Creating a Workflow Chart: Improvement of Preoperative Check-In Process for Surgery

Introduction

Efficiency within an organization depends upon the processes they develop and utilize.  Workflow is used to describe actions and their execution of tasks in a uniformed order (McGonigle, D. & Mastrian, K., 2018).  In order to define workflow, one must use it to obtain an end result such as creating and adding value to a process that needs further improvement and developing for added value.  Workflow optimization is achieved by analyzing each step in the process and implementing changes that will provide a more effective way to complete it (McGonigle & Mastrian, 2018). However, before analyzing the workflow one needs to understand the current process that is being performed. Flowcharts provide a simple way to gain this understanding by planning each stage of the task from beginning to end (U.S. Department of Health & Human Services, n.d.).  Attempting to streamline the check in and preoperative process will reduce the time from the preoperative area to surgery, assist with preventing errors in the process, improve the patient experience and reduce costs associated with delays to surgery.

Therefore, the purpose of this paper is to create a flow chart of an activity, analyze each step in the process, and propose changes that will expedite improvements.

Explanation of Flowchart and Process

The process chosen for this workflow analysis is the current action of placing preoperative patients in the preoperative setting from the check in process up to actual release for surgery.  This current process is unorganized, inefficient, time consuming and often leads to delays in surgery at the beginning of each day which trickles down to the surgeries scheduled throughout the remainder of the day.  The unit secretary currently makes room assignments and retrieves the patient from the check in area and places that patient into the appropriate room assigned.  The charge registered nurse which is the nurse lead for the department does not presently make the room assignment. The patient chart is placed in an obscure area that has no appropriate chart placement deposit. The chart is carelessly placed in an area which is near the appropriate room such as on a common workflow desk, however, the preoperative nurses are not always alerted to this placement and are, therefore, unaware a patient has been placed in a room. Basically, each preoperative nurse functions not only as the primary nurse for each patient but also as the unit secretary, nursing assistant, transporter, and “chart hunter.”

This process does not allow the preoperative nurse to determine who is waiting to be processed for surgery.  The nursing assessment is performed after the placement of a room assignment by way of obtaining consent, placing an I.V., reconciling medications and obtaining a current health history. This preoperative assessment time also allows the nurse to determine whether or not all the necessary documents are signed by the physician. However, while preparing the patient for surgery, the nurse often forgets to check for documents, lab orders, and preoperative drug orders.  This process is not efficient as there is no step by step systematic way for the nurses to make sure the patient has all the necessary criteria met for surgical intervention. The preoperative area currently holds approximately 10 patients at one time.  Each preoperative nurse spends 30-45 minutes preparing a patient for surgery.

The following workflow chart in

Figure 1

depicts the sequence of events as they are currently being executed from patient check in to the patient being taken to the operating room.  This flowchart explains the process of the patient currently checking into the preoperative area and then retrieved for surgery.  The process flowchart goes on to explain the functions of the nurse process currently, anesthesia involvement, and physician interaction.  Should all of the criteria be met the patient, per the flowchart, continues to surgery.  If all of the steps are not completed, surgery is then delayed which is often the case.

Flowchart of Check In Process and Preoperative Assessment

Evaluation of Current Process

The current metrics being used to evaluate the effectiveness of the workflow process is by word of mouth as there is no technological system in place designed to alert the preoperative nurses about the status of upcoming patient placement and preoperative assessments.  The current process is not efficient as the process of room placement, chart placement, obtaining a current health history, acquiring necessary documentation and placing the IV should be a relatively simple process but steps are often missed, orders not completed, and documentation not signed.   This process of events often causes surgery to be delayed as the nurse spends critical time running in and out of the patient’s room attempting to complete all of the required tasks. This current method has not been effective as the continued process of delayed surgeries are still occurring which signifies a need for changes to be made.  Using an effective method such as checklists, as explained by the U.S. Department of Health & Human Services (n.d.), is an easy tool to use when attempting to track a sequence of events in a timely manner.

Proposed Changes to Workflow

Attempting to streamline the presurgical assessment and preoperative process is very important in order to maintain time and efficiency in a surgical environment.  Surgery is only productive when the turnover from one surgical procedure to the next maintains a standard of efficiency for the patients, doctors, and staff.  In order for the check in process and room placement assignment to become more efficient, a Registered Nurse Charge nurse should be the one to place the patient and assignments to the appropriate preoperative nurse.  The chart for the patient awaiting preoperative intervention should be placed in one designated area so as to limit the time spend searching for a chart. A checkoff list should be implemented with the current steps in order of importance so that should one be overlooked, it is easy to see where that process may have failed.  As reported by McGonigle & Mastrian, (2018), if the flow of the activity is not efficient, it can lead to wasted time for nurses, increase costs for organizations, and impact the delivery of patient care.

After the patient has been placed in the designated room, a nursing assistant (NA) should be allowed to assist with placement of SCD’s, ted hose, and placement of the patient on monitors.  A head to toe assessment for skin condition can begin at the same time as the preoperative nurse is obtaining a beginning set of vital signs. Before the patient signs the necessary consent forms for the procedure, the preoperative nurse should look over the orders to obtain any necessary missing documentation such as the history and physical from the physician, lab orders, preoperative procedure orders and any medications that may be ordered before surgery. Each preoperative nurse should attempt to simultaneously begin his or her patient assessment while starting the I.V. for surgery.  Each of these completed tasks should be checked off the preoperative check list in order to prevent skipping an important step.  Often times, the ordered antibiotic, EKG, and lab tests are forgotten and must be obtained after the circulating nurse has arrived to transport the patient to the operating room. This step is critical to the preoperative area as this is where the delay begins. The human resources and time wasted in this process impact the organization financially as well as employee moral as this is a constant source of discord between the preoperative area and the operating room.

The circulating nurse begins to scan the current document listing procedure name, allergies, and other criteria while obtaining report from the preoperative nurse.  The circulator relies on memory to determine if all the necessary information has been obtained and the steps are completed for the transport to the operating room. When methods are dependent on memory there is always a chance it can result in an error (Agency for Healthcare Research and Quality, 2013). If a checklist were filled out with each step completed, the circulating nurse would not need to rely on memory for information.  An electronic board should be implemented with a designated notation of which patients have been completed and are ready for the operating room and a flag if further documentation is needed.  An electronic board would also be helpful for the surgeons as well to assist with the location of the patients and would decrease the time spent issuing new orders before and after surgery. This process would decrease the amount of time the circulator had to spend in the preoperative area attempting to complete the missed steps (Dameus, J. 2018).

Summary

The success of an organization is very dependent on the productivity of activities that employees complete daily.  If the flow of the activity is not efficient, it can lead to wasted time for nurses, increase costs for organizations, and impact the delivery of patient care (McGonigle & Mastrian, 2018).  According to HealthIT.gov (2013), redesigning workflow within an area can help organizations to maximize efficiencies, enhance health care quality and safety, remove chaos from the current workflow, and improve care coordination.  “Technology can provide a mechanism to improve care delivery and create a safer patient environment, provided it is implemented appropriately and considers the surrounding workflow” (Mastrian & McGonigle, 2018).  When a currently documented technological workflow process is implemented, below standard patient care is decreased, and workflow does not become hindered by our own less than optimal practices.  Using flowcharts to illustrate the step-by-step actions involved in a process will give a clear view of areas in the process that require improvement.  As stated by Cain & Haque (2008), “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.”

References

• Agency for Healthcare Research and Quality. (2013) Module 5.
  
  Mapping and redesigning workflow
  
  . Retrieved from http://www.ahrq.gov/professionals/prevention-chronic care/improve/system/pfhandbook/mod5.html
• Cain, C., & Haque, S. (2008). Organizational Workflow and Its Impact on Work Quality. In R. G. Hughes (Ed.),
  
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• Dameus, J. (2018).
  
  More cases start on time after nurses change workflow
  
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  More cases start on time after nurses change workflow

  
  

• HealthIT.gov. (2013).
  
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  Retrieved from https://www.healthit.gov/providers-professionals/faqs/ehr-workflow-redesign
• McGonigle, D., & Mastrian, K. G. (2018). Nursing informatics and the foundation of knowledge (Laureate Education, Inc. custom ed.). (4
  
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• U.S. Department of Health & Human Services. (n.d.).
  
  Workflow assessment for health IT toolkit.
  
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