A. Sammann1, L. Z. Chehab1, A. Sammann1 1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA
Introduction: Trauma patient rounds are complex, with a high volume of complicated patients in a dynamic environment with competing priorities and workflows. This presents challenges to improving quality, care experience, and resource use as single-method research approaches fail to comprehensively understand these complex systems. We combined the commonly used lean methodology with human-centered design (HCD), a methodology that is well-established in the technology and design community but novel to healthcare. We used this mixed methods approach to understand factors contributing to care team dissatisfaction on daily patient rounds at a safety-net teaching hospital and level 1 trauma center.
Methods: HCD uses ethnographic observations and in-depth interviews to understand the challenges and needs facing users of a system. We performed observations to identify 'work-arounds' and conducted 22 interviews with a cross-section of care team members (physicians, NPs, RNs, pharmacists, fellows, residents, students), hospital administrators (bed control, AOD), patients and families. Using lean, we performed time observations of 15 rounds, tracking activities related to flow and classified them as ‘clinically relevant’ and ‘non-clinically relevant.'
Results: The greatest source of dissatisfaction with rounds was the perceived inefficiency by care team members. Lean time observations confirmed that 34.2% of time was spent on ‘non-clinically relevant’ activities. Teaching was minimal and interruptions and clarifications were frequent which disrupted the flow of rounds. Through HCD we discovered that rounds were populated by 3 different groups of users: advocates (patients and RNs); learners (students and interns); and doers (residents, NPs and physicians). Each group had a different set of needs and expectations, resulting in disagreement over the purpose of rounds. Advocates wanted to share the patient perspective and understand the care plan; learners wanted to be educated and contribute to decision-making; and doers wanted to create a care plan without compromising quality of patient care.
Conclusion: By mixing methods using lean and HCD processes, we are able to gain a more comprehensive understanding of the system- and human-centered factors affecting rounds on a trauma surgical service. The system measures efficiency as a function of work and time, and lean demonstrated that our rounding process was inefficient as much of the time spent was on ‘non-clinically relevant’ work. Humans measure efficiency by the speed with which they can get their needs met. If their needs remain unmet, the experience is inefficient and satisfaction remains low. HCD allowed us to understand these subtleties and to classify the different needs of our user groups. To adequately address complex environments, we need to understand the strains on both the system and its users so that we can create sustainable quality improvement programs.