# Quality and Safety in Nursing/Tools for Analyzing Workflow
### Current Nursing Shortage and the Impact on Patient Care

With a median age for registered nurses (RN) in the workforce being 46 and 50% of the RN workforce approaching retirement, the current nursing shortage facing the United States does not look like it will be going away. To compound this problem the "baby-boomers" are approaching 65 years of age and having an increase in healthcare needs (American Nurses Association, n.d.). When surveyed, registered nurses tend to have stronger views of how the nursing shortage has affected the quality of care being delivered within the healthcare system than by other colleagues including, physicians, chief nursing officers, and chief executive officers. The reduction of care quality can come in a variety of forms including but not limited to: delay in patient calls, staff communication problems, increase in patient complaints, delayed dishcarges, increased wait times, and bed availability (Buerhaus, Donelan, DesRoches, et al., 2007). While the nursing shortage does not seem to be going away, it is important for the healthcare systems to analyze workflow to maximize the efforts of the nursing workforce.

### Methodologies for Analyzing Workflow

With the introduction of electronic documentation, several barriers existed to an effective implementation, particularly surrounding point-of-care documentation of patient vital signs. Throughout healthcare organizations, both intra- and extra-facility, there can be found a lack of standardization leading to inefficient documentation and potential room for errors. Another factor leading to problems in the workflow was technological setup for documentation leading to delays in documentation rather than documenting at the time of service. These problems associated with workflow lead to nursing workaround ingenuity, which can circumvent safety measure and reduce workflow efficiency (Yeung, et al., 2012). Below are a few methodologies that can be used to analyze workflow within the healthcare setting.

##### Human Factors Engineering

Human factors engineering (HFE) is the study relating to how individuals interact with the tools and environment for performing tasks or other activities within their domain. Within the healthcare organization HFE can be well utilized in analyzing workflows related to optimization of admitting processes, medication administration and distribution, and requisition of laboratory specimens. However, HFE is not designed as well to look at intellectual process that might be involved in the nursing profession; the cognitive portion of care delivery (Potter, et al., 2004).

##### Ethnographic Analysis

Ethnography is the study of a phenomena as it occurs within a given culture. It is qualitative in nature and healthcare organizations can use this methodology in order to better describe and understand organization systems. One approach to gathering information for enthnographic analysis includes direct observation or shadowing of parties being analyzed (Yeung, et al., 2012).

##### Link Analysis

The cooperative analysis of human factors engineering and ethnographic analysis can be used to form a link analysis. Through link analysis, time-motion of a process can be evaluated for "wasted motion" or inefficiencies within a process. An analysis could look at the number of phone calls, other staff inquiries, procedures, or missing care items that interrupt a nursing care process. Information obtained can then be used to form graphs, tables, and timelines showing interruptions in care delivery, types of interruptions, as well as shifts in the nurses' cognitive processes as she switches between patients (Potter, et al., 2004).

##### Unified Modeling Language

In order to graphically represent a process for improvement, Unified Modeling Language (UML) can be utilized. While UML was designed for graphically displaying software production steps (Object Management Group, 2005), graphical display of analysis of clinical tasks can assist in modifying healthcare workflow processes, particularly in relation to integrating technologies. Once implemented, UML can help clinicians or other professionals identify weak workflow areas and develop organization targets for improvement (Yeung, et al., 2012).

### Tools for Analyzing Workflow

The Agency for Healthcare Research and Quality (AHRQ) acknowledges that there are many methods for analyzing workflow, however makes recommendations to understand certain tools with which different methodologies could be used within the tool as below:
* Benchmarking
* Checklist
* Flowchart
* Interview
* Risk Assessment
* Usability Evaluation (Agency for Healthcare Research and Quality, n.d.)
While these are fundamental tools, the AHRQ provides a more comprehensive list of more than 100 tools that can be used for analyzing workflow.

### Example of Methodologic Implementation for Analyzing Workflow

One tool that was created using several methodologies for the purpose of analyzing workflow was developed by the University of Virginia termed, Remote Analysis of Team Environment (RATE). This electronic tool captures time-motion data while recording both quantitative as well as qualitative data during observed workflow. This workflow analysis tool was utilized in order to describe and evaluate workflow barriers and opportunities to improve nursing workflow in documentation of vital signs. RATE was used in order to minimize the intrusive nature of having a shadow or observer throughout the day, while providing multiple methodologies within a single study tool (Yeung, et al., 2012).

### Summary

Despite an aging workforce and continuing shortage of nursing within the healthcare organization, excellence in healthcare must still be achieved. To fill in this gap, healthcare organizations must optimize the resources they have available. While nursing provides the majority of patient care, focusing on analysis of nursing workflow will be an integral part of this optimization. Utilizing methodologies and tools that have a foundation in research will be important in ensuring that nurses ad hoc workarounds are minimized and improvement in care processes is obtained.

### References:

Agency for Healthcare Research and Quality. (n.d.). Workflow assessment for health IT toolkit. Retrieved from http://healthit.ahrq.gov/portal/server.pt/community/health_it_tools_and_resources/919/workflow_assessment_for_health_it_toolkit/27865.
American Nurses Association. (n.d.). Nursing Shortage. Retrieved from http://www.nursingworld.org/nursingshortage
Buerhaus, P., Donelan, K., DesRoches, C., Ulrich, B., Norman, L., & Dittus, R. (2007). Impact of the nursing shortage on hospital patient care: Comparative perspectives. Health Affairs, 26(3), 853-862.
Buerhaus, P.I., Staiger, D. O., & Auerbach, D. I. (2009). The future of the nursing workforce in the United States: Data, trends, and implications. Jones and Bartlett Publishers:Sudbury, MA.
Object Management Group. (2005). Introduction to OMG's Unified Modeling Language. Retrieved from http://www.omg.org/gettingstarted/what_is_uml.htm.
Potter, P., Boxerman, S., Wolf, L., Marshall, J., Grayson, D., Sledge, J., & Evanoff, B. (2004). Mapping the nursing process: A new approach for understanding the work of nursing. Journal of Nursing Administration, 34(2), 101-109.
Yeung, M. S., Lapinsky, S. E., Granton, J. T., Doran, D. M., & Cafazzo, J. A. (2012). Examining nursing vital signs documentation workflow: barriers and opportunities in general internal medicine units. Journal of Clinical Nursing, 21, 975-982, doi: 10.1111/j.1365-2702.2011.03937.x