduled
MIS over-ride. Cannot
calls
activate patient, enter orders,
contact patient at all.
No
Message left
recorded on chart
by date
Patient calls
back?
No
Can continue in closed loop
fashion up to day afternoon
before surgery
44
Yes
Patient call
answered
Obtain needed
information
Yes
No
Patient leaves
answering
machine message
E
Can continue in closed loop
fashion up to day afternoon
before surgery
Examples of CWF Defects
Antibiotic Protocol Process
Antibiotic
ordered?
Chart
Dungeon
Process
Yes
Copy antibiotic
order
Place on clipboard
Enter orders into
SCM
No
Procedure
requires AB per
nursing
experience?
This occurs in
ASU
not PAU
Allergies, height weight, etc
All required
information
available?
Yes
No
Yes
Call surgeons
office and obtain
order
Surgeon known
to take care of it
in the morning?
Yes
No
end
No
Chart to ASU
PAU NUrsing
Case cancelled
Fax to Pharmacy
Patient allergy
to ordered
antibiotic?
Yes
Write ALLERGY
on order sheet
Fax to surgeons
office
Office contacts
surgeon
Chart to ASU
No
45
Examples of CWF Defects
Antibiotic Protocol Process
Antibiotic
ordered?
Chart
Dungeon
Process
Yes
Copy antibiotic
order
Place on clipboard
Enter orders into
SCM
No
Procedure
requires AB per
nursing
experience?
This occurs in
ASU
not PAU
Allergies, height weight, etc
All required
information
available?
Yes
No
Yes
Call surgeons
office and obtain
order
Surgeon known
to take care of it
in the morning?
Yes
No
end
No
Chart to ASU
PAU NUrsing
Case cancelled
Fax to Pharmacy
Patient allergy
to ordered
antibiotic?
Yes
Write ALLERGY
on order sheet
Fax to surgeons
office
Office contacts
surgeon
Chart to ASU
No
46
Examples of CWF Defects
WB Charting Process
Well Baby
Admission
& Initial
Assessment
Process
O2 Saturation
or Vital sign?
Yes
Chart in SCM
Result
Abnormal or
Inappropriate?
Yes
Notify MD
No
Weight?
Yes
Chart in Weight
Book
Discharge Form
Chart on NB
Progress Flow
Form
Initiate Appropriate
Protocol
Well Baby Nursing
No
Glucose?
Yes
Nurses Notes
Glucose
worksheet
No
No
Metabolic
Screen?
Yes
Chart on Face
Sheet
WB Patient
Care
Process
Discharge Form
Charge in SCM
No
Hearing
Screen?
Yes
Face Sheet
Hearing Screen
Book
Charge in SCM
No
Nurses Notes
Discharge Form
Charge in SCM
Other
Trans Cutaneous
Bilirubin
47
Calculate risk
factor using
INtrAnet tool
Chart on
Discharge Form
Identify and Categorize
the Defects
Find as many defects as you can in the
following workflow diagrams
Physician Inpatient Evaluation Process
Physician Documentation and Ordering
Process
Tag them according to our defect categorization
48
Physician Inpatient Evaluation
Process
Physician Inpatient Evaluation Process
Patient
needs
physician
evaluation
Physician
List
Maintenance
Process
Old Chart
Needed?
Yes
Old admission
at present
patient
campus
location?
Yes
Locate old
chart in
record room
and transport
to patients
location
Are appropriate
vital signs in
chart?
No
Telephone other
campus and
request
photocopy of
summaries, other
documents
No
Patient found?
Yes
Physician looks
for presentadmission
patient chart
Physician
reviews any
outside
documentation,
results, films,
materials
Review Chart
Yes
No
Physician views
labs, xray reports,
other documentation
on SYSTEM
Physician looks
for bedside chart
Yes
Physician reviews
xrays on PACS
No
Bedside
chart
found?
Chart
available?
Try another
Yes
patient /floor
Patient listed
on board as
in procedure?
Yes
Are appropriate
vital signs in
chart?
Yes
Nursing
Ancillary/
Clerk
Physician
examines patient
End
Physician
Documentation and
Ordering Process
No
No
Review bedside
chart
No
Physician takes
new readings of
vital signs
himself
No
Yes
Ask nurse
Patient found?
No
Find CNA to
locate Bedside
chart
49
Physician Documentation and
Ordering Process
Physician Documentation and Ordering Process
Dictated
documentatio
n required/
desired?
Office
documentation
to be used as
inpatient
documentation?
No
Physician Patient
Evaluation Process
Physician
using
template on
line?
No
No
Yes
Yes
Yes
Physician
dictates note
Office document
placed in hospital
chart
Template in
StaffNet?
Yes
Physician
No
Look in Physician
Email (adult Psych)
Physician
typing in
WORD for
documentatio
n?
Physician
using email
information
for
documentatio
n?
No
No
Yes
Yes
Physician
documents in
WORD and prints
out
documentation
Physician finds
email, cuts and
pastes into WORD
document, prints out
documentation
Physician
documents in
chart by hand
Physician prints it
out
Physician fills
out template
Paper placed in
chart
Order sets
downloaded and
printed or pulled
from repository
END
No
Physician writes
orders
Orders stat,
urgent or
complex?
Ancillary/
Nursing
Clerk
Yes
Physician finds
and notifies
nurse of orders
50
No
Yes
Preprinted
orders
available?
Agenda
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to
future state defect free
Discussion
What is the Process to Move
from Present to Future State?
Map present state workflow
Analyze present state workflow
Identify defects
Classify defects
Describe consequences
Identify those amenable to non-technological fixes
Redundant documentation-form elimination
Consolidation of supplies, results
Elimination of the reply to all syndrome
Information to those who need it and will act upon it
Assignment and enforcement of responsibility
Little need to fax pre-op orders to 4 numbers in the hope one
will pick up and keep them
Geographical and temporal re-arrangements
52
What is the Process to Move
from Present to Future State?
Design future state which will
Eliminate defects
Ensure patient safety and excellent clinical results
Maximize efficiency
Think outside the box
Dont rule it out because you think it may be (or actually is)
expensive
Within reason, if Amazon.com, Burger King and the local bank
can do it, so can health care
53
Post Partum Care Mother
Present State
Post Partum Care (Mother)
Mother arrives
from L&D
IV, Bladder Scan,
Catheterization
Report given (oral)
Perineal
Care
Mother admitted to
unit
Procedure
required?
Yes
Bladder Scan?
Charge in SCM
Patient
Transfer
Process
Green sheet
examined
& handed to PP
Nurse
No
Abnormal
findings?
Post Partum (Mother)
Perform Procedure
Transfer (mother)
assessment per
protocol
Yes
No
Document in
Nurses notes
RH
incompatibility?
No
Yes
Rhogam
Protocol
No
Assessment
charted in Post
Partum Flow
record
Site of documentation per
nurse preference, habit
Perineal
Care
Assessment
Intervention as
needed
Document on PCR
Document in
Nurses notes
Administer
medication
Other
Enter order into
SCM
Medication arrives
via tube
Document on Fall
Risk Form
Site of documentation per
nurse preference, habit
Site of documentation per
nurse preference, habit
Rhogam
Protocol
Document under
interventions
Daily Fall risk
assessment
Patient ID on
envelope
containing
medication
Chart on Notes?
Chart in EMAR
Actual Medication Vial has
no Patient ID information
54
Post
Partum
Teaching
Post Partum Care Mother
Future State
Post Partum Care (Mother)
IV, Bladder Scan,
Catheterization
Mother arrives
from L&D
Perineal
Care
Mother admitted to
unit
Patient
Transfer
Process
Procedure
required?
Yes
Perform Procedure
Charge in System
Transfer (mother)
assessment per
protocol
Post Partum Nurse
reviews record in EMR
No
Post Partum (Mother)
Document in
Nurses notes
RH
incompatibility?
Yes
Rhogam
Protocol
Report given (oral)
No
Daily Fall risk
assessment
Perineal
Care
Enter order into
System
Intervention as
needed
Medication arrives
via tube
Document in
Nurses Notes
Document in
Nurses notes
BCMA
Post
Partum
Teaching
Other
Rhogam
Protocol
Assessment
55
Construct the Future State
Convert the workflows you analyzed for defects
into future state diagrams
Physician Inpatient Evaluation Process
Physician Documentation and Ordering
Process
56
Construct the Future State
57
Agenda
Introduction
Brief review of workflow analysis concepts
Definition of defects
Definition of clinical process defects
Identification of clinical process defects
Classification of clinical process defects
Examples of defects in clinical workflow
Moving from present state with defects to
future state defect free
Discussion
Discussion
60
