Jerome Carter, MD December 14, 2016

A workflow analysis is an objective way to find out why a process works the way it does. In order to be useful, a workflow analysis must capture detailed information. Workflow information comes from so many different sources that gathering it can be time-consuming and overwhelming, unless a structured process is used. In my experience, the best approach is to start with written documents (e.g., policy and procedure manual) then move on to interviews, and repeat as needed until done. In addition, it is best to start with a high-level view, then gradually drill down to fine details.

Here, we are tasked with determining how to address the following issues:

  • Attempts to contact patients for abnormal lab results often go to voicemail, resulting in follow-up delays.
  • Patients are complaining about time spent waiting on hold.
  • Patients often call back multiple times regarding the same issue because no one in the practice has contacted them.
  • One clinician accidentally deleted her on-call notes and cannot recall the name of one of the patients who called about severe back pain and dysuria.
  • During flu season, the number of calls increases by 30%.

To begin, it is best to get a feel for how the process is supposed to work. Usually, this information is in the policy and procedure manual or employee training materials. Likely, it is outdated, but even old documents help one to get a feel for what the process is intended to do. The policy and procedure manual, ideally, will provide information concerning key process steps, job roles involved, the information the process should produce, and the expected outcomes. Using the specific issues listed above as a guide, here are examples of the information that one would hope to find in the Typical Primary Care, LLC policy and procedure manual.

  1. Attempts to contact patients for abnormal lab results often go to voicemail, resulting in follow-up delays.
    1. What job role is responsible for contacting patients after a lab is marked as abnormal?
      1. Is it always the ordering clinician, a nurse, or a medical assistant?
      2. If responsibility may shift, what rules govern how shifts are managed?
    2. What are the rules for documenting lab-related patient calls?
      1. Are specific forms required?
  2. Patients are complaining about time spent waiting on hold.
    1. How many job roles are tasked with answering calls?
    2. Is there a script?
    3. Can patients ask for a specific call-back time instead of waiting?
  3. One clinician accidentally deleted her on-call notes and cannot recall the name of one of the patients who called about severe back pain and dysuria.
    1. Is documentation required?
    2. If so, how are on-call interactions documented?
  4. During flu season, the number of calls increases by 30%.
    1. Are there specific procedures for managing high-volume periods?
    2. What triggers the activation of those procedures?

After going through the policy and procedure manual and any training materials, next find all forms related to the process. For each form, determine which job roles are responsible for completing it. Note the fields for each form and which fields are mandatory. After reviewing all documents, create a high-level diagram of the process, which will be used to conduct staff interviews.

The initial diagram should have only major process steps (a flowchart is fine at this stage). At this point, the diagram is mainly a discussion aid. It will be fleshed out using information gleaned from staff interviews.

Group interviews are the best way to avoid misconceptions about how a process works or should work. It is rare that everyone involved in a process has the same understanding of how it works. Use group interviews to complete the high-level version of the process diagram. Bringing all discrepancies and misconceptions to light helps in resolving process issues. Job roles and information movements should be addressed during group interviews, and any conflicts identified will help in setting the agenda for future meetings and needed process changes.

Conduct interviews iteratively. Each round should result in a more detailed diagram. Once the diagram is deemed complete by the group, documentation of the “as is” process will be complete (or as closes as is needed to move forward). This diagram, which represents a shared conception of the current process, can now be used to understand how various aspects of the process have gone awry.

At this stage, fixing the process workflow is not the main goal. Rather, the most useful approach is determining the exact type of workflow issues that are causing problems. Thus, using the “as is” workflow diagram, the next step is looking at each workflow problem recorded in the “as is’ diagram, then relating that problem to specific section of the workflow diagram in terms of one or more of the following: information movements, job roles/responsibilities, control-flow of the process, expected process outcomes. For example, a form that is not properly completed or is not always used as required, represents an information movement problem. If the proper staff person does not sign-off on a form, then a job role issue is present. If a form is often lost in a pile of papers, perhaps a control-flow issue is the reason.

Workarounds should be documented and studied using the process diagram as well. Sticky notes are examples of information movement problems. Use group discussions to review every workflow issue and relate those problems to one or more of the four categories of workflow derangements. Update the workflow diagram as needed to reflect all issues and problems discussed.

Once all issues, problems, and concerns have been discussed and related to the workflow diagram, the next steps are determining why those problems exist and what may be done to address them. Moving beyond the initial “as is” diagram requires workflow modeling tools that are capable of capturing all four aspects of workflows, which means flowcharts will not longer be sufficient.

In the next post, we will look at workflow diagnostics.