Shawna J. Perry

Emergency department status boards: user-evolved artefacts for inter- and intra-group coordination

Large, easily viewed status boards are commonly used in some healthcare settings such as emergency departments, operating theaters, intensive care units, and inpatient wards. Because these artefacts were developed by front-line users, and have little to no supervisory or regulatory control, they offer valuable insights into the theories of work and hazard held by those users. Although the status boards case were locally developed over many years for within-group coordination, they have also become useful for between-group coordination across organizational boundaries. In this paper, we compare and contrast the use of such status boards in two disparate settings: a US emergency department, and a UK pediatric ward, and note striking similarities in their form and usage, despite the large differences in setting.

Shift Changes among Emergency Physicians: Best of Times, Worst of Times

The need for 24-hour emergency care requires emergency department (ED) staff to work in shifts. Shift changes have long been viewed as risky times, for failures in the transfer of information, authority, or responsibility care can result in adverse events. We observed shift transitions in the ED as part of a study on safety in emergency care. We found that, in addition to being an expected point of failure, transitions were also, unexpectedly, associated with recovery from failure. We report two illustrative case studies, and examine implications for strategies aimed at reducing the number of and volume of transitions.

A Comparison of Manual and Electronic Status Boards in the Emergency Department: What's Gained and What's Lost?

Emergency departments (EDs) are complex, high tempo, high risk work environments that require dynamic sharing of information across a group of caregivers. EDs commonly use status boards as tools to facilitate this sharing. Manual status boards have been replaced in some institutions by electronic ones, for a variety of reasons. We contrast the use of manual and electronic status boards in 4 different EDs to assess the gains and losses for workers.

Discourse and Process Analyses of Shift Change Handoffs in Emergency Departments

The need for 24 times 7 × 365 service in emergency departments (EDs) requires physicians and other health professionals to work in temporally delimited shifts. Handoffs between on-coming and off-going workers at shift changes are used to bridge gaps in care and to prepare the on-coming party to assume the ongoing work of care safely and effectively. We audio-recorded shift change conversations at 4 North American EDs and analysed them using a conversational framework. We compare these conversations among ED workers to reports of similar handoff conversations occurring between ED physicians and hospitalist at the time of patient admission. We found receiving parties in ED shift changes to be more active in the elicitation of information, rather than being passive recipients of information. This suggests that a co-construction or distributed cognition framing of handoffs may be more useful in understanding and improving handoffs than the information transfer framing commonly assumed by medically oriented researchers, at least in this setting.

Dynamic Changes in Reliability and Resilience in the Emergency Department

Emergency Departments (EDs) are open systems that routinely cope with highly variable and uncertain inputs. This paper will use two critical incidents to explore system adaptations to demand, complexity, unpredictability, and other threats to performance. We then relate the observations to three recently proposed graphical representations of organizational resilience: the resilience state space model; the stress-strain model of adaptation; and a dynamic model of resilience. We use these graphics to analyze the EDs response to chronic constraints and unexpected shocks. The models are found to be mutually reinforcing - each highlights some important aspects of resilience, while none capture all of the salient features.

Engineering Better Health IT: Cognitive Systems Engineering of a Novel Emergency Department IT System

Often, health IT systems are designed without a sufficient understanding of the clinical activities they are intended to support; thus desired benefits in quality of care, safety, and efficiency may not accrue. We present the first part of a multi-phase study which utilizes cognitive systems engineering methods to design and test novel user interfaces for a hospital emergency department information system. A work domain analysis was performed and the resultant model was used to identify information requirements and display components for a system which can better support work activities of ED clinicians and staff.

Conceptual Framework for Studying Shift Changes and other Transitions in Care

In healthcare systems, division of labor and the need for continuous, 24 hour care subjects patients to multiple transitions in care. These transitions, or turnovers, are potential points of failure but have not been intensively studied. We observed care transitions in 5 EDs as part of a study on safety in emergency care and found that very different sorts of handovers occur in different settings. Based on these observations, we propose a conceptual framework for characterizing turnover events. The ability to characterize certain types of transitions may help clarify future studies and assist in crafting interventions to the context of work.

Semper Gumby sub Rosa: Adaptability in a Healthcare Setting

Clinical work is accomplished by complex, highly distributed, joint cognitive systems, and involves high levels of uncertain and ambiguity. Hospital emergency departments in particular must adapt to uncertainty, ambiguity, and change on a variety of different time scales. Many of these adaptations are unofficial, in part because they cannot be specified in advance, and in part because the official models of healthcare work do not include them. This paper presents two case studies of adaptation in the ED and uses them to explore implications for cognitive engineering and design.