Relationship between number of health problems addressed during a primary care patient visit and clinician workload

INTRODUCTION

Primary care is complex due to multiple health problems being addressed in each patient visit. Little is known about the effect of the number of problems per encounter (NPPE) on the resulting clinician workload (CWL), as measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX).

METHODS

We evaluated the relationship between NPPE and CWL across 608 adult patient visits, conducted by 31 clinicians, using hierarchical linear regression. Clinicians were interviewed about outlier visits to identify reasons for higher or lower than expected CWL.

RESULTS

Mean NPPE was 3.30 ± 2.0 (sd) and CWL was 47.6 ± 18.4 from a maximum of 100. Mental demand, time demand and effort accounted for 71.5% of CWL. After adjustment for confounders, each additional problem increased CWL by 3.9 points (P < 0.001). Patient, problem, environmental and patient-physician relationship factors were qualitatively identified from interviews as moderators of this effect.

CONCLUSION

CWL is positively related to NPPE. Several modifiable factors may enhance or mitigate this effect. Our findings have implications for using a Human Factors (HF) approach to managing CWL.

Modelling the Expected Net Benefits of Interventions to Reduce the Burden of Medication Errors

Objectives

The aim of this study is to estimate the potential costs and benefits of three key interventions (computerized physician order entry [CPOE], additional ward pharmacists and bar coding) to help prioritize research to reduce medication errors.

Methods

A generic model structure was developed to describe the incidence and impacts of medication errors in hospitals. The model follows pathways from medication error points at alternative stages of the medication pathway through to the outcomes of undetected errors. The model was populated from a systematic review of the medication errors literature combined with novel probabilistic calibration methods. Cost ranges were applied to the interventions, the treatment of preventable adverse drug events (pADEs), and the value of the health lost as a result of an ADE.

Results

The model predicts annual health service costs of between £0.3 million and £1 million for the treatment of pADEs in a 400-bed acute hospital in the UK. Including only health service costs, it is uncertain whether any of the three interventions will produce positive net benefits, particularly if high intervention costs are assumed. When the monetary value of lost health is included, all three interventions have a high probability of producing positive net benefits with a mean estimate of around £31.5 million for CPOE over a five-year time horizon.

Conclusions

The results identify the potential cost-effectiveness of interventions aimed at medication errors, as well as identifying key drivers of cost-effectiveness that should be specifically addressed in the design of primary evaluations of medication error interventions.

Nursing Workload and its Effect on Patient and Employee Safety

A well accepted human factors concept is that poorly designed work systems can produce workload levels that pose a threat to safety and performance. The purpose of this study was to assess a systems model of workload and safety developed for nursing/healthcare. Using survey data from six nursing units in two pediatric hospitals, the study measured the relationship between self-reported workload at the unit, job, and task levels on the one hand and job dissatisfaction, burnout, and medication error likelihood on the other. Multiple linear and logistic regression revealed that staffing adequacy and medication administration workload strongly predicted the above patient and employee safety outcomes. Design priorities and strategies for future research are discussed, including the need for multiple-level approaches.

Protocol Violations during Medication Administration in Pediatrics

The paper uses a new measure of protocol violations to explore the extent of violations in the medication administration process. 203 nurses in three units of a free-standing pediatric hospital were provided with a survey assessing violations in the medication administration process; 120 nurses responded for a response rate of 59%. Violation data were collected for three stages of the medication administration process: matching medications to the medication administration record, checking patient identification, and documenting administration. The percentage of nurses who reported violating protocol in the medication administration process ranged from 8.4% to 30.2% in routine situations, and from 32.2% to 53.0% in emergency situations. Violations in the medication administration process may lead to medication errors. To improve medication safety, efforts should be taken to discover the system deficiencies that produce such frequent violations. System redesign should then address these deficiencies.

Do Workplace Ergonomic Interventions to Control Musculoskeletal Disorders Really Work?

The purpose of this study was to examine the effectiveness of ergonomic field interventions to control work-related musculoskeletal disorders. This paper is an extension of the one written for the 1998 National Academy of Sciences/National Research Council steering committee to examine the scientific literature relevant to work-related musculoskeletal disorders. Over 600 papers were read, and 98 were found that met the selection criteria. Eighty-four percent of all of the studies found some positive results, although the majority had mixed results. The most effective interventions were those that utilized multiple components. Only 31% of the studies used experimental or quasi-experimental designs. The implications for the conduct of ergonomic interventions and federal regulations are discussed.

An Examination of Employee Participation during New Technology Implementation

The purpose of this study was to examine how end user perceptions of (1) their inputs into the implementation of a new technology, (2) their inputs into the design of a new technology, and (3) the information received about a new technology affected their perceptions of the technology. Fifteen end users involved with or affected by the introduction of a new document imaging system served as subjects. A survey questionnaire was used to collect all necessary data. Participation in the implementation of the system was related to positive perceptions of system characteristics and new technology effects on end user jobs. Participation in the implementation was also related to satisfaction with the new technology. Implications for organizations planning on implementing new technologies are discussed.

Process Improvement in an Outpatient Clinic: Application of Sociotechnical System Analysis

We used a sociotechnical systems analysis to improve the diagnostic testing process in one Midwestern health care organization's outpatient clinics. Outpatient clinic personnel from the clinic were interviewed about their role in the diagnostic testing process. Information on process variances was also collected. A variance matrix and a key variance control chart were constructed for the variances reported by the clinics. Key variances found in the clinic included sample misplaced, sample mislabeled, sample not delivered, sample damaged, request form problems, result tracking breakdown, slow result delivery, result never seen, and patient notification. Based on the variances found in the clinic, recommendations for improvement are given.

The myth of standardized workflow in primary care

OBJECTIVE

Primary care efficiency and quality are essential for the nation's health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns.

METHODS

This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit's progression, and the presence of an electronic health record (EHR) at the clinic.

RESULTS

PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit.

DISCUSSION

PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a "dance" between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice.

CONCLUSIONS

Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP's mental and physical work, resulting in effective, safe, and efficient primary care.

Crossing levels in systems ergonomics: a framework to support 'mesoergonomic' inquiry

In this paper we elaborate and articulate the need for what has been termed 'mesoergonomics'. In particular, we argue that the concept has the potential to bridge the gap between, and integrate, established work within the domains of micro- and macroergonomics. Mesoergonomics is defined as an open systems approach to human factors and ergonomics (HFE) theory and research whereby the relationship between variables in at least two different system levels or echelons is studied, and where the dependent variables are human factors and ergonomic constructs. We present a framework which can be used to structure a set of questions for future work and prompt further empirical and conceptual inquiry. The framework consists of four steps: (1) establishing the purpose of the mesoergonomic investigation; (2) selecting human factors and ergonomics variables; (3) selecting a specific type of mesoergonomic investigation; and (4) establishing relationships between system levels. In addition, we describe two case studies which illustrate the workings of the framework and the value of adopting a mesoergonomic perspective within HFE. The paper concludes with a set of issues which could form part of a future agenda for research within systems ergonomics.

Crossing levels in systems ergonomics: a framework to support 'mesoergonomic' inquiry

In this paper we elaborate and articulate the need for what has been termed 'mesoergonomics'. In particular, we argue that the concept has the potential to bridge the gap between, and integrate, established work within the domains of micro- and macroergonomics. Mesoergonomics is defined as an open systems approach to human factors and ergonomics (HFE) theory and research whereby the relationship between variables in at least two different system levels or echelons is studied, and where the dependent variables are human factors and ergonomic constructs. We present a framework which can be used to structure a set of questions for future work and prompt further empirical and conceptual inquiry. The framework consists of four steps: (1) establishing the purpose of the mesoergonomic investigation; (2) selecting human factors and ergonomics variables; (3) selecting a specific type of mesoergonomic investigation; and (4) establishing relationships between system levels. In addition, we describe two case studies which illustrate the workings of the framework and the value of adopting a mesoergonomic perspective within HFE. The paper concludes with a set of issues which could form part of a future agenda for research within systems ergonomics.

The science of human factors: separating fact from fiction

BACKGROUND

Interest in human factors has increased across healthcare communities and institutions as the value of human centred design in healthcare becomes increasingly clear. However, as human factors is becoming more prominent, there is growing evidence of confusion about human factors science, both anecdotally and in scientific literature. Some of the misconceptions about human factors may inadvertently create missed opportunities for healthcare improvement.

METHODS

The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities.

RESULTS

The primary goal of human factors science is to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. As described in this article, human factors also provides insight on when training is likely (or unlikely) to be effective for improving patient safety. Finally, we outline human factors specialty areas that may be particularly relevant for improving healthcare delivery and provide examples to demonstrate their value.

CONCLUSIONS

The human factors concepts presented in this article may foster interdisciplinary collaborations to yield new, sustainable solutions for healthcare quality and patient safety.

Macroergonomics in Healthcare Quality and Patient Safety

The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.

Automation and adaptation: Nurses' problem-solving behavior following the implementation of bar coded medication administration technology

The most common change facing nurses today is new technology, particularly bar coded medication administration technology (BCMA). However, there is a dearth of knowledge on how BCMA alters nursing work. This study investigated how BCMA technology affected nursing work, particularly nurses' operational problem-solving behavior. Cognitive systems engineering observations and interviews were conducted after the implementation of BCMA in three nursing units of a freestanding pediatric hospital. Problem-solving behavior, associated problems, and goals, were specifically defined and extracted from observed episodes of care. Three broad themes regarding BCMA's impact on problem solving were identified. First, BCMA allowed nurses to invent new problem-solving behavior to deal with pre-existing problems. Second, BCMA made it difficult or impossible to apply some problem-solving behaviors that were commonly used pre-BCMA, often requiring nurses to use potentially risky workarounds to achieve their goals. Third, BCMA created new problems that nurses were either able to solve using familiar or novel problem-solving behaviors, or unable to solve effectively. Results from this study shed light on hidden hazards and suggest three critical design needs: (1) ecologically valid design; (2) anticipatory control; and (3) basic usability. Principled studies of the actual nature of clinicians' work, including problem solving, are necessary to uncover hidden hazards and to inform health information technology design and redesign.

Automation and adaptation: Nurses' problem-solving behavior following the implementation of bar coded medication administration technology

The most common change facing nurses today is new technology, particularly bar coded medication administration technology (BCMA). However, there is a dearth of knowledge on how BCMA alters nursing work. This study investigated how BCMA technology affected nursing work, particularly nurses' operational problem-solving behavior. Cognitive systems engineering observations and interviews were conducted after the implementation of BCMA in three nursing units of a freestanding pediatric hospital. Problem-solving behavior, associated problems, and goals, were specifically defined and extracted from observed episodes of care. Three broad themes regarding BCMA's impact on problem solving were identified. First, BCMA allowed nurses to invent new problem-solving behavior to deal with pre-existing problems. Second, BCMA made it difficult or impossible to apply some problem-solving behaviors that were commonly used pre-BCMA, often requiring nurses to use potentially risky workarounds to achieve their goals. Third, BCMA created new problems that nurses were either able to solve using familiar or novel problem-solving behaviors, or unable to solve effectively. Results from this study shed light on hidden hazards and suggest three critical design needs: (1) ecologically valid design; (2) anticipatory control; and (3) basic usability. Principled studies of the actual nature of clinicians' work, including problem solving, are necessary to uncover hidden hazards and to inform health information technology design and redesign.

A typology of electronic health record workarounds in small-to-medium size primary care practices

OBJECTIVE

Electronic health record (EHR) use in ambulatory care can improve safety and quality; however, problems with design, implementation, and poor interface with other systems lead users to develop 'workarounds', or behaviors users adopt to overcome perceived limitations in a technical system. We documented workarounds used in independent, community-based primary care practices, and developed a typology of their key features.

MATERIALS AND METHODS

Comparative case study of EHR use in seven independent primary care practices. Field researchers spent approximately 1 month in each practice to observe EHR use, conduct patient pathways, and interview clinicians and staff.

RESULTS

We observed workarounds addressing a wide range of EHR-related problems, including: user interface issues (eg, insufficient data fields, limited templates), barriers to electronic health information exchange with external organizations, and struggles incorporating new technologies into existing office space. We analyzed the observed workarounds inductively to develop a typology that cuts across specific clinical or administrative processes to highlight the following key formal features of workarounds in general: temporary/routinized, which captures whether the workaround is taken for granted as part of daily workflow or is understood as a short-term solution; avoidable/unavoidable, referring to the extent to which the workaround is within the practice's power to eliminate; and deliberately chosen/unplanned, which differentiates strategically chosen adaptations from less thoughtful workarounds.

CONCLUSIONS

This workaround typology provides a framework for EHR users to identify and address workarounds in their own practices, and for researchers to examine the effect of different types of EHR workarounds on patient safety, care quality, and efficiency.

The science of human factors: separating fact from fiction

Background

Interest in human factors has increased across healthcare communities and institutions as the value of human centred design in healthcare becomes increasingly clear. However, as human factors is becoming more prominent, there is growing evidence of confusion about human factors science, both anecdotally and in scientific literature. Some of the misconceptions about human factors may inadvertently create missed opportunities for healthcare improvement.

Methods

The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities.

Results

The primary goal of human factors science is to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. As described in this article, human factors also provides insight on when training is likely (or unlikely) to be effective for improving patient safety. Finally, we outline human factors specialty areas that may be particularly relevant for improving healthcare delivery and provide examples to demonstrate their value.

Conclusions

The human factors concepts presented in this article may foster interdisciplinary collaborations to yield new, sustainable solutions for healthcare quality and patient safety.

Using a sociotechnical framework to understand adaptations in health IT implementation

PURPOSE

When barcode medication administration (BCMA) is implemented nurses are required to integrate not only a new set of procedures or artifacts into everyday work, but also an orientation to medication safety itself that is sometimes at odds with their own. This paper describes how the nurses' orientation (the Practice Frame) can collide with the orientation that is represented by the technology and its implementation (the System Frame), resulting in adaptations at the individual and organization levels.

METHODS

The paper draws on two qualitative research studies that examined the implementation of BCMA in inpatient settings using observation and ethnographic fieldwork, content analysis of email communications, and interviews with healthcare professionals.

RESULTS

Two frames of reference are described: the System Frame and the Practice Frame. We found collisions of these frames that prompted adaptations at the individual and organization levels. The System Frame was less integrated and flexible than the Practice Frame, less able to account for all of the dimensions of everyday patient care to which medication administration is tied.

CONCLUSION

Collisions in frames during implementation of new technology result in adaptations at the individual and organization level that can have a variety of effects. We found adaptations to be a means of evolving both the work routines and the technology. Understanding the frames of clinical workers when new technology is being designed and implemented can inform changes to technology or organizational structure and policy that can preclude unproductive or unsafe adaptations.

Barriers to the adoption of ergonomic innovations to control musculoskeletal disorders and improve performance

Despite a growing number of published articles describing studies of ergonomic interventions, little is known about the barriers potential adopters face when deciding whether or not to adopt such innovations. To this end, the purpose of this paper is to examine the barriers identified by potential adopters of ergonomic innovations and compare barriers identified by individuals not interested in adopting to those identified by individuals planning to adopt. Eight hundred forty-eight fresh market vegetable farmers were mailed surveys measuring the adoption of and barriers to the adoption of several ergonomic innovations as part of a multi-year intervention study. Barriers such as cost, lack of information, never having seen the innovation used and not being able to try out the innovation were among the barriers identified. The barriers identified were moderated by whether or not the respondents were likely to adopt. Implications for diffusing ergonomic and safety innovations are discussed.

Electronic health record impact on work burden in small, unaffiliated, community-based primary care practices

BACKGROUND

The use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices.

OBJECTIVE

To study the impact of EHR use on clinician and staff work burden in small, community-based primary care practices.

DESIGN

We conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9-14 days over a 4-8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach.

PARTICIPANTS

All practice members and selected patients in seven community-based primary care practices in the Northeastern US.

KEY RESULTS

The impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHR-related work burden for clinicians, as well as facilitate population-based care.

CONCLUSIONS

The complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.

Modeling nurses' acceptance of bar coded medication administration technology at a pediatric hospital

OBJECTIVE

To identify predictors of nurses' acceptance of bar coded medication administration (BCMA).

DESIGN

Cross-sectional survey of registered nurses (N=83) at an academic pediatric hospital that recently implemented BCMA.

METHODS

Surveys assessed seven BCMA-related perceptions: ease of use; usefulness for the job; social influence from non-specific others to use BCMA; training; technical support; usefulness for patient care; and social influence from patients/families. An all possible subset regression procedure with five goodness-of-fit indicators was used to identify which set of perceptions best predicted BCMA acceptance (intention to use, satisfaction).

RESULTS

Nurses reported a moderate perceived ease of use and low perceived usefulness of BCMA. Nurses perceived moderate-or-higher social influence to use BCMA and had moderately positive perceptions of BCMA-related training and technical support. Behavioral intention to use BCMA was high, but satisfaction was low. Behavioral intention to use was best predicted by perceived ease of use, perceived social influence from non-specific others, and perceived usefulness for patient care (56% of variance explained). Satisfaction was best predicted by perceived ease of use, perceived usefulness for patient care, and perceived social influence from patients/families (76% of variance explained).

DISCUSSION

Variation in and low scores on ease of use and usefulness are concerning, especially as these variables often correlate with acceptance, as found in this study. Predicting acceptance benefited from using a broad set of perceptions and adapting variables to the healthcare context.

CONCLUSION

Success with BCMA and other technologies can benefit from assessing end-user acceptance and elucidating the factors promoting acceptance and use.

Self-reported violations during medication administration in two paediatric hospitals

CONTENT

Violations of safety protocols are paths to adverse outcomes that have been poorly addressed by existing safety efforts. This study reports on nurses' self-reported violations in the medication administration process.

OBJECTIVE

To assess the extent of violations in the medication administration process among nurses.

DESIGN, SETTING AND PARTICIPANTS

Participants were 199 nurses from two US urban, academic, tertiary care, free-standing paediatric hospitals who worked in a paediatric intensive care unit (PICU), a haematology-oncology-transplant (HOT) unit or a medical-surgical (Med/Surg) unit. In a cross-sectional survey, nurses were asked about violations in routine or emergency situations in three steps of the medication administration process.

MAIN OUTCOME MEASURE

Self-reported violations of three medication administration protocols were made using a seven-point 0-6 scale from 'not at all' to 'a great deal'.

RESULTS

Analysis of variance identified that violation reports were highest for emergency situations, rather than for routine operations, highest by HOT unit nurses, followed by PICU nurses and then Med/Surg unit nurses, and highest during patient identification checking, followed by matching a medication to a medication administration record, and then documenting an administration. There was also a significant three-way interaction among violation situation, step in the process, and unit.

CONCLUSIONS

Protocol violations occur throughout the medication administration process and their prevalence varies as a function of hospital unit, step in the process, and violation situation. Further research is required to determine whether these violations improve or worsen safety, and for those that worsen safety, how to redesign the system of administration to reduce the need to violate protocol to accomplish job tasks.

Pharmacy workers' perceptions and acceptance of bar-coded medication technology in a pediatric hospital

BACKGROUND

The safety benefits of bar-coded medication-dispensing and administration (BCMA) technology depend on its intended users favorably perceiving, accepting, and ultimately using the technology.

OBJECTIVES

(1) To describe pharmacy workers' perceptions and acceptance of a recently implemented BCMA system and (2) to model the relationship between perceptions and acceptance of BCMA.

METHODS

Pharmacists and pharmacy technicians at a Midwest U.S. pediatric hospital were surveyed following the hospital's implementation of a BCMA system. Twenty-nine pharmacists' and 10 technicians' self-reported perceptions and acceptance of the BCMA system were analyzed, supplemented by qualitative observational and free-response survey data. Perception-acceptance associations were analyzed using structural models.

RESULTS

The BCMA system's perceived ease of use was rated low by pharmacists and moderate by pharmacy technicians. Both pharmacists and technicians perceived that the BCMA system was not useful for improving either personal job performance or patient care. Pharmacy workers perceived that individuals important to them encouraged BMCA use. Pharmacy workers generally intended to use BCMA but reported low satisfaction with the system. Perceptions explained 72% of the variance in intention to use BCMA and 79% of variance in satisfaction with BCMA.

CONCLUSIONS

To promote their acceptance and use, BCMA and other technologies must be better designed and integrated into the clinical work system. Key steps to achieving better design and integration include measuring clinicians' acceptance and elucidating perceptions and other factors that shape acceptance.

Information chaos in primary care: implications for physician performance and patient safety

PURPOSE

The purpose of this article is to explore the concept of information chaos as it applies to the issues of patient safety and physician workload in primary care and to propose a research agenda.

METHODS

We use a human factors engineering perspective to discuss the concept of information chaos in primary care and explore implications for its impact on physician performance and patient safety.

RESULTS

Information chaos is comprised of various combinations of information overload, information underload, information scatter, information conflict, and erroneous information. We provide a framework for understanding information chaos, its impact on physician mental workload and situation awareness, and its consequences, and we discuss possible solutions and suggest a research agenda that may lead to methods to reduce the problem.

CONCLUSIONS

Information chaos is experienced routinely by primary care physicians. This is not just inconvenient, annoying, and frustrating; it has implications for physician performance and patient safety. Additional research is needed to define methods to measure and eventually reduce information chaos.

Development of a primary care physician task list to evaluate clinic visit workflow

BACKGROUND

Interventions designed to improve the delivery of primary care, including Patient-Centered Medical Homes and electronic health records, require an understanding of clinical workflow to be successfully implemented. However, there is a lack of tools to describe and study primary care physician workflow. We developed a comprehensive list of primary care physician tasks that occur during a face-to-face patient visit.

METHODS

A validated list of tasks performed by primary care physicians during patient clinic visits was developed from a secondary data analysis of observation data from two studies evaluating primary care workflow. Thirty primary care physicians participated from a convenience sample of 17 internal medicine and family medicine clinics in Wisconsin and Iowa across rural and urban settings and community and academic settings.

RESULTS

The final task list has 12 major tasks, 189 subtasks, and 191 total tasks. The major tasks are: Enter Room, Gather Information from Patient, Review Patient Information, Document Patient Information, Perform, Recommend / Discuss Treatment Options, Look Up, Order, Communicate, Print / Give Patient (advice, instructions), Appointment Wrap-up, and Leave Room. Additional subcodes note use of paper or EHR and the presence of a caregiver or medical student.

CONCLUSIONS

The task list presented here is a tool that will help clinics study their workflows so they can plan for changes that will take place because of EHR implementation and/or transformation to a patient centered medical home.

That's nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care

Health information technology (IT) is widely endorsed as a way to improve key health care outcomes, particularly patient safety. Applying a human factors approach, this paper models more explicitly how health IT might improve or worsen outcomes. The human factors model specifies that health IT transforms the work system, which transforms the process of care, which in turn transforms the outcome of care. This study reports on transformations of the medication administration process that resulted from the implementation of one type of IT: bar coded medication administration (BCMA). Registered nurses at two large pediatric hospitals in the US participated in a survey administered before and after one of the hospitals implemented BCMA. Nurses' perceptions of the administration process changed at the hospital that implemented BCMA, whereas perceptions of nurses at the control hospital did not. BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification. The accuracy, usefulness, and consistency of checking patient identification improved as well. In contrast, nurses' perceptions of the usefulness, time efficiency, and ease of the documentation process decreased post-BCMA. Discussion of survey findings is supplemented by observations and interviews at the hospital that implemented BCMA. By considering the way that IT transforms the work system and the work process a practitioner can better predict the kind of outcomes that the IT might produce. More importantly, the practitioner can achieve or prevent outcomes of interest by using design and redesign aimed at controlling work system and process transformations.

A 4-year intervention to increase adoption of safer dairy farming work practices

BACKGROUND

Traumatic and musculoskeletal injury rates have been high in dairy farming compared to other industries. Previous work has shown that social marketing efforts can persuade farm managers to adopt practices that reduce injury hazards compared to traditional practices if the new practices maintain profits.

METHODS

The intervention disseminated information to 4,300 Northeast Wisconsin dairy farm managers about three safer and more profitable production practices (barn lights, silage bags, and calf feed mixing sites) using information channels that these managers were known to rely on. We evaluated rolling, independent, community-based samples, at baseline and then again after each of four intervention years. We also evaluated samples from Maryland's 1,200 dairy farms after the second through the fourth year of the intervention. Maryland dairy managers read many of the same nationally distributed print mass media that we used in the intervention and so were a "partially exposed" comparison group.

RESULTS

The intervention to disseminate information about the innovations was successful. In comparisons before and after the intervention, Wisconsin managers reported getting more information about calf sites from public events and equipment dealers, about silage bags from other farmers and equipment dealers, and about barn lights from public events, other farmers, equipment dealers, consultants, and electrical suppliers. Wisconsin managers also reported getting more information than Maryland managers from public events for barn lights and silage bags. During years three and four, the intervention managed to sustain, but not improve, earlier increases in adoption and awareness from the first 2 years. After adjusting for farm manager and operation variables, intervention years was associated with increased Wisconsin manager adoption of two of three practices in comparisons between the baseline and the fourth intervention year: barn lights (odds ratio = 5.58, 95% confidence interval = 3.39-9.17) and silage bags (OR = 2.94, CI = 1.84-4.70). There were similar results for awareness of barn lights and the calf feeding sites. Compared to Maryland managers, Wisconsin managers reported greater awareness of barn lights.

CONCLUSIONS

Disseminating information to managers through information channels that they usually consulted was associated with increased reports of getting information and with greater adoption and awareness of safer, profit-enhancing work practices in a high hazard industry.

Health information technology: fallacies and sober realities

Current research suggests that the rate of adoption of health information technology (HIT) is low, and that HIT may not have the touted beneficial effects on quality of care or costs. The twin issues of the failure of HIT adoption and of HIT efficacy stem primarily from a series of fallacies about HIT. We discuss 12 HIT fallacies and their implications for design and implementation. These fallacies must be understood and addressed for HIT to yield better results. Foundational cognitive and human factors engineering research and development are essential to better inform HIT development, deployment, and use.

Factors affecting home care patients' acceptance of a web-based interactive self-management technology

OBJECTIVE

With the advent of personal health records and other patient-focused health technologies, there is a growing need to better understand factors that contribute to acceptance and use of such innovations. In this study, we employed the Unified Theory of Acceptance and Use of Technology as the basis for determining what predicts patients' acceptance (measured by behavioral intention) and perceived effective use of a web-based, interactive self-management innovation among home care patients.

DESIGN

Cross-sectional secondary analysis of data from a randomized field study evaluating a technology-assisted home care nursing practice with adults with chronic cardiac disease. MEASUREMENT AND ANALYSIS: A questionnaire was designed based on validated measurement scales from prior research and was completed by 101 participants for measuring the acceptance constructs as part of the parent study protocol. Latent variable modeling with item parceling guided assessment of patients' acceptance.

RESULTS

Perceived usefulness accounted for 53.9% of the variability in behavioral intention, the measure of acceptance. Together, perceived usefulness, health care knowledge, and behavioral intention accounted for 68.5% of the variance in perceived effective use. Perceived ease of use and subjective norm indirectly influenced behavioral intention, through perceived usefulness. Perceived ease of use and subjective norm explained 48% of the total variance in perceived usefulness.

CONCLUSION

The study demonstrates that perceived usefulness, perceived ease of use, subjective norm, and healthcare knowledge together predict most of the variance in patients' acceptance and self-reported use of the web-based self-management technology.

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life

BACKGROUND

Nursing workload is increasingly thought to contribute to both nurses' quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualising and measuring the effects of workload in healthcare. In contrast, we conceptualised a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes.

METHODS

To test this model, we analysed results from a cross-sectional survey of a volunteer sample of nurses in six units of two academic tertiary care paediatric hospitals.

RESULTS

Workload measures were generally correlated with outcomes of interest. A multivariate structural model revealed that: the unit-level measure of staffing adequacy was significantly related to job dissatisfaction (path loading=0.31) and burnout (path loading=0.45); the task-level measure of mental workload related to interruptions, divided attention, and being rushed was associated with burnout (path loading=0.25) and medication error likelihood (path loading=1.04). Job-level workload was not uniquely and significantly associated with any outcomes.

DISCUSSION

The human factors engineering model of nursing workload was supported by data from two paediatric hospitals. The findings provided a novel insight into specific ways that different types of workload could affect nurse and patient outcomes. These findings suggest further research and yield a number of human factors design suggestions.

Involving intensive care unit nurses in a proactive risk assessment of the medication management process

BACKGROUND

Vulnerabilities in the medication manage ment process can lead to serious patient harm. In intensive care units (ICUs), nurses represent the last line of defense against medication errors. Proactive risk assessment (PRA) offers methods for determining how processes can break down and how people involved in such processes can contribute to or recover from a breakdown. Such methods can also be used to identify ICU nurses' contribution to the quality and safety of medication management.

METHODS

Observation and interview data of ICU nurses work were used to develop a rich description of the nursing medication management process. A PRA method was conducted in a cardiovascular ICU to identify and evaluate failure modes in the nursing medication management process. The contributing factors to the failure modes and the recovery processes used by nurses were also characterized.

RESULTS

A total of 54 failure modes were identified across the seven steps of the medication management process. For the 5 most critical failure modes, nurses listed 21 contributing factors and 21 recovery processes. Ways were identified to redesign the medication management process, one of which consists of dealing with work system factors that contribute to the most critical failure modes.

CONCLUSIONS

From a data-analysis viewpoint, this PRA method permits one to address a variety of objectives. Different scoring methods can be used to focus on either frequency or criticality of failure modes; one may also focus on a specific step of the process under study. Efforts in eliminating or mitigating contributing factors would help reduce the criticality of the failure modes in terms of their likelihood and impact on patients and/or nurses. Developing systems to support the recovery processes used by nurses may be another approach to process redesign.

Macroergonomics and patient safety: the impact of levels on theory, measurement, analysis and intervention in patient safety research

The study and practice of patient safety has seen a surge over the last 10 years. New resident training and staffing policies, health information technologies, error reporting systems, team models of care, training methods, patient involvement, information handoff strategies, just cultures, and many other interventions have been mandated or attempted to improve the safety of patient care. While some of these interventions focus on individual providers and others focus on organization-level changes, little, if any, patient safety research has purposefully sought to understand how variables at different levels, such as the provider level or organization level, interact to impact patient safety outcomes such as errors, adverse drug events, or patient harm. Looking at relationships across levels is important because adverse events might be related to variables at different levels; consider that adverse events may be nested within patients, patients nested within nurses and physicians, nurses and physicians nested within shifts, shifts nested within hospital units, and so forth. Because these nested levels exist, they may exert as yet untested influence on the levels below. In this paper the impact of levels on theory, measurement, analysis and intervention in patient safety research is discussed.

Value of human factors to medication and patient safety in the intensive care unit

Conventional wisdom suggests that the "human factor" in critical care environments is reason for inadequate medication and patient safety. "Human factors" (or human factors engineering) is also a scientific discipline and practice of improving human performance. Using decades of human factors research, this paper evaluates a range of common beliefs about patient safety through a human factors lens. This evaluation demonstrates that human factors provides a framework for understanding safety failures in critical care settings, offers insights into how to improve medication and patient safety, and reminds us that the "human factor" in critical care units is what allows these time-pressured, information-intense, mentally challenging, interruption-laden, and life-or-death environments to function so safely so much of the time.

Effects of mental demands during dispensing on perceived medication safety and employee well-being: a study of workload in pediatric hospital pharmacies

BACKGROUND

Pharmacy workload is a modifiable work system factor believed to affect both medication safety outcomes and employee outcomes, such as job satisfaction.

OBJECTIVES

This study sought to measure the effect of workload on safety and employee outcomes in 2 pediatric hospitals and to do so using a novel approach to pharmacy workload measurement.

METHODS

Rather than measuring prescription volume or other similar indicators, this study measured the type and intensity of mental demands experienced during the medication dispensing tasks. The effects of external (interruptions, divided attention, and rushing) and internal (concentration and effort) task demands on perceived medication error likelihood, adverse drug event likelihood, job dissatisfaction, and burnout were statistically estimated using multiple linear and logistic regression.

RESULTS

Pharmacists and pharmacy technicians reported high levels of external and internal mental demands during dispensing. The study supported the hypothesis that external demands (interruptions, divided attention, and rushing) negatively impacted medication safety and employee well-being outcomes. However, as hypothesized, increasing levels of internal demands (concentration and effort) were not associated with greater perceived likelihood of error, adverse drug events, or burnout and even had a positive effect on job satisfaction.

CONCLUSIONS

Replicating a prior study in nursing, this study shows that new conceptualizations and measures of workload can generate important new findings about both detrimental and beneficial effects of workload on patient safety and employee well-being. This study discusses what those findings imply for policy, management, and design concerning automation, cognition, and staffing.

Employed family physician satisfaction and commitment to their practice, work group, and health care organization

OBJECTIVE

Test a model of family physician job satisfaction and commitment.

DATA SOURCES/STUDY SETTING

Data were collected from 1,482 family physicians in a Midwest state during 2000-2001. The sampling frame came from the membership listing of the state's family physician association, and the analyzed dataset included family physicians employed by large multispecialty group practices.

STUDY DESIGN AND DATA COLLECTION

A cross-sectional survey was used to collect data about physician working conditions, job satisfaction, commitment, and demographic variables.

PRINCIPAL FINDINGS

The response rate was 47 percent. Different variables predicted the different measures of satisfaction and commitment. Satisfaction with one's health care organization (HCO) was most strongly predicted by the degree to which physicians perceived that management valued and recognized them and by the extent to which physicians perceived the organization's goals to be compatible with their own. Satisfaction with one's workgroup was most strongly predicted by the social relationship with members of the workgroup; satisfaction with one's practice was most strongly predicted by relationships with patients. Commitment to one's workgroup was predicted by relationships with one's workgroup. Commitment to one's HCO was predicted by relationships with management of the HCO.

CONCLUSIONS

Social relationships are stronger predictors of employed family physician satisfaction and commitment than staff support, job control, income, or time pressure.

Evaluation of a 3year intervention to increase adoption of safer nursery crop production practices

BACKGROUND

We conducted a 3year intervention to increase awareness and adoption of eight more profitable nursery crop production practices that reduced certain traumatic and musculoskeletal injury hazards.

METHODS

We disseminated information to nursery managers across seven states using information channels they were known to rely on (e.g. trade publications, public events, university Extension, other managers). We evaluated rolling, independent, probability samples (n=1200) with mail questionnaires before the intervention and after each of 3 intervention years. We also evaluated samples (n=250) from a comparison group of New Zealand nursery managers.

RESULTS

The intervention was associated with increased awareness of four of the eight practices among US managers after year 3 compared to their baseline: zippers (20 vs. 32%, p<or=0.000), stools (11 vs. 22%, p<or=0.001), pruners (29 vs. 40%, p<or=0.014), and tarps (24 vs. 33%, p<or=0.009). There were no changes in adoption. New Zealand manager awareness was increased for hoes after year 2 compared to their baseline (35 vs. 52%, p<or=0.010).

CONCLUSIONS

A modest, regionwide information dissemination intervention was associated with increased awareness, but not adoption.

Work exposures, injuries, and musculoskeletal discomfort among children and adolescents in dairy farming

Little research is available about the specifics of child or adolescent work on dairy farm operations. The objective of this study was to investigate work performed by children and adolescents on these operations. The authors administered mail questionnaires to a community-based, age- and operation size-stratified sample of individuals aged 6 to 18 (n = 240) who worked on dairy operations in Wisconsin. Data were collected in 1999. The 197 children and adolescents reported averaging 567 hours of dairy farm work in the last year (10.9 hours/week) and completed over 1/3 of all calf feeding, 1/5 of the milking, 1/5 of cow feeding, and 1/10 of tractor operation hours on their farm during the weeks they worked. Some of these young workers reported accomplishing duties also judged by some experts as hazardous work, including nearly half of the 9- to 11-year-olds driving tractors. Six nonfatal injuries were reported that required stopping work (14.6 per 100 full time equivalents per year), including those that required medical attention. Musculoskeletal discomfort and disability reports were unremarkable compared to existing studies of general and working populations. Wisconsin dairy farm youth appeared to be working no more hours per week than their peers in other studies of agricultural populations. Adolescents and some children largely performed the same range of tasks and often the same scope of work as adults, including some performing hazardous work. There is a need for further investigations with larger samples of dairy youth to confirm these findings. The exposures of very young workers to hazardous tractor driving and tower silo tasks suggest that there is an urgent need for improved and validated interventions to reduce these exposures.

Intervention to increase adoption of safer dairy farming production practices

OBJECTIVES

We conducted an intervention to increase adoption of three dairy farming practices shown to reduce certain traumatic and musculoskeletal injury hazards.

METHODS

The intervention disseminated information to 4,300 Wisconsin dairy farm managers about three safer, more profitable production practices (barn lights, bag silos, and calf feed mixing sites) using information channels upon which these managers were known to rely. We evaluated rolling, independent, community-based samples at baseline and after each of two intervention years. We also evaluated a single sample after the intervention's second year from 1,200 Maryland dairy farm managers who were exposed only to the intervention's nationally distributed print publications, as a "partially exposed" comparison group.

RESULTS

In before/after comparisons, Wisconsin managers reported getting more information from print media, public events, and resource people for barn lights and bag silos. Also, Wisconsin managers, in comparison with Maryland managers after the intervention's second year, reported getting more barn lights and bag silo information from public events and resource people, but not from print media. Analyses that adjusted for farm manager, farm operation, and herd variables associated the intervention with increased Wisconsin manager adoption of all three practices after the second intervention year: barn lights (odds ratio [OR] = 2.268, 95% confidence interval [CI] 1.476, 3.485), bag silos (OR = 3.561, 95% CI 2.684, 4.728), and calf feeding sites (OR = 2.433, 95% CI 1.059, 5.591). There were also increases in awareness of barn lights and calf feeding sites.

CONCLUSION

Disseminating information to managers through well-known information channels was associated with increased reports of information gathering, adoption, and awareness of safer, profit-enhancing work practices in a high-hazard industry.

A systematic review of safety violations in industry

It is widely known that intentional non-malevolent violations of safety procedures and norms occur and evidence shows that safety violations can increase the risk of accidents. However, little research about the causes of these violations in work settings exists. To help shed light on the causes, this paper systematically reviews the empirical causes of safety violations in industry. Electronic database literature searches were performed to identify relevant articles published prior to January 1, 2007. Thirteen articles met the inclusion criteria and 57 different variables were examined as predictors of safety violations. Study settings were healthcare delivery, commercial driving, aviation, mining, railroad, and construction. The predictors were categorized into individual characteristics, information/education/training, design to support worker needs, safety climate, competing goals, and problems with rules. None of the reviewed studies examined whether violations can improve system performance or safety. Methodological suggestions and a macroergonomic framework are offered for improving future studies of the epidemiology of safety violations.

A systematic review of patient acceptance of consumer health information technology

A systematic literature review was performed to identify variables promoting consumer health information technology (CHIT) acceptance among patients. The electronic bibliographic databases Web of Science, Business Source Elite, CINAHL, Communication and Mass Media Complete, MEDLINE, PsycArticles, and PsycInfo were searched. A cited reference search of articles meeting the inclusion criteria was also conducted to reduce misses. Fifty-two articles met the selection criteria. Among them, 94 different variables were tested for associations with acceptance. Most of those tested (71%) were patient factors, including sociodemographic characteristics, health- and treatment-related variables, and prior experience or exposure to computer/health technology. Only ten variables were related to human-technology interaction; 16 were organizational factors; and one was related to the environment. In total, 62 (66%) were found to predict acceptance in at least one study. Existing literature focused largely on patient-related factors. No studies examined the impact of social and task factors on acceptance, and few tested the effects of organizational or environmental factors on acceptance. Future research guided by technology acceptance theories should fill those gaps to improve our understanding of patient CHIT acceptance, which in turn could lead to better CHIT design and implementation.

Human factors and ergonomics in home care: Current concerns and future considerations for health information technology

Sicker patients with greater care needs are being discharged to their homes to assume responsibility for their own care with fewer nurses available to aid them. This situation brings with it a host of human factors and ergonomic (HFE) concerns, both for the home care nurse and the home dwelling patient, that can affect quality of care and patient safety. Many of these concerns are related to the critical home care tasks of information access, communication, and patient self-monitoring and self-management. Currently, a variety of health information technologies (HITs) are being promoted as possible solutions to those problems, but those same technologies bring with them a new set of HFE concerns. This paper reviews the HFE considerations for information access, communication, and patients self-monitoring and self-management, discusses how HIT can potentially mitigate current problems, and explains how the design and implementation of HIT itself requires careful HFE attention.

Human Factors and Ergonomic Concerns and Future Considerations for Consumer Health Information Technology in Home Nursing Care

Sicker patients with greater care needs are being discharged to their homes to assume responsibility for their own care with fewer nurses available to aid them. This situation brings with it a host of human factors and ergonomic (HFE) concerns, both for the home care nurse and the home care patient, which can affect quality of care and patient safety. Many of these concerns are related to the critical home care tasks of information access, communication, and patient self-management. Currently, a variety of consumer health information technologies (CHITs) are being promoted as possible solutions to those problems, but those same technologies bring with them a new set of HFE concerns. This article reviews the HFE considerations for information access, communication, and patient self-management, discusses how CHIT can potentially mitigate current problems, and explains how the design and implementation of CHIT itself requires careful HFE attention.

A change management framework for macroergonomic field research

With the proliferation of macroergonomic field research, it is time to carefully examine how such research should be managed and implemented. We argue that the importance of attending to high-quality implementation of field research is equal to that of methodological rigor. One way to systematically manage the implementation process is to adopt a change management framework, wherein the research project is conceptualized as an instance of organization-level change. Consequently, principles for successful organization-level change from the literature on change management can be used to guide successful field research implementation. This paper briefly reviews that literature, deriving 30 principles of successful change management, covering topics such as political awareness, assembling the change team, generating buy-in, and management support. For each principle, corresponding suggestions for macroergonomic field research practice are presented. We urge other researchers to further develop and adopt frameworks that guide the implementation of field research.

Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety

The authors develop a typology of clinicians' workarounds when using barcoded medication administration (BCMA) systems. Authors then identify the causes and possible consequences of each workaround. The BCMAs usually consist of handheld devices for scanning machine-readable barcodes on patients and medications. They also interface with electronic medication administration records. Ideally, BCMAs help confirm the five "rights" of medication administration: right patient, drug, dose, route, and time. While BCMAs are reported to reduce medication administration errors--the least likely medication error to be intercepted--these claims have not been clearly demonstrated. The authors studied BCMA use at five hospitals by: (1) observing and shadowing nurses using BCMAs at two hospitals, (2) interviewing staff and hospital leaders at five hospitals, (3) participating in BCMA staff meetings, (4) participating in one hospital's failure-mode-and-effects analyses, (5) analyzing BCMA override log data. The authors identified 15 types of workarounds, including, for example, affixing patient identification barcodes to computer carts, scanners, doorjambs, or nurses' belt rings; carrying several patients' prescanned medications on carts. The authors identified 31 types of causes of workarounds, such as unreadable medication barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient identification wristbands (chewed, soaked, missing); nonbarcoded medications; failing batteries; uncertain wireless connectivity; emergencies. The authors found nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted. Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations. Shortcomings in BCMAs' design, implementation, and workflow integration encourage workarounds. Integrating BCMAs within real-world clinical workflows requires attention to in situ use to ensure safety features' correct use.

Human factors and systems engineering approach to patient safety for radiotherapy

The traditional approach to solving patient safety problems in healthcare is to blame the last person to touch the patient. But since the publication of To Err is Human, the call has been instead to use human factors and systems engineering methods and principles to solve patient safety problems. However, an understanding of the human factors and systems engineering is lacking, and confusion remains about what it means to apply their principles. This paper provides a primer on them and their applications to patient safety.

Evaluation of a four year intervention to reduce musculoskeletal hazards among berry growers

PROBLEM

Fresh market berry production workers are exposed to physical risk factors for musculoskeletal injury.

METHOD

We disseminated information through trade publications and other sources to berry managers in seven U.S. states about five prevention through design practices that were both safer and more profitable than traditional methods. We administered mail evaluation questionnaires prior to the intervention and after each of four intervention years to rolling, independent U.S. samples and to comparison New Zealand berry farm manager samples after years one through three.

RESULTS

U.S. manager self-reports of reading trade publication information increased compared to baseline values for two of five practices and self-reported awareness increased for four of five practices. There were no increases in adoption. More U.S. than New Zealand managers reported getting information about two practices from trade publications and about four practices from public events. No U.S. versus New Zealand differences were observed in reported awareness or adoption for any practice.

IMPACT ON INDUSTRY

This study showed that even a modest campaign can build awareness of safer practices fairly quickly in three to four years among small agricultural firms but that increasing adoption apparently requires more time. Widespread adoption of safer practices could help keep operators in business longer as they age by reducing the workload and musculoskeletal strain associated with labor intensive crop production for them and their workforce. Adoption of practices that also improve profits, like the five practices featured in this study, could also help managers stay in business.