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System Life Cycle Tools

Denise D. Tyler

INTRODUCTION

The American Nurses Credentialing Center defines the System Life Cycle (SLC) as having four phases: Planning and Analysis, Designing and Building, Implementing and Testing, and Monitoring, Maintaining, Supporting, and Evaluating. (American Nurses Credentialing Center, 2018). There are variations of these phases, some experts include the functional testing in the analysis phase, and some include, for example, the development and customization in the system design phase. No matter how they are broken down, each of these phases has specific elements and tools that can aide in the goal of a successfully installed and maintained system that meets the needs of all stakeholders.

Like the nursing process, the SCL is a continuous series of system changes, or evolutions. Even after the system is installed, there is continuous analysis, design and implementation of new modules, upgrades, and improvements. SLC and project management share tasks and functions; the outstanding difference is that project management has a clear start and stop, whereas the system life cycle is a continuous process. Table 14.1 provides a visual comparison of the nursing process, the SLC, and project management methodology.

ANALYSIS AND DOCUMENTATION OF THE CURRENT PROCESS AND WORKFLOW

A workflow analysis is a way to document each step or task in a process and is often done as part of a system implementation and optimization. Karsh and Alper (2005) describe system analysis and workflow analysis as a way to understand how a system works, and how the different elements in the system interact. The American Nurses Association (ANA) describes expertise in workflow analysis as an essential competency to enhance safety and reduce inefficiencies (ANA, 2015). Process mapping and flow charting are two methods to document the steps in a process in order to analyze it (California HealthCare Foundation, 2011). Workflow analysis can be used during implementation to plan for workflow, and after implementation as part of optimization and improvement initiatives. Workflow analysis can also be used to determine if staff are adopting changes, and help determine why if staff are not adopting change.

Documenting a workflow may be done by walking through the steps via an intensive interview with those intimately familiar with the process, by observation, or by a combination of the two. A combination of observation and interviews is the most effective way to capture all of the nuances of a process. According to Kulhanek (2011, p. 5), “Analysis provides the data with which you will base decisions that must be made in the design, development, implementation, and evaluation stages of the training project. Using a workflow diagram to document the current state is useful when planning for a system implementation, and to identify problems or opportunities for improvement with an existing system or workflow. A workflow diagram documents the processes of the users; the data workflow diagram documents the interaction and flow of the information system(s) (The National Learning Consortium, 2012).

There are several types of diagrams that can be utilized to document a process, including swim lanes, data flow diagrams (DFDs), fishbone diagrams, and process flow charts. A swim lane diagram represents a process and is usually grouped in lanes (either columns or rows) to help visualize the users or departments involved. Workflow can be documented using a simple list of the steps in the process, a swim lane, or a workflow diagram. No matter what method is used to display the process, it needs to be clear and complete for an accurate analysis. A simplified process for a diet order might be documented and displayed in the following manner:

1.   Nursing performs the assessment and documents no known allergies or issues related to swallowing or diet intake.

2.   The provider reviews assessment data and enters the order.

a.   Nursing reviews the order.

b.   The order prints in the dietary department.

3.   The diet aide files the order.

4.   The diet prints for the tray line preparation.

5.   The diet is delivered to the unit.

6.   The tray is delivered to the patient.

Figure 14.1 displays an example of the same simplified process for a diet order in a swim lane format. The swim lanes can be displayed in either a vertical or horizontal format. Note that in Figure 14.1, each row is a “swim lane.” This and other workflow diagrams can be developed using sticky notes rather than a computer program effectively, but transcribing into an electronic display increases the ability to read and share the information.

• FIGURE 14.1. A Swim Lane Presentation of a Simplified Diet Order Process.

Workflow and process flows can be carried out by individual or group interviews, or by observation. The combination of both observation and interviews is the most effective way to capture each step of a process. Understanding how technology can impact and improve workflow and patient outcomes is an important informatics skill. Simpson (2013) includes the ability to document and evaluate workflow as important informatics skills.

System Selection and Implementation

An information system should support patient care by allowing clinical staff to easily navigate the system to enter information about the system, monitor, and be alerted to changes. Selecting a system that meets the needs of all levels of stakeholders, from bedside staff to the executive team, is a complicated process with multiple factors involved. The TIGER Usability and Clinical Application design team came up with the following attributes of successful implementations (The TIGER Initiative, n.d., p. 20).

•   User and key stakeholder involvement began early in the project with system requirements development and system selection.

•   Clinicians worked with developers to create definitions, wording, and graphics that represented workflow process.

Systems must be easy to use in relation to entering and obtaining data and information. Today’s clinical systems included embedded analytics, clinical decision support (CDS) to prompt clinicians with warnings and evidencebased suggestions, as well as business intelligence to capture financial and operational data. Clinical and Business Intelligence provides historical and predictive perspective of the operations and clinical areas to improve business and clinical decisions (Carr, n.d.).

Understanding how the different parts of the system work together as well as how the system will impact the clinical workflow are key elements to consider during the system selection process. While having a system that is easy to learn and use is important, if the data cannot be reported or shared its value decreases significantly. Figure 14.2 is an example of a system diagram, or a data diagram, which shows how the Clinical Information System (CIS) relates to other systems required for patient care. For example, the CIS sends reports to the Document Imaging (DI) system, that also stores scanned documents such as a Durable Power of Attorney, which are in turn available in the CIS. The Pharmacy system works with the Bar Code Medication Administration (BCMA) system and Pyxis (Smart pumps thought not displayed here would be another component of medication safety). The financial components for revenue cycle management start with registration, admission, transfer, and discharge (ADT) through coding, billing, and accounts receivable (AR). As the patients move through the system. As the patient progresses through the system, ideally the clinical system and the financial system will update each other so that the systems are current and in sync. The Lab Information System (LIS) may work with an application similar to the barcoding used for drug administration to ensure that the correct tests are drawn; some may also be used for blood administration. Orders may be sent from the CIS to the LIS and Radiology Information System (RIS) that in turn send Order Status Updates (OSU) along with results, reports, and images back into the CIS.

• FIGURE 14.2. An Example of a Data Workflow demonstrating How Systems Might Work Together with More Difficult Work and Maintenance.

System Implementation

System implementation requires system design and building, and system testing. System design should involve key stakeholders, especially end users. Testing involves making sure that each part of the system works, and that the system works correctly with other modules and systems. Table 14.2 is an example of the unit testing required for a Lab interface, whether the LIS, the CIS, or both are being replaced or implemented. Each order needs to be tested from start to finish, so ordered, the Order Status Update (OSU) received in the CIS when Lab puts the order in progress, and when the preliminary and final results are posted. Each result associated with the order should display correctly (many Lab orders, such as a CBC have multiple results associated with them). The charge also needs to be verified for each order. Table 14.3 is an example of a tool that can be used when testing Radiology orders. Like Lab, each order needs to be tested from the time it is ordered through the time it is performed and the final report is posted. Being able to display the report and the associated image from the picture archiving and communication systems (PACS) also needs to be verified for each exam. Verification that the appropriate charges drop is also important.

Integrated testing is done after unit testing has been accomplished and is the last phase of testing, ensuring that all systems that share data are working correctly in real-life scenarios (National Learning Consortium, 2012). Similar tools can be used for integrated testing involving interfaced system or, conversion verification to ensure that converted information is correct. Table 14.4 is an example of a tool to verify that the fields related to patient information are correct when being converted from one system to another, or when being interfaced from one system to another. Attention to each field on both displays and printed documents is required. Doing an analysis of each type of admission to make sure a good sampling is done for integrated testing will help ensure that testing is comprehensive. Testing needs to include all aspects of the patients’ experience, from registration to any testing, documentation, and verification that the bill has dropped correctly.

Testing the interfaces for fields that are used by multiple applications such as the height (ht), weight (wt), and allergies in Table 14.5 illustrates testing for interfaces between multiple applications. If both standard and metric values are allowed, both need to be tested. Even though the interfaces were already tested for ancillary departments during unit testing, they need to be tested again during integrated testing. This testing should include any printed notices that are associated with the orders, along with populating work lists and reports as shown in Table 14.6. Each field for each assessment needs to be tested and verified for all displays during unit testing and a large, realistic sampling also needs to be included in the integrated testing. Table 14.7 includes examples of a checklist for assessment testing that includes integration of plan of care and alerts based on the assessments. Any printed documents such as discharge instructions should also be included.

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