Monday, December 2, 2019

Blueprints Before Build

Hi fellow CMIOs, CNIOs, HealthIT, and Clinical Informatics friends,

I'm writing today to talk about burnout, or what's also sometimes referred to as "moral injury".  

In the bigger discussion about healthcare reform, burnout is a hot topic, largely because of the multiple problems it's causing. A number of physicians are leaving the medical field, usually after about 10-15 years in practice, to find non-clinical jobs. 

And it's not just physicians - Nurses, pharmacists, and other clinical staff are feeling the same way. Healthcare is becoming 'too much'. 

When clinical staff leave either their position, or the field entirely, this creates problems for everyone : 
  • There is the personal (emotional and sometimes physical/financialinjury to the provider/nurse/pharmacist themselves (and their family)
  • There is the replacement cost for that provider/nurse/pharmacist, including a recruiting costcredentialing/onboarding cost, and training cost, which industry estimates show, together, can cost over $50-$75k to replace a provider.
  • There is the industry loss of a talented and hard-working clinical staff member, one that could be helping to care for patients as our country ages and the demand for providers in the next ten years goes up.
I know this topic well because, as a physician, I've been there myself, and personally understand the pain of bad workflows. This is one of the reason I blog about clinical workflow design. While the EMR is often maligned for its contributions to provider burnout, I'd like to share a deeper clinical informatics understanding of where these workflow issues can stem from. 


I usually tell people - Workflow is a lot like carbon monoxide. It's silentinvisible, and odorless, but if you don't know about it, it can kill you

When discussing workflow with clinical staff, I often get questions like : 
  • By workflow, do you mean the way this button in the EMR makes this window open?
  • By workflow, do you mean the registration policies of the organization?
  • By workflow, do you mean the documentation policies, that are often shaped by payor/insurers?
Workflow is all of the above

I've shared this once before, but one of the most well-known leaders in the national discussion about clinical workflow and Business Process Management (BPM) is Charles Webster, MD ( Twitter : @wareflo ) who in 2016 offered this great definition of workflow in his post, "Task workflow and interoperability definitions: Pragmatic interoperability part 2" : 
"Workflow is a series of tasks, consuming resources, achieving goals."
When I train people on workflow design, I usually offer a slightly different definition, that I think still fits with Dr. Webster's definition above, but has a few small distinctions. My definition is below : 
"Workflow is a series of ordered tasks that uses people, time, and resources to achieve a desired goal."
I expanded the definition because I feel it's important to show the relationship between workflow and another important definition - procedures. From Google's definition of procedure : 

What you start to see is that workflows and procedures are, largely, the same thing - They are both essentially your 'recipe for getting things done'. 

How exactly does a healthcare organization get things done? This is an interesting topic. Healthcare operations is a complex dance between people (staff) and their environments. People often think of the EMR as the sole purveyor of workflow issues, but environments and clinical workflows are actually shaped by tools both inside and outside of the EMR : 

Experienced Clinical Informatics professionals know that, when analyzing and fixing workflows, that half of the work is inside the EMR, and half of it is outside the EMR. Alternatively, it's easy to create workflow inconsistencies by only focusing on the tools inside the EMR, or only focusing on the tools outside the EMRGood workflow depends on synchronizing the tools on both sides of this technology fence. 


Bad workflow feels inconsistent. As I started to explain above, bad workflow happens when the procedures of an organization don't fit as seamlessly as they could or should. Especially in healthcare, this can be difficult to manage, since patient care depends on the timely delivery of quality care, 24/7, no holidays or exceptions. In most industries, a 2-hour delay or downtime is tolerable. In healthcare, it is not

Bad or incomplete workflow is not easy to find electronically or on paper, but it's easy to spot through clinical staff interviews, or just listening to conversations. Some clinical staff understand workflows enough to recognize workflow issues (and complain about them), but more often you will hear statements like : 
  • "Who made that decision?"
  • "Why does it take so long to get things done?"
  • "Why is it so hard to do the right thing?"
  • "I can't keep up."
  • "I stay after my shift to get things done."
  • "I'm constantly getting paged." (or, "I'm constantly having to page the doctors.")
These are all symptoms of problematic or incomplete workflows. If it takes more than one phone call to schedule a patient, or more than one order to obtain a medication, lots of clicks to get through an order set, or lots of extra documentation to ensure reimbursement from a payor - These are all signs of workflow problems. 

Because so few people talk about workflow design, it's easy to unknowingly create workflow issues by either : 
  • Only focusing on tools inside the EMR, or only focusing on tools outside the EMR (as described above)
  • Incompletely addressing the workflow (e.g. Only having 80% of the orders needed to admit a patient in your admission order set.)
  • Some combination of the above.


Good workflow just feels right. It gives clinical and administrative staff confidence that the right thing is happening. It feels like someone with your specialty configured your EMR, wrote your policies, and trained you. I've even heard it described as a 'leisurely walk down a street, where the things you need pop up in front of you just when you need them - not before, and not after.'

Technically speaking, good workflow means : 
  • All of your tools, both inside and outside the EMR, support the same good, evidence-based, best-practice, efficient, and user-friendly workflows. 
  • The workflows are completely built out(Note : Incomplete workflows generate extra telephone calls and pages!!
Generating consistently smooth and complete workflows can be difficult, due to the large number of stakeholders that all healthcare organizations have to interact with, all of whom have an impact on the local workflows and configuration : 

Again, it's important to remember that configuration isn't just the tools inside the EMR - The tools outside the EMR are just as important, and should be roughly half of the deliverables of any clinical workflow project.


Building good, smooth, and user-friendly clinical workflows consistently requires strategy, planning, and infrastructure. 

First, you'll want to propose a consistent change-management process, one that has a single point-of-entry (intake process), and follows all the way through to delivery of services and the monitoring and support required after your implementation. I recently started the Twitter hashtag #Blueprintsbeforebuild to try to create awareness of the importance of this change management process : 

The above process shows the sort of rigor and discipline that's needed to help ensure all of the current- and future-state workflows are well-understood, best-practice, cost-effective, and planned for - and that all of the stakeholders and deliverables have been properly identified during the project planning stage. 

Next, you'll need leadership support for this change management process, as well as agreement, both inside and outside of IT, to use the new process - as well as agreement on how to address complex project management situations like urgent or emergent projects that come up from time-to-time.

You'll also need governance, to help balance the needs of the many stakeholders who play a role in shaping your configuration and your workflows, and prioritize projects after they have been properly evaluated, analyzed, and scoped. 

Finally, you'll need a good project intake process, one that helps your directors to submit projects that get evaluated, analyzed, and scoped in a timely basis, before they get prioritized by your agreed-upon governance and leadership.


If the above seems complicated, you're right - It is a lot of workClinical Informatics professionals are constantly working on building out this sort of governance, prioritization, change management, and project management, all with the goal of delivering smoother and more complete configurations (both inside and outside the EMR), that then help improve workflows, and : 
  • Increase stakeholder engagement
  • Increase provider satisfaction
  • Reduce variation in practice
  • Increase consistency
  • Increase quality of care
  • Reduce clicks
  • Reduce unnecessary pages / phone calls
  • Reduce training time
  • Reduce burnout
You can start by asking your Clinical Informatics team about your current- and future-state workflows, supporting them in these important operational discussions, and sharing your knowledge about the relationship between good change management, solid governancegreat configuration (both inside and outside the EMR), and great workflow - the kind that makes both clinical and administrative users smile. :-)

Remember, this discussion is for educational purposes only - Your mileage may vary. Always check with your clinical leadership, legal team, and clinical informatics leadership, before you consider any changes to your change management strategy. 

Have any project management or change management tips to share? Feel free to leave them in the comments below! 

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