Unclogging workflow bottlenecks

Nov. 18, 2014

When a patient infected with the Ebola virus somehow eluded detection after arriving at a Texas hospital back in October, the blame game began.

Fingers pointed to clinicians who didn’t follow protocols, then to an electronic health record system that failed to communicate with other systems.

Much like the war veteran who jumped the White House fence and somehow made it past what’s supposed to be the tightest security in the nation – guarding and protecting the first family – these incidents simply reflected a deviation, if not a complete breakdown, in workflow processes.

Traditional workflow strategies tended to involve manual process steps that either are written down on paper and shared or communicated verbally. Errors occurred, typically because a worker didn’t consult the “manual” or misunderstood spoken directions, or maybe the person who gave the directions got it wrong, too. Or maybe the directions simply were too complicated. You get the idea.

Enter information technology, software systems in particular, which were designed to reduce, if not eliminate, many of those process errors by simplifying and streamlining steps. But software comes with its own set of foibles and snafus. After all, software is programmed by error-prone humans. Plus, what happens when there’s an electronic glitch, an interface or integration hiccup, or a loss of electrical power?

Suffice it to say, workflow strategies remain a work  in progress with an inherent need for flexibility. So what works and what doesn’t?

To explore successful workflow strategies – and failures – Health Management Technology tapped several information technology experts for their perspectives.

HMT: What are some of the key factors provider organizations should consider when establishing and maintaining a workflow strategy using IT?

Ryan Kalember, Chief Product Officer, WatchDox

Kalember: Regardless of the type of industry, IT-based workflows must consider the end user. By building workflow strategies around the needs and habits of employees, organizations are far more likely to realize broad adoption and acceptance of those workflows. This should include the tools and procedures employees are expected to use in the course of their daily work, as well as how information is accessed, stored and shared. For instance, do they use box-like services to collaborate on files? Is mobile access to company files a must-have? 

Doug Cox, Chief Strategy Officer, Elixir Technologies

Cox: There are four key factors to consider when establishing and maintaining a workflow strategy using IT.

The first is horizontal value and vertical scalability. Can the solution serve workflow needs beyond its original purpose? Can it scale to serve the organization through times of growth?

Second to consider is abstracting processes for reusability.  One way workflows build efficiencies across an organization is by repeating certain processes in the same or similar ways. Two workflows may serve entirely different business purposes; however, the approval or authorization process should follow standard paths established by the organization. Abstracting workflow processes into individual reusable objects allows companies to create workflows quickly from pre-designed standard processes and, by modifying the source object, update all workflows accordingly if needed.

Amy Hester, BSN, R.N., BC, Director of Clinical Informatics and Innovation, University of Arkansas for Medical Sciences

The third factor is enabling IT to distribute responsibilities. Provide IT with the absolute control to define, manage and change workflows, along with the ability to distribute those activities to non-technical users. This gives IT the flexibility to directly manage as much or as little of the process as required.

Lastly, the workflow strategy should complement existing environments. A collaborative workflow is one that ties in current applications, content, data, people and other company assets, allowing visibility into the process as a whole. Companies should take into consideration all their business processes prior to making a decision, even if that means some are deemed not critical to the workflow strategy.

Hester: Clinicians and end users affected by the workflow should be involved in the design of the workflow. Operations should drive change as it relates to establishing and maintaining workflows in healthcare. Workflows must be congruent with regulatory guidelines and standards of care. New workflows should not duplicate existing ones and should not impair or interfere with other workflows within the system. All new and revised workflows must be tested and validated prior to implementing.

Andy Jones, Vice President, Workflow Automation, Large Enterprise Operations, Xerox

Jones: New workplace technology equips workers with the tools they need to become more productive, but it’s important for organizations to keep in mind that tech alone isn’t a strategy. Tech deployments that automate business processes must reflect the way people actually work, while supporting compliance, privacy and the provider’s overall objectives. This will help bridge the gap between a tool that simply supports document management, and one that makes digital transformation – through process automation and efficient document management – a reality. 

Thao Nguyen, Director of Pharmacy Services, White Memorial Medical Center, Los Angeles

Nguyen: Our document management solution – built around Xerox DocuShare Enterprise Content Management software – provides a single view of a patient’s business/administrative records and their medical records. We recommend that healthcare organizations look for a comprehensive solution like this that can be customized to provide flexible search and retrieval. In the medical center pharmacies, we built a system to automate processing of medication orders electronically. Physician orders are scanned in at one of 25 to 30 locations, and orders are put into an electronic queue where they are reviewed, approved, filled and sent to the nurse’s station. The process helps deliver medications to patients more quickly and includes quality control steps to meet patient safety and government regulations. 

HMT: What are some of the mistakes made by provider organizations when establishing and maintaining workflow patterns via IT?

Kalember: Forcing employees to use technology that is either too complicated or too restrictive will often backfire. This leads to the unauthorized use of devices, mobile apps and cloud services that fall outside IT control and introduce significant risk to sensitive data. For provider organizations, this is a compliance issue as well. Not surprisingly, this type of activity will likely result in the enforcement of greater security measures to protect patient and clinical data, thereby limiting workflow and productivity even more.

An example is an overreliance on virtual desktop-type solutions. They work reasonably well until someone needs to get access to a file on an iPad, and then they don’t work at all. This forces even well-intentioned employees to find their own solution, potentially violating corporate policy on data handling and increasing the risk of a breach.

Cox: One mistake is not future proofing. Workflows, by their very nature, are constantly changing. New people participate, new systems are implemented into the organization and new situations need to be planned for. The processes that affect the workflow, the activities and how people participate should be constantly monitored, tested and adjusted.

Another mistake is limiting participation. Workflows work best when they fully leverage the expertise of all personnel, distributing activities, tasks and decisions out to everyone who needs to participate. Locking down access to a subset of stakeholders creates bottlenecks. Team members need to be engaged in the workflow at times when their specific participation is required. Allowing wide participation is a function of the workflow application from both technical and usability standpoints. Applications that tightly control who has access and are designed for use by non-technical staff members allow everyone to contribute easily, efficiently and securely to the process.  

Hester: Often, organizations allow IT to drive change in workflows. This can result in workflows that are not efficient, not salient to the work that needs to be accomplished and burdensome for the clinician or end user. Organizations also fail to consider downstream usage of the data generated by the workflow and whether that data will be retrievable and usable later on. In addition, there is often no risk/benefit analysis or testing/validation conducted prior to workflow design and implementation. Occasionally, a fix in one system will break another. This is especially true in enterprise systems that are integrated.

Jones: When determining a workflow strategy, all stakeholders must have a seat at the table – from the CIO to the end user. When decisions are made in a silo and then rolled out to employees, adoption can suffer. Transparent communication is key when an organization is changing a process or implementing a new one. When employees understand why and how a change is being made, and know their voice is heard, successful adoption is more likely. 

Another critical failure when rolling out technology is to assume that all processes are alike, and therefore can be streamlined in the same way, or using the same toolset. Our research has found that, even in heavily automated or digitized environments, workers still use paper as a tool for collaborating and driving processes to completion. It is essential that management and system architects understand when, and why, workers choose the simplicity and portability of paper, and that they be prepared to provide a substitute. For their specific audience, what is an acceptable digital alternative to paper?

Workflow peaks and pratfalls

What are some workflow strategies that succeed and fail, according to several healthcare industry executives? Here’s what they say.

What works

Andy Jones, Vice President, Workflow Automation, Large Enterprise Operations, Xerox

There are four key technologies driving transformation around workplace technology.

  • Mobile: Mobility is impacting every industry. For example, healthcare workers spend a large amount of time referencing and interacting with documents from many different devices. In order to maintain control over information that is accessed via mobile devices, employers must give mobile workers a secure, easy way to find files and perform routine business processes. Like many hospital systems, St. Peter’s Health Care Services was reliant on hard copy documents, and its team of hospice caregivers routinely carried around boxes of paper. The health system implemented an electronic content management system where files are scanned directly into a secure repository that can be accessed from a patient’s home, a remote office, an employee’s laptop or a mobile device.

  • Social: Collaboration in the workplace has been completely redefined by social. In today’s world, it’s not just about sharing ideas; it’s about sharing information in context with teams spread across different locations, networks and even organizations. One well-established approach is to incorporate collaboration tools into existing enterprise applications, such as an enterprise content management (ECM) system.

  • Cloud: A private cloud content management solution is a secure way to give mobile employees simple and round-the-clock access to the business content they need to get work done. This solution provides all the benefits of mobile, remote and partner access, but without the compliance and security risks of a consumer-grade file-sharing application.

  • Big Data analytics: As organizations gather and manage more information than ever, many are not equipped to decipher and analyze it effectively. By installing data capture, normalization and analytics tools, companies can make sense of structured and unstructured data to make more strategic decisions. For example, document analytics and workflow assessment tools give organizations an enterprise-wide view into document operations such as printing and storage, as well as document-based processes and workflows. This helps organizations make more informed technology and workflow decisions in order to save money and increase productivity.

In addition, it is critical that organizations fully understand how work actually gets done. It’s not enough to simply look at an existing process and transform it into a digital process using a business process management (BPM) or workflow engine, some rules and some training. Especially in healthcare, where the interaction between the provider and the patient has a huge impact on outcome, the tools and technologies need to seamlessly support the health worker, not distract them or add additional layers of complexity and frustration to their day. 

Ryan Kalember, Chief Product Officer, WatchDox

In the current cyber-threat landscape, the key to effective workflow rests in a blend of process and technology that offers a balance between data security and productivity.

Some of the most effective and secure workflow solutions will:

  • Embrace user-centric IT. Design workflows from the perspective of the end user, rather than architecturally across IT systems;

  • Plan to enable workflows across platforms, cloud storage repositories and devices. Users increasingly demand to work from whatever device they want, which should be enabled within reason;

  • When considering content-based workflows, strategies that deliver content access and sharing from a single pane of glass to repositories both new (cloud storage) and old (file shares, SharePoint) tend to be more successful;

  • Enable data security at the file level. This ensures that data is protected and tracked wherever it travels, reducing the risk of a breach; and

  • Incorporate compliance standards, secure clinical and patient data, provide audit trails and administrative safeguards to protect health information data, ideally through file-level security.

Doug Cox, Chief Strategy Officer, Elixir Technologies

  • Create predictable outcomes in all cases. Collaborative workflows enable companies to define specifically how people and systems will interact in all possible scenarios. Exceptions and unforeseen changes become planned events and are handled as efficiently as possible to provide a more realistic view of the end result.

  • Manage and limit ad-hoc activities. Removing ad-hoc activities in favor of specific assigned tasks adds discipline to the process and builds in consistent reactions for future similar scenarios.

  • Add business logic and automation. At the heart, workflows need to be formula and rules based. Complex workflows get their name because they change course often. When rules, rather than a personal decision, can handle this, the workflow happens faster and is less prone to error. And when an automated process takes the place of a manual task, even more time is saved and accuracy gained.

  • Use technical transparency for business accuracy. Make complex processes transparent to the team. Let them manage the business process rather than the technical steps to achieve the business result. Workflows can change any number of times, dynamically initiating alternate processes and involving different people. The user experience remains focused on their role and specific responsibilities given the new scenario.

  • Grant visibility. Adding the capability to report on activities regardless of where or when they occurred enables a real-time view of the entire process, giving management valuable context for the information.

Amy Hester BSN, R.N., BC, Director of Clinical Informatics and Innovation, University of Arkansas for Medical Sciences

  • Having an official workflow change request and response system that is successful as it creates a repository of requests and responses to those requests that are structured and usable.

  • Change governance including stakeholders is necessary to vet and approve all changes to workflows. This prevents one discipline from creating a “fix” for one area that is a “break” to another.

  • All changed and new workflows should be tested and validated by end users whose work is affected.

  • Training/education on new workflows is key. Without this, implementation of new workflows will be varied and inconsistent.

  • Whatever the workflow, the end user should have the resources to carry out the workflow when they need to. This is important because when end users are under-resourced, whether that resource is hardware, staff, software, etc., they are set up for failure.

Thao Nguyen, Director of Pharmacy Services, White Memorial Medical Center, Los Angeles

Integrating paper-based and administrative records with a centralized system for patient medical records provides an inexpensive way to compile a complete patient record. Benefits include: 

  • Better patient care. Staff can review a patient’s history immediately, as medical decisions need to be made.

  • Access from anywhere. This provides a safeguard during unforeseen circumstances. For example, during heavy flu season, when half the pharmacy staff was out ill, I was able to log in from home to review the flow of medication orders and troubleshoot if there was a delay.

  • Improved compliance. Any changes made to a document or digital image are tracked and captured as new versions, providing a complete history of the changes for regulatory compliance.

  • Timely billing. Reducing lost and misplaced documents and providing immediate access to information allows our accounts receivable department to bill for patient services faster and more accurately, resulting in more predictable and reliable revenue flow.

  • Emergency preparedness. Staff can access the DocuShare applications 24/7 from anywhere using the Internet, providing an important safeguard should there be a problem with physical access.

What doesn’t


  • Porting the old (virtual desktops) to the new (tablets). Mobile virtualization may be great for IT, but not so for end users since not every vendor makes mobile virtualization products. IT must ensure that the tools and apps employees need to access data from their mobile devices are supported.

  • Over-engineering processes. This tendency is not uncommon, especially in large and bureaucratic organizations, and generally results in processes that are overly complex and inefficient.
  • Having an internally focused architecture that doesn’t permit secure collaboration with the outside world. It’s next to impossible to do business of any kind today without external collaboration.


  • Lack of scope. Workflow practices need to cover a minimum number of areas or processes to truly have an effect. Failure to identify these areas results in a workflow that only partially addresses the problem.  Lack of scope also takes the risk that the workflow solution may not be positioned to serve future needs.

  • Lack of reporting. Reporting is necessary to understand what is actually happening in a workflow and critical in times when corrective action is needed. Reporting tools are often an overlooked feature in workflow applications, so it’s well worth the time to do due diligence on the software prior to buying, or design your own reports. 
  • Fair-weather planning. Too often, workflows are designed and tested only under ideal scenarios; however, workflows really earn their keep in bad situations, where problems need to be identified and resolved quickly. Companies should map out these situations, design workflows around them and test in as real a situation as possible.


  • Having IT drive and/or design clinical workflows often fails, as IT is not the expert in the workflow. The end user or clinician should be the architect of the workflow design. IT is the carpenter that builds it.

  • Implementing changes in workflows without governance often fails, and the work has to be redone. Without an evaluation method for new workflow requests, there is lack of insurance that all steps of the change process are implemented.

  • Implementing workflow changes without testing and validation often fails as issues that should be resolved prior to implementing the change with end users does not happen. This frustrates end users and impairs adoption of the new workflow even after the bugs are worked out.
  • Implementing workflow changes in “certain areas” versus all the areas affected is also a strategy that tends to fail. This usually occurs when a change governance process is not utilized that identifies all the affected stakeholders for a given workflow.

  • Implementing multiple workflow changes together often fails. It is more difficult to ensure adequate training of end users when multiple workflows are impacted simultaneously.

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