NSG/542 Week 4: Redesigned Workflow, sample paper

A Trigger the Record Notices, One Owner and a Referral Number in a Field: A Redesigned Organ and Tissue Donation Referral Workflow

[Student Name]

University of Phoenix

NSG/542: Information Workflow

Week 4 Assignment

[Instructor Name]

[Date]

The hospital, its systems and the redesign are a composite written for a model paper.

The current-state map and data needs analysis identified five failure points and five data gaps. The two most consequential were that trigger data were documented but not noticed and that no one owned the referral once a trigger was met. This paper proposes a redesigned workflow and explains how each change addresses what was found.

Design Principles

Four principles guided the redesign. Let the system notice what it already knows: the triggers are already data in the record. Give the task one clear owner. Capture each data element once, in a structured field, at the time it happens. And place prompts where the work is done, not in a separate application. Unertl et al. (2010) describe artifacts, such as forms and screens, as part of workflow; the redesign changes the artifacts so that the right action becomes the easy one.

The Future-State Workflow, Lane by Lane

Lane 7, the electronic health record: a rule runs whenever a Glasgow Coma Scale score is filed for a ventilated patient, a goals-of-care or comfort care order is entered or a brain death evaluation order is placed. When any trigger is met, the record displays an alert to the patient's assigned nurse and the charge nurse, adds a "Donation referral due" task to the nurse's worklist with a one-hour clock and shows a banner on the patient's chart. The alert opens a referral form prefilled with demographics, diagnosis, the trigger and time, current vital signs, ventilator settings and key laboratory values.

Lane 2, bedside nurse, the owner: acknowledges the alert, reviews the prefilled form, calls the referral line with the form open and enters the referral number and time into required fields, which completes the task. If the nurse is occupied with care, the nurse delegates the call to the charge nurse with one click, which transfers ownership.

Lane 3, charge nurse: receives the same alert and sees the worklist task on the unit dashboard; if the task is not complete in 45 minutes, the charge nurse is prompted to make the call.

Lane 1, intensivist: sees the chart banner showing referral status and the organization's plan, and coordinates the family meeting with the coordinator.

Lane 4, unit clerk: no longer makes clinical calls; may place the call only if the nurse is present to answer questions.

Lane 5, organization call center: receives the referral and, with the prefilled summary read aloud or sent, completes intake faster; issues the referral number.

Lane 6, organization coordinator: receives remote read-only access to the patient's record for a limited time after referral, rather than requesting access for each case.

How the Changes Close Each Failure Point

Failure point A, trigger documented but not recognized: closed by the rule and alert, since the record now notices the trigger. Failure point B, no clear owner: closed by assigning the task to the bedside nurse with a visible clock and a one-click handoff to the charge nurse. Failure point C, waiting for the family meeting: addressed by education and by the chart banner, which frames referral as the step that allows the organization to plan the family approach with the team. Failure point D, late or missing documentation: closed by required structured fields for referral number and time, which replace the sticky note. Failure point E, nonclinical callers: closed by removing clerks from clinical calls and prefilling clinical data.

Tissue and Eye Referral for All Deaths

A second, simpler rule runs when a death time is documented. It adds a "Tissue and eye referral" task for the nurse and blocks completion of the death documentation until the referral number is entered or the organization's decline is recorded. Decedent affairs sees the status on its release checklist, which it now checks electronically before release.

Burden and Alert Design

Alerts are a common source of burden, and a poorly designed one would be ignored. The alert fires only when a defined trigger is met, goes only to the two people who can act and completes itself when the referral fields are filled, so nurses see it rarely and never twice for the same event. Based on last year's volume, the organ trigger alert will fire about five times a month across the intensive care units and emergency department. The prefilled form is estimated to save three to five minutes per call; the structured fields add about 30 seconds.

Coordinating the Family Conversation

One aim of the redesign is to bring the organization in early enough to plan the family conversation with the medical team. When referral happens at the trigger, the coordinator can review the case, speak with the intensivist and, when appropriate, be present for or follow the goals-of-care meeting. Research on family consent has found that contact with organization staff and the way donation is discussed are associated with whether families agree to donate (Siminoff et al., 2001). Earlier referral does not guarantee a different decision, but it gives families the full conversation the process is meant to offer.

What the Redesign Does Not Do

The redesign does not change who approaches families; that remains the organization or a trained designated requestor, consistent with the conditions of participation (Condition of Participation: Organ, Tissue, and Eye Procurement, 2023). It also does not replace the nurse's clinical judgment; a nurse who recognizes a trigger the rule misses, such as a sudden decline before the next score is filed, can open the referral form at any time.

Testing Before Go-Live

The rule will be tested against the past year's 58 trigger cases to confirm that it fires for each, and against a sample of 200 ventilated patients who did not meet triggers to count false alerts. Nurses, a charge nurse and an organization coordinator will walk through the new workflow in the test environment with scripted scenarios, and their timing and comments will be recorded. Changes will be made before a pilot in one intensive care unit for 30 days.

Communication and Education

Staff will be taught three messages: referral happens at the trigger, not after the family meeting; the bedside nurse owns the call and can hand it to the charge nurse; and the referral number goes in the field, not on paper. Short sessions at huddles, a one-page guide and a coordinator's visit to each unit will support the change, and the family's chance to make a choice, which timing affects, will be the reason given.

Conclusion

The redesigned workflow lets the record notice triggers, gives the task one owner with a visible clock, captures referral data once in structured fields and removes nonclinical callers from clinical calls. Each change closes a specific failure point or data gap, and the added burden is small and measured. Week 5 will address the interoperability, standards and privacy questions the redesign raises.

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