Oamain Process Mapping

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OA Main- Using Process Mapping to Optimize Care

Presented by [Phil Deering, Project Mgr. Stratis Health and Regional Coordinator for REACH] (52-minute Webinar) [08-14-2013]

Karla Weng: Good afternoon everyone this is Karla Weng from Stratis Health and I’d like to welcome you all to today’s call on using process mapping to optimize care. This is the third of five learning sessions that are part of a statewide initiative to help improve and sustain quality of care provided by critical access hospitals.

Stratis Health with support from the Minnesota Department of Health offers a role in health and primary care is proud to host and offer this free programming for all 79 of Minnesota’s critical access hospitals.

Our presenter today is Phil Deering, a Project Manager here at Stratis Health and of the many roles he has here at Stratis he is the Regional Coordinator for the REACH program, the Regional HIT Extension Center for Minnesota and North Dakota.

We’re also grateful to have a guest speaker, Anita Zalinko, is with us today. Anita is an infection prevention practitioner, nurse and wears several other hats as does everyone at Chippewa County Montevideo Hospital. She’s been there since early 2012 working extensively on best practices and the prevention of catheter associated urinary tract infections or CAUTI. We’ll talk with Anita for a bit about that work and how it links together with process mapping.

With that I’ll turn the call over to Phil and Anita.

Phil Deering: Hi everyone. Thank you Karla. Good afternoon everybody. I’m sure I know a number of you on the line through my REACH work, so hello to all of those out there who have worked with me or any of our REACH colleagues.

Initially we were going to ask Anita to speak at the end of the presentation, however, one of Anita’s hats is also being a trainer and she has to get to the other side of the building by 1:00 to start a class, so we decided to start with our conversation with Anita. I’ll ask her some questions and Anita will tell you a little about her initiative.

Anita, we understand that you engage in an initiative designed to prevent hospital acquired infections, HAI’s and that you’re working specifically around CAUTI’s.

Could you tell us briefly about when you started the initiative and what the baseline was that you were working with and trying to change?

Anita Zalinko: We started the initiative’s actual paperwork and agreement in November of 2011. We put out press releases, but the data collection and the 2:40 in the National Healthcare Safety Network began in January of 2012. We didn’t really have a baseline because we had not done any CAUTI audits prior to that.

Stratis Health | 952–854-3306 | www.stratishealth.org Page 1 We started out Kay Peterson worked with us at that time through Stratis Health. We developed a work plan in April and revised it in May with much of it being based on a CAUTI readiness assessment that was sent out. All those things helped us look at what we were doing and what kind of improvements we could make. That’s how we got started.

Phil Deering: I understand from talking to Bruce here at Stratis as well that you didn’t really use… what you were trying to reduce or the metric you were using wasn’t CAUTI’s because you weren’t actually having any during the measurement period but you used a metric called ‘catheter days’.

Can you talk about that a little bit and why that was the appropriate thing to track?

Anita Zalinko: Since we didn’t have any CAUTI’s per the guidelines, the way to measure improvements is if you’re reducing the number of days that a person has a catheter in, so when we do our audits we actually do it by timing.

You put it in on November 18th at 11:00 o’clock and measure how many days from that time on. Then you want to improve and reduce the dates. If we look at a graph from January through March of 2012 we were up to 26.6% of catheter days and now we’re down to four. In fact, since January of this year we’ve been at 6, 6 and 4% so we feel pretty good that we’ve reduced the days.

The ways we reduced those days, everybody knows that the longer a catheter is in the more the chance it increases the risk of getting UTI’s associated with your catheter. Things we did to make changes were that we have nurse education days educating the nurses on getting an order to stop the catheter from the doctor, making sure we have good technique. We showed videos on how to put a catheter in appropriately because you get turnover of nurses and some people have bad habits.

We revised our computer assessment which was big, because in that assessment we included the days and times of insertion, the size and then also the removal. We did a lot of different things that were based on a readiness plan.

Phil Deering: Well first thing, congratulations. Karla’s eyebrows sprang up because we’re all excited because that’s a fabulous reduction. So basically, the method you used to decide what to do came from the work plan. Talk a little more about the method.

Anita Zalinko: There was a CAUTI readiness assessment that Kate had sent out to me back at the beginning of all this and that really made us look at what we were doing along with our processes, and how you can improve it. We developed a work plan from that part and we’re still improving.

We have found that even though we do our audits our people aren’t documenting all the time when they take it out and we still feel we can continue to reduce it, that people don’t need these catheters just for comfort as long as they need to and that’s been a big education for the nurses.

Bruce recently sent out this little card about removing urinary catheters and reasons that they’re indicated. He sent that out to us and then we modified it, reminding the nurses and then we applied one of those to every kit. I have an assistant and I, we taped one to every single catheter kit that’s in our supply room where the nurses are supposed to pull it off and put it on the chart to also remind the doctors.

So I think even though we’re doing well we can always do better.

Phil Deering: That’s the attitude behind quality, in that it’s not a single point but it’s a journey and to the extent that you realize that you can always continue to reduce that potential and you’ll have great outcomes.

Stratis Health | 952–854-3306 | www.stratishealth.org Page 2 In the presentation I’m about to give I’ll talk a lot about the underlying concept that if you want to change something you have to focus on who does what, and you’ve talked about that already that you looked at your current processes and changed them.

Did you use any sort of documentation at the beginning to clarify who was doing what?

Anita Zalinko: That was a hard thing for me to understand. Nurses do everything… the nurses need to do the documenting, to make sure things happen so I guess I didn’t quite understand that question. Who else would do it other than nurses?

Phil Deering: If you think about the whole process of the catheter insertion, there’s probably a part where the MD actually makes some decisions or does something, are there parts where nurses observe it.

Is the removal generally done by the nurse or the MD?

Is there inspection along the way where the MD assesses again?

Perhaps not, maybe it’s like catheter in, nurse times and removes.

Anita Zalinko: Yes. It’s pretty nurse driven as far as even getting the catheter in and out, because we’re one-on-one with the patients. We have a daily assessment where the nurse has to look and assess what’s going on with a catheter to see if everything’s right and if they need it. The doctors obviously have to write the order for insertion and removal, but it’s basically nurse driven.

A lot of catheters go in for surgery, so we had an issue in surgery where they weren’t putting the cath-secure on and it was coming to the floor and that was getting missed. The cath-secure comes as a kit, but they weren’t doing it because of the way they position the patient. We had to change that process and now they do and surgery now has to document that it’s in place, whereas they didn’t have to do that before.

Like I’m saying it’s nurse driven, managing the whole catheter thing. Doctors have a lot of other things they’re looking at with the patient and they forget about it. A lot of times the patients want the catheter to stay in, but we have to say hey if these patients never have a reason to get up we’ll never get them out of bed.

Phil Deering: That’s understood. So, clearly you did start to change some of the processes so you’re just saying for the cath-secure and making sure it went on, that took some process changes. Perhaps now there’s a work instruction about positioning the patient and secondly, making sure that when the kit is opened that it’s identified that the catheter goes in and the cath-secure goes on.

How do you document those processes or procedures?

Anita Zalinko: What do you mean?

Phil Deering: Is there a written instruction for these things or is it done verbally with training? How do you make sure everyone knows the new way of doing things?

Anita Zalinko: We do training because again we have nurse education days. We also have a nurse memo, a newsletter that goes out every week to all of nursing in both departments, surgery and on the floor. It advises of any changes that are happening. This is something new we’re doing and then we do individual feedback as well.

Since we’re auditing, and we’re a small hospital so we might only have 16 people that have had catheters this month, not a lot, but if we see that someone didn’t do something or didn’t document when we’re auditing, what I’ll do if the person is there that day I’ll go talk to them or email them and say this is what’s going on. Stratis Health | 952–854-3306 | www.stratishealth.org Page 3 Basically, our computerized assessments has to be gone through everyday. It’s an ongoing assessment of the urinary catheter so everyday a nurse has to look to see if the cath-secure in place, is the foley draining, is it unclamped, and what does the urine look like? Our daily assessment should catch all that stuff. If someone missed it one day then the next shift should catch it.

Phil Deering: Did you have an assessment in place before that?

Anita Zalinko: We did but I greatly modified it once I got involved with doing the CAUTI. We were missing things. We modified the assessment and got it changed by our computer people. That holds people accountable, I mean they need to have why they put a foley in and then we constantly remind the nurses and check on them.

Phil Deering: That’s great. The last question I have you’ve already answered which was, are you continuing to tweak your processes now that you’ve implemented these changes? You made it very clear that you do that and there isn’t an end point where you’re going to stop doing that, something where we’ll be perfect and we won’t have to do that anymore.

Anita Zalinko: I don’t think that will happen.

Phil Deering: Right. I think too many humans are doing this work for us to get it to be perfect. That’s been very helpful to talk about. Some of these things we’ll go through in the presentation and others always make sense in any kind of forum on quality improvement and you’ve touched on so many important steps. Thinking about what you’re doing, having a plan to go ahead, changing important things, getting it in the computer system so it’s locked in and then continuing reinforcement through training and work direction and continuous improvement.

It’s all very impressive, thank you Anita.

Anita Zalinko: I just want to add that I find when you educate staff and they understand why we’re doing things that they are receptive and take ownership of it. They feel good when they’re doing things the right way and it’s for a good reason.

Phil Deering: Thank you for that, very well stated.

Anita Zalinko: Thank you.

Phil Deering: For everyone on the line now, I’m going into the presentation and I’ll try to remember to tell you when I’m changing pages. We won’t spend time on the first one. This is a joke I included that says… brevity is the soul of wit, if you don’t understand the joke now or at least maybe if your family is like my family, this isn’t so much of a joke and more like how your spouse feels about your ability to fix things.

The next slide is animated and doing the hokey-pokey. The point is that when we get to the end, again we’ve seen a flow chart in action. A flow chart takes steps and makes them clear to us, breaks them down, but we come up with the question is that what it’s all about? We know it’s not really all about the hokey-pokey.

Following that are some of the things that it really is all about and we know that so many process improvement efforts and maybe even deeper, so many things that we do in our rapidly changing environment have the potential to cause a lot of problems. One of the things we’ve seen with critical access hospitals very much is that when the implementation of the EHR goes on, it’s not always done completely and the new processes aren’t always in place.

Let me give you a couple of examples from real life that we’ve seen. One is where the hospital installed computers in every room or at least are on stands so that the computer is in the room with the patient.

Stratis Health | 952–854-3306 | www.stratishealth.org Page 4 We know the MD’s in many places are still not entering their orders, so the nurses then instead of taking advantage of the expense of having the computer in there or the doctors are taking the orders and going back to the nursing station because that’s where they always used to sit to enter the orders. Of course, there are many things that are going wrong there, inefficiency being one and second, because the orders aren’t being entered right on time and not entered by the MD, which is very much the best practice, we’re not taking advantage of the power of the EHR.

Another example is where we encountered this, where the MDs are entering the orders on paper. The nurses then enter that order in the EHR and there’s a transfer of paper that goes on. Sometimes we were seeing that that paper again maybe in the journey back to the nurses station because people are uncomfortable with EHR or the process is more detailed than those drugs might not get administered or maybe the drugs were being administered but the order wasn’t in the system. Then the next doctor would come in which led to a lot of concern with safety issues.

Next I want to provide an illustration about the power of flow charts and why they’re so valuable. Here we have a policy, that I made up, but it’s written out by the Bestville Rural Health Center and it was to make sure that all employees are trained properly to perform their jobs. So there are 845 words that describe something. If you continue the whole process is broken down and described on another page in a flow chart that makes it very clear what has to happen.

I’m not saying for a minute that you can get away without having written policies and procedures, but if you want to inform people and have them understand things quickly, often a flow chart is much more powerful than a big block of text. So the classic saying that a picture is worth a thousand words is very true in flow charting and much of the power comes from that.

You’ll also notice in this flow chart that we’re using something we call swim lanes. That way the employee can see their role on the chart, they’re in the employee swim lane at the bottom and the manager or supervisor can see their role. That’s another example of the power of a flow chart.

The title of this is using process mapping to improve care, so I think it’s worth talking about what an underlying model or way we proceed when we’re going to try to improve care. Anita summed this up perfectly. Basically, they did an assessment and understood what was going on today. Their goal was to reduce catheter days because they know the longer a catheter is in the more likely there is for an infection.

Then they decided and implemented changes. Anita got the computer people that put the new assessment in the computer and they talked about what they were going to do. She did the labeling of all the kits. They changed the position of the patient and had other things with design and implementation. It was important to convince people that these changes were important and desirable, which Anita talked to that as well.

People want to do the right thing and when they understand what that is and the reason to do it they start to do it. It’s not enough that they want to do it we need to train them on the new way. They had to take them through the screens, the positioning of the patient in surgery, wanting to make sure all those pieces have gone right.

Maybe someone was a little slack on their knowledge of how to do the attached piece, so there was training and then we always want to continue to measure which they’re doing and then repeat and continue probing. We all know this it the plan-do-study act method for improving things.

So how to process maps that help us to do all this… as we said, they’re illustrative. A picture is worth a thousand words. Process maps help us illustrate what we’re doing today and sometimes in more complex environments maybe everyone isn’t quite sure what everybody’s doing and it’s important to make pictures to clarify that. Stratis Health | 952–854-3306 | www.stratishealth.org Page 5 They help us spot places where we can improve and we’ll talk about that more, but it turns out that when you get a group of people together and talk about what you’re doing and you make pictures of it, opportunities for improvement seem to jump out at us. Process maps help clarify functional requirements. Often if you’re working with a new system or bringing in a new piece of equipment or the EHR is designed generally, in order to make sure it works for your system and your people you have to understand today about what’s special or unique about the way you do that. That’s where flow charts help in clarifying functional requirements.

In addition to understanding the current state, when we move to the future state they allow us to document and explain new ways of doing things. For example, that back to the Bestville employee training process, you needed the written procedure but then you could use the flow chart as a way to train people.

Process mapping begins the change management process by engaging users. So, if you’re going to change something, one of the issues is that you don’t want to turn the change on, start doing things in the new way and then suddenly everybody is in rebellion saying, we’re not going to do that or are you crazy that’s not my job. We find in organizations that do change successfully, often there are process maps put out where everyone can walk by and look at them to begin the process of the emotional engagement, ability to get angry and say I can’t do that or even point out failures.

Again, rather than a big set of words, if they are pictures than people can begin to look at those and use them.

Finally, by understanding who does what, process maps help us design training programs.

Again, process maps engages in structured thinking, who does what. They almost always create aha moments. They capture key controls, processes and important ways that you and your environment are unique. The underlying point here is that technology, whether it’s your computer system, medical devices or tele-medicenter or any of those things, they only bring benefits when the people or process are integrated properly with the technology.

So, the catheter kit had all the great stuff in it but wasn’t being used properly. To get the benefits we have to make sure those catheters are well attached and not popping out. It only works when we have people, process and technology all integrated and process maps help make that connection.

We’ll do a brief tutorial here on how to do process mapping. The first thing, if you’re going to do process mapping don’t just do it for the heck of it. You have to do it with a reason and it’s way too much work to just start mapping processes. Always do process mapping with a team of experts, who are those that do the work. Anita and her team didn’t do process mapping, but essentially they deconstructed and understood what they were doing today. Why were they able to do it? Because they are the experts that know how to do that work.

When you’re doing process mapping you want to try doing it in some type of dynamic or electronic format or, as you see later even with sticky notes, but process maps change and you want to have a way you can update them. You don’t want to make them static, spending a lot of work on something that you’re going to change.

Finally, what’s the sense of engagement or excitement? Turns out, in every organization I’ve ever worked with, there is someone who loves this stuff. In some people, for whatever reason, it flips a switch in them and makes a tremendous amount of sense, so you want to try and find those people and use them. I know also, just from hearing Anita talk, when you’re making a change you want to make sure you are engaging and exciting people, getting them dedicated to what’s going on.

Stratis Health | 952–854-3306 | www.stratishealth.org Page 6 In detail how do we do it? Basically, there are three shapes. There’s a circular or oval shape that we use that’s the terminator which we use to identify the beginning and end of a process. There’s a basic square that’s the process step and in this square we always write who- so there’s some sort of role, does-some sort of verb and what, so who does what? Then finally there’s this powerful tool call the decision diamond which allows us to deal with questions or choices that come up and usually we have a yes/no, so we try to put in the decision diamond a question with a yes/no answer.

In most cases you’ll have a yes/no question in that decision diamond. Then I’ll take you through an exercise that you can use if you’re trying to train other people to do process mapping, but also I think it illustrates how you do process mapping and we do it in a way that isn’t associated with a clinical thing where there is always a lot of discussion. If you’re training people it’s best to start with something neutral.

I know, Sue Seiverson used to use making a peanut butter sandwich, so basically you would bring people together and present them with this scenario and it’s about a parent who has had problems because her 9-year old is showing up at school without the right lunch and there are a lot of issues with the school. Here’s the child situation, on Monday- Wednesday and Friday it’s a regular bag lunch. On Tuesday the child buys lunch because the parent leaves early and on Thursday the child takes some extra snacks because she stays late for practice.

We want to start to diagram this process and see if we can fix it. So we start here with a big piece of paper and I give everyone on the team a bunch of post-it notes and we ask them to think for a while and write down steps on the process on their post-it notes and then we begin to assemble them.

The first question is- what’s the beginning and what’s the end of this process? We use those as the terminator symbols. So we have morning begins and the child leaves here. Then we start building out the process and interestingly this process starts with a number of questions because what you do depends on what day it is, so we can have some decision diamonds there.

To make a decision diamond you don’t use a diamond piece of paper you just have a square post-it note. Now here was ask the questions is it Monday-Wednesday and Friday because there’s one process there, or is it Tuesday or Thursday? Don’t draw any lines as you’re starting to do this because things will move around. The beauty of post-it notes is that you can pick them up and put them down.

Then quickly we fill in the steps. So we have the process where the parent makes the lunch puts it on the counter and the child takes the lunch. Here is the $3.50 where the parent puts it in the backpack and then on the right is the Thursday process. Then you post this up and you want to start looking it over and check to see if there are any obvious improvements.

We see then where it didn’t really make sense to leave that bag lunch on the counter because maybe the child is running late, grabs the backpack and heads for the bus. Instead, if the parent would actually put the lunch in the backpack, it seems the child would never leave without the backpack. So we’ve identified a process improvement. We note it with a different color so it sticks out and this process improvement could also go over on the Thursday side where we still have the parent putting the lunch on the counter.

So by putting things out in the open and identifying the steps we can find some process improvements.

Finally, what you want to do is begin to draw in those lines and then when it’s stable you can either leave it here for a while and have people look at it and comment on it, but at some point you want to move it into an electronic format.

Stratis Health | 952–854-3306 | www.stratishealth.org Page 7 Obviously pictures work, at this level I just used my phone to take these pictures but sooner or later you want to get this into electronic format. Visio works great or PowerPoint. Many of the tools have flow charting capabilities.

One of the questions people often get hung up on is, how much detail do we do in a process map? To get to that answer I think it’s important to go back to the purpose. Whatever you’re doing with this process map can help you understand to what detail you have to do. If you’re doing the design for the EHR, roles become very important so you want to make sure you’ve covered the steps and who’s going to do what at each one of the roles.

Sometimes you may be doing a relatively high level process and you can have very few steps. Right now I’m working with the Stratis and REACH management to develop a management information system and I just have five boxes about the core of what we do and then I can show them that so they can begin to make decisions from there.

Often in hospital and clinic documentation we need to distinguish between the flow chart and the work instruction. The flow charts are the higher level they are the picture, where as work instructions are the detail. So say you have a phlebotomist draws blood, that’s a flow chart step. The details of making sure that you’ve cleaned the area, the way you open the tools, where you place the blood, how you get it to the lab, all those things then would be in a work instruction.

Next is an example of this where this is a clinic working with teens where they go visit the teens home and engage with the parent. There are a number of steps in blue going from left to right. The provider goes to the client home. The parent and provider complete the forms. The client and the parent complete the SVQ. The provider performs the diagnostic assessment and in red the provider completes the 35:46.

For any of these last three boxes on the top level there’s an underlying set of instructions of how to complete that document and how the provider needs to do that. That doesn’t go in the flow chart because that’s the work instruction. All our boxes have who… provider, front desk, parent, client… who does because there’s always a verb and then what they do. Again here, this was in their paper environment. Maybe they have an EHR but maybe they need to have a laptop so they can complete some of those things online, so process improvements begin to jump out quickly.

A quick note on the power of swim lanes. We’ll use an example here of some process improvements that were implemented when they started moving from paper to electronic and then enforcing CPOE by the MDs.

When you’re documenting processes again, the big issue here is who does what and making it clear that everyone understands who does what, either in the initial state where you’re trying to figure out what’s going on today or in the future state. By using the swim lanes, essentially what you’ve done is you’ve taken a part of your flow chart and made a line/barrier and you’ve put the role in the left margin of the swim lane.

It makes it very easy for people to look across the row that they work in and see what they’re doing. It’s an easy way to identify who’s doing what and if you’re changing things it’s an easy way to communicate what goes on. The other point here is that we know in process or quality improvement activities, often the place where things go wrong is when there are hand-offs from one person or one department to another person or a department.

There is individual competency a lot and where things get messed up is when we suddenly change something. So from ED to the hospital, from the hospital to the nursing home, all those places is where we see the information getting messed up. It’s very important to understand who’s doing what at those times, so we can work on improving those.

Stratis Health | 952–854-3306 | www.stratishealth.org Page 8 Here’s where they’ve identified with the yellow blocks and little star callouts, what was going to be improved when they move to an electronic record. So this whole thing about searching for the paper chart, we know that whole nightmare has to go away. Therefore, we see that we can save time, efficiency and labor. We’re also noting concerns here so there’s a part where the physician fills out med order form. How is that going to happen in the new system? You can also use flow charting to identify areas of concern and problem that you’ll have to work on as you move to the new way.

That’s the interim step where we’re looking at the current and identifying ways to change.

Moving on we’re seeing the new state and we’ve clarified that and over here on the far right there’s a box that says physician places order in CPOE. Right now you could start, if you were in this process, to publicize this flow chart and then maybe a number of physicians have seen CPOE at other places and feel like that would be a problem for them, might slow them down or not allow for them to give the level of care they want. Maybe they are just concerned about their ability to type.

By publishing this and putting it out before the change is implemented, you can begin to service the issues and decide if you’re going to do it through policy and training or change the swim lane and instead that will become the nurse responsibility. Flow charts allow us to begin that discussion and further refine the changes that we’re going to put in place.

Next is post implementation, but still there are many areas for improvement. We’re finding that it’s taking too long. Maybe they don’t have the right amount of licenses so that the software isn’t available and if you quickly do the math then you’ll find out it’s worth it to buy a couple more licenses because our provider time is worth way more than waiting time. We can’t kick people out because that causes a lot of concern internally. So that would be something you could do there.

On the right, suddenly we’re now into the whole area of CPOE, which in many computer systems is going to trigger a series of alerts and we know that those alerts as they come out of the box might not be appropriate. We want to make sure if we want our physicians to do CPOE if we have to have good order steps already in place that can make that go much quicker and does that then set in motion a whole other effort around standardized order sets?

The ongoing process improvements can come and it’s so much easier for people to see what’s going on, point out those places and communicate and redesign when it’s in a picture as opposed to words, or if you’re just trying to remember everything, the changes you’re going to forget some opportunity are there without documenting.

So, moving toward the end, again we started with the hokey-pokey and we know that’s not what it’s all about. We know that process and quality improvement is what it’s about, but we also know that change causes problems and one of the final things I want to try to bring out is that process maps allow us to address those change management issues that come up so much.

We know that redesign is the easy part, but when you know who does what you can begin to design the change management effort. So if in your new design your aides will continue to do what they did in the past then you don’t have to worry about that, but instead if you’re going to ask them to do a lot of new things then you know you want to give them time to engage with the change, express any concerns and get over it in a way so that you’re getting ready to train them and implement the new process.

In addition to the change management process, the training plan emerges from who does what, because we won’t train everybody on everything we’re going to train people on the new things they’re going to do when that’s documented in flow charts and swim lanes, it’s easy to do.

Stratis Health | 952–854-3306 | www.stratishealth.org Page 9 Then the new policies and procedures emerge as well, because things have changed. You know the new world and what you’ll have to get in place and document.

Real quickly, principles for change management and training…

. Role base process focus, people don’t have time to learn about stuff that isn’t what they do. You want to make sure you’re training the right people on the right things.

. The people that have the most change need to get the most effort.

. People want to be told and shown they don’t want a lot of written stuff or to go home and have to read stuff on their own, but again if you understand who does what then you can figure out who is going to do that shoulder-to-shoulder training, which in a lot of ways is the way many people learn best.

. Training and communication are two sides of the same coin. We say that you begin your training with communicating about what’s going on and training completes the communication plan and now everyone knows how to do the right thing in the right way at the right time.

. We say if the head and heart aren’t engaged the hands won’t follow. I’ll talk about that a bit. This is a good way to develop a change management program and I think people in rural America can relate to three of the four H’s pretty well. It’s a little checklist. If we want people to change we know they have to be able to understand it and to think about things in a new way.

. Thinking isn’t enough humans are emotional beings who need to be motivated to want to do things the right way. They need to hear it from people that are important to them. They need to understand it and they need to feel that it’s the right thing to do.

. Finally, people need to be able to do it well. They have to use their hands or skills so they need training that allows them to make the change happen in the new way.

Anita was articulate about this. They educate people, people feel like they’re doing the right thing, they want to do it and then she trains them and they make sure everyone knows how to use the tools and elements in the kit in the right way.

In designing a training plan you have to understand the constraints, because you may not be able to pull everyone off the floor so you’ll have to do a lot of on-the-job training. On a video they have the nurses newsletter and that’s a great way to get information out there.

Again, we think that in almost all cases if you begin training with a picture of who does what, it will make it easier for people to begin to understand. You create that role task matrix and you understand who does what and then you figure out within those roles what you have to train people on and what the step-by-step work instructions, the screen shots and other things are.

Look for the hand-offs because that’s where things go wrong and that’s where the, who does what is breaking down a little bit, so you have to put both those people together and make sure the process will work for that hand-off.

Remember with all these things, as Anita also said, go live it’s just the end of the beginning because you’ll have to continue to retrain and work with people repeatedly.

In conclusion, the power of process mapping lies in the visual representation of complicated concepts. It’s a vital step for preparing for change implementation. If you Stratis Health | 952–854-3306 | www.stratishealth.org Page 10 want to change something you have to engage the people who do the work. If you want to understand it and document it, you have to do that. Do process mapping with experts, those who do the work.

Understanding and communicating who does what empowers the documentation that makes it accurate and relevant. It empowers those change management and training efforts and it can contribute to the sustainability of the changes you’re going to make.

With that I think we’ll close out the call. Thank you very much for your time.

Because I don’t hear any questions I’ll be coming out and auditing for flow charts now. Again, thanks everybody. My contact information is on the last slide and you’ll all have access to these. Essentially, any critical access hospital in Minnesota is a potential client of REACH. Many of you are, so know that this is part of our mission to help people understand as well as other issues associated with meaningful use and health information technology.

Many of you are working with field service consultants and you can also get a hold of that person as well.

Karla Weng: Thank you everyone for participating in today’s call. Thank you to Phil and Anita for taking time out of their day to share with us.

Make sure you complete the evaluations and note that the next learning session: creating partnerships with physicians, is scheduled for Noon on Thursday, September 12.

Have a good rest of your day.

This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 10SOW-MN-C7-13-109 090913

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