Organizational workflow and its impact on work quality

Cain, C., & Haque, S. (2008). Organizational workflow and its impact on work quality. In R. G. Hughes (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses (pp. 2-217-2-244). Rockville, MD: Agency for Healthcare Research and the Robert Wood Johnson Foundation.

Workflow, loosely defined, is the set of tasks—grouped chronologically into processes—and the set of people or resources needed for those tasks, that are necessary to accomplish a given goal. An organization’s workflow is comprised of the set of processes it needs to accomplish, the set of people or other resources available to perform those processes, and the interactions among them. Consider the following scenario:

On a slow Friday afternoon in the emergency room, as one nurse prepares to go off shift, the clerk looks up from the desk and asks, “By the way, since you’re passing by housekeeping on your way out, would you remind them that room 12 still needs to be cleaned?”

“No problem,” replies the nurse, and indeed, on a slow Friday afternoon, it is no problem. The informal methods and processes that the hospital has developed over the years to keep the enterprise humming work well, in general, and can work very well in optimal times. It’s no trouble to remind housekeeping to come up; it’s no trouble to run a special specimen down to the lab, and certainly no trouble to catch the attending physician during rounds to get a quick signature. Even if these small adjustments are forgotten, in due time the regular hospital schedule will bring the right people to clean the room, to pick up the lab specimen, to document the encounter.

These same methods that an organization uses to get work done, however, can begin to show stress under trying circumstances. When the ward is full and it takes 12 hours for a room to be readied for the next patient, that impact is felt throughout the organization. When the number of small interruptions outweighs the amount of planned work done in a given hour, that impact is felt in slower progress, lower job satisfaction, and potentially lower quality of care. In many situations, it is very clear to all what needs to get done. Where organizations differ is in how they do it. The examination of how an organization accomplishes its tasks often concerns the organizations’ workflow.

In health care, as in other industries, some workflows are designed, while others arise organically and evolve. The systems and methods by which organizations accomplish specific goals differ dramatically. Some organizational workflows seem more straightforward than others. Most often, when workflow processes are looked at in isolation, the processes appear quite logical (and even efficient) in acting to accomplish the end goal. It is in the interaction among the processes that complexities arise. Some of these interactions hide conflicts in the priorities of different roles in an organization, for example, what the nursing team is accountable to versus the physician team and its schedule. Organizations also adapt workflows to suit the evolving environment. Over time, reflecting on organizational workflows may show that some processes are no longer necessary, or can be updated and optimized...