Flow Chart

In healthcare, minimizing errors is key to improving patient outcomes.  To minimize errors, healthcare organizations must evaluate and re-evaluate their processes.  As technology improves, facilities seek to implement upgrades to current, antiquated systems in an effort to reduce potential errors.  However, “…there is a potential for patient safety…from technology implementations that do not address workflow…” (McGonigle & Mastrian, 2015, p. 231).  Workflow describes a sequence of steps, often performed by different members of the staff, executed to complete a task (Agency for Healthcare Research and Quality AHRQ, 2013).  Creating a flow chart to map out a task, allows the task to be broken down step by step and analyzed.  By mapping out each step in an activity, a design team can evaluate each task including who does this task, what technology is used, what polices are involved, and what information is required to execute this task.  The evaluation of these steps allows the design team to determine if the workflow is effective and to examine any areas of potential improvement.  For example, let’s examine a simple flowchart of how a patient receives an x-ray in the emergency department (ED).  

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The Process

The process (see attachment 1) begins with an x-ray order, which is placed by the provider into the computer.  An icon then appears on the patient tracker, which signals the unit secretary.  The secretary picks up the phone and calls the patient transport dispatcher notifying dispatch that the patient needs to be taken from the ED to the x-ray department.  The dispatcher sends a page to the patient transporter.  Once the transporter receives the page, he/she arrives in the ED, picks up the ticket to ride, has the nurse sign the ticket, and takes the patient to x-ray.  The patient then receives the x-ray.  Upon completion of the x-ray, the x-ray technician picks up the phone, calls the patient transport dispatcher to have the patient taken back to the ED.  The dispatcher sends a page to the patient transporter.  The transporter then receives the page, arrives in the x-ray department, picks up the ticket to ride, has the technician sign the ticket, and returns the patient to the ED.  The radiologist reviews the x-ray and types the report into the computer.  When the report is complete, an icon appears on the patient tracker, signaling the provider that the x-ray is complete.  The provider reads the report and then informs the patient of the results and follow up recommendations. 

Order Initiated

The provider, upon determining a patient’s need for an x-ray, initiates the order by typing the order into the computer.  The only personnel involved in this step is the provider, orders must always come from the provider.  Placing orders is within their scope of practice and is to be executed only by them.  In this step the only technology that is used is the computer.  However, the hardware and software must be working properly for this step to be executed.  Once the provider has placed the order into the patient’s electronic chart, an icon on the patient’s tracker pops up indicating the need for an x-ray. 

Transportation

The icon on the patient’s tracker prompts the unit secretary to pick up the phone and call the patient transport dispatcher, print the ticket to ride and place the ticket into the out-rack.  The dispatcher then sends out a page to the patient transport person, who then goes to the ED to pick up the patient.  When the transporter arrives in ED, he/she takes the ticket to ride from the out-rack and has the nurse sign the ticket.  The ticket to ride is a patient safety measure.  There is information on the ticket including the patient’s name, code status, fall risk and mental status.  This ticket must be filled out completely and signed with date and time by the nurse to ensure proper transportation of the patient through the hospital.  Personnel involved in this step include the unit secretary, the patient dispatcher, the patient transporter and the nurse.  Technology utilized includes the computer with the icon and a printer, the telephone, and a pager.       

To X-ray

With a signed ticket to ride, the patient transporter pushes the patient on a stretcher to the

x-ray department.  Once in the x-ray department, the x-ray technician signs the ticket indicating what time the patient arrived to have the test preformed.  The technician completes the test and calls patient dispatch informing them that the patient is done and ready to return to the ED.   In this step, personnel involved include patient transported, x-ray technician and patient dispatcher.  Technology utilized in this step includes the telephone and pager.

Transportation

When the dispatcher receives the call from x-ray, a page is sent to the patient transporter.  Upon receiving the page, the transporter returns to the x-ray department, picks up the ticket to ride, has the technician sign, date and time the ticket and then transports the patient in the stretcher back to the ED.  After returning the patient to the room, the transporter has the nurse sign, date and time the ticket ride.  Personnel involved in this step include the x-ray technician, patient dispatcher, patient transporter and the nurse.   Technology utilized in this step includes the telephone and the page.

The Report

After the x-ray images have been taken, the radiologist reads them and types up the report.  The report is then entered into the computer, and the icon on the patient’s tracker changes color indicating the test is complete, and results are ready.  The provider then reads the radiologist’s report, informs the patient of the results and makes recommendations for treatment.  This final step of the process requires involvement from the provider and the radiologist.   The only technology used in this step is the computer.  The report is typed into the computer, the provider reads the report in the computer, and the icon changes color based on the submission of the report by the radiologist.

Does This Work?

The current workflow for a patient to receive an x-ray in the emergency department is relatively effective.  There are minimal variables involved in this activity which allows for evaluation of effectiveness to be relatively simple.  The process by which a patient receives an

x-ray is dependent on six people and four pieces of technology.  Fewer variables mean there are fewer opportunities to interrupt the workflow, which leads to a decreased chance of errors (McGonigle & Mastrian, 2015). 

Room for Improvement

In this example, there isn’t much room for improvement.  The only step of the process that might make this example more efficient is from the dispatcher to the transporter.  That step is dependent on the dispatcher who chooses which transporter is sent to do which job.  Many times several transporters are available to transport patients, but because they were not assigned that job, they are not permitted to carry out the task.    

Importance of Activity Flow

Understanding the flow of activity via the workflow map “…helps to communicate the process of exchanging information and alleviates the misalignment in expectations” (Grinberg & Rendek, 2013, p. 127).  Ultimately, all healthcare organizations strive for operational efficiency, effective delivery of patient care, and positive patient outcomes.  Understanding the workflow can improve the flow of work, eliminate waste and reduce errors.  By evaluating each activity, strategies to remove waste and inefficiencies can be created.      

Conclusion

Comprehending the link between responsibility and the influence on results, team members engage in an efficient process.  Workflow mapping is an important step to manage workflow smartly.  Mapping allows the workflow to be understood, evaluated and improved in order to help root out inefficiencies, and ultimately optimize the effectiveness of workflow (Collaborative Minds Blog, 2016).   In a busy emergency department, efficiency is extremely important.  Timely management of a patient’s stay is directly tied to patient satisfaction scores which are tied to Centers for Medicare and Medicaid Services (CMS) reimbursements (Welch, 2018).