Complex healthcare systems present opportunities for optimization

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 to carefully examine systems, and more specifically workflows, that can enable optimizations for better efficiency, safety, and satisfaction. In this article, we’ll look at how workflows in a healthcare system can be characterized and developed with usability design approaches to gain greater efficiencies, reduce risks and regulatory snafus, and ultimately benefit patient care.

In a healthcare setting, processes may be interdependent and overlap in various areas of responsibility, potentially impacting patient experience and outcome. Process management, especially for clinical approaches, is typically articulated in a set of repeatable algorithms, or protocols. In a hospital setting, for example, the ED and ICU teams may be involved in the same patient care continuum but have very different roles and responsibilities. These include unique equipment, protocols, and reporting requirements and thus different workflow processes. While teams agree on what needs to be ultimately accomplished, the way they complete these tasks can be 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. However, the interaction among disparate processes, technology, resources, and individuals can give rise to complexities and challenges, or pinch points.

The perspective of a workflow varies depending on objectives. The continuum of care journey that a patient and their loved ones experience involves 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 allows 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 this development, 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 policies or optimization of existing ones.

New pressures prompt scrutiny of processes

Without a doubt, COVID-19 has driven a renewed focus on updating or optimizing systems. When the pandemic first swept the nation, it was a clear call for organizations to reexamine the way providers and patients interact with the healthcare system 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 healthcare 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.

This initial approach will create the foundation on which to develop new systems, processes, workflows, and best practices. It provides opportunities for discovery. For example, what are the challenges and what patterns of behavior have been established for workarounds? Have these workarounds been successful in one area of the care continuum while introducing risk or disruption in another? How can the workarounds be 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 both regarding patient care and from a regulatory perspective. Understanding the challenges is the best way to collaboratively and proactively generate solutions to problems. The bottom line is to elevate everyone to the same level of understanding—operations, administration, clinicians, patients, technicians, risk management, etc. These groups all have a vested interest 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 enable the following insights:

• Reveal spoken and unspoken needs, challenges, and aspirations of applicable stakeholders
• Identify and characterize usability challenges, risks, near misses, workaround 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 and responsibilities
• Equipment interoperability
• Resource life cycle and waste
• User 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 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, as there may be a need to pivot when previously undiscovered opportunities are revealed.

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 healthcare-associated infection touchpoint zones throughout the ICU environment.
   • Characterize the criticality of the zones by frequency, impact, risk level, and protocol.
3. Patient’s journey: Identify unmet clinical needs in the continuity of care for a patient who enters the hospital on a ventilator and leaves on a ventilator.
   • Why does the acuity level of the ventilator change from 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 units?
   • When, where, and why does weaning between acuity levels occur?

Research: The creative fuel

Once embarking on the mission to optimize a system—whether it be throughout the continuum of care or focused on a specific procedure—collaboration will serve as the foundation for success. Developing an approach for collecting data to inform the mapping process is a key step to employ different methods to better discover truths, such as a combination of subjective and objective techniques. It should be noted that there are often deficiencies in methods such as surveys and questionnaires. Someone conducting a survey may not know the right questions to ask, may get different answers depending on how they ask the questions, and may fail to take into account what they don’t know. Second, study participants will have a multitude of biases in their answers; the most common is inaccuracy in memory. No single methodology is most appropriate.

An observational approach, like contextual inquiry or ethnography, can minimize biases and is not dependent on knowing the right question to ask—it relies on showing rather than telling. For example, in a personal interview, posing questions like, “How do you complete that task?” will often elicit the person’s 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. Granted, interviews can still be 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, often involving cross-functional teams, for dissecting research findings into relevant groupings, identifying patterns and trends, using related risk assessments, and determining root causes to characterize problems. The analysis may often identify a need for further research, as gaps are found and questions are discovered that stakeholders didn’t previously know to ask. 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 it is particularly impactful during the translation of study insights and needs into actionable deliverables.

If analysis disassembles 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 preemptive buy-in, since the stakeholders were part of the creation process.

A carefully orchestrated workshop can engage stakeholders in the synthesis process. 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

Many internal and external factors impact workflows in a healthcare system. If the workflow process is not resilient and periodically tailored, these factors can compromise efficiencies, introduce risks, and create regulatory snafus, ultimately affecting patient outcomes. Guided by usability experts, an organization can develop a workflow design process that exemplifies best practices and helps optimize the continuum of care. An infographic map can enable stakeholder collaboration by illustrating the relationships and metrics of healthcare processes. Furthermore, the mapping process can create opportunity for reducing risk and discovering new possibilities.

Sean Hägen is founding principal and director of research and synthesis at BlackHägen Design.