Difference between revisions of "Clinical workflow analysis"

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'''Clinical Workflow Analysis'''
 
  
 +
== '''Clinical Workflow Analysis''' ==
  
  
 
'''Introduction:'''
 
'''Introduction:'''
 +
The term workflow has been variably defined. The Agency for Healthcare Research and Quality (AHRQ), defines workflow as a sequence of cognitive and physical tasks listed chronologically that occur both within and between organizations that are required to accomplish specific work objectives. It can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously. When applied to the clinical setting the above definition generally holds true, with the work objective being a direct or indirect patient care function. For example, the workflow of ordering a medication includes communication between the provider and the patient, the provider's thought process, the physical action by the provider of writing a paper prescription or entering an electronic prescription into an electronic health record and transmitting the order electronically or having the patient take the prescription to the pharmacy to have the prescription filled.
  
 +
It is important to assess workflow because inefficiencies can negatively influence patient care and outcomes. Evaluating workflows can find deficiencies and areas that would benefit from improvements. In addition, when deciding to implement CDS, it is important to understand where in the workflow alerts should be used to most efficiently affect physicians.  Research assessing health IT implementations demonstrates that delays in patient care, billing, and communication are likely to occur if workflow is not taken into account. This is generally due to the fact that clinical and practice management requirements are overlooked or oversimplified. As a form of ongoing process improvement, workflows should be continually assessed.
  
The term workflow has been variably defined [[(1)]]. Workflow could be defined as a sequence of cognitive and physical tasks listed chronologically that occur both within and between organizations that are required to accomplish a specific work objective. When applied to the clinical setting the above definition generally holds true, with the work objective being a direct or indirect patient care function. An example of a clinical workflow, seen in the example presentation below, is ordering lab tests on an outpatient during a routine appointment.
 
  
 +
'''Tools:'''
 +
A variety of tools are available to aid in the analysis of clinical workflows. The website of the Agency for Healthcare Research and Quality (AHRQ) contains one repository of tools useful in clinical workflow analysis (5). Some of the tools commonly used in clinical workflow analysis and redesign are:
  
  
'''Importance of Clinical Workflow to Health IT:'''
+
''1) Benchmarking'': The process of evaluating best practices of other organizations. This requires communicating with peers in similar organizations that are seen as successful in the objective being analyzed and determining whether these lessons can be applied to the workflow under consideration (6).
  
  
While clinical workflow has always been an essential factor in the delivery of health care it has taken on increased importance with the introduction of digital clinical information systems (CIS), including CPOE and electronic health record systems, over the past few decades. Workflow integration with health IT systems is seen as critical to their successful implementation and end user acceptance [[(2)]]. Poor CIS integration into clinical workflows are likely to negatively impact efficiency of care delivery, overall quality of care, and provider satisfaction with the work experience, all of which are generally accepted aims of health care delivery organizations [[(3)]].  
+
''2) Check Sheet:'' A structured form for analyzing data about a specific work process or function (7). It is useful for documenting observational data about specific tasks in a workflow. Referenced is an example of a workflow assessment checklist provided by AHRQ (8).
  
  
 +
''3) Flowchart or Process Map:'' Flowcharts visually demonstrate specific steps in a work process arranged in sequential order. This allows understanding of the overall process and where improvement can be made (9).
  
'''Framework for Clinical Workflow Analysis:'''
 
  
Useful analysis of clinical workflows requires a multidisciplinary approach. In addition to understanding of the specific cognitive and physical tasks required to fulfill the clinical objective under analysis, the workflow is impacted directly by organizational factors and culture, specific technical details of associated information systems, and human cognitive processes [[(4)]]. End user participation is seen as essential to robust workflow analysis, in the case of clinical workflows this includes those representing physicians/advanced practitioners, nurses, and administrative staff in the analysis depending on the specific workflow under scrutiny.
+
'''Steps in making a flowchart:'''
  
 +
1. DEFINE THE PROCESS that will be represented in the flowchart.
  
 +
2. DETERMINE ALL INDIVIDUALS, DEPARTMENTS, AND GROUPS INVOLVED in the process.
  
'''Tools:'''
+
3. BRAINSTORM THE STEPS in the process. The specific sequence is less important than determining all of the steps at this point (although thinking sequentially may help identify any missing steps).
  
A variety of tools are available to aid in the analysis of clinical workflows. The website of the Agency for Healthcare Research and Quality (AHRQ) contains one repository of tools useful in clinical workflow analysis [[(5)]]. Some of the tools commonly used in clinical workflow analysis and redesign are:
+
4. CONSTRUCT THE FLOWCHART GRAPHICALLY using rows or columns corresponding to the associated work units (e.g., provider, nursing).  
  
1) Benchmarking: the process of evaluating best practices of other organizations. This requires communicating with peers in similar organizations that are seen as successful in the objective being analyzed and determining whether these lessons can be applied to the workflow under consideration [[(6)]].
+
5. ARRANGE THE STEPS SEQUENTIALLY
  
'''Bold text'''
+
6. DRAW ARROWS between steps to show the process flow.  
2) Check Sheet: A structured form for analyzing data about a specific work process or function [[(7)]]. It is useful for documenting observational data about specific tasks in a workflow. Referenced is an example of a workflow assessment checklist provided by AHRQ [[(8)]].
+
  
 +
7. REVIEW THE FLOWCHART and validate its accuracy with other individuals who are actually involved in the process.
  
3) Flowchart or Process Map: Flowcharts visually demonstrate specific steps in a work process arranged in sequential order. This allows understanding of the overall process and where improvement can be made [[(9)]]. Referenced is an example flowchart of a medication prescribing workflow offered by AHRQ [[(10)]].
 
  
 +
'''Advantages of flowcharts:'''
  
 +
• Demonstrates whether the flow of events makes sense and is smooth or if there is a lot of back-and-forth (numerous handoffs) between individuals
 +
 +
• Highlights areas where decisions must be made
 +
 +
• Shows which parts of a process are redundant or out of place
 +
 +
• Identifies who completes each task in addition to what gets done
 +
 +
• Shows areas that can be improved
 +
 +
• Allows staff to clearly visualize their roles
 +
 +
• Easy to learn and create
 +
 +
 +
'''Disadvantages:'''
 +
 +
• Does not show value
 +
 +
• Requires in-depth knowledge of the process
 +
 +
 +
'''Flowchart Example:'''
 +
 +
• Medication reconciliation of original (A) and revised (B) workflows
 +
 +
 +
'''Example Flowchart:'''
 +
 +
https://qualitysafety.bmj.com/content/qhc/20/4/372/F1.large.jpg
  
  
Line 43: Line 78:
  
  
 +
== '''Workflow in the Emergency Department:''' ==
  
 +
 +
'''Barriers to Efficiency:'''
 +
 +
• Overcrowding
 +
 +
• Increasing volumes
 +
 +
• Boarding
 +
 +
• Nurse/tech staffing
 +
 +
• High acuity patients
 +
 +
• Physician multitasking/interruptions
 +
 +
 +
'''Common ED Metrics:'''
 +
 +
• Door to doctor time
 +
 +
• Patient LOS
 +
 +
• Time from admission order to transfer to inpatient ward
 +
 +
• Door to room time
 +
 +
• Time to lab draw/IV placement
 +
 +
• Time from imaging order placed to completion
 +
 +
• Physician patients per hour
 +
 +
• Time from discharge order to patient leaving the ED
 +
 +
• Number of patients who left without being seen
 +
 +
 +
'''Areas of Success in ED Workflows:'''
 +
 +
'''1) Stroke'''
 +
 +
• “Time is brain.” Decreasing time to thrombolytics and reperfusion therapies improve patient outcomes
 +
 +
• EMS stroke activation to mobilize ED and neurology teams
 +
 +
• Physical design and layouts of the ED can optimize stroke care: Resuscitation rooms close to CT scanners
 +
 +
'''2) STEMI'''
 +
 +
• Achieving door to balloon times under 90 minutes is important for STEMI outcomes
 +
 +
• In the field STEMI activation and EKG transmission
 +
 +
• Allowing ED physicians to activate cath labs have improved door to balloon times
 +
 +
 +
'''Ways to Improve Efficiency with ED Imaging:'''
 +
 +
'''1) POCUS''' (point of care US)
 +
 +
• Physicians using POCUS instead of formal US can decreased ED LOS
 +
 +
• One specific study showed that POCUS as a screening tool for intussusception could reduce ED LOS and unnecessary referrals for US
 +
 +
'''2) CT scans'''
 +
 +
• Having a “CT expediter”: Their role is to check imaging protocol, check priority, check NPO status, preg test , renal function, IV placement, contrast allergies, isolation precautions, call for transport and CT availability. Decreased work up time by 35%, decreased LOS by 4%
 +
 +
• Having radiologists prioritize ED reads
 +
 +
 +
'''Ideas for Improving Triage Workflow:'''
 +
 +
'''1) Group triage'''
 +
 +
• Physician and nurses going to new patients together
 +
 +
• Can expedite treatment, initiation of orders, door to doctor time
 +
 +
'''Physician triage'''
 +
 +
• Physicians doing the initial triage evaluation instead of nurses
 +
 +
• Diagnostic tests are entered earlier, expedites treatment, patient LOS is decreased
 +
 +
 +
'''Other Ideas for Improving ED Workflow:'''
 +
 +
• Point of care lab testing
 +
 +
• Mobile computers for efficient physician charting/order entry
 +
 +
• Decreased ED referrals from clinic and increased direct admissions
 +
 +
• Phlebotomists
 +
 +
 
'''References:'''
 
'''References:'''
  
Line 68: Line 201:
 
11) https://www.healthit.gov/sites/default/files/tools/workflow_redesign_templates_v1.pptx
 
11) https://www.healthit.gov/sites/default/files/tools/workflow_redesign_templates_v1.pptx
  
 +
12) Carayon P, Karsh B-T, Cartmill RS, et al. Incorporating Health Information Technology Into Workflow Redesign--Summary Report. (Prepared by the Center for Quality and Productivity Improvement, University of Wisconsin–Madison, under Contract No. HHSA 290-2008-10036C). AHRQ Publication No. 10-0098-EF. Rockville, MD: Agency for Healthcare Research and Quality. October 2010.
  
 +
13) White CM, Schoettker PJ, Conway PH, et al. Utilising improvement science methods to optimize medication reconciliation. BMJ Qual Saf Health Care. Epub 2011 Feb 11; doi: 10.1136/bmjqs.2010.047845
  
 +
14) Burström L, Engström ML, Castrén M, Wiklund T, Enlund M. Improved quality and efficiency after the introduction of physician-led team triage in an emergency department. Ups J Med Sci. 2016;121(1):38-44. doi:10.3109/03009734.2015.1100223.
  
 +
15) Gyftopoulos S, Jamin C, Wu TS, et al. The Use of an Emergency Department Expeditor to Improve Emergency Department CT Workflow: Initial Experiences. J Am Coll Radiol. 2019;16(3):327-332. doi:10.1016/j.jacr.2018.11.003.
  
Submitted by Frank Longano.
+
16) Huded C, Kravitz K, Menon V, et al. Impact of the Cms Algorithm for Door-To-Balloon Time Public Reporting on Door-To-Balloon Time Performance. J Am Coll Cardiol. 2018;71(11):A1161. doi:10.1016/s0735-1097(18)31702-9.
  
 +
17) Iannone P. Ameliorating the emergency department workflow by involving the observation unit: effects on crowding. Emerg Care J. 2015;11(1). doi:10.4081/ecj.2015.4957.
 +
 +
18) Jauch EC, Holmstedt C, Nolte J. Techniques for improving efficiency in the emergency department for patients with acute ischemic stroke. Ann N Y Acad Sci. 2012;1268(1):57-62. doi:10.1111/j.1749-6632.2012.06663.x.
 +
 +
19) Kim JH, Lee J-Y, Kwon JH, Cho H-R, Lee JS, Ryu J-M. Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception. Pediatr Emerg Care. 2017;00(00):1. doi:10.1097/pec.0000000000001283.
 +
 +
20) Lee EK, Atallah HY, Wright MD, et al. Transforming hospital emergency department workflow and patient care. Interfaces (Providence). 2015;45(1):58-82. doi:10.1287/inte.2014.0788.
 +
 +
21) Nguyen M, Louis C, Sahota PK, et al. 90 Improvement of Emergency Department Workflow and Their Effects on Patient Satisfaction. Ann Emerg Med. 2018;72(4):S39. doi:10.1016/j.annemergmed.2018.08.095.
 +
 +
22) Nugus P, Braithwaite J. The dynamic interaction of quality and efficiency in the emergency department: Squaring the circle? Soc Sci Med. 2010;70(4):511-517. doi:10.1016/j.socscimed.2009.11.001.
 +
 +
23) Ozkaynak M, Wu DTY, Hannah K, Dayan PS, Mistry RD. Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program. Appl Clin Inform. 2018;9(2):248-260. doi:10.1055/s-0038-1641594.
 +
 +
24) Slain T, Rickard-Aasen S, Pringle J, et al. An Operational Analysis of Integrating Screening and Brief Intervention into the Normal Workflow of the Emergency Department Without Additional Resources. Ann Emerg Med. 2013;62(4):S101. doi:10.1016/j.annemergmed.2013.07.100.
 +
 +
25) Strear C, Vissers R, Yoder E, Barnett H, Shanks T, Jones L. 30: Applying the Theory of Constraints to Emergency Department Workflow: Reducing Ambulance Diversion Through Basic Business Practice. Ann Emerg Med. 2010;56(3):S11. doi:10.1016/j.annemergmed.2010.06.059.
 +
 +
26) Subash F, Dunn F, McNicholl B, Marlow J. Team triage improves emergency department efficiency. Emerg Med J. 2004;21(5):542-544. doi:10.1136/emj.2002.003665.
 +
 +
27) Building one brown. HVP High Vol Print. 2005;23(2):34-37.
 +
 +
28) Research Forum. Otolaryngol Head Neck Surg. 2000;123(2):P85-P144. doi:10.1016/S0194-5998(00)80031-5.
 +
 +
29) https://www.healthcatalyst.com/success_stories/improve-appendectomy-care-outcomes-using-analytics-in-healthcare
 +
 +
 +
 +
 +
 +
Contributions from
 +
[[User:Msoutzen|Msoutzen]] 07:57, 8 March 2012 (PST)
 +
Submitted by (M. Outzen, MS, OTR/L)
 +
[[Category:BMI512-WINTER-12]]
 +
Submitted by (Frank Longano).
 
[[Category:BMI512-FALL-17]]
 
[[Category:BMI512-FALL-17]]
 +
 +
Submitted by (Lindsey Spiegelman)
 +
[[Category:BMI512-FALL-19]]
 +
Combined these two sections into the: Clinical Workflow Analysis Page
 +
https://clinfowiki.org/wiki/index.php/Clinical_workflow_analysis
 +
https://clinfowiki.org/wiki/index.php?title=Methods_to_capture_workflow&action=edit&section=7
 +
Added first three sentences to paragraph #2
 +
Added in the section: Workflow in the Emergency Department
 +
References: 14-29

Latest revision as of 22:55, 18 October 2019

Clinical Workflow Analysis

Introduction: The term workflow has been variably defined. The Agency for Healthcare Research and Quality (AHRQ), defines workflow as a sequence of cognitive and physical tasks listed chronologically that occur both within and between organizations that are required to accomplish specific work objectives. It can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously. When applied to the clinical setting the above definition generally holds true, with the work objective being a direct or indirect patient care function. For example, the workflow of ordering a medication includes communication between the provider and the patient, the provider's thought process, the physical action by the provider of writing a paper prescription or entering an electronic prescription into an electronic health record and transmitting the order electronically or having the patient take the prescription to the pharmacy to have the prescription filled.

It is important to assess workflow because inefficiencies can negatively influence patient care and outcomes. Evaluating workflows can find deficiencies and areas that would benefit from improvements. In addition, when deciding to implement CDS, it is important to understand where in the workflow alerts should be used to most efficiently affect physicians. Research assessing health IT implementations demonstrates that delays in patient care, billing, and communication are likely to occur if workflow is not taken into account. This is generally due to the fact that clinical and practice management requirements are overlooked or oversimplified. As a form of ongoing process improvement, workflows should be continually assessed.


Tools: A variety of tools are available to aid in the analysis of clinical workflows. The website of the Agency for Healthcare Research and Quality (AHRQ) contains one repository of tools useful in clinical workflow analysis (5). Some of the tools commonly used in clinical workflow analysis and redesign are:


1) Benchmarking: The process of evaluating best practices of other organizations. This requires communicating with peers in similar organizations that are seen as successful in the objective being analyzed and determining whether these lessons can be applied to the workflow under consideration (6).


2) Check Sheet: A structured form for analyzing data about a specific work process or function (7). It is useful for documenting observational data about specific tasks in a workflow. Referenced is an example of a workflow assessment checklist provided by AHRQ (8).


3) Flowchart or Process Map: Flowcharts visually demonstrate specific steps in a work process arranged in sequential order. This allows understanding of the overall process and where improvement can be made (9).


Steps in making a flowchart:

1. DEFINE THE PROCESS that will be represented in the flowchart.

2. DETERMINE ALL INDIVIDUALS, DEPARTMENTS, AND GROUPS INVOLVED in the process.

3. BRAINSTORM THE STEPS in the process. The specific sequence is less important than determining all of the steps at this point (although thinking sequentially may help identify any missing steps).

4. CONSTRUCT THE FLOWCHART GRAPHICALLY using rows or columns corresponding to the associated work units (e.g., provider, nursing).

5. ARRANGE THE STEPS SEQUENTIALLY

6. DRAW ARROWS between steps to show the process flow.

7. REVIEW THE FLOWCHART and validate its accuracy with other individuals who are actually involved in the process.


Advantages of flowcharts:

• Demonstrates whether the flow of events makes sense and is smooth or if there is a lot of back-and-forth (numerous handoffs) between individuals

• Highlights areas where decisions must be made

• Shows which parts of a process are redundant or out of place

• Identifies who completes each task in addition to what gets done

• Shows areas that can be improved

• Allows staff to clearly visualize their roles

• Easy to learn and create


Disadvantages:

• Does not show value

• Requires in-depth knowledge of the process


Flowchart Example:

• Medication reconciliation of original (A) and revised (B) workflows


Example Flowchart:

https://qualitysafety.bmj.com/content/qhc/20/4/372/F1.large.jpg


Example of Clinical Workflow Analysis:

An example of workflow analysis and redesign around implementation of an EHR is offered by ONC (11). This presentation discusses multiple clinical workflows in an outpatient medical practice and provides editable flowcharts for use as templates.


Workflow in the Emergency Department:

Barriers to Efficiency:

• Overcrowding

• Increasing volumes

• Boarding

• Nurse/tech staffing

• High acuity patients

• Physician multitasking/interruptions


Common ED Metrics:

• Door to doctor time

• Patient LOS

• Time from admission order to transfer to inpatient ward

• Door to room time

• Time to lab draw/IV placement

• Time from imaging order placed to completion

• Physician patients per hour

• Time from discharge order to patient leaving the ED

• Number of patients who left without being seen


Areas of Success in ED Workflows:

1) Stroke

• “Time is brain.” Decreasing time to thrombolytics and reperfusion therapies improve patient outcomes

• EMS stroke activation to mobilize ED and neurology teams

• Physical design and layouts of the ED can optimize stroke care: Resuscitation rooms close to CT scanners

2) STEMI

• Achieving door to balloon times under 90 minutes is important for STEMI outcomes

• In the field STEMI activation and EKG transmission

• Allowing ED physicians to activate cath labs have improved door to balloon times


Ways to Improve Efficiency with ED Imaging:

1) POCUS (point of care US)

• Physicians using POCUS instead of formal US can decreased ED LOS

• One specific study showed that POCUS as a screening tool for intussusception could reduce ED LOS and unnecessary referrals for US

2) CT scans

• Having a “CT expediter”: Their role is to check imaging protocol, check priority, check NPO status, preg test , renal function, IV placement, contrast allergies, isolation precautions, call for transport and CT availability. Decreased work up time by 35%, decreased LOS by 4%

• Having radiologists prioritize ED reads


Ideas for Improving Triage Workflow:

1) Group triage

• Physician and nurses going to new patients together

• Can expedite treatment, initiation of orders, door to doctor time

Physician triage

• Physicians doing the initial triage evaluation instead of nurses

• Diagnostic tests are entered earlier, expedites treatment, patient LOS is decreased


Other Ideas for Improving ED Workflow:

• Point of care lab testing

• Mobile computers for efficient physician charting/order entry

• Decreased ED referrals from clinic and increased direct admissions

• Phlebotomists


References:

1) Unertl, K et al. J Am Med Inform Assoc. 2010 May-Jun;17(3):265-73

2) Harrington L. Electronic health record workflow: why more work than flow? AACN Adv Crit Care. 2015 Jan-Mar;26(1):5-9.

3) Bowens FM, Frye PA, Jones WA. Health information technology: integration of clinical workflow into meaningful use of electronic health records. Perspect Health Inf Manag. 2010 Oct 1;7:1d.

4) Sheehan, B and Bakken, s. Approaches to workflow analysis in healthcare settings. Nurs Inform. 2012; 2012: 371

5) https://healthit.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit

6) http://asq.org/learn-about-quality/benchmarking/overview/overview.html

7) http://asq.org/learn-about-quality/data-collection-analysis-tools/overview/check-sheet.html

8) https://healthit.ahrq.gov/sites/default/files/docs/workflowtoolkit/Workflow_Assessment_Checklist.pdf

9) http://asq.org/learn-about-quality/process-analysis-tools/overview/flowchart.html

10) https://healthit.ahrq.gov/sites/default/files/docs/workflowtoolkit/In-officePrescribing-PaperSystem.pdf

11) https://www.healthit.gov/sites/default/files/tools/workflow_redesign_templates_v1.pptx

12) Carayon P, Karsh B-T, Cartmill RS, et al. Incorporating Health Information Technology Into Workflow Redesign--Summary Report. (Prepared by the Center for Quality and Productivity Improvement, University of Wisconsin–Madison, under Contract No. HHSA 290-2008-10036C). AHRQ Publication No. 10-0098-EF. Rockville, MD: Agency for Healthcare Research and Quality. October 2010.

13) White CM, Schoettker PJ, Conway PH, et al. Utilising improvement science methods to optimize medication reconciliation. BMJ Qual Saf Health Care. Epub 2011 Feb 11; doi: 10.1136/bmjqs.2010.047845

14) Burström L, Engström ML, Castrén M, Wiklund T, Enlund M. Improved quality and efficiency after the introduction of physician-led team triage in an emergency department. Ups J Med Sci. 2016;121(1):38-44. doi:10.3109/03009734.2015.1100223.

15) Gyftopoulos S, Jamin C, Wu TS, et al. The Use of an Emergency Department Expeditor to Improve Emergency Department CT Workflow: Initial Experiences. J Am Coll Radiol. 2019;16(3):327-332. doi:10.1016/j.jacr.2018.11.003.

16) Huded C, Kravitz K, Menon V, et al. Impact of the Cms Algorithm for Door-To-Balloon Time Public Reporting on Door-To-Balloon Time Performance. J Am Coll Cardiol. 2018;71(11):A1161. doi:10.1016/s0735-1097(18)31702-9.

17) Iannone P. Ameliorating the emergency department workflow by involving the observation unit: effects on crowding. Emerg Care J. 2015;11(1). doi:10.4081/ecj.2015.4957.

18) Jauch EC, Holmstedt C, Nolte J. Techniques for improving efficiency in the emergency department for patients with acute ischemic stroke. Ann N Y Acad Sci. 2012;1268(1):57-62. doi:10.1111/j.1749-6632.2012.06663.x.

19) Kim JH, Lee J-Y, Kwon JH, Cho H-R, Lee JS, Ryu J-M. Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception. Pediatr Emerg Care. 2017;00(00):1. doi:10.1097/pec.0000000000001283.

20) Lee EK, Atallah HY, Wright MD, et al. Transforming hospital emergency department workflow and patient care. Interfaces (Providence). 2015;45(1):58-82. doi:10.1287/inte.2014.0788.

21) Nguyen M, Louis C, Sahota PK, et al. 90 Improvement of Emergency Department Workflow and Their Effects on Patient Satisfaction. Ann Emerg Med. 2018;72(4):S39. doi:10.1016/j.annemergmed.2018.08.095.

22) Nugus P, Braithwaite J. The dynamic interaction of quality and efficiency in the emergency department: Squaring the circle? Soc Sci Med. 2010;70(4):511-517. doi:10.1016/j.socscimed.2009.11.001.

23) Ozkaynak M, Wu DTY, Hannah K, Dayan PS, Mistry RD. Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program. Appl Clin Inform. 2018;9(2):248-260. doi:10.1055/s-0038-1641594.

24) Slain T, Rickard-Aasen S, Pringle J, et al. An Operational Analysis of Integrating Screening and Brief Intervention into the Normal Workflow of the Emergency Department Without Additional Resources. Ann Emerg Med. 2013;62(4):S101. doi:10.1016/j.annemergmed.2013.07.100.

25) Strear C, Vissers R, Yoder E, Barnett H, Shanks T, Jones L. 30: Applying the Theory of Constraints to Emergency Department Workflow: Reducing Ambulance Diversion Through Basic Business Practice. Ann Emerg Med. 2010;56(3):S11. doi:10.1016/j.annemergmed.2010.06.059.

26) Subash F, Dunn F, McNicholl B, Marlow J. Team triage improves emergency department efficiency. Emerg Med J. 2004;21(5):542-544. doi:10.1136/emj.2002.003665.

27) Building one brown. HVP High Vol Print. 2005;23(2):34-37.

28) Research Forum. Otolaryngol Head Neck Surg. 2000;123(2):P85-P144. doi:10.1016/S0194-5998(00)80031-5.

29) https://www.healthcatalyst.com/success_stories/improve-appendectomy-care-outcomes-using-analytics-in-healthcare



Contributions from Msoutzen 07:57, 8 March 2012 (PST) Submitted by (M. Outzen, MS, OTR/L) Submitted by (Frank Longano).

Submitted by (Lindsey Spiegelman) Combined these two sections into the: Clinical Workflow Analysis Page https://clinfowiki.org/wiki/index.php/Clinical_workflow_analysis https://clinfowiki.org/wiki/index.php?title=Methods_to_capture_workflow&action=edit&section=7 Added first three sentences to paragraph #2 Added in the section: Workflow in the Emergency Department References: 14-29