A QUALITY FUNCTION DEPLOYMENT APPROACH TO DEVELOPING ELECTRONIC MEDICAL RECORD COURSE CONTENT, DESIGN AND DELIVERY FOR HEALTHCARE EMPLOYEES

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1 A QUALITY FUNCTION DEPLOYMENT APPROACH TO DEVELOPING ELECTRONIC MEDICAL RECORD COURSE CONTENT, DESIGN AND DELIVERY FOR HEALTHCARE EMPLOYEES Megan Martin Business Information Technology Virginia Polytechnic Institute and State University 1007 Pamplin Hall Blacksburg, VA Lance Matheson Business Information Technology Virginia Polytechnic Institute and State University 1007 Pamplin Hall Blacksburg, VA ABSTRACT The healthcare industry faces the challenge of incorporating electronic medical record (EMR) systems, principles and practices into day-to-day work life for healthcare employees. The primary concern is to ensure newly-trained healthcare program graduates are proficient on EMR systems and related IT subjects. In response to the growing challenge, Virginia Highlands Community College applied for and received a 4.7 million dollar federal grant for communitybased job training called Health Information Technology Education. With this funding and based on previous research, we used Quality Function Deployment to develop curricula to meet the needs of our healthcare industry partners. Our study resulted in a taxonomy composed of nine subject areas. Each area had twelve topics, tracking information from modules to chapters down to the page. INTRODUCTION The healthcare industry faces the challenge of incorporating electronic medical record (EMR) systems, principles and practices into day-to-day work life for all healthcare employees. New and existing healthcare employees experience frustrations with the EMR interface by not understanding or mastering the EMR system. In addition, many healthcare employees are not proficient at basic computer skills which limits the ability to use and troubleshoot EMR systems. In response to these needs, Virginia Highlands Community College applied for and received a 4.7 million dollar federal grant for community-based job training called Health Information Technology Education (HITE). Quoting the grant application, The HITE initiative s primary goal is the recruitment, training, placement, and retention of EMR Savvy Healthcare

2 Professionals for healthcare employers such as ambulatory healthcare service, hospitals, and nursing and residential care. [1, 1-20] The HITE initiative concentrated training and employment services for five target healthcare occupations: (1) Medical Records/Health Information Technicians (2) Medical Assistants (3) Pharmacy Technicians (4) Licensed Practical Nurses (5) Registered Nurses The HITE initiative has three committees: the Project Management Committee (PMC), the Advisory Committee (AC) and the Curriculum Modification Committee (CMC). The PMC was responsible for the oversight of the entire HITE initiative including activities like monitoring partner performance and submitting reports to the Department of Labor. The AC was composed of industry and academic partners. The AC provided input on the modification and implementation of EMR training activities (See Table 1). The CMC was composed of faculty members from Virginia Polytechnic Institute and State University, University of Virginia s College at Wise and the five participating community colleges (See Table 1). The purpose of the CMC was to provide research, consulting and curriculum modification services to enhance the five community college programs. The authors of this paper served as members of the CMC. Table 1: HITE Participants Academic Partners Virginia Highlands Community College (VHCC) New River Community College (NRCC) Virginia Western Community College (VWCC) Southwest Virginia Community College (SVCC) Mountain Empire Community College (MECC) Additional Partners Southwestern Virginia Workforce Investment Board New River/Mount Rogers Workforce Investment Board Western Virginia Workforce Investment Board Virginia Polytechnic Institute and State University (VT) University of Virginia s College at Wise (UVa-Wise) Industry Partners Hospital Corporation of America (HCA): 1. Montgomery Regional Hospital 2. Pulaski Community Hospital Mountain States Health Alliance including: Carilion Clinic Clinch Valley Medical Center (Lifepoint) Holston Medical Group Buchanan General Hospital Wellmont Health Systems 1. Dickenson Community Hospital 2. Johnson Memorial Hospital 3. Russell County Medical Center 4. Smyth County Community Hospital 5. Francis Marion Manor The CMC met monthly and worked to achieve the following three goals:

3 (1) Develop a new or modified curriculum to create EMR training programs tailored to the five targeted occupations. (2) Identify additions to existing community college staff, curriculum and/or equipment to upgrade existing health information technology programs. (3) Develop an online curriculum modification portal. The portal is under development and will be covered in future papers. Quality Function Deployment (QFD) is a product design method typically used in operations management. QFD translates the voice of the customer into technical design requirements. [5] We wanted to conduct a thorough evaluation of the needs, wants and requirements of EMR training and convert the information into technical training items for academia. In addition, we wanted to map those technical items to actual course delivery and course management elements. In the HITE application, we customized the QFD approach from a manufacturing venue to an education venue. The first matrix of QFD, known as the house of quality (HOQ), maps customer requirements to product-design characteristics.[5] In the HITE application, we collected detailed student/employee characteristics and skills from the community colleges, industry partners, and federal regulations. We used these to outline the design through a series of QFD matrices converting the information into course characteristics, design and delivery. LITERATURE REVIEW In 1998, Franceschini and Terzago used QFD to describe all activities needed to develop a theoretical yet practical industrial training course. The QFD model outlined the prioritized customer requirements (student needs), the service characteristics (technical design) and the relationship between the requirements and characteristics. The authors suggested collecting customer requirements information from students and training agencies. The data was organized by grouping the information into categories based on similarity. This process was challenging due to intersecting and/or overlapping customer requirements which fell into two or more categories. Francschini and Terzago stressed that the construction of a perfect hierarchy is not the most important element of the process. Incorporating all information from the data collection stage was the most important element [3, ]. In the HITE application, we used a similar process in the organization of healthcare customer requirements and design characteristics. In 2003, Duffuaa, Al-Turki and Hawsawi customized QFD to design a basic statistics course at King Fahd University of Petroleum and Minerals. The customer requirements were collected from external customers (companies) and internal customers (students and faculty). Students and companies were given a survey to identify prioritized customer requirements. The design characteristics were obtained from faculty via surveys to identify the most important elements of design and delivery of the course. Each design characteristic had subsections allowing for detailed information for the logistics of the course. For example, the design characteristic prerequisite included subsections calculus and college algebra [4, ]. In the HITE application, we used the same approach to the design characteristics by creating a hierarchy of subsections. In addition, Duffuaa, Al-Turki and Hawsawi concentrated on the logistics

4 development of a course. We concentrated on the course design and delivery but included the development of course content as the primary objective. In 2005, Denton, Kleist and Surendra used the HOQ to overcome resource constraints while delivering a comprehensive curriculum within a well-designed course in Management Information Systems (MIS). They converted customer requirements into expected abilities of the program graduates. The product was the graduate and the customer was the future employer [2, 111]. Denton, Kleist and Surendra used curriculum guidelines provided by a university to build the customer requirements. In the HITE application, we recognized the concern that newly-trained healthcare graduates lacked proficiency in EMR systems and related IT subjects. Therefore, we used not only curriculum guidelines but college and industry feedback as well. In addition, Denton, Kleist and Surendra used the trade-off matrix, the competitive assessment section and the target value section of the HOQ. In the HITE application, we removed the tradeoff matrix and the competitive assessment in its entirety. Also, we did not incorporate the target value section until the fourth matrix. Moreover, Denton, Kleist and Surendra used an extension of the HOQ application which moves from the HOQ straight to the logistics of course design and delivery. We extended the detailed levels of design characteristics into five matrices. This enabled academia and industry to understand how each subject area, topic, module, chapter and page fit into the course design and delivery. Stage I: Fact Finding Process RESEARCH DESIGN The CMC conducted roundtables with academic and industry partners to study the potential needs and/or improvement to the five targeted healthcare occupation academic programs. The off-site meetings consisted of open-ended discussions to ensure a wide range of information was gathered without the participants feeling limited by a specific list of questions. These requirements were sorted and grouped based on commonality. The information was cleared of redundancy. We also labeled the design characteristics with a primary subject area along with subsections called topics. We used QFD matrices to continue organizing the information to ensure an efficient application of course content development, design and delivery. This drove the development of the HITE taxonomy hierarchy of information (See Figure 1). Subject Area Topic Module Chapter Page Stage II: QFD Application Figure 1: HITE Taxonomy Design The QFD matrices map customer requirements to product characteristics to part characteristics to process characteristics and, finally, to operations (See Figure 2).

5 Figure 2: Series of Connected QFD Houses in a Manufacturing Environment [5] The initial house or HOQ, where customer requirements are converted into product-design characteristics, is the most commonly used matrix.[5] The HOQ has six sections: customer requirements, competitive assessment, design characteristics, relationship matrix, trade-off matrix, and target values section (See Figure 3). In the HITE application, we used four of the six sections: customer requirements, design characteristics, relationship matrix and target values section. The remaining sections are more relevant to a manufacturing environment and thus were not used in the academic application. Figure 3: House of Quality versus customized HITE House of Quality Customer requirements (1) generally identify the needs, wants or requirements of internal and external customers. In the HITE application, the internal customers are the community college partners and the external customers are the industry partners. The information identified from the roundtable meetings was listed in this section. Design characteristics (3) are the technical terms that are linked to the customer requirements. We identified these terms through current course syllabi, current course design and healthcare requirements, specifically the American Health Information Management Association (AHIMA).

6 The relationship matrix (4) is the crucial connection between customer requirements and design characteristics. In the event, a customer requirement is not covered in a design characteristic the relationship matrix will detect this gap. In the event a customer requirement is covered in multiple design characteristics the matrix will show the redundancy. The target value section (6) generally adds quantitative values through a technical assessment of the design characteristics. In the HITE application, we do not incorporate the target value section until the fourth matrix for course delivery. This helps quantify classroom time for the specific logistics of course design. The competitive assessment section (2) evaluates the current company against the competitors based on the customer requirements. The trade-off matrix (5) identifies trade-offs between the design characteristics. The relative importance section is a tool to rate or order the customer requirements based on importance. In the HITE application, all customer requirements need to be incorporated in the course; therefore, all of the customer requirements are equally important. Sections (2), (5) and relative importance were not used in the academic application. Stage I: Fact Finding Process RESULTS During our meetings with academic and industry partners, we identified nine primary design characteristics which we called subject areas (See Table 2). We also identified twelve secondary design characteristics or subsections of each subject area called topics (See Table 3). Each subject area had the potential of having twelve topics. Table 2: Subject Area Subject Areas Basic Protocols Communication Critical Thinking EMR Health Informatics Skills Health Information Literacy Privacy and Confidentiality Work-Related Issues Table 3: Topics Topics Continuing Education General Communication Electronic Medical Records Ethical & Quality Practices Legal Environment Medical Industry

7 Meaningful Use Patient-Nurse Relationship/Patient Care Pharmacy Practice Security & Protection Work Practices We continued organizing the information to ensure an efficient application of QFD and developed the HITE taxonomy hierarchy of information. Each topic consisted of modules; each module consisted of chapters; each chapter consisted of pages (See Figure 1). As the organization of information continued, a customer requirement could be mapped from a subject area to a topic to a module to a chapter to a page to ensure coverage in the course design and delivery. An example of the HITE taxonomy of information is shown in Figure 4. Computers & Related Devices Office Applications Excel Menu System Figure 4: Example of the HITE Taxonomy for The hierarchy of information was much more complicated than a simple linear organization of information: subject areas had multiple topics; topics had multiple modules, modules had multiple chapters; and chapters had multiple pages (See Figure 5). Computers & Related Devices Security & Protection General Knowledge Office Applications Module 1 Computer Terminology Word Excel Chapter A Chapter B Hardware Proofread & Edit Menu System Page a Page c Software Tables & Graphs Page b Menu System Figure 5: A detailed example of the HITE taxonomy for. Stage II: QFD Application The initial HITE QFD matrix mapped customer requirements to the design characteristics labeled subject areas and topics. The following two matrices mapped the design characteristics

8 to the page level: subject area and topic to module and chapter to page (See Figure 6). The remaining two matrices map the page characteristics to module delivery and management. Figure 6: Series of Connected QFD Matrices in the HITE Environment The customized QFD matrices were broken down into a four-phase process of converting customer requirements to content development, design and delivery (See Table 4). Table 4: HITE QFD Matrices Phase Label Appendix 1 Customer Needs-Subject Area-Topic I 2 Topic-Module-Chapter Breakdown II 3 Chapter-Page Breakdown III 4a Module Delivery IV 4b Module Management V CONCLUSION AND FUTURE RESEARCH As stated in the introduction, the CMC worked to achieve three objectives for the HITE initiative. We described the tool for developing a new or modified curriculum for EMR training programs. This was done for the five targeted occupations specified in the grant. Also, we identified additions to existing community college staff, curriculum and equipment to upgrade existing health information technology programs. We will develop an online curriculum modification portal to make this process more efficient. The portal will foster communication and collaboration between academia and industry in regards to course content, design and delivery. The new curriculum will be introduced in the academic year.

9 Subject Area B Subject Area A Word Excel PowerPoint Chapter C Chapter D Chapter E Chapter F Chapter G Chapter H Chapter I Chapter J Chapter K Chapter L Chapter M Chapter N Chapter O Chapter P Security & Protection Topic A General Communication Patient-Nurse Relationship/Patient Care Topic B Topic C EMR Ethical & Quality Practices Meaningful Use Medical Industry Topic B Topic C Topic D Topic E Topic F Topic G Topic H Topic I Topic J Topic K Topic L Topic M APPENDIX Appendix I: Phase 1: Customer Needs-Subject Area-Topic Breakdown Phase 1: Customer Needs-Subject Area-Topic Breakdown COMPUTER SKILLS SUBJECT AREA & THEIR TOPICS: Identify topics within each subject area. Communication Critical Thinking Subject Area Subject Area CUSTOMER REQUIREMENTS (college & industry): Insert abilities/skills the customer would like the healthcare employee to possess. College Keyboarding x Need A Need B Need C Industry ing/Attachments x Search x x Research x x Navigation in Word Both Written/Verbal Communication Skills x x x Troubleshooting Hardware Issues x Need D Appendix II: Phase 2: Topic-Module-Chapter Breakdown Phase 2: Topic-Module-Chapter Breakdown MODULES & THEIR CHAPTERS: Identify modules with their chapters within each module Office Application General Knowledge Module C Module D Module E Module F SUBJECT AREA & THEIR TOPICS Topic A Topic B Topic C Topic D Topic E Topic F Topic G Topic H

10 Subject Area B Topic B Module B Chapter B Subject Area A Topic A Module A Chapter A Office Applications Word SUBJECT AREA TOPIC MODULE CHAPTER Mr. X Mrs. Y Dr. Z HW1 HW2 HW3 ABC DEF XYZ Exam 1 Exam 2 Exam 3 Project A Subject Area A Topic A Module A Office Application SUBJECT AREA TOPIC MODULE Proofread & Edit Contents Tables & Graphs Menu System Page C Page D Page E Page F Page G Page H Page I Page J Page K Page L Page M Page N Page O Page P Appendix III: Phase 3: Chapter-Page Breakdown Phase 3: Chapter-Page Breakdown PAGE CHARACTERISTICS: Identify page characteristics within each chapter. MODULES & THEIR CHAPTERS Word Excel Powerpoint Chapter C Chapter D Appendix IV: Phase 4a: Module Delivery Phase 4a-Module Delivery PROCESS CHARACTERISTICS: Identify items needed to deliver each page within each chapter Speakers LECTURES/PPT Homework Interactive Media Exams Project PAGE CHARACTERISTICS Proofread and Edit Contents Tables & Graphs Menu System Page C Page D Page E Page F Page G Page H Projected Classroom Hours

11 Subject Area B Topic B Module B Chapter B Subject Area A Topic A Module A Chapter A Office Applications Word SUBJECT AREA TOPIC MODULE CHAPTER How When Who Module 1 Module 2 Module 3 Other Site A Site B Site C RN 3-5 years experience in healthcare 3-5 years experience with teaching Appendix V: Phase 4b: Module Management Phase 4b-Module Management OPERATIONS CHARACTERISTICS: Identify each item needed to manage/operate each topic within each module. Student Registration Pre-requisites Location Class Size Faculty PAGE CHARACTERISTICS Proofread & Edit Contents Tables & Graphs Menu System Page C Page D Page E Page F Page G Page H REFERENCES 1. Bonham, W., Technical Proposal-SGA/DFA PY 09-07, 2009: Blacksburg, VA. p Denton, J.W., V.F. Kleist, and N. Surendra, Curriculum and Course Design: A New Approach Using Quality Function Deployment. Journal of education for business, (2), p Franceschini, F. and M. Terzago, An application of quality function deployment to industrial training courses. The International journal of quality & reliability management, (7), p Hawsawi, M.M., U.M. Al-Turki, and S.O. Duffuaa, Quality function deployment for designing a basic statistics course. The International journal of quality & reliability management, (6), p Russell, R.S. and B.W.T. III, Operations Management: Creating Value Along The Supply Chain. 7th ed2011: John Wiley & Sons, Inc.