1. Workflow Analysis in Healthcare Lauren Gray, BSN RN October 7, 2015

2. Objectives Workflow analysis terminology Common approaches to workflow analysis Workflow analysis tools Applicability to Health/Clinical/Nursing Informatics

3. Workflow Terms Current State Future State Inter-organizational workflow: Includes processes occurring across organizations such as hospitals and ambulatory clinics Intra-organizational workflow: Can include the flow of workers, patients, and information across space and time in a department as well as the interdependencies of tasks carried out Individual workflow: aka, “cognitive”. Refers to a person’s flow of thoughts related to a task. (Karsh, 2009)

4. Common Approaches Information/Computer Science – Petri-nets use workflow management systems to gather data re: events and model the work (organizational) – Contextual Design 3 phases: Contextual Inquiry, Work Modeling, Consolidation Purpose is to uncover 4 aspects of work that are relevant to design: Motive behind th etasks, patterns used in carrying out tasks, structure in place that enables task accomplishment, conceptual distinctions between aspects of work. (organizational & individual)

5. Common Approaches Computer-Supported Cooperative Work – Begun by technology developers in an effort to understand the activities of groups engaged in collaborative work activities – Guided by two theories Activity Theory: human beings engage in purposeful interactions (activities) that are goal-directed and context- specific Coordination Theory: task-interdependencies among workers that result in harmonious goal-achievement – Useful for examining workflow within and across organizations. It would not be useful for understanding individual workflow.

6. Common Approaches Computer-Supported Cooperative Work – Begun by technology developers in an effort to understand the activities of groups engaged in collaborative work activities – Guided by two theories Activity Theory: human beings engage in purposeful interactions (activities) that are goal-directed and context- specific Coordination Theory: task-interdependencies among workers that result in harmonious goal-achievement – Useful for examining workflow within and across organizations. It would not be useful for understanding individual workflow.

7. Common Approaches Cognitive Science: interested in understanding human thought processes including knowledge attainment, memory and problem solving Organizational Science: aimed at clarifying internal structures within organizations for the purpose of influencing change and directing process re-design.

8. Common Approaches Computer-Supported Cooperative Work – Begun by technology developers in an effort to understand the activities of groups engaged in collaborative work activities – Guided by two theories Activity Theory: human beings engage in purposeful interactions (activities) that are goal-directed and context- specific Coordination Theory: task-interdependencies among workers that result in harmonious goal-achievement – Useful for examining workflow within and across organizations. It would not be useful for understanding individual workflow.

9. How Do You Choose? On the requirements and goals of the project On the setting On the people doing the work Any analysis is better than no analysis

10. Why workflow analysis? Where are we? Where do we want to be? What do we need to do to get there? How do we know if we’re successful? Reinforce training Mangers & users will use as reference

11. Tips Multidisciplinary teams Staff who actually does the work Don’t rely on the vendor Assign responsibility (Project Manager, Data Steward, other point person)

12. Example: Analysis Make the workflow fail! – FMEA (Failure Modes Effects Analysis) – Root Cause Analysis – Spaghetti diagrams Evaluate how to address each failure

13. Example: Analysis Make the workflow fail! – FMEA (Failure Modes Effects Analysis) – Root Cause Analysis – Spaghetti diagrams Evaluate how to address each failure

14. Example: Analysis Make the workflow fail! – FMEA (Failure Modes Effects Analysis) – Root Cause Analysis – Spaghetti diagrams Evaluate how to address each failure

15. Example: Current State Describe workflow – Multiple people – Find variations Watch the workflow Document the workflow – Exhaustively! Be annoying! – Visio, markers & paper, Word/Pages, mind mapping software – Screen capture: SnagIt, Snipping tool

16. Example: Analysis Make the workflow fail! – FMEA (Failure Modes Effects Analysis) – Root Cause Analysis – Spaghetti diagrams Evaluate how to address each failure

17. Example: Future State Document new workflows including the fixes & changes Run through the Current State steps to test them out

18. Good Questions to Ask What IS the process? Are there important patient care processes that do not involve seeing a patient? What are the steps involved? What are the variations to these processes? Are there acceptable reasons for process variations by clinic site? Who completes the process? How long does it take? Where are the bottlenecks? Is there repetition in the work? Is there potential for confusion or misunderstanding?

20. Can be relatively simple…

21. Or can make you feel crazy… (and this one is the “High Level” version…)

22. Why document like a crazy person? Shows where sequence is critical Shows bottlenecks & interruptions Identifies opportunities & waste Helps create solutions to issues Takes advantage of automation provided by the EHR

23. What happens if we don’t do good workflow analysis?

24. Questions?

25. References California Healthcare Foundation (2011). Workflow analysis: EHR deployment techniques Karsh BT. In: Clinical practice improvement and redisign: How change in workflow can be supported by clinicial decision support.Quality AfHRa, editor. Rockville, Md: 2009. p. 42. Duffy, J. (2013). Get organized: Document your workflow., May 13, 2013. Sheehan, B., & Bakken, S. (2012). Approaches to Workflow Analysis in Healthcare Settings. NI 2012: Proceedings of the 11th International Congress on Nursing Informatics, 2012, 371.