Interprofessional communication with hospitalist and consultant physicians in general internal medicine : a qualitative study

This study helps to improve our understanding of the collaborative environment in GIM, comparing the communication styles and strategies of hospitalist and consultant physicians, as well as the experiences of providers working with them. The implications of this research are globally important for understanding how to create opportunities for physicians and their colleagues to meaningfully and consistently participate in interprofessional communication which has been shown to improve patient, provider, and organizational outcomes

Customising doctor-nurse communications

Doctor-Nurse communications are critical for patient safety and workflow effectiveness. Our research question was: What further improvements can be made to current communication systems? A variety of mobile and land based communication systems have been used and experimented with. In the study, the pager was found to be most common and more recent attempts to provide broadband capability with systems such as the iBeep. We built an alternative information system using Android phones and a software application that was customised by feedback from the medical professionals. The trial in five wards with 22 doctors and 170 nurses over one month showed marked improvement in the end users’ perception of technologies to help their work. Customising the Doctor-Nurse communication channel with role based communication applications, smart phone capabilities enhanced the efficiency, safety, and effectiveness of a time challenged work force. Nurses found they could provide more information and that it was easier to portray how unwell a patient is. Doctors found they were better able to prioritise their time and that urgent tasks were more apparent for immediate action. Each effect had beneficial work impact

Pharmacist-Physician Communications in a Highly Computerised Hospital:Sign-Off and Action of Electronic Review Messages

<div><p>Background</p><p>Some hospital Computerized Physician Order Entry (CPOE) systems support interprofessional communication. The aim of this study was to investigate the effectiveness of pharmacist-physician messages sent via a CPOE system.</p><p>Method</p><p>Data from the year 2012 were captured from a large university teaching hospital CPOE database on: 1) review messages assigned by pharmacists; 2) details of the prescription on which the messages were assigned; and 3) details of any changes made to the prescription following a review message being assigned. Data were coded for temporal, message and prescription factors. Messages were analysed to investigate: 1) whether they were signed-off; and 2) the time taken. Messages that requested a measurable action were further analysed to investigate: 1) whether they were actioned as requested; and 2) the time taken. We conducted a multivariable analysis using Generalised Estimating Equations (GEE) to account for the effects of multiple factors simultaneously, and to adjust for any potential correlation between outcomes for repeated review messages on the same prescription. All analyses were performed using SPSS 22 (IBM SPSS Inc., Chicago, IL, USA), with p<0.05 considered significant.</p><p>Results</p><p>Pharmacists assigned 36,245 review messages to prescriptions over the 12 months, 34,506 of which were coded for analysis after exclusions. Nearly half of messages (46.6%) were signed-off and 65.5% of these were signed-off in ≤ 48 hours. Of the 9,991 further analysed for action, 35.8% led to an action as requested by the pharmacist and just over half of these (57.0%) were actioned in ≤ 24 hours. Factors predictive of an action were the time since the prescription was generated (p<0.001), pharmacist grade (p<0.001), presence of a high-risk medicine (p<0.001), messages relating to reconciliation (p = 0.004), theme of communication (p<0.001), speciality, (p<0.001), category of medicine (p<0.001), and regularity of the prescription (p<0.001).</p><p>Conclusion</p><p>In this study we observed a lower rate of sign-off and action than we might have expected, suggesting uni-directional communication via the CPOE system may not be optimal. An established pharmacist-physician collaborative working relationship is likely to influence the prioritisation and response to messages, since a more desirable outcome was observed in settings and with grades of pharmacists where this was more likely. Designing systems that can facilitate collaborative communication may be more effective in practice.</p></div

TURF for Teams: Considering Both the Team and I in the Work-Centered Design of Systems

Teams are an inherent part of many work domains, especially in the healthcare environment. Yet, most systems are often built with only the individual user in mind. How can we better incorporate the team, as a user, into the design of a system? By better understanding the team, through their user, task, representational, and functional needs, we can create more useful and helpful systems that match their work domain. For this research project, we utilize the TURF framework and expanded it further by also considering teams as a user, thus, creating the TURF for Teams framework. In addition, we chose to examine teams in the emergency department environment. We believe that designing a system with the team also fully incorporated and acknowledged in the work domain will be beneficial for supporting necessary team activities. Using TURF for Teams, we first conducted an observational field study in the emergency department to get a better understanding of the users, teams, tasks, workload, and interactions. We then identified the need for team communications to be better supported, especially in the management of interruptions, and further categorized the interruptions by their function in order to design a team tool that could help team members better manage their interruptions by focusing on the necessary, or domain, types of interruptions and more easily disregarding the unnecessary, or overhead, types of interruptions. We then administered some surveys and conducted a card sort and cognitive walkthrough with emergency clinician participants to help us better identify how to design interfaces for the team tool and simulation that would better match the needs of team communication behaviors observed and reported by emergency clinicians. After designing and developing the team tool and simulation, we conducted an evaluation of this system by having emergency medicine, medicine, and informatics graduate student teams go through the system and utilize the team tool and simulation as a team. Though we had a small sample size, we found that emergency medicine teams found the team tool and simulation to be very usable and they reacted favorably to its potential in helping them better understand and manage their team communications. In summary, we were able to utilize the TURF framework for incorporating teams into the design of systems, in this case a team communication tool and microworld simulation for the emergency department. Our findings suggest that TURF for Teams is a viable framework for designing useful and helpful team based systems for all work domains

Communication in Healthcare: Opportunities for information technology and concerns for patient safety

Understanding healthcare workflow is fundamental for design and implementation of information systems. Communication and information exchange between healthcare professionals plays a pivotal role in developing smooth workflow within and between healthcare organizations. The study in this thesis analyzes the interaction between Information Technology (IT) and the medication process within and between healthcare organizations. The focus is on the interactions that lead to communication problems and as a result lead to unintended negative consequences on patient safety. The thesis examines several cases of IT intervention to improve intra- and inter-organizational communication. It raises important implications on how to design and implement IT systems that support healthcare processes without jeopardizing patient safety. The author concludes for IT to improve healthcare communication and patient safety, at intra-organizational level, it has to support the highly integrated nature of the shared healthcare work. At inter-organizational level the main challenge is that different pieces of the shared work are not sufficiently integrated

NURSING INTERRUPTION DYNAMICS: THE IMPACT OF WORK SYSTEM FACTORS

Interruptions occur frequently in healthcare work systems. Hands-free Communication Devices (HCDs) were implemented in healthcare work systems to support the interruption process. However, from a sociotechnical systems perspective, HCDs may introduce new complications and unintended consequences to the work system. Research gaps exist in investigating the complexity of HCD interruptions in the real-world context. This dissertation aims to understand HCD interruption dynamics in the nursing work systems, using qualitative research methods. The first study examined the major differences between face-to-face and HCD-mediated interruptions, based on 30 hours of field observations in the acute care setting. Three major differences included: (1) The available cues to understand interruptee’s interruptibility, (2) The delivery of interruption content, and (3) The options to manage interruptions. The results uncovered facilitators and barriers that appeared to influence nursing work in the interruption process. The second study explored HCD interruption dynamics in more depth. It examined which system factors impact the interruption dynamics and how they influence nurses’ decisions and performance regarding the use of HCDs, based on 15 hours of field observations and 15 in-depth interviews with registered nurses in the pediatric intensive care units. This study was framed by the meso-ergonomics paradigm and activity theory. A descriptive model of HCD interruption dynamics was developed, comprising of five proximal system factors, 17 indicator and moderator system factors, and four distal system factors. These system factors interact and create integrated causal chains to impact interruption dynamics and influence the nurses’ decisions and performance regarding the use of HCDs. Specifically, the proximal system factors immediately impact interruption dynamics, the indicator or moderator system factors provide partial inputs and contextual circumstances of the proximal system factors, and the distal system factors are further down the causal chain. The results of the dissertation provided the basis for improving the design of interruption-mediating tools as well as the nursing work system, to better support the HCD-mediated interruption process, which may ultimately enhance the quality and safety of healthcare work systems

UNDERSTANDING INTERRUPTIONS IN HEALTHCARE: DEVELOPING A MODEL

Developing a Model Interruption is a known human factor that contributes to errors and catastrophic events in healthcare as well as other high-risk industries. The landmark Institute of Medicine (IOM) report, To Err is Human, brought attention to the significance of preventable errors in medicine and suggested that interruptions could be a contributing factor. Previous studies of interruptions in healthcare did not offer a conceptual model by which to study interruptions. As a result of the serious consequences of interruptions investigated in other high-risk industries, there is a need to develop a model to describe, understand, explain, and predict interruptions and their consequences in healthcare. Therefore, the purpose of this study was to develop a model grounded in the literature and to use the model to describe and explain interruptions in healthcare. Specifically, this model would be used to describe and explain interruptions occurring in a Level One Trauma Center. A trauma center was chosen because this environment is characterized as intense, unpredictable, and interrupt-driven. The first step in developing the model began with a review of the literature which revealed that the concept interruption did not have a consistent definition in either the healthcare or non-healthcare literature. Walker and Avant’s method of concept analysis was used to clarify and define the concept. The analysis led to the identification of five defining attributes which include (1) a human experience, (2) an intrusion of a secondary, unplanned, and unexpected task, (3) discontinuity, (4) externally or internally initiated, and (5) situated within a context. However, before an interruption could commence, five conditions known as antecedents must occur. For an interruption to take place (1) an intent to interrupt is formed by the initiator, (2) a physical signal must pass a threshold test of detection by the recipient, (3) the sensory system of the recipient is stimulated to respond to the initiator, (4) an interruption task is presented to recipient, and (5) the interruption task is either accepted or rejected by v the recipient. An interruption was determined to be quantifiable by (1) the frequency of occurrence of an interruption, (2) the number of times the primary task has been suspended to perform an interrupting task, (3) the length of time the primary task has been suspended, and (4) the frequency of returning to the primary task or not returning to the primary task. As a result of the concept analysis, a definition of an interruption was derived from the literature. An interruption is defined as a break in the performance of a human activity initiated internal or external to the recipient and occurring within the context of a setting or location. This break results in the suspension of the initial task by initiating the performance of an unplanned task with the assumption that the initial task will be resumed. The definition is inclusive of all the defining attributes of an interruption. This is a standard definition that can be used by the healthcare industry. From the definition, a visual model of an interruption was developed. The model was used to describe and explain the interruptions recorded for an instrumental case study of physicians and registered nurses (RNs) working in a Level One Trauma Center. Five physicians were observed for a total of 29 hours, 31 minutes. Eight registered nurses were observed for a total of 40 hours 9 minutes. Observations were made on either the 0700–1500 or the 1500-2300 shift using the shadowing technique. Observations were recorded in the field note format. The field notes were analyzed by a hybrid method of categorizing activities and interruptions. The method was developed by using both a deductive a priori classification framework and by the inductive process utilizing line-byline coding and constant comparison as stated in Grounded Theory. The following categories were identified as relative to this study: Intended Recipient - the person to be interrupted Unintended Recipient - not the intended recipient of an interruption; i.e., receiving a phone call that was incorrectly dialed Indirect Recipient – the incidental recipient of an interruption; i.e., talking with another, thereby suspending the original activity Recipient Blocked – the intended recipient does not accept the interruption Recipient Delayed – the intended recipient postpones an interruption Self-interruption – a person, independent of another person, suspends one activity to perform another; i.e., while walking, stops abruptly and talks to another person Distraction – briefly disengaging from a task Organizational Design – the physical layout of the workspace that causes a disruption in workflow Artifacts Not Available – supplies and equipment that are not available in the workspace causing a disruption in workflow Initiator – a person who initiates an interruption Interruption by Organizational Design and Artifacts Not Available were identified as two new categories of interruption. These categories had not previously been cited in the literature. Analysis of the observations indicated that physicians were found to perform slightly fewer activities per hour when compared to RNs. This variance may be attributed to differing roles and responsibilities. Physicians were found to have more activities interrupted when compared to RNs. However, RNs experienced more interruptions per hour. Other people were determined to be the most commonly used medium through which to deliver an interruption. Additional mediums used to deliver an interruption vii included the telephone, pager, and one’s self. Both physicians and RNs were observed to resume an original interrupted activity more often than not. In most interruptions, both physicians and RNs performed only one or two interrupting activities before returning to the original interrupted activity. In conclusion the model was found to explain all interruptions observed during the study. However, the model will require an even more comprehensive study in order to establish its predictive value

Mediating ICU patient situation-awareness with visual and tactile notifications

Indiana University-Purdue University Indianapolis (IUPUI)Healthcare providers in hospital intensive care units (ICUs) maintain patient situation awareness by following task management and communication practices. They create and manipulate several paper-based and digital information sources, with the overall aim to constantly inform themselves and their colleagues of dynamically evolving patient conditions. However, when increased communication means that healthcare providers potentially interrupt each other, enhanced patient-situation awareness comes at a price. Prior research discusses both the use of technology to support increased communication and its unintended consequence of (wanted and unwanted) notification interruptions. Using qualitative research techniques, I investigated work practices that enhance the patient-situation awareness of physicians, fellows, residents, nurses, students, and pharmacists in a medical ICU. I used the Locales Framework to understand the observed task management and communication work practices. In this study, paper notes were observed to act as transitional artifacts that are later digitized to organize and coordinate tasks, goals, and patient-centric information at a team and organizational level. Non digital information is often not immediately digitized, and only select information is communicated between certain ICU team members through synchronous mechanisms such as face-to-face or telephone conversations. Thus, although ICU providers are exceptionally skilled at working together to improve a critically ill patient’s condition, the use of paper-based artifacts and synchronous communication mechanisms induces several interruptions while contextually situating a clinical team for patient care. In this dissertation, I also designed and evaluated a mobile health technology tool, known as PANI (Patient-centered Notes and Information Manager), guided by the Locales framework and the participatory involvement of ICU healthcare providers as co designers. PANI-supported task management induces minimal interruptions by: (1) rapidly generating, managing, and sharing clinical notes and action-items among clinicians and (2) supporting the collaboration and communication needs of clinicians through a novel visual and tactile notification system. The long-term contribution of this research suggests guidelines for designing mobile health technology interventions that enhance ICU patient situation-awareness and reduce unwanted interruptions to clinical workflow

A Multi-Method Evaluation Of A Guideline Based Clinical Decision Support Intervention On Provider Ordering Behavior, System Acceptance And Inter-Professional Communication

Background and aims: Unnecessary variation in the delivery of patient care is well documented in the medical literature; evidence-based clinical practice is critical for improving the quality of care. Clinical decision support systems (CDSS) are promising tools for improving the systematic integration of evidence into clinical practice. This study evaluated a CDSS in a domain of care that had not yet been explored—namely, decision support for venous catheter selection. This dissertation study aimed to (1) evaluate the effect of this CDSS on provider ordering behavior before and after implementation and explore the differential impact of this tool by provider type and service and (2) identify organizational, individual, usability, and workflow factors that impact CDSS acceptance by physicians and advanced practice nurses and to elicit information about the impact of this system on communication between providers and the nurse-led vascular access team. Methods: This was a multi-method study. Aim one was single group pre-post analysis of longitudinal data. Variables included those related to patient and provider level factors. The main analysis was conducted with linear regression models with random effects to account for clustering of data. We conducted semi-structured interviews for aim two and use conventional qualitative content analysis to identify themes. Results: We found mixed results in the impact of the CDSS on provider ordering behavior. While the CDSS did not have an impact on the number of venous catheters ordered, we saw a statistically and clinically significant decrease in the proportion of double lumen catheters ordered. Findings for the qualitative aim showed that the CDSS improved process efficiency and inter-professional communication. We found that it also facilitated education for evidence based practice for novice providers. Discussion: This dissertation study showed a clear impact of the CDSS on double lumen catheter ordering, which has implications for patient outcomes. Furthermore, we found impacts by provider type. Additional work is needed to evaluate this CDSS in other settings and to further assess differential impacts by provider type