C792 Task 1 Workflow Analysis Example

Workflow Analysis: Suicide Risk Screening in a Rural Emergency Department, Current Paper Process Against the Proposed Structured EHR Process

Student Name

Leavitt School of Health, Western Governors University

C792: Data Modeling and Database Management Systems, Task 1

Course Instructor

Month Day, Year

Workflow Analysis: Suicide Risk Screening in a Rural Emergency Department, Current Paper Process Against the Proposed Structured EHR Process

Purpose and Scope

Workflow is the sequence of tasks, people, information and tools through which work gets done, and informatics research uses the term in several overlapping ways, from the flow of a single task to the coordination of a whole team (Unertl et al., 2010). This analysis concerns one process in a composite 14-bed emergency department (ED) at a 110-bed rural hospital: screening patients for suicide risk and acting on the result. The hospital plans to retire its paper version of the Columbia Suicide Severity Rating Scale screening questions (the C-SSRS) in favor of a structured version inside the electronic health record (EHR) and to widen screening to all ED patients 12 years and older, well beyond the behavioral health patients the national patient safety goal requires it to screen (The Joint Commission, 2019). The analysis documents the current workflow, identifies its failure points, specifies the future workflow and names the data the future workflow must capture. That data list becomes the input to the database design in the next part of this project.

Current times were estimated by observing 20 screenings over four shifts and reviewing 60 records. They are approximate, but they are consistent enough to show where time and information are lost.

Current State: The Paper Workflow

The table lists each step as it happens now, who performs it and what goes wrong.

Analysis of the Current Workflow

Three problems explain most of what the table shows. First, the decision about whom to screen depends on individual judgment at triage, which is exactly the gap that universal screening closes; in a multisite study, universal screening lifted the share of ED visits with a documented screen from about a quarter to more than four in five (Boudreaux et al., 2016). Second, the process has no data at all until a person transcribes it: the risk level exists only in handwriting, so nothing can trigger precautions, remind a nurse of a missing answer or tell an inpatient nurse what the ED found. Third, several handoffs are verbal and undocumented, so neither the time from screen to sitter nor the time a provider was informed can be measured.

The workarounds staff use make sense locally but add risk. Nurses keep blank forms in their pockets because the triage folder runs out, which means some are older versions. Charge nurses keep a sticky note of patients on precautions because the tracking board has no field for it.

Future State: The Structured EHR Workflow

In the future workflow, the screener becomes a required section of the triage documentation for every patient aged 12 and older. The EHR presents the six screener questions with branching, so later questions appear only when earlier answers make them relevant, and it will not allow the section to be closed with an unanswered question unless the nurse selects a reason, such as patient unable to respond. When the section is completed, the system calculates the risk level from the answers and displays it on the ED tracking board with a color indicator. A high-risk result opens a precautions order set for the provider to sign, sends a secure message to the behavioral health liaison and adds a task for the charge nurse to arrange one-to-one observation. The time of each of those events is recorded automatically. If the patient is admitted, the most recent screen and risk level appear in the inpatient admission navigator, where the admitting nurse either accepts it or rescreens.

Expected Benefits and New Risks

The future workflow should raise the screening rate toward all eligible patients, shorten the time from a high-risk screen to observation and give inpatient nurses the ED result at admission. It also gives the quality coordinator an automatic report instead of a monthly chart audit.

It introduces new risks that the design must address. A required screen at triage adds about two minutes per patient during surges; the design allows the screen to be deferred once, with a reason, and reminds the primary nurse within an hour. More patients screened means more positive screens, most of them low risk, and the behavioral health liaison's workload will rise; the order set therefore routes only moderate and high-risk results to the liaison. Finally, structured sensitive data raises privacy questions, so the screener answers will carry the same access controls as other behavioral health documentation.

Implications for the Database Design

The data column of the future state table defines what the database must hold: patients and encounters, each screening event with its individual answers, the calculated risk level, the interventions ordered and their times, the staff who performed each action and the notifications sent. Several relationships are already visible. A patient has many encounters; an encounter can have more than one screening, since inpatients may be rescreened; each screening has many answers and one risk level; and a high-risk screening can lead to many interventions. The next part of this project turns those entities and relationships into an entity relationship diagram.

References

Boudreaux, E. D., Camargo, C. A., Arias, S. A., Sullivan, A. F., Allen, M. H., Goldstein, A. B., Manton, A. P., Espinola, J. A., & Miller, I. W. (2016). Improving suicide risk screening and detection in the emergency department. American Journal of Preventive Medicine, 50(4), 445-453. https://doi.org/10.1016/j.amepre.2015.09.029

The Joint Commission. (2019). R3 report issue 18: National patient safety goal for suicide prevention. The Joint Commission.

Unertl, K. M., Novak, L. L., Johnson, K. B., & Lorenzi, N. M. (2010). Traversing the many paths of workflow research: Developing a conceptual framework of workflow terminology through a systematic literature review. Journal of the American Medical Informatics Association, 17(3), 265-273. https://doi.org/10.1136/jamia.2010.004333