Southwestern Medical Clinic Software Revisions to Family Practice Rooming Workflow (Annual Exam) Background Background Southwestern Medical Clinic s (SWMC) Electronic Health Record (EHR) Team expects to upgrade to the next version of the EHR between July-August 2010. Due to changes in the new version, the organization s software Rooming Workflow needs to be rewritten to reflect software changes. (The software Rooming Workflow documents what a clinical staff member needs to do in the EHR software between calling the patient from the waiting room to sending the electronic chart to the provider.) Overall Goal/Objectives Overall Goal At the completion of this project, a family practice clinical staff member, using a written EHR rooming workflow, will be able to accurately (with no errors) complete all the steps for documenting patient information while rooming a patient for an annual exam. Specific Objectives A rooming staff member will be able to find the appointment of a given patient and start an EHR chart with no prompts. A rooming staff member will, with no errors, document height, weight, and blood pressure in the Vitals section of the EHR. A rooming staff member will be able to accurately select a reason for visit based on a patient s chief complaint. A rooming staff member will be able to apply the correct Review of Systems template based on the reason for visit. A rooming staff member will be able to correctly (with 100% accuracy) document patient responses to Review of Systems questions. Bargerhuff BOSCARD Page 1 of 10
A rooming staff member will be able to perform medication reconciliation in the history section of the EHR with no errors. A rooming staff member will be able to send the chart (with no errors) to the provider seeing the patient. Scope Scope This project is divided into five stages: Analysis/Design/Development, Testing, Training, Implementation, and Ongoing Evaluation. The phases will run sequentially except for areas where overlap occurs. For instance, some training will need to occur in order for the testing phase to be initiated, and evaluation will occur throughout the entire process to gauge progress and understanding. Analysis, Design, Development This stage covers the analysis, design, and development necessary to planning/designing an accurate rooming workflow. It includes the following elements: 1. Complete value stream mapping a. Review Current Workflow b. Design Future Workflow 2. Create and affinitize a Murphy s list (list of things that could go wrong) 3. Create idealized state 4. Plan testing, implementation, and evaluation 5. Design and develop instructional videos 6. Design and develop instructional and evaluation materials Testing During the Testing stage, the rooming workflow will be tested to ensure it is accurate, efficient, and effective. EHR Functional Experts (expert EHR users from Family Practice clinical settings) will be expected to train a few key users on the use of this rooming workflow so the users can pilot or test the rooming workflow and recommend changes. Family Practice physician champions will also be asked to participate in a comment session to assess the effectiveness of the rooming process in the testing stage. The following sections will be tested in this phase: 1. Starting a chart 2. Vitals documentation 3. Reason for Visit documentation Bargerhuff BOSCARD Page 2 of 10
4. Review of Systems documentation 5. History documentation 6. Physical Exam template application 7. Consent documentation 8. Local/Mail-Order pharmacy documentation 9. Sending the chart to a provider Also, the video prototype, instructional materials, and evaluation materials will be tested and revised as necessary. Training This phase will cover training staff on the rooming workflow. Medical assistants, licensed practical nurses, and registered nurses working in a Family Practice environment will be trained. Training will be offered in a blended learning format. A simulation/demonstration video will be offered during the first phase of instruction, and completion of it will be tracked through Southwestern Medical Clinic s e-learning program. This instruction will be followed by a faceto-face practice session where groups of Family Practice rooming staff will meet at their respective locations with a clinical EHR expert to role-play and practice the rooming skills learned in the video. Implementation The Implementation stage will be the stage of the project where the rooming workflow will be implemented, and all EHR Family Practice rooming staff will be expected to use the workflow as instructed in the Training phase. Functional experts will be on site to advise of any questions and handle concerns. For the first 3 days of implementation, a phone conference for the Functional Experts will be held by the EHR Analyst at 4:00 p.m. daily to discuss concerns and questions. Ongoing Evaluation Once implementation is complete, EHR functional experts, the EHR analyst, and the nurse managers will observe users (electronic observation) based on a checklist of skills, audit completed charts, and evaluate and address concerns in order to continually improve EHR use. In Scope/Out of Scope In Scope This project will address revising the Family Practice EHR Rooming Workflow for the annual exam (complete physical) visit type for all Family Practice locations of Southwestern Medical Clinic. This project will only address revisions to the software-based rooming workflow, and will affect Family Practice rooming staff (medical assistants, licensed practical nurses, and registered nurses). For this particular report (for class), only the Analysis phase will be in scope. Bargerhuff BOSCARD Page 3 of 10
Out of Scope This project will not address any other Family Practice visit types such as sick/acute visits or procedures. The project will also not address any other department s rooming workflow or any other staff other than those identified in the In Scope section above. Rooming workflows for additional visit types and departments will be addressed in future projects. For this report (for class), the Design/Development, Testing, Training, Implementation, and Ongoing Evaluation phases will be out of scope. Measures of Success Transfer of knowledge will be measured through audits of rooming staff EHR documentation and shadowing (real-time electronic observation) of rooming staff documentation. Reactions to analysis/design/development, testing, training, and implementation phases will be collected from rooming staff, providers, and project team members. Post-project chats will be scheduled to provide time for staff and the project team to reflect and suggest future project improvements. This project will be considered successful if project milestones are met and if designated accuracy checks are completed at a certain percentage (to be determined by nurse managers). Constraints The following constraints have been identified. Merger SWMC s administrative offices recently merged with a local hospital on March 1, 2010. SWMC s physician practices will merge with the local hospital on June 1, 2010. These separate mergers will affect the project by incrementally changing organizational goals and objectives as well as leadership and reporting lines. Thus, it is likely it will change the way daily tasks occur at administrative and clinical levels. The unknown quantity of change that will occur and the likely realignment of goals have the potential to change the timeline and direction of this project. Time (EHR Analyst, Functional Experts, Family Practice Rooming Staff) For various reasons, SWMC staffing is lean. Two EHR analysts currently cover five full-time analyst positions. Though the analysts have some part-time assistance, time for anything other than the bare necessities of support is difficult to muster. Functional experts and Family Practice rooming staff are also experiencing shortages in staff and increased work time that makes it difficult to break away for training periods. Bargerhuff BOSCARD Page 4 of 10
Physical Exhaustion/Change Fatigue Physical exhaustion and change fatigue are factors due to lean staffing and overstressed staff. It has been two years since the EHR was implemented, and there have been few breaks from its fast-paced change. The fast pace of change is expected to increase as the federal government s rule on meaningful use of an EHR will affect reimbursement, and the rule carries with it many technological and people-oriented changes that will affect staff. New Provider Training Due to the necessary intensity of new provider EHR training, if a new provider arrives before the completion of this project, his/her learning will take precedence over any other EHR project. Due to the availability of one analyst to do this training, if new provider training falls in the analysis/design/development or testing phases, this project will have to wait to proceed until new provider training is complete. The nurse managers and Functional Experts can handle the project during the training and implementation stages. Provider Compliance Some Family Practice providers can exert pressure on staff to complete tasks in a certain way (different from the way the rooming workflow is written). Throughout the process, input from the Family Practice provider champions and nurse managers will be collected to ensure the rooming workflow has a broad base from which information is drawn so consensus is achieved. Assumptions The following assumptions are made in this project: The new administration will support EHR objectives and will provide/support the use of staff time and resources to accomplish the project s objectives. Technology (hardware and software) for all phases of the project will be available 24 hours, 7 days a week, and will be a stable environment in which to work. Federal regulations will not drastically change the way electronic information is documented and/or captured. The majority of Family Practice nurses will be experienced nurses, familiar enough with typical non-technological nursing tasks that they can focus on new technological tasks without compromising patient care. The Information Services Director will continue to be the same person for the duration of the project. This position provides key support in obtaining and/or maintaining technology in all phases of the project. The Chief Medical Officer will continue to be the same person in the same role. (A change in this position would redirect EHR vision.) Family Practice providers will agree to consensus on what information is documented and how it is documented in the EHR. Bargerhuff BOSCARD Page 5 of 10
All project team members will remain healthy and available during the project. See following page for Roles and Responsibilities. Bargerhuff BOSCARD Page 6 of 10
Roles and Responsibilities Key members of Southwestern Medical Clinic s staff will hold the following roles and responsibilities during the project: Role Project Lead/ EHR Analyst (H. Bargerhuff) Responsibilities Manage project (budget, timelines, design) from the organizational perspective Act as liaison between teams (provider, nurse, functional expert) Collaborate with project team members in all phases of project Analyze all phases of project in relationship to best practices of EHR use, federal/state/local laws and regulations, and best practices in patient care Use Adobe Captivate to create instructional videos Subject Matter Experts (SMEs) - Provider Chief Medical Officer (CMO) Dr. K. O Neill EHR Provider Champions - Dr. J. Kroeze, Dr. B. Ferrari (representing Family Practice providers) CMO Provide overall medical vision Offer medicolegal counsel Remove organizational roadblocks that impede project Cast final decision-making vote (in case of lack of consensus) CMO, Provider Champions Provide medical advice on rooming workflow details Complete video usability/prototype testing Assist with project evaluation Subject Matter Experts (SMEs) Clinical Rooming Staff RN Managers J. Bailey, M. Hurrle (providing legal nurse counsel and general workflow oversight) Functional Experts G. Veres, D. Smith, P. Morlock, C. Boardman (representing rooming staff) RN Managers Provide nursing advice on rooming workflow details Assist with project evaluation Functional Experts Provide nursing advice on rooming workflow details Complete video usability/prototype testing Assist with project evaluation Bargerhuff BOSCARD Page 7 of 10
Roles Information Services Liaison (JC Hearn) Responsibilities Provide technology resources and support in all phases of the project. See following page for Task/Responsibility Chart. Bargerhuff BOSCARD Page 8 of 10
Task/Responsibility Chart FP Task HB KO JK BF JB MH GV DS PM CB JH JC Rooming Staff Create Value Stream Map (Review Current Workflow, R C C C C C A A A A I I Design Future Workflow) Create and affinitize a Murphy s list R C C C A R I A I I Create an idealized state A C I I C C A R A A I I Create instructional materials R I I I C C A A A A I I Create instructional videos R I I I I I A A A A I I Complete video prototype R I A A I I A A A A I I testing Plan testing R C C C A A A A A A I I Plan implementation R C C C A A I A I I I I Plan evaluation (Develop evaluation materials) A A C C R I I I I I I I Testing phase A C C C A A A R A A I I I Training phase R I I I A A A A A A A I I Implementation A C I I R R A A A A A I I Ongoing evaluation A C C C R R I A I I I I I Responsibility Key R Responsible for task A Accountable for task C Consulted with for task I Informed of task Staff Names HB: H. Bargerhuff KO: Dr. O Neill JK: Dr. Kroeze BF: Dr. Ferrari JB: J. Bailey MH: M. Hurrle GV: G. Veres DS: D. Smith PM: P. Morlock CB: C. Boardman JH: J. Hindmon JC: JC Hearn FP Rooming Staff (as stated) Bargerhuff BOSCARD Page 9 of 10
Deliverables Deliverables/Criteria Based upon the activities previously discussed, the following deliverables will be developed for SWMC: Deliverable Format Recipient Acceptance Criteria Analysis (Documents) PDF Nurse Managers Functional Experts Finalized workflow version (completed after value stream mapping) GANNT Chart Design/Development (Videos) Flash Provider Champions, Nurse Managers, Functional Experts Video Prototype Final instructional video Instructional Materials PDF CMO, Nurse Managers, Functional Experts Practice session teaching materials Job aids may be created as deemed necessary Evaluation Materials MS Word document; Online survey CMO, Provider champions, Nurse Managers Observation/task checklist Interviews Analysis of chart documentation Survey Monkey survey Bargerhuff BOSCARD Page 10 of 10