For current state problem understanding, cross functional process maps were developed of loop closing processes through a series of interdisciplinary interviews and meetings (including clinicians, scheduling and administrative staff, patients), both in general and focused specifically on dermatology and gastroenterology referrals. Results then were used as input to process design characterization analyses, failure analyses, and prototype design exercises. These approaches helped to highlight the low overall system reliability of these processes, identify common and critical failures, and brainstorm potential solutions to address these failures.

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Informed by the above, recent work has focused on prototyping and piloting several solution ideas to either improve existing loop closure processes or design new processes. The FMEA and FTA failure analysis results are being used to focus on the most critical and most promising areas to improve or redesign within current processes. To consider new processes altogether and avoid focusing only on improving the existing mental model of referral processes, an engineering process design exercise (structural analysis design technique, SADT) was used in this project to instead identify necessary process activities and information flows (i.e. “what” needs to occur rather than “how” it occurs). Reliability engineering design methods also are being used to stimulate new ways of thinking about closing loops more reliably and sooner, including failover designs, forcing functions, and process simplification. A broad range of resulting pilots now are being developed and tested across process flow stages (e.g. ordering, scheduling, preparation, completion, communication of findings, rescheduling, and follow-up).

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Systems engineering computer or mathematical models have been used in several manners throughout the above activities to help understand process performance, inform research team discussions, evaluate potential interventions, and examine disparities. Examples include predictive, discrete event computer simulation, and cost/benefit models of engaging community health workers in closing loops (workflows, resource needs, performance); reliability models of alternate approaches for incorporating home-based and hybrid home-colonoscopy testing for GI patients; and fault tree and probability block diagram models of referral processes and symptom monitoring processes.