Transcript Transitions of care: Handoffs

Participatory user-centered design
approach to tool/checklist
development
Mahiyar Nasarwanji PhD, Ayse P. Gurses PhD, Anping Xie, PhD
Armstrong Institute for Patient Quality and Safety
Goals
• Use a participatory approach to
– Improve (handoff) communication
– Consider information needs of all players
– Develop a shared standardized form
• Develop your own tool/checklist
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Toolkit
• New material
– User centered design approach to tool /
checklist development
– Assessment of Care Transitions (ACT)
Today
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• Reinforcement
– Teamwork across unit tool
– Barrier identification and mitigation tool
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• Currently implemented
– Transitions of care survey
– Part of HSPOS
– Relational Coordination
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Systems Engineering Initiative for
Patient Safety (SEIPS) Model
Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System
Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006.
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Participatory Ergonomics (PE)
• Key characteristics
Ergonomics
• Involvement of
end users
• Use of Human
Factors and
Ergonomics
(HFE) Principles
Participatory
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Participatory Ergonomics
• Dimensions
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–
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Permanence: Temporary, ongoing
Involvement: Representative, direct
Level of influence: Unit, department, hospital
Decision-making: Consensus, consultation, delegation
Mix of participants: providers, management,
(patients/families)
– Requirement to participate: Voluntary, compulsory
• Role of human factors and ergonomics specialist
– Initiates process
– Trains participants
– Available as consultant / guide
Wilson, 1995; Haines et al., 2002
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Good Checklist Design
• Should include all stakeholders and experts
• Content of checklist
– Number of items
– Categories and sequence of items
• Format of checklist
– Readability, use of color, length, jargon
• Checklist should fit workflow
• Clear roles of people involved, including leader
Winters BD, Gurses AP, Lehmann H, Sexton JB, Rampersad CJ, Pronovost PJ. (2009)
Clinical review: checklists - translating evidence into practice. Crit Care. 13(6):210
Degani & Wiener, 1993; Evans & Dodge, 2010; Hales et al., 2008; Herring et al., 2011; Winters et al.,
2010; World Alliance for Patient Safety, 2008
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Good Checklist Implementation
• Pilot test to assess usability
– Get feedback to revise
• Appropriate training before implementation
• Local champions and rapport building
• Continuous evaluation and improvement
Evans & Dodge, 2010; Hales et al., 2008; Lingard et al., 2005; Lingard et al., 2008;
Mahajan, 2011; Thomassen et al., 2011; Vats et al., 2010; Winters et al., 2010
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Challenges with Checklist
• The checklist may disrupt workflow
• Clinicians used to working independently
• Skepticism from clinicians
• Lack of familiarity with checklists
• Checklist may be filled out incompletely or dismissively
• The checklist may divert attention away from the patient
Lingard et al., 2005; Lingard et al., 2008; Mahajan, 2011; Thomassen et al., 2011; Vats et
al., 2010
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Participatory user centered design
approach to tool / checklist development
Identify needs
Finalize design
Identify
requirements
Iterative testing
Need analysis
Design
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Identify
needs
Identify needs
Finalize
design
Identify
requirement
s
Iterative
testing
Need
analysis
Design
• Define overall goals
– What is the goal of the tool / checklist?
– Is the tool / checklist really needed?
• Implementation support
– What is needed to support the successful implementation of
the tool?
• Identify all players their roles and responsibilities
• Develop the teams
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Identify
needs
Identify Requirements
Finalize
design
Identify
requirement
s
Iterative
testing
Need
analysis
Design
• Define the context or situation of use
– When? Where? How? Who? What? Why?
– Consider how the tool / checklist will influence work
– Proactively identify potential negative consequences
• Benchmark
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Provider information
Patient information
Plan of care
Discussion and
questions
Successful transfer of
information
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Clear leadership
Good
communication
Team involvement
Avoid interruptions
Discussion and
questions
With the aid of
checklists, tools and
technology
Dedicated time
Sufficient length
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•
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Close to work area
Large enough space
Free from
distractions
Access to required
information and
technology
Why?
What?
•
•
•
•
When?
Handoffs
How?
Where?
•
Who?
•
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Key personnel / players
Active involvement of
senior physicians
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Adapted from: AMA Clinical Handover Guide - Safe Handover: Safe Patients: https://ama.com.au/ama-clinical-handover-guide-safe-handover-safe-patients
Identify
needs
Identify Requirements
Finalize
design
Identify
requirement
s
Iterative
testing
Need
analysis
Design
• Define the context or situation of use
– When? Where? How? Who? What? Why?
– Consider how the tool / checklist will influence work
– Proactively identify potential negative consequences
• Benchmark
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Identify
needs
Need Analysis
Finalize
design
Identify
requirement
s
Iterative
testing
Need
analysis
Design
• Define needs of all users
• Prioritize needs
• List all constraints of use and
hazards
• Refine and summarize needs
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Identify
needs
Design
Finalize
design
Identify
requirement
s
Iterative
testing
Need
analysis
Design
• Layout and format the tool
– Can model based on pre-existing formats
– Use human factors principles to
• Cluster related information together
• Highlight key pieces of information
• Order information using common or standard
conventions (head to toe assessment)
• Use appropriate terms that are universally
understood, clear and not easily mistaken
• Develop a prototype of the tool / checklist
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Pre-existing formats to help
organize information
Name
Description
SBAR
Situation, Background, assessment, recommendation
ISBARQ
Introductions, Situation, Background, assessment, recommendation, questions
I PASS the
BATON
Introduction, Patient, Assessment, Situation, Safety concerns, Background, actions, timing,
ownership, next steps
SHARQ
Situation, history, assessment, recommendations/results, questions
ANTIcipate
Administration info, New clinical info, Tasks to be performed, Illness severity and assessment,
contingency plans of anticipated problems
BSAP
Background, Situation, Assessment, Plan of care, problems, Precautions, Pain
SEAM
Summary, every active problem, management,
SHARED
Situation, history, assessment, request, evaluate, document
DRAW
Diagnosis, recent changes, anticipated changes, what to watch for in the next interval of care
Joint Commission (2007). Improving hand-off communication
Follow up care
needs and
Follow up care
recommendations
needs and
interventions
Recommendation
s for continuation
of care
To do list
Actions
What part can
you play during
the next shift?
Plan of care
Goals to be
achieved
What is pending?
What happened
next
Alerts for
incoming
information and
actions if any
Prioritization of
actions
Future treatments
for patient
Rationale for care
plan
Here is why
Next steps in the
next 2 hours
Daily goals and
shift goals
Discharge plan
Continuing needs
Explicit timing
Timeline
Time frame
Pending lab
results
Pending labs and
their implications
Short term results
to look out for
Labs to check on
and what to do
about them
Long term results
to look out for
What did and
didn’t work
Oxygen and
weaning
instructions
Diet and weaning
orders
Tests to order or
follow up on
Set parameters
for when, how
and by who
provider should
be contacted
Nothing by
mouth
Clinical findings
supporting plan
of care
Relate current
health status and
issues to
patient’s
progress
Patient safety
issues
Any contingency
plans
Fall precautions
What may go
wrong and what
to do about it
Any anticipated
changes in
condition of care
Frequent issues
to be expected
with a plan to
resolve them
Recent and
anticipated
changes in
condition
What would you
do to correct the
problem
What you should
keep an eye on
Know what is
going on and
plan for what
might happen
next
Isolation
Specialty bed
What is expected
to be different
Prepare cross
coverage
See something I
did not
Specify using if
then statements
Nasarwanji et al 2013 Working
paper
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Identify
needs
Design
Finalize
design
Identify
requirement
s
Iterative
testing
Need
analysis
Design
• Layout and format the tool
– Can model based on pre-existing formats
– Use human factors principles to
• Cluster related information together
• Highlight key pieces of information
• Order information using common or standard
conventions (head to toe assessment)
• Use appropriate terms that are universally
understood, clear and not easily mistaken
• Develop a prototype of the tool / checklist
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Identify
needs
Iterative testing
Finalize
design
Identify
requirement
s
Iterative
testing
Need
analysis
Design
• Pilot test the tool
–
–
–
–
Use the tool as part of simulated training
Evaluate effectiveness
Evaluate Use
Summarize results of the test
• Re-design, refine and improve the tool based
on input from the pilot testing
• Re-evaluate the usability of the tool iteratively
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Identify
needs
Finalize tool
Finalize
design
Identify
requirement
s
Iterative
testing
Need
analysis
Design
• After iterative usability testing and refinement finalize
the tool
• Implement the tool in a real world setting
• Collect feedback from users on tool
• Continual improvement and refinement of the tool
based on input from users
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Participatory user centered design
approach to tool / checklist development
Identify needs
Finalize design
Identify
requirements
Iterative testing
Need analysis
Design
22
Lessons learned
• Participatory ergonomics
• Good checklist deign
• User centered design approach to tool /
checklist development
– Improves handoff communication
– Considers the information needs of all
players
– A shared standardized form
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Your handoff checklist …
• Let us see your
handoff tool /
checklist
• Tell us how you
designed your
checklist
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Thank you!
Mahiyar Nasarwanji, Ph.D.
[email protected]
Ayse Gurses, Ph.D.
[email protected]
Anping Xie, PhD
[email protected]
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