Utilization of Workflow Process Maps to Analyze Gaps in Critical Event Notification at a Large, Urban Hospital.

Stroke care is a time-sensitive workflow involving multiple specialties acting in unison, often relying on one-way paging systems to alert care providers. The goal of this study was to map and quantitatively evaluate such a system and address communication gaps with system improvements. A workflow process map of the stroke notification system at a large, urban hospital was created via observation and interviews with hospital staff. We recorded pager communication regarding 45 patients in the emergency department (ED), neuroradiology reading room (NRR), and a clinician residence (CR), categorizing transmissions as successful or unsuccessful (dropped or unintelligible). Data analysis and consultation with information technology staff and the vendor informed a quality intervention-replacing one paging antenna and adding another. Data from a 1-month post-intervention period was collected. Error rates before and after were compared using a chi-squared test. Seventy-five pages regarding 45 patients were recorded pre-intervention; 88 pages regarding 86 patients were recorded post-intervention. Initial transmission error rates in the ED, NRR, and CR were 40.0, 22.7, and 12.0 %. Post-intervention, error rates were 5.1, 18.8, and 1.1 %, a statistically significant improvement in the ED (p < 0.0001) and CR (p = 0.004) but not NRR (p = 0.208). This intervention resulted in measureable improvement in pager communication to the ED and CR. While results in the NRR were not significant, this intervention bolsters the utility of workflow process maps. The workflow process map effectively defined communication failure parameters, allowing for systematic testing and intervention to improve communication in essential clinical locations.