Christopher Nemeth

Discovering Healthcare Cognition: The Use of Cognitive Artifacts to Reveal Cognitive Work

Healthcare systems, especially hospital operating room suites, have properties that make them ideal for the study of the cognitive work using the naturalistic decision-making (NDM) approach. This variable, complex, high-tempo setting provides a unique opportunity to examine the ways that clinicians plan, monitor, and cope with the irreducible uncertainty that underlies this work domain. As frontline managers, anesthesia coordinators plan and manage anesthesia assignments for surgical procedures. As frontline managers, coordinators develop and use cognitive artifacts to distribute cognition across time and among members of the acute care staff. Examination of these cognitive artifacts and their use reveals the hidden subtleties of the coordinators’ work. The use of NDM methods including cognitive artifact analysis to understand cognitive work generates insights that extend beyond the operator level to the study of team-level cognition. Results can be used to create computer-based artifacts that aid individual and team cognition.

The Messy Details: Insights From the Study of Technical Work in Healthcare

—The papers in this special issue demonstrate productive methods of coping with the messy details of technical work in healthcare. The studies demonstrate both how difficult it is to do in depth studies of healthcare technical work and also how rewarding such studies can be. They prompt us to look at technical work studies more generally and ask why they are so well suited to research on the human factors of a hyper-complex setting—healthcare.

Regularly irregular: how groups reconcile cross-cutting agendas and demand in healthcare

The flow of technical work in acute healthcare varies unpredictably, in patterns that occur regularly enough that they can be managed. Acute care organizations develop ways to hedge resources so that they are available if they are needed. This pragmatic approach to the distribution of work among and across groups shows how rules can be used to manage a response to irregular demands for care. However, no rule set can be complete enough to cover this setting’s variety of care demands. Expertise is also needed to tie together the loose ends of conflicts that remain where rules no longer suffice. Many informal solutions to systemic problems go unnoticed unless they are the subjects of study. Naturalistic decision making (NDM) methods such as observational study, interviews, and process tracing reveal the activities of workers in their natural settings. Results of findings from such explorations of technical work can improve understanding of large scale work processes and, ultimately, patient safety. We have explored how practitioners cope with the demands that the system presents to them. While not all succeed, successful initiatives workers have developed demonstrate how their solutions create resilience at large scale.

Cognitive artifacts in complex work

The Indian folk tale recorded in the well-known John Saxe poem tells of six blind men, each grabbing a different part of an elephant, and describing their impression of the whole beast from a single parts perspective. So the elephant appears to each blind man to be like a snake, a fan, a tree, a rope, a wall, a spear. As the poem concludes: “And so these men of Indostan, Disputed loud and long, Each in his own opinion, exceeding stiff and strong. Though each was partly right, All were in the wrong.” Although this tale suggests a general metaphor for poor collaboration and social coordination, the insinuation of blindness indicates an inability to share the common information that is normally available through visual perception. When fundamental cognitive resources such as shared information or visual cues are missing, collaborative work practices may suffer from the “anti-cognition” suggested by the elephant metaphor. When individuals believe they are contributing to the whole, but are unable to verify the models that are held by other participants, continued progress might founder. We may find such “blind men” situations when organizations value and prefer independent individual cognition at the expense of supporting whole system coordination. Blindness to shared effects is practically ensured when those who work together are not able to share information.

Between choice and chance: the role of human factors in acute care equipment decisions.

Objectives: We report on a human factors evaluation project at a major urban teaching hospital that was intended to use human factors methods to assist the selection of a new infusion device among 4 commercially available models. Methods: The project provided an expert evaluation of the pumps, collected data on programming each pump by a sample of practitioners, tabulated recent adverse event reports in the US Food and Drug Administration Manufacturer and User Device Experience database, and observed actual use in intensive care and hematology/oncology units. Results: Programming by clinicians showed no correlation between clinical experience and ability to program any of the pumps under consideration. Field observations reflected diverse use patterns across services that required ease of use pumps did not offer. Upon review of a final candidate pump, purchasing preferences superceded clinical considerations. Conclusions: Equipment and systems that are intended for use by clinicians must necessarily reflect an understanding of actual clinical practice to be well suited for use at the sharp (operator) end. However, purchase decisions for medical equipment including infusion devices are typically made by hospital staff members who are experienced in administrative and clinical matters but have no expertise in the evaluation of complex equipment. This project demonstrates how collaboration by human factors and clinical professionals can inform equipment decisions and assist clinician performance to improve patient safety. It also reveals how technical decisions that directly influence anesthesia staff performance and patient safety are subject to organizational factors such as social and political pressure.

Healthcare IT as a source of resilience

Healthcare information technology (IT) systems can be used to inform workers and managers about changes to workplace vulnerabilities and new means that may be available to meet challenges such as widely varying demand. IT system success, though, depends on adaptability in the face of change, which is a property that IT systems do not currently demonstrate. Resilience engineering seeks to create and maintain systems that can cope and adapt to complex, changing environments and can be used to develop IT systems that are capable of adaptation as the sharp (operator) end of healthcare requires. Research into resilience needs to address questions that have genuine import for healthcare and IT systems that are intended to support it.

Reliability versus Resilience: What Does Healthcare Need?

System performance in healthcare pivots on the ability to match demand for care with the resources that are needed to provide it. High reliability is desirable in organizations that perform inherently hazardous, highly technical tasks. However, healthcares high variability, diversity, partition between workers and managers, and production pressure make it difficult to employ essential aspects of high reliability organizations (HROs) such as redundancy and extensive training. A different approach is needed to understand the nature of healthcare systems and their ability to perform and survive under duress; in other words, to be resilient. The recent evolution of resilience engineering affords the opportunity to configure healthcare systems so that they are adaptable and can foresee challenges that threaten their mission. Information technology (IT) in particular can enable healthcare, as a service sector, to adapt successfully, as long as it is based on cognitive systems engineering approaches to achieve resilient performance.

Before i forget: How clinicians cope with uncertainty through ICU sign-outs

Transitions between shifts in the intensive care unit (ICU) create potential gaps in the continuity of care, and practitioners necessarily rely on distributed cognition to prevent the formation of gaps during work-cycle shift changes. The complexity and uncertainty of each ICU patients condition require efficient communication between practitioners during transfers between departments or when cycling work through shifts. This study observed twelve unit-level exchanges among six clinicians handing off a 33-bed PICU and step-down unit, then examined them using conversation analysis. Our research shows that pediatric ICU fellow sign-outs demonstrate high context sensitivity, compact reference, gestures, and stylized expressions. We find that sign outs account for both what is known and what is not known about a patients condition, and to assess expectations for the oncoming shift. Uncertainty about patient condition influences handoff content and form. Clinicians change the amount time that they allocate to handoffs based on other aspects of work load, such as rounds or procedures. Clinicians apportion time to discuss individual patients according to the perceived severity and stability of each patients condition. Expertise in hand-off communications depends on the ability to prioritize relevant information and to transfer insights effectively. Relevant, efficient hand-offs significantly affect the ability of clinicians to provide care at the unit level, within and between departments, and across specialties such as intensivists, nurse anesthetists, and anesthesia technicians. Even though they affect patient care quality and continuity, sign outs are not taught but are instead learned on the job. Formal study of, and training in, the conduct of sign outs may benefit both care providers and patients alike.

Healthcare groups at work: further lessons from research into large-scale coordination

The first special issue in Large-Scale Coordination earlier this year showed the breadth of application research from air traffic control to the military and multi-agency emergency response. This special issue shows depth of research at large scale in healthcare. These studies of large-scale coordination examine work between and across groups, beyond earlier conceptions of social human factors. Revealing the complexity of work domains and the subtle, yet effective, ways that workers negotiate its challenges opens the way to develop information and communications technology support tools that are grounded in a scientific understanding.

Groups at work: lessons from research into large-scale coordination

Study of large-scale coordination seeks us to understand work between and across groups beyond earlier conceptions of social human factors. Revealing the complexity of work domains and the subtle yet effective ways that workers negotiate its challenges opens the way to develop support tools that are grounded in a scientific understanding. This first special issue in Large-Scale Coordination shows the breadth of application research from air traffic control to the military and multi-agency emergency response. A second special issue later this year will show depth of research at large scale in healthcare.