Workflow, loosely defined, is the set of tasks—grouped chronologically into processes—and the set of people or resources needed for those tasks, that are necessary to accomplish a given goal. An organization’s workflow is comprised of the set of processes it needs to accomplish, the set of people or other resources available to perform those processes, and the interactions among them. Consider the following scenario:
These same methods that an organization uses to get work done, however, can begin to show stress under trying circumstances. When the ward is full and it takes 12 hours for a room to be readied for the next patient, that impact is felt throughout the organization. When the number of small interruptions outweighs the amount of planned work done in a given hour, that impact is felt in slower progress, lower job satisfaction, and potentially lower quality of care. In many situations, it is very clear to all what needs to get done. Where organizations differ is in how they do it. The examination of how an organization accomplishes its tasks often concerns the organizations’ workflow. In health care, as in other industries, some workflows are designed, while others arise organically and evolve. The systems and methods by which organizations accomplish specific goals differ dramatically. Some organizational workflows seem more straightforward than others. Most often, when workflow processes are looked at in isolation, the processes appear quite logical (and even efficient) in acting to accomplish the end goal. It is in the interaction among the processes that complexities arise. Some of these interactions hide conflicts in the priorities of different roles in an organization, for example, what the nursing team is accountable to versus the physician team and its schedule. Organizations also adapt workflows to suit the evolving environment. Over time, reflecting on organizational workflows may show that some processes are no longer necessary, or can be updated and optimized. Health care has often faced the pressure to design, or redesign, its workflows to be more efficient and effective. In many cases, the trigger for examining workflow is in response to changes in how things are done. Today, the need to think about workflow design is more pressing due to several factors, including:
One important reason that workflow is of pressing concern for today’s clinicians is the introduction of new health care information technology (health IT) into clinical practice. Health IT promises many benefits for improving quality and efficiency. However, the introduction of health IT can be very disruptive to existing workflows in an organization. Health IT systems often implicitly assume a workflow structure in the way their screens and steps are organized. Organizations that are thoughtful about workflow design are more likely to be successful in adapting to health IT.1 In contrast to industries such as manufacturing, health care is a service industry that relies heavily on good information. In closely following and taking care of patients, nurses are guardians of a rich source of information. This valuable information can be lost when poor workflows impede communication and coordination or increase interruptions.2 Characteristics of a poorly functioning work process include unnecessary pauses and rework, delays, established workarounds, gaps where steps are often omitted, and a process that participants feel is illogical. The design of good organizational workflow is not simply about improving efficiency. Workflow processes are maps that direct the care team how to accomplish a goal. A good workflow will help accomplish those goals in a timely manner, leading to care that is delivered more consistently, reliably, safely, and in compliance with standards of practice. An excellent workflow process can accommodate variations that inevitably arise in health care through interaction with other workflow processes, as well as environmental factors such as workload, staff schedules, and patient load. Health services researchers have explored workflow issues from several angles, including mapping processes from other industries into health care. Literature about workflow can be found in several different domains, such as quality improvement, technology implementation, and process improvements. One common thread throughout the literature is the importance of interdisciplinary involvement in all aspects of workflow analysis and implementation. Reviewing the evidence to date, targeted studies of particular interventions and technologies amply show that good workflow design has significant (expected and unexpected) impacts on care delivery.3 The literature also demonstrates a relative lack of sophistication in studies of the field: whether researchers are initially concerned with the problem or whether it arises organically from the results; whether the researchers have a theoretical framework to interpret their findings; whether there is consistency in the outcomes of interest; whether the target(s) of study are structural, cultural, and/or functional; and whether the researchers are able to generalize from the findings in one setting to another. Many studies demonstrated significant benefit from careful consideration of workflow, but few studies provided easily adaptable tools and methods for immediate, consistent implementation. Workflow analysis has often been used with the goal of improving efficiency. In response to financial pressure and incentives driving provider organizations, minimizing slack time has become important. Some of the studies discussed below demonstrated the power of analyzing and changing workflow to improve efficiency. Workflow analysis can be used to redesign existing processes. A classic study of this type is Cendan and Good's4 analysis of the routine tasks of the various members of the operating room (OR) team. They found that there was a wide variability in functions based on clinical and organizational factors. They designed a new workflow based on the analysis and conducted a pilot study. Part of their recommended solution involved defining functions in a more consistent fashion. They were able to improve turnover and improve the mean number of cases handled in a day. A significant factor in their success was their consideration of workflow from both the physician and the nursing perspectives. Efficiency can also be improved by carrying out processes in parallel, rather than improving the efficiency of existing steps.5 Friedman and colleagues6 compared the impact of administering anesthesia in the induction room versus in the OR for hernia repair patients. They found that the OR time used by the surgeon decreased without significant impacts on patient satisfaction or outcomes.6 Harders and colleagues7 employed a combination of approaches. They used parallel processing and process redesign to improve workflow in a tertiary care center with multiple OR suites. This combination of approaches allowed for a reduction in nonoperative time. Similarly, in a study of trauma teams, Driscoll and Vincent8 modified task allocation so that standard tasks performed during a trauma code were conducted in parallel rather than sequentially. In each of these approaches, role definition played a critical role in the success of the efforts. Each study found that nursing routines often included nonclinical tasks, such as tracking down missing information or supplies.9 By defining roles and essential processes, it was possible to use ancillary staff for these tasks. In order for the redesign to be successful, nursing involvement was important from the beginning. An interdisciplinary approach provided the basis for the workflow analysis and redesign; this was cited as a success factor in multiple studies.4, 6, 7 Workflow issues often arise in studies of technology. One well-studied domain area is barcode medication administration (BCMA).10 BCMA is a technology that has been shown to improve care quality by reducing reliance on memory, increasing access to information, and increasing compliance with best practice. However, very simple inconveniences—such as the need to access a patients’ wrist for the barcode strip—have led to workflow workarounds, such as scanning barcodes off a key ring rather than the patient. In this case, the nurses’ adaptation to make their work more efficient circumvents some of the intended benefits of the defined process. More complex interactions have also been observed. Because many BCMA systems require that the physician enter an order before the nurse can have access to the medication, some nurses have, in critical situations, “borrowed” medication from one patient on the ward to give to another until the medication for the second patient appears in the system. As a result, the nurse cannot readily document the administration of the order until the order has been entered by the physician. In some situations, a shadow system of informal paper documentation supplements, duplicates, or confuses the documentation captured in an electronic system. When technology does not adequately support the goals of the care team, it often causes workaround workflows. These alternate workflows are a cause for concern because these informal, evolutionary systems rely on the clinicians’ memories, and bypass decision-support safeguards that the system may provide. Studies have documented other negative effects,11 such as degraded coordination between nurses and physicians, nurses dropping activities during busy periods, and decreased ability to deviate from routine sequences. Health care organizations provide valuable services that rely on large amounts of high quality information. Information transfer is complicated because caring for one patient can involve many providers and information sources. Thus, many errors occur at handoff or transition points.12 Dykes and colleagues13 found that many hospitals in the United States have dual paper and electronic records, leading to redundancies and inefficiencies in information. Other information tools include proprietary paper forms, the phone, the electronic record system, the whiteboard, the pager, and schedules.14 In addition, informal meetings and verbal orders frequently also serve as information transfer devices.15 One attempt to address this complexity is an electronic portal that provides access to systems through one interface.16 Though this can mitigate the problem, it cannot fully address the communication needs of a care team. A common class of problems with information transfer and handoffs includes degradation of information.17 If methods of transfer are informal and not documented, patient information may not be passed on when staff members leave a unit. In addition, the lines of responsibility and expectations are not always clear.17 Incorporating formalized information transfer tools and protocols into workflow processes may help. Another problem complicating information transfer is interruptions. These interruptions often cause a break in workflow, which can impact what information is documented and passed on.18, 19 Nursing work is often fragmented and rushed, due to external pressures and the dynamic environement.20 However, nurses serve as critical integrators and coordinators of care. Health IT tools, which can help nurses better manage and transfer information and make the information more widely available have the potential to improve practice.21 Intraprofessional handoffs may occur within or across departments. In either case, communication and coordination is improved by having a structured documentation format.22 Lamond23 reviewed the content of nursing intershift reports and found that more information was documented in the patient notes than was given in the report. The report information tended to be more overall assessments of patient care, which was not necessarily documented. Thus, it is not clear if the detailed information was transferred in subsequent reports. Perrott24 found that customizing data fields and having nurses involved from the beginning enhanced nursing handoffs in the intensive care unit (ICU). By understanding nursing workflow, barriers and facilitators for information transfer can be discussed and improved upon.25 If handoff mechanisms are informal, then they might not be documented in a workflow analysis.26 Health IT systems should not replace these handoffs, but could be used to augment the process.27 However, when the processes are not well understood, the technology may not be used and may even be a burden. Inconsistent or incomplete information during patient care transfers is a commonly cited communication difficulty.28 This problem is exacerbated by systems and processes with duplicate or outdated information. There is a great deal of information available, but it is not always available in a streamlined or organized fashion.29 Clinical providers trained in different disciplines are socialized and trained differently, so they do not necessarily know what the others need.29 Thus, when designing and implementing information technology across departments, it is important to have an interdisciplinary team involved throughout the process.22 Physicians and nurses do not generally have the same employer and often have varying loyalties and end goals.4 Thus, it is important to consider many perspectives when designing handoff and communication practices. One way to look at interprofessional collaboration is to look at information needs. Reddy and colleagues30 reviewed information needs of various providers in the ICU. They found that some roles, including nurses, served as information sources for other providers. Thus, it is important to consider the workflow implications of changing information sources. When a face-to-face communication with a nurse is replaced by an electronic report, what is lost and gained? Electronic access provides the benefits of ready access to large quantities of source data, potentially supplemented with decision support. What may be lost are functions of information synthesis, summarization, and coordination. In a survey of chief nursing officers, Dykes and colleagues13 emphasized the role of nurses as coordinators and communicators. Riley and Manias31 looked at physician–nurse communication in an OR setting. They found that nurses often had informal knowledge of physicians and their habits, which they used to control practices. This knowledge was not necessarily codified formally, so new nurses would have difficulty in estimating workflow. Health care organizations have engaged in efforts to standardize inter-professional communication, for example through requiring the use of SBAR for situational briefing.32 It is not always necessary to have a separate process for interprofessional communication. Indeed, other efforts can be repurposed for interprofessional communication. For example, Cunliffe33 described a nursing discharge summary process which was repurposed to provide a nurse–general practitioner communication device. A nursing discharge summary provided detailed information about nursing and social care for the patient after they left the hospital. In addition, sending this to the general practitioner (GP) provided a mechanism for communication so that the GP would be well-informed about the patient’s care. Similarly, a resident sign-out system could also be accessed by other professionals.34 However, communication lines tend to be separate and dependent on professionals, so it is not clear how much intraprofessional access occurs. Patterson and colleagues35 studied handoff strategies in other industries and outlined some common strategies for effective handoffs. Often, documentation was a supplement to the handoff, rather than the sole mechanism for information transfer. Health IT, used well, can improve efficiency and organizational workflow. In health care, redundant information is often created and stored. As a result, care providers spend a great deal of time reconciling information from various sources. Integrating health IT with the workflow of various departments can help to reduce this redundancy.22 However, if workflow is not considered and the technology is not thoughtfully implemented, the benefits cannot truly be achieved. To use technology most effectively, its potential impact to transform care delivery must be realized.36 While it is important to consider workflow when implementing health IT, it does not mean that health IT should leave processes intact. Health IT can bring about positive process change and better workflow. Because IT can consolidate and display information, it can be used as an opportunity to improve upon teamwork and communications.37 Understanding existing clinical workflow prior to implementation provides a baseline to redesign systems and develop better processes.38 Scharmhorst, Johnson, and Li39 emphasized the importance of understanding the system prior to implementing technology, to ensure that technology streamlines nursing workflow, rather than making it more complicated. In a study of mobile cabinets with barcode scanning for medications, Braswell and Duggar40 found that, by analyzing workflow ahead of time, both pharmacy and nursing staff reported improvements to existing work processes after implementation. Workflow concerns can lead to failure to adopt new technologies. A study of electronic prescribing systems standards finds that many of the electronic standards are adequate but provider adoption is low because the systems do not fit into workflow.41 The evaluators recommend that the standards and systems be revised to accommodate the large role of nurses in electronic prescribing in the office setting. Computerized Provider Order Entry (CPOE) is an easily measurable, frequently implemented, and often intrusive instance of health IT, and has been studied often in the literature. CPOE is commonly associated with its impact on physician practice. However, there are workflow implications in CPOE implementation for the entire care team, including physicians and nurses.42 For example, if physicians refuse to use the CPOE system, it creates adverse impacts on nursing workflow.3, 28 Sometimes, nurses become the de facto order entry personnel, in addition to their nursing duties. These workarounds also have effects downstream. Delays in order entry can hold up medication delivery. The introduction of CPOE technology may surface informal practices that may not be in compliance with prescribing scopes of practice. Thus, nurses are a key success factor in CPOE implementation.43 Because nurses often are primarily responsible for communication and coordination of care, understanding nursing workflows with respect to order entry is critical.44 Payne45 found that implementing CPOE had a profound impact on work patterns, communication methods and roles. In analyzing workflow around electronic prescribing, the range of tasks completed by the nonprescribers was outlined.46 After outlining the work processes and information flows, they were able to adapt the system to accommodate the necessary tasks. Similarly, Wright and colleagues47 found that physician-nurse communications were impacted by the CPOE implementation. Paper-based order entry often relies on visual cues, such as a folded piece of paper. If the loss of context and visual cues is not accounted for in the CPOE implementation, then the nursing workflow is adversely impacted because of the uncertainty around orders. Piasecki and colleagues48 conducted a workflow analysis to look at the benefits of implementing CPOE in an emergency department setting. These researchers developed a return-on-investment tool to measure the outcomes of the implementation and found that many of the savings did not make a direct impact on the bottom line of the organization. This was, in part, because the changes in workflow were not fully understood until after implementation. Though guidelines for analyzing workflow are few, the common factor was consideration of all affected roles in the organization, not only those involved with entering data into the IT system. Breslin and colleagues49 found that having an interdisciplinary team was important in the success of a Vocera implementation. This team included clinical and nonclinical staff. By being inclusive, they learned about workflow from a variety of perspectives and were able to implement their tool in a fashion that would improve upon existing practices. Research into the workflows of nurses has long roots in studies of how nurses spend their time and how nursing teams should be staffed.50–52 Nurse researchers embarking on observational research of nursing work can take advantage of previously developed tools for work task analysis and time motion study.53–55 With the introduction of new technologies, the research frontier includes studies of how nursing work is affected, with the aim of ensuring quality time at the bedside. An ongoing large multi-site time-motion study of nurse workflow56 includes the involvement of frontline nurses in the design and improvement of their work spaces and technologies. It represents one way that lessons learned from past research can be brought to bear on future workflow design, with the intent of mitigating the pain of learning workflow and technology weaknesses through implemented experience. The research findings for these studies of operational workflows have practice implications for nurses and researchers. Throughout the literature, the importance of bringing multiple parties to the table was emphasized. Because organizational workflows often cross the lines of professional disciplines, workflow design from any single perspective runs the risk of suboptimizing against other constraints, priorities, and schedules. Conscious workflow design has been shown to improve the efficiency of existing work processes or enable parallelization of work. In designing such systems, researchers emphasize the importance of clearly defining roles and responsibilities, preferably with multi-disciplinary input. Designing workflow is of critical importance to all roles in a health care organization, because the effects of decisions by an expert in one role may have downstream effects on others. A workflow optimized to serve one role, such as the nurse, can be onerous or seem irrational to another. Because each professional role deals with fairly complex, role-specific work processes, it is often difficult for experts in one role to understand and envision how proposals will affect other roles, even with the best intentions. Research on information transfer in organizational settings demonstrates that adaptations to poor workflows can lead to increased interruptions, workarounds, and informal or ill-defined communication. To improve the reliability of workflows accomplishing their desired goals, and to reduce the risk to patient safety, researchers recommend structured communications and clear agreements about roles and responsibilities in a hand-off. Health IT systems surface many of the long-standing issues around workflow. The implementation of health IT systems can, at first glance, seem like a superficial intrusion into the way things are done. For some, it feels like the addition of another documentation step in the process of regular clinical care. This step can be disruptive and a burden, but it does not dramatically change the way work is done. Yet there are many downstream effects on communication and coordination within an organization. Analyzing workflow beforehand can help prevent some of these unintended consequences. Technology does not necessarily improve institutional efficiencies, but can bring opportunities for improvement to light.42 Sittig and colleagues38 found that while considering that technology was important, it was also important to consider organizational and workflow factors prior to implementation, or the benefits may not be realized. In order to realize good outcomes, interdisciplinary consideration of process and technology factors was important.57 In many organizations, the adoption of health IT is motivated by the desire to accomplish goals that are difficult without a structured electronic system. These goals include reducing medication errors through barcoding; improving clinical decisionmaking through decision support, such as alerts and reminders; measuring clinical quality performance; proactively reaching out to patients for population health management; or simply the ability to analyze clinical information, for example, by charting a patients’ blood pressure based on nursing notes. These additional expectations of a health IT system mean that the organization can expect dramatic changes in workflow—the health IT implementation is a vehicle to trigger larger improvement activities. It is important to realize that health IT systems have a built-in sense of how things are done, in fact, have an inherent workflow that may or may not map to the organizations’ workflow. Consider the case of CPOE. Let’s describe the workflow process as a series of tasks, linked chronologically, that require organizational resources. The logical model within a health IT system usually goes something like this:
There are two things to note about this perfectly reasonable assumption about how things are done. The first is that the workflow is very linear. It will be very important to understand what happens if that linearity is disrupted somehow. For example, if the pharmacist fails to verify the order, will the system prevent the order from being “released” until this step is accomplished? Flexibility within a linear workflow is very important to the smooth operation of a complex service organization like a health care institution. Practitioners have a responsibility to check that a health IT system reacts gracefully to a change in workflow, lest patient care be compromised. The second thing to note is that the workflow within the system only reflects one of the ways health care is delivered in an organization. In many critical care settings, for example, medications must be administered quickly, before any interaction with a CPOE system. Practitioners should also ask whether the health IT systems they are implementing reflect all of the main workflow processes within their organization. When a new health IT system or a new technology fails to accommodate the real workflows of an organization, interacting with the technology becomes a greater burden on the organization than is required. In essence, there is “the way the world works” and then “the way the computer thinks the world works,” and it is the constant responsibility of system users to reconcile the two world views. In fact, implementing health IT systems within organizations poses such a challenge that the Office of the National Coordinator for Health IT has estimated that as many as 30 percent of all implementations fail.58 Thoughtfully constructing the workflow inherent to the technology can smooth technology acceptance.59, 60 Before implementing information technology in a health care environment, it is important to have an understanding of processes and information flows. In addition, it is important to consider various roles in the different departments, and to consider ideas from multiple sources.22 Each department and role may have a different perspective of the encounter and its necessary elements.36, 61 In addition, many organizations have a variety of tacit assumptions and information exchanges which might not be documented in a traditional analysis. Thus, it is important to consider multiple sources of data in order to develop a more complete understanding of workflow and processes.36 In the United States, hospitals are generally organized by functions. Because of that, workflow is also organized around these functions. Information systems were developed around these functions and were designed to meet the needs of a particular department. However, patient care takes place through a broader perspective. Thus, these functions need to be integrated.20 In conducting a workflow assessment, it is important to consider how workflow currently functions and how it might change to improve patient care and reduce errors throughout the system.20, 62 In addition, this kind of analysis can help find flaws in the process for which information technology can be leveraged.20 The truth is that many care teams do well even when workflow processes are designed poorly. Health care practitioners understand the clinical needs of patients. Health care workers often go to heroic lengths to make sure that the right thing gets done. When a problem arises, most clinicians would not hesitate to pick up the phone, run the errand, or do what is necessary to insure good care. Yet clinician resources are not unlimited. When nurses, like all people, get tired, they may become forgetful When they are rushed, they may not remember to do everything necessary.63 These issues may be exacerbated by a health IT system that seems not to understand what the clinicians want to do—sometimes because the workflows in the health IT system do not match those in the real organization. In the seminal work on clinical error, the health care community acknowledged that most errors are the result of systematic deficiencies.64 Good workflow processes are an aid to practitioners to insure that the system behaves to support high quality care. Nurse informaticists can work with their counterparts to apply some of the principles found in the literature to practice. Workflow design is a difficult endeavor because of the complexity of most health care organizations and the division of labor into expert roles. Health care organizations are service organizations that are very flexible and interdependent in response to dynamic patient needs. For many work processes, the established workflow evolved over time in response to the kind of tasks and resources available, and were not explicitly considered or designed. Changes to organizational workflow are an opportunity to think through how the care team can provide good patient care reliably under a variety of circumstances. Research on workflow issues can be very rewarding because of its closeness to real-world operational challenges. Study participants often experience a high level of frustration with their current situation, and are eager to have assistance in thinking through complex organizational effects. The research often starts with a theoretical model that helps define the problem space, such as conceptualizing the structure, process, and outcomes65 or the tasks, actors, and information.66 The model can be made operational through computer modeling, and used to represent particular problems. In support of workflow design activities, computer simulation tools have been developed to help decisionmakers map their organizational roles and understand the impact of different workflow choices.67–69 Models of workflow processes show the trajectories of the care providers, patients, and information. By representing workflow in a manner which is easily accessible to others, managers and researchers can identify where issues are likely to arise and develop tools to prevent them. Modeling workflow also usefully defines roles and delineates how the care team understands its job functions and work processes For health IT, workflow design is especially difficult because many of the assumptions about workflow are implicit. The designers of IT systems benefit from conversations with their users to understand how clinical care is provided in the organization. Without the input of users, it is tempting to apply the same workflows to different organizations. Many issues can be easily resolved through small changes in user interface or clinical decision support rules—changes that are very difficult to predict in advance. Although some issues can be resolved through customizing the health IT system, others are more intractable. The health IT system may simply reveal latent problems with the old workflow. As more organizations embark on large-scale health IT implementations, a scalable method for incorporating workflow considerations is urgently needed, so that new health IT systems do not cause harm.70 When issues have been surfaced, through conversations, observation, modeling, and other methods, researchers have the opportunity to bring to bear established quality improvement methods to workflow design. Studies to date have relied on ad-hoc methods to effect improvement after studying workflow, and there are opportunities to apply structured methods to assist an organization in responding to workflow discoveries. Many of the research articles reviewed involved a descriptive case study. Some studies utilized a grounded theory approach. Few articles utilized a conceptual framework to frame the results. While research on service organizations has been applied to health care organizations, much work remains to be done in delineating how health care work differs from other industries, in particular to understand whether results from inquiries in other fields, such as manufacturing, can be generalized to health care. In addition, there is a need for research to demonstrate a link between performance indicators and workflow.71 Nurse researchers have an opportunity to take the research that has been done to date and apply it on a broader scale. Much of the work that has been done outlines specific implementation efforts or describes a single department. By taking a systems approach to organizational workflow, coordination of patient care throughout the trajectory of their stay can be improved. The search for workflow issues in delivering high quality nursing care is complicated because workflow, by its nature, touches on many organizational issues and roles. Literature that identifies specific problems in patient safety may allude to their greater systemic workflow causes or effects. Even literature that specifically considers workflow may limit the analysis to one organizational role. Thus, our literature search did not attempt to be a comprehensive search of literature published on workflow, but rather a scan of areas in the medical and nursing literature where relevant publications are likely to appear. There is also a longer history of research literature in other fields, notably industrial engineering and management. We looked at MEDLINE® and CINAHL® articles published in English. Because workflow is not a standardized term in either database, we searched it as a keyword in its various permutations. We did the same with handoffs, as we knew that this was a common study topic where workflow issues surface. In addition, we did searches using combinations of related terms in each database. The terms we used were in categories dealing with continuity of care, care teams, information needs, information systems, and patient safety. We found that the keyword search yielded more consistent information than the standardized terms, in part because the terms were developed with specific purposes in mind. Studies of workflow are still fairly new, and it is hoped that as the field matures, it will be easier to identify a unique body of work. |
Which step should be done first when implementing a workflow redesign
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