Participatory user-centered design approach to tool/checklist developmentMahiyar Nasarwanji PhD, Ayse P. Gurses PhD, Anping Xie, PhD
Armstrong Institute for Patient Quality and Safety
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Goals
• Use a participatory approach to– Improve (handoff) communication– Consider information needs of all players– Develop a shared standardized form
• Develop your own tool/checklist
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Toolkit
• New material – User centered design approach to tool / Todaychecklist development– Assessment of Care Transitions (ACT)
• Reinforcement– Teamwork across unit tool – Barrier identification and mitigation tool
• Currently implemented– Transitions of care survey – Part of HSPOS – Relational Coordination
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Systems Engineering Initiative for Patient Safety (SEIPS) Model
Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006.
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Participatory Ergonomics (PE)
• Key characteristics
• Involvement of end users
Participatory
• Use of Human Factors and Ergonomics (HFE) Principles
Ergonomics
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Participatory Ergonomics
• Dimensions– Permanence: Temporary, ongoing– Involvement: Representative, direct– Level of influence: Unit, department, hospital– Decision-making: Consensus, consultation, delegation– Mix of participants: providers, management, (patients/families)– Requirement to participate: Voluntary, compulsory
• Role of human factors and ergonomics specialist– Initiates process– Trains participants– Available as consultant / guide
Wilson, 1995; Haines et al., 2002
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Good Checklist Design
• Should include all stakeholders and experts• Content of checklist
– Number of items– Categories and sequence of items
• Format of checklist– Readability, use of color, length, jargon
• Checklist should fit workflow• Clear roles of people involved, including leader
Winters BD, Gurses AP, Lehmann H, Sexton JB, Rampersad CJ, Pronovost PJ. (2009) Clinical review: checklists - translating evidence into practice. Crit Care. 13(6):210
Degani & Wiener, 1993; Evans & Dodge, 2010; Hales et al., 2008; Herring et al., 2011; Winters et al., 2010; World Alliance for Patient Safety, 2008
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Good Checklist Implementation
• Pilot test to assess usability – Get feedback to revise
• Appropriate training before implementation
• Local champions and rapport building
• Continuous evaluation and improvement
Evans & Dodge, 2010; Hales et al., 2008; Lingard et al., 2005; Lingard et al., 2008; Mahajan, 2011; Thomassen et al., 2011; Vats et al., 2010; Winters et al., 2010
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Challenges with Checklist
• The checklist may disrupt workflow
• Clinicians used to working independently
• Skepticism from clinicians
• Lack of familiarity with checklists
• Checklist may be filled out incompletely or dismissively
• The checklist may divert attention away from the patient
Lingard et al., 2005; Lingard et al., 2008; Mahajan, 2011; Thomassen et al., 2011; Vats et al., 2010
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Participatory user centered design approach to tool / checklist development
Identify needs
Identify requirements
Need analysis
Design
Iterative testing
Finalize design
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Identify needs
• Define overall goals – What is the goal of the tool / checklist?– Is the tool / checklist really needed?
• Implementation support – What is needed to support the successful implementation of
the tool?• Identify all players their roles and responsibilities • Develop the teams
Identify needs
Identify requiremen
ts
Need analysis
Design
Iterative testing
Finalize design
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Identify Requirements
• Define the context or situation of use– When? Where? How? Who? What? Why?
– Consider how the tool / checklist will influence work
– Proactively identify potential negative consequences
• Benchmark
Identify needs
Identify requiremen
ts
Need analysis
Design
Iterative testing
Finalize design
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Handoffs
Why?
When?
Where?
Who?
How?
What?
• Successful transfer of information
• Dedicated time• Sufficient length
• Close to work area• Large enough space• Free from
distractions• Access to required
information and technology
• Key personnel / players• Active involvement of
senior physicians
• Clear leadership • Good
communication• Team involvement • Avoid interruptions • Discussion and
questions• With the aid of
checklists, tools and technology
• Provider information • Patient information• Plan of care • Discussion and
questions
Adapted from: AMA Clinical Handover Guide - Safe Handover: Safe Patients: https://ama.com.au/ama-clinical-handover-guide-safe-handover-safe-patients
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Identify Requirements
• Define the context or situation of use– When? Where? How? Who? What? Why?
– Consider how the tool / checklist will influence work
– Proactively identify potential negative consequences
• Benchmark
Identify needs
Identify requiremen
ts
Need analysis
Design
Iterative testing
Finalize design
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Need Analysis
• Define needs of all users
• Prioritize needs
• List all constraints of use and hazards
• Refine and summarize needs
Identify needs
Identify requiremen
ts
Need analysis
Design
Iterative testing
Finalize design
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Design
• Layout and format the tool – Can model based on pre-existing formats– Use human factors principles to
• Cluster related information together• Highlight key pieces of information• Order information using common or standard
conventions (head to toe assessment)• Use appropriate terms that are universally
understood, clear and not easily mistaken• Develop a prototype of the tool / checklist
Identify needs
Identify requiremen
ts
Need analysis
Design
Iterative testing
Finalize design
Pre-existing formats to help organize information
Joint Commission (2007). Improving hand-off communication
Name Description
SBAR Situation, Background, assessment, recommendation
ISBARQ Introductions, Situation, Background, assessment, recommendation, questions
I PASS the BATON
Introduction, Patient, Assessment, Situation, Safety concerns, Background, actions, timing, ownership, next steps
SHARQ Situation, history, assessment, recommendations/results, questions
ANTIcipate Administration info, New clinical info, Tasks to be performed, Illness severity and assessment, contingency plans of anticipated problems
BSAP Background, Situation, Assessment, Plan of care, problems, Precautions, Pain
SEAM Summary, every active problem, management,
SHARED Situation, history, assessment, request, evaluate, document
DRAW Diagnosis, recent changes, anticipated changes, what to watch for in the next interval of care
18Nasarwanji et al 2013 Working paper
Follow up care needs and
interventions
Long term results to look out for
What part can you play during the next shift?
What is pending?
Plan of care
To do list Recommendations for continuation
of care
Daily goals and shift goals
What happened next
Discharge plan
Goals to be achieved
Next steps in the next 2 hours
Alerts for incoming
information and actions if any
Short term results to look out for
Actions
Pending labs and their implications
Labs to check on and what to do
about them
Pending lab results
What did and didn’t work
Diet and weaning orders
Future treatments for patient
Oxygen and weaning
instructions
Explicit timing
Set parameters for when, how
and by who provider should
be contacted
Continuing needs
Nothing by mouth
Time frame Timeline
Tests to order or follow up on
Prioritization of actions
Relate current health status and
issues to patient’s progress
Clinical findings supporting plan
of care
Rationale for care plan
Here is why
What would you do to correct the
problem
What may go wrong and what
to do about it
See something I did not
Prepare cross coverage
Any contingency plans
What you should keep an eye on
Know what is going on and plan for what might happen
next
Any anticipated changes in
condition of care
Recent and anticipated changes in condition
What is expected to be different
Frequent issues to be expected with a plan to resolve them
Specify using if then statements
Isolation
Specialty bed
Patient safety issues
Fall precautions
Follow up care needs and
recommendations
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Design
• Layout and format the tool – Can model based on pre-existing formats– Use human factors principles to
• Cluster related information together• Highlight key pieces of information• Order information using common or standard
conventions (head to toe assessment)• Use appropriate terms that are universally
understood, clear and not easily mistaken• Develop a prototype of the tool / checklist
Identify needs
Identify requiremen
ts
Need analysis
Design
Iterative testing
Finalize design
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Iterative testing
• Pilot test the tool– Use the tool as part of simulated training – Evaluate effectiveness – Evaluate Use– Summarize results of the test
• Re-design, refine and improve the tool based on input from the pilot testing
• Re-evaluate the usability of the tool iteratively
Identify needs
Identify requiremen
ts
Need analysis
Design
Iterative testing
Finalize design
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Finalize tool
• After iterative usability testing and refinement finalize the tool
• Implement the tool in a real world setting
• Collect feedback from users on tool
• Continual improvement and refinement of the tool based on input from users
Identify needs
Identify requiremen
ts
Need analysis
Design
Iterative testing
Finalize design
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Participatory user centered design approach to tool / checklist development
Identify needs
Identify requirements
Need analysis
Design
Iterative testing
Finalize design
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Lessons learned
• Participatory ergonomics • Good checklist deign• User centered design approach to tool /
checklist development – Improves handoff communication– Considers the information needs of all
players– A shared standardized form
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Your handoff checklist …
• Let us see your handoff tool / checklist
• Tell us how you designed your checklist
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Thank you!
Mahiyar Nasarwanji, Ph.D. [email protected]
Ayse Gurses, Ph.D. [email protected]
Anping Xie, [email protected]
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