Collaborative, Human-Centered Approach to Workflow Optimization
Observation and Interview
Excited to present this collaborative, impactful project at the March 31 International Symposium on Human Factors and Ergonomics in Health Care poster session.
See you in Toronto!
Identify opportunities to improve process + increase critical workflow efficiency
Project
Client: A large health system undertaking an Electronic Health Record transition.
Timeframe: 22 weeks
My Role: Lead UX + Human Factors Researcher
Team: Sarah Casteel, supporting Human Factors Researcher, cross-functional team including five key stakeholder groups
Methods: Observation, Interview, Satisfaction Survey, Workflow Analysis, Thematic Analysis
Techniques: Field Note-Taking, Note Transcription and Cleanup, Open + Axial Coding, Deductive Coding, Current State Workflow Visualization, Barrier + Gap Analysis, Classifying Variations, Remote Workshop
Tools: Pen + Paper, Clipboard, Mobile Phone + Camera, Microsoft tools (Excel, Word, Outlook, PowerPoint SharePoint, Teams), Lucidchart, Dropbox, Slack, SurveyMonkey
Project Overview
Objectives
Identify opportunities to improve process/increase critical Women’s Health clinical workflow efficiency.
Determine specific opportunities to improve Electronic Health Record (EHR) user interface issues that contribute to inefficient workflows.
Client Engagement
Initial kickoff meeting to ensure client + project team alignment.
Weekly planning meetings between project team, client, and interested stakeholders.
Emailed post-meeting summaries including key actions and due dates.
Regular virtual communication (email, Microsoft Teams) of key status updates throughout project.
Approach
Mixed methods approach including in-person observation and interview.
Observed and documented EHR users’ in-clinic activities, including actions, interactions with people and technology, tasks, and processes.
Interviewed users to identify users’ needs and understand the reasons/motivations behind their observed actions.
Collaborative reporting workshop.
Facilitated discussion of key findings with client and stakeholders.
Fostered engagement, gathered user feedback, and aligned on interpretations of findings and next steps.
End-of-project satisfaction survey.
Distributed at the end of the remote workshop and planned to distribute again six months later to gauge satisfaction with site visit and improvements made as a result of project activities.
Project Milestones
Study Planning
Study Preparation
Data Collection
Data Analysis
Reporting, Workshop, + Outcomes
Project Closeout
Study Planning
Study Design Considerations
User centered approach
Context and environment
Cross-functional collaboration
User Centered Approach
A top-down approach was common within the client’s organization.
Standardized recommended EHR screen flows were created with expert rather than end user input.
We took a user-centered approach to documenting workflows to reflect how work was done in the EHR in practice by users who regularly completed clinical workflows.
Context and Environment
As Erika Hall states: “Everyone’s behavior changes with the context and the circumstances.”
In-person observation was key to determining how people, processes, technology, and environments intersected to influence users’ workflows.
Our client and stakeholders selected two clinics to allow observation of common patterns and site-specific workflow variations.
Cross-functional Collaboration
Collaboration with EHR consultants ensured that participating end users received in-person troubleshooting and coaching tips.
National workgroup involvement ensured that any suggested workflow changes aligned with organizational priorities and constraints.
Stakeholders shared their findings, provided feedback, and aligned on goals, ensuring that the research addressed diverse perspectives and resulted in actionable next steps.
Study Preparation
Reviewed existing workflow process models and user-generated standard operating procedures
Facilitated guided EHR screen flow walkthroughs
Stakeholder collaboration
Process Model Review
To understand the client organization’s baseline knowledge of current state Women’s Health clinical workflows:
UX + Human Factors team members reviewed existing BPMN+ process models created through subject matter elicitation sessions.
We also requested and reviewed user-generated documentation of day-to-day standard operating procedures.
Screen Flow Walkthroughs
To better understand the client organization’s expectations for user interactions with the EHR, we facilitated guided walkthroughs of standardized, recommended screen flows, leveraging insights from EHR consultants.
Stakeholder Collaboration
Stakeholders identified key user roles, and individuals in those roles, and prioritized workflows, such as Women’s Health provider office visits and scheduling, to inform our approach to onsite observations.
Data Collection
We scheduled data collection over two full days at two clinical specialty sites.
Data collection included:
Scheduled meetings with partner stakeholders
Onsite observation: clinician appointment, chart update, and registration + scheduling shadowing
Interviews informed by observation sessions
Site Selection and Scheduling
Clinic contacts, stakeholders, and the client collaborated to select two Women’s Health clinic sites for participation.
Selection was guided by considerations including clinic culture, scheduling constraints, and the willingness of clinicians and staff to participate.
We adjusted our observation schedule to align with active clinic days and the availability of partner stakeholders.
Data Collection Overview
Morning and end-of-day meetings with partners, including EHR consultants and stakeholders participating remotely, helped us plan observation sessions and discuss initial findings.
Introductions to end users allowed us to explain our role as observers and align with users’ and patients’ expectations (e.g., leaving the room immediately if a user, patient, or caregiver asks).
During observation sessions, we shadowed one end user at a time.
Observers maintained a low profile by:
Not interacting with patients and caregivers
Refraining from eye contact during observations
Stepping out of the exam room and re-joining observation sessions as directed by users.
We took handwritten notes, recording clock time for each observed activity.
We requested artifacts that users referenced, like user-generated documents that facilitated patient handoff between clinicians.
Follow-up interviews with end users provided opportunities to clarify questions arising from observations and gain a deeper understanding of users’ priorities and motivations.
Planned satisfaction survey to distribute after reporting workshop.
Data Analysis
Structured analysis focused on identifying themes, workflow patterns, and variability.
Workflow visualization to map current processes and pinpoint pain points and best practices within workflows.
Impact assessment + prioritization to categorize workflow variations and observations by impact.
Structured Analysis
Data Transcription + Cleaning
We enlisted transcribers to begin converting handwritten observation and interview notes to electronic format beginning mid-day on Day 1 of observations.
Observers reviewed and cleaned the transcribed data following site visits to remove inconsistencies, redundancies, and errors.
Thematic Analysis
Used inductive and deductive coding to identify themes and workflow patterns.
Compared observations against standardized, recommended EHR screen flows.
Synthesized findings into actionable insights, focusing on opportunities to improve workflow and process efficiency.
Debrief with Stakeholders
Shared preliminary findings with EHR consultants and stakeholders during scheduled post-visit debrief meetings.
Gathered feedback and additional context to refine observations and align with stakeholder priorities.
Workflow Visualization
Map Current State Workflows
Created detailed workflow maps to visualize current state processes for prioritized clinical workflows.
Consolidated data across sites and participants in common roles to highlight common patterns and variation.
Identify and Classify Pain Points + Best Practices
Documented specific pain points during EHR interactions and workflows.
Identified blocks (organization-imposed friction), barriers (user-imposed friction), gaps (missing pieces), and workarounds (user strategies to address challenges).
Identified facilitators or best practices that enhanced workflow efficiency or user experience.
Map Observations + Pain Points
Organized observations and pain points across phases of the patient experience:
Living Life: General health management outside clinic settings.
Before Encounter: Scheduling and preparing for clinic visits.
During Encounter: Activities and interactions within clinic visits.
After Encounter: Follow-up actions post-visit.
Population Management: Long-term health monitoring and care planning.
Impact Assessment + Prioritization
Classify Observations + Pain Points Based on Impact
Evaluated and ranked observations and pain points by their impact on workflows and users.
Prioritization of pain points/opportunities was based on:
Risk to staff/patients.
Inefficiencies introduced.
Whether pain points were difficult/impossible to overcome.
Potential to improve workflow/efficiency for as many patients and staff as possible.
Identify Workflow Variations + Associated Sources
Documented workflow variations observed across clinic sites.
Linked variations to specific sources (e.g., clinic culture, user roles, technology or facility constraints).
Classified variations by their impact on workflows and users.
Reporting, Workshop, + Outcomes
Prepared comprehensive report on findings.
Facilitated collaborative reporting workshop focused on knowledge sharing, team alignment, and actionable next steps.
Multi-disciplinary collaboration facilitated short-term and planned process and system changes.
Reporting
Comprehensive Report on Findings
Our comprehensive report included a service blueprint visualization of each observed prioritized workflow across phases of the patient experience with the people involved and activities and technology observed.
For each workflow, we detailed each observation/pain point, organized by category (e.g., technology, non-technology), impact criticality, and frequency of recurrence.
For each workflow, we summarized variation between clinic sites, noting source of variation and observed impact.
Collaborative Reporting Workshop
A four-hour virtual workshop brought together key stakeholders, including site contacts and participants, national workgroups, EHR consultants, and other essential contributors.
As the facilitator, my role centered on fostering engagement among users and stakeholder groups.
The UX+ Human Factors team activity summarized key theme areas with specific examples drawn from observations, and encouraged discussion through a corresponding user poll.
EHR consultants reviewed prioritized workflow opportunities, including software updates that were already being worked on by developers.
Additional stakeholder groups gave short presentations to link site visits with next steps.
The business process modeling group discussed using site visit data to begin building BPMN+ current state process maps and recruited subject matter experts to contribute.
To increase survey completion rates, we reserved time for users to complete a satisfaction survey at the end of the remote workshop to gauge satisfaction with site visit activities.
We planned to distribute the survey again in six months to gauge satisfactions with improvements made as a result of project activities.
Outcomes
National workgroup leaders contributed to onsite observations and participated in the reporting workshop, helping decision-makers gain deeper insights into user needs.
During site visits and the reporting workshop, end users connected directly with EHR consultants, enabling real-time troubleshooting and providing a platform to address more complex issues.
Workshop outcomes included removing barriers to completing next steps and determining ownership for next steps.
Project Closeout
Held internal and client-facing After Action Reviews.
Create a prioritized backlog of short- and long-term opportunities.
After Action Review
UX + Human Factors team held internal and client-facing After Action Reviews to document problems encountered and lessons learned for future studies.
Each team member describe problems encountered and recommendations to address each problem in the future.
As a team, we consolidated, summarized, and presented our lessons learned to our client.
We incorporated our client’s input into our After Action Review and documented it per organizational processes.
Prioritized Backlog
We continued collaborating with key stakeholders to create a prioritized backlog of short- and long-term opportunities, with plans to track opportunity status over the long term.