Alone Together: Is Strain Experienced Concurrently by Members of Operating Room Teams?: An Event-based Study.

Objective: To identify which strain episodes are concurrently reported by several team members; to identify triggers of strain experienced by operating room (OR) team members during the intraoperative phase. Summary: OR teams are confronted with many sources of strain. However, most studies investigate strain on a general, rather than an event-based level, which does not allow to determine if strain episodes are experienced concurrently by different team members. Methods: We conducted an event-based, observational study, at an academic medical center in North America and included 113 operations performed in 5 surgical departments (general, vascular, pediatric, gynecology, and trauma/acute care). Strain episodes were assessed with a guided-recall method. Immediately after operations, participants mentally recalled the operation, described the strain episodes experienced and their content. Results: Based on 731 guided recalls, 461 strain episodes were reported; these refer to 312 unique strain episodes. Overall, 75% of strain episodes were experienced by a single team member only. Among different categories of unique strain episodes, those triggered by task complexity, issues with material, or others' behaviors were typically experienced by 1 team member only. However, acute patient issues (n = 167) and observations of others' strain (n = 12) (respectively, 58.5%; P < 0.001 and 83.3%; P < 0.001) were often experienced by 2 or more team members. Conclusions and relevance: OR team members are likely to experience strain alone, unless patient safety is at stake. This may jeopardize the building of a shared understanding among OR team members.

Implementing Root Cause Analysis and Action: Integrating Human Factors to Create Strong Interventions and Reduce Risk of Patient Harm.

OBJECTIVES: The goal of this study was to develop a systems approach for root cause analysis and action to achieve strong, sustainable interventions. The team integrated human factors principles into the design of interventions to ensure solutions maintain compatibility with human capabilities and limitations resulting in stronger solutions to prevent reoccurrence. METHODS: This study was conducted at a 7-hospital health system located in southwestern Virginia. Including human factors in a new root cause analysis and action process allowed the team to design strong interventions. To assess the results of this process, a team evaluated all interventions over a 4-year period (2.75-y preimplementation and 1.4-y postimplementation). Interventions were initially blind coded and then consensus coding was executed to finalize the strength of each intervention according to the VA National Center for Patient Safety evaluation tool. RESULTS: The new process resulted in an efficient method to address adverse events with increased staff satisfaction and interventions more resilient to human error. The number of events with strong interventions increased from 43% to 69% after implementation of the new process. CONCLUSIONS: Tailoring an event investigation process to an organizational culture is critical to implementation success. Adding human factors into the design of interventions helped facilitate intervention implementation and sustainability. Blinded ratings showed that with the integration of human factors, there was improved strength of interventions. This indicates that a focus on strong system improvement (rather than weaker individual human-based solutions) will lead to improved staff satisfaction and patient safety.

Inclusion of Clinicians in the Development and Evaluation of Clinical Artificial Intelligence Tools: A Systematic Literature Review.

The application of machine learning (ML) and artificial intelligence (AI) in healthcare domains has received much attention in recent years, yet significant questions remain about how these new tools integrate into frontline user workflow, and how their design will impact implementation. Lack of acceptance among clinicians is a major barrier to the translation of healthcare innovations into clinical practice. In this systematic review, we examine when and how clinicians are consulted about their needs and desires for clinical AI tools. Forty-five articles met criteria for inclusion, of which 24 were considered design studies. The design studies used a variety of methods to solicit and gather user feedback, with interviews, surveys, and user evaluations. Our findings show that tool designers consult clinicians at various but inconsistent points during the design process, and most typically at later stages in the design cycle (82%, 19/24 design studies). We also observed a smaller amount of studies adopting a human-centered approach and where clinician input was solicited throughout the design process (22%, 5/24). A third (15/45) of all studies reported on clinician trust in clinical AI algorithms and tools. The surveyed articles did not universally report validation against the "gold standard" of clinical expertise or provide detailed descriptions of the algorithms or computational methods used in their work. To realize the full potential of AI tools within healthcare settings, our review suggests there are opportunities to more thoroughly integrate frontline users' needs and feedback in the design process.

'Strangers in a strange land': Understanding professional challenges for human factors/ergonomics and healthcare.

Human Factors and ergonomics (HFE) expertise continues to have difficulty integrating its experts into healthcare. This persistent disconnect is compounded by unique aspects of healthcare as an institution, industry and work system. Clinically-embedded HFE practitioners, a new HFE sub-specialty, are a conduit for addressing substantive mismatches between the two domains. Greater HFE penetration will require a fundamental change in stance for both domains, however, the burden will lie with HFE to be the more adaptive of the two. Learning more about the in situ work of this sub-specialty will provide insights for more nuanced approaches to bridging domain specific mismatches and obstacles.

A review of performance assessment tools for rescuer response in opioid overdose simulations and training programs.

Since the 1990s, more than 600 overdose response training and education programs have been implemented to train participants to respond to an opioid overdose in the United States. Given this substantial investment in overdose response training, valid assessment of a potential rescuers' proficiency in responding to an opioid overdose is important. The aim of this article is to review the current state of the literature on outcome measures utilized in opioid overdose response training. Thirty-one articles published between 2014 and 2020 met inclusion criteria. The reviewed articles targeted laypersons, healthcare providers, and first responders. The assessment tools included five validated questionnaires, fifteen non-validated questionnaires, and nine non-validated simulation-based checklists (e.g., completion of critical tasks and time to completion). Validated multiple choice knowledge assessment tools were commonly used to assess the outcomes of training programs. It is unknown how scores on these assessment tools may correlate with actual rescuer performance responding to an overdose. Seven studies reported ceiling effects most likely attributed to participants' background medical knowledge or experience. The inclusion of simulation-based outcome measures of performance, including the commission of critical errors and the time to naloxone administration, provides better insight into rescuer skill proficiency.

Predictors and triggers of incivility within healthcare teams: a systematic review of the literature.

OBJECTIVES: To explore predictors and triggers of incivility in medical teams, defined as behaviours that violate norms of respect but whose intent to harm is ambiguous. DESIGN: Systematic literature review of quantitative and qualitative empirical studies. DATA SOURCES: Database searches according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline in Medline, CINHAL, PsychInfo, Web of Science and Embase up to January 2020. ELIGIBILITY CRITERIA: Original empirical quantitative and qualitative studies focusing on predictors and triggers of incivilities in hospital healthcare teams, excluding psychiatric care. DATA EXTRACTION AND SYNTHESIS: Of the 1397 publications screened, 53 were included (44 quantitative and 9 qualitative studies); publication date ranged from 2002 to January 2020. RESULTS: Based on the Medical Education Research Study Quality Instrument (MERSQI) scores, the quality of the quantitative studies were relatively low overall (mean MERSQI score of 9.93), but quality of studies increased with publication year (r=0.52; p<0.001). Initiators of incivility were consistently described as having a difficult personality, yet few studies investigated their other characteristics and motivations. Results were mostly inconsistent regarding individual characteristics of targets of incivilities (eg, age, gender, ethnicity), but less experienced healthcare professionals were more exposed to incivility. In most studies, participants reported experiencing incivilities mainly within their own professional discipline (eg, nurse to nurse) rather than across disciplines (eg, physician to nurse). Evidence of specific medical specialties particularly affected by incivility was poor, with surgery as one of the most cited uncivil specialties. Finally, situational and cultural predictors of higher incivility levels included high workload, communication or coordination issues, patient safety concerns, lack of support and poor leadership. CONCLUSIONS: Although a wide range of predictors and triggers of incivilities are reported in the literature, identifying characteristics of initiators and the targets of incivilities yielded inconsistent results. The use of diverse and high-quality methods is needed to explore the dynamic nature of situational and cultural triggers of incivility.

Eye tracking in surgical education: gaze-based dynamic area of interest can discriminate adverse events and expertise.

BACKGROUND: Eye-gaze metrics derived from areas of interest (AOIs) have been suggested to be effective for surgical skill assessment. However, prior research is mostly based on static images and simulated tasks that may not translate to complex and dynamic surgical scenes. Therefore, eye-gaze metrics must advance to account for changes in the location of important information during a surgical procedure. METHODS: We developed a dynamic AOI generation technique based on eye gaze collected from an expert viewing surgery videos. This AOI updated as the gaze of the expert moved with changes in the surgical scene. This technique was evaluated through an experiment recruiting a total of 20 attendings and residents to view 10 videos associated with and another 10 without adverse events. RESULTS: Dwell time percentage (i.e., gaze duration) inside the AOI differentiated video type (U = 13508.5, p < 0.001) between videos with the presence (Mdn = 16.75) versus absence (Mdn = 19.95) of adverse events. This metric also differentiated participant group (U = 14029.5, p < 0.001) between attendings (Mdn = 15.45) and residents (Mdn = 19.80). This indicates that our dynamic AOIs reflecting the expert eye gaze was able to differentiate expertise, and the presence of unexpected adverse events. CONCLUSION: This dynamic AOI generation technique produced dynamic AOIs for deriving eye-gaze metrics that were sensitive to expertise level and event characteristics.

Evaluating New Skill Sets for Performance Improvement: Human Factors as a Case Study.

New skill sets and improvement disciplines are constantly arising across the vast industrial and academic landscape of modern economies. Prescient hospital administrators are routinely searching for new and innovative ways to improve care, care delivery, safety, quality, and access. But, it can be challenging to identify those emerging skill sets, which will likely have lasting effect and will provide strong return on investment, from passing fads with little capacity to move performance benchmarks for a hospital. Here, we present a rubric for investigating new skill sets, using The Children's Hospital of Philadelphia's investigation into human factors engineering as a case study, and determining whether they can support hospital operations and improvements while providing sufficient return to justify the expense and challenge of incorporating ideas and methods into a quality and performance improvement environment.

Honouring patient's resuscitation wishes: a multiphased effort to improve identification and documentation.

BACKGROUND: Do Not Resuscitate (DNR) orders are intended to safeguard patients' autonomy and prevent unwanted resuscitative care. However, DNR orders may be miscommunicated between health care providers, leading to errors honoring patient wishes during cardiac arrest events. This project focused on improving accuracy of DNR ordering processes for an academic, tertiary care hospital. INTERVENTION: We describe a performance improvement process and outcomes for implementation of an inpatient electronic ordering system that included an automated, decentralized printing process for resuscitation status armbands. Specific phases of this project involved: (a) identification of common factors contributing to errors honoring patients' resuscitation wishes, (b) design of an electronic ordering process, (c) design and integration of a new DNR armband and (d) evaluation of the impact of changes on communication accuracy. The primary outcome was percentage of patients with incorrect designation of resuscitation status on armbands compared to the active resuscitation order in the electronic medical record. RESULTS: After implementation of an electronic ordering process we identified that 37/196 (19%) patients had an armband that did not reflect their documented wishes versus 2/103 (2%) after integration of automated armband printing into the process (p<0.001). No armband discrepancies were found after the first two weeks of post-implementation audits. CONCLUSIONS: Design and implementation of an electronic ordering and armband labeling process reduced discrepancies between patient wishes and the armband labeling of the patient's desired DNR status. It is anticipated that these improvements will reduce the risk of adverse outcomes, and better align clinical processes with patient wishes.

The Surgeons' Leadership Inventory (SLI): a taxonomy and rating system for surgeons' intraoperative leadership skills.

BACKGROUND: Surgeons must demonstrate leadership to optimize performance and maximize patient safety in the operating room, but no behavior rating tool is available to measure leadership. METHODS: Ten focus groups with members of the operating room team discussed surgeons' intraoperative leadership. Surgeons' leadership behaviors were extracted and used to finalize the Surgeons' Leadership Inventory (SLI), which was checked by surgeons (n = 6) for accuracy and face validity. The SLI was used to code video recordings (n = 5) of operations to test reliability. RESULTS: Eight elements of surgeons' leadership were included in the SLI: (1) maintaining standards, (2) managing resources, (3) making decisions, (4) directing, (5) training, (6) supporting others, (7) communicating, and (8) coping with pressure. Interrater reliability to code videos of surgeons' behaviors while operating using this tool was acceptable (κ = .70). CONCLUSIONS: The SLI is empirically grounded in focus group data and both the leadership and surgical literature. The interrater reliability of the system was acceptable. The inventory could be used for rating surgeons' leadership in the operating room for research or as a basis for postoperative feedback on performance.

Towards a model of surgeons' leadership in the operating room.

BACKGROUND: There is widespread recognition that leadership skills are essential for effective performance in the workplace, but the evidence detailing effective leadership behaviours for surgeons during operations is unclear. DATA SOURCES: Boolean searches of four on-line databases and detailed hand search of relevant references were conducted. A four stage screening process was adopted stipulating that articles presented empirical data on surgeons' intraoperative leadership behaviours. CONCLUSIONS: Ten relevant articles were identified and organised by method of investigation into (i) observation, (ii) questionnaire and (iii) interview studies. This review summarises the limited literature on surgeons' intraoperative leadership, and proposes a preliminary theoretically based structure for intraoperative leadership behaviours. This structure comprises seven categories with corresponding leadership components and covers two overarching themes related to task- and team-focus. Selected leadership theories which may be applicable to the operating room environment are also discussed. Further research is required to determine effective intraoperative leadership behaviours for safe surgical practice.