MMHA 6600 Week 1 Admission Workflow Redesign Example

Asked Twice Before Supper: Redesigning the Emergency-to-Floor Admission Intake at a Small Composite Hospital

Student Name

Walden University

MMHA 6600: Healthcare Informatics and Technology Management

Instructor Name

Month Day, Year

Asked Twice Before Supper: Redesigning the Emergency-to-Floor Admission Intake at a Small Composite Hospital

Introduction

Bramble Creek Hospital is a composite 96-bed community hospital used for this course. About a third of its medical-surgical admissions arrive from its own emergency department, and on those admissions the floor nurse opens a nursing admission database that asks many of the questions the emergency nurse and the admitting physician already asked and charted a few hours earlier. This paper maps that intake as it runs today, rebuilds it so that answers already in the record are confirmed rather than collected again, and explains which repeated questions were kept on purpose.

The redesign changes no software. Every change sits inside the configuration the hospital's own build team can make: which fields pull forward, which questions become a confirmation, and who is expected to act at which moment. Workflow is treated here the way the systems engineering literature treats it, as the interaction of people, tasks, tools, setting and organization rather than as screens alone (Carayon et al., 2006).

The Admission as It Runs Today

Table 1 follows one admission from the moment transport arrives on the floor to the last signature, written step by step from two observed shifts. Each step carries the same four labels used in the redesign: who acts, when, where the answer is written, and whether the record already held that answer.

Table 1

Current Emergency-to-Floor Admission Intake, Observed Steps

Seven of the eleven steps ask for information the record already held. The emergency contact is asked by two different people on the floor itself.

The Cost the Patient Carries

From the bed, the admission looks different. A patient admitted with pneumonia in the late afternoon was asked about allergies at triage, again by the admitting physician, and a third time by the floor nurse before supper. Each time she gave the same answer about a rash with sulfa drugs. She was asked whether she had fallen in the past year twice, and whether she had an advance directive twice, once by a registration clerk holding a clipboard. By the third round of questions she told the nurse that nobody seemed to read what she said downstairs.

That remark carries the argument for change. Repetition costs nursing time, which time-and-motion work has measured in the hours clinicians spend on documentation (Hripcsak et al., 2011), but it also teaches patients that their answers vanish, and it trains staff to ask without looking first. Systems that duplicate entry also create two places for the same fact, and the two can drift apart, which is one of the unintended consequences of clinical information systems described by Ash et al. (2004).

The Redesigned Admission

Table 2 shows the same admission after the redesign. The guiding rule is simple: if a trustworthy answer exists in the record from the same encounter, the floor nurse sees it pulled forward and confirms it with the patient in a single sentence; if no answer exists, the question is asked.

Table 2

Redesigned Emergency-to-Floor Admission Intake

Four questions become confirmations, two are asked only when the field is blank, and one is removed from the nurse's list entirely.

Repetition Kept on Purpose

Not every repeat is waste. Three were kept deliberately, and each is paired with the error it catches. Identity confirmation stays because a wrong-patient admission is a catastrophic and well-documented failure that a second check reliably intercepts. The home medication review stays as a full spoken review, not a confirmation, because emergency medication lists are frequently incomplete; the floor nurse's conversation is where a missing anticoagulant or a recently stopped diuretic usually surfaces. The pain score stays because pain changes after transport, and a value carried forward from the emergency department would set a false baseline for the first as-needed dose.

Keeping these three shows that the redesign was selective. A redesign that removed every repeated question would be shorter, but it would trade nursing minutes for safety checks, which is the kind of change Sittig and Singh (2010) warn about when a technical fix ignores how the clinical work actually protects patients.

What the Change Requires

Three configuration changes carry the redesign. First, the allergy, fall screen, advance directive and social history fields in the admission database are set to display the most recent value from the same encounter, with its source and time, and a confirm button that records who confirmed it. Second, the admission database's completion rule is changed so that a confirmed value counts as complete. Third, the unit clerk's registration checklist takes sole ownership of the emergency contact. None of these require a vendor change request; all sit within local build privileges.

The human changes are smaller but matter more. Floor nurses are asked to read the emergency summary before the patient arrives rather than relying on the phone report alone. The phone report stays, shorter, for what the record cannot hold: how the patient is doing right now and what worried the emergency nurse.

A Trial Shift With an Owner

The unit educator and an informatics nurse will own the change. The first trial runs on a weekday evening shift, when emergency admissions peak, on six admissions. An observer will record three things for each: how many questions the patient was asked that the record already answered, the minutes from arrival to a signed admission database, and any discrepancy the confirmations caught, such as an allergy the patient corrected. That last measure matters most. If confirmations catch errors, the design is doing its safety work; if they catch nothing, the team should ask whether nurses are clicking confirm without reading.

After the trial, the owners will meet with charge nurses for thirty minutes, adjust the field list, and decide whether to extend the change to the second medical-surgical unit.

Conclusion

The admission intake at Bramble Creek asks patients the same questions several times because each screen was built to stand alone. Treating answers from the same encounter as starting points rather than strangers removes most of the repetition, keeps the three checks that protect patients, and asks nothing the hospital cannot configure itself. The patient who said nobody reads what she said downstairs is the best measure of success: on the redesigned unit, someone would have.

References

Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Informatics Association, 11(2), 104-112. https://doi.org/10.1197/jamia.M1471

Carayon, P., Schoofs Hundt, A., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 15(Suppl 1), i50-i58. https://doi.org/10.1136/qshc.2005.015842

Hripcsak, G., Vawdrey, D. K., Fred, M. R., & Bostwick, S. B. (2011). Use of electronic clinical documentation: Time spent and team interactions. Journal of the American Medical Informatics Association, 18(2), 112-117. https://doi.org/10.1136/jamia.2010.008441

Sittig, D. F., & Singh, H. (2010). A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care, 19(Suppl 3), i68-i74. https://doi.org/10.1136/qshc.2010.042085