Interactive parallel simulation environments

Ph.D.Richard M. Fujimot

Enhancing hospital care coordination : a resilience-centric approach to challenges and potential strategies

Background: The realms of patient flow management and care coordination, both aiming to optimize care delivery, are governed by distinct operational logics. Patient flow management is primarily a strategic tool concerned with optimising resource utilization via efficient movement of patients through the healthcare system. Care coordination emphasizes a holistic patient-centred approach. It focuses on integrating and coordinating services across the continuum of care to meet the individual patient needs. Technological improvements, demands for cost control and a shift toward redirecting lower acuity patients to primary and secondary care levels, accentuates the need for specialized staff and equipment in increasingly specialised hospitals. Resource constraints enhances conflicting quality, safety, and production goals as they keep challenging frontline hospital managers to constantly adapt to new situational demands. The theoretical description of hospitals as complex adaptive systems suggest that resilience is essential for maintaining the systems functions and avoiding loss of control of care delivery. The ability to adapt in response to both critical events and long-term pressures are a hallmark of resilient systems. Adaptations require adaptive capacity, such as extra resources, opportunities, degrees of freedom and/or a flexible goal setting. As well as strategies for control at individual, team, and strategic levels. For this thesis, the system’s ability to adapt is explored through care coordination at the first line management level. Care coordination has been studied primarily in specific single unit settings or for specific type of management roles such as navigators, nurse coordinators and lead medical doctors. There is a need for studies of how adaptive capacity is realised in-situ from a systems perspective, in highly specialised hospital settings, and to harness first line managers experiences of improvisations and informal practices (Invisible work). Aim: This thesis aims to contribute to bridging the gap between theory and practice of how first-line hospital managers realise adaptive capacity to avoid loss of control. Methods: An ethnographic approach that build three cases of care coordination in various in-hospital settings. The studies utilise a broad, inductive-deductive approach to explore how care coordination is realised in-situ using primarily participant shadowing observations and interviews for data collection. Study I. Describes care coordination in a Neonatal Intensive Care Unit. That is an integrated system of intensive care, emergency intake, step down unit and home care nested within one department. This study includes 100 hours of shadowing observations of coordinators, their conversations, tasks, meetings, and artefacts. Data were analysed using an inductive-deductive approach to content analysis from the perspective of resilience engineering. Study II. Explores the intersection of hospital wide patient flow management and care coordination (between wards and units). It incorporates five semistructured individual interviews with high level managers, 56 hours of shadowing observations with hospital bed-coordinators and 14 observations of hospital coordination team huddles. Inductive-deductive content analysis was applied, guided by a framework of Joint Cognitive Systems. Study III. Explores lead-nurses’ strategies and challenges for coordinating care at the emergency department (ED). Data were collected through four focus group interviews guided by a table-top sandbox simulation of the ED. Analysis were conducted using reflexive thematic analysis. Findings: Study I. Describes a functional relationship between operational stress and a progression of adjustments in the actual situation, expressed through recurring patterns of adaptation. Everyday work of the management team was characterised by seamlessly and actively organising and reorganising. Sacrificing low level goals based on up-to-date information and making continuous assessments of what would be minimally intrusive for the overall performance of the ward. Study II. Adds to the exploration of care coordination by describing how situations in the hospital’s patient flow is defined as problematic (or disastrous) by being on a course towards unacceptable quality- and safety trade-offs. And additionally, how the hospital management team huddle is an arena for sensemaking and negotiation between wards, but also act as a threshold and delay for information and decisions. Study III. Describes that the “normal state” of the ward is a moving target depending on the current demands. Activities for monitoring the status of the ward are in competition with coordinating activities as they both require managers attention. Coordinating care within the ED extends beyond the boundaries of the physical department within a variety of temporal demands for “on-the-day” adaptations and anticipatory strategies. Conclusions: The apparent stability of the organisation was found to be a dynamic balance between patient flow and care coordination activities. Care coordination is a team effort that transcend physical or organisational boundaries, teams of managers assert dynamic control as their strategies allow the system to increase the complexity of its control function when needed. The distributed nature of care coordination offers no ‘one point of control’ for tactical or strategic decision makers, which is problematic as a point of control is a common target for patient flow management interventions. Furthermore, frontline managers lacked the aid of tailored decision support systems for matching and visualising current operational stress of their units. It was not obvious outside the head of individual managers what strategies were available for any given situation

Dynamic Virtual Logical Processes

The implementation of a cloning mechanism that allows for the evaluation of multiple simulated futures is presented and its performance is analyzed. A running parallel discrete event simulation is dynamically cloned at decision points to explore different execution paths concurrently. In this way what-if and alternative scenario analysis in gaming, tactical and strategic applications can be evaluated interactively or non-interactively. Performance results show that virtual logical processes, a new mechanism developed to avoid repeating common computations among clones improves efficiency. 1 Introduction The goal of the research described here is to provide a decision aid that allows engineers and scientists to simulate complex situations and facilitate rapid and informed planning. Different possible futures are explored and compared by cloning an on-going parallel simulation. The tool supports critical decision making such as determining whether or not to mobilize reinforcements in a..

Nursing work at a neonatal intensive care unit : a timestudy

Risken för att drabbas av stressrelaterade sjukdomar är hög bland sjukvårdspersonal bland annat då kraven på kvalitet, effektivitet och arbetstempo har ökat. I diskussionen kring sjuksköterskors arbetssituation är saknas det aktuell kunskap om hur sjuksköterskor inom den neonatala intensivvården fördelar sin tid under arbetsdagen och vilka arbetsmoment som sjuksköterskorna utför i sitt dagliga arbete. Syftet med studien var att undersöka vilka arbetsmoment en sjuksköterska på neonatalintensiven utför under ett arbetspass samt kartlägga hur tidsåtgången fördelade sig mellan dessa arbetsmoment. En strukturerad tidsstudie genomfördes därför på en neonatal intensivvårdsavdelning i Sverige. Resultatet visade hur sjuksköterskorna fördelar sin tid mellan 69 olika arbetsmoment i 23 kategorier inom åtta kompetensområden samt hur omvårdnadsarbetet fördelade sig tidsmässigt mellan den direkt patientnära kontakten och övriga patientrelaterade uppgifter. 54 procent av den totalt arbetade tiden ägnades åt indirekt omvårdnad som förberedande arbete, hantering av material och samverkan i vårdkedjan medan 35 procent ägnas åt patientnära omvårdnad. Sjuksköterskearbetet är uppdelat mellan många olika arbetsmoment och arbetsområden, det är hög tid att se över sjuksköterskerollen och de uppgifter hon tilldelas som leder iväg från patientsängen.The risk for acquire stress related diseases is high in medical staff since the demand on quality, efficiency and work pace has increased. There is not much recent knowledge about how nurses in neonatal intensive care spend their time and which work tasks the nurses perform in their everyday work. The aim of this study was to examine which work tasks a nurse in neonatal intensive care perform during their workday and present a survey to how the time divides between these different tasks. A structured time study was performed at a neonatal intensive care unit in Sweden. The result show how the nurses divide their time between 69 different work tasks divided in to 23 categories in eight areas of competence and how the nursing work divide in terms of time between direct patient care and other patient related tasks. Nurses spend 54 percent of the total worked time to indirect care like preparations for nursing tasks, material and cooperation with external caregivers while 35 percent where spent at direct bedside care. The nurses time is divided between many different tasks and areas of expertise, it is necessary to evaluate the nursing profession and the tasks that leads them away from the patients bed