Workflow and Human Factors for Quality Evaluation

custom workflow management system

Welcome to Post number 3 of Abbott Informatics.  This week we are going to discuss workflow related to the chest pain program.   Workflow is the sequence of physical and mental tasks performed by various people within and between work environments. It can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously.

To meet all the requirements for a population specific program, many aspects of care delivery must be considered.  As discussed in a previous post, the University of Wisconsin’s own Systems Engineering Initiative for Patient Safety (SEIPS) model can be applied to each desired outcome that the patient requires.  We can break down the five components of a work system: People, tasks, tools and technologies, the physical environment, and organizational conditions.  When multiple processes are group together and placed in sequence, it comes back to workflow.  Imagine trying convey these detailed sequences of tasks in an understandable way and also have the ability to evaluate the whole process for the six domains of healthcare quality.

There are many different tools that are used to communicate a workflow process and also to evaluate a process.  The U.S. Department of Health & Human Services through the Agency for Healthcare Research and Quality (AHRQ) offers many examples of these tools.  Some of the tools explored on the site are benchmarking, checklists, flowcharts, interview, and usability evaluation.  Many of the tools require additional education or experience to properly use.The website allows one to open examples of applications for each tool and also evaluates the strengths and weaknesses of each.

In the example we will explore, a workflow flowchart will be the tool used.According to the AHRQ website, Flowcharts are a tool that visually convey the steps in a process.  They can also be used to find one or multiple sources of a problem or identify potential areas for improvement, examine the handoffs that occur in a process, identify personnel, groups, or entire departments that are responsible for processes or tasks.  As mentioned, once the flowchart exists, it can be used to demonstrate current processes and aid in identifying areas for improvement.

Patients who present to the Emergency Department (ED) with chest pain or other acute coronary syndrome symptoms must be evaluated for ST elevated Myocardial Infarction (STEMI).  A STEMI is a medical emergency that must be intervened upon in a timely manner to avoid cardiac muscle cell death.  As you can imagine, the first step is recognizing we have a problem.  One of goals and critical measure tracked by the American College of Cardiology for Chest Pain Center accreditation is time from walk in arrival time to ECG obtained time and physician read time.  Even if you don’t work in an ED, you can begin to imagine how complex this goal can become.

So where to start and how to begin?  The AHRQ website even has educational presentations in Powerpoint format to guide you through the steps.  For flowcharts, it is recommended to break the process into five steps:

• Step 1: Decide what processes to examine
• Step 2: Create a preliminary flowchart
• Step 3: Add detail to the flowchart
• Step 4: Determine who you need to observe and interview
• Step 5: Do the observations and interviews

Step 1.  In our example of getting an ECG read as fast as possible on a walk in patient, the process could have been chosen to examine secondary to reviewing of measures over time.  Looking at the larger flowchart that exists for the program, and focus can be placed on any of the process boxes.

Step 2.  The preliminary flowchart can be built just by placing the patient at the center of the SEIPS work model as the person and start walking the patient through the current state of the environment of the ED following the organizational flow until the patient encounters another person in the process.  If the patient first contact is with a receptionist or a triage nurse, the box would be placed.  this would continue until and ECG is read.

Steps 3 & 4 can be simultaneous in this example.  Interviewing is detailed on the AHRQ website as well and is important to understand the human factors that each person placed at the center of the work model.

Step 5.  It is important to start considering user focused design of any clinical decision tool such as electronic flow sheets in the electronic medical record very early in a project, but can continue in parallel with other work. Designers must know about the work the tool will perform – who performs it, how and in what environment.  Key information that is acquired already can be collected into screening tools by rows to alert the user to a best practice to obtain an ECG.

A major human factor that was discussed in a previous post is related to the type of ECG machine used.  To review, this facility uses paper copy ECG without transmitting capabilities.  The physician as the person in the center of the SEIPS work model being handed a paper ECG with or without prompts from the tech or nurse that this is a chest pain patient.  The physician must hand sign the date, time and initials with a readable description of STEMI or NO STEMI.

Once a flowchart is created, there are opportunities for process improvement of the work and the flowchart tool.  One tool offered by AHQR is Value-added Analysis Value-added analysis is a method for identifying problems within a process. The analysis allows a team to examine individual process steps so it can separate the steps that add value for the user from the steps that do not.  This can be used at department level meetings, task forces or other work groups including the Chest Pain Program Steering Committee.

Consumer Health Informatics

interestingly, the ACC does measure the proportion of patient who present to the ED as a walk in with chest pain or other heart related systems.This measure is designed to help  evaluate the effectiveness of the organization’s community outreach program by calculating the percentage of patients entering your ED who sought assistance using 911. This is a critical operational measure to track to increase Early Heart Attack Care (EHAC) awareness within the community. How are people getting this information?

One of the challenges for consumers is not finding information on the internet, it’s finding reliable information.  Many hospitals are attempting different interventions such as giving patients list of reliable sites, expanding the hospital organizational website better provide health information including portals to validated sites such as the Government websites.

In an organization that uses Epic products, there is a MyChart function.  This function can be accessed by tablet and other mobile devises. There are even interactive software to communicate though mobile devises such as the Apple watch called Haiku, Canto, and Limerick.  Individual devises can be customized to enhance the user experience to receive information.

We can keep improving the workflow for treatment of STEMI, but we forget that even the best, most efficient, invasive treatment is actually a failure to prevent.  If we can improve the community awareness of heart care and place tools in the hands of the consumer that can prevent rather than treat, we can increase quality of life.