Professional Documents
Culture Documents
PCPF Module 10 Workflow Mapping PDF
PCPF Module 10 Workflow Mapping PDF
Practice Facilitation
Curriculum
Module 10: Mapping and Redesigning Workflow
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
www.ahrq.gov
Prepared by:
Mathematica Policy Research
Princeton, NJ
Project Director: Deborah Peikes
Deputy Project Director: Dana Petersen
Principal Investigators: Deborah Peikes, Erin Fries Taylor, and Jesse Crosson
Primary Author
Lyndee Knox, Ph.D., LA Net Community Health Resource Network
Contributing Author
Cindy Brach, M.P.P., Agency for Healthcare Research & Quality
The findings and conclusions in this document are those of the authors, who are responsible for
its contents; the findings and conclusions do not necessarily represent the views of AHRQ.
Therefore, no statement in this report should be construed as an official position of AHRQ or of
the U.S. Department of Health and Human Services.
Suggested Citation
Knox L, Brach C. Primary Care Practice Facilitation Curriculum (Module 10). AHRQ
Publication No. 15-0060-EF, Rockville, MD: Agency for Healthcare Research and Quality;
September 2015.
Instructor’s Guide
Practice facilitator (PF) competencies addressed in this module:
General skills in basic quality improvement and coaching
Time
Pre-session preparation for learners: 45 minutes
Session: 85 minutes
Objectives
After completing this module, learners will be able to:
1. Describe the purpose and process for mapping workflow.
2. Identify activities that take place in a primary care practice setting that may be important to
map.
3. Create a workflow map of common and complex activities.
4. Use the redesign reflection questions to help a practice redesign a workflow.
Discussion. Ask questions and explore answers with learners. (10 minutes)
1. What did you learn from the mapping exercise?
i. Mapping the process as it is, rather than what you think it is or think it should be.
ii. Having the person who owns the process map their part of the process.
iii. Understanding the role of the facilitator in supporting the mapping process.
Use Redesign Reflection questions from Table 10.1 in module to redesign workflow.
Discussion. Ask questions and explore answers with learners (10 minutes)
1. What changes did you make to your workflows and why?
2. What did you learn about working with a group to redesign a workflow?
3. How will you use this with a practice?
Clinicians and staff in busy practices suggest that one of the most helpful things a facilitator can
do for them is help them map key workflows. Workflow mapping is a way of making the
invisible “visible” to a practice so they can look for ways to improve their processes to increase
efficiency, reduce errors, and improve outcomes. As a facilitator, you will have the skill, time,
and vantage point to help a practice map its key workflows and then to lead discussions about
improving them.
While many practices will have participated in workflow mapping for implementing electronic
health records, many will not have used these processes with the idea of improving quality and
outcomes. Workflow mapping is the process of documenting the specific steps and actions that
take place in completing a particular task. Creating a workflow map enables you and the practice
to see what is currently happening, identify opportunities for improvement or change, and design
new, more effective processes.
You and the quality improvement (QI) team will need to consider workflows associated with the
following three processes:
The perceived process can be obtained by having the group map what they believe the current
process is. The reality process is obtained by having various group members validate the former
through direct observation; the ideal process should reflect the workflow the improvement group
aspires to and wants to implement.
Workflow Maps
Creating a workflow map is not difficult. However, it is very important to map what is actually
happening, not what the practice “thinks” is happening or wants to happen. Figure 10.1 shows an
example of a detailed workflow map. You will need to identify every step of the activity and
who performs it. It is important that each individual involved in a process can describe how a
particular activity takes place. In addition to a traditional form of detailed workflows, Swimlane
workflows are also an option. Swimlane mapping is performed when you want to illustrate a
single process that involves more than two roles simultaneously across time. Figure 10.2 is an
example of a Swimlane workflow. When mapping a workflow, you should not rely on a single
person to describe a process unless that person controls and executes all steps of the process
being mapped.
MA gives
chart and lab
result to
RN/LVN
Normal or
RN/LVN RN/LVN writes mildly RN/LVN calls RN/LVN
follows lab normal, mildly Lab result abnormal patients about lab schedules repeat
result abnormal, or very is? results lab for mildly
protocol abnormal
Very abnormal lab per
abnormal standing orders
RN/LVN brings
lab result to
clinician
Implemented
standing lab
order Clinician reviews
lab result
Clinician gives
instructions to
RN/LVN
RN/LVN implements
instructions per standing
orders
Source: Bodenheimer T. Workflow mapping: a tool for achieving meaningful use. University of California San Francisco, Department of Family and Community Medicine,
Center for Excellence in Primary Care. Reprinted with permission. See Appendix 8.
Adapted from “Physician Assistant (PA) Office Visit,” Health Resources and Services Administration.
An important rule of thumb when mapping a process is “the person who controls the process
controls the pen.” This means the person who actually carries out a particular process is the one
who maps that step of the process.
Answering phones
Making appointments
Scheduling procedures
Making referrals
Providing health advice by phone or e-mail
Assigning patients to panels
Completing new patient workups
Educating patients and family
Managing patient panels
Planning patient visits
Coordinating referrals
Conducting patient outreach
Checking formularies
Entering lab results into the information systems
Making referrals for specialty care and community services
Consulting with specialists
Many additional activities carried out by a practice will need to be redesigned when it transitions
to team-based care. These include:
Registration
Appointment scheduling
Medical assistant role (pre-visit, vitals, agenda setting, checking chronic and preventive
care needs, ordering)
Receipt of test results by clinician (lab, x ray, other)
Receipt of test results by patient (normal, slightly abnormal, very abnormal)
Internal messaging (which messages go to whom, what action is required)
Prescription refills (chronic meds, acute meds, secure script meds)
You should also be prepared to assist in mapping and redesigning clinical care processes for
specific patient groups:
Preventive care
Acute problems (major/minor)
Chronic conditions (diabetes, hypertension, asthma)
Complex care needs
Mental health
Chronic pain
Women’s health
Pregnancy
Well child care
Palliative/end-of-life care
Many resources available online for free or at a small cost can assist you in preparing polished
maps. Maps can also be handwritten or constructed with sticky notes to allow a practice to move
activities around and redesign workflow. These types of maps are better during the active
mapping stage. Your program may provide these resources or ask that you use them, or you may
want to explore them on your own.
Helping practices redesign workflows. Redesigning workflows has two goals: improving
performance and increasing efficiency. Once you document the reality process, you will need to
assist the QI team and other members of a practice to redesign the workflow to incorporate the
desired improvements and then test these changes using the Plan Do Study Act (PDSA) process.
When redesigning workflow, it is essential to have all key players involved in the process. The
frontline staff who are currently or will be implementing the workflow will have
recommendations and ideas for how to maximize efficiency and effectiveness.
It is rare that a workflow is completely independent of other processes in the practice. In most
cases, workflows for one activity will overlap or depend on the execution of another activity or
process. It is important to identify and consider these dependencies when redesigning workflow,
as the effects of redesigning a workflow can be positive or negative.
It will be important for the team to be able to determine the potential peripheral effects of
redesigning workflows. The Model for Improvement and PDSA can help a practice identify
unanticipated effects of redesigned processes and correct them before taking them to scale.
New workflows will often require realigning jobs, changing staff time allocation, roles, and
responsibilities to fit the redesigned workflows. This in turn will require changes to policies and
procedures, job descriptions, training, and accountability/reporting systems for ensuring tasks are
completed.
o If more skills are required, can current staff be trained or do duties need to be shifted
to more qualified staff?
o Could someone with fewer skills perform this step? Would they need training or
support?
o Could someone be hired to perform this step?
o Could this step be outsourced?
Is there any technology that would make this process more efficient or easier to do? Are
you thinking outside the box? Is there an entirely different way to get this done?
Who do you know that handles this task very well (an exemplar)? Can you study their
workflow?
Implementing and sustaining new workflows. Once the team has developed a new workflow,
it will need to be implemented and evaluated. The PDSA process from the Model for
Improvement can be a good way to test the effectiveness of a new workflow. You will need to be
prepared to assist the QI team in implementing and evaluating the impact of a new workflow as
part of the PDSA cycle. You also need to include them in thinking through the different
administrative changes that will be required to fully implement and sustain newly redesigned
workflows.
Throughout this process, your goal as a facilitator will be to build the team and practice’s
capacity to engage in these processes in the future, as understanding and modifying existing
workflows is an essential component of any improvement process. AHRQ’s Integrating Chronic
Care and Business Strategies in the Safety Net toolkit contains resources from Clinical
Note: this module is based on Module 5 of AHRQ’s 2013 Practice Facilitation Handbook.
Available at: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/
pfhandbook/
This is an introductory course on workflow mapping. This session is meant to provide basic
knowledge in workflow mapping, while demystifying the process.
1
2
3
4
5
Become familiar with the following symbols. Your team will want to construct its workflow
diagram to include these. The symbols offer an immediate visual representation of:
start/end, decision point, delay, and direction.
1) Indicates the start or end of a process
2) A specific task or activity performed
3) A point in the process where a decision needs to be made to determine the path in the
process
4) Indicates a point in the process where there is delay or wait in line
5) Arrows indicate the direction of flow
6) Use this as a cross reference from a process on another page
6
7
8
9
This is an example of what is referred to as a “swim lane map.” A swim lane map displays
processes that are carried out for multiple roles across multiple stages.
Each swim lane is representative of a role, in this case: PCP, Clerk, LVN.
The stretch of each lane is marked by the stages in the process. Here they are marked in
the following order: 1) Appointment list review, 2) Appointment status, 3) scrubbing
10
11
After Step 6 Your next step will be to PDSA one of the identified fixes for
improvement
Step 1: Agree on a process to map: (HAVE A PLAN) Consider surveying your
staff, patients, or others on which processes are the biggest problems Process
that are the most time consuming, most labor-intensive, have the most
complaints, etc.
Refer to your “Know Your Processes” assessment template for guidance.
12
Ask each member of the staff to rate the core and supporting processes using this
worksheet.
Based on these findings, staff members chose what to work on improving.
Rate each process by putting a tic mark under the heading which most closely matches
your understanding of the process.
13
Give 2 examples from needs assessment to conduct
DO NOT USE WITH TEAMLET. Only one right answer. The reason we are showing this to
you, is for you to use it and select low complexity processes. If for some reason, you have a
highly functional team, then you might consider jumping into a higher complexity process.
But what you do not want is taking on if not ready. Digest this.
To be successful, build hope that they can change something. IC should know that not all
processes are created equal. Your job as an IC is to help teams
14
15
16
17
18
19
20
22
Module 10. Mapping and Redesigning Workflow
Workflow mapping:
a tool for achieving meaningful use
Tom Bodenheimer, MD
Goals
MA makes 3
photocopies
of lab result
MA places RN/LVN
patient’s lab writes normal,
result on abnormal, or
chart urgent
RN/LVN
MA gives gives lab
Clinician result to
chart to receives all
clinician clinician
3 copies of
lab result
Clinician sorts
lab results by
patient
Clinician writes
Did no Clinician
normal,
RN/LVN write on looks
abnormal,
lab result? at lab result
or urgent
yes
Urgent or
Patient Clinician calls Clinician calls abnormal
informed of patients with patients with Lab result is?
lab result abnormal labs urgent labs
normal
No action
Example 1b: Lab result follow-up after workflow mapping
MA takes MA pulls
Lab results
lab result patient’s
faxed
from printer chart
MA gives
chart and
lab result to
RN/LVN
Normal or
mildly
RN/LVN RN/LVN writes abnormal RN/LVN schedules
RN/LVN calls
follows lab normal, mildly repeat lab for
Lab result is? patients about
result abnormal, or mildly abnormal lab
lab results
protocol very abnormal per standing orders
Very
abnormal
Implemented
standing lab RN/LVN brings
order lab result to
clinician
Clinician reviews
lab result
Clinician gives
instructions to
RN/LVN
RN/LVN implements
instructions per
standing orders
Example 2a: How not to do Rx refills
Receptionist
Patient calls Receptionist writes down
clinic for Rx answers patient’s Rx
refill phone request on slip of
paper
Medical records
Medical records Medical records
clerk figures
clerk picks up Medical records clerk checks
DELAY note one hour clerk pulls chart name of patient’s
out which MA
is working with
later clinician
which Clinician
DELAY
MA calls pharmacy
to refill Rx two
hours later
Example 2b: Rx refills after workflow mapping
Patient
calls clinic Other workflow changes:
for Rx refill 1) MAs teach patients to contact pharmacy for
refills
Receptionist
Receptionist calls
2) Clinicians give patients with chronic meds lots
Receptionist writes down
answers patient’s Rx
medical records of refills
clerk to pick up Rx
phone request on Rx
refill form
refill form
3) Clinicians implement standing orders for MA
to refill meds for patients with well controlled
diabetes, hypertension, and cholesterol
yes
Clinician
Clinician puts
approves refill
chart on MAs
within one hour of
desk
receiving request
MA calls
pharmacy to
refill Rx
What is a workflow map?
EHR adoption
Practice Practice
Manager Manager
Workflow mapping pre-EHR
reveals inefficiencies and waste
Detailed Flowchart: Provides a detailed picture of a process by mapping all of the steps and
activities that occur in the process. This type of flowchart includes such things as decision
points, waiting periods, tasks that frequently must be redone (rework), and feedback loops.
This type of flowchart is useful for examining areas of the process in detail and for looking for
problems or areas of inefficiency.
Know your symbols
START/END: Indicates the start and end points of a process
DIRECTION: Arrows connect steps in the process and direct flow of information
UNCLEAR: Use this when a step in the process is unknown or not clear
Note: There are many more symbols than those listed, but these are
the most commonly used ones
Simple steps for workflow mapping
Record patient demographics Yes Someone in the practice needs to enter and
update demographics
Record vital signs electronically Yes Medical assistant adds to rooming tasks:
calculating BMI, entering height, weight, BP,
growth charts into EHR
Maintain up-to-date problem list Yes Clinicians often fail to keep problem lists updated.
MA reviews problem list during rooming and
reminds clinician to update. MA does not make
updates in EHR
Maintain active med list Yes MA does med-rec during rooming and makes or
pends updates in EHR
Maintain active allergy list Yes MA has series of questions about allergies and is
responsible for this task
Record smoking status Yes MA adds this to rooming task and could do brief
counseling (readiness to change, perhaps call
state quit line)
Core requirement Workflow Workflow change ideas
changes
needed?
Provide patients with clinical Yes The clinician does this and trains MA to carry it out
summaries for each office visit
Exchanging electronic Yes Care coordinator (probably RN) can assist clinicians
information with other sites of with this, particularly tracking/follow-up. If there is no
care RN, a workflow map would show which steps could be
performed by a non-clinician staff person
Report clinical quality measures Yes Someone would be responsible, perhaps practice
to CMS or states manager. The responsible person would need training
in CQI, numerators and denominators, measures, etc.
Menu of additional tasks (choose 5 Workflow Workflow change ideas
out of 10) changes
needed?
Drug formulary check system No
Lab results into EHR No
Generate lists of patients for QI or Yes The generation of the lists is a technical issues, but
outreach (registry) panel managers will be needed to work the lists to see
which patients need which services, and provide out-
reach or in-reach. MAs could be the panel managers
except their workload is becoming excessive. MAs would
do in-reach.
Electronic health education Yes Health educator is responsible (if available), but
resources clinicians/MAs would also provide the information to
patients
Med reconciliation between care Yes Between settings is complex, but within the primary care
settings practice, MA can do med-rec as part of rooming
Summary of care record for referrals Yes This is mainly a clinician function but it also needs to be
and transitions tracked and reminders done (MA and/or RN care
coordinator)
Immunization data to regional Yes Someone on team responsible
registries
Patient access to lab results, Yes Creating a secure patient portal is technical issue, but
problem and med lists, allergies actually providing the information would be an MA task
Suggested workflows for meaningful use
no
Obtain patient’s
medication history Clinician updates
yes Does clinician
from former primary patient’s Patient sees
change
care clinic medication list in clinician
medications?
EHR
no
MA/clinician prints
out after visit
summary with
updated medication
list
yes
yes
MA asks MA inputs
MA opens Does patient no patient if they allergies into
patient’s allergy have an active
have any patient’s allergy
list allergy list?
allergies list
Allergy list
updated
Example flowchart: documenting smoking status for patients 13 and up
yes
no
yes
MA asks patient if
they smoke
yes
no
Patient receives
MA/nurse summary
Clinician finishes performs task
writing progress and documents
note within 3 appropriately
business days
MA/nurse sends
Clinician informs How does electronically clinical summary
MA/nurse that patient receive clinical
via secure
note is complete summary?
patient portal
Example flowchart: reporting on clinical quality measures to CMS
(example: % of diabetes patients with A1c>9)
no
Data manager
queries number of
patients in
denominator
(denominator=#
diabetes patients)
Reporting
deadline
Within 7 days
Are reports pre-made?
Data manager
calculates % by dividing
numerator by the
denominator
(%DM pts with
A1c>9=#DM pts with
A1c>9/# DM pts)
See how to
First Friday of Care team member generate a Care team member
the quarter generates list of prints reminder Care team member
query (list of
patients who have patients) letters and labels mails out letters
not completed FOBT for all patients on with FOBT cards
workflow
in the last 11 months query list
yes
Does practice Do Care team member
have a registry? patients on the list have no
indicates in registry
visits scheduled? that patient
received FOBT
cards
no
yes
yes
Does EHR
have query function? 1 month later, care
Care team member See in-reach team members runs
performs in-reach workflow query of patients who
to patients received FOBT cards
but have not
no completed FOBT in
the last 11 months
no
no
Doesn’t
want to
Supervisor
perform addresses staff Supervisor brings
Forgot Why is staff member function concern to team
not performing member’s concern
new function? over new job role
Supervisor does
additional training
Doesn’t
know
how
This is not a meaningful use requirement but will be needed to achieve meaningful use
Conclusion