Challenge:    I work as a nurse informaticist for a large healthcare organization that has multiple hospitals  spanning several states.  One of my responsibilities is co-facilitating a weekly women’s health  workgroup meeting with hospital clinical informatics stakeholders.  Because the workgroup  consists of hospital constituencies spread out across a large geographic radius, these meetings  are held virtually.  A key workgroup objective is to complete the value prioritization, design,  communication, and implementation of hospital stakeholder submitted enhancement requests to  the electronic medical record (EMR).  Approval of any enhancement request design or solution  must achieve consensus across the multiple hospital organizations impacted.  The enhancement requests submitted should state the pain point or problem to be solved and  an alternative solution than the current workflow that would mitigate the pain point.  The weekly  workgroup meetings are intended to be the forum to distill the pain point prompting the  enhancement request for better insight into the design criteria that the group agrees would solve  the problem.    Selection:    Mind mapping is a tool that allows for immersion into current state workflows or data to identify  the meaning or patterns underlying a specific stakeholder problem and to define design criteria  that might solve it.  I chose mind mapping as a tool because of the rich insights it can reveal  from current state and the translational yielding of design criteria to satisfy the intent of a  submitted enhancement request.  It also provides a way for a diverse set of stakeholders to  participate in the design process.    Application:    The women’s health workgroup was struggling with a particularly challenging enhancement  request to streamline nursing workflow with labor and delivery documentation.  The hospital  stakeholders knew that the nurses were not satisfied with the current labor and delivery  documentation because it was too cumbersome, it was taking them too long to complete, and  that they were forgetting to chart key elements needed to meet regulatory requirements.  What  they did not understand was what changes were required to improve the nursing documentation  workflow and create efficiencies.  To facilitate this transition, a mind mapping process was used.    The first step we took was to pull a query of all the documentation fields contained in the labor  and delivery documentation.  The second step was to have each hospital constituency group  review the data separately to identify where improvements to the nurse’s documentation might  be made and where efficiencies might be derived. We then met together over several sessions  as a larger workgroup to review the insights that each hospital stakeholder group unearthed with  me functioning as facilitator.

Each documentation field was color-coded based on the insight derived from the stakeholder  assessment and subsequently discussed amongst the larger group.  Through the mind-mapping  process, we were able to gain an understanding of what was contributing to nurse  dissatisfaction and why it was leading to inefficiencies and missed charting in the labor and  delivery documentation workflow.  Notable patterns included multiple instances of duplicative  documentation and charting data elements ordered out of sequence with how nurses manage a  labor and delivery workflow.  From these insights, the stakeholders reached a consensus on a  redesign of the labor and delivery documentation which included removal of the extra  documentation and reorganization of the charting fields to make it easier to find and document  the data elements required.     Insight:    Taking current state data and providing it to the stakeholder groups helped unearth the patterns  underpinning the problem and shed light on what design criteria would be necessary to  formulate a solution.  A helpful byproduct of our mind-mapping exercise was insight into  additional EMR optimization opportunities unrelated to the initial request.  These items were  color-coded from our analysis and have been submitted, prioritized, and worked iteratively by  the workgroup.    Approach:    A notable barrier to use of mind mapping is how to make a typical in person exercise work  virtually.  The use of collaborative tools like google sheets and teleconferencing as well as  setting the ground rules for the mind mapping exercise helped spur engagement and  participation from the stakeholders in a virtual environment.  However, a big challenge was  ensuring all stakeholders had the chance to voice feedback.  If I use mind mapping again to  work through an enhancement request, I will explore what other types of digital tools (google  forms, as an example) might be more advantageous to use to achieve the same outcomes of  pattern and insight generation.

