Audio Transcripts. Workflow Analysis. Optional Lectures

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1 Audio Transcripts Workflow Analysis Optional Lectures

2 WORKFLOW ANALYSIS Audio Transcript Component 10 Unit 3 Lecture A Fundamentals of Health Workflow Process Analysis & Redesign Interpreting and Creating Process Diagrams Introduction Slide 1 Welcome to the Fundamentals of Health Workflow Process Analysis and Redesign: Interpreting and Creating Process Diagrams: Introduction. This is Lecture a. The Component Fundamentals of Health Workflow Process Analysis and Redesign, examines different diagramming methods for developing graphical representations of processes in the health care setting. Throughout the last century, different diagrams and notations have arisen. There is considerable overlap between them. Some have fallen by the wayside and others remain in use. Some have become international standards, while others exist in textbooks and articles. In this unit, we present major formalisms for process diagramming in use today and the process aspects that each covers. Unit 3 is composed of several lectures, one for each diagramming method. Lecture a, Interpreting and Creating Process Diagrams: Introduction, provides an introduction to these concepts and reviews information from Unit 2, Lecture b. Based on feedback from practitioners, we recommend using two methods (data flow diagrams in Yourdon notation, and flowcharts). In Lecture a, we review the process aspects that each diagram type covers. In separate presentations, we cover each diagram type. For the two recommended methods, the presentation covers concepts and skills from reading and interpreting the diagrams to actually creating them. For the rest of the diagrams, we cover only background, use, and notation, i.e., the presentation prepares the student to read and interpret the diagram but not to create them. Slide 2 The objectives for this unit, Fundamentals of Health Workflow Process Analysis and Redesign: Interpreting and Creating Process Diagrams: Introduction are to: Create a process flowchart for a health care system (or system component) using appropriate ISO 5807 symbols and conventions, Create context and data flow diagrams for a health care system (or system component) using appropriate Yourdon symbols and conventions, Choose the correct scope and detail level for a process flowchart and data flow diagram, Read and interpret Gane-Sarson data flow diagram, Read and interpret an entity relationship diagram in crow s foot notation, and Read and interpret UML class, activity, and state diagrams.

3 Slide 3 The topics covered in lecture a of unit 3 include: Key process aspects that may require analysis and diagraming Types of process diagrams In lecture a, these topics are combined into a framework that organizes process diagram types according to the process aspects that each type of diagram represents. Thus, lecture a serves as an introduction to the unit 3 material. Slide 4 There are different kinds of process diagrams. They differ in the aspects of processes they represent and in the notations, i.e., symbols and conventions, used for diagramming or mapping processes. The types of diagrams covered in unit 3 include: ISO 5807 information processing diagrams, the same symbols used for Flow Charting, Yourdon notation for data flow diagrams, Gane-Sarson notation for data flow diagrams, Unified Modeling Language (UML) that represents several different aspects of processes, and Entity relationship (E-R) diagrams that concentrate solely on information content. In unit 3, we will review the process aspects that each diagram covers and show an example of each type of diagram. Lecture a of Unit 3 provides a brief introduction and overview to the material in the unit. Here we enumerate the process aspects, e.g., informational versus process steps, etc., that are covered by each diagram type. This brief introduction serves as a framework to help you organize the different diagraming notations according to which process aspects they cover. Later, this framework will serve as a reference when choosing which type of diagram best fits a process analysis & redesign need. Slide 5 The process aspects to be featured will determine the type of diagram to be used, i.e. the diagram that best represents the process aspects that you are interested in. The six important process aspects are: Context Process steps Information flow Information content Information transformation Sequence and other control Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 2 Interpreting and Creating Process Diagrams: Introduction Lecture a This material Comp10_Unit3a was developed by Duke University, funded by the Department of Health and Human Services, Office

4 Who or what role performs the step Unfortunately the words used to describe the process aspects have different connotations and even meanings in different disciplines. Briefly, by context, we mean how a system or process interacts with the rest of the world, e.g., a context diagram is used to view the system in the context in which it operates. Context diagrams show main system components and the ways in which the system interacts with things outside of the system, e.g., inputs and outputs. By process steps, we mean the physical and mental tasks or activities that are involved in a process. We separate diagraming these physical and mental steps from data flow. Here Data flow means the path through which data and information travel data flow is the process from the data s perspective. Process flow is usually the process from, for example, the patient or provider s perspective. Information content refers to the pieces of data / information required for process or informational steps or decisions. Data and information transformation refers to manipulations performed on data, e.g., calculating age from a patient's date of birth and today s date. Step sequence, flow control and state or status all refer to the order in which data or things move through a process, and the logic that controls that flow. And finally, roles refer to who or what performs the process steps. The following table in the next slide indicates which process aspects are covered by the notations/diagramming methods. Note: The health care setting in which you work may have standardized on one particular notation/method for their process representation. Further, health care facilities may have participated in quality improvement or software development efforts, in which case, there may be existing process diagrams that may be of use to you. So, while you may prefer a particular method and can select that method of use in this course, it is important to be aware of the major notations/methodologies, and to understand the basic uses and notation of each. Slide 6 This unit covers five notations that are commonly used to diagram processes: ISO 5807, Yourdon, Gane-Sarson, UML, and E-R diagrams. ISO 5807 can be used to represent process or data flow steps and their sequence and control, as well as information transformation and roles involved in the process. Yourdon data flow diagrams represent context, data flow steps, and information transformation. In Yourdon diagrams, information content is captured through text but not captured in structured form. Gane-Sarson represents the same process aspects as Yourdon with the addition of capturing flow control and state in text. Unified Modeling language, or UML, developed a few decades after and heavily influenced by the earlier methods was designed to represent important aspects of system functionality. The Entity-relationship diagram is designed to represent only information content. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 3 Interpreting and Creating Process Diagrams: Introduction Lecture a This material Comp10_Unit3a was developed by Duke University, funded by the Department of Health and Human Services, Office

5 Supplemental material for this unit will cover each of these five methodologies. Slide 7 Not all of the process aspects noted earlier are critical for clinical workflow analysis and process redesign. For our work here, we concentrate on the following: Yourdon data flow diagrams for Context diagrams ISO 5807 Flowcharts - for Process steps, and step sequence and control as well as roles performing steps Yourdon Context Diagrams and ISO 5807 Flowcharts are covered in this unit in lectures b and c. Detailed instructions are provided on how to create and use these diagrams. Some organizations use these diagrams while others use UML. From the examples received from the Regional Extension Centers and available on the AHRQ and clinical quality improvement websites, it appears that Flowcharts and context diagrams are the most common in health care workflow analysis and process redesign and, thus we concentrate on these diagrams here. Because you may encounter other notations, e.g., Gane-Sarson, UML, and logical data models (E-R diagrams) we provide exposure to those diagrams as well. Your instructor will pick and choose from the available material to best prepare you for local applications. Slide 8 The goal of workflow analysis and process redesign is to represent aspects of the process that help the analyst and health care facility staff identify areas where the process can be improved. The diagrams here meet this need by concentrating on process steps, data flow, roles, and visualizing the whole. There are other process aspects that are not critical to this analysis and thus will not be considered. Other efforts where the methods here have been used to successfully analyze and redesign health care processes include the Public Health Institute s Business Process Analysis and Redesign program to improve the performance of the U. S. public health system The Public Health institute (PHI, 2006) reference provides great case studies and we recommend it. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 4 Interpreting and Creating Process Diagrams: Introduction Lecture a This material Comp10_Unit3a was developed by Duke University, funded by the Department of Health and Human Services, Office

6 Slide 9 Subsequent slide sets on this unit will cover the following top diagramming methods in detail: Lecture b - ISO 5807 Flow Charting Lecture c - Yourdon Data Flow Diagrams Lecture d - Gane-Sarson Lecture e - E-R diagram Lecture f - Unified Modeling Language (UML) Slide 10 This concludes Lecture a, Interpreting and Creating Process Diagrams: Introduction. You should be able to: Understand key process aspects that may need to be diagramed Suggest a diagram type for a given process aspect to be represented Slide 11 No audio. End. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 5 Interpreting and Creating Process Diagrams: Introduction Lecture a This material Comp10_Unit3a was developed by Duke University, funded by the Department of Health and Human Services, Office

7 WORKFLOW ANALYSIS Audio Transcript Component 10 Unit 3 Fundamentals of Health Workflow Process Analysis & Redesign Interpreting and Creating Process Diagrams Lecture B Process Mapping: ISO 5807 Slide 1 Welcome to Fundamentals of Health Workflow Process Analysis and Redesign: Process Mapping: ISO This is Lecture b. The Component, Fundamentals of Health Workflow Process Analysis and Redesign, examines different diagramming methods for developing graphical representations of processes in health care settings. Throughout the last century, different diagrams and notations have arisen. There is considerable overlap between them. Some have fallen by the wayside and others remain in use. Some have become international standards, while others exist in textbooks and articles. In this unit, we present major formalisms for process diagramming in use today and the process aspects that each covers. Lecture b, Process Mapping: ISO 5807, covers creating flowchart style process diagrams and the associated standard symbols. This is the second of six lectures in the Process Mapping Unit. Slide 2 The objectives for this unit, Process Mapping: ISO 5807 are to: Create a process flowchart for a health care system (or system component) using appropriate ISO 5807 symbols and conventions, Create context and data flow diagrams for a health care system (or system component) using appropriate Yourdon symbols and conventions, Choose the correct scope and detail level for a process flowchart and data flow diagram, Read and interpret Gane-Sarson data flow diagram, Read and interpret an entity relationship diagram in crow s foot notation, and Read and interpret UML class, activity, and state diagrams. Slide 3 In Unit 2 we introduced the concept of ISO 5807 flowcharting notation to diagram a process. In lecture b, Process Mapping ISO 5807, we will provide further details about the International Organization for Standardization (ISO) 5807 symbols and conventions. Lecture b also covers reading an ISO 5807 flowchart in terms of the information that could be generated and the workflow steps that are being communicated. And finally, lecture b prepares you to create ISO 5807 flowcharts for a health care system (or system component) using correct symbols and conventions.

8 Importantly, most organizations use flowcharts in information technology and in quality improvement efforts. As a Practice Workflow and Information Management Redesign Specialist, you will see, need to interpret, and need to create flowcharts. Slide 4 Recall that each of the methods for diagramming a process has its own set of capabilities. With ISO 5807 flowcharts a process analyst is able to represent the process or data flow steps, any information transformations that occur or should occur, the order or sequence of the steps involved in the process, and the roles of the persons completing the steps in the process. The flowchart is a useful, and probably the most common tool in mapping the workflow processes in health care. Slide 5 A flowchart is a graphic depiction of the steps or activities that constitute a process. The International Organization for Standardization (ISO) defines flowchart as a graphical representation of the definition, analysis, or method of a solution of a problem in which symbols are used to represent operations, data, flow, equipment, etc. (ISO, 1985) The ISO 5807: 1985 standard defines symbols to be used in information processing documentation and gives guidance on conventions for their use in data flowcharts and other diagrams. Many organizations require the documentation of dataflow or process flow. Some organizations require a flowchart to accompany every Standard Operating Procedure (SOP). Organizations also use flowcharts to document and communicate the data flow or process flow for information technology and quality improvement projects. Slide 6 Flowcharts are constructed from standard symbols. It is important that standard symbols be used because flowcharts are used to communicate processes. When people see a specific symbol in a chart, they understand a specific meaning like a road sign. Thus, to read, use, and create flowcharts, knowing the meaning of the standard symbols is important. The ISO 5807: 1985 specifies the standard flowchart symbols for information processing. Many software applications have flowcharting functionality. Some of these are Microsoft Word, Microsoft PowerPoint, and Visio. The functionality that is important in flowcharting programs includes the availability of standard shapes and connectors that latch to the shapes unless you specifically detach them. This allows you to reposition the shapes in the drawing canvas and facilitates editing the flowchart. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 2 Process Mapping: ISO 5807 Lecture b This material Comp10_Unit3b was developed by Duke University, funded by the Department of Health and Human Services, Office

9 Slide 7 Reviewing from unit 2: The terminal symbol is a rounded rectangle which identifies the beginning or end of a process or origin and destination of data. The process symbol is a rectangle which designates an activity. Within the rectangle is a brief description of that activity. The decision symbol is a diamond which designates a decision point from which the process branches into two or more paths. The path taken depends on the answer to the question which appears within the diamond. Each path is labeled to correspond to an answer to the question. The document symbol is a human readable document pertinent to the process. The flow line represents a process path which connects process elements. The arrowhead indicates the direction of the flow. The connector is a circle which is used to indicate a continuation of the flow diagram. Slide 8 The Basic Process symbol represents any kind of processing function, for example, executing a defined operation or group of operations resulting in a change in value, form or location of information, or in the determination of which one of several flow directions is to be followed. (ISO, 1985) In this example, the basic process symbol represents the following: Patient signs-in and checks-in with the front desk, Receptionist enters the patient into the visit system as present and confirms the insurance information with the patient The nurse pulls the chart from the filing stacks and Escorts the patient to the exam room. Slide 9 The decision, or diamond, symbol represents a decision or switching type function having a single entry but where there may be a number of alternative exits, one and only one of which may be activated following the evaluation of conditions defined within the symbol. The appropriate results of the evaluation may be written adjacent to the lines representing the paths. (ISO, 1985) Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 3 Process Mapping: ISO 5807 Lecture b This material Comp10_Unit3b was developed by Duke University, funded by the Department of Health and Human Services, Office

10 Decision symbols can show nominal decisions (yes or no), or decisions with multiple possible outcomes. In this example, the patient is given a drug susceptibility test and a decision is made as to the appropriate type of prescription to write based on the test results. Note that the actions are different for the patients who are susceptible and the patients who are not, thus, the decision symbol denotes a point at which, depending on the result of the decision, the process will proceed via different paths. Slide 10 This is an example of the Terminator symbol. The Terminator symbol represents an exit to, or an entry from, the outside environment, for example, start or end of a program flow, external use and origin or destination of data. (ISO, 1985) This symbol is described in section of the ISO 5807 documentation. Here the Terminator symbol is used to represent the entry of the patient into the process (health care workflow setting). Slide 11 Examine the flowchart closely. Take a few minutes and list the symbols that are correctly and incorrectly used according to the flowchart symbols on the previous slide. Correct symbols are used for the decision boxes and the connectors. Incorrect symbol use is a matter of which notation one is following, and how formal or conformant to any one notation one wants to be, i.e., correctness with respect to notation is a relative matter. Comparing the flowchart on this slide to the list of symbols on the previous slides, i.e., according to the ISO 5807 standard, we see that the rounded-corner rectangle used as a terminator should be a different shape, one with parallel lines on the top and bottom and half-circle curvature on the left and right sides. The arrow heads should be shaded or filled in rather than open. Slide 12 The process flow diagrams can become quite complicated. The example in front of you is taken from a hospital setting where there are multiple decisions to be made and multiple actions based on these decisions. This complexity is found in most health care settings. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 4 Process Mapping: ISO 5807 Lecture b This material Comp10_Unit3b was developed by Duke University, funded by the Department of Health and Human Services, Office

11 In this In-patient hospitalization example, we will walk through key decisions and actions as displayed in this slide. 1. A patient is admitted to the hospital and placed in an examination room The Admission Summary is completed 2. Various observations per the hospital standards are obtained. : Vital signs and temperature Continuous 12-lead monitoring Cardiac enzymes Distal pulse Noting of wounds, pain, and/or other symptoms Presence of a hematoma or clotting time if there is bleeding 3. Medication is administered, and 4. Continuations of the medical assessment which will be determined by preliminary findings. Examples are: If there is chest pain, then collect duration of hospital stay related to chest pain If the patient displays oozing of hematoma, then evaluate for surgical repair of puncture site and prepare for the Operation Room If the patient is improving, then transfer to step-down facility and plan for the patient to be discharged If the patient is not improving, then manage medically by continuing various observations per hospital standards and continuing medical assessments If the patient has a planned Coronary Artery Bypass Graft (CABG) which is expected, then prepare for the Operation Room If the patient has complications from a procedure, either expected or unexpected in this representation, the staff will prepare for the Operation Room. 5. Finally, a discharge summary will need to be prepared. Slide 13 This symbol (a rectangle with the bottom long side is curved such that the left side is lower) represents human readable data, the medium being, for example, printed output, an OCR [optical character recognition] or MICR [magnetic ink character recognition] document, microfilm, tally roll, data entry forms. (ISO, 1985) Here the staff member reviews the patient s charts and files them. The documents in the patient chart, i.e., the patient chart, is represented by a document symbol. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 5 Process Mapping: ISO 5807 Lecture b This material Comp10_Unit3b was developed by Duke University, funded by the Department of Health and Human Services, Office

12 Slide 14 According to ISO 5807 section , the symbol for manual input is a quadrilateral with two parallel sides, two 90 angles, one obtuse angle and one acute angle. This symbol represents data, the medium being of any type where the information is entered manually at the time of processing, for example, on-line keyboard, switch settings, push buttons, light pen, bar-code wand. (ISO, 1985) According to ISO 5807 section , the symbol for a manual operation is an isosceles trapezoid (a quadrilateral with two parallel sides and the sides that aren't parallel are equal in length and both angles coming from a parallel side are equal). This symbol represents any process performed by a human being. (ISO, 1985) Slide 15 In this example, the manual operation of receiving the forms and manual input of keyboard entry of data are represented. The example is as follows: Billing form arrives at the receptionist. Afterward, presumably the receptionist locates the patient in system and performs keyboard entry of the patient form. For this operation, the form for the patient visit appears on the screen. The standard claim form is an input to the process. Slide 16 According to ISO 5807 section , the symbol for Data is a parallelogram (opposite sides are parallel and equal in length, and opposite angles are equal). This symbol represents data, the medium being unspecified (ISO, 1985). According to ISO 5807 section , the symbol for stored data is a four-sided figure with two-parallel sides, one rounded concave end and one rounded convex end. This symbol represents stored data in a form suitable for processing, the medium being unspecified (ISO, 1985). Slide 17 Here is a Data Symbol example: The process starts with the logging of a Patient, presumably into a data system. Afterwards, two things occur in parallel: 1) a data record from a referring physician is sent to the database for storage, and 2) data is collected during the Patient visit. After the during patient visit data collection which presumably occurs on a paper form signified by the manual process symbol, a data entry operator locates the Patient record Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 6 Process Mapping: ISO 5807 Lecture b This material Comp10_Unit3b was developed by Duke University, funded by the Department of Health and Human Services, Office

13 in the system. After which two things occur, 1) the entry form for Patient visit appears, and 2) keyboard entry of patient form followed by storage of the data in a database. In this example data are represented in two distinct ways. Note that the generic data symbol is used for data from the referring physician. It does not specify medium, such as disc or electronic file transfer, however, because the data go directly to the database, it would be reasonable to infer electronic transfer. Use of the stored data symbol for the office database also signifies data; the symbol specifically indicates stored data. The vertical cylinder could also have been used. In flowchart creation for process analysis, the chart should be specific enough so that the assumptions signified in the example by the word presumably, and the assumption about the medium of data transfer are not required. Such assumptions should trigger the analyst to learn and diagram in more detail. Slide 18 The Display symbol represents data, the medium being of any type where the information is displayed for human use, for example, video screens, on-line indicators. (ISO, 1985) The Display symbol is shaped like the traditional cathode ray tube (CRT) computer monitor viewed from the side. For people who have only used flat screens, the symbol shape is less intuitive. The flowchart example on the slide shows the following: Patient arrives Receptionist checks Patient in Receptionist locates Patient in EHR Form for Patient visit appears (on computer screen) Keyboard entry of patient information Slide 19 According to ISO section 9.4.1, the symbol for a Connector is a circle with a number in it. This symbol represents an exit to, or an entry from, another part of the same flowchart, and is used to break a line, and to continue it elsewhere. The corresponding connector symbols shall contain the same unique identification. (ISO, 1985) Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 7 Process Mapping: ISO 5807 Lecture b This material Comp10_Unit3b was developed by Duke University, funded by the Department of Health and Human Services, Office

14 Example: Page 1 of flowchart: Presumably the patient is escorted to exam room, after which chief complaint & vitals are recorded. Next, the provider is notified that the Patient is ready. After the Notify provider Patient readyprocess box, the connector indicates for the reader to Go to the next page and start at the circle with a 1 in it. Continuing on page 2 of the diagram, the reader would start at the circle with a 2 in it, which directs the reader to the next process step, Examine Patient. This step in the process is followed by a decision, presumably made by the provider about whether or not an order is required. If an order is required, the process continues to the order writing step. Note that the connector with a 1 connects the process across pages one and two. Slide 20 The symbols used to represent a delay in a process are given here. The bullet, although not listed in ISO 5807, is commonly used because in logic diagrams, it represents an and gate. An and gate denotes that two or more things (thing 1-and-thing 2, two inputs) have to happen before proceeding. Two parallel lines are used to denote that things above them must be done before things below them can be done. In the diagram, adapted from the ISO 5807 standard, processes B and C cannot start until process A has been completed. (ISO, 1985) Slide 21 In this section, we will cover non-symbol conventions of flowcharting. These include use of text descriptions, indication of detail level, flow direction, and lines. These conventions are just as important as standard symbols. Not using them leaves the impression that the analyst is not familiar with the standards. Slide 22 It is often important to include text descriptions in a process representation. This is done using annotationsaka call-outs. This keeps the text in the box to a minimum so the chart is more readable. Lengthy text descriptions can be referenced to another page or footnote if necessary. If text descriptions refer to more than one box in a flowchart, a dotted line can be drawn around the steps that the text describes or refers to. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 8 Process Mapping: ISO 5807 Lecture b This material Comp10_Unit3b was developed by Duke University, funded by the Department of Health and Human Services, Office

15 Slide 23 While flowcharts can be used to represent different levels of process detail, items shown on the same diagram should be at the same detail level. The example flowchart at the top shows the main components of the research data collection process at the same detail level; a high-level view of the research data collection process. The bottom diagram is an example of combining items at different detail levels on the same diagram. Note the different level of detail in the bottom flowchart which includes the data processing steps. This would be better in a second flowchart. Combining items at different detail levels can cause confusion. Slide 24 Flowcharts should read from top to bottom or right to left. Affirmative responses to yes or no decisions should all be in the same direction. Flow direction for process steps that show re-work (i.e. queries for data discrepancies going back to a data sender) should be opposite of the direction of the progressing process. In the incorrect example on the left of the slide, arrows denoting forward process progress are diagrammed in two different directions. When possible all forward process progress should be in the same direction. The preferred way to diagram this process is shown on the right. Slide 25 Flowcharts should read from top to bottom or left an right. Lines should run up & down or left and right. Do not use diagonal lines. An incorrect diagram is shown on the left. The preferred way to diagram the process is shown on the right. Note this is left and right; not left to right. Slide 26 There are multiple ways to connect process and data flow. A solid line is used to denote data or process flow. Arrows represent the direction of the flow. A dashed line is used to denote an alternate path. Arrows represent the direction of the flow. A jagged line is used to denote data transfer by a telecommunications link. Arrows represent the direction of the flow. Two parallel lines denote a synchronization between two parallel processes. i.e. that the things above it have to happen and all come to the denoted state before the things below it can occur. There are no arrows on synchronization lines. All lines that represent flow based on decisions should be labeled. Lines should run up & down or left and right. Do not use diagonal lines. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 9 Process Mapping: ISO 5807 Lecture b This material Comp10_Unit3b was developed by Duke University, funded by the Department of Health and Human Services, Office

16 Slide 27 This concludes Lecture b of Process Mapping: ISO After completing lecture b, you should be able to: Recognize and use ISO 5807 standard symbols and conventions, Read and interpret an ISO 5807 flowchart, and Create ISO 5807 flowcharts for a health care system (or a system component) using correct symbols and conventions. Slide 28 No audio. Slide 29 No audio. End. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 10 Process Mapping: ISO 5807 Lecture b This material Comp10_Unit3b was developed by Duke University, funded by the Department of Health and Human Services, Office

17 WORKFLOW ANALYSIS Audio Transcript Component 10 Unit 3 Lecture C Fundamentals of Health Workflow Process Analysis & Redesign Interpreting and Creating Process Diagrams Process Mapping Yourdon Notation for Data Flow Diagrams Slide 1 Welcome to Fundamentals of Health Workflow Process Analysis and Redesign: Process Mapping: Yourdon Notation for Data Flow Diagrams. This is Lecture c. The Component, Fundamentals of Health Workflow Process Analysis and Redesign, examines different diagramming methods for developing graphical representations of processes in health care settings. Throughout the last century, different diagrams and notations have arisen. There is considerable overlap between them. Some have fallen by the wayside and others remain in use. Some have become international standards, while others exist in textbooks and articles. In this unit, we present major formalisms for process diagramming in use today and the process aspects that each covers. Lecture c, Process Mapping: Yourdon Notation for Data Flow Diagrams, covers Yourdon notation for data flow diagrams. Slide 2 The objectives for this unit, Process Mapping: Yourdon Notation for Data Flow Diagrams, are to: Create a process flowchart for a health care system (or system component) using appropriate ISO 5807 symbols and conventions, Create context and data flow diagrams for a health care system (or system component) using appropriate Yourdon symbols and conventions, Choose the correct scope and detail level for a process flowchart and data flow diagram, Read and interpret Gane-Sarson data flow diagram, Read and interpret an entity relationship diagram in crow s foot notation, and Read and interpret UML class, activity, and state diagrams. Slide 3 The topics covered in Lecture c are: Recognize and interpret Yourdon data flow diagram symbols and conventions, and Create data flow diagrams (DFDs) for health care scenarios. Slide 4

18 Data flow diagrams provide a way to document and visualize the movement of data through a process. As such, they document several aspects of processes that analysts and process designers are interested in. There are multiple notations for data flow diagrams, including ISO 5807 flowcharts, Yourdon notation and Gane-Sarson notation. We will only cover Yourdon notation for data flow diagrams in lecture c. Yourdon notation was introduced in Edward Yourdon s 1989 book Modern Structured Analysis. (Yourdon, 2006). Yourdon notation exists for three types of diagrams 1) data flow diagrams, 2) state transition diagrams, and 3) entity-relationship diagrams. (These are different from the entity-relationship diagrams that are logical relational data models covered in lecture e.) The most commonly used Yourdon diagram in health care is the data flow diagram. Slide 5 Each of the methods for diagramming a process introduced in lecture a covers certain aspects of processes. Recall that Yourdon data flow diagrams, also known as DFDs, can represent the highlevel context in which a process operates, i.e., interfaces between a system and the rest of the world. Data Flow Diagrams (DFDs) can also be used to illustrate the details of entities from and to which data are received or sent, process steps, i.e., data or information transformations that occur, and data movement between entities & processes, processes and processes, and processes and data stores. Data flow diagrams do not represent information content, roles, or the logic of flow control (sequence of processes or flow can be indicated as we will see). Here we note data flow diagrams as representing data flow steps and not process steps. This is somewhat artificial; as Yourdon describes in his 2006 revision of Just Enough Structured Analysis, the data flow diagrams can be used to diagram processes. Doing so requires using flows to represent physical things such as materials or supplies and the process symbols represent operations on the materials rather than on data. (Yourdon, 2006) However, we describe DFDs as just representing data flow steps rather than process steps. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 2 Process Mapping: Yourdon Notation for Data Flow Diagrams Lecture c This material Comp10_Unit3c was developed by Duke University, funded by the Department of Health and Human Services, Office

19 Slide 6 We will cover two uses of data flow diagrams in this presentation: 1) a high-level version that is called a context diagram, and 2) more detailed versions called data flow diagrams. Both context diagrams and DFDs use the same notation, the only difference is that the context diagram is the 50,000 foot bird s-eye view rather than the details. At the highest detail level, the context diagram represents an entire system as a single process and highlights the interfaces between the system and the outside world. Thus, context diagrams are helpful to document and share knowledge about what is included in a process (the scope). Slide 7 A context diagram (shown on the slide) is the highest level (i.e., least detail) DFD. The context diagram depicts the system or process you are modeling as one process, here private practice patient care. Entities that interact with that process are shown, here patients, payers, pharmacies, etc., as are the data stores (the EMR and an eprescription data store), and the data flow among the entities, processes and data stores. Context diagrams are very helpful in making sure that our analysis is complete and that interactions with external entities are not forgotten. Slide 8 The example data flow diagram on this slide shows the data movement and transformations as a patient goes through the entire visit process. This begins with the reception/intake process where the intake data are entered or written to the administrative database that will be used for billing. After intake, the medical office assistant is given the room assignment. In the examination room the provider assesses the patient, charts clinical data and generates orders for further processes. The orders and clinical data are stored in the EHR. The EHR data are then used in the billing process to generate the claim for financial reimbursement (from the payer). Slide 9 Entities are origins or consumers of data (also called terminators), they are typically individuals, groups of people (for example, another department or division within the organization), external computer systems, and external organizations. Entities are referred to as external entities, because they are outside the process being analyzed, i.e., not changeable. For example in the previous diagram, the patient is not part of the receptionist s intake process, but the patient s information is an input to the process. Processes are shown by the circles, or bubbles,in the diagram. They represent the various individual functions or transformations that the system carries out, that is, actions or work performed on data that change them in some way, i.e., take inputs and Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 3 Process Mapping: Yourdon Notation for Data Flow Diagrams Lecture c This material Comp10_Unit3c was developed by Duke University, funded by the Department of Health and Human Services, Office

20 creates different outputs (input allergies and drug order and output an allergic alert or drug-drug interaction alert). Flows are shown by curved, directional arrows. They are the connections between the processes (system functions), and they represent the information moving between processes as input and/or the information they generate as output. Yourdon refers to flows as data in motion. (Yourdon, 2006) Data stores represent data at rest. (Yourdon, 2006) They are shown by two parallel lines with a closed end and opposing open end. This is essentially a rectangle with one of the vertical lines missing. They show collections of data that the system must remember for a period of time. When the systems designers and programmers finish building the system, the stores will typically exist as files or databases. Yourdon published several books and papers with different people. Variations of this notation exist. We chose one here and use it consistently. Slide 10 Entities represent people, organizations, or other things that interact with the system, i.e. entities are outside of the system, they may, of course, be part of a larger workflow process, but they are EXTERNAL to the information system processing the data. Entities send or consume information, and are also called sources or sinks of information. Data flows can come to and from entities ONLY from processes. This is because entities are used to represent sources or consumers of information that are NOT a part of the system being analyzed; if flow between entities, for example, were represented on the diagrams, then that would imply that they were PART of the system being analyzed. As such, data flows to and from entities represent system interfaces (a very important thing to show). Slide 11 A Process should be named or described with a single word, phrase, or simple sentence that describes what the process does. A good name consists of a verb-object phrase such as assessment or assess patient. In some cases, the process will contain the name of a person, group of people, computer, or mechanical device. That is, the process sometimes describes who or what is carrying out the process, rather than describing what the process is. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 4 Process Mapping: Yourdon Notation for Data Flow Diagrams Lecture c This material Comp10_Unit3c was developed by Duke University, funded by the Department of Health and Human Services, Office

21 Slide 12 The process Flow is represented by curved arrows. Arrow heads on the flow indicate the direction of the movement of data, i.e., whether the data are moving into or out of a process or both. The name of the process represents the meaning of the data that moves along the flow. Importantly, the same content may have a different meaning in different parts of the system. For example, the address as given by a patient versus the address that has been matched and validated. Slide 13 The Data Store represents a collection of data at rest. It should be named with a noun or noun phrase, and can be computerized or non-computerized, such as paper charts. Data stores are passive, i.e., processes put data in or read data out of the data store. Arrows to data stores mean write, update, or delete data into the data store. Arrows from data stores mean read, retrieve, or use data from the data store. Data flows to data stores cannot come from other data stores or from entities. As previously mentioned, a data store resembles a rectangle lacking one of the vertical lines. Slide 14 In Yourdon notation, an event list accompanies a data flow diagram. An event list contains things that stimulate action from the system. For example, for prescribing: a patient calls for a re-fill, a pharmacy calls for a re-fill, or a patient presents with a problem requiring medication. Slide 15 Yourdan notation conventions are important. The analyst should choose meaningful names for all processes, flows, stores, and terminators. Also, number the processes by placing a unique number in the circle at the top. You should redraw the DFD as many times as necessary until it is clear and complete and simplify the DFDs as much as possible. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 5 Process Mapping: Yourdon Notation for Data Flow Diagrams Lecture c This material Comp10_Unit3c was developed by Duke University, funded by the Department of Health and Human Services, Office

22 A good DFD fits on one page and is not too crowded. If additional details are needed, processes can be exploded on a new page. Everything on one page should be at the same detail level. Slide 16 Style matters in Yourdon notation and can be used by the analyst to provide additional meaning to DFDs. The size and shape of bubbles are up to the diagram creator and their client. Curved or straight arrows can be used. A diagram looks neater with one or the other but not both in the same process. There is no excuse for hand-drawn diagrams today except during a white-boarding stage. The analyst may choose to name the processes for the role that they perform, as well as use colors to differentiate the types of entities or flows in the diagrams. With all of these style options the DFDs can provide as much or as little detail as is needed to appropriately represent the process for the given audience. Slide 17 Beware of the following potential flaws in your process diagrams: Black holes as Yourdon calls them, are processes that have inputs but no outputs. Miracles are processes that have outputs but no inputs. Mysteries are unlabeled flows and unlabeled processes. Slide 18 We encourage the analyst to represent processes with leveled diagrams where necessary in order to have a diagram that is readily understood and can be provided at the appropriate level of detail for the audience. Start with higher level (context) diagrams to understand the scope and boundaries. These may be used for discussions with leadership in the health care setting. Then decompose the processes to lower levels of detail when needed. Remember the ultimate goal is an optimized clinic process, not a large detailed set of diagrams. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 6 Process Mapping: Yourdon Notation for Data Flow Diagrams Lecture c This material Comp10_Unit3c was developed by Duke University, funded by the Department of Health and Human Services, Office

23 Slide 19 Remember the guidance from Edward Yourdan s 1989 work, Just Enough Structured Analysis. I quote: even if our job were to design the world, we would have to recognize that the world is only a part of the solar system, which is part of a small, obscure galaxy, which is (ultimately) part of the universe. the first major model that you must develop as a systems analyst is one that does nothing more than define the interfaces between the system and the rest of the universe, that is, the environment. Slide 20 There have been several variations on Yourdon notation. Two of these are: Yourdon- Code and Yourdon-DeMarco. Yourdon concepts and notation have been adapted to suit the needs of individual projects. Yourdon notation for data flow diagrams has been adapted for health care process analysis and redesign by the Public Health Informatics Institute (PHII) in their recent Common Ground Initiative, and by the Agency for Healthcare Research and Quality (AHRQ) funded initiatives (Yourdon, 2006). Yourdon himself makes the point that the actual shape chosen is not important as long as the analyst uses the shape to consistently represent the same meaning. (Yourdon, 2006) Slide 21 This DFD uses one shape and does not distinguish between process, entity and data store. In Yourdon parlance, because it is high-level, it would be called a context diagram even though it takes a notational liberty in differentiating the types of flows. Importantly, the diagram met the need for software selection and process re-design in many public health departments. The moral is, take what is useful and do not carry extra baggage. Slide 22 Without looking at the next slide, draw a one-page DFD for a prescription refill process at a primary care provider based on the following scenario: Mrs. Jones takes Benecar 20mg QD for blood pressure control. She has taken this medicine for two years with good results. She does not use the auto refill program at her local pharmacy. Today, she called her provider, who does not use e-prescribing, and asked if the prescription could be called in to her pharmacy. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 7 Process Mapping: Yourdon Notation for Data Flow Diagrams Lecture c This material Comp10_Unit3c was developed by Duke University, funded by the Department of Health and Human Services, Office

24 Slide 23 This example prescription refill context diagram shows the process steps and people required to refill a prescription without using a pharmacy auto-refill program or e- Prescribing through the provider. Slide 24 Yourdon notation is a set of symbols and conventions named for the person who developed it, Edward Yourdon. Yourdon notation has not been adopted as a standard. As such, there is no formal maintenance organization. Individuals use and adapt it to suit their needs. For an adaptation to still be a context diagram, it must show entities, processes and interactions. Slide 25 This concludes Lecture c, Process Mapping: Yourdon Notation for Data Flow Diagrams. After completion of this lecture, you should be able to: Explain two ways process diagrams are used as models, Distinguish the physical steps from information flow in a health care process involving an EHR, and Choose an appropriate process diagram to model given aspects of a process. Slide 26 No audio. End. Health IT Workforce Curriculum Fundamentals of Health Workflow Process Analysis and Redesign 8 Process Mapping: Yourdon Notation for Data Flow Diagrams Lecture c This material Comp10_Unit3c was developed by Duke University, funded by the Department of Health and Human Services, Office