Presentation
Exploring the Work Systems of Patient Placement Specialists
DescriptionIntroduction
As healthcare organizations continue to expand via new mergers and acquisitions, the work of admitting a patient from the emergency department (ED) and placing them into a hospital bed has become more and more complex. Where a patient, previously, would have either gotten a bed on a hospital unit or boarded in the ED, systems can now manage capacity by transferring patients to other in-network hospitals—especially essential for large academic medical centers or Level III trauma facilities that must prioritize the care of the highest acuity patients in the region. Thus, effectively placing patients is essential to delivering high quality care, facilitating throughput, and ensuring the health system does the greatest good for the most people.
Many health systems employ patient placement specialists (PPS) or similar staff to apply institutional expertise to appropriately assign patients to the units that can best meet their needs. Despite the essential role that PPS play in the modern health care system, their work has not, to our knowledge, been studied. Our objective is to describe the work of PPS using a human factors (HF)-based work systems model (Systems Engineering Initiative for Patient Safety or SEIPS) (Carayon et al., 2006).
Methods
This study is part of a large multi-disciplinary study aimed at implementing a machine learning (ML) algorithm, which predicts the likelihood of an ED patient to be admitted, into the electronic health record (EHR) of a large academic medical center in the Midwest US to support patient placement and throughput.
Data collection. To support the implementation of the algorithm, we first aimed to understand the work of PPS. For the purposes of this study, we chose to focus on patient placement into the highest-acuity hospital in the health system. One researcher (HB) conducted 8 hours of contextual inquiry over two days which involved shadowing PPS and, when appropriate, asking clarifying questions about their work (Holtzblatt & Beyer, 2016). The researcher took hand-written notes during the contextual inquiry and wrote detailed research memos to capture details of the observation and clarify the notes.
Data analysis. Research memos were coded for the SEIPS work system components—person, tools and technologies, tasks, organization, and physical environment—by one researcher (HB). Preliminary findings of this work system analysis are presented here.
Results
Organization. From the hours of 11am-11pm, the busiest time for patient admissions, two PPS are assigned to the highest-acuity hospital in the health system. One PPS works from 7am-7pm, the other from 7pm-7am, with another PPS covering 11am-11pm. PPS are supported by a manager and director and collaborate most closely with the care team leaders (CTL, the equivalent of a charge nurse) to coordinate patients’ bed assignments. PPS also collaborate with two “house supervisor” nurses who are stationed in the hospital to coordinate system-wide nurse staffing and capacity management.
People. The two PPS shadowed were trained as RNs, though not all PPS are clinically trained. The first PPS had experience working in the hospital into which they were placing patients. The other PPS had experience working in an intensive care unit (ICU) in another health system. The PPS with experience working in the hospital had a tacit knowledge of which units took certain patients as well as an intuition for whether the unit would want a patient or see a patient as “theirs.”
Tasks. The primary task of the PPS is to place patients with bed requests, i.e., patients coming from the ED, from a surgery, or from another hospital, into beds on appropriate units in the hospital. In practice, when there are two PPS working, one PPS focuses on placing the general care patients, while the other focuses on placing patients into ICU and intermediate care (IMU) beds. The second PPS also manages stepping patients down from ICU/IMU care (to general care beds) when possible, to free up higher acuity beds. Both PPS are in regular communication with CTLs, either by initiating a call to ask about the status of the unit or whether they can assign a specific patient to a bed in their unit or by fielding urgent calls from units. The work of the PPS changes dynamically as new information becomes available and priorities change, e.g., the PPS must stop reviewing the chart of an ED patient when alerted to a new bed request for a patient in a clinic that must be addressed given the heightened risk of the patient’s current location and level of care.
Tools and technologies. The PPS rely on the “bed board” view of the EHR, which shows the status of each bed in the hospital, i.e., available, blocked for maintenance, blocked for cleaning, or in use. Additionally, because their job requires significant amounts of communication, they utilize messaging functions within the EHR (primarily to direct message a CTL) and outside of the EHR (within group chats of a specific purpose, e.g., ED Patient Placement). They also utilize various tools as cognitive aids, i.e., a printed and laminated sheet summarizing the type of patients that each unit will take and a digital (and often printed) sheet listing all the ICU/IMC patients currently in the hospital.
Physical environment. The PPS work in a building off the hospital campus. In the bay of cubicles that the PPS work from, there are 6 sit-to-stand desks. Each day, PPS can choose which desk to work from. Every desk features a computer with four monitors—one directly in front of the PPS, two others flanking each side, and one above the center monitor. The offices of the manager and director are within 50-feet, and across the bay of cubicles is a makeshift conference room with a large central table. This table regularly housed snacks, as did the manager’s office.
Discussion and Conclusion
Understanding the work of PPS is a vital step toward achieving key operational objectives, e.g., throughput, of health systems. From this preliminary analysis of the PPS work system, it is clear that PPS are asked to develop a specialized expertise—understanding the specific cultures, preferences, and skills of hospital units—which they must apply to make high-stakes decisions of where to place patients. The dynamic nature of this work means that a PPS may make the “right” decision given the information they have at one moment and moments later receive new information that makes them “regret making that decision.” This value judgement on their decision-making is exacerbated by interaction with frustrated or disappointed system stakeholders, e.g., CTLs or attending physicians. Thus, the work of PPS is highly sociotechnical, relying not only on sufficient technologies to display and communicate the status of the health system, but also on maintaining complex relationships with stakeholders with diverse values, goals, and perceptions of system status. HF has the potential to support PPS through the redesign of technologies and organizational policies/structures that better support PPS decision making, make the current state of the system more transparent, and facilitate communication among system stakeholders.
Carayon, P., Schoofs Hundt, A., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: the SEIPS model. Qual Saf Health Care, 15 Suppl 1, i50-58. https://doi.org/10.1136/qshc.2005.015842
Holtzblatt, K., & Beyer, H. (2016). Contextual Design, Second Edition: Design for Life. Morgan Kaufmann Publishers Inc.
As healthcare organizations continue to expand via new mergers and acquisitions, the work of admitting a patient from the emergency department (ED) and placing them into a hospital bed has become more and more complex. Where a patient, previously, would have either gotten a bed on a hospital unit or boarded in the ED, systems can now manage capacity by transferring patients to other in-network hospitals—especially essential for large academic medical centers or Level III trauma facilities that must prioritize the care of the highest acuity patients in the region. Thus, effectively placing patients is essential to delivering high quality care, facilitating throughput, and ensuring the health system does the greatest good for the most people.
Many health systems employ patient placement specialists (PPS) or similar staff to apply institutional expertise to appropriately assign patients to the units that can best meet their needs. Despite the essential role that PPS play in the modern health care system, their work has not, to our knowledge, been studied. Our objective is to describe the work of PPS using a human factors (HF)-based work systems model (Systems Engineering Initiative for Patient Safety or SEIPS) (Carayon et al., 2006).
Methods
This study is part of a large multi-disciplinary study aimed at implementing a machine learning (ML) algorithm, which predicts the likelihood of an ED patient to be admitted, into the electronic health record (EHR) of a large academic medical center in the Midwest US to support patient placement and throughput.
Data collection. To support the implementation of the algorithm, we first aimed to understand the work of PPS. For the purposes of this study, we chose to focus on patient placement into the highest-acuity hospital in the health system. One researcher (HB) conducted 8 hours of contextual inquiry over two days which involved shadowing PPS and, when appropriate, asking clarifying questions about their work (Holtzblatt & Beyer, 2016). The researcher took hand-written notes during the contextual inquiry and wrote detailed research memos to capture details of the observation and clarify the notes.
Data analysis. Research memos were coded for the SEIPS work system components—person, tools and technologies, tasks, organization, and physical environment—by one researcher (HB). Preliminary findings of this work system analysis are presented here.
Results
Organization. From the hours of 11am-11pm, the busiest time for patient admissions, two PPS are assigned to the highest-acuity hospital in the health system. One PPS works from 7am-7pm, the other from 7pm-7am, with another PPS covering 11am-11pm. PPS are supported by a manager and director and collaborate most closely with the care team leaders (CTL, the equivalent of a charge nurse) to coordinate patients’ bed assignments. PPS also collaborate with two “house supervisor” nurses who are stationed in the hospital to coordinate system-wide nurse staffing and capacity management.
People. The two PPS shadowed were trained as RNs, though not all PPS are clinically trained. The first PPS had experience working in the hospital into which they were placing patients. The other PPS had experience working in an intensive care unit (ICU) in another health system. The PPS with experience working in the hospital had a tacit knowledge of which units took certain patients as well as an intuition for whether the unit would want a patient or see a patient as “theirs.”
Tasks. The primary task of the PPS is to place patients with bed requests, i.e., patients coming from the ED, from a surgery, or from another hospital, into beds on appropriate units in the hospital. In practice, when there are two PPS working, one PPS focuses on placing the general care patients, while the other focuses on placing patients into ICU and intermediate care (IMU) beds. The second PPS also manages stepping patients down from ICU/IMU care (to general care beds) when possible, to free up higher acuity beds. Both PPS are in regular communication with CTLs, either by initiating a call to ask about the status of the unit or whether they can assign a specific patient to a bed in their unit or by fielding urgent calls from units. The work of the PPS changes dynamically as new information becomes available and priorities change, e.g., the PPS must stop reviewing the chart of an ED patient when alerted to a new bed request for a patient in a clinic that must be addressed given the heightened risk of the patient’s current location and level of care.
Tools and technologies. The PPS rely on the “bed board” view of the EHR, which shows the status of each bed in the hospital, i.e., available, blocked for maintenance, blocked for cleaning, or in use. Additionally, because their job requires significant amounts of communication, they utilize messaging functions within the EHR (primarily to direct message a CTL) and outside of the EHR (within group chats of a specific purpose, e.g., ED Patient Placement). They also utilize various tools as cognitive aids, i.e., a printed and laminated sheet summarizing the type of patients that each unit will take and a digital (and often printed) sheet listing all the ICU/IMC patients currently in the hospital.
Physical environment. The PPS work in a building off the hospital campus. In the bay of cubicles that the PPS work from, there are 6 sit-to-stand desks. Each day, PPS can choose which desk to work from. Every desk features a computer with four monitors—one directly in front of the PPS, two others flanking each side, and one above the center monitor. The offices of the manager and director are within 50-feet, and across the bay of cubicles is a makeshift conference room with a large central table. This table regularly housed snacks, as did the manager’s office.
Discussion and Conclusion
Understanding the work of PPS is a vital step toward achieving key operational objectives, e.g., throughput, of health systems. From this preliminary analysis of the PPS work system, it is clear that PPS are asked to develop a specialized expertise—understanding the specific cultures, preferences, and skills of hospital units—which they must apply to make high-stakes decisions of where to place patients. The dynamic nature of this work means that a PPS may make the “right” decision given the information they have at one moment and moments later receive new information that makes them “regret making that decision.” This value judgement on their decision-making is exacerbated by interaction with frustrated or disappointed system stakeholders, e.g., CTLs or attending physicians. Thus, the work of PPS is highly sociotechnical, relying not only on sufficient technologies to display and communicate the status of the health system, but also on maintaining complex relationships with stakeholders with diverse values, goals, and perceptions of system status. HF has the potential to support PPS through the redesign of technologies and organizational policies/structures that better support PPS decision making, make the current state of the system more transparent, and facilitate communication among system stakeholders.
Carayon, P., Schoofs Hundt, A., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: the SEIPS model. Qual Saf Health Care, 15 Suppl 1, i50-58. https://doi.org/10.1136/qshc.2005.015842
Holtzblatt, K., & Beyer, H. (2016). Contextual Design, Second Edition: Design for Life. Morgan Kaufmann Publishers Inc.
Event Type
Oral Presentations
TimeWednesday, March 278:50am - 9:10am CDT
LocationSalon A-1
Hospital Environments