Assessing and improving healthcare workflow.

Healthcare delivery workflow is said to have a domino effect on a health system. An optimal workflow could help improve patient outcomes and ensure continuity of care. Flaws in the process, however, might result in a negative patient experience or a failure of care. With labor challenges and increasing emphasis on measuring patient outcomes as well as managing costs, healthcare providers may want to optimize their healthcare workflow by assessing, measuring, and then implementing a new workflow. Overall, optimizing even small changes could have a positive impact on clinical staff and patients, both in specialties like cardiology and across primary care pathways. 

JUMP TO A TOPIC:

• Potential impact.
• Clinical workflows.
• Assessing workflows.
• RFID analytics framework.
• Implementing changes.
• Measuring success.

Defined as “the sequence of steps associated with delivering healthcare” by the Textbook of patient safety and clinical risk management,¹  workflow “can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously.”²  Michela Tanzini et al. explained workflow this way: “Clinical workflow is .  .  .  the who, what, when, where, for how long, and in what order, for each healthcare task.”³

Accordingly, workflow optimization could potentially help to improve the standard of patient care and accelerate patient flow and treatment by streamlining the use of resources. It could also help to lessen medical errors and decrease hospital readmissions, while also providing a higher touch of care to patients who may need medical intervention sooner. 

Potential impact.

For example, Zheng et al. say, due to “concerns about burnout and clinical inefficiencies that result from suboptimal workflow, there is an urgent need to continue to devote effort and attention to studying and improving clinical workflow in the EHR [electronic health record] context.”⁴

As such, workflows would ideally be interconnected because patients access health systems at different points of entry — i.e., primary care, cardiology, emergency department, etc. — and an interconnected workflow is likely to help ensure patients receive the optimal care at each point of entry. 

EHR integration might be an additional step to help automate the workflow process. Meaning, manual and repetitive tasks would be performed digitally. Additionally, “EHR could help to simplify and automate redundant workflow processes,” said Elizabeth Overstreet, senior manager of customer experience at iRhythm Technologies. This potentially decreases the likelihood of human error and might also lessen administrative burden.

The HIPAA Guide⁵ points out another area that’s impacted by workflow: readmissions.

Good Healthcare Workflow Management Reduces Readmissions and Improves Patient Outcomes; when workflows are not properly managed there is potential for mistakes to be made that can have severe consequences for patients. One of the main points of failure where medical errors occur is information transfer. If important information about a patient is not effectively communicated during shift handovers, or vital information about a patient is not provided to a physician, incorrect treatment decisions could be made, and treatment could be delayed. When information is not effectively communicated to patients there will be an increased chance of readmission. Complete, accurate, up to date information is critical in healthcare, so formal processes for information transfer are essential.⁶      

Additionally, workflows are an important part of nursing and they can often be turbulent, says Jennings et al.⁷  Making improvements to a nurses work environment “has the potential to reduce burnout thereby improving nurses’ work life, well-being, and patient safety,” Jennings et al. (cited Lake et al., 2019).⁸

Clinical workflows.

An article on MGMA describes how EnhanceMed, an after-hours staffing group for urgent care (emergency department and hospitalist services), moved all of its operations into one location run by Mayo Clinic. To implement changes, they formed project teams to define improvement goals and not only look for existing gaps in process, but also share any successes they found.⁹

To enhance efficiencies and manage workflows among reduced staff, we used Lean principles and value stream mapping. Lean tools and techniques include standardized work and workplace organization such as 5S (Sort, Set in Order, Shine, Standardize and Sustain) to maximize quality and efficiency by eliminating waste. Value stream mapping creates a visual flow of a process or activity and uses observations and data collection to help identify variation and inefficiency.¹⁰

The results were a 40% improvement in efficiency for EnhanceMed/Mayo Clinic Outreach.¹¹  

When mapping clinical workflows, it can be helpful to include the amount of time each step in a process takes. Below is an example workflow format for ambulatory cardiac monitoring.

This example ambulatory cardiac monitor workflow shows one method of diagraming the patient monitoring process.

Assessing workflow.

Authors of the textbook Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Cain and Haque say, “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.”¹²

Before the effectiveness of a workflow can be improved, the components of the workflow need to be assessed. A first step could be spending time understanding the current state of a health system’s workflow. This could be followed by observing, asking questions, and establishing a time motion analysis to understand how, where, and why time is being allocated to tasks, according to Ms. Overstreet. Associating the time and costs with the steps of the workflow process may help to provide a clearer operational picture of what is and what is not working. It can also potentially be a way to measure costs such as labor, capital expenditures, the impact of retest rates, etc. Altogether, assessing, measuring, and understanding the current workflow, could inform what the desired future state workflow will look like.

For example, understanding and providing visibility to the workflow could help to expose gaps, opportunities for efficiency, and ensures staff time is being optimized. Understanding workflow interactions will likely allow an understanding of where tasks may be overlapping, disjointed, or duplicative. Lastly, tasks should reveal the activities associated with the workflow such as looking at healthcare records, seeing which vitals have been measured and documented, plus reviewing the overall administrative process.¹³

Once each component is identified and assessed, process mapping could be an effective method to provide a high-level view of the entire workflow and gain an understanding of how the different parts move together.

Purdue University recommends the following five-step plan that is based on the Lean Six Sigma process¹⁴:  

1. Determine the beginning and end of the process.
   “Using an emergency room as an example, the desired outcome may be to shorten wait times for patients. In this case, the starting point could be when the patient arrives and fills out their paperwork, and the end would be when the patient is discharged.”¹⁵
2. Create a list of each step in the process.
   “In our emergency room example, the steps would include greeting the patient, having them fill out intake forms, entering the information into the computer system, and having the patient see the triage nurse. List the inputs and outputs associated with each step—the items or data that are received (input), and whatever should result from that step (output).”¹⁶
3. Arrange the steps in the current order.
   Looking at the current process could shed light on ways to improve it.¹⁷
4. Use the correct flowchart symbols¹⁸ or consider Business Process Model and Notation (BPMN) to diagram the process. 
   Software diagramming tools including Microsoft Visio and Miro can be used to build a process map. 
5. Get a stakeholder to review the process map.
   Ask a person who is involved in the process but has not contributed to the workflow assessment to “ensure every step of the current process is listed and described correctly.”¹⁹

RFID analytics framework.

There are multiple ways to analyze processes. Vankipurum et al. studied radio frequency identification (RFID) as a “clinical workflow analytics framework.”²⁰ This methodology allows those studying the workflow to track the people involved in it and pay attention to time spent doing activities pertaining to the workflow.

The researchers said, “Workflow analysis typically involves qualitative study but in our work, we have shown that RFID data can be used to complement the data from a human observer.”²¹

Implementing changes.

What does improvement look like? Once clinical stakeholders identify a place for improvement in workflows, implementing change is often the next step, which may look different for each healthcare system, depending on the inefficiencies in workflow they identified. One approach for implementing a workflow change is to do a pilot at a single location, then assess the new workflow before rolling it out to other locations.

Bataldum et al. suggest a definition of “quality improvement” in the context of healthcare workflows as follows: “The combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development.”²²

Vankipuram et al. found that, “Medical institutions have recently attempted to introduce technological interventions to develop quantifiable quality metrics to supplement existing purely qualitative analyses.”²³ 

Predictions from Grand View Research seem to confirm this trend. The firm says, “global clinical workflow solutions market size was valued at USD 7.59 billion in 2020 and is expected to expand at a compound annual growth rate (CAGR) of 12.4% from 2021
to 2028.”²⁴ 

Grand View Research goes on to say, “The importance of a clinical workflow management system has been acknowledged across several entities, including the public and private sectors. Furthermore, clinical settings undertaking initiatives for promoting the installation and integration of EHR and clinical decision support systems are expected to positively impact the market by encouraging hospitals to implement such services.”²⁵ 

When implementing a workflow change, it’s important to remember there may be additional aspects that might need to be altered, tweaked, or further adjusted in the process to continually streamline.

Measuring success.

No matter how the workflow is addressed, to reap the complete benefits of a change, it’s important to know whether the workflow was, indeed, optimized. According to a Varkey et al. study: “A systematic measurement of quality demonstrates whether improvement efforts (1) lead to change in the primary end point in the desired direction, (2) contribute to unintended results in different parts of the system, and (3) require additional efforts to bring a process back into acceptable ranges.”²⁶

Would you like more inspiration to take a closer look at important workflows within your practice? Listen to cardiologist Dr. Daniel Bensimhon as he speaks about his experience with nursing workflow. Watch the video (1:16 min).