Workflow is defined as a series of steps, frequently performed by different staff members and often dependent on related workflows, that accomplishes a particular task. Workflows represent how work actually gets done, not the protocols that have been established to do the work.
Clinicians and staff in busy practices suggest that one of the most helpful things a facilitator can do for them is help them map key workflows. Workflow mapping is a way of making the invisible “visible” to a practice so they can look for ways to improve their processes to increase efficiency, reduce errors, and improve outcomes. As a facilitator, you will have the skill, time, and vantage point to help a practice map its key workflows and then to lead discussions about improving them.
While many practices will have participated in workflow mapping for implementing electronic health records, many will not have used these processes with the idea of improving quality and outcomes. Workflow mapping is the process of documenting the specific steps and actions that take place in completing a particular task. Creating a workflow map enables you and the practice to see what is currently happening, identify opportunities for improvement or change, and design new, more effective processes.
You and the quality improvement (QI) team will need to consider workflows associated with the following three processes:
- Perceived process (what we think is happening);
- Reality process (what the process actually is); and
- Ideal process (what the process could be).
The perceived process can be obtained by having the group map what they believe the current process is. The reality process is obtained by having various group members validate the former through direct observation; the ideal process should reflect the workflow the improvement group aspires to and wants to implement.
Creating a workflow map is not difficult. However, it is very important to map what is actually happening, not what the practice “thinks” is happening or wants to happen. Figure 5.1 shows an example of a workflow map. You will need to identify every step of the activity and who performs it. It is important that each individual involved in a process can describe how a particular activity takes place. You should not rely on a single person to describe a process unless that person controls and executes all steps of the process being mapped.
To be effective in helping your practice map and redesign workflow, you will need a good working knowledge of the practice’s electronic health record and information technology systems so that you can assist them in redesigning workflows that use these systems. A good way to map complex processes is to observe the process in action. You may find that there is not a single process for carrying out a particular task, but several variations in how the activity takes place.
An important rule of thumb when mapping a process is “the person who controls the process controls the pen.” This means the person who actually carries out a particular process is the one who maps that step of the process.
Important processes that you will need to be prepared to help a practice map include:
- Answering phones
- Making appointments
- Scheduling procedures
- Making referrals
- Dispensing phone advice
- Assigning patients to panels
- Completing new patient workups
- Educating patients/family
- Managing patient panels
- Planning patient visits
- Coordinating referrals
- Conducting patient outreach
- Checking formularies
- Entering lab results into the information systems
- Making referrals for specialty care and community services
- Consulting with specialists
Many additional activities carried out by a practice will need to be redesigned when it transitions to team-based care. These include:
- Appointment scheduling
- MA role (previsit, vitals, agenda setting, checking chronic and preventive care needs, ordering)
- Receipt of test results by clinician (lab, x ray, other)
- Receipt of test results by patient (normal, slightly abnormal, very abnormal)
- Internal messaging (which messages go to whom, what action is required)
- Prescription refills (chronic meds, acute meds, secure script meds)
- Billing workflow
- Form completion (clinician role, other team member role)
You should also be prepared to assist in mapping and redesigning clinical care processes for specific patient groups:
- Healthy/preventive care
- Acute problems (major/minor)
- Chronic conditions (diabetes, hypertension, congestive heart failure)
- Complex care needs
- Mental health
- Chronic pain
- Women’s health
- Well child care
- Palliative/end-of-life care
Many resources available online for free or at a small cost can assist you in preparing polished maps. Maps can also be handwritten or constructed with sticky notes to allow a practice to move activities around and redesign workflow. These types of maps are better during the active mapping stage. Your program may provide these resources or ask that you use them, or you may want to explore them on your own.
Helping Practices Redesign Workflows
Redesigning workflows has two goals: improving performance and increasing efficiency. Once you document the reality process, you will need to assist the QI team and other members of a practice to redesign the workflow to incorporate the desired improvements and then test these changes using the Plan Do Study Act (PDSA) process.
When redesigning workflow, it is essential to have all key players involved in the process. The frontline staff who are currently or will be implementing the workflow will have recommendations and ideas for how to maximize efficiency and effectiveness.
It is rare that a workflow is completely independent of other processes in the practice. In most cases, workflows for one activity will overlap or depend on the execution of another activity or process. It is important to identify and consider these dependencies when redesigning workflow, as the effects of redesigning a workflow can be positive or negative.
It will be important for the team to be able to determine the potential peripheral effects of redesigning workflows. The Model for Improvement and PDSA can help a practice identify unanticipated effects of redesigned processes and correct them before taking them to scale.
New workflows will often require realigning jobs, changing staff time allocation, roles, and responsibilities to fit the redesigned workflows. This in turn will require changes to policies and procedures, job descriptions, training, and accountability/reporting systems for ensuring tasks are completed.
When working with a QI team and practice staff on redesigning workflow, you will need to provide them with a copy of the existing workflow. This should be large enough for everyone on the team to view together and to mark up as they design new processes. Table 5.1 contains some questions that can be useful in starting a team on the redesign process. Review the following questions with the practice:
Once the team has developed a new workflow, it will need to be implemented and evaluated. The PDSA process from the Model for Improvement can be a good way to test the effectiveness of a new workflow. You will need to be prepared to assist the QI team in implementing and evaluating the impact of a new workflow as part of the PDSA cycle. You also need to include them in thinking through the different administrative changes that will be required to fully implement and sustain newly redesigned workflows.
Throughout this process, your goal as a facilitator will be to build the team and practice’s capacity to engage in these processes in the future, as understanding and modifying existing workflows is an essential component of any improvement process. AHRQ’s Integrating Chronic Care and Business Strategies in the Safety Net toolkit contains resources from Clinical Microsystems for training practices in workflow mapping. This toolkit is available at: https://archive.ahrq.gov/professionals/systems/primary-care/businessstrategies/index.html.