CPIA Module 4, Section 3: Workflow Mapping and Process Redesign
MODULE 4: MEDICATION-USE SYSTEMS & ARCHITECTURE

Section 4.3: Workflow Mapping and Process Redesign

A practical guide to visualizing clinical workflows. We will learn how to create process maps that expose inefficiencies and opportunities for technological improvement.

SECTION 4.3

Workflow Mapping and Process Redesign

From “How We Think It Works” to “How It Actually Works”: The Foundation of System Improvement.

4.3.1 The “Why”: Making the Invisible Visible

In your pharmacy experience, you operate within a highly complex workflow every single day. The journey of a prescription from the moment it is dropped off to the moment the patient walks away with their medication is a multi-step process involving numerous tasks, handoffs, and system interactions. Yet, if you were asked to draw a detailed map of this entire process, including every single decision point and potential failure mode, you would likely find it a surprisingly difficult task. This is because most workflows are invisible. They are a collection of habits, assumptions, and tribal knowledge that we execute without conscious thought.

In the hospital environment, this invisibility is magnified a hundredfold. The medication-use process is not a linear path but a sprawling web of interactions between multiple disciplines—physicians, nurses, pharmacists, technicians, respiratory therapists—and a complex array of information systems. The single greatest barrier to improving this process is that no single person understands it in its entirety. The physician understands the ordering process, the pharmacist understands verification, and the nurse understands administration. But the gaps, delays, and redundancies happen in the “white space”—the handoffs between these silos. These invisible friction points are the breeding ground for inefficiency, staff frustration, and, most critically, medication errors.

Workflow mapping is the discipline of making these invisible processes visible. It is a powerful diagnostic tool that allows us to move from “how we think it works” to “how it actually works.” By creating a visual representation of a process, we can, for the first time, see it as a whole system. We can identify bottlenecks, quantify delays, pinpoint redundant tasks, and uncover dangerous workarounds that have become normalized over time. For a pharmacy informaticist, workflow mapping is not an abstract academic exercise; it is the fundamental starting point for every single project you will undertake. You cannot safely build a new order set, implement new technology, or change a policy until you first deeply and humbly understand the current state of the workflow you are about to change.

Retail Pharmacist Analogy: The Mystery of the Long Wait Time

The district manager visits your high-volume pharmacy and says, “Our customer satisfaction scores are down. The number one complaint is wait time. I need you to fix it.” Your first instinct might be to blame a single cause: “We need more technician hours,” or “The verification queue gets backed up.” But these are just symptoms. To truly solve the problem, you must become a workflow detective.

You decide to map the entire process. You get a giant whiteboard and assemble your team: a drop-off technician, a data entry technician, a filling technician, a staff pharmacist, and a cashier. You start mapping the “happy path” of a simple e-prescription for amoxicillin. But then you start asking questions and observing reality.

  • The Handoffs Emerge: You discover that the data entry tech often has to walk over to the drop-off window to clarify insurance information, creating a delay. After filling, the technician places the bottle in a bin, but there’s no clear signal to the pharmacist that it’s ready for verification. The pharmacist has to periodically check the bin, introducing another wait.
  • The Bottlenecks Appear: You realize that only one computer has the software for processing manufacturer coupons, and technicians often have to wait in line to use it. You notice that the verification pharmacist is also responsible for answering all incoming phone calls, constantly interrupting their primary task and causing the queue to swell. This task-switching is a major bottleneck.
  • The Rework is Uncovered: You find out that 15% of prescriptions entered are rejected by insurance. The data entry technician then has to send them to a “rejection queue,” which the pharmacist has to work on later. This rework loop adds significant time to the overall process.

By the end of the session, your whiteboard is covered in boxes, arrows, and notes. It’s a complex, messy, and brutally honest picture of how things *really* work. You can now see that the problem isn’t just “not enough staff.” It’s a series of small, invisible inefficiencies, handoff delays, and rework loops that add up to a frustratingly long wait time. Now, and only now, can you begin to have an intelligent conversation about solutions. “What if we had a dedicated person for the rejection queue? What if we installed the coupon software on a second computer? What if we used colored baskets to signal when a prescription is ready for verification?” This process of visualizing the current state to enable a data-driven redesign is the essence of workflow mapping.

4.3.2 The Tools of the Trade: A Practical Guide to Process Mapping

Workflow mapping is both an art and a science. It requires facilitation skills to draw information out of people and analytical skills to structure that information visually. While there are many complex notations (like the full Business Process Model and Notation, or BPMN), a pharmacy informaticist can accomplish 95% of their goals by mastering a few simple shapes and one powerful diagramming technique: the swimlane map.

The Basic Building Blocks (Simplified BPMN)

You don’t need complex software to start. You just need a whiteboard, markers, and an understanding of what the basic shapes represent.

Task

Task / Activity

A simple rectangle. This represents a single step or action being performed. It should be described with a verb-noun phrase (e.g., “Verify Order,” “Prepare IV Admixture,” “Administer Medication”).

Decision

Decision Point

A diamond. This represents a point where the workflow diverges based on a question. The paths leaving the diamond must be labeled with the outcomes (e.g., “Yes/No,” “Approved/Rejected,” “STAT/Routine”).

Start

Start / End Event

An oval (or a circle/rounded rectangle). This marks the trigger that starts the process (e.g., “Patient Arrives in ED”) and the final resolution that ends it (e.g., “Medication Documented on MAR”).

The Most Valuable Player: The Swimlane Diagram

A simple flowchart using the shapes above is useful, but it hides the most important information in a hospital setting: **who** is performing the task and **where** the handoffs occur. The **Swimlane Diagram** (also known as a cross-functional flowchart) solves this brilliantly. It organizes the entire process map into horizontal or vertical bands, with each band representing a specific role, department, or system. The flow of the process moves across these lanes, making the handoffs between participants visually explicit.

For pharmacy informatics, this is your desert-island diagram. It is the single most effective tool for understanding the sociotechnical complexity of the medication-use process. A typical swimlane map for a medication order might include lanes for: Provider, Nurse, Pharmacist, Pharmacy Technician, and then, crucially, lanes for the key information systems like EHR, PharmIS, and ADCs.

4.3.3 Masterclass: Facilitating a “Current State” Workflow Mapping Session

Mapping a workflow is a team sport. Your role as an informaticist is often that of a facilitator—a neutral party whose job is to guide a group of frontline experts to build a collective, honest picture of their own process. This requires a structured approach and strong interpersonal skills. You are not there to provide answers; you are there to ask the right questions and document the reality that emerges.

The Step-by-Step Playbook for a Successful Mapping Session
Step Action Informatics Pearl: Why This Matters
1. Define the Scope Be ruthlessly specific about the start and end points of the process you are mapping. Don’t try to “boil the ocean.” Instead of “The Medication Process,” choose “The Process for Administering a First Dose of a STAT IV Antibiotic from the Central Pharmacy to an Inpatient on a Med-Surg Unit.” A clear scope is the single most important factor for success. It keeps the team focused and prevents the mapping session from becoming an endless, unproductive conversation about every problem in the hospital. You can always map adjacent processes later.
2. Assemble the Right Team Identify every single human role that touches the process within your scope. For our STAT IV antibiotic example, you absolutely need a hospitalist/provider, a floor nurse, a central pharmacy pharmacist, and an IV room pharmacy technician. Invite them to a 90-minute meeting in a room with a large whiteboard. You cannot map a process without the people who actually do the work. Mapping with only managers or leadership in the room will result in a map of how they *think* it works, which is often dangerously disconnected from reality.
3. Go to the Gemba (The Real Place) Before the meeting, you must perform direct observation. “Gemba” is a Lean manufacturing term meaning “the real place.” Go to the nursing unit. Shadow a nurse. Go to the central pharmacy. Shadow a pharmacist and a technician. Take notes. Ask questions. “What are you doing now? What system is that? What happens next?” Observation is your superpower. It allows you to see the workarounds and inefficiencies that people won’t mention in a meeting because they’ve become so routine. It also gives you the credibility to ask informed questions during the mapping session.
4. Facilitate the Mapping Start by drawing your swimlanes on the board. Ask the group, “What is the very first thing that triggers this process?” (The provider decides to order the antibiotic). Draw the “Start” oval in the Provider lane. Then ask, “What happens next?” and then “And then what happens?” for the next 90 minutes. Your job is to listen, ask clarifying questions, and draw what they tell you. Let the team build the map. Your role is to be the scribe and the guide. Use phrases like, “So, after the pharmacist verifies the order, tell me exactly what happens. Does a label print? Where does it print? Who sees it first?” Constantly focus on the handoffs between the lanes.
5. Capture Reality, Not Perfection The group will describe exceptions, workarounds, and “what-if” scenarios. Capture them! Use sticky notes or a different color marker. If the nurse says, “Well, usually the label prints in the IV room, but sometimes the printer jams and we don’t know the order is there,” that is a golden piece of information. That is a failure mode. A “Current State” map is meant to be messy. Its value comes from its honesty. You are not designing the ideal process yet; you are documenting the real, imperfect process that exists today, warts and all. This is your problem-finding mission.
6. Digitize and Validate After the session, take a picture of the whiteboard. Then, use a simple diagramming tool (like Visio, Lucidchart, or even PowerPoint) to create a clean, digital version of the map. Send this diagram back to all the participants and ask, “Did I capture this correctly? Is there anything I missed?” This validation step is crucial. It ensures you have a shared, accurate understanding of the current state before you take any steps to change it. This document becomes the foundation for all future analysis and redesign efforts.

4.3.4 Practical Example: Mapping the “STAT First Dose IV” Workflow

Let’s apply these principles to create a simplified but detailed swimlane diagram for our scoped process: “The Process for Administering a First Dose of a STAT IV Antibiotic from the Central Pharmacy.” Below is a visual representation of what a “Current State” map might look like, followed by a detailed narrative breakdown of each step. This is the kind of artifact you would produce after a successful mapping session.

ROLE / SYSTEM
Provider
EHR / CPOE
Interface Engine
Pharmacist
Pharmacy Tech
Nurse
Patient / BCMA
1. Decides to order STAT Cefepime
2. Enters order in CPOE; flags as ‘STAT’
3. Generates HL7 ORM message
4. Receives and routes message to PharmIS
5. Order appears in STAT queue; Pharmacist opens order
6. Performs clinical review in EHR
7. Verifies order in PharmIS
8. Label prints in IV Room
9. Tech compounds Cefepime IVPB
10. Pharmacist performs final check
11. Tech delivers dose to unit
12. Nurse receives dose
13. Performs BCMA scan & administers
Narrative Breakdown: Uncovering the “White Space”

The diagram provides the skeleton, but the real learning comes from adding the detailed narrative and asking “what could go wrong?” at each step.

  • Step 1-2 (Provider in CPOE): The process begins. Potential Failure: The provider forgets to flag the order as “STAT.” The order then enters the “Routine” queue in the pharmacy, where it might sit for an hour or more before being seen, completely defeating the clinical urgency.
  • Step 3-4 (EHR to Interface Engine to PharmIS): The digital handoff. This is usually instantaneous. Potential Failure: A rare but serious failure mode is an interface delay or error. The message could get stuck in the interface engine’s queue. From the provider’s perspective, the order is placed. From the pharmacy’s perspective, it doesn’t exist. This is a dangerous “limbo” state.
  • Step 5-7 (Pharmacist Verification): The pharmacist begins their cognitive work. Potential Failure (The Bottleneck): There is only one pharmacist responsible for verifying all orders from the ED and all STATs from the floors. At 3 PM on a busy day, this pharmacist is overwhelmed. Even though the order is in the STAT queue, it might wait 15-20 minutes before it’s even opened. This is a classic resource bottleneck.
  • Step 8 (Label Printing): The verification action triggers a label to print in the IV room. Potential Failure (The Physical World Intrudes): The IV room is loud. The printer is out of paper. The label prints, but it falls behind the counter and goes unnoticed by the technician for 10 minutes. This is a classic example of a “black hole” in the workflow—a point where information can be lost in the physical environment.
  • Step 9-10 (Compounding & Checking): The technician prepares the dose and the pharmacist checks it. This is a well-controlled process. Potential Failure: The technician needs a specific diluent that is out of stock in the IV room. They have to go to the main pharmacy storeroom to get it, adding 5-7 minutes of delay.
  • Step 11 (Delivery): The technician must deliver the dose. Potential Failure (Logistics): The hospital has a pneumatic tube system, but IV bags can’t be tubed. The technician has to wait for the next hourly “medication run” to deliver the dose, adding a potentially massive delay. Or, they have to walk it up themselves, taking them away from compounding other critical medications.
  • Step 12-13 (Nursing Administration): The nurse receives the dose and prepares to administer. Potential Failure: The nurse is with another critical patient when the dose arrives. The STAT Cefepime sits on the counter for another 15 minutes. When she is finally ready, she discovers the patient’s IV has infiltrated and she needs to start a new one before she can administer the drug.

4.3.5 The Goal: From “Current State” Analysis to “Future State” Redesign

The exhaustive, and often painful, process of mapping the current state is not the end goal. It is the diagnostic workup. Its purpose is to give you a data-rich foundation from which to design a better process. The “Future State” is a new workflow map that you design with the team to explicitly address the pain points, bottlenecks, and failure modes you uncovered in the current state.

Process redesign is a creative and collaborative effort. You bring your knowledge of technology and best practices, and the frontline staff bring their deep understanding of the practical realities of their work. Together, you brainstorm solutions that can eliminate waste, improve communication, and build in new safety checks. The goal is not just to make the process faster, but to make it more reliable, less frustrating, and safer for patients.

Masterclass Table: Redesigning the STAT IV Workflow
“Current State” Pain Point / Failure Mode “Future State” Redesign Solution (People, Process, or Technology)
Provider forgets to flag the order as “STAT,” causing a delay in pharmacy. Technology Solution: Work with the EHR team to build clinical decision support. If a patient has a sepsis diagnosis and the provider orders an antibiotic, a “Best Practice Alert” fires, asking “Should this be ordered STAT?”
Pharmacist verification is a bottleneck due to a single pharmacist being overwhelmed. Process Solution: Redesign the pharmacy staffing model. Create a dedicated “STAT/ED Pharmacist” role during peak hours whose sole responsibility is to manage this high-priority queue. Technology Solution: Implement workload balancing dashboards that are visible to all pharmacists, making it clear when one queue is becoming overloaded.
The printed label is lost or goes unnoticed in the IV room. Technology Solution: Implement an IV Workflow Middleware system. When the pharmacist verifies the order, it appears on a large digital dashboard in the IV room. The technician must acknowledge the order on the screen, creating a digital handshake and eliminating the risk of a lost label.
Delivery of the STAT dose is delayed by waiting for a scheduled run or a busy technician. People/Process Solution: Create a “STAT medication runner” role (often a shared responsibility) whose job is to immediately deliver any STAT medication the moment it is checked. This decouples the delivery task from the highly-skilled compounding task.
The nurse is busy and the STAT dose sits on the counter. Technology Solution: The IV Workflow system can be configured to start a timer the moment the pharmacist checks the dose. If the dose is not documented on the MAR via BCMA within a certain timeframe (e.g., 20 minutes), the system can send an automated alert to the charge nurse’s phone, prompting a check-in.
Technology is Not a Magic Wand

It is tempting to look at every workflow problem and assume that a new piece of software is the answer. This is a classic and dangerous trap for a new informaticist. As the table above shows, solutions can involve people (changing roles and responsibilities), process (changing how the work is done), and technology. Often, the most powerful improvements come from simplifying the process first, before applying technology.

Automating a bad, inefficient, or unsafe process does not fix it; it just makes the bad process run faster. The discipline of workflow mapping forces you to deeply understand the human and process components first. Only then can you strategically apply technology to support a well-designed, human-centered workflow. Your job is not to implement software; your job is to improve the way care is delivered, and technology is just one of the tools in your toolbox.