# Presentation: 353482

## Process management techniques to move the patient across a system of care

- John Grout, Ph.D.
- Campbell School of Business
- Berry College
- Mt. Berry GA 30149-5024
- jgrout@campbell.berry.edu
- (706) 238-7877

*Patient Safety Across Settings and Populations*

- Analysis & Artifacts: Process mapping and Mistake-proofing

## A definition of “process”

- “A collection of interrelated work tasks,
- Initiated in response to an event
- Achieving a specific result for the customer and other stakeholders of the process.”

- Source: Sharp and Mc Dermott Workflow Modeling 2001

*Patient Safety Across Settings and Populations*

- Eliminating or changing a problem
- so that it is trivial is usually more effective
- than optimizing its current instance
- (for example see Washington Post June 3, 2005 A01)

## Process Mapping Options

- graphical representation of a process
- Numerous formats or approaches exist
- Level of detail
- Multi-layered
- Multiple types of flows
- Shows hand-offs
- Icons
- Logical operators
- Flow time

*Patient Safety Across Settings and Populations*

**Notes:**
What is the best process mapping method for medicine: that’s an open question.

## Top-Down Flow Chart

- 1

- 2

- 3

- 4

- 5

- PSA test
- ordered

- Draw
- Sample

- Analyze
- Sample

- Report to
- Physician

- Results
- Filed

- _Subprocesses_
- Order Written
- Entered in CPRS
- Received in lab

- _Subprocesses_
- ID patient
- Select proper equip
- Draw blood
- Label

- _Subprocesses_
- Report Received

- _Subprocesses_
- Telephone
- Visit setup
- Result

- _Subprocesses_
- Review
- Centrifuge
- Verify calibration
- Run QC
- Run sample
- Report results
- Enter in CPRS

- DeRosier et al. joint commission Journal on Quality Improvement (28)5: 248-267.

- Typical of
- FMEA flow-chart

*Patient Safety Across Settings and Populations*

## Enhanced map showing handoffs and collaboration (“Swimlanes”)

- Flowchart superimposed on rows
- Rows are organizations, departments, functions, or individuals (answers the questions “who?”)
- Tasks are arranged chronologically left to right
- Changing rows indicates a hand-off
- Team or joint activities indicated by boxes

- “In some cases, it is easier for customers to define
- the business process because they are the
- only one who see it all.”  (Sharp & McDermott)

*Patient Safety Across Settings and Populations*

## Swimlanes: Susan’s Lumpectomy

- Swimlanes: Susan’s Lumpectomy

- Patient

- General
- Practitioner

- Radiology

- Hospital

- Surgeon

- Pathology

- Radiological Oncologist

- Medical Oncologist

- Physical therapist

- appt

- Mammo
- gram

- appt

- Phys-
- ical

- appt

- consult

- Phys-
- ical

- consult

- Rec’v

- send

- Dev-
- elop

- Mammo
- gram

- appt

- consult

- Consult

- Sched
- orders

- Sched
- orders

- consult

- Consult

- consult

- Consult

**Error #1 **
**occurs**

*Patient Safety Across Settings and Populations*

## Swimlanes: Susan’s Lumpectomy

- Swimlanes: Susan’s Lumpectomy

- Pre-
-  admit

- Surg-
- ery

- Pre-
-  admit

- Surg-
- ery

- Surg-
- ery

- Rec’v
- samp

- Anal-
- yze

- Type
- up

- send

- Plan
- treat

- Plan
- treat

- Consult
- treat

- treat

- ...

- Consult

- Consult

- treat

- ...

**Error #2**

**Error #1 caught **
**by patient**

**Error #2 caught**
**By patient**

- Consult

- Consult

- treat

- treat

- Request
- report

- Study
- report

- Pathology

- Radiological Oncologist

- Medical Oncologist

- Physical therapist

- Patient

- General
- Practitioner

- Radiology

- Hospital

- Surgeon

*Patient Safety Across Settings and Populations*

## Helping patients be involved

**The single most important way you can help to prevent errors is to be an active member of your health care team.**
- That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results. Some specific tips, based on the latest scientific evidence about what works best, follow.

- http://www.jcaho.org/
- general+public/
- gp+speak+up/
- speakup.pdf

*Patient Safety Across Settings and Populations*

**Notes:**
Recognize microsystems
Make comfortable about speaking up as part of team.

## Helping patients be involved

- Reduce the use of Jargon
- Make process more transparent

*Patient Safety Across Settings and Populations*

## Mistake-proofing Identification

**Blood Loc**:  The pad lock (circled) at the top of the bag containing a unit of blood prevents access to the unit until a code is entered.  The code is only found on the patient’s wrist band.

- 2a

*Patient Safety Across Settings and Populations*

## No good deed goes unpunished

- AuBuchon, transcript: Best Practices for Reducing Transfusion Errors - OBRR/CBER/FDA Workshop http://www.fda.gov/cber/minutes/0215bloo.htm

- 	“It was noon in the ICU. Half the nurses go to lunch, the other half take care of two patients rather than one.
- 	“The nurse knew a transfusion had been ordered for her patient, Patient A, and she assumed that the recent unit of blood delivered to the floor was his blood.
- 	“She went to the bedside of Patient A, was joined by another registered nurse, and the two of them verified all the information on the unit label that said it was really for Patient A, and the medical record number matched, and so forth, and so on. They then went to unlock the blood lock, and** it wouldn't open**. “

*Patient Safety Across Settings and Populations*

## No good deed goes unpunished

- AuBuchon, transcript: Best Practices for Reducing Transfusion Errors - OBRR/CBER/FDA Workshop http://www.fda.gov/cber/minutes/0215bloo.htm

- 	“We got a ***call from a very grumpy nurse*** in the ICU telling us the blood lock won't open.
- 	“We said, "Well, what patient are you trying to transfuse?" And she said, ‘Well, Patient A.’ We said, ‘Well, we haven't sent blood up yet on Patient A.’
- 	“There was ***a moment of silence*** at the other end of the phone, and then the nurse was much more cooperative because she realized that we had not only saved her patient a problem, we had saved her a big problem, as well.”

*Patient Safety Across Settings and Populations*

## Mistake prevention for patients 

- Problem:
- patient’s home chart becomes lost among the patient’s belongings
- not available for documentation or continuity of care.
- Environmental conditions of the patient’s home are beyond the control of the agency staff.

*Patient Safety Across Settings and Populations*

## Mistake prevention for patients 

- Solution:
- hang the chart from the bedroom door knob in a sturdy bag with the agency’s contact information printed on the bag.
- Any supplies, equipment or documentation (patient education information) are also placed inside the bag.
- This makes it difficult for the chart to get mixed in with newspapers or other clutter that might be in the home.”

*Patient Safety Across Settings and Populations*

## A modest proposal for EMR at NCSU

- Give each student a USB drive keyring with their medical records on it
- Records are readily available
- Privacy controlled by information owner

## A final thought on process improvement

- There is a performance improvement paradox:
- Healthcare workers can spend time doing the “core work” of  providing care,
- Or they can spend time doing process improvement work creating better care delivery.
- Process improvement work use up time that could be spent doing “core work.”

- Nobody Ever Gets Credit for Fixing Problems that Never Happened: Creating and Sustaining Process Improvement. ** ***Repenning, N. and J. Sterman (2001)* *California Management Review 43(4): 64-88*

## A final thought on process improvement

- You can improve performance in the short-term by avoiding process improvement work and doing more “core work.”
- The process deteriorates over time creating more _*need*_ for process improvement work but more _*pressure*_ to get “core work” done.

## A final thought on process improvement

- In practice, the* pressure* usually trumps the *need.*

- Way to go!

- You stink!

**Performance **_**without**_** **
**process improvement**

**Performance **_**with**_** **
**process improvement**

- Time →

- Time →

- performance→

- performance→

## Applied behavior analysis 

- The most powerful motivators are
- Soon
- Certain
- Positive
- The least powerful motivators are
- Delayed
- Uncertain
- Negative

## Thank You!  Questions?

*Patient Safety Across Settings and Populations*