Workflow Process Mapping: A Novel Approach to Promote Implementation of Evidence Based Practices [39I

Abstract

INTRODUCTION: National guidelines recommend offering immediate postpartum long-acting reversible contraception (LARC). However, hospitals lack evidence-based approaches for embedding this care into existing workflow. We used a multiple case study to understand immediate postpartum LARC workflow at early-adopter sites and create a tool to help embed this care into practice at new sites. METHODS: A systematic literature search identified hospitals offering immediate postpartum contraceptive care. We purposively sampled information-rich sites. From 8/2017 to 9/2018, we conducted site visits with semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research (CFIR). Workflow process mapping was used to develop detailed workflow maps and describe drivers of observed workflow variation. Institutional IRB approval was obtained. RESULTS: After interviewing 79 key informants at 11 hospitals, workflow process mapping revealed variation across sites, especially related to timing and staff involved in 1) counseling, consent, and documentation of patient preferences, 2) addressing insurance coverage, 3) device ordering, 4) contraceptive insertion technique, and 5) post-insertion management. Observed variation was often driven by context (e.g., degree of integration between inpatient and outpatient teams, variation in L&D staff composition) and gaps in clinical evidence (e.g., uncertainty about the comparative effectiveness of intrauterine device insertion techniques). Only two sites prospectively designed a workflow. At other sites, workflows were often inefficient, requiring adaptations after initial implementation and clarification about roles and responsibilities. CONCLUSION: Pre-implementation workflow process planning using the self-assessment tool may help sites engage key stakeholders, customize workflow to local needs, and minimize need for future adaptations.