http://hfrp.umm.edu human factors techno- logy medicine 2009 © xiao, um course objectives 1.review...
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2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Course Objectives
1. Review concepts and theories of coordination in literature
2. Characterize problems and issues of coordination and workflow in healthcare
3. Review of case studies in healthcare
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Yan Xiao, PhDProfessor of AnesthesiologyDirector, Research in Patient SafetyUniversity of Maryland School of MedicineBaltimore, Maryland, USA
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
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1960 1970 1980 1990 2000 2005 2010*
Nursing home care
Prescription drugs
Physician andclinical servicesHospital Care
2006 National Health Spending:
$2.1 Trillion$7,026/person16% of Gross Domestic Product (GDP)
Challenges of Coordination in Healthcare
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination in Healthcare: How it matters
• #1 priority for research: "Lack of communication and coordination (including coordination across organisations and discontinuity)" (British Medical Journal 2009)
• Poor coordination results in:• Low quality and efficiency• Errors in medication and treatment• Conflicting information
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination and mortality
• Medicare mortality lower among hospitals known for good nursing care - particularly the ability to coordinate across units
Source: Aiken, Sochalski, and Lake, Medical Care, 1997.
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Shortell, Zimmerman and Rousseau et al. Medical Care, 1994.
Coordination and Quality
• National Study of 42 Intensive Care Units
• Nursing leadership, ability to manage conflict, and better care coordination positively associated with lower risk-adjusted length of stay, lower nurse turnover, better evaluated technical quality of care and ability to meet family member needs.
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination and surgical outcomes
• A study of 3,000 CABG patients in 16 hospitals
• A group-oriented, collaborative, participative culture was significantly associated with higher patient physical and mental functional health status scores six months post-discharge and shorter post-operative intubation times.
Shortell, Jones, Rademaker, and Gillies et al. 2000.
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination and quality
• In a nine hospital study of patients with total hip and total knee replacement, relational coordination was significantly associated with less post-operative pain, greater post-operative functioning, and shorter length of stay.
Source: J. Gittel, K. Fairfield, and B. Bierbaum, et al.“Impact of Relational Coordination on Quality of Care,Post-Operative Pain and Functioning andLength of Stay,” Medical Care, 2000, 38(3):807-819.
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination in Healthcare How it matters
• Highly inter-dependent activities – Care is usually provided by
• multiple care providers
• over time
• at distributed locations
– Care needs are episodic and unpredictable– Highly variable patient needs
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
What Does Coordination Mean?(or Not*)
• Have what is need– “Medical record missing information had to wait for info to complete both surgical &
anesthesia consent.” – Case delayed 35 min.
• Have the correct information– “Final printed posting was changed from the correct original posting. Change did not reflect
the correct surgery. All supplies and instrument trays were wrong.”– Case delayed 40 min.
• Have the “left hand” to know what the “right hand” is doing– “Both Dr L and Dr R were scheduled for case.
Dr L thought Dr R was to start and Dr R thought Dr. L would start. Dr L was scheduled for another 1st case, when contacted he stated
he was the consult on the case.” – Case delayed 1 hr 45 min.
• Have the most current information– “OR front desk did not know pt was on 10 W.”
Case delayed 15 min.
*Reports courtesy of Kate Bott and Mike Harrington
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
ICU
Time
TRU
OR 1
OR 2
PACU
Surg 1
Anesth
CRNA
Surg 2
Nurse 2
(Lecture)
Nurse 1
Trajectories
• Phenomenon definition: multiple people working on multiple “projects”, over long span of time and distances
• Problem definition: how people manage different trajectories
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Examples of Trajectories
• Care activities for a surgical patient– Patient admission– Preparation of documents, supplies, personnel– Start and end of surgery– Post anesthesia care and intensive care– Recovery and rehabilitation– Discharge
2009 © Xiao, UM
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Human Factors
Techno-logy
Medicine
Coordination in Healthcare What it is: Trajectory” of Patient Care
Admission
Diagnosis (MRI, CT, ETC)
Surgery Stabilization
Assessment+Disposition Discharge
Primary Team Consulting physicians O.T., P.T.
Social workerTransporter
2009 © Xiao, UM
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Human Factors
Techno-logy
Medicine
Patient with Traumatic Brain Injury
Trauma Admitting Unit ICU Step Down
Treatment:Orthopedic
Surgery
Treatment: IVC orNeurosurgery
Stabilization:Vent weaning
ICP managementAdmission
Diagnosis:X-ray/CT/FAST
Primary Team Neurosurgery
Orthopedic Surgery
OT/PT
Case ManagerSocial WorkTransporter
Fnancial Advisor
9/28/2007 - 10/5/2007Preparation
For DC
Discharge:Specialized care (TBI rehab)Or transfer to Stepdown unit
Discharge:Specialized care
(TBI rehab)
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination in Healthcare What it is: the example of car crashes
• Time 0: two cars collided• Landmark 1: Emergency medical services system
activated• Landmark 2: Patients extricated and placed on
ambulances• Landmark 3: Patients arrived at trauma center• Landmark 4: Patients received definitive surgical
care
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination saves lives
Coordination challengesin emergency medicalservices (EMS)
Field
Command center
Hotline
NotificationBoard
TraumaResuscitation
Unit
Landing pad
Operatingroom
2009 © Xiao, UM
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Human Factors
Techno-logy
Medicine
Coordination in Healthcare What it is: A broad definition
• Objects of coordination: what to coordinate– Information– Mental models– Expectations– Expertise– Authorities– Relations– Tasks
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination in Healthcare What it is: A broad definition
• Means of coordination: how to coordinate– Explicit versus implicit– Low versus high bandwidth– Routine versus mutual adjustment mechanisms– Spontaneous versus reactive
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Summary
• Coordination is a key challenge for healthcare, because of – Variations– Uncertainties– Distribution
• The objects of coordination include tasks, information, authorities, expectations
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
University of Maryland Medical Center and Shock Trauma Center
• 32 operating rooms, 6 dedicated to trauma
• 10 trauma bays• 7000 annual trauma
patient admissions
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Studies of Coordination at University of Maryland
• Healthcare context for coordination studies– Trauma resuscitation: Action teams – Operating rooms: Operations management of surgical
services– Intensive care units: transfers of information and
responsibilities
• Perspectives of understanding coordination– Social system of relations and conflicts– CSCW system of computing and cognition– Economic system of efficiency– Workflow system of activity and materials
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination Studies: Experience at University of Maryland
• Coordination in high intensity team (HIT) situation – Adaptive team structures (Xiao 2005)– Dynamic delegation and leadership (Klein
2006)
2009 © Xiao, UM
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Human Factors
Techno-logy
Medicine
Coordination Studies: Experience at University of Maryland
• Orchestrating information flow in ICU– Structures of rounding communication
(Cardarelli in press)– Preparing for team meetings (Cervenka in
revision)– Reaching and communicating goals in team
meetings (“rounds”) (Xiao in review)– Information arena model of team
communication
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination Studies: Experience at University of Maryland
• Managing workflow in operating suites– Communication burden of coordinators (Moss
2004)– Distributed coordination through OR video
(Xiao 2005)– Acceptance and usage of OR video (Xiao 2007)– Visual versus table display of procedural
duration uncertainty (Dexter, Ho 2008)
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Coordination Studies: Experience at University of Maryland
• Exception handling in trauma patient care– Discharge rounds (Sen 2008)
2009 © Xiao, UM
http://hfrp.umm.edu
Human Factors
Techno-logy
Medicine
Summary
• Healthcare is a fertile domain to develop theories and concepts of coordination
• Different types of coordination problems facing care providers in different contexts