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)
À Ã
Õ
œŒ
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
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 3
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
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 4
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??)
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 5
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??)
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 6
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
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 7
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
performing clinical tasks
Both anesth. crew members
performing clinical tasks
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
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 8
Challenges� Comparison of methods without “gold standard”
� At what level of aggregation?
� Bland Altman plots?
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 9
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
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 10
Composition of coordination activities
Zur Anzeige wird der QuickTime™ Dekompressor „TIFF (Unkomprimiert)“
benötigt.
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 11
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
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 12
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)
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 13
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.
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 14
Coordination patterns & clinical performance
� Task Management
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 24.279 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.
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 15
Coordination patterns & clinical performance
� Information Management
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 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.
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 16
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
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 17
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??)
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 18
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?!
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 19
Challenges� Comparison of methods without “gold standard”
� At what level of aggregation?
� Bland Altman plots?
� 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.
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 20
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??)
?
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 21
Challenges� Comparison of methods without “gold standard”
� At what level of aggregation?
� Bland Altman plots?
� 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?
Center for Organizational and Occupational Science Tanja Manser • 15/08/2008 • 22
Some results of previous studies
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