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www.mc.vanderbilt.edu/criss
Teaching & TrainingFaculty and staff provide guidance in
theories, methods and tools related to human factors through simulation-based
training and assessment.
Highly interdisciplinary and collaborative, CRISS conducts basic and applied research in healthcare informatics, patient safety and clinical quality, and designs and evaluates health information technology, care processes and medical devices.
Simulation-Based Performance Assessment
Checklist Tool Improves Quality of NICU Intraoperative Handovers Frequency-Selective Silencing Device for Digital Filtering of Alarm Sounds
The Epidemiology of Clinician- and Patient-reported Non-Routine Events (NREs) Patient-Reported Non-Routine Events (PNREs) in Oncology Treatment Pilot Study
Center for Experiential Learning & Assessment
Clinical Decision Support Tool for Cirrhosis Treatment Design and Evaluation of Hybrid Nuclear Power Plant Control Rooms
Patient-Centered Outcomes Research Institute (PCORI) Department of Energy (DOE) Agency for Healthcare Research and Quality (AHRQ) National Institutes of Standards
and Technology (NIST) Veterans Affairs Health Services Research & Development Anesthesia Patient Safety Foundation (APSF) National Institutes of Health (NIH) Foundation for Anesthesia Education & Research (FAER)
Injecting Healthcare with Human Factors
Communication & Decision Making
We investigate team communication, coordination, adaptive problem solving, culture and effectiveness, and individual and group performance-shaping factors.
Design & UsabilityCRISS investigators design and evaluate medical devices and health information technology. We have collaborated with
the VA, other Vanderbilt centers and outside vendors to develop and
improve the user experience.
Work Analysis & Improvement
Using human factors engineering, cognitive psychology, biomedical
engineering and implementation science, CRISS studies performance during patient
care to understand how and why care deviates from optimal.
Core Faculty & Staff
Sources of Research Support
Intraoperative handovers (patient care transitions) between anesthesia providers are variable, error prone and not well studied. Neonatal Intensive Care Unit (NICU) patients are especially vulnerable to medical errors. Our study evaluated how a NICU-to-OR structured handover assessment tool, developed during multi-disciplinary participatory design sessions, affected the quality of handovers and the frequency of transition-of-care –related events.
Free-field auditory medical alarms, although widely present in intensive care units, have created a number of hazards for both patients and clinicians in this environment. The harsh characteristics of the alarm noise profile combined the frequency at which they sound throughout the ICU have created discomfort for the patients and contribute to psychological problems, like PTSD and delirium.
CRISS collaborated with the Veteran’s Health Administration to develop a clinical decision support (CDS) tool aimed at improving the quality and continuity of care for patients with serious chronic diseases. The intervention’s focus is patients with advanced liver disease (cirrhosis), which constitutes a significant burden for veterans, requires resource intensive care, and is often under-diagnosed and under-treated. Cirrhosis provides a representative model for a number of complex, chronic diseases with recurrent exacerbations where integrated CDS tools may be highly effective.
Existing control rooms of nuclear power plants in the U.S. are analog, with electro-mechanical instruments and manual controls. Many control rooms are in the process of digital upgrades for greater reliability, operational efficiency, and cost-effectiveness. Funded through the Department of Energy’s Nuclear Energy University Program (NEUP), we are developing: 1) meta-level design guidance, 2) simulation scenario ontology, and 3) control room operator performance measures for the design and evaluation of the human-system interface in hybrid control rooms.
Matt Weinger, MDCRISS DirectorHIT & Technology Usability, Event Analysis
Matt Shotwell, PhDAssistant Professor (Biostatistics)Statistical Computing and Inference
Arna Banerjee, MDAssociate Professor of Anesthesiology, Assistant Professor of SurgeryEducation & Training
Shilo Anders, PhDResearch Assistant Professor (Anesthesiology)HIT UI Design & Evaluation
Jason Slagle, PhDResearch Assistant Professor (Anesthesiology)Task, Workload & Event Analysis
Scott Watkins, MDAssistant Professor (Pediatric Cardiac Anesthesiology)Cognitive Aids & Decision Support
Russ Beebe User Experience DesignerSarah Moroz Research Assistant IIKelly Peters Program CoordinatorCarrie Reale, MSN, RN-BC Informatics Nurse SpecialistEmma Schremp Research Assistant IIChristopher Simpson Research ManagerKatie Tippey, PhD, AHFP Postdoctoral Research FellowJie Xu, PhD Postdoctoral Research Fellow
Dan France, PhDResearch Associate Professor (Anesthesiology and Medicine)Healthcare System Modeling
Justin Liberman, MDInstructor (Anesthesiology)Interprovider Communication, Perioperative Research
Amanda Lorinc, MDAssistant Professor (Pediatric Anesthesiology)Patient Safety, Quality Improvement
Joseph Schlesinger, MDAssistant Professor HIT, Alarm Development, Multisensory Integration
Laurie Lovett Novak, PhD, MHSAAssistant Professor (Biomedical Informatics)Impact of HIT on Work Patterns
We observed 60 handovers pre- and 60 handovers post-implementation of the tool. Communication of critical information increased in all but one patient data category. When using the tool, staff satisfaction with the handover process improved and perception of a safe handover increased.
It is important for physicians to maintain their competence throughout their career. We used standardized high-fidelity simulation scenarios to assess the performance of practicing board-certified anesthesiologists (BCAs) during medical emergen-cies. Consenting BCAs, who already participated in simulation-based courses at one of 8 simulation centers, performed as the primary physician in standardized medical emergency scenarios. Video recorded performances were rated by trained, independent, blinded, and experienced BCAs. 263 participants managed 284 simulated events. Rater reliability for most measures was good.
Participants successfully completed 81% (median; interquartile range: 75 to 90%) of the critical performance elements. Both technical (5.0 ±2.1) and non-technical (5.4 ±2.0) ratings were distributed across the full 1–9 scale. Approximately one-quarter of participants received low holistic ratings (i.e. , three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated. Greater use of simulation-based assessment and training as part of physicians’ lifelong learning may be warranted.
CRISS collaborates closely with Vanderbilt’s Center for Experiential Learning and Assess ment (CELA), a multi purpose, high-fidelity simulation facility with 12 fully equipped clinical exam rooms, a 4-bed ICU or ED, and an OR suite. It’s equipped with two complete control rooms, mannequin-based simulation, and the latest in virtual reality simulators and partial task trainers. CELA affords an optimal environment for research and teaching.
Clinical practice frequently varies from optimal care, yet medical errors causing no patient harm often go unreported. We introduced to health care the concept of the Non-Routine Event (NRE), modeled after safety processes in the nuclear power industry where every deviation from standard operating procedures is reported and investigated. In health care, an NRE is defined as “any aspect of clinical care perceived by clinicians, patients, their family members (e.g., parents and caregivers) and/or trained observers as deviating from optimal care for that patient in that clinical situation.”
We explored the feasibility of collecting safety-relevant and experience-related PNREs and potentially related systems-safety data in the oncology environment. 20 adult radiation and 20 pediatric oncology patients completed a minimum of three data collection sessions, including PROMs and PNREs surveys, over two months.
[email protected]@vanderbilt.edu [email protected] [email protected]@[email protected]@vanderbilt.edu [email protected] [email protected] [email protected]@vanderbilt.edu
Clinicians routinely deviate from published guidelines and care teams often delay initiating resuscitative measures during cardiac arrest despite the knowledge that adherence to consensus guidelines improves patient survival and outcomes. It is increasingly evi dent that these failures are the result of deficiencies in both technical skills (TS) and non-technical skills (NTS).
Effect of Decision Support Tools on Team Performance in Simulated CrisesThe goal of this project is to determine if an electronic decision support tool (DST) can improve clinician performance by improving the clinical team’s NTS. In this study, the effect on clinical teams of different versions of an electronic DST (a version that emphasizes only TS, a version that emphasizes only NTS and a version that emphasizes both TS and NTS) will be evaluated during simulated emergencies.
In a series of studies across care domains (e.g., perioperative care, cardiology, oncology), we show that clinician- and patient-reported NREs: 1) are frequent (≥1 NRE in up to an average of 51% of all cases studied, depending on domain and reporting source); 2) capture a wide cross-section of system failures; 3) are associated with increased clinician workload and signifi-cant patient physiological disturbances; and 4) very few of the patients/family NREs were also reported by their clinicians and many were actually unknown to the clinicians. NREs provide a window on system safety and can be used as a dependent variable in safety interventions.
Using our expertise in medical simulation development, we created an initial framework for the scenario ontology. For example, requirements of scenario task may include monitoring critical plant parameters, manual input, and tasks prioriti-zation. Detailed observations of simulation training sessions and interviews with simulation training instructors were conducted based on the framework to understand the process of developing scenarios for control room interface evaluation.
Patient Chronic Illness Routines
We employed a user-centered design process to ensure the tool is both usable and useful for clinicians. Early phases of the project involved field observations and interviews with clinicians at multiple VA medical centers to identify decisions and tasks relevant to users and understand the contextual factors that may present barriers to the implementation and effectiveness of the tool. Early stage design concepts and preliminary clinical content were translated into to a functional CDS prototype.
Quantitative findings indicate that patient distress, quality of life, perception of the quality of the institution, race, and religion, all impact the likelihood of NRE occurrence, with safety-relevant events more heavily associated with quality of life than experience- related events.
Identification and development of a comprehensive set of valid and reliable control room operator performance measures is another ongoing effort of our team. Commonly used measures for workload, situation awareness, task performance and teamwork were identified and reviewed in nuclear power and other domains, and we are actively exploring the application of newly developed wearable physiological sensors in this environment.
The frequency-selective silencing device we are assessing seeks to attenuate these problems by removing the alarm sounds from the patient perspective. Patients do not need to hear these alarms as the alarms primarily serve to alert clinicians, and this device, through the use of a Raspberry Pi and digital filters, removes the alarm sounds present in the environment while passing all other sounds to the patient without distortion. This allows for patients to hear everything occurring around them and to communicate effectively without experiencing the negative consequences of audible alarms.
Qualitative findings suggest that PNREs are predominantly due to issues in clinical care processes, logistical and system factors, and patient factors, with safety-relevant and experience-related events associated with both factors. Overall, pediatric NREs were more often due to patient factors than clinical care process or logistical and system factors.
In four separate studies, we examine routines used by patients and their families to manage chronic illness:
• Cardiac Patients: We explored the activities involved in self-care routines and the role of physical artifacts and other actors.
• People with Diabetes: In two studies, we documented diabetes routines in everyday life and how routines are disrupted in a natural disaster.
• Teens with Asthma: We examined asthma management routines among teens and their parent caregivers, exploring the role of teens’ emerging autonomy on the stability of chronic illness routines.
View from CELA’s control room out to test bays.
How everyday practice can deviate from best practice.
Decision support tool screen listing technical skills during pulseless arrest management.
Shared elements among the many medication managing routines produce structure, which may increase resilience of the routines.
Obtaining
Preventive/ Predictive
Monitoring
Administration
Organizing/ Storing
Video rating software.
Analog (left) and digital (right) control rooms.
Categories of NREs, safety-relevant NREs, experience-related NREs.
Causal CategoryTotal NREs
Safety NREs
Experience NREs
All categories 111 38 73Patient factors 35 5 30Logistical & system factors 35 9 26Clinical care processes 26 17 9Teamwork 6 4 2Equipment or supplies 5 2 3Environment of care 4 1 3Individual factors 0 0 0
Handover tool design.
Handover Items Missed
NameAgeWeight
Attending
Allergies
H&P
Pre-Implementation Post-Implementation
Did Not Use Tool Used Tool
Handover Items Missed Post-Intervention60
40
20
0%
60
40
20
0% NameAgeWeight
Attending
Allergies
H&PPlan for
Emergence
The tool’s UI displays focused patient data with evidence-based guidelines.
Frequency-selective silencing device.Improved phoneme and word scores with alarm filtering.
Phoneme Score
Scor
e (%
cor
rect
)
70%
60
50
40
30
20
10
0Word Score
Unfiltered AlarmFiltered Alarm
