HLTH5643 Module 1 current state information flow analysis example

A Whiteboard, Three Phones and a Spreadsheet Nobody Mentions: How Bed Assignment Information Actually Moves in a 318-Bed Hospital

Student Name

American College of Education

HLTH5643: Information Systems Management for Healthcare Administrators

Module 1 Assignment

Instructor Name

September 4, 2028

Why Map Before Buying

The composite 318-bed regional hospital used in this course has approved funds to buy an electronic bed management system. The request came from the emergency department, where admitted patients wait for inpatient beds for hours, and from the house supervisors, who manage bed placement from a whiteboard. Before anyone writes requirements or watches a vendor demonstration, the information systems steering committee asked for an account of how bed information moves today, not as the policy describes it but as it actually happens. A system bought to automate the official process will fail if the real process runs on something else.

The delay matters to patients. In a retrospective study of more than 41,000 admissions from one emergency department, Singer et al. (2011) found that in-hospital mortality rose from 2.5 percent among patients who boarded less than two hours after the decision to admit to 4.5 percent among those who boarded twelve hours or more, and hospital length of stay also increased with boarding time. A clean room that nobody has reported keeps a sick person on a hallway stretcher downstairs.

Method

Over two weeks in August, two analysts from the information systems department traced 46 consecutive admissions from the emergency department to medical and surgical units, on all three shifts. For each admission they recorded every communication that moved information about the patient or the bed: who contacted whom, by what means and when. They also shadowed the house supervisor for four full shifts, spent two shifts each with environmental services dispatch and unit secretaries and interviewed eleven charge nurses. Timestamps came from the electronic record where they existed and from observation where they did not. Staff were told that the purpose was to understand the process, that no individual would be identified and that nothing observed would be used for performance review, which was essential to learning about workarounds at all.

The Official Process

According to hospital policy, the process has six steps. The emergency physician enters an admission order, and the emergency department nurse calls the house supervisor to request a bed. The supervisor consults the bed board, a large whiteboard in the supervisor's office updated from the census report printed three times a day, and assigns a bed. When a patient is discharged from an inpatient unit, the unit secretary enters the discharge in the electronic record and calls environmental services to request cleaning. Environmental services dispatches a housekeeper by pager, and when cleaning is complete, the housekeeper calls the unit secretary, who calls the supervisor to report the bed clean. The supervisor updates the whiteboard and assigns the bed to the next waiting patient, and the emergency nurse calls report to the unit nurse before transport.

How Information Actually Moves

The traced process was more complicated. The supervisor did not rely on the whiteboard, which was accurate only immediately after each census printout. Instead, the supervisor kept a personal spreadsheet on a desktop computer, updated from phone calls and texts throughout the shift, and used the whiteboard mainly for the benefit of visitors to the office. Of the 46 admissions, 31 were placed using information that existed only in that spreadsheet. The discharge entry in the electronic record did not reliably start the cleaning process: in 19 of the 34 discharges observed, the call to environmental services came only after the patient physically left the unit, sometimes more than an hour after the discharge was entered, because unit secretaries waited to see the room empty.

Cleaning completion was reported in three different ways: by the housekeeper calling the unit secretary as policy required, by the housekeeper writing "clean" on the unit's own whiteboard or by the housekeeper telling whichever nurse was nearby. The median time from cleaning completion to the supervisor learning the bed was clean was 24 minutes. Across the whole sample, a bed was assigned a median of 94 minutes after the emergency physician's admit order, and the patient reached the unit a median of 71 minutes after that.

The Workarounds Nobody Admits To

Four workarounds carried much of the process. First, the supervisor's spreadsheet, described above, existed because the official bed board could not be kept current. Second, charge nurses and the supervisor texted each other on personal phones about bed status and expected discharges, which was faster than calling but placed patient information on devices the hospital does not manage. Third, charge nurses on two busy medical units sometimes held a clean bed off the report for up to an hour near shift change, so that an admission would not arrive during handoff. Six charge nurses described this practice when asked what they did at busy times, although none called it by name. Fourth, when environmental services was short-staffed, unit nurses occasionally cleaned rooms themselves to speed an admission, without notifying dispatch, which meant the environmental services record showed the room still dirty.

Debono et al. (2013), reviewing 58 studies of nurses' workarounds in acute care, found that workarounds arise from organizational, work process, patient-related, individual, social and professional factors, and that group norms and local culture strongly influence them. They are not simply rule breaking; staff often use them to deliver care when the formal process does not work. Each of the workarounds observed here solves a real problem: an inaccurate bed board, slow telephone relays, unsafe admissions at handoff and cleaning delays.

Workarounds as Requirements in Disguise

The workarounds show what the hospital's staff need from any new system. The spreadsheet shows that the supervisor needs a real-time view of every bed's status, updated at the moment it changes. The texting shows that charge nurses and the supervisor need a fast, secure way to communicate expected discharges before they happen. Holding beds at handoff shows that units need a way to signal a brief, visible pause in admissions without hiding capacity. Nurses cleaning rooms shows that environmental services needs faster dispatch and a way to record who cleaned a room. Koppel et al. (2008), studying barcode medication administration at five hospitals, found 15 types of workarounds with 31 types of causes and concluded that shortcomings in a system's design, implementation and fit with real workflow encourage workarounds.

A bed management system that ignores these needs will create a new set of workarounds rather than replace the old ones. Tortorella et al. (2013) described how an interdisciplinary team at a large cancer center implemented an electronic bed management system to improve the bed turnover part of patient throughput, and their approach began with the process across all the disciplines involved rather than with the software. The most useful finding of a current state map is usually the thing the policy says does not happen.

Conclusion

Bed assignment at the hospital depends on a private spreadsheet, personal texts, beds quietly held back at shift change and cleaning that sometimes happens outside the dispatch record. The official process describes none of these, and a system built to automate it would miss most of what actually moves the information. The 46 traced admissions show where time is lost, especially between a discharge and the start of cleaning and between a clean bed and the supervisor learning about it. The next step is to write requirements that meet the needs the workarounds reveal, before any vendor is invited to demonstrate a product.

References

Debono, D. S., Greenfield, D., Travaglia, J. F., Long, J. C., Black, D., Johnson, J., & Braithwaite, J. (2013). Nurses' workarounds in acute healthcare settings: A scoping review. BMC Health Services Research, 13, Article 175. https://doi.org/10.1186/1472-6963-13-175

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616

Singer, A. J., Thode, H. C., Jr., Viccellio, P., & Pines, J. M. (2011). The association between length of emergency department boarding and mortality. Academic Emergency Medicine, 18(12), 1324-1329. https://doi.org/10.1111/j.1553-2712.2011.01236.x

Tortorella, F., Ukanowicz, D., Douglas-Ntagha, P., Ray, R., & Triller, M. (2013). Improving bed turnover time with a bed management system. Journal of Nursing Administration, 43(1), 37-43. https://doi.org/10.1097/NNA.0b013e3182785fe7