Workflow mapping and stakeholder perspectives to enhance quality improvement in pediatric clean intermittent...

Clean Intermittent Catheterization (CIC) is commonly used to manage urinary retention and lower urinary tract dysfunction in pediatric patients. Despite its widespread use, variability exists in how CIC education and support are delivered across clinical settings. This exploratory qualitative study aimed to examine current CIC education workflows, identify barriers and facilitators to care delivery, and inform future quality improvement efforts within a high-volume pediatric urology program.

Using an interpretive description approach within the exploratory phase of a broader quality improvement initiative, we conducted semi-structured interviews and focus groups with 16 healthcare providers and administrative staff involved in CIC education across pediatric urology care settings. Discussions explored CIC referral processes, scheduling workflows, teaching practices, follow-up approaches, and perceived barriers and facilitators to CIC education. Interviews were audio-recorded, transcribed verbatim and analyzed inductively using thematic analysis and workflow mapping.

Workflow mapping identified four interrelated processes in the CIC teaching pathways, referral and decision-making, scheduling and pre-visit preparation, the CIC teaching encounter, and post-teaching follow-up, with substantial variability across each. Four themes were identified: 1) variability in referral and scheduling processes, 2) nursing staff as central coordinators of CIC education, 3) caregiver readiness and psychological factors influencing teaching, and 4) variability in follow-up and lack of standardized reinforcement. Opportunities for improvement were also identified.

This CIC workflow assessment identified variability and key barriers influencing CIC education across pediatric care settings and highlighted opportunities for improvement. Findings informed a preliminary, practice-informed toolkit proposing standardized workflows, pre-visit educational materials, and patient- and caregiver-centered protocols. The toolkit has not been implemented or evaluated; its effect on adherence, experience, and outcomes remains to be tested.