Clinical workflow analysis

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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.


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).


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

Flowchart Example:

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

Example Flowchart:

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


• 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


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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 Added first three sentences to paragraph #2 Added in the section: Workflow in the Emergency Department References: 14-29