Tuesday, July 9, 2019

Why You Should Always Map the Current State

Hi fellow CMIOs, CNIOs, #Informatics, and other #HealthIT leaders,

Today I'm writing to discuss a fairly common question in clinical change management, related to the practice of 'mapping the current state': Is it really necessary?

When planning a clinical improvement project, it may be one of the most common newbie mistakes: Thinking you can't, or don't need to analyze the current state : 

It has been said that Clinical #Informatics and #workflow engineering is a bit like 'rebuilding the plane while it is still in the air' - Healthcare is in business 24x7, and can't really shut down, even for a few minutes, without a potential impact on patient care. (This is one of the things that separates #HealthIT from #BusinessIT, #AcademicIT, and #ResearchIT.)

So in today's fast-paced healthcare environment, it's more important than ever to make sure that projects are executed well, on-time, on-budget, and according to plan. And this is where our discussion starts : How to make sure you're really planning well

First - Without mapping the current state, it looks something like this : 

... and then it becomes impossible to tell if your project is going to look like this : 

... or this...

... and so without a current-state assessment, it's easier to either under- or over-estimate the work it will require to get to Point B. 

Remember, smooth workflow change is not just about the configuration you need to do inside the EMR - It's the work you need to do outside of the EMR too, including development of staff education needed to get your clinical teams from Point A to Point B - See #7 in the grey box on the left-handed side below : 
Taken from my 11-18-2015 blog post, 

Again, in today's healthcare environment, having smooth, well-executed workflows and projects is more important than ever. As an example, Dr. Danielle Ofri recently wrote this very relevant opinion piece in the New York Times which really introduces the importance of well-designed, well-planned workflows :

(June 8th, 2019)

... in which she writes, "With mergers and streamlining, [corporate medicine] has pushed the productivity numbers about as far as they can go." After she describes some real problems with the efficiency of some EMR documentation, she shares this insight, "But in health care there is a wondrous elasticity - you can keep adding work and magically it all somehow gets done."

While Dr. Ofri is quite right that this is a commonly-held belief, there's still a basic problem: Math is math. Healthcare should not plan to do 25 minutes of work in a 15 minute timeframe. So in the national discussion about physician burnout (#physicianburnout, or as ZDoggMD describes it, 'moral injury'), it's more important than ever to make sure workflows serve the needs of the patients, providers, nurses, pharmacists, and other clinical and administrative people working in #healthcare. To make sure we're not overloading our clinical teams, every data element needs to be well-analyzed, well-studied, well-planned, and serve a legitimate patient care or business function.

And this is why the current state is important. Without studying the current state, it becomes very challenging to answer questions like: 
  • Which stakeholders need to be involved in this project?
  • How much time will this project take?
  • What training and support will we need to go-live with the planned future state?
Still, some people express concern about the work it takes to map the current state, or question the real benefits. Allow me to share some common arguments, along with my counter-arguments
ARGUMENT : "We don't have time or resources to map the current state." 
COUNTER-ARGUMENT : "Will we have time or resources to fix things that we didn't account for? How will we know the scope of the effort, who to invite to meetings, or how much educational effort we will need to plan for?" 
ARGUMENT : "It's not worth mapping the current state, last time it took us hours and we still couldn't figure it out." 
COUNTER-ARGUMENT : "Not being able to map the current state, despite best efforts, is still a really important factor to consider when scoping and planning a project." 
ARGUMENT : "We don't want to map the current state because we don't want to bring old habits into our new workflow." 
COUNTER-ARGUMENT : "Even though there may be parts of your current-state workflow worth keeping, it's not to bring old habits into your new workflow - It's to make sure we're covering all of our bases, and doing the best job planning, designing, and executing that we can."
ARGUMENT : "It takes too much work to map the current state." 
COUNTER-ARGUMENT : "It doesn't need to take a lot of work, and you don't always need Visio swimlane diagrams. For many workflows, a simple well-written procedure with each line written as [WHO] will/may [WHAT] will do the trick. Even if it's not documented - it's still important that whoever plans the project has ample access to someone with a good understanding of the current-state workflow(s)."
Fortunately, most experienced Clinical #Informatics and #HealthIT professionals know the importance of mapping the current state in planning clinical improvement projects, and how to map it quickly. So if you ever need help mapping the current state, ask your local Clinical #Informatics or #HealthIT experts for assistance!

Remember, this blog is for academic discussions only - Your mileage may vary. Seek expert advice from your leadership, legal counsel, clinical informatics, or project management teams before changing strategies. Do you have any questions, comments, or feedback? Leave them in the comments section below!

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