NURS 6421 Week 7 future state map example

Fourteen Boxes Where There Were Twenty-Two: A Future-State Map of the Sleep Clinic Referral Around Electronic Intake, With What It Makes Worse

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College of Nursing, Walden University

NURS 6421: Supporting Workflow in Healthcare Systems

Instructor Name

Month Day, Year

Fourteen Boxes Where There Were Twenty-Two: A Future-State Map of the Sleep Clinic Referral Around Electronic Intake, With What It Makes Worse

What Changes

This map redraws the referral process mapped in Week 3 for the same composite sleep medicine clinic, redesigned around an electronic intake capability. The capability is described by what it does, not by product: referring offices submit referrals through a structured web form that will not accept a submission without the required fields, referrals enter one queue that also holds scheduling status, patients receive a link to choose their own appointment, and the referral closes automatically when an appointment is booked. The redesign targets gap A from the Week 5 gap analysis, the split between referral status and scheduling, and gap C, incomplete referrals.

The Future-State Map

Table 1

Future-State Steps, With New Steps Marked

Removed Steps

Table 2

Current-State Steps Removed, With Reasons

Loop A, incomplete referrals, disappears from the map because the form enforces completeness at the source. Loops B and C survive and are drawn, because the redesign does not change how payers respond or whether every patient answers.

Assumptions

The future state rests on four assumptions, each of which could fail. Referring offices will use the form rather than continuing to fax; if a third keep faxing, the front desk steps return in a parallel path. The required fields will be the right ones, capturing what triage needs without asking for so much that offices abandon the form. Most patients can use a self-scheduling link; older patients and those without reliable internet access may not, and step F11 exists for them. And the authorization coordinator's electronic submission will reach the major payers the clinic serves; for payers that still require faxed requests, Loop B will look much as it does today. A review of process mapping in health care improvement projects found that maps are most useful when they feed a wider improvement effort rather than standing alone (Antonacci et al., 2018), so the assumptions are written beside the map to be tested in the first months after go-live.

What the Redesign Makes Worse

Three consequences land on people who never requested it. First, referring office clerks now do structured data entry that the clinic's front desk used to absorb by reading faxes. The work has not disappeared; it has moved outside the clinic, where the clinic cannot see it or support it. Second, patients now do part of the scheduler's work, choosing among slots and completing the questionnaire online. For many that is a convenience; for some it is a barrier, and the burden falls hardest on the patients least able to carry it. Third, the medical assistant, who previously had no role in referrals, now fields questions about the link and the form, which competes with rooming during the busiest hours.

Studies of unintended consequences after order entry systems were introduced found that more or new work for clinicians was the most common category, along with unfavorable workflow changes and persistent paper (Campbell et al., 2006). This redesign shows the same pattern in a smaller setting: work is removed from the front desk and redistributed to others. Human factors frameworks predict this, since changing one part of a work system shifts demands onto others (Holden et al., 2013). The clinic should track calls to the medical assistant about the link, faxes that still arrive and the proportion of patients who self-schedule, and should treat a rise in any of them as a signal that the redesign has moved work rather than removed it.

How the Future State Will Be Checked

A future-state map is a prediction, and it should be tested as one. Three months after go-live, the same observation method used for the current-state map will be repeated on two mornings, and the redrawn process will be compared with what actually happens. Four questions guide the comparison: whether any removed step has quietly returned, for example faxes still being logged by the front desk; whether Loop C has shortened; how often the medical assistant is interrupted by questions about the link; and whether the referral closes automatically as designed. If a removed step has returned, the map will be redrawn to show it rather than defended, because a map that describes a process no one follows is worse than none. The comparison will go first to the staff who book, triage and check in patients, before it reaches the clinic's leaders, so the people doing the work can correct it first.

References

Antonacci, G., Reed, J. E., Lennox, L., & Barlow, J. (2018). The use of process mapping in healthcare quality improvement projects. Health Services Management Research, 31(2), 74-84. https://doi.org/10.1177/0951484818770411

Campbell, E. M., Sittig, D. F., Ash, J. S., Guappone, K. P., & Dykstra, R. H. (2006). Types of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association, 13(5), 547-556. https://doi.org/10.1197/jamia.M2042

Holden, R. J., Carayon, P., Gurses, A. P., Hoonakker, P., Hundt, A. S., Ozok, A. A., & Rivera-Rodriguez, A. J. (2013). SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 56(11), 1669-1686. https://doi.org/10.1080/00140139.2013.838643