Chapter 31. Organizational Workflow and Its Impact on 

Work Quality 

Carol Cain, Saira Haque 

Background 

What Is Workflow? 

Workflow, loosely defined, is the set of tasks—grouped chronologically into processes—and 

the set of people or resources needed for those tasks, that are necessary to accomplish a given 

goal. An organization’s workflow is comprised of the set of processes it needs to accomplish, the 

set of people or other resources available to perform those processes, and the interactions among 

them. Consider the following scenario: 

On a slow Friday afternoon in the emergency room, as one nurse prepares to go 

off shift, the clerk looks up from the desk and asks, “By the way, since you’re 

passing by housekeeping on your way out, would you remind them that room 12 

still needs to be cleaned?” 

“No problem,” replies the nurse, and indeed, on a slow Friday afternoon, it is no 

problem. The informal methods and processes that the hospital has developed 

over the years to keep the enterprise humming work well, in general, and can 

work very well in optimal times. It’s no trouble to remind housekeeping to come 

up; it’s no trouble to run a special specimen down to the lab, and certainly no 

trouble to catch the attending physician during rounds to get a quick signature. 

Even if these small adjustments are forgotten, in due time the regular hospital 

schedule will bring the right people to clean the room, to pick up the lab 

specimen, to document the encounter. 

These same methods that an organization uses to get work done, however, can begin to show 

stress under trying circumstances. When the ward is full and it takes 12 hours for a room to be 

readied for the next patient, that impact is felt throughout the organization. When the number of 

small interruptions outweighs the amount of planned work done in a given hour, that impact is 

felt in slower progress, lower job satisfaction, and potentially lower quality of care. In many 

situations, it is very clear to all what needs to get done. Where organizations differ is in how they 

do it. The examination of how an organization accomplishes its tasks often concerns the 

organizations’ workflow. 

In health care, as in other industries, some workflows are designed, while others arise 

organically and evolve. The systems and methods by which organizations accomplish specific 

goals differ dramatically. Some organizational workflows seem more straightforward than 

others. Most often, when workflow processes are looked at in isolation, the processes appear 

quite logical (and even efficient) in acting to accomplish the end goal. It is in the interaction 

among the processes that complexities arise. Some of these interactions hide conflicts in the 

priorities of different roles in an organization, for example, what the nursing team is accountable 

to versus the physician team and its schedule. Organizations also adapt workflows to suit the 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

evolving environment. Over time, reflecting on organizational workflows may show that some 

processes are no longer necessary, or can be updated and optimized. 

Why Is It Important to Nurses? 

Health care has often faced the pressure to design, or redesign, its workflows to be more 

efficient and effective. In many cases, the trigger for examining workflow is in response to 

changes in how things are done. Today, the need to think about workflow design is more 

pressing due to several factors, including: 

• The introduction of new technologies and treatment methodologies into clinical care 

• The challenge of coordinating care for the chronically ill 

• The participation of a growing array of professionals in a patient’s care team, and new 

definitions in their roles 

• Cost and efficiency pressures to improve patient flow 

• Initiatives to ensure patient safety 

• Implementation of changes to make the care team more patient-focused 

One important reason that workflow is of pressing concern for today’s clinicians is the 

introduction of new health care information technology (health IT) into clinical practice. Health 

IT promises many benefits for improving quality and efficiency. However, the introduction of 

health IT can be very disruptive to existing workflows in an organization. Health IT systems 

often implicitly assume a workflow structure in the way their screens and steps are organized. 

Organizations that are thoughtful about workflow design are more likely to be successful in 

adapting to health IT.1

In contrast to industries such as manufacturing, health care is a service industry that relies 

heavily on good information. In closely following and taking care of patients, nurses are 

guardians of a rich source of information. This valuable information can be lost when poor 

workflows impede communication and coordination or increase interruptions.2 Characteristics of 

a poorly functioning work process include unnecessary pauses and rework, delays, established 

workarounds, gaps where steps are often omitted, and a process that participants feel is illogical. 

The design of good organizational workflow is not simply about improving efficiency. 

Workflow processes are maps that direct the care team how to accomplish a goal. A good 

workflow will help accomplish those goals in a timely manner, leading to care that is delivered 

more consistently, reliably, safely, and in compliance with standards of practice. An excellent 

workflow process can accommodate variations that inevitably arise in health care through 

interaction with other workflow processes, as well as environmental factors such as workload, 

staff schedules, and patient load. 

Research Evidence 

Health services researchers have explored workflow issues from several angles, including 

mapping processes from other industries into health care. Literature about workflow can be 

found in several different domains, such as quality improvement, technology implementation, 

and process improvements. One common thread throughout the literature is the importance of 

interdisciplinary involvement in all aspects of workflow analysis and implementation. 

Reviewing the evidence to date, targeted studies of particular interventions and technologies 

amply show that good workflow design has significant (expected and unexpected) impacts on 

2 
Workflow 

care delivery.3 The literature also demonstrates a relative lack of sophistication in studies of the 

field: whether researchers are initially concerned with the problem or whether it arises 

organically from the results; whether the researchers have a theoretical framework to interpret 

their findings; whether there is consistency in the outcomes of interest; whether the target(s) of 

study are structural, cultural, and/or functional; and whether the researchers are able to 

generalize from the findings in one setting to another. Many studies demonstrated significant 

benefit from careful consideration of workflow, but few studies provided easily adaptable tools 

and methods for immediate, consistent implementation. 

Effect on Efficiency 

Workflow analysis has often been used with the goal of improving efficiency. In response to 

financial pressure and incentives driving provider organizations, minimizing slack time has 

become important. Some of the studies discussed below demonstrated the power of analyzing 

and changing workflow to improve efficiency. 

Workflow analysis can be used to redesign existing processes. A classic study of this type is 

Cendan and Good's4

 analysis of the routine tasks of the various members of the operating room 

(OR) team. They found that there was a wide variability in functions based on clinical and 

organizational factors. They designed a new workflow based on the analysis and conducted a 

pilot study. Part of their recommended solution involved defining functions in a more consistent 

fashion. They were able to improve turnover and improve the mean number of cases handled in a 

day. A significant factor in their success was their consideration of workflow from both the 

physician and the nursing perspectives. 

Efficiency can also be improved by carrying out processes in parallel, rather than improving 

the efficiency of existing steps.5 Friedman and colleagues6 compared the impact of administering 

anesthesia in the induction room versus in the OR for hernia repair patients. They found that the 

OR time used by the surgeon decreased without significant impacts on patient satisfaction or 

outcomes.6 Harders and colleagues7 employed a combination of approaches. They used parallel 

processing and process redesign to improve workflow in a tertiary care center with multiple OR 

suites. This combination of approaches allowed for a reduction in nonoperative time. Similarly, 

in a study of trauma teams, Driscoll and Vincent8

 modified task allocation so that standard tasks 

performed during a trauma code were conducted in parallel rather than sequentially. 

In each of these approaches, role definition played a critical role in the success of the efforts. 

Each study found that nursing routines often included nonclinical tasks, such as tracking down 

missing information or supplies.9

 By defining roles and essential processes, it was possible to use 

ancillary staff for these tasks. In order for the redesign to be successful, nursing involvement was 

important from the beginning. An interdisciplinary approach provided the basis for the workflow 

analysis and redesign; this was cited as a success factor in multiple studies.4, 6, 7 

Common Issues 

Workflow issues often arise in studies of technology. One well-studied domain area is 

barcode medication administration (BCMA).10 BCMA is a technology that has been shown to 

improve care quality by reducing reliance on memory, increasing access to information, and 

increasing compliance with best practice. However, very simple inconveniences—such as the 

need to access a patients’ wrist for the barcode strip—have led to workflow workarounds, such 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

as scanning barcodes off a key ring rather than the patient. In this case, the nurses’ adaptation to 

make their work more efficient circumvents some of the intended benefits of the defined process. 

More complex interactions have also been observed. Because many BCMA systems require 

that the physician enter an order before the nurse can have access to the medication, some nurses 

have, in critical situations, “borrowed” medication from one patient on the ward to give to 

another until the medication for the second patient appears in the system. As a result, the nurse 

cannot readily document the administration of the order until the order has been entered by the 

physician. In some situations, a shadow system of informal paper documentation supplements, 

duplicates, or confuses the documentation captured in an electronic system. 

When technology does not adequately support the goals of the care team, it often causes 

workaround workflows. These alternate workflows are a cause for concern because these 

informal, evolutionary systems rely on the clinicians’ memories, and bypass decision-support 

safeguards that the system may provide. Studies have documented other negative effects,11 such 

as degraded coordination between nurses and physicians, nurses dropping activities during busy 

periods, and decreased ability to deviate from routine sequences. 

Information Transfer 

Health care organizations provide valuable services that rely on large amounts of high quality 

information. Information transfer is complicated because caring for one patient can involve many 

providers and information sources. Thus, many errors occur at handoff or transition points.12

Dykes and colleagues13 found that many hospitals in the United States have dual paper and 

electronic records, leading to redundancies and inefficiencies in information. Other information 

tools include proprietary paper forms, the phone, the electronic record system, the whiteboard, 

the pager, and schedules.14 In addition, informal meetings and verbal orders frequently also serve 

as information transfer devices.15 

One attempt to address this complexity is an electronic portal that provides access to systems 

through one interface.16 Though this can mitigate the problem, it cannot fully address the 

communication needs of a care team. 

A common class of problems with information transfer and handoffs includes degradation of 

information.17 If methods of transfer are informal and not documented, patient information may 

not be passed on when staff members leave a unit. In addition, the lines of responsibility and 

expectations are not always clear.17 Incorporating formalized information transfer tools and 

protocols into workflow processes may help. Another problem complicating information transfer 

is interruptions. These interruptions often cause a break in workflow, which can impact what 

information is documented and passed on.18, 19 

Intra-Professional Information Transfer 

Nursing work is often fragmented and rushed, due to external pressures and the dynamic 

environement.20 However, nurses serve as critical integrators and coordinators of care. Health IT 

tools, which can help nurses better manage and transfer information and make the information 

more widely available have the potential to improve practice.21 Intraprofessional handoffs may 

occur within or across departments. In either case, communication and coordination is improved 

by having a structured documentation format.22 

4 
Workflow 

Lamond23 reviewed the content of nursing intershift reports and found that more information 

was documented in the patient notes than was given in the report. The report information tended 

to be more overall assessments of patient care, which was not necessarily documented. Thus, it is 

not clear if the detailed information was transferred in subsequent reports. Perrott24 found that 

customizing data fields and having nurses involved from the beginning enhanced nursing 

handoffs in the intensive care unit (ICU). 

By understanding nursing workflow, barriers and facilitators for information transfer can be 

discussed and improved upon.25 If handoff mechanisms are informal, then they might not be 

documented in a workflow analysis.26 Health IT systems should not replace these handoffs, but 

could be used to augment the process.27 However, when the processes are not well understood, 

the technology may not be used and may even be a burden. 

Inter-Professional Information Transfer 

Inconsistent or incomplete information during patient care transfers is a commonly cited 

communication difficulty.28 This problem is exacerbated by systems and processes with 

duplicate or outdated information. There is a great deal of information available, but it is not 

always available in a streamlined or organized fashion.29 

Clinical providers trained in different disciplines are socialized and trained differently, so 

they do not necessarily know what the others need.29 Thus, when designing and implementing 

information technology across departments, it is important to have an interdisciplinary team 

involved throughout the process.22 Physicians and nurses do not generally have the same 

employer and often have varying loyalties and end goals.4 Thus, it is important to consider many 

perspectives when designing handoff and communication practices. 

One way to look at interprofessional collaboration is to look at information needs. Reddy and 

colleagues30 reviewed information needs of various providers in the ICU. They found that some 

roles, including nurses, served as information sources for other providers. Thus, it is important to 

consider the workflow implications of changing information sources. When a face-to-face 

communication with a nurse is replaced by an electronic report, what is lost and gained? 

Electronic access provides the benefits of ready access to large quantities of source data, 

potentially supplemented with decision support. What may be lost are functions of information 

synthesis, summarization, and coordination. In a survey of chief nursing officers, Dykes and 

colleagues13 emphasized the role of nurses as coordinators and communicators. 

Riley and Manias31 looked at physician–nurse communication in an OR setting. They found 

that nurses often had informal knowledge of physicians and their habits, which they used to 

control practices. This knowledge was not necessarily codified formally, so new nurses would 

have difficulty in estimating workflow. Health care organizations have engaged in efforts to 

standardize inter-professional communication, for example through requiring the use of SBAR 

for situational briefing.32 

It is not always necessary to have a separate process for interprofessional communication. 

Indeed, other efforts can be repurposed for interprofessional communication. For example, 

Cunliffe33 described a nursing discharge summary process which was repurposed to provide a 

nurse–general practitioner communication device. A nursing discharge summary provided 

detailed information about nursing and social care for the patient after they left the hospital. In 

addition, sending this to the general practitioner (GP) provided a mechanism for communication 

so that the GP would be well-informed about the patient’s care. Similarly, a resident sign-out 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

system could also be accessed by other professionals.34 However, communication lines tend to 

be separate and dependent on professionals, so it is not clear how much intraprofessional access 

occurs. Patterson and colleagues35 studied handoff strategies in other industries and outlined 

some common strategies for effective handoffs. Often, documentation was a supplement to the 

handoff, rather than the sole mechanism for information transfer. 

Health Information Technology 

Health IT, used well, can improve efficiency and organizational workflow. In health care, 

redundant information is often created and stored. As a result, care providers spend a great deal 

of time reconciling information from various sources. Integrating health IT with the workflow of 

various departments can help to reduce this redundancy.22 However, if workflow is not 

considered and the technology is not thoughtfully implemented, the benefits cannot truly be 

achieved. To use technology most effectively, its potential impact to transform care delivery 

must be realized.36

While it is important to consider workflow when implementing health IT, it does not mean 

that health IT should leave processes intact. Health IT can bring about positive process change 

and better workflow. Because IT can consolidate and display information, it can be used as an 

opportunity to improve upon teamwork and communications.37 Understanding existing clinical 

workflow prior to implementation provides a baseline to redesign systems and develop better 

processes.38 Scharmhorst, Johnson, and Li39 emphasized the importance of understanding the 

system prior to implementing technology, to ensure that technology streamlines nursing 

workflow, rather than making it more complicated. In a study of mobile cabinets with barcode 

scanning for medications, Braswell and Duggar40 found that, by analyzing workflow ahead of 

time, both pharmacy and nursing staff reported improvements to existing work processes after 

implementation. Workflow concerns can lead to failure to adopt new technologies. A study of 

electronic prescribing systems standards finds that many of the electronic standards are adequate 

but provider adoption is low because the systems do not fit into workflow.41 The evaluators 

recommend that the standards and systems be revised to accommodate the large role of nurses in 

electronic prescribing in the office setting. 

Focus on Computerized Provider Order Entry 

Computerized Provider Order Entry (CPOE) is an easily measurable, frequently implemented, 

and often intrusive instance of health IT, and has been studied often in the literature. CPOE is 

commonly associated with its impact on physician practice. However, there are workflow 

implications in CPOE implementation for the entire care team, including physicians and nurses.42

For example, if physicians refuse to use the CPOE system, it creates adverse impacts on nursing 

workflow.3, 28 Sometimes, nurses become the de facto order entry personnel, in addition to their 

nursing duties. These workarounds also have effects downstream. Delays in order entry can hold 

up medication delivery. The introduction of CPOE technology may surface informal practices 

that may not be in compliance with prescribing scopes of practice. Thus, nurses are a key success 

factor in CPOE implementation.43 Because nurses often are primarily responsible for 

communication and coordination of care, understanding nursing workflows with respect to order 

entry is critical.44

6 
Workflow 

Payne45 found that implementing CPOE had a profound impact on work patterns, 

communication methods and roles. In analyzing workflow around electronic prescribing, the 

range of tasks completed by the nonprescribers was outlined.46 After outlining the work 

processes and information flows, they were able to adapt the system to accommodate the 

necessary tasks. Similarly, Wright and colleagues47 found that physician-nurse communications 

were impacted by the CPOE implementation. Paper-based order entry often relies on visual cues, 

such as a folded piece of paper. If the loss of context and visual cues is not accounted for in the 

CPOE implementation, then the nursing workflow is adversely impacted because of the 

uncertainty around orders. 

Piasecki and colleagues48 conducted a workflow analysis to look at the benefits of 

implementing CPOE in an emergency department setting. These researchers developed a returnon-investment tool to measure the outcomes of the implementation and found that many of the 

savings did not make a direct impact on the bottom line of the organization. This was, in part, 

because the changes in workflow were not fully understood until after implementation. 

Though guidelines for analyzing workflow are few, the common factor was consideration of 

all affected roles in the organization, not only those involved with entering data into the IT 

system. Breslin and colleagues49 found that having an interdisciplinary team was important in the 

success of a Vocera implementation. This team included clinical and nonclinical staff. By being 

inclusive, they learned about workflow from a variety of perspectives and were able to 

implement their tool in a fashion that would improve upon existing practices. 

Ongoing Work in Nursing Workflow Research 

Research into the workflows of nurses has long roots in studies of how nurses spend their 

time and how nursing teams should be staffed.50-52 Nurse researchers embarking on observational 

research of nursing work can take advantage of previously developed tools for work task analysis 

and time motion study.53-55

With the introduction of new technologies, the research frontier includes studies of how 

nursing work is affected, with the aim of ensuring quality time at the bedside. An ongoing large 

multi-site time-motion study of nurse workflow56 includes the involvement of frontline nurses in 

the design and improvement of their work spaces and technologies. It represents one way that 

lessons learned from past research can be brought to bear on future workflow design, with the 

intent of mitigating the pain of learning workflow and technology weaknesses through 

implemented experience. 

Practice Implications 

The research findings for these studies of operational workflows have practice implications 

for nurses and researchers. Throughout the literature, the importance of bringing multiple parties 

to the table was emphasized. Because organizational workflows often cross the lines of 

professional disciplines, workflow design from any single perspective runs the risk of suboptimizing against other constraints, priorities, and schedules. 

Conscious workflow design has been shown to improve the efficiency of existing work 

processes or enable parallelization of work. In designing such systems, researchers emphasize 

the importance of clearly defining roles and responsibilities, preferably with multi-disciplinary 

input. Designing workflow is of critical importance to all roles in a health care organization, 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

because the effects of decisions by an expert in one role may have downstream effects on others. 

A workflow optimized to serve one role, such as the nurse, can be onerous or seem irrational to 

another. Because each professional role deals with fairly complex, role-specific work processes, 

it is often difficult for experts in one role to understand and envision how proposals will affect 

other roles, even with the best intentions. Research on information transfer in organizational 

settings demonstrates that adaptations to poor workflows can lead to increased interruptions, 

workarounds, and informal or ill-defined communication. To improve the reliability of 

workflows accomplishing their desired goals, and to reduce the risk to patient safety, researchers 

recommend structured communications and clear agreements about roles and responsibilities in a 

hand-off. 

Health IT systems surface many of the long-standing issues around workflow. The 

implementation of health IT systems can, at first glance, seem like a superficial intrusion into the 

way things are done. For some, it feels like the addition of another documentation step in the 

process of regular clinical care. This step can be disruptive and a burden, but it does not 

dramatically change the way work is done. Yet there are many downstream effects on 

communication and coordination within an organization. Analyzing workflow beforehand can 

help prevent some of these unintended consequences. Technology does not necessarily improve 

institutional efficiencies, but can bring opportunities for improvement to light.42 Sittig and 

colleagues38 found that while considering that technology was important, it was also important to 

consider organizational and workflow factors prior to implementation, or the benefits may not be 

realized. In order to realize good outcomes, interdisciplinary consideration of process and 

technology factors was important.57

In many organizations, the adoption of health IT is motivated by the desire to accomplish 

goals that are difficult without a structured electronic system. These goals include reducing 

medication errors through barcoding; improving clinical decisionmaking through decision 

support, such as alerts and reminders; measuring clinical quality performance; proactively 

reaching out to patients for population health management; or simply the ability to analyze 

clinical information, for example, by charting a patients’ blood pressure based on nursing notes. 

These additional expectations of a health IT system mean that the organization can expect 

dramatic changes in workflow—the health IT implementation is a vehicle to trigger larger 

improvement activities. 

It is important to realize that health IT systems have a built-in sense of how things are done, 

in fact, have an inherent workflow that may or may not map to the organizations’ workflow. 

Consider the case of CPOE. Let’s describe the workflow process as a series of tasks, linked 

chronologically, that require organizational resources. The logical model within a health IT 

system usually goes something like this: 

1. The provider enters an order. 

2. The pharmacist verifies the order. 

3. The order is delivered to the point of care. 

4. The nurse administers the order. 

There are two things to note about this perfectly reasonable assumption about how things are 

done. The first is that the workflow is very linear. It will be very important to understand what 

happens if that linearity is disrupted somehow. For example, if the pharmacist fails to verify the 

order, will the system prevent the order from being “released” until this step is accomplished? 

Flexibility within a linear workflow is very important to the smooth operation of a complex 

service organization like a health care institution. Practitioners have a responsibility to check that 

8 
Workflow 

a health IT system reacts gracefully to a change in workflow, lest patient care be compromised. 

The second thing to note is that the workflow within the system only reflects one of the ways 

health care is delivered in an organization. In many critical care settings, for example, 

medications must be administered quickly, before any interaction with a CPOE system. 

Practitioners should also ask whether the health IT systems they are implementing reflect all of 

the main workflow processes within their organization. 

When a new health IT system or a new technology fails to accommodate the real workflows 

of an organization, interacting with the technology becomes a greater burden on the organization 

than is required. In essence, there is “the way the world works” and then “the way the computer 

thinks the world works,” and it is the constant responsibility of system users to reconcile the two 

world views. In fact, implementing health IT systems within organizations poses such a 

challenge that the Office of the National Coordinator for Health IT has estimated that as many as 

30 percent of all implementations fail.58 Thoughtfully constructing the workflow inherent to the 

technology can smooth technology acceptance.59, 60

Before implementing information technology in a health care environment, it is important to 

have an understanding of processes and information flows. In addition, it is important to consider 

various roles in the different departments, and to consider ideas from multiple sources.22 Each 

department and role may have a different perspective of the encounter and its necessary 

elements.36, 61 In addition, many organizations have a variety of tacit assumptions and 

information exchanges which might not be documented in a traditional analysis. Thus, it is 

important to consider multiple sources of data in order to develop a more complete 

understanding of workflow and processes.36 

In the United States, hospitals are generally organized by functions. Because of that, 

workflow is also organized around these functions. Information systems were developed around 

these functions and were designed to meet the needs of a particular department. However, patient 

care takes place through a broader perspective. Thus, these functions need to be integrated.20 In 

conducting a workflow assessment, it is important to consider how workflow currently functions 

and how it might change to improve patient care and reduce errors throughout the system.20, 62 In 

addition, this kind of analysis can help find flaws in the process for which information 

technology can be leveraged.20 

The truth is that many care teams do well even when workflow processes are designed 

poorly. Health care practitioners understand the clinical needs of patients. Health care workers 

often go to heroic lengths to make sure that the right thing gets done. When a problem arises, 

most clinicians would not hesitate to pick up the phone, run the errand, or do what is necessary to 

insure good care. Yet clinician resources are not unlimited. When nurses, like all people, get 

tired, they may become forgetful When they are rushed, they may not remember to do everything 

necessary.63 These issues may be exacerbated by a health IT system that seems not to understand 

what the clinicians want to do—sometimes because the workflows in the health IT system do not 

match those in the real organization. In the seminal work on clinical error, the health care 

community acknowledged that most errors are the result of systematic deficiencies.64 Good 

workflow processes are an aid to practitioners to insure that the system behaves to support high 

quality care. Nurse informaticists can work with their counterparts to apply some of the 

principles found in the literature to practice. 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Research Implications 

Workflow design is a difficult endeavor because of the complexity of most health care 

organizations and the division of labor into expert roles. Health care organizations are service 

organizations that are very flexible and interdependent in response to dynamic patient needs. For 

many work processes, the established workflow evolved over time in response to the kind of 

tasks and resources available, and were not explicitly considered or designed. Changes to 

organizational workflow are an opportunity to think through how the care team can provide good 

patient care reliably under a variety of circumstances. 

Research on workflow issues can be very rewarding because of its closeness to real-world 

operational challenges. Study participants often experience a high level of frustration with their 

current situation, and are eager to have assistance in thinking through complex organizational 

effects. The research often starts with a theoretical model that helps define the problem space, 

such as conceptualizing the structure, process, and outcomes65 or the tasks, actors, and 

information.66 The model can be made operational through computer modeling, and used to 

represent particular problems. 

In support of workflow design activities, computer simulation tools have been developed to 

help decisionmakers map their organizational roles and understand the impact of different 

workflow choices.67-69 Models of workflow processes show the trajectories of the care providers, 

patients, and information. By representing workflow in a manner which is easily accessible to 

others, managers and researchers can identify where issues are likely to arise and develop tools 

to prevent them. Modeling workflow also usefully defines roles and delineates how the care team 

understands its job functions and work processes 

For health IT, workflow design is especially difficult because many of the assumptions about 

workflow are implicit. The designers of IT systems benefit from conversations with their users to 

understand how clinical care is provided in the organization. Without the input of users, it is 

tempting to apply the same workflows to different organizations. Many issues can be easily 

resolved through small changes in user interface or clinical decision support rules—changes that 

are very difficult to predict in advance. Although some issues can be resolved through 

customizing the health IT system, others are more intractable. The health IT system may simply 

reveal latent problems with the old workflow. As more organizations embark on large-scale 

health IT implementations, a scalable method for incorporating workflow considerations is 

urgently needed, so that new health IT systems do not cause harm.70 When issues have been 

surfaced, through conversations, observation, modeling, and other methods, researchers have the 

opportunity to bring to bear established quality improvement methods to workflow design. 

Studies to date have relied on ad-hoc methods to effect improvement after studying workflow, 

and there are opportunities to apply structured methods to assist an organization in responding to 

workflow discoveries. 

Many of the research articles reviewed involved a descriptive case study. Some studies 

utilized a grounded theory approach. Few articles utilized a conceptual framework to frame the 

results. While research on service organizations has been applied to health care organizations, 

much work remains to be done in delineating how health care work differs from other industries, 

in particular to understand whether results from inquiries in other fields, such as manufacturing, 

can be generalized to health care. In addition, there is a need for research to demonstrate a link 

between performance indicators and workflow.71 Nurse researchers have an opportunity to take 

the research that has been done to date and apply it on a broader scale. Much of the work that has 

10 
Workflow 

been done outlines specific implementation efforts or describes a single department. By taking a 

systems approach to organizational workflow, coordination of patient care throughout the 

trajectory of their stay can be improved. 

Search Strategy 

The search for workflow issues in delivering high quality nursing care is complicated 

because workflow, by its nature, touches on many organizational issues and roles. Literature that 

identifies specific problems in patient safety may allude to their greater systemic workflow 

causes or effects. Even literature that specifically considers workflow may limit the analysis to 

one organizational role. Thus, our literature search did not attempt to be a comprehensive search 

of literature published on workflow, but rather a scan of areas in the medical and nursing 

literature where relevant publications are likely to appear. There is also a longer history of 

research literature in other fields, notably industrial engineering and management. 

We looked at MEDLINE® and CINAHL® articles published in English. Because workflow is 

not a standardized term in either database, we searched it as a keyword in its various 

permutations. We did the same with handoffs, as we knew that this was a common study topic 

where workflow issues surface. In addition, we did searches using combinations of related terms 

in each database. The terms we used were in categories dealing with continuity of care, care 

teams, information needs, information systems, and patient safety. We found that the keyword 

search yielded more consistent information than the standardized terms, in part because the terms 

were developed with specific purposes in mind. Studies of workflow are still fairly new, and it is 

hoped that as the field matures, it will be easier to identify a unique body of work. 

Author Affiliations 

Carol H. Cain, Ph.D., practice leader, Incubation. Care Management Institute, Kaiser 

Permanente. E-mail: Carol.H.Cain@kp.org. 

Saira Haque, M.H.S.A., doctoral candidate at Syracuse University, School of Information 

Studies. E-mail: snhaque@syr.edu. 

References

1. Ash JS, Sittig DF, Poon EG, et al. The extent and 

importance of unintended consequences related to 

computerized provider order entry. J Am Med Inform 

Assoc 2007 Jul-Aug;14(4):415-23.

2. Laxmisan A, Hakimzada F, Sayan OR, et al. The 

multitasking clinician: decision-making and cognitive 

demand during and after team handoffs in emergency 

care. Int J Med Inform 2007 Nov-Dec;76(11-12):801-

11.

3. Campbell EM, Sittig DF, Ash JS, et al. Types of 

unintended consequences related to computerized 

provider order entry. J Am Med Inform Assoc. 2006 

Sep-Oct;13(5):547-56.

4. Cendan J, Good M. Interdisciplinary work flow 

assessment and redesign decreases operating room 

turnover time and allows for additional caseload. 

Arch Surg 2006;141:65-9. 

5. Sandberg WS, Daily B, Egan M, et al. Deliberate 

perioperative systems design improves operating 

room throughput. Anesthesiology 2005;103:406-18. 

6. Friedman D, Sokal SM, Chang Y, et al. Increasing 

operating room efficiency through parallel 

processing. Surgery 2006;243:10-4. 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

7. Harders M, Malangoni MA, Weight S, et al. 

Improving operating room efficiency through process 

redesign. Surgery 2006;140:509-16. 

8. Driscoll PA, Vincent CA. Organizing an efficient 

trauma team. Injury 1992;23(2):107-10. 

9. Waring J, McDonald R, Harrison S. Safety and 

complexity: inter-departmental relationships as a 

threat to patient safety in the operating department. J 

Health Organ Manag 2006;20:227-42. 

10. Patterson ES, Rogers ML, Chapman RJ, et al. 

Compliance with intended use of bar code medication 

administration in acute and long-term care: an 

observational study. Hum Factors 2006 

Spring;48(1):15-22. 

11. Kobayashi M, Fussell SR, Xiao Y, et al. Work 

coordination, workflow, and workarounds in a 

medical context. Proceedings of CHI 2005, 

Conference on Human Factors in Computing. pp. 

1561-4.

12. Burke KG. Executive summary: the state of the 

science on safe medication administration 

symposium. J Infus Nurs 2005;28(2):87-92. 

13. Dykes P, Cashen M, Foster M, et al. Surveying acute 

care providers in the U.S. to explore the impact of 

HIT on the role of nurses and interdisciplinary 

communication in acute care settings. J Healthc Inf 

Manag 2006;20(2):36-44. 

14. Gurses A, Hu P, Gilger S, et al. A preliminary field 

study of patient flow management in a trauma center 

for designing information technology. AMIA Annu 

Symp Proc 2006:937. 

15. Philpin S. Handing over: transmission of information 

between nurses in an intensive therapy unit. Nurs Crit 

Care 2006;11(2):86-93. 

16. Egan M. Clinical dashboards: impact on workflow, 

care quality, and patient safety. Crit Care Nurs Q 

2006;29(4):354-61. 

17. Powell SK. Handoffs and transitions of care: where is 

the Lone Ranger's silver bullet? Lippincott's Case 

Manag 2006;11(5):235-7. 

18. Brixey JJ, Robinson DJ, Tang Z, et al. Interruptions 

in workflow for RNs in a level one trauma center. 

AMIA Annu Symp Proc 2005:86-90. 

19. Brixey JJ, Robinson DJ, Johnson CW, et al. Towards 

a hybrid method to categorize interruptions and 

activities in healthcare. Int J Med Inform, 

2006;76:812-20. 

20. Spear S. Fixing healthcare from inside, today. Harv 

Bus Rev 2005 Sep;83(9):78-91, 158. 

21. Brown DN, McCormack BG, McGarvey H. Factors 

influencing the control of post-operative pain in older 

people. Rev Clin Gerontol 2005;15(2):149-56. 

22. Guite J, Lang M, McCartan P, et al. Nursing 

admissions process redesigned to leverage EHR. J 

Healthc Inf Manag 2006;20(2):55-64. 

23. Lamond D. The information content of the nurse 

change of shift report: a comparative study. J Adv 

Nurs 2000;31:794-804. 

24. Perrott D. Achieving rapid implementation without 

disrupting workflow. Medication administration 

technology meets nurses' need for "perfect" 

technology. J Nurs Adm 2004;34 Suppl:5-6. 

25. What does JCAHO expect for handoffs? OR 

Manager, 2006 April;22(4)11.

26. Patterson, E. Handoffs: lessons from other industries. 

OR Manager 2005;21(8)11-2. 

27. Strople B, Ottani P. Can technology improve 

intershift report? What the research reveals. J Prof 

Nurs 2006;22(3):197-204. 

28. McKnight L, Stetson PD, Bakken S, et al. Perceived 

information needs and communication difficulties of 

inpatient physicians and nurses. J Am Med Inform 

Assoc 2002;9:S64-9. 

29. Bowcutt M, Delashmutt S, Kirkley D, et al. The 

nurse, M.D. and IT. Executive dialogue series. Hosp 

Health Netw JT 2003;77(12):61-71, 2. 

30. Reddy M, Pratt W, Dourish P, et al. Asking 

questions: information needs in a surgical intensive 

care unit. Proc AMIA Symp. 2002:647-51. 

31. Riley R, Manias E. Governing time in operating 

rooms. J Clin Nurs 2006;15:546-53. 

32. Kaiser Permanente of Colorado. SBAR technique for 

communication: a situational briefing model.

http://www.ihi.org/IHI/Topics/PatientSafety/SafetyG

eneral/Tools/SBARTechniqueforCommunicationASit

uationalBriefingModel.htm. Accessed January 8, 

2008. 

33. Cunliffe J. Developing a nursing discharge summary. 

J Community Nurs 2003;17(3):11-2, 14. 

34. Van Eaton E, et al. Organizing the transfer of patient 

care information: the development of a computerized 

resident sign-out system. Surgery 2004;136(1):5-13. 

12 
Workflow 

35. Patterson E, Roth EM, Woods DD, et al. Handoff 

strategies in settings with high consequences for 

failure: lessons for health care operations. Int J Qual 

Health Care 2004;16(2):125-32. 

36. Plsek P. Innovative thinking for the improvement of 

medical systems. Ann Intern Med 1999;131:438-44. 

37. Meadows G. Chaiken BP. Using IT to improve 

clinical teamwork and communication. Nurs Econ. 

2003 Jan-Feb;21(1):33-4. 

38. Sittig D, Ash JS, Zhang J, et al. Lessons from 

"Unexpected increased mortality after 

implementation of a commercially sold computerized 

physician order entry system." Pediatrics 

2006;118(2):797-801. 

39. Scharnhorst A, Johnson LC, Li N. Smaller and faster: 

using a handheld computer to support a bedside 

vascular access team. AMIA Annu Symp Proc 

2003;996. 

40. Braswell A, Duggar S. The new look of bedside 

technology: the point-of-care evolution drives 

providers to rethink nursing workflow and 

medication management. Nurs Manage 

2006;Suppl:14-32. 

41. Department of Health and Human Services. Pilot 

Testing of initial electronic prescribing standards 

cooperative agreements required under Section 

1860D-(4) (e) of the Social Security Act as amended 

by the Medicare Prescription Drug, Improvement, 

and Modernization Action (MMA) of 2003. 2007. 

http://healthit.ahrq.gov/images/apr07cmserxreport/er

xpilotsreport.html. Accessed January 8, 2008. 

42. Mekhjian HS, Kumar RR, Kuehn L, et al. Immediate 

benefits realized following implementation of 

physician order entry at an academic medical center. 

J Am Med Inform Assoc 2002;9(5):529-39. 

43. Ghosh T, Norton M, Skiba D. Communication, 

coordination and knowledge sharing in the 

implementation of CPOE; impact on nursing practice.

AMIA Annu Symp Proc 2006:928. 

44. Banet GA, Jeffe DB, Williams JA, et al., Effects of 

implementing computerized practitioner order entry 

and nursing documentation on nursing workflow in 

an emergency department. J Healthc Inf Manag 

2006;20(2):45-54. 

45. Payne TH. The transition to automated practitioner 

order entry in a teaching hospital: the VA Puget 

Sound experience. Proc AMIA Symp 1999;589-93. 

46. Johnson KB, Fitzhenry F. Case report: activity 

diagrams for integrating electronic prescribing tools 

into clinical workflow. J Am Med Inform Assoc 

2006;13(4):391-5. 

47. Wright MJ, Frey K, Scherer J, et al. Maintaining 

excellence in physician nurse communication with 

CPOE: a nursing informatics team approach. J 

Healthc Inf Manag 2006;20(2):65-70.

48. Piasecki JK, Calhoun E, Engelberg J, et al. 

Computerized provider order entry in the emergency 

department: pilot evaluation of a return on investment 

analysis instrument. AMIA Annu Symp Proc 

2005;1081.

49. Breslin S, Greskovich W, Turisco F. Wireless 

technology improves nursing workflow and 

communications. Comput Inform Nurs 

2004;22(5):275-81. 

50. Linden L, English K. Adjusting the cost-quality 

equation: utilizing work sampling and time study data 

to redesign clinical practice. J Nurs Care Qual 

1994;8(3):34-42. 

51. Needleman J, Buerhaus P, Mattke S. Nurse-staffing 

levels and the quality of care in hospitals. N Engl 

Med 2002;346(22):1715-22. 

52. Urden L, Roode J. Work sampling: a decisionmaking tool for determining resources and work 

design. J Nurs Adm 1997;27(9):34-41. 

53. Moss J, Berner ES, Savell K. A mobile data 

collection tool for workflow analysis. Medinfo 

2007;12(Pt 1):48-52. 

54. Fontaine BR, Speedie S, Abelson D et al. A worksampling tool to measure the effect of electronic 

medical record implementation on health care 

workers. J Ambul Care Manage. 2000 Jan;23(1):71-

85. 

55. AHRQ National Resource Center for Health 

Information Technology. Using time and motion 

studies to measure the impact of health it on clinical 

workflow. 

http://healthit.ahrq.gov/portal/server.pt?open=514&o

bjID=5554&mode=2&holderDisplayURL=http://pro

dportallb.ahrq.gov:7087/publishedcontent/publish/co

mmunities/k_o/knowledge_library/features_archive/f

eatures/using_time_and_motion_studies_to_measure

_the_impact_of_health_it_on_clinical_workflow.htm

l. Accessed January 8, 2008. 

56. Robert Wood Johnson Foundation. Engaging nurses 

in quality improvement. 

http://www.rwjf.org/pr/product.jsp?id=21151&catid=

18. Accessed January 8, 2008. 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

57. Lykowski G, Mahoney D. Computerized provider 

order entry improves workflow and outcomes. Nurs 

Manage 2004;35(2):40G-H. 

58. Connolly, C. Cedars-Sinai doctors cling to pen and 

paper. Washington Post March 21, 2005. p. A01; 

http://www.washingtonpost.com/wpdyn/articles/A52384-2005Mar20.html. Accessed 

January 8, 2008. 

59. Kirkley D, Rewick D. Evaluating clinical information 

systems. J Nurs Adm 2003;33(12):643-51. 

60. Bahlman DT, Johnson FC. Using technology to 

improve and support communication and workflow 

processes. AORN 2005;82(1):65-73. 

61. LaPenotiere L. Enhancing the pediatric ED work 

environment: a case study. Top Emerg Med 

2004;26(4):322-30. 

62. Kinney K. A systems approach to purchasing and 

implementing new technology. Nurs Adm Q 

2007;31(1):27-32. 

63. Reason J. Human error. New York: Cambridge 

University Press, 1990. 

64. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is 

human: building a safer health system. A report of 

the Committee on Quality of Health Care in America, 

Institute of Medicine. Washington, DC: National 

Academy Press; 2000. 

65. Donabedian, A. Evaluating the quality of medical 

care. Milbank Q 2005;83(4):691-729. 

66. Galbraith, JR. Organization design: an information 

processing view. Interfaces 1974;4(3):28-36. 

67. Carley KM, Prietula MJ, eds., Computational 

organization theory. Mahwah, NJ: Lawrence 

Earlbaum, Publishers; 1994. 

68. Bricon-Souf N, Renard JM, Beuscart R. Dynamic 

workflow model for complex activity in intensive 

care unit. Int J Med Inform1999;53(2-3):143-50. 

69. Malhotra S, Jordan D, Shortliffe E, et al. Workflow 

modeling in critical care: piecing together your own 

puzzle. J Biomed Inform 2007 Apr;40(2):81-92. 

70. Koppel R, Metlay JP, Cohen A, et al. Role of 

computerized physician order entry systems in 

facilitating medication errors. JAMA 2005 Mar 

9;293:1197-203. 

71. Griffin KF, Swan BA. Linking nursing workload and 

performance indicators in ambulatory care. Nurs 

Econ 2006 Jan-Feb;24(1):41-4, 72. 

72. Adams JM. Applying e-health to case management. 

Lippincotts Case Manag 2000;5(4):168-71. 

73. Ammenwerth E, Mansmann U, Iller C, et al. Factors 

affecting and affected by user acceptance of 

computer-based nursing documentation: results of a 

two-year study. J Am Med Inform Assoc 

2003;10(1):69-84. 

74. Ash JS, Bates DW. Factors and forces affecting EHR 

system adoption: report of a 2004 ACMI discussion. 

J Am Med Inform Assoc 2005;12(1):8-12. 

75. Bigelow SM, Xu X, Del Fiol G, et al. Integration of 

interdisciplinary guidelines with clinical applications: 

current and future scenarios. Stud Health Technol 

Inform 2006;122:430-4. 

76. Browne JA, Covington BG, Davila Y. Using 

information technology to assist in redesign of a fall 

prevention program. J Nurs Care Qual 2004;19(3): 

218-25. 

77. Campbell E. AORN guidance statement: creating a 

patient safety culture. AORN J 2006; 83:936-42. 

78. Chan EA, Chung JW, Wong TK, et al., An evaluation 

of nursing practice models in the context of the 

severe acute respiratory syndrome epidemic in Hong 

Kong: a preliminary study. J Clin Nurs 2006;15:661-

70. 

79. Christakis D,Wright JA, Zimmerman FJ, et al. 

Continuity of care is associated with wellcoordinated care. Ambul Pediatr 2003;3(2):82-6. 

80. Clegg A, Abley C, Tindle N, et al. Ask the experts. 

Single assessment process. Nurs Older People 

2006;18(2):14-5. 

81. Cronin P. Automation optimizes nursing workflow. 

An organization follows its pledge to lead with 

process, enable with technology. Healthc Inform 

2004;21(5):56. 

82. Elder KN, O'Hara N, Crutcher T, et al. Managed 

care: the value you bring. Am J Nurs 1998;98(6):34-

40. 

83. Gulliford MC, Naithani S, Morgan M. Measuring 

continuity of care in diabetes mellitus: an experiencebased measure. Ann Fam Med 2006;4:548-55. 

84. Joint Commission Resources. Focus on five. 

Strategies to improve hand-off communication: 

implementing a process to resolve questions. Joint 

Commission Perspectives on Patient Sadety, 2005m 

5(7):1. 

14 
Workflow 

85. King LA, Wasdovich A, Young C. Transforming 

nursing practice: clinical systems and the nursing unit 

of the future. J Healthc Inf Manag 2004;18(3):32-6. 

86. Lium JT, Faxvaag A. Removal of paper-based health 

records from Norwegian hospitals: effects on clinical 

workflow. Stud Health Technol Inform 

2006;124:1031-6. 

87. Manias E, Street A. Nurse-doctor interactions during 

critical care ward rounds. J Clin Nurs 

2001;10(4):442-50. 

88. Meadows G. The nursing shortage: can information 

technology help? Nurs Econ 2002;20(1):46-8. 

89. Meadows G. Information systems & technology. 

Improving the patient experience with information 

technology. Nurs Econ 2003;21(6):300-1. 

90. Pape TM. Evidence-based nursing practice: to 

infinity and beyond. J Contin Educ Nurs 

2003;34(4):154-61;quiz 189-90. 

91. Price A, Price B. Problem-based learning in clinical 

practice facilitating critical thinking. J Nurses Staff 

Dev 2000;16(6):257-64;quiz 265-6. 

92. Sandberg WS, Sokal SM, Berger DL, et al., Impact 

on PACU workload of a direct from PACU discharge 

pathway after laparoscopic cholecystectomy 2006.

Anesthesiology 2006;105:A1298. 

93. Shefter SM. Workflow technology: the new frontier. 

How to overcome the barriers and join the future. 

Lippincotts Case Manag 2006;11(1):25-34;quiz 35-6. 

94. Stahl JE, Sandberg WS, Daily B, et al. Reorganizing 

patient care and workflow in the operating room: a 

cost-effectiveness study. Surgery 2006;139:717-28. 

95. Wright MJ, et al. Maintaining excellence in physician 

nurse communication with CPOE: a nursing 

informatics team approach. J Healthc Inf Manag 

2006;20(2):65-70. 

15 
Evidence Table 

Source Issue Related to Practice Design Type Study Design and Outcome Measures Study Setting and Population Study Intervention Key Findings Adams 200072 IT; workflow Changing practice project and Published Guidelines Case studies Case management Teaching hospitals IT brings abou

information rethe case manneed to transf

Ammenwerth 200373 User acceptance Pretest and post- test Questionnaire: 3 months before system implementation, 3 months after, 9 months after Nurses on four wards of a hospital in Germany Questionnaire Previous acce

process and tconfidence arinfluencing accomputer basconsider fit beand functionaadapted systeothers did notwhat they do a

Bahlman 200560 Workflow; OR; Information transfer; Implementation Pretest and Post- test Reviewed workflow processes for redesign OR Changed workflow processes Needed to rev

first; figured oto have techn

Banet 200644 Workflow; ED; Information transfer; implementation Pretest and Post- test Looked at implementation of CPOE in ER and nurse perceptions ER staff CPOE implementation Nurse percep

design is needimplementatiochanges; introworkflow is cotime might no

Bigelow 200675

Workflow; Standards 

Pretest and Posttest Case study Hospital system Placed standards in an accessible 

document repository 

New format aworkflow becalooked up from reducing time information 

16
17

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Bowcutt 200329 Interprofessional communication; 

Information transfer 

Unpublished research 

Roundtable discussion 

NA NA Systems can 

they need to mmore informatnot streamlinedon't want to dsuffers; clinicatheir documenworkflow 

Braswell 200640 Implementation Pretest and Post- test Reviewed workflow and time 

spent before and after implementation 

Nursing unit Added mobile 

cabinets with barscanning for medications 

Better teamwoimprovement documentatio

Breslin 200449 Implementation Case–control 

study, Pretest and post-test study 

Observation; Documented communication workflows; Looked at phone calls; Survey 

Staff within units in a hospital in Baltimore 

Implemented Vocera and compared units with and without it 

Having the tecoverhead pagworkflow; time 

Bricon-Souf 199968

Workflow; Modeling 

Noncomparative study 

Modeled flow of actors and information 

ICU NA Development 

needs to incluflexibility and important beccomplex 

Brixey 200518 Workflow; 

Interruptions 

Noncomparative study 

Observation; Ethnography 

RNs at a level 1 trauma center 

NA Understanding 

interruptions iworkflow; gooimplications o

Brixey 200619 Workflow; 

Interruptions 

Noncomparative study 

Observation; Ethnography 

RNs and MDs at a level 1 trauma center 

NA Categorized a

for doctors ancause break isupplies or infinterruptions; contribute to m
18

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Browne 200476

Workflow; Process redesign 

Noncomparative study 

Description Hospital Integrated fall alert 

so that other areas can see it; feedback was positive 

Redesigned faincluded it in cdeveloped evinterventions tintegrated fall system 

Burke 200512 Medication 

administration; Information transfer 

Unpublished research 

Discussion of medication administration 

NA NA Many medicat

care transition important at th

Campbell 20063 Safety Unpublished research Discussion of unintended 

consequences 

NA NA Think about b

many medica

Campbell 200677 Safety Quality improvement Observation, interviews, 

conference. 

5 medical centers with different CPOE products 

Identify, describe and categorize unintended consequences of CPOE implementation 

More/new wounfavorable wfor systems chto use paper spatterns and p

Cendan 20064 Change; 

Workflow; OR 

Pretest and Posttest Analyzed and improved 

workflow 

OR staff of a tertiary care center 

Workflow diagrams were redrawn; critical moments were identified 

Turnover imprnumber of casinterdisciplina

Chan 200678 Workflow; 

Efficiency 

Pretest and Posttest Interviews Nursing staff Changed nursing delivery model Some nursing 

task-oriented allocate work skills; some roformalized 

Christakis 200379 Continuity; Information 

transfer 

Cross-sectional study 

Survey Parents of 

patients at a pediatric clinic who received care at multiple sites 

Cross-sectional survey of patients' families compared to organizational measures 

Importance of promote coordmeasure of cowith improved coordination; is associated coordination 
19

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Clegg 200680 Workflow, 

Efficiency; information transfer; Interprofessional communication 

Pretest and Posttest Implementation of a single 

assessment process for elderly patients 

Elderly population in the UK 

Implemented the new process and changed workflow to enhance information transfer 

Improved docsharing informhelped to makavailable to threducing redupatient 

Cronin 200481 Workflow, 

Efficiency 

Noncomparative study 

Description Hospital NA Described cha

into workflow 

Cunliffe 200333 Discharge; Communication; 

Coordination 

Noncomparative study 

Description of rationale and processes for developing a nursing discharge summary 

Hospital in UK Developed a 

standardized, structured formal discharge summary 

Communicatiowith discharge applied to othinformation tomultiple purpo

Driscoll 19928 Coordination; 

Team structure 

Pretest and Posttest Observation, Survey Trauma teams in Hospitals Organizational changes were 

made during resuscitations - task allocation and horizontal team organization 

When the struchanged, comindividual taskget team memsimultaneouslrecurred 

Dykes 200613 Information 

technology; Interprofessional communication 

Pretest and Posttest Survey, Interviews Health care professionals 

in acute settings 

Survey by HIMSS nursing informatics task force 

95% of responelectronic syscommunicate both formally reduce clinica

Egan 200616 Information 

transfer 

Noncomparative study 

Reviewed a dashboard of relevant patient information 

ICU and OR staff 

Determined who looks at what information and at what stage of the process 

A dashboard wcould help synacross hospitadepartments; transform worflowing from dsingle interact
20

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Elder 199882 Nurse role Unpublished 

research 

Discussion NA NA Need to clarify 

moved from taoutcome orienfollowing ordeand being a m

Friedman 20066 Change; Workflow; OR Case–control study Reviewed time and workflow of 

group with standard versus parallel processing 

Patients undergoing hernia repairs under local anesthesia 

Case group has anesthesia in the OR at the start of surgery; control group had local anesthesia in the induction room during turnover time 

Time decreassatisfaction sichange; OR tidecreased by and team coh

Ghosh 200643 CPOE; 

Implementation; Interprofessional communication 

Noncomparative study 

Interviews, focus groups 

Chief Nursing Officers 

How nurses impact and are impacted by CPOE 

Nurses are a CPOE implemcritical role in coordination aunderstanding processes is kimplementatio

Guite 200622 Change; 

Workflow; Implementation 

Pretest and Posttest Ethnography, interviews, 

process modeling 

Level 1 trauma center 

Documented each step of the current process with detailed flow diagrams; looked for opportunities for improvement and implemented a new process 

Use IT to help considerable dpeople have tinfo; Consider for shared datintegrate with departments 

Gurses 200614 Information 

transfer; Coordination 

Noncomparative study 

Ethnography Case 

managers at a level 1 trauma center 

Information tools and processes 

Information tobundle, phonepager, schedu
21

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Gulliford 200683 Continuity; Information 

transfer 

Unpublished research 

Discussion NA NA Integration, co

information acimportant; neeand provider pa relational, minformational 

Harders 20067 Change; 

Workflow; OR 

Pretest and Posttest Analyzed current and new workflow OR in tertiary care Redesigned workflow Reduction in n

were redesignentire process 

Johnson 200646 Prescribing Noncomparative study Modeled development of 

electronic prescribing 

ED Implementation of 

an electronic prescribing model 

Activity diagratechniques to information exprocesses; Lacompleted by need to be coimplementatio

Joint Commission 200584

Handoffs Unpublished 

research 

Discussion of JCAHO expectations of handoffs 

Handoffs arendepartments, department; nand facilitators obtain team in

King 200485 IT; Workflow Unpublished 

research 

Discussion NA NA Challenge to d

multiple careginformation nedepartments 

Kinney 200762 IT; Workflow Unpublished 

research 

Discussion NA NA Need to unde

system before technology creunearths exist

Kirkley 200359 Workflow Noncomparative 

study 

Description Nursing NA IT can help st

implement IT reorganize woUnderstanding think like a nu
22

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Lamond 200023

Information transfer; Shift change 

Changing practice 

Content analysis of medical notes, nursing documentation and shift reports 

Medical and surgical units in hospitals 

Looked at types and amount of information, order of information in shift report 

More informatthan what was some informacommunicated patient notes; judgments are information abare more oftethan in other d

LaPenotiere 200461

Workflow; Process redesign 

Changing practice 

Triage process design 

Triage; ED ED expansion built 

to fit desired processes. 

Workflow cha

Lium 200686 Workflow Cross-sectional 

study 

Survey Hospital Frequency of EMR 

use 

Nurses reportthey changed need to figure system in eve

Lykowski 200457

CPOE; Workflow Noncomparative 

study 

Description of CPOE implementation process 

Hospital Multidisciplina

incorporating led to good ou

Malhotra 200769

Workflow; Modeling; ICU 

Noncomparative study 

Interviews and observations to document process and information flows in ICU 

ICU in U.S. Completed models 

at various levels 

Communicatioinformation neof workflows i

Manias 200187 Rounds; Roles Noncomparative 

study 

Ethnographic study of 6 RNs; Participant observation, journals, interviews, focus groups 

Critical care unit of a hospital in Australia 

Description of process 

Doctors use ninformation anabout patientsnursing knowl
23

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

McKnight 200228

Information transfer; Interprofessional communication 

Cross-sectional study 

Surveys, focus groups 

Hospital Semi-structured 

survey about perceptions of information needs and communication difficulties; focus groups with physician and nurses 

Information nedifficulties are errors; problefinding informoutdated inforknowing the sidentifying and care providersinformation; neducation maabout paging, communicatiocare; need feeface to face comistrust or dislack of communear-misses; their own efficsystem efficie

Meadows 200288

Workflow; Efficiency; Staffing 

Unpublished research 

Discussion Think about h

using technoloworkflow and 

Meadows 200389

Information transfer, Interprofessional communication 

Unpublished research 

Discussion Use of techno

and communiworkflows with workflow acro

Mekhjian 200242

CPOE; Workflow; Implementation 

Case–control study 

Rapid system evaluation; time and motion study; comparison of data between areas with differential implementation of systems 

Inpatient units; academic medical center; 

Implemented CPOE on some units 

Process breaksafety issues, inefficiencies; necessarily imefficiency; incerrors and inteneeds to be c
24

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Patterson 200435

Handoffs Unpublished 

research 

Discussion Various 

industries 

NA Can learn less

other industrierailroad and acenters); manas in health ca

Pape 200390 Workflow; 

Evidence based practice; Information transfer 

Noncomparative study 

Reviewed nursing practices 

Nursing unit Description of 

practices and implementation of evidence-based practices 

IT can change decisions; disincorporate evand counter “carguments; hoidentify them, 

Patterson 200526 Interprofessional communication; 

Information transfer 

Noncomparative study 

Observed handoffs; Interviews across different industries 

Various industries 

Description of handoff practices 

Found 21 strahandoffs; provdocumentatiohandoff; Systepotentially be strategies 

Payne 199945 CPOE; 

Implementation; Interprofessional communication 

Noncomparative study 

Description of first three months post implementation 

Hospital CPOE 

implementation 

Implementing patterns, com

Perrott 200424 Workflow; 

Medication 

Noncomparative study 

Ethnography, Document review, Interviews 

ICU nurses Nursing handovers 

in an ICU 

Customization education; nuinstallation (froorganization) 

Philpin 200615 Information 

transfer; ICU; Interprofessional communication 

Unpublished research 

Discussion of nursing role 

NA NA Nurses work w

occupation grother people mdiscovered seobservations awork; differendocumentatiodiffer from org
25

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Piasecki 200548

CPOE Changing 

practice 

Review workflow to determine time and FTE savings before and after CPOE implementation 

Emergency Department 

CPOE implementation 

Worked with ba ROI tool to mtechnology imworkflow befoimplementatiotime and mon

Plsek 199936 Change; 

Workflow 

Unpublished research 

Focus groups Clinical and 

support staff of a multispeciality clinic 

NA Use a high-lev

typical visit, bdifferent perspescape from tworkflow; can with workflow are done 

Powell 200617 Information 

transfer; Handoffs; Interprofessional communication 

Unpublished research 

Discussion about improving handoffs 

Problems identransition, tranresponsibility receiving provexpectations wgroups; use aas coordinato

Price 200091 Workflow; Safety Literature review Discussion NA NA Problem base

classroom, bufloor as part oabout issues ocompeting de
26

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Reddy 200230 Information 

needs; Information transfer 

Noncomparative study 

Ethnography to understand information needs of physicians, nurses, students, pharmacists etc 

SICU Observed rounds; 

looked to see who asked questions, the kind of questions asked, resource used to answer question 

Nurses and pinformation soinformation sewere used mosources as the information; odocumented; workflows and (keeping the psystems to su

Riley 200631 Interprofessional 

communication; Information transfer 

Noncomparative study 

Observational fieldwork; Individual and group interviews using 11 nurse informants; Journaling 

OR nurses Evaluated how 

they dealt with each other and physicians with respect to time and identified practices 

Practices founand timing, cosurgeons' use different perceof individual spower for nurs

Sandberg 20055 Process redesign; OR Cross-sectional study Analyzed current workflow; 

changed and evaluated new workflow 

OR Staff Redesigned OR Changed the 

activities and improved throOR 

Sandberg 200692 Change; Workflow, OR Pretest and Post- test Looked at recovery room 

flow sheets, time, and nursing effort required 

Ambulatory laparascopic cholecystectomy patients 

Implementation of a pathway 

PACU nurses workload incresupport that cinterventions sfluids - but is naccurate capt

Scharnhorst 200339 Implementation; Workflow Noncomparative study Workflow analysis and usability 

testing 

Nursing staff Implementation of 

handhelds 

Collecting nurdefine and artin health carereduction of re
27

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Shefter 200693 Workflow; 

Implementation 

Unpublished research 

Discussion Case 

management 

Introduction of workflow tools 

Workflow techhinder case mpatient level adata to help wtools (databastools can help consider not jsupport 

Sittig 200638 CPOE; 

Medication; Implementation 

Noncomparative study 

Discussion of CPOE implementation 

NA NA Need to consi

and workflow technology); Calter workflow share experieuse opportunisystems 

Spear 200520 Change; 

Workflow 

Noncomparative study 

Multiple case studies to demonstrate best practices 

Hospitals NA Hospital care 

functions, but to integrate thexcellence by where work is problems soosolutions are qpeople are taulevels of the oa lot of time trservices and iproviding care 

Stahl 200694 Change; 

Workflow, OR 

Noncomparative study 

Redesigned systems before making a new OR 

OR Suite Redesigned 

processes emphasizing parallel processing; added staff 

Increased patadditional nurdisciplines an

Strople 200627 Information 

transfer 

Noncomparative study 

Reviewed shift report content, format and media 

Nursing staff at hospitals 

Analyzed content Use of electro

to the shift reppatient care 
28

Source Issue Related to 

Practice 

Design Type Study Design 

and Outcome Measures 

Study Setting and Population 

Study Intervention 

Key Findings 

Van Eaton 200434

Information transfer 

Changing practice 

Evaluation, analysis and prioritization of existing system content; Planned for a new system using a model, focus groups, modifying and implementing system 

Resident run inpatient and consult services at two teaching hospitals (31 residents) 

Developed and implemented system 

Most residentmanage work combined datsystems with popular and wneeded for proand sign-out a

Waring 20069 Workflow; OR; 

Information transfer; Interprofessional communications 

Noncomparative study 

Ethnography, Interviews 

OR in the UK; Teaching hospital 

Analyzed routines and patterns of work; did some interviews; looked at different roles 

Nursing staff ocoordinating sfiguring out weach departmhub with spokdepartments; dependent on they don't eacthe big picturebreakdowns; dbetween surgoften did transwhich led to min" and do wo

Wright 200695 CPOE Noncomparative 

study 

Reviewed processes and communications 

Hospitals CPOE 

implementation 

CPOE impactcommunicatioimplementatiochanges woulvisual cues or contextual infopaper reports know about odepartments belsewhere or 

* IT = information technology; EHR = electronic health record; EMR = electronic medical record; OR = operating room; ED = emergency departmen

provider order entry; ICU = intensive care unit; RN = registered nurse; MD = physician; HIMSS = Health Information and Management Systems So