Richard J. Holden

SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients

Healthcare practitioners, patient safety leaders, educators and researchers increasingly recognise the value of human factors/ergonomics and make use of the disciplines person-centred models of sociotechnical systems. This paper first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, ‘SEIPS 2.0’. SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement and adaptation. The concept of configuration highlights the dynamic, hierarchical and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at ‘a moment in time’. Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed. Practitioner Summary: SEIPS 2.0 is a new human factors/ergonomics framework for studying and improving health and healthcare. It describes how sociotechnical systems shape health-related work done by professionals and non-professionals, independently and collaboratively. Work processes, in turn, shape patient, professional and organisational outcomes. Work systems and processes undergo planned and unplanned adaptations.

Human factors systems approach to healthcare quality and patient safety

Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety.

Automation and adaptation: nurses' problem-solving behavior following the implementation of bar-coded medication administration technology

The most common change facing nurses today is new technology, particularly bar-coded medication administration technology (BCMA). However, there is a dearth of knowledge on how BCMA alters nursing work. This study investigated how BCMA technology affected nursing work, particularly nurses’ operational problem-solving behavior. Cognitive systems engineering observations and interviews were conducted after the implementation of BCMA in three nursing units of a freestanding pediatric hospital. Problem-solving behavior, associated problems, and goals were specifically defined and extracted from observed episodes of care. Three broad themes regarding BCMA’s impact on problem solving were identified. First, BCMA allowed nurses to invent new problem-solving behavior to deal with pre-existing problems. Second, BCMA made it difficult or impossible to apply some problem-solving behaviors that were commonly used pre-BCMA, often requiring nurses to use potentially risky workarounds to achieve their goals. Third, BCMA created new problems that nurses were either able to solve using familiar or novel problem-solving behaviors, or unable to solve effectively. Results from this study shed light on hidden hazards and suggest three critical design needs: (1) ecologically valid design; (2) anticipatory control; and (3) basic usability. Principled studies of the actual nature of clinicians’ work, including problem solving, are necessary to uncover hidden hazards and to inform health information technology design and redesign.

Macroergonomics in Health Care Quality and Patient Safety

The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.

Macroergonomic factors in the patient work system: examining the context of patients with chronic illness

Abstract Human factors/ergonomics recognises work as embedded in and shaped by levels of social, physical and organisational context. This study investigates the contextual or macroergonomic factors present in the health-related work performed by patients. We performed a secondary content analysis of findings from three studies of the work of chronically ill patients and their informal caregivers. Our resulting consolidated macroergonomic patient work system model identified 17 factors across physical, social and organisational domains and household and community levels. These factors are illustrated with examples from the three studies and discussed as having positive, negative or varying effects on health and health behaviour. We present three brief case studies to illustrate how macroergonomic factors combine across domains and levels to shape performance in expected and unexpected ways. Findings demonstrate not only the importance of context for patients’ health-related activities but also specific factors to consider in future research, design and policy efforts. Practitioner Summary: Health-related activities of patients are embedded in and shaped by levels of social, physical and organisational context. This paper combined findings from three studies to specify 17 contextual or macroergonomic factors in home- and community-based work systems of chronically ill patients. These factors have research, design and policy implications.

Technical infrastructure implications of the patient work framework

In their response to our original paper, “Transforming Consumer Health Informatics through a Patient Work Framework: Connecting Patients to Context,” Marceglia and colleagues propose an architecture that integrates the patient work framework into a higher-order framework linking consumer health informatics (CHI) applications and professional health information systems (designated by the authors as the health-Information Technology (IT) ecosystem).1 The purpose of our letter is threefold. First, we detail how an expanded understanding of the patient work framework already conceptually encompasses the larger contexts in which CHI use must occur. Second, we assert that meaningful application of the patient work perspective yields implications not only for integration with professional health information systems but also with the larger information infrastructures within the community. Third, we propose modifications to Marceglia and colleagues’ architecture to explicitly represent a “shared space” between CHI applications and professional health information systems; this space contains collaborative work and collaborative informatics. Our original patient work framework was intended to serve as a foundation for CHI design by enabling the understanding of people, their daily contexts, and their daily activities. As such, we limited the scope of our discussion to the immediate home and community environments of the …

Data collection challenges in community settings: insights from two field studies of patients with chronic disease

AbstractPurposeCollecting information about health and disease directly from patients can be fruitfully accomplished using contextual approaches, ones that combine more and less structured methods in home and community settings. This paper’s purpose was to describe and illustrate a framework of the challenges of contextual data collection. MethodsA framework is presented based on prior work in community-based participatory research and organizational science, comprised of ten types of challenges across four broader categories. Illustrations of challenges and suggestions for addressing them are drawn from two mixed method, contextual studies of patients with chronic disease in two regions of the USA.ResultsThe first major category of challenges was concerned with the researcher–participant partnership, for example, the initial lack of mutual trust and understanding between researchers, patients, and family members. The second category concerned patient characteristics such as cognitive limitations and a busy personal schedule that created barriers to successful data collection. The third concerned research logistics and procedures such as recruitment, travel distances, and compensation. The fourth concerned scientific quality and interpretation, including issues of validity, reliability, and combining data from multiple sources. The two illustrative studies faced both common and diverse research challenges and used many different strategies to address them.ConclusionCollecting less structured data from patients and others in the community is potentially very productive but requires the anticipation, avoidance, or negotiation of various challenges. Future work is necessary to better understand these challenges across different methods and settings, as well as to test and identify strategies to address them.

Performance barriers among elderly chronic heart failure patients An application of patient-engaged human factors and ergonomics

Applications of the human factors and ergonomics (HFE) approach in the healthcare domain have largely targeted the work of healthcare professionals. Here, we argue for the importance of targeting the work of patients and their lay caregivers, a relatively underdeveloped approach we call patient-engaged HFE. A multi-method study of the barriers to the self-care work of elderly chronic heart failure patients (N=27) and caregivers (N=11) illustrates the approach. Analyses of interview data using a macroergonomic Work System framework revealed a large variety of barriers unique to patient work as well as to CHF self-care. The most common person-related barriers were physical limitations and knowledge gaps. Task-related barriers included medication complexity and side-effects. Tool and technology barriers included lack of or overdependence on aids. Context barriers were organizational (e.g., no indoor gyms), social (e.g., sodiumrich food culture), and physical-environmental (e.g., stairs). Findings motivate further applying HFE concepts and methods (e.g., workload, decision support, distributed cognition, resilience) to patient work.

Lean implementation at different levels in Swedish hospitals: the importance for working conditions and stress

Healthcare organisations in Sweden are reorienting toward horizontal organisation around care processes. This papers aim was to investigate how implementation approaches for improvements of care processes in line with lean production (LP), at hospital strategic and operative levels, are associated with working conditions and stress-related health among the employees. Five hospitals working with improvements to care processes were studied using questionnaires to employees (n = 1,303) and interviews at strategic and operative levels at baseline and follow-up. The process redesign implementation strategies varied between the strategic and operative levels. There were associations between a higher degree of LP at operative level and increased work resources and decreased work demands. Physical, cognitive and mental stress-related symptoms were only weakly associated with strategic or operative LP initiatives. There was evidence of more beneficial or improved working conditions in relation to higher degree of LP at operative levels.

Human Factors Engineering and Human–Computer Interaction: Supporting User Performance and Experience

Clinical informatics systems should be designed to support the performance and experience of its users, allowing them to perform their tasks effectively, efficiently, and with the highest possible satisfaction. The disciplines of human factors engineering and human–computer interaction offer a set of models, practices, and principles for improving the design and usability of interactive systems. In this chapter, we describe models such as the TURF usability framework for electronic health records systems, practices such as user-centered design and testing, and principles such as user interface design heuristics. We cite additional resources for information, education, and tools to enhance performance and user experience. Lastly, we discuss relevant emerging trends such as team-based care, personal informatics, mobile computing, and big data visualization for learning health systems.