2009 © Xiao, UM

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Human Factors

Techno-logy

Medicine

Course Objectives

1. Review concepts and theories of coordination in literature

2. Characterize problems and issues of coordination and workflow in healthcare

3. Review of case studies in healthcare

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Yan Xiao, PhDProfessor of AnesthesiologyDirector, Research in Patient SafetyUniversity of Maryland School of MedicineBaltimore, Maryland, USA

2009 © Xiao, UM

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0

200

400

600

800

1000

1200

1400

1600

1800

2000

1960 1970 1980 1990 2000 2005 2010*

Nursing home care

Prescription drugs

Physician andclinical servicesHospital Care

2006 National Health Spending:

$2.1 Trillion$7,026/person16% of Gross Domestic Product (GDP)

Challenges of Coordination in Healthcare

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Medicine

Coordination in Healthcare: How it matters

• #1 priority for research: "Lack of communication and coordination (including coordination across organisations and discontinuity)" (British Medical Journal 2009)

• Poor coordination results in:• Low quality and efficiency• Errors in medication and treatment• Conflicting information

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Medicine

Coordination and mortality

• Medicare mortality lower among hospitals known for good nursing care - particularly the ability to coordinate across units

Source: Aiken, Sochalski, and Lake, Medical Care, 1997.

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Shortell, Zimmerman and Rousseau et al. Medical Care, 1994.

Coordination and Quality

• National Study of 42 Intensive Care Units

• Nursing leadership, ability to manage conflict, and better care coordination positively associated with lower risk-adjusted length of stay, lower nurse turnover, better evaluated technical quality of care and ability to meet family member needs.

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Coordination and surgical outcomes

• A study of 3,000 CABG patients in 16 hospitals

• A group-oriented, collaborative, participative culture was significantly associated with higher patient physical and mental functional health status scores six months post-discharge and shorter post-operative intubation times.

Shortell, Jones, Rademaker, and Gillies et al. 2000.

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Coordination and quality

• In a nine hospital study of patients with total hip and total knee replacement, relational coordination was significantly associated with less post-operative pain, greater post-operative functioning, and shorter length of stay.

Source: J. Gittel, K. Fairfield, and B. Bierbaum, et al.“Impact of Relational Coordination on Quality of Care,Post-Operative Pain and Functioning andLength of Stay,” Medical Care, 2000, 38(3):807-819.

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Medicine

Coordination in Healthcare How it matters

• Highly inter-dependent activities – Care is usually provided by

• multiple care providers

• over time

• at distributed locations

– Care needs are episodic and unpredictable– Highly variable patient needs

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Medicine

What Does Coordination Mean?(or Not*)

• Have what is need– “Medical record missing information had to wait for info to complete both surgical &

anesthesia consent.” – Case delayed 35 min.

• Have the correct information– “Final printed posting was changed from the correct original posting. Change did not reflect

the correct surgery. All supplies and instrument trays were wrong.”– Case delayed 40 min.

• Have the “left hand” to know what the “right hand” is doing– “Both Dr L and Dr R were scheduled for case.

Dr L thought Dr R was to start and Dr R thought Dr. L would start. Dr L was scheduled for another 1st case, when contacted he stated

he was the consult on the case.” – Case delayed 1 hr 45 min.

• Have the most current information– “OR front desk did not know pt was on 10 W.”

Case delayed 15 min.

*Reports courtesy of Kate Bott and Mike Harrington

2009 © Xiao, UM

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Human Factors

Techno-logy

Medicine

ICU

Time

TRU

OR 1

OR 2

PACU

Surg 1

Anesth

CRNA

Surg 2

Nurse 2

(Lecture)

Nurse 1

Trajectories

• Phenomenon definition: multiple people working on multiple “projects”, over long span of time and distances

• Problem definition: how people manage different trajectories

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Medicine

Examples of Trajectories

• Care activities for a surgical patient– Patient admission– Preparation of documents, supplies, personnel– Start and end of surgery– Post anesthesia care and intensive care– Recovery and rehabilitation– Discharge

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Medicine

Coordination in Healthcare What it is: Trajectory” of Patient Care

Admission

Diagnosis (MRI, CT, ETC)

Surgery Stabilization

Assessment+Disposition Discharge

Primary Team Consulting physicians O.T., P.T.

Social workerTransporter

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Medicine

Patient with Traumatic Brain Injury

Trauma Admitting Unit ICU Step Down

Treatment:Orthopedic

Surgery

Treatment: IVC orNeurosurgery

Stabilization:Vent weaning

ICP managementAdmission

Diagnosis:X-ray/CT/FAST

Primary Team Neurosurgery

Orthopedic Surgery

OT/PT

Case ManagerSocial WorkTransporter

Fnancial Advisor

9/28/2007 - 10/5/2007Preparation

For DC

Discharge:Specialized care (TBI rehab)Or transfer to Stepdown unit

Discharge:Specialized care

(TBI rehab)

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Medicine

Coordination in Healthcare What it is: the example of car crashes

• Time 0: two cars collided• Landmark 1: Emergency medical services system

activated• Landmark 2: Patients extricated and placed on

ambulances• Landmark 3: Patients arrived at trauma center• Landmark 4: Patients received definitive surgical

care

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Medicine

Coordination saves lives

Coordination challengesin emergency medicalservices (EMS)

Field

Command center

Hotline

NotificationBoard

TraumaResuscitation

Unit

Landing pad

Operatingroom

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Medicine

Coordination in Healthcare What it is: A broad definition

• Objects of coordination: what to coordinate– Information– Mental models– Expectations– Expertise– Authorities– Relations– Tasks

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Human Factors

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Medicine

Coordination in Healthcare What it is: A broad definition

• Means of coordination: how to coordinate– Explicit versus implicit– Low versus high bandwidth– Routine versus mutual adjustment mechanisms– Spontaneous versus reactive

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Medicine

Summary

• Coordination is a key challenge for healthcare, because of – Variations– Uncertainties– Distribution

• The objects of coordination include tasks, information, authorities, expectations

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Human Factors

Techno-logy

Medicine

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Medicine

University of Maryland Medical Center and Shock Trauma Center

• 32 operating rooms, 6 dedicated to trauma

• 10 trauma bays• 7000 annual trauma

patient admissions

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Medicine

Studies of Coordination at University of Maryland

• Healthcare context for coordination studies– Trauma resuscitation: Action teams – Operating rooms: Operations management of surgical

services– Intensive care units: transfers of information and

responsibilities

• Perspectives of understanding coordination– Social system of relations and conflicts– CSCW system of computing and cognition– Economic system of efficiency– Workflow system of activity and materials

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Medicine

Coordination Studies: Experience at University of Maryland

• Coordination in high intensity team (HIT) situation – Adaptive team structures (Xiao 2005)– Dynamic delegation and leadership (Klein

2006)

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Medicine

Coordination Studies: Experience at University of Maryland

• Orchestrating information flow in ICU– Structures of rounding communication

(Cardarelli in press)– Preparing for team meetings (Cervenka in

revision)– Reaching and communicating goals in team

meetings (“rounds”) (Xiao in review)– Information arena model of team

communication

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Human Factors

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Medicine

Coordination Studies: Experience at University of Maryland

• Managing workflow in operating suites– Communication burden of coordinators (Moss

2004)– Distributed coordination through OR video

(Xiao 2005)– Acceptance and usage of OR video (Xiao 2007)– Visual versus table display of procedural

duration uncertainty (Dexter, Ho 2008)

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Human Factors

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Medicine

Coordination Studies: Experience at University of Maryland

• Exception handling in trauma patient care– Discharge rounds (Sen 2008)

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Medicine

Summary

• Healthcare is a fertile domain to develop theories and concepts of coordination

• Different types of coordination problems facing care providers in different contexts

2009 © Xiao, UM

http://hfrp.umm.edu

Human Factors

Techno-logy

Medicine

HeadCam

Pan-Tilt-ZoomCamCeiling Mic

IR Duplex Audio