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Mapping a Complete Workflow for a Clinical Process

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Workflow and process mapping is the task of documenting how workflows and processes are performed currently, or how changes will be made. It should be noted that a “process” is work performed and “workflow” is how the work moves from one stage to another toward the process’ completion. Mapping a process and its workflow is a fairly well-defined science, with a number of tools and techniques that can be used to understand current workflows and processes as well as identify opportunities for improvement.

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The typical workflow for a patient visit at this primary care clinic begins with the patient intake portion which includes the request for appointment, patient registration, history taking and beginning the clinical exam. The patient contacts the clinic for an appointment via phone call or in-person for a walk-in appointment, taken as available. In both instances, the receptionist collects demographic data from the patient, including date of birth, age, address, social security number, emergency contacts and insurance provider information

This information is entered into the demographic and insurance component of the clinic’s electronic registration system. New patients are scheduled for a forty-five minute appointment and receive a unique patient identification number (ptID). This number remains the same for the life of the patient at the clinic. A returning patient’s information is retrieved, including the ptID, and is scheduled for a twenty minute appointment. After the patient is scheduled and registration is complete, a new paper chart is developed by the file clerk and the registration information is printed and placed in the chart.

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Workflow issues often arise in studies of technology. One well-studied domain area is barcode medication administration (BCMA)

(Patterson ES, Rogers 2006) 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. 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, (Kobayashi M, Fussell) such as degraded coordination between nurses and physicians, nurses dropping activities during busy periods, and decreased ability to deviate from routine sequences.

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By and large, 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.

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Patterson ES, Rogers ML, Chapman RJ, et al. Compliance with intended use of bar code medication administration in acute and long-term care: an observational study. Hum Factors. 2006

Kobayashi M, Fussell SR, Xiao Y, et al. Work coordination, workflow, and workarounds in a medical context. Proceedings of CHI 2005, Conference on Human Factors in Computing; pp. 1561–4.

Galbraith JR. Organization design: an information processing view. Interfaces. 1974;4(3):28–36.

Carley KM, Prietula MJ, editors. Computational organization theory. Mahwah, NJ: Lawrence Earlbaum, Publishers; 1994.

Bricon-Souf N, Renard JM, Beuscart R. Dynamic workflow model for complex activity in intensive care unit. Int J Med Inform. 1999;53:2–3. 143–50.

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