Chapter 16 Nursing Informatics: Improving Workflow and Meaningful Use

Objectives Provide an overview of the purpose of conducting workflow analysis and design. Deliver specific instructions on workflow analysis and redesign techniques. Cite measures of efficiency and effectiveness that can be applied to redesign efforts.

Introduction An astounding 98,000 Americans are injured each year as a result of medication errors (Institute of Medicine (IOM), 1999). Not only is there an impact on patients from these errors but there is also a significant financial impact to healthcare organizations. IOM report suggests to improve care delivery and minimize error one of the most important tools to employ is the use of electronic records and information system to provide point of care decision support and automation.

Workflow and Technology Workflow is a term used to describe the action or execution of a series of tasks in a prescribed sequence. Another definition of workflow is a progression of steps (tasks, events, interactions) that comprise a work process, involve two or more persons, and create or add value to the organization's activities. One school of thought suggests that technology should be designed to meet the needs of clinical workflow.

Optimization Optimization is the process of moving conditions past their current state and into more efficient and effective method of performing tasks. Nursing informatics should always be included in these activities to represent the needs of clinicians and to serve as liaison for technological solutions to process problems.

Workflow Analysis and Informatics Practice A critical aspect of the informatics role is workflow design. Nursing informatics is uniquely positioned to engage in the analysis and redesign of processes and tasks surrounding the use of technology. As we examine how workflow analysis is conducted it is important to note that while the nursing informaticist is an essential member of the team to participate in or enable workflow analysis; a team dedicated to this effort is necessary for its success.

Building the Team The workflow redesign team is an interdisciplinary team consisting of “process owners.” Process owners are those who directly engage in the workflow to be analyzed and redesigned. They are individuals who can speak about the intricacy of process, including process variations from the norm.

Value Add Versus Non-Value Add A value-added activity or step is one that ultimately brings the process closer to completion or changes the product or service for the better. Some steps in a process do not necessarily add value but are necessary for regulatory or compliance reasons.

Waste Underpinning the Lean philosophy is the removal of waste activities from workflow. Waste is classified as unnecessary activities or an excess of products to perform tasks.

Variation Variation occurs when workers perform the same function in different ways and usually occurs because of flaws in the way a process was originally designed, lack of knowledge about the process or because a process cannot be executed as originally designed due to disruption or disturbances in the workflow.

Transitioning to Future State Future state is constructed with the best possible knowledge of how the process will ideally work. To move from the current state to the future state; gap analysis is necessary. Gap analysis zeros in on the major areas most affected by the change, namely technology. What often happens in redesign efforts is an exact or near-exact replication of the current state using automation. Gap analysis discussion should generate ideas from the group how about best to utilize the technology to transform practice.

Informatics as a Change Agent Technology implementations alone represent a significant change for clinicians as does the workflow redesign that accompanies technology. Often the degree of change and its impact is under-appreciated and unaccounted for by leadership and staff alike. Engagement of the end-user is a critical aspect of change management and therefore adoption. Without end-user involvement, change is resisted and efforts are subject to failure. There are many change theories to explore but regardless of the change theory adopted by the informatics specialist know that communication, planning and support are key factors of any change management strategy. Informaticists should become knowledgeable about at least one change theory and use this knowledge as the basis for change management planning as part of every effort.

Measuring results Metrics provide understanding about the performance of a process or function Process metrics are collected at the initial stage of project or problem identification. Current state metrics are then benchmarked against internal indicators. When there are no internal indicators to benchmark against, a suitable course of action is to benchmark against an external source such as a similar business practice within a different industry.

Future Directions Although workflow analysis principles are described within the context of acute and ambulatory care; the need to perform process analysis on a macro-level will expand as more organizations move forward with Health Information Exchanges (HIE) and medical home models. Health Information Exchanges require the Nursing Informaticist to visualize how patients move through the entire continuum of care and not just a select patient care area. Technology initiatives will become increasingly complex and therefore Nursing Informaticists will need greater preparation in the area of process analysis and improvement techniques to meet the growing challenges technology brings and operational performance demands of fiscally impaired healthcare organizations.

Summary Workflow redesign is a critical aspect of technology implementation and when done well yields technology that is more likely to achieve the intended patient outcomes and safety benefits. Nursing Informatics professionals are taking on a greater role with respect to workflow design and this aspect of practice will grow in light of meaningful use driven objectives. Other initiatives that impact hospital performance will also drive informatics professionals to influence how technology is used in the context of workflow to improve upon the bottom line.