NSG/542 Week 2: Mapping the Current Workflow, sample paper

Seven Lanes and a Sticky Note: Mapping the Current Organ Donation Referral Workflow in an Intensive Care Unit From Observation, Not the Policy

[Student Name]

University of Phoenix

NSG/542: Information Workflow

Week 2 Assignment

[Instructor Name]

[Date]

The hospital, its staff and the workflow are a composite written for a model paper.

In Week 1, I selected organ and tissue donation referral as the process for this course's workflow analysis, after finding 14 late or missed referrals of imminent deaths in a year. This paper maps how referrals actually happen in the hospital's main intensive care unit, where most of those cases begin.

How the Workflow Was Mapped

Three methods were used over four weeks. I reviewed the records of 20 recent cases that met referral triggers, including the 14 late or missed ones, noting every timestamp. I interviewed eight bedside nurses, three charge nurses, two intensivists, a unit clerk, a chaplain and two coordinators from the organ procurement organization. And I observed three cases in real time, with permission, from the moment a trigger was met to the referral. Unertl et al. (2010) recommend describing workflow in terms of actors, actions, artifacts, characteristics and outcomes, and the interview and observation guides were built around those elements.

The Written Policy

The policy states that when a patient meets a trigger, the bedside nurse calls the organization's referral line within one hour, reports clinical information, receives a referral number and documents the call and number in a nursing note. The policy lists four triggers: a ventilated patient whose Glasgow Coma Scale score falls to 5 or below, a planned family conversation about stopping life support, the start of brain death testing and a cardiac death in a patient who could donate after circulatory death. The policy exists because the hospital must notify its organization in a timely way about imminent deaths and deaths (Condition of Participation: Organ, Tissue, and Eye Procurement, 2023).

The Observed Workflow, Lane by Lane

Lane 1, intensivist: notes a neurologic decline on rounds; documents a Glasgow Coma Scale score in the progress note; discusses prognosis with the family, often in the afternoon; writes an order to discuss goals of care. The intensivist does not see calling the organization as part of this role.

Lane 2, bedside nurse: records neurologic assessments every hour in the flowsheet, including the Glasgow Coma Scale; is busy with the patient's care and the family; often does not connect a score of 5 to the referral policy; if aware, waits to call until after the family meeting, "so I don't upset them." When a referral is made, the nurse writes the referral number on a sticky note to chart later.

Lane 3, charge nurse: learns of the family meeting at the afternoon huddle; sometimes asks whether the organization has been called; sometimes makes the call personally.

Lane 4, unit clerk: keeps the referral line number on a laminated card at the desk; in two observed cases, made the call at the nurse's request but could not answer clinical questions, so the organization called back.

Lane 5, organization call center: receives the call, asks clinical questions, issues a referral number and routes the case to a coordinator.

Lane 6, organization coordinator: calls back or arrives on the unit; reviews the record; if the patient may be a donor, coordinates with the team about approaching the family.

Lane 7, the electronic health record: holds Glasgow Coma Scale scores in the flowsheet, the goals-of-care order, progress notes and, eventually, a nursing note with the referral number. It displays no prompt when a trigger is met.

The Family's Experience in the Current Workflow

The map also shows what families experience. In the observed cases, families learned about donation in different ways: once from a coordinator who arrived after a planned meeting, once from a nurse who mentioned it at the bedside before a referral had been made and once not at all, because the family decided to stop life support before the organization learned of the patient. Studies of how families decide have found that the involvement of organization staff and the conversations families have are associated with whether they consent (Siminoff et al., 2001). A workflow that brings the organization in late leaves little room for that conversation.

Where the Observed Workflow Departs From Policy

Four departures stood out. First, trigger recognition: in 9 of 14 late or missed cases, the Glasgow Coma Scale score of 5 or less had been documented in the flowsheet hours before any referral, but nothing in the record connected the score to the policy. Second, timing belief: several nurses believed that referral should follow the family meeting, when the policy intends referral at the trigger so that the organization can plan the family approach with the team. Third, ownership: the policy assigns the call to the bedside nurse, but in practice the call was made by bedside nurses, charge nurses and a clerk, and in the missed cases each assumed someone else had called. Fourth, documentation: referral numbers were written on sticky notes and charted late, and in three cases never charted, so the quality department could not find proof of referral even when one was made.

Characteristics of the Workflow

The workflow is infrequent for any single nurse; most bedside nurses make one or two referrals a year, so the steps are never routine. It is emotionally charged, happening while families are grieving. It is time-sensitive, measured against a one-hour window. And it is fragmented across a paper card, a phone, a sticky note and the record. A process that is rare, emotional, urgent and scattered across four artifacts is almost designed to fail.

Failure Points Marked on the Map

Failure point A, between Lane 7 and Lane 2: the trigger is documented but not recognized. Failure point B, between Lanes 1, 2 and 3: no clear owner for the call once a trigger is met. Failure point C, within Lane 2: the belief that referral should wait for the family meeting. Failure point D, between Lanes 2 and 7: the referral number is recorded late or not at all. Failure point E, between Lanes 4 and 5: a nonclinical caller cannot answer clinical questions, adding delay.

Validation of the Map

The draft map was reviewed with four nurses, a charge nurse, an intensivist and an organization coordinator, who confirmed it and added one detail: on nights, the charge nurse also covers the step-down unit and is less available to prompt referrals. That detail was added to Lane 3.

Why This Matters for Data

Every failure point is also a data failure. The trigger exists as data but is not used. Ownership is not recorded anywhere. The referral time and number are captured late or not at all. The quality department's compliance reports therefore undercount referrals that did happen and cannot explain the ones that did not. Week 3 will examine what each department needs from these data.

Conclusion

The current referral workflow runs through seven lanes, four artifacts and several handoffs that no one owns. Observed practice departs from the policy in trigger recognition, timing, ownership and documentation, and five failure points explain most of the late and missed referrals. The map provides the base for identifying data needs and redesigning the workflow.

References

Condition of Participation: Organ, Tissue, and Eye Procurement, 42 C.F.R. § 482.45 (2023).

Siminoff, L. A., Gordon, N., Hewlett, J., & Arnold, R. M. (2001). Factors influencing families' consent for donation of solid organs for transplantation. JAMA, 286(1), 71-77. https://doi.org/10.1001/jama.286.1.71

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