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DTSTAMP:20240325T185837Z
LOCATION:Salon C
DTSTART;TZID=America/Chicago:20240326T164500
DTEND;TZID=America/Chicago:20240326T181500
UID:HFESHCS_2024 International Symposium on Human Factors and Ergonomics i
 n Health Care_sess128_POST219@linklings.com
SUMMARY:PS8 - Kitchen Sink Methodology for Change in a Rural Healthcare In
 stitution
DESCRIPTION:Poster Presentation\n\nWendy Newman and Matthew Jesso (Guthrie
  Clinic)\n\nIntroduction\nThe desire to quickly solve issues that arise, c
 ombined with limited resources and limited exposure to different methodolo
 gies pose a unique challenge to Human Factors staff who are embedded in a 
 rural health setting. Utilizing methodologies that are routine in the Huma
 n Factors world might be foreign and seem unapproachable to staff that hav
 e not encountered such methods. For those accustomed to rapid resolution t
 hought processes, these methodologies can be seen as unnecessary, slowing 
 down the process, and even wrong at times.  Therefore, a multimodal or "ki
 tchen sink" approach is needed. The "kitchen sink" approach not only shows
  where the opportunities for improvement are; it also identifies how to me
 asure the success and sustainability of those interventions. The "kitchen 
 sink" approach allows us to introduce and show the value of novel, yet sta
 ndard Human Factors methodologies as applied in rural healthcare.\n	High r
 isk medications have additional safeguards in place due to the known heigh
 tened risk of harm when administering such a medication. This is true for 
 rural health care institutions as it is in large urban institutions. A cha
 nge in the electronic tools to assist nurses in calculating heparin rates 
 was implemented at our rural institution in August of 2022. Shortly therea
 fter, issues surrounding heparin were identified by Patient Safety through
  front line event reporting. A multidisciplinary workgroup was formed to u
 nderstand the causal factors leading to each of these events, and to ident
 ify where the opportunities for improvement were throughout the healthcare
  system. The Process Improvement team was tasked with guiding this multidi
 sciplinary workgroup through a project cycle to identify and safeguard aga
 inst as many contributing factors as possible.\nMethods\nThe known methodo
 logies of the group were to talk through the process for ordering, releasi
 ng, monitoring, and administering heparin. This was historically done thro
 ugh the lens of IT experts and higher-level leadership roles who do not ro
 utinely perform these high-risk medication tasks. Furthermore, visualizing
  a process map was not something that the group was accustomed to.  A fail
 ure modes effects analysis (FMEA), while known by work group members, hist
 orically was never part of the process to brainstorm and identify the prio
 rity levels of interventions.\nTo supplement this initial analysis, the pr
 ocess 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 administ
 ration process. A systematic analysis of event reports through the human f
 actors accident classification system (HFACS) was performed to better desc
 ribe and visualize the contributing factors. A heuristic analysis of the o
 rder set being used to administer heparin was performed. Front line staff 
 from targeted units were involved in cognitive walk throughs, semi structu
 red interviews about heparin protocols and tools (N=10). Frontline staff w
 ere also utilized to provide feedback for any software improvements to qui
 ckly iterate a design for better ease of use. \nResults\n	Process Maps\n	P
 rocess maps were made for ordering, monitoring, releasing, and administrat
 ion 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 ide
 ntify 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 educ
 ation, was the confusion of frontline staff surrounding the appropriate ti
 me to collect the lab which helps to inform any rate changes that might be
  needed.\n	FMEA\n	The FMEA tool was filled in based on work group discussi
 ons and the issues that were identified. Key stakeholders were identified 
 for each of the interventions with a proposed timeline. The scores for eac
 h of the potential failure modes were ranked to prioritize the interventio
 ns proposed to senior leadership. The FMEA scores indicated a reduction of
  potential harm surrounding Heparin administration.\n	HFACS\n	The systemat
 ic assessment of the event reports using HFACS showed that while we were s
 eeing errors, there were also improvements surrounding omitted actions, pr
 oper technique, inadequate situation assessments and shortcuts taken when 
 categorizing the event reports. The increase in errors were mainly surroun
 ding incorrect actions, inadequate action responses selected, and an inapp
 ropriate use of tools and technology as a routine error. The latent contri
 buting factors were caused primarily due to the consistency of the Nursing
  task, inadequate software guardrails for the tools and technology provide
 d to staff, and coordination issues surrounding inadequate monitoring to f
 rontline staff from Nursing leaders and Pharmacy. \n	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 f
 rontline staff about the process of administering heparin. Frontline nurse
 s wanted more collaboration with pharmacy as well as software guardrails t
 o help guide them to the right answer instead of having to calculate infus
 ion rates by hand. A post implementation assessment also proved to be a me
 asurement of success, showing the sustainability of the implementations pu
 t in place.\n	Heuristic Analysis\n	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 a
 nd HFACS assessments as well as to create a task analysis and visualizatio
 n to spark conversation in the work group. In conjunction with the other m
 ethodologies this also helped to target questions when asking frontline st
 aff their opinions on areas of improvement.\n	Frontline Feedback\n	Frontli
 ne nurses on three different units were targeted for feedback due to an in
 crease 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 desir
 e to be kept in the loop with how these calculations are being made, inste
 ad of using a “black box”. There was also a desire for better pharmacy col
 laboration to help validate that the nursing decisions are correct.\nEach 
 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 problem
 s arise, we are more likely to ask our frontline staff, map out and visual
 ize 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 opportu
 nities identified.\n\nTrack: Digital Health, Simulation and Education, Hos
 pital Environments, Medical and Drug Delivery Devices, Patient Safety Rese
 arch and Initiatives
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