Hello, I'm Bonnie Westra. I'm an associate professor at the University of Minnesota School of Nursing. Today's presentation is on workflow processes. It's really critical, that nurses and all healthcare providers are able to understand how do you really look at the flow of work, and the information to support the work that needs to be done in health care. What I'm going to cover today is I'm going to go through an example of workflow process management, and I'm going to apply this to a new type of organization called an accountable care organization. And to a specific process that's called the consumer engagement process. This same technique can be applied to any process whether it is pressure ulcer management, whether it's scheduling and managing a surgery, or whether it's a specific process like consumer engagement. First of all, we want to start with carefully identifying what is the problem? So in this case, the problem is there was a new accountable care organization that was formed, and their job was really trying to engage consumers in effectively using the resources that they have available. So the new accountable care organization was composed of a hospital, a clinic, social services, and a payor. And that they served a county, and I made up a fictitious county named Shuster county, and that it existed in a large metropolitan area. What's what happens is patients are offered an opportunity to be able to enroll in accountable care organization. Which is really a different payment mechanism where a healthcare system and the ACO would takes on responsibility for a population, whether they're sick or well. And so they get paid on a per patient basis, rather than for all the services they've provided. So the goal is to prevent services and to keep people as healthy as possible. So, after patients are enrolled in the ACO, a follow up call is made to engage them in being able to know about the services and to use the services that are available in order to stay healthy. They also need to understand the agency, the ACL needed to understand, since it was new, what are the processes that they are using? And what are the opportunities for improving the way their processes are being done? And the flow of information the technologies behind that. And what they knew is that they had multiple information systems where there were redundant processes. And they knew there was an opportunity. So the goal was to really try to map that out to clearly define the opportunities for them. They weren't sure what the best practice was. They had kept trying several different new practices, and so we actually, a group of students and faculty got involved in analyzing their workflow process. So the project goals were to improve the efficiency. Of engaging people in the calling out to consumers and to reach the greatest number of new clients through the engagment calls. What happened was the agency would get a whole list of here's the new people. Call them, let 'em know about the services. And they were still at a new stage where they didn't quite have the staffing up to par. So this was added on to existing work. So they really needed to improve the efficiency as much as they could in order to maximize the opportunity for engaging consumers. Now when we think about workflow process, there are some terms. and there are some people. So one of the terms is called actors. When you do workflow processes, what you try to define is who are the people that are involved. Or even departments sometimes. We call those actors. So a team can be an actor Or a single individual can be an actor. When we do workflow process, each actor will have its own kind of what we call swim lane. And I'll show you what that means. And that swim lane is like a swimming lane in a swimming pool. And its what are all the things they do in that swim lane, and how do they hand off from one swim lane to the other as the process unfolds. So we can understand that, if I get the call Or I need to tell somebody about it. Who do I tell? How do I get the information across? The actors in this case were the executive team. The information systems staff. The engagement team. But the leader had a different job. And so, therefore, she got her own swim lane. Than the rest of the engagement team who had different jobs. As we look at work flow diagramming, one of the things we want to do is understand what's the current process? No judgments, just what is it. So on this slide, what you can see is on the left hand side at the bottom, is kind of the terminator. Where did this end? And at the top in this, and that's the exec, the executive team gets a report at the end. Now if I were to do this over again, I'd actually put that on the far right, but today it's here. Then you have the information system person. So the information system person was responsible to get who got enrolled this month What they would then do is they would create a report in Excel. And then they would email the team leader and tell the team leader that the Excel report of who all needs to have a call is available on the server. If you go to the next swim lane. Then what you can see is team leader for the engagement team. So the team leader picks up the report, creates a split in the report based on how many people are doing phone calls. Has excel spreadsheets set up for each person who is going to do a call. Emails them and lets them know that their reports ready of who they need to call that month. Then, if you go to the next a, column you'll see, here's the engagement team. Now you're going to notice that there some differences when you look at the, the style of the, you know, whether it's an oval, or a diamond, or a rectangle. And you're going to see some differences in some things are in yellow and gold, and some things are in red. The red were the opportunities for improvement as we went through the process. So what happens is the engagement team then picked up the report and they printed it out. And they put it next to their phone. And what they also found is they had to look up phone numbers. Because not everybody had a phone number. When they looked up the phone numbers, the phone numbers might've been in one system or another system. They weren't all in the same system. And then what they would do is they would make calls. And so as they made calls, they had to make decisions, noted by a diamond here. And if the person was available, then they would verify information. Or if not they would have to figure out whether they had time to recall or just end the process. So as they went through the process it was very much a paper-driven process. And they would make, they would handwrite phone numbers, they would use yellow highlighters to note which patients they had called, any notes about what they found as they went through. So it's very much a paper-driven process. And then when they got to the end. They would take and they would give that information back to the team leader and email and let her know that she was done but meanwhile all of their notes were on paper. So the pieces of paper got handed back to the I.T. person who then had to enter the information. And after that person entered the information. Then they went through, and they created a report off of it. And handed it off back to the executive team. On a m-, as a monthly summary. One of the things that's really important is to go through, and to use, 1, the right symbols. So a start symbol and an n symbol are ovals. Or in some cases, you might use circles. Steps in a process are denoted by the rectangular shapes. And diamonds are denoted by the symbols. So those are important pieces, if you're trying to communicate with an information technology person. If you made a decision around circle, they would never understand what you were saying. So learning to use the right symbols. And how to really delineate who does what. And when, in he process, they do something. So kind of in summary when we look at some of the challenges first of all there was a print out of individual sheets. Secondly is they had to look up phone numbers in two seperate systems Next they had to, if they didn't reach the clients when they were trying to call them they ended the call. Or in some cases they would not, they would say there's no phone number or there is a mailbox not set up, or leave a message. and so when they knew there's a possibility of getting back they would try a call again if they had time. And then, they would highlight the client's name on the printout, they would document a narrative back in one information system and then they would go into the electronic health record and document information in that system. And then, as they got done then that report needed to be synthesized so these were some opportunities that were highlighted in red on the previous slide. Where improvements could be made. So what happened is you then design what's the ideal system. Where are the opportunities for improvement when you're doing work flow. So every place there was a red box previously then the system got changed. In this case the recommendations, kind of in summary were don't print. You know, you could use the yellow highlighter in, in excel on the spreadsheet so all the information stays in excel. Another recommendation is maybe the IT person could look up all of the phone numbers instead of everybody having to go into 2 systems to be able to look up phone numbers you know, and so there are a number of different recommendations about how to stream line this process and when the data is handed back it's handed back electronically. In Excel spreadsheet, so it's quicker to combine it to be able to do the report in a much more efficient way. So, in summary, what I wanted to point out from this example is not all the details about engaging somebody, but much more so, how do you think about who the actors are, how to communicate a process, a start and end, or decision points, and how to look at where the opportunities for improvement are. And then use this as a way of being able to communicate the opportunities. Now, when you get started it is best to start with what we call a storyboard. First time I heard that I'm like, say what? And what that really means is you need to first of all sit down and just discuss what is the process. Trying to diagram it before you discuss it makes it actually much more difficult to do. So what's the process? What's the setting in which the process occurs? Who starts the process? When does the process end? What are the steps in the process? Who does the steps in the process? And then mostly, how does the information get captured, and how does it get handed off, and how does the person who's getting it handed off to them actually know there's anything there to go get? So those are all really critical pieces to really fully be able to describe before you diagram, once you have gone through and done a good description, you then can go through and start by creating your swim lanes. Now, my students taught me how to actually do something I had no clue about in Word, which is you can go, and in Word, the program you can do Insert, Table, and Draw, and it actually gives us these wonderful diagrams, or these wonderful swim lanes, that you then can just put in who are the actors at the top of the swim lanes. There are also, now you can very complex in symbols, but we try to keep it just very simple as a starting point. So a terminator, which is an oval or it can be actually a circle, means that it's either the beginning or the end of the whole process. When you look at a process step, it's a rectangle. You connect your steps in the process, by using arrows, and they -- you have to pay attention to the direction of the arrows, like who's handing off to whom, and then diamonds indicate whether there's a decision. So if the answer is no, then you go one path, and if it's yes, you go another path. When you're working on a flow diagram you start by putting in your terminators, who starts, who ends and you can notice here I put the executive team on the far right hand side. As I mentioned earlier I would change the process because that's where it ends. And then you just start going through the steps in the process and add your arrows in as you move through one step to the other. So in summary, what we've covered today is, how to do workflow process diagramming, starting with a storyboard, then looking at who are the actors, what are the steps in the process, going through what is the current process and then looking at what's the ideal process. What are the opportunities for improvement? This is a wonderful communication tool that can be used very effectively between clinicians, quality improvement people and your information technology folks who might be making changes. In how hand, information is handed off for one to another. So, thank you very much and enjoy. [SOUND]
