Designing Smooth Telehealth Workflows

Have you ever thought about the meaning of the word “workflow”? Once you do, it’s quite obvious: the workflow defines how the work flows — literally. In this week’s Telehealth Tuesday I’ll share some of my insights on optimizing telehealth workflows so that they are efficient, effective — and smooth!

And I’ll be leveraging the analogy of a flowing river for all its worth!

The Concept of Flow

Before we move on to telehealth, I’d like to stay a little bit with the quite literal interpretation of the word flow as indicated by this week’s article’s cover image: a beautiful, flowing stream in the woods.

Almost 50 years ago, in 1975, a Hungarian Psychologist by the name of Mihaly Csikszentmihalyi coined the term “Flow” to describe the almost blissful state people enter when the challenge at hand and the skills required to solve the challenge are matched. Being in the state of “flow” is colloquially also described as “being in the zone”.

There are many situations that can throw a person out of the “flow zone”, e.g., obstacles outside of one’s influence, challenges for which the skills were not provided or tasks that do not require much skill and lead to boredom or even apathy.

By applying the following three key elements many of the larger problems can be averted.

The 3 Key Elements of Smooth Workflows

I have been in the business of optimizing service workflows for almost 35 years, starting with a software solution to automate some of the back-office operations of my parent’s neighbor’s forwarding company.

Over time the workflows and engagements got more complex, and, as anyone who has studied healthcare workflows will attest to, I think I’ve reached the pinnacle of complexity with healthcare.

With healthcare delivery being one of the wicked problems (that’s actually a defined term, which I don’t have the space to define today), no single approach can solve the challenge at hand. Rather it requires a multitude of multidisciplinary approaches and techniques to make a dent in solving the challenges.

Over the years I have discerned the following three elements to leverage in the design of smooth telehealth workflows:

1. Practicing on Top of One’s License – the principle that highly qualified individuals (such as physicians) should only do the things that only they can do.
2. Leverage a Change Management Approach: create Awareness, Desire, Knowledge, Ability and provide accountability through Reinforcement.
3. Design and Define the Workflow – the simple concept of actually documenting what everybody agreed on – ideally visually and textually.

Practicing on Top of One’s License

One of the key concepts of smooth telehealth workflows is actually a mindset shift. It’s the notion that all healthcare delivery workflows should be designed based on the unique talents, skills, and licensure of the people involved in the care delivery process.

Practicing on Top of One’s License means that ideally every uniquely-skilled person — whether that’s a physician, a nurse, a coder, or a scheduler — should spend most of their time (>80%) doing the things that only they can do or that only they are allowed to perform.

This has a multitude of positive consequences:

• When qualified individuals, such as physicians, are spending most of their time on the things that they have trained for, they are more likely to enter the state of “flow” as described above, thus experiencing joy and happiness doing the job they love and are best qualified to do.
• Conversely, if these individuals are busy doing those unique things, they don’t have much time for the mundane, boring, or frustrating tasks that these days lead to so much job dissatisfaction.
• This arrangement is also highly beneficial to the patient: if for every step along the way, they are matched with the person that is most qualified to do the job at hand, chances are they are receiving excellent service with a smile.

Be forewarned, though: designing for “Top of License” takes some guts. Over time more and more tasks have been added to the to do list of highly qualified individuals who, oftentimes begrudgingly, have added them to their plate. Redirecting these tasks to others, may prove to be unpopular and will be met with resistance. But it is necessary to rip off this bandaid and replace it with a more effective and sustainable solution.

Leverage a Change Management Approach

The ability to effectively manage the reaction to change has turned out to be the pivotal element in our telehealth implementation and optimization work.

I’ve written about one of my favorite Change Management Models, the Prosci Institute’s ADKAR model, numerous times and will defer to one of my previous articles: Telehealth Success through Conscious Change Management.

Going back to the definition of the state of flow, while we oftentimes can’t do much about the challenges, we can do a lot with the skills aspect. Namely, two elements of the ADKAR model: Knowledge and Ability.

In order to avoid hesitancy or frustration, we must provide each participant in the workflow with the appropriate knowledge on how to do the job, along with sufficient training and appropriate tools to also create the ability to succeed.

Design and Define the Workflow

The final critical element of a smooth workflow is that it is actually documented and communicated. After too many committee meetings at an academic medical center almost 20 years ago where the same topics were oftentimes rehashed at almost every meeting, I developed two aphoristic principles:

The first one is that, Everybody Agreed until Somebody Wrote it Down — as they say in contracts, if it isn’t written, it did not happen.

But most of the time writing it down is not even enough. Quite frequently there are different interpretations or definitions for the key concepts, so the key principle really is Everybody Agreed until Somebody Defined it (in writing).

It is therefore imperative that all workflows are properly defined and documented and agreed on by all key stakeholders.

One of the most powerful techniques of effectively documenting a workflow is to use a swimlane model, which clearly defines who (and what) is involved in each step of the process. I’ll probably do a future Telehealth Tuesday article on this technique.

Another critical aspect of workflow design is to explore upstream (what happens before) and downstream (what happens after) processes. Only when everyone involved understands where work originated from or how the outcome or deliverable of one’s work is consumed and used later, only then can we design truly smooth telehealth workflows.

The Cost of Not Doing It

The cost of not properly defining the telehealth workflows are manifold and almost too many to list. Here’s a quick & dirty list of just 4 things that come to mind:

1. Physicians and other qualified staff are dissatisfied with how seldom they are fully leveraging their unique skills, leading to frustration and disengagement.
2. By not providing adequate training (e.g., on the proper webside manners or on the appropriate use of the telehealth solution) frustration comes easily and leads to further disengagement.
3. Patients are not seen by relaxed, content clinicians, but healthcare professionals that are stressed, rushed, overworked, and frustrated.
4. Telehealth is a new modality in the care delivery spectrum, but still includes all the steps as an in-person visit that must be replicated for the virtual environment. Without a formal design, many critical aspects of a great virtual care experience could be jeopardized. This includes in particular upstream processes like scheduling, rooming, and co-pay collection, as well as post-visit processes. This will lead to a disjointed, subpar care experience.

The human mind is highly creative and is always looking for its path of least resistance. Thus when obstacles are put in the way, the workflow will find a work around as can best be illustrated by this beautiful, but not necessarily very efficient waterfall.

As you can see in the upper falls, over time, the water has found several different ways to get its job done (transporting the water downstream). When the initial waterfall could no longer keep up with the rush of water, the water found 4, 5 other ways to push the water over the edge – without any consideration as to the consequences of this workaround (a.k.a. “flow around” 😉

Ultimately, the conscious design of efficient, effective telehealth workflows that are smooth is not difficult. But it is a task that must be identified, assigned, and executed in order to happen.