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LOCATION:Salon A-3
DTSTART;TZID=America/Chicago:20240325T144200
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UID:HFESHCS_2024 International Symposium on Human Factors and Ergonomics i
 n Health Care_sess122_INDLEC297@linklings.com
SUMMARY:Coordination Patterns That Underpin Adaptive Capacity in Complex S
 ystems: A Sterile Processing Department Case Study
DESCRIPTION:Oral Presentations\n\nSudeep Hegde (Clemson University), Jacob
  Hionis (Michelin), Christine Jefferies (The Ohio State University), Gabri
 el Segarra (Medical University of South Carolina), Steven Foster (Clemson 
 University), Michael Rayo (The Ohio State University), Kenneth Catchpole (
 Medical University of South Carolina), and Lawrence Fredendall and Kevin T
 aaffe (Clemson University)\n\nThe Sterile Processing Department (SPD) in a
  hospital is responsible for decontamination and sterilization of used sur
 gical instruments, and supplying trays of clean instruments to operating r
 ooms (ORs) for upcoming surgeries. The SPD’s functioning is critical for p
 atient safety, care quality, and efficiency in a health system. For instan
 ce, missed or unsterile instruments can result in adverse patient outcomes
 . The SPD is a large and complex sociotechnical system consisting of multi
 ple sub-departments that service thousands of instruments daily. Addressin
 g the scale and complexity challenges of the SPD requires understanding ho
 w stakeholders in the system cope with various pressures and challenges in
  their everyday work. \n\nStudies on resilient performance in sociotechnic
 al systems have consistently pointed to communication and coordination as 
 key components of adaptive capacity. However, in this context, there are r
 elatively few studies that expand on the characteristics of communication 
 and coordination. Designing for adaptive capacity in complex systems invol
 ves designing for coordination.\n\nAim: \nThe aim of this study is to iden
 tify coordination patterns underpinning adaptive workflows that emerge in 
 response to various pressures across the SPD-OR complex in a large multisp
 ecialty hospital. Based on frontline stakeholders’ perspectives, the study
  seeks to identify factors that shape, enable, and impede effective coordi
 nation in the SPD, and to represent the relationship between such factors 
 with a structured approach. \n\nMethods: \nIn order to elicit the perspect
 ives of stakeholders in the SPD, observations of daily procedures and work
 flows were conducted, followed by semi-structure interviews. The interview
  method was based on a synthesis of the Systemic Contributors and Adaptati
 ons Diagramming (SCAD) approach (Jefferies et al., 2022) and the knowledge
  elicitation protocol described in Hegde et al. (2020). Per SCAD, the inte
 rview starts with a description of the ‘text-book’ workflow when the syste
 m is working as expected, followed by questions about how those workflows 
 would vary under systemic pressures and tradeoffs. Per Hegde et al. (2020)
 , cognitive probes focus on the role of specific capabilities (e.g., monit
 oring and anticipation, preparedness to respond, and coordination) that su
 pport adaptive performance.\n\nInterview transcripts and observation notes
  were analyzed for themes under three categories: pressures and constraint
 s, adaptations, and information flows (that support adaptations). Next, th
 e data were examined for relationships across the three categories. Pressu
 re themes were linked to the corresponding adaptive workflows, which were 
 mapped with the corresponding information flows. Here, information flows a
 re considered as the ‘currency’ of coordination. The focus of this present
 ation is specifically on the emergent patterns of coordination, including 
 challenges and strategies, in the context of systemic pressures and adapti
 ve capacity.\n\nFindings: \nSalient themes related to coordination are hig
 hlighted.\n\nCoordination and Communication Challenges\n\n•	Workaround lac
 k documentation, communication protocol: While workarounds are accepted as
  a characteristic feature of ‘work-as-done’, their ad hoc nature, lacking 
 any supervisory oversight, can create coordination gaps elsewhere in the s
 ystem. For instance, SPD technicians may sometimes substitute a damaged in
 strument in a tray with one from another tray without documenting the retr
 ieval, which creates an undocumented missing instrument issue downstream.\
 n\n•	Confusion, ambiguity, or lack of understanding: New SPD employees not
 ed that there were instances where they did not know whom to escalate prob
 lems or questions to. As an example, participants described scenarios wher
 e new hires would answer the phone and gather the information from the OR 
 but not relay the message to those who are more apt to handle the situatio
 n.\n\n•	High staff attrition and tightened staff resources: high attrition
  rates and absenteeism makes it more difficult to divide attention between
  individual operational tasks, and coordinating other workers’ tasks. For 
 instance, supervisors are often pulled into tray management tasks due to t
 he absence of tray workers, and are therefore unavailable for communicatio
 n with the ORs.\n\nAdaptive Patterns and Coordination Demands\n\n•	Role Ev
 olution: Under various pressures and constraints, staff may ad hoc transit
 ion to tasks that are not central to their roles to overcome gaps in workf
 low, such as a supervisor stepping in to help with tray assembly. However,
  the study also found that having a formal role exclusively for coordinati
 on is highly valuable. Specifically, the SPD had instituted an OR-Liaison 
 (OR-L) role as a dedicated resource for coordinating information between t
 he SPD and ORs, which was frequently mentioned in the interviews as helpfu
 l in daily operations.\n\n•	Substitute trays/instruments, such as ‘peel-pa
 cked’ instruments, are available for use in case of missing instruments du
 e to damage or malfunction. This requires communication from the SPD to th
 e ORs notifying them of peel-packed instruments available in place of miss
 ing instruments in the tray.\n\n•	Huddles between SPD managers, supervisor
 s, and technicians are held to share information, whether it be shift-to-s
 hift (within-level) or from supervisor to front-line worker (cross-level).
 \n\nCoordination Cost Matrix\n\nIt is important to note that the above cha
 llenges and gaps in coordination occur under the overarching time pressure
 . Given the OR schedule, utilization goals, and criticality of procedures,
  there is a constant pressure to maintain throughput. Under such severe ti
 me constraints, activities related to coordinating and communicating often
  take a backseat. Time pressure also constricts the room for initiative an
 d reciprocity, key features of adaptive performance in most sociotechnical
  systems. The propensity for initiative and reciprocity in an adaptive env
 ironment is challenged by the ‘cost’ associated with coordination. We char
 acterize this cost qualitatively, in terms of the availability or unavaila
 bility of two resource variables: information, and a channel of communicat
 ion. The relationship between these variables is represented in a 2X2 coor
 dination cost matrix. Each of the four ‘boxes’ in the matrix represents a 
 category of cost, Low, Moderate, Moderate, and High, defined by the specif
 ic combinations of the two variables, Information Available/Unavailable, a
 nd Channel Available/Unavailable. When both information and a channel of c
 ommunication are not readily available, the high cost associated with info
 rmation foraging, i.e. information seeking and ‘wayfinding’, places the hi
 ghest burden on coordination, and could make coordination gaps more likely
 . This was seen in the case of technicians new to the SPD not knowing wher
 e to ‘look up’ some information and how or whom to ask about it. Conversel
 y, when the information source is well known and there is an easily availa
 ble channel, as in the case of the SPD conveying to the OR about an expect
 ed missing instrument through the OR-L, it is more likely that coordinatio
 n occurs, and in a timely manner. When either one of information or the ch
 annel are not immediately available, there is at least a moderate cost ass
 ociated with information seeking, or wayfinding, respectively.\n\nThe matr
 ix representation could serve as a simple framework for organizations to i
 dentify costs of coordination for various workflows. Coordination gaps can
  be addressed by exploring ways to reduce the cost of coordination by maki
 ng both information and the channel(s) of communication more readily avail
 able or accessible by workers. Strategies could include reducing social gr
 adients of communication by using shared platforms system-wide for workers
  to raise issues that need redressal from leadership; having redundant cha
 nnels of communication to avoid information flow bottlenecks; and the use 
 of information visualization toward achieving operational ‘common ground’,
  or shared awareness across stakeholders.\n\nThe presentation will expand 
 on specific instantiations of patterns observed in each of the categories 
 of the coordination cost matrix. Examples of coordination mechanisms evolv
 ed bottom-up, such as informal liaising between individual workers across 
 SPD and OR groups, and top-down, such as the OR-L’s workflows, will be dis
 cussed in terms of how they support overall adaptive capacity of the SPD. 
 Potential strategies for improving coordination, such as those noted above
 , will also be discussed.\n\nTrack: Patient Safety Research and Initiative
 s\n\nSession Chairs: Hanna J Barton (University of Wisconsin - Madison) an
 d Asfand Khan (Embry-Riddle Aeronautical University, AdventHealth)
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