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.

With Crisis Comes Opportunity: Redesigning Performance Departments of Elite Sports Clubs for Life After a Global Pandemic

The suspension of major sporting competitions due to the global COVID-19 pandemic had a substantial negative impact on the sporting industry. As such, a successful and sustainable return to sport will require extensive modifications to the current operations of sporting organizations. In this article we argue that methods from the realm of sociotechnical systems (STS) theory are highly suited for this purpose. The aim of the study was to use such methods to develop a model of an Australian Football League (AFL) club’s football department. The intention was to identify potential modifications to the club’s operations to support a return to competition following the COVID-19 crisis. Subject Matter Experts from an AFL club participated in three online workshops to develop Work Domain Analysis and Social Organization and Cooperation Analysis models. The results demonstrated the inherent complexity of an AFL football department via numerous interacting values, functions and processes influencing the goals of the system. Conflicts within the system were captured via the modeling and included pursing goals that may not fully reflect the state of the system, a lack of formal assessment of core values, overlapping functions and objects, and an overemphasis on specialized roles. The current analysis has highlighted potential areas for modification in the football department, and sports performance departments in general.

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

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

Modeling implementation context in telemedicine: work domain analysis of Endoscopic Retrograde Cholangiopancreatography (Preprint)

BACKGROUND A telemedicine service enabling remote surgical guidance during Endoscopic Retrograde Cholangio-Pancreatografy (ERCP), had shown promising results. When the practice was to be scaled up, it was unclear how contextual variations between the clinical sites could play out. Few telemedicine innovations progress from the pilot stage to routine use, and while many recognize that contextual factors contribute to implementation outcomes, few telemedicine studies account for contextual factors during implementation in a systematic manner that also accommodates the complexity of healthcare settings. Work domain analysis is a method for modeling and analyzing how the structure of complex work environments shapes performance, and can be a way to investigate contextual factors that may influence telemedicine implementation. OBJECTIVE We wanted to conduct a work domain analysis in order to systematically characterize the implementation contexts at the clinics participating in the scale-up. This would allow us to identify constraints, such as objects, processes or priorities that shape ERCP work at the implementation sites, and that set the sites apart or might cause interactions that contribute to implementation outcomes. These findings could then be used to inform implementation and subsequent evaluation of teleguidance. The results could also serve as an example of how a the complex sociotechnical context of a clinical work system can be analyzed and represented in a structured way during telemedicine design and implementation. METHODS We conducted observations and semi-structured interviews with a variety of stakeholders. Conceptual themes derived from work domain analysis framework directed our analysis towards physical, social and cultural constraints that shape clinical work. An iterative “discovery and modeling” approach allowed us to first focus on one clinic, and readjust the scope and system boundaries as our understanding of the work systems became more refined. RESULTS ERCP practice is embedded in a work system with multiple sets of values and priorities, and we characterized the domain as three distinct facets:the treatment facet, the administrative facet (providing resources for procedures), and the development facet(training, quality improvement and research). A large number of causal constraints, such as medical equipment affecting treatment options, and administrative processes affecting access to staff and facilities were identified. Intentional constraints, such as values and priorities affecting assessments during ERCP and resources for the procedure, were also identified. CONCLUSIONS We found that intentional constraints in the treatment facet were largely shared across the implementation sites. There was more variation among the causal constraints, and we identified several factors that might make teleguidance be perceived as clumsy or unpractical. However, if teleguidance matches the values and priorities of the several facets at each site, there may be enough motivation and resources to overcome these types of initial disruptions. By contrasting the devlopment facets at different sites it became clear that some hospitals had less emphasis and resources for training and research. This might allow organizational demands for efficiency and effectiveness to take priority over the training needs or quality efforts that teleguidance answers to, or reduced willingness or ability to accept a service which is not yet fully developed or adapted. Work domain analysis proved to be a way to represent and analyze complex clinical contexts in the face of technological change, and may be a way to increase knowledge about the factors that contribute to the uptake of telemedicine.