Presentation
PS8 - Kitchen Sink Methodology for Change in a Rural Healthcare Institution
DescriptionIntroduction
The desire to quickly solve issues that arise, combined with limited resources and limited exposure to different methodologies pose a unique challenge to Human Factors staff who are embedded in a rural health setting. Utilizing methodologies that are routine in the Human Factors world might be foreign and seem unapproachable to staff that have not encountered such methods. For those accustomed to rapid resolution thought processes, these methodologies can be seen as unnecessary, slowing down the process, and even wrong at times. Therefore, a multimodal or "kitchen sink" approach is needed. The "kitchen sink" approach not only shows where the opportunities for improvement are; it also identifies how to measure the success and sustainability of those interventions. The "kitchen sink" approach allows us to introduce and show the value of novel, yet standard Human Factors methodologies as applied in rural healthcare.
High risk medications have additional safeguards in place due to the known heightened risk of harm when administering such a medication. This is true for rural health care institutions as it is in large urban institutions. A change in the electronic tools to assist nurses in calculating heparin rates was implemented at our rural institution in August of 2022. Shortly thereafter, issues surrounding heparin were identified by Patient Safety through front line event reporting. A multidisciplinary workgroup was formed to understand the causal factors leading to each of these events, and to identify where the opportunities for improvement were throughout the healthcare system. The Process Improvement team was tasked with guiding this multidisciplinary workgroup through a project cycle to identify and safeguard against as many contributing factors as possible.
Methods
The known methodologies of the group were to talk through the process for ordering, releasing, monitoring, and administering heparin. This was historically done through the lens of IT experts and higher-level leadership roles who do not routinely perform these high-risk medication tasks. Furthermore, visualizing a process map was not something that the group was accustomed to. A failure modes effects analysis (FMEA), while known by work group members, historically was never part of the process to brainstorm and identify the priority levels of interventions.
To supplement this initial analysis, the process maps were then created and visualized to allow a single mental model to review, discuss, and adjust. These maps were created for each hospital site within the system to display the differences in the Heparin administration process. A systematic analysis of event reports through the human factors accident classification system (HFACS) was performed to better describe and visualize the contributing factors. A heuristic analysis of the order set being used to administer heparin was performed. Front line staff from targeted units were involved in cognitive walk throughs, semi structured interviews about heparin protocols and tools (N=10). Frontline staff were also utilized to provide feedback for any software improvements to quickly iterate a design for better ease of use.
Results
Process Maps
Process maps were made for ordering, monitoring, releasing, and administration of heparin. The process maps were created In Visio for each inpatient hospital site (N=4). With the creation of the maps the workgroup could identify the variability in processes and staff support. For example, one of the four sites had increased pharmacy monitoring tasks identified, leading to a reduction in overall events related to heparin when compared to the system. Another insight which led to policy improvements and targeted education, was the confusion of frontline staff surrounding the appropriate time to collect the lab which helps to inform any rate changes that might be needed.
FMEA
The FMEA tool was filled in based on work group discussions and the issues that were identified. Key stakeholders were identified for each of the interventions with a proposed timeline. The scores for each of the potential failure modes were ranked to prioritize the interventions proposed to senior leadership. The FMEA scores indicated a reduction of potential harm surrounding Heparin administration.
HFACS
The systematic assessment of the event reports using HFACS showed that while we were seeing errors, there were also improvements surrounding omitted actions, proper technique, inadequate situation assessments and shortcuts taken when categorizing the event reports. The increase in errors were mainly surrounding incorrect actions, inadequate action responses selected, and an inappropriate use of tools and technology as a routine error. The latent contributing factors were caused primarily due to the consistency of the Nursing task, inadequate software guardrails for the tools and technology provided to staff, and coordination issues surrounding inadequate monitoring to frontline staff from Nursing leaders and Pharmacy.
These insights gained from the event reports led to additional failure modes identified for the FMEA to score. Insights also led to more targeted questions when asking frontline staff about the process of administering heparin. Frontline nurses wanted more collaboration with pharmacy as well as software guardrails to help guide them to the right answer instead of having to calculate infusion rates by hand. A post implementation assessment also proved to be a measurement of success, showing the sustainability of the implementations put in place.
Heuristic Analysis
The heuristic analysis of the order set was created to show the bottlenecks and confusion points when interacting with the EMR. This helped to validate the issues identified in the FMEA and HFACS assessments as well as to create a task analysis and visualization to spark conversation in the work group. In conjunction with the other methodologies this also helped to target questions when asking frontline staff their opinions on areas of improvement.
Frontline Feedback
Frontline nurses on three different units were targeted for feedback due to an increase in heparin related issues at those unit locations. Semi structured interviews yielded results that indicated a distrust of the EMR tool. This was due to poor implementation of the tool in the past. There was a desire to be kept in the loop with how these calculations are being made, instead of using a “black box”. There was also a desire for better pharmacy collaboration to help validate that the nursing decisions are correct.
Each of the new (Human Factors, User Centered) approaches supplemented what was already in place and helped to drive the discussion of the workgroup to a more meaningful end. This "kitchen sink" approach has not only helped to sustainably reduce the risk of administering this medication but has also helped to move the culture of a rural healthcare system. When new problems arise, we are more likely to ask our frontline staff, map out and visualize a process, and explore and critique data. We are also more likely to see leadership asking for additional insights that Human Factors staff can provide. The goal of embedded Human Factors staff should not be to solve the problem but to trust the process and guide the experts to the opportunities identified.
The desire to quickly solve issues that arise, combined with limited resources and limited exposure to different methodologies pose a unique challenge to Human Factors staff who are embedded in a rural health setting. Utilizing methodologies that are routine in the Human Factors world might be foreign and seem unapproachable to staff that have not encountered such methods. For those accustomed to rapid resolution thought processes, these methodologies can be seen as unnecessary, slowing down the process, and even wrong at times. Therefore, a multimodal or "kitchen sink" approach is needed. The "kitchen sink" approach not only shows where the opportunities for improvement are; it also identifies how to measure the success and sustainability of those interventions. The "kitchen sink" approach allows us to introduce and show the value of novel, yet standard Human Factors methodologies as applied in rural healthcare.
High risk medications have additional safeguards in place due to the known heightened risk of harm when administering such a medication. This is true for rural health care institutions as it is in large urban institutions. A change in the electronic tools to assist nurses in calculating heparin rates was implemented at our rural institution in August of 2022. Shortly thereafter, issues surrounding heparin were identified by Patient Safety through front line event reporting. A multidisciplinary workgroup was formed to understand the causal factors leading to each of these events, and to identify where the opportunities for improvement were throughout the healthcare system. The Process Improvement team was tasked with guiding this multidisciplinary workgroup through a project cycle to identify and safeguard against as many contributing factors as possible.
Methods
The known methodologies of the group were to talk through the process for ordering, releasing, monitoring, and administering heparin. This was historically done through the lens of IT experts and higher-level leadership roles who do not routinely perform these high-risk medication tasks. Furthermore, visualizing a process map was not something that the group was accustomed to. A failure modes effects analysis (FMEA), while known by work group members, historically was never part of the process to brainstorm and identify the priority levels of interventions.
To supplement this initial analysis, the process maps were then created and visualized to allow a single mental model to review, discuss, and adjust. These maps were created for each hospital site within the system to display the differences in the Heparin administration process. A systematic analysis of event reports through the human factors accident classification system (HFACS) was performed to better describe and visualize the contributing factors. A heuristic analysis of the order set being used to administer heparin was performed. Front line staff from targeted units were involved in cognitive walk throughs, semi structured interviews about heparin protocols and tools (N=10). Frontline staff were also utilized to provide feedback for any software improvements to quickly iterate a design for better ease of use.
Results
Process Maps
Process maps were made for ordering, monitoring, releasing, and administration of heparin. The process maps were created In Visio for each inpatient hospital site (N=4). With the creation of the maps the workgroup could identify the variability in processes and staff support. For example, one of the four sites had increased pharmacy monitoring tasks identified, leading to a reduction in overall events related to heparin when compared to the system. Another insight which led to policy improvements and targeted education, was the confusion of frontline staff surrounding the appropriate time to collect the lab which helps to inform any rate changes that might be needed.
FMEA
The FMEA tool was filled in based on work group discussions and the issues that were identified. Key stakeholders were identified for each of the interventions with a proposed timeline. The scores for each of the potential failure modes were ranked to prioritize the interventions proposed to senior leadership. The FMEA scores indicated a reduction of potential harm surrounding Heparin administration.
HFACS
The systematic assessment of the event reports using HFACS showed that while we were seeing errors, there were also improvements surrounding omitted actions, proper technique, inadequate situation assessments and shortcuts taken when categorizing the event reports. The increase in errors were mainly surrounding incorrect actions, inadequate action responses selected, and an inappropriate use of tools and technology as a routine error. The latent contributing factors were caused primarily due to the consistency of the Nursing task, inadequate software guardrails for the tools and technology provided to staff, and coordination issues surrounding inadequate monitoring to frontline staff from Nursing leaders and Pharmacy.
These insights gained from the event reports led to additional failure modes identified for the FMEA to score. Insights also led to more targeted questions when asking frontline staff about the process of administering heparin. Frontline nurses wanted more collaboration with pharmacy as well as software guardrails to help guide them to the right answer instead of having to calculate infusion rates by hand. A post implementation assessment also proved to be a measurement of success, showing the sustainability of the implementations put in place.
Heuristic Analysis
The heuristic analysis of the order set was created to show the bottlenecks and confusion points when interacting with the EMR. This helped to validate the issues identified in the FMEA and HFACS assessments as well as to create a task analysis and visualization to spark conversation in the work group. In conjunction with the other methodologies this also helped to target questions when asking frontline staff their opinions on areas of improvement.
Frontline Feedback
Frontline nurses on three different units were targeted for feedback due to an increase in heparin related issues at those unit locations. Semi structured interviews yielded results that indicated a distrust of the EMR tool. This was due to poor implementation of the tool in the past. There was a desire to be kept in the loop with how these calculations are being made, instead of using a “black box”. There was also a desire for better pharmacy collaboration to help validate that the nursing decisions are correct.
Each of the new (Human Factors, User Centered) approaches supplemented what was already in place and helped to drive the discussion of the workgroup to a more meaningful end. This "kitchen sink" approach has not only helped to sustainably reduce the risk of administering this medication but has also helped to move the culture of a rural healthcare system. When new problems arise, we are more likely to ask our frontline staff, map out and visualize a process, and explore and critique data. We are also more likely to see leadership asking for additional insights that Human Factors staff can provide. The goal of embedded Human Factors staff should not be to solve the problem but to trust the process and guide the experts to the opportunities identified.
Event Type
Poster Presentation
TimeTuesday, March 264:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives