Methods to capture workflow
In the process of implementing any new systems in the hospital, it is imperative to do workflow studies to determine the “as-is” (current state) and the “to-be” (future state) work processes of the healthcare providers.
Two methods commonly used by project teams to capture the workflows are the time-motion study and the work sampling study. Additional methods include qualitative questionnaires and quantitative measures to track movement. Since neither of these methods can provide a complete illustration on their own, using a combination of approaches can provide the most comprehensive information for workflow assessment.[5,6]
Time motion study
Time motion study basically means the study of what a person is doing and how long it takes to do it. It involves the investigator to follow the subject and record the temporal aspects of events (e.g. tasks) under evaluation. This method is also known as the stop ]watch method and is currently considered as the gold standard in performing a workflow study. It gives detailed description of the workflow processes of the healthcare provider. However, it is tedious and labor intensive and hence is more costly as well. The investigator has to keep up and follow the subject studied for long periods of time as well as capture as accurate as possible the time it takes to perform the action.
In an article by Zheng et al. , the authors used a time motion study to create a checklist called STAMP (Suggested Time and Motion Procedures). Through their observations they were able to make some determinations regarding the time and movement of their study group, but also encountered the issue that healthcare does contain many unpredictable actions and therefore certain actions could not be accurately analyzed.
Work sampling on the other hand is counting how many times the action is done by the subject observed in a fixed time. For example, how many times the physician looks to the computer screen during a 10 minutes consultation. This method can be directly observed, or the person him/herself can keep a log of it. This workflow capturing method can be non-reliable, especially if the subject has to log in the data. Also this method may not be feasible if the person has to constantly travel from one place to another, as the investigator will then have to keep following up with him/her. However,work sampling does not introduce as much bias as time-motion studies, as the investigator does not shadow the subject as much. As data from work-sampling studies are usually extrapolated, a larger sample size is required to get better data representation.
Interviews and Surveys
Interviewing and surveying vital players in a workplace system can also provide fundamental information useful to construct workflows. The subjects are either interviewed on a series of questions about their workflow or subjects are required to fill out surveys detailing their workflows.
Costa et al.  found that one engineering firm created a process for their user interface designers to collect information on the workflows of their clients. This method, the User Behavior and Analysis Modeling (UBAM) process, included inquiring their clients on the environment of the workplace, the user, the tasks performed, the data accessed, and the functions needed to support their tasks. In addition, three types of collection practices were observed among these designers. Fast designers used simple drawings that were only meaningful to the designers themselves. Formal designers used clear and organized displays of their work, which was understood by both the designers and their clients. Finally, beautiful designers used “…visually appealing…”  graphics to present workflows that were also comprehensible by both designers and clients.
However, there are limitations to this method. It only provides information from one point of view at any given time. Although this could be solved with more investigators collecting samples at one time, too many observers can lead to disruptions in the workflow.
Automatic Movement Tracking
Automatic movement tracking utilizes portable devices that are attached to their subjects. The subjects’ movement throughout their workday is monitored. By identifying and tagging certain work stations before the tracking process, an investigator can deduce the type of work being done at time intervals preset in the devices. This method is most similar to a time motion study, yet it allows for the investigator to monitor the time and movement of multiple subjects at one time. The also reduces the cost of having more investigators. The investigator is only limited by the number of devices, and the operability of these devices.
Once the information is compiled, it can be combined with the data collected using the other methods discussed above. This comprehensive approach can be used to create a 3-D or virtual model of the workflow. Regardless of what method is used, a detailed mapping of the workflow is needed to ensure success in the reaching the goals of the change in process.
- A comparison of time-and-motion and self-reporting methods of work measurement. Burke TA, McKee JR, Wilson HC, Donahue RM, Batenhorst AS, Pathak DS. J Nurs Adm. 2000 Mar;30(3):118-2
- Modeling Clinical Trials Workflow in Community Practice Settings Sharib A. Khan, MBBS MA,1 Philip R.O. Payne, MPhil,1 Stephen B. Johnson, PhD,1 J. Thomas Bigger, MD,2 and Rita Kukafka, DrPH, MA1,3 AMIA Annu Symp Proc. 2006; 2006: 419–423.
- A Comparison of Work-Sampling and Time-and-Motion Techniques for Studies in Health Services Research .Steven A. Finkler, James R. Knickman, Gerry Hendrickson, Mack Lipkin, Jr., and Warren G. Thompson.. Health Serv Res. 1993 December; 28(5): 577–597.
- Using the time and motion method to study clinical work processes and workflow: methodological inconsistencies and a call for standardized research. Kai Zheng, Michael Guo, David Hanauer. J Am Med Inform Assoc. 2011 September; 18(5): 704–710.
- Toward automated workflow analysis and visualization in clinical environments. Mithra Vankipuram, Kanav Kahol, Trevor Cohen, Vimla L. Patel. J Biomed Inform. 2011 Jun;44(3):442-440.
- Fast, Formal, & Beautiful: Effectively Capture, Document, and Communicate User Workflow Information for Designing Complex Healthcare Software Systems. Jean M. R. Costa, Xianjun Sam Zheng, Roberto S. Silva Filho, Xiping Song. Proceedings of the Human Factors and Ergonomics Society Annual Meeting. 2012 Sep;56(1):526-530.
Submitted by Jo Nie Sua
Submitted by Cody Schindeldecker
References 5 and 6: Submitted by Jessica S. Pierre
Workflow, as defined by the Agency for Healthcare Research and Quality (AHRQ), is the sequence of physical and mental tasks performed by various people within and between work environments. It can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously. 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 anytime a change is made to the clinical practice, such as implementing an EHR, the workflow associated with clinical and practice management processes will change. 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. Workflow information should be collected as early as possible, and preferably before implementing a health IT system. As a form of ongoing process improvement, workflows should continue to be assessed after EHR deployment.
One of the best ways to assess workflow is through flowcharts. Flowcharts visually convey the steps in a process, are easy to use, and require little or no training to complete.
- Examine the handoffs that occur in a process
- Demonstrate current processes and identify areas for improvement
- Identify individuals, groups, or entire departments that are responsible for processes or tasks
- Show the steps in a process
- Find one or multiple sources of a problem
Steps in making a flowchart:
- DEFINE THE PROCESS that will be represented in the flowchart.
- DETERMINE ALL INDIVIDUALS, DEPARTMENTS, AND GROUPS INVOLVED in the process.
- 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).
- CONSTRUCT THE FLOWCHART GRAPHICALLY using rows or columns corresponding to the associated work units (e.g., provider, nursing).
- ARRANGE THE STEPS SEQUENTIALLY
- DRAW ARROWS between steps to show the process flow.
- 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
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.
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
--Msoutzen 07:57, 8 March 2012 (PST) Submitted by (M. Outzen, MS, OTR/L)