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Lean Workflow for EHR- 2
www.pmcorp.com
Established in 1979; 30+ years of excellence in Productivity
Solutions
Employees: 80 plus - with a number of PhD and Master Degree
holders
6000+ Projects Completed, 600+ Clients Served across many
industry verticals
About PMC
Lean Workflow for EHR- 3
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PMC’s Locations
Headquarters: Dearborn, MI, USA
Other Offices: Texas, California, Seattle, Sweden, India, Thailand, Turkey,
Honduras
For further info: http://www.pmcorp.com/Contacts/index.asp
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PMC’s Expertise
Lean training & implementation
Value Stream Mapping
Kaizen workshops
Line Balancing, Layout
Planning & Work station
design
Simulation and Optimization
Time Studies
Work Sampling
Theory of Constraints Applications
CAD and 3D Modeling
Business Process Re-engineering
Continuous improvement initiatives
Project Management & Support
Production Management
IT - Customized and standard
(COTS) solutions
Quality improvement, training &
certification
Scheduling systems
Full scale implementation
Integration with ERP & technology infrastructure
Lean Workflow for EHR- 5
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PMC’s Experience
6000+ Projects Completed
600+ Clients Servedacross many industry verticals
Lean Workflow for EHR- 6
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What is EHR
The Electronic Health Record (EHR) is a
longitudinal electronic record of patient health
information generated by one or more encounters
in any care delivery setting.
Contains information such as:
past medical history laboratory data
and radiology reports.
patient demographics,
progress notes,
medications,
vital signs
Source: HIMSS
Source: HIMSS
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Background
Electronic Health Records (EHRs) can create practice workflow
efficiency by enhancing:
Office communication
Improving patient flow
Increasing and improving provider-patient interaction
Making patient information available to providers in real time
Source: Maryland Healthcare Commission
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• Emphasis by federal
government on EHR adoption
• Offering a EHR solution is
part of an organization’s
competitive strategy
• Gradual transition of patient
from passive to active role in care
process
• Increasing prevalence and
Incidence of chronic diseases
Drivers• Limited awareness
& comprehension
• Privacy & security
concerns
• Slow migration from paper
to digital storage
• Lack of interoperability
between clinical data systems
• Additional cost burden
• Limited adoption of EHRs
Restraints
Drivers and Constraints
Source: Frost and Sullivan
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Workflow Analysis and EHR
An EHR can be utilized as a workflow tool giving the practice
the ability to collect and present information in one integrated
view.
During the selection and implementation of an EHR, conducting
a 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 specific
task
Gain a better appreciation of how these complex tasks are
accomplished resulting in better automation results.
Source: Maryland Healthcare Commission
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Dealing with Processes
Business Process
Management (BPM)
Business Process
Automation (BPA)
Extension of Current IT Systems
Business• Driven
Development (BDD)
• Key to success of EHR implementation is effective Process
mapping
• Technology is an enabler, not the answer
• Some of the common methodologies used to develop Current
state and future state maps are:
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Experience has proven…
Lack of planning in integrating high volume workflow activities
into the implementation of the EHR can cause problems
More time and emphasis into documenting the existing paper
workflows by the staff needs to be done
Workflow Analysis and Redesign are the Keys to a successful
EMR implementation
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EHR Implementation Methodology
People
ProcessesTechnology
Pursuit of Perfection
Source: HIMSS
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PMC-Healthcare: Our Approach
There is a way to increase the effectiveness of an EHR
system by improving the processes that it affects through
the utilization of ‘Lean’ principles
Lean can help an organization save time and money by
enhancing workflow throughout the organization and
optimizing EHR implementation and usage
Lean Workflow for EHR- 14
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PMC-Healthcare: Our Approach
Form 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 workplace
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PMC-Healthcare: Our Approach
Conduct lean training sessions for all the stakeholders (including
physicians) and communicate the future state processes with the
following goal(s)
Increase OR throughput
Reduce patient wait times
Improve quality of care
Shorten revenue cycle
Streamline admissions
Select department for pilot launch of new processes and roll out the
organization wide implementation plan based on lessons learned
Lean Workflow for EHR- 16
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1 second to look for or do something
X 200 = 200 sec. (3.33 mins)
X 11 = 36.66 mins
X 3 = 110 mins
X 250 = 27,500 mins
/ 60 = 458 hours
/8 = 57 days
or approx. 1 month
Salary:
x$10/hr. =
$4580
x $15/hr. =
$6870
x$20/hr. =
$9160
x$25/hr. =
$11,450
x$30/hr. =
$13,740
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How Do We Define and Measure Value?
Lean Methodology gives us specific rules to use in determining
what activities are value-added (VA) or non-value-added (NVA):
RULE 1: The customer must be willing to pay for the activity
RULE 2: The activity must transform the product or service in some way
RULE 3: The activity must be done right the first time
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Value-Added vs. Non-Value-Added
Department Role VA Activity Example NVA Activity Example
Operating room Surgeon Operating on patientWaiting for delayed procedure or
performing unnecessary steps
Pharmacy Pharmacy technician Creating an IV formulationReprocessing medications that were
returned from patient units
Inpatient unit NurseAdministering medications to
a patient
Copying information from one
computer system into another
Radiology Radiology technician Performing MRI procedurePerforming a medically unnecessary
scan
Laboratory Medical technologist Interpreting a test result Fixing a broken instrument
Department Product VA Activity Example NVA Activity Example
Emergency room Patient Being evaluated or treated Waiting to be seen
Clinical laboratory Patient specimen Being centrifuged or tested Waiting to be moved as a batch
Pharmacy PrescriptionMedication being formulated
or preparedBeing inspected multiple times
Perioperative
servicesSterilized instruments
Time when instruments are
being sterilized
Instruments being sterilized
repeatedly without ever being used
from a standard kit
Nutrition services Patient food tray
Time when food is being
cooked or tray is being
assembled
Being reworked because the tray was
made incorrectly
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Value & Waste
Focus of traditional improvement programs
Work longer
Work harder
Add people
Add equipment
Focus of Lean: Eliminate Waste
Lean Workflow for EHR- 20
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Understanding WASTE
Identification and elimination of WASTE is the central focus of a
LEAN system
Success requires all employees to be trained to identify &
eliminate WASTE from their work areas
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Understanding WASTE
WASTE exists in ALL work...
… and at ALL levels of the organization!
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Understanding WASTE
Waste is anything other than the minimum resources absolutely
necessary to add value to the product:
Equipment & tooling
Direct & indirect labor
Material
Floor space
Energy
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Increase ‘value’ for internal and ‘external’ customers by Eliminating waste
Why use Lean for Workflow Analysis?
Improve your processes first, otherwise, all the automation does is speed up the mess !!!
OverproductionProducing more than what
the customer needs
InventoryBuilding and storing extra
services/products the customer
has not ordered
TransportationMoving product from one
place to another
ReworkReprocessing, or
correcting work
Over-processingAdding excess value when the
customer does not require it
MotionExtra physical/mental motion
that doesn’t add value
IntellectNot using employees full
intellectual contribution
WaitingEmployees waiting for
another process or a
machine/tool
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Lean Workflow for EHR- 25
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Scrap/
Obsolescence
Work in process inventory level
(hides problems)
Unreliable Vendors Capacity Imbalances
Inventory Hides Problems
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ScrapUnreliable Vendors Capacity ImbalancesWIP
Lowering Inventory Reveals Problems
Accommodate lower inventory levels by:
• Reducing variability
• Eliminating waste
• Streamlining flows
• Having Accurate information
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Lean Healthcare – Kanbans
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Kanban Card
46-2811
Yellow Sticky
Notes
Qty
6
Stock Loc:
Central Storage
Shelf 1
Return to:
Supply
Room B
Unique Part #
Description
Refill QuantityWhere to find
replacement
part
Where to return
filled Kanban
Lean Workflow for EHR- 29
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Controls a linear flow of inventory with a static
quantity
Kanbans
Lean Workflow for EHR- 30
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Enter
Hospital
Time
Savings
Move signs
to front to
direct PT’s
Holly (L,H)
Lack of
signage
directions
Move triage
to front office
Stephanie
Sherry
Sign in sheet
doesn’t
match face
sheet layout
I
Wait Move
New Copy
Machine
C,fax,scan
Stephanie
Time
Savings
2-3 mins
Wait pre
registration
Lack of
Copy
Machine Collection of
correct
information,
correction of
incorrect
information
Pre registration
-- CC
-- Consent form
-- ID
(1-3 mins)
Guidelines
consistent,
retraining
Develop std flow
for Regs, train
all employees
Sherry,
Steph,Donna
(L,H)
Nurse sees Pt
1st . Triage
Sherry,
Donna (?,?)
I
WaitMove
Time
Savings
3 min
Cost saving
due to
correct
registration
Revamp PT
collection
form to match
face sheet
Stephanie
(L,H)Cost
savings,
Quality
savings
Wait after
pre
registration
Triage
(5 min)
Labels ,arm
bands, only
print in
triage
Relocate
copier
Sherry,
Donna (L,M)Time
Savings
Standard
work for
Triage
Donna
(L,H)
5S Triage
Donna
(L,H)
Time
Savings,
Savings $
Electronic info flow
I
WaitMove to ER
Room
Nurse/MD
assessment
Radiology
MSE’s ?
patient
leaves
Savings,
600K /yrCapital project
for doc
document
promed
Lab,RadElectronic info flow
Complete
registration
process(5-
10 mins)
Lack of
completion of
insurance
verification
Return to
patient to
collect co-
pay
5 S the
Regist. area
Steph, Cherry
(M,H)
Multiple steps
to register&
-- Pre reg
-- Reg
-- Co’s collect
I
Pyxis not
close to
patients,
high traffic
area
Treatment
~60 mins
(15mins-3
hrs)
Life
packs
not alike
Walk
around
for
supplies
Capital for
new ED
Roy (L,H)
Standardize
rooms, set par
levels Donna,
Sherry,Linda
(L,M)
Time
savings, $
savings &
inventory
I
Patient
disposition
Patients
discharged
that should
be admitted
CM to train ED
nsg on
bluebook+
process
Bonnie, Donna
(M,H)
Guideline
for admit
bluebook
$$$
creation
80K/mo
Discharge
instructions
only printed
in 2 areas
I
Discharge
75%
~10 min
Transfer
10%
~60 min
Admit
15%
~30 min
Staff
education
Donna,
John (M,H)
Holly to
educate
physicians
Holly (H,H)
1 min
1 min
3 min
3 min
1 min
5 min
5 min
20 min
10 min
60 min
10 min
15 min
ED Patient Flow: Current State
Training
Issues I
Cant ask for
Insurance
Info before
Triage?
Eliminate
Lack of
electronic
document--
ationCall Holly on
MSE’s not
done Holly,
Bonnie M,H)
Full
registration
@ bedside
Stephanie
(L,H)
Time
savings,
Quality
savings
Patient Total
Time
134 min
Enter
Hospital
I
Go to nurse
Radiology
Triage
I
Electronic monitorNurse
assessment
I
Wait
I
Medical
screening
I
Lab
Electronic order labElectronic order lab returns
I
Wait
Complete
registration
(Pt pays if non
emergent)
Patient
leaves
Promed visual
I
Wait
Treatment
I
Wait
Collect
money &
disposition I
Discharge
Transfer
Admit
ED Patient Flow: Future State
1 min
1 min
1 min
5 min
1 min
5 min
5 min
5-10 min
10 min
60 min
10 min
15 min
Patient Total
Time
125-130 min1 min
5 min
Planning and Implementing
Current State
Future (Ideal) State
Action Plan to guide
continuous improvement
effort and monitor
implementation
Lean Workflow for EHR- 31
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Brown Paper Mapping
Shows the “Big Picture”
Describes a process as it works today; an “as-is” model
High touch, low-tech
Identifies strengths and opportunities
Captures the complexity and disconnects of key
operational issues
Identifies outside areas involved in the process
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Action Item List
Task Responsible Due Date
Reduce Errors by implementing Kanban on Workstation 6 Mario 10/25/2007
Reduce Headcount by implementing Takt Time on Workstation 2 JoAnn 8/26/2007
Reduce Cycle Time by implementing One-piece Flow on Workstation 3 Mario 10/30/2007
Reduce Cycle Time by implementing One-piece Flow on Workstation 3 Frank 8/19/2007
Reduce Repair Time by implementing 5 S on Workstation 4 Joe 9/13/2007
Increase Quality by implementing Six Sigma on Workstation 8 Sanjay 8/26/2007
Reduce Cost by implementing Takt Time on Workstation 3 Joe 9/29/2007
Reduce Number of Failures by implementing Process Route Table on Workstation 2 Wilbur 8/8/2007
Increase Quality by implementing Process Route Table on Workstation 3 Wilbur 10/24/2007
Increase Quality by implementing Quick Changeover on Workstation 5 Rocco 8/23/2007
Reduce Repair Time by implementing Six Sigma on Workstation 6 Sanjay 9/23/2007
Reduce Cost by implementing Error Proofing on Workstation 10 Frank 8/23/2007
Increase Quality by implementing Lean Metric on Workstation 4 Randy 9/13/2007
Increase Efficiency by implementing JIT on Workstation 1 Mickey 9/25/2007
Reduce Cost by implementing Process Route Table on Workstation 3 Mario 10/22/2007
Reduce Cycle Time by implementing Standardized Work on Workstation 2 Marcelo 8/8/2007
Reduce Repair Time by implementing Takt Time on Workstation 1 Rocco 9/7/2007
Reduce Headcount by implementing Kaizen on Workstation 3 Sandy 10/16/2007
Increase Efficiency by implementing Lean Metric on Workstation 3 Joe 10/15/2007
Increase Efficiency by implementing Visual Management on Workstation 10 Randy 10/13/2007
Reduce Cycle Time by implementing One-piece Flow on Workstation 6 Mario 9/18/2007
Reduce Cycle Time by implementing Kanban on Workstation 7 Sandy 8/23/2007
Increase Efficiency by implementing One-piece Flow on Workstation 5 Sanjay 9/28/2007
Reduce Cost by implementing Workplace Organization on Workstation 5 Rocco 10/17/2007
Increase Quality by implementing Six Sigma on Workstation 11 Wilbur 9/19/2007
Increase Quality by implementing Error Proofing on Workstation 5 Frank 8/15/2007
Reduce Number of Failures by implementing Kanban on Workstation 10 JoAnn 9/17/2007
Reduce Errors by implementing Standardized Work on Workstation 5 Frank 8/9/2007
Increase Quality by implementing Takt Time on Workstation 1 Joe 9/17/2007
Increase Quality by implementing Error Proofing on Workstation 10 Rami 10/25/2007
Reduce Headcount by implementing Kanban on Workstation 10 Randy 10/4/2007
Reduce Headcount by implementing Kanban on Workstation 5 Sanjay 10/28/2007
Increase Efficiency by implementing Visual Management on Workstation 2 Rami 8/8/2007
Reduce Number of Failures by implementing Six Sigma on Workstation 5 Frank 9/12/2007
WHO will do WHAT, by WHEN?
Prioritize based on resources.
Thus…what to do first. We can prioritize by:
the task that will generate
the 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 then
find the solution that has the most impact on it!
Lean Workflow for EHR- 33
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Change Management
Success of change management hinges on:
Well defined, documented, and communicated change
Strong support from leadership
Active participation from stakeholders
Training to build awareness , commitment
Lean Workflow for EHR- 34
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‘Lean’ Change Management
Awareness
Desire
Knowledge
Source: Workflow Redesign in Support of the Use of Information Technology Within Healthcare HIMSS,
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J. P. Kottler’s 8 Steps
1. SET THE STAGECreate A Sense of URGENCY - Help others see the need for change and the importance of acting immediately (i.e. SWOT Analysis, Discussion)
2. Pull Together the Guiding TEAM Make sure a powerful group is leading the change (ie. leadership skills, bias for action, credibility, authority and communication and analytical skills
3. DECIDE WHAT TO DODevelop The Change VISION And Strategy - Clarify how the future will be different to the present, and how to make the future a reality
4. MAKE IT HAPPENCOMMUNICATE For Understanding and Buy-In - Make sure that as many others as possible understand and accept the change
5. EMPOWER Others To Act - Remove as many barriers as possible so that those who want the vision to become a reality can do so
6. Produce SHORT TERM WINS Create some visible successes ASAP. Spread short term success stories so that morale is raised, and employees feel a sense of achievement, because they can see evidence of the change's success
7. DON'T LET UP Be relentless with implementing change, ensuring that the initiation is pushed harder and faster after each Short Term Win
8. MAKE IT STICKCREATE A NEW CULTURE - Make sure that the new ways of behavior succeed, so that they become apart of the very culture of the group
Lean Workflow for EHR- 36
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Conclusions
• Organizational culture is a better indicator of EHR implementation projects
• Workflow processes must be re-engineered by involving stakeholders from the
start of the project.
• Physician involvement is key to success. Dispel the myth that an EMR will
make physicians work faster.
• Develop a plan to manage change and provide governance to ensure rapid
decision making
• Demonstrate the support of senior leadership, communicate frequently and
build consensus
• Train end users by hospital staff members who understand the culture and
workflows
Lean Workflow for EHR- 37
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Questions ?
