1. Participatory user-centered design approach to tool/checklist development Mahiyar Nasarwanji PhD, Ayse P. Gurses PhD, Anping Xie, PhD Armstrong Institute for Patient Quality and Safety

2. 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 2

3. Toolkit New material –User centered design approach to tool / Today checklist 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 3

4. Systems Engineering Initiative for Patient Safety (SEIPS) Model 4 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.

5. Participatory Ergonomics (PE) Key characteristics 5 Involvement of end users Participatory Use of Human Factors and Ergonomics (HFE) Principles Ergonomics

6. 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 6 Wilson, 1995; Haines et al., 2002

7. 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 7 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

8. 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 8 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

9. 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 9 Lingard et al., 2005; Lingard et al., 2008; Mahajan, 2011; Thomassen et al., 2011; Vats et al., 2010

10. Participatory user centered design approach to tool / checklist development 10 Identify needs Identify requirements Need analysisDesignIterative testingFinalize design

11. 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 11 Identify needs Identify requiremen ts Need analysis Design Iterative testing Finalize design

12. 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 12 Identify needs Identify requiremen ts Need analysis Design Iterative testing Finalize design

13. 13 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

14. 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 14 Identify needs Identify requiremen ts Need analysis Design Iterative testing Finalize design

15. Need Analysis Define needs of all users Prioritize needs List all constraints of use and hazards Refine and summarize needs 15 Identify needs Identify requiremen ts Need analysis Design Iterative testing Finalize design

16. 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 16 Identify needs Identify requiremen ts Need analysis Design Iterative testing Finalize design

17. Pre-existing formats to help organize information Joint Commission (2007). Improving hand-off communication NameDescription SBARSituation, Background, assessment, recommendation ISBARQIntroductions, Situation, Background, assessment, recommendation, questions I PASS the BATON Introduction, Patient, Assessment, Situation, Safety concerns, Background, actions, timing, ownership, next steps SHARQSituation, history, assessment, recommendations/results, questions ANTIcipateAdministration info, New clinical info, Tasks to be performed, Illness severity and assessment, contingency plans of anticipated problems BSAPBackground, Situation, Assessment, Plan of care, problems, Precautions, Pain SEAMSummary, every active problem, management, SHAREDSituation, history, assessment, request, evaluate, document DRAWDiagnosis, recent changes, anticipated changes, what to watch for in the next interval of care

18. 18 Nasarwanji et al 2013 Working paper Follow up care needs and recommendations

19. 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 19 Identify needs Identify requiremen ts Need analysis Design Iterative testing Finalize design

20. 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 20 Identify needs Identify requiremen ts Need analysis Design Iterative testing Finalize design

21. 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 21 Identify needs Identify requiremen ts Need analysis Design Iterative testing Finalize design

22. Participatory user centered design approach to tool / checklist development 22 Identify needs Identify requirements Need analysisDesignIterative testingFinalize design

23. 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 23

24. Your handoff checklist … Let us see your handoff tool / checklist Tell us how you designed your checklist 24

25. Thank you! 25 Mahiyar Nasarwanji, Ph.D. mnasarw1@jhmi.edu Ayse Gurses, Ph.D. agurses1@jhmi.edu Anping Xie, PhD axie1@jhmi.edu

26. Identify needs (Notes 1 of 2 ) Define the overall goal of tool / checklist –What is the goal of the tool / checklist you are planning to develop? For Handoffs –To foster a complete and accurate and standardized transfer of information from the sending end to the receive end during the transition of a patient. –Is the tool / checklist really needed, or can an alternate method be used more efficiently, effectively? Checklist increase workload Checklists are an excellent way to reduce cognitive load and can act as memory aids For handoffs –Yes. There is a need for an external memory aid (cognitive artifact) that can help individuals remember what information needs to be transferred, to prevent errors in reported information and create a formal reporting mechanism that the receiving end can keep as a record. Implementation support –What is needed to support the successful implementation of the tool? Consider: Management support, team formation, local leaders, training & education, team involvement 26

27. Identify needs (Notes 2 of 2 ) Identify all key players –Identify all individuals who will use or benefit from the tool or checklist Handoffs from OR  ICU –Anesthesiologist (attending, fellow and resident) –Surgeon (attending, fellow and resident) –Nurse (RN, NP, Charge nurse) –PA, intensivist, respiratory therapist –Describe each players experience, role and responsibilities Handoffs from OR  ICU –Anesthesiologist: Responsible for all blood products, and lines during the surgery, Also responsible for narcotics during the immediately following surgery –Primary Nurse at ICU: Responsible for care of the patient once patient is in the ICU, tracking vitals, drawing blood as needed and administering select medications –Define goals of each player in the context of the overall goal identified earlier Handoffs from OR  ICU –Anesthesiologist fellow: Communicate briefly the results of the echo taken prior to, during and following surgery to the receiving end, including any abnormal findings and X, Y and Z parameters Team development and integration –Ensure your team includes all individuals who will use or benefit from the tool or checklist identified above –From here forward all team members should play an active part in the development and provide input 27

28. Identify Requirements (Notes) Define the context or situation of use (the 6 questions) –When? Where? How? Who? What? Why? –For checklists consider who will fill out the tool, who will use or receive the information on the tool, and who or where will the tool be stored. –Consider how the use of the tool / checklist will influence work the way it is currently performed and if there are any negative consequences Handoffs from OR  ICU –The tool will be filled out prior to the verbal handoff by the anesthesiologist, surgeon and circulating nurse with all required information when in the ICU and prior to the patient leaving the ICU to have all inflation ready. Might involve an additional step in the ICU for each player to fill out the tool. –The sending end will be responsible for verbally communicating information from the tool to the receiving end during the verbal handoff to communicate effectively, efficiently and without errors. This fits in with the current workflow –The tool will be stored with the patients paper chart in the ICU room at the receiving end for no less than 24 hours, following the verbal handoff, as a reference of if additional information is required. May not currently be part of current work practice. Benchmark –Are there other tools / checklists that already do what we want? –How effective are they? 28

29. Need Analysis (Notes) Define what each users requirements / needs are –Think of what information the tool should capture and communicate –List all the information of all players –Can use the teamwork across unit tool –Can interview users Handoffs from OR  ICU –Anesthesiologist: need information about dosage of the most recent infusions to fill out the form –Primary nurse: needs to know the on clamp, off clamp time as well as any complications during surgery. Prioritize requirements / needs and add in constraints –Some requirements may be more critical than others for safety of patient Handoffs from OR  ICU –Cross clamp time is more essential to know as compared to start of surgery time List all constraints of use –There may be limitations to collecting, communicating information Handoffs from OR  ICU –The time that is allocated for the verbal handoff should not be greater than 20 minutes –To surgeon can not fill out the form, until after the surgery is complete and the patient has left the ICU, Surgeon may need his / her own section or sub-checklist Refine list of needs / requirements 29