Blueprints Before Build, Part 1: Defining Workflow (and Bad Workflow)

I’m writing today to talk about burnout, or what’s also sometimes referred to as “moral injury.”

In the bigger discussion about healthcare reform, burnout is a hot topic, largely because of the multiple problems it’s causing. A number of physicians are leaving the medical field, usually after about 10 to 15 years in practice, to find non-clinical jobs.

And it’s not just physicians; nurses, pharmacists, and other clinical staff feel the same way. Healthcare is becoming ‘too much.’

When clinical staff leave either their position, or the field entirely, this creates problems for everyone:

• The personal (emotional and sometimes physical/financial) injury to the provider/nurse/pharmacist themselves (and their family)
• The replacement cost for that provider/nurse/pharmacist, including a recruiting cost, credentialing/onboarding cost, and training cost, which industry estimates show can cost more than $50K to $75k to replace a provider.
• The industry loss of a talented and hard-working clinical staff member, one that could be helping to care for patients as our country ages and the demand for providers in the next ten years goes up.

I know this topic well because, as a physician, I’ve been there myself, and personally understand the pain of bad workflows. This is one of the reasons I blog about clinical workflow design. While the EMR is often maligned for its contributions to provider burnout, I’d like to share a deeper clinical informatics understanding of where these workflow issues can stem from.

What is workflow?

I like to say that workflow is like carbon monoxide. It’s silent, invisible, and odorless, but if you don’t know about it, it can kill you.

When discussing workflow with clinical staff, I often get questions like these:

• By workflow, do you mean the way this button in the EMR makes this window open?
• By workflow, do you mean the registration policies of the organization?
• By workflow, do you mean the documentation policies that are often shaped by payor/insurers?

Workflow is all of the above.

One of the most well-known leaders in the national discussion about clinical workflow and Business Process Management (BPM) is Charles Webster, MD, who in 2016 offered this great definition of workflow in a blog post:

“Workflow is a series of tasks, consuming resources, achieving goals.”

When I train people on workflow design, I usually offer a slightly different definition that I think still fits with Dr. Webster’s interpretation, but has a few small distinctions. My definition is below:

“Workflow is a series of ordered tasks that uses people, time, and resources to achieve a desired goal.”

I expanded the definition because I feel it’s important to show the relationship between workflow and another important definition: procedures. As defined by Google, procedure means “an established or official way of doing something.”

What you start to see is that workflows and procedures are, largely, the same thing; they’re both essentially your ‘recipe for getting things done.’

How exactly does a healthcare organization get things done? This is an interesting topic. Healthcare operations is a complex dance between people (staff) and their environments. People often think of the EMR as the sole purveyor of workflow issues, but environments and clinical workflows are actually shaped by tools both inside and outside of the EMR:

Experienced Clinical Informatics professionals know that, when analyzing and fixing workflows, that half of the work is inside the EMR, and half of it is outside the EMR. Alternatively, it’s easy to create workflow inconsistencies by only focusing on the tools inside the EMR, or only focusing on the tools outside the EMR. Good workflow depends on synchronizing the tools on both sides of this technology fence.

What is ‘bad workflow?’

Bad workflow feels inconsistent. As I started to explain above, bad workflow happens when the procedures of an organization don’t fit as seamlessly as they could or should. Especially in healthcare, this can be difficult to manage, since patient care depends on the timely delivery of quality care, 24/7, no holidays or exceptions. In most industries, a 2-hour delay or downtime is tolerable. In healthcare, it is not.

Bad or incomplete workflow is not easy to find electronically or on paper, but it’s easy to spot through clinical staff interviews, or just listening to conversations. Some clinical staff understand workflows enough to recognize issues (and complain about them), but more often you will hear statements like:

• “Who made that decision?”
• “Why does it take so long to get things done?”
• “Why is it so hard to do the right thing?”
• “I can’t keep up.”
• “I stay after my shift to get things done.”
• “I’m constantly getting paged.” (Or, “I’m constantly having to page the doctors.”)

These are all symptoms of problematic or incomplete workflows. Having it take more than one phone call to schedule a patient, more than one order to obtain a medication, lots of clicks to get through an order set, or lots of extra documentation to ensure reimbursement from a payor are all signs of workflow problems.

Because so few people talk about workflow design, it’s easy to unknowingly create workflow issues by either focusing only on tools inside the EMR or outside the EMR, by incompletely addressing the workflow (e.g. only having 80 percent of the orders needed to admit a patient in your admission order set.), or through some combination of the above.

In the next installment of this two-part series, I’ll discuss what constitutes effective workflow, how it can be created, and why it’s so important, both for clinical and administrative users.

This piece was written Dirk Stanley, MD, a board-certified hospitalist, informaticist, workflow designer, and CMIO, on his blog, CMIO Perspective. To follow him on Twitter, click here.