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Workflow:Effective EHRProject ManagementWebinarRavi Loterlote@pmcorp.com
About PMC Established in 1979; 30 years of excellence in ProductivitySolutionsEmployees: 80 plus - with a number of PhD and Master Degreeholders6000 Projects Completed, 600 Clients Served across manyindustry verticalsLean Workflow for EHR- 2www.pmcorp.com
PMC’s Locations Headquarters: Dearborn, MI, USA Other Offices: Texas, California, Seattle, Sweden, India, Thailand, Turkey,HondurasFor further info: http://www.pmcorp.com/Contacts/index.aspLean Workflow for EHR- 3www.pmcorp.com
PMC’s ExpertiseLean training &implementationValue Stream MappingKaizen workshopsLine Balancing, LayoutPlanning & Work stationdesignSimulation and OptimizationTime StudiesWork SamplingTheory of ConstraintsApplicationsCAD and 3D ModelingBusiness Process Re-engineeringContinuous improvementinitiativesProject Management & SupportProduction ManagementIT - Customized and standard(COTS) solutionsQuality improvement, training &certificationScheduling systems Full scale implementation Integration with ERP &technology infrastructureLean Workflow for EHR- 4www.pmcorp.com
PMC’s Experience6000 Projects Completed600 Clients Servedacross many industry verticalsLean Workflow for EHR- 5www.pmcorp.com
What is EHRThe Electronic Health Record (EHR) is alongitudinal electronic record of patient healthinformation generated by one or more encountersin any care delivery setting.Contains information such as: past medical history laboratory dataand radiology reports. patient demographics, progress notes, medications, vital signsSource: HIMSSLean Workflow for EHR- 6Source:HIMSSwww.pmcorp.com
BackgroundElectronic Health Records (EHRs) can create practice workflowefficiency by enhancing: Office communication Improving patient flow Increasing and improving provider-patient interaction Making patient information available to providers in real timeSource: Maryland Healthcare CommissionLean Workflow for EHR- 7www.pmcorp.com
Drivers and ConstraintsRestraintsDrivers Limited awareness& comprehension Privacy & security Emphasis by federalconcernsgovernment on EHR adoption Slow migration from paper Offering a EHR solution isto digital storagepart of an organization’s Lack of interoperabilitycompetitive strategybetween clinical data systems Gradual transition of patient Additional cost burdenfrom passive to active role in care Limited adoption of EHRsprocess Increasing prevalence andIncidence of chronic diseasesSource: Frost and SullivanLean Workflow for EHR- 8www.pmcorp.com
Workflow Analysis and EHRAn EHR can be utilized as a workflow tool giving the practicethe ability to collect and present information in one integratedview.During the selection and implementation of an EHR, conductinga workflow analysis will help a medical practitioner to: Identify the ways to streamline a process Improve the efficiency of a practice’s clinical workflow Provide an understanding of the complexity in completing a specifictask Gain a better appreciation of how these complex tasks areaccomplished resulting in better automation results.Source: Maryland Healthcare CommissionLean Workflow for EHR- 9www.pmcorp.com
Dealing with Processes Key to success of EHR implementation is effective Processmapping Technology is an enabler, not the answer Some of the common methodologies used to develop Currentstate and future state maps utomation(BPA)Extension ofCurrent ITSystemsBusiness DrivenDevelopment(BDD)Lean Workflow for EHR- 10www.pmcorp.com
Experience has proven Lack of planning in integrating high volume workflow activitiesinto the implementation of the EHR can cause problemsMore time and emphasis into documenting the existing paperworkflows by the staff needs to be doneWorkflow Analysis and Redesign are the Keys to a successfulEMR implementationLean Workflow for EHR- 11www.pmcorp.com
EHR Implementation MethodologyPursuit ofPerfectionPeopleTechnologyProcessesSource: HIMSSLean Workflow for EHR- 12www.pmcorp.com
PMC-Healthcare: Our ApproachThere is a way to increase the effectiveness of an EHRsystem by improving the processes that it affects throughthe utilization of ‘Lean’ principlesLean can help an organization save time and money byenhancing workflow throughout the organization andoptimizing EHR implementation and usageLean Workflow for EHR- 13www.pmcorp.com
PMC-Healthcare: Our ApproachForm cross-functional team to develop current state Value Stream Map(VSM)Develop future state VSM with focus on design of electronic forms Emphasize on: Customer-centric process design Standardized work Quality at Source Reduction in process time Visual workplaceLean Workflow for EHR- 14www.pmcorp.com
PMC-Healthcare: Our ApproachConduct lean training sessions for all the stakeholders (includingphysicians) and communicate the future state processes with thefollowing goal(s) Increase OR throughput Reduce patient wait times Improve quality of care Shorten revenue cycle Streamline admissionsSelect department for pilot launch of new processes and roll out theorganization wide implementation plan based on lessons learnedLean Workflow for EHR- 15www.pmcorp.com
Salary:x 10/hr. 4580x 15/hr. 68701 second to look for or do somethingX 200 200 sec. (3.33 mins)X 11 36.66 minsX 3 110 minsx 20/hr. 9160x 25/hr. 11,450x 30/hr. 13,740X 250 27,500 mins/ 60 458 hours/8 57 daysor approx. 1 monthLean Workflow for EHR- 16www.pmcorp.com
How Do We Define and Measure Value? Lean Methodology gives us specific rules to use in determiningwhat activities are value-added (VA) or non-value-added (NVA):RULE 1: The customer must be willing to pay for the activityRULE 2: The activity must transform the product or service in some wayRULE 3: The activity must be done right the first timeLean Workflow for EHR- 17www.pmcorp.com
Value-Added vs. Non-Value-AddedDepartmentRoleVA Activity ExampleOperating roomSurgeonOperating on patientPharmacyPharmacy technicianCreating an IV formulationInpatient unitNurseRadiologyRadiology technicianLaboratoryMedical technologistAdministering medications to Copying information from onea patientcomputer system into anotherPerforming a medically unnecessaryPerforming MRI procedurescanInterpreting a test resultFixing a broken instrumentDepartmentProductVA Activity ExampleNVA Activity ExampleEmergency room PatientBeing evaluated or treatedWaiting to be seenClinical laboratory Patient specimenBeing centrifuged or testedWaiting to be moved as a batchPharmacyPrescriptionMedication being formulatedor preparedBeing inspected multiple timesPerioperativeservicesSterilized instrumentsTime when instruments arebeing sterilizedInstruments being sterilizedrepeatedly without ever being usedfrom a standard kitTime when food is beingcooked or tray is beingassembledBeing reworked because the tray wasmade incorrectlyNutrition services Patient food trayNVA Activity ExampleWaiting for delayed procedure orperforming unnecessary stepsReprocessing medications that werereturned from patient unitsLean Workflow for EHR- 18www.pmcorp.com
Value & WasteFocus of traditional improvement programsWork longerWork harderAdd peopleAdd equipmentFocus of Lean: Eliminate WasteLean Workflow for EHR- 19www.pmcorp.com
Understanding WASTEIdentification and elimination of WASTE is the central focus of aLEAN systemSuccess requires all employees to be trained to identify &eliminate WASTE from their work areasLean Workflow for EHR- 20www.pmcorp.com
Understanding WASTEWASTE exists in ALL work. and at ALL levels of the organization!Lean Workflow for EHR- 21www.pmcorp.com
Understanding WASTEWaste is anything other than the minimum resources absolutelynecessary to add value to the product: Equipment & toolingDirect & indirect laborMaterialFloor spaceEnergyLean Workflow for EHR- 22www.pmcorp.com
Why use Lean for Workflow Analysis?Increase ‘value’ for internal and ‘external’ customers by Eliminating wasteOverproductionProducing more than whatthe customer needsWaitingIntellectEmployees waiting foranother process or amachine/toolNot using employees fullintellectual contributionOver-processingMotionAdding excess value when thecustomer does not require itExtra physical/mental motionthat doesn’t add valueReworkTransportationReprocessing, orcorrecting workMoving product from oneplace to anotherInventoryBuilding and storing extraservices/products the customerhas not orderedImprove your processes first, otherwise, all the automation does is speed up the mess !!!Lean Workflow for EHR- 23www.pmcorp.com
Lean Workflow for EHR- 24www.pmcorp.com
Inventory Hides ProblemsWork in process inventory level(hides problems)Unreliable VendorsScrap/ObsolescenceCapacity ImbalancesLean Workflow for EHR- 25www.pmcorp.com
Lowering Inventory Reveals ProblemsAccommodate lower inventory levels by: Reducing variability Eliminating waste Streamlining flows Having Accurate informationUnreliable VendorsScrapWIP Capacity ImbalancesLean Workflow for EHR- 26www.pmcorp.com
Lean Healthcare – KanbansLean Workflow for EHR- 27www.pmcorp.com
Kanban CardUnique Part #46-2811Yellow StickyNotesQtyWhere to findreplacementpartDescriptionRefill Quantity6Stock Loc:Return to:Central StorageShelf 1SupplyRoom BWhere to returnfilled KanbanLean Workflow for EHR- 28www.pmcorp.com
KanbansControls a linear flow of inventory with a staticquantityLean Workflow for EHR- 29www.pmcorp.com
ED Patient Flow: Current StatePlanning and ImplementingtriageMove officentto fro nieStephaySherrCurrent StateCopyNewineMach an,scC,fax ainsIssueask forCantnceInsura foreInfo beof Triage?ctionCollectcorre,ationinform on ofcticorre tecincorr onatiinformPre registration-- CC-- Consent form-- ID(1-3 mins)EnterHospitalIateRelocrcopiey,Sherr (L,M)aTimeDonngsSavinmls ,arLabe eseeslinesNurse e EliminaGuide ent,iagst1 . Trconsist gy,ninSherr (?,?)retraiaDonnflowgstdvinlopsainDeveCostgs, trafor Re yeesdue toploctall emcorre iony,ratSherr onnaregisth,DepSt(L,eH)TimgsSavin3 minLab,RadItin sheeSignn’tdoes facematch outt ssmentIMove to ERWaitRoomMoveiage5S me ,gsSavin gsSavinCompleteregistrationprocess(510 mins)ofLackonicelectr nt-medocully onationCall Ho notjectal propitMSE’s lly,CaHocdone M,H)for do ntiemeBonndocu dpromeED Patient Flow: Future Statemp PTReva oncollecti matchtoform eetshface educ ansphysici ,H)(HHollyFullrationregist ideTimebedsps @ hanie savings,le steSteptyMultip er&Qualiist(L,H)gsto regsavinrege-- Prg-- Re collect’sof-- CoofLackletionElectronic info flowcomp encinsura tionverificaElectronic info flowTriage(5 min)IWaitWait MovesignsofMove toLackntgeto frosigna nst PT’stiodirecdirec(L,H)HollyTimegsvinSaStaff onatieduca,Donn ,H)(MJohnTimegsSavinns2-3 min toRetur tontpatie cocollectpayDischarge75% 10 minTreatment 60 mins(15mins-3hrs)InotPyxistoclose ,ntspatie ounkenot aliforliessupp zerdial forCapitStanda set parnew ED H) rooms, nna,Do(L,yelsRoalevy,LindSherr(L,M)Time , gsvinsags &savin ytorinven5 S the areat.Regis CherrySteph,)(M,HRadiologyIrgentsPatieDischa onsctiargeddisch ould instru ntedthat sh tted only pri asmibe adin 2 areEDtrainlineCM toideGumitnsg on k for ad koooobluebbluebssproce Donnaie,Bonn )on(M,HcreatimoK/80Lab1 min3 min1 minFuture (Ideal) Statemin lab returnsElectronic5orderElectronic order lab3 min20visualminPromed1 minTriageINurseassessmentIGo to nurseMedicalscreeningIIWaitWaitI5 min1 minCompleteregistration(Pt pays if nonemergent)10 minTreatmentIIWaitWaitCollectmoney &disposition10 minPatient TotalDischargeTime134 minTransferAdmitI5 min1 minAdmit15% 30 minIPatientleavesRadiology1 min15 min5 minElectronic monitorEnterHospital60 minTransfer10% 60 min5 min1 min5-10 min1 min60 min5 min15 min10 min10 minPatient TotalTime125-130 minAction Plan to guidecontinuous improvementeffort and monitorimplementationLean Workflow for EHR- 30www.pmcorp.com
Brown Paper MappingShows the “Big Picture”Describes a process as it works today; an “as-is” modelHigh touch, low-techIdentifies strengths and opportunitiesCaptures the complexity and disconnects of keyoperational issuesIdentifies outside areas involved in the processLean Workflow for EHR- 31www.pmcorp.com
Action Item ListTaskReduce Errors by implementing Kanban on Workstation 6Reduce Headcount by implementing Takt Time on Workstation 2Reduce Cycle Time by implementing One-piece Flow on Workstation 3Reduce Cycle Time by implementing One-piece Flow on Workstation 3Reduce Repair Time by implementing 5 S on Workstation 4Increase Quality by implementing Six Sigma on Workstation 8Reduce Cost by implementing Takt Time on Workstation 3Reduce Number of Failures by implementing Process Route Table on Workstation 2Increase Quality by implementing Process Route Table on Workstation 3Increase Quality by implementing Quick Changeover on Workstation 5Reduce Repair Time by implementing Six Sigma on Workstation 6Reduce Cost by implementing Error Proofing on Workstation 10Increase Quality by implementing Lean Metric on Workstation 4Increase Efficiency by implementing JIT on Workstation 1Reduce Cost by implementing Process Route Table on Workstation 3Reduce Cycle Time by implementing Standardized Work on Workstation 2Reduce Repair Time by implementing Takt Time on Workstation 1Reduce Headcount by implementing Kaizen on Workstation 3Increase Efficiency by implementing Lean Metric on Workstation 3Increase Efficiency by implementing Visual Management on Workstation 10Reduce Cycle Time by implementing One-piece Flow on Workstation 6Reduce Cycle Time by implementing Kanban on Workstation 7Increase Efficiency by implementing One-piece Flow on Workstation 5Reduce Cost by implementing Workplace Organization on Workstation 5Increase Quality by implementing Six Sigma on Workstation 11Increase Quality by implementing Error Proofing on Workstation 5Reduce Number of Failures by implementing Kanban on Workstation 10Reduce Errors by implementing Standardized Work on Workstation 5Increase Quality by implementing Takt Time on Workstation 1Increase Quality by implementing Error Proofing on Workstation 10Reduce Headcount by implementing Kanban on Workstation 10Reduce Headcount by implementing Kanban on Workstation 5Increase Efficiency by implementing Visual Management on Workstation 2Reduce Number of Failures by implementing Six Sigma on Workstation FrankJoeRamiRandySanjayRamiFrankDue 8/20079/12/2007 WHO will do WHAT, by WHEN? Prioritize based on resources. Thus what to do first. We can prioritize by: the task that will generatethe most Net Profit or The easiest or The fastest or Will take the fewest people Least amount of money or Etc.Find the bottleneck (constraint), and thenfind the solution that has the most impact on it!Lean Workflow for EHR- 32www.pmcorp.com
Change ManagementSuccess of change management hinges on:Well defined, documented, and communicated changeStrong support from leadershipActive participation from stakeholdersTraining to build awareness , commitmentLean Workflow for EHR- 33www.pmcorp.com
‘Lean’ Change ManagementAwarenessDesireKnowledgeSource: Workflow Redesign in Support of the Use of Information Technology Within Healthcare HIMSS,Lean Workflow for EHR- 34www.pmcorp.com
J. P. Kottler’s 8 Steps1.SET THE STAGE6.Create A Sense of URGENCY - Helpothers see the need for change and theimportance of acting immediately (i.e.SWOT Analysis, Discussion)2.Pull Together the Guiding TEAM Makesure a powerful group is leading thechange (ie. leadership skills, bias for 7.action, credibility, authority andcommunication and analytical skills3.DECIDE WHAT TO DODevelop The Change VISION And8.Strategy - Clarify how the future willbe different to the present, and how tomake the future a reality4.MAKE IT HAPPENCOMMUNICATE For Understanding andBuy-In - Make sure that as many othersas possible understand and accept thechange5.EMPOWER Others To Act - Remove asmany barriers as possible so that thosewho want the vision to become areality can do soProduce SHORT TERM WINS Createsome visible successes ASAP. Spreadshort term success stories so thatmorale is raised, and employees feel asense of achievement, because theycan see evidence of the change'ssuccessDON'T LET UP Be relentless withimplementing change, ensuring thatthe initiation is pushed harder andfaster after each Short Term WinMAKE IT STICKCREATE A NEW CULTURE - Make surethat the new ways of behaviorsucceed, so that they become apart ofthe very culture of the groupLean Workflow for EHR- 35www.pmcorp.com
Conclusions Organizational culture is a better indicator of EHR implementation projects Workflow processes must be re-engineered by involving stakeholders from thestart of the project. Physician involvement is key to success. Dispel the myth that an EMR willmake physicians work faster. Develop a plan to manage change and provide governance to ensure rapiddecision making Demonstrate the support of senior leadership, communicate frequently andbuild consensus Train end users by hospital staff members who understand the culture andworkflowsLean Workflow for EHR- 36www.pmcorp.com
Questions ?Lean Workflow for EHR- 37www.pmcorp.com
EMR implementation. Lean Workflow for EHR- 12 www.pmcorp.com EHR Implementation Methodology People Technology Processes Pursuit of Perfection Source: HIMSS. . organization wide implementation plan based on lessons learned . Lean Workflow for EHR- 16 www.pmcorp.com 1 second to look for or do something X 200 200 sec. (3.33 mins)
