Football Plays and EHR Workflow

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A friend of mine is Dave Hubbard, the motivational speaker, an All-American collegiate athlete who played professional football in the 1970’s for Hank Stram of the New Orleans Saints and then the Denver Broncos. Dave is extremely familiar with healthcare both professionally (serial entrepreneur) and personally (broke his back jumping out of a perfectly good airplane!).


We’ve had a series of interesting conversations about, of all things, football plays and EHR workflow. We co-wrote the following post to see if we might enlist you in telling us if you think we’re on to something, or not.

–Chuck & Dave

Medical offices are like football teams: an offensive line moves a patient encounter forward while a defensive line seeks to create chaos and stop encounter progress. This analogy is more productive than you might think!

Medical office staff members interact in ways that are similar to a football team. For example, they have an offensive line whose responsibility it is to efficiently, effectively, and flexibly move an encounter from waiting room to checkout. There’s a quarterback who calls plays. Sometimes it’s the physician who directs staff to administer a vaccination or auditory test; sometimes the plays are called automatically based on the reason for the patient’s visit, such as “well child” versus “ear ache.”

Tasks are “passed” among team members, such as a nurse gathering vitals and checking medications and allergies before passing the assessment and treatment tasks to the physician. “Dropping the ball” results in inefficiency that slows the encounter and ineffectiveness that affects patient care and physician revenue.

The defensive line may be less obvious, but it consists of threats to the accomplishment of efficient, effective, flexible workflow. It is the offensive line’s responsibility to protect this workflow. For example, the phone nurse blocks defensive line interruptions that would otherwise distract the physician from maximizing use of the most important and constrained resource in the practice, his or her time. Anyone (or anything) who contributes to the hassle factor of practicing medicine is part of the defensive line.

Similarities between a medical team and a football team are more than an amusing analogy. All teams are cognitive systems, and their study is called team cognition (with contributions from distributed cognition). Shared mental models, workspace awareness, radar views, and teams of experts versus expert teams are topics of team cognition that apply to all teams, including those in medicine and football.

Using this football metaphor (and some ideas from cognitive science), we encourage you to think (and comment!) about office processes from the perspective that to win, the ways in which the plays are being run must be examined. Doing so will allow people to express what they are most proud of, but also to critically evaluate performance problems in a constructive way, one in which everyone is committed to success.

Questions to consider:

How is your medical practice similar to a football team?

What position does each employee play? Who is offense? Who is defense? Are there any special teams?

Who is the quarterback? The coach? Does everyone know their position?

What about the referee? The coach? The patient? The fans?

Who owns the team? Is there an owners’ association? A players’ association?

If your medical practice were a football team, what would be your version of the following: Holding? Tripping? Unsportsmanlike conduct? Unnecessary roughness? Running versus passing? Huddling? Incomplete pass? Field goal versus touchdown? Memorizing key plays? Time-out? Substitutions?

Suppose you could review game films with your staff. What are examples of plays you’ve run to achieve major yardage or touchdowns?

What are examples of plays where you’ve thrown for a loss, fumbled the ball, or suffered interceptions? Why did they occur and what can you do to keep them from happening again? How do you define victory?

Do different styles of medical practice lend themselves to different sports analogies? Soccer? Golf? Which do you suggest and why?

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  1. ExCollegeFootball
    Posted March 16, 2009 at 7:55 am | Permalink

    In football, the play is diagramed. The movement of the ball and the plan for protecting the person carrying the ball is designed to accomplish certain realistically achievable goals. There are plays called for specific situations, e.g. third down and between 5 and 7 yards to go for a first down or second and long. These designed plays have the goal of moving the ball in the most efficient and effective way in that particular situation. Well visits for kids of a certain age range or sick visits with a specific diagnosis have the same feel. Watching the ball move down the field has the same feel as watching the patient move through the practice. Protecting the patient from procedures they don’t need, optimizing the patient’s movement through the office and keeping their time in the office to a minimum works in the best interest of both the patient and the practice and does have qualities that are analogous to football plays. The concept that needs exploration, in my opinion, is the team or shared consciousness. On a football team the shared goal is clear. In a doctor’s office, I am not so sure the goal of the team is quite as clear. I don’t get the feeling that most doctor’s offices have workflows set up to control doctor’s time efficiently. The study of controlling encounter costs and productivity through managing practice workflows is one that needs a lot of work in the average practice.

  2. chuckwebster
    Posted March 17, 2009 at 12:52 pm | Permalink

    Excellent point! Especially about team/shared consciousness.

    I’m planning a future post on four fundamental categories of workflow, one of which is different person/same time workflow.

    Consider how much coordinated human activity depends on often depends on one person knowing that another person knows something, or even each person knowing that other people know that he or she knows something. In order for this kind of shared mental model to be supported in an automated environment, as opposed to a playing field where everyone can see where everyone else is and can (usually) see who has the ball and can act accordingly, users need some kind of continually updated status screen. This screen functions much like the radar screen in an aircraft control tower, only it is patients and tasks being are tracked, not airplanes. By continually updating a universally accessible display of system state—a universal worklist tagged with information about location, time, and responsibility—all EHR users can maintain a shared mental model, and, more important, they can act with respect to that model under the assumption that others have the same mental model of what needs to be done, where, and who is responsible.

    The value of an EHR workflow management system is that it has a workflow engine that “knows” what activity started where and for how long, as well as who is responsible, and this information can be fed into not just worklists but onto the universally available status screen. Everyone can see which patient is waiting where, for what task, for how long and who is responsible. Cognitive scientists who study team cognition sometimes call this screen a “radar view”. In the EncounterPRO EHR it is called the office view.

  3. ImpatientFineDinner
    Posted March 17, 2009 at 1:37 pm | Permalink

    I really enjoyed the comparison between workflow management and football. As one who loves to eat out but hates to wait I think another good analogy is with restaurants who have mastered delivering fine food with timely service. The secret to a profitable restaurant is the ability to move customers from seating to dessert in an efficient yet elegant manner. What do you think about that analogy?

  4. chuckwebster
    Posted March 17, 2009 at 2:56 pm | Permalink

    Waiter, there’s a football in my soup!

    Several aspects of analogy come to mind. Turning over exam rooms is similar to turning over tables. Point of sale in the restaurant industry tends to rely on simplified touchscreens that sequence automatically through workflow that makes sense to the waiter or bartender. And so on. Maybe someone from the restaurant industry will comment on similarities between football teamwork and restaurant teamwork.

    What Hippocrates can learn from Epicurus, by Jennifer Doggett

    (Hope you’ll click through to read the entire piece.)

    “IMAGINE TURNING UP for dinner at a restaurant and finding that it doesn’t serve drinks. At this hypothetical restaurant, customers order their food and receive recommendations from their waiter on the appropriate beverages to accompany their meals. They are then asked to go elsewhere to purchase their drinks before bringing them back to the restaurant where they can enjoy them with their meal.

    Regardless of how well this restaurant prepares and serves food, at the end of the night you would understandably feel that something was missing from your dining experience. What you wanted from the restaurant was more than just high quality food. You wanted all the elements of an enjoyable meal, including drinks, provided in a single, coordinated package.

    A restaurant like this is, thankfully, an absurdity in our customer-focused and competitive food retail industry. But it is a worryingly accurate analogy for the way consumers experience the delivery of health care in Australia.

    This is particularly the case for health care provided in the community setting. Commonly known as primary care, it includes the health care that consumers access directly from GPs, physiotherapists and psychologists, as well as some referred services, such as x-rays and pathology.”



    …The Restaurant Test.

    At Restaurant “A,” the hostess hands you a pager to wait for a table. You see the restaurant is packed, but the minute someone leaves, the bellboy is waiting with his tray to turn the table over. A few minutes later you are seated, the waitress takes a drink order and brings bread. You are content.

    At Restaurant “B,” you get the pager, but you notice that several tables are empty, and some still have dirty dishes on them. The hostess says the clean tables aren’t covered by a waitress and the dirty ones are awaiting a busboy.

    If your hospital is like Restaurant “A,” it might make sense to add “tables, space and staff” because there would be opportunity for more revenue and more happy little customers. If your hospital is like Restaurant “B,” adding capacity would be ridiculous. In fact, it would make the situation worse, because you are only expanding a problem, while incurring building costs, staffing costs and the wraith of disgruntled customers who tell their friends not to go to your place.”


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One Trackback

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    [...] should check out his full article where he asks a bunch of interesting questions as [...]

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