Designing Workflow Processes That Optimize the Healthcare Continuum

By Sean Hägen

Workflow is a set of tasks grouped into processes that require the interaction of people and resources to accomplish defined goals. There are methodologies for carefully examining systems, and more specifically, workflows, that can enable optimizations that lead to better efficiency, safety and satisfaction. In this article, we’ll take a look at how workflows in a healthcare system can be characterized and developed with usability design approaches in order to gain greater efficiencies, reduce risks, regulatory snafus and ultimately benefit patient care.

In a health care setting, there are multitudes of processes that may be interdependent and overlap into various areas of responsibility, potentially impacting patient experience and outcome. Managing many of the processes, especially the clinical approaches, are typically articulated in a set of repeatable algorithms, or protocols. In a hospital setting, for example, the ED team and the ICU team, may be involved in the same patient care continuum but have very different roles and responsibilities. These roles and responsibilities include unique equipment, protocols and reporting requirements and thus different workflow processes. While there is agreement of what needs to be ultimately accomplished, the way these tasks are completed are often disruptive when divergent workflows or unanticipated events occur, and this can affect efficiencies or heighten risks.

Generally, workflows are designed for a specific purpose, yet others may develop organically as processes evolve. When viewed separately, some workflows may seem straightforward and efficient in the mission to accomplish an end goal. However, it is the interaction among disparate processes, technology, resources and individuals, where complexities and challenges, or pinch-points, can arise.

The perspective of a workflow varies depending on objectives. The continuum of care journey that a patient and their loved ones experience addresses quality of care and business interests of the hospital. Continuity of care, clinical efficacy, patient safety and medical-legal affairs are focal points of procedural protocols. An infographic diagram, or map, can visualize the relationships and metrics of these processes.

A rigorous mapping process is a means for stakeholders to align and collaborate in a mission to streamline the continuum of care. The methodologies that enable rigor in the mapping process should include observational studies, often referred to as ethnography or contextual inquiry. These types of studies are excellent at informing the development of a process map. During the development of the map, collaborative analysis by an interdisciplinary team can translate study findings into insights that characterize pinch-points and needs. A continuation of the collaborative approach in a synthesis process, like a cross-functional workshop, then yields actionable requirements and concept proposals for new systems and policy or optimization of existing ones.

New Pressures Prompt Scrutinization of Processes

Without a doubt, COVID-19 has certainly been a driver for a renewed focus on updating or optimizing systems. During the early months when the pandemic swept the nation and overwhelmed hospitals and other care practices, it was a clear call for organizations to reexamine the way providers and patients interacted with the healthcare system to best configure workflows in response to the impact of caring for the critically ill under dire circumstances. It became painfully apparent that systems and workflows need to be more resilient and vetted for risk. A process mapping approach can address this need.

Creating a New Way Forward with Usability Design

The thought of reconfiguring a health care workflow, or even understanding if it needs to be changed, may seem like a daunting task – and it can be. However, it can be achievable by following a usability design process with specific milestones and guidance based on a thoughtful project plan. Usability design is an interdisciplinary field of system engineering, industrial design and human factors engineering, among other disciplines, that focuses on how to design, integrate, optimize and manage complex systems.

The benefits of this initial approach will create the foundation upon which new systems/processes/workflows/best practices can be developed. It provides the opportunity for discovery. For example, what are the challenges and what patterns of behavior have been established for work-arounds. Have these work-arounds been successful in one area but have introduced risk or caused disruption in another area of the care continuum, and how can they be either revised or enhanced to meet end goals for all involved.

This foundation will also help uncover hurdles that impact efficiency, wellness, safety and risk management for both patient care and from a regulatory perspective. Understanding the challenges is the best way to collaboratively generate solutions to mitigate problems proactively. The bottom line is to elevate everyone to the same level of understanding – operations, administration, clinicians, patient, technicians, risk management, etc. – all have a vested interested in successful clinical outcomes and thus should be part of proactive planning. The map becomes the Rosetta Stone for enabling collaboration.

Mapping a process can characterize the following insights:

• Reveal spoken and unspoken needs, challenges and aspirations of applicable stakeholders
• Identify and characterize usability challenges, risk, near misses, work-around patterns and implications
• Discover new opportunities for improvement and innovation
• De-skill a procedure (design a procedure that enables all levels of users to have an optimal outcome)

Mapping can also visualize aspects of those insights and related metrics:

• Time/motion efficiencies
• User roles & responsibilities
• Equipment interoperability
• Resource life-cycle and waste
• Use error

The resolution of a process map is a function of the focal perspective of scope. For example, the focus can be as granular or as a broad as the following:

• Procedure/Therapy
• Disease-state
• Environment, e.g., ICU, OR, Imaging, Central Supply, IR Lab, etc.
• Continuum of care, e.g., Patient/Family Journey
• Equipment Life-cycle

Planning a Strategic Initiative

Initially, the project charter defines the general objectives and the strategic approach. The charter should be flexible as the project moves forward and revisable when necessary, as previously undiscovered opportunities are revealed there may be a need to pivot.

Establishing the deliverables is a next step. From the charter objectives, what does the outcome of the project look like? The level of scrutiny on a given workflow sets the boundaries of the scope, as mentioned before, the scope may zoom in on a procedure or zoom out beyond the continuum of care.

Here are three examples of focus scope:

1. Procedure: Identify opportunities to optimize an Aortic Valve Replacement.
   • The map communicates what are the essential tasks for each step
   • What devices have to work together?
   • Who are the primary, secondary and tertiary users?
   • What challenges the users per step and the associated risks?
2. Environment: Characterize the influence of environmental context and associated actors on infection control in the ICU.
   • Identify all the actors (people and things) that influence infection transfer
   • Map the HAI touchpoint zones throughout the ICU environment
   • Characterize the criticality of the zones by frequency, impact, risk level, protocol
3. Patient’s Journey: Identify unmet clinical needs in the continuity of care for a patient that enters the hospital on a ventilator and leaves on a ventilator.
   • Why does the acuity level of the ventilator change unit to unit during the journey?
   • Where are there pinch-points in transition of the patient from unit to unit?
   • Where and when is clinical (ventilation) information handed off between unit to unit?
   • When, where and why does weening from one acuity level to another occur?

Research, the Creative Fuel

Once embarking on the mission to optimize a system – whether it be throughout the entire healthcare organization, continuum of care or a specific focus on a procedure, collaboration will serve as the foundation for success. Developing an approach for collecting data to inform the mapping process is a key stepapproach to employ different methods to better discover truths, for example, a combination of subjective and objective techniques. It should be noted that there are often deficiencies in methods such as surveys and questionnaires. First, you have to assume you know the right questions to ask and depending on how you ask the question, you can get a different answer. Then, what if you don’t know what you don’t know? Second, study participants will have a multitude of biases in their answers, the most common is inaccuracy in memory. . There is not a singular methodology that is most appropriate, in fact, it is often a better

An observational approach, like contextual inquiry or ethnography, can minimize biases and is not dependent on knowing the right question to ask – “show me, don’t tell me.” For example, in a personal interview posing questions like, “how do you complete that task,” will certainly elicit answers, often what is their expectation of the “right” answer. However, in a real-time, on-site observation, watching teams in action may result in slightly or even very different practices that could impact the ultimate design of the workflow. Not to say that interviews are not useful, especially if they are informed by observational methods. In addition, there are several techniques to minimize biases.

Analysis, the Cornerstone in the Project

Regardless of the methodologies employed, this type of research can generate a great deal of data that has to be resolved. This is a most critical step. There are many techniques, many involving cross-functional teams, for dissecting research findings into relevant groupings, identifying patterns and trends, use related risk assessment and determining root cause in order to characterize problems. The analysis may often identify a need for further research, as gaps are found and those questions you didn’t know to ask are discovered. The data will evolve from raw findings, to insights, to needs.

Synthesis Translates Research into Action

Collaboration between stakeholders is important during the development of a map but its particularly impactful during the translation of study insights and needs into actionable deliverables.

If analysis dissembles the data into its base components to understand relationships and patterns, synthesis reassembles the data in novel ways to create new ideas. Translating research insights into user needs, actionable requirements and concepts eventually requires buy-in from the stakeholders involved in the process. A collaborative synthesis process that involves the stakeholders in the translation and conceptualization of new ideas is a means of achieving pre-buy-in, since the stakeholders were part of the creation process.

A method that can engage stakeholders in the synthesis process is a carefully orchestrated workshop. The workshop plan may include:

• Orientation/review of the map and research results emphasizing pinch-points and patterns
• Team discussion of the review identifying problem statements and innovation opportunities
• Divergent ideation by cross-functional teams addressing each of the problem statements and opportunities
• Convergent ideation by cross-functional teams developing divergent ideation output
• Development of brainstorming outputs into requirements and concept proposals
• Prioritization and codification of workshop outputs
• Summarization of next steps, timelines and milestones to achieve charter deliverables

In Summary

Workflows in a healthcare system are impacted by many internal and external factors which, if the workflow process is not resilient and periodically tailored, can compromise efficiencies, introduce risks and regulatory snafus, ultimately affecting patient outcomes. Guided by usability experts, a workflow design process can be developed that exemplifies best practices and leads to the optimization of the continuum of care. An infographic map can be an invaluable tool for enabling stakeholder collaboration by visualizing the relationships and metrics of healthcare processes. Furthermore, the mapping process can create opportunity for reducing risk and discovering opportunity.

Sean Hägen is the Founding Principal and Director of Research and Synthesis for BlackHägen Design.