Identifying Constraints on Everyday Clinical Practice: Applying Work Domain Analysis to Emergency Department Care

Background Emergency departments (EDs) are complex socio-technical work systems that require staff to manage patients in an environment of fluctuating resources and demands. To better understand the purpose, and pressures and constraints for designing new ED facilities, we developed an abstraction hierarchy model as part of a work domain analysis (WDA) from the cognitive work analysis (CWA) framework. The abstraction hierarchy provides a model of the structure of the ED, encompassing the core objects, processes, and functions relating to key values and the ED’s overall purpose. Methods Reviews of relevant national and state policy, guidelines, and protocol documents applicable to care delivery in the ED were used to construct a WDA. The model was validated through focus groups with ED clinicians and subsequently validated using a series of WDA prompts. Results The model shows that the ED system exhibits extremely interconnected and complex features. Heavily connected functions introduce vulnerability into the system with function performance determined by resource availability and prioritization, leading to a trade-off between time and safety priorities. Conclusions While system processes (e.g., triage, fast-track) support care delivery in ED, this delivery manifests in complex ways due to the personal and disease characteristics of patients and the dynamic state of the ED system. The model identifies system constraints that create tension in care delivery processes (e.g., electronic data entry, computer availability) potentially compromising patient safety. Application The model identified aspects of the ED system that could be leveraged to improve ED performance through innovative ED system design.

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Accomodating complexity in telemedicine evaluation: using work domain analysis to analyze and represent the implementation context of a telemedicine service (Preprint)

10.2196/preprints.26580 ◽

2020 ◽

Author(s):

Hedvig Aminoff ◽

Sebastiaan Meijer

Keyword(s):

Data Collection ◽

Contextual Factors ◽

Clinical Work ◽

Domain Analysis ◽

Telemedicine Service ◽

Work Systems ◽

Work System ◽

Work Domain Analysis ◽

Implementation Context ◽

Work Domain

BACKGROUND The starting point for this research was a desire to understand the outcomes of scaling up a telemedicine service, which had shown promising results in a feasibility study. Teleguidance is a practitioner-to-practitioner service for remote surgical guidance during a highly technical endoscopic procedure, called ERCP (Endoscopic retrograde Cholangio-Pancreatografy). Due to numerous differences in how ERCP was conducted at the clinics involved, there was a need to create a fuller picture of what set the implementation sites apart sites in order understand the implementation and outcomes of teleguidance. However, the complexity that characterizes highly specialized clinical work systems made understanding the differences between the implementation contexts a methodological and practical challenge. There is increasing recognition that the outcomes of complex interventions are determined by dynamic interactions between social, organizational and design factors. While several recent implementation and evaluation frameworks emphasize complexity, they provide little guidance for how to understand or evaluate technological change in complex settings, or identify the interactions that contribute to implementation success and system-level outcomes. Work Domain Analysis (WDA), a method for analyzing and characterizing complex work settings in systems development, was identified as a candidate method for identifying and charting the contextual factors which shape clinical work during ERCP. However, applying the method was not straightforward, due to a number of methodological issues and practical hurdles: WDA method was initially developed for engineered, industrial systems which contrast to open, adaptive, healthcare systems. OBJECTIVE The objective was to investigate whether and how WDA could be applied to a widely defined clinical work system, by applying WDA to a practical case to create a baseline description of the work systems that would be impacted by the telemedicine implementation. METHODS As expected outcomes of the implementation had been expressed in terms of clinical, economical and training outcomes, the boundaries of the analysis were set widely. Three iterations of qualitative data collection were conducted at five clinical sites, followed by theoretically guided thematic analysis. Service blueprints were made as intermediary graphical representations during data collection. The common WDA representation, a matrix called the abstraction hierarchy (AH), was then constructed through multiple iterations, during which the results were presented to practitioners and suggestions about how to decompose the work system and to populate the cells of the AH-matrix gradually developed. RESULTS Multiple models of the domain representing three facets of the same work system were created. The clinical facet represents “primary” clinical work mainly performed in the operating room, and the administrative and development facets represent the “secondary” work systems providing infrastructure and resources necessary for the clinical procedures. The results show numerous contextual factors on multiple system levels which can come to impact the implementation and use of teleguidance. CONCLUSIONS WDA proved to be an efficient way to model the implementation context, providing guidance for qualitative analysis, identifying multiple sources of variability that can influence implementation outcomes. In addition, WDA provided a compact representation that supported multidisciplinary communication. CLINICALTRIAL n/a

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