Process Change Implementation and Evaluation

Welcome to the Process Change Implementation and Evaluation unit. This unit is from the Fundamentals of Health Workflow Process Analysis and Redesign component, and covers methodology for how to plan, implement and evaluate the process changes in clinic settings. This unit focuses on helping students develop skills needed to implement and evaluate the effectiveness of changes designed to improve workflow processes and the quality of care in health care facility.

This unit prepares you to implement a process change by covering three key skill sets:

  1. develop a process change plan (implementation plan),
  2. communicate a process change plan, and
  3. develop an evaluation plan.

Objectives

After this unit, you should be able to:

  1. Develop a Process Change Implementation Plan for a healthcare facility that includes tasks to be accomplished, responsible parties for various tasks, a timeline, and the human and material resources needed.

  2. Identify management tracking and measurement opportunities for the process change.

  3. Outline elements of an evaluation plan that will help determine the success of a workflow process change implemented in a health care facility.

  4. Describe how the workflow analyst can help a health care facility continually improve its workflow processes, based on the results of ongoing evaluations.

Topics

The topics covered in this unit include:

  • common process changes,
  • implementation plan components,
  • communication for implementation,
  • common implementation problems, and
  • evaluating the new process.

Common Process Changes

To ground ourselves in concrete ideas of what to expect in process change implementation and in this unit, we’ll start with examples of common process changes. Some examples are:

  • From manual to electronic prescribing
  • From receptionist to web-based appointment scheduling
  • From manual to automated appointment reminder calls
  • From manual tracking of test results to automated result tracking
  • From paper to electronic patient charts
  • From paper to electronic test ordering.

While each of these is just a phrase, changes must be considered and thought through from many perspectives and eventualities. This thinking occurs in the analysis and re-design phase. The implementation planning is a group or team activity. Communication of the implementation plan and execution resulting in new improved process will involve many people.

Implementation Plan

The implementation plan documents the who, what, where, when, how, and why of the process change. It serves as a map that helps the clinic staff, leadership, and analyst get from the old process to the new one.

Implementation Plan Components

An implementation plan contains the following components:

  • Reason for the change.

  • Summary of what will be different with reference to the “as is” and “to be” documentation, where it is located in the documents or in an appendix. Where the process change is significant, this may include step by step instructions for new workflows.

  • Sequence of implementation tasks to be accomplished. These can include walkthroughs, training, production and distribution of job aids, software changes or “go-live” of new systems.

  • Responsible parties for each implementation task.

  • An implementation schedule for the entire implementation phase, and statement of how the process will be managed.

  • Contact information for who to call when problems arise and

  • Description of how the process change will be evaluated (an evaluation plan).

An implementation plan does not need to be a long document. Its purpose is to document what will happen, how and when it will happen in a way such that if the implementation plan is followed, the new process will become a reality. The length and detail level should be comparable to the size of the change and number of people impacted. An example implementation plan that shows these components is included in your course materials, and will be reviewed on the next few sections. But first, we will do an exercise.

Exercise

You already know enough to draft an implementation plan for an appointment reminder system. After these instructions, pause and do the exercise.

A practice of 50 staff and providers is implementing an automated appointment reminder system. Review the implementation plan components in the previous section. You may want to go back and print out section. Take 10-15 minutes and on one page of paper, jot down your ideas for each section. Return when you are done. Pause now.

Example Implementation Plan

An example “Reason for the Change” statement for an implementation plan for automated appointment reminders might be:
“In efforts to decrease our ‘no show’ rate, Big City Medical Practice is implementing automated appointment reminder calls. Due to a lack of staff, our practice has not commonly made appointment reminder calls. With our new system, we are now able to do this.”

An example of a statement for what will be different is:

What will be different?

“Our patients are not used to receiving reminder calls. Starting in two weeks (Friday October 29, 2011) each patient that schedules an appointment will receive notice that they will receive a reminder call. This notice will be generated automatically for appointments scheduled on line. For appointments made over the phone or in person, front desk staff scheduling the patient will inform them. Patients with appointments that were scheduled prior to Monday October 30, 2011 will not receive reminder calls.

“We are informing everyone in the practice with patient contact of this new practice in case patients have questions or comments about their reminder call.  For more information, process diagrams and documentation describing details of this change are available in the break room.

Other than notifying patients of this change and being alert for patient questions or comments, there are no significant changes to anyone’s workflow.”

Time Schedule of Events & Responsibilities

Mon, Oct 4 Final system test (A. Smith)
Tues, Oct 5-15 (Fri.) Address issues from testing / retest  (Vendor)
Mon, Oct 18 Live installation (Vendor)
Wed, Oct 20

Data migration and migration test  (A. Smith)

Thurs, Oct 21-25 (Mon.)

Contingency time (C. Doe)

Mon, Oct 25

Talking points ready for Registration review  (C. Doe)

Fri, Oct 29 Go live for on-line and in-person notices (Registration)

An example time schedule and responsibilities for implementation of an automated appointment system is shown in the table above..

Implementation Management

An example of the management statement includes who will actually be responsible for the implementation management. 

For instance, “The implementation will be managed by C. Doe from our local Regional Extension Center with support from Amy Smith, our local IT technical support person. Changes to the schedule above will be posted in the break room.”

When Problems Arise

An example of the “what to do when problems arise” section for implementation of an automated appointment reminder system, might include wording such as the following: “For any unexpected problems and if you notice or patients mention unusual system behavior, please contact Amy Smith at (555) 555-5555; or C. Doe at (777) 777-7777. If problems occur after hours, report through the after hours number at (888) 888-8888.”

Evaluation

An example of the evaluation description for implementation of an automated appointment reminder system might include, “This process change will be evaluated by the decrease in no show visits and by addition of a question to the December patient satisfaction survey.”

Communication of an Implementation Plan

At the point in a process redesign when an analyst is crafting an implementation plan, hopefully the impacted people will already know about the change or have otherwise been involved in creating the change in some way. In this case, the communication about the implementation will be easy and expected by all. If not, expect objections either to the plan or the new process, or both. In this event, the communication and implementation will take longer, and may result in changes to the process or plan. The way to prevent such a situation is to, at a minimum, keep everyone involved throughout the process. Remember our old adage from the previous unit:

“Tell me and I’ll forget;
show me and I may remember;
involve me and I’ll understand.”

What People Need to Know

When communicating an implementation plan, it is important to keep in mind what things people need to know.
As in the automated appointment reminder system implementation plan example, when the change is minor, the plan itself can be short and can double as a notice, i.e., communication. The main goal is to give people information about:

  • What is happening.

  • Why is the change taking place. (Examples of this might include to enable patient self-management or control, to increase safety, quality or efficiency of care, for sustainability of the practice, or to achieve meaningful use.)

  • How they will be affected. (This is often best accomplished by addressing each task or activity that will be added, changed or go away.)

  • How the change will impact their job workflow or responsibilities.

  • How will the change take place.

  • What, if anything, different will the patient see.

Communication can occur via email, posted notices, or staff meetings. In-person communication provides opportunity for attendees to ask questions and for the presenter to get feedback that might increase the success of the project.

Job Aids

When process changes necessitate new steps or tasks, job aids may be helpful. For example, in the automated appointment reminder system implementation, the front desk receptionist needed to notify people scheduling appointments that they would be receiving a reminder call. A job aid with talking points (answers to common questions the receptionist might be asked) was provided as a job aid.

Job aids might include: Talking points, check lists, written procedures, or cheat sheets (memory aids to rescue people when they forget what to do, or descriptions of new system features for common tasks).

The type and extent of the job aid depend on how extensive the change is. The creation and training on job aids should be included in the implementation plan.

Training

When process changes require new skills like using new software, a different way of doing something like completing a lab sample requisition form on the computer versus a paper one, training should occur. Training should also occur when multiple ways of doing something are possible but the job requires that everyone does it the same way. The formality of the training depends on the extensiveness of the change and the number of people that need to be trained and can include class room style training, one-on-one training, or web-based modules for software training.

Time for development or procurement of training should be included in the implementation plan, as should time for the training to occur.

Be Present

An implementation plan does not stand alone. After all of the planning and communication have occurred, it is time for execution, that is, to execute the plan and to make the new process a reality. Most importantly, unexpected things will occur in even the best-planned and managed implementations. Importantly, the person in charge of the implementation needs to be present, visible and available the first few days of a new process to help resolve any problems that may occur.

Process Implementation Problems

It is never fun when problems do occur. While we go to great effort to plan and prepare so that problems will be small and infrequent, problems will occur with every implementation. Problems occur in planning, communication, the design of a new process, i.e., things were left out or not accounted for, or problems in the software itself. The important thing is not that problems occur, but that 1) everything reasonable was done to plan and prepare to prevent problems, and 2) that problems are addressed swiftly.

Exercise

Take five minutes and review the example implementation plan for the automated appointment reminder system. List two possible problems that could occur in each of the following areas:

  •  planning
  •  communication
  •  the process, or
  •  in the software

We will review some common causes of problems on the next slide. Pause now. When you have finished, return.

Review of Exercise

Examples of possible problems include:

  • Planning
    • Timeline didn’t account for other activities such as vacations of key people, or activities were planned for during the work day that would have been better done during off hours
    • Forgot to include migration of legacy data to new system

  • Communication
    • Lack of communication to practice leadership
    • Lack of communication ahead of time with people involved in the plan

  • Process itself
    • Didn’t take into account likely exceptions such as what about people who made appointments before the change
    • What happens if the system gets a voicemail?
    • How does the system know it’s the person?
    • Forgetting to have a process for turning reminders off when appointments are moved

  • Software
    • Lack of testing
    • Found problems in testing and changes can’t be made quickly enough

You may have noted other problems that are equally as valid!

Evaluation

We mentioned evaluation as an implementation plan component. Process changes should be evaluated in some way to make sure that they had the intended impact. The evaluation should be a measure of achievement of the “reason for change.” In the simple example of implementation of an automatic appointment reminders system, the reason for the system and process change was a higher than desirable “no show” rate. The metric for evaluating the change was “decrease in the ‘no show’ rate.” Because the new process impacted patients, a question about the reminder calls was added to the next cycle of the patient satisfaction survey. Some examples of things that can be measured to evaluate a process change include:

  • Patient wait times, for example, from registration to seeing a provider,
  • Total visit time,
  • Percentage of same day appointment accommodations,
  • Increased clinic capacity (higher number of encounters per day per  provider),
  • Patient satisfaction measures,
  • Provider or staff time spent retrieving information,
  • Provider or staff time spent documenting,
  • Provider or staff satisfaction, and
  • Percentage of first-time-file claims returned.

The value gained from the evaluation must be weighed against the effort required to collect the data for the evaluation. Vendors should be questioned about data available for evaluation of planned process changes.

Summary

In this component, we covered:

  • common process changes,
  • implementation plan components,
  • communication for implementation,
  • common implementation problems, and
  • evaluating the new process.

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