Workflow Informed Decision Support Tools for Nursing Homes · Clinical Decision Support Systems •...
Transcript of Workflow Informed Decision Support Tools for Nursing Homes · Clinical Decision Support Systems •...
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Workflow Informed Decision Support Tools for Nursing HomesSession 218, March 8, 2018
Mustafa Ozkaynak, PhD
@mozkaynak
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Mustafa Ozkaynak, PhD
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Agenda• Clinical decision support systems in nursing homes (NHs)
• Studying Workflow in healthcare settings
– Studying workflow in nursing homes
• Our approach to examine workflow in NHs
• Characteristics of workflow in NHs
• Discussion and implications
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Learning Objectives• Appraise the unique characteristics of workflow in NHs
• Assess the importance of considering workflow characteristics in NHs to design clinical decision support systems
• Recognize general design considerations for clinical decision support systems in NHs
• Compose a set of design guidelines related to clinical decision support systems in NHs
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Clinical Decision Support Systems
• Provide clinicians and patients with reminders or cues to make the best clinical decisions
• Five rights of CDSS
– The right information
– To the right person
– In the right intervention format
– Through the right channel
– At the right time in workflow
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Ten Commandments (Bates et al 2003)
• Speed is Everything
• Anticipate needs and deliver in real time
• Fit into the user’s workflow
• Little things can make big difference
• Recognize that physicians will strongly resist stopping
• Changing direction is easier than stopping
• Simple interventions work best
• Ask for additional information only when you really need it
• Monitor impact, get feedback and respond
• Manage and maintain your knowledge-based systems
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Run by Nurses
Low resource environment
Long-Term Care Facility
Skilled Nursing Facility
Nursing Homes
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Promise and Limitations of CDSS• Hold promise for influencing clinician behavior
• More evidence-based practice
• Interruptive alerts and reminders
• Unintended consequences.
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CDSS in Nursing Homes• Alerts for change of conditions
• Medication administration using EHR
• Interventions to reduce acute care transfers
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Workflow in Healthcare Settings
“The flow of work through space and time” (Carayon 2010)
• Contributes to comprehensive, systematic examination of care delivery systems,
• Helps identify quality of care and efficiency problems,
• Leads to development of systematic interventions to remedy these problems.
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Workflow in Nursing Homes
• Nurses run the workflow
• Providers are typically outside of the facility
• Mixture of clinical setting and residents’ daily living setting
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Our Approach-1Settings:
• Two nursing homes in a metropolitan area of the Mountain West Region of the US.
Sample:
• N=31 (7 RN, 13 LPN, 11 CNA)
Data Colllection:
• 18 observation sessions
• 15 interviews
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Our Approach-2
Conceptual framework:
• Multilevel work model
(Holden and Karsh 2009)
Data analysis:
• Qualitative analysis.
• Member checking.
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UTIDecide
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Findings
Our analysis using a multilevel perspective highlighted the characteristics of workflow at following levels
• Individual
• Work group / unit
• Organization
• Industry
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Workflow at Individual Level
• Nurses => Medication management
• CNAs => Activities of daily living
• Individual latent activities
• Establishing baseline for residents
• Time management
• Task prioritizing
• Supporting residents’ sense of independence
• Handling interruptions
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Workflow at Group/Unit level
• Pain management
• Assessing and detecting change in condition
• Treatment
• Admission
• Discharge
• Incident follow-up
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Workflow at Organizational Level-1
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Workflow at Organizational Level-2Description NH-1 NH-2
Majority of RN time used for medication management. √ √
Majority of CAN time spent assisting with activities of daily living √ √
Existence of the latent activities √ √
Unit level activities: (1) Pain management; (2) Assessment and detecting change
in condition; (3) Treatment; (4) Admission; (5) Discharge; (6) Incident follow-up.
√ √
Centralized More Less
Existence of temporal zones √ √
Prolonged relationships between staff and residents √ √
Resident-centered care √ √
Absence of memory aids. √ √
Staff member’s preferences affect work activities. √ √
Physical Layout One story building with long hallways
in a spoke and hub configuration. Multiple floor
Medication Administration Records Electronic Paper
Proximity of Management Nearby Distant
Interdependence between shifts Lower Higher
High variability in complexity of patients √ √
High variability at the task level between staff members and limited variability
within individual’s routines.
√ √
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Workflow at Inter-organizational Level
• Hospitals
• Labs
• Pharmacy
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Discussion/Implication
• Temporality
• Flexibility.
• Resident safety
• Organizational structure
• Relationships
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Temporality
• Each time zone has its own pace and responsibilities.
• Relevant policies may not reflect the work performed at each time zone.
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Flexibility
• Flexibility inherent in how staff perform their work
• Needs and preferences of residents is a driving force
• Staff keeps work under control.
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Resident Safety
• Resident safety is a prime concern.
• The pace of the work and resident preferences can supersede safety precautions
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Organizational Structure• The role of organizational structure in NHs on outcomes merits
further exploration.
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Relationships
• Work is highly impacted by the long-term relationship between staff members and residents.
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Lessons to Learn in the Design and Implementation of CDSS• CDSS should be consistent with organizational clinical guidelines.
• CDSS may be helpful given the temporal and ad hoc nature of the assessment work
• The variable degree of computer literacy of NH staff will impact adoption of CDSS with implications for training of staff.
• CDSS might be used as a collaborative tool.
• CDSS may provide needed feedback.
• The use of CDSS may differ between LTC units and SNF units.
• CDSS may be helpful in reminding staff of what they need to assess before proceeding with a resident assessment.
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Thank You Co-Authors & Collaborators
• Cynthia Drake
• Peter Ferrarone
• Blaine Reeder
• Barbara Trauer
• Heidi Wald
• R. Clark Campbell
• Study participants
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Questions