SEIPS 3.0: Human-centered design of the patient journey for patient safety

Designing digital patient experiences: The digital health design framework

BACKGROUND

Digital health (DH) brings considerable benefits, but it comes with potential risks. Human Factors (HF) play a critical role in providing high-quality and acceptable DH solutions. Consultation with designers is crucial for reflecting on and improving current DH design practices.

OBJECTIVES

We investigated the general DH design processes, challenges, and corresponding strategies that can improve the digital patient experience (PEx).

METHODS

A semi-structured interview study with 24 design professionals. All audio recordings were transcribed, deidentified, grammatically corrected, and imported into ATLAS.ti for data analysis. Three coders participated in data coding following the thematic analysis approach.

RESULTS

We identified eight DH design stages and grouped them into four phases: preparation, problem-thinking, problem-solving, and implementation. The analysis presented twelve design challenges associated with contextual, practical, managerial, and commercial aspects that can hinder the design process. We identified eight common strategies used by respondents to tackle these challenges.

CONCLUSIONS

We propose a Digital Health Design (DHD) framework to improve the digital PEx. It provides an overview of design deliverables, activities, stakeholders, challenges, and corresponding strategies for each design stage.

Revealing complex interdependencies in surgical instrument reprocessing using SEIPS 101 tools

Sterile Processing Departments (SPDs) must clean, maintain, store, and organize surgical instruments which are then delivered to Operating Rooms (ORs) using a Courier Network, with regular coordination occurring across departmental boundaries. To represent these relationships, we utilized the Systems Engineering Initiative for Patient Safety (SEIPS) 101 Toolkit, which helps model how health-related outcomes are affected by healthcare work systems. Through observations and interviews which built on prior work system analyses, we developed a SEIPS 101 journey map, PETT scan, and tasks matrices to represent the instrument reprocessing work system, revealing complex interdependencies between the people, tools, and tasks occurring within it. The SPD, OR and Courier teams are found to have overlapping responsibilities and a clear co-dependence, with critical implications for the successful functioning of the whole hospital system.

Setting new priorities for nursing research: The updated Swiss Nursing Research Agenda-a systematic, participative approach

AIM

To identify current key areas for nursing research in Switzerland, we revised the Swiss Research Agenda for Nursing (SRAN) initially published in 2008.

BACKGROUND

By developing a research agenda, nursing researchers internationally prioritize and cluster relevant topics within the research community. The process should be collaborative and systematic to provide credible information for decisionmakers in health care research, policy, and practice.

SOURCES OF EVIDENCE

After a participative, systematic, and critical evaluation within and outside of the Swiss Association for Nursing Science, the updated SRAN 2019-2029 defines four research priorities (new models of care, nursing care interventions, work and care environment, and quality of care and patient safety) and four transversal themes (organization of research, research methodologies, research in health care policy and public health perspectives).

CONCLUSION

Adding to other national nursing research agendas, the categories are organized in a framework of key research priorities and transversal themes. They relate to the importance of global and local foci of research as well as challenges in health care services and policy systems. The agenda is an important prerequisite for enhancing the influence of nursing research in Switzerland and provides guidance for the next decade.

IMPLICATIONS FOR NURSING PRACTICE

The revised agenda ensures that research projects target key knowledge gaps and the discipline's core questions in respective countries.

IMPLICATIONS FOR HEALTH POLICY

Nursing research should inform and influence health policy on all institutional and political levels. Therefore, the integration of public health perspectives in research is one of the most important new aspects of SRAN 2019-2029.

Mothers' Internet Journeys Through Social, Health Care, and Virtual Systems When Congenital Anomalies Are Diagnosed In Utero

OBJECTIVE

To examine mothers' internet usage, in conjunction with social, health care, and virtual peer support navigations, when congenital anomalies were diagnosed in utero.

DESIGN

Qualitative descriptive, consisting of semistructured interviews.

SETTING

Interview data were collected over Zoom; mothers participated from locations of their choosing.

PARTICIPANTS

Mothers of neonates discharged postoperatively from NICUs for uterine-diagnosed congenital anomalies. The sample was purposefully recruited from private Facebook groups for parents of children with congenital anomalies.

INTERVENTION/MEASUREMENTS

Analysis was done with deductive coding using concepts from the third iteration of the systems engineering initiative for patient safety theory. The a priori codes were health care, social, journey-benefit, journey-risk, task, and technology.

RESULTS

Twenty-two mothers signed up for an interview; 12 completed an interview, and 10 did not. The majority (n = 8, 66%) were White, had a bachelor's or graduate degree (n = 7, 58%) and were between 24 and 33 years of age (n = 8, 66%). Nine themes emerged: (a) Providers cautioned searching for diagnosis information but encouraged private Facebook groups for peer support, (b) Mothers' inquiries for their own care are lacking, (c) Search for information while recognizing parent-partner's coping differences, (d) Pace information from friends and family with patience and appreciation, (e) Manage inquiries from friends and family with group sharing, (f) Private Facebook groups provide a means of receiving and giving peer support, (g) Exposure to difficult stories on Facebook is a risk of stress, (h) Select a NICU, learn about their children's diagnoses, participate in virtual peer support, and (i) Device features frame search strategies.

CONCLUSION

Mothers reflected on the internet as a burden and a source of support in their health care journeys. The ubiquity of internet access calls for mothers to include in their health care journeys the complexities of managing time spent on the internet.

A Qualitative Analysis of Barriers to Evidence-Based Care in the Prehospital Management of Patients with Suspected Acute Coronary Syndrome

OBJECTIVES

Prehospital electrocardiogram (ECG) and administration of aspirin are evidence-based strategies for patients with acute coronary syndrome (ACS). However, emergency medical services (EMS) compliance in patients with suspected ACS varies widely. We sought to understand the barriers to prehospital ECG acquisition and aspirin administration for patients with suspected ACS.

METHODS

In this qualitative study, we interviewed EMS clinicians at three geographically diverse United States (U.S.)-based EMS agencies. We interviewed practicing clinicians and quality and operations leaders at these agencies. Based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, interviews were recorded, transcribed, and analyzed using a grounded qualitative approach with open coding. The Systems Engineering Initiative for Patient Safety (SEIPS) framework and a constant comparison technique were used to identify and refine themes.

RESULTS

Twenty-five paramedics and 20 additional agency personnel participated. Median age was 41 (IQR: 34-51) years and 13 (29%) were female. Themes were organized using SEIPS and longitudinally through four phases of an EMS call. During the pre-arrival phase, staffing challenges, training quality, and dispatch may anchor EMS clinicians on a diagnosis. During the diagnosis and treatment phase, safety and communication barriers may take priority over care delivery. Additionally, EMS clinicians must allocate assets (e.g. whether to send an advanced life support unit) and financial resources; veteran EMS clinicians identified their experience whereas newer clinicians cited their recent education when making these decisions. Also, diagnostic uncertainty due to increasing patient complexity and atypical presentations contributed to diagnostic errors. During the response and transport phase, the scope of practice limits the use and interpretation of the ECG, with clinicians reporting that liberal use of ECG led to more rapid decision-making. Finally, in the after phase, personnel reported the "psychologically taxing" nature of the job contributing to biases, bad habits, and burnout. Performance feedback was desired for personal development, though currently perceived as infrequent and punitive.

CONCLUSIONS

Multiple, interrelated themes underscored the complexities of delivering evidence-based care to prehospital patients with ACS. Education in ECG interpretation, resource allocation, bias, and enhancing feedback may serve as strategies to address the identified barriers.

Improving quality through simulation; developing guidance to design simulation interventions following key events in healthcare

Simulation educators are often requested to provide multidisciplinary and/or interprofessional simulation training in response to critical incidents. Current perspectives on patient safety focus on learning from failure, success and everyday variation. An international collaboration has led to the development of an accessible and practical framework to guide the implementation of appropriate simulation-based responses to clinical events, integrating quality improvement, simulation and patient safety methodologies to design appropriate and impactful responses. In this article, we describe a novel five-step approach to planning simulation-based interventions after any events that might prompt simulation-based learning in healthcare environments. This approach guides teams to identify pertinent events in healthcare, involve relevant stakeholders, agree on appropriate change interventions, elicit how simulation can contribute to them and share the learning without aggravating the second victim phenomenon. The framework is underpinned by Deming's System of Profound Knowledge, the Model for Improvement and translational simulation. It aligns with contemporary socio-technical models in healthcare, by emphasising the role of clinical teams in designing adaptation and change for improvement, as well as encouraging collaborations to enhance patient safety in healthcare. For teams to achieve this adaptive capacity that realises organisational goals of continuous learning and improvement requires the breaking down of historical silos through the creation of an infrastructure that formalises relationships between service delivery, safety management, quality improvement and education. This creates opportunities to learn by design, rather than chance, whilst striving to close gaps between work as imagined and work as done.

Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports

Patient safety incident reports are a key source of safety intelligence. This study aimed to explore whether information contained in such reports can elicit facilitators of safety, including responding, anticipating, monitoring, learning, and other mechanisms by which safety is maintained. The review further explored whether, if found, this information could be used to inform safety interventions. Anonymized incident reports submitted between August and October 2020 were obtained from two large teaching hospitals. The Systems Engineering Initiative for Patient Safety (SEIPS) tool and the resilience potentials (responding, anticipating, monitoring, and learning) frameworks guided thematic analysis. SEIPS was used to explore the components of people, tools, tasks, and environments, as well as the interactions between them, which contribute to safety. The resilience potentials provided insight into healthcare resilience at individual, team, and organizational levels. Sixty incident reports were analysed. These included descriptions of all the SEIPS framework components. People used tools such as electronic prescribing systems to perform tasks within different healthcare environments that facilitated safety. All four resilient capacities were identified, with mostly individuals and teams responding to events; however, monitoring, anticipation, and learning were described for individuals, teams, and organizations. Incident reports contain information about safety practices, much of which is not identified by traditional approaches such as root cause analysis. This information can be used to enhance safety enablers and encourage greater proactive anticipation and system-level learning.

Adopting human factors in early phase and experimental medicine research: A nested pilot study observing controlled human infection with SARS-CoV-2

AIMS

The influence of human factors on safety in healthcare settings is well established, with targeted interventions reducing risk and enhancing team performance. In experimental and early phase clinical research participant safety is paramount and safeguarded by guidelines, protocolized care and staff training; however, the real-world interaction and implementation of these risk-mitigating measures has never been subjected to formal system-based assessment.

METHODS

Independent structured observations, systematic review of study documents, and interviews and focus groups were used to collate data on three key tasks undertaken in a clinical research facility (CRF) during a SARS CoV-2 controlled human infection model (CHIM) study. The Systems Engineering Initiative for Patient Safety (SEIPS) was employed to analyse and categorize findings, and develop recommendations for safety interventions.

RESULTS

High levels of team functioning and a clear focus on participant safety were evident throughout the study. Despite this, latent risks in both study-specific and CRF work systems were identified in all four SEIPS domains (people, environment, tasks and tools). Fourteen actionable recommendations were generated collaboratively. These included inter-organization and inter-study standardization, optimized checklists for safety critical tasks, and use of simulation for team training and exploration of work systems.

CONCLUSIONS

This pioneering application of human factors techniques to analyse work systems during the conduct of research in a CRF revealed risks unidentified by routine review and appraisal, and despite international guideline adherence. SEIPS may aid categorization of system problems and the formulation of recommendations that reduce risk and mitigate potential harm applicable across a trials portfolio.

The benefits and opportunities: Engaging patients in identifying and reporting patient safety incidents

There is growing recognition that patients can and should be engaged in the identification of patient safety incidents arising during their experiences across health systems. In this article, we describe the benefits that can be harnessed from engaging patients in reporting patient safety incidents; identify opportunities to support patient engagement in reporting and learning from patient safety incidents; and describe the potential role of health leaders in connecting patient experience and patient safety using patient-reported patient safety incident data.

Human Factors Contributing to Infection Prevention in Outpatient Hemodialysis Centers: A Mixed Methods Study

RATIONALE & OBJECTIVE

Infection prevention efforts in dialysis centers can avert patient morbidity and mortality but are challenging to implement. The objective of this study was to better understand how the design of the work system might contribute to infection prevention in outpatient dialysis centers.

STUDY DESIGN

Mixed methods, observational study.

SETTING & PARTICIPANTS

Six dialysis facilities across the United States visited by a multidisciplinary team over 8 months.

ANALYTICAL APPROACH

At each facility, structured macroergonomic observations were undertaken by a multidisciplinary team using the SEIPS 1.0 model. Ethnographic observations were collected about staff encounters with dialysis patients including the content of staff conversations. Selective and axial coding were used for qualitative analysis and quantitative data were reported using descriptive statistics.

RESULTS

Organizational and sociotechnical barriers and facilitators to infection prevention in the outpatient dialysis setting were identified. Features related to human performance, (eg, alarms, interruptions, and task stacking), work system design (eg, physical space, scheduling, leadership, and culture), and extrinsic factors (eg, patient-related characteristics) were identified.

LIMITATIONS

This was an exploratory evaluation with a small sample size.

CONCLUSIONS

This study used a systematic macroergonomic approach in multiple outpatient dialysis facilities to identify infection prevention barriers and facilitators related to human performance. Several features common across facilities were identified that may influence infection prevention in outpatient care and warrant further exploration.

Identifying Major Barriers to Home Dialysis (The IM-HOME Study): Findings From a National Survey of Patients, Care Partners, and Providers

RATIONALE & OBJECTIVE

Developing strategies to improve home dialysis use requires a comprehensive understanding of barriers. We sought to identify the most important barriers to home dialysis use from the perspective of patients, care partners, and providers.

STUDY DESIGN

This is a convergent parallel mixed-methods study.

SETTING & PARTICIPANTS

We convened a 7-member advisory board of patients, care partners, and providers who collectively developed lists of major patient/care partner-perceived barriers and provider-perceived barriers to home dialysis. We used these lists to develop a survey that was distributed to patients, care partners, and providers-through the American Association of Kidney Patients and the National Kidney Foundation. The surveys asked participants to (1) rank their top 3 major barriers (quantitative) and (2) describe barriers to home dialysis (qualitative).

ANALYTICAL APPROACH

We compiled a list of the top 3 patient/care partner-perceived and top 3 provider-perceived barriers (quantitative). We also conducted a directed content analysis of open-ended survey responses (qualitative).

RESULTS

There were 522 complete responses (233 providers; 289 patients/care partners). The top 3 patient/care partner-perceived barriers were fear of performing home dialysis; lack of space; and the need for home-based support. The top 3 provider-perceived barriers were poor patient education; limited mechanisms for home-based support staff, mental health, and education; and lack of experienced staff. We identified 9 themes through qualitative analysis: limited education; financial disincentives; limited resources; high burden of care; built environment/structure of care delivery that favors in-center hemodialysis; fear and isolation; perceptions of inequities in access to home dialysis; provider perspectives about patients; and patient/provider resiliency.

LIMITATIONS

This was an online survey that is subject to nonresponse bias.

CONCLUSIONS

The top 3 barriers to home dialysis for patient/care partners and providers incompletely overlap, suggesting the need for diverse strategies that simultaneously address patient-perceived barriers at home and provider-perceived barriers in the clinic.

PLAIN-LANGUAGE SUMMARY

There are many barriers to home dialysis use in the United States. However, we know little about which barriers are the most important to patients and clinicians. This makes it challenging to develop strategies to increase home dialysis use. In this study, we surveyed patients, care partners, and clinicians across the country to identify the most important barriers to home dialysis, namely (1) patients/care partners identified fear of home dialysis, lack of space, and lack of home-based support; and (2) clinicians identified poor patient education, limited support for staff and patients, and lack of experienced staff. These findings suggest that patients and clinicians perceive different barriers and that both sets of barriers should be addressed to expand home dialysis use.

The Perspectives of Healthcare Professionals and Managers on Patient Involvement in Care Pathway Development: A Discourse Analysis

BACKGROUND

The WHO advocates patient and public involvement as an ethical imperative, due to the value of the lived experience of patients. A deeper understanding of the shared meanings and underlying beliefs of healthcare professionals and managers for and against including patients in care pathway development.

OBJECTIVE

To explore the considerations of healthcare professionals and managers on the involvement of patients and public in care pathway development.

METHODS

In a medical rehabilitation centre we conducted a single case study that was part of a 2-year action research programme on blended care pathway development. Following 14 semistructured interviews with healthcare professionals and managers, we analysed their discourses on the value of patient involvement as well as the potential threats and opportunities.

RESULTS

We identified four discourses. Patient as expert frames involvement as relevant, as adding new perspectives and as required to fully understand the patient's needs. Skills and representation is based on the construct that obtaining valuable insights from patients requires certain skills and competences. Self-protection focusses on personal, interprofessional objections to patient involvement. Professional knows best reveals expertise-related reasons for avoiding or postponing involvement.

CONCLUSION

These discourses explain why patient and public involvement in care pathway development is sometimes postponed, limited in scope and level of participation, and/or avoided. The following strategies might minimise the paralysing effect of these discourses: strengthen the capabilities of all stakeholders involved; use a mix of complementary techniques to gain involvement in distinct phases of care pathway development; and create/facilitate a safe environment. Put together, these strategies would foster ongoing, reciprocal learning that could enhance patient involvement.

PATIENT OR PUBLIC CONTRIBUTION

This study belonged to an action research programme on blended care pathway development (developing an integrated, coordinated patient care plan that combines remote, digital telehealth applications, self-management tools and face-to-face care). Multidisciplinary teams took a quality collaborative approach to quality improvement (considering patients as stakeholders) to develop 11 blended care pathways. Although professionals and managers were instructed to invite patients onto their teams and to attend care pathway design workshops, few teams (3/11) actually did. Unravelling why this happened will help improve patient and public involvement in care pathway development.

Working From Within: The Rural Community Participatory Design Framework

OBJECTIVE

This article describes the development of the rural community-based participatory design framework to guide healthcare design teams in their integration of rural community and clinical voice during the planning, design, and construction of a healthcare facility.

BACKGROUND

Rural communities are facing an alarming rate of healthcare facility closures, provider shortages, and dwindling resources, which are negatively impacting population health outcomes. A prioritized focus on rural care access and delivery requires design teams to have a deeper understanding of the contextual considerations necessary for a successful healthcare facility project, made possible through engagement and partnership with rural dwelling community members and healthcare teams.

METHOD

The rural community participatory design framework is adapted from the rural participatory research model, selected due to its capture of key concepts and characteristics of rural communities. Underpinning theories included rural nursing theory and theory of the built environment.

RESULTS

The framework encompasses healthcare facility project phases, key translational concepts, and common traits across rural communities and cultures. As a middle-range theoretical framework, it is being tested in a current healthcare project with a Critical Access Hospital in Montana to facilitate design team and stakeholder collaboration.

CONCLUSION

The rural community participatory design framework may be utilized by design teams as a means of familiarization with rural cultures, norms, values, and critical needs, which relate to meaningful design. The framework further enables design teams to critically appraise best practices of stakeholder engagement throughout the project lifecycle.

Macroergonomic components of the patient work system shaping dyadic care management during adolescence: a case study of type 1 diabetes

The role of the social, physical, and organisational environments in shaping how patients and their caregivers perform work remains largely unexplored in human factors/ergonomics literature. This study recruited 19 dyads consisting of a parent and their child with type 1 diabetes to be interviewed individually and analysed using a macroergonomic framework. Our findings aligned with the macroergonomic factors as presented in previous models, while highlighting the need to expand upon certain components to gain a more comprehensive representation of the patient work system as relevant to dyadic management. Examples of design efforts that should follow from these findings include expanding existing data sharing options to include information from the external environment and capitalising on the capabilities of artificial intelligence as a decision support system. Future research should focus on longitudinally assessing patient work systems throughout transition periods in addition to more explicitly exploring the roles of social network members.

Validating the Effectiveness of the Patient-Centered Cancer Care Framework by Assessing the Impact of Work System Factors on Patient-Centered Care and Quality of Care: Interview Study With Newly Diagnosed Cancer Patients

BACKGROUND

Patients with cancer who have recently been diagnosed have distinct requirements compared to cancer survivors. It is crucial to take into account their unique needs to ensure that they make informed decisions and are receptive to the care provided.

OBJECTIVE

This study suggested a framework titled Effectiveness of Patient-Centered Cancer Care that considers the needs of newly diagnosed patients with cancer and related work system factors. This study investigated how work system factors influence the perceptions of patient-centered care, quality of care, and associated outcomes among newly diagnosed patients with cancer. Patient-centered care is defined in terms of workload and communication considerations, whereas the quality of care is assessed through indicators such as trust in physicians, satisfaction with care, and perceptions of technology.

METHODS

This study used qualitative data collected through interviews with newly diagnosed patients with cancer (N=20) right after their first visits with their physicians. Thematic analysis was conducted to validate the 5 hypotheses of the framework, mapping the interactions among quality of care, patient-centered care, and work system factors.

RESULTS

We found that workload and patient-centered communication impact the quality of care and that the work system elements impact the patient-centeredness (workload and communication) and the quality of care (trust in physicians, satisfaction with care, and perception of technology use).

CONCLUSIONS

Qualitatively validating the proposed Effectiveness of Patient-Centered Cancer Care framework, this study demonstrated its efficacy in elucidating the interplay of various factors. The framework holds promise for informing interventions geared toward enhancing patients' experiences during their initial visits after diagnosis. There is a pressing need for heightened attention to the organizational design, patient processes, and collaborative efforts among diverse stakeholders and providers to optimize the overall patient experience.

Leading Quality and Safety on the Frontline - A Case Study of Department Leaders in Nursing Homes

Purpose

The role of healthcare leaders is becoming increasingly complex, and carries great responsibility for patients, employees, and the quality of service delivery. This study explored the barriers and enablers that department leaders in nursing homes encounter when managing the dual responsibilities in Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS).

Methodology

Case study design with data collected through semi structured interviews with 16 department leaders in five Norwegian municipalities. We analyzed the data using qualitative content analysis.

Results

Data analysis resulted in four themes explaining what department leaders in nursing homes experience as barriers and enablers when handling the dual responsibility of HSE and QPS: Temporal capacity: The importance of having enough time to create a health-promoting work environment that ensures patient safety. Relational capacity: Relationships have an impact on work process and outcomes. Professional competence: Competence affects patient safety and leadership strategies. Organizational structure: Organizational frameworks influence how the dual responsibilities are handled.

Conclusion

Evidence from this study showed that external contextual factors (eg, legislations and finances) and internal factors (eg, relationships and expectations) are experienced as barriers and enablers when department leaders are enacting the dual responsibility of HSE and QPS. Of these, relationships were found to be the most significant contributor.

Assessing care quality in general practice: a qualitative study of GPs in Ireland

BACKGROUND

It is estimated that each year in Ireland, approximately 29 million consultations occur in general practice with a patient satisfaction level of 90%. To date, research has been lacking on how GPs assess the quality of care.

AIM

To examine how GPs assess care quality during routine practice with respect to the following pillars of quality improvement: effectiveness, safety, timeliness, equity, efficiency, sustainability, and person-centredness.

DESIGN & SETTING

Qualitative study of GPs in Ireland.

METHOD

In this qualitative study, semi-structured interviews were conducted with 10 GPs who were recruited via a snowball sampling strategy. Interviews were recorded, transcribed, and analysed. Quality 'assessment points' were identified and themes were synthesised to produce a theoretical framework.

RESULTS

Five female and five male GPs practising in a variety of settings were interviewed. The age range was 33-68 years. In total, 122 assessment points emerged from the data and were collated into the following eight themes: the GP as a professional person factors; the patient and coproduction factors; care team factors; direct care factors; outcome factors; practice environment and organisation factors; external environment factors; and improvement approach factors.

CONCLUSION

This is the first study to examine how GPs in Ireland assess care quality as a holistic construct during daily care. The qualitative approach applied yielded rich and diverse insights into the many assessment points that GPs use to inform their approach and actions as clinicians, managers, collaborators, and leaders to maximise patient care. The theory produced is likely useful and applicable for practising GPs, healthcare administration, policymakers, and funders in planning and executing changes for quality improvement.

Assessment of Patient Safety in a Low-Resource Health Care System: Proposal for a Multimethod Study

BACKGROUND

The high prevalence of adverse events (AEs) globally in health care delivery has led to the establishment of many guidelines to enhance patient safety. However, patient safety is a relatively nascent concept in low- and middle-income countries (LMICs) where health systems are already overburdened and underresourced. This is why it is imperative to study the nuances of patient safety from a local perspective to advocate for the judicious use of scarce public health resources.

OBJECTIVE

This study aims to assess the status of patient safety in a health care system within a low-resource setting, using a multipronged, multimethod approach of standardized methodologies adapted to the local setting.

METHODS

We propose purposive sampling to include a representative mix of public and private, rural and urban, and tertiary and secondary care hospitals, preferably those ascribed to the same hospital quality standards. Six different approaches will be considered at these hospitals including (1) focus group discussions on the status quo of patient safety, (2) Hospital Survey on Patient Safety Culture, (3) Hospital Consumer Assessment of Healthcare Providers and Systems, (4) estimation of incidence of AEs identified by patients, (5) estimation of incidence of AEs via medical record review, and (6) assessment against the World Health Organization's Patient Safety Friendly Hospital Framework via thorough reviews of existing hospital protocols and in-person surveys of the facility.

RESULTS

The abovementioned studies collectively are expected to yield significant quantifiable information on patient safety conditions in a wide range of hospitals operating within LMICs.

CONCLUSIONS

A multidimensional approach is imperative to holistically assess the patient safety situation, especially in LMICs. Our low-budget, non-resource-intensive research proposal can serve as a benchmark to conduct similar studies in other health care settings within LMICs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50532.

Older Adult Patients and Care Partners as Knowledge Brokers in Fragmented Health Care

OBJECTIVE

To describe older adult patients' and care partners' knowledge broker roles during emergency department (ED) visits.

BACKGROUND

Older adult patients are vulnerable to communication and coordination challenges during an ED visit, which can be exacerbated by the time and resource constrained ED environment. Yet, as a constant throughout the patient journey, patients and care partners can act as an information conduit, or knowledge broker, between fragmented care systems to attain high-quality, safe care.

METHODS

Participants included 14 older adult patients (≥ 65 years old) and their care partners (e.g., spouse, adult child) who presented to the ED after having experienced a fall. Human factors researchers collected observation data from patients, care partners and clinician interactions during the patient's ED visit. We used an inductive content analysis to determine the role of patients and care partners as knowledge brokers.

RESULTS

We found that patients and care partners act as knowledge brokers by providing information about diagnostic testing, medications, the patient's health history, and care accommodations at the disposition location. Patients and care partners filled the role of knowledge broker proactively (i.e. offer information) and reactively (i.e. are asked to provide information by clinicians or staff), within-ED work system and across work systems (e.g., between the ED and hospital), and in anticipation of future knowledge brokering.

CONCLUSION

Patients and care partners, acting as knowledge brokers, often fill gaps in communication and participate in care coordination that assists in mitigating health care fragmentation.

Knowledge mapping analysis of safety ergonomics: a bibliometric study

Although a significant attention, the field of safety ergonomics has not yet been systematically profiled based on recent studies. To fully understand the current research status, basis, hotspots, and development trends in the field, 533 documents from the Web of Science core database were used for knowledge mapping analysis by the bibliometric method. The study found that the USA is the top country in publications, and Tehran University is the institution with the highest number of publications. Ergonomics and Applied Economics are the authoritative safety ergonomics journals. Through co-occurrence and co-citation analysis, current safety ergonomics research is focussed on healthcare, product design, and occupational health and safety. The keyword timeline view indicates that the main research paths are occupational health and safety, and patient safety research. The analysis of burst keywords shows that safety ergonomics research in management, model design, and system design areas are research frontiers in the field.Practitioner summary: This paper presents a knowledge mapping of safety ergonomics research through bibliometric analysis. The research results show the research status, research hotspots, and research frontiers in the field of safety ergonomics, which provides a direction for other scholars to quickly understand the development of this field.

Mobile Health Application for Seizure Management: A Human-Systems Integration Approach

OBJECTIVE

The study aims to develop a mHealth application for seizure management based on the human system integration (HSI) approach.

BACKGROUND

Unmet healthcare needs among people with epilepsy continue to exist despite the advancement in healthcare technology. Current seizure management methods are found to be ineffective. Therefore, a more efficient strategy such as mHealth technology is necessary to aid seizure management.

METHOD

The needs identification phase involved identifying the user requirements by interviewing 10 stakeholders and conducting thematic analysis and needs interpretation technique. In the solution identification phase, the system requirements were derived using various human-centered design and systems engineering approaches and were evaluated through quality function deployment to determine design targets. For the design and evaluation phase, the design targets were reflected in the app through the iterative prototyping process, and the interface and functional design were evaluated by seven human factors and ergonomics experts and four stakeholders, respectively.

RESULTS

Three primary needs and ten user requirements were derived from the needs identification phase. Ten out of fifteen system requirements were selected as design targets to be included in the final prototype. Results of the evaluation showed that the interface design of the proposed app showed superior usability compared to a competitor app and that the app functions were beneficial for the stakeholders.

CONCLUSION

The mHealth app designed through the HSI framework showed good potential in addressing the main issues in seizure management.

APPLICATION

The mHealth app design methodology based on the HSI approach can be applied to the design of small-scale systems in various domains.

Interactions in Sociotechnical Systems: Achieving Balance in the Use of an Augmented Reality Mobile Application

OBJECTIVE

We explore relationships between barriers and facilitators experienced by users to understand dynamic interactions in sociotechnical systems and improve a mobile phone-based augmented reality application that teaches users about the contents of a standardized pediatric code cart.

BACKGROUND

Understanding interactions between performance obstacles and facilitators can provide guidance to (re)designing sociotechnical systems to improve system outcomes. Clinicians should know about contents and organization of code carts, and an augmented reality mobile application may improve that knowledge but changes the sociotechnical system in which they learn. Prior work identified barriers and facilitators impacting the use of this application-participants described dimensions together, indicating interactions that are explored in the current study.

METHOD

We conducted four focus groups (number of clinicians = 18) and two interviews with clinicians who used the application. We performed a secondary analysis of focus group data exploring interactions between previously identified barriers and facilitators to application use. We used epistemic network analysis to visualize these interactions.

RESULTS

Work system barriers interacted with barriers and facilitators interacted with facilitators to amplify cumulative negative or positive impact, respectively. Facilitators balanced barriers, mitigating negative impact. Facilitators also exacerbated barriers, worsening negative impact.

CONCLUSION

Barriers and facilitators interact and can amplify, balance, and exacerbate each other-notably, positives are not always positive. To obtain desired outcomes, interactions must be further considered in sociotechnical system design, for example, the potential improvements to the application we identified.

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review

BACKGROUND

Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management.

OBJECTIVES

To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio.

METHODS

Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) 'Key Components of an Ideal Transfer of Care', (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored.

RESULTS

Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support.

CONCLUSION

The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures.

Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study

OBJECTIVES

The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care.

MATERIALS AND METHODS

Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics. We examined differences in timely completion ("loop closure") of tests/referrals for (1) patients who used the portal and read ≥1 note (Portal + Notes); (2) those with a portal account but who did not read notes (Portal Account Only); and (3) those who did not register for the portal (No Portal). We estimated the predictive probability of loop closure in each group after adjusting for socio-demographic and clinical factors using multivariable logistic regression.

RESULTS

Among 12 849 tests/referrals, loop closure was more common among Portal+Note-readers compared to their counterparts for all tests/referrals (54.2% No Portal, 57.4% Portal Account Only, 61.6% Portal+Notes, P < .001). In adjusted analysis, compared to the No Portal group, the odds of loop closure were significantly higher for Portal Account Only (OR 1.2; 95% CI, 1.1-1.4), and Portal+Notes (OR 1.4; 95% CI, 1.3-1.6) groups. Beyond portal registration, note reading was independently associated with loop closure (P = .002).

DISCUSSION AND CONCLUSION

Compared to no portal registration, the odds of loop closure were 20% higher in tests/referrals for patients with a portal account, and 40% higher in tests/referrals for note readers, after controlling for sociodemographic and clinical factors. However, important safety gaps from unclosed loops remain, requiring additional engagement strategies.

What's going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process

OBJECTIVES

Accurate and timely diagnosis relies on close collaboration between patients/families and clinicians. Just as patients have unique insights into diagnostic breakdowns, positive patient feedback may also generate broader perspectives on what constitutes a "good" diagnostic process (DxP).

METHODS

We evaluated patient/family feedback on "what's going well" as part of an online pre-visit survey designed to engage patients/families in the DxP. Patients/families living with chronic conditions with visits in three urban pediatric subspecialty clinics (site 1) and one rural adult primary care clinic (site 2) were invited to complete the survey between December 2020 and March 2022. We adapted the Healthcare Complaints Analysis Tool (HCAT) to conduct a qualitative analysis on a subset of patient/family responses with ≥20 words.

RESULTS

In total, 7,075 surveys were completed before 18,129 visits (39 %) at site 1, and 460 surveys were completed prior to 706 (65 %) visits at site 2. Of all participants, 1,578 volunteered positive feedback, ranging from 1-79 words. Qualitative analysis of 272 comments with ≥20 words described: Relationships (60 %), Clinical Care (36 %), and Environment (4 %). Compared to primary care, subspecialty comments showed the same overall rankings. Within Relationships, patients/families most commonly noted: thorough and competent attention (46 %), clear communication and listening (41 %) and emotional support and human connection (39 %). Within Clinical Care, patients highlighted: timeliness (31 %), effective clinical management (30 %), and coordination of care (25 %).

CONCLUSIONS

Patients/families valued relationships with clinicians above all else in the DxP, emphasizing the importance of supporting clinicians to nurture effective relationships and relationship-centered care in the DxP.

Characterizing barriers to closing cross-institutional referral loops: Workflow and information flow analysis

The specialty referral process consists of primary care clinicians referring patients to specialty consultants. This care transition requires effective care coordination and health information exchange between care teams; however, breakdowns in workflow and information flow impede "closing the referral loop" and delay or prevent referrers from receiving the consultant's "visit notes," particularly in cross-institutional referrals. This study aimed to describe and map the referral process as it occurs in clinics and identify and characterize work system barriers affecting its performance. Referrers and consultants were interviewed about their perceived workflows, barriers, and clinical outcomes to inform a workflow analysis.

Creating safer cancer care with ethnic minority patients: A qualitative analysis of the experiences of cancer service staff

INTRODUCTION

Effective consumer engagement practices can enhance patient safety. This is important for consumers from ethnic minority backgrounds who are exposed to increased risk of patient safety events. Using the Systems Engineering Initiative for Patient Safety model, this study explored staff experiences of creating opportunities for engagement with consumers from ethnic minority backgrounds to contribute to their cancer care safety.

METHOD

A qualitative study was conducted using semistructured interviews with cancer service staff from four cancer services across two states in Australia. Purposive sampling was used to recruit healthcare staff from a diverse range of professions. Data were analysed using the Framework Analysis method.

RESULTS

Fifty-four interviews were conducted with healthcare staff. Analysis of the qualitative interview data identified enablers and associated challenges that contributed to creating a shared understanding between consumers and staff of the information, processes, expectations and problems arising in care. Enablers and challenges are reported in relation to four themes: (1) co-creating safety through shared understanding of care processes; (2) tools and technologies support planned communication; (3) organisational policy levers exist but lack implementation in direct care and (4) formal tasks incorporate consumer engagement more readily than informal interactions.

CONCLUSION

The availability of infrastructure and resources to support communication with consumers from ethnic minority backgrounds was limited to specific tasks across the cancer care continuum. Strategies implemented by health services to foster effective communication during formal interactions now require expansion to support and create conditions for effective consumer engagement during informal and everyday care tasks. The use of innovative language support tools and cultural considerations are required at the service and system level to support consumer engagement in all types of care interactions.

PUBLIC AND PATIENT INVOLVEMENT

The study was embedded within a larger project that included a consumer investigator and was guided by a consumer advisory group (CAG). These consumer team members have lived experience of cancer and are from diverse ethnic backgrounds. CAG members provided feedback on the draft interview guide and participant information for this study.

Managing patient safety and staff safety in nursing homes: exploring how leaders of nursing homes negotiate their dual responsibilities-a case study

Objective

Within healthcare, the role of leader is becoming more complex, and healthcare leaders carry an increasing responsibility for the performance of employees, the experience and safety of patients and the quality of care provision. This study aimed to explore how leaders of nursing homes manage the dual responsibility of both Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS), focusing particularly on the approaches leaders take and the dilemmas they face. In addition, we wanted to examine how leaders experience and manage the challenges of HSE and QPS in a holistic way.

Design/setting

The study was designed as a case study. Data were collected through semi structured individual interviews with leaders of nursing homes in five Norwegian municipalities.

Participants

13 leaders of nursing homes in urban and rural municipalities participated in this study.

Results

Data analysis resulted in four themes explaining how leaders of nursing homes manage the dual responsibility of HSE and QPS, and the approaches they take and the dilemmas they face: 1.Establishing good systems and building a culture for a work environment that promotes health and patient safety.2.Establish channels for internal and external collaboration and communication.3.Establish room for maneuver to exercise leadership.4.Recognizing and having the mandate to handle possible tensions in the dual responsibility of HSE and QPS.

Conclusions

The study showed that leaders of nursing homes who are responsible for ensuring quality and safety for both patients and staff, experience tensions in handling this dual responsibility. They acknowledged the importance of having time to be present as a leader, to have robust systems to maintain HSE and QPS, and that conflicting aspects of legislation are an everyday challenge.

Nurses' preferences for interventions to improve infection prevention and control behaviors based on systems engineering initiative to patient safety model: a discrete choice experiment

BACKGROUND

The evidence of preferences for infection prevention and control (IPC) intervention from system perspective was lacked. This study aimed to elicit nurses' preferences for the intervention designed to improve IPC behaviors based on the Systems Engineering Initiative to Patient Safety (SEIPS) model using Discrete Choice Experiment (DCE).

METHODS

A DCE was conducted among nurses who were on active duty and willing to participate from July 5th to 10th, 2021 in a tertiary hospital in Ganzhou City, Jiangxi Province, using convenience sampling. A self-administered questionnaire included scenarios formed by six attributes with varying levels based on SEIPS model: person, organization, tools and technology, tasks, internal environment and external environment. A conditional logit and latent class logit model were performed to analyze the data.

RESULTS

A total of 257 valid questionnaires were analyzed among nurses. The results from the latent class logit model show that nurses' preferences can be divided into three classes. For nurses in multifaceted-aspect-preferred class (41.9%), positive coefficients were obtained in those six attributes. For person-preferred class (19.7%), only person was positively significant. For environment-preferred class (36.4%), the most important attribute were tasks, tools and technology, internal environment and external environment.

CONCLUSIONS

This finding suggest that nurses have three latent-class preferences for interventions. Multifaceted interventions to improve IPC behaviors based on the SEIPS model are preferred by most nurses. Moreover, relevant measured should be performed targeted the latent class of person-preferred and external-environment-preferred nurses.

Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care

STUDY AIM

This study aims to describe the transition-in-care work process for sepsis survivors going from hospitals to home health care (HHC) and identify facilitators and barriers to enable practice change and safe care transitions using a human factors and systems engineering approach.

BACKGROUND

Despite high readmission risk for sepsis survivors, the transition-in-care work process from hospitals to HHC has not been described.

METHODS

We analyzed semi-structured needs assessment interviews with 24 stakeholders involved in transitioning sepsis survivors from two hospitals and one affiliated HHC agency participating in the parent implementation science study, I-TRANSFER. The qualitative data analysis was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the work process and identify work system elements.

RESULTS

We identified 31 tasks characterized as decision making, patient education, communication, information, documentation, and scheduling tasks. Technological and organizational facilitators lacked in HHC compared to the hospitals. Person and organization elements in HHC had the most barriers but few facilitators. Additionally, we identified specific task barriers that could hinder sepsis information transfer from hospitals to HHC.

CONCLUSION

This study explored the complex transition-in-care work processes for sepsis survivors going from hospitals to HHC. We identified barriers, facilitators, and critical areas for improvement to enable implementation and ensure safe care transitions. A key finding was the sepsis information transfer deficit, highlighting a critical issue for future study.

APPLICATION

We recommend using the SEIPS framework to explore complex healthcare work processes before the implementation of evidence-based interventions.

An integrated approach for evaluating and improving the performance of hospital ICUs based on ergonomic and work-motivational factors

The intensive care unit (ICU) holds significant importance in hospitals. Primarily concerned with monitoring and providing care to critically ill patients, the ICU has proven effective in reducing mortality rates and minimizing complications of diseases, thanks to the highly complex and specific measures taken within this department. Considering the unique contributions made by the staff in this unit, its performance assessment can help improve patient care and satisfaction. This study presents a framework that utilizes ergonomic and work-motivational factors (WMFs) to assess the performance of various ICUs. Upon the identification of these indicators, a standard questionnaire is developed to collect the required data. The mean efficiency score of the units is then determined using the data envelopment analysis (DEA). The model is validated using the principal component analysis (PCA). Ultimately, the SWOT (strengths, weaknesses, opportunities, and threats) matrix is employed to formulate an appropriate strategy and offer improvement measures to the managerial team to enhance their ICU performance. The proposed framework can be applied to evaluate the performance of other healthcare departments. Among the studied ICU centers, including general ICU, isolation ICU catering to individuals with infectious diseases, cardiac care unit (CCU), and neonatal ICU (NICU). NICU and general ICU have the best and worst performance in terms of macro- and micro-ergonomic and motivational indicators, which are on average 0.826% more elevated and 0.659% lower, respectively. According to the performed sensitivity analysis, the ICUs in question demonstrate the most appropriate and inappropriate performance about the indicators of "knowledge, situation assessment, and situation analysis" and "work stress", respectively.

Team Cognition in Handoffs: Relating System Factors, Team Cognition Functions and Outcomes in Two Handoff Processes

OBJECTIVE

This study investigates how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU). We then seek to understand how the sociotechnical system and team cognition are related.

BACKGROUND

Effective handoffs are critical to ensuring patient safety and have been the subject of many improvement efforts. However, the types of team-level cognitive processing during handoffs have not been explored, nor is it clear how the sociotechnical system shapes team cognition.

METHOD

We conducted this study in an academic, Level 1 trauma center in the Midwestern United States. Twenty-eight physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) participated in semi-structured interviews. We performed qualitative content analysis and epistemic network analysis to understand the relationships between system factors, team cognition in handoffs and outcomes.

RESULTS

Participants described three team cognition functions in handoffs-(1) information exchange, (2) assessment, and (3) planning and decision making; information exchange was mentioned most. Work system factors influenced team cognition. Inter-professional handoffs facilitated information exchange but included large teams with diverse backgrounds communicating, which can be inefficient. Intra-professional handoffs decreased team size and role diversity, which may simplify communication but increase information loss. Participants in inter-professional handoffs reflected on outcomes significantly more in relation to system factors and team cognition (p < 0.001), while participants in intra-professional handoffs discussed handoffs as a task.

CONCLUSION

Handoffs include team cognition, which was influenced by work system design. Opportunities for handoff improvement include a flexibly standardized process and supportive tools/technologies. We recommend incorporating perspectives of the patient and family in future work.

Dashboarding to Monitor Machine-Learning-Based Clinical Decision Support Interventions

BACKGROUND

 Existing monitoring of machine-learning-based clinical decision support (ML-CDS) is focused predominantly on the ML outputs and accuracy thereof. Improving patient care requires not only accurate algorithms but also systems of care that enable the output of these algorithms to drive specific actions by care teams, necessitating expanding their monitoring.

OBJECTIVES

 In this case report, we describe the creation of a dashboard that allows the intervention development team and operational stakeholders to govern and identify potential issues that may require corrective action by bridging the monitoring gap between model outputs and patient outcomes.

METHODS

 We used an iterative development process to build a dashboard to monitor the performance of our intervention in the broader context of the care system.

RESULTS

 Our investigation of best practices elsewhere, iterative design, and expert consultation led us to anchor our dashboard on alluvial charts and control charts. Both the development process and the dashboard itself illuminated areas to improve the broader intervention.

CONCLUSION

 We propose that monitoring ML-CDS algorithms with regular dashboards that allow both a context-level view of the system and a drilled down view of specific components is a critical part of implementing these algorithms to ensure that these tools function appropriately within the broader care system.

Receive, Sustain, and Flow: A simple heuristic for facilitating the identification and treatment of critically ill patients during their hospital journeys

Background

Hospital patients can become critically ill anywhere in a hospital but their survival is affected by problems of identification and adequate, timely, treatment. This is issue of particular concern in lower middle-income countries' (LMICs) hospitals where specialised units are scarce and severely under-resourced. "Cross-sectional" approaches to improving narrow, specific aspects of care will not attend to issues that affect patients' care across the length of their experience. A simpler approach to understanding key issues across the "hospital journey" could help to deliver life-saving treatments to those patients who need it, wherever they are in the facility.

Methods

We carried out 31 narrative interviews with frontline health workers in five Kenyan and five Tanzanian hospitals from November 2020 to December 2021 during the COVID-19 pandemic and analysed using a thematic analysis approach. We also followed 12 patient hospital journeys, through the course of treatment of very sick patients admitted to the hospitals we studied.

Results

Our research explores gaps in hospital systems that result in lapses in effective, continuous care across the hospital journeys of patients in Tanzania and Kenya. We organise these factors according to the Systems Engineering Initiative for Patient Safety (SEIPS) approach to patient safety, which we extend to explore how these issues affect patients across the course of care. We discern three repeating, recursive phases we term Receive, Sustain, and Flow. We use this heuristic to show how gaps and weaknesses in service provision affect critically ill patients' hospital journeys.

Conclusion

Receive, Sustain, and Flow offers a heuristic for hospital management to identify and ameliorate limitations in human and technical resources for the care of the critically ill.

CancelRx case study: implications for clinic and community pharmacy work systems

BACKGROUND

Medication prescribing and discontinuation processes are complex and involve the patient, numerous health care professionals, organizations, health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. The health system also operates 15 outpatient community pharmacies.

OBJECTIVE

The goal of this qualitative study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations, before and after CancelRx implantation.

APPROACH

Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n = 3), employed by the health system were interviewed across 3-time periods between 2017 and 2018- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and conducted a hybrid analysis with deductive content analysis following the Systems Engineering Initiative for Patient Safety (SEIPS) framework and inductive analysis to capture additional codes and themes.

KEY RESULTS

CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors.

CONCLUSIONS

This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Technologic and Nontechnologic Barriers to Implementing Behavioral Health Homes in Community Mental Health Settings During the COVID-19 Pandemic

Background

Persons with serious mental illnesses (SMIs) experience disparities in health care and are more likely to die from physical health conditions than the general population. Behavioral health homes are used in public sector mental health programs to deploy collaborative care to improve physical health for those with SMIs. During the COVID-19 pandemic, these programs faced new challenges in delivering care to this vulnerable group.

Purpose

To describe barriers to implementing or sustaining behavioral health homes, experienced by community mental health workers during the COVID-19 pandemic, and the strategies used to address these challenges.

Methods

In-depth qualitative interviews were conducted among the behavioral health workforce in Maryland and Michigan community mental health programs. Interview questions were derived from the Consolidated Framework for Implementation Research (CFIR), and responses related to implementing and sustaining health homes during the pandemic were coded and themes were analyzed by using an inductive approach.

Results

Overall, 72 staff members across 21 sites in Maryland and Michigan were interviewed. Implementation barriers/strategies identified occurred across multiple CFIR domains (client, mental health system, physical health system). Interviewees discussed technologic and nontechnologic challenges as well as strategies to address technology issues. Strategies were more frequently discussed by providers when the barrier was viewed at the client level (eg, low technology literacy) versus the broader system (eg, canceled primary care visits).

Conclusions

Community mental health staff described barriers beyond technology in caring for individuals with SMIs and physical health conditions. Further research should examine how implementation strategies address both technologic and nontechnologic barriers to collaborative care.

Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies

OBJECTIVE

The objective of this review was to develop a taxonomy of pressures experienced by health services and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies were developed from a review of observational studies directly assessing care delivered in a variety of clinical environments.

DESIGN

In the first phase, a scoping review of the relevant literature was conducted. In the second phase, pressures and strategies were systematically coded from the included papers, and categorised.

DATA SOURCES

Electronic databases (MEDLINE, Embase, CINAHL, PsycInfo and Scopus) and reference lists from recent reviews of the resilient healthcare literature.

ELIGIBILITY CRITERIA

Studies were included from the resilient healthcare literature, which used descriptive methodologies to directly assess a clinical environment. The studies were required to contain strategies for managing under pressure.

RESULTS

5402 potential articles were identified with 17 papers meeting the inclusion criteria. The principal source of pressure described in the studies was the demand for care exceeding capacity (ie, the resources available), which in turn led to difficult working conditions and problems with system functioning. Strategies for responding to pressures were categorised into anticipatory and on-the-day adaptations. Anticipatory strategies included strategies for increasing resources, controlling demand and plans for managing the workload (efficiency strategies, forward planning, monitoring and co-ordination strategies and staff support initiatives). On-the-day adaptations were categorised into: flexing the use of existing resources, prioritising demand and adapting ways of working (leadership, teamwork and communication strategies).

CONCLUSIONS

The review has culminated in an empirically based taxonomy of pressures and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies could help clinicians and managers to optimise how they respond to pressures and may be used as the basis for training programmes and future research evaluating the impact of different strategies.

When Positive is Negative: Health Literacy Barriers to Patient Access to Clinical Laboratory Test Results

BACKGROUND

Health literacy is a multidimensional set of skills (e.g., narrative, numeracy, digital, medication) that patients need to access and understand health information timely and accurately to make evidence-based informed decisions.

CONTENT

Multiple barriers prevent patients from effectively interacting with health information. The most salient barriers are poor overall health literacy skills and linguistic proficiency in English. As patients prefer direct access to laboratory test results, especially those of routine tests, contextualization and provider-directed interpretation of results are required to foster shared decision-making to address their healthcare issues and improve health outcomes.

SUMMARY

The use of systematic approaches that account for poor health literacy skills and include culturally and linguistically appropriate planning and availability of resources is warranted at individual and population health levels (e.g., human-centered design of patient portals).

Automation in health care: the need for an ergonomics-based approach

Healthcare quality and efficiency challenges degrade outcomes and burden multiple stakeholders. Workforce shortage, burnout, and complexity of workflows necessitate effective support for patients and providers. There is interest in employing automation, or the use of 'computer[s] [to] carry out… functions that the human operator would normally perform', in health care to improve delivery of services. However, unique aspects of health care require analysis of workflows across several domains and an understanding of the ways work system factors interact to shape those workflows. Ergonomics has identified key work system issues relevant to effective automation in other industries. Understanding these issues in health care can direct opportunities for the effective use of automation in health care. This article illustrates work system considerations using two example workflows; discusses how those considerations may inform solution design, implementation, and use; and provides future directions to advance the essential role of ergonomics in healthcare automation.

Patient portal interventions: a scoping review of functionality, automation used, and therapeutic elements of patient portal interventions

Objectives

We sought to understand the objectives, targeted populations, therapeutic elements, and delivery characteristics of patient portal interventions.

Materials and Methods

Following Arksey and O-Malley's methodological framework, we conducted a scoping review of manuscripts published through June 2022 by hand and systematically searching PubMed, PSYCHInfo, Embase, and Web of Science. The search yielded 5403 manuscripts; 248 were selected for full-text review; 81 met the eligibility criteria for examining outcomes of a patient portal intervention.

Results

The 81 articles described: trials involving comparison groups (n = 37; 45.7%), quality improvement initiatives (n = 15; 18.5%), pilot studies (n = 7; 8.6%), and single-arm studies (n = 22; 27.2%). Studies were conducted in primary care (n = 33, 40.7%), specialty outpatient (n = 24, 29.6%), or inpatient settings (n = 4, 4.9%)-or they were deployed system wide (n = 9, 11.1%). Interventions targeted specific health conditions (n = 35, 43.2%), promoted preventive services (n = 19, 23.5%), or addressed communication (n = 19, 23.4%); few specifically sought to improve the patient experience (n = 3, 3.7%). About half of the studies (n = 40, 49.4%) relied on human involvement, and about half involved personalized (vs exclusively standardized) elements (n = 42, 51.8%). Interventions commonly collected patient-reported information (n = 36, 44.4%), provided education (n = 35, 43.2%), or deployed preventive service reminders (n = 14, 17.3%).

Discussion

This scoping review finds that most patient portal interventions have delivered education or facilitated collection of patient-reported information. Few interventions have involved pragmatic designs or been deployed system wide.

Conclusion

The patient portal is an important tool in real-world efforts to more effectively support patients, but interventions to date rely largely on evidence from consented participants rather than pragmatically implemented systems-level initiatives.

Stratifying Risk of Nonadherence in Lingual Strengthening Dysphagia Rehabilitation

PURPOSE

Exercise-based treatments may improve swallowing safety and efficiency; yet, it is not clearly understood which factors predict nonadherence to recommended treatment protocols. The aim of this study was to construct an algorithm for stratifying risk of nonadherence to a lingual strengthening dysphagia treatment program.

METHOD

Using recursive partitioning, we created a classification tree built from a pool of sociodemographic, clinical, and functional status indicators to identify risk groups for nonadherence to an intensive lingual strengthening treatment program. Nonadherence, or noncompletion, was defined as not completing two or more follow-up sessions or a final session within 84 days.

RESULTS

The study cohort consisted of 243 Veterans enrolled in the Intensive Dysphagia Treatment program across six sites from January 2012 to August 2019. The overall rate of nonadherence in this cohort was 38%. The classification tree demonstrated good discriminate validity (C-statistic = 0.74) and contained eight groups from five variables: primary diagnosis, marital status, Penetration-Aspiration Scale (PAS) severity score, race/ethnicity, and age. Nonadherence risk was categorized as high (range: 69%-77%), intermediate (27%-33%), and low risk (≤ 13%-22%).

CONCLUSIONS

This study identified distinct risk groups for nonadherence to lingual strengthening dysphagia rehabilitation. Additional research is necessary to understand how these factors may drive nonadherence. With external validation and refinement through prospective studies, a clinically relevant risk stratification tool can be developed to identify patients who may be at high risk for nonadherence and provide targeted patient support to mitigate risk and provide for unmet needs.

Sociotechnical Work System Approach to Occupational Fatigue

INTRODUCTION TO THE PROBLEM

Occupational fatigue is a characteristic of excessive workload and depicts the limited capacity to complete demands. The impact of occupational fatigue has been studied outside of health care in fields such as transportation and heavy industry. Research in health care professionals such as physicians, medical residents, and nurses has demonstrated the potential for occupational fatigue to affect patient, employee, and organizational outcomes. A conceptual framework of occupational fatigue that is informed by a sociotechnical systems approach is needed to (1) describe the multidimensional facets of occupational fatigue, (2) explore individual and work system factors that may affect occupational fatigue, and (3) anticipate downstream implications of occupational fatigue on employee well-being, patient safety, and organizational outcomes.

CONCEPTUAL FRAMEWORK OF OCCUPATIONAL FATIGUE

The health care professional occupational fatigue conceptual framework is outlined following the Systems Engineering Initiative for Patient Safety (SEIPS) model and adapted from the Conceptual Model of Occupational Fatigue in Nursing. Future research may apply this conceptual framework to health care professionals as a tool to describe occupational fatigue, identify the causes, and generate solutions. Interventions to mitigate and resolve occupational fatigue must address the entire sociotechnical system, not just individual or employee changes.

Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising

BACKGROUND

Our aim was to understand actions by primary care teams to improve medication safety.

METHODS

This was a qualitative study using one-on-one, semistructured interviews with the questions guided by concepts from collaborative care and systems engineering models, and with references to the care of older adults. We interviewed 21 primary care physicians and their team members at four primary care sites serving patients with mostly low socioeconomic status in Southwest US during 2019-2020. We used thematic analysis with a combination of inductive and deductive coding. First, codes capturing safety actions were incrementally developed and revised iteratively by a team of multidisciplinary analysts using the inductive approach. Themes that emerged from the coded safety actions taken by primary care professionals to improve medication safety were then mapped to key principles from the high reliability organisation framework using a deductive approach.

RESULTS

Primary care teams described their actions in medication safety mainly in making standard-of-care medical decisions, patient-shared decision-making, educating patients and their caregivers, providing asynchronous care separate from office visits and providing clinical infrastructure. Most of the actions required customisation at the individual level, such as limiting the supply of certain medications prescribed and simplifying medication regimens in certain patients. Primary care teams enacted high reliability organisation principles by anticipating and mitigating risks and taking actions to build resilience in patient work systems. The primary care teams' actions reflected their safety organising efforts as responses to many other agents in multiple settings that they could not control nor easily coordinate.

CONCLUSIONS

Primary care teams take many actions to shape medication safety outcomes in community settings, and these actions demonstrated that primary care teams are a reservoir of resilience for medication safety in the overall healthcare system. To improve medication safety, primary care work systems require different strategies than those often used in more self-contained systems such as hospital inpatient or surgical services.

Healthcare leaders' and elected politicians' approach to support-systems and requirements for complying with quality and safety regulation in nursing homes - a case study

BACKGROUND

Healthcare leaders play an important and complex role in managing and handling the dual responsibility of both Health, Safety and Environment (HSE) for workers and quality and patient safety (QPS). There is a need for better understanding of how healthcare leaders and decision makers organize and create support structures to handle these combined responsibilities in practice. The aim of this study was to explore how healthcare leaders and elected politicians organize, control, and follow up the work of HSE and QPS in a Norwegian nursing home context. Moreover, we explore how they interpret, negotiate, and manage the dual responsibility and possible tensions between employee health and safety, and patient safety and quality of service delivery.

METHODS

The study was conducted in 2022 as a case study exploring the experience of healthcare leaders and elected politicians in five municipalities responsible for providing nursing homes services in Norway. Elected politicians (18) and healthcare leaders (11) participated in focus group interviews (5) and individual interviews (11). Data were analyzed using inductive thematic analysis.

RESULTS

The analysis identified five main themes explaining how the healthcare leaders and elected politicians organize, control, and follow up the work of HSE and QPS: 1. Establish frameworks and room for maneuver in the work with HSE and QPS. 2. Create good routines and channels for communication and collaboration. 3. Build a culture for a health-promoting work environment and patient safety. 4. Create systems to handle the possible tensions in the dual responsibility between caring for employees and quality and safety in service delivery. 5. Define clear boundaries in responsibility between politics and administration.

CONCLUSIONS

The study showed that healthcare leaders and elected politicians who are responsible for ensuring sound systems for quality and safety for both patients and staff, do experience tensions in handling this dual responsibility. They acknowledge the need to create systems and awareness for the responsibility and argue that there is a need to better separate the roles and boundaries between elected politicians and the healthcare administration in the execution of HSE and QPS.

Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis

BACKGROUND

Accurate and timely diagnosis relies on sharing perspectives among team members and avoiding information asymmetries. Patients/Families hold unique diagnostic process (DxP) information, including knowledge of diagnostic safety blindspots-information that patients/families know, but may be invisible to clinicians. To improve information sharing, we co-developed with patients/families an online tool called 'Our Diagnosis (OurDX)'. We aimed to characterise patient/family contributions in OurDX and how they differed between individuals with and without diagnostic concerns.

METHOD

We implemented OurDX in two academic organisations serving patients/families living with chronic conditions in three subspecialty clinics and one primary care clinic. Prior to each visit, patients/families were invited to contribute visit priorities, recent histories and potential diagnostic concerns. Responses were available in the electronic health record and could be incorporated by clinicians into visit notes. We randomly sampled OurDX reports with and without diagnostic concerns for chart review and used inductive and deductive qualitative analysis to assess patient/family contributions.

RESULTS

7075 (39%) OurDX reports were submitted at 18 129 paediatric subspecialty clinic visits and 460 (65%) reports were submitted among 706 eligible adult primary care visits. Qualitative analysis of OurDX reports in the chart review sample (n=450) revealed that participants contributed DxP information across 10 categories, most commonly: clinical symptoms/medical history (82%), tests/referrals (54%) and diagnosis/next steps (51%). Participants with diagnostic concerns were more likely to contribute information on DxP risks including access barriers, recent visits for the same problem, problems with tests/referrals or care coordination and communication breakdowns, some of which may represent diagnostic blindspots.

CONCLUSION

Partnering with patients and families living with chronic conditions through OurDX may help clinicians gain a broader perspective of the DxP, including unique information to coproduce diagnostic safety.

What is best for Esther? A simple question that moves mindsets and improves care

BACKGROUND

Persons in need of services from different care providers in the health and welfare system often struggle when navigating between them. Connecting and coordinating different health and welfare providers is a common challenge for all involved. This study presents a long-term regional empirical example from Sweden-ESTHER, which has lasted for more than two decades-to show how some of those challenges could be met. The purpose of the study was to increase the understanding of how several care providers together could succeed in improving care by transforming a concept into daily practice, thus contributing with practical implications for other health and welfare contexts.

METHODS

The study is a retrospective longitudinal case study with a qualitative mixed-methods approach. Individual interviews and focus groups were performed with staff members and persons in need of care, and document analyses were conducted. The data covers experiences from 1995 to 2020, analyzed using an open inductive thematic analysis.

RESULTS

This study shows how co-production and person-centeredness could improve care for persons with multiple care needs involving more than one care provider through a well-established Quality Improvement strategy. Perseverance from a project to a mindset was shaped by promoting systems thinking in daily work and embracing the psychology of change during multidisciplinary, boundary-spanning improvement dialogues. Important areas were Incentives, Work in practice, and Integration, expressed through trust in frontline staff, simple rules, and continuous support from senior managers. A continuous learning approach including the development of local improvement coaches and co-production of care consolidated the integration in daily work.

CONCLUSIONS

The development was facilitated by a simple question: "What is best for Esther?" This question unified people, flattened the hierarchy, and reminded all care providers why they needed to improve together. Continuously focusing on and co-producing with the person in need of care strengthened the concept. Important was engaging the people who know the most-frontline staff and persons in need of care-in combination with permissive leadership and embracing quality improvement dimensions. Those insights can be useful in other health and welfare settings wanting to improve care involving several care providers.

Effectiveness of an Emergency Department-Based Machine Learning Clinical Decision Support Tool to Prevent Outpatient Falls Among Older Adults: Protocol for a Quasi-Experimental Study

BACKGROUND

Emergency department (ED) providers are important collaborators in preventing falls for older adults because they are often the first health care providers to see a patient after a fall and because at-home falls are often preceded by previous ED visits. Previous work has shown that ED referrals to falls interventions can reduce the risk of an at-home fall by 38%. Screening patients at risk for a fall can be time-consuming and difficult to implement in the ED setting. Machine learning (ML) and clinical decision support (CDS) offer the potential of automating the screening process. However, it remains unclear whether automation of screening and referrals can reduce the risk of future falls among older patients.

OBJECTIVE

The goal of this paper is to describe a research protocol for evaluating the effectiveness of an automated screening and referral intervention. These findings will inform ongoing discussions about the use of ML and artificial intelligence to augment medical decision-making.

METHODS

To assess the effectiveness of our program for patients receiving the falls risk intervention, our primary analysis will be to obtain referral completion rates at 3 different EDs. We will use a quasi-experimental design known as a sharp regression discontinuity with regard to intent-to-treat, since the intervention is administered to patients whose risk score falls above a threshold. A conditional logistic regression model will be built to describe 6-month fall risk at each site as a function of the intervention, patient demographics, and risk score. The odds ratio of a return visit for a fall and the 95% CI will be estimated by comparing those identified as high risk by the ML-based CDS (ML-CDS) and those who were not but had a similar risk profile.

RESULTS

The ML-CDS tool under study has been implemented at 2 of the 3 EDs in our study. As of April 2023, a total of 1326 patient encounters have been flagged for providers, and 339 unique patients have been referred to the mobility and falls clinic. To date, 15% (45/339) of patients have scheduled an appointment with the clinic.

CONCLUSIONS

This study seeks to quantify the impact of an ML-CDS intervention on patient behavior and outcomes. Our end-to-end data set allows for a more meaningful analysis of patient outcomes than other studies focused on interim outcomes, and our multisite implementation plan will demonstrate applicability to a broad population and the possibility to adapt the intervention to other EDs and achieve similar results. Our statistical methodology, regression discontinuity design, allows for causal inference from observational data and a staggered implementation strategy allows for the identification of secular trends that could affect causal associations and allow mitigation as necessary.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05810064; https://www.clinicaltrials.gov/study/NCT05810064.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48128.

The Role of Human and Organizational Factors in the Pursuit of One Digital Health

OBJECTIVE

This paper surveys a subset of the 2022 human and organizational factor (HOF) literature to provide guidance on building a One Digital Health ecosystem.

METHODS

We searched a subset of journals in PubMed/Medline for studies with "human factors" or "organization" in the title or abstract. Papers published in 2022 were eligible for inclusion in the survey. Selected papers were categorized into structural and behavioural aspects to understand digital health enabled interactions across micro, meso, and macro systems.

RESULTS

Our survey of the 2022 HOF literature showed that while we continue to make meaningful progress at digital health enabled interactions across systems levels, there are still challenges that must be overcome. For example, we must continue to grow the breadth of HOF research beyond individual users and systems to assist with the scale up of digital health systems across and beyond organizations. We summarize the findings by providing five HOF considerations to help build a One Digital Health ecosystem.

CONCLUSION

One Digital Health challenges us to improve coordination, communication, and collaboration between the health, environmental and veterinary sectors. Doing so requires us to develop both the structural and behavioural capacity of digital health systems at the organizational level and beyond so that we can develop more robust and integrated systems across health, environmental and veterinary sectors. The HOF community has much to offer and must play a leading role in designing a One Digital Health ecosystem.