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Oklahoma State University

Improving Rural Health Care Clinic Efficiency: Identifying Common Rural Clinic Workflow Disruptions

Web Page is dedicated to the OSU Center for Health Sciences Institutional Review Board Approved Study Identifying Possible Factors that Interfere with Workflow in Rural Oklahoma Family Clinics


Dr. William Paiva, Ph.D.

Ipe Paramel, M.S.

Scott Shepherd, D.O.

Marjorie Erdmann, M.S.

Sarah Teague, M.A.

Study introduction

The State of Oklahoma ranks at the bottom of many of the key metrics related to health care. And when you look at the rural health care markets the situation is even bleaker. Due to the demands of the ever changing health industry, it is getting harder for practices within rural Oklahoma to operate at maximum efficiency levels and profitability while delivering optimum patient care.

In order to enhance the current health and financial status, we as a team, focus on rural family clinic workflow efficiency. The CHSI workflow team exists in efforts to understand the state of healthcare delivery in rural Oklahoma. This entails visiting rural clinics, interviewing staff, and observing their operation all with the intent to discover impediments in the workflow of rural family clinics. Prior to this study, no research has been conducted regarding factors influencing business and clinical workflow in rural Oklahoma. Previous studies primarily collected responses from the providers, whereas this study encompasses a greater picture of the state of health care delivery by attaining viewpoints from every constituent employed in each clinic from the physician to the nurse to the staff.

Information collected from clinic constituents undergoes in-depth analysis to formulate common threads of issues across rural Oklahoma. Through identifying impediments to workflow, we can turn to developing innovative solutions to improve and possibly transform business and clinical efficiency, cost, staffing, patient experience, infrastructure and general workflow of rural primary care facilities.

Study objectives

  • To partner with clinics in rural Oklahoma in collecting information from clinic constituents.
  • To identify issues and potential factors that interfere with workflow of the clinics through statistical analysis.

Study secondary objectives

  • To inform CHSI on solutions that need new, novel, and sustainable solutions to specifically address identified workflow impediments.
  • To test and implement the solutions with rural healthcare partners in order to streamline efficiency of clinics as well as maximize productivity, profitability and patient care delivery.

How the study benefits patient care

  • Health Care Delivery: This study assists health clinics with information to understand their barriers in healthcare delivery from an unbiased perspective. It provides an avenue for clinic staff to express their concerns without being reprimanded. Issues discovered regarding day to day workflow will be resolved, enhancing quality of care and cost effectiveness.
  • Patients: Populations in rural Oklahoma have limited access to health care due to shortages in available providers or facilities within a close proximity. Enhancing the efforts of existing clinics adds value to patient experience and improves patient-centered care. Collaboration with clinics and other health service providers would address community-centered issues that impact clinic workflow to promote patient wellness and heighten accessibility. 

Participating Clinic Criteria

The Study Has Exceeded the Clinic Enrollment Goal: If you would like your clinic to participate in the study please contact the Study Program Manager Ipe Paramel at
  • Inclusion criteria
      • Must be a rural primary care clinic located in a rural area as defined by the the US Census Bureau (
      • The clinic must provide primary care and/or family practice.
      • Approval and cooperation by clinic owner/operator for inclusion. Note: All staff individually consented to their own participation in the study.
  • Exclusion criteria
      • Any physician or clinic not meeting the above criterion will be excluded from the study or not contacted.
      • Patient information is excluded from this study. Absolutely no patient information is collected as a part of this study.

Estimated Locations of Rural Clinic Participants:


Data Gathered and Protocol

  • Primary care practice clinics were observed with differing structures such as: multiple and single provider sites, provider organizations and independently owned and operated, Federally Qualified Health Centers, Certified Rural Health Clinics, etc.
  • All consenting clinic employees were interviewed using a pre-installed voice recording application on a tablet. Qualitative audio files are immediately saved to a secure drive and later delivered for audio transcription. Transcribed files are thoroughly examined through text analysis and statistical software. Most appearing phrases and topics will be identified and correlated with other results gathered.
  • Immediately after completion of an interview, respondent was administered an online quantitative survey, preloaded on a tablet. Upon completion the survey responses are automatically stored on a secure drive. Results are formatted then undergo analysis.
  • Classification information was handed to the office manager or appropriate personnel in paper format during clinic visitation. Upon completion of the survey, a researcher collected it and created a digital copy as soon as possible. Responses in the survey are made statistically viable then undergo analysis.
  • A copy of the clinic fire map or clinic layout was collected by a researcher, outlining properties such as, number of exam rooms, number of seats in waiting area and other predetermined metrics are recorded on the map. This too is digitized as soon as possible and undergoes analysis.

First Results: Staff Survey/Quantitative Survey Results (Posted: 10/16/2015)

Category Ratings:


Question Scores:


Poster Presentation:

Major impediments to effective rural clinic management identified through Decision tree techniques, Regression and Clustering (PDF) Onkar Jadhav, Ipe Paramel

Study Contacts

For questions, concerns, or complaints about this study you can email lead investigator William Paiva, Ph.D. at

For participants, this is a reminder that you are welcome to directly contact the study investigator William Paiva, Ph.D. or the OSU CHS Institutional Review Board Chair Richard Wansley, Ph.D., at the phone number provided on the informed consent form.