It's 4 a.m. - Do You Know Where Your Nurses Are? Workflow Technology Helps Achieve High Reliability

Updated: Sep 12

By Paul Gallese, PT, MBA

Understanding the real-time workflow patterns of your nurses is crucial toward achieving high reliability in health care.

Through their movements during the course of each shift, nurses provide insights that can be used to improve patient safety and quality. New workflow monitoring technology can track their movements and engage their support in patient safety, quality and high reliability initiatives. In turn, the technology can help reduce healthcare-acquired infections and conditions such as harm from falls, pressure ulcers and deep vein thrombosis (DVT). These infections and conditions cost hospitals $2 billion in excess hospital costs (Meyer, 2018).

Automated workflow monitoring technology also helps to identify nurse fatigue and – coupled with interventions designed to decrease stress – can improve the job satisfaction of caregivers and reduce burnout and turnover while improving patient safety.

The financial stakes of managing burnout and turnover effectively are high. According to the Nursing Solutions Inc. National Health Care Retention and RN Staffing Report, the turnover rate for bedside RNs is 17.2 percent per year and the average cost to replace a bedside registered nurse is estimated at more than $50,000. The average hospital loses $4.4 million to $6.9 million each year due to turnover (NSI, 2019).

Workflow monitoring technology has great potential, but it’s disruptive

Technology that can track movement and location is more ubiquitous than one may realize. You find this technology in home security systems; on toilets, faucets and soap dispensers; and on light fixtures and doors, with more applications continuing to be deployed. Within the health care setting, the interface between this technology and caregivers is something few truly understand; yet, the potential for the technology to enhance the quality of care nurses and others provide is astonishing.

Workflow monitoring technology can tell you where your nurses are spending most of their time, how often and for how long they are in patient rooms, and whether or not they are complying with hand hygiene and other procedures related to patient safety. The idea behind implementing this technology is not to “spy” on caregivers; it’s not to gain information to hold against them or to use the technology to replace them. The idea is to gather data that will help them to become more effective providers of care.

Knowing the wonderful potential of this technology, I also acknowledge the difficulty of introducing this kind of technology into health care settings. Why is it difficult? Because it’s disruptive. Deploying this technology requires an organization to have a strong interest in better understanding human behavior and the interactions between humans and technology in the health care space.

Better patient safety requires technology-supported processes and compliance reporting

Despite the challenges of implementing this technology, the Vitalacy team perseveres because we believe that patient safety is best assured through the deployment of technology-supported processes and compliance reporting in support of sustainable change. While leading installations of this technology in hospitals, we have encountered four major challenges:

  1. Engagement. How to address “technology fatigue” and gain compliance with the use of the technology

  2. Detractors – how to identify and address their issues

  3. Champions – why their advocacy is essential

  4. Feedback pathways – how to use the data that’s generated to improve quality and safety

The data gained through automated technology is more accurate and more grounded in reality than what is gained through direct observation of caregivers. For example, the Vitalacy patient safety platform was implemented in an academic medical center with a higher-than-average healthcare-acquired infection rate; this rate was high despite the medical center reporting direct observation hand hygiene compliance rates of more than 90 percent on 1,500 direct observations per quarter. Immediately after implementation, Vitalacy’s automated hand hygiene compliance tracking found that the actual hand hygiene compliance was less than 30 percent (Vitalacy, 2019).

Automated observation increases compliance, which improves patient safety

After the platform was implemented and the technology’s compliance alerts were activated, the compliance rate increased to 70 percent in 10 days. Consistent compliance rates over 70 percent at the medical center have resulted in reduced incidence of infections. The platform reports on about 225,000 automated observations per quarter (Vitalacy, 2019).

Direct or non-automated observation, on the other hand, only captures 1.2 percent to 3.5 percent of all hand hygiene events, according to the Electronic Hand Hygiene Compliance Organization. A study of direct observation found compliance rates to be overstated by up to 300 percent (Srigley et al., 2014). Manual observation allows for the Hawthorne Effect – altered behavior by the subjects of the study due to their awareness of being observed – greatly increasing hand hygiene compliance rates (Hagel et al., 2015; Srigley et al., 2014). Both Boyce and Gould (2017) note that for direct observation to be valid, healthcare organizations must invest considerable time and expense for the adequate training and periodic validation of observers, who in turn, must devote considerable time repeatedly observing caregivers in multiple clinical areas.

Technology starts the journey to positive and sustainable change

Technology delivers data, which alone does nothing. But when data becomes information and that information finds its way to enlightened minds, positive and sustainable change enters the realm of the possible. Technological advances will transform how healthcare organizations approach and ultimately improve patient safety challenges and create high reliability. Leaders of healthcare organizations can use this technology to create collaborative conditions for people to advance and sustain improvement. It’s not easy; it’s a journey with many hurdles. But when has anything worth doing been easy?

Paul Gallese is the chief operating officer of Vitalacy, Inc.


Boyce JM. State of the Science Review: Electronic monitoring in combination with direct observation as a means to significantly improve hand hygiene compliance. American Journal of Infection Control, May 2017;45(5):528-535.

Gould D, et al: Impact of observing hand hygiene in practice and research: a methodological reconsideration. Journal of Hospital Infection, 2017;95(2):169-174. 10.1016/j.jhin.2016.08.008 file.

Hagel S, et al: Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observations with automated hand hygiene monitoring, Infection Control and Hospital Epidemiology, August 2015;38(8):957-62.

Meyer H, Modern Healthcare: Avoidable hospital-acquired conditions spark $2 billion in extra costs, October 2018; news.181029995.

Srigley JA, et al: Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system,: a retrospective cohort study, BMJ Quality & Safety, Dec. 2014;23(12):974-980.

Vitalacy, Inc. Finding new ways to prevent healthcare-acquired infections and conditions. Mar. 14, 2019.

57 views0 comments