Sample Assignment 1: Workflow Analysis Directions

Purpose
The Purpose of this assignment is to:

1. Understand the benefits of nurse workflow analysis in improving clinical and

administrative performance using standard flowcharting symbols and rules.

2. Compare and contrast the benefits of information technology and process

improvement to enable nurse workflow and improve clinical and administrative
outcomes.

Directions

1. Review the brief description of the workflow in primary care clinic for a typical
patient visit using a paper medical record.

2. Review standard flowchart symbols at the following website:

http://www.breezetree.com/articles/what-is-a-flow-chart.htm

3. Using the flow chart symbols in Word (Insert => Shapes => Flowchart Symbols)
develop a flowchart of a typical patient visit from the time the patient schedules
an appointment , completes the visit, and leaves the clinic using the format in
Figure 1 (remember this is just an example):

4. Review the Key Workflow Problems listed after the Description of the Workflow
for a Primary Care Clinic.

5. Each student should write a narrative summary (no longer than 4 pages, 12 point
font, double spaced excluding references and title page) that describes how
information technology could address each of the workflow problems listed. For
example; clinical decision support systems integrated into an electronic health
record can alert users to potential drug allergies or e-prescription can eliminate
the need for paper prescription pads. Make sure to not only identify what the
information technology is, but how it will improve workflow and clinical or
administrative outcomes.
 Figure 1
Example of Clinic Flowchart Format

Appointment Scheduling Workflow Template

Provider
Clerk or

Patient needs
appointment

Select provider
No Search for patient and Open Select Reason or
New
in system (MRN, appointment Type of
Patient?
Name, DOB, etc.) schedule Appointment

Yes
Scheduler

Search for specific

Create new record Enter patient date or next
in system information available
appointment

Summarize
Select
Appointment appointment
appointment
Scheduled verbally or give
slot(s) and save
appointment card

Office Visit Workflow Template

Patient

Arrives &
checks in

Obtains Escorts
Views EHR Select & open MU Objective:
Greets patient patient’s patient to Enters vitals
schedule & patient’s Record and chart
and escorts to weight, height, exam room & chief
patient “arrived” electronic changes in vital
clinic area blood pressure, & logs into complaint
status record signs
temp., etc. EHR
Nurse/Support

Record history:
Verify &
Secures past medical, MU Objective:
record
workstation social, family, Maintain active
allergies &
and leaves substance medication &
current
room (smoking medication allergy list
medications
history), etc.

MU Objective:
Record smoking status
for patients 13 years old
or older

Enters the Documents

Performs chart
room, greets Consults with Performs review of Updates problem list
review before
patient, and patient and physical systems & & triggers CDS rules
entering exam
logs onto records HPI exam physical exam if needed
room
workstation into EHR
Provider

MU Objective:
Places
Provides Assigns Maintain problem list
Closes the orders as
patient with Level of of current and active
encounter in necessary
instructions/ Service diagnoses &
EHR (see Orders
materials (LOS) implement relevant
workflow)
CDS rules
 6. Revise your current flowchart to integrate the new information technology and
new process flow described in #5. An excellent resource for this project is listed
at the Office of the National Coordinators website at
http://www.healthit.gov/providers-professionals/frequently-asked-
questions/411#id80 . These include two PowerPoint presentations entitled,
“Workflow Process Mapping for Electronic Health Records” and “Workflow
Redesign Templates”.

7. When you complete your flowcharts and summary of recommendations, post

them in the dropbox for Assignment #1 Workflow Analysis.

Grading Rubric for Assignment #1, Part 1

Number Description Points

1 Design the current state primary care clinic 25
workflow using standard flowchart symbols.
2 Summarize various recommendations to improve 40
workflow and clinical and administrative
outcomes using information technology
(software, hardware and other devices)
3 Integrate recommendations to improve workflow 25
and revise the current state flowchart to reflect
the changes.
4 Use of appropriate references, format and style 10
in completing the paper and flowcharts.
Total 100

CASE STUDY DESCRIPTION

WORKFLOW FOR A PRIMARY CARE CLINIC

WITH A PAPER MEDICAL RECORD

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. If the patient is a returning patient the file clerk pulls the existing paper record

from the file room, updates the demographic information and then places the chart in

the pending charts bin. The day before the patient arrives for their appointment, the file

clerk places the paper chart at the front desk so that it is available when the patient

arrives for their appointment.

Upon the patient’s arrival, the receptionist queries the patient’s social security

number and verifies the patient’s identity with their last and first name. Demographic

information is validated or updated in the registration system. The patient then receives

a paper encounter form, requesting information on past medical history, current health

concerns and reasons for visit, to be completed while waiting to be placed in an exam

room. In the meantime, the nurse is alerted that the patient has arrived and when

available, rooms the patient in an exam room in the clinic.

The second portion of the workflow includes: the physician’s physical exam,

patient laboratory, radiologic and other testing, and patient discharge. Once the patient

is in the exam room, the nurse reviews the completed encounter form, obtains the
patient’s vital signs and enters the patient’s chief complaint and other relevant data into

the paper record. After the nurse completes these tasks, the physician begins his

encounter with the patient and completes the exam. The physician documents the exam

and writes orders, including medications, lab, radiology and referrals in the chart after

the encounter is completed. If the physician writes an order for medication, she

provides a written prescription to the patient before they leave the exam room. The

physician then flags the chart (to indicate that the chart has orders) and then returns it

to the nurse. Upon completion of the visit the patient stops at the clinic front desk and

schedules any return visit. The nurse then executes the orders (facilitates scheduling of

lab, radiology, medication prescriptions and so forth).

When lab and radiology results are ready, they are printed to the clinics printer

and the nurse then places the printed results into the chart. Patients are called with

any abnormal lab and radiology results or sent a letter stating results are within normal

limits. When patients need prescriptions refilled, they contact the receptionist who then

places a hand written note at the nurse’s station in the clinic. The nurse then places the

note in the patients chart and places it in a bin for the physician to review at the end of

the day. Once the physician writes the refill prescription, she places the chart in the bin

and the nurse contacts both the pharmacy and patient.

Key Workflow Problems

1. Patients frequently complain about having to fill out and update the registration

forms and health history in the waiting room when they first arrive at the clinic for

their appointment.
2. Paper charts occasionally become lost and staff spend a substantial amount of

time searching for them.

3. Nurses complain that it is difficult to read the physicians handwriting and have

made errors in transcribing orders.

4. It takes considerable time to sort through printed lab and radiology reports and

place them in patients charts for the physician to review. It would be much easier

to have all lab, radiology and other ready to go for each patient the day before.

5. Nurses complain that they spend an enormous amount of time checking patient’s

drug allergies and validating correct dosages on medication orders. They often

use Google to look up drug information.

6. Patients frequently lose their paper prescriptions written at the office and nurses

spend a considerable amount of time having to call the pharmacy to validate

them.

7. Patients often ask for information regarding their disease condition and nurses

spend a considerable amount of time searching for reliable information on the

Web to educate them. Evidence based guidelines are changing all the time and

it is difficult to keep up with best practices.

8. Clinic physicians complain that there is not a good system of informing them if

one of their patients has been admitted to the emergency room or admitted to the

hospital. Emergency room staff complain that they do not have access to

outpatient records and the patients past medical history when they are seen in

the emergency room.

9. Clinic physicians and nurses complain that it is difficult to piece together the

“patients story” in the paper chart. Much of the information is fragmented and

caregivers need to see key metrics (trended lab, weight, BMI, and other data) in

one place.

10. Patients would like to become more engaged in wellness and make less visits to

the clinic for routine health monitoring such as tracking their weight, blood sugar,

exercise program, adherence to a diet and so forth. Many also would like to

become involved in various support groups but cannot leave their homes. And

they would also like access to their own medical record so that they can review it

at home.