Transcript Operating Room of the Future

Medicine
Human
Factors
Technology
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Course Objectives
1. Review concepts and theories of
coordination in literature
2. Characterize problems and issues of
coordination and workflow in healthcare
3. Review of case studies in healthcare
2009 © Xiao, UM
Medicine
Human
Factors
Technology
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Yan Xiao, PhD
Professor of Anesthesiology
Director, Research in Patient Safety
University of Maryland School of Medicine
Baltimore, Maryland, USA
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Medicine
Human
Factors
Challenges of Coordination in Healthcare
Technology
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2000
1800
1600
1400
1200
1000
800
Nursing home care
Prescription drugs
Physician and
clinical services
Hospital Care
$2.1 Trillion
$7,026/person
16% of Gross
Domestic
Product (GDP)
600
400
200
0
2009 © Xiao, UM
2006 National
Health Spending:
1960 1970 1980 1990 2000 2005 2010*
Medicine
Human
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Technology
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Coordination in Healthcare:
How it matters
• #1 priority for research: "Lack of
communication and coordination (including
coordination across organisations and
discontinuity)" (British Medical Journal 2009)
• Poor coordination results in:
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• Low quality and efficiency
• Errors in medication and treatment
• Conflicting information
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Coordination and mortality
• Medicare mortality lower among hospitals
known for good nursing care - particularly
the ability to coordinate across units
Source: Aiken, Sochalski, and Lake,
Medical Care, 1997.
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Coordination and Quality
• National Study of 42 Intensive Care Units
• Nursing leadership, ability to manage
conflict, and better care coordination
positively associated with lower riskadjusted length of stay, lower nurse
turnover, better evaluated technical quality
of care and ability to meet family member
needs.
Shortell, Zimmerman and Rousseau et al. Medical Care, 1994.
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Human
Factors
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Coordination and surgical
outcomes
Technology
• A study of 3,000 CABG patients in 16
hospitals
• A group-oriented, collaborative,
participative culture was significantly
associated with higher patient physical and
mental functional health status scores six
months post-discharge and shorter postoperative intubation times.
Shortell, Jones, Rademaker, and Gillies et al. 2000.
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Technology
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Coordination and quality
• In a nine hospital study of patients with
total hip and total knee replacement,
relational coordination was significantly
associated with less post-operative pain,
greater post-operative functioning, and
shorter length of stay.
Source: J. Gittel, K. Fairfield, and B. Bierbaum, et al.
“Impact of Relational Coordination on Quality of Care,
Post-Operative Pain and Functioning and
Length of Stay,” Medical Care, 2000, 38(3):807-819.
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Medicine
Human
Factors
Technology
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Coordination in Healthcare
How it matters
• Highly inter-dependent activities
– Care is usually provided by
• multiple care providers
• over time
• at distributed locations
– Care needs are episodic and unpredictable
– Highly variable patient needs
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Human
Factors
Technology
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What Does Coordination Mean?
(or Not*)
•
Have what is need
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Have the correct information
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•
“Final printed posting was changed from the correct original posting. Change did not reflect the
correct surgery. All supplies and instrument trays were wrong.”
Case delayed 40 min.
Have the “left hand” to know what the “right hand” is doing
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“Medical record missing information had to wait for info to complete both surgical &
anesthesia consent.”
Case delayed 35 min.
“Both Dr L and Dr R were scheduled for case.
Dr L thought Dr R was to start and
Dr R thought Dr. L would start.
Dr L was scheduled for another 1st case, when contacted he stated
he was the consult on the case.”
Case delayed 1 hr 45 min.
Have the most current information
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–
“OR front desk did not know pt was on 10 W.”
Case delayed 15 min.
*Reports courtesy of Kate Bott and Mike Harrington
Medicine
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Technology
Trajectories
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• Phenomenon definition: multiple people
working on multiple “projects”, over long
span of time and distances
• Problem definition: how people manage
CRNA
TRU
different trajectories
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OR 1
Surg 1
ICU
OR 2
Nurse 1
Nurse 2
Surg 2
PACU
Anesth
(Lecture )
Time
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Examples of Trajectories
• Care activities for a surgical patient
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Patient admission
Preparation of documents, supplies, personnel
Start and end of surgery
Post anesthesia care and intensive care
Recovery and rehabilitation
Discharge
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Coordination in Healthcare
What it is: Trajectory” of Patient Care
Diagnosis (MRI, CT, ETC)
Admission
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Primary
Team
Surgery
Consulting physicians
Stabilization
O.T., P.T.
Assessment
+
Disposition
Discharge
Social worker
Transporter
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Patient with Traumatic Brain Injury
Discharge:
Specialized care (TBI rehab)
Or transfer to Stepdown unit
Stabilization:
Treatment:
Vent weaning
ICP management
Orthopedic
Surgery
Admission
Diagnosis:
Treatment: IVC or
X-ray/CT/FAST
Neurosurgery
Trauma Admitting Unit
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9/28/2007 - 10/5/2007
Preparation
For DC
ICU
Step Down
OT/PT
Neurosurgery
Primary Team
Orthopedic Surgery
Discharge:
Specialized care
(TBI rehab)
Case Manager
Social Work
Transporter
Fnancial Advisor
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Factors
Technology
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Coordination in Healthcare
What it is: the example of car crashes
• Time 0: two cars collided
• Landmark 1: Emergency medical services system
activated
• Landmark 2: Patients extricated and placed on
ambulances
• Landmark 3: Patients arrived at trauma center
• Landmark 4: Patients received definitive surgical
care
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Medicine
Human
Factors
Coordination saves lives
Technology
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Field
Notification
Board
Command center
Hotline
Trauma
Resuscitation
Unit
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Landing pad
Operating
room
Coordination challenges
in emergency medical
services (EMS)
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Factors
Technology
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Coordination in Healthcare
What it is: A broad definition
• Objects of coordination: what to coordinate
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Information
Mental models
Expectations
Expertise
Authorities
Relations
Tasks
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Human
Factors
Technology
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Coordination in Healthcare
What it is: A broad definition
• Means of coordination: how to coordinate
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Explicit versus implicit
Low versus high bandwidth
Routine versus mutual adjustment mechanisms
Spontaneous versus reactive
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Summary
• Coordination is a key challenge for
healthcare, because of
– Variations
– Uncertainties
– Distribution
• The objects of coordination include tasks,
information, authorities, expectations
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Medicine
Human
Factors
Technology
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2009 © Xiao, UM
Medicine
Human
Factors
Technology
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University of Maryland Medical Center
and Shock Trauma Center
• 32 operating rooms, 6
dedicated to trauma
• 10 trauma bays
• 7000 annual trauma
patient admissions
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Medicine
Human
Factors
Technology
Studies of Coordination
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at University of Maryland
• Healthcare context for coordination studies
– Trauma resuscitation: Action teams
– Operating rooms: Operations management of surgical
services
– Intensive care units: transfers of information and
responsibilities
• Perspectives of understanding coordination
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Social system of relations and conflicts
CSCW system of computing and cognition
Economic system of efficiency
Workflow system of activity and materials
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Technology
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Coordination Studies: Experience at
University of Maryland
• Coordination in high intensity team (HIT)
situation
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– Adaptive team structures (Xiao 2005)
– Dynamic delegation and leadership (Klein
2006)
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Coordination Studies: Experience at
University of Maryland
• Orchestrating information flow in ICU
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– Structures of rounding communication
(Cardarelli in press)
– Preparing for team meetings (Cervenka in
revision)
– Reaching and communicating goals in team
meetings (“rounds”) (Xiao in review)
– Information arena model of team
communication
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Technology
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Coordination Studies: Experience at
University of Maryland
• Managing workflow in operating suites
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– Communication burden of coordinators (Moss
2004)
– Distributed coordination through OR video
(Xiao 2005)
– Acceptance and usage of OR video (Xiao 2007)
– Visual versus table display of procedural
duration uncertainty (Dexter, Ho 2008)
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Technology
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Coordination Studies: Experience at
University of Maryland
• Exception handling in trauma patient care
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– Discharge rounds (Sen 2008)
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Technology
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Summary
• Healthcare is a fertile domain to develop
theories and concepts of coordination
• Different types of coordination problems
facing care providers in different contexts
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Medicine
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