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Chronically ill patients may be at risk of re-hospitalization or even death if their care transitions are poorly coordinated. Transitions of care create challenges for care coordination, such as in...

Background Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration. Methods Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations. Results Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap. Discussion Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change. Conclusions Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.

ObjectiveIn this study, we used human factors (HF) methods and principles to design a clinical decision support (CDS) that provides cognitive support to the pulmonary embolism (PE) diagnostic decision-making process in the emergency department. We hypothesised that the application of HF methods and principles will produce a more usable CDS that improves PE diagnostic decision-making, in particular decision about appropriate clinical pathway.Materials and methodsWe conducted a scenario-based simulation study to compare a HF-based CDS (the so-called CDS for PE diagnosis (PE-Dx CDS)) with a web-based CDS (MDCalc); 32 emergency physicians performed various tasks using both CDS. PE-Dx integrated HF design principles such as automating information acquisition and analysis, and minimising workload. We assessed all three dimensions of usability using both objective and subjective measures: effectiveness (eg, appropriate decision regarding the PE diagnostic pathway), efficiency (eg, time spent, perceived workload) and satisfaction (perceived usability of CDS).ResultsEmergency physicians made more appropriate diagnostic decisions (94% with PE-Dx; 84% with web-based CDS; pConclusionsThis simulation study shows that HF methods and principles can improve usability of CDS and diagnostic decision-making. Aspects of the HF-based CDS that provided cognitive support to emergency physicians and improved diagnostic performance included automation of information acquisition (eg, auto-populating risk scoring algorithms), minimisation of workload and support of decision selection (eg, recommending a clinical pathway). These HF design principles can be applied to the design of other CDS technologies to improve diagnostic safety.

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.

Care coordination is important for chronically ill patients who need assistance from a variety of healthcare professionals especially when they transition through different care settings. There has not been a clear definition of care coordination and its associated activities. This paper provides a two-dimension framework of care coordination for chronically ill patients: 1) coordination activities (i.e. communication and monitoring) and 2) interdependencies (i.e. flow, shared resources, simultaneity). We used this framework in a qualitative content analysis of 12 interviews with healthcare professionals involved in coordinating care of chronically ill patients. We identified a total of 258 care coordination activities and developed categories and sub-categories using the constant comparative method. The first category of care coordination activities involves communication with flow or shared resources interdependencies or both. This category includes arranging services and equipment for the patient, exchanging information about patient transition to different care settings, reporting errors and resolving them, and helping the patient with appointments and transportation. The second category involves monitoring, sometimes combined with communication, with flow or shared resources interdependencies or both. This category includes reviewing medications and services and detecting errors, reviewing patient symptoms and following up if needed, and scheduling follow-up to review patient status. The last category involves communication with simultaneity interdependency. This category involves talking in the same location and developing a plan of care, people exchanging information at the same time, and scheduling delivery of medications/services to correspond with patient arrival home. Finally, we identified characteristics of health information technology that can support these various care coordination activities.

Study objective As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record–integrated clinical decision support technologies implemented in the emergency department (ED). Methods A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias. Results A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials. Conclusion Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.

Care managers who coordinate care for chronically ill patients in hospitals and outpatient settings use multiple health information technologies for accessing, processing, documenting, and communicating patient-related information. Using a combination of 41 interviews and observations of 15 care managers, we identified a range of technology-related barriers experienced by care managers (total of 163 occurrences). The barriers are related to (lack of) access to information, inadequate information, limited usefulness and usability of the technologies, challenges associated with using multiple health IT, and technical problems. In 43% of the occurrences, care managers describe strategies to deal with the technology barriers; these fit in three categories: nothing/delay (9 occurrences), work-arounds (32 occurrences), and direct action at the individual, team, and organization levels (29 occurrences). Our data show the adaptive capacity of care managers who develop various strategies to deal with technology barriers and are, therefore, able to care for chronically ill patients. This information can be used as input to work system redesigns.

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.

IntroductionDaily bathing with chlorhexidine gluconate (CHG) in hospitalized patients reduces healthcare-associated bloodstream infections and colonization by multidrug-resistant organisms. Achieving compliance with bathing protocols is challenging. This non-intensive care unit multicenter project evaluated the impact of organizational context on implementation of CHG and assessed compliance with and healthcare workers' perceptions of the intervention.Materials and methodsThis was a multiple case study based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. The four sites included an adult cardiovascular unit in a community hospital, a medical-surgical unit in an academic teaching pediatric hospital, an adult medical-surgical acute care unit and an adult neuroscience acute care unit in another academic teaching hospital. Complementary data collection methods included focus groups and interviews with healthcare workers (HCWs) and leaders, and direct observations of the CHG treatment process and skin swabs.ResultsWe collected 389 bathing observations and 110 skin swabs, conducted four focus groups with frontline workers and interviewed leaders. We found variation across cases in CHG compliance, skin swab data and implementation practices. Mean compliance with the bathing process ranged from 64% to 83%. Low detectable CHG on the skin was related to immediate rinsing of CHG from the skin. Variation in the implementation of CHG treatments was related to differences in organizational education and training practices, feedback and monitoring practices, patient education or information about CHG treatments, patient preferences and general unit patient population differences.ConclusionOrganizations planning to implement CHG treatments in non-ICU settings should ensure organizational readiness and buy-in and consider delivering systematic and ongoing training. Clear and systematic implementation policies across patients and units may help reduce potential confusion about treatment practices and variation across HCWs. Patient populations and unit factors need to be carefully considered and procedures developed to manage unique challenges.

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.

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.

Intensive care units (ICUs) are complex environments, which rely on teams in order to coordinate patient care. Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major concern for ICU patients, who are frequently immobile. VTE prophylaxis (prevention) occurs throughout different stages of a patient’s stay in the ICU, which range in levels of complexity. The objective of this study is to use social network analysis to understand team adaptation in response to different levels of complexity in the VTE prophylaxis process. The more complex stages of VTE prophylaxis involve more people, more team activities, more team interactions, and more two-way communication compared to the less complex stages. Social network analysis can be used to understand team adaptation to these different levels of complexity in a patient’s ICU care.

BACKGROUND Implementation guides and toolkits have become a common tool developed to facilitate implementation of evidence-based infection prevention and control practices. Unlike published professional guidelines and formal literature reviews, the methods used to develop these guides and toolkits are not detailed in these documents. Although some guidance is available for the design of these documents, little is known about the methodology used in their development and subsequent evaluation of implementation effectiveness. METHODS An implementation pilot of chlorhexidine gluconate (CHG) bathing in nonICU settings was conducted between October 2015 to September 2018 in four VA facilities across the U.S. Toolkit development was a deliverable desirable by the funding agency to facilitate translation of this evidence-based practice into real-world settings. A human factors engineering framework was applied to direct toolkit development for this infection prevention and control evidence-based practice of CHG bathing treatments to reduce multidrug-resistant HAIs. We conducted nine end-user evaluations to ensure acceptability and usability of the toolkit; evaluations were performed using an 11-question survey of a modified version of the System Usability Scale (SUS). RESULTS We had a 67% response rate on the SUS survey. The use of a human factors engineering framework resulted in high acceptability and usability ratings with a score of 83.75, compared to an average score of 68. The toolkit, “Chlorhexidine Bathing Treatment: A Toolkit to Guide Implementation” will be available online in 2019. CONCLUSIONS Implementation guides and toolkits are commonly developed by, and for, infection preventionists to facilitate translation of evidence into practice. We provide an exemplar using a human-centric framework for consideration to future guide and toolkit development. Detailing methodologies used during toolkit development may enhance standardization, usability, ongoing evaluation of effectiveness, and future refinement

Background Clostridium difficile infection (CDI) is a critical patient safety issue. Consistent and regular performance of appropriate practices is effective in preventing CDI. Variation in adherence to these practices can impede their effective implementation and weaken CDI prevention. Methods Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework we convened a focus group of 10 nurses to identify barriers and facilitators to compliance with a CDI prevention bundle that includes (1) prompt diagnostic testing, (2) empirical isolation for patients with suspected CDI, (3) consistent and appropriate contact isolation, (4) hand hygiene, and (5) disinfection of the patient room and objects in the room. On completion of transcript coding, analyses were performed based on bundle intervention and the work system element of the SEIPS model. Results A total of 58 excerpts were coded. Work system barriers or facilitators were associated with nearly every bundle intervention. The work system elements raised in over half of the excerpts were task (n = 31) (eg, amount of additional effort required to don and doff gloves and gowns) and organization (n = 30) (eg, recognition by all staff of the severity of CDI). Contact isolation was the most frequently discussed bundle intervention (n = 24). Conclusions The SEIPS systems engineering framework is useful to evaluate infection prevention practices for CDI and identify opportunities for improvement. Addressing the work system barriers and facilitators identified in this study is essential to effective implementation of infection prevention interventions, specifically for CDI.

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.

"Smart" intravenous infusion pumps (Smart IV pumps) are increasingly being implemented in hospitals to reduce medication administration errors.This study examines nurses' experience with the implementation and use of a Smart IV pump in an academic hospital.Data were collected in three longitudinal surveys: (a) a pre-implementation survey, (b) a 6-week-post-implementation survey, and (c) a 1-year-post-implementation survey. We examined: (a) the technology implementation process, (b) technical performance of the pump, (c) usability of the pump, and (d) user acceptance of the pump.Initially, nurses had a somewhat positive acceptance of the Smart IV pump technology that significantly increased one year after implementation. User experiences associated with the pump in general improved over time, especially perceptions of pump efficiency. However, user experience with the pump implementation process and pump technical performance did not consistently improve from the pre-implementation survey to the post-implementation survey. Several characteristics of pump technical performance and usability influenced user acceptance at the one-year post-implementation survey.These data may be useful for other institutions to guide implementation and post-implementation follow-up of IV pump use; other institutions could use the survey instrument from this study to evaluate nurses' perceptions of the technology. Our study identified several characteristics of the implementation process that other institutions may need to pay attention to (e.g., sharing information about the implementation process with nurses).

Failure mode and effects analysis (FMEA) is a commonly used prospective risk assessment approach in health care. Failure mode and effects analyses are time consuming and resource intensive, and team performance is crucial for FMEA success. We evaluate FMEA team members' perceptions of FMEA team performance to provide recommendations to improve the FMEA process in health care organizations.: Structured interviews and survey questionnaires were administered to team members of 2 FMEA teams at a Midwest Hospital to evaluate team member perceptions of FMEA team performance and factors influencing team performance. Interview transcripts underwent content analysis, and descriptive statistics were performed on questionnaire results to identify and quantify FMEA team performance. Theme-based nodes were categorized using the input-process-outcome model for team performance.: Twenty-eight interviews and questionnaires were completed by 24 team members. Four persons participated on both teams. There were significant differences between the 2 teams regarding perceptions of team functioning and overall team effectiveness that are explained by difference in team inputs and process (e.g., leadership/facilitation, team objectives, attendance of process owners).: Evaluation of team members' perceptions of team functioning produced useful insights that can be used to model future team functioning. Guidelines for FMEA team success are provided.

Patient care transitions have been shown to be critical points at which failure as well as recovery from potential failure may occur. The purpose of this research was to identify transitions in patient care and the flow of associated information at different steps in the outpatient surgery preoperative care process and, in turn, attempt to identify breakdowns in the information flow process and their ramifications. A study of one organization’s preoperative process for outpatient surgery was conducted, employing four means of data collection to gather information on preoperative work processes: employee shadowing, patient shadowing, clinic observation, and dictated feedback. Various facilitators and obstacles in information flow were found to be present in the preoperative care process. Obstacles often resulted in negative consequences for healthcare providers and patients. Helping care providers understand how their actions affect the various elements of the preoperative process, through improved awareness, may be one way to improve information flow problems within the outpatient surgery process.

Background Our objective was to use a human factors and systems engineering approach to understand contributors to surgical readmissions from a patient and provider perspective. Previous studies on readmission have neglected the patient perspective. To address this gap and to better inform intervention design, we evaluated how transitions of care relate to and influence readmission from the patient and clinician perspective using the Systems Engineering Initiative for Patient Safety (SEIPS) model. Study design Patients readmitted within 30 days of discharge after complex abdominal surgery were interviewed. A focus group of inpatient clinician providers was conducted. Questions were guided by the SEIPS framework and content was analyzed. Data were collected concurrently from the medical record for a mixed-methods approach. Results Readmission occurred a median of 8 days (range 1 to 25 days) after discharge. All patients had follow-up scheduled with their surgeon, but readmission occurred before this in 72% of patients. Primary readmission diagnoses included infection, gastrointestinal complications, and dehydration. Patients (n = 18) and clinician providers (n = 6) identified a number of factors during the transition of care that may have contributed to readmission, including poor patient and caregiver understanding; inadequate discharge preparation for home care; insufficient educational process and materials, negatively affected by electronic health record design; and inadequate care team communication. Conclusions This is the first study to use a human factors and systems engineering approach to evaluate the impact of the quality of the transition of care and its influence on readmission from the patient and clinician perspective. Important targets for future interventions include enhancing the discharge process, improving education materials, and increasing care team coordination, with the overarching theme that improved patient and caregiver understanding and engagement are essential to decrease readmission and postdischarge health care use.

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.

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.

Collecting information about health and disease directly from patients can be fruitfully accomplished using contextual approaches, ones that combine more and less structured methods in home and community settings. This paper’s purpose was to describe and illustrate a framework of the challenges of contextual data collection. A framework is presented based on prior work in community-based participatory research and organizational science, comprised of ten types of challenges across four broader categories. Illustrations of challenges and suggestions for addressing them are drawn from two mixed method, contextual studies of patients with chronic disease in two regions of the USA. The first major category of challenges was concerned with the researcher–participant partnership, for example, the initial lack of mutual trust and understanding between researchers, patients, and family members. The second category concerned patient characteristics such as cognitive limitations and a busy personal schedule that created barriers to successful data collection. The third concerned research logistics and procedures such as recruitment, travel distances, and compensation. The fourth concerned scientific quality and interpretation, including issues of validity, reliability, and combining data from multiple sources. The two illustrative studies faced both common and diverse research challenges and used many different strategies to address them. Collecting less structured data from patients and others in the community is potentially very productive but requires the anticipation, avoidance, or negotiation of various challenges. Future work is necessary to better understand these challenges across different methods and settings, as well as to test and identify strategies to address them.

The U.S. Institute of Medicine and health care experts have called for new approaches to manage health care quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to health care quality and patient safety are described, such as the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety and the model of health care professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health information technology and medical devices, violations, and care coordination provide examples of macroergonomics contributions to health care quality and patient safety. Health care systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles, and methods for health care system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety) and macroergonomics of patient-centered care and care coordination.

Healthcare practitioners, patient safety leaders, educators, and researchers increasingly recognize the value of human factors/ergonomics and make use of the discipline’s person-centered models of sociotechnical systems. This paper first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, “SEIPS 2.0.” SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement, and adaptation. The concept of configuration highlights the dynamic, hierarchical, and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at “a moment in time.” Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers, and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed.

Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety.

a trial involving dual licensed personnel insertion and a “safety time out” was implemented in January 2015. The practice change involved review of the indications and proper steps for insertion per hospital policy by the two personnel involved in the procedure. The catheter was then insertedwith the second staff member being solely responsible to assure compliance with proper technique. The procedure was stopped if sterile technique was compromised. A data collection checklist was completed post-procedure indicating compliance with proper technique. The insertion-related CAUTI rate (number of CAUTIs occurring < 7 days after insertion/1000 catheters inserted) for January-June 2015 was compared with 2014 data using an independent t test. RESULTS: During the 6 month trial, 201 patients underwent dual personnel urinary catheter insertion in the ED. None of the patients with the dual personnel insertion developed a CAUTI. Comparison of the previous year’s insertion-related CAUTI rate yielded a statistical significance (P value) of .0078. CONCLUSIONS:Due to the success of the trial, dual personnel urinary catheter insertion has continued to remain as standard practice in the ED. In addition it may be considered hospital wide for specific cases with difficult insertion where technique can be jeopardized during insertion.

To develop, conduct, and evaluate a proactive risk assessment (PRA) of the design and implementation of CPOE in an ICU.We developed a PRA method based on issues identified from documented experience with conventional PRA methods and the constraints of an organization about to implement CPOE in an intensive care unit. The PRA method consists of three phases: planning (three months), team (one five-hour meeting), and evaluation (short- and long-term).Sixteen unique relevant vulnerabilities were identified as a result of the PRA team's efforts. Negative consequences resulting from the vulnerabilities included potential patient safety and quality of care issues, non-compliance with regulatory requirements, increases in cognitive burden on CPOE users, and/or worker inconvenience or distress. Actions taken to address the vulnerabilities included redesign of the technology, process (workflow) redesign, user training, and/or ongoing monitoring. Verbal and written evaluation by the team members indicated that the PRA method was useful and that participants were willing to participate in future PRAs. Long-term evaluation was accomplished by monitoring an ongoing "issues list" of CPOE problems identified by or reported to IT staff. Vulnerabilities identified by the team were either resolved prior to CPOE implementation (n=7) or shortly thereafter (n=9). No other issues were identified beside those identified by the team.Generally positive results from the various evaluations including a long-term evaluation demonstrate the value of developing an efficient PRA method that meets organizational and contextual requirements and constraints.

Coordinating care for hospitalized patients requires the use of multiple sources of information. Using a macroergonomic framework (i.e. the work system model), we conducted interviews and observations of care managers involved in care coordination across transitions of care. When information is distributed across multiple health IT applications, care managers experience a range of challenges, including organizational barriers, technology design problems, skills and knowledge issues, and task performance demands (i.e. issues related to individual information processing and management and sharing of information). These challenges can be used as a checklist to evaluate the proposed IT infrastructure that will allow the integration of multiple health IT applications and, therefore, support coordination across transitions of care.

Objective To assess intensive care unit (ICU) nurses’ acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance. Design The authors analyzed data from two crosssectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation. Measurements Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet. Results On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3 months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months. Conclusion As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1 year following the EHR implementation.

Background: Vulnerabilities in the medication management process can lead to serious patient harm. In intensive care units (ICUs), nurses represent the last line of defense against medication errors. Proactive risk assessment (PRA) offers methods for determining how processes can break down and how people involved in such processes can contribute to or recover from a breakdown. Such methods can also be used to identify ICU nurses' contribution to the quality and safety of medication management. Methods: Observation and interview data of ICU nurses' work were used to develop a rich description of the nursing medication management process. A PRA method was conducted in a cardiovascular ICU to identify and evaluate failure modes in the nursing medication management process. The contributing factors to the failure modes and the recovery processes used by nurses were also characterized. Results: A total of 54 failure modes were identified across the seven steps of the medication management process. For the 5 most critical failure modes, nurses listed 21 contributing factors and 21 recovery processes. Ways were identified to redesign the medication management process, one of which consists of dealing with work system factors that contribute to the most critical failure modes. Conclusions: From a data-analysis viewpoint, this PRA method permits one to address a variety of objectives. Different scoring methods can be used to focus on either frequency or criticality of failure modes; one may also focus on a specific step of the process under study. Efforts in eliminating or mitigating contributing factors would help reduce the criticality of the failure modes in terms of their likelihood and impact on patients and/or nurses. Developing systems to support the recovery processes used by nurses may be another approach to process redesign. Copyright 2010 © The Joint Commission.

Objectives: The aim of this study is to assess the contributions of care management as perceived by care managers themselves.Study Design: Focus groups and interviews with care managers who coordinate care for chronic obstructive pulmonary disease and congestive heart failure patients, as well as patients undergoing major surgery.Methods: We collected data in focus groups and interviews with 12 care managers working in the Keystone Beacon Community project, including 5 care managers working in hospitals, 2 employed in outpatient clinics and 4 telephoning discharged patients from a Transitions of Care (TOC) call center.Results: Inpatient care managers believe that (1) ensuring primary care provider follow-up, (2) coordinating appropriate services, (3) providing patient education, and (4) ensuring accurate medication reconciliation have the greatest impact on patient clinical outcomes. In contrast, outpatient and TOC care managers believe that (1) teaching patients the signs and symptoms of acute exacerbations and (2) building effective relationships with patients improve patient outcomes most. Some care management activities were perceived to have greater impact on patients with certain conditions (e.g., outpatient and TOC care managers saw effective relationships as having more impact on patients with COPD). All care managers believed that relationships with patients have the greatest impact on patient satisfaction, while the support they provide clinicians has the greatest impact on clinician satisfaction.Conclusions: These findings may improve best practice for care managers by focusing interventions on the most effective activities for patients with specific medical conditions.