Human Performance and Patient Safety · Center for Organizational and Occupational Science Tanja...

Center for Occupational and Organizational Science Tanja Manser • 15/08/2008 • 1

Human Performance and Patient Safety

Current research and challenges

Tanja Manser, PhD, Center for Occupational and Organizational Science, ETH Zurich

Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 2

Research context: Human Performance and Patient Safety

Individual level

Team level

Organisational level

Clinical setting Simulator setting

Interview study:Coordination strategies(Manser et al., 2006)

Observational study:Coordination patterns(Manser et al., in press)

Observational study:Activity patterns(Manser et al., 2007)

Interview study:Reality and fiction cues(Dieckmann et al., 2007)

Frame of reference

Observational study:activity patterns(Manser & Wehner , 2002)

Observational study:Cognitive aid use(Harrison et al., 2006)

Observational study:Coordination patternsand clinical performance(Manser et al., under review)

Literature review:Teamwork & team training(Manser , under review)

Interview & observation:Socio-technical systems analysis(Manser et al., 2003)

Interview & observation:Applications of simulator technology(Dieckmann & Manser , 2003)

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Õ

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Hospital SafetyClimate (ongoing)

Safe patient handover(ongoing)

Risk managementin Swiss hospitals(ongoing)

Attitudes towardsincident reporting(ongoing)

Adaptive coordination(ongoing)

Ongoing research projectNote: Previous publications Article to of the habilitation œ


Current PhD projects

Individual

� Attitudes of health care professionals towards incident reporting /

barriers to reporting – Yvonne Pfeiffer

Team

� Adaptive coordination in anaesthesia teams and its relationship

to clinical performance – Michael Burtscher

Organization

� Clinical Risk Management in Swiss Hospitals – Matthias Briner

� Hospital safety climate – Yvonne Pfeiffer


Adaptive coordination in anaesthesia teams and

its relationship to clinical performance

Aim:

integrating and systematically comparing data from

� two descriptive observation systems for coordination activities

(Grote et al., 2004; Manser et al., 2005, 2008)

� non-technical skills ratings (ANTS), and

� different ways of assessing clinical performance

(global expert rating, checklist based rating, time-based measurement)

3 Modules:

a) simulations (asystole), b) live inductions (NRE-analysis),

c) simulations (NREs??)




Aim:







3 Modules:




Observation system A

Coordination Heedful Interrelating

watching the actions of

other team members

verbalizing own

behaviour

verbalized interpretations

of non-routine or sudden

events

giving negative feedback

in a positive manner

provide

unsolicited

task-relevant

information

offer

assistance

request

information

provide

information

upon request

provide

unsolicited

task-relevant

action

giving

unsolicited

feedback

monitoring

Chatting

Technical alarm

asking for help

giving order

assigning tasks

making

decision

Autocratic

behaviour

Silence and action

Coordination of information

exchange

Coordination of actions

Others

explicit implicit explicit implicit

assure

information

summary

questioning

information

provide action

upon request

teaching others

considering the future

questioning

decision

Listening

…

…

…

……

unsolicitedly

obtaining task-

relevant

information

Talking to patient

Silence and no

action


Observation system B

Coordination of the

overall work process

Non-coordination

related communication

Non-codable utterancesOTHER COM-

MUNICATION

Coordination via artifacts

Coordination via listening to

communications of others

Coordination by monitoring

the surgical crew

Coordination by monitoring

other (anesthesia) crew

membersCOORDINATION VIA

WORK ENVIRONMENT

CLINICAL

WORK

Anesthesia crew member A

performing clinical tasks

Anesthesia crew member B


Both anesth. crew members


INFORMATION MANAGEMENT

Discuss options

Make / state a decision

Question a decision

(Re-) evaluate a decision

DECISION MAKING

Acknowledgement

FEEDBACK

Situation assessment

(general)

Review process

SITUATION ASSESSMENT

Information request

Give information

after request

Provide information

without request

PROCESS INFORMATION

Request team

member infor mation

Provide team

member information

TEAM INFORMATION

TASK MANAGEMENT

Planning (general)

Prioritizing

Sequencing

PLANNING

Offering assistance

verbally

Offering assistance

non-verbally

Non-verbal request

for assistance

ASSISTANCE

Verbal request

for assistance

Task distribution (general)

Delegate

Give order

TASK DISTRIBUTION

Clarification

CLARIFICATION

INITIATE ACTION

Initiate an action

Defining coordination cues

METACOORDINATION

Teaching communication

TEACHING


Challenges� Comparison of methods without “gold standard”

� At what level of aggregation?

� Bland Altman plots?


Phase Phase

on-pump

off-pump

Clinical activities Coordination activities

Adaptive coordination: on- vs. off-pump

Effect Hotelling's

Trace

F df p Partial

Eta2

Observed

power

Between Case .15 1.55 2 .235 .13 .290

Within Phase 15.97 45.26 6 .000 .94 1.00

Phase x Case 1.176 3.33 6 .023 .54 .815


Composition of coordination activities

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benötigt.


Adaptation to a crisis situation

� Structural adaptation once the crisis situation is declared

� Additional resources

� More clinical work performed

� Increased overlap of work activities

� Process adaptation: Change in coordination patterns

� More time spent on coordination

� Decrease in coordination via the work environment

� Decrease in other communication


Coordination patterns & performanceActivities/sec.

Only Primary Anesth. present Second Anesth. present

Case 4 Coordination Process (Moving Average 60s)

Clinical Work Process (Moving Average 60s)

Phase I Phase II

Time (sec)

Activities/sec.

Only Primary Anesth. present Second Anesth. present

Case 4 Coordination Process (Moving Average 60s)

Clinical Work Process (Moving Average 60s)

Phase I Phase II

Time (sec)

MH-treatment score:

25 (out of 25)


Coordination patterns & clinical performance

� Coordination activities

Summary of Hierarchical Regression Analysis for Variables predicting Clinical Performance

(N = 23) [Team 3 excluded ]

B SE B

Step 1

Constant 17.892 .961

Cognitive aid Use .991 .322 .558**

Step 2

Constant 24.269 4.060

Cognitive aid Use .892 .321 .502*

Information Management .007 .060 .019

Task Management -.322 .111 -.466**

Coordination via Work Environment .172 .311 .099

Note. R = .311 for Step 1; R = .243 for Step 2 (ps < .05). * p < .05; ** p < .01.



� Task Management


(N = 23) [Team 3 excluded]

B SE B

Step 1



Step 2

Constant 24.279 2.354

Cognitive aid Use 1.102 .284 .620**

Planning -.246 .184 -.205

Task Distribution -.493 .145 -.539**

Clearification .753 .698 .183

Initiate an Action -.186 .457 -.068

Assistance -.465 .667 -.107

Note. R = .311 for Step 1; R = .340 for Step 2 (ps < .05). ** p < .01.



� Information Management


(N = 23) [Team 3 excluded ]

B SE B

Step 1



Step 2

Constant 23.264 5.506

Cognitive aid Use .703 .330 .396*

Information Transfer -.233 .184 -.306

Situation Assessment .531 .200 .569*

Decision Making -.146 .151 -.180

Acknowledging/Feedback -.232 .257 -.170

Note. R = .311 for Step 1 (p < .01); R = .227 for Step 2 (n. s.). * p < .05; ** p < .01.


Qualitative analysis of simulations

� Higher scoring crews

� focus on the coordination of the anesthesia work process

� are more specific about work roles

� prioritize clinical tasks effectively

� tend to “think out loud”

� Lower scoring crews

� activate more resources than they can coordinate effectively

� are more likely to split into sub-crews

� increase workload based on wrong assumptions




Aim:







3 Modules:




Measurement of clinical performance

� Global expert rating

� For whole induction

� For simulations focus on management of CI?

� Checklist-based rating

� For whole induction

� Delphi process to assign weights

� Time-based measurement

� applicable to CI-cases / simulations only?

� Correlations among clinical performance measures?!





� Measurement of clinical performance

� Specification of performance criteria for different clinical contexts / scenarios

� Appropriateness of expert ratings, time-based measures, scoring systems for

critical treatment steps etc.




Aim:







3 Modules:



?





� Measurement of clinical performance

� Specification of performance criteria for different clinical contexts / scenarios

� Appropriateness of expert ratings, time-based measures, scoring systems for

critical treatment steps etc.

� Relationship of clinical performance and teamwork characteristics

� Distribution of clinical performance?

� Consistency of clinical performance over cases or scenarios?

� Linear relationships between team process and clinical performance?


Some results of previous studies

Human Performance and Patient Safety · Center for Organizational and Occupational Science Tanja...

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