Transcript Slide 1

Developing Workflow Process Diagrams
To
Target Interventions
Moderator: Mindy Golatt, RN, MPH, Public Health Analyst,
HRSA/HAB
Presenters: Paul Cassidy, Program Director, GNBCHC
Erika Harding, Health Administrator, CCHC
Facilitator: Nanette Brey Magnani, NQC/HIVQUAL QM Consultant
Learning Outcomes
Participants will be able to:
• Define the steps and symbols used in
workflow process diagrams,
• Engage in discussion with grantees about their
examples, and
• Begin to develop a workflow process diagram
of their own work processes.
Agenda
QI Principles and Framework
Workflow Diagrams
The Basics
Examples
Try it out!
Post AGM
Discuss and Revise with your Team.
Why Look at Processes?
Fundamental Concept of Improvement:
“Every system is perfectly designed to achieve exactly
the results it achieves”
Principles of Improvement:
– Understanding work in terms of processes and
systems
– Developing solutions by teams of providers and
patients
– Focusing on patient needs
– Testing and measuring effects of changes
Most problems are found in processes
not in people.
Understanding Work in Terms of
Processes and Systems
Benefits
•
•
•
•
•
•
Clearer understanding of the overall system and processes
Target processes that need improvement
Efficient allocation of staff and resources
Effective use of team’s input and creative problem solving
Better understanding of each other’s roles
Reduction in waste and time
What are your initial thoughts about this
improvement system?
Regional Quarterly Retention Rate
100
90
Performance Rate (%)
80
70
60
50
40
30
20
10
0
Jan-09
May
Sep
Dec
Jan-10
May
Sep
Dec
Jan-11
May
Sep
Dec
What are your initial thoughts about
this improvement system?
Regional Quarterly Retention Rate
100
90
80
Performance Rate (%)
70
60
50
40
30
20
10
0
When do you develop your workflow
diagram?
QI Project Steps
Step 1: Review, Collect and Analyze Baseline Data
Step 2: Develop a Project Team Work Plan
Step 3: Investigate the Process/Problem
Step 4. Plan and Test Changes – PDSA Cycles
Step 5: Evaluate Results with Key Stakeholders
Step 6: Systematize Change
QI Principle
Most problems are found in processes
not in people.
– A system is made up of processes
– Processes comprise steps
Workflow Diagram Definition
A workflow diagram or flow chart is a picture of
the steps of a process to:
– Understand the process
– Identify potential problem steps and reasons
– Outline the ideal process steps
– Enable communications with others
Creating a Process Diagram
1.
2.
3.
4.
5.
Agree on use and level of detail
Define starting and ending points
Document each step
Follow each branch to the end
Review the chart .
Flowcharts
Testing and Measuring a Workflow
Process
1.
2.
3.
4.
5.
6.
Identify key problem steps.
Write key causes to each identified problem
Select interventions that address key cause.
Then test and measure new process.
Repeat as necessary.
Support new process – e.g. communication,
new procedure guidelines.
Most Commonly Used Flowchart
Symbols
Activity/step
Connecting
lines
Begin/
Terminator
Decision
Flowcharts
Grantee Examples
VL Suppression
• Paul Cassidy – Greater New Bedford CHC, New
Bedford, MA
Gap in Care and Patient Transition to a different clinic
• Erika Harding – Christian CHC, Chicago, IL
Greater New Bedford Community
Health Center, MA
Performance Measure for VL
Suppression
Percentage of HIV patients, regardless of age, with a
viral load less than 200 copies/ml at last viral load test
during the measurement year.
Measurement year 2011
Baseline Data
Viral Load Suppression
84
236
Number of Patients = 320
Suppressed (Blue)= 236
Not Suppressed (Red)=84
Suppression Rate=73%
Improvement Goal
To increase patients’ viral load suppression
rate from 73% to 85% in six months.
Causal Analysis
Problem Steps with Workflow processes on two levels:
Patient Level
• Insufficient time for adherence education for patients not
suppressed
Causal Analysis cont’d
Problem Steps with Workflow processes on two levels:
Program Level
• Weekly (3x/month) multi disciplinary team meetings for
patient review had stopped meeting for 6 months due to
construction; thus a loss of focus on non suppressed patients
• Minimal input of multidisciplinary team members ideas into
tailored care plans for each non suppressed patient
• No feedback loop for reporting results of the interventions
back to the team.
GNBCHC Workflow Process for Established
Patients
PATIENT
REGISTERS
MA TAKES
VITALS
PHYSICIAN
EXAMINES
PATIENT, REVIEWS
RESULTS AND
REGIMEN
>200
Review Meds,
barriers to
adherence, based on
barriers, pre-pack
meds, deliver to
house, review meds
and fill pill box
Determine
next steps
with patient
**
<200
RN
Adherence
Visit
MultiDisciplinary
Team
Review
Give lab
orders,
patient to
Lab
Order Blood
work for next
three month
review
Lab Blood Draw
Schedule
next visit
Lab Results Sent
to Data Entry.
Blood work
electronically
entered into
EHR
Lab Results
sent to
Physician
Lab Results
Sent to RN
Concern
with
Results
N
No
further
Follow-up
Y
Call patient
and make
earlier visit
than
previously
scheduled
GNBCHC WEEKLY MULTI DISCIPLINARY MTGS.
RE- START WEEKLY MTGS-3/MONTH
•REVIEW PATIENTS
•TAKE NOTES
•DEVELOP CARE PLAN TEMPLATE
•DEVELOP PATIENT SPECIFIC CARE PLANS
•TEAM MAKES RECOMMENDATIONS
•ASSIGNED STAFF PRESENT PLAN TO PATIENT
FOR PATIENT INPUT
•FOLLOW –UP ON RECCOMENDATIONS
•INTERVENTION IS INDIVIDUALIZED
Prepare
Reports
Identifying
Patients Not
Suppressed.
RN INTERVENTION
•DEVELOP AND IMPLEMENT
CARE PLAN
•FOLLOW -UP
***
BARRIERS TO VIRAL LOAD SUPRESSION
•SUBSTANCE ABUSE
•HOMELESSNESS
•NOT ATTENDING APPOINTMENTS
•MENTAL HEALTH ISSUES
•REFUSE MEDICATIONS
DATA
ENTRY
SOCIAL WORK
INTERVENTION
•FOLLOW-UP ON PLAN
SCHEDULED TEAM MEETINGSREVIEW RESULTS OF
INTERVENTIONS
# OF PATIENTS WITH VL >200
REVIEWED
# WITH TARGETED CARE PLANS
PATIENT RESPONSE TO
INTERVENTION
PEER NAVIGATOR
INTERVENTION
•FOLLOW –UP ON PLAN
GNBCHC – Measurement
• Data Update
Christian CHC: Improvement Goals
To reduce the gap in care rate from 13% to 5%.
(number of patients with a medical visit in the
last 6 months of the measurement year)
To ensure 170 patients or 69% of our HIV+
population at the Monterey Clinic are
successfully transitioned to the Halsted Clinic.
Quality Improvement Team
GROUP PHOTO HERE
26
Transition Care from Monterey to Halsted
CCHC
Patients notified
Instructed to make appt at different site
Patient
Makes
Appt.?
Requires
Follow-up
No
Yes
Receives reminder call from PHA – 1 day prior
Scheduler
Repeat call
from PHA
No
Appt
Kept.
?
Yes
Patient
Registers
27
Patient Follow-up
Data specialist
initiates Patient
Tracking Tool
Import list of patients from CAREWare who’s last visit
>45 days
Yes
Patient
Has a Scheduled
appt?
Note appt date
in Patient
Tracking Tool
Refer names to Patient Health
Advocate for follow-up
Yes
Refer to Scheduler
for appointment
No
Active,
Continuing?
No
Document status in
list and chart
PHA meets monthly with QI Team for
patients’ status
28 update
Measurement Tracking Data
Yr
Ending
Sept
2011
Nov
2011
Jan
2012
Mar
2012
Apr
2012
May
2012
Rate
13%
16%
18%
7%
6%
8%
29
Measurement Data
Start PSDA
20%
16%
Cycle 1 Ends
12%
Cycle 3 Ends
8%
4%
Sep-11
Nov-11
Jan-12
Mar-12
May-12
Cycle 2 Ends
30
Task: Draw a Workflow Process
Diagram
1. Select a process to improve. It can be just
a few steps.
2. Agree on use and level of detail.
3. Define starting and ending points
4. Document each step. Use paper provided.
5. Follow each branch to the end
6. Review the chart.
Flowcharts
Large Group DeBrief
What improvement processes did you choose?
Who will share your diagram?
What were some of your challenges?
What do you think are the benefits?
What can you do post AGM?
Flowcharts
REMINDER
This is a TEAM effort!
Flowcharts
Contact Information
Paul Cassidy, Program Coordinator, Greater New
Bedford Community Health Center, New
Bedford, MA [email protected]
Erika Harding, MPH, Health Administrator,
Christian Community Health Center, Chicago
[email protected]
Flowcharts
Contact Information
Mindy Golatt, RN, MPH, Public Health Analyst,
HRSA/HAB, Project Officer/Chicago,
[email protected]
Nanette Brey Magnani, EdD, Quality Management
Consultant, NQC/HIVQUAL,
[email protected]
Flowcharts