Presentation
A Systems Engineering Approach to Organ Transplantation
DescriptionINTRODUCTION
Around 43,000 organ transplants were conducted in the U.S. in 2022. A multitude of factors are involved in a successful transplant; delivering the right organ to the right patient at the right time, and with proper consent, involves several multidisciplinary teams and external organizations under substantial time and decision-making pressure, often in non-ideal circumstances. Coordination between departments, team members, external organizations, and the patient is essential, and verification of informed consent from the patient at multiple steps of the process is paramount. Some organs, such as lungs, are particularly challenging to obtain and transplant, while others, such as kidneys, tend to be more readily available and forgiving to work with.
Applying systems engineering principles to healthcare work systems may help to understand and reduce complexity and opportunities for accidental harm, while increasing efficiency and timeliness. SEIPS 101 provides a toolkit designed for studying these factors in complex healthcare systems (Holden and Carayon, 2021). Here, we examined the transplant work systems and processes for lungs and kidneys at a clinical health system in the southeastern United States using a task analysis, process flow map, and SEIPS 101 journey maps to illustrate the people, tasks, tools, technology, work environment, and information involved in transplantation.
METHODS
We first used a basic systems framework to map out the key process phases prior to knife-to-skin, noting the SEIPS factors contributing to the work. This was done for both kidneys and lungs to identify similarities and differences across services, providing a context for more detailed study. An embedded human factors research team next worked with the transplant service to develop a task analysis and a process flow map. A series of interviews were conducted with frontline staff (5 Transplant Coordinators) to understand the details of their role and create the task analysis, which was utilized to construct two SEIPS 101 journey maps for the lung and kidney transplant processes. The maps were validated through direct observations, meetings, and interviews with experienced team members directly involved in the transplant coordination and care delivery processes. The people, tasks, tools, technology, environment, and information involved during each phase were collected and listed, and preliminary versions of the maps were shown to multiple frontline transplant professionals who were asked to confirm their validity and/or suggest improvements. Next, a transplant process flow map was created through direct observations of work as done in the operating room (OR) from the time the procedure was posted on the schedule to the start of the surgery. Validation of this diagram with frontline professionals is ongoing, as is the creation of additional diagrams for other related processes.
RESULTS
The transplant processes for lungs and kidneys have several distinct phases with multiple tasks shared across multidisciplinary teams. Phases included the initial patient visit, pre-transplant evaluation, selection committee, waitlist period, offer review, pre-op admission, and the transplant procedure. Lungs sometimes required additional discussion and evaluation periods for proper matching with patients when compared with kidneys. Individuals involved in the process included the patient, various physicians, nurses, pharmacists, transplant coordinators, surgeons, social workers, a financial team, a behavioral team, a dietary team, a multidisciplinary selection committee, organ couriers, and operating room staff. Information exchanged at each phase included electronic medical records, transplant risks and benefits, patient consent, donor information, waitlist positioning, organ offers and statuses, scheduling updates, transplant procedure details, and signature verifications.
The task analysis revealed the complexity of the work and the different tasks that need to be managed over the course of a shift. To organize information, Transplant Coordinators used an on-call report that was prepared via manual transcription which served as a source of information for many people involved in the process. Coordinators experienced frequent interruptions, a high level of multi-tasking, and often had to juggle several donor situations at once. Surgeons were sometimes unavailable for consultation about a new organ due to work demands and at times no backup consultation cover had been organized. Surgeons expressed frustration when experienced staff were not available, and OR teams regularly dealt with last minute changes to the operating surgeon, requiring rework to obtain preferred instruments and supplies.
Our results also illustrated how workflow differences between kidneys and lungs can contribute to task complexity. Kidney transplants happen substantially more often in the U.S. each year (25,000) than lung transplants (2,700), due to the matching precision required for lungs and the generally greater difficulty in obtaining appropriate lungs. Indeed, despite the various preparation steps we observed, organs delivered to the OR are still sometimes deemed unfit for use, leading to additional logistical, decision making and time pressure challenges for both care teams and patients. Opportunities for improvement remain; while all interviewees showed a high level of diligence and dedication toward their work, none were found to have a full insight into the complexity of the work system and the different system components needed for success.
DISCUSSION
By providing a deeper understanding of systems function for transplant work and the roles of the people within it, we aimed to to understand the wider challenges and systemic demands that need to be taken into account when addressing quality of care. Analysis of our results showed that for transplant procedures to succeed, highly detailed information must be transferred across databases and between teams to ensure the right organ gets to the right patient at the right time, with the proper consent gathered. All of this must be accomplished within a work system with time pressures, resource limitations, workload limitations, and changing teams and roles. An overview of the transplant process phases, detailed examination of the work of transplant coordinators, and direct observation of the process flow within the operating suite elucidated the complexity of the work within wider organizational and technoligical healthcare structures. The SEIPS journey maps and the process flow map also illustrated the complexity of the OR work and provided understanding of the context in which challenges occur.
Closing the gap between transplant work as it is currently understood by workers and decision makers and how the work is directly being performed through modeling can assist decision making and lead to opportunities for improvement. Possible workplace interventions could include aligning workflows across specialties, ensuring backup coverage for organ verification by surgeons, or development of more formal organizational multi-disciplinary learning principles for collaborating teams. Team support tools such as handoffs, huddles, or checklists may help improve proactive situational preparation and information sharing. Improved management of workloads, ongoing support for new team members, and protocols which are more visible and easier to use might also have a positive effect. Increased visibility of critical patient and organ information, improvements to centralized communication, establishment of primary data sources, and automated alternatives to manual entry of information can reduce re-work, save time, and decrease opportunities for mistakes.
CONCLUSIONS:
Transplant work involves a high level of complexity and can represent a substantial risk to the safety of patients and healthcare workers when problems occur. While a culture of diligence around transplantation is certainly present, complex systemic issues can contribute to non-ideal scenarios for healthcare team members, increasing safety risks. Therefore, developing a greater understanding of the transplant work system and the various factors contributing to its daily functioning may enhance quality of care. Systems engineering tools may help reveal factors contributing to system function and safety and facilitate development of possible workplace interventions. More work is needed to understand the complexities involved in the organ transplantation work system and the systemic context within which it functions.
Around 43,000 organ transplants were conducted in the U.S. in 2022. A multitude of factors are involved in a successful transplant; delivering the right organ to the right patient at the right time, and with proper consent, involves several multidisciplinary teams and external organizations under substantial time and decision-making pressure, often in non-ideal circumstances. Coordination between departments, team members, external organizations, and the patient is essential, and verification of informed consent from the patient at multiple steps of the process is paramount. Some organs, such as lungs, are particularly challenging to obtain and transplant, while others, such as kidneys, tend to be more readily available and forgiving to work with.
Applying systems engineering principles to healthcare work systems may help to understand and reduce complexity and opportunities for accidental harm, while increasing efficiency and timeliness. SEIPS 101 provides a toolkit designed for studying these factors in complex healthcare systems (Holden and Carayon, 2021). Here, we examined the transplant work systems and processes for lungs and kidneys at a clinical health system in the southeastern United States using a task analysis, process flow map, and SEIPS 101 journey maps to illustrate the people, tasks, tools, technology, work environment, and information involved in transplantation.
METHODS
We first used a basic systems framework to map out the key process phases prior to knife-to-skin, noting the SEIPS factors contributing to the work. This was done for both kidneys and lungs to identify similarities and differences across services, providing a context for more detailed study. An embedded human factors research team next worked with the transplant service to develop a task analysis and a process flow map. A series of interviews were conducted with frontline staff (5 Transplant Coordinators) to understand the details of their role and create the task analysis, which was utilized to construct two SEIPS 101 journey maps for the lung and kidney transplant processes. The maps were validated through direct observations, meetings, and interviews with experienced team members directly involved in the transplant coordination and care delivery processes. The people, tasks, tools, technology, environment, and information involved during each phase were collected and listed, and preliminary versions of the maps were shown to multiple frontline transplant professionals who were asked to confirm their validity and/or suggest improvements. Next, a transplant process flow map was created through direct observations of work as done in the operating room (OR) from the time the procedure was posted on the schedule to the start of the surgery. Validation of this diagram with frontline professionals is ongoing, as is the creation of additional diagrams for other related processes.
RESULTS
The transplant processes for lungs and kidneys have several distinct phases with multiple tasks shared across multidisciplinary teams. Phases included the initial patient visit, pre-transplant evaluation, selection committee, waitlist period, offer review, pre-op admission, and the transplant procedure. Lungs sometimes required additional discussion and evaluation periods for proper matching with patients when compared with kidneys. Individuals involved in the process included the patient, various physicians, nurses, pharmacists, transplant coordinators, surgeons, social workers, a financial team, a behavioral team, a dietary team, a multidisciplinary selection committee, organ couriers, and operating room staff. Information exchanged at each phase included electronic medical records, transplant risks and benefits, patient consent, donor information, waitlist positioning, organ offers and statuses, scheduling updates, transplant procedure details, and signature verifications.
The task analysis revealed the complexity of the work and the different tasks that need to be managed over the course of a shift. To organize information, Transplant Coordinators used an on-call report that was prepared via manual transcription which served as a source of information for many people involved in the process. Coordinators experienced frequent interruptions, a high level of multi-tasking, and often had to juggle several donor situations at once. Surgeons were sometimes unavailable for consultation about a new organ due to work demands and at times no backup consultation cover had been organized. Surgeons expressed frustration when experienced staff were not available, and OR teams regularly dealt with last minute changes to the operating surgeon, requiring rework to obtain preferred instruments and supplies.
Our results also illustrated how workflow differences between kidneys and lungs can contribute to task complexity. Kidney transplants happen substantially more often in the U.S. each year (25,000) than lung transplants (2,700), due to the matching precision required for lungs and the generally greater difficulty in obtaining appropriate lungs. Indeed, despite the various preparation steps we observed, organs delivered to the OR are still sometimes deemed unfit for use, leading to additional logistical, decision making and time pressure challenges for both care teams and patients. Opportunities for improvement remain; while all interviewees showed a high level of diligence and dedication toward their work, none were found to have a full insight into the complexity of the work system and the different system components needed for success.
DISCUSSION
By providing a deeper understanding of systems function for transplant work and the roles of the people within it, we aimed to to understand the wider challenges and systemic demands that need to be taken into account when addressing quality of care. Analysis of our results showed that for transplant procedures to succeed, highly detailed information must be transferred across databases and between teams to ensure the right organ gets to the right patient at the right time, with the proper consent gathered. All of this must be accomplished within a work system with time pressures, resource limitations, workload limitations, and changing teams and roles. An overview of the transplant process phases, detailed examination of the work of transplant coordinators, and direct observation of the process flow within the operating suite elucidated the complexity of the work within wider organizational and technoligical healthcare structures. The SEIPS journey maps and the process flow map also illustrated the complexity of the OR work and provided understanding of the context in which challenges occur.
Closing the gap between transplant work as it is currently understood by workers and decision makers and how the work is directly being performed through modeling can assist decision making and lead to opportunities for improvement. Possible workplace interventions could include aligning workflows across specialties, ensuring backup coverage for organ verification by surgeons, or development of more formal organizational multi-disciplinary learning principles for collaborating teams. Team support tools such as handoffs, huddles, or checklists may help improve proactive situational preparation and information sharing. Improved management of workloads, ongoing support for new team members, and protocols which are more visible and easier to use might also have a positive effect. Increased visibility of critical patient and organ information, improvements to centralized communication, establishment of primary data sources, and automated alternatives to manual entry of information can reduce re-work, save time, and decrease opportunities for mistakes.
CONCLUSIONS:
Transplant work involves a high level of complexity and can represent a substantial risk to the safety of patients and healthcare workers when problems occur. While a culture of diligence around transplantation is certainly present, complex systemic issues can contribute to non-ideal scenarios for healthcare team members, increasing safety risks. Therefore, developing a greater understanding of the transplant work system and the various factors contributing to its daily functioning may enhance quality of care. Systems engineering tools may help reveal factors contributing to system function and safety and facilitate development of possible workplace interventions. More work is needed to understand the complexities involved in the organ transplantation work system and the systemic context within which it functions.
Event Type
Oral Presentations
TimeTuesday, March 262:37pm - 3:00pm CDT
LocationSalon A-3
Patient Safety Research and Initiatives