Recipes for Success in Clinical Workflow Management

Hi readers,

I had the great fortune today, to collaborate on a presentation with the talented nurse informaticist and designer Andrea Hoffman, RN, to the Informatics team at a fairly large healthcare organization. What a humbling experience! We were in a room with a lot of bright people, working on some truly remarkable and groundbreaking stuff! (It's good to know that healthcare is really working on innovation!)

Anyway, we presented on patient safety ( #ptsafety ) and clinical #workflow management - How to make your own gourmet workflow kitchen! A few people have asked me if they could see the slides, so here they are!

Please note : To make clinical workflow design something real and tangible, and to convey our passion for great workflows, we decided to use a lot of food analogies - After all, the food service industry has a lot of lessons to offer in process design, workflow, and safety.

Enjoy, and feel free to leave any questions or thoughts in the comments section below.

Hope you enjoyed them! New posts to come soon!

- Dirk :)

#Informatics : Why can't I just pre-check this order?

Hi all - Sorry it's been a few months since my last post. No excuse other than lazy blogging. Oh, and developing an Informatics platform in the middle of Meaningful Use, ICD-10, and new regulatory focus on interoperability and configuration - It's can keep you very busy!

For this post, I wanted to try to address a few common questions, that many lonely Informatics people of the world sometimes hear, and sometimes struggle to answer : "Why can't I just ____________?", as in :

1. "Why can't I just pre-check this order?"
2. "Why can't I just make this order set?"
3. "Why can't I just approve this policy?"
4. "Why can't I just do what I used to do BEFORE?"

There is an answer to these vexing questions. It's called workflow. And if you're not clear about workflow is, you won't know how it quietly impacts us all.

WHAT EXACTLY IS WORKFLOW?

Searching the web, I found a few competing definitions of the term "workflow" : 

1. From Wikipedia's entry on Workflow : "an orchestrated and repeatable pattern of business activity enabled by the systematic organization of resources into processes that transform materials, provide services, or process information"
2. From Whatis.com : "Workflow is the series of activities that are necessary to complete a task.
3. From the very talented #workflow expert, Charles Webster, MD : "Workflow is a series of tasks, consuming resources, achieving goals." 
4. Or from Google : "the sequence of industrial, administrative, or other processes through which a piece of work passes from initiation to completion."

Interestingly, Google also reports that the term "workflow" has suddenly become quite popular in writing :

From my perspective, workflow is what you do, how you do it, and when you do it. It's the [ WHO ] will [ WHAT ], in order, that drives the basic processes of your organization. Workflow is your recipe for success. If you're a chef, workflow is your winning recipe, perfectly executed. If you're a hospital, it's your clinical policies, perfectly executed. Workflow does not answer every detail about diagnosing pneumonia, but it outlines the mission-critical steps you need to identify/register your patient, listen to your patient, diagnose their disease, treat their disease, document their treatment, and finally bill effectively.

However you define it, organizations with good workflows generally succeed by delivering a high-quality product, predictably, at a good price. Organizations with bad or confusing workflows will struggle to do that. So it's vitally important to have good workflows to support your goals.

WHAT DOES A WORKFLOW LOOK LIKE? 

When discussing/documenting workflows, it's very common for people to use Visio or other software to create swim-lane diagrams or other algorithms or flowcharts. In experienced hands, they can be vital in documenting current and future-state workflows, but they can require some degree of training and time to create and interpret them correctly.

So I'm proud to share that I recently had the opportunity to collaborate with my outstanding informatics colleague Jessica Gould! Together we did some archetypal analysis and redesign, and developed this handy workflow documentation template that's fairly easy to teach and learn quickly :

[ WHO ] will [ WHAT ] [ how ] [ when ] [ where ] [ why ]

… where :

• [ WHO ] will [ WHAT ] are the mandatory pieces of every workflow line.
• [ how ] [ when ] [ where ] [ why ] are the optional descriptors of every workflow line.

So just as a teaching example, you can use this template to convert your favorite food recipe into a workflow/procedure - e.g. from the Food.com web page, this recipe for Quick Macaroni and Cheese :

1. Cook two cups of macaroni until al-dente
2. Make a roux by melting butter in pan and adding flour
3. Stir constantly and cook until it is the color of caramel candy
4. Slowly and carefully add milk while stirring
5. Add cheese and seasonings when milk starts to steam, until melted and well-combined
6. Pour over cooked macaroni and noodles

If we feed this recipe into our template, we get something that looks like this : 

1. [ WHO ] will cook two cups of macaroni [ until al-dente ] 
2. [ WHO ] will make a roux [ by melting butter in pan and adding flour ] 
3. [ WHO ] will stir constantly and cook [ until it is the color of caramel candy ]
4. [ WHO ] will slowly and carefully add milk while stirring
5. [ WHO ] will add cheese and seasonings [ when milk starts to steam, until melted and well-combined ]
6. [ WHO ] will pour [ over cooked macaroni and noodles ]

Now this incomplete workflow leaves us with a lot of questions, about who exactly should be doing these steps? 

HOW TO BUILD A NICE, LEAN, COST-EFFECTIVE WORKFLOW : 

To help fill out this workflow, we can expand the template just slightly : 

From : 

[WHO] will [WHAT] [how] [when] [where] [why] 

To : 

[WHO] will [WHAT] [how] [when] [where] [why] [time] [materialcost] [laborcost] [TOTALCOST] 

… and this now lets you play several "What-if?" scenarios, to help work out the most cost-effective way to execute your workflow. For example, if we ask a doctor to make this macaroni and cheese, if we assume a salary of $80/hr, then executing this workflow will take 23 minutes and cost you $33.17. (That's an expensive plate of macaroni and cheese!) (Click on the picture below to expand.)

By looking at the workflow designed with this template, you can quickly rearrange steps, reassign roles, and develop lean, cost-effective workflows that ultimately support your organizational goals. I believe that teaching this template to your staff can help them to easily write, analyze, and better develop your common workflows and procedures.

SO WHY CAN'T I JUST ADD THE BOX LIKE I USED TO DO BEFORE OUR EMR?

The reason is because your workflows support your organizational goals. And what supports the workflows? The people and tools in your organization. By that I mean all of your talent, and all of the tools they use to do their jobs : Your policies, procedures, guidelines, orders, order sets, clinical pathways, protocols, Alerts/MLMs (Medical Logic Modules), Documentation, Reports/Dashboards, Patient Education, Staff Education, Budgets, Job Descriptions/Contracts, Glossaries, Wikis, and Org Charts.


So often when a well-trained, seasoned Informaticist is assigned to a project, they might first ask :

1. What is the goal of the project?
2. What workflow(s) is/are needed to achieve the goal?
3. What tools will we need to effectively support the needed workflow(s)?

Visually, this looks something like this :

… where the documents support the workflows that support the goals. And so depending on the workflow change, or desired new workflow, you have to mentally go through each one of those tools and ask : Do we need to create/modify/delete this tool to effectively support the desired workflow?

• Some smaller change projects might be accomplished through developing only one of those tools.
• Other larger change projects might require the development of many tools.

So when someone asks me, "Why can't I just pre-check the order in this this order set?", I will typically ask myself : 

1. What is the organizational goal?
2. What desired workflow does this order set support?
3. What other tools are working together to support this desired workflow?

And if pre-checking the box will mean changes to other tools, then I might tell them something that sounds like this : "I know that pre-checking the order seems like a simple issue, but to make sure it continues to harmoniously support the workflow and organizational goals, we may have to update the staff education, patient education, and pharmacy budget too. Let's look at these and how they work together before we make the change."

Workflows also teach us that we are all, in fact, interconnected - both clinical and administrative staff. Each side depends on the other for success. 

WE DIDN'T DO THIS BEFORE - WHY IS THIS DIFFERENT NOW?

This workflow issue existed in the paper world, but there was one crucial difference - There was more wiggle room. EMRs generally increase workflow accountability through two means : 

• They make large amounts of data easily available for analysis - Reports that used to take months of chart review now takes seconds. It's easier to find poorly-supported workflows.
• They enforce stricter documentation standards that were harder to enforce on paper - The legal-grade authentication of most EMRs prevents scenarios where one-person-filled-out-the-form-and-another-signed-it, just to satisfy a confusing workflow.

So I generally tell people that after their enterprise EMR goes live, they may experience a demand for workflow analysis and redesign to a degree and standard they were unused to in the paper world. I suspect it's this demand for high-grade, well-supported workflows that is driving the demand for trained, qualified, and experienced clinical Informaticists - And I'm proud to be one of them!

As always, this blog is for educational purposes only. I welcome discussion and feedback! How do you explain to end-users why it's sometimes-not-that-simple? All comments below are welcome!

Could Healthcare use a SimHospital?

It's July, 2014. Meaningful Use Stage 2 is underway, ICD-10 has been delayed again, the Affordable Care Act is happening, and healthcare is reforming at a pace it's never been subjected to. Change is afoot. So this has been keeping me quite busy.

So I thought I'd write a bit about the potential value of gaming and simulation in healthcare reform.

As a CMIO in a community hospital, you sometimes fill a lot of roles - Physician informaticist, project manager, trainer, workflow analyst, policy writer, regulatory guru, strategist, and practicing physician all in one. I think this is one of the reasons the CMIO role continues to expand and evolve nationally - It's helpful to have someone who sees so many facets of your care delivery system.

And as an Informaticist, to help the REAL world, you end up spending a lot of time in a VIRTUAL world, with dummy patients, dummy lab tests, and dummy tools, trying to test things in a virtual TEST environment, to make them work properly before they go into the LIVE environment. Sometimes I'm very surprised at what this virtual world teaches us about the real world. (For some Hollywood context, see Gary Sinise playing astronaut Ken Mattingly in the movie Apollo 13, where they work out problems in the virtual training environment that help save the real-life astronauts.)

Anyway, with all of the change going on in healthcare, we need to identify and train future healthcare leaders who will help see healthcare through these changes. Here is where gaming comes in.

Gaming could help healthcare, by allowing our future healthcare leaders to learn strategy in a safe, dummy, TESTING environment - No real workers, no real patients, no real budgets. If pilots can practice flying and landing planes in a simulator, why can't healthcare leaders? What if they could really experiment with revolutionary efficiency and cost-cutting strategies in a safe, TEST environment, where they wouldn't have to worry about departments or hospitals shutting down?

One thing I've learned from studying workflows is that most people behave in fairly predictable ways. Most people want to do the right thing - They want to practice their trade, make a living doing it, and be proud of their work - so if you give them enough structure and reinforcements, they will do it fairly predictably. In other words, predictable things happen predictably.

So if you were designing a healthcare simulator, it probably wouldn't be too hard to develop some common clinical and administrative avatars :

1. [ CLINICAL ] Nurse avatars
2. [ CLINICAL ] Physician avatars
3. [ CLINICAL ] Pharmacist avatars
4. [ CLINICAL ] Ancillary staff avatars (e.g. Respiratory, Dietary, Rehab, Case Management, etc.)
5. [ ADMIN ] Manager-type avatars (e.g. Nursing, Providers, etc.)
6. [ ADMIN ] Director/Chief avatars
7. [ ADMIN ] Executive avatars
8. [ ADMIN ] Board Member avatar

And in this game, with simulated budgets, each of these avatars would generally conduct themselves with a predictable degree of certainty, based on what I think are a few key environmental variables, which are all related to each other : 

1. Amount of Education/Training (includes everything from formal, professional education to organizational orientation to continuing ed)
2. Strength of Operational Infrastructure (includes everything from policies to governance to committee structure to supervision to technology to organized change management)
3. Quality of Documentation (includes everything from contracts to job descriptions to committee charters to bylaws)
4. Efficiency and Flexibility in Finance/Budgeting (includes everything from salaries to budgets to facilities and equipment)
5. Effectiveness of Communication (includes everything from emails to committee meetings to reporting structure to internal/external posters and publicity)

So in a virtual, gaming scenario, you could potentially build a virtual SimHospital, from the ground up, full of these avatars. And if you wanted it to be successful - Or really successful -  you would probably want your virtual avatars to have the highest amount of education, strongest operational infrastructure, highest quality documentation, most efficient and flexible finance/budgeting, and most effective communication.

But the real world doesn't work like that - you can't have the highest degree of all of them. You have to make compromises. Usually limitations come in the form of time, resources, or both. So to be successful, most organizations constantly work to maximize all five of those factors.

But the virtual avatars in this virtual hospital would all be continuously responding to these environmental variables, and in this way, one could build this SimHospital - A virtual environment in which the goal is to make a working, functional, and financially viable hospital. You make the decisions, you juggle the variables, and the avatars and budgets will respond to your decisions. You could be your own virtual board member.

Why would someone want to play this game? To learn safely. To experiment. To try new ideas without people getting hurt. Heck, you could even make it fun and award points for things like delivering a quality procedure without complications, or saving money. What if healthcare administrators played this game at home, competitively, trying to see who could get the highest score?

Let's face it, running a healthcare corporation isn't easy, with these many complex internal and external environmental variables that are constantly changing. But helping leaders to understand the these changing variables in a safe, TEST environment, would have enormous educational value to future healthcare leaders.

After all, if pilots have virtual simulators for flying a plane, why not a virtual simulator for running a healthcare organization?

The challenge with this whole gaming idea, of course, would be deciding : What would you award points for, exactly? Would it be :

1. Financial Profitability?
2. Quality of Care?
3. Quantity of Care?
4. All of the above?

Whatever the scoring schema is, a place for healthcare leaders to learn managerial and leadership skills safely, and try out new ideas without risk, would be a tremendous help in training the leadership we will need to see our industry through the next ten years.

What would you award points for? Leave your thoughts in the comments below! Remember, this post is for educational purposes only, and to stimulate discussion about new and innovative ways to help improve the delivery of healthcare. 

My Open Letter to the New Physician Leader

So I've been in my current position for almost seven years now. I've learned a lot during that time, and I always enjoy sharing my lessons with other people, so maybe they won't have to spend as much time learning them as I did. So in the spirit of education, and with love and fellowship for other physician leaders, I share this blog post:

MY OPEN LETTER TO THE NEW PHYSICIAN LEADER 

To the New Physician Leader,

Welcome! You're a board-certified physician who has been honored by being asked to serve some sort of leadership position in healthcare, generally either a committee chair, department chief, or physician executive. Given all of the reform and change going on, we need good physician leadership in healthcare! We need you to bring a physician's voice to the discussion, and your hours spent in the ED, OR, ICU, floors, or clinic, will help keep you honest and patient-focused. Your experience will help answer detailed questions about how to deliver great patient care. Your clinical hours are being cut with the expectation that you will step into this new role, help coordinate with other physicians, help shape the future of healthcare, and make it great.

Unfortunately, there's no great training course for this new role. Some of you got voted into your positions, whether you wanted it or not. Some of you demonstrated your skills at many long committee meetings, and eventually earned a reputation as a physician leader. And some of you obtained MBAs, MPHs, or other advanced degrees which helped to get you started in your new role.

But I'm writing to share with you some of the lessons that I've learned in my seven years as an eternally questioning physician leader, in the hope that you will use them in any way you see fit - Hopefully, to prevent you from learning the lessons as slowly as I did.

So with that, I humbly offer you these ten lessons that either I've learned myself, or that were shared with me from other physician leaders :

1. Don't think being a doctor prepares you for this leadership role. Medical school teaches us a lot about anatomy, physiology, pathology, and histology. Residency teaches us a lot about medicine, surgery, OB-GYN, pediatrics. Fellowship teaches us a lot about pulmonary/critical care, neurosurgery, and cardiology. Experience may teach us how to do our job, or lead a clinical team to a successful surgery. That education and experience will serve you well in this new role, but there is still much to learn. Leading a clinical team through a surgery is very different than leading a whole department or a clinical service. Always be humble and thankful for the people who teach you new things. In my opinion, as physicians, we should always strive to be both teachers and students for the rest of our lives.
2. Set high standards for yourself. You have one shot at this. Don't just be "good enough." Be "good enough for your children." Attention to detail can be the difference between success and failure, and we need you to be successful in your new role. Don't just aim to succeed - Distinguish yourself by aiming to succeed and wow. Don't just try to meet legal standards, try to meet ethical standards.
3. Learn some basic parliamentary procedure. Buy yourself a copy of "Roberts' Rules of Order" and read it. Keep your copy in your new office. Knowing how to run a good meeting is a critical skill that not everyone has. When the opportunity arises, being able to correctly discuss the difference between a primary motion and a secondary motion is very impressive. You will also need to know this if you have to make any big changes, which will invariably involve politics and governance.
4. Know how to write a really good committee charter, meeting agenda, and minutes. These tools are so essential to success, and still many physician leaders don't pay much attention to them. If you really care about these documents, you will be empowered by knowing how to run really good meetings where people show up and things get done.
5. Control your documents, don't let them control you. Simply put, documentation matters. First, make sure you read your organizational chart, bylaws, rules and regulations, and policies (at least once), and make sure you understand what they all do. Physician leaders sometimes fail because they don't know or understand their governing and operational documents. Next, make sure you know how to develop a really good document - Starting from your idea, to your regulatory/policy/literature search, to your stakeholder list, to your well-designed template, to your first DRAFT, to your stakeholder review, to your final draft, to your FINAL document approval, to your document publication and monitoring - Every step is essential to making a good document. It doesn't matter how good and well-planned your idea is - If it's not properly developed and documented, then it's likely to fail. Finally, keep all of your computer documents somewhere where other people can find them. If you keep all of your tools on your local C: drive, or your email, then nobody else can see them, read them, or collaborate on them. And if you get sick or leave - They may be lost forever! A much better place to keep them is an internal, secure, shared network drive that many people in your organization have access to - It facilitates collaboration, and someone else can find things if you're sick!
6. "Workflow" is everything. While this term is often used when trying to implement an EMR, everyone should know what it means and why it's important. Workflow is actually deceptively simple. It's a procedure. The success (or failure) of your projects and departments will depend on having good, clear, well-designed, cost-effective workflows that build best-practices into your daily routines. To document your current and future workflows, some people try to make elaborate Visio diagrams or flowcharts, but it doesn't need to be that complex, and sometimes the complex diagrams can leave out important details. You may still need expert help when trying to fix workflows, but as a start, try studying food recipes to see how easy it can be to write good procedures. By design, food recipes/procedures/workflows are generally very 'lean' (in process, not necessarily nutrition - Sorry, no pun intended!) You may still need expert help when trying to fix workflows, but you can start writing a good procedure/workflow, line-by-line, using the general format [ WHO ] will [ WHAT ] [ how ] [ when ] [ where ] [ why ], where the bold parts are mandatory and the italic parts are optional (and only used when needed.) Once you have your current state workflows documented in this manner, you'll quickly see where it can be streamlined to develop your future state.
7. Don't just make the future good, make it excellent. It's easy to get lost in trying to preserve the past. Sure, there are some things you'll want to keep (like good patient care, compassion, and continuity), but some of healthcare was broken. Make sure you're not trying to preserve the stuff that was broken. (This is especially important when trying to go electronic - You do not want to build bad workflows into your new electronic system!) Remember - Doctors will still be doctors after healthcare reform. We may look a little different, work a little different, and even get paid a little different, but patients will still need us to help them. Plan to make the future excellent for both patients and caregivers.
8. Finance matters. Through medical school, residency, and fellowship, most doctors don't pay much attention to financial issues (other than student debt!), but at the end of the day, clinical decisions need to make financial sense, and many hospitals close because of insufficient funds. Every penny counts. To make sure everything you do has value, and your projects are well-planned and financially sound, always include someone from finance/accounting early in your clinical discussions. Doctors have as much to learn from finance as finance has to learn from doctors. 
9. Prepare for shared governance. Let's face it - In the old days, doctors 'ruled' the hospital, while nurses actually kept it alive and functioning. That model doesn't work anymore - You were hired because the nurses can't do it alone. Some people mourn the passing of those days. Personally, I don't. In the future, doctors, nurses, pharmacists, quality, regulatory, legal, and financial people will work together to break down silos, answer questions and collaborate on decisions. I love working collaboratively because I learn so much from these other team members. Working together, we reduce costs, avoid workflow problems, and make better decisions. 
10. Always let the patient guide your compass to True North. I was once given this advice by another physician leader when I asked him, "How do you always know what to do?". He basically told me, "As long as you always think about the right thing for the patient, you'll always know what to do." I've spent seven years validating his advice, and I can say that so far it has served me very well.

We desperately need you to help shape the future of healthcare, and shepherd other physicians and advanced practice clinicians (PAs, NPs, etc.) through this transition process. To help our patients, we are counting on you to be both happy and successful in your new position! Good luck, share your lessons with other people, and always remember why you applied to medical school in the first place - to help people.

Humbly submitted,

- Dirk

(fellow student, teacher, and eternally questioning physician leader)

Remember - This blog is for educational purposes only, so I always welcome opinions and feedback! Do you have any lessons you would share for a new physician leader? Leave them in the comments below!

The "Poor Man's Document Sharing" Strategy

Hi - Sorry it's been a while since my last post. As most of you in #HealthIT know, Meaningful Use Stage 2 (MU2), Health Information Exchange (HIE), and ICD-10 - It's a family of acronyms that can keep you very busy.

For today, I wanted to continue talking about document management, and share a creative solution I lovingly call the "Poor Man's Document Sharing" strategy.

Now, I generally pride myself on being vendor-agnostic, so please forgive me as I refer to Microsoft's SharePoint, a fairly popular solution to document management woes, although not the only one out there. Again, please note there are plenty of other solutions to this problem, and this is not an endorsement - I'm mainly using SharePoint as a teaching example, so I can explain a particular problem that sometimes plagues healthcare projects.

Anyway, for those of you who don't know what SharePoint (or document sharing software) is, here's a great video that will give you a basic introduction to the problem :



The video really highlights the problems with emailing a document around for discussion and review :

• It doesn't help organize any discussions - It's very hard for a group to see everyone else's feedback.
• It tends to create monologues, not dialogues. (Generally from sender to recipients only, not recipient-to-sender, or recipient-to-other-recipient.)
• It delays the time to developing a good, well-developed, well-reviewed document.

After all, if you are managing any workflow change, you will need to create documents. Borrowing from the CMIO's Checklist, you might need to revise or create documents like :

1. Charters (e.g. Committee Charters, Project Charters)
2. Committee Agendas
3. Committee Minutes
4. Project Plans (e.g. Project plans, testing plans, education plans, etc.)
5. Orders
6. Order Sets
7. Policies and Procedures
8. Clinical Guidelines
9. Clinical Documentation
10. Clinical Protocols
11. Staff Education (e.g. Posters, Powerpoints, emails)
12. Patient Education (e.g. Patient handouts)
13. Spreadsheets
14. Notes

... among other documents/tools that you will need to support your mission.

So how you get people to collaborate successfully will depend on :

• How you set up your documents
• How your team uses those documents
• How you manage your projects

Now, as I said, SharePoint is a fairly popular solution to this problem, although there are other solutions out there too. But what if you belong to an organization that doesn't yet have the resources to purchase such a solution? For those of you who have to make do without, I'm going to present this solution - A basic recipe for The Poor Man's Document Sharing.

The Goal :
To create a standard set of shared folders/documents that your team uses to share ideas and build documents collaboratively.

Ingredients you'll need :
1. An organization with anywhere from 5-500 employees.
2. An organizational computer network with some sort of a shared drive (e.g. the "J: drive")
3. Multiple computers capable of accessing the shared J: drive.
4. A copy of Microsoft Office (2007 or later will do) on each of the computers in #3 above.
5. Some standardized email system that your entire organization uses. (e.g. Outlook)
6. Standardized archetypes of your favorite document types (project plans, policies/procedures, order sets, protocols, guidelines, etc.)
7. A dedicated manager of this solution (e.g. a fearless informaticist) who knows how to hyperlink to a folder and a file.

The Basic Recipe :
1. STEP 1 - 
Set up a shared project development folder on your shared J: drive, one that you plan lots of people to be able to use to work together, for example :

J:/shared/Informatics

2. STEP 2 - 
Create two sub-folders inside this folder :

• J:/shared/Informatics/templates
• J:/shared/Informatics/projects

3. STEP 3 - 
Inside the J:/shared/Informatics/templates folder, create the following sub-folder:

J:/shared/Informatics/templates/project templates

4. STEP 4 - 
Inside the J:/shared/Informatics/templates/project templates folder, create the following sub-folders :

• ./Charter - Drafts/
• ./Agendas - Drafts/
• ./Minutes - Drafts/
• ./Project Plans - Drafts/
• ./Policies and Procedures - Drafts/
• ./Clinical Documentation - Drafts/
• ./Orders - Drafts/
• ./Order Sets - Drafts/
• ./Guidelines - Drafts/
• ./Staff Education - Drafts/
• ./Patient Education - Drafts/

 ... and fill these folders with your favorite document templates (the ones that your organization uses to standardize the look, appearance, and function of these documents.)
Don't forget :

• It's helpful if all of your document templates have standardized filenames, like : 

DRAFT - ORDER SET - Standardized Order Set Template - Drafted mm-dd-yyyy.doc

DRAFT - POLICY - Standardized Policy Template - Drafted mm-dd-yyyy.doc

• If you do not have standardized templates yet, consult your friendly neighborhood informaticist for help developing these!)

You have now built a standard project template, with a standard set of project folders, filled with standardized templates, that you can literally copy-and-paste into another folder, to get any project up-and-running quickly.

5. STEP 5 - 
Now start developing standardized, shared workspaces for your projects. It helps if you create some standard way of organizing them. For example, you might consider creating the following set of sub-folders, based on speciality, where your teams can actually work together :

• J:/shared/Informatics/projects/Anesthesia
• J:/shared/Informatics/projects/Emergency Medicine
• J:/shared/Informatics/projects/Medicine - General
• J:/shared/Informatics/projects/Medicine - Critical Care
• J:/shared/Informatics/projects/Medicine - Nephrology
• J:/shared/Informatics/projects/Medicine - Endocrinology
• J:/shared/Informatics/projects/Medicine - Cardiology
• J:/shared/Informatics/projects/Medicine - Gastroenterology
• J:/shared/Informatics/projects/Medicine - Infectious Disease
• J:/shared/Informatics/projects/Surgery - General
• J:/shared/Informatics/projects/Surgery - Orthopedics
• J:/shared/Informatics/projects/Surgery - Urology
• J:/shared/Informatics/projects/Surgery - Plastics
• J:/shared/Informatics/projects/Surgery - ENT
• J:/shared/Informatics/projects/Surgery - Podiatry
• J:/shared/Informatics/projects/Psychiatry
• J:/shared/Informatics/projects/Pediatrics - General
• J:/shared/Informatics/projects/Pediatrics - Nursery
• J:/shared/Informatics/projects/OB-GYN
• J:/shared/Informatics/projects/Radiology - General
• J:/shared/Informatics/projects/Radiology - Interventional
• J:/shared/Informatics/projects/Radiation Oncology
• J:/shared/Informatics/projects/MULTISPECIALTY PROJECTS

* - Note : You will need a "MULTISPECIALTY PROJECTS" sub-folder to put all of the projects that cover multiple disciplines (e.g. MU2, Med Reconciliation, Pharmacy projects, etc.)

6. STEP 6 - 
Give READ/WRITE access to your J:/shared/Informatics folder, to as many clinical directors, chiefs, regulatory staff, quality staff, IT staff, analysts, and other clinical and administrative positions as you can.

This may take some getting used to, especially if you aren't used to that level of collaboration. Remember, that means that everyone you appoint internally will have access to all of your development files, which admittedly carries some risk, but remember - 

• These are only DRAFT files.
• This is the "Poor Man's Document Sharing."

7. STEP 7 - 
Need to work on something big like Med Reconciliation? Create a new shared development folder :

• J:/shared/Informatics/projects/MULTISPECIALTY PROJECTS/Med Reconciliation

... and copy-and-paste the standard project folder, with all of your standardized templates, from :

• J:/shared/Informatics/templates/project templates

... into your new shared development folder! You will now have a shared working space that your entire team can find easily and work on collaboratively. It will also be full of the standardized templates that your organization has approved, so they can find them and use them easily.

8. STEP 8 - 
Now try to focus all of your discussions on the documents inside these folders - If you want your group to work on a particular policy in a folder, instead of sending your team an email with a copy of the drafted policy, send your team a hyperlink to the drafted policy document in the shared folder.

For example, in the following sample email below, I've highlighted the hyperlinks in yellow :

"Hi team,
In our shared project folder :

J:/shared/Informatics/projects/MULTISPECIALTY PROJECTS/Med Reconciliation

... is the shared policy draft :

DRAFT - POLICY - Med Reconciliation Policy - Drafted 10-22-2013.doc

Please click on the above hyperlinks to :

1. Open the drafted policy.
2. Review the drafted policy.
3. Edit the policy, using Track Changes, if you need to.
4. Add or delete comments to the document.
5. ave the drafted policy document right back into our shared folder.

Please review it and add your comments within the next 48 hours. After we collect comments and feedback from the team, we will schedule our next meeting to review the comments and plan for next steps.

Email me with any questions."

... This then allows your team members to, very quickly :

• Receive the email from the team leader.
• Open the document with one click.
• Edit the document.
• Leave their comments.
• Have quick access to help (in case they don't know how to use track changes or add comments, the links about tracking changes, adding comments, and saving a document are all actual links to the Microsoft help pages.)
• Save the document back to your shared folder.

If two team members try to access the file at the same time, don't worry - Microsoft (and most computer networks) support file-locking : the one who opens it last will get an error message : "FILE CURRENTLY IN USE BY USER __________, would you like to open a read-only version?" which basically helps make sure only one person is working on it at a time.

If someone makes a significant edit, again it's very simple to change the filename and have it save back into your shared project folder. I actually recommend people change the filename if they make any significant edits, and if you use this as your filename :

DRAFT - POLICY - Med Reconciliation Policy - Drafted 10-22-2013.doc

then it is very easy to change it to :

DRAFT - POLICY - Med Reconciliation Policy - Drafted 10-23-2013.doc

Unfortunately, it's also very easy for a team member to delete the working draft, or edit it beyond comprehension. To reduce the risk of this, I usually email myself a "SNAPSHOT - WORKING DRAFTS" copy of the drafts in the team's folder, before I send the hyperlinks out to the team.

9. STEP 9 - 
Been working for months on a policy? Have six different versions in your shared project folder? People getting lost in the folder? Reduce clutter by creating a sub-folder :

• ./Previous Versions

... and cut-and-paste the older draft versions into the folder. (You might need them for comparison sometime later.)

10. STEP 10 - 

Once you have your project's documents well-built, and well-reviewed by all of the required stakeholders, using your standardized templates, in one common folder - it will probably be very easy to get them approved!

IN CLOSING - This "Poor Man's Document Sharing" recipe may not be the fanciest or most elegant solution, but it does make collaboration a much more organized, standardized, efficient and productive process. 

It's all about making higher quality documents through better communication, improved standardization, and improved productivity.

Like all the posts on this blog, this is for education, fun, and discussion purposes only - Your mileage may vary. Have you developed other ways of collaborating electronically? Any simple tips/tricks I missed? Send me your thoughts or comments!

Why document management and archetypes matter

QUICK QUIZ : What do the following pictures all have in common?

San Cave Art, taken by Valroe at en.wikipedia [Public domain], from Wikimedia Commons

Graffitti in Northampton, MA, taken December 2012

  

Artwork from Thomas Stanley, age 4 (from Jan 2013)

ANSWER : They are all powerful reminders of the anthropologic relationship between human beings and their documentation. In other words, I think that very human attempt at self-understanding, expression, and communication :

... is still very much reflected in the organizations and businesses of today :

In other words, I think one way to help understand organizational dynamics is to see an organization as just many, many iterations of this same loop :

... by asking yourself :

• A - Who are the people in the organization?
• B - What are the documents in the organization?
• How do A and B interact?

This is why document management matters. Documents are tools - Every document serves a unique function.  So the way you manage your documents and information will, at least in part, determine the actions and behaviors of your employees, and collectively the functioning of your organization :

• Give them the right tools to express themselves, in the right way, at the right time - and you will empower your directors and managers to make changes in your organization. (WRITE)
• Publish those tools in the right place, in the right way, at the right time - and you will empower your staff to learn your values, beliefs, and operational standards. (READ)
• Update those tools regularly, and you will make sure that both your documents and employee behaviors are current, and reflect your ongoing changing needs. (GOVERNANCE)

And so, you want to make sure :

• Your managers/directors make the best tools.
• Your tools are published the best way, so people can easily find, read, and learn from them.
• Your tools are updated regularly.

What exactly are those tools? I outlined some common healthcare-related tools in the CMIO's checklist, but they vary from industry to industry. But what you *do* want to make sure of is :

• Each tool has a specific, well-defined purpose. (E.g. Apples=Sweet, Onions=Spicy)
• Your managers have clear guidelines about how to develop the tools (So they grow apples and onions, and don't build a hybrid apple/onion that people are confused by)
• You have some kind of quality check before tools are published (e.g. to weed out the occasional apple/onion hybrid.)
• Your front-line staff knows where to find those tools (so they know to find apples in the apple bucket and onions in the onion bucket) 
• Your front-line staff knows when and how to use those tools (e.g. apples for baking pies, and onions for making soups).

The reason I bring up the issue about hybrid tools is because, unlike real-world, physical tools - The engineering and safety of paper tools is not quite as intuitive.

For example, a hammer is fairly intuitive :

• It serves one purpose : To drive in nails. 
• Its safety is fairly intuitive : You can see it, touch it, and feel its weight, and once you hit your thumb by accident, you'll quickly learn how not to do that again. 
• Its utility is fairly intuitive : If the hammer doesn't successfully bang the nail in, you'll quickly know you need a bigger hammer. And it's fairly easy to see that you shouldn't use a hammer to put in a screw.

Paper tools are tricker. 

• It might not be as immediately clear if the purpose is vague, ambiguous, or serves multiple purposes.
• You might not immediately notice any safety issues, or know when the tools is malfunctioning.
• You might not quickly see if the tool isn't serving its purpose.

This is why it's important to ask yourself about how your paper tools are designed and used. For maximum efficiency, you'll want them to work the best they can - And that means not just designing good clinical documentation, but reviewing it properly, approving it properly, publishing it properly, and monitoring it properly.

Think of your paperwork as the lifeblood of your organization. If the blood doesn't flow from heart, to finger, and back to the heart - Then it's not doing it's job : To transfer information from the center to the periphery, and back again, in a continuous loop.

This is why document archetypes are important in healthcare - They are a big help when it comes designing your paperwork - Which can be a big influence with the READING part of the loop between your employees and your leaders.

SO WHAT EXACTLY IS AN ARCHETYPE?
This is one of those terms that Informaticists sometimes use, that can sound scary or weird, until you know how simple it is - and then it becomes very friendly and helpful.

According to Wikipedia, an archetype is a "universally understood symbol, term, statement, or pattern of behavior, a prototype upon which others are copied, patterned, or emulated..." Think of it as the mold you are going to use to cut your cookies - If you want round cookies, then it helps to have a round cookie-cutter :

• If you wanted a compelling hero template that could serve as a role model (template) for all heroes, to write a blockbuster science fiction movie, then you might make a superhero archetype and name the character "Luke Skywalker".

• If you wanted a compelling policy that could serve as the role model (template) for all policies, to have a blockbuster policy manual, then you will similarly need a superpolicy archetype to set the example for all of your policies.

(One quick unrelated side note : In this way, I think comic book superheroes actually benefit society - By creating templates/archetypes that kids can use to model at least some of their behaviors. I think this is also why it's unusually heartbreaking to see sports heroes sometimes fall from grace: We hold them up as archetypes of goodness, teamwork and fairness - and then feel great disappointment when we find out that they're actually only human.)

Anyway, having well-defined archetypes helps make sure that every document / tool serves a common purpose, and is developed, used, and monitored in a standardized way. It's that predictability that creates harmony, clarity, and efficiency in your organization.

So ask yourself - What are your documentation role models/archetypes? Perfection is near impossible, but you still probably want your documents to be pretty close to superheroes. Are they already superheroes, or do they need help? Once you have some super archetypes that your employees can use to model behaviors and communication, you will generally start to see a real improvement in your quality, operation, and efficiency. 

Remember, these posts are only for fun, education, and friendly discussion - Remember to check with your own experts and superheroes before you take any actions! And I'm always interested to hear people's thoughts and feedback, so feel free to comment below! :)