Clinical workflow analysis
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
• Does not show value
• Requires in-depth knowledge of the process
• Medication reconciliation of original (A) and revised (B) workflows
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:
• Increasing volumes
• 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:
• “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
• 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
• 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
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
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.
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§ion=7 Added first three sentences to paragraph #2 Added in the section: Workflow in the Emergency Department References: 14-28