Workflow and Human Factors for Quality Evaluation

custom workflow management system

Welcome to Post number 3 of Abbott Informatics.  This week we are going to discuss workflow related to the chest pain program.   Workflow is the sequence of physical and mental tasks performed by various people within and between work environments. It can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously.

To meet all the requirements for a population specific program, many aspects of care delivery must be considered.  As discussed in a previous post, the University of Wisconsin’s own Systems Engineering Initiative for Patient Safety (SEIPS) model can be applied to each desired outcome that the patient requires.  We can break down the five components of a work system: People, tasks, tools and technologies, the physical environment, and organizational conditions.  When multiple processes are group together and placed in sequence, it comes back to workflow.  Imagine trying convey these detailed sequences of tasks in an understandable way and also have the ability to evaluate the whole process for the six domains of healthcare quality.

There are many different tools that are used to communicate a workflow process and also to evaluate a process.  The U.S. Department of Health & Human Services through the Agency for Healthcare Research and Quality (AHRQ) offers many examples of these tools.  Some of the tools explored on the site are benchmarking, checklists, flowcharts, interview, and usability evaluation.  Many of the tools require additional education or experience to properly use.The website allows one to open examples of applications for each tool and also evaluates the strengths and weaknesses of each.

In the example we will explore, a workflow flowchart will be the tool used.According to the AHRQ website, Flowcharts are a tool that visually convey the steps in a process.  They can also be used to find one or multiple sources of a problem or identify potential areas for improvement, examine the handoffs that occur in a process, identify personnel, groups, or entire departments that are responsible for processes or tasks.  As mentioned, once the flowchart exists, it can be used to demonstrate current processes and aid in identifying areas for improvement.

Patients who present to the Emergency Department (ED) with chest pain or other acute coronary syndrome symptoms must be evaluated for ST elevated Myocardial Infarction (STEMI).  A STEMI is a medical emergency that must be intervened upon in a timely manner to avoid cardiac muscle cell death.  As you can imagine, the first step is recognizing we have a problem.  One of goals and critical measure tracked by the American College of Cardiology for Chest Pain Center accreditation is time from walk in arrival time to ECG obtained time and physician read time.  Even if you don’t work in an ED, you can begin to imagine how complex this goal can become.

So where to start and how to begin?  The AHRQ website even has educational presentations in Powerpoint format to guide you through the steps.  For flowcharts, it is recommended to break the process into five steps:

  • Step 1: Decide what processes to examine
  • Step 2: Create a preliminary flowchart
  • Step 3: Add detail to the flowchart
  • Step 4: Determine who you need to observe and interview
  • Step 5: Do the observations and interviews

Step 1.  In our example of getting an ECG read as fast as possible on a walk in patient, the process could have been chosen to examine secondary to reviewing of measures over time.  Looking at the larger flowchart that exists for the program, and focus can be placed on any of the process boxes.

Step 2.  The preliminary flowchart can be built just by placing the patient at the center of the SEIPS work model as the person and start walking the patient through the current state of the environment of the ED following the organizational flow until the patient encounters another person in the process.  If the patient first contact is with a receptionist or a triage nurse, the box would be placed.  this would continue until and ECG is read.

Steps 3 & 4 can be simultaneous in this example.  Interviewing is detailed on the AHRQ website as well and is important to understand the human factors that each person placed at the center of the work model.

Step 5.  It is important to start considering user focused design of any clinical decision tool such as electronic flow sheets in the electronic medical record very early in a project, but can continue in parallel with other work. Designers must know about the work the tool will perform – who performs it, how and in what environment.  Key information that is acquired already can be collected into screening tools by rows to alert the user to a best practice to obtain an ECG.

A major human factor that was discussed in a previous post is related to the type of ECG machine used.  To review, this facility uses paper copy ECG without transmitting capabilities.  The physician as the person in the center of the SEIPS work model being handed a paper ECG with or without prompts from the tech or nurse that this is a chest pain patient.  The physician must hand sign the date, time and initials with a readable description of STEMI or NO STEMI.

Once a flowchart is created, there are opportunities for process improvement of the work and the flowchart tool.  One tool offered by AHQR is Value-added Analysis Value-added analysis is a method for identifying problems within a process. The analysis allows a team to examine individual process steps so it can separate the steps that add value for the user from the steps that do not.  This can be used at department level meetings, task forces or other work groups including the Chest Pain Program Steering Committee.

Consumer Health Informatics

interestingly, the ACC does measure the proportion of patient who present to the ED as a walk in with chest pain or other heart related systems.This measure is designed to help  evaluate the effectiveness of the organization’s community outreach program by calculating the percentage of patients entering your ED who sought assistance using 911. This is a critical operational measure to track to increase Early Heart Attack Care (EHAC) awareness within the community. How are people getting this information?

One of the challenges for consumers is not finding information on the internet, it’s finding reliable information.  Many hospitals are attempting different interventions such as giving patients list of reliable sites, expanding the hospital organizational website better provide health information including portals to validated sites such as the Government websites.

In an organization that uses Epic products, there is a MyChart function.  This function can be accessed by tablet and other mobile devises. There are even interactive software to communicate though mobile devises such as the Apple watch called Haiku, Canto, and Limerick.  Individual devises can be customized to enhance the user experience to receive information.

We can keep improving the workflow for treatment of STEMI, but we forget that even the best, most efficient, invasive treatment is actually a failure to prevent.  If we can improve the community awareness of heart care and place tools in the hands of the consumer that can prevent rather than treat, we can increase quality of life.




  1. Hey, Eric! I enjoyed reading your blog post and thought that the flowchart tool you decided to use to analyze your problem area was very applicable. I can also identify with the process of meeting the ACC guidelines for EKG for chest pain patients in my ED setting. I like how you incorporated the SEIPS model factors into your flowchart analysis to depict the complexity that surrounds this seemingly straight forward task. The machine, the task, the person, the environment all interplays together and impacts the ability of someone to actually meet these guidelines. In addition, I think that the flowchart is a great tool to optimize the workflow in your environment. I found an interesting website, Heflo, the entire goal of this website is to help organizations and businesses create detailed flowcharts based on various models (there turns out to be a number of models to create your flowchart off of). Some of the benefits of using flowcharts, according to Heflo include: it creates a broad overview, creates a comprehensive and consistent understanding of the process, helps to analyze key areas where improvement is needed and to create performance indicators (Veyrat, 2016). I think that all these benefits would be very valuable in your pursuit to meet the ACC standards for EKGs and readings in the ED in your hospital!

    Vayrat, P. (2016). Workflow process mapping: Can it help a company? Retrieved on August 10, 2017 from

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  2. Eric-

    I found your application of a workflow process very applicable to the problem you have identified- the time it takes from walking into the ED to obtaining an ECG and having it read. I like how you broke down your workflow into five different steps. As you have identified, once your flowchart has been created, you can then use this information to identify areas for process improvements. It is important to note how an intervention or change to a workflow would affect the flowchart as a whole.

    Liked by 1 person

  3. Eric,
    I am glad you chose to use the flowchart tool in describing the workflow process. I thought the flowchart was an appropriate choice because it helped me visualize the process you were describing. I also liked that you incorporated the SEIPS model with the workflow evaluation. After reading your post, I now realize that a flowchart would have been also an appropriate workflow evaluation of choice in my area of interest, for the sole purpose of being able to identify areas of improvement more efficiently rather than the interview. Great posts Eric!

    Liked by 1 person

  4. Eric, what an interesting topic! I was an ED nurse for several years before choosing to focus on pediatrics and your topic brings me back to a specialty that I enjoyed and still miss at times. Having had this experience, I can relate to the challenges of being efficient with my care and complete with my data collection during these emergency situations. The idea that stuck out the most to me in your post was that even if we have the best treatment available, this is still considered a failure because the event could have been prevented altogether. The number of chronic health conditions experienced by individuals continues to rise in the United States and although I feel the shift of focus from a healthcare standpoint from treatment to prevention, it does not seem to be happening fast enough.

    When I think of how difficult it was to be able to take the time to educate patients in the ED (while I was rushing to get them discharged so I could start caring for the new patient that needed their room), I realized this is actually the worst place to try to treat “prevention”because you can’t do it justice and it is difficult for patients to fully focus in this atmosphere. I do feel the topic should be mentioned though and I am sure your discharge instructions are getting more sophisticated as health technology continues to grow. It seems much more logical for public health to be charged with the responsibility of teaching prevention and according to the CDC, there was a call for a public health action plan in 2010. I thought this action plan was interesting to read as it went through the steps of researching, identifying, planning, implementing, and evaluating.

    I found this paragraph especially interesting because to me, it is describing practice based evidence and it contrasts the differences between RCTs and the real world:

    “In contrast to evidence-based medicine, evidence-based public health depends on different types of evidence. For example, randomized controlled trials are considered essential to evidence-based medicine but are often lacking in the public health arena. On the other hand, population-based observations that are often unavailable in clinical decision making are included in the evidence base for public health decisions. The context of public health practice is the world at large, where many influences on health are continually at play. Therefore, the central question for evidence-based public health is not whether to take a particular action or no action, but whether the status quo, with its prevailing influences on the population’s health, is best. By asking what evidence supports the status quo, as well as what supports a proposed alternative policy or program, evidence-based public health can help establish the relative merits of proposed interventions.” (CDC, pg. 24).

    I am excited to learn more about practice based evidence and hope we, as healthcare providers, can find ways to utilize this data to improve our interventions so people can stay healthier longer.

    CDC. (n.d.). A Public Health action plan to prevent heart disease and stroke. Retrieved from

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