Skip to main content

Clinical Workflow Analysis, Process Redesign, and Quality Improvement

  • Chapter

Abstract

Healthcare workflow is driven by individual, organizational, and societal factors. The resulting complexity and high variability make it challenging to examine workflow in healthcare delivery settings. In this chapter, the authors introduce relevant theories, frameworks, principles, tools, and techniques to guide both (a) workflow examination and (b) systematic organizational interventions for workflow redesign. These theories, frameworks, principles, tools, and techniques can be applied to diverse settings to improve the quality and safety of healthcare delivery.

This is a preview of subscription content, log in via an institution.

Buying options

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  1. Karsh B-T. Clinical practice improvement and redesign: how change in workflow can be supported by clinical decision support. Rockville: Agency for Healthcare Research and Quality; 2009.

    Google Scholar 

  2. Bowers J, Button G, Sharrock W, editors. Workflow from within and without: technology and cooperative work on the print industry shopfloor. Norwell: Kluwer Academic Publishers; 1995.

    Google Scholar 

  3. Luczak H. Task analysis. In: Salvendy G, editor. Handbook of human factors and ergonomics. New York: Wiley; 1997.

    Google Scholar 

  4. Malhotra S, Jordan D, Shortliffe E, Patel VL. Workflow modeling in critical care: piecing together your own puzzle. J Biomed Inform. 2007;40(2):81–92.

    Article  PubMed  Google Scholar 

  5. Brixey JJ, Tang Z, Robinson DJ, Johnson CW, Johnson TR, Turley JP, et al. Interruptions in a level one trauma center: a case study. Int J Med Inform. 2007;77(4):235–41.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Siemieniuch CE, Sinclair MA. The analysis of organisational processes. In: Wilson JR, Corlett N, editors. Evaluation of human work. 3rd ed. CRC Press; 2005. pp. 977–1008.

    Google Scholar 

  7. Unertl KM, Novak LL, Johnson KB, Lorenzi NM. Traversing the many paths of workflow research: developing a conceptual framework of workflow terminology through a systematic literature review. J Am Med Inform Assoc JAMIA. 2010;17(3):265–73.

    Article  PubMed  Google Scholar 

  8. Baker DP, Day R, Salas E. Teamwork as an essential component of high-reliability organizations. Health Serv Res. 2006;41(4 Pt 2):1576–98.

    Article  PubMed Central  PubMed  Google Scholar 

  9. Nemeth CP, Cook RI, Woods DD. The messy details: insights from the study of technical work in healthcare. Syst Man Cybern Part A Syst Hum IEEE Trans. 2004;34(6):689–92.

    Article  Google Scholar 

  10. Franck R. The explanatory power of models : bridging the gap between empirical and theoretical research in the social sciences. Boston: Kluwer Academic Publishers; 2002. p. 309.

    Book  Google Scholar 

  11. Burton-Jones A, Gallivan MJ. Toward a deeper understanding of system usage in organizations: a multilevel perspective. MIS Q. 2007;31(4):657–79.

    Google Scholar 

  12. Carayon P, Karsh B-T, Cartmill R, et al. Incorporating health IT into workflow redesign. Rockville: Agency for Healthcare Research and Quality; 2010.

    Google Scholar 

  13. Davenport TH. Process innovation: reengineering work through information technology: Harvard Business Press. 2013.

    Google Scholar 

  14. Brennan PF. Standing in the shadows of theory. J Am Med Inform Assoc JAMIA. 2008;15(2):263–4.

    Article  PubMed  Google Scholar 

  15. Ozkaynak M, Brennan PF, Hanauer DA, Johnson S, Aarts J, Zheng K, et al. Patient-centered care requires a patient-oriented workflow model. J Am Med Inform Assoc JAMIA. 2013;20(e1):e14–6.

    Article  PubMed  Google Scholar 

  16. Zheng K, Haftel HM, Hirschl RB, O’Reilly M, Hanauer DA. Quantifying the impact of health IT implementations on clinical workflow: a new methodological perspective. J Am Med Inform Assoc. 2010;17(4):454–61.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Sarkar U, Bates DW. Care partners and online patient portals. JAMA. 2014;311(4):357–8.

    Article  CAS  PubMed  Google Scholar 

  18. Cain C, Haque S. Organizational workflow and its impact on work quality. In: Hughes RG, editor. Patient safety and quality: an evidence-based handbook for nurses. Rockville: Agency for Healthcare Research and Quality; 2008.

    Google Scholar 

  19. Becker MC. Organizational routines: a review of the literature. Ind Corp Change. 2004;13(4):643–78.

    Article  Google Scholar 

  20. Pentland BT, Feldman MS. Organizational routines as a unit of analysis. Ind Corp Change. 2005;14(5):793–815.

    Article  Google Scholar 

  21. Unertl KM, Weinger MB, Johnson KB. Applying direct observation to model workflow and assess adoption. AMIA Annu Symp Proc AMIA Symp. 2006;794–8.

    Google Scholar 

  22. Xie A, Carayon P, Cartmill R, Li Y, Cox ED, Plotkin JA, et al. Multi-stakeholder collaboration in the redesign of family-centered rounds process. Appl Ergon. 2015;46, Part A(0):115–23.

    Article  Google Scholar 

  23. Taylor FW. The principles of scientific management. New York: Harper; 1911.

    Google Scholar 

  24. Gilbreth FB, Gilbreth LM. Process charts. New York: Annual Meeting of the American Society of Mechanical Engineers; 1921.

    Google Scholar 

  25. Hollingsworth JC, Chisholm CD, Giles BK, Cordell WH, Nelson DR. How do physicians and nurses spend their time in the emergency department? Ann Emerg Med. 1998;31(1):87–91.

    Article  CAS  PubMed  Google Scholar 

  26. Ozkaynak M, Brennan PF. An observation tool for studying patient-oriented workflow in hospital emergency departments. Methods Inf Med. 2013;52(6):503–13.

    Article  CAS  PubMed  Google Scholar 

  27. Schultz K, Slagle J, Brown R, Douglas S, Frederick B, Lakhani M, et al. Development of a job task analysis tool for assessing the work of physicians in the intensive care unit. Hum Factors Ergon Soc Annu Meet Proc. 2006;50:1469–73(5).

    Article  Google Scholar 

  28. Russ AL, Militello LG, Saleem JJ, Fairbanks RJ, Wears RL. Response to separating fact from opinion: a response to ‘the science of human factors: separating fact from fiction’. BMJ Qual Saf. 2013;22(11):964–6.

    Article  PubMed  Google Scholar 

  29. Dixon BE. Enhancing the informatics evaluation toolkit with remote usability testing. AMIA Annu Symp Proc. 2009;2009:147–51.

    PubMed Central  PubMed  Google Scholar 

  30. Jaspers MW. A comparison of usability methods for testing interactive health technologies: methodological aspects and empirical evidence. Int J Med Inform. 2009;78(5):340–53.

    Article  PubMed  Google Scholar 

  31. Hoonakker P, Carayon P, Gurses A, Brown R, McGuire K, Khunlertkit A, et al. Measuring workload of ICU nurses with a questionnaire survey: the NASA Task Load Index (TLX). IIE Trans Healthc Syst Eng. 2011;1(2):131–43.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Hoonakker PLT, Cartmill RS, Carayon P, Walker JM. Development and psychometric qualities of the SEIPS survey to evaluate CPOE/EHR implementation in ICUs. Int J Healthc Inform Syst Inform Off Publ Inform Res Manag Assoc. 2011;6(1):51–69.

    Article  Google Scholar 

  33. Tory M, Moller T. Human factors in visualization research. IEEE Trans Vis Comput Graph. 2004;10(1):72–84.

    Article  PubMed  Google Scholar 

  34. Sharp A, McDermott P. Workflow modeling; tools for process improvement and application development. 2nd ed. Boston: Artech House; 2009.

    Google Scholar 

  35. Gene C, Sarson T. Structured systems analysis, tools, and techniques. Englewood Cliffs: Prentice Hall; 1979.

    Google Scholar 

  36. Booth TL. Sequential machines and automata theory: Wiley. 1967.

    Google Scholar 

  37. Murphy KP. Machine learning: a probabilistic perspective. Cambridge: MIT Press; 2012.

    Google Scholar 

  38. Blum T, Padoy N, Feußner H, Navab N. Workflow mining for visualization and analysis of surgeries. Int J Comput Assist Radiol Surg. 2008;3(5):379–86.

    Article  Google Scholar 

  39. Rabiner LR. A tutorial on hidden Markov models and selected applications in speech recognition. Proc IEEE. 1989;77(2):257–86.

    Article  Google Scholar 

  40. Vankipuram M, Kahol K, Cohen T, Patel VL. Toward automated workflow analysis and visualization in clinical environments. J Biomed Inform. 2011;44(3):432–40.

    Article  PubMed  Google Scholar 

  41. Vankipuram M, Kahol K, Cohen T, Patel VL. Visualization and analysis of activities in critical care environments. AMIA Annu Symp Proc AMIA Symp. 2009;2009:662–6.

    PubMed  Google Scholar 

  42. Konrad R, Tulu B, Lawley M. Monitoring adherence to evidence-based practices: a method to utilize HL7 messages from hospital information systems. Appl Clin Inform. 2013;4(1):126–43.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  43. van der Aalst W, van Hee K. Workflow management models, methods, and systems. Cambridge, MA: The MIT Press; 2002.

    Google Scholar 

  44. Kristensen LM, Christensen S, Jensen K. The practitioner’s guide to coloured Petri nets. Int J Softw ToolTechnol Trans (STTT). 1998;2(2):98–132.

    Article  Google Scholar 

  45. Zhou Y, Ancker JS, Upadhye M, McGeorge NM, Guarrera TK, Hegde S, et al. The impact of interoperability of electronic health records on ambulatory physician practices: a discrete-event simulation study. Inform Prim Care. 2013;21(1):21–9.

    Article  PubMed  Google Scholar 

  46. Hoot NR, LeBlanc LJ, Jones I, Levin SR, Zhou C, Gadd CS, et al. Forecasting emergency department crowding: a discrete event simulation. Ann Emerg Med. 2008;52(2):116–25.

    Article  PubMed  Google Scholar 

  47. Tucker A. Learning about reducing hospital mortality at Kaiser Permanente. Harvard Business School Case 612–093; 2012 (Revised Feb 2013).

    Google Scholar 

  48. Strong DM, Volkoff O, Johnson SA, Pelletler LR, Tulu B, Bar-On I, et al. A theory of organization-EHR affordance actualization. J Assoc Inform Syst. 2014;15(2):53–85.

    Google Scholar 

  49. Karsh BT, Alper SJ. Work system analysis: the key to understanding health care systems. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in patient safety: from research to implementation. Rockville: Agency for Healthcare Research and Quality; 2005.

    Google Scholar 

  50. Clegg CW. Sociotechnical principles for system design. Appl Ergon. 2000;31(5):463–77.

    Article  CAS  PubMed  Google Scholar 

  51. Carayon P, Wetterneck TB, Rivera-Rodriguez AJ, Hundt AS, Hoonakker P, Holden R, et al. Human factors systems approach to healthcare quality and patient safety. Appl Ergon. 2014;45(1):14–25.

    Article  PubMed Central  PubMed  Google Scholar 

  52. Hall G, Rosenthal J, Wade J. How to make reengineering really work. Harvard Bus Rev. 1993;71:119–31.

    Google Scholar 

  53. National Research Council. Medicare: a strategy for quality assurance, vol. I. Washington: The National Academies Press; 1990. p. 468.

    Google Scholar 

  54. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001.

    Google Scholar 

  55. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743–8.

    Article  CAS  PubMed  Google Scholar 

  56. Walshe K. Pseudoinnovation: the development and spread of healthcare quality improvement methodologies. Int J Qual Health Care. 2009;21(3):153–9.

    Article  PubMed  Google Scholar 

  57. Sperl T, Ptacek R, Trewn J. Practical lean six sigma for healthcare – using the A3 and lean thinking to improve operational performance in hospitals, clinics, and physician group practices. 1st ed. Chelsea, MI: MCS Media, Inc; 2013.

    Google Scholar 

  58. Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance. 2nd ed. San Francisco: Jossey-Bass Publishers; 2009.

    Google Scholar 

  59. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf. 2014;23:290–8.

    Article  PubMed Central  PubMed  Google Scholar 

  60. Seidl KL, Newhouse RP. The intersection of evidence-based practice with 5 quality improvement methodologies. J Nurs Adm. 2012;42(6):299–304.

    Article  PubMed  Google Scholar 

  61. Womack JP, Jones TJ. Lean thinking: banish waste and create wealth in your corporation, revised and updated. New York: Free Press; 2003.

    Google Scholar 

  62. Steinfeld B, Scott J, Vilander G, Marx L, Quirk M, Lindberg J, et al. The role of lean process improvement in implementation of evidence-based practices in behavioral health care. J Behav Health Serv Res. 2014. doi:10.1007/s11414-013-9386-3.

    Google Scholar 

  63. Woodward-Hagg H, Taylor KT, Workman-Germann J, Bidassie B, Bar-On I, Johnson SA, editors. Large system transformation within healthcare organizations utilizing lean deployment strategies. 2014 Industrial and Systems Engineering Research Conference (ISERC). Montreal; 2014.

    Google Scholar 

  64. Institute for Healthcare Improvement. Going Lean in Health Care. IHI Innovation Series white paper [Internet]. 2005. http://www.ihi.org/resources/Pages/IHIWhitePapers/GoingLeaninHealthCare.aspx.

  65. Toussaint JS, Berry LL. The promise of lean in healthcare. Mayo Clin Proc. 2013;88(1):74–82.

    Article  PubMed  Google Scholar 

  66. Sobek DK, Smalley A. Understanding A3 thinking. New York: Productivity Press; 2008.

    Google Scholar 

  67. Graban M, Swartz JE. Healthcare kaizen: engaging front-line staff in sustainable continuous improvements. New York: Productivity Press; 2012.

    Google Scholar 

  68. Jimmerson C. Value-stream mapping for healthcare made easy. New York: Productivity Press; 2009.

    Book  Google Scholar 

  69. Lenfant C. Clinical research to clinical practice — lost in translation? New Engl J Med. 2003;349(9):868–74.

    Article  PubMed  Google Scholar 

  70. Pronovost PJ, Nolan T, Zeger S, Miller M, Rubin H. How can clinicians measure safety and quality in acute care? Lancet. 2004;363(9414):1061–7.

    Article  PubMed  Google Scholar 

  71. Kaplan HC, Brady PW, Dritz MC, Hooper DK, Linam WM, Froehle CM, et al. The influence of context on quality improvement success in health care: a systematic review of the literature. Milbank Q. 2010;88(4):500–59.

    Article  PubMed Central  PubMed  Google Scholar 

  72. Raghupathi W, Raghupathi V. Big data analytics in healthcare: promise and potential. Health Inf Sci Syst. 2014;2(1):1–10.

    Article  Google Scholar 

  73. Roski J, Bo-Linn GW, Andrews TA. Creating value in health care through big data: opportunities and policy implications. Health Aff. 2014;33(7):1115–22.

    Article  Google Scholar 

  74. Holden RJ, Schubert CC, Mickelson RS. The patient work system: an analysis of self-care performance barriers among elderly heart failure patients and their informal caregivers. Appl Ergon. 2015;47:133–50.

    Article  PubMed  Google Scholar 

  75. Shneiderman B, Plaisant C, Hesse BW. Improving healthcare with interactive visualization. Computer. 2013;46(5):58–66.

    Article  Google Scholar 

  76. Wongsuphasawat K, Gomez J, Plaisant C, Shneiderman B, Taieb-Maimon M. LifeFlow: visualizing an overview of event sequences. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems. Vancouver: ACM; 2011. pp. 1747–56. 1979196.

    Google Scholar 

  77. Bigham BL, Kennedy SM, Drennan I, Morrison LJ. Expanding paramedic scope of practice in the community: a systematic review of the literature. Prehosp Emerg Care Off J National Assoc EMS Phys National Assoc State EMS Dir. 2013;17(3):361–72.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Mustafa Ozkaynak PhD .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Ozkaynak, M., Unertl, K.M., Johnson, S.A., Brixey, J.J., Haque, S.N. (2016). Clinical Workflow Analysis, Process Redesign, and Quality Improvement. In: Finnell, J., Dixon, B. (eds) Clinical Informatics Study Guide. Springer, Cham. https://doi.org/10.1007/978-3-319-22753-5_7

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-22753-5_7

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-22752-8

  • Online ISBN: 978-3-319-22753-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics