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The emergency department (ED) is a complex environment where diagnoses must often be made quickly, based on incomplete information. Pulmonary embolism (PE) is an especially challenging diagnosis that is frequently delayed or missed due to its non-specific symptoms, and can be life-threatening when not treated. Clinical decision supports (CDS) have the potential to improve these difficult decisions; however, previous efforts to implement CDS in the ED have faced challenges due to poor usability and lack of workflow integration. The objective of this study is to identify potential barriers to workflow integration from the technology’s implementation and inform the CDS design; this is achieved by analyzing ED physicians’ workflow during a usability evaluation of two different CDS, a web-based risk scoring CDS and a CDS designed using an human-centered design (HCD) process and human factors (HF) design principles. The number of cases matching the guideline-based workflow and the percent of correct diagnostic decisions increased from the use of the HF-based CDS, but varied depending on the patient scenario. We identified three workflow variations, which had both positive and negative implications for the CDS design and implementation. The workflow analysis can be used to inform the CDS design and improve the technology’s usability and integration in physician workflow prior to implementation.

In this paper, we describe the role network analysis method to capture and visually convey healthcare team members’ clinical interactions as well as individual activities performed in light of VTE prophylaxis management for hospitalized patients. Our visual representations expand on the role network analysis work of Pasmore (1988) and flow model of Beyer and Holtzblatt (1998) and offer a deeper sociotechnical representation of the work of healthcare team members.

In this paper we present preliminary findings that address the work system of physicians, nurses and environmental services workers and their ability to comply with one clinically accepted intervention associated with Clostridium difficile infection. Despite differences in their roles, responsibilities and focus related to management of patients with Clostridium difficile infection, numerous similarities exist in the type of work system considerations they must each face.

Healthcare systems are complex dynamic sociotechnical systems, in which groups of people (e.g., patients and families, clinicians) interact with different technologies (e.g., clinical decision support system, consumer health information technology) in various physical (e.g., hospital, patient home) and organizational (e.g., teamwork, culture) environments (Carayon et al., 2006; Effken, 2002; Kleiner, 2007). The complex and dynamic nature of healthcare systems results in their boundaries being increasingly fuzzy (Carayon et al., 2011; Plsek & Greenhalgh, 2001). People are no longer constrained to work in single local work systems. Instead, they work in teams across different system boundaries, including organizational, hierarchical, cultural, spatial, temporal, and process boundaries (Carayon, 2006; Karsh & Alper, 2005). New conceptualizations of healthcare system boundaries are needed to take into consideration the characteristics of complex sociotechnical systems (Carayon et al., 2015). We convene this panel to address the general question of how to conceptualize sociotechnical system boundaries in healthcare. Five panelists present examples from their respective research to illustrate the conceptualization of sociotechnical system boundaries in different healthcare domains.

Multidisciplinary rounds (MDRs) are an important form of team-based process in health care. Team members coordinate patient care and make decisions on care plans jointly. Health IT used during MDRs should be designed to facilitate the team interactions given the specific context or work system where MDRs occur. This study examines and compares team interactions and health IT use in three hospital services (contexts): hospitalist, cardiology and critical care. There were few differences in team interactions and health IT use across services. However, health IT use was different for different rounding tasks and team members. Therefore, health IT should be designed to support team interactions and users’ needs during MDRs in different contexts.

Care coordination is important for chronically ill patients who need assistance from a variety of care professionals, and often transition through different care settings. This paper provides an overview of coordination and its implications for the care of chronically ill patients. Using 12 interviews of different healthcare professionals involved in coordinating care of chronically ill patients, we provide examples of care coordination situations (e.g., patient discharged home with home health services) and identify coordination activities (e.g., communication for arranging resources, building relationships to facilitate information exchange, monitoring patients to plan follow up care) performed by different healthcare professionals.

To maintain and improve their health, patients perform many non-paid activities that may be conceptualized as self-care and self-management work. However, within the domain of health care, macroergonomists have almost exclusively focused on analyzing the work and work systems of those employed by the health care system rather than those served by it. This panel will focus on how macroergonomics principles and models originally developed within an institutional context may be adapted for the contexts in which patients are embedded. The discussion will be grounded in specific analyses of patients’ work and work systems within domains such as consumer health information technology design, self-care work performance, transitions of care, and patient safety. During each of these presentations, panelists will focus on lessons related to the conceptual, methodological and practice-related challenges of understanding and affecting patients’ work and work systems that may be applied by other researchers.

While care managers use multiple health IT applications to coordinate patient care across transitions of care, they experience challenges posed by these multiple health IT applications. We used a macroergonomic framework (i.e. the work system model), and conducted interviews and observations of care managers (inpatient, outpatient, transition of care) and a web-based survey to assess these challenges. The challenges were related to the care managers’ work system: technologies and tools (e.g., poor interface design of health IT), organization (e.g., no access to some health IT applications), and tasks (e.g., duplicate documentation). Care managers consider the following as major barriers: transferring patient-related information between multiple applications, finding correct information for medication reconciliation and other patient information (e.g., patient’s psychosocial background), and duplicate documentation and data entry. The next phase of the research focuses on how care managers deal with challenges posed by multiple health IT applications to perform their job of coordinating patient care across transitions of care.

Implementing large-scale complex health IT projects poses significant challenges to organizations. This paper discusses one Office of the National Coordinator for Health IT Beacon project aimed at implementing an IT-mediated care coordination model across multiple care settings in multiple communities. We posit that using participatory ergonomic methods to collect and promptly report findings to the project management team provides significant impetus for organizational learning and increases the likelihood of success of this large-scale health IT implementation project. We describe how we involve management team members in the ongoing regular evaluation of the project through short monthly Web-based surveys and semi-annual individual interviews. The goal of this process is to promote organizational learning and impact the success of this and future complex large-scale projects.

We report results of safety climate questions from health care professionals involved in the “Systems Engineering Intervention in Outpatient Surgery - a Collaborative Community Perspective” study undertaken at the University of Wisconsin-Madison. Surveys were conducted in five outpatient surgery centers pre- and post-intervention. The objectives of this study were to examine patient safety climate across various outpatient surgery centers pre- and post-specific patient safety interventions and to examine the relationship between patient safety climate and job categories, individual outpatient centers and the respondents' Quality of Working Life (QWL). Our results indicate that four patient safety climate scales can be created from the pre- and post-intervention 12-item questionnaire: (1) Top management commitment to patient safety, (2) General patent safety climate, (3) Employee commitment to patient safety and (4) Patient safety change. In one of the survey centers, patient safety climate became more negative over time.

Technology acceptance is an important predictor of end user technology usage. Perceptions of technology characteristics relating to usability and technical performance are particularly important to understanding user acceptance. This paper reports on the implementation of Smart intravenous infusion pumps at a tertiary care hospital. Nurse user perceptions of the technology usability (five dimensions), technical performance, and acceptance were measured one month after implementation. Overall, 42% of nurses responded positively towards accepting the pump. For 21 of 23 usability characteristics and performance questions, nurses were more likely to report neutral perceptions than positive or negative perceptions. The highest positive perceptions were for ease of learning to operate the pump and reliability of the pump. Six characteristics predicted end-user acceptance. Perceptions that the IV pump enhanced job effectiveness, made the job easier, increased safety of care, and functioned as expected predicted higher acceptance, while perceptions that alarm messages were frustrating and the pump interface was rigid predicted lower acceptance. Therefore, a new finding provided in this study is that highlighting improved patient safety when hospitals implement Smart intravenous infusion pumps may improve user acceptance of the pump.

We examined perceptions of safety climate from health care professionals involved in the “Systems Engineering Intervention in Outpatient Surgery - a Collaborative Community Perspective” study currently underway at the University of Wisconsin-Madison. Surveys were conducted in five outpatient surgery centers. The objectives of this study were to examine patient safety climate across various outpatient surgery centers and to address the relationship between patient safety climate and job categories, individual outpatient centers and the respondents' Quality of Working Life (QWL). Our results indicate that four safety climate scales (1) Top management commitment to patient safety, (2) General patent safety climate, (3) Employee commitment to patient safety, and (4) Change in patient safety can be created from the 12-item questionnaire and they may be a useful measure of an outpatient surgery center's patient safety climate. The four patient safety climate scales are also significantly associated with the outpatient surgery centers employees' QWL.

The aim of this study was to gather information from staff of outpatient surgery centers concerning their perception of the patient safety/quality of care issues at their Center and the performance obstacles they face when doing their work. In addition we wished to determine whether performance obstacles research (Brown & Mitchell, 1988; Peters et al, 1985) can be applied to the conceptual framework that serves as the basis for all of our patient safety research (Smith & Carayon, 1989, 1995; Carayon & Smith, 2000). We distributed open-ended surveys to all health care providers in five local outpatient surgery centers. Based on previous work conducted in the area of performance obstacles (Brown & Mitchell, 1988; Peters, et al, 1985) we asked the caregivers to identify instances when they felt their performance was challenged or below par, as well as instances when they were able to perform their job very well. Because the population we surveyed is not familiar with the totality of the work system model as defined by Smith & Carayon (1989, 1995) and Carayon & Smith, (2000), we provided the elements of the work system as examples to the respondents. The resounding themes caregivers listed as significant performance obstacles included inter-provider coordination and communication of care, equipment, work space, scheduling, time pressure and staffing issues.

In this paper we describe preliminary results of a case study assessing macroergonomic aspects of the implementation of an electronic medical record (EMR) in a small family practice clinic.